A case formulation is the map you and the client draw together of what is actually going on, and which link keeps the problem alive. Kuyken, Padesky and Dudley (2009) put weight on one word: collaborative. You build it with the client, in the room, and you keep testing it.
Draw the maintenance loop first. The history can wait until you have earned it. Every client here is fictional.
All clients on this page are fictional training examples, written to realistic clinical presentations. They are for learning, not clinical advice.
How to write a CBT case formulation
The steps follow the five-part model (Padesky & Mooney, 1990; Greenberger & Padesky, 1995) inside Beck's cognitive model.
- Presenting problem, in the client's own words.
- Triggers. Ask for one recent, specific moment. "Everything is bad" gives you nothing to draw. "Saturday morning, nothing planned" does.
- Thoughts, emotions (each rated from 0 to 100 as your baseline), body sensations and behaviours: what they did, avoided, checked, or used to feel safer.
- The maintenance cycle. Show how the behaviour feeds back into the thought or the feeling. Where a disorder-specific model exists, use it.
- Collaboration, all the way through. Check each arrow with "Does this fit for you?" Call it a draft, and mean it.
Example 1: depression (behavioural activation and cognitive model)
Grace is 45, a primary school teacher in Nairobi. She spent a year caring for her mother and has had low mood for six months. The formulation draws on Behavioural Activation (Martell, Addis & Jacobson, 2001) and Beck's cognitive therapy (Beck, Rush, Shaw & Emery, 1979).
- Trigger: a Saturday morning with no plans.
- Thoughts: "What is the point of getting up?" "I am letting everyone down." Sadness 80, guilt 60.
- Behaviour: stays in bed, cancels a call with a friend, skips choir practice.
- Maintenance cycle: withdrawing cuts her off from the activities that used to bring pleasure and a sense of achievement. With less positive reinforcement her mood sinks further, so she withdraws more.
- Risk: asked about directly in the first session. No thoughts of harming herself; the therapist agreed to check again at each session.
- Treatment targets: an activity and mood diary as a baseline, then activities scheduled by her values rather than her mood.
Example 2: panic disorder (Clark's cognitive model)
Thomas is 38, a bus driver in Dublin, with four months of sudden attacks of a pounding heart and dizziness. His heart checks were normal. The formulation follows Clark's cognitive model of panic (1986), with Salkovskis' account of safety behaviours (1991).
- Trigger: a crowded supermarket queue. His heart beats faster and he thinks "I am having a heart attack" (belief 90 percent). The fear produces more sensations that look like proof. That is the panic vicious cycle.
- Safety behaviours: holds the shelf, leaves the shop, checks his pulse.
- Maintenance: because he always leaves or holds on, he never finds out that the sensations pass by themselves. The safety behaviour gets the credit for the heart attack that did not happen.
- Treatment targets: behavioural experiments that bring on the sensations to find out what really happens; drop the safety behaviours one at a time, rather than reassuring him.
Example 3: OCD (inflated responsibility and reassurance)
Faris is 27, a marketing executive in Kozhikode, Kerala. Before he leaves home he checks the gas knob and the door many times, and sends his mother photos of the locked door. The formulation follows Salkovskis' cognitive model of responsibility appraisals (1985), with Exposure and Response Prevention (ERP).
- Intrusive thought: "What if I left the gas on and the building catches fire?" Thoughts like this are common in the general population.
- Appraisal: "If I do not make sure, it will be my fault if someone is hurt." That inflated sense of responsibility is what gives the intrusion its power.
- Maintenance: checking and reassurance bring short relief, so the urge comes back stronger. Repeated checking also makes his memory of having checked feel less certain, not more (van den Hout & Kindt, 2003). His mother answers every message, which keeps the cycle turning without her meaning to.
- Treatment targets: normalise the intrusions; ERP, such as locking up once and leaving without checking; with his consent, a kind plan agreed with his mother for declining reassurance.
Example exchange: building a formulation together
Guided discovery with Thomas from Example 2. The therapist never explains the panic cycle; Thomas finds each link himself.
Therapist:Can we take the last attack, the one in the supermarket, and go through it slowly? What did you notice first?
One recent, specific attack. Panic in general has no links to draw.
Client:My heart started going faster. It was hot in there.
Therapist:And when you noticed your heart, what went through your mind?
The meaning he gave the sensation is the model. Go straight for it.
Client:That this is it. My heart's going to give out.
Therapist:How strongly did you believe that, right then, from 0 to 100?
The rating is the baseline you will test later.
Client:About 90. I was sure of it.
Therapist:When you thought your heart might give out, what happened to your heart?
He discovers the cycle, rather than being told about it.
Client:It went even faster. I felt dizzy too.
Therapist:So the thought frightened you, and the fear made the sensations stronger. Shall we draw that as a circle?
Summarise, then ask before you write anything down.
Client:Yeah. I never saw it like that.
Practise building a formulation in session
Three moments where formulation work tends to go wrong. Each client is fictional.
Scenario 1
Panic client asking for reassurance
Ravi, 42, runs a shop in Kochi. His heart tests were normal, and he is still certain each attack will kill him.
“Doctor, just tell me honestly. My heart is fine, isn't it? If you say so, I'll relax.”
- Not giving reassurance
- Eliciting the catastrophic thought
- Guided discovery
A strong response: Acknowledge how badly he wants certainty, then turn the request into formulation: what happens in his mind and body when the fear comes.
Common pitfall: Giving him the reassurance. It works for about a day, then the fear returns and he needs you to say it again.
Scenario 2
The client who disagrees with your draft
Hannah, 29, a nurse in Manchester with social anxiety. You drew a formulation between sessions and have just shown it to her.
“I don't think that's right. I'm not avoiding anything, I'm just a quiet person.”
- Collaboration
- Using the client's words
- Treating the formulation as a hypothesis
A strong response: Be glad she said so, and rebuild it together. Her word, quiet, goes on the page.
Common pitfall: Defending your version. A formulation the client does not recognise cannot guide treatment.
Scenario 3
Low mood with a hint of hopelessness
Joseph, 58, a retired bank officer in Kottayam, depressed since he stopped work. He says this while you are mapping his week.
“Honestly, some days I wonder what I'm still here for.”
- Pausing the formulation to assess risk
- Open, non-leading questions
- Safety planning
A strong response: Put the pen down. Ask directly and calmly: "Thank you for telling me. When you say you wonder what you're still here for, do you have thoughts of ending your life?" Then assess intent, plans and protective factors, make a safety plan with him in the same session, and follow your service's risk procedures. The formulation can wait.
Common pitfall: Carrying on with the diagram as if he had said nothing, or asking a leading question such as "You're not thinking of hurting yourself, are you?" That phrasing tells him the answer you want, and most people give it to you.
Read more about Cognitive Behavioural Therapy, the evidence behind it and the skills you practise.