Developing a Conceptual Paradigm for the 21st Century

1. Where do we go from here? Developing a conceptual paradigm for the 21st Century Dr Andrew Worthington www.headwise.org.uk

2. 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

3. “The literature concerning cost-effectiveness of rehabilitation options is poor in terms of both quantity and quality.” McKenna et al. 1992 “There is now a substantial body of high-quality research evidence for the effectiveness, and indeed the cost-effectiveness, of rehabilitation.” Turner-Stokes, 2008

4. 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?

5. Conceptual origins in Behaviourism(operant learning) Therapeutic value of (positive) reinforcement. 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)

6. 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

7. Self-instruction 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.

8. Self-regulation Child sits at desk and is shown marshmallow – adult leaves the room. 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.

9. Marshmallow Test(Mischel)

10. ‘High delay’ in pre-school • As adolescents showed: • Less distractible • Less disruptive • More confident and self-reliant • 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.

11. 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

12. Hot vs Cold thinking • Appetitive qualities • Arousing, motivating • Gooey, • sweet, • chewy, • melt in the mouth • Descriptive qualities • Cognitive, non-emotional aspects • White, • thick, • square-like

13. Decision makingNewcombe 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.

15. Stoic philosophy “Men are not disturbed by things, but by the view which they take of them” Epictetus “You have power over your mind - not outside events. Realize this, and you will find strength” Marcus Aurelius

16. Stoic philosophy • Remove the judgement, and you have removed the thought ‘I am hurt’: remove the thought ‘I am hurt’, and the hurt itself is removed. M Aurelius Meditations IV [7] • Albert Ellis (REBT) + Epictetus • RET: • ‘Disputation’ irrational thoughts • Action-oriented psychotherapy • Focus on the present

17. 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

18. Conscious intent to act

19. 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.

20. ‘..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.

21. Therapy as retrieval competition (Brewin 2006) Pre-therapy P1 P2 P3 N1 N2 N3 N4 Post-therapy P1 P2P3 N1 N2 N3 N4 P5 P6

22. Is positive psychology the answer? Eudaimonia - εὐδαιμονία = Well-being, flourishing Socrates: associated with virtue (incl self-control)

23. 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

24. Neurological basis of Eudaimonia (insula) Lewis et al, (2014)

25. Accentuate the negative‘negative psychology’ • Focusing on things that might go wrong leads to preventative measures • ‘Chronic unease’ • Constructive pessimism • Action-oriented approach

26. Managing risks

27. Action-oriented approach By focussing on what can be done to change a situation … … the emphasis is on our ability to change behaviour: 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

28. Present-focussed behaviourally-based therapies: • REBT (Ellis, 1955) • ACT • Observing Self (Self as context) • ‘Creative hopelessness’ • Mindfulness

29. The future? The absence of an operant framework to cognitive therapies previously has been criticised as promoting an unhelpful form of dualism. Psychologically-based therapies are likely to be increasingly behavioural. Radical behaviourist post-Skinnerian analysis of relations between language and cognition.

30. 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.