Much of the enduring change that is the essence of psychotherapy happens in moments. These are the moments when the problem solving inner mind (I often refer to this as the inner child) has a different interpretation than the conscious adult mind. When all the pieces are in place, then new information replaces old, and, from then on, life is a bit different. So let’s look at the anatomy of those moments to understand better how to assemble such an experience. (Photo by Caleb Woods, Unsplash.)
First, when and how do the inner mind’s problematic interpretations come to light? The first thing we encounter is some form of what my colleagues and I now call EMPs, that is, Entrenched Maladaptive Patterns. This is our way of encapsulating the full range of problems which are the primary targets of psychotherapy. “Maladaptive” doesn’t mean we want to judge anyone. It means ways of responding to circumstances that are less satisfactory to the client than some other way of responding might be.
Let me give a remarkable example that I recently encountered. A war veteran in his 30s was experiencing panic attacks for no apparent reason, clearly an EMP. But this frequent occurrence did not come close to giving the information we needed to make sense of why. Why might his inner mind be deathly afraid, enough to muster all the adrenaline and alertness needed to fend off an attacking predator from 200-300 million years ago when the human mind first evolved.
The man’s thoughts gave clues. He felt his heart beating hard, and imagined it might give out. He pictured himself in the hospital, dying. On one occasion, he actually called Emergency Services, thinking the situation might be gravely serious. He was aware that a healthy male in his thirties was unlikely to die of a heart attack and even aware that he was having a panic attack, but the mind still conjured up images of premature death.
He had not been afraid of death in combat, so why would he have that preoccupation now? It was near the end of a session. Partly on instinct, and partly because I am always interested in what I don’t know, I asked. “Why would you be afraid to die?” The answer surprised both of us and opened a world of new understanding. He immediately responded, “If I die now, I won’t have had the time to make up for all the bad things I’ve done.”
His inner mind clearly had been pursuing a plan, to do enough good in the world to make up for a view of himself as “bad.” Death would mean irreversible failure to reach his goal.
Unlike many EMPs based on a simple misunderstanding, finding an antidote was not so easy. By antidote, I mean a more adult way of looking at things with which to update the old understanding. In this case, it was not so clear that trying to do a lot of good in the world was inappropriate. The therapy took two directions. He believed firmly in a forgiving God and could see that his plan did not take that into account. His inner mind was sure that his offenses could not forgiven, while his adult mind was clear that even he would be forgiven. I’ll discuss how we worked with that contradiction. The therapy also had to deal with his perception of himself as not being a good person, which went back to early trauma, but that is not for this post.
The ingredients for change:
In addressing the belief that a premature death would leave him without redeeming value, we had the two required pieces of information, the old belief and the new one, that God is ready to forgive anyone. But we must look at one additional ingredient, affect.
The word, affect, has been used in different ways, but I’ll use the definition I was taught in residency. Affect is feeling when accompanied by some visceral sensation or changes. It might be hair standing on end, or an involuntary utterance or facial expression. All therapists are tuned to affect. We all recognize it as important. Research has long shown that affect experienced in therapy sessions correlates with successful therapy. Only in the 21st century, with the clarification of the neurobiology of learned fear reactions and memory reconsolidation by Nader, and colleagues, have we come to understand the inner workings of how EMPs can be resolved permanently. What follows is not without controversy, but follows a growing body of well researched evidence.
EMPs, Entrenched Maladaptive Patterns, are almost always aimed at defending against circumstances appraised in the inner mind as threats. They are maladaptive because they are not appropriate to the actual here-and-now circumstances. How does the mind decide what is threatening so as to set in motion a response?
The answer is emotion, but not just any emotion. The emotion here, is the kind we share with other mammals. Emotion deep in the limbic system, specifically the basolateral amygdala, appears to be the essentially universal trigger for responses to threat. Emotion of this kind exists as an activation of neurons in certain locations. We don’t know what other mammals experience, and we don’t even know quite what humans experience when those circuits are activated. The reason is that by the time these deep emotions reach consciousness, they are significantly modified by associations, thoughts, and other higher mental activity. That is why feelings are so rich and are the subjects of poetry. Thus conscious feelings are more nuanced and elaborate than what we presume to be the simple, basic emotions that set off instantaneous instinctive responses to danger such as panic attacks. In fact, research reported by Smith (not myself) and Lane in a [201X] paper, makes it clear that activation of deep emotions can take place with no conscious awareness at all.
This brings us back to affect. When we experience conscious emotion accompanied by visceral changes, then we can be confident that deep emotional circuits have been activated. Thus, affect is the therapist’s best indicator that relevant deep emotions are in play. What this means is that the brain does not have red LEDs or an alarm bell to indicate danger. Rather, it has a small location in an emotion-related area that, when activated, signals threat and triggers a response. Because activation of those areas causes freezing and avoidant behavior in mammals and tends to be associated with conscious feelings of alarm or fear in humans, we identify it as emotion. I’ll call it “deep emotion” to distinguish it from conscious feeling. Thus, fearful or alarming affects, that is conscious feelings accompanied by visceral changes, can be interpreted as activation of deep emotion in the fear area.
What does it take to activate deep emotions of fear, the kind that trigger panic attacks? It takes complex calculations appraising the total intersection of inputs to make a prediction of possible harm. This can involve the neocortex as well as more primitive parts of the brain, and is infinitely complex. It does not even follow a straight chain of logic. Instead, students of computational neurobiology note that arriving at a conclusion of danger involves nonlinear information processing where tentative predictions are compared to actual inputs and go through repeated cycles of trial and error, eventually homing in on a result, in this case, to activate those cells in the basolateral amygdala, that signal threat.
So what is the role of affect in therapy? Affect is our conscious indicator that all the pathways leading to a less-than-healthy conclusion are currently active and susceptible to being updated with new information. In the example given, the affect was not dramatic, but it was present. The sudden awareness of the threat of life ending before resolution of my client’s moral status came with a visceral sense of its significance and importance. It surprised both of us with its spontaneity. Within seconds, we were both aware that it was not in line with his belief in forgiveness. Forgiveness was the antidote.
At that moment, it was hard to determine whether the updating had taken place. Sometimes it is more apparent and sometimes less. Since then, the change has settled in. But what was clear at the moment was that the requirements had been met. Present were maladaptive information processing, affect, and the antidote, all at the same time. (In memory reconsolidation, the antidote has its effect from 10 seconds after the triggering of affect until about 5 hours later). As a therapist, what is important is supporting these three elements happening at the same time, old information, new information and affect indicating relevance. By seeking to recognize and support this combination we are taking advantage of the many purposeful and spontaneous occurrences of the process by which psychotherapy brings about enduring change. At times we may be able to observe and even document the change as Bruce Ecker has described. At other times such as in my example, the action may be harder to follow. Either way, being prepared to recognize and encourage the confluence of ingredients makes us better partners, client and therapist.
Another role for affect
Memory reconsolidation is also relevant to the healing of painful feelings. Trauma is often accompanied by intense painful feelings. In the brain, feelings are neural activity and neural activity is the way the brain encodes information. So feelings are information. When feelings are not appropriate to today, for example related to past trauma, then the connection between circumstances and painful feelings such as fear can be updated as well. It is often the calm support of an empathic therapist or other person that serves as the antidote to the perception of danger.
Experience as information
The resolution of inappropriate fears is only one example of information in the form of experience. When Alexander and French described the “corrective emotional experience” they described situations where clients showed affect related to relational experiences, which were contradicted by unexpected relational events within the therapy. In this way, they were describing a set of conditions precisely as required for memory reconsolidation but where the information was experiential rather than cognitive.
Thus, to recap, enduring change takes place at moments where old information, (experiential, cognitive, or otherwise) meets surprising new information. However for this to be therapeutically significant, it must involve activation of the deep emotional circuits that trigger an EMP and are recognizable clinically by the presence of affect.