The popcorn carton on your lap is empty and the movie is reaching its climax. The hero sits in front of the ticking bomb, watching the counter tick through the final 60 seconds. The panel having been removed, a horribly complicated skein of wires lies exposed before him. By cutting though the right wire he can deactivate the bomb and save the world from certain destruction. Sever the wrong wire and it’s all over…
Strangely enough, as all devotees of the wide screen will know, despite relying almost exclusively on instinct or luck, the hero (or heroine) seldom does hack through the wrong wire. In real life, however, when it comes to disarming the mechanisms that keep our problems going we really do need to understand what is going on if we are to resolve them. In both cases what is needed, of course, is a blueprint – a useful diagram that shows how the various components are connected up and, indeed, how they affect one another.
In CBT such a blueprint is called a formulation. A good formulation maps out in some detail the pathways of mutual influence between the various components of the problem. It not only helps you to understand where your difficulties originated and why they are affecting you right now, but will also help you identify the thoughts, feelings and behaviours responsible for keeping the problem up and running.
Seven brilliant reasons to start formulating
Many introductory guides to CBT do not trouble the reader with advice about how to create an effective formulation but (in my view) this is a mistake. A sound formulation is an invaluable tool when tackling difficulties of all sorts:
1. It gives structure to your difficulties in a way that makes them feel more manageable.
2. Just like the wiring diagram for the bomb it can show you which connections you may need to target in order to alter or remove the problem.
3. It will help you generate theories about your problem and give you a model that can then be tested out against your experience.
4. The discipline of describing the problem in detail can help us identify key thoughts and behaviours that otherwise might be overlooked.
5. The formulation is the point at which you produce a personalised model in which the theories of CBT are made relevant to your situation and uniquely adapted to your needs.
6. A formulation can help you rate your current thinking about the problem. If your formulation doesn’t hang together or make sense then that is a sure sign you may need to retrace your steps or even start from scratch.
7. A good formulation will not only help you identify the origins of your difficulties but, more crucially, help you spot the patterns of thought, feeling and action that are keeping the problem going in the present.
What’s your problem?
This is a more complex question than it may at first appear because all problems can be described at a number of different levels. A woman who takes her watch to the jewellers is well aware that she has a problem: as far as she is concerned the problem is that her watch is broken, she cannot use it to tell the time and keeps running late for her appointments. In a sense it is the effects or consequences of the broken watch that have become problematic for her. Just as astronomers can only detect the existence of black holes by looking at the way they warp the fabric of the time–space continuum around them, so we are usually alerted to the presence of a psychological difficulty in our lives by how it affects us: either we feel bad or find ourselves behaving in ways that we know are unhelpful for us:
· ‘My nerves will stop me from giving a good speech’ (and that will be humiliating).
· ‘I have no friends’ (and that makes me feel sad and lonely).
· ‘I must go back and check I have turned the gas off even though I have done so 20 times already…’ (and I desperately wanted to be on time this morning).
When the negative outcomes of a problem alert us to its presence, we are usually quick to attach a label that appears to offer some form of explanation. If I find myself blushing when I talk and feel self-conscious about meeting new people I will probably conclude that my problem is ‘shyness’; if I keep losing things and forgetting to pay my bills on time I might conclude that I am ‘disorganised’.
Unfortunately these kinds of explanations actually tell us very little about the nature of the problem. When our woman informs the jeweller that her watch is broken, at one level she is, of course, perfectly correct. But for the jeweller the fact that the watch doesn’t work is a description of the outcome of a problem that he needs to redefine in terms of the watch’s component parts and the interactions between them. In order to help the woman, her problem will need translating into the terminology of dead batteries, over-wound springs, faulty connections, misaligned cogs and so on.
When you formulate, CBT is teaching you to think more like the jeweller. It will redirect your focus towards the mental and behavioural processes responsible for the negative outcomes. As we have seen, when we feel bad or act in self-destructive or irrational ways, it is usually because of what we are telling ourselves internally. You might identify your problem as a lack of confidence (outcome) but a formulation might redefine your problem as the interplay between a distorted self-image, warped thinking patterns and unhelpful patterns of behaviour (process) that feed your shyness. A good formulation will expose the inner workings of the problem and show you what thoughts and behaviours may need adjusting in order to resolve your problem’s unwanted effects.
Using goals to define problems
If you are having difficulty translating your problems in CBT terms, try working backwards from the place you want to get to. Ask yourself: what will life be like once the ‘problem’ is resolved? What won’t you be thinking/feeling/doing then? What are the specific feelings, thoughts and patterns of behaviour that currently stand in the way of achieving your objectives? If you can answer the last two questions you will usually find you are well on your way towards a useful formulation.
Pulling it all together
When you are formulating you are seeking to map out the interactions between your thoughts, feelings and behaviour. However, a comprehensive formulation will incorporate most of the following elements.
Triggers
Triggers are the events or environmental factors that kick start your train of negative thought and/or unwanted behaviour. If you can collect enough examples of your triggers you will start to become aware of common themes or repeating patterns. You will gain insight into the sense you are making of such situations and be able to target your negative thoughts and assumptions with greater accuracy.
|
Sue’s trigger events |
Common theme |
Problem behaviour |
|
1 No time to do ironing |
Feeling out of control |
Obsessive cleaning |
|
2 Making a mistake on tax return |
||
|
3 Children squabbling before tea |
||
|
4 Getting drunk on night out with girls |
|
Ben’s trigger events |
Common theme |
Problem behaviour |
|
1 Argument with brother |
Feeling unappreciated |
Becomes needy and attention-seeking, sometimes feigning illness so he gets ‘looked after’ |
|
2 Retirement party not organised for him |
||
|
3 Neighbour didn’t thank him for putting out his bins |
Hot thoughts
Since distorted thinking processes are likely to be responsible for your pain it is particularly important to try to identify any negative automatic thoughts that you experienced in the vicinity of the problem.
The difficulty is that distorted thinking usually only reveals itself as such on closer examination. Most of the time we accept our negative thoughts at face value: distorted thoughts seem no less accurate or distinctive than any of the other thoughts that passed through your mind on that occasion. The relevant thoughts may not even have been conscious which, of course, makes them even harder to spot!
What you are looking for is evidence of ‘hot’ thoughts, which can usually be detected on the basis of the unwanted changes they produce – either in your mood or your behaviour. What were you thinking at that crucial moment? The questions below may help elicit the relevant negative thoughts.
Strategies for accessing hot thoughts
· What did the trigger mean?
|
Trigger event: |
Examiner tells me I have failed my driving test. |
|
Meaning: |
‘I can’t get anything right.’ |
· Complete the following sentence: ‘When X occurred my feelings told me...’
|
Trigger event: |
Briefly losing child in the supermarket. |
|
Meaning: |
‘When I couldn’t see Arthur my feelings immediately screamed at me that he had been taken.’ |
· What was the worst thing about [trigger event]?
|
Trigger event: |
Feeling unwell on the train. |
|
Worst implication: |
‘I could have fainted and been completely helpless…’ |
· If I could put the feeling into words what would they be?
|
Trigger event: |
Putting letter in letter box. |
|
Feeling in words: |
Guilt – ‘I should have kept my mouth shut.’ |
· Is there an image that more adequately summarises what I felt?
|
Trigger event: |
No apparent laughter in response to my joke. |
|
Mental image: |
Hostile crowd jeering and pointing at me in an amphitheatre while lions run out to tear me apart. |
You may be aware of a whole rush of different thoughts and don’t worry if you cannot initially tell which ones are the most salient. For the time being just write them all down and rate them out of a hundred in terms of how uncomfortable they make you feel. You may also find that your thoughts cluster around common themes and that there are certain NATs that appear to summarise the tone and content of others. Finally, bear in mind that once you start trying them out in your evolving formulation the process will help clarify which thoughts are doing the real damage.
Emotions
As we have mentioned, sudden unpleasant shifts in our feelings are often the most reliable way of tracking the emergence and influence of negative automatic thoughts. Sometimes changes in our feelings may be the only trace that a NAT leaves in our consciousness. A fleeting sense of disappointment when my friend passed by and failed to acknowledge me could be the surface manifestation of a key negative thought such as: ‘I am invisible… No one cares whether I am here or not.’
When you are tracking the emotional shifts associated with an event bear in mind the following:
· Try to be aware of the whole spectrum of your feelings at the time – not just the more dominant emotions. Be specific about what you felt and at what point.
· Try to recall what you actually felt even if your emotions seem at odds with the situation. Don’t superimpose what you assume you would have felt or should have felt in that situation. Experts on memory research point out much of what we remember is reconstructed rather than just recalled, so do your best not to use too much artistic licence.
· Be careful not to confuse the feelings that may have arisen in you after the problem occurred with those that may have been around at the time and that may be more closely related to the relevant NATs.
Physiological responses
An emotion is often as much a physiological event as it is a psychological one. Various hormones released by our bodies can have a profound effect on our mood. We also know that making deliberate physical changes in our outward behaviour can influence our feelings. One study found that simply by reminding themselves to smile throughout the day, subjects’ reported levels of happiness were substantially increased. We also know that regular exercise can affect the body’s serotonin levels in the same way as certain antidepressants. What this means is that physical sensations and changes we experience in our bodies are often important sources of information about what we are feeling and thinking.
Behaviour
This includes what you did before, during and after the trigger incident. Just as in a police statement try and be as objective, comprehensive and factual as you can. Be particularly careful of verbs that imply intentions and motives. You need to be open to the fact that actions, including your own, can easily be interpreted (and misinterpreted) in many different ways by both yourself and others.
For example, the shadowy ‘drunken’ stranger ‘prowling around’ your back garden takes on a different complexion when you discover his erratic movements and stumbling gait were the behaviours of a lost and dementing pensioner trying to find his way back to his nursing home. Never assume. Instead, try to describe the events, including your own behaviour, from a neutral third-party perspective.
Behaviour that anticipates the trigger incident can be just as revealing as your actions afterwards. Look out for safety behaviours that may have increased your vulnerability to negative cognitions. For example, if you have developed an irrational fear of strangers and therefore always take the back route away from the crowded thoroughfare, your very act of avoidance is likely to have reinforced your sense of potential danger and made you all the more jumpy when you do encounter someone.
Predisposing factors
These are anything that has made you more vulnerable to the problem, either in the past or present. They might include key formative experiences, personality traits, unhelpful attitudes like perfectionism, or factors that may have undermined your resilience by altering your physical state like drugs, alcohol or exhaustion. The presence of certain people might make you more likely to experience your difficulties or trigger certain chains of thought. Familiarising yourself with the things that give destructive patterns more hold over you means that you can then take action either to avoid them or limit their influence.
Maintaining factors
Look out for beliefs, behaviours and any environmental factors that keep the problem going in the present. Pay particular attention to how you respond once the problem occurs and look out for unhelpful coping mechanisms and safety behaviours that are perpetuating or reinforcing negative patterns of thought, feeling and action.
Mitigating factors
It is also worth thinking about times when the problem does not bother you or occasions when the triggers have been present but the manifestation of your problem has been briefer or less intense. What was different? Did you react in a different way? Did someone else help you to stay calm and, if so, what did they do that helped? Was the impact of the trigger offset by other positive experiences that day?
Thinking about mitigating factors can give you important clues about how best to tackle your problems. If you can work out what helped and why, you can do more of it, weaken the cycle and start to protect yourself.
Three key principles for winning formulations
Principle 1: keep thinking about how things connect up
When you are formulating, remember that just like the jeweller you need to think of your problem as a system of interrelated parts. In this case the main components are elements of your thoughts, feelings and behaviour. You have to be aware not only of which parts in the system you need to focus on, but also how they affect each other. How useful your formulation will be to you depends on how accurately you are able to trace out the critical pathways of cause and effect.
You will remember from Chapter 2 that we talked about the ‘two-way street’ principle – for example that thoughts can influence emotions and that the same emotions can prime or reinforce certain thoughts? When you are formulating half the trick is to keep your eyes open for these kinds of feedback loops, because it is these that make a problem become entrenched.
Principle 2: narrow the focus
Sometimes people can feel that they have so many different problems or that they are so involved that they don’t know where to start. The prospect of trying to get it all down on paper seems daunting. The solution is simple: don’t. One of the joys of CBT is that it allows you to break complex problems down into smaller, more manageable chunks. Looking in detail at a specific example of just one way in which your difficulties are affecting you is often the most reliable way to access key cognitions and behaviours that have a wider relevance. Understanding how you reacted in one situation in which a problem revealed itself will usually give you insight into others. For example, you may spot a tendency towards a particular thinking error that you also make in other contexts.
Think like a detective
The nature of problems is to feel muddled and overwhelming but in order to describe the problem adequately for CBT purposes you will need to identify the thoughts, feelings and behaviours associated with your problem in specific, concrete terms. This is why it can be helpful to concentrate on a particular incident and go over it in fine detail. The process is not far removed from the forensic investigation of a crime scene. You know something untoward has obviously taken place – in this case what George Orwell described as a ‘thought crime’ – but in order to work out what has happened and who is responsible the crime scene needs to be scrutinised and the traces of evidence rigorously collated, catalogued and examined.
CBT regards our day-to-day difficulties as manifestations of deeply rooted habits and processes that operate in much the same way across different contexts, so the chances are that any significant example of the problem is likely to tap into the relevant underlying patterns of thought and behaviour.
Remember, you don’t have to formulate every aspect of your difficulties right away. Mapping out just one aspect of your problems in a way that suggests strategies for controlling a particular symptom is helpful and may well be the best place to start. Understanding one domain or subsystem of the total problem is likely to provide insights into connections with other aspects of your difficulties.
Principle 3: treat your formulation as a work in progress
In CBT the formulation is never the finished product or a definitive account of the problem. In keeping with the exploratory spirit of the whole CBT approach your formulation is always provisional so along the way expect to redraw it, add new bits to it and lose others. This is entirely to be expected: it does not mean you have ‘got it wrong’, it is part of the process of making sense of your difficulties. As Thomas Edison, the great American inventor, once pointed out: ‘Just because something doesn’t do what you planned doesn’t mean it’s useless.’
Just as the early cartographers had to redraw their maps as they developed better instruments, so be ready to make changes. A formulation is just a starting point, a set of hypotheses about your problem that may need to be updated as you learn more about it.
Indeed one of the functions of a formulation is to translate your problem into a set of testable theories. As you conduct experiments or adapt your behaviour on the basis of your formulation, you will be putting those theories to the test. Depending on your results you may need to revise your formulation, or even go back to the drawing board and start again. This is a natural and helpful part of the process in which theory is constantly revised in the light of new experience.
‘Can you see what it is yet…?’
The usual (but not only) way to represent a formulation is in the form of a diagram consisting of boxes joined up with many arrows. There are several advantages of employing this method.
Firstly, it is much easier to think about the relationships that exist between the different elements. You might, for example, depict a causal connection between a belief (e.g. ‘Trying to deal with my problems is pointless’) and aspects of your behaviour (e.g. procrastinating and watching daytime TV).
However, seeing a diagram laid out in front of you may also trigger the realisation that this pattern of behaviour is linked into other negative thoughts such as ‘I can’t get my act together’ which in turn is linked to emotions (such as embarrassment) that encourage you to watch more daytime TV so you don’t have to expose yourself to the judgement of other people. You have discovered a feedback loop!
Isolating the different elements in a visual form will encourage you to consider links and pathways between them that may have escaped your attention. You can also easily try out different permutations and combinations by shuffling the elements and connections around until you develop a network that makes adequate sense of your problem.
Finally, because the web of connections and associations mirrors the way the brain naturally encodes information, mapping out the system in this way is also likely to cue the recall of new relevant information or facets of the problem that might have been overlooked. Tony Buzan (author and educational consultant) claims that this is one of the advantages of mind mapping, which is based on almost identical principles.
Peter’s short fuse
To illustrate the process involved in arriving at an adequate formulation we shall use the example of Peter, a 25-year-old banker. Peter was round at his girlfriend’s last Friday. The evening had been going well, but when they got back to Peter’s flat they had a blazing row. The girlfriend left in tears and Peter downed a bottle of scotch before collapsing unconscious on the sofa. The next day the girlfriend texts Peter and informs him that the relationship is over.
Peter knows he has a problem. Try as he might he seems unable to hold down a long-term relationship. His love life is a catalogue of failed romances and unsatisfying one-night stands. Bizarrely, all his relationships end in much the same way. At the moment Peter doesn’t really understand what is going wrong. He decides the time has come to enlist the help of some CBT principles to try to find out.
‘Where did it all go wrong?’ Searching for the emotional shift
In order to isolate the relevant thoughts, feelings and behaviours, Peter knew he needed to pinpoint the moment the problem began to manifest itself. Peter believed the evening had been going well up to the argument with Laurie. But what were they arguing about? What kicked off the conflict between them? One moment they were fine, the next they were at each other’s throats. What had changed?
Peter mentally replayed the events of the night before, this time focusing on the way his feelings altered over the course of the evening. He recalled being excited and happy on his way to meet Laurie at the station and pleased when he saw her walking towards him. In the restaurant he had felt relaxed and confident in her company, but when they got through the door of the flat something she said turned off all those positive feelings almost as if she had flicked a switch.
After that a wave of very different emotions had swept over him: he felt angry and hurt and, as he pictures them sitting there on the sofa, he could also detect echoes of two other emotions – shame and embarrassment. Suddenly, Peter found he could recollect with great clarity what Laurie said that upset him so much: ‘Maybe next time we could try that Indian in the high street?’
Fire up your memory
Peter had a conveniently recent example of his problem to draw upon but this is not always the case. However, this does not mean that all is lost.
In order to analyse your own behaviour and reactions you will need to bring the triggering event to mind as vividly as possible. Try to recall as much detail about the situation as possible - even if it seems irrelevant. Because of the way our memory works, traces of an event are all connected and recalling one aspect of an event can often trigger other memories. Sensory information is often evocative: can you remember distinctive smells, tastes, textures associated with the target event? What were you wearing? Do you recall what you were doing before the incident took place? Setting the event in context by thinking about other events that took place around the same time can often trigger recall.
Sometimes, to give yourself access to the thoughts and feelings associated with an event, it can even be helpful to physically revisit the scene where it took place. A client of mine who had been involved in a bad road traffic accident could not, try as he might, access any of the NATs associated with the accident itself, even though he had been unable to travel by car since. Only when he visited the scene of the accident was he able to recall exactly what he had thought and felt in the moments before the collision. He was then able to begin tackling the distorted thoughts that had prevented him from getting back behind the wheel.
Identifying the hot thoughts
To you and I, Laurie’s comment about trying the Indian restaurant may seem like a fairly innocuous suggestion, but for Peter it had unleashed a flood of negative automatic thoughts. Becoming aware of this, Peter’s next task in developing his formulation was to specify the content of those thoughts.
Allowing himself to focus on Laurie’s remark and re-experience the emotions that he felt, Peter found it not too difficult to recall the conclusion that this remark had prompted: ‘She obviously didn’t like the meal tonight…’ However, Peter recognised that this thought didn’t explain the strength of his reactions. In order to isolate the NATs responsible for his negative feelings he had to dig a little deeper. He used the downward arrow technique and the questions outlined earlier in this chapter to begin eliciting his NATs.
Using these lines of questioning Peter’s first attempt to identify the relevant NATs produced the following ladder of implications. The ‘hot thought’, i.e. the one that produced the strongest surge of emotion and seemed to sum up the other thoughts he identified was, ‘I am a failure.’
Peter now had a potential candidate for the thought responsible for his feelings and behaviour the previous night. He was in a position to begin completing a basic CBT template.
However, looking at the links between the thought and the emotions in Peter’s chart it becomes clear that something is amiss. While he recognised that his identified hot thought ‘I am a failure’ might generate feelings of shame and embarrassment, emotions like anger and hurt did not tally so readily with the target thought. This tension became even more exaggerated once Peter began to examine evidence to complete the boxes relating to physical sensationsand behaviour.
Peter was already aware that the couple had argued, but looking more objectively at his behaviour he could see that he had responded quite aggressively to Laurie’s suggestion. His actions had included:
· raising his voice
· initially glaring at her without blinking or breaking eye contact
· announcing that he wasn’t sure he wanted to go out with her again anyway
· making several critical remarks about Laurie’s behaviour the day before
· turning his back on her once the argument became heated and heading for the kitchen
· smashing several glass bottles into the recycling box.
He was also able to recall several physiological changes that had taken place at the same time:
· His heart rate had accelerated.
· He recalled a horrible knotted feeling in the pit of his stomach.
· He had felt ‘light-headed’ and was aware he was breathing quite heavily.
· He could remember clenching his fists and them feeling quite hot and sweaty when he did so.
Revising your formulation in the light of new evidence
We have already noted that there appeared to be only a partial correspondence between what Peter felt in response to the trigger and the emotions he experienced immediately afterwards. This is not to say that the thought processes Peter had uncovered were invalid or irrelevant, but his activated core belief ‘I am a failure’ did not fully account for either his behaviour or subsequent physiological response on this occasion.
The thought he had uncovered is more typically connected with more passive, depressive patterns that usually encourage the person to withdraw into himself. Peter’s response was very different. He had initially come out ‘all guns blazing’, so having fed this new information into the diagram Peter realised it was time to scrutinise the incident for another possible NAT that might better account for his overreaction.
Having tested the formulation out against the model Peter now has to go back to the drawing board and see whether Laurie’s reaction could have had another meaning for him that might better explain his reaction. Opposite is his second attempt.
Feeding this new ‘hot’ thought (‘I am under attack!’) instantly made much more sense of his feelings and subsequent behaviour. Jumping to the conclusion that Laurie was criticising him, Peter had felt wounded and then reacted by striking back. The anger that rushed through him was part of a natural defensive reaction as his body prepared itself for combat. Peter also realised that this new account was much more consistent with the physical sensations he had experienced as the adrenaline had set his pulse racing.
What was becoming clear to Peter as he reflected upon the events of the night before was that he has a problem with anger, and that his hypersensitivity to criticism was costing him his love life.
Looking at the emerging formulation and the interactions between the different areas of the diagram, Peter realised there were various ways in which he could learn to protect himself from the consequences of his anger.
Possible interventions
· He could stop interpreting everything other people said to him as a personal attack and challenge his NATs with balanced alternative thoughts.
· He could practise relaxation techniques such as diaphragmatic breathing or visualisation to calm his body’s fight–flight reactions.
· He could learn to modify his actions, lower his tone and make his body language less threatening.
· He could express his feelings with greater clarity at the time and resolve potential misunderstandings rather than avoiding his anger and letting it build towards an explosion.
Because of the way thoughts, feelings and behaviours are all connected, any of these interventions would probably have helped. A combination of all of them might have averted Peter’s romantic suicide altogether. The joy of a good formulation is that it opens up various options for tackling your problems and a multi-pronged approach is often precisely what is required.
Elaborating the formulation
Of course beginning to understand the events of that one night was only the start for Peter. Reflecting on parallels with other incidents in his life, Peter began to flesh out his formulation.
He looked at predisposing factors that included the constant stream of criticism he had been exposed to as a child, and began to see that the cocky, arrogant air he assumed at work was actually a compensatory strategy to mask his damaged self-esteem.
The emerging formulation also showed him how fear of further humiliation had prompted Peter to develop a number of ‘protective’ assumptions and safety behaviours that guaranteed yet more heartache and rejection and were reinforcing his beliefs that he was unlovable and inadequate.
As he reviewed his thought records over the next few weeks Peter also became more aware of the thinking errors and distortions he mobilised to keep his set of dysfunctional assumptions and negative beliefs in place. He learnt to appreciate how polarised thinking, emotive language and rampant catastrophising was closing down opportunities for the intimacy he longed for. A simplified version of Peter’s more elaborate formulation is shown overleaf.
Over the next seven months Peter used his formulation to make a plan of campaign. He learnt relaxation techniques to bring his state of anxious arousal under control. He conducted experiments that involved breaking some of his own taboos. He sought to find alternative interpretations of the behaviour of people around him. He cut back on the drinking and other safety behaviours that were compounding his problems.
Over time colleagues gradually noticed the changes in Peter, and the general consensus was that he had become a more approachable, less pushy individual. Despite this, Peter felt he had more work to do on the legacy of his childhood before he would be ready for a serious relationship. For the time being he decided to concentrate on developing his friendships. However, he was also in no doubt that the process of mapping out his problems in an objective and analytical way had been the start of a personal revolution. At our last session he spoke optimistically about the future: ‘I don’t know whether I will get the girl or not…’ he mused, ‘but hopefully I won’t be acting like a total jerk when she does come looking for me…’
Homework: make a start on your own formulation
Set aside some time this week to begin working on a formulation of your own problems.
Start by analysing one example of your problem in detail and then see whether you can detect themes that apply in other areas of your life.
Don’t feel you have got it right first time. Remember formulating is a process and often one of trial and error at that. However, do try to devise at least one behavioural experiment that will allow you to confirm whether or not you are working along the right lines.