Moss, R. A., & Mahan, M. C. (2014). Emotional restructuring: Clinical biopsychological perspective on brain involvement. The Neuropsychotherapist, 5, 54-65.

The Neuropsychotherapist issue 5 April-June 201454

Emotional Restructuring: Clinical Biological Perspective on Brain Involvement

Robert A. MossM. Christine Mahan

www.neuropsychotherapist.com 55The Neuropsychotherapist

There is a growing awareness of the lifelong effects of childhood negative emotional memories on both physical and psycho-logical health. In relation to detrimental

physical effects, research has shown early adver-sity can affect susceptibility to conditions involv-ing pro-inflammatory processes including heart disease (Miller et al., 2011). Early negative emo-tional memories have also been tied to fatigue in chronic fatigue syndrome (Heim et al., 2006) and breast cancer (Bower et al., 2014). In addition to the known effects of those negative memories on depression (Chapman et al., 2004), there is mount-ing proof that, when compared to those occurring in adulthood, negative emotional memories from childhood are related to more severe posttraumatic stress disorder symptoms in older adults (Ogle et al., 2013).

There are several psychotherapy treatment ap-proaches that, for many clients, can rightfully claim to be effective in addressing influential negative emotional memories tied to past relationships. A common component of those therapies involves experiential procedures such as chair techniques or role plays/reversals. While the therapy proceeds over a number of sessions, there is often one spe-cific session in which dramatic improvements occur. We have seen a typical emotional pattern described from those critical sessions. The first stage is height-ened anxiety, transitioning into anger. With expres-sion of the anger in some manner, the next phase is one of a cleansing sadness involving compassion for self. There can also be a point at which the client has compassion for the person being discussed, rec-ognizing at both a logical and emotional level that the individual was a victim of their own past nega-tive life situations. This can lead to an emotional forgiveness of the offending party.

The brain-based Clinical Biopsychological Model (CBM) proposes an alternative and more directive approach to identifying and dealing with relevant negative relationship memories (Moss, 2001). It involves systematically identifying which relation-ships have been influential in creating current psy-chological problems for a client, and subsequently addressing each relationship in a structured fash-ion. There are several requirements for such an ap-proach to be possible. Since everyone has negative emotional experiences in many relationships during a lifetime, the specific factors that lead to the detri-mental memory storage must be identified in order to determine which relationships need to be ad-dressed in therapy. The next step is that a sensible

conceptualization be presented to the client as to why the past memories continue to impact the cli-ent in current-day functioning, and how the memo-ries can be effectively addressed. Within the actual treatment sessions, there need to be procedures in place to facilitate the anxiety–anger–sadness/self-compassion–forgiveness sequence to allow neu-tralization of the negative memories.

Emotional restructuring (ER) has been proposed as a single-session treatment approach to deal with problematic memories for any given relationship, past or present. In addition to recognizing the im-portant contributions of ongoing factors (e.g., pain, life stressors) and loss issues (e.g., desired relation-ship, job) to most psychiatric disorders, negative emotional memories are considered of extreme im-portance in the clinical biopsychological approach (Moss, 2007, 2010, 2013a, 2013b, 2013c, 2013d, 2014). As described in the treatment manual for this approach (Moss, 2001), the assessment is done in the initial session, at which time each possible in-fluential relationship (e.g., parent, sibling, spouse, boss) is assessed. In the second session, a concep-tualization is presented to the client together with an overview of treatment procedure recommenda-tions. If past negative memories are judged to play an influential role in the client’s current problems, these are usually targeted first; thus the third ses-sion is often the first ER session. If the problematic memories are effectively addressed, the benefits from other current-day treatment approaches, and education on normal emotional reactions to loss, can be greatly enhanced.

Moss (2013a) discussed in detail how the Dimen-sional Systems Model (DSM), a cortical column-based theory (Moss, 2006, 2013d; Moss, Hunter, Shah, & Havens, 2012), translates into understand-ing how different treatments affect different brain areas. The cortical column is the binary unit, or bit, involved in all processing and memory storage. Each column contains several thousand neurons. (For the purposes of this article, recall that when a “column” is mentioned it is simply the brain’s representation of some form of specific informa-tion.) In this article, the model is applied to what theoretically occurs in the brain during the process of an ER session; however, it is important to keep in mind that the following description is based on logical applications of the DSM that have not been demonstrated empirically. This is followed by a case description of an individual who received three ER sessions early in her treatment, with some data showing a clear trend toward improvement.

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Hypothesized Brain Effects during Emotional Restructuring

Overview of Cortical OrganizationTo facilitate an understanding of the theorized

session component effects, we will first give an over-view of the different brain areas that are involved, based on the CBM (Moss, 2013a). Although the cor-tical areas of the brain are the ones directly affected in psychotherapy, there are subcortical effects as well. The primary subcortical structures impacted are the amygdalae. Being paired structures, the lateral nuclei receive input from both the thalami and the cortices. The cerebral cortex is where the memories are stored, with most therapy-relevant verbal aspects being located in the left hemisphere, and most therapy-relevant non-verbal ones in the right. As will be shown, the non-verbal sensory memories in the right hemisphere are those primar-ily impacted with experiential techniques, while the verbal memories in the left hemisphere are those primarily impacted by verbal communication, such as new schemas.

The hypothesized cortical influence on the amyg-dalae—notably involving the sensory, or receptive, cortices—begins with input to the lateral amygda-lae nuclei leading to output from the central nuclei. There are two different pathways of note from the central nuclei (Stermensky and Moss, in press). The first leads to sympathetic nervous system activa-tion (“fight-or-flight” symptoms) via activation of the lateral hypothalamus/perifornical regions, caus-ing activation of the interomediolateral nuclei in the spinal cord that subsequently activate the sym-pathetic ganglia to produce rapid-onset somatic symptoms of fear and anxiety. The second pathway

activates the periventricular nuclei of the hypothal-ami, leading to the hypothalamic-pituitary-adrenal (HPA) axis release of stress hormones, resulting in slower but longer-lasting anxiety/stress effects.

The frontal lobes contain the action columns that control all volitional activities. From a top-down processing point of view, the frontal columns direct the activity of the receptive columns in the posterior lobes (i.e., the parietal, temporal, and oc-cipital lobes); this may involve selective attention to internal and external stimuli, as well as information retrieval from the posterior lobes themselves. The receptive columns involve the representations of all sensory-based information. The action columns are also responsible for working memory—that is, tem-porarily holding information while doing mental manipulations—as well as planning, organization, and motor output direction. An important point in this theory is that whenever a posterior recep-tive column forms, a corresponding action column forms in the frontal lobe. Logically speaking, this makes perfect sense due to the simple fact that for any stimulus important enough for us to form a re-ceptive memory we must be able to act upon that stimulus. The frontal action columns, therefore, are those that lead to our ability to perform mental and physical behaviors.

Another aspect is that “motivation” and “urg-es” are just as much actions (involving the medial cortex) as are verbal thoughts or doing a mental math problem (involving the lateral cortex). The lateral cortex codes for external information, while the medial cortex codes for internal information; the transition areas, such as the insula and frontal pole, code for the combination/synthesis of both internal and external information. The right cortex has fewer columns in its circuits relative to the left, which means it is involved in faster, less detailed W

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functions—for example, processing voice intona-tion and facial expressions, or brief emotional ver-bal expressions such as profanity. Conversely, the larger number of columns in the left cortex results in its being slower in processing speed, but capable of more detailed and higher volume processing, in-cluding, in particular, detailed and logical spoken language.

The left frontal operculum, where Broca’s area is located, contains the “verbal interpreter”. In many respects, this is what is considered one’s conscious-ness, since it involves verbal awareness (i.e., inte-rior verbal dialogue) and metacognition (i.e., the ability to verbally identify one’s own range of cogni-tive abilities). The verbal interpreter is the source of an individual’s verbal schemas and beliefs. If a new schema is presented to a client in therapy, the posterior cortex allows perception and compre-hension. However, it is the action columns of the verbal interpreter that allow the active use of the new schema—in other words, verbal memory “re-consolidation” (in contrast to what has been called “emotional memory reconsolidation”) is an active process allowing one to verbally think differently about a subject or situation.

Passive learning—listening to a lecture, for ex-ample—mainly involves the receptive columns, while active learning involves the frontal columns, such as studying the material and then teaching or applying it. If one learns something passively, the current theory clearly indicates associated frontal columns will form. If, however, the reception and action columns are used only briefly (e.g., just long enough to take a test or simply converse about a new schema with the therapist), the integrity of the new columns will eventually be lost, due to disuse, and the material will be forgotten. In explanation, the columnar theory (Moss, 2006) suggests early long-term memory is chemically-based (e.g., in-creased neurotransmitter stores) while later, and truly permanent, long-term memory is structur-ally based (i.e., increased synaptic connections). If the involved columns are not actively used for a sufficiently long period of time, the permanent structural connections never form and the initially increased neurotransmitter stores lessen. The abil-ity of upstream columns to activate downstream columns (i.e., the new memory circuit) is then lost (i.e., the physiological definition of “forgotten”). It is possible to understand “emotional memory reconsolidation” in exactly the same manner, but this time in the right cortex. In this case new action columns develop in the frontal lobe as a function of

making different responses to sensory information input or memory reactivation. This may be as sim-ple as facing a feared object or memory until anxi-ety dissipates, or as involved as detailed imagery describing new actions or behaviorally engaging in chair techniques. In such cases the individual is actively involved, behaviorally or mentally, which leads to the formation of new receptive and frontal columns. This results in changes in feelings of con-trol and personal adequacy, with the outcome that a person feels differently (i.e., via “emotional think-ing” as opposed to “verbal thinking”) in response to future encounters with associated stimuli. In this context, it becomes clear that “emotional schemas” exist and can be altered.

The emotional memories that have a detrimen-tal impact on a client’s current functioning are those associated with situations in which the client felt a lack of control, or personal responsibility/inadequa-cy, or both (Moss, 2007). Although the individual has many times developed new and healthier ways of verbally thinking about those situations, this does not necessarily alter the right hemisphere’s non-verbal emotional memories. In such a case, the client may voice the fact that he or she logically knows and thinks about those things in a reason-able way, but feels quite different in an emotional sense.

Along these lines, an important point to note is that the frontal action columns of a given hemi-sphere connect to ipsilateral (same hemisphere) posterior columns and contralateral (opposite side) frontal columns. The posterior columns of a given hemisphere, therefore, connect to the ipsialteral frontal columns, and contralateral posterior col-umns. If there are no connections from one cortical location to a given set of action columns, it is only logical that those action columns have no function-al control ability. A prime example is that the verbal interpreter of the left frontal cortex has no direct connections to the posterior columns of the right hemisphere, which is the location of many of the sensory, non-verbal, negative emotional memories tied to problematic relationships. Thus, there is no way of using verbal logical reasoning to prevent the activation of those influential right posterior nega-tive memories.

The interactions of the action columns in one hemisphere with the frontal columns in the oppos-ing hemisphere frequently involve one side inhib-iting the activity of the other. Thus, when there is a difference in how one verbally thinks versus how one emotionally feels about the same thing, the


mutual inhibitory activity is perceived as internal conflict. This is referred to as “interhemispheric in-congruence”. When there is congruence between emotional and verbal action columns, there is a per-ception of internal peace.

The Emotional Restructuring SessionThere are six steps in an ER session. These are:

(1) negative emotional memory recall; (2) interper-sonal relationship pattern description; (3) role re-versal/role play; (4) imagery for anger release and self-nurturance; (5) origins of the relationship pat-tern description; and (6) role-played forgiveness sequence. Since the aim of this article is to discuss how the brain is affected, only brief information about each step will be presented here: the inter-ested reader is referred to the treatment manual (Moss, 2001) for a detailed description of each step, which is beyond the scope of the current article.

Negative emotional memory recall. The first step is to have the client recall specific negative events/situations that occurred in the past. During this recall, indeed at any time in the session when the client is verbally responding, the left frontal verbal interpreter is involved. In like manner, any time the client is listening to the therapist’s verbali-zations, the client’s left posterior cortical areas are involved. The major effect of recall, however, is the activation of negative emotional sensory memories in the right posterior cortex that leads to amygdala activation, and the previously discussed fast tract leading to sympathetic arousal. The client’s per-ception is typically one of anxiety increasing during the time the therapist is collecting detailed infor-

mation. An attempt is made to identify at least one past memory in which anger rose significantly, as this can serve as the situation to be used during the imagery phase.

A very important point here is that, in the ther-apy situation, if there is only discussion about past negative situations/events, the client will leave that situation feeling worse than at the beginning of the session: the client will have formed a new, nega-tive memory of the therapy room and the therapist. This can have the effect of decreasing the client’s motivation to return for additional sessions, due to increased anxiety when re-entering the room be-cause the negative memory is reactivated by the same situational variables. For most clients with influential negative emotional memories, they will have found that avoidance of memory reactivation is the default response since there has been no re-duction in the impact of those memories during the discussions.

Interpersonal relationship behavior descrip-tion. The second step involves the presentation of the behavioral description of the Type-T (Taker) or Type-G (Giver) pattern (Moss, 2013b). The verbal presentation obviously engages the left temporal and temporoparietal areas involved in language comprehension. However, the posterior left col-umns are believed to activate right posterior col-umns in two ways. The first is when some of the de-scriptions lead to visualization in the right posterior cortex (e.g., by using terms like the person having an “outside shell”). A second, and probably more important aspect, is when the description provides an explanation for actual events and behaviors that occurred, tied to the target individual. Describing Pr

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the new schema of why the individual behaved in the manner he or she did, in conjunction with the recognition of interactions in which those behav-iors were actually displayed, provides the verbal interpreter with powerful new insights. The verbal interpreter can then immediately apply the infor-mation to other situations that involved the target individual, leading to these being recalled and visu-alized in the right hemisphere. This allows better acceptance by the verbal interpreter of the emo-tional reactions emanating from the right hemi-sphere, with greater interhemispheric congruence and less internal conflict. It is often observed that the first stages of anger begin with irritation or an-noyance—anger is an expressive emotion involving action, and is frontal in origin, which theoretically corresponds with activation of new right frontal col-umns associated with the new visual images (recall that with each new posterior column a new frontal column forms)—and decreased inhibition from the left frontal area allowing the expression of right frontally based emotions.

Role reversal/role play. The role reversal in-volves a brief interaction in which the client is told to take the position of the target individual, “play-ing by their rules” (which have been described). Af-ter the more detailed descriptions, the basic rules can be greatly simplified for the role reversal. In the case of a Taker, the basic rule is: “I win, I get my way no matter what I have to say or do”. If the person is a Giver, the rule is: “I get to be the good guy and cannot stand to feel like a bad person”. The thera-

pist then initiates the interaction, acting in the role of the client. If the client has difficulty in assuming the target individual’s role, the therapist can model the verbal behavior in a role play to emphasize how it can be done. The process is brief, lasting less than a minute in most cases.

The role reversal involves the verbal interpreter in a unique manner. It is to employ a previously unrecognized set of rules which are attributed to the target individual being discussed. At the same time, the verbal interpreter has access to memo-ries of past verbal exchanges to draw on, and is to use those verbalizations (i.e., simply repeating what was said in the past by the target individual)

as the client pretends to be the other person. The right hemisphere has a large volume of situational memories as well, and has experienced the voice intonations and inflections from the target individ-ual. For clients who mimic the non-verbal voice and facial expressions while using the verbalizations employed by the individual being discussed, the right and left hemispheres’ frontal action columns are directly activated. It is now that those who are able to effectively engage in the role reversal report a major increase in perceived anger. Although it is likely most clients will already have concluded at a verbal, logical level that the target individual was at fault/responsible, this is the first time many clients will have deeply felt the same emotionally, or with such conviction.

Imagery for anger release and self-nurturance. Of all components discussed, imagery is the one leading to the most pronounced and rapid emotion-al change. With the eyes closed, the client is told to visualize a scene described by the therapist involv-ing an interaction with the target individual. At the end of the imagined interaction, the client is de-scribed as inflicting on the target individual an an-ger—expressed physically if the person was verbally or physically abusive, or by desertion/neglect if that was the nature of the predominant negative action. Immediately following the anger release, the de-scription changes to a funeral in which it is believed the deceased person in the coffin is the target indi-vidual who was just attacked or abandoned. How-ever, upon looking inside the coffin, the client sees

himself/herself as the victim lying there, at the age where the most damaging events occurred. The description progresses with a dialogue between the current-age client and the younger victim acknowl-edging the damage and that self-blame had been erroneously given. The scene ends with the young-er victim returning to life, with hugs and affirming statements being given by both the current-age cli-ent and the younger-age client.

The most likely route leading to the activation of the non-verbal sensory emotional memories of the right cortex is via the left posterior cortical areas being activated by the spoken words of the thera-pist. When the right posterior columns activate,

Of all components discussed, imagery is the one leading to the most pronounced

and rapid emotional change“ “


the corresponding right frontal columns activate. Additionally, there is amygdala activation from the right posterior cortex. Notably, as the new events unfold in the description, with anger expression be-ing described, new right posterior columns lead to the immediate formation of new right frontal ac-tion columns. This is the moment when the client perceives control and personal adequacy. Howev-er, the immediate shift to the funeral scene takes advantage of a frequently present, right cortically-based feeling for most clients. This feeling is that taking up for oneself will lead both to the loss of a desired relationship and being seen by others as a bad person. The surprise that the client is actu-ally the victim provides an alleviation of those fears and the immediate perception of an ability to self-nurture. Throughout imagery, the left hemisphere verbal interpreter is being provided with new dia-logues, with the most important ones being relat-ed to the self-nurturing statements. This assists in hemispheric congruence because the verbal inter-preter is accepting the emotional pain associated with the right sensory memories as acceptable and natural. There is both relief and sadness for self.

Origins of the relationship pattern description. This incorporates frequent images, such as the tar-get individual having what others have termed the “inner child” trapped in a hard inner shell and being unable to grow beyond the shell. The negative be-haviors shown by the target individual are explained as an attempt to fill an emptiness that can never be filled. Additional imagery leads to the understand-ing that the target individual was the victim of his or her own past, leading to the entrapment of the child. The final aspect involves images supporting the fact that the target individual was not holding back the compassionate and positive behaviors desired, but was unable to give them because they never existed within him or her.

The same mechanisms described in the imagery section are in play. The verbal interpreter forms new verbal schemas (i.e., new action columns)

based on the left posterior receptive columns (i.e., comprehending the therapist’s words). There are also new right receptive and action columns form-ing with each new visualized image. Pity, or sad-ness for other, becomes the predominant emotion at that point for most clients.

Role played forgiveness sequence. The final step is to give expression of the pity for the target individual. In the role play the client verbally de-scribes the emotional damage done to him or her, followed by a statement that the target individual was not holding back, but simply lacked the ability to give to the client what was desired and needed. In other words, the target individual could not give something he or she had never been given. The fi-nal part is a statement that there is forgiveness. It is not unusual to find that a client may have difficulty overriding the long-standing verbal and emotional schemas (left and right frontal columns) that the target individual really was holding back, leading to difficulty in saying the person did not have the abil-ity to act differently. By gentle verbal reasoning, the therapist can have the client recognize that the

target individual was incapable of different behav-iors. This allows the client to realize there was noth-ing about him or her (e.g., “I am unlovable”) that re-sulted in the target individual’s negative behavior. Instead, it was the shortcomings of that individual (e.g., “You are incapable of loving in the manner I needed”).

As should now be obvious from the foregoing descriptions, the entire process involves exten-sively both the right and left posterior and frontal areas. This is the point at which the client has new right and left frontal action columns, where there is perceived control and personal adequacy, while simultaneously feeling self-compassion and other-compassion. The final emotional state is difficult for the client to describe since it has never been ex-perienced in the past, being a mixture of cleansing sadness and profound relief.

Notably, as the new events unfold in the description, with anger ex-pression being described, new right posterior columns lead to the imme-diate formation of new right frontal action columns. This is the moment

when the client perceives control and personal adequacy

“ “


Case PresentationThe following case was seen by the second au-

thor, who was a second-year graduate student in the first month of her first practicum under the su-pervision of the first author. She adhered closely to the manual in relation to the case conceptualiza-tion, ER treatment sessions, information on Givers and Takers, and education on normal emotional re-actions to loss.

Cathy (not her real name) was a single Caucasian female in her early 20s. She was a full-time univer-sity student in her last semester and was planning to attend graduate school. She was self-referred for treatment reporting an increase in anxiety and depression symptoms over the previous two months. Her anxiety occurred both in school and some social situations, especially when around strangers, with a fear of being judged and humili-ated. She also reported a history of depression that began as a teenager. She said she was “never going to be fixed”. She felt emotionally exhausted with variable sleep patterns characterized by frequent awakenings and constant fatigue. Additionally, she noted reduced interest in others, loss of enjoyment and interest in activities, feelings of worthlessness and guilt, and difficulty making decisions. She also reported intense worry about being depressed, which appeared to make her depression worse. She reported being apprehensive and unable to re-lax, as well as perceiving a racing heart with feelings

of nervousness, being scared, and lacking control. Furthermore, Cathy reported the fear that without treatment her depression would worsen and there could be a “repeat of past behaviors” (described below). She was diagnosed with Major Depressive Disorder, Recurrent, Severe without Psychotic Fea-tures and Anxiety Disorder NOS.

Cathy had always lived in the Midwest, growing up in a small town. She moved away from her fam-ily to go to college and currently resided in a larger city. Her parents divorced when she was young and she lived with her mother. Contact with her father ceased when Cathy was around age 10. Her mother remarried, and Cathy described a poor rela-tionship with her stepfather, although she believed they cared about each other. She helped care for her younger brother, but they did not currently talk much. The relationship with her mother was de-scribed as good. However, Cathy qualified this by noting that she did not share her mother’s religious beliefs, and felt she could not be totally honest. There had been difficulties in the past that had neg-atively impacted her mother. Consequently, Cathy experienced a great deal of guilt associated with her believing she “wasn’t a good enough daugh-ter”. Cathy had a fairly good support system in her small network of friends, with major reliance on one friend who lived out of town and was a mentor from high school. She was employed part-time in a de-partment at the university and relied on her mother for additional financial support. Her developmental W

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history was unremarkable, and her current health status was reported as “good”. Additionally, she had no significant injuries or hospitalizations and was not taking any medications.

Cathy attributed her current problems to the lasting detrimental effects of two same-sex re-lationships. The most recent lasted about seven months and ended approximately two years prior to treatment. The first relationship occurred when she was a teenager. Cathy initially identified as bi-sexual, but she had been questioning her sexuality and stated this was something she wanted to dis-cuss in therapy, although at a later time. She re-ported “falling hard” in both relationships, but the other individuals wanted to keep it a secret. Even-tually both partners concluded that the relation-ship was a “casual experiment” and that they only wanted to be “friends”. After the first relationship ended, Cathy began isolating herself and engaged in cutting behaviors. She eventually told her moth-er about the cutting, due to the recommendation of her teacher/mentor, and Cathy and her mother be-gan seeing a Christian counselor. However, Cathy did not find the counseling very helpful due to her inability to be honest about her “real issues”. While receiving counseling, she attempted suicide by tak-ing a bottle of Tylenol. Afterwards, she changed her mind and threw up. She never disclosed the suicide attempt to anyone prior to therapy with the sec-

ond author. Cathy’s mother terminated counseling when it was suggested that she might be contribut-ing to Cathy’s problems.

Cathy’s intake interview included an assessment of influential relationships that could be addressed with an emotional restructuring intervention. Three were identified, namely, both intimate relationships and the relationship with her mother. Cathy’s first therapy session following intake consisted of psy-choeducation on anxiety in relation to the fight-or-flight system. This discussion explained the stress response system and the typical physiological and behavioral changes that can serve as cues to recog-nizing anxiety, thus reducing the fear commonly as-sociated with the experience.

A case conceptualization was provided in the second therapy session. An explanation of the negative emotional response system included its universal nature and purpose in ensuring surviv-al. It was explained that this system can activate when negative emotional memories are triggered. Cathy’s negative memories regarding all of these relationships were frequently triggered by the more obvious current factors, such as attending the same school as her ex-girlfriend, running into certain peo-ple around town, and interactions with her moth-er. Importantly, when a current situation leads to negative emotional reactions, past seemingly unre-lated memories can be activated by the similarity of


the emotions, and serve to heighten the severity of the reaction. For example, if one feels out of con-trol in a current situation, past thematically unre-lated memories associated with loss of control can activate in the right hemisphere. In Cathy’s case, this resulted in her frequently experiencing nega-tive emotions. Additionally, Cathy was told that the negative emotional memories stored in the right posterior hemisphere of the brain could not be di-rectly accessed, understood, or controlled by her verbal interpreter in the frontal left hemisphere, and that this had led to internal conflict due to the perceived incongruence of her thinking and feeling. For example, she logically believed she should have been able to get over her intimate relationship and move forward; however, the negative emotional memories were still present and very potent, often triggering anxiety, anger and depression.

Cathy participated in three ER treatment ses-sions. The first ER treatment, focusing on her most recent intimate relationship, occurred in her third counseling session, while her second treatment, in her fifth counseling session, focused on her first intimate relationship. Both of these relationships were with individuals who displayed the Taker be-havioral style. Her third ER treatment occurred in the seventh session and focused on the relationship with her mother, who displayed a Giver behavioral style. The sessions between ER primarily consist-ed of processing Cathy’s experience in ER and the relationship of focus. At the close of her first ER treatment, Cathy reported feeling “very sad” and regretting “the time spent in the relationship” and “punishing [herself] over the last 2 years”. During the next session she stated that she “liked it” but was feeling “weird” because, “I think it worked on some level, but I’m skeptical and don’t want to get my hopes up”. After her second ER treatment, Cathy reported being “confronted with a trigger” and had a “better response” than what she had previously experienced. She also reported that her “thoughts and behaviors [were] changing”. She also reported that she “really liked” the role plays and reversals, describing them as “powerful”. At the conclusion of Cathy’s third ER treatment focusing on her mother, she did not report the same dramatic reduction in anger as she did with the other two sessions. This is a common observation when the target individual is a Giver versus a Taker. The best explanation is that the degree and type of damage done by a Taker is much more frequent and egregious than that done by Givers. In the following session she reported a “surprise visit” from her mother that went “better

than usual”, which Cathy attributed to the new un-derstanding of her mother and adjusting her own expectations accordingly. A couple of months later (session 16) the ER treatments were discussed once again and Cathy reported a significant reduction in anxiety, sadness, shame, and anger, as well as an increase in peace regarding all three of the target relationships.

Additional interventions used throughout thera-py included psychoeducation on all of the following: depression, Giver and Taker behavior styles, normal emotional reactions to loss, perfectionism, and quitting smoking. Relaxation techniques, behav-ioral activation, identifying cognitive distortions, self-affirmation skills, and additional role-plays were also utilized. She quit smoking (by session 12), resolved her struggle with her sexual identity and began to identify as lesbian, then came out to her family just prior to transfer. In total, she was seen 31 times over an eight month period, including her intake and transfer session. The BDI-II and BAI were used to track her symptoms throughout therapy (Figure page 64).

ConclusionsWe have presented information both on the ob-

served changes during the ER sessions and theo-rized brain effects associated with those changes. Most of the components are present and have been

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described as effective in other approaches, includ-ing discussion of past situations, role play/role re-versal, imagery techniques, and forgiveness. The unique aspects are the process of identifying the relevant relationships to address, the brain-based conceptualization presented to the client, the structure of the session in which all components are organized, and the Giver/Taker schema that is pre-sented. The approach has been used successfully for many years in a solo private practice and has also been found to have the same results when ad-ministered by five graduate students. Although the opportunity to use the treatment in randomized controlled trials has not presented itself, we hope this may become possible in the near future if inter-est in the CBM and ER grows.

To our knowledge the Clinical Biopsychological approach is the only one based on a comprehen-sive brain model in which cerebral cortical circuits of columns are described—both in processing and memory, and in the way cortical memories inter-face with subcortical structures leading to physi-ological reactions and enhanced memory storage. We believe that this approach offers the new field of Neuropsychotherapy a rallying point, and that it represents a significant stride forward, toward a true “Grand Unified Theory” in psychotherapy, which to date has been considered very unlikely (cf., Stricker, 2013). We hope others will take a seri-ous look at the theory and treatments, and subject these to rigorous evaluation.

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Moss, R.A. (2001). Clinical Biopsychology in Theory and Practice. Greenville, SC: Center for Emo-tional Restructuring.

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Moss, R. A. (2013a). Psychotherapy and the brain: The dimensional systems model and clinical W

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biopsychology. Journal of Mind and Behavior, 34, 63–89.Moss, R. A. (2013b). Givers and takers: Clinical biopsychological perspectives on relationship behavior pat-

terns. International Journal of Neuropsychotherapy, 1, 31–46. Moss, R. A. (2013c). A clinical biopsycholog-ical theory of loss-related depression. International Journal of Neuropsychotherapy, 1, 56–65. Moss, R. A., (2013). A roadmap to the cerebral cortices. The Neuropsychotherapist, 2, 114–117. Moss, R. A. (2014). Brain-based views on psychotherapy integration: Clinical biopsychology. New Therapist, 89, 6–15.

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The Authors:

Christine Mahan, M.A. is a doctoral candidate in clinical psychology at The School of Professional Psychol-ogy at Forest Institute in Springfield, Missouri, USA. Her clinical training has focused on community mental health and providing integrated services to the medically underserved in a free medical clinic. Additionally, she has presented on the Clinical Biopsychological model at an international conference. Her training will continue during her upcoming internship at Four County Counseling Center, Logan-sport, Indiana, USA.

Dr. Robert Moss is currently working with Bon Secours St. Francis Hospital in Greenville, SC., and is the Editor-in-Chief of the AIMS Neuroscience journal. He is board certified in clinical psychology (ABPP) and neuropsychology (ABN). He had over 20 years in private practice in addition to academic positions. He has published a number of professional articles and most recently had two papers on the Clinical Biopsychology approach with former graduate students at the Barcelona meeting of the Society for the Exploration of Psychotherapy Integration. Copies of recent articles are available at his website www.emotionalrestructuring.com.

Moss, R. A., & Mahan, M. C. (2014). Emotional restructuring: Clinical biopsychological perspective on brain involvement. The Neuropsychotherapist, 5, 54-65.

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