cognitive therapy and serious mental illness. an interacting cognitive subsystems approach

Cognitive Therapy and SeriousMental Illness. An InteractingCognitive Subsystems Approach

Isabel Clarke*Psychology Department, Royal South Hants Hospital,Southampton SO14 0YG, UK

The increasing application of Cognitive Therapy to the more enduringforms of psychopathology represented by the DSM-IV Axis IIDisorders has led to the piecemeal development of the discipline,and the incorporation of approaches from other therapeutic modalities,and from wider sources, such as Buddhist meditation. The presentpaper proposed the development of the Cognitive rationale, using as afoundation the research-based insights provided by Teasdales Inter-acting Cognitive Subsystem model (Teasdale and Barnard, 1993). Byemphasizing the close relationship between the emotional (implica-tional) subsystem and states of bodily arousal, this restores aversivearousal states to a central place in the understanding of psychopathol-ogy, and clinical practice. The role of threatening information about theself received through early relationships in leading to chronic aversivearousal states, whether high arousal as in anxiety, or low, as indepression, in Axis II disorders, is considered. The implications of thetension between this aversive information and the basic humanendeavour of constructing the self are discussed, and a clinical exampleis used to illustrate the therapeutic approaches suggested by thisperspective. Copyright # 1999 John Wiley & Sons, Ltd.

INTRODUCTION

Cognitive therapy has recently been advancingrapidly on a number of fronts; both in terms ofthe fundamental research understanding of cogni-tion, memory and arousal, and clinically into areasof ever greater and more complex pathology. Aswell as responding to the available challenge,practitioners are answering the call from on-highto concentrate efforts on those with serious mentalillness. I am here using this term to denote disorderaffecting the organization of the personality, as inDSM-IV Axis II disorders, but not includingpsychosis. Methodology is developed andborrowed in response to this more demanding

client group. In the resulting diversity, the coherentand clearly communicable rationale that is centralto the enterprise of engaging therapy clientscollaboratively with the cognitive model can getleft behind. I am here proposing to draw togethersome of these strands, both theoretical and thera-peutic, in a simple rationale based on TeasdalesInteracting Cognitive Subsystem model (Teasdaleand Barnard, 1993) to address these concerns.

This paper can be regarded as a contribution to adebate as opposed to a wholly original formulation.As well as drawing on Teasdale, I refer to a numberof the contributors to Power and Brewins (1997)recent edited volume, The Transformation of Meaning,and relate my approach to Dialectical BehaviourTherapy (Linehan, 1993) and Cognitive AnalyticTherapy programmes for the treatment of Border-line Personality Disorder (Ryle, 1997). The

CCC 10633995/99/05037509$17.50Copyright # 1999 John Wiley & Sons, Ltd.

Clinical Psychology and PsychotherapyClin. Psychol. Psychother. 6, 375383 (1999)

*Correspondence to: Mrs Isabel Clarke, Psychology Depart-ment, Royal South Hants Hospital, Southampton SO14 0YG,UK.

constructivist cognitive tradition is an organizinginfluence: as Anderson writes Constructivisttherapy is not so much a technique as a philoso-phical context (Anderson (1990), quoted inNeimeyer (1993)). This context informs my viewof the construction of the self. In particular, I citeGreenberg and Pascual-Leones chapter from thePower and Brewin book. Constructivists such asGuidano and Liotti (1983) have been at the forefrontof recognizing the influence of early attachmentrelationships on fundamental assumptions aboutthe self and the world. Recognition of the profoundimpact of early relationships has also been anessential feature of Becks theorizing for many years(Beck and Emery, 1985). This is one example of thetrend towards the widening of the boundaries ofcognitive therapy referred to at the beginning, asideas once characteristic of other therapeutic modal-ities are incorporated.

Employing the Interacting CognitiveSubsystem Model

I am not here attempting a full exposition of theInteracting Cognitive Subsystems model, which canbe found in Teasdale and Barnard (1993), andTeasdales chapter in Power and Brewin (1997),among other places. I am proposing to concentrateon the following features of the model. Firstly, as aninformation processing model, it is based onexperimental evidence for different forms of codinginformation; for instance, immediate and sensorybased, verbal and logically based, or a more holistic,meaning based coding. These and other distinctcodes form the basis for nine postulated sub-systems; three are sensory and proprioceptive, twoinvolve higher order pattern recognition, two, theproduction of response, and two are yet higherorder, meaning based systems on which I will nowfocus, the propositional and the implicational.Memory is integral to each subsystem, and likewisedistinguished by separate codes. Thus, the logical,propositional, memory is verbally coded, whereasthe implicational memory, that records meaningat a more generic level, is encoded in a rich varietyof sensory modalities, and is therefore moreimmediate and vivid.

Another area illuminated by the research intoshort-term memory and humancomputer inter-action on which the theory is based (e.g. Barnard,1985) is the need for a transformation process in theinterchange of information between one sub-system/coding and another, and that this isconstrained by the limitation of the processing

capacity. Thus connections are made more immedi-ately within a particular memory store thanbetween the data stored in different memory storesand coded differently. An example of this that willbe important for the argument that follows is therapid connection made between events of personalsignificance stored in the implicational memory. Forinstance, memory of earlier socially shaming eventsmight flash into the mind of a socially anxiousindividual entering an unfamiliar social situation.These memories will be more immediately acces-sible than logical information about, for instance,interesting possible topics of conversation, stored inthe propositional memory.

The other feature of the system that is central tothe current argument is the immediate connectionbetween the implicational and body state subsys-tems, and the much more indirect route by whichinformation about arousal reaches the propositionalsubsystem. This is intuitively understandable be-cause of the relationship between emotion andarousal. Recent neuroscientific advances clarify thisdirect connection between sensory appraisal ofsalient information and immediate autonomicarousal. See for instance LeDoux (1993), cited inGreenberg and Pascual-Leone (1997).

Arising out of this connection to body stateinformation, the implicational subsystem has amonopoly on emotional meaning, and a feedbackloop can be set up between its appraisal of threat,and arousal, whereas the propositional subsystemcan remain relatively detached from this influence.The social phobics recall of past social disasters willevoke an immediate physical arousal response thatdoes nothing to help the situation. On the contrary,the experience of arousal with its associations withfear simply confirms the individuals hunch thatthere is something to be frightened of. Thus avicious circle is set up, relatively uninfluenced by acool, propositional appraisal of the situation.

The final feature of the model relevant to thisdiscussion is the central place accorded to theinterchange between the propositional and implica-tional subsystems, which Teasdale calls the centralengine of cognition, there being no central execu-tive beyond this interchange (Teasdale and Barnard,1993, p. 78). The limitations of processing capacityalready noted makes possible the establishment ofhabitual patterns of response in these exchanges,which he identifies with schematic models. Asthese are resistant to revision and the incorporationof new information, they can maintain maladaptiveresponses, such as could be amenable to modifica-tion through cognitive behaviour therapy. For this

Copyright # 1999 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 6, 375383 (1999)

376 I. Clarke

modification to take place, the individual needs tobe able to stand aside from the habitual responseand process new information at the propositionallevel. I am going to suggest that states of arousal,which influence the implicational level, have acrucial role in maintaining these schematic patterns,and that attention to issues of arousal facilitatesbringing the propositional subsystem to bear on thesituation to create a new response.

A similar distinction between logical andemotional information processing contained in thepropositional and implicational subsystems iscurrently appearing in a number of guises, forinstance (Brewin, 1989), as verbally and situation-ally accessible memory; and Segal (1988) who refersto automatic and conscious processing. Ellissdistinction between inference and evaluation canbe seen in the same light; according to his theory itis evaluations, or hot cognitions, rather than infer-ences that are associated with emotional problems(Ellis, 1962). Teasdale employs Elliss terminologyof hot cognition to denote implicational levelprocessing, and cold cognition for propositionallevel processing.

INTERACTING COGNITIVE SUBSYSTEMSAND THE CONSTRUCTION OFTHE SELF

The Implicational Subsystem andPersonal Meaning

Cognitive therapy has always been centrally con-cerned with meaning and the self. Both Beck andEllis trace dysfunctional thinking patterns in themoment back to beliefs about the self. The idea thatthe threat lies not in the objective situation, but in themeaning attributed to the situation is also funda-mental, so that the focus of therapy lies in thetransformation of this meaning, to borrow a phrasefrom the title of Power and Brewins (1997) book,already referred to. Teasdales paper in this bookemphasizes the point that the implicational sub-system is concerned with matters that relate directlyto the self and therefore to personal meaning. This isa point I wish to develop further, in order to suggestthat rather than simply uncovering and challengingbeliefs about the self, therapy can become involvedin the ongoing process of the construction of the self.I argue that this is a process which continuesthroughout life, though based on the formativestage of the construction of the self which takes placewithin the context of the primary relationship(s) in

early life; that it only makes sense in terms ofrelationship, whether intimate, or on a wider socialstage, and that it is perhaps the central preoccupa-tion of the human being. The predominant focus ofthe internal dialogue on matters relating to thesafety, and status of the self, and the linked issue ofsignificant relationships, demonstrates this.

The final thread of my argument concerns therole of arousal in this process of self constructionand in psychopathology. Autonomic arousal is abiological mechanism to protect the organism fromphysical harm by preparing it for action, whether inthe form of fight or flight in response to threat. Forhuman beings, as for the higher animals, informa-tion on place in the social order and thereforerelationship is perceived as threat, or proof of value.(I am here employing Gilberts (1992) evolutionaryapproach to human social order and arousal.) Thisinformation is registered at the implicational leveland by the linked arousal system.

I am here adopting a model developed by theconstructivist cognitive therapists, referred to above,and will specifically be citing the argument ofGreenberg and Pascual-Leone (1997). According tothis, the self is a construction forged out ofcumulative information on threat and value inrelation to the individual. Relating this to the ICSperspective, this information would be laid downalong with rich sensory data in the implicationalmemory store, but reflected upon and integrated atthe propositional level. Teasdale, in the samevolume (p. 146), makes the distinction between thepropositional understanding of self as object, andthe implicational level experiencing of self assubject. It is central to understanding the type ofemotional difficulties tackled through cognitivetherapy that these two, and the related informationabout them in the two separate memory stores, canbe quite distinct in certain circumstances. Hence,depressogenic schemata containing informationabout the unacceptability of the self can lurk inthe implicational memory store, untapped innormal life, until triggered by some circumstancein the present that awakes echoes of that particularmemory content (see, for example, Segal, 1988).

The Implicational Memory andAutonomic Arousal

Regulation of arousal is central to an ICS formu-lation, since cognitive restructuring represents thepropositional level appraisal of implicational levelmaterial, and states of high autonomic arousal posean obstacle to this. Physiologically the state of


Serious Mental Illness 377

hypocapnia or decreased alveolar CO2 , producedby the hyperventilation characteristic of autonomicarousal reduces blood flow to the brain (Fried,1993). Subjectively this produces the experience oftunnel vision where concentration on threat-related information, drawn more from the implica-tional memory than from current sensory data,excludes all other considerations. When arousallevels rise towards panic, thinking becomes para-lysed into confusion.

The shift from behaviour therapy to cognitivetherapy over the last 20 or so years has led to areduction in emphasis on regulation of arousal ( forinstance by progressive relaxation techniques(Jacobson, 1964)). Recent trends to reinstate thisaspect are to be welcomed, such as LinehansDistress Tolerance and Emotion Regulation withinDialectical Behaviour Therapy skills training (Line-han, 1993). Attention regulation breaks into thecycle of arousal and concentration on threat at adifferent point. Recent examples are Wells et al.s(1997) investigation of techniques of attention andconcentration training, and Linehans adoption ofBuddhist mindfulness techniques to regulate atten-tion so that it sits fairly between implicational andpropositional systems. Teasdale, Williams and Segalhave adopted the same approach, as expounded byKabat-Zinn (1996), in a study in progress, intorelapse prevention in depression (reported at the1998 BABPC conference).

A Developmental Perspective

I will now develop these ideas by linking an ICSbased understanding of the construction of the self,to issues of arousal regulation to illuminate sourcesof psychopathology. Taking as my starting point thesort of social evolutionary perspective expoundedby Gilbert (1992), I suggest that an individuals senseof self is constructed out of their experience of beingin relationships from birth (and very probably beforethat in the womb) and throughout their subsequentexperience. There is abundant evidence in the inter-subjectivity literature to suggest the fundamentalrole of the infantcaregiver dyad in the creation ofmeaning, communication and therefore a sense ofself in the infant. Researchers from the attachmenttheory school (e.g. Ainsworth et al., 1978) haveexplored and established this through extensiveexperimentation. Greenberg and Pascual-Leonesummarize this process in Power and Brewin(1997) thus:

Infants emotional systems are involved inrapid evaluation of what is good and bad for

them. Thus infants, right from birth, experiencefeelings and, as soon as they can constructschemes of sufficient complexity, they use thesefeelings to construct a conscious personal senseof self. A major determinant of this self con-struction is their intersubjective experience, withtheir caretakers, associated with their ownautomatic emotional reactions. An individualssense of self is permanently organised aroundemotional schemes formed in primary attach-ment relationships. Affect regulation developswith maturation, but also with the way care-takers react to the childs emotions; theseexperiences determine the affectively basedsense of self.

From this earliest stage, information about threatand (the individuals) value, and therefore the selfand its survival, is stored in the implicationalmemory. For the infant there is no distinctionbetween information about interpersonal accept-ability and information about physical survivalbecause of his/her absolute dependency, they areone and the same. This type of threateninginformation about the self is accessed in thepropositional form of an unconditional core belief,of the I am worthless variety during cognitivetherapy. As the child develops, threats aredifferentiated into those involving physical integ-rity, and those involving the social hierarchy. Bothare stored in the implicational memory, andwill trigger autonomic arousal when reactivated,but the former produce the most powerful reaction.

Propositional thinking develops with symbolicaptitude and language, and with this, the sense ofself as subject, based on appraisal of the primary,implicational level data about the self in relation toothers. The stage based developmental theoriessuch as Piaget and Kohlbergs can be seen as anexposition of this developing ability to adopt awider, less egocentric perspective as the childgrows. With the transition from baby to toddler,the picture becomes more complex, as the youngchild recognizes that different aspects of the self aremore or less acceptable to other people. The distinc-tion that here develops between the public self,designed to fulfil the expectations of importantothers, and the privately acknowledged self iscrucial for the practice of cognitive therapy. It isthe basis of the if core beliefs; e.g. I will only beloved if I please others, which reveal a message ofconditional acceptance from the original caregiver,and fear of the revelation of the private selfunderlies shame.


378 I. Clarke

The ICS model is particularly helpful for under-standing disruptions and discontinuities in thedevelopment of the sense of self that will lead tovulnerability to breakdown in case of later adverselife events, and, in cases of serious mental illnessand personality disorder, to a fragmented andpoorly functioning self. The two distinct levels ofprocessing and memory stores represented by theimplicational and propositional levels allowmemories of childhood events that are deeplythreatening to the acceptability of the self to beoverlaid by later experience, until triggered by alater life event. For instance, entering an intimaterelationship, or having a baby can bring a pre-viously well-functioning individual face to facewith early, threatening experiences of relationshipalong with associated arousal state, and thus triggera breakdown. The current, well-functioning, under-standing of the self is overwhelmed, and makesway for the re-experience of an earlier, morethreatened, persona.

A Clinical Example

In order to explore this process in the case ofpersonality disorder, I am going to introduce a(composite) clinical example which will be used asan illustration through the remainder of this paper.A 30-year-old woman, whom I will call Alice, hascaused concern to the services for some timebecause of self destructive behaviours. She some-times presents with cutting and suicide attempts,and at other times with intermittent drug andalcohol abuse; she also experiences dissociatedstates. Her children are a cause for concern, bothbecause of questions around the stability of thehome life Alice is able to provide, and because of apropensity to form abusive partnerships. On thepositive side, Alice impresses people with herdetermination and intelligence, and can also displayan engaging, efficient, well-functioning aspect.However, just as things appear to be progressingwell, helping and healthy relationships are rejected,and self destructive and risky behaviours resurface.It is remarked that it is like dealing with two, ormore, different people.

Developmentally this can be understood inAlices case in the following way, with referenceto ICS. Alices early experiences of relationshipwere: a mother who alternated between beingindulgent and intrusive (when a single parent)and cold and neglectful (when with a partner). Agrandmother who periodically looked after her andwas a good figure, but was only spasmodically

available, as mother used to take her away, andmothers two main partners who were bothphysically abusive, and one also sexually abusedher. Thus the information about threat and value,relevant to her developing a sense of herself, storedin her implicational memory was contradictory, andmuch of it, highly threatening, and therefore, whentriggered, productive of an aversive state of arousal.A wide range of situations, often entailing quiteidiosyncratic memories, could re-evoke this state,and Alices various compensatory behavioursperformed the function of shifting her away fromthis implicational level material. Drink and drugsblocked it out; self harm was consonant with thedegraded sense of self she was experiencing, andbrought her back to the present, and dissociationdistanced her. Unfortunately, all these reactionsdisrupted the smooth process whereby communica-tion between propositional and implicational level,Teasdales central engine of cognition, couldprocess reliable information about herself in thepresent, and facilitate the construction of the self.Because of the constant disruption, the hurts of thepast were perpetuated, not processed, and a unitarysense of self could not be achieved.

Implications for Therapy

I will conclude this paper by using Alices case toillustrate the implications of this model for therapy.The therapeutic task, according to this approach, isto integrate Alices fragmented sense of herself andto enable her to tolerate contact with the implica-tional level information about herself from the past,so that she can at last process it and put it behindher, and to experience the present in a new andhealthy way, so that she is not constantly suckedback into dysfunctional patterns of relating. Themethods that follow are familiar, though sometimesdrawn from outside the strict cognitive behaviouraltradition. It is the ICS rationale that draws them intoa coherent whole that I wish to present.

Therapeutic Methods

FormulationThe power of the threatening information about

the self, locked into place by the arousal feedbackloop, provides an explanation for Alices difficulties.The first task of therapy is to refine this atassessment into a clear formulation, worked out incollaboration with Alice, and shared with herexplicitly, either in the form of a diagram, a letter,or both. The important relationships that gave her



her formative information about herself and herplace in the world are central to this, and in accord-ing this central place to relationship rather than corebeliefs, the approach is here closer to CAT than toCBT in its traditional form. The beliefs could beseen as essentially derived from the experience ofrelating. Thus the formulation would draw outthose experiences, and how they are perpetuated inthe present, both in how Alice relates to herself, andhow she relates to others. Information gathered inthe assessment phase through the use of diaries willadd specific information about the trigger situationsthat re-evoke the threatening memories and accom-panying arousal states. Understanding that there isdiscernible logic behind behaviour she feels drivento irrationally, and further, that this is maintainedby the past rather than the present, gives Alicethe hope and feeling of being understood that canbe the basis for the therapeutic alliance. Threeimmediate goals were identified at the assessmentphase; to maintain the therapeutic alliance, whichcould fall victim to patterns of abandonmentand rejection; to reduce self destructive behavioursand to maintain a new partnership with a man whowas well meaning, good for the children, butunexciting compared to previous, more abusivepartners.

The Body DimensionIt was the aversive states of arousal that kept

Alices dysfunctional patterns locked in place, andso tackling the body dimension was a powerfulprecursor to any change. Alices relationship withher body was itself quite alienated. As well as selfharming, and abusing it with substances, shetended to binge and starve, and was deeply dis-satisfied with her appearance, reflecting earlyconfusing and negative messages she receivedabout herself.

The immediate task was to develop skills inarousal regulation, and hence impulse control. Asmentioned above, DBT is particularly strong on thisaspect, having developed skills teaching pro-grammes to promote mindfulness and emotionregulation. In Alices case, she was taught abreathing designed to bring down arousal rapidlyby focusing on the outbreath. This skill wasreinforced by attendance at a stress managementcourse, at which she refined relaxation skills. Thebreathing was efficient at decreasing arousal withinthe session, and so could be used to help containthreatening material, and to enable her to think, atthe propositional level, about areas such as child-hood abuse, that had previously been experienced

and re-experienced mainly at the implicationallevel. To use these techniques between sessions,she had to learn to read her body, so that shecould start to bring down arousal before it reachedan aversive threshold.

She also worked on promoting a better relation-ship with her body in general; allowing herselfgood food and exercise, and challenging negativebeliefs about it.

Multi Modal ApproachesBoth Brewin, and Teasdale, in their chapters in

Power and Brewin (1997) indicate a new wayforward for CBT suggested by the ICS perspective,where guided discovery is substituted for thoughtchallenging. They argue that simply demolishingthe old way of thinking is insufficient; it isnecessary to foster a new quality of implicationallevel experience of the self. This is in line withcurrent trends within CBTfor instance, Padesky(1993). Where the implicational subsystem is beingactivated and revised, a purely verbal approach islikely to be inadequate, because of the multi modalnature of this system and its memory coding. This iswhere the current emphasis on using imagery intherapy (see Hackmann (1997) for instance), both toexplore trauma, and to reconstruct healthy schema-ta fits in. The same argument supports workingmore directly with emotions. This is a developmentof CBT advocated by constructivists such as Green-berg and Pascal-Leone, in Power and Brewin (1997),but also to be found within Elliss ABC assessmentprocess. As expounded by Trower et al. (1988), thisprocess explores the emotion and attached threats tothe self (expressed in imagery, automatic thoughtsand core beliefs), physiology and behaviouralimpulse. By exploring, and taking seriously theexperienced emotion, it is possible to reconstructthe quality of the identity-threatening informationthat is behind the current pathology. From there it ispossible to embark on the work of naming andintegrating scattered elements of the identity.

In Alices case, imagery work was important inidentifying and defusing the particular keys to therecall of aversive implicational level material thattriggered self harm and relationship breaking. Forinstance, some interpersonal situations seemed tomatch and so could trigger a flashback of the adultabuser looming over her as a child; she wouldpanic, feel trapped and either dissociate, self harmor attack the other. In discussing corrective imagery,she came up with swimming as a situation whereshe felt particularly free, as opposed to theclaustrophobia of the flashback. Accordingly, she


380 I. Clarke

rehearsed the image of swimming from the past tothe present, with purposeful but relaxed strokes.

Working with the feelings enabled her to mournher shattered childhood, access her anger withabusers and mother, and to experience it as the partof herself that knew all along that she was special,however much she was treated with contempt.Accessing this deep implicational level experienceof being someone worthy of protection and righttreatment was the foundation for building a healthysense of self.

Working on Experience in the MomentTaken together, these new approaches shift CBT

away from verbal dialogue (though in essence thisremains the bedrock of therapy) towards a moreholistic experience in the presentin keeping withthe holistic character of the implicational subsystem.The challenge of Alices therapy, for both herselfand the therapist, was to stay in the present; toremain in touch with threatening memories withoutdissociation, rejection of therapy, or other escape, sothat these could be fully appraised at the proposi-tional level. The implicational level sees things inabsolutesthe black and white thinking of theCBT thinking errors, whereas the propositionallevel can handle complexity. Her therapist likenedstaying with this complexity, both in the sessions,and in the week in between, like trying to balanceon the middle of a see-saw. This struggle forbalance was most evident in the relationshipbetween Alice and the therapist, as she reacted tocloseness that her past experience interpreted asdangerous, with every possible impulse to escapeor attack. Talking about thisbringing it into thepropositional level, was a central part of thetherapy.

This way of working, familiar in psychodynamicterms as transference, is not new within CBT; seefor instance Safran and Segal (1990) and Young(1994). However, it fits particularly naturally withinthis ICS conceptualization with its emphasis onworking in the immediacy of the moment and onthe smooth communication between implicationaland propositional subsystems. Thus, the slippingaway from present reality into a familiar pattern canbe challenged, and relationship can be experiencedin a new way. The new initiatives to employmindfulness techniques as an adjunct to cognitivetherapy, cited above, also work on restoring thesmooth communication between the two centralsubsystems, while maintaining detachment fromboth, so sharpening experience in the moment.Cognitive Analytic Therapy has particularly clear

methods for using this experience in therapy withreference to explicit written and diagrammaticformulation material (Ryle 1995).

A New Experience of the SelfAll these approaches are designed to lead the

client towards a new experience of self in whichemotion can be both felt and reflected upon. Aswell as recognizing the distortions of the past, thisrequires the nurturing of strengths that are there allalong, but become submerged by the mobilizationto deal with supposed threat. The 1990s have seengrowing importance within cognitive theory ofusing therapy to help people construct new healthyselves, as well as weaken existing restrictive andcondemnatory self constructions (e.g. Greenbergerand Padesky, 1995). In Alices case, this newexperience was grasped in the reframing of heranger as a wholesome part of herself, and in thebalancing relationships with the therapist and thenew partner. Staying balanced, without retreatinginto familiar escape routes, was a constant struggle.A simple diagram, summarizing the possible waysof viewing familiar situations, with the idealized onone side, the catastrophizing option on the other,and the compromise, representing propositionallevel appraisal in the middle, helped her to locatethe everyday choices. Gradually she was able toreport experiencing living in the middle place, andto comment on its unfamiliar, frightening feeling ofuncertainty, as well as the exhilaration of takingcontrol. This new experience of herself, reflected onand guided at the propositional level, but laid downvividly in the implicational memory as well, wasthe basis for a new stage in Alices understanding ofherself, and therefore in the construction of a morehealthy and unified sense of self. The old patternswere not rapidly or easily erased, but at least theway ahead became clearer.

DISCUSSION AND CONCLUSION

This has been an attempt to integrate a number ofnew concepts and approaches within CBT into asimple and coherent whole. I see it as a contributionto a debate about the development of the therapyinto new areas of complexity, and towards adoptingtherapeutic styles previously associated with othermodalities. This sort of development can lead tocharges of dilution and distortion of the model. Iwould argue that this approach retains and indeedstrengthens the following essential features of CBT;



it is research based; it entails unpacking therelationship between cognition, emotion, behaviourand bodily arousal in a way that clarifies the routeto change, and it works collaboratively and respect-fully with the client, sharing the full understandingof the problem with them, so that they can continueto work with the model after the therapy is over.

In this way, major developments in CBT andrelated therapiessuch as CAT for borderlinepersonality disorder (Ryle, 1997) and dialecticalbehaviour therapy (Linehan, 1993), to name buttwo, are brought together, by postulating under-lying mechanisms, built around the human impera-tive to develop an acceptable sense of self, withinthe context of an ICS information processing modelof the person, which accords a central place toarousal states and memory for threat.

The example given uses this approach to treatborderline personality disorder, but it can beemployed to understand the spectrum of mentalhealth difficulties in a way that cuts acrossdiagnostic labels. All mental health problems areseen as responses to threats to assembling anacceptable sense of self, and to the aversive arousalthat accompanies such threats. Anxiety baseddisorders do not effectively defend against this,except perhaps, through worry according to recentwork on this subject (e.g. Bouman and Meijer,1999). Similarly, depression is a physiological andpsychological expression of defeat and acceptanceof low status or, in more serious cases, annihilation.Substance abuse and other additive behavioursmodify the arousal directly, and temporarily blockawareness of the threats to the self. I would suggestthat obsessive compulsive disorder and eatingdisorders meet the challenge of constructing theacceptable self more ingeniously, by changing therules. In OCD, the threat is focused onto particularactions or thoughts, thereby rendering it moremanageable in the short term, but, since the under-lying anxiety is not addressed, creating moreproblems in the medium to long term. In eatingdisorders, interpreting acceptability in terms ofbody weights leads into the addictive loopsunderlying anorexia and bulimia that make thesebehaviour patterns so hard to eliminate.

This discussion of the possible underlying unitybehind mental health problems, based on threats tothe construction of the self, seen in ICS basedinformation processing terms is, of course, highlyspeculative. I hope it is suggestive of the benefits interms of clear formulation, simple enough to sharewith any client, that this model offers. I wouldfurther suggest that scientific exploration of the

connection between arousal, memory and sense ofself could help to establish this analysis on a firmerbasis.

ACKNOWLEDGEMENTS

My thanks are due to Dr Paul Chadwick forsuggestions and references, and to the two anony-mous reviewers whose comments have helped toshape the final version of this paper.

REFERENCES

Ainsworth, M. D., Blehar, M., Waters, E. and Wall, S.(1978). Patterns of Attachment. Hillsdale, NJ: Erlbaum.

Anderson, W. T. (1990). Reality Isnt What it Used To Be.New York: Harper & Row.

Barnard, P. (1985). Interacting Cognitive Subsystems:A Psycholinguistic Approach to Short Term Memory.In: A. Ellis (Ed.), Progress in the Psychology of Language(Vol. 2) Hove, UK: Lawrence Erlbaum Associates Ltd.

Beck, A. T., Emery, G. and Greenberg, R. L. (1985).Anxiety Disorders and Phobias: A Cognitive Perspective.New York: Basic Books.

Bouman, T. K. and Meijer, K. J. (1999). A preliminarystudy of worry and metacognitions in hypochondriasis.Clinical Psychology and Psychotherapy, 6, 96102.

Brewin, C. R. (1989). Cognitive change processes inpsychotherapy. Psychological Review, 96, 379394.

Ellis, A. (1962). Reason and Emotion in Psychotherapy. NewYork: Lyle Stuart.

Fried, R. (1993). The role of respiration in stress andstress control: toward a theory of stress as a hypoxicphenomenon. In: P. M. Lehrer and R. L. Woolfolk (Eds),Principles and Practice of Stress Management. New York:Guilford Press.

Gilbert, P. (1992). Depression. The Evolution of Powerlessness.Hove: Lawrence Erlbaum Associates.

Greenberg, L. S. and Pascual-Leone, J. (1997). Emotion inthe creation of personal meaning. In: M. Power andC. R. Brewin (Eds), The Transformation of Meaning.Chichester: Wiley.

Greenberger, D. and Padesky, C. A. (1995). Mind overMood. A Therapists Manual. London: Guilford Press.

Guidano, V. and Liotti, G. (1983). Cognitive Processes andEmotional Disorders. New York: Guilford Press.

Hackmann, A. (1997). The transformation of meaning incognitive therapy. In: M. Power and C. R. Brewin (Eds),The Transformation of Meaning. Chichester: Wiley.

Jacobson, E. (1964). Self-operations Control: A Manual ofTension Control. Chicago: National Foundation forProgressive Relaxation.

Kabat-Zinn, J. (1990). Full Catastrophe Living: Using theWisdom of Your Body and Mind to Face Stress, Pain andIllness. New York: Dell.

Kabat-Zinn, J. (1996). Mindfulness Meditation for EverydayLife. Piatkus.


382 I. Clarke

LeDoux, J. E. (1993). Emotional networks in the brain. In:M. Lewis and J. M. Haviland (Eds), Handbook ofEmotions. New York and London: Guilford Press.

Linehan, M. M. (1993). Skills Training Manual for TreatingBorderline Personality Disorder. New York: GuilfordPress.

Neimeyer, R. A. (1993). An appraisal of constructivistpsychotherapies. Journal of Consulting and ClinicalPsychology, 61, 221234.

Padesky, C. (1993). Socratic questioning: changing mindsor guided discovery? European Congresss of Beha-vioural and Cognitive Therapies, London.

Power, M. and Brewin, C. R. (Eds) (1997). The Trans-formation of Meaning. Chichester: Wiley.

Ryle, A. (1995). Cognitive Analytic Therapy. Chichester:Wiley.

Ryle, A. (1997). Cognitive Analytic Therapy and BorderlinePersonality Disorder. Chichester: Wiley.

Safran, J. D. and Segal, Z. V. (1990). Interpersonal Processesin Cognitive Therapy. New York: Basic Books.

Segal, Z. V. (1988). Appraisal of self-schema construct incognitive models of depression. Psychological Bulletin,103, 147162.

Teasdale, J. D. and Barnard, P. J. (1993). Affect, Cognitionand Change: Remodelling Depressive Thought. Hove:Lawrence Erlbaum Associates.

Trower, P., Casey, A. and Dryden, W. (1988). CognitiveBehavioural Counselling in Action. London, UK: Sage.

Wells, A., White, J. and Carter, K. (1997). Attentiontraining: effects on anxiety and beliefs in panic andsocial phobia. Clinical Psychology and Psychotherapy, 4,226233.

Young, J. E. (1994). Cognitive Therapy for PersonalityDisorders: A Schema Focussed Approach (revised edn).Sarasota, FL: Professional Resource Press.



cognitive therapy and serious mental illness. an interacting cognitive subsystems approach

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