CBT Formulation – 5 Areas Model
This article discusses:
- What is CBT formulation? And why is important?
- Basic formulation of strengths and difficulties in Online CBT Therapy
- What can we do with our formulation?
You can listen to this article here:
1.- What is CBT formulation? And why is important in Online CBT Therapy?
In simple terms and in the context of mental health or psychological health, a formulation is an explanation of psychological difficulties and strengths of a person.
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If you were to think about formulation like a road map, you could figure out how each city/county is connected by various roads. Also, you may use a formulation to know that you are in City “A” and you could track down how you got there from the beginning of your life journey. Also, you can understand how to get to City “B”, actually, you may realise what is getting on the way for you to get there. Or, what roads you tried in the past and did not take you there.
Each psychological approach formulates, or conceptualise, the individual differently. We are looking at CBT formulation. However, as I mentioned on my site, I encourage to look into other psychological interventions before making a decision on what psychological approach to take. If you are looking to seek support through the NHS, I would suggest for you to look at the NHS website and NICE guidelines on what support is provided for the difficulties you experience.
During Online CBT Therapy, you and your therapist would work together to get to a shared understanding of your formulation. It is important to clarify that this process may take many sessions, and the formulation is a dynamic road map. By this I mean, you will notice that it is not an opened ended process, but rather a continues process where new information may need to be added.
This article covers a basic here and now formulation, known as the 5 areas model. In future articles and podcasts, I may discuss how to work on a more extended formulation but without the intention to substitute the process that is required for you to undertake in 1-1 treatment.
Once you know what is your individual road map, or explanation of yourself, then you can begin to understand how things impact on your mental health.
Therefore, it is very IMPORTANT!! for you to be aware that this is not a substitute for 1-1 therapy and it is not intended for you to save money in therapy. This is for information purposes only. If you decide to go ahead and begin to formulate your difficulties you are doing this on your own decision. The process may cause distress and emotional instability and I recommend you to seek professional support either privately or through the NHS, if you believe that this will be the case.
2.- Basic formulation of strengths and difficulties in CBT
As mentioned earlier, we will start looking at a basic here and now 5 area CBT formulation.
CBT states that the situation is not making you feel depressed or anxious, but rather your interpretation of it and how you respond to it, your behaviour.
The 5 area model in CBT was initially designed by Padesky and Mooney (1990) and looks like this:
When doing this in session, we tend to look at situations that may be problematic. We gather detail information from various recent situations. I personally like to go through the same process but in situations that people have coped well or they felt better about themselves. The idea behind this is to be able to build on people strengths, to use them in situations when they may be struggling.
When we speak about thoughts, many times we refer also to images, as people may experience intrusive thoughts/images, or have images from the past (memories) or hypothetical images/thoughts of future events.
It is important to note that behaviours can be physical or mental, for example someone who does 5 prayers when they think they may push someone on to the traffic, is “doing” the prayers in their mind but the “thinking or believe” is that this would stop them from pushing someone to the traffic.
Finally, you need to remember that feelings are usually a one-word thing: angry, sad, happy, contempt, frustrated, depressed, anxious, shameful, embarrassment, etc. So, if you were to write I thought I was anxious, you actually were feeling anxious. You may have thought “I will faint if I do not leave this bus”, which made you anxious. So important to differentiate these two.
In order to help you to begin to think on how to find various situations and break them down, I will give you some questions in the table below, that you can ask yourself. These will work whether you are looking at situations you struggle, or you feel good about.
Where were you?
Who were you with?
When was it?
How often were/are you in the situation?
What was happening?
What was going through your mind?
Did you have any images/memories that popped into your mind?
Were you having any thoughts prior this situation in regards the situation?
Did you conclude something after having these thoughts?
Did you have an image of yourself in the situation?
What were you doing that helped?
What were you doing that made things worse?
Did you avoid or not avoid doing something?
What did you do to reduce/increase your emotions/feelings?
Did you do anything prior to the situation that impacted your mood?
Did you do what you always do?
What emotion/s did you experience during the situation?
What about before or after?
What were the intensity of the emotion 0 – 100%? 0 not strong at all 100 the worst you ever felt
What did you notice in your body?
Where did you noticed?
Did you notice any physical changes before/during/after? Did these impact on you/your mood?
Where was your attention?
What did you think others could see you doing?
Did I feel as if I was in the moment? Or as if things were like a film passing by and I was a bystander?
The idea is for people to begin to look at various situations using these questions and ideally put them in a diagrammatic format, like the image above, and to see how they link. In order to see how these may link, or if there are something else going on, you could ask yourself the following questions:
- When I entered the situation, what was the first thing I noticed (this could be thoughts, change in emotion or physical sensation, or doing something different)?
- After noticing this, what did I do/thought? And did that impacted on my mood/physical? And if so, how?
- Did this increase or decrease my feelings/thoughts/physical sensations/behaviours?
- Did you notice if any of your thoughts or behaviours impacted in the situation? Did the situation change?
- Did you do anything intended to improve the situation and had the opposite outcome in your mood/thoughts/physical sensations?
When thinking of these questions and formulating using the 5 areas model in CBT, we are looking at situations where you felt good about yourself/less anxious and the ones you felt anxious/depressed/angry, negative feelings. The intention is to begin to identify what are the differences.
If you would find it useful, you can download an empty 5 areas model by clicking here. If you wanted to have it with prompts please click here.
3.- What can you do with our formulation?
Like I mentioned earlier, the CBT 5 areas model is a here and now formulation, to explain how things are currently in your day to day, like a road map. These could be either positive or negative experiences.
Once you have managed to gather information/examples of what is occurring in the situation you find difficult and the ones you find pleasant, you then can place all of the CBT 5 areas models together and try to find patters of thinking or behaviours that impact on your emotions and physical sensations. On the other hand, you can identify if your feelings/emotions are changing the way you think or act in similar situations.
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For example, you may notice that in very similar situations if you are with a specific person you find it harder to deal with. So, any comment or behaviours from this person will make you think or behave in a certain way and feel more uncomfortable. However, you may find the opposite and some people make you feel more comfortable.
Once you find these links or patters, you can ask yourself:
- What is behind this reaction?
- When did I begin to act/feel/think this way? (this could be in the day when you felt that way, or if you find that this has happened for long time then you may answer when it first begun, but this may be a bit more difficult to do)
- What am I doing to make things better?
- What/When/Where things improve or worsen?
- Did I notice any physical changes? What did I do about it? What was the outcome/and outcome in relation to physical symptoms?
Some of the above questions and more are explored in the blog entry CBT longitudinal formulation, that can be accessed here. Another thing you could try to do with this CBT formulation and the 5 Areas model is to test them out.
So, for example, you have noticed when you are anxious, you look down or at your phone, because you think that people are staring at you in public places, and you think it is everyone. You can just go to a place with plenty of people, if you can manage this, ask yourself how many people is everyone. I know this is silly but if you think everyone looks at you and you mean 5 people out of 100, that is not everyone. Then you need to look up and look in detail if people are looking at you. If they are, how many of them and how long for? If they don’t, what are they looking at?
As I explained on the CBT self-help blog entry, you can read here, it is very difficult to get the exact example for every single human experience.
It is important that you try to put in practice when in a difficult situation what you do and think in the situations where you feel less anxious or in better mood. The idea is for you to test if this makes any difference.
To Sum Up
Conceptualising or formulating strengths and problems in CBT is central for treatment. This is a way of getting to an understanding of yourself. The ideal beginning point is there here and now, which the 5 areas model in CBT is great for. Once you have look at how your strengths function in a CBT formulation, and how these differ from the situations that you struggle with, then you can try to compare and contrast. If you want to look into further detail then you can begin to ask yourself some questions that may put things in context.
Padesky and Mooney 1990 (website)
Corrie, S., In Townend, M., & In Cockx, A. (2016). Assessment and case formulation in cognitive behavioural therapy.