Transcript INTERACTING COGNITIVE SUBSYSTEMS

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.
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:
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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 FormulationNIGHTMARES
PAST ABUSE
LOSSES
CAN’T SLEEP
MORE DIFFICULT
TO COPE
PARTNER
LEAVING
CUT SELF
ATTEMPT SUICIDE
FRIENDS & FAMILY
ALARMED. COULD LOSE
CUSTODY OF CHILDREN
FEAR
RAGE
SADNESS
AVOID GOING
OUT:SEEING
PEOPLE
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.
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•
•
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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.
Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Implicational
Memory
Auditory
ss.
Visual
ss.
Propositional subsystem
Propositional
Memory
Verbal
ss.
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.
Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Implicational
Memory
Auditory
ss.
Visual
ss.
Propositional subsystem
Propositional
Memory
Verbal
ss.
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
REASONABLE
MIND
WISE
MIND
MIND
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 reexperienced.
• 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
other
Self
Self
subject
(as(assubject
Trauma
Transitions
Experience stored in
imp.memory
activated
Early self
reexperienced
Prop.ss
Info. About
self.
Self
(as object
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
Never
Feels
matches
uncertain
reality – flips
into ‘horrible’
Horrible
Leads to
withdrawal