Memory reconsolidation, emotional arousal, and the process of change in psychotherapy

64 Pages·2017·1.06 MB·English

BEHAVIORAL AND BRAIN SCIENCES (2015),Page1of64
doi:10.1017/S0140525X14000041,e1
See p. 24 for: Minding the findings: Let’s not miss the message of memory
reconsolidation research for psychotherapy by Ecker, Hulley, and Ticic
Memory reconsolidation, emotional
arousal, and the process of change in
psychotherapy: New insights from
brain science
RichardD.Lane
DepartmentofPsychiatry,UniversityofArizona,Tucson,AZ85724-5002
DepartmentsofPsychologyandNeuroscience,UniversityofArizona,Tucson,
AZ85721
[email protected]
LeeRyan
DepartmentofPsychology,UniversityofArizona,Tucson,AZ85721
[email protected]
LynnNadel
DepartmentofPsychology,UniversityofArizona,Tucson,AZ85721
[email protected]
LeslieGreenberg
DepartmentofPsychology,YorkUniversity,Toronto,OntarioM3J1P3,Canada
[email protected]
Abstract: Since Freud, clinicians have understood that disturbing memories contribute to psychopathology and that new emotional
experiencescontributetotherapeuticchange.Yet,controversyremainsaboutwhatistrulyessentialtobringaboutpsychotherapeutic
change.Mountingevidencefromempiricalstudiessuggeststhatemotionalarousalisakeyingredientintherapeuticchangeinmany
modalities. In addition, memory seems to play an important role but there is a lack of consensus on the role of understanding what
happened in the past in bringing about therapeutic change. The core idea of this paper is that therapeutic change in a variety of
modalities, including behavioral therapy, cognitive-behavioral therapy, emotion-focused therapy, and psychodynamic psychotherapy,
results from the updating of prior emotional memories through a process of reconsolidation that incorporates new emotional
experiences. We present an integrated memory model with three interactive components–autobiographical (event) memories,
semanticstructures, andemotionalresponses–supported by emerging evidencefrom cognitiveneuroscience onimplicit and explicit
emotion, implicit and explicit memory, emotion-memory interactions, memory reconsolidation, and the relationship between
autobiographicalandsemanticmemory.Weproposethattheessentialingredientsoftherapeuticchangeinclude:(1) reactivatingold
memories; (2) engaging in new emotional experiences that are incorporated into these reactivated memories via the process of
reconsolidation;and(3)reinforcingtheintegratedmemorystructurebypracticinganewwayofbehavingandexperiencingtheworld
inavarietyofcontexts.Theimplicationsofthisnew,neurobiologicallygroundedsynthesisforresearch,clinicalpractice,andteaching
arediscussed.
Keywords:changeprocesses;emotion;implicitprocesses;memory;neuroscience;psychotherapy;reconsolidation
1. Introduction understanding the past, whereas Ferenczi deviated from
Freud by emphasizing the importance of emotional
The modern era of psychotherapy arguably began with arousal in psychotherapy (Rachman 2007). Ferenczi’s ap-
Breuer and Freud’s (1895/1955) Studies on Hysteria. In proach became the basis for the humanistic tradition
thatseminalwork,BreuerandFreudhypothesizedthatthe launched by Carl Rogers and Fredrick Perls (Kramer
inability to express emotion at the time of trauma was the 1995).Withinpsychoanalysis,however,thetherapeuticim-
cause of hysteria (now called conversion disorder). They portanceofemotionwasfurtherrefinedbyAlexanderand
proposedthatthekeytotreatmentwasemotionalabreaction, French(1946),whoproposedthatthe“correctiveemotion-
orcatharsis.Oncethefeelingsthathadnotbeenexpressed al experience” was the fundamental therapeutic principle
werebroughttoconsciousawarenessandrelived,thesymp- of all “etiological psychotherapy.” In their definition it
toms,BreuerandFreudproposed,woulddisappear. meant“tore-exposethepatient,undermorefavorablecir-
Within the psychoanalytic tradition, Freud increasingly cumstances, to emotional situations which he could not
emphasized the importance of remembering and handle in the past. The patient, in order to be helped,
©CambridgeUniversityPress2015 0140-525X/15 1
Laneetal:Memoryreconsolidation,emotionalarousal,andtheprocessofchangeinpsychotherapy
must undergo a corrective emotional experience suitable
RICHARDD.LANEisaProfessorofPsychiatry,Psychol- to repair the traumatic influence of previous experiences”
ogy, and Neuroscience at the University of Arizona. A
(Alexander & French 1946). They also pointed out that
psychiatrist with a Ph.D. in Psychology (cognitive “intellectualinsightaloneisnotsufficient.”
neuroscience),heistheauthorofmorethan130articles
The integrity and reliability of the evidence for Freud’s
and chapters and is senior editor of one book. His
theories continue to be a topic of heated debate (Erdelyi
research on emotion, the brain, and health has been
funded by grants from the National Institute of 2006; Esterson 2002; Gleaves & Hernandez 1999;
Mental Health, the National Heart, Lung and Blood McNally 2005). Research shows that emotional catharsis
Institute and multiple other sources. He is a past alone(e.g.,beatingapillow)doesnotattenuateordissipate
president of the American Psychosomatic Society, a affect but rather leads to a heightening of it (Bushman
Distinguished Fellow of the American Psychiatric 2002).Nevertheless,theimportanceofinducingemotional
Association, an elected member of the American arousal as an ingredient in bringing about therapeutic
College of Neuropsychopharmacology, and an
changehasstoodthetest oftime.Inhisseminal overview
HonoraryFellowoftheAmericanCollegeofPsychoan-
of psychotherapy practices, Jerome Frank (1974a) stated
alysts. He is an award-winning teacher who has been
that emotional arousal was a key ingredient in the success
director of Psychiatric Residency Training in Psycho-
of psychotherapy. Modern psychoanalysts hold that re-
therapy at the University of Arizona for the past 20
years. experiencing and resolving core emotional conflicts in the
transference relationship has a reality and authenticity
LEE RYAN isaclinicalneuropsychologistandaProfes- that cannot be surpassed by other means (Luborsky
sor of Psychology and Neurology at the University of 1984),andevidencefortheeffectivenessofpsychodynamic
Arizona, and the associate director of the Evelyn psychotherapyisemerging(Leichsenring&Rabung2008;
F. McKnight Brain Institute. Her research focuses on Shedler2010).
the role of medial temporal lobe structures in In behavior therapy (BT), cognitive-behavioral therapy
memory,aswellasage-relatedchangesinbrainstruc- (CBT), and emotion-focused therapy (EFT), emotion
tureandfunctionandtheirimpactonmemoryandex-
plays a central role in change. In behavioral therapy (BT)
ecutive functions. She is the author of more than 80
for anxiety disorders, activation of affect in the therapy
peer-reviewedarticles.Dr.RyanisthedirectorofGrad-
session is a critical component and predictor of therapy
uateStudiesintheDepartmentofPsychologyandhas
success(Foa&Kozak1986).CBTassumesthatemotional
won awards for her outstanding undergraduate and
graduate teaching, including the Humanities College distressistheconsequenceofmaladaptivethoughts.Thus,
OutstandingTeacheraward(2012). the goal of these clinical interventions is to examine and
challengemaladaptivethoughts,toestablishmoreadaptive
LYNNNADELiscurrentlyRegentsProfessorofPsychol- thought patterns, and to provide coping skills for dealing
ogyandCognitiveScienceattheUniversityofArizona. more effectively with stressful situations (Dobson 2009).
His research, published in more than 175 journal Eliciting emotional responses through role-playing, imagi-
articles, chapters, and books, has been supported by nation,andhomeworkexercisesiskeytotheidentification
grants from the National Institute of Mental
andreformulationofthesemaladaptivethoughts.Recovery
Health,theNationalScienceFoundation,theNational
isfacilitatedbyactivitiesthatencourageengagementofrel-
Institute of Child Health and Human Development,
evantpathologicalcognitivestructuresinacontextthatalso
the National Institute of Neurological Disorders and
provides information at odds with existing beliefs. In the
Stroke, and several private foundations. He was the
co-recipient in 2005 of the Grawemeyer Prize in humanistictradition,researchonEFThasalsodemonstrat-
Psychology (for the “cognitive map” theory) and re- ed that the intensity of emotional arousal is a predictor of
ceived the National Down Syndrome Society’s Award therapeuticsuccess(Missirlianetal.2005).Onemustcon-
forResearch(2006)andtheSisley-LejeuneInternation- clude that there is something about the combination of
al Prize for Research on Intellectual Disability arousing emotion and processing that emotion in some
(2013). He is a Fellow of the American Psychological waythatcontributestotherapeuticchange,butthespecif-
Society,theAmericanAssociationfortheAdvancement
ics of what it is about emotion that actually brings about
of Science, and the Society of Experimental
changearenotclear.
Psychologists.
Insight-oriented psychotherapy places heavy emphasis
on the recollection of past experiences. It is typically
LESLIE GREENBERG is Distinguished Research
thought that understanding these past experiences in a
Professor Emeritus of Psychology at York University,
new way contributes to psychotherapeutic change
Toronto, and Director of the Emotion-Focused
Therapy Clinic. He has authored texts on emotion- (Brenner 1973). There is disagreement, however, across
focused approaches to treatment, having published therapeutic modalities about the importance of under-
17 booksand more than 100 articles. He has received standing what happened in the past. An alternative view
the American Psychological Association Award for is that the past is clearly exerting an important influence
Distinguished Professional Contribution to Applied on the interpretation of present circumstances, but what
Research, the Distinguished Research Career award is important is to change current construals so they more
of the International Society for Psychotherapy Re- accurately fit present rather than past circumstances
search,theCarlRogersawardoftheAmericanPsychol-
(Lambert et al. 2004). For example, Ellis’ (1962) rational
ogyAssociation,theCanadianPsychologicalAssociation
emotive behavior therapy emphasizes that distress symp-
AwardforDistinguishedContributionstoPsychologyas
toms arise from irrational belief systems developed from
aProfession,andtheCanadianCouncilofProfessional
Psychology award for Excellence in Professional previous experiences and events that elicited strong nega-
Training. tive emotions. For Ellis and others in the BT (Eysenck
1960; Foa & Kozak 1986), CBT (Beck 1979; Rachman
2 BEHAVIORALANDBRAINSCIENCES,38(2015)
Laneetal:Memory reconsolidation,emotionalarousal,andtheprocessofchange inpsychotherapy
1997;1980),andEFTtraditions(Greenberg2010),actual- generalizability of the newly formed memory/semantic
lyunderstandingwhatdevelopmentalexperiencescontrib- structure tonovelsituations andenvironments.
uted to the current way of understanding the world may Importantly,wewillarguethatchangeinpsychotherapy
thereforenotbenecessarytobringaboutchange. isnotsimplyaresultofanewmemorytracebeingformed
Thislatterviewbecomesespeciallysalientwhenconsid- or new semantic structures being developed. Instead,
eringthat memories ofthepastarenotlikely veridicalac- reconsolidationleadstothetransformationofallthecom-
counts of the original event (Heider 1988) but undergo ponents of the memory structure, including the original
revision with repeated recollections and the passage of event memory. By this view, psychotherapy is a process
time (Neisser 1981; Neisser & Harsch 1992; Talarico & thatnotonlyprovidesnewexperiencesandwaystoevalu-
Rubin 2003), especially for the autobiographical compo- ate new experiences, but also changes rules and schemas
nents of those memories (Bergman & Roediger 1999; derived from past experiences in fundamental ways
Coluccia et al. 2006; Nadel et al. 2007; Ost et al. 2002). throughthereconsolidationofmemoryanditsrelatedcog-
Insteadofremainingfaithfulrecordsofpastevents,mem- nitive structures. A number oftherapeutic approaches are
ories are updated and re-encoded through a process re- adopting this as an explanatory construct (Ecker et al.
ferred to as “memory reconsolidation” (see Hardt et al. 2012;Greenberg2010;Welling2012).
2010 for a recent review). As such, there is a need to In thesectionsthat follow, wereview implicit cognition
more precisely define in what way memory processes andimplicitemotion(sect.2),theroleofimplicitprocesses
contribute to therapeutic change and to better define inpsychotherapy(sect.3),andtheevidencethatemotional
how these memory processes interact with emotional arousalisakeyingredientinthesuccessofpsychotherapy
processes. (sect.4).Wethenfocusonseveralkeyareasofresearchrel-
Inthispaper,weproposethatchangeoccursbyactivat- evant to the integrated memory model, including interac-
ingoldmemoriesandtheirassociatedemotions,andintro- tions between memory, emotion, and stress (sect. 5), the
ducingnewemotionalexperiencesintherapyenablingnew inherently dynamic nature of memory (sect. 6), the phe-
emotional elements to be incorporated into that memory nomenonofmemoryreconsolidation(sect.7),andthere-
traceviareconsolidation.Moreover,changewillbeendur- lationship between autobiographic (personal experience)
ingtotheextentthatthisreconsolidationprocessoccursin memory and semantic (generalizable knowledge) memory
awidevarietyofenvironmentalsettingsandcontexts.This (sect.8).Weconcludewithadiscussionoftheimplications
proposedmechanismmaybetimely.Kazdin,forexample, ofthisnew,neurobiologicallygroundedintegratedmemory
stated, “After decades of psychotherapy research, we model for clinical practice, futureresearch, andeducation
cannot provide an evidence-based explanation for how or (sect.9).
why even our most well studied interventions produce
change, that is, the mechanism(s) through which treat-
mentsoperate”(Kazdin2006,p.1). 2. Implicitemotionandemotionaltrauma
Weproposeanintegratedmemorymodelwiththreeas-
sociativecomponents–autobiographical(event)memories, Breuer and Freud (1895/1955) believed that the critical
semantic structures, and emotional responses–that are pathogenic element in hysteria was strangulated affect.
inextricablylinkedandthat,combined,leadtomaladaptive Consistent with Janet’s concept in the late nineteenth
behaviors.Thismemorystructureissimilartopreviousfor- century (Van der Kolk & Van der Hart 1989), trauma was
mulations of the “fear structure” by Foa and colleagues conceptualized as an experience that was psychologically
(Foaetal.1989),butappliedmorebroadlyand,important- overwhelming because of the intensity of the affect that
ly, is predicated on recent neurobiological evidence that was activated, not because it was an event that was inher-
providesabasisforunderstandinghowthememorystruc- entlylife-threatening (asisspecifiedin current Diagnostic
ture is changed through psychotherapy. Briefly, we will andStatisticalManual[DSM-V]criteriaforPost-Traumatic
argue that, broadly speaking, clinical change occurs StressDisorder[PTSD])(AmericanPsychiatricAssociation
through the process of memory reconsolidation. During 2013). They believed that there was a lack of affective ex-
therapy, patients are commonly asked to experience pression at the time of a trauma that kept the memory of
strong emotions, elicited by the recollection of a past the traumatic event alive for years. Once this emotion
event or other precipitating cue. By activating old memo- wasexperienced,expressedandputintowordsinthether-
ries and their associated emotional responses in therapy, apeuticcontextitwouldbecurative.Thisconceptualization
new emotional elements can be incorporated into the was consistent with the Freudian concept of unconscious
memory trace. The corrective experience occurs within a mentalrepresentation,whichwasthatmentalcontentsin-
new context, the context of therapy itself, which can also cluding emotions were fully formed in the unconscious,
be incorporated into the old memory via the processes of were revealed in conscious awareness only when defenses
reactivation, re-encoding, and reconsolidation. Additional- were removed or overcome (Schimek 1975), and that the
ly, recent evidence suggests that event memories and goal of therapy was to “make the unconscious conscious”
semantic structures are interactive (for review, see Ryan (Breuer&Freud1895/1955;Freud 1923/1961).
et al. 2008b). By updating prior event memories through A century of research has altered our understanding of
new experiences, the knowledge and rules derived from unconscious mental representation. We now understand
prior experiences will also change. Thus, new semantic that memories and feelings do not reside in the uncon-
structures, or rules and schemas, will be developed that scious fully formed waiting to be unveiled when the
lead to more adaptive ways of interpreting events, and, in forces of repression are overcome (Lane & Weihs 2010;
turn, more appropriate emotional responses. Change will Levine 2012). In contrast to a model of the unconscious
be enduring to the extent that this reconsolidation asacauldronofforbiddenimpulsesandwishes,the“adap-
process occurs in a wide variety of contexts, allowing tiveunconscious”(Gazzaniga1998)isconceptualizedasan
BEHAVIORALANDBRAINSCIENCES,38(2015) 3
Laneetal:Memoryreconsolidation,emotionalarousal,andtheprocessofchangeinpsychotherapy
extensive set of processing resources that execute complex There is now considerable evidence supporting an im-
computations,evaluations,andresponseswithoutrequiring plicit view of emotion (Kihlstrom et al. 2000; Lambie &
intentionoreffort.Muchofthisprocessingmaybeunavail- Marcel 2002; Lane 2008). Indeed, 25 years of research
abletoconsciousawareness,oratleast,awarenessisunneces- hasdemonstratedtheoccurrenceofspontaneousaffective
saryforsuchprocessingtooccur.Morecommonly,cognitive reactions associated with changes in peripheral physiology
psychologyreferstoimplicitprocessestodifferentiatethem and/or behavior that are not associated with conscious
fromexplicitprocessesthatareengagedduringintentionally emotional experiences (Ledoux 1996; Quirin et al. 2012;
drivenandgoal-directedtasks.Thedistinctionbetweenim- Winkielman & Berridge 2004; Zajonc 2000). For example,
plicitandexplicitprocessinghasbeenappliedinsomeform onecanactivateemotionswithsubliminalstimulianddemon-
to virtually all areas of cognition, including perception, strate that the emotional content of the stimuli influences
problem solving, memory and, as we will discuss, emotion, subsequent behavior, such as consummatory behavior,
leadingGazzaniga(1998)tosuggestthat99%ofcognitionis withoutthepersonbeingawareofsuchinfluencesonbehav-
implicit. Importantly, some psychoanalysts believe that this ior(Winkielman&Berridge2004).
newwayofunderstandingtheunconsciousasfundamentally Furthermore, many decades of research preceding the
adaptivecallsforarevisionofclassicpsychoanalyticmodelsof modern era of neuroimaging demonstrated the evocation
theunconsciousmind(Modell2010). of visceral and somatomotor expressions of emotion in
In the memory domain, implicit memory refers to the brainstem stimulation studies of laboratory animals
impact of prior experience on subsequent behavior in the (Ledoux 1996). Although these phenomena cannot be
absenceofexplicitrecallorawarenessofthatpriorexperi- linked to reportable experiences in animals without lan-
ence(forreview,seeSchacteretal.1993).Inthelaboratory guage, they nevertheless are the physical manifestation of
a brief exposure to a specific word, for example, increases emotion. We believe that implicit emotion, consisting
thelikelihoodthatapersonwillrespondwiththatparticular of these visceromotor and somatomotor expressions of
wordduringvariouslanguage-basedtaskssuchascomplet- emotion, constitute the foundation upon which differenti-
ing a three-letter word stem (Graf & Schacter 1985; ated emotional experience is built. Moreover, subcortical
Schacter & Graf 1989) or producing exemplars belonging structuresincludingthethalamus,hypothalamus,amygda-
to a semantic category (Ryan et al. 2008a). A different la,andperiaqueductalgreylikelycontributetothegenera-
form of implicit learning is the acquisition of complex tionoftheseundifferentiatedemotionalresponsesthatare
sets of rules that govern predictions (Reber 1989), allow not associated with specific emotional experiences (Lane
categorization of novel objects and concepts (Seger & 2008).
Miller 2010), and guide social interactions (Frith & Frith LambieandMarcel(2002)distinguishamongthreedif-
2012). Importantly, this learning occurs regardless of ferent conditions: an emotional state with no phenomenal
whether the individual is explicitly aware of the rules that experience; the first-order phenomenal experience of
have been acquired or that learning has even taken place. emotion, which is expressible; and a second-order experi-
Inthesocialdomain,thislearningconsistsofthesemantic enceofemotionassociatedwithawareness,whichisreport-
rules,expectations,andscriptsforbehaviorthatprovidethe able. Implicit emotion, or bodily felt sensations, can be
basisfortheself-concept (Markus&Wurf1987). transformedintodiscreteconsciousexperiencesofspecific
Thedistinctionbetweenimplicitandexplicitprocesses,a emotions or feelings by putting the felt sensations into
cornerstone of modern cognitive neuroscience, has also words (Barrett et al. 2007; Lane 2008). Through this
been applied to emotion (Kihlstrom et al. 2000; Lane process individuals can feel specific, differentiated
2000). Emotions are automatic, evolutionarily older re- emotions and “know” what it is that they are feeling.
sponses to certain familiar situations (Darwin 1872). Thus,theterm“explicit”isusedtorefertostatesofaware-
Emotion can be understood as an organism’s or person’s nessthataresymbolizedandknown.Inrelationtoemotion
mechanism for evaluating the degree to which needs, the term “implicit” refers to automatic bodily responses
values, or goals are being met or not met in interaction thatareunconsciousinthesensethattheyarenotassociat-
with the environment and responding to the situation edwithawareness,arenotconsciouslysymbolizedandare
withanorchestratedsetofchangesinthevisceral,somato- notknown(butcouldincludetheunattendedconsciousor
motor,cognitive,andexperientialdomainsthatenablethe phenomenalexperienceofthebodilystate).Notethatthe
persontoadapttothosechangingcircumstances(Levenson unconscious can further be differentiated into that which
1994). Implicit processes apply to emotion in two impor- hasneverbeenmentally represented andneedstobefor-
tantsenses.First,theevaluationoftheperson’stransaction mulatedforthefirsttimeversusthatwhichhaspreviously
withtheenvironmentoftenhappensautomatically,without beenrepresented or knownbutisnotconsciouslyaccessi-
conscious awareness, and is thus implicit. Importantly for ble at the moment (Levine 2012). “Emotion processing”
thisdiscussion,thisimplicitevaluationisbasedonanauto- refers toanychange ineithertheimplicitorexplicitcom-
matic construal of the meaning (implications for needs, ponents of the emotional response. “Cognitive processing
values or goals) of the current situation to that person ofemotion”includesattendingtotheexperience, symbol-
(Clore & Ortony 2000). Second, the emotional response izing it (e.g., in words or images) and reflecting upon
itself can be divided into bodily responses (visceral, soma- what the experience means (e.g., determining what one
tomotor) and mental reactions (thoughts, experiences). needs),orsomecombinationthereof.
Thelatterincludeanawarenessthatanemotionalresponse Based on these conceptual distinctions, one can revisit
is occurring and an appreciation of what that response is. the concept of trauma as described by Breuer and Freud
A foundational concept of this paper is that emotional (1895/1955). Trauma may consist of experiences that are
responses can be implicit in the sense that the bodily re- emotionally overwhelming in the sense that the ability or
sponsecomponentofemotioncanoccurwithoutconcom- resources needed to cognitively process the emotions
itantfeelingstatesorawareness ofsuchfeelingstates. (attend to, experience and know them) are exceeded.
4 BEHAVIORALANDBRAINSCIENCES,38(2015)
Laneetal:Memory reconsolidation,emotionalarousal,andtheprocessofchange inpsychotherapy
Traumamayconsistofasingleeventbutmorecommonly probably was not permissible at the time of the trauma to
consistsofarepeatedpatternofabuseormistreatmentthat experience or express it. Experiencing and describing
is emotionally painful to the victim. In the context of anger in therapy helps create a coherent narrative
growingupasachildinafamilyinwhichabuserepeatedly account of what occurred. Doing so is not the same as
occurs, one makes cognitive and emotional adaptations to Freudian catharsis (release of pent up energy) but rather
keep the subjective distress to a minimum. This helps to thecreationofamorecompletepictureofwhathappened,
keep attention and other conscious resources available for how one responded, what one experienced, and how it
other tasks (see Friston 2010). The victim learns to couldhavebeendifferent(Greenberg2010).
acceptcertainkindsofmistreatmentsinordertocontinue Havinganotherpersonsuchasatherapistparticipatein
inrelationships,whichappeartobe(andoftenare)neces- and facilitate this mentalization process in adulthood may
sary for survival. The needed adjustments include tuning beessential(Allen2013).Thecapacityforself-observation
out awareness of one’s own emotional responses or taking islimited,andmoresoifempathicandresponsiveparent-
for granted certain things about the self (such as “you’re ing was limited during development (Paivio & Laurent
no good and deserve to be punished”). Later in life, 2001). Just as having a teacher/coach/observer is helpful
related situations are interpreted implicitly based on the inthedevelopmentandrefinementofanyathletic,intellec-
implicit learning that occurred from these experiences tual,ormusicalskill,inthecaseofpsychotherapythether-
(Edelman 1989). One might conjecture that the more apist is potentially able to view a given situation from a
intensetheabusethemoreimplicitevaluationsindistantly different, if not a broader, perspective, making it possible
relatedcontextsareinfluencedbythetrauma. to construe the situation, and the client’s emotional re-
Alltoo commonly, perhaps as a result of direct physical sponse to it, differently. This relates to the “coaching”
threats,shameorlackofavailableconfidants,theseexperi- aspect of helping someone to get in touch with feelings
ences are never discussed with anyone. When a parent is ofwhichtheywerepreviouslyunaware(Greenberg2002).
the instigator of abuse it is often a “double whammy,” Theguidingthesisofthisarticleisthatthetherapyexpe-
first because of the violation or harm and second because rienceprovidesnewinformationandthattheoldmemory
the parent is not available to assist the victim in dealing (ormemories)isreconsolidatedwiththisnewinformation.
with it (Newman 2013).The lack of an available caregiver Differenttherapymodalitiesfocusondifferentkindsofin-
toprovidecomfortandsupportmaybeacriticalingredient formationthatareinherentinthetherapyexperience(see
inwhatmakestheexperience(s)overwhelmingortraumatic. sects.3and9).Thediscussionabovefocusedonnewinfor-
What this means emotionally is that the implicit emotional mationconsistingofexpansionoftheclient’sunderstanding
responseswereneverbroughttotheconsciouslevelofdis- of what they experienced emotionally. The new informa-
cretefeelingthroughmentalrepresentation,asinlanguage. tion consists, in part, of both the conscious experience of
As a result, the traumatized individual knew the circum- emotions not previously experienced originally or during
stances of the trauma but did not know how it affected prior retellings of the event, and an understanding of
him emotionally. This lack of awareness contributes to the what these experiences are and what they mean. Another
tendencytoexperiencetraumaticthreatsinanoverlygener- sourceofnewinformation,whichisacommondenomina-
alized manner that reflects the inability to distinguish cir- tor across modalities, is the therapeutic alliance with the
cumstances that are safe from those that are not. It is therapist (Horvath & Luborsky 1993). Experiencing the
often only in therapy when the experiences are put into safety, support, caring, and compassion of the therapist in
words that the emotional responses are formulated for the thecontextofrecallingadverseexperiencespermitsincor-
firsttime(Lane&Garfield2005;Stern1983). porationofthisinterpersonalexperience,atypeofinforma-
AlthoughBreuerandFreudbelievedthatexpressingthe tion, into the traumatic memories, which often involve
emotionwascritical,thisalternativeperspectivehighlights being alone and unprotected. The experience of comfort
theimportanceofbecomingawareoftheemotionalimpact and support may be sensed and responded to implicitly
oftheexperience(s)throughsymbolizationandcontextual- withoutbeingbroughttoexplicitawarenessthroughatten-
ization (narrative formation) (Liberzon & Sripada 2008) tion,reflection, andverbaldescription.
andusingthisawarenessinthepromotionofmoreadaptive Therapymodalitiesdifferintheemphasisplacedonself-
responses(thatis,convertingimplicitemotionalresponses exploration and the importance of the interpersonal con-
to explicit emotional responses). When the trauma is first nection with the therapist. A person’s ability to be aware
recalled, the description of experience is likely to include of and process her own emotions, and to engage with a
strong emotions, such as fear, that were experienced at therapist,maybeafunctionofthedegreetowhichcaregiv-
the time and contributed to strong encoding of the event. ers succeeded in providing this function during childhood
As the therapy process unfolds, the events are recalled in in a way that matched the needs of the child in question
the context of a supportive therapist who also helps the (Steklis&Lane2013).Inthecaseofemotionasasubjec-
client to attend to contextual information that may not tiveexperience,thereisnoinformationintheexternalen-
have been available to the client at the time of the vironment that corresponds to the child’s internal
trauma (in part because of temporary hippocampal dys- experience except that which is provided by an attuned
function[Nadel&Jacobs1998];seesect.4).Thisnewin- other. For example, one cannot typically see one’s own
formation in therapy contributes to a construction of the facial expressions and in infancy such expressions may not
events in a new way that leads to emotions that had not be recognized as one’s own even if looking in the mirror.
been experienced before, for example, experiencing This may be contrasted with the example of self-initiated
angeratabusethatcouldnotbeexpressedorexperienced movement(Keysers&Gazzola2006).Thebasiccoordina-
atthetimebecausethethreatwassosevere.Theangerisa tion of intention with actual motor movement can occur
signal that one needs to be protected. In that sense, the without help from other people because one can see
emotional response is adaptive to the circumstances: It what happens when one intentionally moves one’s arm.
BEHAVIORALANDBRAINSCIENCES,38(2015) 5
Laneetal:Memoryreconsolidation,emotionalarousal,andtheprocessofchangeinpsychotherapy
This visual input goes beyond the feedback provided by (sect.3.2),experiential(sect.3.3),andpsychodynamicpsy-
proprioceptive sensation. Thus, in early development the chotherapies (sect.3.4).
abilitytolinksubjectiveexperienceofemotionwithanun-
derstanding of its behavioral manifestations in the real
3.1. Behavioralperspective
worldrequiresinputfromothers(Gergely&Watson1996).
For example, a very young child may recoil and appear Numerous therapies based on exposure have been shown
frightened when a puppy approaches. A parent may say, tobeeffective fortreating traumaandanxiety-related dis-
“Don’t worry. There’s nothing to be afraid of (parent pets ordersincluding PTSD, and their effectiveness appears to
the puppy). See how friendly he is.” A somewhat older bebasedonemotionalprocessing(Foaetal.2003).Effec-
child may manifest avoidance behavior in anticipation of tive therapy requires the activation of a fear structure
an upcoming event at school. Recognition by a parent that includes an associative network of prior distressing
that the avoidance behavior may be an expression of fear, memories, the representations of fear and/or trauma-
labeling it as such, discussing with the child what he per- related stimuli, and emotional responses to those stimuli
ceives as threatening and discussing ways to deal with it (Foa et al. 1989). Components of the fear structure can
all contribute to the child’s ability to experience fear and be implicit, in that the individual may be unaware of the
useitasacueforadaptiverespondinginsimilarsituations circumstancesleadingtothedevelopmentofthefearstruc-
inthefuture.Ifinputsuchasthisfromsignificantothersis ture,oreventhestimulithatactivatethefearresponse.The
missingduringdevelopmentthecapacitytoknowwhatone fear structure becomes pathological when the individual
isfeelingwillbeimpairedinchildhoodandpersistintolater persistently avoids engaging emotionally and experiencing
life, creating a predominance of implicit emotional re- the emotion associated with the fear-inducing memories
sponses relative to explicit emotional experiences and a leading to behavioral avoidance of fear-related stimuli
greater propensity for being overwhelmed (traumatized) and exceptionally strong emotional responses when those
or unable to cognitively process one’s own emotions later stimuli are encountered (Foa et al. 1995). According to
inlife. Rachman (1980), if a fear probe elicits a strong emotional
Theexpansionofawarenessintherapyisnotunlikethat reactionduringtherapy,itsignalsthatadequateemotional
inducedbyaphysicaltherapistwhohelpsextendtherange processing has not taken place. Emotional processing is
ofmotionofajointbyfacilitatingmovementsthatareasso- defined by Foa and Kozak (1986) as the modification of
ciated with tolerable but not excessive levels of pain and memory structures that underlie emotional responding.
discomfort. It is difficult to extend oneself in these ways Change occurs when the fear structure is modulated, that
on one’s own on account of self-protective mechanisms is, when the bonds between specific eliciting stimuli and
(the same ones that led to avoidance of emotional pain a strong (and often maladaptive) emotional response are
through regulatory actions). Parenthetically, the origin of broken.
restrictedmovementinajointtypicallyarisesfrominflam- Thesemodificationsoftenoccurthroughimplicitlearning,
matorymechanismsdesignedtorespondtoandrepairthe becausethechangingemotionalandphysiologicalresponses
original injury, just as psychological adjustments are made toparticularstimuliduringtreatmentmaybeunavailableto
tolimitaccessto“thepartthathurts.”Inpsychotherapy,ac- theconsciousawarenessoftheindividual,asinthecaseofha-
cording to our formulation, expanding awareness involves bituationorextinction(Foa&Kozak1986).Thus,exposure
experiencing,labeling,reflectinguponandusingemotions training can be conceptualized as both intervention and
that were originally associated with the trauma, but which change at the level of implicit emotion. Through exposure
by definition originally exceeded the person’s capacities trainingthesomatomotor(behavioral)responseismodified
for assimilation and coping. Thus, new information fromavoidancetoeithernon-avoidance,approach,orother
brought in or facilitated by the therapist, available for behavioral options, and the initially strong visceromotor
reconsolidation, includes new ways of construing and re- (e.g.,autonomicandneuroendocrine)responseisattenuated.
sponding to the client as a person, a new perspective on
the originally traumatic events, and the facilitation of new
3.2. Cognitive-behavioralperspective
emotionalexperiences.
Fromthisperspective,whatconstitutes traumaticstress Cognitivebehavioraltherapy(CBT)emphasizestheimpor-
variesfrompersontoperson.Thisalsohelpstoexplainwhy tanceofidentifyingtheunderlyingsemanticstructuresthat
trauma early in life predisposes to trauma later in life. As have been built through prior experience and now lead,
we’ll see in section 3, the role of implicit memory in the oftenwithouttheclearawarenessoftheindividual,toinap-
construal of current situations based on past experience propriateevaluationofnewsituationsandtheelicitationof
providesanotherperspectiveonhowwemightcurrentlyin- negative emotional responses (Beck 1979; Foa 2009;
terpretwhatBreuerandFreudmeantwhentheysaidthat Hofmann et al. 2013). Although the learning of the rules,
the lack of affective expression at the time of the trauma schemas, and scripts that make up the semantic structure
keptthememory ofthetraumaticexperience alive. came about because of prior experiences, CBT does not
focusonunderstandingtheseexperiences,becauseasignif-
icant portion of semantic knowledge as it applies to social
3. Roleofimplicitemotionindifferenttherapeutic interaction is obtained implicitly.As such, CBT holds that
modalities thereisnoparticularbenefittoanexplorationofthelearn-
ing sources. Instead, it focuses directly, and presumably
Basedontheconsiderationsabove,implicitemotionplaysa more efficiently, on identifying and making explicit these
criticalroleinavarietyofpsychotherapymodalities.Inthis rules as they are applied inappropriately to recent and
section we will briefly discuss how implicit processes are novelsituations,leadingtoemotionaldistressandmaladap-
relevant to behavioral (sect. 3.1), cognitive–behavioral tiveresponses.Makingtheseimplicitrulesystems,orwhat
6 BEHAVIORALANDBRAINSCIENCES,38(2015)
Laneetal:Memory reconsolidation,emotionalarousal,andtheprocessofchange inpsychotherapy
Reber(1996)referstoasthe“cognitiveunconscious,”explicit 3.4. Psychodynamicperspective
isakeyingredienttotherapeuticsuccess.Theclientisthen
led, through in-session exercises and homework, to experi- Patientswhoseekpsychodynamictherapyorpsychoanaly-
encenovelsituationsandhowtheserulesapply,andtocon- sis typically have long-standing maladaptive patterns of
sider evidence that undermines these rules. In summary, behavior that they want or need to change (Luborsky
theimplicitthoughtsthatarethebasisforautomaticemotion- 1984).TheserepetitivepatternsarerelatedtotheFreudian
alresponsesarebroughttoexplicitawarenessandmodified. concept of repetition compulsion (Freud 1913/1958). Not
Becausetheevaluationisthoughttobethetriggeroftheemo- uncommonly,theseinvolvewaysofrelatingandresponding
tionalresponse,achangeintheevaluationleadstoachangein to people and situations of which they are not consciously
theemotionalresponse. aware. A core component of psychodynamic treatment is
the transference, which is the sum of the feelings of the
patientforthetherapist.Transferencemaybeconceptual-
3.3. Experientialperspective
izedasanemotionalprocedure(animplicitwayofrelating
Inemotion-focusedtherapy(EFT),aneo-humanisticinte- toothers)(Clyman1991)thatisappliedor“transferred”to
gration ofgestalt andperson-centered therapy,emotionis the treatment relationship and is explicitly discussed and
seenascoretotheconstructionoftheselfandakeydeter- understood relative to what “actually” transpired in the
minant of self-organization (Greenberg 2010). In EFT a treatmentrelationship,asconstructedbyboththetherapist
coreassumptionisthat change comesabout boththrough and patient. A second core component of psychodynamic
more complete processing and awareness of emotion and therapy is a developmental perspective, which involves an
through the transformation of emotion schemes. Emotion explicit, co-created historical reconstruction of how the
schemes,in line with Piaget’s notion of schemes,are seen problems,whicharethefocusoftreatment,gotestablished
as action and experience producing implicit structures as earlierinlifeandhowtheyaremanifestedincurrentrela-
opposed to the semantic cognitive schemas of cognitive tionshipsoutsidethetreatmentandinthetransferencere-
therapy. This focus is consistent with the integrated lationship with the therapist. Changing the problematic
memory model (described briefly above in sect. 1 and ex- implicit emotional procedures through insight involves in-
pandedoninsect.9)inthatpersonalexperience(autobio- terruptingtheautomaticbehavioralenactment,consciously
graphical memories), generalized knowledge (semantic experiencing theassociated “underlying” emotions (or im-
structures),andemotionalresponses(includingactionten- plicit emotional processes), consciously extracting the
dencies and emotional experiences) are co-activated and informationinherentintheemotionalresponse,reapprais-
mutually interactive. In this approach, the client is helped ingthesituationandpattern,alteringbehavior,andestab-
to experience and become more consciously aware of lishing new procedures until they become automatic (i.e.,
his or her emotions by focusing attention on bodily sensa- working through) (Lane & Garfield 2005). A guiding as-
tions, action tendencies, thoughts, and feelings, putting sumption,whichdifferentiatesitfromthethreeothermo-
emotional experiences intowords andexamining whatthe dalities listed above, is that change is facilitated by
emotional experiences mean. Bodily sensations and action understanding the origin of the patterns and how they
tendenciesareimplicitemotionalprocessesthatmaygoun- recur due to motivations and behaviors that are out of
noticed in problematic situations but through therapy are awareness.Thecorrectiveemotionalexperienceinthismo-
transformedintoexplicitrepresentationsthroughlanguage dalityinvolvesexperiencingtheon-linefeelingsthatoccur
andotherrepresentationmodes(e.g.,pictorial)andarere- ininteractionwiththetherapistthatarecontrarytoexpec-
experiencedinanintenseandvividfashion.Amajorther- tation, for example, experiencing acceptance and support
apeutic goal is to “change emotion with emotion.” This is whencriticismisanticipated.
done by activating core maladaptive emotion schemes, From the brief discussion above, several commonalities
basedonimplicitemotionmemoriesofpast,oftentraumat- emerge. The maladaptive behavior patterns that bring
ic,experienceofpainfulabandonmentorinvalidation.The people to psychotherapy often include several implicit
empirically validated theory of change (Greenberg 2010; components. First, people may not be aware of how
Pascual-Leone & Greenberg 2007) shows that accessing these patterns of behavior were acquired, increasing the
theunmetneedassociatedwithmaladaptiveemotions,and likelihood that they will be over-applied in new situations
promotingasenseofrightfullydeservingtohavetheunmet that share characteristics with earlier threatening or dis-
childhood need met, creates a sense of agency. Thewith- tressing events (Lane & Garfield 2005). Second, the elici-
drawalemotionsoffearandshamewerefoundtobethepre- tors of the behavior patterns are often themselves
dominant maladaptive emotions and were transformed by implicit. Emotional responses are elicited by semantic
approach emotions such as empowered anger, the sadness structures (rules and schemas) or contexts that derive
of grief and compassion (see Greenberg 2002, pp. 171–91, from each individual’s past experiences. At some level the
for a more detailed discussion of maladaptive emotions). configurationmaybesensedbytheindividual(e.g.,thede-
This new, more agentic self-organization helps generate mandingauthoritarianboss“reminds”oneofademanding
new, adaptive, emotional responses to the old situation. parent), but theunderlying cognitive structures leading to
Thus,onemightfeelassertiveangerathavingbeeninvalidat- emotional responding may not be well articulated, or
ed, which undoes the prior feeling of shame. The method even noticed. Third, these repetitive behavior patterns
doesnotfocusontransferenceoradevelopmentalperspec- often include expressions of implicit emotion. Implicit
tive but rather the experience of new emotional responses emotions lead to action tendencies (Frijda 1986), such as
duringtherapyinthe“hereandnow,”withthegoalofgener- withdrawal and avoidance, that may be inappropriate or
atingnewresponsestochangeoldresponsesandconsolidat- maladaptive.Fourth,emotionalresponses,withtheirasso-
ingthiswithanewnarrativethatincludesalternativewaysthat ciatedmemories,semanticstructures,andactionpatterns,
onecouldrespondtosimilarsituationsinthefuture. can be revised, and thus the tendency for repetitive
BEHAVIORALANDBRAINSCIENCES,38(2015) 7
Laneetal:Memoryreconsolidation,emotionalarousal,andtheprocessofchangeinpsychotherapy
maladaptive behaviors can also be revised. Fifth, the hadparticipatedinoneofthreeemotion-focusedtherapies:
presence and support of an engaged therapist changes AcceleratedExperientialDynamictherapy(Fosha2000),In-
theinterpersonalandemotionalcontextinwhichtheprob- tensive Short Term Dynamic therapy (Abbass 2002), and
lematicpatternsareactivated.Finally,acommonprecursor Emotion-FocusedTherapy(Greenberg2002).Clients’expe-
tochangeistheelicitationofstrongemotionalresponding rienceswereassessedretrospectively.Clientreportsofhaving
inthetherapysituation.Inthenextsectionwereviewevi- experienced deep affect in therapy were clearly related to
dencethatthisissoinpreparationforadiscussionofhow bothsatisfactionwiththerapyandfeelingthatchangehadoc-
this interacts with memory structures that themselves can curred.Therewasasignificantrelationshipbetweenclients’
change. recognition of their therapist’s affect-eliciting techniques
andfeelingsofsatisfactionandchange.Pilero(2004)conclud-
ed that emotional experiencing may be the final common
4. Evidencethatemotionalarousaliscritical pathwaytotherapeuticchange.
topsychotherapeutic success In studies of EFT for depression higher mid-therapy
emotional arousal was found to significantly predict
As noted in the introduction, there is good evidence that outcome, whereas a client’s ability to use internal experi-
emotional arousal appears to be important for the success ence to make meaning and solve problems added to the
of many different forms of psychotherapy. Although this outcomevariance overandabovemiddlephaseemotional
appears to be the case for BT, CBT, EFT, and psychody- arousal (Missirlian et al. 2005). In addition, in a study of
namic psychotherapy, there are important caveats to emotion-focused therapy of depression a curvilinear rela-
consider. tion between emotional arousal and outcome was found
Numerous behavior therapies based on exposure have showing that too much or too little arousal when emotion
been shown to be effective for treating trauma and was being processed was not as predictive of outcome as
anxiety-relateddisorders.Ameta-analyticreviewofthelit- was arousal 25% of the time (Carryer & Greenberg
erature found that exposure therapy is the most effective 2010). Thus, it appears that a combination of emotional
treatmentforPTSD,andthatitseffectivenessisbasedon arousalandreflectingontheemotionisabetterpredictor
emotional processing (Foa et al. 2003). Patients with of outcome than either alone. In addition, productivity of
anxiety disorders who are best able to experience anxiety aroused emotional expression as measured by the ability
during the therapy session are most likely to benefit from to mentalize and work with the aroused emotion was
therapy, including those with phobias (Borkovec & Sides found to be an excellent predictor of outcome (Auszra
1979), agoraphobia (Watson & Marks 1971), obsessive- etal.2013;Greenberg2010).
compulsive disorder (Kozak et al. 1988), and PTSD (Foa InstudiesofEFTfortraumagoodclientprocessearlyin
et al. 1995). In a series of studies on behavioral exposure traumatherapyhasbeenfoundtobeparticularlyimportant
(Foa et al. 1995; Jaycox et al. 1998), positive outcome for becauseitsetsthecoursefortherapyandallowsmaximum
PTSD from rape was predicted by the arousal of fear and time to explore and process emotion related to traumatic
its expression while narrating memories of the trauma memories (Paivio et al. 2001). One practical implication
during the first exposure session and by reduction of dis- of this research is the importance, early in therapy, of
tress over the course of treatment. Findings like this facilitating clients’ emotional engagement with painful
showthatemotionalarousalwhileengaginginimaginalex- memories. Being able to symbolize and explain traumatic
posureisanaspectofthemechanismofchange.Instudies emotionalmemoriesinwordshelpspromotetheirassimila-
ofrecoverypatternsinsexualandnonsexualassaultvictims, tion into one’s ongoing self-narrative (van der Kolk 1995).
long-term recovery in general was foundto beimpeded if Thisformofputting emotionintowords allowspreviously
the indispensable emotional engagement with traumatic unsymbolized experience in emotional memory to be as-
material in therapy was delayed (Gilboa-Schechtman & similated into peoples’ conscious, conceptual understand-
Foa 2001). As Greenberg & Pascual-Leone (2006) note, ings of self and world, where it can be organized into a
research on behavioral exposure (e.g., Jaycox et al. 1998) coherent story. Timing is also important, as there is
has shown that only some individuals actually engaged in strong evidence that debriefing immediately after a
the exposure task and therefore only some were able to traumahasoccurredisharmful inthat such debriefingin-
benefitfrom thetreatment. creases rather than decreases the likelihood that PTSD
JonesandPulos(1993)foundthatthestrategiesofevo- will develop (McNally et al. 2003). The activation of
cation of affect, and the bringing of troublesome feelings emotion in therapy for trauma appears useful only after
into awareness, were correlated positively with outcome PTSDhassetin.
in both cognitive-behavioral and dynamic therapies. Regarding psychodynamic psychotherapy, emotional
Anotherstudy(Coombsetal.2002)bythisgroupexamin- arousalispartofclinicallore.Vividlyre-experiencingemo-
ingthetherapists’stanceinCBTandinterpersonaltherapy tionsinthetransferenceisthoughttocontributetothera-
of depression showed the importance of focusing on peutic change (Luborsky 1984; Spezzano 1993), but
emotion regardless of orientation. Reviews of process– objectiveevidencethatthisisanessentialingredienttopsy-
outcome studies in psychotherapy show a strong relation- chodynamic therapeutic success may not be available.
ship between in–session emotional experiencing, as Monsen et al. (1995) conducted a five-year follow-up
measured by the Experiencing Scale (Klein et al. 1986), study on personality-disordered patients who had been
andtherapeuticgainindynamic,cognitive,andexperiential treated using a psychodynamic psychotherapy that had a
therapies (Castonguay et al. 1996; Goldman et al. 2005; particular focus on patient’s consciousness of affect. Both
Orlinsky&Howard 1986;Silberschatzetal.1986). duringtreatmentandfiveyearsposttreatment,researchers
Asurvey(Pilero2004)investigatedclients’experienceof found significant and substantial changes in the degree to
the process of affect-focused psychotherapies. The clients which patients were aware of affect, characterological
8 BEHAVIORALANDBRAINSCIENCES,38(2015)
Laneetal:Memory reconsolidation,emotionalarousal,andtheprocessofchange inpsychotherapy
defenses, and symptoms. Moreover, at the end of treat- At the opposite end of the continuum, the nature of the
ment, nearly three-quarters of the patients who met trauma may have been emotional neglect associated with
DSM-III criteria for both Axis I and Axis II diagnoses no depressed or listless affect associated with low arousal.
longer met thesecriteria. This finding suggeststhat inten- Both extremes could contribute to the lack of encoding
sive psychotherapy focusing on warded-off affect is of what one experienced at the time of the trauma and
helpful to a group of patients, in whom most studies later lead to impoverished detail when recalling the
report onlymoderatetopooroutcome. emotionsassociatedwiththetrauma.
In sum, the evidence from the psychotherapy research Thereareseveralprinciplesthatfollowfromthis.First,if
justreviewedindicatesthattheexplicit,consciousreported therearedeficitsinemotionalencodingatthetimeofthe
experienceofemotionisanimportantingredientinthera- traumaacompleteaccountofwhatoneexperiencedorigi-
peutic success across all of the modalities listed above, nally needs to be formulated for the first time in therapy.
including those such as behavior therapy and CBT that Second, if during therapy a client is at the low end of the
do not intheoryexplicitly rely on such experiences. Yet, a arousalcurveduringrecall,thearousallevelneedstobein-
coherent theory of the cognitive processing of emotion in creasedtoachievesufficientemotionactivation,whereasif
therapy must account for the fact that emotion activated the arousal level is too high, the arousal level needs to be
in therapy may be adaptive or maladaptive. As illustrated decreased.Third,inconditions ofhigharousal,suchasan
by the work on emotional expression during debriefing emergency or traumatic situation, attention is narrowed
immediately after trauma versus after PTSD has set in, and emotional experience, if it occurs, is simplified and
emotions at times need to be regulated and modified and streamlined, whereas the kind of corrective experience
atothertimesaccessed andusedasguides. thatleadstochangeisamorecomplexblendofemotions,
Thisbalancecanbeunderstoodifonehypothesizesthat suchasfeelingacceptedandcaredforwhilesimultaneously
the relationship between the degree of arousal and the fearing criticism and rejection, which requires more mod-
abilitytocreatementalrepresentationsofone’sownemo- erate levels of arousal. Effective psychotherapy occurs in
tional state is quadratic (inverted U) rather than linear. If conditions of safety promoted by a therapeutic alliance in
emotional arousal is too intense, the mentalizing function whichtheclientcanrelyonthetherapisttofacilitateexpe-
mediated by a network including the medial prefrontal riencesthatarenewbutnotoverwhelming.
cortex(Amodio&Frith2006)goesoff-line,limitingtheca-
pacity for reflection in emergency situations. If arousal is
very low, then cognitive processing of emotion is not 5. Interactions ofemotion,stress, andmemory
likelytooccur.Arousalneedstobemoderateinthepsycho-
therapy session: more arousing than non-emotive thera- Ithaslongbeenunderstoodthatmemoryisinfluencedby
pies, but less arousing than the trauma itself. This the presence of both emotional arousal and physiological
inverted-U effect for emotion and medial prefrontal stress, which are inherent components of distressing
cortex function is parallel to that for dopamine agonism events. An extensive cognitive behavioral literature exists
orantagonismandactivationinthedorsolateralprefrontal on the influence of emotion on attention and memory
cortexduringspatialworkingmemory(Vijayraghavanetal. (for review, see Hoscheidt et al. 2013; LaBar & Cabeza
2007).Inordertoreflectuponagivensituationthecontext 2006; McGaugh 2003; Roozendaal et al. 2009). For
needs to be recalled and brought into working memory, example,apersonexperiencinganemotionalstatewillse-
which has been shown to involve this inverted-U function lectively attend to and process information that is consis-
for dopamine. This inverted-U relationship is also ex- tent with her present emotional state, an attentional
pressed in the Yerkes–Dodson (Diamond et al. 2007) law effectreferredtoas“emotionalcongruence.”Additionally,
ofarousalandperformance(bothmotoricandintellectual), whenapersonexperiencesaneventinaparticularemotional
which states that performance level for complex tasks is state,theeventisrememberedbestwhenthepersonisina
best when arousal level is neither too high nor too low. similar emotional state, referred to as emotion-dependent
Neuroimaging evidence of the important role of superior memory or more broadly, state-dependent memory (Eich
medial prefrontal cortex in mentalizing on the one hand et al. 1994). The intensity of emotion experienced during
(Amodio & Frith 2006), and the positive correlation theoriginalevent,regardlessofpositiveornegativevalence,
between activity in this region and vagal tone (which indi- increases the likelihood that the memory will be recalled
catesthatwhenarousalishighandvagaltoneislowtheac- vividly and the original emotion re-experienced, including
tivity in thisregion is reduced) on the other (Thayer et al. thevisceralorbodilymanifestationsofthatemotion(Talarico
2012), are consistent with the hypothesis that the process etal.2004).Thesebehavioraleffectsarelikelymediatedby
ofcreatingmentalrepresentationsofemotionalexperience interactions among many brain systems, including two that
iscompromisedwhenarousallevelistoohigh. play an important role in mediating emotion and memory,
Theapplicabilityoftheinverted-Urelationshipbetween theamygdalaand thehippocampus. Considerable research
arousallevelandmentalizingcanbecarriedastepfurther with both animals and humans has shown that emotional
in relation to the encoding of the original trauma. At ex- arousal results in increased physiological interaction
tremely high levels of arousal during the traumatic event, betweentheamygdalaandhippocampus,whichleadstoen-
one’s ability to know what one was feeling at the time hancedencodingandlongtermconsolidationofemotionally
would be very limited. This isconsistentwithand extends arousinginformation(Cahill2000;Murtyetal.2010;Phelps
the hypothesis (Nadel & Jacobs 1998) that high levels of 2004;Vyasetal.2002).
arousalduringtraumainterferewithamygdala–hippocampal Theadditionalinfluenceofstressonemotionalmemory
interaction such that encoding of context is impaired. As a is complex, sometimes resulting in enhanced memory for
result,whenrecallingwhatoneexperiencedatthetimethe priorevents,andsometimesresultinginimpairedrecollec-
emotionalcontentwouldbelimitedindetailandcomplexity. tion (Kim & Diamond 2002; Lupien et al. 2005). The
BEHAVIORALANDBRAINSCIENCES,38(2015) 9
Laneetal:Memoryreconsolidation,emotionalarousal,andtheprocessofchangeinpsychotherapy
effectsofstressaredueinparttotheactivationofthehy- (Soraviaetal.2006).Roozendaalandcolleagues(Roozendaal
pothalamic–pituitary–adrenal(HPA)axis,whichresultsina etal.2006;seealsoVocksetal.2007)havesuggestedthatthe
cascade of stress hormones culminating in the release of fear extinction during exposure therapy may be further
glucocorticoids (cortisol) from the adrenal cortex. Many enhanced by therole ofcortisolin attenuating retrievalof
ofthebrainregionsimportantforemotionalmemory(hip- pasttraumaticevents.
pocampus, prefrontal cortex, amygdala) have dense con- These mechanisms are relevant to the encoding and
centrations of glucocorticoid receptors and the function storage of highly emotional and stressful experiences that
ofthesebrainregionsisinfluencedbyelevatedstresshor- are later recalled and discussed in psychotherapy. For
mones(deQuervainetal.2003).Althoughprolongedexpo- past events not associated with either extremely high or
sure to stress interferes with memory function, acute lowarousalatthetimeofoccurrence,emotionalmemories
increases in glucocorticoids enhance the encoding and willbeeasilyaccessiblelateron,andrecollectionwilllikely
consolidation of new emotional memories (for review, see emphasize the emotional elements of the memory, to the
Lupien et al. 2005;Maren 1999; McGaugh &Roozendaal detriment of neutral information. Recollection under
2002). Interestingly, at the same time as enhancing thesecircumstancesisalsolikelytoreinstatetheemotional
memoryforemotionalexperience,stresshormonesmayac- experience, including the visceral components of that
tuallyimpairmemoryfortheneutralelementsofthesame emotion that were experienced originally. For past trau-
event(deQuervainetal.2000,2003).InastudybyPayne maticeventsattheextremesofarousal,however,accessing
et al. (2006), participants were subjected to a stressful ofdetailsincluding whatoneexperiencedatthetimemay
social situation that resulted in increased cortisol levels, bemuch more limited because oftheinfluence ofarousal
and then shown a narrated slide show that included both on initial encoding. Our discussion highlights the integral
emotionallyarousingandneutralinformation.Participants relationshipbetweenpastmemoriesandongoingemotion-
were impaired in recalling the neutral elements of the al responses, and also helps to explain how recollection of
event immediately after the event, whereas memory for prior memories can be distorted over time as emotional
the emotionally salient and arousing information in the components of experience take precedence over other,
event was preserved relative to a no-stress control group. possibly more moderating, information. In fact, Rubin
Subsequently, Payne et al. (2007) showed that after one et al. (2008) have proposed that PTSD symptoms derive
week,memorywasfurtherenhancedforemotionallyarous- not from the emotional experience of the original event
ing material whereas memory for closely matched neutral per se, but from the explicit memory for that event that
material was impaired. These findings are consistent with is constructed and reconstructed through subsequent rec-
the notion of tunnel memory, where high levels of ollections. This leads us to a broader discussion of the
arousal facilitate memory for central details (presumably dynamicnatureofmemories.
those most relevant to the emotional content of the
event) at the expense of peripheral details (Burke et al.
1992;Christianson1992;Christianson&Loftus1991). 6. Thedynamicnatureofmemory
Relevanttothepresentdiscussionarethosecaseswhere
severestressisexperiencedduringanemotionallyarousing Followingtheexperienceofanevent,thememoryforthat
event, such as rape, combat, witnessing an accident, or event undergoes a process of stabilization, often referred
another personally traumatic event. In these circumstanc- toasconsolidation,thatrendersthememorymoreresistant
es,stressappearstoenhancetheencodingandsubsequent tointerferencefromsimilarexperiences,andmorelikelyto
memory for the emotionally-salient aspects of the experi- besuccessfullyrecollectedlateron(Dudai2004;McGaugh
ence. The emotionality of that subsequent recollection is 2000).Consolidation,however,doesnotresultinamemory
probably further enhanced by the fact that neutral ele- representation that is immutable. Memories are not a
ments of the same event are less likely to be recalled perfectrecordofthepast,butundergorevisionandreshap-
lateron.However,theencodingoftheemotionalresponses ing as they age and, importantly, are recollected. The
atthetimeofatraumaticeventmaybecompromisedifthe notion of memory retrieval as a dynamic and constructive
arousallevelatthetimeissufficientlyhigh.Forexample,a process rather than a mere replay of the original event
largestudyofmemoryfortheeventsof9/11/2001revealed hassubstantialempiricalsupport,beginningwithBartlett’s
that recall of the emotions experienced at the time (1932) famous “War of the Ghosts” study. Using what he
event was worse than recall of the factual details (Hirst called the method of repeated reproduction, Bartlett
etal.2009). showed that repeated recollections of the story typically
It is important to emphasize that participants in Payne led to a shortened, more stereotyped version of it, with
etal.(2006;2007)wereexposedtosocialstressimmediate- details either discarded, transformed, or added. Bartlett’s
lyprior toexperiencing theto-be-rememberedevent, and observational study was replicated empirically by
thereforetheresultsinformhowstressaffectstheinitialac- BergmanandRoediger(1999),whoalsofoundthatpartic-
quisitionandearlyconsolidationofemotionalmemories.In ipants distorted information and imported novel proposi-
contrast, stress experienced during recollection of prior tions into the story, most prominently after a delay of six
eventsconsistentlyproducesmemoryimpairment,regard- months.
lessofemotionalityofthematerial(Kuhlmannetal.2005a; Studiessuchasthesefocusingonmemoryfornewlyac-
2005b). This is consistent with many real-world examples quired short stories, or lists of words, pictures, or scenes,
where stress during memory retrieval can have negative may have limited relevance to the remembrance of the
consequences, such as taking an examination or speaking richandpersonallyrelevantemotionsanddetailsassociated
infrontofanaudience.Thisinterferencewithmemoryre- with autobiographical memories. In contrast to Bartlett’s
trievalmayactuallyhaveabeneficialeffectduringexposure (1932) observations, autobiographical memories that are
therapy. Cortisol has a facilitative effect on fear extinction highly emotional and hold importance for the individual
10 BEHAVIORALANDBRAINSCIENCES,38(2015)