Transcript Document

British Association for Behavioural and Cognitive
Psychotherapies Annual Conference and Workshops,
Edinburgh, July 16-19th
Using ICS to inform formulation
with complex cases
Michael Townend, PhD, Reader in Cognitive
Behavioural Psychotherapy,
University of Derby, UK
www.derby.ac.uk
Introduction
ICS theory differs from Beck’s model of emotional
disorders (Beck et al., 1979), in that it specifies two
qualitatively different levels of meaning. These levels
of meaning play distinct roles in the production,
maintenance and modification of emotion, clarifying
the distinction between ‘cold’ or intellectual beliefs
(propositional meaning) and ‘hot’ or emotional
beliefs (implicational meaning).
www.derby.ac.uk
Interacting Cognitive Subsystems
– Attempts to address issues of:
• Memory
• Variability within schema over time
• Return to normal of dysfunctional thinking with no
direct cognitive intervention
• Environmental factors within aetiology (reciprocal
determinism)
• Emotional and cognitive levels of meaning (hot
and cold)
• Information processing models for normal and
abnormal experiences
www.derby.ac.uk
Complexity and ICS
(Modeling depression in ICS - Teasdale and Barnard, 1993)
www.derby.ac.uk
Interacting Cognitive Subsystems –
Simplified Model
Limb Proprioceptive
Object Image
Visual Hue, bright
Propositional
Behavioural
Acoustic Tone
Peripheral
Emotional &
Consequences
Implicational
Articulatory Move
Morphonolexical
Speech, & language
functions
Previous learning experiences, genetic,
cultural, social and environmental
influences. The current environment
www.derby.ac.uk
Critical Evaluation of ICS as the
Basis for Formulation
• Advantages:
– Multi representational models can explain emotional conflict
– Explain how emotions can be produced automatically without
apparent appraisal processes
– Give the opportunity to consider and incorporate transdiagnostic
processes
– Macro theory that can be applied across all disorders.
• Disadvantages:
– Complex theory and need simplification for use with clients.
– Difficulty with the incorporation of physiological process.
Grant, Townend, Mills and Cockx (2008)
www.derby.ac.uk
Formulation and ICS
• A simple rule of thumb when developing formulations with
clients is to ensure that they are not so simple that key
factors are either missed or so complex that they are
overwhelming for both client and therapist – in other words,
the formulation must be parsimonious.
• The formulation needs to be able to account for all the
factors at play in maintaining the client’s psychological
difficulties.
• These include hot and cold cognition, non conscious
processing (Teasdale, 1997), emotions, cognition mismatch
(Gilbert, 1992) and meaning making in response to feelings
(Haidt, 2001).
Grant et al 2008
www.derby.ac.uk
Michael Case Details
• Michael was a 36-year-old, White man who was seen at
a specialist service CBT for perpetrators of domestic
abuse at the University of Derby.
• He was a voluntary client (Not mandated by the courts).
• Michael’s presenting problem was physical and verbal
aggressive behavior toward his second partner. This
usually consisted of screaming at his partner, followed
by kicking or pushing her.
• He was irritable and angry on a daily basis and was
violent to his partner at least once per week.
www.derby.ac.uk
Domestic Abuse and formulation
• Domestic violence is a major social problem, with
estimates suggesting that one fourth of all women
and one sixth of men experience domestic abuse
during their lifetime (Mirlees-Black, 2004).
• Complex interaction of interpersonal, behavioural,
cognitive affective, motivational and physiological
need to be accounted for within formulation.
• Cognitive behavioural models for Domestic Abuse
are not well developed in comparison to specific
disorders.
• Problems with client engagement.
• Range of causal factors for domestic abuse.
www.derby.ac.uk
Domestic Abuse and formulation
• The configuration of these multiple and multilevel
elements in people who abuse others and have angercontrol problems leads to the perpetuation of
idiosyncratic models, where the self or others are viewed
as weak, the environment or others becoming encoded
as threatening, the world being perceived or felt as an
unpredictable place of injustice that is beyond an
individual’s control.
www.derby.ac.uk
Domestic Abuse and Formulation
• For example, anger might be triggered by any number of elements
within the overall configuration, such as being physiologically
aroused.
• The emotive and behavioral responses can be maintained by an
“interlock” (Barnard, 2004; Teasdale & Barnard, 1993), which is a
self-perpetuating loop among threat, injustice configurations that
have been encoded, the individual’s higher-order view of anger as a
way of coping with threat or perceived injustice, and the cognitive
and sensory subsystems.
• The distinction between propositional and implicational systems is
particularly important as it can explain the “non-cognitive” automatic
arousal reported in many people with anger control problems (Power
& Dalgleish, 1997).
• The notion of interlock can be used to explain ruminative processes
found in people who engage in abuse and show poor anger control.
www.derby.ac.uk
Idiosyncratic Conceptualization for a Perpetrator of Domestic Abuse
Based on Interacting Cognitive Subsystems Theory
Townend & Smith (2008)
www.derby.ac.uk
Health Anxiety and Formulation
• People with functional symptoms are a heterogeneous
group of clients with problems such as chronic fatigue
syndrome, somatisation disorders, hypochondriasis or
health anxiety and body dysmorphic disorder (APA,
2000; WHO, 2006).
• It has been estimated that as many as 25–50 per cent
of all consultations in primary care or new outpatients
might fall within this group (Bass, 1990)
www.derby.ac.uk
Anne Case Details
• Anne (a pseudonym) is a 36-year-old white female client
who was seen at a specialist cancer service and offered
psychological therapy for her health anxiety.
• Anne’s presenting problem was preoccupation and fear
that she had breast cancer. Five days a week she would
spend up to 80 per cent of her day thinking about the
possibility that she might have cancer or that she had the
symptoms of cancer in her breasts.
www.derby.ac.uk
Health Anxiety and Formulation
• Anne’s preoccupation with breast cancer, or the belief that she had
breast cancer, was reported as being triggered by a number of
internal (felt) and external triggers.
• A speculative hypothesis was formed during the assessment that her
physical symptoms, emotional responses, avoidance, checking and
reassurance-seeking behaviours had occurred due to the
development of an implicational system related to the danger posed
by the physical symptoms.
• This can be predicted by ICS theory (Barnard, 2004; Barnard and
Teasdale, 1991) where the following subsystems – proprioceptive
(feeling tense), imagery (images of cancer), visual (observation of
self in a mirror), acoustic (hearing or saying the word cancer),
peripheral, articulatory (repeated checking) and morphonolexical
(what was said to her about cancer) – were all feeding into the two
main propositional and implicational subsystems.
www.derby.ac.uk
Formulation, Health Anxiety and ICS
Grant et al (2008)
www.derby.ac.uk
Conclusion: Domestic Abuse, Health Anxiety,
Formulation and ICS
• The ICS theory of the program of therapy underpinning
these case studies specifically targets meanings, sensory
elements, and cognitive processes as a means to
changing aggressive or other abusive behavior and health
anxiety.
• The distinction between propositional and implicational
meanings subsystems is important in formulating domestic
abuse and anger and health anxiety in terms of the
tendency for the abusive/aggressive or health anxiety
behavior to occur immediately (directly via the
implicational route) or after a delay following rumination
and preoccupation (indirectly via the propositional route).
www.derby.ac.uk
Conclusion: Domestic Abuse, Health Anxiety,
Formulation and ICS
• It can also help clinicians to understand beliefs held by the
client that are clearly distorted and seem to go without
question by the perpetrator of domestic abuse or the health
anxiety client to justify his or her inappropriate or unhelpful
behaviours.
• ICS can help the therapist to formulated beliefs as a
representation of the implicational system which can be
difficult for clients to articulate.
• Formulation is at the heart of the therapeutic process, and
when a comprehensive conceptualization is developed in a
way that seems to fit the presentation and responses of the
client and alternative implicational models are built through
cognitive restructuring, behavior changes and adaptive
coping develops.
www.derby.ac.uk
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Beck, A.T., Rush, A.J., Shaw, B.F. and Emery, G. (1979) Cognitive Therapy for Depression. New
York: Guilford Press.
Gilbert, P. (1992) Depression: The Evolution of Powerlessness. Hove: Erlbaum.
Teasdale J.D. and Barnard, P.J. (1993) Affect, Cognition and Change, Lawrence Erlbaum.
Haidt, J. (2001) ‘The emotional dog and its rational tail: a social intuitist approach to moral
judgement’, Psychological Review, 108(4): 814–34.
Teasdale, J. (1997) ‘The relationship between cognition and emotion: the mind-in-place in mood
disorders’, in D.M. Clark and C.G. Fairburn (eds), Science and Practice of Cognitive Behaviour
Therapy. Oxford: Oxford University Press.
Grant, A., Townend, M. et al (2008). Assessment and formulation in cognitive behaviour therapy.
Sage. London.
Townend, M. and Smith M. E. (2007). Prevention of Domestic Abuse. Clinical Case Studies, 6: 443453.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders
(DSM IV), 4th edn, text revision. Washington DC: American Psychiatric Association. International
Classification of Disease, Mental and Behavioural Problems World Health Organistion (2002)
Version 10. Geneva: World Health Organisation.
Gilbert, P. (1992) Depression: The Evolution of Powerlessness. Hove: Erlbaum.
Mirlees-Black, C. (2004). Domestic violence: Findings from a new British crime survey selfcompletion questionnaire. London: Home Office.
Power, M. and Dalgleish, T. (1997) From Cognition and Emotion: From Order to Disorder. Hove:
Psychology Press.
Bass, C. (ed.) (1990) Somatization: Physical Symptoms and Psychological Illness. London:
Blackwell Science.
www.derby.ac.uk