Brainspotting Trainings Inc.

Phase One
Training Manual
David Grand, Ph.D. Developer and
Trainer

Presented by: Nancy Tung, RN, BSP Trainer

Founder, Practice for Systemic Wellness
www.NancyTung.com

2415 Jerusalem Avenue, Suite 105, Bellmore, NY 11710

www.brainspotting.com
 Brainspotting Training Manual – Phase One

DAY 1

AM

Introduction: “The Story of Brainspotting” (including PowerPoint)

PM

Outside Window

Demo and Practicum

DAY 2

AM

Inside Window

Demo and Practicum

PM

Gazespotting

Demo and Practicum

DAY 3

AM

Resource Model of Brainspotting

Demo and Practicum

PM

Summary and Conclusion of Training

 1

Brainspotting
“Where you look affects how you feel”

Released
by
Sounds
True
2013

Now in
digital
audiobook

Sandy Hook Tragedy

Report of Findings from the Community

Survey, September 2016
The mission of the Foundation is to
devote itself to furthering and supporting
operations and activities which address
the short-term and long-term unmet
needs of individuals and the Newtown
community arising from the tragic events
at Sandy Hook Elementary School on
December 14, 2012.

http://www.nshcf.org/wp-content/uploads/2016/09/2016-NSHCF-
Community-Assessment-Report.pdf
 2

Brainspotting
found to be the
most effective
mode of therapy
used in Newtown-
Sandy Hook,
Connecticut for
survivors of the
12/14 school
shooting

Brainspotting – the efficacy of a new

therapy approach for the treatment of
Post Traumatic Stress Disorder in
comparison to Eye Movement
Desensitization and Reprocessing

by Hildebrand, Grand and Stemmler

Mediterranean Journal of Clinical

Psychology MJCP
Vol 5, No 1 (2017)

A preliminary study of the efficacy of

Brainspotting – a new therapy for the
treatment of Post Traumatic Stress
Disorder

By Hildebrand, Grand and Stemmler

Journal for Psychotraumatology,

Psychotherapy Science and
Psychological Medicine
(2015)
 3

Brainspotting: Sustained
attention, spinothalamic tracts,
thalamocortical processing, and
the healing of adaptive orientation
truncated by traumatic experience
by Frank Corrigan, David Grand
and Rajiv Raju
Published in journal Medical
Hypotheses
(May 2015)

Brainspotting: A
Neurobiological Hypothesis
by Frank Corrigan and David
Grand published in journal
Medical Hypotheses
(May 2013)

13,001 Therapists trained in

Brainspotting
65 BSP Trainers Internationally
Argentina, Australia, Austria, Belgium,
Brazil, Canada, Chile, China, Costa Rica,
Ecuador, El Salvador, France, Latvia,
Germany, Greece, Hungary, Indonesia,
Israel, Italy, Japan, Madagascar, Mexico,
The Netherlands, New Zealand, Norway,
Panama, Paraguay, Philipines, Portugal,
Romania, Slovenia, South Africa, Spain,
Sweden, Switzerland, Taiwan,
Turkey, U.S., Ukraine, UK
 4

International Brainspotting
Conference scheduled on July
9-12, 2020 in Denver, Colorado

Go to Brainspotting2020.com
for information and to register

For information go to:

Brainspotting.com

The Brainspotting Model

Phase 1 Day 1
 5

The discovery of Brainspotting occurred in

2003 with a 16 year old figure skater who
couldn’t master the triple loop. David Grand
targeted the moment her jump went awry.

While she tracked his finger crossing her

visual field, her eyes wobbled and froze. He
instinctively held her gaze at that point.

A torrent of trauma material poured out

for the next ten minutes.

Despite a year of weekly 90 minute

sessions, new memories of maternal
abandonment leading to parental divorce
as well as countless sports injuries flowed
out with intense emotion.

Grand was struck by the fact that new

material emerged that had not come
out in a year of intensive treatment.
But Grand was even more struck that
issues that had been “resolved”
reemerged and processed through to a
deeper level.
 6

The next day the young skater performed

a flawless triple loop for the first time.

And she never had the problem again

Grand began to look for these eye

anomalies with his other clients and
held their gaze at the point of the
eye freeze or wobbles

When he saw any eye reflex he

held his finger in place directly
in front of it so the client could
maintain their gaze right
at that spot
 7

Grand noticed that any reflexive

response in the client revealed the
presence of a Brainspot

The clients reported that the processing

was deeper and more powerful.

Some felt it all the way

in the back of their head

Many of his clients were therapists so

they tried it out with their clients and
reported similar powerful experiences
 8

During the following years he discovered

many ways of locating relevant eye
positions in the field of vision

These include:

Outside Window
Brainspotting (BSP)

Inside Window BSP

Gazespotting

In “Outside Window”
Brainspotting the therapist
observes the client’s eyes while
tracking micro-slowly,
searching for reflexive
responses, without the
client’s awareness or
active participation
 9

Outside Window

We can observe a multitude of reflexive

responses including eye wobbles, freezes,
blinks, facial tics, brow furrowing, sniffs,
swallows, head nods & body shifting

When a Brainspot is
activated, the deep
brain appears to
reflexively signal the
therapist, beyond the
awareness of the
client’s neocortex, that
an area of relevance
has been located

What does the subcortical brain perceive

when we respond to a blink by pausing
right at that location?

It appears to feel a sense of connection and

attunement the neocortical brain doesn’t
understand.
 10

What started as Brainspotting Grand later

called Outside Window as he realized
Brainspots can be located & processed from
the Inside Window of the client’s felt sense

Outside Window

&

Inside Window

In Inside Window Brainspotting the therapist and

client participate together to locate Brainspots
through the client’s felt sense of the highest
intensity of somatic activation

In Inside Window Brainspotting eye

positions are divided into two axes, X and
Y. First we find the most activated
(access) spot horizontally (left, center and
right along the X axis) from there we
explore vertically (above, at or below eye
level on the Y axis)
 11

Gazespotting

Fixed gazing while thinking or speaking is

natural Brainspotting and can be harnessed

What is a Brainspot?

It is hypothesized that a Brainspot is the

activity in the subcortical brain in response
to focused activation and eye position.
 12

Brainspotting makes use of Dual

Attunement which is the combined
relational and neurobiological attunement
simultaneously. This fits the model of
Interpersonal Neurobiology (Siegel)

So despite the neurophysiological imperative of

Brainspotting, it’s still a highly relational process

In fact, the therapist doesn’t engage less,

they engage differently

It is the attuned, mindful, witnessing,

compassionate presence of the
therapist that supports the healing

Being mindful of this presence

enhances the healing
 13

The client is like the head of a comet

and the attuned therapist is like the
tail of the comet that follows the head

BSP is an open, creative, integrative model.

It is designed to be adapted into any
clinical approach and therapeutic style

There is no turf when it comes to healing

There are two models of Brainspotting

The Activation Model

The Resource Model

 14

The Activation is paired up with the

location of body activation when
activating the presenting issue

The Resource is the area of calm or

groundedness located in the body while the
client is activated around an issue

Brainspots can be matched with either the

Body Activation or the Body Resource
 15

BSP appears to access the right brain, the 
limbic system and the  brainstem (midbrain) 

BSP is accordingly seen

as a physiological
approach with psychological consequences

For therapists trained in the

70’s and 80’s everything was
taught as “the mind”

Many of us used to wonder “where

is the mind?”

Our answer was “it’s got

to be in the brain”
 16

Brainspotting is a relational,
brain-body, mindfulness
based therapy

BSP therapists think about what’s

going on in their client’s
brain all the time

In Brainspotting we often say, 
“it’s all brain stuff”

And educate their clients

about how their brain works
and where the trauma and
symptoms are held in their brain
 17

“What’s in the brain is in the

body and what’s in the body
is in the brain”

Every brain is a genius, containing one

quadrillion (1-4,000,000,000,000,000)
connections (Daniel Amen). The
subcortical brain controls all bodily
functions and is
the seat of instinct,
thought, creativity
and spirituality

“Neurons that fire together,

wire together”
(Donald Hebb, 1949)
 18

The brain is capable of

neuroplasticity (Norman Doidge)
and neurogenesis

The human brain is an amazing

mechanism that is constantly
processing a remarkable amount
of information

The goal of every psychotherapy is to move

clients from dysregulation to regulation.

Brainspotting aims to engage the regions of

the brain that are specifically in
neurobiological regulation and bypass the
regions that are not involved in it.
 19

The agranular isocortex (ventromedial,

orbitofrontal and anterior pfc) and the
allocortex are involved in ongoing
regulation, the granular isocortex
(neocortex) is not.

The granular isocortex has 6 layers and the

4th is granular. This contributes to higher
order processing but not to regulation

The agranular isocortex has 3 to 5 layers

with no granular layer. It accordingly is
highly involved in regulation

The limbic system has a cortex known

as the allocortex (limbic cortex) which
is highly involved in regulation
 20

Brainspotting attempts to access the

the regulating capacities of the
agranular isocortex and the allocortex
with the dual attunement frame

It is theorized the BSP accesses the visual

(1st) and tactile (3rd) layers of the Superior
Colliculi. The BioLateral Sound may access
the auditory (2nd) layer

Brainspotting appears to promote

coherence between the sympathetic
and parasympathetic activation
 21

Trauma overwhelms the brain’s

processing leaving pieces of the
unprocessed experiences frozen
in time and space

Unprocessed traumas are

held in capsule form in the
brain (Robert Scaer, MD)

A Brainspot is seen as an eye

position that correlates with a
physiological capsule that holds
traumatic experience in
memory form
 22

BSP is a Parts Approach - We are

biologically made up of parts:
molecules, cells, organs, systems and
subsystems

These parts are designed to

operate both independently and
interdependently in harmony
and in synchrony

For our survival and stability (homeostasis)

the brain constantly scans and
adjusts cells, organs and systems
of the body 24 hours a day. The immune system
is an example of this process

It is theorized that BSP taps into and

harnesses this brain/body self-scanning to
locate, hold in place, process and release
focused areas that are in a maladaptive
homeostasis (frozen in primitive survival
modes)
 23

Brainspotting makes use of phenomenology:

“Observe everything and assume nothing”

Ἓν οἶδα ὅτι οὐδὲν οἶδα”

“I know one thing -
that I know nothing”
Socrates

The Uncertainty Principle

(Heisenberg)

“You don’t have to know

what it is, to know that it is”
 24

“All you need to do is observe 
with curiosity, give yourself 
time and space and see 
what happens”

Brainspotting
constructs
a frame
around the client
relationally and
neurobiologically

The Resource Model uses a more

contained frame with greater
containment for clients who become
easily overwhelmed
 25

Intervention is to be used as minimally and

temporarily as possible
as the goal of BSP is
accessing and focusing
client’s self-healing
capacities

Simple (Type 1) PTSD

Complex (Type 2) PTSD and

Dissociative Disorders

The Brainspotting
Window of Tolerance

Simple PTSD

Complex PTSD

Very Complex
PTSD

Extremely Complex PTSD

(DID and severe attachment disorders)
 26

Extremely Complex PTSD is outside

of the Brainspotting Window of
Tolerance and requires both a
modified, expanded, integrative
Brainspotting Resource Model

Brainspotting can be
directed at activation

Brainspotting can be
directed at resources
 27

Brainspotting can be done not only

with eyes open or “Shades Up”

Or with eyes closed

“Shades Down”

Brainspotting appears to process

down to the reflexive core of the
brainstem and the spine

Often when it appears one has

reached a zero activation level, a new
strata is broken through, probing
deeper into the subcortical brain
 28

Brainspotting can be enhanced by

BioLateral Sound CDs. For highly
dissociative clients, Brainspotting can be
initiated without any bilateral stimulation,
which can be added later as the client
becomes more stabilized

The Brainspotting Set-Up

1. The beginning - choose the issue
2. Check on activation
3. SUDS Level (10 to 0)
4. Location of activation in the body
5. Locate eye position of greatest observed or
perceived activity – Outside or Inside Window
6. Focused Mindfulness (Processing)
7. Go back to the beginning to assess change
8. Squeeze the lemon

The beginning
choosing the issue
 29

Activation

BSP works with felt sense and

activation is used as an open,
inclusive term

SUDS Level (10 to 0)

Developed by Joseph Wolpe

Accesses the numerical centers of the

brain to assess level of activation.
There is no inherent value
to it, just a relative,
subjective assessment.

Location of activation in the body

Increases the focus and accesses

the simultaneous brain-body
communication
 30

Locate eye position of greatest

observed or perceived reflexive
or orienting activity
Outside or Inside Window

Focused Mindfulness (Processing)

Observing one’s ongoing

internal process while in a state
of focused activation

Go back to the beginning to

assess change
 31

“Squeezing the lemon” is a technique for

making sure that all remaining remnants of
activation are processed out. When a client
is at a zero SUDS guide them to “go inside
and try to push the activation level as high
as you can”

Repeat the process until

no activation can be elicited

The Brainspotting Outside Window Set-Up

1. The beginning - choose the issue

2. Check on activation
3. SUDS Level (10 to 0)
4. Location of activation in the body
5. Slow horizontal eye tracking to locate reflex
spots observed in the eyes, face and body
6. Focused Mindfulness (Processing)
7. Go back to the beginning to assess change
8. Squeeze the lemon

The Brainspotting Inside Window Set-Up

1. The beginning - choose the issue
2. Check on activation
3. SUDS Level (10 to 0)
4. Location of activation in the body
5. Find highest activation tracking horizontally at
eye level (X axis)
6. Then track above, at and below eye (Y axis) for
the highest activation to locate brainspot
7. Focused Mindfulness (Processing)
8. Go back to the beginning to assess change
9. Squeeze the lemon
 32

Gazespotting

Fixed gazing while thinking or speaking is

natural Brainspotting and can be harnessed

Gazespotting
1. Notice when a client is looking (gazing) unconsciously at
a fixed point while talking about relevant, activated issue

2. Point out that the client is gazing at this spot and ask for
SUDs level and location of body activation

3. Encourage the client to keep looking at Gazespot while

not speaking (to initiate processing) for 1 minute

3. Continue client processing on the Gazespot for

progressively extended periods of time

This will initiate using this gaze spot for full processing of
the issue. Processing should be carried through until full
resolution of issue. This is determined by going back to the
beginning to assess SUDs level. If activation has reached
zero then initiate squeezing of the lemon.

The Brainspotting
Resource Model
Phase 1 Day 3
 33

Brainspotting is
a Resource Model

The core of the Brainspotting Resource

Model is the Dual Attunement Frame
comprised of the relational attunement
accurately focused and framed by the
neurobiological attunement

The attuned, mindful, compassionate

(empathic), witnessing presence of
the therapist is the foundation of the
Brainspotting Resource Model
 34

Limbic countertransference is inevitably

induced (flight, freeze, fight) in the
therapist by exposure to client’s severe
abuse material. This activates the
therapist’s traumas going back to their
original preverbal traumas.

Flight – therapist’s impulse to create

distance from the client:
“get me out of here!”

Freeze – dorsal vagal collapse,

therapist’s extreme sense of
somatic helplessness and
inability to think
 35

Fight – therapist vulnerability to

struggles with client, especially
with aggressive alters

A triggered
therapist is
also likely to
intervene
too quickly
and too
frequently

A Brainspot (activation spot included) is a

neurological resource as it provides an
attuned, focused, framed accessing anchor
to the midbrain (Corrigan and Grand) and is
grounded in the body experience
 36

The essential resource is the

survival instinct which is
deeply subcortical

All animals, including

humans, possess remarkable
capacities for adaptation and
for attaining homeostasis

The Brainspotting
Window of Tolerance

Simple PTSD

Complex PTSD
Very Complex
PTSD

Extremely Complex PTSD

(DID and severe attachment disorders)
 37

The foundational model of BSP

is effective for most clients
inside the Brainspotting
Window of Tolerance

A Body Resource is an area

of the body that feels
calm and grounded

The Body Resource and Resource

Spot may be needed for clients
with Very Complex PTSD
 38

A Resource Spot is an Inside

Window eye position that
matches (gains access to)
the Body Resource

Demonstration and
Practicum of the Resource
Model of Brainspotting

The Brainspotting Resource Model (Inside

Window) Set-Up
1. The beginning - choose the issue
2. Check on activation
3. SUDS Level (10 to 0)
4. Location of resource in the body
5. Find resource location tracking horizontally at
eye level (X axis)
6. Then track above, at and below eye (Y axis) for
the resource location to determine brainspot
7. Focused Mindfulness (Processing)
8. Go back to the beginning to assess change
9. Squeeze the lemon
 39

Extremely Complex PTSD is outside of

the Brainspotting Window of
Tolerance and requires a both
modified and expanded
BSP Resource Model

Each client with DID is like a unique

Swiss watch. The therapist needs to
learn all the component parts and the
system’s internal consistency (it
always makes its own sense)

Key factors in treating clients with DID:

*Personality of client (those with concurrent
personality disorders are harder to treat)
*Motivation level of client is crucial in regard to
engagement and response to treatment
 40

With clients with severe dissociative

and attachment disorders the attuned
presence of the therapist is the core of
the Advanced Resource Model

Extremely Complex PTSD can be

divided into DID Type A and DID
Type B (Grand, 2014)

DID Type A: severe attachment disruption, sexual

abuse, rape, incest, torture and ritual abuse
starting by or before age 2
DID Type B: significant attachment disruption,
sexual and physical abuse after age 2
 41

Type A Clients with DID:

*In a state of 24 hour/day flashback
*Little or no capacity for sleep
*Parts trapped in a flashback state
*Little or no capacity to trust
*Tendency to self-harm and suicidality
*High levels of self-hatred, self-attack and sense
of utter worthlessness
*Often have severe body distortions
*Frequently speak in meta-communications,
often from the most wounded parts

Goals of treatment with

Clients with Type A DID

Identify with client their state of 24

hour/day flashback (oftentimes
somatic). Then begin to establish with
clients islands of non-flashback
 42

Begin to develop capacity for sleep

Help parts who are stuck in flashback

to begin to escape into the present

Gradually teach the

capacity to trust
 43

Intervene to contain tendency

to self-harm and suicidality

Begin to heal severe body distortions

Begin to heal self-hatred,

self-attack and sense of
utter worthlessness
 44

Listen and receive (not challenge

or question) client’s meta-
communications, which emanate
from their most wounded parts
I want to die
I need to die
There is no hope
I can never recover

Brainspotting is designed to be
integrated into the various
effective treatments of DID
(i.e. IFS, DNMS)

Parts can be engaged one at

a time, as well as collectively
 45

In engaging parts one at a time there is the

necessity to engage either the most
wounded (usually very young) or the most
disruptive (aggressive) parts first

The most wounded part

(frequently a baby part) is often
trapped in flashback and is not
aware of the therapist’s presence

The therapist needs

to make contact
with the wounded
part and begin a
rescue and healing
process
 46

A disruptive or aggressive part needs

to be cautiously and respectively
engaged. In time they can become an
ally in the healing process of all parts.

The most powerful Brainspot

for clients with DID is the
Eye Contact Spot

A client in flashback will often

look off in a particular direction
 47

Aligning our face where the

client gazes can imprint a
new image into the flashback

The Brainspotting DID healing process is

one of mutual cooperation and co-creativity
48
 49

Brainspotting, a New Eye Position Model for Brain-Based Psychotherapy

David Grand, Ph.D.

Abstract

Brainspotting (BSP) is a new psychotherapy approach that hypothesizes that the field of vision can be used to
locate eye positions that correlate with relevance to inner neural and emotional experience. After these eye
positions, or Brainspots, are located, they may by maintaining eye fixation, lead to a healing and resolution of
issues that are held deeply in the non-verbal, non-cognitive areas of the neurophysiology. BSP utilizes both
focused activation and focused mindfulness as its mechanisms of operation. It aims at a full, comprehensive
discharge of activation held in the brain and body. BSP is a model that incorporates systemic activation and
resources applied based on both diagnostic and developmental considerations. The BSP model is developed
as both relational as well as technical, with philosophical and physiological underpinnings. It is an open,
inclusive, yet framed model that invites the therapist to make use of their prior study, experience and practice
wisdom.

Background

Brainspotting (BSP) was discovered by David Grand Ph.D., the author of this article, in 2003. This paper will
describe the discovery in detail, as well as elaborate the ongoing development of BSP, from a technical,
clinical, neurobiological and philosophical point of view (Grand, 2009). BSP is a psychotherapeutic approach
that uses the field of vision to locate “relevant eye positions” (or Brainspots) that are postulated to correlate to
neurological activation and internal experience. In order to determine these eye positions, the client is guided
to be in a state of “focused activation” which is usually in response to psychotrauma or emotional or somatic
symptoms. This is assessed the by the SUDs (Subjective Units of Disturbance Scale) level of 0 to 10 (lowest
to highest) followed by determining the location of the highest body activation (except when using the
Resource Model) (Wolpe, 1969). At present there are six distinct variations of BSP (to be discussed in the
body of this paper) for locating the eye positions. Once these Brainspots are determined, the client is guided
to uncritically observe their sequential internal process, which includes affect, memory, cognition and
especially body sensations. This self-observation is called “focused mindfulness” as it is parallel to meditative
practice, and is performed in a state of focused activation. At various junctures, determined by either the client
or the therapist, a brief discussion ensues reviewing the ongoing nature of processing. This is followed by the
therapist reorienting the client to their body experience as the unguided self-observation resumes, while still
gazing at the Brainspot. The process continues until the client arrives at a state of resolution, determined by
returning their original issue of activation with no SUDs activation present. This is reinforced by having the
client “squeeze the lemon” by attempting to internally reactivate the SUDs level, which is again processed
down until it can no longer be reactivated. Based on the diagnosis, complexity of the condition and client
capacity for processing, resolution may occur in anywhere from one session to many months or even years of
treatment (Grand, 2009).
 50

Discovery of Brainspotting

Brainspotting was discovered by the author in 2003 while working with a 16 year old ice skater. She had been
seen for a year of weekly 90 minute sessions to treat significant performance issues that reflected a
dissociative quality. For example, in warm-ups before competition, the skater described either feeling like she
had forgotten her program or that she couldn’t feel her legs. This resulted in performances far below par and
the inability to compete at a national level commensurate with her level of talent. During the year of treatment
with the skater, the author used the approach he developed, designated as “The Grand System” (Grand,
2001) which included aspects of EMDR (Eye Movement Desensitization and Reprocessing) (Shapiro, 2001),
SE (Somatic Experiencing) (Levine, 1997), micromovements and relational insight-oriented therapy. Some of
the factors contributing to the skater’s performance problems were a variety of traumas including maternal
rejection, parental discord leading to divorce when the client was six, and a protracted history of sports
injuries, failures and humiliations. The skater’s treatment had for the most part been successful with a few
exceptions, which included her inability to complete a triple loop. This required jump is not the most difficult for
championship caliber skaters, such as this client, but her inability to perform it rendered completion of
successful short and long programs impossible. To attempt to remedy her performance block with the triple
loop, the client was guided to imagine doing the jump in slow motion and freezing it at the precise moment
she felt and saw herself “going off”. She was then guided to follow the author’s fingers moving slowly back
and forth across her visual field, a variant of EMDR. Within a few passes, just slightly off center, the skater’s
eyes noticeably wobbled in a sustained microsaccade, followed by locking into a frozen position (Martinez-
Conde & Macknik, 2007). Startled by this response, the author reflexively stopped moving his fingers and
immediately held them still directly in front of the eye freeze, approximately three feet away from the client’s
face. During the subsequent ten minutes, a remarkable torrent of trauma processing ensued. A series of new
distressing memories emerged and rapidly processed through to resolution. But even more surprising was
that a significant number of the skater’s “resolved” traumas reopened and processed through to a deeper
level. At the end of the ten minutes, the processing slowed and completed, and the skater’s eye-lock
released. Her ocular manifestations and intense processing was an unusual event indeed, and it was
reinforced the next morning when the young skater called the author after practice and reported excitedly that
she had repeatedly performed triple loops without a hitch. The skater never manifested her difficulty with the
jump again. This dramatic change of behavior caught the attention of the author, and he began to look for
similar eye manifestations in other clients, while tracking slowly across their visual fields. When he observed
these eye anomalies, he repeated the procedure of holding his finger dead center in front of where the
anomaly occurred. He not only noticed an acceleration and deepening of the client’s processes, but he was
again startled by the client’s reports. Comments like, “this is really different”, “this feels much deeper”, “I can
feel it all the way in the back of my head”, and “I can really feel it in my body”, were offered by a wide
spectrum of clients. Of particular note was the feedback from therapist clients, which indicated that they
observed a profoundly different experience and outcome from before with this new approach. Additionally,
guided by instructions from the author as far as how to perform this new eye-gaze technique, many of these
client-therapists tried it out with their own clients and reported back to the author similar experiences of faster
and deeper resolutions in session with their clients. Accordingly, in the course of a month’s duration, the
author, by accumulating his own observations and the feedback from his client-therapists, determined that he
had stumbled onto a new method and perhaps a new paradigm.
 51

Further Development of Brainspotting

Repeatedly applying this procedure during the following months, the author noticed that by stopping the
horizontal eye-tracking at eye level, in front of any reflexive responses by his clients, he elicited a similar
deepening and acceleration of their healing processes. These observed reflexes included blinking, quick in-
breaths, coughing, hard swallowing, mouth movements, eye widening or narrowing, head tilting and change
of facial expression, among other responses. The author found the enhanced treatment effect with his clients
both curious and compelling, as it resulted in his already successful treatment outcomes becoming even more
powerful and comprehensive. He searched for a name for this process and arrived at “Brainspotting”, guided
by the recognition that these “spots” in the visual field appeared to access discrete locations and functions
within the brain. During the course of the subsequent six months, the author increasingly applied his new
technique, amassing anecdotal evidence of its effectiveness with a wide variety of clients carrying different
diagnoses, histories and symptoms. It appeared that the containment provided by the fixed eye-gaze, and the
possible concomitant focused neurological activation, were accomplishing a uniquely successful approach to
emotional healing.

The author recognized the need to have an organized, yet simple, way of accomplishing focused activation,
with his clients, in order to initiate the optimal brain arousal needed to accurately locate the relevant eye
positions. He accordingly developed a simple “set-up” process to accomplish this step-by-step procedure. The
author started by asking the client if they were “activated” around the issue they wanted to address. This
activation was assessed by the SUDs (Subjective Units of Disturbance) level discussed earlier in this paper. If
the activation was not high enough, the client was guided to, “go inside and do whatever you need to do to
push the activation level higher”. If it was high enough, the SUDS was simply rated from zero (lowest) to ten
(highest). The next step was guide client’s to locate their area of somatic activation by observing, “where in
your body you feel it the most”. After the focused activation was accomplished, the set-up was completed by
locating the Brainspot in the client’s visual field. Following the set-up process, the client was guided to
observe their focused mindfulness process, which ultimately was intended to lead the client to the point of
resolution of their issue of activation.

Outside and Inside Window Brainspotting

As his utilization of the Brainspotting process continued over time, the author closely observed and listened to
the client’s reactions and feedback. A number of his clients, while being observed for their external reflexive
responses, provided the author with spontaneous feedback regarding eye positions that resonated with their
internal felt sense. These clients guided the author to specific visual positions where they felt their activation
the most intensely with comments like, “you just passed it”, or, “move the pointer over there”. This surprised
the author as he had not considered that Brainspots could be located by the client from their inner experience.
This, accordingly, gave him two options for locating the relevant eye positions, horizontally at eye level. The
author named the original eye location, determined by externally observing reflexes, “Outside Window
Brainspots” and he called the locations determined by the client self-observed felt sense intensification,
“Inside Window Brainspots”. In order to locate these Inside Window Brainspots, the author asked clients
whether they felt the most activation looking to their left, center or right of their fields of vision, as they tracked
a pointer that he moved to each of these positions. Once the general location was determined, the author
found the most precise location of activation perceived by the client. However, some clients kept directing the
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author, not only to the left and right of their visual field, but also above and below eye level. This development
led the author to first search for client activation along the horizontal, or x axis, followed by exploring up and
down the vertical, or y axis, of the client, for the location of the greatest perceived height of activation. This
allowed for BSP to move from a one dimensional process to two dimensions in exploring the client’s visual
field.

Phenomenology

The author, prior to his discovery of Brainspotting, had developed a modified version of EMDR, which he had
named “Natural Flow EMDR” (Grand, 2001). He incorporated much of this approach in his further
development of BSP. The basic tenets of the Natural Flow approach included the “no assumptions model” or
phenomenology (“observe everything, assume nothing”), body resourcing (borrowed from Somatic
Experiencing) (Levine, 1997) and slower eye movements and gentler bilateral auditory stimulation (Grand,
2002). All of these methods were relevant to BSP and were as such incorporated in the author’s new method.
The phenomenological approach came from the author’s decades of clinical experience, where he noted how
the unexpected always appeared to arise in session with clients. The author combined these unexpected and
unpredictable observations with the growing information he studied about the infinite complexity of the human
brain, and accordingly how unknowable each client’s brain is to the outside observer. This clinical-
philosophical approach, entailed tracking, or following the client, uncritically, and without expectation,
wherever the client went within their process. By recognizing the necessity of following, and not leading the
client, the author also hypothesized that by tracking the client’s associative processes, that he was also
observing a correlate of their neural activity. The author, accordingly, noted how many subtle assumptions
were imbedded in most clinical models, and how these assumptions became a part of the training and belief
systems developed by many therapists. In his trainings, the author employed his clinical observations by often
challenged therapists presenting analyses of client case scenarios with the question, “how can you know
this?”

Dual Attunement Model

BSP is seen as a “Dual Attunement Model” similar to the “Interpersonal Neurobiology Model” (Siegel, 2010).
Dual Attunement entails combining the therapist’s relational attunement to the client, that is central to the
interpersonal model, with neurobiological attunement, derived by the technical locating and harnessing of the
client’s Brainspots. It should be noted that the author had been a relationally-based clinician for twenty-seven
years prior to the point of his discovery of Brainspotting. His original training was in psychoanalysis and
psychodynamic psychotherapy, which developed his skills of attuned listening to the multi-leveled
communications of his clients. However, the analytic model was too structured for the author and he began to
interact in a more open, flexible, accessible manner with his clients. This expanded the reach of his
attunement from the observational to the interactive. The attunement skills of a psychotherapist tend to be
deepened and widened over years and decades of practice, as therapy can be viewed as both an art and a
science. It is accordingly relevant that BSP was discovered and developed by a clinician with over three
decades of therapeutic experience. The determination of a Brainspot, as described earlier as a relevant eye
position, is very technical from a neurobiological point of view. In essence, there appears to be little that is
psychological about determining eye positions that resonate with activation of the client’s brain which is felt in
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their bodies. Determining a Brainspot is a procedural process; the therapist either observes the client’s
reflexive response by eye position, or the client reports to the therapist the eye position where the client feels
the greatest somatic activation. This procedure can be seen as parallel to a physical examination where the
physician determines where their patients feel the most discomfort or pain in their bodies. From this vantage
point, the technical aspect of determining a relevant eye position in clients, is an attunement process that is
dramatically different from that of the relational attunement process of therapy. BSP, however, in contrast to
many other neuro-technical models, is conceptualized and taught from a clinical point of view. The therapy
relationship is not intended to serve the BSP, the BSP is intended to serve and support the healing
relationship. However, there is no skew toward either the attunement power of the technical, or the relational.
The attention is directed to the synthesis of the two together, which is designated as the Dual Attunement
Model, the sine qua non of BSP, and hence the source of BSP’s observed powerful treatment effect.

The Frame

The Dual Attunement Model of Brainspotting is seen as providing a “frame” for the client’s processing
(Focused Mindfulness). The brain is seen as mechanism that is driven by its essential survival instinct and its
unique capacities for adaptation that can be observed in how humans continually process their internal and
external experiences. Trauma is seen, in BSP, as interruptive to these innate human processing capacities,
leaving aspects of the traumatic experience unprocessed and not fully completed in the client’s nervous
system. From a Brainspotting point of view, a client’s decision to seek out psychotherapy occurs when the
client perceives that their usual capacity “to work out their problems on their own” is compromised. With BSP,
the therapist is not seen as possessing the “answers” to the client’s “problems”. Just as the problems, or
unresolved trauma, reside in the human brain, BSP posits that the answers to, and resolution of, the problems
reside in the potential of the client’s nervous system as well. The trauma is accordingly seen as an attendant
neurobiological dissociative barrier, within the client, that blocks the internal brain communication that
potentially connects the problem with its ultimate resolution. With BSP, the therapist’s relational and
neurobiological sustained container of attunement (the Dual Attunement Frame) is seen as supporting the
client’s brain in enhanced internal communication, resulting in the experience of problem resolution for the
client. This BSP model is different from the traditional treatment models that utilize the application of
therapeutic interventions, by the technically informed therapist, to support change in the client experientially
and behaviorally. The BSP model posits that the vastness and complexity of the brain make it impossible for
the therapist to comprehend the unique inner workings, and resultant symptomatology of each client. In
contrast, BSP posits that “the right frame” developed and held for the necessary duration with each client with
result in “the right resolution” for the client.

Integrative Model

BSP is unique as an articulated treatment approach, in the author’s opinion, as it is intentionally designed as
an integrative model. Oftentimes clinical-technical approaches are taught discouraging anything less than a
fidelity to the model and its protocols. With most other defined approaches, integration is usually tolerated
with an, “It’s ok if you do it” attitude. With BSP integration is not only “allowed”, it is encouraged. This dovetails
with how phenomenology is applied to BSP with the recognition that the human system is too vast to be
understood from the outside. Accordingly there can be no one model that encompasses the workings of the
human system. This in fact explains why so many models of the human mind have arisen and have
demonstrated efficacy. Any clinical approach can be used in concert with BSP, or on a Brainspot. In fact, the
 54

complexity of response to BSP necessitates that a therapist be well versed in a variety of modalities to both
understand and respond to the undefined or the unanticipated client reactions. The author has found that
trainees of many different clinical backgrounds find a commonality in BSP, reflecting BSP’s synthetic nature.

Neurophysiology

The mechanisms that underlie the BSP approach are either yet to be understood or are known in fields
outside the purview of the author’s knowledge base. It is known that the eye is an extension of the brain. It
contains about 125 million light-sensitive nerve cells (photoreceptors) which generate electrical signals that
allow the brain to see. There are both conscious and unconscious visual systems and each process along
separate pathways in the brain. The unconscious system guides action and the conscious system recognizes
objects (Carter, 2009). It is posited that with BSP, “where you look affects how you feel” and that different
fixed eye positions correlate somehow to specific neural activity and internal experience. It also appears that
by maintaining this eye gaze, while in a state of focused activation around an issue, that the neural activity
becomes more focused, thus leading to a more highly economical processing and resolution of the internal
neural and felt sense experience. The author believes, as many others do, that we are wired for healing
(Badenoch, 2008). He also believes that this is driven by the survival instinct which is at the foundation of all
animal and human experience. The author also believes that nothing is held in any part of the human system
that does not affect all parts and the entirety of the system, and this explains why BSP has been designed as
a brain-body approach. BSP is also relational, understanding that the original attachment to the mother-
caretaker is the foundation of the therapeutic relationship, and underlies all psychophysiological development
and healing.

The Resource Model of Brainspotting

The “Resource Model” is an essential aspect of BSP. It expands the application of BSP to the most wounded,
dissociative clients who tend to be too overwhelmed to utilize the so-called “power therapies”. Central to the
BSP Resource Model is the “body resource”. The use of the body resource in BSP is derived from the
author’s discussions with Peter Levine, developer of the Somatic Experiencing (SE) model (Levine, 1997).
Levine challenged EMDR as too activating, particularly in its focus on body activation. Levine taught the
author, as performed in SE trainings, to guide the clients to where they felt calmer and more grounded in their
bodies. Levine’s “pendulation” model entails spending more time and attention in the body resource (“healing
vortex”) and much less time on the outer edges of the body activation (“trauma vortex”). In the Natural Flow
EMDR approach, the author, after the final step of the EMDR protocol, guided the therapist to shift the client’s
attention from the body activation to the body resource and then commence processing from there. This
appeared to yield less abreactive and more tolerable processing for fragile, highly traumatized, dissociative
clients. In BSP, the author observed that the containment of the fixed gaze on the Brainspot, was not always
containing enough for these same clients who were so easily overwhelmed. By incorporating this body
resource while on a Brainspot, he observed that many clients were able to better tolerate the emotional
upheaval and body activation, and accordingly process more effectively. He also realized that Brainspots
could be determined, not only by matching them to activation, but located in concert to the body calm or
groundedness which he called “Resource Brainspots”.
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Bilateral Sound

Another aspect the author incorporated from Natural Flow into the BSP was the use of bilateral auditory
stimulation, delivered by his BioLateral Sound CDs. These CDs were engineered to move healing nature
sounds and music, slowly and gently from ear to ear. These CDs, used continuously, had been the primary
mode of bilateral stimulation utilized by the author in his Natural Flow EMDR. The author had temporarily
discontinued use of the CDs with the advent of BSP, feeling it to be unnecessary due to the power of his new
paradigm. However, a number of clients requested to additionally listen to the sound while receiving BSP. To
his surprise, the author discovered that with most clients, the CDs enhanced and provided an “auditory
resource” that deepened and supported the Brainspotting process. In response, he guided the rest of his
clients to listen to the sound during the BSP treatment. The sole exceptions were the easily hyperstimulated
clients who found sound to be challenging to their capacity to remain grounded. It should be noted that doing
BSP with the CDs is simultaneously accessing and activating the visual and auditory systems of the brain.
The observed power of this dual sensory activation and its effect deserve further inquiry and study.

One Eye Brainspotting

As guided and developed by the author, BSP was and still is, an open, integrative, ever-evolving model. One
of the first of these integrations was the use of “One Eye” Brainspotting. This borrowed from the work of
Fredric Schiffer, who determined that each hemisphere of the brain was like a separate personality (Schiffer,
1999). The access to the two sides of the brain through the visual system is cross-hemispheric. Accordingly
he developed goggles that restricted the vision in either eye so that light was only coming in from the extreme
left or extreme right activating the opposite hemisphere of the brain. By switching periodically between the two
goggles, Schiffer observed an integrative response leading to issue resolution. Prior to BSP, the author had
used the Schiffer model with interesting results together with bilateral eye movements and sound. The author
hypothesized that doing BSP on the more active eye would further focus the power of his method when
needed. But he needed to develop modified goggles, as the Schiffer version covered most of the visual field,
making Brainspotting impossible. In contrast, the BSP goggles were designed to obscure 50% of the visual
field, either one eye or the other. To determine which eye held the higher level of activation, he asked his
clients to alternately cover each eye to assess the SUDs level for the open eye. The eye with the higher level
SUDs was called the “activation eye” with the lower SUDs eye called “the resource eye”. Once the activation
eye was determined, the appropriate goggles were put on with the activation eye exposed. Inside Window
BSP was used to find the eye position of greatest activation on the activation eye. The One Eye approach
was used when either the client manifested slow processing, or for vague emotional conditions like
generalized anxiety disorder or chronic depression, or physical conditions like chronic fatigue syndrome or
fibromyalgia. The author originally assumed that when the SUDs level was processed down to a zero, that the
process was completed. But he realized he might be missing something and began checking the resource
eye after the zero SUDs was attained on the activation eye. He observed that in most cases additional
activation was present and that a new Brainspot needed to be determined on this secondary eye. At times the
SUDs level flared up one this resource eye to a 7, 8 or 9 and took considerable time to process down to a
zero. The One Eye approach is also used by the Resource Model of BSP, when used to locate, and process
from, the resource eye first. In recent years, using the One Eye approach for resourcing, because of its high
level of efficacy with complex PTSD, has actually supplanted using the One Eye activation model of BSP.
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Squeezing the Lemon

Another observation made by the author was that a zero SUDs level was not a true zero level of activation.
He observed that even after attaining a zero level of activation, clients were usually able to internally increase
their level of distress. The author developed a procedure that he called “squeezing the lemon”, where the
client was guided, after a zero SUDs was attained, to “go inside and do whatever you need to” in order to
reactivate the SUDs level. This technique was followed up by continuing processing, on the original Brainspot,
back down to zero. This procedure was then repeated until no further activation could be generated. This
squeezing the lemon approach revealed that more unprocessed material than was thought remained, despite
the attainment of the original zero level activation. This deepening, squeezing the lemon technique, also
appeared to reduce the occasions where the effect of the in session progress wore off for the client, days
afterwards, leading to the return of their activation.

The author has thus far articulated three ways of locating Brainspots including Outside Window, Inside
Window and through One-Eye BSP. The remaining three that will be discussed are Gazespotting, Z axis BSP
and Rolling BSP.

Gazespotting

The most natural type of BSP is Gazespotting. This approach makes use of our tendency to gaze at particular
points in our visual field when talking and thinking about emotionally loaded issues. When this behavior is
observed in clients, they appear to be actually talking to the spot with no awareness of their action. The
author, after five years of doing BSP, consciously noticed this phenomenon and wondered what would
happen if clients continued to consciously fix their gaze on these spots, while observing their inner
processing. The client response that that followed these instructions was observed as naturalistic and unique.
Although Gazespotting appeared generally less activating than Inside or Outside Window BSP, it was
nonetheless powerful and deep. Gazespotting is the only form of BSP where a client chooses their own spot
intuitively and unconsciously. Gazespotting tends to be more gentle and resourced than Outside and Inside
Window Brainspotting, with occasional exceptions. Gazespotting is also a good introduction to new BSP
clients, as there is no use of the pointer, which can seem odd until the client experiences the powerful effect
of processing on a Brainspot.

Z Axis Brainspotting

Z axis BSP brings the third dimension of depth into the locating of eye positions. Inside Window first explored
the horizontal or x axis, followed by exploring the vertical or y axis, searching for the highest level of activation
or resource. However, the exploration of the differences between close and far, remained to be probed, after
the Brainspot has been determined on the x and y axes. The author has observed that most clients will have
a higher or lower level of activation looking at the pointer either close or far. Oftentimes, the spot further away
on the z axis appears to have a lower activation than a closer spot. Perhaps the perception of an object
further away feeling less activating, reflects the hard-wiring in the brain that the further away the potential
threat, the safer we are, and the closer the potential danger the more vulnerable we are. It is the author’s
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speculation that when the closer spot feels less activating to the client and the far spot is more activating; that
this may reveal that the client carries significant attachment issues (far feeling more out of reach). The quality,
depth and intensity have been observed to be different between close and far and higher and lower levels of
activation. BSP trainees are instructed to start the processing at the depth location of lower activation, as the
lower levels of activation tend to promote more fluid processing initially.

The choice of z axis BSP, or for that matter any of the six modes of BSP, is determined by the therapist’s
experimentation and experience will all different modes. It has been repeatedly observed that some clients
who responded incrementally to Inside Window BSP experienced a noticeable increase in processing when
the z axis was incorporated. In his practice, the author observed some clients, oftentimes those with
dissociation, made breakthroughs with z axis that were startling and not attained with any other form of BSP.

Rolling Brainspotting

Rolling BSP is a versatile way of utilizing Outside Window Brainspots. It is performed in a similar manner to
how Outside Window Brainspots are initially located and mapped. This constitutes slowly tracking horizontally
across the client’s visual field, stopping at each location where a reflex expresses itself. In Outside Window,
this procedure is used to determine one Brainspot, where the eyes will remain fixated through the entire
process, until all activation is discharged. In Rolling BSP, the movement from Brainspot to Brainspot
continues for the entire process, until discharge has been accomplished. The amount of time paused on each
reflex spot can vary between a few minutes to a momentary pause. It is posited that by using Rolling BSP the
flow of movement from Brainspot to Brainspot will be active, integrative and comprehensive. Additionally,
some clients appear to respond better to Rolling BSP than other forms of BSP, while others simply prefer it.
Although individual application varies from therapist to therapist, and from client to client, the traditional model
of Rolling Brainspotting entails initially spending more time on each spot (one to five minutes), followed by
gradually decreasing the amount of time on each spot as the process continues.

The theory guiding how long to stay on each spot, is that early in the Rolling BSP, greater depth of processing
is the goal, and that as this processing continues, increased movement in the client experience becomes the
goal. Rolling BSP can also be used as a way of integratively finishing the more fixed versions of BSP. Using
Rolling BSP, after either Outside or Inside Window BSP has attained a zero SUDs for the client, can reveal
and process on eye positions that still hold undischarged material. At other times, Rolling BSP can serve as
an integration and deepening of a completed process, attained by processing on a fixed Brainspot.

The Future of Brainspotting

In looking ahead, BSP is an open, rapidly evolving model. By the time this article is published, some new
applications of BSP may already be in development. The human system is so infinitely vast and complex, that
attuning to its expressions, lead to new discoveries and perspectives all the time. As BSP is in its tenth year, it
is still in its infancy and is expected to mature and take its place with the many other validated treatment
methods. Although most of what has been presented in this article has been discovered or developed by the
author, BSP is being increasingly contributed to by many of the 5,000 therapists trained internationally to
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date. As this article is being written, a variety of research projects are being conducted, with more to come.
These include a research study that cross-compares the efficacy of BSP against other therapeutic methods,
an fMRI study and pupillography observational research. Ongoing extensive research is important not only to
understand and validate BSP, but in the author’s opinion, to further understand the interactive mechanisms of
the eye and the brain. In conclusion, the strength of BSP is seen in its Dual Attunement Model, which
integrates the relational practice wisdom of the ages with the current and future understanding of the brain
and its genius for self-observation and self-healing.

REFERENCES

Badenoch, B. (2008) Being a Brain-Wise Therapist: A Practical Guide to Interpersonal Neurobiology. Norton, New York.

Carter, R. (2009) The Human Brain Book. New York: DK Publishers.

Grand, D. (2001) Emotional Healing at Warp Speed: The Power of EMDR. New York: Harmony Books.

Grand, D. (2002) Treating survivors of the world trade center disaster with natural flow EMDR resourcing, EMDRIA
Conference Lecture.

Grand, D. (2009) Brainspotting Phase One Training Manual

Grand, D. (2009) Brainspotting Phase Two Training Manual

Grand, D. (2013) Brainspotting Phase Three Training Manual

Grand, D. (2011) Brainspotting, a new brain-based psychotherapy approach. Trauma & Gewalt, issue 3: 276-285

Grand, D. (2013) Brainspotting: the revolutionary new therapy for rapid and effective change. Sounds True, Louisville,
CO

Levine, P. (1997) Waking the Tiger. Berkeley, CA: North Atlantic Books.

Martinez-Conde, S. & Macknik, L. (2007) Windows on the mind. Scientific American, 56-63, (August 2007).

Scaer, R. (2005) The Trauma Spectrum, Hidden Wounds and Human Resiliency. New York: Norton Books.

Schiffer, F. (1999) Of Two Minds. London: Simon & Schuster

Siegel, D. (2010) The Mindful Therapist. New York: W.W. Norton.

Wolpe, J. (1969) The Practice of Behavior Therapy. New York: Pergamon Press.

What is a Brainspot?
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A Brainspot is the brain’s response to focused activation combined with a designated eye position. A Brainspot is not
a single spot in the brain. It is a network of activation in the brain (see scan below) which is reflected in the body with
somatic activation.

The focused activation is achieved by three steps. First, the client is guided to “go inside and do whatever is
necessary to activate yourself (around the designated issue).” This step is not needed if the client is sufficiently
activated. The second step is the application of the SUDS (Subjective Units of Disturbance Scale – Wolpe) from zero
(no disturbance) to ten (highest level of disturbance). The third step is guiding the client to locate where they
experience the activation in their body.

The corresponding eye position is located through reflexive activity observed externally by the therapist (Outside
Window) or felt internally by the client (Inside Window). This locating of eye position process increases the focused
activation and determines the Brainspot, which is technically more the activation in the brain than the eye position.

Clinical Brainspotting (BSP) – The BSP approach is designed as a neurobiological tool to support the clinical
healing relationship. The clinical work in treatment is not conceptualized as a support to BSP. There is no
replacement for the developed ability to engage another suffering human being in a trusting relationship where they
feel listened to and understood. We further understand the client in part by combining our understanding own
mechanisms and mental processes without imposing it on the client.

BSP gives us a tool, within this clinical relationship, to neurobiologically locate, focus, process and release
experiences and symptoms out of reach of the conscious mind and its cognitive and verbal capacities.
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BSP works with the deep brain and the body through its direct access to the autonomic and limbic systems. BSP is
accordingly a physiological approach with psychological consequences.

BSP is a Parts Approach - We are biologically made up of parts: molecules, cells, organs, systems and subsystems.
These parts are designed to operate both independently and interdependently in harmony and synchrony. Our
psychological parts mirror the separate and interactive body segmentation shifting roles, moods, relatedness and
introspection. Under sustained duress, especially in our early development, our psychophysiological harmony and
synchrony can be disrupted temporarily, sometimes permanently. BSP is a parts approach as a BSP is seen as a
part both physiologically and psychologically. Located by eye position, paired with externally observed and
internally experienced reflexive responses, a brainspot is actually a physiological subsystem holding
emotional experience in memory form.

The Brain Scans the Body and Itself – For our survival and stability (homeostasis) the brain is constantly scanning
and adjusting every cell, organ and system of the body 24 hours a day. This is possible because of the essentially
infinite capacity defined by the one quadrillion connections in the brain. This perpetual scanning mechanism far
outstrips the most extensive scans developed to date. It is theorized that BSP taps into and harnesses this brain/body
self-scanning to locate, process (adjust) and release focused areas (systems) that are in a maladaptive homeostasis
(frozen in primitive survival modes). This may also explain BSP’s ability to at times reduce and eliminate body pain
and tension associated with psychophysiological conditions.

“The one thing I know is that I know nothing.” Socrates

Phenomenology (observing without theorizing) describes a body of knowledge which relates several empirical
observations of phenomena to each other, in a way which is consistent with fundamental theory, but is not directly
derived from theory. Another way of describing phenomenology is that it is intermediate between experiment and
theory. It is more abstract and includes more logical steps than experiment, but is more directly tied to experiment
than theory. The boundaries between theory and phenomenology, and between phenomenology and experiment, are
somewhat fuzzy and to some extent depend on the understanding and intuition of the scientist describing these.

The core of what drives us is the body and the body is natural, instinctive and primitive. Every brain is a genius,
containing one quadrillion connections; more than the stars in the Universe. The deep-brain controls all bodily
functions and is the seat of instinct, thought and creativity. The brainstem is the true mind/body connection.
Everything that travels between body to the brain and back traverses this portal.

Brainspotting allows us to work more phenomenologically as we set a frame for the client both relationally and
neurobiologically that allows us to observe and track the client’s process without needing to rely on theories or
assumptions. We do operate, however, from the assumption that the solution resides inside the client as well as the
problem(s) they bring to us.

The Discovery of Brainspotting occurred during a sports performance session with a 16 year old figure skater who
could not master the triple loop, although she had mastered the more challenging triple axel. We targeted the moment
her jump went awry. Covering her right eye she tracked “as smooth as ice.” Covering her left eye the tracking jumped
and then froze at the inside and I instinctively decided to hold her gaze fixed at that point. A torrent of trauma material
poured out for what seemed like many minutes. Despite the weekly 90 minute sessions that we had held for over a
year, the material about her emotional abandonment by her mother, her parents divorce when she was eight and
many injuries on the ice emerged with intense affect. The next day the young skater performed a flawless triple loop in
practice for the first time. I discovered that by holding on the spot, we were able to go deeper and deeper into the
brain until we reached and dismantled the spot at the reflexive core.

This initial discovery was later defined as “Outside Window” after subsequent observation and exploration revealed
that the client’s internally experienced felt sense was also a powerful indicator of Brainspots which was designated as
“Inside Window”.
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I also found that Brainspotting can be done not only with eyes open, “Shades Up” or eyes closed, “Shades Down.”
Closing eyes can provide relief for clients who have been staring at a spot for an extended period of time. Also going
from eyes open to closed and back to open may provide a change of brain state. Clients have reported a qualitative
difference between processing each way and that using both Shades Up and Shades Down is an excellent approach
to obtain thorough and comprehensive processing.

In Brainspotting the potential eye locations are divided into four sections, upper and lower, left and right.

When we communicate directions to our clients, left and right are reversed to avoid confusion. In “Outside
Window” Brainspotting the therapist locates Brainspots through observing the client’s eyes while tracking micro-
slowly, searching for reflexive responses, outside of the client’s awareness or conscious participation. There are a
multitude of reflexive responses include eye twitches, wobbles, freezes, blinks (hard and double blinks), pupil dilation
and constriction, narrowing, facial tics, brow furrowing, sniffs, swallows, yawns, coughs, head nods, hand signals, foot
movement and body shifting. When a Brainspot is stimulated, the deep brain reflexively signals the therapist,
out of the awareness of the conscious mind, that an area of significance has been located.
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Reflexive facial expressions are powerful indicators of Brainspots.

In “Inside Window” Brainspotting the therapist and client participate together to locate Brainspots through the client’s
felt sense of the highest intensity of affect/body distress. Brainspotting can be done with one eye or two. Brainspotting
can be directed at distress and Brainspotting can be directed at resources.

Brainspotting processes down to the reflexive core (my term for the deepest parts of the brain/body that hold the
substrates of experience). Often when it appears one has reached a zero distress level, a new strata or floor is broken
through, probing deeper into the brain. The reflexive core is in the deep, unconscious body brain. It is as out of our
awareness as our respiration, circulation and digestion. Brainspotting dismantles the trauma, symptom, somatic
distress and beliefs at the core. Brainspotting is a “body to body” approach. The distress is activated and located in
the body which then leads to the locating of the brainspot based on eye position. Everything is aimed at activating,
locating and processing the brainspot.

Simplified Focused Activation:

*Activation/Focus
*SUDS Level (10 to 0)
*Location of Distress in the Body
*Locate Brainspot
*Process on Brainspot until 0 SUDs
*Squeeze the lemon and process until 0

“Squeezing the lemon” is a technique for making sure that all remaining distress is processed out. Often times what
appears to be a zero SUDS is revealed to not be when it is challenged. When a client is at a zero SUDS guide them
to “go inside and try to push the distress level as high as you can”. In this way the client is internally scanning for
anything that still holds a charge. Repeat the process until no distress can be elicited.

Basic Outside Window Brainspotting:

1. Choose cause of activation
2. Focus on the activation
3. Take SUDs – Level of intensity (O – no intensity, 10 max intensity)
4. Identify location of activation in the body
5. Slow eye tracking to locate brainspot through blinks, twitches and other reflexive responses.
6. Process on Brainspot until SUDS is 0
7. Squeeze the lemon - process down to a true 0

Inside Window Brainspotting:

1. Choose cause of activation
2. Focus on the activation
3. Take SUDs – Level of intensity (O – no intensity, 10 max intensity)
4. Identify location of activation in the body
 63

5. Find highest activation tracking the X axis horizontally at eye level (left/middle/right)
6. Then track the Y axis (above/below eye) to vertically locate the Brainspot.
7. Process on Brainspot until SUDS is 0
8. Squeeze the lemon and process down to a true 0

Basic Resource Brainspotting:

1. Choose cause of activation
2. Focus on the activation
3. Take SUDs – Level of intensity (O – no intensity, 10 max intensity)
4. Identify location of greatest calm or groundedness in the body (called the “body resource”)
5. Find the location that matches the body resource tracking the X axis horizontally at eye level (left/middle/right)
6. Then track the Y axis (above/below eye) to vertically locate the spot that matches the Body Resource.
7. Process on Brainspot until SUDS is 0
8. Squeeze the lemon and process down to a true 0

Gazespotting
Notice when a client is looking (gazing) unconsciously at a fixed point while talking about relevant, activated material.
Point out that the client is gazing at this spot and encourage them to keep looking at it while not speaking (to initiate
processing) for 30 seconds to 2 minutes (approximately). This will initiate using this gaze spot for full processing of the
issue at hand. Because this is a spontaneous version of BSP, you may not have time to get a SUDs level or body
location of activation. The opportunity may arise during the process but do not force it. Processing should be carried
through until full resolution of issue at hand (assessed by a squeezed lemon zero SUDs).

Brainspotting is most powerful and effective when enhanced by BioLateral Sound CDs. For highly dissociative
and fragile clients, Brainspotting can be initiated without any bilateral intensification, which can be added later as the
client is more integrated and flexible. The healing sound directly enters the brain through the auditory nerves while the
eardrums are vibrated bilaterally. Used at a low audible level, it serves as background sound which most clients report
is calming and grounding (perhaps parasympathetic). The CDs also provide a baseline bilaterality that appears to
work synergistically with the focus of the Brainspot. The sound can be used as continual stimulation throughout the
session, even during the talking part of the session.

More Reflections on Brainspotting

The brain is a supercomputer with one quadrillion (one million billion) connections, responsible for the ongoing
monitoring and adjusting of all our bodily and mental functioning. Accordingly, our conscious awareness of our vast
inner space is as limited as when we gaze at a star-filled night sky – and see a scintilla of the vast universe. However,
this supercomputer is constantly downloading information to us in the form of body sensations, emotions, insights,
thoughts, reflexive actions and reactions. This information is always perfect in content, degree and timing – just what
we need at just the right time.

The problem is that when our miniscule conscious mind catches a glimpse of the mental processes of the vast deeper
recesses of our unconscious mind, we often feel confused, baffled or threatened. The deepest regions of our
unconscious brain/body are devoid of cognition, language and experience. They are knowing, being, reacting,
instinctual processes, survival mechanisms, reflexes and body awareness and processes - the place where we live
and breathe, literally. When our conscious mind does not understand the communication to it by our deeper brain we
feel lost, confused, blocked and threatened. In reality the information is anything but confusing or blocked, except in
the misperception our conscious mind. In reality or truth, the answers are actually embedded within the misperceived
confusion and blocks.

Additionally, some of this information is uncomfortable or downright painful, which leads us to try to avoid it by
denying, ignoring or suppressing it. This undermines our natural moment-to-moment release process and accordingly
results in confusion, symptoms and maladaptive behavior. The solution is actually quite simple: “mindfully observe
with curiosity, give yourself time and space, and see what happens.” Reacting (downloading information) is our
natural way of experiencing, processing and releasing experience. We tend to experience our reactions as the
 64

problem, yet in actuality the problem is our reactions to these reactions. This phenomenon inhibits our processing
through and releasing our reactions, especially on a somatic level. Reacting to our reactions results in stuckness,
negative spiraling, misperception – it is unnatural. It is the difference between tracking (following) vs. distracting (and
confusing). Processing, which is a focused form of mindfulness, is the experimental exploration by our conscious
mind; the destination is always unknown.

We tend to assume that all memories reach consciousness. Most actually do not, evaporating like the meteorites that
burn up in the earth’s atmosphere before they come close to reaching the surface. Thus our conscious mind holds a
miniscule fraction of our awareness.

Physics is seen as underlying physiology and unconsciously affecting all aspects of the human experience and in the
Brainspotting process as well. The science of matter and energy and of interactions between the two, grouped in
traditional fields such as acoustics, optics, mechanics, thermodynamics, and electromagnetism, as well as in modern
extensions including atomic and nuclear physics, cryogenics, solid-state physics, particle physics, and plasma
physics. The study of the natural or material world and phenomena has been called natural philosophy. The core of
our experience is physiological. This flows into the existential (philosophical) which flows into the psychological (the
last stop in the existential flow). Accordingly physics is seen as underpinning the phenomenon of Brainspotting and
worthy of attention, exploration and discussion. The rapid change that occurs at times in BSP could be considered as
a quantum leap (an abrupt change or step, especially in method, information, or knowledge).

REFERENCES FOR BRAINSPOTTING

Anderegg, J. Effective treatments for generalized anxiety disorder. (2016) In press

Corrigan, F., Grand, D. Brainspotting: Recruiting the midbrain for accessing and healing sensorimotor memories of
traumatic activation. Medical Hypotheses 80 (2013) 759-766. www.elsevier.com/locate/mehy.

Corrigan, F., Grand, D., Raju, R. Brainspotting: Sustained attention, spinothalamic tracts, thalamorcortical processing,
and the healing of adaptive orientation truncated by traumatic experience. Medical Hypotheses 84 (2015) 384-394.
www.elsevier.com/locate/mehy.

Grand, D. (2001) Emotional Healing at Warp Speed: The Power of EMDR. New York: Harmony Books.

Grand, D. (2011) Brainspotting, a new brain-based psychotherapy approach. Trauma & Gewalt, issue 3: 276-285

Grand, D. (2013) Brainspotting: the revolutionary new therapy for rapid and effective change. Sounds True, Louisville,
CO

Grand, D., Stemmler, M., Hildebrand, A. (2014) A preliminary study of the efficacy of Brainspotting – a new
therapy for the treatment of Posttraumatic Stress Disorder. Journal for Psychotraumatology, Psychotherapy
Science and Psychological Medicine.

Patricia FM, Jose FP, de F and Marcelo M. ,Persistent Genital Arousal Disorder as a Dissociative Trauma Related
Condition Treated with Brainspotting – A Successful Case Report. International Journal of School and Cognitive
Psychology (2015) S1:1.

Porges S. (2003) The Polyvagal Theory: phylogenetic contributions to social behavior. Published in Physiology &
Behavior, 79, 503-513.

Porges S. (1995) Orienting in a Defensive World: Mammalian Modifications of our Evolutionary Heritage. A Polyvagal
Theory. Psychophysiology, 32, 301-318.
 65

Schmidt, R. et al. Newtown Sandy Hook Community Foundation: Report of Findings from the Community Survey
September 2016

Stemmler, M., Grand, D., Hildebrand, A, Brainspotting – the efficacy of a new therapy approach for the treatment of
Posttraumatic Stress Disorder in comparison to Eye Movement Desensitization and Reprocessing. Mediterranean
Journal of Clinical Psychology. MJCP VOL 5 N.1 (2017).

Scaer, R. (2005) The Trauma Spectrum, Hidden Wounds and Human Resiliency. New York: Norton Books.

Wolfrum, G., et al. Trauma Zeitschrift fur Psychotraumatologie und ihre Anwendungen. Issue 3- (2017). Brainspotting.
www.asanger.de
66
 67

Report of Findings from the Community Survey

September 2016
The mission of the Foundation is to devote itself to furthering and supporting operations and activities which address
the short-term and long-term unmet needs of individuals and the Newtown community arising from the tragic events at
Sandy Hook Elementary School on December 14, 2012.

This report has been prepared and released by the Distribution Committee of the Sandy Hook
School Support Fund based on solicitation of public input into the current individual and
community needs as it relates to the tragedy on 12/14/12.
The Distribution Committee is comprised of nine Sandy Hook/Newtown residents who represent
perspectives from many different impacted groups including victims, surviving children, surviving
teachers, emergency responders, Sandy Hook parents, community members, and the faith
community. It is the responsibility of the Distribution Committee to solicit public input in order to
better understand the needs and gaps that exist in the community as well as the strengths so that
they can be built upon for long-term sustainable recovery.
For background on the history and formation of the Newtown-Sandy Hook Community
Foundation, Inc. and the Sandy Hook School Support Fund or information about funds spent to
date please visit www.nshcf.org.

Methodology
This year the Foundation chose to utilize a statistical methodology in the community assessment to
have a better understanding of correlations between groups of individuals and how best to provide
services and assistance to those groups. An anonymous on-line survey was released to the public on
May 10, 2016 and remained open until June 9, 2016. The survey was disseminated through the
Newtown Public Schools (Superintendent’s office), the Newtown Bee (May 12th), the Danbury
News Times (May 26th), social media, and the internal distribution lists of the Foundation. The
survey generated 945 responses compared to 999 in 2015 and 1,633 in 2014. It is understood by the
Distribution Committee that this survey represents only a small percentage of the overall
community. Input is continuously sought through on-going dialogue with community groups and
individuals.

Key Findings
The survey focused on better understanding the strengths of the community, what has been helpful
in the 12/14 recovery, what barriers or challenges remain, and what impact the tragedy continues to
have on various segments of the community.

Data from the survey is presented in the following pages using charts and visual graphics to depict
the results in order to help the reader get an overall sense of the responses. A summary of findings
and analysis can be found at the end of the report.
 68

Demographics

Gender Age
1%
5% 2%
18-20

26% 16% 21-29

Female 30-39
31%
Male 40-49
74%
50-59
45%
>60

Survey Respondents Note – respondents were able to select up to three

Response Response
categories in which they identified themselves (i.e. parent as well as a teacher or Percent Count
clergy as well as concerned member of the community, etc.).
Family member of a child or adult who died on 12/14/12 1.6% 15
Parent of a child enrolled at Sandy Hook School on 12/14/12 15.2% 144
Parent of a child enrolled in another Newtown schools (public or private) on
54.8% 518
12/14/12
Parent who did not have children enrolled in a Newtown school on
12/14/12 (i.e. children too young, already graduated, enrolled in a school out of 18.0% 170
district/in another community, moved to community since 12/14, etc)
Teacher or staff member employed at Sandy Hook School on 12/14/12 3.6% 34
Teacher or staff member in another Newtown school (public or private) on
16.2% 153
12/14/12
Police (Newtown PD, State, or other responding community) 1.0% 9
Fire (Newtown or other responding community) 1.2% 11
EMS (Newtown Volunteer Ambulance Corps, Danbury or other responding
1.1% 10
community)
Other responding professional on 12/14 (medical, crisis responder) 0.6% 6
Faith Community (clergy) 0.3% 3
Administrator, Public Official, or Town Employee 6.1% 58
Mental Health or other Community Service Provider 2.9% 27
Spouse, parent, or child of an adult witness/survivor (teacher, emergency
2.6% 25
responder)
Member of the Business Community (employee/employer Newtown/Sandy
5.2% 49
Hook)
Resident of the Newtown/Sandy Hook community that does not fit any of
5.2% 49
the other criteria (i.e. this is the only applicable answer for this questions)
Other (please specify) 72
answered question 945
skipped question 0
 69

% who have participated in % who report feeling connected to

community events and/or activities the Newtown/Sandy Hook
related to 12/14 over the past year. community.
Somewhat Very
untrue untrue
Very
2%
untrue Neutral 4%
Somewhat 15% 9%
untrue
8% Very true
34% Very true
Somewhat 53%
Neutral
true
14% Somewhat 32%
true
29%

*It is noteworthy that family members of loved

ones killed on 12/14 reported not feeling
connected to the community. They were the only
subgroup that showed this statistical correlation.

Number of individuals indicating why they have not participated in

community activities or events

347
225
175 154 139

Not aware of programs Programs not offered at Felt like program was Programs offered were Felt uncomfortable
convenient times not for me but someone not of interest to me interacting with certain
more impacted groups or organizations

There was statisical significance with the families who had loved ones killed on 12/14/12 feeling
uncomfortable with certain groups. This was also true for parents of students enrolled at SHS and
teachers & staff from SHS. SHS parents showed statistical significance with feeling the programs
were not of interest but did feel, along with SHS staff, that the events were designed for their level
of impact.

Number indicating their reluctance to discuss or deal with the

12/14 tragedy
Very untrue 344
Somewhat untrue 193
Neutral 154
Somewhat true 171
Very true 31 3
0 50 100 150 200 250 300 350 400
 70

Number stating which of the services surveyed would they or their

family benefit from OR that they believe would be most important
to support through designation of funds or community efforts
1st Priority
133

73
63
53 55
49
42
37
20 23

Are there services, programs, or funds (or gaps in those areas) that you would like to see
available for a specific purpose that aren't listed in the previous question?

This narrative question generated 109 responses that were very diverse. Despite the variety of
comments, there were two themes that emerged.
 One involved parenting and teaching in a post-tragedy community. Respondents felt that
parents and teachers needed to be better equipped to address anxiety and behavioral
concerns of children/students.
 Another theme that emerged was the idea that the needs of those in the community who
were not directly involved or at Sandy Hook on 12/14 have been largely ignored. This is
supported by past surveys that have indicated that those who weren’t directly impacted
feel guilty about their symptomatology. As one respondent wrote, “Programs for those on the
periphery of this tragedy. I believe there is an entire group of silent sufferers. Those that aren’t directly
impacted by this tragedy but live here and feel the weight of this community’s tragedy. We don’t feel
worthy to speak up because we know there are people suffering far beyond us. We grieve in silence. We
push past our anxiety and fears alone. Creating a forum for this sub set of community members would be
beneficial. It should be promoted specifically to us to give the “permission” to attend.”
 71
% of individuals citing barriers to accessing the help or
support they or a family member has needed

Yes
22%

Not Applicable
43%
No
35%

Number reporting barriers to accessing services or support

N/A - have not experienced barriers
50

Guilt over asking for support, services or resources

46

Not ready to reach out for help

13

Stigma related concerns

12

The treatment I need or has been recommend does not

exist in my community 8

Lack of ease of access to services

34

Lack of awareness or understanding of funding support

available 39

Lack of awareness or understanding of services available

45

Financial -reduced income through loss of work time or

loss of business due to 12/14 18

Financial-treatments received or recommended are not

covered by insurance or the funds available to the public 42

Financial – treatments received have been covered by

insurance but there are still significant out of pocket … 63

0 10 20 30 40 50 60 70

Barriers experienced to accessing services were noted to be statistically significant for family
members of adults/children who were killed and parents of children enrolled at Sandy Hook School.
 72

Brain Health & Wellness Services

This year we asked a series of questions to get a better understanding of the types of
therapeutic interventions used by respondents and the efficacy of the treatment.

% of respondents reporting effectiveness of various types of

therapeutic interventions for themselves
Very Effective Effective Somewhat Effective Not At All

Brain Spotting (n=22) 59.09 9.09 18.18 13.64

MNRI (n=22) 40.91 27.27 22.73 9.09

Somatic Experiencing (n=5) 40 0 20 40

Equine Therapy (n=18) 38.89 38.9 5.56 16.67

EFT/Tapping (n=48) 37.5 15.58 29.17 18.75

Play Therapy (n=9) 33.3 33.3 22.22 11.11

EMDR (n=54) 31.48 12.96 33.3 22.2

Aromatherapy (n=41) 26.83 26.83 39.02 7.32

TF-CBT (n=34) 26.5 20.6 44.12 8.82

Reiki (n=19) 26.32 31.58 31.58 10.53

Traditional Talk Therapy (n=223) 25.11 36.77 34.98 3.14

Music Therapy (n=17) 23.53 29.41 35.29 11.76

Art Therapy (n=30) 23.33 30 33.3 13.33

Acupunture (n=32) 15.63 25 21.88 37.5

Exposure Therapy (n=2) 0 50 0 50

Neurofeedback (n=9) 0 33.3 44.4 22.2

 73

% of respondents reporting effectiveness of various types of

therapetuic interventions for their children
Very Effective Effective Somewhat Effective Not At All

Equine Therapy (n=23) 39.13 30.43 17.39 13.04

TF-CBT (n=43) 34.88 23.26 34.88 6.98

MNRI (n=15) 33.3 13.33 26.67 26.67

Brain Spotting (n=19) 31.58 21.05 21.05 26.32

Music Therapy (n=30) 30 16.7 43.3 10

EMDR (n=32) 28.13 9.38 34.38 28.13

Aromatherapy (n=25) 28 24 28 20

EFT/Tapping (n=29) 27.59 13.79 24.14 34.48

Art Therapy (n=74) 24.32 28.38 39.19 8.11

Play Therapy (n=46) 21.74 26.09 41.3 10.87

Traditional Talk Therapy (n=191) 21 29.32 42.9 6.8

Neurofeedback (n=20) 15 20 40 25

Reiki (n=9) 11.11 11.11 55.56 22.2

Somatic Experiencing (n=3) 0 33.33 66.67

Exposure Therapy (n=2) 0 100

Acupunture 0 30 70
 74

Respondents were asked if they were in any kind of treatment and have stopped, why they
stopped.

Number of individuals citing reasons for discontinuing therapy/treatment

I did not feel my provider had the proper training for my

15
situation
I met my therapeutic goals & was discharged from therapy
35
as a collaborative decsion between myself & my therapist

I did not think the therapy I was receiving was helping me 41

Scheduling & logistics became difficult 52

My therapy became financially burdening 61

I was feeling better and did not feel like I needed to

86
continue

0 10 20 30 40 50 60 70 80 90 100

There was statistical significance for Sandy Hook staff/teachers discontinuing services due to
scheduling and logistical difficulties’, feeling that therapy was not helping, and that the provider did
not have proper training for their situation. For parents of children enrolled in Sandy Hook on
12/14 there was statistical significance for discontinuing services in 4 out of the 6 categories listed
above (everything except believing that therapy was not helping and that providers were not
properly trained). No other groups showed statistically significant correlation.

Qualitative analysis of treatments that have allowed for healing to take place were those that were
supportive via group therapy, talk therapy with a judgment free therapeutic relationship,
transcendental meditation/yoga, and brain based therapies such as Brainspotting, neurofeedback, and
EMDR. Analysis of treatments that have not been helpful were talk therapy where it became a place
to ‘vent’ and not necessarily resolve trauma issues, inconsistent therapy, poor therapeutic alliance,
therapist not being a good fit, provider lacking trauma training, lack of experience working with
children, a need for group therapy, and not receiving enough feedback from therapists.

It is important to note that while many non-traditional treatments were listed among the most
helpful, there is a gap in the number of clinicians who are trained to provide such modalities. It may
be prudent to do further investigation into some of the treatments listed and invest in building
resource capacity for those that prove efficacious.
 75

Respondents were asked to rate their symptomatology directly related to 12/14. Anxiety, stress,
excessive fear/worry, and anger continue to persist with the most frequency. These symptoms were
also reported by clinicians of their clients in a separate survey. There was higher statistical
correlation for nearly every category for populations most directly impacted (parents of children
enrolled at SHS, SHS staff/teachers, and family members of loved ones killed).

Number of individuals citing the following symptoms

To a great extent Somewhat Very little Not at all

Anxiety 210 273 170 100

Stress 149 224 177 195

Fear or excessive worry 138 238 184 191

Anger 101 296 206 142

Sleep related issues 93 157 151 345

Feelings of helplessness 88 211 167 278

Depression 77 227 168 278

Difficulty concentrating 75 205 183 279

Guilt 64 148 167 367

Decreased work/school performance 59 154 213 316

Relationship stress 53 134 149 407

Loss of social connections/friendships 40 110 149 447

Social withdrawl/isolation 35 110 140 458

Loss of interest or pleasure in things 33 121 154 433

Eating problems 32 92 84 538

Increased use of alcohol or drugs 26 59 87 572

Loss of work or income 25 31 74 610

Physical complaints 22 89 113 520

Divorce/Separation 2118 33 671

Regressive behaviors 18 46 63 616

Self-harming thoughts/behaviors 1227 57 647

 76

Conclusion & Recommendations

The use of statistical analysis this year underscored the importance of using data to examine community
needs and make informed decisions about funding and programming. The Committee was pleased that
the assessment validated decisions previously made, such as the importance of supporting a wide range
of trauma treatments and recovery services, including those considered by some to be ‘non-traditional’.

The Foundation is currently leading an effort to get systems and organizations within Newtown to
develop and implement more effective data monitoring systems. Such systems would allow the
Foundation, and others, to have a better understanding of aggregate trends with impacted populations
throughout the community and respond accordingly. As recently reported by New York University
(NYU) in a study of the community, “data monitoring systems, particularly if integrated across a network of
providers, can create coordinated services, reduce inefficiencies, document progress, and be used for continual learning and
quality improvement. The absence of regular data tracking on services delivered and outcomes associated with specific services
interferes with quality improvement efforts. The creation of a shared data monitoring system across agencies would strengthen
the coordination and cohesiveness of the network. This should also be a tool used by the collaborative oversight coalition to
monitor the community’s progress towards shared goals.” Therefore, the Foundation sees this survey as just
scratching the surface on what we can learn about how the community and those impacted by the
tragedy are doing and what we can do to best support on-going recovery and community health.

The Distribution Committee will use the information in this survey along with continued research into
best practices to make the best decisions possible while always upholding donor intent, the mission of
the Foundation, and being compliant with IRS regulations governing non-profit organizations.

To date the Distribution Committee has been focused on using the resources of the Sandy Hook School
Support Fund to assist individuals and the community as a whole based on continuous public input and
on-going research. That has included the following;
 Individual Brain Health & Wellness – providing direct financial support to meet as many
individual brain health & wellness needs and requests as possible.
 Grants Program – providing grants into the community to build capacity for long term
recovery, expand access to alternative trauma treatments, host conferences and workshops to
build knowledge and tools for helping, and develop opportunities to build compassionate and
caring connections throughout the community.
 Community Events – supporting and sponsoring events in the community that provide
opportunities to learn, share, and connect with one another.

We appreciate all of those who participated in this important survey and ask that you continue to
provide feedback through both formal and informal opportunities so that we can be as responsive as
possible to the needs that exist in our community. Committee members, as well as executive director
Jennifer Barahona, are available to meet with individuals and small groups on an on-going basis to solicit
additional feedback. If interested please contact Ms. Barahona at 203-460-0687 or [email protected]
to arrange a time to meet.

Respectfully,
Members of the Sandy Hook School Support Fund Distribution Committee

Dr. Robert Bazuro Cindy Mattioli Bob Schmidt (Chair)

Jennifer Clark Rev. Rob Morris James Viadero
Kevin Cragin Anka Roberto Joeline Wruck
 77

MJCP
Mediterranean Journal of Clinical Psychology MJCP

ISSN: 2282-1619

VOL 5 N.1 (2017)

Brainspotting – the efficacy of a new therapy approach for the

treatment of Posttraumatic Stress Disorder in comparison to
Eye Movement Desensitization and Reprocessing

Anja Hildebrand1, David Grand2, Mark Stemmler1

1
Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
2
Trainer and developer of Brainspotting, psychotherapeutic practice in New York City, USA.

Email Corresponding author: [email protected]

Abstract
Objective: This study aims at determining the efficacy of the new
therapy approach Brainspotting (BSP) in comparison to the established
Eye Movement Desensitization and Reprocessing (EMDR) approach for
the treatment of Posttraumatic Stress Disorder (PTSD). Method: The
sample consisted of 76 adults seeking professional help after they have
been affected by a traumatic event. Clients were either treated with three
60-minute sessions of EMDR (n=23) or BSP (n=53) according to a
standard protocol. Primary outcomes assessed were self-reports of the
severity of PTSD symptoms. Secondary outcomes included self-
reported symptoms of depression and anxiety. Assessments were
conducted at pretreatment, posttreatment and 6 month after the
treatment. Results: Participants in both conditions showed significant
reductions in PTSD symptoms. Effect sizes (Cohen’s d) from baseline
to posttreatment concerning PTSD related symptoms were between 1.19
- 1.76 for clients treated with EMDR and 0.74 - 1.04 for clients treated
with BSP. Conclusion: Our results indicate that Brainspotting seems to
be an effective alternative therapeutic approach for clients who
experienced a traumatic event and/or with PTSD.
 78

HILDEBRAND, GRAND et al.

Keywords: Posttraumatic stress disorder, therapy research, treatment

efficacy, Eye Movement Desensitization and Reprocessing,
Brainspotting

Introduction
Posttraumatic Stress Disorder (PTSD) is defined as “a delayed or
protracted response to a stressful event or situation (of either brief or
long duration) of an exceptionally threatening or catastrophic nature,
which is likely to cause pervasive distress in almost anyone” (World
Health Organization, 1992, p. 147). In general, the range for lifetime
PTSD lies between a low of 0.3% in China to 6.1% in New Zealand
(Kessler & Üstün, 2008). Current past year PTSD prevalence was
estimated at 3.5% (Kessler, Chiu, Demler, Merikangas, & Walters,
2005), with 1.8% among men and 5.2% among women (National
Comorbidity Survey, 2005). The prevalence of full or partial PTSD in
the primary care medical setting is reported with 12% of the primary
care attendees (Stein, McQuaid, Pedrelli, Lenox, & McCahill, 2000).
The presence of PTSD is positively correlated with higher levels of
health-related problems (Schnurr & Green, 2004) and lower levels of
functioning (Thorp & Stein, 2005). Moreover, PTSD is often a
persistent and chronic disorder (Perkonigg et al., 2005). Thus, effective
treatments for PTSD are needed.
There are different treatment approaches to reduce the symptoms of
PTSD. Some already existing approaches were specially modified for
the treatment of traumatic experiences, e.g., trauma-focused cognitive-
behavioral therapy (Benkert, Hautzinger, & Graf-Morgenstern, 2008).
Others are developed primarily for the treatment of PTSD, e.g., Eye
Movement Desensitization and Reprocessing (EMDR, Shapiro, 2001),
Narrative Exposure Therapy (NET, Schauer, Neuner, & Elbert, 2011) or
Brainspotting (BSP, Grand, 2013).
In an early meta-analysis by van Etten and Taylor (1998), the most
effective drug therapies as well as the best psychological therapies,
namely EMDR and behavior therapy, were found equally effective.
Later, at least four other meta-analyses confirmed that EMDR is
empirically proven to be the best treatment for PTSD in addition to the
cognitive-behavioral therapies (Bisson & Andrew, 2007; Bisson,
Roberts, Andrew, Cooper, & Lewis, 2013; Bradley, Greene, Russ,
Dutra, & Westen, 2005; Maxfield & Hyer, 2002; Seidler & Wagner,
2006).
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Primary aims of the present study were to compare the efficacy of Brainspotting
with the established EMDR-therapy and to detect areas of significant
change or lack of change (program evaluation). Outcomes assessed
were the severity of PTSD symptoms as well as the symptoms of
depression and anxiety.

Methods
Design and Sample
The data for this multicenter longitudinal study were collected by
independent psychotherapists in Germany, the United States of
America, Austria, Switzerland and Italy. The therapists were previously
informed about the study by mail or during EMDR and BSP trainings. If
the therapists were interested in participating, they were instructed by
mail and/or phone and then received a package with all study material.
The treatment and data collection was carried out by 27 experienced
trauma therapists. There was a pre-determined standard protocol for
both EMDR and BSP, which the therapists had to follow during their
treatment. Therapists were licensed therapists who were fully educated
in EMDR through an accredited training facility and they had at least
completed the Phase I training in Brainspotting. Thus, clients were able
to choose whether they would be treated with the established therapy
approach EMDR or the new therapy approach BSP. In case the client
chose BSP and the therapy outcome was not satisfactory, he/she had the
right to receive additional EMDR sessions. None of the clients have
taken up this offer.
Data was collected before the first therapy session, after one week after
the third therapy session and after about half a year (M=6 month; range:
2-12 month, with 69% were conducted after 5, 6 or 7 month). The
sample is composed of 76 consecutive clients (79% female; mean age
42.0 years) starting their therapy between 2009 and 2015. The inclusion
criteria were: a) adult clients aged 18 and over; b) the client have either
experienced a traumatic situation and / or suffer from a posttraumatic
stress disorder or acute stress disorder; and c) the client gives his written
consent to participate in the study. The client was deemed not eligible
for the study when the treatment already included more than the
preparatory sessions. Between the posttest and the follow-up assessment
no treatment of the trauma under focus was applied. Only counseling or
supportive sessions were possible and if needed another trauma might
be treated. Finally we collected data of 53 clients treated with BSP and
23 clients treated with EMDR. The study was reviewed and approved
by an ethics committee of the University of Bielefeld. Informed consent
was obtained from all research participants being involved in this
research after the study and the procedures were explained.
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Treatment
The Therapy Approach Eye Movement Desensitization and
Reprocessing (EMDR). EMDR was developed by Francine Shapiro
(2001). It is a well-established therapy for the treatment of PTSD or
other trauma associated diseases. EMDR consists of eight phases, from
which phases three to six are original EMDR stages. After establishing a
good therapist-client relationship and after the introduction of relaxation
techniques or other stabilization techniques, the client is asked to re-
experience the traumatic situation while focusing on the therapist’s
finger tips which are moving on a horizontal axis in front of his or her
eyes. In a safe environment and as part of a good therapeutic
relationship, the client relives the traumatic situation and reprocesses the
feelings, emotions, cognitions and body sensations connected to the
trauma (Schubbe, 2006).
The Therapy Approach Brainspotting (BSP). BSP is a
psychotherapeutic model discovered in 2003 by David Grand, Ph.D..
Grand has conceptualized BSP as brain-wise and body-aware relational
attunement process. In this context he has developed the model of the
Dual Attunement Frame. The foundation of this model is the
articulation of the attuned, relational presence of the therapist with the
client. This relational attunement is seen as being both focused and
deepened by the neurological attunement derived from observing and
harnessing different aspects of the visual orienting reflexes of the client
(Corrigan & Grand, 2013).
By slow eye tracking, either with one eye or with two eyes, locations for
BSP are identified. To find these locations, the techniques of either
“Inside Window“ or “Outside Window” can be used. The “Inside
Window” utilizes the client’s felt sense, the “Outside Window” helps to
locate this location by observation of clients’ reflexive response such as
blinks, eye twitches or wobbles or quick inhalation, by the therapist.
Once the therapist and client determine together the Brainspot, the client
is directed to maintain their fixed visual attention on the position and
mindfully observe their internal process. In BSP this is called Focused
Mindfulness as the mindfulness that ensues occurs in a state of Focused
Activation. The Focused Mindfulness ensues, with the therapist closely
and openly following along until the client comes to a state of
resolution.
BSP is a focused treatment method that works by identifying,
processing and releasing core neurophysiological sources of
emotional/body pain, trauma, dissociation and a variety of other
challenging symptoms (Grand, 2011). In BSP, the therapist is
encouraged to openly follow the client’s process with no assumptions.
The therapist is guided to trust the innate human neurological capacity
for self-regulation given optimal conditions. In this context, the BSP
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therapist also guides the client to become brain-aware through ongoing
opportunities for psycho-education. For a more detailed description of
BSP, the reader may consult Grand (2013). The standardized protocol
determines the usage of “two eyes” and the “Inside Window”.
First results indicate that Brainspotting could be an effective therapy
approach for the treatment of clients having experienced traumatic
experiences and clients with generalized anxiety disorder (Anderegg,
2016; Hildebrand, Stemmler, & Grand, 2015; NSHCF, 2016).

Measures
PTSD and symptom severity. To screen the clients for the presence of
PTSD and to assess the symptom severity and functioning of the clients
the Posttraumatic Diagnostic Scale (PDS; Ehlers, Steil, Winter, & Foa,
1996; Foa, Cashman, Jaycox, & Perry, 1997) was administered. The
PDS has 49 items. It includes a 12 item checklist identifying potentially
traumatizing events experienced by the respondent. Respondents then
indicate which of these events has troubled them most in the last month.
To determine whether the DSM-IV stressor criteria are met, the
response to this event at the time of its occurrence should be rated.
Clients then rate 17 items representing the cardinal symptoms of PTSD
experienced in the past 30 days on a four-point scale (0-3). In the last
part respondents indicate the level of impairment caused by their
symptoms across nine areas of life functioning. By adding up the scores
of the corresponding items, the symptom severity for the three subscales
re-experiencing (5 items), avoidance/numbing (7 items) and
hyperarousal (5 items) is calculated. The total symptom severity score is
obtained by adding up the responses of selected items and ranges from 0
to 51 (1-10 = mild, 1-20 = moderate, 21-35 = moderate to severe, > 36 =
severe).
Additional mental impairment. Additional mental impairment was
investigated through the Hospital Anxiety and Depression Scale
(HADS; Zigmond & Snaith, 1983). This self-rating scale measures
states of depression and anxiety and features seven questions for anxiety
(HADS-A) and seven for depression (HADS-D). The respondent rates
each item on a four-point scale. The scores for the subscales range from
0 to 21.
Demographic data. Data included sex, date of birth, marital status, place
of residence, socioeconomic status (0=low, 1=average, 2=high),
traumatic experience (item “How would you describe the client’s
trauma?”) with a five point rating scale with the response categories
from 1 (minor) to 5 (major) and ICD-10/DSM-IV diagnosis of the
client.

Data Analysis
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HILDEBRAND, GRAND et al.

Analyses were conducted using SPSS 23. Independent samples t-tests and
χ2-analyses were conducted to determine whether there were

statistically significant differences between the means of those treated with

BSP and those treated with EMDR on the demographic variables. We used
univariate two factor analysis of variance (ANOVA) with repeated measures
and χ2-tests to assess treatment effects. Effect sizes were calculated according
to Cohen’s (1988) d statistic. For each scale of the PDS and HADS and for
each treatment group the magnitude of change from pre-to posttest, from pre-
to follow-up and from posttest to follow-up was defined as (M1-
M2)/SDpooled, where SDpooled = [(SD12+SD22)/2]1/2. Positive effect sizes
represent improvements in PTSD and other symptoms (depression, anxiety).
Negative effect sizes indicate a worsening of symptoms. The sample sizes for
the different items vary slightly due to missing data.

Results

Demographic Data and Traumatic Experiences

Demographic data. Results of χ2- and t-test analyses comparing those treated
with BSP and those treated with
EMDR indicated no statistically significant differences regarding gender, age,
family status and PTBS diagnosis –
except place of residence (Table 1).

- Table 1 – Appendix 1

Traumatic experiences. Both groups of clients most frequently listed as the

worst traumatic experience an event that is not explicitly mentioned in the PDS
(EMDR: 48%, BSP: 37%, examples: working with death bodies, psychological
abuse). Accidents were marked by 17% of the clients treated with EMDR and
23% treated with BSP. Sexual assault by someone known was listed by 22% of
the EMDR clients and 18% of the BSP clients. The other traumatic events were
each marked by less than 10% of the client group. Differences between groups
concerning the worst traumatic event were not statistically significant (χ2 [9, N =
75] = 5.11, p = .825).

Outcome Measures
PDS. Table 2 summarizes the means and standard deviations of the PDS for the
pretest, posttest and follow-up for both treatment groups. The results of the
univariate two factor analysis of variance (ANOVA) with repeated measures and
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BRAINSPOTTING
the effect sizes are also listed. We found a significant time effect in all four scales of
the PDS, showing a decrease in the reported symptoms for both treatment

groups. We did not find a significant interaction effect, revealing no significant

differences between the groups concerning the decrease of symptoms. Pre-follow-
up effect sizes for the measures of PTSD symptoms for both EMDR (d = 1.11 -
2.12) and BSP treatment (d = 1.06 - 1.36) were high. The same applies to pre-post
effect sizes for EMDR (d = 1.19 - 1.76) and BSP (d = 0.74 - 1.04).

- Table 2 – Appendix 2

HADS. Results for the HADS are presented in table 3. Clients treated with
EMDR as well as clients treated with BSP reported a significant decline in
symptoms of anxiety and depression. The between groups tests indicate that the
variable treatment group is not significant for both scales. Moreover, the
interaction of time and group is not significant which means that the groups are
not changing in different ways over time.
Pre-follow-up effect sizes for the HADS were high.

- Table 3 – Appendix 3

Discussion

We aimed to investigate a comparison between treatment outcomes in clients

treated with EMDR and BSP. The latter is a new psychotherapy approach which
theorizes that the field of vision can be used to locate eye positions that correlate
with relevance to inner neural and emotional experience (Grand, 2011). With a
growing recognition of BSP as an alternative treatment approach for PTSD, this
study helps to support the need for the evaluation of treatment efficacy.
We found that clients treated with BSP weren‘t more impaired than clients
treated with EMDR in the variables under consideration. Brainspotting seems to
be an effective therapeutic approach for clients who experienced a traumatic event
and/or with PTSD. Additionally, BSP seems to be as effective as EMDR in many
areas under examination (cardinal symptoms of PTSD, anxiety and depression).
In this vein, our study supports the results of Sack et al. (2016) who compared
dual attention, eye movements, and exposure only during EMDR in a randomized
clinical trial. The use of eye movements as a dual-attention task had no additional
treatment effects compared to visual fixation on a nonmoving hand. The pre-post
effect sizes for the EMDR treatment group in our study are comparable to other
findings (Bradley et al., 2005; Maxfield & Hyer, 2002; van Etten & Taylor,
1998), where effect sizes for pre- versus post-treatment comparisons range
between -.50 and 2.22. Even though the pre-post effect sizes for BSP were
apparently a bit smaller, there was no significant difference between groups
concerning the treatment outcome in either of the scales.
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HILDEBRAND, GRAND et al.

Our study had a longitudinal and quasi-experimental design with two
equivalent comparison groups. According to the Maryland Scientific Method
Scale (SMS; Sherman et al., 1997), which evaluates the methodological quality of
studies, our study is positioned at level 3 on a 5-point scale. The authors indicate
that confidence in the results is highest at level 5 and level 3 is required to achieve
reasonably accurate results. As differences between groups were analyzed and not
statistically significant, threats to internal validity were minimized. For example,
regression towards the mean (Stigler, 1997) could be precluded, as there were no
group differences for example in the trauma severity score at pretest.

Limitations of the Present Study

Although improvements in symptoms of PTSD have been observed with BSP,
we can only state preliminary conclusions on the benefits of this intervention due
to the relatively small sample size. Thus, more research with larger samples is
needed to replicate our results.
Another limitation of this paper is that we did not use a randomized trial. As
randomized controlled trial is often considered the gold standard in evaluating
treatment efficacy (Misra, 2012), we also thought about using this design. Due to
organizational and ethical issues (Edwards et al., 1998; Sullivan, 2011), we
decided that clients should have the possibility to choose whether they are treated
with EMDR or BSP.
Both, EMDR and BSP were successful in treating clients with traumatic
experiences. Therefore, the common factors in the two treatment approaches and,
in general, for all effective trauma therapies should be taken into consideration
(Wampold, 2015). Both treatments start with the anamnesis and therapy planning
(Schubbe, 2014). In both treatments, the personality and particular attributes of
the therapist, the therapeutic relationship, the need of establishing personal safety
and stability, and the reprocessing of the traumatic experience could have for
example affected treatment outcome. In our study we did not focus on these
moderators of treatment outcome. In sum, the development of trauma treatment
methods include more and more resource orientation, and BSP follows this
overall direction (Schubbe, 2016).

Conclusions and Future Prospects

To conclude, our study supports the use of BSP to treat subjects who show
symptoms of PTSD. Thus, BSP seems to be an alternative treatment approach for
clients with PTSD. More research is needed to replicate our results and to
evaluate effects in different samples, e.g., clients with substance use disorders and
comorbid PTSD. Moderator analyses are necessary to further evaluate the
contribution of BSP to the treatment of PTSD. Further studies should also analyze
the potential usefulness of BSP with other diagnostic measures like the Clinician-
Administered PTSD Scale for DSM-5 (CAPS-5, Weathers et al., 2013).
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Appendix 1
Tab. 1. – Comparisons of Demographic information of treatment groups.

BSP EMDR
(n = 53) (n = 23)
M or n SD or % M or n SD or % χ2 or t

Gender (female) 41 77.4 19 82.6 .27

Age (years) 43.43 12.30 38.74 12.90 -1.51
(range: 22-69) (range: 19-58)
Marital status 7.00
Married 19 36.5 26

Engaged 1 1.9 0

Cohabitating 12 23.1 13

Divorced 8 15.4 22

Single 12 23.1 30

Other 0 0 9

Place of residence 13.63**

Germany 33 62.3 14 60.9

USA 20 37.7 4 17.4

Austria 0 3 13.0

Switzerland 0 1 4.3

Italy 0 1 4.3

Socioeconomic status 0.63

Low 26 23

Average 65 62

High 9 15

Trauma severity 4.78 3.72 4.22 0.85 -0.72

score (range: 2-5) (range: 2-5)
PTSD diagnosis by .04
therapist a
Simple PTBS 21 42.9 10 45.5
Complex PTBS 28 57.1 12 54.5
PTSD diagnosis by 29 54.7 15 65.2 .725
PDS (yes)
Additional diagnosis 23 43.4 8 34.8 .49
(yes)
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Note. BSP = Brainspotting; EMDR = Eye Movement Desensitization and Reprocessing. aBSP: N=4
missing, EMDR: N=1 missing. * p < .05. ** p < .01. *** p < .001.

Appendix 2

Tab. 2. – PDS. Univariate two factor analysis of variance (ANOVA) with repeated
measures and effect sizes

Pre Post FU ANOVA d

(EMDR: n=18, M SD M SD M SD time group time*gro dPre-FU dPre- dPost

BSP: n=42) F (2, 59) F (1, 60) up Post -FU
η² η² F( 2, 59)
η²
Total score 44.16*** .26 2.03
.60 .00 .07
EMDR 29.4 12.67 10.4 10.42 8.0 6.52 2.12 1,64 0.28

BSP 25.9 12.36 14.6 10.59 10.9 1.30 0.98 0.35

10.59
Reexperience 44.08*** 1.61 1.31
.60 .03 .04
EMDR 8.8 4.33 2.4 2.77 1.7 1.81 1.11 1.76 0.30

BSP 8.5 4.62 4.3 3.39 3.0 3.35 1.36 1.04 0.39

Avoidance 37.15*** .11 1.64

.56 .00 .05
EMDR 11.3 5.48 4.6 5.77 2.6 2.83 1.99 1.19 0.44

BSP 9.8 5.69 5.8 5.17 4.0 4.49 1.13 0.74 0.37

Hyperarousal 31.00*** .04 2.72

.51 .00 .08
EMDR 9.3 4.28 3.3 3.20 3.7 3.12 1.50 1.59 -
0.12
BSP 7.6 3.66 4.5 3.03 3.8 3.54 1.06 0.92 0,21

Note. PDS = Posttraumatic Diagnostic Scale; pre = pretest, post = posttest, FU = follow-up;
BSP = Brainspotting; EMDR = Eye Movement Desensitization and Reprocessing. M=mean;
SD=standard deviation. * p < .05. ** p < .01. *** p < .001. Effect sizes: Cohen (1988): (M1-
M2)/ SDpooled
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HILDEBRAND, GRAND et al.

Appendix 3

Tab. 3. – HADS. Univariate two factor analysis of variance (ANOVA) with

repeated measures and effect sizes
Pre Post FU ANOVA d

(EMDR: M SD M SD M SD time group time*group dPre-FU dPre- dPost-FU

n=18, F (2, 58) F (1, 59) F( 2, 58) Post
BSP: n=43) η² η² η²
Anxiety 44.38*** .13 0.89
.62 .01 .02
EMDR 14.1 4.67 7.1 5.50 6.8 4.93 1.52 1.37 0.06

BSP 12.5 3.55 7.0 4.12 6.8 5.03 1.31 1.43 0.04

Depression 35.83*** .15 1.31

.55 .00 .04
EMDR 11.1 5.13 5.4 5.68 4.7 5.32 1.22 1.05 0.13

BSP 9.5 4.96 5.3 4.79 4.9 4.80 0.94 0.86 0.08

Note. HADS = Hospital Anxiety and Depression Scale; pre = pretest, post = posttest, FU = follow-up;
BSP = Brainspotting; EMDR = Eye Movement Desensitization and Reprocessing. M=mean; SD=standard
deviation. * p < .05. ** p < .01. *** p < .001. Effect sizes: Cohen (1988): (M1-M2)/ SDpooled

© 2014 by the Author(s); licensee Mediterranean Journal of Clinical Psychology, Messina, Italy. This
article is an open access article, licensed under a Creative Commons Attribution 3.0 Unported
License. Mediterranean Journal of Clinical Psychology vol. 5 n.1
Doi 10.6092/2282-1619/2017.5.1376
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Medical Hypotheses 80 (2013) 759–766

Contents lists available at SciVerse ScienceDirect

Medical Hypotheses
journal homepage: www.elsevier.com/locate/mehy

Brainspotting: Recruiting the midbrain for accessing and healing sensorimotor

memories of traumatic activation
Frank Corrigan a,b,⇑, David Grand c
a
Argyll & Bute Hospital, Lochgilphead, Argyll PA31 8LD, UK
b
Manor Hall Centre for Trauma, Doune, Stirling, UK
c
350 West 42nd Street, 17B New York, NY 10036, USA

a r t i c l e i n f o a b s t r a c t

Article history: Brainspotting is a psychotherapy based in the observation that the body activation experienced when
Received 4 March 2013 describing a traumatic event has a resonating spot in the visual field. Holding the attention on that Brain-
Accepted 8 March 2013 spot allows processing of the traumatic event to flow until the body activation has cleared. This is facil-
itated by a therapist focused on the client and monitoring with attunement. We set out testable
hypotheses for this clinical innovation in the treatment of the residues of traumatic experiences. The pri-
mary hypothesis is that focusing on the Brainspot engages a retinocollicular pathway to the medial pul-
vinar, the anterior and posterior cingulate cortices, and the intraparietal sulcus, which has connectivity
with the insula. While the linkage of memory, emotion, and body sensation may require the parietal
and frontal interconnections – and resolution in the prefrontal cortex – we suggest that the capacity
for healing of the altered feeling about the self is occurring in the midbrain at the level of the superior
colliculi and the periaqueductal gray.
Ó 2013 Elsevier Ltd. All rights reserved.

Introduction: Brainspotting as a therapy for posttraumatic the heart may have no external visual correlate but it still has a
disorders Brainspot.
This is an original and important way into the body residues of
Brainspotting (BSP) is a development in psychotherapy which adverse experiences which allows them to process to a healing res-
was discovered by David Grand [1] in the course of a Natural Flow olution. We try to explain why interoceptive distress has a location
EMDR session in which slow eye movements are used [2]. When resonant with it – and towards which the gaze elicits additional
his client’s eye movements wobbled and froze David Grand also activation. The spot can be selected by the client’s subjective ap-
stopped spontaneously and waited with what happened. The client praisal (the Inside Window method) or by the observation of tur-
then processed traumatic material which had not been accessible bulence in the flow of the eye movements at a particular point of
previously. He followed up this observation in other clients and a slow sweep (the Outside Window method). The Brainspot may
discovered a similar pattern of processing. also be selected when the client’s gaze is settled on a particular
If the traumatic episode being targeted had a prominent visual point while talking about activating material (Gazespotting) [3].
focus – an attacker’s weapon or hate-filled face, for example – it is We hypothesize that the orientation to highly emotional, com-
easy to see how one location in the visual field might become plex information that does not require eye movements towards a
linked with maximum body activation during recall. What is more stimulus nevertheless involves the basic orienting response in the
difficult to explain is the finding that traumatic episodes without a midbrain tectum. Just as social pain is based on evolutionary ad-
dominant visual feature nevertheless have a location in the visual vances in systems required for physical pain [4] orientation to social
field, or Brainspot, that is felt to precisely match the somatic dis- information is based in brain networks originally employed for
turbance emerging during the retelling of the trauma narrative. It responding to visual stimuli. We hypothesize that adaptive orienta-
is the activation in the body during remembering and recounting tion to information of a distressing nature involves a nested hierar-
the traumatic event that resonates with the Brainspot. An emo- chy [5] based in the superior colliculi and their subcortical loops
tional experience which felt like a kick in the gut or a breaking of through the basal ganglia but involving higher levels in the thalamic
pulvinar; the amygdala and hippocampus; the sensory cortices; and
the anterior and posterior cingulate cortices. Vogt and Laureys [6]
⇑ Corresponding author at: Argyll & Bute Hospital, Lochgilphead, Argyll PA31 8LD,
describe six stages for the cortical sequence of orientation, including
UK.
E-mail addresses: [email protected] (F. Corrigan), [email protected] (D. head and eye movement, through the cingulate cortex. Also in-
Grand). volved are the frontal and parietal eye fields in the neocortex. The

0306-9877/$ - see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.mehy.2013.03.005
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760 F. Corrigan, D. Grand / Medical Hypotheses 80 (2013) 759–766

intraparietal sulcus is one of the links between the midbrain orient- healing change to occur. The Brainspot provides the bookmark or
ing and the cortical orientation behaviors and it has connections tag on the appropriate information file. The mindful therapist helps
with the insular cortex for linking with body feelings. to maintain this internal focus by checking on the nature and
severity of the activation in the body and allowing it to unfold from
‘‘Outside Window’’ definition of a Brainspot within. The presenting complaint is repeatedly referred to until
there is no body activation associated with its Brainspot – squeez-
When a client discusses an area of emotional difficulty in suffi- ing the lemon until not a further drop can be extracted. Healing is
cient depth to allow focus on the body feeling associated with it, not imposed by technique but is liberated. When time permits the
the therapist asks the client to track a pointer which is slowly process is allowed to proceed to completion and the change in
moved in a horizontal line in front of the eyes. The therapist can state becomes the focus of attention. The resolution of the trauma
then find the Brainspot by observing a disruption of the client’s is accepted with care and patience to give it as much time as pos-
gaze. As this may be an eyeblink it is useful to look at recent find- sible to rewrite the neural pathways which were previously en-
ings on brain activity in relation to spontaneous blinking. Nakano trenched in maladaptive and dysfunctional loops.
et al. [7] observed that eyeblinks were associated with fMRI deac-
tivations in the frontal eye fields and the superior parietal lobe,
components of the dorsal attention network. The brain areas that Dual attunement
control shifts of gaze also control shifts of attention: these are
the superior colliculi in the midbrain and the frontal eye fields in Brainspotting’s difference from other forms of talking therapy
the cortex [8]. Suppression of activity in the superior colliculi lies in its unique ability to predictably access the brain stem compo-
was induced by blinking whereas there were activations in the nents of the trauma memory during the setting of the frame. Other
anterior and posterior cingulate and insular cortices with sponta- body-based therapies are effective at a similar level but the ease
neous blinking. These brain areas are also important components with which they access the midbrain is dependent on a number of
of the interoceptive response to emotional memories as is de- factors not necessarily integral to the treatment modality. The gaze
scribed below. It could be argued that the disruption of focused fixation used in Brainspotting (BSP) immediately involves the supe-
attention during blinking is allowing assimilation of the emotional rior colliculi in the midbrain and this neurobiological aspect of the
and somatic experience by facilitating the emotional and memory dual attunement model is specific to BSP. It involves the procedural
functions of the cingulate and insular cortices. When blinking is exploration of the relevant eye positions through Outside Window,
observed in the Outside Window technique it is picking up the Inside Window and Gazespotting. In other words, the BSP therapist
momentary heightening of the internal experience that follows is attuning to the client’s neurobiology by noticing at which eye
the spontaneous tendency to focus the gaze on what is salient. positions the client manifests increased, sustained reflexive activity
(Outside Window), locating with the client the eye positions where
the client ‘‘feels it the most’’ (Inside Window), and noticing the eye
Non-visual gaze patterns and memory: looking in while looking
positions the client spontaneously identifies by where they gaze
out
when talking about their emotional material (Gazespotting). When
one of these three Brainspots is determined, the client is guided to
The spontaneous activation of eye movements and gaze fixa-
maintain the gaze on the spot or pointer and mindfully observe
tions during mental activity with no visual component has been
the internal experience over time (focused mindfulness). The ther-
extensively studied by Ehrlichman and colleagues [9]. The move-
apist is attuned to the client’s neurobiological connectedness with
ment of the eyes during ‘‘search’’ of long-term memory is followed
the emotional material accessed through the Brainspot at a primar-
by a gaze fixation when the information is ‘‘located’’. This is seen as
ily brainstem level.
analogous to the search for a salient stimulus in the environment
The therapist’s gaze has an effect on the client’s cortical and sub-
and is based in the same brain structures. Saccadic activity and
cortical structures. The response of the right anterior insula to being
gaze fixation are connected with memory through medial temporal
gazed at in a non-threatening way [14] may help to maintain the cli-
regions and basal ganglia output to the superior colliculus. Focus
ent’s focus on the body feelings attached to the Brainspot. Even if the
on a memory sufficient to induce a sustained activation of the
gaze is not strictly mutual – when the therapist is watching the cli-
medial temporal lobe inhibits the striatum, with which there is a
ent focus on the Brainspot – the client’s awareness of the therapist’s
competitive interaction, and releases gaze fixation neurons in the
gaze should accentuate the insular response to the framing. Also, in-
superior colliculus.
creased duration of direct gaze stimulates the anterior cingulate and
ventromedial prefrontal cortices of the person being looked at [15].
Setting the frame So when the direct gaze of the therapist is maintained on the face of
the client who is focused on the Brainspot there is augmentation of
As in Sensorimotor Psychotherapy [10], Somatic Experiencing the medial prefrontal activation achieved in the client through
[11], Lifespan Integration [12] and, it could be argued, EMDR [13] mindful attention to processing. Being gazed at while fixated visu-
the Brainspotting frame is based in the body feelings evoked by ally on the Brainspot is amplifying the circuits framed via the insula
discussion of the traumatic memory. These are accessed through and amplifying the medial prefrontal attention on emerging mate-
mindful attention to what is happening inside during the recount- rial. This promotes organization and integration through coales-
ing to the therapist of the nature of the presenting problem. The cence of hitherto separated information files.
activation is studied carefully and working memory involvement The other aspect of the dual attunement is less specific to Brain-
with it is enhanced by it being rated on a 0–10 scale. spotting. This is the relational attunement of attending to and track-
ing the client’s experience, listening to the verbal and non-verbal
Focused mindfulness communications. The relational attunement includes the somatic
and unconscious interactions between the client and therapist. This
The client’s attention to the internal process recruits medial promotes the focused mindfulness on all the brain systems acti-
prefrontal regions for observing emotions, memories, body sensa- vated while the sustained gaze holds the brain stem bookmark. All
tions and cognitions. Sustained observation of the information files the higher level processes are changed as they are being held under
which have been opened by the Brainspotting set-up allows the focused influence of the neural bookmark. We anticipate that
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the relational attunement will involve a separate nested hierarchy to elicit all the associated negative cognitions, if there is sufficient
based in the midbrain periaqueductal gray (PAG) but with an upper body activation to open the information file which needs to be re-
level in the ventromedial prefrontal cortex. solved. In SP the therapist is actively engaged in mirroring move-
ments, making contact statements, and helping the client to find
the action which leads to resolution, perhaps through completion
Orienting and adaptive orientation
of a truncated defence response. In Brainspotting there is no need
to explore impulses to action, only to observe them with the asso-
A Brainspot is a stored oculomotor orientation to a traumatic
ciated sensations as the information processing moves to resolu-
experience which has failed to integrate. When it is accessed in
tion. The development of Brainspotting was influenced by the
treatment there is potential for greater healing of the emotional
somatic experiencing work of Peter Levine [11] in which the ener-
residues of the unassimilated event. The concept of orienting –
getic residues of traumatic experiences are accessed and dis-
an oculomotor response to a particular stimulus/event in external
charged. All these approaches are based in the clinical
space – has been expanded in relation to trauma by Levine [11] and
observation that there is a natural process which, if liberated, will
Ogden et al. [10]. To avoid confusion with the basic orienting re-
lead to healing. In Brainspotting the therapist is engaged in mind-
sponse we will refer to the full sequence described by Ogden
ful, empathic presence while the client’s healing process moves to-
et al. [10]: arousal; activity arrest; sensory alertness; muscular
wards completion during the period of gaze fixation.
adjustments; scanning; locating in space; identifying; evaluating;
Awareness of the somatic sensations, emotions, and impulses to
taking action; and reorganizing – as adaptive orientation. When
action accompanying the trauma narrative involves the interocep-
the full sequence fails to complete at the time of the trauma some
tive loops through the anterior insular cortex. Body sensations are
components are left unresolved and liable to recur when triggered.
transmitted to the cortex via spinothalamic tracts which originate
There is a truncation of the adaptive orientation which has signif-
in the spinal cord and in the nucleus of the solitary tract [16]. In the
icant clinical effects. The resulting negatively valenced memory is
thalamus there is a divergence with projections to the anterior cin-
stored with physiological activation that has not been discharged.
gulate cortex providing a drive, while projections to the insula give
Accessing the Brainspot in a careful, mindful, way allows the acti-
rise to the emotional feeling. The feeling becomes more differenti-
vation to be processed to completion.
ated as the information is passed through the insula from posterior
External stimuli are detected in sensory systems and can elicit
to anterior and then contributes to the core of ‘‘the sentient self’’
motor reactions, affective reactions and memories within a milli-
[17]. Sensory and visceral information integrated in the sensory
second time scale. It may be the first or most intense orienting of
network of the orbitomedial prefrontal cortex moves on to the
the eyes in response to the external stimuli which creates the
medial or visceromotor network from where there are projections
Brainspot for subsequent elaboration of emotions, thoughts, and
to the emotion-generating areas of the hypothalamus and periaqu-
behavioral impulses to cluster around. Alternatively there may be
eductal gray (PAG) [18]. These structures influence the autonomic
no oculomotor link with any event but the gaze associated with
nervous system nuclei in the brain stem to produce changes in the
the trauma memory has acquired a particular direction through
body which are informed to the cortex through the spinothalamic
top-down cortical influences. A shock which comes from more cor-
tracts. This interoceptive loop has the anterior insula as the point
tical processing of incoming information, for example news about a
of visceral and emotional awareness. The question, ‘‘What do you
sudden death, carries a signature orientation as the inner eye turns
feel in your body when you are telling me about that trauma?’’
to the meaning of the message.
necessarily involves activation of the insula.
Orienting to an external threat or traumatic event starts in the
The point of interaction of this interoceptive loop with episodic
superior colliculi (SC) in the midbrain. The SC have direct input
autobiographical memory circuits through hippocampal and pos-
from the retina but also from the frontal eye fields (FEF), the sup-
terior cingulate areas is in the ventromedial prefrontal cortex
plementary eye fields, and the lateral intraparietal area (LIP) or the
[19]. This visceromotor region [20] is implicated in the clinical ac-
intraparietal sulcus (IPS). The superior colliculi detect luminance
tion of the alternating bilateral stimulation used in EMDR [21]. The
change in the external world and (with the assistance of the basal
Brainspotting protocol includes auditory alternating bilateral stim-
ganglia and the cerebellum) direct movements towards or away
ulation and an empathic therapist to accentuate the insula-VMPFC
from the stimulus – depending on physical characteristics and/or
limb of the interoceptive loop which projects to the hypothalamus,
associations. The superior colliculi are first responders for orienting
midbrain and ventral striatum. There are also projections from the
but that does not necessarily carry an emotional charge: an affec-
insula to the hippocampus and the temporal pole but interconnec-
tive response is one of the consequences only of particular types of
tedness with the basolateral amygdala [22] is most likely to be rel-
activation of the SC – looming, snake- or spider-like movements
evant to somatic components of emotional memory. The insula
(Redgrave, personal communication).
also has connectivity with the intraparietal sulcus [23] providing
The intraparietal sulcus (IPS) has the connections with the
the circuitry for linking gaze with the body sensations.
memory areas of the posterior cingulate cortex which lead us to fa-
There is a large sensory projection to the midbrain PAG [24]
vor the IPS-SC axis for the integrative effect of Brainspotting. Brain-
which may carry information about the visceral components of
spotting combines the activated emotional memory, its impact on
emotional reactions to traumatic experiences and the kind of deep
the self and the oculomotor orienting which has become associated
pain associated with loss. The PAG is also involved in generating
with that memory.
these affective responses [4]. The PAG and the colliculi are exten-
sively interconnected so it is possible that the Brainspot is lining
Interoceptive loops up for treatment the precise feeling registered in the midbrain
PAG – even if an attenuated version reaches the insula via the
During the set-up of the frame in Brainspotting, the client is spinothalamic tracts.
asked to describe the presenting problem and then to notice the le-
vel of activation in the body. This is similar to the practice in sen-
sorimotor psychotherapy [10] in which the body’s response during Orienting and gaze fixation
the description of the problem becomes the starting point for ther-
apeutic intervention. In both Brainspotting and sensorimotor psy- Objects which make a sudden appearance attract attention and
chotherapy (SP) there is no need to get all the narrative details, or induce a saccade, a rapid movement of the eyes towards them [25].
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This orienting saccade can be followed by a gaze fixation on the vi- when there is a conflict between the eyes being drawn to a partic-
sual axis from the retinal fovea through the optical focal point to- ular stimulus and a need to direct the gaze elsewhere [25]. Volun-
wards the object being looked at [26]. Fixation neurons in the tary or intentional saccades in humans are heavily dependent on
colliculi become more active when they reach their fixation point the intraparietal sulcus [39]. A topographical representation of sal-
[27] and microsaccades prevent loss of vision through habituation ience within the IPS implicates this parietal area in the response to
[28]. This allows maximal intake of information about the object the direction: ‘‘Tell me what point in your visual field matches best
which may constitute a sudden threat. Both saccadic eye move- with the feeling in your body when your eyes follow the pointer’’.
ments and visual fixation are initiated in the superior colliculi One of the remarkable findings of Brainspotting is the definite sub-
(SC) [29]. The SC receive projections directly from the retina and jective feeling about what location resonates with a particular acti-
project to brain stem nuclei and to the spine, in direct tectospinal vation. There is often an objective increase in distress at a
tracts, for initiating movements of the head and the eyes and a shift particular point.
of gaze. They contribute to three-dimensional orienting move-
ments of the head and eyes [30]. The SC contain a map that is topo-
Thalamic nuclei between the superior colliculi and the
graphically organized according to retinal coordinates and this is
cingulate cortex
aligned during development with a sensory map carrying spatial
information and an oculomotor map for accurate location of gaze
There are retinal projections directly into nuclei of the thala-
[31]. The superficial layers of the SC project to deep layers where
mus: we focus here on those with greater limbic connectivity.
multimodal sensory integration is translated into motor output
The superior colliculi are connected with the medial pulvinar and
[32].This superficial to deep connectivity is also seen in post-mor-
with the intralaminar nuclei. The medial pulvinar receives affer-
tem studies of human brain [33]. The SC are responsible for orient-
ents from the deep layers of the superior colliculi and projects to
ing to olfactory stimuli as well as visual, auditory and
areas of anterior and posterior cingulate cortex. There are also
somatosensory stimuli [34].
afferents to the intralaminar nuclei from the intermediate and
In the cortex of the cat, the posterior cingulate gyrus is active
deep layers of the SC, especially from somatosensory neurons
during visual stimulation and during saccadic eye movements
[40]. The intralaminar nuclei are involved in orienting and in sen-
[35]. In the monkey, the posterior cingulate neurons which are ac-
sorimotor integration; and their inputs from the brainstem reticu-
tive during gaze fixation may be carrying information about the
lar formation and the cholinergic mesopontine tegmentum
angle of the eye in the orbit for spatial orientation [36]. The posi-
contribute to activation of the thalamocortical mantle. The intra-
tion of the eye in the orbit and in relation to the head in space is
laminar nuclei connect with all parts of the cingulate cortex
being monitored rather than controlled by the posterior cingulate
whereas the medial pulvinar has specific projections to anterior
cortex [36]. Cortical areas with both oculomotor activity and direct
areas 32 and 25 and posterior cingulate areas 23 (ventral), 29
links to the posterior cingulate cortex include the intraparietal sul-
and 30 [41]. The intralaminar nuclei receive projections from ante-
cus. A network surrounding the IPS and including the precuneus,
rior cingulate cortex, area 24, whereas the medial pulvinar receives
posterior cingulate, retrosplenial and parahippocampal cortices
from posterior cingulate, area 23 [40]. Thus, the medial pulvinar is
[37] mediates control of eye movements in response to salience
interconnected with anterior cingulate areas involved in emotion
in the visual field and volition. Gaze fixation therefore activates
processing and with the posterior cingulate area in which multi-
the intraparietal sulcus and the posterior cingulate cortex.
sensory information is coded for self-relevance. The medial pulvi-
nar also influences prefrontal cortex, superior and inferior
Subcortical loops through the superior colliculi parietal lobules, insular cortex and parahippocampal gyrus. It has
a distinct projection to the IPS.
Sensory input to the superior colliculi activates, via the thala-
mus, the striatum which projects back to the SC through the sub-
A nested hierarchy based in the tectum?
stantia nigra. The substantia nigra pars reticulata maintains an
inhibitory control over the superior colliculi. In contrast, cortical
The deep layers of the superior colliculi have inputs from other
areas project directly to the striatum and loop back to cortex via
sensory modalities and their cortical representations. Functional
the substantia nigra and the thalamus. It is conceivable that com-
MRI studies of crossmodal integration in humans suggest that
plex events can have many different segregated loops associated
the superior colliculi constitute the most significant region for this
with them. Whether they become integrated or remain separate,
function while the intraparietal sulcus has a weaker integrative
may dispose to a conflict among cognitive, emotional, and somatic
capacity [42]. When the connectivity of the superior colliculi in
components of a remembered experience. The selection of which
monkeys is studied by microstimulation of the colliculi during
loop is disinhibited to allow action is based in the basal ganglia
functional MRI several areas of visual cortex are activated in addi-
but can be influenced at all the major relay points of the loop by
tion to the frontal and parietal eye fields. However, there were also
activity within the basolateral amygdala in the case of a triggered
changes in the somatosensory cortex, the primary auditory cortex,
fear response.
the primary motor cortex, the anterior cingulate cortex, and the
posterior cingulate cortex [43]. The anterior cingulate cortex is part
Cortical projections to the colliculi: corticotectal systems of the interoceptive loop and the posterior cingulate cortex con-
tributes to self-related memories with an emotional component
In the macaque monkey, there are two distinct corticotectal sys- – and both receive projections from the medial pulvinar. Stimula-
tems [38]. One system is based in the visual information sent from tion of the superior colliculi is being followed by activity in areas of
the retina to the superficial layers of the superior colliculi and the brain involved in autobiographical memory and in focused
mainly involves areas of visual cortex. The visuomotor component, attention on these.
in contrast, projects to the deep layers of the superior colliculi from The anterior part of the intraparietal sulcus is part of a dorsal
areas of frontal and parietal cortex and mediates gaze fixation, sac- fronto-parietal network for the assessment of salience [44] and
cades and the coordination of head and eye movements during ori- may direct attention even in the absence of eye movements (covert
enting. In the human, the intraparietal sulcus (IPS), the equivalent orienting). The posterior part of the intraparietal sulcus may be
of the monkey lateral intraparietal area (LIP), can inhibit the SC more involved with eye movements during overt orienting. In
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F. Corrigan, D. Grand / Medical Hypotheses 80 (2013) 759–766 763

Brainspotting linking eye position with what is salient in the atten- associated body sensations while recounting a traumatic episode
tional field requires anterior and posterior subregions of the intra- is dependent on the anterior insula yet there does not appear to
parietal sulcus. be any significant connection between the insula and the superior
colliculi. In contrast the intraparietal sulcus has an anterior region
The posterior cingulate gyrus: linking sensation and memory (hlP1) which is functionally connected with the insula [23]. This
part of the intraparietal sulcus is closely connected with the angu-
Posterior cingulate area 23 has reciprocal connections with the lar gyrus which, in turn, is linked with medial prefrontal cortex,
retrosplenial cortex for long-term memory and it transfers infor- hippocampus and parahippocampal gyrus, precuneus, occipital
mation about head and eye movements to the caudal cingulate poles, anterior and posterior cingulate cortices. It is clear that these
motor area [6]. After a saccade the coding of the position of the parietal areas have the connectivity necessary to link body sensa-
eye in the orbit is dependent on posterior parietal inputs to poster- tions, emotional awareness, and autobiographical memory – and
ior cingulate cortex. The machinery for linking gaze fixation with gaze direction.
memory circuits is therefore available in these parieto-cingulate
interactions.
Vogt and Laureys [6] propose a six-stage processing model. Healing the deep wounds of the midbrain self
Stage 1 involves the ventral posterior cingulate cortex (PCC) in
extracting self-relevant information from the multisensory inputs, Economically-driven symptom-reduction approaches to psy-
in part through connections with the subgenual anterior cingulate chotherapy work with verbal techniques and checklists at a level
cortex. Stage 2 relates these inputs to memories through the retro- that has little impact on the core feelings about the self. Although
splenial cortex. In stage 3 inputs to dorsal PCC from ventral PCC still to be formally evaluated, clinical experience suggests that
and parietal cortex provide information about the orientation of Brainspotting is effective at a deeper level of the psyche – one that
the body – and the self – in space. The caudal cingulate motor area has its neural correlates in the midbrain. Damasio [48] has argued
is active in stage 4 to orient the head and body via projections to for the primacy of the nucleus of the solitary tract (NTS) and the
the spinal cord. Stage 5 involves intentional behaviors. Stage 6 parabrachial nucleus (PBN) for fundamental feelings of pain and
turns the information received and processed into appropriate pleasure. These nuclei receive full information about the internal
autonomic and behavioral outputs through projections to the mid- state of the body and are connected with each other and with
brain and hypothalamus. These six stages cover many of the fea- the PAG. Sensory input is interpreted by the superior colliculi but
tures of adaptive orientation which are disrupted by trauma. the body sensations are transmitted via these two nuclei – the
NTS and the PBN. The colliculi integrate information in a way
which allows effective action through their outputs to brain stem,
Memory-related imagery spinal cord, thalamus and cortex. Damasio [48] proposes that the
beginnings of mind and the beginnings of self may be found in
Bringing a troubling memory to mind activates autobiographi- the SC.
cal memory circuits which have been established through the emo- An alternative view is that the SC is a simple orienting machine
tional impact of the events. The basolateral amygdala has inputs to that can inform relevant areas of the brain of the occurrence of a
many areas significant in recording emotionally-charged life biologically significant external event and, with connections to
events such as the ventromedial prefrontal cortex, the posterior and from the cerebellum, can solve the spatial-to-temporal trans-
cingulate cortex, and the hippocampal and parahippocampal areas. formation problem: retinal topography is spatial; control of the
It is also reciprocally connected with the insula [22]. In Brainspot- metrics of orienting is temporal (Redgrave, May 2012, personal
ting, as in sensorimotor psychotherapy, the processing is done pri- communication).
marily in the body rather than in the thoughts or feelings. Panksepp [49] differs in emphasizing the motor coordinates
The mind’s eye in which traumatic events and losses can be underlying self-representation. He places these in an area between
‘‘seen’’ is dependent on the precuneus, a medial parietal structure, the somatosensory fields of the superior colliculi and the visceral
which has inputs from the visual cortex. The precuneus is activated integrating and emotion-generating capacities of the PAG. The urge
during the visual imagery associated with a memory [45]. In the to act is considered to be more important for the definition of the
macaque monkey, the precuneus is connected with other parts of self than the impact of sensory experience. ‘‘I act and feel therefore I
the posteromedial cortex, especially posterior cingulate cortical am’’ (49, p203). Interms of the SC the basic urge to action would be
areas [46]. There are no significant direct projections from the pre- orientation towards or away from. The self would become defined
cuneus to the tectum. However the precuneus has connectivity through orienting responses to sensory stimuli rather than simply
with the angular gyrus and, through that, with the intraparietal through the experience of the sensations. I orient towards or away
sulcus [23]. from-therefore I feel who and what I am. Fundamental healing of
The precuneus can be divided into three parts: posterior visual, deep wounds to the self will only occur when the treatment acts
central associative, and anterior sensorimotor regions [47]. The at the midbrain level. We have alluded to the possibility that much
posterior visual part may have a transition zone to the regions in- of the emotional response to an event is generated in the PAG and
volved in memory. Otherwise the precuneus needs to have coacti- the feedback about the visceral changes is directly to the PAG from
vations created during the set-up of the Brainspot to include the the spinal cord. The PAG and the SC are extensively interconnected
emotional charge. It is possible that the gaze fixation on the Brain- making it possible that much of the healing is happening at this le-
spot reduces the precuneus involvement as processing proceeds vel – even although conscious awareness of changes is registering
through interoceptive channels. Visual imagery is not necessarily at upper cortical levels.
prominent during resolution of the traumatic event. The self is elaborated through layers of advancing complexity in
the subcortical-cortical midline systems [50,51] but the most pro-
Interoception and gaze found valence will be established at the level of the emotion-gen-
erating, autonomic-regulating, orienting midbrain. When
The missing step in the argument so far is for establishing neu- consciousness is divided into anoetic, noetic, and autonoetic forms
ral pathways for connecting the awareness of the body feeling and [52] it is assumed that in the human it is the autonoetic, self-know-
the spot in the visual field. The awareness of emotions and their ing across time, mind which needs to be engaged in therapy. If the
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764 F. Corrigan, D. Grand / Medical Hypotheses 80 (2013) 759–766

anoetic consciousness does not just include a simple awareness of Therapeutic interventions may be made at any of these levels but
external stimuli but memories of the action impulses, autonomic lasting and fundamental healing will follow mesencephalic resolu-
adaptations and emotional responses to events, then treatment tion. Brainspotting’s strength is its ability to start with events in
needs to include those areas to be maximally effective. The neural autonoetic consciousness at the cortical level and integrate with
correlates of the self extend from the midbrain through the midline techniques that allow healing to happen from the most basic level
subcortical structures such as the nucleus accumbens, through the of the self at the nidus of the tectal hierarchy, at the fundament of
medial prefrontal cortices, to the posteromedial cortices. the brain’s midline self systems.
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F. Corrigan, D. Grand / Medical Hypotheses 80 (2013) 759–766 765

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Medical Hypotheses 84 (2015) 384–394

Contents lists available at ScienceDirect

Medical Hypotheses
journal homepage: www.elsevier.com/locate/mehy

Brainspotting: Sustained attention, spinothalamic tracts, thalamocortical

processing, and the healing of adaptive orientation truncated by
traumatic experience
F.M. Corrigan a,b,⇑, D. Grand c, R. Raju a
a
Argyll & Bute Hospital, Lochgilphead, Argyll PA31 8LD, UK
b
Manor Hall Centre for Trauma, Doune, Stirling, UK
c
350 West 42nd Street, 17B, New York, NY 10036, United States

a r t i c l e i n f o a b s t r a c t

Article history: We set out hypotheses which are based in the technique of Brainspotting (Grand, 2013) [1] but have
Received 8 November 2014 wider applicability within the range of psychotherapies for post-traumatic and other disorders. We have
Accepted 21 January 2015 previously (Corrigan and Grand, 2013) [2] suggested mechanisms by which a Brainspot may be estab-
lished during traumatic experience and later identified in therapy. Here we seek to formulate mecha-
nisms for the healing processing which occurs during mindful attention to the Brainspot; and we
generate hypotheses about what is happening during the time taken for the organic healing process to
flow to completion during the therapy session and beyond it.
Full orientation to the aversive memory of a traumatic experience fails to occur when a high level of
physiological arousal that is threatening to become overwhelming promotes a neurochemical de-escala-
tion of the activation: there is then no resolution. In Brainspotting, and other trauma psychotherapies,
healing can occur when full orientation to the memory is made possible by the superior colliculi-pulvinar,
superior colliculi-mediodorsal nucleus, and superior colliculi-intralaminar nuclei pathways being bound
together electrophysiologically for coherent thalamocortical processing. The brain’s response to the
memory is ‘‘reset’’ so that the emotional response experienced in the body, and conveyed through the
paleospinothalamic tract to the midbrain and thalamus and on to the basal ganglia and cortex, is no
longer disturbing. Completion of the orientation ‘‘reset’’ ensures that the memory is reconsolidated with-
out distress and recollection of the event subsequently is no longer dysphorically activating at a physio-
logical level.
Ó 2015 Elsevier Ltd. All rights reserved.

Introduction Secondly we propose that this implicates the thalamic intralaminar

nuclei as important way stations in the healing process: the projec-
In this paper we argue that a traumatic experience is not fully tions to the striatum being significant in the resolution of motor
integrated, and can give rise to clinical features, when some aspect impulses and in emotional valence. Thirdly we consider the possi-
of the experience has not been available for full orientation bility that truncated adaptive orientation blocks information pro-
towards it. Reconnection with the elements hidden from conscious cessing and prevents healing from adverse experiences. We
awareness requires a focus on the visceral sensations evoked by define the truncation of adaptive orientation in terms of neuro-
fragments of the memory. We suggest that the visceral sensations chemical responses to extreme emotional states: the associated
and the associated feelings evoked when the traumatic experience memories are susceptible to reconsolidation with no change in
is brought to mind are conveyed to higher centres by the older, their affective loading. Fourthly we consider that the capacity for
rather than the newer, spinothalamic tracts. The paleospinotha- multi-level processing in the advanced human brain means that
lamic tract is extensively interconnected with the brainstem. orientation can be truncated at different levels. We consider how
Brainspotting [1] and other effective trauma psychotherapies
may overcome the obstructions and suggest that orientation and
⇑ Corresponding author at: Argyll & Bute Hospital, Lochgilphead, Argyll PA31 8LD,
its truncation also involve the intralaminar nuclei. The portion of
UK.
the processing which is accessible to awareness may be relatively
E-mail addresses: [email protected] (F.M. Corrigan), [email protected]
(D. Grand), [email protected] (R. Raju). small as much of it may occur below the conscious level. This

http://dx.doi.org/10.1016/j.mehy.2015.01.028
0306-9877/Ó 2015 Elsevier Ltd. All rights reserved.
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F.M. Corrigan et al. / Medical Hypotheses 84 (2015) 384–394 385

differentiates the immediately subconscious, postulated to be mes- 3) Muscular adjustments for facilitating orienting are made
encephalic, from the unconscious, in which complex information by the colliculi projecting downwards to the brainstem
processing occurs without awareness of it. It is proposed that the and spinal cord and to the cerebellum. These can occur with-
pulvinar mediates much of the processing while the relevant out conscious intent or voluntary action to maximise the
information file is held open through gaze fixation binding in the receptivity of the sense organs to the target object. There
intralaminar nuclei. The integrative approach that involves all are also orienting movements derived from the projections
levels from the spinal cord to the neocortex provides the potential of the superior colliculi to the parafascicular nucleus [9].
for full resolution and healing with the previously traumatic Involuntary orienting may be followed by voluntary scan-
memories being reconsolidated without associated distress. ning movements. The cortical coordination of the orienting
movements of eyes and head is through the outputs of the
Stages of adaptive orientation: Becoming aware of the nature of posterior cingulate cortex to the cingulate motor area.
a threat Another level of control is through the frontal eye fields
and premotor cortex which are influenced by the parafasci-
‘‘The Orienting Reflex as a complex functional system includes cular nucleus [10]. All levels of activity combine to impose a
the integrative activities of different brain areas. Its distinguishing selection task on the superior colliculi so that the appropri-
characteristic is that it arises in response to novelty. . .’’ [3]. Pavlov ate action is taken [11].
apparently considered that the Orienting Reflex developed to 4) Muscular adjustments for orientation and defence.
inquisitiveness in humans, predicting a link between orienting to Looped circuits linking midbrain areas, including the SC
novelty and activation of the SEEKING system which had not then and the PAG, with the basal ganglia were described by
been defined by Panksepp [4]. The early work on the Orienting McHaffie et al. [12]: these can be active at a subcortical level
Reflex drew attention to the multiple levels in the brain that were without cortical direction. The ascending projections from
engaged by it. When the many levels have to cope with complex the SC or PAG target parts of the thalamus which project
information with a high emotional charge we argue that it is pos- to the basal ganglia. These in turn project back to the SC or
sible for there to be a mismatch which blocks the smooth resolu- PAG for sequences of orienting and defence response move-
tion of the orientation to the new information about the ments to occur with a life-saving rapidity in circumstances
environment. Specifically in relation to trauma, Levine [5] where cortical evaluation could be too slow. The projections
described a number of aspects of orienting behaviours which have from the SC to the PAG are critical for the rapid deployment
been staged by Ogden et al. [6]. The stages may occur simulta- of defence responses – active or passive [13] – if the stimu-
neously, rather than sequentially, and include: arousal; arrest; lus is instantly perceived to be dangerous. The main tha-
alert; muscular change; scanning; locating; identifying; evaluat- lamic regions involved are the caudal intralaminar nuclei,
ing; taking action; and, finally, reorganisation. Orienting can refer the centromedian–parafascicular complex, which projects
purely to oculomotor behaviour determined at the collicular level; to caudate–putamen, nucleus accumbens, and the substan-
or to head and eye orienting directed from a cortical level; or to tia nigra pars reticulata. The pathway from the ventrolateral
direction of attention which may be either based in the midbrain PAG to the cerebellar vermis activated during freeze
or in the cortex. We seek to clarify by differentiating the stages responses during both conditioned and unconditioned fear
according to likely neural substrates and argue that orientation has been recently described [14].
of the self towards emotionally-valenced information recruits 5) The mammalian development of the ventral vagal complex
these orienting, oculomotor, and attentional systems. Furthermore integrates information from cranial nerves to facilitate turn-
the multiple levels and systems of the brain involved confer the ing of the head towards a novel stimulus with the appropri-
capacity for truncation of a complete response. ate facial expression and vocalization [15]. The vagal brake
Revising the order of the adaptive orientation response on the on arousal based in the nucleus ambiguus is immediately
basis of the anatomical pathways hypothesized to be essential sug- removed if active defence is required [15]. Nevertheless
gests an additional activation before the arrest and arousal stages. the tectospinal adjustment of head and neck position is the
The initial responses are mesencephalic, the later responses are primary influence when the stimulus carries a significant
cortical. The importance of intermediate response levels in limbic and immediate threat. The spinotectal pathway provides
and thalamic structures is less elaborated. the information from the spinal cord which allows regula-
tion of the reflex movements of the head and eyes in
1) Activation/stimulus selection occurs when the retinocollic- response to body stimuli [16].
ular neurons respond to a potentially salient stimulus in 6) Activity arrest may occur if the stimulus represents a poten-
the environment which impinges on the retinotopic map tially life-threatening danger if onward progress is main-
in the superficial layer of the superior colliculus. A visual tained. Voluntary movements are slowed or completely
event is selected from the many available as potentially stilled, and this is possibly mediated by tecto-thalamo-sub-
important and the collicular response occurs within a thalamic circuits. The subthalamic nucleus provides a ‘‘hold
100 ms. It may be followed by a covert shift of attention your horses’’ signal to allow time for selection of the optimal
based in visuomotor neurons in the intermediate layer of response [17]. Although it is often assumed that activity
the superior colliculus [7]. The superficial layer of the SC arrest facilitates increased sensory processing it may be
is in close communication with the intermediate and deep instead to interrupt ongoing behaviour which is dangerous.
collicular layers where visual information is integrated It is better to stop to evaluate an ophidian shape than to step
with signals from somatosensory, auditory and olfactory on a live snake.
systems. The GABAergic tail of the ventral tegmental area receives
2) The foveating saccade occurs as the attention shift becomes somatosensory information from the intermediate layers of
overt – even though this may be outside conscious aware- the SC [18]. This area is also described as the rostromedial
ness. The initiation of a gaze shift is preceded by a pause tegmental nucleus (RMTg) and has an inhibitory effect on
in inhibitory activity on the substantia nigra pars compacta the dopaminergic neurons of the ventral tegmental area
within 100 ms of the stimulus presentation [8]. and substantia nigra pars compacta [19]. The RMTg responds
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386 F.M. Corrigan et al. / Medical Hypotheses 84 (2015) 384–394

especially to aversive stimuli by reducing the capacity for intralaminar nuclei. The brainstem nuclei contributing to
rewarding feelings and the ability to initiate movement. this pathway include the locus coeruleus, the dorsal and
There are projections to the RMTg from the PAG, the locus median raphe, the pedunculopontine and the parabrachial
coeruleus (LC) and the parabrachial nucleus and from mes- [24]. Much of this paper is therefore about non-lemniscal
encephalic and pontine reticular formations [18]. The RMTg activation of thalamocortical projections.
may therefore contribute to the arrest induced by orienting Other pathways for a sudden increase in arousal include the
to aversive stimuli both directly in response to information projections from the SC through the ventral medial thalamic
from the SC and indirectly to sudden changes in arousal nucleus to the neocortex; or from the SC to the gigantocellu-
mediated by other midbrain structures. lar reticular nucleus [25]. The nucleus gigantocellularis has
7) A drop in heart rate is stimulated by the reciprocal projec- excitatory responses to all sensory modalities and contrib-
tion from the superior colliculi to the cuneiform nucleus in utes to motor and emotional reactions through projections
the midbrain reticular formation. The bradycardia occurring to all levels of the spinal cord and midbrain, pons, basal fore-
during orienting in reptiles and mammals is controlled by brain and medial thalamus. Some of these neurons even
the dorsal motor nucleus of the vagus [15] but this must bifurcate so that they can influence higher and lower struc-
occur after the registration of a stimulus as novel by the reti- tures together [26].
nocollicular path. Korte et al. [20] showed that the cunei- 9) Identifying and evaluating. The projection from the SC to
form nucleus is instrumental in increasing blood pressure the pulvinar conveys information to the amygdala which
and reducing heart rate during orienting. This is achieved can further activate the LC if the signal matches stored emo-
through the projections of the cuneiform nucleus to the par- tional memory of threat. There is also evaluation in prefron-
abrachial nucleus and the rostroventrolateral medulla tal cortical areas [27]. Both the basolateral and central nuclei
(RVLM), for the pressor response, and to the nucleus of the of the amygdala project to the PAG for deployment of
solitary tract and the dorsal motor nucleus of the vagus for defence responses and associated autonomic changes when
the parasympathetic fall in heart rate. The cuneiform, soli- the situation requires them. Halgren [28] differentiated sim-
tary tract, ambiguus, parabrachial, tegmental nuclei all pro- ple orienting from an Orienting Complex which involved the
ject to the intralaminar thalamic nuclei, as does the locus amygdala in a response to stimuli which had cognitive sig-
coeruleus [10]. nificance. The amygdala response was between 100 and
8) Arousal is generated from the brainstem and conveyed to 200 ms and the impact on awareness was probably between
the cortex through ascending tracts to the thalamocortical 200 and 400 ms. The interaction with the hippocampus pro-
mantle and from descending pathways to the reticular for- vides contextual information very rapidly.
mation and other brainstem structures. Scaer [21] empha- 10) Alertness (with heightened senses) may reflect increased
sized the role of the locus coeruleus (LC) in orienting to a attention [29] or be part of the sensorimotor integration in
threatening stimulus and the pathway from the LC to the the intermediate and deep layers of the SC with information
amygdala in establishing a memory of the emotionally- being collected from all sensory modalities and their cortical
charged experience. The LC becomes active <100 ms after processors. The collicular projection to the parafascicular
stimulus onset. As there are no direct projections from the nucleus increases readiness for orienting or defensive
SC to the LC it is possible that either a defence response, action.
through the PAG, or an increased drive, through dopamine 11) Alertness. Parietal activity can be picked up within 100 ms
or acetyl choline systems, is needed before arousal occurs. of an unexpected visual event [29]. Visual streams, for vol-
Influences of the SC on the LC are mediated by the PAG untary control of eye movements and for re-orientation to
and by the pedunculopontine and laterodorsal tegmental stimuli of emerging salience [30], overlap in the posterior
nuclei. The locus coeruleus then increases arousal through cingulate cortex and in the superior temporal sulcus. Self-
noradrenergic innervation of the cortex; it inhibits GABAer- relevant visual information is conveyed to the ventral PCC
gic sleep-promoting activity and activates cholinergic wake- from the parietal, temporal, occipital and orbitofrontal corti-
fulness activity in the basal forebrain; it inhibits GABAergic ces [23]. Groenewegen & Berendse [31] proposed that the
neurons of the ventrolateral preoptic area of the hypothala- midline–intralaminar complex of the thalamus might bring
mus to maintain wakefulness; it has an excitatory effect on a state of readiness to the entire basal-ganglia–thalamocor-
the serotoninergic dorsal raphe nucleus to promote wakeful- tical system. This would be especially true for affectively-
ness; it activates the amygdala and hippocampus for emo- loaded visceral information in the spinothalamic tracts ter-
tional memory formation and retrieval; it inhibits minating in the intralaminar nuclei.
parasympathetic nuclei and activates sympathetic nuclei; 12) The dorsal visual pathway through the intraparietal sulcus
and it projects to some of the sensory and motor nuclei of to the anterior insula also communicates a body feeling:
certain cranial nerves [22]. The LC projects to sensory neu- this happens between 150 and 200 ms after the stimulus
rons in the spinal cord, perhaps to inhibit the processing of [32]. Insular activation in response to ascending spinotha-
sensory information if the situation requires that rather than lamic inputs during traumatic experience is likely to precede
continuing increased openness to potentially salient sensory this.
stimuli. The LC also projects to spinal cord motor neurons for 13) Evaluation of the stimulus occurs through comparison of it
increasing muscle tone and to the sympathetic nuclei for with memories stored in the retrosplenial cortex and
specific organ activation [22]. Both arousal and autonomic through valence stored in the subgenual anterior cingulate
nervous system changes are being initiated by LC activation. cortex [23].
Brainstem noradrenergic, cholinergic and serotoninergic 14) Information in ventral PCC is shared with dorsal PCC and RSC
systems all project to the intralaminar thalamic nuclei for multisensory awareness of the head and body posi-
[10]. Cholinergic mesopontine projections to the anteroven- tions in relation to the visual stimulus [23].
tral thalamic nucleus activate cingulate areas [23]. The 15) The dorsal PCC drives the caudal cingulate motor area to
ascending reticular activating system can be defined as a make complex head and body movements through projec-
non-lemniscal projection from the reticular formation of tions to the spinal cord and supplementary motor areas [23].
the brainstem and from several brainstem nuclei to the (This may be why the eye position for the Brainspot is first
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identified with the head still as the SC are engaged but can a constant search for threat. Torticollis and persisting neck pain
then be gazed at with the head turned towards it when after whiplash injuries may be somatic residues of orienting move-
the cingulate levels are enlisted.) ments which have failed to complete [21].
16) Intentional behaviours are derived from the rostral cingu- In addition to bypassed orienting responses we suggest that
late motor area [23]. This stage corresponds with that trauma can lead to orientation being obstructed or incomplete
described by Menon and Uddin [32] in which the anterior through other pathways. For example, intrauterine or neonatal
cingulate cortex links with midcingulate and other motor trauma can leave an energetic residue which in later life carries a
areas to facilitate voluntary actions. However at times of Brainspot, despite there being no external threat to orient towards.
danger the efference cascade from which a behavioural Sudden news of the death of a loved one may carry no external
response is selected from the mass of information flowing point of visual attention, but the interoceptive activation has an
downwards from the cortex is dependent on selection in associated Brainspot. In these instances the emotional distress
the SC [11]. There is also recent evidence that the midbrain has acquired a specific ‘‘place’’ where it can be closely scrutinised
pedunculopontine tegmental nucleus is involved in learning – or avoided. The visceral sensations accompanying the autonomic
associations between actions and predicted outcomes [33]. arousal are transmitted to the cortex via the spinothalamic tracts
‘‘(B)rainstem systems have a sophisticated capacity to ana- and also passed to the nucleus of the solitary tract (NTS), the par-
lyse incoming sensory data, understand that input in terms abrachial nucleus, the PAG, and the hypothalamus for modification
of what is already known and, if appropriate, make an imme- of autonomic activity through homoeostatic circuits in the brain-
diate decision to act’’ [34]. stem. Sensory information from all modalities is integrated in the
17) The brainstem, the cingulate motor areas, the visceromotor intermediate and deep layers of the SC and we hypothesize that
prefrontal areas and the cortical projections to the PAG act the Brainspot is acquired at this level, even if it subsequently
to provide a unified defence response with integrated auto- accessed through the intraparietal sulcus [2]. Of the SC Damasio
nomic, behavioural and emotional components. writes: ‘‘There is no other place in the brain where information
18) The lateral part of the intermediate grey layer of the superior available from vision, hearing, and multiple aspects of body states
colliculus is essential for efficient hunting of insects in the is so literally superposed, offering a prospect of efficient integra-
rat. Lesions of the lateral SC leave rats unable to quickly ori- tion’’ [35, p. 84]. Of relevance to Brainspotting he continues: ‘‘In
ent to prey and their predatory behaviours become clumsy all likelihood, the integrated, in-register maps of the superior col-
and inefficient [25]. There are projections from this area of liculus generate images as well – nowhere near as rich as those
SC to the PAG, perhaps contributing an affective quality to made in the cerebral cortex, but images nonetheless. Some of the
the hunt; and to the substantia nigra pars compacta, provid- beginnings of mind are probably to be found here, and the begin-
ing access to the complex motor programmes of the subcor- nings of self might be found here too’’ [35, p. 85].
tical loops through the basal ganglia. The compacta Unopposed activation of the sympathetic nervous system
projection presumably concerns timing signals for salience would lead to death through hypertensive crisis or arrhythmia so
detection and similar matters related to basal ganglia learn- the ventral vagal complex must intervene to prevent arousal being
ing mechanisms. The influence on the SC then ensures an fatal. This allows survival in the face of overwhelming activation
efficient interaction between orienting to the prey, espe- but the residual autonomic state is unbalanced: the high-revving
cially if it is moving, and the stereotyped movement engine is only just being held by the intense pressure on the brake.
sequences. A continuing episode of activity will require This imbalance – as occurs most obviously in states of tonic immo-
interaction between cingulate cortex and brainstem areas, bility – is readily triggered in less extreme but nevertheless dis-
such as the SC and the pedunculopontine tegmental nucleus, tressing forms for years or decades afterwards. Endogenous
for complex behavioural sequences of response to sudden cannabinoids provide a chemical brake on the glutamatergic acti-
changes in the environment. vation spilling over in excess during the experience of terror [36]
19) Reorganisation of the system to restore the appropriate and they may contribute to peritraumatic dissociation.
level of autonomic functioning, arousal and activation. It is Orientation can be bypassed, incomplete, obstructed or trun-
hypothesized that truncation of the full adaptive orientation cated with residual autonomic and energetic burdens which are
sequence leads to energetic, autonomic and sensorimotor experienced as clinical symptoms. These all acquire a Brainspot
residues which present clinically as anxiety, hypervigilance, through the body’s activation of brainstem structures. The basic
tension, depression, and a negative valence on the self which affects stimulated by traumatic experience – separation distress
may contribute to dysfunctional, relief-seeking behaviours. (PANIC/Grief), RAGE, FEAR, SEEKING safety – all have both PAG
Whether this is in part because of a lack of harmony among and hypothalamic components [37]. If the emotions are not fully
the multiple levels for orientation in the brain remains to be resolved after the trauma has passed their associated energy and
determined. autonomic changes are stored in a dysfunctional form. ‘‘Not
resolved’’ here means that the emotions are repeatedly stimulated
Truncated adaptive orientation and the residues which drive in a way which does not promote reduction in intensity over time.
the clinical sequelae The memory is repeatedly reconsolidated without change in the
affective loading of it. ‘‘Dysfunctional storage’’ implies a ready acti-
Modern warfare employs high velocity weapons which can lead vation of body responses which may not be appropriate to the par-
to death and injury before a soldier is even aware of the presence of ticular contemporary situation. The trauma memories intrude
a threat. He may see his colleague collapse with a fatal wound through body changes in ways which make, for example, easy
before he has had time to register the presence of a sniper. Simi- interaction with others impossible. It may prove to be clinically
larly in road accidents, especially when the vehicle is hit from useful to separate out those truncated responses occurring during
behind, there is no time to register what is about to happen. The orientation to a specific segment of a trauma from those occurring
orientation to threat response is bypassed and the aversive event when the defence responses have been initiated. The grief response
is concluded. Orientation to the realisation of what has happened to the unbearable news of a death, which is just too much to take
may take much longer. Hypervigilance is one consequence of ‘‘an in, has a mesodiencephalic generation with autonomic and ener-
amplified, compulsive version of the orienting response’’ [5, p. getic impacts. Defence responses are not immediately required
156] that channels some of the posttraumatic arousal energy into but may be implemented in an effort to reduce the pain – getting
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angry with the bearer of the news or wanting to run from the sit- 11) The body feeling is activated through different routes but
uation. This dissociation from the truth may be in part neurochem- the primary read-out of the body state is in the anterior
ical – the induction of endocannabinoids or endogenous opioids insular cortex [43]. It is unlikely that any neurochemical
providing analgesia – but its structural roots are in the organisa- truncation occurs in the AIC. A more fundamental conscious-
tion of the orienting brain. Brainspotting targets the truncation at ness of the body state may be arising from the pulvinar [11],
the neural level at which it has occurred. the ILN, or the mediodorsal nucleus [44] and may be subject
Aspects of the orienting response which may be frozen or trun- to peritraumatic disruption at the thalamic level.
cated by neurochemicals mediating stress-induced analgesia and/ 12) Evaluation of the stimulus provided by the trauma mem-
or peritraumatic dissociation include: ory may be mis-informed and appear present rather than
past, for example. In PTSD the functional connectivity of
1) Activation/stimulus selection. The sensitivity of the tectum the thalamus with the anterior cingulate cortex (BA32) and
to specific stimuli may be modified by top-down influences ventromedial prefrontal cortex (BA11) is reduced [45]. This
as has been shown for transcranial magnetic stimulation of component of information processing, when malfunctioning
the frontal eye fields [38]. in PTSD, results in continuing physiological activation when
2) The foveating saccade occurs as the attention shift the cognitive appraisal is, due to circumstances or internal
becomes overt and a gaze shift is initiated by a pause in conflicts, unable to achieve resolution.
inhibitory activity on the substantia nigra pars compacta. 13) The cingulate motor areas and the visceromotor prefrontal
There is here the potential for a Brainspot to be areas and the cortical projections to the PAG act to provide
established. a unified defence response with integrated autonomic,
3) Muscular adjustments for facilitating orienting may be behavioural and emotional components. There is here ample
frozen and even a microfreeze could establish an affec- scope for dis-aggregation of the elements of the response in
tively-charged Brainspot if there is PAG involvement. the memory of an event.
4) Muscular adjustments for orientation and defence. These 14) A continuing episode of activity will require interaction
are the stuff of sensorimotor psychotherapy and are recogni- between cingulate and brainstem areas for complex behav-
sed as potential determinants of the somatic residues of ioural sequences of response to sudden changes in the
traumatic experience. There is no doubt that a freeze can environment. Again there is ample scope for dis-aggregation.
occur at this stage and clinical experience is of an associated 15) Reorganisation of the system to restore the appropriate
Brainspot. It is postulated that the analgesic and dissociative level of autonomic functioning, arousal and activation. Trun-
effects of endogenous opioids and endogenous cannabinoids cation of the full adaptive orientation sequence leads to
contribute to the truncation of a motor sequence which is energetic, autonomic and sensorimotor residues which pres-
then stored in procedural memory circuits. ent clinically as anxiety, hypervigilance, tension, depression,
5) The facial expression and vocalization may be triggered by and a negative valence on the self. The opportunities for
evocation of the original trauma and the associated vocaliza- truncation in the multi-level complex orienting which
tion may be an important component of processing, for engages sensation, defence, attention, arousal, memory, feel-
example, ‘‘leave me alone’’, or simply ‘‘no’’. ing and cognition are many.
6) Activity arrest. The PAG is likely to be the key brain struc-
ture, as has been shown in animal models of tonic immobil- Brainspotting as a therapy for experiences which have not been
ity [39], and it possesses both cannabinoids and opioids for assimilated
stress-induced analgesia.
7) Arousal generated from the brainstem in noradrenergic, Brainspotting (BSP) is a development in psychotherapy which
serotoninergic and cholinergic centres is conveyed through has been originated and described by Grand [1]. It is a novel way
thalamostriatal and thalamocortical tracts to the upper to access the brain’s intrinsic capacity to heal disturbances of men-
structures in the brain. This leads to the establishment of tal and emotional functioning and therefore deserves intense sci-
emotional memories which may be procedural rather than entific scrutiny. Such investigation will be able to shed light not
episodic and may be at the core of what is unprocessed after only on the pathways into healing but illuminate some of the
trauma. The locus coeruleus can be restrained by endoge- organic aspects of the distress-resolution process itself – perhaps
nous cannabinoids which contribute to protection against through the kind of neurophenomenological enquiry applied to
over-activation [40]. preictal states in epilepsy [46]. This is of fundamental importance
8) Identifying and evaluating. The amygdala and prefrontal to the essential nature of any effective psychotherapy which aims
cortex assist in determining the nature of the threat – for healing rather than symptom-reduction.
whether immediate or completed, proximal or distant. It is Distress which swamps the individual’s emotion regulation
postulated that an incomplete resolution of this stage of ori- capacities also disrupts the smooth functioning of the brain’s infor-
enting would lead to a state of prolonged hypervigilance. In mation processing streams. While these have evolved to confer on
the rat cannabinoid receptors are present in the amygdala the human brain an astonishing capacity for information analysis
and in the cingulate cortex [41]. and response generation their very complexity can result in differ-
9) Alertness (with heightened senses) may be incompletely ent strands remaining separate. This disaggregation sends error
resolved and lead to a state of enhanced awareness – a fro- messages into consciousness through unwelcome thoughts,
zen vigilance rather than a narrow attentional field freeze. Of images, affects, moods, and body sensations.
the available routes to cortex from the SC we would favour Experiences which have not been assimilated are tagged by a
the ILN and their role in synchronizing eye movement with body feeling which feels disruptive or distressing. These are
attentional demands when orienting to a threat may need to accompanied by a Brainspot – a spot in the visual field at which
be rapid and attention to the environment sustained. there is resonance with the body activation. For the identification
10) Alertness. This stage can be obstructed in a way which leads of the Brainspot by the Outside Window method, the client visually
to a prolonged attentional field narrowing, possibly a func- tracks the pointer held by the therapist as it is micro-slowly moved
tion of the ILN’s involvement in visual awareness [42]. across the client’s field of vision horizontally at eye level. This
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evinces the reflexive response based on eye position in an activated ing or changes in breath patterns, which argue against a purely
client and this is observed by the therapist. For the Inside Window cortical processing. When the projections from the superior colli-
method the client tracking the pointer identifies the eye position at culi to the pulvinar have parallel projections from the colliculi to
which the activation is maximal by subjectively experiencing the the intralaminar nuclei, Brainspotting allows the appropriate infor-
increase in body activation at a specific eye position. The Brainspot mation file to be opened – and to be kept open while processing
can also be identified by the therapist noticing the eye position occurs.
selected by the patient’s gaze when talking about distressing mate-
rial (Gazespotting): for this the therapist will typically check with
‘‘The unconscious’’, the subcortical, and the journey of healing
the client whether it is indeed a spot associated with activation.
For all of these methods the identification of the Brainspot is fol-
Psychodynamic approaches to the psychotherapy of traumatic
lowed by fixation of the gaze in that position so that processing
experience have focused on the material presented from the
will follow. The Outside Window method provides the most reflex-
‘‘unconscious’’ and used this in various ways to promote healing.
ive and least consciously chosen Brainspot and is therefore the
These approaches have been largely displaced by top-down regula-
most likely to involve brainstem structures.
tory control techniques such as cognitive restructuring. However
The therapeutic frame is structured through attention to the
as the latter are also not 100% effective in all complex trauma dis-
body feelings emerging during recall of the disturbing experiences.
orders [50] there is still a need for psychotherapies which focus on
The therapist’s attuned attention to the client/patient focused on
disturbing clinical features that are not readily down-regulated by
the Brainspot further deepens, it is postulated, the activity in the
force of will or the new perspective provided by a clever rational-
midline prefrontal and insular cortical areas. The emotional aspects
isation. This particularly applies to self-defining experiences which
of this involve the projections from the ventromedial prefrontal
occurred at times of brain maturation such as during preverbal
cortex to the midbrain periaqueductal gray (PAG). The deep
infancy.
somatic attunement in the therapeutic interaction is critical to
In psychoanalysis there was initially a focus on abreactive
the success of Brainspotting and is considered to be part of the
catharsis, ‘‘bringing directly into focus the moment at which the
treatment frame established before processing flows.
symptom was formed, and. . .persistently endeavouring to repro-
duce the mental processes involved in that situation, in order to
direct their discharge along the path of conscious activity.’’ ([51];
Multiple levels of orienting response
Freud translated by Strachey 1914). Then free association, interpre-
tation, and feedback were used to overcome resistance and to help
While the basic orienting response is an oculomotor response to
the patient rediscover ‘‘what he failed to remember’’ [51]. Subse-
a particular stimulus there are more elaborate responses which
quently interpretations of transference phenomena were still
recruit the intralaminar nuclei of the thalamus and the basal gan-
based in the assumption that recognition of a precipitating event
glia and cerebellum. Truncation of orienting is postulated to estab-
was important for clinical recovery. Deterioration during treat-
lish subcortical circuits through the basal ganglia and intralaminar
ment could occur when the ‘‘untamed instincts’’ were released
nuclei which become readily-followed pathways. These may be
by the emergence of repressed memories without constraint; an
dysfunctional and maladaptive rather than always smoothly help-
early description of affective overwhelm in response to resurfacing
ful responses to stimuli. Visual stimuli activate the superficial layer
of a memory which had precipitated dissociation at the time of the
of the superior colliculi but there is then the capacity for an integra-
original event.
tion with auditory, tactile, olfactory and visceral sensations in the
In Brainspotting the reaction to the spot is made with no con-
deeper layers of the superior colliculi. These deeper layers project
scious or wilful intent, as is best exemplified by the ‘‘Outside Win-
to the midline and intralaminar and mediodorsal thalamic nuclei.
dow’’ method in which the reflexive response during the scan of
Attention to the level of activation in the body during the set-
the visual field indicates where processing will best occur.
ting of the therapeutic frame involves the interoceptive loops
through the anterior insular cortex. Body sensations are transmit-
ted to the cortex via spinothalamic tracts which originate in the ‘‘The unconscious’’, the (just) subconscious, and the healing
spinal cord and in the nucleus of the solitary tract [43]. Somatic process
pain is communicated through a posterior part of the ventral med-
ial nucleus (VMpo) or through the ventral posterior medial and lat- According to Merker [11] the first person perspective integral to
eral thalamic nuclei, VPL and VPM [47]. However, there are also consciousness has its origin in the need for action control as the
massive subthalamic projections from the spinal cord back to the sensory experience of the perceived world is a highly transformed
midbrain, especially to the periaqueductal gray (PAG), for trans- cortical construct. The first action tendency, to orient towards or
mission of visceral noxious information [48]. This returns informa- away from the stimulus, occurs in the midbrain. Orientation
tion to the superior colliculi so that there is scope for looping towards a place of safety while simultaneously orienting covertly
through the body and the midbrain – especially where the PAG is to a pursuing threat may be a special case of dual orientation rel-
generating emotional responses. We consider here the subthalamic evant to trauma or the unresolved memory of it. Every cortical area
and indirect spinothalamic flows of information through other has descending projections from layer V pyramidal cells to subcor-
brainstem structures. tical targets such as the basal ganglia, the diencephalon, the brain-
It is possible that the body feelings encountered during the stem and the spinal cord. The midbrain, and specifically the
therapeutic discussion of the traumatic experience are in ‘‘as-if- superior colliculus (SC), acts as the hub which funnels the massive
body-loops’’ [49]; that they are held in cortical body maps rather information load descending from the cortex into an effector out-
than tracing their original pathways from the body to the cortex. put. This in turn influences cortical function via back projection
If this is the case the substrates for healing in Brainspotting may through the thalamus, for example in the pulvinar, to the cortex.
be in the intraparietal sulcus and its memory connections with The colliculus which forms the pivot in self-awareness at the cen-
the posterior cingulate cortex. However the interaction with gaze tre of an individual’s multisensory, phenomenal world is itself out-
direction necessarily involves the midbrain if not structures below side full consciousness [11]. This would imply that the tectal
it. There are also movement impulses, changes in muscular ten- activity could be at times on the verges of consciousness – just sub-
sion, visceral sensations and associated behaviours, such as retch- conscious – and contribute to the feeling of something happening
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in the hinterlands of awareness that accompanies successful pro- ings pulling in memories involve the SC-mediodorsal nucleus path-
cessing in psychotherapies such as Brainspotting. way also, again initially outside awareness. The healing proceeds at
Merker [11] quotes from a 1962 lecture by Denny-Brown in an unconscious level although the subsequent readout of changed
which he wrote: ‘‘Consciousness is a term that implies a subjective feelings and thoughts is necessarily conscious.
element which the physiologist tries to avoid. The mesencephalic
tectum is, however, essential for the reactions we call general
Resonating neurons in the insular cortex during attention to
awareness, for which it has an initiative function, just as its ventral
the body feelings
component, the mesencephalic reticular substance, is vital to orga-
nisation of movement. Further, though there is reason to believe
A pyramidal neuron with a soma in cortical layer V has an apical
that the reactions concerned are at the primitive instinctual level,
dendrite ascending from the top of the soma and an axon descend-
our experiments indicate that they are the essential substrate for
ing from the bottom of it [44]. The axon activates a thalamic neu-
all the more highly developed behavioural reactions. . . The peri-
ron and the return of this activation to the originating cortical
canalicular grey matter of the midbrain has long been regarded
neuron establishes a thalamocortical circuit or loop. The pyramidal
as the essential area for brain function in fishes but its role has
neurons are grouped in minicolumns, structures which have corti-
been thought to have been transferred to the hemispheres in all
cal functions through their organisation into columns. The ascend-
higher vertebrates. . . In the primate nervous system this is still
ing apical dendrites oscillate within a narrow frequency range and
the vital centre of the brain. Its more differentiated peripheral lay-
generally extend to layer I. Their resonating together at a common
ers, the reticulum and tectum, are more essential than the imme-
frequency in a group of columns can be detected by scalp EEG and
diately peri-aqueductal core. . .this small area deserves
the connectivity of two different cortical areas can be achieved
consideration as the most vital for unitary functioning of the
through oscillatory activity in the thalamic neurons serving them
organism. It is the physiological ‘ego’. . . [52].’’
both. Thus activity in the pulvinar may elicit related activity in sep-
Merker [11] favours the pulvinar as the base for the brain’s con-
arated cortical areas during visual attention, for example in the
sciousness space in which feelings and sensations are experienced.
insula and in the parietal eye fields. In complex mental activities
This part of higher-order thalamus is connected with both the dor-
‘‘attention selects a multi-column network whose neural elements
sal and visual cortical visual streams. It is linked with areas integral
are all tuned to a common peak frequency’’ [44]. Minicolumn res-
to memory processing such as the posterior cingulate and parahip-
onant amplitudes may be increased by inputs to the thalamus from
pocampal cortices. It is linked with frontal and parietal eye fields
the superior colliculi when orienting occurs and the required cor-
and with body awareness areas of insular and orbitofrontal corti-
tical areas, even when some distance apart, are then involved
ces. However in the absence of oscillatory binding with the intra-
through similar resonant activity in the thalamic neurons common
laminar nuclei and their projections to cortex the sensory and
to them. The anterior insula has more and larger layer V pyramids
motor activities of the pulvinar do not impinge on the individual’s
than the posterior insula and this may account for the ability to
awareness [53]. The pulvinar requires the intralaminar nuclei for
have a deeper awareness of body feelings with a pronounced emo-
sustained attentional effort which an individual can perceive and
tional component. The sustaining of attention during a psychother-
respond to.
apy session with an intense focus on body feelings would require
This means that information processing engaging the pulvinar
thalamic activity in areas underlying the anterior insula and the
in any sustained fashion will have a parallel projection through
anterior cingulate cortices. In addition to those described by Craig
the intralaminar nuclei to the basal ganglia and cortex. Holding
[43] for the neospinothalamic tract are the mediodorsal nucleus
an attentional gaze on a spot requires especially the central lateral
and the medial pulvinar. Shibata and Yukie [56] describe projec-
and parafascicular nuclei of the ILN [54]. We argue that the intense
tions to anterior cingulate area 24 from midline and intralaminar
body feelings experienced at the time of traumatic experience
nuclei; and projections to area 32 from the mediodorsal nucleus,
engage the intralaminar nuclei more viscerally than the pulvinar.
the medial pulvinar and the midline and intralaminar nuclei. Vis-
The capacity for subcortical loops through these nuclei to be estab-
ceral pain of a physical nature is transmitted to the parafascicular
lished by procedural learning was described by Alexander et al.
nucleus from where the cingulate projections are mainly to area 24
[55] and by McHaffie et al. [12]. Purpura and Schiff [42] propose
although some are to area 25 [57]. It is then possible that the ante-
that the ILN and the pulvinar may act together in certain tasks in
rior insula activity is dependent more directly on resonant activity
which sustained attention in working memory is required. They
in the medial pulvinar and mediodorsal nucleus; and indirectly on
influence layer V pyramidal cells of the cortex which then have
the ILN projections via the anterior cingulate cortex and through
their output back to the SC and the ILN. As processing takes time
sustained attention. This polysynaptic pathway may contribute
in psychotherapy sessions it may be that the oscillatory activity
to the difficulty in accessing the body feelings and body sensations
in the thalamocortical projections to a wide variety of cortical
arising in response to trauma memory, their persistence in
areas is gradually synchronizing during this time.
response to triggers, and the difficulty in sustaining attention in
In summary: The first-person perspective on the world is lar-
the way required for promoting healing.
gely unconscious – consciousness comes in upstream of the colli-
culi possibly in the thalamic pulvinar [11] although visual
awareness may have its base in the intralaminar nuclei [42]. This The body feeling associated with trauma memory activation
places the midbrain and its operations in the psychotherapy and the spinothalamic tracts
unconscious and Brainspotting directly accesses this. However
‘‘all the gaze-related areas in cortex and basal ganglia that receive Trauma therapy emphasises the body feelings and sensations
the collicular signal via the extended intralaminar complex and left behind by the adverse experiences which are then brought to
higher-order thalamus are bound to reflect the play of the collicu- awareness by triggers evocative of the original event. The rele-
lar attention/orienting pointers in their operation.’’ [11]. vance of the triggers – especially with early trauma – is often not
It is possible that in whatever way the Brainspot is formed by recognised in conscious awareness. In 1990 Kurtz [58] described
traumatic experience the therapy session frame opens parallel the incorporation of the body into psychotherapy by a number of
pathways in SC-ILN and SC-pulvinar. If the healing is derived from different approaches and detailed the application of mindfulness.
activity at those levels much of the processing involved feels as if it ‘‘It is a matter of staying a little longer, gathering more information
is just on the edge of awareness – or just outside it. The body feel- and allowing things to happen by themselves’’ [58]. This assisted
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F.M. Corrigan et al. / Medical Hypotheses 84 (2015) 384–394 391

meditation approach to body sensations is also at the clinical core concerned with eye movements. Part of this tract is the spinotectal
of Brainspotting. Somatic Experiencing [5] and Sensorimotor Psy- tract to the superior colliculi for reflex movement of the eyes. The
chotherapy [6] are among the ways in which therapists can be terminations of the spinomesencephalic tract in the PAG are in the
trained in mindful body approaches to the treatment of emotional lateral and ventrolateral columns [48] and are somatotopically
trauma. organised to convey information about superficial, deep, and cuta-
Many of the body sensations associated with trauma are much neous pain. This tract also promotes reflex movement of the head
less discriminated than those carried by the advanced, in evolution- and eyes in response to somatic stimuli. The PAG influences corti-
ary terms, neospinothalamic tract to the insular and anterior cingu- cal activity via the intralaminar, midline, mediodorsal and reticular
late cortices through the ventromedial posterior thalamus. They are nuclei of the thalamus. Most of the thalamic projection arises in
often diffuse, bilateral, and with an emotional or affective quality the lateral and ventrolateral columns of the PAG which may link
which differentiates them from the specific, defined sensations to the paleospinothalamic tract, ‘‘the polysynaptic ascending sen-
associated with non-sensual touch. We consider here that the less sory system thought to mediate diffuse pain and its associated
discriminative medial spinothalamic tract or paleospinothalamic emotional overtones’’ ([48, p. 384], bold added).
tract, which carries information about noxious stimuli experienced
in the body [59], may be more relevant for psychotherapy. (These
The projections of the paleospinothalamic tract to the midline
neurons do not respond to innocuous stimuli other than non-pain-
and intralaminar thalamic nuclei: implications for information
ful taps – which may be important to practitioners of the Emotional
processing
Freedom Technique [60].) The receptive fields for these pathways
are large and usually bilateral so we postulate that they are more
Instead of the ventral posterior (VPL and VPM) or ventromedial
likely to be involved in the chest-gripping, stomach-churning,
posterior (VMpo) nuclei employed by the lateral spinothalamic
throat-tightening experiences encountered with trauma narratives.
tract the paleospinothalamic tract involves some of the midline
and intralaminar thalamic nuclei. The central lateral (rostral intra-
laminar), paracentral (rostral intralaminar), and parafascicular
The involvement of older and newer spinothalamic tracts in the
(caudal intralaminar) were the first to be described as components
processing of emotionally and physically painful stimuli
of the paleospinothalamic tract [59]. The other caudal intralaminar
nucleus is the centromedian nucleus which does not itself have
Primary afferent fibres from the viscera and deep tissues termi-
spinothalamic inputs but is functionally paired with the parafasci-
nate in the spinal cord, mainly in layers 1 and 5 [61]. Lamina 1 neu-
cular nucleus [10]. Other thalamic nuclei which may have paleos-
rons project not only to the thalamus but also to the parabrachial
pinothalamic tract inputs are the paraventricular (midline), the
nucleus, the nucleus of the solitary tract, the nucleus accumbens,
parataenial (midline), and the nucleus reuniens (midline). With
the hypothalamus, the ventrolateral medulla and the cuneiform
the possible exception of the parataenial nucleus, all of these nuclei
nucleus. Lamina 5 may represent a meeting place of pain informa-
of the paleospinothalamic tract also have inputs from the supe-
tion from the skin and muscles and inputs from the viscera. It is
rior colliculi and the periaqueductal gray. Most also have projec-
organised somatotopically and projects not only to the thalamus
tions from the parabrachial nucleus in the pons and there are
but to the cerebellum, the midbrain, and the parabrachial nucleus.
noradrenergic, cholinergic, serotoninergic and histaminergic
The evolutionarily older spinothalamic tract is derived from lay-
inputs from the brainstem. We consider the intralaminar nuclei
ers 1 and 5 and from layers 4, 7, 8 and 10 [61]. Lamina 7 has motor
and those of the medial nuclei with projections from the colliculi
and autonomic functions: inputs from motor cortex, the red
and PAG (paraventricular and reuniens) to be those potentially
nucleus, and the PAG; and outputs to the amygdala and hypothal-
important for the affectively-loaded body feeling encountered in
amus, the cerebellum, the superior colliculus, the parabrachial
treatment.
nucleus and the PAG. Lamina 8 neurons, which are involved in
The thalamic intralaminar and midline nuclei in which the
movement coordination, have input from the PAG and also project
paleospinothalamic tract is terminating have the connections
to the PAG and the cerebellum. Lamina 10, or area 10 [61], is also of
needed for registering the affectively-loaded body sensations
interest as a potential mediator of affectively-charged information
described in psychotherapies like Brainspotting. As well as their
from the viscera as it is activated by somatic and visceral pain and
spinal inputs they are informed by the PAG and the deep layers of
projects to the lateral parabrachial nucleus, the nucleus of the sol-
the SC where the emotional foundation of the Brainspot is thought
itary tract, the amygdala, the PAG, and the hypothalamus.
to reside. Their outputs influence wide areas of limbic cortex for
It is from the deeper levels of the spinal cord that there are pro-
emotional experience and processing and they induce drive, moti-
jections to the intralaminar and midline thalamic nuclei and ‘‘It is
vational and motor responses to the stimuli via the basal ganglia.
hypothesized that the deep neurons are related to aversive
behaviors in response to pain. . . Spinothalamic tract neurons
in laminae 7–10 have large, frequently bilateral receptive fields The intralaminar nuclei of the thalamus: responding to threat
and respond to deep somatic. . .and noxious visceral stimula-
tion’’ ([16, p. 239], bold added). These tracts to the intralaminar There are species-specific motor routines which need to be
and midline thalamus also send collaterals to the medullary retic- deployed immediately at times of danger to ensure safety. A duck
ular formation, the parabrachial nucleus, the PAG, and the nucleus alerted to movement representative of a potential predator will
accumbens. take flight in a different way from a human in a hostile environ-
It can be seen that the midbrain has the circuitry for processing ment who confronts danger. Similarly the fight responses of a
much of the visceral components of the emotions generated in the dog and a human will differ in terms of muscle groups preferen-
PAG and it is able to modify autonomic outputs according to feed- tially engaged and movements enacted. These routines can be
back from the body. There are body–spinal cord–midbrain loops practised by the young of the species during play fighting and it
engaged in emotional activity in response to internal or external is interesting that Panksepp [4] emphasises the parafascicular tha-
stimuli which are relatively remote from cortical control. lamic nuclei for the generation of rough-and-tumble PLAY. The
A separate spinomesencephalic tract passes from laminae 1, 5, parafascicular nucleus is in the group of caudal intralaminar nuclei,
6, and 10 to the deep and intermediate layers of the superior col- with the centre median, or centromedian, nucleus, implicated in
liculi, the PAG, the cuneiform nucleus, and a number of nuclei limbic motor functions [62]. This group has outputs to motor and
 109
392 F.M. Corrigan et al. / Medical Hypotheses 84 (2015) 384–394

PAG

SC deep layers

Raphe nuclei Visual, somatosensory

Locus coeruleus and secondary motor corces

Central lateral nucleus Posterior cingulate and retrosplenial
Cuneiform nucleus
(Anterior or rostral corces
Substana nigra
intralaminar)

Caudate
Paleo Anterior
STT Putamen cingulate
cortex
Parafascicular nucleus

(Posterior or caudal
Parabrachial intralaminar)
Medial PFC
Nucleus (PBN)
Motor cortex
Nucleus of the
Solitary Tract Subthalamic nucleus
(NTS)
Nucleus accumbens
Deep
cerebellar Frontal eye fields
nuclei

Fig. 1. How affectively loaded information in the paleospinothalamic tract (paleoSTT) can influence orientation, arousal, motor responses, and cognitive awareness and
attention through the intralaminar nuclei.

somatosensory cortices and to dorsal and ventral striatal regions. and anterior cingulate cortices [64]. There is also a reciprocal con-
The connections of the caudal intralaminar nuclei confer a role in nection between the frontal eye fields and the parafascicular
motor responses to salient stimuli for which cortical processing nucleus which may be significant for saccadic eye movements [10].
is potentially too slow. Peritraumatic orienting and defence move- In Brainspotting the inner experience described often includes
ments come into this category; and those accompanied by the diffuse peripheral sensations, muscular twitches and motor
basic affective responses to trauma engage the caudal intralaminar impulses. These would perhaps fit better with a non-discriminative
nuclei in subcortical loops through the basal ganglia as described processing of affective sensory information through the midline–
by Alexander et al. [55]. These same nuclei are also a crucial com- intralaminar thalamic nuclei than the discriminated flow through
ponent of the medial pain system and receive somatosensory infor- the dorsomedial and ventromedial nuclei. Vogt and Sikes [65] con-
mation from the intermediate and deep layers of the superior sider the projections from the parafascicular nucleus in response to
colliculi [63]. Their placement allows them to integrate the cortical a noxious stimulus to induce body orientation through the poster-
and limbic levels above with the brainstem below. They may act in ior midcingulate cortex and avoidance behaviour through the ante-
concert with the midline nuclei to raise the level of the entire basal rior midcingulate cortex. There is thus a multi-level motor
ganglia–thalamocortical system [31]. This is important in terms of response that includes, above the brainstem, one from the dorsal
the somatic residues of traumatic experience because adversity striatum and one from the cingulate motor areas. As with orienta-
sufficient to stimulate the noradrenergic, serotoninergic and cho- tion the different levels of response available are more likely to
linergic systems of the brainstem would increase vigilance, arousal, result in a failure of integration when levels of affect are very high.
and the readiness for orienting and defence responses through the The central lateral nucleus has inputs from the reticular forma-
midline–intralaminar complex. Sensory information that is more tions, the raphe nuclei, the substantia nigra pars reticulata, the
affectively-loaded may be alerting to new and potentially danger- superior colliculi (intermediate and deep layers of the SC [9]), the
ous situations so that the rapid, spontaneous basal ganglia PAG (all four columns [66]) and the LC. Cortical inputs are from
response can occur first and then be rapidly modified by the corti- anterior cingulate and retrosplenial cortices but also from some
cal input. This is dependent on the parafascicular nucleus output to visual, somatosensory, auditory and insular areas. There are out-
the dorsal striatum. puts to the anterior and posterior cingulate cortices and to the cau-
The parafascicular nucleus has inputs from spinal cord, reticular date–putamen. The striatum is the main target.
formation, locus coeruleus, dorsal raphe nuclei, NTS, PBN, substan- The key intralaminar nuclei are in a position to integrate corti-
tia nigra pars reticulata (SNpr), zona incerta (ZI), pretectum and cal and brainstem inputs, to have a motor effect through the basal
striatum. The intermediate and deep layers of the SC project to ganglia, and to have a motivational effect through the nucleus
the parafascicular nuclei [9]. There is a significant input to the accumbens. A functional link between the rostral and caudal ILN
parafascicular nucleus from the ventrolateral and lateral columns is suggested by imaging the impact of deep brain electrical stimu-
of the PAG and a lesser input from the dorsolateral and dorsome- lation of the intralaminar nuclei (ILN). Implantation of an electrode
dial columns. The main output is to the striatum – both dorsal into the parafascicular nucleus of the rat leads to increased glucose
and ventral – and the striatal area served by the parafascicular utilization in the central lateral and paracentral rostral ILN [67]
nucleus receives afferents from prefrontal, entorhinal, perirhinal (see Fig. 1).
 110
F.M. Corrigan et al. / Medical Hypotheses 84 (2015) 384–394 393

The paleospinothalamic tract has collateral projections to the The central lateral nucleus, one of the rostral intralaminar
reticular formation, the tectum, and the PAG. When double-label- group, receives spinothalamic inputs important for motivational
ling is used to identify collateral projections to the intralaminar and affective responses to pain [16]. Many of its neurons respond
nuclei and the PAG, neurons projecting to the intralaminar nuclei only to the viscera and mediate the attentional, emotional, motor,
and to the PAG were found in layers 1, 5, 7 and 10 of the spinal hormonal, and autonomic consequences of noxious stimuli [73].
cord, but predominantly in layer 7 and area 10 [68]. This is further Cortical projections from the central lateral nucleus include
evidence of there being wiring available for the complex process- somatosensory areas. The more discriminated pain sensations tra-
ing of affectively-loaded stimuli in spinal cord, brainstem and tha- vel to somatosensory cortex via the ventral posterior medial and
lamic structures which have retained the evolutionarily-older lateral (VPL and VPM) nuclei [73,47] and the posterior part of the
pathways. ventromedial nucleus (VMpo [43]).

The self and the interactions of the superior colliculi with the
Healing at the midbrain origins of the truncated adaptive
PAG
orientation
Panksepp [69, p. 200] ‘‘proposed that the foundation for the
That which cannot be looked at can continue to trouble indi-
self is concentrated in centromedial mesencephalic tissues
rectly through unpleasant sensations, disturbing emotions, and
where all basic emotional circuits converge to generate instinc-
even dispiriting cognitions and self-appraisals. To fully see what
tual survival-promoting behaviours and gut-level affective
is there, to rob it of its power to paralyse gaze before it focuses
experiences which may constitute the primordial form of con-
on that which is intolerable, requires a deep level of attunement
sciousness in mind/brain evolution.’’ This midbrain area contains
between patient and therapist and a liberation of an endogenous
‘‘a basic neuropsychic homunculus, grounded in action urges, from
healing process. The self is redefined by the altered orientation:
which a variety of core emotional states of being could emerge.’’
what I orient towards or away from is fundamentally changed
Self-representation ‘‘has to be built upon stable motor coordinates,
and with that shift in perspective is the new feeling of who and
such as the somatic motor map nestled between the visceral inte-
what I am. The adaptive orientation can occur from the spinal cord
grations of the PAG ventrally and the somatosensory fields of the
to the neocortex and is only complete when all organised layers of
SC dorsally’’. We consider the basic action urge to be orientation
the brain, with their templates laid down through the course of
towards or away from a stimulus. An internal sensation would
evolution, have been harmonised. The memory fragment which
draw our attention towards it in a way which ties in the visual field
provided the access to the stored traumatic material has been inte-
and the body awareness. The apparatus for this is in the superim-
grated into a smoothly functioning system [74]. The self is reorgan-
position of the superficial layers of the SC with the intermediate
ised from its base in the deep layers of the spinal cord through the
and deep layers. Panksepp, again [69, p. 204–205]: ‘‘In the evolu-
brainstem, thalamus, striatum, cingulate cortex and neocortex.
tion of consciousness, integrated action tendencies, perhaps still
Orientation is completed at all levels of the MindBrain and healing
reflected in our emotional urges, came before any thought could
that is deep and powerful ensues. Brainspotting provides the set-
be generated about how to act.’’ The PAG and the intermediate
ting in which such healing can occur and is therefore an ideal lab-
and deep layers of the SC project to the intralaminar thalamic
oratory for neurophenomenological enquiry.
nuclei with the paleospinothalamic tract where an early integra-
tion of affectively-loaded visceral sensation, orientation to an
affective stimulus, and affective response may be channelled into Financial support
basal ganglia and cortical substrates for complex motor and cogni-
tive programmes. No financial support was provided for the writing of this paper.

Autonomic functioning, emotional and physical pain, and the

Conflict of interest
intralaminar nuclei
There is no conflict of interest.
The parabrachial nuclei participate in autonomic function as
they interact with reflex mechanisms based in the medulla and
also with higher regulatory centres [70]. With the nucleus of the References
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 Brainspotting Outside Window Set-Up

1. The beginning - choose the issue

2. Check on activation
3. SUDS Level (0 to 10)
4. Location of activation in the body
5. Slow horizontal eye tracking to locate reflex
spots observed in the eyes, face and body
6. Focused Mindfulness (Processing)
7. Go back to the beginning to assess change
8. Squeeze the lemon
The Brainspotting Inside Window Set-Up

1. The beginning - choose the issue

2. Check on activation
3. SUDS Level (0 to 10)
4. Location of activation in the body
5. Find highest activation tracking horizontally
at eye level (X axis)
6. Then track above, at and below eye (Y axis)
for the highest activation to locate
brainspot
7. Focused Mindfulness (Processing)
8. Go back to the beginning to assess change
9. Squeeze the lemon
 Gazespotting
1. Notice when a client is looking (gazing) unconsciously at a
fixed point while talking about a relevant, activated issue

2. Point out that the client is gazing at this spot and ask for
the SUDS level and location of body activation

3. Encourage the client to keep looking at Gazespot while

not speaking (to initiate processing)

4. Continue client processing on the Gazespot with focused

mindfulness for full processing of the issue.

5. Go back to access change. Check the SUDS level

6. Squeeze the lemon (only if SUDS is zero)

 Body Resource Set-Up

1. Have client choose the issue

2. Check on activation- allow time for client to
connect to the issue, help them activate if
needed
3. Get the SUDs
4. Get body location of the activation
5. Have client scan body for most grounded,
neutral, or calm location in the body (body
resource)
6. Locate eye position most connected to the body
resource spot, tracking at eye level on their Left,
Center, and Right (X Axis)
7. Then, track above, at, and below eye level (Y
Axis) to determine the eye position most
connected to the body resource spot
8. Bring the original issue back into focus on the
resource eye position, then focused mindfulness
(Processing)
9. Go back to the beginning issue to assess change
10. Squeeze the lemon if SUDs is at zero and there is
time left