Author: NeuroAffective-CBT by Daniel Mirea

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 often think 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 adolescents¹ 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. The prospect of making mistakes, makes perfectionists hypervigilant and therefore, perfectionists experience constant states of hyperarousal, shame and defeat.

[..]  ¹ adolescence – starts around 12 years old with the upper age limit considered to be around 24 years old, this is the period of time where the brain is most plastic, according to neurobiology and developmental research.   

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 extremely high and rigid standards. Their own approach to parenting is often based on personal childhood experiences but not always. It is too easy for a parent to fall in this trap given how much more competitive the world is. Failure is not something our society tolerates.

Demanding parents  would require top marks in school, medals in sports and flawless ballet recitals. Mistakes could be harshly punished. The punishment may not necessarily be physical, it may be, and often is an emotional, it is nonetheless severe and abusive. This often involves neglect, public humiliation, downgrading accomplishments, name calling, yelling, shaming, the silent treatment, and/or indeed sometimes even physical aggression. The principal 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 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 anxiety 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 Emotion: Shame & implicit Deeply-Rooted Beliefs:

Not good enough, inadequate and failure averse

OVERCOMPENSATION – AVOIDANCE – CAPITULATION

Overcompensation

The heart of the problem: ‘I am not ready yet, this is not good enough!’ or ‘Whatever I decide to do, it has to be done properly!’ and… of course... ‘Compromise or change is never a good idea!’

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. Double checking or triple checking one’s work or several times, proofreading an email several times before sending it are examples of how working hours are extended and draining often leading to burn out.

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.

Such attitudes or mindsets, apply of course to all areas of life whether personal or work or the local golf club 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 mistakes… commenting when other people are not being appropriate and directing them to more appropriate behaviours… arguing a point over and over again… not knowing when to stop, etc.

Other examples of Overcompensation:

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 especially important. Procrastination and putting plans off are 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. A psychotherapist is literally afraid to open up a therapy practice in spite of being overly qualified and therefore, keeps getting more and more training and more qualifications. A writer keeps proofreading and editing his new book too many times before he ‘feels it’s ready’ to submit for publishing, ends up with too many versions of the same book. 

Getting somebody else to attend in my place! Because I fear underperforming at the next meeting or social event – since I am usually an embarrassment. Even though the evidence is lacking, feeling like a failure and a social embarrassment would be the implicit knowledge that a deeply-rooted belief (DRB)² generates which would justify an avoidant action, or not going to the event. Another example would be, not asking for help! Avoiding asking for help despite the costs; because this would make one look weak, not competent and a failure – implicit knowledge that justifies avoidant behaviours and satisfies the DRB.

[..]   ² Deeply-rooted beliefs (DRBs) – a term coined by Mirea D (2023) in reference to felt-senses or gut-feelings which victims of shame cannot expressed until later in adulthood. DRBs are reminders of early experiences of neglect or emotional depravation, initially DRBs help an individual navigate through a difficult childhood but later they become self-sabotaging and operate like self-fulfilling prophecies. DRBs lead to defences and life strategies that will dictate an individual’s actions and decisions on a daily basis but especially in a critical situations.

Other examples of Avoidance:

• Avoiding social events (because those are a waste of time – implicit knowledge)
• Avoiding intimate relationships or spending time with family that is counter-productive
• Don’t be vulnerable, stay away from people (or potential partners) that could make one feel vulnerable
• Avoiding people that are not driven or ambitious enough or career oriented
• Doing other things or tasks that are not relevant
• Messaging key people to explain the delay
• Moving tasks to the following day
• Always telling myself that tomorrow is not so busy (not at all the case in reality)
• Constantly feeling that one is likely to fail certain tasks – which leads to avoid the tasks

And accompanying justification (the domain of psychological rigidity – more ‘musts‘, ‘should‘ and ‘Ifs‘):

• ‘Stop wasting time’
• ‘Don’t leave for tomorrow what you can do today’
• I can sort it out the next day, my diary is more relaxed’ or ‘If I message this colleague and explain the delay he will understand’ or ‘If I rest now, I will do a better job after’

Once again, a lot of if – then rules, musts and should:

• If I don’t engage with… then I don’t face rejection.
• If someone says NO to me, it means they aren’t interested in me or what I have to offer.
• If I fail, then people won’t like me (people don’t like a failure)
• If I don’t speak to them about it or approach them then I won’t get rejected. I’m shielding myself from them saying no. 
• If I rest now, then I’ll do a better job.
• I’ll sort it out the next day.

Solutions (the domain of psychological flexibility):

• Do it because you can… not because you have to!
• Not getting things 100% perfect does not make me a failure. People will appreciate my projects even when they are a work in progress.
• What I perceive as a failure is not what others may see as a failure!
• People will appreciate the success of making it happen rather than the few people that said NO.
• It’s not the ‘NO’ that matter in the week; it’s a longer process, and it’s the end result that matters…
• Don’t focus on the ‘NOs’ or the rejections but view it as a chance to improve and move on.
• If I complete the task now, I’ll feel much better about it.
• If I send it now, I’ll feel much better about it.
• If you don’t ask, you don’t get!

Capitulation or Surrendering

Sabotaging Self-Confidence… Giving Into Shame and Worthlessness…

I should be amazing all the time... I am the worst for not performing well… If I am failing at something, it is the worst thing ever, that makes me a failure and a looser across the board, I clearly deserve to be invisible, ashamed… Not tolerating mistakes inevitably leads to intensive and long episodes of rumination, like a very unpleasant series of cognitive video reels, packed internal self-critical and self-blaming messages, ideas, and random conclusions, evidence that one is underperforming.

Not celebrating one’s success is also part of the surrendering repertoire! 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 and often saying to oneself ‘since I am so bad, what does it matter anyway… let me show you how bad I really am’.

‘This is hopeless’… or other hopelessness thoughts – Measuring one’s performance against others that are on a much higher level (in their perception – in reality, these specific ‘others’ may not be better off).

Surrendering 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.

• Lack of tolerance towards making any mistakes
• Lack of tolerance towards own mistakes but also no tolerance for colleagues or other people (could be family members) who are not meeting standards… Often not patient enough to explain or teach them how to improve
• Drinking to self-medicate and overcome stress (unable to unwind and self-regulate)
• Blaming other people because for failures or current outcomes
• Always measuring my performance against others
• Lack of assertiveness most times – and not telling people how one really feels or what one really thinks
• Fear of being rejected or not liked
• Fear of being found out (the so-called ‘imposter syndrome’)

And accompanying justification (the domain of psychological rigidity -even more ‘musts‘, ‘should‘ and ‘Ifs‘):

In conclusion…

Most perfectionists feel exhausted after repeated and very long episodes of intensive worry and fears of failing and not reaching the ‘required’ and self-imposed standards. Therefore, at some point, one throws in the towel and retires into a depressive state, a state of shame and guilt. We could easily imagine how it might initially work out, to quit a project very recently started, at first working on it very-very slowly, in order not to miss all important details, and then eventually, giving it all up in exhaustion, due to burn out. Changing is often viewed by the perfectionist as the road less travelled, full of risks and obstacles.

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. The general  view is that self-help in general and especially self-help manuals can only go so far without the expert guidance and compassion of a  CBT psychotherapist.

NA-CBT relies on a clearly prescribed toolkit that aims to disrupt all mechanisms that predispose, perpetuate and precipitate fears of failing, the shame and disappointment with the self, all 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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* Training in Clinical Perfectionism with interventions such as NA-CBT or Integrative-CBT, are detailed here.

Disclaimer: this is not a self-help manual; the intention with all NA-CBT articles is to offer guidance and to develop knowledge. All case studies described are a combination of facts and very little fiction from different sources but mostly personal clinical experiences. More similar work and great resources for inspiration, can be found on TedX -Treating Perfectionism, Brene Brown, Roz Shafran, Christine Padesky, Donald Meichenbaum’s notes on resilience, and others.

This article follows various anonymised cases who received NeuroAffective-CBT for clinical perfectionism, certain details have been changed in order to maintain anonymity; if it resonates with you or someone you personally know, please do not be surprised or make any assumptions, these types of struggles are much more common than you can imagine. Real life situations and case studies are required for authenticity and shared learning. The article also includes specific questions at various crucial points raised by the author which are meant to trigger further enquiry and insights. Finally, please consider that self-teaching cannot replace live therapy or advanced training programs in the above methods which are to be found within the field of Integrative-CBT.

Proof reading and editing by Ana Ghetu

Daniel Mirea (May 2019)
NeuroAffective-CBT® | https://neuroaffectivecbt.com

Introduction

A brief look at Google Scholar shows that cognitive behavioural therapies (CBT), including so-called “third-wave” approaches such as mindfulness and acceptance-based interventions, are by far the most extensively researched and empirically supported psychological treatments to date. NeuroAffective-CBT (NA-CBT), by contrast, is a much younger cognitive and behavioural therapy. It naturally lags behind in terms of large-scale clinical trials; however, it is a reliable, innovative, transdiagnostic model that has been honed over thousands of hours of supervised and reviewed therapy sessions, which have consistently delivered positive outcomes across a range of client groups. NA-CBT shares its theoretical fundamentals and evidence base with the wider family of cognitive and behavioural therapies, which together constitute the current gold standard in psychiatry and psychological treatment (David, Cristea and Hofmann, 2018; Mirea, 2018).

CBT appears to be the best we currently have, but the field is far from perfect. Precisely because CBT is dynamic and rooted in evidence, gaps in provision are constantly being identified. In response, new and creative solutions are proposed and tested. It is within this evolving context that NA-CBT steps forward to address a specific void. Developed by Daniel Mirea and finely tuned over the last 20 years, NA-CBT was designed to target a growing subclinical population presenting with undiagnosed affective disturbances clustered around shame and self-loathing.

Because the treatment of these phenomena crosses the boundaries of clear diagnostic criteria, the therapeutic approach needs to be both holistic and strategic. NA-CBT therefore relies on a clearly prescribed, modular toolkit aimed at disrupting the mechanisms that predispose, perpetuate, and precipitate shame, self-disgust, low self-esteem, and associated difficulties.

By exploring the underlayers of NA-CBT, this article examines the overlapping mechanisms that underpin a range of cognitive and behavioural methods and summarises the evidence that supports the skills and interventions used in this treatment model.

The assessment stage

In keeping with the cognitive–behavioural tradition, the NA-CBT process begins with comprehensive history taking that leads to a case conceptualisation uniquely termed the Pendulum-Effect formulation. NA-CBT proposes that, much like the pendulum of a traditional clock, individuals tend to oscillate between maladaptive coping mechanisms, often outside of conscious awareness. This continual oscillation reinforces dominant core affects such as shame, guilt, fear and self-hatred. These affects are sustained by deeply rooted beliefs or negative self-views that function like narrow lenses through which individuals perceive themselves, their future prospects, and significant others. Such lenses accommodate and perpetuate internalised shame, self-loathing, and guilt, for example: “I am unlovable and unattractive, and nobody wants me.”

It is important to pause here and note that neuroaffective research indicates that the affective states we experience do not always have accurate linguistic equivalents. For instance, Japanese culture includes a term for the emotion one feels after receiving a bad haircut. In many Western cultures, we lack equally precise labels for some moment-to-moment affective states. Limiting narratives can further interfere with the affective experience because language is frequently used as an intensity modulator. For example, thinking or saying “I am feeling really sad right now” can amplify what might initially be a mild “lack of energy” on a rainy day. Given that rain is not an unusual phenomenon in the UK, “sadness” may not be the most accurate descriptor, and it may even elevate the feeling through autosuggestion.

The oscillating Pendulum-Effect suggests that the core affect of shame and/or self-hatred, symbolically located at the centre of the clock’s face, represents the central mechanism driving the system. The core mechanism does not turn the clock without the oscillating movement. In other words, shame, guilt, or self-disgust are constantly perpetuated by reinforcing, self-sabotaging life strategies such as overcompensation, avoidance, and surrendering. These are designed with the precision of an internal clock mechanism and rehearsed over many years.

Equally important is the relationship these coping mechanisms have with each other, the swinging or oscillating effect. People move between these strategies in predictable ways, and this motion becomes central to both assessment and treatment.

Overcompensation

Overcompensation reflects an enduring difficulty in internally saying to oneself: “This is good enough,” “I am good enough,” “I am not helpless or powerless,” or “I am lovable and accepted.” Because one’s worth, value, and personal image depend almost entirely on external validation, internal validation is not perceived as an option. Reassurance seeking, approval, and feeling accepted and appreciated by others become primary goals.

Paying intense attention to one’s appearance, taking provocative selfies for social media, seeking multiple cosmetic or aesthetic procedures, or engaging in elaborate beautification rituals, can feel necessary, even when objective evidence suggests they are excessive. The intention is typically not to attract more sexual attention or partners per se, but to feed a persistent hunger rooted in shame and self-dislike.

A common motto for overcompensators might be: “If someone says jump, I ask how high.” This can become an apparently effective strategy for keeping people close and ensuring that one is seen as a “good friend.” Doing numerous favours, being excessively helpful, showering friends with unexpected gifts or extravagant gestures when they are not required, these behaviours are rarely sustainable and can be costly both emotionally and financially. Over time, this pattern almost inevitably leads to greater self-hatred and resentment toward others, especially when friends do not reciprocate. It becomes a safety mechanism: buying someone’s friendship and trying to keep them close in the long term. However, because these actions lack authenticity, they are more likely to fail.

Another form of overcompensation is the relentless need to control everything or “take control.” This may involve constantly shifting goalposts, doing more and more, or aiming ever higher. A long list of rigid rules, “shoulds,” “musts,” and “if… then…” statements, drives these behaviours, for example: “If I am not always super-nice and performing at 100%, people will reject me.”

Frequent episodes of hyperarousal at work may lead to self-doubt, second-guessing, and repetitive checking: reading and re-reading emails before sending, repeatedly reviewing completed tasks, or staying late to ensure nothing can be criticised. Working hours are extended, leading to exhaustion, guilt, and eventually burnout. Overcompensation rarely provides the long-term relief it promises.

Avoidance

Avoidance is equally diverse. It can manifest as social withdrawal, chronic introversion, avoiding close relationships or intimacy, and even avoiding sex. On the surface, avoidance appears to be the opposite of overcompensation, yet these strategies often complement and reinforce each other – this is the essence of the oscillating effect. For example: “I overcompensate by being extremely provocative and flirtatious online, but in reality I avoid intimacy at all costs, because I fear being ‘found out’ and humiliated.”

Procrastination and lateness can also be understood through this lens: “Looking this good takes time and effort; I cannot afford to look bad on the outside given how rotten I feel on the inside.”

Similarly, “I can work on this later, when I am ready and better prepared” becomes a familiar refrain. When self-worth depends on external validation, it matters deeply how others perceive one’s abilities and competence. Ordinary tasks, such as writing a report or completing a project, acquire overwhelming importance. The sense of being “not ready” or “not just right” fuels avoidance. Procrastination offers short-term relief, but in the long run it reinforces shame and self-criticism.

Capitulating or Surrendering

Capitulating or surrendering is the ultimate self-sabotaging strategy. It involves attacking one’s own confidence and accepting, often unconsciously and unconditionally, the belief that one is “not good enough,” “helpless,” “a failure,” or whatever the dominant shame-based narrative might be.

This can sound like: “Since I am so bad, what does it matter anyway?” or “Since I am so bad, let’s be bad—let me show you how bad I really am.” Surrendering can become a licence to act out of character, for example by drinking excessively, engaging in risky sexual behaviour, or making impulsive decisions. These behaviours rarely alleviate shame; instead, they strengthen the sense of guilt and self-disgust, creating a self-fulfilling prophecy.

Not celebrating one’s successes is another subtle form of surrendering. Achieving a goal becomes a mere “box-ticking exercise” instead of a meaningful achievement. Over time, celebration and self-acknowledgement disappear entirely.

From Not Good Enough to a New Sense of Self

Many people struggle with a deep, core sense of being ashamed, invisible, or “not good enough.” The first step forward is to bring this into awareness in a non-blaming, non-critical way by examining how we cover it up.

Key questions include:

• What am I doing on a daily basis in order not to feel bad, ashamed, or invisible?
• How do I self-sabotage or surrender into the shame of not being good enough?
• What do I avoid far too often?
• How do I overcompensate day to day?
• How would I best describe my self-imposed rules that sometimes help but more often end up serving the very shame they are meant to eliminate?

Understanding our rules, compensations, avoidances, and capitulations, together with their justifications and rigid guidelines, is the breaching point. Reaching this point marks an important milestone: the beginning of a new sense of self, or rather the process of reinventing oneself.

This is also the right time to learn new coping strategies: to “fake it till you make it,” to “act as if” one is good enough, loved, and accepted. It involves becoming more assertive and taking more risks by sometimes acting the opposite of what one’s gut is suggesting.

The journey from a “shamed and scared inner child” to a “confident and independent healthy adult” can be long and challenging, but each successful step is a small win and deserves to be celebrated. There is no single standard path; people respond and learn differently. Artistic journals, audio recordings, written diaries, visual trackers, or even simple “golden stars” can become powerful reminders of the journey taken.

Sarah: case study [1]

To illustrate how internalised shame perpetuates itself through oscillation between overcompensation, surrendering, and avoidance, consider the case of Sarah.

Sarah is a successful paralegal in the City who has struggled with shame-related feelings for most of her life. She is a natural overcompensator, constantly making herself available, useful, and well-liked by everyone, even when completely exhausted and burned out. She hates the idea of letting her colleagues down, and at work her efforts are highly appreciated. Sarah is aware of this dynamic, but she attributes her popularity solely to hard, exhausting work, long hours, and an inability to say ‘No’.

Typically, as Christmas approaches and party invitations begin to accumulate on her desk, she shifts into surrendering, accompanied by harsh self-criticism: ‘I’m not going to perform well; I drink too much to calm my nerves; I’ve put on weight this year; nobody actually likes me for who I am’, and so on. This is followed by avoidance, such as not reading the invitations, not following up, and not responding. All these actions occur before any event takes place and are intended to avoid social situations she feels destined to fail. They are fuelled and justified by exaggerated predictions of social embarrassment and other imagined ‘disasters’.

Her surrendering responses also involve fortune-telling, vivid images of social awkwardness, and rejection of support such as, declining a colleague’s offer to accompany her to one of the events. This particular colleague, who was both insistent and single, turned out to be genuinely interested in dating her, something that only became clear later in therapy. Her surrendering stance prevented her from recognising his intentions at the time. These surrendering strategies then justify the subsequent avoidant behaviour and withdrawal, which inevitably lead to isolation, loneliness, guilt, self-disgust, and intensified self-criticism, ultimately reinforcing her shame-based beliefs.

A simple chain analysis suggests that Sarah overcompensates until she burns out, then falls into self-criticism through surrendering, which is then followed by withdrawal and other avoidant behaviours. This completes a self-perpetuating emotional trap, representing the mechanism that enables the back-and-forth ‘swing of the pendulum‘ through these emotions and associated behaviours over time. These patterns can be best understood as emotion-driven behaviours.

The pendulum as both a timekeeper and a regulator

The metaphor of the pendulum is intended not only to depict the timing and rhythm of these emotional swings but also to serve as a regulatory tool. In therapy, it helps to disrupt the behaviours that maintain the swinging mechanism—or emotional trap. Several reinforcing mechanisms may be active, each of which can be clearly mapped using the Pendulum-Effect formulation. Once these mechanisms are fully understood, they are collaboratively examined, modified, and finely tuned with the patient in a strategic yet compassionate manner throughout therapy.

This work unfolds across six modules in total, the middle four of which are flexible and interchangeable treatment modules:

1. Assessment – Pendulum Formulation
2. Psychoeducation and Motivation
3. Physical Strengthening
4. The Integrated-Self
5. Coping Skills Training
6. Skills Consolidation & Problems Prevention

Module 1: Assessment and the Pendulum-Effect Formulation

The initial consultation serves as the assessment stage, providing an opportunity to establish a strong therapeutic bond through empathic mentalisation. During this phase, the therapist introduces the Pendulum-Effect formulation, helping the client understand their core emotional patterns and the coping strategies, overcompensation, surrendering, and avoidance, that shape their difficulties. This foundation guides the collaborative work that follows across the remaining modules.

Module 2: Psychoeducation & Motivational Enhancement

This module focuses on strengthening resilience, motivation, self-efficacy, and problem-solving skills. Through clear and accessible psychoeducation, clients gain a deeper understanding of their emotional and behavioural patterns, as well as the mechanisms that sustain them. The Pendulum-Effect formulation is actively used to the client’s advantage at this stage to cultivate self-appreciation, helping them recognise their existing resources and coping strategies, and further build motivation for meaningful and lasting change.

Module 3: Physical Strengthening — TED’s your best friend!

Within the NeuroAffective-CBT® framework, TED (Tired, Exercise, Diet) functions as a biologically grounded scaffold of self-regulation that stabilises the Body–Brain–Affect triangle. It is not a list of prohibitions, restrictions, or lifestyle commandments, but rather a set of neuro-behavioural levers capable of influencing key biological systems, including dopamine and serotonin pathways, adrenaline responses, immune signalling, circadian rhythms, and the vagus-mediated gut–brain axis, the intricate ‘wiring loom’ connecting body and mind.

‘TED your way out of trouble‘ has become a favourite phrase within NA-CBT, and for good reason: strengthening the body’s regulatory systems lays the foundation for emotional and cognitive flexibility.

To explore this often overlooked, but essential, dimension of therapy in greater depth, please follow the TED-dedicated article series, where each component is examined in detail and contextualised within modern neuroaffective science.

Module 4: The Development of an Integrated-Self

Internalised shame, often accompanied by self-dislike and self-loathing, creates a profound disconnect between who a person believes they are and who they wish to be. The aim of this module is to help integrate these two extremes, allowing the individual to develop a more coherent, compassionate, and resilient sense of self.

This work involves trauma processing, cognitive reframing and integration, shifting from self-hatred and relentless self-criticism toward self-acceptance and self-compassion. A central part of this process is a non-judgemental understanding of one’s coping mechanisms through the Pendulum-Effect formulation. These patterns, whether overcompensation, surrendering, or avoidance, are recognised as survival strategies that once served a purpose, even if they are now limiting or counterproductive.

When processing a traumatic episode, the therapist’s instructions follow a deliberate and structured sequence. First, the client is guided to notice the location of the affect and the physiological reaction it triggers. Next, they are encouraged to label the negative affect (‘name it to tame it’), whether it is shame, guilt, anger, or fear, and to identify the accompanying bodily sensations such as tightness in the chest, a constriction around the head, a dry knot in the throat, or pain in the abdomen or around the heart. The client then rates the intensity of these sensations on a 0–10 scale in order to track shifts in their physiological state and indeed learns to mindfully observe their physiological and emotional fluctuations and the eventual reduction within the space of a few minutes of recollection. This structured sequence helps reduce amygdala-driven reactivity by training the attention and focusing on abdominal breathing patterns and progressive muscle relaxation. Also, reframing the traumatic experience from an overwhelming emotional event into a umbrella conclusion about the self, world and future prospects (‘I am wiser and stronger because of it’; ‘I am a survival, not a victim’). The traumatic experience is safely contained and relieved in the present, even reduced to a series of manageable cognitive, muscular and physiological responses. This type of processing trains the trauma survivor to adopt the stance of an observer rather than a passive recipient of the trauma narrative. The emotional episodes gradually come to be perceived as natural fluctuations rather than threats, fostering greater acceptance and contributing to a healthier, more adaptive self-concept.

Module 5: Behavioural Coping Skills

This module provides targeted training in exposure (real-life and/or imaginal) to situations that feel overwhelming or unmanageable, alongside skills in assertiveness, grounding, and method acting. Method-acting techniques help individuals embody a desired attitude, behavioural stance, or set of character traits, sometimes even experimenting with a more adaptive or empowered ‘new persona’. This experiential approach accelerates the integration of new emotional, cognitive, and behavioural responses into everyday life.

Module 5 also supports the client in exploring authentic living by identifying new personal goals and values and, embracing the idea of ‘a new beginning’ – ‘What would life be like if I truly believed I am loved and accepted?’ Through this process, clients learn to replace maladaptive, emotion-driven, and self-sabotaging behaviours, whether overcompensatory, avoidant, or surrendering, with more intentional and value-aligned actions.

Module 6: Skills Consolidation & Relapse Prevention

The final module focuses on consolidating newly acquired skills and developing a realistic plan for maintaining progress. Together with the therapist, the client identifies future goals, anticipates potential obstacles, and prepares strategies for managing setbacks with confidence. This stage strengthens long-term resilience and ensures that the gains achieved throughout therapy are carried forward into everyday life.

A revolving-door policy operates post-treatment, often for months or even years. This provides valuable opportunities for booster sessions, ongoing support, and follow-up work, allowing both client and clinician to revisit progress, adjust strategies, and reinforce long-term stability.

The underpinning fundamentals of the approach

Several essential mechanisms underpin NA-CBT. Each treatment module employs a distinct set of skills, but none more essential that the than the ability to build a strong therapeutic alliance. I coined the term empathic mentalisation to describe therapist’s skilful ability to connect with his client in a way that would allow the therapist to not just hear and understand patients’ vulnerabilities, at a prefrontal or intellectual level, but instead to allow himself, to feel client’s pain in a way which will help the client feel felt.

While some attachment-based therapies may claim similar relational engagement, this is where the resemblance ends. In NA-CBT, the therapeutic relationship is not used as a transference or countertransference medium. The therapist remains consistently aware of the client’s goals and maintains a high degree of structure and direction over the therapeutic agenda. The relationship is guided intentionally and collaboratively throughout treatment. Transference and countertransference processes are treated as opportunities for open dialogue, learning, and behavioural insight, not as primary drivers of therapeutic progress. At the core of NA-CBT are the principles of challenging, restructuring, and reframing irrational self-beliefs, installing new coping and emotional-regulation skills, and disrupting unhelpful behavioural patterns.

Psychoeducation is another foundational element of the model. Decades of CBT research show that high-quality psychological education strengthens trust in both the therapist and the therapeutic process. Studies consistently demonstrate that therapist expertise, confidence, clarity of explanation, knowledge of psychopathology, and treatment integrity all contribute significantly to improved outcomes (Donker et al., 2009; Podell et al., 2013). NA-CBT builds on this evidence, using psychoeducation to establish a clear framework of understanding that empowers clients from the very beginning of treatment.

NeuroAffective-CBT provides an excellent platform for integrating emerging disciplines such as neuroscience, nutritional psychiatry, physiology, and cognitive psychology, fields that have expanded significantly over the past 30 to 40 years yet remain underutilised in many psychotherapy models.

Cognitive psychology and meta-awareness research (e.g., Wells A., 2009; Wells A., 2019; Padesky C., 1997), the Interacting Cognitive Subsystems (ICS) Model (Barnard & Teasdale, 1989, 2008), and the Adaptive Information Processing (AIP) model (Shapiro, 1989, 2001, 2007, 2009) all propose that memories are processed in a highly organised and structured manner. Incoming information is filtered through templates shaped by past experiences and internal models of self and world. When childhood experiences are traumatic, memories are often stored in rigid, unprocessed formats that fail to integrate into the broader autobiographical narrative. These unprocessed memories contribute to persistent emotional vulnerabilities and disturbances in self-concept. As a result, unresolved, unintegrated, or shame-laden memories, whether profoundly traumatic or simply distressing, often lie at the core of chronic shame, self-disgust, and low self-esteem (Schore, 1998; Gilbert, 2006; Siegel, 2007; Gilbert, 2011).

A clinical example illustrates the importance of memory specificity (also referred to as hot memories). Jane’s mother would often smile warmly moments before unleashing verbal or physical abuse. As an adult, Jane grew suspicious of ‘nice‘ people who smiled at her and instead gravitated toward individuals she perceived as more ‘genuine‘, often those who were angry, moody, or unpredictable. Unsurprisingly, her relationship patterns became consistently unhealthy and self-sabotaging. Neuroaffective science explains that repeated childhood experiences lay down neural pathways that generate urges, habits, and automatic interpretations, such as: ‘My colleague is too smiley, something must be wrong.. I should keep my distance.’

In NA-CBT, therapy focuses on targeting these specific or hot memories, which activate cascades of negative affect and self-defeating behaviours. This can be more effective than attempting to process the broader abuse narrative; for example, Jane’s overall relationship with her mother and her mother’s chronic unpredictability. Such global narratives tend to become cognitively assimilated over many years in distorted ways (e.g., ‘I was a naughty child who deserved it‘). In contrast, specific memories offer clearer, more precise access points for emotional processing and integration.

During module 4 – Developing an Integrated-Self, the client may be asked to recall the most distressing aspect of an earlier traumatic or shame-laden memory, along with the associated shame-based beliefs and bodily sensations. Increasing attentional focus on internal physiological shifts, particularly psychosomatic reactions linked to shame, is central at this stage. Clients are encouraged to ‘pay attention to what is happening inside you right now, especially the location and intensity of the distress’. Simultaneously, the client is guided to narrate the triggering (specific) memory in detail, with minimal deviation or avoidance. It is expected that certain elements of the memory may have been previously suppressed, fragmented, or pushed aside.

The therapist’s instructions follow a clear and structured sequence:

1. Notice the location of the affect and the associated physiological reaction.
2. Name it to tame it – label the affect (shame, guilt, anger or fear) and identify the corresponding bodily sensations (e.g., tightness in the chest, a pressure around the head, a painful knot in the throat, or discomfort in the abdomen or chest).
3. Rate the intensity of these sensations (0–10) to monitor shifts in physiological arousal.
4. Breathe into the area of tension and progressively relax the body.
5. Observe the affective fluctuations and their gradual subsidence.
6. Reframing the experience (including updated autobiographical belief)

This sequence reduces amygdala-driven reactivity by reframing the trauma response as a combination of maladaptive self-beliefs and manageable muscular and physiological sensations. Through repeated practice, clients learn to adopt the stance of an observer, rather than a passive recipient, of their trauma narrative. Over time, emotional and bodily fluctuations come to be experienced as natural, gradual variations rather than overwhelming threats, an essential step toward increasing acceptance and integrating a healthier, more adaptive sense of self.

If appropriately trained, the therapist may also employ a specific form of memory processing known as bilateral stimulation. Although the research in this area has at times been debated, more recent evidence has been favourable, particularly regarding hands-tapping protocols. Several neuropsychological, developmental, and attachment studies (Kirsch et al., 2007) highlight the therapeutic value of appropriate, clinically attuned physical touch, noting its association with the release of endorphins, serotonin, and dopamine, as well as the formation of new neural pathways. These mechanisms ultimately contribute to improved self-regulation (Siegel, 2007).

Traumatic memory processing is one area in which NA-CBT overlaps with Eye Movement Desensitisation and Reprocessing (EMDR). EMDR is a structured therapeutic approach that uses bilateral stimulation, most commonly eye movements or auditory tones, to facilitate the processing and integration of traumatic memories. However, unlike EMDR, NeuroAffective-CBT is firmly grounded in the evidence-based cognitive and behavioural practices that have demonstrated effectiveness over the past 50–60 years. NA-CBT remains fundamentally a behavioural approach, centred on active, progressive change through the adoption of new and more adaptive behavioural strategies (see Case Study 2).

Case study [2]:

John experienced intrusive flashbacks of physical and emotional abuse whenever his manager raised her voice in the office. After only three hours of desensitisation using bilateral sensory processing (e.g., tapping), the frequency and intensity of his flashbacks reduced dramatically, eventually disappearing altogether. John also reported a marked reduction in hyperarousal.

To prevent relapse and strengthen the newly formed competing memory between sessions, John and his therapist agreed on several behavioural changes for him to implement at work. These included adopting a different attitude and mindset, increasing awareness of his body language and internal reactions, taking notes to track these shifts, and improving his posture. He also prepared a set of responses for potentially challenging situations that would require assertiveness. These strategies and coping skills were rehearsed repeatedly, through imagery rehearsal, role plays, and other behavioural exercises, both inside and outside the therapy room.

Selecting the Appropriate Trauma-Focused Technique

Despite the positive outcomes and clinical success reported with bilateral sensory processing, NA-CBT recognises that narrative exposure, reliving, imaginal and in-vivo exposure, or the processing of activating (hot) memories may be more appropriate interventions for certain trauma presentations. For instance, when a male therapist is working with a female survivor of rape, bilateral stimulation may not feel safe due to the interpersonal dynamics involved. In such cases, memory integration is best achieved through detailed narrative work and behavioural evidence-gathering rather than sensory input.

Therapeutic effectiveness depends heavily on the trust between therapist and client, as well as the client’s expectations of both the therapist and the chosen technique (Kumpasoğlu et al., 2024; Meichenbaum, 2017). The therapist’s expertise and confidence also influence treatment outcomes, since the appropriate selection of technique requires strong clinical judgement and the ability to tailor interventions to the client’s needs, personality, values, and current circumstances (Bartle-Haring et al., 2022; Castonguay & Beutler, 2006).

The Role of Emotional Desensitisation

Regardless of the method, it is essential during emotional or traumatic desensitisation that individuals struggling with shame, fear, anger, or guilt re-experience the relevant memories without becoming overwhelmed, within a safe therapeutic environment that helps them bridge past and present. Clinical experience suggests that bilateral processing can sometimes achieve this more reliably than narrative or imaginal reliving.

Bilateral stimulation works through the multitasking demand of simultaneous focused and distributed attention, enabling the brain to access traumatic, frightening, or maladaptive experiences while activating processing mechanisms that promote transformation and integration. Once fully integrated, the event—and the adaptive meaning derived from it—remains accessible, but the previously associated hyperarousal or shutdown responses diminish significantly or disappear altogether.

For individuals affected by shame, re-experiencing memories without becoming emotionally flooded is crucial. Clinical and neuroaffective observations indicate that bilateral processing can sometimes achieve this more consistently than traditional exposure methods. The multitasking nature of bilateral stimulation appears to activate neural pathways that facilitate the processing and integration of emotional material. When integration is successful, the client can articulate the memory and the learning derived from it, but the corresponding hyper- or hypo-arousal responses no longer accompany the recollection.

Self-Efficacy, Mastery, and the Modulation of Dissociation

An additional and clinically meaningful phenomenon often emerges during bilateral sensory processing (e.g., tapping, alternating visual cues, or other dual-attention techniques). Clients are supported in navigating the internal associations that typically arise during processing. This experience enhances self-efficacy and mastery, particularly the individual’s ability to shift flexibly between re-experiencing the event and returning to present-moment awareness (Oren & Solomon, 2012). This skill reduces dissociative tendencies and improves attention-orientation capacities (Goldin, 2009).

Several trauma studies suggest that physical touch, when used appropriately and therapeutically, can counteract dissociation and foster grounding, safety, and embodied presence. Although the use of touch remains culturally sensitive, particularly between genders, clinical experience, neuroaffective findings, and even anthropological research all indicate that attuned touch can support emotional regulation and integration.

With regard to self-efficacy, Oren and Solomon (2012) propose that experiences of mastery become encoded as adaptive information within memory networks. This perspective aligns with the work of Teasdale and Barnard (1993), Donald Meichenbaum (2017), and Albert Bandura’s (1989) theory of self-efficacy. Together, these frameworks suggest that once a traumatic event is processed and integrated, it can be recalled without the previously attached emotional intensity, allowing the client to remember without reliving.

Attention Training and Mindfulness Mechanisms

Another key mechanism in NA-CBT involves attention training, particularly through mindfulness-based instructions. During desensitisation or memory processing, clients are encouraged to ‘let whatever happens, happen’ and to ‘notice whatever thoughts arise‘, consistent with mindfulness principles (Goldin et al., 2009; Siegel, 2007; De Jongh et al., 2013; Wells A., 2019).

Imagery-based desensitisation and exposure exercises, commonly used in mindfulness and clinical hypnosis, further support the creation of psychological distance. According to working memory theory, maintaining dual tasks results in cognitive overload, which reduces the vividness and emotional impact of distressing material. Although the working memory literature shows some variability, findings from mindfulness, ICS, EMDR, and clinical hypnosis research offer convergent evidence for this mechanism. Maxfield et al. (2008) propose that dual-attention tasks help forge new associative links between related material and the original memory, transforming how the memory is stored within the network.

Final Thoughts

I genuinely stand on the shoulders of giants. Many clinicians have shaped my work over the years, but none more profoundly than my mentor, colleague, and friend Dr Donald Meichenbaum, one of the earliest pioneers of transdiagnostic approaches such as narrative constructivism and stress inoculation training. Psychotherapy continues to evolve, and as Dr Meichenbaum noted in a 2018 Psychotherapy Expert Talks interview, the expanding field of neuroscience, including work on gene expression, is not only cutting edge but highly relevant. Adverse experiences can ‘tune’ stress and emotion systems by altering patterns of gene expression; resilience-building experiences can ‘retune’ these systems in a healthier direction. Psychotherapy and coping skills are therefore, not just simplistic psychological interventions but associated with real biological change over time.

Such developments enrich psychological therapies and help underpin the scientific foundations of models like NeuroAffective-CBT.

It is increasingly clear that the future of psychotherapy will involve a deeper integration of mind and body. Traumatic stress is just one example where working holistically with a client’s psychological and physiological symptoms can lead to more robust and lasting outcomes. This shift will require psychotherapists and psychologists to broaden their expertise beyond traditional cognitive and emotional frameworks to include physiology, nutritional psychiatry, and psychosomatic approaches. The fields of neuroscience, clinical hypnosis, psychosomatic medicine, and biological treatments are only beginning to converge in meaningful ways.

NA-CBT represents one example of what can be achieved under the broader umbrella of Neuroscience and CBT; these new and old integrative, empirically grounded traditions are uniquely positioned to guide holistic approaches to mental health. In this model, the body, brain, and affect are understood as inseparable components of human experience, each informing and supporting the others throughout the therapeutic process.

References:

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Bartle-Haring, S., Bryant, A. & Whiting, R., 2022.
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Brown, S. & Shapiro, F. (2006). EMDR in the treatment of borderline personality disorder. Clinical Case Studies, 5, 403–420.

Castonguay, L.G. & Beutler, L.E., 2006. The Principles of Therapeutic Change That Work. Oxford: Oxford University Press.

David, D., Cristea, I. and Hofmann, S.G., 2018. Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in Psychiatry, 9, p.4. https://doi.org/10.3389/fpsyt.2018.00004

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.

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

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Kumpasoğlu, G.B., Campbell, C., Saunders, R. & Fonagy, P., 2024.
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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 Meichenbaum. Taylor & Francis Group.

Meichenbaum, D., 2017. The Evolution of Cognitive Behaviour Therapy: A Personal and Professional Journey. Abingdon: Routledge.

Mirea, D., 2018. CBT, what’s all the fuss about? NeuroAffective-CBT® [online]. 25 July. Available at: https://neuroaffectivecbt.com/2018/07/25/cbt-whats-all-the-fuss-about/

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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.

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

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Wells, A., 2009. Metacognitive Therapy for Anxiety and Depression. New York: Guilford Press.

Wells, A., 2019. Breaking the cybernetic code: Understanding and treating the human metacognitive control system. Frontiers in Psychology, 10, 2621.

Additional reading to consider:

For more information about Dr Donald Meichenbaum‘s career and research click here !

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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