Case Formulation In Cognitive Behavioural Model
A case formulation is when information is gained from a client in the early stages of therapy. It often starts as a hypothesis looking at the causes and nature of presenting problems, it helps to develop a framework in treatment with your client. It helps discover core beliefs, which have been activated in the presentation of an individual to counselling.
Core beliefs are beliefs that we hold about ourselves, others and the world. These are deep rooted in the sense that they develop in childhood, through our experiences. We will often not recognise these beliefs as we adapt a rule for living or an assumption (unconscious) to help us be protected from others finding out our core belief.
When working in a cognitive behavioural model, we will apply a treatment plan based on the clients case formulation. This is found through exploring the clients past. We look for noxious childhood experiences firstly, within the first 18 years of their life with the exception of a trauma. These can range from a parental separating, bullying to childhood abuse. For them to be noxious they have to be negatively experienced in the clients eyes.
A CBT therapist will then from the NCE’s start to formulate potential core beliefs. This as mentioned above will develop as a result of the NCE. For example- if someone experienced childhood abuse, they may develop a core belief of ‘I am vulnerable, others are untrustworthy, the world is an unsafe place’.
We as individuals develop rules to protect the core belief because we do not want others to know our deeper feelings/ beliefs. Using the example above a client may develop a rule ‘ since I am vulnerable I must not allow people to get close to me, or since others are untrustworthy I must not tell people things about myself, or since the world is an unsafe place I must aim to protect myself at all costs’.
The next stage a CBT therapist will look at in the case formulation is dysfunctional behaviours an individual has adapted in relation to their rules, again taking this example above it could be – self sabotaging relationships or enter into relationships based on sex.
Next is to look at the activating situation- this is what has brought the client into therapy- again taking my example above this could be a relationship breakup.
The next is to complete a 5 part model – taking a situation where your client has felt vulnerable and using a diagram to illustrate negative thinking patterns. For example-
Situation- Friday afternoon in work, they are talking about going out for dinner, Joe who sits beside me keeps at me to go, she will ask me personal questions if I don’t go
Negative thought- ‘I am vulnerable’
Feelings- anxious, scared, worried, frustrated
Bodily sensations- racing heart, tension, headache, shaking
Dysfunctional behaviour- make an excuse as to why I have to leave work early to avoid having to be questioned if I went out.
This highlights to the client their thoughts/ feelings and behaviours are linked and helps you to introduce the concept of case formulations.
In cogntive behavioural therapy we do this by introducing a simple case fomrualtion, this takes one specific NCE’S one specifc Core belief, rule, and dysfunctional behaviour (the therapists will have all NCE’S /Core beleifs in on file for them). Normally it is good practice to address the core belief that is casuing the client most distress currently and link it to the core belief.
The benefits to presenting a case formulation to a client is that it helps them to make links to how their present is a possible cause from their past, and that we develop our core beliefs as a result of our noxious childhood experiences. Clients will get great relief in seeing the links, and often you as a therapist will see almost physically like a leaf has been lifted from them.
From discovery of this clients will often come into therapy and be able to discuss a situation and link it to their core belief and noxious childhood experience.
It is then when a CBT therapist will begin to work on development of a healthy core belief, if the client is willing to do so.