Author: NeuroAffective-CBT by Daniel Mirea

Daniel Mirea is a CBT consultant and the founder of NeuroAffective-CBT. With over 35 years in mental health practice, he continues to work as a university lecturer, clinical supervisor, researcher, writer, and medico-legal expert. His work has consistently explored the intersection between physiology, cognition, and emotional regulation, particularly in complex presentations involving shame, trauma, and resilience under pressure. NeuroAffective-CBT emerged from this long clinical and research journey, integrating behavioural science with state regulation and performance psychology. Through this platform, Daniel shares clinical insights, evolving ideas, and research-informed reflections drawn from decades of practice.

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

NeuroAffective-CBT by Daniel Mirea

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.

xxxx

[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).

References:

Bisson, J., Ehlers, A., Matthews, R. et al. (2007). Psychological treatments for chronic post-traumatic stress disorder. British Journal of Psychiatry, 190, 97–104.

Bisson J, Roberts NP, Andrew M, Cooper R, Lewis C (2013). “Psychological therapies for chronic PTSD in adults”. Cochrane Database of Systematic Reviews. 12: CD003388. PMID: 24338345

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

Callcott, P., Standart, S. & Turkington, D. (2004). Trauma within psychosis. Behavioural and Cognitive Psychotherapy, 32, 239–244.

Cromer, K., Schmidt, N. & Murphy, D. (2006). An investigation of traumatic life events and obsessive-compulsive disorder Behaviour Research and Therapy, 45, 2581–2592.

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

De Bont, P., Van den Berg, D., Van der Vleugel, B. et al. (2013). A multi-site single blind clinical study to compare the effects of prolonged exposure, EMDR and waiting list on patients with a current diagnosis of psychosis and co morbid PTSD. Treating Trauma in Psychosis, 14, 151.

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.

Grey, E. (2011). A pilot study of concentrated EMDR. Journal of EMDR Practice and Research, 5, 14–24.

Greyber, L., Dulmus, C. & Cristalli, M. (2012). EMDR, PTSD, and trauma. Child and Adolescent Social Work Journal 29, 409–425.

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

Gunter, R. & Bodner, G. (2009). EMDR works… but how? Journal of EMDR Practice and Research, 3, 161–168.

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

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

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

Joseph, S. (2002). Emperor’s new clothes? The Psychologist, 15, 242–243.

Kowal, J.A. (2005). QEEG analysis of treating PTSD and bulimia nervosausing EMDR. Journal of Neurotherapy, 9, 114–115.

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

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

Marr, J. (2012). EMDR treatment of obsessive-compulsive disorder: Preliminary research. Journal of EMDR Practice and Research, 6, 2–15.

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.

Meyer, V. (1966). Modification of expectations in cases with obsessional rituals. Behavior Research and Therapy, 4, 273–280.
Nanni, V., Uher, R. & Danese, A. (2012). Childhood maltreatment predicts unfavorable course of illness and treatment outcome in depression: A meta-analysis. American Journal of Psychiatry, 169, 141–151.

Nazari, H., Momeni, N., Jariani, M. & Tarrahi, M. (2011). Comparison of EMDR with citalopram in treatment of OCD. International Journal of Psychiatry in Clinical Practice, 15, 270–274.

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

Propper, R. & Christman, S. (2008). Interhemispheric interaction and saccadic horizontal eye movements. Implications for episodic memory, EMDR, and PTSD. Journal of EMDR Practice and Research, 4, 269–281.
Ray, A. & Zbik, A. (2001).

Cognitive behavioral therapies and beyond. In C. Tollison, J. Satterhwaite & J. Tollison (Eds.) Practical pain management (3rd edn) (pp.189–208). Philadelphia: Lippincott.

Read, J., van Os, J., Morrison, A. & Ross, C. (2005). Childhood trauma, psychosis and schizophrenia. Acta Psychiatrica Scandinavica, 112, 330–350.

Rodenburg, R., Benjamin, A., de Roos, et al. (2009). Efficacy of EMDR in children: A meta-analysis. Clinical Psychology Review, 29, 599–606.

Rothbaum, B.O., Astin, M.C. & Marsteller, F. (2005). Prolonged exposure versus EMDR for PTSD rape victims. Journal of Traumatic Stress, 18(6), 607–616.

Salkovskis P (February 2002). “Review: eye movement desensitization and reprocessing is not better than exposure therapies for anxiety or trauma”. Evidence-based Mental Health. 5 (1): 13.

Shapiro, F. (1989). Eye movement desensitization. Journal of Behavior Therapy and Experimental Psychiatry, 20, 211–217.

Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd edn). New York: Guilford Press.

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

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

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

Siegel, D.J. (2007). The mindful brain. New York: Norton.

Soberman, G., Greenwald, R. & Rule, D. (2002). A controlled study of eye movement desensitization and reprocessing (EMDR) for boys with conduct problems. Journal of Aggression, Maltreatment, and Trauma, 6, 217–236.

Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58, 61–75.

van den Berg, D. & van der Gaag, M. (2011). Treating trauma in psychosis with EMDR: A pilot study. Journal of Behavior Therapy and Experimental Psychiatry, 43, 664–671.

Van den Hout, M., Engelhard, I., Rijkeboer, M. et al. (2011). EMDR: Eye movements superior to beeps in taxing working memory and reducing vividness of recollections. Behaviour Research and Therapy, 49, 92–98.

Vane, J. & Botting, R. (2003). The mechanism of action of aspirin. Thrombosis Research, 110, 255–258.

Varese, F., Smeets, F., Drukker, M. et al. (2012). Childhood adversities increase the risk of psychosis. Schizophrenia Bulletin, 38, 661–671.

Watts BV, Schnurr PP, Mayo L, Young-Xu Y, Weeks WB, Friedman MJ (2013). Meta-analysis of the efficacy of treatments for posttraumatic stress disorder. Journal of Clinical Psychiatry, 74 (6): e541–550.

Wood, E. & Ricketts, T. (2013). Is EMDR an evidenced-based treatment for depression? Journal of EMDR Practice and Research, 7, 225–235.

Third-Wave CBT or three waves of CBT ?

NeuroAffective-CBT by Daniel Mirea

Both are correct! As already explained in my previous article (CBT what’s all the fuss about, 2018) Cognitive Behavioural Therapy is an umbrella term for a range of therapeutic models that successfully combine behaviourism with Buddhist philosophy, social learning theories, cognitive psychology and more recently neuroscience/ neuroaffective research (Mirea and Hickes, 2012)1. A number of different CBT approaches have gradually evolved over the last 70 years, in three distinct waves (Mirea, 2012)2.

In spite of some apparent differences, all of these methods have much in common. They are formulation-based 3 and rooted in empirical research, behaviourism and the bio-psychosocial model4. They have a common framework, the working models are simple enough and easy to learn, with clear therapeutic goals, which are agreed collaboratively with patients by employing a SMART 5 approach (Mirea, 2016) 6. Therapy goals would usually involve carefully planned strategies aimed at disrupting factors that predispose and trigger individuals’ mental health symptoms and maintains the crisis through rather complex mechanisms usually designed at an earlier stage in life.

Let’s examine together the following case study, published in the SEA journal by Mirea and Hickes (2012)1. An excessively jealous and anxious boyfriend revealed in therapy that during his childhood, he experienced significant emotional neglect and an unpredictable and explosive parental relationship, including regular fights, arguments, cheating and jealousy. He internalised all these episodic and emotional, childhood experiences in a particularly disintegrated manner and developed a core-belief (a powerful felt-sense) that he is unlovable (and if found out he would be rejected). This is not usually dialectically expressed with peers or significant others, but it is more of a sense-of-self, a gut-feeling or an identity that the individual has created for himself, based on his early years (emotional) experiences. Over time, the patient would ensure that he is well defended against all of the possibilities that he will be rejected and covers up for his perceived flaw by developing a number of strategies meant to ensure his survival and happiness. Some behavioural strategies will therefore be based on the assumption that “I have to always be on my toes in a relationship…the moment I let my guard down, she would cheat on me”, therefore… “It is justified to be jealous; I will stalk her, check on all her movements all of the time, I’ll go through her mobile phone records and pockets (and so on…), in order to be better prepared”, etc.

Any future therapeutic work, should help the client identify where these complex set of beliefs, associated behaviours and emotions are exaggerated or misguided. During the assessment, the therapist designs a case formulation containing vicious circles (or traps) that help educate the client about the relationship between his early childhood experiences, core beliefs, assumptions, strategies and current critical situations. This formulation or case conceptualisation (which is diagrammatically explained) would act as the basis for a treatment plan.

This article highlights the common ground that all cognitive-behavioural approaches share, the empirical base, the constant focus on change, problem solving and skills development. I have also discussed early treatment processes – the clinical assessment which leads to a case formulation which further leads to strategic treatment planning.

The differences between approaches however, are much more difficult to explain. Fundamentally such differences lie perhaps in the specific design of each method or the original intention. For example, Dialectical Behaviour Therapy (DBT) is a treatment protocol created by Marsha Linehan for Borderline Personality Disorders. Mindfulness-Based Cognitive Therapy (MBCT) is a relapse prevention tool for depression and so on. Of course subsequent research and clinical trials have allowed these methods to be applied successfully with other disorders and this is probably why it may be difficult to figure CBT out at times (especially if one is operating outside of this field).

A historical overview does offer some insights and it shows how dynamic and rapidly this therapy develops. In the very first wave, we have pure behaviourism, highlighted by the reputable and well researched theories of Ivan Pavlov on learning and conditioning, Joseph Wolpe on systematic desensitization, Edmund Jacobson on Progressive Relaxation. The second wave would represent the main body of CBT started off by Aaron Tim Beck’s original cognitive-behavioural therapy and Albert Ellis’ rational-emotive theory. The model is a simple but effective treatment protocol for depression at this stage (1960’s) supported by a range of researched behavioural, learning and cognitive theories. Beck and Ellis had never stood idle but other clinicians such as Donald Meichenbaum (Cognitive Behavioural Modification), Jeffrey Young (Schema Therapy), Adrian Wells (Metacognitive Therapy) or David Clark, to name but a few, have really expanded and pushed the boundaries of CBT in the following 40 years or so. CBT can now be used with a range of disorders, in the short-term or in the long-term. Disorder focused approaches, case formulation approaches, transdiagnostic approaches, have all taken shape during this stage.

Third-Wave, the latest addition, is characterised by the introduction of a new concept which is ultimately going to become very familiar and popular, mindfulness or formally known as Mindfulness-Based Cognitive Therapy. This was introduced to the psychotherapeutic community by Williams, Teasdale and Kabat-Zinn (2007) 7 initially as a relapse prevention method for depression.

In spite of a number of significant developments over recent years, most researchers, authors, and practitioners still draw on the second wave when they describe, challenge or investigate CBT as an approach. This approach to CBT research may not lead to clear outcomes, unless it specifies the model or the interventions investigated. More specifically, studies would have to be more targeted on interventions, such as prolonged exposure for trauma for example or method-focused like investigating the effectiveness of MBCT or ACT. Describing CBT in generic terms, I am afraid, is no longer good enough.

xxxxx

1 Mirea D and Hickes M (2012). CBT and EPT: rival paradigms or fertile ground for therapeutic synthesis. Existential Analysis 23.1, 2012 (p15-31)

2 Mirea D (2012). Cognitive Behavioural Coaching, friend or foe to the existential coach. In Existential perspectives to coaching, edited by Van Deurzen and Hanaway, 2012. Palgrave Macmillan.

3 Formulation or case formulation or (case) conceptualisation can be understood as an alternative to the psychiatric diagnosis, a behavioural analysis firstly introduced in 1965 by Kanfer and Saslow in a seminal paper. Case formulating is part of the assessment process and it is central to providing a coherent and comprehensive treatment plan.

3 The biopsychosocial model (bio-psychosocial or bio-psycho-social) is a broad view that attributes disease outcome to the intricate, variable interaction of biological factors (genetic, biochemical, etc), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.). The biopsychosocial model counters the biomedical model, which attributes disease to roughly only biological factors, such as viruses, genes, or somatic abnormalities. The biopsychosocial model applies to disciplines ranging from medicine to psychology to sociology.

4 SMART goals: Specific, Measurable, Achievable, Realistic and Timed. A 2014 clinical trial by Waller et al. pointed out that there are clear advantages of the ‘GOALS approach’; it is brief and that the frontline mental health workers who are in regular contact with patients in mental health care settings can be readily trained in its delivery. There is therefore scope for developing an effective intervention, which can be made widely available at low cost, improving access to psychological therapies for this client group. See Waller et al. Trials 2014, 15:255

6 Mirea, D (2016). Assessment and case formulation in CBT. Revised 1999 article and re-published in April 2016 in the Family Wellbeing Research and Therapy Journal. Vol.3. 1-24

7 Williams, Teasdale, Segal, Kabat-Zinn (2007). The Mindful Way Through Depression: Freeing Yourself from Chronic Unhappiness. The Guildford Press.

How to best confuse yourself when you are already stressed…

NeuroAffective-CBT by Daniel Mirea

In a few words… start googling, binging or ask Alexa !

If I knew nothing at all about ‘mental health‘ and googled for some help with my stress or anxiety levels, I would probably end up focusing on the only criteria I can understand – money ! What is the cheapest therapist out there or how do I get the best value for my money. Nothing else on Google makes any sense, when it comes to psychotherapy, unless you have a degree in research methods.

The answer to the ‘value for money question’ however, is relatively simple: NHS is by far the cheapest service, because… it is actually free. However, since getting any kind of mental health support from your GP is like pulling teeth, you have no choice but to go private. Unless you are a high risk, it is unlikely that you will get anything else besides leaflets and SSRIs 1 via your local general practitioner.

Incidentally, I am a big supporter of antidepressants and the work GP’s are doing on a daily basis is simply award worthy. I know too many cases where lives have been saved by SSRIs and an outstanding GP support however, I am not a big fun of random prescribing without a thorough MSE (mental state examination 2). GP’s are not psychiatrically trained and nor should they be – this is a highly specialist area reserved for mental health specialists; though what is worse is that, most are not provided with any mental health support on site.

Now… on the other hand, therapists are not making life any easier for their patients with endless squabbles over supremacy and the never ending ‘which school of therapy is more effective’ competition. In this process, we tend to lose track of our patients’ needs and instead we focus on offering them what we were told in training that works best. All the while, the poor victims of mental illness cannot even tell the difference between psychiatry, psychology, psychotherapy or hypnotherapy and wait… there is at least one more… of course, counselling 3 … and life coaching… and mindfulness therapy.. or perhaps existential coaching.. and it goes on and on…and on. Everyone out there seems trained to come to the rescue. But Thank Goodness for Google! Because when it comes to creating even more confusion it wins the prize. One of my least favourites Googles is self-diagnosis ! Simply too many patients come to their assessment with an already Google-made diagnosis. As such, here are just some of the problems that I have with that:

  • It is far too easy to misinterpret physiological symptoms and identify with the incorrect diagnostic criteria; e.g. mood swings do not necessarily equate with a manic-depressive illness !
  • Patients can throw mental health assessors off with their perception of a medical history which could have been at best influenced, if not completely constructed with assistance from Google or its competition Alexa !
  • The issue of chronic medical problems. Patients often think they have panic disorder (a very common self-diagnosis) and miss the diagnosis of hyperthyroidism or irregular heartbeats. On the other hand, heart racing does not (necessarily) means that one is having a heart attack.
  • Confusing one psychological disorder with another. For example, some patients may think they are overwhelmed by agoraphobic reactions which would explain their tendency to socially isolate when in fact, social anxiety or depression or both or even asperger syndrome could be the more likely diagnosis responsible for their social isolation.
  • Self-diagnosis can also create mistrust and may undermine the all essential therapeutic relationship between therapist and patient.
  • Self-diagnosis can precipitate and perpetuate health anxiety.

2023 UPDATE ! If things were not complicated enough, now we have AI to worry about… Hopefully, some of my videos will bring more clarity… or even more confusion, I will let you decide !

Glossary:

  1. SSRIs: Selective Serotonin Reuptake Inhibitors (SSRIs) are a class of drugs that are typically used as antidepressants in the treatment of major depressive disorder and anxiety disorders, Citalopram, Fluoxetine or Sertraline are just three examples of SSRIs that can be prescribed in UK by the GP or a psychiatrist. Even though clinical psychologists, CBT therapists and mental health nurses have extensive training in pharmacology and psychopathology, prescribing falls under the responsibility of a qualified psychiatrist
  2. MSE – mental state examinations: a clinical assessment process in the psychiatric practice. The purpose of the MSE is to obtain a comprehensive cross-sectional description of the patient’s mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis which is subsequently required for coherent treatment planning.
  3. There is no agreed hierarchy of “knowledge” or “expertise” implied by the titles counsellor, psychotherapist, psychologist, or hypnotherapist; these roles often differ most in scope of practice, training route, and regulatory status.
  4. In the UK, many commonly used titles (including counsellor and psychotherapist) are not legally protected, and there is no statutory requirement that someone using these titles must be registered with a professional body. For this reason, the most meaningful marker of professional accountability is often membership of a reputable professional register, particularly one that is accredited by the Professional Standards Authority (PSA), which evaluates standards, governance, and complaints processes.
  5. Professional bodies such as BACP and UKCP maintain registers with defined training, ethical, and supervision expectations, though requirements vary by modality and route. By contrast, British Association for Behavioural and Cognitive Psychotherapies (BABCP) accreditation for CBT practitioners requires substantial postgraduate-level training, supervised CBT practice, and typically a recognised core profession, alongside ongoing supervision and clinical governance requirements. Fully Accredited BABCP therapist earned the equivalent of a post-graduate or doctoral level training. As a result, the CBT therapist designation is comparatively better protected—though also frequently misused. It is therefore advisable for clients to ask explicitly whether a practitioner is accredited and by which body.
  6. Hypnotherapy in the UK is also not statutorily regulated, and training standards can vary considerably across organisations and training providers. Some bodies (including those linked with GHSC/GHR) publish training standards and learning outcomes, those tend to be significantly lower than psychotherapists, prospective clients should carefully check training depth, supervision arrangements, and complaints procedures.
  7. Coaching is a separate field: it typically focuses on performance, goals, and behaviour change rather than the assessment and treatment of mental disorders. Some coaches may also have mental health or psychotherapy qualifications, but coaching itself is not a substitute for regulated clinical care when a diagnosable disorder or significant risk is present.
  8. Psychiatrists are medical doctors specialising in mental health assessment, diagnosis, and pharmacological treatment; some also undertake psychotherapy training.
  9. Finally, clinical psychologists are trained at doctoral level in psychological assessment and evidence-based talking therapies, and the title Clinical Psychologist is among the protected practitioner psychologist titles requiring professional registration.

Disclaimer: this site and article are not intended as a self-help manual or workbook; the intention with all NA-CBT articles is to help by developing knowledge about the subject. All case studies described are a combination of facts and very little fiction from different sources including personal clinical experiences. Similar work and other great resources for inspiration, can be found on Ted – education, Brene Brown, Roz Shafran, Christine Padesky, Donald Meichenbaum’s research on resilience, and others.

It is important to clarify: this article (like most articles on this site) contains what could be described as ‘real life case scenarios’ for learning and authenticity purposes… this is all part of a series of free handouts offered to psychotherapy trainees or students with a particular interest in evidence-based psychology, NeuroAffective-CBT or Integrative-CBT– any personal details identified are a pure coincidence – us humans are all rather similar in many respects I am afraid – real client details would have been changed significantly in order to maintain anonymity.