Saturday, November 08, 2014

Merging Evidence-Based Psychosocial Interventions in Schizophrenia

The approach outlined in this article is almost exactly opposite of how I work with my clients who have symptom collections that are labeled schizophrenia (an intersubjective, relational model), but it's an interesting attempt to create a more integrated and practical model.

The intersubjective model is much more relational than this approach, and it seeks to join with the client in order to understand his/her experience in an experience-near manner. In doing so, we can help the client regain access to emotions that have been dissociated by the psychosis.

Full Citation:
Lecomte, T, Corbière, M,  Simard, S, and Leclerc, C. (2014, Nov 6). Merging Evidence-Based Psychosocial Interventions in Schizophrenia. Behavioral Sciences; 2014, 4(4): 437-447; doi:10.3390/bs4040437

Merging Evidence-Based Psychosocial Interventions in Schizophrenia

, , and

This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

(This article belongs to the Special Issue Management and Treatment of the Major Mental Disorders)

Abstract: Psychosocial interventions are an essential part of the treatment for people with severe mental illness such as schizophrenia. The criteria regarding what makes an intervention “evidence-based” along with a current list of evidence-based interventions are presented. Although many evidence-based interventions exist, implementation studies reveal that few, if any, are ever implemented in a given setting. Various theories and approaches have been developed to better understand and overcome implementation obstacles. Among these, merging two evidence-based interventions, or offering an evidence-based intervention within an evidence-based service, are increasingly being reported and studied in the literature. Five such merges are presented, along with their empirical support: cognitive behavior therapy (CBT) with skills training; CBT and family psychoeducation; supported employment (SE) and skills training; SE and cognitive remediation; and SE and CBT.

1. Introduction

Psychosocial interventions are an essential part of the treatment and recovery of people with severe mental illness such as schizophrenia. It is well-accepted that medication alone is not sufficient to help with the recovery and various issues a person might encounter when attempting to lead a satisfying life in the community. Some practices have gathered sufficient empirical data to be strongly recommended by national guidelines such as the PORT (Patient outcome research team) [1], or the NICE (The National Institute for Health and Care Excellence) [2] guidelines in the UK, whereas others are considered promising until more studies support its effect. In order for a psychosocial practice, namely an intervention or program (an intervention is specific treatment with a targeted therapeutic aim whereas a program typically includes various interventions), to be considered evidence-based, it must not only have accumulated sufficient empirical proof of its efficacy (often in the context of at least two randomized controlled trials) but it must answer a need (such as improve functioning, overcome a deficit or help to cope with symptoms) and be standardized in order to be easily replicable [3]. The 2009 PORT report on psychosocial practices for schizophrenia highlighted eight interventions or programs that could be considered evidence-based [1]. These were in terms of interventions: family psychoeducation, cognitive behaviour therapy, social skills training, weight management, and token economy. In terms of programs, they described: intensive community treatment, supported employment and integrated dual-disorder programs (with first episode programs almost meeting criteria). Since, Mueser et al. [3] has added cognitive remediation, which has demonstrated in various meta-analyses its efficacy in helping individuals overcome cognitive deficits in areas such as memory, attention or problem solving. Although all of the above-mentioned interventions and programs are considered evidence-based and can truly improve the lives of people with severe mental illnesses, implementation studies reveal that few, if any, are ever implemented in a given setting [4]. For some interventions, this is understandable—for instance token economy is only effective in changing problematic behaviors when used in a closed and controlled environment, like a forensic ward [5]. However, most of the other interventions and programs have demonstrated positive effects in improving symptoms, deficits, and community functioning and are under-utilized. A recent review on implementation of evidence-based psychosocial interventions and programs in psychiatry describes various strategies that have been used in order to improve implementation of one or many evidence-based practice [4]. Of the most common strategies, large demonstration projects and effectiveness trials run by researchers, broad service reforms based on new government policies and national agency-led initiatives were identified. Few of these implementation strategies have been studied over the long-term, and fewer even have considered consumer outcomes [4]. Other smaller-scale implementation strategies have also been developed, when large-scale funding was not available. For instance, supported employment programs’ implementation have been facilitated by a group of researchers and clinicians [6] offering standardized training, consultation and encouraging the use of their implementation fidelity scales (The Quality of Supported Employment Implementation Scale (QSEIS) [7] or the Individual Placement and Support (IPS) fidelity scale [8]. In the UK, US and Canada, the implementation of CBT for psychosis has been improved by offering the clinical training to mental health professionals from various backgrounds (e.g., nurses, occupational therapists), offering structured manuals, and brief training sessions [9,10] rather than limiting the treatment delivery to clinical psychologists.

Another approach to improving implementation of evidence-based psychosocial interventions or programs that is being seen more and more in the literature, particularly in the last decade, is to merge two evidence-based interventions, or to offer an evidence-based intervention within an evidence-based program. Are considered merges both: (a) the simultaneous delivery of two practices (two interventions or an intervention and a program) and, (b) modified practices: interventions changed in order become integrated with another intervention or within a program. In settings with limited means, offering such merges has the advantage of targeting more than one therapeutic goal at once (e.g., cognitive distortion and work integration). Some of the merges have been developed in order to adapt an evidenced-based intervention to a specific population group or setting (such as older consumers). However, most of the merges have been developed with the hope of improving the effectiveness of an evidenced-based program by adding an empirically recognized intervention. It is important to mention that few of the merges presented here simply “co-deliver” interventions—most are well-integrated merges or at least aim at truly integrating the interventions and programs together. The following are descriptions of such merges.

2. Cognitive Behavior Therapy (CBT) and Social Skills Training

Granholm and colleagues [11,12] have merged two evidence-based psychosocial interventions to cater to the specific needs of aging individuals with psychosis who might be struggling not only with symptoms but also with social and cognitive deficits. CBT for psychosis has been studied in over 40 randomized controlled trials and various meta-analyses since the first promising studies of the 1990s [13]. Overall, most studies have found that CBT for psychosis is effective in reducing symptoms and improving other indexes of well-being, often with stronger results compared to other interventions overtime than at post-treatment [14,15,16]. However, as in most psychotherapy studies, the most rigorous studies often reveal smaller effect sizes than the non-controlled studies [17]. CBT for psychosis aims at modifying dysfunctional beliefs by helping the person understand the link between perceptions, beliefs and emotional and behavioural reactions. CBT also helps the person question the evidence supporting his beliefs (whether they are psychotic or not). Furthermore, CBT brings the person to self-observe himself, his thoughts and behaviors, and explores various coping strategies the person might use when dealing with distressful thoughts or voices. Finally, CBT for psychosis takes into account cognitive biases a person might have and aims at modifying those biases, by seeking alternatives instead of jumping to conclusions, for instance.

CBT for psychosis has been adapted for various clienteles, used with individuals at high risk of developing psychosis, individuals with early psychosis as well as older individuals with a long history of schizophrenia. This latter group was of particular interest for Granholm and colleagues [12] who wished to offer CBT for psychosis in a format that would be appealing and adapted to clients who were often isolated, and who might have difficulties grasping some CBT concepts, given their cognitive deficits. They therefore decided to include social skills training to the CBT treatment and offer the merged treatment in a group format.

Social skills training has been around since the 1980s in the USA and was considered especially useful for helping people reintegrate society after a long period of institutionalization. The goal behind skills training is to offer skills that are deemed essential to interact with others, manage one’s medication and symptoms, as well as problem solve in different contexts. Skills training is based on Bandura’s self-efficacy theory [18] and uses repetition and positive reinforcement to help people acquire and remember new skills. To date, over 23 randomized controlled trials have shown that skills training can help acquire skills, decrease negative symptoms, and has a moderate impact on independent living skills [19,20]. Skills training can be offered individually but works best in groups, with the use of multiple role-plays preparing for real-life interactions.

Merging CBT and Skills Training

Granholm and colleagues [11,12] developed a group CBT/skills training approach that focuses on CBT for psychosis techniques, such as checking for facts, but presents these in a skills training manner (i.e., a lot of repetition, wallet cards with key words/concepts, use of a big flag in the group to “flag” the beliefs without apparent facts or proof). The group included modules that were repeated over time, enabling the participants to go over the content more than once and allowing new participants to enter the group at any given moment. Although the results did not show an improvement in positive symptoms, it did show improvements in functioning and negative symptoms [11,12]. Of importance, the participants were able to remember the concepts and CBT techniques regardless of the severity of their cognitive deficits.

3. CBT and Family Psychoeducation

Leclerc and Lecomte [21] have recently published promising preliminary data on 40 family members who received a merged group CBT/psychoeducation family intervention. Family intervention, in particular family psychoeducation, is recognized as one of the evidence-based interventions with the most empirical support, especially regarding decreasing rehospitalization rates [3]. More than 50 randomized controlled trials have been published to date supporting the effects of family psychoeducation on increased medication adherence, and decreased stress and symptoms in those receiving psychiatric care [15,22]. As for their family members, these same studies report decreased perceived burden and psychological distress. Most family interventions last an average of six to nine months and offer: information on symptoms and mental illness, recommendations for dealing with crises, emotional support, and coping skills to deal with symptoms and mental illness [23]. Family interventions can be offered to each individual family or multiple families together, with or without the family member receiving psychiatric care. Many family intervention manuals were developed in the 1990s and do not address recent concepts such as recovery and tend to focus mostly on medication, chronicity, and symptoms. During a recent trial on CBT for early psychosis, many family members asked to learn more about CBT for psychosis and how they could use the tools in their lives. We therefore developed the family psychoeducation/CBT module entitled WITH (Wellness-Inform-Talk-Help) [21]. The module can be offered in parallel to the CBT for psychosis groups, i.e., during 24, hourly multiple family sessions, or can be offered in a more intensive format: eight two-hour multiple family sessions (covering 16 activities in the module). Each multiple family group typically consists of an average of 10 parents and two co-therapists. The content of the group is psychoeducational in that it addresses concepts such as recovery, expressed emotions, parental role, personal limits, and expectations, but it is also considered CBT given that the participants learn about CBT principles and techniques and apply them to their own lives during the group and at home (homework). The parents therefore learn to not only use the skills learned with their family member with a mental illness, but also use them with themselves when they are experiencing distress for instance.

Merging CBT and Family Psychoeducation

The intensive (eight two-hour sessions) format was recently studied in a non-controlled study [21] whereby the 40 parents who participated showed significant clinical improvements in psychological distress, namely in psychoticism, depression and interpersonal sensitivity compared to their baseline scores. Qualitative data obtained revealed that parents appreciated the group, found it helpful, and they had integrated recovery as well as CBT notions and skills in order to improve their relationship with their family member receiving psychiatric services. The group format was especially appreciated, as well as the information covered in the module. Although more studies are warranted in order to compare the WITH multiple family intervention to other family interventions, social workers offering the group anecdotally mentioned that their previous multiple family psychoeducational intervention had a retention rate of only 20% of participants from the first to the last session whereas WITH had a retention rate of 80%. The merged intervention has the advantage of covering essential elements of family psychoeducation for psychosis, including updated information on recovery, and also offers concrete CBT tools that can be useful for the person with a mental illness as well for their family members.

4. Supported Employment and Other Evidence-Based Interventions

Supported employment is another evidence-based program that has attracted a few merges over the past decade. Supported employment programs help people with severe mental illness obtain real-world competitive employment, with regular wages, based on their clients’ preferences [6]. Employment specialists working in supported employment programs aim at quickly finding regular paid work for their clients, and offer them unlimited support according to their needs at work. Supported employment programs are recognized as being evidence-based with more than 15 trials in various countries having demonstrated that SE programs are more efficacious in helping people with severe mental illness obtain regular jobs than other vocational or rehabilitation programs [6]. Nonetheless, there is room for improvement given that on average, in North America, between 40%–60% of the clients in SE programs obtain regular jobs and most jobs are only kept for three to five months. Many reasons have been suggested to explain why some individuals might struggle in finding work or in maintaining their jobs. Some have suggested lack of appropriate work-related social skills, others that cognitive deficits impede on work performance, and others still that people with mental health problems might hold irrational beliefs about themselves and the workplace.

Merging Social Skills Training and Supported Employment Programs

The first merge proposed was to offer social skills training that was work specific to people registered in a supported employment program. Charles Wallace [24] developed the Workplace Fundamentals, aiming at helping participants recognize the advantages of work in their lives, their potential stressors at work, how to problem solve various work-related situations, and how to avoid drugs and alcohol to maintain their jobs. The module is offered over the course of 24 sessions, typically twice a week, in groups of six to eight participants. As with most social skills training, the goal is to develop spontaneous behaviors and therefore involves multiple role-plays and repetitive behaviors. Two studies were conducted to verify its efficacy in improving job tenure. The first, including 34 participants, showed improved job tenure and better work satisfaction for those having received the skills training + SE program compared to SE program alone [24], whereas the second study did not show any differences between the two conditions on work outcomes (but reported that the sample was not typical of most studies with higher education and longer tenure, with rates close to one year for their first job) [25]. The participants receiving both conditions did show greater knowledge regarding their work setting, stressors and showed better problem solving abilities than those receiving only the SE program.

5. Cognitive Remediation and Supported Employment

Another explanation for poor work tenure in people receiving SE programs pertains to cognitive deficits. Cognitive deficits are well documented in people with severe mental illness, namely regarding deficits in memory, attention, speed of processing and various executive functioning tasks, and can make performing at work difficult. Various cognitive remediation programs and strategies have been developed over the years with more than 40 randomized controlled trials supporting its efficacy in improving cognitive skills and overall functioning [26]. Cognitive remediation can take many forms: paper-pencil tasks, computer tasks, group training, or training in real-world tasks (using errorless learning, for instance [27]). Although some cognitive remediation can include modifying the environment to compensate for the person’s most important cognitive deficit, most cognitive remediation programs aim at improving cognitive deficits to the point that they no longer interfere with work performance.

Merging Cognitive Remediation and Supported Employment Programs

McGurk and colleagues developed a cognitive remediation program called Thinking Skills for Work specifically for people registered in supported employment programs [28]. The program involves individual computerized training (using CogPack) for an average of 24 hours over the course of 12 weeks, along with cognitively-informed job support consultation with the employment specialist. The computerized program aims at improving attention, concentration, psychomotor speed, learning and memory as well as executive functions. The consultation aims at targeting jobs or at modifying the work environment as needed according to the person’s performance and progress during the cognitive remediation training. Results at the two to three year post- cognitive remediation follow-ups revealed that those who had received the cognitive remediation program had improved on the cognitive tasks and had superior job retention rates than the control condition (registered in supported employment programs only) [29]. These results were however not found for those who presented with comorbid substance use disorders—their work outcomes were poor regardless of the extra treatment added [30].

6. CBT and Supported Employment

A potential obstacle to job maintenance in people registered in supported employment is dysfunctional beliefs regarding the workplace and one’s own abilities. Individuals with severe mental illness who have been away from the job market for some time can hold beliefs and act in ways that are deleterious for their work integration, and could be influenced by lack of confidence, jumping to conclusions bias, and poor coping skills, to name a few. As mentioned previously, CBT has proven efficacious in modifying beliefs and cognitive biases and helps in developing better coping strategies when dealing with stressful situations. CBT has also been modified by Davis and colleagues [31] to target work beliefs and behaviours in a transitional vocational program for veterans with severe mental illness. This program, entitled IVIP, has demonstrated improvements in work performance and job maintenance in those receiving the group IVIP compared to those participating in the vocational program alone [32]. These results were also replicated in a larger trial [33].

Merging CBT and Supported Employment Programs

Lecomte, Corbière, Titone and Lysaker [34] developed a brief CBT group intervention, inspired by the IVIP, but specifically tailored for people in supported employment programs called CBT-SE. The CBT-SE intervention is offered during 8 sessions over the course of one month, in order to ensure that the group does not impede on the rapid job search principle of supported employment programs. The content covered many essential aspects linked to the workplace, such as recognizing and managing one’s stressors at work, determining and modifying dysfunctional thoughts (e.g., not jumping to conclusions, finding alternatives, seeking facts), overcoming obstacles (e.g., problem solving), improving one’s self-esteem as a worker recognizing strengths and qualities), dealing with criticism, using positive assertiveness, finding coping strategies (for symptoms and stress) to use at work, negotiating work accommodations and overcoming stigma. Although the results from the trial of 160 participants are not yet available, preliminary data have been published on 24 participants [35] and suggest that the CBT-SE intervention is feasible, and acceptable, with good attendance and positive feedback regarding the group’s usefulness. In terms of work outcomes, 50% of all participants in both conditions found competitive work but those in the CBT-SE condition were more likely to work more hours per week and for more consecutive weeks than those in the supported employment program alone. These preliminary results are promising, although results from the full trial are needed before concluding that CBT-SE is efficacious in improving job tenure.

7. Conclusions

Evidence-based psychosocial practices for individuals with severe mental illness can greatly improve people’s lives but are unfortunately scarcely implemented. When large-scale governmental or agency supported implementation initiatives are not available, clinical or community settings who are tempted to offer one evidence-based program or intervention could also opt for a merged intervention. Merged interventions have the advantage of targeting two sets of skills at once, and could therefore generalize in other aspects of the person’s life. For instance, individuals having received cognitive remediation within a supported employment program [28] could see improvements in other areas of their lives, outside of work, from their improved memory and attention skills. Similarly, the cognitive behavioural strategies used in the CBT-SE skills [34] are similar to those used in more general CBT for psychosis treatments and could be used to help the person assess situations differently at work as well as outside of work, with friends or family for instance.

This article aimed at presenting some merges of evidence-based programs but is in no way exhaustive. Other merges exist, such as social skills training with token economy for substance misuse [36] cognitive remediation with social skills training (e.g., Integrated Psychological Therapy - IPT [37]) or social cognitive training with CBT and skills training (i.e., Social Cognition and Interaction Training—SCIT [38]). These programs are however described as distinct and unique programs, not as merges of evidence-based interventions. Although evidence-based interventions are empirically supported, their impact on various outcomes can likely be improved by adding elements from other evidence-based interventions, or by offering them within an evidence-based program, as was demonstrated here. Although some of the proposed merged interventions have only been studied in small or uncontrolled studies so far, the strong empirical support for the non-merged evidence-based interventions from which they are derived and the preliminary data available so far is quite encouraging. Future studies on merged evidence-based interventions are warranted, particularly in terms of trials assessing the effectiveness of offering such interventions simultaneously rather than separately and at different times. Furthermore, studies should also consider measuring the level of integration of the practices in order to determine if closely-knit merges are more effective than less integrated practices. Finally, studies should also investigate if these merges increase or not generalization of the skills to other life domains.

Author Contributions
The authors contributed equally to this work.

Conflicts of Interest
The authors declare no conflict of interest.

References at the Behavioral Sciences site

INTERVIEW - Waking, Dreaming, Being: Philosopher Evan Thompson Explores Self and Consciousness in Neuroscience and Meditation

Awesome interview with philosopher Evan Thompson as his new book, Waking, Dreaming, Being: Self and Consciousness in Neuroscience, Meditation, and Philosophy, is just about to be released (scheduled to be released November 18, 2014). Thompson is also the author of Mind in Life: Biology, Phenomenology, and the Sciences of Mind (Harvard University Press, 2007) and the co-author of the seminal work, The Embodied Mind: Cognitive Science and Human Experience (MIT Press, 1991; new expanded edition, 2015).

This was posted in Wild River Review (edited to remove substantial typos).

INTERVIEW - Waking, Dreaming, Being

Philosopher Evan Thompson Explores Self and Consciousness in Neuroscience and Meditation

For a philosopher, staying with the open question means turning it around and examining it from all sides, without trying to force any particular answer of conclusion. But it also means not being afraid to follow wherever the argument leads. Evan Thompson, Waking, Dreaming, Being


I had the privilege of meeting philosopher, professor, scholar and writer Evan Thompson nearly ten years ago at Upaya Zen Center in Santa Fe, New Mexico for a reunion of the Lindisfarne Association hosted by one of Thompson's longtime friends and colleagues, Roshi Joan Halifax.

Thompson is the son of the Lindisfarne Association's founder, cultural philosopher and poet William Irwin Thompson, and grew up in the mileu of some of the late twentieth century's most daring and original thinkers. It was not unusual for Thompson to sit down at the dinner table with social scientist, Gregory Bateson; Buddhist scholar, Robert Thurman; biologist, Lynn Margulis; or Chilean neuroscientiest Francisco Varela, with whom Thompson would later collaborate on a groundbreaking book - The Embodied Mind: Cognitive Science and Human Experience.

 At 16, Thompson, who was home-schooled by his father, enrolled at Amherst College where he majored in Asian Studies, concentrating on Chinese language and Buddhist philosophy. He went on to earn his PhD in Philosophy at the University of Toronto and is an expert in the fields of cognitive science, philosophy of mind, Phenomenology, and cross-cultural philosophy, especially Buddhist philosophy in dialogue with Western philosophy and science. In 2014 he was the Numata Invited Visiting Professor at the Center for Buddhist Studies at the University of California, Berkeley. He is currently Professor of Philosophy at the University of British Columbia in Vancouver, Canada. 


When I was eight years old, my father gave me a copy of Gautama Buddha: In Life and Legend by Betty Kelen. I still have the copy, a 75-cent paperback, with my name in my own handwriting on the first page. I couldn’t put the book down.  I read it in the back seat of our old blue Volkswagen station wagon… I asked my father why he sometimes marked sentences in books he was reading with a red pen. He told me they were important ones he wanted to remember and find again. Like father like son; the red ink I marked on the paragraphs describing the aspiration to attain enlightenment and become a Buddha hasn’t faded against the yellow paper. Something about this drama of enlightenment appealed to me...Waking, Dreaming, Being


WRR: You are a philosopher, and the son of a cultural philosopher and poet. That lineage shows in your new book, Waking, Dreaming, Being. What were the challenges you faced during the writing process?

Evan Thompson: In the beginning, it was to find the right voice, and that took a fair amount of time. I started the book with journal entries, some of which became the personal narratives in the book. I didn't yet have a sense of what I was going to do with those entries, but I knew that I wanted to try to use them in something I would write about consciousness and meditation.

Later, when I tried to take those narratives and cast them into a more reflective intellectual shape, the process was quite challenging. It took me awhile to find the right way to do that. My wife, Rebecca Todd, a cognitive neuroscientist who is on the faculty with me at the University of British Columbia, has a very good ear for words that sound genuine and not mannered, so I showed her many stages of the writing. I went through five or six literary agents trying to get them to work with me. The response I got from all of them was “this is really interesting but it’s too intellectual. It’s going to be too hard for us to work with.”

When I sent the manuscript to Anna Ghosh, she said the same thing except that she really loved what I was trying to do, which was weaving back and forth between Indian philosophy, neuroscience, and personal experience. So she gave me concrete information about how to do that in an accessible way, and that was extremely helpful. It was almost a two-year process of sending the manuscript to agents, and going through different drafts. But once Anna and I started working together and successfully arrived at the tone and the voice, the writing went quite quickly.

WRR: What did Anna and Rebecca say or show you that you weren’t able to see on your own?

Thompson: They told me to assume that the reader knows nothing, and to strive to make every idea concrete through something experiential, through something that can pull a person into the narrative, through an image or a metaphor or an idea or a question. If you can create a way for the reader to relate personally to an idea, then it's much easier for them to pick up technical, scientific or philosophical concepts along the way. I knew abstractly that’s what I had to do, but something about the way that Rebecca and Anna were able to work concretely with specific examples of my writing reinforced what they were saying and provided a breakthrough for me.


It’s three o’clock in the morning in Dharmsala, India. The village dogs are refusing to let the monkeys outside my room have the last screech. I’m jet-lagged, and the commotion woke me up. I listen for a while, enjoying their raucous contest, and then put in earplugs and settle back to bed. The earplugs muffle the racket but amplify the sound of my own breathing, so I focus on this inner rhythm in order to fall asleep…Since I was a kid, I’ve always wanted to capture the exact moment when sleep arrives and notice when I begin to dream…colored shapes start to float on the inside of my eyelids...turning into cows and shacks and mules, like the ones I saw this morning on the bus ride up the mountain…The next thing I know, I’m flying over a large tree-filled valley. I must be dreaming...I’m having a lucid dream––the kind of dream where you know you’re dreaming…


WRR: Your book, ultimately, is a meditation on consciousness. Is consciousness wholly dependent on the brain or does it transcend the brain?

Thompson: That's the fundamental question of the book. I felt compelled to write about it because it kept coming up for me in different ways, some of which were personal and some intellectual. On a personal level I thought about the question a lot when I was working intensely with my friend and mentor, Chilean neuroscientist, Francisco Varela, just before he died. He was terminally ill and we knew that at some point soon he was going to die.

I write about the last real conversation I had with him, how it centered on consciousness and the question of its transcendence. It was fall of 2000 and Cisco and I were in my dad’s apartment in New York on the Upper West Side, writing a scientific article about consciousness and the brain. We weren't raising that question at all in the article but we were talking about it a lot when we weren't working. Cisco was a Buddhist, and knew that he was going to die soon, so transcendence was something he was contemplating. From a Tibetan Buddhist perspective, consciousness is the most fundamental luminous nature of awareness, underlying more ordinary cognitive forms of the mind, and it's not considered to be brain dependent. Cisco took this perspective very seriously, but he was a neuroscientist, so he was also skeptical and doubtful.

The experience of talking to Cisco about this and watching him die and feel the loss intensified the question for me. It was a question that I had always thought about, having studied Asian and Western philosophy, but also having grown up in the New Age and yoga world where it was just taken for granted that people had multiple lives and that consciousness carried on after physical death.

But of course when you start studying philosophy and science those kind of ideas get subjected to intense criticismand all of my professional career as a philosopher working with neuroscientists put a lot of critical pressure on the beliefs that I had been raised with. So, on an intellectual level, doing work in the philosophy of mind, it was natural to constantly return to that question.

WRR: How did Francisco Varela look at all this?  Especially at the end of his life when he still had much work to do. He could have felt that there was a lot he stood to lose.

Thompson: Varela had always been a very successful, groundbreaking scientist. Just before he died, he had major breakthroughs in the work he was doing on the brain basis of consciousness. Some of his studies had gotten a lot of attention, and had been published in places like Nature. He had a fantastic lab in Paris where he was bringing together people with the highest technical skills, but also with a deep interest in contemplative perspectives on consciousness.

So, the conversation I write about in Waking, Dreaming, Being occurred in my father’s apartment at a very pointed moment. Cisco was explaining to me––both from his own experience and from his understanding of Buddhist ideas––why it wouldn't be unreasonable to think that there could be an aspect to awareness or consciousness that would be unchanging across any perceptual or cognitive state, and that wouldn’t be perturbed by any bodily fluctuation. The traditional Indian image for this quality of awareness is luminosity, something I write about in the book.

Cisco was saying that from the experiential perspective of encountering the basic luminosity of awareness, which is what it is whether you're awake or dreaming or deeply asleep or under anesthesia (he had experienced being aware under anesthesia and encountering that quality of luminosity there), it would be natural to think that consciousness is something unchanging or constant, that it wouldn't be terminated by the death and decay of the brain. And as he was presenting that perspective.

I was presenting a neuroscientific perspective on why even that line of consideration––although it’s extremely compelling from a first-person experiential perspective–-does not necessarily imply that there really is a consciousness able to persist in the absence of the brain or the body.

WRR: Was he trying to convince you otherwise?

Thompson: It was a poignant role reversal––Cisco arguing the Buddhist view while I argued the neuroscientific view. But he wasn't trying to convince me or force anything. And I wasn't trying to convince him; we were exploring the matter together. He was, in his words, "staying with the open question."

I use this phrase in the book for the kind of attitude we need to cultivate, especially in the face of death. I f you have the chance, watch the film Monte Grandewhich is about his life, and was done shortly before he died. He talks about precisely what we're talking about--death and what happens to consciousness. He presents the Buddhist view and he presents the neuroscience view; and he says that you have to stay with the open question, instead of trying to resolve it intellectually. You have to do that in an existential way, with your whole being, in the face of death. So that is another key thread for me in the book, this idea of staying with the open question.

WRR: How do you stay with the open question?

Thompson: For me, it means turning the question around, thinking about it from many angles, being open and curious, and following wherever the evidence and argument take you. 

The question about consciousness and brain came to the forefront in the “Mind and Life” dialogues Francisco Varela created with the Dalai Lama. (The Mind and Life Dialogues began in 1987 as a joint quest between scientists, philosophers and contemplatives to investigate the mind, develop a more complete understanding of the nature of reality, and promote well-being.) On several occasions, some of which I've participated in and write about in the book, the Dalai Lama has presented the Tibetan Buddhist view that pure awareness is not brain-based. Of course, the neuroscientists have immediately pushed back.

As a philosopher, I'm interested in these moments when very different traditions come together, traditions that are intellectually rigorous and that can argue with, probe, and challenge each other. I'm interested in writing that does justice to the question itself rather than in trying to present an answer and defend it against all possible objections, which is what philosophers today typically try to do.
I wanted to write a book where the question was the guiding idea for looking at a range of different kinds of experience: sleeping, dreaming, lucid dreaming, the dying process, out of body experience, and perception. I wanted to bring to bear the critical observations and arguments from several different traditions--Western science and philosophy, Indian yogic philosophies, and Indo-Tibetan Buddhist philosophy.


I’m ten years old, sleeping in the top bunk of my room. I know I’m asleep because I’m looking down at myself lying in the bed below.  I’m floating above the bed, just beneath the ceiling... "The Patient was lying in bed and awakened from sleep, and the first thing she remembered was “the feeling of being at the ceiling of the room.”


WRR: I think it’s part of the human condition to believe we are eternal and to believe we exist outside our bodies. You write beautifully about out-of-body and near-death experiences. In one case, you describe an operating room, what was going on physically; and how neurologically someone could think they were outside their bodies watching the surgery. Maybe you could talk a little bit about that.

Thompson: When I was a kid, I had some very vivid out-of-body experiences. My dad explained them to me in terms of the Indian yoga cosmology, in which there are other subtle energy bodies besides the physical body. So it wasn't just that I had been raised with certain beliefs, but that I had had compelling experiences that made sense in terms of those beliefs and that seemed to support them. But then I came to have a lot of doubts when I studied neuroscience, because neuroscience has shown that these experiences are linked to certain kinds of brain activities.

Just after Cisco died, I wrote a paper with one of his PhD students, Antoine Lutz, about how to combine neuroscience with first-person investigations of experience, an approach we called, following Cisco, "neurophenomenology." When the paper was published, we got an email from a cardiologist in the Netherlands, Pim van Lommel, whose research focused on near-death experiences. He thought our approach would be a good one to use in studying near-death experiences, but he added that these experiences present a challenge to the neuroscience view that consciousness is entirely brain-based.

I already knew about near-death experiences but hadn't known there were any scientific studies of them, so I was intrigued by van Lommel's suggestion and I dived into reading a lot of the near-death experience literature. I thought that if the events in the near-death experience narratives happened exactly as they are described, with people remembering events that occurred when their brains weren't functioning, then they would pose a real challenge to the prevailing view in neuroscience that consciousness is based on the brain. So I went in thinking that near-death experiences could be important, that maybe they were an anomaly that neuroscience can’t explain.

When I started to probe deeper, howeverI became quite skeptical. Often, the narratives were constructed in a way in which the timeline made it seem as if certain things were being experienced when the brain was shut down, but if you actually looked at the evidence, there was no support for that. 

WRR: What did you ultimately find?

Thompson: Writing that chapter became a journey of discovery for me. I worked through the near-death experience literature and came out on the other side quite skeptical that these experiences show anything about consciousness having a life beyond the brain. It's not that people don’t have these experiences. People certainly  have very vivid and intense experiences, like out-of-body experiences, particularly in traumatic situations like cardiac arrest. But the way that a certain community within the medical world has presented these experiences as meaning that the spirit transcends the body, or that consciousness exists past the life of the body, that's a construction that's just not supported, let alone confirmed, by the evidence.

In that chapter (which is also published as its own short ebookI try to convey that journey of starting out thinking, "Here are these experiences…what do they mean?”, then thinking, "Let’s take a closer look,” and then thinking, "These experiences shouldn't be understood in the way they're usually described, and we need a different way to understand them." 

Instead of using them to argue for either a spiritualist agenda, which is what many near-death experience writers do, or a materialist one, which is what neuroscience debunkers of these writers do, we need to take them seriously for what they are--narratives of the first-person experience airing from circumstances that we will all in some way eventually face. After all, if one were dying or having a near-death experience, it wouldn't be the truth or falsity of the experience according to some outside religious or scientific standard that would matter most. it would be one's mental ability to be calm or peaceful or mindful in the face of what is happening. In any case, that is what contemplative and yogic traditions tell us.


In September 1983 my father took me to Alpbach, Austria, to the International Symposium on Consciousness, where he had been invited to speak. I had just graduated from Amherst College, where I had majored in Asian studies and studied Buddhist philosophy with Robert Thurman, so the conference which featured the Dalai Lama, quantum physicist David Bohm and Francisco Varela was the perfect graduation present. It was at this conference that Varela and the Dalai Lama first met...


WRR: I'm interested in another figure about whom you paint a compelling portrait: the Dalai Lama.

Thompson: My experience of the Dalai Lama is through the Mind and Life Dialogues. Some of these discussions take place at the Dalai Lama’s home in Dharamsala, with a smaller group of scientists and philosophers, and some at larger public meetings in the United States. The discussions center on the encounter and conversation between Western science and Buddhist philosophy and practice. What makes the dialogues compelling is that the Dalai Lama is interested in what science has to say but he's also not timid about critically questioning the scientists and their assumptions.

What's most interesting to me has been to watch those moments when the Dalai Lama, in confronting neuroscience, seems to allow himself to entertain the idea that consciousness could be physically or biologically based. Given his personal interest in science, and his strong personal and political aspiration to keep Tibetan Buddhism alive in the modern world, he has undertaken to bring science into the Tibetan Buddhist monastic curriculum. I wonder what effect this will have on future generations of monks and nuns, some of whom may go on to become scientists. I wonder what effect it will have on both Buddhist and scientific thinking about the mind.

In my own philosophical work, I've been very enriched by these dialogues. They've really brought home to me how scientific and philosophical efforts to understand the mind can't be limited to the concepts and language of any one tradition or community, but must strive instead to learn from diverse cultures of investigation.

WRR: In Waking, Dreaming, Being, you also explore physical practices such as Yoga and Tai Chi and how they relate to consciousness and the body. 

Thompson: The brain, of course, is part of the body; and we can’t begin to understand how the brain is able to do what it does without seeing it as part of a larger embodied context. All contemplative practices work with the body in one way or another.

If you think about something as basic as sitting meditation, you will find that it is thoroughly somatic. You have to put your body into a certain position so you can meditate, and you have to maintain a posture of stability and alertness. You have to balance between a tendency towards drowsiness and sleep versus a tendency towards mental jumpiness. All of that is bodily in terms of the energy required to directly influence the mental functions of attention or awareness or concentration.

Some traditions work directly with movement, as in walking meditation or yoga asanas (which can be held still or flowing). Then there are practices like Tai Chi with continuous movement. There's also standing meditation, which is an important component of Tai Chi training. Here you have to maintain an open, meditative mental awareness in a standing stationary posture. This practice creates a very distinct quality of awareness and energy.

WRR: You have an ongoing Tai Chi Practice.

Thompson: Yes, and from the perspective of my own experience of Tai Chi and standing and sitting meditation, I don't think we can understand contemplative practices unless we see them in a somatic context. From a scientific perspective, this makes perfect sense because the brain regulates what the rest of the body is doing and the body regulates what the brain is doing. It’s a constant back and forth conversation.

This point about embodiment also applies to dreaming. Some scientists and philosophers talk about dreams as if they were just brain-based hallucinations. I don't think that's right. I think dreaming is a kind of imagining. It puts into play affective and sensorimotor systems of the body. Physiologically, lots of things are going on in the body beyond the brain when you dream, and phenomenologically many dreams are structured in terms of a virtual dream body through which you have the feeling of inhabiting a dream world and moving around in it. So dreaming involves embodiment in both physiological and phenomenological ways.

WRR: You have many examples of dreams in your book, but my favorites are the dreams where you're flying. I've only flown once in a dream - or at least a dream I so vividly remember - and I was nine or ten years old. I'd forgotten the dream until I read your evocative descriptions of your own dreams. I deeply appreciated them because dreams are such a large part of our lives. I also appreciated your examples of different kinds of dreams because I was able to start looking at my own dreams from a technical point of view. I've been dreaming differently since I read your book.

Thompson: I'm happy to hear this because one my aims is to give people new ways to appreciate their dreams. I wrote the dream chapters first. They form the heart of the book. I use my own dreams to illustrate my ideas, along with dreams that friends have told me as well as poetry by many writers from different places and times. It was through writing down my dreams and other personal stories that I found my way into writing the book.

The first thing I wrote was the story about the book on Gautama Buddha that my dad gave me when I was a little kid. That vignette became the opening for the Prologue. Then I wrote the dream chapters, and it was through those chapters that I found my way into a different style of writing from what I had done before--trying to illustrate philosophical ideas through personal experience.

WRR: You write about using dreams to gain control over our negative emotions.

Thompson: One of the central ideas of the Tibetan Buddhist practice called "dream yoga" is to use lucid dreaming––or conscious dreaming where you are aware that you are dreaming––as an occasion for meditation. Once you're able to recognize the dream as a dream, you can try to transform the dream. Emotions tend to be very intense in dreams, but if you can recognize the dream as a dream, you can use it as an opportunity to mentally transform negative emotions like fear or anger into positive emotions like equanimity or compassion. Then you can take this practice of transforming negative emotions into waking life.

In Western psychology, lucid dreaming is often defined as being able to control the dream because you know you're dreaming. The idea is that if you have control over the dream, you can use it as a place to work out personal issues or as your own kind of private fantasy world.

I don't think there's anything wrong with looking at lucid dreaming in this way, but I'd say it's rather limited from a contemplative perspective. It misses a deeper point, which is that what makes a dream lucid isn't being able to control it; it's being able to pay attention to the dream as a dream, regardless of whether you're able to control it. 

A cognitive shift happens with that kind of attention, and that cognitive shift is what dream yoga means by recognizing the dream as a dream. Transforming the dream is about intervening in the dream or trying to control it, and that requires recognizing the dream as a dream. The interesting thing is that if you try to be still or focus your attention on just one thing in the dream, the dream will fall apart. Change, movement, and attentional shifts are needed to keep the dream going. 

So, if you can let all that happen while keeping the awareness that it's a dream, you have the unique opportunity to develop a kind of meta-awareness or mindfulness of the dream. You're able to remember that whatever is happening is a function of your mind and that there's a difference between what your mind creates--the content of the dream--and the simple watching or witnessing awareness of the that process.

WRR:  Is lucid dreaming better than non-lucid dreaming?

Thompson: I don't think we should fetishize lucid dreaming and make it into something that's special and better than non-lucid dreaming. Both belong to human experience and both are valuable. People relate to their dreams in different ways. Some people find lucidity exhilarating and others find it obtrusive. One of the ideas I write about is that dreaming is spontaneous imagining. I don't see why spontaneous imagining is intrinsically better if it's lucid.

Some Buddhist teachers say that it's always better to be lucid than nonlucid when you dream. I don't follow that way of thinking, and in Waking, Dreaming, Being I use a parable from the Daoist thinker Zuangzi (Chuang Tzu) to say why. The parable is the one where first there is a man dreaming he is a butterfly, then there is a butterfly dreaming he is a man, and we can't say whether it's a man becoming a butterfly in a dream or a butterfly becoming a man in a dream. There's no lucidity, just a succession of phases. The parable is traditionally read as an allegory of life and death. With regard to dreaming and lucid dreaming, what I take from the parable is that we need to be able to let go of lucidity and release ourselves to the full presence of the dream. If we can't, then we deprive ourselves of certain natural and valuable experiences. 

WRR: I often think a spiritual practice is ultimately about how we face the end of our lives. We deny death so much in our culture. In Indian and Buddhist traditions, there are manuals giving instruction on how to die. You describe very well a workshop you took with Roshi Joan Halifax at Upaya Zen Center, where she takes you through a guided meditation that simulates your death. It seemed, at least the way you wrote about it, that it was frightening for you. I appreciate how honestly you described your experience.

Thompson: The fear of death is basic to the human condition. We're the only animals, so far as we know, who can think forward in time in order to try to imagine the time of their own deaths, who can grapple with trying to understand how the world will be once we are gone, and who can wonder whether death is the final end or whether there is some further continuation of consciousness. Contemplative traditions, especially the Indian yogic traditions, including Buddhism, are very much concerned with preparing us for the inevitability of dying and death, both one's own and the inevitable loss of loved ones. Buddhaghosa, the fifth century A.D. Indian Buddhist philosopher, says that the moment of death is the most important moment in life and that the point of meditation is to prepare one's mind for that moment.

If you look at probably any religion, or contemplative or spiritual tradition, you'll find a confrontation with death at its source. Siddhartha Gautama renounced life in the world and set out for the forest in search of awakening because he was so distressed by the sights of sickness, old age and dying, and death in the form of a corpse. Sacrificial death is at the basis of Christianity, and of course the image of the dying god is much older than Christianity.

The "dissolution meditation" I describe in the book is Roshi Joan Halifax's modern, nonsectarian adaptation of a Tibetan Buddhist practice. She uses it in her "Being with Dying" program for end-of-life clinicians and caregivers. You imagine the progressive dissolution of your body and mind as you die. The idea is that you cannot be an effective caregiver to the dying if you are constantly turning away mentally from death, so the meditation helps one to confront the thought of one's own death. In the traditional Tibetan Buddhist context, of course, the ritual is very powerful because it's full of cultural and religious symbolism. I found Roshi Joan's version to be very compelling. So was reliving the experience in writing about it.

WRR: I appreciate the little details you put into that chapter, how the thrust of the meditation was to remain conscious, and yet people fell asleep. You describe how a few people were snoring and I imagine I would be one of those.

Thompson: Thats funny. The link between sleep and death is very old. Sleep (hypnos) and death (thanatos) are twin brothers in Greek mythology. Sleep and death were linked much earlier in The Epic of Gilgamesh. They're linked in both Old and New Testaments. In my book, I give reasons for thinking that Tibetan Buddhist descriptions of what happens to our minds when we die are in many ways extrapolation from what happens when we sleep and dream. 

WRR: In your opinion, are we the dreamer or the dream? 

Thompson: You could say we are both.

Evan Thompson, Photo by Christian Coseru

In addition to Waking, Dreaming, Being: Self and Consciousness in Neuroscience, Meditation, and Philosophy (Columbia University Press), Thompson is the author of Mind in Life: Biology, Phenomenology, and the Sciences of Mind (Harvard University Press, 2007) and the co-author of The Embodied Mind: Cognitive Science and Human Experience (MIT Press, 1991; new expanded edition, 2015).

Friday, November 07, 2014

Ruth Buczynski, PhD - Rethinking Trauma: The Third Wave of Trauma Treatment

This comes from the National Institute for the Clinical Application of Behavioral Medicine (NICABM) website. There is nothing new here for those of us who follow developments in PTSD research and treatment, but it's still interesting.

Rethinking Trauma: The Third Wave of Trauma Treatment

By Ruth Buczynski, PhD

As someone who’s been practicing for a while, I’ve seen our view on the treatment of trauma go through substantial development. Our research, theory and treatments have all advanced considerably in the last 40 years.

And as I reflect upon this, I’m seeing 3 waves in the evolution of our outlook.

Looking back at when I first began to practice (in the late 70’s) our understanding of trauma was really quite limited. Of course we recognized the fight / flight response ever since Hans Selye introduced the notion back in the 50’s.

But our prevailing treatment option was talk therapy.

The thinking at the time was that by getting clients to talk about their traumatic event, we could “get to the bottom of” their issues and help them heal.

We were aware of the body and knew it held some power. But few practitioners used it in treatment (except the relatively few who worked with Bioenergetics, Rolfing, Feldenkrais, Rubenfeld, and to some extent Gestalt therapy).

But we were very limited in our ability to explain how body work, or for that matter, a talking treatment, affected the brain (and we had very little evidence-based research for it either). We just didn’t have much of a roadmap to guide us where we wanted to go.

That was the first wave.

Over time, researchers and clinicians started to recognize the limits of talk therapy. We realized that talking about a traumatic event held certain risks. At times, we inadvertently re-traumatized patients, especially if interventions were introduced too soon, before the patient was ready.

We also saw the memory of trauma as more often held in the right brain, the part that doesn’t really think in words.

So we began to use interventions that weren’t as dependent upon talking, interventions like guided imagery, hypnosis, EMDR, and the various forms of tapping.

And as the science surrounding the brain’s reactions to trauma became more sophisticated, clinicians grew to understand more about what was going on.

We began to realize that not everyone who experiences a traumatic event gets PTSD. In fact, most people who experience a traumatic event don’t get PTSD.

And so researchers started to develop studies to determine who did and who didn’t get PTSD. We looked for what factors might predict greater sensitivity to trauma.

And we modified our thinking to add freeze (later known as feigned death) to the fight/flight reaction.

Just adding that piece clarified our thinking about what triggers PTSD.

It also began to expand our treatment options to include sensory motor approaches.

And we started to see how more vastly intricate and multifaceted multiple trauma was compared to single incident trauma.

But I believe a third wave of trauma research and treatment innovations has just begun to crest.

And it’s only come recently.

In just the past year and a half, pioneers in the field of trauma therapy have once again discovered more effective methods for working with trauma patients.

Because of all the research that’s been done, we are much better able to predict who gets PTSD and who doesn’t. Not only that but we’ve got a good handle on why certain people get PTSD.

And as brain science has revealed how different areas of the brain and nervous system respond to traumatic events, we don’t think so often about whether trauma is stored in the left vs right brain.

We think in terms of three parts of the brain, the pre-frontal cortex, the limbic brain and the lower, more primitive brain. And we’re much more sophisticated in thinking about which part needs our intervention.

We understand that the lower brain can command the shutdown response, totally bypassing the prefrontal cortex, totally bypassing any sense of “choice” for the patient.

And we see more clearly the part that the vagal system plays in this shutdown response.

We understand more of the role neuroception plays in feeling safe.

Knowing how the body and brain react to trauma opens the door for the third wave.

We are now beginning to use techniques like neurofeedback (based upon but a long way from the biofeedback we used years ago,) limbic system therapy, and other brain and body-oriented approaches that include a polyvagal perspective.

These are techniques I couldn’t have dreamed of when I began clinical practice, and for the most part, they weren’t prevalent five years or even two years ago.

But these are powerful tools that can offer hope to those who have been stuck in cycles of reactivity, shame, and hopelessness.

I’d like to share with you some of the leading edge research and treatment options that this third wave has introduced – for more information, just click here.

And I’d like to hear from you: What changes have you seen in your work with the treatment of trauma? Please leave a comment below.