EMDR and the lessons from neuroscience research
Bessel A. van der Kolk, M.D.
Professor of Psychiatry
Boston University School of Medicine
Research in laboratories devoted to elucidating human memory processes
have consistently shown that memory is an active and constructive process:
the mind constantly re-assembles old impressions and attaches them to new
information. Memories, instead of precise recollections, are transformed
into stories that we tell ourselves and others, in order to convey a
coherent narrative of our experience of the world. Rarely do our minds
generate precise images, smells, sensations, or muscular actions that
accurately replicate earlier experiences.
However, learning from individuals who have been diagnosed with PTSD
confronted us with the fact that, after having been traumatized,
particular emotions, images, sensations, and muscular reactions related to
the trauma may become deeply imprinted on people's minds and that these
traumatic imprints seem to be re-experienced without appreciable
transformation, months, years or even decades after the actual event
occurred (Janet, 1889, 1894; van der Kolk & van der Hart, 1991; van
der Kolk & Fisler, 1995; van der Kolk, Osterman, & Hopper, 2000).
It
is precisely this failure to transform and integrate the sensory imprints
associated with the trauma that causes people with PTSD to behave as if
they were living in the past, even though they may be quite aware that
their reactions are out of proportion with the current stimulus. However,
because of people’s infinite capacity for rationalizing irrational
feelings and behaviors, traumatized people often do not realize that these
feelings or actions are irrelevant to the present.
The discrepancy between people’s “irrational” feelings and
behaviors, and their rationalizations for them, is a function of human
consciousness, which, among other things, serves to protect them from
becoming aware of the true meaning of the messages that are conveyed by
the areas of the brain that specialize in self-preservation and danger
detection.
Thus,
while is “normal” to distort one’s memories, people with PTSD seem
to be unable to put the event behind and to minimize its impact. The
process that prevents memories from becoming “processed”, i.e.
integrated within the large conglomeration of one’s autobiographical
memory stores is dissociation - failure to integrate all elements of the
experience into a coherent whole. Dissociation is the process that
prevents traumatic memories from becoming integrated, and that causes them
to lead a relatively independent existence from the remainder of a
person’s conscious experience. If the problem with PTSD is dissociation,
treatment should consist of association.
The
traumatic memories that need to be associated are not the verbal account
of the past, but the fragmented sensory or emotional elements of the
traumatic experience that are triggered when the person with PTSD is
confronted with a sufficient number of sensory of emotional elements that
are associated with the trauma. When these are activated the entire neural
net in which the memory is stored is stimulated, precipitating a re-living
of an old, terrifying event (Lang, 1985; Pitman et al, 1990; van der Kolk
& van der Hart, 1991).
Thus,
the core pathology of PTSD is that certain sensations or emotions related
to traumatic experiences keep returning in unbidden ways, and do not fade
with time. That does not mean that the stories
that traumatized people tell to explain
what is going on do not change: narratives are a function of the
interaction between speaker and listener. The words that people use to explain what they are feeling and sensing depends highly on the
context in which the story is told: the cues and feedback received by the
environment, and the language that is culturally acceptable for explaining
internal experience. Treating PTSD consists, in large part, of helping
patients overcome the traumatic imprints
that dominate their lives: sensations, emotions and actions that are
irrelevant to the demands of the present, but that are triggered by
current impressions that keep re-activating old, trauma-based, states of
mind.
Until recently we had little knowledge how to help people integrate such
disintegrated traumatic imprints. Traditionally, before the advent of
contemporary methods of treatment outcome evaluation, many clinicians,
from Pierre Janet to Milton Erikson and his followers, considered hypnosis
to be the treatment of choice. Unfortunately the efficacy of hypnosis for
the treatment of PTSD was never systematically studied. EMDR was the first
of a group of new therapies that did not primarily rely on speaking about
one’s traumatic experiences, but that claimed to be able to rapidly and
effectively integrate traumatic memories by asking PTSD subjects to focus
intensely on the emotions, sensations and meaning of the traumatic
experience, while asking to follow the hand of a clinician who induces
slow saccadic eye movements. EMDR had a number of advantages over hypnosis,
including the fact that it could easily be put into a treatment protocol.
This makes it relatively easy to conduct treatment outcome research. Since
it was first articulated by Francine Shapiro, around 1988, it has received
intense scientific scrutiny and has been found to be quite an effective
treatment of PTSD (e.g. Chemtob et. al, 2000), even though the specific
role of eye movements in its therapeutic action remains controversial.
The
Subcortical Nature of Traumatic Memories
The power of
old memories to come to haunt the present with their uncontrollable
intensity and precision confronts us with the fundamental question of how
the mind processes data that are emotionally overwhelming. After people
have been traumatized, certain feelings, sensations or actions can,
without apparent rhyme or reason, generate a predictable set of emotional
or physical responses that are utterly irrelevant to what is actually
going on. These reactions
seem to occur in people who suffer from PTSD because neuronal networks in
the brain are activated by sensations, emotions, feelings that correspond
to the sensations, emotions, or feelings that were experienced at the time
of the trauma. This then tends to activate a response that would have been
relevant on the original occasion (such as fight or flight), but fails to
resolve the hurt, pain, terror, or helplessness that the person
experiences, just as it failed to do so during the trauma itself (Kardiner,
1941).
By definition, an experience
is traumatic when a particular event, or series of events, comes to define
the way people organize their subsequent perceptions. In the first
comprehensive theory of traumatic stress, in 1889, Pierre Janet proposed
that this is the result of people experiencing "vehement emotions"
at the time of a trauma. These, he thought, made it very difficult to put
the whole experience into a satisfactory narrative. Janet was the first to
propose that the inability to fully observe and “own” what has
happened causes an essential failure of memory: the event is organized,
not as a coherent, integrated part of one's self, but as disconnected
emotions, visual perceptions, or kinesthetic sensations that are
reinstated when people are exposed to sensations or emotions that reminded
them of those events.
Janet
proposed that there are at least two different memory systems for intense
emotional experiences: one is an autobiographical memory system that is
verbal, and which serves the social function of being able to communicate
one’s experiences to others. The
other memory system, which we would call today “implicit” memory,
contains the sensory and emotional imprints of particular events that
determine the value that people attach to those imprints (Pitman et al,
1993, van der Kolk & van der Hart, 1991).
Janet suggested that these two memory systems function relatively
independently from each other.
Today
we would argue that subcortical areas of the brain, the primitive parts
that are not under conscious control and have no linguistic representation,
have a different way of remembering than the higher levels of the brain,
located in the prefrontal cortex. Under ordinary conditions these memory
systems are harmoniously integrated, while, under conditions of intense
arousal, the limbic system and brain stem may produce emotions and
sensations that contradict one’s attitudes and beliefs, which causes
people to behave “irrationally.”
Contemporary research has
shown that high levels of arousal interfere with frontal lobe function (Arnsten,
1999; Birnbaum, Gobeske, Auerbach, Taylor, & Arnsten, 1999), that reliving a traumatic experience interferes with adequate
Broca’s area functioning (the brain region necessary to put one’s
feelings into words) (Rauch et. al., 1996) and executive function, located
in the dorsolateral prefrontal cortex (Lanius, in Press).. This, and the
altered functioning of other brain regions that are necessary for proper
appraisal of incoming stimuli (such as the hippocampus, thalamus, and
cingulate, see below) seem to be responsible for the fact that trauma
imprints are organized as fragmented sensory and emotional traces (van der
Kolk & Fisler, 1995; van der Kolk et al, 1996; van der Kolk et al,
2000).
When people remember a particular event they generally do not also relive
the physical sensations, emotions, images, smells or sounds associated
with that event. Ordinarily, all the remembered aspects of experience
coalesce into one coherent narrative that captures the essence of what
happened. As people remember and tell others about an event, the story is
likely to gradually change with time and telling. The “implicit”
memories of traumatic events have a very different quality. When traumas
are recalled people “have” the experience: they are engulfed by the
sensory or affective elements of past traumas. Traditional psychotherapy
has focused mainly of constructing a narrative that explains why a person
feels a particular way, with the expectation that, by understanding its
context, the symptoms (sensations, perceptions, emotional and physical
reactions) will disappear. Or, as Freud put it in Remembering,
repeating and working through (1914): while the patient lives it
through as something real and actual, we have to accomplish the
therapeutic task, which consists chiefly of translating it back again in
terms of the past”.
Freud and Trauma
After visiting the Salpčtričre,
Freud adopted the concepts about hysteria then current at that institution
and returned to Vienna (James, 1894). In 1893 he and his new mentor, Joseph Breuer, wrote a seminal
paper entitled " The phenomenology of hysteria"(1893), in which
they identified most of the critical questions about the relationship
between trauma, memory, and the therapeutic process.
After noting that these patients often lack a narrative memory for
traumatic events, they claimed that "hysterics suffer mainly from
reminiscences". The main topic of "The phenomenology of hysteria"
was the question: what it is about memories of trauma that makes them
impervious to the normal wearing away processes typical of all memory?
Breuer and Freud postulated that, under ordinary conditions, an
emotionally upsetting event is put to rest by an appropriate physical
reaction. This is accompanied by an autonomic or muscular discharge, which
somehow promotes the mental integration of the experience into
autobiographical memory stores. Like
Janet, they felt that it is crucial to move beyond emotionally upsetting
experiences by associating this experience to other memories that are
stored in the mind. This creates a larger psychological context for the
particular experience. When
proper integration occurs, the event comes to serve as an idea that guides
future actions, rather as something that is being revisited over and over
again without resolution, apart from one’s other life experiences.
In their paper, Breuer and Freud (1893) postulated
that when people find adequate physical expression to alleviate their
emotional distress, e.g. such as occurs in acts of revenge, they
eventually can leave the trauma behind. They essentially proposed, many
years before the concept was introduced in psychology (Maier &
Seligman, 1976), that "inescapable shock" lies at the origin of
traumatic neuroses. However,
they did not see physical action as the only way for people to overcome
emotional imprints of past experience.
In their paper they state their belief that by finding verbal
expression for the emotional and factual elements of the experience,
people eventually can put these intense experiences behind them.
With this statement Breuer and Freud set psychotherapy on the road
of "the talking cure" for the next century.
However, the basic assumption that finding words
to express the facts and feelings associated with traumatic experience can
reliably lead to resolution remains to be proven. It might be equally, or more, valid to postulate that
performing the actions that would have overcome one's sense of
helplessness at the time that the experience occurred, and giving
expression to the sensations associated with the memory of trauma will
effectively help people overcome their traumas.
This is just one of the many questions that remain to be studied.
Breuer and Freud (1893) were
struck by another characteristic of extremely upsetting experiences: That
there often is little or no verbal capacity to represent the event.
Whether this is due to intentional forgetting, involuntary
dissociation, or active suppression and avoidance is not the critical
therapeutic issue: the net result is that patients often cannot talk about
the very things that need to be processed in order to come to terms with
what has happened and go on with life. Thus, the hidden nature of the
traumatic imprints vexed many schools of psychotherapy. The big question
necessary for effective resolution was: how create associative networks
that would allow people to integrate and “own” the reality of what had
happened to them, without repeating it, over and over again, without
resolution. In other words: how to make these unconscious imprints
conscious.
Initially, Freud employed
hypnosis, but after having become concerned with the problem of
suggestibility he came to resort to the technique of free association in
which he hoped that by slips of the tongue and deeper understanding of
dreams and other dissociative processes, patients and analysts would gain
deeper access to the unconscious. At
the same time, Freud discovered that unconscious mental assumptions and
interpersonal experiences would be relived in the transference
relationship. Henceforth, psychoanalytic therapy came to rest upon the twin
pillars of understanding the patients' thought processes, as revealed in
free association and in dreams, and the reenactment of earlier
interpersonal schemes and derivatives of attachment relationships within
the transference. Neither of these actually help patients process the
dissociated memories of the trauma.
The Processing of Experience
Humans
continuously filter, interpret, transform and make meaning out of incoming
sensory input, which may come from inside: muscles, viscera, chemical
balance related to food, breathing and fatigue, or from outside: images,
touch, smell and sounds. These
sensations are meaningless unless they are interpreted and attached to
other sensations, configurations, and the larger scheme of things. A basic task of the human mind is to evaluate the
significance of all incoming information, and integrate its emotional and
cognitive significance. In
this process, it needs to rapidly scan millions of possible connections
and associations in order to create the proper interpretation about their
existential relevance. The
mind then needs to create a response that does not only produce internal
satisfaction, but that also is in harmony with the demands and
expectations of the environment.
From the
moment of birth interpersonal processes provide the meaning and context of
sensations and emotions. Newborn babies are continuously exposed to
stimuli from inside and outside that they do not understand or know how to
relieve. Babies depend on their caregivers to change the way they feel,
and are programmed to cry out in order to attract attention. Babies leave
it to their caregivers to figure out how to relieve their distress, which
they do by acting (feeding, changing diapers) and by providing comfort
merely with their presence, by touching them, making sounds (prosody) and
movements (rocking, etc.).
If they are
well cared for, children come to make associations between bodily signals,
distress and various ways of feelings better and, as a consequence, they
learn to utilize their own bodily signals and emotions as guides for
action. As primates, we are
programmed to look for others to provide us with the soothing and
regulation that we cannot provide for ourselves.
We seek help when we are either unable to understand and cope with
uncomfortable feelings and physical sensations, or when we lack internal
schemes to serve as guides for relief. This makes people prone to blame
other people as the source of their distress and expect others to provide
relief. This dependency may easily lead to the sort of tensions and
misunderstandings that everybody, but particularly the parents of small
children, and therapists of traumatized individuals, are intimately
familiar with. If comfort does not alleviate distress, people keep looking
for other means to provide relief. This may range from helplessly clinging
to others, ingesting drugs or alcohol that alter the way they feel, or
engaging in physical acts such like bulimia or self-mutilation which they
have learned will cause shifts in their internal world.
Regardless
of the quality of early caregiving experiences, one’s bodily awareness
remains the very foundation of one’s consciousness. People continuously
try to figure out the meaning of their sensations and most of the time
they can comfortably put them into the context they belong. As people
mature they develop an ever larger capacity to create mental associations
to particular physical sensations that make sense to them, and hence
prevents the emergence of anxiety. However, when meaning of physical
sensations is mysterious, or is
associated with extreme arousal (or numbing), people may be unable to
figure out what to do to manage their sensation and make them relevant.
The sensations have no chance to be associated with potential solutions,
and people either go into a panic, or shut down in an effort to ignore
them or push them away.
Trauma
and Physical Sensations
The
uniqueness of trauma is that certain sensations are carved into mind and
body that are prone to be
interpreted within the narrow definition imposed by a traumatic past.
Examples are: the reactions of combat veterans to the sound of
firecrackers in the summer (but not in the winter, because the temperature
is different), or how incest survivors may react to certain physical
sensations they associate with violation. After developing PTSD, the mind
loses its flexibility to attach incoming sensory information to a whole
range of associations: trauma becomes a black hole that connects all
sensations, “like the rain drops falling on the roof are collected down
the rainspout” (Tank & Hopfield, 1987, p.106; Pitman & Orr,
1990). If PTSD consists of a frozen sensory world, the therapeutic
challenge is to open the patient's mind to new possibilities so that he or
she can encounter new experiences with openness and flexibility, rather
than interpreting the present as a continuous re-living of the past.
Central to
PTSD is an inability to properly place certain physical sensations into
the context of one’s current experience and to, instead, automatically
react with actions, such as hyperactive physical readiness, or freezing.
Those responses appear the sensorimotor equivalents of visual flashbacks
– intrusions from the past that are irrelevant in the present time. It
appears that the sensorimotor processes from the original traumas have not
been assimilated, and are easily triggered again, if a sufficient number
of sensory elements of the original trauma are activated. The traumatized
person is unlikely to be aware of the physical sensations that precipitate
fearful emotions and threatening actions. They are not consciously
experienced as being caused a reminder of something that occurred in the
past - the hyperarousal or freeze reaction usually has no historical
context. It is as if
traumatized people lack a central organizing force to help them place what
is happening in its proper context- in time and space. Trauma-related
sensations are frozen in time, and the sufferer may believe that they will
never end and that they can do nothing to make them stop.
When they
experience such intense emotions, people follow the human inclination to
make meaning out of what they feel. In their attempt to create a context,
traumatized people try to figure out what in their current environment
makes them feel this way: they search for some current stimulus “out
there” that explains why they are so upset.
They tend to blame themselves and think they're not normal. This is
understandable, because something or somebody likely served as a trigger
of the sensations that precipitate such dread, shame, fury or disgust.
However, the attempt to find an explanation for these sensations in the
present is likely to be lead to an attribution to the wrong stimulus and
thus lead to "false cognitions”.
The Neurobiology of Trauma
While the basic psychological
formulations of how the mind processes traumatic experiences had largely
been formulated by the end of the last century (and were rediscovered
episodically throughout the 20th-century – van der Kolk et al, 1996), it
has only been in the last 20 years that we have gained a real
understanding of how the brain mediates these processes. Understanding
these brain processes, in turn, has started to help us refine the
psychotherapeutic interventions that are necessary to overcome trauma.
Numerous studies have shown
that people with PTSD, when confronted with elements of the original
trauma, have psychophysiological reactions and neuroendocrine responses
that reflect their having been conditioned to respond to certain traumatic
reminders as if they were re-exposed to the actual trauma itself. In other words, their bodies continue to react as if they
were traumatized, even though the event may have occurred many years the
past. As Kardiner put it in
1941: “their focus of attention is narrowed down to stimuli related to
threat”. When confronted with a sufficient number of sensory elements
that match the sensory imprints at the time of the original trauma (such
as being touched the particular way, being exposed to certain smells or in
seeing things that remind them of the earlier event), patients with PTSD
activate biological systems as if they were traumatized all over again.
One of the many biological
systems that have been identified as being affected by traumatic
experiences is the part of the limbic system that is centrally involved in
interpreting the emotional significance of experience: the amygdala.
Research in recent years has shown that the limbic system plays a
significant role in causing traumatized individuals to interpret
relatively innocuous reminders as harbingers of return of the trauma.
A part of the limbic system, the amygdala, serves as the “smoke
detector” that interprets whether incoming sensory information is a
threat. The amygdala forms emotional memories in response to particular
sensations, sounds, images etc. that have become associated with threat to
life and limb. These emotional interpretations are thought to be “indelible”,
i.e. extraordinarily difficult to extinguish (LeDoux, 1996): once the
amygdala is “set” to remember particular sounds, smells, bodily
sensations, etc. as dangerous, the body is likely to respond to any of
these stimuli as a trigger for the return of the trauma.
The challenge of any effective psychotherapy, therefore, is to
decondition the amygdala from interpreting innocuous reminders as a return
of the trauma.
The Tyranny of Language
In an earlier paper (van der Kolk, 1994) I have
outlined how it is likely that in traditional, insight oriented
psychotherapy, people learn to understand that certain emotional or
somatic reactions belong to the past, and are irrelevant to their present
lives. This may help them override automatic physiological
responses to traumatic reminders, but not abolish them.
While providing a deeper understanding why they feel the way they
do, insight of this nature is unlikely to be capable of reconfiguring the
alarm systems of the brain.
In a neuroimaging study utilizing PET scans, we (Rauch
et al., 1996) showed that when people relive their traumatic experiences
there is decreased activation of Broca's area and increased activation of
the limbic system in the right hemisphere of the brain. This suggests that, when people with PTSD are re-living their
trauma, they have great difficulty putting that experience into words.
In fact, relatively increased activation of the right hemisphere,
compared with the left, would imply that, when people re-live their
trauma, they are imbedded in the experience: they are having the
trauma, but lack the capacity to analyze what is going on in appropriate
space and time.
Experience shows that when
people are asked to put their trauma into words, while they are in the
process of re-living it, this can be enormously upsetting, and sometimes
even impossible. Re-living the trauma without being firmly anchored in the
here-and-now leaves people with PTSD often more traumatized than they were
before. Recalling the trauma
can be so painful that many patients choose not to expose themselves to
situations in which they are asked to do so, including to exposure
therapies.
Research with such therapies
has shown that, if people are capable of sticking with treatment and
re-live the trauma in words and feelings in a safe therapeutic context,
there is a substantial likelihood that they will overcome their PTSD (Foa
et al.1999; Resick & Schnicke, 1992). However, these forms of
treatment also have very large dropout rates (Pitman et. al., 1991, Ford
&Kidd, 1998; Spinazzola et. al., 2000), probably because patients feel
too overstimulated by the experiencing of the trauma, without getting
rapid relief. So, when treating PTSD one central challenge is how to help
people process and integrate their traumatic experiences without making
them feel traumatized all over again, or, in the language of neuroscience:
how to process trauma so that it is quenched, rather than re-kindled
(Post, Weiss, Smith, Li, & McCann 1997)?
Clinical
Dilemmas Facing the Therapist of Traumatized Patients
Clinicians treating individuals with PTSD are
confronted with a number of issues that complicate the capacity to provide
effective psychotherapy.
1.
Speechlessness. Traumatized individuals often lack the capacity
to communicate the essence of what has happened to them in words. Instead,
the imprints of their trauma consist of sensations and perceptions that
may have no verbal equivalents. Confronted with sensations that re-instate
a traumatic state, people with PTSD simply have their feelings,
maladaptive behaviors, and uncomfortable bodily sensations, without
knowing where they come from. While words may provide validation, a
context, a capacity to provide an explanation
for the origins of their sensations and emotions, they are unlikely to
neutralize the emotional associations of their sensations and make them go
away. In addition, many traumatized individuals suffer from alexythymia, a
lack of capacity to interpret the meaning of their bodily sensations: they
simply may not know what
they feel.
2.
Re-traumatization. When they recall the trauma,
many people with PTSD become so emotionally distressed that the
recollection of the trauma itself feels to them like a re-traumatization.
As a result many individuals with PTSD avoid talking psychotherapy.
3.
The relationship. Many people with PTSD have seen their trust
shattered and are reluctant to make themselves vulnerable to other human
beings, particularly when it comes to issues that make them feel
frightened and ashamed. Many
clinicians assume that a safe therapeutic relationship is the cornerstone
of any therapeutic enterprise. Most
clinicians seem to believe that providing a relationship in patients can
let down their defenses and abandon their distrust is essential for being
able to access memories of the most painful and shameful elements of their
past. At the same time, clinicians working with traumatized
individuals are all too familiar with the fragility of the therapeutic
relationship in PTSD: the frequent disruptions of trust, the abrupt
terminations, the numerous different therapists who have been asked to
provide relief, over time, the intense transference dilemmas in which love
and hate in all their original intensity can make therapeutic, i.e.
reflective and analyzing, work virtually impossible. Maybe the therapeutic
relationship should attempt to provide a context in which the patient is
encouraged to actively mobilize defenses, even in relation to the
therapist, and become discerning in what he trusts and what he doesn't.
Only when the patient possesses adequate defenses can memories be
accessed without retraumatising the patient.
4.
Avoidance. Many traumatized individuals who are in
psychotherapy seem to have been able to construct a narrative of the
trauma that satisfies their need to communicate the essence of what they
went through, but that leaves out some of the critical elements of the
experience. It may be exactly
those elements, the sensations that the patient actively avoids
confronting and re-living in the therapy relationship, that are most prone
to return as flashbacks, nightmares and behavioral re-enactments.
5.
Physiological conditioning. Even after people remember the
totality of the trauma, understand how they re-enact it in their daily
lives, re-establish trusting interpersonal relationships and create ever
larger islands of safety and competence, people with histories of PTSD
continue to be vulnerable to react physiologically to reminders of the
trauma as if they are back in the past.
The Therapeutic Challenge
Given these various dilemmas,
an ideal treatment would help people process the past without their
reexperiencing it as if it were occurring right now all over again.
Such treatment would be able to decondition people from their
physiologically inappropriate responses which came into being at the time
of the trauma, but which are no longer relevant under ordinary conditions.
While ideal treatment would be expected to occur within a
respectful therapist - patient relationship, it would not force the
patient to re-live the pain, disappointment and shame derived from earlier
interpersonal betrayal within that relationship.
Moreover, effective treatment should minimize the time spent on
re-living the past and its concomitant emotional devastation, and help
patients to be fully present in the here-and-now, without the residual
dissociation and/or hyperarousal that is characteristic of PTSD.
Top-down
versus Bottom-up Emotional Processing
More
than a century ago, William James formulated the James-Lang theory of
consciousness, which held that the feeling of emotion is the result of
perceiving the body's change. This means that consciousness is
fundamentally a product of the interpretations that the central nervous
system attaches to the physical sensations that are the products of bodily
states. One central finding
of contemporary neuroscience, as articulated by such authors as Antonio
Damasio (1999), Jaak Panksepp (1998) and Steven Porges (1995, 2000) is
that sensate experience plays a critical role in generating emotional
states.
Damasio
(1999, p.29) states that “the collection of neural patterns which
constitute the substrate of a feeling arise in two classes of biological
changes: changes related to body state and changes related to cognitive
state.” Most forms of traditional psychotherapy have focused largely on
changes related to the interplay between emotions and thought. When a
person is upset, the therapy attempts to grasp the meaning of what gives
it such emotional power, while happenings in a patient’s life are
examined for their emotional significance. Most therapies have essentially
ignored changes related to bodily states: the sensate dimension of
experience. Emotional states
are generated by the state of the body's chemical profile, the state of
one’s viscera, and the contraction of the striated muscles of the face,
throat, trunk, and limbs (Damasio, 1999).
Infants
learn to first interpret their physical sensations in the context of their
physical interactions with their mothers. The only tool that a mother has
to modulate emotional states of a baby is by directly changing the
infant’s physical sensations: by rocking, feeding, stroking, changing
sources of physical discomfort, such as wet diapers, as well as by making
soothing noises and engaging in other comforting physical interactions.
The infant is a “subcortical creature…[who] lacks the means for
modulation of behavior which is made possible by the development of
cortical control." (Schore, 1994, p. 30).
This is strikingly similar
to the experience of traumatized people who also appear to be at the mercy
of their sensations, physical reactions and emotions, which makes it
difficult for them to modulate how they feel.
This physiological hyperreactivity is characteristic of PTSD (Shalev,
1996).
Even
as they mature, human beings continue to rely on the feedback from their
somatic state to signal whether any particular stimulus is dangerous or
agreeable, and, even though they vastly expand their repertoire of
soothing activities, they continue to rely on being able to establish
physical (sensate) homeostasis to establish as sense of “flow”, or
“being grounded”. Many different brain systems are involved in the harmonious
integration of mental functioning. Self-regulation starts at the level of
the brain stem – a part of the brain that is essentially hidden from
conscious experience, and cannot really be modified by reason. As Damasio
(1999, p.58) says:
We
are about as effective in stopping an emotion as we are at preventing a
sneeze. What we achieve is the ability to disguise some of the external
manifestations of emotion without being able to block the automatic
changes that occur in the viscera and internal milieu.
Once people are traumatized and develop PTSD (or if they were
abused and neglected as children and, as a result, lack the experience of
having been involved in a healthy “regulatory dyad”, of which a
healthy mother-child interaction is the prototype), they loose the
capacity for effective regulation of emotional states, which is
expressed as a hypersensitivity to experience unpleasant experiences as
existential threats. This hypersensitivity is based on deficient
internal emotion modulation mechanisms. Lacking the capacity to sooth
themselves, they rely on actions, such as fight or flight, or pathological
self-soothing, such as self-mutilation, bingeing, starving, or the
ingestion of alcohol and drugs, to regulate internal homeostasis.
Fischer,
Murray, and Bundy (1991) have stated that:
The brain functions as an integrated whole, but is comprised
of systems that are hierarchically organized. The "higher level"
integrative functions evolved from and are dependent on, the integrity of
"lower-level" structures and on sensorimotor experience. Higher
(cortical) centers of the brain are viewed as those that are responsible
for abstraction, perception, reasoning, language, and learning. Sensory
integration, and inter-sensory association, in contrast, occur mainly
within lower (subcortical) centers. Lower parts of the brain are
conceptualized as developing and maturing before higher-level structures;
development and optimal functioning of higher-level structures are thought
to be dependent, in part, on the development and optimal functioning of
lower-level structures. (p. 16).
When the organism perceives a threat, this activates pre-ordained
fixed physiological and motor sequences, such as such the startle reflex
and various expressions of the fight/ flight/ or freeze response.
The simplest sequences are involuntary reflexes, located in the spinal
chord (e.g., the knee jerk reaction). These are the most rigidly fixed,
while more complex response patterns are influenced by early experiences,
such as the automatic motor responses that are come on line at an early
young age, such as walking and running.
The degree to which these lower responses can be inhibited depends,
in part of one’s relative level of emotional arousal, which depends on
the activation of brain stem arousal centers. Under ordinary conditions,
one can suppress one’s anger or irritation, or ignore the sensation of
hunger, even while the appropriate physiological processes associated with
these states, such as increased blood pressure, the secretion of saliva
and contraction of stomach muscles, continue.
This inhibition is called "top-down processing" (LeDoux,
1996, p. 272): higher (neocortical) levels of processing can and often do
override, steer or interrupt the lower levels, elaborating upon, or
interfering with emotional and sensorimotor processing (Ogden & Minton,
in press).
Much
adult activity is based on top-down processing: higher cortical areas act
as a "control center”. Neocortical areas such as the orbitofrontal
cortex, the medial frontal cortex and the dorsolateral frontal cortex
hierarchically inhibit subcortical activity
(e.g. Schore, 1994). It
is as though people most of the time hover above their somatic and sensory
experience, knowing it is there, but not allowing it to dominate their
actions. Under ordinary conditions, consciousness allows people to achieve relative
homeostasis and control the machinery of emotion, attention, and
regulation of body states. Or as Damasio (1999, p.28) claims:
We use our minds not to discover facts but to hide
them. One of things the screen hides most effectively is the body, our own
body, by which I mean, the ins and outs of it, its interiors. Like a veil
thrown over the skin to secure its modesty, the screen partially removes
from the mind the inner states of the body, those that constitute the flow
of life as it wanders in the journey of each day.
The
… elusiveness of emotions
and feelings is probably a symptom, an indication of how we cover the
presentation of our bodies, how much mental imagery masks the reality of
the body. Sometimes we use
our minds to hide a part of our beings from another part of our beings
rather than concentrating resources on the internal states, it is perhaps
more advantageous to concentrate one's resources on the images to describe
problems out in the world, on the options for their solution and their
possible outcomes. But this has a cost. It
tends to prevent us from sensing the possible origin and nature of what we
call self.”
Bottom-up processing represents a different way of processing
information. Young children and threatened adults cannot inhibit emotional
states that have their origin in physical sensations. Top-down processing
is based on cognition and is operated by the neocortex. This allows for
high-level executive functioning by observing, monitoring, integrating and
planning. It can only effectively function if the input from lower brain
levels is inhibited.
Traditional
psychotherapy relies on top-down techniques to manage disruptive emotions
and sensations. These are approached as unwanted disruptions of
“normal” functioning that need to be harnessed by reason, rather than
as re-activated unintegrated fragments of traumatic states. Top-down
processing is focuses on inhibiting rather than “processing” (integrating)
unpleasant sensations and emotions. Ogden
and Minton (in press) describe bottom-up processing as follows:
“Patients are asked to mindfully track the
sequence of physical sensations and impulses (sensorimotor processes) as
they progress through the body,
and to temporarily disregard emotions and thoughts that arise, until the
bodily sensations and impulses resolve to a point of rest and
stabilization in the body. The bottom-up element of the process consists
of people learning to observe and follow the unassimilated sensorimotor
reactions (primarily, arousal and defensive reactions) that were activated
at the time of the trauma”.
Bottom up processing, by itself, does not resolve trauma, but if the patient is directed to track and articulate sensorimotor experience while consciously inhibiting emotions, content, and interpretive thinking, sensorimotor experience can gradually be assimilated.
Awareness, as opposed to avoidance, of one’s internal states
allows feelings to be known, and to be used as guides for action. Such mindfulness is necessary if one is to respond adaptively according to the current requirements for managing one’s life. By being aware of one’s sensations
one introduces new options to solve problems. This allows
people
to not react reflexively, but to find better ways to adopt. “Consciousness establishes a link between the world
of automatic regulation and the world of imagination - the world in which
images of different modalities (thoughts, feelings, and sensations) can be
combined to produce novel images of situations that have not yet happened”
(Damasio, 1999, p.258).
Experiences with EMDR
After we completed our first
collaborative efforts to image people having traumatic memories (Rauch et
al., 1996) we became very interested in pursuing the possibility of
imaging how the brain of people with PTSD may change following effective
treatment. When the
clinicians at the Trauma Center began to show each other videotapes of
patients with PTSD that seemed to demonstrate dramatic improvements after
only a few sessions of EMDR, we decided to embark on a pilot study of
treatment outcome using EMDR in which we would use changes in brain
function as one of the outcome measures.
We recently completed that study and will report the full data set
elsewhere. However, in the
study we found that 8 of the 12 enrolled subjects had more than 30 percent
decrease in their caps
scores after three sessions. Generally,
these decreases in PTSD scores were accompanied by a concomitant decreased
physiological reactivity to a personalized trauma script.
Our brain scan images suggest
that several study subjects had decreased pre-frontal lobe activation when
they were exposed to their personalized trauma script prior to treatment.
Following three sessions of EMDR there appeared to be an increase
in pre-frontal lobe metabolism. This
would reflect increased frontal lobe functioning which would facilitate
being able to make sense of incoming sensory stimulation.
This increased frontal capacity appears to be reflected in the
change in our subjects’ accounts of their traumatic memories.
Following EMDR treatment their narratives of the trauma had a much
more symbolic quality than before. For
example, one subject following EMDR treatment reported:
I remember it is it as though
it was a real memory, but it was more distant, more manageable.
It did not have the vividness that I'm used to having.
Typically, I drowned in it, but this time I was floating on top.
I had a certain our in calling up the memory.
I did not feel as helpless I had to feeling that I was in control,
that I was not going to drown.
Similarly, another subject
said pre-treatment condition, "I saw myself really skinny and naked
in the shower. I just see me,
with my skin kind of listening. He
was dressed and I wasn't.”
After the EMDR treatment the same subject said, “It wasn't as
vivid. I did not see myself
on the floor, skinny and wet and frightened.
I just kind of listen to the tape and didn't see anything, until he
has me against the wall.” A
third subject reported after EMDR treatment, "This time it was like a
cohesive unit. I felt each
and every step of it before. Now,
it is like an event. It is
like a whole, instead of fragments, so it is more manageable."
These sort of changes in personal narratives suggest that EMDR is
capable of helping people generate associations between previously
dissociated, fragmented sensory impressions.
EMDR as Accelerated Information Processing
The central challenges of
psychotherapy have always been the quest to help patients gain control
over the feelings that are usually blocked off, but that intrude in behavior and emotion in unbidden ways. Over the
years, different schools of psychotherapy have attempted to use different
techniques to facilitate access to those feelings and promote harmony
between emotions, cognitions and behavior.
Two well-known tools to promote such associations within the
psychoanalytic tradition have been hypnosis and free association.
Psychoanalysis found the understanding of dreams and their analysis
to be an important tool in helping people understand and make associations
between different life events, motivations, and affect experiences.
For reasons that are not currently understood, EMDR seems to
provide a third avenue to facilitate such linkages, a method that appears
to work much faster than any other non-pharmacological tool that has
hitherto been employed.
While
different patients have very different experiences during EMDR treatment
and even patients themselves may have very different experiences from one
session to the next, many patients report very rapid access to material
that they had not consciously linked as being relevant to their current
quandaries. Some patients are
much more articulate about the images and thoughts that come to their
minds during EMDR sessions that others.
EMDR and the Transformation of Experience
Clinical experience has
demonstrated that, with use of EMDR, a person is able to transform her
experiences and integrate her memories of what has happened to her,
combining them with her wishes and imaginations, which allow her to move
towards a subjective sense of completion and control.
Initially, patients report stark images, bodily sensations, and
other imprints of horrendous childhood experiences (the reality of which
were never questioned, and do not need to, because this is her subjective
experience which dominates her perceptions of the present). During the
EMDR session she is able, with little input
from the therapist, to combine these images and sensations with her
wishes to go on with her life.
The three elements of EMDR
that struck me during my own initial experience are also remarkable
elements of this EMDR session. These
are 1) the lack of, or minimal, input from the therapist, 2) the relative
absence of words to describe the details of the traumatic experience, and
3) the activation of new images and thoughts that have, at best, weak
associations to the core elements of the trauma.
A). EMDR promotes the activation of images and thoughts with only
weak associations to core elements of the trauma.
The apparent capacity of EMDR to activate a whole variety of
unexpected to sensations, feelings, images, and thoughts that are
ordinarily not accessed in conjunction with other memories strikes me as
the single most remarkable feature of this procedure. This capacity for association may be how people ordinarily
integrate day-to -day experience into the totality of their
self-experience. Sigmund
Freud searched for ways in which to activate subconscious connections and
came to rely on free association as the best methods available to him. It is possible that EMDR, as Francine Shapiro (1995) claims,
indeed promotes accelerated information-processing, the very thing that
Freud was looking for when he invented the method of free association.
This lack of association, and the persistence of stark, unmodified and
unsymbolized, imprints of sensory and affective elements of the trauma is
characteristic of traumatic memories (van der Kolk & Ducey, 1989).
Robert Stickgold (2000) has pointed out the
similarity between the associative process produced by EMDR and what seems
to occur in REM sleep. He
points out how REM sleep activates cholinergic activity in the brain. He
has proposed that cholinergic activity during REM sleep promotes the loose
association between various elements of experience. It is these loose
associations that give dreams their irrational quality, but also promote
the sprouting of associative networks that open up the possibility of
multiple, flexible associations. Unlike
in traumatic memories, where one sensation precipitates very specific
associated memories, in REM sleep, seemingly like in EMDR, associative
networks are highly flexible. In
some way (hopefully the future subject of a whole new line of inquiry),
EMDR seems to foster trauma related sensations to be integrated into new
associations that are not necessarily connected with the traumatic past.
B). The therapeutic alliance
is not central to the ability to process information, but therapeutic
attunement is. For
effective therapy to occur it must provide some degree of safety and
structure. These are necessary to prevent the activation of interpersonal
projections of threat or rescue. Therapy must help people fully experience
their sensations and emotions without projecting them onto the environment,
or re-activating a sense of helplessness and dyscontrol.
Effective therapy helps people accept trauma-related feelings for
what they are: reminders of the past.
The
basic human position is social: that danger comes from outside and that we
can manage emotions and sensations by controlling and effectively
responding to the external world. People
tend to project internal states of disorganization or fear onto the
outside in order to defend themselves and regain a sense of power and
control. People are programmed to control and inhibit when they feel out
of control. Being unable to
tolerate and utilize physical sensations and emotional states increases
anxiety and the urge to control: a controlling person is an anxious person.
Being able to manage the sensations as distinct finite chunks that
change as a person attends to them creates a sense of mastery and
ownership. This is the beginning of establishing new islands of safety and
purpose, in which people come to trust the process of the body, instead of
trying to fight and dominate it --using the mind to support body
processing.
When people
feel safe, they tend to have pleasurable physical sensations, accompanied
by feelings of openness and expansion. That, in turn, opens up new
possibilities. Early experiences of safety, comfort and soothing give
people a reservoir of pleasurable and safe memories. When they feel
threatened and under stress people with that repertoire can evoke those
feelings and apply them, at least for a while, to deal with the stress at
hand.
This is
opposite of what happens with traumatized people. They often are unable to
distinguish between internal and external.
The task for them then is to gain awareness of the threatening
sensations they experience and place them where they belong, in their
proper time and place. These
sensations need to come to be organized in such a way that they come into
harmony with current reality.
Good therapy
activates and repairs these damaged internal regulatory processes by
facilitating the organization of inchoate trauma-related sensations into
new metaphors and new contexts.
If the central deficit in
PTSD is a decreased ability to associate new information to existing
experience, but, instead, to hyper-associate current sensations to past
pain, the task of therapy is to help patients form new associations that
do not lead to a re-living of the past.
This is not the same as telling stories: it consists of physically
experiencing new possibilities by welcoming and allowing these split
off bodily feelings to run their course. Having
experiences that contradict prior associations may be capable of
stimulating such flexibility.
One of the hallmarks of
interpersonal traumatization is that people who have been victims of abuse
and betrayal are likely to interpret a host of current interactions as a
re- activation of the past: they easily become distrustful, frightened,
aggressive, suspicious, or withdrawn in response to even minor
provocations. The
clarification and understanding of traumatic reexperiencing within the
transference relationship often becomes a central aspect of many
psychotherapeutic endeavors with chronically traumatized individuals.
Even when patients are rationally convinced of the benign
intentions of the therapist, minor misunderstandings or transgressions
often can trigger full-blown re-experience of trauma related affects,
images, and sensations.
While meticulous attention to
these transference pitfalls is essential for successful therapy outcome,
the relationship itself is unlikely to be able to thoroughly rearrange the
patient's conditioned emotional responses and associated physiological
abnormalities. The notion
that a caring relationship between therapist and patient can provide a
corrective emotional experience that can undo the damage of the past is
fraught with difficulties. Any
technique that can help people deal with their traumatic experiences and
that does not necessarily involve a reliance on a trusting relationship
may circumvent the ubiquitous threat of traumatic reenactment.
Conclusions
While
knowledge of the elements of how trauma impacts mind and body is well over
a century old, there has been a gradual refinement of that body of
knowledge. One of those areas is the understanding that trauma is not
primarily imprinted on people’s consciousness, but, instead, becomes
deeply imbedded in people’s sensate experiences. Talking and insight may
help people regain a sense of mastery, but they are unlikely to change
people’s sensate experiences that form the engines of continues
traumatic reliving. The process that started with showing that bilateral
eye movements can help people to rapidly and effectively process traumatic
sensations and emotions, and their associated attributions of self and
other, was a remarkable step in exploring new ways of helping people move
beyond the tyranny of the past.
At
this point we can only speculate about its mechanisms of action, and we
are only at the beginning of the exploration of the precise elements of
therapeutic action. Aside from its remarkable therapeutic efficacy, this
novel treatment changes our most fundamental paradigms about how therapy
changes psychological programs. Providing bilateral stimulation obviously
does not directly affect consciousness, it is likely to act on subcortical
processes that have little or nothing to do with insight and understanding.
The
efficacy of EMDR as a therapy is relevant for the exploration of the basic
underlying mechanisms of post traumatic stress, such as how trauma affects
subcortical processes of emotion regulation, arousal modulation, threat
information and memory processes. It promises to shed light on the
fundamental question of how the mind comes to integrate experience in such
a way that is prepared for future threat, while being able to make a
distinction between what belongs to the present and what belongs to the
past.
Only careful clinical observations, controlled experimentation and the integration of these with the knowledge base of multiple other disciplines, such as neuroscience, learning theory and developmental psychopathology, will allow us to fully appreciate the richness of this new method of psychotherapy that shows such promise to help people move beyond the tyranny of their traumatic histories.