Is Cognitive Case Formulation Science or Science Fiction?

Peter J. Bieling, McMaster University and St. Joseph’s Healthcare Hamilton

Willem Kuyken, University of Exeter

As with all systematic models of therapy, cognitive ther- 2000), because, in part, of its consistency with the scientist-
apy distills a theory to the understanding of particular practitioner model. Although the scientist-practitioner
cases through the case formulation method. This article model has been controversial (Albee, 1970; Barlow, 1981;
sets out criteria to evaluate whether cognitive case for- Barlow, Hayes, & Nelson, 1984; Garfield, 1998; Rice,
mulation follows the process of scientific inquiry, and it 1997; Strupp, 1976), it has probably been the dominant
questions whether the formulation method meets these
model within clinical psychology since the American Psy-
chological Association’s (APA) landmark Boulder confer-
criteria. In terms of the evidence base for the cognitive
ence (Raimy, 1950).
theory that underpins cognitive case formulation, the
A primary reason for the widespread acceptance of cog-
research suggests that although the descriptive elements
nitive therapy is its concordance with the scientist-
of cognitive theory are substantiated, the explanatory el-
practitioner model. For example, in the area of depression
ements have received less support. In terms of the scien- several scholarly reviews (Clark & Beck, 1999; Coyne &
tific status of the cognitive case formulation process, cur- Gotlib, 1983; Haaga, Dyck, & Ernst, 1991; Kwon & Oei,
rent evidence for the reliability of the cognitive case 1994; Teasdale, 1983; Whisman, 1993) suggest consistent
formulation method is modest, at best. There is a striking support for important aspects of the cognitive theory of
paucity of research examining the validity of cognitive depression. In addition, numerous therapy outcome stud-
case formulations or the impact of cognitive case formu- ies suggest that for a significant proportion of individuals,
lation on therapy outcome. Implications for the clinical cognitive therapy for depression leads to a clinically signif-
use of cognitive case formulation within a scientist- icant relief of depressive symptoms (see Clark & Beck;
practitioner model are discussed, and potential programs
DeRubeis & Crits-Christoph, 1998; Dobson, 1989;
Robinson, Berman, & Neimeyer, 1990). Similar scholarly
of research to evaluate the case formulation method are
reviews suggest support for important aspects of the cog- AQ1
described.
nitive theory of anxiety disorders (e.g., Rapee, 1991) and
Key words: depression, anxiety, personality disorder,
support for cognitive therapy as an efficacious and effective
cognitive therapy, case formulation, cognitive models.
intervention for anxiety disorders (Barlow, Gorman, Shear,
[Clin Psychol Sci Prac 10:52–69, 2003] & Woods, 2000; see also DeRubeis & Crits-Christoph).
Finally, there is also some support for cognitive theory of
Since the seminal publication of Cognitive Therapy and the personality disorders (see Cottraux & Blackburn, 2001).
Emotional Disorders (A. T. Beck, 1976), cognitive therapy Although it is premature to judge the efficacy or effective-
has emerged as one of the most popular and widely taught ness of cognitive therapy for personality disorders, prelim-
therapeutic modalities of the last 20 years (Rush & Beck, inary evidence suggests that patients with comorbid Axis
I and II disorders respond to cognitive therapy, albeit less
Send correspondence to Peter J. Bieling, Department of Psychol- favorably than those with Axis I disorders alone (e.g.,
ogy, St. Joseph’s Hospital, 50 Charlton Avenue East, Hamilton, Kuyken, Kurzer, DeRubeis, Beck, & Brown, 2001; Men- AQ2
Ontario, Canada L8N 4A6. E-mail: [email protected]. nin & Heimberg, 2000).

 2003 AMERICAN PSYCHOLOGICAL ASSOCIATION D12 52

Table 1. Case formulation: definition, properties, and key elements

Definition Properties Elements

A provisional map of a person’s presenting Describes and explains presenting problems in Description of manifest presenting problems
problems that describes the territory of the terms that can be operationalized (cognition, (in clear, specific, and measurable terms)
problems and explains the processes that caused affect, and behavior) Developmental history
and maintain the problems Is reliable and valid Causal factors (distal and proximal)
Provides guides for intervention Maintaining factors
Is an active and ongoing process, responsive Guides for intervention
to new data

However, within the practice of cognitive therapy, there senting problems and to use theory to make explanatory
remains an important weak link. Although cognitive ther- inferences about causes and maintaining factors that can in-
apy is effective at relieving a variety of symptoms in differ- form interventions. Case formulation schemes generally
ent disorders in large-scale randomized, controlled clinical have several shared key elements (Table 1). These schemes
trials and effectiveness studies, researchers cannot conclude include a description of manifest presenting problems, im-
that cognitive therapy is effective because its statements about portant relevant developmental history, causal factors (dis-
etiology and mechanisms of change are correct. That is, cognitive tal and proximal), maintaining factors, coping strengths
therapy may work well—may even well work well by and weaknesses, and guides for intervention. Beyond these
changing maladaptive beliefs—but some of the key as- elements, a case formulation comprises a set of hypothe-
sumptions that underlie the practice of cognitive therapy ses about the underlying mechanisms that link these ele-
may be flawed. Yet, to the scientist-practitioner cognitive ments. For example, why does this person have these
therapist, individualized case formulation is the heart of problems at this time, and what factors are maintaining the
evidence-based practice. It occupies a fundamental place in problems? In most definitions, case formulation is theo-
clinical psychology, like the role of diagnosis in psychiatry. retically grounded while maintaining the “essence” of the
The cognitive case formulation literature (e.g., J. S. Beck, presenting problems for a particular individual (e.g., Den-
1995; Needleman, 1999; Persons & Tompkins, 1997) sug- man, 1995).
gests a broad range of claimed benefits for cognitive case Cognitive case formulation can be defined as a coher-
formulation. These include the provision of a systematic ent set of explanatory inferences about the factors causing
cognitive theory framework for hypothesizing about a and maintaining a person’s presenting problems, inferences
person’s presenting problems, individualized cognitive ther- derived from the cognitive theory of emotional disorders.
apy treatment protocols, improved description and under- In terms of a “here and now” view, this would normally in-
standing of presenting problems (for therapist and client), clude a statement of the core beliefs, dysfunctional as-
improved therapeutic alliance, more focused therapeutic sumptions, and compensatory strategies underpinning the
interventions, and enhanced treatment outcomes. Sur- problems, as well as any problematic cognitive styles or
prisingly, we do not know of any review that evaluates behavioral patterns that maintain the person’s difficulties.
these claims. This article evaluates the research evidence to In terms of a developmental view, this would normally
establish whether the use of individualized case formula- include a statement of how distal and proximal develop-
tions in cognitive therapy can be justified. We first outline mental information might have led to the development of
the case formulation approach and then propose criteria to beliefs, cognitive styles, and compensatory strategies. A
evaluate its evidence base within the scientist-practitioner complete cognitive case formulation would normally in-
model. clude the presenting problems (in terms of cognition,
affect, and behavior), relevant developmental information,
THE COGNITIVE CASE FORMULATION APPROACH hypothesized cognitive mechanisms underpinning the
Most established schools of psychotherapy advocate that a presenting problems, strengths and resources, and implica-
person’s presenting problems be clearly defined and under- tions for intervention.1 A cognitive case formulation is
lying psychological mechanisms be articulated (Eells, emphatically an account of a person’s presenting problems,
1997). Case formulation aims to describe a person’s pre- not of the whole person.

COGNITIVE CASE FORMULATION • BIELING & KUYKEN 53

 There have been several attempts to provide cognitive case formulation. We suggest that criteria can be sepa-
theory–based individualized case formulation systems (e.g., rated into two approaches:“top-down” and “bottom-up.”
J. S. Beck, 1995; Greenberger & Padesky, 1995; Linehan, We call the assumption that a cognitive case formulation
1993; Muran & Segal, 1992; Persons, 1993) that differ in should draw primarily on well-validated aspects of cogni-
emphasis in terms of structural elements included and the tive theory “top-down” (i.e., generalizations from theory
process of formulating. We will briefly review the Persons are applied to particular cases). Like others, we have made
(1989, 1993) and J. S. Beck (1995) schemes, before ex- the assumption that within the scientist-practitioner
trapolating a model that cuts across the different cognitive model a therapist draws on theory and research that in-
case formulation schemes. The Persons (1989, 1993; Per- forms practice (Eells, 1997; Denman, 1995; Salkovskis,
sons & Tompkins, 1997) system focuses on two levels, 2002). As such, “every application of scientific inquiry
overt difficulties and underlying cognitive mechanisms. is based on an inference from hypotheses (which are uni-
Overt difficulties map directly onto what has been de- versal) to single cases, i.e., upon a deduction of singular
scribed as presenting problems (Table 1). Underlying predictions” (Popper, 1959, p. 64). Within a scientist-
mechanisms refer to an explanation of how the maladap- practitioner model, each element in the cognitive case
tive cognitive processing, beliefs, and behaviors cause and formulation should be subjected to the following ques-
maintain presenting problems. Persons (1993) stresses the tions: Are the constructs in cognitive theory that under-
importance of identifying and working with the core be- pin cognitive case formulation substantiated by evidence?
liefs and triggers to render the person less vulnerable. J. S. And are the relationships between these elements sub-
Beck (1995) has developed a system that uses (a) the de- stantiated by evidence? A positive answer to these ques-
velopmental history and (b) several prototypical prob- tions is the basis on which cognitive case formulation
lematic situations to enable the therapist to identify schemes are set out (e.g., J. S. Beck, 1995; Persons &
problematic core beliefs, dysfunctional assumptions, and Tompkins, 1997).
maladaptive compensatory strategies (for a diagrammatic Bottom-up criteria relate to the reliable, valid, and
representation, see J. S. Beck, 1995). Developmental functional mapping of a case formulation onto a person’s
experiences, core beliefs, conditional assumptions, and presenting problems. For evaluating the empirical basis of
compensatory strategies are related to each other in un- cognitive case formulation this criterion can be broken AQ3
derstandable ways. In brief, adverse developmental expe- down into the following bottom-up queries: (a) Can cog-
riences (e.g., an intensely and enduringly critical parent) nitive therapists reliably formulate cases using the cognitive
lead to maladaptive core beliefs (e.g., “I am no good”), case formulation systems? (b) Are the key constructs in
with subsidiary beliefs (e.g., “If I am upbeat and bubbly case formulations meaningfully related to the person’s pre-
at all times, no one will figure out that I am really no senting problems? (c) Does cognitive case formulation lead
good”) that are compensated for by a range of behavioral to improved treatment and treatment outcomes? (d) Does
strategies (e.g., “In all my interactions I will try to be as up- cognitive formulation provide a fertile framework that can
beat as possible”). be readily and usefully applied? We begin by briefly re-
The J. S. Beck and Persons case formulation systems re- viewing the extensive literature relating to the top-down
fer to formalized case formulation approaches. It is likely criteria. Then we examine the literature relating to the
that most cognitive therapists in practice use their own bottom-up criteria. Finally, we outline a research agenda
personalized approach to case formulation, although we for future research into cognitive case formulation.
are aware of no completed research that examines how the At the outset the most critical question might be, “Are
method, content, and process of “real world” case formu- our questions answerable?”2 By reference to a program of
lation differs from formalized systems set out in published research on the Core Conflictual Relationship Theme
work and taught in cognitive therapy training programs. (CCRT) case formulation method (Luborsky & Crits- AQ4
Christoph, 1998), we show how 25 years of research on the
THE SCIENCE AND PRACTICE OF COGNITIVE THERAPY CCRT suggests that the CCRT meets many of the crite-
AND CASE FORMULATION ria we have set out.
Having described cognitive case formulation, we set out A person’s description of his or her relationships is used
some criteria to evaluate the scientific basis of cognitive in the CCRT method to infer core themes in relationship

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V10 N1, SPRING 2003 54

 conflicts (wishes towards the self, wishes towards others, questions we ask of cognitive case formulation are mean-
responses from others, and responses from the self ). The ingful and answerable.
authors make explicit links to underlying psychodynamic
theory and have developed a systematic and transparent A TOP-DOWN ANALYSIS OF COGNITIVE CASE
scoring methodology (Luborsky & Crits-Christoph, FORMULATION: IS CASE FORMULATION
1998). In terms of reliability, a recent review of eight stud- UNDERPINNED BY EVIDENCE-BASED THEORY?

ies examining judges’ agreement about core relationship We have elected to examine the evidence base of cognitive
themes, found agreement in the moderate-to-good range case formulation by using several categories of disorders in
(κ = 0.6–0.8; Luborsky & Diguer, 1998). Reliability was which a cognitive theory (CT) model is available: depres-
better for some aspects of the CCRT than for others, and sion, anxiety disorders, and personality disorders.3 We re-
more skilled and systematic judges tended to show higher view the literature relating to the evidence base for the
rates of agreement with each other (Luborsky & Diguer). key elements of cognitive case formulation by addressing
Evidence of test-retest reliability has been established from a series of falsifiable hypotheses relating to the definable
the assessment-to-early-treatment phase (Barber, Luborsky, and possibly operational factors within formulation (i.e.,
Crits-Christoph, & Diguer, 1998). In terms of validity, situation-emotion-thought-behavior cycle, early life
pervasiveness of core conflictual relationship themes have events and parenting, core beliefs, and dysfunctional as-
been associated in predicted ways with defensive func- sumptions and compensatory strategies). We will then ex-
tioning (Luborsky, Crits-Christoph, & Alexander, 1990). amine the linkages between each of these components.
Furthermore, changes in CCRT pervasiveness have been We begin with the most essential and well-researched
associated with symptom changes during therapy (Crits- component:the situation-emotion-thought-behavior cycle.
Christoph & Luborsky, 1998), although the size of changes
in CCRT pervasiveness was small (especially for wishes) Situation-Emotion-Thought-Behavior Cycle
and the size of the association was modest. The cycle of situation-emotion-thought-behavior (SETB)
In terms of relationship to outcome, accurate interpre- is the most familiar, and perhaps central, feature of the
tations based on CCRT-derived case formulations have cognitive formulation. The cognitive model takes as its
been associated with symptom improvements in a study of starting point the notion that it is one’s interpretation of
43 clients in brief psychodynamic psychotherapy (Crits- any event, rather than the event itself, that leads to emo-
Christoph, Cooper, & Luborsky, 1988). A reasonable tional distress, whether this interpretation is negative affect
explanation of these findings is that accurate case formu- or anxious arousal (A. T. Beck, Rush, Shaw, & Emery,
lations can affect outcome, either directly through the 1979; A. T. Beck, Emery, & Associates, 1985; Clark &
choice of highly appropriate interventions, or more indi- Beck, 1999). What is the empirical status of this assertion
rectly by enhancing the therapeutic relationship. However, in depression, anxiety, and personality disorders?
the evidence is conflicting, with one study suggesting that For depression, at least two sets of reviewers have com-
accuracy on key elements of the CCRT predicted changes prehensively assessed the SETB question separated by a
in the relationship (Crits-Christoph, Barber, & Kurcias, nearly 10-year span (Clark & Beck, 1999; Haaga, et al.,
1993) and another failing to demonstrate this effect (Crits- 1991). For the SETB cycle, four hypotheses are particularly
AQ5 Christoph, Cooper, & Luborsky, 1988). relevant for depression: (a) negativity, depression is charac-
In summary, the CCRT appears to be a case formula- terized by the presence of self-referent negative thinking,
tion method that is reliable, valid, and related to improved (b) specificity, depression has a distinct cognitive profile in
outcomes. However, the CCRT development group has terms of both content and process, (c) selective-processing,
undertaken most of the research, and it remains to be seen depression is characterized by a processing bias for negative
whether independent research will replicate these find- self-referent information, and (d) primacy, negative cogni-
ings. Nonetheless, the CCRT method suggests that a sys- tion influences behavior and emotion. For the negativity
tematic and coherent case formulation approach, when hypothesis, the large majority of critical studies have sup-
used by well-trained and skilled practitioners, can meet ported this notion, using both thought “checklists” and
the scientific criteria we have set out. We would argue more open-ended inquiries about the content of cognition
therefore that this brief review of the CCRT suggests the (A. T. Beck, Brown, Steer, Eidelson, & Riskind, 1987;

COGNITIVE CASE FORMULATION • BIELING & KUYKEN 55

Dobson & Shaw, 1986; Hollon, Kendall, & Lumry, 1986; heart palpitations), and behavior (e.g. avoidance or safety
Ingram, Kendall, Smith, Donnell, & Ronan, 1987; Whis- behavior). Supporting such models, a recent review con-
man, Diaz, & Luboski, 1993). The specificity hypothesis cluded that individuals with panic disorder selectively
argues that psychological disorders can be distinguished attend to threat words and uncomfortable physical sen-
from one another according to distinct cognitive profiles, sations, and social phobics attend selectively to social threat
and indeed depression does appear to be characterized by words (Antony & Swinson, 2000). Individuals with panic
negative cognitions when compared to cognition in other disorder also display explicit and implicit memory biases
disorders (A. T. Beck, Steer, & Epstein, 1992; Clark, Beck, for threat words and physical sensations (Amir, McNally,
& Stewart, 1990; Sanz & Avia, 1994; Steer, Beck, Clark, & Riemann, & Clements, 1996; Lundh, Czyzykow, & Öst,
Beck, 1994). Also, there is good evidence for the selective- 1997; Westling & Öst, 1993). Social phobics also appear
processing hypothesis—depressed persons show a bias to- to be better at remembering faces with a negative or crit-
ward selecting mood-congruent, negative information ical expression, and are more likely to interpret ambiguous
from the environment—and many studies do suggest that social interactions negatively (Constans, Penn, Ihen, &
depressed individuals find negative and positive interpre- Hope, 1999; Gilboa-Schechtman, Freshman, Amir, & Foa,
tations of ambiguous stimuli equally acceptable, whereas 1997; Lundh & Öst, 1996). Overall, this research suggests
nondepressed individuals prefer positive interpretations a coupling of thoughts, emotions, and physical sensations
(e.g., Crowson & Cromwell, 1995, Dykman, Abramson, in anxiety.
Alloy, & Hartlage, 1989; Moretti et al., 1996; Weary & In personality disorders cognitive models emphasize
Williams, 1990). that SETB processes are rooted in deeper cognitive struc-
Most critical for formulation, the primacy hypothesis tures that are central to personality dysfunction (A. T.
suggests a link between negative thoughts, emotions, and Beck et al., 1990; Young, 1990). To date, research on the
behavior. One research program has illustrated that rumi- model is limited, perhaps because of the heterogeneity of
native, self-focused negative thoughts are systematically re- personality disorders and difficulties with reliable diag-
lated to enduring negative mood, particularly among nostic schemes (Arntz, 1999). Nonetheless, in one study
depressed women (Nolen-Hoeksema, 1991; Nolen- using a cognitive profile approach, researchers identified
Hoeksema, Morrow, & Fredrickson, 1993). Other studies a higher proportion of sociotropic thoughts and beliefs
attempt to reduce negative thought content to examine the in Cluster C patients, especially in dependent personality
impact of such cognitive change on affect (Persons & disorders (Nordahl & Stiles, 2000). Preliminary research
Burns, 1985; Teasdale & Fennell, 1982). Overall, both in this area has also supported the cognitive model’s pre-
types of studies demonstrate a reciprocal link between neg- diction that people with particular personality disorders
ative moods and negative thoughts. Depressed individuals will report specific maladaptive beliefs (Dreessen, Arntz, AQ6
also demonstrate negative interpersonal behavior that can Hendriks, Keune, & van den Hout, 1999; Veen & Arntz,
be reliably distinguished from that of nondepressed indi- 2000). Although the overall number of studies is small and
viduals (e.g. Bieling & Alden, 2001; Coyne, 1976; Gotlib contains quite heterogeneous personality pathology in dif-
& Hammen, 1992; Joiner & Metalsky, 1995). Overall, ferent samples, this research has generally supported the
then, for depression there appears to be consistent evi- presence of personality-related processing biases at the level
dence for most components of the SETB cycle, including of automatic thoughts.
negativity, specificity, selective processing, and primacy.
Models for anxiety disorders emerged somewhat later Early Life Events, Parenting, and Cognition
than the original cognitive theory of depression, so less re- A second central feature of cognitive formulation is the de-
search is available on the SETB cycle in anxiety disorders. velopment of a cognitive diathesis. Cognitive theory posits
However, cognitive models of the various anxiety disor- that the “child learns to construe reality through his or her
ders, including generalized anxiety disorder, panic disorder, early experiences with the environment, especially with
and social phobia, use conceptual-theoretical models that significant others,” and that “sometimes, these early expe-
incorporate a cue or situation (e.g., a social situation or an riences lead children to accept attitudes and beliefs that
anomalous physical sensation), a cognition (e.g., threat will later prove maladaptive” (A. T. Beck & Young, 1985,
thoughts), emotional and physical reactions (e.g., fear and p. 207). This notion, termed developmental cognitive media-

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V10 N1, SPRING 2003 56

tion, states that cognitive processes and maladaptive beliefs of what mechanisms mediate pathways to risk of psycho-
mediate between developmental risk factors and subse- pathology unanswered. To date, only limited innovative
quent onset of depression, anxiety, and personality dis- work is beginning to address cognitive mechanisms. This
orders (Ingram & Price, 2001). Given that comprehensive work tentatively suggests that maladaptive beliefs about
and high-quality reviews of these literatures exist (see In- the self and others may emerge early in the development
gram and Price), only a brief summary of the evidence of at-risk children (e.g., Bartholomew & Horowitz, 1991;
base, with some representative studies, will be included Coyne & Whiffen, 1995; Taylor & Ingram, 1999). We sug-
here. gest that there are probably sufficient grounds in the
There is consistent support that loss in childhood (e.g., research literature for practitioners to introduce develop-
Andrews & Brown, 1995; Bifulco, Brown, & Harris, 1987; mental trauma as important antecedents of psychopathol-
Brown & Harris, 1978; Harris, Brown, & Bifulco, 1986), ogy, but the research does not yet support the notion of
problematic parenting behaviors (e.g., Brewin, Firth- specific, cognition-based linkages between adversity and
Cozens, Furnham, & McManus, 1992; Cohn, Matias, the development of specific disorders.
Tronick, Connell, & Lyons-Ruth, 1986; Field, 1984; Gar-
ber, Robinson, & Valentiner, 1997; Hammen et al., 1995; Core Beliefs
Parker, 1983; Reinherz, Giaconia, Hauf, Wasserman, & Core beliefs, or schemas, are fundamental to the cognitive
Silverman, 1999; Tronick & Gianino, 1986), and child- theory of depression (A. T. Beck, 1967; Clark & Beck,
hood sexual abuse (Andrews, Brown, & Creasey, 1990; Bi- 1999), anxiety (A. T. Beck & Emery, 1985), and person-
fulco, Brown, & Adler, 1991; Lizardi et al., 1995; Rose, ality disorders (A. T. Beck et al., 1990). These deep cogni-
Abramson, Hodulik, Harberstadt, & Leff, 1994) increase tive structures are described as information-processing
the risk for development of depression. However, there constructs that also contain specific content (Clark & Beck,
have been relatively fewer tests of the developmental cog- 1999; Williams, Watts, MacLeod, & Matthews, 1997). Re-
nitive mediation hypothesis. In one study using an under- searchers have used a variety of experimental paradigms to
graduate sample, limited support was found for a mediating examine core beliefs, including sentence completion and
relationship of cognitive variables between reports of mal- autobiographical memory recall, and, indeed, numerous
adaptive parenting and subsequent depression (Whisman & studies support the notion of nonconscious, or deep, sche-
McGarvey, 1995). In another study using a young- matic processing in depression and anxiety (Antony &
adolescent sample, self-worth was found to mediate be- Swinson, 2000; Teasdale & Barnard, 1993; Teasdale, Tay-
tween reports of maternal parenting and depressive lor, Cooper, Hayhurst, & Paykel, 1995). There is also strong
symptoms (Garber et al., 1997). evidence that, even between episodes of depression, evi-
Research on cognitive mediation in anxiety is also lim- dence of potentially depressogenic beliefs can be found
ited. In a comprehensive review of this literature, Rapee by using experimental probes (Ingram et al., 1998; Segal,
(1991) concluded that there is a surprising consistency in Gemar, & Williams, 1999). Overall, there is substantial
the research literature suggesting that reports of parental evidence for the operation of deep cognitive structures in
overcontrol are associated with anxiety disorders (e.g., depression, though many specific aspects of these struc-
Dumas, LaFreviere, & Serketich, 1995; Siqueland, Kendall, tures, including their content, are not well understood
& Steinberg, 1996). A more substantive body of research (Clark & Beck, 1999).
has examined the developmental hypotheses for personal- For anxiety the research literature on core beliefs is less
ity disorders (See Bernstein, Cohen, Skodol, Bezirganian, well developed. However, it has been argued that anxiety
& Brook, 1996; Cicchetti & Cohen, 1995; Geiger & Crick, is related fundamentally to activation of a “threat mode”
2001; Millon & Davis, 1995), but, again, the direct evi- that marshals cognitive resources to minimize risk to the
dence for cognitive mediation in these studies is limited. organism (A. T. Beck & Clark, 1997). Another promising,
Support for the notion that early adversity leads to potentially parallel, line of enquiry known as looming mal-
psychopathology, including depression, anxiety disorders, adaptive style (LMS) has also recently been described (see
and personality disorders seems clear. However, there is a Riskind, Williams, Gessner, Chrosniak, & Cortina, 2000,
paucity of research addressing the developmental cognitive for a detailed exposition). There is a reliable self-report
mediation hypothesis, leaving the answer to the question measure of LMS (the LMSQ;Riskind et al., 1992) designed

COGNITIVE CASE FORMULATION • BIELING & KUYKEN 57

to measure expectations about the dynamic progression of based on content, these attitudes may confer vulnerability
threatening situations (Riskind, Kelly, Moore, Harman, & for a variety of different disorders (A. T. Beck, Brown,
Gaines, 2000). Overall, the investigation of core beliefs and Steer, & Weissman, 1991). For example, in personality dis-
schemas in anxiety is still developing, and it is difficult to orders one study using the DAS found that the scores of
make detailed or comprehensive conclusions. people diagnosed with borderline personality disorder
In personality disorder core beliefs or schemas are were higher than those of a control group and quite high
viewed as critical to initiating and maintaining psy- when compared to norms of people with other diagnoses
chopathology (A. T. Beck et al., 1990; Pretzer & Beck, (O’Leary et al., 1991). However, for all the categories of
1996), and two self-report instruments have been devel- disorder we chose to examine, there is little other research
oped to assess the presence of these deep cognitive struc- on the issue of conditional assumptions.
tures. The Young Schema Questionnaire (YSQ; Young,
1990) was developed to assess early maladaptive schemas Compensatory Strategies
(EMS), and in one validity study a number of EMSs were Cognitive formulation makes two related hypotheses about
more prominent in the students who scored highest on coping and compensatory strategies. First, in the presence
personality disorder pathology (Schmidt, Joiner, Young, of stressors, maladaptive use of cognitive and behavioral
& Telch, 1995). Using a different approach, A. T. Beck coping strategies increases the chance of symptom onset or
and J. S. Beck (1991) have developed the Personality Be- symptoms’ worsening. Second, the activation of maladap-
liefs Questionnaire (PBQ) based on current Diagnostic and tive beliefs leads to the use of maladaptive compensatory
Statistical Manual of Mental Disorders (American Psychiatric strategies directed at deactivating the beliefs and reducing
Association, 1994) categorizations of personality disorders. the associated negative affect ( J. S. Beck, 1995). The issue
Using this measure, several studies suggest that dysfunc- of cognitive factors leading to maladaptive coping strategies
tional beliefs hypothesized to characterize personality dis- has not yet been addressed in anxiety or personality disor-
orders are indeed reported at higher rates among people ders. Some research is available in depression, however.
diagnosed with these personality disorders (Beck et al., For example, coping has been found to mediate the rela-
2001; Kuyken et al., 2001). Overall, then, there is some ev- tionship between stressful events and symptoms (Coyne,
idence to support the notion of deep cognitive structures Aldwin, & Lazarus, 1981; Billings, Cronkite, & Moos,
in depression, anxiety, and personality disorders, and some 1983; Swindle, Cronkite, & Moos, 1989), conditional be-
instruments are available to examine these constructs. liefs have been associated with perceptions of social support
However, researchers are far from having a comprehensive (Kuiper, Olinger, & Swallow, 1987; Norman, Miller, &
understanding of how such schemas operate and in what Dow, 1988), and people diagnosed with depression en-
circumstances. This kind of knowledge will have to come gage in more avoidance coping and less approach coping
from carefully conducted experiments and may require the (Billings & Moos, 1984, 1985; Billings et al., 1983; Coyne
development of entirely new research paradigms that go et al., 1981; Kuyken & Brewin, 1994). Despite these find-
beyond self-report (Segal & Swallow, 1994). ings, there is little consensus about the connection be-
tween specific cognitions and specific coping strategies.
Conditional Assumptions
The issue of conditional assumptions in cognitive formu- The Relations Between Constructs of the Formulation Model
lation has received limited empirical attention in the de- Thus far, our review has addressed the main elements of
pression literature and almost none in the anxiety disorders cognitive formulation with the model “cleaved at its
and personality disorders domains. The most comprehen- joints.” We also have addressed what research is available
sive measure of this aspect of the cognitive model is the regarding the theorized relationships between adjacent
Dysfunctional Attitudes Scale (DAS; Weissman & Beck, elements of the model as set out in diagrammatic form
1978), though it is still unclear whether this scale is specific by J. S. Beck (1995). Our review suggests limited to good
only to depression or might be useful in other disorders. support for many of the elements of the formulation when
Because of its content, the DAS may also have applications considered in isolation. However, an analysis of higher
in the anxiety and personality disorders. Nine types of con- order questions that seek to link different components
ditional assumptions are reliably measured by the DAS, and across the “joints” of the model is premature. The amount

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V10 N1, SPRING 2003 58

of evidence is typically stronger for depression, probably A BOTTOM-UP ANALYSIS OF COGNITIVE CASE
because the cognitive model was originally derived in FORMULATION: ARE COGNITIVE CASE FORMULATIONS
RELIABLE, VALID, AND POSITIVELY RELATED TO
depression. Considering only depression, we have seen
OUTCOME?
good evidence for the situation-emotion-thought-behavior
Our second-phase evaluation concerns the bottom-up cri-
cycle, deep cognitive structures, and maladaptive compen-
teria. Specifically, is the process of case formulation reliable,
satory strategies. However, our review also suggests that
clinically valid, and related to improved outcomes?
there is little evidence linking deep cognition to its pro-
posed antecedents, early life events, or its proposed conse-
quences, conditional beliefs, and compensatory strategies. Reliability of Cognitive Case Formulation
Also, although there is increasingly strong evidence for the Can cognitive therapists reliably formulate cases by using
existence of deep-level cognition, much less is known cognitive case formulation systems? In an early study raters
about the structure and processes that govern this level proved 76% accurate in identifying hypothesized under-
of cognition in depression when compared to biases in lying cognitive mechanisms for particular patients that
thinking. had been selected for study by an independent group of
For anxiety, our review suggests that there is consider- therapists (Beckham, Boyer, Cook, Leber, & Watkins,
able evidence for the link between particular cues, anx- 1984). Persons, Mooney, and Padesky (1995) had clini-
ious thoughts, emotions of fear, and physiological arousal. cians identify overt problems and underlying schemas or
Less well characterized in anxiety are developmental beliefs. The results suggested generally good agreement
antecedents, conditional assumptions, and compensation among judges in identifying manifest presenting problems
strategies tied to these beliefs. This paucity of research may but poor agreement in identifying the hypothesized
be a result of the heterogeneity of the anxiety disorders, or underlying cognitive mechanisms. In a further study Per-
the fact that cognitive models for these disorders developed sons and Bertagnolli (1999) attempted to increase reliabil-
more recently than models for depression. Certainly the ity by supplying clinicians with a specific set of problem
notion of a primal threat mode or maladaptive looming domains (psychiatric symptoms, as well as interpersonal,
style is a promising line of inquiry for understanding work, financial, health, housing, and recreational prob-
deeper levels of cognition in anxiety. lems) and more formalized assessment of schemas (using
For personality disorders there are many fewer studies anchor points and specific definitions of a variety of
that have focused on cognitive factors specifically. Al- schemas). Inter-judge reliabilities in assessing schemas re-
though some measures of personality-related beliefs exist mained poor, (κ: 0.37, single judges; 0.72, averaged across
(e.g. YSQ and PBQ), there are few studies using informa- five judges; Persons & Bertagnolli, 1999). However, greater
tion-processing paradigms to validate the SETB cycle in training was associated with somewhat greater reliability
personality disorders. Some results appear promising, but (Persons & Bertagnolli). In a very recent study use of a
the heterogeneity of personality disorders will make vali- highly systematized case formulation method led to con-
dation a long and challenging process. Nonetheless, the ev- siderably higher reliability on some (e.g., core beliefs) but
idence base appears to be growing, and interest in cognitive not all inferential aspects (e.g., dysfunctional assumptions)
formulation and cognitive models of personality disorder of cognitive case formulation (Fothergill & Kuyken, 2002).
is increasing (cf. Arntz, 1999). The findings for level of training were inconclusive, with
Taken together, the elements of our review suggest that the most experienced therapists showing highest agree-
at a nomothetic level cognitive theory of depression, anx- ment on some key elements (e.g., of the primary core be-
iety disorders, and personality disorders is supported in liefs). However, they were not consistently more reliable
many of its descriptive hypotheses, and cognitive models than the less experienced groups. Finally, in an atheoreti-
are under-studied in their more difficult-to-operationalize cal study of the case formulation method, good agreement
explanatory hypotheses. Thus, in the transfer to the idio- was found for the descriptive but not the inferential aspects
graphic level, which defines case formulation, it follows of case formulation (Eells, Kendjelic, & Lucas, 1998).
that descriptive statements are justifiable, but explanatory These studies suggest that good reliability can be obtained
statements should be stated as exploratory hypotheses at for the descriptive but not the inferential aspects of cogni-
best. tive case formulation, and that reliability may be improved

COGNITIVE CASE FORMULATION • BIELING & KUYKEN 59

 through training and use of more systematic case formula- Clinical Validity of Cognitive Case Formulation
tion methods. Are the key constructs in case formulations meaningfully
It is important to note that judgments and inferences related to a person’s presenting problems? Our earlier brief
linking a person’s presenting problem to a psychological ac- review of the CCRT outlined a range of studies examin-
count of the problem are complex and multidetermined. ing this question. We know of no evidence that attempts
There is a distinguished theoretical and research lineage to show hypothesized relationships between the content
suggesting that when people are faced with complex de- of a cognitive case formulation and related aspects of
cisions they maximize the chance of efficient decision by psychological-psychiatric functioning in a particular case.
taking cognitive shortcuts. The short-cut heuristics in- In short, there is no evidence to confirm or falsify the va-
clude halo effects, illusory correlations, framing biases, re- lidity of cognitive case formulation.
cency effects, confirmatory biases, and failure to consider
AQ7 normative standards (e.g., Dawes, 1986; Kuhberger, 1998; Relationship Between Case Formulation and Treatment Outcome
Meehl, 1954, 1973; Simon, 1957; Spengler & Strohmer, Does cognitive case formulation lead to improved treat-
1994; Turk & Salovey, 1988; Wilson, 1996). For example, ment and treatment outcomes? Hayes, Nelson, and Jarrett
a clinician who has a hypothesis that a person’s depression (1987) have argued that the treatment utility of a case for-
is underpinned by a “powerlessness” core belief may look mulation is the cornerstone of its value. We agree that, to-
only for confirming evidence (confirmatory bias) and see gether with reliability and validity, this criterion should be
her or his client’s difficulties regaining employment as a a primary one whereby case formulation stands or falls. To
consequence of this belief (illusory correlation). Clinicians our knowledge, there is limited evidence linking case for-
may make these errors so habitually that in cognitive case mulation with outcome.
formulations of identical cases using identical formulation One early study compared manualized with individu-
methods it is not possible to accurately establish consensus. alized marital therapy of distressed couples. In the individ-
It follows from this fact that more systematic and objective ualized intervention, only interventions that matched a
case formulation systems should be less prone to these in- formulation of the couples’ problems were offered. Al-
ferential biases, and “true” rates of agreement between cli- though both conditions were comparable at termination,
nicians should be observable. individualized treatment led to somewhat improved main-
In summary, past studies make plain a method for eval- tenance of gains at 6-month follow-up ( Jacobson et al.,
uating the reliability of formulation, and they appear to 1989). It is worth noting, however, that the distinction be-
offer evidence that at least some aspects of the model can tween manualized and individualized formulation and
be reliably identified by multiple judges. Moreover, there treatments is somewhat arbitrary, because many factors
is some evidence that more systematic cognitive case for- confound this distinction (client, therapist, and therapy
mulation methods lead to greater reliability and appear to process variables). Furthermore, there is some evidence
improve with training. However, given the methodologi- that therapists tailor manuals to individuals, even if in-
cal constraints, the studies reviewed here are still inade- structed not to (Schulte, Kunzel, Pepping, & Shulte-
quate tests of the reliability of formulation. Finally, there Bahrenberg, 1992).
are two important caveats in establishing the reliability of Cognitive analytic therapy (Ryle, Leighton, & Pollock,
case formulation. First, it may yet be found that clinicians 1997) involves the therapist and client in writing a joint
can reliably complete case formulations; however, this does formulation letter early in therapy. Research using a
not mean that they are valid. Furthermore, whether clini- multiple-baseline, case study approach found no support AQ8
cians can reliably formulate a case is quite distinct from for the hypothesis that the formulation letter would lead to
whether the constructs relate to each in the hypothesized improvements in the therapeutic alliance and treatment
manner across situations or time. We know of no studies outcomes (Evans & Parry, 1996). Two linked studies have
that bear on the reliability of cognitive case formulations used a similar single-case series design to establish the ef-
across situations or time. fect of case formulation on the therapeutic relationship,
beliefs, and symptoms among people with delusions
(Chadwick, Williams, & MacKenzie, in press). It is inter-

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V10 N1, SPRING 2003 60

esting that cognitive case formulation did not discernibly treatment. On the other hand, the use of systematic idio-
affect patients’ ratings of the alliance, but did positively in- graphic cognitive formulation is a relatively recent devel-
fluence therapists’ ratings of the alliance (Chadwick et al.). opment and, with a few notable exceptions (Fothergill &
Furthermore, case formulation, as an intervention in its Kuyken, 2002; Persons & Bertagnolli, 1999), has generated
own right, did not clearly impact beliefs or symptoms, almost no research. In terms of clinical practice, it is in-
even though the evidence suggested that successful subse- creasingly accepted as a dictum among cognitive therapy
quent restructuring of beliefs led to symptom improve- trainers that a comprehensive and valid case formulation is
ments (Chadwick et al.). Of note, the Chadwick et al. needed to successfully treat a person in distress, even more
study is limited to people with psychosis, where the effi- so when the presenting problems are complex ( J. S. Beck,
cacy and effectiveness of cognitive therapy are not fully es- 1995; Needleman, 1999). Indeed, a great deal of time and
tablished and treatment approaches are in development. expense is devoted to the training and supervision of
Finally, these studies share the assumption that the formu- novice cognitive therapists in “the art of case formulation.”
lation should be explicitly shared with the client, whereas Furthermore, cognitive formulation is increasingly being
this sharing is not necessarily a feature of cognitive therapy. used in therapy process research and therapy trials. Beyond
We may use an analogy: A navigator who shares the whole any doubt, cognitive therapy case formulation shows the
road map with the driver may hinder rather than help the promise of meeting the fertility criterion in both practice
driver to keep on track, because the driver is given infor- and research.
mation not directly relevant to the current task and the In terms of the acceptability and usefulness of cognitive
amount of information may be overwhelming. case formulation to clients in cognitive therapy, we know
In summary, there is no compelling evidence linking of almost no research. Chadwick et al. (in press) inter-
cognitive case formulation to improved treatment out- viewed 11 patients with psychosis who had been treated
comes. Indeed, the only positive benefit, noted in one with cognitive therapy, which included a shared cognitive
study, has been improved ratings of the therapeutic alliance case formulation. It is interesting that clients reported pos-
by the therapist. Although standardized cognitive formula- itive (reassured, encouraged, and hopeful) and negative
tions have only recently been published and there has been (saddened, upset, and worried) emotional reactions. The
little time to establish the relationship to outcome, this ab- reactions were based on increased understanding and see-
sence of support for what we consider a basic criterion is ing a way forward on the positive side and on increased
of considerable concern. However, we would argue that perceptions of problems as complex and longstanding on
this may reflect a rather simplistic approach to the issues to the negative side. This suggests that clients may experience
date. Studies have made the problematic assumption that cognitive case formulation as useful but may also experi-
case formulation might directly impact outcome, rather ence it as unhelpful.
than indirectly through the selection of appropriate inter- In insolation, the fertility criterion is neither necessary
ventions. The Jacobson et al. (1989) study offers some nor sufficient to endorse the use of case formulation, be-
support for the argument that the usefulness of case for- cause clinical psychology is littered with examples of highly
mulation is in selecting the most appropriate interventions fertile but ultimately unsubstantiated ideas. However—to
at the most appropriate time. Can cognitive case formula- use an evolutionary analogy—the “fitness” of an idea will
tion be expected to have a direct impact on outcome, or, determine its advance. In this sense, the systematic evalu-
as has been suggested with the CCRT, might cognitive ation of the case formulation approach can only contribute
case formulation affect outcome only through the selection to its fitness with respect to a fuller understanding of its ex-
of appropriate interventions (Crits-Christoph et al., 1988)? planatory power, clinical application, and acceptability to
cognitive therapy providers and consumers.
Usefulness in Practice of an Evidence-Based Cognitive Case
Formulation Approach A RESEARCH AGENDA FOR COGNITIVE CASE
How useful in practice is cognitive case formulation? At FORMULATION
the nomothetic level cognitive theory and therapy have Although the efficacy and effectiveness of cognitive ther-
generated more research than any other psychological apy for patients with a range of Axis I and some Axis II dis-

COGNITIVE CASE FORMULATION • BIELING & KUYKEN 61

 orders are established (DeRubeis & Crits-Cristoph, 1998), practicing cognitive therapists, analyzing transcripts of
an outstanding challenge is to provide an evidence base to therapy sessions, or using survey, interview, and qualitative
the individualized formulations that cognitive therapists research methods. It is likely that this research will ask more
use to understand their clients’ presenting problems and questions than it answers, notably by posing the further
plan their interventions. For the top-down dimension of question, what factors determine which case formulation
evidence-based cognitive case formulation, research is be- approaches are best suited to particular therapeutic con-
ing undertaken that addresses the explanatory elements of texts, clients, and therapists? The case formulation ap-
cognitive theory of a wide range of disorders. From our re- proach for a minimally trained cognitive therapist working
view, we suggest that researchers would be served by ex- in an assertive outreach service for young men with a
amining those “top-down” areas in which evidence for first episode of psychosis is likely to be very different
the formulation is weak or equivocal. Nomothetic tests of from the approach taken by a highly trained therapist
the cognitive model that keep in view not just a specific working in a specialist outpatient clinic for people with
hypothesis about a particular disorder, but also the general mood difficulties.
formulation model, will yield the most important advances There are many outstanding questions about the relia-
for both researchers and clinicians. Luckily, research on bility of cognitive case formulation. Given that the litera-
“top-down” questions emerges almost daily. Thus, the ture is conflicting (e.g., Fothergill & Kuyken, 2002; Per-
outstanding questions about cognitive theory’s ability to sons & Bertagnolli, 1999), it will be important to establish
explain, as well as describe, a range of emotional disorders under what circumstances cognitive therapists can agree
will probably be answerable in due course. In stark con- about a case formulation. There are large related research
trast, there is an urgent need for programmatic research to literatures addressing the question of how people make
answer the many outstanding questions relating to the complex decisions and how decision making is affected
bottom-up dimension of case formulation. That is to say, by a range of situational and individual factors: the per-
what is the evidence base for the many claimed benefits of son’s values, cognitive complexity, and preferred decision-
cognitive case formulation? We have identified several making style; and the situation’s inherent complexity, risk,
foci for this research. The fact that research into the CCRT and uncertainty. Examining clinical decision-making pro-
case formulation method has yielded important advances cesses using established theoretical and methodological
in our understanding about the brief psychodynamic approaches from the decision-making literature (e.g.,
treatment modality (Luborsky & Crits-Christoph, 1998) Dawes, 1986; Kuhberger, 1998) will shed valuable light on
attests to the feasibility of the research program we suggest. the understanding of how therapists make decisions during
AQ9 A first wave of exploratory research might usefully de- the formulation process and when this decision making
velop basic understanding of how practicing cognitive breaks down. Initial studies might identify to what extent
therapists formulate in the real world. For example, how and under what circumstances therapists use various
widely is case formulation practiced by cognitive thera- information-processing biases (e.g., framing, confirmatory,
pists? What form of case formulation is used most often? and recency). An early example of this work amongst the-
At what stage in the assessment-intervention process do oretically eclectic counselors showed that counselors who
cognitive therapists derive working formulations, and how scored lower on a cognitive complexity task were more
are these working formulations revised during ongoing likely to use problematic short-cut heuristics in their clin-
work? What does the application of case formulation look ical decision making (Spengler & Strohmer, 1994). Repli-
like in practice: Does the therapist hold the map, sharing cations and extensions of this sort of study will be of
directions only on an as-needed basis, or is the map as a considerable value.
whole drawn up collaboratively and agreed upon before There are obvious ways in which the methodology of
the therapist and client set off? And what are therapists’ existing reliability studies can be improved. Studies to date
views of the role and importance of case formulation in have used convenience samples rather than fully trained or
their work? Much is assumed about case formulation in established cognitive therapists who might have a better
practice (e.g., Needleman, 1999), and this research would understanding of the theoretical concepts at hand and their
enable research-based advances in the profession’s under- practical application. Furthermore, a combination of well-
standing. This work could take the form of interviewing controlled studies (e.g., Fothergill & Kuyken, 2002) with

CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE • V10 N1, SPRING 2003 62

studies which use the data available to real-world clinicians ing problems, problems encountered in therapy process
(namely videos of face-to-face interviews) is likely to en- and problems that are discussed recurrently in therapy ses-
able increases in understanding. Finally, we would recom- sions. In short, can the formulation predict what clients
mend that studies incorporate in their design the clinical will think, feel, or do and what will happen over the course
reality that case formulation is an ongoing process, re- of cognitive therapy?
sponsive to new data within and between therapy sessions. Perhaps most important, future research should concern
Is there evidence of change in therapists’ formulations on itself with the link between formulation and outcome.
aspects of the formulation that would require adaptation as Studies in this area could examine whether cognitive ther-
new information becomes available? Is there evidence of apists whose cognitive interventions are based on a solid
test-retest reliability on aspects of the case formulation that working formulation achieve better outcomes than ther-
would be expected to remain constant over time? apists who do not use formulation. A related research ques-
The sorts of reliability studies we have suggested pose an tion would be whether adherence to a high-quality case
additional question: Do certain decision-making heuristics formulation improves treatment outcome through in-
affect the process of therapy? The finding that greater creased therapeutic focus. A variable of interest in this sort
counselor cognitive complexity prevents diagnostic over- of study might be case complexity, with the working hy-
shadowing (Spengler & Strohmer, 1994) suggests several pothesis that adherence should prove more useful with
plausible case formulation studies. For example, a study complex patients. Finally, our review suggests that the
might examine whether cognitive therapy for personality research concerning whether aspects of case formula-
disorders is more successful when undertaken by cognitive tion are associated with better therapeutic relationship
therapists with greater cognitive complexity. Increased so- has produced conflicting findings both in the CCRT and
phistication in therapy process research enables these sorts cognitive therapy literatures. Clearly, further research is
of questions to be answered by careful examination of tran- required to increase understanding of the relationship be-
scripts of therapy sessions (to identify when ruptures occur tween case formulation, the therapeutic alliance, and ther-
and examine how they are resolved) and session-by-session apeutic outcome.
measurement of changes in presenting problems and gen- Although we have set out several criteria for evaluating
eral functioning. cognitive case formulation and have suggested avenues for
A further phase of research is required to establish research, it is important to note that not all criteria must be
whether the cognitive case formulation has construct and met for formulation to have value. Formulations may be
convergent validity; that is, do cognitive case formulations reliable and valid but have no impact on treatment out-
relate meaningfully to people’s problems and the factors come. In contrast, they may be unreliable and invalid but
underlying these problems? Triangulation methodologies, lead through some alternative mechanism (e.g., increasing
in which the case formulation is one corner of the tri- therapist self-confidence or enhanced alliance) to improved
angle, would yield valuable information about whether outcome. The research we have outlined would begin to
therapists’ case formulations map meaningfully onto a per- answer these questions and determine which criteria are
son’s problems. Other corners of the triangle might be the ultimately most important. This agenda will enable cogni-
client’s own formulation; the clinical supervisor’s inde- tive therapy research and training programs to include
pendently derived formulation; the person’s diagnostic training in evidence-based case formulation.
profile; information derived from standardized measures
of cognition, affect, and behavior; and information derived CONCLUSION
from methods used routinely in cognitive therapy to derive The cognitive formulation is truly open to investigation
core beliefs (e.g., downward-arrow technique), dysfunc- with experimental methods because of its level of detail,
tional assumptions (e.g., dysfunctional thought records), specificity, and relative simplicity. In reality, the cognitive
and compensatory strategies (e.g., A-B-C analysis; J. S. case formulation is highly interwoven with research into
Beck, 1995). It is also important to establish whether case cognitive theory. The formulation method has deep roots
formulations have predictive validity. A case formulation in these research programs and likely could not have
should enable researchers to make predictions about ex- evolved without this research. Moreover, much of the re-
pected relationships between the formulation and present- search completed to test cognitive hypotheses, especially

COGNITIVE CASE FORMULATION • BIELING & KUYKEN 63

work examining cognitive mediation, has direct implica- 3. This review is necessarily brief, in part because several
tions for case formulation. high-quality reviews of this literature are readily available.
Our review suggests that, contrary to the claimed be-
nefits of cognitive case formulation, it is not a panacea,
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