CBT Model – Maintaining Processes
Formulation is a key component of cognitive behavioral therapy (CBT) and essential to effective practice. Effective cognitive behavioral formulations tend to focus on maintenance cycles that explain why difficulties persist across situations, and research has identified several ‘common’ maintaining factors that operate across psychological disorders – including attentional processes, safety-seeking behaviors, and avoidance. The CBT Model – Maintaining Processes worksheet provides a framework for explaining what triggers a problem and why it persists across time and situations.
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Introduction & Theoretical Background
Formulation in talking therapies
Formulations (also known as case formulations, case conceptualizations, and working hypotheses) are a central component of most talking therapies and a key skill for mental health professionals (DCP, 2010; RCP, 2017; Sperry & Sperry, 2012). In essence, a formulation is a way to make sense of an individual’s difficulties. It is a provisional account or hypothesis, informed by psychological theory, about what an individual is struggling with and why (Johnstone & Dallos, 2014). A formulation is also a tool that therapists use to relate theory to practice (Butler, 1998). Sperry and Sperry (2012) describe formulations as:
A method and clinical strategy for obtaining and organizing information about a client, understanding and explaining the client’s situation and maladaptive patterns, guiding and focusing treatment, anticipating challenges and roadblocks, and preparing for successful termination.
(Sperry and Sperry, 2012, p4)
Formulation is a fundamental part of most (if
Therapist Guidance
"I’d like to explore with you what might keep this problem going. One way we can do that is by drawing a diagram. Can we give it a try?"
Step 1: Explore the client’s experience
Event
Ask the client to identify and describe events that trigger their difficulty. Note that trigger events can be external (e.g., certain situations) or internal (e.g., specific thoughts or sensations). For example:
- "Let’s start by exploring what tends to trigger this issue for you. Can you think of specific situations or experiences that usually set it off? These triggers might be things that happen in world around you or things that go on inside of you."
Thoughts
Help the client identify their negative interpretations in these situations:
- "What goes through your mind in those situations?"
- "What do you think to yourself?"
- "What are the most upsetting or difficult thoughts you notice?"
- "How
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). Problem‐maintaining 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