Anne M. Dietrich, M.A.
University of British Columbia
Vancouver, BC, Canada
ABSTRACT
In this article, the
literature on the Neurolinguistic Programming (NLP) technique of
Visual/Kinesthetic Disassociation (V/KD) is reviewed in relation to the
treatment of Posttraumatic sequelae. An overview of the V/KD technique is
provided, along with postulated mechanisms of change, based on current theory
and research in the field of PTSD. Three published reports -- two case studies
and one, uncontrolled, small-n study -- are reviewed in terms of
treatment effectiveness for Posttraumatic sequelae. Currently, the V/KD
technique is rated as an experimental approach, according to the American
Psychological Association's Division 12 Task Force (1995) report and
recommendations on empirically validated psychological treatments.
Recommendations for use of exposure-based treatments with traumatized
populations are provided.
Key words: Polyvagal Theory
of Emotion; Traumatic Memory; Exposure Practice Parameters; Grounding
A Review of Visual/Kinesthetic Disassociation
in the treatment of Posttraumatic Disorders:
Theory, Efficacy and Practice Recommendations
Visual Kinesthetic
Disassociation (V/KD) (Bandler & Grinder, 1979; Field,
1990; Hossack & Bentall, 1996; Konefal, Duncan & Reese,
1992; Muss, 1992) is an exposure-based approach that helps
individuals attain a degree of kinesthetic detachment from kinesthetic memories
of trauma and thereby enables them to process the event(s) from a de-centered
perspective. Individuals basically attain a "visual-kinesthetic
reframe" of the experience. According to Koziey and McLeod (1987, p. 278),
V/KD was initially used by Erich Fromm, who described the approach as a means
of dissociating the "observing ego" from the "experiencing
ego." Bandler extended Fromm's usage from a 2-point position of
displacement (i.e., the observing ego watching the experiencing ego) to a
3-point displacement (i.e., a "higher order" observing ego watching
the observing ego watching the experiencing ego) (Koziey & McLeod, 1987).
Clients are asked to imagine observing themselves (e.g., from the vantage point
of a projection booth in a movie theatre) watching themselves (sitting in a
theatre seat) view their traumatic experience as though in a moving picture (up
on the screen), while they consciously re-process the event from the safety of
the therapeutic setting.
Visual/Kinesthetic
Disassociation vs. Traumatic Dissociation
Disassociation from trauma
through the V/KD technique differs from the traumatic dissociation that occurs
as a response to an overwhelming experience. Traumatic dissociation
occurs with gradations of severity, ranging from primary through secondary to
tertiary dissociation (van der Kolk, van
der Hart, & Marmar, 1996). Primary dissociationrefers to
a fragmentation of sensory and emotional elements of a traumatic event, such
that certain aspects of the experience remain isolated from conscious awareness
and resurface in the form of intrusive recollections, nightmares, and
flashbacks. Secondary (peri-traumatic) dissociation involves primary
dissociation of cognition plus the experience of leaving one’s body and
observing the trauma from a distance. On the surface, this definition would
seem analogous to Fromm’s notion of a dissociation between observing ego and
experiencing ego. Tertiary dissociation involves the dissociation
of cognition, feelings, and emotions; the dissociative experience of leaving
one's body; and the dissociation of distinct ego states (as in Dissociative
Identity Disorder). The Visual/Kinesthetic Disassociation technique appears to
elicit a state similar to that experienced with secondary dissociation;
however, V/KD does not seem to involve the dissociation from awareness of
cognition. Moreover, the disconnection from kinesthetic feelings occurs in a
controlled manner through the help of the therapist, rather than as a
biologically-mediated response to extreme stress.
V/KD Procedure
At the start of the V/KD
procedure, the therapist is to establish and reinforce safety and comfort for
the clients (Koziey & McLeod,
1987). Once the clients have attained a sense of safety and comfort, they are
asked to form a picture of themselves (a "stillshot") as they were
prior to the traumatic event in question (Bandler
& Grinder, 1979; Koziey & McLeod, 1987). Once they have attained a
clear image of themselves just prior to the traumatic experience, they are to
take an observer perspective and watch themselves watch themselves re-live the
traumatic experience.
One means of having clients
attain this 3-point displacement is to ask them to imagine themselves
"floating out of themselves" (e.g., up into the projection booth)
while they watch themselves sitting there looking at the "younger"
pre-trauma self (Koziey & McLeod,
p. 278). This detachment process can be done as frequently as necessary to
ensure client comfort (i.e., freedom from emotional distress). The clients are
told that they can modulate the degree of feelings they need to connect with in
order to get a clear, focused image of themselves at this earlier point in
time, and they are instructed to have feelings of strength as they watch the
image (Bandler & Grinder, 1979).
Modulation of affect is assisted through the use of imagery such as
"volume control" (the client can increase or decrease the volume),
"colour options" (making the picture black and white to decrease
affect intensity; making the picture colorful to increase affect intensity),
and so forth (Konefal,
Duncan, & Reese, 1992).
When the process has been
completed (i.e., the clients have visualized the traumatic experience in full,
as many times as necessary so that they no longer feel overwhelmed), the
therapist has them "float" back into the present day self, where they
are encouraged to make new meanings and to have the present day self provide
the "younger" self with these new meanings, as well as with feelings
of resourcefulness and other positive affect (Koziey & McLeod). Once
accomplished, the therapist instructs the client to bring the younger self back
inside the body of the present day self (Koziey
& McLeod).
The therapist is to ensure
that client resources that had been segregated from the traumatic context
become available in that context through imagery, while the client is anchored
to the here-and-now by the presence of the therapist. It should be noted that
clients can come to positive reframes spontaneously.
Procedural Variants
There are many variants to
this procedure. One variant involves instructing the client to watch the trauma
while blaring music of the client's choice plays, then playing the music
backwards such that everyone is moving backwards, and so forth. This may
function to modify the client's kinesthetic memory of the trauma so that it no
longer holds the same mnemonic associative power. Another variation is to
completely change the color of the picture (e.g., to all green) to modify the
visual memory of the trauma. These modifications can be done at each
dissociation point in the three-point procedure. Thus, introducing variant
stimulus properties may function to break the previously conditioned chains of
response and to render the strength of the fear conditioning less
powerful. Another variation is to have the clients go through the process
backwards. After each point of reverse displacement (e.g., going from the booth
to the seat, etc.), the therapist can have the clients step back into the
"you" at the end of the movie and have them play the movie backwards
so that they feel themselves going through the trauma backwards.
Postulated Mechanism of
Change
It has been suggested that
following V/KD the traumatically conditioned fear response is replaced, not
only with a new set of feelings associated with the visual trauma stimuli but
also with more choice/control by the client (Gallo,
1996). Bandler and Grinder (1979)
postulate that new sequences (i.e., associations) are formed through the
incorporation of new information (e.g., more adaptive cognitions) that was not
available at the time of the actual trauma. According to Bandler and Grinder
(1979), the aim is not for clients to re-experience the fear/trauma
kinesthetically but to become distanced from the kinesthetic fear sensations as
they associate the images of trauma with inner resources, such as feelings of
power and competence. In so doing, new associations are fostered.
Bandler and Grinder (1979) refer to the
V/KD process as "structured regression," in contrast to a complete
regression in which the client re-lives the experience in all sensory
modalities simultaneously. According to Bandler & Grinder, complete
regression acts to reinforce the associations between fear and the traumatic
situation, whereas structured regression is hypothesized to break the earlier
stimulus-response pattern.
State Dependent Memory
My proposed explanation for
mechanisms of action in effective trauma treatment involves the notion of state
dependent memory. Traumatic experiences may be processed by both current and
latent mental schemes that "compete" with each other, particularly
for individuals who had experienced traumas previous to the most recent
traumatic event (van
der Kolk, McFarlane, & van der Hart, 1996). These competing schemes may
vary for different persons in terms of severity of dissociation. Severe
(tertiary) dissociation between schemes may manifest as dissociative identities
or ego states. Somewhat less severe (secondary) dissociation may manifest
as polarized cognitive/affective states (e.g., Complex PTSD; Borderline
Personality Disorder), and still less severe (primary) dissociation may
manifest as avoidant symptoms in response to intrusions and hyperarousal, as in
simple PTSD. It is possible that there is an even less severe form of
dissociation that may manifest as situation-dependent avoidance or numbing
(e.g., an initial, temporary flight or freeze response when confronted with
trauma-related stimuli), and may correspond to partial PTSD. These gradations
of dissociative experiences may also relate to the notion of dissolution, as
proposed by John Hughlings Jackson (as cited in Porges, 1997), and will be
elaborated upon below.
Clinical experience
suggests that direct exposure techniques (such as flooding and live exposure)
can result in unmodulated activation of more latent schematic content (e.g.,
state-dependent abreactions or elicitation of earlier modes of functioning) during
re-exposure with individuals who are vulnerable, leading to re-traumatization
(e.g., see Briere, 1997). Research findings appear
inconclusive in this regard, with some reports showing improvements in symptoms
of persons with PTSD (e.g., Keane &
Kaloupek, 1982) and others reporting exacerbation of pre-existing morbidity
(e.g., Kilpatrick & Best,
1984; Litz,
Blake, Gerardi, & Keane, 1990; Pitman et al.,
1991; Pitman et al.,
1996; Scott & Stradling,
1997; Solomon
et al., 1992; Vaughan & Tarrier,
1992; Watson et al.,
1995). The reader is referred to
Shalev et al. (1996) for a more complete review. It may be that direct
exposure treatments exacerbate secondary and tertiary dissociation. Studies
comparing direct exposure-based interventions for simple or subclinical PTSD
symptoms with exposure-based interventions for Complex PTSD and Dissociative
disorders would shed some light on this issue; however, such studies present
ethical issues.
Stephen Porges
(1997) has developed a polyvagal theory of emotion, based on evidence for a
phylogenetically advanced ventral vagal system that is postulated to assist in
the modulation of affect. In brief, the autonomic nervous system (ANS) has
undergone a shift with evolution, such that we have progressed in stages. In
the first, oldest stage of ANS development, the vagal system was primitive and
unmyelinated and thus slow in its actions. This system would function to render
the individual immobile in response to stress (i.e., promotes a
"freeze" response). The second stage of nervous organization involves
the spinal sympathetic system, which prepares the individual for fight or
flight responses. The latest, myelinated ventral vagal system originates in the
brainstem and has an inhibitory effect on sympathetic activities, promoting
calm rather than fight or flight or immobilization.
Vagal tone has been shown
to be related to affect regulation (Porges). It is possible that when the
nervous system is overwhelmed by trauma, affective processing reverts from
reliance on myelinated vagal processes to sympathetic (fight or flight) and/or
more basic (immobilization) responses, or what Tinnin (personal communication)
has referred to as an instinctual trauma response. It is also feasible that
utilization of "latent mental schemes" correlates with utilization of
older ANS processes. Porges postulates that when faced with a challenge, people
initially rely on the more advanced ventral vagal system, and if it should
fail, revert to earlier phases of response. When the system is overwhelmed by
traumatic stimuli, it may be that the ability to utilize the ventral vagal
system to calm and self-soothe is lost. Individuals may thus resort to fighting
or running, and should this fail, to immobilization. This parasympathetic
immobilization response may be involved in peritraumatic dissociation.
It is possible, though not
established empirically, that the guided disassociation process in the V/KD
technique may assist traumatized individuals in distancing themselves to some
degree from the distressing affective components of the earlier trauma
experience when faced with trauma-related stimuli (e.g., the "movie")
and, consequently, enables cognitive re-processing and integration. Intense
arousal is known to alter perceptions (van der
Kolk, 2000). In short, the relative distancing from affective distress may
help the individual maintain more objective contact with current cognitive
schemes (e.g., by reducing the likelihood of perceptual distortions from high
arousal), and thereby aid in the counter-conditioning of the traumatic response
and reprocessing of the trauma by way of current schemata. As postulated by van der Kolk,
Burbridge, and Suzuki (1997), intense emotional arousal may prevent the
Central Nervous System (CNS) from integrating traumatic sensory fragments.
Therefore, the lessened affective response that occurs with the V/KD procedure
(Field, 1990) may assist the CNS in the integration of
previously fragmented traumatic material.
The Anatomy and
Neurophysiology of Traumatic Memory
In relation to the above
theory, it should be noted that there is not consensus among neuroscientists
regarding the role of trauma on memory, including dissociative amnesia or
state-dependent recall. Although there is supporting evidence for the view that
traumatic memory (a) may be stored in somatosensory form (see vanOyen Witvliet, 1997) and in a distributed
manner as nodes throughout the cerebral cortex (Nadel
& Jacobs, in press), (b) is not integrated via the hippocampus due to
intense emotional arousal (e.g., Joseph, 1998; Nadel & Jacobs, in press), and (c) is
reported by clients as vivid, veridical flashback experiences of their actual
trauma (see vanOyen Witvliet, 1997; cf.
Frankel, 1994), the view that traumatic memories
are remembered vividly and accurately in the form of dissociated flashbacks is
not generally accepted (van der Kolk, 1998). McNally (1997) states that implicit memory biases for
trauma cues in PTSD patients are not found for memory tasks that involve
perceptual input but may be found only with more conceptually complex tasks.
The implicit memory biases that occur from elicitation by presentation of
trauma-related stimuli in a lab setting may be substantively different from
internally-generated intrusive flashbacks, particularly if those flashbacks
have their basis in neurochemical events.
There is evidence from both
animal and human neurological studies in support of morphological and, to a
lesser degree, functional changes consistent with van der Kolk and Fisler's (1995)
and Jacobs and Nadel's (in press)
theory, including the role of the limbic system in fear conditioning (Bloom, 1995; Joseph, 1998; LaBar, et al, 1998; LeDoux, 1995; LeDoux
& Muller, 1997; Weinberger, 1995); the
role of the limbic system in processing of traumatic material (Bremner et al., 1995; Bremner et al., 1996;
Cahill,,1997; Cahill & McGaugh, 1996; Cahill & McGaugh, 1998; Joseph, 1998; Rauch et al.,
1996; van der Kolk, 1997; van der Kolk & Saporta, 1991);
hemispheric lateralization in the recall of traumatic memories (Rauch et al,
1996; Schiffer,
Teicher, and Papanicolaou, 1995); lateralization in hippocampal atrophy in
traumatized samples, with abused children showing left hippocampal atrophy (Bremner, et al.,
1997), adult combat vets with PTSD showing right hippocampal atrophy (Bremner et al., 1995),
and another study on combat vets showing bilateral hippocampal atrophy (Gurvits
& Pitman, 1996); lateralization of amygdala activation in response to
self-generated trauma imagery in combat veterans (Shin, et al.,
1997); the role of neurohormones and transmitters in emotional memory
processing, including consolidation and storage (Jacobs & Nadel, in press; McGaugh, 1992; Cahill, Prins, Weber,
& McGaugh, 1994; Margarinos,
Verdugo, & McEwen, 1997; Schulkin, McEwen & Gold,
1994); the role of the hippocampus in memory storage and context for memory
storage (Joseph, 1998; Nadel & Moscovitch, 1997; Parkin, 1996); the role of corticosteroids and
enkephalins in hippocampal damage (see Joseph, 1998; cf.
Yehuda, 1997), and the possibility of a kindling-like
phenomenon with repeated exposure to stressors (Adamec,
1997; Yehuda, 1997). However, there is less
evidence in support of the postulated neurobiological events believed to
underlie the complete processing and integration of traumatic memories.
In terms of the functional
processing of memory and its relation to trauma, the view that implicit memory
influences behavior in a nonconscious manner appears to be well-established (Gazzaniga, 1995; Moscovitch, 1995; Schachter,
1995), as is the evidence for state-dependent memory (Rolls,
1995) and the effects of arousal on memory encoding, storage and retrieval (see
Bremner et al.,
1996; Christianson &
Nilsson 1984; Joseph, 1998; Nadel & Jacobs, in press; cf. Christianson & Mjorndal,
1985; Shobe & Kihlstrom, 1997),
which may be mediated by a catecholaminergic stress response system (vanOyen Witvliet, 1997). Moreover, there is
evidence that sexually abused children and adults with PTSD have injury and
atrophy of the hippocampus with related disturbances in memory (Bremner et al., 1995; Bremner et al.,
1997; see also Joseph, 1998). In relation to the
veridicality of flashbacks, Southwick et al (1993) showed that when yohimbine
was administered to Vietnam veterans with PTSD, approximately 50% of the
veterans stated that they experienced perceptions that were identical to their
actual war experiences (as cited in van der Kolk,
Burbridge, & Suzuki, 1997). van
der Kolk and Fisler (1995) found that all of their sample of 46 traumatized
women and men originally remembered their trauma as somatosensory or emotional
flashbacks. van
der Kolk, Burbridge and Suzuki (1997) found that of 62 participants with a
history of childhood or recent trauma, all of the participants in the childhood
trauma sample (N = 34) and 78% of those in the recent trauma sample (N = 28)
reported that their initial memories of the trauma were in the form of
somatosensory flashback experiences, rather than in narrative format.
In summary, this postulated
view that the kinesthetic disassociation technique assists in modulating
arousal upon exposure to trauma-related cues is premised on van der Kolk’s
theory of traumatic memory processing. Although there has been criticism of
this view of traumatic memory, it appears to find a substantial degree of
support from biological studies, as noted above. This evidence is at this time,
however, more suggestive than conclusive.
V/KD Literature Review
Koziey and McLeod (1987) utilized
V/KD in the treatment of two adult female rape victims, who reported having had
received no prior psychological intervention. Both participants were university
undergraduates. Case 1 is a 19-year old female who had experienced acquaintance
rape almost two years prior. Case 2 is an 18-year old woman who had experienced
acquaintance rape about one-and-a-half years prior and had also been sexually
assaulted at age 10 when she was on her way home from school. Both women
reported fear and anxiety, distrust of men, and anger/irritability, all of
which interfered with their interpersonal functioning.
The pre, post, and
in-session assessment package consisted of the Symptom Checklist-90-Revised
(SCL-90-R), the Veronen-Kilpatrick Modified Fear Survey, the Profile of Mood
States, and the State-Trait Anxiety Inventory (STAI). Following initial
assessment, each participant participated in one session of trance induction.
In the second treatment session one week later, participants completed the
assessment package again, the induction was re-administered, and then both
participants received the V/KD intervention. The participants were interviewed
three weeks later, at which time the assessment package was again completed and
the participants provided a subjective evaluation of the procedure and their
respective level of functioning.
Case 1 had pre-treatment
elevations of at least one standard deviation (SD) above the mean on 15 of the
28 dependent measures (the scales were not specified). Following the hypnotic
induction, she had elevated scores on eight of the dependent measures, with a
significant reduction (i.e., at least one SD) in 11 of the measures
(unspecified). After the V/KD procedure, six of the 28 measures remained
elevated. The V/KD treatment for Case 2 was focused on the sexual assault at
age 10. Case 2 had elevations on 16 of the 28 pre-treatment assessment
measures, which had dropped to seven following the hypnotic induction (see
Table 1). Following the V/KD procedure, all scores on all scales were in or
below the normal range for Case 2. Both women reported notable changes in their
affect state and in their interpersonal relationships following treatment.
Table 1. Number of Scale elevations
of at least one standard deviation above the mean on indices of general
psychopathology and fear/anxiety.
________________________________________________
Pre-Treatment Post-Hypnosis
Post V/KD
________________________________________________
Case 1
15
8
6
Case 2
16
7
0
________________________________________________
Muss
(1991) conducted an uncontrolled study with a sample of 19 British police
officers referred for stress management by a medical insurance company. Of 70
officers seen, 19 met DSM-III criteria for PTSD. The nature of their trauma
ranged from near-death experiences to witnessing scenes of horror and death.
All the participants suffered from intrusive images. Muss treated the 19
participants with V/KD. Although "a number of modifications to the technique
were...necessary" (p. 92), Muss did not specify the nature of the
modifications. The mean number of treatment sessions administered to
participants was three. Treatment effectiveness was evaluated by the
participant's verbal self-reports immediately following the procedure, at a
one-week follow-up interview, and at long-term follow-up interviews occurring
in an interval anywhere from three months to two years after V/KD treatment.
Muss reported that most of the participants (exact number was not specified) stated
that they "felt as if a great weight had suddenly been lifted; others
(number unspecified) did not remark on any immediate change" (Muss, 1991,
p. 92). All 19 officers reported "feeling well" at the one-week
follow-up. Fifteen of the 19 officers were reviewed for longer term follow-up,
at which time 10 were contacted by phone and five were reviewed at the clinic.
The other four could not be contacted. Muss (1991, p. 92) reported "all
[fifteen] confirmed freedom from recurring intrusive images and a return to
normal behavior."
Hossack and Bentall (1996) conducted a
study with five males who met DSM-III-R criteria for PTSD. One participant had
survived a helicopter crash, and the other four were survivors of the
Hillsborough football stadium disaster in the UK. The participants had been
receiving psychiatric care, which was discontinued at the start of the V/KD
procedure. Four of the participants had been unable to maintain employment at
the beginning of the study. All five men reported vivid intrusive imagery of
death and dying at the initiation of treatment.
Measures of PTSD
symptomatology were obtained at the beginning of treatment, after treatment was
complete, and at three months post-treatment. Assessment measures included the
30-item General Health Questionnaire (GHQ-30), the SCL-90-R, and the Impact of
Events Scale (IES). Participants also completed the Hospital Anxiety and
Depression Scale (HAD) within the first 17 weeks of the study and completed daily
diaries of the duration, clarity and distress of intrusive imagery on a
nine-point scale.
A multiple baseline design
was used, such that the participants in the baseline condition functioned as
controls for the participants actively receiving the intervention. Case 1 and 2
had a baseline period of three weeks, Case 3 had a baseline period for six
weeks, and Cases 4 and 5 had a baseline of nine weeks. During the baseline
period, assessment measures and daily ratings were recorded. Following the
baseline, participants were taught Jacobson's progressive relaxation method
coupled with relaxing guided imagery using all sensory modalities for two
sessions. In the next two sessions, the V/KD procedure was implemented in a
standardized manner for all participants.
Case 1 evidenced little
change in intrusive symptomatology, other than modest declines in frequency of
the images. Duration and clarity were not diminished. Case 2 evidenced little
intrusive imagery at the beginning of treatment, and the frequency, duration,
and clarity of the images decreased to near zero following the relaxation
procedure. They worsened slightly around week eight (the week following the
second V/KD procedure). As noted by the authors, this was the week of the
anniversary of the Hillsborough disaster, which could account for the increase
in intrusive symptoms. The ratings for Case 3 were not affected by the
anniversary of the disaster. This person experienced approximately 90 intrusive
images in the week prior to the relaxation training. Relaxation training had a
small effect on the duration, clarity, frequency and distress of the images for
this participant, whereas the V/KD procedure resulted in a substantial
reduction in these ratings. Participant 4 was reported to have experienced problems
in following the V/KD procedure, and no improvement was evident in his ratings.
For participant 5, there were dramatic reductions in the frequency, duration,
and clarity of his intrusive images following the relaxation procedure and more
improvement following the V/KD procedure. These improvements were maintained
throughout the follow-up period.
All participants showed
reductions in IES scores except for the fourth participant. Two of the five men
evidenced an increase in avoidance symptoms following the interventions. Cases
2, 3, and 5 showed reductions in HAD scores, and all subjects but Case 4 showed
substantial changes in the GHQ-30 and SCL-90R scores. All participants except
subject 4 showed improvements in social and occupational functioning following
treatment.
Limitations of Studies
Reviewed.
Limitations of the V/KD
studies are as follows: All of the V/KD studies looked at single-event traumas,
with no chronically traumatized populations sampled. Hossack and Bentall (1996) included a
relaxation procedure prior to the V/KD intervention for all subjects; however,
the order of administration of the relaxation and V/KD interventions were not
randomized to control for the confounding of treatment variables. Similarly, Koziey and McLeod (1987) included a
hypnosis session prior to the V/KD intervention, which was not randomized. Muss (1991) measured PTSD as per DSM-III criteria and client
verbal self-report, and did not obtain inter-rater reliabilities or use
standardized outcome assessment instruments. Muss included no description or
discussion of the modified procedure, so the degree to which the intervention
protocol was adhered to is not clear. In summary, two of these studies were
confounded and the third used a modified V/KD procedure.
Summary of Literature
Review
In summary, a database
search resulted in only three published reports on the V/KD technique:
two case studies and one uncontrolled study. Sample sizes were small, ranging
from two to 19. The populations from which the samples were derived include
survivors of sexual assault, near death experiences, aircraft crashes or
near-crashes, and a football stadium disaster as well as witnesses to horror
and death.
Although V/KD is
categorized as an Experimental Treatment according to APA Division 12 Task
Force criteria (1995), the results of these studies suggests that V/KD
appears somewhat effective for treatment of posttraumatic intrusive imagery,
fear, and diminished social/occupational functioning for most participants
studied. Though the experimental design of these studies was generally poor,
the treatment efficacy appears promising. These results need to be qualified by
the confounding of V/KD proper with hypnotic induction/relaxation techniques.
Nonetheless, utilizing V/KD with hypnosis appears to be fairly effective in the
treatment of some posttraumatic sequelae, and controlled, randomized studies
are called for. The study by Hossack and Bentall meets many of the controls for
internal validity in case studies as set forth by Kazdin (1998).
Limitations and
Contraindications of Visual/Kinesthetic Dissasociation
Some limitations and
contraindications of the V/KD procedure are as follows:
(a) Some clients may have difficulties
in obtaining a detached or observer perspective, which will prevent the
effective implementation of the procedure and may increase the risk that
clients will be retraumatized through the re-experiencing of intense affect. As
such, it might prove advantageous to assess the client's ability to obtain a
detached or observer perspective prior to implementation of the technique. If
clients are unable to obtain such a perspective then an alternative treatment
strategy may be advisable. Some clients may experience increased avoidance
symptomology following the V/KD procedure, and thus continual assessment of
client functioning is required throughout the procedure;
Recommendations
It is recommended that all
clients be screened for dissociation and risk factors for decompensation and
that clinicians be familiar with grounding techniques when using V/KD and any
other exposure-based treatment for trauma. In terms of using grounding
techniques, it is advisable that a thorough assessment for dissociative
phenomena and self-resources be conducted prior to any intervention. For
clients who are dissociative and lacking in self-resources, grounding is
advisable to prevent excessive dissociation during exposure-based
interventions.
Caveat: Is Grounding
Always Necessary? Care
needs to be used with grounding techniques as well, especially for clients who
have good ego strength and who are not highly dissociative. For such clients
the utilization of grounding techniques by the therapist when the client is in
the midst of effective trauma processing may be experienced by the client as an
unnecessary or unwanted intrusion and may actually interrupt or impede healthy
processing. Therapists should gain a clear sense of client strengths prior to
trauma-based interventions and need to use care to appropriately discern when
grounding is necessary for the client and when it may be being used to
alleviate the distress of the therapist.
Screening. Use caution with exposure-based
treatments with clients who exhibit the following, as there is some evidence to
suggest they are at increased risk of retraumatization, increased anxiety and
panic, alcohol abuse, increased shame and guilt, and obsessional thinking
following exposure (Litz,
et al, 1990):
· current substance abuse
· history of impulsivity
· ongoing life crises, such as suicidality
· prior failed treatment with exposure-based therapy
· a history of noncompliance
· a recent claim for compensation
· difficulty using imagery
· absence of re-experiencing symptoms
· inability to tolerate intense arousal
· history or presence of a co-existing psychiatric disorder
Clients can be pre-screened
for dissociation by therapists trained in assessment using the Dissociative
Experiences Scale (DES; Carlson &
Putnam, 1993). A cutoff score of 31 is suggestive of PTSD, and a
cutoff score of 57 is suggestive of DID (Wagner, 1999).
Note that these are suggestive, not diagnostic. If a dissociative
disorder is suspected through a preliminary screen using the DES, a more
thorough assessment by way of structured interview can be conducted. The
Dissociative Disorder Interview Schedule (DDIS; Ross et al., 1989)
or the Structured Clinical Interview for DSM-IV Dissociative Disorders-Revised
(SCID-D-R; Steinberg, 1994) is recommended. Note that
these require training for their use. If the client meets criteria for DID or
has highly elevated scores on measures of dissociative symptoms, be aware of
potential complications when using trauma interventions. It is important to
also maintain awareness of possible symptom underreporting. Clients who are
exhibiting avoidance symptoms (including dissociation) may deny or mask
trauma-related symptoms (Elliott &
Briere, 1994; Epstein, 1993). Complete and thorough
pre-assessments are an important component of treatment planning.
Stabilization Techniques. During the exposure-based
technique per se, pay particular attention to evidence of extreme anger,
anxiety, dependency, or fragmentation. Avoid moving too quickly in treatment
with clients who have a known history of trauma yet appear asymptomatic (Briere, 1997).
Signs of dissociation in
session include fixed or glazed eyes, sudden flattening of affect, long periods
of silence, monotonous voice, stereotyped movements, "unreal"
responses, and excessive intellectualization (Briere,
1997).
It is important to take steps to insure that the pacing and timing of
exposure-based interventions are carefully monitored. Slow down the speed of
interventions and/or adjust the intensity of the interventions when clients
attempt to adjust or titrate the emotional intensity (Briere, 1997).
In milder forms, signs of
titration include periods of silence, dissociation, misunderstanding concepts
that are usually understandable, and sudden changes in the direction of the
discussion. At more extreme levels, titration may involve acting out behaviors,
verbal attacks, distraction with sexualized material, an increase in
adversariality, or termination of therapy (Briere,
1997).
In general, stabilization
within sessions may be facilitated through reducing stimulation, reassurance,
and grounding. Have clients attend to their dissociative behavior and ask them
to reduce the dissociative behavior to its minimal level, if possible. If the
dissociation continues, decrease the client’s immediate distress or increase
the client’s level of self-support (Briere, 1997).
Help focus the client on
the facts of what is happening in the here-and-now. The therapist can help set
limits on overwhelming stimuli, divert to less threatening topics, use toys or
objects in the room on which the client can focus, have the client switch seats
or change body posture, stand facing the client with client facing him/her, and
rock back and forth sideways from foot to foot; go cognitive (e.g., talk about
what to do next; talk about the theory behind what is happening), draw
pictures, teach clients to notice how present they are in their bodies by
having them provide a percentage and experiment with how clients can increase
the percentage to about sixty percent (Fisher, 1999; Linehan, 1993).
Summary and Conclusions
Although V/KD was
originally used by Bandler and Grinder
(1979) in the treatment of phobias, the literature reviewed for this paper suggest
that V/KD is useful in the treatment of posttraumatic sequelae. V/KD appears to
be a specialized variant of re-conditioning and exposure therapy, and may
function to assist clients in reprocessing and desensitizing trauma-related
material from a de-centered point of view.
Bandler and Grinder (1979)
postulate that anchoring different (i.e., positive and negative) feeling states
also anchors the respective physiological state that corresponds to each
feeling state. According to Bandler and Grinder, when both anchors are
stimulated simultaneously, the distinct physiological states become integrated,
and the positive feeling state takes precedence whenever the individual is
triggered. This presumes that different feeling states have their own unique
patterns of peripheral physiological arousal, as opposed to the view that there
is one more or less general pattern of physiological arousal that corresponds
to all feeling states and that feelings are differentiated by way of cognition.
It also presumes that positive emotional states will take precedence over
negative emotional states. For persons who suffer from PTSD, this presumption
seems unrealistic. Recent evidence suggests that there is a general arousal
state, as well as different states that correspond to specific emotions (Panksepp, 1999). Anchoring both positive and
negative feeling states may prove harmful, in that integration of positive and
negative affective states may result in further disturbance (e.g., integration
of fear with sexual arousal).
Bandler and Grinder
suggested that V/KD interrupts previously conditioned patterns of association
or sequencing between feared stimuli and response. Through the disruption or
disconnection of various sensory modalities, the previous associations between
fear and the traumatic memory or stimulus are broken, leading to the
opportunity to make new, more functional associations. It is possible that the
guided dissociation process in the V/KD technique assists in the integration of
current and latent mental schemes of the trauma, such that the material can be
processed with reduced levels of affective intensity (perhaps concomitantly
with increased ventral vagal processing) and less chance of treatment
regression and cognitive distortions. Moreover, it simultaneously allows
processing of the material through current cognitive resources.
The studies reviewed for
this paper suggest that V/KD, although currently at an experimental level of
efficacy and in need of further well-designed empirical study, may be a
promising treatment for at least some forms of Posttraumatic Disorder.
Intrusive symptoms, avoidance behaviors, and interpersonal and occupational
functioning improved for many of the participants in the studies reviewed. A small
number of participants evidenced more modest improvement, and two showed
exacerbation of pre-existing avoidant symptoms following the V/KD procedure
proper.
Therapeutic interventions,
including V/KD, should be used with caution with some traumatized client
populations. If clients present with pronounced affect dysregulation, notable
dissociation, or other symptoms of destabilization, trauma treatment should be
postponed until clients have been stabilized (Herman,
1992). Care should be used to monitor clients closely following the
implementation of the V/KD technique proper, since some clients experience
increased avoidance symptomology following the intervention.
Knowledge of
"grounding" techniques or other means of assisting clients in
modulating affective distress or dissociation is an important adjunct to the
use of any trauma intervention, as well as knowledge of when grounding
techniques are needed. Further empirical study is required to shed light on the
effectiveness of V/KD in the treatment of trauma, to tease out the exact
mechanisms of action in the V/KD technique, and to determine more precisely
which posttraumatic sequelae are most suited to the V/KD intervention.
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