Recently I have been enjoying viewing videos of different therapists discussing their work with clients, and applying what I know to their descriptions, to find out what I can learn, and think about what I might do differently. Sometimes they go beyond their descriptions — which are usually mostly somewhat vague theory and nominalizations — and role-play what they would actually say to a client. This provides even more information — though not as much as an actual client session would provide. I have often learned a lot; sometimes this has only sharpened and clarified distinctions that I already knew, or provided some interesting examples.

In a videotaped webcast interview with Rich Simon, editor of the Psychotherapy Networker magazine, Bruce Ecker describes an approach called Coherence Therapy, previously called Depth Oriented Brief Therapy.

The entire interview is a webcast that you can find at:
http://www.icpre.com/Presentations/PN/ATia/Ecker.html

I sent an early draft of this post to Bruce, asking him to point out any errors that I might have made, and offering to post any response from him. We first had a useful email exchange, and then an interesting and friendly Skype call, and then some emails. The post below incorporates many clarifications and suggestions that he made, and includes his reply.

Bruce describes a 30-year-old client who presented with a passive enduring of abuse. His boss repeatedly criticized him and humiliated him in front of others, making his work environment very stressful. His girlfriend and others had told him he needed to find a new job, but he stayed, saying, “I know I need to go, yet I’m staying,” indicating a conflict between his knowing and his inability to act on it.

Bruce uses a variety of ways to to retrieve the implicit emotional necessity for staying. One is direct empathic eliciting. Another is repeated sentence completion: “I need to stay because . . . .” Another is called symptom deprivation, asking the client to imagine beginning to take action looking for another job, and noting any form of discomfort that arises, verbally or nonverbally, in response to being without his symptom of inaction.

When the client did this, he shifted in his chair slightly, and one hand reached over and squeezed his knee, and then he said, “I’ve lost track of what you were asking me to do.” Bruce asks him, “Is something happening that’s distressing you?” and he replied, “Yes, I don’t know why, but a memory is coming up, a memory of the worst time of my life,” and he began to tear up.

In high school he had spent years and great effort becoming a star in track and field events, had already gotten a college sports scholarship, and glowingly imagined a great future doing that. But before his last track meet he sustained an injury, and doctors found that he had a bone disease that prevented an athletic career, and he said that this had “crushed” him. Like many people in this kind of situation, he also described this as a “colossal unfairness and injustice.”

Bruce then engaged the client in a collaborative process of finding words that adequately fit the “core emotional meanings and adaptive strategies” that he formed in response to this multi-faceted blow. The final phrasing, which Bruce then wrote on an index card and handed him, was, “Life suddenly took away and crushed the top-notch life that I worked so hard for, and deserved, and was going to have. I’ve got to never again really want anything, or try for anything I want, because then life could crush me again. If I try for a better job, it could happen to me again, so ‘No, thank you.’”

Briefly stated, I would describe the sequence of events like this:

Discovery of bone disease ? loss of dream ? belief (newly conscious) that he must never again try for something he wants, to be safe from any more devastating, arbitrary crushing.

His loss of his planned career is a classic example of the loss of a future dream. When a very vivid and detailed imagined future becomes unattainable, the loss can be even more extreme than the loss of something that had already been attained. This process can occur at any time in someone’s life; it often occurs in mid-career, when it is called a “mid-life crisis.” This can easily be treated using our grief resolution process, which results in a re-union with the lost experience, which is then experienced as a present resource, and no longer as a loss.

Bruce recognized the importance of the loss, and since the client had suppressed most of his feelings about the loss, Bruce spent some sessions helping the client fully acknowledge, feel and express those feelings. This can certainly be useful, but it does not resolve the loss in the way our grief process does.

Bruce states that the client’s non-conscious, emotionally charged beliefs, expectations, and strategies formed in response to the experience are the “implicit emotional necessity” of the symptom (in this case staying at the job); and that for those meanings and strategies to be disconfirmed and dissolved, they need to be paired with a vivid and viscerally real contradictory experience.

Bruce’s intervention was to ask the client to take stock of the effects on his future life of his self-protective strategy of never trying for anything he wants. This intervention is an example of what he calls the “unacceptable cost” method. The client was asked to go into the future with his strategy and discover its consequences. After doing this, Bruce summarized the client’s discoveries to him as follows, “How is it for you to recognize, so clearly now, that this solution of yours for protecting yourself from ever again being crushed, like you were at the end of high school, actually rules out, for the rest of your life, ever again heading for something you want, something you and your fiancé might really want together, for the rest of your life?”

Some readers will recognize that this long sentence, spoken in a soft, low empathic tone of voice while gazing intently into the client’s eyes, is very hypnotic and impactful.

The client processed internally for a while, and then responded with the classic line, “I hadn’t thought of it that way,” and a little later with, “What was I thinking?” indicating that this longer time perspective shifted the meaning of his belief in a very useful way.

I would describe this intervention as an increase in the scope of time, asking the client to thoroughly review all the consequences of his decision, in order to discover what impact his belief would have on the future. Seeing the impact of this over a long span of time, and in a large number of different contexts, and including his fiancé, made the unpleasant consequences of his overgeneralization excruciatingly clear to him, and I assume that this is what changed his response.

An alternative would be to presuppose the harmful impact in the future, by saying something like, “Have you thought about how this belief prevents you from any success in the future.” However it is much more convincing when the client discovers the harmful consequences for himself. And if the client doesn’t discover them on his own, the therapist can always point it out later.

Expanding the scope of time in this way is very similar to another reframing pattern, increasing the scope of the context in space, often called seeing “the big picture.” A larger context in either space or time includes a great deal of additional content information that often changes someone’s response to an isolated event. For a description of the seventeen different patterns of reframing, and a video demonstration of how to use one of these reframing patterns recursively, see Using Reframing Patterns Recursively.

Later when Bruce tests the client’s response (what he calls verification) in which he tries to re-evoke the original problem response by asking him to read his old belief and discover his response to it now, he responds with another classic line, “Well, I sure can see why I would have reacted that way, but now it’s like hearing about somebody else,” clearly indicating that the belief is now something distant and abstract, not an experience he is immersed in, and that it no longer drives his behavior.

This was a well-chosen and useful intervention, and the client’s responses clearly verified its effectiveness. Despite the success of Bruce’s intervention, I would like to outline some alternative ways to work with this client. I would probably would have done several other things first that would be useful in themselves, and also help soften or weaken the client’s problem response.

Firstly, the client’s belief is based on a single very emotionally impactful personal experience of the loss of the golden future he had worked so hard to create. I would start by gently challenging his huge overgeneralization by saying in response to his urgent need to protect himself from a repetition of that devastating loss, “You, know, I have a friend who knows that all Indians walk single file because he saw one once,” and pause to give him time to process it, and notice his response. This mini-metaphor directed at the process of his belief (rather than its content) might not achieve a complete reorientation, but it would point out the absurd nature of his overgeneralization, and tend to weaken it.

Secondly, I would lead the client through a process to resolve the loss of the dream, as mentioned above, because this loss is likely to affect him in other contexts until, and unless, it is resolved. Resolving this loss would probably have changed his resulting belief that he needs to avoid trying for anything, perhaps making further interventions unneccessary.

Thirdly, I would also want to change his presupposition that life should be fair and just — which it manifestly isn’t. Like his grief, this unrealistic presupposition will likely impact other areas of his life in ways that are not useful. This is a belief that needlessly troubles many people, and you can find some ideas about how to resolve it in my article “It’s Just Not Fair.”

While this was a great intervention, Bruce and I have different ways of thinking about how and why it was effective. You can’t argue with a good result, but how we think about a result can help or hinder us in how effective we are with other clients in the future. In my view, the intervention didn’t actually follow the outline that Bruce proposes:

“What’s needed for this dissolution through reconsolidation is an experience of a very contradictory nature to the makeup of the symptom-requiring emotional learning — a living experience, an emotionally real and vivid experience that absolutely contradicts and disconfirms some key piece of that schema.”

In discussion with Bruce, he points out that in the original learning or schema the implicit presupposition could be verbalized as, “Never again trying for anything I want will protect me from great suffering.” The new, contradictory learning is, in words, “Never again trying for anything I want will cause me great suffering.” While that is certainly true, that very useful change is the result of the intervention, not the intervention itself. The intervention was to go forward in time experientially, and discover the consequences of the belief in the future. This experience of going forward in time was added to his previous experience of being crushed, yielding a different conclusion.

In contrast, a contradictory experience to this client’s overgeneralization would be a personal experience of expending great effort that did turn out to be successful. The client must have had experiences of this kind that he is not paying attention to. If a large group of these counterexamples were first assembled into a robust category in the client’s mind before juxtaposing it, that would be even more powerful in providing a new perspective, because a group of examples is much more convincing than a single one. I would desccribe this as a juxtaposition of a contradictory experience, and in one of the cases in Bruce’s book he does that.

Bruce presents this intervention as an example of memory reconsolidation, a concept that has recently gotten a lot of attention as an explanation of how change occurs, particularly in the case of trauma. Briefly, this theory — which has a lot of supporting experimental studies in both animals and humans — states that when a memory is recalled, there is a brief period of time — a few hours — in which the memory can be modified so that when the memory then becomes “reconsolidated” (stored again) it no longer elicits an emotional response.

Finally, Bruce’s description of the case clearly indicates that the client’s experience of disappointment and loss of his dream was not changed by the intervention. I’m sure that if asked, he would still report that his being crushed by the loss of his dream was horrible for him. What changed was the conclusion that he made about the experience after imagining the consequences in the future. This conclusion is at a higher logical level than the experience itself, just as an emotional response to an event is at a different logical level than the event. For more than you every wanted to know about the usefulness of thinking in terms of logical levels in the context of therapy, read my two-volume book, Six Blind Elephants: understanding ourselves and each other.

Bruce Ecker replies:
I appreciate Steve Andreas’s invitation to respond to his comments about the case I described when interviewed by Rich Simon.

Steve’s approach and ours have much in common — especially the experiential, phenomenological emphasis and close attention to the client’s construction of reality in areas involved in symptom production. In the vast labyrinth of the therapy field, that’s a lot to have in common!

At the same time, there are some significant differences. In addition, Steve chose certain elements of my account for comment and not others, according to his own ways of thinking and priorities. That’s only natural, but as a result his rendition of what I presented does not adequately capture the nature of the therapy process or conceptual framework that my colleagues and I have developed. So, I hope interested readers will go to the original and see it for themselves; here once again is the link: http://www.icpre.com/Presentations/PN/ATia/Ecker.html

There’s a short excerpt on YouTube here: http://www.youtube.com/watch?v=mvPIFSSGdZQ&feature=youtu.be

In that interview, I was using this case example to show that presenting symptoms that seem clearly to imply underlying attachment issues — such as my client’s staying in an abusive situation — sometimes prove not to arise from attachment learnings, as in my client’s case. My main point: It’s only after the symptom’s underlying, implicit (non-conscious) learnings are brought experientially into awareness and made explicit that the presence, or absence, of attachment issues is clear.

Here’s a brief account of how I see the divergence in our approaches.

One area is the recognition of important differences between emotional implicit knowledge formed in prior emotional experiences, versus ordinary conscious or near-conscious cognition. In our view, Steve’s accounts do not adequately recognize the differences in the phenomenology of those two domains. One example is his use of the terms “belief” and “conclusion” to refer to what are completely nonverbal, non-conscious learnings that feel like reality to the client. Consider an overweight woman client who was sexually assualted several times in her youth. If her therapist said to her, “So, you have a belief that if you became thin, you’d be in danger of that happening to you again,” she may well feel and perhaps also say, “It’s not a ‘belief,’ I know it’s true.” Another example is his explanation that he would have told my client, “You know, I have a friend who knows that all Indians walk single file because he saw one once” in order to “point out the absurd nature of his overgeneralization.” To our way of thinking, that approach assumes that the client’s cortical, cognitive, conscious disapproval and dislike of his symptom could dissolve or at least reliably override his subcortical, urgent emotional implicit knowledge — which abundant clinical experience, as well as abundant neuroscience research, tells us is not the case, as a rule. Openly depicting the “absurd” nature of a client’s existing, compulsive pattern is also too likely to result in a sense of both failure and shame for the client.

Another area of difference is in the description of the mechanism of change. Steve says that my client had a new, different experience and then “changed the conclusion” he had previously formed and lived by. To us, that’s merely a description of the outcome, not a description of the precise phenomenological process and conditions that bring about that outcome. It leaves largely unanswered the fundamental question: When a long-standing, emotionally urgent, adaptive, learned, self-protective strategy does dissolve in response to new learning — and such dissolution typically fails to occur in the majority of therapists’ attempts — what are the specific conditions or processes that successfully bring that about and can do so consistently? Our clinical observations spanning 25 years, combined with memory reconsolidation research findings, have provided a sharply focused understanding of that liberating process, and it’s an understanding of how the experiential, subjective level and the neurological, synaptic level interact. Such unification is a big advance that significantly enhances the reliability and scope of our clinical knowledge and know-how.

Steve maintains that I did not carry out the process of change that I claimed I did carry out. His critique gives me the impression that we are talking about different things, however. By “contradictory experience” I mean an experience that contradicts a client’s symptom-generating beliefs, expectations and knowings. This client’s learned, implicit strategy and expectation was that he would suffer less in life by never acting on his desires for a better situation. I guided to him into an experiential recognition that he would suffer more, not less, that way. This was a contradictory experience of the type I mean, and I guided him to hold this experience alongside his original, opposite expectation, creating what we call a juxtaposition experience. It is the juxtaposition experience that I regard as directly causing profound change. (We are currently developing a manual of methods for creating juxtaposition experiences, which will be available (planned for early 2013) here: http://www.coherencetherapy.org/resources/juxt-manual.htm.)

Finally, Steve’s description of reconsolidation is problematic in two ways. First, he calls it a “concept” and a “theory,” which might give the readers the impression that this phenomenon exists largely as a speculative conceptual model. Reconsolidation took neuroscientists by surprise when it emerged from hard observational data in the 1997-2000 period, and since then it has been clarified progressively by hard data from many neuroscience laboratories around the world.

Secondly, and more importantly, it is not true that “when a memory is recalled, there is a brief period of time…in which the memory can be modified.” This widespread misconception about reconsolidation — that a memory becomes modifiable as a result of its reactivation — was neuroscientists’ early interpretation of their observations in the 2000-2004 period. That view turned out to require revision in light of findings first reported in 2004 and then replicated in at least nine other studies. However, the original, incorrect view has continued to be promulgated, particularly in science journalism. The findings since 2004 have shown that a memory (that is, the neural circuits storing a learned response) becomes labile and modifiable when the memory is both recalled (reactivated) and then, in addition, while the reactivation is still occurring, there occurs an experience that sharply mismatches what the memory expects about how the world functions. The required experience of mismatch of the target learning can be either an outright contradiction or a salient novelty. Without this mismatch experience after reactivation, the reactivated memory remains locked and cannot be modified. With the mismatch experience, the learning contained in the memory can be re-written by learning experiences during approximately the next five hours. This process is fulfilled in therapy by creating juxtaposition experiences, as I described in step-by-step detail in the webcast.

In that webcast I was providing a sample of our recently released Routledge book, Unlocking the Emotional Brain: Eliminating Symptoms at Their Roots Using Memory Reconsolidation. The book shows how the core process revealed by reconsolidation research is present in case studies of AEDP, Coherence Therapy, EFT, EMDR and IPNB — suggesting that this process appears to be a unifying framework for transformational change.

The clinical process also reveals whether or not attachment learnings underlie a given symptom. The book gives therapists a clear account of reconsolidation research and how reconsolidation works and translates into clinical work.

I’ve described the book in a 7-minute YouTube video here: http://www.youtube.com/watch?v=raPLE_XjDDQ

A short written description of the framework is here: http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=41665&cn=91