The term formulation refers to a model of the client’s difficulties that is gradually developed in the course of CBT treatment by patient and therapist working together. The formulation looks at the role that early experiences and current difficulties might play in creating the client’s problems, and the way thoughts, feelings and behaviours interact to keep them going in the present. These are often referred to as Maintenance Cycles, and they can often play a crucial role in preventing the client from tackling his or her difficulties. The formulation will often be represented as a diagram or series of diagrams, and the therapist will share these with the client, giving the client the chance to correct anything that does not correspond to his or her experience. The formulation develops throughout therapy, and also guides it, suggesting, for example, different Behavioural Experiments and other ways in which the client can learn to look at his problems in new ways.
People suffering from depression may often begin to do less and less. They often feel fatigued, tired and hopeless, and they may also lose confidence, feeling that if they do something it won’t go well and will cause them more problems. This can lead to a vicious cycle, the maintenance cycle of depression. Because the sufferer is doing less, she has less chance for enjoyment and positive experiences. She may fall behind at work, fail to pay bills, and create new practical problems that will in turn make her depression worse. Physical exercise is often very helpful in depression, but, again, sufferers often avoid it, feeling that it will be too difficult. Behavioural activation is a term used in CBT for helping people to increase their levels of activity. The sufferer is asked to complete an Activity Schedule, which is simply a record of the week’s activities with some indication of how they affect the patient’s mood. This will often help the sufferer to realise that certain activities can lift his mood, and patient and therapist then work together to find ways to increase helpful activities. The improved energy and sense of well being that this approach can create often leads to other positive changes later in therapy.
BEHAVIOURAL EXPERIMENTS: HOW THEY WORK
A new experience is the most effective way to change your mind. Being assured that a vegetable tastes great or a movie is entertaining might make us willing to try them, but it is eating the vegetable or seeing the movie that will really convince us one way or the other. Similarly, a therapist telling you that you are a reasonable parent or that you don’t need to be afraid to travel on motorways will not convince you that these things are true; only experience can do that. A central method of Cognitive Behavioural Therapy is the Behavioural Experiment. Through discussion and careful data gathering, client and therapist try to learn about the client’s unhelpful beliefs, but often it takes a carefully designed Behavioural Experiment to show that it is untrue as well as unhelpful. Client and therapist collaborate in planning the experiment, making sure that is doable and that it will give important data about the client’s problem. The client is asked to record thoughts, feelings and outcome, and to compare them with previous predictions. One or two carefully designed experiments can often produce a huge change in a client’s thoughts, actions and feelings.
Collaboration is the basis of CBT therapy. First of all, CBT focuses on the particular difficulty that the client wishes to address. Early in the therapy patient and therapist, together, devise a unique Formulation that provides a model of the client’s difficulties. Tools like the Activity Schedule and the Thought Record gather important information on the client’s thoughts and feelings, while Behavioural Experiments allow the client to experiment with different actions to see how they influence the problem the client wants to solve. Client and therapist are a pair of experts; the client knows about his thoughts and actions, the therapist about common forms of psychological difficulty, and together they can devise a unique solution for the client’s problems.
The identifying and modifying of maintenance cycles is an important part of CBT therapy. A maintenance cycle is a repeated patter of thoughts, feelings and actions that tends to repeat itself and be hard to change. For example, in depression we often see a cycle of low mood, inactivity and self-critical thoughts. A depressed woman, feeling fatigued and lacking in energy, might neglect her housework. This might in turn lead to lowering of mood, as she finds her environment unpleasant, and also to self-critical thoughts about being useless and pathetic. These thought in turn might lower her mood further and lead to her cleaning even less. A man with panic attacks might avoid social situations and public places. As he avoids more and more things he can grow even more fearful, leading to even further avoidance. In CBT, client and therapist work together to find ways to break these vicious cycles. Behavioural Experiments are often used to explore different ways of modifying unhelpful actions and changing the thoughts that maintain them.
Safety behaviours are behaviours that make us feel safer without making us safer. They are often seen when someone is suffering form anxiety or a phobia. For example, a person with a fear of spiders might never enter a room unless his partner has first checked it, or a person who is anxious in cars might keep a tight grip of the bottom of her seat. Someone with social phobia might wear certain clothes to conceal possible signs of anxiety, while someone with health anxiety might spend a lot of time checking for signs of possible illness. Often safety behaviours result in a Maintenance Cycle, intensifying the fear they are meant to reduce. Safety behaviours are carefully examined during CBT treatment, and the client might be asked to try a Behavioural Experiment to see if these behaviours are helpful for unhelpful.
THE THOUGHT RECORD
Thoughts can have an important influence on how we feel. This is why the Thought Record is a key tool of CBT. The patient is asked to record thoughts that might accompany a change in mood. Normally, depressed people will think self-critical thoughts and anxious people will have thoughts or images of danger. Sometimes this can be difficult, because such thoughts can pass very quickly though the mind, but with practice most people are able to learn this skill. The Thought Record is used to help people look at these thoughts and understand the role they play in creating unhelpful feelings and actions. It is also used to help the patient look at her thoughts in a more rational manner. She will be asked to look at evidence for the unhelpful thought, and also evidence against it. By learning this skill, patients can continue to deal with unhelpful thoughts after the end of therapy, which helps to prevent relapse.
THE ACTIVITY SCHEDULE
The Activity Schedule is a key tool in CBT therapy, with a variety of uses. Basically, it is a table showing all the hours of the week, and it’s used to gather data on how a persons’ s mood fluctuates over that time. It can help to identify factors that might influence that mood, making someone feel better or worse. For example, in someone with depression it plays a key role in identifying activities that can help to lift his mood; this is a key part of Behavioural Activation. With anxiety problems it can help to identify factors that might increase anxiety. Along with the Thought Record, it is a very helpful way for patient and therapist to gather data on the patient’s problems.