#33 What Therapists Do, Part one.

An interesting way to focus on the processes of psychotherapy is to ask what immediate objective we are pursuing at a given moment. As we work, we are generally aware of trying to accomplish something specific. By naming our objective, we can focus more clearly on the processes that might be in play. This post started out as a review of my own cases, where the list of objectives kept growing to the current number, ten. Today’s TIFT is about the first two objectives and the processes they support.

1. Learning all about the problem

Right from the beginning we want to have enough of a picture of our client’s life to identify what is not working as well as it should or what could be better. With the person’s own “chief complaint” as our starting point, we need also to consider our own impressions, fallible as they may be. This does involve judgment and requires taking into account culture, environment, and other factors. Listening to the patient’s complaints and having some humility about forming opinions, we can home in on one or more EMPs (entrenched maladaptive patterns), the basic units of pathology treatable in psychotherapy.

From there, learning all about a specific EMP is one of the most interesting and challenging of the tasks we perform. Where did this pattern come from? What triggers it? What has kept it in place while some other response might be more satisfactory? In a first session, these things are sometimes clear, but in other cases, we may have to wait for the right clues to jump out. As with Miss Marple, the Agatha Christie detective, it might be a small detail that takes us by surprise or it might be our own association to past experience. 

In one case, it was a patient’s subtle but intense disappointment in a doctor visit. The doctor did not seem to care enough to go beyond his usual practice, even a little. Perhaps I was primed to take notice because I had previously said to myself that I really didn’t understand his initial complaints. Suddenly this spontaneous comment, arising from telling about his week, lined up with other things he had said. The composite picture was that he always did his part, but somehow others never did. It struck me that he was still following a childlike logic that doing his part with extraordinary diligence would influence others to do theirs. He did not seem to realize that in adult life not everyone will respond to such a strategy.

That clue was the foundation of a working hypothesis that my patient had felt disappointed at an age when he was old enough to judge the parenting services he was receiving (perhaps 4 or a bit older), but young enough to develop a childlike plan of being a very good boy to get the grown-ups to do better. My hypothesis immediately brought up many more questions to frame both my listening and the questions I asked. Early in therapy, learning all about the problem is often the most prevalent of the objectives we pursue.

What processes does understanding relate to?

Seeking to understand contributes to a number of processes. First, it helps to build a positive relationship since humans generally wish to be understood. Second it leads to supporting the patient’s motivation to do hard things that will be required for change, such as experiencing difficult emotions and trying new behaviors. Third, the understanding we gain will help us know which additional objectives to pursue as we go forward. In particular, clarity about maladaptive patterns will help us determine which of our client’s responses represent growth and which represent resistance and will slow progress. This, in turn, will help us know when to intervene and how. Finally, understanding will help with the other objective to be considered below: “helping the client connect affectively with the relevant material.” Before turning to that objective, the second topic of this post, let’s consider briefly how to go about seeking understanding.

How does one learn all about a problem? 

I see this as a creative process on both sides, one that starts with articulating to ourselves and often to the client what we don’t know, then making use of the patient’s human tendency, even compulsion, to express in multiple ways, verbal and nonverbal, just what we need to know. Many actions can help us gain understanding. Some of them are: keeping quiet, posing questions, offering thoughts, experiential interventions, and giving assignments. Even if our current objective is something else, a puzzling response may call for an instant switch into the task of understanding. We need to be ready to move at any time into noticing, listening, and following our own associations to keep homing in on a more accurate and complete hypothesis.

2. Helping clients connect affectively with the relevant material

The next, and related, objective is to help the client come to affective awareness of issues related to the needed change process. Why is increasing awareness important? Richard Lane, in a 2020 paper, argues that enhancing emotional awareness is “necessary but not sufficient for change.” Awareness does several things, but perhaps the most important is to serve as a clinical indicator that the right neurons are activated for the processes of extinction and memory reconsolidation to take place. This activation, along with experiencing some surprising new  information (the “antidote”), are what allow updating of old, maladaptive memory traces with new, healthier data. In addition, emotional awareness is an important part of motivating patients to take risks and try new behaviors, as well as re-evaluating cognitions and values that contribute to their troubles. In later posts, we’ll consider the role of awareness in those latter change processes. Today, we will stay focused on the objective of eliciting affective connection with relevant material. 

There are almost as many phrases that capture the importance of affectively engaged awareness as there are therapies:  Mindfulness, insight, mentalization, reframing, interpretation, consciousness raising, and many more. With so many synonyms from so many therapeutic traditions, it’s a good bet this activity is of central importance!

What all of the above phrases have in common is that they involve both affect and context or circumstances. Affect without context is of little clinical use, while expression of circumstances without emotion is equally unhelpful. The emotions that are important in psychotherapy are associated with specific circumstances that may be experienced nonverbally, for example, in Somatic Experiencing Therapy, or they can be described in words. Affect without the context from which it arises is not helpful because the important neurons are likely to remain inactive. For example, a patient’s tearful compassion for animals might lead us in the right direction, but will probably not be helpful until we understand it’s specific connection with the patient’s own experience. On the other hand, every therapist knows that intellectual expression of the specifics without affect won’t help either.

Our objective, then, is to help our client experience affect in a context that is relevant to an entrenched maladaptive pattern. Before we discuss how we might pursue this objective and the processes involved, let’s consider what happens if we try but fail to make progress? I’ll digress for a bit to discuss how a blockage to progress due to resistance, lack of skills, or therapist error, will temporarily require a change in our focus and objective.

What if the affects are too painful or frightening and the patient copes by resisting the process. This can be conscious or not, but when our progress is blocked in some purposeful way, then the agent of resistance is another EMP that has been activated. We will need to step back and change our focus to seeking to gain understanding and other objectives related to dealing with this new EMP.

Progress can also be blocked due to a lack of client skills at noticing and attending to emotions. When the this problem comes up, once again, our objective should change. Now our goal is to help the client learn new skills starting from the level where we find them. As enumerated in Lane’s LEAS (Levels of Emotional Awareness Scale), levels of ability to connect with emotion can be distinguished and coded. For the clinician, the implication is that supporting the objective of affective awareness may not be achievable without first focusing on skill building, that is, teaching the client to be tuned in to their own emotional life, whether in the form of conscious thoughts or bodily sensations. In a later post, we will focus on the objective of increasing patients’ level of skill in this and other areas.

Finally, we all make errors, and they, too, require a switch to seeking understanding of just what has gone wrong. Now let’s return to discussion of the objective of connecting affectively.

How to help clients connect affectively

As blocking EMPs and other impediments to progress are resolved we can turn again to the objective of helping the client access the relevant material with authentic feeling. An interesting distinction about methods for helping is the concept of “top-down” and “bottom-up” approaches. I’m not sure if they are really that different in terms of their ultimate effect, but let’s consider some of the techniques in both categories.

In his early days, Freud learned the then-current technique of suggestion. That was definitely top-down. He didn’t like controlling people and was disappointed at its lack of effectiveness, so he abandoned the idea. Next, he tried the “pressure technique.” He pressed his hand on the patient’s chest then released it and asked what came to mind. This seems similar to EMDR, in which the patient experiences bilateral stimuli, then is asked to say what came to mind. Are these top-down or bottom-up? Since the trigger is non-verbal, then I suppose we could call these techniques bottom-up. Freud was not comfortable with the physical contact involved in the pressure technique and soon found that simply asking the patient to free associate gave the same results. Which category might be a fit for free association? I’ll vote for bottom-up. The next thing Freud found was that patients developed powerful transference responses. These patterns, triggered by the therapeutic relationship itself, would definitely qualify as bottom-up.

In a similar way, nonverbal techniques that help increase affective awareness of spontaneous products of the mind can be termed bottom-up. Breathing, meditation, and some forms of touch or massage can be nonverbal triggers for spontaneous experiencing of relevant affective material. While we are there, any activity, that sidelines our conscious attention, for example, showering, driving, and even dreaming, will tend to clear the way for spontaneous thoughts and emotions, some of which may be just the ones that will further the processes of enhancing emotional awareness.

To continue the story, Freud felt the need, as many of us do, to articulate for his patients what he believed was going on. This was called “interpretation” and it is definitely a top-down activity. This, too, helps with emotional awareness, but relates to other objectives as well. Before looking at how it can foster emotional awareness, let’s enumerate some of the other effects of interpretation.

For completeness, interpretation, when misused, can support intellectualization and interfere with affective connection to the relevant material. In addition, interpretation can help motivate the patient to try different behaviors. It can also “put a stake in the ground,” that is, state a truth in a memorable way so as to make it harder to slip back into an old pattern. Now we return to the main thread.

The benefit of interpretation that is most directly relevant to the present objective is that it can give our client words that work to heighten affective awareness. For example, “I guess that really hurt,” might increase connection with the affect associated with a situation. That means activating emotional neurons in context, which is precisely what we are aiming to do. A more elaborate example might be, “To avoid her criticism, you took over the job of driving yourself to perfection.” That might activate or heighten any of several elements. It encourages awareness of feelings around being criticized and feelings about being driven to perfection. And it also suggests the antidote that maybe perfection is no longer so vital to life. The therapist would do well to wait and see which of these threads the client might pick up.

In the end, I think that the objective of helping clients connect affectively with the relevant material can be supported most effectively with a combination of bottom-up and top-down techniques. The current fashion is towards bottom-up, but let’s not forget that words are articulate, that is, they are still our most accurate and encompassing ways to bring experience to life, both for ourselves and for others.

Conclusion

Much of our most exciting work is towards these two objectives, but they do not, by themselves, make psychotherapy complete. In coming posts, I’ll discuss a list of additional objectives or tasks, each of which can be essential in our ultimate success.

Jeffery Smith MD

Reference

Lane, R. D., Subic-Wrana, C., Greenberg, L., & Yovel, I. (2020, September 17). The Role of Enhanced Emotional Awareness in Promoting Change Across Psychotherapy Modalities. Journal of Psychotherapy Integration. Advance online publication.

Photo by Michael Browning on Unsplash.

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