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Clinical Translation of Memory Reconsolidation Research: Therapeutic Methodology for Transformational Change by Erasing Implicit Emotional Learnings Driving Symptom Production

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After 20 years of laboratory study of memory reconsolidation, the translation of research findings into clinical application has recently been the topic of a rapidly growing number of review articles. The present article identifies previously unrecognized possibilities for effective clinical translation by examining research findings from the experience-oriented viewpoint of the clinician. It is well established that destabilization of a target learning and its erasure (robust functional disappearance) by behavioral updating are experience-driven processes. By interpreting the research in terms of internal experiences required by the brain, rather than in terms of external laboratory procedures, a clinical methodology of updating and erasure unambiguously emerges, with promising properties: It is applicable for any symptom generated by emotional learning and memory, it is readily adapted to the unique target material of each therapy client, and it has extensive corroboration in existing clinical literature, including cessation of a wide range of symptoms and verification of erasure using the same markers relied upon by laboratory researchers. Two case vignettes illustrate clinical implementation and show erasure of lifelong, complex, intense emotional learnings and full, lasting cessation of major long-term symptoms. The experience-oriented framework also provides a new interpretation of the laboratory erasure procedure known as post-retrieval extinction, indicating limited clinical applicability and explaining for the first time why, even with reversal of the protocol (post-extinction retrieval), reconsolidation and erasure still occur. Also discussed are significant ramifications for the clinical field’s “corrective experiences” paradigm, for psychotherapy integration, and for establishing that specific factors can produce extreme therapeutic effectiveness.
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International Journal of Neuropsychotherapy
Volume 6, Issue 1 (2018)
ISSN 2202-7653
ISBN-13 978-1719190374
ISBN-10 1719190372
Published by The International Association for Neuropsychotherapy (IACN)
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 ,   () ISSN -
international journal of neuropsychotherapy
Volume 6 issue 1 - 2018
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Volume 6 - 2018
i
CHIEF EDITOR
Matthew Dahlitz (Acting)
MANAGING EDITOR
Jonathan Wills
PUBLISHER
International Association of Neuropsychotherapy
Table of Contents
Clinical Translation of Memory Reconsolidation Research: Therapeutic Methodology for Transformational
Change by Erasing Implicit Emotional Learnings Driving Symptom Production ............ 1
Bruce Ecker
international journal of neuropsychotherapy
Volume 6 issue 1 - 2018
ADVISORY BOARD
Roger Mysliwiec (Chair)
Peter Kyriakoulis
Rita Princi
The International Journal of Neuropsychotherapy (IJNPT) ISSN 2202-7653, is an open access online journal published by the International Association of
Neuropsychotherapy. The publisher makes every eort to ensure the accuracy of all the information contained in this publication. However, the publisher,
and its agents, make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the information herein.
Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of, or endorsed by, the publisher. The
accuracy of the information in this journal should be independently veried with primary sources of information. The publisher shall not be liable for any
losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in
connection with, in relation to or arising out of the use of the information in this journal.
Our mission is to provide researchers, educators and clinicians with the best research from around the world to raise awareness of the neuropsychotherapy
perspective to mental health interventions. For further information about this journal and submission details please email ijnpt@iacn.com.au
EDITORIAL TEAM
DISCLAIMER
ii
Editor’s Note
This issue of the International Journal of Neuropsychotherapy (IJNPT) marks another signicant shift for
the journal. In its inception the IJNPT was a product of The Neuropsychotherapist as a peer reviewed and
open access journal for those writing and researching the nascent eld. The journal was then handed over
to the International Association of Neuropsychotherapy (IACN) for Volume 5 in 2017 and was administrat-
ed by Pieter Rossouw’s company Mediros. Now, after the loss of Pieter Rossouw in early 2018, the journal
is fully administrated and published by the IACN.
To begin this new season of administration the IACN is pleased to present a special issue of the IJNPT
featuring a comprehensive article by Bruce Ecker on the clinical application of memory reconsolidation. I
consider the transforming eects of memory reconsolidation to be one of the most important discoveries
in psychotherapy. Ever since Freud’s topographical model of the unconscious mind, memory, operating
between the conscious and subconscious mind, has been integral to our self perception. I hold this view,
not from academic acknowledgment of sound science but from an experiencing the powerful eects
of memory reconsolidation both through demonstration by masterful clinicians and in my own therapy
room. So it is with much personal bias that I recommend what Bruce is proposing in the following pages.
It is my hope that as the IACN progresses the IJNPT will become a signicant open access resource of
knowledge for everyone in the elds of mental health. And I do hope you nd signicant clinical advan-
tage from this powerful understanding Bruce Ecker brings us in this issue.
Matthew Dahlitz
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
1
methodology
Clinical Translation of Memory Reconsolidation Research:
Therapeutic Methodology for Transformational Change by
Erasing Implicit Emotional Learnings Driving Symptom Production
Bruce Ecker
Abstract
Aer 20 years of laboratory study of memory reconsolidation, the translation of research ndings into clinical
application has recently been the topic of a rapidly growing number of review articles. e present article iden-
ties previously unrecognized possibilities for eective clinical translation by examining research ndings from
the experience-oriented viewpoint of the clinician. It is well established that destabilization of a target learning
and its erasure (robust functional disappearance) by behavioral updating are experience-driven processes. By
interpreting the research in terms of internal experiences required by the brain, rather than in terms of external
laboratory procedures, a clinical methodology of updating and erasure unambiguously emerges, with promising
properties: It is applicable for any symptom generated by emotional learning and memory, it is readily adapt-
ed to the unique target material of each therapy client, and it has extensive corroboration in existing clinical
literature, including cessation of a wide range of symptoms and verication of erasure using the same markers
relied upon by laboratory researchers. Two case vignettes illustrate clinical implementation and show erasure
of lifelong, complex, intense emotional learnings and full, lasting cessation of major long-term symptoms. e
experience-oriented framework also provides a new interpretation of the laboratory erasure procedure known as
post-retrieval extinction, indicating limited clinical applicability and explaining for the rst time why, even with
reversal of the protocol (post-extinction retrieval), reconsolidation and erasure still occur. Also discussed are
signicant ramications for the clinical eld’s “corrective experiences” paradigm, for psychotherapy integration,
and for establishing that specic factors can produce extreme therapeutic eectiveness.
Author information:
Correspondence concerning this article should be addressed to Bruce Ecker: Coherence Psychology Institute, 319 Lafay-
ette St # 253, New York NY 10012 USA. Email: bruce.ecker@coherenceinstitute.org
Cite as: Ecker, B. (2018). Clinical translation of memory reconsolidation research: erapeutic methodology
for transformational change by erasing implicit emotional learnings driving symptom production. Interna-
tional Journal of Neuropsychotherapy, 6(1), 1–92. doi: 10.12744/ijnpt.2018.0001-0092
KEYWORDS: Memory reconsolidation, clinical translation, destabilization, psychotherapy, memory erasure,
behavioral updating, memory interference, emotional schema, transformational change, unlearning, specic
factors, reactivation-extinction, retrieval-extinction, corrective experiences
Submitted: January 19, 2018. Accepted for publication: January 29, 2018 Published online: June 7, 2018
2
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
Contents
1. Introduction ....................................................................... 3
2. Emotional learnings and memories underlying clinical symptoms ......................... 5
3. Verication of memory reconsolidation in psychotherapy ................................ 11
4. How destabilization of a target learning occurs .......................................... 13
5. How erasure of a target learning occurs ................................................ 18
6. From research ndings to clinical methodology ......................................... 24
6.1. e empirically conrmed process of behavioral erasure ............................. 24
6.2. Experiences versus the procedures that induce them ................................ 25
6.3. A proposed universal clinical methodology of memory reconsolidation ................27
7. Clinical observations of the therapeutic reconsolidation process ........................... 32
7.1. Clinical case example: erasure of chronic anger ..................................... 33
7.2. Clinical case example: erasure of complex attachment trauma ........................ 37
7.3. Are the observed transformational changes due to reconsolidation? ................... 50
7.4 Clinical feedback on researchers’ anticipated translation diculties ................... 51
7.4.1. Will mismatch experiences be too exacting for clinicians to create reliably? ........ 51
7.4.2. Do the age and strength of target learnings in therapy cause mismatch diculties? . 53
7.4.3. Will therapeutic changes made via reconsolidation be durable? .................. 54
7.4.4. Is episodic memory resistant to destabilization and updating? ................... 55
7.4.5. Can clinicians navigate complex memory structure? ........................... 58
8. Ramications for fundamental issues in psychotherapy ..................................60
8.1. Reconsolidation claries the “corrective experience” ................................ 60
8.2. Reconsolidation provides a unifying framework of psychotherapy integration .......... 65
8.3. Reconsolidation explains psychotherapy RCT outcome research and refutes
non-specic common factors theory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
9. Other emerging clinical translation methodologies analyzed in relation to reconsolidation
research ........................................................................... 67
9.1. Post-retrieval extinction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
9.2. Episodic memory interference ................................................... 70
9.2.1. Kredlow and Otto, 2015 ................................................... 71
9.2.2. Högberg, Nardo, Hällström and Pagani, 2011 ................................ 72
9.3. Emotional arousal: Lane, Ryan, Nadel and Greenberg, 2015 .......................... 78
10. Conclusion ....................................................................... 80
Acknowledgements ................................................................... 81
References ..................................................................................81
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
3
1. Introduction
A primary dilemma in clinical psychology has been
described by one of that elds leading voices in this
way: “Aer decades of psychotherapy research, we
cannot provide an evidence-based explanation for how
or why even our most well studied interventions pro-
duce change, that is, the mechanism(s) through which
treatments operate” (Kazdin, 2007, p. 1). e present
article proposes that a fundamental breakthrough in
that dilemma may be developing through the trans-
lation of memory reconsolidation neuroscience into
clinical application.
Memory research has identied an innate type of
neuroplasticity in the brain, known as memory recon-
solidation, that can destabilize the neural encoding of
learnings of many types, including emotional learn-
ings. Destabilization in turn allows the target learn-
ing to be nullied either endogenously, by behavioral
counter-learning, or exogenously, by pharmacological
blockade that disrupts the natural molecular and cel-
lular process of restabilization, or reconsolidation, that
normally would occur aer several hours (Duvarci and
Nader, 2004; Pedreira et al., 2002; Pedreira and Mal-
donado, 2003; Walker et al., 2003). us nullied, the
subsequent durable, robust disappearance of all expres-
sions of the target learning has been termed its erasure
by many researchers (e.g., Kindt et al., 2009; for re-
views see, e.g., Agren, 2014; Nader, 2015; Reichelt and
Lee, 2013; Schwabe et al., 2014; for a review of early,
anomalous observations of erasure prior to discovery
of reconsolidation, see Riccio et al., 2006). By putting
the transformational change of memory on empirical
solid ground, research on memory reconsolidation has
paved the way for new common ground between neu-
roscientists and clinicians, who have led ne-grained
anecdotal reports of such transformational change for
decades (e.g., Ecker and Hulley, 1996, 2000a, 2008;
Fosha, 2000; Greenberg et al., 1993; Shapiro, 2001).
Memory reconsolidation is a neurological process
that is experience-driven: behavioral and perceptual
events trigger it into occurring and can govern the
resulting eects on the target learning. e relevance
of reconsolidation research ndings to psychotherapy
is potentially very great because clinical symptoms
are maintained by emotional learnings held in implic-
it memory, outside of conscious, explicit awareness,
in a wide range of cases, including most instances of
insecure attachment, post-traumatic symptomology,
compulsive behavior, addiction, depression, anxiety,
low self-esteem, and perfectionism, among many other
symptoms (e.g., Greenberg 2012; Schore, 2003; Toom-
ey and Ecker, 2007; Van der Kolk, 1994). A versatile,
reconsolidation-based clinical methodology that tar-
gets and reliably nullies the specic emotional learn-
ings maintaining such symptoms would revolutionize
the eld of psychotherapy. Envisioning that new
landscape, neuroscientists Clem and Schiller (2016, p.
340) wrote, “To achieve greatest ecacy, therapies…
should preclude the re-emergence of emotional re-
sponses.” Dening complete elimination of unwanted
emotional responses as the goal of psychotherapy is a
statement that no neuroscientist would have ventured
to make prior to 2000, before the discovery of memory
reconsolidation. It is a goal now recognized as a possi-
bility grounded in empirical research. at goal is the
operational denition of erasure in this article: lasting,
eortless, complete cessation, under all circumstances,
of an unwanted behavior, state of mind, and/or somatic
disturbance that had occurred either continuously or
in response to certain contexts or cues.
Currently, at the end of the second decade of lab-
oratory research into reconsolidation, researchers’
attention is extending to considerations of clinical
translation at a rapidly accelerating pace (e.g., Beckers
and Kindt, 2017; Dunbar and Taylor, 2016; Elsey and
Kindt, 2017a; Krawczyk et al., 2017; Kroes et al., 2015;
Lee et al., 2017; Nader et al., 2014; Treanor et al., 2017).
ose authors have consistently called for a two-way
ow of knowledge between researchers and clinicians
in order to achieve the fullest clinical utilization of
memory reconsolidation. Nader et al. (2014, p. 475)
wrote:
We feel that ongoing discourse between mental
health clinicians and neuroscientists is benecial
both for scientic progress in neuroscience and
mental health treatments. Neuroscientists may
benet from being educated about clinical models
of mental disorders…. e reductionist approach
intrinsic to scientic activity forces neuroscientists
to simplify their models in the pursuit of scientic
questions considered to be of a fundamental nature.
Unavoidably, at times, this approach may ignore
some aspects of mental disorders. A discourse with
clinicians allows neuroscientists to realign their
models to ensure that they represent processes
thought to cause or maintain these disorders.
4
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
Similarly, researchers Elsey and Kindt (2017a)
opined that “Dialogue between researchers and clini-
cians must be maintained” (p. 114) and, in concluding
an extensive review of the prospects for eective clin-
ical application of reconsolidation research ndings,
commented, “there are signicant limitations to exper-
imental research, and ultimately only attempts at treat-
ment can reveal the utility of a reconsolidation-based
approach” (p. 115).
ose comments serve to dene the purpose of
the present article, which is a report from the clinical
trenches of observations made in the course of di-
rectly applying the empirically identied, endogenous
process of memory erasure. is article describes
what appear to be encouraging advances. e author,
a psychotherapist and former research physicist, has
since 2005 maintained close scrutiny of reconsolida-
tion research while also closely observing the eects
in therapy sessions of processes designed to translate
memory reconsolidation research into clinical applica-
tion.
Members of the clinical domain have been en-
thusiastically consuming and working to utilize the
knowledge being generated by laboratory neuroscience
researchers since the 1990s (e.g., Siegel, 1999; van der
Kolk, 1994). ere has been little to indicate a ow of
knowledge in the other direction, however. Undoubt-
edly there is more than one reason for that asymmetry,
which is particularly acute at present as regards recon-
solidation. ere is now a substantial clinical literature
that documents observations ascribed to reconsolida-
tion and that delineates clinical methodologies demon-
strating translation of reconsolidation research (e.g.,
Ecker, 2008, 2010, 2015a,b, 2016; Ecker and Hulley,
2008, 2017; Ecker and Toomey, 2008; Ecker et al.,
2012, 2013a,b; Högberg et al., 2011; Lasser and Green-
wald, 2015; Sibson and Ticic, 2014; Soeter and Kindt,
2015a; Ticic and Kushner, 2015). Rarely, however,
is such literature cited in the writings of laboratory
researchers, who regularly express anticipation of and
need for advances already made by clinicians. Exam-
ples of that are myriad; the two most recent instances
encountered by the author are these: Krawczyk et al.
(2017, p. 16) commented that “outside the laboratory
settings such as in clinical ones, it is unclear how the
reconsolidation process might work.” Elsey and Kindt
(2017a, p. 114) commented that laboratory research
has focused largely on fear learnings and that “experi-
ences of other emotions, such as disgust…or of more
complex feelings such as guilt and shame aer recon-
solidation-based procedures are essentially untapped.
In fact, numerous clinicians’ reports have documented
in a ne-grained manner how a wide range of complex
emotions and emotional learnings have been subjected
to the empirically conrmed reconsolidation process
of behavioral erasure (see citations above in this para-
graph; for online listings of relevant clinical reports,
see http://bit.ly/2tKXdyX and http://bit.ly/15Z00HQ).
Section 7 of this article provides samples of such clini-
cal work and its documentation.
e rigor of the clinical observations reported
here is of a dierent type from that of the quantitative
measurements made in laboratory controlled studies
by neuroscientists. Here the aim is phenomenological
rigor that capitalizes on the unique ability of human
subjects (therapy clients) to direct attention to their
own mental and emotional states and to describe the
moment-to-moment eects as the steps of the destabi-
lization and erasure process are carried out. Neurosci-
entists have barely begun to utilize such articulation of
subjective experience for gaining access to the memory
reconsolidation process, but even their rst forays in
that direction were very fruitful (Sevenster et al., 2013,
2014). e clinical case studies documented in this ar-
ticle are intended to show that examining the raw data
of therapy clients’ real-time phenomenological reports
can signicantly help advance the clinical translation
of memory reconsolidation research (see also Heather-
ington et al., 2012).
e clinical work reported here is intended to
demonstrate the application of reconsolidation re-
search, so an examination of relevant research and its
translational implications precedes the clinical mate-
rial detailed in Section 7. As noted, reconsolidation
has been demonstrated and studied for many dierent
types of memory, but the research covered here is lim-
ited to how the process applies to emotional learning
and emotional memory, as they play by far the princi-
pal role in psychotherapy. (See reviews cited above for
the full range of research.) e cellular and molecular
levels of reconsolidation research are also not covered
here. Clinicians need not attend to the highly complex
neurophysiological and neurochemical substrates of
destabilization and erasure (for a review of which, see
Clem and Schiller, 2016). However, clinicians should
understand that robust functional erasure does not
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
5
necessarily correspond to total loss or ablation of the
entire neural encoding of the erased responses and
learnings, according to recent ndings (Ryan et al.,
2015), and any simplistic image of what happens to
neural circuits when erasure is achieved is almost cer-
tain to be signicantly incorrect.
Lastly, regarding this article’s usage of an emotional
“learning”: A terminology bridge between neurosci-
entists and clinicians is much needed. Memory re-
searchers as a rule refer to a learned item of any type
as a “memory,” not as a “learning”; they refer to the
“target memory” rather than the “target learning.” If
the learned item in question is, for example, implicit
knowledge that would be verbalized as “If I express
myself I’ll be criticized and rejected,” researchers
would refer to that as the “memory” under study. at
usage of “memory,” while perfectly clear to memory re-
searchers, is likely (in the author’s experience) to create
considerable confusion for clinicians, who would tend
to understand “memory” as referring to the person’s
episodic memory and/or declarative memory of the
original childhood events involving rejection, rather
than the semantic memory consisting of a generalized
model and expectation of people being active rejecters.
In order to avoid that confusion for clinician readers
(this article being intended for both memory research-
ers and clinicians), the text here refers to an “emotional
learning.” at syntax is identical to how “understand-
ing” may be used as in “it resulted in the understand-
ing that….
2. Emotional learnings and memories
underlying clinical symptoms
For exploring the clinical application of memory
reconsolidation research, a realistic view of the emo-
tional learnings typically encountered in psychother-
apy is necessary. e characteristics delineated in this
section gure extensively in subsequent sections of this
article.
Understanding symptom production as an eect of
learning and memory is a well established perspective
within clinical psychology and cognitive neurosci-
ence (e.g., Bouton et al, 2001; Eysenck, 1976; Mineka
& Zinbarg, 2006). At the outset of psychotherapy, the
implicit emotional memories and learnings underlying
and maintaining a therapy client’s specic symptom-
(s) are largely or completely outside of awareness, as a
rule. However, in nearly all cases they can be brought
into direct, conscious experience and accurate ver-
bal representation not through analytical insight, but
using experiential methods developed for that purpose
(e.g., Badenoch, 2011; Ecker and Hulley, 1996; Ecker
et al., 2012; Ecker and Toomey, 2008; Greenberg et al.,
1993; Lipton and Fosha, 2011; Shapiro, 2001). ough
initially implicit and nonverbal, the symptom-generat-
ing learnings prove to be well-dened and suciently
retrievable and accessible for further therapeutic pro-
cessing to proceed. ey also prove to be held in two
dierent types of memory: episodic memory of the
personal, subjective experience of particular experi-
ences and events (not to be confused with declarative,
factual memory of the same events) (Tulving, 2002,
2005), and semantic memory of generalized patterns,
rules, mental models, expectations and meanings
(Markus and Wurf, 1987; Reber, 1989). (For a review
of those two memory systems and their linkage, see
Ryan et al., 2008.)
Episodic memories that generate clinical symp-
toms are those that contain unresolved distress of an
intensity that the individual is unable or unwilling to
fully forget, resolve, or contain, and those that contain
reward or pleasure so potent as to generate obsessive
craving and compulsive behavioral repetition. e
most extreme forms of those situations may be, respec-
tively, the post-traumatic condition in which highly
distressing episodic memory intrudes into awareness,
commonly known as ashbacks, and addiction. Oth-
er problematic expressions of episodic memory are
very common. For example, many people carry a
large number of episodic memories of specic mis-
treatments inicted by a sibling, and the cumulative
hurt or anger of this set of memories has strong eects
on mood and behavior during family gatherings and
possibly in non-family situations as well; the individual
might strive unconsciously to get relief from the feeling
of being at the bottom of the pecking order inside the
family by dominating others outside the family, result-
ing in interpersonal problems or job rings.
e mind and brain actively extract generalized pat-
terns, abstractions and meanings from particular ex-
periences, in order to be ready and oriented for novel
situations in which similar features appear. Such gen-
eralized or schematic knowledge constitutes implicit
semantic memory (Dunsmoor et al., 2009; Frith and
Frith, 2012; Seger and Miller, 2010). Operating entire-
6
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
ly outside of awareness, this form of memory generates
a vast range of clinical symptoms. For example, con-
sider the emotional learnings brought into awareness
in therapy by a married, middle-aged man who sought
relief from chronic depression, anxiety, bouts of shame,
and compulsive viewing of pornography. roughout
his childhood, his expressions of distress or needs were
regularly met with his parents’ frightening anger or
cold dismissal, responses that inicted an even more
intense suering than he was initially feeling. at of-
ten-repeated experience set up this cluster of semantic
emotional learnings that had no verbal or conceptual
representation:
the knowledge that his very being is disgusting
and unacceptable (which generates shame; a
young child’s intense feelings of needs and dis-
tress seem to be his very being)
the generalized expectation of receiving the
same responses from anyone, were he to express
any distress or need (which generates his anxi-
ety)
the expectation that his entire lifetime will be
desolately devoid of caring understanding,
warmth, help or comfort from others (which is
both frightening, adding to his anxiety, and also
generates despair felt as his mood of depression)
the urgent necessity of avoiding the expected
responses of anger or indierence by never
expressing or even feeling his own distress or
needs (which requires dissociation of feelings
and avoidance of intimacy, and maintains
perpetual aloneness, which is another source of
despondency felt as depression)
the urgent, ongoing need to blot out and escape
the engulng desolation, despair, aloneness, and
fear (by frequently lling his consciousness with
the intensely pleasurable stimulation of pornog-
raphy and accompanying fantasies)
ose adaptive yet symptom-generating emotion-
al learnings are specic, well-dened and coherent
constructs, yet prior to being retrieved, felt, and verbal-
ized in therapy, they existed only in implicit memory
and operated outside the explicit domain of words,
concepts and conscious awareness. ey are exam-
ples of semantic memory, as distinct from episodic or
autobiographical memory of particular experiences
and events; they are generalized, schematic patterns
abstracted from the concrete instances experienced
by the individual. ey are emotionally compelling
models of reality, and the symptoms they generate are
coherently necessary according to each construct’s
model of reality. e importance of addressing gener-
alized emotional learnings in psychotherapy is widely
recognized (e.g., Beckers and Kindt, 2017; Dunsmoor
et al., 2015; Lane et al., 2015).
e mind’s organization of acquired implicit knowl-
edge into schemas has long been an important feature
of cognitive science and its clinical applications (e.g.,
Eichenbaum, 2004; Foa and Kozak, 1986; Rumelhart
and McClelland, 1986; Toomey and Ecker, 2007; for a
review see Ghosh and Gilboa, 2014). A schema is a co-
herent, composite mental model consisting of linked,
related elements; for example, the ve items-of-learn-
ing listed above are linked components of one schema
in semantic memory. Emotional schemas “carry our
emotional learning and memories and are responsi-
ble for the provision of the majority of our emotional
experience….ese aective / cognitive / motivational
/ behavioral emotion schemes are thus a crucial focus
of therapeutic attention and...are important targets of
therapeutic change” (Greenberg, 2012, pp. 698–699).
Semantic and episodic memory are not completely
dissociated systems, but their linkages are a complex
and subtle matter (reviewed by Ryan et al., 2008). A
frequent observation in clinical practice is that con-
sciously accessing either one does not necessarily also
consciously access the other. Likewise, attending to
an emotional response or behavior generated by either
one does not automatically consciously access the
underlying episodic or semantic material. ere have
been many cases in the authors clinical experience of a
therapy client retrieving an emotionally potent schema
into lucid awareness from semantic memory without
this bringing any corresponding episodic memory of
the experiences in which the schema was learned. In
some of those cases, the client was then able to re-
trieve episodic memory through deliberate internal
searching, but in other cases was not able to do so and
remained mystied by how the retrieved schema had
been learned. ough awareness of episodic memory
is helpful to therapy, and can itself serve as a portal
for accessing semantic memory, absence of episodic
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
7
memory is found clinically not to be an obstacle to un-
learning and nullifying a retrieved emotional schema
through the memory reconsolidation process.
As can be seen in the examples listed above, the
schema is the root cause of any symptom that it gen-
erates, so any symptom based in emotional schemas
ceases to occur as soon as all of that symptoms un-
derlying schemas have been unlearned and erased.
erefore, for any symptom produced by an emo-
tional schema, the schema is the optimal target of
change, rather than the symptom (Ecker and Toomey,
2008). Attempting to prevent or reduce a symptom
with counteractive methods that leave the underlying
memory material intact positions a therapy client to be
prone to relapses (Ecker et al., 2012).
ere is a class of symptoms that serve the function
of suppressing all awareness of distressing episod-
ic memory or distressing knowledge that conscious
episodic memory would create. Examples of episod-
ic-memory-suppressing symptoms are disconnection
from aect, compulsive eating, continual self-dis-
traction via compulsive focus on work, video games,
pornography or any other form of intense excitement
such as gambling, and avoidant behaviors that prevent
encounters with specic reminders of episodic mem-
ory. Such symptoms of episodic memory avoidance
are not produced directly by the episodic memory that
is being avoided. ey are produced, rather, by the
implicit (non-conscious) expectation that experiencing
the avoided episodic memory would be unsurvivably
overwhelming, damagingly devastating, or cause in-
sanity. at expectation and the rule of avoidance that
it necessitates are semantic memory formations. us,
this episodic-memory-avoiding class of symptoms is
produced by semantic memory, and the optimal target
of change is the expectation of devastation.
Clinical experience reveals yet another subtlety of
the interplay of episodic and semantic memory: In
any subjective experience recalled in episodic memory,
the particular emotional qualities and felt meanings
of the experience are produced on the basis of the
semantic knowledge that was already operating at
the time (mental models, attributed meanings, rules,
roles, expected patterns and sequences, etc.). Forma-
tion of semantic knowledge through implicit learning
has been detected at quite early developmental stag-
es (e.g., DeCasper and Carstens, 1981; Olineck and
Poulin-Dubois, 2005; Repacholi and Gopnik, 1997),
and its involvement in episodic memory has been
noted by Tulving (2002, p. 5): “It [episodic memory]
makes possible mental time travel through subjective
time, from the present to the past, thus allowing one
to re-experience, through autonoetic awareness, one’s
own previous experiences. Its operations require, but
go beyond, the semantic memory system.
An illustration of how semantic knowledge gener-
ates the emotional quality of a given experience, both
in its original occurrence and in episodic memory
recall, is provided by one of the authors clinical cases
(Ecker et al., 2012, pp. 86–91). e client is a woman
in her 30s who, during a therapy session, unexpect-
edly began experiencing, for the rst time, intrusive
episodic memory of a traumatic experience at age 8,
when she was in the rear seat of the family car as her
drunk father drove her, her mother and sister on a
careening, lurching trajectory at high speed toward a
bridge visible in the distance. By the very nature of
the ashback, she was not merely remembering the
incident; rather, she was re-inhabiting the scene and
the experience, and describing it from the vantage
point of being there in the car as the living memory
re-played itself in the present. She felt the car graze the
railing at the side of the road and knew she was going
to die. Feeling helpless in hurtling toward her death,
her body was frozen and sti in panic. Yet her trauma-
tizing feelings of helpless vulnerability and panic were
not actually caused by the external physical situation.
Rather, they were caused by her particular semantic
knowledge. e plausibility of that assertion becomes
apparent through the thought experiment of imagin-
ing a dierent 8-year-old in her place in that car: a boy
who had recently moved in next door with his family,
who needed a ride, who had spent most of his eight
years out on the streets among violent youth, and who
had remained alive by being as assertive and aggressive
as necessary for doing so. is boy’s semantic knowl-
edge of the rules dictating his possible responses is
quite dierent. As soon as he sees the degree of danger
developing in the car, he lunges forward, grabs the
driver’s hair with one hand and throat with the other
and screams in his ear, “If you want another breath,
motherf****r, you hit those brakes and pull over right
now!” e driver does exactly that in seconds, and the
boy gets out. He knew he would take command of the
situation, never felt helpless, and therefore experienced
the incident not as a trauma, but as only another mo-
mentary set of choppy waves in a much bigger choppy
8
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
ocean of life.
e therapist guided the woman through an imagi-
nal empowered re-enactment experience of screaming
at her father, commanding him to stop the car. When
he did not do so immediately, she opened the car door
anyway, and then he applied the brakes and pulled
over, and she exited from the car to safety, calling to
other drivers for help and police assistance. at ima-
ginal experience felt vividly and almost physically real
to her. Such assertive behavior not only violated her
semantic rules, but also disconrmed what had seemed
to be their inviolability and absoluteness. ereaer,
the episodic memory no longer contained helplessness,
and the somatic frozen state, which was a frequent and,
until this session, a mystifying symptom in various
social situations in her adult present, ceased to occur.
She retained declarative (factual, cognitive) memory of
having suered terror in that car incident, but recalling
the incident no longer re-aroused that feeling of terror
as part of the episodic memory. (See Kindt et al., 2009,
and Soeter and Kindt, 2012, for laboratory studies that
demonstrated such retention of declarative memory
aer erasure of fear.) e semantic and emotional
components of an episodic memory prove to be mu-
table independently of the perceptual components of
the memory.
Clinical observations such as that one seem to
indicate a phenomenology that operates in this man-
ner: When an episodic memory is retrieved, addressed
in therapy and successfully updated, transforming
the emotion inherent in the memory, what has been
updated is the semantic knowledge that was operating
at the time of the original experience and has been
an implicit component of the episodic memory. at
update fundamentally and retroactively changes the
encoded personal meaning of the experience, which in
turn changes the emotion generated by the incident as
it now exists in episodic memory. Declarative, factual
memory of the concrete happenings of course remains
unchanged; it is the (semantic) personal signicance
and expected contingencies of those happenings that
have been transformed. A common clinical instance
involves erasure of what is referred to in Coherence
erapy as parents’ terms of attachment (Ecker et al.,
2012, pp. 102–114), consisting of rules that dene how
connection, acceptance, and punishment work, and
that are installed in the child’s implicit semantic knowl-
edge, such as the rule that “I must obey my parents
rules requiring my compliance and non-assertiveness.
Nullication of that rule in a replay of a distress-lad-
en episodic memory can transform an experience of
helplessness, defenselessness and passive victimization
into one of agentive self-assertion and self-protection.
at shi in turn transforms the emotional quality of
the memory from traumatizing endangerment and
terror into a far reduced degree of dysphoric feelings
and meanings, such as troubled recognition of parents’
self-absorption and incapacity to give emotional un-
derstanding. Such lesser distresses are directly amena-
ble to therapeutic processing, such as by the emergence
of feelings of anger and/or grief that have until now
been blocked.
us, semantic memory appears to be always the
critical target of the updating and erasure process, even
when the working target memory is an experience in
episodic memory. e episodic memory serves as a
portal to the semantic knowledge governing the emo-
tional quality of the experience. (e same principle
is central to Coherence erapy and is formulated as,
“How a person experiences and responds to a situation
is caused not by circumstances, but by viewing circum-
stances through the lens of unconscious personal con-
structs…”(Ecker and Hulley, 2017a, p. 1)). e same
phenomenology is illustrated in clinical case examples
in Sections 7.1 and 7.5.4.
Schemas in semantic memory, being derived from
particular experiences, have linkages to episodic mem-
ory (Ryan et al., 2008), as well as to schema-driven
emotional states and implicit procedural knowledge
of adaptive (if consciously unwanted) responses. Any
or all of those components of memory may have to be
navigated in the unavoidably complex course of ther-
apy with a particular client, and any of those compo-
nents may serve as a portal or pathway for accessing
the others, though the linkages may be faint or bar-
ricaded and require inner work to utilize. e full
constellation of linked components has been delineat-
ed by Ecker and Hulley (1996, 2017) and by Ecker et
al. (2012, pp. 53–54), who dene this orienting map for
clinicians:
[Episodic memory] Perceptual, emotional, and
somatic memory of original experiences:
is is the “raw data”; matching features in cur-
rent situations are triggers of activation of either
episodic or semantic memory and the internal
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
9
and/or behavioral responses they generate.
[Semantic memory] A mental model or set of
linked, learned constructs operating as living
knowledge of a problem and a solution:
e problem: knowledge of a vulnerability to
a specic suering
is is an ontological model of how the
world works in some area (self, others and/
or the nature of the world itself), and cur-
rent situations that appear relevant to this
model are triggers of the whole schema.
e solution: knowledge of an urgent strategy
and specic tactics (internal and/or behavior-
al) for avoiding that suering; or
Knowledge of lacking any solution to the
problem
is drives emotional states of helpless fear/
anxiety and/or helpless despair/depression,
plus behavioral expressions of those emo-
tional states (such as insomnia, inaction or
substance abuse)
us there are several pathways of access by which
a therapy client can arrive at direct, aective awareness
and verbalization of the schema(s) and/or memories
generating a given symptom. Each pathway may be
characterized by its starting point:
e client’s behavior in the problematic state or
situation
e client’s mood, emotion or emotional reactivi-
ty in the problematic state or situation
Somatic disturbances in the problematic state or
situation
An image that arises in considering the prob-
lematic state or situation
Identication of feature(s) common to all in-
stances in which the symptom has occurred
Episodic memory of formative events and ex-
periences earlier in life, whether coherent or
fragmentary
e contents of a dream, particularly if the
dream is recurring or if the dream occurred on
the night before or aer a therapy session
Ecker and Hulley (2017a, p. 8), emphasizing that a
clinician’s awareness of all avenues for retrieval of sche-
mas is important for optimally ecient and eective
therapy, state:
e discovery work could, for a particular client,
most readily open up through focusing on an image
that has arisen, or on a kinesthetic sensation, for
example, rather than through an initial focus on an
emotion or mood. en, as discovery and accessing
proceed, all other components of the full…schema
come into being experienced and processed, in-
cluding the aective dimension. In short, to regard
aect as the necessary point of access to the deeper
material greatly limits the many ways and many op-
portunities through which the therapist can usher
the client into the material. e core material, too,
may or may not be experienced as predominantly
emotional. It is experienced by some clients more
intensely as a felt meaning than as emotion.
e above multi-component view of memory in re-
lation to symptom production and psychotherapy has
been reiterated by Lane et al. (2015), though with some
notable dierences, among them the present articles
emphasis on semantic memory as being the prima-
ry target for updating and erasure through memory
reconsolidation. Section 9.3 provides a more extended
discussion of those authors’ approach to reconsolida-
tion-oriented psychotherapy.
Psychotherapists observe in daily practice the
tenacious, long-term persistence and retriggering of
implicit emotional learnings formed decades earlier.
at durability has also been well established by re-
searchers, who went so far as to characterize emotional
learnings as “indelible” (LeDoux et al., 1989) prior to
the discovery of memory reconsolidation. Pine et al.
(2014, p. 1) observed that “A unique feature of prefer-
ences [acquired, emotionally compelling avoidances
and attractions] is that they remain relatively stable
over one’s lifetime. is resilience has also been ob-
served experimentally, where . . . acquired preferences
appear to be resistant to extinction training proto-
cols.” Selection pressures in the course of evolution
favored the unfading retention of emotional learnings:
any learning accompanied by strong emotion is made
exceptionally durable, due in large part to the eects of
emotion-related hormones on the memory encoding
10
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
process (McGaugh, 1989; McGaugh and Roozendaal,
2002; Roozendaal et al., 2009).
While implicit emotional learnings are resistant
to extinction procedures, they are susceptible to the
memory reconsolidation process, as many researchers
have demonstrated (e.g., Pine et al., 2014; Reichelt and
Lee, 2013; Schiller et al., 2010). It is a consistent clin-
ical observation, described in detail in Section 7, that
as soon as a particular emotional learning is veriably
unlearned, nullied and erased through the process
identied in memory reconsolidation research, the
symptoms it has been maintaining cease to occur (Eck-
er, 2015a; Ecker and Toomey, 2008; Ecker et al., 2012,
2013a). at observation lends support to the view
that discrete modules or schemas of emotional learn-
ing are the root cause of the symptoms they maintain.
Viewing symptom production as internally driven
by schemas and memories is not to deny or neglect
the role of systemic and social processes in maintain-
ing symptoms. Rather, the individual’s implicit emo-
tional learnings are formed in response to the entire
experiential ecology in which she or he is immersed,
including all received systemic and social meanings,
messages, contexts and contingencies, and are the very
means of their inuence (Bateson, 1979; Hermans and
Dimaggio, 2007; Siegel, 2015). Systemic and social as-
pects are oen of primary importance in the emotional
learnings accessed in therapy.1
Another relevant clinical observation is the unique-
ness of the underlying emotional learnings brought
into awareness by dierent therapy clients who have
presented the same type of symptom, such as panic
attacks or dysthymic depression. For example, one
womans full-strength, physiological panic attacks
were found to arise from her expectation of absolute
rejection by her father were she to fail to be “head and
shoulders above” (superior to) all others at all times
(Ecker, 2015a: NPT article); whereas another woman’s
physiologically similar panic attacks were driven by
the urgent necessity of fullling the weekly quota of
suering that the universe requires of each family, a
quota which the universe is ready to fulll at any time
by inicting catastrophe, if it is not already fullled
1 Of course, there are many symptoms that are not caused
by emotional learning and therefore cannot be dispelled by mem-
ory reconsolidation, including physiologically based conditions
such as hypothyroidism-induced depression, neurologically based
conditions such as dyslexia and autism, and emotional styles
based in genetically determined temperament.
adequately in the ordinary course of things (Ecker and
Hulley, 2000a). One middle-aged woman’s depression
was actually her mood-state of despair and hopeless-
ness following her “illegitimate” pregnancy which, at
the age of 18 in a conservative small town, had plunged
her into certainty of lifelong stigma, rejection and
ruin, an expectation that had never been updated by
the subsequent, actual course of events later in her life
(Ecker, 2015a); whereas another woman’s depression
arose from feeling devoid of interests and motivation
and expecting her entire future life to feel the same,
without awareness that this state of blankness was a
deliberate, self-protective tactic that she had resorted
to in desperation as a child, in order to prevent her
severely self-absorbed mother from continuing to take
over, take away and take credit for everything and
anything the daughter ever did or enjoyed (Ecker and
Hulley, 2002).
As can be seen in the foregoing examples of implicit
emotional learnings that maintain symptoms, they are
adaptive in that they consist of living knowledge of a
particular suering plus either how to avoid it or the
dire dilemma of having no way to avoid it. (For a more
detailed mapping of the content and structure of symp-
tom-generating emotional schemas, see Ecker et al.,
2012, pp. 53–55; Ecker and Hulley, 2017a.) ey are
also coherent, in the sense that they consist of a sensi-
ble, well-knit account of how suering and safety oper-
ate, a mental model that is faithfully based on what was
personally and subjectively experienced earlier in life
(Ecker and Toomey, 2008; Toomey and Ecker, 2007).
e recognition that implicit emotional learnings
are inherently adaptive, coherent, and neurologically
built to persist for a lifetime amounts to a non-pathol-
ogizing view of symptom production that contradicts
the widespread characterization of “pathogenic,” “mal-
adaptive” beliefs driving symptom production. e
emotional learning and memory systems of each of the
ve therapy clients described above certainly were gen-
erating unwelcome behaviors and states of mind and
body, yet were functioning properly in doing so, not
malfunctioning or dysfunctioning, similar to how the
unwelcome swelling, painful tenderness and redness
around a recent wound express the proper function-
ing of healing and immunity systems. In that sense,
many conditions oen termed “disorders of emotional
memory” are not actually disorders at all. To describe
a therapy client’s core beliefs or schemas as incorrect,
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
11
maladaptive or pathogenic is actually to accuse the
process of natural selection of having those attributes,
because a person’s persisting beliefs and schemas exist
due to the proper functioning, not the malfunctioning,
of the emotional brain.
e task of psychotherapy, in this view, is to facili-
tate the thorough unlearning, via memory reconsolida-
tion, of the compelling expectations, meanings, mod-
els, roles, rules and tactics that were learned earlier in
life, and are now maintaining unwanted eects, and
can now be updated and replaced by more eectively
adaptive constructs. at is an unlearning of semantic
memory, an unlearning of how events and experiences
were construed and have continued to be construed
by the implicit knowledge system (Ecker and Toomey,
2008; Ecker et al., 2012). In the subjective experience
of such unlearning, some aspect of the world that has
felt compellingly real and inescapably life-constraining
is recognized as a mirage that has no reality at all. at
nullication, which is clearly apparent in the clinical
case examples in Section 7, leaves intact ones episodic,
autobiographical memory of events and experiences in
one’s life. (For a laboratory demonstration that event
memory is unaected by erasure of emotional learn-
ing, see Kindt et al., 2009.)
If, as noted above, emotional learnings are the root
cause of the symptoms they drive, then their observed
heterogeneity for the same symptom implies that psy-
chotherapeutic treatment, if it is to dispel the symptom
at its roots, must be uniquely tailored to each client. As
described in Sections 4 and 5, memory reconsolidation
research has come to the same conclusion, namely
that the specic, unique features of a target emotional
learning dictate the design of the experiences needed
to induce the destabilizing, unlearning, and nullify-
ing of it. Section 6 shows that research has identied
a well-dened, endogenous process that is readily
tunable to the unique contours of the target learnings
discovered in each clinical case.
3. Verication of memory reconsolidation in
psychotherapy
Laboratory researchers conduct a variety of direct
neurological tests on animal subjects to ascertain with
certainty whether or not reconsolidation has occurred.
e denitive tests are either toxic or require eutha-
nizing, ruling out use with human subjects. Conse-
quently, “As we do not have any incontrovertible neural
measure of whether reconsolidation has taken place in
humans, we can only indirectly infer its presence….
(Elsey and Kindt, 2017a, p. 114). is situation begs
the question: Are the indirect markers of reconsolida-
tion suciently clear and substantial to verify reliably
its successful induction in psychotherapy? erapists
having reliable markers for verifying their use of re-
consolidation is obviously a necessity.
e verication markers that reconsolidation re-
searchers themselves use in human studies are presum-
ably the best choice. For verifying reconsolidation in
human studies, researchers rely upon the behavioral
markers of erasure observed in animal studies where
the decisive tests were conducted, conrming that
reconsolidation had occurred. e prototype of that
is the landmark human study by Schiller et al. (2010),
the rst in which a fear memory was erased. Schiller et
al. concluded that reconsolidation had occurred by ob-
serving the same behavioral markers of erasure as were
observed in rats by Monls et al. (2009), who used
largely the same procedure and also conrmed recon-
solidation decisively. e logic of regarding erasure as
conrmation of reconsolidation also takes into account
the fact that reconsolidation is the brain’s only known
neuroplastic process that can produce those markers.
ere are three well-dened behavioral markers of
erasure:
1. Non-reactivation: An acquired physiological
and/or aective response that formerly occurred
immediately upon perceiving a certain cue or
context no longer occurs. (For example, the rate
of a mouse’s heartbeat no longer increases upon
seeing the red light that formerly became associ-
ated with soon receiving a foot shock.)
2. Non-expression: e overtly manifested behav-
ioral expression of that physiological and/or
aective response no longer occurs. (e mouse
no longer freezes in response to the red light.)
3. Eortless permanence: e above two changes
persist without relapse under all conditions and
without any further training or special condi-
tions implemented to maintain them.
Erasure in the clinical context, as noted in Section 1,
12
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
means lasting, eortless, complete cessation under all
circumstances of an unwanted behavior and/or state of
mind and/or somatic disturbance that had been a per-
sistent occurrence, particularly in certain contexts or
in response to certain cues. In other words, the emo-
tional learning in question can no longer be reactivated
into being felt aectively or somatically, or into being
expressed behaviorally or physiologically. e therapy
client’s experience and behavior are now enduringly as
though the target learning no longer exists (though, as
noted in Section 1, there is evidence that portions of
the target learning’s engram or physical encoding may
still exist (Ryan et al., 2015), as reviewed by Clem and
Schiller (2016)).
e denition of erasure in the previous paragraph
is specically what the phrase transformational change
denotes in this article. In terms of achieving relief
from suering, such transformational change, resulting
from erasure, is the most eective therapeutic out-
come.
Erasure is technically not the only behavioral mark-
er of reconsolidation. A statistically signicant, per-
manent change of any kind in an acquired response or
memory is also a reconsolidation marker that has been
used in some studies, for example those of Hupbach et
al. (2007, 2009) and Forcato et al. (2010), in which the
destabilized target learning incorporated new learning
that either modied or partially interfered with expres-
sion of, but did not fully erase, responses driven by the
original learning. e carefully controlled conditions,
quantitative measurements and statistical power of
laboratory studies render such partial interference
eects conclusive, but in the uncontrolled complexity
of clinical work, partial diminishment of symptoms in
individual cases would not be a decisive verication
that reconsolidation had occurred. Erasure is total 100
percent interference. Its markers, dened above, are
unambiguous in individual therapy cases and therefore
easy to conrm, as the author has personally observed
in many hundreds of cases. Erasure also rules out all
mechanisms of change other than reconsolidation, ac-
cording to present scientic knowledge, which partial
symptom relief does not do. For those reasons, erasure
is the only reliable form of verication of reconsolida-
tion in therapy. Achieving transformational change in
therapy is unmistakable and, of course, is a therapeutic
breakthrough that makes both clients and therapists
very happy.
However, the emotional learnings addressed in
psychotherapy are in most cases considerably more
complex than the elementary emotional learnings
created in laboratories for controlled study of destabi-
lization and erasure. Do the above markers of erasure
verify reconsolidation in psychotherapy as reliably as
in laboratory studies? In other words, when the mark-
ers of erasure dened above are observed to appear in
immediate response to some steps of psychotherapeu-
tic treatment, is it valid to infer that the therapeutic
process has successfully induced memory reconsoli-
dation and erasure? Would it be scientically valid for
therapists to use the markers of erasure as a reliable
means of conrming recruitment of the memory re-
consolidation process in therapy sessions? If so, close
study of such sessions could help reveal and dene
therapist actions that are eective for facilitating the
destabilization and unlearning that nullify and erase
clients’ emotional learnings.
Given the dierence between laboratory and clinical
contexts as regards the complexity of target learnings,
it seems prudent to allow for the possibility that the
markers of erasure observed in therapy might conceiv-
ably be the result of some process other than memory
reconsolidation. Beyond such a priori conservative
prudence, however, there is nothing in the existing
body of memory research that is recognized as indi-
cating either that some other mechanism of erasure is
involved or that acquired emotional schemas of clinical
relevance are not susceptible to destabilization and
nullication. Rather, one is faced with the fact that
reconsolidation has been found to occur for all of the
many types of memory that have been tested. Noting
that fact, Schiller and Phelps (2011, p. 6) summarized,
“ese ndings suggest that reconsolidation is a gen-
eral property of memory and is common to dierent
memory systems.” It therefore seems not imprudent
to apply the same logic to therapy sessions as to lab-
oratory studies, while still respecting the possibility
that some qualitatively dierent mechanism of erasure
could eventually be discovered. us it appears valid
to proceed according to the working hypothesis that
the markers of erasure observed in therapy signal the
preceding occurrence of memory destabilization and
nullication.
e ecological validity and internal consistency of
that approach are supported by clinical observations
made prior to the discovery of memory reconsolida-
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
13
tion. In a systematic search for the therapeutic specic
factors directly responsible for sudden, lasting, trans-
formational changes occasionally observed in their
therapy sessions, Ecker and Hulley (1996) selected and
closely examined sessions that unambiguously pro-
duced the same three markers (cessation of triggerabil-
ity of a specic, aective, problematic emotional sche-
ma and ego-state, cessation of long-term symptoms
of behavior, cognition, mood and somatics produced
during activation of that schema and ego-state, and
eortless persistence of those changes). eir scrutiny
and reverse engineering of therapeutic process were
encouraged by the local clinical scientist paradigm
(Stricker, 2006; Stricker and Trierweiler, 1995), and
were likewise recently employed by clinical researchers
who proceeded “by pinpointing precisely where in the
therapeutic discourse the clients self-narrative shis
and then working backward” (Friedlander et al., 2016).
Ecker and Hulley in that way identied a specic
sequence of experiences that was always present as
the immediate precursor of the markers’ appearance.
e focused, deliberate facilitation of that sequence
was then pursued with a wide range of clients and
symptoms, resulting in observations of transforma-
tional change (the three markers) with unprecedented
frequency in day-to-day clinical practice, for a major
increase of therapeutic eectiveness.
e same critical sequence of experiences as iden-
tied by Ecker and Hulley (1996) was subsequently
identied in memory reconsolidation research as the
experiences required by the brain for destabilizing a
target emotional learnings neural encoding (Pedrei-
ra et al., 2004, plus numerous conrming studies, as
discussed in Section 4) and then behaviorally updating
the destabilized target learning with nullifying count-
er-learning (rst demonstrated by Monls et al. (2009)
and Schiller et al. (2010), as discussed in Section 5).
at conrmation of the clinically identied sequence
of experiences by rigorous empirical studies using rad-
ically dierent methodology indicates the robustness
with which the markers of erasure serve to reveal in
psychotherapy that the sequence of experiences nec-
essary to induce destabilization and behavioral nulli-
cation has occurred. Ecker and Hulley (1996, 2017)
developed a system of psychotherapy designed for
maximally ecient facilitation of the critical sequence
(initially named Depth-Oriented Brief erapy, later
renamed Coherence erapy).
e hypothesis that reconsolidation has been in-
duced in therapy sessions that produce the three mark-
ers of erasure, advanced by Ecker (2006, 2015b) and
Ecker et al. (2012, pp. 126–130), has received support
from ne-grained examination of nine clinical cases
yielding transformational change, each from a dier-
ent psychotherapy system (for a listing of which, with
citations, see http://bit.ly/15Z00HQ). All nine cases
were found to contain the same sequence of experi-
ences identied in reconsolidation research as being
necessary for inducing destabilization and erasure, em-
bedded but unambiguously recognizable in the thera-
peutic process, where they were immediate precursors
of transformational change, that is, the appearance of
the markers of erasure. e hypothesis that recon-
solidation is a deep structure universally responsible
for transformational change of acquired states and
responses, advanced by Ecker (2011) and Ecker et al.
(2013b), has signicant implications for psychotherapy
integration, which is discussed further in Section 8.2.
Elsey and Kindt (2017a), in discussing therapeutic
use of the pharmacological blockade, have suggest-
ed verication of reconsolidation via observations of
eects that result only from pharmacological blockade
of a Pavlovian-type target learning, that is, cue-in-
duced expectation of suering or pleasure. With one
exception, their verication criteria are not relevant to
the behavioral updating and erasure process that is the
principal focus of this article. e exception is “mem-
ory specicity (the manipulation should not indiscrim-
inately aect memory, but only the reactivated memo-
ry trace)” (p. 114). at criterion could be fullled by
a wide range of processes other than reconsolidation,
unlike the markers of erasure, which are unique to
reconsolidation and appear to be its most reliable
verication until such time as neuroscientists devise a
method of direct detection of engram nullication that
is safe and practical.
4. How destabilization of memory occurs
e destabilization of a target learning’s neural
encoding opens the so-called reconsolidation window,
a period of several hours of lability that allows memory
content and/or strength to be altered fundamentally,
and that ends naturally with an automatic restabiliza-
tion (reconsolidation). e experiences that induce
destabilization were rst identied by Pedreira et al.
14
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
(2004), who used animal subjects and created a condi-
tioned fear learning in a standard manner, by pairing
an aversive unconditioned stimulus (US, in this study
the visual image of a predator) with a conditioned
stimulus (CS, in this study a unique context, i.e., a
particular chamber). To reveal whether destabilization
of that target emotional learning had occurred under
various conditions, they used the pharmacological
blockade technique: only if the target learning has been
destabilized does the administered chemical agent
erase the conditioned fear behavior in response to CS
presentation. (A newly destabilized target learning
continues to function as before, is not degraded by
being destabilized, and gives no indication of being
destabilized, hence the need for an additional process
that reveals destabilization decisively.)
Previous researchers had concluded that destabi-
lization results from memory reactivation and that a
memory destabilizes every time it is reactivated (e.g.,
Nader et al., 2000; Eisenberg et al., 2003). Pedreira
et al. (2004) found rather that destabilization did not
occur aer the target learning had been reactivated by
the CS (exposure to the context), but did occur aer
reactivation was followed by an experience of “memo-
ry mismatch” in which the subject’s perceptions of the
present situation diered from what the reactivated
learning expected (in this case, non-appearance of the
expected US aer being placed in the CS context).
e conclusion reached by Pedreira et al. (2004) was
that destabilization requires a sequence of two experi-
ences, memory reactivation plus memory mismatch.
is nding subsequently has received independent
conrmation by at least twenty-ve studies, listed in
Table 1. Many other studies have also reported cor-
roborative results, such as that of Piñeyro et al. (2014),
whose study focused particularly on determining the
role of memory destabilization and who arrived at
the view that “equating mere reactivation to memory
destabilization could lead to erroneous conclusions” (p.
52).
e critical memory mismatch experience is also
referred to as a prediction error experience in many of
these studies. e two phrases are synonymous. e
critical role of mismatch/prediction error for trigger-
ing destabilization has been recognized in numerous
research review articles. For example, Delorenzi et al.
(2014) observed, “strong evidence supports the view
that reconsolidation depends on detecting mismatches
between actual and expected experiences” (p. 309).
Agren (2014), in reviewing research on reconsolidation
of emotional learnings in humans, commented, “it
would appear that prediction error is vital for a reac-
tivation of memory to trigger a reconsolidation pro-
cess” (p. 73) and “the studies that have shown eects
of reconsolidation… must somehow have induced a
prediction error” (p. 80).
Table 1. Studies demonstrating that memory destabilization requires a memory mismatch or prediction error
experience in addition to memory reactivation.
Year, Authors Species, Memory Type Design and Findings
2004, Pedreira et al. Crab: Contextual fear
memory
Learned fear response can be erased by chemical blockade (bicucul-
line and cycloheximide) only aer memory reactivation is accompa-
nied by memory mismatch experience (prediction error).
2005, Frenkel et al. Crab: Contextual fear
memory
New experience modies memory expression only if preceded by a
memory mismatch experience.
2005, Galluccio Human: Operant condi-
tioning
Reactivated memory is erased by new learning only if a novel con-
tingency is also experienced.
2005, Rodriguez-
Ortiz et al.
Rat: Taste recognition
memory
Novel taste following reactivation allows memory disruption by
anisomycin.
2006, Morris et al. Rat: Spatial memory of
escape from danger
Reactivation allows disruption of original memory by anisomycin
only if learned safe position has been changed, creating mismatch of
expectation.
2006, Rossato et al. Rat: Spatial memory of
escape from danger
Reactivation allows disruption of original memory by anisomycin
only if learned safe position has been changed, creating mismatch of
expectation.
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
15
2007, Forcato et al. Human: Declarative
memory
Memory of syllable pairings learned visually is destabilized and
impaired by new learning only if, aer reactivation by presentation
of context, presentation of a syllable to be paired does not occur as
expected, creating mismatch.
2007, Rossato et al. Rat: Object recognition
memory
Memory is disrupted by anisomycin only if reactivated in presence
of novel object.
2008, Rodriguez-
Ortiz et al.
Rat: Spatial memory of
escape from danger
Reactivation allows disruption of original memory by anisomycin
only if learned safe position has been changed, creating mismatch of
expectation.
2009, Forcato et al. Human: Declarative
memory
Memory of syllable pairings learned visually is destabilized and lost
only if, aer reactivation, the expected opportunity to match sylla-
bles does not occur, creating mismatch.
2009, Perez-Cuesta &
Maldonado
Crab: Contextual fear
memory
Reactivated learned expectation of visual threat must be sharply
disconrmed for memory to be erased by cycloheximide.
2009, Winters et al. Rat: Object recognition
memory
Memory is erased by MK-801 only if reactivated in presence of
novel contextual features.
2010, Forcato et al. Human: Declarative
memory
Memory of syllable pairings learned visually destabilizes and in-
corporates new information only if, aer reactivation, the expected
opportunity to match syllables does not occur, creating mismatch.
2011, Coccoz et al. Human: Declarative
memory
Memory of syllable pairings learned visually destabilizes, allowing
a mild stressor to strengthen memory, only if, aer reactivation, the
expected opportunity to match syllables does not occur, creating
mismatch.
2012, Caaro et al. Crab: Contextual fear
memory
New experience modies memory expression only if preceded by a
memory mismatch experience.
2012, Sevenster et al. Human: Associative fear
memory (classical condi-
tioning)
Reactivated fear memory is erased by propranolol only if prediction
error is also experienced.
2013, Balderas et al. Rat: Object recognition
memory
Only if memory updating is required does reactivation trigger
memory destabilization and reconsolidation, allowing memory
disruption by anisomycin.
2013, Barreiro et al. Crab: Contextual fear
memory
Only if memory reactivation is followed by unexpected, mismatch-
ing experience is the memory eliminated by glutamate antagonist.
2013, Díaz-Mataix
et al.
Rat: Associative fear
memory (classical condi-
tioning)
Reactivated fear memory is erased by anisomycin only if prediction
error is also experienced.
2013, Reichelt et al. Rat: Goal-tracking mem-
ory
Target memory reactivated with prediction error was destabilized
and then disrupted by MK-801, but not if brain’s prediction error
signal was blocked.
2013, Sevenster et al. Human: Associative fear
memory (classical condi-
tioning)
Reactivated fear memory is erased by propranolol only if predic-
tion-error-driven relearning is also experienced.
2014, Exton-McGuin-
ness et al.
Rat: Instrumental memory
(operant conditioning)
Memory for lever pressing for sucrose pellet was disrupted and
erased by MK-801 only if the reinforcement schedule during reacti-
vation was changed from xed to variable ratio, creating prediction
er ror.
2014, Sevenster et al. Human: Associative fear
memory (classical condi-
tioning)
Reactivated fear memory is disrupted and erased by propranolol
only if prediction-error-driven relearning is also experienced.
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
Exton-McGuinness et al. (2015) reviewed the role of
prediction errors in reconsolidation studies and sum-
marized their position by stating, “We propose that a
prediction error signal…is necessary for destabilisation
and subsequent reconsolidation of a memory” (p. 375).
Krawczyk et al. (2017), reviewing the functional role
of prediction error in the neurobiology of learning and
memory, stated, “Prediction error induces updating of
consolidated memories in strength or content by mem-
ory reconsolidation” (p. 13) and “When our predic-
tions or understandings of the world do not t with the
current experience, the detection of this incongruence
triggers the destabilization-reconsolidation process,
which allows us to adjust our internal models.” (p. 15).
e experience-driven nature of memory recon-
solidation is strongly apparent in the mismatch re-
quirement. An experience of mismatch, or prediction
error, inherently involves the perceived presence of a
novelty or discrepancy relative to expectancy in a pre-
viously learned milieu, creating a subjective element
of surprise (see, for example, Fernández et al., 2016c;
Lee, 2009; Sevenster et al. 2014). What matters to the
subject’s brain is not the concrete procedure used by
experimenters to set up mismatch in a particular study,
but rather the subjective experience created by the
procedure, an experience in which the world is in some
way not as believed and expected. Behavioral proto-
cols for creating mismatch vary greatly across studies.
For example, Pedreira et al. (2004) used a procedure in
which mismatch consisted of non-reinforcement that
followed reactivation by a variable time delay, making
it clear that the two are distinct experiences, where-
as Rossato et al. (2007) used the presence of a novel
object to create a mismatch that was copresent with
reactivation.
Neuroscientists regard reconsolidation as being the
brain’s innate process for updating memories because
it launches only if an experience of discrepancy and
surprise accompanies reactivation of an existing learn-
ing or schema. Various studies have contributed to a
growing understanding of the boundary conditions of
memory destabilization, i.e., the types and degrees of
mismatch that do or do not trigger memory destabili-
zation for memories of various types, ages, or strengths
(e.g., Gallucio, 2005; Suzuki et al, 2004; Sevenster et al.,
2013, 2014; Schroyens et al., 2017). Importantly for
both research and clinical application, reliable design
of mismatch experiences depends heavily upon knowl-
edge of the detailed content and structure of the target
learning, because that content and structure determine
which experiences register as mismatch/prediction
error and with what strength. at fundamental
principle has been revealed by several studies in which
target learnings containing knowledge of various re-
inforcement schedules or timing patterns were tested
for destabilization by candidate mismatch experiences
of various designs (e.g., Alfei et al., 2015; Jarome et al.,
2012; López et al., 2016; Merlo et al., 2014; Sevenster
et al., 2013, 2014; Schroyens et al., 2017). e same
studies have also shown that if an intended mismatch
experience diers too greatly from the target learning’s
expectations, it does not induce destabilization, pre-
sumably because a too-dierent experience registers
not as a mismatch, but as being in a qualitatively dier-
ent context or category of experience from that of the
target learning, rather than a needed correction to the
target learning. e threshold of excessive mismatch
itself depends on memory strength and age, because
stronger degrees of reactivation and mismatch are
required to destabilize stronger and older memories
(Eisenberg and Dudai, 2004; Frankland et al., 2006; Su-
2015, Alfei et al. Rat: Contextual fear
memory
Reactivated fear memory is disrupted and erased by midazolam
only if reactivation conditions involve prediction error (a temporal
prediction error in this study).
2015, Jarome et al. Rat: Contextual fear
memory
Reactivated fear memory is disrupted and erased by a protein syn-
thesis blocker only if reactivation conditions include a novel contex-
tual feature (mismatch/prediction error).
2016, Forcato et al. Human: Declarative
memory
Recall of memorized items is impaired, revealing destabilization,
only when a memory mismatch (prediction error) accompanies
reactivation.
2016, López et al. Crab: Contextual fear
memory
Learned fear response can be erased by chemical blockade (bicucul-
line and cycloheximide) only aer memory reactivation is accompa-
nied by prediction error.
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
17
zuki et al., 2004; Winters et al. 2009; Wang et al., 2009).
Several studies have shown additionally that by add-
ing a small continuation (such as two more CS-only
presentations) at the end of a post-reactivation proto-
col previously shown to leave the target learning in a
destabilized condition, the target learning is then le
in a stable condition by the extended protocol (Jarome
et al., 2012; Merlo et al., 2014; Sevenster et al., 2013,
2014). is nding implies that a target learning is dy-
namically switched in real time from stable to unstable
or vice versa as the component steps of a post-reacti-
vation protocol are progressively implemented. Ecker
(2015a, pp. 19–23) has proposed that such switching
occurs because each part of the post-reactivation pro-
tocol promptly creates new learning that inuences the
level of prediction error created by the next part of the
protocol, and in that sense functions as (and possibly
may actually be) a modication of the target learning.
In Ecker’s hypothesis, if at any point the new learn-
ing created by the unfolding protocol causes the next
part of the protocol to be experienced with little or no
prediction error, the target learning is switched from
destabilized to stable condition, abruptly closing the
reconsolidation window and preventing the remainder
of the protocol from having any updating eect (un-
less it is structured so as to mismatch the now-revised
target learning, which would again destabilize the
target learning). Ecker (2015a) applied that hypothe-
sized phenomenology to generate for the rst time an
analysis of the time-resolved eects of the protocols
used by Monls et al (2009) and Schiller et al. (2010),
as well as a time-resolved analysis of how the standard
extinction protocol operates (that is, an analysis of the
evolving state of the target learning and the eect of
each successive non-reinforcement trial).
Reviewing experimental ndings noted in the
previous two paragraphs, Ecker (2015a, p. 13) dened
a formal principle of mismatch relativity, a claried for-
mulation of which is: Whether a particular component
of a post-reactivation procedure creates a destabilizing
mismatch experience depends entirely on the model
of reality at that point in time in the target learning,
including modications or supplementations by any
prior components of the post-reactivation procedure.
us, while the various specialized protocols de-
scribed above were designed for the highly simplied
conditions of controlled studies and therefore may
have limited clinical applicability, collectively they
serve to identify a general principle that is critically
important for clinical application: An experience that
is intended to destabilize a particular target learning
must be accurately tailored to the specic content of
that target learning.
For example, for a target learning acquired through
an intermittent reinforcement training, a single expe-
rience of nonreinforcement does not create an expe-
rience of mismatch or counter-learning, because the
expectation maintained by the target learning includes
the occurrence of nonreinforcements (e.g., Sevenster
et al. 2013, 2014). Even two or more nonreinforce-
ment experiences would fail to create a mismatch if
the original, learned pattern of nonreinforcement was
similarly sparse. at example is a rather obvious case,
but in some studies the target learnings created by re-
searchers had subtler features that are not addressed or
accounted for in researchers’ interpretation of observa-
tions. For example, Pine et al. (2014) achieved desta-
bilization but regarded their experimental procedure
as creating no prediction error, so they viewed their
results as indicating that prediction error is not neces-
sary for achieving destabilization, when actually their
procedure generated prediction error in three dierent
ways (for details of which, see Ecker, 2015a, p. 12).
Cognizance of the mismatch requirement did not
spread eciently among reconsolidation researchers
aer its discovery by Pedreira et al. (2004). e prior,
incorrect notion that each reactivation by itself is de-
stabilizing continued to be asserted in journal articles
by many reconsolidation researchers, as well as in sci-
ence journalism. is lack of recognition of the mis-
match requirement has caused the authors of numer-
ous studies to misinterpret their results, particularly in
studies that reported a failure to achieve destabilization
and erasure. e negative result is attributable, as a
rule, to an absence of any mismatch experience in the
experimental procedure (see Ecker, 2015a, for discus-
sion of such cases). In most instances, these studies’
authors made no mention of the mismatch require-
ment and appeared to be unaware of it (e.g., Camma-
rota et al., 2004; Hernandez and Kelley, 2004; Mile-
usnic et al., 2005; Wood et al., 2015). An exception is
the discussion by Bos et al. (2014), who surmised that
their negative result was due to the absence of a mis-
match/prediction error experience and commented,
“Future studies may benet from protocols that are
explicitly designed to assess and manipulate prediction
18
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
error during memory retrieval” (p. 7).
Given that clinical symptoms are frequently main-
tained by generalized, semantic emotional learnings or
schemas, as discussed in Section 2, a critical question
is whether a schema can be reactivated by generalized,
abstract cues, with no reference to any specic experi-
ence that contributed to the formation of the schema,
and then be destabilized and erased. Soeter and Kindt
(2015b) demonstrated that aer the images of two
distinctive spiders were separately paired with electric
shocks and became fear-inducing, seeing the name of
the category of the feared items, “spider,” was eective
for reactivating the subcortical fear memory, allow-
ing destabilization and erasure to follow. is nding
begins to provide an empirical basis for the frequent
clinical observation that a client’s emotional schema is
readily reactivated by verbally naming its constituent
categories, without any reference to the original per-
ceptions or experiences that led to the formation of the
schema.
In another common clinical situation, the expecta-
tion of a particular form of suering (US) is triggered
by numerous dierent occurrences or perceptions
(CSs), such as a feeling and expectation of social rejec-
tion (the US) being evoked by holidays, parties, danc-
ing, restaurants and weekends (the CSs). e clinical
ideal would be a single process that dissolves all such
CS linkages, rather than addressing each separately.
Several laboratory studies have simulated this situa-
tion by pairing a US with two or more CSs (Debiec et
al., 2010; Díaz-Mataix et al., 2011; Doyére et al., 2007;
Liu et al., 2014; Schiller et al., 2010; Soeter and Kindt,
2011). All of those studies found that when reactiva-
tion was induced by the presentation of one of the CSs
alone (without the expected US occurring, creating
mismatch), followed by post-reactivation pharmaco-
logical blockade or behavioral counter-learning, the
conditioned response to only that one CS was then
erased, and all other CSs continued to trigger the state
of expecting the US. In contrast, when reactivation
was induced by re-experiencing only the US (without
any of the expected prior CS presentations, creating
multiple mismatches), the conditioned responses to
all CSs were then erased or impaired (Debiec et al.,
2010; Díaz-Mataix et al., 2011; Liu et al., 2014; Luo et
al., 2015). Further, one of those CSs, which had also
been paired with a dierent US, continued to evoke the
distinct conditioned response created by that pairing
(Liu et al., 2014), showing the specicity of the desta-
bilizations induced via US reactivation. Summarizing
a review of those ndings, Dunbar and Taylor (2017,
p. 168) comment, “Whereas the conventional CS-re-
activation procedure may recruit the neural correlates
of only a single CS-US memory, US reactivation may
recruit neural correlates of all CSs associated with
the reactivated US, thus allowing for destabilization
and, thus, disruption of all CS-US associations for the
reactivated US.” is indicates that in optimal clinical
translation, reactivation of the target learning would
include a reminder of the US, that is, the specic
suering that the client experienced in the past and
learned to anticipate and strive to avoid. Incorporation
of that US-reminder strategy into clinical methodology
is described in Section 6.3 below.
5. How erasure of memory occurs
When a target learning is in the destabilized, labile
condition, its nullication, resulting in the markers of
erasure, can be accomplished in two fundamentally
dierent ways, one of which is endogenous and the
other, exogenous (for reviews, see Agren, 2014; Lee
et al., 2017; Reichelt and Lee, 2013). e endogenous
method is oen labeled behavioral memory updating
or behavioral interference. e exogenous method is
known as pharmacological blockade, pharmacological
interference, or disruption of reconsolidation.
In behavioral updating, rst demonstrated in an-
imal studies by Sekiguchi et al. (1997) and in human
studies by Walker et al. (2003) and Galluccio (2005), a
destabilized learning can be revised in its strength and/
or content by suitably designed new learning, accord-
ing to how the new learning diers from the target
learning (without diering so much that, due to lack
of relevance to the target learning, the new learning
forms separately rather than updating the target learn-
ing, leaving the target learning unchanged). A target
learning can thereby be strengthened, weakened, mod-
ied in its particulars, or erased by suitably designed
new learning during the reconsolidation window (for
reviews see Agren, 2014; Beckers and Kindt, 2017;
Reichfelt and Lee, 2013; Schiller and Phelps, 2011).
e updating/erasure eect occurs through dierent
molecular and cellular processes from the destabiliza-
tion/restabilization process (Jarome et al., 2012; Lee et
al., 2008)
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
19
Because this article’s primary topic is the psycho-
therapeutic use of memory reconsolidation, the focus
here is mainly on the erasure of target learnings, as
it is erasure that is experienced by therapy clients as
decisive, transformational change, that is, complete
and permanent disappearance of an unwanted behav-
ior and/or state of mind and/or somatic disturbance.
Erasure via behavioral memory updating results from
following the destabilization of the target learning
with counter-learning consisting of experiences that
contradict and disconrm the target learning’s specic
model and expectation of the behavior and qualities of
self, others and/or the world. e markers of erasure
are then observed, which is the basis for researchers
concluding that counter-learning during the reconsol-
idation window drives unlearning that nullies and
replaces the labile target learning (e.g., Clem and Schil-
ler, 2016). Erasure produced in this way can be regard-
ed as behavioral memory interference (Bjork, 1992;
Robertson, 2012) at the maximum possible degree of
eectiveness.
e historic rst demonstrations of counter-learn-
ing erasing an emotional learning (conditioned fear)
were the animal study by Monls et al. (2009) and the
human study by Schiller et al. (2010). In those stud-
ies, fear was acquired through Pavlovian associative
conditioning, in which an initially emotionally neutral
CS was repeatedly paired with an electric shock US.
ereaer, the CS by itself triggered a fear response
due to the learned expectation of the US occurring
next. e procedure employed by Monls et al. and
Schiller et al. for erasing that acquired fear response
behaviorally with counter-learning was a protocol that
has come to be known as post-retrieval extinction, re-
trieval-extinction, or reactivation-extinction. Erasure
by this protocol has been conrmed in several animal
studies (e.g., Clem and Huganir, 2010; Flavell et al.,
2011; Piñeyro et al., 2014; Rao-Ruiz et al., 2011) and
human studies (e.g., Agren et al., 2012; Björkstrand et
al., 2015; Oyarzún et al., 2012; Steinfurth et al., 2014).
Negative results from the post-retrieval extinction
protocol were obtained in several other studies (with
animal subjects: Chan et al., 2010; Costanzi et al., 2011;
Flavell et al., 2011; Ishii et al., 2012, 2015; Staord et
al., 2013; and with human subjects: Golkar et al., 2012;
Kindt and Soeter, 2013; Meir Drexler et al., 2014; Soet-
er and Kindt, 2011). ese negative studies have been
interpreted by Auber et al. (2013) and Piñeyro et al.
(2014) as indicating that some of the protocol’s sev-
eral adjustable parameters were set outside the brains
reconsolidation boundary conditions, the range of pa-
rameters of a given protocol that induce destabilization
or counter-learning. at explanation appears to have
been conrmed by a systematic varying of parameters
by Ferrer Monti et al. (2017). However, the matter
is not yet fully resolved, because Luyten and Beckers
(2017) attempted an exact replication of the study by
Monls et al. (2009) and did not observe erasure.
e post-retrieval extinction protocol begins with
reactivation of the target learning by a single unre-
inforced CS presentation, followed by a 10-min time
interval, which is followed by a series of unreinforced
CS presentations. at series of CS-noUS trials is
identical to the conventional protocol used for study-
ing extinction for a century, so researchers refer to that
part of the protocol as an extinction training (which
is arguably a misnomer, as discussed further in Sec-
tion 6.2 below). us in its entirety (retrieval plus
extinction), the post-retrieval extinction protocol can
be understood as being a standard extinction training
with a single modication that may seem minor but
has major eects: an increased time interval of 10 min
between the rst two CS presentations. Monls et al.
and Schiller et al. compared the results obtained with
and without the increased time interval: Without it,
the protocol becomes that of standard extinction train-
ing, and the result was the familiar one known from a
century of extinction studies (Bouton, 2004), namely,
initially the fear response was largely suppressed but
then could be reinstated. In extinction, repetitive
counter-learning applied to a stable target learning
creates a separate contradictory learning that competes
against the target learning and temporarily suppresses
it. (See Ecker 2015a for a detailed analysis of why stan-
dard extinction training does not destabilize and erase
the target learning. Strong evidence that reconsolida-
tion and extinction are distinct and mutually exclusive
phenomena has been produced by Duvarci and Nader,
2004; Duvarci et al., 2006; Merlo et al., 2014.) Sup-
pression induced by extinction training is prone to
relapse because the target learning still exists and again
becomes reactivated and dominant under various
circumstances (Neumann and Kitlertsirivatana, 2010;
Vervliet et al., 2013).
In sharp contrast, with the rst time interval in-
creased to 10 min, the fear response was erased, that is,
it disappeared and could not be reinstated, and the du-
20
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
rability of non-reinstatement was conrmed aer 1 yr
by Schiller et al. (2010) and aer 1.5 yr by Björkstrand
et al. (2015). Evidently the increase of the rst time
interval to 10 min created a mismatch experience that
destabilized the target learning, allowing the following
series of non-reinforced CS presentations to serve not
as a conventional extinction training, but rather as
counter-learning that accomplished erasure.
Understanding how and why the increased time
interval served to create a memory mismatch (predic-
tion error) experience is vitally important for reliable,
successful future utilization of this procedure and its
variants in both research and psychotherapy. However,
neither Monls et al. (2009) nor Schiller et al. (2010)
made reference to the mismatch requirement in their
discussions of results. Ecker (2015a) has proposed a
detailed analysis of the mismatch characteristics of
both studies, and López et al. (2016) have replicated
the experimental result and interpreted it in terms
of prediction error. Both of those accounts join with
those of Fernández et al. (2016a) and Hupbach (2011)
in emphasizing a central principle: In laboratory stud-
ies, the eect of new learning on a target learning is
accurately understood only by examining in detail the
relationship between the acquisition experiences that
originally were encoded into the target learning and
the structure and content of the new post-reactivation
learning.
at principle applies as follows to the studies by
Monls et al. (2009) and Schiller et al. (2010): In
acquiring the target learning, subjects learned not only
the CS-US association but also the time interval be-
tween CS-US pairings: 3 minutes in Monls et al. and
15 seconds in Schiller et al. erefore, upon perceiving
the rst CS of the post-retrieval extinction procedure,
subjects in the two studies expected the next CS to
appear aer those time intervals, respectively. at
expectation was then mismatched by the passage of 10
minutes before the next CS appeared, instead of the
expected 3 minutes or 15 seconds. (Studies have since
demonstrated the use of a purely temporal mismatch
to induce memory destabilization, e.g., Alfei et al.
2015; Díaz-Mataix et al., 2013.) Schiller et al. in addi-
tion had subjects view a TV show during the 10-min-
ute interval, which was a qualitatively dierent type of
novelty relative to the target learnings expectation of
a blank screen, possibly creating a second mismatch
concurrent with the temporal one.
e increased, 10-minute interval is clearly the
distinctive feature responsible for the post-retrieval
extinction procedure’s eectiveness in the Monls
et al. study, so it has been copied in nearly all subse-
quent replications and variants. Yet the analysis in the
preceding paragraph implies that the increased time
interval was eective only because it happened to mis-
match the time structure in the acquisition training,
not because of any intrinsic role of delays or timing in
the destabilization process. In other words, with a tar-
get learning that has no timing structure, the extended
10-min time interval of the post-retrieval extinction
procedure would not create mismatch or contribute
to destabilization. ere is no timing structure in any
of the emotional learnings of therapy clients that were
detailed earlier in Section 2, such as the middle-aged
man’s learned, generalized expectation that anyone
would respond to him with anger or cold indierence
were he to express some need or distress. With target
learnings such as those, which are representative of
most of the emotional learnings that emerge in thera-
py, the timing structure of the post-retrieval extinction
procedure could not contribute to creation of mis-
match/prediction error and therefore could not induce
destabilization.
us the analysis above suggests that the post-re-
trieval extinction procedure of Monls et al. (2009)
and Schiller et al. (2010) would have limited clinical
applicability. It will be argued in Section 6.1 that the
most versatile and optimal procedural format for clin-
ical application consists of using each therapy client’s
unique target learning as the absolute basis for tailor-
ing eective experiences of reactivation, mismatch, and
counter-learning, unconstrained by any preconceived
procedural format and utilizing any known therapeutic
techniques.
e foregoing analysis serves to illustrate why the
superordinate principle put forward in this article is
that an experience-oriented interpretation of recon-
solidation research rather than a procedure-oriented
interpretation is necessary for arriving at accurate
understanding and reliable, ne-grained control of
memory reconsolidation in clinical use. Adherence to
the experience-oriented interpretation consists of an-
alyzing occurrences and non-occurrences of memory
reconsolidation in terms of the experiences required by
the brain for inducing destabilization and revision of
a target learning. e experience-oriented interpreta-
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
21
tion therefore illuminates why, and when, a particular
procedure is or is not eective. e procedure-orient-
ed interpretation in itself cannot do that because, in
eect, it equates memory reconsolidation with certain
procedures rather than with the critical experiences
that actually govern the process.
For example, the experience-oriented interpretation
may provide a simple explanation for what is currently
perhaps the most controversial nding in reconsolida-
tion research. Both Baker et al. (2013) and Millan et al.
(2013) carried out the post-retrieval extinction proto-
col (targeting conditioned fear memory in adolescent
rats and alcoholic beer seeking memory in adult rats,
respectively) and observed signicantly diminished
expression of the target learning. ey also found that
the same diminishment of memory expression resulted
from reversing the protocol, with the single CS-only
“retrieval” component following the extinction training
by 10 min rather than preceding it. at has wide-
ly been viewed as a “remarkable” nding indicating
potentially that the post-retrieval extinction protocol
does not engage reconsolidation mechanisms aer all,
because “Reconsolidation theory would posit that re-
trieval must come before extinction for the procedure
to impair reinstatement” (Dunbar and Taylor, 2017, p.
163) and “it is dicult to reconcile how reconsolida-
tion can be initiated when the reminder trial follows,
rather than precedes, extinction learning” (Treanor
et al., 2017, p. 293) (see also Hutton-Bedbrook and
McNally, 2013).
ose are procedure-oriented analyses. e expe-
rience-oriented interpretation provides an alternative
analysis that is consistent with the reconsolidation pro-
cess, as follows. In this view, the critical condition that
accomplishes behavioral erasure via reconsolidation
is the concurrent experiencing of a reactivated target
learning that is destabilized, and a counter-learning
that contradicts the target learning’s model of how the
world works. Importantly, it does not matter which of
those two experiences is induced rst, because what
the brain requires for updating, in this view, is the
juxtaposition of the two. As soon as both are being
experienced concurrently, erasure is a likely result.
e idea that counter-learning could precede destabi-
lization and still be eective for erasure ceases to seem
counter-intuitive with recognition that for updating,
the brain requires only a juxtaposition (concurrence,
simultaneity) of the two experiences, regardless of
which of the two is activated rst. Each of those two
experiences has an extended though limited duration
of activation, which is why their juxtaposition is possi-
ble.
For example, such juxtaposition could have oc-
curred as follows in the study by Baker et al. (2013).
Acquisition training consisted of three pairings of a
10-sec white noise sound (CS) with paw shock (US)
on day 1. e procedure on day 2 (in Experiment 4)
began with an extinction training in which 30 CS-only
presentations were separated by an interval of 10 sec.
at constitutes strong learning of the expectation that
a CS is followed by another CS in 10 sec. at expecta-
tion was mismatched when, 10 min aer the extinction
training ended, only the single “retrieval” CS presen-
tation occurred, with no other CSs following it. at
mismatch of CS-driven expectation destabilized the
target learning. At that point, the destabilized target
learning and the just-created counter-learning experi-
ence of safe CS were simultaneously present, so be-
havioral updating of the target learning occurred and
a signicant decrease of fear response was observed.
Also tested was a period of 6 hr instead of 10 min aer
extinction until the single retrieval trial. In this case,
the enhanced impairment eect on the fear response
was lost. Since the target learning was destabilized by
the single CS-only presentation no dierently aer 6
hr as compared to aer 10 min, it must be the other
ingredient needed for erasure that was absent: Aer
6 hr, the extinction training experience of safe CS was
no longer a currently activated experience, so there
was no juxtaposition of the destabilized target learning
with a counter-learning experience and therefore no
updating. A separate nding that strongly supports
this interpretation is the recent demonstration that
the neural ensemble encoding a new learning inter-
acts with and participates in a subsequent new learn-
ing for 5 hr but does not do so aer 6 hr (Cai et al.,
2016; Rashid et al., 2016). us in the 6-hr case, the
30 CS-only trials functioned as a standard extinction
training, not as counter-learning for memory updat-
ing, so the enhanced impairment of the fear response
was lost.
e observations of Baker et al. (2013) and Millan
et al. (2013) can therefore be seen as supporting the
experience-oriented interpretation of reconsolidation
phenomena rather than as indicating non-recruitment
of reconsolidation by the post-retrieval extinction
22
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
protocol. In clinical work, likewise we nd that the
required juxtaposition can be assembled either way, by
reactivating the target learning rst (for example, “e
only way to get attention is to do something bad”) or
by reactivating the contrary knowing rst (for example,
“My boss readily met with me to discuss my concerns,
and my friends all showed up for my birthday party”).
Both sequences are equally eective for setting up the
juxtaposition that results in erasure.
Erasure by counter-learning during the reconsoli-
dation window is the fully endogenous utilization of
memory reconsolidation. Alternatively, administra-
tion of a chemical agent during memory destabiliza-
tion can produce exogenous erasure with no count-
er-learning. In that methodology, the agent blocks the
neural protein synthesis necessary for return of labile
memory to the stable consolidated state, but has no
eect on stable memory circuits. When fully eective,
this pharmacological blockade prevents restabilization
(reconsolidation) of the destabilized neural circuitry of
the target learning from ever taking place. e target
learning’s neural encoding becomes nonfunctional
and the markers of erasure are observed. e phar-
macological agent is administered soon before or soon
aer the target memory is destabilized by reactivation
with mismatch, and the blockade takes eect when
restabilization would normally occur, about ve hours
aer destabilization was induced. e pharmacologi-
cal blockade procedure is therefore also referred to by
researchers as disruption of reconsolidation. (For a
review see, e.g., Taylor and Torregrossa, 2015.) Erasure
via pharmacological blockade was rst demonstrated
for learned fear by Nader et al. (2000) and Przyby-
slawski et al. (1999) in animals and by Kindt et al.
(2009) in humans.
Human studies and clinical applications of phar-
macological blockade have relied on the use of pro-
pranolol, as all other blockade agents used in animal
studies have toxicity that precludes them from use with
people. Both positive and negative results have been
reported in numerous studies; for reviews see Beckers
and Kindt (2017) and Steenen et al. (2017). e latter
concluded:
ese meta-analyses found no statistically signi-
cant dierences between the ecacy of proprano-
lol and benzodiazepines regarding the short-term
treatment of panic disorder with or without agora-
phobia. Also, no evidence was found for eects of
propranolol on PTSD symptom severity through
inhibition of memory reconsolidation. In con-
clusion, the quality of evidence for the ecacy of
propranolol at present is insucient to support the
routine use of propranolol in the treatment of any of
the anxiety disorders.
However, an examination by Ecker (2015, pp.
14–15) of some pharmacological blockade studies has
revealed a signicant procedural aw: the absence of
any mismatch experience following reactivation of the
target memory. e lag in recognition of the mismatch
requirement by many researchers was noted earlier,
and in a review of propranolol studies in humans,
Beckers and Kindt (2017, p. 111) commented, “e no-
tion that memory destabilization will occur only when
there is an expectancy violation or an experienced mis-
match at the time of memory retrieval…has not been
taken into account in the majority of clinical trials that
have been conducted so far.” In studies with no mis-
match experience, there would be no destabilization of
the target memory and therefore no pharmacological
blockade eect, so the target memory would be un-
aected and remain in operation. at would be the
reason for the observed failure of the chemical agent
to produce erasure in these studies (which in their
own way add usefully to the evidence supporting the
necessity of mismatch for inducing destabilization).
ese awed studies therefore have no signicance
regarding the inherent eectiveness of the exogenous/
pharmacological approach, and should not be included
in evaluations of that approach. e inclusion of such
methodologically awed studies in the meta-analy-
sis by Steenen et al. (2017) could be responsible for
arriving at a negative conclusion regarding the clinical
eectiveness of propranolol for disrupting the recon-
solidation of humans’ fear learnings. e true clinical
value of propranolol treatment therefore remains am-
biguous, and it is possible that by using methodology
that reliably fullls the brains requirement for memory
destabilization via reactivation and suitable mismatch,
the eectiveness of propranolol treatment might be
established. If Steenen et al. were to repeat their calcu-
lations aer screening out the methodologically awed
studies, the new results could be a signicantly more
reliable indicator of propranolol’s clinical eectiveness
if sucient statistical power remains.
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
23
In contrast to erasure via pharmacological block-
ade, the fully endogenous process of erasure through
counter-learning (i.e., behavioral memory updating)
allows completion of the reconsolidation of the target
learning’s neural encoding in its re-encoded, con-
tent-revised form. Behavioral erasure is a disruption
of the content of the target learning, accomplished
through the reconsolidation process, not the neuro-
physiological disruption of the reconsolidation process
itself.
For psychotherapeutic use, the endogenous (ful-
ly psychological) and exogenous (pharmacological
blockade) approaches have their respective advantages
and disadvantages. It is widely recognized, as Soet-
er and Kindt (2011, p. 358) stated, that “Obviously, a
behavioral procedure will be preferred over pharmaco-
logical manipulations provided that similar eects can
be obtained.” Behavioral updating in fact appears to
have greater eectiveness, according to both laboratory
studies described in this paragraph and clinical obser-
vations described in Section 7. In humans, behavioral
erasure of fear memory by the post-retrieval extinction
protocol has been shown to occur in the subcortical
emotional memory system of the amygdala (through
fMRI brain imaging by Agren et al, 2012; Björkstrand
et al., 2015; Schiller et al., 2013) and also in the declar-
ative, contingency-learning memory system of the
neocortex (through skin conductance measurements
by, e.g., Oyarzún et al., 2012; Schiller et al., 2010).
Pharmacological blockade of fear memory by propran-
olol, in contrast, erases subcortical fear memory but
leaves intact the fear generated by declarative memory
of the CS-US contingency (as detected in the form of
undiminished skin conductance and US-expectancy
measurements by Kindt and Soeter, 2013; Soeter and
Kindt, 2011; reviewed by Beckers and Kindt, 2017).
Further, it has been shown that aer pharmacological
blockade and erasure of a newly encoded memory,
some components of the engram (physical encoding)
continue to exist (Ryan et al., 2015), allowing optoge-
netic (articial) activation of participating neurons to
drive re-expression of the erased behavioral response.
e same test of engram persistence for a behavior-
ally erased memory has not yet been reported, to the
author’s knowledge. Neurochemical evidence sug-
gests that the neural encoding of the target learning
is reconstituted when behaviorally updated by new
learning (Clem and Huganir, 2010; Debiec et al., 2010;
Díaz-Mataix et al., 2011; Jarome et al., 2012, 2015),
but whether the entire engram is thus reconstituted is
not yet known. Implications of post-erasure engram
persistence for the durability of changes produced by
erasure in psychotherapy are discussed below in Sec-
tion 7.5.3.
Table 2. Comparison of features of the endogenous and exogenous clinical use of memory reconsolidation,
based on the totality of controlled studies and clinical observations to date.
Feature Endogenous/psychological Exogenous/pharmacological
Range of symptoms dispelled to date Wide1Narrow2
Effectiveness in clinical practice to date High3Uneven
Memory systems affected in lab studies Subcortical + cortical Subcortical
Resolves varied and complex emotional issues Yes 4Not demonstrated
Duration of treatment Unpredictable;
often brief5
Brief
Level of clinical training required Advanced Intermediate
1 See Table 4 of this article.
2 Fear-based symptoms, specically phobias, panic and symptoms of post-traumatic stress disorder from single-incident, acute
trauma.
3 In twenty years of clinical use, advanced practitioners observe erasure rates of up to 95% of clients.
4 For online listing of published case studies indexed by symptom, see http://bit.ly/2tKXdyX, and for numerous additional case
studies see http://bit.ly/15Z00HQ .
5 For advanced practitioners in general practice, the number of therapy sessions needed to dispel a given symptom is usually in the
range of 6 to 20, though as few as 2 sessions are sometimes sucient and, in cases of severe complex attachment trauma, on the order of
100 sessions may be required to dispel numerous symptoms and their numerous underlying emotional schemas.
24
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
Table 2 compares the currently known attributes of
the endogenous/behavioral and exogenous/pharmaco-
logical methods of erasure. e endogenous approach
is the focus of the remainder of this article. Sections
6 and 7 below describe a versatile clinical methodol-
ogy developed and manualized by Ecker and Hulley
(2017a) (see also Ecker et al., 2012, 2013a,b) for e-
ciently and directly implementing the empirically con-
rmed process of behavioral erasure. at methodol-
ogy has been utilized by clinicians worldwide, many
of whom have reported their own observations of the
markers of erasure (see Ecker et al., 2012, pp. 157–200
for four such detailed accounts; also Sibson and Ticic,
2014). Furthermore, as noted in Section 8 below, the
methodology has potential for contributing a number
of signicant conceptual advances to the clinical eld,
apart from enhancing the eectiveness of individual
practitioners.
6. From research ndings to clinical
methodology
On the basis of the foregoing examination of re-
search, the primary subject of this article can now be
addressed: the translation of reconsolidation research
into clinical application. e main purpose of this
section is to ask and answer this question: What is the
most general clinical methodology of behavioral updat-
ing that is directly and entirely dictated and dened by
reconsolidation research? Section 7 then illustrates and
examines the actual implementation of that proposed
most general clinical methodology; Section 8 identies
the potentially major ramications of this methodol-
ogy for several fundamental theoretical issues in the
psychotherapy eld; and Section 9 uses this methodol-
ogy as a frame of reference for analyzing several other
approaches for clinically recruiting reconsolidation.
6.1. e empirically conrmed process of
behavioral erasure
e extensive memory reconsolidation research
examined in Sections 3, 4 and 5 may be summarized
in essence in this manner: e behavioral erasure of a
target emotional learning is an experience-driven pro-
cess, with the requisite experiences being reactivation,
mismatch, and counter-learning. Reactivation and
mismatch experiences destabilize the target learning,
and then counter-learning experiences disconrm and
nullify the target learning and reconstitute its neural
encoding. Verication of erasure then consists of
observing the three markers dened and discussed in
Section 3: nonreactivation, symptom cessation, and
eortless permanence.
e tripartite sequence of reactivation, mismatch,
and counter-learning experiences will be referred
to henceforth as the empirically conrmed process
of erasure (ECPE). e ECPE is proposed here as a
completely non-theoretical, empirically identied core
methodology for directly applying in psychotherapy
the research on endogenous memory reconsolidation.
As shown in clinical case examples in Section 7, a
therapy client’s experience of behavioral erasure is not
a merely mechanistic elimination of symptoms. Era-
sure occurs through a counter-learning experience in
which the individual decisively unlearns and thereby
profoundly resolves a specic schema or mental model
maintaining emotional distress. Such disconrmation
of what had seemed reality frequently occurs in quite
noticeable, identiable moments during the facilitation
of a counter-learning experience. Conventional no-
tions of the time needed for major therapeutic eects
to develop are challenged by this process of transfor-
mational change through the ECPE. is is a funda-
mentally dierent process of change from the Hebbian
process of building up preferred, competing responses
through their extensive repetition over a prolonged
period to create and strengthen the alternative, com-
peting neural circuits.
If, as the current state of empirical knowledge sug-
gests, the markers of erasure can appear endogenously
only as a result of the ECPE’s component experiences,
then the occurrence of the three critical experienc-
es usually ought to be detectable in hindsight in any
therapy sessions or clinical study in which the unam-
biguous markers of erasure were observed, regardless
of whether the therapy or study was conducted with
cognizance of memory reconsolidation or research
ndings. As previously noted, such ECPE detection
was reported by Ecker and Hulley (1996) prior to the
discovery of memory reconsolidation, and recently
ECPE detection has been demonstrated in the same
way for eight dierent systems of psychotherapy by
studying sessions that produced the markers of erasure
(Ecker, 2015c; Ecker et al. 2012, pp. 126–155; Feinstein,
2015; Lasser and Greenwald, 2015; Ticic and Kushner,
2015; for a list of the individual therapy systems, see
http://bit.ly/15Z00HQ).
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
25
6.2. Experiences versus the procedures that
induce them
e ECPE was dened above as a sequence of
three experiences without reference to any concrete
behavioral procedures for creating those constituent
experiences. Deliberate clinical implementation of the
ECPE of course requires use of concrete behavioral
procedures (oen termed interventions in the standard
parlance of psychotherapy). is matter of behav-
ioral procedures is important not only with regard to
equipping clinicians for eective implementation of
the ECPE, but also with regard to eventual designa-
tion of an ECPE-centered clinical methodology as an
Empirically Supported Treatment (EST) or Evidence
Based Treatment (EBT), which requires a manualized
procedure to be tested for ecacy and/or eectiveness
in controlled studies.
A broad array of behavioral procedures for carrying
out the ECPE in therapy has been developed and is in
use by clinicians (Ecker and Hulley, 1996, 2017; Ecker
et al., 2012). However, most relevant to the present
article is a discussion not of those various concrete
procedures, but of the relationship between the ECPE
and any concrete procedures for carrying it out.
e concrete behavioral procedures used by recon-
solidation researchers for inducing reactivation and
mismatch are myriad. e concrete procedures in
each study were necessarily tailored to (a) the type of
memory under consideration (as noted, many dierent
types of memory have been studied, only a subset of
which is listed in Table 1) and (b) the detailed content
and structure of the target learning used in the study.
Neurological destabilization of a target learning is
triggered by the brain registering subjective experienc-
es of reactivation and mismatch, not by the external
concrete arrangements and procedures used to induce
those experiences. Likewise, profound unlearning
and erasure are the result of an experience of count-
er-learning, which may be arranged in any concrete
manner that is suitable for disconrming the target
learning, and is not restricted to any particular con-
crete procedure or protocol.
us, the empirically conrmed process of erasure
does not dictate any particular behavioral procedures
for creating the required, subjective experiences of re-
activation, mismatch and counter-learning that result
in erasure. e distinction between, on the one hand,
the subjective experiences required by the brain for
destabilization and erasure to occur, and, on the other
hand, the concrete procedures used for inducing those
experiences, is of fundamental importance in order
for memory reconsolidation to be utilized clinically
to its fullest potential. For eectively and responsibly
utilizing memory reconsolidation in an empirically
supported manner, clinicians must facilitate the re-
quired sequence of experiences and then verify erasure
by testing for and observing its markers. For doing
so, however, clinicians need not, and in fact must not,
limit themselves to concrete procedures used in labo-
ratory studies, because those procedures were designed
to be eective only for the particular design of target
learning created in the respective experimental study.
In short, the ecological validity of most experimental
protocols is too limited for general clinical application.
Nevertheless, there has been much reliance on
laboratory protocols for attempting clinical translation,
most notably the post-retrieval extinction or reactiva-
tion–extinction protocol used by Monls et al. (2009)
with rats and by Schiller et al. (2010) with humans for
the rst demonstrations of endogenous erasure of a
learned fear, as discussed in Section 5. Successful era-
sure of a symptom having very high clinical relevance
motivated numerous subsequent laboratory and clin-
ically oriented studies of this protocol and of variants
based upon it (reviewed by Auber et al., 2013; Kredlow
et al., 2016; Lee et al., 2017).
e original post-retrieval extinction protocol
consists of a series of unreinforced presentations of a
conditioned stimulus with an increased time interval
of 10 minutes between the rst two CSs. With that
structure, the procedure is suitable to induce reactiva-
tion, mismatch and counter-learning only for a target
learning having a special structure, namely a Pavlovian
target learning consisting of (a) a CS-cued expectation
of a feared or desired event, plus (b) the expectation
that CS-US pairings will repeat with the same timing
as originally experienced in the acquisition training
(a time interval of signicantly less than 10 minutes).
Most target learnings encountered in real-life clinical
cases have a very dierent composition, such as the
ve clients’ emotional learnings noted in Section 2, and
as shown in the case vignettes in Section 7. erefore
the original post-reactivation extinction protocol can-
not reasonably be expected to be eective in that large
majority of clinical cases.
26
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
To some degree, variants of the original post-re-
trieval extinction protocol can have a wider range of
clinical applicability by replacing the conventional
extinction protocol with forms of counter-learning
that are more suitable for the target learning being ad-
dressed. Many such studies have been made, with both
positive and negative results, as reviewed by Auber et
al. (2013), Kredlow et al. (2016), and Lee et al. (2017).
(See Section 9.1 for further analysis of this approach to
clinical translation.) Of relevance here is to note the
procedure-minded use of the term “extinction” to label
counter-learning aer target learning destabilization.
To term post-destabilization counter-learning “extinc-
tion” is a misnomer that creates misconceptions, in
the author’s opinion, because it produces none of the
eects that have been identied with the term “extinc-
tion” for a century. Even when post-destabilization
counter-learning has the identical procedural form as
in conventional extinction training, its learning func-
tion (namely, disconrmation and unlearning) and
its neurological eect (namely, re-encoding of target
learning) are qualitatively dierent from those of ex-
tinction. It is well established that reconsolidation and
extinction are distinct, mutually exclusive phenomena
(Duvarci and Nader, 2004; Duvarci et al., 2006; Merlo
et al., 2014). e operative principle here is this: A
particular learning procedure (such as the repetitive
non-reinforcement of conventional extinction) can
have entirely dierent neurological and behavioral
eects depending on whether or not it is carried out
during the reconsolidation window.
In relation to the target learnings encountered in
psychotherapy, the possible designs of experiences of
counter-learning are virtually unlimited (Ecker, 2016;
Ecker and Hulley, 2017a; Ecker et al., 2012). Monls et
al. (2009) and Schiller et al. (2010) have shown that, for
the specialized case of a Pavlovian target learning that
has been destabilized, counter-learning in the form of
the standard extinction training protocol can accom-
plish erasure. However, that is a specialized format of
counter-learning for that case.
us it is apparent that the post-retrieval extinction
protocol is a highly specialized instance of the much
more broadly dened ECPE. e procedures used in
psychotherapy for implementing the ECPE with a giv-
en client must necessarily be designed according to the
structure and content of the target learning(s) revealed
by that client, in order to successfully induce reactiva-
tion, mismatch and counter-learning experiences. It is
always the specic content and structure of the target
learning that determines which experiences will, or
will not, register as reactivation, mismatch and count-
er-learning. e clinical case examples later in Section
7 illustrate this critical point.
In psychotherapy, each revealed, symptom-generat-
ing target learning is found to be a unique, idiosyncrat-
ic, multi-component formation that was shaped by the
unique life experiences of that individual; and, as noted
earlier, idiosyncrasy of underlying emotional learning
is the case even among therapy clients whose symp-
toms are in the same formal diagnostic category, such
as panic disorder or dysthymic depression. erefore,
eective ECPE implementation with each client neces-
sarily requires clinicians to have a free hand in choos-
ing concrete behavioral measures (interventions) that
will adequately custom-tailor the critical sequence of
experiences for the unique emotional learnings of each
client. Essentially the same conclusion was reached by
Elsey and Kindt (2017a, p. 113), who reviewed many
factors that inuence whether a particular memory
reactivation procedure will create a mismatch that
achieves destabilization, and in summary commented,
“Taking into account these dierent factors, it begins
to look unlikely that any single reactivation procedure
will prove eective for all who undergo it, potentially
undermining the use of very standardized reactivation
procedures that may be pursued in clinical trials.
It may seem paradoxical that clinicians’ adherence
to the ECPE’s components of reactivation, mismatch
and counter-learning actually requires uidity on
the concrete level of treatment, rather than some
pre-dened concrete protocol that was previous-
ly used successfully in laboratory studies or clinical
trials. Clinical use of a xed concrete intervention
protocol is contra-indicated not only by the totality
of the memory reconsolidation research, as described
above, but also by the thorough idiosyncrasy inherent
in human emotional learning histories. To view any
particular behavioral procedure or protocol as neces-
sary or inherent for utilizing memory reconsolidation
in psychotherapy is a misconception that would limit
the range of use and eectiveness to the particular type
of emotional learnings for which the favored proto-
col happens to be suitable. Whereas, by allowing the
clinical use of the empirically conrmed process to
be open-ended and eclectic on the level of concrete
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
27
behavioral procedure, the range of applicability and
eectiveness encompasses the entire universe of symp-
toms generated by implicit emotional learning.
e necessary eclecticism regarding behavioral
procedures runs counter to the conventional assump-
tion that adherence to a proven, well-dened concrete
treatment protocol is essential for establishing scientif-
ic validity, and has important implications for how the
status of Empirically Supported Treatment (EST) or
Evidence Based Treatment (EBT) is to be achieved for
ECPE-centered psychotherapy. Procedural eclecticism
of course has implications also for clinical training in
the endogenous use of memory reconsolidation, but
that topic is beyond the scope of this article.
6.3. A proposed universal clinical methodology of
memory reconsolidation
Having dened the empirically conrmed process of
erasure (ECPE), the quest for clinical translation takes
the form of the pragmatic question: How can psycho-
therapists best facilitate the ECPE for nullifying symp-
tom-generating emotional learnings? e requisite
experiences identied by extensive research are clear,
as summarized in Section 6.1, namely experiences of
target learning reactivation, mismatch and disconr-
mation by counter-learning. What has to happen in
therapy sessions for those experiences to occur? What
general methodology of psychotherapy is implied or
even necessitated?
A general clinical methodology for ECPE facilita-
tion, proposed by Ecker et al. (2012, 2013a, 2013b),
is based on one of the fundamental ndings of re-
consolidation research, the necessity of tailoring the
requisite ECPE experiences to the specic composition
of the target learning or schema. Whereas laborato-
ry researchers have detailed knowledge of the target
learning because they create the target learning in the
rst place, in contrast a psychotherapist is completely
unaware of the emotional learnings maintaining a new
client’s presenting symptoms. Even the symptoms
(unwanted behaviors, states of mind, and/or somatic
disturbances) are unknown to the therapist at the start.
Furthermore, even when symptoms have been well
identied, their underlying emotional learnings are not
thereby inferable because, as noted in Section 2, the
emotional learning history of each person is unique,
and dierent individuals have dierent schemas or
memories manifesting the same diagnostic category of
symptom.
erefore Ecker et al. (2012, 2013a,b) maintain
that a therapist, in order to carry out the ECPE with
reliable consistency across clients presenting diverse
symptoms, must rst (A) elicit specic descriptions
of the symptom(s) to be dispelled and then (B) elicit
ne-grained descriptions of the emotional learnings
that necessitate and generate those symptom(s). en,
guided by familiarity with the details of a particular
target emotional schema, the therapist can now (C)
nd how to guide a counter-learning experience that
will be used for mismatching and then disconrming
and nullifying that schema.
As soon as the three preparation steps A, B and C
are completed, the therapist is now equipped to fa-
cilitate the ECPE’s three experiences of reactivation,
mismatch, and counter-learning. Lastly, aer complet-
ing the ECPE, the therapist must obtain verication of
erasure in the form of observations of the markers of
erasure delineated in Section 3.
Table 3 lists that seven-step clinical process dened
by Ecker et al. (2012, 2013a). ose authors designate
this methodology as the therapeutic reconsolidation
process, or TRP, and they propose it as being a univer-
sal map of therapeutic process for utilizing memory
reconsolidation to produce transformational change.
e universality of this methodology is posited on the
basis of its applicability for all unwanted behaviors,
states of mind, and somatic disturbances maintained
by implicit knowledge acquired through emotional
learning, as well as its open access to all clinicians
without favoring or requiring any particular clinical
methods or theoretical orientation.
e TRP is a methodology of experiences, not be-
havioral procedures, a distinction discussed in Section
6.2. Clinicians are free to fulll the steps of the TRP
using the concrete methods and techniques in which
they have training and which they deem most suitable
for a particular client. Ecker et al. view the TRP as
being a meta-methodology that is determined en-
tirely by the brains innate functioning, which, if true,
would have two implications: All other methodologies
designed to utilize memory reconsolidation in thera-
py would prove to utilize a subset of the instructions
provided by the TRP (see Section 9 for an examination
of several other such methodologies in relation to the
ECPE and TRP); and if some systems of psychotherapy
28
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
were to prove less suitable for implementing the TRP
than others, that would not be due to any bias in how
the TRP was conceived or structured.
Table 3. e erapeutic Reconsolidation Process, pro-
posed as a universal template derived from reconsoli-
dation research for utilizing memory reconsolidation
in clinical practice.
Therapeutic Reconsolidation Process
Preparation
phase
A. Symptom identication
B. Retrieval of target schema
C. Identication of disconrming knowledge
Erasure
sequence
(ECPE)
1. Reactivation of target schema
2. Destabilization of target schema: Activation
of contrary knowledge mismatches target
schema (rst juxtaposition)
3. Nullication of target schema: Several repe-
titions of juxta-position for counter-learning
during remainder of session
Verication
phase
V. Verication of target schema erasure:
• Symptom cessation
• Non-reactivation of target schema
• Effortless permanence
e remainder of this section provides a degree of
expanded description of the seven steps, all of which
are demonstrated in two case examples of TRP facilita-
tion in Sections 7.1 and 7.2 below. (For more extensive
and intensive accounts, including an array of specic
therapeutic techniques useful for each step, see Ecker
and Hulley, 2017a; Ecker et al., 2012; Ecker, 2015c.)
TRP Step A, symptom identication, consists of
actively engaging the client in recognizing and label-
ing the specic behaviors, somatics, emotions, and/or
thoughts that the client wants to eliminate, as well as
identifying when these unwanted experiences happen,
that is, the situations and perceptions that evoke or
intensify them. is information is essential for car-
rying out Step B eectively. In many cases, symptom
identication can be fully accomplished within the rst
session, but it can require several sessions with some
clients. As basic as this step may seem, the author has
found in over two decades of conducting clinical train-
ings that many experienced therapists are unfamiliar
and unskilled with obtaining a well-dened symptom
picture eciently at the outset of therapy.
TRP Step B, retrieval of target learning, is an ex-
periential process of eliciting into explicit awareness
the emotional learning and memory maintaining a
symptom, guiding the client to verbalize the emer-
gent material while feeling it, and then integrating the
newly conscious knowings and feelings into routine
daily awareness as a personal emotional truth (such as
the sample emotional learnings provided in Section 2).
e subjective, aective quality of this retrieval is criti-
cally important, as has been shown in both clinical and
laboratory studies (e.g., Greenberg, 2012; Yacoby et al.,
2015). e retrieved, symptom-generating material
may consist of episodic memory (specic experiences,
including aective and somatic elements and con-
strued meanings), semantic memory (schema-struc-
tured, generalized knowings regarding certain types
of situation, meanings, self ’s vulnerability to a specic
form of suering, the expected behavior of others/
self/world, self-protective tactics necessitated, etc.), or
both. As described in Section 2, symptom-generating
schemas are multi-component, layered formations
with a recognizable structure that enables the therapist
to know when retrieval of a schema is complete. One
of the components, vivid personal knowledge of a spe-
cic suering that is urgent to avoid, corresponds to
the US (unconditioned stimulus) in laboratory studies,
and, as suggested by research noted at the end of Sec-
tion 4 above, retrieval and reactivation of this compo-
nent (which is mandatory in TRP Step B) may allow
ecient erasure of all of its linkages to associated cues
and contexts (CSs). Typically, one or two of a schemas
component constructs are the most eective targets for
disconrmation (Ecker and Hulley, 2017a; Ecker et al.,
2012, pp. 68–70). Retrieval of a symptom-generating
emotional schema may entail the client feeling signif-
icant vulnerability and dysphoric emotion, and there-
fore requires much skill on the part of the therapist,
who must pace the process workably for the client’s
tolerances and provide empathic accompaniment nec-
essary for the client’s sense of safety and trust. While
an advanced practitioner can oen complete retrieval
of a schema in one or two sessions, more generally a
few sessions are needed, and the number of sessions
increases commensurate with the complexity and emo-
tional intensity of the material. Material revealed in
Step B is the target of change; symptoms identied in
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
29
Step A are not themselves direct targets of change, but
cease when their underlying emotional learnings and
memories are unlearned and nullied. Close familiar-
ity with the learnings and memories revealed in Step
B is essential in order for the therapist to be able to
embark upon TRP Step C, identication of disconrm-
ing knowledge.
TRP Step C, identication of disconrming knowl-
edge, consists of nding past or present experience(s)
in which the client has direct, living knowledge that
is fundamentally contrary to the target learnings and
memories retrieved in Step B, such that both cannot be
true. Specicity of disconrmation is critically import-
ant for consistently achieving successful nullication of
the underlying target material with client aer client.
e needed contrary knowing can either be found in
the client’s already-existing knowledge from past ex-
periences or it can be created by a new experience that
occurs during or between therapy sessions. Each of
those main sources has several subtypes, and all can be
accessed through a wide variety of techniques (Ecker,
2016; Ecker and Hulley, 2017a). Step C consists only of
nding where and how such disconrming knowledge
can be readily accessed for carrying out TRP Steps 2
and 3, described below.
TRP Step 1, reactivation of target learning, is read-
ily accomplished using basic experiential methods
of guiding the client’s attention to key features of the
target schema or memory and inviting the client to
allow and attend to the aective and somatic aspects of
what arises. e client feels empathically accompanied
by the therapist while opening to and entering into the
altered state inside the schema or memory. Reactiva-
tion is adequate when the client’s consciousness, while
maintaining relational connection and communica-
tion with the therapist, is signicantly sampling and
inhabiting the subjective, aective reality and self-state
generated by the target material, with particular, mind-
ful recognition of that material’s specic feature that is
going to be mismatched and disconrmed in the next
step.
TRP Step 2, activation of disconrming knowledge,
mismatching target learning, consists of guiding an
initial experience of the contradictory knowledge
that was found in Step C, while the target schema or
memory remains reactivated from Step 1. is rst
instance of the client experiencing a juxtaposition of
the target material and the contradictory knowledge
is a mismatch or prediction error experience, which is
needed for destabilizing the neural ensemble encoding
the target learning, as reviewed in Section 4. In thera-
py, using the counter-learning experience designed for
the next step, Step 3, to rst create the mismatch here
in Step 2 is simply ecient; there is no need for what
would be the extra step of creating some other type of
experience for the mismatch. Contradiction goes by
the name of non-reinforcement in laboratory studies
that use a Pavlovian target learning. (In some clinical
cases, the reactivated target schema or memory is mis-
matched and destabilized presumably by the presence
of the therapist, the therapist’s oce and the safety
of the environment. at is most likely in the subset
of cases where the target material allows the client’s
experience of the therapist to be the contrary knowl-
edge used as counter-learning. In many other cases,
the therapist and therapy session environment are not
directly relevant to the target schema (discussed at
length by Ecker et al., 2012, pp. 93–100) and are merely
novelties in relation to it. Novelty too can serve to cre-
ate mismatch, as noted in Section 4, if the novel item
also has subjective relevance to the target schema and
therefore requires an update of the schema; novelty
without relevance requires no updating and therefore
does not register as a mismatch. For that reason, Step
2 requires something more reliable than the therapeu-
tic setting to serve as the mismatch. Activation of the
contrary, disconrming knowledge identied in Step
C is always a denite and reliable mismatch because
contradiction always has strong relevance to the target
learning and always requires updating.)
TRP Step 3, counter-learning by repetitions of the
disconrming juxtaposition, consists of guiding the
client a few more times to attend to and aectively feel
both experiences, the target material and the contrary
knowledge. is accomplishes the disconrmation,
unlearning and nullication of the target schema or
memory. (In some cases, complications arise, requir-
ing extra steps, as discussed below.) In that juxtapo-
sition of two mutually contradictory knowings, it is
the target learning that is disconrmed and unlearned
because the target learning consists of a less complete,
less inclusive model of reality (having been formed at a
young age and/or while in distress under extreme, spe-
cial circumstances), and its falseness or too-incomplete
account of reality becomes vividly apparent and viscer-
ally felt in being juxtaposed with a more complete and
inclusive model of reality. A reactivated target schema
30
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
consists of certain denite knowings and expectations
of how the world is, yet now there is a concurrent
experience with direct perception that that is denitely
not how the world is. is subjectively felt juxtaposi-
tion experience, consisting of the two mutually contra-
dictory knowings, is regarded as fullling the brains
requirements for behavioral erasure as identied in
reconsolidation research, and therefore as being the
critical experience required for schema nullication
and transformational change in psychotherapy (Ecker,
2006, 2008, 2010, 2015/2006; Ecker and Hulley, 1996,
2000b, 2002, 2008; Ecker and Toomey, 2008; Ecker et
al., 2012, 2013a, 2013b). Initially both sides of the jux-
taposition experience feel real and true to the therapy
client, yet they cannot both be true. e both-at-once
experience inherently entails a peculiar tension or
edginess, similar to the experience of cognitive disso-
nance (Festinger, 1957), but here it is fully experiential
and visceral rather than only conceptual. With count-
er-learning via a juxtaposition experience repeated a
few times during the remainder of the therapy session,
the compelling realness and urgency of the target
learning’s version of reality immediately wither and
lose all feeling of realness or urgency, and cease driving
symptom production. at is demonstrated in the case
examples in Sections 7.1 and 7.2. Carrying out the
ECPE in psychotherapy amounts to guiding a juxtapo-
sition experience a few times. e entire TRP exists to
bring about that set of juxtaposition experiences.
TRP Step V, verication of erasure of target memory
material, consists of observing and documenting the
markers of erasure discussed in Section 3, namely un-
ambiguous reports from the client that (a) the client’s
initially identied symptomatic behavior and/or state
of mind and/or somatic disturbance has ceased to
occur in all situations where it had been occurring, (b)
the aective self-state or compelling emotional “spell”
created by the reactivated target schema no long oc-
curs in response to any cues or contexts that previously
evoked it, and (c) changes (a) and (b) persist under all
circumstances, without relapse and without any eort
or measures taken to maintain them. In most cases,
marker (b) becomes apparent in the same session
following facilitation of the ECPE, in the form of the
client giving clear verbal and nonverbal messages that
the reactivated self-state of the target memory mate-
rial has disappeared and that it is not re-evoked when
the therapist reapplies imaginal cues that had potently
evoked it previously. Some clients state that the specif-
ic content of the target schema or memory, which had
always felt compellingly real and intensely dysphoric,
now feels “absurd” or “ridiculous” to believe. However,
verication is made conclusive only by the persistence
of the markers over many months and in all real-life
situations that formerly triggered symptom produc-
tion. e therapy work addressing a given symptom
and its underlying emotional learning(s) can be re-
garded as complete only when the markers of erasure
are rmly established.
e TRP, consisting of the seven steps A–B–C–1–
2–3–V described above, is fairly simple in its concep-
tual essence, but it is complex and subtle in its overall
clinical implementation across therapy clients who
dier widely in personality, tolerance for emotional
experience, extent and depth of suppressed emotion-
al distress, readiness to trust the therapist, and other
variables. e clinical methodology now known as
the TRP has been in use by the author and colleagues
plus numerous clinicians worldwide for 25 years
(because, as noted in Section 3, the methodology was
developed based on clinical observations prior to the
laboratory discovery of memory reconsolidation). We
have gained much understanding of how to attune the
process to the unique individual therapy client (Ecker
et al., 2012) and have observed the markers of erasure
ending a wide range of clinical symptoms, as summa-
rized in Table 4. Such broad versatility of application
signicantly extends the clinical translation eorts
previously covered in review articles. Nearly all of
those eorts have addressed only two symptoms: the
intense, fearful aversion that is a chief characteristic of
post-traumatic symptoms, and the intense craving that
is a chief characteristic of addiction. In both cases,
several successful clinical or pre-clinical utilizations
of reconsolidation have been reported; for reviews see
Dunbar and Taylor (2017), Lee et al. (2017), Schwabe
et al. (2014), and Treanor et al. (2017). It is well estab-
lished, however, that all of the many types of memory
that have been tested undergo reconsolidation, as not-
ed in Section 3. e TRP is proposed as a framework
that positions clinicians for addressing the entire range
of memory-based symptomology. Section 7.1 below
demonstrates TRP implementation for a symptom of
lifelong reactive anger. Section 7.2 does likewise for an
adult’s symptoms of formless terror accompanied by
severe kinesthetic disturbances, which were found to
be based in childhood attachment trauma.
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
31
Table 4. Clinical symptoms observed to be dispelled
by the therapeutic reconsolidation process as carried
out in Coherence erapy*
Symptoms Dispelled
Aggressive behavior
Agoraphobia
Alcohol abuse
Anger and rage
Anxiety
Attachment-pattern-based
behaviors
and distress
Attention decit problems
Codependency
Complex trauma symptomol-
ogy
Compulsive behaviors of many
kinds
Couples’ problems of conict
/ communication / close-
ness
Depression
Family and child problems
Fidgeting
Food/eating/weight problems
Grief and bereavement prob-
lems
Guilt
Hallucinations
Indecision
Low self-worth, self-devaluing
Panic attacks
Perfectionism
Post-traumatic symptoms
Procrastination / Inaction
Psychogenic / psychosomatic
pain
PTSD symptoms
Sexual problems
Shame
Underachieving
Voice / speaking / singing
problems
*An online bibliography of published case examples
indexed by symptom is available at http://bit.ly/2tKXdyX
Brief comments follow on a few aspects of TRP
implementation particularly relevant to the current
article. Facilitating the TRP can be complicated by
what therapists typically term client resistance, mean-
ing that the client does not comply with or allow the
process that the therapist is attempting to facilitate.
Resistance is self-protective, is done without conscious
awareness in many instances, and can develop at any
step of the TRP. Resistance occurring in TRP Step
3, counter-learning by repetitions of the disconrm-
ing juxtaposition, is notable as being unique to this
methodology. Clinical experience has shown that a
target schema will not be disconrmed and nullied
by the juxtaposition experiences in Step 3 if the client
(non-consciously) anticipates consequences of nulli-
cation that feel too distressing or costly in any way.
(For a detailed case of this eect, see Ecker et al., 2012,
pp. 77–86.) e brain’s implicit predictive capability
proves to be remarkably astute regarding unacceptable
adjustments entailed by a particular schema losing re-
alness and being decommissioned. e schema simply
remains in force (continues to feel compellingly real
and potent) despite well-craed juxtaposition expe-
riences being guided. at persistence of the schema
is the therapists indicator that there is some blocking
contingency that now must be sensitively brought into
awareness, recognized and addressed. When the client
arrives at feeling that the (now consciously) anticipated
diculty is workable, the therapist repeats the juxtapo-
sition experiences of Step 3, and schema nullication
now is allowed to occur.
A related phenomenon is the persistence of emo-
tional learnings despite numerous personal experienc-
es in which the schema’s expectations clearly do not
occur. A schema can remain immune to disconr-
mation by such experiences in a number of dierent
ways (for discussion of which, see Clarke, 1999; Ecker,
2015a, p. 13; Ecker and Toomey, 2008, pp. 115–116;
Fernández et al., 2017; Proulx et al., 2012), some of
which can also block the disconrmation eect sought
in TRP Steps 2 and 3. As noted in the previous para-
graph, the TRP equips clinicians to reveal and work
directly with a given therapy client’s particular dynam-
ics maintaining such immunity to disconrmation.
e TRP’s preparation Steps A–B–C make it pos-
sible for clinicians to carry out the erasure sequence,
Steps 1–2–3, systematically, consistently and eectively
in day-to-day practice. In other words, Steps A–B–C
are pragmatically necessary in order to implement
Steps 1–2–3 as a deliberate methodology. However,
because Steps 1–2–3 are dened in terms of expe-
riences to be created, not procedures, they can also
occur serendipitously and implicitly, unbeknownst to
the therapist, without Steps A–B–C being carried out.
at is not only possible, but also common. Probably
a majority of clinicians at least occasionally observe
a transformational change (the markers of erasure
dened in Section 3) resulting from methods that may
have little or no obvious similarity to the TRP and
without conceptualizing therapy in terms of memory
reconsolidation. As discussed in Section 3, the mark-
ers of erasure imply the occurrence of the experiences
that Steps 1–2–3 (the ECPE) are designed to create.
e likelihood of facilitating those critical experiences
without awareness of the TRP or knowledge of memo-
ry reconsolidation presumably varies from one system
of psychotherapy to another (even assuming perfect
adherence to and implementation of each systems
methodology). Also presumably, having knowledge of
32
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
and training in the TRP should signicantly increase
any clinicians likelihood and frequency of facilitating
those critical experiences and producing transforma-
tional change in daily clinical practice.
In addition to enhancing an individual clinicians
eectiveness, the TRP also potentially has signicant
methodological and theoretical ramications for the
clinical eld, some of which are discussed in Section 8
(and in the literature cited above in the paragraph on
TRP Step 3.)
7. Clinical observations of the therapeutic
reconsolidation process
e previous section drew upon reconsolidation re-
search ndings to assemble a maximally general clini-
cal methodology of behavioral updating that is directly
and entirely dictated and dened by the research, yet is
not restricted to any particular laboratory procedures.
e methodology that emerges from the research in
that manner is mapped out in Table 3. Its core is the
empirically conrmed process of erasure (ECPE), a
sequence of three experiences, the consistent facili-
tation of which requires the preceding three steps of
preparation, in which relevant material is accessed and
made ready. Following the steps of the ECPE, verica-
tion consists of observations of the markers of erasure
discussed in Section 3. e entire methodology, desig-
nated the therapeutic reconsolidation process or TRP,
is applicable to any symptom generated by emotional
learning and memory and has been used by clinicians
to eliminate the symptoms listed in Table 4.
e TRP is a clinicians map of process. Because
it is a methodology of experiences, not behavioral
procedures, the clinician has to choose the behavioral
procedures to use for fullling the steps of process for
a particular symptom of a particular therapy client.
is section begins by providing two demonstra-
tions of TRP implementation. ese are uncontrolled
clinical case descriptions involving intense, life-long
symptoms of reactive anger in Section 7.1 and terror
accompanied by severe somatic disturbances in Sec-
tion 7.2. Certainly these clinical accounts could be
considered merely anecdotal. However, several ac-
counts of uncontrolled clinical cases have been pub-
lished in support of the clinical translation of recon-
solidation research (e.g., Brunet et al., 2011; Högberg
et al., 2011; Kindt and van Emmerik, 2016; Poundja et
al., 2012). Each of the accounts below is a ne-grained
phenomenological record, not merely a narrative gloss
of what happened. It is proposed that each account
provides unambiguous demonstration of the ECPE’s
sequence of distinctive experiences occurring within
the overall methodology of the therapeutic reconsol-
idation process (TRP), followed promptly by obser-
vation of the markers of erasure, including complete,
long-term disappearance of the presenting symptoms.
As discussed in Section 3, a clinical outcome consist-
ing of the markers of erasure is signicant support for
the hypothesis that erasure via reconsolidation has
occurred. Such demonstrations are of value for devel-
oping clinical translation. Empirical knowledge of the
sequence of experiences required for erasure allows the
very moments of transformational change in therapy
to be plainly apparent and makes the operative ingre-
dients in those moments plainly apparent (Ecker et al.,
2012), even amidst the complexities of the client-thera-
pist interaction.
e case examples are followed in Section 7.3 by
a consideration of whether the observed transforma-
tional changes can be ascribed plausibly to memory
reconsolidation. Section 7.4 concludes this section
by addressing reconsolidation researchers’ anticipat-
ed obstacles to clinical application in light of actual,
extensive clinical observations.
e case examples in Sections 7.1 and 7.2 are sub-
mitted here as a demonstration that the ideal therapeu-
tic goal of a methodology that completely eliminates
unwanted emotional responses, as put forth in Section
1, has become a clinical reality through facilitation of
the process identied in reconsolidation research. e
aim of the author (and colleagues) has been to conduct
and document clinical cases with sucient phenom-
enological detail and specicity to allow meaningful
evaluation of the claim that reconsolidation and era-
sure have been demonstrated. To that end, the em-
phasis in such clinical accounts is on (a) showing the
unambiguous implementation of the required experi-
ences of reactivation, mismatch and counter-learning,
(b) showing that even with the presence of all nonspe-
cic factors widely known to be important for eective
psychotherapy (e.g., Duncan et al., 2009; Wampold,
2001, 2015), it is not until the specic experiences
required for destabilization and erasure occur that a
transformational shi occurs, and (c) the transforma-
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
33
tional shi consists of the markers of erasure being
manifested decisively by the client, including total
elimination of emotional responses and associated be-
haviors for which the client sought therapy. at is the
outcome dened by Clem and Schiller (2016, p. 340) in
order for therapy “to achieve greatest ecacy.
Numerous case studies that fulll those criteria have
been published; a listing of them is available online at
http://bit.ly/2tKXdyX. e system of psychotherapy
used in those case studies is Coherence erapy (Ecker
and Hulley, 2017a), which has a methodology that
explicitly consists of the TRP. e two case studies that
follow were chosen for presentation here on the basis
of the succinct instructional clarity they allow. Other
than that, the results they present are not exceptional
relative to the numerous other published case studies.
e following two clinical case vignettes are also
intended to demonstrate several specic aspects of
applying the empirically conrmed process of erasure
in therapy:
Use of methods developed for revealing the
emotional schema maintaining a given symp-
tom, dening the target learning
Use of the revealed target learning’s specic con-
tents to guide the design of reactivation, mis-
match and counter-learning experiences
Markers of erasure verifying complete, long-
term disappearance of targeted emotional
responses
Erasure of emotional learnings other than fear
learnings and appetitive (addiction) respons-
es, which reconsolidation researchers have so
consistently specied as the potential target
for application of their ndings that clinicians
might be led to assume that only such learnings
can be updated and erased via reconsolidation
Clients’ accounts of the subjective experience of
emotional memory erasure. is information is
of interest to researchers because, as Elsey and
Kindt (2017a, p. 113) have noted, “remarkably
little research has considered what the subjec-
tive experience of these changes is.
Favorable observations regarding researchers’
anticipations of obstacles to applying experi-
mental ndings clinically
7.1. Clinical case example: erasure of chronic anger
e client is a woman in her early 50s, pseudonym
Norina. e therapist is the author. Aer about 15
sessions focused largely on various dicult patterns in
her marital relationship, Norina identied a feeling of
angry resentment that had frequently gripped her and
ruled her state of mind and behavior for hours, days
or weeks, for as long as she could remember, since her
childhood. Her simmering, angry mood had activated
oen toward her husband of 28 years and was a major
factor in the chronic tension between them.
e therapist carried out the therapeutic reconsol-
idation process (TRP; see Table 3) to nd and erase
the emotional learning driving that anger, resulting in
Norina reporting long-term cessation of this emotional
reaction. e process unfolded as described below.
is case is intended to demonstrate the applicability
of the TRP to emotional learnings of any type (not
only those maintaining fear or addiction, the two types
of symptom that nearly all clinically oriented reconsol-
idation researchers have addressed to date, as reviewed
by Dunbar and Taylor, 2017, Schwabe et al., 2014, and
Treanor et al., 2017) and the uniqueness and specicity
of the emotional learnings in each clinical case, requir-
ing TRP Step B, retrieval, to be carried out diligently
and thoroughly.
TRP Step A, symptom identication, was straight-
forward. Her reaction of anger and resentment was
easy for her to name. However, that reaction had
happened in so many dierent situations across the
decades that she could not dene the key features of
situations that triggered it.
In pursuing TRP Step B, the retrieval into explicit
awareness of an implicit schema generating the client’s
anger, the therapist’s task was to elicit the emotional
learning that was driving this angry resentment in so
many dierent situations for a lifetime. In order to be-
gin guiding her attention and awareness into that area
of implicit learning, the therapist said 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 it was something she was already
well aware of: her childhood ordeals of being sexually
molested by her grandfather on a number of occasions,
starting at 6 years of age. She explained that she had
already had extensive therapy for that, long ago.
Hearing that, the therapist thought: It’s natural that
34
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
a person would feel angry resentment about suering
such an ordeal of violation and betrayal. And yet, not
every person who has suered sexual molestation in
childhood has a dominant mood of angry resentment
for the next ve decades, as Norina had. at indicates
something unique and specic in her emotional learn-
ings that has been generating such anger. How to elicit
that specic material?
e therapist next asked gently, “What is it that you
suered in that ordeal that you resent more than any-
thing else about it?” at question guided her atten-
tion into her implicit knowledge to a new degree. Her
previous therapy had not led her to examine with this
specicity what she had suered. As Norina looked
into that, her eyes were blinking, and then she said
with a note of surprise, “Hmm, it doesn’t feel like it’s
my grandfather that I resent the most.” She pondered
a bit more and then said, “It feels like, even more than
resenting my grandfather, I resent the whole world, or
life itself.
e therapist now asked, “What can you see about
why you resent the whole world or life itself?” in order
to continue the ow from implicit knowing into explic-
it knowing.
Norina examined this in silence for several seconds,
and then said, “It’s that the world is just too unfair, to
make this happen to me, and to no one else.
at was the emergence of the emotional learn-
ing that was producing her anger. at construal of
meaning, formed as a young girl, had never before
entered her conscious thinking as an adult. It had
remained a felt knowing in the implicit background,
though it launched anger that came into the explicit
foreground of awareness. e therapist immediately
understood that that single, unique, implicit construct
and attribution of meaning, that it had happened only
to her, led her in turn to view the world as monstrously
and unforgivably cruel and unfair, so she was indeed
profoundly and unceasingly angry and resentful at life.
Aer age 6, whenever Norina perceived anything else
in life as being an unfair and arbitrary treatment, it re-
triggered that same smoldering anger and resentment,
but without awareness of the source of that anger.
Arbitrary, unfair things, small and large, happen fairly
oen in day-to-day life, and in a marriage, so she was
oen swept up into that resentful anger throughout her
life.
She had voiced the words with an indignant into-
nation and a facial expression of consternation, which
gave two important indications to the therapist: First,
she was aectively experiencing this schema in the
moment, not merely intellectualizing about it, which
is the needed quality of accessing here in TRP Step
B. For schemas to become consistently available for
disconrmation and erasure, therapists must guide
clients to inhabit the material subjectively and artic-
ulate it from inside the felt realness of it. Second, the
schema felt as true as ever to her, even though it was
now in her explicit awareness. is continuing poten-
cy of the retrieved schema is found to be the norm in
carrying out Step B. Although in full awareness, the
schema remains in full force and continues to gener-
ate symptoms despite the high-quality presence of the
nonspecic common factors (as discussed in Section
8.3). Nullication of the felt realness of an emotional
schema is observed to occur not by bringing it into
awareness, but by subjecting it to disconrmation and
unlearning in TRP Steps 1–2–3, the ECPE, which was
yet to come.
e target schemas full verbal representation can
be formulated as, “e world allowed that horrible
ordeal to happen only to me, and to no one else, and
that means the world has been unforgivably unfair and
cruel to me. I protest by feeling furious resentment at
the world for being so arbitrarily cruel and unfair to
me, and every time I see or feel any more of that arbi-
trariness or unfairness, I protest again with my angry
resentment.
TRP Step B was now accomplished, but before
describing how the therapist undertook Step C, there
are two noteworthy points illustrated by the revealed
schema. Knowing the detailed content of this target
schema makes it apparent that:
e schema could not possibly be disconrmed
by the clients experience of the therapist. e
therapeutic strategy of using the client-therapist
relationship for a corrective emotional expe-
rience could not be eective for this schema,
because the client’s positive experience of the
therapist is irrelevant to the specic content of
the schema. TRP Step B has the built-in value
of revealing whether or not this widely pursued
clinical strategy is appropriate.
e symptom of reactive anger was arising from
semantic memory, not from episodic memory.
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
35
e sexual molestations by her grandfather were
traumatic, obviously. ey were both acute in-
cident trauma and complex attachment trauma.
TRP Step B had revealed that Norina’s anger
was a post-traumatic symptom. Yet the aspect
of the trauma that had remained highly reactive
in memory and generated life-long, life-shaping
symptoms was neither the physical perceptions,
nor the somatic sensations, nor the emotional
experience with its various intense aspects of
violation, helplessness, fear, entrapment, and
betrayal. It was the client’s semantic constru-
al of the meaning of the ordeals that was the
symptom-generating memory. Post-traumatic
symptoms are most oen conceptualized by
clinicians as arising from episodic memory, but
TRP Step B most oen reveals semantic memo-
ry at the root of symptom production, and that
phenomenological observation is conrmed
when nullication of the semantic structure (the
retrieved schema) is followed immediately by
permanent cessation of the symptom. (See Sec-
tion 2 for discussion of the full constellation of
interlinked semantic memory, episodic memory
and aective/somatic activation.)
Detailed familiarity with the contents of the target
schema from Step B thoroughly guides TRP Step C,
which is nding a decisive, experiential, highly specic
disconrmation of that schema. Step C requires the
therapist nd how to guide the client into experiencing
personal knowledge that feels undeniably true and that
sharply contradicts what the client knows in the target
schema. is contradictory knowledge is to be found
either in the client’s existing knowledge from past
experiences or in new experiences to be created in the
present.
Numerous methods for carrying out Step C are
mapped out by Coherence erapy, as noted in Sec-
tion 6.3. A particular one of them is best for begin-
ning Step C, as a rule, because it is the most likely
to succeed. at method consists of submitting the
discovered schema to the brains always-active mis-
match detection system, by simply having the client
declaratively voice the schema out loud (Ecker et al.,
2012; Ecker and Hulley, 2017a). is method takes
advantage of the fact that in at least half of all cases,
the client is found to already possess vivid contradic-
tory knowledge, but it has not disconrmed the target
schema because the two knowings are held in dierent
memory systems that have little if any direct commu-
nication between them. e target schema has existed
(prior to Step B) only in the implicit and procedural
knowledge networks of the subcortical brain, and the
contradictory knowledge typically exists in the declar-
ative and social knowledge networks of the cortical
and neocortical brain. Voicing the schema out loud
can create a mismatch with any existing contradictory
knowledge, activating the latter and drawing it into
focal awareness. In the present case, a disconrmation
and nullication of “It happened only to me” would
eliminate the very basis of both viewing the world as
cruelly unfair and the angry resentment in protest of
that unfairness.
e therapist, guring it was likely that Norinas
conscious, adult understandings included the certain
knowledge that it most denitely did not happen only
to her, decided to use the mismatch detection method
to access the needed contradictory knowledge. at
decision completed TRP Step C.
In going forward next to actually carry out that mis-
match detection process, the therapist was embarking
upon TRP Steps 1–2–3. He said simply, “Please say it
to me again: ‘It happened only to me.’
Norina said out loud, “It happened only to me.
Norina had already been experiencing the aective
realness of those words, and now they again simply
felt true to her. is fullled the experience dened by
TRP Step 1, reactivation of the target learning; but the
reactivated material was not yet circulating into other
memory systems containing contradictory knowledge.
Mismatch detection oen requires two or three cue-
ings, so the therapist asked her to please say it again.
When Norina said it this time, immediately her
facial expression changed into a look of puzzlement,
which is a familiar marker of the rst conscious sen-
sation of mismatch, just prior to having cognitive
clarity. e target knowledge had begun to register in
her present-day, declarative knowledge networks. e
therapist now invited her to say yet another repetition
of “It happened only to me.
Aer saying it this time, Norina’s eyes began darting
around as cognitive clarity formed. is is the mo-
ment of the juxtaposition experience dened by TRP
Step 2, in which both the target knowledge and the
36
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
contradictory knowledge are present concurrently. e
client’s subjective feeling is as if to say, “Wait a minute.
Hold everything. What I was taking to be reality is n’t.”
On Norinas face now was a look of amazed sur-
prise, and what she said aer a few seconds made it
clear that Step 2 had occurred. She soly 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 wa sn’t singled out.”
Use of the brain’s mismatch detector had worked
and the mismatch had occurred, experienced as a
strong disconrmation of the target schema. e
neural encoding of the target learning was now rapidly
destabilizing, according to reconsolidation research.
It was natural for client and therapist to remain fo-
cused on what had just happened. Norina kept giv-
ing amazed attention to this fresh realization, which
repeated the juxtaposition each time, carrying out TRP
Step 3, the counter-learning that nullies the target
learning and re-encodes it accordingly. In addition,
with empathy the therapist explicitly reviewed both her
old belief and her new realization, in order to repeat
the juxtaposition experience a couple of times more by
empathically reviewing it.
If the process was successful, in those few minutes
Norinas childhood learning that she had been cruelly
and unfairly singled out by life had been unlearned,
dissolved and erased. Erasure means that “It happened
only to me” would no longer feel real or true in any
part of herself, or in any memory network. Without
that construct that life had singled her out for such
suering, there would be no view of life as being hid-
eously unfair to her and, in turn, no more generating
of angry resentment over that. e dissolution would
ripple through that whole linkage.
In the next therapy session one month later, the
therapist began by asking whether she had noticed any
subsequent eects of the previous session’s work. is
was now in pursuit of TRP Step V, verication of the
markers of erasure. In response, Norina’s exact words
were, “I’ve been angry and resentful my whole life. It’s
like something has just turned to dust. Its not alive
any more. Before, something felt like cords and cables
strangling me. I feel so freed up.”
Over the next couple of months she described a new
ease, friendliness and warmth in the marital relation-
ship. Eight months later, she and her husband had a
particularly stressful month of not feeling emotionally
in sync with each other during struggles with the ex-
tended family. Norina said, “It was rough, but I haven’t
felt any resentment toward him.
e therapist took this opportunity to elicit more
follow-up for TRP Step V and asked 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
the shi that you initially described has held.
She replied (and again these are her exact words),
“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.
at’s the way I would describe it…even with all these
troubles.
us the markers of erasure and transformational
change appeared to be well established: e unwanted
emotional reaction and the behaviors it had produced
had disappeared, and were no longer evoked by situa-
tions that formerly evoked them strongly, and this shi
was persisting long-term and eortlessly.
Norina explained that when the molestation ordeal
began as a little girl, she regarded it as something that
was happening only to her, and not to anyone else in
the world, simply because such a thing seemed not to
exist anywhere else. She had never heard of it, and no
one ever spoke of it. Yet it was happening to her, and
its existence overshadowed her entire world. How she
construed it, in all innocence, would have dominant
eects on her life for almost y years.
e internal process of change in this case consisted
of retrieving into awareness and then re-evaluating the
meaning attributed to a childhood ordeal. at pro-
cess could be conceptualized as a cognitive reappraisal
(e.g., Ochsner and Gross, 2005; Ray et al., 2008), but
certain distinctions are essential to make if miscon-
ceptions are to be avoided. Such reappraisal occurs in
ECPE/TRP methodology (as noted in dening TRP
Steps 2 and 3 in Section 6.3) in a juxtaposition of the
original and new meanings that is fully experiential, as
is apparent in the above case vignette, not a merely in-
tellectual, cognitive consideration of the two meanings.
e new meaning must register in the client’s emotional
learning system as being unmistakably real and true,
because that is the memory network containing the
target meaning, and that requires the new meaning to
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
37
be subjectively felt by the client as denitie personal
knowledge, not merely a dry fact that is recognized
intellectually to be true. erefore the therapist’s task
is to guide the client into having her or his own living
experience of the new meaning (and, more generally,
of the contradictory knowledge found in TRP Step C).
e necessity of such fully experiential process in
forming the reappraisal juxtaposition is not always
recognized by researchers, with major eects on exper-
imental results and conclusions. For example, ome
et al. (2016) tested for behavioral memory updating via
cognitive reappraisal in the following manner: Hu-
man subjects learned to fear an image of a spider or a
snake by experiencing a series of eight presentations
of the image paired with an electric shock. One day
later, that fear learning was destabilized by a mismatch
experience consisting of a single presentation of the
image without the shock. is was followed by the
intended cognitive reappraisal experience (which was
one of four experiments in this study), consisting of
listening to a 15-min. neutral, informational narrative
about spiders or snakes, heard via headphones binau-
rally. One day later, physiological measurements of
subjects’ fear in response to a single presentation of the
image showed no reduction in fear, and on that basis
(plus other ndings) the authors state, “In conclu-
sion, our ndings do not support a benecial eect in
using reconsolidation processes to enhance eects of
psychotherapeutic interventions” (p.1). at weighty
conclusion in relation to the reappraisal experiment is
premature and unwarranted, given the weakness of the
tested reappraisal content. According to the crite-
ria dened above, recorded neutral information for
inducing reappraisal of images subcortically linked to
a fearful expectation is predictably ineective, because
hearing dry facts does not generate one’s own direct,
real-feeling personal experience of how the world is.
As such, it does not create a new and dierent know-
ing in the memory systems that contain the target
learning, namely the emotional and sensory memory
systems. Here again, the importance of understanding
behavioral memory updating in terms of experiences
rather than procedures is apparent.
7.2. Clinical case example: erasure of complex
attachment trauma
A pervasive, lifelong feeling of “terror” was the
symptom identied by a female client, age 66, in her
fourth session. She had no awareness of the cause or
content of her terror and could only label the feeling.
Accompanying the session transcripts below are sup-
plemental online session videos in which the subjec-
tive, experiential aspects of the developing process are
more apparent. (Links to the videos are provided in
the text below, but are password-protected. e videos
are available for viewing, with the client’s permis-
sion, only by mental health professionals, researchers,
graduate program teachers, and graduate students. To
obtain the password, send an email to articlevideo@
coherenceinstitute.org and provide a credible form of
documentation that you are in one of those categories.)
e client’s three preceding sessions had addressed
and dispelled a puzzling compulsive behavior of avoid-
ing (procrastinating) important writing tasks in her
professional work. ose sessions revealed a child-
hood in a family system that kept her perpetually in
high anxiety and intense insecurity, and regularly in-
icted emotional trauma of various kinds, creating the
condition designated in the clinical literature by the
various labels of complex attachment trauma, relation-
al trauma and developmental trauma (e.g., Courtois,
2004; Sar, 2011).
As the oldest of six children, she was ordered in no
uncertain terms by intensely self-absorbed, self-im-
portant, authoritarian, recklessly harsh parents to keep
the other children safe, and her explosively rageful
father threatened to kick her out of the family if she
failed to do so. She therefore felt desperate to maintain
continuous hypervigilant monitoring of her younger
siblings. Her emotional learning that it was her job to
keep the children safe and that she would be kicked out
of the family for failing to do that job was a knowledge
module or schema that was found to be still operating
in the present, outside of awareness. at schema and
the fear and urgency that it generated were compelling
her to avoid doing tasks that would strongly absorb
her full attention and allow an accident to happen to
some sibling while she was wasn’t closely watching
over them—even though her siblings were now mid-
dle-aged adults living in distant cities.
In her fourth session, she reported that she had
become able to do the tasks that she had been compul-
sively procrastinating. She then identied the lifelong
feeling of terror as the next focus of therapy. It soon
emerged that this terror was accompanied by intense
38
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
somatic and kinesthetic symptoms, as described below.
e following transcript and videos document how
the therapist (the author of this article) carried out the
therapeutic reconsolidation process (TRP), eliminating
these symptoms in two sessions, followed by 2 years of
verication of all markers of erasure. (C is the client, T
is the therapist.) Comments inserted in the transcript
are limited to pointing out implementation of the TRP
steps; for more extensive clinical commentaries on this
case, see Ecker and Hulley (2017b). Deleted portions
of the session, indicated by an ellipsis (…), have been
made according to the criterion that the deleted seg-
ment contains nothing that was necessary for the ther-
apist to reach the next included segment or to make
progress in carrying out the TRP.
VIDEO SEGMENT 1: http://www.coherencethera-
py.org/videos-pwd/articlevideo/1.htm
C: … I feel like what’s still there is terror.
T: Are there specic situations where that fear is stron-
ger, noticeably stronger, where it’s triggered?
e client’s specication of “terror” begins to fulll
TRP Step A, symptom identication. e therapists
inquiry about when the terror intensies would
further dene the symptom and could also elicit
information that begins TRP Step B, retrieval of an
emotional schema (semantic knowledge) that gener-
ates the terror.
C: [Referring to her boyfriend:] It’s stronger if hes
angry with me—if he gets angry. He even asked me
the other day—I said, “I really get terried.” And he
goes, “I don’t really understand it.” I said, “I don’t
really understand it either.
T: is terror of anybody being angry or upset with
you—angry-ish, irritated, annoyed—
C: Oh yeah. Or criticized. If I’m criticized, that’s the
other one. Displeased with me, almost like in any
way, that kind of displeasure, whether it’s angry or
disappointed or critical.
T: If someone becomes angry, or critical, or displeased,
either what might happen that’s really terrifying for
you, or what does it mean thats really terrifying, or
both?
e therapist’s question comes from assuming that
her terror arises directly from an implicit knowledge
that anger or criticism directed at her could have
an extremely dire result. e question is intended to
prompt her to imaginally sample the experience of
someone responding to her in that way and to attend
to her implicit expectation of the terrifying results.
is is more schema retrieval, TRP Step B.
C: Oh, man. [Silence as she searches internally for what
is terrifying.]
T: Mm-hm. Yeah. And you know I’m not asking you to
gure it out. I just want you to imagine or just admit
to yourself and me—imagine somebody becom-
ing—maybe Burt [boyfriend, pseudonym], just Burt
becoming irritated. What might happen? Or what
does it mean?
C: I mean like, I can go now, like I can sometimes say
when he does that, internally, “I hate him,” how he’s
such a jerk. I can carry on like that, but what’s really
terrifying is it’s almost as if like I’ll go into this, like,
really dark place.
T: Mm. What’s terrifying is that you go into a really
dark place.
C: A dark place, yeah.
Her facial expression and tone of voice now indicate
signicant aect accompanying explicit recognition
of the “really dark place,” which is an experience that
has been plaguing her for a lifetime yet is new for her
to examine and describe.
T: Ok, lets—and what’s that dark place like? Whats
that experience made of?
C: Its like a dark place I’ll never be able to get out of.
T: at sounds terrifying.
C: Yeah, yeah.Not sure. Man.
T: Just sit with it. It’ll show up. You’ve already found it.
Let’s just sit with that much. at’s good. Mm-hm.
Yeah, it’s that you’ll go into a really dark place and
you might not ever get out of it. Yeah. [Silence.] Do
you feel that in your body in any area? What is it
you’re feeling in your body?
C: It feels—and there’s like a—well it’s like, it’s almost
like I’ve become frozen? You know, like—um—
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
39
T: Frozen in the terror of being caught forever in that
dark place?
C: Yeah, yeah.
Her description of the frozen terror that is triggered
in response to receiving anger or criticism is a strong
indication that it is a reactivation of traumatic mem-
or y.
T: Yeah. You’re feeling some of that frozenness now?
C: Yeah, exactly, I’m trying to like stay in this like, this
dark, you know— [Silence.] It’s interesting. I just
wanted to say something: this is the same thing,
you know, this dark place I’m talking about—um,
cause it feels like when I’m in this—the edges of
this—or the dark place, its almost as if, like, I’m not
there and nobody else is there either. It’s a weird—I
mean—but if somebody forgets something I told
them, I get so upset by that and literally the oor
starts to feel like it’s falling under me and I’m de-
scending into this dark place. It’s the same thing.
T: I see.
Somatic and kinesthetic symptoms are now also being
attended to and labeled. Traumatic experience creates
a schema in semantic memory that is retriggered
by current perceptions that in some way match the
original experience. erefore the specic perceptions
that evoke post-traumatic symptoms are indications
of a trauma-based schemas contents. e client has
for the rst time recognized that the same plunge into
dark, stark aloneness happens both when she receives
a sharply negative response and when someone has
forgotten something from their previous conversation.
ose two types of trigger, taken together, indicate
that the target schema contains an expectation of
interpersonal attunement rupture that is so severe as
to feel annihilative—a traumatic plunge into absolute
disconnection and aloneness. e pursuit of TRP Step
B is making progress.
C: And then I’ll like stamp my foot and go, “I told yo u .”
Like that, I’ll be really mad. But the stamping my
foot stops me from falling into that dark place. I’ve
always been wondering, what is this dark place?
And why do I have such a strong reaction to some-
body forgetting something I told them, you know?
Its almost as if like I go into, like, I don’t exist or
something.
T: Yeah, yeah.
C: Its very like—very destabilizing.
T: Yeah, very, yeah.
C: I mean, I have all these like body tools to ground
myself and do all those things—plant myself to feel
my—stay in touch with my body. But there’s—I’ve
never been able to get to this thing.
T: Yeah, let’s get to it. Mm-hm. Yeah, the same dark
place.
C: Because, also, then what has happened is like, some-
times then I think I’ll just, like, shut down. My body
goes into a shutdown, kind of a numb.
T: Yes, because what you’re starting—that dark place is
so terrifying.
C: Yeah, exactly.
T: Nobody else is there. Youre not even there.
C: Right.
T: And it’s like you don’t exist and you could be stuck
there forever.
C: Yeah yeah yeah.
T: So, that’s so terrifying that of course you go numb
and just shut yourself down to not be having that
experience. Yeah.
C: Yes, it’s like being—like being—sometimes, I think
I used to talk about it, or its like being in this, like,
um—like a solitary connement. And also like, it’s
as if I was oating in outer space without a tether.
Like, soundless, lifeless, um—no presence.
C: And no way out.
T: No way out, yes, yeah, like, yes, stuck forever.
C: Yeah, stuck forever.
T: So scary. And, when—let’s see. When someone
doesn’t remember what you said, that can open—
you can be falling into that dark place?
C: Yeah, literally feel myself starting to, like, it’s as if
you like, like you were suddenly like an elevator
dropped really fast. You know, koonnnng.
T: Sinking feeling. Physical.
C: Like a dropping feeling, even literally, like it’s as if
the oor just came out from under me and I’m just
dropping, I’m in a free-fall, or free-drop. at’s what
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
it feels like.
C: And it’s like, terror with it.
T: Yes, yes. What else would you want to say in that
“but I told you!” if you were to really speak from
the terror of what’s really going on and feeling like
you don’t exist? You’re starting to not exist, it feels
like to you, when someone doesn’t remember what
you told them. So what would you say to the person
explicitly about, “Hey, don’t I exist?” Or how would
you say something about that?
e therapist is guiding her experientially to revisit
the rst jolting moments of perceiving an interper-
sonal rupture with someone, in order to continue
retrieving into explicit awareness the cognitive and
emotional components of her emotional learning. Her
next response shows that this focused attending to her
generic (semantic) knowledge of the moment of rup-
ture has now evoked episodic memory of particular
childhood experiences of such traumatic ruptures.
C: I remember I used to have ghts with my mother
about this all the time. “I told you.” And then shed
say, “No, you didn’t.” Or, “You told me this.” “No I
didn’t.” I’d go, “Yeah you did, I remember!”
T: Yeah, “I did tell you.
C: “I did tell you.” “No I don’t—” “Yeah, you did, you
said it, I know you did!” And I was just like—
T: Fightingto exist.
C: And I’d just be so terried, like, you know, like—
T: is memory of it happening with your mother—
C: Again and again and again, like she would deny that
she said things or that I told her things. [rough
tears and with anguish:] It was like, yeah, “You don’t
even remember me, I don’t even exist for you! You
can just forget me so quickly.
T: at’s it: “I don’t exist to you.
C: Yeah, I don’t exist for you—
T: Say it again: “Mom,I don’t exist for you.
C: [rough tears:] It’s just like you don’t even have—
it’s kind of like something like—you don’t even
have—I don’t even know what’s real! ere’s that
sense of I don’t even know what’s real here because
I can’t even—you don’t even remember what you
said to me! And you tell me you didn’t say it and I
remember you said it. Kind of like I’m depending on
you to remember what I tell you and what you tell
me. I’m depending on you to.
T: Yes. Stay in shared reality.
C: Yeah, have a sharedreality! Yeah, like something
here that, this did happen, this did occur. Instead
of you constantly saying, “No, it didn’t occur, no
it didn’t. is didn’t happen.” I remember I would
sometimes feel, “Am I going crazy?” And you know
of course, I was so young.
For a young child, having a consistent, shared reality
with caregivers stabilizes the child’s knowledge of both
herself and the world, and sharp, sudden losses of
shared reality destabilize both areas frighteningly.
T: I wonder if that’s the sinking feeling, that the reality
is just dissolving.
C: Right!
T: And you’re in the black void.
C: at’s exactly it.
T: at’s it.
C: at’s it.
T: And it happened again and again and again with
her, with mom.
C: Again and again.
T: I hear how desperately you would try to get her to
hold up her side of reality.
C: Exactly, what—
T: And she wouldn’t do it.
C: And she wouldn’t do it.
T: And it would dissolve.
C: Yeah! But I remember just feeling so—
T: What’s real? I don’t know what’s real.
C: Right!
T: I don’t know if I’m insane. Am I crazy?
C: Yeah!
T: Yeah. So intense.
C: Yeah, and then I would really try to like track every-
thing, keep track of everything. Just make sure that
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
41
I didn’t forget a thing. Really trying to hold onto,
like—
T: Oh, desperately. Because you’re the one who has to
hold it all together. You can’t trust key other people
to hold it together with you.
As she continued retrieving episodic memory of the
maternal attachment trauma that she suered myr-
iad times, her attention shied from her problem of
mother’s sudden, massive misattunements that feel
annihilative, to her solution of trying to proactively
prevent such ruptures by tracking “everything” herself,
hypervigilantly. is is a desperate attempt to be
ready to oset the predictable failure of her mother to
maintain shared reality or show any caring concern
for her feelings and needs. However, that solution is
not a reliable preventative, so the client feels continual
vulnerability and terror. Clinical experience in carry-
ing out TRP Step B using Coherence erapy shows
that as a rule, a symptom-generating emotional
learning or schema has two main sections: knowledge
of a problem—namely ones vulnerability to a specic
suering, in this case the retriggered trauma of shared
reality suddenly vanishing—and knowledge of a solu-
tion that is the urgently needed way of trying to avoid
that suering—in this case, hypervigilantly keeping
track of everything needed to maintain shared reality.
C: at’s right. I couldn’t trust my mom to do it. I real-
ly couldn’t. I mean she was just so, like, where shed
promise to do something, shed be in the middle of
doing it, and then shed just get [up and say,] “Okay,
I’m done,” and just walk away!
T: And the shared reality dissolves right there.
C: Yeah. en I’d say, “But you said you’d do this for
me!” “Well, I’m done.” And I would just be so crest-
fallen and cry and just, like, and be mad at her, but
it didn’t matter. It’s always feeling like the ground
is almost like quicksand. It’s like it wasn’t solid. I
couldn’t count on her to—
T: To a degree that reality disappears.
C: Right, exactly, yeah.
T: e whole framework just—and you’re just oating.
C: Exactly.
T: Ungrounded. You’re like that astronaut in the black
void.
C: Yeah, exactly. Yeah, that’s exactly—
T: And disconnected!
C: Disconnected. Yes, right. at’s it. at’s exactly it.
Ye a h .
T: Wow.Very intense.
C: And I think when somebody gets angry or criticiz-
es, it sort of like it’s kind of like it comes as like this,
sort of like a jolt or a shock.
T: Is that also a reality disconnect?
C: Yes, yeah, because it catches me by surprise. You
know, like the surprise element of it whenever like
I’m caught by, like, surprise. I’m not expecting it.
ere’s a sense of being blindsided. en it’s like
that jolt, and then it’s back into that, like, I’m terri-
ed of that darkness, of that emptiness.
T: Yeah, I feel I get it. Um, let’s see. Yeah, we started on
this—you were wondering, did it—we were facing
the mystery of, why am I always terried? What’s
always endangering me? Is this it?
C: Yeah, this is it.
T: at with every person—especially important
people, but maybe with any people—you’ve learned
in life that it happens without seeing it coming. It’s
unpredictable how suddenly the fabric of reality is
ripped, and there’s a gap that’s black innite void,
and you’re goin’ in.
C: at’s right.
T: And it can happen with anybody, because human
communication is like that.
C: at’s right, yeah.
e therapist has been conrming that what has
been retrieved and verbalized is actually felt by the
client herself as being the source and the emotional
truth of her chronic terror. is explicit conrming
is important for two reasons: First, the therapist
must have an accurate understanding of the client’s
symptom-generating schema in order to nd next
how it can be disconrmed, unlearned and nullied.
Only by attending closely to the specic elements of a
client’s symptom-generating emotional learning can a
therapist reliably facilitate the empirically established
process of reactivation, mismatch and counter-learn-
ing that yield erasure and transformational change.
Second, engaging the client in a close review of her
42
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
newly retrieved schema promotes integration of that
material. at is needed because a newly conscious
emotional schema is not yet rmly anchored into
conscious awareness and can easily be lost. Integra-
tion makes the schema maximally available for the
disconrmation and erasure process. Coherence er-
apy follows discovery work with an active cultivation
of integration of the newly conscious material through
repeated mindful experiences of it.
T: What’s coming back to me right now here at the end
of the session is the moments when you were in it
back with Mom, here—that little girl, desperate:
“But you said it, don’t you remember?” Just strug-
gling to stay out of falling o the edge of that cli.
C: at’s right.
T: And having reality dissolve out from under
you!at plunging feeling.
C: Right, yeah, that’s right, yeah. Like in a free-fall, or
just suddenly like in a free oat.
T: Yes. And it’s terrifying.
C: Yeah!
T: You’re helpless and so alone.
C: at’s right.
T: And it feels like it’ll last forever. ere’s no way out.
C: Yeah, exactly, yeah.
T: And the terror of that is what is the danger you feel
in daily life now.
C: Yeah, that’s right. Yeah, I’m always scared of going
into that.
As is oen the case with traumatic memory, there
are two distinct terrors plaguing this client: ere is
the primary terror that she feels when her traumatic
memory is actually retriggered by someone losing
track of shared reality and plunging her into the dark,
no-exit void; and there is the secondary terror that
she feels in daily life in anticipation of that terrifying
plunge happening again at any time. at secondary
terror was learned from having numerous experiences
of the primary terror, and is oen termed fear of fear.
at anticipatory fear of fear generates hypervigi-
lance. She is describing that secondary terror when
she says, “Yeah, I’m always scared of going into that.
e session has been almost entirely devoted to TRP
Step B and has made signicant progress retrieving
the terror-generating emotional learning into aware-
ness and verbalization.
T: Yes. Yes, okay, good, we’ve found what that terror,
what that danger is made of.
C: Wow. is is so—I’ve been wondering about this my
whole life, for a lot of years.
T: Good, good. All right, so how about if we set you
up for being between sessions with the awareness of
this? Let’s create a card. …
e card, which is reproduced below, is a device
used in Coherence erapy to sustain the in-session
process between sessions. In this instance, the card
consists of the key verbalizations from the session,
capturing the schema as revealed so far. e purpose
of this card is to keep promoting integration of the
retrieved material simply by returning the client to
mindful, aective experience and awareness of the
material daily. e card is written collaboratively by
therapist and client, with the therapist relying on the
client’s felt sense of the wording that most accurately
captures her emotional truth. e card was emailed in
this case, but some clients prefer a physical index card.
BETWEEN-SESSION CARD
ere is always the danger that Burt or anyone
could suddenly be angry or critical or displeased with
me, or forget what one of us has said to the other—and
that would mean that our shared reality is disintegrat-
ing and falling apart before my very eyes, just like it did
again and again with Mom, and then I’ll be plunged
again into that terrifying darkness, where I don’t exist
for them and I don’t exist for me, and I’m totally alone
and stuck there forever with no way out. So it’s urgent
for me to stay totally alert to everything that’s going
on, so that I can keep my grip onthesharedfabric of
reality, keep it from ripping apart and not get plunged
into that terror.
NEXT SESSION, ONE WEEK LATER
VIDEO SEGMENT 2: http://www.coherencethera-
py.org/videos-pwd/articlevideo/2.htm
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
43
T: I am really interested in hearing about how the card
was for you, but we can start wherever you actual-
ly—
C: No, no, I want to do that, because I’ve been reading
it a bunch during the week, and it’s been really—I
mean, this is, this is, ah—it so ts. What’s interest-
ing though is, just as I was coming in, I just had
this realization that this whole piece about being
in danger isn’t just about my mom, it’s also about
my dad. It’s almost like [it] started with this like
sense of this shared reality piece of that being—you
know, becoming, feeling so like fragile like with
him, too. It was somewhere between two and three,
because—I’ll share this and I’ll just come back to
this.I remember being a little girl and getting up in
the morning, and I think taking o my clothes, not
knowing how to change myself or anything, [and]
climbing in bed with my parents, to snuggle. And
one morning I went in, just felt like this is my thing
to do, like I get to go in and snuggle with them for
a little bit. And I walked into the bedroom, and my
dad just leapt up and said, “Get the hell out of here,
and don’t ever come back. You wait outside and be
quiet till I come and get you.
T: Don’t ever come back?
C: Yeah.
T: How did that feel?
C: Just like heartbroken.
C: It was such a shocker, you know, like here I
thought—
T: is was yours to have. It’s like a right—so unques-
tioned.
C: Unquestioned.
T: And this rejection: “Don’t ever come back.
C: “Don’t ever come back. You sit out there and wait.
You be quiet and you wait until I come and get you,
and don’t come in here ever again.
T: So that’s a heartbreak blow.
C: Yeah. I think that’s part of that darkness, that slip-
ping into that, what I kept calling it over the week,
the dark hole of nonexistence, the black hole of
nonexistence.
T: at’s what you’ve been calling it?
C: [With emotion.] Yeah, yeah, yeah, that’s what came
to me—this terrifying darkness and it just kept
coming up: black hole of nonexistence. And that
just kept coming up. So it’s like I lost it with my dad,
and then I lost it with my mom too! Or I’d think I
would have it with her, and then I’d lose it; I’d think
I would have it with her, and then I’d lose it.
TRP Step B has continued with the retrieval of epi-
sodic memory of her father suddenly shattering her
emotional and physical connection with both parents
by ragefully casting her out of the parental bed into
what she calls “this terrifying darkness” and “the
black hole of nonexistence.” Feeling extreme unsafety
and fragility of attachment with both parents was a
continuous state of terrifying vulnerability through-
out her childhood. Her attachment to both parents
is of the insecure/disorganized type: the parents are
needed for security but are experienced by the child
as a dangerous source of arbitrary aggression because
they behave in unpredictable, extreme and punitive
ways, arousing severe distress in the child but not pro-
viding any comfort or help. e child is helpless and
defenseless in the face of repetitive abuse and harm,
and therefore chronically feels disoriented, frozen or
terrorized, as the client here has described in this and
the previous session. Both her episodic and semantic
memory carry vivid knowledge of abruptly being cut
o from all sense of intersubjective connection and
plunged into a black hole of nonexistence, a state that
she re-experiences in response to any current inter-
personal misattunement or negativity. Knowing she
is ever vulnerable to that plunge is what maintains
the terror she identied as the problem.
T: Yes, yes. And this one you’re telling me about now—
the black hole of nonexistence—is so powerful. You
thought you had the shared reality of that cuddly
coziness together in the bed!
C: Yeah, yeah I did!
T: And that was annihilated so suddenly.
C: Yeah, exactly.
T: So, I see why theres the black hole opening up.
C: at’s right.
T: What you thought was shared reality suddenly is
gone, annihilated; isn’t—
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INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
C: Yeah, it’s just like, it’s just totally taken from me,
[snaps ngers] just like that! You know, what I
thought was so unreal [sic], isn’t. [Tearful:] And
then Mom would do that, you know she did that, all
these—
T: Yes, in terms of things she said, for example.
C: ings she said or things that she promised she
would do and then deny that she promised it.
T: Promises!
C: Yeah, she would say, “I’ll do this for you,” and shed
go, “No, I didn’t. I never said that.” “No, no, you said
you would do that for me!” So, there was sense of
like shes there and then no, she’s not there.
T: Yes, and the sense that she sees you, and remembers
and cares about what matters to you, and then, oh
no, she doesn’t.
C: “No, I don’t. I never said it. I don’t remember that.
C: [rough tears:] So much of my life has been orga-
nized around this, Bruce. So, many choices—bad
choices, you know. Just so much about—just like
all that being deferential, like try to care—create a
shared reality with someone.
T: at’s been priority one, two, and three, instead of
what’s really right for you.
C: Right, exactly. And being able to like—so afraid to
like, nd out—you know, what if I nd out that your
reality doesn’t match mine? Like, scared to do that.
C: It would shatter at a moment’s notice!
T: Yes, so, naturally, you’re anticipating that, and vigi-
lant for that. Is it like bracing yourself for it?
C: A bit that too, yeah. You know, there’s vigilance,
thereschecking, but theres a bracing too, yeah.
I can feel all the tension in my body from it. Like
almost—all through here, in my shoulders, every-
thing. Its almost like in this kind of like, you know,
a vigilant threat response, like walking around like
that. I can literally feel it. ...
To foster integration of the emerging explicit knowl-
edge of what she suered, the therapist has been prompt-
ing her into repeated verbalizations of it as she is aec-
tively feeling it. Additional somatic aspects have now
also been felt and identied, making the accessing of her
implicit knowledge even more thorough. To the therapist,
the Step B retrieval work now seems adequately accom-
plished because the emotional learning underlying the
symptom of terror is explicit in some detail and there
remains no mystery as to why terror arises when it does.
e retrieved schema consists of specic knowings or
constructs that may be verbalized as follows:
TARGET EMOTIONAL SCHEMA
[e learned problem:] No one maintains shared
reality. When anyone loses track of the understandings
we shared, it means:
Shared reality is irretrievably gone.
I don’t matter and don’t exist to him or her.
No shared reality exists with anyone.
I’m plunged into a terrifying vast darkness of
being utterly cut o and alone in the universe,
and there is no way out.
at can and will happen again at any time, and
that is perpetually terrifying!
[e learned solution:] I’ve got to stay totally
alert to everything that’s happening and re-
member everything so that I can keep shared
reality stitched together when anyone would
let it rip apart. I’ve got to keep my body tight
and braced for the next time anyone rips apart
shared reality and I plunge into the black hole
of nonexistence.
All of that material consists of semantic memory,
that is, general patterns and rules that were formed
on the basis of concrete experiences but do not refer to
those formative experiences in their operation. Here
again, as in the previous case example in Section 7.1,
post-traumatic symptoms are found in TRP Step B to
be arising from semantic memory rather than episodic
memory. e above detailed contents of the schema are
the therapist’s crucial guide in the next step, TRP Step C,
the search for specic contrary knowledge that can then
be used in TRP Steps 1–2–3 (the ECPE) to disconrm,
nullify and erase some key part of the schema. In Step
C, nding contrary knowledge requires knowing exact-
ly what is to be contradicted from Step B: the specic
constructs in the target schema. For Step C, Coherence
erapy instructs the therapist to search for disconrma-
tion (contrary knowledge) in the client’s past experience
(that is, in knowledge that she already possesses, without
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
45
realizing it), or in some experience that has occurred in
daily life since the target schema came into awareness,
or in a new experience that the therapist deliberately
creates. e therapist’s attention and thinking are now
engaged in that search.
SESSION CONTINUES
VIDEO SEGMENT 3: http://www.coherencethera-
py.org/videos-pwd/articlevideo/3.htm
C: It came up this morning with my boyfriend. …I
said, “Wait a minute! We talked for an hour. And
we got into some pretty personal stu in that hour!
I was sharing about my work with Bruce and you
were sharing about something that you were realiz-
ing about you. What about that?” Now there’s that,
“Wait a minute, where is this reality that we just
shared?
T: Very good!
C: But I started crying, you know, like I was that piece
about—but I stayed—I said, “What about this? You
know, it’s like, you just erase that?” … You know,
here it is again. I’m crying and feeling like once
again, I don’t exist. …
Her account of the morning’s incident with her boy-
friend shows that the target schema has remained in
force even though it was retrieved into awareness in
the previous session. e therapist has noticed that
her account has stopped at her collapse into non-ex-
istence, and he is now wondering about what had
actually happened next. Did her boyfriend indeed
fulll her schemas expectations that shared reality
was irretrievably lost and that he would be deaf to
her protestations? Or did his ensuing behavior violate
those expectations, which might serve as a disconr-
mation? To probe that possibility, the therapist next
asked her the following question:
T: How did it go with him?
C: Well, he said, “Oh yeah, you’re right.” He said
we—“I guess I dismissed that.”
I said, “Yeah!” I said, “What about that?” I said, “I’m
really hurt that you just erased that.” And then—
T: Perfect, great!
C: —he goes, “Okay, I forgot it. You’re right, okay.
It is now clear that her boyfriend’s behaviors dif-
fered fundamentally from her schemas expectations.
is completes TRP Step C, the task of nding an
experience that can be used as a contradiction and
disconrmation of the target learning. e client
is not yet recognizing her boyfriend’s response as a
disconrmation of the expectations of her traumatic
memory, even though she is describing his behavior
in detail. e therapist must now guide her to register
her boyfriend’s cooperative, respectful response to her
protests as being a direct contradiction of her schema’s
expectations. Holding both the schema’s expectations
and the contradictory experience in awareness con-
currently, in order for the disconrmation to register
viscerally, is the juxtaposition experience (a Coher-
ence erapy term) that implements TRP Steps 1 and
2, and a few repetitions of the juxtaposition fulll
Step 3, completing the ECPE. e therapist is now
aiming to facilitate that sequence.
T: All right. So, right now, I want you to, as you revisit
it—how that went, and what he said, and your suc-
cess in calling his attention to what he had lost. Yes,
he did lose track of shared reality, but this time, you
prompted him to retrieve it, and restore it, and even
acknowledge to you, “Yes, I lost track of something
important between us and I’ve got it back.
C: He said, “Oh yeah, I guess I did. I forgot.” I mini-
mized that.
T: See if you can let those words be nectar in your life.
ose words from him could be gold, could be
nectar. It’s the other person holding up their end of
reassembling shared reality when they fumble it.
What’s more important to you than that?
C: Right. He’s done that many times with me.
T: And maybe it has own by. …
C: Yeah, yeah. I think because also I’ve been so trou-
bled about how intense my reaction was to his
forgetting, you know, or like—and how, like—
T: You were focused on that.
C: at, and just, like, the hurt and like, the heartbreak,
you know. Like, how could you forget about me?
T: eres a lot of intense components that were in
play for you when this was happening. And so,
your attention naturally was on those things. So,
right now, though, selectively I’m prompting you,
inviting you, to—here’s an opportunity to focus on
46
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
this non-helplessness you experienced. Your success,
your actual ability to get him to retrieve the piece
of shared reality that he had lost track of, and put
it back in place and have it be shared again, and in
addition, acknowledge to you and even apologize for
losing track of it. See if you can let that—let’s see, on
the one side you’re holding that. On the other side
is your old lifelong expectation that that will not
happen—you’ll be all alone, stranded and helplessly
stuck in that black hole once the shared reality is
dropped.
C: Right.
T: So, see if you can, you know, feel both of those.
C: I guess what I’m doing right now is just going—
thinking about all the other times he’s done this too
with me. I mean, he’s done this a lot.
e therapist has just now explicitly cued the juxta-
position experience, but the client has not yet directed
her attention to the both-at-once experience.
T: Yeah, let that really sink in now—all those past ones,
as well as this fresh one—how it’s not like it was
back then [with her parents]. You’re with someone
who doesn’t irreversibly drop out of shared reality.
You can express it and he’ll retrieve it and reas-
semble it together and even acknowledge that, and
you’re not helplessly stranded when it does happen.
C: Ok, yeah, that’s the part, about not being helplessly
stranded.
T: …Wow, all along I have been helplessly stranded,
and I’ve been expecting to be again and that’s why
it’s terrifying. But, wait a minute. With him I’m not
helplessly stranded.
C: No, I’m not. No, I’m not! I’m not helplessly stranded.
Yeah, that’s a key piece. I’m not helplessly stranded.
And, he will do this with me.
T: Yes.
e client is now having her rst juxtaposition expe-
rience, in which the emotional schema that generates
her terror (“I’m helplessly stranded in total discon-
nection”) is present in awareness concurrently with
strongly contradictory, disconrming knowledge (“I’m
able to get him to reconnect with me, so I’m not help-
lessly stranded”). e tonality of her voice in her latest
utterances is dierent than at any point in this or the
previous session, and expresses both her wonderment
at this surprising realization of not being helplessly
stranded and the depth of meaning this has for her.
Feeling helpless is what makes an encounter with
danger so frightening as to create traumatic memory,
as a rule. e memory then includes that helplessness
as an expectation: “Whenever situation X occurs,
I’m helplessly endangered!” at expectation in turn
produces panic and/or dissociated freezing. Discon-
rmation of the expected helplessness is therefore
usually the most eective juxtaposition experience
for unlearning and nullifying traumatic memory and
post-traumatic symptoms.
C: I mean— [Silence.]
T: Yes. [Long silence.]
C: Wow.
T: What’s that?
C: Well, just that piece, because that’s denitely been
in there about just feeling helplessly stranded. Yeah.
Like there was nothing I could do about it. Back
then, I cou l dn’t.
T: Right.
C: Even with all my eorts, it didn’t make any dier-
ence.
T: You were helplessly stranded back then.
C: I was helplessly stranded back then.
T: You felt the oor falling away. I mean, your body felt
the falling away of shared reality.
C: Yeah, and there was no way to get it back.
T: No way. ere was no way.
C: ere was just—my mother wouldn’t do it—
T: It takes two. It takes two to get it back.
C: It takes two, and my mom wouldn’t do it with me
and my dad wouldn’t do it with me.
T: ey didn’t have those skills.
C: Yeah, they didn’t.
T: But he does.
C: Yeah. But Burt does, yeah.It’s interesting how many
people I’ve been with who have not had that skill.
T: Mm-hm. And for you, thats just huge—
C: Its been so critical.
INTERNATIONAL JOURNAL OF NEUROPSYCHOTHERAPY Volume 6 Issue 1 (2018)
47
T: —huge, huge. Yes.
C: Didn’t have it, or didn’t want to do it, or whatever.
T: Yeah, whatever. So, yeah, you’re letting it sink in, in
this new way. ere was an “oh wow” there.
C: Yeah. Wow!
T: Yes, yes.
e therapist has continued prompting her to recog-
nize how “helplessly stranded” in shattered rapport
she truly was again and again throughout her child-
hood, and in later relationships as well. e purpose
of this is to then have her freshly re-encounter the
new disconrmation of that expectation of helpless-
ness, creating repetitions of the juxtaposition expe-
rience for TRP Step 3. e therapist guided her back
into the juxtaposition by saying, “But he [Burt] does.
ere will be several more repetitions of the juxta-
position in the rest of this session. In response to the
client’s various indications that the disconrmation
has been registering strongly, the therapist will now
begin TRP Step V, making enquiries that probe for
markers of erasure.
T: How does it feel in your body?
C: It feels like there’s a— I just feel really soer, kind
of like I’m aware of my breathing and just letting go
tension, or something like a little spacy. ere’s sort
of a melting quality, and theres, like, “ahhh, ahhh.
T: Soening.
C: Soening, yeah, this soening. Wow. Wow. And I
really was helpless back then, and they didn’t have
the skill to retrieve it. But Burt does, and he’s done it
repeatedly with me. And I’m not helpless. ose are
the key pieces. You know, that there are people in
the world that do ha