CBT Model – Here And Now

Formulation in talking therapies

Formulations (also known as case formulations, case conceptualizations, and working hypotheses) are a central component of most talking therapies and a key skill for mental health professionals (DCP, 2010; RCP, 2017; Sperry & Sperry, 2012). In essence, a formulation is a way to make sense of an individual’s difficulties. It is a provisional account or hypothesis, informed by psychological theory, about what an individual is struggling with and why (Johnstone & Dallos, 2014). A formulation is also a tool that therapists use to relate theory to practice (Butler, 1998). Sperry and Sperry (2012, p. 4) describe formulations as:

A method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.

Formulation is a fundamental part of most (if not all) therapeutic

"I’d like to explore how the issues we’ve talked about fit together. One way we can do that is by drawing them as a diagram. Would that be OK?"

Step 1 – Explore the client’s experience

Event

Ask the client to identify and describe a specific recent event that triggered their difficulty. Note that trigger events can be external (e.g., a difficult interaction) or internal (e.g., an unusual physical sensation). Some individuals find it helpful to close their eyes and visualize the event (Beck, 2011). Consider asking: 

"Let’s start by writing down a situation that recently triggered [current difficulty]. Can you think of an example? What happened?"

Next, explore the client’s cognitive, emotional, and behavioral responses to the trigger event. Therapists are encouraged to add this information to the formulation in whatever order the client shares it (Kuyken et al., 2009).

Thoughts

Examine the client’s cognitive response to the trigger

• Bakker, G. M. (2008). Problem‐maintaining circles: Case illustrations of formulations that truly guide therapy. Clinical Psychologist, 12, 30-39. DOI: 10.1080/13284200802069050.
• Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.
• Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.
• Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). Guilford.
• Butler, G. (1998). Clinical formulation. In: A. S. Bellack and M. Hersen (Eds.), Comprehensive Clinical Psychology (pp.1-23). Oxford.
• Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461-470. DOI: 10.1016/0005-7967(86)90011-2.
• Division of Clinical Psychology [DCP] (2010). The core purpose and philosophy of the profession. The British Psychological Society.
• Dudley, R., & Kuyken, W. (2014). Case formulation in cognitive behavioural therapy: A principle-driven approach. In: L. Johnstone & R. Dallos (Eds.), Formulation in psychology and psychotherapy: Making sense of people’s