Emotional Restructuring

Clinical Biological Perspective on Brain Involvement

Robert Moss & Christine Mahan

doi: 10.12744/tnpt(5)054-065

There is a growing awareness of the lifelong effects of childhood negative emotional memories on both physical and psychological health. In relation to detrimental physical effects, research has shown early adversity can affect susceptibility to conditions involving pro-inflammatory processes including heart disease (Miller et al., 2011). Early negative emotional memories have also been tied to fatigue in chronic fatigue syndrome (Heim et al., 2006) and breast cancer (Bower et al., 2014). In addition to the known effects of those negative memories on depression (Chapman et al., 2004), there is mounting proof that, when compared to those occurring in adulthood, negative emotional memories from childhood are related to more severe posttraumatic stress disorder symptoms in older adults (Ogle et al., 2013).

There are several psychotherapy treatment approaches that, for many clients, can rightfully claim to be effective in addressing influential negative emotional memories tied to past relationships. A common component of those therapies involves experiential procedures such as chair techniques or role plays/reversals. While the therapy proceeds over a number of sessions, there is often one specific session in which dramatic improvements occur. We have seen a typical emotional pattern described from those critical sessions. The first stage is heightened anxiety, transitioning into anger. With expression of the anger in some manner, the next phase is one of a cleansing sadness involving compassion for self. There can also be a point at which the client has compassion for the person being discussed, recognizing at both a logical and emotional level that the individual was a victim of their own past negative life situations. This can lead to an emotional forgiveness of the offending party.

The brain-based Clinical Biopsychological Model (CBM) proposes an alternative and more directive approach to identifying and dealing with relevant negative relationship memories (Moss, 2001). It involves systematically identifying which relationships have been influential in creating current psychological problems for a client, and subsequently addressing each relationship in a structured fashion. There are several requirements for such an approach to be possible. Since everyone has negative emotional experiences in many relationships during a lifetime, the specific factors that lead to the detrimental memory storage must be identified in order to determine which relationships need to be addressed in therapy. The next step is that a sensible conceptualization be presented to the client as to why the past memories continue to impact the client in current-day functioning, and how the memories can be effectively addressed. Within the actual treatment sessions, there need to be procedures in place to facilitate the anxiety–anger–sadness/self-compassion–forgiveness sequence to allow neutralization of the negative memories.

Emotional restructuring (ER) has been proposed as a single-session treatment approach to deal with problematic memories for any given relationship, past or present. In addition to recognizing the important contributions of ongoing factors (e.g., pain, life stressors) and loss issues (e.g., desired relationship, job) to most psychiatric disorders, negative emotional memories are considered of extreme importance in the clinical biopsychological approach (Moss, 2007, 2010, 2013a, 2013b, 2013c, 2013d, 2014). As described in the treatment manual for this approach (Moss, 2001), the assessment is done in the initial session, at which time each possible influential relationship (e.g., parent, sibling, spouse, boss) is assessed. In the second session, a conceptualization is presented to the client together with an overview of treatment procedure recommendations. If past negative memories are judged to play an influential role in the client’s current problems, these are usually targeted first; thus the third session is often the first ER session. If the problematic memories are effectively addressed, the benefits from other current-day treatment approaches, and education on normal emotional reactions to loss, can be greatly enhanced.

Moss (2013a) discussed in detail how the Dimensional Systems Model (DSM), a cortical column-based theory (Moss, 2006, 2013d; Moss, Hunter, Shah, & Havens, 2012), translates into understanding how different treatments affect different brain areas. The cortical column is the binary unit, or bit, involved in all processing and memory storage. Each column contains several thousand neurons. (For the purposes of this article, recall that when a “column” is mentioned it is simply the brain’s representation of some form of specific information.) In this article, the model is applied to what theoretically occurs in the brain during the process of an ER session; however, it is important to keep in mind that the following description is based on logical applications of the DSM that have not been demonstrated empirically. This is followed by a case description of an individual who received three ER sessions early in her treatment, with some data showing a clear trend toward improvement.

Hypothesized Brain Effects during Emotional Restructuring

Overview of Cortical Organization

To facilitate an understanding of the theorized session component effects, we will first give an overview of the different brain areas that are involved, based on the CBM (Moss, 2013a). Although the cortical areas of the brain are the ones directly affected in psychotherapy, there are subcortical effects as well. The primary subcortical structures impacted are the amygdalae. Being paired structures, the lateral nuclei receive input from both the thalami and the cortices. The cerebral cortex is where the memories are stored, with most therapy-relevant verbal aspects being located in the left hemisphere, and most therapy-relevant non-verbal ones in the right. As will be shown, the non-verbal sensory memories in the right hemisphere are those primarily impacted with experiential techniques, while the verbal memories in the left hemisphere are those primarily impacted by verbal communication, such as new schemas.

The hypothesized cortical influence on the amygdalae—notably involving the sensory, or receptive, cortices—begins with input to the lateral amygdalae nuclei leading to output from the central nuclei. There are two different pathways of note from the central nuclei (Stermensky and Moss, in press). The first leads to sympathetic nervous system activation (“fight-or-flight” symptoms) via activation of the lateral hypothalamus/perifornical regions, causing activation of the interomediolateral nuclei in the spinal cord that subsequently activate the sympathetic ganglia to produce rapid-onset somatic symptoms of fear and anxiety. The second pathway activates the periventricular nuclei of the hypothalami, leading to the hypothalamic-pituitary-adrenal (HPA) axis release of stress hormones, resulting in slower but longer-lasting anxiety/stress effects.

The frontal lobes contain the action columns that control all volitional activities. From a top-down processing point of view, the frontal columns direct the activity of the receptive columns in the posterior lobes (i.e., the parietal, temporal, and occipital lobes); this may involve selective attention to internal and external stimuli, as well as information retrieval from the posterior lobes themselves. The receptive columns involve the representations of all sensory-based information. The action columns are also responsible for working memory—that is, temporarily holding information while doing mental manipulations—as well as planning, organization, and motor output direction. An important point in this theory is that whenever a posterior receptive column forms, a corresponding action column forms in the frontal lobe. Logically speaking, this makes perfect sense due to the simple fact that for any stimulus important enough for us to form a receptive memory we must be able to act upon that stimulus. The frontal action columns, therefore, are those that lead to our ability to perform mental and physical behaviors.

Another aspect is that “motivation” and “urges” are just as much actions (involving the medial cortex) as are verbal thoughts or doing a mental math problem (involving the lateral cortex). The lateral cortex codes for external information, while the medial cortex codes for internal information; the transition areas, such as the insula and frontal pole, code for the combination/synthesis of both internal and external information. The right cortex has fewer columns in its circuits relative to the left, which means it is involved in faster, less detailed functions—for example, processing voice intonation and facial expressions, or brief emotional verbal expressions such as profanity. Conversely, the larger number of columns in the left cortex results in its being slower in processing speed, but capable of more detailed and higher volume processing, including, in particular, detailed and logical spoken language.

The left frontal operculum, where Broca’s area is located, contains the “verbal interpreter”. In many respects, this is what is considered one’s consciousness, since it involves verbal awareness (i.e., interior verbal dialogue) and metacognition (i.e., the ability to verbally identify one’s own range of cognitive abilities). The verbal interpreter is the source of an individual’s verbal schemas and beliefs. If a new schema is presented to a client in therapy, the posterior cortex allows perception and comprehension. However, it is the action columns of the verbal interpreter that allow the active use of the new schema—in other words, verbal memory “reconsolidation” (in contrast to what has been called “emotional memory reconsolidation”) is an active process allowing one to verbally think differently about a subject or situation.

Passive learning—listening to a lecture, for example—mainly involves the receptive columns, while active learning involves the frontal columns, such as studying the material and then teaching or applying it. If one learns something passively, the current theory clearly indicates associated frontal columns will form. If, however, the reception and action columns are used only briefly (e.g., just long enough to take a test or simply converse about a new schema with the therapist), the integrity of the new columns will eventually be lost, due to disuse, and the material will be forgotten. In explanation, the columnar theory (Moss, 2006) suggests early long-term memory is chemically-based (e.g., increased neurotransmitter stores) while later, and truly permanent, long-term memory is structurally based (i.e., increased synaptic connections). If the involved columns are not actively used for a sufficiently long period of time, the permanent structural connections never form and the initially increased neurotransmitter stores lessen. The ability of upstream columns to activate downstream columns (i.e., the new memory circuit) is then lost (i.e., the physiological definition of “forgotten”).

It is possible to understand “emotional memory reconsolidation” in exactly the same manner, but this time in the right cortex. In this case new action columns develop in the frontal lobe as a function of making different responses to sensory information input or memory reactivation. This may be as simple as facing a feared object or memory until anxiety dissipates, or as involved as detailed imagery describing new actions or behaviorally engaging in chair techniques. In such cases the individual is actively involved, behaviorally or mentally, which leads to the formation of new receptive and frontal columns. This results in changes in feelings of control and personal adequacy, with the outcome that a person feels differently (i.e., via “emotional thinking” as opposed to “verbal thinking”) in response to future encounters with associated stimuli. In this context, it becomes clear that “emotional schemas” exist and can be altered.

The emotional memories that have a detrimental impact on a client’s current functioning are those associated with situations in which the client felt a lack of control, or personal responsibility/inadequacy, or both (Moss, 2007). Although the individual has many times developed new and healthier ways of verbally thinking about those situations, this does not necessarily alter the right hemisphere’s non-verbal emotional memories. In such a case, the client may voice the fact that he or she logically knows and thinks about those things in a reasonable way, but feels quite different in an emotional sense.

Along these lines, an important point to note is that the frontal action columns of a given hemisphere connect to ipsilateral (same hemisphere) posterior columns and contralateral (opposite side) frontal columns. The posterior columns of a given hemisphere, therefore, connect to the ipsialteral frontal columns, and contralateral posterior columns. If there are no connections from one cortical location to a given set of action columns, it is only logical that those action columns have no functional control ability. A prime example is that the verbal interpreter of the left frontal cortex has no direct connections to the posterior columns of the right hemisphere, which is the location of many of the sensory, non-verbal, negative emotional memories tied to problematic relationships. Thus, there is no way of using verbal logical reasoning to prevent the activation of those influential right posterior negative memories.

The interactions of the action columns in one hemisphere with the frontal columns in the opposing hemisphere frequently involve one side inhibiting the activity of the other. Thus, when there is a difference in how one verbally thinks versus how one emotionally feels about the same thing, the mutual inhibitory activity is perceived as internal conflict. This is referred to as “interhemispheric incongruence”. When there is congruence between emotional and verbal action columns, there is a perception of internal peace.

The Emotional Restructuring Session

There are six steps in an ER session. These are: (1) negative emotional memory recall; (2) interpersonal relationship pattern description; (3) role reversal/role play; (4) imagery for anger release and self-nurturance; (5) origins of the relationship pattern description; and (6) role-played forgiveness sequence. Since the aim of this article is to discuss how the brain is affected, only brief information about each step will be presented here: the interested reader is referred to the treatment manual (Moss, 2001) for a detailed description of each step, which is beyond the scope of the current article.

Negative emotional memory recall. The first step is to have the client recall specific negative events/situations that occurred in the past. During this recall, indeed at any time in the session when the client is verbally responding, the left frontal verbal interpreter is involved. In like manner, any time the client is listening to the therapist’s verbalizations, the client’s left posterior cortical areas are involved. The major effect of recall, however, is the activation of negative emotional sensory memories in the right posterior cortex that leads to amygdala activation, and the previously discussed fast tract leading to sympathetic arousal. The client’s perception is typically one of anxiety increasing during the time the therapist is collecting detailed information. An attempt is made to identify at least one past memory in which anger rose significantly, as this can serve as the situation to be used during the imagery phase.

A very important point here is that, in the therapy situation, if there is only discussion about past negative situations/events, the client will leave that situation feeling worse than at the beginning of the session: the client will have formed a new, negative memory of the therapy room and the therapist. This can have the effect of decreasing the client’s motivation to return for additional sessions, due to increased anxiety when re-entering the room because the negative memory is reactivated by the same situational variables. For most clients with influential negative emotional memories, they will have found that avoidance of memory reactivation is the default response since there has been no reduction in the impact of those memories during the discussions.

Interpersonal relationship behavior description. The second step involves the presentation of the behavioral description of the Type-T (Taker) or Type-G (Giver) pattern (Moss, 2013b). The verbal presentation obviously engages the left temporal and temporoparietal areas involved in language comprehension. However, the posterior left columns are believed to activate right posterior columns in two ways. The first is when some of the descriptions lead to visualization in the right posterior cortex (e.g., by using terms like the person having an “outside shell”). A second, and probably more important aspect, is when the description provides an explanation for actual events and behaviors that occurred, tied to the target individual. Describing the new schema of why the individual behaved in the manner he or she did, in conjunction with the recognition of interactions in which those behaviors were actually displayed, provides the verbal interpreter with powerful new insights. The verbal interpreter can then immediately apply the information to other situations that involved the target individual, leading to these being recalled and visualized in the right hemisphere. This allows better acceptance by the verbal interpreter of the emotional reactions emanating from the right hemisphere, with greater interhemispheric congruence and less internal conflict. It is often observed that the first stages of anger begin with irritation or annoyance—anger is an expressive emotion involving action, and is frontal in origin, which theoretically corresponds with activation of new right frontal columns associated with the new visual images (recall that with each new posterior column a new frontal column forms)—and decreased inhibition from the left frontal area allowing the expression of right frontally based emotions.

Role reversal/role play. The role reversal involves a brief interaction in which the client is told to take the position of the target individual, “playing by their rules” (which have been described). After the more detailed descriptions, the basic rules can be greatly simplified for the role reversal. In the case of a Taker, the basic rule is: “I win, I get my way no matter what I have to say or do”. If the person is a Giver, the rule is: “I get to be the good guy and cannot stand to feel like a bad person”. The therapist then initiates the interaction, acting in the role of the client. If the client has difficulty in assuming the target individual’s role, the therapist can model the verbal behavior in a role play to emphasize how it can be done. The process is brief, lasting less than a minute in most cases.

The role reversal involves the verbal interpreter in a unique manner. It is to employ a previously unrecognized set of rules which are attributed to the target individual being discussed. At the same time, the verbal interpreter has access to memories of past verbal exchanges to draw on, and is to use those verbalizations (i.e., simply repeating what was said in the past by the target individual) as the client pretends to be the other person. The right hemisphere has a large volume of situational memories as well, and has experienced the voice intonations and inflections from the target individual. For clients who mimic the non-verbal voice and facial expressions while using the verbalizations employed by the individual being discussed, the right and left hemispheres’ frontal action columns are directly activated. It is now that those who are able to effectively engage in the role reversal report a major increase in perceived anger. Although it is likely most clients will already have concluded at a verbal, logical level that the target individual was at fault/responsible, this is the first time many clients will have deeply felt the same emotionally, or with such conviction.

Imagery for anger release and self-nurturance. Of all components discussed, imagery is the one leading to the most pronounced and rapid emotional change. With the eyes closed, the client is told to visualize a scene described by the therapist involving an interaction with the target individual. At the end of the imagined interaction, the client is described as inflicting on the target individual an anger—expressed physically if the person was verbally or physically abusive, or by desertion/neglect if that was the nature of the predominant negative action. Immediately following the anger release, the description changes to a funeral in which it is believed the deceased person in the coffin is the target individual who was just attacked or abandoned. However, upon looking inside the coffin, the client sees himself/herself as the victim lying there, at the age where the most damaging events occurred. The description progresses with a dialogue between the current-age client and the younger victim acknowledging the damage and that self-blame had been erroneously given. The scene ends with the younger victim returning to life, with hugs and affirming statements being given by both the current-age client and the younger-age client.

The most likely route leading to the activation of the non-verbal sensory emotional memories of the right cortex is via the left posterior cortical areas being activated by the spoken words of the therapist. When the right posterior columns activate, the corresponding right frontal columns activate. Additionally, there is amygdala activation from the right posterior cortex. Notably, as the new events unfold in the description, with anger expression being described, new right posterior columns lead to the immediate formation of new right frontal action columns. This is the moment when the client perceives control and personal adequacy. However, the immediate shift to the funeral scene takes advantage of a frequently present, right cortically-based feeling for most clients. This feeling is that taking up for oneself will lead both to the loss of a desired relationship and being seen by others as a bad person. The surprise that the client is actually the victim provides an alleviation of those fears and the immediate perception of an ability to self-nurture. Throughout imagery, the left hemisphere verbal interpreter is being provided with new dialogues, with the most important ones being related to the self-nurturing statements. This assists in hemispheric congruence because the verbal interpreter is accepting the emotional pain associated with the right sensory memories as acceptable and natural. There is both relief and sadness for self.

Origins of the relationship pattern description. This incorporates frequent images, such as the target individual having what others have termed the “inner child” trapped in a hard inner shell and being unable to grow beyond the shell. The negative behaviors shown by the target individual are explained as an attempt to fill an emptiness that can never be filled. Additional imagery leads to the understanding that the target individual was the victim of his or her own past, leading to the entrapment of the child. The final aspect involves images supporting the fact that the target individual was not holding back the compassionate and positive behaviors desired, but was unable to give them because they never existed within him or her.

The same mechanisms described in the imagery section are in play. The verbal interpreter forms new verbal schemas (i.e., new action columns) based on the left posterior receptive columns (i.e., comprehending the therapist’s words). There are also new right receptive and action columns forming with each new visualized image. Pity, or sadness for other, becomes the predominant emotion at that point for most clients.

Role played forgiveness sequence. The final step is to give expression of the pity for the target individual. In the role play the client verbally describes the emotional damage done to him or her, followed by a statement that the target individual was not holding back, but simply lacked the ability to give to the client what was desired and needed. In other words, the target individual could not give something he or she had never been given. The final part is a statement that there is forgiveness. It is not unusual to find that a client may have difficulty overriding the long-standing verbal and emotional schemas (left and right frontal columns) that the target individual really was holding back, leading to difficulty in saying the person did not have the ability to act differently. By gentle verbal reasoning, the therapist can have the client recognize that the target individual was incapable of different behaviors. This allows the client to realize there was nothing about him or her (e.g., “I am unlovable”) that resulted in the target individual’s negative behavior. Instead, it was the shortcomings of that individual (e.g., “You are incapable of loving in the manner I needed”).

As should now be obvious from the foregoing descriptions, the entire process involves extensively both the right and left posterior and frontal areas. This is the point at which the client has new right and left frontal action columns, where there is perceived control and personal adequacy, while simultaneously feeling self-compassion and other-compassion. The final emotional state is difficult for the client to describe since it has never been experienced in the past, being a mixture of cleansing sadness and profound relief.

Case Presentation

The following case was seen by the second author, who was a second-year graduate student in the first month of her first practicum under the supervision of the first author. She adhered closely to the manual in relation to the case conceptualization, ER treatment sessions, information on Givers and Takers, and education on normal emotional reactions to loss.

Cathy (not her real name) was a single Caucasian female in her early 20s. She was a full-time university student in her last semester and was planning to attend graduate school. She was self-referred for treatment reporting an increase in anxiety and depression symptoms over the previous two months. Her anxiety occurred both in school and some social situations, especially when around strangers, with a fear of being judged and humiliated. She also reported a history of depression that began as a teenager. She said she was “never going to be fixed”. She felt emotionally exhausted with variable sleep patterns characterized by frequent awakenings and constant fatigue. Additionally, she noted reduced interest in others, loss of enjoyment and interest in activities, feelings of worthlessness and guilt, and difficulty making decisions. She also reported intense worry about being depressed, which appeared to make her depression worse. She reported being apprehensive and unable to relax, as well as perceiving a racing heart with feelings of nervousness, being scared, and lacking control. Furthermore, Cathy reported the fear that without treatment her depression would worsen and there could be a “repeat of past behaviors” (described below). She was diagnosed with Major Depressive Disorder, Recurrent, Severe without Psychotic Features and Anxiety Disorder NOS.

Cathy had always lived in the Midwest, growing up in a small town. She moved away from her family to go to college and currently resided in a larger city. Her parents divorced when she was young and she lived with her mother. Contact with her father ceased when Cathy was around age 10. Her mother remarried, and Cathy described a poor relationship with her stepfather, although she believed they cared about each other. She helped care for her younger brother, but they did not currently talk much. The relationship with her mother was described as good. However, Cathy qualified this by noting that she did not share her mother’s religious beliefs, and felt she could not be totally honest. There had been difficulties in the past that had negatively impacted her mother. Consequently, Cathy experienced a great deal of guilt associated with her believing she “wasn’t a good enough daughter”. Cathy had a fairly good support system in her small network of friends, with major reliance on one friend who lived out of town and was a mentor from high school. She was employed part-time in a department at the university and relied on her mother for additional financial support. Her developmental history was unremarkable, and her current health status was reported as “good”. Additionally, she had no significant injuries or hospitalizations and was not taking any medications.

Cathy attributed her current problems to the lasting detrimental effects of two same-sex relationships. The most recent lasted about seven months and ended approximately two years prior to treatment. The first relationship occurred when she was a teenager. Cathy initially identified as bisexual, but she had been questioning her sexuality and stated this was something she wanted to discuss in therapy, although at a later time. She reported “falling hard” in both relationships, but the other individuals wanted to keep it a secret. Eventually both partners concluded that the relationship was a “casual experiment” and that they only wanted to be “friends”. After the first relationship ended, Cathy began isolating herself and engaged in cutting behaviors. She eventually told her mother about the cutting, due to the recommendation of her teacher/mentor, and Cathy and her mother began seeing a Christian counselor. However, Cathy did not find the counseling very helpful due to her inability to be honest about her “real issues”. While receiving counseling, she attempted suicide by taking a bottle of Tylenol. Afterwards, she changed her mind and threw up. She never disclosed the suicide attempt to anyone prior to therapy with the second author. Cathy’s mother terminated counseling when it was suggested that she might be contributing to Cathy’s problems.

Cathy’s intake interview included an assessment of influential relationships that could be addressed with an emotional restructuring intervention. Three were identified, namely, both intimate relationships and the relationship with her mother. Cathy’s first therapy session following intake consisted of psychoeducation on anxiety in relation to the fight-or-flight system. This discussion explained the stress response system and the typical physiological and behavioral changes that can serve as cues to recognizing anxiety, thus reducing the fear commonly associated with the experience.

A case conceptualization was provided in the second therapy session. An explanation of the negative emotional response system included its universal nature and purpose in ensuring survival. It was explained that this system can activate when negative emotional memories are triggered. Cathy’s negative memories regarding all of these relationships were frequently triggered by the more obvious current factors, such as attending the same school as her ex-girlfriend, running into certain people around town, and interactions with her mother. Importantly, when a current situation leads to negative emotional reactions, past seemingly unrelated memories can be activated by the similarity of the emotions, and serve to heighten the severity of the reaction. For example, if one feels out of control in a current situation, past thematically unrelated memories associated with loss of control can activate in the right hemisphere. In Cathy’s case, this resulted in her frequently experiencing negative emotions. Additionally, Cathy was told that the negative emotional memories stored in the right posterior hemisphere of the brain could not be directly accessed, understood, or controlled by her verbal interpreter in the frontal left hemisphere, and that this had led to internal conflict due to the perceived incongruence of her thinking and feeling. For example, she logically believed she should have been able to get over her intimate relationship and move forward; however, the negative emotional memories were still present and very potent, often triggering anxiety, anger and depression.

Cathy participated in three ER treatment sessions. The first ER treatment, focusing on her most recent intimate relationship, occurred in her third counseling session, while her second treatment, in her fifth counseling session, focused on her first intimate relationship. Both of these relationships were with individuals who displayed the Taker behavioral style. Her third ER treatment occurred in the seventh session and focused on the relationship with her mother, who displayed a Giver behavioral style. The sessions between ER primarily consisted of processing Cathy’s experience in ER and the relationship of focus. At the close of her first ER treatment, Cathy reported feeling “very sad” and regretting “the time spent in the relationship” and “punishing [herself] over the last 2 years”. During the next session she stated that she “liked it” but was feeling “weird” because, “I think it worked on some level, but I’m skeptical and don’t want to get my hopes up”. After her second ER treatment, Cathy reported being “confronted with a trigger” and had a “better response” than what she had previously experienced. She also reported that her “thoughts and behaviors [were] changing”. She also reported that she “really liked” the role plays and reversals, describing them as “powerful”. At the conclusion of Cathy’s third ER treatment focusing on her mother, she did not report the same dramatic reduction in anger as she did with the other two sessions. This is a common observation when the target individual is a Giver versus a Taker. The best explanation is that the degree and type of damage done by a Taker is much more frequent and egregious than that done by Givers. In the following session she reported a “surprise visit” from her mother that went “better than usual”, which Cathy attributed to the new understanding of her mother and adjusting her own expectations accordingly. A couple of months later (session 16) the ER treatments were discussed once again and Cathy reported a significant reduction in anxiety, sadness, shame, and anger, as well as an increase in peace regarding all three of the target relationships.

Additional interventions used throughout therapy included psychoeducation on all of the following: depression, Giver and Taker behavior styles, normal emotional reactions to loss, perfectionism, and quitting smoking. Relaxation techniques, behavioral activation, identifying cognitive distortions, self-affirmation skills, and additional role-plays were also utilized. She quit smoking (by session 12), resolved her struggle with her sexual identity and began to identify as lesbian, then came out to her family just prior to transfer. In total, she was seen 31 times over an eight month period, including her intake and transfer session. The BDI-II and BAI were used to track her symptoms throughout therapy (Figure 1).

Conclusions

We have presented information both on the observed changes during the ER sessions and theorized brain effects associated with those changes. Most of the components are present and have been described as effective in other approaches, including discussion of past situations, role play/role reversal, imagery techniques, and forgiveness. The unique aspects are the process of identifying the relevant relationships to address, the brain-based conceptualization presented to the client, the structure of the session in which all components are organized, and the Giver/Taker schema that is presented. The approach has been used successfully for many years in a solo private practice and has also been found to have the same results when administered by five graduate students. Although the opportunity to use the treatment in randomized controlled trials has not presented itself, we hope this may become possible in the near future if interest in the CBM and ER grows.

To our knowledge the Clinical Biopsychological approach is the only one based on a comprehensive brain model in which cerebral cortical circuits of columns are described—both in processing and memory, and in the way cortical memories interface with subcortical structures leading to physiological reactions and enhanced memory storage. We believe that this approach offers the new field of Neuropsychotherapy a rallying point, and that it represents a significant stride forward, toward a true “Grand Unified Theory” in psychotherapy, which to date has been considered very unlikely (cf., Stricker, 2013). We hope others will take a serious look at the theory and treatments, and subject these to rigorous evaluation.

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