Observation

The therapist notes shifts in the patient that seem to avoid emotional expression. The topic at the point of the observed shift is registered. This is a topic worthy of safe exploration to both reach a decision point and to help the patient increase emotional tolerance.

For example, a patient may have sorrow from the death of a parent that in the past was too dangerous to experience. Now, the patient may feel safe enough to emotionally thaw out the frozen grief. Memories may be activated. In a therapeutic alliance the sorrow seems tolerable, so the suppressed memories can reach awareness and be discussed. At this point, a formerly incomplete mourning process can move forward and richer narrative about the meanings of the loss to the self can be achieved. In the midst of such work, however, it is common for the patient to repeatedly avoid certain emotional themes.

Even if patients consciously intend to remember a serious life event, they may be observed in the moment to inhibit activation of a particular emergent memory. For example, after the death of a loved wife, a husband may want to recall her face looking affectionately upon him, but he finds that the image will not come into visual representation in the mind’s eye. The discrepancy between the desired closeness to the lost wife and the actuality of her permanent absence would be overwhelming. In the future, after a period of mourning has made the memory of his wife safer to contemplate, the images will more readily come to the surface of conscious thought. The information is not lost, but rather, at the moment, it is observed by the therapist to be avoided unconsciously in spite of conscious intentions to represent it.

What the patient wanted to think about, and theoretically could think about, did not appear. Similarly, with the same patient, at a different time, one might observe experiences of intrusive, unbidden images of the wife’s face. These observations indicate preconscious regulatory process are operating: inhibiting or insisting upon the conscious visual images of the face. These deflections from ordinary conscious attention control indicate conflict and incomplete topical processing.

Formulation

In some phases of response to stress, such as in the example of the loss of a loved one, patients may deflect from ordinary control of emotion to enter a state of over-control, as in periods of denial and numbing, or under-control, as in periods of unbidden ideas and feeling flooded with intense negative emotions such as yearning and heart-sickness. As the stress response is completed, emotional control returns from these extremes to a middle range, with neither under- nor over-control, even when experiencing distressing feelings such a sadness.

In such instances the formulation may focus on inferring where the patient is in a process of working through a difficult topic. Such formulations can be psychoeducational and supportive when shared with the patient: they give an idea about a progress moving forward rather than enduring always in the present level of suffering (Horowitz, 2011). Formulating what phase the patient is in may lead to techniques for that degree of emotional regulation: helping with containment in under-modulated states, and with reducing avoidance in over-modulated states.

One way to formulate the dynamic between potential emotional experiences and efforts to control them is to consider a matching process. Current appraisals of perceived situations are matched with enduring schematizations. Mismatches lead to emotional responses which in a basic way are motivations to plan actions so as to make a match occur. The emotions allow the patient and therapist to examine discrepancies between past hopes and future expectations.

Understanding how a mismatch generates emotion leads to a greater sense of control in the patient, even if the feelings experienced by the patient are unpleasant ones. In working states, the experience of fear, rage, and sadness motivates coping efforts. Such formulations lead to efforts to focus attention on problems that need to be solved. Progress can occur as calmer mental states are stabilized, in a kind of step-by-step approach.

Unintegrated memories of trauma or loss will continue to persist as active memories and intrusive fantasies or bad dreams until a new narrative integrates current self with past self. These incompletely processed themes leave partially unanswered questions of what the trauma and/or loss means for the future. Formulation of such questions leads to focused attention in treatment. Eventually, the root question is: how may self and future expectations be modified to fit realistic probabilities for a better life? The therapist plans to use techniques that keep the focus while allowing dose-by-conceptualizations that keep emotional arousals within the tolerable limits usually necessary for clear thinking and discussion.

Formulations involve configurations that progressively identify a network of linked associations. Configurations connect elements of memory, including earlier perceptions and memories of self-states with high emotional alarm, pain, or distress, with a readiness to react instantly to danger. Some previously established connections between idea and affective arousal are not rational in the present moment: for example, the smell of smoke, though harmless, can lead to an anxiety attack in a patient because that smell occurred during a terrifying fire long ago.

Patients with early conditioned associations can encounter a reminder of a past trauma and react with feelings that are unclear. They do not know why the felt state of experience and fragmentary images came to their mind. Both insight-promoting and exposure techniques can be used, once the formulation is made, to decondition the associational connection. Making the implicit and procedural memories explicit and declarative are part of this adaptive change.

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