Longitudinal CBT Formulation: The “Mad” Queen

The Longitudinal CBT Formulation is coming… and who better to be our star this month than everyone’s favourite Game of Thrones qween: *Deep breath* Daenerys Stormborn of the House Targaryen, First of Her Name, the Unburnt, Queen of the Andals and the First Men, Khaleesi of the Great Grass Sea, Breaker of Chains, and Mother of Dragons… aka Dany.


So…. why do we use formulation, again?!

An intro to what formulation is can be found on the ‘About Psy Fiction‘ page (take another look if you need a refresh!). However, it can be hard to keep this all in mind. So, I just wanted to take a moment to really highlight the key things remember about formulation:

  • Formulation aims to be a compassionate and non-judgmental understanding of a person’s difficulties, based on their past experiences.
  • Formulation is often seen as an alternative to psychiatric diagnosis, wanting to resist the medicalising, pathologising and labelling of psychological and emotional experiences.
  • We want to move away from asking “What’s wrong with you?” (i.e. what medical diagnosis do you have) to “What’s happened to you?” (i.e. let’s understand your difficulties in the context of what you’ve been through).
  • We want to view ‘mental health issues’ and distress, such as anxiety, anger and low mood, as Normal reactions to abnormal experiences”.

In the final season of Game of Thrones, Dany’s dramatic invasion of King’s Landing caused great uproar, with fans feeling that she had just “gone psycho” and become “mad” like her father. Some also felt that she just uncharacteristically “snapped” and her behaviour didn’t make sense in the context of her character arc.

Whether you find yourself in this camp or not, this post is aimed at applying the principles of formulation to Dany, her life and her actions, in order learn about this formulation model, as well as perhaps to provide some perspective and understanding of her “Targaryen madness” in the penultimate episode. And for the sake of brevity/sanity, let’s try to leave our general Season 8 complaints at the door (for the scenes were dark and full of… idk?)

If you’re not a GoT fan or if rewatching all 8 seasons is not on your lockdown to-do list… do not fear – it is not a necessity for learning about the Longitudinal CBT Formulation! If you do however want a quick recap or some background info on our “case” Dany, catch a video summary of her life story here

“Oh fantastic. Another army is here to invade our city. I’m moving to Dorne.”

What is the Longitudinal CBT Formulation?

If the different models of formulation were Houses in Westeros, then the one with the greatest claim to the Psychological Iron Throne, would be Longitudinal CBT formulation. It is revered as a high quality evidence-based model and used widely by clinicians to conceptualise clients’ difficulties.

We have already talked a bit about Dr Aaron Beck‘s CBT (Cognitive Behavioural Therapy) model and the Situational CBT Formulation in a previous post. As illustrated by the loveable Shrek, the Situational CBT Formulation focuses on the interaction between an individual’s thoughts, feelings, bodily sensations and behaviour in a ‘here and now’ situation.

We want to think about the Longitudinal CBT Formulation not as a completely separate model, but as an extension of the Situational CBT Formulation. The Longitudinal CBT Formulation goes beyond the ‘here and now’ using a developmental approach. It provides a more holistic understanding of someone’s present difficulties, by linking their current thoughts, feeling and behaviours to their past experiences, using principles of cognitive and behavioural theory. This in turn provides an evidence-based hypothesis on where difficulties came from, what triggered them, as well as what maintains them.

There are many different versions of the Longitudinal CBT Formulation, so here we will be focusing on the most basic version, featuring its key components. (For more info on different types of Longitudinal CBT Formulation, see ‘Additional Information‘ at the end of this post.) Below is an outline of the Longitudinal CBT Formulation model we will use in this post, where you can see the Situational CBT Formulation at the bottom, but with new ‘longitudinal’ or ‘developmental’ components above it:

Full version available for download on the Psychology Tools website

So what’s different about the Longitudinal CBT Formulation?

The new ‘developmental’ factors in the Longitudinal CBT Formulation are described below, using definitions from Westbrook, Kennerly and Kirk (2011) and Judith Beck (2011):

Early Experiences: what historical factors have been significant and likely to have influenced an individual’s difficulties. Also known as “vulnerability factors”, i.e. what factors made the individual vulnerable to developing the problem, but does not by itself necessarily mean they would develop a problem. For example, losing a parent in childhood may make someone vulnerable to developing mental health difficulties in the future, however not everyone who loses a parent will develop these problems.

Core Beliefs: fundamental ‘bottom line’ beliefs about self, others and the world. Core beliefs are often developed early in life and tend not to be easily accessible to consciousness. They are often general and ‘absolute’ statements, for example: “I am stupid”/”Others can’t be trusted”/”The world is dangerous”. Situations are often stressful if they “activate” or “confirm” these core beliefs, e.g. a low mark in a test may activate the “I am stupid” belief. Core beliefs can also impact how we see/interpret a situation, i.e. they influence our ‘Negative Automatic Thoughts’ (‘NATs’ – discussed in a previous post ). NATs are the more accessible surface level “here and now” cognitions, which often represent the underlying core belief.

Rules for Living / Dysfunctional Assumptions: these cognitions are often viewed as attempts to try to live with and manage difficult core beliefs, by setting rules which minimise core beliefs being activated. They are often conditional statements (e.g. “if….. then”) or presented as “should” or “must” assumptions. If the core belief is “I am stupid”, we may develop assumptions or rules such as, “I must get top marks on everything” and “if I get perfect straight As, then no one will think I’m stupid”. They are “dysfunctional” as they are too rigid, over-generalised and in-flexible to cope with inevitable stressors and difficult life events.

Critical Incidents: these are events or ‘precipitants’ which closely precede the onset of difficulties or worsening of more long-standing issues. Often, these events have broken the rules for living and activated core beliefs. For example, critical incidents could include not reaching grades for university, losing a job and a partner being unfaithful. These would have broken the rule of “I must get high marks” and are likely to activate and reinforce the beliefs of “I am stupid” and “Others can’t be trusted”.

The “Mad” Queen?

“Madness and greatness are two sides of the same coin. Every time a new Targaryen is born, the gods toss the coin in the air and the world holds its breath to see how it will land.”

George R. R. Martin

Full disclosure: I’ve not read the books.

I’m sorry. I know I should. And I will. (Maybe). BUT for now, this post is purely based on the story from the absolute powerhouse that is the Game of Thrones TV series.

Nevertheless, this quote really stuck with me. The assumption that “madness” was something genetic, passed down through the generations of Targaryens. The coin metaphor implies that Dany is a victim of this inevitable biological pre-disposition to “Targaryen Madness” and is powerless in changing this. Particularly with her father being the “Mad King” – basically, she’s a product of her bloodline and it was only a matter of time before she became the “Mad Queen”.

“Jaime, so good to see you, my loyal and faithful subject! What’s that sword for?”

When criticism of Dany’s burning down of King’s Landing surfaced amongst fans (that this behaviour ‘came from nowhere’, and was completely out of character for Dany), the “Mad Queen Theory” (i.e., genetically-inherited “Targaryen Madness”) was used by some as the logical explanation for the way she acted.

Sounding a bit medical model here, aren’t we?!

I would argue however, that watching Dany battle for 8 seasons through trauma, loss and adversity, that her emotional distress may not have in fact “come out of nowhere” or just be down to genetics…

So, primarily the aim of this post is to specifically learn about the Longitudinal CBT Formulation model using a case example. However, it may also help us generate a deeper understanding of Dany’s character and behaviours, if we keep in mind our general principles of formulation: to present a more compassionate hypothesis on someone’s difficulties based on their past experiences, grounded in psychological theory, and moving away from the medical model of diagnostic labelling! Here. We. Go.

Dany’s Longitudinal CBT Formulation

Early Experiences

  • Orphaned – family killed in previous war.
  • Iron throne “taken” from family.
  • Legacy of being the daughter of the “Mad King”.
  • Only family member and close relationship is brother who she fears as he is physically, emotionally and sexually abusive, as well as behaving in a degrading and controlling manner towards Dany. (Learns relationships are abusive – experiences developmental trauma and has no secure attachment figure).
  • Arranged underage marriage and sold to Khal Drogo in exchange for brother making alliances and getting an army. Raped by Khal Drogo. (Feels powerless). Witness to Khal Drogo and his company carrying out horrific violent acts against innocent people.
  • Possible “Stockholm syndrome” with regards to “loving” Khal Drogo, as a way of coping with the horror of captivity, abuse and powerlessness of the situation.
  • Lack of positive, caring and supportive relationships.
  • Lost child in pregnancy, due to engaging in black magic (blames self?)
  • Husband (Khal Drogo) dies, brought back to life in an unresponsive state and views only option is to euthanise him (complicated grief).
  • Sent against her will to ‘Vaes Dothrak’, a commune for widowed wives of Khals.
  • Victim of multiple assassination attempts due to her claim to the throne.
  • Survives fire and has dragons (feels ‘special’)
  • Living in world where slavery is common place and male leaders (“tyrants”) are in power, with women and other minority groups often kept as slaves (are powerless).
  • Found using extreme violence as the “only effective way” to liberate others and overthrow tyrants. Also, when she liberates slaves, they choose to serve in her army (increasing her ‘power’).
New season of “Keeping up with the Targaryens”

Core beliefs

  • Me: I am powerless; I am an outsider/different; I am entitled (to the throne);
  • Others: Others will harm me; others will control me; others will leave me; others need saving; others cannot protect themselves
  • The world: The world is unjust/unfair; the world is dangerous

Rules for living / Dysfunctional Assumptions

  • If I am all powerful/untouchable, then others cannot harm me
  • If others oppose me, then I must destroy them, otherwise I will lose my power
  • If I hold others accountable for what they have done, then they will not harm me or others.
  • If I am on the Iron Throne, then I will make the world/myself safe
  • If I kill all “tyrants”, then the world will not be dangerous
  • I must be in control
  • I must not rely on others
  • I must protect and liberate others
  • I must not act like my father (“mad”, out of control, harm innocent people)

Critical Incidents

  • Arriving in Westeros and people not recognising her as the rightful heir or the powerful leader she views herself to be.
  • Dragons (like children to Dany) are killed.
  • Loses half of army (her power).
  • Loses or is betrayed by close advisors.
  • Loss of closest friend (Missandei) who is murdered by enemies.
  • Finding out Jon Snow’s identity threatening her claim to the throne (and highlighting “complexity” of their relationship, being, you know, related).
“I’m his…. Aunt…?”

Dany’s difficult journey sadly culminated in her committing horrendous atrocities. The important thing to recognise is that formulation is not justifying what she has done (i.e. we are not saying that killing innocent people was right), however it aims to provide an understanding of what traumatic life experiences may have led her down this path. Perhaps instead of this just being a result of a genetic “madness” that took hold, it can be understood in the context of Dany trying to cope with and survive a life filled with trauma, adversity and loss.

For the Season 8 haters, this might be a controversial statement to end on… but maybe Dany’s actions in the final season did fit just right in her character’s development… completely making sense psychologically in the context of her past experiences…?

That’s all folks!

Thanks for reading! I’ll be back with another famous formation soon… but until then I would love for you to stay in touch!

Please subscribe and leave any comments or feedback below!

Which star of the silver screen would you like to see a formulation for in the future?

Let me know in the comments!

References and additional information:

Additional info: Aren’t there lots of Longitudinal CBT Formulations?

In short, yes. Aaron Beck originally developed the Longitudinal CBT Formulation specifically for conceptualising clients with depression. It has since been widely adapted and applied to a variety of presentations. The Longitudinal CBT Formulation model focused on here is the broad cross-diagnostic model, often attributed to Judith Beck‘s (1995) adaptation (Dawson and Moghaddam, 2015). There are different versions of this generic model and as Westbrook, Kennerly and Kirk, 2011 describe, there are not strict rules around how the diagram looks, however we strive to include the key domains outlined in this post. There are also adapted ‘problem-specific’ CBT formulation models (e.g. for PTSD) which will be explored in future posts!

For the quick thinking Tyrion Lannister’s among you, you would be right in thinking there seems to be similarities between the Longitudinal CBT Formulation and the 5 Ps Formulation, which also considers past experiences. The benefit of the Longitudinal CBT Formulation, however, is that it is explicitly grounded in cognitive and behavioural theory. Although the 5 Ps Formulation is often associated with and advised to be linked with CBT theory (Johnson and Dallos, 2014), in reality this is not always the case. The 5 Ps Formulation therefore often attracts criticism for lacking a theoretical base.

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Disclaimer: All Game of Thrones image rights belong to HBO. Star Wars image rights belong to Disney. Images and reference to the original series 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.

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