General ethos. Completion of the microformulation should be a collaborative, curious process, with responsibility for completion shared equally between a therapist and a patient. It is good practice to have the microformulation template where it can be seen by both the therapist and the patient and to encourage the patient to write on the template him- or herself.
Choosing an image to microformulate. A patient may report more than one significant image. The following may be helpful in selecting the image to start a microformulation on: choosing an image that seems directly connected to the treatment target identified by the patient, or an image that is relevant in the current clinical presentation and that has been present in the most recent week(s) preceding the session.
Image description. To aid the patient in describing the image selected, ask her to remember the last time she had the image, then ask her to bring it back to mind and describe it in as much detail as possible (keeping the eyes closed can be helpful but is not necessary). Make sure you get to know from which perspective the image is seen: Is a patient in the picture, or is it seen from an observer position? Elicit details about dimensions, colors, if and how the image(s) changes, if there is any action going on, and so on. Remember to explore characteristics from sensory modalities other than visual, such as sounds, smells, and tactile sensations.
Emotion(s) in image. Ask the patient how she feels as she holds the image in mind and/or how she felt on the last occasion she experienced it. If this is difficult to grasp, you can try prompting the patient by summarizing the image description she gave you and asking how specific details and features in the image make her feel as you describe the image back to her. An image may often elicit more than one emotion; write down as many emotions as are present. Sometimes emotions will not be described using the standard labels but in more idiosyncratic ways. It is fine to keep the patient's exact words in this case, provided that you ask her to explain fully to you what she means so that you share the felt sense behind each word.
Appraisal(s)/meaning(s) in image. The next step is to understand what specific meaning is attributed to the image. You can find this out by asking the patient why she feels the various emotions she has just described—for example, “Why does this image make you anxious?” You can also ask what thoughts are present as she holds the image in mind. Note that images that elicit multiple emotions will tend to have a variety of appraisals attached, perhaps even contradictory ones.
“The power of the image.“ Once you have identified the main emotions and appraisals linked to the emotions, you want to explore further what implications and consequences these have. This can lead to discovering further and more general/deeper appraisals and also behaviors. Behaviors can also lead to or directly represent maintaining factors (see next step). Useful questions to obtain this information are “What does it mean to you that you have this image?”, “What does it say about you?”, “What does it make you think or do?” Answers to these questions will elucidate why the image(s) has such a “powerful” impact on a patient and why the patient is unable or unwilling to dismiss it. Often a patient comments that the image “feels so real” that she thinks that it must be “true” or prophetic in some way.
Maintaining factors. The last step is to identify what the patient does when she experiences the image—that is, actions and behaviors that contribute to the persistence of the image and related emotions, thus creating a vicious cycle. It is useful to ask directly, “What do you have to do when the image pops into your mind? For example, do you try to push it away? Or perhaps replay it in your mind's eye?” It is also useful to investigate not just the immediate reaction, but what further behaviors follow in different contexts and situations. Avoidance strategies (“Do you do anything so that the image does not happen to you again?”) and/or engagement strategies (“Do you do anything to make the image come back or change it?”) are often used to cope with imagery.
From: Chapter 4, Imagery-Based Cognitive-Behavioral Assessment
This version is available for viewing and downloading for personal research purposes only.
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.