Reflections on Active Ingredients in Efficient Treatment of PTSD – Part 2
Part 1 of this essay summarized data and summarized the methods studied in the ‘Active Ingredients’ Project. Part 2 explores possible change-producing ingredients germane to each as well as across the methods. —————————————————————————
Part 2 of this paper focuses on possible active, change-producing elements of the four therapies for PTSD included in the Active Ingredients Demonstration Project (Figley, C and Carbonell, J., 1995). The methods studied were Eye Movement Desensitization and Reprocessing (Shapiro, 1995), Visual/Kinesthetic Dissociation (Bandler & Grinder, 1979), Traumatic Incident Reduction (Gerbode, 1989), and Thought Field Therapy (Callahan, 1985). While detailed research is indicated toward clarifying the extent of treatment effects, as well as the necessary ingredients involved, momentarily allow some speculation as to the active ingredients. The following is not intended to be a comprehensive compilation but rather a highlighting of some feasible ingredients. It is hoped that this will prove of heuristic value toward advancing understanding of active ingredients, stimulating research, and promoting the evolution and utilization of effective means of treating trauma-based conditions.
At the onset it evident that a significant contribution of the Active Ingredient Project is in its exploration of several methods that appear to efficiently treat trauma. The methods are unique and are predicated on revolutionary theoretical positions. It is therefore evident that there are a variety of ways to efficiently treat the same condition. While this is hardly earth shattering, it nonetheless affords reference points for deciphering the ingredients responsible for the methods’ efficacy. That is, what commonalties account for the efficiency of these methods? Perhaps more importantly, when a method excels in some respect, what are the particular ingredients that account for this?
1. EXPOSURE AND ATTUNEMENT
Exposure has been a primary method for treating trauma, clinical experience and research supporting the position that in vivo and imaginal exposure to relevant stimuli over an extended period of time can result in the extinguishing of negative affective responses. So, too, some degree of ‘exposure’ appears to be an ingredient in the methods reviewed. Each requires the subject to ‘think about’ the trauma, this being necessary toward later desensitization or extinguishing of associated symptoms. While the developers of the methods proffer varying theoretical positions, not always favoring terms such as ‘extinguish’ or ‘desensitization,’ this is understandable and permissible in light of the rapidity of treatment effects and the significant departure of these methods from traditional procedures. In this respect it is evident that exposure alone cannot adequately account for the efficacy of these therapies; otherwise, flooding would prove equally efficient. Additionally the degree of exposure induced with some of the methods is so minimal that ‘attunement’, a term preferred by Callahan (1994), should perhaps be substituted. This term does not indicate intense vivification that is generally implied by ‘exposure’. In instances of exposure as generally understood, it should be borne in mind that the subject willingly maintain an unwavering level of attention to the trauma. This is entirely distinct from traumatic material emerging spontaneously, the subject being the victim of such events. Conscious choice in this manner may frequently serve to create a sense of self-efficacy that further figures into the resolution formula.
2. DISSOCIATED OBSERVATION
An “outside observer” position is promoted directly with V/KD (Cameron-Bandler, 1978), while the other methods may provide this ingredient indirectly. In this respect the subject is no longer “in” the memory but “outside,” looking at it. Such a shift stimulates the acquisition of other understandings while emotionality is reduced. The associated distinction becomes clear as a memory is recalled in a similar manner in which the event was initially experienced. In this instance the image is ‘seen’ through the individual’s eyes, as though it is presently occurring. If affect is associated with such a memory, its intensity is readily perceivable when associated. Dissociation, on the other hand, entails recalling the event with the internal image including the observer, an event that could not have occurred at the time of the original event. This position yields significant decrease in affective intensity relative to associated recall.
With V/KD, this perceptual shift appears to be a primary causal factor in promoting relief from the trauma. It should be emphasized, however, that dissociation is a temporarily induced aspect of the procedure, as the patient is later directed to re-associate and maintain the ‘learning’s’ acquired during the dissociation phase.
3. SUBMODALITIES AND TRANSMODAL REATTUNEMENT
Besides viewing from a dis-associated position, trauma neutralization can also be promoted via change in other facets of internal sensory representations, referred to as ‘submodalities’ (Bandler, 1985). For example, the visual modality can be analyzed in terms of elements such as perspective, proximity, movement, etc. V/KD induces alteration of such elements by having subjects see themselves seeing themselves in the scene. Given this shift as well as others prescribed during the process, additional imagery changes frequently follow. This may entail the memory shifting from a movie to a snap shot, from colorful to achromatic, from clear to vague, etc. Also changes in the visual modality often result in transmodal reattunement. For example, closer appearing images may entail a louder auditory component as compared to more distant appearing images. The other methods often appear to produce similar shifts. Shapiro sites the case of a Vietnam veteran treated with EMDR reporting that the auditory component of the memory silenced, the visual aspects became like “a paint chip under water,” and affect calmed (Shapiro, 1995, p. 4). The author has also obtained similar reports from patients treated with TFT as well as EMDR. For instance, some patients report that the memory appears “more distant” or “vague” after treatment is completed. This is not a hard and fast rule, however, since others report being able to distinctly or even more distinctly recall the trauma, albeit without the previously reported negative affects. Of course, recalling a memory clearly does not exclude the presence of other submodality alterations. Additionally there may be a distinction between cause and effect regarding these factors, depending upon the method involved.
These phenomena warrant closer scrutiny.
4. DUAL ATTENTION
Dual focus of attention is assumed to be a primary ingredient of EMDR (Shapiro, 1995) and possibly TFT as well, in that both entail physical stimulation while the subject attends to the traumatic memory. However the manner in which such simultaneous stimulation occurs is likely significant. For a subject to attend to elements within the environment while simultaneously attending to a traumatic memory, a distraction which certainly occurs even when therapeutic efforts are not being made, may not sufficiently provide this ingredient. Specific eye movements, hand tapping and finger snapping (Shapiro, 1995, p. 67), listening to unique bi-lateral sounds (Yourell, 1995), and tapping at specific acupuncture meridian energy points (Callahan, 1985) and are modes of stimulation likely to be most effective in this regard.
TFT is the only therapy represented that addresses the bioenergy system directly by having the client tap on specific acupuncture meridian points in sequence while accessing the trauma (Callahan, 1985, 1995). This procedure is entirely distinct from other methods of simultaneous stimulation and may reasonably account for the rapid treatment effects of TFT as compared to many other methods. Callahan’s position is that such stimulation transduces kinetic energy into the bioenergy system, thus removing perturbations or ‘active information’ (Bohn and Hiley, 1993) from the specific thought field (i.e., which includes a memory of the trauma). Perturbations are hypothesized codes which cause the energy system to activate negative affects.
If all fundamental change entails transformation at the energy level, then other effective methods may also treat the energy system in distinct ways. Perhaps EMDR primarily stimulates a neurologic process that accelerates information processing while balancing the energy system, thus alleviating negative affect and other sequelae associated with the trauma. V/KD may accomplish this same effect via reframing and alteration of internal sensory representations, which are facilitated through reduction of negative affect via temporary dissociation. TIR possibly accomplishes this same end by assisting the patient in accessing interest and promoting the acquisition of repressed information.
Choosing to recall a trauma entails paradoxical elements that have been observed to be curative among a variety of therapeutic systems. Consider Victor Frankl’s paradoxical intention, Milton Erickson’s double binds, and the Zen Master’s koans. As the subject attends to the disturbing memory, perhaps there is a suspension of usual ways of experiencing, thus permanently altering the experience of the trauma. Bear in mind, however, that this may only be a side feature, since it does not appear that paradoxical procedures have generally been as rapidly effective as the methods presented.
Each method departs from pure exposure to varying degrees, assisting the client in feeling more comfortable during the course of attuning the trauma. The least divorced from flooding appears to be TIR, while the most removed and thus most comfortable for both client and therapist is TFT. Comfort is an important aspect of the most rapid means of alleviating trauma. The more comfort experienced during the procedure, the more rapidly neutralization is prone to occur. While it is not entirely accurate to compare the methods studied in the AIP, since the study was not structured to yield such comparisons, the data nonetheless favor such a hypothesis in that results were most rapidly achieved with TFT and least rapidly with TIR. (Although TIR represents a definite advancement over flooding in that it achieves results more efficiently by focusing on resolving the trauma within the context of a single session and by connecting the identified trauma with earlier associated traumas, it nonetheless appears to be in closest propinquity to flooding relative to the other methods.) While methods such as systematic desensitization inhibit anxiety via progressive relaxation while reviewing segments of the trauma (i.e., reciprocal inhibition), these newer therapies utilize other, more rapid means of interrupting associated negative emotionality. Eye movements, bilateral tapping and sounds (EMDR); tapping on meridian energy points (TFT); or dissociation (V/KD), each promote comfort by interrupting the intensity of negative affects. Comfort allows one to attend more easily on the trauma. Additionally comfort becomes associated with the trauma, quelling its effects. Again the reader’s attention is directed to the fact that while comfort appears to be a relevant factor, it can hardly account singularly for the results evidenced with these therapies or efficient therapy in general.
8. POSITIVE EXPECTATION
Expectations are promoted that the memory will be resolved within the context of the session, rather than perpetuating the notion that extended time is needed. This challenges the subject’s belief to the contrary, reinforced by the fact that distress has existed over an extended period of time. As Rosenthal and Frank suggested, “It may well be that the efficacy of any particular set of therapeutic operations lies in the analogy to a placebo in that they enhance the therapist’s and patient’s conviction that something useful is being done” (1956, p. 300). This may be a relevant ingredient with methods such as TIR and V/K D, but it is possibly less likely that odd-appearing TFT and EMDR would be conducive to promoting placebo effects. Subjects may be less inclined to believe that moving one’s eyes or tapping at specific points on the body could neutralize trauma. While some may find this a plausible notion, likely most people in Western culture would be less inclined to experience positive expectation from such procedures.
9. READER’S CHOICE
In the interest of assisting in the identification of active ingredients in trauma therapy, the reader is invited to explore the ingredients suggested in the efficiencies of the therapies presented and to evaluate other trauma therapies in accordance with these and other plausible ingredients.
Bandler, R. and Grinder, J. (1979). Frogs into Princes. Moab: Real People Press.
Bandler, R. (1985). Using Your Brain–for a Change. Moab: Real People Press
Bohm, D. and Hiley, B.J. (1993). The Undivided Universe: an ontological interpretation of quantum theory. Routledge, NY.
Callahan, R. (1985). Five Minute Phobia Cure. Wilmington: Enterprise.
Callahan, R. (1994). Thought field therapy glossary. Unpublished paper, Indian Wells, CA.
Callahan, R. (1995). 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. (1989 ). Beyond Psychology: An Introduction To Metapsychology. Palo Alto, CA: IRM Press.
Rosenthal, D., and Frank, J.D. (1956). Psychotherapy and the placebo effect. Psychological Bulletin, 53(4), 294-302.
Shapiro, F. (1995) Eye Movement Desensitization and Reprocessing: Basic Principles, Protocols, and Procedures. New York: Guilford.
Yourell, R.A. (1995). The reprocessing manual. Denver, Co.