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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

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visceral impact formulation engaging heart as well as head using ics

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

Isabel Clarke

Consultant Clinical Psychologist

why ics
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.
  • 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 driven processing.
features the theories have in common
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.














Propositional subsystem



Linehan’s STATES OF MIND (from Dialectical Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems













the propositional subsystem
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
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
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
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
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.
threat value information
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
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
Self and Relationship.Imp. Ss

Info. About



(as subject


(as object


(as subject






self develops

Experience stored in



Early self



Sense of self as

object disrupted;

early info. Needs


a cbt approach for inpatient and crisis work
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




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





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
Psychosis formulation

The past


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

what does ics tell us about therapeutic approaches
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.
taking experience seriously in 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
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.
shared reality unshared reality

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



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
working with psychosis using the discontinuity model
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
Session 2. The role of Arousalshaded area = anomalous experience/symptoms are more accessible.

High Arousal - stress

linehan s states of mind applied to psychosis
Linehan’s STATES OF MIND applied to PSYCHOSIS

Discussion of Ways of coping suggested by this approach –

management of arousal and distraction.

contact details and references
Contact Details and References
  • 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: