A CBT therapist wonders why the client is so adamant about letting go of unhealthy core values. A psychodynamically trained therapist wonders if might be acceptable to assign homework. How can each of them stretch beyond their initial learning without going back to school?
My training was in classical psychoanalysis, but soon after I entered practice, I was challenged by early life trauma, for which I had no preparation, then addiction. From trauma work I gained a lasting interest in how therapy works, and from addicted people I came to appreciate the power of behavior. Gradually I tried integrating different approaches, and, in the process, became a better therapist.
The Affect Avoidance Model is a way of simplifying and unifying our thinking about problems that are treatable in psychotherapy. It is based on a Darwinian view of the mind/brain and, with a minimum of adjustment, is compatible with all traditional and contemporary theories.
The core proposition of the Affect Avoidance Model is that: Essentially all the pathology treatable in psychotherapy (excluding primarily biological conditions) is a result of the mind/brain’s instinctive avoidance of actual or predicted negative affects.
It would certainly simplify things if such a broad statement were true. But could such a broad principle actually apply to the vast range of problems that bring people to therapy? The answer is actually, yes, but how it is true requires a bit more explanation. First I’ll show how this idea makes sense, then I’ll go through a catalog of pathologies and show that it actually does apply.
Psychological theories tend to be rooted in philosophy and overvalue consciousness and rational thought. This time, let’s approach pathology from a more biological point of view, starting with the mammalian brain from which ours evolved. Neurobiology views mammals as possessing a brain admirably adapted for survival of their species. It’s basic functioning is to appraise incoming information, including that from the animal itself, comparing this to expectations and past experience, and to make predictions about the survival value of what is encountered. Roughly, circumstances divide into either opportunities or dangers. Research, especially on fears and bodily needs, shows that this appraisal triggers emotional circuits and motivational circuits. These energize and direct behavioral reactions, again in relation to past experience and expectations, that are adapted to promote the species.
The Human Mind/Brain
Humans have the same capability of appraisal, emotional activation, motivation and reaction. In addition, we have consciousness. It turns out, however, that somewhere between 95% and 99% of information processing goes on outside of consciousness. We are privy to a small, but greatly prized, sampling of our own mental activity.
Work with alcoholics in early recovery gave me insight into how our human capabilities work together with those we have inherited. One of the reasons AA promotes sponsorship is that in early recovery, it is very common for alcoholics to have ideas pop into their consciousness that, if followed, will soon lead to relapse. The sponsor, having been there before, is more able to recognize when it is “the disease talking.” The most common example is the thought, “maybe I’m not really an alcoholic,” which regularly floats into awareness. Logically, this leads to the next thought, that drinking on a controlled basis should be possible. Hopefully, the addicted person listens to the sponsor and realizes that those thoughts had a purpose and elects not to follow them.
These observations show an important way in which consciousness works. The essence of the addiction is this: Mammalian emotional and motivational circuits have been hijacked into “believing” that survival of the species depends on getting the next drink. They have the capacity to generate thoughts that promote what the mammalian brain determines is best for the species. Mammals are doomed to follow such “thoughts” (perhaps in the form of images or impulses) on into action. The small variation that is (relatively) unique to humans, is that we have the capacity to think out the possible consequences of our own thoughts and to recognize which ones are consistent with our conscious values and goals.
The implications are profound. What this means is what every therapist has observed, that our conscious stream of thoughts is actually an unlabeled mixture of ideas whose origin is either from our mammalian instincts or from our rational thinking. In my experience, listening to the subtlety of alcoholic thoughts, the mammalian brain has the same IQ as the rational one. It even knows how take advantage of “one thing leads to another” as it works to overcome rationality and achieve its aim. At this point, I am ready to postulate that 200,000 years ago, when homo sapiens first evolved, and much of our mental architecture was as it is now, it is likely that this kind of competition between reason and instinct actually gave a survival advantage. In other words, our Dionysian and Apollonian tendencies create an adaptive balance that has helped us thrive under rapidly changing conditions.
Let’s take another example. The most common phobia is fear of public speaking. Our rational mind determines that this is the opportunity of a lifetime, but instinct, perhaps more adapted to life 200,000 years ago, says that speaking out is tantamount to challenging the alpha human and potentially dangerous. We are left to struggle within ourselves to determine which tendency wins out.
Avoidance of Negative Affect
Many therapeutic traditions have identified fear and avoidance of painful, overwhelming, or uncomfortable emotions as the basis of pathology. The problem with this view is that many instinctive reactions happen without conscious awareness of negative affect. Modern neurophysiology helps resolve the dilemma. Our “core” emotional circuits, listed as rage, fear, lust, care, panic, and play by Jaak Panksepp (2012), a pioneer in emotional biology, are closely analogous, anatomically and physiologically, to those of other mammals. These deep circuits, as opposed to conscious feelings, are what trigger those maladaptive reactions that are the targets of psychotherapy.
The important subtlety that the field of psychotherapy is just beginning to absorb is that conscious affect does not have a simple 1:1 relationship with activation of core emotions. For example, a narcissistic individual may have no awareness of a threat to self-esteem yet issues an insult automatically with no conscious thought. Furthermore, the subtle emotions we express in poetry may be far more complex and nuanced than the excitation of limbic neurons. We may also be intellectually aware of some sensations we identify as “feelings” in the absence of activation of core emotions.
What does appear to be important for the field of psychotherapy is that when we are aware of affect, defined as conscious feeling accompanied by visceral concomitants, it is a good indicator that core emotions have been activated. This is important because the two main ways that therapy can modify instinctive reactions require that core emotions be activated. Until we have instruments to detect the state of these deep emotional circuits, the best way we have of knowing they have been activated is the conscious experience of affect. Because the model is aimed at helping with clinical practice, it puts the emphasis on affect rather than core emotions.
Below is a schematic view of the organization of the human mind/brain for self-protection showing how processing multiple inputs leads to activation of core emotions, then to the production of familiar contents of consciousness.
Not only does the mind/brain’s apparatus produce thoughts, its products also include conscious feelings, impulses to act, and visceral sensations such as a pounding heart or tingling in the abdomen. Like automatic thoughts, all of these products have a powerful influence on our decision making, for better or worse.
The next proposition of the Affect Avoidance Model is fairly self-explanatory: Patterns of Appraisal and of Reaction, after they are first elaborated, are stored in memory as information, verbal, nonverbal, procedural, declarative, embodied in the synapses that make up neural networks. They tend to be re-used in later situations, but their form often reflects the developmental assets available at the time of their origin.
More significantly for the purposes of therapy is the next proposition: Those maladaptive patterns that are the focus of psychotherapy are essentially always instinctive reactions to negative core emotions. One of the rare exceptions is that addiction is sometimes initiated by the seeking of pleasure. One reason for this bias towards avoidance of negative core emotions is that evolution spends more energy reacting to danger than to opportunity. More importantly, the more dire the danger, the more any attempt to modify or soften an established defensive reaction is appraised as an additional threat. The result is that the mind/brain works to resist change in defenses, even when they are maladaptive. This is known in practically every therapeutic tradition as “resistance,” the instinctive tendency to avoid therapeutic change.
The Affect Avoidance Model goes on to specify the following with regard to the action of psychotherapy:
So far, neuroscience has only identified three ways in which therapy can change or override maladaptive patterns held in memory:
- Add new learning of healthy patterns of appraisal or reaction.
- Block, by inhibitory signals from the cortex, the ability of core emotions to trigger an unhealthy reaction. This is called extinction and requires simultaneous activation of the core emotion along with exposure to “disconfirming” information, for example, conditions of safety instead of threat.
- Reconsolidation. This is a recently discovered mechanism by which the connection from an appraisal to the core emotion responsible for triggering a maladaptive reaction is “unlearned.” This, too, requires simultaneous activation of the core emotion along with disconfirming information.
This very limited number of low level change mechanisms has profound implications for understanding the action of psychotherapy. In order to accomplish these three end results, all varieties of psychotherapy are ultimately aimed at accomplishing one or more of these seven objectives:
- Help the client acquire new, healthy information, both verbal and experiential.
- Identify and challenge maladaptive patterns of appraisal and reaction.
- Required for both extinction and reconsolidation: Activate troublesome affects that have been responsible for maladaptive reactions.
- Also required for extinction and reconsolidation: Simultaneously expose the client to positive disconfirming information. Often, especially with nonverbal patterns, a positive therapeutic relationship is the vehicle for providing this disconfirming information.
- Facilitating motivation for change may be needed to overcome instinctive resistance and to encourage “behavioral experiments.”
- Since excess or insufficient levels of arousal inhibit these change processes, an additional function of therapy is to help modulate the level of arousal. Once again, the therapeutic relationship is a prime instrument.
- Ensure safety and informed consent.
The combination of #3 and #4 is equivalent to Franz Alexander’s classic “corrective emotional experience.”
Is All Pathology Affect Avoidance?
Finally, as promised at the beginning of this article, I’ll argue that essentially all the types of pathology that can successfully be treated in psychotherapy have in common that they are instinctive reactions to appraised danger triggered by the activation of core emotions. In other words, the Affect Avoidance Modal applies to everything a therapist can treat. The grouping below are based on forms of defense against danger rather than diagnostic categories. This taxonomy is intended to be useful to the clinician in that therapy within each group tends to require similar approaches.
It is also important to note that in actual clinical practice, these avoidance mechanisms occur in layers. Most clients exhibit multiple layers. Pathology often starts with one layer, then, under the threat that that layer may fail, additional layers are elaborated. In therapy, we usually start with the most accessible and identifiable layers and work down to those that were established earlier and are most resistant to change. This list is taken from a draft paper by Smith and Johnson, visible on ResearchGate.com under the name Jeffery Steven Smith.
- Automatic relational patterns: These are the characteristic reactions of attachment disorders and personality disorders. They are learned as adaptations, mostly to adverse conditions, and are maintained mainly because they shield the individual from corrective experience (Bowlby, 1968; Levy, Johnson, Clouthier, Scala, & Temes, 2015). For instance, one with borderline personality may learn at a young age that the only way to obtain care from one’s parents (and avoid core emotions related to unfulfilled interpersonal needs) is to cut oneself to the point of needing medical attention. However, this individual may later repeatedly lose close relationships as an adult due to cutting when distressed.
- Maladaptive emotional reactions: Depression, obsessive compulsive symptoms, anxiety disorders and dissociation make up this group and can arguably be seen as resulting from the mind/brain’s self-preservative functions gone awry. Anxiety may serve to deter an individual from entering dangerous situations, but when misapplied, also narrows the individual’s world, preventing positive experiences as well. Importantly, psychotherapy aims not to eliminate the often-strong biological component of these conditions (i.e., the goal is not to prevent one’s vital ability to experience anxiety), but to strengthen coping with anxiety and redirect the individual’s (maladaptive) efforts to eliminate uncomfortable emotions. Similarly, in depression, which evokes a tendency to isolate and self-protect, behavioral activation (Martell, Dimidjian, & Herman-Dunn, 2013) helps to reverse this protective mechanism when it becomes inappropriately applied or detrimental. Likewise, one may dissociate during highly stressful or traumatic experiences in order to mentally distance and protect oneself from being overly taxed by stress, but psychotherapeutic treatment aims to reduce the impact of traumatic events so that, indirectly, the biological support for dissociation will be eliminated (Foa, Rothbaum, Riggs, & Murdock 1991), thus lessening the negative effects of posttraumatic symptoms on the individual’s wellbeing.
- Maladaptive internalized ideals, values, attitudes, and prohibitions: The quintessential example is identification with the aggressor, in which the individual, driven by the need for interpersonal connection or with the goal of self-preservation, by molding to the wishes of an aggressor, identifies with the attitudes of the abuser towards the self (Ferenczi, 1949; Frankel, 2002). The result is pathological shame and low self-esteem (Stuewig & McCloskey, 2005). Internalization of these important types of mental content can be recognized by inappropriate shame and guilt.
- Maladaptive ideational models: Learned semantic information about the way the world seems to work can lead to maladaptive goals and responses (Persons, 2012; Clarkin, Yeomans, & Kernberg, 2005). These are based on a higher cognitive level than automatic relational patterns (cf. Bowlby, 1968), and have more ideational content. An example is a belief that only if one is perfect, can one be loved.
- Guilty quests: This group includes the classic Oedipus complex, in which the individual’s pursuit of his or her most cherished goals is internally inhibited, resulting in repeated failure to achieve what is most desired in adult life. Inhibition, originally to avoid feared retribution or loss of important relationships, is generalized to the point of blocking healthy and appropriate pursuits.
- Addictions and compulsive behaviors: Maladaptive behaviors, driven as much or more by pain avoidance than pleasure seeking (e.g., Cooper, Frone, Russell, & Mudar, 1995), grow out of behaviors that distort basic biological motivational systems (e.g., dopamine receptor activation; Hyman & Malenka, 2001), which then operate dysfunctionally and override the ability of conscious free will to control them.
To summarize, the Affect Avoidance Model holds that pathology addressable in psychotherapy consists of instinctive but maladaptive patterns of appraisal and reaction to internal and external inputs, evaluated outside of consciousness as dangers. Among the products of this process are conscious thoughts, feelings, impulses and visceral reactions, which further influence decision making. Modification of these patterns requires changes in stored information, making use of a very limited number of neurological pathways. All effective psychotherapies seek to affect these pathways via seven distinct objectives, most prominently, new learning and the simultaneous activation of core emotions and presentation of disconfirming information. Finally, the argument is presented that all individual pathologies treated in clinical practice can be understood within the unifying framework of the Affect Avoidance Model.
The aim of this model is to simplify teaching of psychotherapy and ongoing clinical formulation for purposes of therapy. In addition, it provides a common framework from which researchers and practitioners can more easily understand techniques from different traditions and evaluate clinical decisions about where and how to combine techniques in working with individual clients.
For more about the Affect Avoidance Model, see the bookstore at http://www.howtherapyworks.com. Psychotherapy: A Practical Guide is for professionals and How We Heal and Grow is intended for consumers.
Bowlby, J. (1969). Attachment and loss. Vol. 1: Attachment. New York: Basic Books.
Cooper, M. L., Frone, M. R., Russell, M., & Mudar, P. (1995). Drinking to regulate positive and negative emotions: A motivational model of alcohol use. Journal of Personality and Social Psychology, 69(5), 990–1005. http://dx.doi.org.ezaccess.libraries.psu.edu/10.1037/0022-35184.108.40.2060
Ferenczi, S. (1949). Confusion of tongues between adults and the child (The language of tenderness and of passion). International Journal of Psycho-Analysis, 30, 225–230.
Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treatment of posttraumatic stress disorder in rape victims: A comparison between cognitive-behavioral procedures and counseling. Journal of Consulting and Clinical Psychology, 59(5), 715–723. http://dx.doi.org.ezaccess.libraries.psu.edu/10.1037/0022-006X.59.5.715
Hyman, S. E., & Malenka, R. C. (2001). Addiction and the brain: The neurobiology of compulsion and its persistence. Nature Reviews Neuroscience, 2(10), 695. https://doi.org/10.1038/35094560
Levy, K. N., Johnson, B. N., Clouthier, T. L., Scala, J. W., & Temes, C. M. (2015). An attachment theoretical framework for personality disorders. Canadian Psychology/Psychologie Canadienne, 56(2), 197–207. https://doi.org/10.1037/cap0000025
Martell, C. R., Dimidjian, S., & Herman-Dunn, R. (2013). Behavioral activation for depression: A clinician’s guide. New York: Guilford Press.
Panksepp, J., & Biven, L. (2012). The archaeology of mind: neuroevolutionary origins of human emotions (1st ed). New York: W. W. Norton.
Persons, J. B. (2012). The case formulation approach to cognitive-behavior therapy. New York: Guilford Press.
Stuewig, J., & McCloskey, L. A. (2005). The relation of child maltreatment to shame and guilt among adolescents: Psychological routes to depression and delinquency. Child Maltreatment, 10(4), 324–336. https://doi.org/10.1177/1077559505279308
© 2018, Jeffery Smith MD