Using ICS to inform formulation with complex cases

1
Using ICS to inform formulation with complex
cases
British Association for Behavioural and Cognitive
Psychotherapies Annual Conference and Workshops,
Edinburgh, July 16-19th

• Michael Townend, PhD, Reader in Cognitive
  Behavioural Psychotherapy,
• University of Derby, UK

2
Introduction

• 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 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
  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, 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).
• Michaels 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 individuals 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
  individuals 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 2550 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.
• Annes 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

• Annes 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)
  81434.
• 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.