Emmett Miller MD: Patient/Client Information

Patient/Client Information

Wise Use of Medications
New Patient/Client Information Form
Changing for Good
How to Use Dr. Miller Tapes

The Wise and Effective Use of Psychoactive Medications

It is only after the most careful consideration that I choose to recommend medication. During recent years a number of excellent medications (effective, with few side effects) have been developed. In numerous studies, these have been demonstrated to be of unquestionable value in the treatment of mind-body conditions. My own experience is that when they are used judiciously, they markedly extend the value of other, non-drug treatment. Used in this manner, side effects are generally few, and rather easily controlled, either by temporarily lowering the dosage, or by slowly "ramping" up to a therapeutic dosage at the beginning of treatment.

Often, when starting a medication, I suggest beginning at a very low dose—sometimes less than a child’s dose. In many cases this may mean cutting tablets in half or quarters. In this way, if there is an allergy or side effect it is usually very mild, and we can take appropriate measures. Ramping up allows the body an opportunity to "get used to" this new chemical it has to absorb, distribute and dispose of. But, because we are starting with such a low dose, and gradually increasing it, you may need to be a bit more patient in waiting for the desired therapeutic effect to begin.

What are the medications designed to do?

Antidepressants

Depression, in most cases, is an imbalance in the internal chemistry, often inherited by your brain from previous generations. It may be triggered by external events. Symptoms may vary greatly from person to person, and the diagnosis must be made by evaluating a number of factors. Some people feel a slowing down (retarded depression), while others feel "speedy" (agitated depression). The mood may be one of sadness, but may be anxiety, anger, or even or numbness. Sexual interest may be increased or decreased, and appetite for food may increase or decrease. Sometimes there may be no apparent mood shift, but physical symptoms may dominate. There is usually, however, a noticeable lack of joy in daily activities, and a lack of creativity and concentration. Although sometimes after a major loss in your life you may develop some of the kinds of symptoms we associate with "depression," these are usually mild, and always rather short-lived. A clinical depression may not follow any particular stressful life event at all.

In most modern studies comparing the treatment of depression by various psychotherapeutic techniques versus medication, medication turns out to be more effective than psychotherapy alone, but the best results are obtained when both are used together. The medications I prescribe are designed to move those brain chemicals back to a more healthy balance. This allows for improved functioning and a lessening or disappearance of symptoms. Sometimes this change can be noticed during the first week or so after you begin the medication, but more commonly, it takes three to five weeks to fully evaluate the effect. (This may be even longer, since we often ramp up from tiny doses.)

How long will I have to take these medications?
Generally speaking, they should be taken for at least a number of months before we consider changing them. We can then discontinue them (often it is wise to ramp down from certain of these medications, especially Effexor and Paxil). In my experience, if appropriate therapy and self-healing strategies are used in a committed way, the resolution of symptoms is much more rapid. If symptoms return (and remember, it will probably take as much as four to six weeks for them to return—many people won’t feel any different at all. If the brain slips back to its previous state of functioning, we may elect to re-start this or another medication.

Fortunately, for many people, after the first course of treatment, the brain seems to "reset" itself and no further medication is needed. Self-healing techniques should continue to be used, as they may prevent the return of symptoms. Sometimes, however, depression may return. In such cases, immediate help should be sought, therapy instituted, and it may be nipped in the bud, and more quickly resolve.

What antidepressants do you commonly prescribe?
Among the more effective antidepressant medications are:

Buspar (buspirone), Celexa (citalopram), Effexor (venlafaxine), Paxil (paroxetine), Prozac (fluoxetine), Remeron (mirtazapine), Serzone (nefazedone), Wellbutrin (buproprion), Zoloft (sertraline)

Sedative-hypnotic Medications

Most of these belong to a class known as benzodiazapines. They tend to produce mental, physical and emotional relaxation. They also have a mood stabilizing, calming effect. Of course, the most common side effects of these medications have to do with drowsiness, inattentiveness, feeling a bit dizzy, out of balance or "spaced out." So, if you’re taking one of these medications, be especially careful when you’re doing things that require your full attention—such as operating a moving vehicle or other dangerous machinery. (See below) Always call me if any questionable symptoms arise.

Many of the herbs and non-prescription supplements and over-the-counter remedies may contain ingredients which may add to the effect of sedative-hypnotic medications—in some cases even producing loss of consciousness. Valerian root and kava-kava are frequent offenders. Alcohol and other "recreational drugs" may also have an impact. These should be avoided, except under close supervision by qualified professionals.

What are the typical sedative-hypnotic and mood stabilizer medications you prescribe?
Valium (diazepam), Xanax (alprazolam), Ativan (lorazepam), Klonopin (clonazepam), Restoril (temazepam)

The following are also mood stabilizers, but are in a different, though similar, class from the benzodiazapines.

Depakote (sodium valproate), Lamictal (lamotrigine), Lithobid (lithium carbonate), Neurontin (gabapentin), Tegrital (carbamazepine), Trileptal ((oxcarbazepine)

Topamax (topiramate)

Stimulant medications

Some people have a malfunction of the brain in which certain portions of the brain seem to be underactive, almost as though some of the important cells of the brain are fast asleep. A classic example of this is what is often termed "Attention Deficit Disorder." In such cases the prefrontal cortex, the seat of the "executive functions" (organization, planning, impulse control, concentration, etc.) seems to be underactive. Stimulant medication may serve to "wake up" this part of the brain.

The side effects of these medications, while they can run the gamut, generally are related to their primary effects—they include nervousness, jitteriness, trembling, over-excitability, insomnia, etc.

Typical stimulant medications
Adderall, Adderall XR, Concerta, Cylert, Desoxyn, Dexedrine, Metadate, Ritalin

What can the side effects of a medication be?

A basic rule of thumb is: "any medication can cause virtually any side effect." Occasionally, a medication may even make worse the symptom that required its use in the first place, though usually this phase is temporary. And, as mentioned, most side effects are dose-related, and by starting with minimal doses, we are generally able to keep the occasional side effects mild and temporary.

So, rather than list every possible side effect, I would rather you be aware that you are introducing a new substance into your body. Although it will probably be accepted without incident, please remember that if any unusual symptom appears, consider that it might be a side effect of the medication, and call me with any questions you may have. If you wish a complete list of side effects and possible untoward reactions, I will be happy to provide this.

What about possible drug interactions?

It is very important that you inform me of any other medications—prescribed, over-the-counter, "alternative" medications, or remedies, you are using before we begin treatment. Further, make sure that if any other physician starts a medication, that he or she is aware of the drug you are taking, and inform me at your next visit as well. In the extremely rare case of an emergency, due to an allergic reaction or inadvertent overdose, call your family physician or 911.

Be especially careful if you plan to go diving. It is possible certain medications will have a more pronounced effect in the depths of the ocean.

Avoid the use of alcohol or other mind- or mood-altering chemicals when using psychoactive medications, unless you have cleared their use with your physician.

If you have questions about any specific medications, you can go online to: http://www.Mywebmd.com or to http://www.drugstore.com.

Drug-Drug Interactions
Any two medications, including over-the-counter and "natural supplements," may interact with each other. This may result in one medication being either inactivated or potentiated. It is important that every physician that treats you knows of any over the counter medication, herbal medications, or any nutritional supplements or vitamins you are taking. St John’s Wort has, for instance, has monoamine oxidase activity and can cause severe reactions when used with common SSRI antidepressants. Gingko, as well as some other common herbs can interfere with bleeding time and can cause hemorrhage if they are not stopped a week before surgery. L-tryptophan, when taken at the same time as an antidepressant, can cause a severe "serotonin syndrome," with unpleasant and potentially dangerous results. Grapefruit juice can slow the metabolism of some medications, such as Buspar, and should be used with caution.

Remember, when you discontinue certain medications it is highly advisable to do so gradually. Suddenly stopping a medication you have been on for some time, especially mood stabilizers and anti-anxiety medications, can cause unwanted and sometimes dangerous withdrawal symptoms if they are stopped abruptly. If for any reason you need to discontinue medication you have been taking for some time, call me or obtain other qualified medical advice.

Just to be on the safe side I usually suggest you begin with a miniscule dose, perhaps 1/4th of the normal starting dose, on the first day you’d see whether there is any kind of allergic reaction. Doses this small should have virtually no specific effect; their effect should be virtually undetectable.

What kinds of side effects can I expect?

It is generally a good idea to not expect any side effects, since there are often none, and we don’t want a negative placebo effect. In general, any medication can have any side effect. Side effects and reactions to drugs are extremely idiosyncratic. Technically speaking, any drug can cause any reaction from upset stomach to headaches to death. The medications I prescribe are generally very safe, the side effects are mild or infrequent. Aspirin’s side effects run for several pages. Most of the medications I use, in the way I use them, have few side effects, and these are usually mild and quickly remediable. The most common side effects fall into a few general categories, and vary according to the type of medication.

Upset stomach—usually relieved by taking the medication with meals

Drowsiness—which we often treat with lowering the dose and ramping up more slowly. Be aware of your functional capacities if there is any drowsiness with any medication. This is especially true if you are going to operate a motor vehicle or any other dangerous machinery, be involved in an activity (such as ice skating, etc.) Do not engage in these activities if your performance is significantly impaired. Use your common sense.

Dizziness or loss of equilibrium—Occasionally this, or a "spacey" feeling, may occur as the body is adjusting. If this is present, avoid activities where this might become a problem (rock climbing, hang-gliding, etc.). If it does not clear in a few days or if it is so severe that it significantly interferes with your activities, please call me.

Other occasional side effects include: Excessive stimulation or wakefulness, trouble sleeping, headache, drowsiness, fatigue, nausea, vomiting, diarrhea, loss of appetite, dry mouth, sweating, dizziness, lightheadedness, alteration of sexual function, weight gain or loss, change in taste, nervousness, or tremor. If they continue or are bothersome, please tell me at your next visit, or before. Such side effects are usually mild, if they occur, and there are measures we can take to counteract these effects. Sometimes we need to switch to another medication with a different side effect profile.

CALL ME AS SOON AS POSSIBLE, IF ANY OF THE FOLLOWING OCCUR:

(or, if contacting me is difficult at the time, check with your primary care physician or pharmacist). In any life-threatening emergency, call 911.

Continuing headache, skin rash, blurred vision, or continued weight loss, sore throat or fever; sudden, onset of a cold sweat, dizziness, fatigue, or shakiness; vision changes; confusion; lack of concern; personality changes; thoughts of suicide; or painful or prolonged erections.

If you notice other effects not listed above, please let me know.

Summary

Many effective medications have been developed in recent years, and by using them judiciously, wisely and sparingly, they have proved to be of immense value to my patients. To give them a proper trial, they need to be taken as directed for sufficient time to affect your inner chemistry in the desired way.

Because we usually start at a very low dose, several increases are the rule, and often the effects are unnoticed until sufficient time at the target dose has elapsed. This is your body, and you must feel O.K. about what we are doing, and be committed to being a full participant in the process of taking your medications, just as in the other aspects of healing and psychotherapy. Together we can create success!

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Changing for Good

Practical Suggestions for Personal Change

Congratulations! You have already taken the most difficult step on the path to progressive growth—you’ve decided you want to change.

To break longstanding habits and establish new ones, you need skills as well as knowledge. Your Dr. Miller cassette or CD will teach you the needed skills. In addition, here are some practical hints that can help you achieve your desired goals.

Go gradually, one problem at a time. Trying to lose 40 pounds, learn Chinese, and make a career change all at once is asking a lot of yourself. Take it easy.
Define the problem. Write it down very clearly and specifically, and then list the pros and cons of the behaviors you want to change—including the benefits you derive from these behaviors (so-called "secondary benefit") and also the problems it causes for you. Be honest with yourself—write down everything you can think of, and spend some time reading what you’ve written. For example:
"I smoke a pack a day. It gives me something to do with my hands, calms me down, helps me concentrate, and makes me look cool. It costs a lot, makes me smell, puts people off, wastes time, brands me as an "addict," and harms my health.
Define your goal, and write it down in detail. Make it simple, measurable, and attainable. "I will be district manager by the end of the year." Imagine how you will be when it is achieved. Part B of the tape, and Part C, if your particular program has one, will help you formulate your goals. Take easy, incremental steps. If you want to lose 40 pounds, made a series of goals of 10 or 15 pounds each. Smaller, intermediate goals won’t intimidate you, and one by one they’ll add up to the outcome you want.
Make a concrete plan. Write down the specific steps to reach your goal. "I’ll do aerobics on Monday nights, go running after work Wednesdays and Fridays, and cycle on Sundays. I’ll keep a calorie diary for one month."
Make your commitment firm and real with a contract. The contract should spell out your goal, your plan, and a reward. Rewards don’t have to cost money or be fattening—an evening with friends, a Saturday at your workbench, or a luxurious, scented bath can be enticing enough. Be inventive. Reward each achievement on the path to your final goal. Sign your contract, and have someone witness it. This is for real!
Keep records. A diary is a powerful aid to change. Make columns for What, When, How Often, Where, How Much, and Comments. You can record calories, minutes, pulse rates, miles, thoughts, feelings—anything that is important to you. Set aside a few minutes each day to do this. Every now and then, check yourself out and see how you’re progressing. If you haven’t done what you wanted or expected, can you see why not? If you repeatedly fail to reach a particular goal, perhaps the timing is wrong. Then, revise your goal to one you know you can achieve. This is YOUR program.
Counteract negative mental chatter with positive thoughts. If you keep thinking, "Oh, I’ll never make it. It’s too hard," silently repeat to yourself something like, "I’ve done difficult things before and I can do this one too." Counteract "I’m just the fat type" with "If I eat right and exercise regularly, I’ll become fit, not fat." Remember—you are doing this for yourself. You are worth the effort. As long as you are trying, you are not a failure. If you feel your motivation slipping, enlist support from family and friends, and use Part A of the program again. Good luck!

A. Suggestions for Using Dr. Miller Tapes and CDs

Be comfortable. Let your whole body sink downwards, imagining it being attracted by the force of gravity. If you lie down, let your spine sink towards the surface you are on, especially at the waist level. When lying on a flat surface, it usually helps to raise your knees, with you feet about shoulder width apart and the toes pointing inward just a little to keep your knees from falling outward.
Relax the muscles of your face, shoulders, and upper back. Don’t be concerned about what you look like!
Breathe from your diaphragm, so that your lower belly, of abdomen, rises a little as you breathe in, and sinks back as you exhale. Imagine a balloon inflating and deflating your belly. Don’t hold your belly in, military-style—let it "hang out."
Try to listen to the tape in a room that has a soft, gentle lighting—a shaded lamp is better than a ceiling light, and both are better than a fluorescent lamp.
Isolate yourself. Arrange your listening sessions so that you won’t be interrupted by the telephone, family, or visitors. (You can put a note on the door and leave the phone off the hook.)
Listen in a quiet place. If there are disturbing sounds, it is often better to "white them out" with a steady background noise, like a fan or an air conditioner. Best of all, use stereo headphones to listen to the programs—the kind that cap your ears is the best.
Keeping your eyes closed can help you concentrate. You may want to keep them open at first, to make sure you "keep track", but eventually you’ll probably want to close them. You can take your glasses off, too.
Deep relaxation may surprise you. You may become more relaxed than you are used to, and even feel that you’re a little bit out of control, but you’re not. Just clench a fist, open your eyes, say something out loud, and you’ll soon see who is in charge!
Ignore distractions. Don’t worry if you find you have a stream of thoughts going through your mind while you’re listening. Most people do. Let the thoughts come and go, without paying them any particular attention. If you find your mind following a train of thought, don’t get upset—just let the thought go, focus again on what you hear on the tape, and move on.
Don’t tell yourself that you are doing this wrong. There is no one "right way" to do it. Exactly what you are doing is right for you at the time. Like all skills, this one takes learning and practice. You will become more proficient with time.
Go with the flow. You may have some novel sensations, perhaps a feeling of light floating or if tingling in your hands. Don’t worry about such mild and unusual experiences. Enjoy them, and recognize that they reflect the positive inner changes that you are undergoing.

Don’t forget why you are doing this! It is for your Well-Being, for your Growth, and your Complete Enjoyment of Life. Our Good Wishes are with you!

How to Use Dr. Miller Tapes

You will find these explanations and instructions especially useful for using tapes made specifically for you during a private session. They may also be helpful in self-healing with tapes you have purchased online. Please read this material two or more times to make sure you fully understand the concepts presented. Though deceptively simple, they have been developed over a period of twenty years of careful research and application and are extremely powerful.

Many of us would like a cookbook formula for how to resolve our physical, emotional and relationship problems and to lead a successful, healthy, happy life. But due to the enormous differences between people and their experiences, there is no such single formula applicable to everyone. Still, these goals are achievable. The path to their achievement leads through self-awareness, self-responsibility and self-expression.

In this journey, knowledge, perspectives and techniques can be of enormous value, but ultimately the final answers and choices must come from your own inner wisdom. A physician, therapist, counselor or guide can serve as an expert consultant who can reflect, clarify and suggest options. By following those suggestions that feel appropriate to you and noting carefully the results, you gradually develop your own unique personal system for living your life with greater quality, success, health and joy.

Similarly, the tapes and CDs you receive are guides, which are, when used properly, very potent tools for personal growth and healing. The successes others have achieved working with such tools have been stunning, and the failures are most often due to using them improperly or not using them at all! They cannot help you if they remain comfortably nestled on your bookshelf.

About Choices
Developing the ability to make important life choices,—choices that are healthy, mature, appropriate and wise—is a very central goal of our work. Behavioral approaches, such as the ones we are using, to learn new, more effective mind/body responses can be very powerful. Please understand, however, that you are not being "programmed," you are being given the tools to program your own mind and body. We are working entirely with positive reinforcement: awakening and supporting positive perspectives and behaviors. Mental, emotional and physical behaviors learned in this way can always be overridden consciously if you so desire. You will always be able to recreate your previous dysfunctional behaviors if you want to (it's not clear why anybody would ever want to, but the choice is still yours). Further, you will be able to invent new, even more functional behaviors at any time. Our goal is definitely not to create an automaton!

How to Select Among Your Tapes and CDs
If you have several sessions with Dr. Miller, you will soon develop a collection of tapes. The question arises as to what is the best way to use them. There are three basic types of tapes that may be produced at each session:

Conversation, or Insight Tape: This is, essentially, a recording of important portions of your interaction with Dr. Miller during the session. The tape of each session should be reviewed at least once, preferably twice before your next session, and depending upon the amount of new material, perhaps more often than this.
Deep Relaxation/Image Rehearsal—these consist basically of training in relaxation and seeing yourself in a positive light. Part of the tape made at your first or second session is usually of this type, although additional training tapes in other aspects of relaxation or hypnosis may be made at other times. The ability to relax, to reach a positively affirming state of "I Am", and to picture yourself in an enthusiastically positive light is the most fundamental skill you will learn.

Use these tapes or CDs two or three times a day until you can reliably follow the suggestions, relax, and experience yourself in a positive way. You will probably be able to do this within a period of a few days to a few weeks.

As you become more proficient, occasionally turn off the tape part way through and continue the experience from memory. Finally, practice carrying out the entire imagery process from memory. You may discover you can do this in 1/4 to 1/2 the time it takes on the tape! As in learning any new skill, if you practice at the same time, in the same place each day (at least in the beginning) you will learn easier and faster.

Relaxation is the antidote to stress. First, you will learn to enter deep relaxation during your session. Then, in a graduated fashion, you will expand this ability so you will be able to relax in a safe, familiar place at home. Next, you will learn to relax and hold a positive image anywhere at home, with or without the tape, and finally to be able to enter this relaxed state anywhere, even during periods of stress, simply by traveling over the now familiar mental pathway.

An important side effect of this ability is that your overall stress level will decrease—you will feel generally more relaxed wherever you are, whatever you are doing, eyes opened or closed, standing still or moving, while simultaneously experiencing yourself in a positive, successful light.
Desensitization/Reconditioning/Rescripting Tapes and CDs. It is very important to use these tapes frequently, especially immediately following the session during which they were made, especially when they follow a Selective Awareness Exploration (age regression analysis and synthesis—see description below). Because they deal with specific dysfunctional response patterns—mental, physical, emotional and habit—their effectiveness can generally be measured by the degree of disappearance of those dysfunctional patterns and their replacement with positive, healthy patterns.

Changing Your Behavior Patterns
In your work with Dr. Miller, whether it is counseling, therapy or performance enhancement, you will probably be examining unwanted behavior patterns you employed in the past. This may involve the recent past (such as last week) or the distant past (such as young adulthood, childhood or even infancy). The kinds of behaviors you examine may include:

Physical behaviors—such as nail biting, smoking, codependence, or alcohol usage.
Physical symptom behaviors—like headaches, fatigue, high blood pressure or arthritis.
Thinking behaviors—such as worrying, procrastination, obsessiveness, or lack of concentration, or
Emotional behaviors—such as anxiety, fear, anger or depression.

You will discover that the offending behavior is customarily associated with certain specific situations or events. (E.g., "I tend to get a headache when I have an argument.")

Developing a new way of relating with the world will involve achieving insight, discovering new perspectives, and learning new skills, techniques and approaches. Two most important tools for changing these patterns are deconditioning (or "deprogramming") the old response pattern and writing a new script (or "program") that is more to your liking. This process includes creating the new pattern, and teaching it to your body and nervous system.

The Selective Awareness Exploration
A most powerful method for gaining understanding and insight into dysfunctional behavior, patterns of thought, emotion and behavior is the Selective Awareness Exploration, a therapeutic approach Dr. Miller developed in the early 1970s.

The Exploration utilizes powerful perspectives and approaches drawn from numerous fields, including Psychoanalysis, Meditation, Autogenic Training, Gestalt and Jungian Psychology, Hypnosis, Behavioral Psychology, Family Therapy and Transpersonal Psychology. The typical Exploration involves several steps:

Entering a deeply relaxed state through Selective Awareness.
Exploring, memory by memory, the offending pattern back through time as far as possible, to discover that moment (or those moments) in your life at which this dysfunctional perspective, expectation and behavior was first learned by your mind/body (inner child work).
Experiencing (in the safety of the deeply relaxed Selective Awareness state) the appropriate emotions in the appropriate historical contexts (healing the inner child). Catharsis, emotional accessing, understanding, and increased awareness occur at this point.
Analyzing this series of memories using the mature, nurturing, wise adult perspective to develop insight and understanding. Guilt, shame, fear, and excess anger often dissipate at this step.
Formulating a new, more functional, more appropriate, more reasonable approach to life challenges, armed with the insight gained in step 4.
Deconditioning and Self-nurturing—Now that a new psychological and emotional perspective has been developed, you relive these same memories. This time, however, you relive them with a new understanding, and with a sense of being completely relaxed. Re-living them without the original reaction breaks the internal conditioning. The inner part that had been carrying out the old behavior is treated with kindness, respect, and understanding by the nurturing adult part.
Rescripting—The next step is to relive the memories and write a new "script" for yourself—one in which you are more in charge, more empowered, grounded, self-accepting and independent—in short, in which you possess the traits and abilities which could bring about success in such situations. As you go through each of these scenes, you reenact it according to this new script as though you were a playwright improving upon the script for an actor or actress.
Future Pacing—Finally, you project ahead to similar situations that are likely to occur in the future, this time envisioning yourself meeting such challenges with the new perspective, with new feelings, and with new behaviors. This provides a kind of "post-hypnotic suggestion" to encourage the new behavior automatically.

Writing Your Own Life Script
During your Exploration, a tape recording will usually be made which features a guided imagery experience specifically for the reconditioning/rescripting phase. The theory behind the regular use of this cassette is that the mind/body/emotions/behaviors need to be trained if a particular desired behavior is to become the new, automatic or "default behavior". You can't learn to play the piano or to type without practicing, no matter how well you understand the principle (insight). So when we are changing a maladaptive behavior that has been the standard response for years, the need for such a training phase is even more necessary. No matter how deep your insight, no matter how clear your understanding, no matter how great your desire to change, no matter how clear your decision, in most cases this is not enough. Practice with a new behavior is necessary. Here's how to get the most out of the rescripting process:

Deconditioning "Negative" Emotional Reactions. When your Exploration has involved a great deal of emotion, it is usually advisable to use the tape two or three times a day for at least several days following that session. Each time you listen, any residual emotional reaction will become less and you will feel more calm and empowered. Practice with it at least until the negative emotions are no longer present as you listen.
Rescripting. With a rescripting tape, you must first enter the relaxed state. If listening to the relaxation imagery on this tape is not sufficient, rewind the tape at the end of the relaxation portion, and repeat it, or alternatively, precede the use of this tape with another tape that relaxes you more deeply. Being relaxed as you go through is essential.
Generating Memories for Rescripting. Once you have reached the deeply relaxed state, you will re-view, at each session, two or three memories that fit the pattern. These memories may be those reviewed or uncovered during the Exploration or they may be others that you recall that fit the pattern. It is good to carry a notebook or journal with you during the day—a similar memory may occur to you as you're driving along and jotting down a word or two to remind you of it will help you to keep hold of it. Because these memories are associated with past pain, there's a tendency of the brain to deny, suppress and to attempt to forget them. Once you've written them down, however, they cannot get away!
Creating a Hierarchy of Memories. (This rather explicit and focused way of working with memories is of value primarily in the event we are dealing with phobias and specific fears that cause strong emotional reactions. If simply thinking about your memories causes you to feel fear, anxiety, terror, anger, or other strong emotion, then creating a hierarchy is probably a good idea.) The choice of which memories to begin with is an especially important one when you are dealing with a phobia or any pattern that involves a very strong emotional response. It is wise to construct a hierarchy based upon the amount of tension/fear/emotion associated with each. (If there is very little emotion associated with these memories, you can skip this step and go on to Step 5.)
Reducing the Score. The easiest way to do this is to write a couple of words that will identify each memory on a 3 x 5 file card, using a different card for each memory. For example, your cards might say something like the following: The fear I had at the interview for the city job. Or, the time I got in trouble for being late so much. Or, when the doctor said I might have cancer.

Once you have a set of cards (and this set can be added to as more memories arise) write a number between 1 and 10 on each card. This number will be a measure of the degree of fear/tension you have associated with that memory. A memory that you can think about and even visualize while remaining completely calm would get a score of 0 or 1. A memory highly associated with anxiety and tension (such as watching a friend die) might receive a score of 10. All the other cards will receive a number based on their ranking along this spectrum.

As you work with the tape, you now begin by relaxing with your desensitization tape, and while deeply relaxed, re-viewing those three that have the lowest number (e.g., those with the number 1). As you're able to relax while you re-view memories of Level 1, you will move on to memories of Level 2, on to Level 3 and so forth. You'll discover that by the time you get to Level 4 or 5 you are able to relax just as fully as when you re-viewed memories of Level 1. In fact, do not go on to higher levels until you have made significant progress in remaining relaxed while re-viewing those memories while feeling relaxed. When the emotion associated with a memory is reduced to nearly zero, you can remove the card from the stage. You are finished with this stage when you have eliminated all the cards.
Writing a New Script. Once you have been able to relive those memories feeling calm and relaxed (i.e., once you have inhibited the negative emotional response through relaxation), you now will relive the memories, but this time you will "change history," by imagining yourself behaving differently, changing what you think, say, feel and do.

Clearly, you cannot go back and change history in a physical sense. But, like a parent showing their child how to avoid putting their shoes on the wrong feet, you can go back and demonstrate to your deeper mind another option for behaving that it was not aware of at the time. As you go through the scene, reliving it according to a different script, imagine the different impact this would have had on the environment. Imagine people responding to you differently, imagine yourself being successful where before you failed, imagine yourself feeling really good about how things come out!

You may find it useful to create a hierarchy of memories, as in Step 4, giving higher scores to those you find it most difficult to imagine a positive, adaptive response to.
Future Pacing, (Future Projection). In addition to teaching the mind how to handle the pattern as it has occurred in the past, you also wish to create a positive expectancy within your deeper mind that future situations of the type you have been exploring will be handled in the new, more adaptive, way. To help you do this, the tape will guide you to project forward into the future, to picture in your mind a future situation that might occur which fits the old stimulus pattern, and in which you will have an opportunity to behave according to the new response pattern. Then, just as you wrote a new script for the past memory, you will write a desirable script for this "future memory."

As you listen to the tape and project forward into the future, the procedure will be similar to that used in re-viewing past memories. If the thought or image of a possible upcoming event (an interview, for example) produces emotional distress, or if you have a difficult time even imagining yourself handling this situation appropriately, then it's a good idea to create another hierarchy—making a set of 3 x 5 cards listing on each a different situation, a number which corresponds to the degree of difficulty, etc. and proceed as in step 4.

As you go through the event in your mind, imagine yourself handling it the way you really want; thinking the way you want to think, speaking the way you want to speak and acting the way you want to act. Emotionally, feel positive, strong, and filled with courage, enthusiasm, and a real sense of inner triumph. If it is difficult to do this at first, it is satisfactory simply to feel calm and peaceful as you go through the memory, then gradually teach your nervous system how to feel more positive, exuberant emotions.

Sometimes spaces are left on the tape to give you more time to "get into" a particular imagery experience. If more time is needed than is allowed on the tape, please pause the tape until you have finished completing the last instructions.
Confronting an Actual Challenge. Of course, the point of all this inner training is to prepare you to deal with challenges in the "real world." How quickly you notice the effects depend upon the severity of the pattern you are dealing with, among other things. Some people find that immediately following the session their behavior in the real world has changed. For others the change may happen more gradually, over days or weeks, and require more inner practice.

Again, if there is a great deal of strong emotion or self-doubt associated with the pattern, it is wise to create a hierarchy of challenges, then take them on one at a time, dealing with the easiest first. For instance, being assertive with your children may be easier than being assertive at work, which in turn may be easier than being assertive with your spouse.

If you follow this program as laid out here, gradually you will notice your progress in the outside world paralleling your progress through memories and through your mental imagery future projection exercises. Gradually you notice yourself able to handle more and more major challenges with greater and greater competence and with greater and greater rewards.

How long to continue working with each tape
Use each tape one to three times a day for a week or more. The exact length of time is dependent upon the pattern you are changing. Often, a given pattern has several parts and you may receive several tapes and CDs dealing with different aspects of it. Use your own judgment as to which to use, depending upon which aspect is most in need of work. The most recent are often the most valuable to use.

The amount of time you continue to use the tape will vary from person to person. The goal is to change your reactions and your behaviors. At first, the tape will be used one to three times a day for a week or two or more, depending upon whether another rescripting tape is made for you during the next visit.

Within one to three weeks your attitudes, reactions and behaviors in the identified (target) situation will tend to be different—more positive, more the ones you desire. When you feel secure in the new reaction and behavior, and the new response and behavior pattern, the tape will have done its work and there's generally no need to continue listening on a regular basis (though there's no harm in doing so if you wish.) It is a good idea to decrease your use gradually, cutting back to once every other day, then once or twice a week. Following this, you should store this tape some place you know where to find it with your other self-development tapes, to be used on an occasional basis, or for review should a particularly stressful or intense challenge come up again in the future. In a sense, you are building a "psychological medicine cabinet."

Additional Aids to Personal Growth
There are many things you can do between visits to improve the speed, depth and quality of results. These include listening to the tapes and CDs regularly and frequently, creating a personal journal, making lists of various types, reading appropriate books, meditating and exercising regularly, filling out charts and feedback sheets, and so forth. This brings up the question—How often should I listen to the tapes and CDs, how many additional tasks should I take on?

The future is in your hands; the responsibility is yours. If you take on a set of tasks that is unnecessarily complex and exhausting, you will soon know it. If you make this error, the proper response is not to quit, but to simplify. If, on the other hand, you underestimate the amount of application needed, you will soon recognize this too, as your results will be inadequate. In this case, the wise response is to increase your efforts.

The guidelines presented here will help create a success you can be proud of. If any questions come up which are not answered here, do not hesitate to contact Dr. Miller.