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Compassion Based CBT workshop with Prof Paul Gilbert

Posted on January 9, 2014 at 12:09 PM Comments comments (0)
This is a workshop delivered by Prof Paul Gilbert at Palo Alto University in 2013 about the scientific premise and technique of Compassion Focused Therapy. 

Overview of Compassion Focused Therapy and the process of change with compassion. 

CFT is a psychological model, although it uses elements of CBT, humanistic and psychodynamic therapies. CFT started with Prof Gilbert's interest in patients who were struggling with standard therapies (diagnosis of Borderline Personality Disorder). These patients were focused on shame and self-criticism, which is linked to poor outcomes. He wanted to understand evolutionary mechanisms which maintained emotional problems. 

Cognitive Behaviour Therapy traditionally focuses on replacing on unhelpful thoughts and behaviour with helpful thoughts and behaviour. However some clients say they see the logic of the alternative thoughts but do not feel reassured or helped at the emotional level. They also say: "I know I am not to blame but I still feel to blame"

We need to feel congruent emotion in order for our thoughts to be meaningful to us. Emotions "tag" meaning onto experiences. In order to be reassured by the thought "I am loveable", this needs to be linked with the experience of 'being loveable'. Many patients who come from traumatic backgrounds have few memories of being loveable or soothed and thus may struggle to feel reassured and safe by alternative thoughts. 

Compassion focused therapy targets the activation of the soothing system so that it can be more readily accessed and used to help regulate threat-based emotions of anger, fear, disgust and shame. 

Evolutionary model of psychopathology 

We are an emergent species in the 'flow of life' so our brains, with their mechanisms for motives, emotions and competencies are products of evolution, designed to function in certain ways. 

Anxiety disorders are related to how cognitions trigger innate defences - fight, flight, demobilisation (Marks, 1987) or danger modes (Beck, 1996)

Depressions are related to evolved mechanisms for coping with defeats and loss (Beck, 1987; Gilbert, 1992)

Personality disorders are related to the under or over development of innate strategies (e.g. cooperation vs. competition) (Beck, Freeman et al. 1990; Gilbert, 1987)

The social circumstances of our lives, over which we have no control, have major implications for the kinds of minds we have, the way our genes become expressed, the kids of brains we end up with, the kind of person we become, the values we endorsed and the lives we live. 

How new psychologies emerged in the world
500 mil years ago - Reptilian psychology (territory, fear, aggression, sex, hunting)
120 mil years ago - Mammalian psychology (capacity for caring, group, alliance building, play, status)
2 mil years ago - Human psychology emerged (capacity for symbolic thought and self-identity, theory of mind, meta-cognition)
1 mil years ago - Human capacity for extended caring (looking after the old or the sick) 

Why we have complex brains and minds that are difficult to understand and regulate

The Old Brain: Emotions (anger, anxiety, sadness, joy, lust); Behaviours (fight, flight, withdraw, engage) Relationships (sex, status, attachment, tribalism)
New Brain: Imagination, fantasise, look back and forward, collating and integrating vast amounts of information from different modalities- sensory emotional, plan, ruminate. 
Social Brain: Need for affection and care 

The brain has a number of built-in biases. Biased learning (fear of snakes, heights). Biases can be implicit or explicit. We tend to be self-focused, kin-focused and exhibit in-group preferences. 

We have a capacity to become aware of being awareness. Mindfulness is the capacity to observe one's mind and it naturally calms us down. Compassion comes is a motivating system rooted in the caring system. Compassion has to be understood as an interaction - it depends also on the other being responsive to being cared for. 

The mind is primarily a social signalling system (See Tronick's 'still face' experiment, Joseph Campos experiment on the role of non-verbal communication guiding behaviour in babies) 

Humans have fundamentally have a desire to be helpful( Warneken and Tomasello experiments in compassion in babies). 

Evolutionary functional analysis 

There are three types of emotions, which act as motivators: 
-those that focus on threat and self-preservation
-those that focus on doing and achieving 
-those that focus on contentment and feeling safe. 

The threat system is the dominant system in your brain. It is designed to over-rule and switch off everything else. Attention becomes narrow-focused, scans for threats, moves towards thinking about what could go wrong. In anger and anxiety the body feelings overlap. Borderline patients are not able to distinguish between tension and anxiety. 

ADHD rethought as executive functioning deficit disorder

Posted on May 19, 2013 at 5:43 PM Comments comments (113)
Russel A. Barkley is an expert in ADHD [Attention Deficit Hyperactivity Disorder]. In His 2o12 Burnett Lecture Prof Barkley describes ADHD as Executive Function Deficit Disorder. He says that this new reconceptualisation has profound implications over how ADHD should be tested in the USA. 

His theory is extremely interesting; I question his conclusions as he seems to over-emphasise medication [he is a consultant for pharmaceutical companies who produce the drugs that are used to treat ADHD in children]. The over-use of drugs is a problem as many children out-grow this developmental gap. 

The lecture is available on Youtube: Part 1 and Part 2

Summary of the theory of ADHD as EFDD

There are five brain structures involved in executive functioning: the medial prefrontal cortex, the dorso-lateral prefrontal cortex, the basal ganglia [striatum], the amygdala and the cerebellum. Together they create three distinct neural circuits, which are dopamine based [Javier Castellanos]

The frontal-striatal circuit: associated with deficits in response suppression, freedom from distraction, working memory, organisation and planning, known as the "cool" EF network

The frontal-limbic circuit: associated with symptoms of emotional discontrol, motivation deficits, hyperactivity-impulsivity and proneness to aggression, known as the "hot" EF network

The frontal-cerebellar circuit: associated with motor coordination deficits, and problems with timing and timeliness of behaviour, known as the "when" EF network

[For a longitudinal study of the development of the ADHD brain see the research of Philip Shaw.]

These three circuits are associated with the following functions: timing of actions and behaviour [as well awareness of self in time], goal orientated behaviour, coordination and gracefulness of our movements [and thoughts], working memory [a memory of what I am here to do], emotional inhibition and meta-cognition [self-awareness, planning, problem solving, self-regulation. 

What is executive functioning?

Dimen [198o] describes EF as the seat of social intelligence without which cooperation, reciprocity and group living would not be possible. 
EF is self-regulation [self-control]. Self-control is anything we do to ourselves to change our behaviour. Through EF in the present we are trying to change a distant outcome. [exercising now to get fit and toned in the future], or changing behaviour to change the future that comes towards us. 

There are seven different executive abilities. These abilities develop in a sequence and they are observable [externalised] in young children. In adults they become symbolic/private, unless we are alone and we are less inhibited and give ourselves commands out loud. 

Private self-speech 
o-3 years - no self talk
3-5 years - audible self-speech [no voice in the head]
5-7 years-  the child gives himself commands out-loud but starts suppressing the vocal cords and later the face movements
after 7 years - the voice in the head/the voice governs our behaviour privately

Emotional and motivational self-regulation
Self-talk helps us create and manage emotions and if we can manage our emotions we can manage our motivations. Anticipating pleasure in the future can motivate us to tolerate the time delay in getting the reward. 

Starts at around three months of age and takes ten years to mature. Involves turning attention and sensing to self; self-monitoring; self-watching 

Self-restraint or executive inhibition [stopping self from performing an action, resisting distraction]

Non-verbal working memory: 
is the visual imagery system [theatre in the mind] that guides us to our goals. We resurrect images of our past to guide us towards the future. 

Planning and problem solving 
Children's play solves as a template for problem solving because it involves analysis/synthesis, the source of all human imagination and invention [Daniel Coleman- Thinking fast and slow]

Acting at a distance: interacting towards the future and preferring delayed rewards to immediate ones. 

The pre-frontal cortex only fully matures in our early thirties. The older we get the more we expand our window to the future [anticipation of future events, thinking months and years ahead]. EF helps us create a scaffolding with the group and culture requires: being methodical, self-reliant, self-determined, resisting being manipulated by others to their advantage, being able to put a 'wall or filter' between yourself and others so you cannot be manipulated, self-defensive, reaching out and interacting with others, building friendships, reciprocity, sharing, turn-taking, initiating cooperative enterprise which is the basis of communities and government. 

Understanding ADHD in adults
Time blindness - are nearsighted to time, adrift in time, are "getting pulled along by the 'now'". 

Performance disorder: doing what you know and not knowing what to do; having a lot of knowledge but not being able to use it. It's a problem with knowing when to do and where to do rather than what to do and how

Using the past at your point of performance - the place and time where you should have used your skill but didn't

It is an intention deficit disorder.

Treatment recommendations: Working at the point of performance. Neuro-genetic therapy [using drugs to work at the level of molecular mechanisms, a form of genetic treatment]. Make rewards positive and concrete; visualising and imagining rewards; time-management training - make time concrete through the use of clocks and timers; breaking down long tasks into small chunks; breaking tasks and taking breaks every ten minutes to allow for refuelling [EF depletes our resources]; keep the sugar levels in the bloodstream up; routine aerobic exercise to oxygenate the brain; make problem-solving physical [manipulating objects]; positive self-statements; biofeedback.

Transforming the mind changes the brain

Posted on February 7, 2013 at 7:45 PM Comments comments (102)
Richard Davidson lecture on the impact of mental training on the neural circuits of emotion and attention. Watch here. (min. 5.08)

Circuits of emotion
Sensory information travels from the sensory organs, through relay centres (sensory thalamus) to the cortex. Once the relevance of this information is processed (is it safe or dangerous), this is transmitted to the the visceral organs (heart and the lungs) and to the muscles in our face and body. If we perceive a threatening stimulus (i.e) a predator, our heart beats faster and hour lungs work harder, etc. The information about the state of the viscera and the body then travels back to the brain. It is only when the brain detects the changes in our body that the experience of emotion arises. This is an influential view espoused by William James in the "Principles of psychology". The fact that our perception of emotion is reliant of information from the body was proven through an experiment in which people who had botox injected in their forehead (in muscles associated with the expression of sadness) were tested before and after. The test showed that the lack of signal feedback from these muscles to the brain changed the emotional response of the person (they experienced less sadness).

James Papez was the first to describe a model of the circuit in the brain associated with emotion. His model included the hippocampus, the hypothalamus, the anterior thalamus and the cingulate gyrus.This was the first time that it was suggested that emotion is processed in parts of the brain that lie below the cortex. Later on, studies on patients with lesions to the prefrontal cortex showed that the cortex (the medial prefrontal part) is actually involved in emotional processing.

In the modern understanding, the capacity to regulate our emotions is associated with the prefrontal cortex. No other species can voluntarily regulate their emotions in the way humans do. 

Emotion as a process is distributed throughout a circuit and different areas of the brain interact to create emotion (i.e. the limbic system and the prefrontal cortex. However there is no single site in the brain about which we can say: that is where emotion resides. There are circuits in the brain for positive emotions and circuits that process negative emotion.

Stress changes the structure of the brain, particularly the hippocampus, amygdala and orbito-frontal cortex. When an animal is chronically stressed the nervous cells in the hippocampus shrink shrink (fewer dendrites), whereas cells in the amygdala apear to have more ramifications. (Davidson & McEwan, Nature neuroscience, 2012) 

Networks in the brain important for attention 
Attention has different atributes and some can be distinguished in terms of circuits in the brain. There are three types of attention: alerting, orienting and executive control. Alerting occurs for instance when there is a big loud noise. Something happens in the environment and our attention is pulled towards it. Orienting is the capacity to direct your attention mentally to different senses. Executive control is about resisting distractions and directing our mind to focus on one thing and inhibit the distractive influences that come from somewhere else. There are parts of the brain involved with these attention functions that overlap with emotion. This is not surprising because it is emotionally relevant information in our environment that captures our attention. We do not become alerted to neutral stimuli.

The impact of contemplative training on networks important in attention
Children who have attention deficit hyperactivity disorder are very variable in how they pay attention. In a study in which participants practiced Vipassana meditation for three months, it was shown that this practice greatly helped reduce this variability of attention (Lutz et al. 2009, Neuroscience).