Consultant clinical psychologist Dr Miles Rogish has pioneered the use of Compassion Focused Therapy (CFT) among patients with brain injury. In Here he speaks to NR Times about his experiences of piloting CFT at the York House centre operated by Brainkind (formerly Disabilities Trust).
What are the origins of the CFT model?
CFT is grounded in the evolutionary analysis of basic social-motivational systems. Its aim is to support mental and emotional healing.
Professor Paul Gilbert developed it because, while cognitive behavioural therapy (CBT) was helping a lot of people with depression, there was a large group who it simply never moved.
Through analysis he found that core beliefs around guilt and shame were keeping their emotional system dysregulated.
Dr Miles Rogish (credit: Brainkind)
Why did you decide to apply it at York House?
In a challenging behaviour environment, there is some degree of risk and threat, not only for the staff but also for the people we serve. We must learn to live and work with this.
Also, people with chronic problems often have difficult backstories and a history of trauma, abuse or substance abuse. They may have self-critical or self-hating beliefs.
Lots of people we support have pre-brain injury issues, such as attachment difficulties stemming from early childhood or learning difficulties.
In my own analysis, I discovered that almost every one of the people we have supported over the last decade had had at least a couple of significant, pre morbid, pre-brain injury risk factors.
Before their brain injury, many had never had good experiences of feeling safe or contained. Many didn’t know how to calm themselves or make themselves feel better when things didn’t feel quite right.
Service users often do understand these issues when you talk to them about their background and presenting problems.
Just because they understand, however, they may not be able to modulate or work with these emotions in the moment.
CFT formulations allow for a simple, natural understanding of emotional responses in themselves and in others.
Please elaborate on CFT and its role in supporting a better understanding of emotions in people with brain injury
CFT has an evolutionary aspect to it; All animals including humans have a fight or flight response. It is needed and hardwired in us to help us fight or escape from dangerous situations.
Similarly, all animals have a drive system that pushes them to meet the basic needs; to eat, drink and reproduce.
In humans, drive can also be connected to factors like status, making money or having the right house.
The final system in this research model is the soothing system, which helps us to down regulate and keep ourselves calm.
We start learning this as infants, typically when our mothers cuddle us when we cry. This is how we form attachment and learn to down regulate our emotions.
Some of our people have difficulties self-soothing that stem all the way back to infancy.
Being aware of the history of the people you are working with will help you to recognise those without the ability to down regulate threats.
The ‘3 circles’ emotional regulation model.
How does CFT fit in with the widely-used neuro-behavioural model?
The neuro behavioural model is the overarching model of treatment developed in the late ‘80s for people with acquired brain injury.
It was designed for people with a neurological insult who may have difficulties learning explicit information.
Its aim is to help people learn procedural information and the approach requires repetition and practice for skills acquisition, including social skills.
Within the model, staff act as the external manager of behaviour.
People with executive difficulties will have memory problems, they won’t have the foresight to plan, and will have a reactive presentation. Staff need to be proactive in managing situations.
One of the greatest challenges of this model is how to treat someone’s behaviour the same way and consistently.
The neuro behavioural approach is very effective with executive syndrome.
But if you have just one or two staff who unintentionally reinforce the behaviour by acting the wrong way, it can really impede the individual’s progress.
Executive syndrome involves difficulty in controlling or monitoring one’s own emotions or cognitive functions.
This definition of challenging behaviour has a social focus. It is a behaviour that makes it difficult for a person to make use of regular community facilities.
I love that definition because it takes the blame off the person or behaviour and it puts it in the context of where the behaviours are problem.
Neuro behavioural formulations are great at explaining what happened to the brain and how that issue is causing dysregulation or disinhibition.
However, they rarely talk about the emotions the person might be experiencing.
Neither do they talk about what you as a therapist, support worker, or a family member might be experiencing emotionally in relation to the behaviours of the person you’re trying to help.
One of the real challenges of behavioural work is how to keep staff consistent.
There’s a lot of research out there that shows that general hospital staff just avoid challenging behaviour. That’s normal. That’s something that we all do when someone raises a fist and threatens us.
But when you run away from a behaviour, you are probably reinforcing it.
So getting staff to understand that and helping them to be able to sit with that fear is really what I was hoping to achieve by integrating CFT and repeatable approaches.
Is it difficult to implement CFT among neuro-rehab teams?
The thing I love about CFT is it’s simple. You can understand the model easily and you can teach it easily. You can teach the people that we serve or teach it to their families.
When you break it down to three coloured circles, you can describe this executive syndrome without using neuro anatomy at all, you can just talk about the three circles.
Can you give us a specific example of how CFT is used at York House?
I decided to develop a stress management course for staff using CFT.
Initially I designed a three-hour programme with three weeks of exercises in between, but it didn’t really work out.
Then one of my support workers told me: “I hated working with a particular individual before your tutorial because he scared me. I never knew what to do. He was laughing at me, he was threatening.”
But after the tutorial, she understood that he was behaving that way because he himself was really scared. So she changed her approach to him.
She told him: “Let’s start over. I want to make this good for both of us. Let’s have a nice, relaxed time.”
She approached him like a giant green circle, basically, and it completely flipped their relationship.
It was that conversation that gave me the idea of using an interpretive phenomenological analysis as my methodology.
I used semi-structured interviews and complex questions with open-ended responses.
I then transcribed all the interviews and looked for themes and superordinate themes which were pulled out to get an average lived experience.
With the first study, I had a formulation for a person with challenging behaviour presented to a group of staff.
It included both CFT and neuro behavioural components to explain their challenging behaviours and ways to normalise staff emotional reactions to these behaviours.
It suggested ways that staff could change their approaches to work with him.
The formulation included a three circle model tailored to the specific service user. It included their history, including issues related to his ABI and healthcare support needs.
There was also quite a lot of neuroscience information that had been generated during our three months together.
Small groups of staff were given tutorials and were then asked if they wanted to participate in the research.
Please tell us more about how the approach impacted on the service user
He was a gentleman in 60s who had profound cognitive impairment following a motor vehicle accident.
Initially, when he presented to us, there was also a lot of physical disability and he was using a wheelchair to mobilise.
By the time he got out of York House, however, he was able to walk independently and he had made great physical progress.
But he found everything confusing. He didn’t always understand that he was in hospital and had a brain injury. But by three months in, he understood where he was and why he was there.
He was also starting to recognise people, but it took a few more months before he was remembering names; and whenever people were trying to help him, he would get aggressive.
When I used the formulation to explain the situation to staff, I explained that he didn’t understand what’s happening to him other than that people were trying to grab him.
He had a lot of drive. He was trying to stand up all the time.
You could engage with him on certain topics and he was a lovely man before the accident – and after it, still had a wicked sense of humour.
But he would lash out and hit someone and then start crying because he’d hurt them.
He had no ability to regulate or self-soothe.
A big part of soothing on the part of the staff isn’t just how to soothe them, it’s how you present yourself so that you can meet their needs in that moment.
He needs to feel soothed and know that his needs are being met.
It’s not an easy thing to do when you’re feeling threatened.
But the best thing you can do is remain calm, keep a peaceful expression on your face, recognise that he’s upset and label his emotion so he feels understood.
What are some of the useful insights gained from this particular case study?
Nine staff were interviewed, all of which had been in the service for at least six months and had worked with the person for three months.
Overall, they reported that they felt reassured of their own feelings and their work with the service user.
They also mentioned that the formulation was easy to understand and implement. They understood the service user’s behaviour and how to respond to it.
They also said that it helped staff to be more consistent and that they were able to talk to one another about the formulation and share the information together when discussing service user needs.
Where did your research take you after that?
I decided to do a study comparing this type of formulation verses online training.
The online training consisted of a 20-minute PowerPoint presentation going through the formulation.
I then explained how the trainee should apply it.
In the study, six people who had face-to-face training and four people who had online training were interviewed by Masters students from the University of York.
The questions included those covering behaviour, formulation, pandemic-related issues and the format of the presentation.
What were the standout themes from the analysis?
Number one, establish empathy and compassion for the service user, but also toward the staff themselves.
Care is hard and it can be scary. You’re caring for these vulnerable people and the last thing you want to do is mess up, especially if you’re new to the team.
But this type of training helps people understand that sometimes, even if they do everything right, things will go wrong, even if they follow the formulation and care plan.
When it came to the tutorial preference, everyone preferred face-to-face, but they did see value in online training.
That said, one of the major limitations was that they wouldn’t be able to ask questions there and then.
And often if you’re not there in the moment to ask the question, the question is lost.
What were the wider implications of these findings?
Some people said that they would apply CFT to help them understand their own children and themselves.
One common theme was that CFT helped them manage stress at work before it became overwhelming.
In the past, it would affect their health, but taking the guilt away from the experience helped that.
How have you built on the foundations of these initial studies?
After that work, I asked myself how I could reach more people with this approach.
I developed some simplistic prototype formulations and case studies, one for fear-based aggression and the other for dysexecutive syndrome.
I presented into two groups: one consisted of senior leadership team members and the other, support workers who were CFT-naïve.
In this study, there was an interesting split in how these two groups saw the same information.
Both groups thought that the theme of individuality helped to explain the psychological complexity of service users very well.
But the other two subfields of individuality, education and open mindedness, were only present in the senior leaders.
So that’s how do we educate staff? How do we increase a person’s open mindedness about another?
And how do you use your interactions with them to develop and create meaning in a therapeutic context?
Another theme only present for senior managers was clinical reinforcement, knowledge-based coherence and workplace compliance.
These are all important things that mean nothing to support but everything to senior managers because they want to be consistent.
They want staff who can comply with their plans and formulations.
And then the fourth theme, which was only a theme for support workers, was personal responsibility, removal of blame and personal development.
What did you conclude from the study?
That this training helps support workers to understand what they’re responsible for and what they are not responsible for.
It shows them that as long as they’re following the care plan and the formulation, they are doing their job right.
The take home message was once again that CFT increased staff confidence and led to more consistent interactions that lead to better outcomes.
Overall, it became clear that different members of staff see different benefits from the CFT training.
Frontline workers can use the information to build resilience in their work, be more consistent and increase outcomes.
