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Workshop Presentation Synopses from the 2005 ACAT Annual Conference

Carroll, R., Elia, I., Compton Dickinson, S. and Webster, M., 2005. Workshop Presentation Synopses from the 2005 ACAT Annual Conference. Reformulation, Spring, pp.7-9.

2005 ACAT Annual Conference Workshop Presentations

Affect Regulation and the Body in Psychotherapy

Roz Carroll

The neuroscience revolution gives psychotherapists new information about the regulation of affect, which encompasses interactions of central and autonomic nervous, endocrine, and muscular systems. This means that the whole body is fully involved in the generation of affect, even though it may be contextualised and significantly modulated by areas of the brain. Developments in theory and technology, including MRI and PET scans, have now shown the sequential activation of brain centres in the regulation of affect:

amygdala on line at birth for giving immediate pleasurable/unpleasurable, safety/danger valence to incoming sensory information, initiatating the startle reflex, becoming sensitized in trauma
cingulate activated in third month, associated with motivation to communicate, stimulated by social contact
orbito-frontal cortex organising from 10 to 18 months, links the other (via eye contact) to internal bodily sense; facilitates recovery from disruptions of state and integration of self across states, thereby allowing continuity of experience
right cortex for processing emotional information about relating (context, tone, global intent); generates autonomic response
left cortex for language, abstract concepts, logic, temporal sequence, causality, fine motor control; can dampen autonomic response.

Panksepp has proposed seven emotional operating systems: SEEKING, RAGE, FEAR, PANIC, LUST, CARE, PLAY involving key brain circuits, reflexes, and physiological states which provide a prototype for basic human feelings. Emotions are both biologically and socially determined, arising subcortically initially, then being elaborated socially, becoming encoded and linked to external signs and signals.

This knowledge deepens our understanding of the basis of affective difficulties. A functional insufficiency of the right cortex, for instance, leads to disturbances of attention, distortions of self image, deficits in social relating, affect blunting and concreteness of thought. Attachment experiences during development can alter or impede brain activity. There is still much work to be done to understand how much the hyper- and hypo-activity of brain centres is reversible through new patterns of relating. Research shows that therapy does produce changes in brain functioning, but body and brain are a complex system, which cannot easily be measured.

We, therefore, continue psychotherapy more mindful of the need to be attuned to the language of bodily changes (or absence of expected changes), as they will reflect processing of thoughts and interactions at many levels (autonomic, motor, endocrine, cortical). Bodily phenomena, such as level of tension, skin colour changes, facial expression, voice quality, posture, etc, can be viewed, in light of neuroscientific discoveries, as deeply embedded in brain physiology and arising through a combination of repeated personal interactions and social contextualisations. It is an exciting time of development in theory, and with it, developments in technique, understanding of attachment, body, and structural systems are feeding new innovations in therapeutic practice.

For more detail, see articles on Roz Carroll’s website:
www.thinkbody.co.uk

Dr Roz Carroll is a body psychotherapist and a member of the Society for Neuro-Psychoanalysis. She is a trainer and supervisor at the Minster Centre and the Chiron Centre for Body Psychotherapy.

Mirror Workshop

Irene Elia

Mirrors may help clients and therapists recognise and revise their RRs. This is because mirrors let us see one aspect of role: Appearance, which, if regarded with an eye to detect the messages of facial expression, posture, attire, etc, makes us reflect on our inner dialogue, our transferential responses to ourselves, and what we evoke in others. Mirrors let us role play a new role with ourselves.

In the workshop, we began by considering the three aspects of role:

VOICE (quality, volume, pace, etc) which conveys feeling

APPEARANCE (posture, clothing, facial expression, actions, etc) which conveys intention as well as feeling

SCRIPT (words in our head and the words spoken) which conveys our beliefs and thoughts, as well as feelings and intentions.

We tried to understand that we may be ‘in the audience’ to our own reflections in the mirror. That is to say, an expression may trigger a reciprocal response: a ‘cross, dissatisfied’ look may generate a worried feeling and the placating/striving wish to fix ourselves up. Conversely, a false ‘placating’ smile might make us feel and then look ‘cross and dissatisfied’ with ourselves. The expressions flit back and forth. Self-to-self mirror enactments portray and reinforce our roles.
Each participant received a hand mirror and a worksheet on which to jot down what they saw, heard (inner voice, usually, although there were some audible groans), and felt, as they gazed at their face. Some of us were able to glimpse an expression that was familiar and told us about one of our RRs. Others were absorbed in attending to the physical aspects of their features: how old they looked or who in the family they resembled.

It takes practice to focus on expression and to catch inner comments. Sometimes the sorrow of what is missing from the reflection overwhelms; we may not even be sure why. But we may be uneasy looking; we may even cry. Then, we may try out a new face/voice.

We ended by taking a last look in the mirrors, smiling and saying ‘Well done!’ Using the mirror can be revealing, challenging, and, hopefully, rewarding in the CAT tasks of recognition and revision.

Irene Elia is a cognitive analytic therapist and Supervisor in private practice in Cambridge and Southampton. She is also a Physical Anthropologist. Special interest in facial appearance and expression comes from a project on cross-cultural female beauty consensus and from clients’ statements about their faces.

Beyond Body, Beyond Words: Music Therapy and CAT

Stella Compton Dickinson

Over the last four years I have considered whether it may be possible to develop an integrated approach in which the skills of a qualified music therapist may be combined with those of a cognitive analytic therapist.

Macdiarmid (1980) points out that in Breuer’s famous case of Anna O, her symptoms started when she had a powerful emotion that she couldn’t express. This difficulty in expression is, I suggest, particularly central in treating, redeeming and incorporating dissociative states in personality disordered patients because those feelings have been cast out as unbearable.

When a jointly created artifact in the form of a musical improvisation is produced, it may be felt as part of the Patient’s own self-expression. When self-states have been identified diagrammatically, the Patient can be musically and therapeutically supported to feel these through the musical interaction. In the primary abusive situation he may have been alone and terrified, in the therapeutic situation he may instead gradually tolerate and internalize the feelings rather than act them out. I suggest that the Patient must also accept the recognized feeling, rather than simply acknowledge it. The music may otherwise become dissociated, outside of himself or attributed to the therapist alone.

The therapist requires particular skill to ensure that he is not vulnerable to becoming an object through which a patient could sadistically re-enact abuse. Musical improvisation can however be incorporated into the containing and facilitative structures of cognitive analytic psychotherapy.

Jointly created musical improvisations when recorded can become an artefact which represents the meaning and nature of the therapeutic relationship

Compton Dickinson (2005) Rapping at the door; songs of innocence and experience with ethnic minority offenders. Proceedings of the 11th World Congress of Music Therapy. Brisbane 2005 (Work in progress) www.musictherapy2005com

Compton Dickinson (2003) Community, Culture and Conflict: The role of creativity British Society of Music Therapy. Conference Proceedings 2003

Compton Dickinson (2001) Compare and Contrast the practice of CAT with Dynamic Psychotherapy. Ch.1 An Overview Past and Present. Ch. 4 The musical application of CAT principles in attachment and development Kings College Library: Academic Psychiatry, Guys Campus.

Since 2000, during her MSc training at Guys Hospital, Stella has been linking her music therapy training to ideas from clinical presentations and texts in dynamic psychotherapy, psychiatry, and cognitive analytic therapy. Applications began with learning disabled patients (Compton Dickinson, 2001), then moved on to a patient with paranoid schizophrenia (Compton Dickinson, 2003). Having recently completed cognitive analytic training, she has combined it with music therapy in group work with young black Caribbean patients. (Compton Dickinson, 2005).

Metacognition and the 3rd Wave of CBT

Mark Webster

The workshop looked at how metacognitive ideas within the ‘new wave’ of CBT might fit with CAT in a way that is theoretically coherent and practically realistic. Acceptance and Commitment Therapy (ACT) was used as an illustration.

When looking at definitions of ‘metacognition’ it becomes evident that the term is a bit of a misnomer. ‘Meta’, meaning beyond or hidden, and ‘cognition’, meaning thinking, suggest something other than thinking. However, metacognition generally refers to thinking about thinking. A simpler definition is to refer to a general observing capacity.

The first wave of CBT was characterised by the work of Pavlov and Skinner. In the second wave, internal thought processes were incorporated, as in the work of Kelly, Beck and Ellis. The third wave moves beyond this by introducing ideas of acceptance as well as change into the therapeutic process. Dialectical Behavior Therapy (DBT), ACT, and Mindfulness Based Cognitive Therapy (MBCT) are probably the best known.

ACT theory shows us that we develop strategies to avoid or escape from unpleasant feelings and use these behaviours often to our own detriment. For example, in thinking about a difficult social situation someone may develop anxiety and start to have thoughts of how people might judge or reject them. If the person decides to avoid the situation the thoughts and feelings go away. Because this works at alleviating short-term distress the behaviour gets coupled to the thought and is used more automatically in future. A trap is set up. No experience of the situation is generated so the thought remains untested and is believed.

The practice of ACT is concerned with uncoupling the thought from the behaviour. In order to do this there would be an initial reformulation to highlight the circular nature of the pattern and how it does not work in achieving relationship goals. Next, the client would be encouraged to learn to observe the thoughts without avoiding the situation. This technique is called defusion, and it differentiates ACT from traditional CBT. The ACT stance is to challenge the believability of the thought rather than attempting to restructure it.

Defusion techniques undermine the link between ‘I’ and the judgement. For example the thought ‘I am bad’ suggests that ‘bad’ is a fact about the person. This can lead to behaviours in the category of not getting needs met, since the person does not feel deserving. It is because the person acts as if the thought is true that it is defined as a belief!

Defusion involves moving to a metacognitive position in which the thought can be seen as just a thought. To continue the example, a simple technique would be to get the client to try saying ‘ I am having the thought that I am bad’ and then to get one step further away from it by saying ‘I am noticing I am having the thought that I am bad’. The client has shifted perspective to the observing eye, rather than trying to restructure the thought. From this perspective the behaviour is automatically uncoupled from the thought. Within ACT there are a wide range of metaphors and experiential techniques that are used to practice defusion.

Once the thought can be seen as ‘just a thought’ then the person is free to choose a direction that is in accordance with their core values and so find an exit from the trap. This follows the three Rs of CAT. The defusion move is central to acceptance in the same way that the observing eye is central to CAT. Rather than trying to tamper with thought content or feelings (or Reciprocal Roles in CAT) instead they become ‘observed’ in a metacognitive sense and people are freed from the stuck behaviours which are spoiling their lives.

The data on ACT is accumulating and currently there are 9 published RCTs and another 26 published trials. Many more are in progress. A review of the data is available on the ACT website-http://www.acceptanceandcommitmenttherapy.com/.

ACT may be used in areas from anxiety and depression to addiction and psychosis, even smoking cessation. Outcomes are equal to or better than comparable trials in traditional CBT. The research shows that change in acceptance levels is highly correlated with outcomes, validating the theoretical base of the 3rd wave.

The acceptance component that defines 3rd wave CBT is compatible with Vygotskian ideas and the concept of an observing eye or executive function in CAT. Used at the level of procedures rather than reciprocal roles it can fit seamlessly into CAT and offers another way of working with difficult clients who are not responsive to traditional cognitive restructuring techniques.

Mark Webster initially trained in the computer industry, he started working in addictions in 1990 and trained in CAT, from 1996 he has worked as a CAT therapist at the IPTS in Poole, which is a specialist clinic for personality disorders. Through this he trained in DBT and ACT. In the last three years he has worked both privately and in the IPTS.

Full Reference

Carroll, R., Elia, I., Compton Dickinson, S. and Webster, M., 2005. Workshop Presentation Synopses from the 2005 ACAT Annual Conference. Reformulation, Spring, pp.7-9.

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Mirror Workshop Summary Held On The 9th July 2010
Elia, I., 2010. Mirror Workshop Summary Held On The 9th July 2010. Reformulation, Winter, p.47.

The Clinician’s Guide To Forensic Music Therapy - Book Review
Wakeling, N, 2017. The Clinician’s Guide To Forensic Music Therapy - Book Review. Reformulation, Winter, pp.56-57.

Attachment, The Body and Trauma
Diamond, N., 2005. Attachment, The Body and Trauma. Reformulation, Autumn, pp.25-26.

Mirror, Voice and Reciprocal Role
Elia, I., 2004. Mirror, Voice and Reciprocal Role. Reformulation, Spring, pp.6-8.

BOOK REVIEW
Amanda Lappin and Julie Lloyd, 2013. BOOK REVIEW. Reformulation, Summer, p.50.

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