Integrating approaches to complex cases using Interacting Cognitive Subsystems.

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Integrating approaches to complex cases using
Interacting Cognitive Subsystems.

• Isabel Clarke
• Consultant Clinical Psychologist

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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

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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 persons
  relationship to both thought and feeling
• Mindfulness is a key component.

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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

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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

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• 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'.
• Brewins VAMS and SAMS (just memory).
• Ehlers Clark (following Roediger) conceptual
  v.data driven processing.

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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.

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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.
  Brewins PTSD research)
• Role of past trauma in psychosis and PD is now
  being properly recognised.

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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?

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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.

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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).

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Figure 1. Typical Formulation
NIGHTMARES CANT SLEEP
PAST ABUSE LOSSES
MORE DIFFICULT TO COPE
PARTNER LEAVING
FEAR RAGE SADNESS
AVOID GOING OUTSEEING PEOPLE
CUT SELF ATTEMPT SUICIDE
FRIENDS FAMILY ALARMED. COULD LOSE CUSTODY OF
CHILDREN
MORE TIME TO BROOD
FEEL WORSE
WAYS FORWARD DONT 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.
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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.

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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.

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Interacting Cognitive Subsystems.
Body State subsystem

Implicational subsystem
Auditory ss.
Implicational Memory
Visual ss.
Verbal ss.
Propositional subsystem
Propositional Memory
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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.

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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

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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.

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Interacting Cognitive Subsystems.
Body State subsystem

Implicational subsystem
Auditory ss.
Implicational Memory
Visual ss.
Verbal ss.
Propositional subsystem
Propositional Memory
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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.

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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

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DIALECTICAL BEHAVIOUR THERAPY Linehans STATES
OF MIND

• EMOTION
• MIND

REASONABLE MIND
WISE MIND
IN THE PRESENT IN CONTROL
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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.

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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

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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.

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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.

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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.

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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
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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.

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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

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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.

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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.

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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

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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.

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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?

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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