“Process Empowerment” to enhance any therapy

For Therapists

My story:
Decades ago, I saw how early trauma patients avoided recalling their most terrible experiences, but when they finally brought them into their sessions, healing was rapid and permanent. However those same patients also suffered from low self-esteem, and helping them with that was slow and uncertain. Not only was it very hard for them to see themselves as valuable, but a bad turn of events and the old negative feelings would return. Clearly these were different healing processes. One was rapid and permanent and the other was slow and subject to relapse. I concluded that they must represent two quite different low-level mechanisms. This discrepancy caught my curiosity to the extent that I consciously dedicated my career to understanding just what was going on in therapy. Just recently, neurophysiological research has begun to converge with clinical observation in a way that is bringing some answers into view. Here is what is I see today.

What’s new
When the stars line up, maybe nature is trying to tell us something. That is exactly what is happening in the field of psychotherapy. The same details described for years by clinicians are showing up in recent neurophysiological research. We are experiencing a convergence of knowledge that is illuminating the toughest problem the field has faced: How psychotherapy really works.

The latest discovery is reconsolidation. Early in my career, long before the phenomenon had been discovered, I had the privilege of witnessing pure reconsolidation. I was working with a patient who had been horribly traumatized early in life. It took years to peel away the layers of defense that kept her most horrific memories at bay. We knew we were getting close when she began asking, “what is the color purple.” A few weeks later she recalled that it was the color of the mercurochrome that she, as a young child, applied to her wounds. Soon, over the course of two extended sessions, the story came out in detail, as she re-experienced the trauma along with intense feelings of fear, pain, and horror. Remarkably, after reliving both the events and the feelings, she became calm. The emotions had healed. They had lost their threatening power. What remained was a dull ache and a feeling of exhaustion. Those memories never caused trouble again. There were other traumas, which healed in the same way. Once recalled, none of those experiences led again to the same alarm, upset, and efforts at avoidance as before.

Clinical observation and Freud’s writings
In the early 70s, trauma was for military psychiatrists and bypassed by mainstream practitioners. As trainees in the Freudian tradition, my fellow residents and I had all purchased the collected works of Freud. I knew that trauma was something I knew little about, so I consulted the early writings of the master. Somewhat to my surprise, I found that his first experience of the power of psychotherapy was in treating early life trauma. Not only that, but his experience was very much like mine. In 1893, he formulated the principle that “each individual hysterical symptom immediately and permanently disappeared when we had succeeded in bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect…”

Soon I realized that this dramatic healing (Freud called it catharsis) was not seen every day. It was not even the bread and butter of therapy, but was repeated regularly with my early trauma patients. This dramatic healing process seemed specific to horrific traumas that patients had lost from conscious memory.

Therapy parallels neurophysiology
In 2004 I wrote a paper entitled, “Reexamining Psychotherapeutic Action Through the Lens of Trauma,” contrasting two healing processes. That same year, unbeknownst to me, Duvarci and Nader, a team of neurophysiologists, published findings that explained in detail the basis of the first of those processes, the one in which distressing affects were “detoxified.” They described the mechanism of reconsolidation in which a learned fear reaction could literally be erased. What they found was that, in rats, and later in other mammals, including humans, when the memory of a scary event was recalled, for a period of a few hours afterwards, the neural connections that tagged that memory as frightening could be de-activated, so that the same stimulus would no longer cause a fear response. The change was permanent, but could only happen with there was vivid recall of the triggering event, that is to say, full activation of the neurons representing the originally frightening situation and accompanying emotions.

The phenomenon was called reconsolidation because, in the wild, the most likely scenario would be that the original frightening experience would be repeated and further reinforced. In trauma therapy, as with my patients, we want the opposite. We try to disconnect feelings of fear from reminders of the original situation. We could call that “deconsolidation,” but the original term has stuck and is now the accepted way to describe the permanent erasure of emotional associations to a recalled circumstance.

Now we can line up some stars. First, Freud said that emotion had to be activated. That was identical to what I had experienced. Furthermore what we had witnessed wasn’t mild or intellectualized emotion; it was full bodied affect, defined as awareness of emotion along with the bodily sensations that tell us the emotion is fully present in the room.

This matched Duvarci and Nader’s research. Learned fear in the laboratory had the same characteristics as the healing of traumatic affects in therapy. In both cases, there was a full re-awakening of the memory with affect, followed by resolution of the acute upset. Revisiting the memory no longer elicited the same dread or painful response.

Could the two phenomena be the same?
Some have argued that reconsolidation cannot happen in clinical work because too much time has passed between childhood and adult therapy, whereas the animal experiments are done over a much shorter period. However, Freud’s and my observations took place under very specific circumstances. In our cases, the events recalled had been driven entirely out of consciousness through dissociation. Events and feelings had been walled off and kept hidden for decades until they were recalled in therapy. In effect, therapy was the first time they had been reactivated since the traumas first happened. Thus, the degree of emotional activation was actually very close to that of the animal experiments where memories were also reactivated for the first time since they had been laid down.

Those are not the only stars that line up. In order to remove or “erase” the connection between the memory of the events and the emotional tag, “corrective” information must be present. Thus, a second condition is required for reconsolidation, that during a few hours following activation of the memory and emotions, the context must be distinctly unthreatening. In other words, where the original stimuli were associated with danger, they must now be experienced in a situation of opposite valence. Only then, can the previous connection between the triggering circumstance and fearful affects be removed.

In my experience it was mostly the therapeutic relationship that conveyed safety. Interestingly, this condition was implied, but not mentioned by Freud. My patient became engulfed by the experience as if it were taking place in the here and now. Intuitively I sensed the importance of keeping her aware of the therapy room and my presence. An occasional word was enough to maintain that dual consciousness, and therefore, a context of connection and safety. In his formulation, Freud did not mention the importance of his own presence. As a Victorian scientist, he was probably trying to be “objective,” which meant ignoring the impact of the therapist as a person. The fact that his patient felt safe enough to access very troubling material, suggests that Freud’s presence, too, created a contrasting atmosphere of safety against the backdrop of his patient’s traumatic experiences. Similarly, in Duvarci and Nader’s animal experiments, reconsolidation required that the “unlearning” situation must present an absence of the frightening elements present when the fear reaction was first learned.

The next alignment of stars is the fact that reconsolidation is permanent. Here, once again, there is a match with the clinical observation that the healing I had experienced and that Freud had described was permanent and not subject to relapse. Even with the passage of time, these old memories never regain their frightening quality. Reconsolidation, as far as is known at present, is the only neurophysiological mechanism in which already established fear reactions can be changed permanently without being subject to relapse or return of the fear at a later date. Notably, there is a precise alignment between the two conditions required for healing, the time course of events, and the characteristics of the result. In each detail, Duvarci and Nader’s findings matched up with Freud’s and my clinical experience.

Linking reconsolidation with an established clinical principle
Now we can line up another very bright star. Reconsolidation lines up perfectly with one of the most powerful and robust concepts in clinical psychotherapy: Alexander and French’s 1946 “corrective emotional experience.” Here is their definition:

“to reexpose the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences.”

This concept embodies the same two requirements, activation of emotion and the role of corrective information. Since first described, it has been applied to a wide range of therapies and therapeutic situations. It clearly applies to my patient’s terrifying experience and that experience matches the characteristics of reconsolidation. Thus we have a close parallel between a key clinical formulation and the precise neurobiology of reconsolidation.

A working hypothesis
It is theoretically possible that the mechanism of change might be different in clinical situations other than learned fear or dissociated trauma, but so far, reconsolidation has been extended to other areas such as addiction and shows promise of applying broadly. In the absence of contradictory evidence, it is reasonable, even advantageous, to adopt the working hypothesis that reconsolidation can be taken as one important underlying explanation of the corrective emotional experience. On that basis, we can offer the following general formulation:

Permanent therapeutic modification of established maladaptive reactions to emotionally charged stimuli, can be accomplished by activation of the relevant affect in a context that contradicts the original threat in a manner consistent with the mechanism of reconsolidation.

Reconsolidation is not the only change mechanism.
Before the reader concludes that we now understand how therapy works, there does exist another, distinct change mechanism with significantly different characteristics. Pavlov coined the term extinction to describe the phenomenon by which learned fear reactions would eventually fade away if repeated enough times in a “corrective” context. The difference is that, in contrast to reconsolidation, extinction is not permanent. Without periodical reinforcement, the original fear reaction eventually returns. Perhaps this was the mechanism behind the healing of low self-esteem that was so much slower and uncertain compared to healing by reconsolidation. Remarkably, though, extinction has the same two requirements as reconsolidation. There must be activation of the relevant emotion, and the situation must also present corrective information. So what is the difference between extinction and reconsolidation?

Researchers looking at learned fear in other mammals have precisely clarified the difference. By disabling first one, then the other mechanism, researchers were able to show the underlying neurobiology of each. In extinction, unlike reconsolidation, the cerebral cortex is the source of inhibitory signals sent to the amygdala and limbic system. There, the triggering stimulus is still interpreted as a threat and limbic emotional circuits are still activated, but the next step, a protective reaction, is inhibited. The therapeutic result is similar to reconsolidation. The animal or person no longer reacts intensely to the triggering stimulus. However the differences are that a single exposure is not sufficient and, as inhibitory signals fade, the original fear reaction returns. In contrast to reconsolidation, the learned association between the stimulus and fear circuits remains as it was. Only the reaction to the fear is changed.

Protocols for exposure therapy generally include both repetition and activation of emotions, for example, repeated sessions where battle sounds are played for a war veteran. Since the conditions required for both are so similar, there remains controversy about which one might be operating in a given clinical situation. The most telling observation would be whether or not healing remains constant without further reinforcement.

My early clinical experience appears to represent a pure instance of reconsolidation. Repetition was not required and the result was permanent. On the other hand, in general clinical practice, as in the archaeology of Egyptian tombs, it is unusual to find a instance where the past has never before seen the light of day. Thus it may be more common that therapeutic benefit represents some mixture of reconsolidation and extinction. In order to bias as much as possible towards reconsolidation and permanent change, we may wish to elicit events and accompanying affects in their full and precise form. For example, eliciting specific details of a soldier’s experience may be more valuable than reminding him or her of the general experience of battle. Less sharply defined and intense re-experiencing may still be helpful, but appears more likely to be mediated by extinction, rather than reconsolidation. Perhaps future research will help us learn better when and how we can bias therapy more towards reconsolidation and less towards extinction.

Conclusion
Thus, Alexander and French’s corrective emotional experience can actually utilize either of two distinct pathways. We could formulate the principle as follows:

The corrective emotional experience, that is, the therapeutic modification of established maladaptive reactions to emotionally charged stimuli, takes place when the relevant affect is activated in a context that contradicts the original threat. Such transformations can be hypothesized to be based on the mechanisms of reconsolidation, in which case the change is permanent, and/or extinction, requiring periodic reinforcement.

Three applications of this principle
Exposure therapy is one clear example. Protocols ask for activation of emotion and require a context of safety. While the use of this therapy for PTSD is obvious, an interesting variation is exposure therapy for OCD. In that therapy, voluntary behavior change, that is, prevention of the usual anxiety-relieving behavior, results in the patient experiencing activation of intense anxiety. Since this happens in a context where it is clear that threatening consequences do not happen, once again we have the conditions for a corrective emotional experience.

Second, in psychoanalytic therapy, the phenomenon of transference brings out intense emotions as if the therapist were literally a figure from the past. With interpretation and insight, the patient comes to absorb the fact that the emotions are really from another time and place. The simultaneous experiencing of emotion juxtaposed with knowing it does not belong in the present creates precisely the conditions for a corrective emotional experience and is one of the classic “ah hah” moments of psychodynamic therapy. The result is that the transference-based emotions resolve.

A third application is Emotion Focused Therapy. There, the classic formulation is “changing emotion with emotion.” Emotions that lead to maladaptive responses are actively elicited in the presence of more positive emotions, which create a corrective experience. The end result is that painful emotions are transformed as in each of the first two examples

“Process Empowerment” across diverse therapies
Having an understanding of the underlying change mechanisms that make psychotherapy work does not require any alteration in technique. As illustrated by the three examples above, it is compatible with essentially all existing theories and therapies. However, as I have personally experienced, it does lead to a subtle change in the way one practices. This is what I call “Process Empowerment.”

Now, instead of applying a method and waiting for results, in my own work, I have begun to concentrate on change processes. Sometimes I am focused on bringing affects to the surface or inviting patients to let go of behaviors or defenses that block them. At other times, I am intent on creating a context of safety or helping patients understand how their instinctive emotional reactions are make sense but out of sync with the present. These are three typical paths leading to the conditions that produce a corrective emotional experience. As the therapist’s attention turns to these basic tasks, selection of specific interventions tends to be guided more by individual needs and characteristics than by the rules of a particular brand of therapy. Beyond specific therapies, the often mentioned “common factors” begin to make sense, too, as facilitators of therapeutic change mechanisms.

Conclusion
Finally, we can begin to benefit in our daily practice from an amazing convergence of basic science and clinical wisdom. As neuroscience sheds light on the longstanding mystery of how therapy really works, not only are we gaining clarity, but also the ability to use our understanding of therapeutic process to guide our daily work. That’s what I mean by “Process Empowerment.”

For a more academic exposition of these principles, those who have an account on ResearchGate will find an article under my full name, Jeffery Steven Smith. This point of view is also incorporated in my “nondenominational” textbook of psychotherapy, Psychotherapy: A Practical Guide, (Springer, 2017), as well as my books for a general readership on this website

Also, dear therapist-readers. I would be pleased to base future posts on problems that are troubling today’s therapists. If you would like me to try to address the principles involved in dealing with your more difficult clinical problems, please send me an email via the contact form on this website.

Jeffery Smith MD, © 2019

References:

2004 S. Duvarci, K. Nader. Characterization of fear memory reconsolidation. Journal of Neuroscience 24 (42), 9269-9275 P. 379

2004 J. Smith. Reexamining psychotherapeutic action through the lens of trauma. J Am Acad Psychoanalysis and Dynamic Psychiatry. 32(4):613-31.

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