Trauma treatment challenges (and solutions) by Daniel Mirea

Neuroaffective-CBT

“What happened to you is not your fault, but your future is your responsibility”

For online training in trauma with either Dr Donald Meichenbaum or Daniel Mirea please click on this link

The topic of ‘trauma’ is much more controversial than one would imagine. Research tends to indicate that approximately 25% of people who have experienced a significant trauma go on to develop post-traumatic stress disorder symptoms or PTSD, but that percentage varies. Based on the nature of the trauma those rates are going to be higher, for example for someone who’s experienced rape or sexual assault more like 50% or lower for other kinds of traumatic events like for example a fireman dealing with a fire. An interesting question following on from this data, would be centred around the 25 to 50% people that resume their normal activities, symptoms free after a frightening incident. Such a significantly high percentage might suggest that therapists are presented with an interesting opportunity during treatment, if and when therapy focus is re-directed towards a key aspect of trauma recovery – RESILIENCE. Dr Meichenbaum, one of the CBT pioneers, aka the Freud of CBT, has been talking about this area for decades. Therefore, a justified question would be, how do the up to 75% people deal with their symptoms post-trauma in order to, not develop chronic PTSD? And if resilience is at least one of the answers then what helps improve resilience during treatment?

Whilst there is no agreed definition on what ‘resilience’ means, it is clear that being resilient could describe an individual’s ability to bounce back in face of adversity and according to Dr Meichenbaum it is also relating to an individual’s inner resources and outer immediate support network. His conclusions are backed up by neuroaffective research which describes resilience as the capacity to deal with external challenges, also called ‘exteroception’ or sensitivity to external stimuli, by managing any resulting internal changes, also known as interoception or the perception of internal sensations. Dr Meichenbaum posits that trauma symptoms and resilience engendering behaviours can coexists. The data must not be misinterpreted; it is not that the 75% do not develop some symptoms of PTSD but victims evidence the ability to bounce back and cope with ongoing challenges as such with time symptoms can subside. Moreover, people can be resilient in one area of their lives and not in others. As Bonanno (2022) highlights in his book “The end of trauma”, a key feature of the 75% that are impacted but who engage in resilient engendering behaviours is that they have developed a resilient mindset, a set of optimism and self-efficacy and have ongoing social support (Meichenbaum Roadmap to Resilience).

In cognitive-behavioural terms the implications for treatment are significant; although there is no magic bullet and there seem to be multiple ways to developing resilience, these findings could be translated into high levels of psychological flexibility and adaptability, good problem-solving skills, and an ability to learn and implement new coping strategies which would have to be rehearsed under pressure and in real life experiments.

Trauma characteristics

So, if being resilient is one of the ingredients that could help almost 75% of people exposed to different levels of threat, not to develop symptoms of trauma, how do we identify the remaining 25% ?

When it comes to the label of trauma, much like depression, it seems the over-use of the term itself becomes problematic. The label ‘trauma’ is commonly used to describe a range of situations and experiences that might not fall under that definition.

A traumatic experience may be defined by five main characteristics.  

  1. An experience that is far beyond what may be considered a normal human experience and during which a person feels a significant risk to self or even death; intense fear or helplessness during an attack may also be part of this experience
  2. This experience would extend to witnessing an event where someone is threatened with serious injury or death
  3. This experience is followed by extensive reexperiencing and significant changes to memory
  4. This experience is also followed by increased and frequent states of hyper-arousal
  5. The negative arousal is associated with safety-seeking and other avoidant behaviours

Such experiences are more complex than the stress one would experience during a driving test which might have even resulted in failure and subsequent self-criticism. As upsetting as that can be, it does not amount to a traumatic experience, not unless you had a serious car crash during your test and subsequently kept reexperiencing scenes of the crash, you had become hypervigilant in traffic, and this had also led to avoidance or even social isolation. Waiting for two hours in line at the petrol station during the petrol crisis would not qualify as a traumatic event. Not unless you saw someone get attacked and hurt while waiting in line.

The inconvenience can create distress, but most events we go through daily are not traumatic. One might argue that, to qualify everyday occurrences or even major inconveniences as traumatic is to minimise and trivialise the experience of people who are living with PTSD every day and whose lives were turned upside down by past horrific experiences. It is therefore important to watch over the use of the term because it misses the boat by miles, on how much trauma affects people both psychologically and physiologically.

Another common issue would be convenient access to a lot of online information at a time when unfortunately, not all online resources are legitimate sources of information. The answer is often is a lot simpler. It is wise to try to access a professionally trained clinician or therapist, preferably a trauma specialist. Even though many schools of psychotherapy reject the medical model the evidence stands out. According to Dr Meichenbaum, trust in the therapist, in the therapist’s expertise and in the therapeutic method used, is associated with positive treatment outcomes (link to Therapist Core Skills by Dr Meichenbaum 2022, BABCP competencies – seee BABCP website).

Irrespective of their school of thought, psychotherapists need to familiarise themselves with the psychopathology of trauma, the risks and maintenance factors and feel confident in delivering a variety of therapy methods in response to a traumatic experience or else they are faced with a situation where the blind is leading the blind. In this regard, it seems that choosing the right therapist can be a challenge since a lot of psychotherapists are often led by their personal beliefs or what they might consider healthy scepticism and miss out, on the real symptomatic impact that a traumatic experience can have on an individual (Mirea, 2012). 

Understanding the symptoms of trauma and how these symptoms are being maintained can also facilitate the process of psychoeducation which is yet another important aspect of the trauma treatment. Recovered trauma patients frequently report that if they knew what trauma meant and how it ‘worked’ they would have chosen the right support a lot sooner, they would have had faster results, they would have saved money on treatments and would have resumed their normal lives a lot faster.

Misdiagnosing trauma is surprisingly common for a variety of reasons, not least comorbidity. It seems that 8 out of 10 people with PTSD are more likely to have a comorbidity such as, another anxiety or depressive disorder, or a substance use disorder. Cognitive intrusions and reexperiencing are common across a range of disorders including PTSD, OCD, schizophrenia, or even bipolar disorder, this is where having the skills and the correct training would help therapists peel back all the complex layers of a mental disorder.

An interesting trauma myth is that trauma is only defined by something happening directly to you. You have to be assaulted or raped or something bad has to happen to you. In fact, trauma can also be defined by witnessing something violent like a crime, an assault, a rape or a murder. Common beliefs associated with this type of guilt or shame-based trauma are loud with a strong internal critical or blaming tone: “I’m being ridiculous… I must be weak… I could have done more… How dare I say I have trauma… I am not the real victim here”. 

Trauma reexperiencing and processing methods

Going through a traumatic experience can lead to a very confused memory data base. At the time when the trauma occurs the individual does not get a chance to fully process the event and therefore a range of problems would rise from there. On an ordinary day, memories are coded and laid down in specific structures of the brain, specifically via the hippocampus, and the neocortical system, best viewed as our long-term memory storage. Here we have access to an event in a narrative format, something one can talk about comfortably, distant stories from our past, which eventually would fade with time.

During a traumatic event this natural process is interrupted by a narrowed and focused attention onto the threatening stimulus, facilitated by high levels of cortisol and adrenaline. The traumatic memory is saved by our internal alarm system called the amygdala, a peanut size brain structure located just anterior to the hippocampus in the medial temporal lobe. The amygdala is a different kind of data storage, in charge with our safety and responsible for keeping us alerted to new similar threats. This is basically part of our fight-flight system, essential to our survival. Because of this, memories about threats or dangers, do not fade with time. Such memories capture all sensory modalities, they feel real, current and relevant. Traumatised victims would find it difficult to share memories of trauma even decades later.

So, traumatic memories are saved in the amygdala ready to be activated at a moment’s notice, if a similar emergency should arise again. With assistance from the Autonomous Nervous System (ANS), all mammals have the ability to re-orient attention toward a potential threat and scan the database in 0.025 seconds. This would lead to an immediate series of reactions designed to preserve life.

Unfortunately, the ANS is far from perfect and impacted on by a variety of unhelpful habits very well-rehearsed by other parts of our brain, such as the tendency to ruminate and worry over unpleasant or scary events. Ruminations and worries in particular seem to confuse our internal processing systems and therefore memories are generalised and constantly updated with more threatening material. As a result, the amygdala would get frequent imprints and the sympathetic response gets easier and easier activated by a variety of sensorial triggers.  For example, a lady who was raped by a bald man, years later, she would feel threatened by all bald men she would come in contact with, irrespective of ethnicity, age or size. At least 25-50% of people exposed to a threat describe flashbacks of the traumatic events as a frightening experience, they feel they are right back there, reliving the traumatic experience. As such, significant efforts would go into suppressing and neutralising flashbacks as well as avoiding places or situations that act as reminders and might trigger the flashbacks.

How to safely integrate traumatic memories

Evidence-based psychological treatments such as the family of CBT therapies rely on a few strong principles such as ACT: Assess, Conceptualise and Treat. We have already understood how important it is to be able to separate trauma symptoms from other unpleasant or stressful experiences that do not come under the same umbrella. Therapy alliance, psychoeducation, new learning, problem solving, installing new coping skills, exposure programmes are all essential and well evidenced approaches across the range of CB therapies.

However, with PTSD cases, traumatic memory processing plays a distinct role. The theory that lies behind memory processing focuses on the influence of the Autonomous Nervous System (ANS) our main survival mechanism which gets activated when we are faced with a threat. The ANS has an ON switch called the sympathetic response which leads to arousal and an OFF switch which is called the parasympathetic response that encourages de-arousal or a calming relaxed response. This sounds great, however one of the problems is that we are not able to consciously switch the system On and Off, as we would more than likely prefer, hence the label ‘autonomous’.

With the risk of over-simplifying a process that is otherwise very complex, it might be easier to understand by separating the hardware from the software components of our brain. It may be important to remind our brain’s hardware which includes structures such as the amygdala, hippocampus, the thalamus and the neocortex. Part of the software include sensorial processing, memories processing and the role of attention-orientation.   The software communicates via different hardware components with the help of neurotransmitters, such as adrenaline and noradrenaline in the case of a threat, via neuropathways or brain circuits that all together create our autonomous nervous system.

The role of the amygdala is to analyse and collect data about threats in order to alert us and keep us safe when necessary. For example, the amygdala would correctly alert us through the emotion of fear, that “snakes are dangerous” if we come across a snake on a mountain trail but in fact, not all snakes are dangerous in all situations and as such memory upgrading becomes relevant in relation to threat recognition and threat identification.

Ironically, for at least 25% of the victims exposed to trauma the system seems to be even less effective and therefore this is the category that requires trauma memory processing and better integration in the longer-term memory systems (hippocampus and neocortex), so that eventually when memories are recalled the threat system will not be unnecessarily activated and instead past events simply turn into stories or narratives from our past.

Updating trauma memories involves going over the traumatic event and identifying specific moments that create the highest level of distress during this detailed recall through imaginal reliving.  Next, identifying positive or hopeful messages, symbols or even other people that add new information and meaning to the event. 

In NeuroAffective-CBT at this stage, attention is also directed towards feelings and physiological reactions by encouraging a focus on the location and the intensity of the distress within the body. This is followed by clear but gentle instructions at every step to keep track of the intensity of the distress and self-regulate through breathing and progressive muscle relaxation, in parallel with the memory recall.

It is important to remember that memory recall in a state of high emotion can increase the arousal to the point of overload sending new sensory impressions in the amygdala. In other words, upgrading the memory with more traumatic material, which might have a negative effect.

            As such, a precursor to this exercise would be a strong bond and a trusting relationship with the therapist, which facilitates down regulation and self-soothing during heighten states of arousal or dissociative states. Grounding techniques, attention training techniques, practising safe place, progressive muscle relaxation and body scanning are proven tools that help with self-regulation.

Safe place or grounding imagery can be introduce at different times in order to establish distance and a sense of safety for example: ‘you are safe now travelling on a train looking at the passing scenery, your memories are just passing scenery…or… you are in your own private cinema, it feels safe, comfortable and distant, you are watching your own memories unfold on the screen, just like a movie, scene, after scene..’.  

All the above present-focused exercises are essential, since trauma recall is reported to dissociatively bring online a sense of being back during the event that caused the trauma in the first place, even if/when this took place decades earlier.  Grounding exercises, safe place, bilateral tapping used in NA-CBT or any other sensorial bilateral stimulation used in EMDR are all meant to downregulate and create a sense of ‘hear-and-now’ by distributing, widening and re-orienting attention during the recall (EMDR article Mirea, 2012).

One of the most common reliving exercises in trauma-focused CBT is writing down and reading out the traumatic episode, though with such cases, there is always the risk of retraumatising without specific memory upgrading and creating the right interpersonal safety. According to Clark and Ehlers (NICE recommends their model for PTSD treatments within NHS) negative appraisals of the trauma poses a special challenge as much of the patient’s evidence for the problematic appraisals stems from what they remember about the trauma. Thus, work on appraisals of the trauma needs to be closely integratedwith work directly on specific traumatic memories. The disjointed intentional recall of the trauma in PTSD makes it difficult to assess the problematic meanings by just talking about the trauma, and has the effect that insights from cognitive restructuring may not be sufficient to produce a large shift in affect and those are a precursor to what is know as re-traumatisation.

Understanding trauma triggers is equally important. The aim here, would be to break the link between the triggers and the trauma memory. This could be achieved in several ways, including teaching the patient to distinguish between the past (‘then’) and the present (‘here & now’); i.e., the patient learns to focus on how the present triggers and their context (or the ‘here & now’), are different from the trauma (or ‘then’). This can be facilitated by carrying out actions such as movements or bringing to mind positive images or touching objects that grounds and connects the patient within present moment. Patients would practice these strategies in their natural environment during sessions. When reexperiencing occurs, they remind themselves that they are responding to a memory, and this is not the current reality. They could focus their attention on how the present situation is different from the trauma and may carry out actions that would have not been possible during the trauma.

In NeuroAffective-CBT, imaginal reliving is not presented as an intervention aimed at enhancing emotional habituation to a painful memory but instead this is a moment-to-moment detailed reliving, which could and often should be time framed. This helps to identify specific traumatic memories, highly dissociative moments, which would be addressed through cognitive and somatic processing. Bilateral stimulation does not have to be used, not least because tapping is an unusual technique and for some people even inappropriate, as long as attention training, memory upgrading, and cognitive restructuring is carried out in parallel with emotional regulation with the scope of achieving a renewed sense of distance between the traumatic episode and the present moment. Comments such as, ‘I now feel this happened a few weeks (or years ago) and I am no longer in danger… that moment is less clear…’, ought to be the principle aim with this type of processing.

In summary…

Trauma processing is just a small part of the treatment protocol for trauma, a constant focus on therapeutic alliance, problem solving skills and new coping skills ought to be part of the repertoire that enhances individuals’ resilience.  Cognitive and Behavioural therapies have a range of methods and interventions available. For the newly trained CBT therapist, it is important to study as many as possible, and work under CBT supervision with various interventions, constantly developing and refining their ability to tailor the treatment to each individual’s needs, abilities, learning style and personal values.

This article is focused on traumatic memory processing and only briefly outlines other essential interventions. A comprehensive trauma treatment would have to address all mechanisms that predispose, precipitate and perpetuate symptoms of PTSD. This suggests that a series of bio-psycho-social traps would have to be identified and disrupted. According to Dr Meichnebaum positive outcomes are further enhanced by developing resilience rooted in individuals’ culture, personal values and strengths. Meichenbaum has reminded us in his unique manner that we are not only homo sapiens but also homo-narrans, story tellers or narrators, therefore the stories that traumatised individuals tell us will determine whether the victimised will fall in, either the 25% or 75% category (Meichenbaum, lecture notes 2022).

REFERENCES

Hackmann A, Ehlers A, Speckens A, Clark DM. Characteristics and content of intrusive memories in PTSD and their changes with treatment. J Traumatic Stress. 2004; 17:231–40.(30).

Ehlers A, Clark DM, Hackmann A, McManus F, Fennell M. Cognitive therapy for PTSD: Development and evaluation. Behav Res Therapy. 2005; 43:413–31.(32).

Ehlers A, Steil R. Maintenance of intrusive memories in posttraumatic stress disorder: a cognitive approach. Behav Cogn Psychotherapy. 1995; 23:217–49

Meichenbaum D (2022). Lecture notes donated by author.

Meichenbaum D (2012). Roadmap to resilience: a guide to military, trauma victims and their families. Available on Kindle Amazon and on the websites: UKCHH and Melissa Institute.

Meichenbaum D (2004). Stress Inoculation Training. Pergamo.

Mirea D (2012). How to stress yourself when you are already stressed.

Mirea D (2012). EMDR, not just another therapy with a funny name.

Bonanno G (2021). The end of trauma: How the new science of resilience is changing how we think about PTSD. Amazon book sales

Download article :

https://www.academia.edu/81351271/Trauma_Treatment_Challenges

Relationship-OCD, how is this ‘a thing’…?

Neuroaffective-CBT

One of the problems we encounter in the field of evidence-based, applied psychology, is the firm and long-established reliance on the medical-disease model. In a nutshell, this means that we must diagnose first, and then treat. This is both a blessing and a curse, since indeed we have excellent disorder-focused approaches and CBT protocols, which treat specific psychiatric disorders with some predictable outcomes. On the other hand, not everything we observe in our clinics is diagnosable. Certain emotional problems or psychological conditions do not fall within the strict remit of a psychiatric disorder, as listed under DSM- 5 or ICD- 11. In fact, if we look at the history of such diagnostic manuals, those were firstly published in the 1950’s and subsequently suffered several changes and revisions, every single version introducing new psychiatric conditions and assessment processes.

This might suggest that our understanding of certain psychiatric manifestations has evolved. Or perhaps the reliability of research methods has improved, or maybe clinicians are better aided by better scales and measures. Or is it simply the fact that humans’ needs evolve all the time and cultural values and lifestyles are constantly shifting? Perhaps it is, more than likely, a combination of all of the above. Whatever the case may be, I personally subscribe to the concept that we understand much better than ever, that emotional and mental health conditions are a lot more complex than what we currently find summarised in one or two diagnostic manuals. On the contrary, we are able to identify and clinically observe a lot more ‘variants’ to existing conditions, variants that ultimately fall in-between the cracks.

Within this context, indeed Relationship-OCD or R-OCD is ‘a thing’, a psychopathology without a category, much like clinical perfectionism, or the emotional problems resulting from attachment-disorders or shame-based disorders and so on, the only commonality within these syndromes is the sharing of characteristics from both the anxiety and mood disorders spectrum.

Sounds complicated? It doesn’t need to be… R-OCD could be understood as a type of anxiety, a close relative to obsessive-compulsive disorder where people experience intrusive thoughts and co-respondent compulsive behaviours related to their relationship with their partner. Such condition can create long ruminative episodes and repetitive thoughts that centre on doubts or fears about the relationship. The individual may experience uncertainty about whether their partner really loves them, or whether the relationship will last. These thoughts can then lead to hypervigilance and reassurance-seeking or behaviours that are designed to obtain reassurance.

In NA-CBT, the pendulum formulation suggests that this intensively felt core-affect, experienced as guilt or shame or another similar emotion we don’t yet have a label for, leads to specific behavioural and thinking patterns (in no particular order), that could be organised in three types of reinforcing trends, as indicated in the examples further below. These patterns can create a great deal of anxiety for the person experiencing R-OCD symptoms, and of course it would place a considerable amount of stress on the relationship itself. Behavioural strategies are compulsive and paired with justifying beliefs, for example ‘I deserve to suffer, I am a terrible person’.

As such, R-OCD is successfully maintained over years by several vicious traps. If, for example, a young lady already in a loving relationship comes across someone else with desirable attributes, she may find herself obsessing over the unwanted thought that, ‘I should leave my partner’. This leads to more obsessive thoughts such as ‘Oh my God, I’m interested in my boyfriend’s friend’, and this leads to a lot of feelings of fear, shame, and guilt and inevitably a lot of uncertainty about the future of the relationship. As already explained this emotional state, further leads to specific actions or compulsions like hypervigilance, safety-seeking, and constant reassurance, for example doing a lot of research on the topic or asking Google how others are coping. A series of unsuccessful neutralising, or suppressing unwanted thoughts about the new person, or wanting to leave the partner, thoughts about dishonesty, and needing to share these feelings (which are in fact thoughts) with the partner. Should such action take place of course it would very likely lead to a range of difficulties and discussions, which in a way confirms the initial intrusions that one should leave her partner and maybe his best friend is a better option after all, because he is not as difficult and as jealous. This leads to more feelings of distress, more thoughts, more compulsions, and more arguments, perpetuating a problem that seems to have no end in sight.

The Pendulum-Formulation in NA-CBT, can be particularly helpful because it makes the anxious person aware of embedded and automated habits that are often deeply buried underneath layers of thoughts, justifications, excuses, and co-respondent behaviours. This type of formula proposes that R-OCD individuals are driven to extreme overcompensation, avoidance, and other covert self-sabotaging strategies by an inexplicable core-affect of shame and guilt, what we sometimes call a ‘gut feeling’ or an instinct.

Examples of Overcompensation:

  • Googling, reading forums, reading psychology websites, magazines.
  • Asking boyfriend for reassurance that the relationships is going well, and they are still in love.
  • Checking pictures to make sure one feels the same, observing how the body reacts (positive or negative arousal).
  • Speaking to medical and/or mental health professionals.
  • Being very early at work, always on time, not to be seen as useless or bad. This action happens because the anxious individual is often seeking external validation since internal validation is not accepted or acceptable (e.g., I cannot trust my thoughts and feelings since I am bad person but at least at work, I can do a decent job.. sometimes.. at least according to my colleagues.. in any case, this is something I can control)
  • Working very hard at work or revising, or for a school test after a period of procrastination (this is an example of a pendulum – the relationship between overcompensation and procrastination).
  • Weighing myself or measuring my waist – am I good enough, am I attractive enough, almost always the answer is ‘No’ (this is yet another example of a pendulum – the relationship between overcompensation and surrendering).
  • Constant body and mind scanning for symptoms, signs of things going wrong with the mind or body.
  • Increased listening to podcasts / YouTube videos about similar issues – trying to convince oneself that either there is or there is not a problem (depending on the context).
  • Obsessively watching TV-programmes or YouTube videos about relationship problems.
  • Over-reading medical and scientific documents, even when/if most of the research does not make sense.
  • Writing manifestations, desires, or things one wants over and over again (often filling pages).
  • Obsessing over thoughts of shame and guilt and trying to reassure oneself.
  • Making mental lists and mental notes about the reasons they actually love their partners.
  • Over-analysing and constant reviewing of the content of thoughts and past memories.

Examples of Avoidance:

  • Isolating, staying away from the possibility of meeting the other person.
  • Staying away from partner because of feelings of guilt.
  • Pretending one feels unwell to the point of believing that one is unwell and to support that, one might even take several screening tests, like covid tests, etc.
  • Avoiding people, not getting back to them.
  • Avoiding using spare time more productively.
  • Avoiding TV or movies that might trigger fear, shame, guilt, or self-disgust. Also avoiding movies about breakups and illness.

Examples of Surrendering:

Surrendering into the core-emotion that suggests ‘I am fundamentally really bad’. Surrendering strategies may be understood as self-sabotaging since they appear well intended but in fact, such behaviours are often subconscious admissions of guilt and being a bad person. Depending on the context, those are over-exercised and therefore over-compensatory in nature, once again highlighting the pendulum effect of these strategies.

Examples:

  • Praying to God or praying on angel numbers – for a list of things that I want to happen (list grows, but things get taken off, if they come true).
  • Taking pictures of oneself – either where one looks skinny or checking the skin to track acne or chalazion. Emailing everything to oneself to make sure it doesn’t get lost.
  • When one is upset or sad or angry (i.e., after a fight) – not eating. Again, emailing everything to oneself to make sure it doesn’t get lost.
  • Self-talk:  Since I am so bad let me show you how bad you really are… I deserve to be ill and/or alone… I deserve to be sad and depressed… I deserve the worst… writing a message in my head during landing on a plane to send to family in case plane crashes.
  • Urges to tell partner about the so-called ‘infidelity’ or about the thoughts of ‘infidelity’.
  • Only doing web-research on the incognito browser or deleting internet history (which is once again, a subconscious admission of guilt).
  • Screenshotting, taking and saving pictures to confirm and remember things that prove how bad the individual, yet another subconscious admission of ‘guilt’.
  • Neutralising and suppression of thoughts to the point of exhaustion… Scrolling on phone watching reels or TikTok’s to numb racing thoughts and ‘stop’ the brain from working so hard.
  • Keeping a diary/ calendar of being bad, or crazy or mental (in victim’s language).
  • Writing symptoms into calendar – to convince oneself of being mad or ill.
  • Surrender into a depressive state, where one is completely convinced about their level of guilt and responsibility for the break up. Characterised by low motivation and low mood.

In conclusion…

NeuroAffective-CBT proposes that just like the pendulum of a traditional clock, people oscillate or swing between maladaptive coping mechanisms without being aware of these complex behaviours and in doing so, they reinforce deeply rooted negative views about themselves.

SHAME & GUILT (Core-Affect)

swing

Overcompensating – Surrendering – Avoiding

Visualise for a moment, how the core-affect of shame or guilt is positioned at the centre of the clock’s face, and it represents the very central mechanism behind it. This centre mechanism would not turn the clock if it wasn’t for the oscillating movements – in other words the affect of shame or guilt is reinforced by compensatory, avoidant and surrendering strategies that are very well rehearsed over the years. The relationship that such self-sabotaging mechanisms have with each other, through the swinging-effect action or the oscillating-effect, also perpetuate the psychologically painful and hidden affect of shame or guilt.

In the case of R-OCD, the pendulum’s consistent oscillating-effect is like a chain-reaction exercised time and time again which can be exemplified in how the person often overcompensates in order to surrender in order to avoid.  For instance, spending too much time online researching, leads to taking screenshots and making notes about the newly discovered evidence of ‘being bad or guilty’; only to then finally surrender into a depressive state, where one is completely convinced about their level of guilt and responsibility. This becomes the perfect excuse for procrastinating from essential tasks that could demonstrate the exact opposite.

Such dynamics have to be sensitively explored over time with compassion, no judgement but a clear intention to change. A supportive behavioural plan usually involves modifying or eliminating completely these reinforcing mechanisms from a victim’s repertoire. Working toward an authentic living which involves meeting one’s true needs and values is the new agenda.

Proof reading and editing by Ana Ghetu

***

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

This particular article follows anonymised cases who received NeuroAffective-CBT for R-OCD… this is part of a series of free handouts offered to students on doctoral or advanced training programs in Integrative-CBT; certain details have been changed in order to maintain anonymity; the article includes specific questions at various crucial points ‘[in square brackets]’ raised by the author which are meant to trigger further enquiry and insights into the treatment.

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

Further recommended reading:

What is Cognitive Behavioural Therapy and how does this approach differ from other types of psychotherapy models (audio)

Click to access sexuality-and-obsessivecompulsive-disorder-the-hidden-affair-neuropsychiatry.pdf

TED’s your best friend

Neuroaffective-CBT

Emotional regulation (or self-regulation) refers to our ability to exert control over our own emotional state. It may involve cognitive-behavioural, attention-training or imagery-based methods for example, self-hypnosis, self-to-self dialogue, rethinking a challenging situation to reduce anger or anxiety, hiding visible signs of shame, sadness or fear, or focusing on images and reasons in order to feel happy or calm. Daniel Mirea has developed and introduced TED, a self-regulation tool more than ten years ago; this is a guide consisting of a mental checklist and a series of specific actions which may be summarised as ‘Tired – Exercise – (and) Diet your way out of trouble!’

“T” or ‘being tired‘ is the character symbol for basic sleep hygiene training. It is well evidenced by now that sleep deprivation is the number one risk factor for a range of mental health problems. Basic sleep training ought to be within the repertoire of every clinician but unfortunately this is not the case. The basic rule of thumb is 8 hours of sleep during the night – and I mean during the night ! This is the time when metabolism switches off, parts of your brain is processing data and rebooting, the digestive system slows down, etc. As such, it is important to sleep during the dark hours, and this is easier said than done during the shorter summer nights. No training and definitely no food three to four hours (even longer in some cases) before falling asleep would help improve the quality of the sleep and your blood works test results. Please consider following Dr Huberman’s research in this particular area, a Stanford University professor of neuroscience, who delivers excellent free presentations on a range of sleep relating topics.

‘E‘ or ‘exercise‘ is a symbol for physical strengthening and the need to exercise on a daily basis. Again, it has been shown time and time again that a daily regular routine does not only boosts the immunity but helps with hormonal regulation, protein synthesis (much like sleep does) and can help with a range if not all menta health conditions. Of course, one has to remember that the notion of physical exercise varies with age and sex as well as current physical condition.

‘D‘ or ‘diet‘ refers to eating and drinking – the secret has been out for some time, indeed what we eat and drink throughout the day makes a difference to our mental health. This is an area of increasing interest, and the internet is simply being overwhelmed with interviews, podcasts and papers on this topic. With the risk of sounding like a broken record, I would attempt to recount some fun facts from recent research studies that correlate well-being with nutrition.

In addition to considering the impact that a daily diet has on mental health, research has also started to focus on the role of specific vitamins and minerals. Vitamin C is one such micronutrient that has drawn significant attention in the diet and well-being landscape. Vitamin C is in fact one of the few hormones that humans do not naturally produce, hence our predisposition to fruits and vegetables. In fact, if one considers the human anatomy, we could easily notice that we are a particular type of mammal lacking in the department of adequate equipment for the consumption of tough or raw animal meat. Most of us, do not possess strong fangs or tough long nails, therefore historically, it has always been much easier to rely on a vegetarian or even vegan diet, evidently rich in vitamin C. Not only that, but this simple water-soluble micronutrient that humans, along with only several other species, are unable to synthesize themselves, remains an absolute requirement for a range of important biological functions. This contradiction between an absolute requirement for vitamin C and our species’ loss of ability to synthesise it, has been explained earlier, as such our early ancestors relied on diets rich in vitamin C which led to the eventual pruning of genes involved in endogenous vitamin C synthesis. Therefore, vitamin C must be obtained exclusively from diet, principally through the consumption of fruits, vegetables or more recently supplements. Vitamin C acts as an antioxidant and free radical scavenger and is an essential cofactor in numerous enzymatic reactions including that of dopamine β-hydroxylase, an enzyme that is central to the synthesis of adrenaline from dopamine. Vitamin C also acts as an essential cofactor in the metabolism of tryptophan, a necessary requirement for the synthesis of serotonin. Altered dopamine β-hydroxylase activity has been described in a range of psychiatric conditions including mood and anxiety disorders and disorders of the digestive tract and acute tryptophan depletion has been associated with reduced serotonin levels and lowered mood states. Emerging work in the field of epigenetics indicates that vitamin C contributes to epigenetic modifications in early development which in turn may influence key psychological and physiological outcomes across the lifespan. Reinforcing its role in neurocognitive functioning, the highest concentrations of vitamin C in humans are found in the brain and cerebrospinal fluid and vitamin C is preferentially retained in these areas even when plasma and other organs in the body are depleted of vitamin C.

There are several other important supplements which impact on our mental health, that are currently being investigated including magnesium, zinc, also proteins, and of course links have been established between depressive states and our gut bacteria. Results are conclusive enough for general medicine to at least start paying more attention.

For example, physical and emotional stress, a constant reality in our multi-tasking society, drain the body of magnesium. In fact, studies show inverse relationships between serum cortisol and magnesium, the higher the magnesium, the lower the cortisol. Stress robs the body of magnesium, but the body must have magnesium to respond effectively to stress. Magnesium deficiency afflicts 90% of all people with ADHD and triggers symptoms like restlessness, poor focus, irritability, sleep problems, and anxiety. These symptoms can lessen or vanish one month after supplementation starts. And further more, magne­sium can also prevent or reverse ADHD drug side effects.

Clinicians found that 125 to 300 mg of magnesium glycinate at meals and a bedtime (four times daily) produces clinically significant benefits in mood. This form of magnesium is gentle on the digestive tract. 200 to 300 mg of magnesium glycinate or citrate before bed supports sleep onset and duration through the night. Magnesium in powder or liquid form could be effective alternatives to capsules, particularly for children with ADHD. Ways to increase the bioavailability of magnesium include supplementing with vitamin D3, which increases cellular uptake of the mineral. Vitamin B6 also helps magnesium accumulate in cells. Taking the mineral in divided doses instead of a single daily dose. Taking it with carbohydrates, with improves absorption from the intestine. And taking an organic form, such as glycinate or citrate, which improves absorption by protecting the mineral from antagonists in the digestive tract. It may be best to avoid giving magnesium in enteric-coated capsules, which decreases absorption in the intestine. Magnesium oxide is poorly absorbed and tends to cause loose stools. Magnesium-l-threonate has been shown to readily cross the blood-brain barrier, and animal studies show that it supports learning ability, short and long-term memory and brain function, I don’t typically prescribe it, however, because of its higher cost, and the clinical effectiveness of other forms. The therapeutic response to magnesium i reported to take several weeks, as levels gradually increase in the body.

Although a lot less research on this topic is carried out in the UK, a cross-sectional, population-based data set, the National Health and Nutrition Examination Survey, was used to explore the relationship of magnesium intake and depression in nearly 9,000 US adults. Researchers found significant association between very low magnesium intake and depression, especially in younger adults. And in a recent meta-analysis of 11 studies on magnesium and depression, people with the lowest intake of magnesium were 81% more likely to be depressed than those with the highest intake

For now, it remains important to understand that these articles do not aim to substitute real professionals or live clinical assessments. It remains crucial to see your local GP, or a qualified a nutritionist or even have an assessment with your NeuroAffective-CBT therapist, who will no doubt look at your blood works and try to understand how your lifestyle and choices that you make on a daily basis impact on your mental health. Supplements in general cannot and should not, replace psychatric medication they operate differently and at a completely different level. But the above mentioned supplements would very likely improve your prospects and perhaps bring you closer to your behavioural goals.

In regard to, what this article and video brings to attention, it is clearly important to change one’s lifestyle and redirect the focus on all three ‘TED’ domains – sleeping patterns, physical exercise and daily diet. Let’s not waste anymore time and get close to T E D ! The sooner he becomes your best friend the better !

* As a side note, although this is not a weight loss program, sometimes it delivers this added benefit. I used TED to loose 35 kg – a dramatic 8-10 months weight loss from almost 130kg to 95kg (my usual weight class), weight I started to gain just before and during the long pandemic episode, largely as a result of a static job, less exercise and glucose snacking. This could well be the subject of a new article, but for now I shall leave you with this video.

Transference or Therapy Alliance

Neuroaffective-CBT

Transference in therapy occurs when the patient unknowingly is transferring feelings about someone from their past onto the therapist. Freud described transference as the deep, intense, and unconscious feelings that develop during the therapeutic relationship with a patient. Over the years, the field of psychoanalysis, most likely influenced by attachment theories and early cognitive psychology, has adopted concepts such as templates or patterns of familiar feelings, implicit cognitions and habitual behaviours, which are manifested in the therapy relationship, evidently a common ground with the field of cognitive and behavioural therapy.

Psychologist and author Jonathan Shedler recently wrote in The Psychologist (2023) that “psychotherapy is a relationship and patients bring their templates and patterns into it. As psychotherapists, we enter the gravitational field of our patients’ problematic relationship patterns, experiencing and participating in them. Through recognizing our own unavoidable participation in these patterns, we help our patients understand and rework them.“ Dr Shedler feels this is the very heart of psychoanalysis and, he would be right.

But where does that leave the typical cognitive-behavioural therapy alliance? Could CBT approaches deal much more effectively with attachment issues when and if time allows it, and if true, then how is this so, and why? Because indeed, unlike with other psychotherapies, the expectation from the patient or referring agency would be that the presenting issues and health complaints ought to be addressed rapidly, within very few hours of CBT, as opposed to months or years. This presents the typical CBT therapist with unique challenges when collaboratively setting up realistic therapy goals. The therapy environment (the physical space), coupled with the need for flexible boundaries and challenging ‘working’ conditions (e.g., real life exposure) is precisely why the traditional therapy relationship had to evolve towards an empathic, yet dynamic and collaborative, relationship – the type that you might have with an inspirational but compassionate personal trainer or a motivational life coach. This brings a whole new meaning to the traditional therapeutic relationship that relies much more on transference and countertransference to explain patients’ relationship patterns over years of work. ‘Time’ is a privileged resource as far as the CBT therapist is concerned.

Cognitive-behavioural models (of which there are many), propose that, based on our early experiences, through various associations and learning processes, we develop emotional and cognitive templates, which call for specific behavioural actions or ‘defences’ in a crisis. For example, I know I am unlovable (this is a felt-sense, rather than a verbal expression, supported by historical evidence), however, I can manage a difficult situation if I act in very specific ways, without error or exception (i.e., I must always be cheerful, available and helpful).

As such, we have at our disposal very specific and very well-rehearsed repertoires or responses to a variety of triggering social situations, which we keep repeating throughout our lives. Such patterns, shaped by early poor attachment problems, often coupled with our biological inheritance (Beck and Bredemeier, A unified model of depression, 2016) lead to long-term psychopathology which is maintained by very rigid and specific cognitive, affective and behavioural templates meant to support and sustain relationships with significant others, in spite of a deeply rooted felt-sense that one is being flawed and/or vulnerable.

NA-CBT investigates neuroaffective research, evolution theories, mammal behaviours and emotions studies, and suggests that our brain is the organ solely responsible for controlling the body, whose principle mission is to keep the whole organism alive. Ymmordina and Damasio’s 2009 study and research on emotions and learning, over the last thirty years, adds to the earlier research on social-learning by Albert Bandura, and points towards the neural basis of emotions, which play a central role in social cognition and decision-making. Given how incredibly social and interdependent our species is and since our biology is inherently a social one, we are directly dependent on other people for the translation and formulation of our own sense-of-self. And so, when we interact with one another, we construct a sense-of-self and assign meanings and roles to ourselves, in order to accommodate each other, both mentally and physically. This process of survival, or learning how to relate in order to improve our chances, begins at birth with the mother, and continues with the main care givers, whoever they may be.

In that respect, the latest generation of behavioural therapists, unlike in the beginnings of the last century, acknowledge that within the therapeutic space, besides the practical and dynamic component of the change process, the therapist also acts as a sounding board, often needed for more accurate reflections of The Self.

A brief parenthesis here, the development of the original school of behaviourism into so many different methods and approaches, from exposure, to cognitive psychology and attention training, imaginal rescripting or mindfulness and acceptance, is a testimony to its true nature, its ability to adapt, integrate new theories, and evolve. Relying on research and evidence from all domains of psychology and psychotherapy, physiology, or philosophy even, has always created an advantage for the typical CBT clinician, with very popular results over the years such as SIT, DBT, Compassion Therapy, Mindfulness and Acceptance.

Infants trust others’ observations more than their own. As they grow, they start to rely on their perspective more, indicating not only a unique learning process in infancy, but how much we rely on learning through experiencing and associations to produce emotions and filter actions. It is therefore natural to understand why our first relationships with our primary care givers are suddenly crucial in developing a safe and secure sense-of-self; relying on a safe and secure template will no doubt facilitate trusting and long-lasting relationships throughout life. On the other hand, when these early relationships are disrupted (with or without intention) a sense of insecurity and vulnerability will dominate the internal sense-of-self, and as such (and this is crucial), we have to create a series of cognitive, affective and behavioural templates that will help us navigate the complexities of life with our perceived vulnerability or weakness (i.e. I am unlovable.. I am useless.. or.. I am worthless, etc.). Once again, this would not only increase our chances of survival, but often ensure some degree of progress, and on a bigger scale is even facilitating evolution. Such neuroaffective templates are deeply rooted in our neural networks, where they can be activated with ease by triggering an autopilot system, when and if our brain, the survivalist expert, decides this is needed. An individual would not need to be aware of such embedded and well-rehearsed strategies and there is no need to make an effort to remember them. In that sense, emotions are nothing short of reactions the body has to specific stimuli – external (i.e., a large bear is chasing me) or internal (i.e., I imagine my friend broke his wrist).

An emotion may therefore be understood as a call for action. When we are afraid of something, our hearts begin to race and our muscles tense. This emotional reaction occurs automatically, and physical sensations known as feelings occur only after we become aware in our brain of such physical changes; only then we start experiencing the feeling of fear. So, our brain is constantly receiving signals from the body, registering what is going on inside of us. The brain will then process the signals in very well-designed neural maps, which it further organises into sensory centres. Feelings occur when the maps are read, and it becomes apparent that emotional changes have been recorded as snapshots of our physical state. All these processes happen at an incredible speed.

Without making it sound too complicated, CBT therapists excel at raising awareness by educating clients about the link between thoughts, behaviours, emotions, and our ‘inner templates’ also known as schemas, schema processes and schema maintenance. Dr Donald Meichenbaum calls such patterns or templates ‘tyrannical’. The tyranny of ‘shoulds’, ‘musts’ and ‘if–then rules’ maintains victimisation because of the relentless attacks that such rules unleash on individuals’ core needs, genuine desires or life values; for example, ‘I should always be perfect’ or ‘I must always prioritise Others over Me’… ‘If I let anyone down, then I am not a likeable person, and I will end up alone’.

I should… I must… I always have to…

Identifying the problematic patterns alone is only the beginning, because then an ample process of evidence gathering begins; new learning and new life experiences are collaboratively developed with the therapist, in order to challenge the original templates and create new ones that will serve victims’ needs and goals much better. And this would be the main difference between transference-based approaches and cognitive-behavioural approaches. A trusting and empathic therapeutic alliance is essential when explaining patients how these sets of patterns and templates (aka conceptualisations, formulations, or internal-working models) operate in the background all the time, and how it even impacts on the current therapist–client relationship. For instance, drawing attention to, how unnecessarily hard the patient is trying to be the ‘perfect client’, self-sabotaging the progress, procrastinating, filtering out successes, suppressing emotions, or telling the therapist, what the client thinks the therapist would want to hear. All such transferential processes would be exposed non-critically and empathically within the safety of the therapy alliance with a clear aim to learn and improve.

Once the true cost of early templates and patterns, defences, or rules for living, is exposed and evaluated, a shift towards new life strategies and coping would be negotiated. A lot of shoulder-to-shoulder teamwork, creativity and problem-solving skills are involved in designing new social experiences and real-life experiments that aim to undermine the inherited sense-of-self.

Clinical practice reflects time and time again, the need for adaptability and out-of-the-box thinking required to enhance learning and self-efficacy during the therapy process.

Young Jane was struggling with selective mutism, social anxiety and spells of depression when she came to therapy. She would not communicate her feelings, concerns, dreams or expectations until we changed the therapy location to her art studio. A very talented sketch artist, when she was asked to draw a self-portrait of how she feels right now and another of how she would like to feel in one year’s time, suddenly a new language and specific plans started to emerge.

Martin, a dedicated teacher, developed PTSD after suffering a homophobic attack at the hands of two of his students. This led to social isolation and withdrawal from a lot of activities that he used to enjoy in the past, as well as significant autobiographical alternations such as, a different sense-of-self, more vulnerable, less appreciated and so on. It took more than 10 hours of therapy for him to learn to trust his male therapist and the process began with baby steps, increasing the length of each session from 10 minutes to a full 60 minutes and gradually accepting to take his coat off during sessions and, then the hat, followed by the sunglasses and the headphones. Having a handshake at the beginning and the end of every session was one of the early therapy goals. Besides the usual trauma and memory processing, real-life experiments and new social experiences were agreed on, helping him reclaim some of his pre-trauma hobbies; several realistic role-plays involving new coping skills were rehearsed during sessions in preparation. Eventually going out for a meal at his favourite restaurant with a friend he missed and had not seen in over two years was a game changer, according to Mark’s feedback months later during one of the final follow up sessions.

The above stories are not attempting to show off the range of techniques and instruments available to the cognitive-behavioural therapist, but simply to emphasise the creativity employed, the thinking outside the box, the problem-solving skills, and not least the dynamic and organic nature of the therapeutic alliance which constantly evolves with clients’ needs and goals.

Specialist literature explains how mental disorders are precipitated and perpetuated by psychological rigidity and lack of ability to adapt to new situations. Rigidity impacts on the ability to learn new coping skills and achieve a shift from a narrative and global sense-of-self to a much more fluid sense-of-self.

It seems therefore important to agree early, on the overarching goals of any form of psychotherapy which more than likely would include, improving clients’ psychological resilience, undermining mental health symptoms, and essentially helping individuals move on from a victimising role, in no particular order. Research is very clear, in order to achieve that, a shift from psychological rigidity to psychological adaptability would be required through new learning and skills acquisition in particular.

As such, it seems logical that the therapeutic relationship, whatever label it might have, ought to facilitate all of the above. Over 30 years of clinical and teaching experience, as well as a significant body of research data drawn from clinical supervision studies, point towards a few interesting findings. Here is the list of the top ten things that could influence the therapy relationship:

1. What the therapist believes would work within the therapeutic space.

2. Therapist’s own values – influenced no doubt by early experiences, personal narratives or inner-working models.

3. Therapist’s school of thought or therapist’s preferred modality (usually are the same).

4. Therapist’s beliefs in regard to their preferred school of thought, which they often feel they must represent.

5. Therapist’s assessment skills and ability to diagnose or formulate a case or the ability to develop an internal working model or conceptualisation  (here is an example).

6. Therapist’s psychopathology knowledge or lack thereof.

7. Therapist’s ability to consistently update their knowledge and skills in line with recent research.

8. Therapist’s ability to reflect back, ask for feedback and change therapy course in line with patient’s feedback (aka listening skills with a plus).

9. Ability to work collaboratively towards goals and teach new skills.

10. The quality of clinical supervision and the clinical supervision modality.

Internal-working models are cognitive-behavioural formulations that present an ideal platform for an open dialogue about relationships and the need to change. When early experiences or a disrupted attachment leads to a negative sense-of-self, I am a victim or I am weak, or unlovable or flawed, this embodied sentiment is experienced in all situations with all people. The victim of a negative sense-of-self is forced during earlier years (by the survivalist expert, our brain) to adapt or die of neglect. And thus, the child develops sophisticated strategies, life rules or defences meant to help him or her navigate through life with the knowledge the felt-sense provides (i.e., the knowledge that they are unlovable). This is the cognitive-behavioural translation of what analysis calls defences, patterns or templates from the past. Such deeply rooted defences become over time important life values, rules or guidelines with direct behavioural implications for example: ‘I have to act (implicit behaviour) in a specific way in order to overcome this situation.‘

Whilst helpful to the victimised individual at an earlier stage in life, and at different times even functioning as very useful surviving tools, these defences also encourage psychological rigidity. As they decrease the need for new learning and they are repeated time and time again, in various situations in the here-and-now, with only a minor degree of success (e.g., ‘I should always be available to all of my friends in spite of how exhausted I am’… ‘I must never say NO to anyone’… ‘I should always hide my true feelings’… ‘I should never show my true emotions’…).

Behavioural and cognitive approaches can deliver positive outcomes not only because interventions constantly evolve in line with new evidence and research, but also because therapists adapt and focus their attention on presenting complaints, maintenance and problem-solving, rather than constraining psychotherapy boundaries. The therapy relationship would not be authentic and responsive to patients’ immediate needs, if therapists would rigidly subscribe to a 50-minute session when going through reliving or imagery rescripting with a traumatised patient, for example. Not to mention real-life exposure programs that can last two or three hours outside of the boundaries of the clinic. The relationship adapts and adopts yet another tone, when the therapist shows willingness to swap roles with an OCD patient and touches unsanitised objects or goes on a spider ‘hunt’ in the garden shed with an arachnophobia patient.

Traditional psychotherapies on the other hand, seem to be less willing to redefine the therapy relationship boundaries and align it with their clients’ needs, in favour of clear and strict boundaries. However, there is no evidence to suggest that bonding, respectful and compassionate gestures such as offering a cup of tea, shaking a patient’s hand or gently touching someone’s shoulder in a reassuring manner, is likely to disrupt the therapy process or outcome. Equally so, there is no data to support the idea that silence gaps for prolonged periods of time during therapy, does anything else apart from increasing internal negative ruminations or worry, self-blame or self-critical thinking. Becoming a good object or a positive role model and even appropriate self-disclosure is acceptable and encouraged by the therapy alliance, just like displaying genuine sadness and empathy whilst hearing and ‘feeling’ a sad narrative; e.g., This is what it feels like to me, is this what is this what is going on with you? And… what would I remind you to do in this difficult situation?

If transference is nothing short of feelings triggered by associated thoughts, images or video reels, that can be traced back to early experiences and may result in questionable behaviours in the present-moment, I fail to see how this not exactly what CBT calls a contextual cognitive-behavioural conceptualisation, simply labelled differently in the psychoanalytic literature.

The cognitive-behavioural therapist relies on this type of conceptualisation, formula or indeed ‘inner working-model’ to help the victimised individual ‘verbalise’ their internal psychological pain and translate the untranslatable sense-of-self, thus exposing its true meaning and intention. In doing so, the therapist increases the victim’s ability to learn new coping skills and effectively proposes a way forward by ‘acting as if’; e.g., ‘What would my life look like if I was loved and appreciated by significant others – as opposed to holding on to a core idea that nobody accepts me no matter how hard I try’... 

Within the safety of the therapeutic alliance, the CBT therapist will question the felt-sense and accompany the client on journey towards a new sense-of-self. This will often involve active and realistic short-term plans and essentially starting to live life as if the opposite of whatever the felt-sense is suggesting, is in fact the truth. And revealing that these defences bring more emotional pain, instead of opportunity and joy.

So, what about the question posed in the title? The answer simply does not matter, it seems that, what is needed is more cross-training and dialogue between different schools of thought, alongside a thorough review of data, in order to upgrade therapists’ views about what a therapeutic relationship ought to look like. Schools competing for supremacy does not seem to provide an answer, on the contrary.

All of the above therapy instruments would eventually lead to the best, healthiest and most independent version of the victimised client, irrespective of therapists’ personal beliefs about the intervention itself. Independence from the reliance on rigid defence mechanisms facilitates new learning, adaptability and not least psychological flexibility, which in itself, is one of the main ingredients for a pathology free life. If only, some therapists would also adopt more psychological flexibility themselves…

*****

According to my good friend and colleague Dr Donald Meichnebaum one of the founders of CBT, positive outcomes are further enhanced by developing resilience rooted in individuals’ culture, personal values and strengths. Meichenbaum has reminded us in his characteristic manner that we are not only homo-sapiens but also homo-narrans or story tellers or narrators, therefore the stories that individuals tell will determine if victimised individuals will fall into the 25% traumatised group or 75% symptoms-free group (Meichenbaum, lecture notes 2022).

For online training in trauma with either Dr Donald Meichenbaum or Daniel Mirea please click on this link

[ proof reading and editing by Ana Ghetu ]

What is Cognitive Behavioural Therapy and how does this approach differ from other types of psychotherapy models (audio)

Neuroaffective-CBT

CBT is synonymous with evidence-based psychological treatment. Best understood as an umbrella-term that includes a number of very-well researched therapeutic approaches developed over the last few decades and proven to work with a number of psychopathologies… dynamic talking therapies like Exposure Therapy, Schema Therapy, Stress Inoculation Training, Mindfulness (MBCT), Acceptance and Commitment Therapy (ACT), Hypno-CBT, NeuroAffective-CBT (NA-CBT) and a lot of other acronyms (i.e., MCT, DBT, CFT, FA, etc.) are all part of the CBT family. Although these therapies are designed to operate rather well within the medical model, they remain close to individual values, personal goals and desires…

Daniel Mirea goes into some depth on this topic with accredited psychotherapist Carla Vercruysse on Spotify !

Daniel Mirea about Cognitive Behavioural Therapy

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

This particular article contains an audio podcast and describes real life situations for learning and authenticity purposes, it may follow anonymised cases who received NeuroAffective-CBT … this is part of a series of free handouts offered to students on doctoral or advanced training programs in Integrative-CBT; as already explained certain details have been changed in order to maintain anonymity.