Behavioural Activation Treatment

Fells and Dales CPD group. 15/2/19

Today we reviewed Behavioural Activation Treatment for Depression: Returning to Contextual Roots by Neil S Jacobson , Christopher Martell and Sona Dimidjian 2001. Along with this we looked at the NHS guidelines on the stepped process of mental health care and how Behavioural Activation fits within step 3 of the model.

Behavioural Activation is a stand alone treatment for depression which attempts to help depressed people  to re-engage in their lives through focussed activation strategies.  Rumination and worry is seen as an avoidance strategy and the contents of the worries are not considered relevant to this approach.

Deficiencies are seen as residing in the life of the sufferer rather than within that individual where avoidance patterns narrow the repertoire of behaviour for the individual eg they may stay in bed.

The significance of a persons behaviour is largely driven by the reinforcers maintaining them  and stopping the avoidance behaviours is seen as key to the recovery of the depressed client. The acronyms TRAP and TRAC are used to conceptualise the old and new behaviours as Trigger, Response leading to avoidance pattern leading to response leading to avoidance behaviour (TRAP) and graded activities are created to promote the alternative Trigger, Response leading to alternative coping (TRAC) which in turn leads to breaking the feedback loop and modifying the contextual trigger .

Behavioural activation is seen as necessary and sufficient in and of itself in the treatment of depression and challenging core schema and automatic negative thoughts as in classic CBT are unnecessary.

We considered the effectiveness of such an approach if only parts of it are integrated into therapeutic counselling such as psychoeducation, exercising more, recognising and exploring avoidance patterns  and how that can be rationalised along with the need to believe the whole of the paradigm in order for any of it to be effective.

We then considered the underlying principles of therapeutic change for each of us and the importance of being genuine and congruent  and not necessarily instrumental  in our approach. We looked at how elements can be ethically integrated without totally believing in the paradigm.

A limit of the approach is the presupposition that a person is able to engage in activities and  will be compliant with home work assignments such as keeping a diary or exercising regularly.  Its overt directivity is also noted setting the therapist as expert who may even contact the client in-between sessions to check on compliance with activities.

It was noted that as it is straight forward to conceptualise Behavioural Activation can be and is included in the NHS stepped care process and psychological wellbeing practitioners (PWP’s)  who deliver first step are trained in the approach and the ethic of using  this approach for all when it might not be suitable considered.

Behavioural Activation Treatment

Psychosomatic Illness

Our prompts were: neurologist  Dr Suzanne O’Sullivan’s prize winning book ‘ Its All In Your Head’ where she respectfully tells the stories of numerous patients with extreme symptoms which have originated in the mind – what she calls conversion illnesses; a lecture by Dr Howard Schubiner where he describes the development of neural pathways which lead to an over sensitivity to danger and therefore to symptoms like pain and an interview with Dr John Sarno about his book ‘The Divided Mind’, where he has written about working for 50 years with people who have mindbody back pain.

The medical practitioners we listened to are confident that 25 – 30% of all illness is psychosomatic. These illnesses have real and often debilitating symptoms but are not organic in origin – there is no tissue damage. Instead, neural pathways have evolved to unconsciously distract from emotional suffering by converting the mental pain  into physical symptoms. The assumption is that the unconscious mind has found a creative way to repress the mental pain.

Certain characteristics of a person’s experience are indicators of psychosomatic illness. For example, a person will typically have been unwell for many years, often with a variety of different conditions. They are usually not helped by conventional medicine. The illnesses that come up most often are  pain especially in the back and neck, fatigue, skin conditions, IBS, fibromyalgia and allergies. In terms of personality, Dr Sarno has noticed that these conditions are commoner in people with a tendency to perfectionism, a need to be good and its common for people with this kind of illness to be preoccupied with their health. Many become anxious and depressed and we are therefore likely to meet  them in counselling. It should be noted that all of us have psychosomatic illness to some extent – skin problems when stressed, abdominal reactions to anxiety, headaches when over pressed etc.

Our discussion lead from wonder at the prevalence of psychosomatic illness, to conjecture about some clients’ illness as well as our own. We also talked about  different family cultures and attitudes around illness – especially the shame of illness or incapacity versus illness as a way of being cared for. We touched on some experience of ME.

When it is suggested to people that their symptoms might be psychosomatic , many are angry and offended if they understand it to imply that the symptoms are imaginary. They aren’t. However, for those who can be at least partially open minded, education about the workings of the brain and an opportunity to explore the original root of emotional distress are the ways to recovery. Clearly this is in the realm of counselling and psychotherapy. We were energised to think of the therapeutic opportunities these clients present.


Psychosomatic Illness

Winnicott’s Theory of Breakdown

We discussed firstly an article on Winnicott’s theory of fear of breakdown, the basic premise being that the “real” breakdown has occurred much earlier in a client’s life when some rupture occurs in the mother-infant bond and relationship. This forces the infant “to take on, by himself ,emotional events that he is unable to manage”.

The breakdown, claims the author of this article, “ Fear of breakdown and the unlived life” Thomas H.Ogden (international journal of psychoanalysis,2014 95: 205-223) is survived but not actually registered internally which results in a sense in the adult that “ of himself are missing”; the client then feels he “must find them if he is to become whole” as otherwise he will have to continue to live with the feeling that “what remains of his life” becomes “like a life that is mostly an unlived life”, a feeling perhaps of inner deadness and a potential not fulfilled. We grappled with this concept and felt it needed more elucidation with clinical examples, particularly his references to “psychotic defense organizations” which serve to keep unmanageable feelings at bay.


We moved on then to discuss two papers by Neville Symington which we found illuminating and well-written: “Healing the mind-what is the process?” followed by “Healing the mind-what is the healer’s task?” He draws on his own experience and shows humility in his assessment of what the patient is seeking in therapy- namely that hie is asking the therapist to “ me create a mind that can cope with these disasters that are overwhelming me”. He believes that the therapist must understand the workings of the mind and avoid psychological “muddle” since the therapist has to be able to create a representative image of the client’s pain that fits his experience and he believes that the patient is then able to “embrace” his pain and start to process it. The therapist cannot programme this creation since, states Symington, it is “an inner spontaneous act” but there are outer factors which he claims can facilitate this creation- this is the thrust of the second article where he outlines the four main components of effective therapy as: freedom, the personal, scientific enquiry and compassion.

By the personal, he means : “Don’t ever say anything which is not a personal statement”- he illustrates this idea by describing a friend who “did not generalize, give advice or say how he thought people should act” and who fostered an atmosphere of “freedom” which should be based on a wide-ranging spirit of “scientific inquiry” including a knowledge of the self since he claims that “all personal difficulties flow from our own areas of narcissism”. As therapists we should strive to be “natural” since “the more natural you are, the more a patient will reveal the secrets of the heart”. He tries to define what natural means by saying you have to be “in a role, not acting a role” and the role is combining compassion with a scientific-like probing and curiosity.

We found his two papers interesting and refreshing and less dense than the one on Winnicott.

We then went on to a discussion of whether it is helpful or not for a therapist to cry in the consulting room when affected and moved by a client’s pain. There was some disagreement about whether this demonstration of empathy, whether chosen or out of the therapist’s control, is therapeutic for the client or the opposite. We agreed this would be a useful topic for a future meeting.


Rosemary Pitt


Winnicott’s Theory of Breakdown

The Use of Self

19 Oct. 2018  The Fells & Dales group of counsellors & psychotherapists met today to discuss two papers:  ‘Interview with Carl Rogers on the Use of Self in Therapy’ – chapter 2 in ‘The use of Self in Therapy’ ed. Michele Baldwin, Haworth Press, 2013, and ‘The Use of Self of the Therapist’ by Wendy Lum, Contemporary Family Therapy, March 2002.

We discussed in some detail what ‘use of self’ means:  the in-the-moment awareness of felt sense, experienced when with our clients;  allowing ourselves to be impacted by our clients, and trusting both ourselves to find a way of conveying, and them to be able to receive, what we are experiencing.

Yet this can feel risky at times, as the outcome of such an expression is unknown at the time.  In the very act of reaching out to the client, there is the risk of alienating or confusing them, but hopefully our intention to honour them with our honesty, genuineness and integrity will be received and reflected upon.  Indeed, it can model to the client the value of transparency and self-awareness.  It might be easier to ‘play safe’ and not make the effort or take the risk, thereby depriving the client of what could be a significant learning opportunity to reflect and grow.

Perhaps no one has been able to improve on Carl Rogers’ own descriptions of this process:

Perhaps it is something around the edges of those [core] conditions that is really the most important element of therapy – when my self is very clearly, obviously present.

The important thing is to be aware of this feeling, and then you can decide whether it needs to be expressed or is appropriate to express.

I want to be as present to this person as possible.  I want to really listen to what is going on.

At those moments, it seems that my inner spirit has reached out and touched the inner spirit of the other.  Our relationship transcends itself, and had become part of something larger.

To be congruent means that I am aware of and willing to represent the feelings I have at the moment.

We acknowledged how difficult it is for this level of congruence, or ‘use of self’ to be taught within counselling training courses, and how the (necessary) breaking it down into teachable and observable units somehow diminishes it and misses the point, as perhaps is a danger in Virginia Satir’s model described by Wendy Lum.

Despite the threats of the medical model dominating the helping professions, and despite our kind of work being at times extremely demanding and exhausting as we give of ourselves, we agreed that it is a tremendous privilege to be able to relate to others at such depth and intensity  –  to experience what some might describe as a ‘meeting of souls’.  Where else can clients be met with such realness, at the same time as being held in such deep respect and trust?!

The Use of Self

Emotions and the Brain: the origins of values?

The meeting of the Fells and Dales Counsellors on Friday August 24th 2018, met, through the medium of TED and UTube talks, Professor Mark Solms and Dr Jaak Panskepp, the latter now sadly deceased.

The input stemmed from a visit by one member in July to South Africa. He had been reading a book The Brain and  the Inner World written by Profesor Solms. Noting that Professor Soms was at Cape Town University he discovered that this Vineyard was located ten minutes away from where the holiday accommodation was situated, a visit was therefore possible. Mark Solms is Professor of Neuropsychology at the University of Cape Town. He is also a psychoanalyst and the owner of a Vineyard in Franschhoek.

The relationship to that Vineyard, Solms and Delta Vineyard, is  complicated and offers a fascinating insight into the political and cultural situation in South Africa. The insight of a psychoanalyst to that situation illuminated by the mind of a neuropsychologist is rich indeed. One possible reference to hear about the sociological dynamics can be found at:       Mark Soms giving his land back to farmers.

The focus then was switched to hearing Professor Solms, the academic, speaking of a fundamental theory concerning ethics. He understands and has been able to demonstrate that all mammas have the same brain structure and deep level of emotional response. We share our emotional brain responses with 500 million years of mammalian evolution. Our fundamental emotional responses concern survival and reproduction. All mammals feel the enthusiasm for seeking and finding that which keeps the physical body in being and harmony. When it is not in harmony, the emotional response is such that that balance must be restored. 500 million years ago then, the concept of values was being played out in terms of that which is ‘good’ and achieves physiological balance and that which is ‘bad’ and upsets or destroys that balance. all of which is routed to the inner brain emotionally. Thus our value system was born as was consciousness itself, in an awareness of what our emotions were conveying, namely, ‘how am I doing?’

Professor Solms refers to the work of Jaak Pansksepp, Estonian neuroscientist, and known for his work now into affective neuroscience whose book The Archeology ofthe Mind details his resesarch into those primary and ancient emotions that we share in common with all mamanals. His identification of seven fundamental primary affects is becoming better known. There are several TED videos which feature Jaak Panskepp such as that seen during this meeting at:

Discussion visited the origins of ethics in use today in our professional bodies and curiosity about the tendency towards the apparent doctrinal even dogmatic assertion of our professional ethical boundary statements. Perhaps education in affective neuroscience may help practitioners understanding of their emotional lives that sometimes lead to unwise behaviours.

We were reminded of the association of Sandra Paulsen to Jaak Panskepp and her EMDR workshops inviting participants to consider the existence of these fundamental primary emotional circuits. She proposes that these, due to innumerable forces no doubt, can be ‘damaged’ or ‘distorted’ and not fulfilling their evolved purposes. She teaches EMDR protocols for their ‘resetting’. A member of the group who has benefitted from her workshop and had the privilege of working with some clients in this mode, told of his awareness of and fascination with clients’ processes and work that led to an apparent amelioration of their emotional lives.

All felt that a world of new reading had been offered!



Emotions and the Brain: the origins of values?

Fat Lady by Irvin Yalom

We used this chapter from ‘Love’s Executioner’ to consider out personal responses to obesity. While we had varied experience of obesity in clients, we agreed that it is vital to find a way to talk about it. We acknowledged that it may take courage to broach such a potentially sensitive aspect of a client’s body image but that it was imperative to create  the space to  explore it.

A member of F and D with professional experience of disordered eating pointed out that many overweight people are blind to their size. She thought there would invariably be a reason for a person’s weight to be out of control and therapy is an opportunity to try and find the reason. Emotional emptiness seemed to be a common feature .

We considered the effect of gender on our responses to obesity and decided that social and cultural expectations were harsher on women than men.

Fat Lady by Irvin Yalom

“Real” differences between twins and identity development



The groupm meeting on June 6th 2018, discussed a chapter entitled “ “real” differences between twins and identity development” from Barbara Klein’s book on twins in therapy: “Alone in the Mirror” (Routledge,2012).


This chapter raised a number of interesting issues for our work as therapists:


  • Who mirrors the twin as the twin is often not looking at mother but at their twin and what is the impact of this? (i.e. the essential formative relationship is with the twin rather than the mother)


  • What is the effect of shared experience in the womb, particularly if one twin dies in utero?



  • Effect of a merged and dependent relationship with the other twin as in the clinical example of Chuck


  • The effect of twins being seen as a unit by the parents rather than as separate individuals



  • Impact of a twin’s expectation of others that their feelings and thoughts will be known and understood without the need to express them due to the shared communication with their twin as the imprint

We agreed that the book was thought-provoking and merited further reading and one of the group has already recommended it to a client who is a twin which is sufficient validation!


Rosemary pitt


“Real” differences between twins and identity development