Author: NeuroAffective-CBT

“BOLSTERING Resilience”   with Donald Meichenbaum is part 1 of a series on essential CBT skills for Building Resilience re-edited and re-published by Daniel Mirea on NeuroAffectiveCBT.com and Academia.edu with author’s permission for free use and specialist training – the content belongs exclusively to Dr Donald Meichenbaum (this material can also be found on the Melissa Institute website)

Dr Donald Meichenbaum is an American Psychologist, Distinguished Professor Emeritus of Waterloo University, Ontario and a Research Director of the Mellissa Insititute for Violence Prevention. But to me, Dr Meichenbaum is much more that, a dear friend and a mentor, a grandfather with a beautiful family. With an astonishing career of almost 60 years in mental health, Don Meichenbaum is in fact, one of the three main early CBT innovators, alongside pioneers such as Aaron T Beck and Albert Ellis. He is of course, better known for his ‘Clock Conceptualisation’, SIT model (Stress Inoculation Training) and Cognitive Behaviour Modification approach. Credited for his contributions with the nickname “The Freud of CBT” he was voted by APA in 1982, as one of the most influential psychotherapists of the 20th Century. Some of his extensive research on violent trauma might have been overlooked here in UK where the focus is much more on brief, cost-effective methods that can be applied within an NHS/ IAPT department. My goal is to correct that by drawing attention to his incredibly detailed research on constructivism, resilience, the use of spirituality, stories, metaphors and narration in CB therapies; such interventions can be applied anywhere and translate to any culture. His work is best expressed through his lecture notes and handouts which he graciously donated for free learning and study. I kept these notes intact and whilst editing for online publishing, I realised this material could comfortably amount to a whole new approach, which I would personally label ‘Narrative Constructive Psychotherapy’. But of course, Dr Meichenbaum in his characteristic style is far too modest to accredit himself with yet another therapy label. As such, I will do that for him and in doing so, I take the opportunity to honour and thank him for his contributions over the years and ensure his legacy by passing his ‘teachings’ on to generations of psychotherapy students. When you read these notes, there is a feeling that sometimes he speaks directly to you in one of his lectures. Perhaps you should imagine exactly that…. enjoy. This is for you Don on a special day ! Happy Birthday !

These are authentic lecture notes and handouts written by Dr Meichenbaum, they were intentionally not edited, so that when you will explore the material you would get a sense of ‘here and now’ as if you are attending his lecture right now and he speaks directly to you.

“Bolstering Therapists’ Resilience with Donald Meichenbaum” is part 1 / 2 of a short series of lectures on essential ‘CBT Skills for Building Resilience‘ in draft notes format, re-published by Daniel Mirea on NeuroAffectiveCBT.com with author’s permission for free use and clinical training – as such, the content belongs exclusively to Dr Donald Meichenbaum (this material can also be found on the Melissa Institute and Roadmap to Resilience websites).

For online training with Dr Meichenbaum please follow the UKCHH link below.

Dr Donald Meichenbaum online workshops via UKCHH

The UK College of Hypno-CBT, led by principle Mark Davis is a respectable, ethical organisation committed to evidence-based CBT, Mindfulness and CB-Hypnotherapy, methods that improve resilience, symptomatic independence and self-efficacy.

Lecture Notes from Dr D Meichenbaum

These are authentic lecture notes and handouts written by Dr Meichenbaum, one of the CBT founders, they were intentionally not edited, so that when you will explore the material you would get a sense of ‘here and now’ as if you are at his lecture right now and he speaks directly to you. Enjoy…and then move on to part 2 of the series which is right here !

TABLE OF CONTENTS

          Evidence of resilience

           Possible mediating mechanism

           The nature of resilience

          Implications for conducting psychotherapy

          Intervention strategies for bolstering resilience

          Characteristics of ” HYPE ” in the field of psychotherapy 

        

EVIDENCE OF RESILIENCE

Trauma is everywhere, but so is resilience, the good stuff is more important than the bad stuff “In spite of behaviors”

Resilience can on short be described as positive adaptation despite adversity. Here are a few facts about resilience.

1. Individuals can be resilient at one time in their lives, but not at other times.

2. Resilience is not an all or none phenomenon. Individuals can be resilient in one area of their lives, but not in other areas of their lives.

3. Resilience (positive emotions) and trauma reactions (negative emotions) can coexist, side-by-side.

4. Resilience does not come from rare, special or extraordinary qualities or processes. Resilience develops from the “everyday magic of ordinary resources.” Resilience is not a sign of exceptional strengths, but a fundamental feature of everyday coping skills (Masten, 2014).

5. Resilience rests fundamentally on relationships. Attachment figures act as regulators of stress and provide a secure base. Bystanders provide “social capital”, nurture an adaptive capacity, and provide a sense of security. They foster mastery motivation and a sense of self-efficacy.

6. Resilience-engendering behaviors and positive emotions such as optimism, gratitude, forgiveness, awe, and the like, can contribute to positive neurobiological changes (brain chemistry and structural alterations), and even impact gene expression.

7. Resilience is more accessible and available to some people than for others, but everyone can strengthen their level of resilience and “islands of competence”.

POSSIBLE MEDIATING MECHANISMS

• Exposure to multiple diverse traumatic victimizing experiences can alter brain architecture and function, derail developmental “wear and tear” on the body. (Allostatic Load)

• Neurobiological changes resulting from exposure to Adverse Childhood Experiences (ACE’s) include alterations to the amygdala, hippocampus, anterior cingulate prefrontal cortex, nucleus accumbens, and at the neurochemical level alterations including dopamine, norepinephrine, epinephrine, cortisol, serotonin brain-derived neutrophic factor, endocannabinoids, glutamate and neuropeptides.

• When a child experiences adversity early in life their monocytes and macrophages (types of white blood cells) become calibrated to respond to future threats with a heightened pain inflammatory response, and by influencing the hormonal system and dysregulation of cortisol levels.

• Traumatic stress may alter the organization and “tuning” of multiple stress response systems, including the immune system, the autonomic system and the hypothalamic-pituitary-adrenal (HPA) axis and alter gene expression. For example, childhood maltreatment sensitizes the amygdala to over respond to threat.

• Childhood adversity has been associated with shorter telomeres. Telomeres are receptive DNA sequences that cap and protect the ends of chromosomes from DNA damage and premature aging.

• In terms of the developing brain, exposure to cumulative adverse events contributed to:

1. Reduction in the volume and activity levels of major structures including the corpus callosum (connective fibers between the left and right side of the brain), limbic system (amygdala and hippocampus) that is involved in emotional regulation.

• Cerebral lateralization differences or asynchrony. Abused children are seven times more likely to show evidence of left hemisphere deficits.

• Impact the communication between the Prefrontal Cortex (PFC) (upper portion of the brain) and the Amygdala (lower portion of the brain). The “top-down” regulation of executive skills can be compromised by perceived threats and stressors.

The bottom-up emotional processes (amygdala) can “hijack” the PFC.

• The earlier and the longer the exposure to cumulative ACE, the greater the neurological impact.

THE NATURE OF RESILIENCE

Such psychological processes as positive emotions, optimism, active coping, social supports and prosocial behaviors, meaning making, humor, and exercise can foster and support resilience and reduce the intensity and duration of stress responsivity. Such positive activities are associated with reduced HPA axis reactivity. The impact of positive emotions is cumulative; repeated positive emotional experiences over time prime the system for optimal response to negative stimuli by expanding physical, psychological, intellectual and social resources (Fredrickson, 2001). There is a protective capacity of positivity. The presence of Oxytocin that accompanies engaging in resilience -engendering behaviors can counteract the impact of stress-engendering processes.

NEURO-PSYCHOLOGICAL MECHANISMS THAT NURTURE RESILIENCE

1. Reframing/Reappraisals is the ability to frame events in a relatively positive light. Functional MRI studies have shown increased activation in the lateral and medial prefrontal cortex regions and decreased amygdala activation during reappraisal. The increased activation in the lateral prefrontal cortex (the “executive” center) helps modulate the intensity of emotional responses and keeps the amygdala in check. Resilient individuals are better able to extinguish and contextualize traumatic emotional memories and can more readily retrieve positive memories.

2. Use of Humor is a way to engage in cognitive reappraisal and emotion regulation. A network of subcortical regions that constitute core elements of the dopaminergic reward system are activated during humor.

3. Exercise, Meditation, Mindfulness and Acceptance type activities have both neurological and psycho-social benefits, and bolster resilience.

4. Optimism is the inclination to adapt the most hopeful interpretation of the events which influences emotion regulation, contributes to life satisfaction, and increases psychological and physical health. An optimistic future-oriented outlook has been associated with increased activity in the amygdala and anterior cingulated cortex. For instance, optimists have lower rates of dying after cardiovascular disease over 15 years, compared to pessimists.

As Southwick and Charney (2012, p. 25) observe, “optimism serves as the fuel that ignites resilience and provides energy to power the other resilience factors”. But it is realistic optimism that works best, whereby individuals pay close attention to negative information, and not blind optimism that does not work.

5. Active goal-directed problem focused coping of taking direct actions when stressful life events are potentially changeable can increase neurotransmission in the mesolimbic dopaminergic pathways that increase pleasurable feelings and that stimulate reward centers such as the ventral striatum. Dopamine release in the brain leads to “openness to experience”, exploratory behaviors, and to the search for alternatives. A form of active coping is to engage in Behavioral Activation (physical exercise) which has positive effects on mood such as depression and that promotes resilience and neurogenesis. Exercise increases the level of serotonin, norepinephrine, dopamine and by stimulating the reward circuits in the brain. Exercise has also been shown to increase the size of the hippocampus and serum levels and increase brain volume (prefrontal cortex), especially among the elderly.

In some instances, when stressful events are not changeable, the use of emotional-palliative coping strategies such as acceptance, distraction, spirituality are the best ways to cope.

6. Prosocial behaviors and social supports and social competence, altruistic behaviors, helping others, and empathetic capacity facilitate resilience. The neuropeptides oxytocin, and vasopressin have been found to increase trust, compassion and enhance the reward value of social stimuli. Cortical “mirror neurons” have also been implicated in the regulation of positive emotions and can reshape the circuitry responsible for resilience. They play a role in facilitating social interactions by promoting shared understanding and empathy.

For example, compassion contributes to an increase in the level of endorphins, endogenous cannabinoids, endogenous morphine, dopamine, vasopressin, nitric acid, and oxytocin. In addition, the stimulation of the Autonomic Nervous System (ANS) engenders compassion, as compared to negative emotional distress. Compassion also triggers an orientation response and accompanying heart rate deceleration tied to respiratory sinus arrhythmia, heart rate variability and reduced startle responses and skin conductance (vagus nerve response), as well as triggering “mirror neurons”. Resilient individuals are better able to bond with others and attract social support.

Low levels of social support have been linked to increased rates of depression, anxiety and PTSD. In a 9-year prospective study, individuals with no or few social supports had 1.9 to 3 times the risk of dying from a variety of illnesses, including cancer, cerebrovascular and cardiovascular diseases, as compared with those who had optimal social supports. Among the elderly, loneliness is a strong predictor of early morbidity and has the same predictive power of smoking and lack of exercise.

Helping individuals increase their social supports and engaging in caregiving activities trigger the immune system to respond positively and stimulate the reward circuits along the medial forebrain bundle and engages dopaminergic neurons. Various hormones and neuropeptides like oxytocin and vasopressin facilitate social engagement and increase adaptation to stress by increasing empathy, eye contact, social cognition and problem-solving skills. Such positive attachment relationships buffer physiological stress responses.

7. Meaning-making is another strategy that can buffer against negative feelings and is associated with resilience. Having a role model who provides a “guiding light” and developing and following a personal “moral compass”, holding spiritual beliefs, and engaging in religious faith-based practices bolster resilience and facilitate recovery. For example, consider the experiences of Jerry White (2008), who lost limbs to landmine explosions and who founded Landmine Survivors Network, which later became the Survivor’s Corp. It is designed to foster a mindset of “Survivorship”, which he defines as “choosing to live positively and dynamically in the face of death, disaster and disability; a form of meaning making. His approach is designed to combat the development of a “victim mentality” where individuals tend to pity themselves, resent their circumstances, live in the past and blame others. White believes that a victim-minded person is generally inflexible, stuck in his or her grievances, and is seemingly unable to let go, find hope, or move forward. Over time, a victim’s intense focus is on their own personal suffering which can interfere with his or her ability to take positive action, relate to others in a healthy manner, or participate more fully in daily life.

White proposes five steps to help trauma survivors to tap their innate resilience and grow stronger.

1. Face facts: acknowledge and accept what has happened, the suffering and loss. Find a way to live with it and piece together a “personal story”.

• Choose life: live for the future, not in the past.

• Reach out: connect to others who have “been there”. Reach out to peers, friends and family.

• Get moving: set goals and take action for a healthy recovery. Develop an individual action plan and identify your life priorities. Each step engenders hope and builds self-confidence. Regularly evaluate your progress and when needed re-evaluate and change one’s objectives. Such individual action plans are a contract of sorts with oneself and with others.

• Give back: be thankful for what you do have. Contribute to others and to your community. Express gratitude – – thanking people who have helped. Express generosity – – giving back more than taking. Move from being a beneficiary to a benefactor.

8. Hamby has highlighted three areas of resilience-engendering activities:

  a) Emotional regulation of both negative and positive emotions— emotional

            awareness, distress tolerance, a positive Mindset, feelings of 

            self -efficacy, and the ability to cheer oneself up after bad things

            have happened.

b)  Interpersonal supports– family support, able to share feelings, problems 

           and family rituals/parent monitoring and investment in academic competence/ 

      sense of belonging “mattering”/ support from prosocial peers/ at least two adults 

      outside of the immediate family who have connected with the child/ teacher

     engagement and school connectedness/ feeling safe in school and in the

     community/community supports.

• Meaning-making activities– religion and spirituality/ dedicated to a cause,

           sense of purpose / belief in a better future / commitment to a specific role

(student, worker, father, mother)/ adhere to code of honor or possess a “moral   compass”.  As Viktor Frankl observed, “Anyone who has a WHY in their life can  learn to handle any HOW.”

In summary, the experience of positive-balanced emotions such as optimism, joy, pride, contentment, compassion, love, forgiveness, gratitude, humor have been associated with distinct neurobiological and psychological changes that provide a protective capacity. The positive emotion of awe, which reflects positive feelings of being in the presence of something vast that transcends our understanding of the world contributes to altruistic behaviors and to a sense of community. Awe helps shift one’s focus from a narrow self-interest to the interests and well-being of a group to which individuals belong. Sights and sounds of nature, collective rituals, artistic events of music and dance elicit positive emotions that have behavioral and physiological sequelae. These neurobiological responses include:

Increase of neurotransmitters like cortisol levels that facilitate pathway communication between Prefrontal Cortex (PFC) and subcortical systems like the amygdala. For instance, GABA (gamma amino butyric acid) which is an inhibiting neuropeptide made in the orbitomedium PFC (OBPFC) when released “turns down” the alarm system of the amygdala. The left PFC, a site associated with positive emotions such as happiness, is more activated during Compassion Meditation.

These positive emotions reduce physiological arousal and broaden and build an individual’s focus of attention, allowing more creative inclusive, flexible, integrative perspective taking, engenders positive reappraisal of difficult situations, fosters problem-focused coping, and facilitates the infusion of ordinary events with meaning. Fredrickson, in her Broaden-and-Build Theory, highlights that the impact of positive emotions is cumulative. Repeated positive emotional responses to negative events expands and builds psychological and behavioral resources.

IMPLICATIONS FOR CONDUCTING PSYCHOTHERAPY

The research on neurobiology of resilience underscores the value of conducting psychoeducation on neuroplasticity (the power of the human brain to change and repair itself) and the potential recovery from experiencing traumatic and victimizing experiences. The therapist can help clients learn a variety of skills and engage in activities that bolster positive emotions and improve resilience and health. When discussing with clients the lingering impact of traumatic and victimizing experiences, the therapist can convey examples of how the body “keeps score” and the enduring impact on the clients brain and behavior. The good news, however, is that the brain is a remarkable resilient organ and clients have the potential ability to reverse this process. Clients can learn to capitalize and build upon what is called neuroplasticity, and moreover, even begin to “turn on” and “turn off” the genes in their body (neurogenesis).

The therapist can say: “Let us begin by having you better appreciate the possible impact that traumatic and victimizing experiences may have on your brain and behavior. Traumatic events and losses can lead the lower part of your brain that is the emotional center to:

… hijack; overwhelm; flood; overshoot; ramp up; exceed; trigger action pathways;  over activate and have a spiraling, cascading snowball effect; prime or kindle;  shorten your fuse; and undermine and shut down the upper part of your brain, the  frontal lobe executive control center.”

            When conducting this type of psychoeducation, the therapist should choose one or two of these illustrative verbs to describe the impact of traumatic and victimizing experiences and accompanying losses. Do not overwhelm the client. The therapist should then solicit personal examples from the client that reflects that activity.

            “Can you give me an example of how you did X?” (Choose one of the following):

“Magnified your fears; time slide back to your old ways of coping that once

worked for you; went into a kind of autopilot mode of survival; engaged in

safety behaviors; were hypervigilant and constantly on the lookout for possible

threats; repeatedly conducted a kind of after-action analysis in the form of

ruminating; had difficulty sleeping; sought an adrenaline-rush by engaging

in high-risk behaviors, used booze or drugs to self-medicate?”

            The therapist can convey to the client that he/she noticed, and wondered if the client also noticed, these behavioral patterns and “What is the impact, toll and price that resulted?” After discussing such consequences and how they may interfere with achieving the treatment goals, the therapist can convey that the therapy can help the client learn how to: (Choose one)

     “Regulate, modulate, control, strengthen, regain, restore, reprogram, reshape,

re-right myself, re-establish, re-define, mobilize, adapt, calibrate, blunt, improve

their error detection skills; soothe, down-regulate, label and tame emotions,

surmount your fears, orchestrate, get accustomed, accepted, organize your

traumatic memories into a narrative account, develop coherent redemptive

stories that have a beginning, middle and ending, note what you have done to

survive, contextualize and put the landmark traumatic events into a larger

autobiographical account.”

            The therapist can highlight that attention and increased awareness are the key first steps in the ability of the brain to repair itself. The client can learn how to “talk back” to the amygdala or the lower part of the brain and take charge once again. For instance, clients can learn emotion-regulation skills and they can come to tell themselves and others:

 “I can rewire my brain.”

 “I can talk to my amygdala (the alarm center) and train my emotional brain.”

 “Not allow my amygdala to hijack my frontal lobes.”

 “I can use the upstairs part of my brain to calm down the downstairs part of my brain.”

  “My positive emotions can Re-shape my brain.”

 “Positive relationships that I have can switch on and off different gene contributions  and leave a positive chemical signature on my genes that affect my brain development.”

“By being kind I can raise my level of oxytocin which curbs stress-induced rises in  heart rate and blood pressure and that reduces feelings of depression. Being kind  protects my heart.”

“I can reduce my heart rate by 6 to 10 beats per minute by taking slow deep  (diaphragmatic) breaths.”

“I remind myself that my brain is not fixed, nor static. It is highly plastic and flexible.

It can repair itself, with my help.”

“As with other parts of my body, I need to use my brain or lose it.”

“If I don’t stimulate my brain, my brain cells will die and be pruned away.”

“I have the capacity to bend, but not break.”

“I can see the big picture and find the silver lining and develop a new normal.”

“I can get myself to do what I do not feel like doing and get myself out of my comfort  zone.”

INTERVENTION STRATEGIES THAT BOLSTER RESILIENCE

(See Meichenbaum’s Roadmap to Resilience book for examples)

Use Physical exercise – – Behavioral Activation and use Active Coping Strategies.

Use Emotional Regulation and Distress Tolerance Skills and Increase the Protective Capacity of Positivity that Buffers Negative Feelings.

Focus and savor positive emotions and past reminiscence and anticipate positive emotions (anticipating). Engage in goal setting and affective forecasting in the form of positive future-oriented imagery that nurtures hope. Avoid “dampening” or minimizing positive events, “I don’t deserve this”… “This won’t last”.

Engage in Mindfulness Exercises – – pay attention in a particular way, on purpose in the present moment, and nonjudgmentally.

Engage in Loving-kindness Meditation and engage in Acts of Kindness.

Engage in gratitude exercises “Give back and pay forward”.

Engage in Forgiveness exercises Toward others and Toward Oneself – – Compassion is the awareness of the suffering of others and oneself, coupled with the wish and effort to alleviate it.

Engage in Meaning-making Activities and Cognitively Reappraisal (“Healing through meaning”)

Use Spiritual-related Activities – – Use of One’s Faith and engage in communal religious activities (See Meichenbaum “Trauma, spirituality and recovery” )

Increase Social Supports – – keep interpersonally fit by participating in positive activities; selectively choosing and altering situations, improving self-presentation (smiling, dressing up), improving communication skills and accessing social networks.

Use humor, Have fun and build-and-broaden Positive Emotions (“Bucket List Activities”)

Each of these Activities will help bolster resilience by increasing the accompanying neurobiological processes. There is increasing data that a course of psychotherapy- even without medication- had measurable physical consequences in the brain.

CHARACTERISTICS OF “HYPE” IN THE FIELD OF PSYCHOTHERTAPY

Your attendance at this conference reflects your interest in increasing your knowledge and your clinical strategies and skills to help your patients achieve better treatment outcomes. Such concerns are timely given the research findings in the field of psychotherapy on the marked variability in effectiveness across psychotherapists. The most effective psychotherapists average 50% better outcomes and 50% fewer dropouts than psychotherapists in general (Wampold, 2017).  One of the characteristics of more “expert” psychotherapists is their penchant for maintaining a critical attitude apropos of Paul Meehl’s (1973), admonition of “Why he does not attend case conferences,” and the presence of “SELF-DOUBT.”  Research indicates that psychotherapists self-reported self-doubt predicted treatment outcomes- more doubt about their skill in helping patients (e.g., “Lacking confidence that you might have about a beneficial effect on a patient.” and “Unsure about how best to deal effectively with a patient.”), had better treatment outcomes, particularly if they also had a positive sense of self. Consistent with the article by Nissen-Lie et al. (2015) entitled  “Love yourself as a person, doubt yourself as a therapist “, the present Psychotherapy Consumer Checklist is designed to plant the seed of self-doubt and nurture a healthy sense of  “HUMILITY “, and hopefully improve treatment outcomes. What follows is a Checklist of “Psychotherapy Beware Signals.”

 1. Advocates for a therapeutic approach state that their treatment is “revolutionary” and offer outlandish unsubstantiated claims for its superiority (Over 90% improvement rates). “Simple, but powerful” treatment approach. “A breakthrough treatment.”

2. Make claims that you can learn from a “master”, “leading expert” or “guru” and use marketing terms like “powerful”, “transformative”, “unique and ultimate training,” “life-changing benefits”, “deep psychological healing”, and moreover, assure that your “complete satisfaction is guaranteed.”

3. Advocates use Acronyms (Acronym Therapies) and “psycho-babble” to sell their treatment approach.

4. Claim that the treatment approach could be applied successfully with patients who have a wide variety of psychiatric and physical conditions, and across multiple age groups without any clinical trial demonstrations.  Advocates often imply that their treatment approach “fits all” (“One size fits all”).

5. Claims that treatment approach is “evidence-based”, scientifically proven, because it has met the criteria of two randomized controlled trials, but they do not report Effect Sizes, nor provide details about the exclusionary criteria of the patients. “Cherry-pick” the patients. Also, does not report on the attrition and drop-out rates, follow-up data. Advocates often broadly and subjectively define “evidence” (e.g., “I saw it work with my clients, and that is my evidence”.)

6. Advocates state that “Over X number of studies have consistently demonstrated efficacy and superiority”, without citing or critiquing these studies.

7. Compare proposed treatment to “weak” comparison groups. Does not compare treatment to “bona-fide” comparison groups that are intended to be effective (See Wampold et al., 1997).

8.  Compares the proposed treatment versus a reduced, or weaker version of the comparative treatment. For example, see Foa et al. (1999) comparison of Prolong Exposure versus Stress inoculation training (SIT), where the third application phase of SIT was omitted.

9. Do not report on possible “allegiance effects” of who conducted the controlled outcome studies.  Moreover, the cited supportive studies that were initially conducted yielded more effective results than later conducted studies. (“Strike while the iron is hot”, and when the enthusiasm for the new therapeutic approach is highest.) See the provocative informative article by Lehrer (2010) of the “decline effect” in research attempts to replicate clinical trials. For example, the efficacy of antidepressant medication has gone down as much as threefold in recent decades.  Effect Sizes from studies from treatment studies drop off.  He observes that the researcher’s belief can act as a kind of blindness. 

10. Do not independently determine if the treatment rationale offered to the alternative treatment and control groups is judged as being as credible and believable as for the advocated treatment. This can lead to differences in expectancy effects across groups.

11.  Do not highlight the role of non-specific treatment factors, such as therapeutic alliance, expectancy effects, and other placebo considerations. For example, does not include any measures of the ongoing quality of the therapeutic alliance, such as the Therapeutic Alliance Scales, or the Quality of Relationship Measures, or the session-by-session treatment-informed feedback (Prescott et al., 2017).

12. Does not include a critical account of the scientific validity, or theoretical basis, for the effectiveness of the proposed treatment. Offers little scientific basis for the proposed change mechanisms for the treatment. See controversy over so-called “energy –based” treatments such as Tapping, Eye Movements, Magnetic fields, Meridian band techniques and the like. The intervention may work, but it has little to do with the proposed treatment model. The proposed treatment may do better than no treatment, or weak control and comparison groups because of non-specific factors, such as placebo effects.

13. Advocates use “neuro-babble” and “neuro-networks” and reductionism (often with colored versions of the brain) to explain the treatment approach. They resort to a dubious neurological basis for the explanation of their treatment approach.

14. Advocates fail to discuss criticisms of their treatment approach. They fail to mention the results of dismantling studies that question the basis of their treatment approach.

15. Advocates tell their patients that “If this treatment does not help you, then nothing else will.” They convey an expectancy that reinforces treatment outcomes.

16. Advocates promote advance training, sell paraphernalia, tapes that go along with their treatment approaches. They require that trainees sign statements that they will not share treatment protocols with others. “Commercialism is rampant.”

17. Advocates are very defensive and “thin-skinned” about their approach. They often question the motives and background of those who have questioned the efficacy, theoretical basis of their treatment approach. They fail to question what they are proposing and readily dismiss skeptics. They may disregard “inconvenient truths” and offer “alternative facts”, thus, holding onto debunked theories.

18. The advocates of their treatment approach rely on the endorsements of a leaders in the field. For example, some therapists in the trauma field cite Bessel van der Kolk as an advocate and endorser of their treatment approach.

19. Advocates establish a coterie of trainers and an International organization to promote the treatment. Advocates use public media (television, blogs, print) and they over sell their treatment approach. Advocates are “slick salespersons,” setting up clinics, training settings, and conferences.

20. The advocates will provide a Certificate that you have taken the training and can call yourself an X therapist. Offers to put you on a referral list of Certified X practitioners.

HOW MANY OF THESE 20 ITEMS DOES YOUR TREATMENT APPROACH INCORPORATE?

REFERENCES

Frankl, V E (2004). Man’s search for meaning. Waterstones

Frederickson, B (2004). Broaden and build theory of positive emotions.  Philos Trans R Soc Lond B Biol Sci. 2004 Sep 29; 359(1449): 1367-1378.  doi: 10.1098/rstb.2004.1512 PMCID: PMC1693418 PMID: 15347528

Masten, A. (2015). Ordinary magic. New York.

Southwick, S. & Chaney, D.  (2012).  Resilience: The science of making life’s great challenges. New York: Columbia University press. 

Meichenbaum D. Roadmap to resilience. WordPress

For more resources from Dr Meichenbaum please click on the Melissa Institute link right here !

When is perfect, perfect enough?

Perfectionism is not about excellence or healthy development, but a rather sophisticated bio-psycho-social mechanism that internally sounds something like this: ‘if I deliver at 100% all the time and if I look perfect all the time and if I achieve 100% academically all the time, I shall no longer feel ashamed, embarrassed and will no longer be judged for underperforming – everyone will love and accept me then’.

Striving for a specific ‘reward’, whether material, professional or academic, is wired into our neurological system and can be healthy for both the mind and body. However, when suffering from low mood and low self-esteem, perfectionism is usually turned into an unhealthy obsession by constantly shifting the goal posts or aiming for unrealistic, or even impossible, standards.

Shafran (2002), a leader in this field, views perfectionism as the overdependence on self-evaluation, the determined pursuit and achievement of self-imposed, personally demanding standards of performance, in at least one salient domain, despite the occurrence of adverse consequences.

This obsessive drive forward is often misread by significant others (usually immediate family and close friends) as ambition. There is a threshold nonetheless, observable to the trained eye, by the experienced clinician who understands the blurred line between pathological tendencies that reinforce anxiety and depression, and a healthy motivation to achieve.

Mary, a case of severe clinical perfectionism

Mary did not present to NA-CBT because she wanted help with perfectionism, but because she felt low, and was sick and tired of feeling isolated. She also wanted to feel less anxious and improve her sleeping; socially, she needed a better connection with people but on the other hand, she was very good at pushing them away. As such, she was depressed much of the time, pessimistic, cynical, and generally unsatisfied.

Focusing on the main complaint, which, in Mary’s view, was her increasing social isolation, I directed the guided discovery towards how she is usually pushing people away; this is typical a functional or behavioural chain analysis. In any case, this is what the discovery revealed. Mary enjoyed a senior position at work and explained that she was, by her own admission, intolerant and naturally so, given the circumstances, since most people surrounding her are slow and stupid. As I was sitting across from her, tried to really concentrate on what would be like to work for someone like Mary and be made to ‘feel stupid’; and thus imagined being one her colleagues feeling inadequate as a result of an interaction with Mary [imagery method used – emphatic mentalisation]. I asked her… do you ever feel that you’re stupid or is it just other people or is this perhaps just another stupid question? She immediately responded… Oh no, I could be stupid, and I hate that even more, because deep down, I actually know I’m pretty smart, so if I do something stupid it’s even worse, there are no excuses for me…

I pressed on and asked for an example of her being stupid and she said… Well, I binge on alcohol and sugar you know, not so often now, but I waste a lot of money on drinks and sweets and that is pretty stupid in my books. Mary had been binge drinking and indulging with sweets for a long period of time; naturally this felt enjoyable in the moment, but this process provided also an excellent platform for launching a series of self-blaming thoughts and self-criticism which will relentlessly follow [these reinforcing activities would later be explored in simple ABC type formulas – explore the concept functional chain analysis and vicious cycles]. Her all-or-nothing attitude to drinking or eating was carried over destructively to other parts of her life; her mind was set to self-criticism and her being stupid inventory was off the charts… if someone says the wrong thing that’s it, I feel like I just don’t want anything to do with them anymore… everybody gets one chance and if they blow it that’s it [Mary].

The therapeutic alliance and use of ‘empathic-mentalisation’

If I was your colleague and needed your help, I would feel intimated by you – I used empathic mentalisation to picture this narrative like watching it unfold on a stage play that I am part of, and therefore, by default, projected it externally into the therapeutic space. Outwardly, I just looked at her and nodded with a slightly intimidated face… and as if she’d heard my thoughts, she then said…  people often find me intimidating… I nodded again, eyebrows raised imitating a little fear and a little surprise… Oh reeally!?… I said and continued to visualise what came up next for me, how I might not immediately turn to Mary for some friendly support as her colleague, if I could avoid it.

[At this stage consider the difference between analytical transference/countertransference and empathic mentalisation in NeuroAffective-CBT, and what would need to happen next]

Inside, Mary was torn, since she knew she needed to change; her suffering was pretty clear.…  it is rather lonely being perfect especially when you’re not…  But is this subjective or therapist’s non-transferential, informed conclusion? In order to understand that, beyond cognitive reasoning at a prefrontal level, it was important to attempt to feel what her colleagues or friends are feeling at this stage, and try to figure out why they are avoiding her at an emotional level. I coined this intervention ‘empathic-mentalisation’ or the ability to feel, different participants’ affective or lived experiences, only to explore and discuss these other points of view and the others’ emotional states, i.e., I wonder what Joe (her colleague) would feel at this stage (in your story). Could you put yourself in her shoes, what does it feel like?

[It may be important to debate the topic of ‘empathic-mentalisation’, which is one of the most important aspects of NeuroAffective-CBT. What is the alternative approach at this stage? In traditional CBT we usually view transference and countertransference as opportunities for an open dialogue – see Donald Meichenbaum]

Mary was lonely because other people irritated her, but she irritated herself even more so [double bind]; work relationships and even friendships had gradually disappeared over the years, usually because other people couldn’t stand the attacks and her constant judgements. The unforgiving standards justified by her beliefs around mediocrity. She quickly found people’s imperfections not a sign of their humanity but laziness or lack of desire to improve, and as such she rejected people right away [where would such values be placed in the CBT conceptualisation and what type of beliefs are we faced with at this level].

Having high standards, being solution-focused and driven, can help us achieve wonderful things in life. But for Mary and many others, suffering from pathological perfectionism, this life strategy would be so over-used, it would eventually lead to blocking any sense of achievement or reward usually experienced by taking pleasure in activities that are performed.

Early Years

As a child Mary was a fast learner, but as she was quick to give up athletics because she was not the fastest runner, she had also given up ballet, even though she had shown great promise. Mary used to rip up her music sheets when her clarinet practise didn’t go as planned and never went back to any of those activities; there was no sense of achievement or enjoyment. This wasn’t unusual, in fact it was perfectly aligned with the family culture; her parents valued achievement above all else and being the best at everything; if you weren’t the best, move on there’s no point in doing it. She recalls her father’s catch phrase vividly ‘if you don’t do it well, might as well not do it at all’. The father passed on these attitudes to his children including Mary.

Nowadays she also struggles with procrastination, putting things off (until she feels 100% ready), or deleting reports or emails reviewed for hours on end for reasons other people probably couldn’t even see (in her own words).

My life has been full of stops & starts… I hesitate all the time, I am uncertain about the quality of my writing (an email or a report) …  if something is wrong or doesn’t fit how I think it should be, I tend to give up on it immediately… I’ve had so many opportunities I should have pursued… I’ve stopped even trying to do stuff I feel maybe hard although I won’t be good at that’s what she told me.

The trap of perfectionism

Mary needed of course to relax her standards and disrupt this childhood association that she is not worthy unless she performs extremely well. Cognitive rigidity is a major risk factor for chronic pathologies, research has found links between perfectionism, addictions and eating disorders. Perfectionism is particularly unforgiving to the self. Rigid thinking that characterises maladaptive perfectionism can also contribute to the onset and maintenance of depressogenic thinking. Cognitive biases such as all-or-nothing thinking or minimising successes, maximising failures, act as situational filters that lead to black-and-white conclusions about self and others. 

[Taking all of the above into consideration, what would the formulation look like at this stage]

NA-CBT treatment plan

The focus of Mary’s treatment was around improving interpersonal skills, decreasing social isolation and improving her stress levels; we began building her social and interpersonal skills by role playing [discuss method acting] a variety of case scenarios within the safety of the therapy space, helping her develop compassion and appreciation of herself and other people above and beyond what they were good at!

[How would you best achieve all of the above? Below there is a brief overview of how NA-CBT helped Mary go from an intolerant to compassionate attitudes towards herself and other people. Consider what is missing from this plan and what else would you have done]

Psychoeducation:  

In CBT we start by describing the bio-psycho-social traps, these maintenance formulas (explained further below) keep the perfectionistic mechanism going over the years. Mary like most perfectionists, is a detailed analytical thinker and likes to know why she is even thinking in this way, the origins of it and so on. This is not an intellectual or psychoanalytical exercise, nor a brief overview of her earlier years but rather an exercise of exposing the earlier narrative through a strong hypothesis about the episodic origins (and associated specific memories) of her perfectionism. And more importantly the link between these episodes and the present attitude and life strategies.

[how would this be achieved]

The origins of her perfectionism were very clear in Mary’s case. It was simply her parents’ personal ambitions, unrelenting goals and high standards imposed to her from a very early age; reading already at the age of three, her parents were very proud of her. Mary’s need to please her main caregivers was backed up (reinforced) over the years by appropriate and timely rewarding (i.e., every time she would get the highest mark, an A+, she would be praised but criticised harshly and compared unfavourably with other peers, when she would bring a lower grade, a B or a C). This was further reinforced and conditioned by her teachers, peers and friends, all too willing to praise and appreciate her efforts. This would eventually lead to a rigid personality and a strong association between self-appreciation and good performance. which would be maintained by specific life strategies (behaviours) and all-or-nothing thinking. Creative diagrams and metaphors were used to explain the nature of negative thinking and all these vicious traps.

[case formulation: diagrammatical explanation or narrative, what would work best in this case]

Cognitive interventions:

I asked Mary to spend some time with her eyes closed (within an imagery and almost hypnotic state), drawing a world in her mind, in which no mistakes were ever made, where everything was always done entirely correctly, and skills were picked up instantly by everybody… where people were perfect and operating at their full potential without error.  She imagined a range of different scenes, involving all sensory modalities (making very real – this is not a fantasy world but a real world, in present tense).

She described this world in detail, just like a perfectionist would, drawing with her mind’s eye, this very detailed perfect world for 15 minutes or longer… and when I asked her what she felt after, on reflection, she said that….  it is silent, too cold, not much fun at all; she noticed no satisfaction from having overcome challenges and in a nutshell, it’s a horrible place.

Chronic perfectionism is always a case of being (unrealistically) too goal and task oriented in parallel with an imminent self-critical mind. As such, we need to directly tackle this aspect, by encouraging a wider context and more psychological flexibility. If we consider experiences within a strict goal-oriented narrative (i.e., the scope is to win or my goal is to be the best), we miss much of the finer details of the process (of winning), for example playing a friendly game with relatives at Christmas or some other get together, is a chance to have fun, to be creative, to laugh and bond with significant people in your life, a chance to help other people feel good when they win, a way of communicating with loved ones, regardless of who wins!

But a chronic perfectionist may miss out on all these wider contextual elements of playing a game, so for instance when I would ask Mary what is the point of a competition, she immediately replied, well to win of course. It was a genuine revelation to her when we explored other possible purposes or by products of a competition; and how she was intrigued to generate new ideas because she’d always thought … in fact, what’s the point was a standard response to any idea or suggestion in therapy, as if everything could be whittled down to one thing. The ‘what’s the point’ syndrome is often a sign that someone’s thinking is too task oriented and too black-and -white.

[the exercise of overcoming perfectionism sharpens perception and makes it more flexible and context aware, while also increasing compassion to oneself and other people – but how can this best be achieved]

Behavioural interventions:

A lot of social experiments at work or at home would be designed based on the above conceptualisation of Mary’s perfectionism. For example, going to a colleague that may be particularly intimidated by her and asking for advice in spite of already knowing the answer. Encouraging relaxation and downtime is remarkably important; all-or-nothing thinking is exhausting as a result of being hyper-aroused, on high alert all of the time, in search for good outcomes and excellent results; no activity feels rewarding unless it’s results driven, so even the immediate time that follows a successful endeavour can feel depressing to the perfectionist; free time isn’t valued or tolerated very well.

Mary’s life was organised on paper, literally, because keeping notes (including smaller notes about the main notes) was very important [implicit life strategy or one of the ‘musts’: ensuring not to miss anything or make mistakes]. Her calendar, therefore, was packed with ‘essential activities’. Preferred activities were manically cleaning the apartment, crossing tasks off the lists, or rigorous dieting. What she needed in contrast (another behavioural intervention) more rewarding activities and relaxation, were more of respite episodes, which would not include marathon running, which incidentally was a hobby of hers.

[can you guess why – could it be because it was a task-oriented activity, where the goal posts can easily be shifted upwards… another vicious cycle… Tip: the answer should be in your conceptualisation].

Mary understood why it was important at this stage in therapy to learn how to let go and perhaps even fail. We talked about compassion, self-appreciation and how being human and flawed by design, means also getting comfortable with failure; this in fact could be the first step towards more realistic success, on a social and professional domain. She also needed a break from having to be seen as perfect by other people and the best at everything all the time. Therefore, we agreed on the following behavioural experiment. Mary was asked to meet up with a friend she hadn’t seen for a while [behavioural and social experiments are designed to contradict life strategies, the obligatory should and musts of which are very much part of perfectionist’s life repertoire]. Her friend remained reasonably close to her over years but kept her distance for obvious reasons; eventually they agreed to meet. The challenge was to tell her friend a story of how she [Mary] had failed in some way. During therapy, Mary told me that she completed this task only because after all, she liked to do what she said she would do. And so, she had met up with her friend and told her how she cheated on one of her reports at work. At the time Mary had been mortified but while telling her friend about this episode something suddenly began to happen Mary relaxed and they both laughed at the irony of it all. In the end they were both crying with laughter, and it was wonderful.

Roadblocks and opportunities to successful therapy outcomes

A trusting therapeutic relationship is essential and always key to a successful treatment. This is where empathic mentalisation can be useful not only in the earlier stages of therapy in order to authentically relive difficult situations but to continue to support your client feel felt throughout the process [I don’t just understand (cognitively), but I am feeling your pain]. This enhances collaboration and self-efficacy.

Mary admitted that initially when she was exposed to the idea of behavioural experiments, she felt that… She had to carry out the task, because if she hadn’t, she would have failed it and that would be terrible… This is a classic therapeutic challenge when working with perfectionism. The therapist must be aware of such tendencies and expose these types of beliefs also. This type of admission would not be possible outside of a safe and confidential alliance. Therapist must retain a positive attitude and explain such vicious traps and the role of reinforcing mechanisms.

Behavioural experiments would have to be creatively enhanced, with more and more challenges, and repeated over several weeks of treatment. I kept asking Mary to make small mistakes and practise laughing about them, tell other people about these mistakes; this is in line with research that shows that people like you more when they see you make small mistakes and own them. Of course, gradually people did seem to respond to her positively as they discovered that they could relax around her and she didn’t make them feel bad.

Behavioural experiments are based on maintenance formulas that are clearly explained to the client during the initial assessment stage (i.e., psychoeducation). In NeuroAffective-CBT we identify three categories of maintenance: overcompensation, avoidance and surrendering (or covert self-sabotaging). Here are some examples of maintaining traps that eventually need to be at the very least modified, challenged and disrupted.

The principle motivational messages that need to be sent to the client are simple:

‘The main purpose of this exercise is to help you switch off the autopilot and be more self-aware, as such the first step would be to label your compensatory, avoidant and self-sabotaging actions aka maintenance programs… once we can name it, we can tame it. It is equally important to remember that these actions (or strategies) are contextual (or situational) – sometimes those makes sense in specific circumstances but only… to a certain degree. Outside of that, they encourage and perpetuate psychological rigidity.’.

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, proof reading 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.

Avoidance (specifically procrastination): ‘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.

Surrendering or self-sabotaging one’s confidence… this is like the subconscious, unconditional acceptance of being ‘not good enough’ or ‘helpless’, or ‘a failure’ or whatever the core-affect is suggesting… For example, 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 and often saying to oneself ‘since I am so bad, what does it matter anyway.. or… in that case, let me show you how bad I really am’.

Understanding the fundamentals of NeuroAffective-CBT interventions

Let’s now attempt to examine how during therapy, individuals could learn to disrupt the above reinforcing (compensatory and/or avoidant or self-sabotaging) strategies, by understanding those mechanisms as part of a chain of events, traps or vicious cycles. The FTA trap or the ‘Fear-Thinking-Action’ trap, which ‘fear of failing’ in this case, creates in the background, has clear reinforcing phases or stages that complete a vicious maintenance trap. Each phase would need to be questioned during therapy and therefore, potential solutions have to be identified under each stage.

The Situational ‘A-T-A’ cycle

Phase 1 – the triggering Situation which instantly activates high levels of Negative Arousal (aka Situational ‘A’rousal): the short-circuit between the triggering situation and the emotional response would be incredibly difficult to notice, in fact neuroaffective research points out that the amygdala which is in charge with processing both threats and rewards can assess a situation in a 25^th of a second. The activating or triggering event could be anything and it could spark anywhere, since fears of failing are easily triggered by a range of perceived social-threats often shameful or embarrassing situations. Intensive feelings of shame and embarrassment can be characterised by symptoms akin to traumatic stress. If we were to unpack any work-related situation, that leads instantly to high levels of hypervigilance and hyperarousal, we could notice how in such situations, the Autonomous Nervous System (ANS) is activated instantly engaging large parts of the musculoskeletal system. As the ANS is ‘autonomous’, it basically has a mind of its own and, it thinks that ‘YOU are under threat’. At this point all we can ‘feel’ is a state of physiological hyperarousal and muscular stress in preparation for fight or flight only that, of course there is no one we could physically fight at work. So phase one would consist of a difficult situation (at work) which instantly leads to physiological distress and an overwhelming feeling of fear. 

Potential solutions discussed later in therapy for this phase would be, to raise self-awareness by teaching the anxious individual to switch off the autopilot when at work and be more observant or mindful, notice when and how one is being triggered. Ask Yourself: Am I under threat or is this my anxious mind trapping me again… am I catastrophising at all? How can I be sure that it is not real and I am just being anxious… well, let’s check in with my body? Should this fail, I do not judge myself and I accept this self-to-self dialogue is not enough, to down-regulate or self-regulate. So, I press on with body scanning in a non-judgemental and calm way… Am I still hyperarousal and if so… where exactly in my body? Which part of my body is tense and stressed in a painful way?

And if the body is stressed… then which precise muscle or set of muscles, how intensive is the physical distress on a subjective scale from 0 – 10… ok, now we know… relax the muscles in that area to a level of 1 or 2 or whatever seems realistic and achievable right now… relax using progressive muscle relaxation and abdominal breathing.

Phase 2 – Catastrophising is like a rapid cascade of Negative Automatic Thinking about the imagined (social) threat or underperforming and being a failure, about not being competent, not good enough and shamed by this situation; it is like having a cascade of negative predictions, e.g., I am getting this wrong, I will fail, I cannot deal with this and I will be fired.

Potential solutions – a much more realistic and assertive, internal self-talk (or self-to-self dialogue) which should get easier and easier over time and with practice. Like with everything else, we never aim for perfection, but regular practice helps. Make sure you have a pen and paper handy, before starting... breathe and focus on your relaxed breath, remember how calming this can feel… now let’s remember in the most compassionate way that you have a bad habit and a tendency to catastrophise.. But in fact, what does catastrophising really mean, and how does it works? Well, lets remember the simple formula.. I overestimate the level of threat and underestimate my coping skills, resources and other rescue factors. Let’s write all these down and remind myself how I could cope should the threat occur (you can make a mental note to begin with and write it down when you open your eyes). Remember that often, I have a cascade of thoughts that fall rapidly towards one CONCLUSION and one conclusion alone – ‘I am failing and will be sacked or something terrible will happen’... but really… mperhaps it is time for me to consider looking for another job anyway if this thought turns out to be true. Getting fired could also be a ‘Blessing in Disguise!’ Let’s also write down some opportunities and potential doors this will open. And in doing so, perhaps I can eventually learn to tolerate some UNCERTAINTY.

Learning to decatastrophise and re-orient attention by visualising a list of coping mechanisms. Resources vary and are often in good supply, much easier to identify those when we are relaxed and biologically not under threat. If the threat is a social one, like being judged or losing a job and feeling ashamed in front of other colleagues, it may be important to have an existential, but behavioural and goal-oriented discussion about what it means to live authentically. Learning to identify and work towards one’s true values is important, a first step in this direction would be some research and even writing one’s thoughts… a simple question could help: If my daughter or son (sister or brother or someone I truly care about) was faced with this dilemma, what advice would I give them? Would I want them to live in fear every day? What have I learned from previous experiences or others I look up to about life, what feels important right now?

Phase 3 – the Action phase consists of a series of reinforcing actions, which eventually have to be exposed, rationalised, and countered – such actions can have an avoidant nature or overcompensatory nature are self-sabotaging and not in line with one’s true life values.

• Action: always talking to the most trusting friend or the partner, usually the same person and seeking reassurance when faced with a crisis (a therapist could easily fall in this trap and become an unhelpful resource) – such an action could have about 50% success rate (although it is best for the client has to measure the level of success); however, even though it might lead to some success, it closes the trap of feeling fearful and uncertain and lacking in confidence in one’s decisions. In a future perceived crisis, the victim would only fall in the same trap.
• Action: researching – looking at other jobs – this strategy has 0% success rate because it shifts attention away from problem solving the crisis (which triggered the situation in the first place).
• Action: talking to the manager, seems like a logical move but covertly the individual is seeking reassurance rather than solutions – 50% success rate because this can lead to actual solutions, however it closes the trap by making the individual feel tired, shamed and like an impostor. Asking for help is a sign of weakness, eventually they will be fired anyway…
• Actions vary and can happen in parallel (several actions at the same time); those are mostly characterised by reassurance and other types of safety-seeking including, avoidance of being shamed and avoidance of failing tasks at all cost! All efforts are exhausting and lead to helplessness. 

Potential solutions: simply taking an opposite action or question such ‘gut instincts’ actions by measuring the success rate that a specific action could deliver. Is the success rate proportionate with the solution needed, in other words, is it worth taking that action? Does it lead to a solution without the added stress and feeling exhausted over time. Does it help the individual in the long run… does one grow in confidence over time or do they become less trusting in their abilities and less assertive. Do these actions help the individual live authentically and in line with their true values?

Phase 4 – The vicious trap is finally closed by self-inflicted shame, guilt, burn-out and exhaustion resulting from all the effort. Stress keeps the focus away from a potential practical solution demanded by the initial critical situation because instead the focus is oriented on FAILING and BEING HELPLESS. Biologically this is expected since stress is triggered by the fight-flight system (or the ANS) and impacts on problem-solving skills.

Potential solutions: psychoeducation about all of the above, problem-solving and assertiveness training and developing strong ‘muscle’ memory.

In conclusion…

The main message we need to send out to our anxious and perfectionist clients, would be that we are asking them to do a tough job and act against their instincts, but they need to learn to take some risks and approach life and people assertively with a higher degree of self-belief. In regard to the above reinforcing strategies, we have to be able to translate and label those, and of course, it is not about getting it 100% correct all of the time, but it is important to name it, in order to tame it. You cannot raise self-awareness if you do not know what exactly you need to look out for, or be aware of. Eventually one should be able to switch off the auto-pilot, become more aware of their thoughts and actions, and live an authentic life, truer to their values. That is when your job as therapists is done.

References:

Daniel Mirea (2019). Is ‘perfectionism’ a deal maker or a deal breaker https://neuroaffectivecbt.com/2019/05/08/is-perfectionism-a-deal-maker-or-a-deal-breaker/

Roz Shafran (2002). Overcoming Perfectionism. Robinson edition.

For further training opportunities in Clinical Perfectionism as part of your NA-CBT or Integrative-CBT certification, click on this link: Treating the Perfectionist: CBT for Perfectionism Workshop – with Daniel Mirea, BABCP Accredited Psychotherapist – The UK College of Hypnosis and Hypnotherapy – Hypnotherapy Training Courses (ukhypnosis.com)

Disclaimer: this is not a self-help manual; the intention with all NA-CBT articles is to help and to develop knowledge. All case studies described are a combination of facts and very little fiction from different sources including 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 the anonymised case of Mary who received NeuroAffective-CBT for clinical perfectionism, this is part of a free handout offered to students on doctoral or advanced training programs in Integrative-CBT; certain details have been changed in order to maintain anonymity; the article includes specific questions at various crucial points ‘[in square brackets]’ raised by the author which are meant to trigger further enquiry and insights into the treatment.

Proof reading and editing by Ana Ghetu