Clinical Translation of Memory Reconsolidation Research

methodology

Clinical Translation of Memory Reconsolidation Research: Therapeutic Methodology for Transformational Change by Erasing Implicit Emotional Learnings Driving Symptom Production Bruce Ecker

Abstract

Afer 20 years of laboratory study of memory reconsolidation, the translation of research fndings into clinical application has recently been the topic of a rapidly growing number of review articles. Te present article identifes previously unrecognized possibilities for efective clinical translation by examining research fndings from the experience-oriented viewpoint of the clinician. It is well established that destabilization of a target learning and its erasure (robust functional disappearance) by behavioral updating are experience-driven processes. By interpreting the research in terms of internal experiences required by the brain, rather than in terms of external laboratory procedures, a clinical methodology of updating and erasure unambiguously emerges, with promising properties: It is applicable for any symptom generated by emotional learning and memory, it is readily adapt- ed to the unique target material of each therapy client, and it has extensive corroboration in existing clinical literature, including cessation of a wide range of symptoms and verifcation of erasure using the same markers relied upon by laboratory researchers. Two case vignettes illustrate clinical implementation and show erasure of lifelong, complex, intense emotional learnings and full, lasting cessation of major long-term symptoms. Te experience-oriented framework also provides a new interpretation of the laboratory erasure procedure known as post-retrieval extinction, indicating limited clinical applicability and explaining for the frst time why, even with reversal of the protocol (post-extinction retrieval), reconsolidation and erasure still occur. Also discussed are signifcant ramifcations for the clinical feld’s “corrective experiences” paradigm, for psychotherapy integration, and for establishing that specifc factors can produce extreme therapeutic efectiveness.

KEYWORDS: Memory reconsolidation, clinical translation, destabilization, psychotherapy, memory erasure, behavioral updating, memory interference, emotional schema, transformational change, unlearning, specifc factors, reactivation-extinction, retrieval-extinction, corrective experiences

Submitted: January 19, 2018. Accepted for publication: January 29, 2018 Published online: June 7, 2018

Author information: Correspondence concerning this article should be addressed to Bruce Ecker: Coherence Psychology Institute, 319 Lafay- ette St # 253, New York NY 10012 USA. Email: [email protected]

Cite as: Ecker, B. (2018). Clinical translation of memory reconsolidation research: Terapeutic methodology for transformational change by erasing implicit emotional learnings driving symptom production. Interna- tional Journal of Neuropsychotherapy, 6 (1), 1–92. doi: 10.12744/ijnpt.2018.0001-0092

1 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) Contents

1. Introduction ...... 3 2. Emotional learnings and memories underlying clinical symptoms ...... 5 3. Verifcation of memory reconsolidation in psychotherapy ...... 11 4. How destabilization of a target learning occurs ...... 13 5. How erasure of a target learning occurs ...... 18 6. From research fndings to clinical methodology ...... 24 6.1. Te empirically confrmed process of behavioral erasure ...... 24 6.2. Experiences versus the procedures that induce them ...... 25 6.3. A proposed universal clinical methodology of memory reconsolidation ...... 27 7. Clinical observations of the therapeutic reconsolidation process ...... 32 7.1. Clinical case example: erasure of chronic anger ...... 33 7.2. Clinical case example: erasure of complex attachment trauma ...... 37 7.3. Are the observed transformational changes due to reconsolidation? ...... 50 7.4 Clinical feedback on researchers’ anticipated translation difculties ...... 51 7.4.1. Will mismatch experiences be too exacting for clinicians to create reliably? ...... 51 7.4.2. Do the age and strength of target learnings in therapy cause mismatch difculties? . 53 7.4.3. Will therapeutic changes made via reconsolidation be durable? ...... 54 7.4.4. Is episodic memory resistant to destabilization and updating? ...... 55 7.4.5. Can clinicians navigate complex memory structure? ...... 58 8. Ramifcations for fundamental issues in psychotherapy ...... 60 8.1. Reconsolidation clarifes the “corrective experience” ...... 60 8.2. Reconsolidation provides a unifying framework of psychotherapy integration ...... 65 8.3. Reconsolidation explains psychotherapy RCT outcome research and refutes non-specifc common factors theory...... 66 9. Other emerging clinical translation methodologies analyzed in relation to reconsolidation research ...... 67 9.1. Post-retrieval extinction...... 68 9.2. Episodic memory interference ...... 70 9.2.1. Kredlow and Otto, 2015 ...... 71 9.2.2. Högberg, Nardo, Hällström and Pagani, 2011 ...... 72 9.3. Emotional arousal: Lane, Ryan, Nadel and Greenberg, 2015 ...... 78 10. Conclusion ...... 80 Acknowledgements ...... 81 References ...... 81

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 2 1. Introduction compulsive behavior, addiction, depression, anxiety, low self-esteem, and perfectionism, among many other A primary dilemma in clinical psychology has been symptoms (e.g., Greenberg 2012; Schore, 2003; Toom- described by one of that feld’s leading voices in this ey and Ecker, 2007; Van der Kolk, 1994). A versatile, way: “Afer decades of psychotherapy research, we reconsolidation-based clinical methodology that tar- cannot provide an evidence-based explanation for how gets and reliably nullifes the specifc emotional learn- or why even our most well studied interventions pro- ings maintaining such symptoms would revolutionize duce change, that is, the mechanism(s) through which the feld of psychotherapy. Envisioning that new treatments operate” (Kazdin, 2007, p. 1). Te present landscape, neuroscientists Clem and Schiller (2016, p. article proposes that a fundamental breakthrough in 340) wrote, “To achieve greatest efcacy, therapies… that dilemma may be developing through the trans- should preclude the re-emergence of emotional relation of memory reconsolidation neuroscience into sponses.” Defning complete elimination of unwanted clinical application. emotional responses as the goal of psychotherapy is a Memory research has identifed an innate type of statement that no neuroscientist would have ventured neuroplasticity in the brain, known as memory recon- to make prior to 2000, before the discovery of memory solidation, that can destabilize the neural encoding of reconsolidation. It is a goal now recognized as a possi- learnings of many types, including emotional learn- bility grounded in empirical research. Tat goal is the ings. Destabilization in turn allows the target learn- operational defnition of erasure in this article: lasting, ing to be nullifed either endogenously, by behavioral efortless, complete cessation, under all circumstances, counter-learning, or exogenously, by pharmacological of an unwanted behavior, state of mind, and/or somatic blockade that disrupts the natural molecular and cel- disturbance that had occurred either continuously or lular process of restabilization, or reconsolidation, that in response to certain contexts or cues. normally would occur afer several hours (Duvarci and Currently, at the end of the second decade of lab- Nader, 2004; Pedreira et al., 2002; Pedreira and Mal- oratory research into reconsolidation, researchers’ donado, 2003; Walker et al., 2003). Tus nullifed, the attention is extending to considerations of clinical subsequent durable, robust disappearance of all expres- translation at a rapidly accelerating pace (e.g., Beckers sions of the target learning has been termed its erasure and Kindt, 2017; Dunbar and Taylor, 2016; Elsey and by many researchers (e.g., Kindt et al., 2009; for re- Kindt, 2017a; Krawczyk et al., 2017; Kroes et al., 2015; views see, e.g., Agren, 2014; Nader, 2015; Reichelt and Lee et al., 2017; Nader et al., 2014; Treanor et al., 2017). Lee, 2013; Schwabe et al., 2014; for a review of early, Tose authors have consistently called for a two-way anomalous observations of erasure prior to discovery fow of knowledge between researchers and clinicians of reconsolidation, see Riccio et al., 2006). By putting in order to achieve the fullest clinical utilization of the transformational change of memory on empirical memory reconsolidation. Nader et al. (2014, p. 475) solid ground, research on memory reconsolidation has wrote: paved the way for new common ground between neuroscientists and clinicians, who have fled fne-grained We feel that ongoing discourse between mental anecdotal reports of such transformational change for health clinicians and neuroscientists is benefcial decades (e.g., Ecker and Hulley, 1996, 2000a, 2008; both for scientifc progress in neuroscience and Fosha, 2000; Greenberg et al., 1993; Shapiro, 2001). mental health treatments. Neuroscientists may beneft from being educated about clinical models Memory reconsolidation is a neurological process of mental disorders…. Te reductionist approach that is experience-driven: behavioral and perceptual intrinsic to scientifc activity forces neuroscientists events trigger it into occurring and can govern the to simplify their models in the pursuit of scientifc resulting efects on the target learning. Te relevance questions considered to be of a fundamental nature. of reconsolidation research fndings to psychotherapy Unavoidably, at times, this approach may ignore is potentially very great because clinical symptoms some aspects of mental disorders. A discourse with are maintained by emotional learnings held in implic- clinicians allows neuroscientists to realign their it memory, outside of conscious, explicit awareness, models to ensure that they represent processes in a wide range of cases, including most instances of thought to cause or maintain these disorders. insecure attachment, post-traumatic symptomology,

3 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) Similarly, researchers Elsey and Kindt (2017a) ences of other emotions, such as disgust…or of more opined that “Dialogue between researchers and clini- complex feelings such as guilt and shame afer recon- cians must be maintained” (p. 114) and, in concluding solidation-based procedures are essentially untapped.” an extensive review of the prospects for efective clin- In fact, numerous clinicians’ reports have documented ical application of reconsolidation research fndings, in a fne-grained manner how a wide range of complex commented, “there are signifcant limitations to exper- emotions and emotional learnings have been subjected imental research, and ultimately only attempts at treat- to the empirically confrmed reconsolidation process ment can reveal the utility of a reconsolidation-based of behavioral erasure (see citations above in this para- approach” (p. 115). graph; for online listings of relevant clinical reports, Tose comments serve to defne the purpose of see http://bit.ly/2tKXdyX and http://bit.ly/15Z00HQ). the present article, which is a report from the clinical Section 7 of this article provides samples of such clini- trenches of observations made in the course of di- cal work and its documentation. rectly applying the empirically identifed, endogenous Te rigor of the clinical observations reported process of memory erasure. Tis article describes here is of a diferent type from that of the quantitative what appear to be encouraging advances. Te author, measurements made in laboratory controlled studies a psychotherapist and former research physicist, has by neuroscientists. Here the aim is phenomenological since 2005 maintained close scrutiny of reconsolida- rigor that capitalizes on the unique ability of human tion research while also closely observing the efects subjects (therapy clients) to direct attention to their in therapy sessions of processes designed to translate own mental and emotional states and to describe the memory reconsolidation research into clinical applica- moment-to-moment efects as the steps of the destabi- tion. lization and erasure process are carried out. Neurosci- Members of the clinical domain have been en- entists have barely begun to utilize such articulation of thusiastically consuming and working to utilize the subjective experience for gaining access to the memory knowledge being generated by laboratory neuroscience reconsolidation process, but even their frst forays in researchers since the 1990s (e.g., Siegel, 1999; van der that direction were very fruitful (Sevenster et al., 2013, Kolk, 1994). Tere has been little to indicate a fow of 2014). Te clinical case studies documented in this ar- knowledge in the other direction, however. Undoubt- ticle are intended to show that examining the raw data edly there is more than one reason for that asymmetry, of therapy clients’ real-time phenomenological reports which is particularly acute at present as regards recon- can signifcantly help advance the clinical translation solidation. Tere is now a substantial clinical literature of memory reconsolidation research (see also Heather- that documents observations ascribed to reconsolida- ington et al., 2012). tion and that delineates clinical methodologies demon- Te clinical work reported here is intended to strating translation of reconsolidation research (e.g., demonstrate the application of reconsolidation re- Ecker, 2008, 2010, 2015a,b, 2016; Ecker and Hulley, search, so an examination of relevant research and its 2008, 2017; Ecker and Toomey, 2008; Ecker et al., translational implications precedes the clinical mate- 2012, 2013a,b; Högberg et al., 2011; Lasser and Green- rial detailed in Section 7. As noted, reconsolidation wald, 2015; Sibson and Ticic, 2014; Soeter and Kindt, has been demonstrated and studied for many diferent 2015a; Ticic and Kushner, 2015). Rarely, however, types of memory, but the research covered here is lim- is such literature cited in the writings of laboratory ited to how the process applies to emotional learning researchers, who regularly express anticipation of and and emotional memory, as they play by far the princi- need for advances already made by clinicians. Exam- pal role in psychotherapy. (See reviews cited above for ples of that are myriad; the two most recent instances the full range of research.) Te cellular and molecular encountered by the author are these: Krawczyk et al. levels of reconsolidation research are also not covered (2017, p. 16) commented that “outside the laboratory here. Clinicians need not attend to the highly complex settings such as in clinical ones, it is unclear how the neurophysiological and neurochemical substrates of reconsolidation process might work.” Elsey and Kindt destabilization and erasure (for a review of which, see (2017a, p. 114) commented that laboratory research Clem and Schiller, 2016). However, clinicians should has focused largely on fear learnings and that “experi- understand that robust functional erasure does not

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 4 necessarily correspond to total loss or ablation of the rule. However, in nearly all cases they can be brought entire neural encoding of the erased responses and into direct, conscious experience and accurate ver- learnings, according to recent fndings (Ryan et al., bal representation not through analytical insight, but 2015), and any simplistic image of what happens to using experiential methods developed for that purpose neural circuits when erasure is achieved is almost cer- (e.g., Badenoch, 2011; Ecker and Hulley, 1996; Ecker tain to be signifcantly incorrect. et al., 2012; Ecker and Toomey, 2008; Greenberg et al., Lastly, regarding this article’s usage of an emotional 1993; Lipton and Fosha, 2011; Shapiro, 2001). Tough “learning”: A terminology bridge between neurosci- initially implicit and nonverbal, the symptom-generat- entists and clinicians is much needed. Memory re- ing learnings prove to be well-defned and sufciently searchers as a rule refer to a learned item of any type retrievable and accessible for further therapeutic pro- as a “memory,” not as a “learning”; they refer to the cessing to proceed. Tey also prove to be held in two “target memory” rather than the “target learning.” If diferent types of memory: episodic memory of the the learned item in question is, for example, implicit personal, subjective experience of particular experi- knowledge that would be verbalized as “If I express ences and events (not to be confused with declarative, myself I’ll be criticized and rejected,” researchers factual memory of the same events) (Tulving, 2002, would refer to that as the “memory” under study. Tat 2005), and semantic memory of generalized patterns, usage of “memory,” while perfectly clear to memory re- rules, mental models, expectations and meanings searchers, is likely (in the author’s experience) to create (Markus and Wurf, 1987; Reber, 1989). (For a review considerable confusion for clinicians, who would tend of those two memory systems and their linkage, see to understand “memory” as referring to the person’s Ryan et al., 2008.) episodic memory and/or declarative memory of the Episodic memories that generate clinical symp- original childhood events involving rejection, rather toms are those that contain unresolved distress of an than the semantic memory consisting of a generalized intensity that the individual is unable or unwilling to model and expectation of people being active rejecters. fully forget, resolve, or contain, and those that contain In order to avoid that confusion for clinician readers reward or pleasure so potent as to generate obsessive (this article being intended for both memory research- craving and compulsive behavioral repetition. Te ers and clinicians), the text here refers to an “emotional most extreme forms of those situations may be, respec- learning.” Tat syntax is identical to how “understand- tively, the post-traumatic condition in which highly ing” may be used as in “it resulted in the understand- distressing episodic memory intrudes into awareness, ing that….” commonly known as fashbacks, and addiction. Oth- er problematic expressions of episodic memory are very common. For example, many people carry a 2. Emotional learnings and memories large number of episodic memories of specifc mis- underlying clinical symptoms treatments inficted by a sibling, and the cumulative hurt or anger of this set of memories has strong efects For exploring the clinical application of memory on mood and behavior during family gatherings and reconsolidation research, a realistic view of the emo- possibly in non-family situations as well; the individual tional learnings typically encountered in psychother- might strive unconsciously to get relief from the feeling apy is necessary. Te characteristics delineated in this of being at the bottom of the pecking order inside the section fgure extensively in subsequent sections of this family by dominating others outside the family, result- article. ing in interpersonal problems or job frings. Understanding symptom production as an efect of Te mind and brain actively extract generalized pat- learning and memory is a well established perspective terns, abstractions and meanings from particular ex- within clinical psychology and cognitive neurosci- periences, in order to be ready and oriented for novel ence (e.g., Bouton et al, 2001; Eysenck, 1976; Mineka situations in which similar features appear. Such gen- & Zinbarg, 2006). At the outset of psychotherapy, the eralized or schematic knowledge constitutes implicit implicit emotional memories and learnings underlying semantic memory (Dunsmoor et al., 2009; Frith and and maintaining a therapy client’s specifc symptom- Frith, 2012; Seger and Miller, 2010). Operating entire- (s) are largely or completely outside of awareness, as a

5 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) ly outside of awareness, this form of memory generates ples of semantic memory, as distinct from episodic or a vast range of clinical symptoms. For example, con- autobiographical memory of particular experiences sider the emotional learnings brought into awareness and events; they are generalized, schematic patterns in therapy by a married, middle-aged man who sought abstracted from the concrete instances experienced relief from chronic depression, anxiety, bouts of shame, by the individual. Tey are emotionally compelling and compulsive viewing of pornography. Troughout models of reality, and the symptoms they generate are his childhood, his expressions of distress or needs were coherently necessary according to each construct’s regularly met with his parents’ frightening anger or model of reality. Te importance of addressing gener- cold dismissal, responses that inficted an even more alized emotional learnings in psychotherapy is widely intense sufering than he was initially feeling. Tat of- recognized (e.g., Beckers and Kindt, 2017; Dunsmoor ten-repeated experience set up this cluster of semantic et al., 2015; Lane et al., 2015). emotional learnings that had no verbal or conceptual Te mind’s organization of acquired implicit knowl- representation: edge into schemas has long been an important feature of cognitive science and its clinical applications (e.g., • the knowledge that his very being is disgusting Eichenbaum, 2004; Foa and Kozak, 1986; Rumelhart and unacceptable (which generates shame; a and McClelland, 1986; Toomey and Ecker, 2007; for a young child’s intense feelings of needs and dis- review see Ghosh and Gilboa, 2014). A schema is a co- tress seem to be his very being) herent, composite mental model consisting of linked, related elements; for example, the fve items-of-learn- • the generalized expectation of receiving the ing listed above are linked components of one schema same responses from anyone, were he to express in semantic memory. Emotional schemas “carry our any distress or need (which generates his anxi- emotional learning and memories and are responsi- ety) ble for the provision of the majority of our emotional • the expectation that his entire lifetime will be experience….Tese afective / cognitive / motivational desolately devoid of caring understanding, / behavioral emotion schemes are thus a crucial focus warmth, help or comfort from others (which is of therapeutic attention and...are important targets of both frightening, adding to his anxiety, and also therapeutic change” (Greenberg, 2012, pp. 698–699). generates despair felt as his mood of depression) Semantic and episodic memory are not completely • the urgent necessity of avoiding the expected dissociated systems, but their linkages are a complex responses of anger or indiference by never and subtle matter (reviewed by Ryan et al., 2008). A expressing or even feeling his own distress or frequent observation in clinical practice is that con- needs (which requires dissociation of feelings sciously accessing either one does not necessarily also and avoidance of intimacy, and maintains consciously access the other. Likewise, attending to perpetual aloneness, which is another source of an emotional response or behavior generated by either despondency felt as depression) one does not automatically consciously access the underlying episodic or semantic material. Tere have • the urgent, ongoing need to blot out and escape been many cases in the author’s clinical experience of a the engulfng desolation, despair, aloneness, and therapy client retrieving an emotionally potent schema fear (by frequently flling his consciousness with into lucid awareness from semantic memory without the intensely pleasurable stimulation of pornog- this bringing any corresponding episodic memory of raphy and accompanying fantasies) the experiences in which the schema was learned. In some of those cases, the client was then able to re- Tose adaptive yet symptom-generating emotion- trieve episodic memory through deliberate internal al learnings are specifc, well-defned and coherent searching, but in other cases was not able to do so and constructs, yet prior to being retrieved, felt, and verbal- remained mystifed by how the retrieved schema had ized in therapy, they existed only in implicit memory been learned. Tough awareness of episodic memory and operated outside the explicit domain of words, is helpful to therapy, and can itself serve as a portal concepts and conscious awareness. Tey are exam- for accessing semantic memory, absence of episodic

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 6 memory is found clinically not to be an obstacle to un- and its involvement in episodic memory has been learning and nullifying a retrieved emotional schema noted by Tulving (2002, p. 5): “It [episodic memory] through the memory reconsolidation process. makes possible mental time travel through subjective As can be seen in the examples listed above, the time, from the present to the past, thus allowing one schema is the root cause of any symptom that it gen- to re-experience, through autonoetic awareness, one’s erates, so any symptom based in emotional schemas own previous experiences. Its operations require, but ceases to occur as soon as all of that symptom’s un- go beyond, the semantic memory system.” derlying schemas have been unlearned and erased. An illustration of how semantic knowledge gener- Terefore, for any symptom produced by an emo- ates the emotional quality of a given experience, both tional schema, the schema is the optimal target of in its original occurrence and in episodic memory change, rather than the symptom (Ecker and Toomey, recall, is provided by one of the author’s clinical cases 2008). Attempting to prevent or reduce a symptom (Ecker et al., 2012, pp. 86–91). Te client is a woman with counteractive methods that leave the underlying in her 30s who, during a therapy session, unexpect- memory material intact positions a therapy client to be edly began experiencing, for the frst time, intrusive prone to relapses (Ecker et al., 2012). episodic memory of a traumatic experience at age 8, Tere is a class of symptoms that serve the function when she was in the rear seat of the family car as her of suppressing all awareness of distressing episod- drunk father drove her, her mother and sister on a ic memory or distressing knowledge that conscious careening, lurching trajectory at high speed toward a episodic memory would create. Examples of episod- bridge visible in the distance. By the very nature of ic-memory-suppressing symptoms are disconnection the fashback, she was not merely remembering the from afect, compulsive eating, continual self-dis- incident; rather, she was re-inhabiting the scene and traction via compulsive focus on work, video games, the experience, and describing it from the vantage pornography or any other form of intense excitement point of being there in the car as the living memory such as gambling, and avoidant behaviors that prevent re-played itself in the present. She felt the car graze the encounters with specifc reminders of episodic mem- railing at the side of the road and knew she was going ory. Such symptoms of episodic memory avoidance to die. Feeling helpless in hurtling toward her death, are not produced directly by the episodic memory that her body was frozen and stif in panic. Yet her trauma- is being avoided. Tey are produced, rather, by the tizing feelings of helpless vulnerability and panic were implicit (non-conscious) expectation that experiencing not actually caused by the external physical situation. the avoided episodic memory would be unsurvivably Rather, they were caused by her particular semantic overwhelming, damagingly devastating, or cause in- knowledge. Te plausibility of that assertion becomes sanity. Tat expectation and the rule of avoidance that apparent through the thought experiment of imagin- it necessitates are semantic memory formations. Tus, ing a diferent 8-year-old in her place in that car: a boy this episodic-memory-avoiding class of symptoms is who had recently moved in next door with his family, produced by semantic memory, and the optimal target who needed a ride, who had spent most of his eight of change is the expectation of devastation. years out on the streets among violent youth, and who had remained alive by being as assertive and aggressive Clinical experience reveals yet another subtlety of as necessary for doing so. Tis boy’s semantic knowl- the interplay of episodic and semantic memory: In edge of the rules dictating his possible responses is any subjective experience recalled in episodic memory, quite diferent. As soon as he sees the degree of danger the particular emotional qualities and felt meanings developing in the car, he lunges forward, grabs the of the experience are produced on the basis of the driver’s hair with one hand and throat with the other semantic knowledge that was already operating at and screams in his ear, “If you want another breath, the time (mental models, attributed meanings, rules, motherf****r, you hit those brakes and pull over right roles, expected patterns and sequences, etc.). Forma- now!” Te driver does exactly that in seconds, and the tion of semantic knowledge through implicit learning boy gets out. He knew he would take command of the has been detected at quite early developmental stag- situation, never felt helpless, and therefore experienced es (e.g., DeCasper and Carstens, 1981; Olineck and the incident not as a trauma, but as only another mo- Poulin-Dubois, 2005; Repacholi and Gopnik, 1997), mentary set of choppy waves in a much bigger choppy

7 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) ocean of life. rules requiring my compliance and non-assertiveness.” Te therapist guided the woman through an imagi- Nullifcation of that rule in a replay of a distress-lad- nal empowered re-enactment experience of screaming en episodic memory can transform an experience of at her father, commanding him to stop the car. When helplessness, defenselessness and passive victimization he did not do so immediately, she opened the car door into one of agentive self-assertion and self-protection. anyway, and then he applied the brakes and pulled Tat shif in turn transforms the emotional quality of over, and she exited from the car to safety, calling to the memory from traumatizing endangerment and other drivers for help and police assistance. Tat ima- terror into a far reduced degree of dysphoric feelings ginal experience felt vividly and almost physically real and meanings, such as troubled recognition of parents’ to her. Such assertive behavior not only violated her self-absorption and incapacity to give emotional un- semantic rules, but also disconfrmed what had seemed derstanding. Such lesser distresses are directly amena- to be their inviolability and absoluteness. Tereafer, ble to therapeutic processing, such as by the emergence the episodic memory no longer contained helplessness, of feelings of anger and/or grief that have until now and the somatic frozen state, which was a frequent and, been blocked. until this session, a mystifying symptom in various Tus, semantic memory appears to be always the social situations in her adult present, ceased to occur. critical target of the updating and erasure process, even She retained declarative (factual, cognitive) memory of when the working target memory is an experience in having sufered terror in that car incident, but recalling episodic memory. Te episodic memory serves as a the incident no longer re-aroused that feeling of terror portal to the semantic knowledge governing the emo- as part of the episodic memory. (See Kindt et al., 2009, tional quality of the experience. (Te same principle and Soeter and Kindt, 2012, for laboratory studies that is central to Coherence Terapy and is formulated as, demonstrated such retention of declarative memory “How a person experiences and responds to a situation afer erasure of fear.) Te semantic and emotional is caused not by circumstances, but by viewing circum- components of an episodic memory prove to be mu- stances through the lens of unconscious personal con- table independently of the perceptual components of structs…” (Ecker and Hulley, 2017a, p. 1)). Te same the memory. phenomenology is illustrated in clinical case examples Clinical observations such as that one seem to in Sections 7.1 and 7.5.4. indicate a phenomenology that operates in this man- Schemas in semantic memory, being derived from ner: When an episodic memory is retrieved, addressed particular experiences, have linkages to episodic mem- in therapy and successfully updated, transforming ory (Ryan et al., 2008), as well as to schema-driven the emotion inherent in the memory, what has been emotional states and implicit procedural knowledge updated is the semantic knowledge that was operating of adaptive (if consciously unwanted) responses. Any at the time of the original experience and has been or all of those components of memory may have to be an implicit component of the episodic memory. Tat navigated in the unavoidably complex course of ther- update fundamentally and retroactively changes the apy with a particular client, and any of those compo- encoded personal meaning of the experience, which in nents may serve as a portal or pathway for accessing turn changes the emotion generated by the incident as the others, though the linkages may be faint or bar- it now exists in episodic memory. Declarative, factual ricaded and require inner work to utilize. Te full memory of the concrete happenings of course remains constellation of linked components has been delineat- unchanged; it is the (semantic) personal signifcance ed by Ecker and Hulley (1996, 2017) and by Ecker et and expected contingencies of those happenings that al. (2012, pp. 53–54), who defne this orienting map for have been transformed. A common clinical instance clinicians: involves erasure of what is referred to in Coherence Terapy as parents’ terms of attachment (Ecker et al., 2012, pp. 102–114), consisting of rules that defne how • [Episodic memory] Perceptual, emotional, and connection, acceptance, and punishment work, and somatic memory of original experiences: that are installed in the child’s implicit semantic knowl- Tis is the “raw data”; matching features in cur- edge, such as the rule that “I must obey my parents’ rent situations are triggers of activation of either episodic or semantic memory and the internal

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 8 and/or behavioral responses they generate. clinician’s awareness of all avenues for retrieval of sche- • [Semantic memory] A mental model or set of mas is important for optimally efcient and efective linked, learned constructs operating as living therapy, state: knowledge of a problem and a solution: • Te problem: knowledge of a vulnerability to Te discovery work could, for a particular client, a specifc sufering most readily open up through focusing on an image Tis is an ontological model of how the that has arisen, or on a kinesthetic sensation, for world works in some area (self, others and/ example, rather than through an initial focus on an or the nature of the world itself), and cur- emotion or mood. Ten, as discovery and accessing rent situations that appear relevant to this proceed, all other components of the full…schema model are triggers of the whole schema. come into being experienced and processed, in- • Te solution: knowledge of an urgent strategy cluding the afective dimension. In short, to regard and specifc tactics (internal and/or behavior- afect as the necessary point of access to the deeper al) for avoiding that sufering; or material greatly limits the many ways and many opportunities through which the therapist can usher • Knowledge of lacking any solution to the the client into the material. Te core material, too, problem may or may not be experienced as predominantly Tis drives emotional states of helpless fear/ emotional. It is experienced by some clients more anxiety and/or helpless despair/depression, intensely as a felt meaning than as emotion. plus behavioral expressions of those emotional states (such as insomnia, inaction or substance abuse) Te above multi-component view of memory in relation to symptom production and psychotherapy has been reiterated by Lane et al. (2015), though with some Tus there are several pathways of access by which notable diferences, among them the present article’s a therapy client can arrive at direct, afective awareness emphasis on semantic memory as being the prima- and verbalization of the schema(s) and/or memories ry target for updating and erasure through memory generating a given symptom. Each pathway may be reconsolidation. Section 9.3 provides a more extended characterized by its starting point: discussion of those authors’ approach to reconsolida- • Te client’s behavior in the problematic state or tion-oriented psychotherapy. situation Psychotherapists observe in daily practice the • Te client’s mood, emotion or emotional reactivi- tenacious, long-term persistence and retriggering of ty in the problematic state or situation implicit emotional learnings formed decades earlier. Tat durability has also been well established by re- • Somatic disturbances in the problematic state or searchers, who went so far as to characterize emotional situation learnings as “indelible” (LeDoux et al., 1989) prior to • An image that arises in considering the prob- the discovery of memory reconsolidation. Pine et al. lematic state or situation (2014, p. 1) observed that “A unique feature of prefer- • Identifcation of feature(s) common to all in- ences [acquired, emotionally compelling avoidances stances in which the symptom has occurred and attractions] is that they remain relatively stable over one’s lifetime. Tis resilience has also been ob- • Episodic memory of formative events and ex- served experimentally, where . . . acquired preferences periences earlier in life, whether coherent or appear to be resistant to extinction training proto- fragmentary cols.” Selection pressures in the course of evolution • Te contents of a dream, particularly if the favored the unfading retention of emotional learnings: dream is recurring or if the dream occurred on any learning accompanied by strong emotion is made the night before or afer a therapy session exceptionally durable, due in large part to the efects of emotion-related hormones on the memory encoding Ecker and Hulley (2017a, p. 8), emphasizing that a

9 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) process (McGaugh, 1989; McGaugh and Roozendaal, adequately in the ordinary course of things (Ecker and 2002; Roozendaal et al., 2009). Hulley, 2000a). One middle-aged woman’s depression While implicit emotional learnings are resistant was actually her mood-state of despair and hopeless- to extinction procedures, they are susceptible to the ness following her “illegitimate” pregnancy which, at memory reconsolidation process, as many researchers the age of 18 in a conservative small town, had plunged have demonstrated (e.g., Pine et al., 2014; Reichelt and her into certainty of lifelong stigma, rejection and Lee, 2013; Schiller et al., 2010). It is a consistent clin- ruin, an expectation that had never been updated by ical observation, described in detail in Section 7, that the subsequent, actual course of events later in her life as soon as a particular emotional learning is verifably (Ecker, 2015a); whereas another woman’s depression unlearned, nullifed and erased through the process arose from feeling devoid of interests and motivation identifed in memory reconsolidation research, the and expecting her entire future life to feel the same, symptoms it has been maintaining cease to occur (Eck- without awareness that this state of blankness was a er, 2015a; Ecker and Toomey, 2008; Ecker et al., 2012, deliberate, self-protective tactic that she had resorted 2013a). Tat observation lends support to the view to in desperation as a child, in order to prevent her that discrete modules or schemas of emotional learn- severely self-absorbed mother from continuing to take ing are the root cause of the symptoms they maintain. over, take away and take credit for everything and anything the daughter ever did or enjoyed (Ecker and Viewing symptom production as internally driven Hulley, 2002). by schemas and memories is not to deny or neglect the role of systemic and social processes in maintain- As can be seen in the foregoing examples of implicit ing symptoms. Rather, the individual’s implicit emo- emotional learnings that maintain symptoms, they are tional learnings are formed in response to the entire adaptive in that they consist of living knowledge of a experiential ecology in which she or he is immersed, particular sufering plus either how to avoid it or the including all received systemic and social meanings, dire dilemma of having no way to avoid it. (For a more messages, contexts and contingencies, and are the very detailed mapping of the content and structure of symp- means of their infuence (Bateson, 1979; Hermans and tom-generating emotional schemas, see Ecker et al., Dimaggio, 2007; Siegel, 2015). Systemic and social as- 2012, pp. 53–55; Ecker and Hulley, 2017a.) Tey are pects are ofen of primary importance in the emotional also coherent, in the sense that they consist of a sensi- learnings accessed in therapy.1 ble, well-knit account of how sufering and safety operate, a mental model that is faithfully based on what was Another relevant clinical observation is the unique- personally and subjectively experienced earlier in life ness of the underlying emotional learnings brought (Ecker and Toomey, 2008; Toomey and Ecker, 2007). into awareness by diferent therapy clients who have presented the same type of symptom, such as panic Te recognition that implicit emotional learnings attacks or dysthymic depression. For example, one are inherently adaptive, coherent, and neurologically woman’s full-strength, physiological panic attacks built to persist for a lifetime amounts to a non-pathol- were found to arise from her expectation of absolute ogizing view of symptom production that contradicts rejection by her father were she to fail to be “head and the widespread characterization of “pathogenic,” “mal- shoulders above” (superior to) all others at all times adaptive” beliefs driving symptom production. Te (Ecker, 2015a: NPT article); whereas another woman’s emotional learning and memory systems of each of the physiologically similar panic attacks were driven by fve therapy clients described above certainly were gen- the urgent necessity of fulflling the weekly quota of erating unwelcome behaviors and states of mind and sufering that the universe requires of each family, a body, yet were functioning properly in doing so, not quota which the universe is ready to fulfll at any time malfunctioning or dysfunctioning, similar to how the by inficting catastrophe, if it is not already fulflled unwelcome swelling, painful tenderness and redness around a recent wound express the proper function- 1 Of course, there are many symptoms that are not caused by emotional learning and therefore cannot be dispelled by mem- ing of healing and immunity systems. In that sense, ory reconsolidation, including physiologically based conditions many conditions ofen termed “disorders of emotional such as hypothyroidism-induced depression, neurologically based memory” are not actually disorders at all. To describe conditions such as dyslexia and autism, and emotional styles a therapy client’s core beliefs or schemas as incorrect, based in genetically determined temperament.

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 10 maladaptive or pathogenic is actually to accuse the quently, “As we do not have any incontrovertible neural process of natural selection of having those attributes, measure of whether reconsolidation has taken place in because a person’s persisting beliefs and schemas exist humans, we can only indirectly infer its presence….” due to the proper functioning, not the malfunctioning, (Elsey and Kindt, 2017a, p. 114). Tis situation begs of the emotional brain. the question: Are the indirect markers of reconsolida- Te task of psychotherapy, in this view, is to facili- tion sufciently clear and substantial to verify reliably tate the thorough unlearning, via memory reconsolida- its successful induction in psychotherapy? Terapists tion, of the compelling expectations, meanings, mod- having reliable markers for verifying their use of re- els, roles, rules and tactics that were learned earlier in consolidation is obviously a necessity. life, and are now maintaining unwanted efects, and Te verifcation markers that reconsolidation re- can now be updated and replaced by more efectively searchers themselves use in human studies are presum- adaptive constructs. Tat is an unlearning of semantic ably the best choice. For verifying reconsolidation in memory, an unlearning of how events and experiences human studies, researchers rely upon the behavioral were construed and have continued to be construed markers of erasure observed in animal studies where by the implicit knowledge system (Ecker and Toomey, the decisive tests were conducted, confrming that 2008; Ecker et al., 2012). In the subjective experience reconsolidation had occurred. Te prototype of that of such unlearning, some aspect of the world that has is the landmark human study by Schiller et al. (2010), felt compellingly real and inescapably life-constraining the frst in which a fear memory was erased. Schiller et is recognized as a mirage that has no reality at all. Tat al. concluded that reconsolidation had occurred by ob- nullifcation, which is clearly apparent in the clinical serving the same behavioral markers of erasure as were case examples in Section 7, leaves intact one’s episodic, observed in rats by Monfls et al. (2009), who used autobiographical memory of events and experiences in largely the same procedure and also confrmed recon- one’s life. (For a laboratory demonstration that event solidation decisively. Te logic of regarding erasure as memory is unafected by erasure of emotional learn- confrmation of reconsolidation also takes into account ing, see Kindt et al., 2009.) the fact that reconsolidation is the brain’s only known If, as noted above, emotional learnings are the root neuroplastic process that can produce those markers. cause of the symptoms they drive, then their observed Tere are three well-defned behavioral markers of heterogeneity for the same symptom implies that psy- erasure: chotherapeutic treatment, if it is to dispel the symptom at its roots, must be uniquely tailored to each client. As described in Sections 4 and 5, memory reconsolidation 1. Non-reactivation: An acquired physiological research has come to the same conclusion, namely and/or afective response that formerly occurred that the specifc, unique features of a target emotional immediately upon perceiving a certain cue or learning dictate the design of the experiences needed context no longer occurs. (For example, the rate to induce the destabilizing, unlearning, and nullify- of a mouse’s heartbeat no longer increases upon ing of it. Section 6 shows that research has identifed seeing the red light that formerly became associ- a well-defned, endogenous process that is readily ated with soon receiving a foot shock.) tunable to the unique contours of the target learnings 2. Non-expression: Te overtly manifested behav- discovered in each clinical case. ioral expression of that physiological and/or afective response no longer occurs. (Te mouse no longer freezes in response to the red light.) 3. Verifcation of memory reconsolidation in 3. Efortless permanence: Te above two changes psychotherapy persist without relapse under all conditions and Laboratory researchers conduct a variety of direct without any further training or special condi- neurological tests on animal subjects to ascertain with tions implemented to maintain them. certainty whether or not reconsolidation has occurred. Te defnitive tests are either toxic or require eutha- nizing, ruling out use with human subjects. Conse- Erasure in the clinical context, as noted in Section 1,

11 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) means lasting, efortless, complete cessation under all However, the emotional learnings addressed in circumstances of an unwanted behavior and/or state of psychotherapy are in most cases considerably more mind and/or somatic disturbance that had been a per- complex than the elementary emotional learnings sistent occurrence, particularly in certain contexts or created in laboratories for controlled study of destabi- in response to certain cues. In other words, the emo- lization and erasure. Do the above markers of erasure tional learning in question can no longer be reactivated verify reconsolidation in psychotherapy as reliably as into being felt afectively or somatically, or into being in laboratory studies? In other words, when the mark- expressed behaviorally or physiologically. Te therapy ers of erasure defned above are observed to appear in client’s experience and behavior are now enduringly as immediate response to some steps of psychotherapeu- though the target learning no longer exists (though, as tic treatment, is it valid to infer that the therapeutic noted in Section 1, there is evidence that portions of process has successfully induced memory reconsoli- the target learning’s engram or physical encoding may dation and erasure? Would it be scientifcally valid for still exist (Ryan et al., 2015), as reviewed by Clem and therapists to use the markers of erasure as a reliable Schiller (2016)). means of confrming recruitment of the memory re- Te defnition of erasure in the previous paragraph consolidation process in therapy sessions? If so, close is specifcally what the phrase transformational change study of such sessions could help reveal and defne denotes in this article. In terms of achieving relief therapist actions that are efective for facilitating the from sufering, such transformational change, resulting destabilization and unlearning that nullify and erase from erasure, is the most efective therapeutic out- clients’ emotional learnings. come. Given the diference between laboratory and clinical Erasure is technically not the only behavioral mark- contexts as regards the complexity of target learnings, er of reconsolidation. A statistically signifcant, per- it seems prudent to allow for the possibility that the manent change of any kind in an acquired response or markers of erasure observed in therapy might conceiv- memory is also a reconsolidation marker that has been ably be the result of some process other than memory used in some studies, for example those of Hupbach et reconsolidation. Beyond such a priori conservative al. (2007, 2009) and Forcato et al. (2010), in which the prudence, however, there is nothing in the existing destabilized target learning incorporated new learning body of memory research that is recognized as indi- that either modifed or partially interfered with expres- cating either that some other mechanism of erasure is sion of, but did not fully erase, responses driven by the involved or that acquired emotional schemas of clinical original learning. Te carefully controlled conditions, relevance are not susceptible to destabilization and quantitative measurements and statistical power of nullifcation. Rather, one is faced with the fact that laboratory studies render such partial interference reconsolidation has been found to occur for all of the efects conclusive, but in the uncontrolled complexity many types of memory that have been tested. Noting of clinical work, partial diminishment of symptoms in that fact, Schiller and Phelps (2011, p. 6) summarized, individual cases would not be a decisive verifcation “Tese fndings suggest that reconsolidation is a gen- that reconsolidation had occurred. Erasure is total 100 eral property of memory and is common to diferent percent interference. Its markers, defned above, are memory systems.” It therefore seems not imprudent unambiguous in individual therapy cases and therefore to apply the same logic to therapy sessions as to lab- easy to confrm, as the author has personally observed oratory studies, while still respecting the possibility in many hundreds of cases. Erasure also rules out all that some qualitatively diferent mechanism of erasure mechanisms of change other than reconsolidation, ac- could eventually be discovered. Tus it appears valid cording to present scientifc knowledge, which partial to proceed according to the working hypothesis that symptom relief does not do. For those reasons, erasure the markers of erasure observed in therapy signal the is the only reliable form of verifcation of reconsolida- preceding occurrence of memory destabilization and tion in therapy. Achieving transformational change in nullifcation. therapy is unmistakable and, of course, is a therapeutic Te ecological validity and internal consistency of breakthrough that makes both clients and therapists that approach are supported by clinical observations very happy. made prior to the discovery of memory reconsolida-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 12 tion. In a systematic search for the therapeutic specifc Te hypothesis that reconsolidation has been in- factors directly responsible for sudden, lasting, trans- duced in therapy sessions that produce the three mark- formational changes occasionally observed in their ers of erasure, advanced by Ecker (2006, 2015b) and therapy sessions, Ecker and Hulley (1996) selected and Ecker et al. (2012, pp. 126–130), has received support closely examined sessions that unambiguously pro- from fne-grained examination of nine clinical cases duced the same three markers (cessation of triggerabil- yielding transformational change, each from a difer- ity of a specifc, afective, problematic emotional sche- ent psychotherapy system (for a listing of which, with ma and ego-state, cessation of long-term symptoms citations, see http://bit.ly/15Z00HQ). All nine cases of behavior, cognition, mood and somatics produced were found to contain the same sequence of experi- during activation of that schema and ego-state, and ences identifed in reconsolidation research as being efortless persistence of those changes). Teir scrutiny necessary for inducing destabilization and erasure, em- and reverse engineering of therapeutic process were bedded but unambiguously recognizable in the thera- encouraged by the local clinical scientist paradigm peutic process, where they were immediate precursors (Stricker, 2006; Stricker and Trierweiler, 1995), and of transformational change, that is, the appearance of were likewise recently employed by clinical researchers the markers of erasure. Te hypothesis that recon- who proceeded “by pinpointing precisely where in the solidation is a deep structure universally responsible therapeutic discourse the client’s self-narrative shifs for transformational change of acquired states and and then working backward” (Friedlander et al., 2016). responses, advanced by Ecker (2011) and Ecker et al. Ecker and Hulley in that way identifed a specifc (2013b), has signifcant implications for psychotherapy sequence of experiences that was always present as integration, which is discussed further in Section 8.2. the immediate precursor of the markers’ appearance. Elsey and Kindt (2017a), in discussing therapeutic Te focused, deliberate facilitation of that sequence use of the pharmacological blockade, have suggest- was then pursued with a wide range of clients and ed verifcation of reconsolidation via observations of symptoms, resulting in observations of transforma- efects that result only from pharmacological blockade tional change (the three markers) with unprecedented of a Pavlovian-type target learning, that is, cue-in- frequency in day-to-day clinical practice, for a major duced expectation of sufering or pleasure. With one increase of therapeutic efectiveness. exception, their verifcation criteria are not relevant to Te same critical sequence of experiences as iden- the behavioral updating and erasure process that is the tifed by Ecker and Hulley (1996) was subsequently principal focus of this article. Te exception is “mem- identifed in memory reconsolidation research as the ory specifcity (the manipulation should not indiscrim- experiences required by the brain for destabilizing a inately afect memory, but only the reactivated memo- target emotional learning’s neural encoding (Pedrei- ry trace)” (p. 114). Tat criterion could be fulflled by ra et al., 2004, plus numerous confrming studies, as a wide range of processes other than reconsolidation, discussed in Section 4) and then behaviorally updating unlike the markers of erasure, which are unique to the destabilized target learning with nullifying count- reconsolidation and appear to be its most reliable er-learning (frst demonstrated by Monfls et al. (2009) verifcation until such time as neuroscientists devise a and Schiller et al. (2010), as discussed in Section 5). method of direct detection of engram nullifcation that Tat confrmation of the clinically identifed sequence is safe and practical. of experiences by rigorous empirical studies using rad- ically diferent methodology indicates the robustness with which the markers of erasure serve to reveal in 4. How destabilization of memory occurs psychotherapy that the sequence of experiences nec- Te destabilization of a target learning’s neural essary to induce destabilization and behavioral nulli- encoding opens the so-called reconsolidation window, fcation has occurred. Ecker and Hulley (1996, 2017) a period of several hours of lability that allows memory developed a system of psychotherapy designed for content and/or strength to be altered fundamentally, maximally efcient facilitation of the critical sequence and that ends naturally with an automatic restabiliza- (initially named Depth-Oriented Brief Terapy, later tion (reconsolidation). Te experiences that induce renamed Coherence Terapy). destabilization were frst identifed by Pedreira et al.

13 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) (2004), who used animal subjects and created a condi- Te conclusion reached by Pedreira et al. (2004) was tioned fear learning in a standard manner, by pairing that destabilization requires a sequence of two experi- an aversive unconditioned stimulus (US, in this study ences, memory reactivation plus memory mismatch. the visual image of a predator) with a conditioned Tis fnding subsequently has received independent stimulus (CS, in this study a unique context, i.e., a confrmation by at least twenty-fve studies, listed in particular chamber). To reveal whether destabilization Table 1. Many other studies have also reported cor- of that target emotional learning had occurred under roborative results, such as that of Piñeyro et al. (2014), various conditions, they used the pharmacological whose study focused particularly on determining the blockade technique: only if the target learning has been role of memory destabilization and who arrived at destabilized does the administered chemical agent the view that “equating mere reactivation to memory erase the conditioned fear behavior in response to CS destabilization could lead to erroneous conclusions” (p. presentation. (A newly destabilized target learning 52). continues to function as before, is not degraded by Te critical memory mismatch experience is also being destabilized, and gives no indication of being referred to as a prediction error experience in many of destabilized, hence the need for an additional process these studies. Te two phrases are synonymous. Te that reveals destabilization decisively.) critical role of mismatch/prediction error for trigger- Previous researchers had concluded that destabi- ing destabilization has been recognized in numerous lization results from memory reactivation and that a research review articles. For example, Delorenzi et al. memory destabilizes every time it is reactivated (e.g., (2014) observed, “strong evidence supports the view Nader et al., 2000; Eisenberg et al., 2003). Pedreira that reconsolidation depends on detecting mismatches et al. (2004) found rather that destabilization did not between actual and expected experiences” (p. 309). occur afer the target learning had been reactivated by Agren (2014), in reviewing research on reconsolidation the CS (exposure to the context), but did occur afer of emotional learnings in humans, commented, “it reactivation was followed by an experience of “memo- would appear that prediction error is vital for a reac- ry mismatch” in which the subject’s perceptions of the tivation of memory to trigger a reconsolidation pro- present situation difered from what the reactivated cess” (p. 73) and “the studies that have shown efects learning expected (in this case, non-appearance of the of reconsolidation… must somehow have induced a expected US afer being placed in the CS context). prediction error” (p. 80).

Table 1. Studies demonstrating that memory destabilization requires a memory mismatch or prediction error experience in addition to memory reactivation. Year, Authors Species, Memory Type Design and Findings 2004, Pedreira et al. Crab: Contextual fear Learned fear response can be erased by chemical blockade (bicucul- memory line and cycloheximide) only afer memory reactivation is accompanied by memory mismatch experience (prediction error). 2005, Frenkel et al. Crab: Contextual fear New experience modifes memory expression only if preceded by a memory memory mismatch experience. 2005, Galluccio Human: Operant condi- Reactivated memory is erased by new learning only if a novel con- tioning tingency is also experienced. 2005, Rodriguez- Rat: Taste recognition Novel taste following reactivation allows memory disruption by Ortiz et al. memory anisomycin. 2006, Morris et al. Rat: Spatial memory of Reactivation allows disruption of original memory by anisomycin escape from danger only if learned safe position has been changed, creating mismatch of expectation. 2006, Rossato et al. Rat: Spatial memory of Reactivation allows disruption of original memory by anisomycin escape from danger only if learned safe position has been changed, creating mismatch of expectation.

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 14 2007, Forcato et al. Human: Declarative Memory of syllable pairings learned visually is destabilized and memory impaired by new learning only if, afer reactivation by presentation of context, presentation of a syllable to be paired does not occur as expected, creating mismatch. 2007, Rossato et al. Rat: Object recognition Memory is disrupted by anisomycin only if reactivated in presence memory of novel object. 2008, Rodriguez- Rat: Spatial memory of Reactivation allows disruption of original memory by anisomycin Ortiz et al. escape from danger only if learned safe position has been changed, creating mismatch of expectation. 2009, Forcato et al. Human: Declarative Memory of syllable pairings learned visually is destabilized and lost memory only if, afer reactivation, the expected opportunity to match syllables does not occur, creating mismatch. 2009, Perez-Cuesta & Crab: Contextual fear Reactivated learned expectation of visual threat must be sharply Maldonado memory disconfrmed for memory to be erased by cycloheximide. 2009, Winters et al. Rat: Object recognition Memory is erased by MK-801 only if reactivated in presence of memory novel contextual features. 2010, Forcato et al. Human: Declarative Memory of syllable pairings learned visually destabilizes and in- memory corporates new information only if, afer reactivation, the expected opportunity to match syllables does not occur, creating mismatch. 2011, Coccoz et al. Human: Declarative Memory of syllable pairings learned visually destabilizes, allowing memory a mild stressor to strengthen memory, only if, afer reactivation, the expected opportunity to match syllables does not occur, creating mismatch. 2012, Cafaro et al. Crab: Contextual fear New experience modifes memory expression only if preceded by a memory memory mismatch experience. 2012, Sevenster et al. Human: Associative fear Reactivated fear memory is erased by propranolol only if prediction memory (classical condi- error is also experienced. tioning) 2013, Balderas et al. Rat: Object recognition Only if memory updating is required does reactivation trigger memory memory destabilization and reconsolidation, allowing memory disruption by anisomycin. 2013, Barreiro et al. Crab: Contextual fear Only if memory reactivation is followed by unexpected, mismatch- memory ing experience is the memory eliminated by glutamate antagonist. 2013, Díaz-Mataix Rat: Associative fear Reactivated fear memory is erased by anisomycin only if prediction et al. memory (classical condi- error is also experienced. tioning) 2013, Reichelt et al. Rat: Goal-tracking mem- Target memory reactivated with prediction error was destabilized ory and then disrupted by MK-801, but not if brain’s prediction error signal was blocked. 2013, Sevenster et al. Human: Associative fear Reactivated fear memory is erased by propranolol only if predic- memory (classical condition-error-driven relearning is also experienced. tioning) 2014, Exton-McGuin- Rat: Instrumental memory Memory for lever pressing for sucrose pellet was disrupted and ness et al. (operant conditioning) erased by MK-801 only if the reinforcement schedule during reactivation was changed from fxed to variable ratio, creating prediction error. 2014, Sevenster et al. Human: Associative fear Reactivated fear memory is disrupted and erased by propranolol memory (classical condi- only if prediction-error-driven relearning is also experienced. tioning)

15 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 2015, Alfei et al. Rat: Contextual fear Reactivated fear memory is disrupted and erased by midazolam memory only if reactivation conditions involve prediction error (a temporal prediction error in this study). 2015, Jarome et al. Rat: Contextual fear Reactivated fear memory is disrupted and erased by a protein syn- memory thesis blocker only if reactivation conditions include a novel contextual feature (mismatch/prediction error). 2016, Forcato et al. Human: Declarative Recall of memorized items is impaired, revealing destabilization, memory only when a memory mismatch (prediction error) accompanies reactivation. 2016, López et al. Crab: Contextual fear Learned fear response can be erased by chemical blockade (bicucul- memory line and cycloheximide) only afer memory reactivation is accompanied by prediction error.

Exton-McGuinness et al. (2015) reviewed the role of Neuroscientists regard reconsolidation as being the prediction errors in reconsolidation studies and sum- brain’s innate process for updating memories because marized their position by stating, “We propose that a it launches only if an experience of discrepancy and prediction error signal…is necessary for destabilisation surprise accompanies reactivation of an existing learn- and subsequent reconsolidation of a memory” (p. 375). ing or schema. Various studies have contributed to a Krawczyk et al. (2017), reviewing the functional role growing understanding of the boundary conditions of of prediction error in the neurobiology of learning and memory destabilization, i.e., the types and degrees of memory, stated, “Prediction error induces updating of mismatch that do or do not trigger memory destabili- consolidated memories in strength or content by mem- zation for memories of various types, ages, or strengths ory reconsolidation” (p. 13) and “When our predic- (e.g., Gallucio, 2005; Suzuki et al, 2004; Sevenster et al., tions or understandings of the world do not ft with the 2013, 2014; Schroyens et al., 2017). Importantly for current experience, the detection of this incongruence both research and clinical application, reliable design triggers the destabilization-reconsolidation process, of mismatch experiences depends heavily upon knowl- which allows us to adjust our internal models.” (p. 15). edge of the detailed content and structure of the target Te experience-driven nature of memory recon- learning, because that content and structure determine solidation is strongly apparent in the mismatch re- which experiences register as mismatch/prediction quirement. An experience of mismatch, or prediction error and with what strength. Tat fundamental error, inherently involves the perceived presence of a principle has been revealed by several studies in which novelty or discrepancy relative to expectancy in a pre- target learnings containing knowledge of various re- viously learned milieu, creating a subjective element inforcement schedules or timing patterns were tested of surprise (see, for example, Fernández et al., 2016c; for destabilization by candidate mismatch experiences Lee, 2009; Sevenster et al. 2014). What matters to the of various designs (e.g., Alfei et al., 2015; Jarome et al., subject’s brain is not the concrete procedure used by 2012; López et al., 2016; Merlo et al., 2014; Sevenster experimenters to set up mismatch in a particular study, et al., 2013, 2014; Schroyens et al., 2017). Te same but rather the subjective experience created by the studies have also shown that if an intended mismatch procedure, an experience in which the world is in some experience difers too greatly from the target learning’s way not as believed and expected. Behavioral proto- expectations, it does not induce destabilization, pre- cols for creating mismatch vary greatly across studies. sumably because a too-diferent experience registers For example, Pedreira et al. (2004) used a procedure in not as a mismatch, but as being in a qualitatively difer- which mismatch consisted of non-reinforcement that ent context or category of experience from that of the followed reactivation by a variable time delay, making target learning, rather than a needed correction to the it clear that the two are distinct experiences, where- target learning. Te threshold of excessive mismatch as Rossato et al. (2007) used the presence of a novel itself depends on memory strength and age, because object to create a mismatch that was copresent with stronger degrees of reactivation and mismatch are reactivation. required to destabilize stronger and older memories (Eisenberg and Dudai, 2004; Frankland et al., 2006; Su-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 16 zuki et al., 2004; Winters et al. 2009; Wang et al., 2009). serve to identify a general principle that is critically Several studies have shown additionally that by add- important for clinical application: An experience that ing a small continuation (such as two more CS-only is intended to destabilize a particular target learning presentations) at the end of a post-reactivation proto- must be accurately tailored to the specifc content of col previously shown to leave the target learning in a that target learning. destabilized condition, the target learning is then lef For example, for a target learning acquired through in a stable condition by the extended protocol (Jarome an intermittent reinforcement training, a single expe- et al., 2012; Merlo et al., 2014; Sevenster et al., 2013, rience of nonreinforcement does not create an expe- 2014). Tis fnding implies that a target learning is dy- rience of mismatch or counter-learning, because the namically switched in real time from stable to unstable expectation maintained by the target learning includes or vice versa as the component steps of a post-reacti- the occurrence of nonreinforcements (e.g., Sevenster vation protocol are progressively implemented. Ecker et al. 2013, 2014). Even two or more nonreinforce- (2015a, pp. 19–23) has proposed that such switching ment experiences would fail to create a mismatch if occurs because each part of the post-reactivation pro- the original, learned pattern of nonreinforcement was tocol promptly creates new learning that infuences the similarly sparse. Tat example is a rather obvious case, level of prediction error created by the next part of the but in some studies the target learnings created by re- protocol, and in that sense functions as (and possibly searchers had subtler features that are not addressed or may actually be) a modifcation of the target learning. accounted for in researchers’ interpretation of observa- In Ecker’s hypothesis, if at any point the new learn- tions. For example, Pine et al. (2014) achieved desta- ing created by the unfolding protocol causes the next bilization but regarded their experimental procedure part of the protocol to be experienced with little or no as creating no prediction error, so they viewed their prediction error, the target learning is switched from results as indicating that prediction error is not neces- destabilized to stable condition, abruptly closing the sary for achieving destabilization, when actually their reconsolidation window and preventing the remainder procedure generated prediction error in three diferent of the protocol from having any updating efect (un- ways (for details of which, see Ecker, 2015a, p. 12). less it is structured so as to mismatch the now-revised Cognizance of the mismatch requirement did not target learning, which would again destabilize the spread efciently among reconsolidation researchers target learning). Ecker (2015a) applied that hypothe- afer its discovery by Pedreira et al. (2004). Te prior, sized phenomenology to generate for the frst time an incorrect notion that each reactivation by itself is de- analysis of the time-resolved efects of the protocols stabilizing continued to be asserted in journal articles used by Monfls et al (2009) and Schiller et al. (2010), by many reconsolidation researchers, as well as in sci- as well as a time-resolved analysis of how the standard ence journalism. Tis lack of recognition of the mis- extinction protocol operates (that is, an analysis of the match requirement has caused the authors of numer- evolving state of the target learning and the efect of ous studies to misinterpret their results, particularly in each successive non-reinforcement trial). studies that reported a failure to achieve destabilization Reviewing experimental fndings noted in the and erasure. Te negative result is attributable, as a previous two paragraphs, Ecker (2015a, p. 13) defned rule, to an absence of any mismatch experience in the a formal principle of mismatch relativity, a clarifed for- experimental procedure (see Ecker, 2015a, for discus- mulation of which is: Whether a particular component sion of such cases). In most instances, these studies’ of a post-reactivation procedure creates a destabilizing authors made no mention of the mismatch require- mismatch experience depends entirely on the model ment and appeared to be unaware of it (e.g., Camma- of reality at that point in time in the target learning, rota et al., 2004; Hernandez and Kelley, 2004; Mile- including modifcations or supplementations by any usnic et al., 2005; Wood et al., 2015). An exception is prior components of the post-reactivation procedure. the discussion by Bos et al. (2014), who surmised that Tus, while the various specialized protocols de- their negative result was due to the absence of a mis- scribed above were designed for the highly simplifed match/prediction error experience and commented, conditions of controlled studies and therefore may “Future studies may beneft from protocols that are have limited clinical applicability, collectively they explicitly designed to assess and manipulate prediction

17 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) error during memory retrieval” (p. 7). (Liu et al., 2014), showing the specifcity of the desta- Given that clinical symptoms are frequently main- bilizations induced via US reactivation. Summarizing tained by generalized, semantic emotional learnings or a review of those fndings, Dunbar and Taylor (2017, schemas, as discussed in Section 2, a critical question p. 168) comment, “Whereas the conventional CS-re- is whether a schema can be reactivated by generalized, activation procedure may recruit the neural correlates abstract cues, with no reference to any specifc experi- of only a single CS-US memory, US reactivation may ence that contributed to the formation of the schema, recruit neural correlates of all CSs associated with and then be destabilized and erased. Soeter and Kindt the reactivated US, thus allowing for destabilization (2015b) demonstrated that afer the images of two and, thus, disruption of all CS-US associations for the distinctive spiders were separately paired with electric reactivated US.” Tis indicates that in optimal clinical shocks and became fear-inducing, seeing the name of translation, reactivation of the target learning would the category of the feared items, “spider,” was efective include a reminder of the US, that is, the specifc for reactivating the subcortical fear memory, allow- sufering that the client experienced in the past and ing destabilization and erasure to follow. Tis fnding learned to anticipate and strive to avoid. Incorporation begins to provide an empirical basis for the frequent of that US-reminder strategy into clinical methodology clinical observation that a client’s emotional schema is is described in Section 6.3 below. readily reactivated by verbally naming its constituent categories, without any reference to the original perceptions or experiences that led to the formation of the 5. How erasure of memory occurs schema. When a target learning is in the destabilized, labile condition, its nullifcation, resulting in the markers of In another common clinical situation, the expecta- erasure, can be accomplished in two fundamentally tion of a particular form of sufering (US) is triggered diferent ways, one of which is endogenous and the by numerous diferent occurrences or perceptions other, exogenous (for reviews, see Agren, 2014; Lee (CSs), such as a feeling and expectation of social rejec- et al., 2017; Reichelt and Lee, 2013). Te endogenous tion (the US) being evoked by holidays, parties, danc- method is ofen labeled behavioral memory updating ing, restaurants and weekends (the CSs). Te clinical or behavioral interference. Te exogenous method is ideal would be a single process that dissolves all such known as pharmacological blockade, pharmacological CS linkages, rather than addressing each separately. interference, or disruption of reconsolidation. Several laboratory studies have simulated this situation by pairing a US with two or more CSs (Debiec et In behavioral updating, frst demonstrated in an- al., 2010; Díaz-Mataix et al., 2011; Doyére et al., 2007; imal studies by Sekiguchi et al. (1997) and in human Liu et al., 2014; Schiller et al., 2010; Soeter and Kindt, studies by Walker et al. (2003) and Galluccio (2005), a 2011). All of those studies found that when reactiva- destabilized learning can be revised in its strength and/ tion was induced by the presentation of one of the CSs or content by suitably designed new learning, accord- alone (without the expected US occurring, creating ing to how the new learning difers from the target mismatch), followed by post-reactivation pharmaco- learning (without difering so much that, due to lack logical blockade or behavioral counter-learning, the of relevance to the target learning, the new learning conditioned response to only that one CS was then forms separately rather than updating the target learn- erased, and all other CSs continued to trigger the state ing, leaving the target learning unchanged). A target of expecting the US. In contrast, when reactivation learning can thereby be strengthened, weakened, mod- was induced by re-experiencing only the US (without ifed in its particulars, or erased by suitably designed any of the expected prior CS presentations, creating new learning during the reconsolidation window (for multiple mismatches), the conditioned responses to reviews see Agren, 2014; Beckers and Kindt, 2017; all CSs were then erased or impaired (Debiec et al., Reichfelt and Lee, 2013; Schiller and Phelps, 2011). 2010; Díaz-Mataix et al., 2011; Liu et al., 2014; Luo et Te updating/erasure efect occurs through diferent al., 2015). Further, one of those CSs, which had also molecular and cellular processes from the destabiliza- been paired with a diferent US, continued to evoke the tion/restabilization process (Jarome et al., 2012; Lee et distinct conditioned response created by that pairing al., 2008)

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 18 Because this article’s primary topic is the psycho- eral adjustable parameters were set outside the brain’s therapeutic use of memory reconsolidation, the focus reconsolidation boundary conditions, the range of pa- here is mainly on the erasure of target learnings, as rameters of a given protocol that induce destabilization it is erasure that is experienced by therapy clients as or counter-learning. Tat explanation appears to have decisive, transformational change, that is, complete been confrmed by a systematic varying of parameters and permanent disappearance of an unwanted behav- by Ferrer Monti et al. (2017). However, the matter ior and/or state of mind and/or somatic disturbance. is not yet fully resolved, because Luyten and Beckers Erasure via behavioral memory updating results from (2017) attempted an exact replication of the study by following the destabilization of the target learning Monfls et al. (2009) and did not observe erasure. with counter-learning consisting of experiences that Te post-retrieval extinction protocol begins with contradict and disconfrm the target learning’s specifc reactivation of the target learning by a single unre- model and expectation of the behavior and qualities of inforced CS presentation, followed by a 10-min time self, others and/or the world. Te markers of erasure interval, which is followed by a series of unreinforced are then observed, which is the basis for researchers CS presentations. Tat series of CS-noUS trials is concluding that counter-learning during the reconsol- identical to the conventional protocol used for study- idation window drives unlearning that nullifes and ing extinction for a century, so researchers refer to that replaces the labile target learning (e.g., Clem and Schil- part of the protocol as an extinction training (which ler, 2016). Erasure produced in this way can be regard- is arguably a misnomer, as discussed further in Sec- ed as behavioral memory interference (Bjork, 1992; tion 6.2 below). Tus in its entirety (retrieval plus Robertson, 2012) at the maximum possible degree of extinction), the post-retrieval extinction protocol can efectiveness. be understood as being a standard extinction training Te historic frst demonstrations of counter-learn- with a single modifcation that may seem minor but ing erasing an emotional learning (conditioned fear) has major efects: an increased time interval of 10 min were the animal study by Monfls et al. (2009) and the between the frst two CS presentations. Monfls et al. human study by Schiller et al. (2010). In those stud- and Schiller et al. compared the results obtained with ies, fear was acquired through Pavlovian associative and without the increased time interval: Without it, conditioning, in which an initially emotionally neutral the protocol becomes that of standard extinction train- CS was repeatedly paired with an electric shock US. ing, and the result was the familiar one known from a Tereafer, the CS by itself triggered a fear response century of extinction studies (Bouton, 2004), namely, due to the learned expectation of the US occurring initially the fear response was largely suppressed but next. Te procedure employed by Monfls et al. and then could be reinstated. In extinction, repetitive Schiller et al. for erasing that acquired fear response counter-learning applied to a stable target learning behaviorally with counter-learning was a protocol that creates a separate contradictory learning that competes has come to be known as post-retrieval extinction, re- against the target learning and temporarily suppresses trieval-extinction, or reactivation-extinction. Erasure it. (See Ecker 2015a for a detailed analysis of why stan- by this protocol has been confrmed in several animal dard extinction training does not destabilize and erase studies (e.g., Clem and Huganir, 2010; Flavell et al., the target learning. Strong evidence that reconsolida- 2011; Piñeyro et al., 2014; Rao-Ruiz et al., 2011) and tion and extinction are distinct and mutually exclusive human studies (e.g., Agren et al., 2012; Björkstrand et phenomena has been produced by Duvarci and Nader, al., 2015; Oyarzún et al., 2012; Steinfurth et al., 2014). 2004; Duvarci et al., 2006; Merlo et al., 2014.) Sup- Negative results from the post-retrieval extinction pression induced by extinction training is prone to protocol were obtained in several other studies (with relapse because the target learning still exists and again animal subjects: Chan et al., 2010; Costanzi et al., 2011; becomes reactivated and dominant under various Flavell et al., 2011; Ishii et al., 2012, 2015; Staford et circumstances (Neumann and Kitlertsirivatana, 2010; al., 2013; and with human subjects: Golkar et al., 2012; Vervliet et al., 2013). Kindt and Soeter, 2013; Meir Drexler et al., 2014; Soet- In sharp contrast, with the frst time interval in- er and Kindt, 2011). Tese negative studies have been creased to 10 min, the fear response was erased, that is, interpreted by Auber et al. (2013) and Piñeyro et al. it disappeared and could not be reinstated, and the du- (2014) as indicating that some of the protocol’s sev-

19 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) rability of non-reinstatement was confrmed afer 1 yr Te increased, 10-minute interval is clearly the by Schiller et al. (2010) and afer 1.5 yr by Björkstrand distinctive feature responsible for the post-retrieval et al. (2015). Evidently the increase of the frst time extinction procedure’s efectiveness in the Monfls interval to 10 min created a mismatch experience that et al. study, so it has been copied in nearly all subse- destabilized the target learning, allowing the following quent replications and variants. Yet the analysis in the series of non-reinforced CS presentations to serve not preceding paragraph implies that the increased time as a conventional extinction training, but rather as interval was efective only because it happened to mis- counter-learning that accomplished erasure. match the time structure in the acquisition training, Understanding how and why the increased time not because of any intrinsic role of delays or timing in interval served to create a memory mismatch (predic- the destabilization process. In other words, with a tar- tion error) experience is vitally important for reliable, get learning that has no timing structure, the extended successful future utilization of this procedure and its 10-min time interval of the post-retrieval extinction variants in both research and psychotherapy. However, procedure would not create mismatch or contribute neither Monfls et al. (2009) nor Schiller et al. (2010) to destabilization. Tere is no timing structure in any made reference to the mismatch requirement in their of the emotional learnings of therapy clients that were discussions of results. Ecker (2015a) has proposed a detailed earlier in Section 2, such as the middle-aged detailed analysis of the mismatch characteristics of man’s learned, generalized expectation that anyone both studies, and López et al. (2016) have replicated would respond to him with anger or cold indiference the experimental result and interpreted it in terms were he to express some need or distress. With target of prediction error. Both of those accounts join with learnings such as those, which are representative of those of Fernández et al. (2016a) and Hupbach (2011) most of the emotional learnings that emerge in thera- in emphasizing a central principle: In laboratory stud- py, the timing structure of the post-retrieval extinction ies, the efect of new learning on a target learning is procedure could not contribute to creation of mis- accurately understood only by examining in detail the match/prediction error and therefore could not induce relationship between the acquisition experiences that destabilization. originally were encoded into the target learning and Tus the analysis above suggests that the post-re- the structure and content of the new post-reactivation trieval extinction procedure of Monfls et al. (2009) learning. and Schiller et al. (2010) would have limited clinical Tat principle applies as follows to the studies by applicability. It will be argued in Section 6.1 that the Monfls et al. (2009) and Schiller et al. (2010): In most versatile and optimal procedural format for clin- acquiring the target learning, subjects learned not only ical application consists of using each therapy client’s the CS-US association but also the time interval be- unique target learning as the absolute basis for tailor- tween CS-US pairings: 3 minutes in Monfls et al. and ing efective experiences of reactivation, mismatch, and 15 seconds in Schiller et al. Terefore, upon perceiving counter-learning, unconstrained by any preconceived the frst CS of the post-retrieval extinction procedure, procedural format and utilizing any known therapeutic subjects in the two studies expected the next CS to techniques. appear afer those time intervals, respectively. Tat Te foregoing analysis serves to illustrate why the expectation was then mismatched by the passage of 10 superordinate principle put forward in this article is minutes before the next CS appeared, instead of the that an experience-oriented interpretation of recon- expected 3 minutes or 15 seconds. (Studies have since solidation research rather than a procedure-oriented demonstrated the use of a purely temporal mismatch interpretation is necessary for arriving at accurate to induce memory destabilization, e.g., Alfei et al. understanding and reliable, fne-grained control of 2015; Díaz-Mataix et al., 2013.) Schiller et al. in addi- memory reconsolidation in clinical use. Adherence to tion had subjects view a TV show during the 10-min- the experience-oriented interpretation consists of an- ute interval, which was a qualitatively diferent type of alyzing occurrences and non-occurrences of memory novelty relative to the target learning’s expectation of reconsolidation in terms of the experiences required by a blank screen, possibly creating a second mismatch the brain for inducing destabilization and revision of concurrent with the temporal one. a target learning. Te experience-oriented interpreta-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 20 tion therefore illuminates why, and when, a particular which of the two is activated frst. Each of those two procedure is or is not efective. Te procedure-orient- experiences has an extended though limited duration ed interpretation in itself cannot do that because, in of activation, which is why their juxtaposition is possi- efect, it equates memory reconsolidation with certain ble. procedures rather than with the critical experiences For example, such juxtaposition could have oc- that actually govern the process. curred as follows in the study by Baker et al. (2013). For example, the experience-oriented interpretation Acquisition training consisted of three pairings of a may provide a simple explanation for what is currently 10-sec white noise sound (CS) with paw shock (US) perhaps the most controversial fnding in reconsolida- on day 1. Te procedure on day 2 (in Experiment 4) tion research. Both Baker et al. (2013) and Millan et al. began with an extinction training in which 30 CS-only (2013) carried out the post-retrieval extinction proto- presentations were separated by an interval of 10 sec. col (targeting conditioned fear memory in adolescent Tat constitutes strong learning of the expectation that rats and alcoholic beer seeking memory in adult rats, a CS is followed by another CS in 10 sec. Tat expecta- respectively) and observed signifcantly diminished tion was mismatched when, 10 min afer the extinction expression of the target learning. Tey also found that training ended, only the single “retrieval” CS presen- the same diminishment of memory expression resulted tation occurred, with no other CSs following it. Tat from reversing the protocol, with the single CS-only mismatch of CS-driven expectation destabilized the “retrieval” component following the extinction training target learning. At that point, the destabilized target by 10 min rather than preceding it. Tat has wide- learning and the just-created counter-learning experi- ly been viewed as a “remarkable” fnding indicating ence of safe CS were simultaneously present, so be- potentially that the post-retrieval extinction protocol havioral updating of the target learning occurred and does not engage reconsolidation mechanisms afer all, a signifcant decrease of fear response was observed. because “Reconsolidation theory would posit that re- Also tested was a period of 6 hr instead of 10 min afer trieval must come before extinction for the procedure extinction until the single retrieval trial. In this case, to impair reinstatement” (Dunbar and Taylor, 2017, p. the enhanced impairment efect on the fear response 163) and “it is difcult to reconcile how reconsolida- was lost. Since the target learning was destabilized by tion can be initiated when the reminder trial follows, the single CS-only presentation no diferently afer 6 rather than precedes, extinction learning” (Treanor hr as compared to afer 10 min, it must be the other et al., 2017, p. 293) (see also Hutton-Bedbrook and ingredient needed for erasure that was absent: Afer McNally, 2013). 6 hr, the extinction training experience of safe CS was Tose are procedure-oriented analyses. Te expe- no longer a currently activated experience, so there rience-oriented interpretation provides an alternative was no juxtaposition of the destabilized target learning analysis that is consistent with the reconsolidation pro- with a counter-learning experience and therefore no cess, as follows. In this view, the critical condition that updating. A separate fnding that strongly supports accomplishes behavioral erasure via reconsolidation this interpretation is the recent demonstration that is the concurrent experiencing of a reactivated target the neural ensemble encoding a new learning inter- learning that is destabilized, and a counter-learning acts with and participates in a subsequent new learn- that contradicts the target learning’s model of how the ing for 5 hr but does not do so afer 6 hr (Cai et al., world works. Importantly, it does not matter which of 2016; Rashid et al., 2016). Tus in the 6-hr case, the those two experiences is induced frst, because what 30 CS-only trials functioned as a standard extinction the brain requires for updating, in this view, is the training, not as counter-learning for memory updat- juxtaposition of the two. As soon as both are being ing, so the enhanced impairment of the fear response experienced concurrently, erasure is a likely result. was lost. Te idea that counter-learning could precede destabi- Te observations of Baker et al. (2013) and Millan lization and still be efective for erasure ceases to seem et al. (2013) can therefore be seen as supporting the counter-intuitive with recognition that for updating, experience-oriented interpretation of reconsolidation the brain requires only a juxtaposition (concurrence, phenomena rather than as indicating non-recruitment simultaneity) of the two experiences, regardless of of reconsolidation by the post-retrieval extinction

21 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) protocol. In clinical work, likewise we fnd that the phobia. Also, no evidence was found for efects of required juxtaposition can be assembled either way, by propranolol on PTSD symptom severity through reactivating the target learning frst (for example, “Te inhibition of memory reconsolidation. In con- only way to get attention is to do something bad”) or clusion, the quality of evidence for the efcacy of by reactivating the contrary knowing frst (for example, propranolol at present is insufcient to support the “My boss readily met with me to discuss my concerns, routine use of propranolol in the treatment of any of and my friends all showed up for my birthday party”). the anxiety disorders. Both sequences are equally efective for setting up the juxtaposition that results in erasure. However, an examination by Ecker (2015, pp. Erasure by counter-learning during the reconsoli- 14–15) of some pharmacological blockade studies has dation window is the fully endogenous utilization of revealed a signifcant procedural faw: the absence of memory reconsolidation. Alternatively, administra- any mismatch experience following reactivation of the tion of a chemical agent during memory destabiliza- target memory. Te lag in recognition of the mismatch tion can produce exogenous erasure with no count- requirement by many researchers was noted earlier, er-learning. In that methodology, the agent blocks the and in a review of propranolol studies in humans, neural protein synthesis necessary for return of labile Beckers and Kindt (2017, p. 111) commented, “Te no- memory to the stable consolidated state, but has no tion that memory destabilization will occur only when efect on stable memory circuits. When fully efective, there is an expectancy violation or an experienced mis- this pharmacological blockade prevents restabilization match at the time of memory retrieval…has not been (reconsolidation) of the destabilized neural circuitry of taken into account in the majority of clinical trials that the target learning from ever taking place. Te target have been conducted so far.” In studies with no mis- learning’s neural encoding becomes nonfunctional match experience, there would be no destabilization of and the markers of erasure are observed. Te phar- the target memory and therefore no pharmacological macological agent is administered soon before or soon blockade efect, so the target memory would be un- afer the target memory is destabilized by reactivation afected and remain in operation. Tat would be the with mismatch, and the blockade takes efect when reason for the observed failure of the chemical agent restabilization would normally occur, about fve hours to produce erasure in these studies (which in their afer destabilization was induced. Te pharmacologi- own way add usefully to the evidence supporting the cal blockade procedure is therefore also referred to by necessity of mismatch for inducing destabilization). researchers as disruption of reconsolidation. (For a Tese fawed studies therefore have no signifcance review see, e.g., Taylor and Torregrossa, 2015.) Erasure regarding the inherent efectiveness of the exogenous/ via pharmacological blockade was frst demonstrated pharmacological approach, and should not be included for learned fear by Nader et al. (2000) and Przyby- in evaluations of that approach. Te inclusion of such slawski et al. (1999) in animals and by Kindt et al. methodologically fawed studies in the meta-analy- (2009) in humans. sis by Steenen et al. (2017) could be responsible for Human studies and clinical applications of phar- arriving at a negative conclusion regarding the clinical macological blockade have relied on the use of pro- efectiveness of propranolol for disrupting the recon- pranolol, as all other blockade agents used in animal solidation of humans’ fear learnings. Te true clinical studies have toxicity that precludes them from use with value of propranolol treatment therefore remains am- people. Both positive and negative results have been biguous, and it is possible that by using methodology reported in numerous studies; for reviews see Beckers that reliably fulflls the brain’s requirement for memory and Kindt (2017) and Steenen et al. (2017). Te latter destabilization via reactivation and suitable mismatch, concluded: the efectiveness of propranolol treatment might be established. If Steenen et al. were to repeat their calcu- lations afer screening out the methodologically fawed Tese meta-analyses found no statistically signif- studies, the new results could be a signifcantly more cant diferences between the efcacy of proprano- reliable indicator of propranolol’s clinical efectiveness lol and benzodiazepines regarding the short-term if sufcient statistical power remains. treatment of panic disorder with or without agora-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 22 In contrast to erasure via pharmacological block- neocortex (through skin conductance measurements ade, the fully endogenous process of erasure through by, e.g., Oyarzún et al., 2012; Schiller et al., 2010). counter-learning (i.e., behavioral memory updating) Pharmacological blockade of fear memory by propran- allows completion of the reconsolidation of the target olol, in contrast, erases subcortical fear memory but learning’s neural encoding in its re-encoded, con- leaves intact the fear generated by declarative memory tent-revised form. Behavioral erasure is a disruption of the CS-US contingency (as detected in the form of of the content of the target learning, accomplished undiminished skin conductance and US-expectancy through the reconsolidation process, not the neuro- measurements by Kindt and Soeter, 2013; Soeter and physiological disruption of the reconsolidation process Kindt, 2011; reviewed by Beckers and Kindt, 2017). itself. Further, it has been shown that afer pharmacological For psychotherapeutic use, the endogenous (ful- blockade and erasure of a newly encoded memory, ly psychological) and exogenous (pharmacological some components of the engram (physical encoding) blockade) approaches have their respective advantages continue to exist (Ryan et al., 2015), allowing optoge- and disadvantages. It is widely recognized, as Soet- netic (artifcial) activation of participating neurons to er and Kindt (2011, p. 358) stated, that “Obviously, a drive re-expression of the erased behavioral response. behavioral procedure will be preferred over pharmaco- Te same test of engram persistence for a behavior- logical manipulations provided that similar efects can ally erased memory has not yet been reported, to the be obtained.” Behavioral updating in fact appears to author’s knowledge. Neurochemical evidence sug- have greater efectiveness, according to both laboratory gests that the neural encoding of the target learning studies described in this paragraph and clinical obser- is reconstituted when behaviorally updated by new vations described in Section 7. In humans, behavioral learning (Clem and Huganir, 2010; Debiec et al., 2010; erasure of fear memory by the post-retrieval extinction Díaz-Mataix et al., 2011; Jarome et al., 2012, 2015), protocol has been shown to occur in the subcortical but whether the entire engram is thus reconstituted is emotional memory system of the amygdala (through not yet known. Implications of post-erasure engram fMRI brain imaging by Agren et al, 2012; Björkstrand persistence for the durability of changes produced by et al., 2015; Schiller et al., 2013) and also in the declar- erasure in psychotherapy are discussed below in Sec- ative, contingency-learning memory system of the tion 7.5.3.

Table 2. Comparison of features of the endogenous and exogenous clinical use of memory reconsolidation, based on the totality of controlled studies and clinical observations to date. Feature Endogenous/psychological Exogenous/pharmacological Range of symptoms dispelled to date Wide1 Narrow2 Effectiveness in clinical practice to date High3 Uneven Memory systems affected in lab studies Subcortical + cortical Subcortical Resolves varied and complex emotional issues Yes4 Not demonstrated Duration of treatment Unpredictable; Brief often brief5 Level of clinical training required Advanced Intermediate

1 See Table 4 of this article. 2 Fear-based symptoms, specifcally phobias, panic and symptoms of post-traumatic stress disorder from single-incident, acute trauma. 3 In twenty years of clinical use, advanced practitioners observe erasure rates of up to 95% of clients. 4 For online listing of published case studies indexed by symptom, see http://bit.ly/2tKXdyX, and for numerous additional case studies see http://bit.ly/15Z00HQ . 5 For advanced practitioners in general practice, the number of therapy sessions needed to dispel a given symptom is usually in the range of 6 to 20, though as few as 2 sessions are sometimes sufcient and, in cases of severe complex attachment trauma, on the order of 100 sessions may be required to dispel numerous symptoms and their numerous underlying emotional schemas.

23 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) Table 2 compares the currently known attributes of encoding. Verifcation of erasure then consists of the endogenous/behavioral and exogenous/pharmaco- observing the three markers defned and discussed in logical methods of erasure. Te endogenous approach Section 3: nonreactivation, symptom cessation, and is the focus of the remainder of this article. Sections efortless permanence. 6 and 7 below describe a versatile clinical methodol- Te tripartite sequence of reactivation, mismatch, ogy developed and manualized by Ecker and Hulley and counter-learning experiences will be referred (2017a) (see also Ecker et al., 2012, 2013a,b) for ef- to henceforth as the empirically confrmed process ciently and directly implementing the empirically con- of erasure (ECPE). Te ECPE is proposed here as a frmed process of behavioral erasure. Tat methodol- completely non-theoretical, empirically identifed core ogy has been utilized by clinicians worldwide, many methodology for directly applying in psychotherapy of whom have reported their own observations of the the research on endogenous memory reconsolidation. markers of erasure (see Ecker et al., 2012, pp. 157–200 for four such detailed accounts; also Sibson and Ticic, As shown in clinical case examples in Section 7, a 2014). Furthermore, as noted in Section 8 below, the therapy client’s experience of behavioral erasure is not methodology has potential for contributing a number a merely mechanistic elimination of symptoms. Era- of signifcant conceptual advances to the clinical feld, sure occurs through a counter-learning experience in apart from enhancing the efectiveness of individual which the individual decisively unlearns and thereby practitioners. profoundly resolves a specifc schema or mental model maintaining emotional distress. Such disconfrmation 6. From research fndings to clinical of what had seemed reality frequently occurs in quite methodology noticeable, identifable moments during the facilitation On the basis of the foregoing examination of re- of a counter-learning experience. Conventional no- search, the primary subject of this article can now be tions of the time needed for major therapeutic efects addressed: the translation of reconsolidation research to develop are challenged by this process of transfor- into clinical application. Te main purpose of this mational change through the ECPE. Tis is a funda- section is to ask and answer this question: What is the mentally diferent process of change from the Hebbian most general clinical methodology of behavioral updat- process of building up preferred, competing responses ing that is directly and entirely dictated and defned by through their extensive repetition over a prolonged reconsolidation research? Section 7 then illustrates and period to create and strengthen the alternative, com- examines the actual implementation of that proposed peting neural circuits. most general clinical methodology; Section 8 identifes If, as the current state of empirical knowledge sug- the potentially major ramifcations of this methodol- gests, the markers of erasure can appear endogenously ogy for several fundamental theoretical issues in the only as a result of the ECPE’s component experiences, psychotherapy feld; and Section 9 uses this methodol- then the occurrence of the three critical experienc- ogy as a frame of reference for analyzing several other es usually ought to be detectable in hindsight in any approaches for clinically recruiting reconsolidation. therapy sessions or clinical study in which the unambiguous markers of erasure were observed, regardless of whether the therapy or study was conducted with 6.1. Te empirically confrmed process of cognizance of memory reconsolidation or research behavioral erasure fndings. As previously noted, such ECPE detection Te extensive memory reconsolidation research was reported by Ecker and Hulley (1996) prior to the examined in Sections 3, 4 and 5 may be summarized discovery of memory reconsolidation, and recently in essence in this manner: Te behavioral erasure of a ECPE detection has been demonstrated in the same target emotional learning is an experience-driven pro- way for eight diferent systems of psychotherapy by cess, with the requisite experiences being reactivation, studying sessions that produced the markers of erasure mismatch, and counter-learning. Reactivation and (Ecker, 2015c; Ecker et al. 2012, pp. 126–155; Feinstein, mismatch experiences destabilize the target learning, 2015; Lasser and Greenwald, 2015; Ticic and Kushner, and then counter-learning experiences disconfrm and 2015; for a list of the individual therapy systems, see nullify the target learning and reconstitute its neural http://bit.ly/15Z00HQ).

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 24 6.2. Experiences versus the procedures that the subjective experiences required by the brain for induce them destabilization and erasure to occur, and, on the other hand, the concrete procedures used for inducing those Te ECPE was defned above as a sequence of experiences, is of fundamental importance in order three experiences without reference to any concrete for memory reconsolidation to be utilized clinically behavioral procedures for creating those constituent to its fullest potential. For efectively and responsibly experiences. Deliberate clinical implementation of the utilizing memory reconsolidation in an empirically ECPE of course requires use of concrete behavioral supported manner, clinicians must facilitate the re- procedures (ofen termed interventions in the standard quired sequence of experiences and then verify erasure parlance of psychotherapy). Tis matter of behav- by testing for and observing its markers. For doing ioral procedures is important not only with regard to so, however, clinicians need not, and in fact must not, equipping clinicians for efective implementation of limit themselves to concrete procedures used in labo- the ECPE, but also with regard to eventual designa- ratory studies, because those procedures were designed tion of an ECPE-centered clinical methodology as an to be efective only for the particular design of target Empirically Supported Treatment (EST) or Evidence learning created in the respective experimental study. Based Treatment (EBT), which requires a manualized In short, the ecological validity of most experimental procedure to be tested for efcacy and/or efectiveness protocols is too limited for general clinical application. in controlled studies. Nevertheless, there has been much reliance on A broad array of behavioral procedures for carrying laboratory protocols for attempting clinical translation, out the ECPE in therapy has been developed and is in most notably the post-retrieval extinction or reactiva- use by clinicians (Ecker and Hulley, 1996, 2017; Ecker tion–extinction protocol used by Monfls et al. (2009) et al., 2012). However, most relevant to the present with rats and by Schiller et al. (2010) with humans for article is a discussion not of those various concrete the frst demonstrations of endogenous erasure of a procedures, but of the relationship between the ECPE learned fear, as discussed in Section 5. Successful era- and any concrete procedures for carrying it out. sure of a symptom having very high clinical relevance Te concrete behavioral procedures used by recon- motivated numerous subsequent laboratory and clin- solidation researchers for inducing reactivation and ically oriented studies of this protocol and of variants mismatch are myriad. Te concrete procedures in based upon it (reviewed by Auber et al., 2013; Kredlow each study were necessarily tailored to (a) the type of et al., 2016; Lee et al., 2017). memory under consideration (as noted, many diferent Te original post-retrieval extinction protocol types of memory have been studied, only a subset of consists of a series of unreinforced presentations of a which is listed in Table 1) and (b) the detailed content conditioned stimulus with an increased time interval and structure of the target learning used in the study. of 10 minutes between the frst two CSs. With that Neurological destabilization of a target learning is structure, the procedure is suitable to induce reactiva- triggered by the brain registering subjective experienc- tion, mismatch and counter-learning only for a target es of reactivation and mismatch, not by the external learning having a special structure, namely a Pavlovian concrete arrangements and procedures used to induce target learning consisting of (a) a CS-cued expectation those experiences. Likewise, profound unlearning of a feared or desired event, plus (b) the expectation and erasure are the result of an experience of count- that CS-US pairings will repeat with the same timing er-learning, which may be arranged in any concrete as originally experienced in the acquisition training manner that is suitable for disconfrming the target (a time interval of signifcantly less than 10 minutes). learning, and is not restricted to any particular con- Most target learnings encountered in real-life clinical crete procedure or protocol. cases have a very diferent composition, such as the Tus, the empirically confrmed process of erasure fve clients’ emotional learnings noted in Section 2, and does not dictate any particular behavioral procedures as shown in the case vignettes in Section 7. Terefore for creating the required, subjective experiences of re- the original post-reactivation extinction protocol can- activation, mismatch and counter-learning that result not reasonably be expected to be efective in that large in erasure. Te distinction between, on the one hand, majority of clinical cases.

25 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) To some degree, variants of the original post-re- tion, mismatch and counter-learning experiences. It is trieval extinction protocol can have a wider range of always the specifc content and structure of the target clinical applicability by replacing the conventional learning that determines which experiences will, or extinction protocol with forms of counter-learning will not, register as reactivation, mismatch and count- that are more suitable for the target learning being ad- er-learning. Te clinical case examples later in Section dressed. Many such studies have been made, with both 7 illustrate this critical point. positive and negative results, as reviewed by Auber et In psychotherapy, each revealed, symptom-generat- al. (2013), Kredlow et al. (2016), and Lee et al. (2017). ing target learning is found to be a unique, idiosyncrat- (See Section 9.1 for further analysis of this approach to ic, multi-component formation that was shaped by the clinical translation.) Of relevance here is to note the unique life experiences of that individual; and, as noted procedure-minded use of the term “extinction” to label earlier, idiosyncrasy of underlying emotional learning counter-learning afer target learning destabilization. is the case even among therapy clients whose symp- To term post-destabilization counter-learning “extinc- toms are in the same formal diagnostic category, such tion” is a misnomer that creates misconceptions, in as panic disorder or dysthymic depression. Terefore, the author’s opinion, because it produces none of the efective ECPE implementation with each client neces- efects that have been identifed with the term “extinc- sarily requires clinicians to have a free hand in choos- tion” for a century. Even when post-destabilization ing concrete behavioral measures (interventions) that counter-learning has the identical procedural form as will adequately custom-tailor the critical sequence of in conventional extinction training, its learning func- experiences for the unique emotional learnings of each tion (namely, disconfrmation and unlearning) and client. Essentially the same conclusion was reached by its neurological efect (namely, re-encoding of target Elsey and Kindt (2017a, p. 113), who reviewed many learning) are qualitatively diferent from those of ex- factors that infuence whether a particular memory tinction. It is well established that reconsolidation and reactivation procedure will create a mismatch that extinction are distinct, mutually exclusive phenomena achieves destabilization, and in summary commented, (Duvarci and Nader, 2004; Duvarci et al., 2006; Merlo “Taking into account these diferent factors, it begins et al., 2014). Te operative principle here is this: A to look unlikely that any single reactivation procedure particular learning procedure (such as the repetitive will prove efective for all who undergo it, potentially non-reinforcement of conventional extinction) can undermining the use of very standardized reactivation have entirely diferent neurological and behavioral procedures that may be pursued in clinical trials.” efects depending on whether or not it is carried out during the reconsolidation window. It may seem paradoxical that clinicians’ adherence to the ECPE’s components of reactivation, mismatch In relation to the target learnings encountered in and counter-learning actually requires fuidity on psychotherapy, the possible designs of experiences of the concrete level of treatment, rather than some counter-learning are virtually unlimited (Ecker, 2016; pre-defned concrete protocol that was previous- Ecker and Hulley, 2017a; Ecker et al., 2012). Monfls et ly used successfully in laboratory studies or clinical al. (2009) and Schiller et al. (2010) have shown that, for trials. Clinical use of a fxed concrete intervention the specialized case of a Pavlovian target learning that protocol is contra-indicated not only by the totality has been destabilized, counter-learning in the form of of the memory reconsolidation research, as described the standard extinction training protocol can accom- above, but also by the thorough idiosyncrasy inherent plish erasure. However, that is a specialized format of in human emotional learning histories. To view any counter-learning for that case. particular behavioral procedure or protocol as neces- Tus it is apparent that the post-retrieval extinction sary or inherent for utilizing memory reconsolidation protocol is a highly specialized instance of the much in psychotherapy is a misconception that would limit more broadly defned ECPE. Te procedures used in the range of use and efectiveness to the particular type psychotherapy for implementing the ECPE with a giv- of emotional learnings for which the favored proto- en client must necessarily be designed according to the col happens to be suitable. Whereas, by allowing the structure and content of the target learning(s) revealed clinical use of the empirically confrmed process to by that client, in order to successfully induce reactiva- be open-ended and eclectic on the level of concrete

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 26 behavioral procedure, the range of applicability and memories manifesting the same diagnostic category of efectiveness encompasses the entire universe of symp- symptom. toms generated by implicit emotional learning. Terefore Ecker et al. (2012, 2013a,b) maintain Te necessary eclecticism regarding behavioral that a therapist, in order to carry out the ECPE with procedures runs counter to the conventional assump- reliable consistency across clients presenting diverse tion that adherence to a proven, well-defned concrete symptoms, must frst (A) elicit specifc descriptions treatment protocol is essential for establishing scientif- of the symptom(s) to be dispelled and then (B) elicit ic validity, and has important implications for how the fne-grained descriptions of the emotional learnings status of Empirically Supported Treatment (EST) or that necessitate and generate those symptom(s). Ten, Evidence Based Treatment (EBT) is to be achieved for guided by familiarity with the details of a particular ECPE-centered psychotherapy. Procedural eclecticism target emotional schema, the therapist can now (C) of course has implications also for clinical training in fnd how to guide a counter-learning experience that the endogenous use of memory reconsolidation, but will be used for mismatching and then disconfrming that topic is beyond the scope of this article. and nullifying that schema. As soon as the three preparation steps A, B and C 6.3. A proposed universal clinical methodology of are completed, the therapist is now equipped to facilitate the ECPE’s three experiences of reactivation, memory reconsolidation mismatch, and counter-learning. Lastly, afer complet- Having defned the empirically confrmed process of ing the ECPE, the therapist must obtain verifcation of erasure (ECPE), the quest for clinical translation takes erasure in the form of observations of the markers of the form of the pragmatic question: How can psycho- erasure delineated in Section 3. therapists best facilitate the ECPE for nullifying symp- Table 3 lists that seven-step clinical process defned tom-generating emotional learnings? Te requisite by Ecker et al. (2012, 2013a). Tose authors designate experiences identifed by extensive research are clear, this methodology as the therapeutic reconsolidation as summarized in Section 6.1, namely experiences of process, or TRP, and they propose it as being a univer- target learning reactivation, mismatch and disconfr- sal map of therapeutic process for utilizing memory mation by counter-learning. What has to happen in reconsolidation to produce transformational change. therapy sessions for those experiences to occur? What Te universality of this methodology is posited on the general methodology of psychotherapy is implied or basis of its applicability for all unwanted behaviors, even necessitated? states of mind, and somatic disturbances maintained A general clinical methodology for ECPE facilita- by implicit knowledge acquired through emotional tion, proposed by Ecker et al. (2012, 2013a, 2013b), learning, as well as its open access to all clinicians is based on one of the fundamental fndings of re- without favoring or requiring any particular clinical consolidation research, the necessity of tailoring the methods or theoretical orientation. requisite ECPE experiences to the specifc composition Te TRP is a methodology of experiences, not be- of the target learning or schema. Whereas laborato- havioral procedures, a distinction discussed in Section ry researchers have detailed knowledge of the target 6.2. Clinicians are free to fulfll the steps of the TRP learning because they create the target learning in the using the concrete methods and techniques in which frst place, in contrast a psychotherapist is completely they have training and which they deem most suitable unaware of the emotional learnings maintaining a new for a particular client. Ecker et al. view the TRP as client’s presenting symptoms. Even the symptoms being a meta-methodology that is determined en- (unwanted behaviors, states of mind, and/or somatic tirely by the brain’s innate functioning, which, if true, disturbances) are unknown to the therapist at the start. would have two implications: All other methodologies Furthermore, even when symptoms have been well designed to utilize memory reconsolidation in thera- identifed, their underlying emotional learnings are not py would prove to utilize a subset of the instructions thereby inferable because, as noted in Section 2, the provided by the TRP (see Section 9 for an examination emotional learning history of each person is unique, of several other such methodologies in relation to the and diferent individuals have diferent schemas or ECPE and TRP); and if some systems of psychotherapy

27 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) were to prove less suitable for implementing the TRP ings that many experienced therapists are unfamiliar than others, that would not be due to any bias in how and unskilled with obtaining a well-defned symptom the TRP was conceived or structured. picture efciently at the outset of therapy. TRP Step B, retrieval of target learning, is an ex- Table 3. Te Terapeutic Reconsolidation Process, pro- periential process of eliciting into explicit awareness posed as a universal template derived from reconsoli- the emotional learning and memory maintaining a dation research for utilizing memory reconsolidation symptom, guiding the client to verbalize the emer- in clinical practice. gent material while feeling it, and then integrating the newly conscious knowings and feelings into routine Therapeutic Reconsolidation Process daily awareness as a personal emotional truth (such as Preparation A. Symptom identifcation the sample emotional learnings provided in Section 2). phase B. Retrieval of target schema Te subjective, afective quality of this retrieval is critically important, as has been shown in both clinical and C. Identifcation of disconfrming knowledge laboratory studies (e.g., Greenberg, 2012; Yacoby et al., Erasure 1. Reactivation of target schema 2015). Te retrieved, symptom-generating material sequence may consist of episodic memory (specifc experiences, (ECPE) 2. Destabilization of target schema: Activation of contrary knowledge mismatches target including afective and somatic elements and con- schema (frst juxtaposition) strued meanings), semantic memory (schema-structured, generalized knowings regarding certain types 3. Nullifcation of target schema: Several repe- of situation, meanings, self’s vulnerability to a specifc titions of juxta-position for counter-learning form of sufering, the expected behavior of others/ during remainder of session self/world, self-protective tactics necessitated, etc.), or Verifcation V. Verifcation of target schema erasure: both. As described in Section 2, symptom-generating phase • Symptom cessation schemas are multi-component, layered formations with a recognizable structure that enables the therapist • Non-reactivation of target schema to know when retrieval of a schema is complete. One of the components, vivid personal knowledge of a spe- • Effortless permanence cifc sufering that is urgent to avoid, corresponds to the US (unconditioned stimulus) in laboratory studies, and, as suggested by research noted at the end of Sec- Te remainder of this section provides a degree of tion 4 above, retrieval and reactivation of this compo- expanded description of the seven steps, all of which nent (which is mandatory in TRP Step B) may allow are demonstrated in two case examples of TRP facilita- efcient erasure of all of its linkages to associated cues tion in Sections 7.1 and 7.2 below. (For more extensive and contexts (CSs). Typically, one or two of a schema’s and intensive accounts, including an array of specifc component constructs are the most efective targets for therapeutic techniques useful for each step, see Ecker disconfrmation (Ecker and Hulley, 2017a; Ecker et al., and Hulley, 2017a; Ecker et al., 2012; Ecker, 2015c.) 2012, pp. 68–70). Retrieval of a symptom-generating TRP Step A, symptom identifcation, consists of emotional schema may entail the client feeling signif- actively engaging the client in recognizing and label- icant vulnerability and dysphoric emotion, and there- ing the specifc behaviors, somatics, emotions, and/or fore requires much skill on the part of the therapist, thoughts that the client wants to eliminate, as well as who must pace the process workably for the client’s identifying when these unwanted experiences happen, tolerances and provide empathic accompaniment nec- that is, the situations and perceptions that evoke or essary for the client’s sense of safety and trust. While intensify them. Tis information is essential for car- an advanced practitioner can ofen complete retrieval rying out Step B efectively. In many cases, symptom of a schema in one or two sessions, more generally a identifcation can be fully accomplished within the frst few sessions are needed, and the number of sessions session, but it can require several sessions with some increases commensurate with the complexity and emo- clients. As basic as this step may seem, the author has tional intensity of the material. Material revealed in found in over two decades of conducting clinical train- Step B is the target of change; symptoms identifed in

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 28 Step A are not themselves direct targets of change, but is a mismatch or prediction error experience, which is cease when their underlying emotional learnings and needed for destabilizing the neural ensemble encoding memories are unlearned and nullifed. Close familiar- the target learning, as reviewed in Section 4. In thera- ity with the learnings and memories revealed in Step py, using the counter-learning experience designed for B is essential in order for the therapist to be able to the next step, Step 3, to frst create the mismatch here embark upon TRP Step C, identifcation of disconfrm- in Step 2 is simply efcient; there is no need for what ing knowledge. would be the extra step of creating some other type of TRP Step C, identifcation of disconfrming knowl- experience for the mismatch. Contradiction goes by edge, consists of fnding past or present experience(s) the name of non-reinforcement in laboratory studies in which the client has direct, living knowledge that that use a Pavlovian target learning. (In some clinical is fundamentally contrary to the target learnings and cases, the reactivated target schema or memory is mis- memories retrieved in Step B, such that both cannot be matched and destabilized presumably by the presence true. Specifcity of disconfrmation is critically import- of the therapist, the therapist’s ofce and the safety ant for consistently achieving successful nullifcation of of the environment. Tat is most likely in the subset the underlying target material with client afer client. of cases where the target material allows the client’s Te needed contrary knowing can either be found in experience of the therapist to be the contrary knowl- the client’s already-existing knowledge from past ex- edge used as counter-learning. In many other cases, periences or it can be created by a new experience that the therapist and therapy session environment are not occurs during or between therapy sessions. Each of directly relevant to the target schema (discussed at those main sources has several subtypes, and all can be length by Ecker et al., 2012, pp. 93–100) and are merely accessed through a wide variety of techniques (Ecker, novelties in relation to it. Novelty too can serve to cre- 2016; Ecker and Hulley, 2017a). Step C consists only of ate mismatch, as noted in Section 4, if the novel item fnding where and how such disconfrming knowledge also has subjective relevance to the target schema and can be readily accessed for carrying out TRP Steps 2 therefore requires an update of the schema; novelty and 3, described below. without relevance requires no updating and therefore does not register as a mismatch. For that reason, Step TRP Step 1, reactivation of target learning, is read- 2 requires something more reliable than the therapeu- ily accomplished using basic experiential methods tic setting to serve as the mismatch. Activation of the of guiding the client’s attention to key features of the contrary, disconfrming knowledge identifed in Step target schema or memory and inviting the client to C is always a defnite and reliable mismatch because allow and attend to the afective and somatic aspects of contradiction always has strong relevance to the target what arises. Te client feels empathically accompanied learning and always requires updating.) by the therapist while opening to and entering into the altered state inside the schema or memory. Reactiva- TRP Step 3, counter-learning by repetitions of the tion is adequate when the client’s consciousness, while disconfrming juxtaposition, consists of guiding the maintaining relational connection and communica- client a few more times to attend to and afectively feel tion with the therapist, is signifcantly sampling and both experiences, the target material and the contrary inhabiting the subjective, afective reality and self-state knowledge. Tis accomplishes the disconfrmation, generated by the target material, with particular, mind- unlearning and nullifcation of the target schema or ful recognition of that material’s specifc feature that is memory. (In some cases, complications arise, requir- going to be mismatched and disconfrmed in the next ing extra steps, as discussed below.) In that juxtapo- step. sition of two mutually contradictory knowings, it is the target learning that is disconfrmed and unlearned TRP Step 2, activation of disconfrming knowledge, because the target learning consists of a less complete, mismatching target learning, consists of guiding an less inclusive model of reality (having been formed at a initial experience of the contradictory knowledge young age and/or while in distress under extreme, spe- that was found in Step C, while the target schema or cial circumstances), and its falseness or too-incomplete memory remains reactivated from Step 1. Tis frst account of reality becomes vividly apparent and viscer- instance of the client experiencing a juxtaposition of ally felt in being juxtaposed with a more complete and the target material and the contradictory knowledge inclusive model of reality. A reactivated target schema

29 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) consists of certain defnite knowings and expectations ic content of the target schema or memory, which had of how the world is, yet now there is a concurrent always felt compellingly real and intensely dysphoric, experience with direct perception that that is defnitely now feels “absurd” or “ridiculous” to believe. However, not how the world is. Tis subjectively felt juxtaposi- verifcation is made conclusive only by the persistence tion experience, consisting of the two mutually contra- of the markers over many months and in all real-life dictory knowings, is regarded as fulflling the brain’s situations that formerly triggered symptom produc- requirements for behavioral erasure as identifed in tion. Te therapy work addressing a given symptom reconsolidation research, and therefore as being the and its underlying emotional learning(s) can be re- critical experience required for schema nullifcation garded as complete only when the markers of erasure and transformational change in psychotherapy (Ecker, are frmly established. 2006, 2008, 2010, 2015/2006; Ecker and Hulley, 1996, Te TRP, consisting of the seven steps A–B–C–1– 2000b, 2002, 2008; Ecker and Toomey, 2008; Ecker et 2–3–V described above, is fairly simple in its concep- al., 2012, 2013a, 2013b). Initially both sides of the jux- tual essence, but it is complex and subtle in its overall taposition experience feel real and true to the therapy clinical implementation across therapy clients who client, yet they cannot both be true. Te both-at-once difer widely in personality, tolerance for emotional experience inherently entails a peculiar tension or experience, extent and depth of suppressed emotion- edginess, similar to the experience of cognitive disso- al distress, readiness to trust the therapist, and other nance (Festinger, 1957), but here it is fully experiential variables. Te clinical methodology now known as and visceral rather than only conceptual. With count- the TRP has been in use by the author and colleagues er-learning via a juxtaposition experience repeated a plus numerous clinicians worldwide for 25 years few times during the remainder of the therapy session, (because, as noted in Section 3, the methodology was the compelling realness and urgency of the target developed based on clinical observations prior to the learning’s version of reality immediately wither and laboratory discovery of memory reconsolidation). We lose all feeling of realness or urgency, and cease driving have gained much understanding of how to attune the symptom production. Tat is demonstrated in the case process to the unique individual therapy client (Ecker examples in Sections 7.1 and 7.2. Carrying out the et al., 2012) and have observed the markers of erasure ECPE in psychotherapy amounts to guiding a juxtapo- ending a wide range of clinical symptoms, as summa- sition experience a few times. Te entire TRP exists to rized in Table 4. Such broad versatility of application bring about that set of juxtaposition experiences. signifcantly extends the clinical translation eforts TRP Step V, verifcation of erasure of target memory previously covered in review articles. Nearly all of material, consists of observing and documenting the those eforts have addressed only two symptoms: the markers of erasure discussed in Section 3, namely un- intense, fearful aversion that is a chief characteristic of ambiguous reports from the client that (a) the client’s post-traumatic symptoms, and the intense craving that initially identifed symptomatic behavior and/or state is a chief characteristic of addiction. In both cases, of mind and/or somatic disturbance has ceased to several successful clinical or pre-clinical utilizations occur in all situations where it had been occurring, (b) of reconsolidation have been reported; for reviews see the afective self-state or compelling emotional “spell” Dunbar and Taylor (2017), Lee et al. (2017), Schwabe created by the reactivated target schema no long oc- et al. (2014), and Treanor et al. (2017). It is well estab- curs in response to any cues or contexts that previously lished, however, that all of the many types of memory evoked it, and (c) changes (a) and (b) persist under all that have been tested undergo reconsolidation, as not- circumstances, without relapse and without any efort ed in Section 3. Te TRP is proposed as a framework or measures taken to maintain them. In most cases, that positions clinicians for addressing the entire range marker (b) becomes apparent in the same session of memory-based symptomology. Section 7.1 below following facilitation of the ECPE, in the form of the demonstrates TRP implementation for a symptom of client giving clear verbal and nonverbal messages that lifelong reactive anger. Section 7.2 does likewise for an the reactivated self-state of the target memory mate- adult’s symptoms of formless terror accompanied by rial has disappeared and that it is not re-evoked when severe kinesthetic disturbances, which were found to the therapist reapplies imaginal cues that had potently be based in childhood attachment trauma. evoked it previously. Some clients state that the specif-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 30 Table 4. Clinical symptoms observed to be dispelled remains in force (continues to feel compellingly real by the therapeutic reconsolidation process as carried and potent) despite well-crafed juxtaposition expe- out in Coherence Terapy* riences being guided. Tat persistence of the schema is the therapist’s indicator that there is some blocking Symptoms Dispelled contingency that now must be sensitively brought into Aggressive behavior Food/eating/weight problems awareness, recognized and addressed. When the client Agoraphobia Grief and bereavement prob- arrives at feeling that the (now consciously) anticipated Alcohol abuse lems difculty is workable, the therapist repeats the juxtapo- Anger and rage Guilt sition experiences of Step 3, and schema nullifcation Anxiety Hallucinations now is allowed to occur. Attachment-pattern-based Indecision behaviors Low self-worth, self-devaluing A related phenomenon is the persistence of emo- and distress Panic attacks tional learnings despite numerous personal experienc- Attention defcit problems Perfectionism es in which the schema’s expectations clearly do not Codependency Post-traumatic symptoms occur. A schema can remain immune to disconfr- Complex trauma symptomol- Procrastination / Inaction mation by such experiences in a number of diferent ogy Psychogenic / psychosomatic ways (for discussion of which, see Clarke, 1999; Ecker, Compulsive behaviors of many pain 2015a, p. 13; Ecker and Toomey, 2008, pp. 115–116; kinds PTSD symptoms Fernández et al., 2017; Proulx et al., 2012), some of Couples’ problems of confict Sexual problems which can also block the disconfrmation efect sought / communication / close- Shame in TRP Steps 2 and 3. As noted in the previous para- ness Underachieving graph, the TRP equips clinicians to reveal and work Depression Voice / speaking / singing directly with a given therapy client’s particular dynam- Family and child problems problems ics maintaining such immunity to disconfrmation. Fidgeting Te TRP’s preparation Steps A–B–C make it pos- *An online bibliography of published case examples sible for clinicians to carry out the erasure sequence, indexed by symptom is available at http://bit.ly/2tKXdyX Steps 1–2–3, systematically, consistently and efectively in day-to-day practice. In other words, Steps A–B–C are pragmatically necessary in order to implement Brief comments follow on a few aspects of TRP Steps 1–2–3 as a deliberate methodology. However, implementation particularly relevant to the current because Steps 1–2–3 are defned in terms of expe- article. Facilitating the TRP can be complicated by riences to be created, not procedures, they can also what therapists typically term client resistance, mean- occur serendipitously and implicitly, unbeknownst to ing that the client does not comply with or allow the the therapist, without Steps A–B–C being carried out. process that the therapist is attempting to facilitate. Tat is not only possible, but also common. Probably Resistance is self-protective, is done without conscious a majority of clinicians at least occasionally observe awareness in many instances, and can develop at any a transformational change (the markers of erasure step of the TRP. Resistance occurring in TRP Step defned in Section 3) resulting from methods that may 3, counter-learning by repetitions of the disconfrm- have little or no obvious similarity to the TRP and ing juxtaposition, is notable as being unique to this without conceptualizing therapy in terms of memory methodology. Clinical experience has shown that a reconsolidation. As discussed in Section 3, the mark- target schema will not be disconfrmed and nullifed ers of erasure imply the occurrence of the experiences by the juxtaposition experiences in Step 3 if the client that Steps 1–2–3 (the ECPE) are designed to create. (non-consciously) anticipates consequences of nulli- Te likelihood of facilitating those critical experiences fcation that feel too distressing or costly in any way. without awareness of the TRP or knowledge of memo- (For a detailed case of this efect, see Ecker et al., 2012, ry reconsolidation presumably varies from one system pp. 77–86.) Te brain’s implicit predictive capability of psychotherapy to another (even assuming perfect proves to be remarkably astute regarding unacceptable adherence to and implementation of each system’s adjustments entailed by a particular schema losing re- methodology). Also presumably, having knowledge of alness and being decommissioned. Te schema simply

31 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) and training in the TRP should signifcantly increase et al., 2011; Kindt and van Emmerik, 2016; Poundja et any clinician’s likelihood and frequency of facilitating al., 2012). Each of the accounts below is a fne-grained those critical experiences and producing transforma- phenomenological record, not merely a narrative gloss tional change in daily clinical practice. of what happened. It is proposed that each account In addition to enhancing an individual clinician’s provides unambiguous demonstration of the ECPE’s efectiveness, the TRP also potentially has signifcant sequence of distinctive experiences occurring within methodological and theoretical ramifcations for the the overall methodology of the therapeutic reconsol- clinical feld, some of which are discussed in Section 8 idation process (TRP), followed promptly by obser- (and in the literature cited above in the paragraph on vation of the markers of erasure, including complete, TRP Step 3.) long-term disappearance of the presenting symptoms. As discussed in Section 3, a clinical outcome consisting of the markers of erasure is signifcant support for 7. Clinical observations of the therapeutic the hypothesis that erasure via reconsolidation has occurred. Such demonstrations are of value for devel- reconsolidation process oping clinical translation. Empirical knowledge of the Te previous section drew upon reconsolidation re- sequence of experiences required for erasure allows the search fndings to assemble a maximally general clini- very moments of transformational change in therapy cal methodology of behavioral updating that is directly to be plainly apparent and makes the operative ingre- and entirely dictated and defned by the research, yet is dients in those moments plainly apparent (Ecker et al., not restricted to any particular laboratory procedures. 2012), even amidst the complexities of the client-thera- Te methodology that emerges from the research in pist interaction. that manner is mapped out in Table 3. Its core is the Te case examples are followed in Section 7.3 by empirically confrmed process of erasure (ECPE), a a consideration of whether the observed transforma- sequence of three experiences, the consistent facili- tional changes can be ascribed plausibly to memory tation of which requires the preceding three steps of reconsolidation. Section 7.4 concludes this section preparation, in which relevant material is accessed and by addressing reconsolidation researchers’ anticipat- made ready. Following the steps of the ECPE, verifca- ed obstacles to clinical application in light of actual, tion consists of observations of the markers of erasure extensive clinical observations. discussed in Section 3. Te entire methodology, designated the therapeutic reconsolidation process or TRP, Te case examples in Sections 7.1 and 7.2 are sub- is applicable to any symptom generated by emotional mitted here as a demonstration that the ideal therapeu- learning and memory and has been used by clinicians tic goal of a methodology that completely eliminates to eliminate the symptoms listed in Table 4. unwanted emotional responses, as put forth in Section 1, has become a clinical reality through facilitation of Te TRP is a clinician’s map of process. Because the process identifed in reconsolidation research. Te it is a methodology of experiences, not behavioral aim of the author (and colleagues) has been to conduct procedures, the clinician has to choose the behavioral and document clinical cases with sufcient phenom- procedures to use for fulflling the steps of process for enological detail and specifcity to allow meaningful a particular symptom of a particular therapy client. evaluation of the claim that reconsolidation and era- Tis section begins by providing two demonstra- sure have been demonstrated. To that end, the em- tions of TRP implementation. Tese are uncontrolled phasis in such clinical accounts is on (a) showing the clinical case descriptions involving intense, life-long unambiguous implementation of the required experi- symptoms of reactive anger in Section 7.1 and terror ences of reactivation, mismatch and counter-learning, accompanied by severe somatic disturbances in Sec- (b) showing that even with the presence of all nonspe- tion 7.2. Certainly these clinical accounts could be cifc factors widely known to be important for efective considered merely anecdotal. However, several ac- psychotherapy (e.g., Duncan et al., 2009; Wampold, counts of uncontrolled clinical cases have been pub- 2001, 2015), it is not until the specifc experiences lished in support of the clinical translation of recon- required for destabilization and erasure occur that a solidation research (e.g., Brunet et al., 2011; Högberg transformational shif occurs, and (c) the transforma-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 32 tional shif consists of the markers of erasure being 7.1. Clinical case example: erasure of chronic anger manifested decisively by the client, including total Te client is a woman in her early 50s, pseudonym elimination of emotional responses and associated be- Norina. Te therapist is the author. Afer about 15 haviors for which the client sought therapy. Tat is the sessions focused largely on various difcult patterns in outcome defned by Clem and Schiller (2016, p. 340) in her marital relationship, Norina identifed a feeling of order for therapy “to achieve greatest efcacy.” angry resentment that had frequently gripped her and Numerous case studies that fulfll those criteria have ruled her state of mind and behavior for hours, days been published; a listing of them is available online at or weeks, for as long as she could remember, since her http://bit.ly/2tKXdyX. Te system of psychotherapy childhood. Her simmering, angry mood had activated used in those case studies is Coherence Terapy (Ecker ofen toward her husband of 28 years and was a major and Hulley, 2017a), which has a methodology that factor in the chronic tension between them. explicitly consists of the TRP. Te two case studies that Te therapist carried out the therapeutic reconsol- follow were chosen for presentation here on the basis idation process (TRP; see Table 3) to fnd and erase of the succinct instructional clarity they allow. Other the emotional learning driving that anger, resulting in than that, the results they present are not exceptional Norina reporting long-term cessation of this emotional relative to the numerous other published case studies. reaction. Te process unfolded as described below. Te following two clinical case vignettes are also Tis case is intended to demonstrate the applicability intended to demonstrate several specifc aspects of of the TRP to emotional learnings of any type (not applying the empirically confrmed process of erasure only those maintaining fear or addiction, the two types in therapy: of symptom that nearly all clinically oriented reconsol- • Use of methods developed for revealing the idation researchers have addressed to date, as reviewed emotional schema maintaining a given symp- by Dunbar and Taylor, 2017, Schwabe et al., 2014, and tom, defning the target learning Treanor et al., 2017) and the uniqueness and specifcity of the emotional learnings in each clinical case, requir- • Use of the revealed target learning’s specifc con- ing TRP Step B, retrieval, to be carried out diligently tents to guide the design of reactivation, mis- and thoroughly. match and counter-learning experiences TRP Step A, symptom identifcation, was straight- • Markers of erasure verifying complete, long- forward. Her reaction of anger and resentment was term disappearance of targeted emotional easy for her to name. However, that reaction had responses happened in so many diferent situations across the • Erasure of emotional learnings other than fear decades that she could not defne the key features of learnings and appetitive (addiction) respons- situations that triggered it. es, which reconsolidation researchers have so In pursuing TRP Step B, the retrieval into explicit consistently specifed as the potential target awareness of an implicit schema generating the client’s for application of their fndings that clinicians anger, the therapist’s task was to elicit the emotional might be led to assume that only such learnings learning that was driving this angry resentment in so can be updated and erased via reconsolidation many diferent situations for a lifetime. In order to be- • Clients’ accounts of the subjective experience of gin guiding her attention and awareness into that area emotional memory erasure. Tis information is of implicit learning, the therapist said to her, “Just see of interest to researchers because, as Elsey and what comes to mind when I ask you this question: In Kindt (2017a, p. 113) have noted, “remarkably your whole life, what is it that you resent the most?” little research has considered what the subjec- She answered that it was something she was already tive experience of these changes is.” well aware of: her childhood ordeals of being sexually • Favorable observations regarding researchers’ molested by her grandfather on a number of occasions, anticipations of obstacles to applying experi- starting at 6 years of age. She explained that she had mental fndings clinically already had extensive therapy for that, long ago. Hearing that, the therapist thought: It’s natural that

33 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) a person would feel angry resentment about sufering She had voiced the words with an indignant into- such an ordeal of violation and betrayal. And yet, not nation and a facial expression of consternation, which every person who has sufered sexual molestation in gave two important indications to the therapist: First, childhood has a dominant mood of angry resentment she was afectively experiencing this schema in the for the next fve decades, as Norina had. Tat indicates moment, not merely intellectualizing about it, which something unique and specifc in her emotional learn- is the needed quality of accessing here in TRP Step ings that has been generating such anger. How to elicit B. For schemas to become consistently available for that specifc material? disconfrmation and erasure, therapists must guide Te therapist next asked gently, “What is it that you clients to inhabit the material subjectively and artic- sufered in that ordeal that you resent more than any- ulate it from inside the felt realness of it. Second, the thing else about it?” Tat question guided her atten- schema felt as true as ever to her, even though it was tion into her implicit knowledge to a new degree. Her now in her explicit awareness. Tis continuing poten- previous therapy had not led her to examine with this cy of the retrieved schema is found to be the norm in specifcity what she had sufered. As Norina looked carrying out Step B. Although in full awareness, the into that, her eyes were blinking, and then she said schema remains in full force and continues to gener- with a note of surprise, “Hmm, it doesn’t feel like it’s ate symptoms despite the high-quality presence of the my grandfather that I resent the most.” She pondered nonspecifc common factors (as discussed in Section a bit more and then said, “It feels like, even more than 8.3). Nullifcation of the felt realness of an emotional resenting my grandfather, I resent the whole world, or schema is observed to occur not by bringing it into life itself.” awareness, but by subjecting it to disconfrmation and unlearning in TRP Steps 1–2–3, the ECPE, which was Te therapist now asked, “What can you see about yet to come. why you resent the whole world or life itself?” in order to continue the fow from implicit knowing into explic- Te target schema’s full verbal representation can it knowing. be formulated as, “Te world allowed that horrible ordeal to happen only to me, and to no one else, and Norina examined this in silence for several seconds, that means the world has been unforgivably unfair and and then said, “It’s that the world is just too unfair, to cruel to me. I protest by feeling furious resentment at make this happen to me, and to no one else.” the world for being so arbitrarily cruel and unfair to Tat was the emergence of the emotional learn- me, and every time I see or feel any more of that arbi- ing that was producing her anger. Tat construal of trariness or unfairness, I protest again with my angry meaning, formed as a young girl, had never before resentment.” entered her conscious thinking as an adult. It had TRP Step B was now accomplished, but before remained a felt knowing in the implicit background, describing how the therapist undertook Step C, there though it launched anger that came into the explicit are two noteworthy points illustrated by the revealed foreground of awareness. Te therapist immediately schema. Knowing the detailed content of this target understood that that single, unique, implicit construct schema makes it apparent that: and attribution of meaning, that it had happened only to her, led her in turn to view the world as monstrously • Te schema could not possibly be disconfrmed and unforgivably cruel and unfair, so she was indeed by the client’s experience of the therapist. Te profoundly and unceasingly angry and resentful at life. therapeutic strategy of using the client-therapist Afer age 6, whenever Norina perceived anything else relationship for a corrective emotional expe- in life as being an unfair and arbitrary treatment, it re- rience could not be efective for this schema, triggered that same smoldering anger and resentment, because the client’s positive experience of the but without awareness of the source of that anger. therapist is irrelevant to the specifc content of Arbitrary, unfair things, small and large, happen fairly the schema. TRP Step B has the built-in value ofen in day-to-day life, and in a marriage, so she was of revealing whether or not this widely pursued ofen swept up into that resentful anger throughout her clinical strategy is appropriate. life. • Te symptom of reactive anger was arising from semantic memory, not from episodic memory.

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 34 Te sexual molestations by her grandfather were tory knowledge, but it has not disconfrmed the target traumatic, obviously. Tey were both acute in- schema because the two knowings are held in diferent cident trauma and complex attachment trauma. memory systems that have little if any direct commu- TRP Step B had revealed that Norina’s anger nication between them. Te target schema has existed was a post-traumatic symptom. Yet the aspect (prior to Step B) only in the implicit and procedural of the trauma that had remained highly reactive knowledge networks of the subcortical brain, and the in memory and generated life-long, life-shaping contradictory knowledge typically exists in the declar- symptoms was neither the physical perceptions, ative and social knowledge networks of the cortical nor the somatic sensations, nor the emotional and neocortical brain. Voicing the schema out loud experience with its various intense aspects of can create a mismatch with any existing contradictory violation, helplessness, fear, entrapment, and knowledge, activating the latter and drawing it into betrayal. It was the client’s semantic constru- focal awareness. In the present case, a disconfrmation al of the meaning of the ordeals that was the and nullifcation of “It happened only to me” would symptom-generating memory. Post-traumatic eliminate the very basis of both viewing the world as symptoms are most ofen conceptualized by cruelly unfair and the angry resentment in protest of clinicians as arising from episodic memory, but that unfairness. TRP Step B most ofen reveals semantic memo- Te therapist, fguring it was likely that Norina’s ry at the root of symptom production, and that conscious, adult understandings included the certain phenomenological observation is confrmed knowledge that it most defnitely did not happen only when nullifcation of the semantic structure (the to her, decided to use the mismatch detection method retrieved schema) is followed immediately by to access the needed contradictory knowledge. Tat permanent cessation of the symptom. (See Sec- decision completed TRP Step C. tion 2 for discussion of the full constellation of interlinked semantic memory, episodic memory In going forward next to actually carry out that mis- and afective/somatic activation.) match detection process, the therapist was embarking upon TRP Steps 1–2–3. He said simply, “Please say it to me again: ‘It happened only to me.’” Detailed familiarity with the contents of the target Norina said out loud, “It happened only to me.” schema from Step B thoroughly guides TRP Step C, Norina had already been experiencing the afective which is fnding a decisive, experiential, highly specifc realness of those words, and now they again simply disconfrmation of that schema. Step C requires the felt true to her. Tis fulflled the experience defned by therapist fnd how to guide the client into experiencing TRP Step 1, reactivation of the target learning; but the personal knowledge that feels undeniably true and that reactivated material was not yet circulating into other sharply contradicts what the client knows in the target memory systems containing contradictory knowledge. schema. Tis contradictory knowledge is to be found Mismatch detection ofen requires two or three cue- either in the client’s existing knowledge from past ings, so the therapist asked her to please say it again. experiences or in new experiences to be created in the present. When Norina said it this time, immediately her facial expression changed into a look of puzzlement, Numerous methods for carrying out Step C are which is a familiar marker of the frst conscious sen- mapped out by Coherence Terapy, as noted in Sec- sation of mismatch, just prior to having cognitive tion 6.3. A particular one of them is best for begin- clarity. Te target knowledge had begun to register in ning Step C, as a rule, because it is the most likely her present-day, declarative knowledge networks. Te to succeed. Tat method consists of submitting the therapist now invited her to say yet another repetition discovered schema to the brain’s always-active mis- of “It happened only to me.” match detection system, by simply having the client declaratively voice the schema out loud (Ecker et al., Afer saying it this time, Norina’s eyes began darting 2012; Ecker and Hulley, 2017a). Tis method takes around as cognitive clarity formed. Tis is the mo- advantage of the fact that in at least half of all cases, ment of the juxtaposition experience defned by TRP the client is found to already possess vivid contradic- Step 2, in which both the target knowledge and the

35 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) contradictory knowledge are present concurrently. Te ship. Eight months later, she and her husband had a client’s subjective feeling is as if to say, “Wait a minute. particularly stressful month of not feeling emotionally Hold everything. What I was taking to be reality isn’t.” in sync with each other during struggles with the ex- On Norina’s face now was a look of amazed sur- tended family. Norina said, “It was rough, but I haven’t prise, and what she said afer a few seconds made it felt any resentment toward him.” clear that Step 2 had occurred. She sofly said, “Oh my Te therapist took this opportunity to elicit more God, I really thought it happened just to me. But it follow-up for TRP Step V and asked her, “Can I check happens everywhere. It’s a part of life everywhere. It’s with you about the work we did on that core belief, ‘It an ugly part of life, but it keeps happening to girls and happened only to me’? I’m wondering whether or not boys too all the time, everywhere. I wasn’t singled out.” the shif that you initially described has held.” Use of the brain’s mismatch detector had worked She replied (and again these are her exact words), and the mismatch had occurred, experienced as a “My resentment had been relentless. Even with all strong disconfrmation of the target schema. Te these troubles, that anger is not taking over…. Most of neural encoding of the target learning was now rapidly the time I’m in a wonderful, energized, peaceful state. destabilizing, according to reconsolidation research. Tat’s the way I would describe it…even with all these It was natural for client and therapist to remain fo- troubles.” cused on what had just happened. Norina kept giv- Tus the markers of erasure and transformational ing amazed attention to this fresh realization, which change appeared to be well established: Te unwanted repeated the juxtaposition each time, carrying out TRP emotional reaction and the behaviors it had produced Step 3, the counter-learning that nullifes the target had disappeared, and were no longer evoked by situa- learning and re-encodes it accordingly. In addition, tions that formerly evoked them strongly, and this shif with empathy the therapist explicitly reviewed both her was persisting long-term and efortlessly. old belief and her new realization, in order to repeat the juxtaposition experience a couple of times more by Norina explained that when the molestation ordeal empathically reviewing it. began as a little girl, she regarded it as something that was happening only to her, and not to anyone else in If the process was successful, in those few minutes the world, simply because such a thing seemed not to Norina’s childhood learning that she had been cruelly exist anywhere else. She had never heard of it, and no and unfairly singled out by life had been unlearned, one ever spoke of it. Yet it was happening to her, and dissolved and erased. Erasure means that “It happened its existence overshadowed her entire world. How she only to me” would no longer feel real or true in any construed it, in all innocence, would have dominant part of herself, or in any memory network. Without efects on her life for almost ffy years. that construct that life had singled her out for such sufering, there would be no view of life as being hid- Te internal process of change in this case consisted eously unfair to her and, in turn, no more generating of retrieving into awareness and then re-evaluating the of angry resentment over that. Te dissolution would meaning attributed to a childhood ordeal. Tat pro- ripple through that whole linkage. cess could be conceptualized as a cognitive reappraisal (e.g., Ochsner and Gross, 2005; Ray et al., 2008), but In the next therapy session one month later, the certain distinctions are essential to make if miscon- therapist began by asking whether she had noticed any ceptions are to be avoided. Such reappraisal occurs in subsequent efects of the previous session’s work. Tis ECPE/TRP methodology (as noted in defning TRP was now in pursuit of TRP Step V, verifcation of the Steps 2 and 3 in Section 6.3) in a juxtaposition of the markers of erasure. In response, Norina’s exact words original and new meanings that is fully experiential, as were, “I’ve been angry and resentful my whole life. It’s is apparent in the above case vignette, not a merely in- like something has just turned to dust. It’s not alive tellectual, cognitive consideration of the two meanings. any more. Before, something felt like cords and cables Te new meaning must register in the client’s emotional strangling me. I feel so freed up.” learning system as being unmistakably real and true, Over the next couple of months she described a new because that is the memory network containing the ease, friendliness and warmth in the marital relation- target meaning, and that requires the new meaning to

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 36 be subjectively felt by the client as defnitie personal symptom identifed by a female client, age 66, in her knowledge, not merely a dry fact that is recognized fourth session. She had no awareness of the cause or intellectually to be true. Terefore the therapist’s task content of her terror and could only label the feeling. is to guide the client into having her or his own living Accompanying the session transcripts below are sup- experience of the new meaning (and, more generally, plemental online session videos in which the subjec- of the contradictory knowledge found in TRP Step C). tive, experiential aspects of the developing process are Te necessity of such fully experiential process in more apparent. (Links to the videos are provided in forming the reappraisal juxtaposition is not always the text below, but are password-protected. Te videos recognized by researchers, with major efects on exper- are available for viewing, with the client’s permis- imental results and conclusions. For example, Tome sion, only by mental health professionals, researchers, et al. (2016) tested for behavioral memory updating via graduate program teachers, and graduate students. To cognitive reappraisal in the following manner: Hu- obtain the password, send an email to articlevideo@ man subjects learned to fear an image of a spider or a coherenceinstitute.org and provide a credible form of snake by experiencing a series of eight presentations documentation that you are in one of those categories.) of the image paired with an electric shock. One day Te client’s three preceding sessions had addressed later, that fear learning was destabilized by a mismatch and dispelled a puzzling compulsive behavior of avoid- experience consisting of a single presentation of the ing (procrastinating) important writing tasks in her image without the shock. Tis was followed by the professional work. Tose sessions revealed a child- intended cognitive reappraisal experience (which was hood in a family system that kept her perpetually in one of four experiments in this study), consisting of high anxiety and intense insecurity, and regularly in- listening to a 15-min. neutral, informational narrative ficted emotional trauma of various kinds, creating the about spiders or snakes, heard via headphones binau- condition designated in the clinical literature by the rally. One day later, physiological measurements of various labels of complex attachment trauma, relation- subjects’ fear in response to a single presentation of the al trauma and developmental trauma (e.g., Courtois, image showed no reduction in fear, and on that basis 2004; Sar, 2011). (plus other fndings) the authors state, “In conclu- As the oldest of six children, she was ordered in no sion, our fndings do not support a benefcial efect in uncertain terms by intensely self-absorbed, self-im- using reconsolidation processes to enhance efects of portant, authoritarian, recklessly harsh parents to keep psychotherapeutic interventions” (p.1). Tat weighty the other children safe, and her explosively rageful conclusion in relation to the reappraisal experiment is father threatened to kick her out of the family if she premature and unwarranted, given the weakness of the failed to do so. She therefore felt desperate to maintain tested reappraisal content. According to the crite- continuous hypervigilant monitoring of her younger ria defned above, recorded neutral information for siblings. Her emotional learning that it was her job to inducing reappraisal of images subcortically linked to keep the children safe and that she would be kicked out a fearful expectation is predictably inefective, because of the family for failing to do that job was a knowledge hearing dry facts does not generate one’s own direct, module or schema that was found to be still operating real-feeling personal experience of how the world is. in the present, outside of awareness. Tat schema and As such, it does not create a new and diferent know- the fear and urgency that it generated were compelling ing in the memory systems that contain the target her to avoid doing tasks that would strongly absorb learning, namely the emotional and sensory memory her full attention and allow an accident to happen to systems. Here again, the importance of understanding some sibling while she was wasn’t closely watching behavioral memory updating in terms of experiences over them—even though her siblings were now mid- rather than procedures is apparent. dle-aged adults living in distant cities. In her fourth session, she reported that she had 7.2. Clinical case example: erasure of complex become able to do the tasks that she had been compul- attachment trauma sively procrastinating. She then identifed the lifelong feeling of terror as the next focus of therapy. It soon A pervasive, lifelong feeling of “terror” was the emerged that this terror was accompanied by intense

37 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) somatic and kinesthetic symptoms, as described below. you, or what does it mean that’s really terrifying, or Te following transcript and videos document how both? the therapist (the author of this article) carried out the Te therapist’s question comes from assuming that therapeutic reconsolidation process (TRP), eliminating her terror arises directly from an implicit knowledge these symptoms in two sessions, followed by 2 years of that anger or criticism directed at her could have verifcation of all markers of erasure. (C is the client, T an extremely dire result. Te question is intended to is the therapist.) Comments inserted in the transcript prompt her to imaginally sample the experience of are limited to pointing out implementation of the TRP someone responding to her in that way and to attend steps; for more extensive clinical commentaries on this to her implicit expectation of the terrifying results. case, see Ecker and Hulley (2017b). Deleted portions Tis is more schema retrieval, TRP Step B. of the session, indicated by an ellipsis (…), have been C: Oh, man. [Silence as she searches internally for what made according to the criterion that the deleted seg- is terrifying.] ment contains nothing that was necessary for the therapist to reach the next included segment or to make T: Mm-hm. Yeah. And you know I’m not asking you to progress in carrying out the TRP. fgure it out. I just want you to imagine or just admit to yourself and me—imagine somebody becoming—maybe Burt [boyfriend, pseudonym], just Burt VIDEO SEGMENT 1: http://www.coherencethera- becoming irritated. What might happen? Or what py.org/videos-pwd/articlevideo/1.htm does it mean? C: … I feel like what’s still there is terror. C: I mean like, I can go now, like I can sometimes say … when he does that, internally, “I hate him,” how he’s such a jerk. I can carry on like that, but what’s really T: Are there specifc situations where that fear is stron- terrifying is it’s almost as if like I’ll go into this, like, ger, noticeably stronger, where it’s triggered? really dark place. Te client’s specifcation of “terror” begins to fulfll T: Mm. What’s terrifying is that you go into a really TRP Step A, symptom identifcation. Te therapist’s dark place. inquiry about when the terror intensifes would further defne the symptom and could also elicit C: A dark place, yeah. information that begins TRP Step B, retrieval of an Her facial expression and tone of voice now indicate emotional schema (semantic knowledge) that gener- signifcant afect accompanying explicit recognition ates the terror. of the “really dark place,” which is an experience that C: [Referring to her boyfriend:] It’s stronger if he’s has been plaguing her for a lifetime yet is new for her angry with me—if he gets angry. He even asked me to examine and describe. the other day—I said, “I really get terrifed.” And he T: Ok, let’s—and what’s that dark place like? What’s goes, “I don’t really understand it.” I said, “I don’t that experience made of? really understand it either.” C: It’s like a dark place I’ll never be able to get out of. … T: Tat sounds terrifying. T: Tis terror of anybody being angry or upset with C: Yeah, yeah. Not sure. Man. you—angry-ish, irritated, annoyed— T: Just sit with it. It’ll show up. You’ve already found it. C: Oh yeah. Or criticized. If I’m criticized, that’s the Let’s just sit with that much. Tat’s good. Mm-hm. other one. Displeased with me, almost like in any Yeah, it’s that you’ll go into a really dark place and way, that kind of displeasure, whether it’s angry or you might not ever get out of it. Yeah. [Silence.] Do disappointed or critical. you feel that in your body in any area? What is it … you’re feeling in your body? T: If someone becomes angry, or critical, or displeased, C: It feels—and there’s like a—well it’s like, it’s almost either what might happen that’s really terrifying for like I’ve become frozen? You know, like—um—

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 38 T: Frozen in the terror of being caught forever in that C: It’s very like—very destabilizing. dark place? T: Yeah, very, yeah. C: Yeah, yeah. C: I mean, I have all these like body tools to ground Her description of the frozen terror that is triggered myself and do all those things—plant myself to feel in response to receiving anger or criticism is a strong my—stay in touch with my body. But there’s—I’ve indication that it is a reactivation of traumatic mem- never been able to get to this thing. ory. T: Yeah, let’s get to it. Mm-hm. Yeah, the same dark T: Yeah. You’re feeling some of that frozenness now? place. C: Yeah, exactly, I’m trying to like stay in this like, this C: Because, also, then what has happened is like, some- dark, you know— [Silence.] It’s interesting. I just times then I think I’ll just, like, shut down. My body wanted to say something: this is the same thing, goes into a shutdown, kind of a numb. you know, this dark place I’m talking about—um, T: Yes, because what you’re starting—that dark place is ‘cause it feels like when I’m in this—the edges of so terrifying. this—or the dark place, it’s almost as if, like, I’m not there and nobody else is there either. It’s a weird—I C: Yeah, exactly. mean—but if somebody forgets something I told T: Nobody else is there. You’re not even there. them, I get so upset by that and literally the foor C: Right. starts to feel like it’s falling under me and I’m de- scending into this dark place. It’s the same thing. T: And it’s like you don’t exist and you could be stuck there forever. T: I see. C: Yeah yeah yeah. Somatic and kinesthetic symptoms are now also being attended to and labeled. Traumatic experience creates T: So, that’s so terrifying that of course you go numb a schema in semantic memory that is retriggered and just shut yourself down to not be having that by current perceptions that in some way match the experience. Yeah. original experience. Terefore the specifc perceptions C: Yes, it’s like being—like being—sometimes, I think that evoke post-traumatic symptoms are indications I used to talk about it, or it’s like being in this, like, of a trauma-based schema’s contents. Te client has um—like a solitary confnement. And also like, it’s for the frst time recognized that the same plunge into as if I was foating in outer space without a tether. dark, stark aloneness happens both when she receives Like, soundless, lifeless, um—no presence. a sharply negative response and when someone has forgotten something from their previous conversation. … Tose two types of trigger, taken together, indicate C: And no way out. that the target schema contains an expectation of T: No way out, yes, yeah, like, yes, stuck forever. interpersonal attunement rupture that is so severe as to feel annihilative—a traumatic plunge into absolute C: Yeah, stuck forever. disconnection and aloneness. Te pursuit of TRP Step T: So scary. And, when—let’s see. When someone B is making progress. doesn’t remember what you said, that can open— C: And then I’ll like stamp my foot and go, “I told you.” you can be falling into that dark place? Like that, I’ll be really mad. But the stamping my C: Yeah, literally feel myself starting to, like, it’s as if foot stops me from falling into that dark place. I’ve you like, like you were suddenly like an elevator always been wondering, what is this dark place? dropped really fast. You know, koonnnng. And why do I have such a strong reaction to somebody forgetting something I told them, you know? T: Sinking feeling. Physical. It’s almost as if like I go into, like, I don’t exist or C: Like a dropping feeling, even literally, like it’s as if something. the foor just came out from under me and I’m just T: Yeah, yeah. dropping, I’m in a free-fall, or free-drop. Tat’s what

39 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) it feels like. said to me! And you tell me you didn’t say it and I … remember you said it. Kind of like I’m depending on you to remember what I tell you and what you tell C: And it’s like, terror with it. me. I’m depending on you to. T: Yes, yes. What else would you want to say in that T: Yes. Stay in shared reality. “but I told you!” if you were to really speak from the terror of what’s really going on and feeling like C: Yeah, have a shared reality! Yeah, like something you don’t exist? You’re starting to not exist, it feels here that, this did happen, this did occur. Instead like to you, when someone doesn’t remember what of you constantly saying, “No, it didn’t occur, no you told them. So what would you say to the person it didn’t. Tis didn’t happen.” I remember I would explicitly about, “Hey, don’t I exist?” Or how would sometimes feel, “Am I going crazy?” And you know you say something about that? of course, I was so young. Te therapist is guiding her experientially to revisit For a young child, having a consistent, shared reality the frst jolting moments of perceiving an interper- with caregivers stabilizes the child’s knowledge of both sonal rupture with someone, in order to continue herself and the world, and sharp, sudden losses of retrieving into explicit awareness the cognitive and shared reality destabilize both areas frighteningly. emotional components of her emotional learning. Her … next response shows that this focused attending to her T: I wonder if that’s the sinking feeling, that the reality generic (semantic) knowledge of the moment of rup- is just dissolving. ture has now evoked episodic memory of particular childhood experiences of such traumatic ruptures. C: Right! C: I remember I used to have fghts with my mother T: And you’re in the black void. about this all the time. “I told you.” And then she’d C: Tat’s exactly it. say, “No, you didn’t.” Or, “You told me this.” “No I T: Tat’s it. didn’t.” I’d go, “Yeah you did, I remember!” C: Tat’s it. T: Yeah, “I did tell you.” T: And it happened again and again and again with C: “I did tell you.” “No I don’t—” “Yeah, you did, you her, with mom. said it, I know you did!” And I was just like— C: Again and again. T: Fighting to exist. T: I hear how desperately you would try to get her to C: And I’d just be so terrifed, like, you know, like— hold up her side of reality. T: Tis memory of it happening with your mother— C: Exactly, what— C: Again and again and again, like she would deny that T: And she wouldn’t do it. she said things or that I told her things. [Trough tears and with anguish:] It was like, yeah, “You don’t C: And she wouldn’t do it. even remember me, I don’t even exist for you! You T: And it would dissolve. can just forget me so quickly.” C: Yeah! But I remember just feeling so— T: Tat’s it: “I don’t exist to you.” T: What’s real? I don’t know what’s real. C: Yeah, I don’t exist for you— C: Right! T: Say it again: “Mom, I don’t exist for you.” T: I don’t know if I’m insane. Am I crazy? C: [Trough tears:] It’s just like you don’t even have— it’s kind of like something like—you don’t even C: Yeah! have—I don’t even know what’s real! Tere’s that T: Yeah. So intense. sense of I don’t even know what’s real here because C: Yeah, and then I would really try to like track every- I can’t even—you don’t even remember what you thing, keep track of everything. Just make sure that

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 40 I didn’t forget a thing. Really trying to hold onto, T: And disconnected! like— C: Disconnected. Yes, right. Tat’s it. Tat’s exactly it. T: Oh, desperately. Because you’re the one who has to Yeah. hold it all together. You can’t trust key other people T: Wow. Very intense. to hold it together with you. C: And I think when somebody gets angry or criticiz- As she continued retrieving episodic memory of the es, it sort of like it’s kind of like it comes as like this, maternal attachment trauma that she sufered myr- sort of like a jolt or a shock. iad times, her attention shifed from her problem of mother’s sudden, massive misattunements that feel T: Is that also a reality disconnect? annihilative, to her solution of trying to proactively C: Yes, yeah, because it catches me by surprise. You prevent such ruptures by tracking “everything” herself, know, like the surprise element of it whenever like hypervigilantly. Tis is a desperate attempt to be I’m caught by, like, surprise. I’m not expecting it. ready to ofset the predictable failure of her mother to Tere’s a sense of being blindsided. Ten it’s like maintain shared reality or show any caring concern that jolt, and then it’s back into that, like, I’m terri- for her feelings and needs. However, that solution is fed of that darkness, of that emptiness. not a reliable preventative, so the client feels continual … vulnerability and terror. Clinical experience in carrying out TRP Step B using Coherence Terapy shows T: Yeah, I feel I get it. Um, let’s see. Yeah, we started on that as a rule, a symptom-generating emotional this—you were wondering, did it—we were facing learning or schema has two main sections: knowledge the mystery of, why am I always terrifed? What’s of a problem—namely one’s vulnerability to a specifc always endangering me? Is this it? sufering, in this case the retriggered trauma of shared C: Yeah, this is it. reality suddenly vanishing—and knowledge of a solution that is the urgently needed way of trying to avoid T: Tat with every person—especially important that sufering—in this case, hypervigilantly keeping people, but maybe with any people—you’ve learned track of everything needed to maintain shared reality. in life that it happens without seeing it coming. It’s unpredictable how suddenly the fabric of reality is C: Tat’s right. I couldn’t trust my mom to do it. I real- ripped, and there’s a gap that’s black infnite void, ly couldn’t. I mean she was just so, like, where she’d and you’re goin’ in. promise to do something, she’d be in the middle of doing it, and then she’d just get [up and say,] “Okay, C: Tat’s right. I’m done,” and just walk away! T: And it can happen with anybody, because human T: And the shared reality dissolves right there. communication is like that. C: Yeah. Ten I’d say, “But you said you’d do this for C: Tat’s right, yeah. me!” “Well, I’m done.” And I would just be so crest- Te therapist has been confrming that what has fallen and cry and just, like, and be mad at her, but been retrieved and verbalized is actually felt by the it didn’t matter. It’s always feeling like the ground client herself as being the source and the emotional is almost like quicksand. It’s like it wasn’t solid. I truth of her chronic terror. Tis explicit confrming couldn’t count on her to— is important for two reasons: First, the therapist T: To a degree that reality disappears. must have an accurate understanding of the client’s symptom-generating schema in order to fnd next C: Right, exactly, yeah. how it can be disconfrmed, unlearned and nullifed. T: Te whole framework just—and you’re just foating. Only by attending closely to the specifc elements of a client’s symptom-generating emotional learning can a C: Exactly. therapist reliably facilitate the empirically established T: Ungrounded. You’re like that astronaut in the black process of reactivation, mismatch and counter-learn- void. ing that yield erasure and transformational change. C: Yeah, exactly. Yeah, that’s exactly— Second, engaging the client in a close review of her

41 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) newly retrieved schema promotes integration of that she says, “Yeah, I’m always scared of going into that.” material. Tat is needed because a newly conscious Te session has been almost entirely devoted to TRP emotional schema is not yet frmly anchored into Step B and has made signifcant progress retrieving conscious awareness and can easily be lost. Integra- the terror-generating emotional learning into aware- tion makes the schema maximally available for the ness and verbalization. disconfrmation and erasure process. Coherence Ter- T: Yes. Yes, okay, good, we’ve found what that terror, apy follows discovery work with an active cultivation what that danger is made of. of integration of the newly conscious material through repeated mindful experiences of it. C: Wow. Tis is so—I’ve been wondering about this my whole life, for a lot of years. … … T: What’s coming back to me right now here at the end of the session is the moments when you were in it T: Good, good. All right, so how about if we set you back with Mom, here—that little girl, desperate: up for being between sessions with the awareness of “But you said it, don’t you remember?” Just strug- this? Let’s create a card. … gling to stay out of falling of the edge of that clif. Te card, which is reproduced below, is a device … used in Coherence Terapy to sustain the in-session process between sessions. In this instance, the card C: Tat’s right. consists of the key verbalizations from the session, T: And having reality dissolve out from under capturing the schema as revealed so far. Te purpose you! Tat plunging feeling. of this card is to keep promoting integration of the C: Right, yeah, that’s right, yeah. Like in a free-fall, or retrieved material simply by returning the client to just suddenly like in a free foat. mindful, afective experience and awareness of the material daily. Te card is written collaboratively by T: Yes. And it’s terrifying. therapist and client, with the therapist relying on the C: Yeah! client’s felt sense of the wording that most accurately captures her emotional truth. Te card was emailed in T: You’re helpless and so alone. this case, but some clients prefer a physical index card. C: Tat’s right. T: And it feels like it’ll last forever. Tere’s no way out. BETWEEN-SESSION CARD C: Yeah, exactly, yeah. Tere is always the danger that Burt or anyone T: And the terror of that is what is the danger you feel could suddenly be angry or critical or displeased with in daily life now. me, or forget what one of us has said to the other—and C: Yeah, that’s right. Yeah, I’m always scared of going that would mean that our shared reality is disintegrat- into that. ing and falling apart before my very eyes, just like it did again and again with Mom, and then I’ll be plunged As is ofen the case with traumatic memory, there again into that terrifying darkness, where I don’t exist are two distinct terrors plaguing this client: Tere is for them and I don’t exist for me, and I’m totally alone the primary terror that she feels when her traumatic and stuck there forever with no way out. So it’s urgent memory is actually retriggered by someone losing for me to stay totally alert to everything that’s going track of shared reality and plunging her into the dark, on, so that I can keep my grip on the shared fabric of no-exit void; and there is the secondary terror that reality, keep it from ripping apart and not get plunged she feels in daily life in anticipation of that terrifying into that terror. plunge happening again at any time. Tat secondary terror was learned from having numerous experiences of the primary terror, and is ofen termed fear of fear. NEXT SESSION, ONE WEEK LATER Tat anticipatory fear of fear generates hypervigi- VIDEO SEGMENT 2: http://www.coherencethera- lance. She is describing that secondary terror when py.org/videos-pwd/articlevideo/2.htm

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 42 T: I am really interested in hearing about how the card T: Tat’s what you’ve been calling it? was for you, but we can start wherever you actual- C: [With emotion.] Yeah, yeah, yeah, that’s what came ly— to me—this terrifying darkness and it just kept C: No, no, I want to do that, because I’ve been reading coming up: black hole of nonexistence. And that it a bunch during the week, and it’s been really—I just kept coming up. So it’s like I lost it with my dad, mean, this is, this is, ah—it so fts. What’s interest- and then I lost it with my mom too! Or I’d think I ing though is, just as I was coming in, I just had would have it with her, and then I’d lose it; I’d think this realization that this whole piece about being I would have it with her, and then I’d lose it. in danger isn’t just about my mom, it’s also about TRP Step B has continued with the retrieval of epi- my dad. It’s almost like [it] started with this like sodic memory of her father suddenly shattering her sense of this shared reality piece of that being—you emotional and physical connection with both parents know, becoming, feeling so like fragile like with by ragefully casting her out of the parental bed into him, too. It was somewhere between two and three, what she calls “this terrifying darkness” and “the because—I’ll share this and I’ll just come back to black hole of nonexistence.” Feeling extreme unsafety this. I remember being a little girl and getting up in and fragility of attachment with both parents was a the morning, and I think taking of my clothes, not continuous state of terrifying vulnerability through- knowing how to change myself or anything, [and] out her childhood. Her attachment to both parents climbing in bed with my parents, to snuggle. And is of the insecure/disorganized type: the parents are one morning I went in, just felt like this is my thing needed for security but are experienced by the child to do, like I get to go in and snuggle with them for as a dangerous source of arbitrary aggression because a little bit. And I walked into the bedroom, and my they behave in unpredictable, extreme and punitive dad just leapt up and said, “Get the hell out of here, ways, arousing severe distress in the child but not pro- and don’t ever come back. You wait outside and be viding any comfort or help. Te child is helpless and quiet till I come and get you.” defenseless in the face of repetitive abuse and harm, T: Don’t ever come back? and therefore chronically feels disoriented, frozen or C: Yeah. terrorized, as the client here has described in this and the previous session. Both her episodic and semantic T: How did that feel? memory carry vivid knowledge of abruptly being cut C: Just like heartbroken. of from all sense of intersubjective connection and plunged into a black hole of nonexistence, a state that … she re-experiences in response to any current inter- C: It was such a shocker, you know, like here I personal misattunement or negativity. Knowing she thought— is ever vulnerable to that plunge is what maintains T: Tis was yours to have. It’s like a right—so unques- the terror she identifed as the problem. tioned. T: Yes, yes. And this one you’re telling me about now— C: Unquestioned. the black hole of nonexistence—is so powerful. You thought you had the shared reality of that cuddly T: And this rejection: “Don’t ever come back.” coziness together in the bed! C: “Don’t ever come back. You sit out there and wait. C: Yeah, yeah I did! You be quiet and you wait until I come and get you, and don’t come in here ever again.” T: And that was annihilated so suddenly. … C: Yeah, exactly. T: So that’s a heartbreak blow. T: So, I see why there’s the black hole opening up. C: Yeah. I think that’s part of that darkness, that slip- C: Tat’s right. ping into that, what I kept calling it over the week, T: What you thought was shared reality suddenly is the dark hole of nonexistence, the black hole of gone, annihilated; isn’t— nonexistence.

43 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) C: Yeah, it’s just like, it’s just totally taken from me, also been felt and identifed, making the accessing of her [snaps fngers] just like that! You know, what I implicit knowledge even more thorough. To the therapist, thought was so unreal [sic], isn’t. [Tearful:] And the Step B retrieval work now seems adequately accom- then Mom would do that, you know she did that, all plished because the emotional learning underlying the these— symptom of terror is explicit in some detail and there T: Yes, in terms of things she said, for example. remains no mystery as to why terror arises when it does. Te retrieved schema consists of specifc knowings or C: Tings she said or things that she promised she constructs that may be verbalized as follows: would do and then deny that she promised it. TARGET EMOTIONAL SCHEMA T: Promises! [Te learned problem:] No one maintains shared C: Yeah, she would say, “I’ll do this for you,” and she’d reality. When anyone loses track of the understandings go, “No, I didn’t. I never said that.” “No, no, you said we shared, it means: you would do that for me!” So, there was sense of like she’s there and then no, she’s not there. • Shared reality is irretrievably gone. T: Yes, and the sense that she sees you, and remembers • I don’t matter and don’t exist to him or her. and cares about what matters to you, and then, oh • No shared reality exists with anyone. no, she doesn’t. • I’m plunged into a terrifying vast darkness of C: “No, I don’t. I never said it. I don’t remember that.” being utterly cut of and alone in the universe, … and there is no way out. C: [Trough tears:] So much of my life has been orga- Tat can and will happen again at any time, and nized around this, Bruce. So, many choices—bad that is perpetually terrifying! choices, you know. Just so much about—just like [Te learned solution:] I’ve got to stay totally all that being deferential, like try to care—create a alert to everything that’s happening and re- shared reality with someone. member everything so that I can keep shared T: Tat’s been priority one, two, and three, instead of reality stitched together when anyone would what’s really right for you. let it rip apart. I’ve got to keep my body tight and braced for the next time anyone rips apart C: Right, exactly. And being able to like—so afraid to shared reality and I plunge into the black hole like, fnd out—you know, what if I fnd out that your of nonexistence. reality doesn’t match mine? Like, scared to do that. All of that material consists of semantic memory, … that is, general patterns and rules that were formed C: It would shatter at a moment’s notice! on the basis of concrete experiences but do not refer to those formative experiences in their operation. Here T: Yes, so, naturally, you’re anticipating that, and vigi- again, as in the previous case example in Section 7.1, lant for that. Is it like bracing yourself for it? post-traumatic symptoms are found in TRP Step B to C: A bit that too, yeah. You know, there’s vigilance, be arising from semantic memory rather than episodic there’s checking, but there’s a bracing too, yeah. memory. Te above detailed contents of the schema are I can feel all the tension in my body from it. Like the therapist’s crucial guide in the next step, TRP Step C, almost—all through here, in my shoulders, every- the search for specifc contrary knowledge that can then thing. It’s almost like in this kind of like, you know, be used in TRP Steps 1–2–3 (the ECPE) to disconfrm, a vigilant threat response, like walking around like nullify and erase some key part of the schema. In Step that. I can literally feel it. ... C, fnding contrary knowledge requires knowing exact- To foster integration of the emerging explicit knowl- ly what is to be contradicted from Step B: the specifc edge of what she sufered, the therapist has been prompt- constructs in the target schema. For Step C, Coherence ing her into repeated verbalizations of it as she is afec- Terapy instructs the therapist to search for disconfrma- tively feeling it. Additional somatic aspects have now tion (contrary knowledge) in the client’s past experience (that is, in knowledge that she already possesses, without

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 44 realizing it), or in some experience that has occurred in It is now clear that her boyfriend’s behaviors dif- daily life since the target schema came into awareness, fered fundamentally from her schema’s expectations. or in a new experience that the therapist deliberately Tis completes TRP Step C, the task of fnding an creates. Te therapist’s attention and thinking are now experience that can be used as a contradiction and engaged in that search. disconfrmation of the target learning. Te client is not yet recognizing her boyfriend’s response as a disconfrmation of the expectations of her traumatic SESSION CONTINUES memory, even though she is describing his behavior VIDEO SEGMENT 3: http://www.coherencethera- in detail. Te therapist must now guide her to register py.org/videos-pwd/articlevideo/3.htm her boyfriend’s cooperative, respectful response to her protests as being a direct contradiction of her schema’s … expectations. Holding both the schema’s expectations C: It came up this morning with my boyfriend. …I and the contradictory experience in awareness con- said, “Wait a minute! We talked for an hour. And currently, in order for the disconfrmation to register we got into some pretty personal stuf in that hour! viscerally, is the juxtaposition experience (a Coher- I was sharing about my work with Bruce and you ence Terapy term) that implements TRP Steps 1 and were sharing about something that you were realiz- 2, and a few repetitions of the juxtaposition fulfll ing about you. What about that?” Now there’s that, Step 3, completing the ECPE. Te therapist is now “Wait a minute, where is this reality that we just aiming to facilitate that sequence. shared?” T: All right. So, right now, I want you to, as you revisit T: Very good! it—how that went, and what he said, and your suc- C: But I started crying, you know, like I was that piece cess in calling his attention to what he had lost. Yes, about—but I stayed—I said, “What about this? You he did lose track of shared reality, but this time, you know, it’s like, you just erase that?” … You know, prompted him to retrieve it, and restore it, and even here it is again. I’m crying and feeling like once acknowledge to you, “Yes, I lost track of something again, I don’t exist. … important between us and I’ve got it back.” Her account of the morning’s incident with her boy- C: He said, “Oh yeah, I guess I did. I forgot.” I mini- friend shows that the target schema has remained in mized that. force even though it was retrieved into awareness in T: See if you can let those words be nectar in your life. the previous session. Te therapist has noticed that Tose words from him could be gold, could be her account has stopped at her collapse into non-ex- nectar. It’s the other person holding up their end of istence, and he is now wondering about what had reassembling shared reality when they fumble it. actually happened next. Did her boyfriend indeed What’s more important to you than that? fulfll her schema’s expectations that shared reality C: Right. He’s done that many times with me. was irretrievably lost and that he would be deaf to her protestations? Or did his ensuing behavior violate T: And maybe it has fown by. … those expectations, which might serve as a disconfr- C: Yeah, yeah. I think because also I’ve been so trou- mation? To probe that possibility, the therapist next bled about how intense my reaction was to his asked her the following question: forgetting, you know, or like—and how, like— T: How did it go with him? T: You were focused on that. C: Well, he said, “Oh yeah, you’re right.” He said C: Tat, and just, like, the hurt and like, the heartbreak, we—“I guess I dismissed that.” you know. Like, how could you forget about me? … I said, “Yeah!” I said, “What about that?” I said, “I’m really hurt that you just erased that.” And then— T: Tere’s a lot of intense components that were in play for you when this was happening. And so, T: Perfect, great! your attention naturally was on those things. So, C: —he goes, “Okay, I forgot it. You’re right, okay.” right now, though, selectively I’m prompting you, inviting you, to—here’s an opportunity to focus on

45 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) this non-helplessness you experienced. Your success, previous session, and expresses both her wonderment your actual ability to get him to retrieve the piece at this surprising realization of not being helplessly of shared reality that he had lost track of, and put stranded and the depth of meaning this has for her. it back in place and have it be shared again, and in Feeling helpless is what makes an encounter with addition, acknowledge to you and even apologize for danger so frightening as to create traumatic memory, losing track of it. See if you can let that—let’s see, on as a rule. Te memory then includes that helplessness the one side you’re holding that. On the other side as an expectation: “Whenever situation X occurs, is your old lifelong expectation that that will not I’m helplessly endangered!” Tat expectation in turn happen—you’ll be all alone, stranded and helplessly produces panic and/or dissociated freezing. Discon- stuck in that black hole once the shared reality is frmation of the expected helplessness is therefore dropped. usually the most efective juxtaposition experience C: Right. for unlearning and nullifying traumatic memory and post-traumatic symptoms. T: So, see if you can, you know, feel both of those. C: I mean— [Silence.] C: I guess what I’m doing right now is just going— thinking about all the other times he’s done this too T: Yes. [Long silence.] with me. I mean, he’s done this a lot. C: Wow. Te therapist has just now explicitly cued the juxta- T: What’s that? position experience, but the client has not yet directed C: Well, just that piece, because that’s defnitely been her attention to the both-at-once experience. in there about just feeling helplessly stranded. Yeah. … Like there was nothing I could do about it. Back T: Yeah, let that really sink in now—all those past ones, then, I couldn’t. as well as this fresh one—how it’s not like it was T: Right. back then [with her parents]. You’re with someone C: Even with all my eforts, it didn’t make any difer- who doesn’t irreversibly drop out of shared reality. ence. You can express it and he’ll retrieve it and reas- semble it together and even acknowledge that, and T: You were helplessly stranded back then. you’re not helplessly stranded when it does happen. C: I was helplessly stranded back then. C: Ok, yeah, that’s the part, about not being helplessly T: You felt the foor falling away. I mean, your body felt stranded. the falling away of shared reality. T: …Wow, all along I have been helplessly stranded, C: Yeah, and there was no way to get it back. and I’ve been expecting to be again and that’s why T: No way. Tere was no way. it’s terrifying. But, wait a minute. With him I’m not helplessly stranded. C: Tere was just—my mother wouldn’t do it— C: No, I’m not. No, I’m not! I’m not helplessly stranded. T: It takes two. It takes two to get it back. Yeah, that’s a key piece. I’m not helplessly stranded. C: It takes two, and my mom wouldn’t do it with me And, he will do this with me. and my dad wouldn’t do it with me. T: Yes. T: Tey didn’t have those skills. Te client is now having her frst juxtaposition expe- C: Yeah, they didn’t. rience, in which the emotional schema that generates her terror (“I’m helplessly stranded in total discon- T: But he does. nection”) is present in awareness concurrently with C: Yeah. But Burt does, yeah. It’s interesting how many strongly contradictory, disconfrming knowledge (“I’m people I’ve been with who have not had that skill. able to get him to reconnect with me, so I’m not help- T: Mm-hm. And for you, that’s just huge— lessly stranded”). Te tonality of her voice in her latest utterances is diferent than at any point in this or the C: It’s been so critical.

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 46 T: —huge, huge. Yes. few minutes, changing her model of the world. Also, C: Didn’t have it, or didn’t want to do it, or whatever. an additional contradictory knowing emerged: In revisiting her amazed realization about her boyfriend, T: Yeah, whatever. So, yeah, you’re letting it sink in, in she realized further that he is not a unique anomaly, this new way. Tere was an “oh wow” there. but is representative of a class of people who strive C: Yeah. Wow! to maintain shared reality. Tis recognition is the most potent schema-disconfrming new knowing yet T: Yes, yes. experienced, so the therapist will actively keep incor- Te therapist has continued prompting her to recog- porating this new knowing into the juxtaposition as nize how “helplessly stranded” in shattered rapport the session continues. she truly was again and again throughout her child- T: Mm-hm. When you’re with a person who does have hood, and in later relationships as well. Te purpose the skills and the willingness or cooperativeness to of this is to then have her freshly re-encounter the do that, you are not helpless about the black hole. It new disconfrmation of that expectation of helpless- doesn’t even have to develop into a black hole. ness, creating repetitions of the juxtaposition experience for TRP Step 3. Te therapist guided her back C: Tat’s right. …Tere are people in the world who into the juxtaposition by saying, “But he [Burt] does.” will restore that with me and I can do that with Tere will be several more repetitions of the juxta- them, and I have the capacity to do that and will do position in the rest of this session. In response to the that, so I’m not helpless. And if I encounter people client’s various indications that the disconfrmation that either don’t have the capacity or don’t want to has been registering strongly, the therapist will now do that, I’m not helpless with them either, because begin TRP Step V, making enquiries that probe for I’m not stuck. I don’t have to stay in that. I can walk markers of erasure. away. I can disengage and go, “Tank you very much. Have a merry life, but I ain’t dancin’ with T: How does it feel in your body? you,” or whatever. [Chuckles.] C: It feels like there’s a— I just feel really sofer, kind T: I’m writing down your exact words: “I’m not help- of like I’m aware of my breathing and just letting go less with them either, I’m not stuck.” tension, or something like a little spacy. Tere’s sort of a melting quality, and there’s, like, “ahhh, ahhh.” C: I’m not stuck. T: Sofening. T: “I don’t have to stay.” C: Sofening, yeah, this sofening. Wow. Wow. And I C: And I was stuck as a little girl. I was so stuck; sub- really was helpless back then, and they didn’t have jected to that. the skill to retrieve it. But Burt does, and he’s done it T: Tat’s right. Couldn’t go away. repeatedly with me. And I’m not helpless. Tose are the key pieces. You know, that there are people in C: Didn’t have a choice. Wow. I mean, it’s so obvious, the world that do have the skill to do that with me. but I’m just putting it— T: Yes, that’s it. T: It’s obvious to one part, but there are other parts that needed to know this. C: Tat’s a piece. Ten that there are people in the world that have the skill to re-establish shared re- C: And just to be acknowledged: yeah, really, I was ality—I guess that’s a way of saying it. And, I’m not helpless as that little girl, and there wasn’t any real helpless. way out of it. I would come out of that experience, but it was always there to go into again. I had no T: Yeah, yeah, let that sink in. control over that, because I was a kid dependent on C: I’m not helpless, yeah. my parents. Te client’s description of somatic sofening and open- T: Yeah, totally. Yeah. ing, in contrast to the tightness and bracing described C: Wow, this is so big. [Chuckles.] Tis is so big. earlier, possibly could be early indications that the schema has been unlearned and nullifed in the last T: Good. Feel it, feel it. Let it course through you. Yes.

47 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) C: Wow. I just feel my whole body going, “Yes, yes, yes.” my existence.” Consequently there is no black hole to I mean I’m aware of this spontaneous nodding that fall into, so her anticipatory terror of the black hole I’m doing. disappears. Her response to a lapse of attunement T: Good. [Silence.] would be fundamentally diferent because her model of the world of people has fundamentally changed. If C: [Big exhale.] Actually, I’m really feeling my feet, too. these shifs were to persist efortlessly even when Burt Because this week when I was at one point really and others fail to maintain shared reality with her, experiencing the terror, I was very aware of, “Oh my TRP Step V would be fulflled and erasure would be God, I don’t even feel my feet.” It’s almost like I don’t verifed. even have—I couldn’t even stand, it was that kind of quality to it. And I was just very aware of, oh, I can C: …I want to be with those people that have this actually feel my feet. capacity to re-establish shared reality. T: I can see you’re wiggling them and rocking them. T: Tose are your people. C: Feel my legs, my—kind of like my capacity, my C: Tose are my people, yeah. Yeah, those are my peo- adultness. ple. [Silence.] Yeah. [Silence.] T: Well, you’re in your body. … C: I’m in my body. T: Te people of the shared reality. T: You’re not feeing your body— C: Te people of the shared reality. [Laughs.] Yeah, that I can fall back on in that circumstance like a C: Yeah, right. safety net of sorts, you know? Tat’s what it feels T: —in terror— like, rather than just being all alone in the world and all I have is this. And so if I turn away from C: Exactly. this I have nothing. Yeah, you’re right, I don’t have T: —because it’s plunging through black space! that now. I don’t—it isn’t that I have nothing. I have C: Right. [Laughs.] Yes, right. Yeah, yeah, and also the people of the shared reality to turn to. I’m not this kind of sense of like I’m not helpless, like, I can alone! Yeah, that is so—yeah! I’m really glad you stand up for myself. mentioned that, ’cause that’s a piece of this too. A really big piece. … T: Yes, you’ve got your feet under you. To keep making the disconfrming juxtaposition as C: Yeah, I’ve got my feet under me. I’ve got my ground. potent as possible, the therapist has continued to I literally can stand for myself, and I can walk away, cultivate her new knowing that a subset of human you know. beings actually cares about maintaining shared re- T: Yes, both. ality and has the skills to restore shared reality when it has been lost. In commenting, “Tose are your C: I can move, move. Yeah. people” and in designating them as “Te people of the She has re-encountered the juxtaposition several shared reality,” the therapist has been further devel- more times and her revised experience of the world oping her basic recognition that such people exist, by is persisting. More somatic markers of fundamental inviting her into regarding those people as her own change have emerged, all bodily expressions of feeling sacred community in which she intrinsically is a full, empowered rather than helpless in response to the permanent member. In relation to those people, she situation of someone failing to maintain attunement always exists and is always in the web of connection, with her. She feels freed from the grip of a severely because they maintain shared reality. Her immedi- traumatized state of mind. A terrifying, ever-pres- ate response to that was a felt sense of having what ent danger in her world seems to have disappeared. she termed a “safety net.” Tat phrase expresses her Someone dropping shared reality now means, “Oh, bodily feeling of now being protected from falling into this person doesn’t see my existence, but there are the black hole. Tat feeling and that phrase will grow other people who do and who will continue to see into a bedrock of security as the session continues.

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 48 Knowing she has the people of the shared reality as huge it is. her safety net is the fully contradictory knowing that C: Yeah, yeah. And I don’t have to be—it’s not all up to disconfrms, unlearns and nullifes the schema that me to be the safety net. had been generating her terror. I have my capacity and I’m not helpless, but there’s a C: It feels like that—not helplessness, not stranded, not bigger holding for me. desolate, stuck, all that. Tat’s the key piece—and T: Yes, yes. Te people of shared reality are your safety then this thing that there are people in the world. net. And if a person isn’t one of them, okay. You know that literally feels like a safety net. It really does! I never had one! C: Yeah, that’s okay. But there are people who are, that’s my safety net. Tey’re my safety net. T: Never! T: Yes. C: Ever! C: Yeah. C: So I would always feel like— T: Yes. T: Tere was no safety net! Next, therapist and client collaboratively wrote C: Tere was no safety net. a card that would keep her in touch with these cru- T: You were only as safe as whether the person you cial felt knowings between sessions. Te card, shown were interacting with is going to stay in shared below, uses her own phrases to capture and maintain reality. the juxtaposition experience created in the session. Te C: Tat’s right. frst paragraph expresses her life-long, terror-generating emotional learning that she is totally and forever T: You were so vulnerable— alone because no one will stay in shared reality. Te C: I was. second paragraph juxtaposes and disconfrms that with her own living knowledge that there are people who T: —all the time, as I understand it. do maintain shared reality, enabling her to walk away C: Yeah, all the time. securely from people who do not maintain it. T: All the time! C: Just like how— Tis is like— In the sense of, like, BETWEEN-SESSION CARD relief about: oh my God, it’s over. It’s really over. All along I’ve felt helpless and powerless and totally T: Yes. Ah. alone as soon as anyone drops out of shared reality, C: It’s really, really over. Wow. [Chuckles through her stranding me in the black hole of nonexistence. tears.] What a surprise that I now have a safety net and T: It’s almost—it’s like mythic. I’m not helpless or totally alone: I can walk away from people who don’t stay in shared reality. I can walk C: It is! away because there are people who do value shared T: How big it is. reality and restore it when gaps occur. So I’m not stuck like I was as a little girl with no way out. People who C: It is. It is, that’s exactly it. care about tracking and maintaining shared reality are T: It’s like the darkness is of of the land. my people. With them I can exist and stand for myself C: Yes, right. and get them to restore shared reality, like Burt does. T: It’s over. All my life I’ve been tiptoeing around on thin ice above a black hole. C: For the frst time in my life, having the sense of feel- It’s fnally over. ing like I have a safety net! I mean that’s huge. T: It’s hard to fnd words big enough to capture how

49 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) SUBSEQUENT SESSIONS 0.5, 3.5, AND 11 were rocky and shaky between you [and your boy- MONTHS LATER friend], you said “although I feel some anxiety and VIDEO SEGMENT 4: http://www.coherencethera- fear and confusion about what happened this morn- py.org/videos-pwd/articlevideo/4.htm ing, I am not feeling like I am in danger of going into stark/dark aloneness or the sense that I have no shared reality.” In the next session two weeks later, TRP Step V, C: Right. Yeah. So that’s like— verifcation of markers of erasure, was fulflled to a signifcant degree when the client reported complete T: Tat’s holding. absence of both her hypervigilant terror in general and C: Yeah, that’s really holding; because—that’s so big for the somatic downward plunge sensation in response me. You know, it’s like…the foor was going to come to recent sudden ruptures of shared reality with her out from under me, that kind of—and that dropping boyfriend. (See video for that report from client; it is sensation that would come with that. And I don’t— not included in transcript here.) Other symptoms of that doesn’t—that’s not coming up. I’m mean, I’m complex attachment trauma now became the focus of still kind of like troubled or preoccupied, but it isn’t, therapy. In a session three months later (see video), like, umm, this, you know, terror that I would feel the therapist followed up on Step V for the terror and before. somatic plunge. Te client cited recent sharp conficts T: Wonderful. with her boyfriend, which previously would certainly have triggered the plunge into the black hole state, but C: Yeah, yeah. now did not do so. About those conficts she said: Two years afer the ECPE session, the client again C: And it bugs me. It’s a little disconcerting, disorient- reported absence of the anticipatory terror and the ing in a certain sense, but nothing that’s debilitating, plunge into the black hole in a very recent situation or that I’m scared that the foor is falling out from which, she said, defnitely would have triggered them under me, or like I’m dropping into that elevator previously. like before, or like the elevator’s just going kthoom. Te two sessions of TRP facilitation described here T: Yeah, the plunge. were a small subunit within a far more extensive course of therapy addressing the client’s complex attachment C: Yeah, that plunge, like, quick drop, kthoom. trauma, which comprised numerous other symptoms T: So is that gone? and their underlying emotional learnings. For each C: Yeah, that feels gone. Tat really does. symptom identifed by the client, the therapist carried out the TRP, in that way progressively erasing schema T: All right. It sounds like you’re feeling the sensible afer schema, resolving emotional issues and ending experience of a loss of connection, but it’s not at all symptoms. in that zone anymore. C: Right, yeah, right. 7.3. Are the observed transformational changes due T: So is that a zero? It’s a zero plunge, zero black hole. to reconsolidation? C: Yeah, I would say a zero. Yeah, I would say a zero. Te proposal that reconsolidation and erasure have In a session 7.5 months later (11 months afer the been demonstrated in the foregoing two case examples ECPE session of juxtaposition experiences), the ther- (and in many other published case studies, such as apist again pursued Step V for the anticipatory terror those listed online at http://bit.ly/2tKXdyX and http:// and the plunge into the black hole, and again the bit.ly/15Z00HQ) is supported by the following consid- client reported the efortless and complete absence of erations: those symptoms under all circumstances: First, as noted in Section 3, the observed efort- T: I got your email…and you mentioned—well, there’s less permanence of non-reactivation of schema and a lot of important pieces here. One of them I’ll just non-expression of symptoms are the same markers mention now is how you said, even though things used by neuroscientists to confrm erasure via recon-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 50 solidation in human studies (e.g., Schiller et al., 2010), 7.4. Clinical feedback on researchers’ anticipated based upon animal studies that linked the same be- translation difculties havioral markers to rigorous neurobiological proof of memory destabilization via the pharmacological block- Reconsolidation research has seen explosive growth ade test (e.g., Monfls et al., 2009). since its launch 20 years ago. Quite recently, laboratory researchers’ review articles have focused to an Second, the markers do not occur in therapy un- unprecedented degree on clinical application (e.g., til the requisite sequence of experiences (the ECPE) Beckers and Kindt, 2017; Dunbar and Taylor, 2017; occurs, and then are manifested by the client immedi- Elsey and Kindt, 2017a; Krawczyk et al., 2017; Kroes ately. et al., 2015; Nader et al., 2014; Treanor et al., 2017). Tird, the changes observed clinically cannot be One of the topics addressed in these reviews is the explained by other known types of neuroplasticity, possibility of inherent obstacles to the translation of that is, by a type of learning diferent from behavioral research fndings into clinical application. Tis section updating via reconsolidation. Regulation (inhibition) responds to the main concerns identifed by laboratory of an existing, acquired emotional response can be researchers by reporting clinical observations regard- developed through various other types of learning, all ing whether those concerns materialize, in hope of of which are competitive in nature (e.g., Ochsner and providing researchers with useful feedback that helps Gross, 2005; Toomey and Ecker, 2009). However, none to clarify and expedite the translation process. of those processes of inhibition by competitive learn- Here it may be worth repeating the opinion of Elsey ing have been shown capable of the decisive, lasting and Kindt (2017a, p. 115) that “there are signifcant changes described in the examples detailed in Sections limitations to experimental research, and ultimately 7.1 and 7.2. In those examples, the frst juxtaposition only attempts at treatment can reveal the utility of a re- experience, TRP Step 2, was followed in a matter of consolidation-based approach.” One of main purposes seconds by the client experiencing and describing of this article is to report back from the clinical trench- complete loss of the compelling subjective realness es about more than 25 years of “attempts at treatment” and motivating power of an emotional schema that in which the ECPE/TRP methodology was deployed had dominated life for decades, and neither the sche- in several thousand cases by the author and colleagues ma nor the symptoms it had been driving were ever plus numerous experienced clinicians worldwide (the again reactivated under any circumstances. Te case methodology having been developed, based on clinical in Section 7.2 involved post-traumatic, hypervigilant observations, almost a decade prior to the laborato- terror, a symptom that is deeply rooted in the subcor- ry discovery of memory reconsolidation, as noted in tical brain and is widely regarded by clinicians as being Section 3). tenaciously treatment resistant. To the author’s knowledge, there is no process or mechanism of competitive Te observations summarized below reference the learning known to science that is capable of producing case examples in Sections 7.1 and 7.2 for illustration, those efects, including recent research on enhanced but it should be borne in mind that, as noted earlier, extinction protocols (Dunsmoor et al., 2015). Tat is those two cases are representative of a large array of strong support for the hypothesis that the observed well documented clinical cases of ECPE/TRP method- changes were not due to competitive learning causing ology listed online at http://bit.ly/2tKXdyX and http:// inhibition of target schema reactivation. Te only bit.ly/15Z00HQ. viable explanation appears to be erasure via reconsolidation. 7.4.1. Will mismatch experiences be too exacting for Te circumstantial evidence delineated above is clinicians to create reliably? substantial, and, given that there currently exist no As discussed in Section 4, for the reconsolidation direct, neurological detection and proof of reconsoli- process to be triggered, the post-reactivation experi- dation in humans, it is the highest standard of verifca- ence has to be similar to the original learning, but not tion currently available. identical to it. For a target learning acquired through Pavlovian-type associative conditioning, small varia-

51 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) tions in laboratory post-reactivation procedures can er-learning that nullifes the schema. Presumably, the have the large efect of determining whether or not the markers of erasure could not appear if the target sche- target learning is lef in a destabilized condition (Alfei ma had not been destabilized. Tose two illustrative et al., 2015; López et al., 2016; Jarome et al., 2012; Mer- cases are representative of general experience in using lo et al., 2014; Sevenster et al., 2013, 2014; Schroyens the ECPE/TRP methodology in therapy: Te foreseen et al., 2017). Te failure to destabilize has been found delicacy of creating just the right degree of mismatch to be due to the post-reactivation procedure creating that destabilizes, allowing erasure to ensue, is not either too little or no prediction error or too great a observed. Emotional learnings retrieved in therapy are dissimilarity from the target learning. For a given found to be wide targets for a destabilizing mismatch, acquisition training, a given type of post-reactivation not narrow targets, via ECPE/TRP methodology. Two procedure has to satisfy boundary conditions, a limited factors, taken together, may explain that clinical good range of parameters that produce destabilization. news: Researchers have therefore concluded it is a delicate First, the delicacy of mismatch observed in labora- matter to design a post-reactivation procedure that tory studies is a direct efect of the artifcially precise creates the degree of prediction error that serves as structure of the target learnings created by researchers, a memory mismatch experience and destabilizes the not an inherent feature of the reconsolidation pro- target learning. Tat conclusion in turn implies that cess that would necessarily carry over into the clinical clinical translation of research into efective clinical setting. As explained in Section 4, the detailed struc- application may be elusive (reviewed by, e.g., Beckers ture and content of the target learning determine the and Kindt (2017); Treanor et al, 2017). For example, post-reactivation experiences that will, or will not, Sevenster et al. (2014, p. 583) concluded, “Even though mismatch and destabilize the target learning. Tus the the fear reducing efects are very robust and promising fnding that Pavlovian target learnings are mismatched for the development of reconsolidation-based treat- and destabilized by post-reactivation procedures that ments, the success of the manipulation depends on may vary within only a narrow range of parameters subtle diferences in the reactivation procedure. Tis is entirely due to the precisely ordered structure of poses a real challenge for clinical practice, which can Pavlovian target learnings designed by researchers. be resolved by careful selection of the reactivation pa- In other words, laboratory studies have had to create rameters.” Likewise, Beckers and Kindt (2017, p. 111) mismatch of subjects’ episodic memory of the acquisi- observed, “The transition from insuffcient prediction tion training, which involves all details of that training error to suffcient prediction error to excessive predic- in the mismatch. In contrast, clinical experience has tion error for inducing memory destabilization may be shown that as a rule, generalized semantic schemas, quite subtle…. Tat only a narrow degree of expectan- not episodic memories, emerge as the emotional learn- cy violation allows for the induction of amnesia upon ing driving symptom production, as illustrated by the memory retrieval greatly limits the translation into case examples in Sections 7.1 and 7.2. Even when the efective clinical interventions. It remains to be seen focus of therapy is on episodic memory, what emerges whether it will be feasible to establish, in a principled are the semantic learnings that were operative at the way, how to elicit an optimal level of expectancy vio- time. Reactivation of such schemas in therapy does lation during memory retrieval in the individualized not require any reference to episodic memory (also context of clinical treatment.” observed in a laboratory study by Soeter and Kindt, Tose somewhat pessimistic anticipations are fully 2015b), and mismatching such schemas is a qualitative warranted on the basis of laboratory results. However, matter, not a quantitative matter, which eliminates the in the two illustrative clinical cases detailed in Sections need for parameter precision in forming mismatch- 7.1 and 7.2, there is no sign of difculties achieving a es. For example, no careful adjustment is needed on destabilizing mismatch with the frst juxtaposition ex- duration of reactivation of a schema that is being mis- perience (TRP Steps 1 and 2), as indicated by prompt matched by a contradictory knowing, whereas for mis- and lasting appearance of decisive markers of erasure matching a Pavlovian conditioning memory, duration of the target schema afer a few repetitions of that dis- of reactivation is a critically sensitive parameter (e.g., confrming juxtaposition (TRP Step 3) for the count- Alfei et al., 2015; reviewed by Treanor et al., 2017).

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 52 Second, while the TRP does not dictate any partic- destabilization and require stronger reactivation and ular behavioral procedure, it does dictate creation of mismatch for destabilization to occur (e.g., Robinson a type of mismatch that has been shown in numerous and Franklin, 2010; Schroyens et al., 2017; Suzuki et laboratory studies to be efective for destabilizing tar- al, 2004; Wang et al., 2009; Winters et al. 2009; for a get learnings. Tis mismatch consists of an absolute or review see Elsey and Kindt, 2017b). Regarding some ontological contradiction and disconfrmation of the studies in which older memories did not destabilize, target learning. In laboratory studies, absolute contra- Lee (2009, p. 419) commented, “it is also possible that diction of a 100% reinforcement, asymptotic, Pavlov- all memories undergo reconsolidation regardless of ian target learning is created by a single non-reinforce- their age, but that previous studies have failed to use ment trial (CS–noUS) (e.g., Pedreira et al., 2004; Alfei sufciently intense memory reactivation conditions for et al., 2015), which is well established as a destabilizing older memories.” Likewise, Elsey and Kindt (2017b) mismatch. As discussed in Section 6.2, what matters concluded from their research review that greater age to the subject’s brain is the experience of absolute con- and strength of memories do not inherently prevent tradiction of expectation, not the CS–noUS procedure reconsolidation, and they demonstrate that point with that created that experience. Te TRP creates mis- a single-case study in which a woman’s intense, 30-year match consisting of absolute contradiction by requir- phobia of mice lastingly disappeared afer reactivation ing the therapist to elicit the detailed contents of the via exposure to a live mouse followed by propranolol symptom-generating schema (in TRP Step B) and then ingestion. fnd how the client can have an experience that spe- Ecker (2015a, pp. 12–13) has proposed that the ob- cifcally contradicts that schema’s model of reality (in served efects of memory age and strength on suscep- TRP Step C). Tat is followed in TRP Steps 1 and 2 by tibility to destabilization are actually more fundamen- pairing those two experiences, creating the mismatch, tally the efects of mismatch relativity for the highly or juxtaposition experience, in which both knowings structured acquisition trainings used in laboratory or models of reality are simultaneously present but studies. In other words, the memory age and strength both cannot be true. Destabilizing mismatch is in that fndings would be accurately interpreted only by close- way reliably built into the TRP. Use of an ontologi- ly examining how reactivation conditions interacted cally contradictory experience for mismatch appears with the detailed structure of the acquisition trainings to solve the problem of boundary conditions in clin- that formed the target learning in each case. Tis in- ical work. Absolute contradiction has direct, strong terpretation and the detailed analyses that it yields are relevance to the target learning and clearly requires qualitatively diferent from those made by laboratory an updating of the target learning, so destabilization researchers to date. is triggered. Whether implementation is successful depends on the skill of the individual clinician, not For example, in the study by Suzuki et al. (2004), on the inherent properties of the methodology or the each rat was placed in a context/CS for 2.5 min before reconsolidation process. receiving a 2-s foot shock either once or three times at 30-s intervals, and then were removed from the context/CS 30 s afer the fnal shock. Researchers then 7.4.2. Do the age and strength of target learnings in waited 1 day, 1 week, 3 weeks or 8 weeks and tested therapy cause mismatch difculties? for memory destabilization afer memory reactivation by shock-free re-exposure to the context/CS of dura- In clinical practice, the memories encountered tion 1 min, 3 min or 10 min. In that way, the duration (both episodic and semantic) are usually much older of reactivation needed to achieve destabilization was and stronger than the memories created for laboratory determined for target memories of varying strength studies of reconsolidation. Various laboratory studies and age, for a total of 24 diferent permutations of the have demonstrated that both recent and old memories parameters. Discussing only two of those permuta- can be destabilized and undergo reconsolidation in tions here will sufce for present purposes. animals (e.g., Debiec et al., 2002; Debiec and LeDoux, 2004) and humans (Steinfurth et al., 2014). As noted In the case of 1 shock, a 1-min reactivation did not in Section 4, several studies have found that older and destabilize, but a 3-min reactivation did destabilize stronger target learnings have lower susceptibility to for memory age of 1 day, 1 week, or 3 weeks. Tat

53 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) observation, as analyzed by Ecker (2015a, pp. 12–13) mismatch due to memory strength and age, because according to mismatch relativity, was caused by the in every case all that matters is designing the mis- 2.5-min pre-shock interval in the acquisition training: match according to the unique particulars of the target Each animal learned to expect that no shock occurs for learning being addressed. In that view, what appeared 2.5 min, and in relation to that expectation, a 1-min in laboratory research to be mismatch challenges due shock-free re-exposure did not create a mismatch, but to greater age and strength of memories were actually a 3-min shock-free re-exposure did mismatch that mismatch relativity efects caused by the highly struc- expectation, triggering destabilization. (See Section 4 tured features of laboratory acquisition trainings. for review of research on temporal mismatches.) Tus Tat conclusion appears to be supported by the full the longer 3-min re-exposure was efective not for range of clinical experience in applying the ECPE/ the reason that it was a stronger reactivation (which is TRP methodology, as represented by the two case the interpretation of the study’s authors), but simply studies in Sections 7.1 and 7.2. Mismatches created because it was actually a memory mismatch. by that methodology, consisting of highly specifc, In the case of 3 shocks, which certainly is a stron- ontological contradiction of decades-old, emotionally ger emotional learning (being a more severe and intense, symptom-generating semantic memory, are prolonged experience of sufering), the 3-min re-ex- found to result consistently in the markers of erasure, posure no longer destabilized at 1 day, 1 week, or 3 indicating successful destabilization. Te case detailed weeks, but a 10-min re-exposure did destabilize. In the in Section 7.2 involves possibly the strongest clinical mismatch relativity analysis, the fact that the stronger challenge posed by memory age and strength, name- memory required a longer re-exposure for mismatch ly, long-term, severe symptoms arising from memory implies that the memory of the duration of the 2.5- formed by multiple, cumulative traumatic experiences min pre-shock period was altered by being followed that occurred throughout all developmental stages. In by a full minute of repeated shocks instead of a single such a case, the lasting disappearance of both emotion- shock. Ecker (2015a, pp. 12–13) points out that three al reactivation and symptoms, immediately following 2-s shocks coming every 30 s is a grueling minute that ECPE implementation, would seem to be a maximally could presumably feel to a rat much longer than one encouraging indication of the efectiveness of reconsol- minute of curiously exploring a harmless place, just as idation-based behavioral updating in psychotherapy. humans too experience the subjective fow of time very diferently depending upon the presence or absence of pain. Te 2.5-min period could have been length- 7.4.3. Will therapeutic changes made via ened or blurred in memory retroactively by this long, reconsolidation be durable? traumatic minute of shocks, such that a 3-min shock- Te value of memory reconsolidation for psycho- free re-exposure did not register as a defnite mismatch therapy would be maximal if changes induced through of expectation, but a much longer 10-min re-exposure reconsolidation were permanent. In laboratory stud- did create a clear mismatch, achieving destabilization. ies, observations of the markers of erasure have been Here again, as noted throughout this article, the made for at most several weeks in nearly all cases. potential importance of considering qualities of sub- A notable exception is the one-year confrmation jective experience, as distinct from external proce- obtained by Schiller et al. (2010) for the behavioral dures, is apparent. Attunement to how the qualities erasure of Pavlovian fear in human subjects. Tose of subjective experience drive psychological dynamics fndings regarding durability are promising, but not is a critically important skill set for most clinicians. proof of permanence. Whether erasure is permanent More broadly, however, the devaluing and disregard of therefore remains an important open question from subjectivity has been a pervasive infuence in Western the viewpoint of researchers (e.g., Elsey and Kindt, civilization, particularly in the sciences, as document- 2017a). ed, for example, by Wallace (2000). Te possibility of non-permanence of erasure If the foregoing considerations based on the princi- seems indicated by a study (Ryan et al., 2015) that used ple of mismatch relativity are valid, they would imply pharmacological blockade to erase a fear response that there is no extra difculty in creating memory in mice and then reactivated the erased response by

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 54 optogenetically stimulating individual nerve cells that erasure is permanent currently appears to have more had participated in the encoding of the fear memo- support from clinical observations than from laboratory. Encoding neurons were also shown to have more ry studies. It is worth noting here that, as discussed in connectivity with each other afer erasure than with Section 3 regarding the markers of erasure, the criteria non-encoding neurons, even though their levels of used by the author and colleagues for verifying recon- synaptic potentiation and dendritic spine density had solidation and erasure in psychotherapy (in the fnal now decreased to the levels measured prior to memory step of the therapeutic reconsolidation process, TRP acquisition. Te fact that an artifcial stimulation of Step V) are the same as those used in human studies of nerve cells was required to produce relapse may mean behavioral erasure by laboratory neuroscientists (Schil- that relapse would never happen otherwise. Mice that ler et al., 2010; Oyarzún et al., 2012). had the erased fear response optogenetically restim- ulated did not display the fear response subsequently when re-exposed to the fear context under normal 7.4.4. Is episodic memory resistant to destabiliza- (non-stimulated) conditions. However, the observation and updating? tions imply that robust functional erasure induced by Perhaps the largest potential obstacle to clinical pharmacological blockade does not necessarily elim- translation is the fact that the highly specialized emo- inate the target learning’s encoding entirely. Tis dis- tional learnings that laboratory researchers create covery of persistence of encoding afer erasure raises for studying the fundamental properties of reconsol- doubts about the permanence of erasure, because if the idation are not representative of the real-life, symp- target memory’s engram (physical encoding) continues tom-generating emotional memory contents of therapy to exist to any degree afer erasure, relapse is possible, clients. Te sizable gap between bench and clinic at least in principle. means that procedures developed in laboratory studies Behavioral erasure has not been similarly tested as may not be efective in clinical practice for many possi- yet, to the author’s knowledge. If it were found that ble reasons. In full agreement with that sober outlook, behavioral erasure fully eliminates encoding, perma- in Section 6.2 of this article, the author has argued for nence of therapeutic efects would be a possibility rec- abandonment of the procedure-oriented perspective, ognized by laboratory researchers if clinical translation in favor of an experience-oriented perspective, for the were successful. translation of reconsolidation research into clinical practice. Te claim made in the present article is that clinical translation actually is quite far along and already is Some researchers have described interpretations of successful, with abundant demonstrations that such is research that would imply that episodic memory may the case, some with verifcation of long-term erasure. have relatively low susceptibility to destabilization and/ Examples include the case of complex attachment trau- or updating, and therefore might be resistant to change ma in Section 7.2, with erasure verifed for 2 years as of through reconsolidation-based methods in clinical this writing; a case of long-term depression also with work: Beckers and Kindt (2017) have conjectured 2 years of verifcation of erasure (Ecker and Hulley, about two ways in which the post-traumatic symptom 2002); and a case of long-term compulsive behavior of intrusive episodic memory (fashback) might not with 6 years of verifed erasure (Ecker, 2008). Te readily succumb to reconsolidation-based therapy. erasure of lifelong anger detailed in Section 7.1 was Schiller and Phelps (2011) and Kroes et al. (2015) have verifed for 8 months, and Högberg et al. (2011) ver- hypothesized that memories that are inherently encod- ifed for 22 months the cessation of severe PTSD symp- ed in an anatomically distributed set of brain regions, toms in adolescents afer use of a treatment protocol such as episodic memory, rather than in a single highly that is analyzed below in Section 9.2.2. In all of those localized region, such as conditioned fear or motor cases, erasure persisted even as clients’ life circum- procedural memory, are less susceptible to erasure stances produced many potent re-cueings of schemas by behavioral updating. As indicated in the follow- and symptoms under novel, stressful conditions, which ing paragraphs, clinical observations of the efects of satisfes researchers’ most stringent tests for erasure. ECPE/TRP methodology on episodic memory suggest that those concerns may be unwarranted. Tus the possibility that behaviorally induced

55 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) Beckers and Kindt (2017, p. 112) point out that lab- nical, and is beyond the scope of this article (see, for oratory studies have addressed memories consisting of example, Ogden and Minton, 2000; Payne et al., 2015). “the anticipated repetition of a remembered event” (as Te altered emotional experience of the event can created by Pavlovian associative conditioning) in con- then be created in various ways, limited only by clini- trast to “intrusive memories of a trauma where mem- cians’ creativity. Two methods used many times by the ory retrieval is not accompanied by the expectation of author, and described below, consist of replaying the the actual traumatic event repeating itself; such mem- memory as a diferentiated witness (viewing the orig- ories may not be violated [mismatch and destabilized] inal incident from a diferent ego-state from the trau- as easily, because they do not imply an expectation of matized ego-state that the memory normally induces) the traumatic event happening.” and empowered re-enactment with disconfrmation of Indeed, an intrusive episodic memory episode or helplessness. fashback is a re-immersion in and re-living of the Witnessed memory replay has many variations of original experience and not an expectation of the event technique. One of the simplest and most natural is repeating, so it is not possible during such a fashback applicable if the trauma occurred in childhood and to create a mismatch consisting of the non-reinforce- the client is now an adult. Te emotional intensity of ment type (CS–noUS), that is, a perception that the the memory can be drastically reduced by shifing the event is not repeating, because subjectively the event is client’s viewpoint in replaying the incident from the repeating. However, there are other types of mismatch child’s original viewpoint to the adult’s viewpoint. For to which the episodic memory is susceptible. Tese are example, being lef alone at home all night at 4 years of described below, afer noting frst that complicating the age was horrifying, and that unbearable horror of the symptomology in such cases is a secondary but clini- child is thereafer a dominant feature of the episodic cally equally severe symptom ofen termed fear-of-fear: memory and necessitates its suppression. When the Te personal history of having fashbacks does main- memory is de-suppressed in therapy in adulthood, tain a fearful expectation, between fashbacks, of the afer the child’s horrifed viewpoint is frst experienced, traumatic event repeating itself in the next fashback. in a natural manner the adult’s view of the experi- (Te case example in Section 7.2 above is of this type, ence comes to the fore or can be invited to do so. Te a primary traumatic memory that has been retriggered incident as witnessed in imagination by the adult is numerous times and is therefore accompanied by con- not horrifying. Te diferentiated adult’s experience tinuous anticipatory “terror” of the next retriggering.) is verbalized typically as, “Oh, what happened doesn’t As long as the primary traumatic memory remains look or feel so intense to me now as an adult, but I can intact, maintaining the client’s vulnerability to another see how intense it was for me as a child.” Tat experi- retriggering or fashback, the fear-of-fear expectation ence, sustained and dwelt upon for several minutes, is a remains intensely real-feeling to the client and is not mismatch, disconfrmation and counter-learning of the feasible to mismatch, as a rule. Te fruitful focus of expected emotional intensity of the memory, so it car- memory erasure is therefore the primary traumatic ries out TRP Steps 1–2–3 (the ECPE) and permanently memory, not the fear-of-fear memory. adjusts (updates) the memory’s emotional valence to a Te primary traumatic episodic memory can be much reduced, sub-traumatic level. Tis brings imme- mismatched within ECPE/TRP methodology in ways diate cessation of memory intrusion as well as fear- other than non-reinforcement of an expected event, of-fear symptoms and various symptoms produced in many cases. One approach involves facilitating in for memory suppression (enumerated in Section 2), imagination a surprisingly diferent emotional expe- because memory suppression is no longer necessary. rience of the same event. If the intrusive memory is Numerous other techniques of witnessed memory only a perceptual fragment, a somatic sensation or an replay are in clinical use for treating traumatic episodic afective state, it is necessary frst to guide de-suppres- memory, such as EMDR (e.g., Shapiro, 2001; Solomon sion and retrieval of the more complete, unifed epi- and Shapiro, 2008), Neurolinguistic Programming sodic memory of the incident. Such retrieval is usually (e.g., Ecker, 2015c; Gray and Liotta, 2012; Gray and a delicate therapeutic task that requires a number of Liotta, 2012; Gray and Bourke, 2015; Gray and Teall, clinical skills and processes, both relational and tech- 2016), Traumatic Incident Reduction (e.g., Volkman,

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 56 2008), and Progressive Counting (e.g., Lasser and to imaginally reinhabit the traumatic incident and Greenwald, 2015). All of these techniques arrive at a respond to the situation in a vigorously self-protective mismatch and disconfrmation of the expected ex- manner, either by giving full expression to a self-pro- perience of the memory and also, in many cases, of tective action impulse that was blocked in the original generalized learnings (schemas) based on the original experience or by being coached by the therapist to experience. Published case examples of these tech- consider and select from various self-protective possi- niques typically contain observations of the markers bilities. Te author has found it efective in some cases of erasure, which, as discussed in Section 3, serves to to suggest that the client, as a child in the scene, imag- verify that reconsolidation and behavioral memory ine her or his adult-self arriving and carrying out the updating have occurred (though no such conceptual- protective action; or the therapist can join the action ization may be indicated). Analyzing such accounts and protectively confront and fend of a perpetrator for how experiences of mismatch and disconfrmation and give comfort and understanding to the child. were created (because they must have been) is an efec- Te examples of episodic memory transformation tive way to build an extensive repertoire of techniques in the preceding paragraphs serve also to illustrate the that carry out the steps of the TRP for traumatic point, discussed in Section 2, that the target of updat- memory. (See Section 9.2.2 below for such an analy- ing and erasure is semantic knowledge even when an sis.) Clinical experience with this class of techniques episodic memory is the focus of attention in therapy. suggests that viewing episodic memory contents from Te helplessness experienced in the original incident a vantage point outside of the ego-state inherent in the was generated by the individual’s implicit semantic memory allows mismatches and disconfrmations to learnings that were operative at the time, in many be found and brought into juxtaposition by the brain’s (but not all) cases. Tat semantic knowledge, which always-operating mismatch detectors (for further dis- is embedded in the episodic memory, is fundamen- cussion of which, see Ecker, 2015c). tally revised by the empowered re-enactment process Another way of erasing much of the emotional (updating via ECPE), which correspondingly produces charge in a traumatic memory is by disconfrmation of a profound change in the episodic memory’s emotional the helplessness component of the episodic memory quality of the event. Te original semantic knowledge through empowered re-enactment (e.g., Ogden et al., that is accessed through the episodic memory and 2006). De-suppression of the memory produces famil- transformed pertains to identity and developmental iarity with the details of the traumatic incident, which stage as well as interpersonal rules that dictate and re- allows the therapist to call attention to the specifc strain personal choices and responses (Frith and Frith, conditions in response to which the client felt helpless 2012; Markus and Wurf, 1987). or unbearably vulnerable in the face of danger. As Te emotional realness of the imaginal experiences noted in Section 7.2, the encounter with serious danger described above is what gives them disconfrming po- or harm is made traumatic due to feeling helpless and tency; research has shown that the emotional learning defenseless. In many cases, the helplessness compo- and memory system responds to imaginal experienc- nent of an episodic traumatic memory is amenable to es almost indistinguishably from in vivo experiences being disconfrmed in therapy through an imaginal (Agren et al., 2017; Kreiman et al., 2000). Terefore empowered re-enactment experience. In the author’s use of imaginal processes that replay the original scene experience, nullifcation of the helplessness component with novel features and/or novel subjective viewpoints of the original episodic memory immediately reduces have much promise for dispelling traumatic memory the memory’s accompanying emotional distress dra- through ECPE/TRP methodology. (A therapeutic sys- matically and de-traumatizes the memory. (Note that tem with a particularly rich repertoire of techniques of this process is diferent from a disconfrmation and this kind is Neurolinguistic Programming (e.g., Gray nullifcation of helplessness expected in future instanc- and Bourke, 2015; Gray and Liotta, 2012; Gray and es of the same type. Te latter is an erasure of seman- Teall, 2016). For detailed case examples of such tech- tic memory and is illustrated by the case example in niques implemented within the TRP, see Ecker, 2015c; Section 7.2.) Ecker et al., 2012, pp. 86–91.) It remains to be seen In empowered re-enactment, the client is guided whether clinical inventiveness eventually can subject

57 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) all types of traumatic memory to transformational 7.4.5. Can clinicians navigate complex memory change through ECPE/TRP methodology. structure? Te second conjecture about how intrusive traumat- Te heterogeneity of symptom-producing memory ic memory might elude reconsolidation-based therapy, is a potential problem for translation of reconsolida- according to Beckers and Kindt (2017), is based on tion research in that clinicians face the challenge of various laboratory studies showing that an associative targeting the specifc components of memory that fully (Pavlovian, CS–US) memory becomes less susceptible govern production of a given symptom. In that regard, to destabilization if elevated stress is present either researchers have identifed two particular aspects of at original acquisition or at subsequent reactivation. memory heterogeneity that could prove problematic Both instances of elevated stress are characteristic for translation: a given symptom may be generated by of traumatic memory, so both adverse efects might episodic and/or semantic memory (that is, by event apply, blocking memory destabilization in therapy for memory and/or generalization/schema memory) post-traumatic symptoms. (Beckers and Kindt, 2017); and a given symptom may For emotional learnings and memories addressed be generated by a learning that was formed on the in therapy, elevated stress at original acquisition and at basis of a more primary learning while also by the reactivation during recall in therapy is the rule, not the primary learning itself (Elsey and Kindt, 2017a), a con- exception. Certainly those two stresses are higher still fguration whose reconsolidation behavior has been in cases of more severe trauma. Clinical observation studied using the simplifying experimental paradigm of successful erasure in many such cases (as discussed of second-order conditioning (Debiec et al., 2006). In above and exemplifed by the case example in Section addition, not mentioned by researchers (to the author’s 7.2) seems to indicate that the conjectured stress-relat- knowledge) are cases in which more than one separate ed obstacle does not in fact block the efective use of and distinct emotional learning drives production of reconsolidation in therapy for post-traumatic symp- the same symptom (discussed with clinical illustration toms. by Ecker et al., 2012). Will clinicians be able to navigate those complexities astutely, and thereby consis- Likewise, the concern raised by Schiller and Phelps tently identify the correct symptom-governing memo- (2011) and Kroes et al. (2015), that the anatomically ry or memories as target for the empirically confrmed distributed encoding of episodic memory inherently process of erasure? Discussion of each of those clinical reduces susceptibility to nullifcation and erasure of challenges follows. memory features, seems mitigated by the observed clinical successes of transforming the emotional qual- Learning and memory researchers have given much ity and/or the meaning of original experiences in epi- attention to the phenomenon of generalization of sodic memory (the case study in Section 7.1 being an memory (e.g., Dymond et al., 2015), in which pat- example of erasure of meaning attributed to traumatic terns, rules, abstractions, expectations, adaptive tactics incidents). Te clinical observations appear to support and emotional responses are extracted from episodic instead the analysis given by Hupbach (2011) in reply memory of particular experiences and are encoded to Schiller and Phelps (2011), which proposes that as categories and schemas in semantic memory (e.g., susceptibility to erasure is governed not by anatomical Eichenbaum, 2004). As discussed in Section 2, seman- extent of encoding, but by whether the content of the tic/schematic memory of generalizations operates as target memory is amenable to disconfrmation. Epi- the basis of adaptive responses largely autonomously sodic memories are multi-component, multi-dimen- from its episodic origins (though linkages may persist sional formations, within which are efective therapeu- between the two memory systems and may be uti- tic targets for disconfrmation, unlearning and erasure, lized in therapy). In that way, the individual is set to as described above. For example, certainly the fact respond to novel situations that share salient features of being lef alone all night at age 4 cannot be discon- with original experiences. frmed, but the emotional signifcance of that situation Te fact that a given symptom of a therapy client can be disconfrmed by viewing the incident from the is produced by episodic memory of events, semantic subjective standpoint of the client’s progressed devel- memory of generalizations, or both, poses potential opmental stage. problems for clinicians aiming to utilize reconsoli-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 58 dation for behavioral updating and erasure (Beckers simplifying experimental paradigm of second-order and Kindt, 2017). One problem would be clinicians fear conditioning (SOFC) to begin to study the recon- selecting event memory as the target learning when solidation behavior of that confguration (Debiec et al., actually the symptom is being driven by generalization 2006). In SOFC, animals are trained frst by a standard memory. Another problem is the reverse: clinicians fear-conditioning procedure, the pairing of a tone might target generalization memory to treat a symp- (CS1) with a shock (US). Ten a second conditioned tom driven by event memory. stimulus (CS2) is paired repeatedly with CS1, and the Avoiding those two potential pitfalls in translation animal also develops a fear response to CS2. Debiec will obviously require clinician education and train- et al. found that afer presenting CS1–noUS for reacti- ing that emphasizes cognizance of how both types of vation and destabilization, followed by administration memory can drive symptom production (as discussed of a pharmacological blockade, fear responses to both in Section 2). Assuming such cognizance on the part CS1 and CS2 were dramatically reduced. When CS2– of the therapist, it is proposed that ECPE/TRP meth- noCS1 was used for reactivation and destabilization, odology addresses and dispatches those two problem- pharmacological blockade then impaired responses to atic scenarios as follows. CS2, but CS1 responses were unchanged. Te potential clinical error of targeting event mem- Te implication for clinicians is that targeting a ory for symptoms based in generalization (semantic) derivative emotional learning will not necessarily also memory seems related to what the author perceives access the primary one. For example, an adult therapy as a widespread tendency among clinicians, noted client’s primary emotional learning involved anger at earlier, to assume that symptoms arise from episodic his father for repeated physical violence inficted on memory and to be relatively unfamiliar with semantic his mother throughout his childhood. His secondary memory and implicit emotional schemas. TRP Step B emotional learning formed from a single incident at by defnition requires clinicians to carry out retrieval age 8 in which a police ofcer arrived, made excuses of all contents in memory, whether episodic or seman- for the father’s behavior and failed to protect the moth- tic, that drive production of the symptom identifed er, resulting in the client forming a generalized anger at in Step A. Tat requirement is based on this simple police ofcers and other male authority fgures, which principle: Te symptom will cease to occur only when was the secondary learning that was based on the every one of the underlying, symptom-generating episod- primary one. In therapy at age 45, the man presented ic and semantic memory formations have been subjected his anger at male authorities as the problem, with no to the ECPE and transformed (updated) so that nothing mention or awareness of the original incidents. Initial- remains in memory that necessitates the symptom. Te ly the TRP was used in an attempt to disconfrm and client’s generalizations are in that way kept squarely on nullify the client’s felt knowing that police ofcers do the clinical radar in ECPE/TRP methodology (and in bad things and deserve anger and distrust, but no shif Coherence Terapy, which is based on that principle ensued. Ten episodic memory of the incident at age 8 of symptom cessation, and which supplies an array of emerged into awareness, and the therapist recognized techniques for TRP implementation (Ecker and Hulley, that the primary emotional learnings pertained to the 1996, 2017); as noted in Section 6.3, ECPE/TRP meth- father. Focusing the TRP now on that set of learnings, odology is a meta-map that does not defne concrete both episodic and semantic, resolved and eliminated methods or techniques for implementation). anger and other distresses in relation to father, and the client then found that his anger and distrust toward Te reverse potential clinical pitfall, addressing a police ofcers had disappeared with no further work in client’s generalizations for a symptom that is main- that area. tained by event memory, obviously also is addressed by the approach just described. As that example suggests, in practice the pragmatics of systematically applying the TRP solve the problem Clinicians face another complexity of memory of memory complexity described by Elsey and Kindt when a given symptom is produced not only by some (2017a): If, afer carrying out the ECPE (TRP Steps primary emotional learning, but also by a secondary 1–2–3), the current target learning remains in force learning that formed on the basis of the primary one and seems immune to disconfrmation, that is an (Elsey and Kindt, 2017a). Researchers have used the

59 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) indication that either the target learning is second- corrective experiences, psychotherapy integration, and ary to some other one that is primary and must now the roles of nonspecifc versus specifc factors. Tis be found, or that disconfrmation is being blocked to section sketches how our knowledge of reconsolidation prevent some intolerable consequence of disconfrma- and the ECPE in particular would drive the further tion, which must now be retrieved into awareness and evolution of understanding in those three areas. Refer- addressed, as discussed in Section 6.3. ence is also made below to the therapeutic reconsolida- Lastly, the memory complexity of two or more sepa- tion process or TRP, defned in Section 6.3 as being the rate, primary emotional learnings generating the same general form of clinical implementation of the ECPE. symptom is routinely navigated by clinicians using the TRP in much the same systematic manner as described 8.1. Reconsolidation clarifes the “corrective just above (Ecker et al. 2012). If the client reports that experience” the distinctive afective experience of the current target learning is now never felt in any of the situations that Beginning with the corrective emotional experience formerly triggered it, indicating successful unlearning (CEE) defned by Alexander and French (1946), an and erasure, yet the symptom that that target learn- important strand running through the development of ing had been generating continues to occur in those psychotherapy has been the various eforts to identify, or other situations, the therapist understands this to based on clinical experience and observations, how indicate the existence of another symptom-generating transformational change occurs. If one regards the emotional learning that must now be found. Te ther- empirically confrmed process of erasure (ECPE) that apist then carries out the TRP anew, beginning with has emerged from laboratory reconsolidation research identifying the situations in which the symptom now to be a fundamental and decisive breakthrough in still occurs (TRP Step A), and then works to retrieve understanding how transformational change occurs, it the underlying learning that is responding in those sit- then sheds new light on those prior clinical accounts uations and producing the symptom (TRP Step B). In and authoritatively clarifes their strengths and limita- that way any number of symptom-generating schemas tions. and/or episodic memories are progressively retrieved A thorough survey of relevant clinical methodolo- and nullifed until full cessation of the symptom under gies of transformational change and how they compare all circumstances indicates that the unlearning and to the fndings of reconsolidation research is beyond erasure process is complete for that symptom. the scope of this article. (For analyses of ECPE/ TRP fulfllment by eight widely used psychotherapy systems, see Ecker et al., 2012, pp. 126–155, and Te 8. Ramifcations for fundamental issues in Neuropsychotherapist, issue 10, January 2015.) Here, a psychotherapy few sample points are ofered regarding the CEE and Sections 3, 6, and 7 present the manifold indications its subsequent evolution, as regards fulfllment of the that transformational change of a person’s established ECPE/TRP. patterns (including, but not limited to, the unwanted Te description of CEEs provided by Alexander patterns presented in psychotherapy) is always the re- and French (1946) has recently been closely examined sult of certain internal, concurrent experiences, which and itemized in detail by Sharpless and Barber (2012, have been identifed independently in clinical obser- p. 34), who listed twelve signifcant components as vations and in reconsolidation research, and which in follows: this article are labeled the empirically confrmed process of erasure, or ECPE. If it is indeed true that only this combination of experiences produces transforma- 1. Te client must have experienced traumatic tional change of acquired (implicitly learned) states of events (construed fairly broadly) or events that mind, body, and behavior, this would have signifcant caused a traumatic infuence which were not ramifcations not only for case conceptualization in successfully or adaptively dealt with in the past. psychotherapy, but also for several of the psychothera- (p. 66) py feld’s important conceptual frameworks, including 2. Te client must be reexposed to these emotional

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 60 situations that were not successfully/adaptively current with an experience that contradicts the expec- dealt with. (p. 66) tations inherent in the problematic response (items 2, 3. Tis reexposure must occur in more favorable 3, and 6 in the list above). Tose two steps form the circumstances than the original situation al- juxtaposition that creates the all-important memory lowed. (p. 66) mismatch, which destabilizes the neural encoding of the problematic response, launching the reconsolida- 4. Te client must be able and willing to face the tion process. Te ECPE’s third step, a few repetitions reexposure (implied in defnition). of the juxtaposition experience during the remainder 5. Tis reexposure does not necessarily need to of the session, driving unlearning and erasure, is not take place with the therapist or within typical explicitly called for in the CEE defnition, but once the session confnes. (p. 66) juxtaposition experience is created, including repetitions of it is a simple matter in practice. 6. Te therapist (or another person in the client’s life) must assume or express an attitude difer- In addition, the CEE is also in accord with the ent from that of the individual or individuals ECPE/TRP in two other important ways: It emphasiz- involved in the original traumatic event. (p. 66) es the experiential nature of the process, with cognitive insight in a secondary and variable role (item 10); and 7. Building on Item 6, with CEEs specifcally in- it recognizes that the crucial violation of expectations volving the therapist, the therapist may or may is not necessarily produced only by the client’s expe- not self-consciously assume a particular role or rience of the therapist, and therefore allows for the attitude (or, similar to Kierkegaard [1884/1980], juxtaposition to occur either within or outside of a facilitate a particular emotional atmosphere) to therapy session (item 5). elicit the emotional situation (i.e., manipulation may be present, but not necessarily; Alexander, Certain limitations of the CEE as originally defned 1961; Alexander & Selesnick, 1966). (p. 66–67) also become apparent. Juxtaposition is seen as occurring only in interpersonal interactions, that is, from the 8. Te client must handle or react to this novel behavior of people. However, both laboratory studies situation (Item 6) in a manner diferent from (e.g., Galluccio, 2005; Schiller et al., 2010) and clinical before. (p. 67) observations (e.g., Ecker et al., 2012, pp. 93–97; Hög- 9. Such a result ofen takes repetition of the con- berg et al., 2011) have shown that other types and do- ficts before a new ending occurs (i.e., it seems mains of experience can drive unlearning and erasure unlikely that CEEs occur with a single reexpo- of acquired emotional responses. As noted in Sections sure). (p. 67) 5 and 6, disconfrmation of a target emotional learn- 10. Patient insight into these patterns may accom- ing must be highly specifc to the content of the target pany a CEE but is neither necessary nor suf- learning. In therapy it is found that clients sometimes fcient to cause the CEE, and the experiential have problematic emotional learnings that were not component holds predominance. (p. 67) formed in response to other people and therefore cannot be disconfrmed by experiences of people. An 11. As a result of the above, the trauma becomes example is the man who had no initiative to escape an “repaired” in some way. (p. 66) abusive situation at work. Te underlying basis of his 12. Te results of the CEE should generalize to oth- passivity was found: At the end of high school, he was er situations and experiences (implied). diagnosed with a serious osteopathic illness, which suddenly ruled out the brilliant athletic career he was eagerly expecting to enjoy in college. In response to From that fne-grain itemization by Sharpless and this crushing loss, he implicitly learned a self-protec- Barber (2012), it is apparent that the CEE of Alexander tive strategy that became verbalized in therapy as, “If I and French (1946) signifcantly fulflls the ECPE/TRP: try for what I really want, the world will crush it, so I First and foremost, the CEE calls for the frst two steps better not try for, or even feel, what I really want.” Tat of the ECPE, namely, a reactivation of the problematic learning of self-protective passivity was not produced response (via reexposure to its particular cues) con- by, and therefore was unlikely to be disconfrmed and

61 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) unlearned by, having experiences of other people. 355–356). Te original CEE defnition also falls short in two In that defnition, the primary emphasis on “discon- other ways. First, it leads clinicians not to expect or frmation of a client’s conscious or unconscious expec- strive for decisive, transformational change in a single tations” is in exact agreement with the reconsolidation session of disconfrming reexposure (item 9). How- research fndings reviewed above in Sections 4 and 5. ever, such rapid, decisive change does indeed occur, Also matching the neuroscience research is the breadth as illustrated by the case examples in Sections 7.1 and of that defnition: Te experiences that disconfrm 7.2, and is ofen observed by experienced practitioners existing emotional learnings and induce transforma- of the ECPE/TRP. Second, while the CEE specifes tional shifs are diverse in nature and are not necessar- what conditions bring about change, it does not iden- ily themselves “emotional” (as can be seen in the case tify how change occurs, i.e., the mechanism of change, example in Section 7.1; on this point see also Ecker et invoking only a general notion of “repair” (item 11). al., 2015). Te ECPE/TRP framework provides a full and clear Numerous aspects of CEs were considered by group account of both the mechanism of symptom produc- participants, including CEs induced by a new inner ex- tion (via adaptive emotional implicit learning) and the perience versus those induced by trying a new behav- mechanism of symptom cessation (via unlearning and ior in the problematic situation; CEs that occur fully erasure of implicit knowledge through the memory in one decisive, discrete event versus those involving a reconsolidation process). series of events that reach a tipping point; the variable Alexander and French (1946) had introduced the role of cognitive insight in CEs; client factors that con- CEE within the context of psychoanalytic psychothera- tribute to CEs; the range of therapist behaviors that can py (where it encountered ferce opposition, as reviewed precipitate a CE; and the consequences of CEs. by Sharpless and Barber (2012)). Goldfried (1980), Section 1 of this article addressed the current aiming to make the CEE phrase and concept transthe- absence of reciprocal cognizance between reconsoli- oretical, so as to be broadly relevant to pivotal experi- dation neuroscientists and clinical psychologists. Tat ences observed in various types of psychotherapy, used mutual unawareness is well illustrated by the absence instead the phrase corrective experience (CE) in his of any reference to memory reconsolidation in the seminal article, “Toward the Delineation of Terapeu- seventeen chapters of the group members’ published tic Change Principles.” Goldfried proposed that CEs contributions (Castonguay & Hill, 2012), even though are a common factor found in many diferent forms of reconsolidation research has achieved a major break- psychotherapy, and his article launched the study of through of empirical clarifcation of transformational CEs as a way to identify therapeutic change principles. change events, the phenomenon addressed by the More recently, the CE construct was addressed by a group. group of twenty-seven psychotherapy scholars representing diverse theoretical orientations, who convened In fact, as described below, reconsolidation re- to discuss and pool their latest conceptualizations, search fndings have illuminated important features clinical observations, and research on transformational of transformational change events/CEs that are not change events in psychotherapy (Castonguay & Hill, identifed in the CE accounts produced by the group 2012). (Castonguay & Hill, 2012). Tree such features are described here next: 1. Transformational change events Te group arrived at this consensus defnition of a consist of a well-defned process of profound unlearn- CE: “Currently, we understand CEs in psychotherapy ing of implicit knowledge that was adaptively learned to involve a disconfrmation of a client’s conscious or by the subcortical brain earlier in life. 2. Designating unconscious expectations…as well as an emotional, in- transformational change events as “corrective” per- terpersonal, cognitive, and/or behavioral shif. In CEs, petuates pathologizing views of symptom production clients typically reencounter previously unresolved that are inconsistent with the neuroscience of implicit conficts…or previously feared situations (whether learning and unlearning. 3. Disconfrmation, the cru- internal or external) but reach a new outcome in terms cial ingredient for transformational change, requires of their own responses, the reactions of others, or new specifc conditions for clinical implementation that are ways of interacting with others” (Hill et al., 2012, pp. mentioned minimally, if mentioned at all, in CE litera-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 62 ture. Elaboration of those three features follows: experiences without any lasting shif resulting. Tus a 1. Transformational change events are the profound standing question of much importance for the clini- unlearning of implicit knowledge that was adaptively cal feld is: Why do such experiences induce sudden, learned by the subcortical brain earlier in life. Tis is transformational change in some instances but not in illustrated by the case examples in Sections 7.1 and 7.2. many others? As described throughout this article, there is much An empirically based answer to that key question usefulness for clinical work in understanding trans- is provided by the memory reconsolidation research formational change within a broader understanding reviewed in Sections 4 and 5: In order for any expe- of emotional learning and unlearning (Ecker et al., rience to produce disconfrmation and robust, en- 2012). Reconsolidation is the brain’s innate process during cessation of an unwanted behavior or state of for updating existing learnings, and one form of such mind, certain specifc factors are required by the brain, updating is profound unlearning that erases previously namely, the new experience must occur concurrently acquired semantic knowledge (expectations, meanings, with reactivation of the problematic emotional learn- schemas, rules, roles, mental models). Tis meta-level ing (negative expectation) maintaining the unwanted perspective on the process and mechanism of change is behavior or state of mind, and must contradict that not yet supplied by the CE framework (Castonguay & emotional learning with high specifcity. Disconfrma- Hill, 2012). tion consists of the client having the new, unexpected 2. Designating transformational change events as experience while also experiencing the old expectation “corrective” perpetuates pathologizing views of symp- or attribution of meaning, as delineated in Section 6.3 tom production that are inconsistent with the neuro- and exemplifed in Sections 7.1 and 7.2 (and as speci- science of implicit learning and unlearning. “Correc- fed by Alexander and French (1946), as noted above). tive” implies that the client’s prior emotional learnings It is the subjective juxtaposition and felt dissonance of are incorrect at least in the milieu of the present, even the two that creates the memory mismatch (prediction if they were correct in the original learning context. error) that destabilizes the neural encoding of the old However, as noted in Section 2, brain science contra- expectation, launching the reconsolidation process and dicts the conventional notion that the acquired beliefs allowing unlearning and erasure to occur. or schemas underlying symptoms are incorrect, irra- In short, the new, unexpected experience must tional, maladaptive or pathogenic. Te brain evolved occur as part of a juxtaposition experience, but it is by in such a way that implicit emotional learnings are no means automatic that it would do so. It is entirely neurologically built to persist and reactivate for a life- possible and even commonplace for a therapy client to time (see, e.g., LeDoux et al., 1989) unless erased via have a new, unexpected experience while the old, nega- reconsolidation, which requires special conditions that tive expectation is dissociated and suppressed, outside rarely occur in the ordinary course of life. Tus the of awareness, such that no juxtaposition occurs. In persistence for decades of implicit beliefs, expectations that case, no transformational change occurs, puzzling and schemas adaptively formed in childhood rep- or frustrating the therapist and bringing disappoint- resents the proper functioning, not the malfunction- ment and perhaps also a sense of personal failure for ing, of the subcortical emotional learning and memory the client. Attempted CEEs and CEs ofen consist system, and should not be described in pathologizing of only the desired new experience, without the full terms. “Corrective experiences” could be replaced by juxtaposition. Both therapists and clients are highly “unlearning experiences,” “erasure experiences,” or prone to what has been described as a counteractive “transformational experiences,” for example. refex (e.g., Ecker, 2006, 2008, 2015; Ecker et al., 2012), 3. Disconfrmation, the crucial ingredient for an urge to avoid and suppress unwanted behaviors and transformational change, requires specifc conditions states of mind while building up and attending to pre- which, as a rule, are barely mentioned, if mentioned ferred behaviors and states of mind. Attempted CEEs at all, in CEE and CE literature. Disconfrmation is and CEs are all too easily shaped by that counteractive usually depicted as consisting of the client having the tendency: Te therapist guides the client’s attention new, unexpected experience. However, therapists are to be fully engaged in the desired new experience and all too familiar with guiding a client into having such disengaged and dissociated from the unwanted reac-

63 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) tion or ego state and its core schema. Tat confgura- experience was shown to be a primary clinical impli- tion is the opposite of the explicit, foreground, expe- cation of reconsolidation research (Ecker, 2008, 2010, riential awareness of the target schema that is needed 2015; Ecker et al., 2012; Ecker & Toomey, 2008). for reliably creating the juxtaposition that destabilizes Tus the clear message of reconsolidation research the target schema. New experiences structured in that to clinicians is: An experience that could efectively one-sided manner in therapy can feel deep, meaningful serve to create disconfrmation and transformational and freeing in the moment, but they nevertheless can- change fails to do so if the target learning is not con- not result in lasting change if they create only competi- currently reactivated. Tat point was emphasized in tive new learning, with the core schema underlying the comments to the author from neuroscientist Javiera problem remaining intact, as it does if it is not subject- Oyarzún (as noted in Section 1, neuroscientists use the ed to a juxtaposition that disconfrms and dissolves it. term memory to refer to all types of memory contents Te requirement of the two-sided (i.e., juxtapo- and memory systems, including episodic and seman- sition) experience for producing transformational tic memory): “If we don’t remember many details of change was articulated, based on clinical observations, such memory (a very old one), we won’t be able to by Ecker and Hulley (1996, 2000b, 2002). For example: generate a reliable prediction error and thus we won’t have much of a memory transformation. Te better we retrieve our old memories, the better we will be able to “Te new construct or view of reality must be clear- generate this PE.” (Javiera Oyarzún, private communi- ly and compellingly inconsistent with the view of cation, 20 June 2016) reality in the client’s pro-symptom position [symptom-necessitating schema]…. Te task of the ther- In light of the foregoing considerations, it is pro- apist is to arrange for the client to take in this new posed here that the juxtaposition experience should be construct while inhabiting and vividly experiencing regarded as an update of the CEE and CE concepts ac- the pro-symptom position, so that both the new and cording to memory reconsolidation research, with the the old constructs are vivifed and experientially updated therapeutic change principle perhaps stated as real to the client at the same time.” (Ecker & Hulley, follows: 1996, p. 239) In psychotherapy, cessation of an unwanted, ac- “If the new constructs are created while the old quired (learning-based) behavior, state of mind, or position is not activated, the client does not actually somatic disturbance is accomplished most consis- experience an inconsistency or disconfrmation. Te tently by facilitating a few repetitions of a juxtapo- simultaneous vivifying of the old and the new con- sition experience in which the individual lucidly structs in the same feld of awareness is the essential experiences both the underlying emotional learning condition for the transformation of position to occur.” or schema and, concurrently, any personal, direct (Ecker & Hulley, 1996, p. 237) knowing that specifcally and inescapably contradicts and disconfrms that emotional learning.

“[T]he strategy consists of having the client experience subjectively both the pro-symptom emotional Tat defnition embodies the empirically confrmed reality and some other, incompatible construction process of erasure, and its implementation is illustrat- of reality simultaneously, in the same feld of aware- ed by the case examples in Sections 7.1 and 7.2. A ness. Te experiential quality of the disconfrmation therapist who regards a juxtaposition experience as is essential, and is not achieved by merely attempt- necessary for reconsolidation and transformational ing to refute, convince, or “correct” the client by change does not stop with creating the missing, needed contrasting “irrational beliefs” with “rational” new experience but also works to create a concurrent ones…” (Ecker & Hulley, 2000b, p. 169) experience of the problematic learning underlying the problem. An instance of such mindful facilitation of juxtaposition has been given by Ecker (2015a, p. 31): Subsequently the requirement of a juxtaposition

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 64 8.2. Reconsolidation provides a unifying framework [A] client accidentally knocks over a small clock in of psychotherapy integration the therapist’s ofce and apologizes anxiously and Section 3 addressed the hypothesis that transforma- profusely. Te therapist says with a relaxed, warm tional change produced by psycho-therapy is always smile, “It’s really ok. To me that’s a very small thing, the result of memory reconsolidation, and Sections and not a problem at all. Little accidents like that 4, 5 and 6.1 refned that idea into the hypothesis that happen for all of us, including me. Can you see transformational change produced by psychotherapy that I’m not at all upset?” Te client takes this in is always the result of the specifc experiences in the and feels much relieved to recognize that with the empirically confrmed process of erasure (the ECPE, therapist he is safe from negative judgments, anger, which is TRP Steps 1–2–3). humiliation, or rejection over such things. Probably Tat hypothesis has potential ramifcations for the most therapists would regard that as a corrective feld of psychotherapy integration, as described by Eck- emotional experience for this person. However, if er (2011) and Ecker et al. (2012, pp. 126–155; 2013c), the insecure attachment learnings underlying the who proposed that the TRP is a deep structure shared client’s fearful apology have not yet been made con- by all systems of psychotherapy that demonstrably pro- scious and explicit, this new experience is not jux- duce transformational change (a continuation of Gold- taposing with those learnings, so transformational fried’s (1980) quest for delineating common factors change is not occurring. In order for that positive that produce transformational change across therapy new experience to help bring about transformation- systems). If the TRP actually is universal in that sense, al change, the therapist has to guide the client into then TRP Steps A-B-C-1-2-3 should be detectable in experiential, embodied awareness and verbalization hindsight in any sufciently detailed account of any of the underlying target learning, such as, “Mom’s therapy sessions that produced the markers of erasure rage and disgust at me for any accident or mistake and transformational change in Step V (in much the mean I’m worthless if I do anything wrong, and I same manner as Ecker and Hulley (1996) detected the expect everyone else to react to me that way too.” TRP steps by looking back from the markers of era- Ten the therapist guides a juxtaposition experi- sure, as described in Section 3). Employing that logic, ence, for example by saying empathically, “All along various authors have reported unambiguous detection you’re expecting that anyone would go into rage and of the TRP steps embedded in the therapeutic process disgust at you for any little thing you do wrong, just in published case studies from ten systems of psy- as Mom did so many times. And yet here you’re chotherapy (listed online, with citations, at http://bit. having an experience of me feeling it’s really no big ly/15Z00HQ). Both the ECPE’s critically necessary deal at all that you accidentally knocked over this Steps 1–2–3 and the preparation steps, Steps A–B–C, little clock. Can you hold both of those at once, were detected in that way. and see what that feels like?” Tat explicit, experiential juxtaposition gives the new experience its Tus the TRP is emerging as a common factor in maximum infuence toward actual unlearning and therapies of transformational change. Te steps of the dissolution of the target learning. TRP are specifc common factors, in contrast to the non-specifc common factors widely regarded as being responsible for therapeutic efcacy in randomized Te CEE and CE memes and accounts of transfor- controlled trials (e.g., Wampold, 2001, 2015). Te TRP mational change are venerable in the psychotherapy could potentially serve as a unifying, empirically based feld. At the same time, in light of progress in recon- framework for illuminating the operation of therapies solidation research and its clinical translation (labeled of transformational change independently of theo- ECPE/TRP methodology in this article), it may now be retical constructs and biases. Te TRP could provide appropriate to regard the reconsolidation framework practitioners of diferent therapy systems with a shared as superceding the historical CEE and CE accounts of frame of reference and a shared, universal vocabulary, transformational change. enabling them to discuss how their seemingly dissimilar methodologies facilitate the same empirically confrmed process of erasure, without challenging any

65 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) system’s conceptualization of itself. dures of any given system of therapy contribute at most For individual clinicians, having the TRP as one’s weakly (15%) to therapeutic change, and that efcacy primary orienting framework reveals the TRP capa- must therefore be attributed mainly (85%) to non-spe- bility of every particular system of psychotherapy, and cifc features that are equally present in all therapies converts the panoply of psychotherapies from being a as statistically sampled in RCTs (e.g., Duncan et al., severely fragmented and confusing situation into a rich 2009; Wampold, 2001, 2015). Te nonspecifc common repertoire of options to choose from for best facilitat- factors include the qualities of the client, the therapist, ing the brain’s process of erasure for a particular client. and the client-therapist relationship, such as qualities (For a case vignette illustrating a clinician’s use of that of trust, empathy, therapeutic alliance, and the thera- unifying framework, see Ecker, 2015c.) pist’s belief in the treatment, among other aspects. Welling (2012) has proposed a psychotherapy Nonspecifc common factors theory faces two main integration scheme in which diverse therapy systems challenges (reviewed by Ecker, 2015b; Ecker et al., induce reconsolidation by creating experiences that 2012, pp. 153–155; Shean, 2014). First, the statistical connect “maladaptive” emotion with “adaptive” emo- nature of RCT data analysis inherently hides the exis- tion. However, that account does not adequately or tence of any potent specifc factors utilized efectively accurately represent reconsolidation research fndings in a small percentage of outlier sessions within the (as reviewed in sections 4 and 5; and see section 9.3 study. Tat fact makes it illogical and inappropriate below for why that is the case). Te psychotherapy to conclude from RCTs that specifc factors are funda- integration scheme defned by Lane et al. (2015) is mentally weak. Second, numerous studies designed based on a comprehensive map of the diferent types to detect potent specifc factors have indeed done so, of memory involved in symptom production and tags showing that the specifc factor of inducing afective therapy systems according to which type of memory experiencing of previously suppressed emotion and they target. Tat is an interesting and useful scheme, emotional meaning has a much stronger correlation but it is not based on the memory reconsolidation and with therapeutic change than do the nonspecifc erasure process. common factors. For example, a meta-analysis by Weinberger (1995) found that the therapeutic alliance, which is one of the most widely emphasized non-spe- 8.3. Reconsolidation explains psychotherapy RCT cifc factors, accounted for 11 percent of the variance outcome research and refutes non-specifc common in therapy outcomes, whereas the specifc factor of factors theory guiding clients to face what they had been avoiding accounted for 40 percent of variance. Seventy-fve years of randomized controlled trials, or RCTs, have measured essentially the same efca- Memory reconsolidation research adds what ap- cy for all tested systems of psychotherapy (at least pears to be decisive empirical evidence in favor of fourteen of them; for reviews see, e.g., Duncan et al., the existence of potent specifc factors (Ecker, 2006, 2009; Wampold, 2001, 2015). In the outcome research 2013, 2015b). Te empirically confrmed process of literature, a positive frame has ofen been put around erasure (or ECPE, defned in Section 6.3) consists of a this remarkable fnding by referring to it as the Dodo sequence of specifc experiences that produce the most bird verdict, meaning that all have won, all have done efective therapeutic change possible, as detailed in this equally well, so “all must have prizes,” as declared by article. Application of the ECPE in clinical practice, the Dodo bird in Alice in Wonderland. Actually, the producing such efectiveness, is a present reality, not an measured level of efcacy is quite modest, being little awaited future development, as shown by the clinical better than the efcacy of placebo therapy, leading cases presented in Section 7 and in numerous other ac- Ecker (2006, 2015b) to suggest that perhaps all have counts (Ecker et al., 2012; http://bit.ly/2tKXdyX). For lost. Be that as it may, the uniformity of efcacy has consistent clinical implementation, the ECPE inherent- required explanation. Te most predominant and ly requires the three preparatory steps and subsequent now widely accepted hypothesis is nonspecifc com- verifcation step described in Section 6.3, forming all mon factors theory, which interprets the uniformity of together the therapeutic reconsolidation process or efcacy to mean that the specifc processes and proce- TRP. One of the preparatory steps, Step B, the expe-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 66 riential retrieval of a symptom-generating emotion- all research on how a target learning is destabilized and al schema, is inherently the efective specifc factor then erased by behavioral updating. described in the previous paragraph. Tus the TRP As the importance of reconsolidation to psycho- embodies not only the most efective specifc factor therapy has become increasingly apparent to clinicians previously identifed by clinical researchers, but also over the past decade, more and more exponents of the ECPE, the specifc factor identifed in reconsolida- particular therapeutic systems have published accounts tion research, which produces transformational change proposing that reconsolidation is the mechanism of (permanent cessation of symptom and core emotional change responsible for the observed efectiveness of issue resolution). Te TRP appears to ft naturally the favored system’s process of therapy (e.g., Bade- within an “empirically supported principles of change” noch, 2011; Coughlin, 2016; Gorman and Roose, 2011; system (Rosen and Davidson, 2003). Gray and Liotta, 2012; Greenberg, 2010; Solomon and In light of the credibility now accruing to specifc Shapiro, 2008). Such claims may acquire plausibility factors, Ecker (2013, p. 137) suggested that psycho- by synchronizing with reconsolidation research in therapy RCTs might be more accurately interpreted two main ways: by demonstrating observation of the as showing that about 15% of therapists participating markers of erasure in specifc cases (because, as noted in RCTs across the decades of outcome research have in Section 3, it is believed that only reconsolidation can applied efective specifc factors knowingly or unknow- produce those markers), and by showing in concrete ingly. He concluded by noting that “the client-thera- and specifc terms how the clinical methodology im- pist relationship remains indispensably important for plements the empirically confrmed process of erasure. good psychotherapy. Tis is not an either/or situation. Tose two types of plausibility are referred to below as It now seems clear that in the most efective psycho- erasure evidence and methodology evidence, respective- therapy, an environment of good nonspecifc common ly. factors supports facilitation of the specifc factors of Erasure evidence in specifc clinical cases seems emotional accessing and memory reconsolidation.” necessary for making a strong claim that a particular system or protocol of psychotherapy actually recruits the reconsolidation process. Adding methodology 9. Other emerging clinical translation evidence makes the case as strongly as is now possible, methodologies analyzed in relation to until neuroscientists create a method of direct detec- reconsolidation research tion of engram nullifcation that is safe and practical. In defning the empirically confrmed process of Te present author and/or clinical colleagues have erasure (ECPE) and its pragmatic extension into the documented both erasure evidence and methodology therapeutic reconsolidation process (TRP), this article evidence for nine diferent systems of psychotherapy as attempts to translate reconsolidation research into clin- of this writing; they are listed online, with citations, at ical methodology in the most general and broadly ap- http://bit.ly/15Z00HQ. plicable manner possible, while maintaining rigorous Unconvincing claims are those that lack erasure fdelity to research fndings to date. Tis article would evidence. Some claims include erasure evidence be incomplete without a discussion of other eforts at but provide methodology evidence that is either too translating reconsolidation research into clinical meth- vague to establish ECPE fulfllment or is based on odology, in comparison to the framework advanced misconceptions of how reconsolidation operates and here. Tis section covers a few approaches that have an inaccurate account of reconsolidation research received considerable attention, but it is by no means fndings. Adequate familiarity with and citation of exhaustive. Te main aim in this section is to demon- relevant reconsolidation research fndings is relatively strate how the action and efects of any given method- rare in accounts of clinical application to date, in this ology or protocol can be specifed in terms of research author’s experience. It is not uncommon for claims of fndings with clear, consistent, objective standards, methodology evidence to be manifestly far afeld from by mapping the methodology in question onto the the specifc process (the ECPE) identifed by research ECPE/TRP framework. Te ECPE/TRP framework is and delineated in this article. Lack of accountability claimed to be no more and no less than a distillation of to research fndings and apparent lack of awareness

67 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) of research fndings spurred the present author and not guided the design of all studies, as noted in this ar- colleagues to publish an article titled, “Minding the ticle and by Ecker (2015a), and that also seems true of Findings: Let’s Not Miss the Relevance of Reconsolida- several attempts to use post-retrieval extinction proto- tion Research for Psychotherapy” (Ecker et al., 2015). col variants for clinical tranlation. Indeed, the reviews Evaluating claims of methodology evidence by by Auber et al. (2013) and Kredlow et al. (2016) show rigorously examining published clinical procedures many hits and many misses by procedures labeled in relation to reconsolidation research fndings seems post-retrieval extinction. necessary and legitimate in support of the clinical feld It was noted in Section 6.2 (and also by Ecker, acquiring accurate, and thereby maximally efective, 2015a) that labeling this protocol with the term “ex- knowledge of the workings of reconsolidation. Car- tinction” is a misnomer that invites misconceptions. rying out such evaluation of claimed methodology However, the label has become standard terminology, evidence is also an instructive exercise. so it is used here. For understanding any given study, the principle of mismatch relativity is critically important: Wheth- 9.1. Post-retrieval extinction er the study’s procedure can fulfll the ECPE is de- As the frst behavioral procedure to demonstrate termined by the detailed structure of the protocol’s erasure of a learned fear (Monfls et al., 2009; Schiller post-reactivation experiences interacting with the et al., 2010), post-retrieval extinction has attracted detailed structure of the encoded target memory expe- much interest and use by both laboratory and clinical riences (the original acquisition learning experiences). researchers (reviewed by Auber et al., 2013; Kredlow As shown in Section 5, the original post-reactivation et al., 2016; Lee et al., 2017). In the discussions of extinction protocol has a specialized structure that post-retrieval extinction in Sections 5 and 6.2 above, is efective for a Pavlovian target learning acquired it is apparent that, in the form originally implemented through multiple CS-US pairings evenly spaced in by Monfls et al. and Schiller et al., this protocol un- time. In particular, the protocol’s most distinctive ambiguously carries out the ECPE (that is, it provides feature is a 10-minute time delay afer a single CS pre- well-defned experiences of reactivation, mismatch and sentation reactivates the target learning. In relation to counter-learning as necessary for erasure to result). a Pavlovian target learning created by an evenly repet- Both erasure evidence and methodology evidence are itive time structure and an inter-training interval of strong for this protocol in its original form. much less than 10 minutes, the 10-minute delay creates Many subsequent studies have used variants of this a temporal mismatch that destabilizes the target learn- protocol to target fear learnings or addiction learnings, ing (Alfei et al., 2015). However, most target learnings while retaining the label of post-retrieval extinction encountered in clinical practice were not acquired or reactivation-extinction (see reviews cited above as with such a time structure. Te 10-minute delay in well as those by Dunbar and Taylor, 2017; Schwabe et this protocol would create mismatch or destabilization al., 2014; Treanor et al., 2017). In these studies, the only if the target learning happens to contain temporal constitution of the target learning, the manner of target expectations on a time scale signifcantly less than 10 learning reactivation, and the form of post-reactivation minutes. counter-learning have varied signifcantly from those A second distinctive feature of this protocol is the in the studies by Monfls et al. (2009) and Schiller et unexpected viewing, during the 10-minute delay, of an al. (2010). As noted in Sections 4 and 5 of this article, entertaining TV show or cartoon. In clinical practice, numerous reconsolidation studies have shown that the whether this feature would create the needed mismatch brain requires a particular relationship between those experience is doubtful due to its lack of relevance to three variables in order for destabilization and erasure the target learning (except perhaps in a rare few ser- to result: A memory mismatch experience must be endipitous cases). As noted in Section 4, research has created, consisting of a violation of the expectations or shown that a post-reactivation experience that is too knowings of the reactivated target learning, and count- dissimilar from the target learning fails to register as er-learning must then disconfrm the specifc content a mismatch requiring updating, and target memory of the target learning. However, those fndings have destabilization does not occur.

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 68 Another distinctive feature of this protocol is the destabilizing efect for any target learning, rather than use of extinction training for counter-learning, as recognizing it to be a specialized mismatch that can discussed in Sections 5 and 6.2. Tat format of count- destabilize only a special, narrow class of target learn- er-learning presumably succeeds only for a target ings, and they concluded, learning consisting of cue-triggered expectation of a discrete event, whether appetitive or aversive. Some target learnings encountered in clinical practice do Our data highlight how modifying the timing of have that structure. However, as a rule it is not pos- therapeutic sessions based on principles of memory sible to have the real-life CS occur during therapy reconsolidation could lead to more efective atten- sessions in order to create non-reinforcement (CS- uation of conditioned fear in both adolescents and noUS) experiences. Imaginal experience can be highly adults. A modifed version of an exposure-based efective in therapy for various purposes, but whether CBT protocol based on memory reconsolidation imaginal CS-noUS events could feel real enough to might involve reminding patients of why they are register as counter-learning is doubtful, in the author’s there when they frst arrive at the clinician’s ofce opinion; controlled studies of imaginal CS-noUS expe- (i.e., reminder cue), then establishing a safe and riences are needed to settle this question. Many target positive rapport for approximately 10 minutes (i.e., learnings encountered in therapy do not consist of waiting for reconsolidation window) before initiat- cue-triggered expectation of a discrete event (such as ing desensitization with exposure therapy. in the case example of Section 7.1), and for such cases the post-reactivation extinction protocol presumably It is predictable, in light of the research-based could not provide efective counter-learning. considerations delineated above, that the procedure Tus, according to research-based criteria for suggested by Johnson and Casey would not induce achieving erasure, the clinical applicability of the reconsolidation and would prove to be nothing more post-retrieval extinction protocol appears to be lim- than, and no more efective than, exposure therapy as ited, and that conclusion appears to be supported by usual. the reviews of Auber et al. (2013) and Kredlow et al. An important class of clinical emotional learnings (2016). Te above analysis again illustrates the dis- consists of attributions of meaning that are nonverbal cernments gained by understanding memory recon- and outside of awareness, but can be verbalized afer solidation in terms of requisite subjective experiences being attended to while felt, such as the frst of the rather than in terms of laboratory procedures that examples in Section 2: Getting Mom’s and Dad’s anger happened to be efective under specialized, simplifed or cold disregard when I express my needs or distress conditions, as discussed in Section 6.2. For purposes means that my very self is disgusting and unaccept- of clinical translation, interpreting reconsolidation able. Tat learned construal of the parents’ behavior research on the basis of procedures alone can result in would typically be one component of a more complex the proverbial wild goose chase. emotional schema found to be underlying and main- For example, Johnson and Casey (2015) elegantly taining a therapy client’s symptom. Te full schema is demonstrated the efectiveness of the post-retrieval found to be a multilayered formation of interconnect- extinction protocol with adolescent human subjects, ed meanings, models, expectations, roles, rules and who acquired an aversive Pavlovian CS-US association tactics (Ecker et al., 2012; Ecker and Toomey, 2008). on day 1 of the study and were completely free of that With such target learnings, the post-retrieval extinc- conditioned fear at the end of the study. However, tion protocol is not suitable, as a rule, for inducing Johnson and Casey interpreted their decisive results reactivation, mismatch and counter-learning, unless its entirely in terms of procedures. Neither their text nor defnition is made to be so general as to designate any citations refer to the need for a mismatch/prediction form of counter-learning following target learning re- error experience (which is consistently the case in activation. In that case, the term “extinction” is a clear studies of this protocol, beginning with its originators, misnomer, as noted above. Monfls et al. (2009) and Schiller et al. (2010)). Tus, they viewed the 10-minute delay as having an intrinsic

69 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 9.2. Episodic memory interference ic memory, the memory of a traumatic incident, and have sought reduction of post-traumatic symptoms. Tis article focuses on behaviorally induced erasure Two such studies are examined in this section, below, of semantic memory because such erasure produces using the ECPE/TRP framework to analyze the action transformational change, which is the most efec- of their clinical procedures according to research fnd- tive therapeutic change in that symptoms completely ings. Section 9.2.1 reviews a study that employed sole- cease and a potent theme of emotional distress is fully ly episodic memory interference and produced mild resolved. Behaviorally induced erasure is the most efects, whereas strong efects (in fact, the markers of thorough degree of memory interference by new erasure) were observed in the study covered in Section learning, and it requires new learning that is an abso- 9.2.2, which will be shown to have gone beyond epi- lute contradiction of the target learning, as described sodic memory interference by carrying out the ECPE, and illustrated in Sections 5, 6 and 7. When episodic so the study’s impressive results cannot be ascribed to rather than semantic memory is chosen as the target episodic memory interference. of change by behavioral updating, complete erasure is not possible because it is neither feasible nor ethical How efectively episodic memory interference alone to create counter-learning experiences that contradict can reduce post-traumatic symptoms is an open ques- the very existence of experiences remembered by the tion. Te assumption that post-traumatic symptoms individual’s declarative/factual memory (Dunbar and arise from episodic memory is in many cases incorrect Taylor, 2017). because semantic memory is ofen the source, as discussed in Section 2 and as the case examples in Section However, as discussed above in Sections 2 and 7 demonstrate (though that assumption is made by 7.5.4, erasure is possible (and therapeutic) for certain probably a majority of clinicians, in the author’s expe- components of the episodic memory of an experience, rience). Certainly the particular symptom of intru- specifcally the semantic knowledge schemas that sive fashback of perceptual and sensory memory of a existed at the time of the experience and generated its discrete traumatic event is due to episodic memory, as emotional quality, and which still exist as implicit com- are symptoms driven (consciously or non-consciously) ponents of the episodic memory. Te disconfrmation, by the emotional distress component of non-traumatic unlearning and erasure of those schemas during epi- episodic memories. Experienced clinicians are also sodic memory recall transforms the emotional qual- familiar with various post-traumatic symptoms that ity of the episodic memory, eliminating present-day are actually tactics needed for suppressing traumatic symptoms that had been generated by the episodic episodic memory out of awareness (such as disconnec- memory’s original emotional quality. tion from afect, compulsive eating, continual self-dis- As noted in Section 5, a target learning can be traction via compulsive focus on work, video games strengthened, weakened, modifed in its particulars, or pornography, and avoidant behaviors that prevent or erased by suitably designed new learning that encounters with specifc reminders of episodic mem- becomes incorporated into the target memory during ory). Such symptoms of episodic memory avoidance the reconsolidation window. If, rather than decisively are produced not directly by the episodic memory that contradicting and disconfrming any component of the is being avoided, but rather by the expectation of being target learning or memory, the new learning rather is unsurvivably overwhelmed, damagingly devastated or designed either to counteract, dilute or scramble the even driven insane were the episodic memory to be original material, the result can be a partial but signif- experienced. cant diminishment of expression of the original learn- Tat expectation and the rule of avoidance that it ing or memory. Numerous laboratory studies have dictates, which are semantic memory formations, are demonstrated such efects on episodic, declarative, and the targets of change for dispelling that class of symp- motor memory (e.g., Fernández et al., 2016b; Hupbach toms, and they are dispelled by the ECPE via experi- et al., 2007, 2009; Walker et al., 2003; for reviews see ential disconfrmation: Te therapist uses empathic Schiller and Phelps, 2011; Scully et al., 2017). accompaniment, the safety of the client-therapist Clinical studies of episodic memory interference relationship, and sensitive pacing (what is termed have focused mainly on a particular subclass of episod- “small enough steps” in Coherence Terapy) to guide

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 70 the client to bring attention to the episodic memory by the post-reactivation stories that were intended as in progressively fuller degrees, until the client has the memory interference, or both. As noted in Section disconfrming experience of in fact being capable of 4, the occurrence or non-occurrence of mismatch is experiencing the memory without being damaged or determined by how the details of the target learning overwhelmed by it. Te client’s resulting recognition interact with the details of reactivation and post-reac- of his or her own mental and emotional sturdiness is a tivation experiences. Each subject in this study had a signifcant therapeutic gain that persists independent- unique target learning, so there may have been sub- ly of the particular features of the traumatic incident. jects for whom mismatch and reconsolidation did not However, full, conscious familiarity with those par- occur, while for others it may have occurred to varying ticulars can then be used to identify generalizations degrees, since the strength and quality of mismatch (semantic schemas) that formed based on the incident probably varied greatly across subjects, correspond- and that generate other symptoms (if such schemas ing to diferences in the extent and degree of memory have not already been retrieved via pathways other destabilization. Tis a major confounding factor in than episodic memory). Tose schemas are then tar- interpreting results obtained with this protocol, and it gets of erasure using the ECPE/TRP. constitutes a lack of methodology evidence for utilizing reconsolidation. Lack of erasure evidence precludes verifcation of 9.2.1. Kredlow and Otto, 2015 having induced reconsolidation. Te observed efect of Kredlow and Otto (2015) tested an interference the KO protocol, a partial reduction of episodic memo- protocol (hereafer termed the KO protocol) applied to ry expression, leaves much room for competing expla- post-traumatic symptoms by having individuals who nations other than reconsolidation-enhanced interfer- had experienced the Boston Marathon bombing write ence. For example, the negative story condition could an autobiographical account of the experience. With have exacerbated subjects’ non-conscious discomfort the event memory reactivated by the writing exercise, with the memory of the event, producing stronger subjects then listened to either a negative, positive, or non-conscious resistance to attending to the episodic neutral story (all unrelated to the bombing incident), memory, which would appear to be an attenuation of or no story (the control condition). One week later, episodic memory. Terapists frequently witness such subjects were given exactly the same instructions to self-protective inattention in far more glaring forms. write an account of the incident. Each subject’s two Memory interference protocols applied to episodic accounts were analyzed for replication of specifc ele- memory of distressing events may be fundamentally ments, revealing a modest but statistically signifcant beset with confounding factors in such ways. overall reduction in recall of episodic memory details Targeting episodic memory for dispelling fear and for negative-story interference relative to the control other emotional reactions has inherently limited ther- condition, whereas the neutral- and positive-story apeutic efectiveness. Te ease with which episodic interference had smaller and non-signifcant efects. memory can be accessed and tested makes it an ap- Viewed in relation to the ECPE, the KO protocol pealing target of change for researchers, but for clinical can be characterized as follows: application its limitations are intrinsic and large. As As used by Kredlow and Otto, the protocol does not the case examples in Section 7 show, the semantic contain an identifed or well-defned mismatch experi- components of emotional learnings are ofen the most ence. Teir article’s account contains no mention of potently symptom-generating constituents, and as mismatch or prediction error or the necessity of same a rule the semantic components are not accessed by for triggering reconsolidation. Teir study therefore focusing attention on the episodic components, that is, seems to have been conducted under the early, mistak- the consciously noticed perceptions, sensations, emo- en assumption that reactivation alone destabilizes the tions and thoughts experienced in the event. Kredlow memory of the event. Nevertheless, some subjects may and Otto (2015, p. 36) acknowledge that a reduction have experienced mismatch due to the novelty of at- in episodic, declarative memory “may or may not be tending to the traumatic memory while writing about related to the emotional aspects of a trauma memo- it for researchers, or mismatch may have been created ry,” and, signifcantly, they found no change in the net

71 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) emotional valence of words used in each subject’s pair still present at the 22-month follow-up.” of written accounts. Tus episodic memory inter- Te strength of the erasure evidence reported by ference proposed as a therapeutic strategy raises the HNHP (essentially complete and lasting cessation of question of whether impairing access to memory of a symptoms) implies that the treatment protocol suc- distressing event is therapeutic. cessfully induced both the reconsolidation process and In light of the lack of both erasure evidence and counter-learning, which in turn implies successful im- methodology evidence, it seems premature for Kred- plementation of the steps of the empirically confrmed low and Otto to have concluded (p. 36), “Tese fnd- process of erasure (ECPE). However, the methodology ings indicate that reconsolidation interference efects evidence as presented by HNHP does not, on the face can be achieved for trauma-related episodic memo- of it, clearly show fulfllment of the ECPE. How the ries….” treatment protocol in fact does fulfll the ECPE is described below, but is not identifed by HNHP, and they neither discuss nor cite the relevant research fndings. 9.2.2. Högberg, Nardo, Hällström and Pagani (2011) Tus the presentation of methodology evidence is sig- Högberg, Nardo, Hällström and Pagani (2011), nifcantly compromised. referred to hereafer as HNHP, conducted a review of Lacking the full research picture, HNHP adhere to the brain’s neuroanatomical correlates of post-trau- and reassert researchers’ early and widespread mis- matic memory, made a number of inferences based on conception, discussed in Section 4, that every reacti- that information, and designed a treatment protocol vation of a memory is destabilizing, despite extensive intended to utilize memory reconsolidation for en- disproof of that view accumulating for over a decade, hanced interference of episodic memory of traumatic as documented in Table 1. Consequently, HNHP do incidents. Te protocol proved to be highly efective not specify how their protocol creates the mismatch in eliminating the post-traumatic symptomology of experience needed to trigger memory reconsolidation. suicidal adolescents in a small number of sessions. Tey also assert that certain methodological choices Tat is a challenging population, and such excellent are inherent necessities for utilizing reconsolidation efectiveness serves well to demonstrate the promise clinically, but on close consideration those necessities of memory reconsolidation for enhancing therapeutic are seen to derive not from reconsolidation research efectiveness. Te HNHP protocol is therefore import- fndings, but rather from the authors’ choice of meth- ant to understand rigorously in relation to reconsolida- odology and their particular conceptualization of their tion research fndings. methodology. Te account given by HNHP appears to provide Nevertheless, despite conceptualization problems, erasure evidence in both a single case study and a se- their procedure facilitates all necessary experiences in ries of 14 cases. In the single case, a 17-year-old male the ECPE. Te HNHP protocol steps, listed next, are had symptoms of difculty falling asleep, severe night- followed by a review of the conceptualization given mares, frequent, inexplicable day-time crying spells, by HNHP and then by a research-based analysis of breathing difculties, feeling depressed, fainting, and their protocol according to the ECPE and TRP defned nausea. Medical examinations had detected no phys- above in Section 6.3. iological causes. In his fourth session, client reported HNHP preparation step: Creation of positive self- that now “He has no problem falling asleep, no anxiety state. Client selects and assembles positive memories spells, and no somatic complaints. His score in MFQ and resources to create a readily available fear-free state is 0 and in WHO-5 92…” (Högberg et al., p. 94). At of positive emotional valence. Te authors explain, follow-up 3 months later, he reported the same. In the (p. 92), “Tis can be achieved by relaxation exercises: case series (p. 94), “14 suicidal adolescents…present- breathing and meditation, safe-place imagery, per- ed a post-trauma reaction with suicidality, insomnia, haps walking on a treadmill or bicycling on a spinning bodily symptoms, and disturbed mood regulation. … cycle. …Once activated, the positive emotion can be Of the adolescents 13 out of 14 had lost their severe anchored in a scene or image with focus on all sens- symptoms within 4 to 20 treatment sessions. …Te sig- es. Tis means that specifc instruction can be given nifcant change towards normality afer treatment was to note the sight, hearing, proprioception, gustatory

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 72 feeling, and total body sensation in a state of safety and key phenomenon of trauma-reaction pathology – the control.” memory disturbance with reliving episodic memory…” HNHP step A: Sensory review. While based in (p. 91). However, their own case example begins by the prepared positive experience of safety and control, stating, “On the frst visit the patient complains mainly client mentally revisits and moves through the traumatic about difculties in falling asleep, severe nightmares, incident as an inner movie, with focus on the sensory and frequent day-time crying spells without having any experience. During this re-experiencing, the client hunch as to possible cognitive content or any mem- receives cues to also maintain concurrent awareness of ory associated with the complaints.” Tere was no the positive emotional state, with its perceptions and reliving of episodic memory in that client’s presenting feelings of safety and control. symptomology. Episodic memory is by defnition any aspect of memory of the event itself. Absence of event HNHP step B: Somatic review. While based in the memory in the presenting symptoms seems to imply a prepared positive experience of safety and control, client less than central role of episodic memory in symptom mentally revisits and moves through the traumatic production. incident as an inner movie, with focus on the somatic experience. Tis is the same as Step A, except now Further, HNHP state (p. 92), “Te aim of the treat- client is attending to how his or her body is responding ment in cases of dysfunctional fear-memory reaction is and feeling as the incident unfolds. Tis is a focus on to change the valence and the intensity of the traumat- autonomic nervous system activity. ic memory and to increase control of memory retrieval. Te goal of the treatment is to change a reliving HNHP step C: Motor impulse review. While based intruding memory into a more distant episodic mem- in the prepared positive experience of safety and control, ory.” Regarding how the protocol causes change, the client mentally revisits and moves through the traumatic authors state (p. 93) that because their Steps A-B-C are incident as an inner movie, with focus on motor impuls- “a process with a combination of negative and positive es. Tis is the same as Steps A and B, except now client afects, the original event can fnally be re-experienced is attending to how his or her body wants to move and without fear, and the fnal outcome will be an emotion- take action in the incident, but was blocked or disal- ally less disturbing memory.” With Steps A-B-C com- lowed from doing so. When that is felt and identifed, pleted, “there is space for a new memory of the original client is guided to replay a new version of the scene in events, and this is done [in Step D] as imagination of which client fully carries out the motor impulse. how the original event should have been in a positive HNHP step D: How it should have been. Client cre- fantasy. Tis is a repair fantasy that will be added to the ates and moves through a new version of the traumatic memories associated with the traumatic event.” Te incident in which all happens in the ideal manner client net efect of Steps A-B-C-D is asserted as being that wishes would have been the case. For example, client’s “the traumatic exposure…is linked less with negative parents console and protect him when he arrives home associations but rather to positive alternatives….” Te badly bruised afer being mugged, instead of denigrat- authors re-emphasize the point in their concluding ing and raging at him and canceling plans for him to remarks (p. 94): “the approach presented focuses on acquire his frst car because of how “irresponsible” this changing old emotionally negative episodic memories incident shows he is. and on creating new positive memories.” HNHP step E: Positive future expectation. Client All of those statements express the authors’ view envisions life going forward as desired, without symp- that the source of symptom production is episodic toms, in the coming time period, and then experiences memory and that the memory reconsolidation process imaginal inner scenes of that happening. can embed or graf or at least strongly link emotionally positive states and feelings into the incident’s fear-gen- HNHP are emphatic in regarding episodic mem- erating episodic memory, causing the emotional va- ory (event memory) as the source of post-traumatic lence of the new composite memory to shif from ex- symptom production and the target of therapeutic tremely negative and fearful (and therefore intrusive) treatment. Tey defne episodic memory as including to moderately positive (and therefore non-intrusive). the somatic (autonomic) and motor impulse aspects of the original experience. Tey state, for example, “the Tat is a memory interference model of how their

73 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) protocol produces the observed cessation of symptoms, Rather, it is the particular design of the HNHP proto- and it is a main aspect of the authors’ conceptualiza- col and the aim of inducing a counteractive memory tion. According to HNHP, positive-valence states and interference efect that necessitates the sequence of feelings become memory additives in four ways in positive followed by negative states. their protocol: by maintaining the initially prepared HNHP’s conceptualization also includes a second positive state while revisiting the negative incident intended symptom-dispelling efect driven by Step C of memory in Steps A, B and C; by allowing expression their protocol, the blocked motor impulse review and of the blocked motor impulse in Step C; by experienc- replay with freely expressed motor impulse. Invoking ing a positive version of the incident in Step D; and by the fact that certain pairs of brain networks are coupled envisioning and sampling a symptom-free future in so that only one or the other can be activated, HNHP Step E. reason as follows (pp. 91–92): “It is well known that Tus, in the conceptualization of HNHP, there is no a trauma in which the victim is immobilized is ofen consideration of semantic memory (the existence and related to severe post-trauma symptomatology. Could involvement of implicit emotional schemas); and there it be that immobilization leads to the passive expres- is no mention of the erasure of anything in memory. sion of fear with a high level of anxiety, and that active Te conceptualization relies rather on memory recon- coping motor activity during the traumatic event leads solidation to bring about a strong fastening of new, to subsequent less severe later manifestations of fear positive episodic memories to the original negative reactions?” In other words, they hypothesize that Step episodic memory, making it impossible for the new C switches the episodic memory from being coupled composite memory to generate the original symptoms. to the parasympathetic system’s passive mode (creating Erasure is maximal, optimal memory interference high anxiety when partnered with a fear memory) to produced by counter-learning in the ECPE, nullifying the sympathetic system’s active mode (creating much much (though evidently not all, as shown by Ryan et lower anxiety during fear-memory reactivation). Pre- al., 2015) of the encoding of original learning. In con- sumably, they posit that the reconsolidation process trast, memory interference as intended and conceptu- allows this switching to be a decisive and permanent alized by HNHP loads the original negative learning rewiring of neural connections. with competing positive qualities, largely counteracting By examining the HNHP protocol in relation to but not necessarily fundamentally disconfrming and the ECPE and TRP methodologies defned in this nullifying the original learning. Te HNHP version of article, additional, more potent memory-changing memory interference has been demonstrated in nu- efects become apparent, namely erasure of a number merous controlled studies, as reviewed by Scully et al. of semantic, symptom-generating emotional learnings. (2017). Te ECPE/TRP perspective calls for examining the Observation of the markers of erasure by HNHP HNHP protocol in terms of the emotional learnings suggests that that their protocol accomplished not that it subjects to the empirically confrmed process of counteractive interference of episodic memory but erasure. full nullifcation of semantic memory and/or critical As noted, HNHP do not consider the existence and elements of episodic memory. Te analysis below the symptom-generating action of emotional schemas shows that the protocol indeed fulflls the empirically in semantic memory, an important focus of ECPE/ confrmed process of erasure (ECPE) in more than one TRP methodology. Te role of semantic memory is way. most apparent in therapy cases in which long-term HNHP emphasize that establishing the initial, pos- post-traumatic symptoms are found to be generat- itive state of well-being is a necessity before beginning ed entirely by semantic memory and not by episodic to access the afectively negative memories in Steps A, memory, as exemplifed by the case studies detailed in B and C. Teir account seems to suggest that the se- Section 7. Studying the action of the HNHP protocol quence of positive followed by negative states is inher- through ECPE/TRP lens reveals that episodic memory ently required by the memory reconsolidation process. activation served as a portal for accessing other aspects However, that is not the case, as the structure of the of emotional learning and memory formed in response ECPE, derived directly from research, makes apparent. to the incident, including semantic (schema) memory,

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 74 to produce the observed symptom cessation. of, and/or disallowed from, facing and feeling the full How the HNHP protocol implements the ECPE memory. A client who non-consciously expects unsur- becomes apparent by identifying the subjective experi- vivable overwhelm or severe and unacceptable social ences produced by the HNHP protocol. Tat analysis costs does so on the basis of (semantic) emotional reveals how several diferent components of the HNHP learnings to that efect. Diferent therapy clients have protocol fulfll the ECPE and thereby transform symp- diferent schemas that urgently require avoidance of tom-generating memory for potent therapeutic efects. feeling emotion, with each schema centered on knowl- Te ECPE/TRP conceptualization takes account of the edge of a particular sufering that would result and subjectivity of emotional learning and unlearning, and must be avoided. HNHP Steps A–B–C guide a very in that way reveals dynamics of emotional learning and thorough accessing of the experience of the original unlearning that are missed in purely reductive analyses incident, thereby creating a decisive disconfrmation based upon external procedures and the functions of and erasure of the expectation of overwhelm. Some brain regions. schemas of social prohibition could also be erased, but others would not be because the relationship with the Te ECPE/TRP analysis, which follows, identifes therapist is not representative of social relationships these specifc, symptom-generating semantic con- for many clients, so the experience of visibly feeling structs that the client unlearns through the HNHP emotional and somatic reactions in therapy would not protocol: (1) the necessity of suppressing memory necessarily disconfrm all such schemas. of the incident, based on the construed incapacity of the self to face and feel the intense sufering in the Te HNHP protocol does not call for explicit incident, (2) the state of helplessness originally felt retrieval of the schemas involved in symptom produc- and now expected in the class of situations defned by tion, so the therapist remains unaware of their specifc the incident’s salient features, and (3) the necessity of contents. In contrast, the TRP does call for retrieving avoiding facing and afectively experiencing the depri- each target schema into afective experience with ex- vation of what was needed but missing, resulting in the plicit verbalization, so that the therapist, equipped with traumatizing incident. detailed knowledge of schema contents, can guide new experiences that are accurately designed to disconfrm Each of those emotional learnings is mismatched, the unique content of each target schema, making disconfrmed, nullifed and erased by the HNHP pro- achievement of erasure maximally reliable. tocol, as understood from the ECPE/TRP perspective. From a clinician’s viewpoint, that is a powerful set of Regarding target learning (2), vulnerability to therapeutic efects, and in many cases that set covers helplessness: In incidents where a natural, self-protec- all of the main areas requiring resolution in order for tive motor impulse arises but is blocked, preventing an individual to get free of post-traumatic symptomol- enactment of the impulse, the immediate result is a ogy. To have designed a well-defned protocol capable subjective construal and feeling of helplessness and de- of having those efects in a small number of sessions is fenselessness, which in turn maximizes the subjective a signifcant achievement. Te range of applicability construal and feeling of endangerment. Helplessness of the HNHP protocol is addressed at the end of this is the ingredient that makes the incident traumatizing, subsection. How the HNHP protocol acts on each of because (a) helplessness is both maximally terrifying the above three target learnings is considered next. in itself and (b) it actually converts a merely unpleas- ant situation into a highly endangering one due to the Regarding target learning (1), urgent avoidance of absence of a self-protective action that would avoid feeling the sufering in the incident: In HNHP Steps harm. Tat is presumably why, as HNHP note, immo- A–B–C, the client has the experience of (a) being ca- bilization during a frightening incident is positively pable of revisiting, facing and feeling the full memory correlated with post-traumatic symptoms. Enacting of the original incident without being destructively the self-protective motor response during a frightening overwhelmed by doing so, and (b) being free to do so incident (such as standing up and walking or running without costly social consequences of feeling emotion- away) would in many cases even prevent the situation al distress and vulnerability. Tat experience serves as from being perceived as signifcantly dangerous or a specifc counter-learning that disconfrms what had frightening in the frst place. In other words, in many been the implicit presuppositions of being incapable

75 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) (but not all) post-traumatic cases, the original inci- to pathology” (p.94). Tat statement would be true if dent reached traumatizing levels of helplessness and it ended with three more words: “in many cases.” In endangerment because of blocked motor impulses. the general form given, that conclusion is not warrant- Motor blockage during the incident can be caused in ed, in light of the following considerations. HNHP a number of diferent ways. It can be non-consciously addressed a specialized class of target learnings (those compelled by a semantic emotional schema prohibit- that maintain post-traumatic symptoms) and a special- ing assertive action, as in a freeze response; it can be ized treatment protocol (one they designed based on enforced by a conscious assessment of the risk of ex- making inferences from a review of the neurological pressing the impulse; or immobility can be enforced by correlates of post-traumatic symptoms). Te authors physical constraints that make it impossible to express arrived at the above broad conclusion with no apparent the impulse. reference to research (discussed in Sections 4 and 5 Te efect of HNHP Step C, according to the ECPE/ above) showing that the outcome of behavioral updat- TRP perspective, is creation of the subjective experi- ing via memory reconsolidation is determined by the ence of actually having the personal power and agency interaction of the specifc elements in the target learn- to keep oneself safe in the very circumstances where ing with the specifc elements of the post-mismatch the original experience (and learning) was helpless- counter-learning experience. Blocked motor impulses ness. Tat experience of unblocked empowerment is a are involved in forming the target learning in many counter-learning that mismatches and precisely contra- cases of post-traumatic symptoms, but not all such dicts and disconfrms the existing, semantic-memory cases (for example, those detailed in Section 7 of this expectation of being helpless in the class of situations article, involving sexual molestation and annihilative having the original incident’s salient features. attachment rupture). If the target learning was formed in experiences that did not involve blocked motor im- In that way, HNHP Step C in itself implements pulses, HNHP Step C would be irrelevant to the target the complete ECPE and erases the learned, seman- memory and would therefore have no therapeutic tic-memory expectation of helplessness. Such nul- efect, in great contrast to the transformational change lifcation of the helplessness component of the orig- it can produce when relevant. Te details of the target inal memory immediately de-traumatizes the entire learning completely determine what experiences will, memory in many (but not all) cases of post-traumatic or will not, have a disconfrming and nullifying efect, symptoms, in the author’s experience. Tis step alone and the details of the target learning are idiosyncratic can therefore result in the markers of erasure, ending and must be carefully discerned, and not assumed, in post-traumatic symptoms, for many such clients. In every clinical case. Tus understanding the specifc addition, if it was an emotional schema that disallowed fndings of memory reconsolidation research is indis- enactment of the motor impulse, fulflling the motor pensable for interpreting clinical results and for devel- impulse in Step C also subjects that specifc schema to oping clinical methods for the full range of symptom- the ECPE, which can erase it. ologies based in emotional learning. Tis “empowered reenactment” technique (for an Regarding target learning (3), avoidance of feeling example of which see Ecker et al., 2012, pp. 86–91) unmet needs and the pain of mistreatment: HNHP is suitable and safe only for traumatic incidents in Step D targets this (though the authors do not com- which there was perception of danger of imminent ment on it) by guiding the client to identify, in contrast harm, making a self-protective response physically and to the intensely negative, unkind treatment sufered at humanly possible. Ten an empowered reenactment the hands of life in the incident, the kind treatment she can be subjectively credible to the client as a discon- or he wishes life would have provided instead. frmation of helplessness. When that is not the case (for example, in experiencing an unforeseeable bomb As noted, HNHP regard Step D as generating fur- explosion), a subjective replaying of the experience ther positive-valence memories that become linked to aiming for empowered reenactment is likely to be re- the target negative memory of the incident, strength- traumatizing rather than therapeutic. ening the interference of the latter by the former. Step D does signifcantly more than that, however, as under- HNHP conclude in a very general manner that “the stood in terms of the ECPE/TRP framework. It carries motor component in the emotional memory is central

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 76 out the entire ECPE for this target learning. that become apparent from the ECPE/TRP perspec- Consider the example of Step D given above: the tive. adolescent client imagines that his parents caringly Attending to perceptions and feelings of safety and console and protect him when he arrives home badly control while also attending to reactivated negative bruised afer being mugged, instead of denigrating and memories is a technique used in several systems of raging at him and canceling plans for him to acquire trauma therapy (such as EMDR, NLP, progressive his frst car because of how “irresponsible” this inci- counting, and acupoint tapping) and is widely termed dent shows he is. Tis imaginal experience would of dual focus (e.g., Lee et al., 2006). By juxtaposing the course tend to generate positive feelings of receiving target memory’s “I’m in danger and don’t have control the desired and needed consoling and protecting. over it” with “actually I’m safe and in control,” the dual However, in probably a majority of cases it would also focus creates a mismatch experience, a violation of the evoke long-suppressed, quite distressing feelings over target memory’s model of reality. As explained in Sec- having received not the needed, kind responses, but tion 4, a mismatch experience destabilizes the target unkind responses in many instances over many years. memory’s neural encoding, allowing it to be erased by Hurt, anger, unworthiness, emotional abandonment, counter-learning. Dual focus therefore carries out the neglect, betrayal, aloneness, being unseen, not mat- frst two of the three experiences in the ECPE (TRP tering, desolation, despair and painful grief, among Steps 1 and 2). other feelings and reactions, can emerge strongly Dual focus also promotes the third and fnal re- from a sustained focus on the caring responses that quired experience, that of counter-learning, by main- were needed but missing. Tis is familiar territory for taining a self-state in which the client has maximal ac- almost any experienced practitioner of in-depth ther- cess to disconfrming knowledge. As noted in Sections apy, particularly those who address issues of insecure 5 and 6.3, an extended experience of contrary, discon- attachment and low self-esteem, which are among frming knowledge, concurrent and juxtaposed with the most frequently encountered issues in therapy. the experience of the reactivated target learning, is Similarly as for target learning (1), most people are the needed counter-learning that completes the ECPE highly avoidant of allowing direct experience of such (TRP Step 3). Clinicians who utilize dual focus meth- feelings and meanings, so they are chronically sup- ods regularly observe the enhanced accessing of dis- pressed out of awareness. It therefore requires clinical confrming knowledge that it promotes. Ecker (2015c) skills of several kinds, both technical and relational, has proposed that the enhancement results from the to facilitate de-suppression and afective experiencing client attending to the contents of the target memo- of such emotions and meanings. For the client, the ry from a subjective viewpoint that is outside of the experience of allowing such emotions and meanings afective self-state normally produced by that memory. to emerge and be felt, and of having the capacity for Normally, attending to the target memory reactivates that without being destroyed by it and actually valuing it, causing the client’s consciousness to inhabit the the deep connection-with-self it entails, disconfrms memory and merge into the afective experience of and erases the learned expectation of being damaged the memory’s percepts, somatics and semantic elab- or destroyed by such feelings and the urgent necessity orations. In that subjective self-state, the contents of of suppressing them. Te result is cessation of a wide the memory completely fll the feld of awareness and range of avoidance behaviors, afect-phobic responses feel compellingly real, while the client’s myriad other and generalized anxiety, all of which are concomitants self-states and knowings disappear and are inaccessible of carrying signifcant levels of suppressed distress. for all practical purposes. In contrast, dual focus keeps HNHP regard the initially prepared positive state, the client’s consciousness anchored and positioned in a which is maintained and attended to throughout Steps safe context outside the memory while attending to the A, B and C, as both a source of interfering positive in- memory’s contents. In this state of unmerged attending put to the negative target memory and as an emotional (Ecker, 2015c), the client’s other self-states and know- stabilizer for the client while accessing distressing ma- ings remain accessible, and existing knowledge that terial. Once again, those efects are strongly plausible, is contrary to the target memory can readily activate but there are additional signifcant therapeutic efects into foreground awareness due the brain’s automatic

77 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) detection of mismatches, a background process always sodic memory as a portal for accessing certain implicit, scanning current conscious experience (Ecker and symptom-generating emotional schemas in semantic Hulley, 2017a; Ecker et al., 2012). Tat activation of memory, and erases those schemas by subjecting them a contrary knowing in response to the target learning to the ECPE. Tus this study by HNHP is not actually creates the juxtaposition, noted just above, that drives a test of the strategy of counteractive interference of the counter-learning needed for unlearning, nullifca- episodic memory, and the efectiveness of the proto- tion and erasure to occur. col in eliminating post-traumatic symptoms is not a Regarding the range of applicability of the HNHP demonstration of the efectiveness of that strategy. protocol, the foregoing discussion implies the follow- Even if pure counteractive interference of episodic ing considerations. (a) Te protocol is designed for memory (with no semantic memory efects) were to be treating post-traumatic symptomology and as such is implemented and shown to be efective at alleviating organized completely around imaginal re-experienc- certain symptoms, its use in psychotherapy is con- ing of a critical incident. Many therapy clients present tra-indicated, in the author’s opinion, because making symptoms rooted in distressing experiences that were it more difcult to remember a distressing experience repetitively part of the fabric of life in one or more con- would be iatrogenic, not therapeutic. As any experi- texts (family, social, work, or other), rather than acute enced practitioner of in-depth therapy knows, actual incidents. How the protocol could be applied efective- resolution and nullifcation of the efects of the worst ly in such cases is not readily apparent. (b) One of the experiences in one’s life occur through deeply and protocol’s main components, Step C for blocked motor fully revisiting one’s distressing life experiences and impulses, to which HNHP give much discussion and consciously recognizing what was sufered and what emphasis, would be inefective in cases where target coping tactics one put in place. Cutting of the episod- learnings (whether episodic or semantic) involve no ic memory pathway to that material would be signif- blocked motor impulses. Not all traumatizing inci- cantly disadvantageous and might perpetuate rather dents evoke motor impulses, but probably all do create than eliminate distress. the experience and expectation of helplessness. To the extent that Step C is the protocol’s main way of erasing the learned expectation of helplessness in the target 9.3. Emotional arousal: Lane, Ryan, Nadel and incident’s class of situations, the protocol could be rela- Greenberg, 2015 tively inefective in such cases. (c) Te HNHP protocol Lane, Ryan, Nadel and Greenberg (2015), referred focuses only on episodic memory, so it could fail to be to hereafer as LRNG, state, “In this paper, we propose efective in some cases where only implicit semantic that change occurs by activating old memories and memory drives symptom production (such as the life- their associated emotions, and introducing new emo- long reactive anger driven by the attributed meaning tional experiences in therapy enabling new emotional “it happened only to me” in the case example in Sec- elements to be incorporated into that memory trace tion 7.1). As noted earlier, accessing a specifc, symp- via reconsolidation” (p. 3). Combining an emotional tom-generating mental model or attributed meaning experience of the activated target memory with a new in implicit semantic memory is not prescribed by the emotional experience is the condition required for protocol and is therefore by no means assured. producing change, according to LRNG. Tey reiterate In summary, though the HNHP protocol has a lim- that emphasis by later stating, “Tis model highlight- ited range of applicability, the ECPE/TRP analysis of ing the importance of new emotional experiences…” its operation reveals numerous strengths, beyond those (p. 16). Te emphasis placed on emotional arousal is described by HNHP, by identifying symptom-gen- also apparent in the article’s title, “Memory Reconsoli- erating emotional learnings that are subjected to the dation, Emotional Arousal and the Process of Change empirically confrmed process of erasure. HNHP in Psychotherapy.” conceptualized their protocol as acting only upon LRNG show that assigning such importance to episodic memory of a traumatic incident and as rely- emotional arousal in therapy has much support from ing on counteractive memory interference efects. Te psychotherapy process research, which has consistently ECPE/TRP analysis shows that the protocol uses epi- found a strong correlation between successful thera-

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 78 peutic outcome and experiences in therapy sessions of emotional learnings (e.g., target learning consisting of previously blocked emotion and/or emotional mean- a safety platform position in animal studies; Morris et ing. Tat correlation has also been cited by Ecker al. 2006). It is frmly established that emotional arous- (2013) and Ecker et al. (2012, pp. 153–155) as consti- al per se is neither intrinsic to nor needed for inducing tuting a signifcant refutation of nonspecifc common reconsolidation and erasure. factors theory, which is the prevailing model of ther- If the target learning happens to involve emotion, apeutic efectiveness and of why all therapy systems as is nearly always the case in psychotherapy, then its subjected to randomized controlled trials have scored reactivation (the frst step in the empirically confrmed essentially the same level of efcacy for over 70 years process of erasure and TRP Step 1) of course entails (Wampold, 2001, 2015). an experience of that emotion. Te visible presence of While the importance of experiencing emotion in that emotion gives a therapist an important indication psychotherapy appears to be well established, what re- that an adequate degree of target learning reactivation search has shown about the relationship between emo- has occurred. Tose are clinical pragmatics having tion and memory reconsolidation is a diferent mat- nothing to do with the inherent nature of memory ter. It seems inevitable that many of LRNG’s readers reconsolidation. would acquire the understanding that reconsolidation Even with a reactivated, emotionally intense target requires emotional arousal, but that would be a misun- learning, however, the disconfrmation experience derstanding, because reconsolidation research shows needed next for mismatch, destabilization, nullifcation that no such requirement exists, as is further explained and erasure of the target learning (TRP Steps 2 and 3) below. Also, LRNG’s treatment includes no consider- is not required to be emotional in itself, as can be seen ation of, or reference to, any of the extensive research in both laboratory and clinical observations. Tis too that identifes the specifc experience-driven process is not in agreement with the methodology defned by of memory reconsolidation (namely, the requirements LRNG, which calls for “new emotional experiences in for a memory mismatch/prediction error experience therapy enabling new emotional elements to be infor destabilizing a target learning, and for a disconfr- corporated….” Te disconfrming new experience or mation or counter-learning experience for erasing a knowledge must be experienced as being unmistakably target learning, with both experiences designed strictly true and real, but that is not necessarily an emotional according to the specifc content of the target learning experience. As an example of a laboratory observation being addressed, as reviewed above in Sections 4 and of a non-emotional new experience inducing erasure 5). Rather, the authors extensively refer to multiple of an emotional target learning, consider that afer trace theory and its assertion that every reactivation Schiller et al. (2010) reactivated their human subjects’ of a memory is destabilizing, which, as discussed in Pavlovian fear response, the disconfrming experience Section 4, was reconsolidation researchers’ early mis- that then destabilized and subsequently erased the conception, disproven since 2004 by all of the studies fear was the completely neutral experience of nothing listed in Table 1. happening: No electric shock occurred. Similarly, the central premise of LRNG regard- As examples of corresponding clinical observations, ing the necessity of emotional arousal for recruiting each of the case studies in Section 7 shows an intensely reconsolidation is contradicted by extensive research emotional target learning being mismatched, discon- (Ecker et al., 2015). Tis is one of several widespread frmed and nullifed by a juxtaposition of the target misconceptions about memory reconsolidation (Ecker, learning with a contrary knowing that was just a plain 2015a). Te independence of the reconsolidation pro- fact, that is, a knowing that was not in itself experi- cess from emotion is apparent in the fact that memory enced as signifcantly emotional prior to the juxta- mismatch has been shown to induce destabilization, position experience. Te woman with lifelong anger launching the reconsolidation process, for numerous rooted in the implicit construal, “Life allowed this to types of memory ranging from declarative, neocortical, happen only to me,” formed a juxtaposition of that factual learnings devoid of emotional content (e.g., tar- learning with the contrary knowing that sexual moles- get learning consisting of a set of meaningless syllable tation of children is widespread, which was a familiar pairings; Forcato et al., 2009) to subcortical, intensely fact already in her possession and which had no great

79 INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) personal emotional signifcance before the juxtaposi- pist and client may be focused on derivative emotion. tion occurred. Only when that familiar fact was newly Te methodology works, and yet the critique is correct perceived in relation to (i.e., in juxtaposition with) the and necessary. At stake is the degree to which mental target learning did it acquire intense emotional signif- health clinicians understand memory reconsolidation icance and charge, because in that context the familiar accurately and therefore become able to utilize its full fact suddenly functioned as the liberating disconfrma- potential for relieving sufering. tion of a construal that had been distressing her profoundly for a lifetime. Her anger and her view of the world as arbitrary and unfair then disappeared. Te 10. Conclusion woman with attachment trauma maintaining chronic Te empirically established existence of an erasure terror and a kinesthetic plunge through the foor with process now allows a new coordination between the every interpersonal misattunement, all rooted in the observations made by memory researchers and those implicit construal, “Tere is no one who maintains made by mental health clinicians, who have anecdotal- shared reality,” formed a juxtaposition of that learning ly reported the distinctive markers of such erasure for with the contrary recognition of the plain fact that many decades. Te present article maintains that, ow- actually there is a large subset of people who do main- ing to a fortunate convergence of clinical observations tain shared reality and repair shared reality as needed, and brain research, the translation of reconsolidation including her own boyfriend. Her symptoms then research fndings into efective psychotherapeutic use disappeared. appears to have advanced at an accelerated pace unex- In the empirically confrmed process of erasure, pected by and still largely unknown to neuroscience the juxtaposition experience that unlearns, nullifes researchers. and erases an emotionally intense target learning does It is widely assumed, as asserted by Elsey and Kindt not require an emotionally intense contrary knowing (2017b, p. 477), that “uncontrolled trials and case stud- or counter-learning for this reason: Te essence of ies alone are insufcient for demonstrating the thera- the target learning is its implicit model of reality (its peutic potential of reconsolidation-based procedures, semantic content), not the emotion that arises from as they cannot rule out factors such as placebo efects, that construal of reality. It is the model that is being or convincingly demonstrate that reconsolidation is disconfrmed and unlearned, not the emotion. (For the best explanation for the observed treatment efect.” further discussion of this point, see Ecker, 2015a, Te present article challenges that a priori view by pp. 25–30.) A transformational change in the model showing that clinicians facilitate the same distinct se- immediately produces profound change in the emo- quence of experiences that neuroscientists have identi- tion generated. Tat is clearly apparent in the two case fed as being required for erasure, and then observe the examples noted in the previous paragraph. same distinct markers of erasure that neuroscientists In response to the critique above, the author would use in laboratory studies as confrmation of behavioral expect the G of LRNG to argue, in essence, that he memory updating through memory reconsolidation regularly observes the markers of erasure as a result of because there is no other known process that can pro- carrying out the LRNG clinical methodology, so the duce these markers of erasure. Te detailed correspon- critique must be incorrect. To which the author would dences of unique process and unique outcome consti- reply: Various systems of therapy carry out recon- tute a plausible demonstration that reconsolidation is solidation and erasure with no conceptualization of the best explanation for the observed treatment efect. doing so. LRNG’s conceptualization has the problems Tat clinical advance has been possible largely indicated above regarding how the reconsolidation because of the clinician’s attention to the experiential, process operates, so it is not an accurate account of subjective dimension of the process of change. Tis LRNG’s methodology, which indeed works in prac- article has introduced the principle that optimal clin- tice. By combining emotional reactivation of the target ical translation requires understanding the memory learning with a very diferent emotional experience reconsolidation process in terms of internal, subjective of the original situation, a disconfrmation of model experiences, as distinct from external procedures used occurs implicitly, even though the attention of thera- for creating those experiences.

INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018) 80 It is the author’s hope that this article will help to Alexander, F., & French, T. M. (1946). Psychoanalytic synchronize researchers and clinicians by opening a therapy: Principles and application. New York, NY: channel of collaborative communication for the shared Ronald Press. goal of a new level of therapeutic efectiveness through Alfei, J. M., Ferrer Monti, R. I., Molina, V. A., Bueno, def, versatile use of the reconsolidation process. Re- A.M., & Urcelay, G.P. (2015). Prediction error and searchers Elsey and Kindt (2017a, p. 116), seeing the trace dominance determine the fate of fear memo- magnitude of the potential advance for psychotherapy, ries afer post-training manipulations. Learning & concluded their review by stating, “…if reconsoli- Memory, 22, 385–400. doi: 10.1101/lm.038513.115 dation-based procedures become a viable treatment option, then they would be one of the frst mental Auber, A., Tedesco, V., Jones, C., Monfls, M., Chiam- health treatments to be directly derived from basic ulera, C. (2013). Post-retrieval extinction as recon- neuroscience research. Tis would surely be a triumph solidation interference: Methodological issues or for the scientifc study of mind and brain.” Te present boundary conditions? Psychopharmacology, 226 , article has suggested that, in the work of the clinical 631–647. doi:10.1007/s00213-013-3004-1 early adopters of the empirically confrmed process Badenoch, B. (2011). Te brain-savvy therapist’s work- of endogenous erasure, that triumph may already be book. New York: W. W. Norton & Co. materializing. Baker, K. D., McNally, G. P., & Richardson, R. (2013). Memory retrieval before or afer extinction re- Acknowledgements duces recovery of fear in adolescent rats. Learn- ing & Memory Cold Spring Harbor N, 20, 467– Te author wishes to express much gratitude to each 473. doi:10.1101/lm.031989.113 of several colleagues for valuable feedback generously provided in the development of this article: Dr. Sara Balderas, I., Rodriguez-Ortiz, C. J., & Bermudez-Ratto- K. Bridges, Dr. Hanna Levenson, Dr. Melissa Reading, ni, F. (2013). Retrieval and reconsolidation of object and Robin Ticic. Neuroscience researcher Dr. Javiera recognition memory are independent processes in Oyarzún generously provided a detailed critique of a the perirhinal cortex. Neuroscience, 25 3, 398–405. presentation by the author, which was of much value doi:10.1016/j.neuroscience.2013.09.001. for clearly and accurately representing some of the Barreiro, K. A, Suárez, L. D., Lynch, V. M., Molina, more nuanced aspects of reconsolidation research in V. A., & Delorenzi, A. (2013). Memory expression relation to clinical application. Helpful input was also is independent of memory labilization/reconsoli- received from Dr. Gregory Carson, Laurel Hulley, and dation. Neurobiology of Learning & Memory, 106 , Alexandre Vaz. 283–291. doi:10.1016/j.nlm.2013.10.006 Bateson, G. (1979). Mind and nature: A necessary unity (advances in systems theory, complexity, and the hu- References man sciences). Hampton Press. ISBN 1-5 7273-434-5 Agren, T. (2014). Human reconsolidation: A reacti- Beckers, T., & Kindt, M. (2017). Memory reconsoli- vation and update. Brain Research Bulletin, 105 , dation interference as an emerging treatment for 70–82. doi:10.1016/j.brainresbull.2013.12.010 emotional disorders: Strengths, limitations, chal- Agren, T., Björkstrand, J., & Fredrikson, M. (2017). lenges, and opportunities. Annual Review of Clinical Disruption of human fear reconsolidation using Psychology, 13, 99–121. doi:10.1146/annurev- clinp- imaginal and in vivo extinction. Behavioural Brain sy- 032816- 045209 Research, 319, 9–15. doi:10.1016/j.bbr.2016.11.014 Bjork, R. A. (1992). Interference and memory. In L. R. Agren, T., Engman, J., Frick, A., Björkstrand, J., Lars- Squire (Ed.), Encyclopedia of learning and memory son, E.M., et al. (2012). Disruption of reconsoli- (pp. 283–288). New York: Macmillan. dation erases a fear memory trace in the human Björkstrand, J., Agren, T., Frick, A., Engman, J., Lars- amygdala. Science, 337, 1550–1552. doi:10.1126/ son, E. M., Furmark, T., & Fredrikson, M. (2015). science.1223006 Disruption of memory reconsolidation erases a

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