Many have explained human problems as a result of coping with difficult early experiences. Based on many years of practice and teaching, I am convinced that all those human psychological problems that can be resolved through psychotherapy come from one source. They all start out as ways to avoid painful, overwhelming and uncomfortable feelings. As the original purpose loses its relevance, the patterns remain, but are now dysfunctional and life-limiting. Why do dysfunctional patterns remain, even though they have become a liability? The most intense resistance to positive change comes from dread of the difficult feelings that caused the patterns to be maintained in the first place, which has also remained in place, unchanged.
This model makes it clear that the work of therapy is to change the patterns, but that, in order to do so, we often need to help our patients face their dread and risk encountering the feelings that have been avoided. It is the safe and attuned therapeutic relationship, more than anything else, that makes it possible to experience and heal the dreaded affects.
In helping patients with their change processes, therapists engage in five activities.
Whatever the school or technique, psychotherapy seeks to help people change dysfunctional patterns and to heal or detoxify the dreaded feelings that often stand in the way. At any one moment, the job of helping people make these changes has the therapist focused on one or more of these five tasks:
1. Creating a safe and attuned relational context: A safe and empathically attuned therapeutic relationship is not only the key to patients’ motivation to be vulnerable and try new patterns, but also provides disconfirmation of fear memories, allowing extinction and reconsolidation to heal painful affective responses.
2. Helping to bring dreaded feelings into consciousness: The primary focus of experiential therapies, a side effect of cognitive-behavioral therapies and the primary reason for challenging defenses in psychodynamic therapies, bringing feelings into the room, is an essential aspect of all psychotherapy. Recognizing this centrality goes far to integrate a range of constructs and techniques.
3. Challenging and inviting change of dysfunctional patterns of thought, values and behavior: A central theme of the book is that dysfunctional patterns exist for the purpose of shielding the individual from dreaded affects. Modifying these patterns accomplishes the dual aims of improving functioning and uncovering feelings that need to heal. Techniques include attention to motivation, education, understanding, and finding the courage to make voluntary changes.
4. Building together a narrative framework to support change: Narrative building is part of every therapy. Why both patients and psychotherapists instinctively embrace this task is not fully understood. Narrative seems to be fundamental to disconfirming erroneous beliefs. It is also a part of mindfulness, giving a sense of perspective. Storytelling seems also closely tied to our deepest motivational systems.
5. Seeking to understand what is observed: Therapists have always needed to develop a working hypothesis to understand what they observe. They also need to treat their hypothesis or formulation with appropriate skepticism and to be ready at any time to find a better understanding.
Ten Ways We Avoid Affect
While this model is simple, human problems are not. The vast complexity of mental pathology comes from the range of means we employ to avoid affects. These start with the simplest nonverbal schemas learned in early childhood, progress to the sophistication of imaginary life plans and on to self-administered psychopharmacology. Furthermore, our mind’s strategies for affect avoidance tend to be layered, with one layer protecting us from the next, and that protecting us from the feeling itself. In order to make this complexity more accessible, I have outlined ten groups of affect avoidance patterns below.
1. Schemas, nonverbal learned patterns of perception and behavior that avoid pain and seek pleasure. Often originating before language, schemas reflect the assets available as well as the typical problems of the preverbal years, especially those relating to attachment and the development of the self. Personality disorders such as borderline and narcissistic personalities are among these patterns.
In more behaviorally oriented treatments, patients are helped to identify patterns, see that they are counterproductive and given tools to contain emotion and practice healthier ways of interacting. In both DBT (Dialectical Behavior Therapy), experiential therapies and psychodynamic therapies, the focus is on difficult interactions with the therapist. Through encountering strong emotions in relation to the therapist and processing them in a benign way, emotional triggers are activated and can be erased by reconsolidation.
2. Dissociative patterns: Dissociation is a key component of PTSD and an under-recognized avoidance mechanism allowing the individual to distance from emotions at times of extreme stress.
In treatment, a very safe and attuned relationship, and sometimes cognitive tools help patients to tolerate exposure to reminders of the traumatic situation, leading to resolution of dissociative barrier and recovery of emotions and/or memories. At that point, healing of the emotions takes place. In addition, narrative building and discussion of the meaning of the traumatic experience help to bring perspective.
3. Inborn avoidance mechanisms: Anxiety, depression, and obsessive-compulsive patterns. These patterns have major genetic and biological aspects, but also function to protect against affects. Behavioral treatment for OCD has demonstrated how relinquishment of behaviors leads to intense affect and, once the affect is metabolized, to clinical improvement.
While these patterns are intensely uncomfortable in themselves, they can be seen as avoidance mechanisms as well. Therapy seeks to challenge and change irrational thoughts and behaviors that support the symptoms. Dread of once-difficult feelings makes patients tend to rationalize and avoid changing their symptoms. A strong therapeutic relationship helps to process these emotions and encourage change.
4. Distortions of thinking: Traditional defenses such as denial and projection as well as cognitive distortions like catastrophization serve to regulate affect. In doing so, they block processing or healing of avoided feelings.
Therapists seek to show that these distortions are irrational, but do serve the purpose of avoiding feelings. As patients understand, they are willing to let go of the ideas and encounter the dreaded feelings behind them.
5. Dysfunctional behavior patterns: These include acting out as an avoidance of feeling, re-enactment of unresolved experiences and re-enactment within the therapeutic relationship. The latter instance, also called “transference” can interfere with positive change. When it does, the resolution of that blockage does the equivalent of healing unresolved emotions belonging to a different time and place. Resolution of transference problems requires a strong therapeutic relationship.
6. Conscience problems: Pathological shame, guilt and even pride are the products of a dysfunctional conscience and are the result of judgments based on faulty attitudes, values, ideals and prohibitions. These four types of “core values” are powerfully internalized and resistant to change. Because the emotions are based on judgment, they are different from primary emotions, such as fear and anger. They do not heal without the values, etc. being challenged first.
Therapy seeks to clarify and change the underlying values, allowing resolution of inappropriate feelings of shame and guilt, and change in positive behaviors such as taking better care of the self, that had been blocked by shame or guilt.
7. Hidden agendas—patterns of dysfunctional best understood as childhood attempts to influence adults. At a more advanced developmental level, patterns such as self-defeating behaviors often represent a child’s attempts to signal to adults that they should re-evaluate their behavior. Problems with forgiveness and acceptance often result from secret goals of changing others.
8. Guilty quests—fantasy visions of a future where problems will be solved by anticipated achievement. The developmental acquisition of the ability to imagine a distant future allows fantasy solutions to problems. Classically addressed by psychoanalysis, these plans may come into conflict with superego prohibitions as they play out in adult life.
9. Arrested development—how avoidance of experience can stop development at any stage. Development of coping and life skills happens when we try out new behaviors. Avoidance of experience can shield from dreaded emotions, but can have the side-effect of limiting development. The therapeutic solution is to try out unfamiliar behaviors, but this can be blocked, even in adulthood, by the dread of uncomfortable feelings.
10. Addictions: Behavior patterns usually learned in teens or adulthood that suppress affects. Often with a genetic and biological component, chemical addictions as well as other compulsive behaviors are potent suppressors of affect. Often a crucial component of recovery is learning to face and cope with previously avoided emotions.