The Antidote in Psychotherapy

Alfonso Castro-Unsplash

You probably haven’t heard the term antidote used in this context, but I’m proposing it because it is really helpful in bringing together elements from many therapies. It describes one of just three core elements that need to be present for psychotherapeutic change, regardless of orientation or school. To give a preview, the antidote is a piece of surprising new information that can shake up and modify old, maladaptive patterns of response. When I say information, I mean anything the mind can capture and store. It can be a feeling, an attitude, a motivation, an atmosphere, an idea, or even a fact. Let me give a bit more background.

Problems Clients Bring to Psychotherapy

With colleagues in SEPI, the Society for the Exploration of Psychotherapy Integration, we have been thinking about consensus in the field of psychotherapy. We first focused on a universal notion of what it was we actually aim to change. We realized that psychotherapy does not seek directly or primarily to change genetics or biology. Those might be long range results of therapy, but what we are primarily aiming to do is change the MIND. We are aiming to change the way the unconscious and conscious minds evaluate circumstances and how they design responses that were adaptive in some context, but are no longer. Importantly, the way the mind does this rests heavily on past experience stored in memory. So we are seeking to change responses based on remembered patterns. Note that this places our art and science directly in the realm of information.

When we looked at it that way, we further narrowed our notion of the universal targets of psychotherapy. it became clear that the overwhelming majority of maladaptive patterns were responses, not to opportunities, but to threats, either experienced or predicted. It is rare for maladaptive responses to be driven by pleasure seeking, even though some addictions can start out that way.

Three Elements Lead to Change

This increased precision dovetailed with recent science. Changing maladaptive responses meant changing synapses, and recent neurophysiology identifies just three fundamental pathways for accomplishing that. One is to learn a new pattern where the advantage is so clear and powerful that if anything was there before, it simply evaporates. The next two are Extinction and Memory Reconsolidation, both capable of modifying what we called “entrenched maladaptive patterns” (EMPs). I won’t go into the latter two change mechanisms here, but what they have in common are two requirements. 1) the old pattern must first be in an activated state (Affect is our clinical indicator of this activation). And 2), both processes require new information to be present that contradicts the old information that shaped the maladaptive response.

The Antidote

Contradictory information is central to every therapy, but we need a single term as a bridge, so I’m proposing to call it the antidote. It can be an experience, an idea, a narrative, an emotion that surprises, anything that invalidates what the person’s mind had predicted. The reason I’m calling it an antidote is that, as with toxins, what works in psychotherapy must be quite specific and precise, but can come in a wide variety of forms. For example, Alexander and French called it a “corrective experience,” but that isn’t broad enough. Sometimes the antidote can be an idea, not an experience. Or it can be a new narrative or a reframing. When we call an abuse “victim” a “survivor” the new terminology changes the story of what happened. 

The effect (and effectiveness) depends on context. It only works when the antidote is unexpected and when emotion is activated. Otherwise it is just another platitude and has no real benefit. How many times have you experienced a client having read something that you have said many times, but this time it “clicked,” as if heard for the first time. The context made the difference.

The Antidote in Practice

The art of psychotherapy is guiding conversation in such a way that two events happen at the same time: The activation of emotions related to the maladaptive pattern and exposure to the antidote.

Much of the time we can’t predict quite how and when this will happen. Watching soccer games, I have noticed that if the ball stays at one end of the field for a while, it is likely that a goal will be scored. It may work to let the conversation move along without intervention, but it is also likely that defenses will quietly go to work to steer away from the troublesome areas. 

Another common problem in therapy is that the client repeatedly finds justification for reinforcing the maladaptive information. “See, it happened again. I tried something new, and that only brought grief.” Even if the negative result was minor and unrelated, the conclusion reinforces the maladaptive information. CBT has ways to contradict this, which may or may not come at a moment of readiness for change. Psychodynamic therapy might seek to undermine the maladaptive conclusion by noting why it is constantly restated, thus setting up the experience of realizing, while in the midst of restating the old “truth,” that a different interpretation might be true. Some therapists use surprise. Others might bring in humor to sidetrack the usual avoidances. The options are without limit.

Seeking a Common Language

The main point, here, is that by using the word, antidote, we can bring together many experiences described differently in diverse therapies, but amounting to the same thing. Irrational thoughts, schemas, internal models, intrapsychic conflicts (between two views of things), and patterns of misinterpretations within significant relationships are all examples of mental contents that lead to maladaptive responses and that psychotherapy seeks to update.

By giving one name to the many forms of information needed to counter the infinite variety of maladaptive ways of interpreting and responding to events, we can focus on the universal processes that lead to change in all forms of psychotherapy.

Jeffery Smith MD

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