Formulation on One Page

Case formulation is central to most CBT models, but the research is thin: reliability varies, quality is often low, and a link to better outcomes has not been demonstrated.

On the worksheet itself

• Formulations can be built reliably for some elements, but their link to outcomes hasn’t been shown. (Easden & Kazantzis 2018)
• Agreement between clinicians ranged from slight to substantial, and training helped. (Flinn et al. 2015)
• In a 115 clinician study, only 44% of formulations were rated good enough; experience helped. (Kuyken et al. 2005)

On the clinician page

• State of the science. 24 studies: experienced therapists can reliably construct some elements, but the importance of formulation for CBT efficacy has yet to be demonstrated. (Easden & Kazantzis 2018)
• Reliability varies. 18 studies: inter-rater reliability ranged from slight to substantial; training and experience led to higher agreement. (Flinn et al. 2015)
• Quality is uneven. 115 practitioners given the same case: agreement was good on descriptive parts and dropped for inferential parts; only 44% were rated good enough. Experience helped. (Kuyken et al. 2005)
• Individualizing. 50 patients with bulimia nervosa: individualized CBT and manual based CBT were mostly similar, with some outcomes favoring individualized; the authors call the support preliminary. (Ghaderi 2006)

Honest limitation

Little evidence that writing a formulation improves outcomes. The strongest case is training and supervision value: structure improves agreement and quality.

When not to use it (yet)

• As a chart note, or anywhere that adds PHI outside the EHR
• As a fixed label rather than a hypothesis
• Without the client’s input
• Crisis sessions: stabilize first, formulate later