Cognitive Therapy is Based on a Cognitive Formulation of the Presenting Problems

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Cognitive therapy distils cognitive theories of emotional disorders to the understanding of particular cases through the case formulation method. A skilled cognitive therapist aims to understand presenting problems in terms of cognitive theory while maintaining the 'essence' of the presenting problems for a particular individual. To the scientist-practitioner cognitive therapist, individualised case formulation is the heart of good practice (Tarrier & Calam,

2002). The process of clinical formulation has been described as'... the linchpin that holds theory and practice together' (Butler, 1998), serving as a clinical tool that practitioners use as a framework for describing and explaining the problems that individuals may present with in cognitive therapy (Bieling & Kuyken, 2003). A case formulation should guide treatment and serve as a marker for change and as a structure for enabling practitioners to predict beliefs and behaviours that might interfere with the progress of therapy. It guides the practitioner in planning and delivering the right intervention, in the right way at the right point towards the collaboratively agreed goals for therapy. It can help therapists make sense of complex, multi-faceted presenting problems. Therapists can use formulation to anticipate and plan for difficulties in therapy, and thereby reduce drop-out rates. Finally it can increase empathy for clients, by making sense of what otherwise appear 'difficult-to-understand' behaviours (such as self-injury or anti-social behaviours).

There have been several attempts to provide individualised case-formulation systems firmly based in cognitive theory that can be used by cognitive therapist in day-to-day practice and in treatment process and outcome research (J.S. Beck, 1995; Greenberger & Padesky, 1995;Linehan, 1993; Muran& Segal, 1992;Needleman, 1999; Persons, 1993). For example, the J.S. Beck (1995) case formulation approach uses the client's developmental history and several prototypical problematic situations to identify problematic core beliefs, dysfunctional assumptions and maladaptive compensatory strategies. Developmental experiences, core beliefs, conditional assumptions and compensatory strategies are related to each other in understandable ways. In brief, adverse developmental experiences (for example, an intensely and enduringly critical parent) lead to maladaptive core beliefs (such as 'I am no good') with subsidiary beliefs (such as 'If I am upbeat and bubbly at all times, no one will figure out that I am really no good') that are compensated for by a range of behavioural strategies ('In all my interactions I will try to be as upbeat as possible') (Figure 2.2).

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