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Case Formulation
Case formulation is a framework used by practitioners of cognitive behavioural therapy (CBT) to identify and understand the client’s problems.
While the standard generic (sometimes referred to as ‘nomothetic’) case formulations offered by CBT manuals provide a useful starting point for working with a particular client presentation (e.g. anxiety or depression), fine-tuning this to develop an idiosyncratic formulation that provides an accurate fit with the individual client allows the therapist to offer a higher-quality and more effective treatment. This is done at the very start of therapy, using material gathered from assessment.
Case Formulation
Assessment questions typically cover:
The information collected will generally provide enough information for the client and therapist to work together to create an initial case formulation (explaining succinctly – in diagrammatic form, on one A4 page – how and why the client’s problems developed, and were persisting through patterns of thinking, feeling and behaving).
There is no hard or fast rule about formulations, and there is no rule that states how detailed or complex they should be. The simplest format looks at just three key areas: thoughts, feelings (emotions and physical sensations) and behaviours. Five additional elements are often added to this (referred to as ‘the five Ps’):
Case formulations are often presented in a visual format that breaks down the client’s issue into manageable chunks.
It is important to develop the case formulation collaboratively, and to share the written form of this with the client. This encourages a solid working alliance and also helps the client to feel hope through portraying the problem in context and concisely, with clear explanation of how change is possible.
Many CBT practitioners choose to display the formulation within visibility of both themselves and the client at each session, for easy reference by both.
Some clients might choose to photograph it using their mobile phone, so that they can refer to it between sessions – and possibly share it with loved ones if they wish to do so (so helping the latter to gain insight into the client’s problems – especially useful if the family or ‘system’ around the client is inadvertently helping to maintain the problem).
Additional information can be added to the formulation as therapy progresses, when new insights are discovered through the therapy sessions and homework. At all stages and in addressing all key concepts of the CBT approach, flexibility is vital, allowing the problem list, goals and formulation to be adjusted in the light of incoming information (e.g. from homework assignments and session work).
Case Formulation
Case formulation supports:
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