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

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

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).

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 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.

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.

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.

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

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. 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.

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

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 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:

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

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 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

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 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