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.

Low Self-Esteem CBT Formulation: Encanto’s Surface Pressure

After a wee break, Psy Fiction is back with another fictional formulation for all you fellow psychology/movie fans! Our “case study” this time is from Disney’s amazing new animation Encanto. The magical Madrigal sisters will be helping to explain the CBT Formulation for Low Self-Esteem

“No pressure, Sis!”

There I was minding my own business in yet another COVID lockdown, contemplating my twelfth rewatch of Hamilton*… when BAM! Disney drops Encanto. Now… I can’t be the only one that fell in love with this gorgeous movie, particularly in the psychology crowd. With a refreshing change from the classic Disney tropes of princesses, love interests, and there being a ‘big baddie’ to fight… Instead we have a complex but engaging story touching on themes of family roles, culture, intergenerational trauma, self-worth, perfectionism, unrelenting standards, and healing through relationships.

*this month

Can I get an Amen for emotionally intelligent and progressive kids fillllllmsss?! Also not to mention Lin Manuel Miranda’s soundtrack which has absolutely no right to slam so hard. But before you head off to play ‘We don’t talk about Bruno’ on repeat for the rest of the day… can we please talk about the psychological themes in Encanto? Case formulation is once again our friend when it comes to understanding what is going on for these characters!

There are many themes raised by different Madrigal family members which we could focus on and explore in Psy Fiction; Abuela’s trauma and grief for instance, or the emotions around Tío Bruno leaving the family. However, I wanted to focus on a common theme for the 3 Madrigal sisters: self-esteem. Our loveable lead character Mirabel battles with her own self-worth, being the only family member without a magical gift. Isabela also talks about her struggles in needing to be the “perfect golden child”. But the star of our formulation to illustrate self-esteem will be the eldest Madrigal sister Luisa, who opens up about the pressure of her role as being the strongest family member.

The CBT Formulation Model for Low Self-esteem

What is Self-Esteem?

Self-esteem is how we value and perceive ourselves. It’s based on our opinions and beliefs about ourselves, which can sometimes feel really difficult to change. (Mind)

Low self-esteem is defined as a self-evaluation or representation which is negatively biased and inflexible.

Having low self-esteem isn’t a mental health problem in itself, but they are closely linked. If lots of things affect your self-esteem for a long time, this might lead to feeling depressed or anxious (Mind). It is important to note that low self-esteem is not a diagnosis, and in true Psy Fiction style we want to focus on psychological principles and formulation models that helps us to understand someone’s difficulties, without the need for a medical approach with diagnostic labels.

What is the CBT model for low Self-Esteem?

Fennell (1997; 1998) proposed low self-esteem as a predisposing or vulnerability factor, which may underlie both depression and anxiety symptoms. This self-esteem formulation is a Longitudinal Formulation, similar to Beck’s original CBT formulation developed for low mood (see Game of Thrones blog post) and the specific anxiety longitudinal formulation (see Finding Nemo blog post). Longitudinal means it considers past experiences in someone’s current presenting problems.

Fennell 1997

This self-esteem CBT model suggests that low self-esteem stems from global negative core beliefs about the self (the ‘bottom line’), which develop from early life experiences. This leads to unrealistic life rules or high standards (‘dysfunctional assumptions’), which need to be met to feel worth and protect the individual from activating ‘bottom line’ beliefs. When a situation (‘critical incident’) is inevitably encountered where the unrealistic standards are challenged, this activates the ‘bottom line’, and triggers vicious cycles of feelings, thoughts, and behaviour.

Incidents where rules and standards may not be met, trigger negative predictions (e.g. “I’ll fail my exam”) resulting in anxiety symptoms (right cycle on the model), such as physiological responses (e.g. heart racing). This subsequently leads to maladaptive safety behaviours, (e.g. avoidance or over preparing), which end up making anxiety worse and enhancing evidence for the ‘bottom line’ negative beliefs. In situations where dysfunctional assumptions/standards have not been met, it leads to confirmation of the bottom line, and subsequent self-critical thinking. This maintains feelings of depression, which perpetuates and strengthens patterns of negative future predictions (left cycle on the model).

Luisa Madrigal’s Formulation

Luisa is Mirabel’s eldest sister, whose miracle gift is super strength. She is portrayed as playing the role of a quiet, gentle giant in the family and village, who undertakes numerous tasks such as building houses, moving bridges, carrying donkeys etc… She is always happy to help and seems to pride herself in using her strength to support others.

However, we see Luisa’s strong and calm exterior starting to crack when her gift begins to fade and she notices that she is getting less strong, and feels less able to undertake the heavy lifting which she usually does with ease. It is at this point that we see Luisa questioning her self-worth, as well as opening up about the high expectations put on by herself and others. Luisa communicates this all, of course, via the absolute banger “Surface Pressure” – so if you haven’t seen Encanto (or even if you have and just want to relive it) then this song in the video below will help you to get a sense of Luisa’s character *cranks the volume up to 11*.

Low Self-Esteem CBT Formulation Example

In the movie, Luisa presents with feelings of nervousness and anxiety when her strength begins to fade, and her mood drops significantly when she loses her gift completely. We can use the low self-esteem model to understand Luisa’s experiences, her self-identity, as well as her presentation of anxiety and low-mood (used interchangeably with ‘depression’ in this model).

The formulation demonstrates how Luisa’s early experiences, family history, and role within the family, contribute to her identity and responsibility to look after others. It also explains the source of her link between self-worth and her gift of strength, as well as her viewing emotions as weakness. This all gives rise to the development of dysfunctional assumptions about the need to be strong and perfect at all times in order to feel worthy, to protect others, and for others accept her. However, when these assumptions or standards are challenged (when her gift starts to fade), this leads to anxiety. When these standards are completely not met (when she loses her gift), this leads to low mood.

These vicious cycles of anxiety and low mood then both maintain feelings of low self-esteem, by confirming the bottom line negative core beliefs about herself. This is all described in more detail in the diagram below:

Fennell 1997

So, based on Luisa’s past experiences, as well as her family’s understandable response to trauma and loss, we can use the self-esteem CBT formulation to understand her difficulties around anxiety and low mood during the movie. But this is not where we leave the lovely Luisa… for we see, in the final musical number, how support and validation from her family and wider social network of the village help her to start breaking the vicious cycles of low self-esteem.

Hearing messages from Abuela and the family such as “I think it’s time to learn you’re more than your gift” and “the miracle is you, not your gift, just you” helps to challenge the core negative beliefs about her worth. Luisa shares with her sisters that she is strong “but sometimes I cry”, only to receive acceptance and validation from her sisters who tell her “So do I”, helping to normalise a range of emotions, showing these are not weaknesses.

We leave Luisa with her acknowledging that “I may not be as strong but I’m getting wiser” and her taking a restful break – yasss to this self-care queen!

Hasta La Vista, folks!

Thanks for reading! Psy Fiction will 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!

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

Let me know in the comments!

References and additional information:

  • About Self-Esteem – Mind Charity website
  • Safety Behaviours – Information sheet from Get Self Help
  • Fight or Flight – Information Sheet from Therapist Aid
  • About Anxiety – Mind Charity
  • Fennell, M. (2009). Overcoming Low Self-Esteem, 1st Edition: A Self-Help Guide Using Cognitive Behavioral Techniques. London: Constable & Robinson Ltd. (Book – also available for £2.99 on kindle)
  • Fennell, M. (1997). Low Self-Esteem: A Cognitive Perspective. Behavioural and Cognitive Psychotherapy, 25(1), 1–25. 
  • Fennell, M. J. V. (1998). Cognitive Therapy in the Treatment of Low Self-Esteem. Advances in Psychiatric Treatment, 4(5), 296–304.

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Anxiety Cognitive Formulation: Facing Fears in Finding Nemo

15th March 2021

Disclaimer: All original Encanto and Finding Nemo image and video rights belong to Disney Pixar. 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.

Phobia CBT Formulation: Marge Simpson’s Fear of Flying

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)

*Phobia’s are basically specific triggers for anxiety and panic – if you want to find out more about these presentations, check out previous posts on Anxiety and Panic formulations.

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:

Adapted from Westbrook et. al. (2011)

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!)

*For more information on these different types formulations, check out previous posts on CBT Situational Formulation and CBT Longitudinal Formulation.

Breakdown of Phobia CBT Formulation model

  1. Development – early frightening experiences associated with the feared stimulus can explain where the phobia may stem from
  2. 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.
  3. Triggers – external objects/situations are thus interpreted as threatening, which leads to….
  4. 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…
  5. Anxiety – the person experiences physiological anxiety response / arousal
  6. 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…
  7. Failure to learn that worst does not happen – the negative anxious predictions are never disproven…
  8. 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.
Avoidance – the most common safety behaviour!

*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.

(Am I the only one who just started to get The Simpson’s cinematic references re-watching them now as an adult? A not-so-subtle nod to Alfred Hitchcock here!)

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!

“Hi, I’m Troy McClure and thanks for tuning in to another Psy Fiction blog post! You might remember me from such posts as ‘Harry Potter: Fantastic Formulations and Where to Find Them’ and ‘Finding Nemo: Tears of a Clownfish’!”

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?

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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.

Anxiety Cognitive Formulation: Facing Fears in Finding Nemo

We’re continuing the theme of CBT formulations with this month’s Psy Fiction post… with a little help from a Disney Pixar classic, Finding Nemo! We’re diving into one of the longitudinal CBT formulations for anxiety, starring Nemo’s dad Marlin as our ‘case study’! Being a parent is a tough gig… and it seems being a Clown Fish is no exception… so let’s explore this dad’s anxiety a bit further…

CBT Formulation Model for Anxiety

What is anxiety?

Anxiety is a normal adaptive response. It is what we feel when we are worried, tense or afraid – particularly about things that are about to happen, or which we think could happen in the future (Mind).

Everyone has feelings of anxiety at some point in their life. For example, you may feel worried and anxious about starting a new school, having job interview, or being told that you are going to be Darla’s new pet…

During times like these, feeling anxious can be perfectly normal. But some people find it hard to control their worries. Their feelings of anxiety are more constant and can often affect their daily lives. (NHS)

Characteristics of anxiety can include restlessness, trembling, poor concentration, sweating, heart palpitations, shortness of breath, sleep difficulties, and irritability. These responses can be attributed to the body’s ‘fight or flight’ response. (If this is a new topic and you want more details on the symptoms of anxiety, you can find this from Mind here.)

Anxiety is considered a mental health issue when:

  • the anxiety level exceeds the reality of potential danger
  • it features excessive fear, vigilance in preparing for perceived danger, and/or lasts for a long time
  • it results in negative behavioural changes such as avoidance e.g. avoiding situations that make you anxious.
  • it causes significant distress and negatively impacts one’s day-to-day life

What is the cognitive formulation model for anxiety?

This post is going to focus on a longitudinal formulation model for anxiety.

As already mentioned, there are lots of different formulation models for different presentations. For anxiety, there are ‘problem-specific’ CBT formulation models which focus on specific forms of anxiety – some of which we have already covered in Psy Fiction e.g. for Iron Man’s Panic or Harry Potter’s PTSD.

We have also covered the general Longitudinal Formulation in a previous Game of Thrones post, which was originally developed for individuals with depression. In contrast, the present formulation model is a specific longitudinal formulation model for anxiety, developed by Beck (2005) and Wells (1997… no relation to moi…):

Wells (2007); image source – Think CBT

This cognitive theory of anxiety suggests that anxiety stems from having maladaptive ‘schemas‘ which develop through early life experiences. These schemas are similar to ‘core beliefs’ which have been discussed in a previous post. Schemas can be seen as the cognitive frameworks which we develop to help us to understand the world.

The model suggests that individuals who suffer from elevated anxiety are likely to have schemas which focus on danger, i.e. they interpret life experiences through a lens of expecting the world to be dangerous. These maladaptive ‘danger schemas’ are activated by ‘critical incidents’, which are trigger incidents that reflect dangerous situations, e.g. being approached by Bruce the shark asking you to come to his party, may trigger your ‘danger schema’….

In this theory, when danger schemas are activated by critical incidents, it triggers ‘negative automatic thoughts’ (NATs – these are discussed in more detail in the previous Shrek post). These are surface level cognitions, which represent the core underlying ‘danger schemas’.

Schema activation also introduces ‘cognitive biases’ in information processing. Thus, events are interpreted in a way that is consistent with the schema, resulting in negative beliefs and appraisals being maintained. Examples of cognitive distortions include ‘overgeneralisation’, where a conclusion based on an isolated event is applied to all situations, and ‘catastrophizing’ which involves predicting the worst possible outcome of a situation.

This can result in both Fight or Flight driven physiological anxiety symptoms (e.g. feeling faint or rapid breathing) and behavioural responses to reduce danger (e.g. safety behaviours and avoidance). Although these reduce feelings of anxiety in the short term, it can prevent challenging the danger schemas and NATs, which maintains the anxiety symptoms.

This model underpins Cognitive Behavioural Therapy (CBT) for anxiety.

Marlin’s Anxiety Formulation

We’re focusing our formulation on the start of the movie, where we get a glimpse of Marlin’s past experiences, examples of his anxious thoughts, as well as the anxiety provoking situation of his son Nemo starting school for the first time. If you haven’t seen Finding Nemo or struggling to remember the details – here’s a few snippets for some context!

Marlin can come across as a bit of an anti-social and irritable ol’ clown fish, whose over-protectiveness can be annoying to others, particularly Nemo! Marlin sometimes comes across as a bit of a know-it-all about the ocean to his son, and doesn’t allow Nemo any independence. One could therefore jump to conclusions and think that this is just Marlin’s personality and he’s not doing very well at this parenting lark… but maybe we can use formulation to delve a bit deeper to understand his behaviour in a different way…?

*Remember! Formulation is moving away from “what’s wrong with you” to “what happened to you and how are you coping with those experiences?”

Cognitive Model of Anxiety applied to Marlin

This formulation demonstrates how Marlin’s early life experiences lead to the development of his ‘danger schemas’, predisposing him to elevated levels of anxiety. These danger schemas are activated during ‘critical incidents’ which may include reminders of past experiences. In this case, Nemo starting school is triggering as it means Marlin will have to leave Nemo alone and therefore not be around to protect him 24/7 as before. Then, the school trip to the drop-off significantly triggers his danger schemas and subsequent anxiety symptoms, as this is a clear reminder of his past experiences.

We see that Marlin generally has many anxious tendencies earlier in the film. For example, he displays compulsive behaviours going in and out of his home to check for danger. He also panics when Nemo falls out the anemone and gets stuck, worrying he has been significantly harmed. You can also see his tendency towards avoidance, saying to Nemo he doesn’t have to go to school (for 5 or 6 years….). All of these anxiety characteristics are then escalated after the critical incidents.

When Marlin sees Nemo at the drop-off, we see a flurry of NATs arising. These are all in line with the cognitive distortions. This negative thinking would then lead to Marlin experiencing physical anxiety symptoms, such as heart palpitations*. We then see Marlin’s behaviour change in response to these difficult feelings, e.g. being more snappy and irritable towards others. He also engages in many safety behaviours, such as avoidance and over-protectiveness. All these feedback into negative thinking styles, leaving his NATs and danger schemas unchallenged.

*I am using some artistic license here as these symptoms are not mentioned in the film but these are common anxiety responses Marlin was likely to be experiencing… although full disclosure I have no knowledge about the neurobiological fear responses of fish… but we are referring to talking fish so maybe we can suspend our belief just this once!

So… is this the whole story?

The above formulation is great at understanding where someone’s anxiety comes from, when it is most likely to be triggered, and how that links to their experience of anxiety in certain situations. It also highlights some of the cycles which maintain the anxiety. The bit which is perhaps missing from the boxes above, is the role of others in anxiety maintenance, as well as the impact someone’s anxiety has on others.

For example, the anxiety-fuelled way in which Marlin responds to Nemo whilst at the Drop-Off, actually contributes to his son swimming away and getting caught. So in a way – in trying to avoid Nemo coming to any harm, Marlin’s over-protective behaviour ends up resulting in his worst fear becoming realised! This can be understood in a simple ‘self-fulfilling prophecy’ formulation model maintenance cycle (Westbrook, Kennerly & Kirk):

For this case, you could therefore use a combination of longitudinal formulation models, as well as using a simple maintenance cycle along side this, in order to fully understand an individual’s anxiety.

Finding Nemo = the best anxiety intervention

Hopefully this formulation helps to more fully understanding Marlin’s “anti-social”, irritable and over-protective behaviour through a more compassionate lens. At the core he wants his son to be safe – but unfortunately, unintentionally his anxiety and safety behaviours push people away and end up confirming his worst fear!

Marlin’s story in Finding Nemo in a way continues along the CBT theme; at each stage in his journey to find Nemo, he engages in exposure to anxiety-provoking situations, he undertakes ‘behavioural experiments’ which show him not everything is as dangerous as he predicts, and he meets others who help to challenge his NATs and danger schemas!

So in the end… Marlin facing and overcoming his anxiety, with a little help from some pals, means he can swim across the ocean and save Nemo! Dad of the Year or what!

Will be back soon with our next famous formulation. But for now…

That’s all folks!

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 below!

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Situational CBT Formulation: Like an onion, it has layers

13th April 2020

Disclaimer: All original Finding Nemo image and video rights belong to Disney Pixar. Shrek image 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.

PTSD Cognitive Formulation: Harry Potter, The Boy Who Lived

After an intermission of a few months, Psy Fiction is back with another psychological formulation blog post! Sorry for the radio silence… things got a bit hectic in this ol’ pandemic! But some unexpectedly altered Christmas plans and subsequent low-key lockdown annual leave, has allowed time for some blog writing… and naturally the traditional festive Harry Potter movie marathon sparked some inspo…

So this time, we’re heading over to the Wizarding World for a formulation “case study” of the boy who lived, the chosen one… Harry Potter. This famous wizard will illustrate the PTSD Cognitive Formulation… with his response to a very traumatic experience at Hogwarts…

So… which of Harry’s many traumatic experiences are we referring to…?

Re-watching all the movies was a stark reminder that Hogwarts is a death trap, Dumbledore’s management as headmaster is more than questionable, and a visit from the magical equivalent of OFSTED (and child protection services) is long overdue…

And parents still send their kids to this school?! Anyway… I digress… but seriously there was not a shortage of traumatic experiences to chose from which poor old Harry has had to endure in conjunction with his studies. For the purpose of this blog we are going to be focusing on the absolutely horrifying end to the 4th book/movie, the Goblet of Fire. After unexpectedly being transported to an unknown location via the Triwizard Cup which was secretly a port key (an enchanted object which transports whoever touches it to a specific location), Harry is faced with the return of Voldemort, being captured, threatened, physically assaulted, tortured, and witnessing the murder of his school friend, Cedric Diggery…


For those of you who are not Potterheads and are just in it for the hard-core psychology biz-ness (who could blame you), or if you simply need your memory refreshing – no problemo! Here’s two short videos of the events which will be the focus of Harry’s PTSD formulation:

Following these events, the story continues in the fifth book/film, The Order of the Phoenix. There were some mixed responses to Harry’s character in this book, with comments on Harry’s changed demeanour, seeming like an ‘angry hormonal adolescent’ who seemed increasingly irritable towards others, often shouting and dismissing his friends. In this blog we want to take a different perspective… could we in fact instead consider Harry’s behaviour as a response to the extremely traumatic events he experienced, rather than just being a moody self-centred teenager…?

What is PTSD?

Someone can experience Post-Traumatic Stress Disorder (PTSD) as a response to being exposed to a traumatic event.

There are two types of traumatic events:

  • Type 1 Trauma: aka ‘Simple’ Trauma – this involves a single-event traumatic event, e.g. a one-off random attack by a death eater at a Quidditch World Cup, or crashing your flying car into the Whomping Willow.
  • Type 2 Trauma: aka ‘Complex’ Trauma – this involves chronic and repeated trauma/abuse, often of an interpersonal nature, which can occur early in a person’s development, e.g. being forced to sleep in a cupboard under the stairs as a young child, or being tortured using the Cruciatus curse.

For this post, we will focus on a formulation for PTSD in response to Type 1/single-event trauma (although Harry has experienced plenty of both types across his life…).

Many people experience trauma and recover without any long-term consequences. There is often a period up to a month after a single-event trauma where an individual experiences an acute stress response. In this time, they may exhibit characteristics of PTSD, which are natural responses to traumatic events, but these often reduce within the month timeframe. If a person’s difficulties persist for longer, they may be be experiencing a post-traumatic stress response which could benefit from treatment.

Characteristics of PTSD, defined by the American Psychiatric Association:

  • Intrusion: Intrusive thoughts such as repeated, involuntary memories, distressing dreams, or flashbacks of the traumatic event. Flashbacks may be so vivid that people feel they are re-living the traumatic experience or seeing it before their eyes.
  • Avoidance: Avoiding reminders of the traumatic event may include avoiding people, places, activities, objects and situations that may trigger distressing memories. People may try to avoid remembering or thinking about the traumatic event. They may resist talking about what happened or how they feel about it.
  • Alterations in cognition and mood: Inability to remember important aspects of the traumatic event, negative thoughts and feelings leading to ongoing and distorted beliefs about oneself or others (e.g., “I am bad,” “No one can be trusted”); distorted thoughts about the cause or consequences of the event leading to wrongly blaming self or other; ongoing fear, horror, anger, guilt or shame; reduced interest in activities previously enjoyed; feeling detached or estranged from others; or being unable to experience positive emotions (a void of happiness or satisfaction).
  • Alterations in arousal and reactivity: Arousal and reactive symptoms may include being irritable and having angry outbursts; behaving recklessly or in a self-destructive way; being overly watchful of one’s surroundings in a suspecting way; being easily startled; or having problems concentrating or sleeping.

Reference: Above symptom list taken from American Psychiatric Association’s page – What is PTSD?

As already described in the ‘About Psy Fiction‘ page, the purpose of psychological formulation is to go beyond a specific diagnosis or list of symptoms, to develop a more detailed understanding of someone’s difficulties. This is particularly important with PTSD as we know everyone responds to trauma in different ways. Using a formulation allows us to go beyond the list of characteristics above, to identify maintenance cycles for these difficult post-traumatic experiences. This aims to help someone understand their individual experience and trauma response, in turn helping them to make changes and overcome their difficulties.

What is the Cognitive Model for PTSD?

There are a few different psychological models of trauma and PTSD, however for this post we are focusing on learning about Ehlers and Clark’s (2000) cognitive model of PTSD. Below is the model lifted from their paper.

Ehlers and Clark (2000)

For the Hermione Granger’s out there, the above model may be self-explanatory, in which case feel free to head straight down to Harry’s formulation below. For others, you may find at first glance the diagram looks like a complicated route to a hidden room at Hogwarts on the Marauder’s Map… if so, do not fear – we’ll walk through it step by step!

Characteristics of Trauma / Prior Experiences

The first part of this formulation could be separated into two parts: 1) Prior experience – this considers what may have predisposed the person to have a post-traumatic response to this incident, e.g. if they had similar experiences in the past; what were their prior core beliefs about self/world/others. 2) Context/characteristics of trauma – such as whether this was a life threatening event, do they know the perpetrator, did they feel overwhelmed/certain they would die.

Cognitive processing during trauma

Activation of the brain’s fight or flight threat response in a traumatic event can have an impact on how the brain remembers and processes the experience. Dissociation as well as phenomena such as weapon focus can also negatively impact on attention and information processing, e.g. being ‘zoned out’, or focusing on the weapon but not other factors.

Nature of trauma memory

Due to the changes in cognitive processing during a traumatic event, the brain stores trauma memories differently to normal memories. They can be fragmented, as well as some parts be very vivid, with strong sensory memories. This can lead to intrusive memories, flashbacks, and nightmares, which can feel like the traumatic event is happening again in real time, as the the memory has not been stored properly and ‘time stamped’ in our brain. (The ‘filing cabinet’ or ‘linen cupboard’ metaphors can be a helpful way of understanding these)

Appraisals of trauma and its effects

These appraisals are the person’s negative beliefs about what the traumatic experiences (and the effects of these) mean about themselves, others and the world. For example, the event could mean ‘I am weak’, ‘others are dangerous’, or ‘the world is unsafe’. This can be influenced about how others respond afterwards e.g. ‘others do not care’, ‘I deserved it’, ‘It’s my fault’. Appraisals of the effects (‘sequelae’) of the trauma, can include beliefs such as ‘I am going mad’, ‘I am damaged’, ‘I have no future’.

Current threat

The brain’s threat system continues to be activated in the present and on high alert to potential threats (‘hypervigilence’). We can think of the brain’s threat system like an ‘over-sensitive’ fire alarm. When ‘matching triggers’ are experienced, this causes a full fight or flight response. These triggers could be things closely related to the trauma (e.g. seeing the perpetrator), however more often they are safe everyday experiences which have a small resemblance to the trauma e.g. a smell , a specific colour, or a tone of voice. This hypervigilence can cause a constant feeling of fear, irritability, as well frequently trigger flashbacks, making the danger seem real and in the present, despite the person being safe.

Strategies intended to control threat/symptoms

i.e. ‘safety behaviours‘ or ‘coping strategies’, which often have unintended negative consequences. The most common is avoidance, such as avoiding trauma reminders. Individuals can also avoid thinking about the trauma, due to fear of not being able to cope with these memories. For some it may feel safer avoid other people and isolate themselves. People can feel ‘numb’, detached or dissociated from difficult memories or emotions. People can also use other means such as substances to try to numb or cut off from memories or threat response.

Maintenance cycles (arrows)

The arrows in the model demonstrate how the coping strategies such as avoidance, unintentionally maintain the individual’s difficulties and level of current threat. Avoiding memories and triggers, mean that appraisals are not challenged and memory isn’t processed. As the memory continues to be unprocessed, it continues to come back intrusively as flashbacks. This maintains ‘scariness’ of memory, as well as negative assumptions about the world being a scary and unsafe place. Additionally, avoidance means that people have reduced access to things that may help in their recovery, such as social support, which maintains a feeling of isolation. Heightened emotions and irritability can further cause interpersonal difficulties, which adds to feeling alone and that there is something ‘wrong’ with them.

Harry Potter’s PTSD Formulation

So is there evidence that Harry is experiencing characteristics of PTSD? Lets take a look at the initial symptom list…

  • Intrusion: at the start of the Order of the Phoenix which takes place after the traumatic events in the graveyard, there is evidence that Harry is experiencing instrusive flashbacks of the events in the form of nightmares.

“Don’t think about that, Harry told himself sternly for the hundredth time that summer. It was bad enough that he kept revisiting the graveyard in his nightmares, without dwelling on it in his waking moments too.”

J.K. Rowling, Harry Potter and the Order of the Phoenix

  • Avoidance: the book further describes Harry wanting to avoid thinking or talking about what has happened at all costs, due to it being too painful. He also described a feeling of emotional numbness and disconnect from reality, which could be seen as a form of dissociation.

“Harry nodded. A kind of numbness and a sense of complete unreality were upon him, but he did not care; he was even glad of it. He didn’t want to have to think about anything that had happened since he had first touched the Triwizard Cup. He didn’t want to have to examine the memories fresh and sharp as photographs, which kept flashing across his mind. Mad-Eye Moody, inside the trunk. Wormtail, slumped on the ground, cradling his stump of an arm. Voldemort, rising from the steaming cauldron. Cedric … dead … Cedric, asking to be returned to his parents …”

J.K. Rowling, Harry Potter and the Order of the Phoenix

  • Alterations in cognition and mood: there appears to be a lot of shifts in Harry’s thoughts, belief system and mood after this traumatic event. Most notable is Harry seeming to have a more negative view of life, as well as frequent angry outbursts.

“I DON’T CARE!” Harry yelled at them, snatching up a lunascope and throwing it into the fireplace. “I’VE HAD ENOUGH, I’VE SEEN ENOUGH, I WANT OUT, I WANT IT TO END, I DON’T CARE ANYMORE!”

J.K. Rowling, Harry Potter and the Order of the Phoenix

  • Alterations in arousal and reactivity: In addition to Harry’s increased irritability, it also appears he was experiencing heightened arousal, being on high alert and over-reactive to potential threat. An example of this is his response to a noise he hears at the Dursleys’:

“A loud, echoing crack broke the sleepy silence like a gunshot; a cat streaked out from under a parked car and flew out of sight; a shriek, a bellowed oath, and the sound of breaking china came from the Dursleys’ living room, and as though Harry had been waiting for this signal, he jumped to his feet, at the same time pulling from the waistband of his jeans a thin wooden wand as if he were unsheathing a sword.”

J.K. Rowling, Harry Potter and the Order of the Phoenix

So we’ve got evidence of Harry displaying characteristics of PTSD for several months after the traumatic incidents. But we want to really understand what is going on for Harry… why is he suffering with these difficult experiences? What is maintaining these challenging thoughts and emotions? You guessed it… it’s formulation time…

We’ll now apply Ehlers and Clark’s PTSD model to Harry’s experiences at the end of Goblet of Fire…

So this formulation allows us to consider the impact of Harry’s past experiences and the personal connections to this traumatic experience (e.g. his past link with the perpetrator, Voldemort) which helps to understand how this event is much more complex than, for example, a one-off attack from a stranger. It also demonstrates how the way in which other people respond to Harry after the events also has such a huge impact on his ability to process and cope with this experience.

In terms of maintenance cycles, Harry’s avoidance and emotional numbing means he does not have opportunities to process what has happened to him. This means these memories stay vivid and painful, and a strong emotional response is triggered at any reminder of the event. Dumbeldore eloquently describes this vicious cycle of avoidance/emotional numbing in his quote:

Numbing the pain for a while will make it worse when you finally feel it.

J.K. Rowling, Harry Potter and the Order of the Phoenix

This avoidance of the trauma means the memory remains intolerably painful. Harry is therefore constantly in ‘fight or flight’ to be on high alert to potential triggers he needs to avoid, to protect himself from this memory becoming activated. This leads to him being on edge, often feeling irritable or having angry outbursts in response to trauma reminders (e.g. the argument with Seamus in the common room when he questions if Voldemort is actually back).

This further entrenches the belief that the world is unsafe and others are not to be trusted, not allowing these appraisals to be challenged. These interpersonal outbursts can also lead to others distancing themselves from him, causing further feelings of isolation and beliefs that others do not understand. This maintains the constant state of high alertness, in the context of a diminished social support network.

So… does harry have post-traumatic stress forever then?

So there we go… using formulation we can understand why Harry’s acts how he does in Order of the Phoenix, giving a more compassionate understanding of where his irritability and anger may be stemming from… (rather than just being a moody teenager or it being down to questionable acting…)

Although this is a heart-breaking account of a young person striving to manage multiple traumatic experiences… we see that Harry’s nightmares and intrusive traumatic memories, as well as his angry outbursts, do in fact reduce over the films. This is the case even with Harry facing new traumatic experiences on the regular. The tale of Harry Potter therefore also sheds light on factors which can help people overcome traumatic events and subsequent post-traumatic symptoms. The two main things which stood out to me were:

  1. Empowerment: As a response to Harry’s trauma, he felt like he was out of control and helpless as to whether Voldemort would come back and attack again. However, the establishment of ‘Dumbledore’s Army’ enabled Harry and others to act on fears of being helpless, by training in magic which would equip them for future battles. Harry takes a key role in this due to his past experiences, giving him purpose and ownership to changing his and others’ futures. This could be linked to the idea of ‘post-traumatic growth‘ where individuals feel able use their experience of trauma to positively benefit themselves/others. Harry is also encouraged to feel ownership of his emotions and behaviours, trying to shift the narrative from “I can’t control my feelings/memories” to feeling more empowered that he has some control in the choices he makes and how he behaves. This is evident in his conversation with his godfather Sirius Black:


2. Connection/Relationships: Despite Harry’s attempts to push others away or outward irritability towards others, his close friends stuck by him with unconditional positive regard, coming back to offer support at all times. Harry also had adults he could turn to for support such as Sirius. Other adults, such as Dumbledore, encouraged Harry to face his difficult memories and talk through his traumatic experience, to break the avoidance cycle, which may have helped Harry to process this experience. The creation of ‘Dumbledore’s Army’ was also a very clear message that people did believe what Harry had been through, which challenged the narrative that he was lying about his traumatic experience.

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:

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Once you’ve entered your email above, you’ll just need to click the link sent to your inbox to confirm your subscription! Send me a message (in the contact section on About Me page) if you have any issues signing up.

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Check out a previous post!

Longitudinal CBT Formulation: The “Mad” Queen

29th June 2020


The aim of this blog is for informal educational purposes only. However, some of the things discussed may resonate with your own experiences, so please do what you need to keep yourselves safe and well. If you are affected by any of the issues discussed in the blog and feel you need further support, please do seek help and advice from appropriate services, such as your GP or local mental health services. Other reputable mental health support helplines can be found on the NHS website: https://www.nhs.uk/conditions/stress-anxiety-depression/mental-health-helplines/

Disclaimer: All Harry Potter film images and video rights belong to Warner Bros. Pictures Game of Thrones image rights belong to HBO. 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.

Panic CBT Formulation: Iron Man, An Anxious Avenger

This month’s psychology model is the CBT formulation for Panic, starring (you know who he is…) Marvel’s Avengers very own Tony Stark, aka Iron Man. Perhaps not the first name that comes to mind when we think of anxious characters, however it seems even the bravest of heroes can have moments of fear and panic to contend with…

The CBT Formulation Model for Panic

What is Panic?

Panic or panic attacks are a form of anxiety, characterised as a sudden distinct episode of discomfort and/or fear that is accompanied by:

(a) physical symptoms: heart palpitations, trembling, sensations or choking or shortness of breath, sweating, chest pain, nausea, dizziness, numbness, tingling, hot or cold flashes, light-headedness;

(b) cognitive symptoms: fear of losing control, fear of dying, wanting to escape the situation, as well as feelings of ‘going insane’, detachment or unreality.

Panic attacks often last up to 30 minutes, with peak anxiety being present for approximately 10 minutes. Attacks can at times seem to come from nowhere (“unexpected” attacks) or they can have a clear trigger and occur in the presence of specific feared environment (“situational” attacks). If people have persistent panic attacks, they can then worry about future attacks and/or the repercussions of these. People can also alter their behaviour as a result of anxieties around attacks, such as avoiding certain situations, which can then have a significant impact on day-to-day life.

(Definition taken from Leahy, Holland and McGinn, 2011)

What is the CBT model of Panic?

The CBT (Cognitive Behavioural Therapy) formulation model for panic is a Situational Formulation model. This means it focuses on the ‘here and now’ factors which maintain an individual’s panic or panic attacks, rather than the influence of past experiences. You can recap on the basic Situational CBT formulation model (or ‘hot crossed bun’) in this previous post. This basic situational model has been adapted to explain different types of presentations, however the fundamental principles remain the same. Situational CBT formulation models always centre around the main concept of exploring the links between thoughts, emotions, behaviours and physiological symptoms. This highlights maintaining factors and ‘vicious cycles’, which help to understand what keeps the problem going and highlights areas to be targeted to break these cycles and help to reduce difficulties.

The CBT formulation model for Panic was developed by Clark (1986). There have been various adaptations of this model since then, however the fundamental concepts are kept the same. The model and definitions used in this post are informed by Clark’s (1986) original model, as well as Westbrook, Kennerly and Kirk’s (2011) interpretation.

The CBT model of Panic:

  • There is an external (environment) or internal (thought/image/sensation) trigger. An example of an external trigger could be going into a busy shop.
  • This triggers a ‘perceived threat’ i.e. a prediction of something bad happening. For example, “I might get lost in this shop”.
  • This leads to an emotional and cognitive response of anxiety/panic.
  • This further brings on the physical symptoms of anxiety, described above.
  • There is then a catastrophic interpretation of these bodily sensations, believing they indicative of impending mental or physical harm (e.g. stroke, heart attack, brain aneurysm).
  • This then causes increased anxiety, leading to a vicious maintenance cycle of panic.

At times, the CBT model also considers how safety behaviours may also maintain someone’s anxiety and panic, contributing to these vicious cycles. Safety seeking behaviour can take many forms, although it is often avoidance, e.g. avoiding certain environments or situations. The aim of this behaviour is to reduce the likelihood of a feared catastrophe occurring, as well as avoid the actual feeling of anxiety or panic. This gives a short-term relief from anxiety and panic symptoms. This lack of catastrophe and presence of ‘safety’ is then attributed to the safety behaviour, reinforcing this as necessary to do to keep safe in the future. For example, “I avoided the shop, which meant I didn’t get lost and didn’t have a panic attack. I am safe because I didn’t go to the shop. It’s best to avoid shops in the future to stay safe.”

However, this is more problematic in the long-term. In avoiding situations, an individual’s anxious appraisals of that situation are never challenged. For example, someone may be worrying that they will get lost in a shop, have a panic attack, and then they will collapse. If they never go into this situation and experience something other than these negative predictions, their beliefs remain unchallenged and unchanged. This in turn means that their anxiety around these situations is maintained in the long-term.

Iron Man’s Formulation

As the Panic CBT model is a ‘Situational Formulation’, we will not be exploring Stark’s past (an interesting one for another post perhaps… for example, his panic attacks being part of a wider post-traumatic reaction to his near death experience in the worm hole during Loki’s assault on New York in the first Avengers film? Or perhaps just him being a case for a formulation on Narcissism? We could go on…).

This post will instead focus on this specific situation in Iron Man 3. Stark experiences a few moments of panic throughout the films and his ‘anxiety attacks’ become a theme throughout this story and his character development. For this formulation, we are focusing on the first time we see this in the film, in the scene in the video below. Here our hero demonstrates a textbook example of a Panic Attack, including common responses to the emotional and physical experiences associated with panic.

We can apply the CBT model of Panic to this situation:

In terms of safety behaviours, throughout the movie Stark engages in a number of strategies to try and manage these feelings of panic and anxiety. We could think of these as attempts to build protection around himself to keep him and others safe from perceived threats (he literally builds protective casings for himself in the form of his suits).

His safety behaviours are also attempts to avoid the feeling of fear. Stark’s avoidance strategies can be seen in a number of forms, for example, throwing himself into building his suits as a means of distracting himself from the anxiety and panic linked to his past experiences. He also tries to avoid any reminders of his past traumatic experiences, such as talking about these events. This seems to be in order to reduce the likelihood of him having another panic attack. This is all likely to have maintained his difficulties and increased his anxiety in the long run.

We do however see throughout the movie, Stark recognises these unhelpful safety strategies and in the end he starts to reduce these. This was seen vividly at the end of the movie when he destroys all the suits which he has been building and hiding behind.

As we can see, our Anxious Avenger has been on quite a journey battling with his experience of panic attacks and the impact this has on his life. The emotions and behaviours we see Tony Stark portray in this movie remind us that despite him being a “billionaire, genius, playboy, philanthropist” (and superhero), he is as human as the rest of us.

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:

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5 Ps Formulation: The Dark Side and the Light

15th May 2020

Disclaimer: All Marvel image and video rights belong to Disney. Game of Thrones image rights belong to HBO. 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.

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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PTSD Cognitive Formulation: Harry Potter, The Boy Who Lived

8th February 2021

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.

5 Ps Formulation: The Dark Side and the Light

Welcome to post number two! We’re exploring another staple of psychological formulation: The 5 Ps. Our star of the screen this week is Anakin Skywalker… whose troubled journey leads him to become one of the most iconic villains of all time, the Sith Lord himself – Darth Vader.

But why? What factors contributed to Anakin’s path to the dark side? Is he just “twisted and evil” as Obi-Wan Kenobi describes him, or are his behaviours understandable in the context of his past experiences? Let’s find out…

What is the 5 Ps Formulation?

The 5 Ps is one of the most commonly used formulations in clinical settings. It allows a structured conceptualisation of an individual’s presenting problems. Unlike the CBT Situational Formulation, the 5 Ps starts to go beyond the “here and now”, to consider what historical factors have contributed to the development of an individual’s difficulties. It also explores what factors keep these difficulties going, as well as outlining an individual’s resilience factors. In addition, it goes further than considering just the individual’s internal experiences (e.g. cycles of thoughts and feelings) and how these contribute to mental health difficulties, to allow consideration of the influence of wider systemic influences.

The “5 Ps” are the titles of the five different sections in this formulation, under which the information is organised. The following definitions of these are based on Johnson and Dallos (2014).

  1. Predisposing Factors: internal or external historical factors which are likely to have increased someone’s vulnerability to developing their current problems, e.g. early life trauma.
  2. Protective Factors: both internal and external resiliency and strengths which help to maintain an individual’s emotional health, e.g. engaging in hobbies such as physical exercise.
  3. Precipitating Factors: the triggers of the current presenting issues, which can be internal or external, e.g. loss of a close family member.
  4. Presenting Issues: a description of the individual’s presenting difficulties, including thoughts, feelings and behaviours, e.g. feeling anxious in crowds and avoiding social gatherings.
  5. Perpetuating Factors: internal and external factors which maintain the presenting issues, e.g. unhelpful coping strategies which feed into maintenance cycles, such as substance misuse.

As you can see, it’s a pretty simple concept for a formulation. It is therefore understandable why it’s so widely used. The 5 Ps structure can be a straightforward way of organising information with the client in the therapy room, as well as a comprehensive approach for team formulations, particularly as it is a template often familiar to many disciplines.

Some formulation models can get a bad rep for focusing solely on more negative presentations and contributing factors. It is viewed that these models can neglect positive factors, such as an individual’s strengths and resilience, which may protect them against the impact of difficult past experiences and/or give them helpful tools to positively manage their mental health difficulties. A strength of the 5 Ps is therefore that it actively makes us consider both of these areas:

  1. the “dark side” of an individual’s past and present, such as past traumas or negative coping mechanisms which may perpetuate their difficulties, and
  2. the “light side” of a person’s protective internal and external factors, such as intelligence or creativity, as well as having a supportive friend or community.

This all helps us to bring balance to the force…. formulation.

What theory underpins the 5Ps?

Despite its wide use, the 5 Ps comes under fire for over-simplifying an individual’s presentation and lacking a theoretical base. There are arguments that the 5 Ps formulation simply lists different factors, rather than considering the theoretical links between them, which helps to conceptualise an individual’s difficulties in more detail.

Some however view that the 5Ps is a Biopsychosocial formulation. Although this sounds like some pseudo-science term from a cheesy 1980s Sci Fi movie, it actually just means that the formulation considers three themes of factors contributing to a person’s presenting difficulties:


e.g. predisposing factors may be genetic family history.


e.g. perpetuating factors may be cycles of negative thinking.


e.g. protective factors may be a supportive friendship group.

Due to this, the 5Ps can potentially provide a framework which has the freedom to draw on range of different factors, including a variety of psychological theories and principles, e.g. attachment theory or systemic approaches. The 5Ps is however commonly associated with the CBT model, in line with Johnstone and Dallos (2014). Therefore, for our example, I will use this Biopsychosocial idea and draw on a range of different underpinning approaches, however coming predominantly from a CBT perspective.

(For an introduction to CBT and situational formulation – see my last post here)

Anakin Skywalker’s 5 Ps Formulation

So, lets be real… if Anakin had his own 5 Ps that summed up his slippery slope to the dark side, it would be more like Pod-Racing, Padowan, Padmé, Palpatine & Planet-destroying-death-star… but we’re going to stick with our psychology terms for the sake of learning stuff. Before writing this, I “had” to rewatch the entire Star Wars saga in chronological order for “blog research”… and I would thoroughly recommend this as an excellent way to spend your time in lockdown. However, don’t worry, if you’re here for the psychology more than the Sci Fi – having watched the Star Wars films is not necessary for understanding this formulation! For those who would find it helpful, here’s a brief reminder of who Anakin is and some of the key life events we will consider.

Now we’re all caught up… let us crack on. For context, our formulation aims to take place when Anakin has just transformed into Darth Vader, focusing on his “presenting difficulties” at this point. (For the Star Wars fans among us, this is of course the end of Episode III: Revenge of the Sith.)

“I find your lack of faith in the prequel triology disturbing…”

So here it is – our understanding of Anakin Skywalker/Darth Vader using the 5 Ps formulation:

Predisposing Factors

First we consider what things happened in Anakin’s early years which may have made him vulnerable to his difficulties. We consider the quality and quantity of past stressors, as well as the impact these may have had on Anakin’s view of himself, others and the world:

Feeling a lack of control/power due to Anakin and his mother being slaves. They were not able leave their slaver (Watto) or make decisions about their own lives. Anakin also had his self-worth measured in the price he was sold as a slave. It is also likely he felt different to others and an ‘outcast’ due to these living circumstances.

Deprived of age-appropriate opportunities for learning, creativity and socialising. Not at school and working in a workshop from a young age.

Frequent experience of loss and being alone:

  • Separation from mother – his “safe base” – at young age. Leaves with a man he has just met to to train as a warrior with the Jedi council (some may say “cult”?!), which prohibits relationships and enforces suppression of negative emotions.
  • Absent father
  • Padmé (close friend at the time) leaving just after he left home
  • Leaving C3PO (droid/friend) behind
  • Death of “adoptive” father figure (Qui-Gon Jinn)

Exposed to potential and actual danger/trauma from a young age, meaning constant activation of his ‘threat’ or ‘fight or flight’ system. He learns that others and the world are dangerous and he has to be on high alert to protect himself and his loved ones:

  • Emotional abuse from slaver (Watto) e.g. shouting at him.
  • Extreme living conditions – exposed to non-age appropriate activites e.g. gambling; “fast and dangerous” pod-racing.
  • Received death threats as a child from rival pod-racer (Sebulba)
  • Frequent natural dangers in home town e.g. sandstorms.
  • “Adoptive” father figure (Qui-Gon Jinn) exposed him to dangerous situations e.g. lightsaber battles and shoot outs.
  • Witnessed lots of violence and killing is normalised.
  • Wider context: political unrest. Aware of wider danger of the Empire killing people and causing suffering.

High expectations and pressure placed on Anakin by his role models (Jedi Council) of him being the ‘Chosen One’ who should bring balance to the force.

“Be a good boy and go train to be a warrior in Liam Neeson’s weird cult. Bye forever son!”

Protective Factors

We also want to consider the positive characteristics, strengths and factors which build confidence and resilience, protecting Anakin from his difficulties and emotional distress worsening:

  • Intelligence
  • Good pilot – “only human” who can pod-race.
  • Quick reactions.
  • Practical skills (builds robots).
  • Skilled fighter/Jedi knight.
  • Physically fit.
  • Engages in meditation practices to manage emotions.
  • Secure attachment with mother as young child.
  • Mum openly loving and giving praise e.g. “I’m so proud of you”.
  • Seeks and builds relationships.
  • Padmé (now his wife) provides a positive and loving relationship – he confides in her about his difficulties and she gives him emotional support, advice and validation.
  • Confident and brave.
  • Strong sense of self/identity in context of slavery , e.g. “I’m a person and my name is Anakin”.
  • Obi-Wan Kenobi as a teacher encouraging positive “CBT-style” thought challenging – “you are focusing on the negative, be mindful”.
  • Has adults who strive to provide and care for him, in the absence of his mother: Qui-Gon and Obi-Wan –“you’re the closest thing I have to a father“.
  • Cares strongly for his family.
“Chicks dig the rat tail and no one can tell me otherwise…”

Precipitating Factors

Next is to consider what internal or external events triggered the onset of Anakin’s presenting problems. You can see this clearly in the films where Anakin starts to experience extreme distress and have difficulty managing his emotions after a series of stressors. It seemed that prior to this, he was able to manage his difficulties by drawing on his protective strengths, however these triggers overwhelmed his ability to cope:

  • Mum kidnapped and tortured by Sand People.
  • Mum dies – Anakin finds her but it is too late to save her. Another loss accompanied by feeling powerless and that things were out of his control. He therefore has to be “all powerful” to ensure won’t happen again.
  • Dreams indicating that Padmé (his wife) will die – becomes obsessive about preventing a further loss.
  • Not being given the rank of “Jedi Master” by the Jedi Council. Told to stay behind when other Jedi go on a mission. Feeling inadequate, not trusted and not understood. Feeling rejected, different from others and outcast from the group.
“Son, I think it’s finally time to tell you about my summer fling with Darth Plagueis the Wise…”

Presenting Problems

Overall, the main presenting issue is arguably Anakin turning into a Sith Lord and using the dark side of the force to build an “evil empire” dictatorship type thing… but breaking it down psychologically, his presenting problems may look a bit like this:

  • Anxiety/Fear
  • Anger
  • Sadness/emptiness/loss
  • Risk-taking, impulsive behaviour and poor decision-making
  • “Narcissistic” personality traits/arrogance
  • Guilt, shame & self-criticism e.g. about killing women/children (sand people); not saving his mother; not being a good Jedi as he ‘gave in’ to anger.
  • Emotionally/physically abusive towards those close to him (e.g. pregnant wife, Padmé and adoptive father figure Obi-Wan Kenobi)
  • Extreme violence towards others, even those unarmed and vulnerable (e.g. children).
  • Lack of remorse for many of his violent acts.

Perpetuating Factors

The perpetuating factors are likely to have had the strongest impact on Anakin. There was such a wide range things which perpetuated his presenting difficulties, meaning that he was unable to utilise his protective factors to mitigate against his challenges. There is often some overlap between the ‘Presenting Factors’ and ‘Perpetuating factors’, however for perpetuating factors we are looking at the things which keep the presenting difficulties going, such as thinking patterns or behaviours which lead to negative consequences. To organise these a bit clearer, I’ve organised them into CBT categories of ‘thoughts and emotions’, ‘physiology’ ‘behaviour’ and ‘environment’. This is the same as those used in the situational formulation in my previous post. We can think about these sorts of situational cycles when describing perpetuating factors (e.g. vicious cycles of thoughts/feelings/behaviours).

Thoughts and feelings:

  • Anakin’s suspiciousness and paranoia around others trying to betray him or undermine his ‘power’ leads to him engaging in “black and white thinking” e.g. saying to Obi-wan “if you’re not with me, you’re my enemy”. This leads to further isolation.
  • When Anakin is denied the rank of Jedi Master, to avoid painful feelings of inadequacy, he rationalises this as Obi-Wan (his teacher) being “jealous” of his power. e.g. “I’m ahead of him”. This perpetuates his arrogant/narcissistic presentation, contributing further to poor decision-making and interpersonal difficulties e.g. Padmé feeling distant from him.
  • Anakin thinks about emotions in line with Jedi teachings, which say to suppress negative emotions, e.g. not to feel emotions of fear/anger/loss. This leads to Anakin not being able to process these complex emotions, seeming to lead to complicated grief about losing his mum. He bottles up these feelings until they become impossible to manage and “burst out” in negative ways, such as violence towards others.

Physiology/body sensations:

  • Anakin is likely to be experiencing continued activation of his ‘fight or flight‘ system, due to ongoing feelings of anxiety and anger. This will likely cause difficult physiological symptoms such as feeling hot, heart-racing, muscles being tensed – all of which will cause him to be on constant high alert to potential threat and being ready to fight. Due to this ongoing heightened physiological state, Anakin is often in an “emotional reasoning” mindset and is unable to engage in rational thinking. He therefore does not have the capacity to see perspectives of others, or entertain the possibility he may be in the wrong. This further perpetuates poor decision-making and pushing others away.
  • Poor sleep and nightmares about his mum and Padmé also cause ongoing anxiety about loss.


  • Ongoing impulsivity/risk-taking, e.g. impulsively running at Count Dooku and having his arm cut off. This perpetuates feelings of being a failure and not “good-enough”. An additional consequence of this behaviour is the biological side of physical pain and adapting to his disability/prosthetic arm, which could potentially have had a negative impact on his emotional state.
  • Difficulty sleeping and eating likely to have poor impact on mood.
  • Keeping relationship with Padmé a secret, further withdrawing from Obi-wan and other Jedi – feeling “different” from the others.

Systemic/environmental factors:

  • Feeling ‘undermined’ by teacher/father figure Obi-Wan. e.g. “he’s over-critical, he doesn’t listen, he doesn’t understand – it’s not fair”. Additionally, experiencing a lack of praise and appreciation from the Jedi council – contributing to feeling not good/powerful enough.
  • Continually told by the Jedi council that he should not feel negative emotions, such as fear and anger. This invalidates his feelings and implies that he is a failure if he does experience these.
  • The prophecy of Anakin being the ‘Chosen One’ fuels both his arrogance/narcissism, as well as his notions of inadequacy (feeling that he is not the powerful Jedi that his role models expected/wanted him to be).
  • Attachment/possession is forbidden for Jedi. This means Anakin is ordered not to build close relationships, which can lead to either further isolation or potential guilt when he does have relationships.
  • Palpatine “grooming” Anakin to turn to the Dark side: Palpatine is seen to intentionally encourage Anakin’s belief that he is more powerful than the other Jedi, which turns Anakin against those whom he has a somewhat positive and protective relationship with e.g. Obi-Wan. Palpatine also takes advantage of Anakin’s fear of loss, presenting the Dark Side as the only solution to keeping his loved ones safe.
  • Ongoing wider context of there being an intergalactic war, perpetuating the likelihood of Anakin being constantly in the ‘fight or flight‘ threat system, as there is an increased chance that his loved ones will die. This contributes further to the idea he needs to be “all powerful” to ensure him and others are safe.
“FINALLY. A father figure who will emotionally support me in a healthy way…”

Phew… so that’s it! A very full formulation trying to understand the motivations of one of cinema’s favourite and most complex villains. We know Darth Vader was consumed by the dark side of the force for years and did terrible acts as part of leading the Empire. As our favourite little green Jedi once said:

“Fear is the path to the Dark Side”


However, from our formulation, we think the path to the dark side would be more accurately described as:

  • the need to feel all powerful, in order to cope with the fear of losing those close to you, as well as to avoid feelings of powerlessness and inadequacy. This can be understood in light of past trauma, adversity and loss (growing up in a “wretched hive of scum and villainy” will do that to you…);
  • being in an environment lacking emotional support and validation (this means you Jedi…);
  • having a negative/manipulative relationship with an older man in a position of power (classic Palpatine);
  • and the chronic exposure to danger through living in war zone (it’s literally called Star ‘Wars’…).

(But perhaps that doesn’t have the same ring to it as the classic quote….)

Nevertheless, perhaps we can agree that Darth Vader wasn’t born “twisted and evil”? I think we can all understand how in this systemic context and exposure to these stressors, perhaps anyone may fall down the wrong path to the dark side?

“Don’t get me wrong Dad, I’m not happy that you sent troops to incinerate my aunt and uncle, froze my best friend in carbonite and chopped off my left hand…. but I’m mostly pissed that you didn’t tell me Leia was my sister…”

And a final thought… although Anakin’s strong attachments to his wife and family played a part in his turning to the dark side, we also know that in the end, these attachments were also a protective factor which enabled him to save his son, Luke Skywalker, and overthrow (literally) the evil Emperor! Better late than never eh, Darth….

That’s all folks!

Clapper-board clip art (met afbeeldingen) | Filmfeestje, Bioscoop ...

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

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

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Check out a related post!

Longitudinal CBT Formulation: The “Mad” Queen

29th June 2020

Disclaimer: All Star Wars image rights belong to Disney. 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.

Situational CBT Formulation: Like an onion, it has layers

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.

CBT Or Antidepressants For Depression? - Business Insider
Image by Lionsgate Television

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).

Image by Fantasy Films

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.

Image by Disney Pixar

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:

  1. The external situation or environment
  2. Thoughts/appraisals/cognitions about the situation – in CBT these are called “Negative Automatic Thoughts”.
  3. Emotions
  4. Body sensations
  5. 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.

The Ogrelord is not pleased. | Shrek | Know Your Meme

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….)

Geek Couples: Shrek and Fiona - Warped Factor - Words in the Key ...

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.

I would love for you to stay in touch!

Please subscribe and leave any comments or feedback below!

Will be back soon with our next famous formulation. But for now…

That’s all folks!

Clapper-board clip art (met afbeeldingen) | Filmfeestje, Bioscoop ...

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:

Follow My Blog

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Join 382 other followers

Once you’ve entered your email above, you’ll just need to click the link sent to your inbox to confirm your subscription! Send me a message (in the contact section on About Me page) if you have any issues signing up.

Follow and stay in touch about #PsyFiction on:

Twitter: @DrLaurajean_W

Instagram: @psy.fiction

Check out a similar post!

Panic CBT Formulation: An Anxious Avenger

9th August 2020

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.

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