Thursday, 21 October 2010

The Worse it Gets, The Worse it Gets: The Viciousness of Vicious Cycles

CBT is sometimes thought of as being “just common sense”. While common sense is of course essential in the practice of any form of professional helping, it should be clear from some of the previous blogs that there is much more to CBT than this. Socratic Questioning and Behavioural Experimentation, for instance, are often quite counter-intuitive and are not part of the way we ordinarily think; the same applies to the important idea of Vicious Circle Causality.

The human mind generally tends to think of causality in a linear way, where “one thing leads to another”, and of course this the way things happen a lot of the time. But causal processes can also loop back on themselves, leading to cyclical processes which can become stable and self-sustaining, and may even spiral out of control. We are aware of this, of course, in relation to examples such as “The Snowball Effect” (the bigger the rolling snowball gets the bigger it gets) and “Arms Races” (the more weapons they have, the more we have to have; the more we have, the more they have to have). However, we don’t habitually think of our own mental and behavioural processes in this way (therapists, of course, often use exactly the kind of examples I have just given as metaphors in helping clients to understand some of what is happening in their lives).

This is one of the ideas in CBT which first engaged my interest, and I’ve found it to be a very powerful concept in helping to understand and work with many mental health problems. The idea is not, of course, unique to CBT, but CBT as an approach does put a stronger emphasis than some other approaches on the perpetuating, maintaining factors contributing to a mental health problem along with the predisposing and precipitating factors.

This emphasis is valuable in three main ways:

As a description: Finding the relevant vicious cycles can make sense of the stuckness that a client experiences in relation to their depression, anxiety, anger etc. As I have emphasised previously, the presence of vicious cycles tends to block the experiential re-learning necessary for recovery and growth. Such cycles tend to take on a dynamic of their own, relatively unaffected by other influences such as the environment.

As an explanation: The progressive nature of vicious circular processes can help make sense of how the client developed such a serious problem, especially if there is no obvious major cause in their developmental history. The fact that a major problem does not have to have a major cause is one of the ideas presented here which go against “common sense”.

As a generator of hope: If we understand some of how the problem is being maintained in a circular way, then this may help makes sense of possible ways out; the good news is that positive changes in thinking, behaviour, mood etc are also processed through the cycle, reversing the downward progression and making the cycle no longer vicious (a “virtuous circle”?).



As I described in an earlier blog (25 May), a basic Case Formulation can be put together with a client by identifying vicious cycles of thoughts/feelings/behaviours/physiology that are keeping a problem going.

For instance, in a depressed client, their negative thoughts feed their depressed feelings, lack of activity, and exhaustion, and are in turn reinforced by each of these symptoms (lack of productive activity reinforces a negative self-view, lack of rewarding activity reinforces low mood, etc).

In recent years, a number of clinicians and researchers have developed models of the typical vicious cycles found in mental health problems such as Depression, Social Anxiety, Panic, OCD, Substance Addiction, etc.

Here are a couple of examples which I have found to be indispensable:

Panic (Clark, 1986):

The catastrophising misinterpretation (“I’m having a heart attack”) of anxiety symptoms, such as tightness in the chest and heart palpitations, are the crucial element which closes the cycle, leading to further and further increases in anxiety. Reduction in the strength and plausibility of these cognitions (through Psychoeducation, Socratic Questioning, Behavioural Experimentation etc), can completely dissolve the cycle in many cases.



Sexual Addiction (Carnes, 1983):

According to Carnes,

“For sexual addicts an addictive experience progresses through a four-step cycle, which intensifies with each repetition:

1. Preoccupation: The trance or mood wherein the addict’s mind is completely engrossed with thoughts of sex. The mental state creates an obsessive search for sexual stimulation.

2. Ritualization: The addict’s own special routines, which lead up to sexual behaviour. The ritual intensifies the preoccupation, adding arousal and excitement.

3. Compulsive sexual behavior: The actual sexual act, which is the end goal of the preoccupation and ritualization. Sexual addicts are unable to control or stop this behaviour.

4. Despair: The feeling of utter hopelessness addicts have about their behaviour and powerlessness.

The pain the addict feels at the end of the cycle can be numbed or obscured by sexual preoccupation, which re-engages the addiction cycle.”



References:

Carnes, P. J. (1983) Out of the Shadows: Understanding Sexual Addiction. Minneapolis: CompCare.

Clark, D. M. (1986). A Cognitive Approach to Panic Disorder. Behaviour Research and Therapy, 24, 461–70

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