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This case study is a good example of the creativity and spontaneity we can use in our experiential work. It also demonstrates how, when we are working experientially to transform a problematic model of reality with the Empirically Confirmed Process of Erasure (ECPE) for memory reconsolidation (MR), we need to continuously evaluate the progression of the target learning we are working on in order to make the necessary adjustments until we achieve a profound transformation.
Here is a quick summary for the ECPE and its correspondence with Coherence Therapy (Ecker et al., 2012)
This patient was an adult woman in her thirties who works in the field of mental health. She was in treatment with me and we had agreed on Coherence Therapy as the main approach for her psychotherapy.
Symptom identification
She expressed feeling in danger whenever she might frustrate another person by not giving them what they want. As a result, she felt it was forbidden to say “no” and felt an intense pressure to give 400% in everything she did. She gave the recent example of her boss dropping a difficult situation on her, which she felt she had to accept right away.
Discovery work
It was time to create experiences that would allow her to “bump into” the implicit predictions generated by her problematic model of reality in this situation (and of course generalized to other, related situations), reveal them to me, and hold them in explicit awareness.
While visualizing her boss in the situation she had previously described, I guided her to replay the same scene without her symptom (imagining herself setting boundaries and refusing the added workload instead of accepting it). This is called a Symptom Deprivation exercise in CT. I invited her to observe the part of her that cringed or wanted to avoid this scenario. She identified the prediction : “I’m going to die and I’ll be abandoned!”. We took a minute to fully integrate the emotional truth of that statement.
I then offered her another type of experiential exercise. The patient cleverly shared : “Right now, I’m feeling that I have to say yes to your proposal.”
Noticing that the problematic reality model (target learning) was now activated in the therapeutic relationship, I also saw an opportunity to play a little trick on her brain. At the time, I was helping a close friend by hosting her rabbits for the winter, and one of them surprised us with a charming litter of 7 kits. As a result, my office was converted into a nursery, and thanks to my practice being 100% online because of the pandemic, Mama Doe happily nursed, hopped and snoozed around my office during my sessions, unbeknownst to my patients.
I informed my patient that I was going to play a little trick on her, and made sure she was open to the experience. I picked up this very fluffy long-eared mama, and then asked her, while petting and nuzzling this sweet animal right against my chest, to look me in the eye and make an Overt Statement :
“If I say no, you’ll get into such a rage that you’ll become violent and abandon me. I’ll die!”
I saw Step 2 of the Therapeutic Reconsolidation Process (TRP) happen right before my eyes : the patient blinked, sat back into her chair and reported that it was now impossible to see me as a threat. She reported feeling both the terror and the safety distinctly, and that it was a “weird feeling”.
She shared that it had been absolutely impossible to tolerate a human face in that very vulnerable space, but next to the bunny, which helped her achieve enough emotional regulation to regain some neural integration (Daniel
Siegel) and feel more secure, my face suddenly became tolerable.
It was a first important shift of perspective (a first transformation), which allowed me to be part of her experiential work without being automatically perceived as a mortal threat by her model. Nevertheless, it was insufficient. Part of her was still terrified, and my face could still not be experienced without the bunny in that vulnerable space, because it was still threatening on some level. I needed a better contradictory knowledge/experience. I put Mama down (most rabbits do not like being held for long periods of time anyway).
I proceeded with more experiential work, in which I asked her to picture me next to her boss and repeat the overt statement. I chose this exercise to guide an experiential prompt that followed the progression of her predictions after that first shift. I aimed to juxtapose her brand new experience of me next to her boss to see if it would also shift her experience of her boss. Although she was cognitively aware that her boss was not doing anything overtly threatening, a part of her still felt threatened anyway.
I also wanted to help her bump into more detailed predictions coming from her problematic reality model. At this stage of the therapy, her problematic reality model still held the prediction of people going into a violent, abandoning rage and, in a very coherent manner, could only tolerate my presence if the bunny was also present. Although I was in fact no longer holding the rabbit, her schema adapted coherently and spontaneously to the perceived situation by visualizing the bunny alongside my face.
That feeling of partial safety allowed her to open up about her mother, who is diagnosed on the autistic spectrum (ASD). She is an only child, and her mother would often explode into a very dangerous rage when the patient was young, and even now. There were situations, when she was young, in which her life was in real danger. She revealed that when she asserted herself 8 years ago during a conflict, her mother exploded into a rage and abandoned her. “I’ve always been an object to her; her love vanished instantly.” Her mother has not talked to her ever since.
So I guided her to repeat the overt statements in experiential mode (see the first part of the index card below for the phrasing), this time to her mother, her boss, and me (still visualizing me covered in fluffy rabbits) At this point she had achieved a solid state of integration (meaning that she was fully inhabiting the emotional truth of why she perceived such danger in these situations and recognized the necessity to produce her symptom of subjugation and hyper-performance to avoid a mortal threat), but the right contradictory material necessary to mismatch that target learning and create a fundamental disconfirmation of her problematic reality model was still not leaping to the surface of her consciousness.
Something did jump forward in my mind, however. The kind of rage and abandonment she was afraid of, while typical of the worst cases of the spectrum, does not happen exactly that way with neurotypical people outside of the spectrum. During her experiential work, she had even shared that she had worked with extremely unstable and violent patients in her career and felt no fear at all. Her brain already knew the difference; I just had to bring it forward in her field of awareness.
I asked her, on a very candid note, if her mother’s behaviour is subtle. A different knowing started to emerge for her : you quickly feel that something is not right when you are disagreeing with her mother as a result of her extreme rigidity and explosiveness. With this realization sprung up the perfect contradictory material I needed in order to trigger a fundamental disconfirmation of her problematic reality model. She had spotted ASD very quickly in a patient with very violent outbursts although that patient had gone through several psychiatric evaluations and had been wrongly diagnosed with ADHD with a severe behaviour disruption disorder by other clinicians. Her clinical opinion had been validated by the interdisciplinary team at work, who had recognized her very astute clinical eye. My patient had a fine-tuned clinical radar that was perfectly capable of detecting that kind of danger when it was really there.
As a result, with no additional prompting on my part, the patient suddenly bounced into her new emotional truth : “I am safe, safe, safe!” We wrote an index card juxtaposing her old problematic reality model, and the new reality model as it was rewritten with her transformation experience during that session, in order to help her inhabit her new perspective explicitly, and also notice manifestations of these both models in her daily life (both old, if still active, and new):
If I displease you, or annoy you, you will explode into a murderous rage and abandon me like an object; your love will vanish instantly, just like Mom. I’ll die and it terrifies me!
So I must do everything to avoid contradicting or displeasing you by giving my 400% and by forbidding myself to ever say “no”. It’s the only way I can protect myself against this terrible threat.
Wait a minute…!
People who are really like mom are not subtle! If you are like Mom (and it’s always a possibility to come across someone like her one day), there will be obvious signs that I am able to detect immediately. If I never contradict you I will never know your limits and see your capacities for compassion and kindness. I am perfectly able to rapidly detect a violent ASD when I meet one. This means I am safe, safe, safe!
The patient felt profound relief at the end of the session, and it was a significant leap forward for her. She reported that visualizing bunnies remained a powerful new trigger for emotional regulation in order to improve neural integration for several weeks afterwards.
The following session, I did the Verification Step in order to evaluate if the problematic reality model we were working on was still intact, in part or in whole. Some markers indicated a partial transformation : she had dyed her hair (a form of self-affirmation and self-care that also made her more visible, which required a better feeling of safety to be allowed), she had asserted herself in front of her boss without holding anything back, as well as in other situations, without feeling threatened. This had been achieved and maintained effortlessly.
However, she still felt activated when she read “abandon me like an object” and “love will vanish instantly” on her index card. She still needed to process pain and sadness associated with grief relating to several relationships: an ex-partner, her best friend, her mother and her daughter.
Using Coherence Therapy experiential techniques once again, I soon noticed that the intensity of her connexion with her pain was becoming high and could take us out of the optimal limbic intensity window for memory reconsolidation (which needs to be not too much, not too little). I offered her to work with Mama Doe again, and she immediately accepted. I turned my laptop to show her the animal, who was sprawled out comfortably on my desk. I kept talking to the patient, and made sure my hands were still visible on her screen through the webcam so she felt I was still there.
This created another powerful mismatch and juxtaposition experience for her. It activated a new problematic reality model in her memory, the expectations of which were contradicted by her actual experience. Contrary to the predictions of this now explicit schema, someone was able to a) notice that she was in pain, b) was able to sense accurately what she needed, and c) (in the client’s words) “bothered herself to” go get it and bring it to her. This intense experience of emotional attunement (Daniel Siegel) was completely unexpected in her problematic reality model and was thus in immediate and radical mismatch with it. Further juxtaposition was achieved when I stayed with her while she was watching the bunny, validating and attuning with the deeply soothing and comforting effect it had on her.
And once she had regained enough neural integration and felt ready to resume the experiential exercise we were doing, she had yet another surprise. When I turned my laptop to continue the session, she noticed my eyes for the very first time. This allowed us to see a marker of transformation right there, for she was now able to experience my face on its own, even while she felt vulnerable and exposed, and feel soothed, comforted, no longer alone. Just like with the bunnies, she reported that saying my name now triggered that profound response of comfort, safety and soothing. We were able to resume the work on her grief towards those relationships, she ended the session with an increased feeling of safety, and her sadness had lifted.
As a result of our work, new emotional truths about many other ways in which she was already able to protect herself emerged and completed the rewriting of her old problematic reality model, rendering the original solution of symptom-production (never saying “no” and giving her 400%) obsolete:
I also realize that…
Mom is the only one who truly treats me like an object all the time. Others like [Friend] and [Ex] do it intermittently, and only because they’re immature. If I give my 400% in my relationships, it makes things inequitable. I didn’t make mistakes; I was indeed able to quickly realize what I had gotten myself into. I gave good, honest chances to people who had real potential to co-create my dream with me… but who did not do their part when it was their turn… and I did pull out at that moment without falling into the trap. I feel right, in just action, seen and heard.
With smiles, I’ll hop out of my office and wish you a fluffy good day!
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References:
Ecker, B., Ticic, R., Hulley, L. (2012). Unlocking the emotional brain: Eliminating symptoms at their roots using memory reconsolidation.-
Sophie Côté, Ph.D., is a psychologist in private practice in Québec City, Canada. She is the president and co-founder of Momentum Psychology Inc., a clinic that teaches and provides neuroscience-based psychotherapy services (mainly Coherence Therapy). She defended the first doctoral thesis in Canada on cybertherapy (cognitive mechanisms in the efficacy of in vivo and in virtuo exposure). She is also the first francophone to become a certified advanced practitioner of Coherence Therapy, and is the translator of the French edition of Unlocking the Emotional Brain (Ecker, Ticic & Hulley, 2012) and the Coherence Therapy Practice Manual (Ecker & Hulley, 2018). She is also co-author of a book about the therapeutic reconsolidation process and Coherence Therapy to be published by Dunod in 2022 (in French). Her special interests include: anxiety, self-worth issues, adaptation to medical conditions, and fertility issues. Sophie presents workshops on the therapeutic reconsolidation process and conducts Coherence Therapy training and psychotherapy in French and in English.