**3.2 The CCC explanation**

The Interacting Cognitive Subsystems (ICS) model of cognitive architecture [65] distils this information into a useful map of connections and disconnections within the brain. ICS posits two central meaning making systems, the implicational and the propositional, each with their own memory system, representing the evolutionarily older and newer parts of the brain respectively. Normally these communicate, but can become desynchronized at high and low arousal. This leaves the older, emotional and threat attuned, implicational subsystem, in charge without access to the contextual information from the propositional. This model provides a succinct rationale for the background to trauma symptoms outlined above that is communicated within CCC by means of a modified form of the Dialectical Behaviour Therapy States of Mind diagram (**Figure 1** below) that adds the separate memory systems.

This states of mind diagram with addition of memory provides a normalising explanation. For many people, this lifts the stigma of a sense of innate pathology and substitutes a simple rationale for the unbearableness of current adversity which for other people would be more manageable.

It also ushers in the agenda of facing up to the past trauma and its potential to intrude into the present if not managed. Mindfulness provides a means to do this without being overwhelmed by the accompanying emotion, and, importantly, to disentangle what belongs to the past from what belongs to the present. Much of the therapy is focused on identifying strengths and potential and finding new, effective ways forward. There is growing clinical evidence, which needs back up by proper research study that this can enable people to move forward from even serious trauma without need for detailed reliving.

**Figure 1.** *States of the mind. From Clarke, I. (2016). Reproduced with permission from Hodder & Stoughton ltd.*

Another feature of CCC is that it is trans-diagnostic – or perhaps more accurately, blind to diagnosis. Most of the literature on therapy for trauma starts with a diagnosis of PTSD, and this certainly makes research tidier. CCC has developed particularly in situations where diagnostic uncertainty abounds, such as Acute and Inpatient Mental Health Services [48] and those who fail to benefit from diagnostically organised protocols in primary care. Unsurprisingly, trauma of one sort or another, usually of the complex variety, features heavily in both these groups, and only a minority will have a diagnosis of PTSD.

#### *3.2.1 Participants' experience of trauma*

**Table 1** above lists the IAPT study participants (n = 20) and elements, if any, of complex trauma as identified in their formulations, along with the disproportionate current response attributable to the impact of the past. This table illustrates the universality of some sort of trauma or earlier adversity impacting present functioning within a community sample selected for ethnic diversity. Some of the instances are culturally connected (e.g. illegal immigration status and racial bullying), but many would be found in any sample. This illustrates the ubiquity of the impact of such past adversity on mental health presentation. The table also lists the interventions applied in addition to mindfulness. See Appendix 2 for the principle interventions post formulation.

#### **3.3 Case Example 1: 'Celine'**

#### *3.3.1 Background and contact with the service*

Celine was a 58 years old woman of mixed race heritage, born in French Guyana. She moved to England with her family in her teens. She was a mother to three children, two older ones from a first marriage and a 10 year old daughter from her second marriage, at the time of therapy. Celine and her parents retained strong family connections with country of origin, Guyana. Relations with the wider family were important to her, but could also be a source of stress where she was expected to fulfil a particular role by powerful individuals.

She was recruited into the study and received 8 sessions of Culture Free CCC. Previous psychological history revealed several previous episodes with mental health services; two episodes for support with her employment difficulties, and one further episode when she first received generic group input, and was then stepped up for individual therapy and received 15 sessions of CBT for Generalised Anxiety Disorder (GAD), without achieving reliable improvement.

She was a well-educated high achiever and had made a good career as a Solicitor specialising in business and financial cases. A critical incident for her was in 2008 when she had loss in her daughter at about the same time as she lost a parent. She struggled to cope; she related that her second husband and the firm she worked for were unsupportive. Her psychiatric history revealed a diagnosis of depression in 2008 and she had been on anti-depressants from then on.

She reported that the attitude of her employer to her health struggles developed into bullying and discrimination with strong racial overtones. She reported feeling she did not fit into the firm and desperately wanted to leave the job and change career. She described her marital relationship had become increasingly abusive and controlling.

#### *3.3.2 Initial therapy session*

At the point at which Celine entered therapy, she had managed to separate from her husband, to leave her job and embark on a training for a new career in the social care

#### *Culture Free CBT for Diverse Groups DOI: http://dx.doi.org/10.5772/intechopen.93904*



*Mindfulness is the core intervention; it informs the application of the others.*· *Arousal Management includes Relaxation Breathing and lifestyle adjustment.*

<sup>ç</sup>*Emotion management includes facing, expressing and letting go of emotion.*

*\* Aspects of Self is mindfulness managed subpersonality work.*

*\*\*Relationship management includes assertiveness.*

**Table 1.** *Case table.*

#### *Culture Free CBT for Diverse Groups DOI: http://dx.doi.org/10.5772/intechopen.93904*

sector. She related that she was proud of herself for managing to make the break, and enjoying her new career and receiving recognition for her abilities and achievements after years of being undervalued and bullied. However, many stresses remained. The course was demanding, both physically and mentally. She was a single parent.

However, she was left with a legacy of chronic hypertension and sleeplessness from long endurance of bullying and control in both work and marriage. This left her exhausted and reporting low energy levels and lack of self-confidence. Furthermore, a recent serious road traffic accident exacerbated her distress and lack of wellbeing, leaving her with chronic pain.

Relations with her ex-husband were another major source of stress. As she had previously had a high income and he was on statutory benefits. Celine felt he was trying to extract as much financial advantage as he could. However, she had experienced a major financial impact after her career change resulting in financial worries and anxiety.

She also experienced ongoing, realistic, anxiety that her ex-husband's cynical bid for custody of their daughter, she was able to recognise that this was unrealistic but she felt overwhelmed and stressed over child access arrangements. Her traumatic experiences left her universally mistrustful of people, meaning she was cut off from support and warmth from her two, surviving, older children and her friends.

#### *3.3.3 Formulation*

Her feelings and emotions were validated accordingly and her chronic hypertension and insomnia were discussed as understandable in light of long endurance of bullying and controlling former employer and marital problems. The intrusion of past sense of threat compounding current adversities was explained using the States of Mind diagram (**Figure 1** above). We worked collaboratively to make sense of her presenting problem using the CCC formulation diagram (**Figures 2** and **3**) which labelled the feelings of loneliness and mistrust; anxiety, regret and sadness at its heart. These emotions were understandable in the light of her current stressful situation and the car accident, but the loss of her son and the years of bullying and abuse were still active in her life, exacerbating the hypertension and mistrust.

The other legacy of the past that was interfering with life in the present was mistrust of people and avoidance of getting close. The trauma of the loss of her

#### **Figure 2.**

*Spikey formulation diagram. From Clarke & Nicholls (2018). Reproduced with permission from Hodder & Stoughton ltd [66].*

**Figure 3.** *Celine's spikey formulation.*

son interfered with closeness within the family, so that, for instance, she avoided hugging her eldest child, which was a source of pain to both. This reticence also affected relationships with her other children and her friends. Long experience of bullying at work and the behaviour of her ex-husband made her highly mistrustful in relationships in the wider world, but at the same time, sapped her ability to be appropriately assertive, and so defend herself.

We identified Celine's many strengths; she was resilient and had high principles. She was committed, hardworking and able. She was held in high esteem in the extended family and family honour was important to her, as was her Christion faith which gave her the structure to live by.

We then identified the two major vicious circles that kept her trapped in the past, despite having broken free of abusive marriage and job through heroic effort.

#### *3.3.4 Vicious circle 1*

The fear she had lived with for so many years combined with current anxiety to maintain her body in a state of hypertension. This in turn oriented the mind to fear so that she always expected the worst, which maintained her stress levels.

The intervention following formulation was informed by goals agreed as the means to break the hold of the vicious circles, as follows:

**Goal 1.** Let go of fear, questioning the sense of threat that belongs to the past and keeps the past in the present. Mindfully let go of worries about the present and future.


#### *3.3.5 Vicious circle 2*

The other cycle tracked the way that long exploitation and bullying, combined with the loss of her son, had made her mistrustful of relationships and avoidant of closeness. This avoidance felt safer, so was maintained, but kept her lonely and unsupported. It was particularly undermining of her relationship with one of her children whom she did not dare hug as this brought back the loss of her daughter. It also caused distance from her other children.

To break this cycle we agreed **Goal 2** would focus on the following:

• To allow yourself to get close to family and to deepen trust and closeness with others, while exercising caution and not being taken advantage of.

The formulation phase was concluded with a compassionate letter, shared in Session 4 that summed up the formulation and the agreed goals of therapy.

## *3.3.6 Intervention phase [session 5–8]*

We worked on breaking the first cycle by using breathing and mindfulness techniques in the short term. Celine was receptive to therapy and responsive to the use of mindfulness to enable her to observe and revise habitual patterns, and this brought a regular practice into her routine.

As the therapy progressed we did more work using emotions positively through mindfulness. This laid the ground work for rebuilding a new relationship with the past self. Self-Compassion is an important intervention, both to ensure that she was giving herself the best chance in the present, and in order to apply compassion for her past self, to enable her to accept and go forward from things that had gone wrong in her life. Positive anger work was also crucial here, in order to give her the courage to face the legacy of fear, without getting tangled up in bitterness. Targeted mourning enabled her to meet and let go of the sadness of all that had happened. Thus she was able to construct a new relationship with the past, facing it without letting it rule her. We never explored it in detail.

We used mindful awareness of the internal barriers to the impulse to hug to question and reverse them. Being able to hug her daughter proved something of a breakthrough, which she was able to translate into warmer relations with the wider family and friends.

## *3.3.7 End of therapy and clinical outcomes*

By the end of therapy, Celine reported feeling more relaxed and able to take control of her life. In 'Aspects of Self-Work'1 we did, she gained a sense of being able to use mindfulness to balance her confident, lonely persona that kept her separate, with her more gregarious and family oriented side, which had seen her exploited and bullied by others in the past. Paradoxically becoming more assertive with her ex-husband improved the relationship considerably.

Letting go of mistrust of people outside the family, born of her employment experience, was work in progress, but she knew how to proceed with it. Similarly, she had managed to reduce her ongoing hypertension significantly, but there was still progress to be made. This is in line with the philosophy of CCC, which takes the view that, once the formulation has been collaboratively arrived at and goals arising from breaking the cycles agreed, the rest of the therapy provides a tool kit of strategies, some of which will be successfully applied with the support of the therapy, but which the individual can continue to work with, helped by natural supporters, long after the end of therapy.

Celine's routine outcome measures on PHQ-9 and GAD-7 scores presented in **Figure 4** below are indicative of the progress she has made in this treatment. The spike in the graph December 2018 represents the coincidence of a bereavement, Christmas holiday, course and family pressures and was resolved by the next session meeting in January, with progress maintained at follow-up with GAD-7 scores significantly reducing to 7 at follow-up time point.

#### **3.4 Case Example 2: Jade's journey through services**

Jade was a 44-year-old married woman with two children, a 9-year-old boy and a 4-year-old girl. She grew up in the Seychelles and moved to the UK in her early adulthood to train as a teacher, leaving her family home and mother in The Seychelles. Due to the information she provided during her psychological assessment, which detailed traumatic experiences, and using the ICD-10, she was classified under the F43.1 Post-Traumatic Stress Disorder problem descriptor. Although with reference to the current ICD-11, she may have been classified under the 6B41 Complex Post-Traumatic Stress Disorder.

She defined her main problem as low mood and difficulty coping with her physical health issues (including chronic pain). "The low mood is to do with my past which I wish I could get out of my head and causes inactivity, depression and anxiety." She was recruited from the IAPT service's waiting list to take part in the Culture Free study as she met the inclusion criteria and consented to take part in this study. In line with the study protocol, she commenced a course of 12 CCC therapy sessions during the study period.

#### *3.4.1 Initial therapy session - Jade's background and current.*

During the first therapy session, Jade was encouraged to talk about what was not working in her life at the time. Using open ended questions and active listening, an exploration of her current difficulties and how these affects her life and relationships. Information about her early experiences and how these might impact on the current problem was also gathered.

Jade grew up in a single-parent household with what she described as "a strong and critical mother," who prided academic achievement overall and any deviation from this focus was met with physical punishment and critical verbal abuse. When Jade was 4 years old, she would spend time with her grandmother, but was sexually abuse by her male cousin during these visits to her grandmother's house. She told her mother of this sexual abuse, but her mother physically abused her

**Figure 4.** *Routine outcome measures: PHAQ-9 and GAD-7 scores.*

#### *Culture Free CBT for Diverse Groups DOI: http://dx.doi.org/10.5772/intechopen.93904*

and blaming her for provoking the cousin into these acts; although she never went back to her grandmother's house again.

She attributed this history as the cause of her current feelings of sadness and anger, as she thought about it often and wished she could stop these ruminations. Additionally, she discussed how having a punishing mother who expected academically high achieving children has made her self-critical and perfectionistic, which had an impact on her relationship with her health conditions. Her experiences of having fibromyalgia were also conveyed, specifically how this health condition affected her ability to do everyday tasks, such as housework, childcare and cooking. She expressed feeling guilt and shame regarding her reliance on her husband to assist with these duties, and often wished that her body functioned as it did when she was younger. This also led to feelings of sexual inadequacy and desired a "proper" relationship with her husband.

Validation was expressed regarding her current situation and emotional experiences in light of her history and current ways of coping. The states of mind diagram in **Figure 1** above was also explained to Jade using examples that she had shared to help her understand how her emotion mind memories were being experienced in the present, and also why she attempted to avoid feeling emotions by withdrawing and disconnecting with others. These psychoeducational interventions offered a normalising and validating explanation to her experiences and is an important part of CCC as it aids the person-therapist collaboration by establishing a warm and trusted therapeutic relationship, especially in cases such as Jade's who have experienced invalidating and neglectful relationships in the past. This validating, non-pathologising stance was adopted throughout therapy. Additionally, short mindfulness exercises were practiced from the start with a simple grounding, noticing practice being shared in the first session. Mindfulness continued to be introduced in each session throughout therapy.

#### *3.4.2 The formulation*

**Figure 5** below illustrates Jade's spikey formulation diagram, that was collaboratively arrived at during sessions 2–4 and summarised Jade's past and current situations in a concise and clear manner. The formulation was started with the "spikey" in the centre, which focuses on the felt sense of the person. For Jade, this was sadness, anger, feeling "useless," shame, guilt, and anxiety. Situations where these feelings were triggered were explored next (the box above the spikey), and in the top box, her past

#### **Figure 5.**

*Jade's spikey formulation diagram.*

experiences were summarised in a way that both of us understood without too much unnecessary detail. Together, the diagram was evaluated and validation for her current felt sense was shared in light of the past that has led to a sensitivity to the triggers. Next her strengths were explored and are detailed in the two bowed texts at the top of the formulation diagram; she was proud to be a good mother and wife, with a strong sense of justice, respectfulness and was non-judgemental to her children. She also drew strength from having created her own loving and supportive family. Next her vicious cycles were explored, Jade chose to address her anger, sadness and anxiety and on each in turn identified the physical experience of the emotion, what this feeling led her to do, the reinforcer to managing the emotion in this way, and the consequences of coping in this way that keeps her stuck with the difficult emotions in the "spikey."

Her goals stated in the formulation diagram above were collaboratively arrived at from Jade's own ideas of what she wanted to achieve throughout therapy and also the therapist's understanding of the interventions that would aid a new ways of coping that might aid the breaking of the vicious cycles. These goals informed the interventions and the remaining therapy sessions.

#### *3.4.3 Interventions*

#### *3.4.3.1 Managing your body's safety system*

The CCC module entitled "managing your body's safety system" was covered with reference to the states of mind diagram and her individualised formulation diagram. This involved using specified examples applicable to her way of coping with responses for threat (fight, flight and freeze). Grounding mindfulness was an important intervention to help stabilise Jade and help her to feel safe in the present moment. For Jade this involved identifying that her threat system was being activated by triggers of her anxiety, anger, sadness and shame. These were based on the ways she had learned to manage her emotions as a child through her experiences of abuse and neglect, by covering up the fear of being punished by her mother. When Jade was younger, this was perceived as a sign of "strength" that acted as a reinforcer for being self-critical and perfectionistic, but as she grew older, she realised that this "strength" had made her miserable and disconnected from others.

Additionally, and specific to Jade's experiences of fibromyalgia, gaining an honest appraisal of her somatic experiences of her emotions, rather than overriding them, was key to her validating and accepting her emotions, which also aided the management of her pain and energy levels.

#### *3.4.3.2 Your relationship with yourself*

Self-compassion features heavily within the CCC programme and was addressed with Jade. Self-compassion, and becoming a good, honest friend with oneself, was explained as a way to break vicious cycles that featured self-criticism, which were evident in Jade's formulation diagram. This was initially tricky for her, especially the self-compassion mindfulness practice. She experienced a sense of dissociation from the feeling of welcoming herself as a person in need of care, love and protection. However, with practice in therapy and on her own between sessions Jade began to experience herself with a sense of worthiness.

#### *3.4.3.3 Using anger positively*

Within the CCC programme, anger is pitched as a very useful emotion that can facilitate action where sadness has kept people stuck. For Jade, she often suppressed

#### *Culture Free CBT for Diverse Groups DOI: http://dx.doi.org/10.5772/intechopen.93904*

anger and withdrew from others when she felt angry. By acknowledging that anger was an emotion that alerted her to injustice, she began noticing situations where she was being taken advantage of or treated as undeserving, which she could .

Mindfulness of a strong centre was practiced alongside this module in order to instil a sense of being the observer of the situation and your own emotions without dissociating from the emotional experience.

### *3.4.3.4 Building a new relationship with the past*

The states of mind diagram in **Figure 1** was used again to frame her emotional experiences of the past in terms of how memories is understood from the two ways of knowing; emotion mind knowing and reasonable mind knowing. The formulation diagram was also used to highlight how the past can be brought into the present by the person by them going around the vicious cycles and drawing in the past relevant to the emotion.

Mindfulness of an emotion and self-compassion helped Jade to accept the past, instead of fantasising of a preferred scenario or becoming self-critical about things she wished she had done differently.

Jade also made a connection between her own experiences aged 4 and her own daughter reaching that age, and her anxiety regarding keeping her safe from potential sexual abuse. This was acknowledged as an understandable fear, that Jade was doing all she could to keep her safe, and that she could work on reducing this fear with the use of long outbreath breathing and grounding mindfulness.

Towards the end of therapy, Jade shared that she had confronted her mother about her past. Although her mother did not acknowledge what she had to say and continued to be critical of her, she was satisfied that she had spoken her truth to her mother. She attributed the self-compassion and anger work as important in her being able to confront her mother and accept that she was not capable of being the loving mother that she wished she could have been, in a sense she had accepted the loss of the ideal mother.

#### **3.5 End of therapy and clinical outcomes**

At the end of therapy Jade reported feeling a sense of achievement that she had worked towards the goals from her formulation diagram. She felt that she had accepted herself, was less perfectionistic within the home, and more accepted of help from her husband. She had faced her past and accepted her relationship with her mother. She also felt that she was more in control of her emotions. This was reflected in her PHQ and GAD scores **Figure 6** below which shows a reliable recovery with both outcome measures. PHQ-9 score at baseline was 20 and reduced to 10, under the clinical cut off. GAD-7 score at baseline was 14 and reduced to 7 at the end of therapy.

**Figure 6.** *Routine outcome measures: PHQ-9 and GAD-7 scores.*

### **4. Conclusion**

This research project has facilitated the development of a therapist's manual for working with cultural diversity in psychotherapy. Many aspects of cultural learning have been identified and used to develop this manual and evaluate it by therapists involved in the study. The study therapists reported that the CCC formulation was simple, effective, and validated the participants' experiences well. Whereas therapy drop-out rates among ethnically diverse populations are generally higher than for the general population, this study's retention rate of over 90% demonstrated the acceptability of this adapted intervention. A recent study of referrals to IAPT services by Baker [67] found that, compared to people from White British backgrounds, people from most Black, Asian and Minority Ethnic (BAME) groups were more likely to drop out of therapy (46% of white service users complete treatment in comparison to 40% of Asian service users). It was therefore agreed that the interventions were acceptable to participants and led to real concrete changes in behaviour.

Therapist's feedback was also used to evaluate and develop the manual for further studies and practice guidance. It was key to note that balancing Western and traditional cultures within the family is an important aspect that has been managed with mindfulness of emotions and self-compassion as well as exploring the development of interpersonal skills. Moreover, where religion is concerned, it can provide a source of strength and comfort as well as a sense of divine retribution. This challenging conflict can be explored with the individual by both validating their religious faithfulness and practicing self-compassion mindfulness exercises. The CCC conceptualisation of faith in terms of an experience of relationship with the divine opens the way to discussion of this relationship, where it is proving problematic, in ways that side-step religious dogma. Acceptability of therapy was assessed using the Patient Experience Questionnaire with overall experience rated high.

The study is also interesting in demonstrating the spectrum of trauma and past adversity contributing to current mental health difficulties across a primary care sample not selected for trauma. It further demonstrates the effectiveness of a structured way of working with trauma, using emotions positively, and drawing on identified strengths going forward, that does not entail reliving or detailed exploration of the trauma or past adverse events. This way of rebuilding a new relationship with the past is illustrated in both the case examples. By-passing detailed exploration of the past is useful, as reliving, though effective for many, can be unacceptable or inadvisable for a substantial minority of trauma sufferers. This element of CCC is as yet merely noted anecdotally and has not been systematically evaluated. Such evaluation awaits a future study.

The Culture Free study found that CCC was both feasible and acceptable in diverse populations, echoing existing research on cultural adaptions which found use of mindfulness to be accepted and appreciated as an effective intervention that can elicit concrete positive change across a broad range of mental health presentations, including trauma and trans-diagnostically. Further investigations utilising a robust methodology and powered sample are warranted in particular with diverse populations presenting with complex trauma.

#### **Acknowledgements**

The authors would like to thank all the participants contributed to the Culture Free Study. The authors would like to thank Matthew McNought and Carmen Caro Morente for their contributions as research therapists' project and Demi Perkins for her contribution to literature search.
