As a cognitive-behavioral therapist, have you wondered how to effectively understand the problem your patient comes to you with? How to discover the mechanisms underlying the problems and plan effective therapy? The key to success is a well-conducted conceptualization of the patient’s problem. In this article, you will learn what conceptualization is, how to build a good and useful conceptualization. You will get to know the most important conceptualization models in CBT therapy.
What is conceptualization?
Conceptualization (formulation) is simply the creation of a working model that allows the psychotherapist to explain the psychological basis of the difficulties reported by the patient. It is the foundation on which the entire therapeutic plan is built. Conceptualization is an attempt to recognize the patient’s personal pattern of cognitive functioning. It is a kind of “map” showing how different elements of the patient’s experience connect and maintain their difficulties.
Please remember that working together with the client on the conceptualization of their case is key to successful therapy. Why? Because no one knows the client’s experience better than they do. Using their knowledge and observations, you can create a more complete and accurate picture of the situation.
How to build a conceptualization?
First – gather all relevant information. The source of knowledge will be not only direct conversation with the patient, but also test results, questionnaires, as well as an inquisitive interview about development, relationships, and past events. The more specifics you can gather, the better. Please remember that if you are unable to obtain the most important information from the patient, you can always return to the conversation at the next meeting.
Second – organize the data using theoretical categories. Try to make sense of the patient’s story. Automatic thoughts, core beliefs, coping strategies are the “heart” of conceptualization. Ask about the patient’s thoughts and emotions, how they have dealt with difficulties so far.
Third – form hypotheses and don’t seek their confirmation. By listening carefully and asking questions, you will verify your assumptions about the mechanisms of the problem. Remember to refrain from hasty interpretations – the patient is the expert on their own life.
Fourth – create a coherent conceptualization model. Try to identify factors that may have contributed to the problem and factors that maintain it “here and now”. Such a model will allow you to predict difficulties and plan appropriate interventions.
Fifth – have the courage to modify the conceptualization. Conceptualization is not a rigid element – it should evolve as therapy progresses and new information emerges. Be open to collaborating with the patient and making changes to the original concept.
Characteristics of a good conceptualization
Individualization
- It is “tailored” to a specific patient.
- Takes into account their unique history and life context.
Understanding
- It is clear and transparent for the patient.
- Allows the patient to see connections between key elements.
- Connects past experiences with current difficulties.
Comprehensiveness
- Includes all relevant areas:
- Current problems.
- Past events.
- Core beliefs.
- Coping strategies.
- Maintaining factors.
- Patient’s resources.
Dynamics
- It is modifiable as therapy progresses.
- Evolves with new information.
- Remains a “living document”.
Practicality
- Indicates clear therapeutic goals.
- Suggests specific interventions, especially in the area of relationships.
- Allows prediction of potential difficulties.
Empiricism
- It is based on evidence.
- Contains concrete examples from the patient’s life.
- Can be verified during therapy.
Coherence
- All elements logically connect with each other.
- Shows clear cause-and-effect relationships.
- Creates a meaningful whole.
Please remember that a good conceptualization answers key questions:
- How did the patient’s problems develop?
- What currently maintains them?
- What are the main patterns of thinking and behavior?
- How can the vicious cycle be broken?
Levels of conceptualization
Level 1 – what is happening?
- Gather all relevant information about the patient’s current difficulties.
- Identify problem areas (what, when, where, how often does it happen?).
- Determine what the problem prevents the patient from doing (goals and values).
- The “miracle question” will elicit expectations and vision for change.
- Helpful questions: how would you describe your problem? What brings you to therapy? What is your biggest concern? Imagine waking up and the problem is gone – what would you do differently then?
Level 2 – why is this happening?
- Create hypotheses explaining the mechanism of the problem’s formation and maintenance.
- Examine the history of the development of difficulties (when they began, what intensifies/weakens them, what life events and messages from the past may have influenced them).
- Identify critical events from the patient’s life, automatic thoughts, emotions, behaviors, and beliefs specific to the patient.
- Ask about the patient’s past, their experiences with parents and peers. Ask about initial difficulties and how the patient dealt with them.
- Look for resources and factors facilitating change (strengths, successes, relationships).
- Valuable questions: how does it usually start? How do you recognize the problem? What thoughts come to your mind? What do you do in such a situation? How did you perceive yourself and the world as a little girl/boy? Who/what helped you deal with difficulties?
Dimensions of understanding – who do we create the conceptualization for?
In your therapeutic practice, you will work with two types of conceptualization:
Cross-sectional conceptualization – this is the one you usually co-create with the patient. It focuses on the “here and now” and uses a 5-part model (situation, thoughts, emotions, physiological reactions, behaviors). It is primarily a psychoeducational tool that helps the patient understand their current difficulties.
Longitudinal conceptualization – is more complex and includes the history of core belief development, formative experiences, and cognitive schemas. And here’s an important tip from Padesky – we don’t always share this entire conceptualization with the patient!
The “as much as needed” principle – key to effective therapy
As Padesky advises, share with the patient only those elements of the longitudinal conceptualization that are directly useful to them at a given moment in therapy. It’s a bit like a map during a journey – you don’t need to show the whole map, just the fragment that is needed at the current stage of the trip.
Consider:
- Will this information help the patient change?
- Is the patient ready to receive this knowledge?
- Will you not overload the patient with too many concepts at once?
Example? When working with a patient with social anxiety, you can initially focus only on the 5-part model for specific social situations or work with the Clark and Wells social anxiety model. Only when they have mastered the basic techniques can you gently ask: “I’ve noticed these thoughts about evaluation often recur. Would it be helpful for you if we talked about how such beliefs might have developed?”
Conceptualization for the therapist – your “roadmap”
The full longitudinal conceptualization is primarily a tool for you as a therapist. It helps you:
- Give structure to the therapeutic process.
- Predict potential difficulties.
- Plan long-term strategies.
Think of it as a detailed map of the terrain that you as a guide must know, but you don’t need to show every fragment of it to the person you are leading.
Process individualization – each patient is different
Remember that Padesky strongly emphasizes a flexible approach. Some patients:
- Will benefit from a deeper understanding of historical patterns.
- Others will respond better to practical “here and now” strategies.
It’s you, knowing your patient, who decides how much theory to introduce. Observe their reactions and adjust the level of detail.
Gradual introduction instead of information overload
Introduce elements of the longitudinal conceptualization gradually:
- Initial phase of therapy – focus on the cross-sectional model and psychoeducation.
- Middle phase – introduce patterns and intermediary beliefs.
- Advanced phase – if helpful, work on the genesis of core beliefs.
A practical example? When a patient says: “I always react this way in evaluation situations,” you can ask: “I wonder if you remember when such a reaction first appeared?” This is a gentle introduction of a longitudinal element, without overwhelming the patient with the entire theory.
It happens that as therapists, we fall in love with our own conceptualizations. They are elegant, connect and explain everything… but are they helpful for the patient at this particular moment? Padesky warns against turning the session into a “theoretical lecture.” Conceptualization is a tool, not an end in itself.
Empiricism in practice
When presenting elements of conceptualization, always verify them with the patient’s experience:
- “How does this sound to you?”
- “Does this fit your experience?”
- “How helpful is this explanation for you?”
Be ready to modify your understanding – the patient is the expert on their own life!
Conceptualization and the power of therapeutic change
Remember that in Padesky’s approach, the priority is to introduce changes in the patient’s functioning. Understanding the genesis of beliefs has value insofar as it supports this change. Sometimes a patient may need to understand “why this is happening” to believe in the possibility of change, and at other times, knowing “how to change it” is enough.
Practical examples of sharing conceptualization
Instead of saying: “Your core belief about worthlessness developed as a result of critical messages from your parents.”
Say: “I’ve noticed that in evaluation situations, the thought ‘I am worthless’ appears. I wonder if it would be helpful for you to look at where such thoughts might come from?”
Instead of saying: “Your abandonment schema triggers anxiety in relationships.”
Say: “I see that when your partner doesn’t respond to a message, strong anxiety appears. Do you notice that this pattern might repeat in different situations?”
Conceptualization models
Below, I will present two proven models that can be useful in working with your client/patient on a specific problem or disorder. Let’s take a closer look at each of them separately.
- 5-part model
- Box/Arrow In/Arrow Out Model
5-part model. A holistic view of the client’s experience
The 5-part model, developed by Christine A. Padesky and Kathleen A. Mooney, helps capture the connections between thoughts, emotions, behaviors, physical reactions, and environmental factors of the client. It is a great tool for a holistic view of the situation and not just a single situation.
How does it work in practice? Imagine you are working with a client suffering from depression. Instead of focusing solely on their depressed mood, the five-part model will allow the patient to see how this mood affects their thoughts (e.g., “I am hopeless”), behaviors (e.g., avoiding social contacts), physical reactions (e.g., sleep problems), and how all these elements are related to their environment (e.g., stressful work).
Importantly, we create this model together with the client, using their own words and observations. Not only does this give us a more complete picture of the situation, but it also helps the client better understand their experiences and see connections they may not have noticed before.
Box/Arrow In/Arrow Out Model. Focusing on a specific problem
The Box/Arrow In/Arrow Out Model focuses on identifying specific triggers and reactions that maintain the problem. It is particularly useful when we want to focus on one specific problem.
How does it look in practice? Imagine you are working with a client suffering from anxiety disorders. We place the main problem – in this case, “my anxiety” – in the central place. Then, together with the patient, we identify triggering factors (e.g., pressure at work, new tasks) and their typical reactions to anxiety (e.g., “I check everything multiple times”, “I take Xanax”).
Such an approach allows us to see how the client’s reactions, although they may bring temporary relief, actually maintain the problem in the long run. This will help us plan targeted interventions that will help break the cycle. It gives us a wide range of possibilities for interventions and modifications of triggering and maintaining factors.
Flexibility and collaboration
Remember that the key is flexibility. Adjust the model to the needs and capabilities of the client. Some will do well with the full 5-part model, while for others, a simplified variant or focus on the Box/Arrow In/Arrow Out Model will be better.
Importantly, conceptualization is a dynamic process. Please be open to modifications as therapy progresses and new observations are made by the client. It is not a diagnosis carved in stone, but a living work tool that evolves as therapy progresses.
Collaborating with the client on conceptualization has many advantages:
- Increases client engagement in therapy.
- Helps them better understand their own experiences.
- Strengthens the client’s sense of agency.
- Facilitates planning therapeutic interventions.
- Builds a stronger therapeutic alliance.
The power of patient strengths
Remember to utilize the client’s strengths. Ask what helps them cope with difficulties. These resources can become an important part of the therapy plan. It could be a hobby, support from loved ones, or problem-solving skills. Including these positive aspects in the conceptualization not only gives a more complete picture of the situation but can also be a source of hope and motivation for the client.
Challenges and limitations
Of course, every model has its limitations. Conceptualization may be more difficult to use with clients with serious cognitive disorders or in crisis situations. In such cases, it may be necessary to simplify the model or focus on the most pressing problems. Interactions focused primarily on providing the patient with practical knowledge or developing specific skills may also be helpful.
Summary
A well-conducted conceptualization is the key to understanding the unique situation of the patient and creating a “tailor-made” therapy plan. It is a solid foundation on which to build effective, individualized cognitive-behavioral interventions.
Treat this process as an opportunity to deepen your empathy, curiosity, and insight as a therapist. Don’t be afraid to formulate hypotheses and creatively look for connections between data. Conceptualization is partly the art of understanding another person, and partly a science based on solid theory.
I hope these tips will help you build useful conceptualizations. In case of doubt, reach for the knowledge of a supervisor or return to theoretical sources. Creating conceptualization is a skill that develops with experience.
And if you’re just starting your adventure with CBT, don’t get discouraged. Every cognitive-behavioral therapist started with timid first steps. Practice, humility, and a willingness to learn are qualities that will allow you to grow into an excellent professional.
Bibliography:
2024. Kuyken, C.A. Padesky. Conceptualization in Cognitive-Behavioral Therapy. Edra Urban & Partner 2024. https://www.padesky.com/
2024. Stefania, M.Łysiak. Conceptualization in Cognitive-Behavioral Therapy. Scientific Publishing House N