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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.