This month we’re introducing the CBT formulation for specific phobias! To help get our heads round this one, we’ve got one of the biggest stars of the small screen – Marge Simpson! Marge’s plane phobia is explored in a great episode of The Simpsons… so let’s use formulation to find out what’s driving Marge’s fear of flying…
What are Specific Phobias?
A specific phobia is a fear of an object or situation , exposure to which leads to immediate anxiety or panic.
Other aspects of a phobia include:
- Intensity of fear is often associated with proximity to feared object/situation, and a person’s appraisals about the ability to escape it
- It often leads to avoidance of feared object/situation
- It is present for a significant period of time (typically over 6 months)
- Has a significant impact on someone’s day-to-day functioning
Common categories of phobias:
- Animals (e.g. dogs, spiders)
- The natural environment (e.g. thunder, lightening)
- Blood injury/injections (especially from Dr Nick…)
- Situational (e.g. lifts, heights)
- Other uncommon or atypical phobias (e.g. noise, beards, Krusty the Clown…)
A ‘fear of fear’ is also considered in addition to the original feared stimulus. People often experience fear of the original phobic stimulus, but also fear the anxiety/panic* that they will experience when they come into contact with it.
(Kirk & Rouf, 2004)
What is the CBT formulation model for Specific Phobias?
It is generally viewed that there is not yet a specific evaluated cognitive formulation model recommended for Phobias (Kirk & Rouf (2004); Westbrook et. al. (2011); UCL CBT Competency framework).
A preliminary model was proposed by Kirk & Rouf (2004) and is shown below. This is clearly a very detailed academic model which illustrates the development and maintenance of phobias, strongly grounded in cognitive and behavioural theories. Some clinicians may decide to use this model with clients if they feel they are able to digest this level of detail (particularly if they’re working with the Lisa Simpson’s of the world!). But – (just a wee disclaimer here – the next bit is my personal opinion!) I do wonder if this model may be quite complex for a lot of people to work through in a session (clients and therapists alike!)…
I know when looking through it my brain feels a bit…
We want to ensure formulations are accessible and help someone to understand their difficulties in a clear way that helps them to make meaningful change. Sometimes there are more academic models which therapists may keep in mind, but in sessions you may use parts of it or simplified versions if this feels more appropriate….
Simplified CBT formulation for Specific Phobia
With this in mind, I’m going to use a simplified version of this model in this post, as proposed by Westbrook et. al. (2012). This model takes the principles of Kirk & Rouf’s more detailed model in terms of cognitive and behavioural maintenance cycles:
I have made a slight amendment to the Westbrook et. al. model by adding in the ‘development’ box from the Kirk & Rouf’s bigger model above. This just allows a space for considering what early experiences may have contributed to the development of a phobia, making it more ‘longitudinal’ instead of just a ‘situational’ formulation*. (This is an example of how formulations are flexible and you don’t have to be too rigid with models – you can make them work for you, as long as we ensure they remain grounded in psychology theory and models!)
Breakdown of Phobia CBT Formulation model
- Development – early frightening experiences associated with the feared stimulus can explain where the phobia may stem from
- Focus on threat – due to prior experiences and development of a specific phobia, the brain will be hyper-focused on anything related to the feared stimulus. This hypervigilance means the ‘fight or flight’ response is hyper-sensitive to any possible link to the phobia, meaning someone is on high alert and more likely to experience anxiety/panic.
- Triggers – external objects/situations are thus interpreted as threatening, which leads to….
- Anxious predictions – exaggerated estimations of harm/danger associated with feared stimulus. Someone may also have anxious predictions about the possible physiological arousal associated with anxiety/panic (e.g. I’m going mad) – this is the ‘fear of fear’*. This exacerbates feelings of…
- Anxiety – the person experiences physiological anxiety response / arousal
- Safety-seeking behaviour/avoidance – the individual engages in safety behaviours, such as avoidance of facing the stimulus associated with phobia. This relieves anxiety in the short-term, however leads to…
- Failure to learn that worst does not happen – the negative anxious predictions are never disproven…
- Beliefs remain unchanged – which feeds back to continuing to have hyper-focus on threat, causing the vicious cycle to continue round and round – maintaining the specific phobia.
*Fear of fear is not explicitly outlined in Westbrook et. al.’s simplified model, although it is part of Kirk & Rouf’s more detailed model above. However, as described above – you can add in relevant boxes and arrows depending on what would be helpful for the individual – so if you were developing a formulation for someone where ‘fear of fear’ was a big part of understanding the maintenance of their phobia – you may want to add in an extra section such as this:
As Fear of Fear is not a huge part in Marge’s phobia – we won’t use this extra bit in the example – but just here for an extra nugget of formulation possibilities!
Marge Simpson’s CBT Formulation for Specific Phobia
So now let’s bring in a TV veteran for our phobia case study – Marge Simpson! A big part of Marge’s character is typically being the calm, tolerant mother and wife, who barely ever expresses her own needs or shows intense emotions (that’s a whole other formulation in itself…). However, in the Season 6 episode ‘Fear of Flying’ – we see Marge uncharacteristically completely fall apart at the thought of travelling on a plane for a family holiday.
For those who haven’t seen the episode – here’s a brief clip to give you an idea! But do not fear – it isn’t necessary to have seen the episode to understand the formulation example! (Although heads up… all seasons of The Simpsons are currently on Disney+ so…. do with that what you will…)
Marge’s Plane Phobia Formulation Model
So, based on Marge’s responses in this episode – here’s an example-specific phobia formulation! (As per Psy Fiction tradition, I have used some artistic licence around a few of the anxious predictions/physiological symptoms – as these weren’t all explicitly discussed in the episode but they were implied and/or typical of someone experiencing a phobia!)
This formulation model is a great one for illustrating the maintenance cycles of phobias. We see that Marge’s fear of planes and flying stem from various upsetting or scary plane-related experiences when she was a child. This predisposed her to believing planes were dangerous and should be avoided. Therefore, when an opportunity comes up for her to go on a family holiday, she does all she can to avoid flying on the plane. This starts with small avoidance strategies (not talking about it / putting others off going) but escalates to a significant panic attack on the plane. This subsequently leads to Marge (and the family) getting off the plane and not going away.
This is a classic example of avoidance in the context of a phobia, as Marge’s anxiety will have reduced in the short-term by going off the plane. However, it means that her beliefs about planes being dangerous are never challenged, so these remain intact, causing more anxiety and hypervigilance in the long run. It also has a huge impact on day-to-day life, as it prevents the family from going away on the planned holiday. Marge furthermore continues to feel on edge and anxious, managing this in unhelpful ways (such as fixing the roof tiles loudly at 3am…)
However, in the end Marge takes the brave step to face her phobia by going to therapy, working through the route of her fear of flying and challenging her anxious thoughts around this! What an absolute role model for seeking help when you need it! Now just time for the small matter of marital counselling, hey Marge…….
That’s all folks!
Thanks for reading! I’ll be back with another famous formulation 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:
- An introduction to Cognitive Behavioural Therapy: Skills and Applications, (2011) by David Westbrook, Helen Kennerley and Joan Kirk
- Specific Phobias, Kirk & Rouf – chapter in Oxford Guide to Behavioural Experiments in Cognitive Therapy (2004)
- CBT Competency Framework, UCL
- Fight or Flight information sheet, Therapist Aid
- Safety behaviours information sheet, Get Self Help
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Check out a previous post!
Anxiety Cognitive Formulation: Facing Fears in Finding Nemo
15th March 2021
Disclaimer: All Simpsons image and video rights belong to 20th Century Studios (The Walt Disney Company). Finding Nemo image rights belong to Disney Pixar. Images and reference to the original television shows/movies 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.