Collaborative Formulation

Collaborative Formulation

What if the map only makes sense once your body, relationships and environment are on it?

What a formulation is

A formulation, sometimes called a case conceptualisation, is a working explanation of how a difficulty developed and what keeps it going. In CBT it usually links a situation to thoughts, emotions, bodily sensations and behaviour, and shows how these feed one another in a cycle.

Christine Padesky and Kathleen Mooney’s widely used five-part model has a feature that matters here: alongside thoughts, moods, behaviour and physical reactions, it includes the environment. The world a person lives in is already part of the classic CBT map. A disability-informed formulation does not add something foreign to CBT. It takes that part seriously.

Three levels

Willem Kuyken, Christine Padesky and Robert Dudley describe formulations developing over time, at three levels:

• Descriptive: what is happening, in the person’s own words.
• Explanatory: what triggers and maintains the difficulty.
• Longitudinal: how earlier experiences, beliefs and strengths make sense of the pattern.

They also emphasise two principles that are especially useful for disabled clients: collaborative empiricism, where the formulation is a shared hypothesis tested together, and building in strengths, not only problems. Kuyken, Padesky & Dudley, 2008

A disability-informed map

A useful formulation for a disabled client usually needs a few more questions than the standard diagram prompts:

A worked formulation, in text

This is an illustrative composite. Each part is written out so it can be read without a diagram.

• Situation: Niamh is invited to a work training day at a venue she hasn’t been to.
• Interpretation: “It probably won’t be accessible. If I ask, they’ll see me as difficult.” The first part is checkable. The second is a prediction about other people.
• Emotions: dread, and irritation.
• Body: a tight chest, which may be anxiety. Her pain is also worse after a long week, which is not anxiety.
• Actions: she says she’s busy, and doesn’t ask about access.
• Short-term effect: relief, no awkward conversation, and energy saved.
• Longer-term effect: she misses the training, her manager wonders whether she is interested, and she feels more isolated at work.
• Environment: the venue publishes no access information; the last training was inaccessible; her manager has been supportive once before.
• Strengths: a good relationship with one colleague, and a clear sense of her own access needs.

Hypothesis: not asking may be keeping the fear of being seen as difficult going. Niamh’s correction: “It’s not only fear. I’m tired of asking.” Later revision: she checks the venue, which turns out to be partly accessible. The map changes. The main thing keeping the problem going is now the cost of asking again and again, so the work shifts to asking HR for a standing process for checking access in advance.

Physical responses need checking

Standard formulations often place bodily sensations as a consequence of thoughts and emotions: the racing heart of anxiety, the heaviness of low mood. For disabled people, physical responses may also come from pain, neurological differences, medication, positioning, sensory overload or illness. They should not automatically be attributed to anxiety. Where it is unclear, the formulation can hold both possibilities, and new or changing symptoms may need medical input.

When the client corrects the map

An illustrative exchange, written for teaching. It is not a real session.

An illustrative exchange, written for teaching. It is not a real session.

A formulation is a shared hypothesis. A client’s disagreement is not resistance. It is information that improves the map.

Where the difficulty lives

This site’s own Mine, Yours, Ours, System tool can sit alongside a CBT formulation. It asks which parts of a difficulty belong to the person, to someone else, to the pattern between them, or to the system around them. It is our synthesis rather than a standard CBT model, but it helps prevent a formulation from placing everything inside the individual.

A process to try

1. Start descriptively. Map one recent, specific moment in the client’s words.
2. Include the environment explicitly. Access, attitudes, support, energy and cost.
3. Check bodily factors before attributing them to emotion.
4. Draw it together, in whatever format works: paper, screen, spoken, visual.
5. Invite correction. Ask what is missing or wrong.
6. Choose where to work, based on the map, not the manual.
7. Revise as you go. A formulation is never finished.

Where to slow down

• The environment box is empty.
• Every arrow points from a thought.
• The client is agreeing to a map that doesn’t feel right to them.
• Bodily symptoms are being interpreted psychologically without checking.

For therapists

• Does my formulation include anything outside the client’s head?
• Have I asked what the behaviour does, not just what it looks like?
• Would the client recognise themselves in this map?
• Have I included strengths, not only problems?

A different experience

Some clients don’t want a diagram. They find formulations abstract, or feel reduced to boxes and arrows. A formulation can be held in conversation, in a few sentences, or in a story. The point is a shared understanding, not a drawing.

Evidence and status

• Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it, not that it does not exist.
• Sources checked in October 2026, using targeted searches rather than a systematic review. “We have not located” means our searches did not find it, not that it does not exist.
• Documented theory: case formulation is central to CBT; the five-part model and the three-level approach are widely taught.
• Research: Kuyken, Padesky and Dudley (2008) noted that evidence that formulation itself improves CBT outcomes was strikingly absent, and that therapists agree less well on inferred elements such as core beliefs than on descriptive ones. A 2018 state-of-the-science review reached a similar conclusion: experienced therapists can reliably build some elements of a formulation, but its contribution to outcomes has yet to be demonstrated. Easden & Kazantzis, 2018
• Our synthesis: the added areas and the emphasis on environment and bodily factors. We have not located trials testing disability-informed formulation specifically.

A question worth carrying: what would this map look like if the environment were drawn as large as the thoughts?