10.4324 9780203380574-2 Chapterpdf

Chapter 2
Case formulation in cognitive

behavioural therapy
A principle-driven approach
Robert Dudley and Willem Kuyken
A principled approach to CBT case

conceptualisation
Case formulation is described as the ‘lynchpin’ of Cognitive Behavioural
Therapy (CBT) (Butler, 1998). This is because it improves practice by
explaining clients’ presentations in a theoretically informed, coherent and
meaningful way which leads to effective interventions. Essentially formulation
helps marry the unique experience of the client with the skills, theory and
knowledge we bring as therapists to help us understand and alleviate the
client’s presenting issues. Given this, it is understandable why formulation
is seen as one of the key elements of CBT (Beck, 2011). In this chapter
we describe principles that underpin effective CBT case formulation. We
illustrate this process with reference to the cases of Jack and Janet.
CBT has an established evidence base for helping a wide variety of
presenting issues. Consequently, there is now an abundance of treatment
manuals for clinicians to base their therapy on. However, this can leave the
clinician with the daunting challenge of drawing on a vast range of resources
whilst at the same time attending to the very human and important task of
engaging with, understanding and helping the individual client.
A second challenge is that clients rarely present with one single disorder
(Dudley et al., 2010). Co-morbidity is the norm but the evidence base
demonstrating the effectiveness of CBT largely reflects the results of research
on single disorders. In such instances there may not be a treatment manual
that fits the client’s unique presenting features. So whilst CBT prides itself on
its scientific foundations there is considerable art in its application. For these
reasons we advocate a principle-based approach to formulation rather than
recommending a specific template or manual. This ensures that the formulation
is tailored to the client rather than vice versa.
Kuyken, Padesky and Dudley (2008, 2009) use the metaphor of a crucible
to illustrate the process of CBT case conceptualisation. A crucible is a robust
vessel for combining different substances so that they are synthesised into
something new. In the same way, the case conceptualisation process synthesises
Case formulation in cognitive behavioural therapy 19
a person’s presenting issues and experiences with CBT theory and research to
form a new understanding, personal and specific to the client. CBT theory and
research are key ingredients in the crucible.
The crucible metaphor further illustrates three defining principles of case
conceptualisation. First, the process of change is facilitated by heating the
vessel to drive the reactions. In our model, collaborative empiricism produces
the heat that encourages the process of conceptualisation and accelerates the
transformation. In a collaborative approach, the perspectives of therapist and
client are combined to develop a shared understanding that accounts for the
development and maintenance of the presenting issues. Working together
increases the likelihood that the outcome is acceptable and useful to the client,
and informs the selection of helpful interventions.
Second, like the reaction in a crucible, a conceptualisation develops over
time. Typically it begins at more descriptive levels (e.g. describing presenting
issues in cognitive and behavioural terms), moves to include explanatory
models (e.g. a theory-based understanding of how the symptoms are
maintained or perpetuated) and, if necessary, develops further to include a
historical explanation of how pre-disposing and protective factors played a
role in the development of the issues (e.g. the developmental history). In this
way formulations can be built up layer upon layer over the course of therapy.
Third, what is formed in the crucible depends on the properties of the
ingredients placed into it – including the client’s experiences and CBT theory
and research. Historically there has been an emphasis on clients’ problems and
distress, but while these are naturally included in our model it also incorporates
client strengths at every stage. This helps both to alleviate distress and build
client resilience. Their personal and social resources are protective factors
which have prevented problems from escalating; have enabled clients to build
up a repertoire of resources and successes; and suggest an intervention strategy
of ‘least resistance’ that builds on strengths. Protective factors can be described
as ‘all that is right with a person’, including personal resources (e.g. intellectual
ability, physical health, hobbies and interests, financial resources, etc.) and
social resources (e.g. a close and confiding friendship or relationship).
Accordingly, client strengths are an essential part of the crucible’s ingredients.
We illustrate the three key principles of case conceptualisation, which are
levels of conceptualisation, collaborative empiricism and incorporation of
client strengths, with particular reference to the case of Jack. In this way we
demonstrate how the principles help inform the decision as to which cognitive
model to select as the basis of the formulation, how to develop the
understanding with the client and then how to utilise this shared understanding
to help the client optimally. Before we do this, it is important to note that the
authors of this chapter have not spoken to the real Jack (or Janet). Normally
within CBT there would be detailed eliciting of the client’s perspective and
the thoughts, feelings and behaviours associated with the presenting issues.
Moreover, collaboration means that conceptualisations are co-created by client
20 Robert Dudley and Willem Kuyken
and therapist which clearly has not been possible in this instance. However, in
the spirit of the book we will illustrate the process of cognitive formulation
for Jack using the available material.
Jack
Principle 1: levels of conceptualisation

As a starting point it is helpful to understand that a CBT formulation is
developed from the cognitive model. The cognitive model is based on the
deceptively simple idea that how we view ourselves, the world and the future
shapes our emotions and behaviours. People are thought to develop emotional
disorders when they are locked into unhelpful patterns of interpretation and
behaviours (Beck, 2011). These moment-to-moment appraisals or interpretations
of current experience are shaped by more enduring beliefs that we hold about
ourselves, other people and the world around us. From this comes the idea that
if we evaluate and modify unrealistic or unhelpful thinking, we can profoundly
affect our emotional wellbeing. Lasting changes occur when people are able to
modify dysfunctional beliefs and learn healthier and more adaptive beliefs. This
helps prevent relapse and enables people to remain well in the future.
We suggest a framework for CBT formulation that helps link the person’s
experiences to the cognitive model using the five Ps: presenting issues,
precipitating, perpetuating, predisposing, and protective factors. We examine
the Ps in turn, outlining how each relates to therapy (Table 2.1). They are
presented as we might typically expect them to unfold in the course of therapy,
from description to inference.
We begin with the presenting issues, as preliminary conceptualisations are
usually quite descriptive and should be closely mapped onto the experiences
and difficulties that clients report.
Presenting issues
When people come to therapy they are usually looking for help with specific
problems, even if these may not initially be well articulated in their own minds.
They may feel sad, lack energy or be anxious when around people. The assessment
phase seeks to generate a list of presenting issues that is specific, clear and useful
to the client and therapist. For instance, instead of writing the problem as
‘depression’, the person might be asked, ‘In what way does depression show
itself in your day, or your life?’ This may indicate very specific and individual
problems like not getting out of bed. A comprehensive assessment in terms of
cognition, affect and behaviour in the context of relevant psychosocial factors
helps us better understand the needs of the client and address the question of
where to start working when faced with a multitude of presenting problems. A
Table 2.1 The five Ps of CBT formulation
The five Ps Relationship to therapy
Presenting issues. Statement of the This process goes beyond diagnosis in that we
client’s presenting problems in terms begin to define the current problems the
of emotions, thoughts and behaviours. person faces. This introduces specificity and
individualisation. We also define short-,
medium- and long-term goals that can help
identify the likely end point of therapy.
This process helps to develop the therapeutic
relationship, clarifies problems and instils
hope.
Precipitating factors. The proximal Introduces the cognitive model and provides
external and internal factors that initial focus for CBT interventions. If successful
triggered the current presenting issues. builds clients’ confidence in themselves,
therapy and therapist.
Perpetuating factors. The internal Provides a focus for intervention by breaking
and external factors that maintain the the maintenance cycle.
current problems.
Predisposing factors. The distal Provides a longitudinal understanding of the
external and internal factors that problems and a focus for more in-depth
increased the person’s vulnerability to interventions that aim to maintain change and
their current problems. prevent relapse.
Protective factors. The person’s Provides a path of least resistance by
resiliency and strengths that help suggesting interventions that build on existing
maintain emotional health. resiliency and strengths. Also provides
pathways to long-term recovery.
clear description of the issues helps establish the goals of treatment. Agreement
of goals is a key process in the development of an effective therapeutic alliance,
which is a robust predictor of outcome (Martin et al., 2000).
Despite the initial focus on current problems and goals, CBT is also interested
in the developmental origins of the difficulties. Hence, an initial assessment
would normally include relevant background and context to the presenting
issues (onset of the problems, family, educational, occupational and psychiatric
history, personal and social resources and so on), which in the later stages of
formulation enable a more in-depth understanding. While the assessment
process is not strictly formulation, it is essential groundwork for a CBT
formulation.
Jack is described as experiencing a number of problems including periods
of mania and low mood, anger and anxiety that seems to result from persistent
delusional beliefs with both persecutory and grandiose themes. He has had
problems with substance misuse and had a period of inpatient admission.
We would ask Jack for concrete and specific examples of how his presenting
problems affect him. He may identify his difficulties as feeling low, lacking in
motivation, feeling afraid when out or having no money. From this initial
description, goals of treatment are articulated (Greenberger and Padesky,

1995). Jack and his therapist may agree to focus on trying to feel better in
mood, to have more money and to be able to go out without fear of being
beaten up. If he were more able to go out, we would ask how he would like to
spend his time and with whom (which may reveal something about his
strengths and his values; see principle three).
Having constructed a list of presenting issues and goals the therapist would
work collaboratively with Jack to identify the area that caused greatest distress
or had greatest impact on his life. Thus, low mood or his fear of being attacked
may become the initial focus of therapy. Generating a presenting issues list
that is collaboratively reviewed and prioritised is an important initial task of
treatment.
The next level of CBT formulation involves articulating the external and
internal factors that tend to trigger the presenting issues. On closer questioning
it is usually the case that people experience some variation in their presenting
problems according to time and place. As already described, the cognitive
model emphasises that it is not the events themselves, but a person’s view of
the events, that explains their reaction. When people are asked what has led
to them being anxious or sad they often describe events: ‘I am unhappy because
I am divorced/bankrupt/out of a job’. It goes without saying that these
situations can be distressing to us all. However, it is also obvious we do not all
respond to stressful events in the same way. To begin the process of socialisation
to the cognitive model we might draw upon a simple four factor version that
differentiates situation, thoughts, feelings and behaviour. This helps separate
out the original event from the interpretation and consequences. The person
may say ‘I am sad because I spilled my coffee’. The simplified model helps
illustrate the importance of thoughts (or Negative Automatic Thoughts as
they are referred to) and images (Hackmann et al., 2011) in determining
distress by explicitly introducing the notion of an appraisal between the
situation and the emotion (see Figure 2.1).
Such specific and personalised examples help illustrate the fact that there
may be different ways of seeing any situation and that thoughts and images
are not necessarily facts or truths, but points of view. Using the collaborative
but questioning style of CBT we can ask whether everyone would feel sad on
spilling coffee, would others react differently, would the person him or herself
have thought and reacted differently before they became depressed.
Jack seems to meet the diagnostic criteria for a psychotic illness characterised
by persecutory beliefs. Whilst disorder-specific approaches exist for such
difficulties (Freeman, 2007), the common starting point is to map the
presenting issues, and develop an initial understanding that is not limited by
a specific model. The key point is that the model is not pre-selected and the
client is not fitted to the model.
In Jack’s case (Figure 2.2), a simple descriptive model may help to reveal
that his low mood, anger and anxiety are intimately tied to his persecutory
Situation
Spill coffee
Thoughts
I cannot do
anything right, I
am useless
Emotions Behaviours
Sad Go to bed
Figure 2.1 Illustration of an initial cognitive model
concerns. We may initially build up a series of such descriptive formulations

using recent examples from Jack’s life. In this way we can identify common
triggering factors, common appraisals and common reactions that help us
understand his experience. These could be summarised as in the last example
in Figure 2.2.
Perpetuating factors
Although the descriptive model is a useful heuristic device it does not really
explain what maintains the issues in the long term. Hence, we draw on an
expanded model that articulates the relationship between the elements, and
helps to show the reinforcing nature of the problems. This model often
includes more explicit information about the physiological responses to
a situation (Greenberger and Padesky, 1995). This cross-sectional or
maintenance model emphasises the perpetuating features that add inferential
hypotheses about how the problem is maintained by cognitive and behavioural
factors (see Figure 2.3). This is the classic maintenance or vicious cycle of
Cognitive Therapy.
In such a model, the direction of the arrows is important and the initial
phase of therapy must provide a defensible rationale for the links between
components. For instance, we need to consider the way that behaviour in a
given model might maintain an appraisal.
Within the CBT research literature there is an increasing emphasis on
understanding the specific and key features unique to each different disorder
(see Wells, 1996). However, there are several core cognitive and behavioural
mechanisms that are common to a range of different types of psychopathology
(Harvey et al., 2004). These include various forms of emotional and behavioural
Example 1 Situation
Listening to
music
Thoughts
Robbie stole
my music, it is
unfair, I have
Emotions let my family Behaviours
down
Angry Dwell
Sad Ruminate
Example 2
Situation
Go outside, see
Robbie
Williams
merchandise
Thoughts
His men are out

Emotion to get me Behaviour
Fearful Vigilant
Avoid going out
Example 3
Situation
Music/Robbie
Williams
merchandise
Thoughts
I am at risk
I have been
treated badly
Emotions I have failed Behaviour
Fearful Vigilant
Angry Ruminate
Sad Avoid going out
Figure 2.2 Jack’s presenting problems mapped onto a simple descriptive formulation
Situation
Spill coffee
on shirt
Thoughts
I cannot do
anything right, I
am useless
Feelings Behaviour
Go to bed,
Sad avoid work
Physiology
Tearful
Figure 2.3 Perpetuating factors
avoidance, attentional processes such as vigilance for threat, and cognitive

processes like rumination and worry (Dudley et al., 2010).
An important perpetuating mechanism in many CBT formulations is
avoidance, which prevents the person finding out whether a feared
consequence will occur. In the case above (Figure 2.3), by avoiding going to
work the person may actually confirm a view of him or herself as useless.
Avoiding situations can also lead to a loss of rewarding and pleasurable
behaviours, and thus help to maintain problems like depression. However,
problems may continue even without avoidance. It seems that when people
do go into difficult situations, they may engage in subtle behaviours that
serve to keep them safe, or ‘safety-seeking behaviours’ (Salkovskis et al.,
1996). For instance, Jack may be worried about being noticed and attacked
when he leaves home, and so he may keep his sweatshirt hood up to stop
people recognising him. These behaviours, intended to help, prevent
disconfirmation of the belief, and maintain it. Paradoxically, they can even
make things worse; for instance, by masking his face Jack may be more
scrutinised by shop staff or security guards when he goes out, thereby
increasing his belief that he is being watched.
A cognitive behavioural model of maintenance provides a rationale for a

number of interventions, since change in any of the maintenance elements
will create change in the others. Clients will be encouraged to identify,
evaluate and challenge their thoughts, which in turn means that they are
likely to appraise situations differently and thus feel and behave differently.
Behavioural methods may help overcome avoidance and prompt change in
feeling and thoughts. The main behavioural approaches involve increasing
positively reinforcing behaviours (e.g. behaviours that are pleasurable and
generate a sense of mastery in people diagnosed with depression) and
extinguishing or replacing negative behaviours (e.g. ‘safety behaviours’).
Maintenance formulations or cross-sectional formulations capture the
reinforcing and spiralling nature of Jack’s current difficulties (Figure 2.4) in
which avoidance and vigilance seem to be important factors.
Situation
Listening to music
Thoughts
Robbie’s friends
are going to beat
me up, it is unfair,
I am a failure
Feelings Behaviour
Fear, anxiety, Avoid going out,

anger, low mood stay at home and
dwell or ruminate.
Be vigilant for
Robbie
merchandise,
records, fans etc.
Physiology
Heart races,
sweaty
Figure 2.4 Jack’s perpetuating factors

Jack also reports using rumination and this would be incorporated into the
developing conceptualisation as well. This provides a strong rationale for
targeting these processes with specific interventions for overcoming avoidance,
and rumination (Watkins et al., 2007).
Precipitating factors
Although cross-sectional or maintenance models help us understand what
may be perpetuating a problem we may still be unclear what led to the onset
of the difficulties. To understand this we introduce the notion of a longitudinal
or historical formulation that identifies a precipitant or trigger to the onset of
the difficulties, which commonly turns out to be a particularly stressful event
or time.
Quantity of stressors
Stress-vulnerability models help us to understand the onset of difficulties (e.g.
Neuchterlain and Dawson, 1984) by emphasising that we are all susceptible
to stressors in our lives and our vulnerability specifies the point at which we
can no longer function or cope. Although this broad model specifies the
likelihood that a breakdown will occur, it is less specific on what may lead one
person to develop depression and another anxiety. Here, we need to consider
the meaning of the events to the person and whether there were specific risks
for that person that made those events particularly stressful; in other words,
the quality rather than the quantity of events, their particular and unique
meaning to the person, and whether they carried a specific vulnerability or
predisposition.
Quality of stressors
To account for potential predisposition or vulnerabilities we draw upon a
longitudinal model (see Figure 2.5). In this (Beck 2011; Persons 2008),
precipitating factors trigger access to a deeply seated view of oneself (core
beliefs or schema, or internal predisposing factors) that was learned through
formative developmental experiences (external predisposing factors). For
instance, a person may see him or herself as fundamentally unlovable (core
belief) owing to early experiences of neglect. This basic belief is highly
emotionally charged and deeply ingrained. Before the triggering event
occurred, the person has managed or coped by employing a rule or assumption
of some sort that has prevented accessing this affect-laden view of oneself (e.g.
‘If I am in a relationship then I am OK’). Rules, assumptions or conditional
beliefs are often phrased in this style of ‘if ... then’; or sometimes as imperatives
such as ‘I must’, ‘I should’; or as ‘I ought’; for example, ‘I must always be in a
relationship’. The rules, assumptions and conditional beliefs in turn are
directly linked to a repertoire of compensatory strategies that keep the person

living within their belief system (e.g. working hard to maintain relationships
and avoid perceived abandonment, perhaps by being unfailingly attentive and
loyal to their partner). Here we can see that the developmental experiences,
core beliefs, conditional assumptions and compensatory strategies are related
to each other in understandable ways. At the end of the relationship the rule
is broken and accesses the very affect-laden core belief. This event acts as the
trigger or precipitant for the presentation. Once started, the presentation is
perpetuated through the patterns of relationships outlined in the maintenance
models.
a. Developmental Experiences:
Abandoned by biological parents
Raised by a series of foster parents,
and care institutions
Core Beliefs:
I am unlovable
Predisposing Factors
Rules and Assumptions
or Conditional Beliefs:
If I am in a relationship, then I am ok.
Compensatory Strategies:
Work hard to avoid relationship
ending.
Triggering events Precipitating Factors
End of the relationship

b. Maintenance Cycles
Perpetuating factors
Spill coffee
on shirt
I am
useless
Sad Go to bed
Tearful
c. Problems Presenting issues

Difficulty concentrating,
Problems attending work
Feeling lonely
Not ringing people to arrange to go out
Not answering the phone
Avoiding people in case I cry
Not being able to sleep
Feeling sad and low
Resilience and strengths Protective factors

Supportive adoptive mother and sister
Good friend
Good job, well paid
Interest in sports, and plays badminton every week
Good sense of humour
Figure 2.5 An illustration of a longitudinal formulation

In the middle and later stages of CBT, conceptualisations increasingly draw

on theory and inference to explain how predisposing and protective factors
contribute to clients’ presenting issues. Each disorder-specific model indicates
the key processes, beliefs and assumptions that are thought to help account for
the particular disorder.
Predisposing factors: quantity of events

When working with people with psychosis a very common process is to
generate an understanding of the events leading to the emergence of the first
psychotic symptoms, using a stress-vulnerability model (Brabban and
Turkington, 2002). The particular stressors for Jack appeared to consist of a
series of difficult life events, perhaps precipitated by sexual abuse. Trauma
experiences are increasingly being recognised as important in the onset and
maintenance of psychosis (Callcott et al., 2010; Dudley et al., 2010). For Jack,
the trauma seemed to have led to drinking and drug taking, and resulted in
him failing his GCSEs. These experiences, combined with moving house to a
less affluent area where the family was burgled, his father leaving following
the parental separation, and loss of contact with his friends, left Jack
increasingly isolated. This is very much a quantity model, in that we can see
Jack was under considerable stress in the time preceding the development of
his depression and eventual psychotic breakdown. Understanding the
precipitants would allow the provision of information about the role of sleep
deprivation, trauma, drug use and so on in the onset of persecutory beliefs.
This could help normalise the onset of psychosis (Dudley and Turkington,
2010) and help Jack to identify triggers and risk factors. Thus, a longitudinal
formulation may help us understand Jack’s particular vulnerabilities and what
it was about the triggering events that was so very upsetting for him.
Predisposing factors: quality of events

Jack’s history indicates that he was subject to physical and presumably verbal
abuse when his father was drunk. He may have seen himself as to blame for his
father’s anger, and may have believed that he was a disappointment in his
father’s eyes: ‘not good enough’. He may also have internalised the notion that
men cope with their distress by drinking alcohol. Hence, we have a hypothetical
and provisional core belief, as well as some possible rules. Jack’s early
experiences may also have led him to internalise a view of himself as having to
provide for and protect his sisters and mother. This is the role his father
undertook, and possibly a view shared by the community he comes from. This
would probably give Jack a view of success as consisting of working hard,
being financially successful and fulfilling the roles expected of a man. As a
result Jack may once again see himself as weak or as not good enough. Also,
given his experiences of abuse he may well view others as untrustworthy, cruel
and unkind. Negative beliefs about others are characteristic of people with
paranoia in the context of psychosis (Freeman, 2007). His compensatory
strategies are to cope with difficult emotions with drugs, and to work hard to
achieve success and financial security. However, alcohol abuse eventually led
to losing his job. This increased the pressure on him to succeed, and hence
increased the pressure to cope by drinking.
Trauma such as sexual abuse can manifest itself as a post-traumatic stress
disorder (PTSD), or as a damaged view of self (Callcott et al., 2010). In the
absence of overt PTSD symptomatology we would consider the possible
meaning of these events for Jack: perhaps he concluded that he is in some way
a bad person; or that he should not have let this happen; or he may have
questioned his own sexuality. Given the role of masculinity in Jack’s
community, an experience like this would probably be difficult to discuss,
thus denying him the opportunity to consider alternative perspectives on
abuse. All of these hypotheses would be examined by questioning Jack gently
about what he understood to have happened to him, what this says about him
as a person and what it means about other people.
These experiences and beliefs help us understand the importance of the
triggering events: Jack’s parents’ relationship deteriorating and his father
leaving and losing contact. Faced with this pressure, Jack began to drink as
presumably this was his model of how men coped with stress. He failed his
GCSEs, the family moved, and his mother had to go to work, further reminding
Jack that he was not providing for the family. It is likely that he was depressed
from around this time. His mother’s ill health presumably increased the
pressure on Jack even more, and he began to develop psychotic and persecutory
beliefs. People with paranoia have a tendency to blame others for negative
events (Freeman, 2007) and consequently when Jack was trying to make sense
of his lack of success he may have been drawn to an explanation that blamed
another person rather than himself or the situation.
Jack’s lifestyle of sleeping rough and using drink and drugs will have
dysregulated his basic self-care (e.g. sleep, diet), increasing the chance of
abnormal ideation and experiences such as seeing his father’s face in the mirror
(Collerton et al., 2012).
At this level of conceptualisation, a number of interventions may help to
interrupt the maintenance processes and also encourage Jack to consider the
usefulness of his strategies and the helpfulness of his beliefs about himself and
other people (Beck, 2011). Owing to the speculative nature of this formulation
(see Figure 2.6) there is no way in which we can determine its accuracy.
However, in the clinical setting we would use the principle of collaborative
empiricism to help us establish its accuracy and utility.
The therapist and client would work together to co-create the formulation
using the questioning style of cognitive therapy (see Kuyken et al., 2009:
193–195 for illustrations of this process). Hence we now consider the second
principle of collaborative empiricism.
Early Experiences:
Father physically and verbally abusive when drunk
Only son in a family in which the expectations are men will provide for the family
Successful father works hard and provides a high standard of living
Core Beliefs:
I am not good enough/I am a failure/weak
Others are cruel and rejecting
Rules and Assumptions or Conditional Beliefs:

If I work hard and provide for others then I am ok and not a failure
If I show my emotions others will be cruel and reject me
Compensatory Strategies:
Work hard to achieve and provide for others through work
Do not show emotions, mask them with drink or drugs
Triggering events:
Sexual abuse, end of the parental relationship, social changes, change in house and lifestyle
Situation
Listening to music
Thoughts Thoughts
Robbie’s friends are going to Robbie stole my songs, and
beat me up, I am not a man raped my sister, I am useless,
Feelings Behaviour Feelings Behaviour

Fear Avoid going out, Sadness Withdraw,
Anxiety Vigilant for Robbie Depression Avoid family
Sad records, drink, drugs,
drink, drugs ruminate
Physiology Physiology
Heart races Tearful
Sweaty
Protective factors:
Music, school, previous community, mother and sisters
Figure 2.6 Jack’s longitudinal formulation

Principle 2: collaborative empiricism

Collaboration refers to both therapist and client bringing their respective
knowledge and expertise together in the joint task of describing, explaining
and helping ameliorate the client’s presenting issues. The therapist brings his/
her relevant knowledge and skills of CBT theory, research and practice. The
client brings his/her in-depth knowledge of the presenting issues, relevant
background and the factors that he or she feels contribute to vulnerability and
resilience.
Empiricism within therapy is evident in two main ways. First, the therapist
draws on the research on CBT to determine its appropriateness for the
particular presenting issue. Cognitive therapy was first developed to help
people with mood disorders (Clark and Beck, 1999), but has been increasingly
applied to a range of presenting problems and disorders. The breadth of
application results from a commitment to empiricism, and the careful
observation of specific diagnostically based disorders. This has helped to
elucidate the cognitive and behavioural processes that characterise and
maintain each presentation. These unique differences are empirically tested
between people with the disorder and those without and are targeted with
specific interventions (Wells, 1996) which are in turn evaluated using
manualised treatments in Randomised Controlled Trials (RCTs). CBT has
thus established an evidence base for a range of psychological and emotional
difficulties (Butler et al., 2006; Wykes et al., 2008). CBT therapists use
conceptualisation to adapt these manualised disorder-specific models and
treatments and incorporate client-specific information and direct treatment
with real world impact, equivalent to that seen in RCTs (Kuyken, 2006;
Persons, 2008).
Given the substantial evidence base for many disorder-specific CBT
approaches, a relatively straightforward mapping of client experience and
theory may be possible with many clients. Nonetheless, it is always important
to derive the case conceptualisation collaboratively so the client understands
the applicability of the model to his or her issue. When clients experience
multiple or more complex presenting issues it is often helpful to attend to
trans-diagnostic processes like rumination, vigilance and avoidance (see
Figures 2.1 and 2.2).
Another aspect of empiricism in therapy is the emphasis on observation and
evaluation of experience. Therapists and clients develop hypotheses, devise
adequate tests for these hypotheses and then adapt the hypotheses based on
feedback from therapy interventions. This makes CBT an active and dynamic
process, in which the conceptualisation guides and is corrected by feedback.
Since clients often do not have experience of CBT, in the early stages it can
help to offer a rationale for collaborative working and to follow this up with
actual experience of working together on a task. For instance the therapist
may say to Jack: ‘I find it best if we can work together to try and understand
and help your problems. It helps if we combine our efforts, so I need you to
tell me what is important for you to cover, and I will have some ideas about
what I think we should cover in our sessions together. How does that sound?’
This would then be followed up by asking Jack what particular questions or
issues he would like to work on in the session. This openness about collaboration
would also be extended to the process of developing a formulation. The
therapist may say: ‘You know a lot about your situation and what has helped
or not helped in the past, and I know what has helped other people. Perhaps
if we can put this together we will find that we can share some ideas that may
help you. How does that sound?’
Similarly, the therapist may introduce an element of a model, such as the
potential maintaining role of vigilance, rumination or use of safety-seeking
behaviours and then encourage Jack to gather evidence of whether this plays
a contributory role in his case. The therapist may ask Jack to record over the
coming week how often he finds himself dwelling on the idea that his music
has been stolen and to note what effect it has on his mood. By jointly reviewing
the outcome of this task using Socratic questioning, the therapist could
establish whether vigilance has a legitimate role in the emerging
conceptualisation of his concerns. Disorder-specific models of paranoia
(Freeman, 2007) emphasise that people with delusions may have a tendency
to ‘jump to conclusions’, blame others for negative events, or find it difficult
to generate or consider alternative explanations for their experiences. These
processes may be introduced and tested with Jack as well. This curiosity acts
as a check and balance on the development of the formulation and to ensure
its accuracy and usefulness.
Principle 3: include client strengths and conceptualise

resilience
As discussed, we argue that a strengths-focused approach at every stage of
conceptualisation helps to alleviate client distress and builds a person’s
resilience (Kuyken et al., 2008). For example, goals may include not just
reducing distress (e.g. for Jack, to feel less anxious being around people) but
increasing strengths or positive values (e.g. to be more able to enjoy time with
my mother and sisters) as well. Accordingly, clinicians can routinely ask in
early therapy sessions about positive goals and aspirations and add these to the
client’s presenting issues and goals list.
Specific discussion of positive areas of a person’s life may reveal alternative
coping strategies to those used in problem areas. These presumably more
adaptive coping strategies can be identified as part of the same process that
identifies triggers and maintenance factors for problems.
Owing to Jack’s low mood it is possible that he easily overlooks or
undervalues his strengths, but in the early stages of assessment and treatment
the therapist can purposefully ask about those areas of his life which he
manages more effectively, and even enjoys, and how he copes with his low
mood and persecutory ideas. For example, Jack may notice that he becomes
less upset when he spends time with his family. His love of music could be
utilised to help interrupt maintenance processes and to help increase positively
valued activities and interests (Beck, 2011) and to disrupt the maintenance
cycle as illustrated in Figure 2.7.
It is also important to enquire about cultural values or identity that can
serve as potential sources of strength (Padesky and Mooney, 2012). People’s
values may derive from their faith, sexual orientation, or other cultural, leisure
or sporting activities, and can help us to understand some of the vulnerability
for the onset of the difficulties (in Jack’s case that men are valued for their
ability to provide for others, and that men do not show emotions) as well as
indicating resources for change. Throughout therapy, client values,
longer-term goals and positive qualities can serve as a foundation to build
toward long-term recovery and full participation in life.
Jack’s ruminations may be a key maintaining factor of his low mood and
persecutory ideation. However, the content of these thoughts reveals much
about the areas he invests in, and about his strengths and values. These beliefs
about what is most important in life are typically relatively enduring across
situations and shape a person’s choices and behaviours. Incorporating values
into conceptualisations enables us to better understand clients’ reactions
across different situations. People may worry about work, family, attractiveness
Situation
Listening to
music
Thoughts
Robbie stole
my music, it is
unfair
Emotions Behaviours
A little sad Spend time

with my sisters,
ask them about
how they are
Figure 2.7 Use of cognitive framework to identify use of strengths to overcome

difficulties
or health according to how these are valued. Jack is worried about not
providing for and not protecting his sisters as it represents an important
domain in which he is heavily invested, in part owing to the abandonment of
the family by his father.
Discussion of the events leading to the person seeking help often reveals a
person trying to achieve important and valued goals by utilising previously
helpful strategies to an excessive degree and/or in the context of too many
additional demands (Neuchterlain and Dawson, 1984). Clearly, one goal of
successful treatment is to find more adaptive ways to engage constructively
with these valued domains. For Jack, this was defined as his ability to take
care of his family, but without the crippling paranoia and sadness that this
was causing. A second important goal for Jack was to remain well even if faced
with further potentially excessive demands. In short, the goal was to help Jack
be more resilient.
Resilience is a broad concept referring to how people negotiate adversity. It
describes the processes of psychological adaptation through which people
draw on their strengths to respond to challenges and thereby maintain their
well-being (Padesky and Mooney, 2012). It has multiple dimensions, and
people do not need strengths in all areas to be resilient. Masten (2007) draws
an important distinction between strengths and resilience. Strengths refer to
attributes such as good problem-solving abilities or protective circumstances
such as a supportive partner. Resilience refers to the processes whereby these
strengths enable adaptation during times of challenge. Thus, once therapists
help clients to identify strengths, they can be incorporated into conceptual-
isations to help understand client resilience.
Among Jack’s strengths are his ability to form and make good use of a
number of family relationships in the past, notably with his sisters; and his
positive engagement with mental health services, which bodes well for
considering integrated interventions. In Jack’s case we might try and
encourage him to revisit some of his previous strengths such as playing music,
rebuilding his relationship with his sisters, and other activities that indicate
he is a good person. Such approaches have been shown to both increase self
esteem and reduce psychotic symptoms (Hall and Tarrier, 2003).
Clearly, the acid test of a formulation is whether it leads to helpful
interventions. Chadwick and colleagues (2003) have demonstrated that people
with psychosis do not necessarily report that formulations increase therapeutic
alliance or alleviate distress in themselves. This is not surprising as CBT is not
just an insight-oriented therapy. We consider increased understanding as
valuable if it leads to a change in cognitions and a change in behaviour. The
formulation can be helpful in providing an alternative explanation that can be
tested to see if it accounts for the experiences. In addition, the formulation
should direct us to appropriate interventions. Discussion of all of the
appropriate interventions is well beyond the scope of this chapter, but readers
are directed to the work of Morrison et al. (2004).
Janet
Formulation of Janet’s presenting issues from a cognitive perspective would
also draw on the principles represented in the crucible. A crucial first step
would be to undertake a comprehensive assessment. The groin injuries, refusal
to visit her father overnight and the night terrors could all be regarded as
signs of serious assaults and/or abuse of Janet. However, without more detail,
and in the absence of converging sources of information it would be out of
keeping with the CBT formulation to speculate on such events and their
impact on Janet. There are many people involved in this case and we would
draw on all these sources (school nurse, school reports, CAMHS reports, Social
Services, paediatricians, health visitors, etc.) in our assessment as well as on
Janet’s and her mother’s views. Such an assessment would help determine if
there is evidence of historic abuse, provide information about current risk and
ensure proper safeguards are in place. During this process we would spend
time with Janet, building a therapeutic relationship and ensuring she feels
safe and comfortable with the therapist.
Levels of conceptualisation
Following assessment we would begin in the same way as with Jack and define
a presenting issues list. This would help to identify the issues to work on. For
Janet we may identify travelling on public transport, having nightmares,
feeling angry, and problems with eating and low weight. Then the therapist
would enquire about each of these areas and tentatively describe them within
a cognitive behavioural framework and crucially begin to get a sense of Janet’s
point of view. This may be achieved with questions such as ‘What do you
think, Janet, when your mum puts food on the table?’ or ‘What do you think
to yourself when you are most upset at bedtime?’ Such questions and the use
of techniques like family trees, or genograms, may be used to help determine
Janet’s view of the problems as well as her family relationships and hence
provide the beginnings of a window into her world.
Outlining the issues within a simple descriptive cognitive behavioural
framework is a helpful starting point. By gathering examples over time and
across situations we can identify themes or commonalities that may help
understand the issues better and also direct us to potential treatment options.
If we do not understand her issues we may choose inappropriate interventions.
For example, we may conclude that Janet is avoiding transport owing to being
bullied because of her Romany heritage. It is a hypothesis but one that needs
to be tested against the evidence. In discussion, it may emerge that Janet will
not travel by transport as her mother is dependent on it and that this reflects
her anger towards her mother. Equally, if Janet states that she refuses food
prepared by her mother for the same reason, then we may have identified
anger as a common theme that fits with the evidence (frequent temper
outbursts and setting the dog on her mother). Understanding the precipitating
and perpetuating factors may then direct us towards an intervention addressing
anger.
It is a pertinent to ask whether longitudinal conceptualisations can be
developed for very young children. Beck’s cognitive model of emotional
disorders is increasingly being applied to this age group. However, our
understanding of how to adapt the model for a 5-, 8- or 15-year-old is still
limited. Where we are able to set goals using descriptive and maintenance
formulations we may not need to develop a longitudinal formulation. Of
course, if we were to do so, we would draw on the principle of collaborative
empiricism as with adult clients.
Collaborative empiricism
Through the process of collaboration we would agree with Janet what areas to
work on and then begin to develop an understanding of the maintenance of
the presenting issues using five factor models. This will also help us to assess
how able Janet is to describe and label thoughts and emotions – clearly an
important process when considering whether CBT is a good match to the
issues she faces (Braswell and Kendall, 2001).
Careful consideration will need to be given to whether there is an evidence
base for the use of CBT with a child of this age. We do not know if Janet
meets diagnostic criteria for a particular disorder. However, a number of
reviews have indicated that CBT is an effective treatment for problems such
as depression and anxiety disorders (Cartwright-Hatton et al., 2004). There is
a general assumption that children from around eight years of age may benefit
from CBT but this is largely untested. It may need to be adapted so that it is
acceptable, understandable and helpful to young children (Cresswell and
O’Connor, 2011).
With a very young child, there is evidence that involving the family in the
form of family-based CBT may well be helpful for anxiety disorders such as
obsessive compulsive disorder (Freeman et al., 2008), although whether
family-based CBT is as effective clinically as individual work or is cost effective
for older children is disputed (Bodden et al., 2008). So, if Janet’s assessment
indicated she experienced anxiety or depression problems there would be a
rationale for offering CBT.
Strengths and resilience

Given Janet’s age and developmental stage it would be important to avoid
pathologising her feelings or behaviour. Even if individual work was offered,
throughout treatment there would be an emphasis on recognising and
harnessing her strengths. Careful enquiry about areas of her life in which she
feels she is doing well (perhaps at school, with friendships, or in an ability
such as a sport) would enable such factors to be woven into intervention

strategies. Humour and play would be particularly helpful in working with
Janet and her family. Her Aunty Cindy seems to be a particular source of
support and it may be that her close interest in Janet can be utilised, possibly
to help with the eating concerns as Janet seems to eat food prepared by others,
and possibly in helping establish a consistent sleeping pattern.
Of course another potential strength in Janet’s life may be her mother. It
may be possible to use a formulation of Janet’s presenting issues but not
directly work with Janet. As with carers of people with dementia, difficult
behaviours (such as the refusal to use transport, or food refusal) can be
conceptualised within a CBT framework and suggested to the carers as a
different, alternative explanation to the potentially unhelpful explanation
the carer has come up with (DCP, 2011: 19). For example, Mary may see
Janet’s food refusal as a sign that Janet hates her because of a failure in
bonding. This attribution will probably make Mary feel very sad. However,
the formulation may come up with an alternative explanation that does not
attribute blame to Mary, and thus increases the chance of her trying to help
Janet. Similar methods can be used when working with families of people
with psychotic illness (Barrowclough and Tarrier, 1992) and may be an
option for Jack’s family.
This issue of working indirectly with resources in Janet’s life raises an
obvious question of who is the client and what is the most effective route to
creating change? It is clear that Mary herself has experienced and continues to
experience very difficult circumstances. A cognitive approach may be useful in
helping understand Mary’s reported depression. A perpetuating model of
Mary’s postnatal difficulties might start with Mary looking at Janet and
thinking, ‘I don’t feel close to my baby’. This may lead Mary to think that she
is a bad mother as she did not feel this way with her other children, and she
may then feel guilty and depressed. This in turn may lead her to withdraw
from Janet, hence reinforcing the sense of being distant and not caring. The
loss of energy and tiredness associated with depression make it even harder to
motivate herself to care for Janet, and means that it is likely that other people
such as her husband will assume responsibility for Janet, hence increasing
Mary’s guilt. Mary now involves herself heavily in the care of her grandchildren,
perhaps as compensation, but this may serve to remind her that she did not do
the same with Janet, and hence perpetuate her guilt even some years on. A
provisional formulation (Figure 2.8) such as this could form the basis of an
intervention designed to improve Mary’s functioning, and hence indirectly
lead to improvements in Janet’s perceived problems as Mary becomes better
able to manage these difficulties.
In summary, there are four potential ways that work with Janet could be
informed by a CBT formulation. First, there is direct work with Janet. It is
difficult to develop a CBT formulation for Janet owing to the lack of detailed
information about her perspective and developmental ability. However, we
Situation
Notice Janet
watching TV
Thoughts
I do not feel
close to her, I
am a bad
mother
Feelings Behaviour
Sad Withdraws from

Guilty Janet, others
look after Janet
Physiology
Tearful,
Low energy
Poor sleep
Figure 2.8 Mary’s perpetuating factors
have indicated some potential routes to this information. Second, the

formulation could be used as part of family-based CBT in which Mary and
possibly Cindy are key contributors. Third, the formulation may be used
indirectly with Mary to help her better understand and consider how to help
Janet. Fourth, it may be that Mary needs help with her own mood difficulties
for which CBT may be useful.
Reflections
We have made some suggestions for CBT formulations based on the available
information about Jack and to a lesser extent Janet. It is important to
re-emphasise that what would make this a CBT formulation are the principles
set out earlier, which can be used with a range of presenting problems and
clients of different ages and socio-cultural backgrounds. We have elected to
draw on a generic CBT model to describe and explain Jack’s presentation. Other
models, for example of PTSD, trauma and psychosis (Callcott et al., 2010) or
mania (Basco and Rush, 1996) could have been credible alternative frameworks.
The only way of establishing the value of a formulation is to develop it in the
spirit of collaborative empiricism, changing it as new understandings emerge
from the assessment and therapy. Done well, this leads to strengthening of the
therapeutic relationship and better-targeted interventions.
Formulation also has an important role in supervision and self-reflective
practice. A key question for a practitioner is: ‘If I thought the same as the
client in those situations, would I be likely to feel and act in the same way?’ If
the answer is yes, then there is a good chance that the formulation has captured
the distress experienced by the client and has provided the therapist with a
glimpse of the world as if seen through the client’s eyes. Where the answer to
the question is no, then a frequent focus of supervision will be in the
development of the formulation and identification of strategies to elicit this
information collaboratively, perhaps by the development of behavioural
experiments that will help identify the missing pieces of the jigsaw.
Gillian Butler (1998) outlines ten tests for a formulation (see p. 264),
including whether it demonstrates logical coherence across the levels and
whether it accounts for the onset and maintenance of the difficulties. Clinicians
and supervisors may find it helpful to consider the formulation against these
criteria.
Conclusions
In this introductory chapter we have indicated that CBT, like other
psychotherapeutic approaches, places a strong emphasis on formulation. We
liken CBT formulation to a crucible where the individual particularities of a
given case, relevant theory and research synthesise into an understanding of
the person’s presenting issues in CBT terms that informs the intervention. As
such, formulation is considered to be central to the process of undertaking
effective CBT, mirroring its intrinsic orientation to evidence-based practice.
We have argued that what makes CBT formulation distinct is its use of CBT
theory, its emphasis on collaborative empiricism, its emphasis on the current
problems and goals and its evolving status as new understandings come to
light throughout therapy. We have suggested a framework for CBT
formulation that moves from descriptive frameworks in CBT terms, to simple
inferential models (ie five factor models), to more complex explanatory models
starting from what maintains the presentation and leading onto what may
have made the person vulnerable. These principles and frameworks are
illustrated through case examples.
Key characteristics of CBT formulation

• Based on the cognitive model.
• Utilises core concepts of schemas/beliefs, conditional assumptions and
rules, and maintenance cycles to explain onset and maintenance of
emotional difficulties.
• Formulation developed in levels from presenting issues to more
predisposing factors.
• Client and therapist work as a partnership or team to co-create a
formulation.
• Strong emphasis on evidence-base for the effectiveness of the intervention.
• Strong emphasis on empiricism in session so that appraisals are treated as
ideas to be tested and alternatives considered.
• CBT is closely associated with diagnostic frameworks in that RCTs are
usually based on diagnostic categories. CBT formulation is complementary
to psychiatric diagnosis. Diagnosis may be a reason to consider a hypothesis
or intervention strategy, but the diagnosis will probably only have
marginal bearing on the process of formulation.
Acknowledgements
Many people have contributed to the shaping of the ideas in this chapter. We
are indebted to the valuable contributions of many colleagues including Aaron
Beck, Peter Bieling, Paul Chadwick, Mark Freeston, Kathleen Mooney and
particularly Christine Padesky. RD would also like to express his thanks to
Stephen Westgarth who provided valuable thoughts on the case of Janet.
However, the ideas expressed remain the responsibility of the authors.
References
Barrowclough, C. and Tarrier, N. (1992) Families of Schizophrenic Patients: Cognitive
Behavioural Intervention. London: Chapman and Hall.
Basco, A.G. and Rush, A.J. (1996) Cognitive Behavioural Therapy For Bipolar Disorder.
London: Guilford Press.
Beck, J.S. (2011) Cognitive Therapy: Basics and Beyond. London: Guilford Press.
Bodden, D.H., Bögels, S.M., Nauta, M.H., De Haan, E., Ringrose, J., Appelboom,
C., et al. (2008) Child versus family cognitive-behavioral therapy in clinically
anxious youth: an efficacy and partial effectiveness study. Journal of the American
Academy of Child & Adolescent Psychiatry, 47(12), 1384–1394.
Brabban, A. and Turkington, D. (2002) The search for meaning: detecting congruence
between life events, underlying schema and psychotic symptoms. In Morrison,
P.M. (ed.) A Casebook of Cognitive Therapy for Psychosis. East Sussex: Brunner-
Routledge, pp. 59–77.
Braswell, L. and Kendall, P.C. (2001) Cognitive behavioral therapy with youth. In
K. Dobson (ed.) Handbook of Cognitive Behavioral Therapies. New York: Guilford
Press, pp. 246–294.
Butler, G. (1998) Clinical formulation. Comprehensive Psychology, 6(1), 1–23.
Butler, A.C., Chapman, J.E., Forman, E.M. and Beck, A.T. (2006) The empirical
status of cognitive-behavioural therapy: a review of meta-analyses. Clinical
Psychology Review, 26(1), 17–31.
Callcott, P., Dudley, R., Standardt, S., Freeston, M. and Turkington, D. (2010)
Treating trauma in the context of psychosis: a case series. In Hagen, R., Turkington,
D., Berge, T. and Grawe, R.W. (eds) CBT for Psychosis: A Symptom-based Approach.
East Sussex: Routledge, pp.175–192.
Cartwright-Hatton, S., Roberts, C., Chitsabesan, P., Fothergill, C. and Harrington,
R. (2004) Systematic review of the efficacy of cognitive behavior therapies for
childhood and adolescent anxiety disorders. British Journal of Clinical Psychology, 43,
421–436.
Chadwick, P., Williams, C. and MacKenzie, J. (2003) Impact of case formulation in
cognitive behavioural therapy for psychosis. Behaviour Research and Therapy, 41(6),
671-680.
Clark, D.M. and Beck, A.T. (1999) Scientific Foundations of Cognitive Theory and
Therapy of Depression. Chichester: Wiley & Sons.
Collerton, D., Dudley, R. and Mossiman, U. (2012) Visual hallucinations. In Blom,
J. and Somner, I. (eds) Hallucinations: Research and Practice. New York: Springer, pp
75–90.
Creswell, C. and O’Connor, T.G. (2011) Cognitive-behavioural therapy for children
and adolescents. In Skuse, D., Bruce, H., Dowdney, L. and Mrazek, D. (eds) Child
Psychology and Psychiatry: Frameworks for Practice. 2nd edn. Oxford: Wiley-Blackwell,
pp. 265–270.
Division of Clinical Psychology (2011) Good Practice Guidelines on the Use of Psychological
Formulation. Leicester: The British Psychological Society.
Dudley, R., Kuyken, W. and Padesky, C.A. (2010) Disorder specific and trans-
diagnostic case conceptualisation. Clinical Psychology Review, 31, 213–224.
Dudley, R. and Turkington, D. (2010) Using normalising in cognitive behavioural
therapy for schizophrenia. In Hagen, R., Turkington, D., Berge, T. and Grawe,
R.W. (eds) CBT for Psychosis: A Symptom-Based Approach. East Sussex: Routledge,
pp. 77–85.
Freeman, D. (2007) Suspicious minds: the psychology of persecutory delusions.
Clinical Psychology Review, 27, 425–457.
Freeman, J.B., Garcia, A.M., Coyne, L., Ale, C., Przeworski, A., Himle, M., et al.
(2008) Early childhood OCD: preliminary findings from a family-based cognitive-
behavioral approach. Journal of the American Academy of Child and Adolescent
Psychiatry, 47(5): 593–602.
Greenberger, D. and Padesky, C.A. (1995) Mind Over Mood: Change How You Feel by
Changing the Way You Think. New York: Guilford Press.
Hackmann, A., Bennett-Levy, J. and Holmes, E. (2011) Oxford Guide to Imagery in

Cognitive Therapy. Oxford: Oxford University Press.
Hall, P.L. and Tarrier, N. (2003) The cognitive-behavioural treatment of low self-
esteem in psychotic patients: a pilot study. Behaviour Research and Therapy, 41(3),
317–320.
Harvey, A.G., Watkins, E., Mansell, W. and Shafran, R. (2004) Cognitive Behavioural
Processes Across Psychological Disorders: A Transdiagnostic Approach to Research and
Treatment. London: Oxford University Press.
Kuyken, W. (2006) Evidence-based case formulation: is the emperor clothed? In
Tarrier, N. (ed.) Case Formulation in Cognitive Behaviour Therapy: The Treatment of
Challenging and Complex Clinical Cases. London: Brunner-Routledge, pp 12–35.
Kuyken, W., Padesky, C. and Dudley, R. (2008) The science and practice of case
conceptualisation. Behavioural and Cognitive Psychotherapy, 36, Special Issue 06,
757–768.
——(2009) Collaborative Case Conceptualization. Working Effectively with Clients in
Cognitive Behavioural Therapy. New York, London: Guilford Press.
Martin, D.J., Garske, J.P. and Davis, M.K. (2000) Relation of the therapeutic alliance
with outcome and other variables: a meta-analytic review. Journal of Consulting
Clinical Psychology, 68 (3), 438–50.
Masten, A.S. (2007) Resilience in developing systems: progress and promise as the
fourth wave rises. Development and Psychopathology, 19, 921–930.
Morrison, A.P., Renton, J.C., Dunn, H., Bentall, R.P. and Williams, C. (eds) (2004)
Cognitive Therapy For Psychosis, A Formulation-Based Approach. London: Brunner-
Routledge.
Neuchterlein, K.H., and Dawson, M.E. (1984) Vulnerability and stress factors in the
developmental course of schizophrenic disorders. Schizophrenia Bulletin, 10 (2),
158–159.
Padesky, C.A. and Mooney, K.A. (2012) Strengths-based cognitive–behavioural
therapy: a four-step model to build resilience. Clinical Psychology and Psychotherapy,
DOI: 10.1002/cpp.1795.
Persons, J.B. (2008) Cognitive-Therapy in Practice: A Case Formulation Approach. New
York: Norton.
Salkovskis, P.M., Clark, D.M. and Gelder, M.G. (1996) Cognition-behaviour links in
the persistence of panic. Behaviour Research and Therapy, 34(6), 453–458.
Watkins, E., Scott, J., Wingrove, J., Rimes, K., Bathurst, N., Steiner, H., et al.
(2007) Rumination-focused cognitive-behaviour therapy for residual depression: a
case series. Behaviour Research and Therapy, 45, 2144–2154.
Wells, A. (1996) Cognitive Therapy of Anxiety Disorders: A Practice Manual and
Conceptual Guide. Chichester: John Wiley and Sons Ltd.
Wykes, T., Steel, C., Everitt, B. and Tarrier, N. (2008) Cognitive behavior therapy
for schizophrenia: effect sizes, clinical models, and methodological rigor.
Schizophrenia Bulletin, 34, 523–537.

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Chapter 2

Case formulation in cognitive

A principled approach to CBT case

Principle 1: levels of conceptualisation

Table 2.1 The five Ps of CBT formulation

The five Ps Relationship to therapy

description, goals of treatment are articulated (Greenberger and Padesky,

Figure 2.1 Illustration of an initial cognitive model

concerns. We may initially build up a series of such descriptive formulations

His men are out

Figure 2.3 Perpetuating factors

avoidance, attentional processes such as vigilance for threat, and cognitive

A cognitive behavioural model of maintenance provides a rationale for a

Fear, anxiety, Avoid going out,

Figure 2.4 Jack’s perpetuating factors

directly linked to a repertoire of compensatory strategies that keep the person

Abandoned by biological parents

Raised by a series of foster parents,

and care institutions

Rules and Assumptions

If I am in a relationship, then I am ok.

Work hard to avoid relationship

Triggering events Precipitating Factors

End of the relationship

c. Problems Presenting issues

Resilience and strengths Protective factors

Figure 2.5 An illustration of a longitudinal formulation

In the middle and later stages of CBT, conceptualisations increasingly draw

Predisposing factors: quantity of events

Predisposing factors: quality of events

Rules and Assumptions or Conditional Beliefs:

Feelings Behaviour Feelings Behaviour

Figure 2.6 Jack’s longitudinal formulation

Principle 2: collaborative empiricism

Principle 3: include client strengths and conceptualise

A little sad Spend time

Figure 2.7 Use of cognitive framework to identify use of strengths to overcome

Strengths and resilience

such as a sport) would enable such factors to be woven into intervention

Sad Withdraws from

Figure 2.8 Mary’s perpetuating factors

have indicated some potential routes to this information. Second, the

Key characteristics of CBT formulation

Hackmann, A., Bennett-Levy, J. and Holmes, E. (2011) Oxford Guide to Imagery in

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