#13 The Role of Learning in Psychotherapy

In recent posts, I have talked a lot about general application of two change mechanisms, Extinction and Memory Reconsolidation, both implicated in research on how learned fear can be “unlearned” or suppressed. I have been a bit vague about a third foundational change mechanism, New Learning. In this post, I’ll offer some thoughts about the role of this important process. The post is organized around different clinical scenarios.

Lack of Exposure to Healthy Responses

The essence of psychotherapy is trading maladaptive response patterns for healthier or more satisfactory ones. It often happens that patients have either not been exposed to healthy patterns or may not have taken in the knowledge. In such cases, they may be able simply to add the new knowledge, cognitive or experiential, to their repertoire. Technically, I think of this as counseling, where good ideas are taken in without significant resistance. In other words, the non-conscious mind experiences an increase in capability and no loss. On the other hand, when maladaptive patterns are sufficiently entrenched to require professional help, psychotherapy is how we help our patients deal with resistance to change as the non-conscious mind tries to hold on to its familiar means of protection.

Through sports and in many other areas, we are all familiar with the process of learning new responses and practicing them. Marvin Goldfried expresses it neatly as going from “conscious incompetence” to “conscious competence” and, finally, to “unconscious competence.”

Values, attitudes, ideals, and prohibitions

These are the internalized rules that inform judgments, leading to feelings of pride, shame, guilt, and probably hate as well. Together, they form a special case regarding learning. Pathological values (using the term “values” generically to cover all four types) are common and very troublesome. For example, negative attitudes towards the self are near universal consequences of trauma. The problem is that values are essentially permanent (see TIFT #9 on Shame). We can’t exactly exchange them for healthier ones because the old values are kept, though dormant, susceptible to being re-awakened under triggering circumstances. What we can do is learn new values that contradict the maladaptive ones or, perhaps even better, recover healthy values that pre-existed the maladaptive ones. Clinical observation suggests that what needs to happen is for the new values to be embraced intellectually, then acted upon to the point where they take precedence over the old ones.

A note here for research:  We may have much to learn from cult indoctrination and brainwashing about how values are internalized. These may be instances of rapid and unusually deep internalization of values in people who are already susceptible or have been made so.

New Learning that has been blocked

Many of the Entrenched Maladaptive Patterns (EMPs) encountered in practice involve avoidance of information that might lead to painful affect. Here the therapy may involve creating conditions where the patient is more ready and able to face knowledge that has been hidden, distorted, or denied. For example, a survivor of child sexual abuse may become ready to learn that trusted family members were actually complicit. In that case, the focus is not as much on the new learning as it is on the emotional work of processing the painful affect, which involves mainly Memory Reconsolidation, where pain is acknowledged, honored, and, at the right moment, brought into a larger perspective.

New learning as part of Extinction

Technically, one aspect of Extinction is Learning in which the cortex takes in new knowledge that the unconditioned stimulus (i.e. combat danger) is no longer to be expected when the conditioned stimulus (i.e. loud noise) is encountered. When this learning is juxtaposed with activation of the old expectations, then the learned protective response is inhibited via neural pathways traveling from the cortex to the limbic system where triggering of responses takes place.

New information and Memory Reconsolidation

Finally, to clarify, Memory Reconsolidation involves updating old learning based on new information, rather than establishing entirely new memory traces.

For Further Research

Learning is one area where neurophysiology is of limited help, but research from other areas of psychology may be of real benefit. We all have our favorite metaphors and ways of explaining that we hope will facilitate letting go of patterns of avoidance and support healthy change. It seems that these pearls are best tailored to the individual and restated in multiple ways. Then there is the issue of when informing leads to intellectualization. For more automatic behaviors, I have often suggested practicing and imaginal exercises but I’m sure there is relevant research. A lot has gone into the study of peak performance and how athletes, as well as first responders and the military, can best go from “conscious competence” to “unconscious competence.” What kinds of exercises will best help patients incorporate new ways of responding? Once again, this is a common situation that cuts across all styles and orientations of psychotherapy.

Jeffery Smith MD

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