Using ICS to inform formulation with complex cases

1. 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

2. 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).

3. 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

4. Complexity and ICS (Modeling depression in ICS - Teasdale and Barnard, 1993)

5. Interacting Cognitive Subsystems – Simplified Model Limb Proprioceptive Object Image Visual Hue, bright Acoustic Tone Peripheral Articulatory Move Morphonolexical Speech, & language functions Emotional & Behavioural Consequences Propositional Implicational Previous learning experiences, genetic, cultural, social and environmental influences. The current environment

6. 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)

7. 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

8. 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.

9. 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.

10. Domestic Abuse and formulation • The configuration of these multiple and multilevel elements in people who abuse others and have anger-control 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.

11. 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.

12. Idiosyncratic Conceptualization for a Perpetrator of Domestic Abuse Based on Interacting Cognitive Subsystems Theory Townend & Smith (2008)

13. 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)

14. 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.

15. 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.

16. Formulation, Health Anxiety and ICS Grant et al (2008)

17. 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).

18. 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.

19. References • 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: 443-453. • 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 self-completion 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.