Making CBT Work For
You With Case
Formulation
Cedar Koons, LCSW and Alisa Montano, LMSW presenters
Case Conceptualization—
Why?
 Helps you understand what is causing and
maintaining your client’s problems.
 Makes it clear what new behaviors the client needs
to learn to replace old, problematic behaviors
 Helps you recognize when exposure techniques are
needed.
 Highlights client’s problematic beliefs and thinking
errors.
 Clarifies where to start.
From Conceptualization to
Formulation
 Step One—Understand the Problem Behaviors
 Step Two—See the Patterns in Behavior
 Step Three—Recognize the Stage of Treatment
 Step Four—Formulate the Targets
 Step Five—Formulate the Solutions
Review’s Today’s Case
1. Read through your case.
2. Rank problems in order of severity
3. What crucial information do I not know?
4. Rank problems in order of priority to address
5. You have ten minutes for this exercise
Getting Started:
Conceptualize your Case
1. What are this persons goals?
2. Why are they seeking treatment?
3. What is their environment and how does it
contribute to the problems? Does the environment
reinforce the problem?
4. You have 15 minutes.
Step One: Understand the
Problem Behavior
Behavior Analysis
 Antecedents
 Behavior
 Consequences
Conduct a Pattern Analysis
of the Behavior
 Analyze several instances of the problematic
behavior including mild, moderate and severe
episodes
 Determine the common antecedents for the
behavior
 Explore the similar kinds of thoughts, emotions and
events that happen before and after the behavior
 Analyze the consequences of the behavior—are they
often similar?
Common Antecedents:
Examples
 Feeling rejected
 Feeling abandoned
 Health crisis
 Work or financial crisis
 Relapse on drugs or alcohol
 Onset of a depressive or manic episode
 Discontinuance of medications
 Traumatic cues or triggers
Common Behaviors:
Examples
 Self-harm, suicide ideation, suicide attempt
 From substance use to abuse to addiction
 From treatment noncompliance to treatment
dropout
 From overeating to binge eating, from purging to
severe restriction
 From problem gambling to gambling addiction.
 From avoidance to total isolation.
Common Thoughts,
Emotions and Events
 Thoughts such as “I can’t help myself,” or “I am
such a loser,” or “I deserve this.”
 Emotions such as shame, sadness, anger, fear,
disgust, even love or joy.
 Events such as a lonely holiday, a family fight,
reaching out and being rejected, being unable to
sleep, not eating, being sick.
 Hallucinations, delusions and disordered thinking.
Common Consequences:
Examples
 Immediate relief
 Distraction from the main problem
 Possible reinforcing attention from family and
friends
 Possible reinforcing attention from care providers
 Long term loss of self-respect, relationships, selfefficacy
 Addiction, misery, hopelessness
Common Factors
Influencing the Problem
Behavior
 Client lacks skills to manage the antecedents—
 Client gets rewarding consequences for the
maladaptive behavior and/or punished for
adaptive behavior, or is mainly ignored except
when misbehaving.
 Client has problematic thinking anywhere during
the behavior
 Client avoids or misinterprets due to overwhelming
or classically conditioned response.
Once you have the pattern
examine specific examples
Understand the Behavior
Each Time it Occurs
 All behavior takes place in a context—it is your job
to know that context so you can help the client
change the context.
 Examine the ABC’s of each episode of behavior as it
occurs. Be specific!
 Assess do not assume—purpose of behavior
analysis.
Practice with Cases
1. What do you know about antecedents of the most
severe behavior?
2. What do you know about the consequences of the
most severe behavior?
3. What skills does client lack?
4. What is the client avoiding?
5. What problematic thinking do you see?
Step Two: See the Patterns
in the Behavior
 What behavior patterns does this client manifest?
 How do these patterns set them up to fail?
 How do the patterns link together?
Examples of Patterns
 Acting on intense, hard to manage emotions
 Avoidance and mood dependent behavior
 Emotional shutdown, going numb
 Self-Invalidation, self-loathing
 Lack of clarity about goals and values
 Problems with the sense of self
 Perfectionism
 Not following through on commitments
Examine Underlying
Influences
 What behavior patterns might underlie the problem
behaviors? Why do you think so-what is your
evidence?
 What emotions might be most prominent for this
client? Why do you think so—what is your
evidence?
 Discuss the relationship between the underlying
patterns, emotions and the problem behaviors
 How do you think the problem behaviors might
affect your feelings about your client?
Step 3: Stage of Treatment
 Is client engaging in behavior that is dangerous to herself
or others?
 Is client able to engage in therapy effectively? (example,
will they attend sessions and comply with treatment?)
 Does client engage in behaviors inconsistent with an
adequate quality of life such as being homeless, abusing
drugs or alcohol or being totally isolated?
 Is client so impaired by PTSD that they cannot have
normal functioning? Can the client tolerate the distress of
exposure treatment without decompensating?
Orientation and
Commitment
 All CBT treatment starts with a full orientation to
what to expect in treatment.
 Orientation includes a lot of teaching of the client
about what you will do and why as well as
revealing your training and expertise to conduct
treatment.
 Each phase of treatment requires a full commitment
to what is required. Whenever commitment
appears to fade, return to commitment strategies.
Step 4: Targeting
Behaviors to Decrease
 Self-harming behaviors
 Self-destructive behaviors
 Behaviors that interfere with therapy
 Behaviors that interfere with quality of life
 Behaviors that interfere with accomplishing the
client’s goals.
Behaviors to Increase
 Behaviors directed toward the client’s goals
 Self-care around eating, exercise, health
maintenance.
 Positive social interactions
 Adaptive work related behavior
 Observing and describing emotions
 Noticing thoughts, feelings, urges
How to Monitor
 Use of diary card—orient and commit
 Review the diary card each week
 Deal with diary card non-compliance
 Change up the targets as client progresses
 Get consultation if client is not progressing
Case Work: What Will You
Target?
1. Describe, as specifically as possible, three behaviors
that need to decrease, starting with the most
severe.
2. Describe, as specifically as possible, what three
behaviors you would like to see increase.
3. What emotions or health behaviors do you need to
monitor?
Casework: Troubleshoot
your Targets
1. What might I anticipate coming up when I target
these problems—even if we are successful?
2. What environmental factors are most likely to
interfere with progress toward these targets?
3. What might I do that will get in the way of staying
on target?
Step 5: Formulate Solutions
 If the behavior happens because skills are lacking
teach skills and get skills to “pop out” in life
 If the behavior happens because the client is
reinforced by the consequences use contingency
management and self-management
 If the behavior happens because of faulty thinking
use cognitive modification
 If the behavior happens because of avoidance use
exposure
Step 5a: Skills
 What skills are already on board?
 What skills are needed?
 Teaching skills in session
 Finding resources in the community to impart skills
 Behavioral rehearsal
 Assigning homework practice
Step 5b: Contingencies
 How contingencies work in the real world
 Use of contingencies in therapy
 The use of self-management
Step 5c: Cognitive
Modification
 Examine and challenge thinking errors
 Help client to step back from automatic thoughts
 Notice the role thoughts play “on the chain” toward
problem behavior
 Practice skills to censor ruminating, stop obsessive
thoughts and manage worry
Step 5d: Exposure
Formal vs. Informal
Learn the protocol and use the protocol
Avoid reinforced exposure
Get consultation as needed
Additional Solutions
 Problem-solving for complex environmental
problems
 Evidence- based protocols for panic, PTSD, BPD,
etc.
 Orient, commit, troubleshoot
When Change is Slow or
Impossible
 Teach Acceptance strategies
 Teach Mindfulness
 Validate, validate, validate
What Solutions Will Work?
 Examine all the problems for your case that might
be solved.
 What solutions will work? Consider skills training,
cognitive modification, contingency management
and exposure.
 What evidence-based protocols might you explore?
 What community resources should you try to
access?
 What kind of consultation do you need?
Formulate Your Case
 Prepare a summary of your findings to bring to the
group including any insights you have gained from
this case formulation process.
 Name your top targets and the solutions you plan to
work on with your client
 Describe what you think will get in your way, both
from the client, from the environment and from
yourself.
 Describe how you will monitor your progress