Appendix A:

Nontouch Havening*

On occasion, and with the permission of the client, I have had observers in the room, generally stationed behind the client and able to watch the therapy being performed. It has not escaped my notice that invariably, attentive observers felt calm after the treatment was over. They became relaxed after simply observing the therapy, without my ever having touched them. At first, this was puzzling, as I had postulated that the touch itself was critical to the outcome of havening. How could one be comforted and made to experience calmness and relaxation without being touched?

Mirror Neurons.

The answer may lie in a group of neurons called mirror neurons. An Italian research group1 seeking to explore the brain's response produced by visually observing an action by another was the first to describe mirror neurons. They were astonished to discover that both doing and observing an action activated similar neurons. Why should this be? These workers suggested that these mirror neurons played an important role in learning done through imitating actions, for example, see then do. Indeed, many world-cla.s.s athletes train by watching themselves performing a task. In addition, researchers studied clients both observing others experiencing emotions and feeling the same emotions themselves. Here, too, they discovered the same groups of neurons would fire under either circ.u.mstance. This, they felt, was the source of empathy, feeling what others feel when observing them. Language and other learning processes seemed also to use the mirror neuron system. Maldevelopment of the mirror neuron system is felt by some researchers to be the root cause of autism.

Functions mediated by mirror neurons depend on the anatomy and physiological properties of the circuit in which these neurons are located. Motor behavior was studied in the initial mirror neuron research. Accordingly, activations were found in circuits related to motor action. Later studies involving exposure to disgusting odorants and viewing movie clips showing individuals displaying a facial expression of disgust found that similar pathways were activated. Data have been obtained for sensory pain and seeing a painful situation experienced by another person loved by the observer.2 Taken together, these experiments suggest that generating emotions by thought activates circuits that also mediate the corresponding emotion generated by extrinsic stimuli.3 It should come as no surprise that watching someone being havened would have a response similar to that of the person actually being havened. The implication of this is of interest. One could theoretically make a movie of havening and use that to treat others merely by having them activate the problem while watching the video.

References

1. Rizzolatti, G., & Craighero, L. (2004). The mirror neuron system. Annu. Rev. Neurosci. 27:169192.

2. Saarela, M. V., Hlushcuk, Y., Williams, A. C., Schurmann, M., Dalso, E., & Hari, R. (2007). The compa.s.sionate brain: Humans detect intensity of pain from another's face. Cereb. Cortex 17:230237.

3. Gallese, V., Keysers, C., & Rizzolatti, G. (2004). A unifying view of the basis of social cognition. Trends Cognitive Neurosci. 8:396403. Retrieved from http://www.scholarpedia.org/article/Mirror_neurons

Appendix B:

Cultivating Resilience*

While some are traumatized by an event, others are not. As mentioned in the text, there are four requirements that need to be met for an event to be traumatizing. One of these components is the suitable landscape of the brain. First, we must define psychological resilience. In simplest terms, it is the capability of a landscape to resist being altered, or being able to rapidly return to a level that does not meet the requirements for traumatization. Resilience, therefore, increases the threshold to traumatization. How can this be accomplished?

Asking someone how they recovered from a trauma can do this. This provides an opportunity to learn how others have found solutions to stressful experiences. This learning process increases a belief in the ability to solve problems. By improving these skills, it enables us to cope better. Holding this belief, even if the problem is not solvable at the moment, reduces the risk of traumatization. These skills can include communication skills, problem-solving techniques, previewing (the ability to plan), and resource management. The goal of this process, what we wish to achieve, is a modulated response to an intense emotional situation. Like any skill set, this requires practice. Amazingly, none of this is taught in schools. While certain inherent characteristics make individuals more or less susceptible, all can improve. This curriculum has been described and is outlined in a book by Dr. Tony Newman called Promoting Resilience: A Review of Effective Strategies for Childcare Services. This book in its entirety can be downloaded from www.ripfa.org.uk/aboutus/archive//files/reports. PromotingResilience.pdf.

Aside from formal teaching, nonspecific approaches such as yoga and meditation can be used. Techniques that decrease levels of stress hormones raise the threshold to traumatization. Staying fit is an excellent example, as it removes the stress of an out-of-shape body. Proper sleep, good food, loving attachments, and the practice of effort and reward, wherein effort toward an attainable goal is rewarded, are among these trainable approaches.

An unusual approach developed by primitive cultures involves the use of totems to aid the individual. Although not for everyone, the idea is to find a living object, be it animal or plant, that contains some of what is already part of you and has attributes that you wish to acquire. For example, you might find that the beauty of a hummingbird, along with its agility and skill, would fit you. Or a monkey who grooms its tribe members so that in turn it will be groomed, or the loyalty of penguins, or the rapid growth of a vine, or the power of a religious symbol, and so on. As part of healing, I have asked patients so inclined to choose a totem. One patient chose a blade of gra.s.s. When I asked why she chose this as her totem, she replied, "Because every time it gets mowed down it grows back." Ascribing special powers to these totems and extracting them for our own use can be of great use in enhancing resilience.

Carl C. Bell describes some characteristics of resiliency in his article "Cultivating Resiliency in Youth" (www.giftfromwithin.org/ html/cultivat.html). He describes the personality traits, abilities, characteristics, and spiritual approaches that increase resilience: Have curiosity and intellectual mastery Have compa.s.sion with detachment Have the ability to conceptualize Have the conviction of one's right to survive Possess the ability to evoke images of good and sustaining figures Be in touch with one's feelings Have a goal Have the ability to attract and use support Have the need and ability to help others Resourcefulness Have a sense of true self Develop "kokoro" (heart), a fighting spirit Have a totem William Osler, the founder of Johns Hopkins Medical School, in his address to the first graduating cla.s.s, offered one way of developing resilience. Here, his totems are men. He writes: It is sad to think that, for some of you, there is in store disappointment, perhaps failure. You cannot hope, of course, to escape from the cares and anxieties incident to professional life. Stand up bravely, even against the worst. Your very hopes may have pa.s.sed on out of sight, as did all that was near and dear to the Patriarch at the Jabbok ford, and, like him, you may be left to struggle in the night alone. Well for you, if you wrestle on, for in persistency lies victory, and with the morning may come the wished-for blessing. But not always; there is a struggle with defeat that some of you will have to bear, and it will be well for you in that day to have cultivated a cheerful equanimity. Remember, too, that sometimes "from our desolation only does the better life begin." Even with disaster ahead and ruin imminent, it is better to face them with a smile, and with the head erect, than to crouch at their approach. And, if the fight is for principle and justice, even when failure seems certain, where many have failed before, cling to your ideal, and, like Childe Roland before the dark tower, set the slug-horn to your lips, blow the challenge, and calmly await the conflict. (see www.medicalarchives.jhmi.edu/osler/aeqtable.htm for the complete essay.) I read this on my first day of practice.

Appendix C:

An a.n.a.lysis of Fear of Flying*

Carrie experienced severe anxiety about flying. Days before a flight she would begin thinking about it and become very agitated. She avoided flying where possible and needed to take medicine before she could board a plane. She dates this to a particularly bad flight on a smallish plane where the turbulence was extreme. Since that time she feared flying, and after 9/11 it became even worse.

If you are afraid to fly, you may be suffering from aviaphobia.

A phobia is defined as a marked and persistent fear that is excessive or unreasonable, cued by the presence or antic.i.p.ation of a specific object or situation. Thus, thought, like one of the five senses, can also activate the fear response merely by bringing the object or situation to mind. For someone with aviaphobia, the thought of being on a plane can produce fear.

This brief introduction to conquering the fear of flying will not provide statistics about safety, explain the funny sounds you hear when you are flying, or familiarize you with the aircraft. That would be a waste of time. Irrational fear does not lend itself to amelioration by rational calculation. What we will do is to understand how the problem was encoded in your brain and how we can get rid of it.

What is fear? Fear is a survival response. It makes us ready to fight or run for our lives. It tenses our muscles, makes us breathe harder, and can make us aware of our heart. It causes us to sweat, we are uncomfortable, our thoughts race. "Let's get out of here!" our mind yells. Muscle tone increases, pupils dilate, and we focus on escape. This biological orchestration is meant to improve our chances of survival, literally causing us to feel our life is at stake.

Sitting in business cla.s.s, cruising at 35,000 feet with a drink in our hand, hardly qualifies as a life-threatening situation. Yet many become terrified, but when they look around no one else seems scared. It is difficult to explain to someone who has not experienced it. In medical terms it's called phobic anxiety or, in the extreme, a panic attack. You may think you are going to die. You can try to explain to yourself that there is no danger, but your brain and body tell you differently. Your brain always wins.

Since fear is a response to a survival need, rapid action is required. No long a.n.a.lysis, no pondering options, just action. The emotion of fear is what makes us want to act. Here's how it works. Sensory input-the fact that you are on a plane, the fact there are some funny noises, the fact that there is some turbulence-is first sent to an area called the thalamus, sort of a central post office for incoming sensory information. This is the first stop before information is sent either to the amygdala directly or to the thinking and evaluation part of our brain called the cortex.

The amygdala was designed to make us better at survival by making us vigilant, preparing for flight or fighting and motivating us to action. Under normal conditions a fear response is generated by a stimulus that is evolutionarily hardwired to signal a threat. In order to maximize survival, the system needed to identify threats the first time. Sometimes you don't get a second chance. It needed to have hardwired patterns that shouted danger. There are fear stimuli that provoke action and vigilance in all animals. These are called unconditioned fear stimuli and they include: A closed s.p.a.ce An open s.p.a.ce Loud noises Low-pitched sounds (think Jaws) Heights Creepy-crawly slithery things Things out of left field Fear of injury or pain or being killed Fear of suffocation Things that feel slimy If a pattern of an unconditioned fear stimuli (UFS) is recognized, it is sent to both the amygdala and the cortex of the brain. The pathway to the amygdala is almost instantaneous, while the cortex processing takes a little longer.

Sensory input (UFS pattern) Thalamus Amygdala Fear Response The signal from the cortex to the amygdala can either inhibit or sustain the response.

Thalamus Cortex Processed information Pattern a.n.a.lyzed Amygdala Activation Under normal circ.u.mstances, when evaluation of these signals proves not to be of any danger, the prefrontal cortex (where we evaluate danger) sends an inhibitory signal to the amygdala and the fear response is stopped. This is a clever and simple solution. So while we might jump when walking in the woods and seeing something move in the gra.s.s, cortical evaluation shows it is just a stick (not a snake) and we calm down.

Medial prefrontal cortex Amygdala No fear If there were never a plane crash or near miss or other mental image of this big bird falling out of the sky, you would think we would not have fear of flying. But we are in an aluminum tube 35,000 feet above the ground traveling at 300 mph with no way of getting off until the plane lands. There are plenty of reasons to be afraid to fly.

Let us look at all the unconditioned fears that arise from a plane ride: 1. Heights 2. Being trapped 3. Fear of being killed 4. Strange noises 5. Changes in alt.i.tude (turbulence causes a feeling in the stomach as if you were falling) 6. Fear of terrorists or a hijacking You look out the window and the ground recedes from your view and you wonder how this multi-ton thing stays afloat on nothing but air. (The physics of airflow over a wing, giving it lift, is quite interesting but not of relevance here.) Height also comes into play in an unusual way, and it is involved with the experience of turbulence. During turbulence, the plane might suddenly drop and you have that funny feeling in the pit of your stomach. This feeling is an UFS as it occurs only when you are rapidly falling (it is unclear why this feeling occurs, but you immediately know its consequences, and you are afraid you will be killed). This fear might arise from childhood, when at one time you were frightened on a roller coaster. After reaching the top of the first hill, you were dropped precipitously, and both fear of heights and falling occurred at the same time the feeling in the stomach was happening. If traumatized at that moment, you then a.s.sociate that feeling in the stomach with fear, so when there is turbulence and the plane dips, you experience the fear.

You are on a plane and the doors of the plane close: You are trapped. You hear a strange noise, or turbulence makes you feel that you are falling. You look out the window as the ground recedes. Now there is a big problem: There is no escape. Inescapability is the key. There is nowhere to run. If the landscape of the brain is appropriate, fear and traumatization occur.

Now every time you think of being on the plane, you are conditioned to have a fear response. We can now look at the plane as a conditioning stimulus. This fear can generalize and lead to a fear of going to the airport, of packing your suitcase, or of ordering your boarding pa.s.s days before the flight. You have been conditioned. You now have a fear of flying.

If everyone is exposed to these UFS, why doesn't everyone have a fear of flying? The answer is that they have not been traumatized. Since being on a plane is inescapable, it is the meaning, the previous experiences, and the person's temperament that decide who becomes traumatized. If you have had relatives who died in a plane crash or have seen it happen, you are more susceptible. If you generally feel anxious, you are more susceptible to developing a phobia.

Extinguishing a Phobia

So how does one cure a phobia? There are several ways, including: Havening, EMDR, and EFT Cognitive therapy Systematic desensitization These approaches have success in treating a long-standing fear of flying. Havening begins by taking a good history. Asking about predisposing factors is helpful in determining the landscape of the brain. Many with a fear of flying can relate it to an event or specific flight. Others can acquire it from hearing about it from a parent or friend or watching a scary movie about a plane in trouble. Many anecdotal reports showed a marked increase in fear of flying after 9/11. The therapist should ask about related phobias, such as claustrophobia or height phobia, which need to be addressed as part of the treatment of the fear of flying. Indeed, there may be related issues, such as a preexisting need to feel in control. These issues become important when havening is incomplete or unsuccessful.

In Practice

We have the client imagine the process of preparing to go to the airport, checking bags, going through security, handing in the ticket, sitting down (generally I have the client in a window seat in the back of the plane and an overweight individual sitting on the aisle), taking off, and landing. This activates most of the a.s.sociated parts of the fear of flying. We then address other aspects that are troublesome as identified by the client, such as turbulence. At the end we teach self-havening and have the client practice and perform it if there is any activation of fear during this process.

The success rate is extremely high if a thorough evaluation is done.

Carrie was able to produce a fear response by bringing an upcoming plane flight into her imagination. Havening brought the subjective unit of distress (SUD) score from a 9 to a 3 but could not lower it further. Further history taking told of the flight where this began, and this was havened. Although a little better, the SUD score of getting on a plane could not be brought to 0. She then disclosed that it was the turbulence that was most frightening, and that she had a similar feeling on a roller coaster ride when she was little. Remarkably, she could bring that distant (over 50 years ago) memory back and it still produced a fear response! This was havened and brought the SUD score to 0. She has now been able to fly comfortably and on occasion will self-haven if she feels a little anxious.

Appendix D:

Nightmares, Night Terrors, Just Bad Dreams, and Havening*

This essay is a theoretical and highly speculative a.n.a.lysis of the use of havening for recurrent dreams. While this essay focuses on nightmares and night terrors, any distressing dream can be treated, and with it the underlying issues. Dreams are suffused with confusing symbolism and metaphorical meaning. Why does the mind make dreams such a mystery? Freud believed the images presenting in dreams were disguised or manifest because during sleep, even though the barrier between the subconscious and conscious mind becomes more fluid, the frightening or offensive material would still need to be censored to avoid causing distress.

To uncover the true ident.i.ty of the symbol, an a.n.a.lysis of the dream was required. During this process, elements of the dream (thoughts or feelings) could be used as clues for the client to free a.s.sociate. Through the process of free a.s.sociation, the true latent (undisguised) meaning could be divined. The process is similar to archeology, like digging in ruins with many doors, seeking the door to the King's chamber.

How does the subconscious mind choose the symbols that arise during dreams? Freud felt that the symbols were acceptable alternatives to unacceptable thoughts and feelings.

Modern-day a.n.a.lysis of how information is stored in the brain-mind provides another view. Objects are stored in categories either as a prototype (where the object is the composite of many of the same type of an object, e.g., "dogness") or as a group of exemplars (exemplars are groups of objects that share much in common). How the mind-brain does this selection, though, remains unclear. Recurring dreams are of interest because they reflect not the content of the dream, but the affect. The feeling remains the same, but we have different story lines, with different characters. We dream of being chased, of standing naked, of being unprepared, of being trapped, and so on. All produce anxiety. While dream interpretation can vary, the specific reason for the dream often remains unknown to the dreamer. Some researchers suggest the purpose of a recurrent anxiety dream is to find an escape, a haven so that the ending is changed and repet.i.tion is avoided.

During dreaming, which occurs during rapid eye movement (REM) sleep and non-REM (NREM), changes in neuromodulator release occur. In REM sleep, both norepinephrine and serotonin levels dramatically drop. What are the consequences of the loss of these neurochemicals? The lack of norepinephrine, we speculate, diminishes the logical connectivity between narrative of the dream and the objects chosen for the dream. It means that the mind-brain goes to a location where the prototype/exemplars are stored and chooses one to be brought into the dream. Thus, in the category of male figures could be your best friend, grandfather, father, teacher, and so on.

The lack of serotonin decreases the threshold to a.s.sociation, broadening the categories from which symbols can be used. This only further hinders recognizing the origin of the symbol.

Night terrors are different. As David Richards points out (excerpted by permission from www.nightterrors.org): People who have night terrors are often misdiagnosed. The most common incorrect diagnosis is a simple nightmare. Any of you who have had a night terror can say they aren't even close! Another common misdiagnosis (especially among veterans) is PTSD. For this reason I have included a description of the difference between nightmares and night terrors.

Night Terrors Symptoms: Sudden awakening from sleep, persistent fear or terror that occurs at night, screaming, sweating, confusion, rapid heart rate, inability to explain what happened, usually no recall of "bad dreams" or nightmares, may have a vague sense of frightening images. Many people see spiders, snakes, animals or people in the room, are unable to fully awake, difficult to comfort, with no memory of the event on awakening the next day.

Night Terror or Nightmare: Nightmares occur during the dream phase of sleep known as REM sleep [stage 2]. Most people enter the REM stage of sleep sometime after 90 minutes of sleep. The circ.u.mstances of the nightmare will frighten the sleeper, who usually will wake up with a vivid memory of a long movie-like dream. Night terrors, on the other hand, occur during a phase of deep non-REM sleep usually within an hour after the subject goes to bed.... During a night terror, which may last anywhere from five to twenty minutes, the person is still asleep, although the sleepers [sic] eyes may be open. When the subject does wake up, they usually have no recollection of the episode other than a sense of fear. This, however, is not always the case. Quite a few people interviewed can remember portions of the night terror, and some remember the whole thing.

Unlike nightmares, there is no escape from a night terror; awakening does not appear to be an option. Night terrors are probably the equivalent of a daytime panic attack for which no plan is available and the decision-making processes, usually entrusted to the prefrontal cortex, are taken off line. The lack of awakening suggests that the part of the brain that allows access to conscious awareness is blocked.

Nightmare Therapy

Nonetheless, if, as we speculate, the emotional state is the glue that ties together the components of a traumatization, and if a recurrent nightmare is the result of a traumatization, recalling the dream and generating an emotional response followed by havening should disrupt the path that activates the emotion.

Clinically, the client should bring the feeling state to conscious awareness by recalling the dream and generate a subjective unit of distress (SUD) score. This should activate the pathway through the BLC. There is no need to interpret or understand its symbolic meaning. If an event is recurrent, then this procedure should not only prevent the reoccurrence of the dream, but also remove the traumatization itself. If a client awakens after a recurrent nightmare, they should attempt self-havening the emotional distress until the SUD reaches zero.

Dr. Sergio Serrano suggests a simple routine to follow (http://www.emofree.com/Articles2/eft-dreams-core-issues.htm): 1. Before falling asleep, tell yourself that dreams are important and that you wish to remember them if you naturally awake.

2. If you awaken in the night, immediately replay the dream as vividly and as clearly as you can, focusing on the emotional content of the dream. Apply self-havening (Dr. Serrano applies tapping).

3. Return to sleep after the emotional response has been eliminated.

4. If you do not awaken during the night but can recall the dream during the day, apply havening after activation of the emotional content of the dream.

This technique can be used for any distressing dream or, for that matter, any distressing intrusive thought, such as those seen with PTSD. Further research is required to determine the efficacy of this approach.