Improving basic self-reflectivity: accessing thoughts and emotions and relation among variables, from dynamic assessment to the course of therapy

The first goal we pursue involving patients in bodily and imagery work is to improve self-reflectivity. In early sessions many patients with PD, eating disorders, Obsessive-Compulsive Disorder and Post-Traumatic Stress Disorder have difficulty describing their inner experiences. A clinician may gather narrative episodes but psychological elements may not surface clearly.

Patients may have difficulty replying to questions such as “What did you feel when your boyfriend was lying on the sofa channel surfing and you were eating one hazelnut after another?”, “How did you feel when your mother was checking all the windows to look for burglars?”, “What pushed you to drink during your friend’s wedding?”

To get the information necessary for case formulation, clinicians can even very early on propose many different types of work. Sometimes, if the therapeutic relationship is good and patients accept the proposal, it is possible to start from the first or very early sessions. We name it dynamic assessment (Chapter 4). Therapists for example propose behavioural experiments, practicing simple mindfulness exercises, using guided imagery. The goal of these exercises is to create an action and reflection context facilitating access to inner experience.

We would recall that, according to embodied cognition principles, humans get to know the world by interacting with it, attempting to achieve goals and relating with people and objects. Gaining knowledge on inner states only on the basis of dialogue can thus be insufficient, because the body and mind are more likely togenerate ideas and emotions in the natural context for which they are designed: acting. Whatever the exercise proposed during assessment, a patient will have to confront avoidance and automatisms, but while trying to counteract them! This is likely to trigger thoughts and emotions that at this point are available to the therapist and patient for a shared formulation of functioning. The aim of dynamic assessment is not to promote premature change but to create an action context where patients are asked to reflect proactively on what happens inside them in particular contexts and on how they interpret events. We now depict a moment from a dynamic assessment where guided imagery led to important information.

Thorsten was a Norwegian patient, followed by a local MIT therapist, and suffered from apathy and mild depression. He felt there was no momentum in his life, with the days passing monotonously. He worked as a manager in a firm of which he was the owner, but was dissatisfied by his work. He felt sluggish and incapable of reacting, and considered himself immature because he was wasting his time. Comparing himself with other colleagues, he saw them as more satisfied, happy and successful. In comparison he felt small and inferior. He experienced moments of satisfaction only when problem-solving for others, things his clients did not think about on their own. For a few minutes he would feel clever and competent and capable of helping others but this sensation did not last. Thorsten suffered from covert narcissism and had depressive personality traits. The idea of not being in control of one’s actions is a typical sign of lack of agency. At the start of his assessment session he did not know how to describe his inner states beyond his feelings of emptiness and apathy and a sense of powerlessness. As a result of the therapist’s questions, he recalled that this sense of not being in control was rooted in his relationship with his mother. He talked about how she decided everything for him and there was no room for any disagreement, at the risk of being considered stupid. At the time Thorsten tended to comply with his mother’s opinion: thinking about being a musician or pilot, the real desires of his youth, led him to believe he was an idiot.

The therapist decided to explore the inner states preceding Thorsten’s self-criticism and consequent paralysis. He asked him to recall an episode where his mother criticised him. Thorsten closed his eyes but had difficulty recalling a detailed episode. However he managed to visualise his mother’s face. The therapist asked him: “Can you describe it to me? What can you see?” Thorsten’s reply was revealing: “Her face seems kind but her eyes are stiff and her mouth rigid.” “What is your mother doing at this moment?” “She’s not looking at me.” The therapist picked up the importance of the observation: “How do you feel at this moment?” “Sad. As if I didn’t count for anything.”

As a result of this exercise it was possible to quickly see that Thorsten had two dominant schemas. The first arose from the wish to be appreciated (rank) with the idea that the other was better, more powerful (mother and colleagues) and critical (mother). At the same time attachment was activated with the idea that the other was distant, cold and unavailable. This second schema emerged

Use of imagery and bodily techniques 91 thanks to guided imagery and made it possible to pinpoint the self’s response to the other’s response, which was of loneliness, despondency and a feeling of being not lovable. Thorsten accepted this exercise gratefully, because it made it possible for him to discover feelings he had not thought about for some time.

We would recall that MIT is not a therapy model with stages. Each session starts by evaluating which interpersonal schemas are active and what current metacog-nitive skills are, and then by trying to regulate the therapeutic relationship appropriately and stimulating the immediately higher level of metacognition. Given this, if a patient has difficulty identifying thoughts and emotions and establishing links among events, ideas, emotions, behaviour and symptoms, the aim of the various techniques should be to promote self-reflectivity, whether this occurs in the first 10 minutes of the assessment session or after three years of therapy.

To stimulate access to mental states, mindfulness and interoceptive attention exercises are very useful, often in combination with guided imagery and drama techniques. As we showed in Thorsten’s example, guided imagery, here of an informal type (Chapter 5), almost systematically generates new information, especially about affects and their causes. Behavioural exposure, both during sessions and between one and another, also has this ability. Exposure operations can be the only ones able to stimulate self-reflectivity where there is a co-occurrence of PD and symptomatic disorders. In such cases the stimulation of metacognition can start with behavioural exposure centred on the symptom.

Saverio was 55 years old and suffered from Obsessive-Compulsive PD. He asked for therapy for panic attacks, which had led him to avoiding using his car. His initial fear was to lose control of it on a viaduct and fall into the void. From then on he avoided roads with bridges, but the avoidance spread as far as stopping him from crossing bridges on foot. During his assessment session he had difficulty describing his emotions and using the term anxiety, which was evident in his nonverbal communication. With difficulty the therapist managed to get him to identify' it, but it remained impossible for him to grasp what event or condition was triggering it and what degrees of intensity it reached in various contexts. Saverio clearly felt awkward and closed up when faced with the therapist’s questions. The conversation proved to be unproductive. The therapist first explored whether Saverio had difficulty' talking with him, given his visible awkwardness, but Saverio said no. The therapist then revealed he had difficulty' grasping how Saverio’s anxiety worked and proposed a behavioural experiment to understand this better together.

The room where the session took place had two windows filling up the outside wall and in front of them the floor was raised. The therapist suggested him to gradually' approach a window and monitor and describe out loud his level of anxiety'. Saverio could pinpoint when his anxiety started to rise: near the window he got to 7 on a scale from 1 to 10. He said he would not be capable of getting up on the raised section. The therapist asked him if he feltup to putting just one foot on it while holding onto the frame of the window, which at that moment was open, with one hand. Saverio hesitated but tried and realised that his anxiety had increased to 9. The therapist asked him to stay a bit longer in this position and suggested he do a few simple mindful breathing exercises. His anxiety fell progressively to 6, a level Saverio said he found tolerable.

Right at that moment, without realising it, Saverio got down from the step! The therapist took the opportunity to point out that this was an avoidance mechanism: his anxiety was low but his body nevertheless moved away from the danger. Thanks to this exercise, Saverio’s emotional and cognitive monitoring improved and the therapist could tackle panic attacks. After only a few sessions Saverio had already started driving again and after a month he began crossing bridges.

To improve the first levels of self-reflectivity, awareness of thoughts, emotions and event-thought-emotion-behaviour links, is an MIT goal throughout therapy. The ongoing prime objective of the work described in this book is to boost it. With some patients it is a question of promoting basic emotional and cognitive awareness, when, for example, they have difficulty describing what they feel or what thought stirred them towards a particular behaviour.

When metacognition grows, and patients become capable of, for example, saying: “I was angry because as usual my sister left me loads of things to do and couldn’t care less”, or else “I feel anxious because I’ve got to hold a lesson with a class and I don’t feel sufficiently prepared to be able to face their testing standards”, goals become more complex. In such cases clinicians should aim to stimulate access to distressing emotions that are more difficult to pinpoint: guilt or those linked to mourning. At the same time they help patients to see any emotions and thoughts linked to positive self-images. In the autobiographical episodes patients relate, either spontaneously or after being asked by their clinician, elements correlated to pathogenic interpersonal schemas are likely to surface, but there is not what a clinician needs for an adequately precise schema formulation.

Here is an example involving Alessia, suffering from Dependent PD with obsessive-compulsive personality traits. In session 1 she related a memory associated with recent situations where she was criticised, occurring when she was 10 years old.

“I had to take part in the school play. My mother had given me some money and a little jacket to use for my part. When the play was over I realised someone had stolen it. When my mother turned up I was in despair. I told her everything and she replied that I was an idiot and I deserved it.” When the therapist asked her what she felt, Alessia replied: “Angry. I can feel the anger welling up now too. Mummy shouldn’t have reacted like that. It wasn’t fair.”

On the basis of this first version the therapist thought that she was frightened and driven by the attachment motive, and that anger was a protest at being left alone in a difficult situation. However, Alessia displayed signs of

Use of imagery and bodily techniques 93 restlessness and said she felt confused. There was something she could not manage to say and she started to ruminate: “Perhaps I deserved the punishment. Perhaps I’m wrong to take it out on my mother.” The therapist suggested a guided imagery exercise to help Alessia to better distinguish what she felt. Alessia accepted and went back to the school corridors after the play. To the therapist’s surprise, she did not talk about her fear about being robbed but about going up to her mummy and being afraid of the latter’s judgement: “I’m petrified by what she’ll say. I feel my legs trembling.” In the guided imagery she asks in tears for help, saying: “Mummy, I didn’t mean to do it.” Her expression changed, which prompted the therapist to ask her: “What do you feel now towards your mummy?” “I feel sad. I’ve disappointed her.” “Anything else?” “Yes, I’m ashamed because I shouldn’t have made a mistake.”

As a result of the information acquired during the guided imagery, Ales-sia’s inner world became clearer to the therapist: right from the beginning Alessia was searching for confirmation of her self-worth (rank). She found herself faced with a critical and disparaging other and consequently experienced feelings of dejection and shame, both consistent with the motivational system under way. The despair she reported at the start was anxiety about a feared judgement, and it emerged that her dejection was due to failure and not to being forsaken. At the same time Alessia depicted herself as worthy and deserving approval, and, when faced with her mother’s mercilessness she considered her unfair.

 
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