I'm Katrina Karlsson and I'm a Swedish psychiatrist with a research background in cognitive neuroscience and functional imaging. So I want to begin with suggesting that a crisis is part of most psychiatric consultations. We're trained to find the accurate diagnosis and the pharmacological choice and that's very important and we have that down. Today I will offer you some other tools for your crisis consultation. At the end of this presentation you will have available a simply remembered crisis integration, something to hold on to that will help people to grow through and be with their crisis. In particular you will get insights on how to guide your patients to use their body in terms of sensing their body from within when processing their crisis. Let me see how to use this. Most importantly you will get the theoretical background to why that is effective. I've learned to use this device. So the presentation is based on a book that I wrote together with Kajsa Strössl, one of the three founders of acceptance and cognitive therapy or ACT and Laura Roberts, professor at Stanford. It was published last summer by APAP and it means that it's a textbook directed to psychiatrists. However I wanted to write it in an accessible way so we could read it after work hours. I wanted to write a page-turner on crisis. In this presentation we'll launch from what we already know about crisis and we'll move on to our new crisis integration model of the distinct psychological processes that alleviate suffering in crisis and we'll also talk about what leads to increased suffering when in crisis. What we've called crisis instigation. We'll explore why crisis instigation is common and logical from the perspective of evolutionary psychology and neuroscience. A presentation of the brain for brains for learning systems will provide the foundation for the neuroscience theory or predictive coding and its interface to mindfulness of body. This I promise will be cutting-edge and just out of curiosity how many of you are familiar with the predictive coding theory? Wow it's gonna be exciting. In the book we have many clinical applications referring to practice but this talk will have a more theoretical emphasis and you will find the predictive coding theory to be the red thread throughout the talk. We'll shine light on what why on the paradox why acceptance of what's going on inside actually leads to the change that we desire and we'll discuss what drives the decision-making and engagement and also how substance abuse disorders can be understood as a loop of crisis instigation and how to turn that around with our model. Afterwards we'll have ample of time for Q&A. I just wonder is this sound okay or is it too loud? It's okay. Throughout the presentation I'll be pausing a few short times for some experiential exercises. Now I was given the gift of having a one and a half hour session with you which I will use for leading you through an amazing landscape. So if you're interested in the interface between concrete clinical applications of crisis integration and modern neuroscience theory just sit back and enjoy. Once upon a time my boss asked me if I could do a synopsis on what to offer our patients when they were in crisis. What I found was that there were no clinical handbooks on crisis really suitable for psychiatrists and I thought to myself how is this void even possible given the amount of crisis we're all going through and our patients even more so. I began with getting a grip on the crisis science literature and started with definitions. Crisis definitions more or less boils down to life stress exceeding coping capacities in such a way that it may lead to danger. Crisis is typically thought of as the first acute month of uproar and during this time what's usually recommended is stabilizing the situation to reduce the risk of danger happening. That is practical help routines, food, sleep and listening. But what we clinicians usually get to see is the psychopathology that sometimes evolves after this month. In this presentation we therefore will recognize crisis reactions not only of short but also long duration sometimes lingering for years in terms of PTSD, depression, anxiety disorders, substance abuse, the danger. In a crisis situation we have vulnerabilities and stress on one side and the resilience factors on the other side. In the vulnerability literature we find genetics, epigenetics, attachment style, early trauma, socioeconomic factors, nothing new. In the resilience literature we find acceptance, expressing positive emotions such as gratitude and humor, discovering a meaning and purpose in life and connecting to one's ethics and altruistic motivations, self-efficacy. Now this all belongs to a descriptional crisis definition. In a little while I'll provide you with a new functional one. Furthermore the crisis science field has moved on from the assumption that resilience is a stable personality trait, something that you are and inertia in proximity to stressor is something opposite to vulnerability factors. To understand resilience as a flexibility as a willingness to be internally changed by an external factor. In a flexible response you take care of the inner world as well as the practicalities of life in a dynamic process like this also called the dual model. So this is the state of the art. Now moving on to the new stuff. The crisis science findings inspired me to draw this crisis integration model. In the typical example of becoming severely ill you alternate between tender acceptance of your inner world and engagement, choosing behaviors that best serves your needs and values in this new situation in a dynamic process. But before acceptance happens we need to know what is going on inside and this is done through observing or mindfulness. And it was here that I contacted Kirk because this aligns with act and psychological flexibility. So this practice is easy as a pie. It's just these three processes right? But also a locus of profound learning throughout our lifetime and we'll expand on this model today. But first if this model helps us integrate a crisis we have called the opposite model crisis instigation model. Instigating in the meaning of provoking, prompting, advancing, inciting. An inner flexible response is largely driven by avoidance and disengagement. Avoidance is trying to change things that ultimately cannot be changed by will, such as emotionally emotional and bodily responses, memories of the past. In disengagement we lose sight of what can be changed. We're doing more or what used to work but no longer does so. Keeping busy and unwillingness to approach important areas in life. And these kinds of behaviors are usually done in service of avoidance and therefore they are interconnected. Here we have moved from descriptive definition to a functional one. So this is our crisis formula. We have moved from describing what a crisis is to how a crisis is instigated. So even though we tend to feel alone in our suffering the processes that instigate crisis are neither personal nor unique. They have to do with how we are shaped by evolution in interplay with our individual prior learning. Down the line crisis instigation has to do with our learning of how to avoid nasties and approach goodies. And with that our behavior are more or less habits from before. What's important is that we want to remove guilt from our crisis instigation response. Instead we want to become crystal clear aware of this response. Normalize it. Even love it. And then find new responses. To do so we need to learn a little about the brain and the evolution. Principally the brain was developed with add-ons. The latest radical shift to our brain function happened 70,000 years ago. And what I want to visualize here is that 70,000 years is a very short time in the evolutionary perspective. Our old ancestors appeared two and a half million years ago. But two and a half million years is also a very short time considering for how long time organisms with a central nervous system have been on this planet. The brain that we have as a result has principally four learning systems that have been added on one another. And we call them evolutionary shaped learning, model-free learning, model-based learning and finally with the cognitive revolution we got access to meta abilities. With these abilities we can become aware of the urges, models, thoughts and rules that have may have served us well in previous situations but no longer does so. Meta abilities provide the foundation for mindfulness, acceptance and engagement and are crucial to flexibility during crisis. I feel like dancing here. What's going on in there? But remember we got access to this ability only 70,000 years ago. And with these abilities we have to balance up all the programming that our brain has that has taken place for hundreds of millions of years in terms of perceiving, learning and responding. We'll expand on this slide also during the presentation. Our ancestors have done the first type of learning and is now expressed in hardwired feature and how we perceive and respond to the world. Organisms then evolved the ability to learn so that they could adapt to new environments during their lifetime. Model-free learning is learning about rewards and punishments which involves associative learning and trial and error. These learning modes don't require an internal model, explicit knowledge and this is important, of either stimulus or the response and its consequence. Hence it's called model-free learning. In the human brain such learning involves mainly subcortical areas which also goes for trial and error of course. I didn't count on this one. On top of the model-free learning system the human brain and to some extent animal brains have access to a far more flexible learning system, learning based on internal models of the world. So I have a laser thing out here and I have an internal model in here of it. So model-based learning still evaluates the values of one's actions but it does so based on internal models. So if I push this button something valuable happens. So freed from having to learn about the world through trial and error humans can play with both verbal and nonverbal models of the world using imagination, guesswork, comparisons, recall and a thousand modes of other modes of cognition, both regarding the external world and the internal. With these ways of learning, these ways of learning help us function. Sometimes however when we behave in compliance with previous learning whether shaped by evolution or by model-free or model-based learning we find ourselves in trouble. The key words here are previous learning. A crisis situation requires new responses. Luckily humans have at their disposal these higher order capacities for perception learning metabilities. We'll come back to them. Another useful way to visualize how these different learning systems relate to one another is to emphasize the hierarchy of awareness and levels of processing. The first level pertains to the model-free system that doesn't require a conscious experience but nevertheless greatly influences our responses to the world more than we think. Then humans have access to two types of consciousness. The primary type being the inner representation of the world what is sometimes called sentience. After the cognitive revolution our brain became able to generate not only the subjective experience but also an awareness of having these experiences. So metabilities allows for the mindful observing of thoughts, feelings and bodily responses and knowing them as such. And I would argue that metabilities and mindfulness are what we need to cultivate for crisis integration to happen. I just don't see any way around it. Therefore we'll use this model throughout the rest of the presentation. To begin with it will inform a neuroscience based definition of mindfulness. The first dimension regards our subjective experience of the now which if we refer back to the hierarchy of awareness takes place in level two. Remember level one was the unconscious experience or processing. Our pets are good at reminding us what this is about but although for example our dog's attention is in the now it is not particularly mindful. The next necessary quality is meta-awareness of the present moment. A movement from only feeling despair for example to also observing the despair and this takes place at level three. The third quality that we commonly forget is to be meta-aware of any filter through which we attend our experience which also takes place on level three. Are we observing what's going on with an ever so slight aversion, wanting to avoid it, judge it, put it away? That would be just another level of avoidance and I don't know about you but I certainly know about my mindfulness practice that I take one mindful breath and then I check, did the discomfort go away? Do you relate to that? So I use mindfulness as another avoidance strategy and I'm not alone. As a rule, our observing is infused by fear and wanting, avoidance and clinging. In the end, mindfulness is not about rejecting, it's about recognizing. Sorry, go back. So this becomes an iterative process. Through practice we learn to recognize this inner push and pull and with time only this generates an attitude of equanimity toward the content in charge of this experience. And here we may stop for one moment since we need to address one important question. Why should mindfulness be essential in crisis when there is so much emotional distress and generally so many real-world problems to take care of? Mindfulness is thought of a luxury for those with the privilege of time and resources, yet it has been shown that the harsher our life is, the greater the adversities we face, the more beneficial it is to have this practice, the more difference does it make. And today we learn why that is. To do so, we'll take a look at the predictive coding theory of the brain and how it informs the inner experience of the now. Our experience of the now comes namely as much, if not more, from the brain's guesses about the now as it does from the now itself. In other words, what we perceive in the moment is in large part a reflection of what our brain predicts it's happening on the basis of prior learning. Everything is filtered by and understood through prior knowledge. Our experience of the now becomes as such a large part an echo of before. And when I talk about the echo or previous experience, I mean what I, Katrina, have learned in my lifetime as well as what my ancestors have learned. The echo in the meaning of the totality of conditions that culminate in the now. All the previous learning will play in co-creating the experience of the now. The big question is what happens when there's a mismatch between then and now. So if this is the brain's prior model of what's going on, and here is the present event, when prior knowledge and present event doesn't match, there will be a so-called prediction error which alerts the brain that the current model is wrong and that something in the world, inner or outer, appears to have changed. In other words, ascending predictive errors seem to broadcast newsworthy information that is present events that cannot be explained away by prior knowledge. A prediction error is a problem that the brain will aim to resolve. It's fundamental to our health and well-being and this can be done in two ways. Either through changing the world to fit the model, this movement here. This provides us with the stability we need but also sometimes prompts a crisis. Or we can change the model to fit the world and this is important. The movement here means that a perception happens on the short time scale. An inner experience of the now and learning happens on the longer time scale. This will contribute to the flexibility we need in crisis, so hold this in mind until we get to the mindfulness in crisis integration. Furthermore, we say that the predictive coding function computes or guesses the probable cause behind what's happening here in terms of light hitting our eyes with the wavelength of 500 nanometers is experienced as green. We get a perception of green. As we know, there is no green out there. It's just our predictive coding function in the brain that guesses that it's green and produces such a particular experience. The interface between the brain and the matter and our subjective experience has always fascinating mankind and is still somewhat a riddle that will not fully solve today. Instead, we'll move on to our experiences when in crisis. Specifically, the predictive coding function of the brain guesses that the probable cause behind what's happening in the body is experienced as emotions. For example, increased osmotic pressure is experienced as the homeostatic emotion of thirst and increased heartbeat symptoms as fear. Now, and I'm happy you're all still here, because now we'll bring to bear all what we learned about the brain and predictive coding to learn about emotional processing in crisis. Emotions consist of several aspects and here we've chosen three. Physiology, motivation to act and the subjective experience. Emotions, however, can be unaware but the more we're aware of them the greater flexibility we access. This aware processing happens in the insula in coordination with other areas, of course. Posterior insula processes bodily information and the anterior processes emotional information. The insula is one of the areas that increased in size the most during the cognitive revolution leaving us with increased flexibility regarding emotional processing. But in crisis what we usually see is this. Nothing we do seems to promote bodily ease and there is nothing we do can do that deals with the situation and the subjective experience is unbearable. The strategy commonly used then is to avoid, inhibit and if necessary dissociate from body and feelings. Even though avoidance may be the only response available at the time of the event and may so be functional we'll get in trouble if we continue to avoid over time. When the terrifying outer situation becomes history the most frightening phenomena are found inside the body. Even if we're doing our best to avoid the body emotional learning from before still resides as model-free subcortical processes. That is the first level of processing in this hierarchy. We may say that the suffering hides out under the radar of consciousness. In the language of predictive coding input from the body becomes underweighted. In other words ascending input from the body will be assigned less validity, less significance and will not reach awareness. By affording bodily input less precision weight the brain has changed the inner world to fit the model of staying calm or rather numb. The brain has muted the signaling system. When bodily information is avoided in this way naturally also other information from the body will be regarded as less important as underrated and this will lead to a general failure to regulate the body which leads to even more suffering. So what we see here is a transdiagnostic phenomenon for most psychiatric conditions, mood, anxiety substance use disorders, PTSD etc. which leads to an insensibility to yourself and to your life. Avoidance as we know is met with exposure in psychotherapy. It almost goes without saying but when we are mindful of the body we're exposed to bodily sensations and emotions here in the torso. For this to happen we first need to establish meta-awareness over a sustained period of time so that we have something to expose the previous learning to, something that can be with experience. We can gather our attention by observing or listening to any type of information be it radio channel one, the body or any other channel. However the easiest channel to stay with for the sustained period of time is the body for most of us but not just any part of the body. It has to be a fairly emotionally neutral one which is in crisis typically found far from the torso where feelings reside. Otherwise it will be difficult to access meta-awareness of the bias. What we want to do with the feelings will easily get stuck in avoidance of the pain. But if the foot for example is neutral we'll just feel the foot, you're level two and know that we feel the foot, level three. So let us think about why focusing attention is beneficial in crisis. Take a moment to think about times where you have experienced the benefit from gathering the attention in crisis of having an attentional anchor, you or some of your patients. It is found that we access rest and soothing and calm and equanimity. It provides a place to lean out of the pain. But this is not a matter of avoidance. We actually seize avoidance strategies such as thinking. After we have established meta-awareness in this way we can open up to be mindful of all of the body. When we listen to the body instead of avoiding it the reverberations of prior learning can show up for exposure and processing. In the language of mindfulness of body we allow for any bodily signal to appear which becomes exposure for body and emotion. In the language of predictive coding the brain assigns more weight, more validity and significance to bodily input as sending predictive errors relative to the prior model of avoidance of staying numb. Bodily sensations will be regarded as more newsworthy. And here I can with surprise notice the vast amount of mindfulness research make a concluding point in the abstract that some people actually feel worse with mindfulness. Of course they do for some time. When they're not avoiding feeling surface then we need to learn how to lean out in meta-awareness for some rest before we lean in again. And this is the trick in exposure which we don't talk so much about. You're in the emotional pain and with the pain knowing the pain. I believe that exposure in PTSD treatment for example will have much to gain by including sensing the body from within and knowing the sensations as such while telling the details of the trauma. For repetition in mindfulness bodily input is assigned more weight and is allowed to reach level two and three for awareness and meta-awareness. Bodily information and emotions can thereby be known. Here comes possibly one of the most important slides of this presentation. In mindfulness of body we begin by establishing a meta-awareness through attending to the foot or the breath for example. We then allow for bodily information to be known and we learn through knowing, touching, observing what shows up say heart pounding or fear. And this is not an intellectual learning. It's a learning without a teacher. It can feel like first you see the vase and then you see the face is a sort of an inner shift, an inner click. It's a learning that with time establishes a new model of safety as well as new subcortical connections. Perceptions, perception of the now leads to learning and to psychological flexibility implemented in tiny steps. It's a gradual learning. In mindfulness we open our heart to the past, saying yes to everything. This slide speaks to the paradox that mindfulness of what is, just being with it, leads to the change we're after. Typically in open attention allowing any bodily information to be known this happens. We're able to be with and be in the pain. We can lean out and we can lean in. This will be a time of interceptive exposure which increases distress tolerance and leads to crisis integration, integration of bodily and emotional reactions to difficulties then and now. This increases trust that the body is a safe place to be in and it increases adaptive homostatic reticulation. So I wonder, may I ask, I had an idea of having a three-minute exercise internally. Would you be willing or would you like me to move on? Okay good. I want to take a moment to contemplate the implication of what we talked about. So, you will have a little moment to spend some quality time with yourself and some rest, but most importantly to integrate how interoceptive exposure can be used in crisis integration. So you may want to close your eyes or let the gaze rest softly in your lap. Can take a few longer breaths and feel the expansion of the belly and chest on the in-breath and the relaxation of the out-breath. Feel how the chair supports you so that your back can rest. Relaxing whatever can be relaxed around your eyes, the jaw, relaxing the tongue all the way through its space so that the throat can relax. The whole face softening. Sense the soothing effect of gravity. Sense how the feet rest on the floor, small tingling sensations in the feet. You can wiggle the toes a bit, sensing your right foot from within and the left foot inside out. A soft, light presence with your feet as a way to settle. Now if you would move your soft attention to the torso, the area of the belly, chest and throat and sense how the weather is in there. You may ask, is there anything in there that would like my attention? Take your time. Noticing whatever sensation or feeling, just if you never have met anything like it before and are curious to get to know it a little bit more and welcome it. You may say hi to the sensation. Hi, I know you're there. Welcome. You don't have to understand what the sensation is about. Just let it know that you're aware of it and that you'll keep it company for a little while. Noticing if the sensation has any shape, if it's flat or thick or light or heavy, where it begins and ends. Is it cold or warm? Does it change in any way or does it stay the same? Does it seem shy or ready to speak up loudly? Keep it company. You may even want to place your hand where you feel the sensations and feel the warmth of your hand. If you notice an ever so slight wish to change the sensation, avoid it or even suppress it, you may also extend your tender acceptance to that tendency. We'll soon end but before we do that you may say thank you to your body and to the sensations that may have appeared for a little while. Thank you, I'll be back soon if that feels right to say. Stay as long as you need and only in your own time slowly open your eyes and I'll move on to put words onto what we just did. We began with gathering the attention with establishing a metta awareness. Before we opened up to the torso, we befriended the bodily aspect of what's going on inside by asking about the texture, for example. From there we examined any bias or aversion and included it in acceptance and finally we suggested a new way, a new accepting way of relating by offering compassion and gratitude. We have explored how the predictive coding theory maps onto mindfulness. We'll now move on to the role of acceptance in crisis and thereafter engagement. Let's see how the predictive coding informs acceptance and the sense of self. Acceptance is about being in the pain but we don't want to marinate in our pain. We need some space of metta awareness also observe the pain to be with the pain. We can be 90% in acceptance and 10% in mindfulness or 50-50 or any ratio doesn't matter as long as we have both but turning our gaze inwards is not uncomplicated. Our patients often meet a confusing landscape. They may find the primary reaction to the adverse event but also the inner critical voice of self-blame and self-rejection. It's your own fault, you're no good and the bodily reactions to those self-accusations. So now, what exactly are they to accept, to open up to? The simple answer is to everything but when there is self-criticism, self-compassion gives the therapeutical leverage. Self-compassion is about strengthening the ability to receive everything in kindness and this often needs practice, a practice that involves letting go of stories, thinking, doing, letting go of avoidance and one block to this process is the identification with me as a content, as a narrative, as a life story. We have a better chance for crisis integration, we're able to stay with me as process. This is happening now and now this and now this in terms of emotions but even better bodily sensations and then of course the more we nurture the loving witness of it all the more we access the flexibility and sense of belonging. In the end the sense of isolation when we suffer is rooted in a self separate from other selves. Just as we can have a perception of green, an inner model of green, we can have a perception of a self. Now we can wrap our mind around that there is no green out there but normally the sense of self is so familiar, so continuous that it's difficult to relate to me as just another perception. Normally we think that there is a me here, Katrina, a little Katrina inside Katrina who does the perceiving but in reality the self too is a perception not that which does the perceiving. The experience of self is a construction of predictive coding as Anil Seth puts it, I predict myself therefore I am. Ultimately we cannot comprehend suffering if we're totally identified with the pain. We'll benefit from some space related to the experience of me suffering. We will not get rid of a me, the perception of a me, it will still be there, it's a function of the brain. Instead we'll receive the sense of a me in mindfulness, acceptance and self compassion. We don't try to change it, criticize it, it's actually easier to let go of a self that is loved than a self that is criticized. So let's take just a brief moment to experientially work with this idea and something to keep in mind as we do this is that for many of us this is an unusual kind of practice, this is something that we usually don't do with our patients, yet it could be a very powerful practice to hold in mind while working with them and it could be part of your own practice. So just sense inward and experience with experience with the idea that the self is a perception among other perceptions and explore what implication that might have. Do you sense a strong resistance to letting go of the me as a reality or you may find the letting go liberating or both? There is no once and for all letting go of a me, it's to be done thousands of times and it will support crisis integration moving from a sense of separation to a sense of belonging, a common humanity. There we are moving on to engagement. At heart ACT is a radical behavior therapy and the goal of every ACT session is to get the patient to try something new and different. In the last six slides coming up we learn about the predicaments and solutions to this endeavor and then we'll open up to the Q&A. As much as we in crisis integration need learning with respect to perception of the inner world, we need new learning regarding decision making in the outer world. This learning is informed by reward prediction errors. The huge problem in crisis is that model free short term learning about rewards is the main driver to our behavior. Our decision making is mainly motivated by positive reinforcement that is adding a reward and the negative reinforcement withdrawing punishment. Although liquor and substances are used to experience joy sometimes which would be a positively reinforced behavior, the more common and problematic use is in the service of avoiding difficult emotions or experiences. Although substance use disorders are a loop of crisis instigation, let us spell out the mechanisms underlying it from the perspective of model free learning. One driver is avoidance of the pain related to the primary crisis event. It provides relief from anguish on a short term basis and is negatively reinforced. Another common of one is avoidance of social anxiety and over time we get avoidance of withdrawal systems and craving. And when our main pursuit is narrowed down to short term avoidance, we forget our longer term values. We have no idea what could bring zest into our life again. Reduced values and model based control is yet one transdiagnostic factor in many forms of psychopathology, not only substance abuse. Step one in engagement becomes the probing of articulation of values and needs. In general, this motivational shift to long term values requires mental effort and metacognition. What's helpful is that contacting our values, for example self care related ones or prosocial ones, and imagining acting in line with them is rewarding in and of itself. In other words, we get a reward signal merely through anticipation of a future reward. But this is intricate. This is not to say that acting according to our values will only be a feel good exercise. When we're not avoiding anymore, when we're moving towards in life, we'll experience the short term consequence of emotional pain that we previously avoided. What's then helpful is that contacting our long term values will change the function of that immediate pain. People come to understand that pain is actually something that means that I'm the right track. If I'm acting according to my values, emotional pain will be part of the deal on a short term basis. So if the first step is contacting our need, our values, the second tipping point involves identifying the behaviors that will bring about the life qualities that we desire. And the third challenge is to form a committed action plan. Examples of how to do this, all of this, also what we talked about before, is found in the book. To summarize, although we tend to feel alone in our suffering and sometimes blame ourselves for it, the processes that lead to crisis instigation is logical from the perspective of learning psychology. In this presentation I've suggested that a crisis is instigated when something adverse happens to us. We then try to avoid feeling the emotions and bodily sensations that naturally arise in response and to disengage by clinging to behaviors that have ceased to be useful. Avoidance will become the major driver of disengagement from life and disengagement in turn will trigger a second wave of distressing emotions in reaction to a mounting list of unmet needs. Fortunately, with the cognitive revolution, it gave us the ability to observe and evaluate the utility of previous learning. This witnessing capacity provides the basis for the new learning and the psychological flexibility needed in crisis. However, the practice of neither marinating our inner pain nor trying to get rid of it is for many people a new way relating to their inner pain and this needs moment-to-moment coaching by the psychiatrist. In crisis, because present moment experience builds on the past, mindfulness of the now means being mindful of the difficulty that came before. When held lightly and tenderly in mindfulness, acceptance and self-compassion, both of our painful inner experience and the sense of a criticized self will become less opaque, less dense, less burdensome. Mindfulness integration builds on moments of perception, exposure and learning. Acceptance will further bring the clarity needed to engage wisely in the world. Likewise, engaging with our long-term values will expand our willingness to make contact with the devastating emotions of the crisis and any additional discomfort that arises when acting in accordance with values in ways counter to previous learning. With this slide, we have brought into completion the crisis integration model, and now I'm curious to hear if there's any reflections or questions or anything, otherwise this is what you can just take home in the pocket to use in your crisis. Thank you for coming and for staying and for your attention, it was a privilege to be with you. I thank you for your presentation, I've got a question with regards to how you inform patients about the illusion of self, because maybe informing people about the illusion of self, like the feeling that you're behind your eyes and between your ears, if you inform people about that, that may itself create a crisis within people, because they may have feelings of nihilism, so yeah, what are your thoughts on that? Well, thank you for asking that question, and it was, as I said, this is maybe something that you don't do with your patients, especially not on your first encounter. I wanted to introduce you here because, as an inspiration for you to experiment with the idea, and also because it prevents burnout, it has been shown. If you yourself have that connection to that idea, or to that experience yourself, and so we're just two people here trying to understand suffering, and it's nothing personal, it's not about you particularly, it's just common humanity. And also expressed in Christine Neff's definition of self-compassion, you have, let me see if I can remember it, mindfulness versus over-identification, you have self-kindness versus self-criticism, and you have the self versus common humanity, they're all in the same boat. This is just suffering. So, thank you for clarifying, I will not just suggest that this is not about you, I will not say that in words, I'll just have it in my mind. Thank you. But what if someone encounters it themselves, like the information, maybe they will search something on Google, I don't know, about the self-illusion or something, how do you inform them when they come to you with that? Okay, so I would say that having an experience of the self is normal, and natural, and it's a function of the brain, and it helps us protect this organism, it's functional, it's the evolution brought about this quality. And we can hold it lightly, maybe it's not the only reality, maybe there's more to it. Thank you. Thank you. Thank you for asking. Thank you so much for your presentation, I really appreciate it, especially the evolutionary context. And I wondered if you could opine upon what feels to me like a real revolutionary change in our human experience, which is that people spend 90% of their time now indoors, in sterile environments similar to this one. And it becomes much easier to have a very, in my mind, a very limited concept of self because you don't see yourself as having sort of like an integrated connection with a larger world, it's like just this little person in a box, and now it's even like a little person in a box, a tinier box, a tinier box, so I don't know, to me it feels like a really important part of understanding why all of this is so, so, so hard for us right now. Thank you. And also to me personally, I relate very much to the planetary crisis that we're in. And as much as I want to be hopeful, I'm also a little bit feeling despair because we're not engaging in that meta-awareness that is more easily to get in contact with when we're out in nature, for example, or relating to one another. And at the same time, I just don't see any way around it. We just need to cultivate that, and otherwise we're stuck in that crisis instigation mode and just being occupied, preoccupied with businesses before. So I don't know the solution, I would just very much like to know it, but I think John Kabat-Zinn said that mindfulness is the most socially radical thing that you could engage in, and I tend to agree with this knowledge anyway. Thank you. Thank you. Thank you for asking. Thank you for the presentation. I was able to center myself in the seat, so I appreciate that. I think throughout the day I haven't had a moment to center myself, so I really took that time to ground. My question is, I work with a population with severe mental illness, schizophrenia, PTSD, treatment-resistant mood disorders. Can any tips on applying this model to somebody who's highly dysregulated and like PTSD or experiencing psychosis? I'm not very well read upon psychosis, but PTSD, actually mindfulness-based modules have less dropouts than pure exposure therapy that's been shown, because it's a little bit softer, they can regulate it better. I also would tend to say that what we need is also stabilizing the situation and just holding, so it's not about just exposure, because it's very easy to just get into the marinating part of it, just getting lost in it and just digging, like it's like having a wound that you sort of dig into, so we want to avoid that and just to apply as much as the leaning out part of it as possible, the grounding and the whatever works for them, usually not being here in the torso. And that's what I've experienced, that a lot of the times they kind of come here and the crisis kind of blows up, that's what I'm taking away, I didn't realize that being here was actually very harmful for some folks, and creating that other space works out. Yeah, well thank you, thank you for that clarification, it was good for you. Really appreciate your presentation. I'm just thinking that you're proving me wrong with making the world fit and how we all are biased by our previous experiences. What I'm thinking of as you're talking a little bit though is Fonagy and them and their mentalization. One more time, I didn't hear. The mentalization work done by Fonagy and them, is this kind of, reminds me a little bit of that with the three tiers, and sorry, can you help me sort of bring that together or relate one to the other, or help me understand? So I'm not crystal clear about the mentalization with that as a psychotherapy branch, or inform me. It's a very, it's similar to what you're talking about here, although you're talking about specifically with crisis, the crisis intervention bit, which is new, but it's also talking about that idea, the mentalizing, the being aware of what we're experiencing, like the three tiers. Yeah, okay, okay, okay, okay, the cake model, so to say, yeah. So the cake model was inspired by a neuroscientist called Chris Frith. He was writing a paper coming out 2021. He's one of my mentors, so to say. And for me, it was clarifying the different levels of consciousness, the two levels, and how we can use both of them, and also, it's not very easy to get that experientially difference between feeling the pain and being with the pain. It's not all that obvious all the time, but his model helped me clarify that, and also to tie it back to interneuroscience was very, I was enjoying it very much when I read about it. Yeah, so I don't know, I'm sorry I can't say anything more about, okay, yeah. Thank you for your presentation. It was both, you know, it was fun, educational, and very therapeutic. The question I have is sort of a follow-up of the prior question, but less about diagnostic considerations for applying the therapy, but more, are there special populations, maybe age-related, you know, children of certain ages that you might consider this therapy not to be useful, or other populations? Yeah, well, thank you. Act, actually, to tie back to the crisis topic, there were two very new published papers that were studies based in Sudan and Syria, and they used, like, comic, like, there were people that didn't have educations that they used pictures, drawings, and had them experience acceptance and mindfulness in that kind of way, and it showed really promise, I mean, it was like cutting half the PTSD symptoms from 44% to 22%, and rigorous numbers published in a JMA, it's called JMA in English, so I'm not afraid of using it in, I had act groups for suicidal patients, like, severely bipolar, doing electroconvulsive therapy, and they're really hard duty, and, but of course, we need to monitor it. I was releasing back a patient and said to her, well, you could just practice mindfulness with your toe for one second, and she came back and said, well, I had, I cried for two hours just after one second with my toe, what's going on? So I was realized, okay, I need to be a little bit more, we do it together, and not just going home with exercise, so just be a little bit careful, but I'm not, there is nothing dangerous about it, I would say, if you just keep seeing them, even if they're, you know, battling with suicidal ideations and so forth. Children, of course, I think ACT is done with children too, I'm not a child psychiatrist, so I don't know fully, so sorry, yeah. Hi there, my name is Pranav, and I'm a psychiatry resident, and the question that I have is, you have experience teaching patients mindfulness through mindful exercise or physical activity, and I think where this question comes from is, you know, I enjoy running, and when I run, I feel like, you know, sensations from my body are heightened, and I can access them better, heart's racing, I'm breathing, getting input from all my muscles, and I think about, you know, sedentary behavior is also very transdiagnostic, and so I'm just curious if you found, or had experience teaching mindfulness. Okay, yes, thank you. Personally, you know, these exercises where you're taught that you have your thought and put it on a leaf, and let the leaf go through the stream, and all that, doesn't work so well for me, I just go in thinking, what if the leaf goes in the wrong direction, and is that leaf correct, and am I doing this right, and just for me, that kind of thought metaphor, mindfulness exercises doesn't work, that's why I like the body so much, and I agree with you, like exercising, doing things, and especially when in crisis, you know, the emotions are, like, extreme, so you have to ground yourself, like walking, doing things with your body, just to release also the, like the birds, you know, they're flapping their wings when they're, after they're having a fight, just getting out, so I do that, but with patience, a little bit more difficulties, but like the, I don't know if you have read the book, The Body Keeps the Score, it's like, he talks about when he, like, he lifts the arms with the patience, and then he, like, they just have, do this qigong movements, just to have a little bit more grounded in the body, or any kind of qigong movement is working well, I do that all the time, yeah, and walking, touching the feet with the foot, yeah, yeah. Hi, thank you for your presentation of grounding us. Oh, thank you, it was a little bit scary, so thank you for the feedback, yeah. I'm a resident in psychiatry at UMC Utrecht, and I noticed that during your presentation, there's mostly, you talked about mindfulness and acceptance, and not so much about diffusion. Diffusion, okay. Not as important in, like, crisis model, or how would you integrate that? Thank you for asking, for diffusion is an act concept, right? Is anybody not familiar? Diffusion is, like, not being fused, it's like, fused with the pain, or diffused from it, like, having a little space. Diffusion is most commonly in act, talked about with regard to thoughts, like, I'm not, the thoughts is not reality, it's just my thought, I'm having a thought instead of, the thinking is real. I mean, what's, it's true what I'm thinking. So, I tend to not work so much with thinking, they can think and blah, blah, blah, blah, blah, but just back again to feet, the sitting bones against the chair. I'm not so, I don't go into that theoretical realm of, we're not the thoughts, the thoughts are not true, and all of that. It just tends to get into a war, like, thinking, like, in my opinion, anyway, that you have a thought, and then, okay, I shouldn't be thinking, actually, or this thinking is not real, and then get even more thinking. So, so just simple, like, movements, and breathing, and touching. Thank you. And also diffusion, I mentioned the diffusion is not to be fused with your pain, or fused with your sense of me, and all of that, it's just to create the sense of space. That's very important to me. Thank you. I really enjoyed your presentation. Very, very helpful. I'm a psychotherapist for many, many years, and I've come to a lot of these kinds of same conclusions about, you know, treating patients, especially now I'm treating patients with a lot of chronic pain. The thing that's most healing and therapeutic is when they can actually experience their distress, and it really does relieve the pain. Yeah. So, what you're saying is when they experience the pain, and the emotional situations, their characteristic, usually there's a theme they keep repeating over and over, and they're distressed, and disappointed, and they suppress it, they don't feel it, and just getting them to be aware of it. Yeah. Seems to be the most helpful thing. It's just like that, right? It's simple, just know it. No, it takes a lot of work over, and over, and over. Oh my God, it does. Letting go. Thank you. It does. It's just a never-ending work, yeah, for all of us. Yeah. Yeah, one more time. Yeah, please. When you were talking about the self, it just reminded me of Buddhism, and I don't, you know who Ram Dass is? Yes, I love him. He got me to laugh a lot, yeah. I listened to him a lot when I was younger. Yeah. Great sense of humor. Yes. Shall we call it an evening? Yeah. Thank you for coming. It was truly a pleasure.

crisis integration

psychiatric crises

mindfulness

cognitive neuroscience

functional imaging

Acceptance and Commitment Therapy

meta-awareness

emotional processing

interoceptive exposure

self-compassion

behavioral change