“Memory is not a recording of an ‘image’ or a ‘trace’ but part of the process of knowing and understanding.” —Rosenfield, 1992; p.18

There are polarizing beliefs when it comes to eye movement desensitization and reprocessing (EMDR) therapy. On one end, it is viewed as a+ cure-all treatment for mental health symptoms. On the other, critics see it as a treatment akin to modern-day snake oil.

The protocol for EMDR therapy is comprehensive and detailed. Put simply, the idea is to transform disturbing input—process and decondition it—into an adaptive resolution and a psychologically healthy integration. The model is past-focused, meaning one is going back in time to recall events as opposed to addressing current life stressors (not that the two are mutually exclusive). This includes redefining the event, finding meaning in it, and alleviating self-blame while integrating new skills (Shapiro, 2001). The modality focuses on the core cognitions or self-referential beliefs individuals associate with the disturbing events. These often fall into domains related to personal responsibility, safety, and power or control. “Trauma in each of these domains is reflected by the client’s distorted self-referencing beliefs linked to the effects of unresolved memories” (Nickerson, 2017).

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EMDR is an evidence-based therapy primarily used to treat posttraumatic stress (PTSD), but as it gains momentum in mental health circles, indications for its use are ever-expanding. The question for me is less about EMDR efficacy or benefit. The concern is the theory behind it and my general curiosity regarding its unique properties. There are aspects of the treatment that are altogether strange. Likewise, it contains components that are familiar to popular understanding of memory and a few things that tend to go overlooked or are forgotten.

Strange

EMDR was founded by Francine Shapiro in 1989. The legend is she was walking in a park and thinking about something distressing to her. She noticed that moving her eyes from tear duct and back to her periphery (i.e., side to side) lessened her distress. This was the early evolution of utilizing what is called bilateral stimulation. During the processing stage of EMDR therapy, the practitioner will use their fingers, tactile sensors, and/or auditory sounds that activate from left to right or vice versa. The theory is this process stimulates each hemisphere of the brain. The left hemisphere is primarily focused on language, linguistics, and narratives of our experience as opposed to the experiential aspect of the right hemisphere. In this manner, the person processing the traumatic memory integrates both the story and the felt experience. The bilateral stimulation is said to parallel how memory is consolidated during dream or REM (rapid eye movement) states when we sleep.

Fundamentally speaking, accelerated processing during EMDR splits the attention of the individual. During bilateral stimulation (i.e., finger movements, tones in the ear, or hand sensors), working memory is taxed because one must partially focus on the stimulation. This multitasking softens the emotional blow of recalling disturbing memories.

For those unfamiliar to the processing aspect of EMDR, practitioners are trained to sit close to the person in treatment. During this process, the therapist and person in therapy are cohabiting each other’s personal space, with one knee a couple of inches from the other’s. The direction is for the two people to be seated in an orientation “like two ships crossing in the night.” This unique approach to treatment creates an added level of intimacy and implicit vulnerability. It is strange and often overlooked when considering how the intervention benefits people in therapy. In a garden-variety individual therapy session, the two people are often sitting across the room from each other or at least several feet away.

Another oddity of EMDR is the historical context and initial hypothesis pertaining to trauma. In 1989, Shapiro questioned if trauma was essentially a disruption in the excitatory and inhibitory balance of the brain. This was two years after Prozac was introduced to the United States and a year before the Decade of the Brain. Mental health was beginning to be understood from a chemical or biological perspective. EMDR benefited from hitching the idiosyncratic trauma treatment to the biological wagon of mental health. EMDR’s individualized treatment would offer a correction to this brain imbalance akin to the overly simplistic solution for depression being a deficit of serotonin.

Familiar

Popular understanding of memory is that it is solely a brain function, with stored archives of our moments from the past organized in little synaptic shelves of neurons. This concept of memory as photographic snapshots stored in an album of existence is analogous to social and news media feeds displaying a history of ourselves across set positions on timelines. The click or swipe reveals the exact same image with no distortion. In Israel Rosenfield’s book The Strange, Familiar, and Forgotten: An Anatomy of Consciousness, he notes our false conception of memory based on Freudian ideas of the unconscious: “The problem is that we have tended to think of memories as unconscious items that one brings to consciousness, not as part of consciousness” (1992; p. 12). The false dichotomy of consciousness versus unconsciousness holds this misconception in place.

In Pixar’s animated film Inside Out, the main character’s memory process was portrayed in a similar manner. Her brain would produce marble-like spheres that rolled down a mechanical carousel to produce videos of previous experiences. The film portrays an exact reconstruction of past events as if these histories could be called upon via a brigade of emotional activity. This is not unlike the theory behind EMDR therapy. Disturbed memory channels in the limbic system are said to be clogging or inhibiting the individual from moving past the traumatic event. A subtle distinction is important to note: each time one thinks of a memory, they are essentially reconstructing or imagining what happened. This process creates tiny errors similar to the manner in which one copies a computer file. Over time, these little distortions add up and the factual elements of the memory are changed. The most salient and accurate memories are the ones we only rarely recall (like the original file before it is copied). The misconception of memory processes fits with Western culture’s ego-centric, fixed sense of self; “the conviction that memory is one thing is an illusion” (Eagleman, 2011; p.126).

The idea of having storage units or filing cabinets in the brain holding our past experiences aligns with current cultural frameworks (i.e., email, cloud technology, digital folders) and therapeutic modalities related to trauma and clogged memory channels (i.e., EMDR therapy). Rosenfield (1992) is explicit in drawing attention to this faulty neurology. When one remembers, they are referring to an event/object/person as they are represented based on one’s own subjective experience, “not mechanical reproduction” (p.42). Memory is less of a product of history or biological remnant, but a dynamic ability to integrate knowledge in a relational manner. The timestamp or notarizing of the event occurs within a conceptualization of who it is we think we are as a person.

Memory is rooted in our sense of time and part of the very structure of conscious knowledge. It is not an isolated phenomenon, but rather a manifestation of subjective states created by brain activities (Rosenfield, 1992). Therefore, failure of memory is not due to the loss of specific items “stored” somewhere in the brain, but rather a breakdown of the mechanisms of consciousness; “there are no memories without a sense of self.” As Rosenfield (1992) notes, “Without knowledge of one’s own being, one can have no recollections. How can I remember my parents, my house, if I am not sure I exist?” (p.41).

Forgotten

You need to remember EMDR therapy is an intervention that implies a Western understanding of the self or mind. It turns out the way highly educated, wealthy, democratic minds think is not representative of the entire globe. Most of us in the West do not think of ourselves as a body; we think we “have” a body. There is a notion we are the chariot drivers of our experience or, put another way, there is this little person inside our heads that has all types of likes and dislikes, proclivities, and things we retract from or avoid. This is an ego-centric perspective of the mind.

If you stop and pay attention to the present moment, one’s habitual patterns of cognition start to become clearer. The ego-dominating belief of our existence lying somewhere in the center of our skulls begins to be challenged. This is worth remembering.

By comparison, if you ask a Sri Lankan about themselves, they may describe their interpersonal relationships, family, and roles or responsibilities. This is a socio-centric version of the self with less of a demand on individuality. Watters (2010) articulates this distinction via several cultural specific examples in his book, Crazy Like Us: The Globalization of the American Psyche. He describes the 2004 Indian Ocean tsunami that killed around a quarter million people. Sri Lanka was one of the areas hit especially hard by this tragedy.

Western mental health practitioners rushed into these areas without knowledge of the culture. They did not know how to speak the language or have any awareness of local conceptualizations of trauma. This included benevolent EMDR therapists who assumed there would be an epidemic of PTSD. However, if you asked the Sri Lankans where their trauma resided, they generally did not point to their heads or speak of their minds being broken. For them, the damage was to the community and broken relationships. “Because Western conception of PTSD assumes the problem, the breakage, is primarily in the mind of the individual, it largely overlooks the most salient symptoms for a Sri Lankan, those that exist not in the psychological but in the social realm” (Watters, 2010; p.92).

The Westernized perspective is assumed to be a universal one. When one considers trauma, they must consider the time it happens and the cultural frame it occurs in. The consequence of an ignorant global construct for trauma is we remove the nuanced experience from other cultural narratives and beliefs that might give meaning to how the person suffers (Watters, 2010).

Self-Centered Awareness

David Foster Wallace (2005) hit on the margins of this notion—self-centered awareness—in his commencement address to Kenyon College titled This Is Water. He spoke about the choice of where we place our attention within conscious awareness (as opposed to relying on our “default setting” or autopilot) and how one can cultivate compassion within the banal aspects of daily life:

And the so-called real world will not discourage you from operating on your default settings, because the so-called real world of men and money and power hums merrily along in a pool of fear and anger and frustration and craving and worship of self. Our own present culture has harnessed these forces in ways that have yielded extraordinary wealth and comfort and personal freedom. The freedom to be lords of our tiny skull-sized kingdoms, alone at the center of all creation.

There is an ancient technology available to emancipate us from the constraints of these small, isolative worlds. To notice this ostensible imprisonment, all one need do is sit down in silence and observe where their mind goes. Who is producing this stimulation and is there a navigator of control? What happens when all you do is focus on the inhalation and exhalation of the breath?

Mindfulness and meditation practices will not cure individuals from the impacts of trauma or reoccurring disturbing memories. However, it is a prophylactic to inhibit self-centeredness or personalization of momentary experience (which tends to lead to the anxiety-provoking reoccurrences of mind).

When one has a thought, feeling, or sensation, it is often turned into a belief that becomes self-referential. A simple interaction with a partner or family member illuminates this silly human deficiency. If the person yawns during a conversation (the thought), this can lead to a belief (e.g., the person is bored) which is then internalized (i.e., “I am unlikable” or “unlovable.”). One falls down this self-deprecating rabbit hole all too quickly. The antidote is to just notice what is arising in terms of thoughts and beliefs before assuming a story about yourself.

If you stop and pay attention to the present moment, one’s habitual patterns of cognition start to become clearer. The ego-dominating belief of our existence lying somewhere in the center of our skulls begins to be challenged. This is worth remembering.

References:

1. Eagleman, D. (2011). Incognito: The secret lives of brains (1st American edition). New York: Pantheon Books.
2. Rosenfield, I. (1992). The strange, familiar, and forgotten: An anatomy of consciousness. New York: Knopf.
3. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures (2nd edition). New York: Guilford Press.
4. Wallace, D.F. (2005). This is water. Transcript retrieved from https://web.ics.purdue.edu/~drkelly/DFWKenyonAddress2005.pdf
5. Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York: Free Press.

Western culture seems to be increasingly fascinated with the human brain. Emerging evidence in the field of interpersonal neurobiology links physiological processes of the brain with mindfulness and psychotherapy, and most of our efforts to understand illness, disease, creativity, innovation, attention and cognitive ability have long focused on the three pounds of flesh harnessed within our skulls.

The brain is only a small percentage of our body weight, but approximately 20% of our energy is required for its operation. Its three main parts, sometimes referred to as the “triune brain,” consist of the brain stem, the limbic system, and the prefrontal cortex. These parts, which evolved in that order, can be thought of as having “stacked up” over millions of years.

The Brain Stem and Limbic System

The brain stem, which is considered the foundation of the brain, travels up the spinal cord and connects to the brain. Because this initial part of the brain operates the basic systems of the body common to most lower-order animals, it is often called the reptilian brain. Processes of the brain stem include the functions most newborns are capable of: they can regulate the body’s temperature, experience pain, digest food, and monitor their breathing as well as heart rate and blood pressure. Babies do not have to think about these processes since they are automated by this lower order aspect of the brain.

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The brain stem is connected within the subcortical limbic system.  The limbic system can be considered a sort of “center house” for our emotional experiences, a registry for the things in life we move toward or away from. Also known as the mammalian brain, this aspect of the brain is contained within the middle part of the structure and is more evolved than the reptilian brain. The connection between the brain stem and the limbic system is what gives rise to the commonly understood defense mechanisms of fight, flight, or freeze.

The structure largely responsible for reactions to stimuli in our environment is the amygdala, a small, almond-shaped structure in the limbic system. This “smoke detector” of the brain determines whether a sound, image, or body sensation is perceived as a threat or is relevant to survival and activates the body’s stress response, or not, accordingly. When a noise that sounds like gunshot is heard, for example, then the body’s amygdala turns on, releasing stress hormones and nerve impulses to raise blood pressure, oxygen intake, and heart rate in order to prepare the body for fight or flight. An adverse noise can lead to a startle response, or goosebumps, perspiration, and the hair on the back of the neck standing up. The body responds in this way whether we actively think about these things or not.

The Prefrontal Cortex

What separates us, in a number of ways, from other animals is the prefrontal cortex, the so-called “human” brain. This structure lies just behind the forehead and is part of the larger neocortex that envelops the limbic system and contains all the other parts of the brain. Its overlap with the limbic system allows for an interplay between these systems and allows us to regulate our emotional responses.

When we hear a loud noise that could have been a gunshot, we startle, but the higher order processing of the prefrontal cortex allows us to reflect on the stimuli in our environment. After reflection, we might realize the sound was actually a car backfiring or a door slamming and regain a sense of calm. There is a dance of sorts that occurs between the prefrontal cortex and the limbic system. In general, the prefrontal cortex functions to regulate the body by balancing emotion, moderating fear, and granting us the ability to gain insight as well as a deeper understanding of morality, intuition and empathy.

Think back to a time when you were distracted, perhaps with your phone or by a child or partner, while grocery shopping. Executive functioning (discernment of the shopping aisles) becomes increasingly taxing when we are also engaged in a conversation. Our attention is split, and this can overload our working memory. When this occurs, the emotional part of the brain is left unchecked. Sometimes we leave the store and realize our shopping bags are filled with snacks and impulse purchases, not the items we had planned to buy. This occurs in part because shutting down the resources of the prefrontal cortex (talking on the phone) gives full autonomy to the emotional center of the brain, a non-conceptual framework focused on stimuli that grab our attention.

The Triune Brain in Relation to Mental Health

The three aspects of the brain can easily be associated with mental health treatment, psychotherapy, and mindfulness practice.

Individuals who have experienced traumatic events in their lives often have a limbic system (specifically the amygdala) that is overactive, in part because they can become fixated on flashbacks and memories associated with what happened. The ability to regulate and discern safety in their environment becomes challenging, to say the least, and the result of this is often a chronically activated stress response. The ability to name the emotion that coincides with an experience has been shown to decrease this amygdala firing, and psychotherapy, thus, often focuses on developing awareness of emotions within certain contexts in order to gain a wiser understanding of the reasons behind our typical reactions.

Engaging the prefrontal cortex to understand emotional habits and sequences is the essence of most psychotherapy. This top-down approach often has the effect of allowing us to connect with another person we trust and feel safe with. This modulation and intimacy that occurs in the context of a therapeutic relationship gives us the opportunity to comprehend what is going on internally while also helping us learn how to process those memories from our past we might rather avoid. The bottom-up approach to regulating experience happens by constantly returning to what we are doing in the here and now. The constant acceptance of “just this,” without any added judgment of whether we like or dislike what is happening, creates a kind of biological equanimity.

A path increasingly being traveled in contemporary societies is the disruption of symptoms via biological approaches. Pharmaceuticals have burgeoned as a method of altering psychological experiences in the West. Psychotropic medications such as Abilify have the effect of shutting down inappropriate alarm reactions, potentially changing the way the brain organizes information in the short term. The dampening effect of such drugs can provide a temporary solution to hyperactivity or dysregulation, but many find that using these medications prevents them from mastering their emotional responses and learning to self-regulate.

Developing the ‘Human’ Brain

Research suggests one way to exercise and strengthen the human part of the brain is to simply pay attention to the processes automated in our body. Recall the brain stem: it is essentially responsible for our breathing, so we don’t have to remember to breathe in the same way that we might try to remember to use the bathroom before going to a movie, for example.

The bottom-up approach to regulating experience happens by constantly returning to what we are doing in the here and now. The constant acceptance of “just this,” without any added judgment of whether we like or dislike what is happening, creates a kind of biological equanimity. The amygdala is less likely to sound its alarm as the prefrontal cortex becomes a better moderating feature.

Many studies have shown meditation practices create more of an approach orientation for individuals. We become less likely to avoid things and more stable within the storms of everyday life. This is not to say we will stop experiencing emotions and feelings. On the contrary, our senses are often heightened and deepened, and we are able to recover and navigate these moments in a more pointed and skillful way. Bessel van der Kolk notes in his book The Body Keeps the Score that for trauma survivors, a bottom-up approach allows “the body to have experiences that deeply and viscerally contradict the helplessness, rage, or collapse that result from trauma.”

We can use cognition to orient our attention to our experiences and discern how our actions have affected others, but for some, the prefrontal cortex, and the ability for self-reflection granted by it, is both an advantage and a disadvantage. We are able to dredge up the past and ruminate on our anticipated future, but with this comes comprehension of the temporary nature of our circumstances. In other words, we realize our own mortality: we know we will someday die.

Psychotherapy and mindfulness practices, then, merge as bottom-up processes for emotion regulation. Both are methods we can use to begin to recondition a habit or pattern of turning away from what is happening. An acceptance of the temporary nature of our circumstances and an increased focus on compassion, both for ourselves and others, are often direct consequences.

References: 

1. Briere, J. N., & and Scott, C. (2013) Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment. Thousand Oaks, CA: Sage Publications.
2. Siegel, D. J. (2010). The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration. New York: W.W. Norton & Company
3. van der Kolk, B. A. (2014). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma. New York, NY: Penguin Books.

How important is the therapeutic relationship—the relationship between a person in therapy and his or her therapist—to the change process? Is the relationship itself the primary source of healing or are techniques the mechanisms for positive outcomes? And where does “love” fit in to all of this?

Out with the Old

My career in social work began with a full-time psychotherapy position in a rural town at a small mental health clinic. I was convinced my recent academic instruction had taught me everything under the sun, but also that I was clinically inept to practice as a therapist. Fortunately, the thoughtful, compassionate, and experienced supervisors at the clinic reined in my earnest energy.

I met with a clinical social worker on a weekly basis for supervision. She was a former nun with a wicked proclivity for curse words and an extreme disdain for computers. The topics that arose in the supervision hour varied. We talked about my personal issues, people who got under my skin in the therapy setting, and even her recollection of the days when people in therapy—as well as therapists—smoked cigarettes throughout sessions. What I remember most from our time together was her insistence that the beginning and end-all goal of psychotherapy was the same: you want the people you help in therapy to love you.

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She did not mean love in the romantic sense, nor was she veering from any ethical boundaries. This was not a trick or gimmick. She believed that the person in therapy improved based on the degree of emotional connection, including shared trust and belief in the therapeutic relationship. I immediately dismissed the idea. My graduate school never talked about love, and I didn’t know of any research to back what my supervisor was saying.

I was trained to understand psychology as a series of universal principles. These principles are translated cross-culturally. I was clinically oriented and meticulously uniform with many of the therapeutic modalities I applied. The rigid stance I took on this disallowed vulnerable feelings from surfacing within the therapeutic relationship. It was easier for me to sit back and diagnostically judge than to truly join with people in therapy.

The Role of Therapeutic Alliance

My supervisor at the time was describing (and to some degree going beyond) the concept of the therapeutic alliance. Simon Goldberg of the University of Wisconsin-Madison has conducted research on this concept. It is an emotional bond between the therapist and the person in therapy, which includes a shared agreement regarding the goals to work on as well as the form of psychological intervention used (Goldberg et al., 2013).

Goldberg brought up a related construct—the real relationship (Gelso & Carter, 1994)—which involves the “actual, non-transferential relationship between a client and a therapist” which he feels most accurately reflects what we might call love in therapy. The real relationship is theorized to operate in tandem with the therapeutic alliance, combining the emotional bond of therapist and person in therapy with agreement on the tasks and the goals of where the therapy work is headed. “Love has something major to do with effective therapy,” he adds.

Part of the therapeutic alliance includes a positive attachment contracted around the mutually defined treatment plan for therapy. The role of the therapeutic alliance is central to psychotherapy, and the effect is independent of the type of therapy used. The quality of the therapeutic alliance accounts for approximately 30% of the clinical outcome, while the guiding theory or model used accounts for 15% (Walsh, 2013).

In other words, therapists are all different, but the methods or theories they use are far less important in terms of a person feeling better (Germer et al., 2005). This means that the alphabet soup of therapy acronyms (e.g., EMDR, CBT, DBT, ACT, etc.) are relatively minor ingredients to what really fills the therapeutic bowl: a person’s individual characteristics (participation, motivation, problems, background) and the therapeutic alliance (Walsh, 2013).

However, many therapists swear by their affiliated or credentialed techniques. So, what accounts for the change that occurs in therapy?

Phases of the Therapeutic Alliance

Goldberg states that the theory and technique offer a “rationale on some ritual that the client and therapist engage in.” This collaborative partnership with mutual agreements as to the problem and solution is the predominant factor for change in psychotherapy.

For alliance to build, the therapist needs to be flexible and not hold tightly to an agenda. Priority is placed on collaborating with the person in therapy to establish and maintain the therapeutic relationship.

Past research looked at this alliance as developing from two phases. Phase one sees the person in therapy believing in the therapist as the desirable source of assistance. With warm regard and support from the therapist, the caring relationship commences. Therapy begins on this foundational level. In phase two, the alliance involves the person in therapy buying into the process of therapy via commitment to the procedure (i.e., shared understanding of the problem, value of the examination of the problem) as well as each person’s responsibility for the process (Horvath et al., 2011).

For alliance to build, the therapist needs to be flexible and not hold tightly to an agenda. Priority is placed on collaborating with the person in therapy to establish and maintain the therapeutic relationship (Horvath et al., 2011). The quality of the relationship can be assessed based on the “level of mutual and collaborative commitment to the ‘business of therapy’ by therapist and client” (Horvath et al., 2011; p. 15). This is the “collaborative enterprise” of psychotherapy. Essentially, the question and answer comes down to how well the person in therapy and the therapist work together in sessions.

Collusion Versus Confrontation

Specific variables and behaviors can be assessed for each role of the enterprise. The therapist’s non-reactivity to comments or overall antagonism of the person in therapy is reflected in the therapeutic alliance. My work centers on the conceptual space between collusion and confrontation. It is essential for the therapist to hear—not ignore—criticisms, but this must be done by threading the needle between colluding with the person in therapy or confronting his or her ideas. This perspective requires a dance between total agreement or affirmation and a scared-straight challenge or proverbial wrestling match.

For example, a person might say, “Am I a bad patient?” The therapist’s collusion with this statement might come across as, “Let’s talk about something else,” or, “You can be difficult at times.” The other end of the spectrum is confrontation. A therapist says, “No, no, no. You are not a ‘bad patient.’ ” Or the therapist could say, “Where did you get that idea?” in direct opposition to the statement. A middle-ground response finds the therapist replying, “What would it mean to you to be a ‘bad patient’?” This is the essence of non-defensive but attuned responsiveness.

The therapist does not personalize or absorb any statements, but also does not ignore or avoid emotional comments (Horvath et al., 2011). This is the narrow window or divide between collusion and confrontation that fosters alliance. This is an attuned, appropriate, and nonjudgmental response. Isn’t that love?

References:

1. Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41, 296–306.
2. Germer, C. K., Siegel, R. D., & Fulton, P. R. (2005). Mindfulness and psychotherapy. New York: Guilford Press.
3. Goldberg, S. Personal communication, December 5, 2015.
4. Goldberg, S.B., Davis, J.M., & Hoyt, W.T. (2013). The role of therapeutic alliance in mindfulness interventions: Therapeutic alliance in mindfulness training for smokers. Journal of Clinical Psychology, Vol. 69(9), 936–950.
5. Horvath, A. O., Del Re., A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16.
6. Walsh, J. (2013). Theories for direct social work practice (2^nd). Belmont, CA: Thompson Brooks/Cole.

In the 21^st century, as mindfulness-based practices become more mainstream, our society and psychotherapeutic community may be more willing to accept that Buddhism could be a valid psychological approach to reducing human suffering. —Danielle A. Einstein (2007)

In some ways, mindfulness is to Buddhism as worshiping is to religion. Mindfulness is a mental practice that is one core feature within a scaffolding of knowledge, tradition, and awakening. Now removed from its casing, mindfulness practices such as meditation are rigorously operationalized for psychotherapeutic purposes, including research designs. This detached arm of Buddhism has come alive in the West to gain size and strength despite the secular environment. Imagine if the “auditing” process in Scientology was an evidenced-based practice for relieving psychological distress. It is hard to imagine detaching such a practice from its larger cultural understanding and history.

There is an interesting emergence of Buddhist practices in psychotherapy as well as subtle distinction between religion and therapeutic models. The concept of religion relates to a social group’s preferred lifestyle, set of values, and interests, as well as committed practices, principles, and experiences (Mohr, 2011). To act “religiously” is to consciously and methodically conduct oneself in an activity, behavior, or ideology. A modern, magnified version of spirituality now includes positive psychology, whereby one searches for meaning, connection, and other secular hopes of universal inclusion (2011).

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“Mindfulness” has become a stand-alone contemporary practice for focus, affect regulation, and stress management. Mindfulness techniques have been incorporated into psychotherapy practices that, as a result, have taken on religious forms. The fat of the pre-modern (500 B.C.) tradition of Buddhism has been trimmed, and the leaner version (i.e., mindfulness) has migrated from desolate monasteries into empirical research and pop-psychology vernacular. Questions arise: Are the new-age psychotherapy practices religious? When teaching and conducting mindfulness-based practices, is it possible to parcel out the roots, allegiance, and ideology of its origin?

‘Third-Wave’ Therapies and Mindfulness

Mindfulness and other contemplative practices extracted from Buddhism are implanted in several evidence-based, cognitive behavioral practices. Mainstream cognitive behavioral-based therapies have evolved (called the “third wave”) to include mindfulness components. Despite secular efforts aimed to separate mindfulness from Buddhism, when examined closely, religious components are implicit to mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MCBT), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT) (Andersson & Asmundson, 2006). Much like a car’s side mirror, these are closer to religious belief systems and religious practices than they may appear.

The conceptual scaffolding of Kabat-Zinn’s MBSR stems from Theravada Buddhism (Einstein, 2007). The fundamental attitudes are acclimated practices of Buddhist awakening systems and reference the Four Noble Truths. For psychotherapy purposes, MBCT adds the empirical practices of cognitive behavioral therapy (often in group formats) to the MBSR program. Buddhism and MBCT join at the concept of “meta-cognitive insight.” Instead of viewing thoughts as an experiential reality, meta-cognitive insight notices thoughts just as thoughts, with a focus on the individual’s relationship with the thoughts (i.e., not the content).

The structural basis of ACT is relational frame theory (RFT), which is a behavioral explanation of human language and cognition. RFT is applied broadly, so it can be used to understand social processes including religion and spirituality (Andersson & Asmundson, 2006). Interventions derived from RFT and used in ACT approach religious values and practices. In the ACT model, one aim is for the client’s willingness “to clarify life values; and to behave in accord with chosen values through behavioral commitment strategies” (Hayes, 2002).

A significant commonality between ACT and other spiritual traditions (e.g., Buddhism) is the rationale that all humans experience inescapable suffering and the specific role of attachment, mindfulness, valued actions, and issues surrounding self (Andersson & Asmundson, 2006, and Hayes, 2002). Both ACT and Buddhism note the inherent problem of viewing and attaching to this unwavering “self” as something that can be managed with mindfulness practices (2002). For example, a belief that “I am depressed” or “I am a bad person” is a belief one attaches to, which perpetuates further anxiety or suffering. Mindfulness can elicit awareness and acceptance of this process of identification by allowing the person to step back from the internal experience (Sparks, 2015).

Much of psychotherapy is a movement out of a negative state and into a desired, often positive direction. In ACT, the goal is to feel emotions in the context of living a valuable life, while resisting avoidance tactics (Hayes, 2002). There is only a subtle behavioral difference between Buddhist mindfulness practices and ACT, in that the former accepts or actively sits with the thoughts, while the latter focuses on changing the thoughts that get in the way of progress (2002).

Zen Buddhism inspired aspects of DBT, along with behavioral science and dialectical philosophy. The concepts of being whole, interconnected, and amenable to change are central to the dialectical view of the world (Neacsiu & Linehan, 2014). Buddhist dialect uses matching concepts: embodiment, interdependence, or co-arising and impermanence (Einstein, 2007). Zen Buddhism and DBT both focus on the here and now with radical acceptance and letting go of ego. People who use DBT are committed to developing a stable lifestyle (e.g., not engaging in self-harm or suicide) with nonjudgmental awareness and acceptance to reality (Neacsiu & Linehan, 2014).

The fat of the pre-modern (500 B.C.) tradition of Buddhism has been trimmed, and the leaner version (i.e., mindfulness) has migrated from desolate monasteries into empirical research and pop-psychology vernacular. Questions arise: Are the new-age psychotherapy practices religious? When teaching and conducting mindfulness-based practices, is it possible to parcel out the roots, allegiance, and ideology of its origin?

The structure of the DBT model from the perspective of clinicians mirrors the subtle paternalism occupied within DBT practice. Therapists are required to be part of a consultation team and/or a group with an almost dogmatic commitment to a list of rules (Neacsiu & Linehan, 2014). They must use compassion, properly assess problems before giving feedback, exercise assertiveness, emotionally repair with the team, as well as make agreements (e.g., no absolute truth, accept change as natural, empathic interpretations, fallibility). The guidelines are very reasonable and necessary for therapeutic alliance, but the process has an ideological structure one also finds within religious institutions.

In terms of beliefs, a DBT therapist must have a “willingness to believe in the client’s ability to change” (Neacsiu & Linehan, 2014, p. 429) and to use “irreverent communication,” offer “cheerleading,” as well as prescribe “punishments,” such as “vacations from therapy” (p. 437). Is this a conducted activity, behavior, and/or ideology that is conscious and methodic?

Hayes (2002) described Buddhism as the inclusion of “traditions of faith, ritual, practice, and community that are designed to support mindfulness and wholesome actions, and short of becoming a religion, no system of psychotherapy will include all of these elements” (p.65). Perhaps DBT merely falls short in the category of faith.

DBT therapists also use traditional metaphors, parable, and myth with people. They will at times “play devil’s advocate” in a practice called “extending” (Neacsiu & Linehan, 2014). In Zen Buddhism, to reduce dominate meaning of events, “koans” or stories are often “presented as verbal puzzles” as a provocation for questioning principles of reality through meditation (Hayes, 2002, and Fischer, 2013). The dialectic approach activates “What is being left out here?” while Zen koans, similarly, unearth “what is there when the puzzle is no more” (2002, p. 64). Both DBT and Buddhism aim for the individual to let go of their patterns of reactivity to relieve suffering (or in Buddhism, “dukkha”) (Einstein, 2007).

Applicability to Therapy Techniques

When applied to psychotherapy techniques, the separation of mindfulness practices from the origin—Buddhism—initially resulted in a secularization (2007). The cultural taboo of speaking about religion need not apply to “mindfulness” if it is a culturally accepted, therapeutic tool. Neuroscientist and mindfulness proponent Richard Davidson dedicated a chapter in his book, The Emotional Life of the Brain, to this process. He writes about keeping his meditation practice a secret based on perceived stigma or misunderstanding by colleagues. He speaks topically to the idea of spirituality and Buddhism, but there is no explicit mention of an affiliation with Buddhism.

The increasing segregation or nonconformity of “mindfulness” from Buddhism has actually created an independent spiritual practice (i.e., within modernity) that is being measured scientifically. This is akin to the obstinate historical nature of atheism against—largely—monotheistic religions. Although seemingly isolating, the active disbelief in God created a scientific movement (e.g., led by Richard Dawkins, Sam Harris, Daniel Dennett). The degree of this conscious extension of nonconformity essentially created a religion according to this article’s conceptualization (i.e., methodic and behavioral group ideology).

Buddhism is actually counter to our modern, Western culture. “Mindfulness” is a lighter version with more individualistic aspects (e.g., self-improvement, stress reduction). Buddhism is a radical, pre-modern tradition born within a society that emphasizes the collective “we” versus “I”. For individuals to learn mindfulness apart from Buddhist tradition and precepts is as arbitrary as the isolation of genuflecting prayer (e.g., Christianity) or “auditing” (i.e., Scientology) to use as singular tools for eradicating suffering. The dialectical question for contemporary mindfulness practice becomes: what are we leaving out?

References:

1. Andersson, G., & Asmundson, G. (2006). CBT and Religion. Editorial. Cognitive Behaviour Therapy (35): 1.
2. Castillo, R. (1997). Culture & Mental Illness: A Client-Centered Approach. Pacific Grove, CA: Brooks/Cole Publishing Company.
3. Davidson, R. J., & Begley, S. (2012). The Emotional Life of Your Brain: How Its Unique Patterns Affect the Way You Think, Feel, and Live—And How You Can Change Them. Hudson Street Press.
4. Einstein, D. A. (2007). Innovations and Advances in Cognitive Behaviour Therapy. Huxter, M.J.: Chapter 4 Mindfulness as Therapy from a Buddhist Perspective. Australian Academic Press.
5. Fischer, N. (2013). Training in Compassion: Zen Teachings on the Practice of Lojong. Shambhala Publications.
6. Frankl, V. (1959). Man’s Search for Meaning.
7. Germer, C.K. (2005). Mindfulness: What is it? What does it matter? In C.K. Germer, R.D. Siegel, & P.R. Fulton (Eds.), Mindfulness and Psychotherapy (pp. 3-27). New York: The Guilford Press.
8. Hayes, S. C. (2002). Buddhism and Acceptance and Commitment Therapy. Cognitive and Behavioral Practice: 9, 58-66.
9. Mohr, S. (2011). Integration of Spirituality and Religion in the Care of Patients with Severe Mental Disorders. Religions (2): 549-565.
10. Neacsiu, A. D., & Linehan, M. M. (2014). Dialectical Behavior Therapy for Borderline Personality Disorder. In: D.H. Barlow (ed.) Clinical Handbook of Psychological Disorders. Fifth Edition. New York: The Guildford Press 394-461.
11. Sparks, F. “Using Mindfulness in Your Practice: Wisdom and Compassion in Counseling and Coaching.” University of Wisconsin Continuing Studies Workshop. March 10-11, 2015. Madison, Wisconsin.

People I work with in psychotherapy often tell me how they manage bothersome thoughts or worries: “I just try not to think about it.” This process of mental avoidance—trying not to think about specific thoughts or feelings—can actually trigger unwanted thoughts. For example, if I instruct you not to picture an elephant, what happens? Do you not think of an elephant?

Our ability as humans to distract and compartmentalize our problems and emotional experiences is part of an evolutionary and complex mental system. Avoidance is not inherently good or bad as a widely applied coping skill. However, the way one avoids stress may affect his or her level of engagement with others. Mentally speaking, avoidance is a typical response to stressful thoughts and events. Crossing the street so as to not pass by someone walking in your direction is an example of physical avoidance. The paradoxical effect of anxiety and mental avoidance leads us to a new therapeutic model.

Acceptance-based behavioral therapy (ABBT) is from the third wave of cognitive behavioral therapy (CBT) approaches. This new flood of therapies incorporates mindfulness practices. ABBT, for its part, focuses on the management of cognitive avoidance. It addresses the omnipresent suffering that encompasses the mind’s ability to project into the future and dwell or ruminate on the past. Our thinking in this department is more complex than for any other mammal on the planet, but to a fault.

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The worry that we create through habitual patterns of thinking serves as a form of avoidance from the present moment experience. The avoidance becomes automatic or habitual over time, so we tend not to be aware that we are avoiding things. We might not realize that the worrying or our perception of an association in the future distracts us from other emotional topics.

This is especially resonant in American culture. Westernized values center on productivity and success as determinants of self-worth. This egocentric position ingrains our fixation on what the future will bring. It is eloquently framed the “intolerance of uncertainty.”

Worrying or attempting to not fixate on an idea or memory is viewed by ABBT as a “natural response” rather than inherent pathology. The worrying takes place as a way to reduce physiological arousal around something aversive or feared, but allows us to avoid more distressing issues. One of the ways this directional thinking or grasping (i.e., future or past) causes us so much stress is that the observation becomes self-identification. An inability to tolerate the ambiguity of an uncertain future creates a tendency to respond in a negative way. Negative prediction or judgments of the future lead us to further worry, which we then try to manipulate as the cycle perpetuates.

Take an invitation to public speaking as an example. If you are asked to give a presentation in front of a group of coworkers tomorrow, you might start thinking about material to reference or what the room looks like that you will present in. Then you ponder how many people will be in attendance. You consider what type of attire you should wear and how people will be staring at you. What if you make a mistake? The thinking and worrying narrows your focus toward potential social threats (the coworkers watching, the bosses evaluating, etc.).

The associations can begin to entangle the person and they become hooked by their own mental processes around the potential experience. The cognitive aspect pairs with physical reactivity such as increased heart rate or a sinking feeling in one’s stomach to condition the anxiety. Rather than noting this experience as anxiety, people often self-define as saying or thinking, “I’m really anxious!” The idea of being anxious is fused with the person. The person views himself or herself negatively and further worries about how he/she will respond in this perceived state of mind. A conclusion often stems from personal judgments around the anxious state and can come in the form of a belief: I am weak.

If your way of operating includes attaching to these beliefs, certain states of mind (fear, sadness, anxiousness) become framed as personal deficits or flaws. Put more simply, the idea that there is “something wrong with you” is cemented. When a person believes there is something wrong with him or her, often the thought is that if I could just fix [insert a perceived deficit], then my life would be better. The self-criticism and judgmental thinking—not the perception of stress or deficit—tends to be the issue needing addressing. Awareness of your state of mind throws a wrench in this way of thinking and changes the operating system.

Acceptance-based behavioral therapy facilitates a system of operation with an emphasis on active awareness of one’s mind. Thoughts and feelings are not being replaced or altered. You recognize or observe what is occurring in the present moment.

Acceptance-based behavioral therapy facilitates a system of operation with an emphasis on active awareness of one’s mind. Thoughts and feelings are not being replaced or altered. You recognize or observe what is occurring in the present moment. Initial worry manifests as a thought and not who you are. However, beginning to worry about the worry and the avoidance strategies that accompany that way of operating is the process ABBT is directed toward. It also arranges a structured framework for therapists to work with the reactions of people in therapy (i.e., the behavioral component to the CBT coin).

The ABBT approach presents as a new way of operating for some people. Think about the functional change that occurs in the transition from desktop computers to mobile devices for using the Internet. The first major step of ABBT is being connected. It is like finding a Wi-Fi network to link with. The connection enables you to cultivate an expanded awareness or Wi-Fi signal as opposed to the narrow Ethernet cord-to-wall technology of the desktop computer. One must carry this signal of awareness and not be tangled up or fused with internal experiences (i.e., thoughts, rumination, etc.). The second step is a willingness to read or face the news of your experience (i.e., feeling states). The analogy here is once you are connected to a signal, you can open up a single web browser like Google or Internet Explorer. Engaging with the browser (don’t be tempted by random advertisements, Facebook or Twitter) offers the third metaphorical piece to ABBT: mindfully participating in personally meaningful behaviors.

As humans, we all benefit from increased awareness and empathic responses to environmental changes. Cultivating this practice of momentary acceptance while observing one’s own internal states will intrinsically create meaning within the activities one engages in. Put simply, if you are open and willing to put out a clear signal and connect with the world, your options for engagement are boundless.

Reference:

Roemer, L., & Orsillo, S. M. (2014). An Acceptance-Based Behavioral Therapy for Generalized Anxiety Disorder. In: D.H. Barlow (ed.) Clinical Handbook of Psychological Disorders. Fifth Edition. New York: The Guildford Press, pp. 206-236.

There is a paradox when it comes to bipolar mood episodes in terms of the treatment versus the prevention of episodes. On the one hand, the treatment of mood episodes can be rigorous, prolonged, and unsatisfying for people with bipolar and those around them. However, there are things people with bipolar can do to empower themselves in managing and, in some cases, staving off mood episodes.

Here is a focused outline on three self-guided components for living with bipolar: sleep, self-care, and support.

1. Train Yourself to Sleep

Your body responds to natural circadian rhythms. Based on a 24-hour cycle, a person’s physical and mental processes (e.g., mood) are affected by the changes of light and darkness. Setting the same wake and sleep schedule can dramatically improve your mood. Try to go to bed around the same time each night (even weekends) and get up around the same time in the morning. To do this, utilize these sleep hygiene tips.

Establish a routine to wind down in the evening. Pay attention to what time it is, so there is room to slowly navigate the dental routine, preparing for tomorrow’s workday, and the contact lens storage process. Avoid projects and other mentally taxing activities. Instead, read a novel, take a shower, or do some light stretching in the evening. Using alcohol, nicotine, or other drugs can disrupt nighttime habits, which consequently leads to increased stress and less capacity to manage it. Finish eating at least two to three hours before you go to bed, and abstain from caffeinated beverages in the evening. It takes approximately six hours for caffeine to leave the body, so a reasonable rule would be switching to decaf by 4 or 5 p.m.

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When you are ready to hit the sack, use your bed for two things: sleep and sex. This means not binging on Netflix or writing a dissertation from the confines of the bed. Train the body to know that when you are getting into and lying in bed, it is time to fall asleep. You do not want to be alert in front of a screen or stimulated by a task you are doing while in bed. Consistent, alert activity in bed teaches us to be awake; when we do want to go to bed, the brain is confused as to whether dreamland is approaching or to perk up for Breaking Bad.

Similarly, do not submit to long periods of insomnia (no more than 10 or 15 minutes at a time). Although seemingly counterintuitive, this goes back to the idea of training the body. After 10 to 15 minutes of not being able to fall asleep, do not continue counting sheep; go to another room and get a glass of water, read a brief article or part of a book, and wait until you are a little sleepy before returning to bed. This reminds the body that the bed is for sleeping. Life can get in the way, but aim for seven to eight hours of sleep per night.

2. Practice Regular Self-Care

Recent research shows that exercise is at least as effective for relieving depression as antidepressant medication. It also comes with a lot of less intrusive side effects (i.e., feeling relaxed, improved sleep and energy levels). Exercise regularly and make sure to finish a few hours before bedtime. Our bodies did not evolve to sit in office chairs for 12 hours per day, so getting your heart rate up or simply going for a long walk is a great stress release.

The more one understands about contributing factors to bipolar episodes, the more empowered he or she is to take preventative actions. You can develop a lifestyle management routine around your specific needs for mental health.

In addition, the mind, which regulates the flow of energy in our bodies, needs time to regenerate without stimulation. Develop a mindfulness practice or other type of spiritual process that you really value as necessary for mental well-being.

Prayer or meditation is best practiced in the morning after waking up. This establishes an intention for mindfully approaching daily life. Sit in silence while paying attention to your breathing for 20 to 30 minutes (start in smaller increments). Mindfulness group practices and classes are ever more ubiquitous and offer instruction to guide your work. Practicing these techniques within a community can be especially powerful. Contemplative activities are not rooted in gaining or self-improvement, which drive our identification with productivity. It is a commitment to sustaining a healthy lifestyle for the betterment of your relationships with others. Being curious and actively aware of the present will elicit awareness to subtle symptoms while decreasing impulsive behaviors.

A simple tracking sheet for mood and anxiety levels as well as self-care initiatives is a constructive way of monitoring behavioral and mental changes. Use a spreadsheet and leave it next to the bed or, if applicable, next to your daily supplements and/or medication box. Quickly note on a scale from 1 to 10 (1 being depressed and 10 equaling manic symptoms) what your mood was for the previous day. You can do this for anxiety levels as well. Also, note whether you exercised or practiced other self-care (yoga, meditation, etc.) and any significant events (interpersonal issues, medication changes, etc.) that took place. Over time, you will have a noteworthy amount of data to compare the actions you have been taking with changes in your routines, moods, and levels of stress. Utilize the correlations you find and make predictions about what you need to do—or not do—in order to stay on top of emerging problems.

The more one understands about contributing factors to bipolar episodes, the more empowered he or she is to take preventative actions. You can develop a lifestyle management routine around your specific needs for mental health. This includes clues to early warning signs and possible factors you have identified that get you into psychological trouble.

3. Lean on Others for Support

The effects of bipolar rarely occur within a vacuum. When a person tries to manage it alone, it can consume the person. Like any stressor or bothersome life event, the symptoms of bipolar pull on relationships. This becomes a systems issue that requires the support of others. Wright et al. (2009) state that “family members and friends are generally good observers and may be able to recognize the subtle changes in behavior, emotions, and thought processes that signal the onset of mania.”

Having individuals in your life who are aware of your historical battles raises the likelihood that mood changes will be identified before complete manifestation. Talk to people who are close to you when you have medication or drug-use changes, feelings of depression, or energy changes, and allow space for them to discuss your routines or behaviors. Appreciate their information and knowledge while assuming they love and want the best for you. Transparency will alleviate the concerns of others and lessen the burden you feel for managing the prevention of mood episodes.

It is essential to develop close relationships with your health providers so they have a longitudinal vista into your mental health. If you wanted to see how your face aged over time, you could take a selfie on a daily or weekly basis and run the images through a video program. Similarly, regular meetings with a psychotherapist will foster insight, but also enable the psychotherapist to notice subtle changes in your mental health presentation. A psychotherapist typically takes a “snapshot” of you each week—or two—and, akin to a series of selfies, compares and contrasts the “images.” This clinical timeline is examined with you in order to make correlations and inferences about mood episodes as well as behavioral changes. A disciplined regimen of psychotherapy is necessary to understand our habitual processes. You become aware of the holes you continuously fall into despite seeing warning signs.

If you can regulate your sleep, monitor internal changes, and stay physically active—while also training your mind—you and your therapist might not have much to talk about.

References:

1. Archer, A.J. (2013). Pleading Insanity. Bloomington, IN: Archway Publishing.
2. American Psychiatric Association. (2013). Diagnostic & Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
3. Kirsch, I. (2010). The Emperor’s New Drugs: Exploding the Antidepressant Myth. New York: Basic Books.
4. Kirsch, I., Deacon, B.J., Huedo-Medina, T.B., Scoboria, A., Moore, T.J., & Johnson, B.T. (2008). Initial severity and antidepressant benefits: a meta-analysis of data submitted to the food and drug administration. Public Library of Science Medicine 5 (2): 260-268.
5. Miklowitz, D.J. (2014). Bipolar Disorder. In: D.H. Barlow (ed.) Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual. (5th ed.). New York: The Guildford Press. 462-501.
6. Murray-Swank, A., & Dixon, L. (2005). Evidence-Based Practices for Families of Individuals with Severe Mental Illness. In: R.E. Drake, M.R. Merrens, & D.W. Lynde (eds.). Evidence Based Mental Health Practice. A Textbook. New York: W. W. Norton & Co., pp. 425-452.
7. National Institute of General medical sciences: basic discoveries for better health. Circadian Rhythms Fact Sheet. Content reviewed November 2012. Retrieved from: http://www.nigms.nih.gov/Education/Pages/Factsheet_CircadianRhythms.aspx
8. Siegel, D.J. (2010). The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration. New York: WW Norton & Company.
9. Wright, J.H., Turkington, D., Kingdon, D.G. & Basco, M.R. (2009). Ch. 8 Mania. In: Cognitive-Behavior Therapy for Severe Mental Illness. An Illustrated Guide. Washington, D.C.: American Psychiatric Publishing, Inc. pp. 181-209.

“…Not all psychological impacts can be encompassed by a list of symptoms or disorders.” —From Principles of Trauma Therapy

Make no mistake about it, Principles of Trauma Therapy: A Guide to Symptoms, Evaluation and Treatment is a psychiatric textbook. However, it is a rare breed of psychiatric textbook. It has a soul. To borrow from the dialectic wisdom of Marsha Linehan, the question in mental health treatment is often “What is being left out?” This book fills the void in terms of a comprehensive examination of the causes of trauma. It is not solely focused on the lists of symptoms. There are some areas where the book has “left out” important information, but emphasis on cultivating compassion for trauma survivors makes up for it.

John N. Briere and Catherine Scott describe how challenging behaviors exhibited by people who have gone through traumatic events are normal and within the context of psychological resilience: “Although therapists may interpret these behaviors as ‘resistance,’ such avoidance often represents appropriate protective responses to therapist process errors.” (p. 170). The adaptive functioning—or attempts to “metabolize” the trauma—is often interpreted as sabotaging or therapy interfering, but in reality, it suggests the clinician is in error (e.g., moving too fast in therapy). Unfortunately for the person in therapy, these attempts to lessen the pain can inadvertently prolong their trauma (this is what’s called the “pain paradox”). The unskillful attempts used to extinguish the pain often produces an increase in pain for the individual.

[fat_widget_trauma_ptsd_right]The pervasive message in Principles of Trauma Therapy is that a person’s symptoms due to a trauma can resolve via therapeutic engagement within a safe, therapeutic environment. The treatment approach is eclectic, and it weaves together strategies from various models (e.g., cognitive behavioral therapy, psychodynamic approaches, and mindfulness). People in therapy are given the opportunity to develop a coherent narrative of their past experiences, while learning stress reduction skills and psychoeducation through validation, respect, and supportive encouragement.

At the heart, Principles of Trauma Therapy comes from the theoretical perspective of exposure therapy and much of the content centers around this orientation for treatment. The clinician invites the person in therapy to develop alternative perceptions to their negative beliefs about themselves (oral and written) and the environment where the trauma manifested, while reducing “conditioned emotional responses” (CER).

To simplify, the recollection of the traumatic memory (i.e., exposure) occurs by activating the emotional states and schemas. The “disparity” that occurs is based on the idea that the therapy space is safe, so the person in therapy is counter-conditioned to realize they will not be harmed by experiencing the intense emotions that surround the memories. The integration of memories and emotions through exposure—along with the inability to avoid (i.e., CER) in the moment—creates resolution. The emotions are no longer as powerful. The positive results occur if the clinician is able to finesse the client’s capacity to “regulate and tolerate the associated painful affect” (p. 267). Briere and Scott advocate a titrated exposure to avoid both undershooting the level of exposure and not overwhelming the person in therapy. This person should be emotionally activated to allow processing to take place, but not to the point that their coping resources are overwhelmed, which leads to avoidant behaviors (i.e., to seek safety from the distress).

Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane?

There are a couple of areas that should have been addressed more thoroughly in the text. Exposure therapy techniques are undoubtedly effective and reliably decrease posttraumatic stress. However, the dysregulated elephant in the room during my review of this book was a question of ethics: is exposure therapy humane? This form of therapy elicits pain for the person in therapy, often expressed in the form of panic attacks, dissociation, and intense anxiety through a re-experiencing of the trauma. Is it morally right for clinicians to prescribe this approach? Does the end justify the means? Or, are there other treatment approaches that can be used to relieve the immense amount of suffering experienced by trauma victims?

Principles of Trauma Therapy provides only a brief conceptualization of eye movement desensitization and reprocessing therapy (EMDR). In 2004, the APA acknowledged EMDR as a recommended effective treatment of trauma. According to Shapiro (2001), EMDR is the most empirically studied treatment for posttraumatic stress (PTSD). The philosophy of EMDR treatment does not differ drastically from exposure therapy: deconditioning disturbing input, redefining the event, finding meaning in it, and eliminating self-blame, while integrating new skills (Shapiro, 2001). The stark difference between EMDR and exposure therapy is the method of delivery, as well as the path a person in therapy takes toward healing. Exposure therapy is analytical with a narrative-driven process that involves a significant amount of “homework” assignments for the person in therapy. It also runs a risk of vicarious traumatization (for both the therapist and person in treatment) due to repeatedly describing the often horrific events.

The internal process of EMDR utilizes an approach of holding a negative cognition (e.g., “I am unlovable”) paired with what is often an image of the traumatic event (a pre-established target). The person is instructed to focus on the image, negative thoughts, and body sensations while simultaneously engaging in EMDR processing using sets of bilateral stimulation (e.g., eye movements, auditory stimuli, or tactile sensors). They are witnessing in their mind’s eye what surfaces. The clinician does not hear all of the details of the trauma, nor does he or she provide analysis of the experience. Dialogue is at a minimum. It is provided through repeated, brief check-ins between sets of bilateral stimulation; “What comes up now?” or “What did you notice that time?”

Principles of Trauma Therapy has an agenda in terms of promoting exposure therapy, but it also offers a holistic array of coping strategies—for both the therapist and the person in therapy—to increase one’s awareness of bodily reactions and ways to create a vocabulary for the feelings that arise. This mindful mentality is more than a subtle emphasis. Empirically validated mindfulness interventions are presented (e.g., acceptance & commitment therapy, dialectical behavior therapy, mindfulness-based stress reduction, and mindfulness-based cognitive therapy) as to disillusion the reader from the spiritual, Buddhist connotation. Clinicians are encouraged to maintain an open awareness to their own mental states (e.g., reduction of reactivity) without judgement, in order to mirror this process for people (e.g., attending to the breath, a here-and-now focus). There are also scripts for new clinicians and comprehensive assessment material that is applicable to anyone in therapy.

Principles of Trauma Therapy has a final, comprehensive directory of trauma-centered psychopharmacological interventions with content relative to psychobiology. This is extremely informative, but one has to question some of the research that was referenced. One concluding statement regarding the efficacy of selective serotonin re-uptake inhibitors (SSRIs) as antidepressant medication gave me pause. It was noted that SSRIs “have been found to be equally effective in reducing symptoms and improving quality of life across most clinical trials” for many diagnoses. The example reference was to a 2000 study comparing monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants and some selective serotonin re-uptake inhibitors (SNRIs) for depression. ^[1] The citation did not match the broad sweeping claim as the study itself notes “clinically insignificant” differences in efficacy as well as tolerability between SSRIs. ^[1] Read this section with a grain of salt and consider newer research when determining the efficacy of medication for victims of trauma.

Despite the focus on the individual in this book, the reader is walked through the “victim variables”, “characteristics of the stressor”, and “social response and supports” that affect the outcome for the trauma victim, which forces a cultural vista. Briere and Scott implicitly connect to the fact that our society’s disenfranchised groups of individuals (e.g., people of color and in poverty) are much more susceptible to posttraumatic symptoms.

Trauma is no longer just a micro level problem, but an issue of social justice and equality. The book maps out the generational influences and cyclical effects of trauma. There is an “additive effect” of multiple traumatic events throughout one’s life. For example, a survivor of childhood abuse who has residual effects into adulthood will react with “especially severe, regressed, dissociated, or self-destructive responses to the adult trauma” (p. 22). Earlier treatment interventions are essential to desensitize these reactions to stress.

Briere and Scott provide a stylish blend of the metaphysical and tangible aspects of trauma. They do this with learned experience, academic research, and hope as a means to expose the wide-ranging consequences of trauma. If you are a clinician searching for an in-depth examination of the components, conceptualization, causal mechanisms and treatment of trauma, then Principles of Trauma Therapy is here to the rescue.

References:

1. Mace, S. and Tayler, D. (2000). Selective serotonin reuptake inhibitors: a review of efficacy and tolerability in depression. Expert Opinion on Pharmacotherapy: 1(5). 917-933.
2. Briere, John & Scott, Catherine. Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment (2^nd Edition). SAGE Publications, Inc; Second Edition – DSM-5 Update edition (March 26, 2014).