Reflections on Active Ingredients in Efficient Treatment of PTSD – Part 1
This two-part essay summarizes the therapeutic procedures presented at The Active Ingredients in Efficient Treatments of PTSD Conference at Florida State University, May 12-13, 1995, and delineates some possible salient change-producing ingredients germane to these approaches.
Four therapies for PTSD were presented at the Active Ingredients in Efficient Treatments of PTSD Conference, Florida State University, May 12-13, 1995. The conference was presided over by the principal investigators of the clinical demonstration study by the same title (Figley, C.R. and Carbonell, J., 1994). The methods included Eye Movement Desensitization and Reprocessing (Shapiro, 1995), Visual/Kinesthetic Disassociation (Bandler & Grinder, 1979), Traumatic Incident Reduction (Gerbode, 1995), and Thought Field Therapy (Callahan, 1985). Each method was summarized by the developers and/or representatives, preliminary results of the demonstration project were provided, workshops were presented and penetrating discussion ensued.
The four approaches were selected on the basis of nominations by traumatology professionals in response to the investigators’ request, the Internet facilitating the process. Over a dozen nominations were initially received; however, most did not fulfill criteria for inclusion in the study: verification of effectiveness by at least 300 licensed/certified clinicians who regularly treat PTSD clients; replicable under laboratory conditions at FSU; readily teachable to paraprofessionals; willingness of the principal developers to defend the approach to academic, clinical researchers at FSU; and willingness of the developers and/or principal practitioners to treat clients at FSU for a week under research conditions.
Four to six month follow-up’s revealed that all of the approaches yielded sustained reduction in subjective units of distress relative to treated traumatic memories (although some rebound in SUD’s was evident in many cases). The average pre-treatment SUD rating on a 10-point sacle was between 8 and 9. Noting that the follow-up evaluation time frames and N’s varied considerably across treatment conditions, notably imposing variables, respective Mean Group Treatment Times and Post-Treatment follow-up SUD ratings were as follows: TFT (N14) 63 mins, 3.60; V/K D (N11) 113 mins, 3.30; EMDR (N6) 172 mins, 2.64; TIR (N9) 254 mins, 5.67. (A variety of psychometric and physiologic measures not discussed in this article were also obtained.) While strict comparisons among the methods would not be valid due to varying client selection criteria across methods as well as other variables, preliminary results nonetheless support the contention of the nominating professionals that the methods are effective in reducing distress associated with traumatic memories.
What, then, accounts for the reduction in symptomotology? This paper succinctly describes each method and offers hypotheses as to active ingredients specific to and/or across methods. The hypotheses are not necessarily those endorsed by the developers of the methods but are presented for heuristic purposes.
EMDR directs the client to attend to traumatic memories while ‘tracking’ eye movements, in response to the therapist!s prompting. The client also internally rehearse an associated negative belief (e.g., ‘I’m powerless.’) initially and sometimes intermittently during the eye movements, and attends to emotional and physical factors stimulated during the process. SUD’s are monitored, while the therapist follows the client in a fairly non-directive manner, prompting eye movements as relevant material emerges. After this results in significant reduction in SUD’s, the client rehearses an appropriate positive belief (e.g., ‘I’m worthwhile.’) during eye movements, in order to ‘install’ the belief. It should be noted that during EMDR associated memories, evidence of a greater memory network, often emerge and are treated in a similiar manner. Other phases of treatment include ‘body scan’ to evaluate progress and determine targets for additional sets of eye movements if necessary, and ‘closure’, which includes assessment of safety, client debriefing, etc. Forms of stimulation other than eye movements, including tones, light, and physical tapping, have also been found to be effective.
Shapiro believes that the stimulation triggers ‘a physiological mechanism that activates the information-processing system’ (1995, p.30). She lists various mechanisms that may be responsible for activating and facilitating processing: ‘…dual focus of attention…to present stimuli and the past trauma; a differential effect of neuronal bursts caused by the various stimuli, which may serve as the equivalent of a low-voltage current and directly affect synaptic potential; [and] deconditioning caused by a relaxation response’ (p.30). The traumatic material is assumed to be processed to an adaptive resolution via accelerated information processing. It is proposed that this tends to occur naturally with lesser issues, but is frequently blocked when one is exposed to intense experiences such as trauma. EMDR serves to activate this natural mechanism.
V/K D assists the client in disassociating from the negative feelings associated with the traumatic memory by visually reviewing the event from a different perspective (Cameron-Bandler, 1978). One approach to V/K D is to direct the client to visualize a snap shot of a moment immediately prior to the event, and then to introduct disassociation by having the client watch himself in that past scene. Disassociation can be further enhanced by having the client maintain a perceptual position that entails an additional level of dis-association as contained in the instructions: ‘Watch yourself watching the younger you over there in the past going through [the trauma].’ Most clients are able to achieve this perceptual shift with assistance. While disassociation is maintained, the client is directed to allow the !movie! of the memory to unfold and to become aware of understandings or resources needed in order to promote resolution. For instance, it may become evident to the client that ‘It is over and I survived.’ The client is then asked to ‘share’ this knowledge with the ‘past self’, the one who suffered the trauma.
The sharing obviously takes place in imagery. This often results in significant reduction of negative affect with any future recall of the memory.
V/K D is a Neuro-Linguistic Programming (NLP) technique. NLP is a method of modeling and not a theoretical position. It entails patterning the internal and external behaviors of people who have been able to achieve consistent results in various activities, including psychotherapy. V/KD was likely modeled from the behavior of hypnotists such as Milton H. Erickson, MD. It is based on the recognition of synesthesia patterns, S-R bonds between sensory systems. For example, an external or internal visual stimulus can result in an unpleasurable kinesthetic response. When employed to treat trauma, the focus is on interrupting the synesthesia pattern by introducing dis-association while the client attends to the memory. This creates a revised S-R bond. That is, since the individual no longer recalls the trauma in an associated manner, negative emotionality is removed from the memory.
This process should not be confused with the global dissociation that is characteristic of conditions such as PTSD; dissociative amnesia, fugue, and identity disorder; depersonalization disorder; etc. While these disorders involve severe disruptions of various integrative functions, VK/D merely entails a shift in one’s perception of a memory from associated (i.e., as if one is reliving the experience) to dis-assiciated (i.e., not experiencing the memory in an associated manner).
TIR is a method whereby the client, referred to as ‘viewer’, visualizes the traumatic incident while the therapist provides instructions. The viewer locates an incident that is believed by the therapist to be resolvable within the course of the session, which may require several hours. The viewer is instructed to choose a most ‘interesting’ traumatic event, since it is assumed that ‘interest’ signals the capacity and inclination to learn. Once an incident is located, the viewer is instructed to note any awareness just prior to the event unfolding. Next the event is viewed silently from beginning to end, after which the viewer reports what was observed. This process is repeated until the viewer arrives at a resolution. It is assumed that there are gaps in the viewer!s awareness and that by repeatedly viewing the event, this information comes to the fore, thus resulting in alleviation of negative emotions and cognition associated with the event. The resolution of an earlier associated trauma, the awareness of which may emerge during this process, is also assumed to be relevant in this regard.
TFT directs the client to attend to a disturbing traumatic memory or other emotionally charged condition while physically tapping on specific acupuncture meridian points. The therapist often follows a diagnostic process involving a muscle testing procedure to discern a specific sequence of meridian points needed in order to achieve therapeutic results. Another TFT diagnostic procedure, the Voice Technology, determines a sequence by electronically evaluating frequencies in the voice. A standard TFT trauma algorithm, derived from diagnostic procedures, has the client attune to the traumatic memory, determine a SUD’s rating 1-10, and then briefly tap on each of the following potent meridian points (i.e., major treatments) in sequence: beginning of an eyebrow above the bridge of the nose, directly under an eye orbit, approximately four inches under an armpit, and under the collarbone next to the sternum. After these treatments are completed, the SUD rating generally dropping by several points, the client is directed through the Nine Gamut Treatments (9G), which involves simultaneously tapping between the little and ring fingers on the back of a hand while doing the following: eyes closed and opened, eyes down left and down right, eyes in clockwise and counterclockwise directions, humming notes, counting, and humming again. At this point the SUD!s are generally lower yet, and the client is directed to repeat the major treatments. Frequently at this phase, all or most distress associated with the memory has been alleviated. If the SUD rating is not down to a 1, repeating the treatments will often achieve the desired results.
Sometimes associated memories emerge when treating a targeted traumatic memory. The TFT treatments are then merely directed at the new material, which is generally treated just as quickly an effectively as the target memory.
Also at times a client evidences a condition referred to as psychological reversal (PR), which blocks the treatments from working. It is hypothesized that PR entails reversed energy flow in the meridians which results in a negativistic, self-sabotaging state. PR treatment often quickly corrects this condition so that therapy can proceed successfully. While a variety of PR!s have been identified, the most common form is corrected by having the client simultaneously tap on the little finger side of a hand while repeating an affirmation such as, ‘I accept myself even though I have this problem.’ TFT is based on the assumption that psychological problems are manifestations of isolable active information (Bohm, D. and Hiley, B.J., 1993) energically coded within !thought fields.’ Callahan (1994) defines a thought field as follows: ‘… the specific thoughts, perturbations and related information which are active in a problem or treatment situation. In order to diagnose and treat effectively the appropriate thought field must be attuned.’
Examples of thought fields include traumatic memories, thinking about or being in proximity of phobic object, or even the thought of an elephant. A perturbation is defined as ‘the fundamental and easily modifiable trigger containing specific information which sets off the physiological, neurological, hormonal chemical and cognitive events which result in the experience of specific negative emotions’ (Callahan, 1995). By removing the perturbation(s) from the thought field, distress associated with the traumatic memory, the phobia, or the thought about an elephant (if one is phobic of elephants) is alleviated.
Thus Part 1 comes to a close. Part 2 of these reflections will delve into various mechanisms that may account for the therapeutic efficacy of these “power” therapies.
Bandler, R. and Grinder, J. (1979). Frogs into Princes: Neuro-Linguistic Programming. Moab: Real People Press.
Callahan, R. (1985). Five Minute Phobia Cure. Wilmington: Enterprise.
Callahan, R. (1994). Thought field therapy glossary. Unpublished paper, Indian Wells, CA.
Callahan, R. (1995, August). A thought field therapy (TFT) algorithm for trauma: a reproducible experiment in psychology. Paper presented at the Annual Meeting of the American Psychological Association, New York.
Cameron-Bandler, L. (1978). They Lived Happily Ever After. Cupertino, CA: Meta Publications.
Figley, C. R. And Carbonell, J. (1995). The ‘Active Ingredient’ Project: The Systematic Clinical Demonstration of the Most Efficient Treatments of PTSD, A Research Plan. Tallahassee: Florida State University Psychosocial Stress Research Program and Clinical Laboratory.
Gerbode, F. (1995 ). Presentation on Traumatic Incident Reduction at ‘Active ingredients in efficient treatments of PTSD’ Conference at Florida State University, May 12, 1995.
Shapiro, F. (1995) Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. New York: Guilford.