Neuroaffective-CBT

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

Dr Donald Meichenbaum is an American Psychologist, Distinguished Professor Emeritus of Waterloo University, Ontario and a Research Director of the Mellissa Insititute for Violence Prevention. But he is much more that, Dr Meichenbaum is one of the CBT founders alongside earlier pioneers such as Beck and Ellis; he is better known for his ‘Clock Conceptualisation’, SIT model (Stress Inoculation Training) and Cognitive Behaviour Modification approach. Credited for his contributions with the nickname “The Freud of CBT” he was voted by APA in 1982, as one of the most influential psychotherapists of the 20th Century. Some of his extensive research on violent trauma might have been overlooked here in UK where the focus is much more on brief, cost-effective methods that can be applied within an NHS/ IAPT department. My goal is to correct that by drawing attention to his incredibly detailed research on constructivism, resilience, the use of spirtituality, stories, metaphors and narration in CB therapies; such interventions can be applied anywhere and translate to any culture. His work is best expressed through his lecture notes and handouts which he graciously donated for free learning and study. I kept these notes intact and whilst editing for online publishing, I realised this material could comfortably amount to a whole new approach, which I would personally label ‘Narrative Constructive Psychotherapy’. But of course, Dr Meichenbaum in his characteristic style is far too modest to accredit himself with yet another therapy label. As such, I will do that for him and in doing so, I take the opportunity to honour and thank him for his contributions over the years and ensure his legacy by passing his ‘teachings’ on to generations of psychotherapy students. When you read these notes, there is a feeling that sometimes he speaks directly to you in one of his lectures. Perhaps you should imagine exactly that…. enjoy. This is for you Don! Happy Birthday!

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

TABLE OF CONTENTS

          Evidence of resilience

           Possible mediating mechanism

           The nature of resilience

          Implications for conducting psychotherapy

          Intervention strategies for bolstering resilience

          Characteristics of ” HYPE ” in the field of psychotherapy 

        

EVIDENCE OF RESILIENCE

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

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

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

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

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

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

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

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

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

POSSIBLE MEDIATING MECHANISMS

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

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

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

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

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

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

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

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

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

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

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

THE NATURE OF RESILIENCE

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

NEURO-PSYCHOLOGICAL MECHANISMS THAT NURTURE RESILIENCE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

            awareness, distress tolerance, a positive Mindset, feelings of 

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

            have happened.

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

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

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

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

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

     community/community supports.

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

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

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

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

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

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

IMPLICATIONS FOR CONDUCTING PSYCHOTHERAPY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

traumatic memories into a narrative account, develop coherent redemptive

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

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

autobiographical account.”

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

 “I can rewire my brain.”

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

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

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

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

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

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

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

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

It can repair itself, with my help.”

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

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

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

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

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

INTERVENTION STRATEGIES THAT BOLSTER RESILIENCE

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

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

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

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

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

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

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

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

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

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

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

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

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

CHARACTERISTICS OF “HYPE” IN THE FIELD OF PSYCHOTHERTAPY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

https://www.ukhypnosis.com/cpd-workshops/

The UK College of Hypno-CBT, led by principle Mark Davis is a respectable and ethical organisation commited to evidence-based CBT, Mindfulness and innovative Hypnotic approaches that improve resilience, symptomatic independence and self-efficacy.

REFERENCES

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

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

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

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

Meichenbaum D. Roadmap to resilience. WordPress

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

When is perfect, perfect enough?

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

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

According to Roz Shafran (2002) “the overdependence of self-evaluation on the determined pursuit (and achievement) of self-imposed, personally demanding standards of performance, in at least one salient domain, despite the occurrence of adverse consequences”, explains the mechanism behind perfectionism.

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

Mary, a case of clinical perfectionism

This article follows Mary’s NA-CBT treatment for clinical perfectionism, and it is part of a handout offered to students on doctoral training in CBT; as such certain details have been changed in order to maintain anonymity; the article includes specific questions at various crucial points ‘[in square brackets]’ raised by the author which are meant to trigger further enquiry and insights into the treatment.

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

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

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

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

The therapeutic alliance and use of empathic mentalisation

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

Inside Mary was torn [therapist’s or an informed conclusion], since she knew she needed to change; her suffering was pretty clear.…  it is rather lonely being perfect especially when you’re not….  But in order to understand that (beyond cognitive reasoning at a prefrontal level), it was important to feel what her colleagues or friends are feeling and try to figure out, why they are avoiding her at an emotional level, only to explore these options with her session.

[It may be important to debate the topic of empathic mentalisation, which is s typical NA-CBT method. What is the alternative approach at this stage? Tip: in traditional CBT we use transference and countertransference as opportunities for an open dialogue]

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

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

Early Years

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

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

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

The trap of perfectionism

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

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

The CBT treatment plan

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

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

Psychoeducation:  

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

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

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

Cognitive interventions:

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

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

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

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

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

Behavioural interventions:

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

Mary’s life was organised on paper, literally, because keeping notes (including smaller notes about the main notes) was very important [implicit life strategy or one of the ‘musts’: ensuring not to miss anything or make mistakes]. Her calendar, therefore, was packed with ‘essential activities’. Preferred activities were manically cleaning the apartment, crossing tasks off the lists, or rigorous dieting. What she needed in contrast (another behavioural intervention) more rewarding activities and relaxation, were more of respite episodes, which would not include marathon running, which incidentally was a hobby of hers [can you guess why – could it be because it was a task-oriented activity, where the goal posts can easily be shifted upwards… another vicious… Tip: the answer should be in your conceptualisation].

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

Roadblocks and opportunities to successful therapy

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

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

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

References:

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

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

Further training opportunities in Clinical Perfectionism:

Treating the Perfectionist: CBT for Perfectionism Workshop – with Daniel Mirea, BABCP Accredited Psychotherapist – The UK College of Hypnosis and Hypnotherapy – Hypnotherapy Training Courses (ukhypnosis.com)

Disclaimer: the intention with all NA-CBT articles is to help and develop knowledge. All case studies described are a combination of facts and very little fiction from different sources including personal clinical experiences. More similar work, great resources for inspiration, can be found on TedX, Treating Perfectionism, Uncommon Practitioners, Roz Shafran, Keith Gaynore and others.

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

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

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

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

The potential consequences of self-isolation

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

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

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

 CBT strategies for social isolation

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

Mind or Cognitive Interventions

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

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

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

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

Decatastrophising COVID-19

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

Mindfulness & acceptance of your distressed thinking

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

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

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

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

Facts Finding, Installing Hope and Positive Self-Talk

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

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

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

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

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

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

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

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

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

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

“We are not giving up!”   (0-100%)

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

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

Positive Data Logs

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

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

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

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

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

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

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

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

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

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

….. For example only a few days ago I discovered for the first time how much I enjoy gardening with my family. It is something I would have never considered Pre-COVID19… I might decide now, to show off by posting online this gardener-version of myself; I may briefly describe my newly found talent and in doing so, perhaps I will inspire another friend….

Behavioural interventions

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

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

Enjoyment, Achievement and Connection!

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

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

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

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

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

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

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

Avoidance and Safety-Seeking

When you are analysing your catastrophical thoughts or even when you are compiling your PDL’s you might, from time to time, notice a tendecy to avoid situations that are likely (in your perception) to cause you harm through contamination. Such ‘safety-seeking behaviours’ can be excessive and would maintain anxiety or the feeling of being under threat. For instance, wearing a face masks in a shop is a necessary measure, whereas wearing a mask in your own home where you live alone or in your garden or even in your car may be an exagerrated behaviour that maintains a sense of threat. Carefully examine your tendancy to avoid and safety-seek and ask a trusted friend or a trusted family member for their opinion if it helps – it may be important to modify such behaviours.

Refocusing on Personal Values & Interests

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

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

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

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

Emotional checking-in

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

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

Try to answer these questions:

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

–What are you grateful for?

–Who do you want to acknowledge this week?

–Was there a day when you felt not so great?

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

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

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

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

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

Emotional Regulation

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

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

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

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

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

8-Emotional Regulation Exercises for Mind, Body and Soul

1. The 3 – 4 – 5 Breathing Method

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

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

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

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

3. Progressive Muscle Relaxation

4. Body Scanning

5. Mindfulness training: Exploring Difficulties

6. Mindfulness training: The 3 minute Breathing Space

7. Body Appreciation

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

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

8. Physical Strengthening

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

The basic principles of Emotional Regulation:

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

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

Summary

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

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

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

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

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

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

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

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

Stay Healthy and Hopeful!

by  Daniel Mirea (4.04.2020)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Pendulum-Effect Formulation

(NA-CBT by D Mirea)

Core Schema: NOT GOOD or PERFECT ENOUGH

OVERCOMPENSATION – AVOIDANCE – SURRENDERING

Overcompensation:

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

Overcompensation reflects your inability to internally say to yourself: ‘this will actually do’ or ‘this is good enough as it is’. To stop constantly shifting the goalposts or to refrain from aiming higher and higher and at the same time believing that it is not just realistic but also very-very important – to reach such high standards. Double checking or triple checking one’s work or several times, proof reading an email several times before sending it are examples of how working hours are extended and draining often leading to burn out.

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

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

Avoidance:

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

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

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

Getting somebody else to attend in my place! Because I fear underperforming at the next meeting or social event – implicit knowledge that justifies avoidance.

Not asking for help! Avoid asking for help at all costs: because this will make me look weak and not good enough like a failure – implicit knowledge that justifies avoidance.

Surrendering:

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

Giving up in shame or giving up too soon: “This is hopeless…” Measuring one’s performance against others that are on a much higher level (in their perception – in reality these specific ‘others’ may not be better off).

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

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

Treating yourself with Neuroaffective-CBT (NA-CBT)

This method was developed by Daniel Mirea in response to a growing subclinical population of undiagnosed affective disorders that fall under the umbrella of shame and self-disgust. Since the treatment of such phenomenon crosses the boundaries of a clear diagnostic criteria, the therapeutic approach has to be both comprehensive and strategic. It is my view that self-help in general and especially self-help manuals can only go so far without the guidance and support of a kind, generous and well prepared CBT therapist.

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

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

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

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

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