Visceral Impact Formulation; engaging heart as well as head using ICS.

1. Visceral Impact Formulation; engaging heart as well as head using ICS. Isabel Clarke Consultant Clinical Psychologist

2. Why ICS? • Neat explanation for the head/heart split – normalizing rationale. • Takes the horrible feeling;the sense of threat, seriously – helps engagement • Normalizes human fallibility – the person as a wobbly balancing act • Multiple memory stores provide an explanation for the persistence of trauma memory • Sound rationale for third wave CBT approaches and for mindfulness as a central therapeutic approach • Desynchrony between the two organizing subsystems gives a neat explanation for psychotic symptoms • A way of normalizing the different quality of experience in psychosis.

3. LEVELS OF PROCESSING – A THEORETICAL JUNGLE! • The cool reflection problem leads to the recognition of different types or levels of processing within CBT e.g.s of theories of this. • Ellis: Inference and Evaluation • Hot and Cold cognition • Power & Dalgleish. SPAARS (theory of emotion). • Mark Williams: overgeneral autobiographical memory. • Metacognition. • Wells & Mathews. S-REF • Brewin’s VAMS and SAMS (just memory). • Ehlers & Clark (following Roediger): conceptual v.data driven processing. • AND INTERACTING COGNITIVE SUBSYSTEMS!

4. Features the theories have in common. • There is one direct, sensory driven, type of processing and a more elaborate and conceptual one. • The same distinction can be found in the memory. • Direct processing is emotional and characteristed by high arousal. • This is the one that causes problems – e.g. flashbacks in PTSD. • The two central meaning making systems of ICS provides a neat way of making sense of this.

5. Interacting Cognitive Subsystems. Body State subsystem Implicational subsystem Auditory ss. Implicational Memory Visual ss. Verbal ss. Propositional subsystem Propositional Memory

6. Linehan’s STATES OF MIND (from Dialectical Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems EMOTION MIND (Implicational subsystem) REASONABLE MIND (Propositional Subsystem) WISE MIND IN THE PRESENT IN CONTROL

7. The Propositional Subsystem • Verbal coding. • Manages logical thought - “cool cognition” • Verbally coded memory store integral to the subsystem. • Communicates directly only with the other language subsystems. • Intercommunication between it and the implicational subsystem = “Central Engine of Cognition.”

8. Implicational Subsystem • Coded in all modalities - memory and current processing • Concerned with meaning and significance • Information about threat and value • Particularly concerned with the status of the self. • Directly connected to sensory and body subsystems • Because it does not ‘do’ distinctions, past and present; subject and object - are merged

9. Important Features of this model • Our subjective experience is the result of two higher order processing systems interacting – neither is in overall control. • Each has a different character, corresponding to “hot” and “cool” cognition. • The IMPLICATIONAL Subsystem manages emotion – and therefore relationship. • The verbal, logical, PROPOSITIONAL ss. gives us our sense of individual self.

10. A challenging model of the mind. • The mind is simultaneously individual, and reaches beyond the individual, when the implicational ss. is dominant. • This happens at high and at low arousal. • There is a constant balancing act between logic and emotion – human fallibility • Mindfulness is a useful technique to manage that balance.

11. Features of Emotion Driven Processing • Emotion regulates relationship – both with yourself and others • It mobilises the body for action • That physical mobilisation gives the emotion its punch • The Implication ss. is constantly watching for information about threat to or value of the self. • Information about unacceptability leads to a disagreeable level of arousal. (cf. Gilbert and evolutionary approaches) • Where physical arousal is prolonged it is unpleasant – motivates people to avoid emotion • Time is collapsed in Emotion driven processing – past threat is added to current threat (cf. Brewin’s PTSD research) • Role of past trauma in psychosis and PD is now being properly recognised.

12. Threat/Value Information • Threat to physical survival • Threat to our place in the social world • For the baby - the two threats are the same • For the child – bullying and position with peers are common social threats • sexual abuse gives a deeply threatening and confusing message about the self. • A sense of value and specialness is, I suggest, universally present.

13. The ‘horrible feeling’ • Human beings need to feel physically safe and OK about themselves • Emotion Mind/Implicational Subsystem produces a sense of threat when those conditions are not met • Emotion Mind/Implicational memory presents past events as present (trauma) • People develop ingenious ways of avoiding facing the sense of threat

14. Self and Relationship.Imp. Ss Prop.ss Info. About self. Self (as subject Self (as object Self (as subject other Trauma Transitions Early provisional self develops Experience stored in imp.memory activated Early self re- experienced Sense of self as object disrupted; early info. Needs re-integration

15. A CBT Approach for Inpatient and Crisis Work Cross diagnostic Suitable for working with high states of arousal – identifies the individual’s relationship to feeling awful inside as the problem. Effective over one, two or three sessions (evaluated – see Durrant et al). Introduces approaches to change that can be supported by staff on the ward, and carried on by CPN etc. in the community after discharge.

16. FEAR RAGE SADNESS Nightmares: can’t sleep Cut self Attempt suicide More difficult to cope Friends and family alarmed. Could lose custody of children. Avoid going out and seeing people More time to brood Feel worse Typical formulation PAST ABUSE LOSSES PARTNER LEAVING WAYS FORWARD Don’t let the feelings be in control: YOU ARE IN CHARGE Do things despite the feeling Breathing and mindfulness to get back to the present Use the energy of the anger positively

17. Psychosis formulation The past Fear Sense of threat Being in crowds, busy places Intrusive thoughts Hears voices This means I’m bad and others want to hurt me This also means I’m bad and others want to hurt me Escapes from thoughts By slipping into unshared world Withdraw, hide away Or Fight, becomes aggressive Tense, sweaty, heart races

18. What does ICS tell us about Therapeutic Approaches • Arousal management and mindfulness – operating between the 2 central subsystems • Grounding in the body and the present – where the individual can be in control • Engaging at an implicational level – use imagery, metaphor etc. • Addressing and coping with the emotion (Linehan; Greenberg etc.) as opposed to being bullied by it • Encouraging behavioural change (Bennet Levy’s research) – get support with this from the team • Mobilise the strong elements in the (scattered) self – anger can be key here.

19. Applying ICS to Psychosis

20. Taking Experience Seriously in Psychosis • Psychosis: when Emotion Mind/Implicational does not mesh properly with Reasonable Mind/Propositional • This leads to a different quality of experience – fine in the short term – a problem when stuck • Normalising the difference as well as the continuity – shared and unshared reality • Sensitivity and openness to anomalous experience – continuum with normality • Understanding the role of emotion – the feeling is real; the ‘story’ is improbable

21. Evidence for a new normalisation • Schizotypy – a dimension of experience: Gordon Claridge. • Mike Jackson’s research on the overlap between psychotic and spiritual experience. • Emmanuelle Peter’s research on New Religious Movements. • Caroline Brett’s research: having a context for anomalous experiences makes the difference between whether they become diagnosable mental health difficulties • and whether the anomalies/symptoms are short lived or persist. • Wider sources of evidence – e.g.Cross cultural perspectives; anthropology. Richard Warner: Recovery from Schizophrenia.

22. Ordinary Clear limits Access to full memory and learning Precise meanings available Separation between people Clear sense of self Emotions moderated and grounded Logic of Either/Or Supernatural Unbounded Access to propositional knowledge/memory is patchy Suffused with meaning or meaningless Self: lost in the whole or supremely important Emotions: swing between extremes or absent Logic of Both/And Shared Reality Unshared Reality

23. Working with Psychosis using the Discontinuity Model • Managing arousal – the transliminal is accessible at both high and low arousal • Validate the experience • Validate the feeling • Persuasion to join “shared reality” • “Sensitivity” – normalisation based on Claridge’s work on schizotypy.

24. Session 2. The role of Arousalshaded area = anomalous experience/symptoms are more accessible. High Arousal - stress

25. Linehan’s STATES OF MIND applied to PSYCHOSIS Discussion of Ways of coping suggested by this approach – management of arousal and distraction.

26. Contact Details and References • Isabel.Clarke@hantspt-sw.nhs.uk • Hannah.Wilson@hantspt-sw.nhs.uk • Durrant, C., Clarke, I., Tolland, A. & Wilson, H. Designing a CBT Service for an Acute In-patient Setting:A pilotevaluation study. Clinical Psychology and Psychotherapy. 14, 117-125. • Cognitive Behaviour Therapy for Acute Inpatient Mental Health Units; working with clients, staff and the milieu. Edited by Isabel Clarke & Hannah Wilson. Routledge. 2008 • Isabel’s website: www.isabelclarke.org