Formulations in Cbt

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Formulations in CBT

Introduction

This essay discusses what we understand by case conceptualization which is also called case formulation ( this paper refers to it in that term) in Cognitive Behavioral Therapy (CBT), and reminds us of some historical background and conceptual underpinnings of CBT case formulation. It then discusses why it’s important, as well as how we use it, in CBT approach. Further the paper draws some differences with Psychiatric Diagnosis. The essay includes some critics from different disciplines and what they say about CBT formulation. It discusses its strengths and weaknesses, and how we work with these. It offers an opinion when and how a case formulation is helpful.

Following that, the essay points to different types of formulation models and illustrates which types are useful for what, and which may not be useful in CBT clinical setting. It describes the steps involved in developing a case formulation and presents case examples.

The final part of the essay summarizes some of the main points of case formulation and closes by reflecting what has been learned and what will enhance and improve therapists skills in coming up with collaborative and useful formulation when working with clients in a CBT therapeutic clinical setting.

What is case conceptualization? Why and how we use it

The model of CBT case formulation has multiple historical origins. The most important is probably functional analysis (Haynes & O’Brien, 2000; Nezu, Nezu, Friedman, & Haynes, 1997), which itself has origins in ‘operant conditioning’ theory and the tradition in psychology of the study of the single organism. Skinner ( 1938) was a particularly strong advocate of single-organism time-series designs, probably because they allow for tracking what interested him most: when, how, and under what conditions new behavioral repertoires unfold in real time. (Morgan & Morgan, 2001).

Case formulation is referred to as a CBT keystone, and is considered essential to the practice of CBT. It is the blueprint to help both therapist and client figure out what is going on. It’s a foundation of CBT because it describes and explains clients' presentations and it’s at the heart of understanding client’s difficulties (Beck, 1976) in ways that inform interventions. Case formulation can be described as the process of using sound theoretical frameworks to organise interview data, observational data and assessment data to formulate hypotheses that may explain the underlying dynamics of presenting problem in order to formulate an appropriate intervention plan. Formulation is the tool used by clinicians to relate theory to practice and it can be best understood as hypothesis to be tested (Johnstone, 2006). Kuyken (2009) states that the formulation is the heart of evidence based practice, and from the research evidence the therapists view the formulation as an important part of treatment.

In CBT the case formulation is based on the Cognitive Model of emotional disorders which was developed by Aaron T. Beck. In those early developmental stages he focuses on Negative Automatic Thoughts which are interwoven with dysfunctional emotions, behaviours and somatic symptoms. Later he also included more ongoing dysfunctional underlying cognitions in the form of Assumptions and Core Beliefs. In CBT there is always a cognitive case formulation i.e. an hypothesis and plan based on the Cognitive Model of emotional disorders. Judith Beck (1995, p. 1) defines this as follows: ‘In a nutshell, the cognitive model proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances.’

According to J Beck, in order to arrive at formulation, in practice this means that the therapist both presents his own formulations to the client, as hypotheses for discussion, and also helps the client to formulate his own hypotheses through guided discovery (Beck, 1995). Case formulation...
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