Just a snapshot look at Google scholar would reveal that CBT therapies, including third-wave CBT (e.g. mindfulness, acceptance and commitment therapy, etc.) are by far the most researched and evidenced methods of psychological treatment. When it comes to trauma at least, EMDR does not stray too far either (Bisson et al., 2013). In a recent article, I discussed EMDR’s efficacy in spite of what it can only be described as a sketchy evidence-base (Davidson and Parker, 2001). Neuroaffective-CBT (NA-CBT) on the other hand is a much younger therapy falling far behind in research, nonetheless a reliable transdiagnostic model which shares all fundamentals and evidence-base with the family of cognitive and behavioural therapies. The approach was developed by Daniel Mirea in response to a growing subclinical population of undiagnosed affective disorders that fall under the umbrella of shame and self-disgust. Since the treatment of such phenomenon crosses the boundaries of clear diagnostic criteria, the therapeutic approach has to be both comprehensive and strategic. NA-CBT therefore, relies on a clearly prescribed modular toolkit that aims to disrupt all mechanisms that predispose, perpetuate and precipitate shame, guilt, self-disgust or indeed chronic low self-esteem.
Through exploring the underlayers of NA-CBT, this article aims to look at the overlapping mechanisms that underpin a range of cognitive and behavioural methods and review some of the evidence supporting the skills and interventions relied upon during treatment.
The assessment
In keeping with the cognitive-behavioural framework, the NA-CBT therapy process starts with a comprehensive history taking which leads to a case conceptualisation, uniquely termed as the ‘Pendulum-Effect’ case formulation. NA-CBT proposes that just like the pendulum of a traditional clock, people oscillate or swing between maladaptive coping mechanisms without always being aware of this and in doing so, they reinforce deeply rooted negative views about themselves and others – which are ultimately responsible for their shame and self-disgust, e.g. “I am unlovable and unattractive and nobody wants me”.
Staying with the above (pendulum) metaphor, this core schema would very much be at the centre of the clock’s face, it represents in fact, the very central mechanism behind it. The centre mechanism would not turn the clock if it wasn’t for the oscillating movements – in other words the affect of shame (and therefore chronic low self-esteem) is reinforced by compensatory mechanisms designed and rehearsed over years (e.g. avoidance or surrendering or over-compensation) as well as the relationship that the such coping mechanisms have with each other through the swinging-effect action or the oscillating-effect.
Shame related beliefs
Overcompensating – Surrendering – Avoiding
Case study [1]
To illustrate how a victim of shame oscillates between the three main reinforcing mechanisms (i.e. overcompensating, surrendering and avoiding) let’s consider Sarah’s case. Sarah is a successful paralegal in the City who struggled with shameful feelings most of her life. She is a natural ‘overcompensator’ by making herself available, useful and liked by everyone in spite of being completely exhausted and burnt out by this. She hates letting her colleagues down and therefore at work her efforts are very much appreciated. Sarah is aware of this but she attributes her popularity to very hard, exhausting work, long hours and not being able to say ‘no’ ! Typically as Christmas was approaching and lots of party invitations started to arrive on her desk, she would ‘surrender’ into self-criticism (i.e. I am not going to perform well, I drink too much to calm my nerves, I’ve put on a lot of weight this year, nobody likes me ‘for me’ anyway) and ‘avoidance’ (i.e. not reading the invites, not following up, not responding to invitations, etc.). All actions taken (before various Christmas parties are due) are in order to ‘avoid’ social situations she feels likely to fail and would be supported and justified by an exaggerated set of predictions about social embarrassment or other ‘social disasters’. As such, the ‘surrendering’ or the ‘giving up’ mechanism would involve fortune telling, images of social awkwardness and also rejecting a colleague who offered to accompany her to one of those events. The insisting (and very single) colleague in this case, happened to be interested in dating her, and this will become evident later during the course of therapy; though her surrendering attitude and actions would not allow her to see the true nature of his intentions at the time. Such surrendering strategies will justify the avoidant behaviour and the eventual withdrawal which would inevitably lead to feelings of isolation, loneliness, guilt, self-disgust, and more self-criticism which ultimately would reinforce her shame-related beliefs.
A simple chain-analysis of her behaviours would suggests that Sarah overcompensates until she burns out, then she falls into self-criticism by surrendering which is then followed by withdrawal and other types of avoidance. This completes a trap which represents the mechanism that enables the back and forth ‘swing of the pendulum’ through all these emotions and associated behaviours over time. These behaviours could be best understood as emotion-driven behaviours.
The pendulum is meant to act not only as a timekeeper but also as a regulator (figure 1).
The above statement proposes that the pendulum metaphor can be equally used as an emotional regulatory tool by disrupting the behaviours that are part of the swinging mechanism (or the emotional trap). There are of course, several similar reinforcing mechanisms at play, which would be clearly described by the pendulum-effect (formulation). When all these mechanisms are fully understood, they would be further examined, modified and/or finely tuned 9with the patient in a strategic but compassionate manner, throughout the therapy over five flexible and interchangeable treatment modules:
(1) Psychoeducation and motivation, (2) Physical Strengthening, (3) The integrated-Self, (4) Coping Skills Training (including Self-Regulation) and (5) Skills Consolidation & Problems Prevention (figure 2).
Figure [2]:
- Initial consultation : Clinical Assessment & The ‘Pendulum Effect’ Formulation
- Module 1 : Psychoeducation & Motivational Enhancement: including building motivation, enhancing self-efficacy, problem solving skills training. How to use the Pendulum Effect to your advantage !
- Module 2 : Physical Strengthening: TED’s your best friend ! Physical conditioning, grounding and self-regulation. Further information provided here.
- Module 3 : The development of an integrated-Self: cognitive reframing (appraisal-reappraisal). Traumatic memories processing (through bilateral stimulation, narrative exposure or reliving. At this stage, the Vygotsky method acting can be used in order to embody a desired attitude or even a character trait.
- Module 4 : Coping Skills Training (incl. Self-Regulation): including further training in Mindfulness, Self-hypnosis and/or Relaxation Skills Training; also introducing the concept of EDRB’s (Emotion-Driven Reinforcing Behaviours: Overcompensatory, Avoidant and Surrendering Actions.
- Module 5 : Skills Consolidation and Relapse Prevention or future plans !
The underpinning fundamentals of the approach
Several essential mechanisms underpin NA-CBT and each treatment module attracts a particular set of skills, none more relevant that the skill of building a therapeutic alliance. I coined the term empathic mentalisation to highlight therapist’s skilful ability to connect with his client in a way that would allow the therapist to not just hear and understand at a pre-frontal level, patients’ vulnerabilities but instead to allow himself, to feel his client’s pain in a way which will help the client feel felt.
Whilst some attachment-based therapies would perhaps claim to engage the patient in a similar manner, this is where the similarity stops because in NA-CBT, the therapeutic relationship is no longer used as transference or counter transferential medium of communication. The therapist remains aware of client’s goals and he is in full control of the agenda. Thus the therapist guides the relationship and the (collaboratively agreed) agenda throughout the therapy process. The transference & countertransference processes are viewed as opportunities for open dialogue and learning. Challenging, restructuring and reframing irrational self-beliefs into adaptive beliefs, installing new coping skills and disrupting unhelpful strategies stays at the core of this therapy.
Psychological education is another NA-CBT fundamental. Clinical experience and trials indicate that psychoeducation does not only establish trust in therapist’s expertise but also in the therapy itself. Research has shown time and time again that psychological education, therapist’s clinical experience and knowledge of psychopathology, therapist’s confidence and style, as well as treatment integrity are all associated with improved treatment outcomes (Donker et.al.,2009 and Podell et al., 2013).
NA-CBT offers an excellent platform for the application of neuroscience and in particular neuroaffective research that has taken place over the last 30 years and remains largely ignored or segregated by different schools of thought [1].
Cognitive psychology studies (Padesky C.,1997), the Interacting Cognitive Subsystems model (ICS) by Barnard and Teasdale (1989, 2008) as well as the Adaptive Information Processing model (Shapiro, 1989, 2001, 2007, 2009) propose that memories are processed and assimilated not in a random way but in a highly organised fashion, using screening templates such as individuals’ past experience and understanding of themselves and the world they live in. However, if childhood experiences are traumatic, the information processing system stores the memory in the wrong parts of the brain and in a frozen or rigid format without adequate processing and integration. This suggests that traumatic memories fail to become integrated into the individual’s life experience and concept of the self which eventually creates psychological and emotional vulnerability. As such, unprocessed, unintegrated or upsetting memories (not only traumatically charged memories) may be at the core of shame and self-disgust or chronic low self-esteem (Schore A, 1998; Gilbert P, 2006; Siegel D, 2007; Gilbert P, 2011).
It is important to understand the nature of memory ‘specificity’. Jane’s mother used to smile at her just before (and sometimes immediately after) a torrent of harsh verbal abuse, often also accompanied by physical abuse. Jane grew up feeling very suspicious of ‘nice’ people who would smile at her – as such, the tendency for her was to get closer to people who were in her view more ‘genuine and authentic’ for example being angry, moody and unpredictable most of the time. One can only imagine that her adult relationship choices would be far from ideal. With such cases, the neuroaffective science is there to explain that neuropathways develop over years which lead to urges, habits and compulsive responses (i.e. I cannot help but feel suspicious of my ‘overly nice and smiley’ work colleague therefore I must stay away and avoid him…). Childhood ‘specific’ memory or memories have to be targeted in therapy, rather than the wider ‘abuse narrative’, i.e. mother’s explosive and unpredictable attitude in general. Not least because these narratives have been integrated over years in a particularly dysfunctional manner for example.. I was a pretty naughty child and deserved what I was getting..
During the third NA-CBT treatment module, developing an integrated-self, the patient may be asked to recall the worst aspect of an earlier shameful memory together with the accompanying and currently held shame-related beliefs and associated bodily sensations [2]. An increased attentional focus on the internal physiological changes (or psychosomatic reactions associated with shame) can be very useful at this stage (i.e. ‘pay attention to what goes on inside you right now, even the location of the distress and intensity’). Simultaneously, the patient is directed to narrate in detail the triggering episode.
If trained the therapist might even employ hand tapping as a specific form of bilateral stimulation. Although the research has often been challenged, more recently the evidence has been favourable to bilateral-stimulation and this extends to hands tapping in particular. A number of neuropsychological, developmental and attachment studies (Kirsch et al., 2007) have pointed out the usefulness of (appropriate and therapeutic) physical touch and associations with the release of endorphins, serotonin or dopamine as well as the formation of new neural pathways which ultimately leads to an improved self-regulation (Siegel D, 2007).
It may be important to remind that the area of traumatic memories processing, would be the only domain where NA-CBT crosses paths with EMDR but unlike this method, NA-CBT is rooted in evidence-based cognitive and behavioural practices proven to work over the last 50 to 60 years. This suggests that NA-CBT is primarily a behavioural approach relying on active and progressive changing through the adoption of new and more adaptive behavioural strategies (e.g. case study 2).
Case study [2]:
John used to have flashbacks of being physically and emotionally abused every time his manager would raise her voice in the office. He started to experience less and gradually no flashbacks at all, after only 3 hours of desensitisation via bilateral sensory processing (e.g. tapping). In addition, John also experienced significantly less hyperarousal. In order to decrease the possibility of a relapse and reinforce the newly formed competing memory (in-between sessions) the therapist agreed with John that when at the office, he must adopt a different attitude, a different mind-set, be more aware of his body language and mental activity, make notes and improve his body posture. He also agreed to have in place a number of responses to potentially challenging situations which would require a more assertive approach. He worked on clear strategies and detailed coping skills which would have been rehearsed (e.g. imagery rehearsal, role plays, etc.) inside and outside the therapy room and in-between sessions.
NA-CBT views narrative exposure, re-living or exposure in-vivo more appropriate forms of treatment (when compared with memory processing) for some cases of trauma – for example when a male therapist is treating a female victim of rape; therefore the integration process does not always relay on bilateral sensory input but on detailed descriptions of the traumatic event and on building evidence against associated unhelpful beliefs through behavioural experiments and other types of practical exercises.
During desensitisation, it remains important for the victim of shame to re-experience the related shameful memories whilst not feeling overwhelmed by it. Clinical experience shows that bilateral processing can at times achieve this more successfully than reliving or other types of exposure. Through the multi-tasking exercise of a focused but distributed attention [3] our brain seems to be able to access dysfunctionally stored experiences and stimulate the processing system, allowing it to transform and integrate the information much better. When fully integrated, the event and what has been learned about the event, can be verbalised however the inappropriate emotions and physical sensations (of hyper or hypo-arousal) would have been discarded and those can no longer be felt.
Yet another interesting phenomenon seems to take place. During bilateral sensory processing (e.g. tapping) the shamed patient is assisted with navigating through the various associations that would usually arise internally. This leads to an increase in the sense of self-efficacy and mastery and specifically an increase in patient’s ability to go back and forth between re-experiencing the event and the present moment (Oren and Solomon, 2012). This does not only diminish dissociative symptoms but also improves attention-orientation skills (Goldin, 2009). A number of trauma studies indicate that physical touch undermines dissociative tendencies and contributes to achieving a feeling of safety and being grounded in the here-and-now (e.g. feeling grounded in the present, being more aware of own physical presence and the voice or the touch of the therapist, etc.).
In regards to self-efficacy in particular, Oren and Solomon (2012) propose that the experience of mastery and self-efficacy would become encoded as adaptive information into memory networks. This may in fact be in line with other studies from established clinicians, for example Teasdale and Barnard (1993), Donald Meichenbaum (2017) or even Albert Bandura’s (1989) self-efficacy theory. This might also suggest that eventually, although the traumatic event and what has been learned can be recalled, the inappropriate emotions and associated sensations of hyper or hypo-arousal would have been discarded and can no longer be felt with the same level of intensity.
One other mechanism at work in NA-CBT, relates to the training of attention through mindfulness. During the desensitisation or processing phase, patients are instructed to ‘let whatever happens, happen’ and to ‘just notice whatever thoughts come to mind’, which is consistent with principles of mindfulness (Goldin et al., 2009; Siegel, 2007; De Jongh et al., 2013).
Imagery-based desensitisation and exposure exercises (routinely used in mindfulness and clinical hypnosis) can also improve individuals’ ability to create a gap or a distancing effect according to the working memory theory. This process may be facilitated by the degradation of the working memory due to cognitive overload, which allows the individual to stand back from a shameful or an upsetting memory, observe it with less emotionality and re-evaluate their understanding of it. Even though the literature on the working memory hypothesis seems inconsistent, research on mindfulness, ICS, EMDR and even clinical hypnosis offers more clarity in this direction. Maxfield and colleagues [4] propose that ‘links are forged between the associated material and the original memory, thus transforming the way that the traumatic memory is stored in memory networks’ (Maxfield et al., 2008).
Final thoughts
In a 2018 interview with Psychotherapy Expert Talks, Donald Meichenbaum pointed out that the field of neuroscience (including gene expression and so on) is not only ‘cutting edge but highly relevant’ with the potential to further tailor interventions for patients suffering from very specific psychopathology. Research coming out of this field certainly adds value to psychological therapies and stays at the basis of models such as NA-CBT. It is my subjective view that in the near future, schools of psychotherapy will adapt and learn to focus on the body as well as the mind, which would imply a deeper understanding of bodily functions not only mind functions for all psychotherapists and psychologists. The fields of neuroscience, clinical hypnosis, psychosomatic medicine and biological treatments are only just starting to come together. NA-CBT is only one example of what could be achieved under the umbrella of Cognitive & Behavioural Therapies, an integrative school that remains best positioned, because of its empirical base, to oversee attempts to treat mental illness holistically.
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[1] For example, the Adaptive Information Processing model (Shapiro, 1989, 2001, 2007, 2009) is mostly seen as the property of EMDR whilst the Interacting Cognitive Subsystems model (ICS) by Barnard and Teasdale (1989, 2008) belongs to cognitive psychology and CBT.
[2] ICS theory and research, explains its account of emotion development and production. ICS emphasises the importance, as part of the total cognitive configuration producing emotion, of a schematic synthetic level of processing that integrates both propositional meaning and direct sensory contributions. Processing at this level corresponds, subjectively, to holistic sense or feeling rather than to thoughts or images explains the link between information processing.
[3] The term distributed attention refers to the complex exercise that involves recalling the trauma and paying attention to traumatic episode, whilst keeping oneself grounded in the present and paying attention to the here-and-now, and all at the same time with further assistance from bilateral sensorial stimulation such as hands tapping.
[4] Maxfield, L., Melnyk, W. & Gordon Hayman, C. (2008). A working memory explanation for the effects of eye movements in EMDR. Journal of EMDR Practice and Research, 2, 247–261.
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Neuroaffective-CBT 