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The underlayers of NeuroAffective-CBT

Just a snapshot look at Google scholar would reveal that CBT therapies, including third-wave CBT (e.g. mindfulness, acceptance and commitment therapy, etc.) are by far the most researched and evidenced methods of psychological treatment. When it comes to trauma at least, EMDR does not stray too far either (Bisson et al., 2013). In a recent article, I discussed EMDR’s efficacy in spite of what it can only be described as a sketchy evidence-base (Davidson and Parker, 2001). Neuroaffective-CBT (NA-CBT) on the other hand is a much younger therapy falling far behind in research, nonetheless a reliable transdiagnostic model which shares all fundamentals and evidence-base with the family  of cognitive and behavioural therapies. The approach was developed by Daniel Mirea  in response to a growing subclinical population of undiagnosed affective disorders that fall under the umbrella of shame and self-disgust. Since the treatment of such phenomenon crosses the boundaries of clear diagnostic criteria, the therapeutic approach has to be both comprehensive and strategic. NA-CBT therefore, relies on a clearly prescribed modular toolkit that aims to disrupt all mechanisms that predispose, perpetuate and precipitate shame, guilt, self-disgust or indeed chronic low self-esteem.

Through exploring the underlayers of NA-CBT, this article aims to look at the overlapping mechanisms that underpin a range of cognitive and behavioural methods and review some of the evidence supporting the skills and interventions relied upon during treatment.

The assessment

In keeping with the cognitive-behavioural framework, the NA-CBT therapy process starts with a comprehensive history taking which leads to a case conceptualisation, uniquely termed as the ‘Pendulum-Effect’ case formulation. NA-CBT proposes that just like the pendulum of a traditional clock, people oscillate or swing between maladaptive coping mechanisms without always being aware of this and in doing so, they reinforce deeply rooted negative views about themselves and others – which are ultimately responsible for their shame and self-disgust, e.g. “I am unlovable and unattractive and nobody wants me”. Staying with the metaphor, this core schema  would very much be at the centre of the clock’s face, it represents in fact, the very central mechanism behind it. The centre mechanism would not turn the clock if it wasn’t for the oscillating movements – in other words the affect of  shame (and therefore chronic low self-esteem) is reinforced by both the compensatory mechanisms designed and rehearsed over years  (e.g. avoidance or surrendering or over-compensation) but also by the relationship that the such coping mechanisms have with each other through the swinging-effect action or the oscillating-effect.

                     Shame related beliefs

swing

Surrendering                                Avoidance 

 

 

Case study [1]

To illustrate how a victim of shame oscillates between two compensatory mechanisms – avoidance and surrendering, in order to reinforce their shame schema, please consider Sarah’s case. Sarah is a successful paralegal in the City who struggled with shameful feelings most of her life. Typically as Christmas was approaching and lots of parties invitations started to arrive on her desk, she would surrender into procrastination and self-criticism before the party is due, in order to avoid a situation she feels likely to fail, supported by an exaggerated set of predictions about social embarrassment or other social ‘disasters’. As such, the surrendering (or giving up) mechanism would involve fortune telling, images of social awkwardness and arguing with a colleague who offered to accompany her to the event. Avoidance inevitably leads to feelings of guilt, self-disgust, and more self-criticism which ultimately would reinforce her shame-related beliefs.

The pendulum is meant to act not only as a time keeper but also as a regulator. There are of course, several similar reinforcing mechanisms at play, clearly outlined by the pendulum-effect (formulation). When all these mechanisms are fully understood, they would be further examined, modified and/or finely tuned with the patient in a strategic but compassionate manner, throughout the therapy over five flexible and interchangeable treatment modules: (1) Psychoeducation and motivation, (2) Physical Strengthening, (3) The integrated-Self, (4) Coping Skills Training & Self-Regulation and (5) Skills Consolidation & Problems Prevention (figure 1).

 

Figure [1]:

  • Initial consultation : Clinical Assessment & The ‘Pendulum Effect’ Formulation
  • Module 1 : Psychoeducation & Motivational Enhancement: including building motivation, enhancing self-efficacy, problem solving skills training.
  • Module 2 : Physical Strengthening: TED’s your best friend
  • Module 3 : The development of an integrated-Self: cognitive reframing (appraisal-reappraisal). Traumatic memories processing (through bilateral stimulation, narrative exposure or reliving).
  • Module 4 : Coping Skills Training & Self-Regulation – including Mindfulness, Self-hypnosis and/or Relaxation Skills Training and also introducing EDRB’s (Emotion-Driven Reinforcing Behaviours)
  • Module 5 : Skills Consolidation and Relapse Prevention (future plans)

 

The underpinning fundamentals of the approach

Several essential mechanisms underpin NA-CBT and each treatment module attracts a particular set of skills, none more relevant that the skill of building a therapeutic alliance. I coined the term empathic mentalisation to highlight therapist’s skilful ability to connect with his client in a way that would allow the therapist to not just hear and understand at a pre-frontal level, patients’ vulnerabilities but instead to allow himself, to feel his client’s pain in a way which will help the client feel felt.

Whilst some psychoanalytically-based therapies would perhaps claim to engage the patient in a similar manner, this is where the similarity stops because in NA-CBT, the therapeutic relationship is no longer used as transference or countertransferential medium of communication. The therapist remains aware of client’s goals and he is in full control of the agenda. Thus the therapist guides the relationship and the (collaboratively agreed) agenda throughout the therapy process. The transference & countertransference processes are viewed as opportunities for open dialogue and learning. Challenging, restructuring and reframing irrational self-beliefs into adaptive beliefs, installing new coping skills and disrupting unhelpful strategies stays at the core of this therapy.

Psychological education is another NA-CBT fundamental. Clinical experience and trials indicate that psychoeducation does not only establish trust in therapist’s expertise but also in the therapy itself. Research has shown time and time again that psychological education, therapist’s clinical experience and knowledge of psychopathology, therapist’s confidence and style, as well as treatment integrity are all associated with improved treatment outcomes (Donker et.al.,2009 and Podell et al., 2013).

NA-CBT offers an excellent platform for the application of neuroscience and in particular neuroaffective research that has taken place over the last 30 years and remains largely ignored or segregated by different schools of thought [1].

Cognitive psychology studies (Padesky C.,1997), the Interacting Cognitive Subsystems model (ICS) by Barnard and Teasdale (1989, 2008) as well as the Adaptive Information Processing model (Shapiro, 1989, 2001, 2007, 2009) propose that memories are processed and assimilated not in a random way but in a highly organised fashion, using screening templates such as individuals’ past experience and understanding of themselves and the world they live in. However, if childhood experiences are traumatic, the information processing system stores the memory in the wrong parts of the brain and in a frozen or rigid format without adequate processing and integration. This suggests that traumatic memories fail to become integrated into the individual’s life experience and concept of the self which eventually creates psychological and emotional vulnerability. As such, unprocessed, unintegrated or upsetting memories (not only traumatically charged memories) may be at the core of shame and self-disgust or chronic low self-esteem (Schore A, 1998; Gilbert P, 2006; Siegel D, 2007; Gilbert P, 2011).

During the third NA-CBT treatment module, developing an integrated-self, the patient may be asked to recall the worst aspect of an earlier shameful memory together with the accompanying and currently held shame-related beliefs and associated bodily sensations [2]. An increased attentional focus on the location of the physiological (psychosomatic) reaction is required at this stage. Simultaneously, the patient is not directed to move their eyes from side to side (like in EMDR), but instead the therapist would employ tapping  as another form of bilateral stimulation. Although the research has often been challenged, more recently the evidence  has been favourable to bilateral stimulation and this extends to hands tapping in particular. A number of neuropsychological, developmental and attachment studies (Kirsch et al., 2007) have pointed out the usefulness of (appropriate and therapeutic) physical touch and associations with the release of endorphins, serotonin  or dopamine as well as the formation of new neural pathways which ultimately leads to an improved self-regulation (Siegel D, 2007).

It may be important to remind that the area of traumatic memories processing, would be the only domain where NA-CBT crosses paths with EMDR but unlike this method, NA-CBT is rooted in evidence-based cognitive and behavioural practices proven to work over the last 50 to 60 years. This suggests that NA-CBT is primarily a behavioural approach relying on active and progressive changing through the adoption of new and more adaptive behavioural strategies (e.g. case study 2).

Case study [2]:

 John used to have flashbacks of being physically and emotionally abused every time his manager would raise her voice in the office. He started to experience less and gradually no flashbacks at all, after only 3 hours of desensitisation via bilateral sensory processing (e.g. tapping). In addition John also experienced significantly less hyperarousal. In order to decrease the possibility of a relapse and reinforce the newly installed competing memory, during the NA-CBT treatment, the therapist agreed with John that when at the office, the he must adopt a different attitude, a different mind-set,  be more aware of his body language and mental activity, make notes and improve body posture. He also agreed to have in place a number of responses to potentially challenging situations which would require a more assertive approach. He worked on clear strategies and detailed coping skills which would have been rehearsed (e.g. imagery rehearsal, role plays, etc.) inside and outside the therapy room and in-between sessions. 

NA-CBT views narrative exposure, re-living or exposure in-vivo more appropriate forms of treatment for some cases of trauma (for example if a male therapist is treating a female victim of rape) and therefore, the integration process does not always relay on bilateral sensory input but on detailed descriptions of the traumatic event and on building evidence against associated unhelpful beliefs through behavioural experiments and other types of homework.

During desensitisation, it remains important for the victim of shame to re-experience the related shameful memories whilst not feeling overwhelmed by it. Clinical experience shows that bilateral processing can at times achieve this more successfully than reliving or other types of exposure. Through the multi-tasking exercise of a focused but distributed attention [3] our brain seems to be able to access dysfunctionally stored experiences and stimulate the processing system, allowing it to transform and integrate the information much better. When fully integrated, the event and what has been learned about the event, can be verbalised however the inappropriate emotions and physical sensations (of hyper or hypo-arousal) would have been discarded and those can no longer be felt.

Yet another interesting phenomenon seems to take place. During bilateral sensory processing (e.g. tapping) the shamed patient is assisted with navigating through the various associations that would usually arise internally. This leads to an increase in the sense of self-efficacy and mastery and specifically an increase in patient’s ability to go back and forth between re-experiencing the event and the present moment (Oren and Solomon, 2012). This does not only diminishes dissociative symptoms but also improves attention-orientation skills (Goldin, 2009). A few trauma studies indicate that physical touch undermines dissociative tendencies and contributes to achieving a feeling of safety and being grounded in the here-and-now (e.g. feeling grounded in the present, being more aware of own physical presence and the voice or the touch of the therapist, etc.).

In regards to self-efficacy in particular, Oren and Solomon (2012) propose that the experience of mastery and self-efficacy would become encoded as adaptive information into memory networks. This may in fact be in line with other studies from established clinicians, for example Teasdale and Barnard  (1993), Donald Meichenbaum (2017) or even Albert Bandura’s (1989) self-efficacy theory. This would mean that although the event and what has been learned can be recalled, the inappropriate emotions and associated sensations of hyper/hypo-arousal would have been discarded and can no longer be felt with the same level of intensity.

One other mechanism at work in NA-CBT, relates to the training of attention through mindfulness. During the desensitisation or processing phase, patients are instructed to ‘let whatever happens, happen’ and to ‘just notice whatever thoughts come to mind’, which is also consistent with principles of mindfulness (Goldin et al., 2009; Siegel, 2007; De Jongh et al., 2013).

Imagery-based desensitisation and exposure exercises (routinely used in mindfulness and hypnosis) can also improve individuals’ ability to create a gap or a distancing effect according to the working memory theory. This process may be facilitated by the degradation of the working memory due to cognitive overload, which allows the individual to stand back from a shameful or an upsetting memory, observe it with less emotionality and re-evaluate their understanding of it. Even though the literature on the working memory hypothesis seems inconsistent, research on mindfulness, ICS, EMDR and clinical hypnosis offers more clarity in this direction. Maxfield and colleagues [4] propose that ‘links are forged between the associated material and the original memory, thus transforming the way that the traumatic memory is stored in memory networks’ (Maxfield et al., 2008).

Final thoughts

In a 2018 interview with Psychotherapy Expert Talks, Donald Meichenbaum pointed out that the field of neuroscience  (including gene expression and so on) is not only cutting edge but highly relevant with the potential to further tailor interventions for patients suffering from very specific psychopathology. Research coming out of this field certainly adds value to psychological therapies and stays at the basis of models such as NA-CBT. In it is my view that in the near future, schools of psychotherapy will adapt and learn to focus on the body as well as the mind, which would imply a deeper understanding  of bodily functions not only mind functions for all psychotherapists and psychologists. The fields of neuroscience, clinical hypnosis, psychosomatic medicine and biological treatments are only just starting to come together. NA-CBT is only one example of what could be achieved under the umbrella of Cognitive & Behavioural Therapies, an integrative school that remains best positioned, because of its empirical base, to oversee attempts to treat mental illness holistically.

 

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[1] For example, the Adaptive Information Processing model (Shapiro, 1989, 2001, 2007, 2009) is mostly seen as the property of EMDR whilst the Interacting Cognitive Subsystems model (ICS) by Barnard and Teasdale (1989, 2008) belongs to cognitive psychology and CBT.

[2] ICS theory and research, explains its account of emotion development and production. ICS emphasises the importance, as part of the total cognitive configuration producing emotion, of a schematic synthetic level of processing that integrates both propositional meaning and direct sensory contributions. Processing at this level corresponds, subjectively, to holistic sense or feeling rather than to thoughts or images explains the link between information processing.

 [3] The term distributed attention refers to the complex exercise that involves recalling the trauma and paying attention to traumatic episode, whilst keeping oneself grounded in the present and paying attention to the here-and-now, and all at the same time with further assistance from bilateral sensorial stimulation such as hands tapping.

[4] Maxfield, L., Melnyk, W. & Gordon Hayman, C. (2008). A working memory explanation for the effects of eye movements in EMDR. Journal of EMDR Practice and Research, 2, 247–261.

 

References:

 

Bandura, A. (1989). Regulation of cognitive processes through perceived self-efficacy. Developmental Psychology, Vol 25(5), 729-735.

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

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

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

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

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

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

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

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

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

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

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

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

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

Maxfield, L., Melnyk, W. & Gordon Hayman, C. (2008). A working memory explanation for the effects of eye movements in EMDR. Journal of EMDR Practice and Research, 2, 247–261.

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

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

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

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

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

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.

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.

Schore,  A. (1998). Early shame experiences and infant brain development. In P. Gilbert & B. Andrews (Eds.), Series in affective science. Shame: Interpersonal behavior, psychopathology, and culture (pp. 57-77). New York, NY, US: Oxford University Press.

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.

Teasdale, J.D. and Barnard, P.J. (1993). Affect, Cognition and Change: Re-modelling Depressive Thought. Hove: Lawrence Erlbaum Associates.

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.

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): e541–55

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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

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

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

More questions than answers..?

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

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

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

EMDR mechanisms explained

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

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

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

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

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

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

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

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

Final thoughts…

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

Who can get training in EMDR

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

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

 

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

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

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

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

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Third-Wave CBT or three waves of CBT ?

Both are correct! As already explained in my previous article (CBT what’s all the fuss about”, 25.07.18) Cognitive Behavioural Therapy is an umbrella term for a range of models that successfully combine behaviourism with social learning theories and cognitive psychology and more recently neuroscience research as well as Buddhist philosophy (Mirea and Hickes, 2012)1. A range of CBT approaches have 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.

Here is an example (published in 2012 article by Mirea and Hickes)1. An excessively jealous and anxious boyfriend came to his assessment and revealed 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 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 relationshipthe 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 brought 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 may no longer be sufficient. Studies will have to be more specific about what intervention (e.g. exposure) or method (e.g. MBCT) is being investigated rather than describing CBT in generic terms. I am afraid, this 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…

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 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). Most GP’s are not psychiatrically trained and nor should they – this is a highly specialist area and what is worse, 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 minfulness therapist.. and existential coaching.. and it goes 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. However, 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 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 perhaps 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.

xxxxx

  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 in terms of knowledge or expertise when it comes to the title of counsellor, psychotherapist, psychologist or hypnotherapist. However, each of these titles is backed by an accreditation which is essentially a licence, administered by a very specific regulatory body such as BABCP (British Association for Behavioural and Cognitive Psychotherapies), UKCP (UK Council for Psychotherapy) or BACP (British Association for Counselling & Psychotherapy); these bodies demand a certain standard of training, practice and ethics. The least demanding organisations are those that regulate the field of hypnosis, for example the GHSC – General Hypnotherapy Standards Council. Some of the hypnotherapy organisations register hypnotherapists with as little as 21 days of training, minimum or no supervision, no personal therapy and no compulsory clinical practice hours and no core profession (e.g. psychologist or psychiatric nurse for example). The standards of all other counselling and psychotherapy regulatory bodies in UK are significantly different with accreditation subjected to intensive training between 2 to 7 years, clinical supervision, personal therapy and supervised practice. Unlike counsellors or psychotherapists, psychiatrists are medical doctors trained in psychiatry (mental health diagnosis, pharmacology, etc.)  but not in counselling or psychotherapy (or talking therapies). Clinical psychologists are also doctors in psychology trained in talking therapies. All BABCP accredited CBT therapists are post-graduates and/or doctoral psychotherapists (with a core profession) specialising in psychological and behavioural treatments (rather  than generic counselling).

CBT, what’s all the fuss about ?

I rushed into writing my first blog to mainly introduce my own brand of CBT without perhaps giving sufficient credit to the ‘parent company’, the big daddy: Cognitive-Behavioural Therapy ! But better late than never, so here we go…

CBT, what’s all the fuss about?

Well.. most rumours are actually true. At least according to Frontiers of Psychiatry (the January 2018 edition) CBT is the gold standard in the field of psychotherapy, because of its clear research support and continuous development and improvement based on research findings. It presently dominates the international guidelines for psychosocial treatments, making it a first-line treatment for most disorders, as noted by the National Institute for Health and Care Excellence’s guidelines 2 and American Psychological Association.3

This is no longer the new kid on the block, even though it was the latest to join in at the big boys table in the mid-60’s. Back then, CBT was merely a treatment protocol for depression written by the brilliant Aaron Tim Beck an analytically trained psychiatrist. The clinical world soon realised that this new kid (CBT) is here to stay and might even attempt to take over. So much so that today, we are talking about ‘CBT’ being an umbrella term for a number of therapies or approaches that aim to treat a variety of different psychiatric disorders: Schema Therapy, MCT, MBCT, DBT, ACT, CFT and a lot of other acronyms.

CBT is a pretty fast paced, short-term, modern therapy with flexible therapeutic boundaries. Yes that’s correct fellow therapists, behaviourists have always steered away from traditional psychotherapeutic boundaries – in my humble opinion, these dated boundaries are probably still rooted in an unworkable Freudian-psychoanalytical approach. I am sure this is a gross exaggeration, but nonetheless it does not change the fact that CBT does not necessarily adhere to the traditional therapeutic boundaries. Whilst some therapists still wonder over the usefulness of shaking hands with their patients or comforting someone crying, we stick our hands down the toilet to demonstrate to our OCD patients that germs don’t instantly kill.. and then we shake their hands. Sessions can take place in the comfort of a clinic (if we are lucky enough) or in patient’s residence or outdoors or at patient’s work place. It all depends on the type pf exposure exercises or social experiments that we would have agreed on, in advance, with the patient.

The formal term used in CBT is ‘collaboration’. Indeed we collaboratively agree on most (or all) experiments but in reality, this model is directive, problem-solving and goal oriented, relying on a lot of teaching and a clearly prescribed evidence-based process usually led by an expert therapist. The treatment methods (exposure or relaxation training) are steeply rooted in learning theories and physiology. The works of BF Skinner, J Watson, I Pavlov, E Jacobson, A Salters and a few other creative but not always popular (or even ethical by today’s standards) behavioural psychologists from the beginning and middle of the 20th century, form a solid foundation for all CBT approaches.

Nowadays cognitive-behavioural practitioners describe three distinct waves of CBT. The first wave is characterised by the above mentioned behaviourists, the second-wave was kicked off by Aaron T Beck and Albert Ellis – this is ‘the CBT’ that most people are familiar with! Third-wave CBT is marked by a slight departure from earlier methods with the arrival of imagery-based philosophically informed approaches such as mindfulness (MBCT). Even though though mindfulness and compassion based therapies are associated with the Buddhist philosophy it is important to acknowledge that the main drivers that underpin these methods (as developed by John-Kabat Zinn, J Mark Williams JD Teasdale or Paul Gilbert) are not just philosophical aspects of our daily living as much as the focus on training the attention and affect regulation (or stress regulation).

So what do all these methods in common ?

That is the subject of my next blog. See you soon ! Stay sane !

Introducing NeuroAffective-CBT

Neuroaffective-CBT or on short NA-CBT is a transdiagnostic and modular therapeutic model developed and refined over the last 12 years by Daniel Mirea. As described in the opening comment this approach was born out of a need to better understand and better respond to deeply rooted emotions that ‘feel’ too complex and confusing to most people who have never been strangers to painful and unmanageable affective experiences.

Often such affects (or emotions) are difficult to describe and may fall under the low self-esteem umbrella, shame or guilt. But not only… I find in my classes (I teach qualified practitioners at a doctoral level mostly) as well as in my clinical supervisions that psychotherapists are often guilty of assuming too much. Patients or clients (depending on where one is practising therapy) are often confused about their affective states and even appropriate transient emotions such as fear, sadness or fleeting anger can be often misread or misunderstood, which of course leads to an amplification of unwanted emotions.

In any case, to begin with it may be important to define the concept of ‘transdiagnostic’ and ‘modular’ psychological treatments. Transdiagnostic approaches evolved in CBT in response to a range of symptoms that often cross the boundaries of a specific diagnostic criteria.

In other words, emotions such as shame, guilt and low self-esteem are consistent with symptoms that can be found in depression, social anxiety, personality disorders or even PTSD. NA-CBT is a transdiagnostic approach because it can be used with any of these psychiatric disorders since it aims to undermine the maintaining mechanisms that reinforce the presenting problems. The diagnostic criteria, although extremely important is not necessarily the main driver during therapy.

NA-CBT is also a modular approach because, just like in the structure below, the treatment can be split into different modules. The reason I have not labelled those treatment phases or treatment stages is simply because in NA-CBT, these modules do not follow a rigid order, modules are intersectable and interchangeable. This means that one can start the treatment with module 3 and then move on to module 2 depending on patient’s therapeutic goals, needs and ability to learn new coping skills.

For example with traumatic memories such as that of an emotional abuse, e.g. being shouted at regularly as a child – those memories may need to be processed more immediately, as suggested in module 3 – The integrated Self, before returning to module 2 – where the focus is on Physical Strengthening. Sometimes, it may appropriate to work through both modules in parallel. During the Physical Strengthening module, we ask people to be more aware of their bodies, their posture and musculature action, since those have a direct and reverse impact on how we feel about ourselves. Our mind instructs the body but the body also instructs the mind. For example, where appropriate I teach people about the direct impact of shameful feelings onto our musculature, physical posture and body language overall. Internal self-awareness and managing our focused attention becomes an important aspect of the training at this stage also.

An easy to remember model called TED is also part of the Physical Strengthening module:

  • Tired (energy levels and sleep deprivation)
  • Exercising (physical exercises)
  • Diet (drinking & eating)

You can only imagine my excitement when my son introduced me to a comedy with the same name a few years ago; turns out that TED is a cute teddy bear with a flair for excitement and fun but more importantly he is the main hero’s best friend. So Yes indeed… “TED’s your best friend” and “When in doubt check with TED” is the type of catchphrases popular with my clients even today. In future posts I will be writing more about the benefits of using catchphrases, fun relatable stories and metaphors in therapy. And along the same lines, about the benefits of appropriate self-disclosure.

Neuroaffective research points out that an integrated or balanced sense-of-self, an improved confidence and well-being can be achieved through better hormonal regulation. A lot of education is offered on how to achieve ‘balance’ and well-being through improving emotional-hormonal regulation.

Recent neuroaffective and neuroimaging research has influenced psychological treatments, CBT in particular and is constantly shaping therapists’ understanding of brain wiring and the relationship between brain circuits, hormonal regulation and primary emotions.

An overview of the NA-CBT treatment toolkit:

  • Assessment and case formulating: the “Pendulum-Effect” case formulation: since all CBT treatment protocols begin with a thorough assessment, where the principle purpose is to arrive at a formulation which will then form the basis for the treatment plan, I do not consider this initial stage a module. The assessment and case formulation plays a pivotal role in the treatment – this is not a ‘negotiable’ phase but a treatment condition. During this initial stage however, a strong emphasis is placed on building an alliance and a strong therapeutic relationship by using (uniquely to NA-CBT) methods such as emphatic mentalisation.
  • Module 1 : Psychoeducation & Motivational Enhancement: including building motivation, enhancing self-efficacy, problem solving skills training.
  • Module 2 : Physical Strengthening: TED’s your best friend
  • Module 3 : The development of an integrated-Self: cognitive reframing (appraisal-reappraisal). Traumatic memories processing (through bilateral stimulation, narrative exposure and/or reliving).
  • Module 4 : Coping Skills Training & Self-Regulation – including Mindfulness, Self-hypnosis and/or Relaxation Skills Training and also introducing EDRB’s (Emotion-Driven Reinforcing Behaviours)
  • Module 5 : Skills Consolidation and Relapse Prevention – this is all about future plans…

Where can you get training in NA-CBT

In London, NA-CBT is taught at Regents University and Existential Academy (via Middlesex University) on their advanced post-graduate and doctoral programmes. An introduction or overview of the model is also on offer at other organisations where Daniel Mirea regularly teaches including UK College of Hypnosis & Hypnotherapy (training organisation focused on Hypno-CBT, CBT and evidence-based psychology only). Since this is advanced cognitive-behavioural training and the approach places itself under the umbrella of CBT therapies, it is not presently offered outside the psychological, psychiatric and CBH community which means that one would have to have a core mental health profession or to at least be accredited in Cognitive-Behavioural Hypnotherapy (CBH) before attending training in NA-CBT.