MiCBT FOR CRISIS INTERVENTION, CHRONIC CONDITIONS AND RELAPSE PREVENTION: A 2 DAY INTRODUCTORY WORKSHOP

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1 MiCBT FOR CRISIS INTERVENTION, CHRONIC CONDITIONS AND RELAPSE PREVENTION: A 2 DAY INTRODUCTORY WORKSHOP NOTE: This schedule is oly a approximate guide. Times may chage based o group eeds DAY 1 9:00am 5:00pm MODALITY Lecture (PowerPoit) TOPIC Brief overview of the MiCBT 4 stage program Lecture (PowerPoit) ad discussio Ratioale for the iclusio of midfuless i therapy: The Co emergece model of reiforcemet 10:40am 11.00am Morig Break Practice of midfuless PowerPoit PowerPoit Itroductio to Stage 1: Midfuless with breathig Dyamics of itrusive thoughts Emphasis o iteroceptio: Icreased perceptio of 4 basic characteristics of body sesatios Usig the Iteroceptive Sigature Scale 12:45pm 13:30pm Luch Break Practice of midfuless Teacher demostratio of rapid distress reductio Video screeig Midfuless of Breath Deliverig the ratioale for midfuless to cliets Rapid distress reductio Egagig cliets i the treatmet pla Footage: Demostratio of skill with cliet 15:30pm 15:50pm Afteroo Break Lecture ad discussio Neural substrates of midfuless ad europlasticity Home practice: Midfuless of breath toight & tomorrow morig 5:00pm Ed of Day 1

2 MiCBT FOR CRISIS INTERVENTION, CHRONIC CONDITIONS AND RELAPSE PREVENTION: A 2 DAY INTRODUCTORY WORKSHOP NOTE: This schedule is oly a approximate guide. Times may chage based o group eeds DAY 2 9:00am 5:00pm MODALITY Practice of midfuless TOPIC Uilateral ( part by part ) body scaig Lecture ad discussio Itroductio to Stage 2 of MiCBT: The exposure stage ( Bipolar Exposure) 10:40am 11:00am Morig Break Lecture ad discussio Itroductio to Stage 3 of MiCBT: The iterpersoal stage Experietial owership ad assertive commuicatio 12:45pm 13:30pm Luch Break Group work Case coceptualisatio ad treatmet plaig with MiCBT 15:00pm 15:20pm Afteroo Break Discussio ad practice Discussio Itroductio to Stage 4 of MiCBT: The empathic stage Prevetig relapse Brief itroductio of the Applied Course ad optio to erol, subject to availability of places 5:00pm Ed of Day 2 A lik to your Learig Outcome Questioaire will be ed to you. Thak you for fillig it i at your earliest coveiece.

3 Itroductio to MiCBT Itroductio to Midfuless-itegrated CBT for Crisis Itervetio, Chroic Coditios ad Relapse Prevetio Alice Shires 2-day Itroductory MiCBT Workshop 1 The 4 Stages of Midfuless-itegrated Cogitive Behaviour Therapy Exteralisig skills Iteralisig skills Stage 1 Persoal stage Stage 2 Exposure stage About 2 weeks Stage 3 Iterpersoal stage 1 to 2 weeks Stage 4 Empathic stage 1 to 2 weeks 3 to 4 weeks 2 MiCBT Istitute 1

Itroductio to MiCBT Midfuless 3 complemetary defiitios 1. Sustaied attetio: payig attetio o purpose, from momet to momet, ad ojudegmetally (Kabat-Zi, 1994). 2.

4 Itroductio to MiCBT Midfuless 3 complemetary defiitios 1. Sustaied attetio: payig attetio o purpose, from momet to momet, ad ojudegmetally (Kabat-Zi, 1994). 2. Cogitive flexibility: a state of cotiuous category formatio. A midful idividual creates ew approaches to evets ad situatios. He or she is ot boud by previously formed rigid attitudes; rather, the midful perso, situated i the preset, explores a situatio from several perspectives (Margolis & Lager, 1990). 3. Ihibitory cotrol: midfuless is achieved through the developmet of experietial awareess ad equaimity, which is the ability to remai uperturbed by a evet experieced withi the framework of oe s body ad thoughts as a result of objective observatio (Cayou, 2003). 3 Usual meaig of equaimity (Upekkha i Pali) 4 MiCBT Istitute 2

5 Itroductio to MiCBT 5 Mechaisms of Actio ad Defiitio Awareess ad equaimity as core mechaisms. Equaimity i the midfuless cotext: The ability to see without beig caught by what we see (Gil Frosdal, 2004) The ability to remai uperturbed by a evet experieced withi the framework of oe s body ad thoughts as a result of objective observatio. Therefore equaimity relies o awareess of oe s thoughts ad somatic sesatios (Cayou, 2003) 6 MiCBT Istitute 3

6 Itroductio to MiCBT Do we really eed to meditate? 7 Practice & Operatioalisatio 1. Cocetratio o breathig (attetio regulatio) Traiig i sustaied attetio, meta-cogitive awareess, ihibitory cotrol ad attetio switchig Beefits iclude decreased distractibility from irrelevat thoughts ad sesory stimuli ad cogitive flexibility 2. Systematic body scaig to develop equaimity (emotio regulatio) Geeralised iteroceptive exposure ad respose prevetio Requires ihibitory cotrol to prevet leared resposes ad foster acceptace Geeral Aims Develop greater self-awareess, objectivity, acceptace ad detachmet with each experieces 8 MiCBT Istitute 4

7 Itroductio to MiCBT The Co-Emergece Model of Reiforcemet Explais behaviour maiteace ad chage i terms of their pheomeology, as experieced durig midfuless traiig Relies o itegrative priciples Mid ad body caot be separated withi a experiece Itegrates ad emphasises atural laws Impermaece Ievitability of chage i all evets, icludig the self 9 Experiecig Iformatio STIMULUS Iteral/Exteral 10 MiCBT Istitute 5

8 Itroductio to MiCBT Experiecig Iformatio STIMULUS Iteral/Exteral SENSORY PERCEPTION Icl. metacogitive awareess 11 Experiecig Iformatio STIMULUS Iteral/Exteral SENSORY PERCEPTION Icl. metacogitive awareess EVALUATION Propositioal & Implicatioal 12 MiCBT Istitute 6

9 Itroductio to MiCBT Experiecig Iformatio STIMULUS Iteral/Exteral SENSORY PERCEPTION Icl. metacogitive awareess EVALUATION Propositioal & Implicatioal INTEROCEPTION Locus of reiforcemet 13 Experiecig Iformatio STIMULUS Iteral/Exteral SENSORY PERCEPTION Icl. metacogitive awareess EVALUATION Propositioal & Implicatioal REACTION OR RESPONSE INTEROCEPTION Locus of reiforcemet Cravig ad aversio towards body sesatios act as reiforcers The 4 compoets fuctio i equilibrium whe metal health is optimum, ad disequilibrium whe ormal fuctioig is challeged. 14 MiCBT Istitute 7

10 Itroductio to MiCBT System i Disequilibrium STIMULUS SENSORY PERCEPTION EVALUATION Decreased metacogitive awareess Icreased reliace o most accessible etworks for iterpretatio REACTION INTEROCEPTION Decreased iteroceptive awareess Decreased iteroceptive acceptace ad attempt to decrease sesatios Attetio is polarised to the most useful fuctios to reduce effort ad time for rapid decisios Experietial avoidace is also eabled by this patter (Hayes, 2003) The system ca be set off balace by stressors ad ca be taught to maitai disequilibrium as a ew stable state i the system Leared respose patters do ot require coscious evaluatio ( automatic ) 15 A Ratioale for Midfuless-itegrated CBT Leared disequilibrium ca lead to psychopathology The more stable ad established is the disequilibrium, the more chroic the coditio Implicatios for the developmet ad maiteace of persoality System i equilibrium resists psychopathology More healthy ad relaxed idividuals ted to feel subtler body sesatios more readily ad have a greater ability for metacogitive awareess Daily traiig i midfuless leads to europlasticity i correspodig etworks, which facilitates the trasfer of skills i daily life 16 MiCBT Istitute 8

11 Itroductio to MiCBT Creatig Equilibrium Stage 1 of MiCBT: Midfuless meditatio Systematically body-scaig helps develop iteroceptive awareess ad acceptace (i.e., equaimity) Emotio regulatio Attetio regulatio Socratic Dialogue to challege resistace ad selfdefeatig thoughts, ad ecourage practice 17 Creatig Equilibrium (Cot) Attetio is reallocated from Evaluatio ad Reactio to Sesory Perceptio ad Iteroceptio to promote balace ad stability i the system STIMULUS SENSORY PERCEPTION EVALUATION Payig attetio to sesory iformatio Decreasig reliace o habitual views (schematic models) REACTION INTEROCEPTION (BODY SENSATION) Decreasig reactivity by acceptig thoughts & body sesatios Payig attetio to sesory iformatio The mai aim is explaied to cliets i terms of recalibratio of CNS (a o-pathologisig approach) 18 MiCBT Istitute 9

12 Itroductio to MiCBT Short practice of Midfuless of Breath 19 Operatioalisig Distractibility: The Self Orgaisatio of Thought Itrusio Itrusive thoughts are explaied i terms of eural etworks competig for access to coscious awareess Determied by activatio stregth Highly activated etworks lead to thought itrusio: rececy of use frequecy of use Co-emergece effect Competitio i eural etworks for access to cosciousess Thoughts with greater activatios stregth i associated eural etworks or greater co-emergece (emotioal load) emerge first i cosciousess. With equaimity, weaker etworks ca also emerge 20 MiCBT Istitute 10

13 Itroductio to MiCBT Emphasis o Body Sesatios Feelig body sesatios durig body-scaig techiques facilitates access to schematic models Established assumptios ( implicatioal codes or schematic models ) emerge ad are reprocessed with acceptace Experieced as pleasat, upleasat, or eutral Neutral sesatios ofte tur upleasat (boredom) 4 basic characteristics (4 cotiua): Neutral Motio stillest most agitated Mass lightest heaviest Temperature coldest hottest Cohesiveess loosest desest 21 Iteroceptive Sigature Scale Ager regulatio 22 MiCBT Istitute 11

14 Itroductio to MiCBT Iteroceptive Sigature Scale Sadess regulatio 23 Iteroceptive Sigature Scale Axiety regulatio 24 MiCBT Istitute 12

15 Itroductio to MiCBT Iteroceptive Sigature Scale Cravig/bige regulatio 25 Moitorig Iformal Practice 26 MiCBT Istitute 13

Itroductio to MiCBT Rapid Distress Reductio: PTSD, Chroic Pai, Methadoe Depedece 13mi 27 Geeral Beefits of Midfuless Traiig Developmet of metacogitive awareess Awareess ad acceptace of oe s thoughts

16 Itroductio to MiCBT Rapid Distress Reductio: PTSD, Chroic Pai, Methadoe Depedece 13mi 27 Geeral Beefits of Midfuless Traiig Developmet of metacogitive awareess Awareess ad acceptace of oe s thoughts Maladaptive thoughts are reprocessed more eutrally (Teasdale, Segal, & Williams, 1995; Chambers, Che Yee Lo, &Alle, 2006) Developmet of experietial acceptace (i.e., awareess ad acceptace of thoughts ad body sesatios) Practice of systematic body scaig (two 30-mi sessios per day) Uilateral, Bilateral ad Sweepig methods Facilitates skill trasfer Promotes europlasticity i prefrotal ihibitory etworks ad somatosesory pathways (Davidso et al., 2003; Carey, Bhatt & Nagpal, 2005; Lazar et al, 2005) Icreases iteral locus of cotrol (see Witkiewitz, Marlatt, & Walker, 2004) 28 MiCBT Istitute 14

Itroductio to MiCBT Deliverig the ratioale to cliets 1. Explai the basic co-emergece model of reiforcemet to the cliet 2. Egage cliet to evoke a distressig situatio 3.

17 Itroductio to MiCBT Deliverig the ratioale to cliets 1. Explai the basic co-emergece model of reiforcemet to the cliet 2. Egage cliet to evoke a distressig situatio 3. Use of guided imagery to iitiate arousal (closed eyes) 4. Use of Socratic questioig ad dowward arrow techique to elicit the Evaluatio compoets 5. Guide cliet through the 4 characteristics of body sesatios 6. Use timig sets of 30-secods) ad guidace to decrease arousal ad SUDS ratigs 7. Summarise the outcome ad use this uderstadig to egage the cliet i treatmet 29 Experietial delivery of the ratioale-cliet with Complex trauma/borderlie PD 41mi 30 MiCBT Istitute 15

18 Itroductio to MiCBT Neuroplasticity: Accoutig for Chage Neuroplasticity Defiitio The capacity of euros to adapt to a chaged eviromet (Fitzgerald & Fola-Curra, 2002) Hebbia Learig Each learig experiece stregthes euroal coectios Pre-syaptic termials chage i umbers accordig to usage 31 Neuroplasticity Research Semial study: Lazar et al. (2005) MRI study measured cortical thickess i 20 log-term midfuless meditators ad 20 matched cotrols. Cortical thickess was greater (P < ) i the prefrotal (BA 9/10), Right aterior isula ad right middle ad superior frotal sulci ad somatosesory cortices of the meditators relative to cotrols. These regios correlated with meditatio experieces Betwee-group differeces i prefrotal areas were most proouced i older adults, suggestig that midfuless might offset age-related cortical thiig Implicatios for demetia 32 MiCBT Istitute 16

Uilateral scaig 2. Bilateral scaig 3. Partial sweepig 4. Sweepig e masse 5.

19 Itroductio to MiCBT Somatosesory Networks ad Body-Scaig Techiques Areas 1, 2, 3 of the cortex ad the isula (located i limbic area) are cetral to iteroceptive awareess Areas 9, 10 are cetral to equaimity 1. Uilateral scaig 2. Bilateral scaig 3. Partial sweepig 4. Sweepig e masse 5. Trasversal scaig (From FitzGerald & Fola-Curra, 2002) 6. Sweepig i depth 33 (Adapted from FitzGerald & Fola-Curra, 2002) (Adapted from Baich, 1997, p.30) 34 MiCBT Istitute 17

20 Itroductio to MiCBT Somatosesory Cortex ad Body Scaig Techiques WEEK 1 WEEK 2 WEEK 3 WEEK 4 35 Neuroplasticity i Parkiso s Disease? 36 MiCBT Istitute 18

21 Itroductio to MiCBT Walkig retraiig: After 1 moth of midful walkig 37 Probability of practice 38 MiCBT Istitute 19

22 Itroductio to MiCBT 3 Exteralisig Stages of MiCBT 2. Exposure stage (approx 2 weeks) Graded exposure to avoided situatios 3. Iterpersoal stage (approx. 2 weeks) Uderstadig others by applyig oe s kowledge of midfuless to hadle others reactivity 4. Empathic stage (1-2 weeks) Developig empathy for oeself ad others 39 Stage 2 of MiCBT: Learig Exposure Skills SUDS 40 MiCBT Istitute 20

23 Itroductio to MiCBT Stage 2 of MiCBT: Learig Exposure Skills (Cot) Bi-polar Exposure I-vivo Exposure 5 miutes visualisa-o Worst case sceario 1 miute rest Midfuless of Breath 5 miutes visualisa-o Best case sceario Apply equaimity throughout the exercise 41 E.g.: Obsessive Compulsive Disorder 42 MiCBT Istitute 21

24 Itroductio to MiCBT E.g.: Avoidat Persoality Disorder 43 Explaiig Stage 2: Exposure (Cliet with Complex Trauma/Borderlie PD) 12mi 44 MiCBT Istitute 22

25 Itroductio to MiCBT Stage 3 of MiCBT Learig Iterpersoal Skills I Stage 3, the cliet is taught to use leart exposure skills to address iterpersoal issues while cotiuig to develop awareess ad equaimity with more advaced scaig techiques. Uderstadig ad acceptig others Not reactig to others reactivity Assertive commuicatio (verbal ad o-verbal) 45 Stage 3 of MiCBT (Cot) Experietial Owership 7 Statemets of Assertiveess Gettig attetio 1. Statig fact 2. Statig how I feel 3. Statig how I thik 4. Ackowledgig possible errors 5. Statig what I wat 6. Reward (cooperatio or attetio) 7. Fidig a wi/wi solutio (if o cooperatio) Role-play of expected iteractios I-vivo Exposure 46 MiCBT Istitute 23

26 Itroductio to MiCBT Theory Cogruece Iterpersoal Skills are i lie with the Co-emergece model of Reiforcemet 47 Case Coceptualisatio ad Treatmet Plaig with MiCBT 48 MiCBT Istitute 24

27 Itroductio to MiCBT Stage 4 of MiCBT Leaig Empathic Skills & Prevetig Relapse Compassio for self ad others (who is feelig it first?) Empathy is grouded i bodily experiece by pairig free flow of pleasat sesatios with positive affirmatios For oeself For loved oes For everyoe else Acts as coutercoditioig Empathy is also grouded i behaviour through adherig to 5 ethical challeges (as a experimet for 1 week): Prevetig: harmful speech, stealig, killig, itoxicatig, harmful sexual behaviour (out of compassio, ot guilt). 49 The Applied Course Brief Descriptio This week s homework Progressive Muscle Relaxatio (14mi) twice daily (see Week 1 istructios o CD 1 cover or i Chapter 2), Midfuless of the body (posture ad movemets, see Chapter 2) Read book chapters 1 to 4 You will receive a from the Istitute with istructios o how to log i ad access course resources ad Adobe Coect for weekly classes All iformatio about the course ad olie classes is o the Studets Applied Course page (logi required) 50 MiCBT Istitute 25

29 Iteroceptive Sigature Scale Istructios Use oe of the blak forms below to idetify your experiece of body sesatios o each of the four categories (Mass, Temperature, Motio, Cohesiveess). Whe you experiece a distressig evet, otice the body sesatios associated with it. The, as soo as you ca (either durig or soo after), represet the strogest sesatio i your body by placig a small dot o each of the four lies represetig a category of body sesatio. The joi each of the dots with a full lie. This is the distress lie. After focusig o the sesatio eutrally ad with acceptace for half a miute, place aother dot o each of the four categories to represet how you are experiecig body sesatios after practice. The joi those dots with aother lie (a dotted lie) to show ay chage. Record also the chage i itesity by placig a small dot o the straight lies. Date: Time: Brief evet descriptio: Mass Lightest Neutral Heaviest Temperature Coldest Neutral Hottest Motio Stillest Neutral Most movemet Cohesiveess Loosest Neutral Desest/tightest Itesity before Itesity after Least Most * * Least Most * * Date: Time: Brief evet descriptio: Mass Lightest Neutral Heaviest Temperature Coldest Neutral Hottest Motio Stillest Neutral Most movemet Cohesiveess Loosest Neutral Desest/tightest Itesity before Itesity after Least Most * * Least Most * * Date: Time: Brief evet descriptio: Mass Lightest Neutral Heaviest Temperature Coldest Neutral Hottest Motio Stillest Neutral Most movemet Cohesiveess Loosest Neutral Desest/tightest Itesity before Itesity after Least Most * * Least Most * * Copyright 2011 Bruo A. Cayou. May be reproduced for research ad cliical purposes

30 Date: Time: Brief evet descriptio: Mass Lightest Neutral Heaviest Temperature Coldest Neutral Hottest Motio Stillest Neutral Most movemet Cohesiveess Loosest Neutral Desest/tightest Itesity before Itesity after Least Most * * Least Most * * Date: Time: Brief evet descriptio: Mass Lightest Neutral Heaviest Temperature Coldest Neutral Hottest Motio Stillest Neutral Most movemet Cohesiveess Loosest Neutral Desest/tightest Itesity before Itesity after Least Most * * Least Most * * Date: Time: Brief evet descriptio: Mass Lightest Neutral Heaviest Temperature Coldest Neutral Hottest Motio Stillest Neutral Most movemet Cohesiveess Loosest Neutral Desest/tightest Itesity before Itesity after Least Most * * Least Most * * Date: Time: Brief evet descriptio: Mass Lightest Neutral Heaviest Temperature Coldest Neutral Hottest Motio Stillest Neutral Most movemet Cohesiveess Loosest Neutral Desest/tightest Itesity before Itesity after Least Most * * Least Most * * Copyright 2011 Bruo A. Cayou. May be reproduced for research ad cliical purposes

31 DIARY OF REACTIVE HABITS Fill i the boxes each time you ecouter a situatio that evokes a emotioal or stressful experiece SITUATION INTERNAL / EXTERNAL SENSORY PERCEPTION EVALUATION What actually happeed? How did (do) you kow this was happeig? What did it mea to you? DATE OF EVENT: TIME OF EVENT: What did you do to make yourself feel better? How did it make you feel to thik this way? INTENSITY OF DISTRESS: The % INTENSITY OF DISTRESS: Now % NAME: IN THERAPY SINCE (Date): REACTION / RESPONSE BODY SENSATION Copyright 2003 Bruo A. Cayou. May be copied for cliical ad research purposes. Writte permissio from the author is required for all other purposes.

32 Exteralisig skills Tasks Topics Iteralisig skills Stage 1: Persoal Midfuless traiig to develop experietial awareess ad acceptace of impermaece ad egolessess i all pheomea - Develop a sese of self-cotrol ad self-resposibility - Emphasis o commitmet to the practice ad trai i equaimity - Use daily schedule of practice ad iteroceptio forms Sessio 1- Progressive Muscle Relaxatio & Midfuless of body Sessio 2- Midfuless of breath Sessio 3- Part by part uilateral bodyscaig Sessio 4- Uilateral body-scaig without CD ad Applied practice usig Iteroceptive Sigature Form to moitor progress with equaimity Stage 2: Exposure Itroducig exposure procedures - Use of SUDS forms - Visualisatio of avoided situatios ad use of bi-polar exposure - imagiig worst ad best scearios while remaiig equaimous (mi x4) - I-vivo exposure to these situatios (SUDS items) Sessio 5- Symmetrical Scaig to wide iteroceptive awareess (Advaced Traiig CD) Fill i SUDS forms, bi-polar Exposure (BPE) ad i-vivo exposure (IVE) to 2 to 3 situatios o SUDS Sessio 6- Partial Sweepig to develop equaimity with subtle body sesatios ad associated emotios Review SUDS items Completig Stage 2: BPE ad IVE to the remaiig SUDS items Stage 3: Experietial Owership Stage 3: Iterpersoal Iterpersoal midfuless to uderstad others ad remai equaimous to their reactios - Use ew SUDS forms for iterpersoal avoidace - Experietial owership - Combiig midfuless skills ad assertiveess Sessio 7 Sweepig e masse for further detectio ad eutralisatio of emotioal memories ad accelerated europlasticity Review SUDS items Use the SUDS form to list iterpersoal items Use BPE ad IVE to implemet the 7 statemets of assertiveess i at least 2 iterpersoal situatios Stage 4: Empathic Livig ethically, coectedly ad compassioately - Directig attetio to others, prevetig relapse Sessio 8- Trasversal scaig (or sweepig e-masse if ecessary) ad Lovig Kidess meditatio Review Stage 3 SUDS items Exposure to midfuless-based ethical awareess ad coduct Sessio 9- Trasversal scaig ad Sweep i depth ad Lovig Kidess meditatio (without CD) Exposure to midfuless-based ethical awareess ad coduct Sessio 10 Program revisio ad evaluatio The 4-stage model of Midfuless-itegrated Cogitive Behaviour Therapy (MiCBT) from Cayou, B.A. 2011

Mindfulness-integrated CBT for trauma: Using the Mindfulness-based Interoceptive Exposure Task

Mindfulness-integrated CBT for trauma: Using the Mindfulness-based Interoceptive Exposure Task Midfuless-itegrated CBT for trauma: Usig the Midfuless-based Iteroceptive Exposure Task Bruo A. Cayou Topics Covered 1. The europheomeology of reiforcemet 2. The case coceptualisatio of avoidat behaviour