1. Isabel Clarke Consultant Clinical Psychologist
Integrating approaches to complex cases using Interacting Cognitive Subsystems.
Isabel Clarke
Consultant Clinical Psychologist

2. “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

3. “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.
Basic CBT’s model of mind is simple. Mind is about thought,physical arousal,feeling,&behaviour in interaction. The therapy seeks to effect change by altering thought and behaviour. This worked so well for straightforward anxiety and depression type conditions, that it has been progressively extended to more and more challenging diagnoses, such as pd and psychosis.
It has done this first by elaborating the basic model; adding in schemas, the second wave,
Picking up ideas from humanistic and psychodynamic approaches
and then by the development of the 3rd Wave therapies (term coined by Hayes, whose ACT is one of them)

4. 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

5. 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

6. Brewin’s VAMS and SAMS (just memory).
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.
Having reviewed these trends within the cultural map of therapy, I will return to the central challenge faced in attempting to facilitate change where the patterns to be changed are rooted in early or major trauma, and are deep seated, or where psychopathology is severe, as with serious psychosis.
The split between thought and feeling underlies the logic of CBT. Behaviour, and so the course of life and relationship tends to be governed by feelings and habitual patterns (schemas). If these can be thought about, with the facilitation of therapy, they can be changed. It was then noted that the relationship between thought and feeling operated differently in different situations. Under high threat/high arousal/ high emotion, the reaction was automatic and not reflected upon at all (hot cognition). For revision to happen – it had to be appraised coolly.
Different CBT therapist-researchers have come up with a bewildering variety of ways into the levels of processing split - which I will not bore you with. Instead, I will bewilder you with Interacting Cognitive Subsystems, which provides a neat explanatory framework across these areas (I suggest).

7. 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.

8. 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.

9. 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?

10. 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.

11. 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).

12. Figure 1. Typical Formulation
NIGHTMARES
CAN’T SLEEP
PAST ABUSE
LOSSES
MORE DIFFICULT
TO COPE
PARTNER
LEAVING
FEAR
RAGE
SADNESS
AVOID GOING
OUT:SEEING
PEOPLE
CUT SELF
ATTEMPT SUICIDE
FRIENDS & FAMILY
ALARMED. COULD LOSE
CUSTODY OF CHILDREN
MORE TIME TO BROOD
FEEL WORSE
WAYS FORWARD
DON’T LET THE FEELINGS BE IN CONTROL – x IN CHARGE!
DO THINGS DESPITE THE FEELING
BREATHING AND MINDFULNESS TO GET BACK INTO THE PRESENT
USE THE ENERGY OF THE ANGER POSITIVELY.

13. 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.

14. Features of Interacting Cognitive Subsystems
There are 9 subsystems, each with its own type of coding.
Some deal with sensory perception - auditory and visual
Some deal with language processing
There are two higher order systems: the propositional and the implicational.

15. Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Auditory
ss.
Implicational
Memory
Visual
ss.
This is a diagram of some of the processing subsystems in the brain, according to Teasdale and Barnard - based on research on cognitive processing. .
I am going to concentrate on the two large ones here - p and i.
p = verbal based logical reasoning - with a verbally coded memory store.
i = holistic, overall meaning processing. Direct connections with sense modalities (in contrast to p) and a memory store coded in every sensory modality - vivid and immediate. The connection with emotional response made possible by the direct connection with state of bodily arousal.
For complete processing, for “construing” in a Kellyan sense, you need both working in close communication. Because the systems are distinct, it is possible for this communication to become overloaded or skewed in some way.
This helps to explain a lot of what goes wrong for human beings.
Verbal
ss.
Propositional subsystem
Propositional
Memory

16. 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.”

17. 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

18. 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.
Human fallibility; our proneness to emotional overload and breakdown, leading to the sorts of depression, anxiety disorder and psychosis that are the stuff of my working life. This model give me a clear way of understanding psychopathology and an alternative perspective to the dominant “illness” model; one that I find useful in therapy as it makes sense to people; it gives them a way of taking responsibility for their process without blaming them.

19. Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Auditory
ss.
Implicational
Memory
Visual
ss.
This is a diagram of some of the processing subsystems in the brain, according to Teasdale and Barnard - based on research on cognitive processing. .
I am going to concentrate on the two large ones here - p and i.
p = verbal based logical reasoning - with a verbally coded memory store.
i = holistic, overall meaning processing. Direct connections with sense modalities (in contrast to p) and a memory store coded in every sensory modality - vivid and immediate. The connection with emotional response made possible by the direct connection with state of bodily arousal.
For complete processing, for “construing” in a Kellyan sense, you need both working in close communication. Because the systems are distinct, it is possible for this communication to become overloaded or skewed in some way.
This helps to explain a lot of what goes wrong for human beings.
Verbal
ss.
Propositional subsystem
Propositional
Memory

20. 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.

21. 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
The problem of the emotion/reason split has been tackled differently by different CBT therapists and researcher. I, along with a number of other people, see ICS as the most satisfactory and complete explanatory system – there is a recent paper by Barnard on the reference list on this subject.
Clearly, there is a neuropsychological substrate to any account of cognitive architecture, but because of the complexity of interconnections, our current state of knowledge cannot give us an exact mapping.
It is interesting to note that the respected neuropsychologist, Damasio (1994) arrives at a similar sense of continuous interplay between different systems when talking in general terms about the model of the mind, while drawing somewhat different distinctions. He considers emotions, based on gut level responses experienced in the body, as the basis for the sense of self, and recognises three levels of the self:

22. DIALECTICAL BEHAVIOUR THERAPY: Linehan’s STATES OF MIND
EMOTION
MIND
REASONABLE
MIND
WISE
MIND
Though L does not refer to it specifically, the ICS split maps onto the basic DBT model of the mind, as follows: The idea of a shifting balance is central to DBT, so that the self is seen as moving between the minds. Wise mind is the same as the two central ss. in ICS working smoothly together; reasonable mind dominance suggests an avoidance of the emotional (because the physical state of arousal produced by memories is anticipated as too unpleasant). Emotional Mind is where the implicational is dominant, and a loop can be set up that excludes current reflection, and so revision of past patterns – whether of depressive rumination or impulsive action.
IN THE PRESENT
IN CONTROL

23. 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.

24. 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

25. 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.

26. 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.

27. 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.

28. Self and Relationship. Imp. Ss Prop.ss
Info. About
self.
Self
(as subject
Self
(as object
Self
(as subject
other
Trauma
Transitions
Early
provisional
self develops
Experience stored in
imp.memory
activated
Early self
re-
experienced
Sense of self as
object disrupted;
early info. Needs
re-integration

29. 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.

30. 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

31. 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.

32. 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.

33. 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

34. 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.

35. 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?

36. Implicational thinking is all or nothing
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