Guest Article

Environment Is Part of the Case Formulation

Cassidy Cousens

For much of my 25 years in behavioral health and addiction treatment, I worked in and operated conventional programs across the full continuum of care. I understood treatment partly through the environments we built around it. A predictable schedule and a consistent team gave difficult work somewhere to happen. Running programs also meant understanding why those arrangements existed, including the need to coordinate care safely and keep a program functioning from one day to the next.

Over time, I became more interested in what those environments asked of the people in them. Much of the treatment took place inside four walls, with people sitting for relatively long stretches. There was considerable emotional work happening, but a full schedule could still leave someone physically inactive, with much of the day decided for them. I began to question how that affected participation, particularly for someone already feeling stuck. More hours of treatment did not necessarily mean more opportunities to act on what was being discussed.

The gap between insight and action became central to my thinking. Someone can describe a pattern accurately and still struggle to respond differently when it returns. That is familiar territory in our work. I wondered how much the treatment setting helped us understand that gap, and how much it kept parts of it out of view. Being able to follow a program’s schedule tells us something, but it leaves open how someone will manage a day when they have to organize it themselves.

I began to wonder whether static environments could sometimes reinforce static thinking. I do not mean that sitting prevents change. An office may be precisely where someone feels safe enough to begin. I am interested in what happens when the same arrangement stops helping, yet we continue to interpret the difficulty mainly through the person. Restlessness, for example, may tell us something about the setting as well as the client. It deserves a closer look before we decide what it means.

Walking as a Medium

Movement offers another way into that question. Walking changes the physical arrangement of a conversation. There is somewhere else to look, and a pause can be part of walking together rather than a silence someone feels obliged to fill. A person may find it easier to approach a difficult subject under those conditions. For someone else, the unfamiliarity may make speaking harder. Either response can tell us something about how the setting affects participation.

The surroundings can also change what holds someone’s attention. In an office, sustaining attention can take considerable effort. Outside, wind, water, and the scale of a landscape can give attention somewhere else to settle. A problem sometimes loosens its grip, not because it has been solved but because it is no longer the only thing in view. What surfaces in that quiet may be something the person had not planned to say.

A changing environment also introduces small demands. A route is unavailable, or a plan needs adjusting. Consider the difference between asking someone how they respond to disappointment and being alongside them when something does not go as expected. The conversation can include what is happening now. We can notice whether help is welcome, whether a pause is useful, and whether the original goal still makes sense. The person has a chance to recognize their response while there is still room to influence it.

That friction matters to me. I would not want treatment to become an exercise in removing every difficulty, any more than I would want difficulty manufactured to teach someone a lesson. Ordinary circumstances provide enough material. With appropriate support, a manageable setback can offer a chance to try something different and see what follows. There is an opportunity to develop capacity through experience, alongside the work of understanding it.

The demands have to remain within reach. If a person is exhausted or overwhelmed, adding challenge may only make participation harder. Slowing down, changing the plan, or stopping can be part of the work. Physical endurance is not a measure of psychological readiness. I am interested in whether someone has enough room to make a choice and remain engaged, not whether they can complete an activity that I selected.

Bringing the Work into Nature

These questions influenced my decision to create Arago Integrative Recovery, an Oregon-based, one-on-one approach that brings recovery work into natural environments. I wanted enough continuity to work through those moments as they happened, with time to return to them as the day unfolded. Movement became part of how I thought about the work itself. I have written more about that perspective in Why Movement Changes the Mind.

There are limits to what a different setting can offer. Outdoor work requires attention to a different set of details, including privacy and whether the person even wants to be there. It cannot substitute for medical stabilization or a level of care someone needs. The practical question is whether the setting supports the purpose of the work. Sometimes that means going outside. At other times it means a familiar room with a door that closes.

Back in the Office

I think these questions are useful well beyond outdoor work. In any setting, what are we able to observe, and what are we assuming about how someone manages elsewhere? Where does the person have an opportunity to practice what we are discussing? An office conversation can help prepare for an ordinary task between sessions, followed by a careful look at what actually happened. The useful connection is between the understanding reached in treatment and the circumstances in which the person needs to use it.

My years in conventional treatment remain the foundation of how I work. They also left me with questions I wanted to pursue in a different setting. I am more reluctant now to treat what happens in one room as the whole picture of how a person functions. I want to know what happens when the circumstances change, and whether we can help the person work with that change while it is happening.

About the Author

Cassidy Cousens is a CADTP-certified counselor and interventionist with 25 years of applied behavioral-health practice across the full continuum of care. In that time, he has owned, operated, and sold multiple traditional rehabs. He later founded Oregon-based Arago Integrative Recovery to offer a one-on-one alternative to conventional treatment. Learn more at www.aragorecovery.com.