TIFT #102: Affect–Therapy's North Star

“Where are we and what to do next?” These questions come frequently as we practice psychotherapy, sometimes in the background, but just as often arising as conscious questions. This post is about three very different situations and how each has a different tempo and requires a different approach. They are as follows:

• Affect is right there
• Affect is near by but not yet manifest
• Affect is nowhere to be seen 

1. Affect is right there:

The first is the easiest. The client is in the middle of experiencing strong emotion, and that tells us right away what to do: Nothing. Even when emotion seems overwhelming, humans are meant to experience strong feelings. They are our safest outlet for problems we don’t know how to solve. They are our way of eliciting compassion from others and our way of diluting the immediacy of pain by stretching it over time. Think of a car without springs and shock absorbers slamming into bumps in the road. Emotion does the same as springs, softening the impact of what has happened.

Yes, the client may be “dysregulated.” But now is not the time to teach breathing exercises. Nature has given us a natural and very powerful tool, relationship. Since infancy, the soothing presence of a trusted other has been the most basic cure for emotional distress. Simply being there as an empathic witness is often the most effective way to help modulate another’s pain. Maybe the silent listening takes seconds, maybe minutes. What really tells the client we are present with them is that we know when to break the silence. It is when the client begins to have some control. Then our wish to understand becomes the sign that we care. If the meaning of the emotion is clear, then the slightest word or gesture may be enough to show that we are tuned in. In situations where we really don’t know, the most caring thing we can do is to seek a true understanding.

It hasn’t happened often, but I still remember years ago, the client who began crying and I had no idea why. After a short time, I said, “I’m so sorry, but I don’t understand yet what you are feeling.” Jarring as it seemed, that helped us to get back on the same wavelength. Asking can also be counterproductive if it leads away from the emotion and towards pure ideas. As I said in the last post, abstract analysis can de-activate unconscious emotion and eliminates one of the conditions for memory reconsolidation. Genuine interest in the substance, not in labeling, will usually lead in the right direction.

Is memory reconsolidation really the healing process here? Yes. It is working to change the deep limbic meaning of what has happened, transforming it from something immediately dire to one more event in the course of a life. The two conditions for memory reconsolidation are clearly in place, first, activation of the old schema, as demonstrated by the presence of affect, and second, provision of disconfirming information contained in the nonverbal communication of the therapist’s calm presence. For practical purposes, the only need for words in this situation is to show you are tuned in and that you are interested in a true understanding, that is, in accurate empathy.

2. Affect is near by:

Here, we can sense that affect is not far away. The conversation is beginning to feel like there are reverberations from within. The client is coming nearer to activation of an unconscious emotion, but the inner mind is doing what it is supposed to do, keeping a troublesome emotion from becoming active. That is the immediate goal of the inner limbic protective system, the source of the Entrenched Maladaptive Patterns (EMPs) that psychotherapy is designed to change. Why? Because unconscious emotion is the mind’s proxy for danger or threat. The rumbling of inner emotions is the signal that an inner threat could soon move into the active category where a response will be required.

Both client and therapist will often be tempted to shut down the emotion before it can become active. This is when either one may, without realizing it, have impulses to change the subject or to introduce a more abstract version. “Well, I know my father was doing his best.” Or, unconsciously, the therapist might be sensing the need to move away from the emotion, “Maybe this is a good time to go over those breathing exercises we talked about.” Don’t do it! The reason behind this post is to highlight what is going on and the value of staying attentive to the incipient emotion even when it might soon get uncomfortable.

In fact, there are potentially two motivations balanced against one another. One is to shut down the inner unconscious emotion. The other is to seek relief by sharing it with you, the therapist. The more experience the dyad has in finding relief through empathic connection, the more the client will be willing, even eager to linger with the potentially painful material. Our job, in this phase of treatment is to invite the emotion out. We want to influence towards allowing the feeling to become active so that an inner collision between the old meaning and a new one can take place. Anticipation of the relief that comes from sharing is what can tip the balance in our favor. What can we do to coax emotion to the surface? It is our sensitive balancing of respect for the client’s discomfort versus seeking to understand that creates an effective invitation to share.

3. Affect is nowhere to be seen

When affect is nowhere near, with no hint of its potential presence, that means some kind of defense is keeping activation of unconscious emotion at bay. I like the term, “bracing." It conjures up a stance adopted for the long haul, a steady way of blocking limbic activation and awareness of a potential threat. It can take a number of different forms. Let’s start with an idea held as a constant presence.

One client blamed herself for her mother’s psychotic behavior. That belief kept her rage at bay until the day she learned her mother had been hospitalized for psychosis before she was born. In a flash, the realization coursed through her mind and she exploded in anger, anger that had previously been dormant. The movie, Good Will Hunting gives another example of self-blame as a stance that kept pain far from consciousness.

Another kind of bracing is behavioral. Repeating a self-negating behavior pattern can be a way of demonstrating and reiterating to the inner self that mistreatment is the way things are supposed to be. Repeated behaviors can stand as a powerful ongoing statement  in response to the pressure of incipient unconscious emotion. (See TIFT #101 for an explanation of unconscious emotion.) 

Hope can be another way of holding the status quo. Maintaining hope and persistently waiting for a desired event can keep the mind far from pain or the discomfort of acceptance. A stance can be directed outward as well. Hate as well as the hope of revenge or closure can keep sadness or hurt from being experienced. What these dynamics all have in common is their power to maintain an effective block against the activation of unconscious emotion related to a distressing circumstance.

When such a block is in place, our job as therapists is to invite the client to let go of the bracing. We will only be successful when we first build awareness and a desire to change. In my experience, this generally starts as a joint exploration. Mutual curiosity may then lead to some discussion of pros and cons of trying a new approach. From there, a path will usually appear leading to a change in conscious thinking or behavior. Such a change process may not have the magical quality of memory reconsolidation. It starts with a more “top-down” movement. First therapist and client need to understand the bracing, how it works, why it is there, and what most likely lies behind it. We will have to discover how the bracing is blocking progress and how putting it aside will ultimately lead to relief.

In many instances, what makes change desirable to the client may not be the resolution of a deep, unconscious problem, but a more superficial improvement in functioning. Any positive change is good, but deep forces keeping the old status quo in place may re-assert themselves, leading to a disappointing relapse or return to the familiar. That asks for a deeper look at the why behind the bracing.

Long term blocking of unconscious emotion often comes in onion layers, each one similar to the one before. For example, realizing that “it isn’t my fault” may be followed by another layer of, “I must somehow have caused the situation.” In that way, letting go of one level of self-blame reveals another deeper one. Similarly, a negative attitude may be supported by negative behaviors like treating oneself badly. What this means is that this phase of therapy can be slow and frustrating for patient and therapist. It is important not to give in to labeling and blaming. It’s not a matter of laziness or that some people can’t change. The real reason is that inner children are very persistent. They are there to protect from an existential threat, and in matters of life and death, they don’t give up after just one round.

Here, I am suggesting an active kind of therapy. Wilhelm Reich was an early Freudian who talked about “character armor,” and realized the need to be patient and persistant. I fully agree, but we also need to recognize the danger of the therapist becoming too invested in an outcome and the client not fully accepting it. Motivational Interviewing is an entire system built on how to work with clients who don't want to be told what to do. It emphasizes making sure the client is the full owner of the change process. The one who must ultimately cope with uncomfortable inner emotions is the client and, in the end it is the client who benefits.

Just to be clear, these bracing defenses are, themselves, examples of Entrenched Maladaptive Patterns, EMPs. The difference is that they are highly effective at suppressing unconscious emotion and not so obvious in their intent. In this phase, as in the others, the Five Questions mentioned at the end of TIFT #101 (link below) are no less relevant.

Recognizing the three phases of therapy

 I hope this post clarifies how the work of therapy can feel very different in each of the three phases. The immediate objectives are different and the pace is different, but the ultimate aim is the same, to make progress towards fulfillment of the two primary requirements for memory reconsolidation, activation of the old schema and communication to the limbic system of new, disconfirming information to overwrite the old.

For our Five Question Method for memory reconsolidation through accurate empathy, CLICK HERE.

Jeffery Smith MD

Photo credit,  Heidi Fin, Unsplash