TIFT #122: Bringing Emotion Into the Room

This post brings material from a pilot training program a group of us have given online for six psychiatric residencies around the country. The subject is one of the two main requirements for memory reconsolidation (MR), the “queen” of change mechanisms because its effects are lasting and effortless. Its first requirement is activation of an unconscious subcortical neural alarm signal indicating that a threat is predicted. That sounds pretty obscure and technical but when the threat is creating a distressing reaction and when the danger has long since passed, then fulfilling this requirement might be an important goal of psychotherapy. How might we reach into the subconscious mind to activate an alarm signal? That is the subject of this post.

Affect

The key to translating neuro-babble into a clinically recognizable marker is affect. Those bodily changes that are the involuntary accompaniments of emotion are the clinician’s most reliable indirect indicators of unconscious emotion precursors activated in deep structures such as the amygdala. Let’s break that down. First the inner mind (subcortical, evolutionarily older parts of the brain dedicated to survival), is tasked with gathering a wide range of current information, comparing it with past experience, and calculating the odds of a disaster happening. What happens if the answer is yes? There is no red flag to raise, but the brain uses its available methods, setting off a group of neurons to create an alarm signal.

When your dog is peacefully eating from her bowl and you get too close, you can picture an alarm signal going off in the dog’s brain, which then leads her produce a growl. We know perfectly well that she is “feeling some irritation” and giving us a warning. Some neurophysiologists such as LeDoux, fearing confusion, will object to our saying that the dog “has feelings,” since we can’t know what a dog’s experience actually feels like. On the other hand, our capacity for empathy tells us what we would be feeling if someone invaded our own personal space. When it comes to babies, the situation is the same. Technically we have no right to imagine what they experience, except that we will soon teach them to verbalize their inner experience. Soon they will describe feelings in ways similar to the way adults do, as we teach them to “use your words.” 

The long and short of this is that, for me, the best phrase to describe the inner, subcortical alarm signal is “unconscious emotion.” Unconscious definitely means we can’t know it, and it is definitely true that conscious feelings are more elaborate, constructed with associations and vocabulary as well as later experiences. But in the end, given that the subcortical, autonomous, “system 1 mind” is the ground from which our emotional life grows, I like the term, “unconscious emotion” as a synonym for the brain’s threat alarm signal.

How, then, does affect relate to unconscious emotion? Just like the dog’s growl, affect refers to the involuntary bodily responses that are chosen and launched by the inner mind. Affects are the first responses to appear. Milliseconds later, we may experience other responses such as automatic thoughts, feelings, and impulses as they “pop” into consciousness. These begin to tell us about the meaning the affects are carrying.

The client begins to tear up. We wait a moment so as not to disturb the process taking place. Our voice changes and we might indicate some sympathetic response, “Oh, my…” Soon the response settles and we can ask more. “This really touches you. What exactly made you feel teary?” That’s when we invite the subcortical mind to respond to our question by sending information upwards along the now open channel to consciousness. It’s a complex voyage. The nonverbal emotion precursor is translated into a form that activates emotion words along with associations to the circumstances that triggered the alarm. I am often surprised by what I hear. One client suddenly teared up in response to the thought of acting more independently. She had the feeling that the new behavior would leave her alone, banished from the comfort of her family. Soon it was clear that the family in question was the dysfunctional family of her early life, dominated by her alcoholic father’s harsh criticism. The dreaded feeling of no longer belonging created a powerful deterrent to acting in her own best interest. I could not have guessed that nostalgia for a dysfunctional family could be the unconscious emotion that held her back from enjoying independence. The combination of affect with spontaneous thoughts were the necessary conditions for understanding her and, more important, for meeting the first requirement of MR and the enduring change it could bring.

Is affect necessary

It’s a real question. Much research has verified that in-session affect correlates with success in therapy. But there is also talk these days that it may not be necessary to re-experience trauma for healing. I see this as illusory wishful thinking, based on our natural avoidance of painful affects. However there is a difference between remembering events and experiencing affect. Examples of healing without remembering the specifics of a trauma still depend on activation of the inner mind’s alarm signal. In some cases the affect can come into the room, based on more general experience of a toxic set of conditions. That is tricky to accomplish, but in some cases of chronic trauma, it is possible, as there may not be a single event responsible for PTSD, or the trauma may be pre-verbal. It also happens that, having recalled the traumatic incidents, it turns out that the real source of affect is not an obvious event, but related traumas like shame due to a child’s sense of having been responsible for their own abuse or the realization that the other parent was aware of the abuse but did nothing.

Yet another twist is something that has only recently come to my attention. It’s where a painful memory is accessed in a flash, so briefly that it doesn’t reach consciousness. The first condition for MR is nonetheless met and healing can occur. In another variation, a distracting intellectual task keeps consciousness occupied while the healing takes place. Personally, so far, I’m tending to lean towards facing whatever the mind has retained, even if it takes longer for the individual to gain the confidence to cope with whatever the memory might hold.

People ask if they “have to remember.” My answer is that that is the wrong question. Usually, “having to remember” means using the “task positive network,” the TPR to dig up memories by association. That rarely works, both because it is the wrong brain network and because the inner mind senses an attempt to bypass its defenses. It is the “default mode network,” DMN (“My Favorite Network” in TIFT #95 ), that operates during free association and is the one to deliver spontaneous memories and answers to questions. Affect laden memories come when we have created conditions such that the client is emotionally ready. 

What if the memory doesn’t exist?

Does the critical memory exist? Yes. If an experience is causing trouble, then it must occupy space in memory in some form. That can be pre-verbal, such that the details are not specifically accessible, but the emotion still is. There must be a metaphor, image, or other content capable of connecting with "unconscious emotion," the alarm signal. It must exist for a subcortical “survival circuit” to detect danger and trigger an EMP. And if that is the case, then it must be accessible in some way, allowing healing through MR. That will happen when there is both affect and when the inner danger detection collides with the second requirement for MR, disconfirming information in a nonverbal form the inner mind can process.

The answer, then, is that affect is necessary as our indicator of a two-way channel between consciousness and the subcortical place where an unconscious emotion is in an active state.

EMPs that keep affect far away?

One common way EMPs manifest themselves is without affect. In fact, affect can be far away. An example might be a longstanding habit of treating oneself as inferior. These patterns can become part of the individual’s identity and remain hidden in plain sight for a lifetime. There is no acute feeling of being a “bad” or “inferior” person. It stays there as a quiet and constant background hum. It may be that the only indicator is a distortion in behavior, a difference between how the person expects to be treated and how they should be treated. This is one reason why therapists do need to be ready to pass judgment about lifestyles. We need to think about how this person’s life could be. It may be that the client has no interest in changing, but it is valid for us to explore the possibility and to ask for informed consent to seek change, or not to seek change.

What brings affect into the room in those cases is making voluntary changes in behavior. Just as the thought of becoming more independent in the example above was a trigger for strong affect, changes towards healthier behavior are powerful drivers of affect. I often ask people to recall the TV show, “What Not To Wear.” Simply dressing more fashionably, rather than according to the person’s personal habits, led to intense emotional reactions.

No way to avoid affect

Why do we put so much effort into finding ways around the experience of affect? It is precisely because affect is the perceptible product, the visible sign, of activation of the client’s dreaded unconscious emotion, the signal the inner mind is programmed, for the sake of survival, to avoid. The very same unconscious emotion is the sine qua non, the necessary element in launching the EMPs that cause so much human suffering and that psychotherapy works so hard to change. Paradoxically, therapy must activate the dreaded unconscious emotion in order to bring relief by substituting a more satisfactory response. 

How to bring affect into the room:

Every therapy has ways to do this. Our ability to do so starts in the first years of life. When mothers communicate in words, touch, and tone of voice, their empathic understanding of a child’s tragedy, they are laying the groundwork for MR. They are encouraging and supporting the child’s outward expression of affect, while providing disconfirming information about its seriousness. Their tone of voice and touch are conveying, in nonverbal language, that it’s not the end of the world and its going to be OK. What do we do at the end of life when a parent lies dying? Hopefully we do the same thing. We make a place for them to share what they feel and we allow our empathy to make a connection that helps heal the fears, regrets, etc. that go with letting go of life.

Bookended by these experiences, the essentials in psychotherapy are conveying permission for affect and asking for more detail so we can approach accurate empathy (perhaps better called complex caring). That deep, emotionally engaged understanding allows us to connect in a more concrete, more genuine and more real way with our client’s inner unconscious emotion. Here are some good ways to do it:

• Exploration leads to affect, unless EMPs (client’s or therapist’s) block it.
• Transference naturally forms over time and brings out affective responses
• Experiential techniques like two-chair exercises “make it real.”
• Voluntary behavior change unleashes powerful affects.
• Creating an atmosphere of safety and trust invites affect into the room.

What techniques do your favorite therapies use?

Jeffery Smith MD

Photo credit: Ashkan, Unsplash