Healing Emotional Wounds
By Marilyn Sulzbacker, LCSW, BCD, CGP
It is an exciting time for psychotherapists and their patients to work more effectively together. Thanks to current findings in the field of neuroscience, new therapies have developed that focus on "rewiring" the brain by using techniques to open up new avenues in the brain which will allow the patient to be receptive to learning new and more positive ways to cope with restrictive, stifling and negative behavior patterns. By focusing on getting to the bottom of what factor(s) cause the problematic behavior pattern(s), the therapist and patient collaborate to change the brain's "muscle memory" to be more flexible in how it reacts to situations, ideas and people, thus allowing the patient to achieve a freer and more positive way of coping with day-to-day life as well as with past traumas which, in turn, will promote healthy individual growth.
The writings of Dan Siegel, Bessel Van der Kolk, and Allan Schore have transformed our knowledge of neuroscience. Neuroscience shows that the brain is capable of changing (neuroplasticity) and developing new nerve cells (neurogenesis) which ultimately results in the formation of new pathways and behavioral change. For the formation of new networks, certain parts of the brain need to be working together (neural integration). Experiences create and develop these neural networks. It is important for us to understand how the brain is affected by all experiences, but, in particular, experiences of “trauma” which exist on the continuum of ongoing misattunement to severe abuse.
We think of the brain as a “triune brain” (McClean, 1967) which includes: (i) the brainstem as the most primitive part of the brain - the reptilian brain - that carries our instinctive responses, heart rate, respiration, fight-flight, adrenalin release (sympathetic nervous system) and freeze/immobilization response (parasympathetic nervous system) and it is the first area that gets affected by trauma; (ii) the limbic system (comprised of the amygdala, hippocampus and hypothalamus) which controls affect, attachment, memory and meaning making The amygdala is the brain’s “smoke detector” or fire alarm system and acts on the premise of “better safe than sorry.” It continues to repeat the same response/action because the initial experience gets generalized and there is not yet another context from which to draw. Therefore, if a child burns his/her hand touching a hot stove, he/she may not understand that it's okay to touch a stove if it is not hot. The data is not passed on to the hippocampus which passes the narrative to the left frontal cortex which can put it in context. The hypothalamus activates the hormonal system (CRF, ACHT, cortisol) This is an important area for psychotherapy; and (iii) the cortex, which includes the right and left hemispheres and the prefrontal cortex. The right hemisphere deals with perception, holistic nonverbal and autobiographical memory, whereas the left hemisphere is factual, linear, logical, and deals with language. The right hemisphere takes information from the body and the brainstem and integrates it with the left hemisphere. The prefrontal cortex, a key structure, involved in mindfulness, is vital in coordinating all the areas of the brain mentioned above to function as a whole. The anterior cingulate with the prefrontal cortex is involved in emotional processing and working memory. Mirror neurons, crucial to empathy and connection also reside in the cortex. The cortex is the seat of our foresight, hindsight, and insight.
It is essential to use this information to understand how memory gets laid down, runs our lives, and is not immutable. We know that neurons that fire together wire together and strengthen with repetition. Experiences that have strong emotion, whether attachment related or not, trigger our limbic brain function, taking our prefrontal lobes off-line. The memory of the event then becomes implicit memory, of which we do not have conscious or explicit memory, and it drives our behavior, beliefs, and emotions. We are on automatic pilot and we strengthen these neural networks with each repetition.
The good news is that with our understanding of neuroplasticity, we can rewire the brain and downgrade or remove the older neural pathways using new therapies, including: Bruce Ecker’s “Coherence Therapy; Diane Fosha’s AEDP (accelerated experiential dynamic psychotherapy); Pat Ogden and Janina Fisher’s Sensorimotor Psychotherapy; Richard Schwartz’s IFS (Internal Family Systems Therapy) and Francine Shapiro’s EMDR (eye movement desensitization reprocessing).
The basic tenet is that experience structures and wires the brain. As a result, we think, feel, behave in a specific manner, and the whys are often buried in the unconscious mind. Different approaches can be used, as Bruce Ecker describes, to "unlock the emotional brain.” It is important to remember there is always a reason and coherence for behavior and those issues need to be known, appreciated, respected, accepted and understood. When this occurs in the presence of a nonjudgmental caring other, the opportunity for neural restructuring and memory reconsolidation takes place.
The Richard Schwartz Internal Family System (IFS) envisions the person as having a multiplicity of selves that interact. He divides the person into three parts: (i) the self, (ii) the protectors (managers and firefighters), and (iii) the exiles. We are all born with a core self described as holding the qualities of curiosity, compassion, clarity, calmness, confidence, creativity and courage. (Diane Fosha speaks of the core state as embodying many of these qualities). This self is always with us and, since we do not live in a perfect world, we have experiences that, to varying extents, submerge the self. Examples of such experiences include suffering neglect/abuse, loss of a significant person, birth of a sibling, bullying, accidents, and moving. These experiences may be momentary or chronic. The exiles carry the burdens of those past wounds and hold extremely painful emotions and beliefs (such as shame, loneliness, worthlessness, neediness, unlovability, powerlessness, fear, grief) and keep them isolated from the conscious self to protect the person and the rest of the system. But they are always there pushing to be heard and accepted. The protectors are the proactive, future-oriented managers in place to protect the person from feeling rejected or hurt as he/she had been when the exiles came into being. Furthermore, they are the usually socially acceptable organizers, controllers, caretakers, strivers, judges, critics, etc., and, when fired up, are tenacious in fulfilling their perceived function. The firefighters are present-oriented protectors, usually less socially acceptable and more reactive. They emerge almost like a last line of defense when the self and managers are not keeping the exiles at bay. We see this manifested in various addictions, violence, self-harm, and suicidal ideation. They, too, want to be seen and appreciated for their work.
In the IFS protocol, we work to enable the person be self-led so that a dialogue can be had between the self and the part. For example, dialogue with the manager would focus on the manager's purpose and its fear of what would happen should the manager cease doing its "job” The “critic” could be there to help the person “shape up” so he/she won’t feel inadequate (which is really what the “exile” is experiencing).
To heal the exile of the burdens it has carried, we need to stay at an optimal arousal level and not trigger the autonomic nervous system or limbic brain. In IFS, we would ask the exile not to overwhelm the self so we can hear its story. Sharing the past painful, overwhelming emotion and extreme beliefs it holds in the present with the self (and having it witnessed and validated) sets the stage for new transformations. As part of the protocol, the self enters the scene with the exile and provides it with what the exile says it needs by imagining it. Usually the exile is just happy to be heard and wants to maintain the connection with the self. (It is important that this is done to sustain new neural networks—any change needs reinforcement for it to take hold). The exile part can then, using a specific imagery, unburden or let go of these extreme beliefs or emotions. New qualities are then brought in to replace what was given up. The protector part chooses a new role as well. In this IFS process, and in the presence of the self, the exhausted protectors and the exiled parts unburdening these extreme beliefs and emotions, makes implicit memory explicit, and allows for the brainstem, limbic brain, and cortical parts to work together in forming new neural networks.
Francine Shapiro’s EMDR focuses on adaptive information processing, seeing (misguided) patterns of behavior, feelings and thoughts as being locked in neural pathways, closed to taking in new and relevant information, and being repeated in daily life. Her technique uses bilateral stimulation of the right and left hemispheres to open the brain to develop new neural pathways. The oscillating bilateral stimulation could be eye movements, auditory or tactile. Her particular protocol is to have the person describe the emotionally charged incident (target); the feelings, body sensations, negative belief about self the person connects to the experience; the positive belief they would like to have (important for hopefulness) and how disturbing it is. (Negative beliefs include: safety/vulnerability, i.e.” I cannot be trusted,” responsibility, i.e. “I did something wrong,” control, i.e. “I am powerless/helpless”. Positive belief should be congruent with the negative, i.e. “I can be trusted, I did the best I could, and I have choices”). The person is asked to hold on to all of this and bilateral stimulation begins. The only instruction is to go with the flow and notice what emerges. The “optimal window of arousal” is maintained by having the person appreciate that the process involves having “one foot in the present and one foot in the past.” Using EMDR, the memory, however disturbing, is seen as in the past so as not to overwhelm or retraumatize the person.
Other strategies also ensure the optimal window of arousal is maintained. When it appears the person has had an experience via the bilateral stimulation, the person is asked to report it. As long as the person makes connections and associations related to the target, the process continues without therapist intervention. If, however, there is an interference with the processing, certain “cognitive interweaves” are used to get it back on track. It is important to note we are not inserting in false memories, but creating opportunities so the person may be open to new experiences. The memories do not change – the relationship to the memories do. We know this experience has been completely processed when there is no longer any disturbance in the memory, the body scan reveals calmness, and the person strongly believes in the positive cognition. This is a transformational shift that gets reinforced by having the person experience themselves in the same situation and practicing the new response. (This is what is established as the future template). Neural integration has taken place.
Pat Ogden‘s Sensorimotor Psychotherapy (SMP) has the body experiences as the entry point for interventions, while the emotional experiences and meaning making arise out of the subsequent somatic reorganization of the habitual responses. In this instance, the focus is on how the body is processing information in the here and now, rather than on the narrative or “story” of past events. The goal is to develop the capacity for mindful internal awareness that allows for the integration of experience, to weave together the unconscious somatic reactions, habitual cognitive schemas and the reflexive emotional responses. The person is encouraged to notice what happens in the body - the physiological changes, inner sensations, movements (small or large), and gestures that occur as the story is being told and we ask for the beliefs and/or emotions that go with this.
SMP uses a body-centered focus to create opportunities for new experiences that can undo old habitual responses. For example, a bullying victim arrives for a session and cowers as he/she speaks softly. The therapist encourages the patient to connect with the ebb and flow of his/her feelings, thoughts, and body sensations, after which a shift occurs and the patient might sit up straighter or push his/her arm out. We have him/her very slowly and in small steps just continue to sit up straighter and extend the arm further out and keep checking in with her what that is like. The patient says she/ he wants to say “stop” and at first this is said softly. At this point, the therapist introduces “experiments” into the session and suggests the patient try to say "stop" a little louder and/or extend the arm a little further as if to gesture pushing away something. Sometimes it helps if therapist and patient shout “stop” together and the therapist offer counter-pressure to the arm pushing. This is done several times and, if successful, the patient reports reports an internal shift – feeling a sense of power. The patient continues to practice these movements and, sessions later, reports that he/she is able to stand up to being bullied. There are several sensorimotor techniques used to maintain affect regulation, enhance coping skills, and offer new challenges. The hallmarks of this work are that it is experiential, not interpretive; develops mindfulness by observation and noticing; and uses “experiments” (rather than suggestions).
Diana Fosha’s accelerated experiential psychodynamic psychotherapy (AEDP) uses emotions as its point of entry and works within a relational framework. Emotions are seen as playing a primary role in organizing and motivating behavior. Psychopathology results when a person feels alone when faced with overwhelming emotion and necessitate instituting defenses against the affective experience. The underlying belief in AEDP is that change takes place when aloneness is counteracted in the context of the affect regulating relationship with the therapist which allows for the person to reconnect to his/her capacity to experience deeply buried emotions. The focus is on the recognition and tracking of these emotional experiences. These emotional experiences are fully explored it in all its detail: naming it, naming and noticing what gives rise to the defenses as they emerge, validating the experience, and always asking the patient what it is like to have that experience with the therapist. This “metaprocessing” is unique to AEDP and provides the opportunity for new connections to solidify and take hold—it is the glue that reinforces the transformations that the patient has gone through.
Bruce Ecker’s Coherence Theory (CT) rests on understanding that our symptoms or behavior patterns have a reason. The work begins by getting to the emotional truth of why a person feels exhibiting a certain symptom is necessary. The focus is maintained on the pro symptom position. Specific techniques implemented include symptom completion sentences, symptom deprivation, overt statement, and going for what is underneath the presenting problem. Emphasis is on having the patient speak about the emotional truth and working to see all the ways it is connected to earlier experiences. Giving the patient an index card stating the purpose of each symptom and the applicable trade-off is a powerful tool to help keep the process alive.
Take, for example, an overly responsible woman who assumes the role of family caretaker while subverting her own feelings and time management to accommodate her family members. The patient receives an index card stating: “If I were to take care of myself, my sense of guilt about not being responsible in meeting other people's needs would be so overwhelming and my fear of losing that family connection is so strong that I prefer to sacrifice myself and not count as a person.” The patient reports feeling a “familiar, sick, sinking feeling” if she does not handle things for others regardless of how doing so may adversely affect her. The patient would feel responsible if anything bad happens as a result of her not taking care of things. She finds it difficult to ask anyone else for help because, if she does accept assistance, she feels she is being a burden. The patient's early experiences supported that she was expected to sacrifice herself for her family and be responsible for their well being. The demands were often inappropriate and unreasonable and her needs were not validated. As this truth became more explicit for her, and as she continued to be aware of all the ways she lived her life abiding by this belief , she developed a better sense of her own autonomy and and was better able to focus on personal growth.
Another empowering, self-validating experience is achieved by having the person engage in an imaginary dialogue with the significant other responsible for the pro symptom position and telling them (in a non-accusatory tone) how their behavior affected him/her. In a session, the woman noted that other people were able to ask the boss for something and it was fine. Working through the process, she was finally able to ask the boss for something and it turned out to be a mutually beneficial request. She began to see that being responsible did not mean she had to take over for the other(s). She learned that her husband felt more "like a man" when she didn't take responsibility for doing everything and she was able to help her children feel more empowered and more open to learning by working with them rather than doing things for them. She is now more demonstrative in her requests and sees positive results. She is encouraged to keep noticing these contradictions and to reflect upon them. These acknowledged juxtaposing experiences challenge the old patterns which begin to lose its power and sense of realness. Memory reconsolidation occurs when these transformations take place. We know that the old synapses have been replaced because now, in her interactions, she can still feel her needs as valid even if the others disagree and she can maintain healthy boundaries of responsibility at work and with her family.
The therapies discussed above are in keeping with the understanding of neuroplasticity and how experiences shape the brain. In addition to curiosity, noticing and observing (being mindful) are the guiding forces in this work. There is trust in the process to help heal and unlock the emotional brain and in the knowledge that the brain will strive to heal. The therapist is always sensitive to working in the “window of optimal arousal” so transformational work can take place. The therapist does not interpret, does not lead, but follows the patient's processing furthering the patient’s sense of empowerment. All of these approaches are nonpathologizing. There is respect, appreciation, and understanding for our behaviors as having served an important purpose. An important part of these therapies is: (1) witnessing extreme emotions and negative beliefs in a self to self and self to other way and (2) succeeding in reparenting via the brain engaging in imaginary healing.
When we and our patients know ourselves fully in our heart, body and mind and are open to acknowledging, trusting, experimenting and communicating in a compassionate manner ideas and processes, can there then be new and exciting opportunities to heal. These therapies offer patients a diverse and creative way to work through personal growth issues. Furthermore, the new processes challenge patients to be more receptive to and benefit from being open to new ways of getting to the bottom of behavioral issues that impede healthy personal growth. By using these new therapies to help change the brain's "muscle memory," both the therapist and the patient will see positive results which will foster a better life and focus for those participants.
On a personal note, I am so grateful and appreciative of having the opportunity to learn from the masters mentioned above in ongoing supervision and training groups and I look forward to more innovative approaches in the future. I welcome your comments and questions.
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Marilyn Sulzbacker, LCSW, BCD, CGP 165 West 66 Street, apt. 3E
New York, New York 10023-6538