CBT Model - Maintaining Processes

The CBT Model - Maintaining Processes worksheet provides a useful framework for explaining what triggers a problem and why it persists across time and situations.

Download or send

Language

Professional version

Offers theory, guidance, and prompts for mental health professionals. Downloads are in Fillable PDF format where appropriate.

Client version

Includes client-friendly guidance. Downloads are in Fillable PDF format where appropriate.

Editable version (PPT)

An editable Microsoft PowerPoint version of the resource.

Overview

Psychological therapies such as cognitive behavioral therapy (CBT) use formulation to connect theory with practice. This worksheet helps therapists and clients explore what triggers a problem and why it persists over time. It focuses on key maintaining factors such as attentional biases, safety behaviors, and avoidance strategies.

This tool provides a framework for creating a personalized case conceptualization that helps clients understand their difficulties and identify patterns that perpetuate them.

Why Use This Resource?

Formulation is critical for understanding clients' difficulties and guiding the direction and process of CBT. It acts as a bridge between theory, research, and lived experiences, and makes therapy more personalized and effective.

Identifies key factors that maintain client difficulties.
Guides treatment planning and intervention choice.
Links theory to practice.
Ensures therapy is tailored to the clients' needs.

Key Benefits

Structure

Offers a simple framework for identifying triggers and maintaining factors.

Clarity

Breaks down complex issues into smaller, understandable elements.

Collaboration

Encourages clients to play an active role in developing case conceptualizations.

Evidence-base

Draws on well-researched factors that often maintain psychological difficulties.

Who is this for?

Anxiety

Catastrophic thinking and excessive avoidance.

Depression

Ruminative cycles and withdrawal behaviors.

Social Anxiety

Fear of social interactions and use of unhelpful coping strategies.

Low Self-Esteem

Self-criticism and unassertive behavior.

Integrating it into your practice

Identify

Begin with identifying events that trigger the client's difficulty.

Clarity

Explore key thoughts and images associated with the trigger event.

Understand

Help clients see how their feelings, attention, and behavior maintain these negative thoughts.

Reflect

Discuss the implications of the formulation and starting points for change.

Theoretical Background & Therapist Guidance

CBT formulations aim to comprehensively describe clients' difficulties using cognitive and behavioral theory. They tend to focus on key maintaining factors, including selective attention, emotions, sensations, safety behaviors, and avoidance, which have been shown to perpetuate psychological difficulties.

Maintenance cycles help simplify complex issues and highlight key areas for intervention. They enable therapists to draw on evidence-based interventions tailored to individual client needs, facilitating more effective therapy.

What's inside

An overview of case conceptualization in CBT.
Descriptions of key maintaining factors that often feature in psychological difficulties.
A structured framework for creating a personalized formulation that focuses on maintaining processes.
Prompts and therapist instructions for guiding the process of formulation.

Get access to this resource

FAQs

A CBT formulation provides a comprehensive understanding of what maintains a clients' difficulties, strengthens the therapeutic alliance, and helps guide decision-making throughout treatment.

This worksheet aids therapists by organizating information about what is maintaining a problem, thereby enhance understanding of the clients' issues and guiding treatment.

Yes, it can be combined with longitudinal formulations that explore the development of client difficulties.

How This Resource Improves Clinical Outcomes

This resource can help therapists develop a comprehensive understanding of clients' difficulties, enabling more targeted and effective treatment interventions. By mapping maintenance cycles, clinicians can devise tailored interventions that break these negative patterns. Therapists gain:

A versatile tool for making sense of complex psychological issues.
Detailed guidance for constructing a comprehensive case conceptualization.
Enhanced ability to develop personalized treatment plans.

Clients benefit through increased insight into their issues and a clearer path toward change.

Clinicians Who Use This Resource Also Use

References And Further Reading

Arntz, A., Rauner, M., & Van den Hout, M. (1995). "If I feel anxious, there must be danger" :Ex-consequentia reasoning in inferring danger in anxiety disorders. Behaviour Research and Therapy, 33, 917-925. DOI: 10.1016/0005-7967(95)00032-S.
Bakker, G. M. (2008). Problemâmaintaining circles: Case illustrations of formulations that truly guide therapy. Clinical Psychologist, 12, 30-39. DOI: 10.1080/13284200802069050.
Barry, T. J., Vervliet, B., & Hermans, D. (2015). An integrative review of attention biases and their contribution to treatment for anxiety disorders. Frontiers in Psychology, 6, 968. DOI: 10.3389/fpsyg.2015.00968.
Beck, A. T. (1963). Thinking and depression: I. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324-333. DOI: 10.1001/archpsyc.1963.01720160014002.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. Meridian.
Beck, A. T., Freeman, A., & Davis, D. D. (2015). General principles and specialized techniques in cognitive therapy of personality disorders. In: A. T. Beck, D. D. Davis, & A. Freeman (Eds.), Cognitive therapy of personality disorders (3rd ed.), (pp. 97-124). Guilford Press.
Beck, A. T., Rush, J. A., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. Guilford Press.
Blakey, S. M., & Abramowitz, J. S. (2016). The effects of safety behaviors during exposure therapy for anxiety: Critical analysis from an inhibitory learning perspective. Clinical Psychology Review, 49, 1-15. DOI: 10.1016/j.cpr.2016.07.002.
Burns, D. D., & Good, M. F. (1980). The new mood therapy. New York: William Morrow.
Butler, G. (1998). Clinical formulation. In: A. S. Bellack and M. Hersen (Eds.), Comprehensive Clinical Psychology (pp.1-23). Oxford.
Butler, G., Fennell, M., & Hackmann, A. (2008). Cognitive-behavioral therapy for anxiety disorders: Mastering clinical challenges. Guilford Press.
Clark, D. M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461-470. DOI: 10.1016/0005-7967(86)90011-2.
Clark, D. M. (1999). Anxiety disorders: Why they persist and how to treat them. Behaviour Research and Therapy, 37, S5-S27. DOI: 10.1016/S0005-7967(99)00048-0.
Division of Clinical Psychology (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 problems (2nd ed.), (pp.18-44).
Frijda, N. H., & Mesquita, B. (2000). Beliefs through emotions. In: N. H. Frijda, A. S. R. Manstead, & S. Bem (Eds.), Emotions and beliefs: How feelings influence thoughts, (pp.45-77). Cambridge University Press.
Harvey, A. G., Watkins, E., Mansell, W., & Shafran, R. (2004). Cognitive behavioral processes across psychological disorders: A transdiagnostic approach to research and treatment. Oxford University Press.
Hayes, S. C., & Follette, W. C. (1992). Can functional analysis provide a substitute for syndromal classification? Behavioral Assessment, 14, 345-365.
Horney, K. (1936). The problem of the negative therapeutic reaction. The Psychoanalytic Quarterly, 5, 29-44. DOI: 10.1080/21674086.1936.11925271.
Hsu, L. G., & Holder, D. (1986). Bulimia nervosa: Treatment and short-term outcome. Psychological Medicine, 16, 65-70. DOI: 10.1017/S0033291700002543.
Johnstone, L., & Dallos, R. (2014). Introduction to formulation. In: L. Johnstone & R. Dallos (Eds.), Formulation in psychology and psychotherapy: Making sense of peopleâs problems (2nd ed.), (pp.1-17). Routledge.
Kennerley, H., Kirk, J., & Westbrook, D. (2017). An introduction to cognitive behaviour therapy (3rd ed.). Sage.
Kuyken, W. (2006). Evidence-based case formulation: Is the emperor clothed? In: N. Tarrier (Ed.), Case formulation in cognitive behaviour therapy: The treatment of challenging and complex cases (pp.12-35). Routledge.
Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualisation: Working effectively with clients in cognitive-behavioral therapy. Guilford.
Mennen, A. C., Norman, K. A., & Turk-Browne, N. B. (2019). Attentional bias in depression: understanding mechanisms to improve training and treatment. Current Opinion in Psychology, 29, 266-273. DOI: 10.1016/j.copsyc.2019.07.036.
Moorey, S. (2010). The six cycles maintenance model: growing a âvicious flowerâ for depression. Behavioural and Cognitive Psychotherapy, 38, 173-184. DOI: 10.1017/S1352465809990580.
Muse, K., McManus, F., Rakovshik, S., & Thwaites, R. (2017). Development and psychometric evaluation of the Assessment of Core CBT Skills (ACCS): An observation-based tool for assessing cognitive behavioral therapy competence. Psychological Assessment, 29, 542-555. DOI: 10.1037/pas0000372.
Padesky, C. A., & Mooney, K. A. (1990). Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13-14.
Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. Guilford Press.
Persons, J. B., & Hong, J. J. (2016). Case formulation and the outcome of cognitive behavior therapy. In: N. Tarrier and J. Johnson (Eds.), Case formulation in cognitive behaviour therapy: The treatment of challenging and complex cases (2nd ed.), (pp. 14-37). Routledge.
Royal College of Psychiatrists (2017). Using formulation in general psychiatric care: Good practice. Royal College of Psychiatrists.
Salkovskis, P. M. (1991). The importance of behaviour in the maintenance of anxiety and panic: a cognitive account. Behaviour Research and Therapy, 19, 6-19. DOI: 0.1017/S0141347300011472.
Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition-behaviour links in the persistence of panic. Behaviour research and therapy, 34(5-6), 453-458.
Salkovskis, P. M., & Warwick, H. M. C. (2001). Making sense of hypochondriasis: A cognitive model of health anxiety. In: Asmundson, G., Taylor, S., & Cox, B. (Eds.), Health anxiety: Clinical and research perspectives on hypochondriasis and related conditions (pp.46-64). Wiley.
Salkovskis, P. M., Warwick, H. M., & Deale, A. C. (2003). Cognitive-behavioral treatment for severe and persistent health anxiety (hypochondriasis). Brief Treatment and Crisis Intervention, 3, 353-367.
Spencer, H. M., Dudley, R., Johnston, L., Freeston, M. H., Turkington, D., & Tully, S. (2023). 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, 96, 328-346. DOI: 10.1111/papt.12442.
Sperry, L., & Sperry, J. (2012). Case conceptualization: Mastering this competency with ease confidence. Routledge.
Teasdale, J. D. (1985). Psychological treatments for depression: How do they work? Behaviour Research and Therapy, 23, 157-165. DOI: 10.1016/0005-7967(85)90024-5.
Tolin, D. F. (2016). Doing CBT: A comprehensive guide to working with behaviors, thoughts, and emotions. Guilford Press.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Problem formation and problem resolution. New York: Norton.
Wender, P. H. (1968). Vicious and virtuous circles: The role of deviation amplifying feedback in the origin and perpetuation of behavior. Psychiatry, 31, 309-324.
Wells, A. (1998). Cognitive therapy of social phobia. In: N. Tarrier, A. Wells, & G. Haddock (Eds.), Treating complex cases: The cognitive behavioural therapy approach (pp. 1-26). John Wiley and Sons.