Case Formulation

What Is 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.

CBT Assessment and Initial Formulation

Assessment questions typically cover:

• problem/symptoms the client would like to work on
• frequency of problem
• intensity of problem
• situations or events that trigger the problem
• effect on work/social/personal life
• thoughts about self, other people or situation
• emotions
• physical sensations
• things the client does or avoids doing
• what makes the problem worse
• what makes the problem better
• ideas on causes of the problem (going back in time to the start point)
• internal strengths and weaknesses
• what the client is grateful for or wishes was different in their life currently
• goals for therapy.

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).

Structure and Presentation of Case Formulations

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’):

• presenting problem(s)
• predisposing factors
• precipitating factors
• perpetuating factors
• protective factors.

Case formulations are often presented in a visual format that breaks down the client’s issue into manageable chunks.

Collaborative Working

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).

Using the Formulation in Subsequent Sessions

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).

Benefits of Case Formulation

Case formulation supports:

• development of the therapeutic relationship (often referred to as the ‘working alliance’ in CBT)
• agreement of a treatment plan
• guiding of the work and facilitation of the client’s process of change
• assignment of in-session and between-session tasks, allowing the therapist and client to look together at maintenance cycles (based on negative automatic thoughts) – and so to identify cognitive and/or behavioural interventions that could help replace this vicious cycle with a virtuous one
• identification of any potential barriers to effective CBT, for example if the client is prone to use avoidance
• self-awareness through developing understanding of self (for the client and in the therapist’s own personal development)
• structuring of clinical supervision sessions, as individual client case formulations may be used as the basis for discussions, as the core structure on which to hang both the therapeutic work with the client and exploration/evaluation of this in supervision.