BRAIN CHANGE THERAPY: Clinical Interventions for Self-Transformation

The underlying driver of the fight–flight–freeze response is fear, and the chronic activation of that response can express itself in a number of dysfunctional modes. Apart from rage, the primary modes are anxiety, depression, and shame. Since the latter three states are often found as an interwoven set in many clients, this chapter examines the dynamics between them and the therapeutic approaches to resolving them through BCT.

Bruce McEwen, in The End of Stress as We Know It (2002), observed that the mind is so powerful that it can set off the stress response just by imagining a frightening situation. A person can literally bring on a complete stress reaction just by conjuring up a worst-case scenario. The chronic activation of the fight–flight–freeze response not only leads to immediately dysfunctional behavior, but over time, can also inflict sufficient damage to the frontal and temporal regions of the brain to precipitate frontotemporal dementia (Bremner, 2005). Frontotemporal damage impairs the ability to control fear as well as the abilities to reason and understand the significance of events (Bremner, 2002), leaving the afflicted person in a generalized state of confusion and anxiety. Fear in its various expressions also increases cortisol in the brain. Cortisol counteracts a brain-nourishing hormone called brain-derived neurotrophic factor (BDNF; Bremner, 2002). Loss of BDNF leads to neuronal cell death within the hippocampus, which also impairs memory (Siever, 2009).

Eeyore, a donkey who was so depressed that he found no joy in life and expected everything to go badly, first appeared in Winnie-the-Pooh (Milne, 1926). The donkey lived in the Hundred Acre Wood in a place called “Eeyore’s Gloomy Place: Rather Boggy and Sad.” He held strong judgments about all the other animals and believed them to have no brains—just fluff. A perennial pessimist, Eeyore might have been heard to remark, “The sun is shining. I’ll probably get a burn.” Whatever it was, Eeyore imagined the worst. He was especially sensitive to events that threatened his sense of internal security. Whether Eeyore had an attachment disorder or suffered some trauma in his early life is unknown.

The “Eeyore syndrome” refers to the tendency in some people to fixate on the darkest element in any situation, no matter how favorable the overall event: the one thoughtless comment made by someone at an otherwise delightful garden party; the one time the driver took a wrong turn and became lost over the course of a 4-day road trip; or the one time the person put quarters into a vending machine and the candy bar got stuck. A person with the Eeyore syndrome might agree with Douglas Adams (1995): “In the beginning the Universe was created. This has made a lot of people very angry and been widely regarded as a bad move” (p. 34). Such people have the unerring ability “to turn even the finest wines to vinegar” and then brood about the situation, grinding a deeper and deeper rut in the neuropathways of pessimism. And some of them become clients.

Anyone can experience an “Eeyore day,” particularly during a period of uncertainty. However, clients in whom this tendency is exacerbated are some of the more difficult to treat. These clients are chronically disappointed with life, family, friends, and work, and they frequently have a shame overlay based on their inability to control their state of mind. Depression is often their response to seeing themselves as helpless, as “victims of circumstance.” Equally disappointed with the therapeutic experience, they tend to move from therapist to therapist in the hope of solving the chronic sense of feeling bad.

Being continually disappointed and expecting the worst, these clients are apt to discount any positive comment the therapist might make. The clinician can sense that no comment gets past their filters so that it can be experienced as empathic or supportive. No matter the intervention, there is something not quite right about it. Even if the therapist notices that some aspects of the client’s life have improved, often the client cannot recognize it.

Robert Sapolsky, a Stanford University neuroscientist, suggested that depression occurs “when your cortex thinks an abstract negative thought and manages to convince the rest of the brain that this is as real as a physical stressor” (2004, p. 354). Sapolsky suggested that stress is anything that knocks a person out of homeostatic balance. The states that usually need to be activated in the Eeyore syndrome are those of curiosity and safety. In addition, using humor will effect a state change. In the process, the therapist will find it helpful to discover what the depression is related to, whether it be early disruption, head injury, or bonding issues that need clinical attention. Frequently, early caregivers of these clients were anxious, fearful, and perfectionistic.

Being unable to shift out of a chronic state is often a matter of brain circuitry and neurological inefficiency rather than some chemical imbalance (Sams, 2006), and using brain-training devices or hypnotic deep state training may be helpful. However, for an individual to be able to move from a sense of hopelessness and helplessness into one of control, the therapist first needs to accept his or her reality and explore the reported areas of the client’s life where “nothing is working.” By accepting the person’s ideas of how things are, the clinician can make the client right about something.

The following is a transcript of how one client was able to move into a more empowering state.

Therapist: You have said you are old and alone. Your house is falling down around you. You have no friends. Your car is in need of repair. There just is nothing working well for you, and even if it did, it wouldn’t be long before that too would be in a mess.

Barry: Nothing in my life is going well. I can’t remember a time when anything worked well, so I just go to the pub one day a week and numb the feelings by drinking beer.

Therapist: And when you numb the feelings, it is not that you really feel any better; it is just a temporary experience of feeling no pain?

Barry: That’s so right. Even though I may like the beer and the band, when I leave the pub, everything is the same.

Therapist: So that experience of everything being the same is a state you return to so much of the time, and it may even be difficult to recognize feeling even a little better. Tell me about the pub and why you go to the same one each week.

Barry: It’s familiar; people know me there. Every once in a while, they have a good band.

Therapist: So you see the same people each week and even though you may feel in a rut, there is something familiar. What is familiar like?

Barry: Familiar is the same thing over and over again; it can really be boring.

Therapist: Familiarity can be boring and just “more of the same,” and sometimes it might be interesting to experience the boringness of familiarity when so many aspects of life are uncertain. [This comment was designed to turn on curiosity about the possibilities of things getting better.]

Therapist: It is something you yearn for: you wonder what life would be like if you were doing what you really wanted, and you think about how to make that happen. We just went through Hurricane Ike. How was that for you?

Therapist: Someone in our neighborhood put up a sign after the storm that said “Ike, Tina doesn’t live here anymore. Go away.” (Client starts to smile.) And then after a number of days without power, signs started to go up that read, “Will trade favors for power.” (Client continues to smile and adds his own funny stories.)

For someone who experiences habitually pessimistic feelings, one intervention of stimulating curiosity and humor is a very small event, but it accomplishes two things: It changes the client’s state during the interchange, and it helps the client begin to develop the ability to shift states for him- or herself. We followed this shift with more intense work. Gradually, Barry learned how to move into a neutral state by noticing the flowers and plants in his yard and naming them without judgment. In the process, he became aware that he had negative judgments about almost everything. With practice, he became more able to notice elements in his surroundings without immediately assigning them a “good” or—far more often—a “bad” label. In so doing, Barry started to learn to shift his neural patterns, control his mind, and keep it from wandering into Eeyore’s Gloomy Bog.

Habituated patterns of anxiety often have their beginnings in early childhood trauma. When caregivers are quick to mete out sudden retribution, particularly for reasons that children may not grasp, the children can develop a nearly permanent state of vigilance, eventually deteriorating into a chronic and unfocused state of anxiety. Additionally, such an individual may have a neurological predisposition toward anxiety.

A wide range of mental health disorders fall under the umbrella of anxiety, including generalized anxiety disorder (GAD), panic disorder, social phobias, obsessive–compulsive disorder (in its intrusive, anxiety-producing ideation or impulses), and PTSD. All anxiety disorders entail a chronic and exaggerated fear of impending doom. Peter Levine, in Waking the Tiger (1997), described the core of the anxiety reaction as involving the following characteristics:

When these characteristics become chronic, they may trigger secondary conditions such as hypervigilance; intrusive imagery; extreme sensitivity to light, sound, or noise of any kind; extreme anxiety; startle reactions or temper outbursts followed by shame or grief responses; disturbed dreams or frequent waking in the night; moodiness; stress vulnerability; and sensitivity to textures and smells.

Even more severe symptoms may ensue: panic attacks; phobias; a fear of dying or having a mental breakdown; the avoidance of other people, including the inability to be involved in social situations; the inability to bond with others; diminished emotional response; and sweating, hot flashes, and trembling. By the time these symptoms develop, the individual no longer has any rational explanation for the reactions. When internal states are discontinuous or inexplicable, people begin to develop ancillary symptoms. In a state of high anxiety, it is impossible to assimilate new information or access other resources, such as one’s ability to self-soothe. Attention is narrowly focused, and perception is distorted. Memory declines, and it becomes difficult to hold a thought. Reactions are automatic; thinking becomes concrete. In a full-blown panic attack, lower-order behaviors are accessed, age regression ensues, and primitive thinking, with associations from childhood, can be experienced.

Fear, specifically the fear of being unable to prevent the worst possible future from occurring, often underlies the feelings of anxiety. In a study conducted by Richard Davidson (2003), researchers found a positive correlation between the emotions of fear and sadness, increased cortisol levels, and frontal EEG asymmetry. Anxiety and, in its more extreme expression, panic, occur as a result of dysregulated centers in the central nervous system. Fear-producing stimuli are first processed by the amygdala. Aiding the amygdala, the thalamus helps in determining to what extent the stimulus is an actual threat. The hippocampus and cortical regions of the brain also play a part in the evaluation of the information sent from the thalamus. In this process, the interpretation of the stimulus is filtered through past experience and conditioned responses. Messages go out to the peripheral nervous system to increase blood pressure, heart rate, and the fear response of fleeing, fighting, or freezing. Even if an individual “knows” the response is an overreaction, once neurological processing has passed a certain point, it must run the course of excitation, response, and subsequent calming.

Several neurotransmitters are involved in anxiety disorders. Low serotonin levels seem to be a factor, and symptoms tend to improve in many when medication allows more serotonin to be present in the neurons. Compounding matters, individuals with chronic anxiety issues tend to have decreased levels of GABA (gamma-aminobutyric acid) as well as an increase in plasma epinephrine, even when in a resting state. As the levels of serotonin and GABA are reduced in the brain, anxiety and distress increase (Moss, 2003; Berstein, 1995).

Closely related to the experience of anxiety is altered breathing. Anxious people rarely breathe deeply enough. An individual who feels highly anxious may begin to hyperventilate, resulting in decreased carbon dioxide in the blood and decreased cerebral blood flow (Mars, 1998). This reduction results in the stimulation of the sympathetic nervous system, and a variety of symptoms may ensue: fatigue, tension, tremors, stomach pain, difficulty breathing, dizziness, visual distortions, and heart palpitations. As the heart begins to beat faster, the person is apt to become fixated on the physical sensations and is further apt to make negative interpretations of them. What follows is often a closed feedback loop: With increased attention, the symptoms are likely to become more pronounced, which draws even more increased attention.

The individual who is prone to anxiety can eventually become so attuned to bodily sensations that any slight change will be interpreted to mean that death may be imminent. A watchful eye on heart rate, taste, and skin sensations can contribute to the problem. After a time, the anxiety takes on a life of its own, until even a slight stimulus can cause an intense reaction. In fact, the anxious-prone person can set off an anxiety attack merely by thinking it might happen. In essence, the person mentally rehearses it until it occurs.

If the anxiety pattern begins early in life, a person may become so habituated that the discomfort is perceived as normal. This feeling state can become automatic and affect perceptions and thinking. Diaphragmatic breathing and heart rate variability training (e.g., using the emWave device) can be useful in changing to calmer states. Teaching clients to discriminate among various body signals, make accurate interpretations of what they feel, and react with appropriate responses is also important. For example, a client may need to learn to distinguish between a normal tensing in the body in relation to feeling excited or surprised and the out-of-control feeling of a panic problem, so that normal tensing does not inevitably lead to panic.

Anxiety disorders tend to run in families, meaning that the likelihood for developing the disorder is higher if someone in the family already has it. In one study, researchers concluded that children whose parents have issues with panic, depression, or both have an increased risk for panic disorder, social anxiety disorder, depression, disruptive behavior disorders, and poor social functioning (Biederman et al., 2001).

For a client with anxiety issues, the voice and the face of the therapist can serve a powerful function as a holding environment and a bridge to new interpretations of experiences. When a client feels genuinely cared for, anxiety can be tolerated more easily and channeled toward change until, eventually, the old feelings and provocations no longer trigger the same negative states of consciousness.

Panic attacks, or the temporary heightening of anxiety to the point that complete physiological dysfunction may ensue, often drive individuals to seek therapeutic counseling. However, clients seldom have panic attacks in the therapist’s office; instead, they occur out in the “real world.” For that reason, we recommend “tools” or techniques that they can take with them to address the physiology of a panic attack. In addition to their actual efficacy, the techniques function in part by invoking the placebo effect (the measurable, observable, or felt improvement in health or behavior not attributable to a medication or invasive treatment) and in part as transitional objects (items used to provide psychological comfort, because by association they are connected to a person who represents security). We suggest the following techniques to our clients:

• David was an attorney specializing in contract law who had decided to go back to graduate school. He had always experienced difficulty speaking in front of a group. As a contract attorney, he had not needed to speak in public. However, in graduate school, there was no way to avoid it. Every time he had to make a presentation in class, he experienced an anxiety attack. He would break out in a cold sweat, and by the time he finished speaking, his shirt would be literally soaked. Using hypnosis, we led David to the edge of sleep while maintaining awareness and allowed him to “float” there in a healing theta state for at least 10 minutes. We also suggested he take 500 mg of GABA prior to a presentation to ameliorate the sweating response. Both GABA and 5HTP (5-hydroxytryptophan) have a calming effect on the brain; a severe shortage of these chemicals can actually cause an anxiety disorder. After six sessions, David was able to relax enough to make effective presentations, and he completely stopped perspiring when he spoke in public.

• Mike had a history of emotional and physical abuse by his mother. He was so highly attuned to any bodily sensation that he slid from noticing a slight physiological sensation into experiencing a full-blown panic attack two to three times a day. At the age of 38, Mike was a successful CPA, but another one of the partners in his firm realized he was near the breaking point and suggested that he look into some therapy. By the time he came to Carol’s office, he was experiencing severe insomnia, was in tears more than once a day, and complained of a funny metallic taste in his mouth.

Carol began by working to modify his breathing, which was very shallow. Sitting opposite him, she explained that he needed to breathe more deeply and that they would start by breathing together. Moving her hand up and down to indicate the inbreath and outbreath (like a musical director setting the beat), she began to breathe slowly, and instructed Mike to breathe with her. Twenty minutes later, a smile slowly began to tug at the corners of Mike’s face. He reported that, for the first time in many days, he experienced relief.

In subsequent sessions, Mike explained that he had been in therapy with someone who encouraged him to relive the past repeatedly. He had been trying to scream his way to health. We believed that this process was restimulating his childhood trauma and suggested that he stop that process. Carol recommended some other breathing exercises. For example, in one exercise originally developed by Herbert Benson, who pioneered the relaxation response based on Transcendental Meditation, a person visualizes the number 1 on his or her mental screen. As the person exhales, the number moves into the background. With inhalation, the image of 1 returns to the foreground. In addition, alpha–theta training was used to calm his whole system. Before long, Mike had improved enough that he was again working in his office and meeting with his clients rather than having all the work delivered to his home by the office manager.

• Arriving at the office one morning, Carol picked up a telephone message from a man with a strong Middle Eastern accent who said he was calling on behalf of a prince(!) who was in desperate need of treatment. We presumed the message was someone’s idea of humor and deleted it. What followed was a complete surprise. Two days later when we were in the office, the gentleman called back. During a half-hour conversation, he asked us to head a treatment team (that would include a psychiatrist) to assist a young man of royalty in the Middle East. We were told that the young man suffered from panic attacks, agoraphobia, and acrophobia. He could not leave his palace either by automobile or by plane without experiencing crippling anxiety. It was close to Thanksgiving, and we were struggling with the decision. A couple of days later, the prince himself called and, in halting English, personally asked us to come to the Middle East to treat him. Not at all certain what we would be getting into, we consented.

First-class airline tickets arrived a day later by Express Mail. Stepping off the plane, we were met by the prince’s driver and a couple other security agents, literally waved through customs, and escorted to the hotel. We began to formulate how we might help a young man whose anxiety was so debilitating that he could no longer leave his palace to attend school.

Our initial consultation took place in the palace, a bold modern structure incorporating design elements abstracted from traditional Arabic architecture. We were served a very strong black tea, highly sweetened and flavored with cardamom. Later we learned that the prince drank many glasses of that tea daily and wondered about a possible relationship between a high caffeine intake and his anxiety. Talking to us through an interpreter, he told us that his father and sister also suffered immensely from panic disorder. Thirty minutes into our first meeting, a loud horn sounded. Our host stood up, asked us to wait until prayers had been finished, and excused himself.

As the directors of the therapeutic team, we knew that we would have complete freedom to use any combination of treatments that we felt would be effective and therefore had taken a neurofeedback device with us. By the end of a week of neurofeedback, hypnosis translated by one of his advisors, and an SSRI (that he first gave to one of his attendants to confirm its safety), the prince took us to his mother’s palace for dinner. This was the first time he had ventured outside his own compound in 2 years. We encouraged him the entire way and on arrival began to “high-five” his success. Revealing some of the family dynamics and the fact that her son could not do enough to please her, his mother greeted him with evident disdain and scornfully asked why he could not have come the night before. As the dinner progressed, we better understood her curious response. Explaining that the Qur’an allows a man to have up to four wives and that it was the custom for royal men to have four, she complained that she never saw her husband. Generally pessimistic and disappointed with her life, she seemed wrapped in a mantle of permanent defeat. We could only surmise that beneath that defeat lay the rage that she seemed to take out on her son.

On the last day of our visit, the prince personally escorted us to the airport and thanked us for our work. A year later, we heard from him again. He had completed his degree and was busy managing one of his father’s businesses.

Shame is generally an amalgam of inadequacy, frustration, anger, depression, and failure. These emotional states create neural pathways that then often reinforce behavioral patterns of emotional pain, self-neglect, and a sense of victimization. Such self-destructive patterns are warped forms of endurance that are developed early as a means of survival. Clients, of whatever age, may still be under the negative “spell” of someone who was abusive in childhood, when they were conditioned to experience deep embarrassment and anxiety.

There are three key aspects to consider in a shame state reaction: a tendency to experience disproportionate shame, which commonly develops from excessive early criticism by someone important in an individual’s family of origin; a fear of someone’s judgment (the individual has been judged and “found guilty”); and, usually, self-blame (the individual agrees with the judgment). Collectively, these three factors tend to create a negative trance state in which an individual experiences a negative physiological sensation of “shrinking” accompanied by a flooding of feelings. Not understanding that they can control their states, clients may feel at the mercy of their own ingrained patterns of neural firing and behavior. The therapist must empathically resonate with and attune to a client to help the person move beyond these negative states into areas of possibility and openness, and finally, to states of happiness and thriving.

The first experience of shame generally occurs around the age of 2, when a child becomes aware of a parent’s disapproving tone and negative facial expressions. Schore (2003) pointed out that shame involves the internalized image of a mother’s face, whose expression was mismatched to what the child was doing. Shame becomes an imprint of the parent’s unhappiness at the child’s behavior, to the extent that the child experiences a significant fear of rejection and of the parental bond being broken.

Researchers have discovered that the pain of social rejection is neurologically similar to that of physical pain. Participants in a study played a virtual ball-tossing game, during which they were eventually excluded. During exclusion, their brain scans showed increased activity in the dorsal anterior cingulate cortex and in the anterior insula—the same areas often associated with the distress of physical pain (Eisenberger, Lieberman, & Williams, 2003). Over time, the parent’s response results in a “shame signal”—that is, the trigger for the resulting hesitancy and doubt that suppress “bad” behavior and thereby allow the child to avoid the pain of actual rejection.

The experience of shame activates the dorsal medial nucleus of the hypothalamus. This part of the brain produces changes in mood and smooth muscle activity (Schore, 1997). The emotion of shame also activates the parasympathetic nervous system and can immobilize a person in the freeze response. Shore observed that shame rewires the brain and tends to deactivate and prune connections between the limbic and prefrontal systems. The most serious effects, however, are the increased activation of the fight–flight–freeze survival response of the amygdala, the entrenched circuit of FEAR, and the resulting defensive behavior.

In order for the shame-based client to recover, the therapist needs to (1) activate connections to the prefrontal system through empathy and rapport-building and (2) inhibit the shame responses. When intense shame is activated due to poor attachment history, an individual may have difficulty being alone and may even develop manic defenses that cause impulsivity and avoidance of introspection—a reaction that precludes addressing deeper feelings and concerns (Winnicott, 1958). Cozolino (2002, p. 200) suggested that people with manic defenses are frequently misdiagnosed as having attention-deficit disorder.

Shame is an emotion in which a person has an overwhelming experience of badness based on an external value system. Derived from presumed external judgments, shame involves a person’s self-image in front of others. Shame says, “They say I am bad.” Shame can be debilitating: The more shameful a person feels, the more likely he or she is to be defensive, deny any wrongdoing, and become anxious or depressed.

Guilt occurs when an individual transgresses an internally held value system, especially in the case of harming another individual. Guilt has to do with a person’s self-image in front of him- or herself. Guilt says “I did something harmful—something I know was bad.”

The therapist will need to distinguish between two types of guilt. One type is an internalized shame carried over from childhood. That guilt adds, “You make me feel so guilty… .” The underlying emotion here is resentment, an unacknowledged anger directed at the other. This can be addressed therapeutically within the context of shame.

A different type of guilt arises from adult situations in which, simply put, “bad things happen” that are only partly due to a person’s volition. This guilt adds, “I’m terribly sorry.” Soldiers who are required to kill other humans often experience major guilt. Automobile accidents in which a pedestrian or bicyclist is killed often leave the driver with profound guilt. Having to consign an aging parent to a nursing home against the parent’s wishes, due to the requirements of the parent’s care and the larger family circumstances, can cause terrible guilt. The underlying emotions in those cases tend to be sorrow and deep regret. The essence of the work, then, is helping the client to experience forgiveness and particularly to find self-forgiveness, often through some form of reparation or penance.

There is also a middle ground. For example, when a partner needs to feel loved and appreciated in a relationship but does not, this need may be in conflict with the personally held value of commitment to a marriage. If this individual steps outside the relationship to try to meet that need, the breaking of the marital vows may result in either shame or guilt: shame, if the person feels that his or her behavior was largely justified, or guilt, if the person feels it was intrinsically wrong.

To resolve shameful feelings, we suggest that a client identify the “wave” nature of a feeling. People caught in the web of shame commonly react to situations in which they experienced embarrassment or shame by repetitively reviewing them and engaging in emotional self-flagellation. The rumination can become more painful than the precipitating event. We encourage the client to observe that, if he or she doesn’t hold onto it, the feeling comes and goes just as a wave comes into the shore and then retreats. By simply sitting with the physiological sensations he or she associates with shame, a person will notice that, eventually, they dissipate, and a new feeling will arise. The mind chatters incessantly, and if a client can observe the mind’s contents without identifying with those contents, he or she can become his or her own mental anthropologist and begin to observe without judgment.

A second, or alternative, antidote for shame is to bring it out into the open. The more an individual can talk about the experience, the more the sensation of shame will abate. Sharing the associated emotions with a clinician who responds empathically can ultimately shift the state from shame to one of less anxiety or depression, and eventually to relief. As long as a sense of disgrace is held in secrecy, its grip on the psyche remains intact.

The final possibility is to have the client embrace the feelings of shame as a way to transmute the energy into insight and awareness. This attempt may interrupt the sensation and allow the person to begin to develop greater self-understanding and forgiveness.

When a client feels shame starting to dissipate through whatever means, confusion about what is occurring may follow. In fact, whenever there is improvement (for example, in the abatement of anxiety), the client will expect and look for the same level of intensity (neural activation) somewhere. It is as if the individual’s sense of internal homeostasis has become so accustomed to a certain level of activation (whether driven by shame, anxiety, or another habitual pattern) that any alteration feels confusing. We suggest to the client that confusion may be a step toward a change that is getting ready to occur. We encourage clients to allow the “wave” of confusion to pass.

We have found that hypnosis can assist a client considerably in letting go of shame. This shift is due both to increased relaxation and to increased suggestibility. To use hypnosis in this context, we suggest the following protocol:

1. Ask the client to focus visually on a spot in the room or to focus on his or her breathing.

2. Assist the client in developing a sense of safety by imagining the place where he or she feels most “at home,” relaxed, or at peace. This step is particularly critical, because people who have shame reactions frequently feel insecure. This process begins to shift the internal state to one of comfort. By carefully watching, the clinician will be able to tell from the facial reaction when the person has accomplished this part. Frequently, the client will take a deep breath accompanied by a slight shudder that indicates that a neurological shift has occurred.

3. For emotional grounding, suggest that the client keep his or her feet flat on the floor. We sometimes suggest that the client imagine breathing through the soles of the feet, placing the breath lower in the body in imagination.

4. Assist the client in identifying a figure of comfort, such as an older, wiser individual. When families are working well, parents and/or grandparents validate their children/grandchildren consistently, who thereby learn to trust their own decisions as adults. Parents give compliments, suggest positive futures, and look forward to each child building on the success he or she feels in the moment. Although a client may not have had these experiences in the family or origin, he or she will often have experienced another powerful figure of comfort. If the client has difficulty identifying any figure of comfort, the clinician may develop an imaginary figure who can give a “blessing” to the client. (See the following section for an example of the dialogue used in a hypnotic induction with a figure of comfort.)

5. Find areas of growth on which to compliment the client so that the reinforcement continues in the present. At this point, the therapist becomes the immediate figure of comfort who extends the validation.

6. It may be appropriate to suggest that a client’s negative schema or emotional pattern may have come from someone else in the family who felt ashamed. Frequently, children develop a kind of synchrony with a particular parent and end up carrying the negative feelings the parent has not worked through. By suggesting that the shame does not “belong” to the client, it is often easier for the client to let go of it. The goal is to rid the person of the shame reaction and to change the neurophysiological response.

One technique for resolving shameful feelings and building self-confidence is to invoke a figure of comfort, such as a mentor, kindly grandparent, a neighbor, or an aunt, who held the client in high-esteem. Giving a voice to this important figure can enhance the client’s self-esteem and underscore the fact that he or she has been loved.

We begin by having the client identify someone in the past or present who acknowledged, perceived accurately, and felt empathy and love for the person. If the client cannot think of anyone, a universal figure can be used: a character from film or television, a grandparent figure, or, if appropriate, a religious or mythological figure.

Particularly when we are working therapeutically with someone who is also a clinician, we may use Milton Erickson as a figure of comfort and tell his life story. Many therapists have imagined Erickson as a consultant for either their professional or personal life. The following is a sample of the hypnotic instructions we might use in this context:

“Sit comfortably in the chair and take a breath. Close your eyes and shift your attention so you can begin to alter your internal state and shift your brain state. It takes such little effort. Continue the inner process of developing comfort and focus on the pleasant feelings in your body. As you tune into those sensations, all the outside sounds can fade into the background. It is now only you with me, here in this moment. Just the two of us right here and now. Go deeper inside now. There are varieties of experiences along the way that allow the development of such a nice feeling of comfort. You have experienced many by now. I don’t know which of those might come to your attention as you think about it, but any would be perfectly all right. As you breathe comfortably, going deeper, deeper, and deeper now… .

“Everyone who is able to go to Phoenix, where Milton Erickson used to live, takes some time to climb Squaw Peak, a small mountain nearby. In fact, Erickson used to send people to climb it in order to have a learning experience. With every experience you have, there is learning of some sort. It happened not long ago that we took a trip to Squaw Peak with a friend of ours. We climbed the mountain all the way to the top. The interesting thing was that, as you climb up the mountain, you must lean into the side of the hill to compensate for the steepness and angle. As you go up, up, up, by the time you get almost to the top of the hill, you can see all around the Phoenix area, and it is a spectacular view. When you reach the summit, it is an amazing view. We sat on the top of the mountain and became pensive and quiet, and each of us wondered what learning was occurring.

“We were feeling close to Dr. Erickson, because when he died, his ashes were spread on this very place. We could imagine his essence being with us. Sitting on the top of the mountain, it was almost as if you could experience Dr. Erickson sitting right there with you. Here was a man who struggled with adversity many times in his life, and yet he had the most positive outlook. He had people throughout his career who made light of him, who were dishonoring, and yet when you looked into his eyes, you could see that twinkle that comes from such a good spirit; that comes from someone who wishes only the best for you. Sitting where we were, we could almost hear Dr. Erickson whisper into your ear: ‘You are a good person, and you are making an important contribution to the world. You need to go on with your work. Everyone makes an error somewhere along life’s journey, but you can put that behind you and accept your own self-forgiveness. Move on into the future and learn from the experience. Take the learning and put it to good use in the future. My voice will always be with you in the wind and the trees; always with you, supporting you, every step of the way. It is important for you to know: You are not alone. There is always more to learn, and you can be excited about what there is to know. Using that in your particular, special way and implementing it in your unique perspective is your path. As you sit here, you can remember these words. You are here for a reason. Move on with your life and look forward to the future.’ As you listen to those words of Dr. Erickson, you can take them inside yourself and really feel full.

“Now, we didn’t know how much time had elapsed, but we decided to walk back down the mountain, walking carefully to keep a good footing. As you go back down, you must change your way of stepping carefully, taking one foot at a time and planting it firmly to keep the balance. When we were about three-quarters of the way down, the most unusual thing occurred. We both heard the most interesting music. Our eyes cleared, and we saw who was playing the music. There was a hillbilly band at the bottom of the hill. They were playing jugs, saws, and homemade instruments, and they were making a beautiful sound. Isn’t it interesting sometimes when you experience something you would never expect to encounter? A hillbilly band at the bottom of Squaw Peak was an amazing sight. That experience, marked by the music, stimulated our feeling, thinking, and thoughtful meditation.

“You may have someone in your life like Dr. Erickson. Perhaps there was a grandparent you felt close to, or a favorite teacher. And when that person looked at you, you felt really loved. This person believed you would be successful; believed in your positive future and knew you would make a contribution to the world just by being you. Sometimes you don’t know how that will occur, but it is nice to know there were people in your life that are now inside of you, and who will stay with you and guide you from an internal perspective forever. It may be now or later that some of that person’s words might come back to you. You might remember what that individual said that was so encouraging along the way. Perhaps you might write those words down so as to really remember them and memorize them. You can really appreciate that person’s contribution to your life as you go on to make a contribution to someone else’s.

“Now, begin to come back gently into the room, taking all the time you would like. Reconnect now with all parts of yourself, slowly and comfortably. Ponder for a while what you have experienced.”

Without any knowledge of the technique, one of our clients used figures of comfort for herself as a child. Her family situation was marked by enormous conflict and chaos; no one felt safe. She knew that her home life was different from that of other kids, and she was too deeply ashamed to invite anyone from school to come over. Watching the Roy Rogers television show, she used to imagine herself as belonging to that family and having Roy and Dale Evans as parents. In so doing, she began an internal reparenting process that changed her default state and helped her learn how to feel good about herself.

She told us that one day she decided to write Roy Rogers a letter. She mailed it simply to “Hollywood California” and each day went to the mailbox to see if he had responded. After a while, she forgot about checking. One day, a brown envelope appeared in the mailbox, and her mother told her she had something from California. Her heart beat wildly as she opened the envelope. Inside she found a picture of Roy Rogers autographed to her. She said, in that moment, she knew she was loved. Her recollection of this event continued to comfort her for many years, enhanced her ability to feel good about the person she was becoming, and added to her self-esteem.

We use the following techniques for dissolving shame. As examples, they can also be used as springboards for therapists who wish to create their own techniques.

• Many children who grow up in a healthy family have the experience of sitting between their parents and hearing them both speak warm and empathic words. The therapist can create a similar inner holding environment to help a client begin to build a sense of personal security. People who feel secure will recover from an embarrassing incident quickly and are able to refrain from ruminating on the event. Use two imaginary figures of comfort, one sitting on each side of the client. Suggest to the client that they are speaking, one in each ear, at the same time. Through the therapist, the figures express positive ideas and feelings about the client.

• The therapist can use a transitional object, which may be any object that represents personal success, power, and competence to the client. Such an object may be either a small gift from the therapist, of symbolic value only, or something that the client already owns. In either case, the therapist’s interaction infuses it with an enriched meaning that validates the client. Possessing this object helps the client dissolve early programming that caused the individual to believe that he or she was somehow flawed. If the item is small, the clinician can have the client carry it around in a pocket or purse. For example, the renowned Japanese baseball player Sadaharu Oh (Oh & Faulkner, 1985) always carried a small carved dragon in his pocket. He would touch the talismanic dragon, traditionally symbolizing auspicious power, before he stepped up to bat.

• The therapist can reparent through metaphors of early learning. If our evaluation identifies a missing developmental task, we can use a metaphor and construct the learning in a hypnotic trance.

• The use of hypnotic comforting mechanisms, such as the sound of the therapist’s voice, the sound of running water, or any other soothing, calming tone, will help change the client’s internal experience. After discovering what sound is particularly comforting to a client, this can become part of all further hypnotic interventions with him or her.

• The therapist can retrieve resiliency. Each person has many resiliency resources based on previous challenges that were conquered or completed. Anyone who has finished school has managed feelings of frustration or even failure and worked through them.

• Using hypnotic empathy, the therapist can foster basic trust with the client, as another facet of healing shame. By communicating a sense of caring, warmth, and respect in the way we speak to a person, we can issue a reminder of early nurturing that can build a sense of trust. Once this relationship is established, the potential for growth is unlimited.

In conversation with a client, we can easily identify the shame-based self-induction (the elements or situations that consistently trigger the sensations and “trance of shame”). Invariably the essence of this negative self-induction focuses on something about the self that is “less than” rather than “good enough.” The task is then to shift the focus to the person being “good enough.” We might say:

“You have been discussing how you feel inadequate compared to the people you are around, and it is difficult, when you have that sensation, to remember a time when you felt a bit better. It is difficult, when you are having that experience, even to recognize how that couch you are sitting on gives good-enough support. It is difficult to notice when you receive good-enough responses from people around you. And I wonder what it might entail if you were to really hear a good-enough response from people?”

This response to a litany of shortcomings helps shift the client’s expectation that everything will continue to be the same, and it may encourage the client to begin noticing subtle positive responses from others. We further suggest to clients:

“Perhaps you can begin to notice how you are better on a daily basis. Because the natural state is one of healing, you can find those subtle clues in your environment that help you learn, grow, and develop in ways you really want. It might be that one day when you wake up in the morning and look in the mirror, you can notice something different about yourself that will let you know that an important shift has occurred.”

This series of suggestions sows an expectation that the client is improving and will be able to notice something that leads toward a better feeling and away from negativity. Since it is possible to practice feelings, the more the client practices feeling well, the less he or she may ruminate on negative feelings. Ultimately, the goal is to move the client to a self-perception of “good enough.”

Marital partners tend to regulate each other’s psychobiological states and can participate in stimulating good feelings or, when upset, create what amounts to shame-based inductions. When couples are getting along, there is a resonance between them, a smooth flow of energy back and forth. Negotiations are easy and the energy exchange is dance-like. Partners have easy access to good feelings, and it is almost impossible for them to remember feeling upset with each other.

But when two people are in conflict, the stress response of fight, flight, or freeze is activated in both. Each person participates in heightening the dysregulation of the other’s nervous system and stimulating various high-arousal states. If couples do not have the capacity for self-soothing, they can escalate into name calling, attacking, and demeaning the other person in the most vulnerable and sensitive areas.

John Gottman described diffused physical arousal (DPA), the physiological state of emotional flooding, as a major cause of marital dysfunction. He suggested that the most successful couples do not allow themselves to escalate into this degree of physical arousal. On the whole, these partners have the capacity to keep themselves from being reactive, and they have the ability to soothe the other. The partnership may be considered as an interactive state that, when more stable, contributes to self-regulation from the shared desire to provide healthy responses (Gottman, 1999).

When a person is overaroused, the flooding of emotion activates the sympathetic nervous system. The hypothalamic–pituitary–adrenal axis (HPA) becomes hyperactivated, and heart rates of 15 beats per minute above resting heart rate are reached. Cognitive ability declines, age regression often occurs (wherein partners feel and act younger), frustration tolerance is low, and people respond with defensive behavior. Partners tend to avoid looking at each other directly. When the couple system disintegrates, partners often misjudge intentions and experience the other person as malicious. Gottman (1995) suggests that couples are less likely to be successful in marriage if they incorporate what he calls the “four horsemen of the apocalypse” in their communication styles: criticism, contempt, defensiveness, and stonewalling. Contempt, in particular, is highly destructive and shame-inducing. As Gottman observes, the antidote is to build a culture of appreciation.

Tatkin (2003) wrote that the escalation can involve “the use of primitive defense(s) such as denial, blame, transference, acting-out, splitting, projection, projective identification, avoidance and withdrawal becomes intensified, along with the appearance of core affects such as murderous rage, disgust, helplessness, shame and terror” (p. 76). Panic sets in, and to reestablish control, one partner may attempt to calm down by withdrawing, while the other may attempt to calm down through pursuing interaction. Frequently, these strategies for state change meet with failure. Alternatively, both may move toward complete withdrawal. In this case, both partners experience decreased heart rates, and the emotional pain is often experienced as physical pain (Pelphrey, Singerman, Allison, & McCarthy, 2003).

Shame-based systems may operate in the midst of retroflection (a split within the self and subsequent substitution of the self for another, as in doing to the self what one wants to do to someone else, or doing for the self what one wants someone else to do for self). People who imagine that others hold negative judgments about them are often projecting their own sense of personal antipathy and then punishing themselves on the basis of the judgments of “others.” The process can be like two mirrors facing each other that reflect a frozen and closed looped state of negativity: No new information can enter, and thus, no corrections can occur.

Because people entrain to the dominant states around them, particularly in the case of partners, we often see couples experiencing this closed loop. In part, this may be a reflection of poor self-boundaries and indicative that a person may not be able to maintain his or her state around someone else. However, it appears that all humans are sensitive, at least unconsciously, to the states of those around them. Tatkin (2003) suggested that how well partners regulate each other’s autonomic nervous systems reflects the stability of the couple system. (This is also why we suggest that the clinician, as the primary initiator of state change, should be in the state with which the client needs to align.) In the case of shame, when one person feels embarrassed by a confrontation from his or her partner (i.e., shamed by having been caught), it may trigger a similar feeling in the other partner. In order to break the intolerable feelings of shame, couples may begin to argue. These interactions are painful, unproductive, and often keep partners locked in a continuous loop of negativity.

Negative hypnotic trance states engendered by painful interactions that repeatedly produce shame and anxiety frequently create a pattern of habitual escalation or withdrawal and preclude intimate contact. Couples who are caught up in them have difficulty disentangling themselves enough to work constructively to resolve conflict (Kershaw, 1992). One effective approach to depotentiating the joint negative trance states is the use of conjoint alpha–theta training, a synchrony training wherein the hemispheres of both people entrain to each other in their calmest states. We use the Cygnet software for this training. Each partner is hooked up to a computer (with EEG leads). We have noted, and mention to clients, that in this process of brainwave alignment, they may sense the state of the other as they both become quite calm. When this training is incorporated into marital therapy, partners learn how to shift gears more quickly. If there are shame-based patterns, they can more easily be interrupted and altered. As a couple’s physiology calms, frequently, the partners are also able to make more effective use of relationship therapy.

When clients present with intense anxiety, depression, or shame, there are often issues surrounding trauma that may not have been fully processed or even disclosed to the therapist. Issues related to social betrayal and attachment, fear, and memory problems emerge from trauma. Bessel van der Kolk noted the following: “Many traumatized children and adults, confronted with chronically overwhelming emotions, lose their capacity to use emotions as guides for effective action. They often do not recognize what they are feeling and fail to mount an appropriate response… . Unable to gauge and modulate their own internal states they habitually collapse in the face of threat, or lash out in response to minor irritations” (2006, p. 1). Because physiological overarousal is at the basis of so many disorders, including posttraumatic states, helping individuals reduce their baseline states of arousal is a key aim in many mental health treatments. Van der Kolk discovered that clients who use neurofeedback as an intervention were generally able to return to full normal functioning. In addition, neurofeedback allows clients to significantly improve their ability to “mentalize”—that is, the ability to observe one’s own feelings and those of others without reacting (Fonagy, Gergey, Jurist, & Target, 2005).

In her first meeting with Carol, Patrice reported a remarkable story of emotional abuse in her family of origin and described her former marriage to a man who worked undercover in a U.S. intelligence agency. Her ex-husband had been just as emotionally abusive as her father: He would intimidate her with tactics such as telling her he knew where she was every moment—and then casually add that he could “take her out” any time he felt like it, and no one would ever suspect a thing. Patrice had left him, but she knew that in the year and a half since their divorce, he had broken into her apartment at least half a dozen times and changed small things simply to terrorize her. Her resultant anxiety had become sufficiently chronic and acute that she was experiencing severe insomnia nightly. Her level of daytime anxiety was compromising her ability to perform adequately at her job. Patrice not only felt embarrassed by her situation, feeling that it was “her fault,” but she also felt very apprehensive about telling anyone what she was facing. Although she literally feared for her life, she didn’t want to “drag anyone else into it” and possibly put that person also at risk. Understandably, Patrice reported feeling depressed. Stating that she was unable to find any respite from hopelessness in anything, she disclosed transient suicidal ideation.

Carol described to her the process of alpha–theta training and its healing potential, and explained that if she could allow her mind to go all the way to the edge of sleep with awareness, she could experience a shift in state to complete relaxation. After 10 weeks of sessions twice a week, Patrice’s anxiety was noticeably reduced, and she was sleeping much better. As the shame, anxiety, and depression lifted, Patrice began to feel able to take some concrete actions to improve her situation. Two months later, she moved to an apartment complex with enhanced security features where she felt safer from her ex-husband.

Recognizing that anxiety, depression, and shame are all expressions of fear, this chapter has examined their common underpinning and discussed therapeutic interventions using BCT. The next chapter focuses on the many factors that contribute to weight issues and the BCT approach to assessment and intervention.

CHAPTER 8

Resolving Fear with Brain Change Therapy