Wednesday 1 September 2010

I Love it when a Plan Comes Together: Case Formulation in Integrative CBT

Case Formulation in Counselling/Psychotherapy can be seen as consisting of

(a) a hypothesis, or set of hypotheses, concerning the sources and maintaining factors of the client’s presenting psychological problem(s)
(b) a plan, based on the above hypotheses, as to when, where and how to intervene, with a view to bringing about some reduction in the client’s problems.

The Case Formulation process therefore guides and structures the course of treatment by unifying and prioritising symptoms, influencing the choice and timing of interventions, and predicting possible difficulties. It should be an ongoing process, open to modification at any stage.

This process is not carried out explicitly in all forms of counselling/therapy, though presumably all therapeutic intervention must be based on some such hypothesising and planning, even if it remains largely implicit. Carl Rogers considered that “a diagnosis of the psychological dynamics is not only unnecessary but in some ways is detrimental or unwise” (1951, p. 223). He was concerned that the process of making a diagnosis leads to an inequality in the power dynamic between counsellor and client. Similar concerns are part of Integrative CBT (at Level 1), but I believe that a collaborative approach to arriving at a formulation should resolve this difficulty. In practice, this means that the therapist presents his own formulations to the client as hypotheses for discussion, and also helps the client to formulate his own hypotheses through guided discovery (J. Beck, 1995). The client should have as full as possible an understanding of what is happening in their own treatment. As Persons remarks (1989, p. 48), ‘If the formulation is so helpful to the therapist, we might also expect it to be helpful to the patient in understanding and managing his behaviour.’

In Integrative CBT, developing the hypothesis is an explicit process, and is part of the work that we do at Levels 3 and 4. Because this is “Integrative Cognitive Behavioural Therapy”, and not just Integrative Psychotherapy in general, the formulation is based on the Cognitive Model of emotional disorders, which “proposes that distorted or dysfunctional thinking (which influences the client’s mood and behaviour) is common to all psychological disturbances” (Judith Beck, 1995, p. 1). As we have seen in earlier blogs, at its simplest level it focuses on Negative Automatic Thoughts which are locked into vicious cycles with dysfunctional emotions, behaviours and physiology. It can also be expanded to include more ongoing dysfunctional underlying cognitions in the form of Assumptions and Core Beliefs.

So the questions an Integrative CBT therapist would be asking themselves about any client would be:

1. How do I best connect with this particular person, and form a therapeutic relationship with them?

There are some general principles here, of course, but also individual differences in how we need to adjust to different clients. Our initial therapeutic engagement will be based on initial impressions, but this can be adjusted in line with whatever emerges at the next levels of exploration. For example, a currently active addiction problem may require a firmer and more directive stance; hopeless thinking may require a gentle exploration of possible suicidality; mistrust and abandonment schemas may require reassurance and clearer discussion of contractual boundaries.

2. What are the immediate problems that need action?

Often the client and therapist agree to work on the most urgent problems, i.e. the most damaging ones, first. But there are also other possible criteria for prioritising problems, such as the likelihood of achieving reasonably quick progress (thereby raising hope and increasing motivation). And new priority issues may emerge as therapeutic exploration continues, especially at Levels 3 and 4.

3. What is the individual psychology/psychopathology of this person?
What are their typical cognitive distortions, automatic thoughts, compensatory behaviours?
What is the inner logic of their irrational problems?
What are the relevant emotional and physiological factors, and maintaining cycles?

Sometimes the pattern which emerges fits well into an existing diagnostic category such as Social Anxiety (see e.g. the Case Example blog from 30 June); in other cases it is a more idiosyncratic mix. But this distinction is a continuum, not a dichotomy – there is always an individual aspect to the most textbook diagnosis, and familiar patterns in the most idiosyncratic psychopathology.

4. What are the developmental sources of the above difficulties?
How does this client see the world, what are their Core Beliefs?
What has been their relevant experiential learning?

This is a crucial piece – it can help clients enormously to see that their problems, and dysfunctional strategies, can actually make sense in the light of their underlying beliefs, and that these beliefs in turn can make sense in the light of their core learning experiences.

5. What core human issues are they struggling with?

It can also be helpful for both client and therapist if problems are seen in their larger human context. Social Anxiety problems, for instance, can be seen as understandably arising in relation to such central human concerns as Status, Belonging, Community, Reputation etc.

As mentioned above, the formulation which emerges at these later levels may in turn influence the style and focus of our work at Levels 1 and 2.

What I have described at levels 2, 3 and 4 are classic Cognitive Case Formulation; 1 and 5 are essential to any good therapy work, whether Cognitive-Behavioural, Humanistic or Psychodynamic. I believe that only Integrative CBT Case Formulation clearly combines them all.

Next week, some I plan to discuss some case examples from an Integrative CBT Case Formulation viewpoint, which hopefully will make everything clear...!


Beck, J. (1995) Cognitive Therapy: Basics and Beyond. New York: Guilford Press.

Persons, J.B. (1989) Cognitive Therapy in Practice: A Case Formulation Approach. New York: W.W. Norton.

Rogers, C.R. (1951) Client-centered Therapy. Boston

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