Kate Cohen-Posey MS LMHC LMFT

Author bio at end of article.

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A client we’ll call Clara is lamenting about death: 

“My sister is in remission but I worry about her constantly; I go on social media and I keep finding all these stories about death; then I start researching statics on COVID and I just can’t stop. And, I have to finish my course work for my BA by the end of the year.”  

This is fertile ground for talk therapy. Possible interventions might be: “Maybe you should remove your social media app;” “You’re making such thinking errors as assuming, exclusion (of positive), and fortune telling;” “You can challenge those automatic thoughts with questions like, How do you know that is absolutely true? What happens when you believe that thought?  Still more queries might be posed: Imagine that a miracle has occurred. Your problem has suddenly vanished. What does your life look like without this worry? Were there earlier times in your life when you feared death or felt abandoned?  Finally an empathic response might reflect, “It seems you’re worried about your sister and then that mushrooms into all kinds of fears about death until you feel consumed.”  

Mind-Body Connection

The last intervention mentions Clara’s emotions and is likely to help her feel understood and even calmer. However, two therapeutic ingredients have been woefully neglected. Perhaps the following clip will provide clues to the missing elements:

Therapist:  As you talk about your sister, death all around, and COVID, I see your eyes widening, you brows pulling together, and I’m wondering if there is a tightness, a pressure, a heaviness somewhere else.  

With this comment Clara begins to slow down.  She’s searching for those or similar sensations.  She identifies the feeling of a vice squeezing her chest.  What will happen if Clara continues to observe this tightness? It could get tauter, loosen, or stay the same.  Regardless of what happens, the two elements that have been added are:  body sensations and the observation of them.

When Clara is talking about her worries she is using a part of her brain cortex underneath her left temple (between eye and ear). Locations in her temporal lobe are involved in the production and comprehension of speech (Wernicke’s and Broca's areas).  The accurate naming of her feeling state down regulates her fear center, possibly curbing sensations. The use of cognitive queries accesses parts of her frontal lobes beneath her forehead that further manage emotions. But, what brain structures produce fear and the observation of same? The notorious amygdala is in a border (limbic) area below the cortex, making it subcortical.  It triggers a release of adrenalin that gives rise to many body sensations as muscles prepare to fight or flee. Secondly, the cerebral region that observes disturbing sensations straddles the frontal and temporal lobes. This hidden cortex is the insula, dedicated to mapping or observing both unpleasant and rewarding feelings. Thus, talking therapies mainly involve the evolved brain cortex.  When subcortical regions are brought on line, clients can have a richer experience and a brain-body connection is made. 

Visual Metaphor

What if the therapist deepens this experience by accessing the visual (occipital lobe) cortex?  

Therapist: It sounds like a part of you is very frightened. It’s telling you your sister might die, there’s death all around, and it even makes you check on social media for stories of death.  Could any of the pictures in this set of images represent that part?   

Because this is a telehealth session, Clara goes to a platform where she can choose one of 8 fearful pictures: https://askandreceivecoaching.com/brain-change-cards-kate-cohen-posey/fear-yellow-brain-change-cards/. 

She is asked how the picture she chose personifies the part of her that fears death. 

Clara says,

“It’s that one.  It’s telling me people could drop dead any minute! I wish it would stop.” 

The sensations in Clara’s chest get stronger. 

What just happened?   A picture can be a metaphor, creating symbolic associations to access deep feelings and add poignant words. A new layer of meaning has been added to Clara’s concerns (dropping dead any minute). The work of the neuroscientist, Richard Davidson (2012), tells us that looking at a disturbing image will activate the right prefrontal cortex sending signals to the amygdala in milliseconds. 

Memory Reconsolidation

A distressing visual that is personally evocative can be a vehicle for emotional arousal, but is such activation necessary for therapeutic change? The theory of memory reconsolidation (Ecker, 2012) holds that when a memory (or thought) is felt (somatically), neural circuits are poised for re-coding. However, adaptive revision will only occur in the presence of an experience that mismatches, disconfirms, or contradicts the target learning. When these opposing conditions of arousal and reversal are met, distinctions can be made about what is important to remember for survival and what is not.  Clara’s choice of an image she perceives as imminent death overstates her fear in a way that could, paradoxically, undermine it.  

The therapist calm presence while echoing Clara’s words (drop dead any minute) may launch a juxtaposition experience of two sharply incompatible possibilities. This can be extended with an exercise that eases Clara’s angst. A novel method called Brainspotting (Grand, 2013) has discovered that where people look affects how they feel. The therapist helps Clara find an eye position associated with the tightness in her chest while encouraging focused mindfulness. 

Therapist:  (After removing the disturbing image) you feel a vice in your chest. As you follow my pointer (moved horizontally at eye-level), is there a point that slightly increases those sensations?

Clara:  Right there, and then when you move the pointer up (vertical axis), the tightness becomes a little more intense. 

Therapist:  Focusing on pointer and the tightness, find out where your mind goes or how the sensation changes in your body. You can say as much or as little as you like.

After a couple of minutes Clara looks surprised and says that the tightness has loosened. It’s more like a squeeze than a vice. She is encouraged to just keep noticing and to find out if tension heightens again or comes close to neutral. In a few more minutes Clara nods Yes.  Does this mindfulness of the body fit into the theme of pairing differing experiences?         

Focused Mindfulness

Consider how observing is different from thinking. Generally observing occurs through perception of sight, sound, taste, touch, and smell. Interoception of sensations and proprioception of body position and movement are additional forms of perception.  Thinking involves manipulation of ideas to analyze, evaluate, create, theorize, objectify, or find solutions.  Observing sensations distracts people from the emotionally laden thoughts or events that are causing them. A-tension of sensations takes away tension (the prefix a means not, without, or to negate). The locus of inner observation in the brain is the insula.  It “uploads” sensations where inputs from the chief emotional regulator (anterior cingulate gyrus) can turn down the volume of these felt senses. Emotional thoughts arise from the “monkey mind” (newly named the default mode network) found in areas along the midline of the brain (medial prefrontal cortex and posterior cingulate cortex), the memory encoders (hippocampi), and the Amygdalae.  

During mindfulness of the body, emotional ideas are temporarily divorced from their associated sensations, providing a pause. After Clara enjoys a brief respite from her fear, she is again asked to consider the thought, people will drop dead any minute. She reports a return of sensations although now they are slightly muted. The exercise of exposing Clara to the disturbing thought or image is repeated two more times until she says,

“It’s just a silly thought.”

We can imagine adrenalin being wrung out of the muscle tissue that has absorbed it in an exercise called “squeezing the lemon.” To reiterate, Clara’s thinking error was not challenged.  Its effects were simply observed until they lost their punch. She has been liberated to initiate her own line of questioning or free association.

Clara: You know, I think I’m sabotaging myself with all these fears. My obsession with death and family drama is distracting me from completing course work that must be finished in a month.  I can give you a list of times I’ve dropped the ball to avoid failure when I’m on a brink of success. I think what I’m really afraid of is failure.”

The Body as a Lie Detector 

 Clara is asked to again look at the set of eight fearful pictures to discover if there is one that could represent this “fear of failure.” 

She spies a likely candidate and says,

“Failure is like I’m standing alone in the dark.” 

Again, the picture has elicited an extreme emotional learning that invites contradiction. As Clara continues to gaze at the picture she says she is not really feeling anything in her body, but she hears a voice saying, You can do it. 

She is asked to notice what effect this thought has on her body and she replies,

“I feel calm...it’s like I can breathe.  My arms even feel lighter.”  

Why would the therapist bring Clara’s attention to her body when she voices a lovely thought like, You can do it.  Many times an affirmation elicits distress.  Invite a client who says they have nothing to work on to say, “My life is perfect.”  Before they even repeat the words, they will be likely to smile and come up with an issue.  Noticing somatic effects of a confident statement is a “body check.” Clara’s therapist believes that the body is a lie detector. If she felt a twinge of angst, that would become a new focus of attention that might have led to the origin of failure being like standing alone in the dark.  

Window of Tolerance

The danger of talk therapy is that information can be substituted for going through an emotional process required for healing.  Beliefs are elicited to override reactions, but triggers can go unheeded. On the other hand, experiential therapies can propel people outside their “window of tolerance.” They can become so flooded by hyper arousal or freeze states that access is blocked to either (1) cognitive functions needed for reflection, or 2) emotional networks that warrant rewiring. It would seem that evocative pictures that exaggerate reactions should be handled with caution. While the therapist did use an image to heighten arousal, it was quickly replaced by a fixed gaze and instructions to observe body sensations. If Clara’s mind had free associated to another disturbing thought, the therapist would have promptly refocused attention to how that idea landed in her body. The experience of observing is used to oppose thinking. 

          However, pictures have their own built in mechanisms for optimal arousal. They personify thoughts as (personality) parts.  This helps people unblend from and be less identified with those thoughts. Clara seems to be stuck in swirling notions of death, but her chosen picture externalized the part of her that is caught in this vortex.  She even wished it would stop telling her death is imminent.  Visuals are mnemonic aides that prompt people to be mindful of intrusive ideas. Her image will become a mental fixture to help her notice, Oh, it’s the drop-dead thought again.

It becomes a midpoint that balances affect and cognition. Pictures can also provide systematic desensitization by moving them to tolerable distances and gradually bringing them closer. However, the ultimate effect of pictures is yet to be revealed.  

Resourcing 

If images can intensify distress, can they likewise enhance and reinforce the positive? When Clara chose her fearful images, she was also shown a section of the platform with 24 uplifting pictures and she was simply instructed to choose ones she likes for any reason:  https://askandreceivecoaching.com/brain-change-cards-kate-cohen-posey/uplifting-peach-brain-change-cards/. Then, she was asked what she liked about her chosen image. 

Clara:  I like this person sitting under a tree because he looks so peaceful. That’s the way I feel when I’m connecting with nature.  

Therapist: It sounds like somewhere within you, you have peace of mind.

The picture is set aside for later use. Naming what she liked about her chosen image employs the process of projection. A mental abstraction is attached to a visual object. The variety of qualities one image can elicit is evidence of the individuality of our minds.  Another person may like the blossoms and say they show the tree is growing and healthy. Abilities for growth and health are named. When people like colors, a second question is useful: What do you like about the color X? Drives for vibrancy, fun, or comfort may be revealed. Treatment methods that focus on personality parts, ego states, or subpersonalities profess that the mind is multiple with inner voices that carry varying beliefs, emotions, desires, and more. Some theories also suggest there is an inner leader or higher Self (Schwartz, 1995; Assagioli, 1965/2000). This paper proposes that even at our core we have multiple assets, abilities, and potentials that lay hidden or forgotten, but can be aroused by looking inward.

We left Clara with an inner voice telling her, You can do it.  She felt calm, noticed her breath, and her arms even seemed lighter. She is shown her uplifting image to strengthen these sensations. Her therapist says,

“Maybe it’s your peace-of-mind picture telling you, You can do it. Just notice what is happening in your body as you gaze at the image.”

Indeed, Clara can feels openness in her chest and warmth in her face. Embodied experiences of rest and restore often go unnoticed. When they are highlighted and expanded, treatment is enhanced. The afore mentioned neuroscientist, Richard Davidson, found that positive imagery activates the left prefrontal cortex that then inhibits the amygdala and triggers a release of a motivating, energizing, focusing neurochemical (dopamine) from the brain’s reward center (Nucleus accumbens).  

              Like their negative counterparts, inspiring images have metaphorical qualities.  “Fantastic realities” or as-if spaces are created that make the impossible possible. Clients go beyond their usual points of reference in search of solutions not governed by laws of reality and logic. Elements of empowerment and wishful thinking can give insights for real-life situations (Lahad & Doron, 2010). 

No-Fail Homework

 A collage is created using Brain Change Cards® found on the Ask-and-Receive platform (see Amazon link below). Per her instructions, pictures are arranged to show how much or little influence they have. They are texted to Clara to use as a “transitional object” between sessions.  This is no-fail homework. Clients often find that when they start over-thinking, a chosen image comes to mind that stirs awareness that they are ruminating. Others use encouraging images as screen savers where they become emblazoned on their devices and in their brains. 

        Clara’s collage was made by holding her resource image closer to the camera lens, placing it in the foreground where it appears larger and clearer then her personifications of anxious voices.  If she begins morbidly obsessing, she can glance at her frightened parts and then expand the positive image in the gallery on her phone to experience neural effect of inhibiting the brain’s fear center and activating rewarding nuclei.  Amazon link:  https://www.amazon.com/Brain-Change-Cards-difficult-neurochemistry/dp/B01M67O5PY/. 

Neuroscience and Theoretical Conclusions

            Any discussion of experiential therapy deserves inquiry into the difference between perception of pictures and the creation of mental images.  This paper argues that perception is a more direct experience than imagination.  The later requires coordination of long term memory (of initial perceptions), working memory, and attentional processes. Likewise, several areas of the brain from the thinking frontal lobes to the actual visual cortex must work in concert. Perception takes a direct route from retina, via the optic nerve, through the mid brain, to the visual cortex. Therefore the use of pictures may have the advantages of in vivo over imaginal exposure, especially since people vary greatly in how well they can visualize.  

         Clara’s case integrates brainspotting, parts work, and art. There is not a set protocol in this leading-from-behind approach. When the therapist hears a thought or feeling that can be converted into a part, pictures are offered that suggest inner critics, feeling states (sad, fear, anger), pushers, pleasers, avoiders, and distractors. While this mini art gallery is readily available, people choose images they like for any reason from a contrasting collection.  Triggering events are processed by following thoughts, recollections, and sensations (implicit memories) as they emerge. In Clara’s case the focused mindfulness of Brainspotting was all that was needed for transformative change, yet an image was still used to reinforce her adaptive response. 

      People who are hyper-reactive to body sensations found in panic disorder, may need to gaze at uplifting images instead of a fixed spot or pointer. The cascade of brain changes that come from looking at pleasing pictures make sensations more tolerable and help dilute distress. Sometimes contrasting images are held up and clients are instructed to allow their eyes to move back and forth without any deliberate intention, pausing at will to voice new discoveries. Other times people are assisted in creating dialogue with a card depicting a subpersonality or inner strength. The possibilities for incorporating art with any experiential approach are endless and emerge from a creative collaboration between client and therapist that becomes a learning experience for both parties.  

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References:

Assagioli, R. (1965/2000). Psychosynthesis. MA: Synthesis Center Edition.

Davidson, R.J.  & Begley, S. (2012). The emotional life of your brain. NY: Hudson Street Press.

Ecker, B., Ticic, R., Hulley, L. (2012). Unlocking the emotional brain, Eliminating symptoms at their 

        roots using memory reconsolidation.  New York: Routledge

Grand, D. (2013). Brainspotting: The revolutionary new therapy for rapid and effective change. 

         Louisville, CO: Sounds True.

Lahad, M., Farhi, M. Leykin, D. Kaplansky, N. (2010). Preliminary study of a new integrative approach in 

     treating PTSD: SEE FAR CBT.  The Arts in Psychotherapy. 37391-399.  

Schwartz, R. C. (1995). Internal family systems therapy.  New York: Guilford Press.

Kate Cohen-Posey, MS, LMFT, LMHC runs a Facebook group for therapists of all persuasions and the general public who have practiced PICTURE GAZING (PG), which pairs images that personify upsetting thoughts/feeling with qualities in uplifting pictures. Change happens by mismatching stress hormones with calming, rewarding, joyful neurochemicals. Pictures evoke poignant words for painful memories that are transformed while gazing at resource images that hold untapped wisdom. This is called memory reconsolidation. Her Brain Change Cards are displayed on the FB page.