Yesterday was my second full day here in Amsterdam at the "Achieving Clinical Excellence" conference put on by the International Center for Clinical Excellence.  The first full day had been a workshop with Scott Miller on "Feedback informed treatment: pushing your clinical effectiveness to the next level".  This second day was the start of the conference proper and was entitled "Excellence: what do we know and what can we learn?".   I walked in from my hotel thinking that I'd be hard pushed to come up with a day of lectures that would interest me more than this exploration of what makes for clinical excellence.

I was particularly looking forward to hearing Professor Anders Ericsson speak on "What excellence requires".  Anders Ericsson is probably the world expert on what is involved in achieving excellence and his books are all time classics in this field.  For a short introduction to some of his key ideas, see his comments on "Expert performance and deliberate practice".  We were also due to have several presenters talking on the general theme of "What do we know about Supershrinks?" and then, after lunch, a choice of symposia on "Deliberate practice" and "Implementing feedback informed treatment".  Finally we were due to end with a brief keynote by Scott and performance by the magician Michael Ammar. 

More to follow ... 

I wrote yesterday about coming to Belfast for this two day BABCP spring meeting.  So how was the workshop I attended with Professor Arnoud Arntz talking about schema therapy for personality disorders?

Points to possibly enlarge on:

Where is this treatment compared with other psychotherapies for borderline (and comments about how widespread borderline is)?

Key issue of the prevalence & therapeutic relevance of personality disorders more broadly ... and the possibility too that schema therapy might be useful for chronic "Axis I" disorders as well.

The overlap with, for example, compassion-focused and emotion-focused therapies ... and narrative therapy to an extent as well ...

The huge issue about "limited re-parenting" 

My own "needs-beliefs-behaviours" model

The path coefficients slide linking child abuse in different forms to different personality disorders.

The flight/fight/freeze triad ... links to temperament ... and links to basic physical responses to threat

The usefulness of the schema mode map

Note links between various coping modes and various personality disorders

Note the relevance of the "impulsive/undisciplined" child and protector & over-compensating modes

Value of validating the intention behind currently maladaptive coping modes ... and the value of the "fighting spirit" behind over-compensating modes ... but the importance of upgrading the responses to help them fit current life circumstance.

How assess & monitor progress in personality disorder treatment? 

More to follow ...

Now it's two days of the British Association for Behavioural and Cognitive Psychotherapies (BABCP) Spring Workshops and Conference. 

BABCP details for this Spring conference workshop are: Schema  Therapy (ST) developed from CBT as it is applied to axis-I disorders. In trying  to apply ordinary CBT techniques to axis-II disorders, clinicians experienced  limited effects. The developers of ST therefore started to develop new methods  and to integrate techniques derived from other models, including attachment  theory, CBT and experiential (especially Gestalt Therapy).   Instead of being an eclectic approach, ST  aims to offer an integrated method based on the cognitive (schema) model of  psychopathology. Like the early learning theories, ST assumes that people have  basic needs, which drive their behaviour, and that when these needs are not  adequately met, psychological problems develop. When basic needs are not  adequately met in children, dysfunctional schemas and coping strategies develop  that may lead to personality disorders. For severe psychopathology like  personality disorders, ST uses the concept of schema mode, which refers to the  moment-to-moment state of the individual, characterized by typical combinations  of emotions, cognitions (schema content), and behaviour. Schema Mode models  have now been developed and tested for almost every personality disorder, and  help patient and therapist to understand the strong moment-to-moment changes  personality disorder patients often experience, and to choose the appropriate  technique to address the mode that is activated during the session.  

Learning  objectives
1.  to understand and apply the schema mode model of BPD, so  that BPD-symptoms  and behaviours  can be understood
2.  communicating the mode model to patient
3.  to be able to detect the mode  the patient is in, and choose appropriate techniques, eg    overcoming  coping modes (overcompensating avoidance, surrender); treating vulnerable child modes (imagery  rescripting and caring part of the therapy relationship);  dealing with angry and impulsive child modes, treating dysfunctional parent modes (demanding, punitive, eg  via chair dialogues);strengthening healthy adult  mode (implicit and explicit techniques)
4.  to be able to choose focus and  type of technique according to the phase of therapy

Implications  for the everyday practice of CBT:
Schema  Therapy has now been tested as a treatment for cluster-C, cluster-B, and  paranoid personality disorder, and effects are often very favourable compared  to other approaches. New applications include personality disordered patients  in high security forensic hospitals, and group-ST which seems to be especially  effective in Borderline PD. Evidence from recently completed and preliminary  evidence from running trials will be presented. The results indicate that  Schema Therapy is an effective and cost-effective treatment. Neuroscience  studies suggest that Schema Therapy not only leads to symptomatic change, but  also to changes at deep brain levels, where emotional responsivity is  regulated.  Applications of ST in some Axis  I disorders and with milder personality issues are being developed and it is  argued that it helps to address some limitations of CBT working with recurrent  problems in intimate relationships and with processing memories and behaviour  patterns from childhood.

Arnoud Arntz studied Physics and Mathematics as  well as Psychology  at the University of  Groningen. He completed his PhD on psychological aspects of pain at the  University of Maastricht. In the same period he participated as therapist and  researcher in the establishment of the academic Experimental Psychopathology  unit at the Maastricht Community Mental Health Center.  He was appointed as full professor in  2000 and scientific director of the research institute of Experimental Psychopathology  in 2001. With Marcel van den Hout he is chief editor of the Journal of Behavior  Therapy and Experimental Psychiatry. His fields of interest are the  experimental study of pain, anxiety disorders and personality disorders, with a  special interest in investigating information processing in these areas.

References:
1. Arntz, A. & Jacob, G. (2012). Schema Therapy in  Practice: An Introductory Guide to the Schema Mode Approach. Wiley-Blackwell
2.  Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van  Asselt, T., Kremers, I., Nadort, M., & Arntz, A. (2006). Outpatient Psychotherapy for Borderline Personality Disorder.  Archives of General Psychiatry, 63, 649 - 658.
3. Young,  J.E., Klosko, J., & Weishaar, M.E. (2003). Schema  Therapy: A Practitioner's Guide.  New York : Guilford .

More to follow ...

Well here's a good example of being taught by our patients.  I've had two or three people, who come to see me, singing the praises of the C25K NHS website.  The site states that "Our C25K plan is designed to get just about anyone off the couch and running 5km in nine weeks."  That looks good ... and both my patients and the numerous appreciative comments on the C25K website underline how helpful people have found the written advice and more especially the downloadable MP3 podcasts that are to be used when running.  

The site's general introduction comments "Taking up running can seem like a scary prospect, especially if you feel out of shape or unfit.  But, did you know that regular running can help reduce the risk of chronic illnesses such as heart disease, type 2 diabetes and stroke, boost your mood and
keep your weight under control?"  Actually that ain't the half of it!  If you click on "exercise" in this website's tag cloud, you bring up a list of over 50 blog posts on the benefits of exercise.  Standouts include the somewhat stark "15 minutes of exercise daily reduces mortality by 14% - and each additional 15 minutes gives 4% additional mortality benefit" with its comment "So for happier mood, less disease risk, a better sex life, improved cognitive function, and a longer life - let's get exercising!".  Physical fitness is quite possibly the single most important lifestyle factor people can focus on to improve the quantity and quality of their lives.  Steven Blair's article "Physical inactivity: the biggest public health problem of the 21st century" demonstrates " ... low cardiorespiratory fitness accounts for about 16% of all deaths in both women and men in this population, and this is substantially more, with the exception of hypertension in men, than the other risk factors (obesity, smoking, high cholesterol, hypertension, & diabetes)".  And additionally we know of the "Association of enjoyable leisure activities with psychological and physical well-being".  On this website, it's worth visiting the six part series: "Exercise 1: checking it's safe to start", "Exercise 2: UK Department of Health, resources for assessment & advice", "Exercise 3: US Department of Health & Human Services, resources for assessment & advice", "Exercise 4: pedometers can help us walk more", "Exercise 5: the recommendation to do strengthening exercises" and "Exercise 6: where can I do what?".  Also useful is the handouts page "Exercise & light".

So I'm a big fan of exercise's value ... and it's great that the free NHS C25K website is a helpful additional resource for people wanting to exercise more.  The site contains a general introduction to the nine week programme, a good week by week overview of what the runs involve, tips for new runners, a section called how to run correctly, the opportunity to join supportive discussion groups, helpful links to other running websites, and much more.  Good stuff.  Most of my own exercise is via cycling, badminton, dance & hill walking. I have typically just used running as "bread & butter" exercise to underpin what else I do.  For a long time now, I have been going out and jogging for about 15 minutes before breakfast on three mornings a week.  I thought it would be interesting to use the C25K programme to try pushing this up to 30 minutes three times a week.  I have now reached week nine, the final week of the programme, and am about to head out for a 30 minute run.  It's been fun and has been made much easier with the support of the downloadable programme MP3 podcasts. If you're tempted, do give it a try!

"My father considered a walk among the mountains as the equivalent of churchgoing."    Aldous Huxley

I'm a member of a therapists' Emotion-Focused Therapy (EFT) support group.  We have been meeting every month or two for a while to talk about and practise using EFT methods.  I wrote about this last month in the post "Therapeutic cross-breeding: EFT's approach to self-interruption splits applied to outdated coping modes in schema therapy".  Although my primary training is in cognitive therapy I've mentioned before that therapists seem to be more likely to thrive, maintain their enthusiasm, and help clients to better outcomes, when they stay theoretically broad & integrative in their approach - see "Orlinsky & Ronnestad's 'How psychotherapists develop': three key recommendations for maintaining effectiveness".  It is noteworthy too that in the most recent comparative reviews, higher process-guiding humanistic-experiential therapies like emotion-focused approaches have been shown to achieve slightly greater outcome effect sizes than CBT comparison approaches ... see the 2013 edition of the classic "Handbook of psychotherapy and behaviour change".  Yesterday evening our EFT group met, caught up, talked about using EFT, and then ... for the second half of the evening ... we practised using the EFT "empty chair" method for working on "unfinished business".  This is well described in Elliott, Watson, Goldman & Greenberg's helpful book "Learning emotion-focused therapy" (pp. 243-265) and there is web information too.  Here's a very busy diagram that I use as an aide-memoire: 



                                                (this diagram is downloadable as a Powerpoint slide or as a PDF file)

I do like Emotion-Focused Therapy.  I like the way it prioritises emotion ... how we feel is so central to the quality of our lives.  I like the "roll up our sleeves & get speaking from our hearts & guts" style.  I like the way that EFT's focus on feelings fits so well with the much broader, across different schools of psychotherapy, understanding that for lasting therapeutic change we often need to drop down under standard chatty conversations into the underground rivers of feelings.  And I very much like the way that EFT tries to test its theories with research.  So for example, with empty chair work there are at least a couple of studies: Paivio & Greenberg's "Resolving "unfinished business": Efficacy of experiential therapy using empty-chair dialogue" with its abstract reading "In this study, 34 clients with unresolved feelings related to a significant other were randomly assigned to either experiential therapy using a Gestalt empty-chair dialogue intervention or an attention-placebo condition. The latter was a psychoeducational group offering information about "unfinished business." Treatment outcomes were evaluated before and after the treatment period in each condition and at 4 months and 1 year after the experiential therapy. Outcome instruments targeted general symptomotology, interpersonal distress, target complaints, unfinished business resolution, and perceptions of self and other in the unfinished business relationship. Results indicated that experiential therapy achieved clinically meaningful gains for most clients and significantly greater improvement than the psychoeducational group on all outcome measures. Treatment gains for the experiential therapy group were maintained at follow-up." and Greenberg & Malcolm's "Resolving unfinished business: Relating process to outcome" with its abstract "This study related the process of the resolution of unfinished business with a significant other to therapeutic outcome in a population of 26 clients who suffered from various forms of interpersonal problems and childhood maltreatment. Clients were treated in emotion-focused, experiential therapy with gestalt empty-chair dialogues. Those clients who expressed previously unmet interpersonal needs to the significant other, and manifested a shift in their view of the other, had significantly better treatment outcomes. The presence of the specific process of resolution in the clients' empty-chair dialogues was also found to be a better predictor of outcome than the working alliance. Degree of emotional arousal was found to discriminate between resolvers and nonresolvers."

Emotion-Focused Therapy's careful exploration of two chair work on conflict splits has informed a whole series of other therapies ... for example Compassion-Focused Therapy and Schema-Focused Cognitive Therapy. I don't think other therapy school however have picked up so well on EFT's teaching on empty chair work on unfinished business. I think I've been lax myself.  I'm confident that quite a few of the therapy conversations I've had with clients over the last few years ... especially about their relationships with their parents ... might well have benefitted if I'd encouraged the moving into empty chair/unfinished business work more.  This is probably especially the case when the conversations have felt rather "heady" & poorly linked to feeling.  Last month's post on self-interruption is relevant here too as I find it usual that when clients have "criticised" their parents (often for deeply understandable reasons) they pretty soon start to have second thoughts about the validity of their remarks.  I think this self-interruptive process could often benefit from being explored as a dialogue as well. 

And we then went on in the second half of the evening to practise these techniques on ourselves.  In the pair that I worked in I volunteered to be "client" while my colleagues took the therapist role.  I decided to talk to my father (who died 24 years ago) ... hence the quote at the start of this blog post.  I haven't explored dialogue work with my dad before.  He was a very fine man ... as with so many of his generation, not particularly emotionally literate ... but a very good man and a loving committed father.  One of my regrets is that he & I didn't talk deeply about our feelings.  I don't think he really knew how to.  As I've discussed in the past, this kind of imagined dialogue work recruits many similar brain areas to when one is involved in real behaviour ... and it connects richly too to emotion.  Fascinating to feel the powerful difference between chatting about my relationship with my dad (which I've done many times over the years with friends) and actually speaking with him in this dialogue format.  Great to feel this kind of thing from the inside.  I think in CBT training we often don't get into the experience like this enough.  It reminds me of my friend James Bennett-Levy's research ... for example, his paper "Acquiring and refining cbt skills and competencies: Which training methods are perceived to be most effective?" with its abstract reading "Background: A theoretical and empirical base for CBT training and supervision has started to emerge. Increasingly sophisticated maps of CBT therapist competencies have recently been developed, and there is evidence that CBT training and supervision can produce enhancement of CBT skills. However, the evidence base suggesting which specific training techniques are most effective for the development of CBT competencies is lacking. Aims: This paper addresses the question: What training or supervision methods are perceived by experienced therapists to be most effective for training CBT competencies? Method: 120 experienced CBT therapists rated which training or supervision methods in their experience had been most effective in enhancing different types of therapy-relevant knowledge or skills. Results: In line with the main prediction, it was found that different training methods were perceived to be differentially effective. For instance, reading, lectures/talks and modelling were perceived to be most useful for the acquisition of declarative knowledge, while enactive learning strategies (role-play, self-experiential work), together with modelling and reflective practice, were perceived to be most effective in enhancing procedural skills. Self-experiential work and reflective practice were seen as particularly helpful in improving reflective capability and interpersonal skills. Conclusions: The study provides a framework for thinking about the acquisition and refinement of therapist skills that may help trainers, supervisors and clinicians target their learning objectives with the most effective training strategies."

And I think it was no accident that ... after my brief immersion in personal experience of dialogue work ... the next day was particularly precious in my work with clients.  I was more ready to dip under conversations into deep feeling and it certainly seemed that this hugely benefitted the therapeutic work I did. Fascinating and worthwhile ... both the way that dialogue methods can take us deeper, and the way that therapists exploring methods for themselves can encourage and enrich the way we use the methods for our clients.

Yesterday I wrote the blog post "A day spent 'idle & blessed': revisiting an experiment - savouring & positive state mindfulness" describing walking out on a lovely Spring day to wander for eight hours with no real plan, open to what emerged.  I had a dictaphone with me and occasionally I spoke into it.  I've jotted down what I said and added a few further notes:

"Layers of psychological distance or closeness ... so I can be quite personal ... think ... have the thought ... "Ah, here I am 63 in a couple of days' time and I could be retired, I could be going on these walks every day if I wanted before breakfast" and, laughing, the thought comes "Oh I'd be sad if I wasn't working, be sad if I had the space to do this every day, if that was ‘all' that was there for me to do".  And I ask myself ... layers! ... "Am I thinking that, making a virtue of necessity, it would be hard to retire.  Psychotherapists aren't rich."  And tumbling down into "What's the truth of this?  How do I feel about my life?  Standing here up in the Pentlands.  When I ask myself.  If I tumble in ... if I drop that pebble down "I feel absolutely totally content with my life in every way."  And I drop that down the well of my being just to see what ripples it produces and there was a splash of sadness ... and a glow ... a glow ... is that the right word? ... a warmth, gentle light ... and ... "I feel totally happy about every aspect of my life" ... "Gosh, I'm so deeply grateful that I've had this last year ... deeply grateful that I might have another year."  Kind of, in my chest, that joyful sense of tears of gratitude.  Like a burn, a Scottish stream tumbling down the slopes in the sunshine.  Tears and happiness.  Tears and joy.  "I feel totally happy.  Totally satisfied.  Totally content.  Completely at ease.  Totally one.  I don't know ... with every aspect of my life."  Gratitude ... warm gratitude in my chest.  And that lovely Shunryu Suzuki "To stretch out our arms and legs as wide as possible.  Breeze cool on my face and curlews calling.  Dance of the time I give to competence and the time I give to relatedness.  Birds, beautiful birds singing.  Gratitude.  Wanting to live ... still that appetite for living ... happiness."

"And another layer.  The layer of stepping back and thinking "How well my father knew these hills.  How he would come out in the bus as a young man."  He told me "He would come out in a bus and then walk in the hills maybe all day and then catch a bus back to Morningside or wherever he was living (he'd been in Morningside as a child)."  Generations.  And in a few hours, aiming to be at the station to meet my own son up for the weekend from London for my birthday."

"And stepping back further than that.  Here in the dry heather ... calls of the curlews again, trills, falling ... it's so beautiful in the sunshine ... the lambs ... the skylarks.  Being with this like everyman, everywoman ... on a hillside ... in the beauty of this world.  Aware.  And that old Christian thing of "We're here to praise God."  And at some level, we're here to see the lark falling, tumbling down.  Here, everyman, everywoman ... to cry with the ... tenderness of it.  Hmm ... impersonal there ... generations of that ... thousands of years of that ... just humans like that ... animals like that ...  present in the world ... feeling its body moving through this landscape ... grateful to be alive ... and that's just a feeling of muscles moving under fur, under skin, under hair.  Aagh.  Poetry and song.  e e cummings  "I thank you God for most this amazing day: for the leaping greenly spirits of the trees, and a blue true dream of sky; and for everything which is natural which is infinite which is yes".  And looking up at the blue sky and the skylark just pouring down this song.  Laughing ... that's the only way I can respond.So that slight fear of looking down the well, of feeling down the well, when I didn't know what I might find ... fear, anxiety ... yeah ... know that one ... and also ... this thing of being and doing ... and the Seligman, Peterson, wasn't it, mm, ways of being ... so meaning, engagement and savouring/hedonism ... and needing a bit of all of them, and how I've got meaning and engagement, not a lot of hedonism ... and how good it is to have a taste of savouring ... it's almost gives another meaning for that amazing childhood end of winter term experience ... that little boy mesmerized by the final lesson of the nine lessons and carols ... "There was a man sent from God.  His name was John.  He was not that light, but he came to bear witness of that light" and a feeling then that I wanted to be a missionary ... seeing it very much as preaching, missionizing ... and in a way as a doctor, as a therapist, there's some taste of that, trying to work to ease problems, to share what's good ... but bearing witness to the light is here, with the amazing calls of the skylarks and the curlew and the sunlight on the hills ... this is bearing witness to the light as well.And there's also the image of doing ... of the well trodden path that allows me to move fast and effectively ... get so much done ... and the being more off track ... how it's slower walking through the heather off the track and ... different ... like the Country of Marriage quote" (from the Selected Poems of Wendell Berry):

Sometimes our life reminds me
of a forest in which there is a graceful clearing
and in that opening a house,
an orchard and garden,
comfortable shades, and flowers
red and yellow in the sun, a pattern
made in the light for the light to return to.
The forest is mostly dark, its ways
to be made anew day after day, the dark 
richer than the light and more blessed,
provided we stay brave
enough to keep on going in.

 

" ... don't know that it's better, but it's complementary."

"Noticing as a I walk right down along, right down by the shore of a reservoir, along the pebbles just by the water ... that I've never done before here in these local Pentlands ... I notice myself feeling "Oh I'd like to share this too with the family ... I'd like to share this walk."  And it's lovely to be alone like this, by choice, and it's also true that shared pleasures tend to be even more joyful.  Is that true?  Is that true for me?  It's the general finding, but actually being moved by tears of joy ... being with other people can sometimes distract me from that, so I'm not sure I totally agree, but I think there's a lot of truth in it.?  At the moment? that fun coming into the day as I gradually take off layers of jerseys and hats and gloves ... arriving in the day ... snuggling in."

"Following a series of whims ... "There are no paths.  Paths are made by walking."  So that's what a curlew looks like ... (laughing) ... "Flip, flip, flip, flip, flip, flip ... wings flip flipping ... crisscrossing over the landscape ... a pair."

"Thinking ‘Oh I've never been there' ... so going there ... or ‘I wonder what that is ... what it's like up there?" ... so going there."  Curiosity. Is it really the most common positive emotion?  Memory of the yellow-covered book about this (It's Todd Kashdan's "Curious? Discover the missing ingredient to the fulfilling life."  The dust jacket states "Dr Todd Kashdan offers a profound new message missing from so many books on happiness: the greatest opportunities for joy, purpose, and personal growth don't, in fact, happen when we're searching for happiness.  They happen when we are mindful, when we explore what's novel, and when we live in the moment and embrace uncertainty.  Positive events last longer and we can extract more pleasure and meaning from them when we are open to new experiences and relish the unknown."   That image I know so well of climbing up into the Pentlands from Swanson and now Bonaly ... and like looking up and over a garden wall ... suddenly you're looking out into country ... one ... two, three ... four, five, six ... seven ... eight Pentland tops stretching away.  I can see why my father ... why it was good for his soul ... and mine.It's now about to ten in the morning ... nearly four hours since I left the house ... could have been here in about an hour on a mountain bike, maybe a couple of hours if I'd been pushing with the walking ... it's been nearly four, strolling & sitting ... mm ... paths I've never walked ... paths I've never walked before in the Pentlands."

"Under a sky thick with skylarks."

"Seeing a runner coming along the ridge makes me realise that I haven't seen a soul for over an hour ... here, just outside Scotland's capital city."

More to follow ...

Gilbert, P., K. McEwan, et al. (2008). "Feeling safe and content: A specific affect regulation system? Relationship to depression, anxiety, stress, and self-criticism."  "Recent work in the neuroscience of positive affect has suggested that there may be two different types of positive affect. One is linked to a drive/seeking system (and may be dopaminergic mediated) and the other is a soothing-contentment system (and may be opiate/oxytocin mediated). This study sought to develop a self-report scale that could tap these positive affects in regard to characteristic feelings individuals may have. Results from 203 students suggested three (rather than two) underlying factors: activated positive affect, relaxed positive affect, and safe/content positive affect. It was the safe/content positive affect that had the highest negative correlations with depression, anxiety and stress, self-criticism, and insecure attachment. Hence, greater clarity on the different types and functions of positive affect may demystify the relationship between positive emotions and well-being."

Luke, M. A., C. Sedikides, et al. (2012). "Your love lifts me higher! The energizing quality of secure relationships"  "Three studies tested and confirmed the hypothesis that secure attachment relationships lead to feelings of security and energy, as well as willingness to explore. In Study 1, priming a secure attachment relationship increased felt security and energy. In Studies 2 and 3, felt energy mediated the effect of (primed) secure attachment relationships on willingness to explore. In Study 3, the effect of (primed) secure attachment relationships on felt energy and willingness to explore was independent of general positive affect. Secure attachments energize partners, thus enabling exploration."

Feeney, B. C. and R. L. Thrush (2010). "Relationship influences on exploration in adulthood: The characteristics and function of a secure base."  

"This investigation advances theory and research regarding relationship influences on exploration in adulthood. This is accomplished by (a) identifying important characteristics of a secure base, (b) examining the influence of the presence or absence of these characteristics on exploration behavior in adulthood, and (c) identifying individual-difference factors that are predictive of the provision and receipt of secure base support. In 2 sessions, married couples (N = 167) provided reports of relationship dynamics involving exploration, and they participated in an exploration activity that was videotaped and coded by independent observers. Results indicated that the 3 identified characteristics of a secure base (availability, noninterference, and encouragement) are strongly predictive of exploration behavior, and that the provision and receipt of these behaviors can be predicted by individual differences in attachment. Implications of results and contributions to existing literature are discussed."

Last September I went back to Cambridge for a reunion ... the first time I'd ever been back to school or university for such a thing.  It was an experiment in "emotional archaeology" and I wrote a series of blog posts about it.  At one stage I experimented with a dialogue between the 22 year old and the current 62 year old versions of me.  In the post "Going back for a university reunion: self-esteem, hallucinogens, wonder & the transpersonal", I wrote "I changed subject too from philosophy to medicine (in 1970).   Life speeded up and gradually I see now that so much of that wonder, that waking to be "blessed", so much of that has ebbed away in the course of what has in many other ways been a life that I have felt immensely grateful for.  And in the acted out dialogue between my younger and my current self, that's what emerged. A reminder of what I had forgotten."  In the last post of the sequence - "Going back for a university reunion: emotional archaeology unearths a treasure trove of insights & new directions" - I talked about a whole series of fascinating possibilities that had emerged from revisiting the past like this.  One comment I made was: "How about the reminders from my student to my current self?   There's potentially an awful lot here.   Options include ... experimenting with taking a day every so often when I explore "just being", a bit as I did in those old ecstatic pilgrimages to Trinity Fellows Garden.   I want to remember Mary Oliver's words "I don't know exactly what a prayer is. I do know how to pay attention ... how to be idle and blessed, how to stroll through the fields, which is what I have been doing all day. Tell me, what else should I have done? Doesn't everything die at last, and too soon? Tell me, what is it you plan to do with your one wild and precious life?" I intend to explore making more time for "strolling through the fields ... all day ... (in this) one wild and precious life." 

And at the end of November I followed up this idea, spending a day "drawn like blown cloud" around Edinburgh.  I wrote about it in the post "A day spent 'idle & blessed': report of an experiment".  It was precious ... "An experiment with 'being' in this surging, so appreciated, sea of 'doing'" ...  and yesterday I revisited the experiment.  I was immensely lucky.  After a wet, cold Spring, this mid-April day was stunningly beautiful.  Especially early on.  My son & his girlfriend were arriving from London by rail at a bit after two in the afternoon.  I wanted to be out for eight hours or so and get back to meet them.  The maths was straightforward.  I left the house just after six in the sun-drenched dawn.

It's a funny one, writing about this kind of personal experience.  This blog is primarily here to be helpful ... "An evidence-based blog on stress, health & wellbeing" ... and although most of what I write about is at-emotional-arm's-length research based information, many people have told me that they appreciate the posts that mix the personal with the evidence base.  In fact some people have commented that these are the posts that they find most useful.  So be aware of what's on the tin here.  This is a series of remarks I made into a dictaphone while I was on the walk, and a bunch of added facts & figures put in the next day. 

"So looking out ... starting a little after six in the morning ... and it's just an amazing day ... I can't see a single cloud in the sky."

"Thoughts of those who've died ... my mother just over three years ago, my father nearly quarter of a century ago, friends, my own death ... nearly ... a year ago.  And now, sitting on a great fallen tree trunk in the sunshine having breakfast, listening to the birds ... "mixing memory and desire" ... no, much better than that ... beginning to melt a bit ... allowing the out breath."

"Still early in the morning, walking up by Bonaly Primary School and I see three quotations on a long glass partition that of course I've never noticed when going past in a car.  "Happy hearts and happy faces, happy play in grassy places.  That was how in ancient ages, children grew to kings and sages."  Robert Louis Stevenson.  And "Education is the leading of human souls to what is best, and making what is best out of them."  John Ruskin.  And "Learning is a treasure that follows its owner everywhere." Chinese proverb.  Lovely.  Particularly nice that it's quite subtle (the writing on the glass).  I can imagine if I'd gone to that primary school ... yeah ... it would have touched me.  Nice. "

And I head on up the hill, stopping by Bonaly Tower to stroke a huge ginger cat, and ... instead of following my usual route (veering left up the hill), I turn right to Torduff Reservoir, walk along the side of it, and then come back up to Bonaly Reservoir, and from there to Capelaw Hill and Allermuir.  

"Interesting this taking the track unknown or less known.  I can feel myself beginning to fall asleep psychologically on the well known tracks and then following that gentle impulse to go to places that I hardly know or don't know at all ... I wake up a little bit more ... and it's a beautiful morning."  I've noted Ritchie & Bryant's 2012 study before ... "Positive state mindfulness: A multidimensional model of mindfulness in relation to positive experience" ... with its finding that three factors seem to particularly link mindfulness to positive experience - "Focused Attention, Novelty Appreciation, (and) Open-Ended Expectations."  In the blog post "Ways to happiness and life satisfaction" I wrote about the particular importance of "Engaged" and "Meaningful" life orientations, but I also highlighted the value for overall life satisfaction of being able to "stop & smell the flowers" ... that one can appreciate and feel pleasure & joy.  If you want to see how you score on these three life components, try the "Approaches to happiness" questionnaire on Martin Seligman's website.  In "Orientations to happiness and life satisfaction: The full life versus the empty life" Peterson & colleagues wrote "Different orientations to happiness and their association with life satisfaction were investigated with 845 adults responding to Internet surveys. We measured life satisfaction and the endorsement of three different ways to be happy through pleasure, through engagement, and through meaning. Each of these three orientations individually predicted life satisfaction. People simultaneously low on all three orientations reported especially low life satisfaction. These findings point the way toward a distinction between the full life and the empty life."  Or as the Christian mystic Angelus Silesius put it rather more confrontingly "All in good time we shall see God and his light you say.  Fool you shall never see what you don't see today."  And, more gently, Lao Tzu's "Who will prefer the jingle of jade pendants if he once has heard stone growing in a cliff?" 

I do find Richie & Bryant's study on "Positive state mindfulness" intriguing.  In the post "Mindfulness during daily activities: is it helpful to vary the proportions of the five facets?" I wrote "To me, mindfulness during daily activities seems to have different flavours at different times.  I wonder if this is useful, if varying the flavour depending on the situation can be helpful?" and I gave three contrasting examples from the previous three days.  There are fascinating cross-connections here ... mindfulness, wonder, joy, openness, inner quietness, exploration.  That classic passage from the King James version of St Matthew's gospel "At the same time came the disciples to Jesus, saying, Who is the greatest in the kingdom of heaven?  And Jesus called a little child to him, and set him in the middle of them, And said, Truly I say to you, Except you be converted, and become as little children, you shall not enter into the kingdom of heaven."  And the New International version is even simpler "Truly I tell you, unless you change and become like little children, you will never enter the kingdom of heaven."  Simplicity, inner quiet, wonder, joy.  I remember at university slipping into gentle ecstasy eating a bowl of muesli in the sunlight.  What is this deep connection?  How does this depth of being fit into a life full of doing?  T. S. Eliot's poem "Four quartets":

"We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
...
The voice of the hidden waterfall
And the children in the apple-tree
Not known, because not looked for
But heard, half-heard, in the stillness
Between two waves of the sea.
Quick now, here, now, always—
A condition of complete simplicity
(Costing not less than everything)"

... and the next post is "A day spent 'idle & blessed': revisiting an experiment - reviewing life balance."

Nearly four years ago I wrote a blog post "Assessing attachment in adults" where I discussed this field and gave more details of the 36-item "Experiences in close relationships - revised (ECR-R)" questionnaire.  Despite the ECR-R being much easier to administer than (related but different) heavyweight methods like the Adult Attachment Interview, I haven't regularly used it over the years - quite largely because answering & then scoring 36-items for a series of different relationships is pretty time-consuming. 

My interest in attachment has continued, it informs many aspects of my work as a therapist, and I frequently talk about it with clients - for example when linking to the importance of self-compassion or the potential value of schema-focused cognitive therapy.  There are a series of downloadable handouts on attachment towards the bottom of this website's "Good knowledge" page on "Relationships, families, couples & psychosexual".  Additionally clicking on the search tag "attachment" will bring up several pages of relevant blog posts including one entitled "Some great attachment websites" which opens a door onto the sea of internet information we can reach out to.

One of the great attachment websites I revisited recently is Professor Chris Fraley's at the University of Illinois.  It's very good ... informative, witty, generous and fascinating.  Taking a journey through the website I looked again at his 2011 paper "The Experiences in Close Relationships-Relationship Structures questionnaire: A method for assessing attachment orientations across relationships" with its abstract reading "Most research on adult attachment is based on the assumption that working models are relatively general and trait-like. Recent research, however, suggests that people develop attachment representations that are relationship-specific, leading people to hold distinct working models in different relationships. The authors report a measure, the Relationship Structures questionnaire of the Experiences in Close Relationships-Revised (ECR-RS; R. C. Fraley, N. G. Waller, & K. A. Brennan, 2000), that is designed to assess attachment dimensions in multiple contexts. Based on a sample of over 21,000 individuals studied online, it is shown that ECR-RS scores are reliable and have a structure similar to those produced by other measures. In Study 2 (N = 388), it is shown that relationship-specific measures of attachment generally predict intra- and interpersonal outcomes better than broader attachment measures but that broader measures predict personality traits better than relationship-specific measures."

Now the ECR-RS questionnaire does look very interesting.  It is only 9-item so it makes assessment of attachment style across a series of relationships much more feasible.  Here is a downloadable Word version of the ECR-RS and here a PDF version.  I have also put together a score chart downloadable as a Powerpoint slide or as a PDF diagram.  Having the questionnaire on one side of A4 is useful, but sacrifices space that could have been used to explain the scale a bit more fully.  Downloading a copy of this blog post could help as an additional handout. 

So when filling in the questionnaire, note that there are five columns - "m" for mother (or a mother-like figure), "fa" for father (or father-like figure), "p" for current (or former) romantic partner, "fr" for best friend (or close friends more generally).  When relevant the "th" column can be used for a relationship with a psychotherapist.  A query that people filling in the questionnaire sometimes raise with me is the time period that it refers to - specifically in relationship with one's parents.  I suggest answering primarily thinking about how it was in childhood.  Often there isn't a big difference between answers for childhood and answers that describe the relationship across adulthood as well.  If you want to, you can answer for both and compare the scores to see what has changed and what hasn't.

Fraley comments that there is a tendency for scores for partner and friend to resemble each other a bit, and for mother and father to resemble each other a bit (although avoidance scores tend to be higher for fathers).  I have added a column for "therapist".  This is sometimes helpful to assess in my work, particularly when a client has known me for some time.  Fraley comments that one can use the ECR-RS with a wide variety of relationships including siblings, teachers, God, and pets (although one might need to leave out some of the questions with pets!).  Interestingly what look like similar answers may not mean exactly the same across different relationships. So - for example - I might "strongly disagree" that "I worry that this person won't care about me as much as I care about him or her" with both my mother and my therapist.  However with my mother it might be because I feel very secure about her love, while with my therapist it might not be a concern because it simply doesn't matter to me as much.  As a therapist I find using the ECR-RS of considerable potential help as one can compare, contrast and work directly with the scores the client gives for their relationship with me and the scores they give for other relationships like their mother and father.

The maths of working out the average scores is slightly clunky.  Note that one answers items 1 to 4 using the 1 to 7 scale, but then reverse scores each item by subtracting the initial score from 8 to get the final score.  Average avoidance is calculated by adding the answers for items 1 to 6 (with 1 to 4 reverse scored) and dividing the total by 6.  Average anxiety is calculated by adding the answers for items 7 to 9 (no reverse scoring here) and dividing the total by 3.  One can then record attachment avoidance & anxiety for each relationship over the page on the ECR-R/RS dimensions chart.

Fraley gives scores from an internet study involving over 23,000 people.  Their average age was 31.  They came from a variety of mainly English speaking countries.  They were all in exclusive dating or marital relationships.  The women tended to score a bit more highly than the men on anxiety.  The men tended to score a bit more highly than the women on avoidance.  Note these people are not a "representative sample" of the general population, but internet samples like this are still "typical" enough to produce useful comparison scores. 

Average anxiety & avoidance scores for the women were 2.15 (1.66) & 3.52 (1.78) for their mothers; 2.46 (1.86) & 4.21 (1.76) for their fathers; 3.29 (1.99) & 2.44 (1.32) for their partners; and 2.32 (1.55) & 2.38 (1.24) for their closest friends. 

Average anxiety & avoidance scores for the men were 1.92 (1.42) & 3.77 (1.62) for their mothers; 2.28 (1.64) & 4.15 (1.63) for their fathers; 3.05 (1.90) & 2.56 (1.28) for their partners; and 2.41 (1.45) & 2.89 (1.35) for their closest friends.  

The figures in brackets are standard deviations.  Taking the average score and first subtracting  and then adding the standard deviation (SD) gives a range which covers approximately 70% of subjects in the survey.  So for women's mothers, the anxiety score was given as 2.15 (1.66).  Subtracting the standard deviation gives 2.15 - 1.66 = 0.49 as the bottom of the range and 2.15 + 1.66 = 3.81 as top of the range.  Since 1 is the lowest score obtainable with the questionnaire, this means that 70% of women in this survey score their mother between 1 and 3.81 for attachment anxiety.

Note you can download a Word version or a PDF version of the ECR-RS.  There is also a scoring chart downloadable as a Powerpoint slide or as a PDF diagram.  This blog post is also downloadable too as an additional background handout in a Word version or a PDF version.    

I had lunch with a health professional friend the other day.  Later they emailed me saying "The last few times we have met you have mentioned the importance of attachment style in determining aspects of the interaction between patients and health care professionals."  They went on to raise a series of questions about health professional-patient relationships, about the way that the attachment style of both health professional and patient can affect outcomes, about how adult attachment is measured and the possibility of improving attachment patterns, and about links between attachment & mindfulness.  Gosh a lot of interesting questions being raised here.

Phil Shaver & Mario Mikulincer are key figures in our evolving knowledge of attachment in adults and Phil Shaver's Adult Attachment Lab website at the University of California is well worth visiting.  I thought I had been around for a while, but Shaver's huge list of publications goes back to 1967.  It's possible to request copies of his papers and of central importance for this blog post is his 2012 publication "An attachment perspective on therapeutic processes and outcomes" with its abstract reading "Over the past decade there has been an explosion of interest in clinical applications of attachment theory. In the present paper, we briefly describe John Bowlby's model of therapeutic change, the therapeutic relationship, and the therapist's role in emotional healing. We then review empirical evidence for three key propositions in Bowlby's model. First, a client's sense of security during therapy is crucial for facilitating therapeutic work. Second, a therapist's own sense of security contributes to positive therapeutic outcomes. Third, attachment insecurities can be effectively reduced in therapy, and movement toward greater attachment security is central to achieving favorable therapeutic outcomes. In sum, research evidence confirms the importance of establishing what Bowlby called a safe haven and a secure base within a therapeutic relationship."

Awareness of attachment issues informs therapy, it doesn't dictate it.  I have written several blog posts about this area over the years.  Clicking on the "attachment" tag will list them, including the 2009 post "Assessing attachment in adults" which gives links to the widely used 36-item "Experiences in close relationships - revised (ECR-R)" questionnaire.  Since I wrote that blog post, Chris Fraley & colleagues at Illinois University have published the important 2011 paper "The experiences in close relationships-relationship structures questionnaire: A method for assessing attachment orientations across relationships" with its abstract reading "Most research on adult attachment is based on the assumption that working models are relatively general and trait-like. Recent research, however, suggests that people develop attachment representations that are relationship-specific, leading people to hold distinct working models in different relationships. The authors report a measure, the Relationship Structures questionnaire of the Experiences in Close Relationships-Revised (ECR-RS; R. C. Fraley, N. G. Waller, & K. A. Brennan, 2000), that is designed to assess attachment dimensions in multiple contexts. Based on a sample of over 21,000 individuals studied online, it is shown that ECR-RS scores are reliable and have a structure similar to those produced by other measures. In Study 2 (N = 388), it is shown that relationship-specific measures of attachment generally predict intra- and interpersonal outcomes better than broader attachment measures but that broader measures predict personality traits better than relationship-specific measures."

So it seems likely that patients may well have attachment styles with health professionals that differ somewhat from, for example, their attachment style with their own parents or their spouse (but they may well be linked).  Similarly a health professional's provision of care for their patients may well differ from their provision of care for their children, spouse or friends (but again they may well be linked).  And it's worth pointing out here that care-seeking (attachment) and care-giving systems are likely to be related, but they are different - see the post "Behavioural systems: attachment (care seeking), care giving, exploration, sex, & power" and Mikulincer & Shaver's 2011 book chapter "Adult attachment and caregiving: Individual differences in providing a safe haven and secure base to others" for more on this.  Fraley has a great website that looks a bit more "current" than Shaver's.  Superbly it gives full text PDF's of most of his publications.  It also gives an extremely useful set of "links & resources" including details & expert advice on using both the ECR-R and the ECR-RS questionnaires.  The latter, by the way, only involves 9 items in contrast to the 36 items of the ECR-R.

Very interesting stuff.  As Oscar Wilde put it "The truth is rarely pure and never simple".  So there are a whole bunch of research studies assessing the attachment styles of various groups of health professionals.  They're interesting, but I ask myself whether it would have been more helpful to assess care-giving patterns rather than care-seeking in these groups.  Heigh-ho, the issue of attachment styles in health professionals and other care-providing groups is still a worthwhile question in a whole series of ways.  For example Black & colleagues, back in 2005, published the paper "Self-reported attachment styles and therapeutic orientation of therapists and their relationship with reported general alliance quality and problems in therapy" with its abstract stating "The aims of this study were to explore the relationship between therapists' self-reported attachment styles and therapeutic orientation with the self-reported general therapeutic alliance and therapist-reported problems in psychological therapy.  A sample of 491 psychotherapists from differing therapeutic orientations responded to a postal questionnaire. The questionnaire contained standardized measures of therapeutic alliance quality, attachment behaviours, a checklist of problems in therapy, and a brief personality inventory.  Therapist-reported attachment styles generally explained a significant additional proportion of the variance in alliance and problems in therapy, over and above variance explained by general personality variables.  Self-reported secure attachment style was significantly positively correlated with therapist-reported general good alliance.  Self-reported anxious attachment styles were significantly negatively correlated with good alliance, and significantly positively correlated with the number of therapist-reported problems in therapy.  Therapeutic orientation independently predicted a small but significant amount of the variance in reported general alliance quality in addition to that explained by attachment behaviours."

More to follow ...

I have just been in Belfast for the BABCP Spring workshops & conference.  My mind is still buzzing from all the input.  It was exciting.  I went to Arnoud Arntz's workshop on Schema-Focused Therapy.  I have been to several training days with Arnoud before, but it was helpful getting an update on what he is doing.  At the conference proper, highlights for me were the first reports by Arnoud of results from a major new study on the treatment of six different personality disorders using schema therapy, a fascinating case series by John Swan using "CBASP" to treat chronic depression, and a bloody great rock thrown into the pool of my cosy understanding of intrusive thoughts by David A Clark.  Alongside all that were a report on the treatment of severely obese clients by the marvellously named Aurelia Ciblis from Dublin, another slightly depressing walk around the findings from the Oxford study on mindfulness for health anxiety by Freda McManus, and a bunch of three studies on support for therapists by Margaret O'Rourke, Craig Chigwedere and Joe Curran.

I've been away a lot recently attending conferences & on holiday.  I intend to write up the BABCP Spring workshops & conferences from my notes and then post descriptions on this website next month.  There were some interesting & encouraging new research findings ... watch this space!