Clinical Psychology and Psychotherapy

Clin. Psychol. Psychother. 6, 375383 (1999)

Cognitive Therapy and Serious

Mental Illness. An Interacting
Cognitive Subsystems Approach
Isabel Clarke*

Psychology Department, Royal South Hants Hospital,

Southampton SO14 0YG, UK
The increasing application of Cognitive Therapy to the more enduring
forms of psychopathology represented by the DSM-IV `Axis II
Disorders' 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 present
paper proposed the development of the Cognitive rationale, using as a
foundation the research-based insights provided by Teasdale's `Interacting Cognitive Subsystem' model (Teasdale and Barnard, 1993). By
emphasizing the close relationship between the emotional (implicational) subsystem and states of bodily arousal, this restores aversive
arousal states to a central place in the understanding of psychopathology, and clinical practice. The role of threatening information about the
self received through early relationships in leading to chronic aversive
arousal states, whether high arousal as in anxiety, or low, as in
depression, in Axis II disorders, is considered. The implications of the
tension between this aversive information and the basic human
endeavour of constructing the self are discussed, and a clinical example
is used to illustrate the therapeutic approaches suggested by this
perspective. Copyright # 1999 John Wiley & Sons, Ltd.

INTRODUCTION
Cognitive therapy has recently been advancing
rapidly on a number of fronts; both in terms of
the fundamental research understanding of cognition, memory and arousal, and clinically into areas
of ever greater and more complex pathology. As
well as responding to the available challenge,
practitioners are answering the call from on-high
to concentrate efforts on those with serious mental
illness. I am here using this term to denote disorder
affecting the organization of the personality, as in
DSM-IV `Axis II disorders', but not including
psychosis. Methodology is developed and
borrowed in response to this more demanding
*Correspondence to: Mrs Isabel Clarke, Psychology Department, Royal South Hants Hospital, Southampton SO14 0YG,
UK.

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

client group. In the resulting diversity, the coherent

and clearly communicable rationale that is central
to the enterprise of engaging therapy clients
collaboratively with the cognitive model can get
left behind. I am here proposing to draw together
some of these strands, both theoretical and therapeutic, in a simple rationale based on Teasdale's
Interacting Cognitive Subsystem model (Teasdale
and Barnard, 1993) to address these concerns.
This paper can be regarded as a contribution to a
debate as opposed to a wholly original formulation.
As well as drawing on Teasdale, I refer to a number
of the contributors to Power and Brewin's (1997)
recent edited volume, The Transformation of Meaning,
and relate my approach to Dialectical Behaviour
Therapy (Linehan, 1993) and Cognitive Analytic
Therapy programmes for the treatment of Borderline Personality Disorder (Ryle, 1997). The

376
constructivist cognitive tradition is an organizing
influence: as Anderson writes `Constructivist
therapy is not so much a technique as a philosophical context' (Anderson (1990), quoted in
Neimeyer (1993)). This context informs my view
of the construction of the self. In particular, I cite
Greenberg and Pascual-Leone's chapter from the
Power and Brewin book. Constructivists such as
Guidano and Liotti (1983) have been at the forefront
of recognizing the influence of early attachment
relationships on fundamental assumptions about
the self and the world. Recognition of the profound
impact of early relationships has also been an
essential feature of Beck's theorizing for many years
(Beck and Emery, 1985). This is one example of the
trend towards the widening of the boundaries of
cognitive therapy referred to at the beginning, as
ideas once characteristic of other therapeutic modalities are incorporated.

Employing the Interacting Cognitive

Subsystem Model
I am not here attempting a full exposition of the
Interacting Cognitive Subsystems model, which can
be found in Teasdale and Barnard (1993), and
Teasdale's chapter in Power and Brewin (1997),
among other places. I am proposing to concentrate
on the following features of the model. Firstly, as an
information processing model, it is based on
experimental evidence for different forms of coding
information; for instance, immediate and sensory
based, verbal and logically based, or a more holistic,
meaning based coding. These and other distinct
codes form the basis for nine postulated subsystems; three are sensory and proprioceptive, two
involve higher order pattern recognition, two, the
production of response, and two are yet higher
order, meaning based systems on which I will now
focus, the propositional and the implicational.
Memory is integral to each subsystem, and likewise
distinguished by separate codes. Thus, the logical,
propositional, memory is verbally coded, whereas
the implicational memory, that records meaning
at a more generic level, is encoded in a rich variety
of sensory modalities, and is therefore more
immediate and vivid.
Another area illuminated by the research into
short-term memory and humancomputer interaction on which the theory is based (e.g. Barnard,
1985) is the need for a transformation process in the
interchange of information between one subsystem/coding and another, and that this is
constrained by the limitation of the processing
Copyright # 1999 John Wiley & Sons, Ltd.

I. Clarke
capacity. Thus connections are made more immediately within a particular memory store than
between the data stored in different memory stores
and coded differently. An example of this that will
be important for the argument that follows is the
rapid connection made between events of personal
significance stored in the implicational memory. For
instance, memory of earlier socially shaming events
might flash into the mind of a socially anxious
individual entering an unfamiliar social situation.
These memories will be more immediately accessible than logical information about, for instance,
interesting possible topics of conversation, stored in
the propositional memory.
The other feature of the system that is central to
the current argument is the immediate connection
between the implicational and body state subsystems, and the much more indirect route by which
information about arousal reaches the propositional
subsystem. This is intuitively understandable because of the relationship between emotion and
arousal. Recent neuroscientific advances clarify this
direct connection between sensory appraisal of
salient information and immediate autonomic
arousal. See for instance LeDoux (1993), cited in
Greenberg and Pascual-Leone (1997).
Arising out of this connection to body state
information, the implicational subsystem has a
monopoly on emotional meaning, and a feedback
loop can be set up between its appraisal of threat,
and arousal, whereas the propositional subsystem
can remain relatively detached from this influence.
The social phobic's recall of past social disasters will
evoke an immediate physical arousal response that
does nothing to help the situation. On the contrary,
the experience of arousal with its associations with
fear simply confirms the individual's hunch that
there is something to be frightened of. Thus a
vicious circle is set up, relatively uninfluenced by a
cool, `propositional' appraisal of the situation.
The final feature of the model relevant to this
discussion is the central place accorded to the
interchange between the propositional and implicational subsystems, which Teasdale calls `the central
engine of cognition', there being no central executive beyond this interchange (Teasdale and Barnard,
1993, p. 78). The limitations of processing capacity
already noted makes possible the establishment of
habitual patterns of response in these exchanges,
which he identifies with `schematic models'. As
these are resistant to revision and the incorporation
of new information, they can maintain maladaptive
responses, such as could be amenable to modification through cognitive behaviour therapy. For this
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Serious Mental Illness

modification to take place, the individual needs to
be able to stand aside from the habitual response
and process new information at the propositional
level. I am going to suggest that states of arousal,
which influence the implicational level, have a
crucial role in maintaining these schematic patterns,
and that attention to issues of arousal facilitates
bringing the propositional subsystem to bear on the
situation to create a new response.
A similar distinction between logical and
emotional information processing contained in the
propositional and implicational subsystems is
currently appearing in a number of guises, for
instance (Brewin, 1989), as verbally and situationally accessible memory; and Segal (1988) who refers
to automatic and conscious processing. Ellis's
distinction between inference and evaluation can
be seen in the same light; according to his theory it
is evaluations, or hot cognitions, rather than inferences that are associated with emotional problems
(Ellis, 1962). Teasdale employs Ellis's terminology
of `hot cognition' to denote implicational level
processing, and `cold cognition' for propositional
level processing.

INTERACTING COGNITIVE SUBSYSTEMS

AND THE CONSTRUCTION OF
THE SELF
The Implicational Subsystem and
Personal Meaning
Cognitive therapy has always been centrally concerned with meaning and the self. Both Beck and
Ellis trace dysfunctional thinking patterns in the
moment back to beliefs about the self. The idea that
the threat lies not in the objective situation, but in the
meaning attributed to the situation is also fundamental, so that the focus of therapy lies in the
`transformation' of this meaning, to borrow a phrase
from the title of Power and Brewin's (1997) book,
already referred to. Teasdale's paper in this book
emphasizes the point that the implicational subsystem is concerned with matters that relate directly
to the self and therefore to personal meaning. This is
a point I wish to develop further, in order to suggest
that rather than simply uncovering and challenging
beliefs about the self, therapy can become involved
in the ongoing process of the construction of the self.
I argue that this is a process which continues
throughout life, though based on the formative
stage of the construction of the self which takes place
within the context of the primary relationship(s) in
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377
early life; that it only makes sense in terms of
relationship, whether intimate, or on a wider social
stage, and that it is perhaps the central preoccupation of the human being. The predominant focus of
the internal dialogue on matters relating to the
safety, and status of the self, and the linked issue of
significant relationships, demonstrates this.
The final thread of my argument concerns the
role of arousal in this process of self construction
and in psychopathology. Autonomic arousal is a
biological mechanism to protect the organism from
physical harm by preparing it for action, whether in
the form of fight or flight in response to threat. For
human beings, as for the higher animals, information on place in the social order and therefore
relationship is perceived as threat, or proof of value.
(I am here employing Gilbert's (1992) evolutionary
approach to human social order and arousal.) This
information is registered at the implicational level
and by the linked arousal system.
I am here adopting a model developed by the
constructivist cognitive therapists, referred to above,
and will specifically be citing the argument of
Greenberg and Pascual-Leone (1997). According to
this, the self is a construction forged out of
cumulative information on threat and value in
relation to the individual. Relating this to the ICS
perspective, this information would be laid down
along with rich sensory data in the implicational
memory store, but reflected upon and integrated at
the propositional level. Teasdale, in the same
volume ( p. 146), makes the distinction between the
propositional understanding of `self as object', and
the implicational level experiencing of `self as
subject'. It is central to understanding the type of
emotional difficulties tackled through cognitive
therapy that these two, and the related information
about them in the two separate memory stores, can
be quite distinct in certain circumstances. Hence,
depressogenic schemata containing information
about the unacceptability of the self can lurk in
the implicational memory store, untapped in
normal life, until triggered by some circumstance
in the present that awakes echoes of that particular
memory content (see, for example, Segal, 1988).

The Implicational Memory and

Autonomic Arousal
Regulation of arousal is central to an ICS formulation, since cognitive restructuring represents the
propositional level appraisal of implicational level
material, and states of high autonomic arousal pose
an obstacle to this. Physiologically the state of
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378
`hypocapnia' or decreased alveolar CO2 , produced
by the hyperventilation characteristic of autonomic
arousal reduces blood flow to the brain (Fried,
1993). Subjectively this produces the experience of
`tunnel vision' where concentration on threatrelated information, drawn more from the implicational memory than from current sensory data,
excludes all other considerations. When arousal
levels rise towards panic, thinking becomes paralysed into confusion.
The shift from behaviour therapy to cognitive
therapy over the last 20 or so years has led to a
reduction in emphasis on regulation of arousal ( for
instance by progressive relaxation techniques
(Jacobson, 1964)). Recent trends to reinstate this
aspect are to be welcomed, such as Linehan's
`Distress Tolerance and Emotion Regulation' within
Dialectical Behaviour Therapy skills training (Linehan, 1993). Attention regulation breaks into the
cycle of arousal and concentration on threat at a
different point. Recent examples are Wells et al.'s
(1997) investigation of techniques of attention and
concentration training, and Linehan's adoption of
Buddhist mindfulness techniques to regulate attention so that it sits fairly between implicational and
propositional systems. Teasdale, Williams and Segal
have adopted the same approach, as expounded by
Kabat-Zinn (1996), in a study in progress, into
relapse prevention in depression (reported at the
1998 BABPC conference).

A Developmental Perspective
I will now develop these ideas by linking an ICS
based understanding of the construction of the self,
to issues of arousal regulation to illuminate sources
of psychopathology. Taking as my starting point the
sort of social evolutionary perspective expounded
by Gilbert (1992), I suggest that an individual's sense
of self is constructed out of their experience of being
in relationships from birth (and very probably before
that in the womb) and throughout their subsequent
experience. There is abundant evidence in the intersubjectivity literature to suggest the fundamental
role of the infantcaregiver dyad in the creation of
meaning, communication and therefore a sense of
self in the infant. Researchers from the attachment
theory school (e.g. Ainsworth et al., 1978) have
explored and established this through extensive
experimentation. Greenberg and Pascual-Leone
summarize this process in Power and Brewin
(1997) thus:
`Infants' emotional systems are involved in
rapid evaluation of what is good and bad for
Copyright # 1999 John Wiley & Sons, Ltd.

I. Clarke
them. Thus infants, right from birth, experience
feelings and, as soon as they can construct
schemes of sufficient complexity, they use these
feelings to construct a conscious personal sense
of self. A major determinant of this self construction is their intersubjective experience, with
their caretakers, associated with their own
automatic emotional reactions. An individual's
sense of self is permanently organised around
emotional schemes formed in primary attachment relationships. Affect regulation develops
with maturation, but also with the way caretakers react to the child's emotions; these
experiences determine the affectively based
sense of self.'
From this earliest stage, information about threat
and (the individual's) value, and therefore the self
and its survival, is stored in the implicational
memory. For the infant there is no distinction
between information about interpersonal acceptability and information about physical survival
because of his/her absolute dependency, they are
one and the same. This type of threatening
information about the self is accessed in the
propositional form of an unconditional core belief,
of the `I am worthless' variety during cognitive
therapy. As the child develops, threats are
differentiated into those involving physical integrity, and those involving the social hierarchy. Both
are stored in the implicational memory, and
will trigger autonomic arousal when reactivated,
but the former produce the most powerful reaction.
Propositional thinking develops with symbolic
aptitude and language, and with this, the sense of
`self as subject', based on appraisal of the primary,
implicational level data about the self in relation to
others. The `stage based' developmental theories
such as Piaget and Kohlberg's can be seen as an
exposition of this developing ability to adopt a
wider, less egocentric perspective as the child
grows. With the transition from baby to toddler,
the picture becomes more complex, as the young
child recognizes that different aspects of the self are
more or less acceptable to other people. The distinction that here develops between the `public self',
designed to fulfil the expectations of important
others, and the privately acknowledged self is
crucial for the practice of cognitive therapy. It is
the basis of the `if' core beliefs; e.g. `I will only be
loved if I please others', which reveal a message of
conditional acceptance from the original caregiver,
and fear of the revelation of the private self
underlies shame.
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Serious Mental Illness

The ICS model is particularly helpful for understanding disruptions and discontinuities in the
development of the sense of self that will lead to
vulnerability to breakdown in case of later adverse
life events, and, in cases of serious mental illness
and personality disorder, to a fragmented and
poorly functioning self. The two distinct levels of
processing and memory stores represented by the
implicational and propositional levels allow
memories of childhood events that are deeply
threatening to the acceptability of the self to be
overlaid by later experience, until triggered by a
later life event. For instance, entering an intimate
relationship, or having a baby can bring a previously well-functioning individual face to face
with early, threatening experiences of relationship
along with associated arousal state, and thus trigger
a breakdown. The current, well-functioning, understanding of the self is overwhelmed, and makes
way for the re-experience of an earlier, more
threatened, persona.

A Clinical Example
In order to explore this process in the case of
personality disorder, I am going to introduce a
(composite) clinical example which will be used as
an illustration through the remainder of this paper.
A 30-year-old woman, whom I will call Alice, has
caused concern to the services for some time
because of self destructive behaviours. She sometimes presents with cutting and suicide attempts,
and at other times with intermittent drug and
alcohol abuse; she also experiences dissociated
states. Her children are a cause for concern, both
because of questions around the stability of the
home life Alice is able to provide, and because of a
propensity to form abusive partnerships. On the
positive side, Alice impresses people with her
determination and intelligence, and can also display
an engaging, efficient, well-functioning aspect.
However, just as things appear to be progressing
well, helping and healthy relationships are rejected,
and self destructive and risky behaviours resurface.
It is remarked that it is like dealing with two, or
more, different people.
Developmentally this can be understood in
Alice's case in the following way, with reference
to ICS. Alice's early experiences of relationship
were: a mother who alternated between being
indulgent and intrusive (when a single parent)
and cold and neglectful (when with a partner). A
grandmother who periodically looked after her and
was a good figure, but was only spasmodically
Copyright # 1999 John Wiley & Sons, Ltd.

379
available, as mother used to take her away, and
mother's two main partners who were both
physically abusive, and one also sexually abused
her. Thus the information about threat and value,
relevant to her developing a sense of herself, stored
in her implicational memory was contradictory, and
much of it, highly threatening, and therefore, when
triggered, productive of an aversive state of arousal.
A wide range of situations, often entailing quite
idiosyncratic memories, could re-evoke this state,
and Alice's various compensatory behaviours
performed the function of shifting her away from
this implicational level material. Drink and drugs
blocked it out; self harm was consonant with the
degraded sense of self she was experiencing, and
brought her back to the present, and dissociation
distanced her. Unfortunately, all these reactions
disrupted the smooth process whereby communication between propositional and implicational level,
Teasdale's `central engine of cognition', could
process reliable information about herself in the
present, and facilitate the construction of the self.
Because of the constant disruption, the hurts of the
past were perpetuated, not processed, and a unitary
sense of self could not be achieved.

Implications for Therapy

I will conclude this paper by using Alice's case to
illustrate the implications of this model for therapy.
The therapeutic task, according to this approach, is
to integrate Alice's fragmented sense of herself and
to enable her to tolerate contact with the implicational level information about herself from the past,
so that she can at last process it and put it behind
her, and to experience the present in a new and
healthy way, so that she is not constantly sucked
back into dysfunctional patterns of relating. The
methods that follow are familiar, though sometimes
drawn from outside the strict cognitive behavioural
tradition. It is the ICS rationale that draws them into
a coherent whole that I wish to present.

Therapeutic Methods
Formulation
The power of the threatening information about
the self, locked into place by the arousal feedback
loop, provides an explanation for Alice's difficulties.
The first task of therapy is to refine this at
assessment into a clear formulation, worked out in
collaboration with Alice, and shared with her
explicitly, either in the form of a diagram, a letter,
or both. The important relationships that gave her
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380
her formative information about herself and her
place in the world are central to this, and in according this central place to relationship rather than core
beliefs, the approach is here closer to CAT than to
CBT in its traditional form. The beliefs could be
seen as essentially derived from the experience of
relating. Thus the formulation would draw out
those experiences, and how they are perpetuated in
the present, both in how Alice relates to herself, and
how she relates to others. Information gathered in
the assessment phase through the use of diaries will
add specific information about the trigger situations
that re-evoke the threatening memories and accompanying arousal states. Understanding that there is
discernible logic behind behaviour she feels driven
to irrationally, and further, that this is maintained
by the past rather than the present, gives Alice
the hope and feeling of being understood that can
be the basis for the therapeutic alliance. Three
immediate goals were identified at the assessment
phase; to maintain the therapeutic alliance, which
could fall victim to patterns of abandonment
and rejection; to reduce self destructive behaviours
and to maintain a new partnership with a man who
was well meaning, good for the children, but
unexciting compared to previous, more abusive
partners.

The Body Dimension

It was the aversive states of arousal that kept
Alice's dysfunctional patterns locked in place, and
so tackling the body dimension was a powerful
precursor to any change. Alice's relationship with
her body was itself quite alienated. As well as self
harming, and abusing it with substances, she
tended to binge and starve, and was deeply dissatisfied with her appearance, reflecting early
confusing and negative messages she received
about herself.
The immediate task was to develop skills in
arousal regulation, and hence impulse control. As
mentioned above, DBT is particularly strong on this
aspect, having developed skills teaching programmes to promote mindfulness and emotion
regulation. In Alice's case, she was taught a
breathing designed to bring down arousal rapidly
by focusing on the outbreath. This skill was
reinforced by attendance at a stress management
course, at which she refined relaxation skills. The
breathing was efficient at decreasing arousal within
the session, and so could be used to help contain
threatening material, and to enable her to think, at
the propositional level, about areas such as childhood abuse, that had previously been experienced
Copyright # 1999 John Wiley & Sons, Ltd.

I. Clarke
and re-experienced mainly at the implicational
level. To use these techniques between sessions,
she had to learn to `read' her body, so that she
could start to bring down arousal before it reached
an aversive threshold.
She also worked on promoting a better relationship with her body in general; allowing herself
good food and exercise, and challenging negative
beliefs about it.

Multi Modal Approaches

Both Brewin, and Teasdale, in their chapters in
Power and Brewin (1997) indicate a new way
forward for CBT suggested by the ICS perspective,
where guided discovery is substituted for thought
challenging. They argue that simply demolishing
the old way of thinking is insufficient; it is
necessary to foster a new quality of implicational
level experience of the self. This is in line with
current trends within CBTfor instance, Padesky
(1993). Where the implicational subsystem is being
activated and revised, a purely verbal approach is
likely to be inadequate, because of the multi modal
nature of this system and its memory coding. This is
where the current emphasis on using imagery in
therapy (see Hackmann (1997) for instance), both to
explore trauma, and to reconstruct healthy schemata fits in. The same argument supports working
more directly with emotions. This is a development
of CBT advocated by constructivists such as Greenberg and Pascal-Leone, in Power and Brewin (1997),
but also to be found within Ellis's ABC assessment
process. As expounded by Trower et al. (1988), this
process explores the emotion and attached threats to
the self (expressed in imagery, automatic thoughts
and core beliefs), physiology and behavioural
impulse. By exploring, and taking seriously the
experienced emotion, it is possible to reconstruct
the quality of the identity-threatening information
that is behind the current pathology. From there it is
possible to embark on the work of naming and
integrating scattered elements of the identity.
In Alice's case, imagery work was important in
identifying and defusing the particular keys to the
recall of aversive implicational level material that
triggered self harm and relationship breaking. For
instance, some interpersonal situations seemed to
match and so could trigger a flashback of the adult
abuser looming over her as a child; she would
panic, feel trapped and either dissociate, self harm
or attack the other. In discussing corrective imagery,
she came up with swimming as a situation where
she felt particularly free, as opposed to the
claustrophobia of the flashback. Accordingly, she
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Serious Mental Illness

rehearsed the image of swimming from the past to
the present, with purposeful but relaxed strokes.
Working with the feelings enabled her to mourn
her shattered childhood, access her anger with
abusers and mother, and to experience it as the part
of herself that knew all along that she was special,
however much she was treated with contempt.
Accessing this deep implicational level experience
of being someone worthy of protection and right
treatment was the foundation for building a healthy
sense of self.

Working on Experience in the Moment

Taken together, these new approaches shift CBT
away from verbal dialogue (though in essence this
remains the bedrock of therapy) towards a more
holistic experience in the presentin keeping with
the holistic character of the implicational subsystem.
The challenge of Alice's therapy, for both herself
and the therapist, was to stay in the present; to
remain in touch with threatening memories without
dissociation, rejection of therapy, or other escape, so
that these could be fully appraised at the propositional level. The implicational level sees things in
absolutesthe `black and white thinking' of the
CBT thinking errors, whereas the propositional
level can handle complexity. Her therapist likened
staying with this complexity, both in the sessions,
and in the week in between, like trying to balance
on the middle of a see-saw. This struggle for
balance was most evident in the relationship
between Alice and the therapist, as she reacted to
closeness that her past experience interpreted as
dangerous, with every possible impulse to escape
or attack. Talking about thisbringing it into the
propositional level, was a central part of the
therapy.
This way of working, familiar in psychodynamic
terms as transference, is not new within CBT; see
for instance Safran and Segal (1990) and Young
(1994). However, it fits particularly naturally within
this ICS conceptualization with its emphasis on
working in the immediacy of the moment and on
the smooth communication between implicational
and propositional subsystems. Thus, the slipping
away from present reality into a familiar pattern can
be challenged, and relationship can be experienced
in a new way. The new initiatives to employ
mindfulness techniques as an adjunct to cognitive
therapy, cited above, also work on restoring the
smooth communication between the two central
subsystems, while maintaining detachment from
both, so sharpening experience in the moment.
Cognitive Analytic Therapy has particularly clear
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381
methods for using this experience in therapy with
reference to explicit written and diagrammatic
formulation material (Ryle 1995).

A New Experience of the Self

All these approaches are designed to lead the
client towards a new experience of self in which
emotion can be both felt and reflected upon. As
well as recognizing the distortions of the past, this
requires the nurturing of strengths that are there all
along, but become submerged by the mobilization
to deal with supposed threat. The 1990s have seen
growing importance within cognitive theory of
using therapy to help people construct new healthy
selves, as well as weaken existing restrictive and
condemnatory self constructions (e.g. Greenberger
and Padesky, 1995). In Alice's case, this new
experience was grasped in the reframing of her
anger as a wholesome part of herself, and in the
`balancing' relationships with the therapist and the
new partner. Staying balanced, without retreating
into familiar escape routes, was a constant struggle.
A simple diagram, summarizing the possible ways
of viewing familiar situations, with the idealized on
one side, the catastrophizing option on the other,
and the compromise, representing propositional
level appraisal in the middle, helped her to locate
the everyday choices. Gradually she was able to
report experiencing living in the middle place, and
to comment on its unfamiliar, frightening feeling of
uncertainty, as well as the exhilaration of taking
control. This new experience of herself, reflected on
and guided at the propositional level, but laid down
vividly in the implicational memory as well, was
the basis for a new stage in Alice's understanding of
herself, and therefore in the construction of a more
healthy and unified sense of self. The old patterns
were not rapidly or easily erased, but at least the
way ahead became clearer.

DISCUSSION AND CONCLUSION

This has been an attempt to integrate a number of
new concepts and approaches within CBT into a
simple and coherent whole. I see it as a contribution
to a debate about the development of the therapy
into new areas of complexity, and towards adopting
therapeutic styles previously associated with other
modalities. This sort of development can lead to
charges of dilution and distortion of the model. I
would argue that this approach retains and indeed
strengthens the following essential features of CBT;
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382
it is research based; it entails unpacking the
relationship between cognition, emotion, behaviour
and bodily arousal in a way that clarifies the route
to change, and it works collaboratively and respectfully with the client, sharing the full understanding
of the problem with them, so that they can continue
to work with the model after the therapy is over.
In this way, major developments in CBT and
related therapiessuch as CAT for borderline
personality disorder (Ryle, 1997) and dialectical
behaviour therapy (Linehan, 1993), to name but
two, are brought together, by postulating underlying mechanisms, built around the human imperative to develop an acceptable sense of self, within
the context of an ICS information processing model
of the person, which accords a central place to
arousal states and memory for threat.
The example given uses this approach to treat
borderline personality disorder, but it can be
employed to understand the spectrum of mental
health difficulties in a way that cuts across
diagnostic labels. All mental health problems are
seen as responses to threats to assembling an
acceptable sense of self, and to the aversive arousal
that accompanies such threats. Anxiety based
disorders do not effectively defend against this,
except perhaps, through worry according to recent
work on this subject (e.g. Bouman and Meijer,
1999). Similarly, depression is a physiological and
psychological expression of defeat and acceptance
of low status or, in more serious cases, annihilation.
Substance abuse and other additive behaviours
modify the arousal directly, and temporarily block
awareness of the threats to the self. I would suggest
that obsessive compulsive disorder and eating
disorders meet the challenge of constructing the
acceptable self more ingeniously, by `changing the
rules'. In OCD, the threat is focused onto particular
actions or thoughts, thereby rendering it more
manageable in the short term, but, since the underlying anxiety is not addressed, creating more
problems in the medium to long term. In eating
disorders, interpreting acceptability in terms of
body weights leads into the addictive loops
underlying anorexia and bulimia that make these
behaviour patterns so hard to eliminate.
This discussion of the possible underlying unity
behind mental health problems, based on threats to
the construction of the self, seen in ICS based
information processing terms is, of course, highly
speculative. I hope it is suggestive of the benefits in
terms of clear formulation, simple enough to share
with any client, that this model offers. I would
further suggest that scientific exploration of the
Copyright # 1999 John Wiley & Sons, Ltd.

I. Clarke
connection between arousal, memory and sense of
self could help to establish this analysis on a firmer
basis.

ACKNOWLEDGEMENTS
My thanks are due to Dr Paul Chadwick for
suggestions and references, and to the two anonymous reviewers whose comments have helped to
shape the final version of this paper.

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