Integrating approaches to complex cases using Interacting Cognitive

Subsystems.

Isabel ClarkeConsultant Clinical

Psychologist

“Third Wave” – term coined by Hayes (Acceptance & Commitment Therapy)

• Kabat-Zinn. Applied mindfulness to stress and pain.

• Segal, Teasdale & Williams. Mindfulness Based Cognitive Therapy (relapse in depression.)

• Linehan. Dialectical Behaviour Therapy (BPD)

• Chadwick. Mindfulness groups for voices.

• Hayes

“Third Wave” Cognitive Therapies

• Developments in CBT as it tackles personality disorder, psychosis etc.

• Therapeutic relationship important• Past history is significant• Change lies not so much in altering

thought to alter feeling, but in altering the person’s relationship to both thought and feeling

• Mindfulness is a key component.

AIMS• Consider current trends in CBT and the

challenge of finding theoretical coherence, linked to cognitive science.

• Introduce the cross diagnostic, third wave approach we use at Woodhaven – opportunity to try this out.

• Theoretical background for this approach in ICS – introduce the model.

• Relate it to Attachment Theory, Evolutionary theories etc.

• Use this to clarify:– levels of processing– motivation issues– the formation and maintenance of schemas– triggering of early trauma memories– the role of relationship

• More clinical applications based on this approach

Applying CBT to Severe Mental Health Problems.

• Therapy is about healing the relationship between an individual and themselves.

• Relationship is governed by emotion• CBT works on emotion by seeking to alter

thought, behaviour or state of arousal• Where problems are rooted in early trauma

etc. patterns are set up that are resistent to revision

• The cool reflection needed is hard to achieve

LEVELS OF PROCESSING – A THEORETICAL JUNGLE!• This problem leads to the recognition of different

types or levels of processing within CBT e.g.s of theories of this.

• Ellis: Inference and Evaluation– Hot and Cold cognition

• Power & Dalgleish. SPAARS (theory of emotion).• Mark Williams: overgeneral autobiographical

memory.• Wells & Mathews. S-REF and Metacognition• Metacognition.• Wells & Mathews. S-REF

– . 'Vulnerability to psychological dysfunction is associated with a cognitive-attentional syndrome characterised by heightened self-focussed attention, attentional bias,ruminative processing and activation of dysfunctional beliefs. ...mediated by executive processes that are directed by the patient's beliefs'.

• Brewin’s VAMS and SAMS (just memory).• Ehlers & Clark (following Roediger): conceptual

v.data driven processing.

Features the theories have in common.

• There is one direct, sensory driven, type of processing and a more elaborate and conceptual one.

• The same distinction can be found in the memory.

• Direct processing is emotional and characteristed by high arousal.

• This is the one that causes problems – e.g. flashbacks in PTSD.

Features of Emotion Driven Processing

• Emotion regulates relationship – both with yourself and others

• It mobilises the body for action• That physical mobilisation gives the emotion

its punch• Where physical arousal is prolonged it is

unpleasant – motivates people to avoid emotion

• Emotion driven processing does not ‘do’ time – past threat is added to current threat (cf. Brewin’s PTSD research)

• Role of past trauma in psychosis and PD is now being properly recognised.

Ideas to think about• Symptoms are just different ways of

escaping from or avoiding unpleasant emotions – what examples can you find?

• In the light of this way of looking at things, what should be the main goals of therapy?

• To meet those goals, where does CBT need to direct its efforts?

• What therapeutic methods are likely to be useful?

• What becomes less important?

Woodhaven Brief CBT Model

Simple formulation based on the levels of processing split between the emotional and logical thinking.

A “Third Wave” Cognitive therapy – focus on intervening between thought and feeling rather than altering thought to effect feeling (see Hayes et al. 1999)

Management of arousal (breathing control), and mindfulness training to facilitate intervention in the cognitive/emotional process.

Nurses, community keyworkers and others can support people to do this.

Key features cont. Techniques of meeting, expressing and

letting go of emotion as opposed to the previous avoidance.

This draws on Linehan's (1993) approach and has similarities to Emotion Focused Therapy (Greenberg 2002).

Practical discussion of lifestyle management to ensure the continuation of a better adjustment.

All these features are designed to enable someone to take control of their own recovery – in sympathy with the Recovery Approach (e.g. Repper & Perkins, 2003).

Figure 1. Typical Formulation

FEARRAGESADNESS

PAST ABUSELOSSES

PARTNERLEAVING

CUT SELFATTEMPT SUICIDE

FRIENDS & FAMILY ALARMED. COULD LOSECUSTODY OF CHILDREN

FEEL WORSE

NIGHTMARESCAN’T SLEEP

MORE DIFFICULTTO COPE

AVOID GOINGOUT:SEEINGPEOPLE

MORE TIME TO BROOD

WAYS FORWARDDON’T LET THE FEELINGS BE IN CONTROL – x IN CHARGE!DO THINGS DESPITE THE FEELINGBREATHING AND MINDFULNESS TO GET BACK INTO THE PRESENTUSE THE ENERGY OF THE ANGER POSITIVELY.

Providing a cognitive science based theoretical

context.• Interacting Cognitive Subsystems• Evolutionary approaches - Gilbert etc.• Attachment theory - Bowlby etc.• Cognitive Analytic Therapy.• Current approaches to CBT for

personality disorders:• Schema focussed approaches• Dialectical Behaviour Therapy (Linehan)• ACT.

BodyState

subsystem

Auditoryss.

Visualss.

Interacting Cognitive Subsystems.

Implicational subsystem

ImplicationalMemory

Propositional subsystem

PropositionalMemory

Verbalss.

The Propositional Subsystem

• Verbal coding.• Manages logical thought - “cool cognition”• Verbally coded memory store integral to

the subsystem.• Communicates directly only with the other

language subsystems.• Intercommunication between it and the

implicational subsystem = “Central Engine of Cognition.”

Implicational Subsystem

• Coded in all modalities - memory and current processing

• Concerned with meaning and significance

• Information about threat and value• Particularly concerned with the

status of the self.• Directly connected to sensory and

body subsystems

A challenging model of the mind.• The mind is simultaneously individual,

and reaches beyond the individual, when the implicational ss. is dominant.

• This happens at high and at low arousal.

• There is a constant balancing act between logic and emotion – human fallibility

• Mindfulness is a useful technique to manage that balance.

BodyState

subsystem

Auditoryss.

Visualss.

Interacting Cognitive Subsystems.

Implicational subsystem

ImplicationalMemory

Propositional subsystem

PropositionalMemory

Verbalss.

Important Features of this model

• Our subjective experience is the result of two higher order processing systems interacting – neither is in overall control.

• Each has a different character, corresponding to “hot” and “cool” cognition.

• The IMPLICATIONAL Subsystem manages emotion – and therefore relationship.

• The verbal, logical, PROPOSITIONAL ss. gives us our sense of individual self.

Other views of this balancing act of the mind/self• Hayes – split between experience and

mind (for him mind = language)• Damasio and the neuro perspective:

3 types of self– proto self (body state maintenance);– core self (concerned with the

experience of here and now – linked to emotions)

– Autobiographical self; extended consciousness = identity

DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND

EMOTION

MIND

REASONABLE

MIND

WISE

MIND

IN THE PRESENTIN CONTROL

ICS AND THE SELF.Imp. Subsystem and Arousal

• Body ss. Information means Imp. Ss. is directly influenced by state of arousal.

• Information about threat and value influences arousal (feedback loop).

• High arousal interferes with flow of info. Between imp. and prop. Ss.

• New prop. Information not integrated leading to redundant loops, or schemas.

ICS AND THE SELF Results of the arousal - imp. Ss

connection.

• Similar levels of arousal / threat trigger memories from imp. Memory

• These experiences are vividly re-experienced.

• This is unpleasant - the triggering is avoided

• This blocks areas of experience to full appraisal.

• Threatening experiences are incompletely processed

ICS AND THE SELF The Role of Feelings

• We experience all this as feelings.• Where there are problems - feelings

become either blocked off, or overwhelming.

• To function well, we need to be able to express and experience our feelings.

• We also need to be able to think about them.

THE CONSTRUCTION OF THE SELF

• The Implication ss. is constantly watching for information about threat to or value of the self.

• Information about unacceptability leads to a disagreeable level of arousal.

• This triggers any matching memories about unacceptibility in the imp. ss.

• Where this happens, there is strong motivation to prevent access to this information.

Relationship, trauma and the construction of the self – a way into understanding Personality Disorder.

• A sense of self is gained through relationship.• The reaction of others gives us information

about threat, safety and value.• Identity formation is dynamic & comprises

– sense of self as subject - imp.ss;– sense of self as object - prop. Ss.

• Major threat disrupts the sense of self – hence personality disorder.

Self and Relationship.Imp. Ss Prop.ss

otherSelf

(as subjectSelf

(as object

Self (as subject

Info. Aboutself.

Experience stored in imp.memory

activated

TraumaTransitions

Early selfre-

experienced

Early provisional

self develops

Sense of self as object disrupted;early info. Needs

re-integration

Threat/Value Information

• Threat to physical survival• Threat to our place in the social world• For the baby - the two threats are the

same• For the child – bullying and position with

peers are common social threats• Sexual abuse gives a deeply threatening

and confusing message about the self.• A sense of value and specialness is, I

suggest, universally present.

WAYS OF COPING WITH FEELINGS WHERE THREAT TO SELF IS TOO

GREAT

• Giving in - signalling submission (depression)

• constant anxiety, worry and hypervigilance• anger - attribute elsewhere.• displacing anxiety - OCD, eating disorder• drink, drugs, etc.• dissociation - flipping between different

experiences of the self

Therapeutic Methods suggested by this

approach•1. Control of Arousal.• Breathing techniques• Mindfulness • DBT techniques to extend

tolerance of aversive emotion.• Body state awareness and

monitoring.

2.Addressing Imp. level wounds

• Uncovering these by interrogating the emotion (exploratory techniques).

• Bring this material into propositional space - make sense of it by formulation.

• Basis for new meaning.• Making connections between past and

present while working at staying in the present.

3. Mobilising and nurturing the strong sense of self.

• Anger leads into innate sense of entitlement, despite abuse etc.

• Mourn what has been lost and damaged• Celebrate what is strong. Often the deviant,

rebel part that was suppressed to create the acceptable self.

• Naming and integrating scattered elements of identity.

• Mobilising and nurturing strengths

• Building a comfortable sense of self

Some useful phrases

• If it feels uncertain - you are on the right lines.

• Your feelings give you important information about yourself.

• You can take a feeling seriously and express it without acting upon it - acting upon it stops you thinking about it.

Applying this approach to one of your clients.

List the aspects of the case that are explained by the model

Does the model provide any normalising and non blaming explanations? Come up with some phrases.

Try a formulation of the case using the ‘spikey diagram’

What interventions are then suggested?Who would support these? Do they all need

therapist support, or is there scope for delegating?

Implicational thinking is all or nothing. Use the diagram to

organise what is presented and encourage realistic engagement in

the middle. Ideal Middle Way Horrible

Never matches reality – flips into ‘horrible’

Feels uncertain

Leads to withdrawal