Memory reconsolidation: A potent process of lasting change shared across therapies – B.Ecker, A.Vaz

hello everyone welcome to lisbon i'm very happy to be presenting my friend bruce and the presentation is about to give on memory consolidation and why it's important hopefully for the field of psychotherapy i'm sorry we can't all be together so i'm gonna make a just a very brief intro to get things started and just to give you my sense of why whatever bruce is going to talk about is i think of importance for most people in the integrative psychotherapy community and i think the main thing is that you know most of us have been in

some ways influenced by classic texts classic articles books in the more psychotherapy vein psychotherapy integration vein and i was very influenced by marv gold freed's 1980 article called toward the delineation of therapeutic change principles so that's a you know a very classic psychotherapy integration paper many of you know about it those who don't i really recommend going back and reading it and basically what marv goldfree did there was stating that there's different levels of abstraction when it comes to talking about psychotherapy and the practice of psychotherapy and the research of psychotherapy and we usually talk

at the very technique based level or which is very concrete very minute or a very broad abstract concept theoretical level right and different therapy modalities would basically fight in these two levels of abstraction and marv i think was you know of course there's a lot of people preceding him but i think he did a wonderful job in really systematizing this as a problem proposing a solution in trying to delineate change principles therapeutic change principles um which would be a middle level of abstraction that would cut across different therapies it's more broad than the specific technique

but more concrete than you know more abstract theory so we're talking about corrective emotional experiences the therapeutic clients you know promoting positive treatment expectations things that since the writing of that article have gained even more empirical support for its importance so you know that was 1980 since then marv and the rest of the gang have created a ton of fantastic work regarding the idea of change principles even i believe it was last year the third edition of the handbook of psychotherapy duration was out and catherine eubanks and marv goldfruit offered this wonderful chapter on the

principle-based approach to psychotherapy integration so you know clearly that has struck a nerve and i don't think it's just in the integrative community i think it's it's a very important contribution for anyone interested in psychotherapy at large so i think that discussion of therapy change principles and what cuts across you know different therapeutic modalities is very much connected with a different contemporary debate that is perhaps the most important question we can ask in psychotherapy research today i should make a dramatic pause there and i think the most important question and i think other authors have

also pointed in this direction is that while we do know we have demonstrated that therapy does work at least for a good majority of people we don't know exactly why it works or how it works we have a lot of theories about you know why we produce therapeutic outcomes but it's very very hard to actually produce empirical basis for the reasons why we get those outcomes so i think it was particularly influential the work of alan kasden here and bruce is going to talk about him as well basically putting to the forefront the question or

the importance of studying mechanisms of change mediators and mechanisms of therapeutic change really trying to understand what is it in the therapeutic intervention what's the mechanism there that leads to the therapeutic outcomes it's interesting because even more recently pim kuch perez did a you know an influential kind of review basically restating that at this point we really don't have a lot of knowledge about how therapy works right um and by the way if there's anything that i'm talking about or that bruce talks about that's of particular interest to you i'm sure that both myself and

him are very happy to send you reprints of all of these offers papers studies etc we like to disseminate the cool stuff so anyway now jumping to bruce you know i met bruce some years ago we hit it off immediately we are incredible nerds for all this kind of stuff and so what happened is i i kind of got a sense that what bruce had been working for the past two decades more at this point i'm sorry bruce i'm making you feel old maybe more than two decades yeah like three decades um that what he

was working on and his interest in memory consolidation and his deep knowledge in memory consolidation was actually very much connected to these questions of therapeutic change principles mechanisms and mediators of change like without using those words it seemed like he was constantly kind of dealing with that same issue so we started talking about this and over the course of like a year or two it just developed into realizing that yeah this is the conversation the conversation is how is memory consolidation potentially something that might help us understand psychotherapy why psychotherapy works right so memory consolidation

per se has a lot of good research to support it the translation of that to the clinical sphere is something that people are more and more starting to do right and there's bruce but of course you know there's a lot of other people i mean i know in the psychotherapy community and the sepi community uh richard lane has been very influential in doing it as well and there's just you know a lot of interest starting to build up on this topic which is wonderful so i'm gonna pass it over to bruce because i think his

particular brand of thinking about memory consolidation is particularly helpful in two ways first i think it's amenable to research which is very much needed and secondly because it's pragmatically useful for clinicians so whether you don't care about doing research and just want to provide good therapy or whether you're a researcher or want to be researcher that's looking for interesting topics for research i think this topic that you're gonna hear from bruce now is probably gonna be of interest to you so i hope you enjoy it and i'll come back at the end just to give

some final notes on bruce's talk all right see you soon hello i'm bruce ecker and i'm going to begin with a fresh look at some of the powerful statements made by dr marvin goldfreed and a few other eminent voices who have identified and defined what is arguably the psychotherapy field's most serious problem its darkest and most fundamental dilemma and i'm going to propose a way out of that dilemma thanks to the empirical knowledge of memory reconsolidation that we now have plus extensive clinical observations indicating that in memory reconsolidation we have a potent process of lasting

change shared across therapies i want to point out that in my presentation all of the material regarding the findings of psychotherapy outcome research was contributed by alex vage who will appear again at the very end to offer his closing thoughts just a few months ago in december 2020 dr gold freed authored a short online article that he titled psychotherapy when will it be a grown-up and it begins with these words although the field of psychotherapy has been in existence for well over 100 years it nonetheless still cannot be classified as a mature science one where

there exists an agreed upon core or consensus with its numerous competing schools of thought psychotherapy has yet to achieve an agreed upon consensus after all these years i think it is time that we have found something we need to do what we can to move psychotherapy in achieving a firmer agreed-upon core just one month before that blog post a journal article by dr goldfreed and co-authors avery gaines and michael constantino was published online titled revived call for consensus in the future of psychotherapy in that article they described the psychotherapy field's problem of being stuck in

fragmentation with power struggles among disparate schools of therapy and incompatible theoretical models they also say this even with many clinicians identifying as integrative the heterogeneity of integrative approaches leaves us with little agreement on what comprises the core knowledge of psychotherapy consequently the defining feature of our discipline arguably remains disintegration right there we have the crux of the dilemma defined so clearly in the psychotherapy field there is quote little agreement on what comprises the core knowledge of psychotherapy please burn that phrase into your memory as the very definition of the crisis in the field of psychotherapy

it's a field that has not identified bedrock knowledge that most participants agree upon soon this presentation will show why knowledge of memory reconsolidation is a very strong candidate for being that missing core knowledge of psychotherapy and the way out of this crisis i realize that it may be a new idea for perhaps even a majority of you in the audience of this presentation that our field is in the grip of this crisis indeed the invisibility of the crisis is part of the problem the status quo of fragmentation and parochial division is thoroughly taken for granted

as if it's just the nature of the field but actually it's a chronic crisis a chronic symptom you might say and marvin goldfreid has been working to get the field to see that ever since he first began beating a drum about the problem in his seminal 1980 article toward the delineation of therapeutic change principles but he's finding the field curiously unresponsive his 2019 article in the journal american psychologist titled obtaining consensus in psychotherapy what holds us back examines why the fields stick so strongly to the fragmented status quo maintaining the crisis now if you're grappling

with a crisis it's good to have a place to go where people understand i see this sign often because i live near it in greenwich village in new york city this cafe goes back to the 1850s it's one of manhattan's oldest hangouts struggling with a crisis here's the cafe for you do you see that small dark plaque on the wall there let's have a closer look at it it shows thomas paine who certainly was grappling with a crisis known as the american revolution which his writings helped to inspire the plaque tells us that he died

at this location in 1809 of the many famous statements in his writing supporting independence my personal favorite is this one but such is the irresistible nature of truth that all it asks and all it wants is the liberty of appearing it seems to me that dr goldfreed has been simply pointing to the truth that the psychotherapy field has this crisis and he's trying to give that truth the liberty of appearing and his persistent effort is needed because it isn't given the liberty of appearing for the most part the crisis remains out of view and yet

the absence of unifying transtheoretical empirical knowledge at the core of our field is why our field has been free to splinter endlessly into hundreds of theory-driven competing parochial factions and frameworks and as we'll soon see there are others who have chimed in quite strongly to help identify exactly what's missing and make us aware of being in the dark you know being in the dark happens in all fields from time to time what matters for progress is not being in the dark about being in the dark there was a similar situation in the field of physics

in the 1920s when quantum mechanics was very new and was so very strange all physicists were newly in the dark about quantum physics meant about reality suddenly the core of knowledge in physics was very dark in that context bertrand russell gave an inspired lecture on quantum physics at harvard university and when his lecture ended alfred north whitehead who was chairing the meeting stood and famously said we are thankful for your efforts and not least for leaving the vast darkness of the subject unobscured what a fine example of not being in the dark about being in

the dark however the darkness at the core of the psychotherapy field is obscured for the most part with most participants not realizing that the field is drifting about without a transtheoretical empirical foundation so let's allow the truth of that darkness the liberty of appearing keeping it highly visible and striving to find the missing knowledge and let's go back now to gaines goldfeed and constantinos very recent article to see what they call for to get us out of the crisis and then we'll see how memory reconsolidation fulfills every aspect of what they're calling for and goes

even farther and delivers even more than that i've combed through their article and plucked out what they centrally emphasize is needed this is the first of three short excerpts and i've colorized the key words reproachment across divided camps may be possible by divesting from particular theories and techniques and instead investing in core transtheoretical change strategies that can be responsively tailored to individual patients it is here that we have the greatest likelihood of finding commonality to unify our discipline working here with acceptable levels of empirical support for such change principles therapists can be freed from theoretical

loyalties and here are the second and third excerpts to expand on the preliminary support for these principles we believe that future research will need to experimentally test their causal influences on patient improvement we believe the discipline will need to set aside our deeply rooted rivalries and place greater value on creating a knowledge base that can be shared by all this may demand a culture shift as much as a shift in specific aims in service of our patients we may need to demonstrate greater allegiance to our science as a whole than to our own insulated professional

sub-communities let's now boil that down even more the program urged by gaines goldfied and constantino consists of a knowledge base acceptable to all psychotherapists consisting of transtheoretical principles and strategies of change that are tailored to individual receivers of therapy empirically supported and experimentally tested to confirm causal influence now right here i wish it were possible to pull everyone who's viewing this presentation in order to tally up the percent who are comfortable with this formulation of how to create an agreed upon core of knowledge for psychotherapy obviously we need the acceptability of this to be very

high if this approach is to have a chance of succeeding at creating a core of fundamental knowledge that is affirmed and used by all psychotherapists i'll share that i'm quite comfortable with this program especially because of the item at the bottom of the list confirmation of causal influence that's a strong condition much stronger than the mere correlations that are usually what's measured in outcome studies what more could i want as a psychotherapist than being equipped with a trans theoretical strategy of change that is a proven cause of lasting change that's what i call bedrock and

that's why ever since 2005 i refocused my clinical career on memory reconsolidation in studying the research on memory reconsolidation by neuroscientists it became clear to me that those findings can supply the kind of solid ground called for by gaines goldfeet and constantino i'll explain next how memory reconsolidation does that here's a one sentence definition of memory reconsolidation that by itself immediately starts to indicate why this is major for psychotherapy memory reconsolidation is the brain's built-in mechanism for unlocking the encoding of what was previously learned and encoded into memory allowing revision of existing memory content by

current experiencing before the encoding relocks well nearly all of the symptoms and problems addressed by most therapists are generated by the contents of memory and that's why memory reconsolidation has such broad applicability in therapy for example the many different symptoms of insecure attachment arise from learned relational expectations held in memory and called working models by various attachment theorists the many different post-traumatic symptoms arise from either memory of the traumatic event itself which is episodic memory or from memory of what was learned about the world in the event which is a mental model or schema the

contents of semantic memory and symptoms of many many other types also are generated by the contents of memory the discovery of memory reconsolidation in the 1997 to 2000 period was the discovery that the encoding of a well-established memory can be unlocked or destabilized as the neuroscientists say while the encoding of a target schema in memory is unlocked the content of that schema can be revised by new learning in any way it can be strengthened or weakened or revised in its details or fully unlearned and nullified full nullification has been termed erasure by neuroscientists and obviously

erasure is the most potent application of memory reconsolidation for psychotherapy laboratory studies with human subjects have demonstrated erasure of emotional learnings ranging from relatively simple pavlovian learnings to considerably more complex emotional preferences full nullification or erasure is permanent when you consider that standard extinction procedures never nullify or erase the target learning but only suppress it temporarily you see why the discovery of memory reconsolidation is so significant it's a fundamentally different mechanism than extinction the observable markers of erasure are well defined and unambiguous behaviors and emotions generated by the target learning disappear completely the mental model

or schema that is the core of the target learning cannot be reactivated and it behaves as if it is non-existent and both of those changes then persist effortlessly and permanently so this is profound unlearning and i think you can see why we also refer to these markers of erasure as transformational change in sharp contrast with incremental change the gradual partial reduction of symptoms erasure transformational change is achieved by a set of well-defined experiences that are apparent in each of the many neuroscience studies that have demonstrated erasure how all of that research establishes an empirically confirmed

process of erasure is covered in my 2018 review article titled clinical translation of memory reconsolidation research the well-defined empirically confirmed process of erasure is the very heart of the matter here so i'm going to spell out its components which are the crucial experiences required by the brain to produce erasure first is the experience of the reactivated target learning and that means a subjective experience of specific expectations and knowings plus any accompanying emotions and somatic sensations in a laboratory study this is typically the experience of a conditioned response for example seeing a yellow square on a

computer screen reactivates the fearful expectation of an electric shock to the wrist in a therapy session an example is visualizing a social situation reactivating the client's fearful expectation that each person in the room would respond the same way that dad always did to any mistake with harsh denigration and shaming the next required experience has to happen during that reactivation of the target learning and it's a direct perception that the world's actual behavior or nature is contradicting those specific expectations and knowings in the target learning this is a surprising violation of expectations and it's what memory

researchers call a prediction error experience or a memory mismatch experience it is this prediction error experience that triggers the rapid unlocking of the neural encoding of the target learning that is a physical biochemical unlocking of encoding which allows the revision or updating and rewriting of the target learning the unlocking of the of the encoding is the start of the reconsolidation process dozens of different studies have confirmed that prediction error triggers that unlocking of the encoding and those findings are reviewed in my 2018 article shown earlier the final required experience for erasure of the target learning

is just a few repetitions of that same concurrence or juxtaposition of the target learning experience and the contradictory experience these several repetitions of that juxtaposition function as disconfirmation of the target learning driving profound unlearning which rewrites the neural encoding of the target learning accordingly nullifying it this set of experiences is the empirically confirmed process of erasure but that's quite a mouthful so i'll just call it the ecpe following this set of experiences the markers of eurasia are observed functionally the target learning no longer exists in over a century of research on learning and memory by

psychologists and neuroscientists there is no other behavioral endogenous process that has ever produced those markers of erasure so the observation of those markers of erasure is itself strong evidence that the memory reconsolidation process has occurred you can see that this ecpe which was identified in laboratory studies is fully and directly replicable in psychotherapy sessions everything in it can be facilitated in therapy and soon we'll have a case vignette illustrating that the ecpe has been adopted as a methodology of psychotherapy by myself and many colleagues around the world for well over a decade and we've documented

in moment-to-moment detail it's trans diagnostic use in many articles books and videos showing that this process produces the markers of erasure and transformational change for a very wide range of intense long-standing symptoms here's a list of symptoms that we've seen fully eliminated by the ecpe now the markers of erasure and transformational change are very distinct and salient and they show up very differently than gradual incremental change in both magnitude and timing as this slide shows on the left is the time progression of incremental change which is the type of change that occurs when therapy consists

of building up preferred behaviors and states of mind in competition with existing symptom production we call that counteracting such as when therapy for anxiety consists of learning relaxation techniques counteracting means building up preferred behaviors and states of mind so they will happen hopefully instead of symptom production and on the right is the very different time progression of transformational change and that's what we actually often observe when we shape therapy to carry out the ecpe as i will soon illustrate with a short case vignette the peer-reviewed psychotherapy literature contains many documentations of therapy sessions producing transformational

change in various therapy systems but to our knowledge there is no recognition of the existence of transformational change in the literature of psychotherapy outcome research transformational change has been neglected by outcome researchers which i thought is worth mentioning now a short case vignette after the vignette we will return to considering the program of gains gold feed and konstantino and see how memory reconsolidation via the ecpe completely fulfills that program what i'm aiming for in sharing this vignette with you is to provide glimpses of both the ecpe in action and the markers of transformational change appearing

especially showing that the ecpe and the markers of change are distinct and easily detectable which is crucially important for doing empirical studies of them a point i'll return to later now to facilitate the experiences in the ecpe a therapist is completely free to use any experiential techniques that means that any case example of the ecpe is really an example of a particular choice of techniques for creating the experiences what you're about to hear is therefore not at all a cookie cutter template for how the ecpe is carried out it's just how i was able to

do it with this client my other sessions with other clients can seem completely different from this vignette on the level of techniques even though i'm carrying out exactly the same core methodology of ecpe facilitation as a methodology for psychotherapy we call that coherence therapy the client here is a woman in her early 50s pseudonym norina and after we had done perhaps 12 sessions on other things she identified a symptom i had not heard about before it was a mood of angry resentment that had frequently ruled her state of mind and behavior for extended periods ever

since childhood her bouts of simmering angry mood were a major factor in the chronic tension in her 28-year marriage carrying out the ecpe begins with identifying a symptom or problem and then finding the emotional learning that is producing that symptom emotional learnings almost always consist of implicit knowledge operating from outside of awareness in order to elicit noreena's emotional learning underlying her angry resentment i began by saying to her just see what comes to mind when i ask you this question in your whole life what is it that you resent the most she answered that she

was already well aware of the answer what she resents the most are her childhood ordeals starting at age six of being sexually molested by her grandfather on several occasions which had been the focus of extensive therapy long ago next i gently asked what is it that you suffered in that ordeal that you resent more than anything else about it that question she could not readily answer so she considered it in silence and finally said with some surprise that doesn't feel like it's my grandfather that i resent the most she pondered some more and then said

it feels like even more than resenting my grandfather i resent the whole world or life itself next i asked her what can you see about why you resent the whole world or life itself after another silence noreena said it's that the world is just too unfair to make this happen to me and to no one else well i was surprised to hear that but i understood that that utterance was the emergence into awareness of the implicit emotional learning that had been producing her anger for a lifetime what was emerging was the naive mental model or

schema of a young girl who had never heard of the existence of child sexual abuse she construed that it had happened only to her which in turn makes the world monstrously and unforgivably cruel and unfair so she was indeed profoundly and unceasingly angry and resentful at quote the whole world or life itself i understood this as soon as she said it's that the whole world is just too unfair to make this happen only to me and to no one else that schema had been outside of awareness it had never received conscious attention in adulthood after

age six that schema reactivated whenever anything else in life also seemed arbitrary and unfair and reactivation of that implicit schema brings smoldering anger and resentment but without awareness of the source of that anger well arbitrary unfair things happen fairly often in daily life including adult married life as you may have noticed so her resentful anger was a frequent presence throughout her life when she said it's that the world is just too unfair to make this happen to me and no one else her voice had an indignant intonation and she had a facial expression of consternation

indicating that she was affectively experiencing the schema in the moment not merely intellectualizing about it the schema felt real and true to her even though she was now experiencing it consciously it was directly in awareness explicitly for the first time so i recognized that ecpe experience number one was happening right now subjective accessing and reactivation of a symptom generating emotional learning and in therapy we always prompt the explicit verbalizing of those subjectively felt expectations and knowings what i'm pointing out here is that ecpe experience number one is quite apparent and detectable as a rule and

that's important again for empirical measurement purposes such as by a session video rater and the same level of detectability will soon be apparent for ecp experiences numbers two and three in response to noreena saying it's that the world is just too unfair to make this happen to me and to no one else i replied by saying i see please say it to me again it happened only to me norena said out loud it happened only to me and it was clear from her entire manner that those words once again simply felt true for her then

i asked her to please say it again this time upon saying that her facial expression changed immediately into a look of puzzlement the target learning emerging from subcortical emotional memory had now begun to connect with her adult declarative knowledge networks specifically her factual knowledge that child sexual abuse is a widespread reality i then quickly invited her to say it yet again it happened only to me this time norina's eyes began darting around as she met a cognitively registered the juxtaposition experience in which both the mental model of the target learning and the contradictory knowledge are

present concurrently now i saw a facial expression of amazed surprise and noreena softly said oh my god i really thought it happened just to me but it happens everywhere it's a part of life everywhere it's an ugly part of life but it keeps happening to girls and boys too all the time everywhere i wasn't singled out those were her exact words ending with i wasn't singled out this is now ecp experience number two highly visible and detectable a direct experience of a contradictory knowing while still experiencing the target learning and with various verbal and nonverbal

indicators of affective richness showing that this is a subjective felt experience of that juxtaposition not merely intellectual insight so this is truly a prediction error experience and according to abundant laboratory research the neural encoding of the target learning is now rapidly unlocking in response during the rest of that session several times with empathy i reviewed her words that had expressed both her lifelong belief it happened only to me and her new realization i wasn't singled out each empathetic review repeated the juxtaposition experience which quite visibly and detectably fulfilled ecp experience number three repeating the juxtaposition

is counter learning while the neural encoding is unlocked so it disconfirms and nullifies the target learning and re-encodes it accordingly during these repeated juxtapositions her comments about her old belief it happened only to me kept indicating quite clearly that that belief already no longer felt at all real or true to her this was the first marker of transformational change to appear the loss of realness of the target schema and notice that that first marker appeared immediately after the ecpe had been carried out if that facilitation of the ecpe was successful in those few minutes marina's

childhood learning that she had been arbitrarily and unfairly singled out by life for cruel treatment had been unlearned and erased eliminating the very basis of her angry resentful reaction to any new encounter with arbitrary unfairness in daily life that erasure would have to be confirmed by the markers of transformational change continuing to appear effortlessly so in our next session one month later i was eager to ask whether she had noticed any effects of the previous sessions work noreena's exact reply was i've been angry and resentful my whole life it's like something has just turned to

dust it's not alive anymore before something felt like cords and cables strangling me i feel so freed up she said there we have a good example of how salient and how easily detectable and unambiguous the markers of transformational change are over the next few months norena reported to me that the marital relationship had a new ease and friendliness and warmth eight months later more markers of transformational change continued to appear the couple had a particularly stressful month due to not feeling emotionally in sync with each other in the course of struggles with the extended family

norena told me quote it was rough but i haven't felt any resentment toward him unquote so that's the marker of non-occurrence of the symptom i took this opportunity to probe for the marker of schema non-reactivation by asking her can i check with you about the work we did on that core belief it happened only to me i'm wondering whether or not that shift that you initially described has held her exact words in reply were quote my resentment had been relentless even with all these troubles that anger is not taking over most of the time i'm

in a wonderful energized peaceful state that's the way i would describe it even with all these troubles so the markers of erasure and transformational change which first began appearing immediately after the ecpe facilitation were now quite well established the the target emotional learning and the symptoms of mood and behavior it had produced were no longer revoked by a wide range of situations that formerly evoked them strongly and these shifts were persisting long-term and effortlessly even in strongly stressful situations in introducing that case vignette i commented that it should not be viewed as being representative of

techniques for carrying out the ecpe however some of its other aspects are general the vignette shows that the emotional learnings that are the target for unlearning and erasure via the ecpe are not episodic memory of particular emotional events and experiences nor is the target of change the client's problematic behaviors or emotions but rather the target is the schematic semantic knowledge and mental models that were formed implicitly and non-verbally by the individual in response to emotionally significant life experiences noreena's lifelong angry resentful mood was arising from a particular mental model that she formed as a child

so that mental model was the target for disc confirmation and profound unlearning through the ecpe carrying out the ecpe is sometimes a considerably more complex process than it was for norena's anger various complications may have to be addressed as many of our published case studies describe in detail the available time here is so short that i had to choose an uncomplicated case in order to illustrate quickly the ecpe and the markers of transformational change okay now as promised let's return to considering the program of gains gold feed and constantino for creating a solid core of

empirical transtheoretical knowledge for the psychotherapy field and let's see how memory reconsolidation via the ecpe fulfills that program let's just move through these elements the first element to check is the transtheoretical requirement well certainly the ecpe is non-theoretical because it's entirely an apparently discovered and confirmed process not at all arising from or dependent on any theoretical constructs component experiences in the ecpe are not based on any theoretical model they're just descriptions of what was done in controlled studies confirmed many times over so the ecpe is non-theoretical but is it transtheoretical meaning can it be used

within diverse therapy systems that have mutually alien theories the strong answer is yes and there are two ways we know that first we hear it from colleagues who use different therapy systems but who report great satisfaction with how the ecpe guides their use of their preferred system to produce significantly more effective work we see such feedback expressed regularly in our online listserv community for example and remember the measure of success with the ecpe is transformational change the markers of eurasia which are very distinct and unambiguous very different from mild degrees of incremental change so actually

it's hard to fool yourself about whether the ecpe is making a difference in your work the second indication that the ecpe is transtheoretical is from our examination of published cases of transformational change from various different therapy systems in each case we have found and documented that the specific experiences in the ecpe in fact occurred embedded in the work just prior to the appearance of the markers of transformational change appearing we've done that exercise for 10 different therapy systems at this point and they are listed in this slide and if indeed what the brain requires is

the ecpe in order to produce erasure or transformational change then finding the ecpe in all therapy sessions that actually produced transformational change is what you'd expect and so far our scrutiny indicates that this potent process of change is shared across therapies trans theoretically as our title for this talk states we intend to keep extending this list in support of our hypothesis that whenever the markers of transformational change appear in any therapy sessions the ecpe has just occurred previously i'm sure you can see the possibility of a remarkable unification emerging here by understanding therapeutic action in

terms of memory reconsolidation therapy systems that may seem incompatibly different in technique and theory come together as a rich repertoire of alternative ways to facilitate the same core process optimally for a particular therapy client okay then transtheoretical check the next requirement is for the candidate therapeutic strategy to be sensitively tailorable to the individual receiver of therapy this too is strongly fulfilled by the ecpe just minutes ago i described how we've detected the ecpe being fulfilled in a wide range of very different therapy systems that already indicates that the ecpe can be facilitated using an extremely

wide range of techniques now why is that the case the ecpe consists of and is defined by certain subjective experiences internal experiences not by any particular external procedures or techniques that may be used for inducing those internal experiences across the dozens of different laboratory neuroscience studies that have achieved erasure by fulfilling the ecpe a huge range of different concrete procedures was used to create this same set of experiences which shows that the brain cares about the subjective experiences and doesn't care about the external procedure understanding this distinction between internal experiences and external procedures is crucial

for understanding how supremely tailorable the ecpe is it doesn't limit the therapist's choice of techniques or style at all if that distinction isn't fully clear yet just imagine a study in which one person is simply required to make another person have the experience of laughing if every one of you listening to this talk would write down what you would do to make the other person have that experience of laughing we could collect all of your techniques into a long list of so many different procedures that can be used to create the one experience of laughing

that's the distinction okay tailorability check next is the requirement for empirical support well this element i have already covered by explaining earlier that from extensive neuroscience research the ecpe has strong extensive empirical confirmation of being a specific process that produces profound change transformational change of an existing acquired mental model and behavioral response empirical support check and lastly we have the requirement of proven causality toward proving causality the most important evidence is two types of data combined a resulting effect that is strong and therefore distinct and the effect happening after the cause with definite timing that

is intrinsic to the mechanism and is verifiable usually that evidence of causality is very difficult to establish in psychotherapy research but remarkably both strong effect and definite timing are easy to demonstrate for memory reconsolidation carried out through the ecpe because the effect is very strong in fact it's the strongest possible effect namely 100 reduction of all aspects of the symptom or problem and because the timing is definite and intrinsic and verifiable with the distinct markers of transformational change appearing next after the ecpe is carried out without any further therapeutic work on that target emotional learning

or the symptoms it generates there is an inherently tight temporal relationship there so the causality of the ecpe in producing transformational change is very amenable to empirical confirmation and this time i invite you to say it with me causality check so we've seen here that memory reconsolidation via the ecpe is an empirical potent process of lasting change that is shared across therapies and is poised to fulfill all aspects of the vision of goldfreit and colleagues for how to create finally a core of knowledge that is embraced by the whole psychotherapy field but that isn't all

i really think there ought to be a table at marie's place that's reserved for psychotherapists always ready for us when we stagger in because well our crisis is even more serious i mean dr goldfree's description of the crisis is completely accurate when he writes that there is little agreement on what comprises the core knowledge of psychotherapy and that therefore the field of psychotherapy cannot be classified as a mature science one where there exists an agreed upon core or consensus but when we look closely at the nature of the missing core knowledge that's when we see

the true seriousness of the crisis and recognize the necessity of having a table ready for us at marie's helping us to see the nature of the missing core knowledge we have other esteemed voices from alan kasden we have this after decades of psychotherapy research we cannot provide an evidence-based explanation for how or why even our most well-studied interventions produce change that is the mechanisms through which treatments operate i realize those are frequently quoted words but don't they sting just as much each time they sting because of how sharp they are in identifying exactly what's missing

a mechanism of change he's saying point blank that the psychotherapy field has not identified a mechanism of change ouch now you may think you know what he means by mechanism of change and you may think he's wrong because you've read so many articles that identified a mechanism of change and you may think that those articles have shown that a strong alliance is a mechanism of change or that experiencing previously suppressed emotions is a mechanism of change or that cognitive restructuring is a mechanism of change but it's kazdin again who shines a light on the matter

with this haiku-like statement mechanism explains how the intervention translates into events that lead to the outcome he's pointing out that the intervention such as forming a strong alliance or cognitive restructuring is distinct from the mechanism of change because the mechanism is that which generates change in response to the intervention and so far it has eluded detection by psychotherapy research the intervention itself is conceptualized by researchers as a mediator a mediator is any particular action or condition that instigates a mechanism to operate and then it's the mechanism that in turn produces lasting change many mediators have

been identified by outcome researchers but remarkably this has not revealed a mechanism inside the client or patient that actually produces change in response to those mediators and here is how this was acknowledged by norcross vandenboss and friedheim in many ways current knowledge on the outcome of psychotherapy can be viewed as correlational that is a therapist performing a particular behavior say empathy or feedback or cognitive restructuring correlates with and predicts a salubrious result but its causal link cannot be conclusively demonstrated and even more recently a 2019 review by couch pairs and colleagues considered several criteria that

must be met by any candidate mechanism of change and they concluded that so far quote no common or specific factor meets these criteria and can be considered an empirically validated working mechanism that is what i meant by saying the crisis is even more serious and this seriousness persists even when we hold these last several quotes alongside the program mapped out by goldfreed and colleagues and this is why goldfeed and colleagues are calling for the field to nucleate around empirically validated principles of change and strategies of change but as the last few quotes emphasized principles and

strategies of change are mediators of change not mechanisms of change and identifying those mediators does not identify an underlying mechanism so even if the program of gains goldfield and constantino were to prevail and bring the entire field into recognizing a shared core of knowledge consisting of empirically validated principles of change and strategies of change well that would be certainly excellent progress but we would still feel the sting of kasdan's words because we still would not have identified an internal mechanism of change that is the great darkness of the situation i hope i have succeeded in

not obscuring it but as they say it is darkest just before the dawn i and my colleagues in the coherent psychology institute think memory reconsolidation can bring the dawn and the blue sky and get us out of this crisis and now i'll explain how and why it can do that first as we've already seen memory reconsolidation indeed is an internal mechanism of change here again is the one sentence definition of it that we saw earlier memory reconsolidation is the brain's built-in mechanism for unlocking the encoding of what was previously learned and encoded into memory allowing

revision of existing memory content by current experiencing before the encoding relocks however knowledge of memory reconsolidation comes from neuroscience research and its existence was not considered or referenced at all by any of the authorities i quoted earlier so this definite knowledge of an internal mechanism of change finally comes from outside of this psychotherapy field from neuroscience it may seem peculiar or ironic that objective trans theoretical knowledge of a mechanism of therapeutic change would come from outside the clinical field but maybe that's exactly what's needed because it may well be necessary for a universally credible mechanism

of change to be empirically identified and understood independently of all of the clinical phenomena that it explains how else could we escape from the factionalism that has such a tight grip on our field memory reconsolidation is a very versatile mechanism of change earlier i mentioned that laboratory studies have shown that during the period when a target memories encoding is unlocked the memory contents can be revised by current experiencing in any way the target learning can be strengthened or weakened or revised in its details or fully unlearned and nullified depending on the experience created during the

unlocked period that experience is the mediator that engages the mechanism of memory reconsolidation to produce that mediator's particular type of resulting change if between unlocking and re-locking there is no experience relevant to the target learning and therefore no revision or updating then the target learning remains essentially unchanged except for a slight strengthening of how readily it activates the unlocking and re-locking done by the memory reconsolidation mechanism is a distinct and separate action from the updating of memory content that can be driven by a mediator experience while the inco encoding is unlocked updating is a completely

auxiliary and optional process driven by a mediator not an inherent feature of the memory reconsolidation process of unlocking and re-locking in other words the term memory reconsolidation in itself does not denote any particular type or degree of change it denotes only the fundamental general mechanism of physically unlocking and encoding and then automatically re-locking it several hours later a period of time known as the reconsolidation window the window allows updating of the existing encoding but updating occurs only if one applies some mediator consisting of an experience that contains the same situation or context that is the

central focus of the target learning but also has a discrepancy relative to the target learnings version of it that discrepancy is what drives the revision the updating if you want the memory reconsolidation mechanism to produce erasure and transformational change the mediator that's required by the brain to get that result is the ecpe the ecpe consists of the experiences that engage the memory reconsolidation mechanism to produce that type of change i mentioned earlier that empirical knowledge of principles of change and strategies of change does not reveal the underlying mechanisms of change that are operated by those

principles and strategies in reverse however knowledge of a mechanism of change does reveal why the principles and strategies of change are what they are that is the power of knowledge of a mechanism of change so memory reconsolidation occurring via the ecpe definitely is an internal mechanism of change but merely recognizing that fact as a general truth does not end the crisis of mechanism in the psychotherapy field to end the crisis decisively it's necessary to establish empirically that observations of transformational change in therapy are in fact caused by the occurrence of the ecpe as soon as

we have valid empirical evidence that the ecpe causes the markers of transformational change to appear that will also be empirical evidence that memory reconsolidation is the operative mechanism of change empirically establishing the ecpe's causal role seems entirely feasible thanks to several factors that i mentioned earlier and now we'll quickly review first the component experiences in the ecpe are distinctive and salient as a rule they occur in therapy sessions at particular moments quite detectably as i pointed out in the case vignette of noreena second the effect caused by the ecpe is very strong and also unique

the effect is the profound unlearning and erasure of the target schema which shows up very detectably as the markers of transformational change and third there is a definite intrinsic verifiable timing relationship between completion of the ecpe and its effect in producing those distinct markers the markers show up next all of those observable verifiable features together constitute significant evidence of causality and those features have been demonstrated again and again in the many case examples of the ecpe that i and colleagues have published we've shown that the markers of transformational change appear immediately after the ecp is

detectably facilitated whether or not the therapist knowingly carried out the ecpe deliberately those extensive clinical observations are very encouraging and on that basis i have assembled an international team of researchers the research associates of the coherent psychology institute and we are now setting up an empirical study designed to detect and measure the occurrences and non-occurrences of both the ecpe and the markers of transformational change and the accurate timing of both in therapy sessions that span a wide range of symptoms and therapist variables and client variables that data should confirm or falsify our hypothesis that whenever

the markers of transformational change appear in any therapy sessions they are always immediately preceded by the ecpe and as i described earlier the combination of a strong effect and tight timing would be evidence of the causal role of the ecpe in producing transformational change and that of course would mean that memory reconsolidation is the operative mechanism of change in such cases and that finding would end a century of the psychotherapy field drifting without knowledge of a mechanism of change so it is interesting to consider how having empirical knowledge of a mechanism of change would reconfigure

the psychotherapy field after all not having such knowledge is exactly what has allowed the clinical field to fragment creatively into hundreds of frameworks each consisting of a particular combination of theory and particular mediators and selected results of therapy outcome studies so having empirical knowledge of a mechanism of change would greatly change the landscape of the clinical field now as always in science creativity has to has to operate within the zone of consistency with existing empirical knowledge once a knowledge community reaches consensus regarding a shared core of empirical knowledge participants can no longer theorize or conjecture

whatever one likes it has to be consistent with the existing empirical knowledge after a century of being free to design a new therapy system however one likes an empirically validated mechanism of change would function as a major new constraint limiting the interpretive free hand that psychotherapists and psychologists have long enjoyed that constraint is the price of graduating into being a discipline that is based on a foundation of rigorous empirically validated knowledge in fact already there are several freely interpretive accounts of therapeutic memory reconsolidation that have wandered quite far out of consistency with the memory reconsolidation

research findings if memory reconsolidation research had revealed only the very general truth that new experiences can revise the contents of memory and nothing more specific than that then psychotherapists and psychologists would continue to have license to draw upon their own fields knowledge and observations to propose models of how memory reconsolidation operates and what has to happen in therapy sessions to recruit the memory reconsolidation process effectively however memory reconsolidation research by neuroscientists has revealed far more than the general fact that the contents of memory are revisable it has revealed the details of the neurobiological mechanism and

the details of the empirically confirmed process of erasure the operational behavioral experiential process required by the brain for recruiting memory reconsolidation to erase and emotional learning that's why it is now possible to state factually that several accounts of therapeutic memory reconsolidation in peer-reviewed journals are incorrect as a field we really cannot have it both ways we cannot shift into being a mature scientific discipline and continue to be free to interpret and theorize the process of change however we like when mechanisms of change are empirically identified and confirmed then only therapeutic models consistent with those mechanisms

can sensibly claim validity and in that way consensus is then built into the clinical field and its evolution but that still allows therapists enormous freedom of technique and style remember the ecpe does not dictate any particular techniques as i emphasized earlier the entire universe of experiential techniques is the available repertoire of the ecp-oriented therapist the therapists creative freedom and versatility are greatly enhanced by that unification not reduced no it is the theorists and the ambitious creators of therapy systems who will have to adjust to the healthy constraint of working within a scientific framework but for

therapists it's a wonderful expansion that allows the seamless combining of methods from different therapy systems as an example of the therapist being empowered by that expansive unification alex vage and i published an account of one of his therapy cases last year in the journal of clinical psychology titled memory reconsolidation and psychotherapy for severe perfectionism within borderline personality the article describes alex's experience of the ecpe's therapeutic versatility and power in a complex and very challenging case with a young woman who had recently attempted suicide i feel it was very courageous work that probably saved not only

her biological life but her psychological life as well well there is only enough time here to just mention quickly several other major impacts on the psychotherapy field that memory reconsolidation as a mechanism of change is poised to deliver it reveals the difference between attempted corrective experiences that do produce lasting change and those that do not it can resolve the debate over specific versus common factors it can solve the mystery of why there is an extreme difference in effectiveness across therapists even when applying the same manualized therapy and it can raise the psychotherapy field's standard of

effectiveness from the mild level set by the dodo bird verdict from rcts to life-changing transformational change so from this point of view the future of psychotherapy looks very bright next alex vaj will conclude this presentation with his thoughts about implications for the future thank you all right so i hope you enjoyed bruce's presentation as much as i always do he is particularly good at creating excitement over very nerdy things and i'm very happy you know to have the luxury of of of hearing him often and discussing often these ideas that he just presented so i

wanted to very quickly highlight two major implications or two major themes from what you just heard and that's on the one hand the issue of research on the other issue of psychotherapy training so very briefly you know bruce already touched on the issue of research and in terms of psychotherapy research you know there was a time where randomized clinical trials or randomized control trials rcts were the thing that only got grants or mostly got grants for psychotherapy research what's been and there's been a lot of of course uh critical thought over that and many offers

including in the psychotherapy integration community have said that this really leaves out a lot of nuance including leaves out a lot of process research uh qualitative research that is so essential for our understanding of psychotherapy what's been i don't know if it's ironic but like a recent kind of development is that even the randomized trials the rcts are in a certain sense on their way out in terms of like grand policies and just general support for psychotherapy research so we're in this kind of weird phase where like in the one hand it's a very hard

time to do psychotherapy research on the other i think it's the best time to do psychotherapy research because we are quite free from constrictions from major policies now this will mostly mean that probably only like very excitable people in or out of a university or university setting we'll be able to do meaningful psychotherapy research and that's okay as long as we build a community around that so one community one possible community that's an implication from what bruce just presented on is creating a sort of a worldwide interest in community over the topic of memory consolidation

for psychotherapy and bruce has very bravely taken the first step in that direction and there's a cool team of people already starting to work on investigating the therapeutic process and how it memory consolidation might help explain therapeutic outcomes so it's a very important first i think and i hope i speak for bruce here he'll let me know for sure if if i don't that we need a lot of independent research on this topic so this is kind of a plea for attention which is if you are interested in what bruce just said this should not

be the bruce alex whomever's show right like we need a lot of different people ideally who never talked to each other to a certain extent actually trying out these ideas and trying to investigate them so again for anyone who's interested in this and is connected with psychotherapy research i think this is a very viable and promising venue for future research so just throwing it out there if you need your graduate students to do something for the next three decades here's an opening that's one the other is a topic that i'm particularly interested in which is

psychotherapy training training and supervision but we'll stick just with psychotherapy training and the fact is that most of our you know training methods have produced mixed to unremarkable results or effects on therapeutic outcome which frankly makes total sense given what you just heard from bruce and other psychotherapy research because if we don't exactly know how we're producing therapy outcomes then we can't really train people in ways to produce therapy outcomes so said in another way it's very hard to train people to get more effective in psychotherapy if you don't know how psychotherapy works right so

i think this is the other major contribution for the future of psychotherapy that potentially memory consolidation might do is for the training of psychotherapists and so this is another plea for supervisors out there trainers teachers etc if you are interested in what you just heard from bruce this is one area that actively needs development so developing strategies methodologies to practice and train the kind of principles that you have just heard and again you can i do think that there is a community to be built around this so not just the research community but the community

built around training people in common principles of change be it those that marv goldfruit like we said before already stated which are super important and these potentially very exciting mechanisms that might be promoting the therapeutic results that we are looking for so again whether you're a trainer teacher supervisor writer researcher i think the topic you just heard from bruce is can give something to everyone so just to close off i think this is the the perfect time to for you to kind of reflect is there something in what you just heard from bruce and in

this topic that you might take in and actually want to do something with it because i think that's the most important part like we love going to conferences and going to presentations and it's very interesting but i think the ultimate outcome is it exciting you the the attendee to want to do something right so those are the two major venues or at least some of the major venues research and training that i think you can really take and do something with it and again just to close off if there's any kind of reprint brainstorm debate

that you want to continue on from here i'm sure that bruce is very open to that communication myself as well so feel free to reach out and yeah and i hope to see you in person fairly soon and thank you so much for attending