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Case Formulation and Disorder-Specific Models

“[Formulation is] The lynch pin that holds theory and practice together” (Butler, 1998).
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.
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What Keeps Fears And Phobias Going?

What Keeps Fears And Phobias Going?

The “What Keeps It Going?” series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concis ... https://www.psychologytools.com/resource/what-keeps-fears-and-phobias-going

Information handouts

What Keeps Low Self-Esteem Going?

What Keeps Low Self-Esteem Going?

The “What Keeps It Going?” series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concis ... https://www.psychologytools.com/resource/what-keeps-low-self-esteem-going

Information handouts

What Keeps Obsessive Compulsive Disorder (OCD) Going?

What Keeps Obsessive Compulsive Disorder (OCD) Going?

The "What Keeps It Going?" series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concise, t ... https://www.psychologytools.com/resource/what-keeps-obsessive-compulsive-disorder-ocd-going

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What Keeps Panic Going?

What Keeps Panic Going?

The "What Keeps It Going?" series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concise, t ... https://www.psychologytools.com/resource/what-keeps-panic-going

Information handouts

What Keeps Perfectionism Going?

What Keeps Perfectionism Going?

The “What Keeps It Going?” series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concis ... https://www.psychologytools.com/resource/what-keeps-perfectionism-going

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What Keeps Post-Traumatic Stress Disorder (PTSD) Going?

What Keeps Post-Traumatic Stress Disorder (PTSD) Going?

The "What Keeps It Going?" series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concise, t ... https://www.psychologytools.com/resource/what-keeps-post-traumatic-stress-disorder-ptsd-going

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What Keeps Social Anxiety Going?

What Keeps Social Anxiety Going?

The "What Keeps It Going?" series is a set of one-page diagrams explaining how common mental health conditions are maintained. Friendly and concise, t ... https://www.psychologytools.com/resource/what-keeps-social-anxiety-going

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What Keeps Tinnitus Going

What Keeps Tinnitus Going

What Keeps Tinnitus Going is a tinnitus formulation diagram which combines information about neurological-level change (the brain’s ‘filter’) an ... https://www.psychologytools.com/resource/what-keeps-tinnitus-going

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Window Of Tolerance

Window Of Tolerance

The window of tolerance concept was coined by Dan Siegel in his 1999 book The Developing Mind. Siegel proposes that everyone has a range of intensitie ... https://www.psychologytools.com/resource/window-of-tolerance

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Assessment

  • Collaborative Case Conceptualization Rating Scale (CCC-RS) | Kuyken, Padesky, Dudley | 2009
    • Rating scale & coding manual download archived copy
    • Score sheet & feedback form download archived copy
    • Kuyken, W., Beshai, S., Dudley, R., Abel, A., Görg, N., Gower, P., … & Padesky, C. A. (2016). Assessing competence in collaborative case conceptualization: Development and preliminary psychometric properties of the Collaborative Case Conceptualization Rating Scale (CCC-RS). Behavioural and Cognitive Psychotherapy, 44(2), 179-192. download archived copy

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Presentations

  • The case formulation approach to cognitive behavior therapy| Jacqueline Persons | 2014  download   archived copy
  • A case formulation approach to cognitive-behavior therapy | Jacqueline Persons | 2015  download   archived copy
  • The role of a case conceptualization model and core tasks of intervention | Donald Miechenbaum   download  archived copy
  • Cafe formulation in cognitive-behavioral therapy | Caleb Lack download archived copy

Recommended Reading

Case formulation / Case conceptualization

  • Geisser, S., & Rizvi, S. L. (2014). The Case of” Sonia” Through the Lens of Dialectical Behavior Therapy. Pragmatic Case Studies in Psychotherapy, 10(1), 30-39. download archived copy
  • Haynes, S. N., Leisen, M. B., Blaine, D. D. (1997). Design of individualized behavioral treatment programs using functional analytic clinical case models. Psychological Assessment, 9(4), 334-348 download   archived copy
  • Kuyken, W., Padesky, C. A., Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36, 757-768  download  archived copy
  • Persons, J. B., & Lisa, S. T. (2015). Developing and Using a Case Formulation to Guide Cognitive-Behavior Therapy. Journal of Psychology & Psychotherapy, 5(2), 1  download archived copy
  • Special issue: Team formulation. (2015). Clinical Psychology Forum, 275. download archived copy
  • Spencer, H. M., Dudley, R., Johnston, L., Freeston, M. H., Turkington, D., & Tully, S. (2022). Case formulation—A vehicle for change? Exploring the impact of cognitive behavioural therapy formulation in first episode psychosis: A reflexive thematic analysis. Psychology and Psychotherapy: Theory, Research and Practice. download archived copy

Cognitive Behavioral Models Of Disorders

  • Boelen, P. A., van den Hout, M. A., & van den Bout, J. (2006). A Cognitive-Behavioral Conceptualization of Complicated Grief. Clinical Psychology: Science and Practice, 13(2), 109–128.
  • Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and generalized anxiety disorder. Generalized anxiety disorder: Advances in research and practice, 2004.
  • Chapman, A. L., Gratz, K. L., & Brown, M. Z. (2006). Solving the puzzle of deliberate self-harm: The experiential avoidance model.Behaviour Research and Therapy, 44(3), 371–394.
  • Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24(4), 461-470.
  • Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. Social phobia: Diagnosis, assessment, and treatment, 41(68), 00022-3.
  • Dugas, M. J., Gagnon, F., Ladouceur, R., & Freeston, M. H. (1998). Generalized anxiety disorder: A preliminary test of a conceptual model. Behaviour research and therapy, 36(2), 215-226.
  • Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38(4), 319-345.
  • Espie, C. A. (2002). Insomnia: conceptual issues in the development, persistence, and treatment of sleep disorder in adults. Annual Review of Psychology, 53, 215–243.
  • Fairburn, C. G., Cooper, Z., & Shafran, R. (2003). Cognitive behaviour therapy for eating disorders: A “transdiagnostic” theory and treatment. Behaviour Research and Therapy, 41(5), 509-528.
  • Fennell, M. J. (1997). Low self-esteem: A cognitive perspective. Behavioral and Cognitive Psychotherapy, 25(1), 1-26.
  • Fernie, B. A., Bharucha, Z., Nikčević, A. V., Marino, C., & Spada, M. M. (2017). A Metacognitive model of procrastination. Journal of Affective Disorders, 210, 196-203.
  • Garety, P. A., Kuipers, E., Fowler, D., Freeman, D., & Bebbington, P. E. (2001). A cognitive model of the positive symptoms of psychosis. Psychological Medicine, 31(2), 189-195.
  • Harvey, A. G. (2002). A cognitive model of insomnia. Behavior Research and Therapy, 40, 869–894.
  • Heimberg, R. G., & Becker, R. E. (1981). Cognitive and behavioral models of assertive behavior: Review, analysis and integration. Clinical Psychology Review, 1(3), 353-373.
  • Mansueto, C. S., Golomb, R. G., Thomas, A. M., & Stemberger, R. M. T. (1999). A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice, 6(1), 23-43.
  • Marlatt, G. A. (1985). Relapse prevention: Theoretical rationale and overview of the
    model. In G. A. Marlatt & J. R. Gordon (Eds.), Relapse prevention (1st ed., pp.
    280–250). New York: Guilford Press.
  • Morrison, A. P. (2001). The interpretation of intrusions in psychosis: an integrative cognitive approach to hallucinations and delusions. Behavioural and Cognitive Psychotherapy, 29(3), 257-276.
  • Moscovitch, D. A. (2009). What is the core fear in social phobia? A new model to facilitate individualized case conceptualization and treatment. Cognitive and Behavioural Practice, 16. 123-134
  • Salkovskis, P. M., Forrester, E., & Richards, C. (1998). Cognitive–behavioral approach to understanding obsessional thinking. The British Journal of Psychiatry, 173(S35), 53-63.
  • Salkovskis, P. M., Warwick, H. M. C., Deale, A. C. (2003). Cognitive-Behavioral Treatment for Severe and Persistent Health Anxiety (Hypochondriasis). Brief Treatment and Crisis Intervention, 3, 353-367
  • Vlaeyen, J. W. S., & Linton, S. J. (2000). Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85(3), 317–332.
  • Wells, A. (1995). Meta-cognition and worry: A cognitive model of generalized anxiety disorder. Behavioural and cognitive psychotherapy, 23(3), 301-320
  • Whalley, M. G., & Cane, D. A. (2017). A cognitive-behavioral model of persistent postural-perceptual dizziness. Cognitive and Behavioral Practice, 24(1), 72-89.

What Is Case Conceptualization / Case Formulation?

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.

References

  • Beck, J. S. (1995). Cognitive behavior therapy: Basics and beyond. New York: Guilford Press.
  • Butler, G. (1998). Clinical formulation. In A. S. Bellack and M. Hersen (eds) Comprehensive clinical psychology. New York: Pergamon Press
  • Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in cognitive therapy. New York: Oxford University Press.
  • Padesky, C. A., & Mooney, K. A. (1990). Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13–14.
  • Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York: WW Norton.
  • Persons, J. (2008). The case formulation approach to cognitive-behavior therapy (guides to individualized evidence-based treatment).
  • Weerasekera, P. (1993). Formulation: A multiperspective model. Canadian Journal of Psychiatry, 38(5), 351–358.

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