Professional Topics: Articles: Psychotherapy Methods

Levels of Consciousness in Psychotherapy: Identification and Utilization

You can see these levels in your clients. Use the guidelines to improve progress in therapy.

Robert A. Yourell, LMFT

This article offers ways to improve therapy based on seven levels of client awareness. Each level offers distinct therapeutic opportunities. Your client's comments and other behaviors tell you which is predominant at any given moment, and which level your client characteristically experiences normally and when regressed. The article describes the value clients derive from progressing through these levels and many example ways the therapist can facilitate such progress. It offers ways to adjust treatment from moment to moment as well as over the longer arc of therapy. These levels and the tendency of clients to move through them is especially apparent in therapy based on the adaptive information processing model as described by Francine Shapiro and as used in EMDR.

This article is a draft, but is fairly polished at this point. Please pardon any typos. The bulleted material in levels one and two is not central to the article and most readers will only want to scan it at most. The article will be reorganized with this kind of thing in mind. (7/21/04)

Note that the article includes an attempt to describe trauma recovery from the perspective of a therapist influenced by somatic therapies and EMDR. It does not attempt to faithfully express the ideas of any specific theoretician so much as to show how several lines of thought should influence therapeutic approaches that use the adaptive information processing model and the influence of somatic therapies.

A Different Perspective

Understanding and working with states of consciousness can improve psychotherapy effectiveness, rapport, client motivation, as well as therapist responsiveness and flexibility. This system of seven levels offers some immediate applicability, and is of greatest use to the clinician versed in EMDR and other approaches that can embrace the adaptive information processing model, such as Ericksonian work and body-integrative therapy.

Note that the mapping of a therapeutic school of thought is explained in more detail below, and is an important part of this perspective. While not an original idea, I would like to see it used more, and more consciously. A map is not a protocol, because of it's attention to dynamics. A good protocol often includes mapping to some degree.

Don't be tempted to view this as a scale of cognitive functioning or emotional development. That perspective would lose the point of these levels. These levels are formulated to encompass the nature of adaptive information processing and the fact that movement through levels can occur in an instant. This creates a moving target with implications for your therapeutic approach from moment to moment.

Adaptive Information Processing and The Levels

Information from a Biological Systems Perspective

Think of information as the changes in a biological system that result from experience. (You could take a broader view, but this will do for this article.) In this view, the meaning of information ranges from the memories and attitudes that you can verbalize and skills you can choose to use, to unconscious memories and attitudes, and any other biological changes that your experiences trigger. For the purposes of psychotherapy, the term information must recognize that our thoughts and feelings do not flow from a single place where information is encoded as logical verbal information for us to reference and express. Our sense of consciousness and self, biologically speaking, is how we experience multiple processes that run in parallel and reciprocally. The verbal consciousness we experience as making decisions and exercising choice is largely a reflection of all this. When our biology cannot effectively maintain a familiar integration of these processes, the vulnerability of this sense of self is apparent. Post traumatic stress disorder symptoms exemplify this disruption. Some thinkers have used the metaphor of a hologram, in which the "information" can create an image under the right circumstances, but that information bears no visible resemblance to the image it can express. It is not even a digitally encoded image.

For our purposes: The changes that result from experience equal information.

Processing from a Biological Systems Perspective

Processing refers to the way the organism responds to information as part of its functioning. Processing, at its best, enhances the organism. For example, child development requires many kinds of stimulation. Without appropriate stimulation, physical, cognitive, emotional, social, and any other aspect of development can be seriously impaired. Given how much this sounds like digestion and nutrition, you can see that "information" in a biological model, is about energy and the biological processes it triggers.

Organisms, of course, have limits to what they can process. Like shock aborbers on a car that are damaged by a pot hole, traumatic experiences may exceed one's ability to process them. The resulting dysfunctions show themselves in brain scans, the complaints of persons with PTSD, and the changes in thier functioning. Post Traumatic Stress Disorder is the most obvious diagnosis that describes dysfunction resulting from an experience that exceeds processing capacity.

Adaptive Information Processing

Given that various species, including humans, are known to recover from experiences that exceed their immediate ability to cope with them, the adaptive information processing model theorizes that there are biological mechanisms that cause us to recover from such loss. With its survival value, adaptive information processing must be a sophisticated genetic trait as are our abilities to process toxins and bacteria.

People who recover from traumatic experiences describe changes in the qualities of their memories, and in the emotions and thoughts that those memories trigger. This supports the model's assumption that the encoding of memories can change as a result of adaptive information processing. The term "adaptive", then, refers to the adjustment of encoding into a more functional form, and the adaptation to traumatic experience that this adjustment affords.

From the perspective of personal growth, this adaptation can build wisdom, character and peace of mind. Psychotherapy helps this happen. The psychological and spiritual teachings of many cultures emphasize the importance of deriving such qualities from life's challenges.

When our processing abilities are exceeded, the resulting loss of function shows up not only as symptoms such as anxiety, but also as being stuck in life. With aspects of brain functioning impaired, one cannot grow from life experience as expected. This sums up two of the most common reasons people seek therapy: being stuck and having psychological symptoms from traumatic experiences, or other experiences that exceed one's capacity to effectively process them. Also, much data supports the contention that the lion's share of visits to general practitioner physicians is for physical complaints that have psychological causes. Much of this must be from systemic breakdowns resulting from overwhelm of adaptive information processing.

Dr. Shapiro emphasises the idea that the dysfunction arises from incomplete processing of memories. This incompleteness includes isolation of the memory from psychological resources such as knowledge that would help. For example, a traumatic childhood experience that involved extreme feelings of helplessness could linger in ways that cause a person to become terribly unresourceful in circumstances that are related to that experience. Therapeutic reprocessing of that memory (or related feelings that are part of its encoding) can allow the person to use their existing inner resources, or new ones, in situations that previously caused much trouble or distress. Of course, developmental deficits that result from long-term dysfunctions must also be addressed, but with restored processing, this is much more likely to be successful.

State Dependent Learning and Memory in Reprocessing

State dependent learning and memory theory states that we tend to organize ourselves into states that are cohesive because certain inner resources and processes go together for performing instinctual or learned roles. These states may be instinctual or be a learned combination of resources. If one is taking a test, it would not be good to be in a state that is ideal for running away from a hungry tiger. But if prior failures and other experiences cause test taking to trigger a fight-or-flight reaction, grades will needlessly suffer. After reprocessing, tests would not trigger this panic. With the added benefit of cognitive therapy (or simply the natural problem-solving that was previously inhibited), the student would also develop valuable attitudes about success and thier own identity that would reflect much more than the optimism resulting from successful test taking.

This paper theorizes that states are of great value to adaptive information processing. Based on the map this article provides, the therapist can make decisions about which states are of value at various points in a session, including during EMDR. Central to this is the idea that shifting into a "positive state" within a short time after connecting with poorly processed information (therapists might use the term "material" or memories), contributes to adaptive information processing. A helpful metaphor might be that of making a bridge between a resourceful place, and one in need of resources.

A Reprocessing State?

Since states tend to generate cohesively (several aspects of physical functioning and mental resources that belong together arise together), once a state is adequately triggered, it can take off and allow the body and mind to complete work that is best done in that state. This means that sometimes merely removing an obstacle such as anxiety is all the system needs in order respond to its own need to reprocess. The distress of experiences that were encoded in an incomplete and dysfunctional way, and the presense of internal resources for that problem, would function as triggers of natural adaptive information processing. Many cultural rituals appear to serve this function, and to have developed intuitively.

Reprocessing can be referred to as a state in the sense that there is a specific point in time and sensed state in which one experiences it taking place. But it should usually be seen as a sequence, since blocked processing requires a means to elicit reprocessing, whatever that might be in any given case. Also, reprocessing often involves numerous changes in state, such as when various aspects of a group of associated memories are accessed. There is probably more than one state, mechanism or means for reprocessing, and some of these means may naturalistically take place over various spans of time and even be thought of as developmental processes. This presumed innate set of resources provides context for therapy, and provides many implications for psychotherapy innovations.

Some believe that only a state of relaxation is necessary to constitute the positive state useful in reprocessing. In my work, I tend to use multiple means of helping the client achieve various qualities that appear to contribute to reprocessing. This kind of positive state can be a very profound experience. The levels described in this article can help the therapist understand the elicitation and value of such a state, not only in reprocessing, but in the larger picture of the client's personal development and progress in therapy.

Therapists trained in somatic and hypnotic methods often come to similar conclusions. However, people who experience reprocessing do not always experience it as a profound or even a relaxed state. For example, there is the true story of a woman who happened to get the giggles purely by coincidence at a key point that eliminated her intense fear of driving over bridges. In talk therapy, therapists with at least an intuitive knowledge of reprocessing can have a remarkable knack for inducing changes in state at key points in therapy that appear to elicit reprocessing. I'm inclined to think that reprocessing-oriented therapies with a somatic component will prove to have the greatest success with many problems because of the use of more modalities that can trigger reprocessing, and that appear to trigger it more completely and with more clarity of purpose.

What is Reprocessed? Memories?

The adaptive information processing model is often described as applying to memories, but unconscious material and states that cannot offer memories are also fair game. It is usually possible for clients to put such feelings into words, and realize that irrational decisions from an earlier state of development or from a traumatized state of mind, have been controlling them in some ways. This can be a very liberating feeling. It is often an "Ah ha!" experience that is simultaneously about something very familier, yet also something that was never adequately made accessable.

From this perspective, it is possible for dramatic improvements in cognition to result, not from direct cognitive work, but symptomatically from changes in function and state. Remember that states arise cohesively. A more resourceful state will appear to spontaneously generate thinking that is more resourceful. A well-known example is the dramatic increase in uncharacteristic self-deprecatory thoughts expressed by persons experiencing onset of depression, and the reduction or elimination of such thinking with the resolution of the depression. Another is the changes in cognition that result from therapies such as Thought Field Therapy, that do not usually emphasize cognitive work, but do use methods that, by my view, consistently, strongly facilitate reprocessing.

The Essence of Adaptive Information Processing

Look at adaptive information processing through these two dynamics: improved thinking and increased awareness.

By completing the processing of experience, psychological defenses that diminished thinking and awareness are reduced. Improvements in brain function also occur. The shift away from anxiety improves abstract and other thought. Other improvements in state yield other imrovements in cognition including self concept. These improvements function consciously and subconsciously.

Greater awareness plus improved thinking yields personal growth. Many clients, after EMDR, make an exclamation such as, "So THAT's how it all works. It's like a flow chart!" in reference to their own psychodynamics.

The levels are based on broad generalizations. The other maps you use (consciously or unconsciously) as a therapist add resolution to the topography. With enough good maps, therapists are responsive and effective. You might want to think about the schools of therapy you are familiar with. What variables would show up on their map? How high is its resolution? Does it impose any assumptions that make you less flexible? Does it spell out points of reference that help you select modalities? If you had to, how well could you explain the maps you use? Can your maps be phrased in ways a lay person, a psychiatrist or a child could feel good about or understand? If you took away the modalities that school of thought uses, what other modalities would be suggested by the map? Do any modalities seem to be missing, given what you know about that school's map?

Don't underestimate the capacity for increased awareness and processing that can occur in people who have limited cognitive abilities or a long-standing ceiling on their awareness. The adaptive information model is demonstrated most dramatically by clients who, through sufficient activation of processing, have a sudden reduction in the need for defenses and a resulting increase in awareness and insight. Many clients, after EMDR, make an exclamation such as, "So THAT's how it all works. It's like a flow chart!" in reference to their own psychodynamics.

The Importance of Mapping Therapy

I hope this has made it clear why therapists can increase their effectiveness by monitoring and influencing states according to a good map. I want the map in this article to not only provide useful guidelines, but to provide an example of the kind of cartography that therapists need for improved effectivness, better training, and better communication in developing treatment plans. Such mapping not only serves in managing states in reprocessing, but in any dynamics.

Characteristics of good mapping include addressing in-session dynamics as a moving target (the equivalent of calculus for therapy), a level of resolution appropriate for the functions of the map, and meta-awareness of the theoretical basis of the map to allow for incorpiration of all appropriate modalities and strategies, thus supporting evolution of the school of thought upon which the map is based. Maps based on orthodoxy, mystification, turf-protection, elitism, anti-scientism, or other insular symptoms of dysfunctional systems will have pracitioners that attempt to mediate against influences such as new scientific data or evolution in application, but such interferance will require rhetorical tricks to appear sound.

After these introductory comments, this article provides:

A brief summary of the levels.

A section that provides more detail on each level, such as representative comments from clients and some therapeutic methods and direction that exemplify what is likely to be useful for the level, and that are fairly easy to explain for the purposes of this article. I include comments about EMDR and adaptive information processing.

The Levels in Therapy

I found these levels of consciousness (or frames of mind, if you like) to be especially evident in conducting EMDR. I reviewed numerous session summaries that showed how levels contrasted with one another, and how each level was responsive to different work in therapy.

I don't think that seasoned therapists will find this material revolutionary, but I think you'll find practical value in viewing these levels as discrete therapeutic opportunities, especially in processing or EMDR, where shifts in these levels may happen several times in a session and may be profound. Nonetheless, your clients generally have a profile of problems, defenses, acting out and life circumstances that suggest that the have an upper limit to the levels they generally experience, and a level that they tend to operate from. The suggestions for each level include this consideration.

You'll see some similarity between this perspective and motivational interviewing, where phases of motivation warrent methods that correspond to each. This may look a little like it is about chakras, but I made no attempt to make the levels correspond to any spiritual belief system, despite the fact that there are seven levels. You might be reminded a bit of Maslow's heirarchy of needs, as well.

I believe that, generally speaking, clients are naturally drawn to the next level and experience blocks to such movement as discomfort, that is, if they are able to experience the blocks. Otherwise, they are likely to attribute the suffering taking place at that level exclusively to the challenges they experience from that level's perspective. One of my goals in a typical session is to guide clients toward releasing these blocks and experiencing the next level. This may include experiencing the obstacles as discomfort, using methods to assist in releasing blocks on a body or cognitive level, and ego strengthening methods that reduce client vulnerability. From the perspective of the next level, clients are better able to perceive solutions or naturally resolve long-standing problems, as well as increase their peace of mind. Adaptive information processing theory appears to explain spontaneous resolution of symptoms or substantial, enduring shifts in perspective.

The next level is very attractive once the client has experienced it, so that the perspective that goes with it becomes more valuable to the client. I remember a client who was not interested in stress management, but whom I felt really needed it. One week he came in intensely interested in this and everything connected with it, such as the visualization work I suggested. He said that he had had an injury that week, and was given a muscle relaxant. He said that he had never been so relaxed, and feels that letting go like that was his first spiritual experience, and that it was very meaningful to him. He was eager to learn about experiencing this naturally. Often, the doorway to the next level is as simple as relaxation. Of course, achieving that in a safe, therapeutically relevant way is not usually so simple.

Another client was reacting very intensely to his wife's decision to leave their relationship. He was drinking and driving wildly, as if he would welcome death, or a rescue from his wife. He had some character traits that made change nd intimacy difficult for him, and contributed a great deal to the problems in the relationship. In a single session, he dramatically calmed, stopped his self-destructive behavior, and even expressed a philosophical attitude toward the relationship split. But the session included little cognitive work. The most effective method, according to the client, was learning to store excess energy in two areas of the body in a way taught by Tibetan yogis (the lower back and behind the knees). Apparently, he was so agitated, that his normal ability to process his experiences and move to another level was blocked and his distress was nearly intolerable. But the client was not expressing himself in a way typical of his more durable character style, either. The combination of methods used in the session appear to have allowed the client's natural capacity for processing to take place, once the energy technique reduced the acute agitation.

The article on reprocessing provides a perspective on EMDR and the adaptive information processing model in psychotherapy. It explains ways that any therapy method may elicit adaptive information processing, but argues that by consciously applying methods that facilitate processing, the clinician can produce better, more consistent results.

Summary of Levels

Note: At times, these descriptions may sound like enduring personality profiles. This is because many clients show indications that they have been mostly living at a particular level. Also, they may tend to drop to a different level whenever they are dealing with the presenting issues. Many of the suggestions for therapy address issues that can cause fixation at a given lower level. Since fixation at a level may occur with quite varied clinical profiles, only some suggestions will be relevant. The point is to provide examples that will help you think in terms of these levels and the ways they can inform your work. However, these states can be quite fluid, especially in therapy. Movement from one level to another may not be in sequence nor in a forward direction.

1. Surface: Stereotypical reactions showing little insight or introspection. Defensiveness, whether flat or emotional, asserts and maintains a clearly defined and superficial interpretation of events and their meaning. The client shows little sense that current problems are part of a maturational process, or of psychological needs or dynamics that appear to underlie the client's behavior or symptoms that are related to the problem. The client may harbor a simplistic view of the solution, and it may hinge on a concrete change in external circumstances that the client feels dependent on. The change may be desirable, but the client does not recognize that the problem definition is arbitrarily limited. Potential personal change or resolution is often omitted.

2. Reactive: The client gives the impression of allowing their awareness to move closer to alternate perspectives and explanations. The client will react to this movement, but the reaction depends of variables such as the client's level of organization and the emotional intensity of the material. A client that reacts strongly to someone simply pointing out information that contradicts something the client believes, when it is a belief that is part of their defenses, is an example of someone at the reactive level. The reactivity, by itself, however, does not indicate that the client is vulnerable to disorganization or behavioral volatility.

3. Deep Reactive: At this level, the client is more aware of their own process and material, but is has not yet effectively processed it. If the client has spent much time at this level, they are probably better able to perceive and understand their psychological defenses and underlying irrational or primitive motives. Nonetheless, at this level, they are still reactive to unprocessed material, and can find it more distressing. Their efforts to manage it may be more enlightened, but can consume much time and energy. The client may have automatic defenses despite their margin of psychological sophistication, communication, and emotional breadth. A loss of these defenses or other means of coping can collapse the client into an immobilized or agitated state that their current level of awareness does not understand. Clients at this level often appear to be at a more pivotal point in life or treatment, venturing forward and retreating as if this level cannot be easily tolerated when life or therapy challenges their defenses or offers sufficient hope. This is often the precipitating event that brings them to therapy.

4. Potentialized: The client has at least an intuitive sense that greater inner awareness and experience is valuable, and constructively responds to this kind of awareness. You are more likely to see a release of tension such as a full sigh or at least amusement or excitement when the prospect of deeper change is associated with hope and creative solutions. The client can sense that releasing tension could be good for their health. The client may show more freedom to look at a situation from different perspectives and to seek creative solutions. As a therapist, you are more likely to feel "met" by this client, and sense a depth of humanity that seems absent at the prior levels. Therapeutic objectives may seem more accessible, and the therapist may feel more optimistic.

From a body-integrative or energy psychology perspective, this, and especially the following levels, appear to benefit most from increasing the charge (sense of energy, including emotion) the client experiences, because it does not usually cause intensified defenses or regression that make the client less capable of processing and other kinds of participation in therapy. If anything, it may propel the client in their processing and in having a memorable experience that serves as a reference point that they use to navigate toward a more meaningful, vivid life. It seems that such client's innate adaptive information processing is sufficiently active that adding charge to their psychological make up serves as fuel for the client's psychological life and growth. Rather than reactive, this level and up is responsive.

5. Deep Potential: The client seems to experience a fundamental sense of validity or connectedness, and a sense of internal safety that does not require stereotypical defenses. The client at least intuitively understands the value of releasing chronic tension and defenses that have built up. Change during a session may seem more playful, flexible, collaborative or wise. Clients are more likely to express an experience that resembles energy, or at least more sense of aliveness.

6. Spiritual: The client may cross what seems to be a profound boundary into a sense of a spiritual reality. They may express a sense of all things being connected in some way. This experience can serve as a reference point that helps them sense whether they are moving toward or away from a resourceful state and a perspective that is aligned with their highest values. Clients often refer to this experience as one they will always remember, and it can result in a shift in their feelings about life, death and love. Clients who experience this level can lose their fear of death and commit themselves to improving relationships for a higher purpose. They may sense support from a higher power that corresponds to their religious beliefs or that is more abstract and hard to define.

The state istelf is rarely long-lasting, but the client may now have a sense of being either on or off "the path" and take measures to stay on the path. For example, they may work to build the qualities that support their expanded awareness and values. The client sees the value of activities that move toward meaning, rather than avoiding fear.

A person who can openly discuss the difference between these types of activities is probably able to use a mere conversation to produce substantial psychological movement, and derive much metaphorical significance from everyday experiences. This tends to compound the sense of life as being a mysterious or magical source of support, and of life as being a path that transcends material objectives. At the same time, this can arouse considerable ambivalence or simply fade from a person who is not well grounded in a discipline and support to reinforce this state of awareness.

7. Deep Spiritual: This level is an intensified experience of the previous one. The client may describe transpersonal experiences such as contact with a religious figure or other symbolic experiences, or a strong sense of energy or peace of mind that is difficult to explain but is meaningful. Clients may experience a reverie that provides waves of insight. It is usually easy for therapists to reinforce the positive aspects of the experience, and clients are usually quite willing to perceive them in this way. Clients often wish to have some time at this level that does not involve actively working on issues.

Detailed List:

1. Surface:

Stereotypical reactions showing little insight or introspection.

Content Type: Rationalization; denial; day-to-day details; obsession or rumination; uninsightful emotional reactions; controlling interaction through monologue, redirection, obfuscation or flat statements. Defensive emotional reactions may appear somewhat contrived or one dimensional, such as ready anger that intimidates or blames, or bitter self-pity and withdrawing from life.

Example Verbalizations: "I don't have to be a purist, I can smoke once in a while." To girlfriend: "Baby, you have to keep the faith in our relationship... Okay, just give me ten good reasons why you should leave me." "I'm gonna make this business fly if it kills me." "I'm staying clean this time, but my probation officer needs to trust me because she's driving me nuts." "I love my children unconditionally, and I expect something for that." "You know, when we're talking about war, we're talking about peace."

Note that primitive, stereotypical verbalization or defenses may result from medical problems such as an undiagnosed psychiatric disorder, not just extreme results of trauma. They may also be quite consious, and represent overt manipulation by a client with antisocial personality disorder. On the other hand, your client may surprise you by yielding these defenses quite easily, because your client adopted them from role models and group culture. Check for this opportunity with inoffensive but straight talk or expressions of curiosity to test the client's defenses.

Values in Psychotherapy: Therapists often feel helpless or bewildered, unless they have good experience with such clients, and may not see much value to this level. However, most clients, even those with some cognitive impairment, have specific desires that can be harnessed in service of therapeutic outcomes. So that you don't waste time in unproductive talk therapy, you must do a well-rounded assessment that includes external systems. If the client is fixed at this level because of impairment such as a personality disorder, external systems such as the court may be involved and able to serve as resources. These systems may cooperate with you in setting up an effectively coercive situation that increases the odds of progress, at least in key areas such as ensuring safety. Clients are capable of making treatment progress even when treatment is mandatory and the therapist is connected to an external system.

Many of these clients will respond to down-to-earth objectives having to do with their material well being, health, and staying out of trouble. With enough trust, many will respond to direct and concrete confrontation about the linkage between their behaviors and the results.

Tips for the Surface Level:

The list below is almost a primer for beginning therapists. However, I think even seasoned therapists may find it helpful to see these tips collected with this level of consciousness in mind, and with the goal of getting to the next level as a focus.

• Processing
  • Processing through means such as EMDR does not appear to depend upon clients being at a higher level. This level is not, in itself, resistant to movement, but for a client to have been functioning at this level, there are often factors that make movement difficult.
  • At the Surface Level, it is often best to limit targets to concrete symptoms and memories initially. This comment is not intended to imply that there such targeting is primitive, only that it may be easy to make your client defensive and uncooperative.
  • When increased awareness corresponds to a physical sensation such as tension or discomfort, targeting the sensation may help lead the client to the significance of the memory, or to more significant memories. This technique is useful with most clients, this comment on the timing is especially important for Surface Level work. It is also likely to reduce discomfort that may otherwise distract from processing.
  • The more subtle targets that are often accessible and meaningful to Surface Level work include prior psychological binding, feelings of coercion and inability to control others.
  • Looping is likely to occur where your client judges something as unacceptable, such as a parent's behavior. If your client is unwilling or unable to shift the targeting to feelings or negative thoughts, it may help to ask client to shuttle between the act of judging and the feeling of judging. It may be possible to shift out of the loop and into other aspects of judging, such as feeling less vulnerable, the desire to feel less vulnerable, the fact of having felt vulnerable, and so forth.
  • Right hemispheric resources may have more capacity for processing than are obvious from client verbalizations and looping. Covert conditioning methods such as asking the client to allow a visual symbol to emerge from the situation, to target it and to "watch what happens" may yeild a change in the symbol that metaphorically suggests that reprocessing is taking place. If your client is sufficiently entranced by the targeting process and bilateral stimulation, they may be quite credulous and willing to try this experiment. There are plenty of other techniques that help terminate looping.
  • At the Surface Level, clients are more likely to explore if the experience of EMDR is framed as an experiment in which you would like them to report on what happens when they focus their attention on the various targets. In this mode, they are merely reporting, and their conscious mind can be kept occupied in a "legitimate" role. This framing does not require misrepresenting EMDR, it takes place in the way you instruct your client to target. "Tell me what you notice when you pay attention to the pain in your back while following this... Well, since it's diminishing, let's see what begins to take its place... Move your awareness about three quarters of an inch behind that immovable, blank feeling for about twenty seconds and watch what happens..." There is no implication that they are going with anything, going to anything, or experiencing much of anything, unless your client welcomes a deeper approach.
  • Describe the goals of EMDR in very concrete terms that the client can identify with. Examples: being able to look at the divorce papers with healthy blood pressure and a clear mind.
  • Normalize any vulnerable or strong feelings that emerge in a straightforward way. Direct the client to allow those feelings to crest, praising their courage and strength in allowing them to be processed.
• Diagnostic Tips
  • Long-standing functioning at this level may have left the client with a poor ability to handle numerous situations effectively. That can create unconscious avoidance and other acting out. What will your client really need in order to function effectively in various situations? Consider social skills, the ability to understand the significance of the situation, what is fair and expected, what motivates people to do things the client may think is unfair, and so forth. This can amount to a kind of developmental disability. Mentoring or other structured or intensive intervention may be in order. Assess for trait-based or chronic reactive depression that causes this functioning, is caused by it, or both.
  • Successfully-functioning people who present at this level may have very focused limitations to awareness that do not interfere with much of their effectiveness as they and their peers see it. This client's entrenchment may be much more culture and value-based. It is important not to make assumptions about what this client defines as a successful outcome to treatment. This client's perspective of human nature and narrow definition of relevant dynamics may be foreign to you if you think in abstract, humanistic terms. It may take you by surprise, given their ability to communicate and function. Unless you are on guard, you may express ideas or potential goals that will make you appear to be either a threat or useless. In couples work, the spouse may operate at another level, creating a delicate line to walk in maintaining rapport and agreement on objectives.
  • Assess for ways your client has handled deeper intrusions into their defenses, and in what ways intimacy is a challenge, as well as possible sources of these defenses and adaptations. A key goal is to avoid triggering significant loss of rapport. This information can help the therapist avoid learning the hard way.
  • Assess for personality disorders, neurological problems, trauma history, substance abuse, and other factors that may be related to high defensiveness or lack of effective self-soothing. Where emotional volatility and sudden, irrational changes in perspective occur at the same time, there may be a strong biochemical element such as chemical sensitivity, borderline personality disorder and so forth. Therapists sometimes focus so much on the childhood roots of intimacy problems, that the biological aspect is not addressed.
  • Assess for vulnerability to disorganization, volatility or dissociation indicative of ongoing risk requiring special care.
  • Assess for antisocial personality disorder and ulterior motives for participation in therapy.
  • If there are deficits in abstract intelligence, determine what your client is actually capable of understanding. Assess for soft signs of psychosis, delusions and cognitive impairment. Isolated areas of cognitive impairment may be disguised by overall intelligence or by gifted abilities, particularly high verbal skill. your client may be reticent to disclose hallucinatory, delusional or other material that they have learned is stigmatizing.
  • Get permission to communicate with collateral information sources, particularly where they may provide support or leverage for change and stability, where they may have additional personal or clinical information, or where there may be undisclosed legal issues. This is a common omission by therapists.
  • Ask very direct questions in areas where clients would normally volunteer information or where your client is being vague. Learn about all the people involved, what they have expressed to your client, legal problems, employment problems, violence history, ways you may be asked to supply information or testify, prior treatment and the outcomes, health problems, medication, other systems and treatment currently active, financial problems, your client's attitude toward people and systems involved, and so forth.
  • Getting numerous clear descriptions of what your client likes and dislikes in people and experiences. This can help in rapport building and be a method of connecting your client with feelings. It can restore a connection with influences that may inspire your client to increase the scope of their awareness and behavior. Drawing on your client's personal history may be useful for this. It may help restore dormant aspects of your client's mental resources.
  • Gently touch upon various defenses to assess the rigidity and nature of the defenses. Expressions of open curiosity are often least offensive.
• Framing and Rapport-Building Tips
  • Build initial but superficial rapport by appealing to client's superficial desires and needs. For example, the therapist may agree to objectives such as how to "play the game" in coping with probation or how to influence people more effectively. However, they will be offered in a way likely to help your client maintain stability or stay out of trouble and continue to participate in therapy and assessment and build trust in the therapist. Additionally, the therapist uses skills such as metaphor, subconscious resource building, motivational interviewing and framing to build your client's potential for deeper work and awareness.
  • Frame the problem definitions in a way that helps your client begin to see connections between their behavior and its results. Take care to preserve rapport. If a system such as probation or the workplace requires treatment, then the therapist may move faster by taking a "let's agree to disagree on this, but in addition to what you want, this will also be on the table" approach. Such matters should be framed in very common-sense and concrete terms. The beginning therapist will need to practice re-languaging many of their ideas. Running through events chronologically, and predicting events based on your client's behavior may help build the therapist's credibility in your client's mind, and help your client practice making connections.
• Progress Tips
  • Your client can begin to connect behavior with results and develop more respect for the gravity of neglected aspects of the situation by asking your client to project what will happen if current trends continue. Elicit details on the negative projected outcomes. The therapist can help your client tie behavior to outcomes as therapy progresses, as well as build motivation for alternate outcomes and behaviors.
  • When your client has entrenched "matters of principle" that are immature and self-destructive, get your client to clearly express which of their values are begind this principle. Help your client frame them in the most positive, high-minded and compelling manner possible. With this, the therapist can help your client connect their values with outcomes rather than automatic reactions, while helping your client improve their self esteem, sense of passion for life, expressiveness, social attractiveness, faith in themselves, ability to negotiate and understand others' values, and alignment with their own values.
• Moving From the Surface Level In-Session
  • Developmental deficits resulting from long-standing functioning at this level may make client movement less fluid from this level. However, the therapist should be prepared for sudden movement, even from clients who appear quite stuck, especially where processing is involved.
  • Pre-emptively describing how clients cope with emerging feelings, and the progress that this leads to may help your client be less confused with new awareness and feelings. You can normalizing and supporting such emergence through respectful acknowledgement and praise, identifying with the feelings appropriately, and offering an optimistic view of where this can lead.
• Example Approaches at the Surface Level
  • Provide psychosocial education and other modalities to increase your client's understanding of others' feelings and motives to make more sense of the world and elicit better results in relationships.
  • Work through what-if's that can help your client sense that desirable things could come from new behaviors or perspectives.
  • Expose your client to successful "out of the box" thinking examples for creative solutions that may help your client develop interest in wider exploration.
  • Clearly identify and acknowledge your client's efforts in service of their values, regardless of whether the outcomes are constructive. Clearly show your understanding of their frustrations in these efforts. I call this "honoring the hero." If you are sincerely aware of their heroism, your client will probably be more motivated and express their best efforts. This is an aspect of "state management." State dependent learning and memory theory states that memories, behavior and other resources tend to be tied to various states that can be triggered. Also, you will help the client express ways they feel undermined and misunderstood or other difficult feelings as they discuss their frustrations in trying to live according to their values and to be seen in this positive light. When these feelings are expressed in relation to higher values, clients are more likely to tap into more vulnerable feelings that may be a gateway to the next level of consciousness.
  • Use motivational interviewing to help the client express constructive thoughts and perceive self-contradiction, and to avoid causing the client to resist you.
  • Tie your client's most conscious and strong values with outcomes that are constructive and that your client does not dismiss. In time, you will be able to discuss means of achieving those outcomes with less likelihood of arousing defensiveness.
  • Make sure that the level of intervention actually needed will take place. Solicit the level of involvement from external systems and persons necessary for this.
  • Have clear, detailed discussions of what you expect from your client, the nature of your boundaries and obligations, confidentiality, and other areas to build a formal, concrete type of trust and respect from the beginning.
  • Appeal to unconscious resources through means such as Ericksonian communication (e.g. metaphor), covert conditioning, and so forth in a manner that does not elicit defenses.
  • Desensitize your client to, and prepare your client for, outcomes that may occur, but that your client finds unacceptable. This may help your client maintain stability and reduce regression and acting out when their rigidity or other defenses are overwhelmed by such circumstances.
  • Find an opportunity to say this, filling in the blanks: "Wouldn't it be something if you could X (do or experience something outside of client's tolerance) but experience Y (a collection of rewarding feelings and confident body languaging)?"
  • Cognitive work needs to respect concrete thinking and small shifts or openings, if that is your client's ability. If your client attempts to reinforce prior, more limited thinking, help your client note what feelings led to the retreat, and how the two perspectives contrast in terms of the feelings or images they evoke. Do this to soften your client's defense against that kind of awareness, and highlight the safety of acknowledging them. Do this to help your client experience and understand how defenses work, and how opening these defenses may help them in life.
  • I use approaches like these with macho or stoic men. These men often have limited outlets for feelings and habitually direct them into judgement and anger. Nonetheless, many of these men quickly accept new feelings once they begin increasing their range of internal perception and their acknowledgement of deeper needs, even when there is a traumatic basis for their chronic anger.

2. Reactive

The client gives the impression of allowing their awareness to move closer to alternate perspectives and explanations, and are more likely to show that they can perceive and disclose more of their internal process. Client's who are more psychologically vulnerable or have emotionally intense material may be in urgent distress because of their more permeable defenses, and the fact that they have poor measures for coping because of limited awareness. At this level, clients are less likely to respond effectively than to react defensively through means such as acting out of obsession, distraction or blame. They may have initiated addictive behaviors such as compulsive eating specifically in reaction to emotions. Things like these indicate that your client's defenses are not as deep-rooted, internal and automatic as the prior level.

Content Type: helplessness, anger, projection, panic, inner conflict, struggling with own behavior, situations that result from defensive acting out, underestimation of the seriousness of the acting out, difficulty being aware of how acting out is primed.

Verbalization Examples: "I fought it, but I lost $700 gambling last night." "I can barely speak when I am introduced to someone at those corporate get-togethers, I must look like such an idiot." "I don't know why I pick men like that, but I feel so manipulated and neglected, I think I pick fights with him just to get some other kind of attention."

Values in Psychotherapy: Clients at the Reactive Level are more likely to experience emotional distress, concern regarding their own behavior, or a sense that they can prevent destructive situations that plague them. Any of these factors can create great motivation to participate in therapy. Coupled with their awareness, they are able to disclose more than those at the Surface Level. You may have an easier time assessing psychodynamics and discerning issues that may be largely medical. You may find it easier to process issues because the client is aware of anxiety. The contrast between the client's distress and the relaxation response during typical processing is more evident at this level the the previous one. This contrast may contribute to client motivation. The client may be more open to attending a group that supports them in altering compulsive behaviors.

Tips for the Reactive Level

• Processing and EMDR at the Reactive Level
  • Although you may have an easier time identifying and discussing targets at the reactive level, your client may have problems with ambivalence about changing compulsive behaviors. Initially, you may need to take care to select targets that are more fundamental than discomforts that precede compulsive acting out. Learning a protocol for addictions and compulsions may be helpful.
  • Knowing your client's phase of motivation according to motivational interviewing may improve your use of processing.
  • Clients at this level and the previous one are the most likely not to have experienced a level of release into relaxation that may occur with processing. They are especially likely to need work that will prepare them for EMDR. Your assessment for dissociation, tolerance of affect, stability and safety history and so forth are important here.
  • EMDR protocols for establishing a safe place and resource installation may be especially important at this level.
  • At this level, therapists may need to be especially creative at helping their client experience a positive state or relaxation in the course of reprocessing. Your client may benefit from methods involving visualization or imagination to counter the experience of being stuck in fears. Your client may benefit from direct methods of inducing relaxation such as brainwave entrainment, energy methods or hypnotic techniques. These are not established in EMDR protocol as of this writing. The therapist should not be tempted to venture outside of their scope of training and successful practice.
  • Unless the client is fragile, I elicit negative cognitions during processing rather than as a preparatory step. These cognitions tend to emerge more spontaneously and meaningfully in processing. Generally, positive cognitions readily emerge at the Potentialized level.
• Examples of Therapy at the Reactive Level
  • Use psychosocial education regarding the basis of acting out, the difference between traumatic anxiety or other symptoms and traits seen as medical, the uses and value of group where applicable, the value of cognitive therapy in reducing the triggering of negative emotional states and acting out, and processing.
  • Normalize the emotions and behavior in terms of the ways many people have solved these problems and the importance of ongoing commitment in the face of habituated reactions. Emphasize the value of support and the changes needed in your client's life that will support lasting change.
  • Increase your client's discomfort with their more destructive defenses, and status quo. Help the client be acutely aware of the negative results of acting out.
  • Deal very directly with any medical and safety implications of their acting out, such as those of an eating disorder. A medical assessment may not only uncover medical problems, but it may also add to your client's motivation for change.
  • Provide a compelling description of twelve-step or other appropriate program of treatment that reduces the fears the client may have about participating.
  • As always, be skeptical of the levels of acting out or alcohol or drug consumption your client reveals and seek collateral information if possible.
  • Limitations to awareness and motivation may be resulting directly from chemical abuse.
  • Train your client on how to solicit appropriate responses from friends and family that supports progress, and do whatever family therapy is needed to ensure adequate support and understanding of your client's needs, along with whatever other work is needed there. This is a key source of collateral information as well.

3. Deep Reactive

At this level, the client is more aware of their own process and material, but is has not yet effectively processed it.

Content Types: Deeper hurt, fear and insight. Greater acknowledgement of the significance of their problems and behaviors. A richer perception of their needs. See sawing between progress and less functional coping.

Example Verbalizations: "I'm realizing how much I really am angry underneath my depression." "I'm realizing how much I really hurt underneath my anger, and how I've been trying to control her to save myself from hurt, but only I can really control it." "Yup, I actually started setting that relapse up two weeks in advance. Jeez!"

Values in Psychotherapy: If your client is not already there, this level will support movement at least into the contemplation phase of motivation (in which your client thinks seriously about change). Since your client is in a more fluid state of consciousness at this level, they may be progress more easily with cognitive therapy and be more open to body-integrative work.

In EMDR or reprocessing: Your client may participate more meaningfully in cognitive reprocessing and future pacing at this level. Processing at this level often feels that is it at its most dynamic and ready to give way to a positive state, which the client usually does by shifting to the next level (Potentialized) and perhaps beyond.

Psychotherapy at the Deep Reactive Level: The previous level's comments largely apply here. Often, your clients greater tolerance of awareness stems from them having sufficient organization and safety. It is easier to help such a client identify and value the full range of treatment goals you would suggest.

4. Potentialized

The client has at least an intuitive sense that greater inner awareness and experience is valuable, and constructively responds to this kind of awareness.

Content Type: At this level, your client experiences valuable cognitions fairly readily. They experience a greater sense of perspective and responsibility. Your client more easily becomes aware of both the impairments and (simultaneously) the responsibilities of any perpetrator that is part of the problem. Your client is likely to exhibit and appreciate a deep physical release of tension, and possibly a sense of "streaming" (a feeling of energy running through portions of the body).

Example Verbalizations: "If I start smoking now, I know I'll lose control. I'm an all-or-nothing person." "My teacher was wrong. Shaming me in front of the class was destructive." "I'm realizing how pathetic my abusive ex- was, and how his upbringing damaged him. I'm still going to press charges for this latest incident, though" "My shoulders really let go just now!"

Values in Psychotherapy: Initial experience of definite physical release; smoother and often spontaneous cognitive restructuring; initial sense of positive physical state that serves as an alternative to the typical reactions of your client; may have dramatically enhanced rapport with therapist.

Psychotherapy Approaches: Continued cognitive restructuring, enhancement and anchoring of the positive physical state; reinforcing your client's increased sense of motivation for meaningful change.

In EMDR and Reprocessing: Your client has probably arrived at this level because processing has led to a release into relaxation and a positive state. The subsequent levels 5, 6, and 7) can be quite valuable, but are not necessary for processing most issues and symptoms. Your client's feeling of "getting to the bottom of the root canal" (processing the most fundamental targets) probably corresponds with this level. This level can emerge from the increased awareness and the positive state that processing allows. With the material processed, unneeded defenses cease, allowing increased brain functioning, understanding and awareness.

With clients that are not fragile, I tend elicit positive cognitions at this level or higher, because these cognitions are much more likely to arise spontaneously, and ring with more profound meaning to the client. This approach also requires less session time. I think it is less effective, or at least less efficient, to work on deliberately constructing cognitions in a state of consciousness that is not involved in more active processing such as EMDR.

5. Deep Potential

A fundamental sense of validity allows a healthy perspective to emerge.

Content Types: Fundamental sense of validity (not dependent on accomplishment or perceptions of others): Deep sense of release.

Example Verbalizations: "I dunno...I just have this feeling that underneath it all I am OK and deserve to be respected just because I'm alive." "I feel like a deep part of me just relaxed. I didn't know I was tense there. It's as if it had been tense for years. I feel a flowing feeling streaming from my heart out along my arms."

Psychotherapy Approaches: Mental rehearsal of appropriate behavior; Relaxed reverie that your client will consciously or unconsciously reference for creative problem solving, being able to respond to emotionally arousing situations in a more confident and constructive manner, stress management, and so forth.

In EMDR or Reprocessing: Body scanning and reviewing targets for remaining reprocessing targets; It may be appropriate to shift focus exclusively to enhancing the client's positive state through means such as hypnotic suggestion, energy work, body awareness work, and visualization; Further development and review of the positive cognitions your client has developed.

6. Spiritual

Feelings commonly described as spiritual are in the foreground.

Content Type: Sense of perfection and connectedness of all things; Sense of self as consciousness.

Example Verbalizations: "I just feel the truth that somehow, behind all this stuff, the universe is perfect." "I just feel my mind separate from my body, like my core self is OK."

Values in Psychotherapy: This state commonly validates positive cognitions in a profound way for your client at an abstract and physical level; the state provides a kind of guiding beacon that orients your client to their potential for handling situations and for their growth, even their relationship to death.

Approaches to Psychotherapy: Brief, not distracting, reinforcement of insights and feelings verbalized. Allow client time in this state to increase the likelihood that it will become a body mind memory for future conscious and unconscious reference.

In EMDR and Reprocessing: If this state occurs early in the session, it may be best to seek additional targets or return to mental rehearsal in which new targets can be elicited (for example, in a case in which a person with cannabis abuse rapidly moved to this state, we spent much of the remaining time moving to situations in which your client might be tempted to use pot and reprocessing the feelings and cravings elicited, as specified in a substance abuse protocol by A.J. Popkey. There was also a longer-than-usual amount of time to focus on cognitive restructuring and future planning including mental rehearsal, as well as simply enjoying the positive state and recognizing it as an innate alternative to drug use. For a summary of this session go to the Cannabis Abuse EMDR Session Summary.

7. Deep Spiritual

Client experiences transpersonal phenomena often described as crossing some kind of threshold.

Content Type: Sometimes described as experiencing another dimension, as in an out-of-body experience.

Example Verbalization: "It's like I crossed some kind of threshold into a different reality."

Value in Psychotherapy: Many clients report this as a life-changing experience that enhances their philosophy of life.

Approaches in Psychotherapy: Many therapists are content to validate the experience and reinforce their client's new patterns of behavior and feeling. Transpersonal therapists may actively work with this state, using training in Shamanic journeying, past life regression, their religious training, and so forth.

Mohamed Taha Siddik, M.B.B.Ch., MSc.Psych. on "Gestalt Games in Group Psychotherapy: Analysis of Structure and Functions"

Mohamed Taha's animated Power Point Presentation provides insights into the levels of consciousness as described in this article. His creative visuals and text also relate the levels to other thinking in psychology, such as Ericksonian developmental stages, and to the experiences of participants in his dynamic, creative psychotherapy groups. Dr. Taha's talk and Power Point presentation took place at The Department of Psychiatry and Neurology, Al-Mynia University Hospital, Egypt on Monday June 20, 2005. Sorry, the talk itself is not available yet.

Mohamed Taha, M.B.B.Ch., MSc.Psych. is an assistant lecturer of psychiatry in the Neurology and Psychiatry Department, Al-Mynia faculty of medicine, Egypt. He works with a team of colleagues under the supervision of Professor Refaat Mahfouz, professor and head of the psychiatry department, Al-Mynia faculty of medicine, Egypt. They have been conducting the Group Therapy Training Program since July, 2000. Over 20 Researches and 100 presentations have been held in relation to this training program.

More About Mohamed Taha: At the time of publication of this presentation (6/27/05) Mohamed Taha is 30 years old. He is working on his MD thesis on Psychotherapy as a Creative Process: An Application in a Dynamic Interactive Therapy Group. He has done work on, (presentations are available):

• Basics of Group Psychotherapy
• Gestalt Psychotherapy
• Creativity
• Group Psychotherapy Training
• Mental Imagery
• Gestalt Games in Group Psychotherapy
• The Dialectic Between Insanity and Creativity