Winning the mental warfare with COVID-19 (CBT Self-Help for COVID-19 Anxiety)

Audio version

Recent reports indicate that the level of mental health symptoms amongst the general population are on the increase. A Young Minds study published in The Guardian on March 31st 2020 asked 2,111 under 25s with a history of mental health needs, how the pandemic had affected them. 83% said the pandemic had made their mental health worse.

More recent clinical experience also indicates that the overall numbers of mental health disorders, in particular anxiety and depression  are on a steady increase and will eventually cover many different segments of the population.

There is currently a justified, growing concern for the mental health of all frontline workers from NHS and the police forces across the country; but also for delivery drivers, various transport workers, engineers, cleaners and supermarket workers. No doubt, these truly are the heroes of the day.

On the other hand there seems to be less focus on other clinicians from the second tier of exposure who may not necessarily be on the frontline, directly tackling COVID-19 patients, for instance mental health nurses, psychotherapists, psychiatrists, physiotherapists in smaller hospitals or private clinics. Even less thought is given to the general population who cannot it seems, cope psychologically and emotionally in self-isolation.

The potential consequences of self-isolation

We know from various psychopathology,  biology and behaviour studies  that in spite of displaying incredible resilience in the face of various diseases, humans are not well equipped to deal with social isolation and ‘psychological  uncertainty’ for prolonged periods of time –  this would inevitably be a catalyst for a range of mental health pathologies including depressive and anxiety disorders. For those that are already suffering from a mental health problem, it could symptomatically be even worse, as the recent Young Minds study clearly outlined only a few days ago. Social isolation, catastrophical thinking, long episodes of negative rumination, lack of purpose, increased drinking and less physical exercise are risk factors for major depressive disorders and anxiety disorders.

Self-isolation therefore may be both a blessing and a curse, since it will clearly help us manage COVID-19 but at the same it might bring with it a series of challenges including, how to spend time at home in a way that improves our mood and does not increase feelings of fear, sadness, anger, isolation and lack of purpose.

There are several self-help tools originating in the family of Cognitive Behavioural Therapies that are likely to help. To offer some context, Cognitive Behavioural Therapy or CBT is an umbrella term for a range of evidence-based psychotherapies that successfully combine behaviourism with philosophy, learning theories, cognitive psychology and more recently neuroscience and neuroaffective research. Unlike other therapies, CBT is structured, symptoms focused, goal-oriented and aims to enhance self-efficacy by introducing a range of self-help technology. These techniques could  be very helpful in the current climate.

 CBT strategies for social isolation

A number of evidence-based strategies are recommended by CBT therapists. It might be best to organise those in 3 categories: mind, body and regulation of emotions; or in CBT terms, cognitive interventions, behavioural interventions and regulation of affect (or emotional regulation).

Mind or Cognitive Interventions

When it comes to the ‘mind’ everyone is different but individuals’ reactions to threats are very similar.  The current ‘threat’ is obviously that of being infected with a dangerous virus which leads to fear, intense preoccupation, hypervigilance and a range of other symptoms associated with an anxiety disorder and stress.

A good place to start is by understanding and truly accepting that ‘fear’ is an essential emotion, much like sadness, anger or joy; all these emotions are very well embedded and encoded in our genes, in our neurological circuits. Such complex connections essentially enabled our species to survive over tens of thousands of years. And as such, this is not an emotion we would want to get rid of. For example, if we would not experience a higher degree of fear in relation to COVID-19 we would be too laid back and less inclined to protect ourselves and other members of our community. 

Nonetheless, there is a very fine line between the emotion of fear and an anxiety disorder, best explained perhaps by some of the cognitive psychology research which stipulates that people tend to get anxious when they overestimate the probability and possibility of the threat and underestimate their coping skills or other (external) rescue factors, resources and so on, they might have at their disposal (when or if faced with the predicted threat).

Following up from that, a very useful self-help strategy evolves from this formula which focuses on ‘de-catastrophising‘ the impact of the threat. In this case obviously, it translates into decatastrophising the threat that COVID-19 would pose to our health and our community in the long run.

Decatastrophising COVID-19

The process of decatastrophising might feel a little slow involving several daily practices, it is best to be patient and thorough.

Mindfulness & acceptance of your distressed thinking

To begin with, we could attempt a very simple mindfulness and acceptance technique.  My advice for everyone at home is to practice regularly and gradually learn to increase their awareness of unhelpful ‘trains of negative and catastrophical thoughts’ in order to learn to distance themselves from them.

Just allow your thoughts to come and go as they please and do not engage with the content, with the message these thoughts are trying to deliver…  just accept them…

You will soon learn to view your thoughts exactly for what they are – just normal mental activities – you do not have to believe every thought that pops into your mind AND feel the need to immediately act on it… learn to indentify Gaps of Silence in-between these ‘trains of thoughts’…  gaps where you feel safe and not urged to do anything… it might be helpful to imagine [whilst engaging your slow abdominal breathing] that there is always a gap in-between these long, sometimes connected trains.. Aim for the Gap.. Aim for the Silence. 

Mindfulness-based techniques can feel difficult when you try them for the first time, be patient with yourself, allow for mistakes, you do not have to get it perfect. It is a bit like going to the gym for your first time, your muscles will hurt, however you will get stronger if you persist.

Facts Finding, Installing Hope and Positive Self-Talk

A completely different way of dealing with catastrophic or negative thoughts, would be to practice generating a much more optimistic and hopeful ‘Self-Talk’ or ‘Self-to-Self dialogue’ between your ‘Anxious-Self’ and ‘Strong-Self’.

This optimistic and positive dialogue could be extended to someone in your household or to your social media community and consists of research and careful examination of all the evidence surrounding the threat (i.e. CORONA-19), keeping a focus mostly on positive facts:

Fact number 1: in regards to the level of threat, the virus is indeed dangerous but the majority of people will recover and most will build immunity against it.

Fact number 2: NHS, universities and research labs across the world are working tirelessly to develop testing tools and treatments which would more than likely build our immunity against COVID-19.

Fact number 3: there are a lot of specific examples of successful treatments, perhaps people that we know (i.e. Matt Hancock, Health Secretary) and have now recovered and are well. It may be important to write down these specific cases in bullet points and describe in detail a situation that impressed you and gave you hope.

Fact number 4: in regards to available resources and coping skills, much can be said about external resources which are literally improving every day (i.e. the new Nightingale Hospital in East London). But in regards to coping, ask yourself the following questions:

– Given all the above facts and the real threat this virus poses to me, how could I cope and what resources are currently at my disposal?

– What else lingers from my recent findings… perhaps more optimism… more coping strategies… or more hopeful facts…?

– In light of all my research and recent evidence, how true are all these statements?

The human race is fighting back in a variety of ways!”  (0-100%)

“We are not giving up!”   (0-100%)

We have seen much worse! We refuse to fall victims!”  (0-100%)  

* Rate the level of your belief in those statements from 0-100% and if the scoring is below ‘50%’ ask yourself, what could you do in order to improve the rating? How about backing these statements up with some more research and even more examples of resilience and recovery or other recent achievements and posting those on social media or write it in your personal journal (as opposed to focusing mostly on negative and sad stories).

Positive Data Logs

Another useful cognitive-behavioural intervention, would be compiling a Positive Data Log (PDL) on social media or indeed in your personal journal (or both, if you prefer it).

It is important to use these questions as guidance for your new PDL, though one could get very creative and add to it, there are no limits put on your exploration.

What am I learning from this experience about myself, about significant others (i.e. family & friends) and about the world around me?  

In how many positive ways has my life changed as a result of this situation?

I could of course think of a few things including, having more time with my wife and child, the desire to help the most vulnerable in the community, writing this article, being less focused on material things and more focused on the health needs of the family, on the needs of community in general, a renewed focus on hobbies long forgotten, on my true values, religion or spirituality or indeed the positive impact the virus has on pollution and nature.

All such mental strength or resilience building exercises could be viewed as ‘personal training’ for the mind; is it not curious that we find it absolutely normal and natural to go to a gym, invest time and money in strengthening our bodies and yet when it comes to our minds we hesitate… Why don’t we start right now infusing and enriching our minds with a positive attitude, more optimism and hope… What would that feel like?

The one thing that most people in social-isolation would have right now is time, this makes us a lot wealthier than we were this time last year.

Time can be used to catch up on your hobbies or unfinished projects, it provides space for creative and positive thinking, an opportunity to reconnect and talk to your partners or old friends (… I probably spoke more with my wife this last week then the whole of 2019 – we had a lot of catching up to do…)

Time provides us with an opportunity to repaint the spare bedroom, make bad music, practice our weird dance moves or read more. So what if you have not read a book in years – right now might be a good time to start by choosing the one you missed as kid.

All of the above strategies are very effective mind techniques or cognitive interventions against negative and catastrophical thinking and in favour of installing hope and a more optimistic outlook on life. Such positive mental focus and creative thinking would eventually lead to a variety of self-discoveries, interesting experiments and more valued actions.

….. For example only a few days ago I discovered for the first time how much I enjoy gardening with my family. It is something I would have never considered Pre-COVID19I might decide now, to show off by posting online this gardener-version of myself; I may briefly describe my newly found talent and in doing so, perhaps I will inspire another friend….

Behavioural interventions

I already mentioned earlier how my own positive data log and research lead to the discovery that I like gardening and enjoy longer talks with my family. Of course, not acting on these self-discoveries would have not provided me with the evidence that I actually enjoy new activities and therefore I could incorporate them in my daily or weekly routine. 

It is therefore important that we put into practice all new valued actions through routine and structure. In CBT we propose a self-management tool called Behavioural Activation this intervention is based on a simple idea – we feel much better when we engage with activities that we Enjoy, Feel a Sense of Achievement or Feel Connected with Others.

Enjoyment, Achievement and Connection!

Research into treating depression indicates that a day that includes a good balance of those three types of activities leads to significant improvements in our mood. Getting stuck in a vicious cycle of not doing things would make us feel unsatisfied, low in mood, less productive and less likely to want to do anything in the future.

Another important Behavioural Activation principle (briefly mentioned earlier) includes having clear routines and a daily structure. It might be tempting, even enjoyable in the short-term to have a flexible daily schedule however, once again the evidence clearly suggests that having a clear sleep routine, specific mealtimes and a strict exercise routine is much more helpful. Of course, there is no harm in having some unstructured or ‘down’ time during the day however, a general lack of achievable goals and structure may lead to helplessness and hopelessness (which could predispose an individual to more symptoms of depression).

SMART Planning at this stage becomes very important. For those that are not familiar with the concept, having SMART goals refers to goals which are Specific, Measurable, Achievable, Realistic and Timed – SMART ! If your goals do not meet the criteria, they need further tweaking or even changing.

For example, the goal ‘I want to be happy’– is not specific enough and cannot be measured whereas… ‘I would like to spend 20 minutes every day doing yoga with my partner’ is clearly a SMART goal, more likely to lead to feelings of joy and relaxation.  

When planning your day or even your week ahead, we must remember to carefully examine what we actually planned for. Look out for a combination of activities that include enjoyment, achievement and connection. If you are missing one element in the day try to build that in, later in the week – it is important that you do not abandon your plans and you do not procrastinate if it seems at times too challenging.

Give your Behavioural Activation diary an interesting name like Katie’s journal, Journal of my Achievements, Mr Big’s Diary, etc., own it and design it, in any way you want to.

You could create your own list/s for the day or a timetable for the week. You could use digital diaries with reminders, smart mobile phones or tablets, you could use Alexa or Google Home or simply use post-it notes which you could move around if need be.

Refocusing on Personal Values & Interests

One other behavioural self-help tool is Refocusing on Personal Values, Hobbies & Interests. You can ask yourself:

Is the way I am spending my time in line with my own personal values and interests?

At this stage, it might be a useful to study your PDL and compile a list of all your values and interests. If you are someone that likes to help others, it is important to make sure that some of your time is dedicated to activities that do that… you might consider donating or even volunteering for a day or two every week.

If learning new things is important for you, make sure that there is time for that. You could make time for creative activities for relaxation or lots of other things that could be done from a distance, like writing, painting, or sending letters to loved ones.

Emotional checking-in

Another important technique is creating a routine of ‘Emotional Checking-ins’ (or emotional sharing) on a weekly basis. This is like calling a regular team meeting at work with all your colleagues for the regular feedback and follow-ups, only in this case the focus on the agenda is our emotional state and what we do.

Take a little bit of time for yourself when you are with your family or your housemates at the end of the week on each Friday evening, to review how things have gone for you during the week and work out if there are things you want to improve for the following week.

Try to answer these questions:

Did any activities noticeably affect your mood in a positive way?

What are you grateful for?

Who do you want to acknowledge this week?

Was there a day when you felt not so great?

What was going on then and what could you do in order to improve next week?

Checking-in with ourselves and each other about how we feel and what we have done, can improve the mood and quality of the communication between different members of the household. As a weekly exercise this could lead to many insights, though some families prefer to do it daily – for example, every dinner time or before bedtime.

Remember – this is a checking-in exercise it is not a forum for resolving outstanding problems, everyone gets a turn for a 3 to 5 minutes to talk about themselves, and everybody else listens, acknowledges and thanks the speaker.

Assuming that you plan to have these feedback sessions on every Friday evening, it may be important not forget to plan something special,  more relaxing and even more fun for the weekend, at the end of the each session, something to look forward to. This might involve a family movie or 60 minutes of ‘disco night’ whatever works for you, your family or your housemates.

Let’s also remember that for now, we are allowed to use the outdoors for 30 minutes of training or walks, we can use our gardens but also our balconies.

Emotional Regulation

When we are dealing with any kind of mental health problems we cannot ignore how the body reacts to all external negative feedback and internal catastrophical thinking. Our system is very complex, it relies on the body to communicate to our mind that something is up or something is going on and vice-versa. 

We know in other words, that stress and anxiety have an immediate impact on our physiological state and mood through a variety of, what could be perceived as, unpleasant symptoms.

Anxiety and stress in particular are characterised by symptoms of hyperarousal such as heart palpitations, sweats, laboured breathing, chronic muscular tensions and so on. Such symptoms maintain the illusion of severe anxiety and over time could even trigger a fear of actual symptoms of anxiety.

Therefore it becomes vital for us to learn to down regulate when we are in a state of hyperarousal to a normal state, so that our physiological system does not weaken the immunity further and in the long term it does not develop stress related chronic illnesses (such as chronic pains for example or a worse).  

Research shows that regular physical training, attention training exercises, abdominal breathing and progressive muscle relaxation can help with the process of down regulation.

8-Emotional Regulation Exercises for Mind, Body and Soul

  1. The 3 – 4 – 5 Breathing Method

Breathe in up to 3 (counting in your mind)… hold your breath up to 4 (counting in your mind).. and finally, very-very slowly breathe out, counting in your mind to 5 or more…  This breathing pattern is very important! It is preferred that you breathe in through your nose opening your diaphragm widely and relaxing your abdomen and slowly breathe out through your mouth. 

2. The Breathing Square (also known as the Breathing Box)

The Breathing Square is similar, though in this case you also visualize drawing a square with your minds-eye while synchroning your breathing patters with the drawing of an imaginal square. You could also use your hand (or finger) to ‘air draw’ the square…   

Breathe in as you start drawing a lateral of the imagined square (starting with the right low corner), hold your breath on another lateral and exhale slowly through your mouth on the other two laterals, thus closing the square…

3. Progressive Muscle Relaxation

4. Body Scanning

Williams & Penman

5. Mindfulness training: Exploring Difficulties

Williams & Penman

6. Mindfulness training: The 3 minute Breathing Space

Williams & Penman

7. Body Appreciation

Body Appreciation’ might sound a little unusual for a mindfulness training exercise but experience shows that we can easily forget how to love, care and appreciate our bodies…

Have a long bath instead of a shower in the evening… use scents and your favourite bath cream… take your time to notice the pleasant smells… to feel the warmth of the water touching your body… imagine right now how this feels… give yourself permission to relax.. dont look back at your day.. dont look ahead at the rest of your night.. just allow your sense to come alive and feel… notice how the cream feels on your body as you gently apply it… do not rush this will only take a few more minutes.. minutes that you will soon learn to enjoy and appreciate..

8. Physical Strengthening

Physical Strengthening exercises are not any more difficult if you’re stuck indoors, but the motivation is usually low since training is naturally associated with going to a gym or a even park. Seek inspiration from tens of YouTube personal trainers, yoga teachers and other online classes. At the moment we still have the option to go out for 30 minutes of training but be realistic regarding your ability and plan a set of exercises which are tailored to your body and current ability. A walk with the dog is excellent exercise for some people whereas for others, complex martial arts or yoga exercises might be more appropriate.  

The basic principles of Emotional Regulation:

It is important to learn NOT to be afraid of our emotions, try to understand their role and allow them to alert you without immediately feeling the need to ACT – unless you are indeed in an imminent danger.

Learn to use your abdominal breathing and creative imagination to down regulate and calm yourself down… there is a lot of help, a lot of websites, apps and YouTube channels that provide excellent training in Mindfulness, Progressive Muscle Relaxation or Hypno-CBT.

Summary

  1. Write down a daily routine (your BA Diary should help with that) for Monday to Friday and a separate one for Saturday & Sunday – more relaxing and fun activities at the weekend and more time for hobbies and interests. Just like an ordinary week. Mon to Fri could be allocated to working from home but do not be tempted to work for more that 7 hours a day plus your regular breaks. Learn to switch off from work – working from home it’s not as straight forward as it sounds, it can be a mental health trap !
  2. Review your week every Friday (see Emotional Check-ins chapter) and make changes for the following week if necessary.
  3. Make sure your weekly plans include a combination of activities, the key words are: Achievement, Enjoyment with Connection.
  4. Check with your PDL, or personal journal and make sure that your values and interests are covered and leave some room for new ones that you will soon discover.
  5. Exercise – daily and schedule it in your diary, reserve 30 mins for physical training – outdoors (if safe and possible) and 30 mins more indoors if you can cope (i.e. jogging plus aerobic routines).
  6. Mindfulness – daily ! Aim to gradually increase your times over the following few weeks from 10 – 15 – 30 to 45 minutes of regular minfulness practice; no limits on this, as much as you can cope with – be patient you will not get it at first !
  7. If you are tired Sleep ! Do not fight it by trying to stay awake. Also train yourself to have power naps during the day or use a Mindfulness exercise to unwind.
  8. Nutrition and hydration: be sensible.. the temptation is to snack more and drink more alcohol, stay focused on healthy options, creative cooking (including smoothies) could be one of your new Values! Eat Well But Sensibly and Reduce the Alchool Intake ! Drink 1-2L of Water Every Day !
  9. Read and Write as much as possible… Start with the CBT exercises proposed above. Also do not forget to check out all the interesting links I have attached here for you, just click on the highlighted sections.

After all of that, do you still feel you are on a ‘holiday lockdown’?

A Free Podcast and more Free Links will be added to this article over the next few days, please feel free to come back and ‘check-in’ from time to time.

Whatever type of exercise or self-help tool you feel is appropriate for you and those you live with, it remains vital that you include this in your daily structure, you enjoy it, you feel a sense of achievement and even a sense of being connected with others while doing it.

As a final note, I would like to share a surprising poem of hope with you by O’Meara, C.

And the people stayed home. And read books, and listened, and rested, and exercised, and made art, and played games, and learned new ways of being, and were still. And listened more deeply. Some meditated, some prayed, some danced. Some met their shadows. And the people began to think differently.

And the people healed. And, in the absence of people living in ignorant, dangerous, mindless, and heartless ways, the earth began to heal.

And when the danger passed, and the people joined together again, they grieved their losses, and made new choices, and dreamed new images, and created new ways to live and heal the earth fully, as they had been healed.

Stay Healthy and Hopeful!

by  Daniel Mirea (4.04.2020)

*Acknowledgement to Mark Williams & Danny Penman for some of the mindfulness materials used fairly and for non-profit purposes. Their complete training programme can be purchased via the link provided, currently there are free offers on on Amazon Prime through the Audible app.

*Training in Evidence-based Hypnosis ( Hypno-CBT ), Relaxation and Stress Management offered on-line during the lockdown here.

Beat Anxiety with Attention Training (NA-CBT)

One of the problems with anxiety and psychopathology in general is lack of psychological flexibility which translates without exception into poor attention training skills. When self-critical, self-blame thoughts, worry or shameful thoughts enter our awareness, our attention is literally hijacked by these thoughts and we start engaging with them.

For example, in the case of clinical perfectionism, when we are requested to produce an important business report we tend to worry about the language, typos, the format and so on, even after it has been completed. After we submit our work we might continue to worry about it or about the perceived negative feedback we could receive as a result of poor quality work. Of course, these are all false projections into the future or even catastrophical predictions (e.g. this is the end of me, I will lose my job this time 100%).

When these negative thoughts (predictions and so on) enter our mind our attention is 100% directed towards the content of such thoughts, which triggers our sense of threat. This means that our brain (and body) starts to believe that we are under threat and it responds by further triggering the Autonomic Nervous System (the sympathetic response), which manifests through a range of physiological symptoms of anxiety (heart racing, sweating, etc.). And thus, the ‘perceived threats’ start to ‘feel’ real. Over time and with lots of practice such negative thoughts begin to govern our existence and become more and more believable. In other words we become very good at getting anxious.

autonomic-nervous-system

Selective and narrowed attention, directed towards the content of the thought (e.g. false predictions about the future) is clearly one of the principle precipitating (or triggering) factors and also an important perpetuating (or maintaining) factor in anxiety disorders.

So what can we do about it? Some of the methods involve learning to re-orient the attention towards something else, more positive or more constructive. But at times this exercise alone, would often fail. We have more recently discovered that, re-orienting the attention towards the breath and breathing, enables a shift towards the ANS parasympathetic response (the rest mode) which cancels symptoms of anxiety generated by the ANS sympathetic response (the threat mode) by encouraging a calm and relaxed state. When the action of breathing is coupled with a visualised self-instruction, the process is significantly faster and longer lasting.

For example, right this moment, direct your attention towards your breath, feel the air coming in and out for a few seconds, slow your breath down (shorter inhalations and longer exhalations) then.. with each outbreath, merge more and more into your favourite relaxation place (could be your garden, a yoga class, or your favourite holiday spot). Try it once again, right now…

ANS system

Awareness is key! Every time a negative thought enters your mind, you could train yourself to be aware by simply noticing without judgement that, this is happening. At this stage, you can start training your ‘attention muscles‘. Notice your thoughts, accept them as just thoughts and zoom out, bring your attention back to the present task (to whatever it is that you were doing a moment earlier) and then take your attention back to the thought – is it now just as captivating as it was earlier or did it move on? Accept if the thoughts are still there.. but also accept if they are not… just be an observer of your own mind… Be proud of your newly discovered ability and don’t attempt to master this. Allow for mistakes, just notice that sometimes you cannot get it right… remind yourself you are still in training. You are a student of your mind… indeed of your life… just allow this natural movement to happen.

Awareness (or self-awareness rather) is attention training !

Attention training is a major component in NeuroAffective-CBT and mindfulness based therapies which places this type of therapy under the third wave umbrella (see previous article on Third-Wave CBT). By paying attention to what happens right now (in the present moment), and doing it with an accepting attitude (towards whatever you notice), you become a safe and confident observer of your internal world and experience… your breath, body sensations, thoughts, feelings, sensory experiences, etc. Awareness and attention training involves practising how to notice when your attention is wandering away from the present, and then skilfully redirecting your attention back to the ‘here and now’. This is not an attempt to suppress, neutralise or control your thoughts in any way. But instead allowing these thoughts to be present and active, to do what they are meant to be doing. At the same time, develop efficacy and confidence by choosing to shift your attention back on to something purposeful.

For specialist courses in attention training follow the link below – the training is open to all !

https://www.ukhypnosis.com/evidence-based-approaches-to-ptsd-tf-cbt-emdr-with-daniel-mirea/

Is ‘perfectionism’ a deal maker or a deal breaker ?

Most people would consider having high standards a good thing but at times this is just part of the plot or in other words, part of a complex trap called ‘perfectionism‘. Striving for excellence might indicate that you have a solid work ethic, strength and ambition. But if and when achieving success (in any domain) is consistently associated with one’s value, self-worth and esteem, we risk falling into the trap of perfectionism.

High standards could indeed propel one towards the peak level of their potential. This is very common with professional athletes or musicians for example, who train long and hard to reach excellence in their respective sport or art. Clinical perfectionism could however develop when the individual believes that his/ her worth, value and appreciation by others, uniquely depends on achieving success all of the time and never failing a task. In parallel with that, standards are set so high that they often cannot be met, or are met with a great deal of difficulty. Perfectionists tend to believe that anything short of perfection cannot and should not be tolerated, and that even minor mistakes or imperfections will lead to one conclusion only: that they are not worthy or good enough individuals.

Generally speaking, we might believe that it is important to try to do the best that we can in one or more areas of life. However, most people also believe that making mistakes from time to time is reasonable and inevitable. Making a mistake does not mean they have failed entirely and this will ‘define’ them and ‘follow’ them forever. Perfectionism positions itself within this spectrum. Adults and even adolescents* with perfectionism tend to believe that they should never make mistakes and that making a mistake means they are a failure across the board, they are unworthy individuals, consistently disappointing others. Thinking like this makes perfectionists hypervigilant because of the prospect of making mistakes and as such, perfectionists experience constant states of hyperarousal, shame and defeat.

When exploring an individual’s early years it is easy to understand the origins of such attitudes to self and others. Perfectionism is encouraged in many families. Sometimes parents consciously or unconsciously set very high and very rigid standards. It can actually be very easy for any parent to fall in this trap given how much more competitive the world is. Demanding parents however would require top marks in school, medals in sports and flawless ballet recitals. Mistakes could be harshly punished. The punishment does not need to be physical; it is mostly emotional, it is severe and abusive. This may include neglect, public humiliation, downgrading accomplishments, name calling, yelling, shaming, the silent treatment, and/or indeed sometimes even physical aggression. The principle message conveyed to the child via words or behaviours is very clear: ‘failure is not acceptable and it will not be tolerated’. It is natural for children to have a strong need to impress adults and main caregivers in particular. This ‘need’ is a natural surviving instrument and therefore parents’ unhealthy expectations and demands are viewed as the norm which gives rise to fear of failure and perfectionist attitudes (within children). Reinforcing behaviours and assumptions about how to navigate through a competitive world would soon follow. Those will become embedded and programmed in one’s bio-psycho-social system and neuroaffective systems and as such, adolescents could struggle with symptoms of depression and low self-esteem and/or anxiety for years before treatment is sought and the correct diagnosis is identified.

This is in fact, exactly what makes perfectionism difficult to identify and treat. It has roots in an emotionally abusive and demanding environment and it crosses borders into the depression and trauma spectrum, chronic low self-esteem, OCD, eating disorders, even some personality disorders. Unfortunately a range of mental health pathologies rely on psychological rigidity and unrealistic self-imposed standards.

For the typical perfectionist adolescent or adult, trying to be perfect is a daily effort and it does not stop when leaving the school or the office. Martina is a well regarded and respected nurse manager who would consistently take additional responsibilities when on duty. She does not like to delegate, because ‘no one can deal with certain tasks as well as she does’. She is the ideal employee and therefore managers reward her by assigning more and more complex cases. This would lead to stress and burn out almost on a daily basis. When she gets tired, she would make mistakes which would not be tolerated since it confirms her worst fears that she is a failure, she is an embarrassment to her patients and colleagues.

Problems do not stop here. When she leaves work and arrives home, her equally high and rigid standards would continue to be applied and diligently enforced. With very clear daily instructions and (hour by hour) rules in place her expectations from her husband and their children to deliver everything on time and at a high standard (e.g. washing up, homework, etc.) are relentless and exhausting for all involved. This would lead to frequent arguments and further feelings of worthlessness, shame, embarrassment and failure.

If investigated carefully, subtle differences between the two case scenarios (i.e. the work situation vs. the home situation) may be observed. Although all behavioural responses and associated assumptions (i.e. beliefs)  have a perpetuating role (or a role of maintenance which is, to reinforce the not good enough, failure or shame schemas), such elaborated cognitive strategies may be better understood as justifications or facilitating beliefs about why having high standards is important to the individual.

The diagram further below explains the reinforcing mechanism. For example, at work it is all about keeping everyone happy (in order to be appreciated and valued) which involves (in the NA-CBT formulation) a series of Compensatory, Avoidant or Surrendering strategies (like not allowing ‘weaker’ workers to work on certain tasks). At home it is all about ensuring that her children are successful and parents are appreciated, respected and valued for their efforts. This is also backed up by a series of compensatory, avoidant or surrendering strategies (excessive organising and list making, not compromising on the timing, etc.).

The Pendulum-Effect Formulation

(NA-CBT by D Mirea)

Core Schema: NOT GOOD or PERFECT ENOUGH

PENDULUM

OVERCOMPENSATION – AVOIDANCE – SURRENDERING

Overcompensation:

The heart of the problem: “I am not ready yet, this is not good enough!”

Overcompensation reflects your inability to internally say to yourself: ‘this will actually do’ or ‘this is good enough as it is’. To stop constantly shifting the goalposts or to refrain from aiming higher and higher and at the same time believing that it is not just realistic but also very-very important – to reach such high standards.

The need to ‘control’ everything or ‘take control’ is yet another compensatory mechanism that facilitates perfectionism. Facilitating beliefs or justifications such as: ‘no one can do this as well as I can’ or ‘If I don’t do this, nobody else will..’ would inevitably lead to burn out, stress and eventually some type of failure – a sentiment that the perfectionist would like to avoid at all costs.

These attitudes or mindsets apply of course, to all areas of life whether personal, work or sports and therefore the language, behaviours and beliefs vary: having strong and rigid views or rules… being tough and correcting people or children when they make mistakescommenting when other people are not being appropriate and directing them to more appropriate behavioursarguing a point over and over again… not knowing when to stop, etc.

Avoidance:

Procrastinating: “I can work on this later, when I am ready and when I am better prepared!”

Since your worth, your value and even personal image depends on constantly reaching a specific standard, the process of completing a project becomes very important (i.e. an essay that you wrote for school or a project you have to complete at work); therefore preparation and feeling ready or ‘right’ to get started on it can be very important. Procrastination and putting plans off is almost always the answer.

Other types of avoidance include indecisiveness or avoiding tasks the perfectionist fears is outside their sphere of competence in spite of all the evidence (i.e. an over qualified psychotherapist still afraid to open up a practice).

Surrendering:

Not celebrating one’s success ! When achieving a goal  (even at the required standard) this soon becomes a ‘box ticking exercise’ rather than a celebration. And over time celebrations ( or celebrating achievements) would become completely absent from one’s life repertoire.

Giving up in shame or giving up too soon: “This is hopeless…”

This is not the same as avoidance, it is much more about giving up something already started and thus giving into the schema that suggests you are a failure and worthless. Surrendering could also involve ‘drinking to unwind’ – important to point out, this is not an effective relaxation exercise but part of the giving up process (a secondary problem such as binge drinking would develop in some cases); acting out of character, not being able to accept or assume a fault, frequent episodes of anger directed towards the self or (incapable) others, etc.

Most perfectionists feel exhausted after repeated and very long episodes of intensive worry and fears of failing and not reaching the (self-imposed) ‘required’ standard. Therefore at some point, one throws in the towel and retires into a depressive state, a state of shame and guilt. Examples would be quitting a project very recently started or even doing something very-very slowly, not to miss important details and then giving up.

Treating yourself with Neuroaffective-CBT (NA-CBT)

This method 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 a clear diagnostic criteria, the therapeutic approach has to be both comprehensive and strategic. It is my view that self-help in general and especially self-help manuals can only go so far without the guidance and support of a kind, generous and well prepared CBT therapist.

NA-CBT relies on a clearly prescribed toolkit that aims to disrupt all mechanisms that predispose, perpetuate and precipitate the fears of failing, the shame and disappointment with the self, that are at the core of perfectionism.

There is a difference between the healthy and helpful pursuit of excellence and the unhealthy and unhelpful striving for perfection (though at times there is a very fine line). Experiencing negative consequences of setting such demanding standards, yet continuing to go for them despite the huge costs would point towards clinical perfectionism. An initial step is recognizing that there is a problem which needs to be addressed. Understanding the nature of the problem, the costs and benefits that perfectionism brings to one’s life and also understanding how one has firstly developed and then kept falling in the trap of perfectionism over years, is just the first part of the changing process.

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* adolescents – the upper age limit is considered to be 24 according to neuroaffective case studies.

*** Training in Clinical Perfectionsim in West London on 20th May 2019. Details below

https://www.ukhypnosis.com/the-cure-for-perfectionism-cbt-for-perfectionism-workshop-with-daniel-mirea-2/

The underlayers of NeuroAffective-CBT

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

swing

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).

PENDULUM

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 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 countertransferential 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).

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 location of the physiological (psychosomatic) reaction is required at this stage. Simultaneously, the patient is not directed to move their eyes from side to side (like in EMDR), but instead the therapist would employ tapping as another 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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Bisson J, Roberts NP, Andrew M, Cooper R, Lewis C (2013). “Psychological therapies for chronic PTSD in adults”. Cochrane Database of Systematic Reviews. 12: CD003388. PMID: 24338345

Brown, S. & Shapiro, F. (2006). EMDR in the treatment of borderline personality disorder. Clinical Case Studies, 5, 403–420.

Davidson, P. & Parker, K. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69, 305–316.

De Jongh, A., Ernst, R., Marques, L. & Hornsveld, H. (2013). The impact of eye movements and tones on disturbing memories of patients with PTSD and other mental disorders. Journal of Behavior Therapy and Experimental Psychiatry, 44, 447–483.

Donker, D., Griffiths, K.G., Cuijpers, P., Christensen, H., (2009). Psychoeducation for depression, anxiety and psychological distress: a meta-analysis. BMC Med. 2009; 7: 79. Published online 2009 Dec 16. doi: 10.1186/1741-7015-7-79

Gilbert P., Procter S., (2006). Compassionate mind training for people with high shame and self-criticism.: overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy, 13, 353-379.

Gilbert P., 2011. Shame in psychotherapy and the role of compassion focused therapy. In R. L. Dearing & J. P. Tangney (Eds.), Shame in the therapy hour (pp. 325-354). Washington, DC, US: American Psychological Association.

Goldin P, Ramel W, Gross, J (2009). Mindfulness Meditation Training and Self-Referential Processing in Social Anxiety Disorder: Behavioral and Neural Effects. Journal of Cognitive Psychotherapy, 23(3): 242-257

Herbert, J., Lilienfeld, S., Lohr, J. et al. (2000). Science and pseudoscience in the development of EMDR. Clinical Psychology Review, 20, 945–971.

Hofmann, A. (2012). EMDR and chronic depression. Paper presented at the EMDR Association UK & Ireland National Workshop and AGM, London.

Jaberghaderi, N., Greenwald, R., Rubin, A. et al (2004). A comparison of CBT and EMDR for sexually abused Iranian girls. Clinical Psychology and Psychotherapy, 11, 358–368.

Lee, C.W. & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy and Experimental Psychiatry, 44, 231–239.

Logie, R. & De Jongh, A. (2014). The ‘Flashforward procedure’: Confronting the catastrophe. Journal of EMDR Practice and Research, 8, 25–32.

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.

Meichenbaum, D (2017): “Constructive narrative perspective”. In The Evolution of CBT: a personal and professional journey with Don Michenbaum. Taylor & Francis Group.

Oren, E. & Solomon, R. (2012). EMDR therapy. Revue européenne de psychologie appliquée, 62, 197–203.

Padesky, C. (1997). Schema change process in cognitive therapy. Clinical Psychology and Psychotherapy. Vol 1. (5), 267-278.

Podell J.L., Philip C. Kendall, Elizabeth A. Gosch, Scott N. Compton, John S. March, Anne-Marie Albano, Moira A. Rynn, John T. Walkup, Joel T. Sherrill, Golda S. Ginsburg, Courtney P. Keeton, Boris Birmaher, and John C. Piacentini. Therapist Factors and Outcomes in CBT for Anxiety in Youth. Prof Psychol Res Pr. 2013 Apr; 44(2): 89–98. Published online 2013 Mar 18. doi: 10.1037/a0031700

Propper, R. & Christman, S. (2008). Interhemispheric interaction and saccadic horizontal eye movements. Implications for episodic memory, EMDR, and PTSD. Journal of EMDR Practice and Research, 4, 269–281.
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Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd edn). New York: Guilford Press.

Shapiro, F. (2007). EMDR, adaptive information processing, and case conceptualization. Journal of EMDR Practice and Research, 1, 68–87.

Shapiro, F. & Maxfield, L. (2002). In the blink of an eye. The Psychologist, 15, 120–124.

Shapiro, R. (2009). EMDR Solutions II. New York: Norton.

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Why EMDR is more than just another therapy with a funny look and a strange name

When Mel B publicly announced this summer that she was going into treatment for Post-Traumatic Stress Disorder (PTSD), an unusual kind of psychotherapy started to draw attention: EMDR formerly known as, Eye Movement Desensitization and Reprocessing. Talking about her diagnosis in particular, it appears that Mel B had been self-medicating with sex and alcohol, which is otherwise not uncommon with this diagnosis. In an interview during the summer of 2018, she pointed out that “[I am] still struggling but if I can shine a light on the issue of pain, PTSD and the things men and women do to mask it, I will do […]”.

More recently comedian Adam Cayton-Holland recounts in his book (Tragedy Plus Time: A Tragi-Comic Memoir) the death of his sister, who took her own life. In an exclusive excerpt from his book, Cayton-Holland reveals that EMDR helped him recover from PTSD following his sister’s suicide.

So what exactly is EMDR, why is it getting the headlines, and does it in fact, help with traumatic experiences? If so, is this evidence-based treatment and, is there a connection with Cognitive Behavioural Therapy (CBT) the golden standard in psychological treatments?

More questions than answers..?

For a therapy that is committed to resolving traumatic re-experiencing, PTSD [1] would have been an obvious starting place for the application of EMDR. Most of the earlier work and research into this therapy, discovered by complete accident [2] by Francine Shapiro, would naturally focus on traumatic memories processing. Shapiro`s earlier research (in the late 80’s and early 90’s) would successfully demonstrate EMDR’s efficacy (Shapiro, 1989). Subsequently, numerous research and clinical trials followed, which would have culminated with a meta-analysis of no less than 38 randomised controlled trials (RCTs). The conclusions were very clear: EMDR and Cognitive Behavioural Therapy with a trauma focus (TF-CBT) are the two most effective treatments for adults with this disorder (Bisson et al., 2007). A separate review of the efficacy of EMDR for traumatised children also showed that EMDR and TF-CBT are superior to all other treatments. EMDR however, was found to be slightly more effective when compared with CBT by Rodenburg et al. in 2009.

Two further meta-analyses in 2013 found that EMDR is better than no treatment, it is similar in efficacy to TF-CBT and also that ‘the eye movements do have an additional value in EMDR treatments’ (Bisson et al., 2013 and Watts et al., 2013). However, due to high drop outs, poor quality of evidence, and significant rates of researcher bias, authors warned against inconclusive analyses and inaccurate interpretations of the results.

In spite of a work in progress understanding of all the mechanisms involved in EMDR, a few strong hypotheses have been proposed over recent years. Those theories coupled with demonstrated efficacy, have been sufficient for EMDR to secure a place alongside CBT, within the treatments recognised by the National Institute for Health and Clinical Excellence (NICE) and the World Health Organization (WHO) as the psychotherapeutic treatments of choice for post-traumatic stress disorder.

EMDR mechanisms explained

So how does it actually work? And what are the mechanisms and approaches involved in the treatment process? Simply put, the patient is asked by therapist to recall distressing images while generating a type of bilateral sensory input, on short bilateral processing or bilateral stimulation (the preferred terms for this article). This basically refers to side-to-side eye movements or hands tapping (though tapping is less common in EMDR). The effect is to desensitise the client to the distressing memory but, more importantly, to process the memory so that the associated cognitions and affects become more adaptive.

The EMDR toolkit is clearly prescribed but to the untrained eye, it can appear almost mechanistically applied, which makes this approach an easy target for many critics from other schools of psychotherapy, usually positioned outside the spectrum of CBT therapies.

A standardised template consisting of an eight-stage protocol is routinely employed with every traumatised patient. The treatment typically starts with comprehensive history taking and case formulation, a process that is very similar to CBT. This is followed by a preparation phase in which the client is provided with the all necessary (internal) resources to safely manage the processing of their distressing memories (e.g. stop signals, etc.).

The assessment phase involves identifying the patient’s target memory, the associated negative cognition, the desired positive cognition (this would become a therapeutic goal), bodily sensations and various ratings for the level of distress and the level of belief in the positive cognition (other immediate therapy goals would be to improve these ratings).

The assessment is followed by the desensitisation phase or the actual memory processing [3] through bilateral stimulation. The final phase would involve installing the desired positive cognition (this process is normally referred to as installation) and a final body scanning for any residual physiological symptoms before the final debrief. This work is not usually backed up by real life exposure or other behavioural exercises in-between sessions, which would usually be the case with cognitive-behavioural therapies.

The adaptive information processing model (Shapiro, 2007) suggests that new experiences are integrated into already existing memory networks. Memories are processed and integrated via sophisticated cognitive screening mechanisms based on individuals’ past experience and understanding of themselves and the world they live in (also known as schemas and/or schema processes in CBT). However, if the experience is traumatic, the information processing system stores the memory incorrectly, often in the wrong parts of the brain and in a still (rigid or frozen) format without adequately processing it to an adaptive format. Thus traumatic memories fail to become integrated into the individual’s life experience and concept of the self. For example, an individual who becomes traumatised as a result of a car accident would experience a much more global sense of vulnerability. In other words, the trauma victim would feel weak and vulnerable across a range of situations not only when he comes in contact with the traumatic stimulus (e.g. the vehicle responsible for the trauma). In PTSD, individuals continue to relive the trauma as if the event is happening all over again, in the present moment. Patients therefore become avoidant of anything that would be connected to the trauma and tend to become hyperaroused and hypervigilant.

The above formulation which simply explains some of the perpetuating and precipitant mechanisms involved in PTSD is strikingly similar to the CBT approach for trauma. In fact, not just the conceptualization of trauma, but also a range of empirically based cognitive-behavioural interventions [4] such as exposure, desensitization, meta-awareness, attention-orientation training, are all at the very core of EMDR also. Professor Paul Salkovskis a renowned UK based CBT researcher and author, pointed out in a 2002 article, that the eye movement in EMDR is completely irrelevant, and that EMDR effectiveness is solely due to having similar properties to CBT, such as desensitization and exposure (Salkovskis, 2002).

It would be fair to describe the side-to-side eye movements or hands tapping as somewhat unorthodox exercises for the traditional psychotherapist, and therefore it should be no surprise that bilateral stimulation has been the target of many debates and studies. To make matters worse, the evidence hasn’t always been favourable. Some studies compared using EMDR with and without the use of bilateral stimulation and even a meta-analysis of 13 studies (Davidson & Parker, 2001) concluded that eye movements made no difference to its effectiveness. But on the other hand, Stickgold (2002) proposes that eye movements in EMDR produce a brain state similar to the one during REM sleep. It has been shown that REM sleep serves a number of adaptive functions, including memory consolidation. Observing the parallels between REM sleep and EMDR, Stickgold proposes that EMDR reduces trauma-related symptoms by altering emotionally charged autobiographical memories into a more generalised semantic form (Stickgold, 2002). Interestingly, when investigating the neurobiological processes involved in attention training in third-wave CBT (mindfulness), Philippe Goldin (2009) also observed a shift from a rigid narrative sense-of-self to a more fluid or experiential sense-of-self aided by attention training exercises and focused breathing. Propper and Christman (2008) draw upon research suggesting that retrieval of episodic memories is enhanced by increased interhemispheric communication. Gunter and Bodner (2009) found that although vertical eye movements do not enhance hemispheric communication, they did decrease memory emotionality as effectively as horizontal movements.

Final thoughts…

It is my opinion that, to the traumatised patient often in distress, such clinical debates and views very little matter. Improved neuroplasticity and cognitive-behavioural changes could be achieved in a variety of different ways as shown by Golden (2009) and numerous other CBT studies. A number of additional covert factors that facilitate change are equally important. For instance, if patients’ motivation remains high and expectations from a specific therapeutic intervention are equally high, treatment outcomes would be positively influenced. This further implies that the therapeutic alliance and trust in the clinical skills of the therapist are also essential. As such, these important resources have to be given priority throughout the therapy process.

Who can get training in EMDR

In UK the more advanced cognitive-behavioural training programmes also include training or at least an overview of EMDR in the context of evidence-based treatments for trauma. However EMDR has its own accredited training organisations (via EMDR UK & Ireland) and therefore it does not placed itself under the umbrella of CBT therapies (or BABCP). Training in this method is not usually offered outside the psychological or psychotherapeutic community, which means that one would have to have a core mental health profession or to be CBT accredited before specialising in EMDR. There are three levels of EMDR competences that can be achieved and the highest level would indicate the most skilled level of EMDR application.

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[1] Post-traumatic stress disorder (PTSD) is a severe form of anxiety caused by exposure to very stressful, frightening or even distressing events. PTSD victims often relive the traumatic event through flashbacks (memories of the trauma) and they experience states of hyperarousal (intense fear), isolation, shame and guilt in different degrees. Years of clinical research have noted a range of trauma-related psychological problems that were not captured in the DSM framework of post-traumatic stress disorder until recently. PTSD, dissociation, somatization, and affect dysregulation represent a spectrum of adaptations to the traumatic experience. They often occur together, but traumatized individuals may suffer from various combinations of symptoms over time. When treating PTSD patients, it is critical to attend to self-regulation and cognitive integration of traumatic experience and to provide systematic treatment that addresses both intrusive recollections and, all the other symptoms associated with the trauma (van der Kolk et al., 1996).

 

[2] In 1987, Dr Francine Shapiro (Senior Research Fellow Emeritus at the Mental Research Institute in Palo Alto, California) was walking in the park when she realized that eye movements appeared to decrease the negative emotion associated with her own distressing memories. She assumed that eye movements had a desensitizing effect, and when she experimented with this she found that others also had the same response to eye movements. It became apparent however that eye movements by themselves did not create comprehensive therapeutic effects and so Shapiro added other treatment elements, including a cognitive component, and developed a standard procedure that she called Eye Movement Desensitization (EMD).

[3] The working memory hypothesis proposes that eye movements and visual imagery both draw on a limited capacity of the visual and central executive working memory resources. The demand and competition created by two or more tasks will impair imagery, so much so that images become less emotional and less vivid. It has been established that horizontal eye movements tend to tax working memory (Van den Hout et al., 2011). In support of the working memory hypothesis, studies have found that other taxing tasks during recall also reduce vividness and/or emotionality of negative memories (De Jongh et al., 2013).

[4] The cognitive model for PTSD by A Ehlers and D Clark, the Interacting Cognitive Subsystems (ICS) model by Barnard and Teasdale, the typical Socratic dialogue used, the psychopathological understanding of trauma and various aspects of the therapeutic alliance are common to both CBT and EMDR approaches. Another common mechanism with both approaches would be mindfulness. During the desensitisation phase of EMDR, clients are instructed to ‘let whatever happens, happen’ and to ‘just notice what is coming up’ (Shapiro, 2001) which is consistent with mindfulness methods (Siegel, 2007).

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