TIFT #106: Bringing Order to What Therapy Treats

What has helped me most as a therapist is going beyond diagnosis to work with my patients to deepen our mutual understanding of the patterns causing their suffering. This post is aimed at taking some of the mystery out of those entrenched maladaptive patterns.

Human psychological problems cover such a vast range. When founders in the field of psychotherapy asked why we experience so much irrationality, the possibilities seemed endless and hard to explain. With what we know today we can pursue the question from a different direction. What maladaptive patterns does psychotherapy change? (Note that I’m leaving out long term effects like epigenetics because therapy is not designed to change them.) From that point of view, the answer becomes much simpler. While the inner mind produces many wonderful, inventive responses, what psychotherapy seeks to change are responses representing less than satisfactory solutions to serious problems, past and present. Not only does that clarify our clinical focus but it leads to better understanding of just how we can help.

In this post, I want to make sense of the range of entrenched maladaptive patterns, (EMPs) by organizing them according to eight products of the mind’s protective system. First I’ll list the products, then discuss them individually:

1. Control over bodily and mental functions
2. Conscious thoughts
3. Conscious feelings
4. Conscious impulses
5. Conscious inhibitions
6. Automatic actions
7. Influenced but chosen actions
8. Influenced but chosen inaction

Like a computer, the mind can control many things directly like hormones and heart rate. Also, like a computer, it can project information onto a screen (consciousness) to inform decision making. We’ll look at both the mind’s direct effects as well as indirect ones where the inner mind influences our choices.

I must note here that when I talk about the mind as the information processing function of the brain, some very smart people have taken exception. That’s because when I mention “information,” they think I mean things like words and numbers on which we are able to perform formal logic. But the inner, largely limbic, mind works with metaphors. It can record and process all kinds of information using groups of neurons that fire together. They can represent just about anything, for example, a tone of voice or a fashion “look.” The mind’s information processing works by seeing metaphorical connections rather than applying formal logic. So far, my best definition of the kind of information the inner mind works with is “anything that can be expressed in poetry.”

Some notes about EMPs: First, please remember that these are not diagnoses, but “subunits of pathology,” identified because they are precisely what psychotherapy aims to change. Too much therapy is focused on treating a diagnosis rather than the highly individual and specific patterns our clients sadly repeat. By working always towards a better understanding of the individual, we not only enhance our relationship, but gain specificity in what we can do to help.

Also, it is useful to note that in any given case, EMPs can represent mixtures of more than one of the types of mental products listed here. They can even result from tension between more than one conflicting strategy. What is essential is that they all represent the mind’s efforts, at some point in time, to solve serious problems. And we’re not looking for the “right” understanding of the client’s patterns, only the one we can agree is the most true, that is until we do better.

1.  Control over bodily and mental functions

These are the first indicators of the mind’s producing a coping response. Tremor, racing heart, inner hormonal changes, changes in the immune system, muscle tension… All these and many more are signs that the mind is predicting the likelihood of a challenge and is preparing for it. Of course genetic and other physiological factors also influence our responses. Importantly, physiological changes are often the first ones we notice. They are rapid because they come directly out of what Kahneman calls “thinking fast.” That is not the slower, logical analysis of conscious thought, but the rapid, survival oriented processing that does so much of the mind’s work.

These bodily changes are most commonly noticeable in panic attacks, anxiety, and depression. Others may be part of a response but happen without our awareness. For therapists, it’s always good to be thinking about how the body is participating in a response.

Another kind of response belonging in this group is dissociation. This can be thought of as coping through regulation of the mind's functioning. There, protective barriers are created which appear purposeful in distancing feelings or experiences that consciousness is not ready to cope with. Perhaps the unnecessary hypervigilance of PTSD can be considered in this group as well, and there may be other ways besides dissociation by which the mind keeps information from consciousness.

2. Conscious Thoughts

First, a note about consciousness. Modern research is showing that consciousness is not an absolute, but something more like a flimsy curtain, where we are shown what the mind deems most salient. Work with alcoholics in early recovery is what brought to my awareness how powerfully the mind uses spontaneous thoughts to influence behavior. In spite of a strong desire and firm resolve not to drink, people in early recovery from alcoholism very often find themselves having spontaneous thoughts like, “Maybe I’m not really an alcoholic.” It appears that the mind has come to the erroneous conclusion that drinking is synonymous with survival and is generating conscious content to convince the addict to return to the addictive pattern. The variety of these thoughts and the way they are crafted for the greatest possible effect makes it hard not to conclude that they are purposeful products of a mind intent on managing the person’s behavior. There are, of course, many other examples, but this is one place where the inner mind works actively and directly in opposition to conscious desire and determination.

Spontaneous thoughts are recognized prominently in CBT as sources of maladaptive choices. In psychodynamic therapy they are also taken as indicators of unconscious thought. These are also the sources of the mental defenses named by Anna Freud and the cognitive distortions of CBT. What is most helpful in psychotherapy is to think of spontaneous thoughts that lead to maladaptive patterns as the mind trying to influence behavior in ways designed to solve a serious problem. In many, if not most cases, these solutions were originally “invented” long ago under different conditions and with different cognitive capacities. In this way, EMPs often represent “young” solutions that have become rigid and unchanging in spite of their heavy cost.

In addition to influencing choices, spontaneous thoughts can also be problems in themselves. Obsessing appears to be one way the mind responds to problems that have no solution, as if grinding away at the issue might result in a breakthrough. Full blown OCD appears to have strong biological roots, but can also represent the mind’s invention of a seemingly solvable problem as a substitute for one, usually outside consciousness, that can’t be solved.

3. Conscious Feelings

I use the word “feelings” to refer to conscious emotion. Let’s start with what Les Greenberg calls “primary” emotions, spontaneous feelings that arise naturally and automatically from circumstances. These are feelings like sadness after a loss, anger at an injustice, etc. (See TIFT #104 for an in-depth discussion of the relationship between conscious feeling and unconscious emotion). 

It is hard to say with certainty what evolutionary purpose conscious feelings serve, but for us humans, a highly social species, many of their consequences are healthy. For example, they play an important role in our social interactions as a means of eliciting empathy and support. They are the basis of connecting with others who can soften the impact of an event by witnessing the feeling. In this way, feelings serve as “springs and shock absorbers” for difficult experiences.

Conscious feelings can also trigger patterns from the person’s repertoire, which are not always optimal. Resilience exemplifies healthy responses to adversity. Its opposites consist of responses that increase the negative effects of an adverse event. Such unhelpful responses are examples of entrenched maladaptive patterns influenced by primary feelings.

Sometimes the response is dysregulation or being overwhelmed by a feeling. We can think of that as a breakdown of functioning but it is just as true to see apparent loss of control as an EMP, an instinctive and possibly maladaptive pattern of response. In general, the younger the origin of an emotion, the more powerfully it is experienced. In many cases of dysregulation, witnessing and acknowledging a feeling may be more natural and effective than “top down” attempts to regulate the feeling without addressing the underlying dreaded emotion.

Once regulated, the challenge of helping with distressing feelings often arises from incomplete processing at some earlier time. When unresolved feelings are causing distress, having been re-activated, the EMP is whatever is blocking the definitive healing and processing of the feeling.

As Les Greenberg of Emotion Focused Therapy also points out, conscious feelings can serve protective purposes, as well. These include feelings like anger that might distract from deep sadness or sadness that might cover up a layer of rage. Another kind of feeling with purpose is “instrumental” feeling, emotional expression that serves maladaptively but all too effectively, to control or manipulate others.

4. Conscious Impulses

Impulses work a lot like feelings, but may not be experienced that way. The experience is simply a yearning to take some specific action. When the action is maladaptive, we can think of the whole sequence, from its nonconscious origin to its outward manifestation, as an EMP. Identifying the whole as having meaning and purpose helps to begin forming a working hypothesis about its functioning. Re-enactments are an example, where the influence of the impulse is hardly noticed, only the “decision” to act. The nonconscious purpose may be to repeat an unprocessed experience in the hope of a better outcome, or maybe simply to turn a passive experience into an active one, avoiding the dreaded emotion of powerlessness.

Compulsive but self-harming actions often start with powerful impulses. Here again, the entrenched maladaptive pattern is the whole sequence from trigger to outward action. In the case of chemical addictions, if not others, the power of our survival systems seems to get recruited to promote the addictive behavior. The lengths to which the mind goes to maintain the compulsive behavior suggest nonconscious purposefulness as a major factor.

5. Conscious Inhibitions

It is easy to miss the vast importance of “feeling like not doing.” In a way analogous to impulses, the mind not infrequently steers away from particular areas of behavior. The result may be failure to heal or process a painful event, but inhibitions can also distort development. In its essence, development consists of practicing new behaviors and experiences. When important aspects of functioning are inhibited, then development in those areas is blocked and that can have serious consequences. For example, a person who consistently experiences an inhibition in the form of not wanting to interact with others may become afflicted with lifelong isolation and loneliness.

6. Automatic Actions

Automatic actions range from crying out when hurt to more patterned responses that are, at first, involuntary but may, with work, become voluntary. Perhaps the most common and clinically important are automatic responses associated with attachment styles. For example, people who act avoidantly in relationships are not usually aware of the things they do to destroy a relationship that has become too real. In therapy working with such patterns starts with awareness of their existence. With awareness, clients may move towards gaining voluntary control, and from there to practicing and choosing a better response.

7. Influenced but chosen actions

May decisions to act take place consciously and are experienced as free choices. Especially when they are not in the individual’s best interest, these choices usually turn out to have been heavily influenced by feelings, thoughts, impulses, or inhibitions, all products of the mind’s protective system. What makes these patterns “entrenched,” that is resistant to change, is the inner mind’s natural resistance to letting go of a protective strategy that has been retained as important for survival. By way of evidence, if this nonconscious “resistance” did not exist, then maladaptive patterns could be expected to melt away with no more than self-help suggestions. The fact that that is rarely the case suggests an inner purposefulness.

Patterns of conscious choice often involve complex behaviors. Some of the simpler ones represent denial of some characteristic that is unconsciously (and maybe consciously) dreaded. For example, homophobia or hyper-masculinity can function as defenses against a dread of identifying as homosexual. Other patterns may be designed to influence or change other people, often surrogates for an early figure. An example is the “sick sibling” syndrome (TIFT #28) in which a child becomes fixed on making no demands in order to relieve the caregiving parent of excess stress. Ultimately the strategy can be driven by the hope that the parent, relieved of stress, will be able to pay attention to the client. Other “hidden agendas” include getting someone to admit guilt, getting support or attention to make up for deprivation, and avoiding a behavior that once led to criticism or abuse. A particularly powerful strategy becomes available around age 4 1/2, as children become able to picture the arc of time. With that cognitive ability, they can, and do, place their hope on repairing past failures through future successes, pictured (safely) in the distant future (TIFT #10).

As pointed out in the explanation for the Five Key Questions, these interpretations are working hypotheses, however their veracity can be supported by the fact that they “resonate” with the client, as well as by therapeutic results. Nonetheless, we need to stay open to alternative explanations, as our thinking can turn out to be wrong or incomplete. Treatment can be both “top down,” working to change the behavior, and “bottom up,” working to resolve the underlying dread.

8. Influenced but chosen inaction

As with nonconscious inhibition, patterns of avoidance of action can have a powerful and lasting impact on healthy functioning. In normal development there is a balance between fear of unfamiliar experiences and the anticipation of pleasure, especially when the individual can identify with another’s experience. When such role modeling is not available, when rewards are missing, or when the balance favors avoidance, choices often go away from practicing new skills. Failure to gain experience shapes the individual’s development and can place lasting limits on important abilities.

Fortunately from the point of view of treatment, encouraging healthy emotional risk-taking and new experience can be highly rewarding and can lead to restarting stalled development regardless of age.

Conclusion

What each of the eight groups of patterns have in common is that they are held outside of consciousness in procedural memory and triggered by limbic (unconscious) emotion. Deep and deepening understanding, as in “accurate empathy,” is not only good for the relationship, but can create conditions for memory reconsolidation and the rewriting of procedural memory, helping our client trade the old, maladaptive pattern for a new and more satisfactory one.

Jeffery Smith MD

Photo credit,  reubx-GAscwTkEOy8, Unsplash