TIFT #101: Simplifying Therapy Teaching and Practice

This post is adapted from a lecture given given in Marrakech, Morroco, at a conference of the World Association for Dynamic Psychiatry and the World Federation for Psychotherapy on 4/16/2024.

Introduction: Modernizing the teaching and practice of psychotherapy

A worldwide need for more and better therapists is colliding with a growing number of competing but incompatible therapies, with the result that there is too much "how ya doing" therapy, reverting to good listening skills but failing to address painfully maladaptive patterns.

This problem can be solved by combining two areas of science. The first is a modern view of the brain as a computational organ evolved to predict opportunities and threats and to generate solutions that increase the chances of survival and procreation. From this pint of view, the human limbic protector is closely analogous to those of mammals, but not always optimally suited to solving the problems of human life. Looking at the psychopathology that psychotherapy aims to treat as solutions arising from this limbic protector invites us to incorporate the neuroscience of change from learned fear research. There, recent work shows how maladaptive patterns of response, encoded as procedural memory, can be modified, in particular, through memory reconsolidation.

Adopting these combined insights leads to a clear, easily teachable and clinically relevant view of the active ingredients in diverse and seemingly incompatible therapies, as well as what therapist actions, regardless of therapeutic model, will support lasting change.

Why the field of psychotherapy remains unnecessarily divided

But our field has a problem. The lack of science on how the brain works forced Freud and others after him to invent explanations for what they saw. To this day, one founder’s conjecture is as good as another’s, which greatly complicates both learning and practice. In the year 2000, elucidation of the change mechanism of memory reconsolidation was the last puzzle piece needed to complete the missing trunk and roots of our field. My aim today is to describe the infrastructure that applies to all therapies in a way that makes it easier to teach and more accessible for daily practice.

Information

I’ll be taking the somewhat unusual point of view of the flow of information. When I have mentioned information in the past, some people thought I was excluding emotion. Not at all. Eric Kandel showed that groups of neurons that fire together can capture an unlimited range of types of information, far beyond prosaic words. My favorite definition for the information the mind can store and processes is, “anything that can be described in poetry.” Broadening our repertoire to embrace all that is what makes psychotherapy an art.

What all therapies aim to treat

To build a science-based framework, we will need a single, universal definition of what all psychotherapies aim to treat. Currently, every therapy has its own idea and they are not compatible with one another. That makes it difficult to find what they have in common. Let’s let the science of evolution be our guide.

Over time, mammalian central nervous systems have become ever more complex to cope better with changing environments. From this point of view, our brains are information processing organs evolved to take in large amounts of data from inside and outside. They continuously process that information to identify opportunities and threats, and to calculate strategies that will increase the odds of survival and procreation.

In humans, our complex social structures and slow development create special challenges and, not surprisingly, more opportunities for what we might call “coping gone awry.”

To be a bit more precise, a group of us at SEPI, the Society for the Exploration of Psychotherapy Integration looked at the mind’s problem responses and came up with the term, “Entrenched Maladaptive Patterns,” EMPs. The term describes responses that are resistant to change, dysfunctional, and liable to be repeated. These are the subunits of pathology that all psychotherapies are designed to treat.

While EMPs are ubiquitous, the concept may be unfamiliar. Examples include irrational feelings, behaviors, perceptions, and values. They are responses generated automatically and outside of consciousness that degrade life experience and can potentially be replaced by more satisfactory ones. As you can see, the range of problems is vast, as is the suffering they cause. Many are influenced by biology, but the parts that therapy seeks to change are the results of the mind’s calculations about what is best for survival.

How the inner limbic protector works

Having a universal definition of what we are aiming to change, we can now look at how the mind’s automatic and largely unconscious protective system works. Below is a functional diagram. Information about the current state of the outer and inner environments is gathered and processed. In the fear system, where much of the research has been done, the final appraisals take place in the amygdala. As I see it, in that final stage, three critical factors are weighed.

1. Will the threat impact survival or procreation?
2. What is the best strategy to deal with the threat?
3. Do we have enough power and resources for the strategy to succeed?

Based on those factors, the amygdala sends out a signal, a specific call to action transmitted to other limbic structures to specify and initiate the protective strategy. That signal is hugely important because changing the signal will change the response. It has two faces, a scientific one and a clinical one. Neurophysiologists think of the signal as the firing of a modest number of neurons. On the other hand, we clinicians can think of it as unconscious emotion. That is the necessary link between inputs and the mind’s output of responses. Yes, there is good scientific evidence to show that unconscious emotion exists. Unlike other constructs in the field of psychotherapy, unconscious emotion is real! It can be measured with electrodes and scanners in the laboratory. No one knows exactly what an unconscious emotion feels like but, even without lab equipment, we clinicians have excellent indirect ways to learn about it. We do that by observing the components that make up the mind’s responses as shown on the right in the mirror of consciousness. The quickest of those indicators to appear, and among the most reliable, is affect, that is, bodily reactions such as tears or changes in breathing. Other components of the response are also important. Spontaneous thoughts and impulses can tell about the unconscious emotion that triggered them. Conscious feelings represent more highly elaborated reflections of unconscious emotion. And finally, it often happens that a verbal description either “resonates,” or does not, giving yet another window on the specifics of unconscious emotion and the protective strategy it embodies.

We want to change the unconscious emotion because it is responsible for the specific entrenched maladaptive pattern, EMP, we aim to change. But we can’t because unconscious emotion is automatic and determined by the implicit logic that evaluated those three factors I mentioned before, the seriousness of the threat, the chosen strategy, and our ability to carry it out. Instead, we will have to change the final layer of logic that determines the unconscious emotion. Like the programming in a computer, and like all the other information held in the brain, that logic is stored in memory. In this case, it is called “procedural memory,” similar to the kind that tells us how to drink from a glass or to form grammatically correct sentences. How might we do that? Once again, science comes to the rescue. There is only one known way to rewrite the logic, and it is the well-researched change mechanism of memory consolidation.

Three change mechanisms

For completeness, there are two other change mechanisms relevant to psychotherapy. One is new learning by repetition, which is involved when patients acquire new and unfamiliar response patterns, which are then added to their repertoire of possible responses. The other, extinction, was first observed by Pavlov, but has the disadvantage of being only temporary.

I’ll leave those aside from here on because memory reconsolidation is the only one that can produce dramatic healing moments like the ones Freud and Breuer described in 1893. As I suggested earlier, this amazing change mechanism has just two primary requirements. Let’s look at them, one at a time.

The first requirement for memory reconsolidation

The first requirement is to set the old response pattern into a neurologically active state. This is the requirement Freud described so clearly, and it is one place where science validates existing therapeutic techniques by showing why they are needed.

Now I want each of you to take a moment to think of your favorite technique for bringing affect “into the room.” Here are some ways different therapies do it: 1) Verbal exploration, free associations, and examination of automatic thoughts can do it. 2) Transference and the relationship are powerful ways to awaken old responses. 3) Exposure therapy aims explicitly to awaken conscious feelings, which, as I said earlier, are indirect indicators of unconscious emotion. 4) Experiential therapies use techniques like empty-chair exercises. 5) More recently the importance of bodily movement has been recognized. 6) And, finally, one of the most powerful, and perhaps least acknowledged, techniques is voluntary behavior change, often leading to profound emotional activation.

Not only does the science validate these techniques, embedded in every therapy, but by focusing purposefully on awakening relevant affects, we have an opportunity to sharpen our practice. I’ll give some thoughts at the end about a simple but sophisticated way to teach this.

The second requirement for memory reconsolidation

The second requirement for memory reconsolidation is, simultaneously, to bring in a new perspective, new information that contradicts the old logic. I like to call it an “antidote.” As the new information collides with the old, it causes what neurophysiologists call prediction error, which then initiates a 5-hour period during which the old logic, held in limbic procedural memory, can be rewritten. Every therapy has its own ways of imparting new, disconfirming information. Much of this is nonverbal and, as in Freud’s catharsis, it may not be made explicit. Here, again, I would like you to think about what you do in your own practice to bring new, disconfirming information, verbal and nonverbal, to your patient.

Since Freud’s original observations, many therapies have recognized healing moments where both of the two requirements for memory reconsolidation are met. Perhaps the second oldest way to supply disconfirming information is interpretation. CBT therapists do something similar when they correct irrational beliefs. The potential problem with these communications is that they can also promote intellectualization. The science now shows why that’s a problem. When patients go into an intellectual mode, affect is extinguished, unconscious emotion is deactivated, and the conditions for memory reconsolidation are no longer met.

Other descriptions include Alexander and French’s “corrective emotional experience” in which the patient’s emotionally charged expectations are contradicted by experience within the therapeutic relationship.

The Boston Change Process Study Group identifies “Moments of Meeting,” times when new understanding comes serendipitously and may be pivotal to the therapy. Unfortunately, these moments are seen as taking place by chance, events we must wait for if they are to happen at all.

Other techniques are more purposeful. Clinical mentalization and mindfulness, for example, capture the collision between self-involved emotional experiences and a larger, outside perspective.

Once again, gaining a clear picture of events going on deep in limbic structures can sharpen our technique by inviting us to be more focused and thoughtful about how we convey new information.

The art of psychotherapy

That leads to a third requirement that is less obvious but embodies the art of psychotherapy. We need to remember that we are communicating with a part of the mind that processes information, that is, anything that can be described in poetry, in its own way. The associative logic used there works differently from formal logic. Here is an example…

Recently, a patient shared specifics of childhood abuse that had caused her a great deal of shame. She dared to ask if I was so disgusted that I wanted to throw her out of treatment. Later, she told me it was not my quick denial, but involuntary body language as I spoke that told her the question had taken me by surprise and discharge had not even entered my mind.

What this means for us is that we need to pay close attention to our patient’s communications and listen to and trust our own limbic system and its intuitive thinking as we work.

A simple but sophisticated way to teach clinical memory reconsolidation

As promised, I’ll offer one final takeaway that can help with both teaching and practice. I like to say, "Common factors set the table, while memory reconsolidation is the meal." A practice that fulfills requirements for both is continuously to seek what Carl Rogers called “accurate empathy.” That term encapsulates an attitude of curiosity, aiming for an ever more detailed, clear, and emotionally sensitive understanding of each of those EMPs, subunits of pathology that are behind the patient’s suffering and are what we want to change.

Five questions

Click Here:  Get your copy of the five questions with explanations

In our therapy coaching program, we have developed a simple but sophisticated way to do this by pursuing five questions about each EMP, starting with the ones that are most accessible or easiest to change. Working with the patient to pursue a deeper understanding helps build the alliance and fulfill common factors, while curiosity about the specifics leads to achieving the two requirements for memory reconsolidation, namely, activating the old pattern and providing the disconfirming antidote. In this way, seeking accurate empathy through these five questions gives us a simple formula for rewriting the implicit logic behind the patients’ EMPs, which leads to a change in unconscious emotion, and, in turn, shapes a more satisfactory response. And that is the central aim of psychotherapy.

Jeffery Smith MD