Problem Lists, Case Formulations and Treatment Plans
The basis of the therapeutic approach in CBT is known as ‘collaborative empiricism’. In this modality, the therapist is active-directive (in contrast to the non-directive nature of the person-centred approach, for example).
The therapist and the client together look at the client’s present life in a logical way, identifying their thoughts and underlying beliefs.
This process of guided discovery is facilitated by the therapist using Socratic questioning, ‘which is characterised by questions and answers, by reasoning and deduction, and is aimed at discovering the truth’ (Feltham & Dryden, 1993: 179).
Typical questions that the CBT therapist might ask the client during the first (assessment) session include:
- What problem would you like to work on?
- How often do you experience this problem?
- How intense is the problem? (perhaps on a scale of 1 to 10, or 1 to 100)
- What situations/events trigger the problem?
- What effect does the problem have on your work/social/personal life?
- When the problem is triggered, what thoughts or images are you aware of running through your mind? And emotions? And physical sensations?
- What do you do to avoid doing to help you cope with the problem?
- What makes the problem worse? And better?
- What do you think might have initially caused the problem?
- What would you like to achieve through coming to therapy?
Case formulation is a framework used by CBT therapists to identify and understand the client’s problems. Case formulations are often presented in a visual format that breaks down the client’s issue into manageable chunks.
The written formulation is shared with the client, so encouraging a solid working alliance and helping 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).
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
This is what brings the client to therapy. Clients may have specific problems such as depression, low confidence, chronic worry, substance misuse issues, marital difficulties or stress. Other clients may have problems that are less well-defined, such as ‘just wanting to be happy’ or ‘wanting some peace and quiet’.
As clients often present with more than one problem, listing the problems they wish to work on helps to emphasise the importance of collaboration and ensure that the work focuses on areas likely to be clinically productive, and manageable in the time available. This is particularly important when working in a time-limited manner (e.g. with a maximum of six sessions).
It may be possible to reduce what appear to be multiple problems into one key theme – for example, with a client who is struggling with different relationships in their life, it may be possible to spot a key theme/pattern that characterises all these (such as a tendency to overextend themselves with those they love).
When a clear presenting problem has been identified, the therapist can move onto the next stage of the formulation.
This part of the formulation looks at what has happened to the client during their lifetime that makes them susceptible to the problems they now face. For example, have they suffered abuse, trauma, family problems or relationship breakdowns?
Predisposing factors can often be traced back to childhood. These events can lead to negative core beliefs (also known as ‘schemas’) that can cause difficulties in adult life. The idea here is that nothing exists in a vacuum: people’s responses to problems have their roots in past events.
What has happened to trigger the client’s mood state? This is often referred to as the ‘who, what, why, when and how’.
Context plays a pivotal role in behavioural choices, so it is important to understand all these elements in order to build a picture of the client’s problem. Triggers can be anything from family issues, money worries and health concerns.
CBT therapists will often ask clients to complete a mood diary in order to understand the context around any triggers of emotional disturbance.
What are the cognitive mechanisms and behaviours that are keeping the client locked in their problem?
An example might be a depressed client who avoids social interactions. This avoidance may lead to isolation and loneliness, which bring more depression and more resistance to socialising, and so on.
Are the client’s solutions short-term solutions to problems generating bigger problems long term? What is keeping the client stuck in the here and now?
Therapists will ask what positives the client has in their lives. What can they draw on that can help them with their problem? Does the client have a good support network? Have they any hobbies or interests? Do they have a sense of humour? They may be asked to complete a wellbeing questionnaire to highlight what is going well for them and what areas they need to work on.
Clients may be asked about their previous coping strategies and how they might employ these to help them deal with current problems. Protective factors are important as they contribute to a client’s overall resilience to problems.
Importance of Flexibility
Beck (2018) states that formulations offer a roadmap to help treat a client’s problems. While roadmaps can get a person from A to B, they cannot tell us about events that may occur along the way, such as traffic jams, accidents or roadworks.
Therapy will present new information; this means that therapists need to be flexible and be constantly reassessing and adjusting the formulation to the individual needs of the client. For example, new insights may be discovered through the therapy sessions and homework.
Once a formulation has been developed, the therapist uses this to plan and write up a treatment plan – often in the form of a letter – which can then be presented to the client in their next session. Clients often really appreciate the personalised nature of this, being addressed to them in name and describing in narrative form (and with empathy and UPR) the agreed formulation.
It is important for the therapist to adopt a congruently hopeful tone in this, encouraging the client to see just how feasible it is for the client to effect change now that they are learning about CBT (including receiving psycho-education). This will enable them to become their own therapist over the course of the sessions, so empowering them not only to maintain but also to further build on the positive results.
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Problem Lists, Case Formulations and Treatment Plans
Beck, A. (2018). Applying the Generic Cognitive Model to Complex Case Formulation. [online] YouTube. Available at: https://www.youtube.com/watch?v=SJ2J9um-nMA [Accessed 16 March 2020]
Feltham C & Dryden W (1993) Dictionary of Counselling, Whurr Publishers