Affect and Change

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.

An example:

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.

Affect

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.

Jeffery Smith

8 Comments

  • I have been to therapy a lot. In my life, I have seen over 75 mental health professionals. I used to have a “life story” perspective on my troubles, but it was not adequate. The last therapist I went to, which was about 3 years ago, for about 2 years, was more skilled in attachment disorder, but this is what happened: I told him about my childhood. I wanted him to nurture me. That’s what he told me, instead of acknowledging and validating my pain. I had gone off my medication because I want to be able to handle myself and be healed. The pain that made me be on meds is the pain of my childhood, but was it real – the pain – or is it an illness?? What was so bad? Could lack of nurturing cause the pain I was experiencing, or was it an illness that made me feel I was not being nurtured?

    When my therapist did not acknowledge my pain, and I was not taking my meds, I became very sick, and was unable to care for myself.

    I was hospitalized, and the behavioral treatment I received there actually made me learn to cope with my anxieties. I was locked up for 2 1/2 months. There was no where to go. I had to ask people if I wanted a change of clothes or to take a shower. Having to do things like this repeatedly, and having to stay there because I could not go anywhere forced me to cope with a certain anxiety I had about people.

    I was also given medications and injections at various times. I found this very aversive, but it did help modify my behavior.

    I was classified as “Seriously Mentally Ill”, and continued to receive treatment in a community mental health center. Sometimes I was forced to receive injections of psychotropic medications, which I found very aversive, but it did help to modify my behavior.

    I have learned to tolerate some very terrible feelings. I have learned to soothe myself sometimes. Most of the time, I manage to cope. I have sought alternative therapies on my own, and the combination has helped me recognize and learn to manage the feelings and symptoms better. Yay.

    But the dysfunctional pattern that I think is the basis for my suffering continues. My mother was not mothered the way she needed; her mother’s mother died when her mother was a teenager, and she became a professional at a time when that was more rare among women. So my mother was mothered by a professional woman with a mothering wound.

    I feel like my mother wants me to make up for this. I feel like she wants to be my baby. Because I was raised in a strictly religious household, I believe (that’s how it seems) that it is my religious duty to provide this soothing for my mother. But it makes me ill.

    I have told my mother about that it is not good for me when she tells me her problems, but I don’t seem to be able to stop the dynamic alone, and the therapist who was most skilled at attachment disorder – I got sick. The other day, I went to help me mother, and because I was quiet, she told me about all her problems, and her feelings of confusion. I felt like her therapist, and I didn’t know how to socially stop what was going on.

    That night, I woke at 3 am, again upset by her behavior and my inability to get away form her or stop my suffering. I feel tortured by my relationship with my mother. I think that is whey I must take medications.

    When I lay awake feeling tortured, I tried to support myself by holding acupressure points. I realize that in the past, these feelings seemed intolerable, and I had no idea how to manage them.

    In therapy, you learn to change your own behavior. I realized when I was starting to feel like her therapist, but I didn’t do anything that time.

    • SB, Thank you for sharing your story. There is much I can’t glean from what you say, but the importance of validating your feelings seems very important to me, too. Also I notice how sometimes being in a position where one can’t escape feelings may be necessary for one to learn to face them. With regard to a mother who insists on being taken care of emotionally, my rule for all kinds of situations is “When people get ‘squirly’ on you, DISENGAGE.” I don’t mean to be disrespectful with my language, and there are many tactful ways to disengage. Also, trying to fulfill others’ childhood emotional needs tends to perpetuate impossible expectations. JS

  • I have a question.
    Over many years I’ve found therapy helpful. The therapist I see now has encouraged me to take on more challenges – and, as a result, I like myself more and I often feel competent when previously I felt helpless. This has resulted in me not having a depressive episode for a long time.

    But my main problem is the result of significant childhood trauma. As my therapist puts it I’m hyper-vigilant and in a state of constant anxiety. Therapy had assisted me to the extent that when I’m upset out of proportion to the actual incident – I can understand and tell myself that the anxiety I’m experiencing is related to my childhood trauma and not to the current situation. That’s good – but here’s my problem. My mind can accept that my anxiety is not related to the present situation, but my emotions and body can’t? Nothing seems to have changed emotionally – if I lose my mobile it affects me emotionally just as much as losing a family member. The result is just about every second day I’m dry retching through terror and need medication to get some sleep.
    Can trauma therapy just help you to see that your responses are overblown and not related to the present situation in your mind? Is there any therapy that can change the emotions as well? I can’t help thinking that the trauma I experienced as a child has changed my brain in some way.

    • Thank you for sharing this. You describe the most challenging part of therapy. As in the post, it is the juxtaposition of the triggered response, and the antidote With Affect. The purest example I have experienced of full healing was with a person who had dissociated her trauma for decades, and when it came out in therapy, it was sudden and was the first time those memories had been accessed since the trauma. It was very intense. She was present in the present, but also fully connected to those experiences. The antidote was the safety of the therapeutic setting. The healing was complete in two prolonged sessions.

      On the other hand, I think what prevents that kind of healing is that the trigger brings up an intense response, but in a way that still hides the connection to the original experience. I’m not sure whether it is a defense that is keeping the triggering experience from being fully activated or whether the original experience needs to be activated. In short, I believe healing is possible, but that the most likely is that those neural networks that identify the current situation with the original one, are somehow not being made accessible in the therapy.

      Perhaps you and your therapist can look at that question, what would bring the triggering experience into full activation at the same time as the safety of the present.

      JS

      • Jeffery, you say here, “On the other hand, I think what prevents that kind of healing is that the trigger brings up an intense response, but in a way that still hides the connection to the original experience. I’m not sure whether it is a defense that is keeping the triggering experience from being fully activated or whether the original experience needs to be activated. In short, I believe healing is possible, but that the most likely is that those neural networks that identify the current situation with the original one, are somehow not being made accessible in the therapy.”

        The original trauma situation arose when I was nine years old. A time when I needed a parent to take charge – but they couldn’t in the case of one parent and didn’t in the case of the other parent. Through therapy I’ve learnt that my trigger to the original trauma arises when a situation overwhelms me, and I feel as helpless and unsupported as I did at nine. Now my brain and intellect is well aware that I’m a mature woman, and have many more resources than a nine years old child – yet my body and emotional response is of that nine years old!
        My therapist said that she has noticed that if immediate help is not available to me that’s when I go to pieces. Two years ago I had a bad trigger crisis -and the minute my sister stepped in, and in a sense parented me, I recovered.
        Perhaps the way forward is for me to just accept, that I will always respond, when triggered, to the original trauma -and look for someone to “parent” me in the short-term until I recover. (And, from previous experience -it is only short-term, the intervention of a “parent” figure is enough to hasten my return to health and normality).
        Curiously, the original trauma ended with the intervention of a “parent” figure. Briefly, my sister and I were taken to a neighbour’s house. She had this dolls hose that had belonged to her daughters and she gave it to us to play with. My sister happily started moving the furniture and dolls. I felt overwhelmed by our situation and .started trashing the doll’s house. My sister yelled at me to stop -or I’d get into trouble. The neighbour came into the room, and rather than get angry, she picked me up, gave me a glass of milk, hugged me, and said “You’re worried about your Mum, aren’t you?”
        No milk has ever tasted so good……
        I would welcome your comments, Jeffery, as this is such an important issue for me.

        • Dear Christine, This detail helps a lot. If you think of the need for an “antidote,” there isn’t anything more satisfying than that glass of milk, so your inner self has no doubt at all how to solve those terrible moments, and I can’t think of anything a therapist might offer that would work as well. I believe in a situation like this that your idea that “Perhaps the way forward is for me to just accept, that I will always respond, when triggered, to the original trauma -and look for someone to “parent” me in the short-term until I recover” is exactly right. Being able to reassure your inner self that her plan is appropriate for you, and that you will do your best to support it, might be the most powerful way to calm the hypervigilence that has continued. Actually one stress is the original trauma, and another is the fear that it might happen at any moment and there might not be a sister or other person to give you a hug and milk, or some equivalent. Becoming accepting and tolerant of those needs may be a very good way to calm the second stress, and that would help bring the distress level of the first one down to a level that can be worked with. This also illustrates how important it is to look at the fine detail, and to see it from the point of view of the inner self.

  • Reading your post on maladaptive behaviours I was struck by how a fair amount mapped onto Ellert Nijenhuis’ writing on structural dissociation & working with EP’s & ANP’s. Are you familiar with this theory & the spectrum of dissociative experiences?

    • Thanks for the note. I was not familiar with this person, but I’ve downloaded one of Ellert’s papers. Many people have written about DID, but the actual reality has a way of shaping everyone’s thinking (except the doubters) in similar directions. Two of my patients have written books about their DID experience and treatment:
      1. Robert Oxnam, A Fractured Mind, and Vivian Conan, Losing the Atmosphere, which is also about attachment.

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