This blog is a Re-cap of a presentation on Picture Gazing presented by Kate Cohen-Posey, MS, LMHC, LMFT. Cohen-Posey started her talk by discussing Neural Research and Imagery. As summarized by Davidson in The Emotional Life of Your Brain, 2012.
1982 EEG EXPERIMENTS: measured brain activity while viewing happy or upsetting videos.
- Left prefrontal cortex (PFC) showed increased activation while viewing pleasant clips and identified the locus of positive emotions (happiness, enthusiasm, joy) involved in seeking rewards.
- The right (PFC) showed increased activation while viewing upsetting clips. It determined the locus of negative emotions originally involved in avoiding danger.
- Depressed an non-depressed subjects both showed this brain asymmetry, but depressed subjects had less left PFC activation.
- Effects of mindfulness practice: within 3-4 months EEG tests showed significant increase in left prefrontal lobe activation. Subjects began reporting reduced stress, increased calmness and wellbeing.
- The results are consistent: positive imagery increases left PFC activation; negative images increased right PFC activation. The study has been replicated many times and with infants, 8 month olds, and adults.
2009 fMRI Experiments: scanned peoples’ brains while looking at pleasant and unpleasant images. Subjects were taught how to enhance positive emotions by looking at pictures. The findings are as follows:
- The left PFC sends inhibitory signals to the amygdale (fear, anxiety, etc.), instructing it to quiet down.
- The Nucleus Accumbens NA (reward, motivation center) was activated by teaching subjects to enhance effects of positive images; however, with depressed people, the connection between the left PFC and the NA declined after an initial rise, while in normal subjects it continued to grow stronger.
She states the relevance of Davidson’s findings to BSP Picture Gazing is as follows:
-In traditional BSP the SC (superior colliculus) is considered a key player in the orienting response and the doorway to relevant emotions. Looking at an image involves the optic tract which extends axons to the SC to coordinate rapid eye movement (via the pulvinar) to fixate on a target. Could this activation of the SC with personally significant symbolism also provide a doorway to relevant autobiographical information?
-The “spatially aware” intraparietal sulcus is utilized (in picture gazing) to access the autobiographical relevant eye position, could the deep symbolism of the image also access relevant autobiographical information?
-Processing happens in the traditional BSP because (1) the insula “observes” activated muscular tensions and returns them to baseline (homeostasis); (2) the therapist’s gaze heightens insual activity, stimulates the ACC and vmPFC to maintain focus on sensations, and promotes release of oxytocin to further reduce painful sensations/emotions. What additional neural activity aides processing in Picture Gazing?
–Simultaneously orienting towards a place of safety and a threat may suggests the apex of “dual orientation” relevant to unresolved trauma (Corrigan, 2015 referencing Merker 2013). Could the use of positive and negative imagery support healing via this dual orientation?
-How can calming and activating imagery be integrated into BSP?
In step 1 Ms. Cohen-Posey talked about using Cognitive de-fusion (CD) which alters interaction with thoughts (not content). Thoughts can be watched without judgement, repeated in a different voice, externalized (with symbols, shapes, size, color) or reframed as a part or rescue. Attachment to beliefs is reduced. (Hayes ACT 1999).
She uses an exercise with Erickson’s psychosocial crises that correspond with Stone’s major subpersonalities and Richard Schwartz division of personality parts. For the purpose of using second person core beliefs to detach from thoughts. The benefit for the clinician can be understanding where your patient is stuck developmentally.
IT LOOKS LIKE THIS:
Directions: Check any beliefs you have about yourself in your worst moments
DIRECTING VOICES
Trust v. Mistrust (Attachment voices)
You can’t find love, caring, approval, attention…
You could be abandoned; you’re empty, alone…
Autonomy v. Shame & Doubt (Controllers)
You cannot…handle it, be trusted, stand it…
You cannot…show emotions; speak up…
You have to control/fix everything
You’re powerless, helpless
Initiative V. Guilt (Protector/Perfectionist vocies)
You’re trapped. You’re not safe
You cannot tell, speak up…
You might (will) fail, get hurt.
You cannot make a fool of yourself.
You might get sick, die, make others sick…
You could do something awful.
You cannot handle new, unfamiliar situations.
You’re responsible for others, everything
You (your judgement) cannot be trusted.
You cannot trust others.
You are (will be) ruined, damaged…
You have to be perfect; you cannot make mistakes
What if…what if…what if…?
Industry V. Inferiority
You have to.., you better…, you should…
Have you done…, Have you done…
You have to get it (done) NOW
Identity V. Role Confusion (Please voices)
you have to please everyone
You (our needs) are not important; others come 1st.
Others might no like how you sound, look, act…
You have to make others lvoe, understand, care for , approve of you…
You need others; you’re incomplete on your own…
Introjects (Critic Voice)
You’re worthless, defective, inadequate, a failure,
disappointing, different, weak, dirty, at fault…
You’re helpless, powerless, a fool…
You don’t deserve love, happiness, to live…
You’re not good, smart, attractive enough…
You should have…
DISTRACTING VOICES
Controller (blaming) Voices:
They have no right to…,
They shouldn’t be so…
Protector (perfectionist) Voice:
They can’t be trusted;
They can’t handle…
Pusher Voice:
They have to…, better, should…,
Pleaser (clinger) Voice
They have to love, understand, be there for me…
Critic (judger) Voice:
They’re disappointing, foolish, weak, dirty, at fault.
Addict Voice:
You have to have what you want when you want it.
You have to find excitement, what you want.
This will be the last time I’ll…
It won’t matter if I
Ms. Cohen-Posey’s 4-step protocol for Picture Gazing:
- Personify & Externalize Negative Thoughts/Emotions
- Listen for automatic thoughts or core beliefs. If clients experience an emotion, ask, What thought do you get when you feel …..?
- Rephrase 1st person thought in the 2nd person: A part of you is saying…
- Personify the thought: Pick an image or object that represents the part that tells you…Offer a limited choice of negative images.
- Instruct clients to gaze at the image and notice sensations.
- (Optional) give the part a name, inner critic, mini mom, people pleaser, etc
- Clients name & identify with positive image.
- Choose desirable images/objects
- What do you like about ….?
- Reframe: you have resources..
- Identify: Be your resource.
- Notice body sensations as you gaze at the image? (If client have several positive images, choose the one(s) that would most help their distressing part/thought.)
- Picture gazing
- Look at the disturbing image and think about the event/thought linked to it. Clients place the image on a chair or floor in front of them.
- Where do you notice sensations of upset in your body? Rate them on a 0-10 scale.
- Hold the resource image(s) in your hand and focus on body sensations and the image (dual focus). As clients report changes, keep them focused on sensations until they reach a 0.
- Look back at the disturbing image. How much distress do you feel as you look at it and think about…? If distress goes up, repeat step 3.c. If client seems to be looping, proceed with dialogue:
- Dialogue: is there something you want to silently tell or ask the upsetting part (see below)? Listen and tell me what it says. Observations & questions continue until the negative part is quiet and the body feels calm. If clients notice distress in their bodies, repeat 3.c. Continue until clients can look at the negative image or think about related events without activation (steps 3.c.-3.d.). If clients no longer feel distress when gazing at the disturbing image, ask “do you have a new truth..?
- Clients make a composition of parts and resources in the way they would like them to be in their minds. Arrangements can be photographed or photocopied.
Questions & Observations to Use in Step #3.c Above
Question the disturbing part:
- Intentions: do you still need to warm (scold, order, remind)….Are you trying to help…?
- Effects: which is better for….being calm or feeling… (caused by extreme message)?
- Who’s “talking”: Is that idea coming from the pushy/critical part or from your resource?
- Accuracy: Is that really true? What is the chance of….happening?
- Sources: When did you start giving John these thoughts? On whose authority are you saying…?
- Experience: What’s is like for you when the….part becomes quiet?
- Feelings towards parts: How are you feeling toward the pushy part right now?
Make observations
- Changes in distressing parts: it seems like your controller is more tentative
- Past helpfulness: It’s good you were around when…was young to keep her mother from yelling.
- Identify new parts: it sounds like a critical voice just jumped in and said, “….”
NOTE: This list is neither complete nor required. Use your intuition.
Combining Picture Gazing with Traditional BSP
Use a resource (RI) image when:
-Clients plateau during processing. RI may help reduce SUDs.
-Clients have difficulty focusing on tip of pointer.
-Clients easily reduce activation by squeezing the lemon, but SUDs repeatedly return to high levels when thinking of disturbing event
-Clients’ SUDs remain at a 0 after squeezing the lemon, but they cannot access a “new truth” (insight) about the upsetting event/thought
-Client’s processing is not complete at the end of the session and a photo(copy) of the RI may help them safely process later.
Use an ego state image (ESI) when:
-Disturbing parts present themselves during processing. Use ESI to further squeeze the lemon.
-RI alone does not reduce SUDs and inner dialogue between resource and ego state is needed. Similar to, “ask your brain and body…” in traditional BSP.
-Ego states are obvious when clients describe their issue pre-processing.
-Clients are activated by defensive emotions (anger, resentment, etc.) that keep them fixated on others rather than internally focusing on vulnerable emotions.
-To better attune to clients’ emotion, if needed, (hurt v. fear).
When not to use PG:
-RI takes SUDs level down too quickly. Reducing body sensations through interoceptive awareness may be a vital part of healing.
-The RI stimulates too many thoughts that derail somatic awareness.
-Looking at the tip of the pointer produces more intense focus (cingulate activation).
-There is insufficient time to pick a RI.
General rule of thumb:
- Start with traditional BSP
- Add images if processing is stuck
- Add dialogue if processing remains stuck
