Box–arrow in–arrow out: A game plan for taking corrective action in the moment

When helping clients address their issues in therapy, part of the work often involves helping them to deal with the issues when they are experiencing them. Examples include a client with anxiety issues encountering a situation which triggers strong anxiety or a client with depression experiencing an event during their day which has a significant negative effect on their mood.

At these times, the way the client responds to the onset of the particular issue’s ‘episode’ can make the difference between whether the issue’s negative effects subside relatively quickly or continue for an extended period of time. In the following sections, I will discuss a framework which can be used to identify the right ways and the wrong ways to respond when the negative effects of an issue are experienced.

Box—arrow in—arrow out analysis: Triggers, symptoms and responses to symptoms

A framework for understanding and addressing your issues as they arise is ‘box–arrow in–arrow-out’, often referred to as ‘cross-sectional analysis.’ This scheme helps clients to anticipate triggers for the experience of episodes associated with their issues, understand the symptoms they are likely to experience when these episodes occur, and recognize the possible responses they can make when experiencing the symptoms.

Each of these elements is written in a box going from left to write across the page. The left box is labelled ‘triggers’, the middle box is labelled ‘symptoms’ and the right box is labelled ‘responses’. Right-pointing arrows are drawn between the ‘triggers’ box and the ‘symptoms’ box as well as between the ‘symptoms’ box and the ‘responses’ box. I will discuss each of these boxes in the next sections.

The left box: Triggers

The left box of the box–arrow in–arrow out analysis is labelled ‘triggers’. This box refers to factors which lead the person to experience an episode associated with their issue at that moment. The particular triggers are written inside this box. For example, triggers for a client with the issue of depression might include, ‘performed poorly at work’, ‘being alone on the weekend’ and ‘talking on the phone with my mother.’

Anticipating triggers is helpful because it is often easier to respond effectively to the symptoms associated with the issue if you are prepared to do so. In contrast, responding effectively to the symptoms is typically more difficult if you experience the symptoms unexpectedly because you have not anticipated triggers.

The middle box: Symptoms

The middle box of the box–arrow in–arrow out analysis is labelled ‘symptoms’. In this box you list the symptoms of the issue which you experience as a result of the triggers. Using the example, symptoms for depression might include depressed mood, negative thoughts about yourself, lack of interest in activities and decreased appetite.

Listing the symptoms in the middle box is important because it will prepare you to respond in a manner which will help to alleviate the symptoms. I will discuss these helpful responses and alternative unhelpful responses to symptoms in the next section.

The right box: Responses

The right box of the box–arrow in–arrow out analysis is labelled ‘responses’. In this box you list the responses you can make to the symptoms which you experience as a result of the triggers. The responses box is the most important element of the framework. The reason is that the type of responses you make to the symptoms can either serve to alleviate the symptoms or to prolong and even exacerbate them.

The responses box has two options listed in it—maintenance responses and good coping responses. Maintenance responses, as the name suggests, are those responses which serve to maintain the experience of the symptoms. On the other hand, good coping responses are those which allow you to cope effectively with the symptoms and alleviate them.

Using the example, maintenance responses to symptoms of depression could include cognitive responses such as dwelling on negative thoughts about yourself as well as behavioural responses such as isolating yourself from contact with others. Good coping responses to depressive symptoms could include cognitive responses like doing a thought record to evaluating and change your negative thoughts along with behavioural responses like engaging in an enjoyable activity, doing some exercise and talking with someone who helps you to feel good about yourself.

Differences between the two kinds of responses

Maintenance responses are typically easier to engage in compared with good coping responses when you’re experiencing symptoms. For example, when you’re feeling depressed it is easy to respond by dwelling on negative thoughts about yourself and to isolate yourself from contact with others.  Unfortunately, these responses serve to prolong and even exacerbate the symptoms.

On the other hand, it is usually takes more energy and effort to engage in good coping responses when you’re experiencing symptoms. For example, doing a thought record takes more energy and effort than dwelling on negative thoughts about yourself. Likewise, contacting someone with whom a conversation could allow you to feel better about yourself may take more energy and effort than isolating yourself from social contact.

How to choose good coping responses over maintenance responses

Therefore, the challenge is forego your impulse to engage in maintenance responses when you are experiencing symptoms and choose instead good coping responses. These responses generally take more energy and effort to initiate but ultimately provide you with relief from your symptoms.

Meeting this challenge can be made easier by being prepared for your experience of symptoms by anticipating triggers followed by being ready to engage in specific good coping responses like those discussed in the example. Using the box–arrow in—arrow out analysis will help you in the execution of this process.

A psychologist can help you to implement the strategies discussed in this article.

May you benefit from using the box–arrow in–arrow out analysis,

Dr. Pat