A New PTSD Treatment Paradigm (excerpted from Science of Psychotherapy, December, 2022)
Steve and Connirae Andreas (1993), two master trainers in the neuro-linguistic programming (NLP) movement, created eye movement integration (EMI) in 1989. Although procedurally similar to the first eye movement technique introduced by Shapiro (1989), EMI’s theoretical underpinnings were manifestly different. EMI’s design was grounded in NLP theory, principles and strategies, whereas Shapiro insisted her procedure was not. Both techniques directed clients to focus on a representation of a distressing memory in front of them while they simultaneously followed the movement of a finger, or an object like a pen, with their eyes. What made the techniques so similar, I would discover, was their common ancestry.
I was fascinated the first time I saw Ron Klein demonstrate EMI at a seminar in 2002. I’d never observed a method so simple, yet so fast and effective at relieving posttraumatic stress disorder (PTSD) symptoms. As a survivor of childhood sexual abuse, I tend to scrutinize all PTSD methods with a steely, existential eye. Experience has taught me that the most popular therapies are not as effective as they claim (Steenkamp et al., 2015; van der Kolk, 2015). To my surprise, when I began using EMI with clients, I was amazed by its ability to quickly and permanently desensitize the sensory and kinesthetic disturbances associated with PTSD. I was equally impressed by how uncomplicated EMI’s theory and procedures were when compared to Shapiro’s eye movement desensitization and reprocessing (EMDR), a technique I’d experienced as a client in therapy. There were two problems though—EMI had never been developed beyond the modeling stage and it was only taught in one-day seminars.
When I began offering EMI seminars to other practitioners in the mid-2000s, I discovered that, without prior NLP training, attendees struggled to understand the technique’s theory and guiding principles. And requiring therapists to attend multiple NLP trainings prior to learning EMI would not have been practical. Attendees also expressed a reluctance to use the approach with their clients until its procedures had been fully documented. In 2008, I decided to write an EMI practitioner’s guide, a task I estimated would take a few months. Unexpectedly, the project mushroomed into a multifaceted research and development effort that culminated 13 years later with the publication of Multichannel Eye Movement Integration: The Brain Science Path to Easy and Effective PTSD Treatment (Deninger, 2021). While researching the history of eye movement therapies for this book, I ascertained that existing accounts had erroneously traced the origins of these approaches to a single story about a walk in a park. But that explanation was notably deficient; the true story is much more convoluted. Rather than just a chance occurrence, the genesis of eye movement therapies actually began two decades before the first technique was conceived.
Split Brain Research
In experiments conducted in the 1960s, American neuropsychologist Roger Sperry (1968) determined that the separate halves of the brain were able to function independently, albeit differently, and that the content processed by each was quite distinct. Sperry’s subjects were epilepsy patients whose brains had been surgically bisected to reduce seizure activity, making the hemispheres independent of each other. Researchers already knew from stroke patient studies that the left brain controlled mobility and vision on the right side of the body, and the right brain controlled those functions on the left side. From his experiments, Sperry confirmed that the left hemisphere processes verbal information—like speech and language—while the right brain manages spatial, numerical and abstract tasks. Sperry described the brain as exercising two different modes of thinking—one verbal and one nonverbal—represented separately in the left and right hemispheres, respectively. Just a few years after these results were published, the implications of his discovery were being explored in relation to brain hemisphere activations, sensory processing, and most important to this discussion, eye movements.
Eye Movements and Brain Hemisphere Lateralization Studies
Given that vision and mobility on either side of the body were controlled by opposite hemispheres of the brain, and given that the left and right sides of the brain processed disparate functional tasks, researchers began to question whether eye movements might also play a role in hemisphere activations. In the early 1970s, a trio of research studies explored whether eye movements to the left or right in right-handed subjects were associated with opposite brain hemisphere activations (Kinsbourne, 1972; Kocel et al., 1972; Galin & Ornstein, 1974).Subjects were asked questions designed to activate the right or left hemispheres (e.g., verbal questions for the left side and spatial or numerical questions for the right) while eye movements were observed.
Each of the studies confirmed that eyes move in the opposite direction of (i.e., contralateral to) the brain hemisphere being activated, but two of the studies also reported unexpected secondary findings. Subjects often moved their eyes to the right when processing verbal problems and to the upper left when processing numerical or spatial problems (Kinsbourne, 1972). In the Galin and Ornstein (1974) study, verbal questions elicited more downward and right-directed movements. These associations between eye movements to specific locations, and the mental processing of images and speech or language, provided the first empirical evidence that eye movements might be associated with neurology. In an NLP study conducted a few years later, the validity of these relationships was tested more methodically.
NEURO-LINGUISTIC PROGRAMMING: THE BASIS FOR EMI AND MEMI
John Grinder and Richard Bandler developed NLP—a collection of sensory-based counseling approaches and modeling techniques—in the 1970s. NLP’s guiding precepts were derived primarily from the therapeutic methods of master therapists Milton Erickson, Fritz Perls and Virginia Satir (Bandler & Grinder, 1979; Dilts et al., 1980). After analyzing the works of these experts, and after collaborating with Satir and Erickson, Bandler and Grinder identified several unifying beliefs about the intersection of language, communication and therapy underlying the successful methods of the three. The pair then reasoned that the beliefs and techniques of these masters could be modeled and taught to others. Of the many books from that period, four stand out as important records of the research, rationale and initial models that constituted NLP: The Structure of Magic (Bandler & Grinder, 1975), The Structure of Magic II (Grinder & Bandler, 1976), Frogs into Princes: Neuro Linguistic Programming™ (Bandler &Grinder, 1979) and Neuro-Linguistic Programming: Volume I—The Study of the Structure of Subjective Experience (Dilts et al., 1980).
To bridge the divide between theory and practice, Bandler and Grinder codified the beliefs of the masters into a number of predictive statements they called presuppositions. Presuppositions are defined as assertions or propositions based on subjective experience that are accepted as true in order to test a theory or pursue a desired outcome, even if scientific evidence has not confirmed a particular proposition. The strength and value of a presupposition is therefore determined by its ability to consistently predict an outcome. For instance: Human experience is stored and retrieved using sensory data. Considered as a whole, the presuppositions laid the foundation upon which NLP products and strategies were developed.
1. Human experience is organized and systematic.
Humans acquire attitudes, beliefs, values, behaviors and language from our experiences and those around us. These values and beliefs do more than shape our preferences; they determine how we think, feel, act and speak. They are organized and systematic, rather than unstructured or haphazard. Sociocultural norms reinforce the structures and sequences that guide our thoughts and actions. Books always have titles, chapters and numbered pages. Gadgets come with operating manuals. On a personal level, when we take a shower, dress ourselves, or eat a slice of bread, we tend to follow the same routines, unless something disrupts our current system’s structure. This principle also applies to our physical, cognitive and sensory systems.
2. Human experience has a structure.
Each of our experiences has a structure comprised of four elements: context, thoughts, sensory information and feelings. Context is the who, what, when and where of an experience. Thoughts are the cognitions associated with an experience. Sensory information (from four of the sensory modalities) includes the images, sounds, smells and tastes of an experience. Feelings can be visceral (i.e., physical), emotional or tactile. These four elements provide dimension to all human states of being—whether positive, neutral, or negative. These four elements allow us to organize our experiences, create order in our lives, and respond to the world around us. Because human experiences have a structure, the elements of past experiences can be recalled and examined in the present. This also enables us to monitor changes in a memory’s elements after therapeutic interventions in MEMI. A modified version of NLP’s interactive structure of experience theory that provides the framework for MEMI’s protocol, procedures and assessment techniques is shown in this image.
3. Experiences are stored and retrieved using sensory data.
Sensory information provides the medium through which memories and ideas are mentally represented when they are stored and later retrieved. When accessing stored sensory data in MEMI—most frequently in the form of visual images—we ask clients to mentally revivify memories with the use of modifiers (called submodalities in NLP). By applying variables such as distance (near or far), movement (movie or still photo) orclarity (clear or unclear), we are able to establish a baseline of characteristics which can be reassessed after eye movement sets. These variables are tested, retested and then recorded on a MEMI worksheet, a portion of which is shown in this image.
We also ask clients how intense or threatening the sensory characteristics are with a five-point intensity scale (I-Score)—0 represents no intensity at all and 4 the highest possible intensity. In this way, micro assessments of the effects of eye movement interventions are measured pre- and post-treatment. Changes in I-Scores after each set of eye movements are also shown in this image.
4. When patterns are interrupted, human experience reorganizes.
Because habitual patterns of behavior are organized and systematic, they also tend to be enduring human attributes. However, if interrupted, habitual patterns (e.g., images of traumatic memories) will reorganize. In his publication Man’s Search for Meaning, Frankl (1959) described being so demoralized at a Nazi concentration camp that he decided to change his troubling thoughts. While he was presenting a lecture to his bunkmates about the psychology of prison camps, from the far end of their decrepit barracks, he imagined himself speaking to a professional audience in a posh Vienna lecture hall instead. By visualizing this change in context, he was effectively splitting his awareness between two scenarios: “All that oppressed me at that moment became objective, seen and described from the remote viewpoint of science. By this method, I succeeded somehow in rising above the situation, above all the sufferings of the moment, and I observed them as if they were already of the past” (p. 77).
This visual pattern interruption of Frankl’s allowed him to observe his plight as an observer, not a participant, blunting the effects of the prison camp to some degree. As will be discussed, the use of embedded hypnotic commands and metaphors are other types of pattern interruptions used in MEMI, in addition to its guided eye movements while thinking about a traumatic experience.
5. When experience reorganizes, the results tend to be beneficial.
Six months after a police officer was fired upon late one night while sitting in his patrol car, he was still having flashbacks about the experience. Whenever the memory was triggered, his hands would tremble like they had on the steering wheel and his eyes would dart uncontrollably from point to point. I asked him to replay a movie of that night in his mind—but instead of being in the car, I asked him to watch his younger self going through the experience from twenty feet away. When asked if the memory was the same or different following the exercise, the officer was surprised to find that his hands were no longer shaking. This MEMI presupposition assumes that, when interrupted, the structure of an experience will very often improve. While not guaranteed, that result is predicted. MEMI’s use of a variety of sensory and kinesthetic pattern interruptions is what makes this therapy a multichannel approach.
NLP Eye Movement Model
Two of NLP’s early models were essential to the development of MEMI. One was its eye movement or eye accessing cue (EAC) model and the other its visual kinesthetic dissociation (V/K/D) procedure. According to Dilts (1983), the EAC model shown in Figure 3 was based on clinical research done by Bandler and Grinder and a 1977 eye movement study of his own. He was undoubtedly familiar with Sperry’s split-brain research and the three hemisphere lateralization studies mentioned previously.
Although the study Dilts conducted was a logical extension of those earlier investigations, his was broader in scope. In keeping with MEMI’s first presupposition—that human experience is organized and systematic—Dilts hypothesized that eye movements are not random. Instead, they act as behavioral “cues” providing evidence of a connection between those movements and human neurology. His study tested whether eye movements to specific locations in one’s visual field (e.g., lower left or upper right) would correlate with the type of neurosensory information being processed in the brain. Study participants were asked questions requiring visual, auditory and kinesthetic processing while electrodes tracked their eye movements and EEG activations in both hemispheres (Dilts, 1983).
According to Buckner et al. (1987), the Dilts study produced incomplete results, in part, because the ocular electrodes used to detect eye movements were inadequate. And although subjects’ lateral eye movements did not correlate directly with contralateral EEG brain wave patterns as hypothesized, analyses of subjects’ sensory-specific cognitive tasks did confirm a strong relationship between eye movements and contralateral brain hemisphere activations. Although the creation of the EAC model is often attributed to Dilts, he credits Bandler and Grinder with the initial coding of its eye accessing positions (Dilts, 2006).
As illustrated in the model, eye movements up to either corner correlate with the processing of images, while eye movements to either side on the horizon are associated with the processing of sounds. Depending on the direction (left or right), the visual and auditory locations can also exhibit a past or future orientation (left indicates encoded sounds or images from the past; right indicates an image or sound never seen or heard before). Although this left (past) and right (future) orientation is depicted in the model, Dilts and DeLozier (2000) later proposed that these directions are sometimes reversed based on right- or left-handed dominance, similar to results reported by Kinsbourne (1972).
Thomason, Arbuckle and Cady (1980) were unable to validate the model’s eye positions, but their results did confirm that eye movements are not random. Dilts (1983) recommended that future tests of the model should videotape subjects’ responses to more precisely determine the sensory modality activated at the time of each eye movement. In a commentary, Beck and Beck (1984) rejected the findings of Thomason and colleagues, arguing that they misunderstood the model. Beck and Beck also recommended that future studies should use sensory-specific stimulus questions, film the responses, and as Dilts had suggested, ask follow-up questions to determine the sensory modality in use at the time of the eye movements.
In an analysis published online of all peer-reviewed studies of the EAC model from its introduction in 1977 until the time of the review, Diamantopoulos, Woolley and Spann (2009) reported that a clear conclusion as to the validity of the model could not be reached. Four of the ten studies found evidence to support the model, while six others reported a lack of support. However, the reviewers cited serious methodological problems with each of the six non-supportive studies due to erroneous assumptions that were made about the EAC model. Diamantopoulos and colleagues concluded that there was insufficient research to either prove or disprove the model.
One methodologically sound study of the model conducted by Buckner et al. (1987) incorporated the recommendations of both Dilts and Beck and Beck in its design. Its most significant finding was that rater observations of eye movements to four of the locations in the model—the past and future visual and auditory accessing positions—were highly correlated (p<.001) with subject observations of the modality in use at the time of the eye movements. Eye movements to the kinesthetic (feelings) location could not be validated and movements to the “self-talk” position were not tested. Although the model was only partially validated, the results confirmed that eyes do move to prespecified locations in tandem with auditory and visual processing.
Despite its incomplete validation, I believe that the EAC model’s significance has been underreported and underappreciated. One could even argue that eye movement therapies might not have been invented without the model’s existence. The reasons for this are described in greater detail in the book Multichannel Eye Movement Integration. Based on existing studies of the EAC model and extensive clinical experience with MEMI, I conclude that eye movements are indeed organized and systematic, whatever the specific pattern might be for any individual. Furthermore, perhaps because of their unconscious nature, the evidence is also strong that eye movements are active components in a complex neurophysiological system.
Results from the Dilts and Buckner et al. studies introduced a new eye movement and sensory processing paradigm evidencing a neurological connection between eye movements and the activation of sensory modalities. The results also affirmed that eyes do move systematically, not randomly—to at least four of the six accessing positions in the model. Even Thomason and his colleagues, who were detractors of the model, confirmed that eye movements are not random. Because technological advances now allow for more accurate detection and tracking of eye movements (e.g., PCEye eye tracker for accessibility - TobiiDynavox US), and because brain scanning technologies are much more advanced, we believe this would be a good time to replicate the Buckner study.
Like Dilts, the Andreases (1993) believed that eye movements are not only organized and systematic, but they also correspond to sensory modalities being processed simultaneously in the brain: “They are the means by which these brain functions are activated,” they argued (p. 3). And, most relevantly, the following statement establishes why this is critical to understanding the role of eye movements in MEMI: “By deliberately moving the eyes in specific directions, one can alter the way a subject’s brain processes a given piece of content” (p.3). Now, almost three decades after the Andreases made this observation, studies and commentaries are beginning to produce evidence that eye movements and neurology are in fact interrelated (Jung and Huberman, 2018; de Voogd et al., 2018; Bone et al., 2019; Mace et al., 2018; Damiano & Walther, 2019; Wynn et al., 2020; Sweeton, 2021; Johansson et al., 2022). Thus, whether a connection between eye movements and neurology exists should no longer be in question.
NLP’s Visual Kinesthetic Dissociation(V/K/D) Procedure
Another NLP model critical to the development of all eye movement therapies was a visual procedure designed to treat phobias and traumatic memories. Called the fast phobia cure—also known as visual kinesthetic dissociation (V/K/D)—it was an application of a Milton Erickson hypnotic technique. V/K/D was first described by Bandler and Grinder (1979) and later formalized by Bandler (1985).
In a more recent version of this procedure, sometimes referred to as the movie metaphor (Dilts & DeLozier, 2000), clients are instructed to imagine themselves seated near the stage of a movie theater, watching a blank screen. Next, from a location at the back of the theater, they are asked to watch both themselves seated near the stage and a movie of the distressing memory playing onscreen. Image depicts this scenario. While watching the movie, the client is grounded in a confident or competent psychological state (reciprocal inhibition) using NLP resource anchoring. In MEMI, a resource anchor is defined as a positive experience from a client’s past, that when re-instilled in them, becomes an uplifting force offsetting the negative reactions to a disturbing memory.
Viewing the movie from the back of the theater creates a twofold visual separation between the self and a memory’s image, called a double dissociation in NLP. By creating this distance and psychological separation, the event can be viewed by an observer-self without experiencing its attendant physiology and emotions—similar to what Frankl described in Man’s Search for Meaning. And because the image is farther away in space and time (as a result spatial and visual reframing by a practitioner), it can be perceived as less threatening.
Klein (2015) popularized a sister technique adapted from V/K/D and used in MEMI, called therapeutic dissociation. With resource anchoring, it became another dynamic safety mechanism to assure client security during exposure to disturbing memories. In his procedure, a client is asked to project an image of the distressing event on a wall across the room, while the therapist uses gestures, body language and vocal inflections to emphasize the visual, temporal and spatial separations between the client and the experience. Incidentally, Shapiro (1989) incorporated a technique similar to V/K/D into her first eye movement procedure by having clients envision the distressing image in front of them while eye movements were conducted, but she failed to give attribution to Frankl, Erickson or NLP developers.
FROM EMI TO A MULTICHANNEL APPROACH
EMI is based on NLP theory and presuppositions. Thus, the technique’s procedures closely track those used in other NLP models. Because I had completed NLP practitioner training prior to learning EMI, I was familiar with several of its change strategies. But because EMI was being faulted for its lack of written procedures, I resolved to fully document the approach. During that process, I decided to insert NLP theory and presuppositions into the new therapy’s design. Transforming EMI into what would eventually become MEMI also offered opportunities to improve the method by adding innovations inspired by clinical experience and advances in research.
I began by documenting the procedures I was using and compiling supplementary materials for distribution at seminars. In order to bring the new model to life, I developed a straightforward, 10-step protocol with instructions, procedures, therapist scripts, assessments and a worksheet for recording results following eye movement sets. I endeavored to make every aspect of the therapy straightforward and user-friendly. These enhancements, along with the adoption of a standardized PTSD checklist, made systematic evaluations of MEMI possible. However, the foundations of the therapy—the theory, presuppositions and beliefs framing its operations—are true to those referenced by the Andreases when they created EMI in 1989. And all of this, I'm delighted to write, was accomplished with the approval of the Andreases!
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