Download Where do we go from here? Developing a conceptual paradigm for

Where do we go from here?
Developing a conceptual paradigm for
the 21st Century
Dr Andrew Worthington
www.headwise.org.uk
Achievements
to date
• Functional vs syndrome-based approach
• Behaviour disturbance seen as situational
not dispositional
• Formulation rather than diagnosis
• Treatment focussed on learning methods
rather than drugs
• Emphasised importance of
transdisciplinary working
• Essentially a psychological rather than
medical approach
• Recognise organic basis to behaviour
disorder
• Focus on behaviour not psychometric
testing
“The literature concerning costeffectiveness of rehabilitation options is
poor in terms of both quantity and
quality.”
McKenna et al. 1992
“There is now a substantial body of highquality research evidence for the
effectiveness, and indeed the costeffectiveness, of rehabilitation.”
Turner-Stokes, 2008
What kind of
neurobehavioural
rehabilitation do we want?
What should be our aims?
By what means should we strive
to achieve them?
What values should we uphold
in so doing?
Therapeutic value of (positive)
reinforcement.
Conceptual
origins in
Behaviourism
(operant learning)
Importance of staff embracing
‘a general atmosphere of positivity’
and of adopting
‘a slightly over-effusive social
demeanour’
in order that contingencies of
positive reinforcement would be
more salient.
Eames (1988)
Social cognitive
theories
Self-efficacy
Expectations of reinforcement
determine how much effort and
persistence people demonstrate
to achieve an objective
(Bandura, 1977)
Improve learning by enhancing
self-efficacy
Selfinstruction
Language-mediated learning
Acknowledges the role of the
frontal lobes in verbal regulation
of behaviour, addressing some of
the attentional constraints on
learning.
Strategies to support positive
behavioural change in specific
learning environments
Ylvisaker et al.
Child sits at desk and is
shown marshmallow
– adult leaves the room.
Self-regulation
Told if they wait for adult to come back into the
room they can have two.
They can ring a bell at anytime and adult will
return to the room.
If child rings the bell, starts to eat sweet or
leaves the chair, they will receive only one
sweet.
Marshmallow
Test
(Mischel)
• As adolescents showed:
– Less distractible
– Less disruptive
– More confident and self-reliant
‘High delay’ in
pre-school
• As adults exhibited:
– Higher self-worth
– Lower BMI
– Better able to cope with frustration
and stress
– Different patterns of brain activity
in areas linked to addictions and
obesity.
Strategies
• Children waited longer if:
• Primed to think happy
thoughts beforehand
• Saw photograph only
• Imagined real sweet was a
picture
• Waited less time:
• Primed to think about the
sweet while waiting
• Reminded of how tasty it is
• Appetitive qualities
• Arousing, motivating
Hot vs Cold
thinking
– Gooey,
– sweet,
– chewy,
– melt in the mouth
• Descriptive qualities
• Cognitive, non-emotional aspects
– White,
– thick,
– square-like
Decision
making
Newcombe et al., 2011
Neuroanatomical correlates of regional apparent
diffusion coefficient in patients with behaviour
on Cambridge Gambling Task. Subcomponents:
(A) Risk adjustment, (B) impulsivity index,
(C) rational choices, (D) deliberation time.
“Men are not disturbed by things, but by the
view which they take of them”
Epictetus
Stoic
philosophy
“You have power over your mind - not outside
events. Realize this, and you will find strength”
Marcus Aurelius
• Remove the judgement, and you
have removed the thought ‘I am
hurt’: remove the thought ‘I am
hurt’, and the hurt itself is removed.
Stoic
philosophy
M Aurelius Meditations IV [7]
• Albert Ellis (REBT) + Epictetus
• RET:
– ‘Disputation’ irrational thoughts
– Action-oriented psychotherapy
– Focus on the present
CBT requires …
Brain injury causes …
Complex understanding
Reduced comprehension of abstract ideas
Introspection
Diminished self-awareness
Logical thinking
Impaired reasoning, rigid thinking
Articulate expression
Memory and conversation problems
Intellectual detachment
Emotional volatility
Motivation for change
Apathy
Conscious
intent to act
Nisbett &
Wilson
(1977)
– We are unaware of what influences
our behaviour
– Unaware we have modified our
behaviour
– Unaware of the one causing the other
Implications:
– The introduction of psychological
concepts must complement not
contradict basic behavioural
principles.
‘..there is little empirical support for
the role of cognitive change as
causal in the symptomatic
improvements achieved in CBT.’
(Longmore & Worrell,2007)
Behaviour activation is critical.
Pre-therapy
P1 P2 P3 N1 N2 N3
Therapy as
retrieval
competition
(Brewin 2006)
N4
Post-therapy
P1 P2 P3 N1 N2 N3 N4
P5 P6
Is positive psychology
the answer?
Eudaimonia - εὐδαιμονία
= Well-being, flourishing
Socrates: associated with virtue
(incl self-control)
• Very relevant to brain injury
rehabilitation
Evans (2011)
• Anecdotal evidence of value in
challenging behaviour after brain
injury.
Andrewes et al., (2014)
• Larger study needed
Cullen et al., 2016
Neurological basis of Eudaimonia
(insula)
Lewis et al, (2014)
Accentuate the
negative
‘negative
psychology’
• Focusing on things that
might go wrong leads to
preventative measures
• ‘Chronic unease’
• Constructive pessimism
• Action-oriented approach
Managing risks
Clinician
Likelihood of event occurring
Value attached to outcome
Client
By focussing on what can be done to
change a situation …
… the emphasis is on our ability to
change behaviour:
Action-oriented
approach
What we can do here and now
= focus on the present
“Men are not disturbed by things,
but by the view which they take of
them”
Epictetus
Present-focussed
behaviourally-based therapies:
• REBT (Ellis, 1955)
• ACT
– Observing Self (Self as context)
– ‘Creative hopelessness’
• Mindfulness
The absence of an operant framework
to cognitive therapies previously has
been criticised as promoting an
unhelpful form of dualism.
The
future?
Psychologically-based therapies are
likely to be increasingly behavioural.
Radical behaviourist post-Skinnerian
analysis of relations between language
and cognition.
Philosophically
grounded at last
Framework for integrating cognitive
neuroscience and technology with
philosophically-derived notions of the
Self in context.
This lends itself to both Positive and
Negative psychology constructs befitting
a focus on competencies, not
deficiencies, that fits current evidence
on primacy of Behavioural Activation as
means of promoting learning and
effecting change.