MOYA CBT FORMULATION GUIDE Page 1

CBT FORMULATION
A GUIDE TO EFFECTIVE FORMULATION IN CBT PRACTICE

Formulation is a key skill and tool in

cognitive behavioural therapy. It is the
focal point of therapy and drives
treatment, therefore it needs to be done
effectively. The aim of formulation is to
develop a shared understanding of the
presenting problem and what is
maintaining it.

Formulation can be done at different

levels, starting with a vicious cycle in
the here-and-now and a longitudinal
formulation that provides a theory of
the onset and development of the
person's beliefs and how they become
A good formulation can change lives
activated and cause distress.

Formulation is a collaborative process.

You are developing understanding
based on the person's lived experience
and your skills in using CBT theory and
practice to provide an explanatory
framework to make sense of their
distress. Resist the temptation to
control the process, and take the time
necessary to do it well.

It is a complex skill and will develop

with experience. This guides aims to
provide an overview of what CBT
formulation is, the different types of
formulation and when to use them, and
some tips for practice. Build the formulation together

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Assessment
Perform a full CBT assessment as you would do for any presenting problem. A
simple adaptation to the initial vicious cycle maintenance formulation is to
explore worry and rumination in the cognitions/thought box. We know that these
thought processes are key maintenance factors in all presentations so raising
awareness from the start is very helpful.

Worry Thoughts Rumination

Attentional focus
education starts at
assessment. Do a
grounding technique
at the end of the
session and give them
this as homework

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Tips & examples

When developing a maintenance formulation it is important that it is done
collaboratively. This means that the pacing needs to be slow enough for the
person to assimulate the information. Some therapists use generic statement
like "it all feeds into each other and keeps the cycle going". This can be
confusing for someone who is at their first session and probably feeling
overwhelmed. Try mapping the cycle out in one direction when developing the
formulation, then you can explain that it can be activated at any point.

Too general & confusing

each box is
connected and
keeps the cycle
going

Go in one direction first

in this situation you

noticed A that led to
B then C..etc. This
creates a cycle

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Additional features to a standard 5 areas formulation

To encourage conceptualisation of the CBT model we can use the initial maintenance cycle to
start the psycho-education regarding cognitive processes. This includes attentional focus which
we know is more threat focused when we are anxious. By highlighting this we can also map out
the effects of this attentional focus on the formulation - so recognising that the physical
sensations are a result of adrenaline and behaviours will fall in the fight, flight or freeze
responses. The acknowledgement of the pervasive nature of worry and rumination as cognitive
processes also helps to see how the cycle continues. By adding these features the learning is
increased.

You can also include different levels of cognition to point out a rule or identify a potential core
belief. This can be done with good Socratic questioning to explore whether the thought is a
Negative Automatic Thought (NAT) specific to that situation, or if it resonates at a deeper level
and is triggered often and in many situations.

Example of an adapted vicious cycle from assessment

On this vicious cycle there is a 'threat' bubble to indicate that the cycle occurs when the
brain is on threat alert. Associated with this are the behavioural options of fight, flight or
freeze responses. This sets the scene and forms part of the template. This cycle was
completed as always but particular attention was paid to his fear of losing control during
the presentation. As this indicates a rule for living we formulated this on a post it note and
added it to the diagram. This also demonstrates the general nature of rules as it can be
removed and addedd to other cycles.

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The best gift to take away from

assessment is a good formulation

It is tempting to rely on handouts to do the explaining, but remember that

true collaboration involves creating the explanation in the therapeutic
space. The best resource we have is the moment by moment opportunities
to develop a shared understanding. This includes seeking feedback from
the person to make sure they understand what you are presenting, and
encouraging them to make notes or take photos of diagrams which will
reinforce learning.

If there is not enough time to develop a comprehensive formulation in the

session then provide a brief explanation of the vicious cycle. Here is one I
have produced. A handout version is available at the end of this guide.

Example
SITUATION
CBT VICIOUS OR TRIGGER
Waiting for a video
call from your
CYCLE boss

EXPLANATION OF WHAT IS
MAINTAINING A DIFFICULT
OR DISTRESSING EMOTION THOUGHTS
I won't know what
to say. He will
think I look stupid.
Cycle Diagrams show how specific I might lose my
job.
elements are related to one another,
PHYSICAL
forming a repeating pattern. This SENSATIONS EMOTIONS/
diagram can be used to understand heart racing, feel DISTRESS
sick, shaking, Anxiety
how our thoughts, feelings and tension Sadness
behaviour contribute to our distress.
In this example, the fear of negative
judgement led to cancelling the BEHAVIOUR/
meeting. Avoidance will reduce the RESPONSE
anxiety temporarily, but prevents Make an excuse to
cancel meeting
discovery of what would actually
happen in the meeting. This
maintains the fear and makes the
pattern more likely to recur next
time there is a similar trigger.

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Disorder specific formulation

Disorder specific formulations are maintenance cycles for the evidence based protocols
used to treat anxiety disorders and depression. These are recommended by NICE and are
outlined in the Roth & Pilling CBT competency framework. Once you have completed
assessment and diagnosed the presenting problem you can move to the specific
formulation that matches the treatment rationale.

Some dos and don'ts with disorder specific formulations

Make sure you have been taught the Use formulation diagrams that don't
protocol correctly fit the protocol
Read the original source of the Download formulations from
protocol disreputable websites
Have a supervisor who is experienced Cut corners when delivering the
using the protocols protocol
Practice the skills required Mix more than one protocol at a
Go through the protocol completely time
at least a few times

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Longitudinal formulation
Longitudinal formulation is part of the cognitive therapy approach introduced by Beck.
It provides an explanatory framework to describe the onset and development of a
person's belief system. This helps to understood what might make them vulnerable to
developing depression or anxiety. The basic structure starts with early experiences
which make the person vulnerable to develop negative core beliefs about self, others
and the future (cognitive triad). These key early experiences are often referred to as
predisposing factors. The resulting core beliefs then give rise to rules for living
which help us to either negate or minimise the activation of the core beliefs.

Once these layers of beliefs have been identified we can theorise as to what they may
make us vulnerable to. For example, if early experiences indicated neglect, bullying
and excessive criticism from others, and this results in negative beliefs about self,
others and the future, we can theorise that these beliefs could make the person
vulnerable to depression. We then want to identify critical incidents in which the core
beliefs have recently been activated. For example, bullying and harrassment in the work
place that mimics bullying in early childhood. The belief system is then activated and
causes emotional distress. It is this that then gives rise to the current problems
presented at assessment and mapped out in a vicious cycle formulation to indicate
current maintenance factors.

Basic structure to longitudinal formulation

Early experiences
(predisposing factors)

Core beliefs

Rules for living

What this makes me vulnerable to

(depression or anxiety for example)

Critical incidents
(precipitating factors)

Maintenance factors
(vicious cycle in here-and-now)

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Tips & examples

When explaining the rationale for doing a longitudinal formulation it is useful to go through
a hypothetical example. It is also helpful to break it down into the first three sections first
to ensure understanding. This is how you can show the link between early experiences,
core beliefs and rules for living. Here is an example.

Longitudinal formulation

Early experiences
Youngest of two. Mostly a happy family life but a period of arguments
between parents so became peace keeper. Mum had OCD and had
long rituals and would get angry easily. Both parents worked
antisocial hours. Learned to be very self-sufficient and looked after
others. Liked rules and order. Did very well at school. Hated being
told off and any confrontation.
Core beliefs develop
as a result of our
interpretation of
events in our early Core beliefs
life
I am.... not important
Others... are unpredictable, unreliable
World is ... uncertain
We develop rules for
living to try and
counter the core
beliefs or be able to Rules for living
live with them.
If I don't put others first, then I will be rejected
If I am not in control, then something bad will happen
If I express my emotions, then I will be rejected

The notes in the pink margin provide explanations for the links between these three
levels. However, you need some fundamental CBT skills in order to elicit core beliefs
and formulate rules for living.

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Formulation skills
A key skill for good formulation is the

Guided use of guided discovery. This is based

on the method of Socratic questioning
which guides the person to make
discoveries of the connection between
their experiences and the meanings
they give them. We may have a good
idea of what core beliefs or rules a
person could have, but we must NOT
make assumptions or lead the person
to OUR conclusions.

Consider both positive and negative core beliefs. The positive Core beliefs
ones can be extremely helpful in therapy to build resilience and
tailor interventions. Beck's cognitive triad refers to beliefs about
self, others and the future. However, many people also formulate
core beliefs about the world in general (as dangerous, uncertain,
harsh and so on).

Use the downward arrow technique in the Socratic dialogue to

guide the person to identify the meaning they have ascribed to
events in their life. Ask the question 'does that resonate with
you'? as this is normally an indicator that you are in the right
area. Look for physical and emotional signs in the room, as core
beliefs often resonate somatically.

Rules for living

The rules need to make sense in terms of the core beliefs. For example, if the person has beliefs
'the world is uncertain' and 'I am vulnerable', then you would expect a rule regarding control.
Approval would not map onto those particular core beliefs.

There are themes to rules. Common ones are control, approval, subjugation (putting others
before yourself) and all or nothing. Beck also identified 'cherished ideals' as a rule, and when
this one breaks it can lead to depression through perceived loss of life goals.

It is useful to formulate the rules as an 'If..., then....' in the negative as this makes it easier to test
them out. For example: 'If I do not please others, then I will be rejected'. This helps to see if the
feared consequence (rejection) actually happens if you act against the rule.

Formulating rules is a complex skill. Keep practicing

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The remainder of the formulation helps the

person to recognise how their core beliefs
and rules make them vulnerable to certain
problems and make a connection between
then (early experiences) and now.
You can bring out the vicious cycle from
assessment as a recent example of some of
the maintenance factors currently active and
affecting mood and anxiety.

Vulnerability
These beliefs and rules make me vulnerable to anxiety
(uncertainty & unpredictability) and depression (subjugation)

Critical incidents
Recent events that
have activated the Break down of a long-term relationship, and stress at work
core beliefs and
made the rules more
difficult to live by Maintenance factors

Ex-partner came to
pick up belongings

She's not happy. I

need to make her
This is a vicious feel better.
cycle of a recent
example of feeling
Butterflies Anxiety 90%
anxious since the tension Sad 100%
critical incidents restless

Offered to help
Reassurance seeking
mental rituals

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Creative formulation

bring the
formulation to
life
Use Sho
wh
p o s t - it beli ow
efs
n o tes be f ca
lexi n
ble
pu
ll o
off ne
foc to
us
on

We did some work on the core

belief 'I am not good enough'.
This is some psycho-education
showing how when the core
belief is activated it feels like
everyone can see it and we view
the world through this lens.

On this formulation the core beliefs are

organised into the cognitive triad by colour.
The rules for living are in a different colour.
Each core belief or rule can be removed and
examined in more detail
Give it a try!

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 Example
SITUATION
SUOICIV TBC OR TRIGGER
Waiting for a video
call from your
ELCYC boss
EXPLANATION OF WHAT IS
MAINTAINING A DIFFICULT
OR DISTRESSING EMOTION
THOUGHTS
I won't know what
to say. He will
think I look stupid.
I might lose my
job.
Cycle Diagrams show how specific
PHYSICAL
elements are related to one another,
SENSATIONS EMOTIONS/
forming a repeating pattern. This
heart racing, feel DISTRESS
diagram can be used to understand how
sick, shaking, Anxiety
our thoughts, feelings and behaviour
tension Sadness
contribute to our distress. In this
example, the fear of negative judgement
led to cancelling the meeting. Avoidance
will reduce the anxiety temporarily, but BEHAVIOUR/
prevents discovery of what would RESPONSE
actually happen in the meeting. This Make an excuse to
maintains the fear and makes the pattern cancel meeting
more likely to recur next time there is a
similar trigger.
 Longitudinal formulation
Early experiences
Youngest of two. Mostly a happy family life but a period of arguments
between parents so became peace keeper. Mum had OCD and had
long rituals and would get angry easily. Both parents worked antisocial
hours. Learned to be very self-sufficient and looked after others. Liked
rules and order. Did very well at school. Hated being told off and any
confrontation.
Core beliefs develop
as a result of our Core beliefs
interpretation of
events in our early I am.... not important
life Others... are unpredictable, unreliable
World is ... uncertain

Rules for living

We develop rules for
living to try and If I don't put others first, then I will be rejected
counter the core If I am not in control, then something bad will happen
beliefs or be able to If I express my emotions, then I will be rejected
live with them.

Vulnerability
These beliefs and rules make me vulnerable to anxiety
(uncertainty & unpredictability) and depression (subjugation)

Recent events that Critical incidents

have activated the
Break down of a long-term relationship, and stress at work
core beliefs and
made the rules more
difficult to live by Maintenance factors

Ex-partner came to
pick up belongings

She's not happy. I

need to make her
This is a vicious feel better.
cycle of a recent
example of feeling
anxious since the Butterflies Anxiety 90%
tension Sad 100%
critical incidents restless

Offered to help
Reassurance seeking
mental rituals