September 04, 2013 at 7:36 AM
Much has been made of the importance of non-specific factors (such as empathy, therapeutic alliance, etc.) to therapy outcome, and rightly so: therapists who use the common factors get better outcomes (Duncan, Miller, Wampold, & Hubble, 2010). However, that does not mean that only the common factors matter. For example, it’s well established that the trauma-specific treatments actually do treat trauma better than generic treatments do (Ehlers et al, 2010). So however important the common factors may be, there’s more to it.
The primary criticism of the common factors research is that it has relied on statistical analysis of randomized clinical trials. This means that outliers – for example, individual cases in which dramatic and lasting improvement occurred – have been rendered invisible in the group average, rather than specifically studied. On the other hand, process research focusing on individual cases has identified a specific factor that typically quickly leads to large and durable changes: guiding clients to face and process previously avoided emotional experiences (see Ecker, Ticic, & Hulley, 2012). Guiding the client to face, process, and resolve a trauma memory is arguably the most profound and impactful example of such a treatment activity.
This does not mean that the common factors are not important; indeed, these specific treatment activities are unlikely to occur without a treatment approach incorporating the common factors. It is probably most useful to conceptualize the common factors as the necessary foundation for the specific change-making activities to be implemented.
Now there is a definitive body of brain research that confirms and elucidates this specific factor. The book, Unlocking the Emotional Brain (Ecker, Ticic, & Hulley, 2012) explains how this research maps the deep structure of healing via memory reconsolidation. Memory reconsolidation occurs if the following sequence of events (Eckers et al) take place:
1. Reactivate. The memory must be accessed and reactivated.
2. Mismatch/Contradict. While the memory is reactivated, create an experience that contradicts the problematic learning or mental model that the memory had created
3. Create New Learning. Within the subsequent five hours, provide further experiences (possibly just repetitions of the Step 2 mismatch/contradiction) that eliminate or revise the associated mental model.
For example, a young woman identified the birth of her brother as the initial source of her negative belief, “I’m not important.” Early in working on this memory, she recalled her father being far more excited about the boy’s birth than he had been for anything to do with her; and she felt sadness and shame. Thus the memory was reactivated.
Then she suddenly recalled, “My uncle loved me. He thought I was important.” This was a mismatch, in that it contradicted the essential thing she had learned about herself from this memory. [This moment did not heal, but it destabilized the memory so that further intervention of a certain kind could have transformative impact.]
As the work progressed within this session, the client recalled more and more instances of feeling important, having accomplished something, being viewed by others as mattering, etc. Thus new learning was created and repeated. Within perhaps half an hour from starting the session, she no longer saw herself as unimportant. Instead, she said, “My father was so pathetic, he didn’t even know how to love his own child.”
This is how memory reconsolidation happens. For twenty-something years this client was driven by the belief, “I’m not important”. But she was able to reactivate, challenge, and permanently transform the memory so that it no longer supported that negative belief. Indeed, she now saw herself in a much more positive light.
Eckers and colleagues (2012) describe most presenting problems as being driven by schemas or mental models that are locked in the brain as a result of traumatic events (my term, used broadly to include any upsetting events that have not been fully processed or integrated). They characterize most therapy approaches as counteractive in that the focus is to manage or over-ride the mental model, emotional reactivity, and associated symptoms. Such approaches tend to be slow, incremental, and subject to relapse because the underlying mental model and emotional reactivity remain.
Instead, they recommend a transformative approach – using the brain’s ability to reconsolidate memory – to permanently modify the underlying mental model and eliminate the emotional reactivity. Transformative trauma resolution procedures, such those taught in our programs, can effect memory reconsolidation at the source of the associated symptom-generating mental model
Does your therapy include activities that will systematically and reliably facilitate memory reconsolidation?
This is healing. This is deep, lasting change. Don’t settle for less.
Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what works in therapy (2nd Edition). Washington, DC: APA.
Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. NY: Routledge.
Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., Schnurr, P. P., Turner, S., & Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder? Clinical Psychology Review, 30, 269-276.
Please add a comment
nice to see that we both have independently discovered the reconsolidation mechanism as a proper description of how trauma therapy (and all other psychotherapy too) works. The German psychotherapy researcher Klaus Grawe has figured out the same in the 90th. Now neurobiology has reached the same point.
I hope to be able to enable commenters to post their own web sites along with their comments, but meanwhile here's a shout-out to those who have commented on this post so far:
Lesa Fechte runs Continuing Education for the University at Buffalo (NY) School of Social Work, including their Trauma Certificate Program.
Thomas Hensel runs Kindertraumainstitut (Child Trauma Institute) in Germany.
Kriss Jarecki practices in the Buffalo, NY area and is one of our own (TI/CTI) trainers.
Sheri Oz is an author and expert in treatment of sexual abuse, in Israel.
And Robin Ticic is a coherence therapy expert in Germany, and co-author of the book featured in this blog post.
And we didn't have to fly anywhere to chat with each other :^)
There's a bit too much "solid" for me in the word reconsolidation. I use words with clients/patients more on the order of reframe and reorganize, and I talk about an alternate view rather than mismatch/contradict. That said, the thrust of what's here is right on the mark.