Figure 4.1

Case formulation. From Cognitive Therapy in Practice: A Case Formulation Approach (p. 79), by J. B. Persons, 1989, New York, NY: Norton. Copyright 1989 by Norton; and The Case Formulation Approach to Cognitive–Behavior Therapy (p. 120), by J. B. Persons, 2008, New York, NY: Guilford Press. Copyright 2008 by Guilford Press. Adapted with permission.

The other major system for case conceptualization is by J. S. Beck (1995, 2005), as shown in Figure 4.2. This system incorporates most of the same information as the system developed by Persons, as it includes the childhood or developmental bases of the case, the schemas or beliefs that are the focus of therapy, and the triggers or stressors. It also incorporates conditional assumptions or rules that the patient has adopted, based on his or her belief system, and compensatory behavioral strategies. It does not include information about diagnosis and the patient’s positive coping resources. This format for case conceptualization is used as a training and treatment resource in the Beck Institute and is “required” by therapists from the first session with a patient, despite the recognition that it evolves and becomes more complete with further contact and information gathering.

Figure 4.2

Case conceptualization model. From Cognitive Therapy for Challenging Problems: What to Do When the Basics Don’t Work (p. 140), by J. S. Beck, 2005, New York, NY: Guilford Press. Copyright 2005 by J. S. Beck. Adapted with permission. AT = automatic thought.

All three of the above case conceptualizations share certain elements. Among them are the need to articulate the core beliefs or schemas, the activating triggers for these schemas, and the resulting cognitive/behavioral/emotional processes. These elements form the core features of the case conceptualization. Other aspects of the case, such as the historical determinants of the schema and maintenance strategies, are often critical pieces of information used in treatment planning. All formats recognize that the therapist and patient will both discover information to add to the case conceptualization over time. In this sense, the case conceptualization is an evolving model of the patient’s functioning.

Which of the above three systems is the “correct” one to use will depend on circumstances. One will be more useful than the others for certain cases or for different phases of the same case. The bubble diagram could be used early in therapy, as it is simple and easy for most patients to understand. It could be replaced with something like the Beck format as the case becomes more complicated and its history clearer and after the therapist has witnessed schema activation in different situations. This format is also easy to teach to new cognitive therapists because it is comprehensive. Also, since it is similar to the case formulation model used by the Academy of Cognitive Therapy (http://www.academyofct.org), there is a linkage to the credentialing process for trainees with this aspiration. It does appear that the process of doing case conceptualizations can be trained and that with experience trainees will get closer to models in this area.