When the Past is Always Present Part 9

The clinician's posttreatment ratings suggest that for major endogenous depression, personality disorders, and dissociative disorders, other therapies are superior as the primary treatment approach. Energy interventions might still be useful when used in an adjunctive manner.

Rating of 5: No Clinical Improvement or Contraindicated.

The clinician's ratings of energy therapy with psychotic disorders, bipolar disorders, delirium, dementia, mental r.e.t.a.r.dation, and chronic fatigue indicated no improvement.

Relapse rates, which mean a complete return of symptoms, were reported as 9% for the CBT/medication group and 4% for the tapping group.

Although this paper was criticized for lack of absolute rigor as to patient selection, a.s.sessment techniques, data a.n.a.lysis, and overall design, the sheer number of patients treated and the consistency of the results were intriguing.

These exposure therapies, CT-TFT, EFT, EMDR, and havening, all use an intervention immediately after reexposure. This time frame is critical for success. It is when the glutamate receptors are open and subject to disruption. The differences lie in the specific modes and frequency of touching, tapping, eye movements, or other sensory stimulation.

While all these approaches are successful, we believe that a neurobiological model allows us to understand this process and therefore to optimize therapy. Havening provides such a model.

Havening.

Havening has three aspects: 1. Recall and activation of an emotional core.

2. Distraction/other sensory input.

3. Havening touch.

The first is a process that recreates part or all of the traumatic encoding moment. This is followed by the simultaneous use of distraction and other sensory input to displace the component from working memory and havening touch to fool the brain into thinking a safe haven has been found. When successful, the individual is havened. Applying havening raises many questions that we have tried to answer.

* Why is it necessary to activate a component state before it can be treated?

* If an individual has a snake and elevator phobia, why do these problems need to be treated separately?

* Why does the same protocol work for different problems?

* What is the purpose of the touch/other sensory input and distraction?

* Why does the distress appear to diminish during the procedure?

* What is the transduction event that converts touch into a biological event in the brain?

* Why do patients feel calmer after treatment?

* Why and how do the memories become altered?

* Why does it produce a lasting effect?

* Why do some symptoms occasionally reoccur elsewhere?

To answer these questions, a recapitulation of what has been discussed is offered. Retrieval of a traumatized component by conscious or subconscious stimuli causes the release of the neurotransmitter glutamate in areas of the basolateral complex (BLC) corresponding to the specific neural circuit that initially encoded the traumatization.4 It is by activating the pathway that the glutamate receptors become exposed and are susceptible to disruption.

Activation of the emotional component of the traumatized eventWorking memoryHippocampusBLC glutamate receptors activatedDistraction/sensory input/Havening touchSerotonin/ GABA/Low-frequency signal is generatedDepotentiation of activated BLC glutamate receptors Outflow from AmygdalaEmotional core de-linked from narrativeTraumatization cured Havening causes the depotentiation of activated glutamate receptors and the de-linking of the emotional pathway in the BLC of the amygdala5 (Figure 8.3). The CorticalContext/Complex Content Recalled Event pathway sometimes remains intact (see Post-Havening), but without emotional amplification. (Figure 8.4).

Mechanism of Havening.

Glutamate is the electricity that lights the event so it can be seen in the mind. Without the activation of glutamate receptors in the amygdala Figure 8.3 Havening disrupts amygdala activation and the emotional core is de-linked from the recalled event.

and the locus coeruleus, we are unable to permanently interrupt the pathway that allows us to reexperience the event. It can be speculated that each emotion and different circ.u.mstance has a specific and unique intra- and extra-amygdala pathway. Though feeling states can overlap, it is best to treat each emotion separately. The emotion of guilt should be treated separately from anger, and so on. On the other hand, if the stimulus uses the same pathway (e.g., fear of bridges), then removing the pathway that activates an emotion response for a generic bridge should suffice, although recalling the encoding event would be best. Because activation of glutamate receptors is common to all treatment approaches, the same protocol should work for all amygdala-based components. Decreasing distress from distraction during treatment results from diminished input to the amygdala from working memory. This inhibits outflow from the BLC to the Ce and diminishes NE outflow from the locus coeruleus. Unlike EMDR, where the client is asked to focus on the event, during havening, once the emotional component is activated, the client attends only to the instructions given by the therapist.

The pathways by which stimulation of peripheral mechanoreceptors in the skin produces a rise in serotonin and GABA and transduces a low-frequency signal remain unclear (see Appendix F). Havening touch produces a comforting sense, of feeling safe, not abandoned, and sleepiness. The low-frequency brain signal produced by havening, a delta wave, is seen in stage 3 sleep, the deepest, most restorative part of sleep. It would be impossible to reach stage 3 if there were any perceived threat. After havening, attempts at retrieval of the emotion generated by the memory are unsuccessful. The memory is no longer a traumatic memory; it no longer engages the amygdala (see "Post-havening" section below). If you have havened a symptom other than the emotional core, then it remains possible to reestablish a link to the original or related traumatic component. This is so because the amygdala-based emotional component has not been dissolved.

Successful havening removes the amygdala-activated traumatic emotion forever, and unless the exact moment of encoding is replicated, the ability of the traumatic components to activate the amygdala is lost forever. The process of depotentiation of the glutamate receptors Figure 8.4 Post-havening without amygdala activation: Context and complex content no longer have emotional amplification.

in the amygdala has permanently altered the process of memory retrieval (Figure 8.4).

Since the havening has a hardwired soothing component, it should be possible to modulate and soothe everyday routine reflective emotions such as cravings, sadness, anger, and others. If not encoded as a trauma, why should this be so? The reason is the individual is emotionally activated and has an activated amygdala. Havening causes a rise in serotonin. This rise acts to decrease information flow and salience. It allows the working memory to let go of the stimulus. Of course, unlike removing a permanently encoded traumatic memory, once you stop havening, this feeling may return later.

Details of Havening.

Recall and Activate the Emotional Core.

If at all possible, the first task is to find and activate the event's emotional core. In many cases, multiple traumatic events have been encoded. This requires a thorough history, which, as treatment progresses, often unfolds in unpredictable ways. History taking is an ongoing process; it is really an inner-view, an internal view so to speak. We do this without intent to alter this view by talk; its purpose is to find the emotional core so that it can be havened. This is the fundamental difference between talk therapy and havening.

Janice's difficulty walking on uneven surfaces seemed odd. She carried a folding chair with her at all times so she could sit down as her feet became tired. She traces this problem to an event in the hospital when she had knee surgery and her legs were elevated and her feet not supported. For reasons that are not clear, she developed a bruise on the back of her leg, and from that time on she could not walk easily. After many sessions we were able to track numerous traumatizing events that could affect her perception of her feet. Havening events such as being held down in a dentist's chair with her feet dangling over the edge while having four wisdom teeth painfully extracted, watching a chicken being killed while its legs were held, walking on venetian blinds on the floor and cutting her foot, and having a nail stuck in her heel has yet to completely solve her problem. This lack of resolution suggests that earlier events have yet to be uncovered.

During the taking of a history it is important to inquire about the meaning of the event, previous landscapers (other life events that produce stress), and the individual's sense of inescapability about an event. Look for unconditioned fear stimuli, especially a sense of abandonment and unresolved anger (what we would call defensive rage). Ask if there was a prior injury to the area that now has chronic pain. Ask if there were any unresolved childhood memories that still produce distress today. Ask if there were any motor vehicle accidents, or whether he or she recalls when the problem first started. Follow trails and observe physiological responses to statements and memories. Be prepared to ask difficult questions, but don't press for answers. Search dreams. After a thorough history, the therapist must decide whether the behavior or the feelings he or she observes are consequences of a traumatization. As mentioned earlier, traumatization can occur even with what appears to be a trivial incident if it has meaning to the individual.

A good therapeutic relations.h.i.+p is critical to tease out these areas so they can be addressed. The clues, the dead ends, and the lack of progress are all part of the process that eventually leads to a cure. This seems to be particularly true in the case of chronic pain and posttraumatic stress disorder (PTSD), where the memories remain unavailable or are dissociated and one might think that havening hasn't worked. Gary Craig, the originator of EFT, describes many ideas for getting around what seems like failure (www.eftuniverse.com). There is much that can be learned as one uses this approach, and using the model described here, your skills will improve over time.

If one cannot readily find the emotional core, focusing on a distressing symptom is often useful. Simply activate the distress surrounding the symptom. Be as specific as possible when describing the symptom (e.g., the right side of the upper back or neck) prior to havening (see Appendix E).

Havening sometimes produces the most remarkable of medical miracles, an instantaneous cure. Observing this process seems to belie the statement that seeing is believing. Surely a trick has been played and the long-term emotional problems, the pain, the fear will most certainly return. Most patients are in disbelief. More often, only a part of the underlying emotional issues is resolved during any single treatment session. This is true because traumatization begets traumatization, so that removal of one event uncovers others.

Distraction and Other Sensory Input.

The therapeutic component of the havening process requires that both distraction and other sensory input and havening touch be performed immediately after activation. We use a relatively standard sequence, but the therapist can use what he or she thinks works best for the patient. Future research will look at different tasks to optimize distraction and comforting. The client and I are comfortably seated facing each other so our eyes are pretty much aligned. I then give him or her a brief set of instructions: 1. Once we start, I want you just to listen to the sound of my voice as I tell you what I need you to do.

2. After bringing the event/symptom to consciousness and stating an SUD score, it is important to keep your mind focused on the tasks at hand.

3. During the session I request that you not speak spontaneously.

4. In between havening rounds, I want your eyes to remain closed and for you to stare at the back of your eyelids.

5. If for any reason you begin to feel uncomfortable, let me know.

After recall of a traumatic component with their eyes closed, an SUD score is obtained from the client. I start with tapping on the collarbone with both hands on both sides; it has a nice vibratory sense to it. While I am doing this, I have the client open their eyes, look down to the left, down to the right, and make a big circle, first one way and then the other. I have them close their eyes and count slowly (one number per second) from 1 to 20 aloud as they visually imagines walking up a flight of stairs, one number for each step. I instruct them as follows: "As you walk up the stairs, each step causes you to feel more relaxed, and when you reach the top, a beautiful vista awaits you." This activates the visual-spatial (imagining walking up stairs) component of working memory. I then have them hum a tune to activate the phonological component of working memory. The cycle of visual-spatial and phonological distraction along with various touch techniques is repeated with different stimuli. Different tasks, for example, visualizing shooting basketb.a.l.l.s, throwing horseshoes, climbing stairs, or rowing a boat, and different tunes, for example, "Mary Had a Little Lamb," "Take Me Out to the Ball Game," and so on, are used with each round. Several rounds are repeated until the SUD score either reaches 0 or cannot be lowered further. Finally, I have the client open their eyes and have them follow my hand to the four corners of the visual field. I ask them to close their eyes, take a deep breath, then say OMMMMM while exhaling. I suggest the client should lower their shoulders as I stroke from their shoulders down to their hands. I then obtain another SUD score.

Havening Touch.

Touch is among the most powerful forms of communication. Havening touch is meant to be comforting, soothing, relaxing, and unhurried. It is not a light touch, nor is it heavy handed. Some of the areas that are touched are shown in Figures 8.5 to 8.8. I generally vary the areas of touch during each cycle.

During this process I use an unmodulated, somewhat monotonous voice that is never hurried. I am always encouraging. Phrases in the same unmodulated tone, such as "almost home" and "you are Figure 8.5 Face havening. (Courtesy of Ronald Ruden and Steve Lampasona.) Figure 8.6 Arm havening. (Courtesy of Ronald Ruden and Steve Lampasona.) excellent at this," are interjected while comforting and soothing by havening touch. Rarely does this process take more than 10 minutes, and for most, an SUD score of 0 is reached. If an SUD of 0 is not reached, I take a further history to look for earlier clues. As I begin Figure 8.7 Hug havening. (Courtesy of Ronald Ruden and Steve Lampasona.) Figure 8.8 Forehead havening. (Courtesy of Ronald Ruden and Steve Lampasona.) to explore the emotional and physical effects of traumatization, I am often struck by how many emotional issues an event can produce. For example, individuals who have been s.e.xually abused in their youth experience anger, shame, and guilt. Each of these emotions must be treated separately. In addition, sometimes the anger is also directed at the parent who allowed the abuse to occur. People with back pain secondary to an accident need to have not only the accident havened but also the fear of recurrence of the pain. The more specific one can be, the more likely havening will be successful. One might be afraid of snakes, but it is the slithering aspect that makes the patient's skin get goose b.u.mps and activates the amygdala. Kinesthetic aspects, involving movement, are very important.

Havening: A Summary.

After obtaining a history, have the client activate an emotional core of the traumatic event. This is the most critical aspect of the therapy, and time spent here is well rewarded. If this is not possible, have the client focus on their most troublesome symptoms. At the outset of event activation, I encourage them to make a movie of the event as bright and detailed as possible. I occasionally aid him or her in his or her visualization. Generally no more than 30 seconds is given before I request that they provide an SUD score. After an SUD score is obtained: 1. Instruct them not to think about the event or component again.

2. While tapping on the client's collarbone, have the client open their eyes and look down to the left, then right, and then make a circle with his or her eyes in both directions.

3. Instruct the client to once again close their eyes and imaginally perform a distracting visual process (walking up a flight of stairs while counting aloud from 1 to 20 for 20 steps). This is performed while the therapist applies arm havening.

4. After the count reaches 20 have the client hum a song with his or her eyes closed (e.g., "Take Me Out to the Ball Game," "Happy Birthday," "Old McDonald Had a Farm," etc.). Arm havening is continued. After completion of the song, have the client open his or her eyes and follow your finger for one sequence: up, down, to both sides, then up again.

5. Have the client take a deep breath and exhale with an OMMMMM; move your hand downward as they close their eyes.

6. Ask them to lower their shoulders and continue arm havening.

7. Ask them to close their eyes, look at the back of their eyelids, and only listen to your voice. Obtain an SUD score.

8. Repeat processes 1 to 7 using different havening touch methods and distractions until the SUD is 0 or remains fixed after three rounds.

I have found great difficulty in treating trauma with havening if a severe anxiety disorder (i.e., obsessive compulsive disorder) is also present.

Self-Havening.

Havening can be self-applied for many routine emotional states. However, for reactive and reflective emotions that are traumatically based, it is best to have a therapist involved. There are many subtleties involved with using this approach, and guidance by an experienced pract.i.tioner is helpful.

Self-havening may be a useful approach to disorders involving obsessional thinking and repet.i.tive behaviors. Thus, as described by Dr. David Lake (see p. 185), this works for compulsive disorders such as bulimia, checking, hand was.h.i.+ng, and hair pulling. It is best not to fight the desire to perform the action. Rather, view the desire as an activation of the BLC and apply havening at that moment. Over time, a person should be able to control or eliminate the unwanted behavior. In addition, for those who struggle with panic disorder, a.s.sume the attack is an activation of the BLC and apply self-havening. Try not to understand why it is happening or attempt to will it away. Diagrams of self-havening methods are shown in Figures 8.9 to 8.10.

Self-havening can be done in the presence of a therapist. However, unless the client is touch averse (see Appendix G), I believe that the Figure 8.9 One way of face self-havening. (Courtesy of Ronald Ruden and Steve Lampasona.) Figure 8.10 One way of face self-havening. (Courtesy of Ronald Ruden and Steve Lampasona.) therapist should touch the patient, as the difference between self-touch and a therapist's touch may be significant.

Post-Havening.

A relaxed state is always seen after successful havening, and retrieval of the memory is altered in one of four ways: 1. The memory is blocked and is inaccessible.

2. The memory is fuzzy and incomplete.

3. The memory is viewed from a distance and as a detached observer.

4. The memory is richer in peripheral detail, but the fearful component is less clear or absent.

These four outcomes are directly related to the loss of norepinephrine, depotentiation of the BLC pathway, and the subsequent elimination of the emotional response (see Figure 8.4). Recall of the fearful component of the memory is immediately impaired and further diminishes over time. Thus, when recalling an event after successful havening, it appears distant; a few minutes later it will appear more distant.

Figure 8.11 Self-havening hug. (Courtesy of Ronald Ruden and Steve Lampasona.) The component parts are no longer linked because the UFS/unimodal sensory content a.s.sociation that led to an emotional response has been disrupted. The removal of the emotional component detaches us, and we view the event dispa.s.sionately. Finally, if the feared object is eliminated, the context of the event that had been overshadowed may now become available. For example, for a traumatized memory, prior to havening, we selectively remember the emotionally rich component of a memory at the expense of other aspects of the memory of the event. In this moment of fear we often narrow our focus to the fearful object. We recall the gun, the knife, but not necessarily the surroundings; they are not readily accessible to conscious recall because our main focus is the feared object. If the feared component is eliminated, the context can be recalled.

Fannie remembers that the door was open when her cousin told of her father being killed in a motorcycle accident. It was only after havening that she remembered her cousin was wearing pink pants.

It is useful to debrief the client by asking him or her to see if he or she can recall the memory and tell how it appears to him or her. Both the therapist and the client will learn from this question. The mind solves the problems in sometimes remarkable ways. The most common solution is metaphor.