This topic is coming into view for a reason. The Pilot group in the Howtherapyworks Training Program has just finished the first trimester on theory and, in our next term, will be working on therapy skills and technique. In this post, I want to use the concepts of Entrenched Maladaptive Patterns (EMPs) as units of pathology and Memory Reconsolidation as a basic change mechanism to bring some clarity to one of the most challenging issues in psychotherapy, how to help patients bring affect laden problem patterns into the room in a way that makes them accessible to change.
Let’s step back and review. As stated in previous posts, Memory Reconsolidation and Extinction are the two known ways to change existing maladaptive patterns, and they have essentially the same requirements:
- Activation of neural networks representing the old maladaptive pattern and its associated deep emotion, clinically recognizable through affect, defined as conscious feeling plus bodily changes.
- Exposure, at about the same time, to surprising and contradictory new information, “the antidote”, which generates prediction error.
“Bringing emotion into the room” is every day language for the first of the two requirements. Furthermore, the affect-laden response pattern should be experienced as intensely as possible. However we also know that for therapeutic gains to take place, the patient can not be in too high a state of arousal. How can we reconcile the two?
In cases where the patient becomes “dysregulated,” such as fight or flight, the first task is to help the patient regain control and learn to manage intense emotions. (Arousal regulation is one of the four “facilitative factors,” I have mentioned elsewhere as requirements in addition to basic change mechanisms.) However that is not the main subject for today. In this post I want to talk about those patients who are already very adept at regulating emotions, where achieving vivid activation of emotional material is a problem for the therapist.
Patients who are too well regulated
When I first began to think about this post, what came to mind were techniques aimed at helping patients “get in touch” with their emotions. To mention a few, emotion Focused therapy talks about two-chair exercises. Somatic Experiencing therapy focuses on critical moments locked in the body. Accelerated Experiential Dynamic Therapy homes in on maladaptive patterns explored within a very safe dyadic partnership. Psychoanalysis uses a high frequency of sessions and a special closeness to bring out what I prefer to think of as the inner child with his/her needs and emotionally intense agendas. All of them are excellent, proven strategies so how might we choose?
What effective techniques have in common
Each of the above techniques and others depend on the unconscious problem solver, the 95% of mental activity mainly responsible for suppressing affect, arriving at a positive evaluation of the safety and importance of risking a painful experience. Depending on the patient and the emotional experience to be brought to consciousness, different techniques may feel more natural and more suitable, but the most important factors involve the quality of the relationship. Here are four qualities of a relationship conducive to emotional risk taking.
For patients who naturally avoid uncomfortable emotion, allowing intense responses represents an emotional risk and these often high functioning patients already have powerful methods for avoiding just that.
Note that these avoidance patterns, themselves, are EMPs. They are maladaptive because they don’t help the patient live better, but serve a defensive purpose. More important, they have the same structure as any EMP. They have a triggering emotion, actual or anticipated, and they have an avoidance pattern or schema keeping the emotion from coming to consciousness. They are deployed automatically, so the circumstances must be evaluated outside of consciousness as safe, and belief in the therapist and the therapy is a major part of what establishes trust.
How do we cultivate trust? The best answer is by being trustworthy. That is easy to say, but covers the vast territory of human interaction where we have the power to bring unnecessary hurt but choose not to. It means being accurately tuned in and sensitive to the patient’s experience, acknowledging errors, not making too many of them, repairing ruptures, being consistent, being authentic, taking appropriate care of our own (therapist’s) essential needs, while putting the patient’s interests above all others.
It means being aware of our own patterns, as well, and keeping them from interfering with the patient’s work of self-revelation. This is where supervised experience is invaluable for learning. For example, I once supervised a therapist who was becoming frustrated and losing motivation to do the work. The problem was that the therapist was trying too hard to get results. There was no way that therapist would have been able to see the problem while immersed in the middle of it.
Trust is not enough. It is still too easy for a well-defended patient and therapist to slip into a comfortable pattern that feels good to both but is not producing movement. Taking risks requires a leap into the unknown. That is hard even when there is no shortage of trust. Therapists cannot be infinitely accepting or completely unconditional. This attitude is what I call “expectancy.” We have been hired to do a job, and need to convey the expectation that the patient will take needed emotional risks. Expressing expectancy is a very delicate thing. Patients are exquisitely sensitive to any threat, so only if needed, our expectations have to be conveyed with tact, understanding, and great gentleness.
Research is very clear about the necessity of an agreed upon rationale and plan for treatment. Part of the nonconscious problem solver’s assessment is whether the plan is a good one and whether the benefits of taking the emotional risk outweigh the costs.
Hope is the anticipation of a positive result. As the experts, we need to believe that a positive outcome is possible and justified. We convey this conviction, without which motivation will not sustain the effort. Since the course of therapy is often not knowable at the outset, we need also to believe that we will be able to navigate unforeseen hurdles and enlist others in consultation if necessary.
What about technique?
When the therapeutic partnership embodies trust, expectancy, purpose, and hope, specific techniques are important but secondary. Some patients are more comfortable with structured procedures. Others prefer open exploration. Some want science, while others do better with relationship. Some problems are more somatically rooted, while others involve cognition and emotion. Technique is perhaps best seen as a way to match the patient, the problem, the moment in time, and the characteristics of the therapist.
I would urge all therapists to study and learn different techniques and to be ready to use them to match specific patients’ needs at any given time. Talking to many therapists, after initial training, most have had experiences with alternative techniques based on fortuitous encounters or actively seeking to fill gaps in their knowledge. Extra training and supervision in new techniques gives confidence and therefore authenticity when using them, adding to the level of trust.
In the meantime, when affect is near, it’s time to open your curiosity and heart to invite your patient to risk vulnerability and enter into a new realm of experience.
Jeffery Smith MD
As always, I would invite comments in the Howtherapyworks blog, and also, if you find these posts interesting, please tell your friends and colleagues.
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