Box/arrow in/arrow out is a level 2 conceptualization that zooms in and looks more closely at one issue the client wants to understand better and change. It helps clients identify triggers and maintenance factors for specific issues of concern. This model could be used with a client a few sessions later in therapy when the focus is more closely on one of his/her issues (e.g., sleep difficulties, anxiety, depression, conflict with their partner, etc.) to identify its triggers and maintenance processes.

In this way, it is similar to the SORC. Box/arrow in/arrow out can also be helpful as a first strategy for collaborative case conceptualization when a client comes to therapy for problems maintained by maladaptive behavior patterns or avoidance. Thus, it can be appropriate to use box/arrow in/arrow out in the session following the intake interview when a client comes to therapy for help with anxiety disorders, addictions, or interpersonal issues.

For this formulation, the therapist is expected to understand how the early experiences have led to specific unhelpful core beliefs and how those negative core beliefs then lead to specific assumptions and self-imposed rules that the individual then creates unhelpful compensatory mechanisms around in an attempt to adjust/fit into the world.

As a result of the above, the individual will find their presenting symptoms triggered in certain situations – i.e. these situations trigger negative automatic thoughts leading to emotions/symptoms and reactions/behaviors.

This formulation/conceptualization requires more in-depth knowledge about the client and will take time to understand and fill out. It is considered a level 3 case conceptualization if using the levels proposed by Kuyken and colleagues (2009).

(see diagram for details).

Whichever case conceptualization you choose to use with your clients, the important thing is that you do it in a collaborative manner, in a way that makes sense to your client, and that you develop it according to what they offer you rather than any assumptions you may be making.

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The CCD uses the cognitive model based on Beck’s work, proposing the following interaction: relevant history influences core beliefs which influence intermediate beliefs, assumptions, and rules; these, in turn, influence the development of compensatory strategies/coping methods that influence how a situation might trigger automatic thoughts and reactions (emotional, physical or behavioral).

Some of the more commonly used case conceptualisations in CBT include the following:

-       Five Part model

-       5Ps

-       Box/Arrow In/Arrow Out

-       Cognitive Conceptualisation Diagram (CCD)

While you might like to use a specific case conceptualisation with your clients, the main thing is acknowledging that there is not just “one conceptualisation” for each client. Rather, a case conceptualisation can evolve naturalistically over the course of therapy, incorporating just enough information to facilitate the tasks of that stage of therapy. That is, levels of conceptualisation may exist that are more beneficial to clients

Kuyken and colleagues' (2009) described three levels of case conceptualisation depending on where the client is at in therapy:

In modern CBT, the aim would be for the therapist to gauge the client’s stage of progression and work with a formulation that matches that stage (e.g. a client may come in with all the background knowledge from previous therapy and is able to go straight into the level 3 formulation (such as the CCD) or in depth functional analysis (such as a SORC that has been developed over time to include lots of factors); others may need to start from level 1 using a formulation such as the Five-Part Model or simpler functional analysis; there is also a choice to be made from the therapist as to which formulation to use when there are multiple options for a specific level. For new therapists, it may be easiest to start with a level 1 formulation (e.g. Five-Part Model), then move to either the 5Ps or Box/Arrow in/ Arrow Out, and then the CCD (or other comprehensive formulations).

Let’s look at each of these case formulations in more detail.

This case formulation aims to gather information for each of the following areas (each one starting with a “P”):

The 5Ps can be used as a level 2 case conceptualisation; however, it can still be utilised early in therapy.

Box/arrow in/arrow out zooms in and looks more closely at one issue the client wants to understand better and change. It helps clients identify triggers and maintenance factors for specific issues of concern. This model could be used with a client a few sessions later in therapy when the focus is more closely on one of his/her issues (e.g., sleep difficulties, anxiety, depression, conflict with their partner, etc.) in order to identify its triggers and maintenance processes.

In this way, it is similar to the SORC. Box/arrow in/arrow out can also be helpful as a first strategy for collaborative case conceptualization when a client comes to therapy for problems maintained by maladaptive behaviour patterns or avoidance. Thus, it can be appropriate to use box/arrow in/arrow out in the session following the intake interview when a client comes to therapy for help with anxiety disorders, addictions, or interpersonal issues.

The CCD uses the cognitive model based on Beck’s work, proposing the following interaction: relevant history influences core beliefs which influence intermediate beliefs, assumptions, and rules; these, in turn, influence development of compensatory strategies/coping methods that influence how a situation might trigger automatic thoughts and reactions (emotional, physical or behavioural).

For this formulation the therapist is expected to understand how the early experiences have led to specific unhelpful core beliefs and how those negative core beliefs then lead to specific assumptions and self-imposed rules that the individual then creates unhelpful compensatory mechanisms around in an attempt to adjust/fit into the world.

As a result of the above, the individual will find their presenting symptoms triggered in certain situations – i.e. these situations trigger negative automatic thoughts leading to emotions/symptoms and reactions/behaviours.

This formulation/conceptualisation requires more in depth knowledge about the client and will take time to understand and fill out. It is considered a level 3 case conceptualisation if using the levels proposed by Kuyken and colleagues (2009).

(see diagram for details).

Whichever case conceptualisation you choose to use with your clients, the important thing is that you do it in a collaborative manner, in a way that makes sense to your client, and that you develop it according to what they offer you rather than any assumptions you may be making.

Some of the more commonly used case conceptualisations in CBT include the following:

-       Five Part model

-       5Ps

-       Box/Arrow In/Arrow Out

-       Cognitive Conceptualisation Diagram (CCD)

While you might like to use a specific case conceptualisation with your clients, the main thing is acknowledging that there is not just “one conceptualisation” for each client. Rather, a case conceptualisation can evolve naturalistically over the course of therapy, incorporating just enough information to facilitate the tasks of that stage of therapy. That is, levels of conceptualisation may exist that are more beneficial to clients

Kuyken and colleagues' (2009) described three levels of case conceptualisation depending on where the client is at in therapy:

In modern CBT, the aim would be for the therapist to gauge the client’s stage of progression and work with a formulation that matches that stage (e.g. a client may come in with all the background knowledge from previous therapy and is able to go straight into the level 3 formulation (such as the CCD) or in depth functional analysis (such as a SORC that has been developed over time to include lots of factors); others may need to start from level 1 using a formulation such as the Five-Part Model or simpler functional analysis; there is also a choice to be made from the therapist as to which formulation to use when there are multiple options for a specific level. For new therapists, it may be easiest to start with a level 1 formulation (e.g. Five-Part Model), then move to either the 5Ps or Box/Arrow in/ Arrow Out, and then the CCD (or other comprehensive formulations).

Let’s look at each of these case formulations in more detail.

This case formulation aims to gather information for each of the following areas (each one starting with a “P”):

The 5Ps can be used as a level 2 case conceptualisation; however, it can still be utilised early in therapy.

Box/arrow in/arrow out zooms in and looks more closely at one issue the client wants to understand better and change. It helps clients identify triggers and maintenance factors for specific issues of concern. This model could be used with a client a few sessions later in therapy when the focus is more closely on one of his/her issues (e.g., sleep difficulties, anxiety, depression, conflict with their partner, etc.) in order to identify its triggers and maintenance processes.

In this way, it is similar to the SORC. Box/arrow in/arrow out can also be helpful as a first strategy for collaborative case conceptualization when a client comes to therapy for problems maintained by maladaptive behaviour patterns or avoidance. Thus, it can be appropriate to use box/arrow in/arrow out in the session following the intake interview when a client comes to therapy for help with anxiety disorders, addictions, or interpersonal issues.

The CCD uses the cognitive model based on Beck’s work, proposing the following interaction: relevant history influences core beliefs which influence intermediate beliefs, assumptions, and rules; these, in turn, influence development of compensatory strategies/coping methods that influence how a situation might trigger automatic thoughts and reactions (emotional, physical or behavioural).

For this formulation the therapist is expected to understand how the early experiences have led to specific unhelpful core beliefs and how those negative core beliefs then lead to specific assumptions and self-imposed rules that the individual then creates unhelpful compensatory mechanisms around in an attempt to adjust/fit into the world.

As a result of the above, the individual will find their presenting symptoms triggered in certain situations – i.e. these situations trigger negative automatic thoughts leading to emotions/symptoms and reactions/behaviours.

This formulation/conceptualisation requires more in depth knowledge about the client and will take time to understand and fill out. It is considered a level 3 case conceptualisation if using the levels proposed by Kuyken and colleagues (2009).

(see diagram for details).

Whichever case conceptualisation you choose to use with your clients, the important thing is that you do it in a collaborative manner, in a way that makes sense to your client, and that you develop it according to what they offer you rather than any assumptions you may be making.