BRAIN CHANGE THERAPY: Clinical Interventions for Self-Transformation

How a client presents in psychotherapy is indicative of his or her psychoneurological development. If there has been good-enough parenting, the adult has learned how to self-regulate emotional states and to be aware of others’ feelings (Wake, 2008). If there are developmental delays, however, the therapist must work with the perceptions of the client and access “resources within the therapeutic relationship to enable … learning for the client while at the same time containing the process in a way that is safe and ecological for the client and therapist” (Wake, 2008, p. 78). BCT is a therapeutic approach based on neurological research demonstrating that learning alters the brain by changing the number and strength of synapses and that people have the ability to turn brain circuits on and off in a way that changes their psychophysiological states. In order for change to be more than temporary and for the client to learn how to manage state changes, the client must engage in neurological repatterning. At the most commonly shared level, what clients are reprogramming is their stress reaction—stress is the underpinning to most (if not all) clients’ problems.

Almost without exception, by the time someone phones a therapist to schedule an initial session, the person is in emotional distress. Some aspect of the person’s life isn’t working; the individual has already done as much as he or she could to address the situation, and whatever the person tried was not adequate. The person turns to a therapist hoping someone else will have the insight and wisdom to help.

Reflecting the person’s emotional distress, the individual’s brain–body experiences the chemistry of stress. Because clients arrive in a state of stress, it is important for therapists to understand the neurochemistry of stress, the patterns of brain activation that typically occur during stress, and the effects of stress on memory, learning, and emotional stability. Based on the recognition that stress is the starting point, BCT focuses on therapeutic interventions that can create ultimately longstanding changes in clients’ brain–mind–body states.

In this chapter we first provide an overview of stress and its chemistry, brain involvement, and impact on memory, and then explore the components of the BCT approach, with case examples as illustrations.

Most people tend to think of stress in terms of stressors—causative factors—but the two are not synonymous. Stress is the response to stressors—we feel stressed by the erratic driving of a nearby motorist, a job loss, or a schedule filled with too many commitments, all of which are stressors. We can categorize the vast domain of possible stressors—the events or situations that lead to the body’s stress response—into four broad categories: physical, physiological, psychological, and psychosocial.

• Physical stressors include situations of physical danger and environmental factors such as extreme temperatures, constant noise, a high pollen count, compromised air quality, or lack of sunshine.

• Physiological stressors include hunger, exhaustion, and injury or illness that changes a person’s quality of life and ability to perform normal, everyday tasks. Surgery of any kind, particularly with full anesthesia, can be a significant stressor. In addition, an inadequate supply of oxygen or impaired breathing, which many people have because they do not breathe deeply enough, can stress the whole system.

• Psychological stressors are any events that are perceived as overwhelmingly stressful, such as the death of a loved one, financial hardship, the possibility of losing employment, or a move to a new community. Psychological stress can foreshadow cardiac events such as heart attack, cardiovascular disease, and stroke. In the months after the attack on the World Trade Center, there was a large increase in incidents of abnormal heart rhythms in cardiac patients living in New York City (Mahr, 2007).

• Psychosocial stressors are events that affect a family system’s overall functioning. For example, juggling the needs of children, a partner’s substance abuse, the care of a special-needs child, or even something as seemingly minor as restrictions on topics of discussion, can be perceived as sources of stress. One client told the quasi-humorous story of her mother, who always asked, “What three things about this difficulty are good?” even when the problem was quite devastating. When people in the family needed to speak about difficult things, the mother would abruptly respond, “I don’t want to hear anything negative.”

According to Hans Selye (1978), the “father” of stress research, the stress response is initiated when a threat is perceived by the brain. At this point, an alarm goes off in the body that begins a chain reaction. The hypothalamus activates the pituitary, which releases adrenocorticotropic hormone (ACTH) into the bloodstream. The brain also produces glucocorticoids, which are chemicals triggered by stressors that flow along the hypothalamic–pituitary–adrenal (HPA) axis. ACTH travels in the bloodstream to the adrenal glands, causing them to secrete various hormones including adrenaline and cortisol. These hormones travel throughout the body and cause the changes that produce the fight–flight–freeze response: (1) blood is diverted from internal organs to the brain and skeletal muscles; (2) pupils dilate; (3) heart rate increases and blood pressure elevates; (4) metabolism and stomach acidity increase; (5) the brain shifts to a higher beta frequency; and (6) cortisol is released to reduce swelling and inflammation. All of these physiological changes are accompanied by one or more emotions (e.g., fear, anger, anxiety, depression).

Because most of today’s stressful situations do not require the body’s engagement in a physical response, these chemicals are not efficiently eliminated from the system. In particular, the prolonged elevation of cortisol levels can damage the adrenal glands and impair the body’s ability to deal with infection. In 1991, a group of British and American scientists published a study in the New England Journal of Medicine that concluded that people under stress were more likely to catch colds (Cohen, Tyrell, & Smith, 1991). In the study, 394 volunteers took nasal drops containing cold viruses. Those who described themselves on a questionnaire as under a great deal of stress were five times as likely to become infected (as measured by viral replication) as those who were under less stress, and twice as likely to develop clinical cold symptoms.

A constant activation of the stress response causes wear and tear on numerous body organs and will eventually hasten death. Cortisol directly influences metabolism and insulin levels; by increasing insulin, it also plays an indirect role in chronic inflammation. Chronic illnesses such as cardiovascular disease, immune deficiency, or gastrointestinal problems may develop. Crucial in minimizing inflammation, a factor in many chronic diseases, is learning how to manage the mind.

Researcher Richard Davidson used fMRI (functional MRI) and advanced EEG analysis to identify the brain activity of people in certain moods. His studies indicated that when the subjects were anxious, depressed, or angry, the most active sites in the brain were the amygdala, part of the emotional center, and the right prefrontal cortex. These areas are strongly implicated in the hypervigilance of people who are chronically stressed, suffer from anxiety, or who have posttraumatic stress disorder (PTSD). When people feel happy and positive, these brain areas are quiet, and there is more activity in the left prefrontal cortex (Davidson, Scherer, & Goldsmith, 2002).

Stress tends to detract from a person’s ability to change brain–mind states and use more effective strategies in problem resolution. In fact, when normal coping abilities do not seem adequate, chronically stressed individuals tend to fall back on older—and even less effective—strategies that put them in a rut (Dias-Ferreira et al., 2009). Badenoch (2008) identified four adaptations to stress: anxiety, addiction, depression, and dissociation. These dysfunctional states may develop as a result of “a soup of genetic vulnerability, alterations in neurotransmitters and hormones, certain deficits in brain structure and function, inner community disruption based on internalized patterns of relating, and social networks that often reinforce engrained neural circuits, rather than changing them” (p. 120). Badenoch defined the inner community as “multiple states of mind we all experience within ourselves” (p. 271).

The internalization of important figures throughout life, and especially at birth, often results in a tendency to favor the emotional circuits of a primary caregiver or significant other, even if they are physiologically damaging and psychologically dysfunctional. Prenatal research has discovered that newborns’ nervous systems are shaped by the mother’s mental state during the pregnancy. In fact, if the mother is depressed during the pregnancy, the newborn shows the same biochemical markers of an adult experiencing a depressive episode, including higher cortisol and lower dopamine and serotonin levels (Field, Diego, & Hernandez-Reif, 2006).

Stress can contribute to brain dysfunction and erode memory in three ways. First, with the release of cortisol, the hippocampus is inhibited from utilizing blood sugar. The shortage of blood sugar inhibits the storage of memory; this is why people often have difficulty remembering accurately what happened in a stressful situation. Secondly, if a memory is recorded, it can be difficult to access because cortisol interferes with neurotransmitters and reduces the brain’s ability to communicate with itself. Finally, cortisol actually kills brain cells by disrupting cell metabolism so that excessive calcium enters brain cells and produces harmful molecules called free radicals.

This process has been confirmed in animal studies, and there is evidence that it also occurs in human brains. Indeed, this may be the process that leads to the development of Alzheimer’s disease (Khalsa, 1997). Cancer survivors who have the posttraumatic stress symptom of intrusive recollections of the experience have smaller amygdalas (Matsuoka et al., 2003). Over time, energy storage is compromised, and hypertension, myopathy, fatigue, and increased risk of adult-onset diabetes can occur. Suppression of digestion in this chronic state can lead to ulceration, and a lowered immune system response can lead to increased risk of death (Sapolsky, 2003).

External stressors need not inevitably lead to physiological states of stress. Herbert Benson, pioneer of stress management, suggested that a relaxed state of mind should be the ordinary state. Unfortunately, for most of us, it is an extraordinary state. Benson described the relaxed state as intuitive, vibrant, and magical, and suggested that this state could be achieved with practice (Benson, 1997). In support of that idea, Davidson and Jon Kabat-Zinn trained workers in a high-stress job to meditate 3 hours a week over 2 months. Their internal experience shifted to a feeling of less stress and more happiness, and measurements of their immune systems also indicated improvement over this period. The study, among others, (1) demonstrated the ability of a person to significantly change the emotional circuitry of the brain, (2) confirmed earlier evidence of the plasticity of the brain, and (3) reinforced the idea that no one is necessarily a prisoner of either his or her early conditioning or physiology (Goleman, 2003).

States of low stress, safety, and peacefulness help clients reflect and allow them to integrate and resolve emotional issues. When these states are difficult for clients to access or maintain, brain technologies may be useful. If clients have experienced trauma, it may be dealt with best by teaching them how to increase their state flexibility safely through the use of brain-training devices (Chapter 6). Clients’ problems need to be framed as having a variety of solutions, as long as clients can access and sustain an appropriate brain–mind state. The mind can create many ways to resolve a situation; it can generate ideas, author empowering visualizations, and imagine possibilities; and it can form new emotional patterns—if brain functioning is stable. At that point, new perspectives and ways of assigning meaning become possible. Particularly in the context of stressors, an essential element of psychological health is brain stability: the “proper balance of activation, inhibition, and integration of systems biased toward left-and-right-hemisphere control” (Cozolino, 2002, p. 123). The result of brain stability is psychological flexibility—that is, the successful management of the basic emotions of happiness, surprise, fear, sadness, anger, and disgust.

BCT uses brain–mind state change as a focus of treatment. As noted in Chapter 1, the therapeutic approach is based on the working assumption that effective therapeutic change must inevitably include a repatterning of neural pathways. We emphasize the necessity of changing states of consciousness and conditioning the changed state, through repetition, to access or build internal resources. When appropriate as an adjunct and support to brain-mind state change, BCT helps clients create new, empowering life experiences that can serve as the basis for new neural patterns. For positive state stability, however, attention training may be necessary. Whatever a person focuses on—a fear or an insight, a dear friend or a personal nemesis—tends to maintain the brain–mind state associated with the experience (Rock & Schwartz, 2007a). Learning to hold a focused attention will contribute to stabilizing brain circuits and improving the brain–mind’s ability to maintain a state associated with a particular positive experience.

Table 4.1 summarizes the BCT approach from the perspectives of both the client and the therapist. The sections that follow amplify the points and processes noted in this table.

As noted, each person has an emotional set point of arousal falling somewhere along a continuum stretching from underaroused through balanced to overaroused. Under chronic stress, this set point moves further from the balanced middle such that increasingly softer stimuli can set off a full-blown emotional reaction. Brain studies have found that it takes less than one second for a word or statement to trigger an emotional reaction (LeDoux, 1996). By the time someone says, “Don’t get me started!” it’s too late. When an individual is overwhelmed by an emotional reaction, access to rational thinking, memory, and the ability to be objective are greatly reduced. At that point, an individual is no longer regulated or in charge of his or her brain–mind states.

The hippocampus stores that negative experience, and the person’s neural and emotional reaction to it, in long-term emotional memory. Elements of the original event can then become sensory triggers that reignite the same chains of neural firing—and the concomitant emotional reactions. These triggers can include actual images, internal images, or visual cues, such as a particular color. One man became overaroused and ill at ease whenever he was in a room that was any shade of green. Eventually we learned that his mother, with whom he had attachment issues, had had dark red hair and had dressed extensively in greens. Because she favored the color, she had also decorated the family home in the same shades.

Power words, particular words or phrases that have come to have an emotional charge, whether positive or negative, can trigger a nearly instantaneous emotional response. One husband called his wife “cute,” much to her dismay. From her childhood experience of being teased by boys in school who called her cute, she had a strong negative reaction to the word, such that her association to it carried the feeling of being demeaned. For another woman, the phrase “I’m sorry” carried a highly positive valance. As a child, she had never received an apology for anything from her parents, who had assumed that adults never needed to apologize to children. Thus, in later life whenever someone sincerely said “I’m sorry,” she felt “treated like an equal” and found it immediately easy to access a gracious largesse.

Client	Therapist
Develops habituated emotional set point of arousal.
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When overwhelmed by sensation—including images/visual cues, power words, sounds, tastes, smells, touch, events, or textures—sensory gates are turned on, engendering intense emotions involving: • Problematic states of consciousness • Overarousal or • Underarousal or • Arousal instability (combines aspects of under- and overarousal)
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Emotional systems (neural circuits) generally activated: fear, panic, rage
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Person creates a negative narrative and/or internal movie accompanied by one or more of the following emotions: frustration, anger, fear, malaise, chronic disappointment, depression
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Attempts to reduce these unpleasant states often involve problematic behavior and, as a systemic pattern, can stimulate similar problematic behavior in others.
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Individual determines that his or her attempts have not been adequate.	Conduct initial evaluation of client while establishing therapeutic rapport (Chapter 3).
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Person seeks therapeutic assistance.	Develop therapeutic hypotheses and an initial treatment plan
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	Accept the client’s reality. Acknowledge client’s presenting state: its content and underlying issues.
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	Articulate the positive intention behind the dysfunctional behavior.
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Learn to reduce or increase level of arousal to more functional degree.	Define markers for improvement, generate a therapeutic hypothesis, and devise initial treatment plan.
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	Define the problem as solvable.
	Utilize a variety of interventions to effect state change: • Facilitate a shift in physiology. • Use humor. • Expand vision from foveal/tunnel vision to peripheral, particularly with anxiety/panic states. • Engage motivation. • Use therapeutic hypnosis, including voice tone of empathy and hypnotic conversation (Chapter 5). • Use brain change technologies/equipment, e.g., alpha–theta training (Chapter 6). • Facilitate deep state work using hypnosis or brain training equipment (Chapter 7).
	↓
↓	Implement therapeutic strategies as appropriate: • Utilize state progression. • Employ neural talk. • Assist client in becoming aware of and activating inner resources. • Identify where client’s self-regulation already occurs; teach client to expand when and where it occurs. • Use therapeutic metaphor.
Learn to identify current state and how changing that state enables client to move toward the target state with focused attention (deconstructing emotional reactivity, mind shifting).	Teach client to self-initiate state change by: • Understanding the process of the mind. • Deconstructing emotional reactivity. • Using mind shifting.
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	Encourage a belief in the “impossible”
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Resolution of problem behavior and activation of new neural pathways characterized by: • Brain stability: increased ability to maintain desired state and level of arousal • Mood stability • Motivation to accomplish goals • Sleep-cycle stability	Condition and reinforce the new state(s).
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	Establish the new state as a means of resolving the underlying issues.
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Increase activation of emotional systems of seeking, care/nurturance, and play.
↓	↓
Create workable alternatives to previously intractable issues.	Assist the client in creating workable alternatives or responses.
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Implement newly identified courses of action and ways to resolve life situations.	Encourage client to take action and follow up.
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	Link the action to the client’s social context so that new behaviors are generalized and practiced in the client’s wider environment

A particular sound may be troublesome for a client (see below). Some people develop an oversensitivity to certain noises and may react physically to them with headaches, anger, or irritation. Certain music may be annoying to some people. The volume alone of an auditory stimulus can stimulate emotional circuits to create negative states.

Tastes, smells, even textures, can trigger highly negative reactions. One client with an eastern European background had a father who often made what she referred to as “peasant soups.” In her experience, soup came to symbolize, and reevoke, all the trauma she had experienced growing up in a household that was not fully “Americanized,” and, in later life, she never ate soup. Soup is a small thing and it’s not particularly difficult to skip. But other clients may have triggers that are unavoidable and thus cause far more dismay.

Internal images of a parent disregarding a child or being emotionally or physically abusive can haunt clients, and the emotions connected to these images may easily trigger similar feelings in the present time. When this happens, the fight–flight–freeze response is activated, breathing is inhibited, and more intense upset may follow. When such situations are recounted in the therapeutic interaction, what often follows is a narrative, either spoken or internal. An explanation will be found to express states of overarousal, underarousal, or arousal instabilities that may involve fear, anger, frustration, or chronic disappointment. The narrative may be an attempt to alleviate emotional suffering as well as an explanation for a person’s behavior, but it may in fact make the problem worse. When the story or explanation involves some malicious or pathological intent on the part of another, where none may actually exist, we can use what Carol called “siding descriptions” in The Couple’s Hypnotic Dance (Kershaw, 1992). These are side-by-side interpretations of the same event from two perspectives: the client’s negative interpretation and the therapist’s suggestion of a more open and workable frame of the situation. Thus the therapist might ask: “Does your husband have a temper tantrum when things do not go his way [per the wife’s description], or is he overcome with fear and panic and having difficulty knowing how to manage these feelings that therapy can help him master?” (p. 175).

The neural activation patterns that clients experience in the form of repetitive feelings and problems can change only when they have been activated. When such activation does occur, it is useful to guide it toward mastery experiences; negative feelings can then become pathways toward success (Grawe, 2004). For example, consider the following case.

Case Example: Appropriate Level of Arousal Facilitates Access to Creative Solutions

Caroline, a successful commercial real estate broker whom we had previously seen, called in a quandary over how to handle her business partner. As their firm began to have more difficulty finding commercial tenants, her partner started to complain that Caroline was not working hard enough to line up prospective tenants. Ostensibly to help her, he began attempting to micromanage her schedule and requested detailed reports of her efforts to secure new business. She was alternately anxious and depressed. Her husband showed little patience with her situation and told her to dissolve the partnership. However, because of legal and contractual obligations, she felt she could not just walk out.

Since they were on her managed care plan, Caroline had been to other therapists recently. All of them had encouraged her to take medication for depression. Bill listened to her, then validated her feelings of frustration and concern over the stability of the business partner. He reassured her that she was not crazy: Anxiety and depression would be understandable responses, given her situation. He also observed that although an antidepressant would treat her symptoms, she might not need medication. What she did need was to find a solution to the stressful situation in which she found herself.

Since Caroline had been an executive in a major corporation and was well-connected in the city prior to marrying and having children, Bill wondered aloud to her whether she was as backed into a corner as she thought, and he suggested that the problem had solutions. Bill used this intervention only after being sure that her level of arousal had decreased. He began to talk about strategies with which she could begin to make changes, dissolve contractual obligations, and end the business relationship. She told Bill that no other therapist had been as pragmatic with her. Pleased with his approach, she began to access states of self-empowerment. By the next session, Caroline had begun to take steps to terminate the contractual obligations, and both her anxiety and depression were noticeably improved. The addition of alpha–theta training (Chapter 7) helped her maintain a lowered arousal state and be more creative in her problem-solving efforts as she moved through the process of dissolving her business partnership. All Caroline needed was access to a calmer state, which then allowed her to marshal her own considerable abilities and resources.

The BCT therapist proceeds organically, though with an underlying structure in mind. None of us lives in the linear world that analysis and description convey; nevertheless, some linearity can be useful in early learning stages, and so we provide a linear structure here. As noted in Table 4.1, the therapist begins with a comprehensive evaluation focused around the problematic state. We use the following questions to help clients become conscious of their habituated stress response patterns:

2. “What is your focus of attention—how and where are you focusing?” [Develop conscious awareness]

3. “How do you explain this state? What led you to develop it?” [Life pattern]

4. “How are you breathing? Do you feel that you are in the middle of an emergency response or can you slow your breathing and create a calm response?” [Sympathetic vs. parasympathetic breathing; see Chapter 6]

5. “Do you find yourself frequently in this state?” [Default state or new state]

A formal evaluation, however, is not always appropriate. In some cases the initial evaluation will need to be conducted slowly and much more casually while a stable therapeutic relationship is being developed. The following case demonstrates the use of accepting the client’s reality and using empathic attunement as a means of creating a working relationship. The client evaluation was carefully integrated into the early stages of treatment.

Kevin, now in his early 20s, had a history of paranoid schizophrenia with a fixed delusional system. At the time he was referred to Bill, Kevin believed that he was an artist and that people were trying to keep him from a career in the arts. He had constructed an imaginary life that included being married and having a son. He was also convinced that Bill had cameras in the office and was taking pictures of him. Bill told him that he was correct about the camera in the office: It was in his cell phone.

Kevin had stopped taking antipsychotic medications and, although quite intelligent, was unable to hold a job. He was living at home and had physically attacked his parents. Although he did not look like a street person, he was disheveled and unkempt. During the first few visits, Bill mirrored his behavior; since Kevin would not look at him, Bill avoided eye contact.

Suspecting that Bill was part of the plot to derail his career in the arts, Kevin wondered aloud if Bill were colluding with his parents. Bill confirmed that he had spoken with his parents and added that they were concerned about the amount of time he spent drawing. Bill asked to see some of his drawings and said that he liked them. As an aside, he commented that it was difficult to make a living as an artist.

Since Kevin was clearly in distress, Bill told him that he did not know how he managed to handle the fear and stress and said to him, “I could not go through what you experience. I would need to take the medication.” Kevin began to shift states with this intervention and open up to the therapy. He became curious about what therapy might be able to do for him. Bill found that Kevin could tolerate only a short session of 20–30 minutes. Most of the early sessions ended abruptly when Kevin would say it was enough.

Because Kevin talked about his delusions, such as the delusion of having a son, and could identify them as imaginary, Bill discussed these with him. Bill reflected his feelings and suggested that it must be horrible to have a son you cannot see and to believe that people are trying to ruin your career. The empathic comments that conveyed acceptance of Kevin’s reality helped him begin to move into states of comfort and trust. Gradually, Kevin became less agitated, and Bill asked what it was like to be on medication. Kevin acknowledged that he felt much better on medication. Bill encouraged him to take the medicine in order to alleviate his distress. As Kevin continued to experience feelings of comfort with Bill, he resumed taking his medication on a regular basis.

Kevin was able to access his own ability for self-comfort by attuning to Bill’s nurturing. Eventually, the medications cleared the delusions, and therapy took the path of helping him begin to socialize with others and hold a job.

Next the clinician considers what states need to be activated to help this client. Arousal states for learning include anticipation, curiosity, urgency, or confusion and may be thought of simply as a range of beta frequencies. Other states, such as well-being or what Thayer (2001) called “calm energy,” need to be activated when a client is anxious; these reside in the alpha range of frequencies. We can stimulate states of well-being by evoking positive memories, describing social connectedness (Panksepp & Burgdorf, 1999), or describing experiences of success. Helping a client have these experiences will build access to these states.

States of low stress, safety, and peacefulness help clients self-reflect and allow them to integrate and resolve emotional issues. When these states are difficult for a client to maintain, brain technologies may be useful. If clients have trauma, it may be dealt with best by teaching them how to increase state flexibility safely through the use of brain training devices (Chapter 6) and view what happened in the past from a witness perspective without blaming themselves.

The client’s problem needs to be framed as having a variety of solutions once the client learns to access and maintain an appropriate brain–mind state. The mind can create many ways to resolve a situation; it can generate ideas, author empowering visualizations, and imagine possibilities; and it can form new emotional patterns—if the brain is stable. At that point, new perspectives and ways of assigning meaning become possible. Particularly in the context of stressors, an essential element of psychological health is brain stability: the “proper balance of activation, inhibition, and integration of systems biased toward left-and-right-hemisphere control” (Cozolino, 2002, p. 123). The result of brain stability is psychological flexibility, that is, the successful management of the basic emotions of happiness, surprise, fear, sadness, anger, and disgust.

Grigsby and Stevens noted: “Physiological state can be conceptualized as a complex, multidimensional control parameter influencing behavior by affecting the probabilities associated with the activation of specific neural networks” (2000, p. 362). Clients frequently become stuck in a particular negative state and do not know how to shift into a more functional state without the help of a guide. Since all clients have had the experience of shifting states of consciousness, this natural process can be made more deliberate as a means of facilitating transformational learning (Lankton, 2003).

In common with all defense mechanisms, a sustained focus on symptoms often has aspects of trance phenomena. Every psychological symptom has an element of dissociation with concomitant brain frequency ratios; every physiological symptom can be interpreted as an indication of being out of control—although, in another context, the same physical sensations may be interpreted as completely safe. For example, rapid heart rate and perspiration in a gym are to be expected. The same response while climbing the steps to a stage may be interpreted as anxiety. The issue is not the physiological sensations per se; rather it is always the meaning a person attributes to them. If a person becomes overly focused on symptomatic expression, he or she often begins to play internal mind movies of the worst possible future (Kershaw, 1992). In essence, this mental rumination is preparation for handling a negative outcome and may be seen as a survival mechanism. By helping the client to change states, a negative trance can be depotentiated. From the resulting more open state, the client may discover a new perspective or even an internal resource that had been previously overlooked.

State change can be accomplished in a matter of seconds and through a variety of ways: by altering physiology, using humor, focusing attention, and/or engaging motivation (Grigsby & Stevens, 2000; Fehmi & Robbins, 2007; Lane & Nadel, 2002). We discuss each in turn.

Physiology can be changed with a simple adjustment in the way a client stands, sits, looks, eats, or breathes. For example, with a depressive client who is slouched in a chair, create some reason for the person to get up out of the chair and walk a few feet. Such a reason might be to look at a diagram the therapist has quickly sketched on a piece of paper to illustrate a situation the client is describing (a few circles and arrows with a verbal description will do). The therapist can show the sketch and ask, “Do I have this right?” As well as engaging the client’s curiosity, having him or her stand up, take three or four steps, look at a piece of paper, and sit back down will change his or her physiology, focus of attention, and state. In addition, changes in sensory stimulation from the external environment (e.g., opening a window for fresh air or changing the lighting) can change a client’s physiology and result in a reduced anxiety level.

Humor is an effective way to change states. It turns on the play circuit and fosters attachment to others. In the context of psychotherapy, humor can provide relief from tension and stress and can shift a client’s state from anxiety or depression to playfulness (Fredrickson, 2001). Sharing humorous experiences or stories encourages people to spend more time in social connection (Buckman, 1994; Driscoll, 1987).

Parents who were disturbed by their son’s latest habit of ripping books out of frustration brought him to see Bill. After connecting with the family, Bill turned to the son and said with a twinkle, “Do you rip up telephone books? You need to be careful. I just tore my rotator cuff by gripping weights too tightly. If you grip too tightly, you may give yourself tendonitis.” This intervention shifted a tense and fearful atmosphere to one of curiosity and play while still suggesting that the behavior had negative consequences. However, it was said in such a kind and funny way that it was clear there was no judgment, and the young man opened to therapy. On another occasion, after listening to a client recount the harrowing details of a weekend with her teenage sons, Carol smiled and said, “Well, I guess it comes down to this: How much life can you stand?” Suddenly the client broke into laughter and wryly commented, “How much indeed? I’m already having as much fun as I can stand.”

One’s focus of attention can either narrow—for example, in anxiety—or broaden to facilitate a shift from the problematic stimulus. Fehmi and Robbins (2008) suggested that high arousal states can result in a narrowed and inflexible style of attending that can lead to mental and physical distress. An example would be an individual who is attuned to a partner’s negative behaviors and constantly holds them as a mental list, ready for immediate critical review.

When it accompanies anxiety, tunnel vision (extreme foveal vision) can provoke an extreme sympathetic response. If that state remains unrelieved for a sufficiently long time, the person may begin to feel helpless and hopeless—and that can trigger an extreme parasympathetic response. In the therapeutic setting, it may be important to assist the client in bridging from a highly parasympathetic response to a more balanced one by having the person get in touch with his or her anger over the matter in question. The anger in this case need not be seen as rage but simply as energy. If the therapist not only validates the client’s hopelessness but also, given the situation, the legitimacy of his or her anger and frustration, the client may feel safe enough to consciously perceive the underlying anger. From there, the client can be assisted in using the liberated energy to shift into a problem-solving mode. With that shift, the client’s vision will broaden to include elements in his or her peripheral vision, and his or her state will become calmer. As a means of reinforcing this broader vision, we then suggest that the person notice what specifically is in his or her peripheral vision and describe it.

Prochaska and DiClemente (1982) developed a model of motivational change that was accepted as a therapeutic standard for many years. They conceived of the process of change as proceeding in several stages: precontemplation (not having given thought to any change), contemplation (ambivalent about a possible change), preparation (experimenting with a change), action (practicing a new behavior for at least 3 months), maintenance (the new behavior becomes habitual and is continued beyond 6 months), and possible relapse. About the same time, Miller (1983) developed an approach of motivational interviewing wherein clients were persuaded to resolve ambivalence about changing behaviors using cognitive strategies. Taken together, the work of Prochaska and DiClemente and Miller provided an excellent framework for structuring the therapeutic alteration of dysfunctional behavioral patterns.

Recent neuroscience discoveries have suggested that motivation can be increased by specifically engaging certain neural circuits (Panksepp, 1998). When we can activate the SEEKING/CURIOSITY circuit for any problem, clients are more open to treatment. Curiosity leads to motivation and is reinforced when it is followed by success. Furthermore, seeing success in one area can give a client “leverage” with which to attempt other therapeutic goals. For example, one client who’d had severe neck pain had a surprising experience of pain reduction when she went into deep hypnosis. After this gratifying success, she became highly curious about what else she could accomplish and began a food management program that she had put off for years for fear of failure. A state of anger can be swiftly shifted into motivation, and the SEEKING circuit turned on, if the therapist asks an open-ended, judgment-free question that poses a plausible but radically different interpretation of an event. An example would be a parent complaining furiously about a teenage daughter who “doesn’t hear” or “forgets” things said to her. “Would you consider conducting an experiment? It’s possible that Sally is literally so focused on her own thoughts that she doesn’t mentally process your words. When you need her to hear you, would you be willing to stand directly in front of her and make eye contact before you speak in a quiet conversational tone? Why don’t you try that experiment at home and then keep track: How many times does she hear—or not hear—the things you say to her when you do it that way?”

An individual intervention may be thought of as a building block. To help move the client from a problematic state of consciousness to an integrated, desired state and ultimately to experience more time in a state of thriving, interventions can be built into effective strategies. Such strategies—structured groupings or sequences of interventions—should be focused on activating the client’s resources rather than on the client’s problem. Research has shown that a focus on resource activation is a common characteristic of the most successful therapists (Gallmann & Grawe, 2006).

In addition to correcting the neural foundations of dysfunction, an important therapeutic focus will be to help shape the client’s life experiences such that the person’s life is more congruent with his or her goals. Grawe noted, “Greater positive changes will be attained when one concentrates on the positive goals of the patient than when one focuses predominantly on fears and anxieties” (2007, p. 327). This does not mean that we should avoid talking about what is painful, but rather, that it should not be the emphasis in therapy. Here we describe state progression, neural talk, and resource activation as examples of BCT strategies.

The purpose of the therapeutic interaction is to help clients learn to move from dysfunctional—or unresourceful—states to resourceful ones. In some cases, this will require a process of state progression: the gradual transition from an unresourceful state to a less unresourceful state to a neutral state to a mildly resourceful state and finally to a more effectively resourceful state. When a person achieves an optimal state and level of arousal for a task, he or she unlocks the possibility for healthy emotions, attitudes, and behaviors in relation to that task.

The first step is to identify the unresourceful state the person experiences (Hall, 2009). In discussion with the client, the second step is to identify a desired or target state conducive to achieving the client’s therapeutic goals. The third step is to depotentiate the dysfunctional pattern and, in stages, activate state change toward the target state. As the level of arousal is increased or decreased while moving toward a balanced state, one or more state shifts will occur. If the presenting dysfunctional state is one of overarousal, it will be necessary to facilitate movement into a more relaxed and calm state of mind where a potential reorganization of perspective can more easily occur. If the brain is underaroused, as in depression, a therapeutic process that activates the person is a better approach. Activating anger or action of some sort can help the client change states.

State progression can be used as a strategy either within the confines of the therapeutic hour or as a series of exercises/assignments that the client does between sessions. Within the clinical setting, the therapist participates with the client in shifting states through changes in voice tone, timing, gaze, and focus of attention to begin to move toward more positive states. With this gradual shift the client loosens the rigidity of a previously held mindset, softens the energy directed toward the therapist, and begins to open to a new perspective and set of emotional experiences. Within the therapeutic encounter, the target state is an “access state” (Goleman, 1988) in which the client is more receptive to what the therapist has to offer. As “homework assignments,” state progression can slowly dismantle a dysfunctional emotional response and its entrenched neural pattern.

We use our work with Melissa and her husband as an example of state progression accomplished through a series of homework assignments. Melissa came in with the complaint that her husband Brad made the worst sounds with his mouth when he was having sinus problems. Her very description caused her to curl up on the couch as she remembered how the sound made her feel. The state she entered was obviously uncomfortable (disgust is never pleasant) and intense. We asked her to bring her husband in and when she did, she pointed out the terrible, disgusting sound he made. We made every attempt to hear this sound, but our ears lacked Melissa’s attunement.

Learning more about her history, we discovered that her mother used to scream in her face. As a young girl, Melissa had learned to use extreme tunnel vision to focus only on her mother’s mouth so she could survive the ordeal. In doing so, she developed a sensitivity to sound that caused her to be overly sensitive to her husband’s “sticky mouth.”

We talked with her about this trauma and how painful it must have been to be screamed at so often by such a central figure in her early life. As she told her story, we noticed that she began to focus on our mouths and our mouths became a little dry. It can be easy to share the client’s negative trance state and pick up a “mental virus.”

As a way to help her begin to shift her negative state and “spread the symptom” (Kershaw, 1992) away from her husband, we suggested that she view certain newscasters to determine if any of them made this horrible noise (engaging her seeking circuit through curiosity). She discovered several who had “sticky mouth syndrome.” We then suggested that she might notice if the newscasters did anything else that was annoying—for example, wiggle ears, raise eyebrows, or make other odd movements.

When she accomplished this task, we suggested that she begin to notice other movements with hands, feet, eyes, etc. Melissa reported that she had discovered other interesting and quirky movements that people make habitually; in fact, she was beginning to have fun with the assignments (engaging the play circuit). We asked her to continue to “spread the symptom”; as she paid more attention to total body language, the less she was emotionally assaulted by incidences of “sticky mouth.” Finally she began to gain some control over her irritation.

Later in the therapy, Melissa finally acknowledged how upset she was with her husband. She felt that Brad was not helping her with their newborn son, but could not bring herself to complain about it directly. Instead, she hyperfocused on his mouth. We encouraged her to share this insight with her husband in a marital session and suggested that she had practiced the state-specific ability to hear sound so well that the next time she was disturbed by her husband’s mouth noises, she should notice whether she was keeping her “voice” to herself when she needed to talk to him. Ultimately, this reframed symptom became a resource: It became a warning sign that she needed to share her feelings. In the process, she had rewired longstanding neurological circuits, calmed her hyperresponsive amygdala, and turned on circuits of curiosity, play, and self-nurture. As LeDoux (2002) wrote: “Psychotherapy is fundamentally a learning process for its patients, and as such is a way to rewire the brain. In this sense, psychotherapy ultimately uses biological mechanisms to treat mental illness” (p. 299).

Neural talk is a strategy that makes intentional use of words, metaphors, phrasing, and tone of voice to access appropriate brain circuits for change and to inhibit neural connections that lead to dysfunction. Acting as a bridge from one state to another, neural talk may shift a client’s state only in a small way, but so effectively that the person cannot continue to feel and behave in the same way. Neural talk uses empathy to come into an emotional alignment with the client and then, carrying the client along, it takes off in a new direction. We use this method to move people from states of stress, anxiety, depression, or other problem states to states of calm, cheerfulness, and affiliation (Porges, 2007). For example, with a client struggling with insomnia, we might say, “This situation has really been difficult for you, and while you feel terrible, and would certainly like to feel better, you managed this fatigue and have been doing amazingly well these last few weeks.” Neural talk is often used to shift the client’s attention from problems to resources.

The following case shows the use of neural talk in an initial therapeutic session. Because Carol had been given substantial background information from the referring physician, she did not begin with a formal client assessment but opened the conversation to establish rapport. Evelyn, age 86, was referred for therapy for help with anxiety about using her CPAP (continuous positive airway pressure) machine. She needed to learn how to accommodate this method of respiratory ventilation to ameliorate the oxygen deprivation caused by her sleep apnea.

Of an independent nature and embarrassed that she needed help, Evelyn had been resistant to seeing a psychologist and was initially quite ill at ease. As Carol began working with her, she complimented Evelyn’s independence and told her that this was a wonderful resource that had helped her throughout her life (empathic pacing). The client began to relax visibly and nod her head in agreement. Carol told her she had many abilities and might even discover some things she could do that she hadn’t known previously (moving the conversation in a new direction). Then Carol explained that practically everyone has trouble getting used to sleeping with a breathing machine but that, as with any other learned skill, the brain can adapt with practice. Carol noted as Evelyn’s breathing slowed and she became more attentive and curious. Carol alluded to the client’s independence again (maintain pacing). At that point, feeling secure enough to be more open, Evelyn admitted that she at times felt frightened when alone, especially at night. Carol suspected that, to some extent, Evelyn’s general nighttime anxiety had become focused on using the CPAP machine. She suggested that Evelyn allow her “deep mind” to give her an image or symbol of something in her house that made her feel safe and secure. The client began to smile; she had a collection of crosses on the wall. Carol nodded and suggested that there is an energy that radiates from sacred symbols, that if you are quiet, you can almost feel it (reinforce new state of security). Carol suggested that that energy can fill an entire space so that when Evelyn looked at her collection, she could feel safe and secure. The client began to look even more comfortable (further reinforcement). By the end of the session, when Carol asked her to come back and said that together they would work on Evelyn’s unease with the CPAP equipment, Evelyn’s anxiety regarding being in a psychologist’s office was reduced significantly, and she was amazed at what she had already accomplished.

We want to identify how and in what context a client has experienced past success and, when appropriate, we want to refer to the success. Those areas in which the client is already motivated can clue us in on the client’s intrinsic sources of motivation and strengths to make change (Grawe, 2007, p. 328). To notice where clients have acted in courageous and confident ways is to suggest that the resource is available to them in other contexts. For example, Bill asked the boy who ripped up books to tell him how he felt when he played tennis. The young man shifted states and described feeling calm and powerful. Bill suggested this was a solution state he could access more frequently at school. The young man was intrigued by the comment, and that curiosity led him to explore other empowering states.

We had one client who identified himself as a “loser” but who happened to mention early on that he’d had a successful experience of skydiving. He had disregarded this example of courage, risk taking, and confidence that he could accomplish the goal. As he began to appreciate these aspects in himself, he became increasingly less apt to think of himself in such a negative manner.

The clinician can also facilitate change and access highly resourceful states by altering the cognitive or perceptual frame that a client places around a particular problem. Questions such as “What are the possibilities we have not thought of?” or “What else could work in this situation?” or “What can you learn from this situation?” are better questions than asking “What is wrong?” Open-ended frames lead a client toward generative states and support growth and healing. For example, when a husband complains that his wife is uncooperative in a particular situation, we might respond: “Is she doing this on purpose or might there be some other motivation behind her behavior? What might her reasons be? When she behaves that way, how do you feel? What is stirred up in you? Is there anything you do in response that escalates the situation?” When we ask such questions in a warm and inquiring way, we engage the client’s curiosity (the emotional circuit of seeking) rather than defensiveness. What then goes on at the client’s unconscious level is quite a different conversation and may lead to a reconnection with the partner.

We are always reworking the past by the way we remember it. Life experiences affect memory, and the more we understand life’s difficulties, the more we are inclined to view the past (both our own and that of others) compassionately. As clinicians, we hear stories of heartbreak and despair, madness and destruction, accomplishment and love. Sometimes the narratives people share are painful childhood memories; sometimes they are explanations of current pain; at times they are frozen narratives that provide no clear way out of a dilemma. Joan Didion (1979) remarked: “We tell ourselves stories in order to live… . We live entirely … by the ‘ideas’ by which we have learned to freeze the shifting phantasmagoria which is our actual experience” (p. 11). Clients’ stories often reflect narrow and rigidly maintained beliefs that fail to account for much of the complexity of life and that keep them on a barren path, with certain emotional circuits and states chronically turned on. At other times, the stories express resiliency and abilities that even the narrators themselves fail to recognize.

We suggest to clients that giving a mental state a metaphorical name can be useful in managing the responses of their autonomic nervous system. Mental imagery can rewire the brain and have a therapeutic effect (MacIver, Lloyd, Kelly, & Nurmikko, 2008; Ganisa, 2004). One of our patients called his state of upset “trigger happy”; another person used the phrase “red-lined” (as when a car engine is so wound that the tachometer is in the red section) when she was overwhelmed to the point of “seizing up” and being unable to function. Both of these metaphorical descriptions helped the person to observe a brain state and subsequently to shift the emotional circuit to one of increased calm and self-nurturance.

To use metaphor in the session, the clinician merely needs to review his or her own learning during some adventure, trip, conversation, or experience. The object is to assist the client in focusing on positive possibilities that open a life, rather than on negative frames that close potential portals. Sharing a brief vignette with the client can shift the neural circuit and the frame the individual has been using to order his or her life. Carol tells the following favorite anecdote:

“A few years ago when I was in New York on business, I took the time to stroll through Central Park. It was a pleasant day with a slight breeze, and the park was full of interesting sights. I saw one man who had trained his cat to balance on his shoulder while he took a walk. Winding around the paths, I came upon the merry-go-round. The calliope was playing and the children’s voices sounded so excited as they stood in line for a ride. Then I saw the sign: TWENTY-FIVE CENTS FOR A RIDE.

“Twenty-five cents—that’s all it takes for the ride of a lifetime when you are a little child. Just twenty-five cents, a quarter of a dollar, just a little change to experience a new adventure. So when you go on your trip, perhaps you will discover something wonderful that will offer you an interesting perspective, or you could just have a great time.”

The story suggests that “a little change” is all it takes to begin having more fun. A person may make only a slight state shift, and yet this can open up new vistas, new options, and new potential solutions to old problems. The suggestions, embedded within the story, speak to the unconscious mind. A metaphor does not need to be elaborate. Something simple can be very effective. The skeleton of Carol’s anecdote above is: I took a walk; I saw something; it made me reflect.

To create a metaphor, the therapist starts at the end (the point to be conveyed) and works backward to the beginning. Holding the point of the metaphor in mind, think of something that exemplifies the point. It may be an event, a single fact, or just an object. For example, we had a Scottish client who grew up drinking tea. With her, we used the process of letting tea leaves steep in a teapot as a metaphor for the idea that once something has been set in motion (e.g., the client has begun therapy), there will be a good outcome—if the client is patient and allows the process to unfold. Create the minimum number of characters needed to interact in the event. An implied “you,” the client, may be the only character. For example, the therapist might introduce the tea metaphor by saying, “When you make tea… .” If the metaphor is centered on an event, place the event in an appropriate locale. At the end of the metaphor, create a sense of closure: “And when the tea is ready, you pour it into your favorite cup, add two sugars, and sit down to relax with a lovely hot cup of tea.” To make the story more engaging, use details that appeal to as many of the five senses as possible; elements of smell and touch are particularly effective. The crucial element is the therapeutic message; it will suggest all the rest of the metaphor. After telling the metaphoric anecdote, it is important to allude to the point. The allusion should be overt enough that the client understands it unconsciously, as evidenced by ideomotor indications (e.g., a slight change in facial expression or posture), and yet subtle enough that it does not ruffle the conscious mind and possibly create resistance. Figure 4.1 summarizes the process of constructing a simple metaphor.

Therapeutic metaphors can also be used to activate potential resources by tapping into the unconscious and retrieving memories of past learning, as well as to teach skills a person needs. In listening to a story, a client will make certain associations and may be able to grasp a different perspective. Personal shifts in feeling and attitude can happen. By helping to contain a client’s feelings about an experience, metaphoric stories can have a healing power.

Chapter 7 contains a section on how to create lengthier, more involved therapeutic metaphors, which may be used in the context of deep hypnosis. We find that, over time, each therapist develops a unique repertoire of stories that fits the therapist’s personal style of working with clients and is consistently useful in similarly recurring therapeutic situations.

The following is another story that we have repeatedly found meaningful to clients who need to overcome some adversity or who may have been kept from realizing their own potential through a kind of negative hypnosis. Our hope is that the story will encourage the client to access his or her deeper self to problem-solve, build confidence, and create opportunities. The story also is an example of how seemingly negative emotional states (e.g., feeling like the family black sheep) can provide the impetus to accomplish personal goals (e.g., becoming an artist and finding a place where one does fit). As we explain to our clients, “If you can change the way you envision your possibilities, you can definitely change your future.”

“Several years ago, when we were in San Antonio for a conference, we spent an afternoon walking along the river and browsing through a variety of shops. One gallery featuring wood sculpture especially caught our attention. Its shelves held all kinds of animals from mythical to real. Each of the hand-carved animals had exceptionally long legs, and the underside of one foot was stamped with the image of a black sheep. We asked the gallery owner about these creatures.

“He told us the artist was a young woman who grew up in a poor family and, although she yearned to attend art school, her parents told her that her dream was completely impractical. They were worried about having enough money for the family and knew art was a difficult way to make a living. The young woman kept her dream to herself and read as much as she could on her own. Because her siblings teased her and discounted her dream whenever they saw her reading an art book, she felt ostracized from her family and retreated further. When she was old enough to move out on her own, she worked and put herself through art school. She began to carve these beautiful animals and eventually became a successful artist. She gives all her animals long legs to symbolize the ability to rise above difficulty, and she stamps a black sheep on one foot of each. In her family, she said she felt like the ‘black sheep’ and wanted to remember the challenges she needed to overcome to be successful.”

We can also help clients see that their own life experiences can be understood as metaphors. Rose Marie was a musician who entered therapy for neurofeedback training to stimulate brain functioning after having brain surgery in the frontal lobe area to remove a benign but invasive growth. Although her cognitive processing was quite slow afterward, she still maintained the ability to play the violin. We asked her to bring her violin and play something for us. She tenderly removed the instrument from the case, tuned it, and began a lovely interpretation of Ave Maria. Tears came to our eyes and, with them, hope for continued improvement.

When she finished playing, Rose Marie told us a story that was, to us, a living metaphor of future possibility. While in the north of France and shopping in a small village antique shop, a friend called her over to see a dusty, old, unstrung violin tucked among other things in a back corner of the shop. The shopkeeper said that she had kept the violin a long time, but that what she did in life was bring the past into the present, so she would sell it for the equivalent of $20. Our client picked it up, looked it over, and saw a dark indentation of inlaid wood around the edge. In turning the instrument over, she saw written at the very top a violin maker’s name. From that, she guessed the instrument was over 100 years old and might be quite valuable. She bought it, brought it home, and had it refurbished and restrung. The violin had a richness of tone that only a handmade instrument crafted by an artist can produce. In fact, the violin was worth thousands of dollars. Touched to be a part of her recovery journey, we said to her, “Perhaps you don’t realize just how alike you and this beautiful instrument are.” Eventually, Rose Marie regained much, though not all, of her functioning and went on to play more expertly and artistically than before her surgery.

Ultimately, the client needs to take personal responsibility for the process of self-regulation. Dysfunctional emotional states and their concomitant neural patterns tend to fall into two broad categories: Either they are responses to immediate, external events (e.g., a partner’s behavior) that trigger well-worn neural circuits, or they are responses to immediate internal events—the brain’s activation of neural circuits, which are then often consciously rationalized by internally generated scenarios (e.g., a state of anxiety or depression can always be justified on some basis). The state may actually have been triggered by a fleeting thought, which may not even be remembered a few seconds later; it may have been triggered by an unconscious resonance with someone else in that state (transference); or it may simply be one of a person’s default states of neural patterning.

Here we discuss three approaches to state change that clients can learn to self-initiate: understanding the process of the mind, deconstructing emotional reactivity, and using mind shifting.

Before a client can learn to shift states, often the person must learn to perceive the process through which he or she stepped into the negative state. In explaining the process of the mind to a client, we describe a common progression of thoughts that leads from registering a physical sensation or experiencing an event to an internally held, and frequently negative, state. The following is a example of what we might say as we teach clients to become consciously aware of this process in their daily lives:

“The human mind is constantly chattering; over the course of each day, it entertains thousands of thoughts. Frequently, a person will notice a physical sensation, such as pain or warmth, and then label it—that is, give it words such as ‘warmth on the back of my neck.’ This is almost immediately followed by a judgment as to whether that warmth is good or bad. The judgment commonly leads to an internal response: turning on one of the emotional circuits or states [as identified by Panksepp, 2003].

“The state is followed by developing a story about the feeling. ‘It feels good to get out and get some sunshine. What a great afternoon for a hike with the kids [play].’ Or: ‘I forgot to bring sunscreen [irritation]; I’m worried about the kids getting sunburned [anxiety].’ Double-binds are frequently part of the judgment, the state, and the story: ‘I want to be a good parent and spend more time with my sons, but I wish I hadn’t promised to take them on a hike this afternoon because I need to be working on a presentation that I’m scheduled to give next week.’ With the story in place, often the ability to shift states, particularly to shift from a negative state to a positive one, becomes difficult.

“Any negative experience, whether it is an occurrence of physical pain or an emotionally painful situation, has many elements. There is the sensation of pain, memories of past painful experiences, certain associations to the pain, and future projections on what might occur [Salmon & Maslow, 2007]. However, being attentive to what occurs without any judgment begins to initiate a change. When all of these elements are simply observed, the mind becomes calmer and the sense of discomfort lessens. Also, in the process of observing, it is possible to notice thoughts and emotions without acting on them. And you may catch sight of reactive patterns that would otherwise be well underway. Over time, the simple act of observation helps you develop a nonreactive mind and stay focused in the present rather than the past or the future. The worries we carry or conversations we replay are the mind’s way of recalling a past or rehearsing for a future, but in fact they only serve to maintain internal states of stress.

“The process of the mind can be interrupted at any point by becoming curious about a sensation, exploring the feeling for its texture, color, or trigger, rather than analyzing it. Another way to interrupt the process of the mind is simply to drop the judgment and the story. Becoming aware of the mind patterns that were probably learned in your family of origin creates an opportunity to understand something that may have been hidden from your awareness for most of a lifetime.

“The mind senses the world in habitual ways, and its patterns can easily develop into rigidities. Too often, these patterns become lenses through which we view our experiences. The patterns cause us to make assumptions about ‘how things are’ that may be incorrect. For example, to try to make sense of events, we tend to make a story about all that transpired. Storytelling is particularly likely when we try to understand someone else’s behavior. But our stories are not always accurate. However, if we can hold our interpretations lightly and know that things may be more complex than we had presumed, we may be able to have an interaction or resolve a conflict in a way that we feel good about. If we calm the mind chatter, put aside our habitual or learned interpretations, and give up believing the sole ‘truth,’ we are more likely to be able to resolve conflicts and solve problems. Clutching tightly to a particular meaning puts us in negative states. Being aware of the process of the mind allows you to interrupt the negative state and replace it with a more functional and flexible one.”

When an emotional trigger is external, typically a person is aware of the immediate triggering event, the emotional reaction, and the consequent behavior, but will not know how to alter the pattern. To begin to change it, the client must learn to recognize and name the reactivated state into which he or she has fallen. The process of identifying a state when it occurs and naming it gives it a visibility that it may not have had previously. The next step is to be able to refrain from responding with a habitual behavior even when flooded with the emotional state. Eventually the individual needs to learn to “step aside” internally and detach from the emotion. Without reacting to the feeling, he or she needs to shift into a stance of curiosity and attempt to understand it.

One method for deconstructing an emotional reaction is to have the client observe the feeling state as though from a position outside the self and identify which life pattern has been activated. The client may even be able to identify an early triggering event that shaped the life pattern. Next we ask the client to observe and evaluate his or her usual reactive response from this external perspective. Another way to frame the notion of detachment is to ask the client to imagine being a cultural anthropologist gathering data about members of a newly discovered indigenous society. Observing from a distance calms a reactive response. In either case, the client activates a seeking state characterized by a distanced curiosity; the key is being “warmly aloof” in order to remain centered. For example, with a client who has conflicted relationships with family members, we may suggest the following: “Go and visit your family. When you are there, I want you to take mental field notes just as an anthropologist might do. If, during the visit, you find that you have become caught up in the family drama, just internally step back and silently return to talking mental notes.” The process creates a detachment that tends to lessen potential reactivity to comments that family members may make.

This process is also particularly important for therapists who may feel an internal negative charge when working with certain clients. For example, some clients adopt a dismissive style of interacting with the therapist. This subtle aggression and mixed message (“I want you to help me, but I don’t want the help you are offering”) can be frustrating and hurtful. To avoid becoming entangled by the client’s style of interaction, the clinician can mentally move his or her personal boundary closer and stay focused on his or her curiosity as to what led the client to adopt this way of interacting with people.

When the trigger for a dysfunctional state is internal, we suggest that clients learn to shift states quickly by identifying the present state and its content and the desired state and its object of focus. They can practice “mind shifting” by changing breathing rate, body posture, and/or object of attention, or remembering a time when they experienced the preferred state. Since overfocusing on a sensation or problem can lead to tunnel vision, they may also find it helpful to expand their field of vision. They can use the term mind shift as a cue to themselves to practice changing states more quickly. In addition, clients may use music, thoughts of a beautiful place, or a relaxed activity such as sipping tea or lying in a hammock to change to peaceful states. In this case, it is the act of altering the mental focus that shifts the brain state.

One client was a successful portrait painter, but she greatly feared throwing up in public and would often overfocus on the sensation of anxiety in her stomach to the point that she did throw up. We explored her original family system, in which violent eruptions occurred frequently. She had developed a hypersensitive stomach in response to stress and carried this symptom into adulthood. By having her become aware of what was on either side of her (“Focus on what is directly on your left and name the exact color of the closest left object. If you wanted to mix that shade in oils, what paints would you use? Focus on what is on your right and name the exact color of the closest right object. If you wanted to mix that shade in oils, what paints would you use?”) and breathe more deeply, she developed the ability to control her stress symptoms and keep her state managed.

The following case exemplifies the process of assisting a client to identify preexisting self-regulation skills and inner resources in order to self-initiate state change.

This therapeutic process involved retrieving the memories, sensations, and emotions of childhood play and turning them into resources. Elaine could board airplanes but, when her husband was with her, she would dig her fingernails into his arm so firmly that, on occasion, she had even drawn blood as the plane was taking off or when it encountered turbulence. If he was not flying with her, she would grab the arm rest and experience a panic attack. She was an interior designer and began therapy because she knew that she needed to make a multilegged trip from the United States to Singapore and then to Hong Kong and back.

Bill had Elaine focus her attention and go into a trance with an accompanying arm levitation. He reassured her she would adapt to the feeling of having her hand float in the air. Bill then had her revisit memories of bouncing up and down as a child. These included memories of bouncing on her father’s knee and jumping up and down on the bed, a sofa, a hobby horse, and a trampoline. Bill did this by telling stories about Tiffany, our daughter; as he talked he would switch the pronouns from the third to the second person. For example: “Tiffany knew that when you jump up and down on your bed, not only is it fun, but you are doing something mischievous.” Bill would watch for ideomotor signaling, such as rapid eye movement or a slight smile on her face. Then Bill asked her to memorize the good feelings.

Continuing to tell stories, ostensibly about Tiffany, Bill next asked Elaine to remember riding a bicycle down a hill, over a bumpy road. Bill did this in order to identify the sensation as if she were watching a movie, without alerting her consciously that the process was intended to address her issue. Bill had her experience an arousal of adrenaline by telling stories of Tiffany and him going through a haunted house and of children playing telephone games, like calling people up and asking them silly questions such as, “Is your refrigerator running? You should go and catch it.” In telling the stories, he mentioned the physiological symptoms of increased adrenaline, such as a racing heart, fast breathing, and sweaty palms—followed by simple childhood laughter.

At each step, Bill asked Elaine to memorize the sensations and corresponding emotions, and told her she would use these later in a directed fashion. This process was repeated a few times. All of these suggestions were designed to stimulate the play circuit (curiosity) and to connect fear and play so that if she became frightened, it could be exciting and fun rather than anxiety-inducing. Bill also suggested that while her conscious mind did not know what he was saying, her unconscious understood quite well.

Between some of the stories, Bill brought her partially out of trance to look at her hand. He asked her how it felt to see it floating. She was amused by it. At the end of each session, Bill would suggest that her hand could come down and “land safely.” After four or five sessions, Elaine asked if she could just imagine her hand floating up on the plane. Bill understood, although Elaine may not have, that her unconscious was prompting her to create a way to reconnect with Bill and remember the playful safety of the trance experiences while in the stressful situation. Bill nodded, “Yes.”

After Bill was certain that she could experience these emotions, he had her relive these early experiences more quickly (jumping up and down and riding a bicycle down a hill). Bill was preparing her to make the connection between these experiences and similar sensations encountered in flying. He would say, “Your unconscious mind knows where you are going to experience these sensations and emotions.” She looked confused (turning on curiosity), and Bill would say, “You are going to feel these sensations, and it is alright to feel them on an airplane. You are certainly entitled to have a good time and laugh. Every time the airplane bounces, you can remember bouncing on your daddy’s knee and all the other wonderful times from childhood.” Bill had her feel an adrenaline rush by remembering the haunted house or the telephone pranks and connected this to the adrenaline rush she would feel when the plane would drop suddenly.

There is a fine line between experiencing a surge of adrenaline as fear and experiencing it as excitement. In their later sessions, Bill reduced the negative connotations of fear by directly pairing it with excitement. He suggested that both stem from encounters with novelty and surprise—and that both are cures for boredom.

When Elaine returned for a session after the trip, Bill learned that three significant things had taken place. First, she had flown from Houston to Los Angeles and Singapore without trouble. As she was leaving Singapore, an airplane crash was on all television monitors, but she had experienced little fear. And finally, as the plane was descending into Hong Kong, there was substantial air turbulence, because the mountain ranges create uneven heating of the atmosphere. During the landing, a number of people were shouting and upset, but Elaine burst out laughing. People around her wondered what she’d had to drink, but she had drunk no alcohol. One passenger even said, “I want what she had.”

She learned to pair the experience of bumpiness or a sudden drop in altitude with the fun of those sensations in an earlier context. In doing so, Elaine shifted the “meaning” of adrenaline rushes from fear to excitement and bridged the excitement of childhood events to the experience of commercial flight.

We suggest to clients that we have all been told that our dreams are impossible—and too often we have accepted that dictate as true. Almost everyone has dreams of something that he or she secretly wishes to accomplish but has been told is impossible. Instead of believing in the impossible, we learn to imagine that the possible is much smaller than it really is. When Alice in Wonderland said she did not believe in impossible things, the Queen of Hearts replied, “I dare say you haven’t had much practice. When I was your age, I always did it for half an hour a day. Why, sometimes, I’ve believed in as many as six impossible things before breakfast” (Carroll, 1872, pp. 220–221).

As a homework assignment, we encourage the client: “Write down six ‘impossible’ but desired life achievements. Then set these impossible goals aside for a while. The power of the unconscious mind is tremendous; it will work on solutions to accomplish goals while the conscious mind is thinking about other matters.”

Changes in brain state, like changes in behavior, are not usually a one-shot accomplishment. Only with time do the changes become familiar and feel “natural.” When a client has successfully achieved a target state, we have the person practice the new state in the office by reviewing it repetitively or by moving slowly into it and enjoying the feeling of the target state. As the therapeutic interaction progresses, target states shift from being states that the therapist has identified as resourceful to being goals that the client has identified. When the client becomes more capable of entering into and sustaining the target state outside the therapeutic container, we suggest that the client very consciously begin to take note of when he or she achieves the target state. This effort effectively reinforces and conditions it. Each time the client experiences the new state and reports it to us, we congratulate him or her for experiencing the desired target state.

In the process of conditioning and reinforcing new states, it is important for therapists to do two things: (1) Wait for an opening created by the client, when he or she asks the therapist for assistance, and (2) model appropriate states for the client. Much of what we do will be processed at an unconscious level by the client—for example, modeling an ability to laugh at life’s paradoxical situations. The therapist also needs to use humor at appropriate times to keep pleasant states going and link them to him- or herself. When the therapist is confident, respectful, and uses him- or herself as the target of humor, it teaches the client not to take him- or herself so seriously. The new state of calmness and humor is linked to the resolution of underlying issues, and the client begins to develop new alternatives (plans) to move toward the future he or she most wants.

In her first session, Trish said that she no longer loved her husband. She explained that following back surgery, George had been out of work for the last year; he still suffered from chronic pain and was depressed. Bill worked with each of them separately, first validating Trish’s emotional state and her stress over having her husband at home 24 hours a day, 7 days a week. She felt that running the house was up to her and resented the fact that because George was now at home all the time, he frequently wanted to have a say in how things should be done. By going through her e-mails, George had also discovered that she was having an affair with a boyfriend from her college days who lived in a different city. George was extremely angry, and Bill’s work with him included providing initial emotional support. George defined the problem as one of uncertainty over whether the marriage would last.

As Bill worked with Trish, he continued to validate her stress but called into question the reality of her love for her college flame and his love for her. Whether the love affair was a fantasy and a break from the stress of her marriage was a question Trish needed to consider. As it turned out, she discovered from her boyfriend that he did not want to leave his wife or children and that he had done the same thing with other women. She realized that her husband was not so bad and decided to stay.

Bill’s work with George shifted from validating his anger to helping him overcome that anger and drop his obsessive tracking of his wife’s every electronic move. George began to realize that he did not want to spend the rest of his life being angry with his wife. Bill suggested that that this problem could be solved and that there were approaches that could help him resolve his anger. Bill suggested that he read Thich Nhat Hanh’s Miracle of Mindfulness, as well as The Joy of Living, by Yongey Mingyur Rinpoche. Through these books, George learned the basics of meditation.

Trish soon dropped out of therapy, but George continued and, through his meditation practice, became able to change his state of mind more easily. He learned more about how to live in the moment and how to allow his thoughts to pass through his mind without fighting with them. This was the target state George had yearned to discover. As Bill reflected in an approving way that George was making progress, he was helping George condition and maintain the target state of calmness for increasingly longer periods of time.

With the marital situation much improved, Bill turned his attention to the background issue and suggested to George that this period of unemployment might be an opportunity to pursue some skills retraining, make a career shift, and do what he had always wanted to do professionally. In suggesting this, Bill was fostering George’s activation of curiosity and his play circuits. When Bill acted in a nurturing way, he was not only modeling the nurture circuit but encouraging George to turn it on. Bill was also supporting George to take action (investigate job retraining programs and local community college credentialing programs) and linking those actions to his social context.

It is not generally enough for a client to learn to adopt more resourceful states. Frequently, the client also needs to utilize those inner resources to make some changes in his or her situation. However, often we find that clients are “frozen” or immobilized and have difficulty taking action to make a difference in their lives. To overcome this tendency, we have to help the client discover the motivation to make changes. This may occur in therapeutic assignments or by stimulating motivating anxiety (see Chapter 9).

Bob grew up with a neglectful father who failed to provide adequate warmth and shelter, both literally and emotionally. Bob’s father had been so depressed that he spent a lot of money on a stereo system and then sat for years in a house in which the interior walls had been framed but lacked sheetrock and drywall finishing. Construction debris and miscellaneous junk were piled in the front yard, and, as a teenager, Bob had been acutely embarrassed by his home.

Bob had not filed an income tax return for several years because he was overwhelmed by the task. He could build anything and was expert at computer work, but he was terrified of facing the IRS. The task was to help him reframe what or whom he feared and access a feeling of courage. Bill put him in trance and, as a metaphor, told him a brief history of the Buddha’s life. In Buddhist mythology, a character named Mara, the personification of evil or the Buddhist version of Satan, shows up several times. When the Buddha was meditating, Mara came at him as a herd of elephants and warriors to frighten him. He then sent his most beautiful daughters to seduce the Buddha. At each encounter, the Buddha said, “Ah, old friend, I know you” (Bachelor, 2002). Bachelor suggested that Mara is part of the Buddha’s own self, and the encounter between the two is played out as a psychodrama. Mara leaves when the Buddha acknowledges his awareness of this part of himself.

Bill told the story to move Bob out of his spiral of shame and panic and to encourage him to accomplish the goal through curiosity and competence. In truth, Bob was afraid not of the IRS, but of his own psychological dynamics, and this led to procrastination. He needed to face his fears and walk through them. Bill helped him differentiate between the capable adult that he currently was and the child who had needed care so long ago. Bill then assigned him the task of downloading the appropriate forms and instructed him that whenever he encountered any fear, he was to say, “Ah, old friend, I recognize you.” In using therapeutic metaphor (the story of the Buddha conquering his own weaknesses), Bill helped Bob mobilize his own motivation and adult capabilities to take action.

New states leading to new behaviors need to be attached to and practiced in the client’s wider environment. The more a person does something, the more it becomes a habit. For example, we might initially ask the client to perform a low-risk behavior, such as talking to the checkout clerk at the grocery store in order to establish social contact if the issue is overcoming a fear of interaction. We might precede our request with a metaphor or story.

Anna was a person who took everything personally and wound up quarreling with everyone with whom she had contact. After a trance induction, Bill began to recount some of the history of the United States during the 19th century, years filled with episodes of national conflict and resolution. For example, during the War of 1812, the battle of New Orleans and particularly the earlier successful defense of the city of Baltimore (which inspired our national anthem) engendered a wave of nationalistic exuberance over winning a “second war of independence” against Britain. That in turn led to the “Era of Good Feelings,” and England became our ally. Less than 50 years later, the “War Between the States” broke out. But eventually the Civil War was over, and resolution took place. Again we became one nation. In another hypnotic session, Bill used as a metaphor all the different local ethnic restaurants and talked about how the world would be poorer if everyone were the same. He suggested that perhaps Anna had forgotten that there is beauty in diversity.

With hypnotic work, one must wait to see how a client responds to the seeds that have been planted. We look for indications that the unconscious mind has understood that, in this case, conflict and resolution are two parts of a process of working things out. The link to Anna’s social context was implied, along with the suggestion that she needed to be more open to different opinions (different restaurants). At that point, Bill assessed the degree to which behavioral change was beginning to occur. Had it been necessary, he would have worked further around issues of conflict. From there, the focus of the work moved to encouraging Anna to learn to consider things from the other person’s point of view and then to forgive people. Bill tackled these issues both through the use of metaphor and by finding instances in Anna’s past where she had forgiven others. We later heard that she had begun connecting with her peers in a more positive way.

This chapter has examined the brain chemistry of stress and its effects on memory, functioning, and well-being. Stress, however, is not inevitable. By learning how to change habitual brain–mind states, a client can reduce stress, access previously unavailable internal resources, and take action to make positive life changes. The chapter then outlined the BCT model both from the perspective of the person entering therapy and from the perspective of the therapist. Following that, each aspect of the BCT model was elaborated.

In the next chapter we explore how Ericksonian hypnosis facilitates state change by utilizing clients’ already existing resources and the multiple levels of communication that are possible in trance states.

CHAPTER 4

Brain Change Therapy Model