Neuroaffective-CBT is a cognitive-behavioural method developed and refined over the last 12 years by Daniel Mirea, a senior CBT lecturer, writer and consultant psychotherapist. This model evolved alongside the latest generation of CB therapies, in response to a need to better understand and better respond to deeply rooted emotions that feel too complex or too confusing. Often such emotions are difficult to describe and may fall under the low self-esteem umbrella, shame or guilt. Such affects are equally difficult to investigate or diagnose as they cross over into so many psychiatric disorders. Although a new and innovative therapy, NA-CBT is rooted in years of research on cognitive-behavioural techniques like exposure, which have placed CBT in a completely different league when it comes to treatment outcomes.
CBT is synonymous with evidence-based psychological treatment. Best understood as an umbrella-term that includes a number of very-well researched therapeutic approaches developed over the last few decades and proven to work with a number of psychopathologies… dynamic talking therapies like Exposure Therapy, Schema Therapy, Stress Inoculation Training, Mindfulness (MBCT), Acceptance and Commitment Therapy (ACT), Hypno-CBT, NeuroAffective-CBT (NA-CBT) and a lot of other acronyms (i.e., MCT, DBT, CFT, FA, etc.) are all part of the CBT family. Although these therapies are designed to operate rather well within the medical model, they remain close to individual values, personal goals and desires…
Daniel Mirea goes into some depth on this topic with accredited psychotherapist Carla Vercruysse on Spotify !
Dr Donald Meichenbaum has won many titles and rewards in the field of psychology and cognitive-behavioural therapy but he is less known for his storytelling qualities. If you attended a masterclass in storytelling and writing, you would probably soon learn that gifted storytellers would typically open up with an exciting anecdote or a real story that grabs the audience’s attention, and then they will make sure the last thing they say is something that can resonate with the audience long after the story is over.
Dr Meichenbaum’s personal story has all of these qualities and more. In listening to his story, it is hoped that you will learn something about love, loss, resilience as well as story telling… Because afterall the best gift we can offer the world is our personal stories.
Enjoy…
References mentioned in the podcast by Donald Meichenbaum, PhD:
“BOLSTERING Therapists’ Resilience” with Donald Meichenbaum is part 2 of a series on essential ‘CBT Skills for Building Resilience‘ re-edited and re-published by Daniel Mirea on NeuroAffectiveCBT.com and Academia.edu with author’s permission for free use and clinical training – the content belongs exclusively to Dr Donald Meichenbaum (this material can also be found on the Melissa Institute and Roadmap to Resilience website)
These are authentic lecture notes and handouts written by Dr Meichenbaum, one of the CBT founders, they were intentionally not edited, so that when you will explore the material you would get a sense of ‘here and now’ as if you are at his lecture right now and he speaks directly to you. Enjoy… but not before you read part 1 of the series which is right here !
HOW TO BOLSTER RESILIENCE IN PSYCHOTHERPISTS AND HEALTH CARE PROVIDERS
INDIVIDUAL LEVEL
Create A Formalized Way To Shift As You Leave Work: An Intentional Way Of Leaving Work At Work To Engage In Your Personal Life.
Walk
Listen to a specific song
Taking a deep breath or two or ten as you leave. Envision breathing in _______ (peace/happiness/serenity etc) and breathing out ______ (stress/anxiety/COVID etc.)
Ceremonial changing of shoes/clothes envisioning leaving your work with what you change out of
Visualization or conscious thought as you leave: building/parking lot, that you are leaving work at work. Look in your rearview mirror and see it behind you.
Write down the stresses you are leaving and put them in a box/envelop/folder that you literally leave at work to be picked up when you return.
Replenish with physical and mental well-being activities and allow yourself to escape
Exercise or outdoor activities
Create a sleep routine including healthy daytime rhythms: Refer to “Roadmap to Resilience” in Appendix A for How To: Improve Sleep Behavior
Outdoor patios/backyards/parks
Cherish and foster connections, friendships and family
Reach out to them: virtually through interactive video calls etc. to talk, or do an activity while on the virtual call such as watch the same movie or a walk, electronically with email, text, message or comments on social media, write an actual letter and mail it: a letter to say hi, or a Thank You letter
Maintain Healthy Life Balance, Allow Yourself To Recharge
Outlets and interests beyond work such as hobbies and social activities
Activities that have a concrete outcome to foster a sense of accomplishment:
Learn a language, instrument, or new skill
Volunteer work, write letters to nursing homes etc
Activities that allow you to create and express feelings
Garden, paint, dance, writing: poetry or journaling
Journaling
Writing your feelings to get them out, in a journal
Write a letter to someone or about something you’re upset or stressed about. Get all the feelings out in that letter and then destroy it. (tear it in to tiny pieces, burn it, wrinkle it up, and throw it away *Any combo of the three)
Recognize You Are Not Alone – Repeat “I Am Not Alone”
Consciously pause, think about that phrase. Remember those words when you’re overwhelmed, before work, before you go home – Anytime you forget
If you forget. Reach out to a colleague or someone else in healthcare who understands the stresses. You can even create a “disaster plan” to have a sponsor where if you get in a dark place and feel alone, you both know you might reach out to say, I’m feeling alone or have a code word or phrase. To hear them respond with, I feel you/I get it/I’m here – will remind you.
“I recognize that others are going through this as well.”
Develop And Cultivate A Philosophical Acceptance Outlook
The Serenity Prayer
“God grant me the serenity to accept the things I cannot change, the courage to change things I can, and the wisdom to know the difference.”
Appreciate the positives
Commit to find one positive in each day. Create a list/collection of sticky notes, write them in a book. Have a physical copy, that you can look back on and see your progress and also to see there is hope when you can’t think of a positive during a dark moment.
Acknowledge and accept things that can and cannot be changed
Create a “To Do” list, of things that can be changed
Create a “To Let Be” or “To Accept” list – to help you acknowledge things you can and cannot change. Once you acknowledge, you can remind yourself they are things you cannot change. Identifying and reminding yourself, is an actionable step you can take towards acceptance.
Work on things you have the ability to change
Create a To Do List, of things you can change.
For each item in the list, create steps of what you can do.
For some of the items, create deadlines. Accomplishing goals gives you a sense of achievement.
Take pride in and recognize the privilege in being in a helping profession, especially in the setting of the stress of a pandemic
With co-workers, with patients, with family: You are all interacting in a vulnerable space. Look for the magic and privilege. Start a list of things you find in each day. Find one thing in each day. (Invite coworkers to add to the list as well. Have it be visible in a common area.)
At work, remind yourself in the moments of interactions with your patients/colleagues/visitors; you are in the helping position that allows you to, during their time of vulnerability, make a difference with simple kindnesses per your interactions of their visit/day.
“The name of the game is IMPROVISE, ADAPT, OVERCOME. Be flexible by necessity. Take one day at a time!”
Spiritual Coping Strategies
Active involvement in a religion, online/TV services, service measures to donate time/clothing/items of need, checking in on or meals for elderly neighbors
Each day converse or have a connection with your higher power, out loud on your way to or from work, in the form of a prayer, symbolistic jewelry/emblems as a reminder you are watched over, express gratitude, find purpose
“I do Nature Therapy daily. Go for walks- review my nature videos and pictures. Appreciate the awe of nature.”
“I find strength in being altruistic – a higher purpose in life.”
“This pandemic is God’s way of testing us. I will meet this challenge and become stronger.”
“When I drive home, I am constantly talking to myself and to a higher power. I keep asking questions for which there are no answers.”
Refer to “Roadmap to Resilience” in Appendix A for Spiritual Fitness Coping Strategies
PEER/COLLEGIAL LEVEL
Assess Your Social Support
“I rely on my “battle-buddy” – my fellow worker who keeps tabs on me and for whom I do the same for him/her. We check on each other frequently at work and at home.”
Create an actual list of who would/could be emotional, informational, and or material support? (Might be different people for each type)
Identify: family, friends, coworkers who are helpful. In what ways are they helpful?
Create a game plan, whether talking to them or having the list and knowing those are people you feel you could go to in those moments
Actively/intentionally maintain connections with peers and colleagues.
Set a goal. I will reach out to ____ # peer/colleague/friend each day. Can be verbal if you see them or a form of communication of your choice. Personalize the communication. Instead of just, “how are you?” “How are you doing with the pandemic/pandemic stress?” “How’s your family/cat/dog/kids/job/ holding up during all of this?” “How are you kids doing in school?” “What have you been doing to keep active/healthy/happy/_____?” “Good job on _____ with that patient/staff/patient family etc. I think the way you (helped them calm down, helped them feel safe, taught them about _____) worked out well”
Ask yourself: Do I have the strategies, abilities, confidence and desire to cope with unhealthy, harmful relationships? If not, what can I do to protect myself? How can I learn, or who can I learn from?”
“There is no shame for asking for help. No one can do this alone. I realize I am not the only one with these problems. You do not have to try and do it yourself.”
Can you identify a mission, cause, group of family or friends that you can engage with that will give purpose?
Can you identify individuals who value joy, improving the situation and who seek productive meaning-making?
Community coping efforts or support that generate a sense of hope, trust, solidarity, and connectedness
Public rituals, prayer circles, memorials, demonstrations, artistic expressive activities, theatre performances, reconciliation meetings, religious services, live music
Can you identify a role model or mentor?
What behaviors, actions or attributes do they have that caught your attention as someone to be a role model or mentor?
What behaviors do they have that stand out during these stressful times?
Can you ask them how they learned the behavior(s) that stands out to you?
What behaviors do you have, that are similar to theirs
What behaviors do you have, that would be helpful to change so you could develop behaviors similar to theirs?
“I nurture and invest in social relationships. I try to be useful to others. I can text, email, call, Skype, join Internet exercise and yoga classes and chat lines on the Internet, use Zoom, watch Netflix movies with others, schmooze on the phone in order to lift the dreadful cloud of COVID-19 for a little time. You have to ‘give in order to get’.”
ORGANIZATIONAL LEVEL
Regular Or Semi-Regular Team Meetings As A Form Of “Emotional Check-Up”
We don’t need to fix or solve the problems of their stress, but employees need to know we care. The simple act of stating that or phrasing it “We know we can’t fix the fact that we are in a pandemic right now and things have continuously been incredibly stressful. What we can do is create venues/opportunities for you to talk and be heard – on various levels.” * coworkers, managers, EAP have various parts
“People in deep grief (stress/trauma) want to feel that you have heard their pain. If you try to ‘fix it’, you may rob them of that passage. They often want someone they can trust…”.
Training/Educational Opportunities To Learn About Resilience, Burnout, Wellness
Bring the interventions to staff (especially initially, in crisis/survival mode, they likely don’t have the mindset to begin, to seek out or know what they need or what would help)
Arrange for EAP to visit the units/departments
Workshops on building resilience to learn which: actions, behaviors and thoughts improve or hinder resilience
Create a campaign to initiate awareness for the concern for the resilience of staff
“… support a “mission” and accompanying activities to actively change the circumstances that lead to victimization. This may be done at the local, organizational, and national levels such as advocating for legislative reform and social action. Help workers transform stress into ways of finding “meaning” and “purpose”.
Community/Team Building Initiatives
Ongoing Supervision, Checking In On Staff
“We have end-of-shift ‘campfires’ – a kind of debriefing where we can give voice to our experiences, vent and problem solve. We have created a kind of social support group.”
Create And Ensure A Psychologically Healthy Workplace In A Way That Is Actionable And Visible And Ongoing
Psychological health includes the need people have for feeling connectedness and sensing belonging
And finally the difficult part… how much time do you spend evaluating your work and if so how do you do it, are you being too critical, or avoidant, or scared to find out what your patient really feels about the therapeutic process and about you… what are the questions that you need to ask in order to improve your approach?
SELF-EVALUATION OF YOUR LEVEL OF PSYCHOTHERAPEUTIC “EXPERTISE”
On a Scale from 1 to 5, where 5 indicates that you are very SKILLFUL at doing the therapeutic’ activity (even can teach it to others), and where 1 indicates that you still consider yourself a NOVICE, Rate yourself. A Rating of 3 indicates that this therapeutic activity is still a BUDDING SKILL.
___ 1. AGENDA SETTING — At the beginning of each session. you and your patient together can establish an agenda to discuss and explore specific issues and patient concerns.
___ 2. PATIENT FEEDBACK — On a session-by-session basis you routinely elicit both your patient’s positive and negative reactions to all aspects of the therapy session. You may use some form of Rating Scale and discuss the patient’s choices and reactions, or you can use the Art of Questioning to elicit such patient feedback.
___ 3. COLLABORATE WITH THE PATIENT — You are able to establish a collaborative relationship with your patient when establishing Treatment Goals, when selecting “Homework” activities (Commitments to undertake personal experiments). You can include a Treatment Rationale that increases the likelihood that your patient will be actively engaged in the therapeutic enterprise.
___ 4 USE GUIDED DISCOVERY AND THE ART OF SOCRATIC QUESTIONING — Help patients better appreciate the interconnections between their feelings’ thoughts and behaviors. (USE THE CLOCK METAPHOR). Help patients better appreciate how they inadvertently, unwittingly, and perhaps, even unknowingly, emit behaviors that trigger reactions from others that reinforce their views of themselves, others and the future.
(Remember “There is no situation so bad, that by your own efforts you can make it worse.”)
___ 5. USE ACCURATE EMPAHTY — You can communicate an understanding of your patient’s feelings and thoughts and address any ambivalence the patients have about changing their behaviors. Convey that you are trying to see the world through their eyes. Validate, normalize, and even help reframe your patients’ reactions.
___ 6. ELICIT YOUR PATIENTS’ STRENGTHS— Help patients access and appreciate the resilience and Islands of competence that they bring to therapy with them, Ask HOW and WHAT questions concerning these “In spite of behaviors”. Help patients develop a RESILIENT MINDSET.
___ 7. CHALLENGE YOUR PATIENTS TO UNDERTAKE PERSONAL EXPERIMENTS — Encourage your patients to engage in between session activities in order to test their hypotheses and expectations. Help them achieve a “new positive ending ” to an old issue or conflict.” Ensure that your patients take these results / data as evidence to unfreeze their beliefs.
___ 8 . USE CHANGE TALK, THE LANGUAGE OF POSSIBILITIES AND BECOMING — Ensure that your patients take credit for any behavioral changes. Ask patients for examples as for how they were able to (USE RE Verbs RE-connect, RE-prioritize, RE-author etc.) engage in Meta-cognitive personal agency activities (“Notice. plan, choose etc”). Not allow their emotions to HIJACK their Frontal Lobe Executive TYPE 2 thinking processes.
___ 9. PACE THE SESSION APPROPRIATELY — You use the therapy time effectively, combining the patients’ concerns and desire to connect with you and the eeded focus on ways to achieve the agreed upon treatment goals, Continually explore how what is being addressed in therapy can be applied by the patients in their everyday experiences?
___ 10. STRATEGICALLY AND SKILLFULLY EMPLOY THERAPEUTIC INTERVENTIONS — Select from an array of Cognitive behavioral and Constructive Narrative interventions those treatments that best meet the clinical needs and patient preferences. Meet the patients where they are at. Build in generalization guidelines, no matter what treatment approach you adopt.
“REMEMBER THE QUALITY OF THE THERAPEUTIC ALLIANCE AND THE LEVEL OF GROUP COHESION ARE THE BEST PREDICTORS OF TREATMENT OUTCOMES“
“MAINTAIN PROFESSIONAL SELF-DOUBT“
“LOVE YOURSELF AS A PERSON, BUT CONTINUALLY DOUBT YOURSELF AS A THERAPIST”
The topic of ‘trauma’ is much more controversial than one would imagine. Research tends to indicate that approximately 25% of people who have experienced a significant trauma go on to develop post-traumatic stress disorder symptoms or PTSD, but that percentage varies. Based on the nature of the trauma those rates are going to be higher, for example for someone who’s experienced rape or sexual assault more like 50% or lower for other kinds of traumatic events like for example a fireman dealing with a fire. An interesting question following on from this data, would be centred around the 25 to 50% people that resume their normal activities, symptoms free after a frightening incident. Such a significantly high percentage might suggest that therapists are presented with an interesting opportunity during treatment, if and when therapy focus is re-directed towards a key aspect of trauma recovery – RESILIENCE. Dr Meichenbaum, one of the CBT pioneers, aka the Freud of CBT, has been talking about this area for decades. Therefore, a justified question would be, how do the up to 75% people deal with their symptoms post-trauma in order to, not develop chronic PTSD? And if resilience is at least one of the answers then what helps improve resilience during treatment?
Whilst there is no agreed definition on what ‘resilience’ means, it is clear that being resilient could describe an individual’s ability to bounce back in face of adversity and according to Dr Meichenbaum it is also relating to an individual’s inner resources and outer immediate support network. His conclusions are backed up by neuroaffective research which describes resilience as the capacity to deal with external challenges, also called ‘exteroception’ or sensitivity to external stimuli, by managing any resulting internal changes, also known as interoception or the perception of internal sensations. Dr Meichenbaum posits that trauma symptoms and resilience engendering behaviours can coexists. The data must not be misinterpreted; it is not that the 75% do not develop some symptoms of PTSD but victims evidence the ability to bounce back and cope with ongoing challenges as such with time symptoms can subside. Moreover, people can be resilient in one area of their lives and not in others. As Bonanno (2022) highlights in his book “The end of trauma”, a key feature of the 75% that are impacted but who engage in resilient engendering behaviours is that they have developed a resilient mindset, a set of optimism and self-efficacy and have ongoing social support (Meichenbaum Roadmap to Resilience).
In cognitive-behavioural terms the implications for treatment are significant; although there is no magic bullet and there seem to be multiple ways to developing resilience, these findings could be translated into high levels of psychological flexibility and adaptability, good problem-solving skills, and an ability to learn and implement new coping strategies which would have to be rehearsed under pressure and in real life experiments.
Trauma characteristics
So, if being resilient is one of the ingredients that could help almost 75% of people exposed to different levels of threat, not to develop symptoms of trauma, how do we identify the remaining 25% ?
When it comes to the label of trauma, much like depression, it seems the over-use of the term itself becomes problematic. The label ‘trauma’ is commonly used to describe a range of situations and experiences that might not fall under that definition.
A traumatic experience may be defined by five main characteristics.
An experience that is far beyond what may be considered a normal human experience and during which a person feels a significant risk to self or even death; intense fear or helplessness during an attack may also be part of this experience
This experience would extend to witnessing an event where someone is threatened with serious injury or death
This experience is followed by extensive reexperiencing and significant changes to memory
This experience is also followed by increased and frequent states of hyper-arousal
The negative arousal is associated with safety-seeking and other avoidant behaviours
Such experiences are more complex than the stress one would experience during a driving test which might have even resulted in failure and subsequent self-criticism. As upsetting as that can be, it does not amount to a traumatic experience, not unless you had a serious car crash during your test and subsequently kept reexperiencing scenes of the crash, you had become hypervigilant in traffic, and this had also led to avoidance or even social isolation. Waiting for two hours in line at the petrol station during the petrol crisis would not qualify as a traumatic event. Not unless you saw someone get attacked and hurt while waiting in line.
The inconvenience can create distress, but most events we go through daily are not traumatic. One might argue that, to qualify everyday occurrences or even major inconveniences as traumatic is to minimise and trivialise the experience of people who are living with PTSD every day and whose lives were turned upside down by past horrific experiences. It is therefore important to watch over the use of the term because it misses the boat by miles, on how much trauma affects people both psychologically and physiologically.
Another common issue would be convenient access to a lot of online information at a time when unfortunately, not all online resources are legitimate sources of information. The answer is often is a lot simpler. It is wise to try to access a professionally trained clinician or therapist, preferably a trauma specialist. Even though many schools of psychotherapy reject the medical model the evidence stands out. According to Dr Meichenbaum, trust in the therapist, in the therapist’s expertise and in the therapeutic method used, is associated with positive treatment outcomes (link to Therapist Core Skills by Dr Meichenbaum 2022, BABCP competencies – seee BABCP website).
Irrespective of their school of thought, psychotherapists need to familiarise themselves with the psychopathology of trauma, the risks and maintenance factors and feel confident in delivering a variety of therapy methods in response to a traumatic experience or else they are faced with a situation where the blind is leading the blind. In this regard, it seems that choosing the right therapist can be a challenge since a lot of psychotherapists are often led by their personal beliefs or what they might consider healthy scepticism and miss out, on the real symptomatic impact that a traumatic experience can have on an individual (Mirea, 2012).
Understanding the symptoms of trauma and how these symptoms are being maintained can also facilitate the process of psychoeducation which is yet another important aspect of the trauma treatment. Recovered trauma patients frequently report that if they knew what trauma meant and how it ‘worked’ they would have chosen the right support a lot sooner, they would have had faster results, they would have saved money on treatments and would have resumed their normal lives a lot faster.
Misdiagnosing trauma is surprisingly common for a variety of reasons, not least comorbidity. It seems that 8 out of 10 people with PTSD are more likely to have a comorbidity such as, another anxiety or depressive disorder, or a substance use disorder. Cognitive intrusions and reexperiencing are common across a range of disorders including PTSD, OCD, schizophrenia, or even bipolar disorder, this is where having the skills and the correct training would help therapists peel back all the complex layers of a mental disorder.
An interesting trauma myth is that trauma is only defined by something happening directly to you. You have to be assaulted or raped or something bad has to happen to you. In fact, trauma can also be defined by witnessing something violent like a crime, an assault, a rape or a murder. Common beliefs associated with this type of guilt or shame-based trauma are loud with a strong internal critical or blaming tone: “I’m being ridiculous… I must be weak… I could have done more… How dare I say I have trauma… I am not the real victim here”.
Trauma reexperiencing and processing methods
Going through a traumatic experience can lead to a very confused memory data base. At the time when the trauma occurs the individual does not get a chance to fully process the event and therefore a range of problems would rise from there. On an ordinary day, memories are coded and laid down in specific structures of the brain, specifically via the hippocampus, and the neocortical system, best viewed as our long-term memory storage. Here we have access to an event in a narrative format, something one can talk about comfortably, distant stories from our past, which eventually would fade with time.
During a traumatic event this natural process is interrupted by a narrowed and focused attention onto the threatening stimulus, facilitated by high levels of cortisol and adrenaline. The traumatic memory is saved by our internal alarm system called the amygdala, a peanut size brain structure located just anterior to the hippocampus in the medial temporal lobe. The amygdala is a different kind of data storage, in charge with our safety and responsible for keeping us alerted to new similar threats. This is basically part of our fight-flight system, essential to our survival. Because of this, memories about threats or dangers, do not fade with time. Such memories capture all sensory modalities, they feel real, current and relevant. Traumatised victims would find it difficult to share memories of trauma even decades later.
So, traumatic memories are saved in the amygdala ready to be activated at a moment’s notice, if a similar emergency should arise again. With assistance from the Autonomous Nervous System (ANS), all mammals have the ability to re-orient attention toward a potential threat and scan the database in 0.025 seconds. This would lead to an immediate series of reactions designed to preserve life.
Unfortunately, the ANS is far from perfect and impacted on by a variety of unhelpful habits very well-rehearsed by other parts of our brain, such as the tendency to ruminate and worry over unpleasant or scary events. Ruminations and worries in particular seem to confuse our internal processing systems and therefore memories are generalised and constantly updated with more threatening material. As a result, the amygdala would get frequent imprints and the sympathetic response gets easier and easier activated by a variety of sensorial triggers. For example, a lady who was raped by a bald man, years later, she would feel threatened by all bald men she would come in contact with, irrespective of ethnicity, age or size. At least 25-50% of people exposed to a threat describe flashbacks of the traumatic events as a frightening experience, they feel they are right back there, reliving the traumatic experience. As such, significant efforts would go into suppressing and neutralising flashbacks as well as avoiding places or situations that act as reminders and might trigger the flashbacks.
How to safely integrate traumatic memories
Evidence-based psychological treatments such as the family of CBT therapies rely on a few strong principles such as ACT: Assess, Conceptualise and Treat. We have already understood how important it is to be able to separate trauma symptoms from other unpleasant or stressful experiences that do not come under the same umbrella. Therapy alliance, psychoeducation, new learning, problem solving, installing new coping skills, exposure programmes are all essential and well evidenced approaches across the range of CB therapies.
However, with PTSD cases, traumatic memory processing plays a distinct role. The theory that lies behind memory processing focuses on the influence of the Autonomous Nervous System (ANS) our main survival mechanism which gets activated when we are faced with a threat. The ANS has an ON switch called the sympathetic response which leads to arousal and an OFF switch which is called the parasympathetic response that encourages de-arousal or a calming relaxed response. This sounds great, however one of the problems is that we are not able to consciously switch the system On and Off, as we would more than likely prefer, hence the label ‘autonomous’.
With the risk of over-simplifying a process that is otherwise very complex, it might be easier to understand by separating the hardware from the software components of our brain. It may be important to remind our brain’s hardware which includes structures such as the amygdala, hippocampus, the thalamus and the neocortex. Part of the software include sensorial processing, memories processing and the role of attention-orientation. The software communicates via different hardware components with the help of neurotransmitters, such as adrenaline and noradrenaline in the case of a threat, via neuropathways or brain circuits that all together create our autonomous nervous system.
The role of the amygdala is to analyse and collect data about threats in order to alert us and keep us safe when necessary. For example, the amygdala would correctly alert us through the emotion of fear, that “snakes are dangerous” if we come across a snake on a mountain trail but in fact, not all snakes are dangerous in all situations and as such memory upgrading becomes relevant in relation to threat recognition and threat identification.
Ironically, for at least 25% of the victims exposed to trauma the system seems to be even less effective and therefore this is the category that requires trauma memory processing and better integration in the longer-term memory systems (hippocampus and neocortex), so that eventually when memories are recalled the threat system will not be unnecessarily activated and instead past events simply turn into stories or narratives from our past.
Updating trauma memories involves going over the traumatic event and identifying specificmoments that create the highest level of distress during this detailed recall through imaginal reliving. Next, identifying positive or hopeful messages, symbols or even other people that add new information and meaning to the event.
In NeuroAffective-CBT at this stage, attention is also directed towards feelings and physiological reactions by encouraging a focus on the location and the intensity of the distress within the body. This is followed by clear but gentle instructions at every step to keep track of the intensity of the distress and self-regulate through breathing and progressive muscle relaxation, in parallel with the memory recall.
It is important to remember that memory recall in a state of high emotion can increase the arousal to the point of overload sending new sensory impressions in the amygdala. In other words, upgrading the memory with more traumatic material, which might have a negative effect.
As such, a precursor to this exercise would be a strong bond and a trusting relationship with the therapist, which facilitates down regulation and self-soothing during heighten states of arousal or dissociative states. Grounding techniques, attention training techniques, practising safe place, progressive muscle relaxation and body scanning are proven tools that help with self-regulation.
Safe place or grounding imagery can be introduce at different times in order to establish distance and a sense of safety for example: ‘you are safe now travelling on a train looking at the passing scenery, your memories are just passing scenery…or… you are in your own private cinema, it feels safe, comfortable and distant, you are watching your own memories unfold on the screen, just like a movie, scene, after scene..’.
All the above present-focused exercises are essential, since trauma recall is reported to dissociatively bring online a sense of being back during the event that caused the trauma in the first place, even if/when this took place decades earlier. Grounding exercises, safe place, bilateral tapping used in NA-CBT or any other sensorial bilateral stimulation used in EMDR are all meant to downregulate and create a sense of ‘hear-and-now’ by distributing, widening and re-orienting attention during the recall (EMDR article Mirea, 2012).
In TF-CBT reading out the traumatic episodes are also common reliving exercises though the risk for retraumatising is higher without specific memory upgrading. According to Clark and Ehlers (NICE recommends their model for PTSD treatments within NHS) negative appraisals of the trauma poses a special challenge as much of the patient’s evidence for the problematic appraisals stems from what they remember about the trauma. Thus, work on appraisals of the trauma needs to be closely integratedwith work directly on specific traumatic memories. The disjointed intentional recall of the trauma in PTSD makes it difficult to assess the problematic meanings by just talking about the trauma, and has the effect that insights from cognitive restructuring may not be sufficient to produce a large shift in affect and those are a precursor to what is know as re-traumatisation.
Understanding trauma triggers is equally important. The aim would be to break the link between the triggers and the trauma memory. This could be achieved in several ways, including teaching the patient to distinguish between the past – ‘Then’ and ‘Here & Now’; i.e., the patient learns to focus on how the present triggers and their context ‘Here & Now’, are different from the trauma (‘Then’). This can be facilitated by carrying out actions such as movements or bringing to mind positive images or touching objects that grounds and connects the patient within present moment. Patients would practice these strategies in their natural environment during sessions. When reexperiencing occurs, they remind themselves that they are responding to a memory, and this is not the current reality. They could focus their attention on how the present situation is different from the trauma and may carry out actions that would have not been possible during the trauma.
In NeuroAffective-CBT, imaginal reliving is not presented as an intervention aimed at enhancing emotional habituation to a painful memory but instead this is a moment-to-moment detailed reliving, which could and often should be time framed. This helps to identify specific traumatic memories, highly dissociative moments, which would be addressed through cognitive and somatic processing. Bilateral stimulation does not have to be used, not least because tapping is an unusual technique and for some people even inappropriate, as long as attention training, memory upgrading, and cognitive restructuring is carried out in parallel with emotional regulation with the scope of achieving a renewed sense of distance between the traumatic episode and the present moment. Comments such as, ‘I now feel this happened a few weeks (or years ago) and I am no longer in danger… that moment is less clear…’, ought to be the principle aim with this type of processing.
In summary…
Trauma processing is just a small part of the treatment protocol for trauma, a constant focus on therapeutic alliance, problem solving skills and new coping skills ought to be part of the repertoire that enhances individuals’ resilience. Cognitive and Behavioural therapies have a range of methods and interventions available. For the newly trained CBT therapist, it is important to study as many as possible, and work under CBT supervision with various interventions, constantly developing and refining their ability to tailor the treatment to each individual’s needs, abilities, learning style and personal values.
This article is focused on traumatic memory processing and only briefly outlines other essential interventions. A comprehensive trauma treatment would have to address all mechanisms that predispose, precipitate and perpetuate symptoms of PTSD. This suggests that a series of bio-psycho-social traps would have to be identified and disrupted, According to Dr Meichnebaum positive outcomes are further enhanced by developing resilience rooted in individuals’ culture, personal values and strengths. Meichenbaum has reminded us in his characteristic manner that we are not only homo sapiens but also homo-narrans or story tellers or narrators, therefore the stories that individuals tell will determine if victimised individuals will fall into the 25% or 75% group (Meichenbaum, lecture notes 2022).
REFERENCES
Hackmann A, Ehlers A, Speckens A, Clark DM. Characteristics and content of intrusive memories in PTSD and their changes with treatment. J Traumatic Stress. 2004; 17:231–40.(30).
Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M. Cognitive therapy for PTSD: Development and evaluation. Behav Res Therapy. 2005; 43:413–31.(32).
Ehlers A, Steil R. Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach. Behav Cogn Psychotherapy. 1995; 23:217–49
Meichenbaum D (2022). Lecture notes donated by author.
Meichenbaum D (2012). Roadmap to resilience: a guide to military, trauma victims and their families. Available on Kindle Amazon and on the websites: UKCHH and Melissa Institute.
“BOLSTERING Resilience” with DonaldMeichenbaum is part 1 of a series on essential CBT skills for Building Resilience re-edited and re-published by Daniel Mirea on NeuroAffectiveCBT.com and Academia.edu with author’s permission for free use and specialist training – the content belongs exclusively to Dr Donald Meichenbaum (this material can also be found on the Melissa Institute website)
Dr Donald Meichenbaum is an American Psychologist, Distinguished Professor Emeritus of Waterloo University, Ontario and a Research Director of the Mellissa Insititute for Violence Prevention. But he is much more that, Dr Meichenbaum is one of the CBT founders alongside earlier pioneers such as Beck and Ellis; he is better known for his ‘Clock Conceptualisation’, SIT model (Stress Inoculation Training) and Cognitive Behaviour Modification approach. Credited for his contributions with the nickname “The Freud of CBT” he was voted by APA in 1982, as one of the most influential psychotherapists of the 20th Century. Some of his extensive research on violent trauma might have been overlooked here in UK where the focus is much more on brief, cost-effective methods that can be applied within an NHS/ IAPT department. My goal is to correct that by drawing attention to his incredibly detailed research on constructivism, resilience, the use of spirtituality, stories, metaphors and narration in CB therapies; such interventions can be applied anywhere and translate to any culture. His work is best expressed through his lecture notes and handouts which he graciously donated for free learning and study. I kept these notes intact and whilst editing for online publishing, I realised this material could comfortably amount to a whole new approach, which I would personally label ‘Narrative Constructive Psychotherapy’. But of course, Dr Meichenbaum in his characteristic style is far too modest to accredit himself with yet another therapy label. As such, I will do that for him and in doing so, I take the opportunity to honour and thank him for his contributions over the years and ensure his legacy by passing his ‘teachings’ on to generations of psychotherapy students. When you read these notes, there is a feeling that sometimes he speaks directly to you in one of his lectures. Perhaps you should imagine exactly that…. enjoy.
This is for you Don! Happy Birthday!
These are authentic lecture notes and handouts written by Dr Meichenbaum, they were intentionally not edited, so that when you will explore the material you would get a sense of ‘here and now’ as if you are attending his lecture right now and he speaks directly to you.
Dr Meichenbaum talking about resilience and trauma with Daniel Mirea
TABLE OF CONTENTS
Evidence of resilience
Possible mediating mechanism
The nature of resilience
Implications for conducting psychotherapy
Intervention strategies for bolstering resilience
Characteristics of ” HYPE ” in the field of psychotherapy
EVIDENCE OF RESILIENCE
Trauma is everywhere, but so is resilience, the good stuff is more important than the bad stuff“In spite of behaviors”
Resilience can on short be described as positive adaptation despite adversity. Here are a few facts about resilience.
Individuals can be resilient at one time in their lives, but not at other times.
Resilience is not an all or none phenomenon. Individuals can be resilient in one area of their lives, but not in other areas of their lives.
Resilience (positive emotions) and trauma reactions (negative emotions) can coexist, side-by-side.
Resilience does not come from rare, special or extraordinary qualities or processes. Resilience develops from the “everyday magic of ordinary resources.” Resilience is not a sign of exceptional strengths, but a fundamental feature of everyday coping skills (Masten, 2014).
Resilience rests fundamentally on relationships. Attachment figures act as regulators of stress and provide a secure base. Bystanders provide “social capital”, nurture an adaptive capacity, and provide a sense of security. They foster mastery motivation and a sense of self-efficacy.
Resilience-engendering behaviors and positive emotions such as optimism, gratitude, forgiveness, awe, and the like, can contribute to positive neurobiological changes (brain chemistry and structural alterations), and even impact gene expression.
Resilience is more accessible and available to some people than for others, but everyone can strengthen their level of resilience and “islands of competence”.
POSSIBLE MEDIATING MECHANISMS
Exposure to multiple diverse traumatic victimizing experiences can alter brain architecture and function, derail developmental “wear and tear” on the body. (Allostatic Load)
Neurobiological changes resulting from exposure to Adverse Childhood Experiences (ACE’s) include alterations to the amygdala, hippocampus, anterior cingulate prefrontal cortex, nucleus accumbens, and at the neurochemical level alterations including dopamine, norepinephrine, epinephrine, cortisol, serotonin brain-derived neutrophic factor, endocannabinoids, glutamate and neuropeptides.
When a child experiences adversity early in life their monocytes and macrophages (types of white blood cells) become calibrated to respond to future threats with a heightened pain inflammatory response, and by influencing the hormonal system and dysregulation of cortisol levels.
Traumatic stress may alter the organization and “tuning” of multiple stress response systems, including the immune system, the autonomic system and the hypothalamic-pituitary-adrenal (HPA) axis and alter gene expression. For example, childhood maltreatment sensitizes the amygdala to over respond to threat.
Childhood adversity has been associated with shorter telomeres. Telomeres are receptive DNA sequences that cap and protect the ends of chromosomes from DNA damage and premature aging.
In terms of the developing brain, exposure to cumulative adverse events contributed to:
Reduction in the volume and activity levels of major structures including the corpus callosum (connective fibers between the left and right side of the brain), limbic system (amygdala and hippocampus) that is involved in emotional regulation.
Cerebral lateralization differences or asynchrony. Abused children are seven times more likely to show evidence of left hemisphere deficits.
Impact the communication between the Prefrontal Cortex (PFC) (upper portion of the brain) and the Amygdala (lower portion of the brain). The “top-down” regulation of executive skills can be compromised by perceived threats and stressors.
The bottom-up emotional processes (amygdala) can “hijack” the PFC.
The earlier and the longer the exposure to cumulative ACE, the greater the neurological impact.
THE NATURE OF RESILIENCE
Such psychological processes as positive emotions, optimism, active coping, social supports and prosocial behaviors, meaning making, humor, and exercise can foster and support resilience and reduce the intensity and duration of stress responsivity. Such positive activities are associated with reduced HPA axis reactivity. The impact of positive emotions is cumulative; repeated positive emotional experiences over time prime the system for optimal response to negative stimuli by expanding physical, psychological, intellectual and social resources (Fredrickson, 2001). There is a protective capacity of positivity. The presence of Oxytocin that accompanies engaging in resilience -engendering behaviors can counteract the impact of stress-engendering processes.
NEURO-PSYCHOLOGICAL MECHANISMS THAT NURTURE RESILIENCE
Reframing/Reappraisals is the ability to frame events in a relatively positive light. Functional MRI studies have shown increased activation in the lateral and medial prefrontal cortex regions and decreased amygdala activation during reappraisal. The increased activation in the lateral prefrontal cortex (the “executive” center) helps modulate the intensity of emotional responses and keeps the amygdala in check. Resilient individuals are better able to extinguish and contextualize traumatic emotional memories and can more readily retrieve positive memories.
Use of Humor is a way to engage in cognitive reappraisal and emotion regulation. A network of subcortical regions that constitute core elements of the dopaminergic reward system are activated during humor.
Exercise, Meditation, Mindfulness and Acceptance type activities have both neurological and psycho-social benefits, and bolster resilience.
Optimism is the inclination to adapt the most hopeful interpretation of the events which influences emotion regulation, contributes to life satisfaction, and increases psychological and physical health. An optimistic future-oriented outlook has been associated with increased activity in the amygdala and anterior cingulated cortex. For instance, optimists have lower rates of dying after cardiovascular disease over 15 years, compared to pessimists.
As Southwick and Charney (2012, p. 25) observe, “optimism serves as the fuel that ignites resilience and provides energy to power the other resilience factors”. But it is realistic optimism that works best, whereby individuals pay close attention to negative information, and not blind optimism that does not work.
Active goal-directed problem focused coping of taking direct actions when stressful life events are potentially changeable can increase neurotransmission in the mesolimbic dopaminergic pathways that increase pleasurable feelings and that stimulate reward centers such as the ventral striatum. Dopamine release in the brain leads to “openness to experience”, exploratory behaviors, and to the search for alternatives. A form of active coping is to engage in Behavioral Activation (physical exercise) which has positive effects on mood such as depression and that promotes resilience and neurogenesis. Exercise increases the level of serotonin, norepinephrine, dopamine and by stimulating the reward circuits in the brain. Exercise has also been shown to increase the size of the hippocampus and serum levels and increase brain volume (prefrontal cortex), especially among the elderly.
In some instances, when stressful events are not changeable, the use of emotional-palliative coping strategies such as acceptance, distraction, spirituality are the best ways to cope.
Prosocial behaviors and social supports and social competence, altruistic behaviors, helping others, and empathetic capacity facilitate resilience. The neuropeptides oxytocin, and vasopressin have been found to increase trust, compassion and enhance the reward value of social stimuli. Cortical “mirror neurons” have also been implicated in the regulation of positive emotions and can reshape the circuitry responsible for resilience. They play a role in facilitating social interactions by promoting shared understanding and empathy.
For example, compassion contributes to an increase in the level of endorphins, endogenous cannabinoids, endogenous morphine, dopamine, vasopressin, nitric acid, and oxytocin. In addition, the stimulation of the Autonomic Nervous System (ANS) engenders compassion, as compared to negative emotional distress. Compassion also triggers an orientation response and accompanying heart rate deceleration tied to respiratory sinus arrhythmia, heart rate variability and reduced startle responses and skin conductance (vagus nerve response), as well as triggering “mirror neurons”. Resilient individuals are better able to bond with others and attract social support.
Low levels of social support have been linked to increased rates of depression, anxiety and PTSD. In a 9-year prospective study, individuals with no or few social supports had 1.9 to 3 times the risk of dying from a variety of illnesses, including cancer, cerebrovascular and cardiovascular diseases, as compared with those who had optimal social supports. Among the elderly, loneliness is a strong predictor of early morbidity and has the same predictive power of smoking and lack of exercise.
Helping individuals increase their social supports and engaging in caregiving activities trigger the immune system to respond positively and stimulate the reward circuits along the medial forebrain bundle and engages dopaminergic neurons. Various hormones and neuropeptides like oxytocin and vasopressin facilitate social engagement and increase adaptation to stress by increasing empathy, eye contact, social cognition and problem-solving skills. Such positive attachment relationships buffer physiological stress responses.
Meaning-making is another strategy that can buffer against negative feelings and is associated with resilience. Having a role model who provides a “guiding light” and developing and following a personal “moral compass”, holding spiritual beliefs, and engaging in religious faith-based practices bolster resilience and facilitate recovery. For example, consider the experiences of Jerry White (2008), who lost limbs to landmine explosions and who founded Landmine Survivors Network, which later became the Survivor’s Corp. It is designed to foster a mindset of “Survivorship”, which he defines as “choosing to live positively and dynamically in the face of death, disaster and disability; a form of meaning making. His approach is designed to combat the development of a “victim mentality” where individuals tend to pity themselves, resent their circumstances, live in the past and blame others. White believes that a victim-minded person is generally inflexible, stuck in his or her grievances, and is seemingly unable to let go, find hope, or move forward. Over time, a victim’s intense focus is on their own personal suffering which can interfere with his or her ability to take positive action, relate to others in a healthy manner, or participate more fully in daily life.
White proposes five steps to help trauma survivors to tap their innate resilience and grow stronger.
Face facts: acknowledge and accept what has happened, the suffering and loss. Find a way to live with it and piece together a “personal story”.
Choose life: live for the future, not in the past.
Reach out: connect to others who have “been there”. Reach out to peers, friends and family.
Get moving: set goals and take action for a healthy recovery. Develop an individual action plan and identify your life priorities. Each step engenders hope and builds self-confidence. Regularly evaluate your progress and when needed re-evaluate and change one’s objectives. Such individual action plans are a contract of sorts with oneself and with others.
Give back: be thankful for what you do have. Contribute to others and to your community. Express gratitude – – thanking people who have helped. Express generosity – – giving back more than taking. Move from being a beneficiary to a benefactor.
Hamby has highlighted three areas of resilience-engendering activities:
a) Emotional regulation of both negative and positive emotions— emotional
awareness, distress tolerance, a positive Mindset, feelings of
self -efficacy, and the ability to cheer oneself up after bad things
have happened.
b) Interpersonal supports– family support, able to share feelings, problems
and family rituals/parent monitoring and investment in academic competence/
sense of belonging “mattering”/ support from prosocial peers/ at least two adults
outside of the immediate family who have connected with the child/ teacher
engagement and school connectedness/ feeling safe in school and in the
community/community supports.
Meaning-making activities– religion and spirituality/ dedicated to a cause,
sense of purpose / belief in a better future / commitment to a specific role
(student, worker, father, mother)/ adhere to code of honor or possess a “moral compass”. As Viktor Frankl observed, “Anyone who has a WHY in their life can learn to handle any HOW.”
In summary, the experience of positive-balanced emotions such as optimism, joy, pride, contentment, compassion, love, forgiveness, gratitude, humor have been associated with distinct neurobiological and psychological changes that provide a protective capacity. The positive emotion of awe, which reflects positive feelings of being in the presence of something vast that transcends our understanding of the world contributes to altruistic behaviors and to a sense of community. Awe helps shift one’s focus from a narrow self-interest to the interests and well-being of a group to which individuals belong. Sights and sounds of nature, collective rituals, artistic events of music and dance elicit positive emotions that have behavioral and physiological sequelae. These neurobiological responses include:
Increase of neurotransmitters like cortisol levels that facilitate pathway communication between Prefrontal Cortex (PFC) and subcortical systems like the amygdala. For instance, GABA (gamma amino butyric acid) which is an inhibiting neuropeptide made in the orbitomedium PFC (OBPFC) when released “turns down” the alarm system of the amygdala. The left PFC, a site associated with positive emotions such as happiness, is more activated during Compassion Meditation.
These positive emotions reduce physiological arousal and broaden and build an individual’s focus of attention, allowing more creative inclusive, flexible, integrative perspective taking, engenders positive reappraisal of difficult situations, fosters problem-focused coping, and facilitates the infusion of ordinary events with meaning. Fredrickson, in her Broaden-and-Build Theory, highlights that the impact of positive emotions is cumulative. Repeated positive emotional responses to negative events expands and builds psychological and behavioral resources.
IMPLICATIONS FOR CONDUCTING PSYCHOTHERAPY
The research on neurobiology of resilience underscores the value of conducting psychoeducation on neuroplasticity (the power of the human brain to change and repair itself) and the potential recovery from experiencing traumatic and victimizing experiences. The therapist can help clients learn a variety of skills and engage in activities that bolster positive emotions and improve resilience and health. When discussing with clients the lingering impact of traumatic and victimizing experiences, the therapist can convey examples of how the body “keeps score” and the enduring impact on the clients brain and behavior. The good news, however, is that the brain is a remarkable resilient organ and clients have the potential ability to reverse this process. Clients can learn to capitalize and build upon what is called neuroplasticity, and moreover, even begin to “turn on” and “turn off” the genes in their body (neurogenesis).
The therapist can say: “Let us begin by having you better appreciate the possible impact that traumatic and victimizing experiences may have on your brain and behavior. Traumatic events and losses can lead the lower part of your brain that is the emotional center to:
… hijack; overwhelm; flood; overshoot; ramp up; exceed; trigger action pathways; over activate and have a spiraling, cascading snowball effect; prime or kindle; shorten your fuse; and undermine and shut down the upper part of your brain, the frontal lobe executive control center.”
When conducting this type of psycho-education, the therapist should choose one or two of these illustrative verbs to describe the impact of traumatic and victimizing experiences and accompanying losses. Do not overwhelm the client. The therapist should then solicit personal examples from the client that reflects that activity.
“Can you give me an example of how you did X?” (Choose one of the following):
“Magnified your fears; time slide back to your old ways of coping that once
worked for you; went into a kind of autopilot mode of survival; engaged in
safety behaviors; were hypervigilant and constantly on the lookout for possible
threats; repeatedly conducted a kind of after-action analysis in the form of
ruminating; had difficulty sleeping; sought an adrenaline-rush by engaging
in high-risk behaviors, used booze or drugs to self-medicate?”
The therapist can convey to the client that he/she noticed, and wondered if the client also noticed, these behavioral patterns and “What is the impact, toll and price that resulted?” After discussing such consequences and how they may interfere with achieving the treatment goals, the therapist can convey that the therapy can help the client learn how to: (Choose one)
their error detection skills; soothe, down-regulate, label and tame emotions,
surmount your fears, orchestrate, get accustomed, accepted, organize your
traumatic memories into a narrative account, develop coherent redemptive
stories that have a beginning, middle and ending, note what you have done to
survive, contextualize and put the landmark traumatic events into a larger
autobiographical account.”
The therapist can highlight that attention and increased awareness are the key first steps in the ability of the brain to repair itself. The client can learn how to “talk back” to the amygdala or the lower part of the brain and take charge once again. For instance, clients can learn emotion-regulation skills and they can come to tell themselves and others:
“I can rewire my brain.”
“I can talk to my amygdala (the alarm center) and train my emotional brain.”
“Not allow my amygdala to hijack my frontal lobes.”
“I can use the upstairs part of my brain to calm down the downstairs part of my brain.”
“My positive emotions can Re-shape my brain.”
“Positive relationships that I have can switch on and off different gene contributions and leave a positive chemical signature on my genes that affect my braindevelopment.”
“By being kind I can raise my level of oxytocin which curbs stress-induced rises in heart rate and blood pressure and that reduces feelings of depression. Being kind protects my heart.”
“I can reduce my heart rate by 6 to 10 beats per minute by taking slow deep (diaphragmatic) breaths.”
“I remind myself that my brain is not fixed, nor static. It is highly plastic and flexible.
It can repair itself, with my help.”
“As with other parts of my body, I need to use my brain or lose it.”
“If I don’t stimulate my brain, my brain cells will die and be pruned away.”
“I have the capacity to bend, but not break.”
“I can see the big picture and find the silver lining and develop a new normal.”
“I can get myself to do what I do not feel like doing and get myself out of my comfort zone.”
INTERVENTION STRATEGIES THAT BOLSTER RESILIENCE
(See Meichenbaum’s Roadmap to Resilience book for examples)
Use Physical exercise – – Behavioral Activation and use Active Coping Strategies.
Use Emotional Regulation and Distress Tolerance Skills and Increase the Protective Capacity of Positivity that Buffers Negative Feelings.
Focus and savor positive emotions and past reminiscence and anticipate positive emotions (anticipating). Engage in goal setting and affective forecasting in the form of positive future-oriented imagery that nurtures hope. Avoid “dampening” or minimizing positive events, “I don’t deserve this”… “This won’t last”.
Engage in Mindfulness Exercises – – pay attention in a particular way, on purpose in the present moment, and nonjudgmentally.
Engage in Loving-kindness Meditation and engage in Acts of Kindness.
Engage in gratitude exercises “Give back and pay forward”.
Engage in Forgiveness exercises Toward others and Toward Oneself – – Compassion is the awareness of the suffering of others and oneself, coupled with the wish and effort to alleviate it.
Engage in Meaning-making Activities and Cognitively Reappraisal (“Healing through meaning”)
Use Spiritual-related Activities – – Use of One’s Faith and engage in communal religious activities (See Meichenbaum “Trauma, spirituality and recovery” )
Increase Social Supports – – keep interpersonally fit by participating in positive activities; selectively choosing and altering situations, improving self-presentation (smiling, dressing up), improving communication skills and accessing social networks.
Use humor, Have fun and build-and-broaden Positive Emotions (“Bucket List Activities”)
Each of these Activities will help bolster resilience by increasing the accompanying neurobiological processes. There is increasing data that a course of psychotherapy- even without medication- had measurable physical consequences in the brain.
CHARACTERISTICS OF “HYPE” IN THE FIELD OF PSYCHOTHERTAPY
Your attendance at this conference reflects your interest in increasing your knowledge and your clinical strategies and skills to help your patients achieve better treatment outcomes. Such concerns are timely given the research findings in the field of psychotherapy on the marked variability in effectiveness across psychotherapists. The most effective psychotherapists average 50% better outcomes and 50% fewer dropouts than psychotherapists in general (Wampold, 2017). One of the characteristics of more “expert” psychotherapists is their penchant for maintaining a critical attitude apropos of Paul Meehl’s (1973), admonition of “Why he does not attend case conferences,” and the presence of “SELF-DOUBT.” Research indicates that psychotherapists self-reported self-doubt predicted treatment outcomes- more doubt about their skill in helping patients (e.g., “Lacking confidence that you might have about a beneficial effect on a patient.” and “Unsure about how best to deal effectively with a patient.”), had better treatment outcomes, particularly if they also had a positive sense of self. Consistent with the article by Nissen-Lie et al. (2015) entitled “Love yourself as a person, doubt yourself as a therapist ” , the present Psychotherapy Consumer Checklist is designed to plant the seed of self-doubt and nurture a healthy sense of “HUMILITY “, and hopefully improve treatment outcomes. What follows is a Checklist of “Psychotherapy Beware Signals.”
1. Advocates for a therapeutic approach state that their treatment is “revolutionary” and offer outlandish unsubstantiated claims for its superiority (Over 90% improvement rates). “Simple, but powerful” treatment approach. “A breakthrough treatment.”
2. Make claims that you can learn from a “master”, “leading expert” or “guru” and use marketing terms like “powerful”, “transformative”, “unique and ultimate training,” “life-changing benefits”, “deep psychological healing”, and moreover, assure that your “complete satisfaction is guaranteed.”
3. Advocates use Acronyms (Acronym Therapies) and “psycho-babble” to sell their treatment approach.
4. Claim that the treatment approach could be applied successfully with patients who have a wide variety of psychiatric and physical conditions, and across multiple age groups without any clinical trial demonstrations. Advocates often imply that their treatment approach “fits all” (“One size fits all”).
5. Claims that treatment approach is “evidence-based”, scientifically proven, because it has met the criteria of two randomized controlled trials, but they do not report Effect Sizes, nor provide details about the exclusionary criteria of the patients. “Cherry-pick” the patients. Also, does not report on the attrition and drop-out rates, follow-up data. Advocates often broadly and subjectively define “evidence” (e.g., “I saw it work with my clients, and that is my evidence”.)
6. Advocates state that “Over X number of studies have consistently demonstrated efficacy and superiority”, without citing or critiquing these studies.
7. Compare proposed treatment to “weak” comparison groups. Does not compare treatment to “bona-fide” comparison groups that are intended to be effective (See Wampold et al., 1997).
8. Compares the proposed treatment versus a reduced, or weaker version of the comparative treatment. For example, see Foa et al. (1999) comparison of Prolong Exposure versus Stress inoculation training (SIT), where the third application phase of SIT was omitted.
9. Do not report on possible “allegiance effects” of who conducted the controlled outcome studies. Moreover, the cited supportive studies that were initially conducted yielded more effective results than later conducted studies. (“Strike while the iron is hot”, and when the enthusiasm for the new therapeutic approach is highest.) See the provocative informative article by Lehrer (2010) of the “decline effect” in research attempts to replicate clinical trials. For example, the efficacy of antidepressant medication has gone down as much as threefold in recent decades. Effect Sizes from studies from treatment studies drop off. He observes that the researcher’s belief can act as a kind of blindness.
10. Do not independently determine if the treatment rationale offered to the alternative treatment and control groups is judged as being as credible and believable as for the advocated treatment. This can lead to differences in expectancy effects across groups.
11. Do not highlight the role of non-specific treatment factors, such as therapeutic alliance, expectancy effects, and other placebo considerations. For example, does not include any measures of the ongoing quality of the therapeutic alliance, such as the Therapeutic Alliance Scales, or the Quality of Relationship Measures, or the session-by-session treatment-informed feedback (Prescott et al., 2017).
12. Does not include a critical account of the scientific validity, or theoretical basis, for the effectiveness of the proposed treatment. Offers little scientific basis for the proposed change mechanisms for the treatment. See controversy over so-called “energy –based” treatments such as Tapping, Eye Movements, Magnetic fields, Meridian band techniques and the like. The intervention may work, but it has little to do with the proposed treatment model. The proposed treatment may do better than no treatment, or weak control and comparison groups because of non-specific factors, such as placebo effects.
13. Advocates use “neuro-babble” and “neuro-networks” and reductionism (often with colored versions of the brain) to explain the treatment approach. They resort to a dubious neurological basis for the explanation of their treatment approach.
14. Advocates fail to discuss criticisms of their treatment approach. They fail to mention the results of dismantling studies that question the basis of their treatment approach.
15. Advocates tell their patients that “If this treatment does not help you, then nothing else will.” They convey an expectancy that reinforces treatment outcomes.
16. Advocates promote advance training, sell paraphernalia, tapes that go along with their treatment approaches. They require that trainees sign statements that they will not share treatment protocols with others. “Commercialism is rampant.”
17. Advocates are very defensive and “thin-skinned” about their approach. They often question the motives and background of those who have questioned the efficacy, theoretical basis of their treatment approach. They fail to question what they are proposing and readily dismiss skeptics. They may disregard “inconvenient truths” and offer “alternative facts”, thus, holding onto debunked theories.
18. The advocates of their treatment approach rely on the endorsements of a leaders in the field. For example, some therapists in the trauma field cite Bessel van der Kolk as an advocate and endorser of their treatment approach.
19. Advocates establish a coterie of trainers and an International organization to promote the treatment. Advocates use public media (television, blogs, print) and they over sell their treatment approach. Advocates are “slick salespersons,” setting up clinics, training settings, and conferences.
20. The advocates will provide a Certificate that you have taken the training and can call yourself an X therapist. Offers to put you on a referral list of Certified X practitioners.
HOW MANY OF THESE 20 ITEMS DOES YOUR TREATMENT APPROACH INCORPORATE?
For online training with Dr Meichenbaum please follow the UKCHH link below.
The UK College of Hypno-CBT, led by principle Mark Davis is a respectable and ethical organisation commited to evidence-based CBT, Mindfulness and innovative Hypnotic approaches that improve resilience, symptomatic independence and self-efficacy.
Neuroaffective-CBT 