Transcript WEST HAMPSHIRE NHS TRUST SOUTHAMPTON

Visceral Impact
Formulation; engaging
heart as well as head using
ICS.
Isabel Clarke
Consultant Clinical Psychologist
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.
►
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
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► Brewin’s
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VAMS and SAMS (just memory).
Ehlers & Clark (following Roediger): conceptual
v.data driven processing.
AND INTERACTING COGNITIVE SUBSYSTEMS!
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.
Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Implicational
Memory
Auditory
ss.
Visual
ss.
Propositional subsystem
Propositional
Memory
Verbal
ss.
Linehan’s STATES OF MIND
(from Dialectical Behaviour
Therapy) – Maps onto Interacting Cognitive Subsystems
EMOTION
REASONABLE
WISE
MIND
(Propositional
Subsystem)
MIND
MIND
(Implicational
subsystem)
IN THE PRESENT
IN CONTROL
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.”
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
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.
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.
Features of Emotion Driven Processing
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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.
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.
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
Self and Relationship.
Imp. Ss
Prop.ss
Info. About
self.
other
Self
Self
subject
(as(assubject
Trauma
Transitions
Experience stored in
imp.memory
activated
Early self
reexperienced
Self
(as object
Early
provisional
self develops
Sense of self as
object disrupted;
early info. Needs
re-integration
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.
Typical formulation
PAST ABUSE
LOSSES
PARTNER LEAVING
Nightmares: can’t sleep
Cut self
Attempt suicide
FEAR
RAGE
SADNESS
More difficult to cope
Friends and family alarmed.
Could lose custody of
children.
Avoid going out and seeing
people
Feel worse
More time to brood
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
Psychosis formulation
The past
Being in crowds, busy places
Intrusive thoughts
Fear
Sense of threat
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
Tense, sweaty,
heart races
Withdraw, hide
away
Or Fight,
becomes
aggressive
Escapes from thoughts
By slipping into unshared world
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.
Applying ICS to Psychosis
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
Evidence for a new normalisation
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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.
Shared Reality
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Unshared Reality
Ordinary
Clear limits
Access to full memory and
learning
Precise meanings available
Separation between people
Clear sense of self
► Supernatural
Emotions moderated and
grounded
Logic of Either/Or
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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
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.
Session 2. The role of Arousal
shaded area = anomalous experience/symptoms are more accessible.
Level of
Arousal
High Arousal - stress
Ordinary, alert, concentrated, state of arousal.
Low arousal: hypnagogic; attention drifting etc.
Linehan’s STATES OF MIND applied to
PSYCHOSIS
Shared and Non-shared Reality
reasonable mind
Ordinary thinking
Shared reality.
wise
Mind –
in touch
With both
emotion mind
or open to other ways
of experiencing
Non-shared reality
in the present
in control
Discussion of Ways of coping suggested by this approach –
management of arousal and distraction.
Contact Details and References
► [email protected]
► [email protected]
► Durrant,
C., Clarke, I., Tolland, A. & Wilson, H.
Designing a CBT Service for an Acute In-patient
Setting:A pilot evaluation 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