It’s the first blog post! To kick us off, we’re starting with the basic CBT formulation, featuring a guest appearance by the loveable (but at times misunderstood) swamp-dwelling Shrek.
What is CBT?
So if IMDB had a top therapies list, I would bet that Cognitive Behavioural Therapy (CBT) would be at the number one spot. It is often recommended as the first-line treatment for a range of mental health difficulties and is the widest used therapy in clinical settings, being backed up by a range of evidence and research.
Movies and TV have a lot to answer for with regards to the general public’s understanding of what happens in the therapy room. Despite CBT being the most widely used therapy, this does not usually translate to what’s on our screens. Mostly, we see a ‘Freudian’ psychodynamic approach (think Betty’s psychiatrist ‘Dr Wayne’ in Mad Men). This often involves lying on a couch, interpreting dreams, or discussing unusual feelings towards family members. Otherwise, it’s mostly quite scary psychiatric hospital procedures or someone prescribing those pills, pills, pills.
To be fair, this is all probably more exciting to have in a movie plot… CBT is a very practical therapy, where therapist and client work together to build an understanding of the client’s mental health difficulties in the here and now (e.g. anxiety or low mood) and develop strategies to manage these difficulties. Other characteristics of this approach are that there are a time-limited number of appointments and the client is often asked to do ‘homework’ outside of the session. I am guessing this approach doesn’t really fit with the romantic or theatrical notion of therapy that seems to draw in the audience (… and Electroconvulsive Therapy must just get better ratings).
ANYWAY, I digress. For the first Psy Fiction blog, we’re going to start with some of the essential building blocks of formulation: the basic CBT ‘Situational Formulation’.
What are the principles behind CBT and the Situational Formulation?
If CBT were nominated for best picture at the psychological equivalent of the Academy Awards, Dr Aaron Beck would be the front runner for best director, having developed this therapy in the 1960s. Beck originally created this approach for depression, however it has since being applied to a range of mental health difficulties. I will not be able to do justice to the complexities of how CBT was developed and the theory behind it in this post. Therefore, please view this as a brief summary and for the purpose of explaining formulation.
In short, CBT assumes that it is more an individual’s interpretation of an event that leads to their distress, rather than the actual event itself. If we think of the film Inside Out (one of my favourites – for those who don’t know, it mostly takes place inside Riley’s mind, where her emotions are different characters who can each be in control of her thoughts at different times). In the movie, there is a scene where Riley sees her new room in the family’s new house, which looks small and run down. ‘Disgust’ reviews the situation as “it’s the worst place I’ve seen in my entire life”, ‘Sadness’ says “she can’t live here”, and ‘Joy’ interprets it as “it’s nothing our butterfly curtains couldn’t fix. I read somewhere that an empty room is an opportunity”. All of them see the same situation but have different interpretations. The meaning which is applied to an event, can therefore have a knock on effect on our how we feel and what we do in that situation.
CBT suggests that there are 5 inter-connected systems which we can explore to understand someones psychological distress and behaviour in a specific situation. These are:
- The external situation or environment
- Thoughts/appraisals/cognitions about the situation – in CBT these are called “Negative Automatic Thoughts”.
- Body sensations
- Behaviour – or what someone ‘does’
All these 5 areas link together and feed into each other like a vicious cycle, which maintains psychological distress. The ideas is, that if one of these areas can be targeted and changed, then it breaks the cycle and distress reduces, (e.g. challenging the negative automatic thoughts).
The ‘Situational Formulation’ (below) is a structured way to explore these 5 factors. It’s known as the ‘5 areas/aspects formulation’ or ‘hot cross bun’ . It focuses on understanding a specific situation in the here and now and does not explicitly consider the role of past experiences.
Example of a CBT Situational Formulation
To illustrate this formulation, our first “case” from the big screen is everyone’s favourite ogre. Shrek is great complex character, who has the brilliant line likening ogres to onions as they have “layers”. We can think of our situational formulation of Shrek as aiming to peel back the different layers to understand why he may have acted in certain ways during the movie.
Shrek is a classic example of somebody with a hard and at times aggressive exterior, which seems to being a coping mechanism for the vulnerability, insecurity and anxiety which he feels internally. When using a Situational Formulation, you focus on a specific and recent example situation, where the individuals’ problems were particularly present. In that vein, I will use the scene where Shrek overhears snippets of Fiona and Donkey’s conversation, leading to an emotional response from Shrek and him and Fiona falling out (video below).
I’m sure that we could all agree that this is a tricky and ambiguous situation. If we were in Shrek’s shoes and we only overheard this part of Fiona’s conversation, our mind may also assume that Fiona was speaking negatively about us. Misunderstandings are a natural part of everyday life. Nevertheless, we want to have a think about how Shrek responded to this situation, both emotionally and in his actions, and the consequence of these. There is a bit of artistic licence with these formulations, as I am imagining the kinds of internal experiences Shrek may be having in this situation. Taking that into account, one way of using the situational formulation for this scene would be the following.
Shrek’s Situational Formulation
As illustrated in the top of the diagram, Shrek is likely to have a head full of negative automatic thoughts after this situation. Negative automatic thoughts can often be organised into themes of “unhelpful thinking habits” (or “cognitive distortions” in fancy CBT terms). We all fall into these traps of unhelpful thinking habits. They are more likely to occur when we are already upset or feeling down.
In this instance, Shrek’s common cognitive distortions seem to be:
- Judgements about the situation (opinions) instead of focusing on the facts, e.g. “she was talking negatively about me“.
- ‘Mind-reading’: assuming that he knows what others (e.g. Fiona) are thinking (this is very common for people who struggle with anxiety in social situations). e.g. “she thinks I’m ugly”.
- Negative predications and catastrophising (such a great word… it means thinking the worst will happen), e.g. “I’ll be alone forever”.
- Self-critical thinking, e.g. “I’m unloveable”.
Understandably, in thinking about the situation in this way, a range of difficult emotions are brought up. Shrek is clearly angry about this situation, an emotion he often conveys. In addition to this, it is likely he’ll be feeling anxious that he will lose something important to him, as well as feel hurt, loss and loneliness, in terms of believing he’s been rejected by Fiona. We all know the horrible physical sensations that emotions cause us to feel in our body, particularly the adrenaline (‘fight or flight’) response that often comes up with anxiety and anger, as described in the diagram.
This then leads to how Shrek acts in the scene, which can all be understood as his best efforts with coping with the negative thoughts and feelings brought up by the situation. The tough exterior and shouting at others, may be a way of avoiding Fiona rejecting him in person. He seems to want to push her away before she gets to speak, protecting himself against hearing what he anticipates will be a hurtful break-up (despite this not being the case). These ‘avoidance’ or ‘safety’ behaviours, work in the short term (i.e. he probably feels better temporarily to have control over the situation and not be broken up with), however in the long-term, they confirm his negative automatic thoughts about being alone and unloveable, as his behaviour has pushed others away. (Also it means that Fiona almost marries that jerk Lord Farquaad!!)
These negative automatic thoughts therefore continue to get stronger, perpetuating the negative emotions, uncomfortable body sensations and unhelpful behaviours. With all the areas feeding into each other, Shrek gets stuck in the vicious cycle.
THANKFULLY… we know from the movie that Shrek overcomes some of these negative, thoughts, feelings and behaviours – so he’s able to break the cycle and live happily ever after with Fiona! (Phew….)
Aaaand that’s a wrap – our first Psy Fiction formulation of a famous character! Thanks for reading and I hope it was a helpful start to learning about formulation. I have added some additional stuff to look at below if you fancy delving into this any further.
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Will be back soon with our next famous formulation. But for now…
That’s all folks!
Which star of the silver screen would you like to see a formulation for in the future?
Let me know in the comments below!
References and additional information:
- CBT and Dr Aaron Beck: Beck Institute website
- I found this a helpful intro to CBT: An introduction to Cognitive Behavioural Therapy: Skills and Applications, by David Westbrook, Helen Kennerley and Joan Kirk
- Situational (5 aspects) formulation template (Get Self Help)
- Cognitive Distortions Information Sheet (Get Self Help)
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Disclaimer: All Shrek images and video rights belong to DreamWorks Animation. Other images are referenced. Images and reference to the original films are used in this blog post in the understanding that it falls under ‘fair use’. This is due to the images and reference to the films being used in the context of a commentary/critique of the original material for educational purposes. To my knowledge, the use of images in this post do not deny the owner of income and they are not being used in this context for monetary gain of the user.