A formulation, or case conceptualization, is a method for understanding and explaining a person’s problems. Case formulations tie together the difficulties that a person is experiencing and the psychological mechanisms underlying these experiences (Persons, 1989). Formulations have been described as “the lynch pin that holds theory and practice together” (Butler, 1998). Consider a simple example: a young woman experiencing feelings of anxiety about an upcoming work event might hold unhelpful thoughts about her performance, “I’ll humiliate myself in front of everyone”. She might act in ways which prevent her from finding out more about the truth of her belief, such as using avoidance or safety-seeking behaviors. Her unhelpful thoughts and avoidance behavior are mechanisms that maintain her anxiety.
Case formulations confer several important benefits:
- They help the client and therapist to understand the problem(s) and how they fit together, instilling feelings of hope.
- They draw the client’s experience together with theories about how an individual’s problem has developed and is maintained.
- They guide the choice of interventions, providing a shared rationale for the most appropriate treatment approach.
- They can be used to draw attention to client strengths (e.g. Kuyken, Padesky, Dudley, 2008).
While some CBT case formulations are longitudinal and encompass the development of problems, this cross-sectional formulation takes a here-and-now approach. Sometimes referred to as the ‘hot cross bun’ formulation it is used to take a ‘snapshot’ of all the key aspects of the CBT model during a single event – you can imagine ‘slicing through’ or taking a cross-section of that event. By focusing on a specific event (situation / context / trigger) a client and therapist can explore what the client thought, felt emotionally, felt physiologically, and how they responded. Further, the client and therapist can explore the inter-relationships between these domains and possible maintenance mechanisms.
The cross-sectional formulation is regarded as a straightforward way of introducing the cognitive behavioral model to clients (Padesky & Mooney, 1990). It can be a helpful way of communicating the core message of CBT: that our thoughts, emotions, physiology, and behavior are linked to one another, and that by making changes in one area we can produce changes in the others.
“This is a model that we use to understand all sorts of problems. We are all affected by what is going on around us or the situations we find ourselves in – that’s represented by the big circle surrounding the others. When we are in a difficult situation it can be helpful to break it down and understand our bodily sensations, our emotions, our thoughts, and our behavior. There are arrows linking all of these aspects to represent how they are all connected to one another: what we think is closely connected to how we feel emotionally and in our bodies, and with how we respond. Would you be willing to explore a recent time when you felt [client’s primary concern – e.g. anxious] using this model?”
Eliciting and elaborating an example
Focus on a specific example. Consider asking the client to close their eyes and using imagery to enhance their memory for the event.
- Can you tell me about a recent time when you felt these strong feelings? Where were you? And what were you doing?
- What went through your mind when that happened?
- What went through your mind when you started to feel that way?
- What feelings did you notice in your body?
- What did you do when you had that thought?
Helping clients to understand interconnections
- So, when you thought that thought, and felt that feeling, how did you respond?
- What happens to your feelings when you think in that way? Do they get stronger or weaker?
- What were the consequences of acting in that way? How did you feel right away? And later on?
- What happens when you avoid something that is making you feel anxious? How do you feel? What goes through your mind?
Thinking about how to achieve change
Reflect on the mechanisms that might be operating to escalate or maintain the client’s response. For example, consider avoidance, safety behaviors, selective attention, unhelpful thinking styles.
- If we make a change in one area, it can break the vicious cycle. Where do you think would be a good place to start?
- If your thoughts, feelings, body sensations, and behavior in that situation are all linked, where do think would be the most helpful place to try making small changes to improve how you feel?
- Butler, G. (1998). Clinical formulation. In A.S. Bellack & M. Hersen (Eds.), Comprehensive clinical psychology. New York: Pergammon.
- Kuyken, W., Padesky, C. A., & Dudley, R. (2008). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. Guilford 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). The case formulation approach to cognitive-behavior therapy. Guilford Press.