Case Formulation in Cognitive-Behavioral Therapy: A Principal-Driven Approach

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By Gillian A. Wilson, MA, and Martin M. Antony, PhD––Department of Psychology, Ryerson University

Cognitive-behavioral treatments are often described in step-by-step manuals. They provide strategies for treating a specific psychological disorder or diagnosis as opposed to addressing the specific problems and symptoms of a particular person.

Manualized treatments may fall short as they tend to adopt a general approach to treatment versus creating a specific approach tailored to each client.

While manualized treatments may be useful under certain circumstances—for example when individuals with a specific diagnosis have highly overlapping symptoms and problems—there are circumstances that call for a more flexible, individualized approach.

Here, we will focus on this specialized method known as a case formulation.

What is case formulation and when is it useful?

A case formulation is a hypothesis about the psychological mechanisms that cause and maintain an individual’s symptoms and problems (Kuyken et al., 2009; Persons, 2008).

It’s a principle-driven approach that targets mechanisms grounded in basic psychological theories—such as cognitive theory, classical and operant conditioning.

As outlined by Persons (2008), a case formulation can be useful when:

  • A client has several disorders or problems.
  • No treatment manual exists for a particular disorder or problem.
  • A client has numerous treatment providers.
  • Problems arise that are not addressed in a manual—nonadherence or therapeutic relationship ruptures.

Steps in Case Formulation

The case formulation should be developed in collaboration with the client to ensure engagement and increase commitment to treatment.

To develop a strong case formulation, the following steps are recommended (Persons, 2008):

  1. Conduct a thorough assessment to determine the presence of specific diagnoses, symptoms, and problems. It’s important to create a list of all of the client’s presenting symptoms and problems in various areas and life domains (i.e., panic attacks, excessive worry, low mood, poor academic performance, relationship difficulties).
  2. Develop an initial case formulation based on tentative or “working” hypotheses about:

     

    • Factors that predisposed the client to develop the symptoms and problems

     

    • Factors that precipitated the most recent episode

     

    • Maintaining factors

     

    • Protective factors
  3. Set up experiments to test out the initial case formulation. The results of these tests will confirm or disprove hypotheses about factors that cause or maintain the client’s symptoms and problems. For example, a therapist may use a thought record to test out whether a client’s procrastination stems from perfectionistic beliefs, which may reveal that procrastination or difficulty initiating tasks is instead due to thoughts of hopelessness. The case formulation should be revised based on the results.
  4. The case formulation should continue to be tested and revised throughout treatment with the goal of targeting mechanisms involved in the onset and maintenance of the client’s symptoms and problems. With ongoing consent of the client, it should be used as a guide for treatment planning and clinical decision making.

Components of Case Formulation 

A case formulation should provide a coherent summary and explanation of a client’s symptoms and problems. It should include the following components (Persons, 2008):

  1. Problems: Psychological symptoms and features of a disorder, and related problems in various areas of life—social, interpersonal, academic, occupational.
  2. Mechanisms: Psychological factors—cognitive, behavioral—that cause or maintain the client’s problems. Mechanisms are the primary treatment targets.
  3. Origins: Distal factors or processes that lead to the mechanisms and thereby predispose the client to developing certain psychological symptoms and problems.
  4. Precipitants: Proximal factors that trigger or worsen the client’s symptoms and problems. Precipitants can be internal—physiological symptoms that trigger a panic attack—or external—a stressful life event that triggers a depressive episode.

The following is an example of a case formulation, based on recommendations by Persons (2008). It illustrates how a case formulation approach provides a parsimonious description of the cognitive and behavioral mechanisms underlying a client’s myriad of symptoms and problems.

When Rachel was in elementary school, her classmates laughed at her during her class presentations and teased her because of her stutter (ORIGINS).

This led Rachel to develop the core schemas “I am socially awkward,” and “People are overly critical.” (COGNITIVE MECHANISMS).

As an adult, she was preparing for a presentation at work (PRECIPITANT), and thought to herself, “I am going to humiliate myself in front of my colleagues.” (COGNITIVE MECHANISM).

This lead to feelings of anxiety (PROBLEM).

As a result, she called in sick the day of her presentation (BEHAVIORAL MECHANISM) and thought “I am a failure” (COGNITIVE MECHANISM) which lead to feelings of sadness and shame (PROBLEMS).

She stayed in bed all day (PROBLEM) to avoid these feelings (BEHAVIORAL MECHANISM).

See also: Exposure Therapy for Anxiety-Related Disorders

A case formulation is an invaluable tool for highlighting how a client’s problems and symptoms are related. It aids the therapist in accurately identifying and targeting underlying psychological mechanisms with increased efficiency, leading to improved therapeutic outcomes

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Recommended Readings

Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. New York, NY: Guilford Press.

Persons, J. B. (2008). The case formulation approach to cognitive-behavior therapy. New York, NY: Guilford Press.