“[Formulation is] The lynch pin that holds theory and practice together” (Butler, 1998).
A case conceptualization is a report that is based on information gathered, organized, and
assessed to provide an explanation of a client’s behavior. Counselors look for emotional, stated,
non-verbal, and behavioral information that will help to develop a picture of the client’s
experience and will lead to collaboration with the client on goals for change.
The case conceptualization (sometimes called a case formulation) is the clinician's collective
understanding of the client's problems as viewed through a particular theoretical orientation; as
defined by the biological, psychological, and social contexts of the client; and as supported by a
body of research and practice that links a set of co‐occurring symptoms to a diagnosis and,
ultimately, leading to develop a treatment plan.
Case formulation-driven CBT is not a new therapy. It is a method for applying empirically supported
CBTs and theories in routine clinical practice. The development of empirically supported treatments
(ESTs) for psychiatric disorders and psychological problems is an important positive development in our
field and a boon to psychotherapists who strive to provide evidence-based treatment.
A strong case conceptualization is guided by the utilization of a theoretical orientation that
provides a framework for the clinician from which to condense and synthesize multiple pieces of
information into a coherent and well‐developed narrative. This narrative aims to identify not only
the precipitating cause(s) of the client's problems, but also the forces at work, both internal and
external to the client, that serve to maintain the problems..
Cognitive conceptualization initiates during first contact with a patient and continue to be
refined by the therapist throughout treatment. It is helpful to view therapy as a journey, and
the conceptualization as the road map. Conceptualization begins at the first contact with
patients and is refined at every subsequent contact. You make hypotheses about patients,
based not just on the cognitive formulation of the case, but also on the specific data patients
present. You confirm, disconfirm, or modify your hypotheses as patients present new data in
subsequent sessions. The conceptualization, there- fore, is fluid. At strategic points, you will
directly check your hypotheses and formulation with patients. Generally, if the
conceptualization is on target, patients confirm that it “feels right”—they agree that the
picture the therapist presents truly resonates with them.
Conceptualizing a patient in cognitive terms is crucial to determining the most
efficient and effective course of treatment. It also aids in developing empathy, an
ingredient that is critical in establishing a good working relationship with the patient. In
general, these questions are to ask when conceptualizing patients :
“How did the patient come to develop this disorder?”
“What were significant life events, experiences, and
interactions?” “What are the patient’s most basic beliefs
about himself, his world,
and others?”
“What are the patient’s assumptions, expectations, rules,
and attitudes (intermediate beliefs)?”
“What strategies has the patient used throughout life to cope
with these negative beliefs?”
“Which automatic thoughts, images, and behaviors help to
maintain the disorder?”
“How did the patient’s developing beliefs interact with life
situations to make the patient vulnerable to the disorder?”
“What is happening in the patient’s life right now and what are
the patient’s perceptions?”
As conceptualization begins at the first contact and is an ongoing process. You base your
hypotheses on information you have collected from the patient, using the most parsimonious
explanations and refraining from interpretations and inferences not clearly based on actual data.
But uou will check out the conceptualization with patients at strategic points to ensure that it is
accurate, as well as to help patients understand themselves and their difficulties. Your
conceptualization is always subject to modification as you continually uncover new data that will
lead you to confirm, refine, or discard your previous hypotheses.
Cognitive behavioral therapists use individually tailored formulations as a framework with which
to understand their patients’ difficulties and to plan effective treatment. A case formulation helps
therapists and patients to understand the origin, current status, and maintenance of a problem.
Formulations are developed collaboratively between therapists and patients during the
assessment phase of therapy and are revised as new information is gathered during the course of
treatment. Jacqueline Persons wrote an influential account of individualized case formulation
(1989). Her current case formulation approach (2008) describes how a complete CBT case
formulation ties together all of the following parts:
all of a patient’s symptoms, disorders, and problems;
hypotheses about the mechanisms causing the disorders and the problems;
proposes the recent precipitants of the current problems and disorders;
describes the origins of the mechanisms.
Process of Case Conceptualization
1. Listen to the client’s story/presenting problem
2. Gather information about how the client perceives his/her world
3. Obtain demographic information
4. Explore social, historical, and cultural context
5. Assess client’s strengths, coping skills
6. Assess for risk; create problem list
7. Diagnose
8. Apply theoretical orientation and hypothesize about the nature of the problem
9. Develop goals
10. Plan interventions
Types of Case Formulation
Case formulations can vary according to their purpose, and according to the information they
attempt to convey. A number of types of formulation have been described:
A cross-sectional formulation presents information relevant to a short time period, as
though an event were sliced open at a particular moment in time to reveal the triggering
event, thoughts (interpretations/appraisals), emotions, body feelings, and behaviors or
reactions. One of the most popular formats for a cross-sectional formulation is Padesky
and Mooney’s ‘hot cross bun’ (1990).
A longitudinal formulation presents information relevant to the origin and maintenance
of a problem. Weerasekera’s “Multiperspective model” popularized the use of the “5 Ps”
approach (presenting, predisposing, precipitating, perpetuating, and protective) to case
formulation (Weerasekera, 1993). Judith Beck’s cognitive conceptualization (1995) links
longitudinal factors (including relevant childhood data, core beliefs, conditional
assumptions, coping strategies) to cross-sectional breakdowns (situation, automatic
thought and appraisal, emotion, behavior).
Micro-formulations have been described as a helpful way of understanding the origin
and effects of troubling imagery (Hackmann, Bennett-Levy, & Holmes, 2011). In this
approach problematic images are explored along with their origin, associated appraisals,
current impact, maintenance factors, and cognitive consequences.
Disorder-specific models describe the critical presenting, predisposing, precipitating,
and perpetuating factors relevant to a condition. Disorder-specific cognitive behavioral
conceptualizations have been published for most conditions including low self-
esteem, panic, obsessive-compulsive disorder, psychosis, post-traumatic stress disorder.
Core belief: “I’m incompetent.”
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Intermediate beliefs Attitude: “It’s terrible to fail.”
Rule: “I should give up if a challenge seems too great.”
Assumptions: “If I try to do something difflcult, I’ll fail.
If I avoid doing it, I’ll be okay.”
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Situation: Reading a new text
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Automatic thoughts: “This is just too hard. I’m so dumb. I’ll
never master this. I’ll never make it as a therapist.”
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Reaction: Emotional: Discouragement
Physiological: Heaviness in body
Behavioral: Avoids task and watches television instead.
Trigers:
Jon :
In childhood and adolescence, Jon was brutally teased and humiliated by his father (ORIGINS). As a
result, Jon learned the schemas “I’m inadequate, a loser,” and “Others are critical, attacking, and
unsupportive of me” (MECHANISMS). These schemas were activated recently by a poor performance
evaluation at work (PRECIPITANT). As a result, Jon began having many automatic thoughts
(MECHANISMS), including, “I can’t handle this job,” and experienced anxiety and depression
(SYMPTOMS, PROBLEMS), with which he coped by avoiding (MECHANISM) important work projects and
withdrawing from collegial interactions with both peers and superiors (PROBLEMS). The avoidance
caused Jon to miss some deadlines (PROBLEM), which resulted in criticism from his colleagues and boss
(PROBLEM) and led to increased sadness, feelings of worthlessness, selfcriticism and self-blame, low
energy, and loss of interest in others (SYMPTOMS, PROBLEMS). Jon’s low energy and hopelessness
(PROBLEM) caused him to stop his regular program of exercise, which exacerbated his prediabetic
medical condition (PR
