Using ICS to inform formulation with complex cases

1、www.derby.ac.ukUsing ICS to inform formulation with complex cases Michael Townend, PhD, Reader in Cognitive Behavioural Psychotherapy, University of Derby, UKBritish Association for Behavioural and Cognitive Psychotherapies Annual Conference and Workshops, Edinburgh, July 16-19thwww.derby.ac.ukIntro

2、duction ICS theory differs from Becks 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

3、or intellectual beliefs (propositional meaning) and hot or emotional beliefs (implicational meaning). www.derby.ac.ukInteracting Cognitive Subsystems Attempts to address issues of: Memory Variability within schema over time Return to normal of dysfunctional thinking with no direct cognitive interven

4、tion Environmental factors within aetiology (reciprocal determinism) Emotional and cognitive levels of meaning (hot and cold) Information processing models for normal and abnormal experienceswww.derby.ac.ukComplexity and ICS(Modeling depression in ICS - Teasdale and Barnard, 1993) www.derby.ac.ukLim

5、b ProprioceptiveObject ImageVisual Hue, brightAcoustic TonePeripheral Articulatory MoveMorphonolexical Speech, & language functionsPropositionalImplicationalEmotional &Behavioural ConsequencesPrevious learning experiences, genetic, cultural, social and environmental influences. The current e

6、nvironmentInteracting Cognitive Subsystems Simplified Modelwww.derby.ac.ukCritical Evaluation of ICS as the Basis for FormulationAdvantages: Multi representational models can explain emotional conflict Explain how emotions can be produced automatically without apparent appraisal processes Give the o

7、pportunity 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.der

8、by.ac.ukFormulation and ICSA 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 for

9、mulation needs to be able to account for all the factors at play in maintaining the clients 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, 200

10、1). Grant et al 2008www.derby.ac.ukMichael 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). Michaels presenting problem was physical and ve

11、rbal 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.ukDomestic Abuse and formulation Domestic violenc

12、e 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

13、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.ukDomestic Abuse and formulation The configuration of these multiple and multi

14、level 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 injustic

15、e that is beyond an individuals control.www.derby.ac.ukDomestic Abuse and FormulationFor 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” (Barn

16、ard, 2004; Teasdale & Barnard, 1993), which is a self-perpetuating loop among threat, injustice configurations that have been encoded, the individuals higher-order view of anger as a way of coping with threat or perceived injustice, and the cognitive and sensory subsystems. The distinction betwe

17、en 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 engag

18、e in abuse and show poor anger control.www.derby.ac.ukIdiosyncratic Conceptualization for a Perpetrator of Domestic Abuse Based on Interacting Cognitive Subsystems TheoryTownend & Smith (2008)www.derby.ac.ukHealth Anxiety and Formulation People with functional symptoms are a heterogeneous group

19、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 2550 per cent of all consultations in primary care or new outpatients might fall within this

20、 group (Bass, 1990)www.derby.ac.ukAnne 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. Annes presenting problem was preoccupation and fear that she had breast cancer. Five days

21、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.ukHealth Anxiety and FormulationAnnes preoccupation with breast cancer, or the belief that she had breast cancer, was repor

22、ted 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 syste

23、m 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

24、 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.ukFormulation, Health Anxiety and ICSGrant et al (2008)www.derby.ac.ukConclusion: Domestic Ab

25、use, 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 propositi

26、onal 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 preo

27、ccupation (indirectly via the propositional route). www.derby.ac.ukConclusion: Domestic Abuse, Health Anxiety, Formulation and ICSIt 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 th

28、e 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 c

29、omprehensive 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.ukReferences1.Beck, A.T., Rush, A.J., Shaw, B

30、.F. and Emery, G. (1979) Cognitive Therapy for Depression. New York: Guilford Press.2.Gilbert, P. (1992) Depression: The Evolution of Powerlessness. Hove: Erlbaum.3.Teasdale J.D. and Barnard, P.J. (1993) Affect, Cognition and Change, Lawrence Erlbaum.4.Haidt, J. (2001) The emotional dog and its rational tail: a social intuitist approach to moral judgement, Psychological Review, 108(4): 81434.5.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 Behavi