When a person enters therapy, they may already have a clear idea of what is troubling them. They might say, “I feel anxious”, “I cannot stop overthinking”, “I keep avoiding people”, or “I feel like I am not good enough”. In some cases, they may even recognise that they need to change the way they interpret situations or develop better ways of responding to difficult emotions.
However, recognising a problem is not necessarily the same as understanding how the problem operates. A person may know that they avoid social situations, for example and may genuinely want to become more confident, yet remain unaware that avoidance is providing immediate relief while reinforcing fear in the longer term. They may also be unsure whether the difficulty lies in their interpretation of social situations, their beliefs about themselves, their emotional regulation skills, their behavioural responses or the interaction among several of these factors.
Understanding these distinctions is important because different maintaining processes may require different therapeutic strategies. This is where case conceptualisation becomes important in Cognitive Behavioural Therapy. Case conceptualisation is a way of bringing together different pieces of a person’s experience to understand how their difficulties developed and what may be maintaining them.
In CBT, formulation is regarded as an important bridge between psychological theory and the particular circumstances of an individual client because it can help therapists select interventions that are relevant to that person’s difficulties rather than relying on techniques in isolation (Kyuken et al., 2008; Easden & Kazantzis, 2018).
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Map Behind The Problem: What Is Case Conceptualisation?
Case conceptualisation can be understood as a map of a person’s psychological difficulties. Imagine that you are trying to understand why a car keeps breaking down. Knowing that “the car is not working” is not enough. You would want to know where the problem started, which parts are affected, what is causing the breakdown, and what is keeping the problem going. CBT case conceptualisation works in a similar way. Instead of looking only at a person’s symptoms, the therapist tries to understand:
- What situations trigger the difficulty?
- What thoughts occur in those situations?
- What emotions and physical reactions follow?
- What does the person do in response?
- What deeper beliefs might influence these reactions?
- What factors are maintaining the problem?
The purpose is to develop an individualised explanation of the person’s difficulties that can guide therapy (Kyuken et al., 2008). Importantly, the formulation is not treated as a permanent or unquestionable explanation. It is a working hypothesis that can change as the therapist and client learn more about the problem (Persons, 2022).
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One Interpretation Can Change The Entire Pattern
One of the central principles of CBT is that situations, interpretations, emotions, physiological responses, and behaviours are closely interconnected. The same event can therefore lead to very different reactions depending on the meaning an individual assigns to it. For example, imagine a student receiving a message from their professor: “Please meet me after class”.
The message itself does not necessarily mean anything negative. However, the student might immediately think: “I must have done something wrong. Maybe I am going to fail.” That interpretation may produce anxiety. The student might experience a racing heart, muscle tension and difficulty concentrating. They might then avoid the professor, repeatedly ask their friends whether they have done something wrong, or spend hours worrying about the meeting.
The cycle might look like this: Situation -> Thought -> Emotion/physical reaction -> Behaviour -> Consequence.
This is important because CBT does not consider the event alone to be sufficient for understanding the person’s reaction. The meaning attached to the event is also significant. Two individuals can encounter the same situation while experiencing substantially different thoughts, emotions, and behaviours because they interpret the situation differently. Case conceptualisation helps the therapist identify these connections instead of looking at each symptom separately (Padesky, 2020).
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Look Beneath The Surface: Core Beliefs And Underlying Patterns
Sometimes, the thought that appears in a particular situation is only the surface of a deeper pattern. For example, suppose an employee receives criticism from their manager. Their immediate thought might be: “I am terrible at my job”. But underneath this thought may be a deeper belief: “I am not good enough”. These deeper beliefs are often referred to as core beliefs. They can influence how people interpret situations and how they respond emotionally and behaviourally.
For example, a person with the core belief “I am not good enough” may interpret a small mistake as evidence that they are a failure. Consequently, the same mistake by another person is interpreted as an opportunity to learn. CBT case conceptualisation therefore tries to connect the person’s current reactions with underlying beliefs and assumptions that may have developed through previous experiences (Kyuken et al., 2008). A simple way to understand this is to imagine an iceberg.
The behaviour and automatic thoughts are visible above the water: “I made a mistake”. -> “I am a failure”. -> Feeling anxious -> Avoiding the task
But underneath the water may be the deeper belief: “I am not good enough”. The purpose of formulation is not to assume that such a belief must be present, but to investigate whether it helps explain the person’s recurring patterns. In this sense, formulation moves from description toward explanation while remaining open to revision.
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Understanding Triggers: Where Does The Pattern Begin?
Another important part of the case conceptualisation is identifying triggers. A trigger is something that activates a person’s thoughts, emotions or behaviours. It might be an argument, criticism, an examination, a social situation, a particular memory or even a thought. For example, consider a person who has developed a strong fear of rejection. When a friend does not respond to a message for several hours, the situation may activate the thought, “they are angry with me”. This interpretation may produce anxiety, which may then lead a person to send several additional messages or repeatedly check their phone.
The sequence can be represented as:
- Trigger: friend does not reply for several hours.
- Automatic thought: they are angry with me.
- Emotion: Anxiety
- Behaviour: repeated messaging or checking the phone.
Understanding this sequence gives the therapist a clearer picture of what is happening rather than simply describing the person as “an anxious individual”. Collaborative models of CBT case conceptualisation especially encourage therapists and clients to identify the situations that trigger problems and the factors that follow and maintain them (Padesky, 2020).
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Identifying Maintaining Factors: What Keeps The Difficulty Going?
Perhaps one of the most useful questions in CBT is: “What is keeping this problem going?” Sometimes a behaviour provides immediate relief but creates a bigger problem in the long term. Consider someone afraid of social situations.
They believe: “Everyone will notice that I am nervous and judge me”. Also, they are invited to a party and become anxious. They decide not to attend. The moment they cancel, their anxiety decreases. That relief feels good. But because they avoided the situation, they never get the opportunity to discover whether people would actually judge them.
The cycle becomes: Social situation -> Fearful thought -> Anxiety -> Avoidance -> Immediate relief -> Fear continues
Here, avoidance becomes a maintaining factor. This is why case conceptualisation is useful. The therapist is not only asking, “What is the person doing?” but also, “What function does this behaviour serve, and how might it be keeping the problem alive?” Padesky’s collaborative formulation models specifically emphasise identifying triggers and maintenance factors in understanding individual problems (Padesky, 2020).
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Understanding To Intervention: Turning The Formulation Into Treatment
A formulation becomes particularly useful when it helps answer: “So, what should we do about it?” Suppose the therapist identifies avoidance as a major factor maintaining someone’s anxiety. Treatment may then include gradually approaching feared situations rather than continuing to avoid them. If negative automatic thoughts are maintaining the difficulty, therapy may focus on examining those thoughts and considering alternative interpretations. If deeper beliefs are important, therapy may explore and modify those beliefs. In this way, case conceptualisation connects understanding the problem with planning the treatment.
A simple way to look at it is: Understanding the problem -> Identifying maintaining factors -> setting goals -> choosing interventions -> monitoring progress
This individualised approach is one of the reasons case conceptualisation has been described as important for tailoring CBT interventions to individual clients (Easden & Kazantzis, 2018).
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Collaboration: Constructing The Formulation Together
It is not supposed to be a therapist sitting in a room and deciding, “I know exactly what is wrong with this person”. Instead, CBT encourages collaboration between the therapist and client. The therapist brings knowledge of psychological theories and evidence-based treatment, while the client brings knowledge of their own experiences, relationships, history and circumstances. Therefore, both perspectives are needed to create a useful formulation (Kyuken et al., 2008). This can also make therapy easier for the client to understand.
For example, instead of simply telling someone, “Your avoidance is maintaining your anxiety”, the therapist can work with the client to examine their own experiences and discover the pattern. The client may eventually say: “Actually, every time I avoid something, I feel better for a while, but then I become even more afraid of doing it next time.” That realisation can become part of the formulation. Recent research has further emphasised the collaborative nature of psychological formulation. A 2024 Delphi consensus study involving clinical psychologists found agreement that formulation should be client-led, collaboratively developed, and informed by relevant evidence-based theory.
The study also identifies strengths, sociocultural factors, personal meaning and developmental experiences as important components of formulation, while demonstrating that clinicians do not agree on every possible element of formulation (Thrower, Bucci, Morris and Berry, 2024)
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Formulation Is Dynamic: Revising The Working Hypothesis
Another important point is that a case conceptualisation is not a fixed diagnosis. As therapy progresses, the therapist may discover new information. A factor that initially appeared important may turn out to be less important, while another factor may become more relevant. For example, a therapist may initially think that a person’s anxiety is mainly maintained by avoidance. Later, they may discover that perfectionistic beliefs are also playing a major role. The formulation can then be updated.
This makes case conceptualisation more like a living map than a final answer. It develops as the therapist and client gather more information and test their understanding of the problem (Kuyken et al., 2008). Recent research also suggests that case formulation can be useful when therapy is not progressing as expected. A 2026 study found that therapists’ use of case formulation was associated with the resolution of episodes of deterioration or lack of progress during CBT for depression, although the study did not show that formulation prevented these episodes from occurring (Eells et al., 2026).
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Why Does This Map Matter?
Without a formulation, therapy can sometimes become a collection of techniques. A therapist might teach relaxation, challenge thoughts, encourage behavioural change and practise exposure. But the important question is: Why this intervention for this person? Case conceptualisation helps answer that question. It provides a logical connection between the person’s difficulties and the treatment plan. It helps therapists identify what needs to change and provides a framework for setting meaningful treatment goals (Kuyken et al., 2008).
At the same time, it is important not to overstate the evidence. Although CBT models consider case conceptualisation an important part of therapy, researchers have historically conducted limited studies on its direct relationship with treatment outcomes. A systematic review by Easden and Kazantzis (2018) found that research had focused heavily on the assessment aspects of conceptualisation, while relatively fewer studies had directly examined how therapists use formulations during sessions or how formulation relates to treatment outcomes. Therefore, clinicians should view case conceptualisation as an important clinical tool while recognising that research on exactly how and when it improves outcomes is still developing.
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Putting The Pieces Together
Case conceptualisation helps CBT therapists move beyond simply asking “What symptoms does this person have?” and instead ask: “How does this particular person’s problem work?” It brings together thoughts, emotions, behaviours, triggers, underlying beliefs and maintaining factors to create a clearer picture of the person’s difficulties.
Think of it as putting together pieces of a puzzle. One piece may be the person’s thoughts, another their emotions, another their behaviour, another their past experiences and another the factors keeping the difficulty going. Looking at each piece separately gives only part of the picture. Case conceptualisation helps the therapist see how the pieces fit together.
Most importantly, the formulation provides a bridge between understanding and treatment. Once the therapist and client understand what may be triggering and maintaining the problem, they can work together to establish treatment goals and choose interventions that target those factors. In this sense, case conceptualisation is not simply about explaining a person’s difficulties. It is about using that explanation to answer the most practical question in therapy: “Now that we understand what is happening, what can we do to help?”
References +
- Bucci, S., French, L., & Berry, K. (2016). Measures assessing the quality of case conceptualisation: A systematic review. Journal of Clinical Psychology, 72(6), 517–533.
- Easden, M. H., & Kazantzis, N. (2018). Case conceptualisation research in cognitive behaviour therapy: A state of the science review. Journal of Clinical Psychology, 74(3), 356–384. https://doi.org/10.1002/jclp.22516.
- Eells, T. D., et al. (2026). Therapist use of a case formulation is associated with the resolution but not prevention of episodes of symptom deterioration and lack of progress during cognitive behaviour therapy. Behaviour Therapy. https://doi.org/10.1016/j.beth.2026.07.003.
- Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualisation. Behavioural and Cognitive Psychotherapy, 36(6), 757–768. https://doi.org/10.1017/S1352465808004815.
- Padesky, C. A. (2020). Collaborative case conceptualisation: Client knows best. Cognitive and Behavioural Practice, 27(4), 392–404. https://doi.org/10.1016/j.cbpra.2020.06.003.
- Persons, J. B. (2022). Case formulation. Cognitive and Behavioural Practice, 29(3), 537–540.
- Thrower, N. E., Bucci, S., Morris, L., & Berry, K. (2024). The key components of a clinical psychology formulation: A consensus study. British Journal of Clinical Psychology, 63(2), 213–226.
