A Stranger Things CAMHS Formulation: Turn it up to Eleven

Now it was only a matter of time before Psy Fiction got round to the most exquisitely-written, psychologically-informed sci-fi show we have been blessed with in our current times… this is of course referring to Stranger Things. So, let’s take a deep dive into haunted Hawkins with our case example for this post being the telekinetic teenager that is El… aka Eleven… Jane… 011… who will help us to learn about a CAMHS formulation model…

*Warning… there are Season 4 spoilers afoot!*

So, as always with Psy Fiction, it matters not whether you’re a super fan of the featured show/film, or have never even heard of it. The blog is for whoever wants to learn about psychological case formulation. Therefore, you can just view the characters as ‘example case studies’ if you’re in it for the pure psychology!

HOWEVER… please just indulge some pure nerdiness very briefly before we get down to the clinical psychology nitty gritty – and permit me to call an exclusive Hellfire Club meeting to discuss the wonders of this show. I can not be the only one absolutely obsessed with Stranger Things this year, particularly Season 4. I mean DAYMN Duffer Brothers! Running up that Hill and Master of Puppets have been on permanent rotation since I finished Volume 2… And the thing with this show is you could do a formulation for every Tom, Dick and Hopper in it; they have such rich back stories! They’ve been through all kinds of ups and (upside) downs, tribulations and trauma. Suffice to say, the character development is all kinds of excellent…

…so much so I couldn’t decide who to write about! Hence I put the decision in the hands of the Psy Fiction fans out there in Internet Land! Via a poll you guys voted on who you most wanted to see a formulation of… I was initially leaning towards the wonderful Hopper with his complex Vietnam Vet background and family grief. There were also some votes for our fierce Max, while others wanted to see one for wee troubled Will. Surprisingly even the Mind Flayer got a vote (maybe next season…) but ultimately the outstanding winner with the most votes was of course, El! So… ye ask and ye shall receive…

Stranger things have happened than a CAMHS Formulation…

What is CAMHS?

So first things first, what is this ‘CAMHS’ business I hear you ask … so CAMHS stands for ‘Child and Adolescent Mental Health Service’. CAMHS is therefore a type of mental health service, rather than a theoretical model (which is what has been the focus of formulations in previous posts). Therefore, this post focuses on outlining a formulation model which is specifically adapted for understanding difficulties experienced by children and adolescents.

What does a CAMHS formulation look like?

It should be noted that there is not a ‘set’ formulation that everyone uses in CAMHS. Formulation is a dynamic and collaborative process, and how this is done in CAMHS is completely dependent on the clinician and the young person they are working with. However, there are some key principles to consider for undertaking psychological formulation with this age group.

Often formulations with children and adolescents are based on models used with adults (e.g. CBT), which have been adapted for a younger population. For example, in order to adapt a formulation to be tailored for children and young people, it is essential to incorporate developmental, attachment, family, and cultural factors into the formulation. A systemic approach is also often used in CAMHS formulations. Systemic theory and therapy focuses not only on the individual level, but also on people in relationships, focusing on groups and systems around a person, and the interactional patterns and dynamics of these groups and relationships. Systemic principles in formulations are commonly used in CAMHS (DCP, 2011), particular in the context of families, as well as wider systems around young people. For example, there are recommendations to include genograms in assessment and formulation to help understand the wider family context (BABPC, 2021).

Dummett’s CBT and Systemic CAMHS Formulation

This post will focus on Dummett’s (2006; 2013) CAMHS formulation. This model takes a standard CBT longitudinal formulation (Beck, 2011), adapting it for use in CAMHS settings by explicitly integrating with systemic principles. You might recognise the CBT longitudinal formulation from the Psy Fiction Game of Thrones post! Dummett initially takes this model but, just like Hawkins in the Upside Down, everything is flipped. This is why it may not look the same initially… but if you look closely it is just the model you have seen in previous posts (with the order reversed). This is just a stylistic choice to help integrate the other factors; all the concepts are the same as we have discussed before.

Dummet (2013)

Dummett then takes this basic CBT model and adds a number of systemic aspects to it:

Dummet (2013)

You may think that this model looks busier than the Starcourt Mall on spring break… and you’re not wrong! However, Dummett specifically highlights that all the different sections of this formulation model are just areas to consider when working with a young person – and the level of detail that’s included in a formulation would depend on the young person’s experiences and their developmental stage. It is advised that the clinician would only need to include enough sections or detail to facilitate therapeutic change. It may also be that different levels of detail are shared with different people, for example, younger child and parents.

Nevertheless just like facing down a demogorgon in a game of Dungeons & Dragons, it’s good to have a thorough understanding of what we’re dealing with. So let’s look at all aspects of the model to begin with and break it down into the different sections:

  • Firstly, the child or young person’s individual CBT longitudinal formulation is central to this model.
  • Secondly, we have an additional timeline on the right which gives space to consider ‘early, later and recent’ events, and how these map onto the young person’s age at the time. This helps us to clearly hold in mind the developmental stages at which these events occurred, and how they may have contributed to core beliefs and assumptions.
  • At the top, we have the genogram, a core component of systemic formulations. This represents the key family relationships around the child, including some background on these family members, as well as their own views and hopes about the child’s current difficulties. Information about key family members is broken down into different topics, including: complaints, wanting, thoughts, affects, behaviours, life events.
  • In addition, on the left, all other relationships involved in support of the young person (protective factors), or those that are possible maintaining problem(s) (e.g., peers/school difficulties).
  • Finally, at the bottom left we have a space to consider the young person’s cultural context and factors which may contribute or protect from current difficulties.

Eleven’s Never-ending Story

Although El may be a superhero, with the powers of telekinesis, inter-dimensional mind travel, and the ability to totally rock a buzzcut, it’ll be no surprise to fans of the show that she’s a prime candidate for an example formulation. From being taken from her mother as a baby and raised for scientific experimentation away from the rest of the world, to fighting monsters, having complicated parental figures, losing those close to her, often being on the run with scary adults trying to abduct or kill her, and surviving purely on a not-so-nutrient-rich diet of eggos… it is needless to say she has been through the wars by the time she is 14 years old.

El has many strengths and superpowers, but also at times struggles to manage her emotions and navigate relationships. We will use a CAMHS formulation to help us to understand how some of these difficulties developed, and what current maintaining factors are keeping these difficulties going. We also consider what relationships are protective for her and help to overcome these difficulties.

As with all our formulations however, we are not saying there is something ‘wrong’ with El. We are also not trying to find a label or a diagnosis for her.

Now did I use this blog as an excuse to go back and rewatch from Season 1…? Maybe… but do not fear, I have saved you the trouble of this task with a summary of El’s so-far short but eventful life in video form! So if you would like a recap or some background – these will just give a quick reminder of her journey for the Stranger Things fans, or an introduction to her story if you are not familiar with the show. Otherwise scroll down for the formulation!

Season 1-3:

Season 4:

Eleven’s CAMHS Formulation

For El’s CAMHS formulation, all components of Dummett’s CBT/Systemic formulation have been included. This is therefore a very detailed/busy example, in order to illustrate all parts of the model. But remember, it’s unlikely you would have a model this detailed in practice! Also, as always… there is some artistic licence with Psy Fiction formulations – with some guesses around e.g. the characters thoughts, physiological experiences etc…

Diagrammatic formulation:

Narrative description of formulation:

  1. Systemic family context

El was raised from birth in MK Ultra’s laboratory where she was experimented on due to her telekinetic powers. She was brought up with other children in the laboratory who she was told were her brothers and sisters, with El and the others calling the lead scientist Dr Brenner ‘Papa’, believing he was their father. Dr Brenner used authoritarian, abusive and manipulative approaches with the children, leaving them scared of disobeying him. They were given numbers instead of names (hence Eleven/011) and even had these forcibly tattooed on them (geez, father of the year award right here…) Eleven was born ‘Jane’ but was removed from her mother (Terry Ives) at birth, with the party line being that Terry had a miscarriage. Terry tried to sue MK Ultra and broke into the lab to save Jane/Eleven. However, she was not believed and underwent ECT which left her in a vegetative state.

Over the series’, Eleven is ‘adopted’ by police chief Hopper, who protects her in secret when she is being hunted by those from Hawkins lab. He is extremely protective, which likely stems from losing his own daughter to cancer. Despite some disagreements, Eleven forms a strong attachment to Hopper, leaving her devastated when he goes missing and is presumed dead. When this happens, she is ‘adopted’ again by Joyce. Eleven appears close to Joyce, however Joyce is often preoccupied with rescuing Hopper (who is alive! – good – but is also trapped in a Russian gulag – bad). As a result Joyce doesn’t notice Eleven is struggling, which likely maintains her difficulties in Season 4. All in all, Eleven has had numerous transitions and changes in living arrangements and carers from a young age.

Actor Matthew Modine (Dr “Papa” Brenner) brining that big ‘controlling parent at the Little Miss America pageant’ energy here.

2. Life events

Eleven did not have experience of a secure attachment or safe base/person throughout her primary years. She was likely to constantly be in a ‘fight or flight’ state of fear. Growing up in the lab meant her basic needs of love, care and socialising were neglected, meaning she was developmentally behind others – both on an academic and social level – creating difficulties when trying to integrate into normal life. El was likely to have grown up feeling she is loved conditionally; her worth was literally determined by how well she can telekinetically crush a coke can. Therefore, it was likely that she would find others unpredictable and have trouble trusting them.

In the context of this developmental trauma and neglect, El was likely growing up constantly in ‘threat mode’, without a containing caregiver to help develop healthy emotional regulation. This may have contributed to Eleven being hyper-vigilant to danger, and struggling to identify and manage strong emotions. She appears at times to be almost void of emotions (perhaps in a dissociative state), flipping to demonstrations of extreme emotions (often anger) when she uses her powers. Even when she escapes the lab, the fact she is being hunted, is having to fight demogorgans, Mind Flayers, and all kinds of Upside Down abominations, with her friends constantly being in danger – all of this perpetuates her need to constantly be in ‘fight or flight’, this having been adaptive and protective for her.

Despite being Hawkins last hope against the horrors of the Upside down, El is still a teenager… which means it makes sense developmentally as to why she is very focused on fitting in with friends and at school, and what her boyfriend thinks. At 14-years old, she is at the developmental stage in adolescence where typically young people are transitioning away from family to wanting to spend more time with friends and considering romantic relationships. Therefore difficulties at school and with Mike may seem as important/scary as attacks from deadly demodogs.

3. CBT Longitudinal Formulation

These past experiences are likely to have contributed to the formation of negative core beliefs (e.g. I am different/a monster; others are untrustworthy; others will leave me), as well as conditional assumptions (e.g. if I act normal, people won’t reject me). This then leads to surface-level negative automatic thoughts when stressful things happen. For example, when experiencing bullying at school El is likely thinking: ‘everyone thinks I’m weird’ and ‘my boyfriend won’t love me if he knows the truth’.

This will trigger the CBT situational vicious cycle of thoughts, feelings, behaviours, and bodily symptoms (described in detail in the Psy Fiction Shrek Post). Her negative automatic thoughts are likely to lead to feelings such as anger, embarrassment and sadness, as well as difficult physiological symptoms e.g. tense muscles and rapid breathing. Considering El’s history of developmental trauma and the impact on her emotional regulation, it is understandable that she struggles to regulate these emotions, which translates in to impulsive behaviours like assaulting bullies. This will further cause her to feel alienated and different to others, perpetuating the vicious cycle.

4. Current systemic and cultural context

The sections on the left of the diagrammatic formulation ensure that other current systemic factors are also considered when understanding El’s difficulties. Many of these highlight the protective nature of her friends and boyfriend in helping to support her (practically in terms of giving her a place to live, but also emotionally and socially). It also highlights the difficulties of being at school, where El struggles to fit into the ‘norm’ and is the victim of bullying. There is also some cultural considerations here, with El being brought up in an artificial world (laboratory), she will have been exposed to abnormal ‘norms’ of relationships, behaviours, values, and emotional management.

So… this formulation has provided a model to integrate numerous complex life events experienced by El, to help us understand why she may have certain difficulties in the present. Also, it highlights the positive impact of some systemic factors such as her parental figures and friends who help to protect her against some of the adversity she has experienced. However, as we know… “friends don’t lie”... and I’m not going to fib by telling you this formulation model is perfect! A critique of this model is that although it gives space for positive relationships, it doesn’t allow space to fully consider someone’s strengths or protective factors as is permitted in the 5Ps formulation model. Overall, it is a good integrative formulation which links CBT, Systemic and developmental principles, making it a good starting point for CAMHS settings! So that’s all from Hawkins for now, just remember…

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:

  • Dummett, N. (2006). Processes for systemic cognitive-behavioural therapy with children, young people and families. Behavioural and Cognitive Psychotherapy34(2), 179-189.

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5 Ps Formulation: The Dark Side and the Light

15th May 2020

Disclaimer: All Stranger Things image and video rights belong to Netflix. Star Wars images belong to Disney. Images and reference to the original 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.

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