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Isabel Clarke — Clinical Home Page

The publications and therapeutic approaches that follow employ ICS as a way of approaching CBT across diagnoses – because:  ICS provides a cognitive science based rationale for:

  • The disjunction between thought and emotion
  • The centrality of arousal in understanding mental health difficulties
  • Attachment and relationship as central to the self, and central to the therapeutic process
  • The role of mindfulness in providing a way into the process between thought and emotion and behaviour
  • Deconstructing diagnosis (see recent book chapter on coping mechanisms)

Cognitive Therapy and Serious Mental Illness

Cognitive Therapy and Serious Mental Illness. An interacting Cognitive Subsystems Approach. Clinical Psychology and Psychotherapy, 6, 375 - 383. 1999

SeeFull Text


Powerpoint Introduction to this initiative which incorporates:
The Emotion Focused Formulation Approach. (EFFA)

CCC/EFFA is a therapy approach that starts with collaborative, individual formulation – which can then inform the thinking of the wider system.
  • Key: Where an individual’s experience of themselves feels unbearable, they will seek to cope with this – for instance by withdrawing, self harming,  drinking alcohol etc.
  • These strategies are understandable and work short term. Most of them are used by everyone at some time.
  • Past trauma and the way that the body picks up threat signals and gets ready for action combine to set up vicious circles that lock people into a trap.
  • Where vicious circles are identified – the individual can choose to break them – and support and skills can be offered to help with this.EFFA offers a compassionate understanding of peoples’ predicament, along with ways forward that lend themselves to support from the system – either other staff or natural supporters such as family and friends.
  • Skills can be taught individually or in groups.
This is a flexible and intuitively understandable approach that is being piloted in different settings (see below). CCC is not another therapy brand, but a broad integration of the Third Wave idea to provide a pared down therapeutic approach applicable across diagnosis. It starts from the premise that all human beings, in all cultures, struggle at times with relationships, (including the internal relationship with themselves), emotions and fitting in with the world around them. This is traceable to the way in which our brains operate. One part of our thinking apparatus gives us our sense of individual self consciousness, and the ability to make precise judgements. All science and technology is based on this ability, which tends to be over-valued in Western cultures. These cultures underplay the other brain circuit, which is designed for relating. This gives us our emotions which enable us to relate to others and, internally, to ourselves. The crucial balance between these two brain circuits is held by state of arousal; the default, relational, circuit is more accessible at high and low arousal. High arousal can be experienced as emotion, or as physical disturbance, and it is this alteration in state of arousal which regulates relationship (see Clarke 2008 and 2009 for a fuller exposition). 

A Relational Approach

From this perspective, our very being is founded in relationship and we only make sense in the context of a web of relationships. Family and those close to us are clearly key to this, but it extends to the widest and deepest experience of relationship, the spiritual or religious. In emphasising the primacy of the emotional/relational aspect of the human being,  CCC is in tune with non Western cultures. Experience and felt sense are at the heart of the approach and ‘symptoms’ are viewed as understandable, but ultimately self defeating, ways of coping with an intolerable internal state, which will have come about because of disruption in the web of roles and relationships that hold an individual together, and/or disruption in the crucial self/self relationship.
Theoretical Background and more detail.

 CCC represents an integration of third wave CBT approaches, on the theoretical foundation of the cognitive science based Interacting Cognitive Subsystems (ICS) model of cognitive architecture (Teasdale and Barnard 1993). This can be seen to underlie Dialectical Behaviour Therapy’s States of Mind diagram (Linehan 1993 ) of a separable Reasonable and Emotional Mind. Working at the level of felt sense is strongly indicated by ICS.
 Felt sense informs  the individual formulation at the heart of the programme, but a central objective is  spreading  a psychological understanding of mental health difficulties  throughout the service through engaging the staff at all levels  with the task of supporting the use of new skills to manage unbearable felt sense. The contribution of past trauma and context are emphasized, but intervention is targeted at the behavioural cycles set up by the individual’s understandable but ultimately self defeating attempts to cope.
Programmes designed to teach alternative coping skills are provided and the delivery of these is distributed as widely as possible through the staff group. The Trans-diagnostic programmes include Dialectical Behaviour Therapy (DBT) based Emotional Coping Skills, Mindfulness, Stress and Anxiety management, Compassionate Mind and managing unusual experiences and beliefs.  Thus the wider staff group can aid generalization of new skills through coaching,  in preference to simply offering medication.

 Applications of CCC.

Acute services,
inpatient and community acute (see CBT for the Acute Care Pathway)
Making Sense of Crisis. A one or two day training package to introduce this approach to a service.
For a full account of the formulation used both with individuals and with teams see:The Emotion Focused Formulation Approach: bridging individual and team formulation.
(Clarke, I. (2015). The Emotion Focused Formulation Approach: bridging individual and team formulation. Clinical Psychology Forum 275. 28-33).

Primary Care. Increasing Access to Psychological Therapies (IAPT).
italk, the Hampshire IAPT service,  conducted an audit of a patient cohort who made limited recovery  with the existing interventions.   The Strategic Health Authority   funded  a project to develop a service for this group. The audit identified the target group as having problems exacerbated by complex trauma (normally characterised by relationship difficulties and chronicity). CCC/ EFFA was used as the approach incorporates consideration of past trauma and relational aspects of therapy into its collaborative formulation and facilitates motivation towards clear treatment protocols for IAPT therapists.

Culturally Adapted Therapy. A project to use  CCC in a Culturally Blind form of therapy with a Mindfulness focus is in its early stages, linking three centres in Pakistan, Canada and Southampton.

Bridging the gap between Cognitive theory and therapy

ICS Symposium 2008: Bridging the gap between Cognitive theory and therapy: using ICS to inform CBT, including talk by I Clarke:
Visceral Impact Formulation; engaging heart as well as head using ICS.
See: powerpoint

The Construction of the Self