Much has been made of the importance of non-specific factors (such as empathy, therapeutic alliance, etc.) to therapy outcome, and rightly so: therapists who use the common factors get better outcomes (Duncan, Miller, Wampold, & Hubble, 2010). However, that does not mean that only the common factors matter. For example, it’s well established that the trauma-specific treatments actually do treat trauma better than generic treatments do (Ehlers et al, 2010). So however important the common factors may be, there’s more to it.
The primary criticism of the common factors research is that it has relied on statistical analysis of randomized clinical trials. This means that outliers – for example, individual cases in which dramatic and lasting improvement occurred – have been rendered invisible in the group average, rather than specifically studied. On the other hand, process research focusing on individual cases has identified a specific factor that typically quickly leads to large and durable changes: guiding clients to face and process previously avoided emotional experiences (see Ecker, Ticic, & Hulley, 2012). Guiding the client to face, process, and resolve a trauma memory is arguably the most profound and impactful example of such a treatment activity.
This does not mean that the common factors are not important; indeed, these specific treatment activities are unlikely to occur without a treatment approach incorporating the common factors. It is probably most useful to conceptualize the common factors as the necessary foundation for the specific change-making activities to be implemented.
Now there is a definitive body of brain research that confirms and elucidates this specific factor. The book, Unlocking the Emotional Brain (Ecker, Ticic, & Hulley, 2012) explains how this research maps the deep structure of healing via memory reconsolidation. Memory reconsolidation occurs if the following sequence of events (Ecker et al) take place:
1. Reactivate. The memory must be accessed and reactivated.
2. Mismatch/Contradict. While the memory is reactivated, create an experience that contradicts the problematic learning or mental model that the memory had created
3. Create New Learning. Within the subsequent five hours, provide further experiences (possibly just repetitions of the Step 2 mismatch/contradiction) that eliminate or revise the associated mental model.
For example, a young woman identified the birth of her brother as the initial source of her negative belief, “I’m not important.” Early in working on this memory, she recalled her father being far more excited about the boy’s birth than he had been for anything to do with her; and she felt sadness and shame. Thus the memory was reactivated.
Then she suddenly recalled, “My uncle loved me. He thought I was important.” This was a mismatch, in that it contradicted the essential thing she had learned about herself from this memory. [This moment did not heal, but it destabilized the memory so that further intervention of a certain kind could have transformative impact.]
As the work progressed within this session, the client recalled more and more instances of feeling important, having accomplished something, being viewed by others as mattering, etc. Thus new learning was created and repeated. Within perhaps half an hour from starting the session, she no longer saw herself as unimportant. Instead, she said, “My father was so pathetic, he didn’t even know how to love his own child.”
This is how memory reconsolidation happens. For twenty-something years this client was driven by the belief, “I’m not important”. But she was able to reactivate, challenge, and permanently transform the memory so that it no longer supported that negative belief. Indeed, she now saw herself in a much more positive light.
Eckers and colleagues (2012) describe most presenting problems as being driven by schemas or mental models that are locked in the brain as a result of traumatic events (my term, used broadly to include any upsetting events that have not been fully processed or integrated). They characterize most therapy approaches as counteractive in that the focus is to manage or over-ride the mental model, emotional reactivity, and associated symptoms. Such approaches tend to be slow, incremental, and subject to relapse because the underlying mental model and emotional reactivity remain.
Instead, they recommend a transformative approach – using the brain’s ability to reconsolidate memory – to permanently modify the underlying mental model and eliminate the emotional reactivity. Transformative trauma resolution procedures, such those taught in our programs, can effect memory reconsolidation at the source of the associated symptom-generating mental model
Does your therapy include activities that will systematically and reliably facilitate memory reconsolidation?
This is healing. This is deep, lasting change. Don’t settle for less.
Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what works in therapy (2nd Edition). Washington, DC: APA.
Ecker, B., Ticic, R., & Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation. NY: Routledge.
Ehlers, A., Bisson, J., Clark, D. M., Creamer, M., Pilling, S., Richards, D., Schnurr, P. P., Turner, S., & Yule, W. (2010). Do all psychological treatments really work the same in posttraumatic stress disorder? Clinical Psychology Review, 30, 269-276.
Ricky, thanks for sharing this valuable article! Sometimes traditional CBT can be frustrating as the lock the old schema or memories have on the person is so powerful. Being able to use a” transformative approach – using the brain’s ability to consolidate memory – to permanently modify the underlying mental model and eliminate the emotional reactivity” gives so much hope, so much future to the person!
Lesa, I agree. We have so much to offer therapy clients now. It’s really a great time in history to be a therapist! Other than all the managed care stuff of course.
nice to see that we both have independently discovered the reconsolidation mechanism as a proper description of how trauma therapy (and all other psychotherapy too) works. The German psychotherapy researcher Klaus Grawe has figured out the same in the 90th. Now neurobiology has reached the same point.
Thomas, All I did was read the right book, I don’t get much credit for that! But I have been saying essentially the same thing as a therapist & teacher for many years, without being aware of the neurological basis for it.
Trauma informed therapists around the world who use Progressive Counting and EMDR have repeatedly witnessed this “magical” transformation. It is a monumental breakthrough for the mental health world to finally have a provable explanation in memory reconsolidation. Ricky, thanks for describing common factors and memory reconsolidation in such clear and concise terms. I forwarded this to numerous therapists as I think all mental health practitioners have a responsibility to their clients to become aware of, gain an understanding of, and implement common factors and memory reconsolidation work. Thanks again!
I have been disturbed for years by those who suggest that reworking memories is not essential to sex trauma resolution. There are some who cannot tolerate the work, but for those who can, not to offer them this opportunity for true healing is unprofessional, in my view. Good to know that the neurological research has caught up with clinical wisdom. Thanks for this.
One of the main reasons that trauma-informed therapy is so useful is that it is trans-diagnostic. It’s not just for PTSD, it’s for any irrational negative beliefs, any emotional reactivity, that is related to upsetting experiences that have not been fully processed. Many trauma therapists understand this well, but many other therapists do not (yet). I think the research on memory reconsolidation will help to move the field towards regarding trauma resolution work as one of therapy’s essential elements.
One of the wonderful aspects of memory reconsolidation is that it can be used with many different forms of in-depth psychotherapy. It’s an integrative approach.
Robin, that’s right. You can get memory reconsolidation done with EMDR, PC, Coherence Therapy, and various other methods. What was so great about your book (among other things) is that it spelled out the required steps. This helps therapists who are already doing one of these methods to fine-tune their interventions to get the biggest memory reconsolidation bang for the buck.
I’m so pleased to see all the shares and comments here! Obviously (since this is only the 3rd post) I’m new to blogging, and very encouraged with the action and discussion this blog is getting.
I hope to be able to enable commenters to post their own web sites along with their comments, but meanwhile here’s a shout-out to those who have commented on this post so far:
Lesa Fechte runs Continuing Education for the University at Buffalo (NY) School of Social Work, including their Trauma Certificate Program.
Thomas Hensel runs Kindertraumainstitut (Child Trauma Institute) in Germany.
Kriss Jarecki practices in the Buffalo, NY area and is one of our own (TI/CTI) trainers.
Sheri Oz is an author and expert in treatment of sexual abuse, in Israel.
And Robin Ticic is a coherence therapy expert in Germany, and co-author of the book featured in this blog post.
And we didn’t have to fly anywhere to chat with each other :^)
Ricky, thanks, much to be gleaned from both your post and comments here. Just obtained the Ehlers et al. paper (2010), so I’m not quite caught up on your reading list.
There’s a bit too much “solid” for me in the word reconsolidation. I use words with clients/patients more on the order of reframe and reorganize, and I talk about an alternate view rather than mismatch/contradict. That said, the thrust of what’s here is right on the mark.
Thanks John. I don’t think I’ve ever used the term with a client myself either. I tend to talk about “digesting” the trauma memory. I do want to convey that the trauma resolution portion of the work is about transformation and healing. But I avoid using technical jargon with most clients.
This was a good article, however, I do not think that the child’s conclusion that her father was pathetic was a solution to her problem. Forgiveness heals- resentment disturbs.
So first of all the client was an adult. Secondly, the client was not expressing resentment; rather, a recognition that the problem was her father’s limitation and not her own deficiency. And finally, I have learned to trust a client’s process; forgiveness is not always required for resolution and healing. That being said, if the client was left with resentment, then the treatment of that memory would not have been finished yet, because (I agree that) resentment is not a healthy resolution.