Journal of Constructivist , 2008, in press

DEPOTENTIATION OF SYMPTOM-PRODUCING IN COHERENCE THERAPY

BRUCE ECKER1 AND BRIAN TOOMEY2

1Private practice in , Oakland, California 2Clinical Psychology Department, University of Memphis, Memphis, Tennessee

In this second of three articles we suggest criteria defining the optimal use of neuro- plasticity (synaptic change) in psychotherapy and provide a detailed examination of the use of neuroplasticity in coherence therapy. We delineate a model of how coherence therapy engages native mental processes that (a) efficiently reveal specific, symptom- generating, unconscious personal constructs in implicit emotional memory, and then (b) selectively depotentiate these constructs, ending symptom production. Both the psy- chological and the neural operation of this methodology are described, particularly how it defines and follows the built-in rules of change of the brain-mind-body system. On neuroscientific grounds we suggest a fundamental distinction between transforma- tive change, which permanently eliminates symptom-generating constructs and neural circuits, and counteractive change, which creates new constructs and circuits that compete against the symptom-generating ones and is inherently susceptible to relapse. We propose that coherence therapy achieves transformative change through the reconsolidation of memory, a recently discovered form of neuroplasticity, and present evidence consistent with this hypothesis. Subjective attention emerges as a critical agent of change in both the phenomenological and neural viewpoints, profoundly connecting these two domains.

The constructivist clinical methodology now tory.2 The goal of this study was to identify the known as coherence therapy and its conceptual brain-mind-body system’s native processes and framework, coherence psychology,1 emerged from rules of change. This was sought through close an ongoing, phenomenological study of psycho- scrutiny of the phenomenology whenever a ther- therapeutically induced change by Ecker and Hul- apy client of Ecker or Hulley had an experience ley (1996). Launched in 1985, this study was car- that led unambiguously to lasting symptom cessa- ried out in the local clinical scientist tradition tion. (Stricker and Trierweiler, 1995), in which a prac- The aim was to let the native phenomenology ticing clinician systematically utilizes his or her guide the shaping of the methodology—that is, to own sessions as an effectiveness research labora- identify the elements of the client’s internal proc- ess of change very accurately in hindsight (if nec- essary by querying the client about it); to discern 1 The name used from 1993 through 2005 was “depth- exactly which client-therapist interaction had suc- oriented brief therapy,” or DOBT. The change to “co- cessfully fostered that change process; to distill the herence therapy” and “coherence psychology” is in- pattern and principle of that interaction into a tended to reflect the central principle of the approach. method that could be applied knowingly with other clients; and to assemble a therapy compris- ______Correspondence: Bruce Ecker, 445 Bellevue Ave., Suite 101, Oakland, CA, USA 94610. 2 Ecker had previously worked in experimental physics E-mail: [email protected] research for fourteen years. 2 Implicit Memory Depotentiation ing only methods selected in that manner, methods ence has very recently developed to the point shaped for cooperating closely with the identified where the correspondences between the reduc- processes (Ecker and Hulley, 1996, 2000a, 2000b, tionist findings of the brain sciences and the holis- 2004). tic phenomenology of psychotherapy can begin to Therapeutic methods not selected-in by this be assessed. According to a neurophysiology re- process were discarded, even if they were deeply searcher at MIT, “Ten years ago we only knew familiar, widely practiced, and time-honored, such what some of the key components of synapses are. as offering interpretations. The working assump- Now we know what most of them are” (Olson, tion was that a therapy formed entirely in this 2004, p. 16). More than 1,000 different proteins way—dictated by the brain-mind-body system’s are active agents in controlling the operation of own terms—would be an optimized therapy that synapses and neurotransmitters. Nobel laureate would yield a marked increase in effectiveness. Eric Kandel states that, “Although we do not have A principal result was the finding that clients’ a complete understanding of how synapses work in-session experiences that resulted in lasting and how they are regulated for plasticity, learning change virtually always stemmed from interac- and memory, we do have a satisfactory under- tions in which the therapist had completely standing” (Olson, 2004, p. 23). stopped trying to counteract or prevent the client’s Attempting to model the psychobiology of symptoms or difficulties. The therapist had fo- optimal therapeutic change is new territory for us, cused instead solely on eliciting from the client for psychotherapy, and for neurobiology, so it is how and why the symptom actually made sense to necessary to create an orienting framework. We have within the client’s world of meaning. This suggest that a defining feature of a maximally ef- hidden coherence of the symptom proved to be fective psychotherapy is an optimal use of the quickly discoverable in most cases, not as a brain’s capacity for neuroplasticity, or synaptic speculation but as a personal emotional truth, even change. We propose a three-part definition of the if the client initially had no conscious notion of it optimal use of neuroplasticity: whatsoever. The observation of consistent, striking effec- (a) Recruitment of the most potent types of tiveness resulting from coherence-focused work, synaptic change, in contrast to the field’s standard, counteractive (b) in the brain regions and neural circuits approaches, led to the development of simple causing symptom production, methods for quickly detecting and revealing the cogent themes and purposes actually maintaining (c) on the shortest timescale neurally possible. clients’ seemingly irrational symptoms. Upon veri- fying in session with virtually all clients the coher- This definition specifies the what, where and ence of their symptoms and problems in living, when that could reasonably be regarded as an op- Ecker and Hulley (1996) defined “symptom co- timal recruitment of neuroplasticity. We will use herence” as a comprehensive model of symptom this definition in this and the following article as a production. gauge of psychotherapeutic optimization. Independently, research in Familiarity with the previous (first) article in has developed a knowledge of the brain’s this series (Toomey and Ecker, 2007a) is assumed native processes and rules of change on the reduc- here, particularly the overview of coherence ther- tionistic level of the brain’s physiology, neurons, apy, the definition of symptom coherence and the synapses, genes and molecules. Neuroscientists case example of Carol. Our purpose now is to de- too think and write in terms of “rules” of change, lineate: and they strive to identify the exact physiological and biochemical implementation of those rules. • The brain-mind-body system’s built-in rules If coherence therapy’s account of the brain- for change as defined by coherence therapy in mind-body system’s built-in rules of change is phenomenological terms. correct, it should be possible to demonstrate that • The methodological procedures of coherence these phenomenological rules correspond closely therapy and how they efficiently follow those to neurodynamic rules and processes. Neurosci- rules for change. Implicit Memory Depotentiation 3

• The neural mechanisms of change that are We will describe each of these, first in coher- plausibly recruited by these procedures. ence therapy’s experiential-phenomenological terms and then in terms of their probable neurody- These three strands, woven together, form a namic substrates. unified fabric of neural and phenomonological The immediate accessibility of unconscious knowledge of how the specific implicit memories constructs (Ecker and Hulley, 1996, 2000a, 2004) driving symptom production can be efficiently is apparent in the frequent observation while car- depotentiated, ending production of a wide range rying out coherence therapy that a person can ac- of symptoms reliably and rapidly. cess and directly experience longstanding, non- With few exceptions, we consider only the verbal, fully unconscious, symptom-requiring con- main features of the methodology, not the finer- structs after a few minutes of suitably designed grain techniques and skills involved in its imple- process. The guiding of attention to the uncon- mentation (for a more complete clinical discussion scious material can occur at any time, from the see Ecker and Hulley, 1996, 2000a, 2004). As de- first session; passage of time per se is not an in- scribed in our prior article, the methodology that trinsic requirement for the accessing to occur. defines coherence therapy has three main compo- Even constructs formed in childhood and uncon- nents: The creation of experiences that (1) dis- scious for decades can usually be brought into ex- cover, (2) integrate, and (3) transform pro- periential awareness through methods that accu- symptom positions. For each of these areas of rately bring attention into them. The unconscious methodology, we will address the three strands status of a personal construct evidently means listed above. only that it is chronically unattended, whether ha- It is also worth noting in advance that in each bitually or purposefully, not that it is inaccessible. area of the methodology, the experiences that are The observation by Ecker and Hulley that the un- created involve guiding the client’s attention in conscious/implicit constructs and schemas driving specialized ways. The coherence-guided use of symptom production are, as a rule, available for attention is the central activity of coherence ther- prompt, direct experiencing stands in contradiction apy. A central theme of this article will be the ex- to the view in that only the periential and neural effects of attention deployed manifested effects of an implicit are acces- in accurate cooperation with the native processes sible to awareness, not the unconscious schema of change. itself (see for example Nisbett and Ross, 1980). In this way unconscious personal constructs appear THE CREATION OF EXPERIENCES THAT to differ from, say, the unconscious schemas gov- DISCOVER PRO-SYMPTOM POSITIONS erning generative grammar or perceptual parsing, which are not transparently available upon intro- Coherence therapy identifies the following spection. native capacities or processes of the brain-mind- Although a person’s universe of unconscious body system and uses them as the guiding rules constructs is vast and dark, the small constellation for the discovery work.3 of unconscious pro-symptom constructs driving production of a given symptom usually can be in- • Unconscious, implicit personal constructs are duced to glow in the dark, as it were, and be spot- immediately accessible to awareness. ted experientially. This is done by selectively elic- iting these constructs through on their • Accessing them occurs through experiencing coherence. That is, the pro-symptom constructs them subjectively, emotionally, somatically. are unique by virtue of being the constructs that • Accessing them requires methods that match compellingly require the existence of the symp- their qualitative characteristics as knowledge tom. Coherence therapy’s discovery methodology structures. exploits this property. The therapist structures an experience designed to elicit from a pro-symptom 3 position a response that is noticeable to the client. Ecker and Hulley (1996) refer to the discovery proc- ess as radical inquiry to denote both its focus on root The therapist then guides the client’s attention to material and its swiftness. focus on this manifestation (an inner image, 4 Implicit Memory Depotentiation meaning, feeling, body sensation, knowing, verbal In coherence therapy, the client’s attention , memory, etc.). drives the formation of this synaptic linkage. A Various simple, experiential techniques are neurodynamic finding of central relevance to co- reliably effective in bringing this about. This oc- herence therapy is the fact that synaptic connec- curs without the therapist knowing or hypothesiz- tions are generated by the subjective focusing of ing about the content of any pro-symptom posi- attention on an item in the conscious field that has tion, as shown in our case example. Carol was subjective importance (Bailey, Kandel, and Si, guided to experience a spontaneous completion of 2004; Kentros, Agnihotri, Hawkins, Muller, and the sentence fragment, “If I were to like having Kandel, 2001; Kentros, Agnihotri, Streater, Haw- sex with my husband, I’d feel—.” Her neocortical, kins, and Kandel, 2004). The use of focused at- conscious attention noticed an emotional response tention to drive synaptic change in the neural net- arising from a non-neocortical, presumably sub- work maintaining symptom production is the es- cortical pro-symptom position, which she verbal- sence of coherence therapy, from the neurody- ized with the word “embarrassed.” The pro- namic perspective. This begins with the discovery symptom source of this response is immediately work, in which the neocortex’s conscious attention evident to the therapist from the symptom- to the contents of the subcortical pro-symptom requiring nature of the content: to feel embar- position generates new, transient synaptic connec- rassed to have sex inclines her not to have sex, tions linking those two neural systems. which is the symptom. The timescale of the clinically observed im- The moment when the client’s attention first mediate accessibility of unconscious construc- registers the elicited pro-symptom response is the tions—the time between the therapist’s spoken moment when accessing has begun—the first evocation and a manifested, noticed response from contact between the neocortex’s conscious atten- the pro-symptom position—is typically 1-10 sec- tion and the pro-symptom knowings residing pre- onds. The rapid, short-term activation of synapses sumably in subcortical brain systems harboring involved in this immediate accessing is presuma- implicit emotional memory. bly no different than that involved when any novel A pro-symptom position activated in daily life perception occurs. The discovery methods of co- is not normally accompanied by any conscious herence therapy induce the pro-symptom neural attention whatsoever, because it is an implicit network to be the source of the novel perception, memory, a knowing one does not know one as described above. knows. The discovery methodology is designed to Teskey (2001), reviewing findings from across involve attention in the activation of this memory, the research on neuroplasticity, notes that in re- like following a pathway that was always there but sponse to a new experience, “synaptic potentiation never before noticed. or depression [of existing, functioning synapses] The neural correlate of this event—conscious can take place on millisecond time scales…” (p. attention registering a specific pro-symptom re- 7). Other forms of neuroplasticity, such as the ac- sponse—is the formation of a new synaptic link- tivation of nonfunctional, “silent” synapses or the age between the neocortex and the part of the creation of entirely new synapses, have been ob- amygdalar and/or other subcortical neural network served on a timescale of hours (Kim, Udo, Li, that encodes the pro-symptom constructs. For an Youn, Chen, Kandel, and Bailey, 2003), too slow event in neural network A to show up directly as to account for moment-to-moment, first-time ac- new information in neural network B means that a cessing (but just right to account for the observed synaptic linkage exists between the two networks. timescale of integration, discussed below). There- (The first suggestion that the creation of new fore, the neural substrate of coherence therapy’s mental contents corresponds on the cellular level creation of discovery experiences can be assumed to the creation of new connections between neu- to be the formation of a new linkage of neurons rons was made by Ramon y Cajal (1894). It was via alterations to existing, active synapses. then 76 years until direct, empirical verification of The client may or may not immediately com- this model was achieved by Castellucci, Pinsker, prehend the pro-symptom significance of the no- Kupfermann, and Kandel (1970) and by Kupfer- ticed, emergent material. The therapist does, how- mann, Castellucci, Pinsker, and Kandel (1970).) ever, and keeps the client’s attention focused on Implicit Memory Depotentiation 5 this material, deepening the client into a fuller content of the pro-symptom constructs (theme, emotional experience of it. It is the client’s con- purpose, knowings, feelings, images, tactics), not tinuing attention to the newly noticed feature that the other way around. The therapist offers no in- maintains the new synaptic linkage. If her or his terpretations. The client would discover the same attention wanders away from that feature, within material by working with any proficient coherence seconds it is completely forgotten. This corre- therapist. sponds to the deactivation of the newly active syn- Accessing a pro-symptom position consists, apses, which return to their prior condition. Neu- then, of the initial formation of a live, experiential roscientists have directly observed the depotentia- and synaptic linkage between at least two neural tion of memory-encoding synapses to be accom- networks: that of the conscious, verbal module in panied by the concurrent disappearance of the be- the neocortex and that of the pro-symptom module havioral responses driven by that memory (Bailey in one or more brain systems harboring emotional and Chen, 1989; Bailey and Kandel, 1993). The implicit memory. This linkage can not be gener- therapist must actively guide the client’s attention ated by the neocortex’s verbal-cognitive, semantic to remain engaged with, or to return to, the pro- knowings about the pro-symptom contents, just as symptom position’s first manifestation. a map drawn on a piece of paper can not bring it- Sustained attention on any one emergent ele- self to the place represented. A cognitive insight is ment of a pro-symptom position not only pre- an internal event in the neocortex that is also expe- serves and strengthens the synapses involved, but rienced by the neocortex, so the synapses created also strongly tends to elicit other, linked elements by the insight do not lead outside of the neocortex. of that pro-symptom position. This occurs either In contrast, when the conscious attention of spontaneously or through another structured the neocortex notices an internal, experiential prompting by the therapist—a process termed se- event whose unconscious source is a pro-symptom rial accessing by Ecker and Hulley (1996). The position, those two neural networks, the neocortex attended experiencing of each additional element and the brain system holding the pro-symptom of pro-symptom material corresponds to a more position, begin to be linked by synapses. thorough synaptic linkage between neocortex and By “conscious attention” we mean not merely the subcortical pro-symptom neural network. Dis- having about the object of attention but covery continues until the entire pro-symptom po- rather, having the subjective experience of the sition is directly attended, experienced, and syn- living encounter with the object of attention. To aptically linked. give attention to the moon is to experience seeing At that point, the coherence of symptom pro- the moon, which is different than giving attention duction is transparent: the client is lucidly aware to thoughts about the moon. To give attention to of how and why the symptom is necessary to have, pro-symptom material is to experience this mate- including the experience of his or her own agency rial’s emotional, perceptual, somatosensory, kin- in producing a symptom that had previously esthetic and energic elements. It is the immersive, seemed to have a life of its own. This initial, sub- multimodal, subjective experience and recognition jective experiencing of a pro-symptom position is of these contents as felt emotional truth that is the an altered state, a state-specific knowing (Singer actual attending to them and the psychological and and Solvey, 1998), which involves inhabiting a neural accessing of them. personal reality quite different than that of the eve- That is the second of the three built-in rules of ryday conscious personality (Tart, 2001). (To discovery: Accessing requires subjective experi- reach this point takes one to six sessions for about encing. A non-immersive, conceptual-semantic two-thirds of the clients in a therapy practice that recognizing of these same contents does not actu- is non-specialized with respect to symptoms, six to ally access them, no matter how closely focused twelve sessions for about one-quarter of all clients, on the material it may be. Cognitive insights result and more than twelve sessions for about ten per- from, but as a rule do not produce, a direct experi- cent who have multiple, entangled pro-symptom ence of the implicit, pro-symptom material. Expe- positions.) riential rather than cognitive methods are required, This discovery process is entirely phenome- the defining features of which we describe below. nological: the therapist learns from the client the 6 Implicit Memory Depotentiation

The phenomenological principle that access- verbal module is in the left cortical hemisphere. ing requires subjective experiencing has a distinct The right cortical hemisphere handles the nonver- neural basis. It was established very recently, both bal experience of conscious and emo- molecularly and behaviorally, that only while a tional meaning, and is anatomically far more con- long-term memory (knowledge structure) is nected to emotional centers in the limbic system evoked and reactivated can its stable, encoding than is the left hemisphere. The elicited responses synapses be switched into a labile, changeable of a pro-symptom position therefore can be as- state (Alberini, 2005; Nader, 2003; Nader, Schafe, sumed to register most directly in the emotional and LeDoux, 2000; Sara, 2000; Walker, Brake- awareness of the right cortical hemisphere, par- field, Hobson, and Stickgold, 2003). This re- ticularly the right orbitofrontal region. Directing quirement of memory reactivation is the neural conscious attention to this experience of emotional correlate of coherence therapy’s tenet that access- meaning can create a linkage, via the corpus callo- ing occurs only through subjective experiencing. sum, across to the left orbitofrontal region, where In order for a knowledge structure in memory it is now available for verbalizing by the left neo- (such as a pro-symptom position) to be change- cortex’s verbal module (Schore, 2001). able, it must be evoked, reactivated, and experi- In effect, the right hemisphere is the verbal left enced, not merely conceptualized. We will return hemisphere’s window into the limbic world of un- to this critically important neural mechanism in conscious, personal emotional truth. When Carol the section on transformation below. Yet even the said she felt “embarrassed,” her left hemisphere initial accessing involved in discovery brings had recognized verbally that in her right hemi- about a neural change, in that the presumably sub- sphere there was a social feeling of embarrass- cortical neurons in which the pro-symptom ment, which in turn presumably had its source in a knowings are encoded are forming new synaptic more primary subcortical recognition of endan- links, which will be used for transformation later. germent due to exposure (which had been brought Of course, pro-symptom positions usually in- to conscious attention in the discovery experience volve elements of core meaning and emo- prompted by the therapist). It is through the ver- tion—deeply tender, vulnerable or painful areas of balization that the conscious personality knows personal experience. If either the emotional dis- what is being experienced by the other brain sys- comfort felt by the client or the client’s resistance tems and in the body nonverbally. make it apparent that the opening steps of discov- Accessing an unconscious emotional response ery are not workable for the client, the therapist and the implicit schema generating it usually oc- reduces the size of the discovery steps down to a curs in those two steps: first, via the right hemi- level that allows the client to go forward with the sphere, is the nonverbal, affective and somatic ex- process, which can then proceed immediately. periencing of activated subcortical material, which Also, for the vast majority of therapy clients, if the is then supplimented by the verbalized knowing of therapist has an emotionally safe presence there is this experience in the left hemisphere. Therapy no delay required for trust-building. These condi- clients vary widely in the amount of time and help tions have been well defined by Ecker and Hulley they need with each of these two steps. The com- (2004). plete discovery experience is the unified feeling- The new circuits created by discovery experi- knowing and verbal-knowing of the elicited sub- ences between the subcortical neural networks cortical material. The neocortex has been informed harboring the pro-symptom material and the neo- of pro-symptom meanings and feelings by the cortical networks subserving the conscious, verbal subcortex. self are complex. The amygdala, for example, has The creation of a discovery experience there- strong connections to the orbital and medial pre- fore entails the formation of new synaptic circuits frontal cortex, which are major centers subserving linking several brain regions. The main linkages conscious emotional experience and which in turn presumably are those from limbic subcortex (the link the amygdala to more cognitive neocortical home of the implicit memory driving symptom circuits. (See Halgren, 1992, for a detailed review production) to right orbitofrontal cortex to left of the reciprocal connections between cortical ar- neocortex, inaugurating the neural integration of eas and the amygdala.) The neocortex’s conscious these systems both vertically and horizontally. A Implicit Memory Depotentiation 7 number of other regions can also be expected to perhaps an image or scene of its instantiation. participate importantly in the process. The hippo- Brain imaging has shown that infants live primar- campus, which is essential for forming and storing ily in the emotional and sensory vividness of their the explicit (conscious) memory of new personal limbic system (Chugani, 1996). experiences, certainly must be involved, as are The therapist’s own mirror neurons4 (Gallese, regions responsible for the experience of specific 2003) presumably facilitate the shared trance in , such as the subgenual cingulate and dor- which the therapist empathically and vicariously sal insula (for sadness, grief, depression), or the accompanies the client into a particular emotional ventral insula and anterior temporal cortices (for reality, perceives some of its experiential features, anxiety) (Liotti, Mayberg, Brannan, McGinnis, and guides the client’s exploration of it. The Jerabek, and Fox, 2000). Other regions likely to therapist needs to be able to experience concur- play a role include the anterior cingulate cortex rently in two modes: the vicarious mode and the (involved in the directing of focused attention and cognitive mode that allows ongoing reference to in modulating emotional responses), and the ven- his or her cognitive map of therapeutic methodol- tral medial prefrontal cortex (involved in recog- ogy. For example, the verbalizing necessary for a nizing and understanding emotional significance). complete discovery experience is not a natural act Therapy clients also appear to vary widely in for the client in the altered state of a discovery where, along the pathways from left neocortex to experience, and needs to be prompted and assisted right cortex to limbic system, they position their by the therapist. In prompting this verbalizing, the consciousness while having a discovery experi- therapist in effect is instructing the client, who ence. Those who keep their awareness based in may be immersed deep in the limbic sea, “Now, their verbal module remain fully in their familiar, stay right here, but reach for your neocortex and conscious personality. From that secure, controlled bring it here.” Such is the experience of neural vantage point, they observe and verbalize the integration for therapy clients who can allow the emotional and perceptual material that their right full slide through the rabbit-hole. hemisphere presents to their observing awareness. Many clients can be guided to allow an incre- Such clients remain almost matter-of-fact as they mental slide into their subjectivity, despite initial register and verbalize the high-stakes, subjective resistance. The greater the subjective immersion, material elicited. the stronger the accessing of the material and the Those who allow their locus of experiencing to more available for change it becomes. A very slide over into the right hemisphere, allowing a small fraction of therapy clients have an incapacity subjective immersion in the emotional and per- for subjective immersion that appears profound. It ceptual material playing there, have a very differ- remains to be seen whether the cause of such inca- ent experience and manner. They are in the elic- pacity is psychological or, perhaps, a structural ited feelings and knowings and display the vari- lack of connectivity between the neural networks ous, congruent signs of actually having an emo- involved. tional experience, which is a moderately altered It remains true, however, that the new syn- state. apses formed even during the fully immersed, Those who allow their attention to slide even more intense discovery experiences would quickly further, through the right hemisphere and all the dissipate—and the rich emotional reality of the way into the pro-symptom material in its subcorti- pro-symptom position would disappear like a vivid cal home are more fully immersed in the vivid, dream that is suddenly irretrievable—unless they compelling, living emotional knowledge carried are rendered durable through repeated use, which there. The client has stepped through the looking- glass—the right hemisphere—into limbic won- 4 derland, a fully altered state of inhabiting an emo- Upon perceiving an action done by another, one’s tional reality in which little remains of the usual mirror neurons fire as if one had performed that action adult personality or ego-state. Instead, the experi- oneself. They are thought to help create a model of the internal states of others, facilitating empathy and the ence typically is comprised of a younger develop- ability to reliably infer the presence of certain subjec- mental state of identity and a subjective immersion tive states in others (sometimes termed mindsight). Mir- in a specific schema, its associated feelings and ror neuron dysfunction has been linked to autism. 8 Implicit Memory Depotentiation is the task of the integration stage of the method- fact accurately designed to engage the coherence ology, described below. of the as-yet unknown constructs necessitating The third native property shaping the discov- Carol’s specific symptom. It prompts Carol to ery work in coherence therapy is the requirement sample imaginally an experience of being without for clinical methods to match the qualitative nature the symptom, which is highly likely to make con- of the subcortical personal constructs driving structs that urgently require the symptom become symptom production. Therapeutic methods that activated and responsive in a noticeable manner, fail to match the nature of the material are far less as indeed occurred most fruitfully when “embar- effective than those that do. Three major features rassed” arose to complete the sentence. (This characterize therapeutic methods that are well symptom deprivation tactic, here implemented in matched to the symptom-generating material: the form of a sentence completion, can be carried out in several other ways, and is itself only one of • Coherence-focused many different coherence-focused methods of cre- • Experiential, empathic, non-interpretive, ating discovery experiences.) phenomenological In addition to being coherence-focused, meth- ods of discovery need to have the interrelated • Non-counteractive qualities of being experiential, empathic, non- interpretive and phenomenological in order for the Therapeutic methods are coherence-focused client to reactivate, experience and direct attention by virtue of serving efficiently to find and inte- to the symptom-requiring material and translate grate into awareness unconscious constructs that the material accurately into explicit, neocortical coherently require the production of the symptom representation. In coherence therapy, the client is (such as the constructs requiring Carol’s aversion guided to encounter and abide with the very mate- toward marital sex in the previous article [Toomey rial causing all the trouble, just as it is. This occurs and Ecker, 2007a]). The opposite of a coherence- to a degree and extent that is counter-intuitive focused method is a counteractive method (as dis- even for most depth-oriented psychotherapists. We cussed below and in the previous article) because offer here only a few comments on key aspects of to counteract is to disown rather than embrace the these four related qualities, as a thorough treat- symptom-requiring material. ment is beyond our scope. The symptom-requiring constructs are non- While carrying out any experiential method, verbal, implicit knowings that were formed in re- the therapist’s style of language is a critical ingre- sponse to experiences earlier in life that had in- dient for its success. Verbal language that accu- tense subjective significance. The brain-mind- rately attunes to, captures and helps elicit uncon- body system is functioning properly, not dysfunc- scious emotional truth is quite different from ordi- tioning, in holding such templates indefinitely, in nary social vernacular. The needed style is con- activating any that match the present situation, and crete, present-tense, highly personal, and vividly in launching the response that an activated schema descriptive of sensory perceptions; and it is utterly knows is necessary (such as a Carol’s suppression candid in naming what is at stake as well as the of sexual feelings). In order to efficiently find, accompanying strong emotions, meanings and ur- reactivate and access the pro-symptom schema gency (Ecker and Hulley, 1996, 2004; Martin, stored in implicit memory, methods of discovery 1991; Watson, 1996). Our earlier case vignette have to utilize the fact that the content of the provides an example in the verbalization written schema is coherently symptom-necessitating, be- on the card given to Carol at the end of her ses- cause that is the only feature that distinguishes this sion. The verbalizing of emergent pro-symptom schema from thousands of other schemas that the positions is crafted to foster the client’s inhabiting person holds in implicit memory. For example, and embracing of the discovered material just as it Carol was asked by the therapist to say this sen- is. Accordingly, it is unconcerned with adult prop- tence and allow it to complete itself spontane- erness, face-saving, or notions of rationality and ously: “If I were to like having sex with my hus- morality, and excludes all styles of phrasing that band, I'd feel _____.” Like a key custom-shaped to would shift the client to an intellectual viewpoint. fit a unique lock, this seemingly simple step is in Implicit Memory Depotentiation 9

The therapist’s consistent empathy toward the active, whether carried out cognitively, behavior- emotional tableau in the pro-symptom position is ally or chemically. also critically important for fostering discovery Many therapists know only counteractive and accessing. As already noted, this tends to be methods, and to such practitioners, ruling out these quite vulnerable territory, and it will be safe to methods might seem debilitating. However, what enter only in a climate of authentic empathy and remains is the universe of non-counteractive, ex- acceptance. Furthermore, each emotional schema periential methods, which is extensive, rich, and formed by the limbic system includes the person’s therapeutically potent. A large class of such meth- developmental state of identity at the time of for- ods involves a guided imaginal process in which mation. This is why, when a therapy client is expe- the client has experiences that could not “really” rientially inhabiting a pro-symptom position, the occur in the therapist’s office. Such techniques, altered state typically feels young, as noted earlier. properly applied, are highly effective for accessing The therapist’s tone, empathy, and choice of because implicit schemas are activated in response words need to be attuned accordingly, in an to both real and imagined perceptions. Kreiman, authentic manner. Koch, and Fried (2000) recorded responses from Giving the client interpretations, the in-depth individual neurons in the amygdala and other parts therapy field’s longstanding, mainstay technique, of the limbic system. They found that of neurons is ruled out because it is the antithesis of ushering that fired in response to both the real (retinal) and the client into his or her own, experiential discov- imagined image of a particular object, but didn’t ery of the emotional truth of the symptom. It is fire in response to other objects, 88 percent had also the antithesis of the therapist learning from identical receptive fields (the same set of objects the client how the symptom is necessary to have. to which they respond by firing, whether the im- The use of non-counteractive methods was age is imagined or real). On this result the authors discussed in the overview of coherence therapy in comment, “The existence of a [neuron’s] selective the opening article of this series, but the impor- response in the absence of concomitant retinal ac- tance of this point warrants a succinct reiteration tivity constitutes one of the strongest possible in- here. Accessing the coherent, symptom-requiring variance properties of a representation that is cor- material means heading toward it and staying with related with perception” (Kreiman et al., p. 11). In it. This cannot occur through counteractive meth- other words, this is compelling evidence that “vo- ods, which attempt to oppose, prevent, fix, eradi- lition-induced imagined percepts share a common cate, avoid, override, weaken or get away from the representation [with retinally generated images] in symptom or its underlying material. All such humans at the level of single neurons” (Kreiman et methods remove attention from, rather than bring al., p. 204, footnote 67). attention to, the constructions requiring the That neurodynamic finding confirms a key, symptom. Examples of counteractive methods of operational aspect of the discovery work in coher- psychotherapy include positive thinking, self- ence therapy: The therapist structures visualiza- soothing, reframing, rational correction of irra- tions and imaginal interactions designed to reacti- tional beliefs, relaxation techniques, all standard vate a specific pro-symptom position, causing it to protocols used by anger management therapists, respond with internally noticeable manifestations behavior therapy, cognitive-behavioral therapy, that reveal more of the content of this symptom- and solution-focused therapy. For some therapists necessitating schema. For example, it is most often it is difficult to comprehend how, for instance, fitting and fruitful to begin discovery work by teaching an anxious client relaxation techniques is guiding the client to imaginally revisit a recent, counteractive until they understand that while the concrete situation in which the symptom or prob- attempt to induce relaxation is in concert with the lem occurred (Ecker and Hulley, 2004). This in client’s anti-symptom position (the wish to be rid itself begins to reactivate the client’s pro-symptom of the anxiety), it is a direct attempt to counteract position, priming it for conscious eliciting. Though and override the pro-symptom position’s cogent there are numerous other ways of creating discov- necessity for having anxiety. To try to replace the ery experiences, the usefulness and effectiveness symptom with a preferred state is always counter- of this tailored, imaginal type of discovery cannot be overstated. 10 Implicit Memory Depotentiation

Integration begins when the client’s attention THE CREATION OF EXPERIENCES THAT has for the first time gone away from some newly INTEGRATE PRO-SYMPTOM POSITIONS discovered material and then returns to it, reusing the new synapses linking the material to the neo- After the first experiential revelation of a pro- cortex. This first going-away and coming-back of symptom position, the next methodological aim is attention often happens unnoticeably, soon after the stabilization of its availability as a conscious the initial discovery experience: the client has al- experience. This long-term stabilization of a new ready lost track of the first pro-symptom fragment conscious knowledge is termed integration in the but then finds it again upon hearing the therapist parlance of psychotherapy, and is known as the make comments that refer to it. This first coming- consolidation of an explicit memory (encoded back can also occur when the therapist first struc- knowledge) in . The process of con- tures an integration experience, perhaps simply by solidation has been recognized and studied for a asking, “Please tell me again what you just dis- century behaviorally, anatomically, biochemically covered,” or by asking, for example, “Would you and neurally (Izquierdo and Medina, 1997; be willing to picture your brother and say directly McGaugh, 1966, 2000). to him what you just got in touch with?” As noted earlier, the synapses initially formed These in-session repetitions of accessing the in discovery are non-durable. Clients often com- pro-symptom material are followed by a struc- pletely lose touch with newly conscious material tured, between-session task of daily re- that was lucid seconds earlier. Ecker and Hulley experiencing the material, such as Carol’s daily (1996, 2000a, 2004) have delineated the following reading of the index card as a cue to internally re- built-in rules of the brain-mind-body system for experience her pro-symptom position as a felt achieving integration. emotional truth. At the start of the next session, the therapist assesses the degree of integration • A pro-symptom position becomes part of the achieved and continues to create integration expe- conscious personality through repeated, affec- riences if and as needed, as well as further discov- tive-cognitive-somatic experiences of it. ery experiences, until the entire pro-symptom po- sition is routinely conscious. • Integration occurs through repeatedly relating The essence of this ongoing series of integra- to the problem from and in the pro-symptom tion experiences is the client’s repeated, subjective position requiring it (rather than from the anti- act of bringing neocortical attention into the ini- symptom position initially expressed) and, tially subcortical pro-symptom material. From the while in the felt experience of this position, neurodynamic standpoint, we may reasonably as- verbalizing all of the specific knowings, feel- sume that integration occurs because this repeti- ings, purposes and tactics that constitute it in tive, attentional use of the new synapses linking highly personal, declarative, adequately in- neocortex to pro-symptom implicit memory tense phrasing. strengthens both these linking synapses as well as the synapses that now encode the neocortex’s own • The cost, hardship or suffering due to having new representation of the pro-symptom position. the symptom must be made sense of in relation It is plausible that two different synapse- to the discovered emotional truth of how and strengthening mechanisms are recruited by inte- why the symptom is actually more necessary gration experiences: to have than not to have. First, Hebb’s (1949) basic rule applies: a syn- apse strengthens if the neurons it connects repeat- Repeated integration experiences install the edly fire together and weakens if they do not. In pro-symptom material increasingly firmly in the integration experiences, we have the repeating, person’s conscious world until it is robustly estab- joint firing of the neocortex’s synaptic encoding of lished there, no longer dissociates into uncon- the pro-symptom position, the subcortical synaptic sciousness, and is at any time readily conscious as encoding of it, and the synapses that link the two a unified feeling-knowing and verbal-knowing of (which involves other brain systems, as noted ear- the emotional truth of the symptom. lier). Implicit Memory Depotentiation 11

Second, because the contents of pro-symptom 1998; Morris, Anderson, Lynch, and Baudry, positions always have strong subjective impor- 1986; see also reviews by Bailey, Kandel and Si, tance, each integration experience is, in itself, an 2004, and by Kandel, 2001). emotional experience, and therefore activates the However, until just now, in the final weeks of hormonal system of emotionally enhanced mem- the preparation of this article (August 2006), there ory encoding. Emotional arousal releases adrenal was no proof that the synaptic states formed by stress hormones that enhance hippocampal en- LTP in vitro are the very same synaptic states that coding of explicit memory of the experience (Ca- are responsible for consolidation—the durable en- hill and Alkire, 2003; McGaugh and Roozendaal, coding of memory, the persistence of know- 2002). Events that evoke emotional responses are ings—in the brains of living animals. Two studies likely to be important for survival and so are more have finally produced the long-awaited evidence important to remember, which the hormonal (Pastalkova, Serrano, Pinkhasova, Wallace, Fenton mechanism promotes.5 The memory being en- and Sacktor, 2006; Whitlock, Heynen, Shuler and hanced in this way during an integration experi- Bear, 2006). We will therefore now take the lib- ence consists of the content of the pro-symptom erty of using “LTP” to refer to the enduring po- position. That is, integration itself is enhanced by tentiation of synapses in vivo (whereas previously the hormonal mechanism. the term usually denoted the in vitro case). The Hebbian and the hormonal mechanisms Achieving stable integration of a pro-symptom would make the transient synapses created in dis- position means, then, that implicit, subcortical, covery experiences undergo a molecular and cel- emotional knowings have been translated and con- lular transition to a more stable, enduring state of solidated into stable, explicit, verbal-conceptual potentiation. Neuroscientists have studied the neocortical knowings. The person now readily ex- long-term potentiation (LTP) of synapses inten- periences both kinds of knowing sively for 30 years, relying heavily on tests of ex- jointly—subcortical (and right cortical) feeling- cised groups of neurons in cell cultures. These knowing and neocortical verbal-knowing. These studies of the artificial, in vitro stimulation of LTP emotional and verbal structures are now firmly (and of LTD, long-term depression or depotentia- linked neurally, so that a reactivation of the affec- tion) have identified numerous molecular mecha- tive material also reactivates the verbal-semantic nisms of synaptic strengthening and weakening. knowing of this material, and vice versa. The dependence of long-term memory in vivo on As noted previously, it is well established that specific molecular processes detected in LTP in the hippocampus, a component of the limbic sys- vitro was demonstrated initially by pharmacologi- tem, carries out the consolidation of explicit mem- cally blocking the in vivo functioning of a specific ory (though little as yet is known about how it type of synaptic receptor known to be critical to does this). We may therefore reliably infer that LTP, and observing a resultant incapacity for long- integration experiences recruit the hippocampus to term memory formation in animals (Kentros, Har- translate the pro-symptom position from its im- greaves, Hawkins, Kandel, Shapiro, and Muller, plicit, subcortical form into explicit form in the neocortex. 5 An opposite effect, the disruption of explicit memory In each integration experience, the person fo- formation, is caused by the yet higher hormonal levels cuses attention on and into his or her symptom- produced during experiences of extreme emotional requiring position, in order to inhabit and experi- arousal or stress, as during trauma (McGaugh, 1989; ence it. This directing of sustained, subjective at- Payne, Nadel, Britton, and Jacobs, 2004; van der Kolk, tention to the pro-symptom material is the critical 1994). Under these conditions the hippocampal mem- action taken by the person in this methodology. ory formation system is rendered inoperative, and The neurodynamic correlate of this key phenome- memories are stored instead as separate, unintegrated nological element would consist of a mechanism affective and perceptual components, which tend to be by which subjective attention drives lasting syn- exceptionally vivid and enduring. Thus, as noted by van aptic potentiation and . der Kolk (1994), the effect of trauma on memory is bimodal: an absence of explicit, narrative memory (am- This mechanism was identified quite recently. nesia) is accompanied by a sharp enhancement of per- By recording the firings of individual neurons in ceptual and affective memory (hypermnesia). vivo in the hippocampus of freely behaving mice, 12 Implicit Memory Depotentiation neuroscientists studying LTP were surprised by whenever a red object happened to be at that spot the unexpected finding that the animal’s subjective in the peripheral visual field. When in addition the attention toward an emotionally important feature monkey had been trained to search for a red ob- in its environment itself triggered LTP, forming ject, that red-sensitive, off-center neuron produced long-term memory6 (Kandel, 2001; Kentros et al., a still larger response even when the monkey’s 2001). Further study led Kentros et al. (2004) to next eye movement was not directed to the red “propose a model whereby attention provides the object. The red item had not yet become the focus requisite neuromodulation to switch short-term of conscious attention, but the response of the neu- homosynaptic7 plasticity to long-term heterosyn- ron still received a boost because red was the color aptic8 plasticity” (p. 283). These authors infer that being consciously sought. This demonstrates that hippocampal synaptic plasticity, in particular the the monkey’s attention—in this case, imaginal establishment of LTP, “is governed by a higher- attention in the form of the intention to find a red order cognitive process. …We define selective object, perhaps in the form of holding a mental attention operationally as the cognitive processes image of redness—had enhanced the synapses resulting from the animal assigning significance to governing the firing of that red-sensitive neuron. [specific features] of its sensory experience” (p. The studies just summarized show the effec- 291). tiveness of focused attention in creating changes in This demonstration by neuroscientists of the synapses and, therefore, in the knowings that syn- potent role of attention in driving synaptic plastic- apses encode. We have so far considered discov- ity is a significant corroboration and correlate of ery and integration, in which attention is used to coherence therapy methodology. In yet more re- create new synapses and to strengthen and potenti- cent work, the critical influence of subjective at- ate them. When we come to transformation in the tention on neurodynamics was strikingly demon- next section, we will see how attention is used to strated by recording the firing of single neurons in turn off—depotentiate—the specific synapses that the visual cortex of an alert macaque monkey as are driving symptom production during a coher- the monkey was searching among many objects ence therapy session. for one with a specific feature, as it had been It is significant, with regard to integration, that trained to do (Bichot, Rossi, and Desimone, 2005, parts of the conscious, left-brain attention system reviewed by Wolfe, 2005). Each recorded neuron also play a crucial role in language use (Frishkoff, was responsive only to a certain spot on the retina, Tucker, Davey, and Scherg, 2004). This means off to the side of the visual field. If a neuron’s re- that verbalizing inherently recruits attention to- ceptive field for color preferred red stimuli, then ward the experience being verbalized. This is pre- that neuron was found to respond more vigorously sumably why the verbalizing of the pro-symptom knowings is so strongly facilitative of their inte- gration. 6 Hippocampal synapses that encoded a mouse’s spatial Prior to integration, the person’s conscious, memory of a newly encountered neutral environment, neocortical construction of what it means to have which attracted little attention, lasted three to six hours, the symptom is the anti-symptom position—the but when an added, specific feature of the same envi- view of the symptom as entirely undesirable, ronment was of special significance to a mouse, at- tracting strong attention, the same synapses mapping senseless, valueless, involuntary, egregious and spatial memory lasted for days, or about twenty times pathological. However, as the neocortex, during longer. integration, pays attention to the implicit emo- 7 Homosynaptic plasticity: a particular synapse be- tional truth of how and why the symptom is ur- comes stronger (“facilitation,” “potentiation”) or gently necessary to have, and adopts this under- weaker (“depression”) because of activity in the pre- standing of the symptom and forms its own rendi- synaptic and postsynaptic neurons of that very synapse. tion of it, the anti-symptom constructs are largely 8 Heterosynaptic plasticity: change in a synapse’s dissolved. From the neuropsychological perspec- strength occurs due to activity in one or more modula- tive, integration in coherence therapy can be un- tory interneurons that act on the presynaptic and/or derstood as the consolidation in the neocortex of postsynaptic neurons of the synapse, and not due to activity in the presynaptic or postsynaptic neurons an encoded representation of the pro-symptom themselves. knowings held in emotional implicit memory. In Implicit Memory Depotentiation 13 other words, the neocortex becomes informed by modulatory transmitters (such as serotonin) ap- and aligned with the subcortical pro-symptom plied to principal neurons by interneurons, was knowings. This result—the aligned state of neural then discovered. The fourth and longest-lasting integration and shared, multi-modal knowledge class of mechanisms, collectively called long-term between these brain systems—is a principal aim of potentiation or LTP, allows synapses to remain in any neurobiologically informed psychotherapy, force from weeks to decades. LTP was discovered according to a consensus of experts (see for exam- in the early 1970s (Bliss and Lomo, 1973) and ple Panksepp, 2004; Schore, 2003; Siegel, 1999). began to be understood at the molecular level in Affective neuroscientist Panksepp, for example, the 1980s. The highly complex intra- and inter- states that the aim of "healthy development is to neural biochemistry that carries out the molecular generate harmonious, well-integrated layers of as well as structural changes involved in LTP is emotional and higher processes, as opposed to now known to a significant degree (Bailey et al., conflicts between [the] emotional and cognitive" 2004; Kandel, 2001; Malenka and Bear, 2004). (Panksepp, 2004, p.132). The molecular details of synaptic and neuronal Of course, the symptom still entails hardship functioning are nearly the same in fruit flies, mol- or suffering that continues to be disliked by the lusks and mammals (Kandel, 2001). The stable person, but now he or she is lucidly aware of har- integration/consolidation sought in coherence boring the expectation of an even worse suffering therapy by definition recruits LTP. due to being without the symptom. For example, Synapse studies have shown that LTP can oc- Carol knew, once her pro-symptom position was cur immediately in response to a single, vivid ex- integrated, that part of her truly expected that if perience that has strong subjective significance, or she no longer stifled her sexuality, she would it can occur after a less intense experience is re- cause her own daughter the same terrible suffering peated sufficiently over time. There are several that had been inflicted on herself as a girl. She different molecular pathways that can bring it knew, at this point, that the marital unhappiness about, and these are utilized differently by differ- caused by her shunning of sexuality was, for a part ent types of neurons.The most durable, “late- of her, a price worth paying to avoid that even stage” LTP involves synaptogenesis, the structural worse suffering. growth of new physical synapses, which have been This clear recognition by the person of how directly observed visually at 24 hours after LTP- and why the symptom is more necessary to have triggering stimulation (Knott, Quairiaux, Genoud, than not to have, even with the suffering it causes, and Welker, 2002, reviewed in Zito and Svoboda, is the goal of the integration work. It is referred to 2002). In one such study, at 24 hours two-thirds of as the pro/anti synthesis (Ecker and Hulley, 1996, the newly functioning synapses had been newly 2004), meaning simply that there is no longer a created and one-third were activations of previ- split or dissociation between the pro-symptom ously inactive synapses (Kim et al., 2003). Several knowings of why the symptom is necessary and weeks are required for the synapses encoding a the anti-symptom wish to be rid of the symptom new explicit memory to reach final, maximum because of the suffering it entails. stability as long-term memory (Milner, Squire, and The observed timescale of integration agrees Kandel, 1998). Spatial analyses of dendrites and closely with the timescales of synaptic change, axons in the brain have concluded that huge num- providing another important neurodynamic cor- bers of potential synapses are always available for roboration of coherence therapy’s methodology. the creation of new, long-term synapse patterns As noted earlier, transient activation of synapses (reviewed in Chklovskii, Mel, and Svoboda, occurs in milliseconds in response to a new expe- 2004). (Whether or not the adult brain can also rience. First discovered in 1951 (Fatt and Katz, create new whole neurons for the synaptic encod- 1951), the neurotransmitters for this fast mecha- ing needed in response to experience is a contro- nism are simple ions. This fast activation can se- versial question at present, with contradictory in- gue into a second form of synaptic potentiation, dications provided by different studies.) lasting minutes and using more complex neuro- The observed range of timescales for synaptic transmitters (Greengard, 1976). A third, more per- plasticity closely fits the phenomenology of inte- sistent synaptic action, lasting days and utilizing gration regularly observed in carrying out coher- 14 Implicit Memory Depotentiation ence therapy. The manifestation of all three short- to conscious attention and experiencing. No longer term plasticity timescales is distinctly apparent: an insulated, autonomous capsule of constructs, an therapy clients in early stages of integration some- integrated pro-symptom position is susceptible to times lose all awareness of a clearly experienced immediate transformation. Exactly how that de- pro-symptom position after seconds, minutes, or potentiation process then operates is the subject of days, which prompts the therapist either to again this section, including the important matter of how create integration experiences that restore and depotentiation is verified. further strengthen the new neocortical connec- A fundamental distinction is made in coher- tions and memory traces; or to probe for and work ence therapy between transformational change with resistance to integration (Ecker and Hulley, that actually alters or dissolves a pro-symptom 1996, 2004), the neural correlate of which is pre- position and counteractive change that merely sumably the presence of a superordinate, inhibi- competes against fully intact pro-symptom posi- tory neural network. tion(s) with the aim of overriding, avoiding or On the other hand, some therapy clients dis- managing symptom production. The difference play a firm degree of integration—a routine, con- between transformational change and counterac- scious experiencing of the pro-symptom posi- tive change is particularly clear when understood tion—in their next session one week later, which at the neural level. is more than enough time for the strongest type of The neural process in counteractive change is long-term potentiation to be underway. The pri- epitomized by the classical extinction of a Pav- mary indicator of stable integration is the client lovian conditioned response. In animal studies, articulating the living experience of the pro- when an unconditioned stimulus (US, such as a symptom material in its specifics, on his or her mild, harmless but unpleasant electric shock) is own initiative, with no reminder from the therapist repeatedly accompanied by a conditioned stimulus (Ecker and Hulley, 2004). The therapist actively (CS, such as an auditory tone), the result is an invites this articulation and probes for degree of aversive conditioned response (CR) when only the integration by asking, for example, “How was it to CS is presented. An acquired fear memory of the live day-to-day with what we put on that card, last CS-US pairing has formed, which is encoded neu- time?” or “What we put on the card seemed to feel rally in the amygdala (Phelps and LeDoux, 2005). like real emotional truths at the time. Did it con- (The conditioned response to the tone corresponds, tinue to feel that way?” we suggest, to a client’s symptom, and the ac- quired memory to a client’s pro-symptom posi- THE CREATION OF EXPERIENCES THAT tion.) Extinction of the conditioned response is TRANSFORM PRO-SYMPTOM POSITIONS then brought about by repeatedly presenting the CS (tone) without the US (shock) until the CR The goal in coherence therapy is a transfor- (aversive behavior) no longer occurs. It is rigor- mation (either a major restructuring or a complete ously established that the neural mechanism of this dissolution) of each of a client’s pro-symptom po- extinction is not an alteration, erasure or forgetting sitions maintaining a given symptom, such that of the acquired memory created by the first train- there no longer exists any constructions of reality ing, but is, rather, a second, separate learning that in implicit memory in which the symptom is nec- the tone is unimportant (Bouton, 2004; Myers and essary to have. As soon as there no longer exists Davis, 2002; Rescorla, 2001). The non-aversive any pro-symptom positions, the immediate cessa- response learned second counteracts and overrides tion of the symptom is highly predictable, based the aversive response learned first, but both learn- on extensive clinical observations (Ecker, 2003, ings are still held in memory. 2005; Ecker and Hulley, 1996, 2000a, 2002a,b; The continued existence of the acquired fear Martignetti and Jordan, 2001; Neimeyer, 2000; memory even after full extinction is graphically Neimeyer and Bridges, 2003; Neimeyer and demonstrable through several different methods of Raskin, 2001; Thomson and Jordan, 2002). re-evoking the conditioned response after extinc- The discovery work reveals pro-symptom po- tion and without re-training (ibid.). For example, sitions phenomenologically. The integration work by simply positioning the subject in a different renders a pro-symptom position readily available environment (context) than the one in which the Implicit Memory Depotentiation 15 extinction was carried out, the conditioned re- amygdalar activation (Kalisch et al., 2005; sponse (fear behavior) occurs again following Ochsner et al., 2004). presentation of the conditioned stimulus (tone), With that counteractive approach, the showing that the acquired memory still exists (and amygdalar fear response circuits remain fully in- that extinction-learning is context-dependent). tact, the fear response would need to be managed Even in the original context, spontaneous recur- in that cognitive manner indefinitely, and relapse rence of the conditioned response may occur after can occur at any time. Furthermore, among ther- extinction, particularly if other stressors are pre- apy clients with presenting symptoms of anxiety sent. The CR can also be strongly re-evoked by a or panic, the fear is far more intense than that in- brief reminder of the original training (presenta- duced in subjects in the studies just cited, and as tion of one or two CS-US pairings), which is far any experienced therapist knows, cognitive anti- too weak in itself to establish a conditioned re- dotes for raw fear are not strongly effective. (To sponse. our knowledge, the efficacy of CBT has not yet The extinction procedure is the explicit pro- been demonstrated to surpass that of a rigorously totype upon which behavior therapy is based. The designed placebo therapy, that is, a placebo that is neurodynamics of extinction—the creation in structurally equivalent to the active treatment. See memory of a separate, new, dominant knowledge for example the meta-analysis of Baskin, Tierney, structure —would seem to be the underlying neu- Minami, and Wampold (2003), which examined ral mechanism of all counteractive methods of 21 efficacy studies, 14 of which were CBT stud- change in therapy, that is, all methods designed to ies.) prevent symptom production by forming a new, If further research confirms that many or all symptom-free state, without having actually trans- other counteractive methods of psychotherapy op- formed the implicit knowledge structures respon- erate through suppression of subcortical centers of sible for symptom production. activation by the mPFC or other brain centers, this Whereas conditioned fear responses are con- would mean that counteractive methods are not an solidated into long-term memory in the basolateral optimal use of neuroplasticity according to our amygdala (Maren, 1999a and 1999b), mounting definition, because the brain region and the im- evidence indicates that extinction learnings are plicit memory circuits actually responsible for stored in the medial pre-frontal cortex (mPFC), symptom production are not made to undergo po- which has modulatory connections to the tent synaptic change. Such extinction-like methods amygdala (Phelps, Delgado, Nearing, and Le- are broadly vulnerable to recurrence of symptoms, Doux, 2004; Quirk, Likhtik, Pelletier, and Pare, particularly when the person is in new contexts, is 2003). There is also evidence that an extinction under stress, or when a reminder (a conditioned learning’s initial, short-term encoding occurs in stimulus, or trigger) occurs, all of which routinely the amygdala, followed by transfer to the mPFC happen in day-to-day life. for long-term memory, or consolidation (Milad Yet psychotherapy as currently practiced con- and Quirk, 2002). sists mainly of counteractive methods. These have We suggest that, like extinction training, many different procedural forms, which may also counteractive therapeutic methods do not directly differ in how they recruit various brain systems so depotentiate the brain’s neural circuits driving as to suppress (but not transform) implicit schemas symptom production, but rather create new learn- driving symptom production in the amygdala or ings (synapse changes) in other regions that com- elsewhere. Despite such differences, the counter- pete against the symptom-generating circuits. active strategy is the same. This reliance on a For example, standard cognitive-behavioral strategy having a neurobiologically limited effec- therapy (CBT) relies heavily on the cultivation of tiveness may prove to be a major reason why, all neocortical thoughts designed to counteract un- such therapies are consistently found to have es- wanted emotional reactions and moods. It has been sentially the same modest level of efficacy—the shown using fMRI brain imaging that such coun- well-known “Dodo bird verdict” (see for example teractive thoughts during moderate (photograph- Luborsky, Rosenthal, Diguer, Andrusyna, Berman, induced) amygdalar reactions of fear do recruit the Levitt, Seligman, and Krause, 2002; Stiles, Bark- medial pre-frontal cortex to partially suppress ham, Twigg, Mellor-Clark, and Cooper, 2006; 16 Implicit Memory Depotentiation

Wampold, Mondin, Moody, Stich, Benson, and typically occur occasionally, and so do not pro- Ahn, 1997). duce extinction learning. In contrast to the counteractive strategy, the A second mechanism that prevents extinction aim in coherence therapy is always a transforma- of pro-symptom positions is, we propose, the tive alteration or dissolution of pro-symptom posi- highly anticipatory and pro-active nature of human tions—a profound depotentiation of emotional construing (Kelly, 1955), which plays out in the implicit memory such that symptom production is following manner. Every pro-symptom position radically ended and no longer can reoccur. includes not only a knowledge or model of a par- The robust stability over time of pro-symptom ticular type of harm or jeopardy—how to spot its implicit memories is impressive. Left alone, they presence and how it operates—but also a proce- remain perfectly intact through hundreds or thou- dural knowledge of a specific tactic for protecting sands of reactivations spanning most of a century. oneself from that harm, a tactic that is imple- During most of those reactivations, the perceived mented immediately upon reactivation of the pro- situation does not unfold in the dire manner pre- symptom position (entailing production of the pre- dicted by the stored schema, yet extinction does senting symptom). When the harm or jeopardy is not occur. As an example, consider a 45-year-old perceived to be imminent but then does not actu- person with an unconscious, pro-symptom position ally occur, the meaning that is implicitly construed that consists of the knowing that hearing another’s for this is that the protective tactic worked, not that angry voice means “I’m going to be hit” and the jeopardy didn’t really exist, which is the brings corresponding bodily and emotional symp- meaning that would produce extinction learning. toms of anxiety, with no awareness of the reason In that way, extinction learning in the natural for these responses. For over 30 years, getting hit course of living is ruled out by the pro-active, has never happened after hearing such a voice protective purpose built into every pro-symptom hundreds of times. Yet, no extinction of this un- position.9 conscious fear memory has occurred. This immu- That intrinsic resistance to change through ex- nity of pro-symptom positions to extinction could tinction is the background against which we now result from two different mechanisms of which we turn to the process that does change these emo- are aware. tional schemas held in implicit memory. We will The first was recently identified in animal describe the built-in rules and procedures of the studies of the time dependence of extinction change process, first in coherence therapy’s phe- learning (Cain, Blouin and Barad, 2003). Twenty- nomenological terms and then in terms of the neu- four hours after rats were conditioned to fear a ral mechanisms plausibly recruited by those pro- sound that had been paired with a mild foot shock, cedures. the sound was presented repeatedly without the shock. If the time period between repeated shock- How constructs change: free sounds was 5 seconds, strong, rapid extinction The phenomenological view of the fear occurred, but if the period was 20 min- utes, there was no extinction for most rats, and The native process of the brain-mind-body some became even more fearful of the sound. A system for transformational change of personal duration of 20 minutes is presumably long enough, constructs has been delineated by Ecker and Hul- for a rat, for each presentation of the sound to be ley (1996, 2000a, 2004) and Ecker (2005, 2006) as experienced as an isolated, single occurrence that functions more strongly as a reminder, a re- 9 Other possible reasons for non-extinction of pro- evoking of the conditioned fear, than as an extinc- symptom positions include a variable ratio schedule of tion learning. (Cain, Blouin and Barad (2004) sub- learning, which is the learning schedule most immune sequently confirmed that the widely spaced, to extinction (Field, Tonneau, Ahearn and Hineline, shock-free sounds induce two separate brain re- 1996); higher-order conditioning (Gewirtz and Davis, sponses, the conditioned fear response and an ex- 2000), which could be largely immune to perceived disconfirmation; and redundant conditioning, in which tinction learning, but the latter is subordinate to multiple percepts, each a conditioned stimulus, tend to the former.) The environmental stimuli that reacti- occur concurrently, again creating immunity to per- vate a person’s pro-symptom position likewise ceived disconfirmation. Implicit Memory Depotentiation 17 follows: learning, which merely competes against but does not alter prior learnings. According to coherence • The brain-mind-body system allows the therapy, reactivation of the original learnings (pro- coexistence of any number of contradic- symptom knowings) combined with a concurrent, tory, incompatible constructions of reality juxtaposed experience of disconfirmation recruits (knowings, schemas, models, ego-states, the brain-mind-body system’s native ability to ac- parts), as long as the contradictory con- tually modify or dissolve the reactivated constructs structions are held separately, never enter (Ecker and Hulley, 1996, 2000a, 2004). Examples the same field of attention, never are con- and evidence follow later in this article. sciously experienced together. How constructs change: The neurological view • The brain-mind-body system does not tol- erate an incompatibility or ontological The corresponding neural picture is perhaps contradiction between disparate construc- best understood by considering the neurodynamic tions that are juxtaposed and experienced life history of a memory. As noted earlier, a newly together in the same field of attention. The created knowledge structure achieves a state of attentive experiencing of juxtaposed, in- long-term sturdiness in memory through a com- compatible constructions, where both are plex neural process known as consolidation, which experienced as real yet both cannot possi- has several phases, takes weeks to complete, and bly be true, is a violation of coherence and involves an interaction of specialized brain regions is therefore the precise condition under (Alberini, 2005; Izquierdo and Medina, 1997; which the brain-mind-body system imme- McGaugh, 1966, 2000). Once consolidated, an diately uses its capability to dissolve one of implicit long-term memory such as a pro-symptom the two incompatible constructions, ending position consists of a set of synapses that are the presence of an ontological contradic- molecularly locked into an indefinitely enduring, tion. potentiated state by certain proteins manufactured on demand by neural genes. • The more limiting and antiquated of the It was canonical knowledge of neuroscience two incompatible, juxtaposed constructions throughout the 20th century that once a conditioned is disconfirmed by the other and is dis- response is consolidated in the amygdala’s long- solved and ceases to have subjective real- term implicit emotional memory, the locking of ness. the synapses is permanent and the encoded mem- ory is unchangeable. The evidence for that indeli- • The brain-mind-body system has the capa- bility came from studies of animal learning, spe- bility of dissolving (erasing) any of its pre- cifically the fact that a subsequent extinction viously formed personal constructs at any learning overrides the original conditioned re- time, but does so only in response to an ex- sponse but does not alter or erase it. Even after perience (as distinct from mere conceptu- complete and successful extinction, the original alization) of disconfirming juxtaposition. aversive, fearful response can be re-evoked in a number of easy ways, which shows that the initial Simply put, for transformation of the nonver- conditioned, implicit memory continues to exist bal, implicit knowledge or pro-symptom position and was not changed by the extinction training. driving a therapy client’s symptom, the person The latter forms a separate, second learning that must (a) attentively reactivate and experience that competes against, but does not change, the original pro-symptom position and (b) alongside and along conditioned response (see for example Bouton, with it, concurrently experience another living 2004; Milad and Quirk, 2002; Milner, Squire and knowledge that is logically incompatible with it Kandel, 1998; Myers and Davis, 2002). and disconfirms it—a simultaneous experiencing Extinction appeared to be the best one could of the two knowledges juxtaposed in the same possibly do to put an end to a response driven by field of attention, and both cannot possibly be true. conditioned emotional learnings. One had to create This differs fundamentally from extinction other learnings that successfully counteract and 18 Implicit Memory Depotentiation override the unwanted response. That counterac- implications for psychotherapy are revolutionary. tive strategy and mechanism is the basis of be- However, reconsolidation was discovered in ani- haviorism and of cognitive-behavioral therapy. It mal studies in the laboratory using specialized was fully recognized that, though this seemed to biochemical and behavioral methods, and it is not be the only viable strategy for getting a condi- yet apparent to neuroscientists how to induce re- tioned response to cease, extinction learning is not consolidation selectively, safely and ethically in highly reliable: a reactivation and relapse can oc- people. Ironically, the clinical evidence described cur at any time because the original learning still in the next subsection suggests that coherence exists. therapy methodology may be already bringing However, from 1968 to 1982 a handful of ex- about reconsolidation in people. Here in this sub- ceptions were published, observations of a condi- section we briefly review how reconsolidation op- tioned response disappearing (“retrograde amne- erates in neural terms. sia”) as a result of special laboratory procedures In the course of experience, when an existing, (Judge and Quartermain, 1982; Lewis and Breg- consolidated, long-term knowledge structure is man, 1973; Lewis, Bregman and Mahan, 1972; called into active use by retrieval and reactivation, Mactutus, Riccio and Ferek, 1979; Misanin, Miller under certain conditions a process can occur in and Lewis, 1968; Richardson, Riccio and Mowrey, which the constituent, locked synapses are 1982). These anomalies received little attention, molecularly unlocked temporarily and become and it was another 15 years before researchers labile and modifiable, which allows for an experi- revisited the matter. Then, from 1997 to 2000, ence-dependent alteration (either strengthening, several articles were published reporting strong weakening, or revision of content) in the mem- new evidence of a type of neuroplasticity, or syn- ory’s model of reality and in the responses that it aptic change, that is capable, after all, of directly generates. Upon deactivation of the memory after revising long-term implicit memory and the con- the reactivating experience ends, the synapses are ditioned responses that it generates (Nader, Schafe re-locked, now in their newly altered configuration and LeDoux, 2000; Przybyslawski and Sara, 1997; (Alberini, 2005; Nader, 2003; Nader et al., 2000; Roullet and Sara, 1998; Sara, Roullet and Sara, 2000; Walker et al., 2003). This is the recon- Przybyslawski, 1999; Sekiguchi, Yamada and solidation of the memory. Suzuki, 1997). The recognition of this neural Comments in recent research papers sum up capacity, termed reconsolidation, meant that a current knowledge concerning memory labiliza- century of regarding amygdalar memory as indeli- tion and reconsolidation: Nader (2003, p. 69), re- ble was turning out to be wrong. Reconsolidation viewing studies by Debiec, LeDoux, and Nader rapidly then became a focus of study in many (2002), states that “even remote memories, when neuroscience laboratories. triggered…, return to a labile…state, and…they This dramatic reversal corroborated the phe- remain in this state for several days…” Frenkel, nomenological finding of Ecker and Hulley (1996, Maldonado, and Delorenzi (2005, p. 1757) state, 2000a, 2004) that a true depotentiation of long- “A considerable body of evidence reveals that term emotional implicit memory is observed to consolidated memories, recalled by a reminder, occur during coherence therapy. In addition, as enter into a new vulnerability phase during which described later in this article (and by Ecker, 2006), they are susceptible to disruption again.” Suzuki, the procedural details of how this neural mecha- Josselyn, Frankland, Masushige, Silva, and Kida nism of depotentiation gets activated match the (2004, p. 4787) state, “Memory retrieval is not a steps of the native process of phenomenological passive phenomenon. Instead, it triggers a number depotentiation identified by Ecker and Hulley. of processes that either reinforce or alter stored The fact that the amygdala’s implicit memory information… Memory reconsolidation after re- is changeable after all means that the counteractive trieval may be used to update or integrate new in- strategy of extinction learning is not necessarily formation into long-term memories (LTMs)… The the most effective strategy for changing condi- finding that LTM may be more dynamic and plas- tioned responses. Actually eliminating a condi- tic than previously thought may have important tioned response would be a more effective and clinical implications for the treatment of emotional reliable change than merely counteracting it. The disorders.” Alberini (2005, p. 54) states, “…the Implicit Memory Depotentiation 19 stronger the reactivation of the learned experience, strated in animal studies that when re-exposure to the more labile the memory becomes.” a conditioned stimulus ended after a relatively The studies cited in the previous paragraphs short time (5 to 40 minutes) without the occur- document reconsolidation of implicit memory of rence of the expected unconditioned stimulus, the aversive, fear-based conditioned learning, stored experience functioned as a reminder and induced in the amygdala. In addition, reconsolidation has synaptic labilization and reconsolidation of the so far been documented for two other, non- original memory (merely preserving the original amygdalar memory systems in the brain: the ap- memory in this case). In contrast, re-exposure for a petitive, food-seeking memory of honeybees longer time (one or more hours) instead induced (Stollhoff, Menzel and Eisenhardt, 2005) and the extinction (the formation of second, separate hippocampal, spatial memory of the rat (Rossato, memory). Subsequent studies of various species Bevilaqua, Medina, Izquierdo and Cammarota, have confirmed this finding that experiences of 2006). The occurrence of reconsolidation across disconfirmation (mismatch) produce either recon- the brain’s memory systems is noteworthy because solidation or extinction—two very different neu- it means that our hypothesis that coherence ther- rological processes—depending on the temporal apy recruits reconsolidation does not stand or fall structure of the experience (Pedreira et al., 2004; on where in the brain pro-symptom positions are Rossato et al., 2006; Stollhoff et al., 2005; Suzuki stored in implicit memory. That hypothesis of et al., 2004). course remains to be verified by neuroscientific It is reasonable to expect that the same will be methods. found true for humans, because neural mecha- It seems necessary to understand reconsolida- nisms are highly conserved across phyla. We will tion in terms of both subjective experience and propose in the next subsection, however, that in neural and molecular processes, with the latter humans there is, in addition, a unique, third type of driven by the former. This is made apparent per- result that can follow from a disconfirmation expe- haps most clearly so far by the research of rience, a result produced by the human capacity Pedreira, Perez-Cuest and Maldonado (2004). for bestowing attention in an inclusive, integrative These authors have demonstrated that what in- manner that animals appear to lack. duces the labilization (mutability) of a conditioned memory’s encoding synapses is not memory An endogenous process of reconsolidation reactivation alone, but rather the experience, dur- ing reactivation, of a decisive mismatch between Coherence therapy’s methodology of trans- what is expected according to the reactivated formation, defined earlier, strongly fulfills the memory’s model of reality, and what is perceived condition described just above for synaptic labili- to actually exist. (Likewise, reactivation alone, zation of the symptom-requiring implicit memory. without a mismatch experience, did not produce The methodology creates for a client the following synaptic reconsolidation in a study by Cammarota, interrelated experiences: Bevilaqua, Medina and Izquierdo, 2004.) This finding matches well with what coherence therapy 1. Deep, explicit reactivation: Attentive, lucid defines as the native process through which im- experience of a reactivated pro-symptom po- plicit constructs get transformed, as described in sition with full emotional arousal plus verbali- the previous subsection—the experience of a dis- zation confirming juxtaposition, a definite mismatch 2. Concurrent lucid experience of a contradic- between what is expected according to a reacti- tory, emotionally vivid knowledge vated pro-symptom position and according to some other, incompatible living knowledge. 3. Decisive experience of the pro-symptom posi- Of course, extinction, too, results from experi- tion’s model of reality as making incorrect ences that mismatch what is expected. The neural predictions and/or attributions of meaning research has shown that the duration and/or total 4. Decisive experience of the contradictory number of disconfirmation experiences determines knowledge as a correct alternate model of re- whether extinction or reconsolidation result. For ality example, Pedreira and Maldonado (2003) demon- 20 Implicit Memory Depotentiation

quence of steps in the neurological process of re- Experiences 1, 2 and 3 fulfill the condition for consolidation. The right column describes the cor- labilization of the pro-symptom, implicit memory. responding, endogenous/experiential steps in the Experiences 3 and 4 guarantee that the pro- methodology of coherence therapy. The middle symptom position is subjected to a massive weak- column supplies the steps used in animal studies of ening, alteration or dismantling. Depth and inten- reconsolidation. Of course, these correspondences sity of subjective experiencing maximizes the ef- do not constitute proof that reconsolidation is fectiveness of each step of this process. brought about by coherence therapy. However, Ecker and Hulley’s (1996) formulation of the when taken together with even stronger evidence- rule of transformation through disconfirming jux- —the inability of strong reminders (former trig- taposition received significant support from mem- gers) to re-evoke pro-symptom schemas after ory experiments conducted neurodynamically and transformation, as described in the next subsec- biochemically by Frenkel et al. (2005), who con- tion—then our reconsolidation hypothesis seems cluded that their “present results constitute the first to merit consideration. [neural] evidence that memory can be positively Coherence therapy, first presented to an audi- modulated during reconsolidation through…a real- ence of psychotherapists in 1993, functions en- life episode. …We propose that during reconsoli- tirely as a methodology for accurately finding and dation it is possible to modify memory strength by transforming the specific implicit memories driv- the influence of a concurrent experience.” Note ing the production of a specific presenting symp- that Ecker and Hulley’s “juxtaposition experience” tom. Now neuroscientists, as a result of discover- qualifies as a “concurrent experience” as meant by ing the memory-altering neural process of Frenkel et al. This very recent neural discovery reactivation, labilization, modification and recon- that so closely aligns with Ecker and Hulley’s solidation, also recognize the native capacity of phenomenologically defined rule for transforma- the brain-mind-body-system for the selective de- tion is a major point of unification between the potentiation of implicit memory. Among neurosci- neural and phenomenological domains.10 entists the search is on for a suitable treatment The possibility that coherence therapy recruits protocol for humans that will reliably depotentiate reconsolidation garners further plausibility in the a reactivated memory while it is temporarily la- close correspondences indicated in Table 1 (from bile. An editorial in the British Journal of Psy- Ecker, 2006). The left column describes the se- chiatry concludes, “The clinical value of the [re- search findings on reconsolidation] remains con-

10 It should be noted that there are two differences be- troversial; can a memory trace be removed indi- tween the memory-changing procedure used by Frenkel vidually without unwanted disruption to other et al. (2005) and that of coherence therapy: (a) The pro- memories? Is the web of connections in human cedure of Frenkel et al. was designed for reconsolida- memory too extensively interlinked to allow for tion of a strengthening or up-regulation of a conditioned the possibility of therapeutic erasure?” (Morrison, response memory by a concurrent experience, whereas Allardyce, and McKane, 2002, p. 197). the procedure in coherence therapy is designed to use The memory depotentiation methods under the same mechanism of reactivation-labilization- consideration by neuroscientists are exogenous, concurrent experience-reconsolidation for a major weakening or down-regulation of a pro-symptom im- such as drugs that block molecular processes nec- plicit memory. Our unified model awaits demonstration essary for memory reconsolidation, or electrocon- of a down-regulatory version of the Frenkel et al. use of vulsive shock, which has been shown to disrupt a a real-life episode. (b) The concurrent experience used reactivated, labilized memory in many animal by Frenkel et al. (2005) was entirely unrelated to the studies and one human study, described below. target memory in both content and context, and oper- In contrast, we hypothesize that coherence ated to strengthen the target memory purely through therapy produces memory depotentiation through endogenous biochemical effects. In contrast, the con- endogenous, natural processes of human attention current experience used in coherence therapy is, by and experiencing. To our knowledge, coherence design, a phenomenological experience strongly related therapy is the only paradigm of psychotherapy to the content and context of the target memory and is change-inducing through experiential disconfirmation with a methodology that matches, in detail, all of the target memory. steps needed for bringing about the native neural Implicit Memory Depotentiation 21

Table 1. The process of transformation of knowledge structures in implicit memory

Neurological process Animal learning process Human phenomenological (Reconsolidation studies) (Behavioral studies) process (Coherence therapy)

1. Reactivation Memory reactivation via presentation Subjective immersion in Firing of the synaptic circuit that of conditioned stimulus pro-symptom constructs encodes the memory (discovery/integration work)

2. Labilization Termination of conditioned stimulus Experience of an incompatible Synapses are unlocked and ren- with no unconditioned stimulus after living knowledge dered labile by a disconfirmation short period (long period triggers experience extinction, not reconsolidation)

3. Mutative influence Blockade or enhancement of mo- Attentional, experiential Alters synapses, strengthening, lecular pathways by pharmaceuticals, juxtaposition of pro-symptom weakening, or remodeling the endogenous biochemical effects, or position and incompatible memory electroconvulsive shock knowledge

4. Reconsolidation Irretrievable disappearance of condi- Symptom cessation; pro- Locks in the altered synapses tioned response or permanent amne- symptom constructs seem unreal sia for a task and are non-evocable by former triggers process of reactivation-labilization-modification- This differs sharply from the standard ECS proce- reconsolidation. dure, in which the patient is anaesthetized and un- During symptom production in the course of conscious when the ECS is administered. Rubin’s living, the responsible implicit memory (pro- procedure was based on prior animal studies in symptom position) is reactivated, but uncon- which reconsolidation was first discovered (Misa- sciously so. It is at such moments that exogenous nin, Miller, and Lewis, 1968) by applying ECS treatment schemes would intervene, that is, during during reactivation of a long-term memory, re- symptom production, while the pro-symptom sulting in significant weakening of the behavioral memory is unconsciously reactivated. expression of that memory, whereas ECS applied In contrast, coherence therapy’s discovery and when the memory was not reactivated had no such integration stages turn that unconscious effect. reactivation into a fully felt, fully conscious expe- Rubin surmised therefore that while a person rience of the specific content of the pro-symptom is producing the symptom, the underlying, implicit memory, which is a much stronger and more com- memory driving its production is in a state of plete reactivation of that memory. The integration reactivation, making the memory vulnerable to process in particular entails keeping attention di- disassembly by ECS. All 28 human subjects in the rectly on and in a pro-symptom position repeat- Rubin studies showed dramatic reduction or elimi- edly or even continually for many days or weeks. nation of previously severe symptoms for periods To our knowledge, the only previous report of of from 3 months to 10 years, when the study was a clinical use of reconsolidation describes the ef- published (reviewed in Nader, 2003). The ECS fects of applying electroconvulsive shock (ECS) to treatment is ineffective for these same symptoms subjects during florid reactivations of hallucina- if given when the individual is anaesthetized (the tions or symptoms of obsessive-compulsive disor- standard form of ECS treatment) instead of during der (Rubin, 1976; Rubin, Fried, and Franks, 1969). memory reactivation. 22 Implicit Memory Depotentiation

Rubin’s demonstration of the use of reactiv- mains dissociated, but can be changed through ation-labilization-modification-reconsolidation to attention-mediated experience of the two knowl- dispel clinical symptoms is of momentous signifi- edges in close juxtaposition. In this way, extinc- cance for the field of psychotherapy. However, tion learning in humans differs qualitatively from ECS is unacceptable for general psychotherapeutic that in animals because it can bring about a muta- use because it causes large-scale, non-selective tive reconsolidation of implicit memory. brain damage. Coherence therapy’s use of native A special term such as transformational ex- experiential process to bring about presumably the tinction, reconsolidational extinction or extinction- same depotentiation of memory makes it highly driven reconsolidation seems warranted to denote suitable for general clinical use. this qualitative joining of extinction and reconsoli- Referring once again to the list, above, of the dation into a single change process that appears to experiences that occur during transformation in have extraordinary potency relative to conven- coherence therapy, note that number 4 (decisive tional psychotherapeutic methods. There are vari- experience of the contradictory knowledge as a ous psychotherapeutic systems that entail the con- correct alternate model of reality) would, by itself, scious retrieval of unconscious, unresolved emo- constitute extinction learning, the formation of a tional themes (implicit schemas), such as psycho- separate, counteractive knowledge structure. It dynamic psychotherapy (Crits-Christoph, Lubor- could therefore seem that coherence therapy’s sky and Barber, 1990), psychoanalysis (Curtis and methodology recruits both mechanisms of change, Hirsch, 2003; Wolitsky, 2003), and existential- mutative reconsolidation and extinction. However, humanistic therapies (Schneider, 2003). However, unlike extinction in animals, the contradictory none of them, to our knowledge, directs the clini- knowledge structure in experience 4 does not re- cian to remain entirely non-counteractive toward main experientially separate from the pro- the retrieved, symptom-generating material and to symptom position it contradicts. In contrast to carry out the specific steps necessary for creating a animals, for whom an extinction memory must disconfirming juxtaposition experience, as re- remain forever dissociated from the acquired quired (according to coherence therapy) for trans- memory that it counteracts, human beings have the formation of the retrieved knowledge structures. capability of putting the two contradictory knowl- The opposite shortcoming characterizes cog- edges into direct, juxtapositional, mutative contact nitive-behavioral therapy, which focuses heavily through the use of conscious attention that encom- on the creation of a disconfirming knowledge passes both knowledges. We therefore hypothesize without adequately finding and accessing the un- that coherence therapy makes use of extinction conscious emotional constructs that require the learning not merely counteractively, but transfor- symptom. CBT dismisses the symptom-requiring mationally, through a uniquely human attentional material as “irrational” and fails to recognize or act. take advantage of its coherence. Again the experi- Thus, in contrast to conventional extinction in ence of true juxtaposition is not built into the which a disconfirming knowledge operates merely methodology (though with some clients it occurs as a dissociated counteractive, coherence therapy’s accidentally), so extinction is the result, not trans- methodology of transformation through juxtaposi- formation and reconsolidation. tion utilizes extinction learnings as a concurrent The enhanced potency of the juxtaposition experience to drive the revision and reconsolida- methodology is most apparent in cases, such as the tion of an acquired, pro-symptom memory. one described below, in which a compelling, life- Coherence therapy, we suggest, demonstrates organizing pro-symptom position that generated that the neuroscientifically accepted rule that an symptoms for decades is lastingly depotentiated in acquired memory is unchanged by an extinction seconds once the condition of disconfirming jux- learning appears to be incomplete in the case of taposition is properly established. The crucial ex- human beings and may need to be modified as perience of juxtaposition is a higher-order, atten- follows: an acquired, implicit knowledge in the tional mediation of mental operations, and is by no emotional domain (such as a pro-symptom posi- means an automatic or inevitable result of the tion) is unchanged by an extinction learning (an holding of an incompatible knowing or of making incompatible, disconfirming knowledge) that re- the pro-symptom position conscious and inte- Implicit Memory Depotentiation 23 grated. literally every interest or pursuit Tina ever had. The solution of self-erasure had worked; it ended Pragmatics of depotentiating the implicit the wretched experience of being invaded and knowings driving symptom production robbed by Mom. Tina had been carrying out that self-protective tactic of being blank ever since A majority of therapy clients already possess a childhood, with no conscious, neocortical knowl- living knowledge that is incompatible with a edge of it at all. newly conscious pro-symptom position. Only for a Consciously she judged herself harshly for her minority must the therapist help create an experi- absence of motivation and achievement, dispar- ence that newly forms a disconfirming knowledge agingly calling herself “a vegetable.” Now her to use for juxtaposition and transformation. recognition of purposefully rendering herself For example, in Carol’s next session after re- blank, completely lacking motivation and inter- alizing that she was presupposing that her sexual- ests, made sudden, enormous sense in a whole new ity would be the same as her mother’s—mortify- way. Her depression was largely a response to that ing and violating to her daughter—she reported a blankness in her life—a combination of anticipat- lucid, contrary knowing that her own sexuality ing an endlessly dull future and feeling intense low could and would differ fundamentally from her self-worth over her seemingly intrinsic dullness. mother’s. That contrary knowing was already Her discovery of her own agency and purpose in available amongst her conscious, cortical models maintaining that dullness was an immediate, pow- of herself and the world, and it came into juxtapo- erful shift. However, Tina soon said that though sition with her pro-symptom constructs spontane- this illumination was very real to her, it did not yet ously, with no prompting by the therapist, quite free her because her mother was still the same and soon after the pro-symptom constructs were also Tina still felt as vulnerable to her as ever. Conse- in conscious, cortical representation. quently her blankness was still needed for safety However, even when a contrary knowing does from Mom and others. already exist, it is not at all automatic or inevitable When the purpose (third-order construct) in a that a juxtaposition will spontaneously occur in pro-symptom position remains in force after be- consequence of the pro-symptom position be- coming conscious, as it did for Tina, it means that coming routinely conscious. Deliberate prompting the core, ontological (fourth-order) construct giv- of juxtaposition by the psychotherapist is neces- ing rise to that purpose is still in force and needs to sary about half the time. be the target of discovery and change. Therefore Deliberate prompting and rapid transformation the therapist (Ecker) sought next to guide Tina’s are illustrated in the case of Tina, 33, who de- attention to that ontological construct. In order to scribed many years of heavy depression, complete find how to do that, he first thought as follows: with “black cloud” despite her use of an SSRI an- “What sort of construct would dictate blankness as tidepressant. Her depressed state proved to have the necessary solution to Mom’s invasiveness and several pro-symptom positions maintaining it, but pillaging? Other solutions are, after all, possible; the one found in her sixth session was the pivotal other children respond very differently to the same breakthrough and demonstrates rapid change of a dilemma. What made blankness the right and nec- major, longstanding, core construct. (For a more essary solution for Tina?” This was orienting, and complete account of this case see Ecker and Hul- he then said to Tina, “Tell me: In what ways do ley, 2002a.) people keep other people from just reaching in and Tina’s sixth session focused specifically on taking away things?” her profound, chronic lack of interests and pur- In that way, the therapist invited Tina’s atten- suits. The experiential discovery work took the tion to encounter (a) the possibility of having form of a guided imaginal process involving her boundaries and (b) to recognize what her own po- parents. This led to a moment in which Tina sition is in relation to the possibility of having blurted out, “I erased myself!” upon realizing that boundaries. During the next minute, she became rendering herself blank had been her own way of conscious of obeying a “no walls rule” imposed by protecting herself from her invasive, omnipresent her mother and of her fourth-order construct of mother, who always took over and took credit for herself as a completely exposed being. Simultane- 24 Implicit Memory Depotentiation ously she recognized the amazing possibility of perience does not in itself rigorously prove that “having walls” and of deliberately keeping her transformation of the implicit, pro-symptom mem- personal affairs “behind walls” and unseen by her ory has occurred. However, the failure of remind- mother or others. The realness of this new possi- ers and context changes to evoke the pro-symptom bility operated at once as a knowing that was in- position and the observation that it does not spon- compatible with her pro-symptom knowing. The taneously recover in situations that previously al- juxtaposition of the two knowings was immedi- ways reactivated it into producing the symptom ately transformational. The spell of the no walls are strong evidence of true depotentiation. rule was broken and the prospect of freedom from Following transformation work that seems ef- her lifelong, self-imposed blankness became very fective, active pursuit of such proof is best practice real to her. Her mood became joyous and in coherence therapy: the therapist probes for any giddy—appropriately so. remaining capacity for reactivation through use of A post-session task of integration, written on vivid reminders. This is done by guiding the client an index card, was created to maintain and solidify either behaviorally or imaginally to re-encounter her new knowings and to guide her to implement cues, percepts and situations known to have them through small experiments in keeping her strongly evoked the pro-symptom position. The personal affairs private from her parents. Tina said pro-symptom position can be re-evoked only if it that if she needed another session, she would call still exists. If, however, the pro-symptom position for it. She never did, and in follow-up telephone has been successfully transformed and no longer contacts six months and two years later she re- exists, the client’s response to the reminder is dis- ported being free of depression, off of antidepres- tinctive in that it consists of a report that the previ- sants and excited about a new career, with her vo- ous realness, seriousness and compelling power of cal tone and inflection congruently expressing vi- the pro-symptom emotional theme and purpose tality. has vanished and was not evoked, and further that This example shows that the new experience that theme and purpose now seem implausible, that will accurately transform a pro-symptom po- silly, lifeless, absurd, nonsensical or even laugh- sition is strictly determined by the content of that able. pro-symptom position and cannot be known or A response of that kind was apparent from designed without first discovering that content. Carol in our case example in the preceding article Transformation can take longer in some cases of this series (Toomey and Ecker, 2007a) when, in due to various complications, such as client resis- the next session, she described her previously tance (stemming from a separate implicit knowl- heavily serious and troubling pro-symptom posi- edge of a daunting loss, difficulty or hardship that tion as now seeming “silly.” In that case, her be- would be suffered if the transformation were al- tween-session task of integration—a daily re- lowed). However, the fact that a lasting phenome- accessing of her pro-symptom position by reading nological depotentiation is sometimes found to its verbalization on an index card—first achieved occur in seconds implies that the synaptic circuits its main goal of integration, then led to a sponta- of subcortical, emotional implicit memory corre- neous, disconfirming juxtaposition, and then func- spondingly can depotentiate on this timescale. tioned as a reminder of the now silly-seeming no- This indication seems worthy of neurodynamic tions she had held. investigation. Several animal studies have already If Carol’s therapist had felt it necessary to test been reported in which neurons of the basolateral for transformation during the session, she would amygdala (the site of long-term memory of fear have done so, for example, by guiding Carol first conditioning, as noted earlier) have been depoten- to picture her husband making a sexual overture to tiated—switched from a turned-on state to a her, and then to respond (within the visualization) turned-off state (Rammes, Eder, Dodt, Kochs and by genuinely feeling and saying to herself, “I’ve Zieglgänsberger, 2001; Rammes, Stecker, Kresse, got to resist this, because if I go along with it and Schutz, Zieglgansberger, and Lutz, 2000; Wang enjoy sex with him, I’ll become like Mom, openly and Gean, 1999). erotic and voyeuristic toward our daughter’s sexu- The observation of permanent symptom ces- ality.” If this construction still existed, it would, sation following a disconfirming juxtaposition ex- with high predictability, have been re-evoked and Implicit Memory Depotentiation 25 unmistakably felt through this exercise. If it no juxtaposition. As a rule it is the fourth-order, on- longer existed, the lack of subjective realness of tological construct (the most superordinate con- the words would have been just as unmistakably struct) that is the most effective explicit target be- apparent to Carol. The client’s report of non- cause the existence and realness of the entire posi- realness in the face of such a strong reminder is, tion depends upon it, as illustrated above in the we suggest, phenomenological evidence that re- case of Tina. Often, though, a disconfirmation ex- consolidation has eliminated the implicit emo- perience that focuses explicitly on the purpose tional constructs. (third-order construct) driving symptom produc- For a non-imaginal, real-life version of the tion is adequate, probably because the directly un- same type of probe, Carol would have been as- derlying ontological construct is so clearly impli- signed the between-session task of internally feel- cated that it too gets disconfirmed, albeit implic- ing and saying to herself the same things on the itly.11 next occasion when her husband makes a sexual The therapist deliberately prompted transfor- overture. (For a real-session example of that trans- mation in work with Tina. However, as already formation test procedure on video, in which the noted, transformation can and often does take client describes a major, lifelong, newly conscious place as a spontaneous result of integration of a pro-symptom position as being extremely funny at pro-symptom position. This occurs because inte- the end of one session of therapy, see Ecker and gration de-insulates and exposes a pro-symptom Hulley, 1997.) position to a wide range of other knowledges held The same type of response was observed by by the person, some of which prove to be incom- Rubin et al. (1969) in one of their electroconvul- patible with pro-symptom knowledge and there- sive shock subjects, a woman obsessed with the fore capable of disconfirming it. urge to stab her mother. After ECS treatment she We noted earlier that the case example of was asked if she still felt like stabbing her mother. Carol illustrates this spontaneous form of trans- In response she laughed at the idea and said, “Oh, formation via disconfirming juxtaposition. Carol’s she doesn’t deserve anything like that.” This congruent report in a subsequent session that her woman was then free of symptoms throughout a own compelling pro-symptom position, read on an two-year follow-up. index card between sessions, began to seem “al- Probing for reactivation requires a reminder most silly” is a clear indication that a considerable that is designed to evoke the specific content of a degree of transformation had followed integration pro-symptom position. If, in response to such an spontaneously. The disconfirming knowledge that evoker/reminder, real or imagined, the client expe- had juxtaposed was indicated by Carol’s com- riences a re-enlivening and re-inhabiting of the ments to the effect that “finding a new way to un- pro-symptom position as still having some degree derstand her sexuality as her own and not her of emotional realness, then that pro-symptom po- mother’s was a freeing experience.” A key con- sition still exists and requires more work. Like- struct in her pro-symptom position was the fourth- wise, when a client reports a reactivation that oc- order knowing that her mother’s sexuality re- curred during any real-life situation, the therapist flected the general nature of sexuality; that any takes this as a cue to carry out further discovery, real appetite for sex on her part meant that her integration and/or transformation work in the con- crete scene and situation that evoked reactivation. 11 In a small minority of cases, the client’s pro- Day-to-day life itself often greatly facilitates the symptom position does not require transformation be- thoroughness of the work by inducing reactiva- cause, upon becoming conscious, the client recognizes tions that reveal exactly where and how the work that it serves his or her best interests just as it is. For is incomplete. example, the unconscious pro-symptom position gener- Transformation of a pro-symptom position is ating a graduate student’s serious procrastination of observed to occur all at once or in incremental course assignments was a refusal to pursue a program stages. A pro-symptom position consists of sev- and a career that had been chosen by his parents and was not his true calling. He did not change this position eral, hierarchical constructs, as described in the (other than to make it conscious); rather, he resigned previous article, and the therapist faces a choice as from the program. Ecker and Hulley (1996) term this to which construct to subject to disconfirming reverse resolution. 26 Implicit Memory Depotentiation sexuality would be the same as her mother’s. edge. The therapist lets the contradiction speak for However, Carol harbored a contrary knowing that itself and scrupulously expresses nothing that came into spontaneous juxtaposition with this. comes across as indicating which of the two in- What felt freeing, actually, was the dissolving of compatible knowings is right and which is wrong, that limiting and anxiety-producing fourth-order and trusts the client’s native process to carry out model of sexuality that she had formed in implicit the depotentiation of the pro-symptom knowings memory as a girl, decades ago. and synapses. The slightest indication of a right- This illustrates one of coherence therapy’s wrong preference from the therapist subverts the principles of change: People are able to change a juxtaposition experience, prevents it from occur- position they experience having, but are not able ring and replaces it with a counteractive, cognitive to change an unconscious position that they do not experience that will have little if any effectiveness. know they have. An in-depth therapist who does If, as we have been arguing, juxtaposition is not know that transformation occurs only as a re- indeed the mind’s and brain’s critical condition for sult of disconfirming juxtaposition is likely to in- profound change in the felt realness of personal correctly construe spontaneous transformation as knowledge structures, it is reasonable to ask: why confirming his or her expectation that implicit is that so? The critical role of juxtaposition seems memory retrieval and integration alone should be to imply the operation of a meta-level rule or self- freeing, though it is not, as noted earlier. Retrieval ordering principle that strictly requires a well-knit alone does not unlock the hold and the realness of consistency among all of the constructs, or know- the material if no juxtaposition occurs. Likewise, ings, that are co-present within any one field of as Ecker (2005) has pointed out, counteractive awareness. Inconsistency evidently is not tolerated methods sometimes result fortuitously in an inter- among constructs being experienced together. In nal, unvoiced experience of juxtaposition of a pro- contrast, knowings that are dissociated—held symptom construct and a disconfirming knowl- separately and never co-attended—are allowed to edge, yielding a transformation and lasting symp- be wildly incompatible. However, once constructs tom cessation, with both therapist and client un- are brought together into the same field of aware- aware of the crucial juxtaposition that happened to ness/attention, the brain and mind appear to be occur and inferring mistakenly that counteracting strict about maintaining compatibility, either by was effective in itself. de-commissioning one construct out of existence When transformation does not occur sponta- or by re-splitting them back into separate com- neously following integration of a pro-symptom partments. position, the therapist must deliberately orchestrate Lastly, the client’s moment-to-moment steps a disconfirming juxtaposition. A wide range of of experiencing a disconfirming juxtaposition are techniques are useful for this purpose (see Ecker noteworthy. When attention first subjectively en- and Hulley, 1996, 2000a, 2004), but techniques counters and holds the two-sided, disconfirming per se are not always necessary, as shown by the juxtaposition, there is a sudden, lucid recognition example of Tina, who was simply prompted to that the pro-symptom constructs, which until this attend to the disconfirming knowings while expe- moment had seemed to be the given reality of the riencing her pro-symptom knowings. matter, are actually notions that had been formed We emphasize that disconfirmation through by oneself. There is a surprising recognition that juxtaposition is, like the rest of the native-process- one was only imagining it to be so. One’s aware- matching methodology of coherence therapy, a ness is suddenly now separate from, and superor- non-counteractive process. Specifically, as our dinate to, the pro-symptom constructs. One recog- case examples have shown, the therapist says and nizes oneself as the author of those now obviously does nothing whatsoever directly opposing the erroneous notions, and in the next moment one de- pro-symptom position. To the contrary, the thera- authorizes them by withdrawing a kind of life- pist continues to accept it, to empathize with it and giving, imaginal consent and participation. This to guide the client’s attention to stay with it, in it, leaves the constructs withered and lifeless (as is and experiencing it, not to get away from it. At the also happening, presumably, to the corresponding same time, the client also is guided to attend to synapses). These experiential events are nonver- and experience some other, contradictory knowl- bal, direct knowings that happen very quickly, si- Implicit Memory Depotentiation 27

lently and implicitly. We believe these experiential durally fulfilling the requirements for neuro- elements to be noteworthy because they suggest a logical reconsolidation and (b) rendering different kind of evidence—phenomonological longstanding, symptom-generating implicit evidence, the intrapsychic perception of the dis- learnings non-evocable, appears to recruit re- solution of constructs—that is consistent with the consolidation, the brain-mind-body system’s view that a disconfirming juxtaposition depotenti- inherent neural process for rapid, transforma- ates the implicit memory requiring the symptom. tive change.

CONCLUSION: TOWARD UNIFYING • Built into coherence therapy methodology is THE PHENOMENOLOGY AND the neural integration of brain regions har- NEUROBIOLOGY OF PSYCHOTHERAPY boring implicit and explicit memory, that is, the neural integration of unconscious, non- Our aim in this article has been to capitalize verbal, emotional-perceptual-somatic know- on strides in neuroscientific research by attempting ings and conscious, verbal knowings. to map the methodology of coherence therapy onto known mechanisms of synaptic change in the • Coherence therapy appears to fulfill our pro- brain. We see this exercise as a new step in the posed criteria for optimal psychotherapeutic unification of the reductionistic and holistic view- use of neuroplasticity: it apparently recruits points on human experience and change. reconsolidation, the most potent mechanism We believe that, based on the specific neuro- of synaptic change; it does so in the brain re- dynamics that we have identified in this article as gions and circuits causing symptom produc- being the plausible neural correlates of coherence tion; and it can proceed as rapidly as neuro- therapy methodology, the following tentative in- plasticity allows synaptic change to occur. ferences can be made, pending direct, rigorous confirmation through neurological study of ther- The phenomenological and neurobiological apy clients undergoing coherence therapy: models and methods set forth in this article are based on extensive clinical observation of thou- • The methodology of coherence therapy ap- sands of psychotherapy clients across two decades, pears to depotentiate the specific implicit as well as our scrutiny of pertinent research in memories generating a given symptom, re- neuroscience and psychotherapy. However, neither sulting in symptom cessation. of the authors is a trained neuroscientist, and con- trolled studies have not yet been conducted for the • The rules of change of the brain-mind-body models and processes that we have described. system, as defined by coherence therapy, ap- Toward that end, we envision the following pear to be corroborated by the rules and research agenda for determining the veracity of mechanisms of neuroplastic change. most of the inferences listed above. 1. Controlled outcome study of efficacy as a • Subjective attention is a powerful agent of function of degree of methodological adherence. change, neurally as well as experientially, if We plan to develop measures of qualitative proc- used in accordance with the brain-mind-body ess adherence that will quantify the degree to system’s rules of change. which the defining features of coherence therapy are carried out. This adherence grid would then be • The distinction between transformative applied to a controlled outcome study to yield change and counteractive change is of fun- plots of efficacy versus level of adherence. Key damental importance to psychotherapeutic ef- dimensions of adherence to be rated will include fectiveness, because counteractive change these descriptors of therapeutic process: coher- fails to remove the cause of symptom pro- ence-focused, non-counteractive, non- duction and is therefore inherently unstable pathologizing, non-interpretive, experiential, phe- and susceptible to relapse. nomenological, depth-focused, process-directive, and specificity of unconscious material accessed. • Coherence therapy, by virtue of (a) proce- The arguments in this article predict that for com- 28 Implicit Memory Depotentiation plete adherence, coherence therapy should yield neural circuits driving a particular symptom (the significantly higher efficacy than has been meas- discovery process), then to use attention to create ured to date for other therapies (exceeding the experiences that connect those neural circuits to Dodo bird verdict). As adherence drops below the neocortex (the integration process), and finally 100%, we expect efficacy to drop rapidly down to to use attention to create experiences that depo- the usual level. tentiate those neural circuits, ending symptom 2. Identification of process markers critical to production (the transformation process). Coher- efficacy. Coherence therapy entails several major ence therapy skillfully applied can often have a milestones of methodology that are deemed neces- high degree of accuracy in locating, accessing and sary for full efficacy. Qualitative studies are depotentiating the implicit memory driving needed to test the recognizability and the necessity symptom production. of these events, which include: (a) experience of The distinction between transformative and discovery of pro-symptom position, (b) experience counteractive change is also so important, in our of previously unconscious purpose and agency in view, that it justifies this final emphasis: We reit- generating the symptom, (c) experience of juxta- erate the view of Ecker and Hulley (2000c) that position of key pro-symptom constructs with a the “common factors” that cause over a dozen disconfirming knowledge, and (d) experience of seemingly different forms of psychotherapy to depotentiated pro-symptom position as lacking score the same modest level of effi- emotional realness and non-re-evocable by former cacy—apparently, the same level as properly de- triggers. signed placebos (Baskin, Tierney, Minami and 3. Identification of differing brain processes Wampold, 2003)—are not any of the factors often subserving coherence therapy versus counterac- cited, such as empathy, trust, attunement and a tive and other non-coherence-focused psycho- good client-therapist working alliance (see for ex- therapies. Our expectation that coherence therapy ample Hubble, Duncan, Miller, and Hubble, is capable of a significant enhancement of efficacy 1999). Rather, as understood from the vantage rests on the hypothesis that it operates through a point of coherence psychology, the common fac- fundamentally different process of change, in- tors responsible for the efficacy barrier are these cluding a different neural process in the brain, than (Ecker, 2006): (a) a counteractive methodology, or do all therapies previously subjected to controlled (b) the lack of a decisive coherence focus within a trials. These differences may be apparent in fMRI non-counteractive methodology (that is, failure to brain images that would compare the brain sys- address adequately the implicit schemas actually tems and circuits active during key processes of causing symptom production), and/or (c) non- change in coherence therapy (see previous para- utilization of the built-in process of change (dis- graph) versus key points in other therapies. Such confirmation of implicit, symptom-requiring studies could help determine whether, as we have schemas through a juxtaposition experience). conjectured, the neural process that occurs in clas- In other words, the usual common factors sical extinction (mPFC activation that limits and analysis, which holds that specifics of therapeutic overrides the continuing activation of the methodology and technique have little influence amygdala’s conditioned response) is also operat- on effectiveness, may well be true within the uni- ing in all counteractive methods of therapy, but verse of counteractive and non-coherence-focused not in coherence therapy. methodologies, but not beyond it (Ecker, 2006). We have emphasized the neuroscientific veri- Indeed, neuroscience suggests why such methods fication of the role of subjective attention in are fundamentally limited, as discussed in this ar- bringing about mental change because this is of ticle. In contrast, in the domain of non- particular importance for coherence therapy. Co- counteractive, coherence-focused, transformative herence therapy is most essentially a coherence- therapies, (a) effectiveness seems to be dramati- guided use of attention so as to create experiences cally higher and (b) methodology matters greatly. that bring about psychological and neural trans- For example, details of methodology determine formation. From the neural viewpoint, a person whether or not the work fulfills the specific condi- undergoing coherence therapy is guided first to tions required for the neural reconsolidation of an use attention to create experiences that locate the implicit memory. Implicit Memory Depotentiation 29

Coherence therapy by design can be effective ing extreme degrees of depression, anxiety or dire only when the cause of a symptom presented in situational crisis are likely to need some degree of therapy is an implicit memory, a set of uncon- relief of symptoms or situation through other scious, subcortical personal constructs, or pro- methods before they have enough free attention to symptom position(s), that were formed previously participate usefully in coherence therapy. And of in response to experience. Thus, if a given symp- course, any symptoms caused not by personal con- tom can be dispelled by coherence therapy, we structs in implicit memory, but by true biochemi- may reliably infer that the cause of this symptom cal, genetic or neural irregularities, or by organic was an implicit memory—a purely psychological damage, will not respond to coherence therapy. In cause—rather than a genetic defect or neuro- the next article in this series we argue that this is chemical imbalance (causes which are considered likely to be the case for a very small minority of in the next, third article in this series [Toomey and therapy clients. Ecker, 2007b]). The effectiveness observed by As depicted through most of this article, neu- coherence therapy practitioners for a very broad roscientists are in the position of being the be- range of symptoms12 is itself evidence that implicit stower of knowledge and psychotherapists are in memory is the cause of many more so-called clini- the position of the receiver and applier of this cal “disorders” than is now recognized by the ther- knowledge. There are a few exceptions, however: apy field. several areas for future neuroscientific research A qualitative yet empirical proof of symptom have been identified: coherence (symptom causation by a pro-symptom position) is built into coherence therapy methodol- • A key element of clinical phenomenology ogy properly carried out with each client: with no documented by Ecker and Hulley (1996, counteractive, symptom-opposing measures ever 1997, 2000a, 2000b) is the depotentiating of applied (as could be verified through qualitative a long-term, emotional implicit memory, analysis), symptom cessation nevertheless occurs, sometimes in seconds, by an experience of immediately following depotentiation of the dis- disconfirming juxtaposition. This degree of covered, symptom-requiring schema in implicit endogenously induced neuroplasticity—this memory. Depotentiation is verifiable in the man- native human capacity for full depotentiation ner described in this article. of synapses storing long-term, implicit emo- While coherence therapy has been used effec- tional memory—has not, to our knowledge, tively for a very wide range of clients and symp- been studied by neuroscience. toms, it is not applicable to certain client popula- tions. The main counter-indication is a profound, • Our neurodynamic analysis of coherence chronic avoidance of interior experiencing of vul- therapy’s use of disconfirming juxtaposition nerable feeling, to a degree that is refractory well to achieve transformation has yielded indica- beyond even a significant level of “resistance.” tions that humans, unlike animals, can, Profound avoidance of interior process tends to be through deployment of attention, put an ex- the case for persons with extreme degrees of sev- tinction learning (a contradictory knowledge) eral types of “character disorder,” persons who are into neural and experiential contact with an active addicts (alcohol, drugs, sex, gambling, etc.), acquired memory to drive reconsolidational and some persons with significant bipolar or psy- (transformative rather than counteractive) chotic symptoms. Also, persons currently suffer- change of that acquired memory. This con- trasts with the almost century-old tradition in neuroscience and learning theory of regard- 12 Symptoms dispelled by coherence therapy include ing all extinction learning as strictly dissoci- depression, anxiety, panic, agoraphobia, low self-worth, ated and counteractive, as in animals. attachment problems, sequelae of childhood abuse, sex- ual problems, food/eating/weight problems, rage, atten- • In the first article of this series (Toomey and tion deficit, complicated bereavement, fidgeting, code- Ecker, 2007a) we reviewed Ecker and Hul- pendency, underachievement, procrastination, and a wide range of interpersonal, couple and family prob- ley’s (1996, 2000b) phenomenological de- lems. lineation of the hierarchical, four-level 30 Implicit Memory Depotentiation

structure of emotional implicit memory, translate physical perceptions into a physical pat- which implies a correlate structure in the neu- tern of synapses, but they have nothing to say ral architecture of emotional implicit memory about the source and ultimate nature of sentient, systems, though to our knowledge, this par- subjective experience. In this we subscribe to Al- ticular hierarchy appears not to have been bert Einstein’s cautionary guideline, “Things identified by brain science as yet. should always be made as simple as possible, but not simpler.” For psychotherapists it should be indeed wel- come to know that among prominent neuroscien- ACKNOWLEDGEMENTS tists there is receptivity to a two-way flow of knowledge. For example, Eric Kandel (2001, p. The authors are grateful to Laurel Hulley and 605) stated toward the end of his Nobel address, to Timothy Desmond for many valuable examina- regarding a range of challenging unknowns in tions and discussions of drafts of this article. Niall brain science, “These systems problems of the Geoghegan and Elina Falck also supplied helpful brain will require more than the bottom-up ap- comments. Critiques provided by the anonymous proach of molecular biology. They will also re- reviewers of this article led to valuable enhance- quire the top-down approaches of cognitive psy- ments, for which we are most appreciative. chology, neurology, and psychiatry. Finally, they will require a set of syntheses that bridge the two REFERENCES approaches.” We share that spirit. In a unified model, there Adolphs, R., Tranel, D. & Damasio, A. R. (1998). The are two complimentary ways to understand the human amygdala in social judgment. Nature, 393, cause of symptom production: phenomonological 470–474. and neural. Phenomenologically we can view the Alberini, C. M. (2005). Mechanisms of memory stabili- cause of most (not all) symptoms of clients as be- zation: Are consolidation and reconsolidation ing the unconscious emotional-perceptual-somatic similar or distinct processes? Trends in Neurosci- knowings, the unattended themes, purposes and ence. 28, 51-56. Baev, K. (1997). Biological neural networks. Berlin, tactics, that necessitate producing the symptom. Germany: Birkauser. Neurally, we can regard the cause as being the Bailey, C. H., & Chen, M. (1989). Time course of subcortical neural circuits of implicit memory and structural changes at identified sensory neuron procedural implementation that encode those synapses during long-term sensitization in Aplysia. knowings and that are firing when symptom pro- Journal of Neuroscience, 9, 1774–1780. duction is occurring. Bailey, C. H. & Kandel, E. R. (1993). Structural Those two dimensions of symptom produc- changes accompanying memory storage. Annual tion—subjective and objective, holistic and reduc- Review of Physiology, 55, 397–426. tionistic—do not exist separately from each other. Bailey, C. H., Kandel, E. R., & Si, K. (2004). The per- Each exists through the other. If we truly trans- sistence of long-term memory: A molecular ap- proach to self-sustaining changes in learning- form the underlying emotional themes driving induced synaptic growth. Neuron, 44, 49-57. symptom production, we also transform the impli- Baskin, T.W., Tierney, S.C., Minami, T., & Wampold, cated neural pathways. B.E. (2003) Establishing specificity in psychother- We caution against concluding that develop- apy: A meta-analysis of structural equivalence of ments in neuroscience imply the need for a reduc- placebo controls. Journal of Consulting and Clini- tionist view that sees consciousness and selfhood cal Psycholology. 71, 973-979. as mere epiphenomena of purely physical proc- Bear, M. F. (2005). Modification of the cerebral cortex esses. In preparing this article we have closely by experience. Howard Hughes Medical Institute studied many dozens of research articles by neuro- website. Retrieved January 22, 2006, from scientists, in which not once was any neurody- http://www.hhmi.org/research/investigators/bear.ht ml namic process or property referred to as a cause of Bennett, A. J., Lesch, K. P., Heils, A., Long, J. C., Lo- sentient experience, but only as a “substrate” or renz, J. G., Shoaf, S. E. (2002). Early experience “correlate.” Neuroscientists have made impressive and serotonin transporter gene variation interact to progress in identifying physical mechanisms that Implicit Memory Depotentiation 31

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