This client had a brother that had been shot and killed 5 years previously, with his ... ment for Jim, let's first discuss a new psychotherapy model. Clinical ...
Clinical Biopsychology: Could A Grand Theory Actually Exist To Allow True Psychotherapy Integration? -
Robert A. Moss
a 42 year old gentleman, was involved in an accident the preceding February, during which his propane truck was struck by a car with the other driving being killed. His truck was overturned and he had immediate concerns over a possible tank rupture and explosion. He was referred by the insurance adjuster handling his worker's compensation case. When initially assessed on 4/3, he recounted details ·with noticeable anxiety. He reported crying spells, increased nausea and frequent nightmares. He noted one particular situation in which he became startled, scared and angry, when his wife unexpectedly applied the brakes. He said his reaction v.ras very much out of character for him. He reported another accident that had occurred 5 years previously in which others had been injured and killed. He was not the driver, but was riding in the truck cab when the car swerved into the truck. He sustained no physical injury in either accident. Shortly after the accident, he saw his family physician who diagnosed PTSD and started him on Zoloft. He was instructed not to do any driving. The client developed nausea and discontinued the medication. He was then prescribed Paxil with his noting improved sleep, reduced nightmares, and decreased crying spells. He had no crying spells in the week prior to the psychological evaluation. He also noted he was beginning to find some enjoyment in activities. Unfortunately, he was experiencing the side effect of inhibited orgasms. During his initial evaluation, he reported a normal appetite and low energy level. He denied suicidal thoughts and hallucinations. He reported dysphoric mood only if he thought about the accident. He reported increased startle response and hypervigilance. He noted increased irritability. He indicated he had always been an organized, detail-oriented, and perfechonishc individual. He denied the use of alcohol and drugs. He had no history of mental health treatment. He was reared by both parents. His mother demonstrated physical affection, used fair punishment, and was not verbally abusive. She drank no alcohol. His father demonstrated no physical affection. He was physically and verbally abusive. He was an alcoholic. This client had a brother that had been shot and killed 5 years previously, with his indicating his brother's death had been quite difficult for him to personally resolve.
The client had left school in the tenth grade due to his desire to leave home. He was a C + student. He ·was outgoing and denied being picked on. He got in little trouble in school. He denied any history of work problems. He had 3 marriages. His first ended because she tired of it. His admitted the end of his second marriage was difficult for him to resolve. His present marriage had gone well. Before discussing the case conceptualization and treatment for Jim, let's first discuss a new psychotherapy model.
Clinical Biopsychology The past two decades have witnessed an explosion in applied brain research. This has been largely related to the development of new technologies, including computer generated algorithms, which allow for measures of brain activities. Obviously, any new psychotherapy grand theory would have to be one based on a model of brain functioning. This realization has led to some speculation as to specific brain areas (e.g., amygdala, anterior cingulate, etc.) being involved in the experience of psychological problems, though there is no real suggestion as to how such activity explains the subjective and objective symptoms. A comprehensive new model was reported by Moss (2006) based on the cortical macrocolumn being the binary unit, or bit, by which all higher cognitive functions exist. The Dimensional Systems Model goes on to discuss how the macrocolurnns interact in feed forward and feed backward patterns with other columns and other structures in the brain. This model actually emerged in 1984, but was rejected by journal peer reviewers for being too speculative and untestable at that time. Over the past 26 years, the model has been applied to a deeper understanding of both the development and treatment of psychological problems. The new applied approach of Clinical Biopsychology was described in a treatment manual (Moss, 2001), with the first professional article following 6 years later (Moss, 2007). The Clinical Biopsychology model is consistent with the psychodynamic views of two semi-independent minds, though these are both considered conscious. The left
cortical hemisphere is viewed as a detail oriented processor based on a larger volume of cortical macrocolumns than that in the right hemisphere. This allows the left hemisphere to control both the sensory memory storage and motor memory production of speech. Moss (2001, 2007) describes this as the side involved in "verbal-thinking", similar to Gazzaniga's (2002) proposal of consciousness in which the left side involves the verbal "interpreter." In contrast, the right hemisphere has a more diffuse pattern of columnar interactions which results in its primary role in the sensory memory storage and motor memory production of emotions. Thus, this is where "emotional-thinking" occurs. The dght cortex is largely non-verbal, with the exception of words associated with strong emotions (e.g., cursing) or housed as lyrics in simple songs. Thus, the right cortex functions have been viewed as "unconscious" since it is largely not accessible by the "verbal interpreter." The hemispheres are viewed as parallel processors with each being capable of controlling one's behavior at any given point in time; thus, both are equally conscious. The cortices are viewed as engaging in frequent interactions, though the interactions can be both excitatory and inhibitory. This would mean that it is possible for one side to suppress the activity of the other side so that conflicting responses could be prevented. The brain is viewed as being intricately involved with the environment to allow survival of the individual. Similar to psychodynamic views, there are factors that "energize" behavior. The brain model explains how enhanced arousal leads to enhanced memory formation. There is the general arousal system (reticular activating system), as well as two interactive selective (i.e., biological needs system, limbic system) arousal systems. These arousal systems are channeled through the attention-memory system (e.g., thalamus), which in turn interacts with the cortical areas where information processing and memory storage occurs. A primary goal of the brain is to attempt to maintain a positive emotional state and avoid a negative emotional state. However, the brain is also viewed to have internal mechanisms (i.e., opponent processing) to prevent any permanent emotional states so that the individual has to continue to engage the environment in an attempt to achieve the primary emotional goals. This engaging of the environment enhances the chances of survival. Since the right hemisphere stores the emotional memories, it has the primary ability of activating both positive and negative emotions. This is based on the simple fact that activation of emotional memodes is associated witl1 activation of subcortical emotional centers (e.g., amygdala, septal area); this would mean the left verbal-thinking processing would not have access to or control of the right side's emotional memories. Therefore, internal verbal dialogue would not be able to directly control (i.e., there are no nerve tracts between the left frontal and right posterior cortical areas) the
right sides emotional sensory memories. This can account for the reason humans can verbally think one way about a situation, and feel different about the same situation. It also suggests that we not only have a native verbal language, but we also have a native "emotional" language as well. The sensory and motor memories of the right side are those that determine what leads to positive and negative emotions in relationships, as well as our behavioral responses in those relationships. This is the basis of what Moss (2001) calls Giver (Type-G) and Taker (Type-T) patterns. A thorough discussion of these patterns is beyond the scope of the current paper. One final aspect of the dual minds concept is 1vhether the cortices are arriving at the same or different conclusions/interpretations. The greater the "think/feel" conflict, the less internal peace. Based on the clinical biopsychology model in total, there would be three potential areas to be both assessed and addressed in psychotherapy. These are verbal-thinking, emotionalthinking, and interhemispheric congruence. Although each theoretical approach can impact each of these three areas, it would appear that cognitive behavioral approaches primarily target the left hemisphere, existential approaches and some aspects of humanistic approaches have addressed right hemisphere, while psychodynamic and humanistic approaches have addressed interhemispheric congruence. The Clinical Biopsychology viewpoint also suggests there are three other areas that need to be considered in determining treatment foci. These are negative emotional memories (e.g., trauma, past problematic relationships), inability to activate previously stored positive emotional memories (e.g., loss issues), and current or ongoing situations (e.g., argument) and states (e.g., chronic pain). Behavioral and cognitive behavioral approaches have emphasized the current and ongoing factors. Psychodynamic and some humanistic approaches have viewed the importance of positive and negative emotional memories and developing a verbalthinking understanding of these. Existential therapies have often addressed the negative emotional memories, as have some cognitive approaches. The loss issues are viewed as the inability to activate previously stored positive emotional memories in the context of an opponent process theory. In other words, when positive memories are first formed, a negative emotional process slowly grows in its strength. Over time, the factors/situations become less positive due to the offsetting negative emotions. If the factor/ situation is then lost, all that is left are the negative emotions. This depressive reaction would be expected to occur tied to the loss ofboth relationships and other situations/factors alike. The greater the initial positive feelings and the longer the duration one has had whatever has been lost, the greater the depressive reaction. As one accepts the permanency of and "grieves"
the loss, there is an eventual return to neutral with the gradual deactivation ofthe negative emotional processing. In relation to negative emotional memories, Moss (2007) discusses that the two probable factors determining the level of impact are the degree to which one feels a loss of control and/or the degree that one feels personally responsible or inadequate. Based on these two factors, there is a discussion of therapists' characteristics that can have both positive and negative impact on patients, as well as how these can be used to identify the memories that will become treatment targets for a given patient. Additionally, two different sensory emotional memory stores likely exist. One involves generic/ factual memories (posterior cortex interconnected with the thalamic pulvinar nuclei) and personal/episodic memories (lateral cortex connected to other thalamic association nuclei and the limbic system). Based on this distinction, Moss discusses what treatments are likely to have impact on each of these forms of sensory memories. One specific treatment approach, Emotional Restructuring, is directed toward negative emotional memories tied to problematic relationships. It involves seven steps conducted in the course of the session. The first step is having the client recall specific n~gative interactions that occurred with the stimulus individual being discussed. This is done to activate the memories and the client typically reports heightened anxiety. This is followed by a brief role play in which the therapist assumes the position of the stimulus individuaL This further enhances emotional memory recall. The third step is the presentation of a behavioral/ motivational description to explain why the stimulus individual did what was done. This was previously discussed as Type-G and Type-T patterns. The fourth step is a role reversal in which the therapist assumes the client's role and the client assumes the role of the stimulus individual being discussed. The client is reminded to handle the role reversal situation as they believe the stimulus individual would, playing by the rules just outlined by the therapist. During the role reversal, there is typically a decrease in anxiety and increased anger. It is believed this experience is processed by the right cortex such that the individual notes a decreased feeling (right hemisphere) of personal responsibility and increased feelings of the stimulus individual's responsibility. The fifth step is directed imagery (right cortex) of a situation in which the stimulus individual was creating difficulties for the client, but resulting in the client assuming control with (right frontal cortex) the stimulus individual and winning. Additional imagery is given in which the client is seen as the victim and is self-nurtured. At the completion of this stage, the client usually
has little anxiety and anger, but notes being mildly sad with feelings of relief. The next stage involves completing information on why the stimulus individual had no choice but to be the person he is, himselfbeing a victim of his own past memories. Metaphor and simile (to evoke visual images in the right cortex and logical analysis in the left) examples are used throughout the verbal description, involving both hemispheres and1ikely improving congruence. This sets up the final step in which the therapist assumes the stimulus individual's position, with the client expressing: (a) the fact that he/she was hurt; (b) the stimulus individual did only what he/she was capable of doing; and (c) the stimulus individual is forgiven. It is believed this facilitates interhemispheric congruence. To date, this technique has been applied only in an uncontrolled fashion within the context of a private practice. It has been found to provide rather dramatic results for a number of clients. Jim is one of those cases in which only negative emotional memories had to be addressed.
Successful Short Term Treatment Briefly, the clinical biopsychological conceptualization was that Jim had stored negative emotional memories with perceptions oflost control tied to the most recent and the past accidents. Based on his learning history, he would have stored numerous loss of control, personal responsibility/inadequacy memories tied to his father's abusive behavior. The personal responsibility aspects are due to a child's lack of ability to comprehend that other's behaviors are often unrelated to him (i.e., the child interprets things as if he is the center of the universe). It is not until later childhood and adolescent years that the myelination patterns in the frontal lobes allows an individual to conceptually think "outside" himself, recognizing other's actions are often independent of his own influence. Based on his learning history there would be poor interhemispheric congruence and he would be expected to be relatively poor at verbally identifying his own negative emotions, and would have a lack of ability to internally deal with high negative emotions related to right hemisphere activity. He developed a pattern of controlling his external environment by being conscientious and organized. When confronted with situations like the accidents and his brother's death, he had no way to control the environment to deactivate the initial negative emotional reactions and later memories. The left frontal area would inhibit emotional expression and resolution of the loss of control aspects to the traumatic memories and would also inhibit the left posterior cortex in its receiving input from the right posterior cortex. The current trauma would directly activate the past negative emotional memories tied to his father, loss of brother, and prior accident due to the loss of control similarity.
Thus, he was experiencing the anxiety and irritability tied to the negative emotional memory activation, as "lvell as having a challenge to his basic belief system of his own ability to control things with sufficient effort (i.e., inability to activate previously stored positive emotional memories). He was next seen on 4/10, at which time he was presented with the conceptualization and felt the explanation was sensible. He independently decided to discontinue the Paxil three days before this session. He was instructed to resume driving his personal vehicle, going only short distances. He drove his vehicle to next appointment, indicating he found he was more comfortable having the control of driving rather than riding with his wife. The first treatment session on 4/12 lasted two hours, involving imaginal flooding (i.e., giving a therapist prompted detailed account of events before, during and after the accident) to the most recent accident. Using a 10 point SUDS (subjective units of distress scale), he rated his anxiety as 6 during the first recall and 7 on the second. He indicated his anxiety was minimal during the third recall with a complete absence on the fourth recall. The session was concluded with a brief role play with his saying goodbye to the deceased driver. He reported being fatigued, but relieved at the end of the session. The next one hour session was on 4/17, with his having resumed driving the propane truck, indicating having experienced mild apprehension that dissipated over the course of the day. This session involved imaginal flooding to the accident that occurred five years in the past. He reported a level of 4 during the first two recalls, with no anxiety during the third. He reported feeling very favorably about treatment. On 4/23, he reported he still had mild anxiety when driving. This one hour session involved emotional restructuring to his father who was described as a Type-T (Taker) individual. He found the description to be surprisingly accurate. He completed the session feeling significant relief and feeling this had been resolved. He was next seen on 5/3, indicating he had done extremely well since the last session. He said he had been surprisingly relaxed, having resumed enjoyable activities with his children that he had stopped doing since the accident. He also noted his family was very pleased with the changes. He said he would never have believed he could ever feel so differently after a single session. This one hour session involved addressing the complicated bereavement tied to his brother's murder. After discussing the events two times, he was able to say goodbye during role playing. He reported additional relief feelings at the completion of the session. When he was seen on 5/10, he continued to express how well he was feeling, indicating he would never have believed how people could carry such baggage and
remain unaware. He said he had no anxiety while driving, and had been by the accident site without difficulty. During this session we discussed his second ex-wife, though there were no rises in negative emotions. It appeared this issue had already been resolved as he felt he had exerted control and won after tl1e divorce. No other areas had been identified and he was scheduled to return in about three weeks to make sure he maintained treatment gains. He agreed to complete a second MMPI-2 prior to that session. On 5/29, he was doing very well. He spontaneously reported he was pleasantly surprised at his ability to have positive thoughts about his brother, recalling positive memories for the first time since his brother's death. He felt he had obtained what he desired from treatment and he was released. The initial MMPI-2 had the following profile: *"3'1264758/90:# *"'-KL/F:#. The F-K index score of -17 indicates he was attempting to minimize psychological difficulties. The profile was considered interpretable. Individuals with the 31 profile typically have symptoms involving the digestive system and/or pain difficulties. Other frequent symptoms include dizziness, weakness, fatigue and numbness. Tension, anxiety, depression and perplexity may be present. However, the operation of denial and repression may permit the expression of optimism. Few of these patients are incapacitated by their symptoms but they have a long history of insecurity, immaturity, and a tendency to develop symptoms under increasing stress. Long-standing needs for affection/attention are typical, along with demands for sympathy and a tendency toward over-control of needs and impulses. Egocentricity, immaturity and repression are usually present. Most of these individuals place little stress on their current emotional state, usually being focused on somatic complaints. When considering the accompanying elevation on Scale 2, these patients are particularly irritable, tense, fatigued and weak. They are anxious to be liked by others. They tend to be conventional and conforming. The MMPI-2 completed on 5/25 had the profile: *"'41329/50867:# *"'-LF/K:#. The profile was interpretable free of qualifying remarks. Since none of the scales were elevated, no interpretation was warranted. Although caution needs to be taken in generalizing from a single uncontrolled case study, this case does suggest it is possible to address directly the negative emotional memories tied to past negative relationships, as well as other non-relationship traumas. In reality, the current author has been doing this successfully for years, though most individuals have ongoing difficulties and losses with which they are also dealing. Thus, it is not possible to always obtain such quick results as in this case where no factors other than memories required treatment. Conceptually, the challenge to his basic belief system of personal control ability was
removed by treatment, thus, allowing him to avoid emotional acceptance of the reality that he does not have such control. This, in conjunction with increased interhemispheric congruence following the treatment session tied to his father and brother, would theoretically have allowed him to resume activities resulting in pleasure. Although his was a worker's compensation case and he had attorney representation, there was no indication of malingering. He was motivated to address his problems and was seen within a couple of months of the trauma. Though placebo effects cannot be excluded, it is important to note he did not believe it was possible to change perceptions and feelings tied to the past significant abuse by a parent, particularly in a single session. Obviously, many psychological professionals would be expected to have similar doubts. Additionally, other non-relationship memories were addressed. However, it is hoped that there will be an interest by treating professionals and academicians to incorporate emotional restructuring procedures with appropriate clients and in clinical research. The true value of this clinical biopsychological model and treatment can only be determined by future research and clinical applications.
References Gazzaniga, M.S. (2002). Consciousness. In V. S. Ramachandran (Ed.), Encyclopedia of the human brain (Volume 2, pp. 31-35). New York: Academic Press. Moss, R. A. (2001). Clinical biopsychology in theory and pract-ice. Greenville, South Carolina: Center for Emotional Restructuring. Moss, R. A. (2006) Ofbits and logic: Cortical columns in learning and memory. The Journal of Mind and Behavim~ 27, 215-246. Moss, R. A. (2007) Negative emotional memories in clinical practice: Theoretical considerations. Joumal of Psychotherapy Integration, 17, 209-224.
Address correspondence to Robert A. Moss, Ph.D., ABN/ABPP, Center for Emotional Restructuring, P. 0. Box 591, Travelers Rest, SC 29690. Phone: 864-281-0600; Fax: 864-281-0645 E-mail: rmoss@ emotionalrestructuring.com Dr. Moss has had a total of over 20 years in private practice.
What if Empirically Supported Psychotherapy Isn't "empirically supported"?: Another Look -larry E. Beutler dentifying scientifically verified and effective treatments is an important and necessary task if the fields of professional psychology are to improve our services to clients and patients and regain our status in the mental health arena. Over a period of nearly two decades scientific groups within the field of clinical psychology have been pursuing the task of identifying treatments that work. Eleven different lists of "Empirically Supported Treatments'' or "EvidenceBased Treatments" have been published, representing approximately 150 different renditions of"Empirically Supported Psychotherapy (Beutler, Malik, Alimohamed, Harwood, Talebi, Noble & Wong, 2003). However, not all of the answers to all of the questions about what works that are asked in this research have been the ones envisioned by those who have been most invested in this task. Indeed, in many ways the answers are quite at variance with what are often considered to be the "accepted facts" within both the scientific and practice communities. And, answers to other questions seem rather anticlimactic. For example, the most important and consistent finding coming from this work has been the demonstration of something we pretty wen knew way back in 1960-that psychotherapy
works and it works pretty darn well (Budd & Hughes, 2009; Wampold, 2001). Beyond this one conclusion, there are four research questions whose answers arc less mundane. Indeed, the answers that are most frequently given to these questions, even by "experts", are not the ones that are most clearly warranted by a careful, empirically based review of the research itself. In the following paragraphs, I will address four questions to illustrate this latter point. The answers to these questions are central to improving your effectiveness as a psychotherapy practitioner. 1.
Do the use of manualized, Research-Supported Therapies, improve clinical effectiveness?
2.
Is there one form of these Research-Supported Therapies (e.g., Cognitive Therapy) tl1at produces better results than all or most of the others?
3.
Is the quality of the therapeutic relationship sufficient to account for therapeutic change? And finally:
4.
What can you do, realistically, scientifically, and economically do to appreciably improve your clinical outcomes?
