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Psychotherapy - A Practical Guide

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Psychotherapy - A Practical Guide

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Elias Ziade

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Jeffery Smith

Psychotherapy

A Practical Guide

123
Psychotherapy
Jeffery Smith

Psychotherapy
A Practical Guide
Jeffery Smith
New York Medical College
Valhalla
New York
USA
www.howtherapyworks.com
[email protected]

ISBN 978-3-319-49459-3 ISBN 978-3-319-49460-9 (eBook)

DOI 10.1007/978-3-319-49460-9

Library of Congress Control Number: 2016961346

© Springer International Publishing AG 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, express or implied, with respect to the material contained herein or for any errors
or omissions that may have been made.

Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG Switzerland
The registered company address is Gewerbestrasse 11, 6330 Cham, Switzerland
Foreword

The practice of psychotherapy has evolved over more than 100 years through various
theoretical explanatory models and, correspondingly, many varieties of therapeutic
techniques. Some approaches focus on the centrality of emotion, while others focus on
cognition and manifest behavior. Simultaneously, some techniques call for psychothera-
pist “neutrality” as others call for “active engagement.” Competing volumes on this
subject often seem devoted to the demonstration of the “specificity”—implicitly,
“superiority”—of a particular psychotherapy model, and hence technique, over others.
To his great credit, Jeffery Smith, MD, takes a stance that can be considered
“atheoretical,” or respectful of many different psychotherapy traditions. A well-
trained and long-experienced psychotherapist, Dr. Smith focuses on the centrality of
the patient-therapist relationship, which remains the central dyadic force in all mod-
els of individual psychotherapy. This applies to the rest of medicine too, a fact often
neglected in the current era of the “industrialization” of the practice of medicine. It
is in the establishment of the psychotherapeutic dyad, with a psychotherapist stance
of safety provision, that the patient is able to most fully explore both the emotional
and cognitive experiences that underlie so much of psychiatric illness.
Unique to this book, Dr. Smith introduces the concept of the entrenched dysfunc-
tional pattern (EDP) and the affect avoidance model, newly proposed terms that
represent a series of explanatory schemas and the resultant avoidance of associated
painful affects to describe deficits in the intrapsychic space expressed in clinical
symptoms. He uses elements of recent advancements in the neurosciences, includ-
ing discussion of learning, long-term potentiation, and neuroplasticity, to propose
neural network underpinnings of clinical phenomena seen in patients. Pertinent to
actual psychotherapeutic technique, he uses the metaphor of the patient’s “inner
child” to advise psychotherapists in the exact approaches to patients who have
experienced long-term suffering (often the residua of abuse experiences) and to thus
assist in targeted psychotherapeutic techniques, particularly as relates to strongly
held emotional material. By psychotherapists understanding EDPs and the affect
avoidance model, patients can then be effectively guided to examine, break down,
analyze, and thus modify dysfunctional emotions and behaviors, ultimately adapt-
ing to a higher degree of psychiatric function.
Why a new instruction book on psychotherapy now? The rising degree of eco-
nomic prosperity and growth in a modernizing and socially interconnected world

v
vi Foreword

surely represents great progress. However, as more people function at a higher

social level, the adverse experience of neurotic and social conflict becomes much
more manifest at a population level. Such empowered, yet symptomatic, patients
will seek out psychotherapy to address these concerns. Simultaneously, diffusion of
information technology gives people everywhere prompt access to the latest
advancements in the clinical literature. Given the need for more access to, and
expectations of success in, psychotherapy, instructional books on the techniques of
psychotherapy necessarily need to be accessible to clinicians from various profes-
sional disciplines and backgrounds. Dr. Smith’s book, describing in a pragmatic
way the elements of various psychotherapy models, provides a synthesis that is as
timely as it is concisely written. It will be of value in training programs for begin-
ning psychotherapists and is a helpful resource for more experienced psychothera-
pists as well. This book should be of particular use in master of social work and
psychiatric nurse practitioner training programs, and a valuable addition for clinical
psychology doctorate programs and psychiatry residency programs.
Anyone interested in the “how and why” of psychotherapy will find this volume to
be an engaging read. For beginning students, the extensive discussion of the momen-
tary experiences within psychotherapy sessions will serve to ground them in basic
psychotherapeutic techniques and prepare them for more productive use of psycho-
therapy supervision of their cases. For the established clinician, the thoughtful organi-
zation of this book will serve to buttress the psychotherapist’s existing strengths while
inspiring still greater mastery. Finally, teachers of psychotherapy now have a volume
that will prove versatile in the areas of basic instruction, technique, and supervision.
With the contemporary pressures to expect all clinical interventions to be patient-
centered, cost-effective, and justified in terms of outcomes, Dr. Smith helps to refine
the powerful role that psychotherapy will continue to play in the management of
psychiatric illness, which is finally being recognized as a major source of disability
worldwide. He advances the field of psychotherapy scholarship at a time when we
in academic psychiatry need to more fully understand and appreciate the role of this
most central of psychiatric interventions.
Dr. Smith has capitalized on his own long experience, seasoned by thoughtful
reflection, to develop a remarkably unifying theoretical framework of understanding
of disorders of emotions, thoughts, and behaviors, which translates into a cogent and
patient-centered approach to psychotherapy. Readers have the opportunity to learn
from his experience in this concise yet thoughtfully thorough book, masterfully and
lovingly provided for the field to share. We are all enriched by this contribution to the
psychiatric literature.

James A. Bourgeois, OD, MD
University of California
San Francisco, USA
Acknowledgments

Since this book is, in a way, the culmination of a career, I owe gratitude to all those
who have inspired and supported me on my journey. First, and most of all, thanks to
Claude, my wife, who stuck with me all the way.
Dr. P., my therapist in college, gave me a taste of what it is to have someone to
talk to. Dr. Stilwell took me seriously when I said I wanted to go to medical school.
J.C.B. Grant, my anatomy professor, showed us how to discern the natural divisions
between structures. Dr. Obeid, “The Ear,” taught how to listen to the heart. Milt
Rosenbaum demonstrated how to connect with patients, and Joel Kovel told me to
go ahead and “mix it up” with them. Leon Balter not only insisted on rigor when it
came to theory but shared his private knowledge of identification with the aggressor.
With Eleanor Galenson, I learned to see the world through the eyes of children. John
Moneypenny was the recovering alcoholism counselor who introduced me to the
wisdom of AA. Dr. H., my therapist, helped me untangle my past.
To my patients I owe enormous gratitude. They taught me, lesson by lesson, a
large part of all I know about healing and growth.
I am grateful to Cindy for urging me to write long before anyone else and to
Robert Oxnam, my second DID patient, who asked me to write an epilogue to his
book, A Fractured Mind: My Life with Multiple Personality Disorder. In doing so,
he gave me my first taste of writing for the reading public.
Thanks to Maj-Britt Rosenbaum for giving me the break that started my private
practice and to Dr. Jim Walkup, who picked up the baton from there. Since the early
1980s, Dr. Michael Blumenfield has quietly encouraged me on every turn of my
pathway, starting with the American Psychiatric Association. He also urged me to
join the American Academy of Dynamic Psychotherapy and Psychoanalysis, where
I met Jim Bourgeois, my writing mentor. Thanks to John Norcross and SEPI, the
Society for the Exploration of Psychotherapy Integration, for providing a supportive
and welcoming intellectual home.
I am grateful to Shelley and Margot, my two development editor sisters who sup-
ported and encouraged my writing, and especially to my daughter, Anne, who has
been a constant source of warm encouragement.
Finally, Rachel Trusheim, my editor, has been a super cheerleader and subtle
helper in shaping and refining this book.

vii
Contents

1 Introduction�� 1

Part I How Therapy Works

2 Layers of Pathology �� 7

2.1 Jack �� 7
2.2 Dividing the Problem�� 8
2.3 Jack’s Personality�� 8
2.4 Dealing with Jack’s Reluctance�� 9
2.5 Jack’s Panic Attack �� 10
2.6 Asking Why�� 11
2.7 A Third Module�� 11
2.8 A More Complete Picture �� 12
2.9 The Basic Unit of Pathology�� 13
2.10 Advantages of the EDP Concept�� 13
2.11 Resisting Positive Change�� 15
2.12 A Fresh Approach to Jack’s Treatment �� 16
2.13 Integrated, Modular Treatment �� 17
References�� 18
3 The Affect Avoidance Model �� 19
3.1 Affect Avoidance�� 19
3.2 Use of the Word Affect�� 20
3.3 The Mind as a Control Structure�� 20
3.4 A Silver Lining �� 22
3.5 Affect Avoidance Is Not a New Concept�� 22
3.6 What Is the Role of Pleasure?�� 23
3.7 What About Biology? �� 24
3.8 Relating the Affect Avoidance Model to Other Therapies�� 25
3.9 Compatibility with Other Models �� 26
3.10 The Detailed Structure of EDPs�� 28

ix
x Contents

3.11 The Nonconscious Problem Solver�� 30

3.11.1 Potential Behaviors �� 30
3.11.2 Helpers�� 31
3.11.3 Symptoms �� 32
3.12 How Protections Become Problems�� 32
3.13 The Gifts of Consciousness�� 34
3.14 The Affect Avoidance Model Applied to Psychotherapy�� 34
3.15 A Unifying View of Psychotherapy�� 35
3.16 Making Use of Different Therapies�� 36
3.17 Putting It All Together�� 36
3.18 Modular Therapy�� 37
3.19 Cyclical Therapy �� 37
3.20 Conclusion�� 38
References�� 39
4 Avoidance Patterns and Mechanisms�� 41
4.1 What Shapes Avoidance Patterns?�� 41
4.2 The New Science of Memory �� 42
4.3 Practical Application�� 43
4.4 Procedural Memory�� 44
4.5 A Catalog of EDPs�� 45
4.5.1 Dysfunctional Behaviors�� 45
4.5.2 Helpers�� 47
4.5.3 Symptoms �� 48
4.5.4 Anxiety-Based Symptoms�� 48
4.6 Conclusion�� 49
References�� 50
5 How Affects Are Healed�� 51
5.1 Breaking the Chain �� 51
5.2 How Healing Works�� 52
5.3 Extinction�� 53
5.4 Reconsolidation�� 54
5.5 Anna O.: A Case of Reconsolidation�� 55
5.6 Healing in the Real World�� 56
5.7 Repetition�� 56
5.8 From Words to Healing�� 57
5.9 Healing Beyond Trauma �� 57
5.9.1 Pride, Guilt, and Shame�� 57
5.9.2 Attachment�� 58
5.9.3 Ideas�� 58
5.9.4 Psychological Development�� 58
5.10 Conclusion�� 59
References�� 60
Contents xi

6 A Context of Connection �� 61

6.1 A Prototype �� 61
6.2 The Ubiquity of Emotional Healing �� 62
6.3 Are There Exceptions?�� 63
6.4 Mindfulness�� 63
6.5 A Proposed Explanation of Mindfulness�� 64
6.6 When a Witness Is Necessary �� 64
6.7 What if the Therapist Is Overwhelmed �� 65
6.8 What About Involuntary EDPs?�� 65
6.9 Conclusion�� 66
References�� 66
7 Motivation, Internal and External �� 67
7.1 The Special Situation of the Trainee�� 67
7.2 What Makes Patients Seek Therapy?�� 67
7.2.1 The Chief Complaint�� 67
7.2.2 Location of the Problem�� 68
7.2.3 Hopes and Expectations�� 68
7.2.4 Eliciting Expectations �� 68
7.2.5 The Inner Child �� 69
7.3 Hope and the SEEKING System�� 69
7.4 Outside Motivation�� 70
7.4.1 Leverage�� 71
7.4.2 When There Is No Leverage �� 71
7.5 Why Do Patients Stay? �� 71
7.6 Why Do Patients Quit? �� 72
7.6.1 Missing Sessions�� 72
7.6.2 Deciding to Quit�� 72
7.7 Internal Resistance to Change�� 73
7.8 Biological Motivation �� 73
7.9 Timing and Motivation�� 73
7.10 The Therapist as Motivator �� 73
7.11 “Cat and Mouse”�� 74
7.12 The Patient Is Part of a System �� 75
7.13 Enabling�� 76
7.14 Patients Don’t Tell Us Unless We Ask�� 76
References�� 77
8 A Developmental Primer �� 79
8.1 Developmental Theory�� 79
8.2 Knowledge Brings Compassion�� 80
8.3 An EDP Most of Us Have�� 80
8.4 Young and Adult Thinking Mixed�� 81
8.5 Working with Rationalizations�� 81
xii Contents

8.6 Developmental Challenges �� 82

8.6.1 Self-Other Differentiation �� 82
8.6.2 Attachment and Separation �� 83
8.6.3 Power Struggles�� 84
8.6.4 Crime and Punishment�� 85
8.6.5 The Rules�� 86
8.6.6 Someday�� 87
8.6.7 Later Childhood�� 88
8.6.8 Adolescence�� 88
8.6.9 Young Adulthood�� 89
8.6.10 Adulthood �� 89
8.6.11 Old Age �� 90
References�� 91
Part II What Therapists Do
9 Conducting an Initial Assessment�� 95
9.1 Do We Need to Ask Why?�� 96
9.2 Working with Uncertainty�� 96
9.3 Beginning the Session�� 97
9.4 Show, Don’t Tell �� 98
9.5 Listening for Style and Content�� 98
9.6 Formulating Questions�� 99
9.7 Following Leads�� 99
9.8 The Patient’s Mind Has the Map�� 100
9.9 The “Chief Complaint” �� 100
9.10 Spiral Organization �� 101
9.11 Listening for What We Don’t Know �� 102
9.12 To Get Feelings, Ask for Facts�� 102
9.13 What if You Get an Evasive Answer? �� 102
9.14 Trauma and Substance Abuse �� 103
9.15 Beginning to Wrap Up�� 103
9.16 Assembling the Data �� 103
9.17 Building a Hypothesis�� 105
9.18 Making a Plan �� 106
9.19 Walking in Thick Fog�� 108
9.20 Arriving at an Agreement�� 108
References�� 109
10 Conducting Generic Talk Therapy�� 111
10.1 Putting the Patient in Charge�� 112
10.2 Every Session Has a Topic�� 112
10.3 A Third Participant�� 113
10.4 The Frame �� 114
10.5 First Follow the Flow�� 115
10.6 When to Intervene�� 115
10.7 The “Three-Step Dance”�� 116
Contents xiii

10.8 The Three-Step Dance in Perspective �� 117

10.9 Second Priority: Understanding�� 118
10.10 Many Kinds of EDP�� 119
10.11 The Value of Listening�� 119
10.12 Beyond the Three-Step Dance�� 120
10.13 Putting Words to Feelings �� 120
10.14 Tell, Don’t Ask�� 121
10.15 When Not to Tell�� 121
10.16 Ending a Session �� 121
10.17 Phases of Therapy �� 122
10.18 Long-Term Resistance�� 122
10.19 Discovery, Emotional Healing, and Behavior Change:
Three Tasks �� 123
10.20 How Long Does Change Take?�� 124
10.21 Conclusion�� 124
11 Building and Maintaining the Therapeutic Relationship�� 125
11.1 The Therapist’s Role �� 125
11.2 Boundaries�� 126
11.3 Effective Boundary Management �� 127
11.4 The Frame �� 128
11.5 Flexibility�� 128
11.6 Attunement�� 129
11.7 How to Achieve Empathy �� 129
11.8 Two Exceptions�� 129
11.9 Breaks in Empathy�� 130
11.10 Eliciting Feedback�� 130
11.11 Maximum Empathy, Optimal Expectancy�� 131
11.12 Agreement Between Patient and Therapist�� 132
11.13 Matching Stages of Change�� 133
11.14 Matching Culture, Religion, and Spirituality�� 134
11.15 Matching Gender and Sexual Orientation�� 135
11.16 Therapists’ Feelings About Patients�� 135
11.17 Liking or Not Liking the Patient�� 136
11.18 The Working Alliance �� 137
11.19 What Doesn’t Work�� 137
11.20 Terminating the Therapeutic Relationship�� 138
11.21 Goals of Termination Sessions�� 138
References�� 139
12 Working with the Inner Child�� 141
12.1 History of the Inner Child Concept�� 143
12.2 Before Meeting the Inner Child�� 143
12.3 How to Recognize the Inner Child�� 144
12.4 A Word of Caution�� 145
12.5 Adult Temper Tantrums�� 146
xiv Contents

12.6 Accepting Unmet Needs �� 147

12.7 Containment�� 147
12.8 Schema Therapy�� 148
12.9 The Manipulative Patient�� 148
12.10 The Self-Sufficient Patient�� 148
12.11 Compassion�� 149
12.12 The Corrective Emotional Experience�� 149
References�� 150
13 Adjustments�� 153
13.1 How Much to Talk�� 153
13.1.1 Arguments for Active Therapist Communication �� 153
13.1.2 Pros and Cons of Less Talk �� 154
13.1.3 Liabilities of More Talk�� 154
13.1.4 Some Goals Furthered by Speaking Up�� 155
13.2 Using Language to Regulate Emotional Arousal�� 155
13.2.1 Emotion-Heightening Words�� 156
13.2.2 Emotion-Lowering Words �� 156
13.3 How Much Support? �� 156
13.4 How Much Authority?�� 157
13.5 Adapting to Attachment Style�� 158
13.6 Internalizing vs. Externalizing�� 159
13.7 Length and Frequency of Sessions �� 159
13.7.1 Length of Sessions�� 160
13.8 How Much Structure? �� 160
13.9 Use of Homework �� 160
13.10 Frame as a Variable �� 161
References�� 162

Part III A Catalog of EDPs

14 Behavioral EDPs�� 165

14.1 Eight Behavioral Avoidance Patterns�� 165
14.1.1 Simple Avoidance�� 166
14.1.2 Nonverbal Schemas�� 167
14.1.3 Reenactment�� 171
14.1.4 Acting Out�� 172
14.1.5 Hidden Agendas�� 173
14.1.6 Guilty Quests�� 176
14.1.7 Developmental Arrest�� 178
References�� 181
15 Addictions �� 183
15.1 Baffling, Cunning, and Powerful�� 183
15.2 Why Do Some People Get Addicted?�� 184
15.3 Secondary Psychopathology �� 184
Contents xv

15.4 The Role of Value Systems �� 184

15.5 Codependency in Five Easy Lessons�� 185
15.6 Treatment Principles �� 186
15.6.1 Hitting Rock Bottom �� 186
15.6.2 Key Questions �� 186
15.6.3 External Motivation Is Acceptable�� 187
15.6.4 Leverage�� 187
15.6.5 Anti-craving Medications�� 188
15.6.6 The Role of the Therapist�� 188
15.6.7 Motivational Interviewing�� 189
15.6.8 Pitting Biology Against Biology �� 189
15.6.9 Positive Prognostic Signs�� 190
References�� 191
16 The First Helper: Emotion�� 193
16.1 Introduction: The Three Helpers�� 193
16.2 EDP #9: Emotions as Helpers�� 194
16.3 Sadness and Tears �� 195
16.4 Helplessness and Hopelessness�� 197
16.5 Anger�� 197
16.6 Panic, Fear, and Anxiety �� 199
16.7 Impulses�� 200
17 The Second Helper: Conscience-Based Emotion�� 203
17.1 Values, Attitudes, Ideals, and Prohibitions�� 204
17.2 Neurophysiology of the Conscience �� 204
17.3 Becoming Aware of the Conscience �� 205
17.4 Like a Justice System�� 205
17.5 Pathology of the Conscience�� 206
17.6 Shame vs. Guilt�� 206
17.7 Internalization of Values �� 207
17.8 Internalization, Fast and Slow�� 208
17.9 Internal Electric Fences�� 208
17.10 Adult Internalization �� 209
17.11 Resistance to Change�� 209
17.12 Values Are Permanent �� 209
17.13 Self-Contradictory Values �� 210
17.14 Treatment Principles �� 210
17.14.1 Tread Lightly�� 210
17.14.2 New Values vs. Old Ones Recovered�� 211
17.14.3 Education�� 211
17.14.4 Modeling Positive Values and Attitudes�� 211
17.14.5 Working with Shame�� 212
17.14.6 “Civil Disobedience”�� 212
References�� 213
xvi Contents

18 The Third Helper: Thoughts�� 215

18.1 Thoughts as Helpers�� 215
18.2 The Contents of Influencer Thoughts�� 217
18.3 Avoiding Thoughts Makes Them Stronger �� 217
18.4 Treatment Principles �� 218
18.4.1 Consciousness Raising�� 218
18.4.2 Distinguishing Healthy Thoughts from Unhealthy Ones�� 218
18.4.3 Resistance�� 218
18.4.4 Mindfulness�� 219
18.4.5 Other Techniques�� 219
References�� 220
19 Involuntary Symptoms: Grief and Depression �� 221
19.1 Grief: A Healthy Response �� 221
19.1.1 Loss and the SEEKING System�� 222
19.1.2 Pathological Grief �� 222
19.2 EDP #12: Depression�� 223
19.2.1 Some Good News�� 224
19.2.2 Focusing on “Major Depression”�� 224
19.2.3 Some Bad News�� 224
19.2.4 Financial Influences�� 225
19.3 Melancholic Depression�� 225
19.3.1 Unique Aspects of Melancholic Depression �� 226
19.3.2 Bipolar Illness �� 226
19.3.3 Two Vicious Cycles�� 227
19.3.4 First Work with the Biological Dysregulation�� 227
19.3.5 The Behavioral Aspect of Depression�� 228
19.3.6 The Emotional Aspect of Depression�� 229
19.3.7 Emotional Components of Milder Depressions�� 230
19.3.8 Agitated Depression and Mania�� 230
19.4 Conditions That Look Like Depression but Are Not�� 231
19.4.1 Stuck in an Unhealthy Lifestyle�� 231
19.4.2 Grief�� 231
19.4.3 Not Getting One’s Way �� 231
19.4.4 Miscellaneous Symptoms�� 232
19.5 Treatment Principles �� 232
19.5.1 Antidepressant Medication�� 232
19.5.2 Psychotherapy �� 233
19.5.3 The Behavioral Approach to Depression�� 233
19.5.4 The Emotional Approach to Treatment �� 233
References�� 236
20 Involuntary Symptoms: Anxiety-Related Problems �� 237
20.1 Two Layers of EDP�� 237
20.1.1 The Surface Layer EDP�� 238
20.1.2 The Deeper Layer of EDP�� 239
Contents xvii

20.2 A Brief Catalog of Anxiety-Related Syndromes�� 241

20.2.1 Anxiety�� 241
20.2.2 Panic�� 241
20.2.3 Obsessions and Compulsions�� 242
20.2.4 Somatization�� 243
20.3 Treatment Principles �� 244
20.3.1 Trying to Control Anxiety Makes It Worse�� 244
20.3.2 Medication Treatment �� 244
20.3.3 The Behavioral Approach to the Preoccupation�� 245
20.3.4 The Emotional Approach to Preoccupation�� 245
20.3.5 Mindfulness Helps�� 246
20.3.6 Healing the Deeper Layer of EDP�� 247
20.3.7 Time Sometimes Heals�� 247
References�� 248
21 Involuntary Symptoms: Trauma and Dissociation �� 251
21.1 Taking the Mystery Out of Dissociation �� 251
21.2 PTSD and Dissociation �� 252
21.3 Complex Trauma�� 253
21.4 The Nature of Dissociation �� 253
21.5 Multiple Personalities �� 254
21.6 Treatment Principles �� 256
21.6.1 The Flight–Fight Cycle �� 256
21.6.2 Accessing Dissociated Facts and Feelings�� 256
21.6.3 Basic Healing�� 257
21.6.4 Building a Perspective and Narrative�� 257
References�� 258
22 Going Forward �� 259
22.1 For the New Therapist�� 259
22.1.1 Psychotherapy Is Still Best Learned Experientially�� 260
22.2 For the Seasoned Practitioner �� 260
22.3 For Knowledge Seekers and Researchers �� 261
22.3.1 Some Specific Questions for Investigation �� 261
22.4 For Students and Teachers�� 262
22.4.1 Today’s Teaching Model �� 263
22.4.2 Moving Out of the Middle Ages �� 263
22.4.3 We Can’t Afford to Waste Resources�� 263
22.5 Conclusion�� 264
References�� 264

Index�� 265
Introduction
1

After 40 years of practice, each new patient is quite different from any I have seen
before. This is why psychotherapy is so compelling, but it also presents a real chal-
lenge in making sense of what we see and hear and deciding what to do. This book
is aimed at helping the new therapist with two pressing questions: what is going on,
and what should I do next?
The traditional way to address these questions is to introduce the trainee to eight
or more incompatible theories and then ask the beginner to choose one and learn to
apply it to all the patients he or she sees until some proficiency is achieved. After
that, it might be okay to put a toe in the water to try some other approaches. But it’s
time for a change. Students don’t want to become disciples; they want to know what
will work best for their patients. Fortunately, the field is beginning to embrace mul-
tiple techniques and understand neurobiological change mechanisms that apply to
all therapies.
Einstein said, “Everything should be made as simple as possible, but not sim-
pler.” Psychotherapy: A Practical Guide is the result of many years’ effort to find
natural dividing lines to simplify the practice and teaching of psychotherapy while
respecting its complexity. This book overcomes a problem of multiple incompatible
theories by building a unifying framework, a roof under which all contemporary
theories in psychotherapy can be accommodated. It makes sense of patients’ com-
plex problems by dividing them into smaller units, which I will call entrenched
dysfunctional patterns or EDPs for short. Both the conceptual framework and the
way we identify and work with entrenched dysfunctional patterns grow out of three
new and unique ideas.
The theory presented here is called the affect avoidance model. The idea that our
problems start out as ways to avoid painful feelings is as old as psychotherapy. What
is new is the realization that not just some but all problems that can be resolved
through psychotherapy are due to the mind’s instinctive efforts to avoid painful,
uncomfortable, and overwhelming emotions. While this idea is not identical with
every contemporary theory, it is compatible with all. For example, psychodynamic
theories may point to conflict between ego and superego, but the reason such a con-
flict leads to pathology is the mind’s work behind the scenes to avoid pain. The ego

© Springer International Publishing AG 2017 1

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_1
2 1 Introduction

doesn’t “want to” feel the pain of giving up its aim, while the superego “tries to”
steer the person so as to avoid the painful feeling of guilt. Similarly, attachment
theory describes patterns of coping with separation, but these patterns can also be
seen as attempts to minimize the pain of loss. Cognitive and behavioral therapies are
compatible as well. They explain pathology as learned under the influence of nega-
tive and positive reinforcement, that is, avoidance of pain and enhancement of plea-
sure. Some may object to applying the language of intentionality and purpose to
avoidance patterns; however, few would object to saying that our instinct to avoid
putting weight on a sprained ankle is purposeful. Furthermore, for the clinician,
avoidance is a metaphor for what really happens in the brain. It is a metaphor that
helps make the unknowable comprehensible and allows valuable predictions about
what patients will say and do.
In sum, the affect avoidance model provides a single, intuitively natural way of
understanding the full range of problems and pathologies that patients bring to us.
At the same time, it is easy to learn and does not compete with existing theories,
rather it provides a common way of looking at how humans get into trouble and how
we can help them find their way out.
Looking for the natural organization of our patients’ symptoms, the second key
concept flows easily out of the affect avoidance model. It is the notion that dysfunc-
tional patterns form layers, each one protecting the individual from an anticipated
painful emotion that might escape from the layer below. I call these units entrenched
dysfunctional patterns, or EDPs, because that phrase captures their most basic charac-
teristics. If they weren’t entrenched, then there would be no need for psychotherapy to
help the patient become free. The fact that the patterns have become dysfunctional is
what brings them to our attention as therapists. If they weren’t identifiable, potentially
repetitive patterns, then we would have no way to work with them.
Dividing our patients’ problems into functional layers makes understanding
much simpler. Each layer is triggered or activated by some dreaded emotion. The
mind functions to block that emotion from coming to consciousness as an affect,
where it will cause pain, discomfort, or be experienced as overwhelming. As we are
sitting with patients, we can ask ourselves what is the problematic emotion that this
pattern was designed to avoid. In addition, each EDP is embodied in an avoidance
mechanism, meaning it is built on some strategy for avoiding the affect. The student
will learn that the form these patterns take depends more on the stage of develop-
ment when they were first “invented” than the nature of the anticipated emotion they
are designed to avoid. Thus, learning about some basic developmental eras and the
cognitive capabilities available at the time the pattern had its origin (Chap. 8) will
help greatly in identifying a particular EDP.
The EDP concept is helpful not only by making it easier for the therapist to see
and describe what lies behind the patient’s dysfunction but also as a clinically ori-
ented alternative to current diagnostic systems. While official diagnostic labels may
be necessary for administrative purposes, some, like oppositional defiant disorder
or even major depression, lump patients together who may require quite different
approaches. Moreover, they often fail to recognize the relationships between mul-
tiple problems in the same patient. When we divide pathology into distinct layers,
1 Introduction 3

similar EDPs call for similar approaches. Not only that but they invite research to
refine our knowledge of optimal techniques for a particular kind of entrenched dys-
functional pattern.
The third key notion is that every EDP is a link between emotion and behavior. One
of the deepest and most long-standing conflicts in the field of psychotherapy has been
between those who emphasize emotion and those who focus on behavior.
Psychodynamic approaches have tended to underemphasize behavior, while behav-
ioral ones have underemphasized emotion. Fortunately, the field is rapidly closing the
gap, embracing the importance of both. The truth is, therapists, whatever their orienta-
tion, do two things. They help patients detoxify painful emotions, and they help
patients trade in dysfunctional patterns of thought and behavior for healthier ones. The
affect avoidance model provides a simple and universal way of seeing how emotion
and behavior are intimately related. Avoidance strategies embodied in every EDP are
driven by emotion but are manifested in patterns of thought and behavior.
For therapists, what this means is that any entrenched dysfunctional pattern can
be approached from two directions. In situations such as trauma, we usually try to
help the patient process and heal the emotion, so that avoidance strategies like drugs
or constant activity are no longer necessary. On the other hand, when the more
accessible aspect of the EDP is a dysfunctional behavior, say avoiding intimacy, we
may first focus on the behavior. In practice, behavior change usually uncovers emo-
tions, while working with emotions facilitates behavior change. Whichever aspect
we start with, the other usually comes into view. Thus, the affect avoidance model
makes clear the close relationship between emotion and behavior and appropriately
erases any gap between them.
What makes psychotherapy so complex and challenging to learn is the tremen-
dous variety of EDPs we encounter. In Part III of this book, we will break down the
range of pathologies into 14 types, or groups, of EDPs. These categories are chosen
because they have a similar look and feel and because the ways of working with
them are similar. The list is complete. All the problems we see in practice have a
place in the catalog of EDPs. Every patient’s dysfunctional patterns are represented
among the 14 types, making it easier for the student to identify those encountered in
working with patients.
The importance of a simple yet comprehensive way of learning psychotherapy
came home to me recently when I learned that from 2010 to 2030 it is estimated that
the middle-class population of the world will double, mainly in developing coun-
tries. This means millions of people will turn from survival to focusing on how to
have a better quality of life for themselves and their children. Among these, many,
like myself, will want to become therapists, learning to help others find their way
out of entrenched dysfunctional patterns. The traditional model for learning psycho-
therapy starting with one “brand” and later assimilating techniques from others is
inefficient and wasteful. Students from widely diverse backgrounds will need a
framework to help them integrate information from many sources into a clear, uni-
fied picture of how therapy works. This book is intended to make basic principles
accessible to the widest possible range of new therapists, regardless of culture or
background.
4 1 Introduction

How did I come to these ideas and write this book? First of all I am a clinician. In
the spring of my freshman year in college I knew I wanted to be a therapist. Since
then, my main allegiance has been to my patients. Helping the next patient who
walks in the door has always been more important than adhering to one technique or
one theory. Soon after residency, I encountered severe early life trauma with a patient.
My training had not prepared me for that and I had to learn about working with
intense emotions. A short time later, I began to work with people with addictions.
Once again, my training did not apply, and I had to learn the importance of behavior.
These experiences focused my interest in understanding exactly how people change.
Soon it was clear that, in contrast to many theories, there are several distinct and
crucial mechanisms of change. This became the focus of my own learning, writing,
and teaching. Dissatisfied with teaching a method without an adequate explanation
of how it works, I began to look for universal ways to explain the action of psycho-
therapy. The Society for the Exploration of Psychotherapy Integration (SEPI) put me
in touch with like-minded colleagues. Starting with a handout for my classes, I
looked for simpler ways to explain and conceptualize psychotherapy and to integrate
widely divergent theories and newly discovered neurobiology. Gradually, a frame-
work took shape of concepts and observations that were useful in practice and easy
to grasp. The ideas incorporated in this book are the ones I use every day, presented
in the best way I know to make them memorable and easy to apply.
Part I of this book, “How Therapy Works,” will explain how the mind functions
to avoid affects and how psychotherapy helps to detoxify troublesome feelings and
helps patients trade dysfunctional patterns for healthy ones. Part II, “What Therapists
Do,” will give concrete guidance and what I call “idea tools” to show how to con-
duct therapy sessions. This learning starts with a generic version of talk therapy and
then brings in adjustments and modifications to improve results in specific situa-
tions and with particular goals like working with emotions or achieving change in
behavior patterns. Part III, “A Catalog of EDPs,” will give many more details about
specific patterns of pathology and how to work with them. As mentioned, this sec-
tion is designed to cover the entire range of problems patients bring to therapy.
What more will you need to become an excellent therapist? First, supervised
practice is invaluable. There is just too much to notice and attend to in psychother-
apy without the help of someone who has been there before. Second, learning to use
the ideas presented here also takes practice. Engaging in conversation with peers
and supervisors is especially formative in learning to apply concepts to real-world
patients and situations. Third, using this unifying framework will make it easier for
you to learn and apply techniques and ideas from the vast store of wisdom gathered
by therapists from many schools of thought. After that, ongoing reading and expo-
sure to new and old ideas will continue to yield an exciting, constantly interesting,
and deeply satisfying professional career.
Part I
How Therapy Works
Layers of Pathology
2

2.1 Jack

Jack, at 32 years old, just had his first panic attack. He had just returned to work
from his lunch break and wasn’t thinking of anything negative. Suddenly, he started
to sweat and feel his heart pounding. Thinking he was having a heart attack, his
coworkers rushed him to the emergency room. He felt he couldn’t breathe. It was
terrifying. The doctor soon reassured Jack that his heart was fine, gave him benzo-
diazepine sedatives, which he should take every 6 h to calm his anxiety, and recom-
mended that he make an appointment to see a therapist.
During Jack’s first therapy session, he explains that his panic came for no
apparent reason. In fact, his life has been going well. He has a good job as a cable
installer and, only a few days ago, was offered a promotion. He has a 2-year-old
child, and his wife told him last week that she is pregnant with a second one.
Taking a history, there isn’t much that is remarkable. Jack was the oldest of four.
Life wasn’t so easy for his parents, but they did their best. His father had a small
appliance repair business and worked long hours. Coming home late and
exhausted, he sometimes drank too much. Jack’s mother shouldered the burdens
of the household. For extra money she watched neighbors’ children while Jack
took care of his younger siblings. According to Jack, his early life was fine. He
was proud to take care of the younger ones and still managed to be an average
student. He played sports in high school and was glad to find a good job soon after
his graduation. When he met Jane in a bar, she admired his sense of responsibility,
and he liked her positive attitude.
With all these good things happening, Jack is baffled about why he might
develop a psychological problem at this point in his life. He prides himself on
being a good provider and feels he can handle whatever challenges come his way.
Not one to complain or ask for help, he was reluctant to see a therapist. Therapy
is for weak people, like his sister, who leans on others and takes pills. If he were
at all like her, he would hate himself. He would like to limit any therapy to one
visit and go on his way.

© Springer International Publishing AG 2017 7

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_2
8 2 Layers of Pathology

2.2 Dividing the Problem

For a therapist, Jack’s case presents two problems. The first is the panic attack itself,
which we want to keep from becoming a repeating pattern. The second problem
could be thought of as a strength, his self-sufficiency. This reluctance to accept help
has been a positive feature of his personality but now creates a serious challenge to
working with him. We’ll call these two troublesome issues modules because divid-
ing Jack’s problems into chunks will reduce their complexity and point the way to
what to do next. Going forward, we will refer to the two modules as Jack’s personal-
ity and Jack’s panic attacks.

2.3 Jack’s Personality

The first module we will have to deal with is actually Jack’s reluctance to engage in
treatment. If we fail to make progress with that, then there will not be any treatment.
His values, and his strengths, are heavily weighted in the direction of being self-
reliant. Not only does Jack not believe in therapy, he would feel genuinely ashamed
if he saw himself in any way like his sister. If we start by telling him he needs more
therapy, he will run the other way.
From this information, we can conceptualize Jack’s personality as a problem mod-
ule. Let’s try to form an educated guess as to why Jack feels so strongly about handling
things himself. Jack may have learned the value of self-sufficiency from his parents,
but he seems to make it the center of his being. Could we understand his value system
as originally a way of coping with some difficulty? He says that his early life was
“fine,” but the facts don’t entirely fit. It sounds as if being the first child in his family
was really quite hard. He had to grow up quickly, and the level of support sounds mini-
mal. If he had complained, he would likely have been rebuffed. A few questions con-
firm that asking for attention was not well received by his father in particular. By
placing emphasis on self-reliance, he aligned himself with his father’s values.
Internalizing these values created a shame barrier against any temptation to seek sup-
port. Now even anticipation of the shame associated with neediness stands as a deter-
rent to seeking help, while doing without results in an internal feelings of pride. Today,
Jack’s values have become an unhealthy block to receiving the treatment he needs.
Let’s look more generally at how internalizing a value system can start out as
helpful strategies and eventually become a handicap. We, like many mammals, are
social beings. Our survival as a species depends on keeping the group together. In
pack animals, the alpha male must be vigilant for transgressions against his author-
ity and is constantly tested. In humans, unlike our mammalian cousins, guarding the
social fabric becomes an internalized function. We put pressure on ourselves to do
what is right for the group instead of relying entirely on the leader for discipline.
But we don’t start out that way.
Dog owners (alphas in their own right) must watch to make sure their dog doesn’t
take over and misbehave. Fortunately, dogs are quite sensitive to discipline so pro-
viding it is not too burdensome. Parenting a 2-year-old is similar but much more
2.4 Dealing with Jack’s Reluctance 9

taxing. Two-year-olds do not yet possess self-control and require constant supervi-
sion. Fear of consequences such as a reprimand from a parent is not strong enough
to stop a curious toddler. Furthermore, human development is prolonged such that
providing constant discipline would make parents’ lives impossible. The pack ani-
mal system of control from outside would not work for us.
Instead, humans internalize a set of values. By age three, they want to be “good.”
Children work at incorporating values such as self-control that will stay with them
for a lifetime. In addition, this system of internal values has a built-in enforcement
function. When we follow our values, we feel pride. When we fail to do so, we feel
shame or guilt. These powerful emotions provide reinforcement for good behavior.
Each person’s values reflect the generally accepted values of the family and culture,
along with values specifically tailored and internalized to solve individual problems
like Jack’s. In this way, humans’ internal controls are designed to maximize group
cohesion while attending to individual survival.
Jack has internalized the value of self-sufficiency. As a child, this was particu-
larly helpful for him. Shame prevented him from asking for attention and shielded
him from repeated painful experiences of being rejected. Valuing self-sufficiency
helped him develop skills in managing for himself without help. The problem is
that, as an adult, Jack’s emphasis on self-sufficiency goes too far and has become
dysfunctional. He has trouble accepting help from anyone, including his therapist.
Later in a joint session, his wife, Jane, complains that he is distant and controlling
as he tries to do everything for himself. This detracts from their life together. She
tries to be positive but suffers as a result of his not seeming to need her.
To summarize, we can formulate Jack’s personality module as follows: Jack, as
a child, experienced pain whenever he asked for attention. Early in life, to keep
himself from being tempted to ask, his mind internalized the value of needing no
one. His internalized value system makes use of shame to prevent him from placing
himself in what was then a very painful situation. This strategy is protective through-
out childhood but becomes partially dysfunctional as he enters adulthood, as it
blocks him from a healthy dependence on others.

2.4 Dealing with Jack’s Reluctance

It would be more natural to start by addressing Jack’s panic, but if he is to accept

treatment we will first have to work with the resistance to treatment that comes from
his shame about dependence. Our choice of approach is immediately influenced by
his personality module. Could there be a way to get around his discomfort with
accepting help? One approach would be to bypass his reluctance by inviting him to
depend on a medication instead. For some patients, dependency can be disguised by
framing it as a “required medical treatment.” This approach is not the best one
because it involves distancing from feelings rather than learning to cope with them.
Nor would Jack accept it, given his attitude about his sister’s dependency on seda-
tives and his father’s tendency to drink too much (alcohol has the same mechanism
of action as sedative medications). Let’s look for a better solution.
10 2 Layers of Pathology

A second approach to Jack’s personality module can be incorporated into stan-

dard cognitive-behavioral treatment (CBT) for panic. We could describe psycho-
logical treatment not as dependence but as a technical intervention in which he will
strengthen his self-sufficiency by learning new ways to deal with a challenge. By
framing the treatment as helping him build positive strength, we might bypass
Jack’s value system and feelings of shame.
Ideally, we would like to modify Jack’s insistence on self-sufficiency.
Unfortunately, at this point, questioning his values would be much too threatening.
How could we question the source of his greatest pride? With a therapeutic alliance
that is already shaky, he would almost certainly feel offended and might run from
treatment. We will need to accept the short-term advantages of the CBT strategy to
work around his values. While necessary, given the present situation, this strategy
will not help with more long-term problems like his marriage. Hopefully later we
may be able to address his personality module in a more direct way.

2.5 Jack’s Panic Attack

Now let’s turn to the other module, Jack’s Panic attack. So far, we have a hypothesis
to explain Jack’s reluctance to depend on therapy, but we have yet to form one about
the forces behind his panic. An experienced therapist will be aware that failure to
address the stresses causing his panic may lead to false optimism about treatment.
It is likely that Jack will not be as easy to treat as it might appear. Unless we address
the issues causing his panic, he may have trouble successfully implementing skills
for coping with panic, or his panic attacks may be more resistant to treatment than
expected.
Looking at Jack’s symptom of panic, some individuals are genetically more
prone to anxiety than others. But that still doesn’t tell us why Jack developed panic
at this point in his life. We can start with the hypothesis that, in his brain, something
triggered a massive alarm reaction. His brain, outside of consciousness, detected
some circumstance it identified as potentially dangerous. Being highly adapted to
anticipate danger, his mammalian brain then sent a strong warning signal that some-
thing was amiss and needed to be addressed immediately. Warning signals like this
start in a brain structure called the amygdala, which serves as a danger detector.
From there, the alarm sets off both subjective terror and an outpouring of adrenalin
into his bloodstream. Adrenalin causes his heart to pound and further amplifies the
feeling of something terrible happening.
What could the trigger be? Research tells us that good news can be as stressful as
bad news [2]. Jack’s learning of a second child and his promotion could be impor-
tant sources of stress. His value system does not allow him to depend on others, so
he has to handle any stress entirely on his own. For this reason, he functions like a
dam holding back rising water. As the level goes up, he shows no indication of
trouble until the water reaches the top, and then it suddenly spills over. His brain,
aware that he has run out of options, reacts to the threat of being overwhelmed by
sending out a powerful alarm. What, exactly, is the stress? Jack puts a high value on
2.7 A Third Module 11

being a good husband and provider. Between the added responsibility of his new
promotion and having a second child, his brain, rightly, anticipates a major increase
in demands with no increase in his already stretched ability to handle them. Of
course Jack would never acknowledge that he was near his limit, so he has no aware-
ness that trouble is near. In dramatic fashion, the water gushes over the dam.

2.6 Asking Why

Why do we have to guess at what is going on in Jack’s mind? The problem is that a
substantial portion [1] of mental processing goes on outside of consciousness.
Certainty about Jack’s inner processes would be highly desirable but is simply not
possible. Watson, the founder of behaviorism, felt that, lacking the certainty of
observable facts, why questions should not be asked, but we will see that asking and
forming an educated hypothesis have important advantages. Fortunately, the impos-
sibility of direct observation is not as big a problem as it might seem.
Therapists are a little like the hunters and trappers of centuries ago. By listening
and learning, over time, we develop skill and confidence in our ability to make pre-
dictions based on subtle clues. Some of our ideas resonate with patients, while oth-
ers do not, and the ones that do tend to lead to therapeutic change. Even without
observing the inner workings of the mind, consistently building hypotheses and
testing patients’ reactions build our own pattern-recognizing ability. Our sense of
assurance increases as we gain wider experience.
With what we know so far, we can say that Jack is experiencing increased respon-
sibility, which is much more stressful than it should be because his value system
does not allow him to reach out for support. Already near his breaking point, he is
caught between life circumstances and his personality. Something has to give, and
his brain is signaling the emergency.
Thus, forming ideas about why gives us a much broader picture of what is hap-
pening in Jack’s mind. If the hypothesis is not entirely correct, it can be rethought
as we go forward. For now, having a coherent picture of the complex causes of his
panic attack gives us a clear advantage in understanding his reactions and planning
his treatment.

2.7 A Third Module

Looking at Jack’s life historically, there is a third and even deeper module of pathol-
ogy. At the bottom of the layers, Jack is actually a survivor of a degree of emotional
neglect. Healthy feelings of pain, anger, and grief should be normal for a child who
had to grow up too fast. He has carried those painful feelings silently, held in check
by a value system that emphasizes toughness. If we ask him how much he suffered
as a young child, he will make light of his experience and tell us that his early life
was like any other. His values block him from feeling any kind of self-compassion
or grief for the childhood he missed. As a result, he has no conscious awareness of
12 2 Layers of Pathology

those feelings or of the relief he might gain from being able to revisit and heal them
with his therapist. Let’s explore this third and deepest module.
Pain and other negative feelings are part of life. They are inevitable but need to
follow a natural cycle to be metabolized. From the earliest age, the cycle is repeated.
Small children cry when they feel distress. Soon they learn to be soothed by the
understanding of a parent or caregiver. With a reassuring look they quickly feel bet-
ter and go back to playing until the next painful event. Even as adults we continue
to make use of this cycle. When we experience negative feelings, sharing with
someone who understands and is not overwhelmed makes us feel much better even
if the painful condition has not changed. We go back to our baseline without carry-
ing a lasting residue. This is what is meant by “metabolizing” an emotion.
On the other hand, when the cycle is blocked, the result is lasting. Painful feel-
ings that are held in mid-cycle are kept outside of consciousness though they can
cause breakthrough symptoms like tears or anger for no apparent reason. In Jack’s
case, his value system has done such an effective job of shielding him from his own
feelings that they are essentially inaccessible. Feelings blocked so completely have
no direct effects but important indirect ones. One result is his lack of compassion for
himself and for others, like his wife. Another is that the presence of such deep, unre-
solved feelings increases his need for support and undermines his resilience. This
actually increases his vulnerability to the panic attack.

2.8 A More Complete Picture

Now we have a full picture of Jack’s problems. They can be described as consisting
of three modules of pathology with one stacked on top of another. The deepest layer
is unmetabolized pain from early deprivation. Painful emotions are held in suspen-
sion. The deepest dysfunctional pattern was suppression of these feelings, an arrest
of the normal cycle of expressing affect and experiencing the healing effect of shar-
ing. When this layer of feeling suppression threatened to fail, his mind anticipated
tears and anger escaping into consciousness where they would lead to a painful
scolding. That, in turn, triggered development of the next layer.
The next layer, his personality and value system, developed early in his life to
keep him from expressing the pain of his emotional deprivation. His mind internal-
ized a value system favoring self-sufficiency, now deeply incorporated in his per-
sonality. While this blockage keeps his feelings at bay, it creates a rigidity that
causes him to be less resilient than someone who could accept support and help.
This is the dysfunctional aspect of his value system. In effect, his personality is the
source of a new vulnerability. Under the pressure of new responsibilities, his mind
anticipates failure of his ability to cope. Jack is threatened with being overwhelmed
by feelings of helplessness so powerful that they could overcome even his strong
sense of shame and enter consciousness.
To protect him from awareness of these natural and healthy emotions, his brain
produces a third module, the panic attack, stacked on top of the other two. This
symptom actually succeeds in shielding him from being overwhelmed because it
2.10 Advantages of the EDP Concept 13

forces him to seek medical help, giving him temporary relief from responsibility
and access to the support he could not otherwise allow himself.
Each module functions to block a painful or overwhelming feeling. When an
earlier one shows signs of failing, the mind anticipates the conscious experience of
a painful feeling. A new layer is placed on top of previous ones to block feelings that
threaten to escape. While Jack’s three modules of pathology seem completely dif-
ferent from one another, they have a common function and, as we will see, many
common features.

2.9 The Basic Unit of Pathology

One of the major ways this book is different from others is dividing problems into
modules. Traditionally, mental pathology is categorized by diagnosis. The problem
is that, as in Jack’s case, no one diagnosis can really capture his interlocking prob-
lems. Multiple diagnoses are possible, but they don’t give any understanding of how
one problem relates to the others. Another approach used in teaching psychotherapy
is to divide problems into dimensions such as personality, acute symptoms, rela-
tional style, etc. This adds complexity in that we have to look at each patient from
several different perspectives at once. It can also miss important relationships
between modules. Dividing Jack’s pathology into modules not only simplifies our
understanding, but each module can be seen as a distinct embodiment of the same
natural drive to avoid painful feelings.
For purposes of this text, we will use a new term, entrenched dysfunctional pat-
terns (EDP), to refer to modules or units of pathology. All of the mental pathology
that can be helped by psychotherapy can be divided into EDPs. Why use this phrase?
The pathology patients seek to change is always entrenched, in that it is resistant to
change. If it weren’t, then professional help would not be needed. These units are
necessarily dysfunctional, meaning that in some way they detract from the life the
patient would like to live. And finally, they can all be seen as patterns, that is, units
that can be described in words and are likely to be repeated.

2.10 Advantages of the EDP Concept

The real beauty of identifying pathology as made up of entrenched dysfunctional

patterns is that each one has the same internal structure. Each one starts with the
mind’s recognition of a circumstance that threatens to bring up an intensely uncom-
fortable feeling. Let’s review Jack’s EDPs from the newest to the oldest, that is,
from the top layer to the bottom. The most recent, Jack’s panic attack, started with
nonconscious perception that his new responsibilities could soon overwhelm his
ability to handle added stress on his own. Underneath that, his dysfunctional value
system was created long ago to shield him from seeking attention when it was not
available. And, at the bottom of it all, stopping the natural cycle of distress and heal-
ing was simple suppression of feelings he dared not share. Each of Jack’s three EDP
14 2 Layers of Pathology

layers is the same in that some perceived circumstance, internal or external, trig-
gered the anticipation of a painful, overwhelming or uncomfortable feeling, which
then led to development of an avoidance mechanism. Once formed, these entrenched
dysfunctional patterns are not forgotten but remain available whenever a threat is
detected.
Besides highlighting the common structure of the psychopathology we seek to
treat, perhaps the most important advantage of the EDP concept is that it shows the
relationship between emotion and behavior. This is of key importance because some
therapies put more emphasis on thought and behavior, while others favor work with
emotion. The EDP concept shows emotion and behavior as different components of
the same unit. From a practical standpoint, each EDP can be approached therapeuti-
cally from either or both sides. One approach is to detoxify the feeling, and the other
is to substitute a healthier pattern of thought or behavior. In fact, these two pathways
represent the two basic actions of psychotherapy, healing emotions and changing
patterns of thought and behavior.
To be more precise, healing painful feelings breaks the link between a perceived
circumstance and the perception of danger. How do we do this? As we will see in
the following chapters, healing emotions is primarily accomplished by helping
patients actually experience the feeling in a context of empathic connection and
safety. As feelings are detoxified or, to use a different term, metabolized, the patient
will no longer feel threatened by a circumstance that was previously a source of
dread. Here, as emphasized in trauma- and emotion-focused therapies, the object is
to take the drive out from under the avoidant behavior or symptom. Alternatively,
helping patients let go of and replace dysfunctional patterns is another way to
improve functioning. Changing dysfunctional thoughts and behavior is a specialty
of CBT, among other therapies.
Much of the time, work on one aspect exposes the need for work on the other.
Processing feelings makes it possible to address problematic behaviors, while improve-
ments in behavior often unmask difficult feelings. Thus, two seemingly opposing
worlds of psychotherapy can be seen as alternative ways to approach the same EDP.
Below let’s preview a diagram that helps visualize the common structure of all
entrenched dysfunctional patterns (Fig. 2.1). On the left, each one starts with some
perception, internal or external, that is recognized as a possible source of danger or
threat. Next the nonconscious mind goes to work and produces some combination
of the following three kinds of avoidance mechanism, which then enter conscious-
ness and may lead to seeking professional help:

• Potential behaviors designed to distance from threatening feelings pop into the
conscious mind, where we have a free choice of whether to implement them or
not.
• Helpers are positive and negative feelings, impulses, special feelings of pride,
shame, and guilt, and automatic thoughts. These enter consciousness to influence
free will to put avoidant behavior strategies into action.
• Involuntary symptoms such as anxiety and depression that have biological roots
but also function to distance from threatening feelings.
2.11 Resisting Positive Change 15

Triggering perception Non-conscious processing Conscious result

Memory of
threatening
circumstance
“Helpers” Avoidant
influence free will behaviors

Involuntary
Associated symptoms
negative feelings

Fig. 2.1 Diagram of entrenched dysfunctional pattern

Each of these avoidance mechanisms enters consciousness where the resulting

pain and dysfunction may cause us to seek professional help. The details of the
diagram will be explained further in the next chapter.

2.11 Resisting Positive Change

Entrenched means resistant to change. In general, when therapy encourages us to let

go of a once protective pattern, our mind anticipates that removing a protection
could put us in danger of experiencing a painful affect. In this way, change itself
triggers anticipation of uncomfortable affects. Naturally, then, our nonconscious
problem-solving mind goes to work to steer us in the opposite direction, that is,
further away from healthy change. This avoidance of change is recognized in all
therapies as “resistance,” meaning a nonvoluntary reluctance to experience uncom-
fortable feelings or to implement new patterns of thought or behavior.
The mind approaches the “danger” of healthy change by inventing or using what
is, in effect, a new entrenched dysfunctional pattern, a new layer of avoidance. For
example, this might be a rationalization to convince the self and the therapist that
change would not be a good idea. In Jack’s case, the idea of limiting therapy to a
single session is one of these.
What makes these avoidant maneuvers EDPs? They have the same structure as
other EDPs. They are triggered by anticipated negative feelings and consist of pat-
terns of avoidance that are dysfunctional in that they block progress in therapy. As
we identify these new EDPs, we can approach them therapeutically the same way
we approach other EDPs.
It is important to note that resistance, in spite of its negative connotation, is
automatic and not willful. The word “resistance” is frequently misunderstood by
patients as an accusation and should almost never be used with them. It is also
16 2 Layers of Pathology

important to note that what looks to the therapist like resistance may be the result
of a therapeutic error or confusion about the process rather than discomfort with
healthy change.
Despite these potential misunderstandings, it is extremely useful to be able to
conceptualize resistance to change as a natural reaction to therapy and as one more
form of entrenched dysfunction pattern. Jack’s statement that he expects to termi-
nate therapy after one session can be seen more completely as an EDP triggered by
anticipation of the shame he would experience if he were to give in to the temptation
to seek help.

2.12 A Fresh Approach to Jack’s Treatment

Armed with an understanding of Jack’s stacked EDP layers, we now have a firmer
grip on how to plan his treatment. We will start with the EDP that stands to block
treatment in the first place, that is, his reluctance to accept therapy. Since changing
his value system is a long-term process, and he is in crisis, we will need to adopt a
superficial approach to the personality layer at this time. The best way to do this is,
in fact, to introduce CBT not as a support but as a technical “procedure” to help him
manage the panic. This less threatening way of presenting treatment will also give
reassurance that his physical health is okay and that panic is a natural reaction that
can be managed. This is likely to be sufficiently nonthreatening to avoid his shame
and allow him to agree to a few sessions.
As CBT treatment gives him some sense of mastery of his panic, we will need
to address that EDP’s emotional driver. CBT sessions and the attention they
embody will satisfy some of the need for support that he can’t acknowledge.
Education about the stress of a second child and a new level of responsibility at
the job will help him begin to acknowledge a bit of neediness. This sharing of
feeling will reduce the emotional pressure behind his panic. If needed we can
also consider recommending a few days off work or adding medication, despite
its disadvantages, to further reduce the threat of his being overwhelmed by feel-
ings of panic.
Making use of the crisis as justification, we can encourage participation by Jack’s
wife in his care. This will legitimize support from her and will also give her a chance
to begin to voice her frustration about his difficulty accepting her help. As he experi-
ences some success in managing the panic, raising his consciousness about his
unhealthy fear of dependence could lead to work with the personality EDP. Motivated
by a desire to be a good husband, he will need education and more long-term work
to understand healthy dependency and to process the shame associated with
acknowledging human needs. In the distant future, as he becomes more accepting of
his own feelings and needs, his frozen feelings of hurt and anger may become acces-
sible. Emotion-oriented treatment will require that these feelings be brought into the
room so they can be healed through an empathic and safe therapist–patient
relationship.
We will review how to build a treatment plan in general in Chap. 9.
2.13 Integrated, Modular Treatment 17

2.13 Integrated, Modular Treatment

By bringing into one frame, feelings, thoughts, and behavior, the entrenched dys-
functional pattern concept shows how seemingly contrasting therapies are actually
different ways to work with the same units of pathology. Therapies focused on emo-
tion work from one direction, while therapies that emphasize thought and behavior
work from the other. Thus, most contemporary treatment orientations can be brought
under the same roof, where we can take advantage of the wisdom each has to offer.
In this way, instead of the more traditional method, learning a single brand of
therapy and then assimilating additional techniques, we can learn a more univer-
sal approach from the beginning. The conceptual framework presented in this
book is a form of psychotherapy integration, that is, the coherent mixing of tech-
niques from different traditions. The choice of what method to use depends more
on the specific change process we are seeking to accomplish rather than to what
tradition it might belong. In general we will be seeking either to process emotions
or to replace the dysfunctional patterns of thought and behavior embodied in a
particular EDP.
Modular therapy, discussed in greater depth in the next chapter, means choosing
the technique that is best suited to the particular problem being confronted rather
than using a single approach for all aspects of a case. By dividing mental pathology
into EDP modules, we can plan our approach more precisely and, for each one, use
techniques that are chosen to be comfortable to the patient, familiar to the therapist,
and effective for the task at hand.

Key Points
• Each patient’s problems can be divided up into distinct modules called
entrenched dysfunctional patterns or EDPs.
• All EDPs are triggered by the anticipation of experiencing a painful, over-
whelming, or uncomfortable emotion and consist of a pattern of thoughts,
feelings, and behaviors designed to avoid the dreaded emotion.
• Any EDP can be visualized as unit with the triggering circumstance and its
associated feeling on one side and the pattern of avoidance on the other. In
between is the invisible mental processing that creates and implements an
avoidance strategy.
• Multiple EDPs can be visualized as stacked in layers starting with the ear-
liest at the bottom. Emotions anticipated to escape from one layer are what
trigger the next.
• For a given EDP, psychotherapy can approach by detoxifying the trigger-
ing feeling or by helping the patient change thoughts and behaviors.
• Integrated, modular therapy is usually targeted at the most accessible
EDP. It can approach via the emotion or via the avoidant thoughts and
behaviors and can be chosen for the precise job at hand.
18 2 Layers of Pathology

References
1. Bargh JA, Morsella E. The unconscious mind. Perspect Psychol Sci. 2008;3(1):73–9.
2. Holmes TH, Rahe TH. The social readjustment rating scale. J Psychosom Res. 1967;11:213.
The Affect Avoidance Model
3

The affect avoidance model is introduced in this book as a unifying conceptual

framework compatible with diverse theories of psychotherapy in contemporary use.
Different schools explain pathology and cure in their own, often incompatible,
terms. It is argued here that affect avoidance is a fundamental function of the mind/
brain and that the kinds of psychopathology that can be resolved through psycho-
therapy can be explained as protections that have become liabilities. In addition to
explaining a great deal of mental pathology, this model also provides a way of
reducing the curative effects of psychotherapy to two processes. First, psychother-
apy comprises methods for detoxifying the negative affects that the mind has sought
to avoid. Second, it provides tools for replacing dysfunctional patterns with health-
ier ones. These two actions, both of which ultimately involve changes in informa-
tion held in the brain, are compatible with the gamut of therapeutic effects ranging
from “resolution of intrapsychic conflict” and “replacement of irrational beliefs” to
“corrective emotional experiences.”

3.1 Affect Avoidance

The approach to teaching psychotherapy embodied here is based on a single foun-

dational principle:

All the human psychological pathology that can be resolved through psychotherapy is the
result of the mind’s natural efforts to avoid painful, overwhelming and uncomfortable
affects.

Let’s break down what this means, and then we can look more deeply into each
aspect.

© Springer International Publishing AG 2017 19

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_3
20 3 The Affect Avoidance Model

• Just as the mammalian brain controls behavior so as to avoid pain and to seek out
pleasure, the human mind/brain is set up to avoid negative affects and to seek
positive ones. (“Mind/brain” is used here because, in today’s thinking, there is no
clear dividing line between the two.)
• The mind naturally seeks to avoid all negative affects, whether it is because they
are painful, overwhelming, or simply uncomfortable.
• Most, but not all, affect-avoiding strategies are created in the nonconscious parts
of the mind.
• When avoidance patterns are maintained in spite of serious costs, even those that
seem motivated by pleasure, such as addiction, are better viewed as ways to get
away from negative affects.
• Not all psychological pathology can be resolved through psychotherapy. Those
conditions that are primarily biological or genetic in their origin cannot usually
be reversed in therapy. The primary function of psychotherapy is to modify dys-
functional patterns, including unhealthy responses to biologically based
conditions.

3.2 Use of the Word Affect

At this point, a bit of clarification about terminology is needed. The word affect is
reserved for emotions that are conscious and accompanied by visceral sensations. In
contrast, the words feelings and emotion are used throughout this book to mean
emotional phenomena without regard to how they are experienced. The human
mind spends a great deal of energy anticipating feelings that may come to con-
sciousness as affects. EDPs are most often triggered by the anticipation of a painful
affect, as opposed to the actual experience. The words “feeling” and “emotion” are
used interchangeably and include anticipated affects. At times we can consciously
identify that a painful affect is “near” but has not yet risen to the level of a visceral
experience. “If you do that, I will feel very angry.” Such incipient affects will also
be referred to as feelings or emotions.
The distinction between affects and feelings that have not yet risen to conscious-
ness is of great importance for therapists. Only when feelings or emotions are acti-
vated to the point of becoming conscious and palpable “in the room” are they
accessible to emotional healing or detoxification.

3.3 The Mind as a Control Structure

Why should the vast range of mental pathology, endemic to humankind, all be the
result of the mind’s efforts to avoid negative affects? Pioneering neuroscientist Jaak
Panksepp states the principle in the following way:

Raw affects provide the essential infrastructure for our most basic instinctual behavior pat-
terns—approach and avoidance—without which we could not survive. Humans and other
animals approach things that evoke pleasant affects, and they stay away from things that
make them feel bad [9].
3.3 The Mind as a Control Structure 21

In other words, the mind/brain is, among other things, a control structure evolved
to manage our behavior, using emotion to steer our choices in ways that maximize
the survival of the species. Why should emotions guide our behavior? Wouldn’t it
be better for the brain to be programmed to react directly to opportunities and
threats? While this answer is speculative, it seems that emotions introduce an
impressive flexibility. What if we were hardwired to eat when our metabolism
required it and to run when a dangerous animal was near? What would happen
when, just as we were about to start a meal, a tiger appeared? How would the brain
know to drop the food and run? By using competing feelings of hunger and fear, the
brain is able to accommodate degrees of necessity and to prioritize which survival-
related behavior should take precedence.
Most of the time the simple principle of avoiding bad feelings and seeking good
ones does, in fact, promote survival. Hunger is a “bad” feeling, and eating gives a
pleasant feeling. Avoiding the negative feeling and seeking the positive one cor-
rectly steer our behavior in the direction of survival. This system works so well that,
most of the time, we humans follow it faithfully. We do precisely what is most
comfortable. We call this our “comfort zone.”
Would it be surprising if this very simple system occasionally gave a wrong
answer? Let’s consider the regulation of our food intake for survival. As long as
food was scarce and starvation a real danger, survival demanded that we eat as
much as possible and store food for the next famine. But, in the twenty-first
century, humans are experiencing an epidemic of obesity. Our brain produces
feelings of hunger, presumably based on the reality of millennia past, that are no
longer good for us. Our natural response to those feelings can be a major con-
tributor to obesity. Thus, a purely emotion-based survival system lacks some
flexibility.
When affect avoidance is applied to problems like the need to maintain the social
fabric, a new layer of complexity is added and, with it, new sources of dysfunction.
Jack’s avoidance of any hint of neediness starts out as an adaptation to help him
survive his dysfunctional and harsh family environment. However, in adulthood, his
former protection leaves him disconnected from healthy feelings of pain and anger.
By avoiding these negative feelings, he is also barred from the emotional healing
that could permanently resolve his feelings about the past. In effect, he has bor-
rowed comfort at the expense of future pain.
Could Jack’s mind have found a better solution? Probably not, since his parents
were not in any way ready to help him process his neediness, pain, and anger.
Furthermore, the level of negative feeling due to Jack’s early deprivation was intense
enough that the avoidance mechanisms his mind first developed remain tightly held
and not easy to change. It would be hard to design a mind/brain capable of anticipat-
ing that Jack’s adult environment would be more receptive to his neediness than his
childhood world.
It seems that the human mind, at least when threatened, is designed more to
avoid negative feelings than to solve problems. The mind seems bent on avoiding
painful feelings by whatever means it can find. This includes strategies like pushing
an uncomfortable circumstance out of consciousness or outright denial. EDPs that
avoid negative feelings by distorting reality don’t even attempt to solve a problem
22 3 The Affect Avoidance Model

but only to hide it from consciousness. As a rule, the more intense the negative
affect and the earlier the pattern is developed, the greater its cost in later life and the
harder it will be to change in therapy.

3.4 A Silver Lining

What may seem like flawed design actually does have a silver lining. The fact that
entrenched dysfunctional patterns are built to avoid affects generally means that our
patients carry unprocessed feelings in a nonconscious form. By doing so, they are
protected from the harm these feelings might bring if they became conscious while
conditions remain toxic. In adulthood, when circumstances improve, a positive out-
come through emotional healing becomes possible for the first time. Dreaded
affects, now experienced in a context of empathic connection such as we cultivate
in the therapeutic relationship, are, at last, accessible to being processed and detoxi-
fied. Perhaps it is good fortune that Jack’s panic attack has forced him to seek help
and discover that there actually is a solution to the original pain. In this way, we can
view psychotherapy as a procedure to help replace now-dysfunctional entrenched
patterns with healthy answers to problems that were avoided rather than addressed
in the first place.

3.5 Affect Avoidance Is Not a New Concept

The notion that avoidance of negative feelings produces pathology is as old as psy-
chotherapy. Sigmund Freud [3] saw psychological symptoms as “defenses” or ways
to avoid uncomfortable material. Psychoanalysis eventually settled on the idea of
conflict between different agencies of the mind as the source of problems. In those
terms, Jack’s “superego” doesn’t want to admit to neediness, but his “id” desper-
ately wants support. The two are in conflict. This way of looking at Jack’s problem
is not wrong, but basing it on the notion of id, ego, and superego automatically
makes this explanation incompatible with other theories. Fortunately, we can
explain the same dynamic as natural feelings of neediness threatening to break
through protection formed long ago when anti-neediness values were internalized
as a shield from pain due to repeated rejection.
Consistent with the principle of affect avoidance, B.F. Skinner [11] emphasized
reinforcement and punishment as drivers of both healthy and unhealthy behavior.
Avoiding any speculation about what could not directly be observed, he left out
discussion of what might be happening in the nonconscious, or even conscious,
parts of the brain; he simply looked at stimuli and asked if they tended to increase a
behavior or decrease it. Thus he would not use the word “avoidance” because it
implies intentionality. Instead he would say that aversive stimuli can be shown to
reduce a behavior. If he had observed Jack’s being rejected as a child when he
expressed hurt or wishes for support, he might also have observed that this aversive
stimulus produced a reduction in Jack’s “neediness expressive behaviors.”
3.6 What Is the Role of Pleasure? 23

In Skinner’s time, scientific measurement or observation of emotional net-

works in the brain and resulting behavioral changes was beyond the limits of
science and, therefore, purely conjecture. Increasingly, the neurophysiology
underlying how emotional circuits affect behavior is becoming known to science.
Thus, it is not so speculative today to say that the pathways by which aversive
stimuli influence behavior involve specific emotional systems in the brain.
Furthermore, Skinner would agree with Panksepp’s thinking that the brain is
fundamentally organized around avoiding noxious stimuli and approaching posi-
tive ones.
More recently, “third wave” therapies including dialectical behavior therapy
(DBT), acceptance and commitment therapy (ACT), and emotion-focused therapy
(EFT), as well as therapies focused on resolution of the pain of trauma, have recog-
nized the importance of working directly with emotions. These therapies all seek to
detoxify negative affects that are seen to lead to troublesome symptoms and dys-
functional patterns of behavior.
Today, it is fair to state that painful, overwhelming, and uncomfortable affects
are important drivers of mental pathology. This notion is compatible with many
existing theories and is increasingly supported by a body of neurophysiological
evidence. To go further and argue that affect avoidance explains essentially all
pathology treatable in psychotherapy require looking at each type of pathology indi-
vidually. Part III of this book will make that argument.

3.6 What Is the Role of Pleasure?

Pleasure and positive emotions have an important role in our motivation. The amyg-
dala, mentioned earlier as the brain’s danger detector, is also the site of pleasure
detection. However, when it comes to entrenched dysfunctional patterns, negative
emotions are far more important. First, evolution gives greater importance to nega-
tive events and dangers that threaten survival compared to pleasure and procreation.
Second, we can observe that those EDPs that protect from the most severe dangers
are the most resistant to change. When highly dysfunctional avoidance mechanisms
are retained in spite of major costs, it is because they once protected against poten-
tially life-threatening events such as helplessness or aloneness. The rigidity with
which EDPs are held generally corresponds to the desperateness of the original situ-
ation. (This is not to minimize the costs of less critical childhood threats. The dys-
functional patterns that protect against them can be well hidden and cause a great
deal of suffering.) Finally, EDPs such as addictions that seem to be driven by crav-
ing for pleasure, when examined more closely, can usually be explained as attempts
to avoid pain. To complicate matters a bit more, the avoidance of pain can also be a
source of pleasure.
Taking these complexities into account, to simplify learning, we will focus on
EDPs as protecting from pain rather than seeking pleasure. This is not to minimize
the importance of pleasure and positive feelings in human life but to concentrate on
the feelings that humans work hardest to ignore and avoid.
24 3 The Affect Avoidance Model

3.7 What About Biology?

So far the discussion has been limited to problems treatable with psychotherapy.
This distinction eliminates those problems that are mainly due to biological pathol-
ogy. For the practicing therapist the distinction is not that simple. It is hard to know
what patient characteristics are inborn or due to a biological abnormality. For exam-
ple, some individuals are genetically prone to experience much more anxiety than
others. Maternity ward nurses will attest to the major variations between newborns.
The most serious mood disorders, for instance, appear to a great extent to be the
result of dysregulated chemistry.
Modern neuroscience has increasingly demonstrated that a sharp distinction
between the brain and the mind is impossible [8]. This is why some neurobiologists
use the term, “mind/brain,” acknowledging that the two can’t be cleanly separated.
To complicate the situation even more, biology is not only a matter of genetics and
disease. Epigenetics is the new but rapidly developing field concerned with how
genes are turned on and off by experience. The role this kind of brain regulation
plays in therapy may be additive and supportive of changes in EDPs. As with all
biological factors, it is hard to tell the difference between improvements in function-
ing due to changes in gene expression and those due to changes in information in
our memory.
For therapists, the problem of biology comes down to two questions. First, what
patient characteristics are unlikely to change substantially? We don’t want to subject
our patients to efforts at change that cannot be successful. Second, we may need to
consider biological interventions. Since the latter are mainly the province of psy-
chiatrists and are the subject of residency training, they will generally be excluded
from this book. However, here are a few thoughts.
Regarding the first question about what characteristics are unlikely to change, we
need to be as ready as possible to recognize mainly biological syndromes. This
requires keeping up to date with the latest information about inborn characteristics
and biological influences on emotions, thought, and behavior. An example is atten-
tion deficit disorder (ADD). For a significant part of the history of psychotherapy,
the only explanation of problems with what we now call “executive functioning”
was “minimal brain dysfunction.” Severe manifestations in children were diag-
nosed, but many children and adults suffered in ignorance. Recently, better under-
standing of the details of executive functioning has permitted recognition of the
syndrome as a common group of characteristics in children and adults. The role of
therapy here is to help the patient overcome inappropriate shame for what can’t be
changed, to help with compensatory patterns of behavior, and to encourage life
choices better suited to a brain that requires higher levels of stimulation to function
optimally.
The second question, when to consider biological interventions, is perhaps best
dealt with pragmatically rather than attempting to base a decision on the presumed
cause of the problem. In practice, the sources of dysfunction are often mixed.
Benefits from psychotherapy may take longer to achieve than improvement from
medication or other biological interventions. On the other hand, approaching the
3.8 Relating the Affect Avoidance Model to Other Therapies 25

problem through psychotherapy is likely to produce more lasting improvement in

coping and result in less negative side effects.
Treatments with medication have an additional problem. Given the mind’s natu-
ral avoidance of uncomfortable feelings, even the hope of avoiding the hard work of
facing feelings, taking medication can undermine patients’ willingness to experi-
ence painful affects. Avoiding uncomfortable feelings through chemistry amounts
to adding a new EDP, one that effectively blocks progress in detoxifying frozen
emotions. Therapy for anxiety is a good example. Relying on medication is not only
a questionable long-term solution, but it actually prevents the patient from develop-
ing new coping skills. On the other hand, when rapid intervention is needed to pre-
vent damage to the patient’s life, biological treatment may be justified. For therapists
who are not trained in biological diagnosis and intervention, a consultation will help
with the decision.
As therapy unfolds, it is always important to monitor progress. When there are
concerns about the rate of progress, it may be time to reconsider biological explana-
tions and to question whether these factors might have been missed or not addressed
adequately. Not infrequently, even problems that have a strong biological compo-
nent may still have aspects that can be identified as entrenched dysfunctional pat-
terns and addressed through psychotherapy. A good example is depression, which
often has a strong biological component but usually involves EDPs as well.
From here on, we will generally exclude discussion of the biological aspects of
psychological problems and concentrate, instead, on the changes in information that
psychotherapy uses to replace EDPs with healthy ways of responding to emotion-
laden experiences.

3.8 Relating the Affect Avoidance Model to Other Therapies

Most therapists today find a single “brand name” therapy too limiting for the needs
of all their patients. The problem for them is finding a coherent framework within
which multiple therapeutic techniques can be combined. The affect avoidance
model is based on the need to encompass the entire range of pathology seen in prac-
tice and to simplify understanding as much as possible without cutting corners.
Currently popular therapies can be arranged in a donut (Fig. 3.1). What is least
fully represented in these therapies is the part in the middle. The missing hole is an
understanding of precisely how they work to bring about change. What we need is
to transform a donut with no center into a wheel where existing therapies form the
rim. In the time since these therapies were developed, important new discoveries
have begun to clarify the neurophysiology of change, allowing a new approach that
starts in the missing middle and reaches out to use existing techniques to accom-
plish the two main jobs of psychotherapy: detoxifying painful feelings and helping
people change unhealthy patterns of thought and behavior.
What makes the affect avoidance model unique, and even possible, is the obser-
vation that essentially all the forms of pathology treatable in psychotherapy can be
seen as avoidance strategies turned dysfunctional. This universal principle then
26 3 The Affect Avoidance Model

Fig. 3.1 Many therapies

but few full explanations Emotion Focused
of how they work ACT
Experiential
AEDP
Missing: Schema
DBT How they really work
Relational
CBT
Behavioral Psychodynamic

makes it feasible to discern the common features of all avoidance strategies, leading
to the concept of entrenched dysfunctional patterns. Once we understand how EDPs
function, it becomes clear how the dual objectives of detoxification of negative
affects and modification of patterns of avoidance form the two points of entry for
therapy. Finally, a more precise understanding of those two therapeutic processes
allows linking to the many existing therapies, since all of them can be seen as meth-
ods for accomplishing either transformation of negative affects or change in dys-
functional thought and behavior.
Thus, we arrive at a simple, unifying framework for understanding our patients’
problems and how best to approach them. Simultaneously, we gain access to the
greatest possible choice of tools for change.

3.9 Compatibility with Other Models

Many other explanations of psychopathology are valid in the sense that they are in
agreement with observed facts. Let’s look at a few examples and how they are com-
patible with the affect avoidance model.
CBT tends to see faulty cognition as the starting point for pathology. Therapy
consists of showing patients their cognitive errors and expecting them to adopt more
rational patterns of thought and behavior. Based on the Victorian notion of scientific
objectivity, behaviorism originally rejected any subjective data including inquiring
into the past or asking about inner thoughts. Much has changed since then. Now,
cognitive therapists always ask about thoughts and sometimes form hypotheses to
explain how erroneous cognitions were arrived at. When they do, they end up with
formulations quite similar to those proposed for Jack. Treatment focuses primarily
on only one of the two approaches to EDPs, the behavioral one (including both
thought and behavior), and has tended to neglect emotion. The benefit of changing
behavior is fully recognized in the affect avoidance model along with tools and
techniques from CBT. In addition, there has been increasing recognition within
3.9 Compatibility with Other Models 27

CBT of the critical role of emotion [10]. A possibly related fact is that the therapeu-
tic relationship has been found empirically to be even more important in cognitive
therapy than in other forms of therapy more overtly oriented toward emotion.
Traditional psychodynamic therapies have emphasized insight, aimed at correct-
ing childhood misunderstandings, as the central change agent in resolving “intra-
psychic conflicts.” Emotion has always been held as important in psychodynamic
formulations. As indicated above, the affect avoidance model is fully compatible
with both emotional healing and the idea of resolving intrapsychic conflict.
Psychodynamic therapy too has evolved. In recent decades the field has experi-
enced a growing recognition that the therapeutic relationship has a central role in
treatment success. There remains a good deal of discussion among thinkers about
exactly what the relationship does. The affect avoidance model makes use of much
of the wisdom of the psychodynamic tradition but ties it to a more naturalistic and
contemporary view of human motivation, compared to Freud’s more philosophical
concepts of sexual and aggressive drives. Here, as with behaviorism, Victorian atti-
tudes continue to cast a shadow. Nineteenth-century notions of scientific objectivity
viewed the influence of the therapist as something that could be eliminated if the
therapist acted like a “blank slate.” The values of “neutrality” and self-restraint still
color therapeutic technique, pulling therapists away from active engagement with
patients and discouraging them from involving themselves with behavior change. It
is perhaps appropriate to mention that this same Victorian tradition is the one that
urged orphanage staff, including those in England and other developed countries, to
abstain from forming any emotional bonds with the children, for fear of fostering
dependence. It wasn’t until 1951 that John Bowlby published a report sponsored by
the United Nations, showing that this practice was devastatingly destructive for the
well-being of children [1]. In this book, this bias against an active and real relation-
ship is questioned, and it is suggested that the relevance of these concepts should be
gauged on the basis of results rather than theory.
Experiential and so-called “third wave” cognitive-behavioral treatments identify
emotion as central to pathology and cure and combine emotional work with meth-
ods for addressing dysfunctional behavior. In this way, they too are compatible with
the affect avoidance model. Among these are emotion-focused therapy (EFT), dia-
lectical behavior therapy (DBT), and acceptance and commitment therapy (ACT).
Emotion-focused therapy is more explicit in seeing avoidance of painful affects
as a driver of pathology. As described by its founder, Leslie Greenberg, the theory
includes the idea that problems can arise from “maladaptive emotional responding
based on painful feelings (e.g., fear, shame) stemming from past experience” [4].
However, EFT places emphasis on conscious experience more than looking at the
mind as a control structure. While largely compatible with the affect avoidance
model, EFT sees human life as the construction of a conscious story of the self,
driven by a natural seeking of growth. The function of therapy is to support growth
and to help make the narrative more coherent. This subtle, humanistic view is rich
with insight about the nature of human experience. On the other hand, as with many
“brands” of therapy, its unique concepts tend to promote exclusive adherence to that
orientation.
28 3 The Affect Avoidance Model

DBT is another world unto itself. Developed as a way to bring cognitive-

behavioral techniques to a group of patients whose emotions were too volatile and
disruptive for the usual cognitive exploration, DBT brought to behaviorism a host of
techniques for managing intense emotion. These range from listening and empathic
connection to skills training, homework, and record sheets. DBT is specialized for
patients who tend to act on intense emotions in disruptive ways. Its methods have
been adapted for a wider range of problems but remain highly structured, which is
more acceptable to some patients than others. DBT tends to be taught as a system
more than a toolbox, making it somewhat challenging to pick and choose tech-
niques within a broader framework. Exposure to DBT will show that techniques
from its well-researched palette ultimately fulfill the same two functions as other
therapies, detoxifying negative emotions and replacing dysfunctional behavior pat-
terns [6].
Acceptance and commitment therapy (ACT) is also a self-contained system, this
time focused on two principles. The first is acceptance of what one can’t change.
This means processing painful feelings, which is based on the same change pro-
cesses that will be explained in detail in this book. The second principle, commit-
ment, means committing to change behavior patterns so they are coherent with
healthy personal values [5]. Implied are dual objectives of processing (or accepting)
painful emotions and replacing dysfunctional patterns of thought and behavior.
Once again, while this therapy tends to focus on its unique constructs and view of
life, it embodies the same two change processes as other therapies.
The affect avoidance model, by placing the emphasis on the details of change
processes, provides a conceptual hub to bring together knowledge and techniques
from therapies that have evolved in separate and competing silos. Appreciating their
common features, the therapist can then focus on finding the best match between
specific EDPs and the vast number of tools and techniques embodied in the collec-
tive wisdom of the world’s therapies.

3.10 The Detailed Structure of EDPs

Now let’s turn to a closer examination of the entrenched dysfunctional pattern as

previewed in Chap. 2. Here again is the diagram (Fig. 3.2).
From the examples given so far, each EDP is first activated by a triggering per-
ception. The circumstance that is perceived can be an external reality or an internal
one. The first step in mental processing is recognition. The perceived circumstance
is matched up in the mind with a memory. In the case of entrenched dysfunctional
patterns, this is not an ordinary memory but one that is associated with danger or
threat. Much of the time, if not always, this recognition takes place in the amygdala,
the brain’s danger detector. Recognition in the amygdala has some very special
characteristics. First, it is not conscious. This part of the brain does not fall within
the modest frame of our consciousness. Second, it is very rapid. We have all had the
experience of a close call where the hair on one’s arm stands up before we are able
to identify the danger we just encountered. Third, the recognition is biased toward
3.10 The Detailed Structure of EDPs 29

Triggering perception Non-conscious processing Conscious result

“Helpers”
influence free will
Memory of
threatening
circumstance • Primary emotion Avoidant
• Conscience-based emotion behaviors
• Automatic thoughts

Involuntary
Associated symptoms
negative feelings

Fig. 3.2 Complete schematic diagram of the entrenched dysfunctional pattern

recognizing of possible danger at the expense of accuracy. False positives are

accepted in order to avoid false negatives. Even if the match is quite weak, we may
still identify a danger. Seeing danger where there is none is far less problematic for
survival than missing a danger that is barely detectible.
We might think of danger as a physical threat, but the “dangers” that trigger
entrenched dysfunctional patterns are emotional as well as physical dangers.
Perceptions that trigger an EDP are circumstances that the mind interprets as lead-
ing to painful, overwhelming, or uncomfortable affects. For example, for a small
child, the feeling of aloneness is equivalent to death and is a potent trigger of
EDPs. In a similar way, depending on age and development, the feelings of help-
lessness and hopelessness can be experienced as life-threatening. A few years
later, say age five or six, the need to find love, for example, may also be a need
that is treated as a matter of life or death. When a child’s quest, such as achieving
a level of perfection equated with being “good enough” to be loved, comes under
threat, the danger is the affect associated with failure to achieve, in this case, a
feeling of total hopelessness.
The process of identification of danger is very important for treatment. When
we “detoxify” an affect, one of the ways this is accomplished is to disassociate
danger from the perceived circumstance. If the circumstance recognized is no
longer treated as dangerous, then no avoidance mechanism will be activated.
This type of “erasure” of the association with danger is called reconsolidation.
While the clinical manifestations were first described by Freud in 1893, the neu-
rophysiology of this type of cure was unknown until 2004. There will be more on
this in Chap. 5.
Another pathway for preventing the triggering perception from activating an
avoidance mechanism is called extinction. Here too the amygdala identifies danger,
but the pathway from recognition of peril to initiation of an alarm signal is inhibited
by the cerebral cortex, the thinking brain. This form of detoxification is not as last-
ing as reconsolidation but is still an important part of therapeutic action [12].
30 3 The Affect Avoidance Model

We need to note again that the mind is highly adapted for anticipating danger.
This means that the triggering perception is often the anticipation of a threatening
affect rather than the affect itself.

3.11 The Nonconscious Problem Solver

As soon as an alarm is activated, the mind sets to work finding a way to prevent the
dreaded emotion from becoming a conscious affect, where it is anticipated to cause
distress. The part of the mind responsible for designing avoidance strategies is
referred to in this book as the “nonconscious problem solver.” The same faculty of
the mind is also the source of creativity, plans, goals, dreams, and many of the
amazing things of which humans are capable. For the moment, we are only consid-
ering the function of inventing and implementing strategies for avoiding trouble-
some affects.
Once a strategy is developed, it is stored in procedural memory, ready to be rede-
ployed again should a similar threat be detected. There is no good reason for a suc-
cessful strategy to be lost or forgotten, so EDPs are generally accessible for life. A
well-known example is addiction, where the dysfunctional, but effective, affect-
avoiding pattern of substance use, once discovered, remains ready for use for the
rest of the person’s life.
For therapists, it is critically important to realize that each of these stored affect
avoidance mechanisms is a product of the tools and abilities available at the time the
strategy was invented. The style and substance of avoidance behaviors shown by
patients are a reflection of the age from which they originated. Patients with the
most florid and severe pathology have generally encountered serious challenges
early in life. Severe personality disorders, for example, can best be understood as
adaptations to adverse conditions in the second and third years of life. As we will
see later, imagining what life was like for a patient as a child long ago is one of the
best starting points for understanding irrational and dysfunctional reactions in adult
life. Let’s look now at the three types of products that the nonconscious problem
solver emits into consciousness.

3.11.1 Potential Behaviors

Like all actions subject to free will, dysfunctional behaviors, such as Jack’s initial
refusal of extended therapy, appear in consciousness as potential actions; they are
ideas or mental images of what we might do if we choose to. There is an infinite
variety of such actions or behaviors.
One especially important type of dysfunctional behavior is the absence of behav-
ior, that is, doing nothing. Growth and development happen when we try out new
behaviors. Refraining from trying new patterns in order to prevent anxiety or other
difficult affects is how developmental arrest becomes entrenched. This important
form of EDP is included with other dysfunctional behaviors. In Part III, the catalog
3.11 The Nonconscious Problem Solver 31

of EDPs, we divide these into seven subtypes, plus addictive behaviors, and describe
them in detail along with ways to help patients take control of them.
Invented in the hidden recesses of the mind, these potential actions simply pop
into our consciousness as possibilities. They have nothing to distinguish them from
healthy ideas, except that they lead to no good. Examining the likely consequences
of an action is the best, and often only, way to tell whether it is dysfunctional or not.
Since people frequently have blind spots about this distinction, it is helpful to get an
opinion from someone outside, such as a therapist or a true friend.
When a potential action is determined to be against our best interest, then the
best thing to do is to refrain from putting it into action. This may seem simple, but
this is where the helpers listed below come into play. They enter consciousness in
order to push our free will toward choosing to implement the dysfunctional action.
A person with a gambling addiction knows it would be better not to make a bet. The
voluntary choice is made to act anyway because the consciousness is bombarded by
helpers that exert a great deal of pressure to go ahead and act on the idea.

3.11.2 Helpers

These are shown in the middle part of the diagram as “primary emotions,” “shame
and guilt,” “conscience-based emotions,” and “automatic thoughts.” They are prod-
ucts of the nonconscious problem solver that functions to influence us to execute a
dysfunctional behavior. In each case, their effect is to increase the likelihood of the
patient exercising free will to choose a dysfunctional pattern of behavior. Below are
descriptions of each of the three types of helpers.

3.11.2.1 Primary Emotions and Impulses

These might consist of hunger, anger, anxiety, or anticipation of relief and satisfac-
tion. These are labeled on the diagram as primary emotions and impulses. Primary
feelings are formed in emotional circuits deep in the nonconscious mind but finally
enter consciousness where they influence free will. We know from the extreme dif-
ficulty of trying to lose weight or giving up an addiction that these feelings are
extremely hard to resist.
Impulses are conscious inner urges to go ahead with an action. As with primary
emotions, resisting them is uncomfortable, while following them feels natural and
easy. We could say that resisting an impulse generates an uncomfortable feeling,
but, strangely, we have no word for this unique feeling, and it is not known how it
originates. One woman with an eating disorder said that if she didn’t eat she felt as
if she would die. People who habitually follow their impulses experience intense
discomfort when they first decide to resist.

3.11.2.2 Conscience-Based Emotions of Shame or Guilt

What distinguishes these specialized emotions is that they are the result of judg-
ments in relation to values held in the conscience. Values and the feelings of shame
and guilt that come out of them are mostly beneficial, but they can also be unhealthy
32 3 The Affect Avoidance Model

and promote dysfunctional actions. Jack’s mind used shame to discourage him from
seeking support when he most needed it. One of the best ways to reverse inappropri-
ate shame or guilt is to disobey the feeling and do the opposite.

3.11.2.3 Thoughts
Cognitive therapists call these “automatic thoughts,” while psychodynamic thera-
pists call them “free associations” or simply thoughts. Thoughts that function as
helpers are ideas that rationalize and promote a dysfunctional behavior. For exam-
ple, “You have already done so much harm to yourself that more won’t make a dif-
ference, so you might as well go ahead” and do the dysfunctional thing.
Thus, the three types of “helpers” form their own layer of reinforcement to make
sure we are successful in avoiding the affects our nonconscious problem solver has
decided are bad for our survival.

3.11.3 Symptoms

Shown in the diagram at the bottom of the frame of consciousness, these EDPs are
unpleasant experiences such as anxiety or depression that are not under voluntary con-
trol. These too can serve to distance uncomfortable feelings. In Jack’s case, his panic
attack was such a symptom. It served to shield him from anticipated feelings of help-
lessness over the fact that he might not be able to fulfill his new responsibilities. The
panic attack had multiple affect-avoiding properties. It took his attention away from
what was really worrying him and secondarily ensured that he received some of the
support he needed, though in a disguised form. Furthermore, it gained him temporary
relief from having to perform at work and at home. Symptoms, like other entrenched
dysfunctional patterns, can be dealt with from the same two directions, either by detox-
ifying the triggering emotion (on the left in the diagram) or by replacing the dysfunc-
tional behavior (on the right in the diagram). Since these symptoms are not voluntary,
the behavioral approach is to help the patient discount automatic thoughts that tend to
reinforce the symptom and to control voluntary actions that also make the symptom
worse. For example, depressed people may increase their depression by isolating and
mistreating themselves as well as by mental self-punishment. Reducing these behav-
iors and riding out the thoughts help undermine the intensity of the depression.

3.12 How Protections Become Problems

Patterns of avoidance may be dysfunctional at the outset or may become so later on.
As they become part of our automatic procedural memory, they tend to be used
repeatedly, whenever triggered by a particular circumstance. Strategies formed in
our early years may continue to be used and bear characteristics of very young
thinking. A therapist might recognize a patient’s black-and-white thinking or ideal-
ized vision of life as “young thinking.” Patterns of avoidance can become dysfunc-
tional in three ways:
3.12 How Protections Become Problems 33

1. Inherently dysfunctional patterns: Avoidance patterns that are invented early in

life, when cognitive development is young and primitive, often represent desper-
ate, life-and-death measures, taken instinctively without regard to cost. They can
be dysfunctional from the beginning. For example, very early in their psycho-
logical development, children are unable to identify clearly whether anger comes
from the self or from others. If circumstances make anger a dangerous experi-
ence, a child might learn to misidentify his or her own anger as coming from the
other person. The result is an unhealthy misperception of persecution. If the
misperception serves to distance from discomfort, the child might learn to over-
use it. The mind’s strategy is this: in order to avoid the affect of anger, which has
become associated with danger, the mind evokes an erroneous idea that reverses
reality so as to ward off the affect (fear). The result is a distortion in perception:
“I’m not angry, you are.”
This pattern does its job of avoiding the fear associated with feeling angry but
is immediately dysfunctional because it causes a distortion in the accurate per-
ception of reality. Furthermore it can be expected to alienate those wrongly
accused of being angry toward the individual. This is an instance of a pattern that
is immediately dysfunctional. At that early point in development, the mind
doesn’t have a better way to protect itself from the threat associated with anger.
Early patterns often distort the accurate perception of reality, which almost
always carries a high cost.
2. The “danger” becomes irrelevant: Perhaps the most common way that avoid-
ance patterns become EDPs is that the original, threatening situation is no longer
dangerous. For example, an individual raised in a chaotic or abusive home may
learn self-protection by always being on guard and never trusting. During child-
hood, when there is no choice about whom to depend on, this may be a wise
stance. In adulthood, when we are able to select those upon whom we depend,
the danger of betrayal is not so great, while the cost of constant guardedness and
mistrust is much higher. The cost–benefit ratio has turned the wrong way, and a
pattern that once protected has become a liability.
3. Childlike plans: In psychotherapy, patient’s nonconscious problem solver often
uses yet another, secret way to avoid painful affects. In parallel with the agreed-
upon treatment approach, but out of sight, the patient is very likely to harbor an
alternative plan. When children encounter a problem they can’t solve, they may
develop a plan. These solutions usually involve the adults in the child’s life. That
is because children know that truly difficult issues can only be fixed by adults
who are seen as capable of doing anything if they want to. In therapy, the one
whom the patient tries to influence is usually the therapist. It is as if an inner
child is hoping to motivate the therapist to fix whatever was unresolved in the
patient’s early life.
The fact that these plans may covertly exist in adulthood suggests that, origi-
nally, the adults were not cooperative. When grown-ups refuse to help, childlike
plans are pushed out of consciousness but not given up. The inner child waits for
a chance at implementation. What therapists may identify as “transference” can,
in fact, be the surfacing of such a plan, which can interfere seriously with the
34 3 The Affect Avoidance Model

work of therapy. In this way hidden plans begin as appropriate ways to solve a
problem that, for some reason, can’t work at the time. Later when they resurface,
their aims are no longer appropriate to adult life or to the circumstances of
therapy.

3.13 The Gifts of Consciousness

The remarkable phenomenon of consciousness possessed by humans gives us the

ability to evaluate our situation and to make new and unprecedented choices. If it
were not for this ability, we would be doomed to remain always in our “comfort
zone” doing whatever our mind/brain deemed best for survival of the species.
Instead, we can do remarkable things like face our feelings, be honest with our-
selves, identify erroneous thoughts coming from our nonconscious problem solver,
share our pain with another person so as to transform its impact, and invent new
solutions to life’s challenges that no one would have imagined before. Without con-
sciousness and the abilities it brings, psychotherapy could not exist. Now, in the
light of the affect avoidance model, let us build a universal overview of psycho-
therapy and how it works.

3.14 The Affect Avoidance Model Applied to Psychotherapy

Every psychotherapy has the same built-in structure. As soon as a patient seeks help
and a therapist agrees to participate, a new relationship is created with an expecta-
tion that it will bring relief of distress or improvement in functioning. These
improvements will require change in entrenched dysfunctional patterns. Whenever
the conscious human mind decides change would be good, the nonconscious prob-
lem solver begins to scan for possible danger. In general, change is always threaten-
ing in some way. For this reason, the basic, universal structure of therapy consists of
the playing out of tension between the conscious desire for improvement and the
mind’s natural fear of and resistance to change.
Whether EDPs are in the form of direct avoidant strategies or childlike plans that
interfere with therapy, they can still be conceptualized as attempts to protect the
individual from difficult feelings. Resistance to change may come in the form of
fear of exposing a difficult feeling, but it can also represent reluctance to abandon a
secret plan, which, if not carried out, would subject the patient to painful feelings of
disappointment. Either way, resistance to positive change is what creates the tension
that is fundamental to the structure of therapy.
Just as tension is fundamental to the stories we make into novels and movies,
tension is a basic fact of psychotherapy and creates the backdrop against which
unfinished business form the past is automatically brought to consciousness to be
resolved. The goal of change naturally challenges the nonconscious problem solver.
Under pressure both to help the therapy and to resist change, the activated problem
solver sends into consciousness an increased flow of free associations, dreams and
3.15 A Unifying View of Psychotherapy 35

automatic thoughts, as well as potential actions. These mental contents entering into
consciousness are a source of data to understand the mind’s inner concerns and
provide road signs to guide the therapy. This same structure can be found in the full
range of therapies.
Traditional talking therapy is largely built on this natural tension. In its original
form, the patient is told simply to say whatever comes to mind without censoring. In
this way, therapy demands open disclosure, while the mind, wishing to protect itself
from change, tends to hold back. It is as if the patient entered a magnetic field. The ten-
sion leads the nonconscious problem solver to generate free associations and dreams,
which enter consciousness and are shared with the therapist. Thoughts designed to
conceal uncomfortable mental contents also reveal. Some spontaneous thoughts are
aimed at helping the desired process of change, and others are helpers supporting the
mind’s efforts at avoidance generated both by the presenting problem and by the pro-
cess of therapy. Therapist and patient work together to make use of material arising out
of this tension to develop an empathic understanding and create a safe place where
painful feelings can come to consciousness and be healed. Simultaneously, the patient
is expected to adopt healthier patterns of thinking and behavior.
Cognitive-behavioral therapy (CBT) may look different but actually embodies
the same structure. Here the therapist may prescribe behavior change and home-
work. In that tradition, the word “resistance” is generally used only for patients’
failure to perform the expected actions or homework. In actual practice, a good deal
of the conversation in the sessions will be devoted to helping the patient overcome
resistance to change and cope with feelings generated by the process. As changes
are achieved, it is also likely that the patient will experience discomfort related to
new patterns of behavior. This too becomes part of the conversation. Overall, even
behaviorally oriented therapy, ostensibly focused purely on cognition and behavior,
still embodies the two basic therapeutic actions: adopting new patterns of behavior
and processing uncomfortable feelings [7].
“Third wave” and experiential therapies, combining cognitive, behavioral, and
emotional elements, are no different. In Linehan’s dialectical behavior therapy
(DBT), for example, one dialectic (alternation between opposites) goes back and
forth between empathic acceptance of the patient’s intense emotions and work on
changing cognition and behavior. Therapies in this group embody the same two
universal components of treatment, healing painful emotions and changing dys-
functional behaviors.

3.15 A Unifying View of Psychotherapy

Seeing different types of psychotherapy as having the same basic tension and struc-
tural elements, we can make the following general statement:

Psychotherapy seeks to exchange entrenched dysfunctional patterns (EDPs) for healthy

ones. In doing so, tension naturally forms between the patient’s rational desire to improve
functioning and nonconscious problem solving aimed at avoidance of anticipated negative
36 3 The Affect Avoidance Model

feelings. In addition, avoidance of difficult feelings may take the form of positive, but child-
like, solutions or strategies. In all cases, the resulting tension is reflected in increased spon-
taneous thoughts, emotions, and impulses coming to consciousness. As the patient comes
nearer to contemplating and implementing positive changes, tension increases. The work of
psychotherapy alternates between attention focused on facilitating voluntary change of
thought and behavior and on the processing of problematic feelings using the safety of an
empathic connection.

3.16 Making Use of Different Therapies

By adopting a unifying model of human dysfunction and change, in effect we gain

a framework under which all these therapies can be seen as ways to work with the
same problems. Much of the time, a therapist can choose techniques based on what
will work best, as well as personal experience. Sometimes there are problems with
compatibility. For example, some therapies consistently avoid giving advice in
order to create an atmosphere of confidence in the patient’s ability to problem solve.
Others employ a great deal of advice giving. Combining the two will require recon-
ciling those opposing philosophies. In such a situation, the therapist might try to
find the best match with the patient’s characteristics. One can ponder whether a
particular patient would benefit more by finding his or her own solutions or by
receiving coaching and ideas from the therapist. Further guidance about this will be
provided in Chap. 13 on “Adjustments.”

3.17 Putting It All Together

Traditionally, therapists were expected to adopt a single therapeutic technique and

use it with every patient. Therapists once asked whether the patient would fit the
technique rather than how to fit the technique to the patient. Over the past 30 years,
this approach has largely been replaced with the one in which therapists learn one
well-established therapy and then assimilate other techniques as they are needed to
deal with the variety of problems presented by their patients. By adopting a unifying
framework, we can now go a step further. We can plan our approach according to
what will help the most with the specific task that is in front of us.
In actual practice, every person’s problems are unique and individual but consist
of layers of EDPs, starting with an original one, aimed at avoiding some painful,
overwhelming, or uncomfortable feeling. On top of that, more layers of protection
are formed to keep the individual as far as possible from the troublesome feeling. In
therapy, we usually start with the one that is most accessible and work our way up
or down to next most accessible layer and finally to the original one. Recalling that
each EDP can be approached from either of two directions, the emotional one (the
left side of the diagram) or the behavioral one (the right side), a first approximation
is to start with the EDP closest to the surface and use whichever point of entry is
easier, or both at once. In Chap. 9 we will look in more detail at how to develop a
complete treatment plan.
3.19 Cyclical Therapy 37

3.18 Modular Therapy

This term has been used since Bruce Chorpita [2] at UCLA wrote about a more flex-
ible approach to therapy with children. Instead of following a single protocol for
every part of the work with every patient diagnosed with anxiety, therapy was broken
down into units and therapeutic strategies chosen for each specific unit. He called this
modular therapy. Using a similar approach for a broader range of problems, we will
break down the work of therapy into an approach for each EDP as it comes up. As we
identify specific EDPs, it will make sense to ask what are the best tools for the emo-
tional and the behavioral approaches to each one. Not every patient–therapist pair will
pick the same methods, and each EDP they encounter may be different. They will
hopefully choose tools according to what will work best, what is most comfortable for
the patient, and what is familiar to the therapist. In that way, treatment for each EDP
can be seen as a module of therapy, hence, modular therapy.

3.19 Cyclical Therapy

As discussed earlier, we can start by working to disconnect the difficult emotion from
the triggering circumstance, or we can work behaviorally to eliminate the dysfunc-
tional pattern. In therapy, we often go back and forth between the two. Therapy fol-
lows a cyclical pathway. This is because change in emotion often makes possible
changes in behavior, while behavior change tends to uncover emotions. Treatment
alternates between helping people heal painful feelings and working with them to let
go of dysfunctional patterns of behavior. As each part of the work is successful, it is
likely to lead to the other. Healing painful feelings reduces the need for an avoidance
pattern and facilitates its replacement. Eliminating a dysfunctional avoidance pattern
may, in turn, expose uncomfortable feelings, making them accessible to healing.
Marsha Linehan has described this alternation as a “dialectic” in her dialectical
behavior therapy. Paul Wachtel uses the term “cyclical psychodynamics” to describe
a similar alternating pattern (Fig. 3.3).

Healing Letting go of
negative affects dysfunctional behavior

Fig. 3.3 Cyclical
psychotherapy
38 3 The Affect Avoidance Model

3.20 Conclusion

Given our intense instinctive avoidance of uncomfortable affects, no matter which

way we approach peeling off the next layer of EDP, we tend to encounter resistance.
This is one of the reasons why dysfunctional patterns have such a strong tendency
to remain in place. One factor that gives therapy the advantage is that patients tend
to use the same entrenched dysfunctional patterns over and over. Each person has a
limited repertoire of avoidance mechanisms and a finite set of dreaded feelings.
While the twists and turns of our avoidance may be extensive, it is within our reach
as therapists to observe and learn each patient’s full repertoire. Then we are in a
better position to use the therapeutic partnership to work with each EDP, one at a
time as it becomes accessible.
The better we know the dance with each patient, the easier it becomes to repeat
successful experiences of facing feelings and of letting go of avoidance. Hopefully,
both therapist and patient become familiar with each patient’s moves, allowing the
work to become easier and more comfortable.

Key Points
• The affect avoidance model views any psychological dysfunction that can
be addressed through psychotherapy as the result of the mind’s automatic
tendency to avoid the conscious experience of negative affects.
• Avoidance of affects appears to be a guiding principle in the mind’s built-
in strategies for adapting to life. This leads to unhealthy avoidance but also
leaves opportunities for facing and detoxifying painful feelings long held
out of consciousness.
• Avoidance patterns in the form of EDPs are triggered by recognition of a
circumstance associated with anticipated negative affect. The emotional
approach to resolution is to prevent this system from activating avoidance
strategies.
• EDPs embody three types of avoidance strategy: dysfunctional patterns of
behavior, helpers aimed at biasing free will toward implementing the dys-
functional behavior, and involuntary symptoms like anxiety and depres-
sion, that also serve to avoid affects. The behavioral approach to treatment
seeks to change these patterns of thought and behavior.
• Helpers include primary emotions like fear, conscience-based emotions
including shame and guilt, automatic thoughts, and impulses.
• In addition to dysfunctional behaviors designed to avoid affects directly,
the mind may seek to implement childlike plans to influence the therapist
in the hope of solving unfinished business from early life. In doing so, the
aim is to avoid the pain of disappointment.
• All therapies exhibit the same structure consisting of tension between the
desire to change in positive ways and the nonconscious problem solver’s
efforts to avoid change. This tension becomes the backdrop against which
issues are revealed and affects come to the surface where they can heal.
References 39

• The affect avoidance model unifies different therapies by focusing on

change processes. In doing so, methods from different therapies can be
chosen pragmatically and put to work in a cyclical alternation between
emotional healing and behavior change.

References
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interventions. Appl Prev Psychol. 2005;11:141–56.
3. Freud S. The neuro-psychoses of defense (1894). The Standard Edition. Vol. 3. London:
Hogarth Press; 1955. p. 50.
4. Greenberg LS. Emotion-focused therapy. Clin Psychol. 2004;11:3–16.
5. Harris R, Hayes SC. ACT made simple: an easy-to-read primer on acceptance and commit-
ment therapy. Oakland: New Harbinger Publications; 2009. p. 2.
6. Koerner K, Linehan MM. Doing dialectical behavior therapy: a practical guide. 1st ed.
New York: Guilford Press; 2011. p. 13.
7. Leahy R. Overcoming resistance in cognitive therapy. New York: Guilford Press; 2001. p. 68.
8. Leduc J. Synaptic self: how our brains become who we are. New York: Penguin; 2002. p. 16–8.
9. Panksepp J, Biven L. The archaeology of mind: neuroevolutionary origins of human emotions,
Norton Series on Interpersonal Neurobiology. 1st ed. New York: W. W. Norton & Company;
2012. p. 23.
10. Samoilov A, Goldfried MR. Role of emotion in cognitive-behavior therapy. Clin Psychol Sci
Pract. 2000;7(4):373–85.
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Skinner Foundation; 1991.
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2004;24(20):4787–95.
Avoidance Patterns and Mechanisms
4

The first thing humans do in life is cry. We can think of the baby’s first vocalization
as a way of avoiding a feeling. This inborn, reflexive act functions as a communica-
tion, telling caregivers to do something to sooth the shock of emerging into a world
full of uncomfortable new sensations. One of the most compelling sounds we know
is a baby’s cry. Usually within seconds, the newborn child is scooped up in a soft,
warm blanket, held, spoken to in a soothing voice, and rocked as if still in the womb.
In this chapter we will explore many more avoidance mechanisms and, in particular,
those that become embodied in entrenched dysfunctional patterns.

4.1 What Shapes Avoidance Patterns?

Let’s start with what doesn’t seem to shape them. The nature of the emotion being
avoided seems the least important. With physical pain or discomfort, there is a tight
correspondence between the nature of the problem and the nervous system’s solu-
tion. An injured muscle is protected by avoidance of strain or movement. Hunger is
attended to by the desire to eat.
But for emotional discomfort, feelings like helplessness, lack of attention or
love, or the discomfort of rage, avoidance mechanisms are not so specific.
Furthermore, the same avoidance mechanism can distance from multiple emotions.
The conscience, for example, produces shame as a deterrent so we won’t engage in
a particular behavior. This very flexible system can be put to use to steer us away
from a wide variety of behaviors that could lead to painful affects.
For this reason, it is quite natural to separate the emotions that trigger EDPs from
the avoidance mechanisms embodied within them. That is why, in this chapter, we
will focus on the avoidance patterns themselves, while in the next chapter we will
examine the emotions that are the objects of our avoidance.
Perhaps the main factor that shapes avoidance patterns is the developmental level
at the time a pattern is first “invented.” The newborn’s cry is purely an inborn reflex.
The “shyness” and fearfulness of strangers that appear around 8 months are a

© Springer International Publishing AG 2017 41

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_4
42 4 Avoidance Patterns and Mechanisms

function of the amygdala, the brain’s danger detector, becoming functional at that
age. At that point the amygdala first becomes able to generate signals that lead to a
behavior pattern of withdrawal from contact with strangers. Around age one, the
word “no” may become available for use in rejecting anything that might lead to a
negative feeling. Soon after that, children develop the ability to deny an uncomfort-
able truth by saying or acting out its opposite. By age three, the conscience begins
to function, providing a lively sense of how things “should” be. More elaborate pat-
terns of thinking, feeling, and behavior are to put into service to avoid the intensely
uncomfortable experiences of forgiving and accepting things we don’t have the
power to change. Around five, children acquire the ability to solve problems in the
future that can’t be solved today. “Someday I will…” This gives them an entirely
new repertoire of responses to the painful experiences of that age. Teens and adults
may discover the impressive power of drugs to erase painful affects.
Through the life cycle, humans’ affect avoidance strategies evolve drastically
over time. The nonconscious problem solver becomes increasingly sophisticated
and inventive, and this seems to have more of an impact on the nature of our EDPs
than the emotions that trigger them.
An additional factor in shaping avoidance mechanisms is the seriousness of the
threat. Evolution seems to reserve more drastic solutions for more serious chal-
lenges. EDPs initially developed in response to life and death dangers tend to be
more extreme. We can infer a greater readiness to incur costs in energy, collateral
damage, and future happiness. Avoidance mechanisms formed under dire circum-
stances are more likely to become deeply entrenched and dysfunctional. Perhaps
because the stakes are so high in such cases, the slightest reminder of an old threat
will trigger a powerful entrenched dysfunctional pattern.
EDPs that come from problems earlier in life also tend both to be more damaging
and more rigid. Patients with personality disorders such as borderline personality
and narcissistic personality, with patterns formed around age two, have EDPs that
are unusually intense and resistant to change. This is partly because earlier in life,
we are limited to more primitive avoidance mechanisms and partly because we are
also more vulnerable. As avoidance patterns become entrenched, resistance to
change insulates them from the influence of present-day reality, and they do not
evolve. Only when they are brought to our conscious attention do we gain the ability
to reshape them and improve our quality of life.
This is not to say that the more sophisticated EDPs that solve 5- or 6-year-olds’
problems “someday” in the future are less painful and troublesome. While they are
more likely to cause disability only in specific, narrow areas, they are likely to rob
the individual of just those goals that are held most dear and important.

4.2 The New Science of Memory

In order to gain the sharpest understanding of the change processes that are our
goals in psychotherapy, we need to carry in our minds a picture of exactly what our
words are doing in the brain of our patient. For many years, we had little more than
the observations of Pavlov and those who followed him, describing the inputs
and outputs of a mind/brain that was otherwise impenetrable.
4.3 Practical Application 43

Advances in neurophysiology have changed that. Two discoveries are par-

ticularly important to us therapists. The most recent is about how the emotions
that trigger EDPs can be detoxified. We will explore that in the next chapter. The
other is directly relevant to the avoidance patterns that are the subject of this
chapter. That key breakthrough is the discovery of how information is stored in the
brain. In 1953, when Watson and Crick first described how genetic information was
stored in DNA, it was still unclear how information stored in the brain was encoded
and kept for future reference. Starting in 1965, Eric Kandel, who won a Nobel Prize
for his work in 2000, began exploring how information is encoded in synapses [2].
The relevance for us is that patterns for avoiding feelings, once invented, are
stored for repeated use, ready to be triggered whenever a current threat “reminds us”
of some past one. In psychotherapy, when we encounter an entrenched dysfunc-
tional pattern, we want to replace it with a healthier one or help the patient develop
an entirely new pathway for responding to the same trigger.
What Kandel and others found is that information is held in the form of groups
of nerve cells in the brain, which have a tendency to fire as a unit. These units are
called neural networks. The same cells can participate in multiple networks. When
one of these groupings of cells fires together, it creates a living representation of
chunks of information. Wilder Penfield conducted experiments during surgery
where he stimulated the surface of the cortex. When he did this with the hippocam-
pus, a structure that is central to memory, patients would report specific memories
or sensations [4]. Penfield was activating neural networks.
What makes neural networks fire as a unit is heightened sensitivity in the syn-
apses that link them together. The result of this sensitivity is that when some cells in
the network are triggered, the whole group is set off. We can say that, in the brain,
information is stored in the form of adjustments to the sensitivity of synapses.
Learning, then, consists in making adjustments to the synapses of very specific
groupings of nerve cells. Long before it was confirmed, Donald Hebb [1] theorized
that learning worked this way. Later, Siegrid Löwel [3] famously summarized the
principle as “neurons wire together if they fire together.”
How are such adjustments made? One important mechanism is called long-term
potentiation (LTP). Recall that nerve impulses flow in only one direction. One cell
can stimulate or inhibit the next one in a chain, but a downstream cell does not send
impulses to the upstream one. LTP causes an increase in sensitivity of the synapse
that transmits an impulse from an upstream neuron to a downstream neuron. This
adjustment takes place only when both neurons happen to be firing at the same time.
In this way, general activation of the cells of a neural network makes all the cells fire
at once, and the linking synapses are strengthened.

4.3 Practical Application

Now we can have a more precise picture of what happens when we give words to a
patient’s emotion. “That must have hurt,” we say. The words at that moment activate
a neural network representing the experience of pain. Perhaps they activate a net-
work representing a general experience of pain, but they also “touch a nerve,” that
is, activate a network representing the specific set of circumstances and feelings that
44 4 Avoidance Patterns and Mechanisms

are close to the patient’s consciousness at that moment. That network is associated
with other networks that quickly transmit signals to the emotional system and trig-
ger tears.
What happens next is important to the therapist. Does the sudden appearance of
the teary affect set off an avoidance strategy or does the patient feel safe enough to
allow the tears to come. Perhaps the patient reacts with a quick denial: “Oh, that was
long ago, and it’s water under the bridge.” The tears dry up and the patient continues
with an intellectual analysis. We have just witnessed the operation of an EDP. For
some reason the patient needed to suppress the feeling that our words have acti-
vated. On the other hand, the patient might be ready for the tears to flow. In that
case, as we will see in the next chapter, the painful affect will be detoxified and will
not again have the same visceral impact.
For now, we are more interested in the pattern of avoidance. Where and how are
avoidant behavior patterns stored? And how can we help that patient learn to react
to feelings with acceptance rather than with denial?
In this case, presumably, the triggering perception for avoidance is a teary affect
coming into consciousness. For some reason, experiencing a poignant feeling in the
presence of the therapist is uncomfortable. Immediately a pattern (EDP) is activated
in which the nonconscious problem solver comes up with an intellectualization that
inhibits the brain’s emotional systems and stops the tears. The pattern is a complex
one in which automatic thoughts are generated, at least in large part, for the purpose
of affect avoidance. After the briefest moment in consciousness, the thoughts are
put into words, contradicting the emotion and suppressing an experience of empathic
sharing which would otherwise heighten the affect.

4.4 Procedural Memory

Where might such a pattern of intellectualization to inhibit feeling be stored? It is

hard to know exactly, but we can make an educated guess that several neural net-
works hold the series of reactions. Furthermore, as a memory, this one falls into the
category of procedural memory. This is the kind of knowledge that we gain without
having consciously learned it and which we don’t have to work to retrieve. The clas-
sic example is drinking from a glass. Once learned, we simply know how to do it and
don’t forget. This kind of memory is presumably embodied in the same adjustments
of synapses and neural networks as other kinds of memory, but it is spread diffusely
throughout the cortex. Even with a serious brain injury, people who can’t remember
how many days there are in June will not forget how to drink from a glass.
Like other procedural memories, the learned patterns in the example above bear
a resemblance to the kinds of learned schemas that are embodied in any sports per-
formance. Except for the fact that this example involves words, it is not unlike the
learned patterns that Pavlov studied in laboratory animals.
Neither therapist nor patient will be able to reach in and erase the pattern from
memory, but with some work together, patient and therapist will have a reasonable
chance of teaching a healthier response, such as letting the tears flow.
4.5 A Catalog of EDPs 45

Several elements are involved in facilitating change in such learned patterns. Our
therapeutic efforts will focus on making the patient aware of the pattern, supporting
motivation to change the pattern, and providing an environment conducive to expe-
riencing the uncomfortable affects that go with change. As the patient begins to
make a change, we will be in a position to provide some degree of encouragement
and help him or her feel pride in a new accomplishment. As the affect becomes less
threatening, we will also be able to point out the benefit of facing the feelings.
Finally, we might think of helping the patient continue to notice forks in the road
where there is an option to experience an affect rather than avoid it. Each of these
strategies belongs in our toolbox for helping patients trade unhealthy patterns for
healthy ones.
In Part II and beyond, we will examine in more detail methods available for
achieving these objectives so as to help patients substitute healthy patterns for
EDPs.

4.5 A Catalog of EDPs

The human mind is already complex, and to add more complication, EDPs develop
starting from the earliest stages and continuing into adulthood. The result is that
they vary greatly in sophistication and in the strategies used to distance feelings.
This catalog, though listed briefly in Chap. 3, is repeated here because it gives an
overview of the full range of problems with which therapists are confronted. Part III
will offer a final version in which each type of EDP is presented along with treat-
ment suggestions and resources.

4.5.1 Dysfunctional Behaviors

The example given above of using intellectualizing words to avoid tears is typical in
that it is an automatic reaction held in procedural memory. With greater awareness,
the patient may begin to resist the impulse to speak his avoidant thoughts and,
instead, allow his feelings to become fully conscious affects.
The following list is a way of categorizing the full variety of these potentially
voluntary, affect-avoiding behavior patterns according to how they are experienced
by patient and therapist. Each will be described briefly.

1. Simple Avoidance—Quite frequently, patients are consciously reluctant to expe-

rience or talk about subjects that bring up painful affects. Here avoidance is
under full voluntary control. The patient may have to be educated about how
affects can heal or, better yet, to experience healing him or herself, before being
willing to let go of simple avoidance.
2. Nonverbal Schemas—The term is used here to refer to patterns in procedural
memory that have been learned in order to avoid difficult feelings. The earlier
their origin, the more they are automatic. When triggered without the patient’s
46 4 Avoidance Patterns and Mechanisms

awareness or control, they may be difficult to change. Nonverbal schemas form

the substance of attachment patterns and personality disorders.
3. Reenactment—Early in the history of psychotherapy, Freud took notice of the
“repetition compulsion.” It is not entirely clear why the nonconscious problem
solver tends to re-create past situations where there is “unfinished business.” One
explanation is to transform what once was a passive experience into an active
one. Another possibility is the hope of a better outcome. Toward this goal, reen-
actment inevitably fails; the original unfinished business will remain unresolved
no matter how many times it is repeated.
4. Acting Out––A common pattern where emotions, such as anger, are expressed
through action rather than experienced as affects. A person who attacks another
may not actually experience the feeling of anger and will not be able to resolve
it. Thus, acting out is a way of avoiding affect and usually leads to other negative
consequences.
5. Hidden Agendas—This important group of EDPs has a common basis, in that,
unlike nonverbal schemas, they are based on an idea in the form of “if-then.”
They appear to originate from around ages three or four on, when children are
able to formulate cause and effect. For example, if I perform perfectly, then if
will be loved. If I show that I can’t manage, then someone will help me. If I fol-
low the rules, then others will feel obligated to follow them, too. If I am faultless,
then others will acknowledge their wrongdoing. As is characteristic of ages three
or four, the solution to any major difficulty is to motivate the grown-up to fix the
problem.
6. Guilty Quests—Around age five to six, children begin to grasp time future. As
they do, they are able to solve today’s problems by imagining that “someday I
will...” This has a tremendous advantage in that the solution might actually hap-
pen, so it does not have to contradict reality. A future solution gives hope and
takes pressure off the child to solve the unsolvable. For example, “someday I will
be big and strong and that will win me the love that is lacking today.” When the
desired goal comes under judgment by the conscience, it is usually banished
from awareness but continues to generate hope. Long-term therapy or psycho-
analysis is a fertile ground for the inner child who is seeking at last to implement
the guilty quest. As the quest becomes more intense, it can create a countercur-
rent to the ostensible goals of therapy. This “transference,” if handled well, leads
to consciousness awareness where childhood wishes can be processed and modi-
fied to fit with adult reality.
7. Arrested Development—One of the most important EDPs is avoiding difficult
affects by avoiding new experiences that would otherwise result in growth and
development. The resulting deficits in maturity in certain areas seriously erode adult
life, depriving the patient of important capabilities. In therapy, the answer is to go
through the experiences that once were avoided, working with whatever uncomfort-
able feelings come up. In doing so the developmental deficit can be repaired at any
age. Often the premature loss of a parent causes some developmental arrest.
Avoiding the stresses of adolescent development is another common source.
4.5 A Catalog of EDPs 47

8. Addictions—Substance use and compulsive behaviors such as food restriction

are potent ways to avoid affects and easily become dysfunctional. They have
much in common with the nonverbal schemas, described above. However they
often have a genetic component and involve powerful physiological reinforc-
ers that increase resistance to change. Usually, the behavior must change
before affects it serves to suppress can come to the surface and be
transformed.

4.5.2 Helpers

As described in the previous chapter, these helper EDPs are made up of mental
contents that appear in the frame of consciousness. They include primary emotions
and impulses, conscience-based emotions of shame and guilt, and automatic
thoughts. All are products of the nonconscious problem solver that functions to
influence free will. Each type represents a somewhat different kind of information
in the brain. They are described in the list below.

9. Primary Emotions and Impulses—The nonconscious problem solver has the

capacity to generate many different feelings for the purpose of affect avoidance.
For example, anger can be used to cover up sadness and influence behavior in
the direction of aggression. Acting on aggressive impulses also keeps sadness
at a distance. Feelings like these, that serve to avoid, appear to engage the same
emotional apparatus as more “authentic” feelings that derive more directly
from circumstances. More about this is in Part III.
Impulses function like emotions though it is not clear if they are a form of
emotion or something distinct. Either way, they exert a strong pull toward
action and work the same as emotions to influence free will to act on avoidance
strategies.
10. Conscience-Based Emotions, Shame, or Guilt—These specialized emotions are
products of the conscience. They grow out of judgments based on internalized
values. Inappropriate feelings of shame or guilt can heal like other feelings, but
without modifying the values behind them, the feelings will reoccur.
Furthermore attempts to challenge values often encounter strong resistance in
the form of justifications that the feeling is “correct.” For example, a patient
will give reasons why he or she is “unworthy.”
11. Automatic Thoughts—Thoughts are products of the mind that enter conscious-
ness for many reasons, one of which is avoidance of feelings. If their influence
is toward acting on dysfunctional behavior, then they can be recognized as the
avoidance pattern of an EDP. Irrational thoughts, once they become conscious,
can be subjected to intellectual testing and, unlike nonverbal schemas, can
change instantly when the evidence no longer supports them. Patients may
resist changing thoughts, even against rational argument when changing the
thought would expose them to a troublesome emotion.
48 4 Avoidance Patterns and Mechanisms

4.5.3 Symptoms

Involuntary and unpleasant symptoms like anxiety have a genetic component but
also serve to avoid troublesome feelings. One of the most important recent discover-
ies of the field of psychology is that trying to suppress a symptom makes it worse.
Accepting uncomfortable anxiety, obsessive thoughts, depression, etc., is the opti-
mal approach. Depending on the severity, there may be a place for medication as
well, especially when the patient’s functioning is seriously compromised. Symptom-
based EDPs include:

12. Depression—Depression comes in many types. The most severe involves the
patient’s biology, causing an obvious change in the appearance of the patient,
often with loss of interest, weight loss, and early morning waking. They can
serve to avoid affects in two ways. In one dynamic, the nonconscious problem
solver tries to avoid the toxic feelings of helplessness imposed by circumstances
by pursuing defeat and helplessness, thus turning passive to active. In the other,
the strategy is to avoid unacceptable anger at others by raging at the self.

Related to depression, grief is a natural healing process that has all the same ele-
ments except anger directed toward the self. The difference supports the argument
that, in depression, self-hate is part of an active strategy to avoid toxic feelings.

4.5.4 Anxiety-Based Symptoms

13. Anxiety and panic are both symptoms where the main problem is the preoccu-
pation, not the symptom itself. The concept of acceptance instead of elimina-
tion of the symptom is most applicable here. Altering one’s lifestyle or using
medication to eliminate these symptoms makes them worse by increasing sen-
sitivity to whatever is causing worry. Symptoms may improve temporarily but
get worse in the long run. Effective treatment is learning to accept and cope
with the feeling without trying to change it.

Obsessions and compulsions are also anxiety-based symptoms, but they involve
hypersensitivity of the brain structure responsible for error checking. These symp-
toms are based on worry that something has been missed or is not being done cor-
rectly. The change process is the same as for anxiety, and the principle still holds
that trying to eliminate thoughts or impulses makes them worse.
Somatization, or physical symptoms such as pain or blindness that have no dis-
cernable physiological cause and can’t be helped by medical treatment, is similar to
obsessive thoughts in that preoccupation is what causes dysfunction and disability.
Treatment is aimed at accepting the symptom and preventing attempts to eliminate it.

14. Dissociation—A capability of the mind to compartmentalize threatening con-

tents. Some people are more prone to dissociate than others. Early life trauma
4.6 Conclusion 49

tends to increase that ability. Entire memories can be dissociated to the point
where the individual has no recall. In lesser forms, only an aspect such as the
emotional part is split off. This results in the “zombie-like” state, common after
disasters, in which the individual is able to function but feels nothing. When
aspects of traumatic events are split off by dissociation, they cause symptoms
of post-traumatic stress disorder (PTSD), such as hypervigilance, flashbacks,
and avoidance of reminders of the trauma.

4.6 Conclusion

The primary importance of this typology of EDPs is that it covers essentially the
entire gamut of dysfunctional patterns seen in clinical practice. The variety may
seem daunting, but with some familiarity, the therapist will be prepared for anything
treatable with psychotherapy.
Conditions that are primarily biological in origin, such as schizophrenia, bipolar
disorder, autism, and attention deficit disorder, cannot, themselves, be resolved
through psychotherapy but may lead to development of EDPs that can be recog-
nized in the above list. These reactions and compensations can be treated in psycho-
therapy. For example, in schizophrenia, important developmental deficits can be
helped. Another example is attention deficit disorder where the patient’s handicap in
executive functioning will often lead to repeated experiences of being told to “just
try harder.” The shame that is generated can lead to entrenched dysfunctional pat-
terns such as becoming the “class clown” to avoid painful hurt to self-esteem.

Key Points
• Avoidance patterns are shaped more by psychological development at the
time they are “invented” than by the nature of the affect being avoided.
• Strategies for distancing affects are products of the nonconscious problem
solver function of the mind.
• Only recently has it become clear how memories are encoded in the brain
as neural networks defined by enhanced synaptic connections linking
groups of neurons.
• Long-term potentiation is an important mechanism of memory formation
in which synapses are enhanced when upstream and downstream neurons
happen to fire simultaneously.
• Procedural memory, where many EDPs are stored permanently, is learned
and recalled without effort and is held diffusely in the brain.
• The catalog of EDPs includes broad categories of (1) potentially voluntary
avoidant thought and behavior, (2) helpers that support acting on avoidant
behaviors, and (3) involuntary and unpleasant symptoms that also serve to
distance from affects.
50 4 Avoidance Patterns and Mechanisms

References
1. Hebb DO. The organization of behavior. New York: Wiley & Sons; 1949.
2. Kandel ER. In search of memory: the emergence of a new science of mind. 1st ed. New York:
W. W. Norton & Company; 2007.
3. Löwel S, Singer W. Selection of intrinsic horizontal connections in the visual cortex by corre-
lated neuronal activity. Science. 1992;255(5042):209–12.
4. Penfield W, Perot P. The brainʼs record of auditory and visual experience. Brain. 1963;
86:595–696.
How Affects Are Healed
5

As already explained, entrenched dysfunctional patterns have two points of access

for psychotherapy. Recall that there’s the avoidance pattern, which develops from
the emotion the patient’s mind is trying to avoid. This chapter is about how the
dread can be taken out of emotions to the point that the avoidance pattern is no lon-
ger needed.
When emotions enter consciousness carrying their full charge of visceral energy
and affective grip, and this takes place in a context of safety and empathic connec-
tion, then something remarkable happens. They are transformed. They lose their
capacity to cause upset. The painful physical reactions and deep emotion that
accompany them are no longer overwhelming and seem to fade. In this chapter, we
will explore in detail how such transformations can take place.
One form of transformation, called reconsolidation, happens immediately and
permanently when the affect comes into the frame of consciousness. Another mech-
anism works more gradually when the affect is experienced multiple times with no
negative consequences. A third setting for transformation is mindfulness medita-
tion, in which the individual acknowledges the feeling but sees it in a broader
perspective.
In this book, the transformation of affects is referred to as “processing,” “detoxi-
fying,” or “healing.” All three terms are used synonymously to refer to the same
phenomenon in which a previously dreaded affect loses its power to cause distress.
Now let’s dig deep into just how such remarkable changes can take place.

5.1 Breaking the Chain

The process of triggering an EDP starts with the usually nonconscious recognition of
a problematic situation or condition in life. More precisely this means that the percep-
tions that trigger an EDP are first matched with some previously encountered memory
or idea, which has been associated with danger or pain. We know from the discussion

© Springer International Publishing AG 2017 51

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_5
52 5 How Affects Are Healed

of memory in the previous chapter that recognition requires that sensory inputs cause
activation of a neural network representing the memory. Knowing that every dysfunc-
tional pattern starts with activation of a group of nerve cells gives us a starting point
for understanding their healing or resolution on a more detailed level.
Once the neural network representing a memory or idea is activated, what hap-
pens next? That particular network is “associated” with a negative emotion. In neu-
rophysiological terms, association means that one neural network has connections
to another so that the two tend to be linked together. The network that represents a
recognized circumstance activates the one representing danger. To schematize a
complex neurophysiology, the danger network sets off anticipation of the painful
experience of a negative affect, which then puts the nonconscious problem solver to
work finding a way to avoid the affect.
Let’s use the example of a survivor of a terrorist attack who is haunted by the
memory. She had been drinking every day to keep the feeling at bay, but having
entered therapy, she has stopped that behavior and is ready to face the painful feel-
ings. In her session, we are seeking to heal or detoxify the horror associated with the
memory of a scene of death. As she gains access to the immediacy of her experience
and holds the affects for a few minutes, feeling both terrified and safe at the same
time, the memory will be transformed. It will no longer have the ability to set off the
same level of emotional pain and distressing visceral sensations. She will leave the
session feeling worn out but relieved and no longer needing to ward off the emotion
with alcohol.

5.2 How Healing Works

Besides the discovery of how memories are stored, the most important scientific
breakthroughs for therapists come from studies of trauma in humans and fear reac-
tions in animals. Neuroscience has been looking intensively at how emotional mem-
ories can be transformed. In neurophysiological terms, this means breaking the link
between an activated memory and its associated emotion so that the memory itself
is no longer synonymous with a painful affect.
In rats, humans, and many other species, learned fear reactions are easy to estab-
lish experimentally when the brain is conditioned to associate fight or flight with a
repeatable set of circumstances. Note that flight and fight are among the behaviors
referred to here as “avoidance mechanisms” or “protective strategies”; however, in
this case, they are not necessarily dysfunctional. As explained earlier, recognition is
known to take place in the brain structure called the amygdala, a center for detecting
danger (or opportunity) and triggering reactions like Jack’s panic. Once fear condi-
tioning is established, this alarm system will remain ready to react whenever the
triggering circumstance is recognized. This can happen even when the response is
no longer appropriate, as when the patient in our example hears the crack of a cel-
ebratory firecracker.
Neuroscientists have been particularly interested in how mammals and humans
might unlearn an association between a remembered circumstance and a
5.3 Extinction 53

distressing emotion because this could help the millions who suffer from anxiety
as well as trauma. How might such unlearning take place? Recent work has clari-
fied neurophysiologically that there are two pathways by which the link between
recognition of a circumstance and triggering of painful affects can be blocked or
unlearned. Both have been studied in detail, down to their very distinct biochemi-
cal signatures.

5.3 Extinction

The first healing mechanism to be elucidated is called extinction. It was initially

described by Pavlov as the gradual elimination of learned behaviors when the trig-
gering reward or punishment is no longer present. On a neurobiological level, it
turns out that the recognition component is not actually unlearned, nor is the link to
a negative emotion [5]. The memory of the original circumstance has been shown to
be essentially permanent and continues to be activated in the amygdala whenever a
triggering circumstance is perceived. The memory of that circumstance still sends
signals to activate a painful affect, but from then on, the chain reaction is stopped.
What is “extinguished” is the emotional reaction itself. Nerve cells connecting
danger recognition to a reaction (flight–fight in animals, painful affect in humans)
receive inhibitory signals and do not fire. When this link is inhibited, the chain is
broken, and both the painful affect and the protective reaction are stopped before
they can be experienced. Work with rats and other mammals has shown that the
inhibitory signals that serve to stop an emotional reaction originate in the frontal
cortex, a part of the thinking brain located just behind the forehead [6]. In effect,
with a triggering circumstance repeatedly presented without the expected pain, the
cortex is gradually able to reassess the level of danger and interrupt the cascade of
reactions. Significantly, this learning requires repetition. Furthermore, when the
unlearning ceases, the flight–fight reaction eventually returns, and the benefit of
learning is lost.
This unlearning and inhibition of painful affects and flight–fight reactions require
two conditions in order to become established and reliable. First, the neural net-
works representing the triggering, “dangerous” circumstance must be activated. If
they are quiet, then the cortex cannot learn to inhibit the reaction. That means that
in a therapy session, the patient must actually feel the affect. The second necessary
condition for extinction is that the thinking brain must also perceive that the current
situation is really not dangerous. In other words, the expectation of danger gener-
ated in the amygdala must be “disconfirmed.” The context of the consulting room
and therapeutic relationship creates this safety.
Exposure therapy makes use of precisely this pathway to recovery. The patient is
purposefully reminded of the traumatic situation, for example, by showing video or
recording of sounds. This activates the memory and the associated fear, but in a
context where it is clear, there is no longer any danger. With repeated pairing of the
feeling of fear with awareness of safety, the fear reaction is gradually suppressed.
This treatment is one of two approved by the US Department of Veterans Affairs for
54 5 How Affects Are Healed

treatment of war trauma. Unfortunately, exposure therapy has disadvantages. First,

the traumatic emotions must be experienced over and over, which is painful for
patients. Second, the cure is not permanent. Repeated practice is needed to establish
and then maintain awareness that what looks dangerous is really not. Without rein-
forcement, the original fear reaction eventually returns, and the EDP is
reestablished.

5.4 Reconsolidation

But the story doesn’t end there. In 2004, a group of researchers led by Sevil Duvarci
and Karim Nader [1] demonstrated a new way to stop fear reactions. Fear reac-
tions can be erased completely and permanently such that maintenance is not
required. Amazingly, this erasure does not require repetition or ongoing therapy
to keep it in place. Through this mechanism, the association between a recognized
“dangerous” condition and the link that leads to distress can be broken forever.
Neurophysiologically, the synapses linking the memory with a painful emotion can
be reset so that the memory, while still recognized, no longer triggers a potentially
painful emotional reaction. What was once recognized as danger is now treated as
something closer to a dull ache.
How can we make this erasure happen? As with extinction, the fear reaction must
first be activated. Clinically, the patient must actually reexperience the scary affect.
Under optimal conditions this needs only to happen once. When the recall and reac-
tivation of emotion are sufficiently intense, then a window in time opens up starting
about 10 min after the activation and lasting till about 3 h later. During this time
period a process called reconsolidation allows information stored in synapses to
change. With recall (activation) of memories, the association between the memory
of a triggering circumstance and the emotion temporarily becomes “volatile” and
subject to being revised as if the memory never was dangerous.
The term “reconsolidation” was originally coined to refer to the more usual situ-
ation for animals where the memory is activated and then reconsolidated, meaning
confirmed and strengthened from the original fearful association. When a deer has
a second close call with an automobile, the memory of danger is reactivated and
reconfirmed so that the next time it encounters a vehicle, the animal will be even
more frightened and stay even farther away.
But what happens if the memory of an old fear is activated in the context of a safe
place or a safe relationship? Then the memory is reconsolidated (maybe “deconsoli-
dated” would be a better term) into a new configuration. Synapses are reset so that
the original condition is no longer associated with fear or danger. Detailed bio-
chemical experiments have proven that his mechanism of erasure is quite different
and distinct from extinction. Where extinction requires repetition and lacks perma-
nence, reconsolidation does not require repetition and remains in place without fur-
ther effort.
In his first paper on psychotherapy, published in 1893, Freud described a trans-
formation with just these characteristics:
5.5 Anna O.: A Case of Reconsolidation 55

We found to our great surprise at first, that each individual hysterical symptom immediately
and permanently disappeared when we had succeeded in bringing clearly to light the mem-
ory of the event by which it was provoked and in arousing its accompanying affect...

Freud and his colleague Breuer called the phenomenon catharsis, probably
because of the strong emotions followed by a feeling of release and then relief
(Freud and Breuer [3]). While this healing has exactly the same characteristics as
the recently described mechanism of reconsolidation, some doubt has been
expressed about whether the mechanism is exactly the same. This is because of the
finding from animal experiments that the older a fear memory, the more strongly it
has to be activated for reconsolidation to work. Doubt has been raised that activation
in therapy is sufficiently intense for reconsolidation to happen. Bruce Ecker [2]
among others is a champion of the point of view that reconsolidation is, indeed, a
major part of the healing in psychotherapy.
Logic supports Ecker’s belief that reconsolidation actually does operate in psy-
chotherapy through a process of elimination. There are two and only two known
healing mechanisms for fear reactions. Unless some additional, unknown mecha-
nism also exists, any clinical example of healing of a fear reaction must involve one
or the other or a combination of the two mechanisms. Since extinction requires
repetition and ongoing reinforcement, then any clinical example of healing that
eliminates the requirements of repetition and reinforcement can only be explained
as the result of reconsolidation.
In fact, since Freud’s account there have been many descriptions over the past
120 years of permanent, stable recovery from painful reactions related to trauma.
Interestingly, Freud’s observation of such a phenomenon was what led him to work
out the details of his therapy and the principle of bringing affects into the room by
“making the unconscious conscious.”

5.5 Anna O.: A Case of Reconsolidation

Anna O. (real name Bertha Pappenheim) was treated by Joseph Breuer, Freud’s
mentor and associate in the early 1880s. She was reportedly the inventor of “talk
therapy” when she told her doctor to quit trying to make hypnotic suggestions (the
accepted treatment for hysteria at the time) and just listen to her. He agreed to listen
to his patient as she recalled, with feeling, her traumatic experiences. As she per-
formed what she called “chimney sweeping,” she described traumatic events that
had been split from memory by dissociation. The severe conversion symptoms such
as paralysis that had crippled her melted away and did not return.
Her treatment was marred by the then unknown phenomena of transference and
countertransference, causing a premature break in her therapy with Dr. Breuer and
a period of return of symptoms. Despite a traumatic termination and difficult years
that followed, she eventually became known as Germany’s first social worker and
went on to escort a group of children to England to escape Nazi persecution during
World War II [4].
56 5 How Affects Are Healed

My own repeated experiences with similar, permanent resolution of symptoms,

was what led to the interest in how therapy works that underlies this book. These
and many similar accounts of healing arising from a single vivid reexperiencing of
affects constitute evidence that reconsolidation is a real and regular part of the
action of psychotherapy.

5.6 Healing in the Real World

Lest this picture of therapeutic healing seem easier and more perfect than it is in real
life, it is important to point out a few clinical observations. First, a great deal of hard
work is often needed to overcome resistance to bringing painful affects into the
consulting room where they can heal. Many EDPs come into play to prevent painful
conscious reexperiencing. Much of the work of therapy involves creating a safe
relationship and working through layers of EDPs that block such dreaded feelings.
In addition, in practice, the painful feelings are often only partially activated.
Avoidance patterns may soften and reduce the level of activation so that it is not
experienced sharply enough for full reconsolidation to take place. When this hap-
pens, it is likely that the mechanism of healing is some combination of extinction
and reconsolidation.
The reason Breuer’s patient experienced what appears to have been pure recon-
solidation is probably that her memories and their associated painful feelings had
been split from consciousness by the mechanism of dissociation, which will be
described in detail in Chap. 21. With the abrupt resolution of dissociation, the veil
that covers a memory and its feelings can be drawn back rapidly and completely as
if the event was happening in the here and now. When this happens in presence of
an empathic and safe relationship, the condition of a disconfirming context is also
met. With such access to affects at full intensity in a context of clear safety, com-
plete erasure of the pain is possible.
While traumatic memories and feelings are often split off by dissociation, their
recovery is not always so sudden and complete. Without dissociation, the intensity
of affects is usually somewhat attenuated by the time they come up in therapy. As a
result, reconsolidation may not take place, or may be partial, and healing by extinc-
tion may contribute to results.

5.7 Repetition

Another clinical issue is whether or not repetition must always be part of healing of
traumatic memories. Even when full reconsolidation is the mechanism, as is often
the case with dissociated, traumatic memories, multiple sessions may still be
required. Each associated affect only has to be reactivated once for healing, but most
traumas have many facets. Each of these may require its own healing process. The
end result can be mistaken for a requirement of repetition, but each recall of affect
is actually from an angle that is different and distinct. For example, one facet of an
5.9 Healing Beyond Trauma 57

abuse experience might be the direct hurt, while another could be the failure of a
family member to intervene. Those are two separate traumas, and each requires a
separate healing process. For pure reconsolidation, repetition is not a requirement
either in humans or in other mammals.
Healing by reconsolidation can also seem to require repetition when parts of an
emotion are too great to be experienced all at once and are detoxified one layer of
intensity at a time in multiple sessions. The principle of dividing the processing of
trauma into more practical “chunks” is regularly embodied in a treatment called eye
movement desensitization and reprocessing, or EMDR, to be discussed below.

5.8 From Words to Healing

These recent insights into the two mechanisms involved in resolution of fear memo-
ries make it possible to trace the full chain of events involved in psychotherapy.
Words describing a terrifying experience such as the trauma of the terrorism survi-
vor described earlier are spoken in session. These activate memories that trigger a
painful potential emotion. As the emotion rises to a conscious, activated state, the
context of the therapy and the relationship evoke safety and disconfirm the danger,
which allows adjustment of synapses either in the cortex or directly (Suzuki [7]). In
extinction, the cerebral cortex learns to inhibit the nerve cells involved in generating
a fear reaction. In reconsolidation, the link between the memory and the associated
negative emotion is erased. In both cases, information in the brain is modified, and
the fear memory no longer triggers painful affects.

5.9 Healing Beyond Trauma

So far, we have examined only the healing of fear reactions by extinction and recon-
solidation. Increasingly, we are seeing that psychopathology is the result of dys-
functional information held in neural networks in the brain. Psychotherapy seeks to
modify either the information itself or the way it influences us. However, the brain
is highly complex. There are different memory systems and different ways their
contents impact us. So far research has only begun to venture beyond fear reactions.
Taking fear reactions as a prototype, let’s look at some situations where the pro-
cesses of change may be similar but also different.

5.9.1 Pride, Guilt, and Shame

These conscience-based emotions are the result of judgments made according to our
values. The feelings may be detoxified temporarily, but to bring about long-term
change, the underlying values have to be modified. Values are also information,
probably held in the prefrontal cortex. The way pathological values or attitudes are
modified is by helping a healthier value become predominant over an unhealthy
58 5 How Affects Are Healed

one. Healthy values can come to override unhealthy ones in a way that prevents the
affect of shame, for example, from being experienced. Presumably, this change
involves learning and synapses, but the precise mechanism by which positive values
can be made to take precedence is not understood.
What is unusual about values is that they are exceedingly difficult or impossible
to change. Reemergence of shame is common when negative circumstances reoc-
cur, suggesting that values are permanent and not erasable, only subject to being
overridden.

5.9.2 Attachment

Attachment is a powerful force in the mind. What makes this most obvious is our
powerful reaction when someone to whom we are attached is lost or dies. The
resulting grief reaction does not heal rapidly as other feelings do but requires time
and may be processed in small increments. This form of healing takes such a dis-
tinct time course compared to the healing of traumatic memories that we must
assume its mechanism is also distinct and yet to be elucidated in neurophysiologi-
cal terms.

5.9.3 Ideas

Some psychological problems, such as “hidden agendas,” are based on ideas. An

example is the childlike idea that to be lovable, one must be perfect. There are some
indications that dysfunctional information of this kind can be modified when the
principle is brought to consciousness or activated in some way. Ecker [2] documents
work focused on such ideas. In such cases, it may be that behavior change is needed,
along with cognitive clarification, to help the mind “understand” that the principle,
held somewhere in a neural network, is not correct. Once again, the exact processes
for this type of change are not understood.

5.9.4 Psychological Development

The transformational processes involved in psychological development and the

building of new patterns appear to involve two mechanisms. First, new patterns of
behavior are learned and stored in procedural memory. Second, emotions, espe-
cially uncomfortable ones associated with new behavior patterns, appear to be pro-
cessed in the same way as other uncomfortable emotions. With this detoxification of
negative affects, we become “used to” the new behavior pattern, and the benign
quality of the new pattern is retained in memory.
5.10 Conclusion 59

5.10 Conclusion

In this chapter, we have examined, down to the level of synapses, at how emotional
healing follows two pathways, both leading to breaking the links between a trigger-
ing circumstance and the associated sense of dread. Other therapeutic situations
seem to involve somewhat different ways of changing information held in the brain.
As more specific tools for investigation become available, each of these distinct
processes should be of interest to researchers as well as therapists. For now, we can
bear in mind that transformation of affects in psychotherapy requires both intense
activation and a context of safety such as we seek to build into the therapeutic
relationship.

Key Points
• Emotional healing is a remarkable phenomenon in which dreaded affective
experiences can be detoxified so they no longer pose a threat and no longer
drive the mind’s avoidance strategies.
• Recent work shows two ways that the neurological link between a circum-
stance and its association with fear can be broken.
• The best known is extinction, in which repeated activation of the memory
and affect in a context of safety leads to inhibition of the fear response.
This healing requires maintenance or it will be lost.
• The newer mechanism, elucidated in 2004, is reconsolidation in which the
neural link between a circumstance and fear can be erased if the affect is
fully activated in a context of empathic safety. In this case, the healing is
permanent and requires no effort to maintain.
• Freud’s first psychotherapy paper published in 1893 described a case of
healing with a clinical picture matching the characteristics of reconsolida-
tion. The patient, Anna O. (real name Bertha Pappenheim), was the inven-
tor of talk therapy and later became the first social worker in Germany.
• In the real world, the main challenge in emotional healing is reluctance to
experience the painful affect. While healing of fear reactions is the proto-
typical change process, therapy in the real world probably involves addi-
tional features and complexities.
• In conclusion, at last, it is possible to trace emotional healing from words
spoken in a session to activation of affects to changes in synapses.
60 5 How Affects Are Healed

References
1. Duvarci S, Nader K. Characterization of fear memory reconsolidation. J Neurosci.
2004;24(42):9269–75.
2. Ecker B, Ticic R, Hulley L. Unlocking the emotional brain: eliminating symptoms at their roots
using memory reconsolidation. New York: Routledge; 2012. p. 69.
3. Freud S, Breuer J. Preliminary communication (1893). The Standard Edition. London: Hogarth
Press; 1955. p. 6.
4. Kaplan M. Bertha Pappenheim. Jewish women: a comprehensive historical encyclopedia.
Jewish Women’s Archive. 2009. http://jwa.org/encyclopedia/article/pappenheim-bertha.
Accessed 22 Sept 2016.
5. LeDoux J. The emotional brain: the mysterious underpinnings of emotional life. New York:
Touchstone Books; 1996.
6. Lee JLC, Milton AL, Everitt BJ. Reconsolidation and extinction of conditioned fear: inhibition
and potentiation. J Neurosci. 2006;26(39):10051–6.
7. Suzuki A, Josselyn SA, Frankland PW, Masushige S, Silva AJ, Kida S. Memory reconsolida-
tion and extinction have distinct temporal and biochemical signatures. J Neurosci.
2004;24(20):4787–95.
A Context of Connection
6

In the previous chapter we saw that emotional healing effectively changes informa-
tion in the mind/brain. The healing process essentially teaches the mind that a situ-
ation associated with intense dread is actually benign. This change in information
depends on substituting new knowledge for old. In this chapter, we will look more
closely at the source of the new information, the therapeutic relationship. Later in
the chapter, we will also review the role of the relationship in helping patients
replace their dysfunctional patterns of avoidance.

6.1 A Prototype

The best way to understand the information exchange in emotional healing is to

examine how a parent or primary caregiver is able to sooth the emotions of a one- or
two-year-old child who has fallen down. If we observe closely, when the toddler
falls, she doesn’t cry immediately. Instead, she makes eye contact with the mother.
As their eyes meet, a complex exchange of nonverbal information begins. Here is a
breakdown of the steps:

• Child’s face tells mother something has happened.

• Child asks mother if it is serious.
• Mother’s look tells child that it’s going to be ok.
• Child receives mother’s point of view.
• Child now sees herself through mother’s eyes.
• Child’s feelings are calmed, and play is resumed.

If the mother shows distress, then the child will cry and will be unable to resume
playing until comforted. This prototypical information exchange contains exactly
the same elements as the exchange that transforms affects in psychotherapy.
First, we know from the study of extinction and reconsolidation that the painful
affect must be activated for healing to take place. For the child, this is not an issue.

© Springer International Publishing AG 2017 61

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_6
62 6 A Context of Connection

The child has not learned to suppress affects, and her full emotional response shows
immediately on her face. Next, this affect needs to be understood empathically by
the mother. If the mother is not in tune and the communication fails, then the moth-
er’s response will be perceived as unhelpful or inauthentic and will not have a sooth-
ing effect. In therapy, the patient must experience the emotion in its visceral intensity
along with the circumstances that have triggered it. Then the therapist must receive
this information on an empathic, emotional level. Only then will the therapist’s
reactions, verbal and nonverbal, be authentic and effective.
Having received the emotional information, the therapist/witness then evaluates
it from his or her point of view. As long as the witness is able to put the event in
perspective as not dangerous, then what is transmitted back to the child or patient
will be perceived as authentic and adopted. In this way, the child’s worry and the
patient’s perception of danger are each disconfirmed. In the case of the child, no
association with danger is formed in the first place. In the case of the adult trauma
survivor, a previously formed association with danger is erased (with reconsolida-
tion) or suppressed (with extinction).
From the first year of life, this way of using an empathic witness’s calm perspec-
tive remains as a mainstay of our emotional regulation. Sharing our frightening and
painful emotions and circumstances in a context of safety and empathic connection
is just as important for adults in distress as it is for toddlers. To shorten this long
description, we can say simply that:

Affects heal when shared in a context of connection.

6.2 The Ubiquity of Emotional Healing

Emotional healing as described above is a common and universal part of human

life. It happens in families, between friends, and even in crowds experiencing the
same emotions at the same time. It is part of popular culture that “a good cry”
makes one feel better. The unspoken but essential element is the context of con-
nection. Also in popular culture, the word “venting” is sometimes applied to the
sharing of feelings with an empathic witness. The image of releasing pressure is
accurate, but the word tends to trivialize one of the most remarkable and sublime
human capacities.
In therapy, the importance of a context of connection is sometimes recognized
and sometimes missed. In the early days of psychotherapy the Victorian notion of
scientific objectivity was interpreted as needing to eliminate the subjective element
of the therapist. Today, even in physics it is understood that such “objectivity” is not
possible, nor desirable. What was missed is that a therapist, hearing the details of a
patient’s experience and the presence of the affect “in the room,” can’t help but be
an empathic witness. The establishment of a context of connection is so basic to
human nature that we can’t stop it from happening. Unless the therapist is under the
influence of some personal EDP or the patient’s emotional communication is some-
how compromised, a context of connection will naturally be formed.
6.4 Mindfulness 63

There are therapies today that de-emphasize the personal relationship. Even
there, a context of connection is regularly established. In purely cognitive therapy,
where logical discourse is used to dispel the patient’s illogical, automatic thoughts,
change brings up feelings, which, recognized or not, are detoxified in the context of
connection between patient and therapist.
Today, psychodynamic, experiential, interpersonal, and “third wave” therapies
are each fully respectful of the importance of an empathic relationship whether or
not they recognize the precise mechanism of healing that a context of connection
makes possible.

6.3 Are There Exceptions?

Can emotional healing take place in the absence of a human witness? Patients often
ask if it might be just as healing to cry in the shower alone. Francine Shapiro [5], the
founder of eye movement desensitization and reprocessing, EMDR, discovered her
technique while walking alone thinking about a situation associated with troubling
emotions, as she moved her gaze back and forth she found that the pain went out of
her thoughts. How can we make sense of this and other instances of healing without
the presence of a witness? First, let’s look in detail at EMDR therapy.
Seizing on the eye movement as the essential element in her experience, Dr.
Shapiro founded a school of therapy (which includes a therapist witnesses) that has
continued to thrive as a treatment for painful affects associated with traumatic mem-
ories. Alternating clicking sounds and other stimuli can be substituted for eye move-
ment, but some elements in the original treatment remain unchanged. The patient is
asked to verbalize aspects of a traumatic experience along with the accompanying
feelings and then told to “hold the feeling” while attending to the alternating stimu-
lation. This sequence is repeated in segments of a few minutes, allowing the trau-
matic experience to be broken into small portions.
Despite Shapiro’s solo cure, EMDR therapy has been implemented since then to
include a context of connection. The therapist is there to guide the process. Whatever
the role of the alternating stimuli, a similar healing happens in other therapies where
all the other elements are present. While the fundamental healing process in EMDR
may not be different from other therapies, it is particularly valuable in helping
patients confront overwhelming feelings by dividing them into small “chunks” and
giving the patient a sense of control and mastery over the process. As it is practiced,
EMDR does not appear to be an exception to the requirement of a context of con-
nection. The question remains about whether a solo cure is possible.

6.4 Mindfulness

Mindfulness meditation is also practiced alone and has been proposed as a method
for healing painful feelings. Mindfulness, in Sanscrit smrti, originally a part of
Buddhist practice, is described as seeing one’s own experience from an outside
64 6 A Context of Connection

perspective. When applied to negative affects, a simple metaphor is “surfing” a feel-

ing. We can imagine an affect as an ocean wave. If caught in the wave we have no
control and are tossed about by its power. On the other hand, on a surfboard, we can
feel the wave coming, experience its power without being overwhelmed, and know
that it will soon pass then break on the shore, losing its energy.
Notice that the essence of the experience contains two familiar elements. First
the affect is accepted and experienced in fully activated form. Second, as it is expe-
rienced, it is also viewed from an outside perspective, just as happens in a context
of connection.

6.5 A Proposed Explanation of Mindfulness

The state of mindfulness is not one of isolation but of connection with humanity and
the universe [1]. Is it possible that the meditator comes into contact with an internal
context of connection?
According to Margaret Mahler [2], children gradually internalize a sense of con-
nectedness, even when the mother is not physically present. This does not happen
immediately but accumulates. The fact that children, by the age of three, can toler-
ate separation with some calmness is taken as evidence that they have internalized a
sense of connection. This internalization makes possible what Mahler terms, “object
constancy,” a sense of relatedness independent of physical presence. Mahler also
points out that this capacity, once acquired, can be disrupted under stress.
Is it possible that mindfulness is practiced solo but not alone? Could the practice
of mindfulness meditation include its own version of a context of connection? It
seems possible that the healing power of mindfulness may make use of the same
elements as interpersonal therapy, activation of affect, and a context of connection.
Mindfulness is also increasingly incorporated into dyadic forms of psychother-
apy based on a therapist–patient relationship. Here the therapist attempts to convey
a sense of perspective similar to what mothers do without words. Once again, the
requirements described above for emotional healing are present, activation of affects
and a context of connection. It is suggested then that the element of calm perspec-
tive is one part of the whole experience and that the elements of activation of emo-
tions and a safe and empathic relationship, internalized or actual, are equally
necessary.

6.6 When a Witness Is Necessary

Consistent with Mahler’s observation, when emotions threaten to be overwhelming

as in cases of severe trauma, the actual presence of a therapist may be needed. Part
of the experience of trauma is often a sense of being totally alone. Traumatic memo-
ries are often accompanied by a feeling of isolation and aloneness even when the
therapist is present. It may be that the aloneness accompanying recall of these expe-
riences has the effect of disrupting whatever internalized sense of connection the
6.8 What About Involuntary EDPs? 65

patient might have internalized. For this reason, in severe cases of trauma, solo
meditation may not be able to supply the needed elements, and an in-person thera-
pist may be required.
Thus, it is proposed that mindfulness, like Elaine Shapiro’s solo experience, may,
like the healing in psychotherapy, represent a slightly different form of the same
emotional healing through activation of affects within a context of connection.

6.7 What if the Therapist Is Overwhelmed

Intuitively we can imagine that an empathic witness who is overwhelmed by the

situation of the other will not be of much help. Fortunately, the affects that once
caused an EDP to form are usually no longer dangerous. Naturally, the therapist,
experiencing the patient’s description as a competent adult, will see the patient’s
experience from a larger perspective and will not be overwhelmed. It is an important
part of our role as witnesses that our own lives are stable enough to be able to hear
the distress of our patients, without experiencing loss of control or hopelessness in
ourselves. In a situation where the therapist may have difficulty coping, outside sup-
port for the therapist or involving a third party might be necessary to avoid reinforc-
ing, rather than healing, the patient’s sense of danger.

6.8 What About Involuntary EDPs?

Many of the avoidance mechanisms embodied in EDPs are not voluntary. We will
see in the parts of this book that follow that helping patients with involuntary pat-
terns usually requires finding aspects that are under voluntary control. An example
would be depression. The symptom itself is involuntary. However, the therapist
might suggest keeping a diary with thoughts that support depression on one side of
the page and more realistic (and positive) thoughts on the other. This could lead to
voluntarily “talking back” to depression-enhancing helper thoughts. The result is a
diminution of depressive feelings.
One of the great discoveries of CBT is that involuntary thoughts and feelings that
enter consciousness against the patient’s will actually become worse when the
patient tries to eliminate them. In the end, the solution is to go to the other point of
entry for this EDP, emotional healing. CBT therapists now recommend mindful
acceptance of anxiety and the other anxiety-related symptoms described in Part
III. Acceptance of the uncomfortable affect, in a context of connection, whether
internalized or actual, leads to healing. As this takes place, the intolerable symptom
becomes tolerable. Over time, the preoccupation becomes less intense, and the
patient’s life improves.
Where anxiety-based symptoms focus on some dreaded eventuality, using ses-
sions focused on the “worst-case scenario” of what bad things might happen can be
a way of achieving maximal activation of the painful affect, so that reconsolidation
can detoxify the emotion.
66 6 A Context of Connection

6.9 Conclusion

John Norcross and the American Psychological Association’s Task Force on

Evidence-Based Therapy Relationships [4] published findings based on meta-
analysis of a large body of research on what works and what doesn’t. Among the
most important of their findings was the fact that while a great deal of research
money has been spent on methods of psychotherapy, very little attention has been
paid to the therapeutic relationship. Furthermore, the brand of therapy accounts for
only about 8 % of variance in outcome, whereas the therapeutic relationship and the
characteristics of the therapist together account for about 24 % [3].
Context of connection, shorthand for “a context of safety and empathic connec-
tion,” is a universal and extremely powerful healing tool, essential both for healing
emotions and for behavior change. In the latter case of changes in thought and
behavior, the role of the context of connection is to help the patient feel confidence
in the process and to help detoxify uncomfortable feelings that are inherent in mak-
ing significant changes.

Key Points
• The context of safety and empathic connection inherent in the therapeutic
relationship provides the element of disconfirmation of danger essential
for healing of troublesome affects.
• The way mother provides affect regulation for toddlers provides a proto-
type for understanding the universal information exchange inherent in all
forms of affective healing.
• Solo healing of emotions, including mindfulness meditation, probably
derives from an internalized context of connection.
• A context of connection is no less helpful when the goal is voluntary
change of behavior. A coaching model covers multiple benefits of an
empathically connected witness as patients traverse stages of readiness for
change.

References
1. Lucas M. Rewire your brain for love: creating vibrant relationships using the science of mind-
fulness. San Francisco: Hay House; 2012. p. 151.
2. Mahler M, Pine F, Bergman A. The psychological birth of the human infant: symbiosis and
individuation. New York: Basic Books; 1973. p. 112.
3. Norcross JC. How people change: relationships and neuroplasticity in psychotherapy.
Conference, UCLA Extension: Lecture contents. 2013.
4. Norcross JC, Wampold BE. Evidence-based therapy relationships: research conclusions and
clinical practices. Psychotherapy (Chic). 2011;48(1):98–102.
5. Shapiro F. Eye movement desensitization and reprocessing (EMDR): basic principles, proto-
cols, and procedures. 2nd ed. New York: Guilford Press; 2001. p. 7.
Motivation, Internal and External
7

What makes people come to therapy? Why do they stay? What is the motivation that
sustains the hard work of change? Every patient has a complex balance of factors
that favor staying on the job and being successful versus becoming discouraged or
going through the motions but not making progress. In this chapter we’ll examine
those factors.

7.1 The Special Situation of the Trainee

Motivation can be especially critical for trainees because they are often assigned to
work with patients whose motivation is less strong and who have serious deficits in
forming a therapeutic relationship that can sustain difficult treatment. Furthermore,
knowing that the therapist is less experienced may increase patients’ tendency to
question the therapist’s actions and competence. These factors can’t be avoided, so
the answer is to pay close attention to understanding the patient’s motivation and, as
treatment goes forward, how each session leads to an increase or decrease in the
desire to continue.

7.2 What Makes Patients Seek Therapy?

7.2.1 The Chief Complaint

The first source of motivation is that the patient experiences some form of suffering.
As will be emphasized in Chap. 9, on the initial assessment, understanding the
patient’s chief complaint in depth is the way to understand whatever pain or dissat-
isfaction is supporting the motivation to take the difficult steps of seeing help.
Along with careful listening to the patient’s complaint, we are interested in iden-
tifying EDPs, entrenched dysfunctional patterns. These are what we will ultimately
want to help the patient change, but they may also contribute to the patient’s pain or

© Springer International Publishing AG 2017 67

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_7
68 7 Motivation, Internal and External

lack of satisfaction. Patients are not always aware, or may not have articulated, how
their ways of functioning undermine their quality of life. It may be that, by identify-
ing areas of dysfunction, we can help patients better describe what is troubling
them. In doing so, we may actually strengthen motivation.

7.2.2 Location of the Problem

Surprisingly, patients, especially those who are less sophisticated, sometimes come
to a therapist even though they identify the problem as someone else or some prob-
lematic circumstance that the therapist can’t change. This will need to be clarified
immediately in order to keep from supporting expectations that will lead to disap-
pointment. Ultimately, the patient will have to be ready to see the problem as located
in his or her mind and belonging to the self.

7.2.3 Hopes and Expectations

A much more accurate and complete way to look at initial motivation is the per-
ceived differential (“delta”) between current, painful experience and the wished for
or expected outcome. When patients hope for an improvement, then, even if life is
positive, a better future has great allure. Hence, the patient’s perception of the ben-
efit of psychotherapy forms the other side of the equation.
Many things can influence the patient’s perceptions both of present suffering or
dysfunction and of hope for the future. Family, friends, media, and personal experi-
ence can have a major impact. The patient may have a fantasy of the ideal helper and
be seeking that person. What the patient learns about the therapist and any initial
contact may increase or decrease the patient’s perception of potential benefits from
therapy. It will obviously help the therapist to gain as much understanding of the
patient’s motivation as early as possible.
In addiction and other EDPs where the patient has never experienced healthy
adult life, the patient may have no adult experience upon which to base expecta-
tions. There may be little basis for hope. In fact, for addicts, abstinence from the
substance or behavior may not seem to offer anything positive at all. In such cases,
the patient may not perceive treatment as an improvement. As one might guess, in
those cases, motivation can be a problem.

7.2.4 Eliciting Expectations

Patients may be reluctant to describe what they are expecting or looking for in therapy.
To tell the therapist is taking an emotional risk. “What if I am wishing for something
that I can’t have?” “What if the therapist thinks my goal is silly or unrealistic?”
7.3 Hope and the SEEKING System 69

It is usually necessary for the therapist to ask some questions to bring out what
the patient is seeking. “Do you know anybody who has had a positive experience
with therapy?” “In your imagination, did you have a picture of what therapy could
bring to your life?”

7.2.5 The Inner Child

Throughout this book we have looked upon the inner child as a separate entity
with its own goals and agenda. This is true from the outset of treatment and is an
important factor in bringing the patient to therapy. Like real children, inner chil-
dren see the therapist as a powerful, parentlike figure who can, if motivated, solve
any problem. The inner child may have ideas both about needs the therapist could
fulfill and about how the therapist could change circumstances so as to support the
child’s growth and development. Patients whose dysfunction comes from earlier
development may be more direct in voicing their wishes. Children whose prob-
lems go back to later eras of development, say three and older, are more likely to
keep quiet for a while before their wishes come close enough to the surface to be
recognizable.
Acknowledged or not, recognized or not, the inner child is a major player in
motivation. The hopes of the child form an important part of the equation of current
suffering and future hope. Whatever we can learn about the child’s motivation will
be extremely helpful in managing the patient’s expectations and progress. The case
of Jack gave us an example. We could say that it was Jack’s inner child who wanted
support and help as he faced greater adult responsibilities. From the beginning of
treatment, awareness of his need as well as the shame involved was critical to con-
structing a treatment where emotional support was provided without being men-
tioned or acknowledged explicitly.

7.3 Hope and the SEEKING System

One of the most important sources of positive motivation is hope. An important

discovery from neuroscience sheds light on both hope and on the depression we
experience when hope is lost. This insight comes work by Jaak Panksepp and col-
leagues working on the neurobiology of mammalian emotional systems. Based on
30 years of research, Dr. Panksepp describes what he calls the SEEKING system
(the capitals are Panksepp’s convention). What this system does is provide psycho-
logical drive to support whatever goals the mind deems important. In other words,
this system represents the biology of hope. The SEEKING system consists of a
network of nerve cells, mainly located in the midbrain. Understanding it sheds light
on the excitement and energy we find in locking onto a goal and pursuing it to the
end. Panksepp has studied this system in different species:
70 7 Motivation, Internal and External

When the SEEKING system is aroused, animals exhibit an intense and enthused curiosity
about the world. Rats, for example will move about with a sense of purpose, sniffing vigor-
ously and pausing to investigate interesting nooks and crannies [2].

For humans, activation of the SEEKING system is intensely pleasurable. We have a

sense of excited anticipation with all our senses heightened. We picture the goal as
we make our preparations. The feeling peaks as we are about to arrive at our goal.
In some endeavors, like playing golf, for example, subgoals keep us reaching. When
we finally grasp what we have pursued so avidly, the level of activation quickly
fades. We may even feel a letdown. The pleasure is more in the chase, so when the
goal is achieved, other emotions must take over.
When we encounter too much discouragement, the SEEKING system shuts
down, and we experience a feeling of darkness and profound discouragement. This
is the same feeling as encountered in depression. Our mind has decided that what-
ever is important to us is beyond our reach, and hope is lost.
Interestingly, medications can have a powerful influence on this system.
Stimulants work on this system and make us feel powerful and focused at first and
then, if doses are increased, over-activate the system and cause paranoia. The
“crash” that is associated with stopping a stimulant is due in part to deactivation of
the SEEKING system. Opioid pain medications also boost the system but can
change its balance and, in withdrawal, can deactivate it, causing depression. The
endorphins produced naturally with strenuous exercise also stimulate the system
and give a “runner’s high.” For this reason, exercise can be a natural antidote to feel-
ings of depression. Some people depend on this biological boost and experience a
corresponding letdown when injury or some other event forces them to discontinue
an exercise program.
The hope that allows patients to seek therapy and to keep coming in spite of dif-
ficulty is supported by the SEEKING system. It is boosted by progress but too many
setbacks, and the SEEKING system may deflate, leaving the patient discouraged
and ready to give up.

7.4 Outside Motivation

At one time in the history of psychotherapy, if patients weren’t motivated, then they
were disqualified from treatment. Now, with the philosophy having moved toward
fitting the therapy to the patient, we must recognize that many patients, especially
those suffering from addictions and compulsive behaviors, may need, at first, to be
motivated by some outside force. In all cases, eventually, motivation must come
from within, but it doesn’t have to start out that way. Outside motivation is discussed
specifically in relation to addictions in Chap. 15.
7.5 Why Do Patients Stay? 71

7.4.1 Leverage

When patients perceive that failure to seek help and address some problem will
result in undesirable consequences, they may choose treatment. Less often, a posi-
tive consequence may also motivate for treatment. Consequences can come from
family members or friends. Some of the most effective ones come from employers,
professional associations, or the legal system. Most of the time, the patient will hold
onto the hope that it might be possible to have both, that is, to keep the behavior and
escape the consequences. People with addictions become especially skilled at
manipulating others. Often, there is a long history of empty threats and success at
evading consequences. For this reason, the challenge may be helping the patient to
understand that consequences are real and unavoidable. It may also be necessary for
the therapist to intervene with family members or other outsiders to gauge whether
consequences are, in fact, likely to be applied.

7.4.2 When There Is No Leverage

Unfortunately, it is not rare that outside factors prevent leverage from being used. A
common example is when patients are declared disabled and receive income based
on that status. Even caring family members willing to bring consequences may not
control anything important enough to motivate an addicted person.
That is not the end of the story. As we have seen, the human need for connection
is extremely powerful. When significant others are ready and willing to let go of a
relationship with the patient, this may create motivation. One word for this type of
motivation is “seduction.” The other person’s disengagement and readiness to walk
away, when exhibited without anger or spite, create a powerful tug to follow. In
Alcoholics Anonymous, the 12-step organization for people in a relationship with
someone who is addicted, the phrase that describes this stance is “detach with love”
(see Chap. 15).

7.5 Why Do Patients Stay?

As we have repeatedly seen, many forces are at work, trying to keep things the
same. On the positive side, several emotional dynamics provide the motivation to
keep working. Perhaps the most important is feeling better after most sessions. If
this is missing, then the patient is likely to stop coming. Few people can sustain an
effort with little or no immediate, experiential reward. Many factors can provide
such rewards. Here is a list of some of them:

• The patient experiences hope, which can have tremendous power to sustain
working toward a goal.
• The patient experiences positive reinforcement from others, including the thera-
pist, family, friends, people at work, etc.
72 7 Motivation, Internal and External

• The patient sees tangible results from therapy.

• The patient’s natural need for attachment drives a desire for connection to the
therapist.
• The patient perceives a difference between the desired or ideal self and the actual
one and experiences progress in bringing the two together.
• The patient’s values favor therapy because it is “the right thing.” Doing what is
right gives a positive sense of pride.
• The child within has hope of fulfilling an agenda or quest. This can be positive or
occasionally negative, like showing the therapist that he or she is not helping or
is unwilling to do the job “right.”
• There are negative factors, such as fear of going backward or facing conse-
quences, that can be part of maintaining motivation to continue.

7.6 Why Do Patients Quit?

Patients may feel disappointed in therapy for many reasons. Painful sessions that do
not end well are obvious. Norcross and Wampold’s research has showed that a ther-
apist who is perceived as critical or judgmental will not have positive outcomes [3].
If the patient perceives that the therapist expects too much, more than he or she can
deliver, the result is toxic. Lack of progress can become a concern of the patient or
of family members and friends.

7.6.1 Missing Sessions

For patients who are more impulsive, when they feel uncomfortable they are likely
to simply miss the next session. They may not have made a decision to quit treat-
ment but forget or have something else to do. It is certainly possible that the osten-
sible reason given by the patient is the real one. Psychological factors involved in
missing a session may or may not be accessible to the patient. Exploring what hap-
pened is an opportunity to learn about the patient’s experience. On the other hand,
when the defenses against such awareness are very strong, a strategic retreat (Chap.
10) may be the best the therapist can do.

7.6.2 Deciding to Quit

When patients make a more considered decision to stop treatment, it is usually safe
to assume that they have been thinking about this for some time. There have prob-
ably been a series of negative experiences or multiple instances of a lack of positive
feeling. The patient has at least hinted at what was felt to be wrong. Perhaps the
therapist has appeared to dismiss the patient’s concerns, or worse, to judge them.
Frequently, cost, family members’ negative perceptions, or other hidden influ-
ences are affecting the balance between staying and quitting. These may only be
revealed if the therapist is alert and willing to ask questions.
7.10 The Therapist as Motivator 73

7.7 Internal Resistance to Change

In addition to outside factors that influence the patient’s motivation, the natural need
to maintain the status quo (resistance) creates a source of headwinds. We have seen
that healthy change is generally interpreted by the nonconscious problem solver as
a relinquishing of protections against dreaded feelings. Naturally the problem solver
goes to work to resist change using available EDPs, including addictions, helpers,
symptoms, and avoidance of new experiences. Any of these entrenched dysfunc-
tional patterns can be used to resist the patient’s positive motivation.

7.8 Biological Motivation

What all chemical addictions have in common is that they produce dopamine in the
nucleus accumbens, a reward center in the brain. In doing so, they have a direct
influence on the motivational systems that make us wish to repeat a behavior.
Nonchemical addictions, such as eating disorders, self-injury, and compulsive gam-
bling, also have direct effects on brain motivational systems. In addition to these
biological sources, the natural drive to avoid uncomfortable affects is a contributor
in these pathologies.

7.9 Timing and Motivation

The balance between resistance and motivation can change over time, allowing for a
mismatch. For the addict who has never experienced sobriety, the negative forces may
be more intense at the beginning before positive motivation has built up. Ideally the
patient’s efforts are rewarded by progress. Success along the way produces feelings of
pleasure due to improved functioning and pride of accomplishment. Even without
tangible success, hope can support motivation. This is not always the case. Trauma
patients sometimes have to work for a long time before they are ready for the veil of
dissociation to evaporate, allowing healing to begin. It may be near the end of treat-
ment that these patients are finally able to experience the emotional healing and relief
they have waited for. During the long process leading up to that point, optimism can
erode and may present a significant challenge to both therapist and patient.

7.10 The Therapist as Motivator

The therapist has a role in motivation. We can remain completely neutral, leaving
the patient to weigh positive and negative factors, or the therapist can become a
cheerleader and add his or her personal influence to support the process. The
therapist’s choice often depends on the individual patient. Too much engagement
can be threatening. The patient may feel that the therapist doesn’t understand his
or her fears. Too little engagement can leave the patient feeling alone and
unsupported.
74 7 Motivation, Internal and External

Some patients are particularly uncomfortable with pressure from the therapist.
Researchers call them people of high “reactance.” With this group, a neutral stance
can be read as respect for the patient’s personal autonomy. Others are more comfort-
able with an engaged therapist and may react positively to the therapist’s emotional
involvement. This is a matter for assessment and decision-making on the part of the
therapist (see Chap. 13).
“Detach with love” can also apply to the therapist. On rare occasions, the thera-
pist’s willingness to let go of the relationship can be a source of motivation. The
patient may feel a drive to maintain the relationship. This should not be used as a
manipulation, but when the therapist recognizes that continuing to struggle is not
working, one option is to disengage or to show a readiness to do so. Therapists may
be under a legal obligation not to “abandon” the patient but can still make a referral
elsewhere if no workable treatment agreement is possible.

7.11 “Cat and Mouse”

The therapist or the patient’s family members are sometimes maneuvered into tak-
ing too much responsibility for providing positive motivation (the cat), while the
patient (the mouse) identifies with resistance. This difficult dynamic is particularly
common with teens resisting adulthood and with addicts who are ambivalent about
sobriety. As in such cartoons, the mouse always wins, which is not good for
therapy.
Internal tension is very uncomfortable. The young person or addict transfers the
conflict from inside to the outside world. He or she feels much better in conflict with
others than in conflict with the self. In family systems, roles and motivation are
quite fluid and can be exchanged from one member to another. Rather than tolerat-
ing intense and uncomfortable internal ambivalence about painful issues, such as
becoming adult or letting go of an addiction, the patient may take advantage of the
therapist or family members’ commitment to positive change by tempting them to
try to take over.
Let’s take the example of a teen who cannot accept more adult responsibility in
his or her life. Part of the teen wants more independence and autonomy. The other
part is frightened and wants to remain a child under the authority of the parents or
caregivers. Usually the dynamic coalesces around a specific issue. For instance, the
parents insist that the young person should act responsible by coming home early
enough to get sufficient sleep before school in the morning. The teen transfers one
side of the ambivalence to the parents by coming in late. The parents, being afraid
to risk seeing their child fail in school, take on the job of making sure the young
person comes home by a certain hour. Now the stage is set. The teen will increas-
ingly abandon his or her desire to become more responsible and will let the parents
take on full responsibility for bedtime. The teen is relieved of painful internal con-
flict and feels more relaxed. On the other hand, the parents are at a great disadvan-
tage, lacking control over the teen. The adolescent uses every tactic to fight the
parent’s efforts to exert control and usually wins.
7.12 The Patient Is Part of a System 75

The teen complains and rages that he or she should be trusted more and that the
parents are making unreasonable demands. Soon the parents are feeling badly that
they have failed. They apply more controls and restrictions, and the teen concludes
that they only want to keep him or her a child. The end result is that the teen avoids
the uncomfortable job of self-regulation and the parents feel frustrated and
helpless.
In therapy this dynamic can happen when the patient threatens or acts in danger-
ous or irresponsible ways. Examples are drug use or threats of suicide. When the
therapist is tempted to try to control an adolescent or adult patient, then the patient
may let go of any responsibility. The end result is that the therapist feels responsible
for healthy behavior, while the patient has become the champion of unhealthy
behavior. Once again the mouse wins.
When therapists find themselves caught in this dynamic, it is time for the thera-
pist to give control and responsibility back to the patient: “I am not going to be able
to control your behavior, so we will have to make some other arrangement, such as
hospitalization. Otherwise, the only way forward is for you to take back responsibil-
ity for your behavior.”

7.12 The Patient Is Part of a System

One of the more helpful advances to shed light on family behavior was developed
by Murray Bowen, who adapted general systems theory to families and groups.
Bowen described “emotional systems,” including families, groups, organizations,
and even cults [1]. These groups may be instrumental in motivating or de-motivating
our patients.
One of the most basic principles is that emotional systems tend to maintain the
status quo. Helping an individual patient to become healthier may unbalance the
family or other system of which the individual is a member. For the therapist, this
means it is wise to be prepared for unconscious family resistance, especially when
the patient is making positive strides. This can be subtle and hidden, while family
members are outwardly cooperative and supportive.
Another very useful concept is that of “open systems” and “closed systems.”
Healthy groups are in the open category, meaning members can come and go
with relative ease and can bring in influence and ideas from outside. Closed sys-
tems are epitomized by cults in which joining is restricted and so is leaving. The
cult demands that each member subjugate him or herself to the group, which
works against individuality and self-determination. Cliques in school have a sim-
ilar structure, where the leader demands absolute allegiance from members.
When families operate like closed systems, they may put powerful pressure on a
patient to act in a way that is acceptable to the group. This may make therapeutic
work impossible.
When working with patients who are influenced by an outside system, the thera-
pist may have to take the working system into account while assessing what changes
may be possible and with which members of the system to intervene. Especially
76 7 Motivation, Internal and External

with younger patients, that individual may not represent the appropriate point in the
system for intervention. It may be, for example, that intervening with the parents
will produce better results than working directly with a teen or young adult.

7.13 Enabling

This common and very important pattern is where an individual patient suffering
from a behavioral EDP such as alcohol abuse or developmental arrest receives some
form of reinforcement against healthy change. Typically the patient might be an
alcoholic who is ambivalent about change or a young person ambivalent about mat-
uration. In situations where there is significant internal resistance, such anti-
therapeutic reinforcement may be just enough to tip the balance of positive and
negative factors against progress.
A form of enabling that is often missed is angry enabling. As will be men-
tioned in Chap. 15, the outsider who tries to argue or punish the patient is engag-
ing in an intense, if negative, relationship. This may provide enough sense of
closeness to eliminate any “connection anxiety,” leaving the patient feeling
secure enough to continue the destructive behavior. The outsider may justify the
anger and argumentativeness and may be surprised to learn that it is counterpro-
ductive. Disengaging and letting go can be a very difficult stance for family
members to adopt.
If there is a connected family member who, through positive or angry enabling,
makes it easy and comfortable for the individual to continue a self-destructive pat-
tern, then realistically, change is unlikely to happen. Outside pressure, added to the
patient’s own reluctance to change, may simply be too powerful. With the best of
intentions, the therapist may have no ability to motivate the patient sufficiently to
make progress.
In general, the person who is doing the enabling is engaged in some form of
codependency, using wishful thinking to imagine that their support is helpful, when,
in fact, it is blocking progress. Getting the therapy unstuck may require that the
enabler change first in order for the identified patient to be ready to do the tasks of
growing. Codependency is discussed in Chap. 15.

7.14 Patients Don’t Tell Us Unless We Ask

Research has found [2] that patients tend not to tell their therapist about their nega-
tive impressions. Therapists have been found to be less aware of negative feelings
on the part of their patients than positive ones. Research also confirms that asking
patients how they are feeling about the therapist and the therapy has a positive cor-
relation to therapeutic success. Clearly it is a good practice to check in regularly
with the patient. This is an important part of becoming aware of factors that can
interfere with motivation.
References 77

Key Points
• Beginning therapists must often deal with challenging situations where
motivation is limited.
• Motivation is what brings patients to therapy and keeps them engaged even
when the work is hard.
• Hope of a better life, sessions that leave a positive feeling, the wish for
closeness, the wish for health, and secret plans to fix old problems all con-
tribute to positive motivation.
• Disappointment in therapy, negative attitudes on the part of the therapist,
outside influences, and many other factors may undermine motivation.
• Addictions and many compulsive behaviors have direct chemical effects
on motivational centers in the brain, making them particularly challenging
to treat.
• Hope is related to the SEEKING system, an important emotional network
that provides pleasurable drive toward any goal the mind chooses.
• Therapists can sometimes have a positive influence but must be careful not
to pressure patients who are resistant or to fall into a trap.
• The family systems theory of Bowen helps understand how families some-
times seem to thwart motivation.
• Enabling means “wishful thinking” and involves complex and important
dynamics.
• Therapists need to ask how they are doing or patients often won’t tell.

References
1. Bowen M. Family therapy in clinical practice. 1st ed. New York: Jason Aronson, Inc.; 1993.
p. 104.
2. Hill C. Helping skills: facilitating exploration, insight, and action. 4th ed. Washington, DC:
American Psychological Association; 2014. p. 52.
3. Norcross JC, Wampold BE. Evidence-based therapy relationships: research conclusions and
clinical practices. Psychotherapy (Chic). 2011;48(1):98–102.
4. Panksepp J, Biven L. The archaeology of mind: neuroevolutionary origins of human emotions.
1st ed. Norton Series on Interpersonal Neurobiology. New York: W. W. Norton & Company;
2012. p. 95.
A Developmental Primer
8

Why should a discussion of psychological development be considered part of a

therapist’s basic knowledge? Entrenched dysfunctional patterns are particularly
shaped by the developmental environment at the time they are first formed. Being
alert to development helps the therapist better understand the patient’s experience.
For example, a patient who screams at the therapist is not being impolite but is more
likely reexperiencing something more like the catastrophic feelings of a small child.
Discerning developmental issues and problems means being able to see behind
shame and EDP avoidance into the mind of the nonconscious problem solver.

8.1 Developmental Theory

Note that developmental psychology is a large subject and there are many theo-
ries and points of view. The one that underlies this discussion is meant to be
useful for clinical psychotherapy. For that reason it is focused on a small number
of key developmental challenges that, when not successfully traversed, account
for the most common types of pathology. The eclectic view of development
behind this description represents a mixing of clinically useful concepts from
many sources. The notion of behavioral patterns or schemas is borrowed from
Jean Piaget. The idea of inborn temperament comes from modern research.
Freudian drives are traded in for thinking of a motivational system based on posi-
tive and negative affects programmed by evolution. On top of a nonverbal world
of procedural knowledge, concepts in verbal form take their place along with the
internalized values that generate the pride, shame, and guilt. Values, along with
likes, dislikes, strengths, and weaknesses, shape much of what we experience as
our identity.
One theoretical position important here is that development is not seen as made
up of “stages.” Patients who have developmental deficits usually have them in one
area, while other areas are normal or even show unusual abilities. Furthermore,

© Springer International Publishing AG 2017 79

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_8
80 8 A Developmental Primer

deficits can be made up at any chronological age and often are in therapy. This is
why we focus on specific developmental challenges and their consequences rather
than overall levels of development.

8.2 Knowledge Brings Compassion

We will see that one of the most challenging periods of development comes around
age two, when patterns associated with narcissistic and borderline personality dis-
orders are often formed (see number two, “attachment and separation,” below).
These patients, in their unending quest for emotional survival, put their therapists to
some of the most severe tests. A therapist who understands the feelings of a small
child will have a better perspective and be far more capable of helping such a patient
than one who reacts as if the patient was fully adult.
Narcissistic patients can’t keep themselves from devaluing the therapist.
Borderline patients, early on, will form a strong positive relationship and then sud-
denly treat the therapist as an enemy. They need a therapist who, like a rock on the
shore, stands firm under the assault of stormy waves. Therapists are humans and can
easily take the patient’s assaults and criticism personally. Reframing the patient’s
underlying experience as a life-and-death struggle allows the therapist to manage
his or her own inner child and stay relatively calm. More important yet, understand-
ing leads to compassion. The therapist, despite the patient’s powerful and personal
attacks, can maintain a compassionate feeling for a desperate human who may be
unable to acknowledge responsibility for the behavior.

8.3 An EDP Most of Us Have

Why do patients and people in general have trouble acknowledging and facing their
developmental deficits? All of us can remember how good it felt when we were
young to be told how “grown-up” we had become. On the other hand, one of the
most painful taunts was being called a “baby.” We all develop a strong value for
maturity and self-control. The entrenched dysfunctional pattern that most of us pos-
sess is avoiding the shame that comes with acknowledging our immaturity. Usually
our nonconscious problem solver offers up some rationalization to explain away our
immature reactions. We try to disguise and justify them as adult ones determined by
the situation, rather than admitting to having areas of immaturity.
Instead of acknowledging our young, hurt feelings, we may turn anger toward
the person who pointed out a weakness. Alternatively, we may change self-criticism
into self-deprecating humor. Or we may try not to show our feelings or talk about
them. Since many of our troublesome EDPs represent failure to advance from an
earlier age, this tendency to avoid acknowledgment of immaturity is a serious block
to the work of psychotherapy.
Once again, understanding leads to compassion. When a 3-year-old announces
proudly that she put her pants on all by herself, and we notice that the pants are
8.5 Working with Rationalizations 81

backward, we feel warmth, not judgment. In the same way, when an adult patient
exhibits an immature reaction, understanding the context from which it came natu-
rally allows us to feel compassion. Furthermore, we are able to model that attitude
for the patient. The therapist’s understanding and warm demeanor help the patient
accept as well, and acceptance opens the doors for change.

8.4 Young and Adult Thinking Mixed

The EDP concept depicts consciousness as a frame into which the nonconscious
problem-solving mind injects feelings, impulses, and thoughts. The mental function
we identify as our own self also contributes thoughts, and there are no labels or
signs to indicate which contents belong to the self and which ones come from the
nonconscious problem solver, seeking to avoid negative affects. Typically, our
stream of thoughts is a mixture of irrational and rational, young and adult.
It is only when thoughts come into consciousness that we are able to discern their
immaturity and see logical contradictions. As long as problem-solving and feelings
remain outside of consciousness, conflict and contradiction are not perceived.
Formal logic is applied only in the realm of awareness. In practice, what this means
is our consciousness receives a jumble of ideas. Only when they arrive in the frame
of consciousness do we begin to feel some discomfort about inconsistencies and try
to rationalize our way to a more harmonious whole.

8.5 Working with Rationalizations

When humans experience ambivalence about a person, the conscious mind will
merge the conflicting ideas in an attempt to find a single truth. Yes, she is a good
person, but sometimes she says things I don’t like. From the point of view of the
therapist, it would be much more productive to break this down into its original
components: I hate her, and I love and value her at the same time. We can look at
each side independently, the way it existed in the nonconscious mind, and begin to
work to resolve the problematic side of the ambivalence.
As with immaturity, most patients are naturally ashamed of inconsistencies. In
addition, they may have values that prohibit certain thoughts, such as criticism of
parents. The shame resulting from judgments based on these values can be another
trigger for EDPs, that is, behavior patterns that work to avoid shame by denying or
covering up the “improper” mental contents. These maneuvers appear as a natural
tendency to rationalize contradictions and to eliminate thoughts that go against our
values. A good deal of patient education and work with shame goes into helping our
patients recognize the value of expressing their raw, extreme thoughts and feelings
out loud where they become subject to healing.
In doing this work, it is helpful to identify some thinking as “young.” This avoids
the pejorative words “immature” and “childish.” A patient who insists on perfect
looks, believing that this is the only way to find love, is exhibiting very young
82 8 A Developmental Primer

thinking. Bringing such a black-and-white, childlike belief under question is a deli-

cate operation requiring tact. Labeling this as “young” and identifying the idea as
belonging to an earlier age and a less-developed mind will help. Education accom-
panied by a warmhearted and compassionate attitude toward the child part of the
adult can allow the patient to see the immature thinking without self-criticism and
shame.

8.6 Developmental Challenges

Development happens when we encounter and face new situations and challenges.
This is when we try new patterns, which feel strange and anxiety provoking at first.
While some new acquisitions depend on having achieved other milestones before,
many threads are independent. Development does not run in parallel in all areas
simultaneously. It is common for development to be stopped in one area of life and
to proceed in others. For this reason, it is better to think of patients’ development
being arrested by inability to solve a particular challenge, than to think in terms of
overall phases or stages.
Similarly, development should not be tied to specific ages. There may be a typi-
cal age at which a certain challenge is encountered, but for those individuals who do
not master it at that age, the work can be done at any point thereafter. In fact, as we
will see, far more 2-year-old behavior is carried into adulthood than one would
imagine, and it may or may not ever be resolved.
Resolution of developmental issues is one of the most important functions of
psychotherapy. As indicated earlier, developmental arrest is yet another form of
EDP, one in which avoidance of difficult feelings associated with a developmental
challenge is manifested by failure to try out new behaviors and to progress.
With the list below, we will briefly survey some of the most critical developmen-
tal challenges and the adult pathology that may result from difficulty in meeting
them.

8.6.1 Self-Other Differentiation

Long ago, I observed the interaction between a mother and her schizophrenic son.
She reported with satisfaction that all she had to do was say wistfully, I wish I had
a newspaper, and her son would go to fetch one for her. Asking him directly would
have been an acknowledgment of his separate existence, which seemed hard for her.
Some time later, the son remarked with subtle irony, You trust your mother, but you
cut the cards. While much of his illness was probably biological, his mother showed
a clear lack of respect for his autonomy. On the son’s part, there was a lack of con-
fidence in the safety of asserting his own will. A delusion neatly solved this prob-
lem. He believed that he could teach his body to do without any food. Employing a
very primitive logic, he thought if he could teach himself no longer to require food,
8.6 Developmental Challenges 83

he would be able to escape his mother’s influence and possess his own separate life.
In order to implement this belief, he set about starving himself until he had to be
hospitalized.
Patients who suffer from schizophrenia and related conditions often have trouble
with self-other differentiation. They tend to perceive that another’s wishes, like
fetching the newspaper, constitute an imperative and a threat to a shaky sense of a
right to exist as a separate person. They may have delusions about being controlled
by others. They may feel attached to their own feces or to idiosyncratic mannerisms
as if these were essential parts of the self. They may want others to merge into their
personal world with them. We can link these phenomena together as the develop-
mental challenge of gaining confidence in the right to be separate. One adult mani-
festation can be difficulty with trust along with an unrealistic insistence on autonomy
and the right to make unwise decisions.
The breadth and depth of these problems, and the fact that they deal with
developmental abilities that are acquired very early, suggest that they originate
well before age two. Does this mean that schizophrenia is purely a problem of
mind? Probably not. A more likely explanation is something like the lack of a
biological “stimulus barrier” such that experiences needed for development of a
boundary between self and other may be too intense for important learning to
take place.
The value of a developmental perspective in working with such patients is in
recognizing their marked vulnerability in areas involving the boundary between the
patient’s will and those of others. The right to a self needs to be acknowledged and
supported consistently and scrupulously. Any potential interpersonal conflict has to
be dealt with very gently. A therapeutic relationship in which these issues are han-
dled with utmost respect and predictability can be reparative over time.

8.6.2 Attachment and Separation

The period from 8 months to about 3 years is challenging in that children first
become upset about the absence of the caregiver but are cognitively unable to pic-
ture her in another place or grasp the idea that she will return. For the child, this
absence presumably feels absolute and therefore potentially catastrophic. Children
use the resources available to cope with this inevitable stress.
Schemas identified by attachment research represent different ways of coping
with separation around age one. These will be described in more detail in Chap. 14,
in the section on nonverbal schemas. They may leave a lasting stamp on the way of
relating shown by adults and can have a profound effect on the unfolding of the
therapeutic relationship. Securely attached patients have an easy time attaching to a
therapist and forming an effective alliance. Those with any of the three remaining
patterns, avoidant attachment, ambivalent attachment, and disorganized attach-
ment, may have to learn relationship skills that allow for a context of connection
before they can tackle their other EDPs.
84 8 A Developmental Primer

8.6.3 Power Struggles

Age two is usually the time when children exhibit strong will and the ability to do
many things their caregiver would prefer they not do. While a sense of omnipotence
is typical of the 1-year-old, power struggles are the hallmark of the “terrible twos.”
During the first 2 years, the child has developed an assumption that the mother’s
will and the child’s will are one and the same. The child might think, being able to
run and jump delights me and delights Mommy just as much. The occasional disap-
proval doesn’t seem to affect this delight of being at the center of the universe,
emperor of the world. Some theorists feel that the absence of being troubled by such
conflict is because the mental schema of negative self and negative other exists
separately from schemas representing a positive self and other. The two are experi-
enced as if they were not related.
Suddenly, around two, the child seems to experience a shock. The mother who
says “no!” is the same one upon whom the child is dependent for love and for life
itself. The all-positive giving relationship is now threatened by discord. As the child
fights for what he or she wants, rage takes over, along with the fear of being utterly
alone and helpless. This conflagration of emotion is the classic temper tantrum: a
hopeless, terrified rage experienced on a scale of life and death. Much of the hard
work of the difficult year ahead concerns reestablishment of confidence that the
child is still lovable in spite of a disagreement and even when the mother is angry or
upset.
Under good conditions, the caregiver picks up the raging toddler in a loving hold
that prevents the child from doing harm. The flailing goes on for a few seconds to a
few minutes and then turns to tears. With the appearance of tears, the rage and fear
have abated enough for the child again to be receptive to being loved. With many
repetitions, this experience is internalized in the form of an expectation that rage is
finite and does not destroy love. When that happens, the schema of good self–good
mother has become merged with the schema of bad self–bad mother. As this new
way of perceiving people begins to extend to other individuals, the child’s world
incorporates a three-dimensional view of humans, who can have positive and nega-
tive aspects simultaneously.
For children who experience this difficult passage as too overwhelming to navi-
gate, two characteristic forms of pathology can become established.

Pathological Narcissism Perhaps the caregiver gives in each time, letting the child
have his or her way. Then the tantrum is avoided but so is the learning that goes with
it. The result is the narcissistic need to always win. Or perhaps the caregiver retali-
ates or punishes the child, who then learns to deny having “lost” the battle of wills.
Either way, the prospect of losing a battle remains unknown and terrifying.
Narcissistic personality disorders (at least their psychological component) are the
result of the child resolving, at any cost, to win every battle with the primary parent,
so as to avoid the intolerable pain of being crushed. The child learns to manipulate
others so as to retain at least the illusion of having won. He or she must build and
maintain a belief in being perfect and adored in order to ward off bad feelings. Any
8.6 Developmental Challenges 85

disagreement or slight is dealt with by denigration and rejection of the other. By

tricks of the mind, the horror of rejection by a needed other must be avoided. The
cost is huge, as maintaining this illusion becomes the center of the child and later
the adult’s life.
The need to win and to receive praise may have a positive effect, encouraging
development of real skills as well as those manipulative ones that force others to
fulfill the narcissistic person’s sense of “entitlement.” People with character disor-
ders of this type often gravitate to positions of great power and control in the world,
though they are not as effective as their healthy counterparts.

Borderline Pathology Here the child retains the 1-year-old cognitive divide such
that negative interactions with the mother are distinct and separate from positive
ones. Psychodynamic therapists call this “splitting,” in which relationships are iden-
tified as purely positive, related to a positive image of self and other or negative and
related to a negative view of self and other. Characteristically, people who exhibit
“borderline personality organization” [4] may spend their lives categorizing others
as either best friends or dangerous enemies with no in-between. There can be no
conflict with a “best friend,” but the perception will suddenly switch to “enemy.”
This is highly disruptive to close relationships, leading to a social life that is full of
love, hate, and drama. The therapeutic relationship is not spared and soon enters
into the same alternation between love and hate. Working with patients like this
needs to start with a deep and compassionate understanding of their internal world
and limitations.

8.6.4 Crime and Punishment

The next critical developmental challenge is dealing with a newly functional but
immature conscience that understands only absolutes and has no comprehension of
misfortunes that are no one’s “fault.” We can identify this phase at age three, when
children understand the difference between good and bad and want to fulfill an
internalized ideal of being good. The development that ushers in this phase is the
conscience. Starting at about 18 months, myelination of the prefrontal cortex makes
it possible for internalized ideals to form [7]. The conscience does not become fully
functional until around three. Then the child begins to make judgments about behav-
ior and exert some self-control in order to feel pride and avoid shame or guilt.
As the conscience begins to function, a violation of an internalized value is expe-
rienced as an absolute. Having not yet learned to forgive him or herself, the child
must find some other solution to such a terrible break. The answers are simple. The
wrong must be righted, or compensated for, or the culprit punished. One solution is
for the child to accept punishment and take cues from the caregiver about whether
the punishment has been sufficient. Under good conditions, the child gradually
learns that mistakes are forgivable and that perfection is not necessary to be lovable.
A less healthy solution is to become “very good,” prematurely subjecting the self to
expectations that are difficult or impossible to fulfill.
86 8 A Developmental Primer

The more problematic situation is where the parent or caregiver fails to fulfill
duty. The child, now capable of seeing that the parent has done something parents
should not do, for example, hitting the other parent, is placed in a terrible dilemma.
Either esteem for the parent is harmed, leaving the child without a competent par-
ent, or there must be some other solution. What children come up with is that hope
can be salvaged by blaming the self for what happened. Self-punishment becomes
the solution to problems the child did not create. Self-condemnation to solve this
problem is one pathway to depression. When these are applied with force, the feel-
ing is one of sincere self-hate. The individual looks at him or herself and sees only
unworthiness and the need for banishment from love.
Another solution is to wait for the wrongs to be righted. This is the source of
what I will call “hidden agendas” described further in Chap. 14. The child holds
onto the belief that the parents might one day acknowledge their wrongdoing or
may someday take care of the duty that was forsaken. Not infrequently these hopes
are kept intact well into adulthood in order to avoid facing the dire feeling of failure
associated with parental wrongdoing.
The healthy outcome for parental failures is an honest assignment of responsibil-
ity and acknowledgment of whatever damage has been the result. The skill of for-
giving is learned from healthy caregivers over time. These developmental
accomplishments, if they don’t happen in childhood, can be achieved in therapy,
especially making use of a positive therapeutic relationship.

8.6.5 The Rules

Starting around age four, children learn that there are rules to follow in life. Along
with a still-rigid conscience, the rules may be taken quite literally as absolute imper-
atives. Having rules to follow promises to bring order and predictability to life. If
you follow the rules, you will be safe and loved. This thinking lasts some time and
around age eight, for example, children will argue interminably over a possible
infraction of the rules of a game.
For children who have to deal with an unpredictable and chaotic home, rules
appear to present a solution. Children sometimes take it upon themselves to fol-
low the rules scrupulously in the belief that if they do so, others will feel obli-
gated to follow them as well. By adolescence, healthy young people learn that
rules alone do not have so much power. People must often be motivated to follow
them. More secure young people learn to exert influence on others and use rela-
tionships to have needs met. Those who have had trouble traversing this develop-
mental challenge may hold onto the belief that following rules should result in an
orderly and controllable world. As adults, they tend to overemphasize rules and
may express endless frustration at the failure of those around them to do the
“right thing.”
8.6 Developmental Challenges 87

8.6.6 Someday

The period around age five is one of rapidly developing cognitive abilities. Freud
saw it as a time when relationships increased in complexity from two-person dyads
to three-person triangles reflecting issues of jealousy. Around the same time another
important cognitive advance takes place, the development of the sense of time
future. At about five and a half, on average, children begin to be able to conceive of
life as an arc, stretching from the present far into the future [2]. This is the age when
children become interested in fairy tales that start with “Once upon a time,” and end
with “happily ever after.”
Prior to this time, emotional problems must generally be solved in the present.
Possessing time future at last gives the child a way to save hope by solving today’s
problems “someday” in the distant future. Piaget says it eloquently: Grasping time
is tantamount to freeing oneself from the present [6].
For example, for the younger child, the distress of being small and weak can only
be solved in the present by denial or in fantasy by identifying with a superhero or
some other powerful figure. A little later, the ability to imagine a solution “some-
day” brings tremendous new power. It allows hope. Hope gives solace in the pres-
ent, an escape from the powerlessness that has caused pain for the child up to this
point. This projection into the future allows freedom from the limitations of today.
In the future, a child can be invincible, beautiful, clever, and infinitely lovable.
The second advantage of someday solutions is that, unlike hidden agendas, they
don’t require changing the adults, at least for now. The focus is on the self, rather
than changing others. The child can form a firm intention of becoming different in
some way so as to solve whatever problem is troublesome today. This makes some-
day fantasies fundamentally different from EDPs that rest on changing others.
Under ideal conditions, someday fantasies are the first answers to the question,
What do you want to be when you grow up? As long as they remain in conscious-
ness, they can gradually be modified through a growing appreciation of reality and
may end up as a plan for life and even a vocation. These dreams are tremendously
powerful in providing the drive for moving forward with life.
While the successful outcome is for the fantasy to stay in consciousness and to
evolve over the years, it is also possible for someday fantasies to run into trouble with
the conscience. For example, a boy was touched in a sexual manner by his mother at
this age. A yearning was awakened and took on great power. He developed a wish for
more physical involvement with his mother, but this was against the values internal-
ized in his conscience. All of this dangerous material was suppressed from conscious-
ness. When he came to puberty, he found himself sexually inhibited with no idea why.
If he thought of being sexual with a young woman, he would experience a great deal
of anxiety. Yet, he wished for a heterosexual relationship. It took years of therapy and
an intensive weekend of eye movement desensitization and reprocessing (EMDR) to
bring his trauma to consciousness where his feelings could be resolved.
88 8 A Developmental Primer

8.6.7 Later Childhood

A developmental challenge that often occurs in late childhood through adolescence

is bullying by other children. Bullying tends to stem from an unhealthy coping
mechanism (EDP) in which some children and adults use power over others to avoid
their own painful feelings of weakness. Their victims tend to be children who have
less self-assurance and may be more sensitive to being humiliated and made to feel
powerless. Prolonged or repeated bullying leaves the victim, often vulnerable to
begin with, with a seriously damaged sense of self.
The period from age eight until perhaps eighteen is a time for the development
of identity and a sense of self-esteem or value. The child transitions from parents as
the sources of personal value to gaining self-worth from accomplishments and the
opinions of outsiders. Especially during adolescence, the young person’s identity is
in flux, making bullying all the more damaging.

8.6.8 Adolescence

We can learn much about adolescent development from a remarkable “experiment

of nature.” When young people smoke marijuana on a regular basis, their emotional
growth and development often stops. Research suggests problems in brain develop-
ment [1, 5]. When they come to therapy in adulthood, their level of maturity is usu-
ally that of a child at the age when they started smoking. Development happens
when we test ourselves with real challenges. Marijuana smoking and the culture
surrounding it in the United States make a virtue of avoiding challenges. Young
people call this a “laid-back lifestyle.” Users tend to remain unformed, untested, and
with little knowledge of the depths of their own being. The result is a chance to see
clinically what is missing and, by extrapolation, what developmental acquisitions
should happen during adolescence.
Making hard choices during adolescence is how we learn our true likes and dis-
likes. Meeting challenges is the way we learn our strengths and how we fare under
pressure, as well as how we learn self-control and discipline. Exercising these skills
teaches impulse control. Forming strong relationships and exposing our deep thoughts
and feelings allow us to learn more about ourselves and how we can relate to others
intimately. All this leads to a transition from values borrowed from our parents to
values that we “own,” to the point where we can become ready to die for them.
The transition from the protection of a family to becoming a freestanding human is
truly anxiety provoking. Adolescents rarely admit to this anxiety or experience it
directly. More often what we see is an alternation between maturity and regression.
Typical is what I call “the adolescent dance.” A more extreme form was described in
the last chapter as “cat and mouse.” This minor version is almost universal. The ado-
lescent does something irritatingly irresponsible like putting clothes on the floor. This
provokes the parents. They are already ambivalent about letting go of the happy pre-
adolescent years when the child was well behaved and obedient. Usually one parent is
strict and the other more lenient. The strict one insists on obedience and responsibility.
The adolescent objects strenuously, and the lenient one takes the adolescent’s side.
8.6 Developmental Challenges 89

Once again, the adolescent’s ambivalence has been realigned so the conflict is
now between the young person and the strict parent. This is more comfortable for
the adolescent but puts tremendous strain on the family. The parents argue and
become even more polarized as the lenient one becomes softer to compensate for
the strict one, and the strict one becomes more strict to compensate for the excessive
lenience of the other. Having transferred the stress onto the parents, the adolescent
does what feels best and pays little attention to the job of maturation.
The family tension can be maintained to a greater or lesser degree until the ado-
lescent finally finds some success and stability. At that point, anxiety dissipates, and
there is no longer such a need to act irresponsible or provoke. Both the parents and
the young person rediscover respect for one another as they become co-adults.
What marks the end of adolescence? When young people begin to focus more on
their own lives than on conflict with parents and authorities, we can conclude that
adolescence has ended and adulthood has begun.

8.6.9 Young Adulthood

Adolescence seems to stretch ever further into the twenties and beyond. Young adult-
hood is often a time of life-shaping decisions. Young adults make bold and fearless
decisions that determine their future. These can be spectacularly successful or disas-
trous. Studies show that the brain at 18 to 20 is still not fully mature, especially in the
frontal cortex where judgments are made [3]. This may actually help with adaptation to
a changing world, but it also means costly mistakes. Young adults’ decisions can be free
from influence and limitations due to unfinished business from the past. In many cases,
the possibility is opened up of taking a fresh new and healthy direction.

8.6.10 Adulthood

As time goes on and adults settle into a more stable life, old unhealthy patterns are
likely to reassert themselves and take hold. Perceptions based on the past may creep
into the relationship with a spouse. Unfulfilled wishes from early life may appear
again. These currents merging with fresh new ones create the rich tapestry of adult life.
As we engage fully with the world, we are challenged with navigating the realities
of life, starting with an understanding that is still largely based on childhood experience
and fantasy. We choose spouses based on early templates and then have to learn to
manage a real relationship so that the needs of both parties are met. We enter the work-
force, not knowing what assumptions we are taking for granted. Soon these become
manifest, and we must adjust to reality. Bosses are not like good parents. They are as
incompetent as we are. Kindness and generosity are not necessarily accepted and may
be punished. The rules we hoped would bring order to the world are not followed. We
must learn to accept these gross imperfections and find our way around them so that we
can contribute what we have and receive what we need. These challenges present fertile
ground for old and new entrenched dysfunctional patterns, as well as for development
of new modes of healthy, resilient functioning.
90 8 A Developmental Primer

8.6.11 Old Age

Old age presents a new developmental challenge. Losses begin to mount up. Older
adults have no choice but to adapt to loss of loved ones, career, friends, home, physi-
cal capability, and, finally, loss of life itself. These changes present enormous chal-
lenges to the individual’s coping ability. The adage that one can’t teach an old dog
new tricks is not true. The majority of older people adapt to these extreme changes
with grace. On the other hand, limitations in coping are likely to manifest them-
selves at this time.

Key Points
• The relevance of psychological development to clinical practice arises pri-
marily from a few developmental issues, which, when not traversed suc-
cessfully, form the basis of much common pathology.
• For the clinician, rather than thinking in terms of stages, developmental
problems are better understood as specific areas of arrest, where there may
be compensatory hyperdevelopment in other areas.
• Taking an interest in how young people experience life not only helps the
therapist understand pathology but helps develop compassion for the
patient’s immature ways.
• The stream of thoughts from outpatients is often a mix of rational and irra-
tional, mature and immature. Therapists do well to cultivate an ability to
hear and identify both.
• Fortunately, repair of developmental arrest happens when the individual, at
whatever age, picks up the trail of new experiences, processing emotions
as progress is made.
• The chapter describes 11 developmental challenges through the life cycle,
including:

1. Self-other differentiation
2. Separation
3. Power struggles
4. Crime, punishment, and the conscience
5. Later childhood and “the rules”
6. Someday and the dimension of time
7. Later childhood
8. Adolescence
9. Young adulthood
10. Adulthood
11. Old age
References 91

References
1. Ashtari M, Cervellione K, Cottone J, Ardekani BA, Kumra S. Diffusion abnormalities in ado-
lescents and young adults with a history of heavy cannabis use. J Psychiatr Res. 2009;43(3):
189–204.
2. Gesell A, Ilg FL, Ames LB, Bullis GE. The child from five to ten. Oxford: Harper Bros; 1946.
p. 87.
3. Giedd JN, Blumenthal J, Jeffries NO, Castellanos FX, Liu H, Zijdenbos A, et al. Brain develop-
ment during childhood and adolescence: a longitudinal MRI study. Nat Neurosci. 1999;2(10):
861–3.
4. Kernberg O. The treatment of patients with borderline personality organization. Intl J Psycho-
Analysis. 1968;49:600.
5. Meier MH, Caspi A, Ambler A, et al. Persistent cannabis users show neuropsychological
decline from childhood to midlife. Proc Natl Acad Sci U S A. 2012;109(40):E2657–64.
6. Piaget J. The child's conception of time [L'épistémologie du temps]. Pomerans AJ, trans.
New York: Basic Books; 1969.
7. Schore AN. Affect regulation and the repair of the self. 1st ed. New York: W.W. Norton &
Company; 2003. p. 186.
Part II
What Therapists Do
Conducting an Initial Assessment
9

The initial assessment in psychotherapy has a lot going on. Let’s break it down to its
simplest elements.

1. Establish a good relationship with the patient. A patient who feels safe and con-
fident in the therapist will provide the greatest depth and clarity of information,
which is what we need most.
2. Learn in depth and detail what negative feeling or positive desire has driven the
patient to seek help. This is the energy source that will power any further work
together, so we need to pay very careful attention and learn as much as
possible.
3. Gather enough data to formulate a plan to give a clear picture of what to expect
so the patient can make an informed decision about whether to proceed.

Beginning with the most generic approach, an unstructured, open format, we will
see how a natural conversation is one of the most effective ways to gather the great-
est quantity and depth of information. The therapist will learn far more this way
than through any attempt to follow a preset format. The therapist’s main tools in
conducting the interview will, fortunately, be skills already acquired simply by
being human.
The first tool is our knowledge of social interaction. Most of us are skilled in this
area through life experience and natural empathy. This allows us to anticipate how
the other person will feel and to learn more specifically as we go how to make the
interaction feel comfortable and safe.
The second tool is our curiosity. People are curious about other humans. As ther-
apists, we have an unusual mandate to ask about things we would not dare to ask in
ordinary social circumstances. Curiosity will be our most accurate instrument for
sensing what we don’t yet know and will help guide our inquiry.

© Springer International Publishing AG 2017 95

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_9
96 9 Conducting an Initial Assessment

9.1 Do We Need to Ask Why?

The subject of our assessment interview is dysfunction, that is, a perception that the
patient is not reacting to circumstances in as healthy a way as possible. Beyond that,
our curiosity wants very much to ask not only what is wrong but why. But do we
really need to know? Wouldn’t our planning be just as effective, based solely on the
nature of the dysfunction? Many therapists feel that understanding why has a fun-
damental role in psychotherapy; however, there is actually some controversy over
this question.
The reason is that we can never be absolutely certain about why. Since the dys-
functions we address with psychotherapy are the creation of the nonconscious prob-
lem solver, we have no window into exactly how and why they were created. Skinner
felt that our educated guesses are too uncertain to be considered scientific and are not
necessary anyway [2]. What follows is an argument that our inquiries into the rea-
sons behind pathology are, in fact, an essential part of the healing action of
psychotherapy.
According to the affect avoidance model, irrational behaviors and other dysfunc-
tional patterns represent attempts to avoid difficult feelings. Each entrenched dys-
functional pattern is composed of both an avoidance mechanism and a problematic
feeling. Stable resolution of EDPs requires processing the feeling as well as chang-
ing behavior. In order to process feelings, as detailed in Chap. 5, they must be acti-
vated or brought into consciousness as affects that the patient can feel. Skillful
exploration is the simplest and most universal way to bring feelings into awareness
so as to allow their activation. Furthermore, the detoxification or healing of these
feelings also requires a context in which their threatening nature is “disconfirmed.”
The therapeutic relationship is, once again, the simplest and most universal way to
supply such a disconfirming context.
In the area of trauma, research on cognitive-behavioral therapy confirms that
detailed exploration of events leading to post-traumatic stress disorder (PTSD) is
one of the most effective ways to bring feelings to consciousness where they can be
processed. As the behavioral tradition has embraced exposure therapy for healing
the emotions of trauma, there has been increasingly wide acceptance of the impor-
tance of emotion in many types of pathology and treatment [1].
Thus, careful and detailed exploration of pathology and its origins serves to bring
about the two recognized conditions for emotional healing: activation of the affect and
a disconfirming context of safety and empathic connection. Generic kindness without
examination of the circumstances behind a reaction often lacks the vividness needed
to evoke affects at their full intensity. For this reason, asking why not only satisfies our
curiosity but is an important part of the processing of difficult emotions.

9.2 Working with Uncertainty

How do we form confident guesses about something we can’t know directly, the
work of the nonconscious problem solver? One of the most highly developed abili-
ties of the human mind is anticipation. When we anticipate that a certain thing will
9.3 Beginning the Session 97

happen and it does not, we react sharply and adjust our understanding. Starting with
our empathic sense of anticipation, we learn from each of the patient’s reactions.
Over time, by forming expectations and observing what happens, we build an
increasingly sophisticated “theory of mind” to describe how the black box of the
patient’s mind will react. Here are the main indicators:

1. Confirmation: When we expect a certain reaction, for example, tears in response

to something we might say, we learn whether our hypothesis was correct.
2. Resonance: Sharing our thinking with the patient, we get feedback about whether
our ideas “resonate” or are aligned with the patient’s inner experience.
3. Flow of new material: When our understanding is on target, we can expect that
the patient will produce a flow of new and fresh material.
4. Therapeutic results: Successful resolution of dysfunction is the ultimate test of
our accurate empathy and understanding.

By making a practice of articulating to ourselves what we think is going on and

what will happen next, we are constantly building our knowledge of both the patient
in front of us and of patients in general. This practice will soon build a degree of
confidence in our thoughtful guesses. Honed over years, the ability becomes increas-
ingly sophisticated and useful in our work.

9.3 Beginning the Session

While the guiding principle of empathy should get us off to a good start, it may be
useful to give some concrete suggestions. Here is a basic formula for conducting an
initial session:

1 . Set the patient at ease according to social conventions for the culture and context.
2. Any time the patient shows or expresses discomfort, acknowledge that and take
an interest in understanding what the patient is feeling.
3. Address the patient’s fear of the unknown by answering basic questions the patient
may not feel comfortable asking. Some of the patient’s questions might be:

• Who is the therapist?

• Where should I sit?
• What are your credentials? How do you fit in this practice?
• What do you already know about me?
• How long will the session be, how much will it cost, and what will be accom-
plished? It isn’t necessary to be wordy or overly detailed. “We’ll talk for an
hour and develop a plan about what to do next.”

4. During the initial assessment, the therapist will be guiding the interview with
questions. Later, the patient will learn to take the lead, but for now, questions are
a way to show the patient how to let the therapist into his or her world so as to
understand as much as possible.
98 9 Conducting an Initial Assessment

5. By the end of the first meeting, it will be time to develop a simple agreement,
outlining agreed-upon goals, what each of you will be expected to contribute,
and how it will help the patient. This might simply cover an assessment period,
crisis situation, or it might be the beginning of a long-term treatment contract.
For example, “Let’s talk like this for one or two more sessions. Then we’ll have
more understanding and will be able to decide how best to help you.”

9.4 Show, Don’t Tell

Beginning therapists tend to be too wordy. Few of the therapist’s carefully chosen
words will be heard by the patient, especially in the first session, so it is better to
keep what we say very simple. More importantly, the therapist’s actions will do
most of the communicating and will have a strong effect on the relationship and the
treatment that follows.
The therapist’s attentiveness will make all the difference to the patient. All of the
suggestions given above are actual ways to demonstrate genuine interest in the
patient’s feelings and concerns, whether spoken or not. That is the essence of
empathic attunement.

9.5 Listening for Style and Content

The mind expresses itself in everything it produces. Its nature as a “metaphor

engine” means that any product of the human mind can suggest or stand for some-
thing else. The therapist should be listening both to content and to the manner of
communication, as well as noticing other, seemingly extraneous products of the
mind such as posture, movement, appearance, affect, facial expression, etc. As
observations come in, we are asking ourselves what they might mean, especially in
relation to other things we have learned.
Changes in the manner of communication can suggest emotion or discomfort
associated with a particular subject. Personal style can be shaped early in life to
express a meaning or ward off some uncomfortable feeling. All of these character-
istics carry meaning and may be important in understanding what agenda the non-
conscious problem solver or the inner child is bringing to the session.
Content, that is, the actual story, is the most helpful in revealing precisely what
emotions might be causing trouble and how. Of course, the way the patient’s words
reveal such information can vary greatly. One thing can be a metaphor for another.
The therapist’s imagination, empathy, and previous experience are the main tools
for deciphering such meanings, subject to testing. Noticing the material that came
just before a reaction or blockage in the flow is an example of how to glean under-
standing from the conversation.
Making sense of style and content means imagining why the patient might have
said, dreamed, or fantasized a particular thought or taken a particular action.
9.7 Following Leads 99

Technophiles call this “reverse engineering,” which means starting with the solution
and then seeking to understand the problem it was intended to solve. This is, in fact,
a creative process. It requires imagining what circumstances, when passed through
the black box of the nonconscious problem solver, might explain the content that is
produced in the interview.

9.6 Formulating Questions

Questions are particularly important in the initial interview. Here, the therapist must
be largely in charge because the patient can’t be expected to know how best to bring
the therapist into his or her personal world. This is where the therapist’s questions
are teaching tools to show the patient the kinds of information and ways of present-
ing it that are the most helpful. The patient will be listening to and learning about
the therapist and the process. Both participants will benefit from adjusting to each
other so as to give as deep and revealing an understanding of the patient’s mental
life as possible.
Traditional teaching says there are “close-ended” and “open-ended” questions.
Questions are verbal picture frames that limit the area to be viewed and come in
infinite shapes and sizes. Interestingly, the broadest and most challenging question
is silence. Assuming that the patient understands what is expected, then silence is a
request to say anything with no limit. This is the most open-ended of all questions
and the most difficult. Thus, when we put a question into words, we are, in effect,
narrowing the field of possibilities.
Too wide a field is frightening, and one that is too narrow feels confining.
Questions can also be abstract or concrete. Abstract questions leave more room:
“Tell me about yourself.” Whereas concrete ones narrow in: “How did you spend
your day?” People with higher education are often more comfortable with abstract
questions, yet others may respond better to concrete questions. Abstract questions
can invite intellectualization, while concrete ones make it easy to give unrevealing
answers. Feeling is especially associated with concrete details. The word abstrac-
tion comes from the Latin to “draw away.” Often a more abstract question means
drawing an idea away from its associated details and feelings, which is not what we
want. Paradoxically, “How do you feel about...” is much more likely to elicit an
abstract, unfeeling answer than the concrete, “How did you react when...?” Above
all, questions reveal how well the therapist is listening and tell the patient whether
it is safe to reveal more.

9.7 Following Leads

While shaping the interview through questions, the therapist’s ability to follow the
patient’s spontaneous leads is the main indication of being empathically attuned.
A “lead” is anything unexpected coming from the patient. These are bits of
100 9 Conducting an Initial Assessment

information the patient is daring to reveal over and above what is asked. Curiosity
will naturally be alerted to both positive leads and unexpected gaps where some-
thing is left out.
The back-and-forth interview that results sounds like an ordinary social conver-
sation, except that therapist has a mandate to be more probing. As long as therapist
curiosity is motivated by the goal of better understanding, it is an appropriate and
very helpful guide.

9.8 The Patient’s Mind Has the Map

In every healthcare interview except psychotherapy, the professional has the

road map. There, the interview is aimed at navigating a preexisting decision
tree. The limited number of possible explanations for a given symptom gener-
ates questions aimed at deciding, which is the most likely among a few possi-
bilities. In psychotherapy the way to obtain accurate information quickly is
quite different. Here, the patient, not the professional, has the road map, and the
possibilities are as limitless as the nonconscious problem solver’s imagination.
Furthermore, the map may not be available in conscious awareness, so therapist
and patient have to engage in joint discovery. The patient’s wish to feel better
and the therapist’s demonstrated willingness to listen will both contribute to
success.

9.9 The “Chief Complaint”

In the first session, the main topic is what is most troubling to the patient. In
medicine this is traditionally called the “chief complaint.” This is the problem or
issue that causes the need to feel better and is the main engine driving the inter-
view and any therapy to follow. The conversation should focus on this issue until
it is thoroughly understood. The importance of this inquiry can’t be overempha-
sized. Even if the patient, like Jack in the first chapter, has no idea why his symp-
tom came upon him, his spontaneous words and the unexpected leads that come
out of them are the best clues we have to go on. Furthermore, the chief complaint
may be the best source of knowledge about the patient’s emotional needs and
hopes.
Beginning therapists may be uncomfortable doggedly drilling down to the deep-
est level of detail, but this is of vital importance. “What does it feel like?” “What
was the context?” “What happened just before?” “What were the consequences?”
“How did others react?” Cultivating curiosity and seeking to understand go far
beyond social conversation to show that the therapist is really interested in
helping.
9.10 Spiral Organization 101

Questioning should continue going deeper until either the therapist has no more
areas to ask about or the patient has no further answers. One more job remains, to
formulate what still remains unknown. What information might be relevant but is
not accessible? In many instances, it is worthwhile to share these unanswered ques-
tions with the patient. Once a question is asked, the nonconscious problem solver
goes to work finding the answer. Most likely it will soon be answered in the form of
a metaphor and probably not the one you were expecting.

9.10 Spiral Organization

After thoroughly exploring the chief complaint, the interview is organized as a spi-
ral, moving outward (Fig. 9.1).
Areas that were only indirectly related at first will become the focus of ques-
tions. Questions will show the patient (like it or not) how the therapist thinks and
what information the therapist thinks is important. Soon it will be up to the patient
to carry the conversation so this is a prime time to teach by example. It is a time
to keep the area covered by each question as large as the patient can handle. This
will leave as much room for spontaneous leads as possible. Unnecessary narrow-
ing can give the patient concerns about being “pigeonholed” into a set definition
or category and not understood as an individual. This will put the patient on the
defensive and may teach the patient to leave out more information that could turn
out to be relevant.

Fig. 9.1 Spiral
organization of the initial
session
102 9 Conducting an Initial Assessment

9.11 Listening for What We Don’t Know

Even more valuable than observing what patients communicate is noticing and
attending to what we don’t know. This will keep us focused on where the conversa-
tion should go. We won’t stop after hearing a superficial version of events. We will
remain interested in details the patient hasn’t thought to share. Perhaps this is
because of fear or reluctance, but more likely the patient simply hasn’t learned to go
deeply into personal areas. Our active interest will help us and will also communi-
cate to the patient that we are really interested. Understanding in detail is the best
way to gain accurate empathy.
Having emphasized what we don’t know, now we can turn to what is revealed.
Helping the patient let us into his or her world starts with observation. Like a paint-
ing and its title, affects are best conveyed through a counterpoint between clues
picked up by our emotion detector and words that articulate the surrounding circum-
stances. Physical signs can also express emotions that are not yet in conscious
awareness but waiting at the door. It may be the therapist who brings them into
consciousness by putting an incipient feeling into words for the patient.
As we follow the cursor of the patient’s emotions, he or she will feel more at ease
and will tend to volunteer the information we need. When something important is
left out, a relevant question will not be distracting or disruptive. It will feel com-
pletely natural. For example, the patient sighs, “I loved my grandmother.” We wait
a moment, and when the patient says nothing, we ask, “Did she pass away recently?”

9.12 To Get Feelings, Ask for Facts

Asking directly about feelings may work occasionally but is usually interpreted by
patients as, “What are your pathological feelings about…?” Naturally, the answer
will tend to be defensive. Instead of asking, “How did you feel about your grand-
mother’s death?” it is usually better to ask, “How did you handle your grandmoth-
er’s death?” Facts will also help us understand the context. Furthermore, in
answering, the patient will give more than just the facts and will help us understand
his or her personal experience.

9.13 What if You Get an Evasive Answer?

Getting an uninformative or evasive answer is important new information. It is

likely to be telling us that some material is experienced as threatening. As men-
tioned before, for therapists, this automatic, nonvoluntary self-protection is referred
to as resistance. In the next chapter, we will deal extensively with resistance and
how to work with it. As a preview, what it means is that the cursor has now shifted
to a new place. The mind’s emotional attention is now focused on protecting against
some distressing emotion. The therapist’s job will be immediately to go with the
patient to the new subject, the discomfort, and begin the work of achieving empathic
attunement in the new situation.
9.16 Assembling the Data 103

9.14 Trauma and Substance Abuse

While the open-ended interview will reveal most of the essential information, two
items, in particular, need to be asked about explicitly. They are trauma or substance
abuse. These problems, about which patients may be inhibited by shame, don’t have
to be asked in the first session but should come up at some point in the initial infor-
mation gathering. Even if the patient fails to answer honestly, an omission will cre-
ate tension that is likely to lead to an important revelation later. Asking these
questions early in the relationship will be understood as a routine and will not dis-
turb the new relationship, while asking later will reveal that the therapist is suspect-
ing something and may result in defensiveness and an uncomfortable moment.

9.15 Beginning to Wrap Up

As time begins to run short, the necessity of arriving at a plan will start to shape the
questions. Some conclusions will be well supported, while others may need to be
flagged as hypothetical, which can be tested later. Yet other areas should be identi-
fied as unknown or incomplete.

9.16 Assembling the Data

During the session, the therapist will begin organizing and thinking about the data
that is being gathered. Before considering how to do that, below is a practical list of
items to take note of. These pieces of data have proved particularly useful to recall
before trying to make sense of all that has been imparted.

Chief Complaint What the patient considers to be the trouble and how he or she
would like things to be better. Often the way to ask this is, “What made you pick up
the phone to call for an appointment?” It is critical, here, to obtain a crystal-clear
picture. Generalities or abstractions are not good enough. At this early stage, patients
may not know how to tell you about their inner workings, so this process may take
some time and persistence. You should only be satisfied when you have a vivid pic-
ture of exactly what happened and understand the context and background enough
to put the events in perspective. This information is vital for developing a formula-
tion and because the patient’s suffering will provide the energy and drive to move
the therapy forward. Furthermore, your interest and insistence will also communi-
cate to the patient that you take his or her concerns with great seriousness.

Background Relevant to Chief Complaint Be sure to gather enough information to

be able to put the chief complaint in perspective. Have you ever had a problem like
this in the past? What happened? Was that different or the same as this time?
How does the patient function in the world? Don’t be afraid to judge. Here is
where your own knowledge of the world will give you a relatively objective sense
of how the patient’s functioning might compare with an average person of this level
104 9 Conducting an Initial Assessment

of education and intelligence. If the patient is functioning less well than one might
expect in some area, then why? This is the place to identify dysfunctional patterns.
Dysfunction is a principal component of all EDPs, so here is a chance to begin to
form a picture of the ones that will become the focus of the therapy. This is also a
way to discover strengths. Recognizing positive attributes will help your patient feel
empowered and also suggest ways to use those strengths to support the work.

Important Relationships Who are the people of importance in the patient’s life?
How are they described? Do they sound like real people? The quality of the descrip-
tion may suggest a level of development. Are these images “two-dimensional,”
which suggest patterns of perception and relationship going back to before age three
or four? Or are they more full and realistic, suggesting successful early develop-
ment? What are the patterns of interaction? How does the patient choose people and
function in relationships? Relationships may reveal problems but also strengths and
important sources of support going forward.

Life Story What are the broad outlines and interesting highlights of the patient’s life
story? How might the facts of childhood point to patterns repeated in the patient’s
contemporary life? This is where I tend to use early life history as a test to confirm or
modify the ideas I might have begun to formulate about his or her adult life.

What Has Stood in the Way? What does the patient think he or she is working against?
Why hasn’t the goal been reached already? What attempts have been made to improve
functioning? Determine which have been promising and which have failed.

The Patient’s Theory At some point it is almost always useful to ask the patient for
his or her private theory as to why things are the way they are. The answer will often
be spontaneous and reveal something important, even if indirectly.

The Patient’s Goal Toward the end of the interview, it helps to ask what the patient
is looking for or expects. This will be another glimpse into the energy source driving
the therapy. The patient’s expressed goal will be filtered by his or her ideas of what
is acceptable and proper. A deeper agenda may exist and may or may not be
expressed in some indirect way.

What Were the Surprises? At what points has the patient said things that were not
at all anticipated? These are likely to be related to the deep concerns of the noncon-
scious problem solver.

When Did Emotions Come Out? Expressions of emotion signal important mate-
rial. What parts of the story brought up feelings? What came just before and what
came after?

Was There Transference? Was the session influenced by an emotional reaction of

the patient to the therapist? While unusual, intense transference reactions can happen
in a first session and usually point to early trauma or difficulties in relationships.
9.17 Building a Hypothesis 105

Were There Things that Struck You? Your own nonconscious mind is working hard
to pick up important clues. If something the patient said left an impression, it is
probably important, even if it is not clear why.

Was Any Material Left Out or Avoided? Part of every EDP is avoidance of feel-
ings. One important way this is manifested is staying away from uncomfortable
areas. Your curiosity will help you notice possible omissions. It is good to ask about
omissions and then note if new information flowed or was still being blocked or
filtered.

9.17 Building a Hypothesis

Let’s go back to the reason we are here. The goal of therapy is to invite the patient
to let go of dysfunctional patterns, one at a time, and to adopt healthy ones.
Identifying at least the most accessible of these patterns, what emotions they might
be designed to avoid, and how to help the patient trade those patterns for healthier
ones will show the way forward. Below are five ways to approach the data that can
and should be mixed together. Sharing this process with peers and supervisors is
always helpful in building a hypothesis and a plan.

1. Ask what is the most immediate blockage to health. Since EDPs are arranged in
layers, it is quite possible only one layer will be accessible. That is okay.
Whatever dysfunction is most clearly visible, when addressed, will start to clear
away the fog that obscures the next layer. As more layers come into view, it will
be possible to enlarge the hypothesis to better anticipate what lies ahead.
2. Listen for themes, issues, or areas of life that carry more intense feelings or are
causing trouble for the patient. These can point to aspects of the patient’s per-
sonal history that remain as “unfinished business.” It is often possible to notice
present-day reactions that carry a similar feeling or tone to events in the past. If
two seemingly distinct phenomena “feel the same,” it is likely that the therapist’s
inner problem solver has detected a common thread.
3. Working from different directions helps to conceptualize causes and conse-
quences. Moving backward, we can start with a behavior and then ask ourselves
what would be the emotional consequences of changing it. What feelings might
have to be faced? For example, letting go of substance abuse might mean facing
the pain of a trauma. Working forward, we can imagine growing up with a trou-
bled sibling causing the patient to feel guilty about needing attention. As stated
earlier, EDPs are approachable from two directions, processing the troublesome
feeling or helping to change dysfunctional thinking and behavior. Are involun-
tary symptoms being supported by voluntary behaviors? What immaturity is
being shown? What experience might the patient need to go through to gain the
missing skills?
4. Transference, that is, emotional reactions to the therapist, is conceptualized here
as the influence of an inner child. The therapist should always be conscious of
the likelihood that there is a child in the room. Naive or unrealistic, childlike
106 9 Conducting an Initial Assessment

Fig. 9.2 Work is moving an

object through resistance A Resistance B

thinking may be a clue. The inner child’s plan may not be verbal. This younger
patient may know exactly how to solve the problem but feel too ashamed to
reveal the plan directly. When children have a problem to solve, they often look
to a grown-up to do the work, and often that is the therapist. The therapist may
feel the tug of the patient’s unspoken wish or desire. Such a feeling can be the
clue that reveals a plan.
5. Look for layers of EDPs, entrenched dysfunctional patterns of thought and
behavior that cover up feelings. Remember that the subject is the mind’s work to
avoid uncomfortable feelings and how these efforts have resulted in patterns of
avoidance that interfere with the patient’s satisfaction in life.
6. In physics, the definition of work is moving an object, over a distance, against
resistance. Picture the therapy as helping the patient go from point “A” to point
“B,” encountering resistance due to the natural discomfort of change or to fear of
unmasking previously avoided feelings. A diagram like this can help to visualize
the work of therapy (Fig. 9.2).

Think of the work that needs to be done. Imagine where the patient is now and
where he or she needs to be. This may be emotional work like grieving or accepting.
What healing will make the dysfunctional pattern unnecessary? It may also be
behavior change, trading dysfunctional patterns for healthy ones in spite of instinc-
tive reluctance. In going from point “A” to point “B,” what work is needed to bring
about change? The required work may be letting go, or it can be growth and devel-
opment, which implies trying out new behaviors that seem scary and strange at first
but lead to a wider range of skills and capabilities.
Making sense of the data, also called formulation, is a complex and creative task.
Practice is extremely important, as is brainstorming together. Discussing cases with
a supervisor or in a group is the best way to learn this kind of thinking.
One warning: Therapists sometimes overvalue their intellectual productions.
Most EDPs are the inventions of children. They are not terribly subtle. Keep in mind
that the goal is not to have the most sophisticated idea but to understand a human
being accurately and help him or her feel and function better.

9.18 Making a Plan

Using the principle of modular therapy, we want to identify EDPs and then ask
which methods might help and how the work might unfold. Here are six key
questions:

• What are the patient’s areas of dysfunction (EDPs)?

• Which are the most accessible, taking the patient’s awareness and current moti-
vation into account?
9.18 Making a Plan 107

• Which can be addressed quickly and which are long term?

• Must certain EDPs be addressed in order to have access to others?
• For EDPs that are not immediately accessible, are there superficial, “quick fixes”
to get around them that will not create trouble later?
• For each EDP, which route of approach is best, the behavioral or the emotional?

Let’s look at these questions in order, referring to the case of Jack from the first
chapter.
Identifying EDPs
As therapists, we can go beyond the patient’s complaints to assess how the patient
might find a more satisfying life. Yes, we should be concerned with not imposing
our own values, but we can ask ourselves, if the patient was aware of a better way,
would he or she choose to function differently?
Jack has problems with panic and with inability to depend on others like his wife
and helping professionals. Behind those, we guess that he has feelings of pain and
anger that have never had a chance to heal.

Accessibility
In the case of Jack, he certainly doesn’t want another panic attack. He is strongly
motivated to remove that threat, making panic quite accessible. His independence
and self-sufficient value system are a problem, but he is far from being motivated to
change those. He will first need to understand how they interfere with his marriage
and therapy.

Short or Long Term?

Jack’s need for support can be dealt with in the near term. His conscience and its
excessive value of self-sufficiency, like all problems involving values, will take
more time. This is a good reason to start with his need for support and make use of
a superficial “quick fix” (see below) to get around his values without challenging
them.

Blocking EDPs?
Jack’s resistance to the idea of therapy stands in the way of the help he needs with
other EDPs. Fortunately the “quick fix” will probably help him get past his reluc-
tance to engage in therapy. A different example of an EDP that could stand in the
way of progress might be a suicide risk blocking work with important underlying
issues.

“Quick Fixes”
For Jack, there are two. First, by framing his therapy sessions as “necessary proce-
dures,” we are able, temporarily, to bypass his reluctance to depend on anyone but
himself. Second, the attention he receives and a brief respite from the responsibility
of his new job reduce his neediness and make another panic attack much less likely.
He will need just the right dose of relief. Too much might have the undesirable
effect of leading to chronic disability.
108 9 Conducting an Initial Assessment

These are superficial and temporary solutions to problems where the long-term
solution is for the patient to change, rather than circumstances. Quick fixes might
include such things as intervention with family or employer, medication, use of sug-
gestion, or the use of the therapist’s authority in allaying fears.

Behavioral or Emotional?
In addressing Jack’s EDPs more definitively, his style and values favor a behavioral
approach. Learning to make use of a “support system” will be easier for him than
approaching emotional needs or deep feelings. The same skills training will help him
modify his value of self-sufficiency through “civil disobedience” (see Chap. 17).

9.19 Walking in Thick Fog

Frequently, at the point of making an initial plan, the whole case is not as clear as
presented in the example of Jack. Planning may feel more like walking in thick
fog, where we can see the foreground clearly, but beyond that the details are
increasingly enveloped in mist. When this happens, we need only work with what
is apparent.
Taking each of the six questions into account, we have now identified a set of
EDP modules and an idea of the order in which the EDPs must be dealt with. In Part
III we will add more detail about methods for addressing specific EDPs. Together,
these are the basic elements in a treatment plan.

9.20 Arriving at an Agreement

After going as far as possible to develop a working hypothesis, as was done in the
first chapter with Jack, it is time to build a contract or agreement with the patient.
This does not have to be formal but should be clear in the minds of both
participants. The contract may be agreed upon at the end of the first session, but
frequently one or more additional meetings may help greatly to develop a more
complete plan.
A second visit often reveals important information about how the patient relates
to the therapist and what use he or she has been made of the first session. In a second
session it is helpful then to ask, “What impressions did you take from our last ses-
sion? Have they made any difference?”
The therapist should be ready to make a simple proposal about what is going on
and how to help. It does not have to be definitive. Hopefully the plan will be con-
crete and make sense to the patient so that he or she can make an informed decision
to follow the suggestion or to negotiate something that is satisfactory to both. It is
also important to leave room to revisit the agreement and to modify it as both par-
ticipants learn more.
References 109

Key Points
• Unstructured exploration is an efficient way to gather pertinent data.
• Therapists should show rather than tell patients how to do their part in
therapy.
• Exploring the feelings and causes behind dysfunction helps to bring affects
to the surface, where they can be healed.
• Our understanding can be tested indirectly by forming expectations, ask-
ing about resonance, watching the flow of information, and observing
progress or the lack of it.
• The mind gives meaning to everything humans do, and this is what we
listen for.
• The art of formulating questions shows our attunement and our skill and
interests.
• Unexpected information is called a “lead” and should be followed. This is
where we learn the most.
• The session starts with the “chief complaint” and spirals out from there.
• Trauma and addictions are two important pieces of data to ask for, since
patients won’t always volunteer.
• Making sense of the data involves going mentally from effects to causes
and from causes to effects.
• Building a hypothesis and plan is a complex creative process where prac-
tice and input from others are particularly helpful.
• Preliminary understanding leads to an informed agreement with the patient
about what is to be done, why, and how.

References
1. Ehlers A, Clark DM. A cognitive model of posttraumatic stress disorder. Behav Res Ther.
2000;38:338.
2. Skinner BF. Why I am not a cognitive psychologist. Behaviorism. 1977;5(2):1–10.
Conducting Generic Talk Therapy
10

Moving on from the initial assessment with the same generic, unstructured
technique, there is more to learn from this most basic form of talk therapy. While the
interaction may seem simple, a lot is going on. Not only are we constantly learning
more about the patient’s issues and dysfunctions, but the interaction is also provid-
ing the perfect conditions for resolving entrenched dysfunctional patterns (EDPs).
Exploration of the patient’s life and issues inevitably heightens awareness of
dysfunctional patterns. The mind naturally moves the unstructured conversation
toward areas of unfinished business and discomfort. As problematic feelings come
up into consciousness, they can be processed and healed because the two necessary
elements required for detoxification are already present: activation of the affect and
a context of connection. At the same time, the conversation clarifies the patient’s
EDPs and in doing so heightens awareness of changes in behavior and thinking that
will move the patient further toward health. In this way, both approaches to the
patient’s entrenched dysfunctional patterns are naturally targeted.
With ongoing sessions, the relationship grows, and the inner child becomes more
active and visible. Childlike wishes and plans are more obvious and have increased
impact on the conversation. This too leads to feelings being activated and to grieving
and acceptance as some childhood wishes are relinquished while others modified to
fit with adult reality.
Generic talk therapy fulfills the three most basic functions needed for resolving
EDPs:

• Discover and characterize the patient’s entrenched dysfunctional patterns as they

become accessible.
• Process the emotions that EDPs are designed to avoid.
• Replace dysfunctional avoidance mechanisms with healthy thinking and
behavior.

Thus, a seemingly natural, free-flowing conversation is actually a sophisticated

method for bringing to light and resolving the patient’s dysfunctional patterns.

© Springer International Publishing AG 2017 111

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_10
112 10 Conducting Generic Talk Therapy

In the sections that follow we will examine in detail how to conduct a generic
session with a focus on fundamental change processes as the hub around which the
therapist’s activity revolves.

10.1 Putting the Patient in Charge

During the initial assessment, the therapist provided guidance through questioning,
and the patient responded to the questions. From here on, we want to shift the job of
leading the conversation to the patient. The reason is, once the chief complaint has
been thoroughly explored, the therapist cannot possibly know what will be on the
patient’s mind at a given time. Our guesses will be poor at best, and our ill-informed
questioning will stifle spontaneity and prevent the session from tracking the patient’s
mental processes. In order to make this switch, the patient will need to be instructed
how to take over the job of carrying the conversation.
The simplest instruction is to follow Freud’s original psychoanalytic dictum,
which was to “say whatever comes into your mind without censoring.” This is not
an easy demand. Being invited to say whatever comes to mind is much scarier but
also more revealing than answering a question. If the patient is able to cope with
such an open-ended instruction, then that is the best one to use.
On the other hand, if the sessions are only held weekly or less, then quite apart
from worries about what may be revealed, the jumble of material “on the patient’s
mind” may make focusing hard. It may be more efficient to narrow the instruction
to something like, “I want to hear about your work to make positive changes and
whatever other thoughts you have.” This narrows the field a bit, without suppressing
spontaneity. As indicated in the chapter on the therapeutic relationship, creatively
adapting instructions to the patient’s characteristics and preferences will be better
for the relationship and more successful overall.

10.2 Every Session Has a Topic

The primary responsibility of a therapist at the beginning of a session is to listen for

the main topic for the day. An overall focus remains on the resolution of the chief
complaint, but this is not always the patient’s immediate concern. The mind’s emo-
tional cursor is always located somewhere, and that is the topic for the day.
Discerning the emotional topic may not be obvious. The human mind can com-
municate on a number of distinct channels simultaneously—words, body move-
ments, facial expression, and seemingly incidental events carry multiple meanings.
The mind is naturally a producer of metaphors that, in some way, point to the topic
of this session. As usual, the therapist’s best tool for picking out what is “on the
patient’s mind” coincides with natural curiosity and ability to perceive meaning. As
soon as we ask ourselves the location of the patient’s mental cursor, our own non-
conscious problem solver will set about seeking an answer. In seeking to pick out
this locus of feeling, the therapist is doing precisely what is needed to establish an
empathic connection.
10.3 A Third Participant 113

Remembering what happened in the previous session is always useful in thinking

about what the topic might be. As a rhythm of sessions is established, a thread will
tend to be carried from one session to the next. However, many events may have
intervened. If a hypothesis doesn’t appear within a few minutes, then it is best to
keep the question of topic open and simply listen. Seeking meaning in this way is
not only good for following the session and maintaining empathic connection but
also practice for being an alert and insightful therapist.

10.3 A Third Participant

Part I emphasized the advantages of seeing the patient as having an inner child. This
alternative to the concept of transference is very good for conducting sessions as well.
On the surface, you and the adult patient have gotten together to work on trading
entrenched dysfunctional patterns for healthier ways of living. You are natural allies and
collaborators. But there is a third participant. At times it will feel like there is also a child
in the room. The nonconscious problem solver is always on duty to protect the patient
from dreaded feelings and even from change itself. Many of the strategies employed
have changed little from childhood, hence the sense of an active, but childlike presence.
When these early avoidance mechanisms are operating, thinking will be simpler and
more black and white. The patient will seem to relate to the therapist more as a “big
person” who has all the answers and can make anything happen. Furthermore, this
young participant may have an agenda quite different from you and your adult patient.
We could call this gradual change in the tone of the relationship “regression.” We
could think of it as the appearance of “transference resistance.” But far richer is to
welcome the appearance of a child who has been waiting patiently to feel safe
enough. It is even more accurate to think of the problem solver as an inner child who
has a “better” idea of how to improve the situation. This point of view leads to
understanding and compassion, which are exactly the attitudes needed to work with
the patient’s less mature self.
The inner child is both an ally and a problem. He or she may have mixed feelings
about the therapy. The child may expect that you, the therapist, will be just as unco-
operative as the parent, years ago. There may be a fear that the conditions that
caused problems in the past will return. On the other hand, the young patient also
has hope that, this time, it will be different. The child wants above all to feel better
and brings new energy to the work.
Let’s say the child felt seriously neglected and has never stopped waiting to
reverse that early shortfall in caring. From a child’s point of view, the solution is
simple: Get the therapist to provide the attention and caring that were missing. Of
course, this is not adult caring. It is the kind of attention required by a small child, a
kind that is total and unlimited. Furthermore, the child expects you, the therapist, to
be reluctant to give, just as the parent was. As soon as you hint that there are bound-
aries and limits to what you can do for your patient, you are confirming the child’s
negative expectation. Will the child’s disappointment be expressed directly? Not
likely. The adult is still ashamed of his or her childlike reactions and will cover them
up, but you may feel the patient slump a little in the chair.
114 10 Conducting Generic Talk Therapy

By this time, unbeknownst to the adult patient, the child participant has gradually
become engaged in a life-and-death struggle to change the therapist. This young
presence is likely to be hidden early on, but the inner child’s hopes and expectations
will influence the session in powerful ways. The patient might say, “I think I am too
sick to be helped.” Or perhaps make a self-destructive decision. This could be the
child, testing to see if you will still care and how willing you might be to provide
rescue.
Thus, being conscious of the presence of a third person in the room is an excel-
lent way to conceptualize many of the EDPs that come from an earlier time, pre-
served in procedural memory, providing answers to pain and danger that were once
more real and relevant than they are today.

10.4 The Frame

Therapy sessions are like a pool of water. If nothing disturbs the water, then the pool
will be calm and give a clear reflection. When stones are thrown in, they create
waves, and the reflection becomes distorted. What gives clarity to the interaction in
psychotherapy sessions is the “frame,” or a set of policies, consistently maintained,
that govern the exchange. When the therapist maintains a constant sameness, a mir-
ror is created, and any perturbation reflected from the patient’s inner workings
stands out sharply and reveals something important.
The frame can be detailed and rigid or more flexible. Rigid rules governed upper
class life in Victorian times, when psychotherapy was born. In these societies, the
smallest deviation took on great meaning. In contrast, the looser manners of today’s
life make such subtle variations harder to discern.
Traditional psychoanalysis dictates relatively rigid policies in therapy, originally
designed to ensure objectivity by removing the influence of the therapist. Such rigid
policies do provide a very consistent, detailed, and clear frame. This is positive for
allowing subtle variations to become noticeable and accessible to exploration and
interpretation. But rigidity has other effects as well. Some patients, especially those
with more ego strength, may better be able to tolerate such rigidity. Other patients
may feel the emphasis on rules as cold and uncaring, causing them to feel less safe
and less open to taking emotional risks. The frame can be the beginning of a fruitful
working alliance or can become a cause of slow progress.
The frame includes details such as the level of adherence to strict beginning and
ending times, how much the therapist reveals of his or her reactions and feelings,
what personal data the therapist might reveal, and how interactions outside the ver-
bal exchange, such as handshakes or even gifts, are handled. These policies, and
their meanings, may depend as well on culture. The affect avoidance model would
suggest putting change processes first and adjusting technique for the greatest effec-
tiveness. The therapist should evaluate the level of rigidity that is optimal for a given
patient. The ideal is to create a calm pool that also imparts a sense of comfort and
safety. Having established expectations, it is the consistency with which the thera-
pist adheres to policies that makes this happen.
10.6 When to Intervene 115

10.5 First Follow the Flow

As we mentioned, the therapist’s first priority is to follow the flow of the session.
This takes precedence over all other jobs except for safety.

Key Rule The therapist’s first and main priority is to follow the flow of the session.
This is more important than understanding.

While both therapist and patient are interested in gaining understanding, the
critical work of monitoring the process belongs to the therapist alone because he or
she is the only one with enough perspective to notice subtle changes. Furthermore,
following the flow will alert the therapist to a problem in empathic attunement and
the need to make repairs.
By simply following the flow, one can learn all that is necessary about the adult
patient and the child. When the flow of information is full and clear, the therapy is
moving forward. Understanding is building and healing is ongoing, along with read-
iness for behavior change. When the flow breaks down, the therapist will be alerted
to precisely the EDPs that need to be addressed, including those that come from the
child’s alternative agenda. Either way, whether feelings and data are flowing freely
or an entrenched dysfunctional pattern is emerging into view, the therapy is moving
along. Let’s look at how the therapist can facilitate the processes.

10.6 When to Intervene

As long as the patient’s conversation is flowing well, we can stay quiet. Intervention
is a good word for the times when we need to act. Intervention implies a break, a
shift in the flow. We will see that our goal is to intervene when the flow has already
shifted and to follow the patient to exactly the place where his or her mental cursor
has moved. How can we tell it is flowing well? Two criteria guide us:

1. Our understanding should be growing steadily. We will be learning new things

about the patient’s life and feelings with each new sentence or reaction.
2. What we learn will be crystal clear. We should be able to form a sharp mental
picture of the patient’s world. This is the quality that builds empathy. Think of a
novel. Good writing lets us visualize just what the writer is describing. When
words don’t convey this kind of crystal clarity, then we lose the trail of empathy.
We will have lost sight of the patient’s mental cursor.

If either of the two indicators is lost, then something is blocking the flow of infor-
mation. This is the signal to intervene. It may be resistance, but remember not to use
that word. When lay people hear the word “resistance,” they understand conscious,
willful resistance and will feel criticized. In contrast, when therapists use the word,
they mean the kind that happens automatically without conscious purpose, the result
of an EDP being implemented from within to ward off some uncomfortable feeling.
116 10 Conducting Generic Talk Therapy

The first possibility that must be ruled out is that what looks like resistance can
be the result of a misunderstanding. Perhaps you didn’t explain well what you
expected or you asked the patient to do something that was not a good fit. If the
problem is due to one of these factors, it is the therapist’s job to clarify. Assuming
this is not the case and that we have given good instructions, ones that are in sync
with the patient’s needs, and they have been understood, then it is time to begin the
three-step dance.

10.7 The “Three-Step Dance”

Unique to this book, this three-step formula will be sufficient to guide our interven-
tions from here on. When information is flowing without resistance, we don’t have
to do anything. In fact, most things we might say or do will actually distract and
disrupt the flow of material. That is why we call our actions “interventions.” They
are inherently disruptive and should only be used when there is a positive need, or
when we encounter a disturbance in the flow.

Step 1 A gentle “nudge” will test to see if the resistance is a significant one.
“I’m not quite clear about that,” we might say. A nudge is some small, unobtru-
sive indication that we expect more from the patient. It could even be a grunt or
facial expression. If this works to get the flow going again, then we can conclude
that the resistance was not a significant one. We will not have disrupted the ses-
sion, and the flow will be back on track. The information will again be fresh and
crystal clear.

Step 2 If the nudge doesn’t work, it means we are dealing with real resistance.
This is an extremely important and positive discovery. Some entrenched dysfunc-
tional pattern has been put into play to deal with a perceived threat. The fact that the
flow has been disrupted means the mind’s cursor has moved to a new place. Now the
patient’s feelings, adult or child, are focused on a threat.
At this point, beginners often try to fight the resistance. They may fire off a close-
ended question as in a cross-examination. The patient is already feeling threatened
in some way. Questions like these leave the patient even less room to find a creative
answer, a compromise between what the therapist is asking and what the patient is
comfortable revealing. Such questions only raise the patient’s already heightened
sense of danger and will not lead to a revealing response. Alternatively, therapists
may try to overcome resistance by “sugar coating” or disguising their questions.
Patients know immediately when we are trying to bypass their (unconscious, non-
willful) efforts to fend off our inquiry. They will close the door firmly and not give
any useful information.
What, then, are we to do? The answer is to shift the focus to the communication
problem rather than the contents. Now the presence of an EDP is the focus. There
will be no disruption because the mind’s cursor has already moved there and we are
simply following.
10.8 The Three-Step Dance in Perspective 117

The patient’s nonconscious concern is the struggle over how much to reveal. Our
intervention will be a metacommunication, or a communication about the commu-
nication. We have shifted the topic 90 ° from the previous subject. Feeling that we
are closely following his or her concerns, the patient will accept this and will likely
be willing to join with us in addressing the communication problem. We are per-
fectly in line with the patient’s emotional cursor, empathically attuned.
An example of metacommunication is “It seems to be hard to talk about your
mother’s death.” This may be all that is necessary to release the resistance. Simply
acknowledging the feeling may release the block or there may be a need for more
exploration. Either way, the new focus will usually work to help the patient get
unstuck.
By coming to an empathic understanding of the resistance, we will be transform-
ing it as well. Whatever the emotion that has been causing the trouble, empathic
listening is the best way to detoxify the feeling. As the patient’s pain or anxiety is
relieved, the patient will usually be able to continue speaking, and the flow of infor-
mation will resume. It is possible that the session will have taken a new direction,
but nonetheless, it will again be flowing in a natural way, and we will be receiving
crystal-clear communication anew.

Step 3 In the rare case that metacommunication (communication about the com-
munication) doesn’t work and the patient remains stuck, it is time for a tactical
retreat. Apparently, we have come upon an issue that is too “hot” to be handled at
this time. For some reason it is more than the patient can tolerate. “Tactical retreat”
means that we tell the patient overtly that we will drop the subject for now and come
back to it at some future time. We haven’t given up, but for now, we grant the patient
permission to let the subject go. Note that neglecting to say this out loud will leave
the patient feeling like a failure. We might explain, “I guess this is really hard mate-
rial. We will come back to it at some time later.” The promise to come back later
leaves the patient with hope and removes demands to reveal material that the patient
is not ready for. The session will make a new start in some other direction.
It is critically important never to forget to come back to the material that has been
deferred. The emotional intensity will ensure that the patient does not forget this
incident, nor our promise. Of course it is critical to remember to follow up, as failure
to do so will eventually be interpreted as a lack of interest or the therapist’s fear of
something extremely important.

10.8 The Three-Step Dance in Perspective

Following this simple three-step dance will keep unstructured sessions moving.
When the flow is blocked, it will uncover the next EDP that needs to be worked
with. Below is a flow chart to show graphically how it works (Fig. 10.1).
These very simple moves amount to a sophisticated and comprehensive way to
conduct psychotherapy. They take care of discovery, healing of emotions, and lead
the patient to change old, dysfunctional thought and behavior patterns and, instead,
118 10 Conducting Generic Talk Therapy

Fig. 10.1 The three-step

dance Flow stops

“Nudge” Success Flow continues

Fails

“Metacom-
Success Flow continues
munication”

Fails

“Strategic Success
retreat” Flow continues

try new, healthy ones. Over time, EDPs will melt away, and the patient will feel
better. Furthermore, by concentrating on following the flow, the therapist will
become an excellent listener, skilled at establishing and maintaining empathic
attunement.
Let’s turn now to some additional tasks and considerations relevant to conduct-
ing sessions of unstructured, generic psychotherapy.

10.9 Second Priority: Understanding

While following the flow is the therapist’s first priority, having an ongoing under-
standing of the action comes next. Recalling earlier discussion, patient and therapist
are pursuing a number of agendas simultaneously:

• The conscious adult patient wants to feel better and lead a healthier life.
• The nonconscious problem solver is trying to keep things the same so as to avoid
painful, overwhelming, and uncomfortable feelings.
10.11 The Value of Listening 119

Fig. 10.2 Therapeutic work

A Resistance B

• The inner child has his or her own way to feel better, often involving the
therapist.
• The therapist wants to understand empathically, to bring uncomfortable feelings
to consciousness, and to help the patient replace dysfunctional patterns.

Our initial curiosity about the “topic” for today will hopefully have yielded at
least a guess about what theme is on the patient’s mind right now. If possible, we
want to fit today’s topic into the overall hypothesis that has grown and evolved from
the initial assessment. If the fit does not seem “just right,” perhaps it offers a learn-
ing opportunity. It may mean that our hypothesis needs to evolve or be modified. As
the session unfolds, we want continuously to follow where the patient is at the
moment, where he or she needs to go, and what stands in the way. The earlier dia-
gram is relevant now as well (Fig. 10.2).
As we seek to understand, we can assume that the most casual, spontaneous
gesture or statement is somehow a representation of what is “on the patient’s mind.”
What is the feeling being expressed or avoided? What change in thinking or behav-
ior would enhance the patient’s life? What EDP is currently standing in the way of
change? Once we arrive privately at an idea of what is happening, we automatically
form expectations of what will come next. Now it is time to listen for confirmation
or perhaps decide that our working hypothesis was wrong and we must again let our
nonconscious problem solver go to work.

10.10 Many Kinds of EDP

Grasping the principles of how to understand is certainly useful but is hardly

sufficient for dealing with the enormous variety of problems seen in practice.
We need to arm ourselves with some ready-made templates to describe the full
range of EDPs, along with hints about how to recognize them and some ideas
for how best to treat them. Part III gives a detailed catalog of the different kinds
of EDPs and should be considered as a supplement to the general principles
outlined here.

10.11 The Value of Listening

Therapists may feel that they should be “doing something” to help, especially when
a patient is in distress. Our understanding of the healing mechanisms of extinction
and reconsolidation indicates otherwise. Simply being there as a feeling witness
contributes the context of safety and empathic attunement that is required for emo-
tional healing to take place. Our willingness to listen and feel is far more valuable
than any words. The fact that this healing process happens in every session and in
every day of our lives should in no way detract from the wonder that one human can
120 10 Conducting Generic Talk Therapy

help heal another’s most dreaded emotion. Furthermore, our belief in this process
will help the patient gain confidence in his or her ability to handle and metabolize
difficult emotions.

10.12 Beyond the Three-Step Dance

So far, intervention has been suggested only at step two of the three-step dance,
when the flow slows down. There are, in fact, other times when a therapist’s com-
ments can make an important difference. Beginning therapists often feel safer ask-
ing questions than making a statement. When they lack skills or understanding,
patients need us to be ready to make statements, especially ones that will help them
understand themselves and their feelings.

10.13 Putting Words to Feelings

One situation where we may need to go beyond the three-step dance is when
patients don’t know how to articulate their feelings. They have not learned to con-
vey what is going on in their emotional life and therefore to benefit from sharing.
In the three-step dance, the therapist reacts only to resistance, but we can also be
proactive in helping the patient articulate feelings by supplying words that sharpen
the patient’s awareness and build a sense of connection and safety. Here is an
example.
A therapist in supervision was working with a patient who kept trying to be per-
fect in the hope that doing so would win her the love that she craved. The patient
described how she cooked a wonderful dish and her guest failed to praise her for her
exquisite work. The therapist recognized that the patient was protecting herself
against the vulnerability and pain of not receiving the recognition she had hoped for.
Bypassing the patient’s focus on her guest’s insensitivity, the therapist put into
words what was just under the surface, “It was very painful to work so hard and not
receive the recognition you hoped for.”
By giving words to the patient’s feeling, the therapist showed how and made it
safe to express difficult personal emotions. In doing so, the patient was taught how
to articulate personal feelings and experience healing. This helped the patient to feel
connected and to have more confidence in allowing herself to be vulnerable in ther-
apy. Experiencing empathic connection with the therapist laid the groundwork for
her eventually learning that showing humanness is a better way to connect with
others than being perfect.
The lesson for the therapist was that in addition to helping the patient
identify EDPs, it is also very valuable to show patients how to articulate emo-
tions and have the experience of being understood in a context of safety and
connection.
When the patient does articulate feelings as part of the flow of information, the
therapist can add his or her understanding of the feeling. Just a nod or sound might
10.16 Ending a Session 121

be enough, but words can say more. “I guess that really made you angry.” This
allows us to:

• Check if our understanding is accurate.

• Let the patient know we are empathically “tuned in.”
• Help the patient experience the feeling as more “real.”
• Offer a calm sense of perspective to help heal the affect.

10.14 Tell, Don’t Ask

Continuing the theme of times when therapists should be willing to go beyond ques-
tions, it is okay to express our thoughts and compare notes in what is referred to as
making meaning. Here, the therapist and patient work together to develop a better
understanding of an EDP, including its details, origin, triggers, and function. In
addition, the therapist might suggest alternative ways of feeling, thinking, or acting,
for example:

• Feeling: “Maybe you feel more strongly about that than you have allowed
yourself.”
• Thinking: “Perhaps you really do have a wish for that.”
• Acting: “I think you could have taken a firmer stand.”

10.15 When Not to Tell

When is not helpful to share an idea with your patient? This is a matter of judgment
and experience, but here are some of the pros and cons: If we are not quite certain
or likely to be “off the mark,” then discussing with the patient may give the impres-
sion that the therapist is really not attuned. Too many misses will test the therapeutic
relationship. Does the patient have a tendency to “intellectualize,” that is, to filter
out feelings and leave only ideas? That might also be a reason to limit our analyzing.
For a patient who is anxious to please, bringing in the therapist’s ideas may inhibit
the patient. Is the motivation really to help the patient, or could a comment be driven
by the needs of the therapist, such as showing brilliance or being a hero? All these
can be reasons to refrain from sharing our thoughts. On the other hand, telling the
patient what we think gives him or her encouragement in seeking understanding and
an opportunity to join with us as a partner in the inquiry.

10.16 Ending a Session

Sessions begin with an attempt to “tune in” to “the topic” for that day or at least
develop a hypothesis. Next we dig into the work and hopefully make some progress
in discovery, healing of difficult affects, or dismantling the dysfunctional behavior
122 10 Conducting Generic Talk Therapy

of an EDP. This work is often intense and leaves the patient in a more or less raw
state. Especially when we are doing significant work with emotions, it is important
to control the end of the session. Trying to stretch the emotional work to the very
end of the session or trying to uncover additional uncomfortable feelings can desta-
bilize the patient just as support is about to be withdrawn. This can nullify the good
progress made before.
As the end of the session approaches, it is time to bring the intense work to a
gentle stop. Some words of summation, preferably a bit more abstract and aimed at
the intellect, will bring a sense of perspective on what has happened and signal time
to move out of the most intense feeling states. Not every session is so intense. In an
unstructured therapy, it may not be necessary to end with anything more elaborate
than a simple statement that you will have to stop.

10.17 Phases of Therapy

The three-step dance highlights short-term variations or phases from moment to

moment in the psychotherapy session. Conversation flows and understanding grows
until some threatening material triggers an EDP and the flow stops or loses its fresh-
ness. This is not the only way the character and quality of the therapy process varies.
Below, we will explore some longer cycles in the psychotherapy process.

10.18 Long-Term Resistance

Resistance can also follow more long-term cycles. For example, when an EDP is
part of the personality, it does not appear suddenly, nor does it resolve with simple
metacommunication. In the case of Jack in the first chapter, his value system,
emphasizing self-sufficiency, is an example. At times, long-term resistance will be
there from the beginning but will not have too much of an effect unless the patient
is challenged to make real changes in behavior. Only then does the EDP begin to
have a more profound effect on progress.
A good way to think of these slower cycles of resistance and resolution is as the
metaphor of the four seasons. Spring is when fresh new material is flowing easily. It is
delicate, and the patient is emotionally vulnerable and feeling safe. The therapist has
little to do but listen and understand. Then comes summer, when the material is not as
new. You both have some understanding and are refining your grasp on the material,
“making meaning” together. Next is fall, when you begin to notice that the freshness
is gone. The flow is slowing. Resistance is beginning to manifest itself but isn’t yet
fully clear. Finally, winter takes hold and progress halts or almost so. Then, out of this
bleak period, empathic exploration and behavior succeed in resolving the blockage,
and spring is back again. The cycles can be of any length, from minutes to years.
Another important source of long-term resistance is the inner child reacting to
the therapist and subsequently blocking progress. The child has an agenda or plan
and experiences the therapist as failing to cooperate with the plan. A good example
10.19 Discovery, Emotional Healing, and Behavior Change: Three Tasks 123

of “transference resistance” is a man who kept asking his therapist for more c oncrete
guidance. The child within knew that the answer was for the therapist to be more
like the father he had not had. The therapist failed to realize what was happening
and acted instead just like the patient’s father, expressing criticism of the patient’s
wish and telling him that guidance was not allowed as part of his therapeutic
technique. This triggered a massive EDP and halted any progress until the patient
finally quit therapy.
Resistance is an inevitable and positive part of the process. Only when it begins
to stand in the way of progress do the emotions and behaviors become intense
enough to allow resolution through healing of the avoided feelings and relinquish-
ment of the behaviors.

10.19 D
iscovery, Emotional Healing, and Behavior Change:
Three Tasks

Earlier “cyclical therapy” was described as an alternation between work on feelings

and work on thinking and behavior. Often, before entering into this dialectic comes
a phase of discovery in which we become aware of the EDP and are ready to seek
its resolution. We could call this a “discovery phase.” Some EDPs are obvious,
while others, usually layered more deeply, may take a longer time to come to light.
Only when the triggering feeling or the dysfunctional behavior come to conscious-
ness can we begin to work on them. Then the work takes on a cyclical pattern in
which work on feelings can facilitate behavior change and success with behavior
can uncover difficult feelings that then need to be healed. Thus, we can identify
three basic tasks of psychotherapy.
This same discovery phase applies to therapy as a whole. At the beginning, we often
focus primarily on making sense of the patient’s layers of EDPs. The discovery phase
is exciting and often pleasurable for patient and therapist as they move toward the goal
of understanding. Discovery mixes in with some emotional healing and behavior
change as well. Gradually, the rapid discovery and healing of painful emotions slow
down. What is left is behavior change, often a slower, more laborious process.
Dysfunctional patterns, such as the nonverbal schemas we will explore in Part III,
do not change easily or rapidly. Long after the discovery phase, we may be working
on stubborn patterns of dysfunctional behavior. Similarly, unhealthy values like
Jack’s excessive need for self-sufficiency are also slow to change. Making changes
in values usually requires behaving in a way opposite to what is valued. Each time a
behavior like Jack’s reluctance to allow his wife to help him is challenged, a wave of
shame is unleashed. Jack feels ashamed of his weakness. This feeling must be pro-
cessed before the next increment of behavior change can begin. Both kinds of change
are slower and signal a phase in the therapy that feels more like summer.
In cases like this one, the work of changing may go on long after EDPs are
discovered and have become familiar to both patient and therapist. Processes of
change may continue even after the end of the therapy provided the patient pos-
sesses the tools to keep up the work.
124 10 Conducting Generic Talk Therapy

10.20 How Long Does Change Take?

One lesson drawn from many years of experience is that successful change can happen
at a much slower pace than we might think or wish. The psychotherapy industry is built
on the idea of change over a few weeks to a few years. Sometimes change is slow
because patterns such as the early schemas described later in Chap. 14 are very deeply
entrenched and hard to change. A biological predisposition to anxiety can mean related
conditions take years to master. Sometimes change is slow because people’s EDPs are
very sophisticated and effective at maintaining the status quo. Finally, a large invest-
ment of emotional energy in a childhood solution to a problem makes it very hard to let
go. In the end, each patient presents a different stack of EDPs. More often than is gen-
erally acknowledged, slow change over decades is the only path to relief.
Another common outcome of psychotherapy is no net change. We need to be
open to that possibility and ready to reassess the plan when progress is not being
made. Knowledge of healing mechanisms is the best insurance we have in dealing
with therapy that is stuck and not producing change.

10.21 Conclusion

Simple-appearing generic talk therapy actually addresses all the needs that patients
bring to their therapist. This basic form of psychotherapy accomplishes the minimum
necessary tasks to produce resolution of entrenched dysfunctional patterns. But, since
the affect avoidance model is focused on change processes, the inevitable question is
“Can we do better?” Are there more efficient and more effective ways than generic
therapy to arrive at the desired results of discovery, affective healing and behavior
change? The affect avoidance model would suggest that we look at specific EDPs, as
will be done in Part III, for further improvements.

Key Points
• Generic talk therapy is a remarkable path to the three tasks of therapy:
discovery of issues, detoxification of affects, and changing dysfunctional
behaviors.
• After the initial assessment, the patient is put in charge of the conversation.
• The first job in each session is to understand what is “on the patient’s mind.”
• The inner child is often a participant and needs to be heard.
• A steady frame helps to highlight the patient’s inner reactions.
• The therapist’s first priority after safety is to follow the flow of the session.
Understanding comes after that.
• The “three-step dance” is a formula for guiding the session.
• Beyond that formula, there are times when the therapist needs to dare to
tell what he or she knows.
• Therapy has short and long cycles of getting “bogged down” then process-
ing a blockage and moving forward again.
Building and Maintaining
the Therapeutic Relationship 11

11.1 The Therapist’s Role

At the beginning, patients often don’t know what to expect from the therapist or
what the therapist’s role may be. They may expect an authority to tell them what to
do, or they may be expecting a friend. These thoughts are largely located in proce-
dural memory and may not be stated out loud. But when the therapist acts the same
or differently from the patient’s expectations, the role begins to be defined. If the
therapist is clear about his or her role, then it will be fleshed out in a way that is
consistent and helpful.
Our role is determined by the two things we need to do. First, therapists help
people heal their dreaded emotions. Second, we help them bring those emotions to
conscious activation at a level that is intense enough for healing to happen without
being overwhelming. Our role is paradoxical. We need to be empathically attuned
so as to maximize the healing, but we also need to resist the patient’s nonconscious
problem solver’s efforts to avoid consciously experiencing the affects. What we do
to bring affects “into the room” is learn about our patients’ avoidance mechanisms,
or EDPs, and invite them to let go of those barriers to feeling. Once in a while, we
do the opposite. When emotions are too intense, we help bring down the level of
activation to where they can be healed. Maintaining empathy is the easier part,
which will be discussed below. The more challenging part is helping bring dreaded
affects to the right level of conscious activation.
Our professional role in helping patients let go of EDPs and face their feelings is
as complex and varied as the human mind. The wide variety of what lies inside those
limits is what makes therapy such exciting, creative, and ever-evolving work.
Because of this variety and complexity, the best way to define our role is by what we
are not. We are not parents, we are not friends, and we are not exploitive.
Parents, unlike therapists, are responsible for shielding their children from dam-
age in the world to the extent that the children’s own ability to protect themselves is
not fully formed and functional. Therapists can’t do this. We can advise and even
warn, but we can’t be responsible for controlling our patients’ actions. In the case of

© Springer International Publishing AG 2017 125

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_11
126 11 Building and Maintaining the Therapeutic Relationship

teenagers, it is the family, the teen, and his or her parents who bear ultimate
responsibility. Only when there is imminent danger does society give the therapist a
mandate to call in the authorities to take charge. The fact that our patients are
ultimately responsible for their own lives gives an essential degree of freedom with
which they can learn healthier, better ways to navigate life.
Therapists are also not friends. Friends have a reciprocal relationship. They give
support, but they also need to receive it. Our patients must pay attention to their
friends’ emotional needs at the same time as their own. This is complicated and
would interfere with therapy. Since many if not most of the problems EDPs try to
solve are problems with give-and-take in relationships, then the privilege of being
concerned only with themselves is essential to successful therapy. Fortunately, as
long as they are not abusive to their therapist, patients do not have to worry about
the therapist’s emotional needs. They can concentrate on themselves exclusively.
Not being friends also means that therapists do not need to support the patient’s
avoidance mechanisms. Friends want to get close and feel good being together.
They usually avoid confronting each other in the interests of friendship. Therapists
have the opposite duty. Their role is to help patients face their painful emotions
unless those emotions are so intense as to be overwhelming.
The third and last thing we are not is exploitative. What that means is that thera-
pists don’t put their own emotional needs ahead of what will help their patients. In
practice, the broadest way to express this is the following rule:

Key Rule Therapists don’t make or imply promises they will not be able to keep.

A therapist once told a patient, “I’ll always be there for you.” This made the thera-
pist feel good, but later, when the therapist moved away, it was devastating to the
patient. A therapist who gives extra time outside of sessions without charging is
implying the promise that this extra gift is free. When the therapist later becomes
resentful or tries to undo the pattern, it feels to the patient like a betrayal. Even worse,
the therapist who has given too much may unconsciously feel entitled to be taken
care of emotionally by the patient. This can lead to more than an emotional betrayal.
Allowing the patient to develop the hope that some dysfunctional behavior is
acceptable may also imply a promise. A patient might mention gambling or sub-
stance use. The therapist’s failure to raise a question about the behavior could imply
approval. Later, when it turns out that the behavior is a critical EDP that stands in
the way of progress, the therapist is in a weak position to insist that it must change.
Similarly, allowing some area of the patient’s life to be “off limits” for discussion
may create a false promise that will be hard to undo later, when it turns out to be
where the patient’s most destructive EDP is hidden.

11.2 Boundaries

The above are principles governing the therapist’s role. Boundaries are a more con-
crete way to define the border between what therapists do and what they do not.
They are complex because what is appropriate may depend on cultural norms and
11.3 Effective Boundary Management 127

the standards of a specific profession. Bodywork therapists may touch, while, for
verbal therapies, this may not be appropriate or safe. The best way to learn specifics
about boundaries is in discussion with supervisors and peers. Gutheil and Gabbard
make the valuable distinction between “boundary crossings” that are not harmful
and may help the therapy by making it more human and “boundary violations” that
are destructive. They define boundary violations as “clearly harmful to or exploit-
ative of the patient” [1].
For the early career therapist the best practice is to be conservative. Follow
community standards closely and discuss questions with a trusted supervisor. With
experience, one can better distinguish between boundary crossings and violations.
Boundary violations happen when therapist needs intrude on a therapy that
should be solely for the patient’s benefit. Physical boundary violations are perhaps
the most common and the most damaging. Trouble usually starts insidiously with
small moves that are questionable in the light of community standards. If there is no
reaction on the part of the patient, then the boundary may slip further until a bound-
ary violation has gone too far to repair. Touch, for example, is quite likely to arouse
powerful wishes and needs that, once triggered, are very difficult to stop and can be
further fueled by “helper” thoughts in the therapist’s mind that come into conscious-
ness to justify what should not be happening. Clear, consistent, and conservative
boundaries make this kind of violation less likely to happen.
The boundary keeping the therapist’s private values and beliefs out of the therapy
protects the patient’s freedom to develop a personal style and identity. Therapists
have been known to try to convert patients to their beliefs. In more extreme cases,
therapists can become cult leaders. Under the guise of service, patients are lured
into a community that treats the therapist as a special person not bound by commu-
nity standards. Exploitation of patients in monetary and other ways ensues. While
parents are expected to shape their children’s values and beliefs, therapists are not.
Other than representing what is healthy, our values should not contaminate the ther-
apy. When our personal beliefs or values become known, the best we can do to
protect our patients’ freedom is to make it as clear as possible, in words and action,
that we value and respect our patient’s choices and beliefs, even if they are different
from our own.
The boundary between the therapist’s private life and the therapy is subtle.
Self-
disclosure is most often distracting and of little interest to the patient.
Occasionally it can be quite helpful. When its purpose slides into gratification or
help for the therapist, then a boundary has been violated and the therapy damaged.

11.3 Effective Boundary Management

The therapeutic relationship, if we take a step back and think about it, is not unlike
the relationship between a waiter and patron in a restaurant. The server is there to
facilitate the dining experience. Everything he or she does either enhances the
dining experience or detracts from it. The most basic requirement is to be attuned to
what the customer needs at any moment. A good server is extremely attentive but
not intrusive or excessively personal. The waiter needs to explain things and interact
128 11 Building and Maintaining the Therapeutic Relationship

with the customer while allowing the customer enough quiet to focus on the meal.
While no one is perfect, too many missteps will detract from the experience. The
same goes for the therapist.

11.4 The Frame

The therapeutic relationship includes a great number of details ranging from how
punctual the therapist is with time to the way personal questions are answered and
money is collected. Together these make up the frame within which the therapy
takes place. The frame is like a lake. When unperturbed it gives a clear reflection of
the surroundings. If disturbed, then reflections are lost. Consistency in managing the
details of sessions makes any perturbation stand out so that we can examine and
understand it.
Because there is so much variability depending on the setting, culture, etc., learn-
ing about how to manage the details is best left to the training program and its
supervisors. New therapists are often most concerned with what is the “right way”
to handle these things, but consistency is probably more important than the policies
we adopt. When the details of the frame are predictable, then the patient can relax,
knowing what to expect and what is expected. This allows both therapist and patient
to concentrate on the work to be done.
Along with consistency, a second variable is rigidity versus flexibility. Mostly a
matter of the therapist’s personality, some therapists are very precise, while others
may be more flexible. One might end sessions exactly on the minute, while another
might vary by a few minutes. It is possible to be consistent even if one is not rigid.
These details have a meaning and may affect the relationship, but the result can be
different for different patients. One patient might be relieved and more comfortable
with absolute punctuality, while another would find that quality jarring and appreci-
ate some leeway.

11.5 Flexibility

The affect avoidance model would suggest that the therapist should be flexible
wherever doing so will improve efficiency or results of therapy. On the other side of
this question, maintaining a steady frame is an important part of lowering anxiety
and creating a safe platform for clarifying EDPs and helping patients tolerate vul-
nerability. Patients need to know that the therapist is “in charge” and will hold firm
under pressure when the patient avoids experiencing some discomfort or facing a
difficult feeling. The solution is that, at first, we do best to follow a consistent set of
policies that maintain our role as helpers. As we get to know the patient’s specific
EDPs, then we may become more accurate and sure in knowing when flexibility
will open a door to avoidance and when it won’t. Experience with many patients and
many situations helps build confidence in our knowing the pitfalls that may come
from bending our usual policies.
11.8 Two Exceptions 129

11.6 Attunement

Now we can move to the positive things that make the relationship such a powerful
instrument for change. Attunement is the single most important factor in psycho-
therapy, and the key to attunement is empathy. Empathy is how we are instinctively
able to know what to do and when, in order to facilitate the patient’s personal change
experience. Research shows that empathy is a predictor of therapeutic success [2].
In addition to providing a compass that guides the therapist, empathy is truly the
perfect “medicine” to help with healing. Unlike other healing agents, it is power-
fully effective and free of negative side effects, and it doesn’t even have a dosage
limit. Even more amazing, we therapists have an unlimited supply at practically no
cost. When we are attuned with our patients, we feel invigorated and refreshed. We
do not feel depleted or drained of energy. Empathy does not take away from us but
actually adds something. Being a therapist is only tiring when we have trouble “get-
ting it” or feel anxious and responsible for circumstances out of our control.

11.7 How to Achieve Empathy

We have seen throughout the book so far that the way to achieve empathy is to help
the patient communicate exactly what he or she is feeling and why. When patients
“let us in,” then we are automatically attuned. Empathy is the core component of the
context of connection that provides both the support and the disconfirming experi-
ence necessary for emotional healing.
As explained earlier, empathy means finding the location of the patient’s emo-
tional cursor. Other concerns may be waiting, just outside of consciousness; how-
ever, only one is currently in focus and therefore available to the calming power of
empathic attunement. This simplifies our lives as therapists. All we have to do is help
our patient tell us the location and nature of the emotional concern of the moment.
Once we “get it,” then everyone will feel better, and the therapy will move forward.
Of course, empathy does not mean being “nice,” and it does not mean being
“solicitous.” Carl Rogers did us a favor when he coined the term “accurate empa-
thy.” What he meant is that for one human being to feel the feelings of another
requires an accurate understanding of the context and exact nature of the other’s
feelings. Empathy is not something we do but something that happens. The way to
make sure it happens is to help our patients let us in on their personal world and the
feelings that go with it on a moment-to-moment basis.

11.8 Two Exceptions

While empathy is nearly the perfect medicine, there are two situations where it can
be problematic. The first is with schizophrenic patients. With them and other patients
whose vulnerabilities go back to a very early era of development, too much under-
standing on the part of the therapist can feel to the patient as if their skin had been
130 11 Building and Maintaining the Therapeutic Relationship

removed. The threat is that if the therapist gets too close, there will be no boundary
left and the therapist may take over. For this reason, with these patients in particular,
it is important to be scrupulous in observing boundaries and careful not to go too
deep too fast.
The second situation is with narcissistic patients whose development has also
become disturbed early in life. For them, being understood can feel like a humilia-
tion, an exposure of personal vulnerability. Their defenses will be turned on the
therapist. Late in treatment, the goal for these patients is to feel strong enough to
allow vulnerabilities to be acknowledged and seen by the therapist, but a great deal
of work needs to be done before arriving at that level.

11.9 Breaks in Empathy

A discussion of the therapeutic relationship would not be complete without acknowl-

edging that no therapist is always on target. No one understands perfectly all the
time. It often happens that we make wrong assumptions or fail to pick up cues.
Sometimes the trail of clues goes quiet. Like happiness, feelings of empathic con-
nection are not continuous. They are strengthened at moments when we suddenly
feel a bond of mutual understanding. These moments don’t always last and may
give way to periods of uncertainty. At these times we may have to wait for thoughts
and feelings to point the way.
Breaks in empathy are fairly frequent and inevitable. You may misunderstand or
ask a question that reveals that your understanding was quite different from the
patient’s. When there is a break, both the patient and therapist will feel it. All of us
are sensitive to breaks because of our nature as social beings.
The most important thing a therapist can do is to be ready to acknowledge what
has happened. Like the mother of the toddler who falls, the acknowledgment shows
that you are confident that the relationship can be repaired and ready to do your part
in making that happen.
If a breach has occurred without acknowledgment, the patient may be left feeling
that he or she has failed somehow and must take responsibility for a misunderstand-
ing or loss of the feeling of connection. This distorts the roles in the patient–therapist
relationship and, as discussed under countertransference in the last chapter, is likely
to be a replay of dysfunctional relationships from the past. A matter-of-fact acknowl-
edgment makes it possible for the patient to metabolize the pain and distress. If the
break is due to an error or miscue on the part of the therapist, a willingness to own
that and apologize is appropriate and very helpful. In fact, since the cursor of the
patient’s mind is now on the break in the relationship, it is the acknowledgment that
tells the patient that the therapist is once again empathically connected.

11.10 Eliciting Feedback

Research has shown [3] that therapists are less aware of the patient’s negative
feelings about them than they are of positive ones. Not surprisingly, patients are
reluctant to tell their therapist about unfavorable thoughts. There is clear evidence
11.11 Maximum Empathy, Optimal Expectancy 131

that asking about how the patient feels about the therapy and the therapist is an
important thing to do to gather accurate information about the state of the relation-
ship. These questions may be hard to ask, but the results are far better when the
therapist shows a willingness to ask than if the patient is forced to take the initiative
or, worse, to show their feelings by missing sessions or stopping therapy.

11.11 Maximum Empathy, Optimal Expectancy

The attitude or stance of the therapist is an important aspect of the therapeutic

relationship. Traditionally, therapies tend to prescribe a single stance to be used
constantly while conducting therapy. Actual observation of experienced therapists
will show their stance actually varying according to the situation. In working with
trauma survivors, a cold or technical stance will reduce the effectiveness of the
therapy. On the other hand, with dangerous or destructive behaviors, too much
acceptance and understanding can amount to “enabling,” making it easy and com-
fortable to avoid real change. This can be especially problematic with patients who
have personality disorders or addictions.
A formula that incorporates the appropriate stance for all circumstances is
“maximum empathy, optimum expectancy.” First, other than the two exceptions
given above, there is never a reason not to work at understanding accurately and
maximizing empathy.
The place where there is room for variability is in what I call “expectancy.” This
is a very light but perceptible insistence on change and indication that the relation-
ship is not quite unconditional. Carl Rogers advocated an attitude of “unconditional
positive regard,” but a strict interpretation of this rule does have a potential pitfall.
Unconditional means accepting anything, including maintaining the status quo. If a
patient is firmly resistant to letting go of an EDP, the therapist may be doing harm
by prolonging a therapy without movement. For this reason, a degree of expectancy
may, at times, be appropriate and optimal.
At one time, for example, it was not uncommon for psychodynamic therapists to
believe that an all-accepting approach would eventually be curative for patients who
suffered from addiction. As the therapy naturally generated stress, which it must do
for change, the patient would use the substance to avoid discomfort. With this
approach, uncomfortable feelings could never be fully activated and therefore could
not be resolved, nor would the substance use pattern change.
A stance of expectancy should be very subtle and soft because any threat to the
relationship carries great emotional power. Expectancy implies that the relationship
can be broken if the patient does not work toward the agreed-upon goals. Humans
are extremely sensitive to the threat of a break in the relationship. Any threat may
simply cause the patient to end the therapy or to feel that the alliance has been bro-
ken. Expectancy is an unusually powerful tool to be used with clear understanding
and sensitivity.
At the opposite end of the spectrum, for example, when the patient is dealing with
very painful emotions related to trauma, this is not the time to show any expectancy
at all. It is a time for a great deal of patience and, as long as empathic attunement is
in place, being ready for the process to unfold at its own pace in its own way.
132 11 Building and Maintaining the Therapeutic Relationship

Another manifestation of expectancy is appropriate monitoring of progress.

When we, as therapists, feel that a therapy is going nowhere, it is usually our respon-
sibility to reassess the treatment plan and to consider either a different plan, a con-
sultation from a respected outsider, or referral to another therapist. How this rare
possibility is communicated to the patient depends on the therapist and the patient
but should definitely be done with a delicate touch.

11.12 Agreement Between Patient and Therapist

As professionals, we are asked by our patients to use our expertise and experience
to help them achieve goals that they deem desirable. There was a time when many
therapists interpreted their job as applying a specific procedure, whatever the results
might be. The idea was to support total freedom of the patient to choose his or her
own path in life. The problem was that the power of psychotherapy to unleash strong
emotions did not always ensure good judgment or decisions that the patient would
later feel were wise. Sometimes this led to the unnecessary breakup of marriages
and other unfortunate outcomes. Therapists would answer that they had accurately
represented the procedure they followed and that the patient was responsible for
agreeing to participate.
In today’s world, this policy is probably no longer consistent with informed con-
sent. What occurs now is a discussion and negotiation of what the therapist can do
and the possible results, positive and negative. This can’t always be known at the
beginning, so the understanding between patient and therapist needs to be reviewed
and updated as new information becomes available.
There are times when patients want a result that the therapist cannot, in good
conscience, support. At other times, the desired result may not be considered
possible or may require actions the patient is not willing to do. The therapist is
obligated, then, to explain his or her position and to let the patient decide to con-
tinue or not.
The author has experienced a patient wanting to learn how to become even more
accepting of an abusive relationship. This was not, in my thinking, an acceptable
goal for psychotherapy. Instead I proposed that she learn better how to defend her-
self. In another memorable instance, a man asked for help with a mental breakdown
after his wife, a mental health professional, told him he was “out of his mind.” It
quickly became clear that it was she, not he, who has having a psychotic episode.
Dr. Norcross and his group have also shown that following patient preferences
whenever possible is good for therapeutic outcome. In a situation where the thera-
pist and patient have differing preferences, keeping a healthy sense of partnership is
usually more important than following the therapist’s wisdom. This may mean argu-
ing for why the therapist’s position will ultimately help the patient, but in the end a
better strategy may be to try out the patient’s way and learn from the results.
A great opportunity to show respect for patient preferences happens at the begin-
ning of treatment as you develop an agreement or contract, whether written or not.
This agreement should be renegotiated along the way if there is any sense that your
11.13 Matching Stages of Change 133

expectations are diverging. The contract should include goals, the rationale for how
the treatment will work, expectations for results, how much time and money the
patient will be expected to invest, and what expectations the patient should have
about their part in the work and that of the therapist.

11.13 Matching Stages of Change

Sometimes it seems that patients with addictions are willing to do all but the things
that are necessary for a successful outcome. Instead of rejecting an uncooperative
patient, a better approach is to recognize that the patient is not yet at the stage of
change for making realistic plans. Rather, the patient is still considering whether
change is worth an all-out effort. Working with the patient to explore his or her
ambivalence will be much more welcome and acceptable to the patient. Prochaska,
Norcross, and DiClemente have defined a series of stages of change particularly
relevant to addictions and other compulsive EDPs [4]. Matching discussion in
therapy to the stage of change is part of their technique, motivational interviewing
(see Chap. 15 on addictions). Below are descriptions of the six stages and how the
therapist has an important role in helping the patient at each one. Which one applies
to the addicted patient who is reluctant to take effective action?

1. Pre-contemplation: This stage represents people who haven’t yet thought about
making any change. The goal of treatment would be to help them become aware
of the possibility and need for change. This means education but delivered in a
non-offensive way such as motivational interviewing (MI). To build trust,
patients need to feel that the therapist has empathic understanding of their feel-
ings and is respectful of their right to make their own choices.
2. Contemplation: The patient acknowledges the need for change but is ambivalent
about whether it is possible or desirable to make the effort. Coaching focuses on
examination together of pros and cons. A context of connection provides support
and safety.
3. Preparation: The patient has made a decision and begins to consider possible
actions. He or she needs coaching on specific steps and how they would work. A
good relationship is as essential as for the other stages, along with education
about the changes being considered.
4. Action: The patient takes action and needs the context of connection to process
the uncomfortable feelings inherent in change. Successes and failures also bring
up feelings that need to be shared in a context of empathic connection. For
humans, times of change always bring up increased neediness for support.
5. Maintenance: Patients have a strong tendency to lose their motivation and to revert
back to old patterns, especially in the face of some setback. An ongoing positive
relationship is critical in maintaining a balance of accountability and support.
Nonprofessional relationships can fulfill this role as they often do in 12-step groups.
6. Termination: The patient has gained a new sense of identity consistent with the
changes made. The balance of benefits greatly outweighs the cost of the changes
134 11 Building and Maintaining the Therapeutic Relationship

made, and the patient is so satisfied with the new way of living that it seems
unthinkable to return to what was. The job of the therapist is to help mark this
change and process the separation, another task of emotional healing. In the case
of addictions, plans for ongoing vigilance are indispensable.

11.14 Matching Culture, Religion, and Spirituality

These are characteristics very close to patients’ sense of identity. What is most
important from the patient’s point of view is being understood and respected.
A sensitive therapist can often overcome the patient’s anxiety about these things,
but it is the patient’s subjective impression that counts the most. Interestingly, avail-
ability is a significant factor. In a remote area, any doctor may be welcome, where
in a large city, residents may expect the best specialist available. In the end, what
will make the difference is the patient’s willingness to partner with the therapist to
help him or her to appreciate the patient’s culture and religious feelings. A therapist
who tries hard and is reasonably successful in learning about the patient’s world will
very often be accepted as a working partner. If not, and there is another option, then
going against the patient’s preference will usually leave too much room for finding
fault and blaming problems on the mismatch.
An attitude of genuine respect and openness to the patient’s point of view is
essential. Seeing a patient’s beliefs as naïve or misguided is likely to be revealed in
subtle ways. A therapist whose own culture, beliefs, or disbeliefs are too strong to
allow flexibility may do better not to try to work with a patient where the match is
not comfortable. One patient quit therapy and complained to the author that the
previous therapist had tried to convert him to religion. If true, this was not a success-
ful or appropriate goal of therapy.
Making assumptions about the patient’s religion or culture is also perilous. The
world is changing rapidly, and the prevalence of mixed, changing, and ambivalent
attitudes about these issues is extremely common. In fact, sensitivity to conflicts
that come from growing up with one set of assumptions and having them change
radically due a change of country or even cultural evolution in the native country
can cause a great deal of stress that the empathic therapist will be able to under-
stand. In India, for example, arranged marriages are still common, but this tradition
is changing rapidly, causing a significant amount of confusion and distress.
At times, culture may not be in sync with western assumptions and attitudes that
tend to be built into psychotherapy. Dr. Betul Sezgin, a Turkish therapist, writes a very
clear account of contrasting attitudes that today are often found in mixed and ambiva-
lent forms and can affect the way patients respond to psychotherapy as well as outside
relationships [5]. These different ways of viewing the human experience require a great
deal of understanding and sensitivity on the part of the therapist. Below is an excerpt:
Cultural characteristics shape the varying forms and degrees of how individuals can reveal
their emotions in therapy. In cultures where individualization is deemed important, indi-
viduals are accepted as the most important social unit. Individuals’ uniqueness, separation
and autonomy are highly valued. Emotional expression, self-assertion and speaking up are
11.16 Therapists’ Feelings About Patients 135

encouraged. In community-based societies, unity, togetherness and harmony are valued

over individual needs. Emotions are considered to be clues to one’s relationships with
others rather than a form of self-expression. Emotions are controlled to ensure group cohe-
sion in community-based societies. In community-based societies, individuals must please
others to receive acceptance. They are expected to sympathize with others’ feelings and
thoughts, and to behave accordingly. Otherwise, they will face separation anxiety and fear,
or feelings of shame.

In individualized societies, anger is deemed important for self-confidence, self-assertion

and personal freedom. It is even encouraged for clarification of events. In community-based
societies, anger is less accepted due to its threat against authority and social harmony.

Feelings of sadness and fear make one feel weak and want to withdraw. Because they do not
threaten the group cohesion, these feelings are accepted more in community-based societies
than in individualized ones.

In Turkish society, like in other community-based societies, it is not welcome to share per-
sonal feelings and family events with outsiders. It is accepted and encouraged for people to
hide their sufferings resulting from their community and to protect the community at any
cost. In failing to express their feelings and thoughts, people may give up on their needs [5].

11.15 Matching Gender and Sexual Orientation

Essentially the same points made about culture and religion apply to gender and
sexual orientation:

• Patient preferences should usually be followed.

• When a match is impossible, then what will make the difference is a combination
of sensitivity and effort on the part of the therapist and willingness to work
together on the part of the patient.
• Therapists should not make assumptions about patient feelings and attitudes but
should listen carefully and open-mindedly.
• If the patient is going to come into conflict with the therapist over something, the
conflict will be likely to coalesce around this issue. This means it is critical to be
genuine, flexible, and work hard at understanding. Only with recognition of
those efforts will a break be repairable.

11.16 Therapists’ Feelings About Patients

Strictly defined, countertransference is when the therapist’s inner child intrudes on

the therapy. For practical purposes, we’ll adopt a looser definition that includes any
feeling about the patient or unusual reaction on the part of the therapist. This is bet-
ter because it may take some soul searching to clarify whether the therapist’s reac-
tion is an ordinary feeling, consistent with the therapist’s personality and values, or
a product of the therapist’s nonconscious problem solver, having been triggered to
activate the therapist’s EDP. Using the loose definition, the therapist may first notice
136 11 Building and Maintaining the Therapeutic Relationship

a feeling reaction related to the patient. Alternatively countertransference can appear

as a deviation from the consistency of the frame.
Noticing one’s own countertransferences and making sense of them are of utmost
importance and usefulness. Countertransference can cause serious distortion in the
therapy, but it can also be an important source of information and understanding
both about the patient and the therapist. What did the patient do that triggered the
therapist? A therapist who is familiar with his or her own issues (often through per-
sonal therapy) will be better able to separate what a reaction tells about him or
herself from what the reaction tells about the patient.
What should we do when we become aware of countertransference? First we
should take an honest look into ourselves. It is important not to hold the patient
responsible for something that derives from our own EDPs. A therapist who defen-
sively refuses to acknowledge such a reaction is being cruel to the patient. In that
case, the patient will most likely accept responsibility for something that may not be
of his or her doing.
If the patient shows no outward reaction, this can mean that the patient has not
noticed. It can also mean that he or she does not feel comfortable enough to speak
up or believe that it is not the patient’s role to say anything. Should the therapist
volunteer to talk about the reaction? The best course is usually to listen for a reac-
tion on the part of the patient. If there is no overt reaction, we can follow the flow of
material to tell if there is a silent one. Any indication of a reaction on the part of the
patient is probably a signal to mention what happened and take responsibility for it.

11.17 Liking or Not Liking the Patient

The task force research shows positive regard is in the category of “possibly effec-
tive” predictor of successful psychotherapy [2]. Some patients are easy to like. They
tend to be the ones who show secure attachment patterns or at least a strong appre-
ciation for the therapist’s efforts. These may be the easiest patients to work with, but
they are not necessarily the ones who need us most.
Many patients, through no fault of their own, do not relate as easily. For the
therapist, hope of being able to help and anticipating a positive outcome can pro-
vide positive feeling in these cases. This carries some risk. More than one difficult
patient has reported that their therapist made promises never to give up, only to
abandon the patient later when therapy became bogged down and genuinely hard
to sustain. Such a promise should not be made lightly. Furthermore, if there is
trouble in the therapy, help should be sought and every effort made to save the
therapy. As in the situation of cultural mismatch, a therapist who makes a genuine
effort can often be forgiven for being human, even when the outcome is not
favorable.
When patients have some characteristic that makes them unattractive or even
unlikeable to the therapist, there is one technique that almost always works to
reverse a potentially major problem. The answer is to make the negative character-
istic a part of the therapy. In a tactful way, the therapist should make the patient
aware of the behavior, identify it as a dysfunctional pattern, and draw it into the
11.19 What Doesn’t Work 137

therapy as a goal for change. When the trait is an object of treatment, perhaps
surprisingly, it will no longer be objectionable. The therapist’s desire to help will be
engaged, and what was once an irritation will become a problem to solve.
Experiencing a patient as boring, or finding oneself unengaged, probably repre-
sents a different kind of problem. This usually means that the therapist is being kept
at an emotional distance and, in some way, feels left out. Somehow a resistance has
become established that is blocking empathy. Here the goal is to identify the resis-
tance and work with it much as one might with an unpleasant characteristic.

11.18 The Working Alliance

Therapist and patient are, in fact, human beings engaged in working together. A strong
and positive working alliance has been shown to predict a positive outcome [2]. The
only warning is that the therapeutic work must take precedence over any other aim. It
is okay to enjoy doing the work together but not to allow the therapist’s needs take
precedence over the patient’s. At that point, a boundary has been crossed.
If the relationship and the work are too hard or painful for the patient, he or she
will soon lose courage and will be tempted to withdraw. If the work feels painful
and there is no experience of pleasure in the collaboration and the gains achieved,
the therapy will be in jeopardy. Humans can only be expected to keep up an unre-
warding effort for a short amount of time, even if they are quite convinced it will be
in their best interest. For this reason, it is good for the therapist to monitor the
patient’s level of comfort and stamina.
In longer-term therapy, a time factor is also in play. Depending on the degree of
improvement in life, there may be a limit to how long a patient can sustain an effort
to change in fundamental ways. It is important to gauge the patient’s patience and
readiness to stay with a prolonged effort. Change is hard, and people do have a limit
to their willingness to tolerate discomfort.
Otherwise, working together in a collaborative endeavor is a healthy activity that
is often pleasurable for both patient and therapist. There is no harm in the therapist
enjoying this relationship. The therapeutic alliance is not only good for doing the
work but makes being a therapist a very satisfying profession.

11.19 What Doesn’t Work

According to the American Psychological Association’s Task Force on Evidence-

Based Therapy Relationships [2], based on meta-analysis of a large number of studies,
four factors clearly detract from the effectiveness of therapy.

1. Confrontation: Especially in the field of addiction, a confrontational attitude was

counterproductive. The methods of motivational interviewing discussed under
addictions in Part III were more effective.
2. Negative comments or behaviors: Hostile, critical, pejorative, or blaming state-
ments by therapists correlated with poor results.
138 11 Building and Maintaining the Therapeutic Relationship

3. Assumptions: Therapists who assume things are going well without enquiring
are often wrong. Similarly, the patient’s perspective on the therapy correlates
better with outcome. Therapists who rely on their own point of view don’t
do as well.
4. Rigidity: Rigid adherence to a particular method risks missing important cues
from the patient and can cause damaging breaks in attunement. Staying with
methods that are not in tune with the patient puts therapy at risk.

11.20 Terminating the Therapeutic Relationship

Therapy comes to an end either because the goals have been fulfilled or because the
perceived balance between cost and benefit has swung toward the negative.
Hopefully this will be a mutual determination. Some goals, such as processing
feelings around a traumatic event, can and should be accomplished during therapy.
Changing nonverbal schemas and internalized values may be a longer, slower pro-
cess that extends beyond the time of the therapy.
One tradition has held that therapy should be ended definitively with no expecta-
tion of later contact. This approach places a high value on individual autonomy and
separateness. More often, therapists leave the door open for future sessions if needed.

11.21 Goals of Termination Sessions

Patients often have issues around separation and going on their own. These may not
come up until the end is imminent, which is why we try to take time to discuss the
end of treatment. Talking about termination allows us to work with feelings that
may only come up when the end of therapy is experienced as a reality. Reactions to
it are entirely individual and require the same open listening that has worked all
along to help the patient activate and work with emotions.

Key Points
• The therapist’s role is best defined by what we are not: parents, friends, or
exploiters. Beyond that our role is to do whatever helps heal feelings and
helps our patients let go of avoidance mechanisms.
• Boundaries are concrete rules to prevent straying from our professional
role.
• The therapeutic frame is like a lake. When it is calm, then it gives a clear
reflection of what surrounds it.
• A good therapist is like a good server: attentive, tuned in, but not intrusive.
• Empathy is the essence of an effective therapeutic relationship and is what
happens when we help the patient let us understand accurately the patient’s
inner life.
References 139

• Breaks in attunement are inevitable and need to be repaired by frank and

matter-of-fact conversation.
• Countertransference in its most significant form means an intrusion by the
therapist’s inner child.
• When patients have unpleasant characteristics, make those part of the ther-
apy, and they will no longer be irritating.
• Adjusting to the patient’s needs and characteristics makes for a more effec-
tive therapy.
• Matching characteristics such as religion and sexual orientation is not
always necessary, but the therapist’s efforts to bridge a gap must be seen as
positive by the patient.
• The “real relationship” is a positive and often pleasurable partnership for
both parties.
• Soliciting patient feedback is important because if we don’t ask, patients
often don’t tell. Not listening to patients or making assumptions about their
point of view is dangerous.
• Criticizing, confronting, or blaming the patient tends to give poor results.
• A universal stance for therapists is “maximum empathy, optimal expec-
tancy.” The latter means a very subtle expectation of progress.
• Termination is a chance to explore feelings about separation that are likely
not to come up until the end of therapy is imminent.

References
1. Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice: theoretical and risk-
management dimensions. Am J Psychiatry. 1993;150(2):188–96.
2. Hill CE. Helping skills: facilitating exploration, insight, and action. 4th ed. American
Psychological Association (APA); Washington, DC: 2014. p. 52.
3. Norcross JC, Wampold BE. Evidence-based therapy relationships: research conclusions and
clinical practices. Psychotherapy (Chic). 2011;48(1):98–102.
4. Prochaska JO, Norcross JC, DiClemente CC. Changing for good: a revolutionary six-stage
program for overcoming bad habits and moving your life positively forward. Reprint ed.
New York: William Morrow; 2007. p. 39.
5. Sezgin B. Application of emotion-focused therapy in Turkey and evaluation of cultural differ-
ences. The Integrative Therapist. 2016;2(2):30.
Working with the Inner Child
12

To the beginning therapist, the term transference has an aura of mystery and
strangeness. However, the intrusion of childlike perceptions and plans is a very
common aspect of adult human life. The way we relate to people upon whom we
depend is shaped by patterns derived from our early years and lodged in procedural
memory. The intensity of our reactions to a spouse or a boss is an example of
transference. Arguments between spouses regularly take on a life-and-death quality
that goes far beyond the trivial issue in question. It is as if our survival is at stake,
and, a long time ago, it certainly was. The result is that interactions today can bear
the intensity of a child’s struggles.
An example would be a patient who quit therapy because the therapist refused to
change the thermostat. She insisted it was too cold in the office. The therapist stood
his ground and refused to change the temperature. Perhaps he believed he was
guarding the frame. Unfortunately, the therapist failed to realize that the patient’s
vehement request, besides being a reasonable one, was also an inner child testing to
see if he would be sensitive to her needs.
If he had agreed, then more needs would have surfaced and helped the two of
them to understand the early life shortfall she had been hoping and planning to
fulfill. By refusing to change the thermostat and not inquiring further, the therapist
was repeating her parents’ uncooperative behavior but failing to recognize the
reenactment. As Santayana is reported to have said, “Those who do not learn history
are doomed to repeat it.”
Here is how the reenactment should have resulted in resolution of this EDP: the
childlike plan, in increasingly explicit forms, would be manifested in her conscious-
ness as potential actions to be implemented via free will. While the first appearances
might be filtered to make sure they appear reasonable, in successful therapy, later
versions would begin to show their true nature as childlike attempts to get the thera-
pist to fulfill early needs. The woman’s therapist could never really fulfill her unmet
childhood needs. On the other hand, if they had explored her request, they might
have become aware of the need and its associated affects. Then the patient could
have been helped to grieve for what she could never have and to find ways to fulfill
those parts of her wishes that were appropriate in adult life.

© Springer International Publishing AG 2017 141

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_12
142 12 Working with the Inner Child

As we learn to put ourselves in the mind of a child, we become more sensitive to

and understanding of such “immature” reactions. Beyond the intensity, we can often
glimpse life though a child’s eyes and understand in a way that is far from adult but
much more accurate. One such vision that is quite common is a child’s view of
adulthood. Children, and sometimes inner children of adults, may see adulthood as
“all work and no play.” They have no taste for that! What they haven’t come to
understand is that well-adjusted, healthy adults freely and comfortably mix child-
like behaviors with adult ones.
The use of the word transference has often been restricted to refer only to feelings
toward the therapist, as opposed to other important figures in life. This is not a very
useful distinction, since the phenomenon in relation to others is identical and just as
important. Another issue is whether the term transference is used for all feelings
toward the therapist or solely to those that carry the imprint of earlier relationships.
When we use the concept of the inner child, there is no question. We are referring
only to those phenomena that hark back to earlier times.
As explained in Chap. 6, which explores the context of connection, the most
important reason we prefer the inner child concept is that it naturally works against
the shame that patients feel about their young selves and leads toward a more positive
and compassionate approach. Clinically, this stance is far more helpful than pointing
out the patient’s distorted thoughts and feelings, which only reinforces shame.
To be precise, we don’t really have inner children. What we do have is a mind on
the lookout for circumstances that match those experienced early in life and natu-
rally fetches the appropriate reactions out of procedural memory. The end result
looks and feels like a child taking over, so why not picture it and speak of it that
way? The more we gain awareness of the extent to which childlike thoughts and
assumptions lace our adult conversation, the better we will understand our patients
and the different contexts and ways of viewing the world that they hold inside.
If childlike reactions are constantly available to us throughout life, why do we
not behave like children all the time? First, we learn through a long process of matu-
ration that there are more appropriate and effective ways to function in the adult
world. Second, we acquire internalized values (residing in the conscience or super-
ego) that bias strongly against our “childish” ways. It is because of these values that
patients feel so much shame about thoughts and feelings that come from the inner
child. When they experience childlike thoughts and feelings, they do their best to
cover them up. In therapy, childlike behaviors often can’t be held back. Patients
typically feel ashamed and angry at themselves when they see their young reactions.
They are inclined to punish themselves and try to eliminate the intrusive thoughts
and feelings. What effect does this have? The inner child simply goes into hiding
and no progress is made. So for our purposes as therapists, giving the inner child as
comfortable a place as possible in the therapeutic relationship is of great value.
The therapist who welcomes the inner child and helps the patient to get over his
or her shame will encourage exploration of “young” feelings and thinking. Childlike
phenomena come to the surface and once again begin to be modified and reshaped
by adult life. A positive attitude allows gradual integration of the child as part of a
whole adult. In other words, the inner child begins to grow.
12.2 Before Meeting the Inner Child 143

Childlike and playful behaviors are and should be part of healthy adult living.
It is when young behavior patterns and procedural learning about life become
locked in and inaccessible to growth that they become dysfunctional. It is then that
childlike patterns become entrenched dysfunctional patterns or EDPs. When a child
has to cope with an insoluble problem, let’s say a family where the parents were
preoccupied with a sick sibling, the child’s solution is to stop growing emotionally.
Needs can’t be eliminated and yet complaining to the parents is inappropriate, so the
child, in effect, stops processing his or her emotional needs. Unmet wishes remain
frozen as they were in childhood, blocked by shame, and the inner child waits for
someone to come along who understands and is ready to fulfill them. The therapist
is the obvious candidate and naturally triggers activation of dormant longings.
Thus, the difference between pathology and healthy growth is that in health,
childlike patterns gradually evolve and are adapted to adult life. In pathology, in the
affected areas, maturation is arrested, and thinking, wishes, and patterns of reaction
remain “fixated” as they were long ago.
Such a combination of shame covering up childlike plans to seek fulfillment of
unmet needs is another example of a classic, two-layer EDP. Like Jack before he
had his panic attack, in order to avoid the painful experiences of insisting on wishes
and being brushed off by parents, the child tries to suppress any needs. When this
fails (as it must because these needs are absolute), the conscience forms a new layer
of EDP, internalizing values against being “self-centered” or “needy” and generates
shame with any expression of personal desire. Wishes remain static in an unfulfilled
state. A simple term for this is “unfinished business from childhood.” Psychotherapy,
especially the therapeutic relationship, is perfectly designed to bring out the inner
child who represents this kind of EDP. Only when therapist and patient become
compassionately aware of its source can it be permanently transformed.

12.1 History of the Inner Child Concept

The concept of the inner child is not new. It goes back at least to Ferenczi [3], who had
a profound respect for the point of view of the child Harris and Kachuck [4]. With new
recognition of the devastation of trauma and the need for compassion, John Bradshaw
[1] brought the concept to popular culture. More recently Richard Schwartz has given
it more systematic treatment with the inner family systems model of treatment [6].

12.2 Before Meeting the Inner Child

Therapists, especially at first, often feel compelled to explain that the patient will have
to do the hard work and the therapist will only be a facilitator. The adult patient nods
in agreement with the obvious. However, the inner child was looking for the therapist
to make things better and experiences intense disappointment and anger. That’s
exactly what the parents did; they refused to help. The example in the next section will
show what a serious impasse can grow out of a seemingly benign explanation.
144 12 Working with the Inner Child

12.3 How to Recognize the Inner Child

The most powerful way to recognize the signature of the child within is to realize
that children not only have different ways of seeing the world, but they approach
problems differently. As mentioned in Chap. 9 on the initial session, children know
that they have little personal ability to solve problems, especially major ones. So
they seek to influence a grown-up to solve the problem. The child has only a vague
and somewhat magical idea of how the adult is going to do this, which can be a tip-
off as we listen. Adults solve problems by tackling them directly, assessing pre-
cisely what is needed and doing that.
A middle-aged patient felt perpetually like a boy pretending to be a man. He had
seen his therapist for a number of years but made little or no progress in dealing
with feelings of being a “fraud.” Over the years they worked together, he diligently
attended sessions and, as instructed, said just what was on his mind. Several times,
he dared to express the wish that his therapist would give him more “concrete help”
in achieving manhood. The therapist, believing in a “hands-off” technique, told him
that that was not part of the technique, and as an intelligent man, he should be able
to find his own way. The patient would bring the issue up from time to time but
knew how the conversation would go. He continued to feel ill equipped to find his
way and did not progress.
As a child, he had very little effective parenting. His father left when he was four,
and his stepfather, who arrived 3 years later, was better at admonition than nurtur-
ing. The patient’s relationship with the therapist soon exemplified a classic transfer-
ence. His inner child related to the therapist as a father figure, hoping he might
receive the fathering he had never had. The therapist’s blank screen technique did
what it was supposed to, bring out childlike feelings. However, instead of “analyz-
ing” the patient’s wish and helping him put it into perspective as called for by good
technique, the therapist reenacted the parents’ part in the childhood drama. Like the
parents, his answer, as heard by the inner child, was simply “no!”
What this patient ultimately needed was to become more accepting of his inner
child. He needed to let go of shame over his immaturity and experience the anger
and grief that had not had a chance to heal. These feelings were entirely appropriate
given the inadequate parenting he had received. Only when they could become con-
scious affects could the feelings heal. Then he could begin approaching his needs
from a more adult point of view. In fact, in a new experience of therapy with a dif-
ferent therapist, it turned out that he didn’t need a lot of concrete coaching at all. He
already knew a lot about adult life, but his inner child had remained in a frozen state,
waiting for the need to be acknowledged. His feeling of being a “fraud” was, in a
way, real. A large part of his psychological being was indeed a child, stuck waiting
and unable to move forward.
Sadly this type of therapeutic error is not uncommon. A therapist who is looking
for transference is likely not to find it because the inner child is too proud to allow
that. Patients rarely express their wishes in a way that is obviously immature.
Instead, they focus on some need that sounds more reasonable, like the thermostat
in the first example or, in this case, getting some more “concrete help with adult
12.4 A Word of Caution 145

life.” This patient wanted help doing what he didn’t feel he knew how to do. His
request sounded adult but wasn’t. The adult was intelligent, resourceful, and good
at problem solving, but the child felt lost and in need of help and support. The thera-
pist wasn’t wrong in seeing that he couldn’t really teach this adult patient to be a
man. Both of them missed the fact that there was a child in the room who was still
looking for guidance that was not provided years earlier and hoping to solve the
problem in the way children do: motivate the therapist to do what was needed.
The subtle tip-off to the child was that a grown man was asking for help with
knowledge that is commonly available to grown-ups. An adult solution to the prob-
lem would be to talk with his wife and friends to fill in any gaps in his understanding
of normal adult ways. This might be a bit embarrassing, but once he got over the
shame, his wife and good friends would be happy to help out.
So, the fact that he was waiting for help to arrive when it was all around him was
the clue that this was a child waiting to have his problem solved by the parental
figure in his life, namely, the therapist. He was trying to influence the therapist to
address the problem, rather than setting about solving it directly. In a childlike way,
he had a simple, global notion of manhood and knew that it was different from his
day-to-day experience but didn’t try to understand more than that. Why should he?
Such a thing would be beyond the ability of a child and better left to the parent to
understand and guide him.
As usual, dysfunction, even if subtle, is our signal to look for an EDP. Here are
some clues that might tell us that a particular dysfunction is coming from an inner
child:

• Seeking things from the therapist that therapists can’t do

• Feelings more intense than expected about issues around the therapy
• Especially intense feelings about the therapist (often not revealed)
• Black-and-white thinking about life, i.e., seeking perfection or seeing people as
“good” or “bad”
• Issues seen as resolving magically, i.e., finding a mate without working at build-
ing a relationship
• Belief that a perfect body or other specific characteristics determine results in life
• Excessive upset over limitations to the frame and what the therapist can do
• Anger about circumstances we can’t possibly control (indicates the point of view
that “someone” has failed)

What all of these have in common is that they reveal childlike patterns of thinking,
which are usually mixed imperceptibly into what sounds like adult conversation.

12.4 A Word of Caution

The most common cause of therapeutic failure is missing an inner child. Childlike
thinking and feelings are often very well cloaked in adult-sounding words. In prac-
tice, transference does not feel like a phenomenon; it feels like life. As in the case of
146 12 Working with the Inner Child

the woman who wanted her therapist to change the thermostat, and in the case of the
man who wanted concrete help, what threatens the therapy appears to be a real-
world problem having little to do with the therapeutic relationship. When consulting
on cases that have come to an impasse, the first question to ask is whether an inner
child has been missed. In the great majority of cases, this is exactly what has gone
wrong.

12.5 Adult Temper Tantrums

Now that we are beginning to have a sense of what it looks like to have a child
cohabitating with an adult, a phenomenon that is more common that one might
think is the early childhood temper tantrum transposed into an adult. The clues are
inappropriate anger or self-destructiveness combined with persistent failure to
access effective, adult solutions to a problem.
Self-destructive behavior patterns that don’t end and anger that doesn’t dissipate
can be signs. The child within is not motivated to stop the behavior because no one
seems to have heard or to be willing to respond. Of course the child has not given
any clear indication of what is expected. To say out loud just what is desired would
be to display shameful immaturity, and the adult patient would not permit that. If the
therapist listens carefully, it will soon be apparent that the child does have wishes or
demands. The therapist can ask, What would make you feel like stopping this
behavior? or Have you had any thoughts or fantasies of someone doing something
for you that would allow you to feel better?
For example, a woman in her thirties was chronically angry. She would find fault
with her employer, her parents, her boyfriend, and her therapist. She had worked
very hard in therapy to let go of compulsive, self-destructive patterns of behavior,
yet she still didn’t have the relationship and career that she desired. After a period
of being particularly good in curbing destructive behaviors, she began a romantic
relationship but after a few weeks was rejected. She went immediately into a ram-
page of self-destruction and wondered why she couldn’t seem to stop. This was a
temper tantrum. She had controlled her behavior very well, but the man, like her
father, did not reward her good behavior with love. Her raging was that of an inner
child who has run out of ways to solve the life-and-death problem of finding love.
The wrong way to deal with a temper tantrum in childhood is to banish the young
person to his room to smash toys, crayon the walls, and make a bad situation worse.
Something similar is what often happens when adults have the equivalent of a tem-
per tantrum. Sadly, they are left to themselves to rage and destroy. Because they
have adult rights, there may be no one in a position to stop them.
A better way to deal with children is to scoop the child up, preventing him or her
from doing harm, and speak in a calm, compassionate voice until the tantrum sub-
sides and the tears begin to flow. Soon the child is over the rage and ready to accept
warmth and comforting. In doing so, the parent is creating a context of safety and
empathy to heal the emotions and allow the child to learn that the angry affect has
not ruined the relationship and that destructiveness is not acceptable. The adult
12.7 Containment 147

equivalent is for the therapist to do as good a job as possible of preventing harm,

including using hospitalization or outside support, and to keep up soothing talk and
listening until the raging child inside comes to the end of his or her anger.
Tantrums like this can go on for a very long time. Children are very persistent,
especially when the needs in question are (from a child’s point of view) life-and-
death necessities. On the other hand, when an adult like the therapist offers under-
standing, the child will be very quick to take notice.

12.6 Accepting Unmet Needs

However, there may still be a problem. Children don’t easily accept substitutes. The
adult therapist may want to speak in adult terms of needs appropriate for an adult.
The inner child has a different idea. The child is still looking for fulfillment of early
needs, frozen in their original bodily form, for example, 24-hour attentiveness and
physical expressions of love like being held. This child, lacking healthy experience
with caregivers, did not learn to compromise. The child saw that needs were not
acknowledged, and so the skill of acceptance, necessary for compromise, was not
learned. With little ability to accept substitutes, the gap between the therapist’s
understanding and compassion and the inner child’s literal needs can present a
major problem in therapy.
Many such early needs will never be met. Adult relationships simply don’t have
room for the complete emotional and physical protection once provided by parents.
The therapist has understanding and empathy to offer. The child may be a long way
from accepting such an inadequate and disappointing substitute. Once again, healthy
children learn to accept empathy and understanding as substitutes when their needs
can’t be met, but this has not been the experience of our patient’s child within.
Going through painful feelings of disappointment and loss and making peace
with a failed childhood are no minor matters, but it is an essential and positive piece
of therapeutic work. The therapist’s patience and willingness to understand the
gravity of the situation are important in helping the patient get past intense shame
that goes with experiencing oneself in such a regressed, childlike position, bom-
barded from within by immature feelings and wishes.

12.7 Containment

Normally, we try to keep the level of arousal in sessions within a modest range
where the patient remains in control and able to self-observe. With feelings at the
level of intensity that sometimes happen in a temper tantrum, this may not be pos-
sible. The patient may experience very intense feelings and not be able to control his
or her expression. Here again the therapist is a rock on the shore, with a wild stormy
sea beating incessantly upon it. In this situation, it is critical to make a clear distinc-
tion between what is destructive or abusive on the part of the patient and what is
simply communication of extremely intense emotion. The therapist who can
148 12 Working with the Inner Child

tolerate this intense expression of feeling, while maintaining a clear perspective on

the line between passion and destructiveness, will provide a rare and crucial sense
of safety and control to a patient who is terrified of his or her own capacity to
destroy and alienate. A good word for this therapeutic function is containment.
Perhaps an appreciation for the vulnerability of a patient in this position will
again reinforce the importance and practicality of the inner child concept. Thinking
in this way, we are able to identify the patient not as a poorly behaved adult but as a
hopeful and positive child struggling mightily to solve a problem left frozen and
unresolved for years.

12.8 Schema Therapy

One therapy has come up with an interesting solution to the gap between what
therapists have to offer and what inner children are waiting for. Schema therapy has
introduced and researched a concept called limited reparenting (Rafaeli [5]), in
which they recognize that the therapist who offers nothing will not even engage the
child. On the other hand, the therapist who tries to fulfill everything is luring the
patient into a painful trap. Instead the therapist tries to meet some of the literal
demands of the child. The therapist must acknowledge very clearly that the fulfill-
ment can only be partial and begin early in the process to work with the child’s real
disappointment. In this way, the therapist models a compromise, and hopefully the
inner child is able to learn acceptance.

12.9 The Manipulative Patient

Inner children come to us with many difficult experiences of early life. When parents
are unresponsive or the child can’t find a way to motivate caregivers to meet basic
emotional needs, the only remaining solution may be to manipulate. A technical defi-
nition of manipulation is to bypass the free will of the other person. When dealing
with people who are not responsive, this may have been the only way to get results.
A past like this can create problems in therapy. The therapist prides him or herself on
being responsive and willing. The child within is far from being ready to trust his or
her fate on the responsiveness of the therapist and may resort to manipulation instead.
The therapist then feels disregarded and unseen, which is a painful experience. A
therapist who does not recognize the presence of an inner child will have a hard time
accepting manipulative behavior and working with this kind of patient.

12.10 The Self-Sufficient Patient

Yet another kind of inner child is the one who, mistrusting others’ willingness to
help, prefers to take care of his or her needs through nonhuman means. Food, medi-
cation, drugs, and self-harming behaviors may represent alternative ways to meet
12.12 The Corrective Emotional Experience 149

emotional needs. One patient sought the company of paid prostitutes because only
they could be trusted to want to interact with him. His loving wife did not feel to
him at all as safe and reliable.
These behaviors are EDPs in that they are ways to avoid the excruciating pain of
having to trust someone when one can’t be certain of their willingness or trustwor-
thiness. Successful resolution of this kind of EDP requires taking emotional risks
with no more than an intellectual conviction that it might be safe. Here the behav-
ioral approach to the EDP must come first. Internalizing the skill of trust is virtually
impossible as long as the need-satisfying behavior continues. Abstinence is a neces-
sary prerequisite for the deeper emotional work of learning to trust.

12.11 Compassion

In each case, the luxury that the child missed out on was someone who understood
and was not critical of perfectly understandable feelings and behavior. Tara Brach is
a proponent of Buddhist meditation and also a leader in recognizing the place of
compassion in fighting the shame that binds so many people who have experienced
deprivation. This is the key to healing, since it addresses the usual two-layer, com-
bination EDP where the top layer is self-denigration or even self-hate. This layer is
like an internalized voice that says, Who do you think you are? You have no right to
feel pain and rage. Compassion from an outsider is what is needed to begin to
remove this ugly bandage.
True compassion is critical. A therapist who is compassionate about the patient’s
disappointment and anger will be in a much better position to be able to move the
conversation to acknowledgment and acceptance of the shortfall that was experi-
enced years ago. When this happens, it provides disconfirmation of the patient’s
self-generated shame and long-standing expectation of disappointment.

12.12 The Corrective Emotional Experience

Inner children are often the beneficiaries of corrective experiences within the
relationship with the therapist. Carl Rogers seeded a great deal of debate on the
true mechanisms of therapeutic action when he coined the famous phrase correc-
tive emotional experience. In describing this key element in the therapeutic pro-
cess, Rogers emphasizes that the effects of psychotherapy are experiential, not
intellectual. In bringing about such transformative events, the therapist is not a
blank screen but a human whose healthy reactivity becomes a part of the experi-
ence, both highlighting the patient’s unhealthy reactions and providing a model
for growth.
The corrective emotional experience is not, as one might naively imagine, pas-
sively experiencing a healthy interaction with the therapist. Passive repetition of
healthy interaction, no matter how many times it is repeated, will not result in
change.
150 12 Working with the Inner Child

Rogers’ concept of the corrective emotional experience is where the interaction

between patient and therapist goes against the patient’s expectations or where the
patient tries something new and unfamiliar. It is the contrast between the patient’s
usual, unhealthy ways of interacting and a new way that, on an experiential level,
raises emotions and challenges implicit assumptions [2].
Looking at these therapeutic events from the point of view of the affect avoid-
ance model, the corrective emotional experience brings together both pathways for
accessing an EDP. On the emotional side, new experience propels feelings into the
room as affects, where a context of connection provides healing. On the behavioral
side, the patient is either voluntarily practicing a new behavior or is forced to
become aware of a dysfunctional reaction. The end result is healing both of the
affect that had previously been avoided and an invitation to learn a new pattern of
interpersonal behavior.

Key Points
• The inner child concept covers the same ground as transference but does so
with more understanding and compassion.
• Many EDPs involve childlike patterns frozen from the past that continue to
influence the patient’s assumptions about the world and reactions to it.
• Patients cover up their childlike reactions due to shame, so transference is
easy to miss.
• Reasonable seeming but dysfunctional patterns with childlike characteris-
tics are signs of an inner child. These are easy to miss and are the most
common source of treatment failure in psychotherapy.
• Persistent anger or acting out that won’t stop can point to an adult temper
tantrum.
• What makes adult temper tantrums so challenging is that therapists mainly
offer understanding, while the child expected much more. Dealing with the
gap is how patients learn acceptance and compromise.
• With adult temper tantrums, manipulation, and addictive behaviors, the
therapist should first be sure the behavior has been contained and safety
established and then respond with persistent understanding of the child’s
point of view and true compassion.
• The corrective emotional experience approaches both the behavioral and
emotional sides of an EDP. Unfamiliar, healthy interaction brings up
affects where they can heal and points the way to new behaviors that need
to be practiced.

References
1. Bradshaw J. Homecoming: reclaiming and championing your inner child. Reprint ed. New York:
Bantam; 1992.
2. Castonguay LG, Hill CE. Transformation in psychotherapy: corrective experiences across cog-
nitive behavioral, humanistic, and psychodynamic approaches. 1st ed. Washington, DC:
American Psychological Association (APA); 2012.
References 151

3. Ferenczi S. The principle of relaxation and neocatharsis. In: Balint M, Mosbacher E, et al. Final
contributions to the problems and methods of psycho-analysis. New York: Brunner/Mazel;
1929. p. 108–125.
4. Harris A, Kuchuck S. The legacy of Sandor Ferenczi: from ghost to ancestor. New York:
Routledge; 2015. p. 151.
5. Rafaeli E, Bernstein DP, Young J. Schema therapy: distinctive features. New York: Routledge;
2010. p. 71.
6. Schwartz RC. Internal family systems therapy. New York: Guilford Press; 1995.
Adjustments
13

In this chapter, we review a number of parameters that the therapist can adjust.
Often, adjustments are automatic and instinctive, driven by our universal drive for
connection. At times, following the flow of sessions will consciously suggest the
need to vary one or another of these parameters. Some have been the subject of
research, while discussion of others is based more on clinical experience.

13.1 How Much to Talk

As mentioned in Chap. 3, the Victorian era still casts a shadow over psychotherapy
technique. Attitudes of restraint (abstinence and neutrality) have been deeply inter-
nalized by generations of therapists. We can surmise that the level of connection
anxiety experienced by new trainees provides fertile ground for internalizing the
values of elder teachers into the conscience. The affect avoidance model espouses a
more pragmatic approach.

13.1.1 Arguments for Active Therapist Communication

1. Words are articulate. Verbal description is one of the most precise ways to
describe a situation in a way that activates neural networks and emotions. As
repeated many times here, activation of emotions is required for their transfor-
mation, along with a context of connection.
2. Mindfulness, meaning a perspective on one’s own feelings, happens when
patients take in the point of view of an empathic witness who is not overwhelmed
by their experience. Communication by the therapist can help develop a perspec-
tive about the patient’s experience.
3. Asserting a new version of reality. Discussing together how best to make
sense of the patient’s life has been made into a “therapy” by social worker
Michael White of Australia and David Epston of New Zealand, based on the idea

© Springer International Publishing AG 2017 153

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_13
154 13 Adjustments

of asserting a new narrative to disconfirm and override old pathological assump-

tions. It may be that the act of asserting one’s new truth is more effective than
simply disconfirming an old one. In relation to trauma, Bessel Van der Kolk also
suggests that behavioral assertiveness is an essential way to counteract the
destructive effects of passive trauma [5].
4. When behavior change is the goal, then a therapist who is active in discussing
possibilities will be more helpful than one who is passive, especially where resis-
tance is high. Motivational interviewing has shown that trying too hard to “push”
the patient may increase resistance, but respect for the patient’s free will can
make discussion productive.

13.1.2 Pros and Cons of Less Talk

Asking a patient to speak when the therapist is silent is a bit like asking a non-artist
to draw a picture. The command raises immediate anxiety. Silence leaves the patient
without cues about what the therapist will think and at the mercy of his or her spon-
taneous thoughts. If the anxiety is not too great, it can enrich the conversation.
These thoughts can be an important source of information. For example, the non-
conscious problem solver may be struggling with wishes or needs that are contrary
to internalized values. Then we can expect a fear that somehow these prohibited
mental contents will come out in spontaneous talk and will cause some dreaded
reaction by the therapist. This can either lead to understanding and relief or to
heightened anxiety. Adjusting therapist talkativeness according to the level of anxi-
ety can be expected to give the best results.
In contrast, one patient had experienced a great deal of chaos in early life. For her
a silent therapist meant predictability, caring, and safety. For patients who are not
made excessively anxious by silence, a blank canvas can elicit the patient’s most
spontaneous and least disguised productions.

13.1.3 Liabilities of More Talk

At the other end of the spectrum, too much talk on the part of the therapist can dras-
tically inhibit what comes from the patient. Speaking too much can signal to the
patient that the therapist is too anxious or motivated by something other than the
patient’s needs. Patients are likely to interpret unneeded talk instinctively according
to their own internal templates.
In addition, the more a therapist says, the more it will reveal how inexact is the
therapist’s understanding. Inevitably, therapists will not understand perfectly and
are likely to be unaware of some of the sensitivities the patient may have.
Communicating what we are thinking and receiving feedback from the patient help
us build a more accurate understanding. However, random-seeming or misguided
ideas or, worst of all, ideas that seem to come from a textbook will cause a break in
attunement. Accumulated errors may make the patient feel less at ease and safe. In
13.2 Using Language to Regulate Emotional Arousal 155

short, what the therapist says can easily be distracting and take both therapist and
patient further away from whatever the patient is working on.
In finding the ideal balance for any given moment, anxiety is the most significant
factor. When patients are too anxious, they will filter their thoughts and produce
little that is actually revealing. On the other hand, when they feel safe, they will dare
to reveal much more about themselves. The ideal is what will make the patient feel
safe enough to share the greatest amount of new insight.

13.1.4 Some Goals Furthered by Speaking Up

1 . Therapist verbalization might increase the patient’s feeling of safety.

2. As explained in the “three-step dance,” the therapist’s nudge or metacommunica-
tion is actually following the mind’s cursor away from the original subject toward
the new subject of danger or threat to the patient that is causing resistance.
3. Therapist verbalization is to check and clarify your own thinking to be sure you
are on the right track.
4. Therapist education can help with the patient’s motivation to face feelings or
identify and make behavioral changes.
5. The therapist’s words are intended to activate emotions and, at the same time,
create a healing context of mindfulness, connection, and safety.
6. The therapist’s collaborative discussion is aimed at helping to build a coherent,
jointly developed narrative.

13.2 Using Language to Regulate Emotional Arousal

Patients’ level of emotional activation is an extremely important parameter to fol-

low. Overarousal probably means that the prefrontal, thinking cortex will actually
shut down physiologically with reduced blood flow. At such times, the patient has
little perspective, and not much processing or healing can take place. At the other
extreme, little progress will be made when the nonconscious problem solver is so
successful at suppressing affect that none is available for healing.
More than any other factors in regulating the level of arousal, the therapist’s
voice and language are our main instruments. This is not surprising considering the
importance of a mother’s voice in helping the baby to regulate its level of arousal.
When in distress, mother’s voice is extremely soothing. When the child is ready for
fun and games, the mother supplies activating verbalizations.
To a large extent, our tone and level of speech are controlled automatically
through empathy. Attempts to regulate this artificially via the intellect will probably
be detected as inauthentic by the patient and discounted. On the other hand, com-
pared to tone, the use of vocabulary and expressions is more easily controllable by
conscious decision-making. Using more direct, emotionally tinged words increases
the level of activation. Using more abstract and intellectual words will lower the
level. Here are some examples:
156 13 Adjustments

13.2.1 Emotion-Heightening Words

Wow, that one hit you hard, right?

That really pissed you off!
He dumped all over you that time!

Emotion-heightening words move away from abstraction and into the immedi-
acy of feeling, using emotionally evocative words.

13.2.2 Emotion-Lowering Words

It seems like you experienced some negative feeling there.

Perhaps this is arousing some strong affect.
I think it may be painful to feel so angry.

Emotion-lowering words are more abstract and emphasize standing outside the
feeling to give a sense of perspective for someone who is excessively caught up in
the immediacy of an affect. This kind of language would be wrong for an
intellectualizer.

13.3 How Much Support?

All therapy is supportive. We have seen that simply being an empathically con-
nected witness already brings to bear the most powerful support we can provide.
The question, then, is to what extent and how might we go beyond the remarkable
support of regular sessions laced with empathic connection.
One of the more unfortunate traditions in psychodynamic therapy is the distinc-
tion between “supportive” and “uncovering” psychotherapy. Coming from a time
when the initial assessment was used to determine if the patient was “suitable for the
therapy” rather than the reverse, patients who could not tolerate “abstinence” and
“neutrality” on the part of the therapist were relegated to a lesser form of therapy
called supportive therapy, which sought not to challenge defenses but to strengthen
them. The problem is that the distinction inevitably creates a two-class system of
therapy that devalues the “supportive” group of patients and those therapists who
treat them.
While proponents have emphasized that supportive therapy is not actually infe-
rior, the negative connotation is hard to erase. In training programs those patients
who receive the supportive version of therapy are inevitably treated as lesser
patients, and their therapists feel they are performing a service of lower value.
A better approach is similar to what parents do with children. Parents regulate
the amount of concrete support according to the child’s abilities and mental state at
the time. When children are too tired or stressed, less is expected. As children grow
13.4 How Much Authority? 157

and become more capable, parents expect more. In a similar way, therapists do well
to respect their patients’ strengths while not overestimating their capabilities. As
with parents, judgment is needed, along with ongoing observation of results so as to
fine-tune our expectations. Inevitably, we will be wrong some of the time, but well-
intentioned misjudgments are not hard to discuss and repair.
What kind of support might this mean? Information about the world? Concrete
suggestions? Intervening with others in the patient’s support system? It could be any
one of these or some other way a therapist might help a patient accomplish a goal
beside our basic function of understanding and helping the patient understand his or
her dysfunctional avoidance of affects.
One more important consideration: often patients will prefer concrete supportive
actions on the part of the therapist as opposed to empathic understanding. The rea-
son is that empathy requires that the patient experience uncomfortable affects.
Receiving concrete help can be a way of feeling better without doing the hard work
of facing painful circumstances. In this sense, the concrete help is, indeed, an infe-
rior form of support. It is less demanding but also fails to produce long-term change.
In general, demands that are too challenging discourage growth and so does
unneeded support. The affect avoidance model seeks to base therapist choices on
what will help most to foster positive change processes. Research on what makes
therapy effective endorses the idea of an optimal matching between the treatment
and the strengths and liabilities of the patient [3].

13.4 How Much Authority?

Therapists with their training and experience carry a certain amount of authority.
How to use this potential power depends on the patient and on cultural expectations.
Some patients crave authority and respond well to being influenced by the therapist.
For better or worse, they feel good about being told how to think and what to do.
Other patients are reluctant to accept the authority of the therapist or to allow others
to influence them in general. Research shows a positive relationship between thera-
peutic success and adjusting treatment to this characteristic. Below are some
considerations:

• Women and highly educated people tend to react better to being treated as equals
and brought into decision-making. In an initial session, one can ask these patients
a broad question like “Tell me about yourself.” They also do better in a more
flexible structure.
• Lower functioning people have been shown to do better with concrete instruc-
tions and expectations. Such a patient could not handle “Tell me about yourself”
but might be more comfortable with concrete questions like “What jobs have you
held?”
• Patients who are timid or deferential in relation to the therapist, either due to
personal characteristics or a cultural style, may overtly accept the therapist’s
158 13 Adjustments

authority, while their nonconscious problem solver is working to escape it. They
are likely to do better with a softer, more question-oriented approach. They may
need the therapist to hold back more, waiting for the patient to dare to speak,
which encourages the patient to learn that speaking up is acceptable and even
praised.
• When patients are resistant to the therapist’s authority, it is best to “roll with the
resistance,” that is, avoid confrontation and adjust by acknowledging and show-
ing respect for the patient’s ultimate authority over their own decisions and life.
These patients, showing what researchers refer to as high “reactance,” are more
likely to question and to resist if the therapist attempts to impose authority or
even influence the patient. People with addictions tend to fall into this category,
which is perhaps the reason why motivational interviewing was developed espe-
cially for this group.
• Changes made based on the therapist’s authority will eventually require that the
patient take ownership. For addictions in particular, doing the right thing for
someone else is quite acceptable at first but must become a personal goal if
recovery is to last.
• Occasionally, patients ask for authority in an unconscious effort to prove that the
authority is wrong. They may do this by following advice in such a way as to
produce negative results. This pattern is discussed in Chap. 14, under “hidden
agendas.” If we make definite, categorical statements or give advice, not only do
we need to be aware of the possibility that we may be wrong but also cautions
about such hidden agendas.

For the therapist, the lesson is to sense what works with the patient’s character-
istics best and make adjustments accordingly.

13.5 Adapting to Attachment Style

Adults often show attachment patterns—that is, how they seek a comfortable level
of closeness—that reflect the kind of attunement that was present in their first years
of their lives. People with a secure pattern of attachment have little trouble regulat-
ing their relationships and bond easily with therapists. They are also less likely to
require psychotherapy. The remaining three styles consist of nonverbal schemas
designed to cope with hard-to-access connection with parents. These patients as
adults may benefit from adjustments on the part of the therapist [2, 4].

• Anxious/ambivalent children try to cope with an inconsistent attunement.

Sometimes it is there and sometimes not. They are likely to become anxious and
clingy adults, angry when the other doesn’t respond, but tending to blame them-
selves. They respond better to shorter-term, structured therapy with a therapist
who is clear, firm, and consistent. These characteristics provide a backdrop for
calming their anxiety and focusing on the work of therapy.
13.7 Length and Frequency of Sessions 159

• Avoidant children solve their problem of connection by pushing the adult away
and learning to be independent. They become adults who shy away from close-
ness and tend to function on their own. They need to be drawn into a longer-term
therapy in which the therapist is warm, attuned, and flexible to meet the patient’s
needs. This encourages the patient to risk getting close and to learn that it feels
good.
• Disorganized children are those who couldn’t find any strategy that worked to
draw the caregiver closer. As adults, they are harder to work with in therapy and
need a very patient therapist who works to find moments of connection and
expands those to draw the patient in. The work of therapy will be harder and take
longer because of the patient’s difficulty in accessing the support of the context
of connection.

13.6 Internalizing vs. Externalizing

Researchers use the phrase “coping style” to distinguish between patients who tend
to see problems as coming from outside and who seek solutions by changing their
environment, compared to those who question themselves first. Therapy works bet-
ter when it is congruent with the style of the patient. Insight helps internalizing
patients, while an emphasis on behavior will work better with externalizers. Note
that these correspond to the two points of entry for any EDP, emotional and behav-
ioral (Castonguay and Beutler [1]).

13.7 Length and Frequency of Sessions

The frequency of sessions has significant effects. Serious work can be done with
some patients as infrequently as once a month. On the other hand, in most cases,
with less than weekly sessions, continuity and a sense of rhythm become difficult to
maintain.
Therapy with more than weekly sessions tends to increase the level of intensity
and to put more emphasis on the therapeutic relationship than on events outside the
therapy. The relationship is one arena for discovery and healing, but the issues tend
to be the same when they are expressed in the patient’s life outside of sessions.
Thus, many patients are able to benefit from weekly therapy, even though more
frequent sessions might move somewhat faster.
Frequent sessions and using a couch, where the patient doesn’t see the therapist’s
face, were originally designed to maximize transference or, in the terms favored in
this book, the participation of the child within. This intensification may be helpful
or can bring up levels of emotion that are overwhelming for the patient and difficult
to manage. When the EDP causing the trouble is a “guilty quest” (see Chap. 14), the
higher frequency and intensity are more likely to bring the problem to light, since
this form of EDP is typically very well hidden from consciousness.
160 13 Adjustments

13.7.1 Length of Sessions

Sessions where emotional work is being done require some time to approach feel-
ings and time to settle after the hard work is done. Doing this in less than half an
hour is not realistic, and 45–50 min is probably best.
Extended sessions are not often worth the extra expense. One exception is in
cases of dissociative identity disorder, where multiple selves have separate agendas.
These patients can usually adapt to 40–50 min sessions when necessary; however
longer sessions may be optimal for the phase of treatment involving work with trau-
matic events and emotions.

13.8 How Much Structure?

Many techniques in therapy that go beyond “talk.” These range from eye movement
as in EMDR to empty-chair exercises, body movement, visualizing scenes, rating
scales, verbal exercises, and all kinds of homework.
When introducing any of these elements, it is most helpful to have specific training
in the technique and to practice under supervision. In general, the danger of adding
such elements to therapy is that they can be distracting and suppress important feelings
and thoughts. On the other hand, where patients have trouble gaining access to feelings
or are slow in implementing behavior change, added elements may help the process.
Assuming that the therapist is familiar with the specialized technique to be used,
a cost-benefit analysis will help decide what to do. The cost may be adding a com-
plexity, distraction, or reducing spontaneity. The benefit can be increased emotion,
awareness, or motivation. As stated in the section on authority, some patients
respond better to a more structured therapy.

13.9 Use of Homework

Homework can range from none at all to elaborate assignments. How much is right?
It depends on the goal. Homework is particularly useful for behavior change. Since
the nonconscious problem solver is usually at work trying to maintain sameness, there
is naturally resistance to behavior change. Good intentions alone are often not enough
to sustain the process of changing habitual behavior patterns. When no homework is
assigned, the patient is left to him or herself to invent and implement methods for
behavior change, which seems inefficient. At a minimum, discussion of plans to
implement and sustain change will help. Simply doing this engages the therapist as a
monitor and supporter of progress. Elements that can help with behavior change are:

• A concrete plan for what to change and how

• Monitoring of ongoing efforts
13.10 Frame as a Variable 161

• Defining and monitoring milestones of progress

• Enlisting others in support of change

Some patients respond better to more elaborate and structured systems for moni-
toring than others. For some, structure can feel confining and expectations oppres-
sive, especially within the intimacy of the therapeutic relationship. It may be more
comfortable for the patient to engage less personal outside resources, such as self-
help programs. The use of rating scales and charts to track progress is similarly
effective unless those feel oppressive to the patient.

13.10 Frame as a Variable

Promptness of starting and ending, the arrangement of the room, positioning of the
participants, furnishings, frequency and length of sessions, and many other details
all have an effect on the unfolding of therapy. First they make statements about the
therapist, and second they establish expectations. As we will see shortly, the latter
are more important.
The room is an expression of the therapist’s attitude toward the work. We seek to
create an atmosphere of acceptance and safety without being distracting. Some
therapists put a bit more personal decoration into the room. This can increase the
patient’s sense of safety by way of the therapist’s humanness. On the other hand, too
much personal expression can be distracting in the same way same as excessive talk
or personal information.
The way a therapist manages time and other events in the course of therapy is an
expression of personal style but will have different effects on different patients.
Some patients may feel best with very precise, very consistent management, while
others find a bit of flexibility is comfortable.
Of course without realizing it, patients interpret these expressions of the therapist
in their own way. Often the adult patient has a very accurate picture of the therapist,
while the child within may have a more personal one. The two can exist quite inde-
pendently. Even if there is an imperfect match, patients are usually able to adapt to
a particular therapist’s style.
Once they have accepted the style of frame, any change to the frame takes on
meaning. Established patterns become expectations. A variation will raise a ques-
tion, consciously or not, in the patient’s mind. Often this means the patient interpret-
ing the therapist’s motives. This kind of conjecture is typically a product of the
patient’s childlike assumptions based on past experience. A variation in the frame
needs to be processed in a manner similar to a break in attunement, as was described
in Chap. 11, on maintaining the therapeutic relationship.
Beyond a few minutes, time management and major events like the therapist
missing an appointment may be more of an issue of boundaries.
162 13 Adjustments

Key Points
• How talkative should a therapist be? Enough to help but not in a way that
distracts.
• The kind of language we use gives a powerful way to regulate the patient’s
level of arousal up or down.
• Therapy is inherently supportive. Support beyond empathic understanding
can be adjusted according to need.
• Therapist authority is a complex tool whose use depends on the patient’s
characteristics and acceptance.
• Different attachment patterns and coping styles respond better to different
therapist approaches.
• Length and frequency of sessions, special techniques, and homework can
all be optimized for effectiveness.
• The frame creates expectations, and how we handle them has more of an
effect than the frame itself.

References
1. Castonguay LG, Beutler LE. Principles of therapeutic change that work. New York: Oxford
University Press; 2005. p. 355.
2. Holmes J. Too early, too late: endings in psychotherapy—an attachment perspective.
Br J Psychother. 1997;14(2):159–71.
3. Norcross JC, Wampold BE. Evidence-based therapy relationships: research conclusions and
clinical practices. Psychother (Chic). 2011;48(1):98–102.
4. Slade A. Attachment theory and research: implications for the theory and practice of individual
psychotherapy with adults. In: Cassidy J, Shaver PR, editors. Handbook of attachment: theory,
research, and clinical applications. New York: Guilford Press; 1999. p. 575–94.
5. van der Kolk B. The body keeps the score: brain, mind, and body in the healing of trauma. 1st
ed. New York: Penguin Books; 2015. p. 217.
Part III
A Catalog of EDPs
Behavioral EDPs
14

Some dysfunctional behaviors are freely chosen, as opposed to helpers and symp-
toms that come upon us whether we like it or not. Please allow me now to repeat the
earlier summary of how entrenched dysfunctional behaviors work: Activation of an
EDP starts with a perception that triggers memory of a potentially threatening cir-
cumstance. As the memory is activated, it triggers an associated negative feeling.
The mind then goes to work “figuring out” how best to distance the feeling. This
nonconscious problem-solving results in voluntary behaviors and involuntary symp-
toms. In addition, the mind sends influencing content into consciousness to steer our
choices of behavior via free will. Below, again, is the EDP diagram (Fig. 14.1).
When we choose to do something dysfunctional, we are not likely to have any
idea that its purpose could be to avoid feelings. What makes avoidant behavior pat-
terns so important in therapy is that once we become aware of their purpose and how
dysfunctional they have become, we gain the option of going outside our comfort
zone and choosing healthier ones instead.
Each type of dysfunctional behavior has a distinctive look and feel to the thera-
pist, and those in each group generally respond to similar treatment approaches.
Therefore, putting like patterns together in this part of the book leads naturally to
modular therapy, optimized for each variety of EDP. Much research has yet to be
done to clarify which approaches are best for specific avoidance mechanisms. I will
offer some suggestions about possible ways to overcome each type of EDP, along
with relevant resources. These are intended as ideas or starting points for therapists
rather than a complete list of treatment options.

14.1 Eight Behavioral Avoidance Patterns

Here, then, are the eight “building blocks” of active affect avoidance patterns.
Together with addictions, helpers, and nonvoluntary symptoms described in the fol-
lowing chapters, we will cover all the types of EDPs from of which patients’ prob-
lems are constructed.

© Springer International Publishing AG 2017 165

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_14
166 14 Behavioral EDPs

Triggering Perception Nonconscious Processing Conscious Result

“Helpers”
Influence Free Will
Memory of
Threatening
Circumstance • Primary Emotion Avoidant
• Conscience-Based Emotion Behaviors
• Automatic Thoughts

Involuntary
Associated Symptoms
Negative Feelings

Fig. 14.1 Diagram of entrenched dysfunctional pattern

14.1.1 Simple Avoidance

Simple avoidance is a behavior we do consciously and purposefully in order to avoid

an uncomfortable affect. When difficult feelings seem too painful or hard to face, it
is not uncommon simply to refuse to face them. This willful avoidance applies not
only to primary feelings like fear or pain but also to conscience-based feelings such
as shame. In fact, one of the most common feelings we consciously evade is shame,
by shaping our words or leaving the embarrassing parts out of a conversation.
Unfortunately, as with other entrenched dysfunctional patterns, avoiding experi-
encing and sharing affects also prevents their healing. In the case of reconsolidation,
this means missing the opportunity to remove the hurt from that feeling permanently.
There are times when simple avoidance might be appropriate. One elderly
woman who had recently lost her husband would open his closet periodically to sort
out his clothes until she had experienced enough grief, and then she would close the
door and occupy herself with another activity. In this way, she regulated the amount
of emotion that she had to process at any one time. Simple avoidance might be also
appropriate in order to find the right time and the right person to share these feelings
with. In general, though, holding back emotion is not a healthy approach.
One of the most important recent research findings in the field of psychotherapy
is that avoidance of obsessions and difficult emotions like anxiety actually increases
the level of suffering and distress over time. Acceptance and commitment therapy
(ACT) has been in the forefront, recognizing that experiential avoidance, meaning
trying to avoid, get rid of, suppress, or escape from unwanted “private experiences,”
consistently makes people feel worse [6].
The most helpful thing a therapist can do is to give the patient the experience of
healing through sharing affects in a context of safety and connection. Educating the
patient about the issue can be helpful but not nearly as valuable as actual experience.
In discussing simple avoidance patterns with a patient, it is particularly important to
14.1 Eight Behavioral Avoidance Patterns 167

try to understand exactly the nature of the patient’s dread. Examples, among others,
may be fear of loss of control, grief that will never end, or shame that is too painful
to bear. The patient may never have had the experience of feeling safe and con-
nected or may have developed a schema or pattern of not trusting enough to try
sharing. Frank discussion of the advantages and disadvantages or risks of talking
about a feeling may be necessary to help a patient overcome a natural reluctance.
Not infrequently, therapists are uncomfortable with strong affects as well. The
therapist may be tempted to intellectualize or change the subject. Recognizing this
tendency is the beginning of keeping it from undermining success.
When patients do dare to share their affects in sessions, it is critical to help the
patient hold the feeling for more than a few seconds. The therapist can reflect back
on what the patient has communicated or leave silence so that the feeling remains
“in the room.” Exploration of the circumstances can help to bring out more emotion
and other facets of the experience, but it also carries the danger of distracting the
patient and pulling the session toward an intellectual discussion. It is best to go
slowly and wait until the feeling has lingered to the point where it no longer holds
the same intensity before going on to another aspect.
Simple avoidance can also happen without the patient’s noticing. A patient who
starts to experience an affect, and then changes the subject, potentially has control
of that avoidance. Pointing out what has happened (see the three-step dance, Chap.
10) can bring the event to the patient’s attention and into consciousness so that vol-
untary control becomes possible. The number-one job of the therapist is to follow
the flow and notice when communication might be skirting around an affect.

14.1.1.1 Treatment Resources

Some patients do best with an experiential introduction to the benefit of facing feel-
ings. Encouraging them to experience intense feelings in a context of empathic
connection has always been part of psychodynamic therapy. This is further empha-
sized in accelerated, experiential dynamic psychotherapy (AEDP).
Other patients may appreciate more structured tools. EMDR, eye movement
desensitization and reprocessing, is a particularly helpful way to break large emo-
tions down into smaller portions and to help patients feel more in control of the
processing of an emotion.
Mindfulness practices also give a conceptual framework and effective techniques
for coping with intense feelings. These, along with structured methods, are incorpo-
rated into several bodies of thinking and writing including dialectical behavior ther-
apy (DBT), acceptance and commitment therapy (ACT), and emotion-focused
therapy (EFT).

14.1.2 Nonverbal Schemas

In discussing schemas, we have to start with a clarification of terms. Here we will

be using the term nonverbal schema to refer only to a subgroup of schemas, those
that begin to develop before the use of words. Piaget used the term “sensorimotor
168 14 Behavioral EDPs

schema” to refer to the nonverbal learned patterns that characterize the reactions of
very young children.
These nonverbal schemas should be distinguished from the more general
(unqualified) schemas used by Immanuel Kant, Piaget, and more recently Aaron
Beck, the founder of cognitive psychology, to refer to all kinds of learned patterns.
Unfortunately, the field of schema therapy tends to confuse this issue by using the
general word but most often meaning the nonverbal kind of schema.
Nonverbal schemas are patterns of reaction learned automatically without effort
by the nonconscious problem solver to maximize positive feelings and minimize
discomfort. For a small child, seeing a glass, reaching for it, and drinking constitute
a fairly well-elaborated nonverbal schema. A nonconscious recognition of emo-
tional closeness associated with an automatic distancing behavior is another exam-
ple. The latter is an EDP. Both are stored in procedural memory. Now, let’s consider
how a nonverbal schema of the dysfunctional kind could develop. A patient, with no
conscious awareness, tends to overemphasize and focus on physical symptoms.
When we learn that as a child this person received a great deal of care and attention
when he was ill but otherwise was neglected, we can guess he learned that illness
was the way to receive love and attention and automatically learned to overvalue
physical symptoms. Such a pattern is a nonverbal schema that has become dysfunc-
tional, an EDP.
This nonverbal type of schema probably begins to form before birth with inborn
reflexes and becomes prominent during the development of early attachments. The
four attachment styles—secure, ambivalent-anxious, avoidant, and disorganized—
are nonverbal schemas observed in the laboratory when mothers are taken away and
returned to their toddlers. Furthermore, the patterns seen in personality disorders
such as borderline and narcissistic personalities are also collections of nonverbal
schemas. Nonverbal schemas are formed throughout life, but the ones that are the
most entrenched and the most dysfunctional tend to be from the early years. We can
presume that the psychological dangers of early life, for example, aloneness, are
experienced as more life-threatening than they are later when we have more
perspective.
Nonverbal schemas whose function is to avoid affects are so automatic that we
hardly notice them. When triggered, these EDPs suddenly take over control of our
actions. For example, at just the wrong moment, while forming a new love rela-
tionship, a patient might suddenly say or do something to distance from the other
person, with irreversible consequences. The nonconscious problem solver recog-
nized danger and accessed an early nonverbal schema to protect against too much
emotional closeness. Patients find themselves behaving in upsetting ways with no
idea of why. Only afterward, when they become aware of the consequences, do
they have the opportunity to recognize that a pattern learned long ago has been
reactivated.

14.1.2.1 Typical Sensorimotor Schemas

The more common maladaptive nonverbal schemas seen in clinical practice will be
reviewed here chronologically through child development. Each sensorimotor schema
14.1 Eight Behavioral Avoidance Patterns 169

described here corresponds to one of the developmental challenges described in Chap.

8, “A Developmental Primer.” Even though every child has to deal with these issues,
the way they are experienced and the solutions adopted are specific for every child.
Therefore, while the broad outlines can be described in general, each inner child is
really an individual.

14.1.2.2 Pre-attachment
The earliest sensorimotor schemas develop before infants are able to react to strang-
ers and experience attachment stress. Even before that, children develop sensorimo-
tor schemas to deal with regulating their level of stimulation. The smallest infants
turn away when stimulation is too intense. As indicated in the chapter on develop-
ment, patients showing very early developmental difficulty, perhaps on a biological
basis, may have a fragile sense of their own boundaries and react as if close human
interaction could overwhelm them, disrupting their physical or psychological integ-
rity. Later in life, difficulty developing healthy emotion-regulating schemas from
this very early period can result in primitive symptoms, such as difficulty parting
with feces, feeling that another’s point of view must be adopted, or difficulty know-
ing whether a feeling belongs to the self or comes from the outside. Delusions can
involve perception of loss of control to outer forces.
Clinically the presence of such severely distorted nonverbal schemas means that
the therapist must be scrupulous about respecting the patient’s boundaries and very
gentle in introducing differing opinions or conflict. One patient was afraid of the
idea of working for pay because that would mean giving another person free access
to his personal will. The explanation that work was temporarily choosing to rent out
a part of one’s free will was one way to make use of an intact intellect to support an
impaired sense of self.

14.1.2.3 Attachment Patterns and the Therapeutic Relationship

As mentioned above, the concept of attachment style is a product of nonverbal sche-
mas. Around 8 months, the amygdala, the site of the brain’s danger detector, begins
to function physiologically. At about that age, babies begin to react to the difference
between familiar adults and strangers. According to the conditions prevalent in their
family, children develop nonverbal schemas to cope with the attachment opportuni-
ties and stresses of their intimate environment. These patterns, once established,
tend to be maintained throughout life.
By about 1–2 years, children respond to an experimental condition involving a
brief absence of the mother according to four distinct patterns, as described by John
Bowlby, Mary Ainsworth, and Mary Main [7]. When the child is easily comforted,
the style is labeled “secure.” The three other patterns can have a profound effect on
the course of psychotherapy because they affect the therapeutic relationship.
Patients who exhibit an anxious-preoccupied style are often appreciated by ther-
apists. They work hard to please the therapist and to maintain the therapist’s inter-
est. They can be very needy or demanding, which can stress the therapist’s ability to
maintain comfortable boundaries, but overall tend to be appreciative of the thera-
pist’s efforts and to do well.
170 14 Behavioral EDPs

Patients who are categorized as avoidant have more trouble and, unfortunately,
tend to gain less from the relationship itself. They do better with more emphasis on
structure, techniques, and procedures than on closeness and empathy.
Patients who show the fearful-avoidant pattern (sometimes called disorganized)
can be recognized as those who have never been able to understand how to get their
needs met through a relationship. They may randomly exhibit different approaches
but carry an expectation of being disappointed. The relationship with these patients
is hard to handle, and there is decreased likelihood of engaging hope and the
SEEKING system (described in Chap. 7) in trying to develop a more productive
relationship. The best results may come from coaching these patients in how to
make the relationship produce positive results.

14.1.2.4 Other Nonverbal Schemas

Personality disorders such as borderline personality, narcissistic, and antisocial per-
sonality disorders represent collections of nonverbal schemas. More detailed
descriptions and resources for working with these problems are covered in Chap.
12, “Working with the Inner Child.”

14.1.2.5 Treatment Resources

Many brands of treatment address dysfunctional sensorimotor schemas. Dialectical
behavior therapy (DBT), emotion-focused therapy (EFT), psychodynamic therapy,
relational therapy, and acceptance and commitment therapy (ACT) all propose ways
to address the instinctive nonverbal reactions of these entrenched dysfunctional pat-
terns (EDPs).

14.1.2.6 Schema Therapy

Perhaps the most detailed and focused approach is schema therapy. This specialized
toolbox sees difficulty meeting universal core emotional needs as the cause of mal-
adaptive nonverbal and other schemas. When circumstances keep basic emotional
needs from being met, children solve the problem by developing patterns that later
become dysfunctional. Schema therapy identifies a long list of basic emotional
needs including safety, stability, nurturance, and acceptance, for autonomy, compe-
tence, and a sense of identity, for the freedom to express one’s needs and emotions,
for spontaneity and play, and for a word with realistic limits which fosters the emer-
gence of self-control [10].
Treatment rests on two major pillars: limited reparenting and empathic confron-
tation. The first means acknowledging what needs were not met and the therapist
fulfilling them as much as can be done within the context of the therapeutic relation-
ship. We have already discussed how the inner child reacts to such partial fulfillment
of the childhood need. The second, empathic confrontation, identifies the maladap-
tive behaviors in an understanding and compassionate way, which helps heal the
shame of acknowledging one’s faults and clears the way for relinquishing the
behaviors. These two approaches are very much in line with the dual emotional and
behavioral approaches to EDPs outlined in this book. In addition, the literature of
14.1 Eight Behavioral Avoidance Patterns 171

schema therapy describes many specific schemas along with methods like “schema
flashcards” to help patients work with them.

14.1.2.7 General Considerations

Therapy for milder dysfunctional nonverbal schemas is similar to what athletes may
do to break a bad habit in their game. First, we identify the problem. Like a coach
in sports, an outsider is often the one to point the issue out. Once the problem is
identified, then we try to notice it and substitute a more functional behavior. In close
emotional relationships such as marriages, it may be hard to catch the schema while
it is unfolding. A cooperative partner can help and so also conjuring up the situation
in imagination. Practice, through visualization and/or by actually doing, is impor-
tant in cementing new behaviors. Unlike problems with sports technique, nonverbal
schemas that ward off an emotion are often more difficult to let go of, since our
mind still anticipates encountering the dreaded affect.

14.1.3 Reenactment

Sigmund Freud noticed how strongly patients tend to reenact traumatic or unre-
solved situations from the past. They have no awareness of the repetition but com-
pulsively recreate the conditions of the past, often with similar results. An example
might be a woman who repeatedly seeks love with men who are not capable of
giving it. On exploration, it becomes clear that her father was similarly unable to
love. Freud puzzled over this pattern because it failed to follow the “pleasure prin-
ciple,” which was that people can be expected to behave in ways that enhance good
feeling.
Looking at this clinical observation from the point of view of affect avoidance,
one of the hypotheses proposed by Freud [5] stands out. Helplessness and power-
lessness are among the most painful feelings known. From the earliest age, humans,
as well as other species, when threatened with powerlessness or helplessness will
struggle intensely to escape or may enter an equally drastic freezing mode. Since
reenactments are the product of that part of the mind that is not accessible to con-
sciousness, we can’t have certainty about why humans regularly and predictably do
this. But we can guess that repeating an experience under our own volition counters
the feeling of being “done to,” even if the reenactment is self-harming. Perhaps an
additional motivation is the vain hope that, this time, we will achieve a different
outcome.
These are complex patterns and challenging in therapy. Not only do they origi-
nate outside consciousness, they are often accompanied by helper EDPs in the form
of automatic thoughts to rationalize and justify the behavior. Reenactment patterns
are dysfunctional in an interesting way. Just like the “cliffhangers” in serialized
stories, where each episode ends with a situation that seems utterly impossible and
hopeless, reenactments set up a situation just as insoluble as the original. It seems
that in the hope of resolving the old unfinished business, the mind recreates a
172 14 Behavioral EDPs

situation every bit as challenging. Anything less would eliminate the hope of this
time coming to a satisfying conclusion. The result is that reenactments start with
high hopes and almost always lead to failure.

14.1.3.1 Treatment Principles

• Help the patient gain awareness of the pattern and its inevitable failure.
• Generate motivation for change with education that there is a way to let go of the
past by healing the emotions.
• Change the behavior, unlocking emotions which then can be healed.
• Note that insight without behavior change cannot lead to successful resolution of
these EDPs.

14.1.3.2 Treatment Resources

Psychodynamic and “third wave” therapies that value exploration of the origins of
problems are more suited to work with this kind of EDP. At the same time, behavior
change, sometimes underemphasized in psychodynamic treatment, is vital in achiev-
ing success.

14.1.4 Acting Out

This valuable concept is simpler and more general than reenactment. It refers to the
principle that putting emotions directly into destructive actions can suppress feeling
them. People who go directly from impulse to action tend not even to be aware of
the feeling that drove them. An angry person who turns immediately to hurting
another or destroying something will hardly feel the anger and certainly not long
enough for it to heal. These actions are automatic and largely involuntary until they
are recognized and curtailed.
Acting out patterns could probably be included under the category of schemas,
but in practice their distinct characteristics make it useful to consider them sepa-
rately. The value in considering acting out apart from other behavior patterns is that
its function of distancing from feelings can become a pervasive style. People who
do this constantly and habitually may have to overcome at least a degree of impul-
siveness before they can benefit from the healing processes of therapy. Thus, an
“acting out lifestyle” can constitute a major blockage to emotional healing as well
as healthy functioning.
Not only does acting out take us away from feelings that might benefit from heal-
ing, it often reinforces dysfunctional thoughts and values. For example, a person
who treats him or herself as unworthy will not notice the anger that is being acted
out but will confirm and reinforce a negative attitude toward the self. In the same
way, acting on hate can cover up personal anger while reinforcing a negative atti-
tude toward others.
The hallmark of acting out is moving so quickly from impulse to action that there
is no time or opportunity to notice the triggering circumstance or associated feeling.
By not allowing the feeling into conscious awareness, healing is prevented, and the
14.1 Eight Behavioral Avoidance Patterns 173

pattern is likely to continue. “Autopilot” is one word to describe the habit of going
directly from some vague unease to impulse to action. Once the action is taken, there
is often some temporary relief as well as the distraction of dealing with the immedi-
ate consequences of the action.
Marriage and other close emotional relationships are a special case of acting out.
In these relationships, the emotional stakes are particularly high because they
engage nonverbal schemas from early life having to do with life and death. When
conflicts bypass emotions and escalate immediately into hurtful acting out, then the
chance to sort out the affective issues is lost in the ugliness of insults and injuries.
By the time the dust settles, neither spouse can recall what uncomfortable feeling
sparked conflict in the first place.

14.1.4.1 Treatment Principles

• Make the patient aware of the pattern and its function.
• Educate and coach about more successful ways to handle emotional hurt.
• Design structured tools to help the patient change the behavior.
• Help the patient experience the value of feeling one’s feelings and how doing so
produces healing and relief, as well as improved results in life.
• Research shows that more externalizing patients, or those who tend more to act
on their impulses and attempt to work out problems in action rather than explora-
tion, do better in treatments that use more structure, tools, and techniques rather
than focusing on the therapeutic relationship [3].

14.1.4.2 Treatment Resources

• Motivational interviewing is helpful with patients who are resistant to following
directives from others.
• Dialectical behavior therapy is a good resource for treatment tools and tech-
niques for behavior change in a context where there are strong feelings.

14.1.5 Hidden Agendas

As the nonconscious problem solver gains maturity—say around age four—it

becomes more sophisticated in creating new EDPs to avoid painful emotions. By
this time, the child has a sense of his or her identity and separateness. There are
rudiments of a functioning conscience and values, such as wanting to be “good.”
Now, the child has, in addition, the cognitive capacity to use ideas for solving prob-
lems. He or she can begin to develop explicit rules to explain how things work or
should work.
Usually the underlying drive for hidden agendas is to deal with a need that can-
not be met but is too important to relinquish. In this period of childhood, we have
little ability to accept failure, at least with regard to fulfillment of important emo-
tional needs. They feel like, and may actually be, matters of life and death.
Furthermore, acceptance is a skill that may not have been developed. The healthy
solution to an unmet need would be to complain in words, but these patterns
174 14 Behavioral EDPs

originate in families where words have long since proven fruitless. The fact that an
old unmet need is still an issue in adulthood tells us that back then no one was listen-
ing. Therefore, the only hope of solving the problem was to try to use nonverbal
influencing and signaling.
Perhaps two parents rage at each other in fights and pay little attention to their
child. Where a younger child might struggle to cope with rage and fear, this time the
problem solver has an idea: there must be a way to influence the caregivers to
acknowledge the wrongness of their behavior and to make them change. The child
adopts exemplary behavior in the hope of shaming the parents into awareness of
their bad behavior. Because the child’s mind still doesn’t grasp shades of gray,
behind the exaggerated goodness is the concept that being perfect is the only way to
send the required message to the parents. Years later in therapy, the adult child suf-
fers from low self-esteem as the goal of perfection seems impossible to achieve,
especially in the light of shameful inner rage at the unfairness of having to be with-
out fault when the parents showed no guilt about theirs.
Two important elements characterize this coping mechanism, which later
becomes an entrenched dysfunctional pattern. First, it is aimed at influencing oth-
ers, and second, it is based on an idea. Younger children have feelings and reactions
but without the intentional aim of motivating the important others in their lives to
change. This young problem solver is able to reason that the only way to solve a
difficult problem is to enlist the effort of the grown-ups. Furthermore, the solution
is built on the mental concept that only perfection would be strong enough to make
the adults notice their imperfection and regret their bad behavior.
This example illustrates the properties of a hidden agenda. What distinguishes
hidden agendas from schemas is that they incorporate a rationale based on a thought
process or idea. They are hidden because no child would dare to announce them
aloud, at least not with caregivers who seem uninterested in self-reflection. Perhaps
the child would not even think the agenda consciously. But the logic is clear and will
continue to influence the patient’s life indefinitely unless brought to light and made
subject to modification.

14.1.5.1 Recognizing Hidden Agendas

When patterns of behavior seem to be sending a nonverbal message (we might call
them “smoke signals”), then we may suspect a hidden agenda. How can we tell? The
signals are usually strong enough that others sense them and experience a tug, often
one that is irritating. It might feel like the other person is constantly seeking attention
or wanting something, though they strongly and sincerely deny any such wish.
A child, and later, adult, may adopt a stance of obviously inappropriate self-
blame, presumably in the hope that the parent or some substitute will notice the
irony and reform. The tipoff is that failures and even self-harm do not lead the
patient toward appropriate regret or efforts to change. Some inner need is being
addressed. There is a hidden payoff.
Some hidden agendas involve erroneous beliefs, for example, that to be lovable,
one must be perfect. The belief, in itself, is a way of clinging to the hope of being
loved, “if only I am perfect…” and functions as a perpetual avoidance of the terrible
feeling of not being loved.
14.1 Eight Behavioral Avoidance Patterns 175

As in the first example, a child may have extreme difficulty accepting the dys-
function or failure of a parent. At this age of total dependence, parenting is a true
necessity. At that age, unaware of the safety nets that might come into play should
the parent be disabled, the child’s nonconscious problem solver invents a strategy of
hope based on its silent communication of needs.
To give an idea of how four-year-olds think and how these thoughts can become
incorporated into personality traits, one mother repeatedly told her four-year-old
son, When you are eighteen, you will have to be on your own. He was terrified, not
knowing if “eighteen” was going to happen tomorrow or the week after. He did his
very best never again to depend on his parents and became increasingly, prema-
turely, independent. In his adult career, he became financially very successful but,
in relationships, had trouble with healthy mutual dependence.

14.1.5.2 Treatment
The most challenging part of work with these patterns is the emotional process of
grieving and acceptance. One must accept painful realities that once would have
been more than a child could bear. What makes this challenging is that the mind still
reacts like the child, as if loss of hope equates to death or something close to it.
Furthermore, due to shame, there will be strong defenses against conscious acknowl-
edgment of the purpose behind the pattern and, especially, the need that drives it.
For this reason, it may take a good deal of thoughtful and gentle exploration of what
feeling might be causing resistance to changing the dysfunctional pattern.
Exploration of resistance to change is the thread that will lead to understanding.
Bruce Ecker, pioneer of what he calls coherence therapy [4], has explored in
detail the application of something like reconsolidation to changing the ideational
part of these patterns. Acceptance and commitment therapy (ACT) is especially
focused on the process of acceptance, which is the emotional work that the child
was unable to face years ago.

14.1.5.3 Treatment Principles

• Be aware that the agenda has remained hidden, and therefore unchanged, since it
was established in childhood.
• Expect significant shame around admitting to having such an agenda. This shame
will have to be worked with from early in the process and may take time. Any
judgment on the part of the therapist will generate powerful shame and anger.
• Work aimed primarily at behavior change without emotional healing will encoun-
ter strong resistance as if the patient’s well-being is threatened. A compliant
patient will try to change and fail.
• The child within may see the therapist as the one to be influenced.
• The patient will have little emotional understanding of any other way to have
needs met, so successful experiences can help build a basis for hope.
• The therapist may need to advocate for the patient’s needs being met and feelings
of injustice validated before there will be any readiness to examine or change
self-defeating behaviors.
• Work to bring to light and challenge the idea behind the behavior can have dra-
matic effects in producing change.
176 14 Behavioral EDPs

14.1.6 Guilty Quests

The hallmark of a guilty quest is the deeply cherished life goal that somehow never
gets accomplished. Two unique elements in guilty quests, compared to hidden agen-
das, are one, they are even more highly detailed and specific, reflecting the cognitive
level of a five-year-old’s more sophisticated thinking, and, two, unlike hidden agen-
das, they don’t appeal to the other person’s parental duty but to adult desires, at least
as they appeared to a young child.
A possible example is the story of J. Paul Getty, who, in his time, was the richest
man in the world. Late in his life, it was written that he said, “I hate to be a failure.
I hate and regret the failure of my marriages. I would gladly give all my millions for
just one lasting marital success [11]”. Without knowing more about his history, one
can imagine that his successful quest for wealth might have been based on a five-
year-old idea that this would bring him love. The fact that he was married and
divorced five times suggests that he may never have been able to allow himself a
satisfying fulfillment of his deepest wish.
Wanting to be a great success or a great beauty are the kinds of things that young
consumers of fairy tales imagine will win them the love and appreciation they need.
In healthy childhood development, these fantasies are not opposed by the con-
science. The result is that they remain on the surface where they can be shaped by a
growing understanding of reality. The wish to be a ravishing princess or powerful
soldier evolves gradually into a more appropriate career choice. Such wishes can
and often do become primary drivers of personal achievement.
On the other hand, a five-year-old’s concept of love may be quite literal and even
physical in a way that runs counter to standards held in the child’s conscience. A
child, for example, whose wish for love is experienced as desire for physical explo-
ration of the parent’s body may be prohibited by the conscience. This is where
shame or guilt produced by the conscience will soon drive the wish underground,
out of awareness, and no longer accessible to reshaping.
Such a wish will then remain in its young form, waiting for the opportunity for
fulfillment. A woman had never felt satisfied with the love she received from suitors
in her youth, nor from her husband. Even while married, she dreamed of an ideal
love. Upon detailed exploration of her wishes, the man would supply discipline as
well as having perfect looks and appreciation for her qualities. When she actually
had a chance to establish a relationship with a man who appeared to have all the
necessary attributes, she found excuses for breaking off the relationship. Her par-
ents had been a glamorous couple and showed little interest in raising the child they
didn’t plan for.
Her wishes were an amalgam of the dreams and actual needs of a five- or six-
year-old. Her allowing the chance to establish a relationship represented a combina-
tion of fear of being disappointed once again and guilt for having such an extravagant
wish. The adult dysfunction engendered by this EDP was a constant state of dis-
satisfaction with her life.
14.1 Eight Behavioral Avoidance Patterns 177

14.1.6.1 “Someday” and the Dimension of Time

Besides a generally greater sophistication compared to hidden agendas, guilty
quests have an important additional element. As described earlier in Chap. 8 on
development, around age five, children begin to grasp an understanding of life as
an arc in time. They become interested in what will happen someday. This new
cognitive ability gives the child an entirely new and superior way of solving
problems.
With the ability to picture a distant future, the child can imagine someday achiev-
ing qualities such as power, attractiveness, and strength that are impossible for small
children. Today’s shortfall of love and attention can be counteracted by a resolve
someday to be so attractive that love will be bestowed. The advantage of this solu-
tion compared to younger ones is that it does not require negating today’s reality.
Younger children are forced to fight current reality either by some form of denial or
by hidden agendas to change those around them. Fantasizing future success gives
hope without having to do the impossible to day. The ability to imagine a better
future provides a powerful new way to wrest hope from disappointing reality.
Unfortunately, some of these ambitions may place the child in illicit and dangerous
rivalry with a parent or in a position of wishing to achieve prohibited ambitions and
pleasures.

14.1.6.2 Treatment
The identification and treatment of these EDPs are the classic subject matter of
psychoanalysis. This type of pathology is particularly hard to unearth and may
require long, patient hours and a strong therapeutic relationship to bring to the
surface. Patient work with dreams and free association is one of the most effective
ways to uncover such a pattern of wishes and guilt. Once they are revealed,
empathic understanding clears the way for acceptance and an often-difficult reas-
sessment and realignment of immature wishes so they can be adapted to fit with
adult reality.

14.1.6.3 Treatment Principles

• Guilty quests have intense and powerful feelings behind them, which cause pow-
erful and sophisticated efforts of the mind to keep them covered and out of
consciousness.
• The subtle and time-consuming exploration of unconscious thoughts and feel-
ings characteristic of psychodynamic therapy and psychoanalysis are well
adapted to work with these patients, who generally function well but have spe-
cific areas of dysfunction.
• As with hidden agendas, attempts to work primarily toward behavior change,
without looking for the underlying dynamics, are likely to encounter powerful
resistance that may appear inexplicable unless the underlying dynamics are
suspected.
178 14 Behavioral EDPs

14.1.6.4 Helpful Readings

• Deborah Cabaniss’s book Psychodynamic Formulation recognizes the impor-
tance of someday. This is an excellent teaching tool along with her Psychodynamic
Psychotherapy [1, 2].
• Nancy McWilliams’s classic Psychoanalytic Formulation is another excellent
resource [8].

14.1.7 Developmental Arrest

What makes development happen is practice. Whatever the drive is that pushes us
toward growth and development, our motivational system pushes the nonconscious
problem solver to come up with new patterns to solve problems and gain access to
pleasure. Along with anticipation of positive emotions, the problem solver may
anticipate painful affects associated with failure or harm and fear of consequences.
When these negative feelings overcome the positive ones, the person may choose to
avoid practicing the new behavior. This is the situation that produces developmental
arrest. A pattern of avoidance of experience will result in failure to traverse devel-
opmental challenges and to gain skills and overcome associated fears.
When bad feelings accompany our attempts to conquer new territory, the easiest
way to avoid those affects is to adopt a behavioral strategy of not trying that new
experience. The result is that we miss out on the chance to develop a new skill. Then
we will continue to rely on old patterns and coping strategies, even when they are
not very successful. The indicators of developmental arrest are lack of expected
positive skills and use, instead, of more primitive or immature coping strategies.
In clinical practice, as emphasized by Antonio Pascual-Leone [9], promoting
new development of novel patterns represents an important part of what therapists
do. As patients encounter and recognize the deficits imposed by their EDPs, they
have an opportunity to invent new solutions to problems and to practice implement-
ing them. Getting out of one’s comfort zone always brings up greater needs for
support from outside. The therapeutic relationship provides some of the needed
supportive context in a manner similar to that of parents for children.

14.1.7.1 Pockets of Immaturity

One reason the thought of immaturity brings up so much shame is that we tend to
think of immaturity as a global phenomenon, as if all maturation stopped at once.
This is not how developmental arrest works. The avoidance of experience usually
happens in very specific areas and leaves others untouched. In fact, patients fre-
quently compensate for a shortfall in one area with hypertrophied skills in another.
The theme of this book, the avoidance of difficult affects, usually brings up the
thought of positive ways to deny or push away feelings. Developmental arrest is, if
anything, an even more direct way to avoid affects through non-behavior. This alter-
native route to affect avoidance, and its reversal through new experience, is proba-
bly underestimated in clinical practice but should not be. Helping patients to grow
is as important as helping them let go of other kinds of EDPs.
14.1 Eight Behavioral Avoidance Patterns 179

14.1.7.2 How to Recognize Developmental Arrest

As therapists, we are already alerted to look for areas of dysfunction. Whenever
patients fail to utilize a coping skill that most people possess, and, instead, rely on a
less mature one, we will probably find developmental arrest. Emotions that are more
intense than expected are another clue, since young feelings are usually on a larger
scale, commensurate with the life-and-death quality of childhood events. Absolutes
or black-and-white thinking can also point to cognition from an earlier era. For
those whose arrest was in the teens, lack of skills such as a well-formed sense of
personal identity, poor impulse control, and limited ability to appreciate the nuances
of a mature relationship are tipoffs.

14.1.7.3 Shame About Immaturity

Perhaps the greatest negative force affecting the course of psychotherapy is that, as
humans, we naturally avoid showing how immature and irrational we really are.
Helping patients overcome this avoidance is one of the most challenging tasks for
therapists. In truth, “real” adults have a major component of child within them, but
most of us feel obligated to cover this up. Habitually we rationalize our irrational
ideas and omit revealing intense feelings that don’t seem sufficiently “adult.” This
avoidance makes it easy to miss avoidance of experiences and the resulting pockets
of immaturity.
This screening of material to cover up shameful immaturity is unfortunate
because among the easiest and most gratifying parts of psychotherapy are trying
new behaviors and growing. Acquiring new skills is exciting and pleasurable. It also
comes with a feeling of pride at becoming a more complete person. Fortunately,
these pleasures are still available even when growth happens later in life.
When patients become aware of how “young” their reactions are, they are usu-
ally judgmental and punitive. This is exactly the wrong approach for parents of
young children and for patients in relation to their young selves.

14.1.7.4 Treatment Principles

• Working with shame: The therapist’s attitude of compassion and acceptance can
model a better, nonpunitive, way to welcome the inner child into the therapy
room. This process may take considerable time and work. Shame is hard to
defeat because it depends on a value stored in the conscience, and we know that
those are resistant to modification.
• Working with fear: Once past the barrier of shame, trying out a new behavior
brings up not only the normal flutter of anxiety that usually accompanies stretch-
ing ourselves out of our comfort zones but a reexperiencing of the old fear that
stopped development in the first place. We can think of this situation as a classic
entrenched dysfunctional pattern, accessible by two routes. Approaching first
through behavior change leads to activation of affects, which makes them reach-
able for healing by reconsolidation in a context of safety and empathic
connection.
• Nonverbal schemas: Developmental arrest in early life is challenging because of
the intensity of the fears and the fact that avoidance patterns may involve nonver-
180 14 Behavioral EDPs

bal schemas that function automatically. These are often difficult to bring into the
therapy room because they happen only when triggered.
• Developmental arrest in adolescence: Failure to navigate the challenges of ado-
lescence is especially problematic because the skills used by patients to face their
uncomfortable feelings are largely learned in adolescence. In particular, treat-
ment asks the patient to go against impulses, which, for those who have not
developed good impulse control, feels strange and very difficult.
• Group treatment: For adolescents and young adults, the support and encourage-
ment of peers are a powerful force for behavior change and maturation.
Experiential approaches embodied in structured environments such as wilder-
ness programs may be particularly helpful.
• Complicating drug abuse: Drug abuse, especially marijuana, can complicate
adolescent development and works against doing what is difficult. The culture of
relaxation rejects practicing uncomfortable behaviors. Furthermore, regular
intoxication largely removes even appropriate feelings of shame or discomfort
arising from failure to practice positive behaviors, both in life and in the course
of therapy. Drug abuse during therapy effectively diminishes activation of affects
and, therefore, blocks the reconsolidation process by which affects are healed.

Key Points
• Behavioral EDPs are sent into consciousness by the nonconscious problem
solver so that, when we choose to act on them, the behavior will help with
affect avoidance. This leaves the potential of choosing not to act, which is
one key to change.
• Simple avoidance is consciously choosing to act so as to avoid difficult
feelings.
• Nonverbal schemas are learned behavior patterns that can potentially come
under voluntary control.
• Reenactment is a human tendency to repeat unresolved situations from the
past, usually with the same unsuccessful results.
• Acting out is putting emotion into action in such a way as to avoid actually
experiencing the affect.
• Hidden agendas are attempts to solve problems by sending covert mes-
sages to the “big people” in our lives.
• Guilty quests are plans to solve problems of today “someday” in the future
through idealized achievements.
• Developmental arrest is an important way of avoiding affect by not prac-
ticing specific new behaviors and skills.
• Changing behavioral EDPs not only improves health and functioning but
usually uncovers the affect that was avoided in the first place, so that, at
last, it can heal.
References 181

References
1. Cabaniss D. Psychodynamic formulation. Hoboken: Wiley-Blackwell; 2013. p. 103.
2. Cabaniss D. Psychodynamic psychotherapy: a clinical manual. Hoboken: Wiley & Sons; 2011.
3. Castonguay L, Beutler L. Principles of therapeutic change that work. New York: Oxford
University Press; 2006. p. 355.
4. Ecker B, Ticic R. Unlocking the emotional brain: eliminating symptoms at their roots using
memory reconsolidation. New York: Routledge; 2012.
5. Freud, S. Remembering, repeating and working-through. In J. Strachey (Ed. and Trans.), The
standard edition of the complete psychological works of Sigmund Freud (Vol. 12, p 151).
London: Hogarth Press; 1961. (Original work published 1914).
6. Harris R. ACT made simple: an easy-to-read primer on acceptance and commitment therapy.
Oakland: New Harbinger Publications; 2009. p. 23.
7. Karen R. Becoming attached: first relationships and how they shape our capacity to love.
Reprint ed. New York: Oxford University Press; 1998. p. 148.
8. McWilliams N. Psychoanalytic case formulation. New York: Guilford; 1999.
9. Pascual-Leone A. Featured interview. The integrative therapist. Vol 2(1). 2015. SEPIweb.org.
2016.
10. Rafaeli E, Bernstein DP, Young J. Schema therapy: distinctive features. New York: Routledge;
2010. p. 7.
11. Vallely P. Don't keep it in the family. London: The Independent; 2007.
Addictions
15

During the “early days” of neuroscience––in the late twentieth century––the discov-
ery was made that all the substances that led to addiction had one thing in common:
they caused an increase in dopamine in a brain structure called the nucleus accum-
bens, which is closely associated with reward. What this means is that addictive
chemicals are able to bypass the hard work of finding satisfaction in life and “hijack”
the brain’s motivational systems.
In this chapter, we will use a broad definition of addiction, the eighth EDP, as
the repetitive pursuit of a soothing behavior in spite of significant negative conse-
quences. In clinical practice and despite some patients’ protestations, the addic-
tions that cause people to seek help are better understood as avoidance of discomfort
than seeking pleasure. As discussed in Part I, humans are heavily programmed to
avoid negative consequences, and this activity, rather than the enhancement of
pleasure, is usually the driving force behind truly destructive behaviors. In this
case, the addictive behavior manipulates motivational systems so as to ignore the
painful consequences and to repeat the behavior anyway. Chemical addictions
clearly fit this definition but so do behaviors like food restriction, cutting, and com-
pulsive sex.

15.1 Baffling, Cunning, and Powerful

This phrase, borrowed from the Big Book of Alcoholics Anonymous [4], describes
quite accurately the distortion that takes over the human psyche under the influence
of addiction. To this day, despite a huge amount of science, many people have dif-
ficulty understanding addiction because we so easily assume that all people have
full possession of their free will. For a person who feels in charge of their own life,
the idea of another who freely chooses to do terribly destructive things is very hard
to grasp. The tendency is to invoke the idea of weakness or failure of the conscience.
What has actually happened is that the individual’s free will has become compro-
mised and is no longer entirely free.

© Springer International Publishing AG 2017 183

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_15
184 15 Addictions

What seems most baffling is that addicted people work hard to justify their dysfunc-
tional behavior and will fend off well-meaning family and friends who try to influence
their free will to let go of the addiction. The fact that these efforts fail tells us a lot about
how the mind works. The nonconscious problem solver [3] responds to whatever the
brain thinks is good for survival. What has happened is that, in effect, the brain now
thinks the addictive behavior is necessary for species survival. As a result, the noncon-
scious problem solver sets about using all the tools available to support the addiction.
Thus, in observing addicted people, we get a very revealing look at the operations of
the problem solver as it works to steer behavior.

15.2 Why Do Some People Get Addicted?

Clearly not everyone becomes addicted, even though addictive substances and behav-
iors are available to all. There are substantial biological and genetic factors in addic-
tion. In particular, alcoholism seems to be heavily genetic. Some alcoholic individuals
show very little psychopathology other than the addiction itself. In other cases, it
seems that the addiction was heavily fueled by unmet emotional needs or troublesome
anxiety. Thus, we can say that addiction often, but not always, fits the pattern of an
EDP, that is, a pattern that started out as a protection and later became a liability.
It is likely that all the behavior patterns that fit the pattern of addiction have simi-
lar effects on motivational systems. They all involve a compromised free will. If
they don’t start out as means to avoid some pain or fulfill some unmet need, they
soon take over that function at the expense of healthy coping.

15.3 Secondary Psychopathology

The longer an individual remains under the spell of addiction, the more their healthy
coping patterns become distorted. This is “secondary pathology.” In other words,
addiction causes psychopathology. If the addiction didn’t begin as an entrenched
dysfunctional pattern, it becomes one. Addiction leads individuals to act in ways
that are upsetting to the people they love. Addicts work hard to try to force others to
accept their behavior, and when that doesn’t work, they reject their best supporters
and isolate. They develop a “denial system,” a set of automatic thoughts used repeat-
edly to justify the addiction. Social isolation has destructive effects on the psyche
and makes the soothing effect of the addiction even more important.

15.4 The Role of Value Systems

Addicted people also have a strong tendency to internalize the value of indepen-
dence and controlling their own destiny. This distortion of the conscience helps to
fend off others’ opinions but makes the work of therapists harder. This is a group
with high “reactance” [1] meaning that they resist the therapist’s authority and any
15.5 Codependency in Five Easy Lessons 185

attempt to influence their thinking. Miller and Rollnick’s technique of motivational

interviewing was invented to avoid patient–therapist power struggles and allow a
dialogue in spite of this characteristic [2]. See “treatment principles” for more on
motivational interviewing.
Another situation where the conscience is usually distorted is anorexia nervosa.
People who have an extreme preoccupation with their weight and food intake usu-
ally experience powerful pride in being able to control their weight and terrible
shame when they succumb to temptation. When therapists succeed in influencing
them to eat more, immediately after, they tend to feel horribly gross and disgusting
and are filled with shame. That should be a clue to us that the conscience and values
are involved. They have developed a value system that places extreme value on self-
control and thinness.
Work with these patients often suggests the following dynamics: the problem
starts with a primitive unmet need for an all-encompassing primal love. When this
neediness threatens to break through in the form of voracious desire and/or uncon-
trollable rage, a powerful “internal electric fence” is developed, based on the value
of self-control. Later, hunger for love is equated with hunger for food, and the value
system based on self-control becomes focused on control of eating.

15.5 Codependency in Five Easy Lessons

Addiction has been called a “family disease” because it so profoundly distorts and
controls family life. Understanding this is important for work with individuals in a
relationship with an addicted person. It is also helpful in working with the addict,
him or herself. A simple but sophisticated definition of codependency is wishful
thinking. Every time family members engage with an addicted person in a way that
is dysfunctional, they do so based on unrealistic hopes of being able to change the
other. Below are four natural patterns that make the situation worse, followed by a
fifth learned pattern that actually helps.

1. Denial: The codependent participates in denial in order not to lose the connec-
tion with the addicted person, who is increasingly focused on the addiction. The
effect is to support the addiction and it gets worse.
2. Control: The codependent then tries to control the addict’s behavior. Marking
bottles, restricting social contacts, arguing, pleading, rewarding, punishing, etc.
None of these works, but the addict feels harassed and increases reliance on the
addiction for comfort. The situation worsens.
3. Anger/Guilt: The codependent reacts emotionally to the failure of efforts to con-
trol the other. Anger gives an excuse to adopt a victim stance and turn even more
to the addiction. Self-blame gives the addict license to blame the codependent
for the problem. The situation worsens.
4. Rejection: The codependent angrily rejects the addict, and the addict uses the
rejection as yet another excuse to increase addictive behavior. Now there are no
external controls, and the addiction gets much worse.
186 15 Addictions

5. Detach with Love: Understanding that the addict’s free will is compromised, the
codependent lets go of wishful thinking and recognizes what actually does and
doesn’t help. For the most part, this is disengaging when the addict is behaving
in an unhealthy way, but doing so with compassion and caring, since the addict
has no real control. Detaching with love is like being at a sports event as a specta-
tor. We would like to tell the players what to do but have to satisfy ourselves with
just cheering for their successes and expressing our feelings of disappointment at
their failures. (Any attempt to use the latter emotional expressions to influence
the addict, as opposed to a pure expression of feeling, will constitute engagement
and will ruin any benefit.) With this stance the situation begins to improve. If not,
the loving other has, at least, done the best that can be done.

Note that detach with love pertains to situations where there is no “leverage.”
When employers, family, or loved ones are able to structure a situation such that the
addicted person will prefer getting help to facing a consequence, such as loss of job,
then using this leverage may be lifesaving. See below.

15.6 Treatment Principles

15.6.1 Hitting Rock Bottom

Sometimes addicted people come to a dramatic point where they realize and are
able to accept that they need to stop their behavior and seek help from others. This
amazing turn in the direction of health happens when the brain and motivational
system become aware that there is something personally more valuable than the
addiction. The realization can be sudden. One day a woman had the thought that if
her child became sick during the night, she would be too intoxicated to provide
needed care. Instantly, she became willing to seek help.

15.6.2 Key Questions

A significant part of what therapists can do with addicted people is to help them
become aware of something more important to them than their addiction, in other
words, hit rock bottom. However, before this can happen, the patient must realize
that he or she can’t have both. Addicted people always try to find some way to keep
the addiction, without giving up on competing needs. Two questions must be
answered to the addicted person’s satisfaction:

1. Controlled Use: The first question patients must answer for themselves is whether
it might be possible to control their use. Controlled use of the substance or limited
reliance on addictive behavior is an extremely attractive solution to the addicted
mind. In particular this would make it possible to maintain self-esteem and
15.6 Treatment Principles 187

relationships without having to give up the addiction. Almost every addict tries
this solution, but, unfortunately, it almost never works. Just as attempts to control
thoughts make them more intense, attempts to control an addiction increase the
compulsion. Usually the addiction reasserts control, and the patient relapses. An
unfortunate outcome is that sometimes addicted people are able to “slip and slide”
through life without giving up the addiction but also without achieving healthy
relationships and a productive life. When the addict concludes that total absti-
nence is the only pathway to recovery, then the next question becomes relevant.
2 . Outside Help: Once the addicted person is personally convinced (usually by
experience) that controlled use is not possible and that abstinence is the only
option, a second question comes into view. Will recovery be possible without
having to turn to others and relinquish a degree of personal control? Unfortunately,
the answer is usually no. The effectiveness of the nonconscious problem solver
is such that some combination of impulses, rationalizations, and the allure of
comfort are enough to make even a determined patient relapse. Once again, per-
haps with some guidance from the therapist, the patient will probably have to
learn this by experience.

Hitting bottom by realizing that there is something more meaningful than the
addiction, that there is no compromise, and that turning to others for help is neces-
sary is the royal road to recovery. While these realizations are, in most cases, even-
tually necessary for success, there are many ways to arrive there.

15.6.3 External Motivation Is Acceptable

A long and valid tradition in mental health is that the patient must be self-motivated
for treatment to work. Addiction has such a powerful grip on the motivational appa-
ratus that external motivation, at first, may be the only way to arrive at recovery.
Expecting the patient to be motivated for recovery is simply not realistic. Fortunately,
the first step in loosening the grip of addiction on the motivational system is to stop
the behavior. Chemical addicts need to stop using the chemical, and people with
nonchemical addictions need to change their compulsive behavior.

15.6.4 Leverage

External motivation is usually in the form of “leverage.” This means making it clear
to the addicted person that failure to seek help will result in some major loss.
Attachments and self-image are the two things most likely to weigh as heavily as the
addiction. Losing a marriage, being fired from a job, and losing other important
relationships are the kinds of consequences that may be sufficient to get our patient
started. Even if the motivation is only to gain temporary relief from outside pres-
sure, this is good enough for a start.
188 15 Addictions

Hopefully, leverage leads to radical behavior change and immersion in a sober

context. The value of inpatient rehabilitation programs is that they combine forced
abstinence (behavior change) with connection anxiety. By providing human con-
nections that are dependent on abstinence, the patient is drawn further from the
influence of the addiction, hopefully enough to allow the patient to bond with a
support system, first in the rehab and then back home. Going far away from home is
usually an advantage, since connections with friends and family are loosened, mak-
ing bonding with a recovery-oriented support system more likely.
Legal mandate forcing passive treatment has been tried and found to be relatively
ineffective. The addict simply waits for a chance to get back to “normal.” On the
other hand, involuntary treatment that engages the patient using connection anxiety
to motivate the patient to follow peers and engage in uncomfortable but healthy
behaviors can work. This is the principle behind “boot camp” treatments as well as
wilderness programs for adolescents.
Ultimately, addicted people must become self-motivated to continue following a
program of recovery. Ongoing vigilance and healthy connections are necessary to
prevent relapse because addictive patterns are indelibly encoded in procedural
memory.

15.6.5 Anti-craving Medications

Medications that promise to reduce craving do work to produce statistical reduc-

tions in the average use of experimental subjects. Unfortunately, a nonconscious
problem solver fighting for the survival of the species often finds its way back to
compulsive use. Furthermore, the patient’s deep down expectation that the medica-
tion will do the hard work leads to complacency that favors eventual relapse.

15.6.6 The Role of the Therapist

The therapist’s job is to keep framing the key questions clearly until they are
answered. Without this guidance, the patient may forget previous “experiments”
and rationalize results so as to avoid coming to a firm conclusion that abstinence is
necessary and that outside help will be needed.
Part of the therapist’s “detachment with love” is to be ready and willing to let go
of the relationship if the patient decides not to seek recovery. Continuing to meet
when the patient is no longer engaged is an indication of the therapist’s unwilling-
ness to put the relationship in question, and is a kind of codependency, that is, wish-
ful thinking.
On the other hand, reading the patient’s stage of readiness for change is impor-
tant, and being out of sync with the patient leads to a tug-of-war that the therapist
cannot win [2]. Assuming prematurely that the patient is ready for change will lead
to a mismatch of goals and failure.
15.6 Treatment Principles 189

15.6.7 Motivational Interviewing

Miller and Rollnick, working with alcoholics, have developed an extensively

researched interviewing technique optimized for working with patients who are
extremely resistant to being influenced by others. Motivational interviewing aims to
help patients identify and resolve their own ambivalence about change. It facilitates
them answering the above two questions and evaluating for themselves, the pros and
cons of changing their addictive behavior. These methods are very consistent with
the principles of “detachment with love,” as described above.
Here is a brief example:

T: “I understand you enjoy going to lively parties and drinking a lot.”

P: “Yes, that’s right.”
T: “I see. How does it feel the next day?”
P: “Terrible, the whole day is wasted.”
T: “I see. So part of you likes the party, and part of you is uncomfortable about it the
next day.”

The patient is left knowing he or she is free to choose what to do but is forced to
face the consequences. This approach can be very helpful with patients who are
more controlling (high reactance) or have a habit of rationalizing dysfunctional
behavior with erroneous statements. Patients who don’t tolerate discussion or input
from others can be led through this technique to engage in self-questioning.
The basic principles of motivational interviewing are as follows:

• Avoid all confrontation or argument, “roll with resistance.”

• Be completely respectful of the patient’s ultimate freedom to choose to act or not
and to be responsible for consequences.
• Use Socratic questioning to raise questions for the patient to ponder.
• Help the patient identify his or her personal ambivalent feelings about change.
• Help the patient identify personal pros and cons of change.
• Be directive in keeping the patient focused on the goal of resolution of
ambivalence.
• The relationship should feel like a partnership or collaboration.

15.6.8 Pitting Biology Against Biology

The genius of 12-step programs is to offer a choice between human connection and the
addiction. Just as addiction taps into our motivational systems, so does the need for
human relationship. In this way, recovery groups use one biological drive against
another. The key is that 12-step members understand the need to “detach with love.”
Their detachment creates a degree of connection anxiety. The addict’s desire to “belong”
adds weight to a personal desire to become healthy. Together these forces can be strong
enough to overcome the nonconscious problem solver’s efforts to keep the addiction.
190 15 Addictions

By maintaining a willingness to disengage or “walk away,” therapists, family

members, and others can trigger this same force in the addict, who then seeks to
regain a connection. This doesn’t always work. The motivational systems may be
too heavily compromised. The addiction may have become a substitute for the need
for others. Opiates, in particular, are able to mimic the feeling of emotional close-
ness, making the need for human connection less important.
Note that wishfully trying to teach or correct the addicted person, even if it car-
ries a negative tone such as anger or criticism, actually provides reassurance that the
connection is intact. By trying to convince or to shame the addict into changing, the
codependent is sending the message that the relationship is safe whether the addict
misbehaves or not. The result is that the addicted person feels secure in continuing
to pursue the addictive behavior.
When the other person detaches and disengages, then the addict begins to feel
some connection anxiety. The immediate reaction is to try to gain reassurance by
engaging. This means provoking an argument or some other reassuring interaction.
The addict tries every strategy possible to have both the connection and the addic-
tion, avoiding the need to choose.
The purpose and effect of the technique of planned intervention are to make it
totally clear to the addict that he or she must choose between family, friends, and job
versus the addiction. The addict is shown that the others are eager to have a relation-
ship but that they are also willing to let go. There is no way to have both and no
possible compromise. At that point, many addicted people will choose inpatient
treatment in the desperate hope that somehow they will be able to survive the treat-
ment without having to give up the addiction. As stated above, this is good enough
for a start if treatment is designed to keep the choice alive.

15.6.9 Positive Prognostic Signs

One sign that is relatively indicative of long-term success in recovery is that sober
life or life without the addiction is much happier and more satisfying than before. As
more and more facets of the recovering person’s life become aligned with health,
the thought of giving all that up can become a force for maintenance of recovery and
appropriate fear of relapse.

Key Points
• Addiction, broadly speaking, is the pursuit of soothing behaviors in spite
of significant negative consequences.
• What all addictions have in common is stimulation of the brain’s reward
systems, allowing compromise of free will. They involve genetics and
biology but also serve to avoid difficult affects.
• Addictions are hard to understand because people tend to assume that free
will is an absolute, rather than a system that can become diseased.
References 191

• Addictions cause psychopathology because they become the only coping

mechanism, allowing healthier ones to fall into disuse.
• The conscience, with helper EDPs producing shame, can function to sup-
port addiction. Anorexia nervosa is one example.
• Codependency can be defined as wishful thinking that one can manage the
other person’s problem.
• Addiction is one area in mental health where treatment does not have to be
purely voluntary at first. “Leverage” means using consequences to make
addiction less desirable than treatment.
• For most patients, the will to recover requires understanding that controlled
use is impossible and that relying on oneself alone does not work.
• Motivational interviewing is a special approach to counseling that is
adapted for people who are particularly resistant to being influenced by
others.
• 12-step groups and other recovery approaches make use of the biological
need for connection as a counterforce to the biological drive behind the
addiction.

References
1. Beutler LE, Moleiro C, Talebi H. Resistance in psychotherapy: what conclusions are supported
by research. J Clin Psychol. 2002;58(2):207–17.
2. Miller WR, Rollnick S. Motivational interviewing: helping people change. 3rd ed. Applications
of Motivational Interviewing Series. New York: Guilford Press; 2012.
3. Panksepp J, Biven L. The archaeology of mind: neuroevolutionary origins of human emotions.
Norton Series on Interpersonal Neurobiology. 1st ed. New York: W W Norton & Company;
2012. p. 95.
4. Smith B, Wilson B. The big book of alcoholics anonymous. 4th ed. New York: AA World
Services, Inc; 2001. p. 32.
The First Helper: Emotion
16

16.1 Introduction: The Three Helpers

In talking abstractly about affect avoidance, it is easy to forget how strongly we

dread uncomfortable feelings and how hard our nonconscious problem solver works
behind the scenes to guard us from such painful experiences. Given how compelling
this task is for the brain, it is not surprising that simply popping a potential action
into consciousness is not enough. The mind uses three additional types of helpers to
make sure we direct our free will to implement those actions favored by the noncon-
scious problem solver. These mental products have impressive powers to steer our
free will in the desired direction. They are:

1. Primary emotions, positive and negative, use reward to influence our choices.
They will be often referred to simply as “emotions,” as in the title of this chapter.
The word “primary” is to distinguish them from conscience-based emotions that
are indirect, in that they depend on an intermediary judgment.
2. Conscience-based emotions, pride, shame, and guilt, are indirect reactions based
on judgments according to values internalized in the conscience. They have a
strong influence on free will and choices.
3. Automatic thoughts “talk us into” taking the actions our problem solver deems
necessary for species survival.

As indicated earlier, the mind sends into consciousness the same three products,
primary emotions, conscience-based emotions, and spontaneous thoughts, in many
forms and for many purposes. Most of these serve us well and lead to some of our
best achievements. These, we tend to identify with the self as “ours.” On the other
hand, when these same products lead us in directions contrary to our true desires,
we think of them as alien and not belonging to the self. Those are the helpers that
are working hard to further the aims of the nonconscious problem solver in shield-
ing us from painful affects that we would actually do better, as adults, to face.

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_16
194 16 The First Helper: Emotion

16.2 EDP #9: Emotions as Helpers

Recalling our discussion in Chap. 3, describing the brain as a control structure,

emotions are the main way the brain guides our conscious decision-making. We
immediately associate potential actions with anticipated emotions, positive and
negative, and we tend very strongly to choose whatever seems most pleasurable and
least painful as we stay close to our “comfort zone.” Emotions, then, while contrib-
uting to our daily experience, also have an important role in influencing behavior.
Seen in their full breadth, emotions function in many different ways:

• Physical feelings tell us to attend to the needs of the body.

• Fear, joy, anger, and emotional pain guide our behavior in healthy and effective
ways.
• Emotions generated by the nonconscious problem solver influence us to choose
avoidant behavior patterns including the dysfunctional ones embodied in EDPs.
• Emotions provide the positive and negative reinforcements that shape our non-
verbal schemas.
• Sometimes anger, hate, and other emotions are incorporated into nonverbal sche-
mas to accomplish interpersonal goals, such as intimidating or manipulating
others.

In this chapter we will examine the variety of emotions that come into conscious-
ness and how to work with them in therapy. As emphasized many times in this book,
detoxification of emotions can only take place when they are activated as conscious
affects. Here are some of the objectives of the therapist in relation to emotions:

• Painful emotions from the past (as in trauma) or present may need to be pro-
cessed so that they are no longer visceral or overwhelming.
• When emotions are overwhelming, before healing, the patient may need to be
helped with regulation to bring the level of activation down to where processing
is possible.
• Emotions that trigger dysfunctional avoidance mechanisms may need to be
detoxified as part of the resolution of the EDP.
• Emotions that are part of a nonverbal schema and serve an unhealthy social func-
tion may need to be approached as part of a whole dysfunctional pattern.

In the sections that follow, we will look at different emotions and how to work
with them in therapy. Note that when the level of intensity is so great as to be
overwhelming, work with the emotion will have to wait for efforts at regulation to
take hold. Simply remaining calm and using empathic attunement, a context of
connection, and sense of perspective may be enough to achieve containment.
When there are threats of acting out, those will have to be contained, using outside
authority if necessary. Dialectical behavior therapy (DBT) is a tradition particu-
larly rich in methods for dealing with levels of emotion that prevent processing
being done.
16.3 Sadness and Tears 195

16.3 Sadness and Tears

These are the natural feelings that accompany loss. We are looking at them first,
because they are relatively uncomplicated and socially acceptable. Tears and sad-
ness are usually not threatening. The natural impulse of humans is to comfort some-
one who has suffered a loss. This is precisely what actually promotes and allows
healing. In some cultures, expressions of grief are more dramatic and in others less,
but within the culture, most people know what to do. Especially when associated
with the threat of helplessness, sadness or grief of another may be experienced as
uncomfortable. People so threatened may feel a need to “fix” the grief or talk the
grieving person out of their feelings. This is not helpful and is usually rejected by
the person experiencing the loss.

Normal Sadness and Grief: As therapists we simply listen and may express some
compassionate words: “I’m sorry to hear. This must feel really painful.” If the
words are too generic, the patient may feel worse, because what they need is
“accurate empathy.” How do we achieve that? We must make sure that we under-
stand precisely what is the loss and why it is so painful. The three-step dance
(Fig. 16.1) should work very well to make sure that we understand in detail and
accurately. If the patient tells of grief or sadness but neglects to let the therapist in
on the specifics, the possibility of avoidance should trigger the three steps of the
dance, leading to a crystal-clear sense of just what is the loss. For example, to
understand the loss of a beloved dog, you may need to know something about
what made the dog so lovable in the eyes of the patient.

In cases of grief, particularly when the loss is of an object of attachment, the

process of healing seems to take its own time. Healing takes place at moments when
the feeling is activated, but these extend over a significant period of time, depending
on the depth of attachment. The attitudes of others and the meaning of the feelings
may depend on expectations of how long grieving or sadness “should take.” People
who are grieving are sometimes frustrated and hurt by others’ insistence that it is
“time” to get over their sadness. Trying to hurry grieving is not therapeutic.
Friends and family may feel uncomfortable and powerless because prolonged
grieving makes them believe that they are unable to influence the process. They may
try to convince the patient to stop feeling sad and get on with life. When grief inter-
feres with functioning, there may be consequences, like at work, for example. The
therapist may be the one to provide reassurance that each person’s grief takes what-
ever time it takes.

Pathological Grief: When grief or sadness seems to drag on and the expected
evolution is not taking place, it is appropriate to wonder if this is pathological
grief. One patient grieving for the unexpected and premature death of his beloved
wife had difficulty accepting that his life had changed drastically. He continued
to compare his life as a widower to the life he had had before, reminding himself
that the present was not acceptable. In this way, continuing grief functioned as an
196 16 The First Helper: Emotion

Fig. 16.1 Three-step dance

Flow stops

“Nudge” Success Flow continues

Fails

“Metacom-
Success Flow continues
munication”

Fails

“Strategic Success
retreat” Flow continues

avoidance of going through the even more painful acceptance of life without his
wife. A therapist should be thoughtful about concluding that sadness or grief has
taken too long, but this is a possibility (see also, Chap. 19).

“My Tears Will Never Stop”: Not infrequently, patients may be fully aware that
they have grieving to do but may be stopped by the conscious thought that their
tears would be too intense or would never end. As a therapist, one can offer assur-
ance that tears do have an end and never go on forever. Besides that, providing a
safe and empathic relationship is essential. EMDR provides a way of breaking
the feelings surrounding a tragedy down into smaller chunks, and this may help
the patient who is afraid of grief.

Tears of Protest: Tears come in two varieties. Tears may represent a protest
against reality or an acceptance of reality. When the therapist is aware that both
kinds can occur, distinguishing one from the other is usually not too difficult. Is
the patient truly accepting or is the patient stuck in a stance of angry refusal to
16.5 Anger 197

believe or accept reality? In the latter case, the therapist will hear how unfair or
wrong it is that the loss has occurred and that it should not be. When the tears are
of protest, the therapist’s job is to help the patient heal the anger that is being
blocked by tears. By helping the patient articulate exactly why the loss seems
wrong and unacceptable, the angry affect will be activated and expressed and
have a chance to heal. As this takes place, then tears of acceptance will come to
the fore where they can be processed.

16.4 Helplessness and Hopelessness

The closely related feelings of helplessness and hopelessness are among the most
toxic and avoided feelings experienced by humans. We need only think of the sever-
ity of measures such as human sacrifice taken by primitive humans, presumably to
ward off conscious knowledge of lack of control over their environment. From the
earliest age, children avoid this feeling by raging and insisting that parents take care
of their needs and wishes. Soon after the child learns to have conscious expectations
perhaps during the second year, their disappointment generates very strong feelings
and strong efforts to avoid those feelings. As language develops, the ability to deny
painful reality soon follows. A little later, a child will be unable to accept failure on
the part of the parent. Instead of acknowledging this ultimate hopeless feeing, the
child may blame him or herself and then use self-punishment to keep hope alive.
The threat of these emotions does not end with childhood. People’s intolerance
of complaints that can’t be fixed and unhelpful attempts to offer solutions are evi-
dence. The difficulty adults have with death and terminal illness is a further indica-
tion of our discomfort with the helplessness embodied in the ending of life.
When patients are able to identify helplessness or hopelessness as the feelings
they are having trouble with, then we can work with them on understanding how
distressing these feelings are and how they are actually not harmful to experience.
Furthermore we can reassure our patients that these feelings too can be survived and
healed. This reassurance may allow them to bring the feeling to conscious activation
where healing is possible.

Acceptance: If there is an answer to helplessness and hopelessness, it is accep-

tance. Acceptance is the word we have for processing and healing feelings of
helplessness and hopelessness. Patients often avoid acceptance as strenuously as
they do helplessness itself. The reason is that, as with other feelings, acceptance
happens only when the helplessness is actively experienced. This one also
requires a context of safety and empathic connection.

16.5 Anger

Anger is perhaps the most complex and difficult emotion. Anger is closely associ-
ated with aggressive actions that have interpersonal and social repercussions. Anger
generates reactions of flight or fight in the other person, which then have
198 16 The First Helper: Emotion

consequences for the one who is angry. As noted previously, anger can serve several
purposes. Let’s look at them one at a time.

Plain Anger: Even the most basic anger is directed at someone. A damaging
lightning strike does not usually bring out an angry response, but a simple dis-
agreement brings up anger depending on our perception of the intention of the
other person. The patient may deny being angry at another or may claim to be
angry at the self, but somewhere lurking in the background, the anger is directed
at someone who has failed to comply with expectations. The therapist may need
to do some exploration to make this clear. Thus, healing of plain anger generally
requires understanding and acknowledging not only the feeling but the circum-
stances and the object of the feeling. “Who are you holding responsible for your
pain and why?” When the patient is able to acknowledge and share this, then the
affect will begin to heal, that is, in a context of safety and connection.

Our job as therapists, when faced with anger, is first to deal with any counter-
transference reaction we may have to the anger and then to listen and help the
patient and ourselves to understand empathically exactly what is the wrong and who
is the perpetrator. A complicating factor is that we may be listening to the child
within, who may not have a realistic understanding of blame and responsibility.
Children are often threatened by a situation that can’t be repaired and are cogni-
tively unable to conceive of something bad that is no one’s “fault.” Layers of shame
and denial may have to be peeled away before the patient can understand and share
the accusative part of the experience of anger.

Anger as Avoidance: Anger can work to block a feeling of sadness or helpless-

ness and the need for acceptance. As long as the patient feels anger, then the
presumed resolution to the feeling is to bring the culprit to justice. Waiting to
accomplish that end, it will not be necessary to acknowledge helplessness or to
go through the painful process of acceptance. Anger can also block healthy feel-
ings of sadness and loss. As in the case of pathological grief above, by protesting
that the loss should not have happened, the patient can avoid having to grieve.
Helping the patient recognize this avoidance may be needed for the patient to let
go of the anger and move toward acceptance.

Anger as a Social Tool: Anger produces reactions in others. Children can learn to
use anger as a tool to control others, forcing them to comply with the child’s
wishes. Children who succeed in this are rewarded with relief from having to
experience healthy but painful feelings of helplessness or loss of control. In par-
ticular, those who have not successfully traversed the 2-year-old developmental
challenge of learning to lose battles gracefully may have learned to use anger to
make sure they have their way. For them, winning is a life-and-death necessity
and a serious burden on those around them.

The challenge of working with anger as a social tool may vary from relatively
minor in a patient who is ready to acknowledge it and let go to severe in patients
16.6 Panic, Fear, and Anxiety 199

who are narcissistic or antisocial and whose entire personality structure is built on
controlling others. For these people, it is the absolute power of their fear of not hav-
ing their way that makes this such a dangerous and difficult EDP. These patients
may learn to “change reality” to meet their emotional needs. They may also decide
that the therapist is wrong and invalidate what the therapist tells them. For this rea-
son, group therapy can be a more hopeful modality. Invalidating a group of peers
who have had similar experiences is significantly harder than contradicting the
therapist.

16.6 Panic, Fear, and Anxiety

Panic—pounding heart and physiological feelings of impending doom—is biologi-

cally distinct from anxiety; however, from the point of view of the therapist, it is
similar. Anxiety is the nonconscious problem solver’s way of telling us to steer clear
of some dreaded circumstance. As in the case of Jack in Chap. 2, the circumstance
may not be conscious, and the mind may even supply some plausible but incorrect
explanation.

Healthy Anxiety: Of course there are many instances when frank fear or even a
tinge of anxiety gives us an appropriate signal that there is something to worry
about and that we need to take steps to protect ourselves.

Simple Anxiety: Ideally, the experience of fear or anxiety, when self-protection is

not needed, may naturally lead to simple acknowledgment and sharing with pri-
mary caregivers and trusted others. As the patient communicates the feeling and
the witness understands empathically, the feeling will naturally heal and abate. A
nonverbal schema of anxiety and healing becomes established. Though some
humans are genetically prone to greater anxiety, when the expectation of healing
is learned, then anxiety is less likely to become a major source of trouble.

There are times in life when the fear is real and consequences are extreme, yet
there is no useful action to take. Waiting for the result of a medical test is an example.
At such times in addition to being an empathic witness, the therapist can help the
patient learn to distract him or herself with activity and to practice mindfulness.

Panic and Anxiety as a Reason for Avoidance: What complicates the picture of
these emotions is attempting to control anxiety by avoiding the dreaded cir-
cumstance. As has been discussed, attempts to eliminate feelings make them
more intense, and the person becomes increasingly intolerant. Intolerance
leads to more desperate avoidance, which, in turn, leads to greater fear. This
cycle can quickly advance to dramatic levels of loss of functioning and per-
sonal crisis.

Cognitive behavioral therapy and third wave therapies have developed many
tools and techniques for helping patients practice coping with anxiety instead of
200 16 The First Helper: Emotion

avoiding it. As patients gain mastery, they feel pride and increased motivation to
work at healing the anxiety rather than avoiding it.

Confronting the “Worst-Case Scenario”: One distinctive approach to anxiety

and other dreaded circumstances is exposure. This means approaching the
dreaded circumstance using words, imagery, or other means, so as to fully acti-
vate the anxious affect. As usual, activation of affects triggers healing processes,
either extinction or reconsolidation, so as to reduce or eliminate their grip on the
individual.

Anxiety as a Social Signal: Anxiety tends to elicit active responses from others.
One such response is to provide support. This is not so problematic. However, if
the other person shows fear instead of reassurance, this may encourage avoid-
ance. Children can learn to elicit this response to support their own avoidance
behaviors. As a life pattern, the result can be a serious block to emotional devel-
opment and restriction of the range of functioning. This was the danger in Jack’s
case of encouraging him to seek disability status. Once patients identify them-
selves as disabled people, returning to functioning can be seriously challenging.

16.7 Impulses

Impulses are not usually thought of as affects, but they function in a very similar
way. As the meaning of the word suggests, an impulse is a signal from the mind that
pushes us to perform some act. An alcoholic in recovery may pass in front of a
liquor store with no special desire to drink and suddenly go into the store. A pur-
chase is made before consciousness and free will have even a chance to evaluate the
wisdom of what just happened. The alcoholic will honestly report that a sudden
impulse caught him or her by surprise. Impulses are often nonverbal.
The feeling of an impulse has distinct characteristics. It is sharply uncomfortable
as long as we resist. The longer and harder we resist, the stronger the feeling tends
to get. While resisting, we feel agitated, restless, and not centered. The experience
exhibits similarities to hunger or pain in driving behavior. It is also similar to feel-
ings like anxiety and anger, which tend also to lead to action.
During our 10 years, most people learn impulse control through practice. Doing
uninteresting school assignments is excellent training in impulse control. The school
years are also when young people learn to perform difficult tasks, such as mastering
a sport or musical instrument, which require a great deal of boring practice.
Conversely, failure to go through these experiences can leave the adult relatively
lacking in impulse control. Those who lack impulse control feel the discomfort of
resisting an impulse much more intensely.
The presence of biologically based attention deficit hyperactivity disorder
(ADHD) increases the power of impulses and interferes with impulse control. There
is still a chance for learning the skill, but these individuals have an additional bio-
logical challenge.
16.7 Impulses 201

Much of the training of first responders in uniformed services consists of practic-

ing proper procedures to ensure that they will adhere to them at times when impul-
siveness would be dangerous and dysfunctional. Impulses are also closely related to
habits, where we systematically omit the step of reflection before acting. When we
work to change a habit or an impulse, much of the work is in becoming aware so that
we can reflect and, if needed, resist the old and practice a new behavior. Mindfulness,
recalling that an impulse is no more than activity in the brain, gives perspective and
helps with choosing not to follow an impulse.

Key Points
• This chapter introduces emotion, the first of three types of helpers, prod-
ucts of the nonconscious problem solver designed to influence our free will
to choose to act on the behavioral component of an EDP.
• When emotions are too highly activated for processing, then “contain-
ment” is the goal.
• Emotions are reviewed including feelings of loss such as sadness, grief,
and tears.
• Helplessness and hopelessness are among the most powerful emotions in
affecting free will.
• Anger is complicated by its social repercussions.
• Panic, fear, and anxiety can function to influence behavior so as to avoid
more compelling fears.
• Impulses are not usually thought of as emotions but function in a very
similar manner to influence behavior.
• Working with emotions in this role starts with identifying the function of
the emotion in question. If possible, healing by extinction or reconsolida-
tion can remove the visceral aspect of the affect. Beyond that, helping the
patient understand the EDP function of the emotion defines the treatment
strategy.
The Second Helper:
Conscience-Based Emotion 17

The tenth EDP, the second of the three types of helper EDPs, consists of the con-
science with its associated values and products. The conscience observes and makes
judgments based on internalized values. Its products are conscience-based emotions
of pride, shame, and guilt, which enter into consciousness to influence us to put
choose those behaviors that serve the aims of the nonconscious problem solver.
Thus, the conscience is a helper that provides backup to the problem solver in case
we, using our free will, might stray from what our mind deems best for species
survival.
So far in this book, the conscience-based emotions, shame, guilt, and pride, have
been mentioned many times. They first appeared with Jack, who was ashamed of
any hint of neediness, based on a value system in which dependence on others was
considered bad. More detail about the conscience was given in Chap. 2 and in Chap.
7 in the section on “Crime and Punishment.” In this chapter we focus on how this
vital “organ” of the mind can turn against our well-being as it helps the noncon-
scious problem solver implement EDPs through inappropriate shame and guilt. This
examination is particularly important for therapists because the conscience is like
no other part of the mind and requires distinct approaches and expectations. Note
that when these same destructive feelings enter into a vicious cycle, locking the
individual into a continuous state of bad feeling, we call it depression. That symp-
tom is the subject of Chap. 18.
For the most part, the conscience is an important asset. It is the component of the
mind that most helps us be good citizens of our family and community. On the other
hand, inappropriate feelings of shame and guilt are common and are some of the
mind’s most troublesome and destructive products. Our conscience and the unique
feelings that come from its judgments have tremendous influence over the way we
act and feel from day to day.
In this book, pride, shame, and guilt are called conscience-based emotions because,
unlike the primary emotions of the previous chapter, these emotions always depend on
a judgment. We feel pride when our actions are judged to be in sync with our values.
And when we act in ways that go against our values, we feel powerful guilt or shame.

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_17
204 17 The Second Helper: Conscience-Based Emotion

It is immediately helpful to therapists to know that when we encounter pride, shame,

or guilt, we should look for the values on which those feelings are based. Healthy feel-
ings of pride, shame, and guilt come from healthy values. Unhealthy conscience-based
feelings come from unhealthy values. As with the various emotions of the previous
chapter, emotional healing of undesirable shame and guilt is possible, but without
changing the values behind those emotions, long-term clinical benefit is unlikely.

17.1 Values, Attitudes, Ideals, and Prohibitions

Before moving into the details of how the conscience functions, it is important to note
that there are different types of values. In this book, the following terms are used:

• Values are principles of what we regard as good and bad. Note that these are differ-
ent from personal likes and dislikes. We think of our likes and dislikes as personal
belongings, but we see our values as true in general, even if others may disagree.
• Attitudes are very close to values. They are biases about what is good and what is
not. Prejudices against racial and other groups are examples. Feelings of disgust
or hate for members of such a group are versions of shame directed outward.
• Ideals are templates of what perfection should be. They represent qualities we
would like to achieve. Children may not understand that there are shades of gray
and may seek absolute perfection, but adults know we will never get there.
• Prohibitions are specific to actions we consider to be bad or wrong in themselves.

In this book, the term “values” is also used as a generic word to refer to all of the
above four types.

17.2 Neurophysiology of the Conscience

Allan Schore is a psychoanalyst who has worked to integrate neurophysiology with

what is known about the mind. Schore concludes that the conscience begins to show
signs of functioning around 18 months of age with the development of a rudimen-
tary ideal. This is the age when the right frontal cortex begins to develop a myelin
sheath around nerve fibers, resulting in much improved communication between
cells. According to Schore, the right orbitofrontal cortex is where the conscience is
located [3] (Fig. 17.1).
In this way, conscience-based emotions are physiologically distinct from the
primary emotions that arise from the limbic circuits of the brain located beneath the
cortex. To reinforce this distinction, Jaak Panksepp, whose focus is on the similarity
between human and mammalian emotions, explicitly makes the point that emotions
such as pride, shame, and guilt are not represented among the basic mammalian
emotional systems [2].
What both of these writers confirm is that conscience-based emotions have a
different neurophysiological origin and should be considered separately from the
primary emotions discussed in the previous chapter.
17.4 Like a Justice System 205

Right
orbitofrontal
cortex

Fig. 17.1 The seat of the conscience

17.3 Becoming Aware of the Conscience

A search of the literature will show that the conscience or superego has all but disap-
peared as a subject of interest and study, yet it remains a major part of psychopathol-
ogy, an important target of therapeutic effort, and a powerful influence on our quality
of life. Modern psychotherapy literature has rather little to say about this subject
except for some interest in moral development. In cognitive therapy, there is acknowl-
edgment of “core values,” but they are treated as no different from other learned pat-
terns. In fact, it will be argued here that internalized values should be seen as distinct
and separate mental contents due to their unique and powerful resistance to change.
For therapists, every time we are aware of the emotions of pride, shame, or guilt
in our patients, we should be thinking that these emotions are products of the con-
science. Next, we should be asking ourselves whether these emotions, or the lack of
them, are serving the best interests of the patient. When they are not, which is quite
frequent, we are dealing with pathology of the conscience and, in particular, the
values internalized as part of the conscience.

17.4 Like a Justice System

In conceptualizing the conscience, we can think of it as analogous to a justice system,

in which courts make judgments based on laws (values) that are enforced through
punishment (and, in the case of the mind, reward). In the human conscience, accord-
ing to Schore [3], this takes place in the frontal cortex, where the operation of the
system is not accessible to consciousness. In the conscience, enforcement is through
the production of pride, shame, and guilt that are directed into our consciousness.
There they exert a strong influence over our moods and voluntary choices.
206 17 The Second Helper: Conscience-Based Emotion

Interestingly the conscience is both a strong and weak motivator. Both the antici-
pation and the actual experience of shame or guilt are powerful emotions that color
our experience of life. On the other hand, we are easily capable, under certain cir-
cumstances, of giving in to temptation and overriding our own values.
The conscience, when dysfunctional, operates as a helper EDP. As with the other
helper EDPs, the conscience adds its weight to push us in the direction of affect-
avoiding actions that will serve the aims of the nonconscious problem solver.
Anticipation of shame or guilt can, and often does, shift the balance of forces imping-
ing on our free will.

17.5 Pathology of the Conscience

Many of the most common and challenging problems we find in clinical work are
due to problems within the conscience. We saw one example in Jack, whose inter-
nalized value against dependency and the shame it threatened to produce prevented
him from seeking support when he needed it most. The end result was that he ran
out of healthy coping strategies and had a panic attack.
As in Jack’s case, a nearly universal aspect of early life neglect and abuse is
internalization of attitudes exhibited by the abusers, which then produce conscience-
based feelings ranging from self-doubt to powerful shame, low self-esteem, and
inappropriate guilt. Helping patients feel and act more positively toward themselves
is one of the most important and challenging tasks of psychotherapy for people who
have been neglected or traumatized by others.
In another variation, children, faced with adult caregivers’ failures, typically
avoid facing the catastrophic hopelessness of that circumstance by blaming them-
selves. If the child is to blame, the parent can be seen as adequate, making it possi-
ble to preserve a childlike hope. In addition, the child may hold onto the belief that
self-punishment or reform might make the situation better. As self-blame is inter-
nalized, inappropriate shame and guilt can become lifelong handicaps.
Entire populations who have been culturally or politically oppressed often strug-
gle with similar negative values and attitudes about themselves. While originally
aimed at avoiding further hurt, these internalized values can support self-fulfilling
expectations of failure and defeat. The actions of members of these groups to free
themselves from internalized negative feelings can be similar to what individuals
must do to escape from their own unhealthy attitudes toward the self.

17.6 Shame vs. Guilt

Here we place little emphasis on making a sharp distinction between shame and guilt.
In general, the word shame refers to a sense of inadequacy as a person, while guilt
refers to the impropriety of a particular act without bringing adequacy into question.
17.7 Internalization of Values 207

What underlies the distinction is a question of development. Shame represents

an earlier developmental era, before a sense of self-identity is well formed. At this
level of development, attitudes are internalized toward the self, positive or nega-
tive. By approximately age four, a basic sense of adequacy and being lovable is
hopefully internalized. This important internalization is one of those “core val-
ues” that become a permanent part of our makeup. Obviously when there are
problems with this development, the result can create a painful and destructive
legacy.
In contrast, guilt generally assumes a solidly formed sense of self but brings into
question specific voluntary choices. Guilt is the feeling accompanying a choice,
made by self or others, that is judged as wrong by the conscience. The feeling of
pride seems to apply to both feelings of being fully adequate and the feeling associ-
ated with “doing the right thing.”

17.7 Internalization of Values

The process of how values are internalized has not been well studied, largely
because they have been lumped in with other learned mental contents such as likes
and dislikes. In fact, as Freud recognized very early, values are internalized, not
learned. A number of observations by different authors help us develop a picture of
how internalization is distinct from the learning that characterizes procedural
knowledge, declarative knowledge, and other learned mental contents.
Freud saw the value of distinguishing the “superego” or conscience as a mental
function and observed its formation from about age three to six. Perhaps because he
saw the superego as the solution to the triangular relationship of the Oedipal period,
he did not emphasize its further development after that period. Many of our basic
values are internalized in those early years, but therapeutic work with patients trau-
matized later in life shows that we are able to internalize standards throughout life.
Freud also suggested two possible mechanisms to explain the process of internaliza-
tion. The first he called “identification with the lost object.” Here, he observed that
a response to loss of an important person was to internalize some of the characteris-
tics of that person. In the second scenario, the child’s attachment to the parent of the
opposite sex was repudiated to avoid jealous anger from the parent of the same sex.
The solution was for the child to internalize a prohibition against sexual feelings
toward the parent. In one case, the trigger for internalization was loss; in the other,
it was the fear of being harmed.
Another source of observations comes from Conway and Siegelman, two soci-
ologists, in their book, Snapping: America’s Epidemic of Sudden Personality
Change, who studied sudden massive personality change. They looked at experi-
ences like cult induction, in which people internalized an entirely new set of values
over a few hours. The trigger in many of the instances they observed and docu-
mented was an intense need for a sense of belonging to a group [1].
208 17 The Second Helper: Conscience-Based Emotion

Observation of children suggests that another pathway for internalization is the

wish to have love and appreciation of the parents. In a sense, this is like cult induc-
tion. The child wishes very much to be accepted and loved by the parents. For
example, with much encouragement from their parents, many children wish to inter-
nalize the value of being toilet trained. Proof that the conscience is involved comes
from the pride children feel about their accomplishment.
A final example is the observation of patients who have experienced abuse in
early life. These patients tend to internalize precisely those negative attitudes their
perpetrators expressed in words or action toward them. Survivors may even feel
guilt about fighting back against their perpetrator, and the words they use against
themselves can be those originally spoken by the perpetrator.
Putting these examples together, subject to further study and verification, one
explanation is consistent with all of them. Internalization of values makes sense as
a reaction to what we could call “connection anxiety,” that is, the fear of losing vital
attachments. In order to shore up the sense of connection, the individual internalizes
the attitudes and values of the other person or “attachment object.”
Even in the case of early abuse, the victim is subjected to extreme stress at the
same time as extreme aloneness. The need for connection could be expected to be
very strong. Such a situation could generate a need to bond with the only person
available, the perpetrator.

17.8 Internalization, Fast and Slow

In some instances, the process of internalization is gradual. Children may be heard

to repeat out loud to themselves the rules they are working on learning [4]. On the
other hand, under circumstances of intense danger or need for connection, the trans-
formation can be very rapid. During rapid internalization, for example, cult induc-
tion ceremonies, the individual experiences intense physiological sensations at the
height of the experience as documented by Conway and Siegelman [1].

17.9 Internal Electric Fences

In recalling the example of Jack in Chap. 2, internalization of the value of self-

sufficiency can be best described not as an attempt to get close to his own father but
as a way of protecting himself from the pain of repeated experiences of being
rejected at times of need. Another example was the anorexia patient’s value of thin-
ness and self-control. A useful term for this type of internalization is an “internal
electric fence,” similar to electrified fences used to keep livestock from straying.
The value system becomes a deterrent to temptation. Should Jack be tempted to
look to his parents for needed support, the anticipation of shame will keep him from
trying. The anorexia patient steels him or herself from the temptation to give in to
need or hunger.
17.12 Values Are Permanent 209

For the record, the trigger for internalization of these internal electric fences is
probably still the need to calm connection anxiety. In this case, it is by avoiding the
feelings associated with rejection or unfulfilled wishes, rather than by seeking posi-
tive approval. In general, in our clinical work, whenever we see shame blocking the
patient from seeking fulfillment of a healthy human need, an internal electric fence
is probably the villain.

17.10 Adult Internalization

Internalization can take place in adulthood. My favorite example is a senior psy-

choanalytic therapist who was in the process of retiring and referring his patients
to other therapists. He confided that the hardest part of making the referrals was
feeling shame about the fact that he had often been generous and supportive to his
patients. As mentioned in the section on “How Much to Talk” in Chap. 12, in
training as a young adult, he had internalized a prohibition against “gratifying”
his patients’ needs. In spite of his natural generosity, and even believing other-
wise, he continued to judge himself by the standard of non-gratification. In fact, it
is likely that a factor in his success with patients was precisely his warmth and
generosity.
We can imagine that as a student surrounded by mentors who believed deeply in
an austere form of psychotherapy, he experienced a great deal of connection anxi-
ety. With what we have learned about the process, it is not surprising that he inter-
nalized a value of deprivation in his relationships with patients.

17.11 Resistance to Change

When patients exhibit inappropriate shame or guilt, the therapist should expect
remarkable resistance to change. Let’s consider why this should be the case. First,
values that could easily be modified would defeat the purpose of the conscience.
The function of the conscience is to resist our personal wishes. If desire could bring
about weakening of values, then the conscience would no longer be able to counter-
act our self-centered wishes. Therefore, a healthy conscience must be resistant to
any effort to bring about change in values, including unhealthy ones, whether initi-
ated by the patient or the therapist.

17.12 Values Are Permanent

Working with unhealthy values, it soon becomes clear that relapse is a fact of life.
When patients who have been abused or neglected begin to feel genuinely good
about themselves, a series of adverse events can often bring back all the old feelings
of unworthiness and shame. The implication is that, unlike fear reactions, old,
210 17 The Second Helper: Conscience-Based Emotion

unhealthy values do not seem to be subject to complete erasure. Like addictions and
nonverbal schemas, they apparently remain lodged somewhere in the brain’s mem-
ory banks, ready to be activated. The result is that a certain level of vigilance and
maintenance is needed to keep positive self-esteem in the forefront.

17.13 Self-Contradictory Values

Clinical work shows that patients often have contradictory internalized values. They
may feel at one moment that they are worthy and even superior beings and then soon
after, see themselves as defective and worthless. It is not the person who has changed
but the standard of measurement. Where values are stored in memory, possible con-
tradictions are not apparent. An analogy is erroneous computer code. The error only
becomes apparent when the code produces an incorrect result. It is only when con-
tradictory judgments are made and the resulting affects arrive in consciousness that
their incompatibility can become apparent. When we recall how values are internal-
ized under the pressure of connection anxiety, it is no surprise that they are not
always logical or consistent.
What happens, then, if when two contradictory values come to light? Which one
wins out? The answer is that we have some ability to choose which values to follow
in our behavior. A useful metaphor is to think of values arranged in layers where
some, especially those that are currently reflected by the environment, have a greater
effect on conscious emotions. In any performance, the effect of active support from
an audience or spectators is an example. Athletes and other performers feel better
about themselves and do better when they feel encouraged by those in attendance.
In treatment, we try to help patients raise their positive attitudes toward the self over
and above the negative ones derived from their trauma.

17.14 Treatment Principles

17.14.1 Tread Lightly

When we as therapists determine a need to question patients’ values, attitudes, ide-

als, or prohibitions, we need to tread very lightly. The first reaction of the patient is
to feel as if the therapist is a corrupting influence. We are proud of our values and
experience them as closely linked to our identity. We tend to feel that if our values
were to change, then we would no longer be the same person. Most people assume
that their conscience is always right, an unimpeachable force for good. To suggest
that a conscience can be dysfunctional, or even wrong, is a radical and frightening
notion. Unless the challenge is done with sensitivity, the patient may turn against
the therapist in defense of his or her values, even if they are dysfunctional ones.
When patients have internalized values rapidly in the face of life-and-death
trauma, it is especially important not to use any treatment approach that might be
17.14 Treatment Principles 211

experienced as coercive in the same manner as the perpetrator of abuse. The child
within is always ready to see the therapist as having the same motives as the
perpetrator.

17.14.2 New Values vs. Old Ones Recovered

When working with negative attitudes toward the self, our goal is to help the
patient reawaken positive feelings that are present somewhere but have become
inactive. This assumes that such values do exist. We hope that, before the trauma
occurred, the patient had already internalized some feeling of being valuable and
lovable. The therapeutic relationship is a source of positive esteem for the patient
that can be expected to bring preexisting positive values and attitudes to the
surface.
Occasionally, patients seem not to have access to any positive feelings. These
patients have difficulty forming bonds with the therapist and require a great deal of
time and consistency in order to form an attachment that helps them feel worthy. In
these cases, the theoretical question of whether the attachment problem is due to a
lack of preexisting positive attitudes toward the self or to nonverbal schemas that
work to block attachment is often hard to answer.

17.14.3 Education

Treatment for this type of EDP may start with education about the fact that the con-
science is not always right. It may be helpful to show the patient where their dys-
functional values come from. Patients are sometimes surprised to learn that their
internalized values were derived from hated perpetrators. Gradual education is an
important tool in enlisting the intellect to work with heavily entrenched ways of
experiencing the self and the world.

17.14.4 Modeling Positive Values and Attitudes

The therapeutic relationship is one of the best tools we have to awaken positive
values. In addition, patients experience a desire to attach to the therapist. This can
be a very powerful force and is one reason why it is critical for the therapist’s words
to be consistent with actions. Especially those who feel the most alone will experi-
ence a significant degree of connection anxiety. We have seen that this is the trigger
for internalization of values. Yes, it is possible for patients to internalize values from
the therapy. We try not to impose our personal values on patients, but, purposely or
not, we do represent valuing health over dysfunction, and we do demonstrate a posi-
tive attitude toward our patients. Over time, these attitudes can be internalized,
which is a positive consequence of therapy.
212 17 The Second Helper: Conscience-Based Emotion

17.14.5 Working with Shame

Shame (the inappropriate kind) is a pervasive problem in psychotherapy. Since the

problem is really one of an unhealthy internalized attitude, which we know will be
hard to change, the best treatment strategy is “the kitchen sink,” that is, to go ahead
and use all available means to support positive self-esteem and to contradict the
negative attitude. Within the therapy, these include the positive attitude of the thera-
pist, the patient engaging in positive “self-talk,” and perhaps, most powerful of all,
the patient behaving in ways that express a positive attitude toward the self (see
“Civil Disobedience” below). Outside the therapy, it is especially important for
patients to enlist and nurture a positive support system.

17.14.6 “Civil Disobedience”

Of the aforementioned therapeutic principles, by far the most powerful is the need
to change behavior. Patients and all of us feel most comfortable behaving in a way
that is consistent with our values and attitudes, especially how and where we fit in
society. Those who experience a great deal of personal shame will naturally behave
in ways that reinforce their bad feelings. Even if they understand intellectually that
those values are dysfunctional, as long as the behavior patterns remain in place,
values will not change. “Civil disobedience” is a memorable phrase to describe
doing the opposite of what the attitudes in one’s conscience dictate. Patients with
negative self-esteem will feel almost delinquent when they treat themselves in
positive ways. Simply changing posture feels unnatural. Furthermore, they can
expect to experience shame when they do act differently. Nonetheless, this is one
of the most powerful ways to “teach” the conscience that it is now safe to face the
world with pride.
Patients may be afraid to engage in civil disobedience. This fear should be
respected and explored, so that whatever new behaviors the patient tries have been
thoroughly evaluated before being put into action. If the fear is not respected, the
mind can unleash powerful and effective EDPs to sabotage the therapeutic effort
through behaviors that appear positive but are not. Patients engaged in behavior
change will also interpret minor negative events as proof that change is not safe.
Education should help them expect such reactions and that steady persistence is the
way to teach the mind that the new way of behaving is safe.
While they don’t directly differentiate internalized values from other beliefs held
in the mind, two contemporary therapies, eye movement desensitization and repro-
cessing (EMDR) and Ecker’s coherence therapy, do propose specific methods for
“installing” healthier mental contents.
References 213

Key Points
• Of the three helpers sent into consciousness to influence our free will toward
some avoidant behavior, the second type, the subject of this chapter, consists
of emotions based on value judgments that emanate from the conscience.
• These conscience-based emotions are pride, shame, and guilt.
• Healthy conscience-based emotions come from healthy values. Unhealthy
ones arise from dysfunctional values.
• Judgments of the conscience are made on the basis of four types of inter-
nalized mental contents, values, attitudes, ideals, and prohibitions.
• Most values are healthy. Many are internalized before age five or six, but
the ability to internalize new ones remains in place throughout life.
• The trigger for internalization of values is connection anxiety, the need to
belong and be attached to those who are important to us. This trigger can
cause people, especially victims of abuse and neglect, to internalize dys-
functional attitudes that are against the self, for example, low self-esteem.
• Because values function to counteract our personal desires when they go
against social needs, they are necessarily and appropriately resistant to
change, including unhealthy ones.
• In clinical work with unhealthy values and negative attitudes toward the
self, erasure of values is not possible, but, using all available resources, we
can help put healthier values ahead of the others.
• The most powerful antidote to negative attitudes toward the self is “civil
disobedience,” that is, behaving in a way that is opposite to the attitude our
mind would like us to reflect.

References
1. Conway F, Siegelman J. Snapping: America’s epidemic of sudden personality change. 2nd ed.
New York: Stillpoint Press; 1995.
2. Panksepp J, Biven L. The archaeology of mind: neuroevolutionary origins of human emotions.
Norton series on interpersonal. Neurobiology. 1st. New York: W. W. Norton & Company;
2012. p. 19.
3. Schore AN. Affect regulation and the repair of the self. 1st ed. New York: W. W. Norton &
Company; 2003. p. 186.
4. Stern DN. The interpersonal world of the infant. New York: Basic Books; 1985. p. 173.
The Third Helper: Thoughts
18

Spontaneous or automatic thoughts constitute the eleventh type of EDP. Along with

feelings, our consciousness receives a more or less constant stream of thoughts.
Many, if not most of them, pass by like flotsam in a river without our noticing. When
we do pay attention, these thoughts have much to tell us about the nonconscious
workings of the problem solver behind the curtain.
Thoughts can be extremely valuable. Some give us ideas for what to do in our
lives. They can include flashes of creativity and new insight. They tell us what to
expect and how others might react. We have good thoughts and bad ones. Some help
us in life, and others seem to talk us into actions we later regret. Freud saw thoughts
as clues to hidden memories and stresses. At first he tried hypnosis to peek into the
recesses of the mind, but he soon found that listening to the stream of thoughts was
more efficient and less intrusive. With a little help from Anna O., who told her doc-
tor to just listen, Freud came to the idea of free association as a tool for understand-
ing. Watson and the early behaviorists avoided patients’ thoughts because they were
not objective or measurable. But later, Ellis and Beck [1], pioneers in cognitive
therapy, brought thoughts back into the behaviorist tradition. They noticed that
thoughts lead to feelings and behavior and, in particular, that helping patients
change irrational thoughts could help relieve depression. Where Freud called the
stream of thought “free associations,” the behaviorists called them “automatic
thoughts.” For our purposes, they are the same.

18.1 Thoughts as Helpers

Where might those thoughts come that rationalize depression and tell us to do things
we will regret? What purpose do they serve? The approach to thoughts taken in this
book comes from an interesting observation about spontaneous thoughts. People in
the early stages of recovery from addiction who are abstaining from use of a sub-
stance that has played an important role in their lives experience a particular kind of
spontaneous thought that seems meant to steer them into relapse.

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_18
216 18 The Third Helper: Thoughts

What is extraordinary about the thoughts of recovering addicts is that they are
exquisitely crafted to do the job of getting the individual back to the substance. A
recovering alcoholic might have the thought that he is doing very well and feeling
better than he has in a long time. Next, he might have the thought that he no longer
needs the support of others, and that his free will is so powerful that he will never
drink again. While friends and family listen in horror, he relaxes, isolates from those
who have supported him, and, to his surprise, succumbs without a fight to the next
temptation to drink.
The reasonable seeming thoughts that led him to relapse had no labels to indicate
their purpose, but another recovering alcoholic would have recognized immediately
that those thoughts were “the disease talking.” They come into the mind cleverly
disguised to seem only positive. They seem purposely designed to deceive the con-
scious mind into following their direction. One other observation: Before the indi-
vidual had seriously resolved to stop drinking, the thoughts were much quieter.
With the initiation of total abstinence, they become more frequent and intense. If the
recovering person ignores these messages, they increase again. Sometimes newly
recovering people return to using simply to calm the rush of thoughts. Such obser-
vations suggest that the nonconscious problem solver:

• Is purposeful in influencing behavior

• Has as much intelligence as the individual
• Designs thoughts for maximum effectiveness
• Produces the thoughts “on the spot”
• Is not always logical but may seem so
• Can mix health and dysfunction into one thought

While thoughts serve many purposes, those that are of most concern to therapists
are the ones that lead to dysfunctional behavior or problematic symptoms. Consistent
with the affect avoidance model, all those thoughts that cause problems can be seen
as part of the mind’s efforts to distance from uncomfortable feelings. We can distin-
guish four varieties of thoughts that relate to entrenched dysfunctional patterns.

1. Potential dysfunctional behaviors start out as thoughts that pop into conscious-
ness in the form of the image or idea of an action we might take.
2. Influencing thoughts, such as those of the recovering addict, come into con-
sciousness designed to steer our decision-making so as to put a dysfunctional
action pattern into effect.
3. Influencing thoughts whose action is to reinforce symptoms like depression also
support the mind’s efforts to avoid painful affects.
4. Intrusive thoughts, such as obsessions and worries that are symptoms in and of
themselves, may serve to distract from, and thereby avoid, deeper concerns and
anticipated affects.

The two forms of influencing thoughts are the ones we are mainly concerned
with in this chapter. They are, in effect, “helpers” that further influence our free will
18.3 Avoiding Thoughts Makes Them Stronger 217

to implement the potential actions that embody the avoidance mechanisms of

behavioral EDPs. In addition, the same treatment principles that apply to influenc-
ing thoughts also apply to unwanted obsessions and worries. To sum up, the non-
conscious problem solver, intent on avoiding painful affects, uses thoughts in a
variety of creative ways to make sure its aims are accomplished.

18.2 The Contents of Influencer Thoughts

Psychodynamic therapists see influencer thoughts as defenses designed to keep the

patient and therapist away from uncomfortable mental contents. Of course this is
fully compatible with the affect avoidance model in which thoughts defend against
the emergence of uncomfortable affects.
Addiction therapists see them as the mind’s ways of steering the patient back to
the substance or compulsive behavior, which is also compatible with the affect
avoidance model.
Cognitive therapists see automatic thoughts as promoters of dysfunctional feel-
ings and actions. These too can be seen in the light of the affect avoidance model as
ways to keep us away from anticipated uncomfortable feelings. In the case of
thoughts that promote feelings like depression, we will discuss those in the next
chapter on “Symptoms.”

18.3 Avoiding Thoughts Makes Them Stronger

Perhaps the most significant recent discovery of cognitive therapy is that attempting
to eliminate dysfunctional thoughts actually strengthens them. In 1987 [2], Wegner
published a paper, “Paradoxical effects of thought suppression,” showing that
attempts to eliminate thoughts cause the mind to focus even more on the thought.
Techniques such as “thought stopping” have been shown to be ineffective.
This happens also to be true of irrational feelings such as anxiety as well.
Attempting to eliminate the thoughts and feelings produced by the nonconscious
problem solver has the paradoxical effect of making them more prominent than
before. Various explanations have been proposed for this phenomenon, but one is
particularly useful and consistent with the theme of this book: The nonconscious
problem solver is trying to protect the individual from troublesome affects and is
programmed in a variety of ways to resist any attempt to thwart its efforts.
This explanation is simple and intuitive. More important for the therapist, it tells us
to be respectful and understanding of the mind’s efforts. Without such a broad under-
standing, we might be tempted to try to outsmart the problem solver with clever strate-
gies. As stated above, the nonconscious mind has the same intelligence as the patient
and is capable of inventing an infinite variety of ways to counter such trickery.
In the end, what patients need to do is work with their own minds as a parent
might treat a frightened child, with respect and understanding, yet clarity about the
necessary outcome.
218 18 The Third Helper: Thoughts

18.4 Treatment Principles

18.4.1 Consciousness Raising

In the beginning, many if not most patients have little awareness of their thoughts
and even less awareness that some of them are causing harm. The first steps include
education about the nonconscious problem solver as well as exercises to help the
patient become more aware of his or her own stream of thoughts. Cognitive therapy
uses workbooks and logs to help patients become aware of their automatic thoughts.

18.4.2 Distinguishing Healthy Thoughts from Unhealthy Ones

The most difficult aspect of unhealthy thoughts is that they are indistinguishable
from healthy ones. Thoughts don’t come with labels, so we must find other ways to
distinguish healthy ones from the others. The primary means to do this is to ask
where the thought will lead if followed. The recovering alcoholic’s thought that his
willpower was invincible led directly to distancing from the people who had sup-
ported his recovery. Similarly, self-critical thoughts, such as “I am weak and dis-
gusting,” lead to more intense feelings of depression. By following the thought, we
can often sniff out its intent.
Besides following the thought, one of the most effective ways to distinguish an
unhealthy thought is to share it with another person. As in the example of the alco-
holic above, those who have the patient’s best interests at heart but do not share his
or her blind spots are likely to recognize immediately the unhealthy intent of the
thought.

18.4.3 Resistance

Challenging dysfunctional thoughts can be expected to bring up resistance. An

authoritarian stance is likely to be rejected. A softer, more respectful Socratic ques-
tioning, such as that used in motivational interviewing (see Chap. 15), may help.
Starting with discussion of the undesirable result and working back to the thoughts
that lead to it can also be easier to accept. Earlier work to educate the patient about
the nonconscious problem solver may also ease the work of pointing out irrational
and unhealthy thoughts.
Another subtle approach taken from motivational interviewing is to “draw the
patient out.” Often the problem solver, aware that its ideas may not sound right, may
keep them quiet. Drawing the patient out means asking questions and probing the
patient’s reasoning so that the patient has an opportunity to hear his or her own
thoughts spoken aloud. This may be enough for the patient to see the unreasonable-
ness of their position. At that point, the therapist can help to soften the patient’s
shame for being unreasonable and support a healthier way of thinking.
18.4 Treatment Principles 219

If the patient is open to discussion and dialogue, then education is an important

tool. As therapists, we have access to information that patients may not. We can
explain, give research results and examples, and use our knowledge to help patients
make healthy decisions. In Chap. 13 in the section on “Authority,” we discuss the
pros and cons of imparting information to patients.
Arguing with patients is rarely helpful, but offering alternative ideas in a mild
challenge may help the patient to look at the question in a new light. Psychoanalysts
and dynamic therapists call this “interpretation.” Similarly, cognitive therapists may
use their authority along with tact to challenge irrational ideas.
Is it ever helpful to force an argument with a patient? Occasionally patients may
push the limits of irrationality, for example, threatening to do something so destruc-
tive that the therapy may be damaged or the patient’s life may be harmed. While
attempting to convince someone who is resisting is always futile, explaining your
position may be productive. This means asking the patient to be willing simply to
listen while recognizing his or her free will and right to make their own decision.
You can then explain your position and why you hold it.
In addition, as a professional, you have a duty not to do harm or to support a
harmful decision. Very rarely, it is necessary to do what therapists call “limit set-
ting.” This means stating that if the patient chooses to do a certain thing, you, the
therapist, will be obligated to respond in a particular way. Responding to a patient
who threatens to buy a handgun, a therapist might explain that if the patient chose
to do that, he or she would have to terminate the therapy. It may not be acceptable
for the therapist to tolerate the burden of concern and responsibility that the patient
might impulsively use the weapon.

18.4.4 Mindfulness

When dysfunctional thoughts intrude upon consciousness and seem compelling, the
most powerful response is mindfulness. The addict’s persistent urges to relapse are
an example. As explained in Chap. 5, mindfulness means accepting dysfunctional
thoughts as natural products of the mind while putting them in perspective as con-
tents that should not guide life decisions. Recall that this sense of perspective cor-
responds both to the Buddhist principle of smrti and equally to the reassuring smile
the toddler receives back when he or she makes eye contact with the empathic care-
giver. In both cases, the mind is pulled out of its focus on the immediate, to a vision
of the self through the eyes of another.

18.4.5 Other Techniques

Persistent and obsessive thoughts will be discussed in more depth in the next chap-
ter. For now, a number of techniques can help. Distraction turns the focus to some
absorbing task instead. Another technique is putting off action. Telling oneself that
220 18 The Third Helper: Thoughts

action can wait and the decision can be put off till later may give enough time for an
urge to abate. Seeking the company of a supportive other at a time of temptation can
be very helpful. Finally, asking the patient to go into graphic detail about the “worst-
case scenario” related to an irrational thought or impulse can help to make it more
real and less a subject of abstract, but ineffective, dread.
Detailed treatment of how to use these basic techniques to help patients with
dysfunctional automatic thoughts is incorporated in the literature of many therapies,
especially CBT.

Key Points
• Thoughts serve many purposes as they stream out of the nonconscious
parts of the mind. One of these is to influence us to choose those actions
deemed necessary for affect avoidance by the problem solver.
• These helper thoughts have no obvious label to differentiate them from
other thoughts, which makes them that much more effective in leading us
take actions that we will later regret.
• Whether we call them automatic thoughts or free associations, observation
of addicts struggling with abstinence shows that they are designed on the
spot to be maximally effective in furthering the aims of the problem solver.
• The more we fight our thoughts, the stronger they get.
• Treatment starts with awareness. The mind resists efforts to clarify and
challenge these thoughts, requiring sensitivity and tact.
• The two most useful principles for distinguishing dysfunctional thoughts
are, first, to ask where the thought will lead and, second, to share with
another who does not have out blind spots.
• When thoughts become intrusive or obsessive, we can think of them as
symptoms, to be discussed in the next chapter.

References
1. Beck J. Cognitive therapy: basics and beyond. New York: Guilford Press; 1995. p. 19.
2. Wegner DM, Schneider DJ, Carter SR, White TL. The paradoxical effects of thought
suppression. J Personality and Soc Psychol. 1987;53(1):5–13.
Involuntary Symptoms: Grief
and Depression 19

In contrast to EDPs consisting of avoidant behaviors chosen by free will, symp-

toms, as discussed in the next three chapters, are unwelcome guests. In this last
component of the catalog of EDPs, we look at the final three types, numbers 12, 13,
and 14, which are depression, anxiety-related troubles, and dissociation, respec-
tively. They consist of symptoms that seem to come upon us for no reason and
against our will. They have in common significant biological aspects and run in
families. Even so, like other EDPs, these symptoms can and do serve an affect
avoidance function. Since they are beyond our direct control, psychological treat-
ment must first focus on indirect approaches, helping patients interrupt vicious
cycles that make them dominate the patient’s life. This means working to change the
ideas and behaviors that support and amplify the symptoms and helping patients to
let go of obsessive efforts to make the symptom go away. Finally, we seek to iden-
tify and detoxify the affects that drive the symptom.

19.1 Grief: A Healthy Response

Grief is not really an EDP. It is not a way to avoid affects but to process and heal
them. It does, however, frequently compel patients to seek the help of a therapist.
Furthermore, it is of importance to us because it can shed light on the related condi-
tion of depression. Grief produces many of the same experiences that are part of
serious depression but, in particular, omits the parts that are self-destructive. By
essentially subtracting the experience of grief from that of depression, we will bring
into focus what is different and unique about depression. For now, let’s return to
look at grieving.
Unlike depression, grief heals over time and seems to serve the necessary function
of letting go of attachments. As pointed out by Konrad Lorenz [6], mammals and birds
appear to undergo very similar symptoms when they lose a lifelong attachment.
Grief is triggered by the loss of a major attachment, which can be a person, an
animal, or an object such as a home, a principle, or a cherished goal. In serious

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_19
222 19 Involuntary Symptoms: Grief and Depression

cases, it begins with a feeling of infinite darkness and complete hopelessness. The
grieving person is taken over by the loss, and any attempt at reassurance will be out
of sync with the experience and will irritate, not help.
At first grief is all consuming, taking up every minute. There is a profound dis-
ruption of normal functioning. Appetite is lost and sleep is disrupted, especially by
early morning waking. The grieving person has difficulty concentrating on anything
but the loss. Tears may flow for days, and all thoughts are about the loss.
Gradually there may be welcome periods of distraction. Sometimes people
divide the “work” purposefully into portions. A recent widow, for example, might
go through her deceased husband’s clothing, a few garments at a time, and then shut
the closet when she has had enough. With each reminder of the loss, she experiences
a wave of feeling. This will last for a period, then abate, permitting her attention to
shift to other things. With the next reminder, the cycle starts again.
Grieving takes its own time, depending on the magnitude of the loss. Attempting
to hurry the process does not work. Eventually, the hopelessness and loss of interest
in other things begin to abate. The appetite returns, sleep patterns resolve, and, over
whatever time course, unbearable sadness gradually transforms into a painful ache.
We don’t know where, but it is a good guess that somewhere in the brain, synapses
are gradually reconfigured, readjusting hormones so as to disconnect the intense
distress reaction from the knowledge of permanent loss.

19.1.1 Loss and the SEEKING System

Recent work in the neurobiology of emotions sheds some further light on the biol-
ogy of both grief and depression. The brain’s SEEKING system (see Chap. 7 on
motivation), whose job is to promote whatever goal the mind deems important,
works as a kind of volume control on mood. When the SEEKING system is locked
onto a goal and we are making progress, it becomes neurologically activated, and
the accompanying feeling is one of pleasure, even elation. On the other hand, when
the SEEKING system runs into discouragement and failure, it shuts down, and the
feeling is one of depression and hopelessness [8]. It feels like the situation will
never get better. This feeling state has little to do with literal reality but is common
both to grief and to depression. Understanding the SEEKING system and the effects
of varying levels of activation gives us a way to make sense of mood swings all the
way from the bottom of hopelessness to excesses of optimism and even mania.

19.1.2 Pathological Grief

Occasionally, grieving fails to progress normally. When this happens it generally

means that the grieving process has morphed into an EDP. That is, grieving has
become a way to avoid an associated affect that the mind is not ready to accept.
First, we need to be careful to distinguish between grief that is simply taking its time
19.2 EDP #12: Depression 223

and grief that is stuck. Grieving normally evolves, even if slowly. When, over a
period of time, there are no signs of the process moving forward, then it is time to
wonder why. Usually this turns out that the person is having trouble with acceptance
of some aspect of the loss [3].
For example, a patient cries constantly, and intense feelings of grief are not
letting up, not even a little. Listening to the patient, we repeatedly hear a lament
about how life will never be the same. The complaint is not about how the person
was cherished or that such a fine person will no longer be a presence but more of
a protest that life should not have to change. This patient is fighting to avoid hav-
ing to accept the loss and the inevitable readjustment it will require. Another situ-
ation might be where the grieving person has unacceptable feelings of guilt or
anger toward the deceased person. By refusing to accept the loss as a fact, these
unacceptable feelings are kept “in limbo” and do not have to be acknowledged or
accepted.
In general, grieving that fails to evolve is an indication of a pattern of avoidance
in relation to unacceptable or overwhelming emotions.

19.2 EDP #12: Depression

Today, in spite of new science, depression has become more confusing, rather than
less. The diagnosis has broadened, causing distinct clinical pictures to be lumped
together. Intense campaigns to influence professionals and the public have raised
awareness of the problem of depression but have made it harder to discriminate
between different clinical situations and determine how to approach them.
For example, a patient in China was in intensive psychotherapy. As the relation-
ship deepened, his therapist began to notice signs that the patient was experiencing
feelings of neediness and, with them, anger. These emotions were far from con-
sciousness. As the intensity increased, the patient became frightened and, without
discussing it with his therapist, went to see an outpatient psychiatrist at the hospital.
He was diagnosed as depressed and given antidepressant medication. The patient
was relieved and told his friends that he “had depression.” His acting out by seeking
outside treatment did not take away his deep feelings but covered them up temporar-
ily and made it harder for his therapist to help him understand that his therapy was
bringing up frightening wishes and emotions.
This brief example shows several things. First, it illustrates the power of psycho-
therapy to bring strong feelings to the surface and how mysterious and frightening
they can seem to the patient. More to the point, as is common today all around the
world, the diagnosis of depression was given with little discrimination, and medica-
tion was prescribed without consideration of the whole picture. What the patient
really needed was help identifying and making sense of the emotions he was expe-
riencing. One point of view is that the easy diagnosis of depression and the rela-
tively indiscriminate use of medications create confusion for patents and
therapists.
224 19 Involuntary Symptoms: Grief and Depression

19.2.1 Some Good News

The worldwide healthcare field is recognizing the seriousness and prevalence of

depression. The World Health Organization (WHO) cites depression as “the leading
cause of disability worldwide in terms of total years lost due to disability” [7].
Attention to this problem is certainly a good thing, but with it comes a tendency to
think that all depressions are the same and that treatment should be simple.
Unfortunately, this is not the case.

19.2.2 Focusing on “Major Depression”

While the DSM-V diagnosis of “major depression” is quite explicit in restricting the
diagnosis to severe forms of depression, prevalence statistics seem to show a dra-
matically higher incidence than what is actually seen in clinical practice. Kessler,
based on a survey of the US public, showed that 6.6 percent of the population expe-
rienced major depression within a 1-year period (2003) [4]. This seems very high.
Perhaps the explanation for such a large number is that only 12 percent of those
were classified as “severe.” It seems that even restricting samples to the official
criteria for major depression, the depressed people being described represent a
broad, and therefore confusing, mix of different levels and kinds of depression.
Ultimately, scientifically responsible studies of major depression still refer to a
mixed group of patients. For example, most clinical descriptions say that patients
can suffer from either weight loss or weight gain and from either insomnia or hyper-
somnia. In my professional experience, people with truly severe depression almost
never have weight gain and hypersomnia, while those with much milder forms can
sleep too much and gain weight. This observation may seem trivial, but trying to
correlate treatment with results when groups of patients are too dissimilar can only
lead to more confusion.

19.2.3 Some Bad News

Penn and Tracey [9] published an analysis of a large number of studies about the
effectiveness of antidepressant medication versus placebo (sugar pills). What makes
their study unusual is that the authors reviewed not only published studies but also
the studies that had negative results but were not published. Many of the articles not
favorable to drug treatment were suppressed and could only be obtained using the
legal procedures of the American Freedom of Information Act.
What the authors found was that, overall, treatment for depression was quite suc-
cessful, but it didn’t matter whether patients were treated with placebo or an active
chemical. In other words, drug treatment was no better than placebo, but both
worked. What does this mean?
First, it could mean that the patients in these studies were so broadly diagnosed
and heterogeneous that the effect of the drugs was statistically insignificant. Second,
19.3 Melancholic Depression 225

the impressive results with placebo support our point of view that depression is in
large part a psychological phenomenon. If depressed patients get better simply from
thinking they are getting treatment, then it seems likely that the causes of depres-
sion, or at least the mechanisms of healing, are largely psychological. We might say
that depression is about feelings and the mind’s ways of perceiving and protecting
the individual, which is exactly what psychotherapy can address and what we are
interested in here.

19.2.4 Financial Influences

Besides the altruistic desire to increase awareness and support for treatment and
research on all kinds of depression, there are other forces at work. The reason so
many negative research studies were never published was probably financial.
GlobalNewswire [2] cites a Zion Research, Ltd. report stating that the already huge
worldwide antidepressant market is forecast to grow dramatically. It was measured
at “USD 14.51 billion in 2014 and is expected to generate revenue of USD 16.8 bil-
lion by end of 2020.” With so much money at stake, it is understandable that corpo-
rations want to influence both professionals and members of the public to believe
that any form of depression warrants antidepressant treatment and that treatment is
simple and effective without problematic side effects. In fact, not all depression
requires or will benefit from medication, and the treatment of depression is far from
simple and without problems.

19.3 Melancholic Depression

Let’s begin with the most serious kind of depression. At times people become so
depressed that no words or actions seem to be able to pull them out of the depth of
their misery. They hate themselves and the world. They see no hope, only blackness.
The Greeks thought this was a biological condition characterized by an excess of
black bile, from which comes the name melancholia. We will use that unofficial
term informally here to designate this most serious kind of depression.
When patients start to slip into an episode of melancholic depression, family
members can tell right of way. The person’s face and manner change dramatically.
If the therapist knows the patient well, the difference is also obvious, even in the
waiting room. The experience is dramatic and upsetting to everyone, as there is little
that talk can do to stop the process as the patient sinks into darkness. Patients who
have experienced this feeling have a powerful dread of ever encountering it again.
Time seems interminable, and the feeling is experienced as beyond what one can
endure.
Many of the symptoms including pessimism, loss of appetite, weight loss, and
early waking are also encountered in severe grief. The symptoms suggest that the
neurophysiology is a shutting down of the SEEKING system. By identifying
226 19 Involuntary Symptoms: Grief and Depression

these components as neurobiologically based changes that happen when humans

suffer a major loss, we can now ask what makes melancholic depression different
from grief.

19.3.1 Unique Aspects of Melancholic Depression

The differences, as Freud pointed out, between mourning and melancholia [1] begin
with the fact that, unlike grief, melancholic depression is not self-limiting. Instead
of regularly progressing toward healing, it progresses in a way suggesting a vicious
cycle. To patient and to therapist, it feels like a slippery slope that takes on increas-
ing negative energy as the person enters further into despair. Patients seem almost
willful in resisting efforts to pull them out of their misery. This urgent hopelessness
makes melancholic depression a severely upsetting condition for patients and fami-
lies and one that is seriously challenging to therapists.
When we listen to patients, once again as pointed out by Freud, the difference
with grief is that they express feelings of self-criticism even to the point of hate.
Their feelings of having done wrong can go to the point of being delusional. Angry
feelings toward others are carefully avoided, even though they may be implied.
Patients often seem to relish self-punishment, and, when they make their lives yet
more difficult, they seem to derive some satisfaction from doing so. While this is
true of many, a subgroup of patients is more concerned with anxiety and worry than
with guilt or self-criticism.
Such an episode can be triggered by a loss or disappointment. Episodes can also
come on when patients stop taking antidepressant medications, and they can also
happen for no apparent reason. Left untreated, these episodes can last for months,
but most eventually resolve by themselves. Treatment will be discussed below.

19.3.2 Bipolar Illness

To complicate things further, a significant portion of people who have the melan-
cholic type of depressive episode also experiences manic episodes in which they
become overexcited and hyperirritable or overconfident. This bipolar condition
seems heavily influenced by genetics and biology and seems hardly related to affect
avoidance. Episodes are more likely to have no identifiable trigger, and psycho-
therapy seems to have little effect on the course of this component of the illness.
For bipolar patients, when a first episode consists of depression only, it may be
appropriate to treat with antidepressants. Unfortunately, these medications can trig-
ger a switch to mania. Such a dangerous medication effect is difficult to predict or
avoid unless the patient has had a manic episode or some degree of “racing thoughts”
or unusual irritability in the past. Once the diagnosis is clear, mood-stabilizing med-
ications as opposed to antidepressants are remarkably helpful, though side effects
remain problematic.
19.3 Melancholic Depression 227

Of course many patients exhibit symptoms that are not entirely typical of any of
the presentations depicted above. Sorting out diagnosis and biological treatments is
the job of psychiatrists and is not covered in this book.

19.3.3 Two Vicious Cycles

In trying to make sense of melancholic depression, the most striking feature is that
in the early part of an episode, patients seem to slip ever further into darkness.
Efforts of family and therapists are to little avail, but medications can sometimes
help to stop the process.
Two simultaneous vicious cycles may help to understand this kind of depression
taking hold. The first is that the patient’s emotional biology has entered a vicious
cycle that is resistant to reversal. Early medication can help, but once the process
has progressed, even powerful medications take days or weeks to make a difference.
At such a time, talk therapy does not have much of an immediate effect.
The second vicious cycle is emotional. Thoughts of self-hate and self-criticism
lead to feeling worse. Acting upon those feelings, for example, by isolating and
punishing the self, makes the feelings even more intense. The worse the feeling, the
more the patient experiences a desire to hurt. We’ll see below how the dynamics of
the emotional vicious cycle begin to make sense as an EDP, that is, a product of the
nonconscious problem solver, desperately trying to deal with an impossible and
unresolvable psychological dilemma.

19.3.4 First Work with the Biological Dysregulation

The severity of melancholic depression is such that, taking a pragmatic approach,

anything that can help is worth doing. Applying this principle, the fastest and most
effective way to bring the patient to a level where talk can be of benefit is generally
to use medication. In the great majority of severe cases, within a few weeks, medi-
cation or a combination of drugs will work in a way that appears to reverse the
biological vicious cycle. This approach to treatment is independent from psycho-
therapy, though as the patient begins to come out of the depths, psychotherapy can
be more meaningful and may begin to make a difference. Interestingly, as the first
glimpses of improvement begin to show, the last person to acknowledge that any-
thing is better is usually the patient.
The biological dysregulation with its hopelessness, sleep disturbances, and loss
of appetite is similar to the experience of severe grieving but, among depressions, is
characteristic of the melancholic kind. As this begins to lessen, we see more clearly
the emotional vicious cycle at work. What remains is a tangle of misdirected anger
and its consequences. Melancholic depression, then, can be seen as a combination
of a biological loss of control that looks much like severe grief, along with an emo-
tional vicious cycle that it has in common with less severe forms of depression. The
228 19 Involuntary Symptoms: Grief and Depression

implication is that the psychological part of understanding and treatment of severe

depression is largely the same as for milder forms. Below is a diagram to show how
both grief and depression can, when severe, be accompanied with biological signs
of melancholia. On the other hand, apart from those common symptoms, they differ
in that grief does not included self-hate, while depression, whether mild or severe,
does (Fig. 19.1).
If the depression is mild enough that talk is possible or when biological treatment
begins to allow the patient to enter into conversation, the therapist can attend to
thoughts and observe emotions. As we listen, we will see the outlines of an
entrenched dysfunctional pattern designed, like all EDPs, to avoid a dreaded affec-
tive situation. Setting aside the biological and focusing on the EDP, we can recall
the principle that every EDP has an affective and a behavioral side, let’s start with
the behavioral, that is, the pattern of thoughts and behaviors that make the patient
feel even worse.

19.3.5 The Behavioral Aspect of Depression

Patients in the midst of depression are under pressure from the nonconscious prob-
lem solver to punish the self. They accomplish this through three strategies. The first
strategy used by the nonconscious problem solver is to bombard consciousness with
helpers, that is, automatic thoughts accusing the patient of inadequacy and failure.
These false accusations, taken very seriously, cause more pain. Cognitive therapists
have documented a number of recurring distortions of thought that emphasize the
negative over the positive. For example, patients “catastrophize,” making something
bad into something terrible. They seek out or even fabricate evidence that the situa-
tion is hopeless and that there is no use trying to make things better. Using intelli-
gence, imagination, and a wide variety of intellectual tricks, automatic thoughts
succeed in making an already dark depression much darker.

Melancholy

Grief Depression

Fig. 19.1 Relating biological melancholy, grief, and depression

19.3 Melancholic Depression 229

Second, the nonconscious problem solver bombards consciousness with poten-

tial actions that further the goal of inflicting hurt. Patients reject help and isolate.
These actions make them feel alone and neglected. The depression deepens. With
the help of natural biological dysregulation, they deprive themselves of food and
go without sleep. These insults to the body further deepen the depression. They
neglect themselves by not washing or changing clothing. They may engage in risky
behaviors with a lack of concern for safety. Finally, they may do active harm to
themselves. All of these actions are forms of punishment that also deepen the
depression.
Third, while all this undeserved punishment is intended to solve a problem, it also
fuels an inner outrage and anger that the wrong person is again being victimized.
These thoughts and feelings can’t be allowed into consciousness but augment the
emotional intensity. They further energize and deepen an out-of-control vicious cycle.
As a preview of treatment principles below, CBT treatment, approaching the
EDP from the behavioral direction, seeks to challenge and reduce these unhealthy,
punitive thoughts and behaviors. Cognitive-behavioral therapists take pains to show
patients the fallacies in their automatic thoughts and introduce more rational ways
of thinking. On a behavioral level, they work to influence patients not to take those
actions that will make the depression worse and to behave in more positive ways. In
so doing, CBT can slow or even stop the vicious cycle in which the patient actively
inflicts undeserved self-punishment.

19.3.6 The Emotional Aspect of Depression

In order to approach the emotional aspect of depression as an EDP, we need to ask

why. Why would the nonconscious problem solver want to punish the self? In case
after case, it turns out that Freud was not wrong. Without going into his notions of
cathexis and emotional energy, the patient was experiencing anger toward loved
ones that was unacceptable and too dangerous to be expressed in any direct way.
What can the problem solver do with this poisonous feeling? There is no right
answer. If the anger is expressed, then the patient’s world (through a child’s eyes)
will collapse, leading to death. If the anger is suppressed, then it will further inten-
sify and eventually come out anyway, causing the same catastrophe. The problem
solver does the only thing it can, which is turn the rage against the self. That will
give some sense of release by putting the feeling into action and will do so in a way
that won’t harm important relationships. In fact, it will do more. It will show the
neglectful and abusive caregivers that the patient is on their side. That should please
them! And furthermore, it might just send them a covert message that they should
think twice about their own morality.
Looked at this way, depression is a brilliant solution to an impossible problem. It
takes care of all the patient’s needs, and any outward expression of aggression
toward the caregivers is well covered up. The only problem is that unfair and unde-
served punishment increases the anger and outrage, rather than diminishing them.
230 19 Involuntary Symptoms: Grief and Depression

On the other hand, the escalating misery the depressed person inflicts on family and
others does accomplish some of what the angry self wished for in the first place.
One factor that is critical in understanding these interactions is seeing them
through the eyes of a child at a certain developmental level. The dynamics only
make sense at a point in development where the conscience is active but still sees
the world largely as black and white. The child’s mind is not able to use more
sophisticated concepts such as the thought that failure in meeting the child’s needs
was unavoidable and no one’s “fault.”
Interestingly, the psychological dilemma is the same as the one that underlies the
nonverbal schemas that produce some personality disorders. There, too, the child
has no good way to handle anger toward caregivers who are needed for survival. The
difference, as pointed out by Melanie Klein [5], is that self-condemnation requires
a conscience, which, at the time character disorders form, is not available. Later,
when they come into what Klein termed the “depressive position,” children are
beginning to have a functioning conscience and to be able to make use of judgment
and punishment. This is the point at which they first acquire the mental equipment
to invent the strategy of turning unacceptable anger against the self.
When we listen carefully to the accusations the depressed person lodges against the
self, they are often an accurate reflection of the specific anger that is troubling the per-
son. One adult patient who was emotionally blocked from complaining about clearly
defective parenting charged herself primarily with “laziness.” Her childlike vision of
the mother was a person who did not bother to do the job of raising her children prop-
erly. Thus, the specific self-accusation matched the inner child’s moral outrage.

19.3.7 Emotional Components of Milder Depressions

Less profound instances of depression involve the same kind of insoluble dilemma
as described above, but the stakes are somewhat less dire. For example, some
strongly desired (but not life-and-death) personal need, in conflict with an important
relationship, can bring on feelings of hopelessness that are intense but not at the
same level of seriousness. The nonconscious problem solver may resolve this kind
of dilemma by self-punishment but a lesser kind such as adopting a low self-esteem
and negative outlook on the future. Each case is different, and the same methods of
understanding used for other dynamics are the ones that are of help here, too.

19.3.8 Agitated Depression and Mania

Some depressed people experience more anxiety than self-hatred. One possible
explanation is that fear of somehow acting on the anger is more prominent than the
need to self-punish. Another is that the agitation is part of a bipolar condition with-
out the elation. Once again, the realities of clinical practice are not always as neat as
one might like.
19.4 Conditions That Look Like Depression but Are Not 231

While on the subject of bipolar illness, we can ask if there are specific dynamics
operating in these episodes as well. The answer is probably yes, but as with melan-
cholic depression, the situation is often so extreme that working with psychological
dynamics is not helpful during an acute episode. In general, as with melancholic
depression, the first order of business is to bring the situation under control, then to
work on behavior and thoughts, and finally to approach underlying affects.

19.4 Conditions That Look Like Depression but Are Not

Since depression has become a kind of “diagnosis du jour,” it is not uncommon for
patients, their families, and their physicians to suggest that they “must be depressed.”
What one actually finds is sometimes depression but often other things. Here are
a few:

19.4.1 Stuck in an Unhealthy Lifestyle

People sometimes find themselves locked into an unhealthy life situation. Perhaps,
it is living in an abusive relationship or working for an abusive boss or a job that
makes impossible demands. When a damaging lifestyle is combined with the impos-
sibility of finding one’s way out of the situation, the result will look and feel like
depression. An adult-life unsolvable dilemma is a lot like a childhood one. If there
is a history or propensity for depression, then the nonconscious problem solver may
reach into procedural memory to rediscover self-punishment as a solution. This can
transform a real adult problem into a depression. Even without self-punishment,
however, the feeling is quite similar to depression. The difference is that, unlike
depression, the abuse is not from within and hopefully there is an adult solution,
something in the realm of acceptance and emotional healing through a context of
connection.

19.4.2 Grief

The experience of significant loss can look much like and be mistaken for depres-
sion. Sometimes well-meaning supporters, frustrated by not being able to help, will
misidentify healthy coping as depression.

19.4.3 Not Getting One’s Way

People with narcissistic or antisocial personality characteristics feel they must have
their way. When they are unable to prevail, they sometimes use the word “depres-
sion” to describe the markedly uncomfortable feeling they experience.
232 19 Involuntary Symptoms: Grief and Depression

19.4.4 Miscellaneous Symptoms

Weight loss, insomnia, unhappiness, difficulty concentrating, and many other symptoms
can make people think of depression. Unless the characteristic signs of blocked anger
are present, then psychotherapy for depression will not yield positive results. The thera-
pist’s job here is to understand what is really going on and to address it appropriately.

19.5 Treatment Principles

As suggested in the above discussion, a three-stage approach to treatment is one

way to make sense in choosing what to do first. From that point of view, the order
of priority and effort is as follows:

1. Bring the biological dysregulation and vicious cycle under control. Medication
is usually the first line for this, and some discussion of antidepressants will be
included, but this area is overall outside the scope of this book.
2. Approach the avoidance pattern aspect of the depressive EDP. This means work-
ing with distorted thinking and behavior in a manner similar to cognitive-
behavioral therapy.
3. Work with the emotional side of the EDP, helping the patient to be more aware
and accepting of the dreaded anger and eventually to heal the troublesome affects
that have fueled self-punishment.

19.5.1 Antidepressant Medication

While it is generally outside the purview of this book to discuss specific medica-
tions, the use of antidepressants is so common that it warrants some mention. Before
the introduction of Prozac, the first serotonin-enhancing drug, medication for
depression was only helpful for serious melancholic depression. Tricyclic antide-
pressants were quite effective with severe depression but didn’t help with milder
cases. With the arrival of Prozac and similar drugs, patients with all kinds of depres-
sion, and other problems as well, began to report an early improvement in mood.
Soon their use widened, and these drugs were prescribed for anxiety, obsessions,
angry irritability, and other conditions. Their wide usefulness confirms what many
patients report, that they suppress emotions in general. Patients report that they
don’t cry anymore and feel their emotions have “gone flatline.” This may explain
how these drugs help with severe depression as well, by suppressing emotion to the
point where the biological vicious cycle is broken.
Where emotions are overwhelming and intolerable, this may be very beneficial
(recall, though, that bipolar patients can be made worse by antidepressants). On the
other hand, when emotions are not overwhelming and functioning is intact, having
full access to one’s emotions may be a good thing. These considerations, pro and
con, can be discussed with decision-makers regarding medication.
19.5 Treatment Principles 233

19.5.2 Psychotherapy

As in other types of EDPs, the affect avoidance model suggests that everyone is
right. The behavioral approach to depression upon which CBT was founded is valid
and helpful, and the emotional approach, viewing depression as an avoidance of
unacceptable affects, is also valid and clinically useful. Much of the time, especially
with more serious depression, the behavioral approach, which does not require that
the patient acknowledge anger or any other unacceptable feeling, is an easier place
to begin. The CBT literature offers much specific direction for working in this way
with depressed patients.

19.5.3 The Behavioral Approach to Depression

As stated above, the basic thrust of CBT for depression follows the problem solver’s
strategies for punishing the patient and making the depression even worse. The first
priority is to help the patient stop behaving destructively in ways that aggravate the
situation. This approach makes use of an interesting factor. Patients are afraid of
expressing any direct aggression, so they are not likely to resist the therapist’s urg-
ing in any overt way. They may resist passively, but with persistence on the part of
the therapist, the patient is likely to comply. In this case, what counts is the behavior,
not the motivation. If the patient behaves in a more positive way without really
wanting to, the benefit is the same. The vicious cycle tends to be broken, and the
patient’s depressed feeling will at least not worsen.
The other cognitive-behavioral strategy is to show the patient how his or her
automatic thoughts are incorrect and what correct thinking would be. Here again,
the nonconscious problem solver is not happy to let go of negative thoughts that
have functioned to make the patient feel worse and to reinforce the patient’s self-
flagellation. On the other hand, direct objection to the therapist’s diligent work is
too close to direct aggression, so the patient will not argue so strongly. Instead, after
a session, patients tend simply to revert to their negative thinking. Patience on the
part of the therapist and willingness to go over the same discussions many times will
gradually have an effect on the patient.
As the patient can be induced to relinquish the worst of the self-punishment, the
level of depression may stabilize and even improve. The psychological vicious
cycle has been reduced or disrupted. This is where the opportunity to make use of
the emotional approach begins to be possible.

19.5.4 The Emotional Approach to Treatment

If all of the pain of depression is an avoidance of unacceptable anger, then it would

seem quite simple to use our usual tools of emotional healing, extinction, and recon-
solidation, to heal the anger to the point where it would no longer have to generate
so much misery.
234 19 Involuntary Symptoms: Grief and Depression

This is precisely true but practically runs into a very big problem. The dread of
having this angry affect come to the surface is very intense. Almost any suggestion
to a depressed person that anger might be behind their symptoms will run into an
immediate and energetic denial.
An interesting confirmation of the aggressive basis of depression is that, once in
a while, using humor, one can slip in an indirect expression of aggression. The
patient will react with an instantaneous smile or laugh. The patient is momentarily
lighthearted and coconspiratorial in sharing a bit of black humor. For just that
moment, the deepest depression lifts completely, the patient’s face brightens, and
then, just as quickly, the depression takes hold again.
The blockage to bringing these angry affects to the surface where they can be
healed is one of the most challenging in psychotherapy. This blockage is, like others
we have seen before, composed of a two-layer EDP. The top layer is a moral objec-
tion to anger. The patient will have extensive logic to support internalized values
saying that anger directed toward the caregiver is morally unacceptable and should
be punished. Beneath that layer is a layer of fear of destroying the vital connection
to the caregiver. As long as the conscience layer is in place, the deeper fear is not
likely to be apparent. It is effectively covered up by the judgment that any aggres-
sion directed toward the caregiver must be eliminated.
As suggested above, before we can approach the angry emotions behind the
depressive EDP, we will have to make substantial progress in both the biological
dysregulation and the behavioral vicious cycle. With headway made in both of those
areas, it may begin to be possible to approach the anger directly.
In psychotherapy, the way this is done is to show the patient how the wrong per-
son is being punished and at the same time to provide reassurance that, should the
patient experience anger, it need not be expressed overtly or directly toward its true
target. The child’s point of view is that feeling anger is no different from an angry
act. The adult intellect can grasp that it might be possible to feel anger without act-
ing on it. Without action, it makes at least some adult sense that anger, itself, is not
morally wrong. With a great deal of discussion of the moral difference between
feeling anger and acting on it, the patient may find him or herself more free to access
true feelings.
With long and patient work to help the patient feel safe with healthy anger, the
feelings may at last come to the surface and be accessible to emotional healing. As
this happens, the “steam” will come out of the depression and leave the patient
increasingly free. As patients are getting better, it often happens in their daily life
that they come to forks in the road where before they would previously have empha-
sized the negative and gone into a cycle of self-criticism and punishment. Suddenly,
for the first time, they find that they have a choice. They can choose not to repeat
negative patterns but to look at the situation more objectively. Step by step, they
begin to approach life in a healthy way that leaves room to be angry, even at authori-
ties and caregivers, when they deserve it.
Not infrequently, as treatment progresses, if the patient is still in an active rela-
tionship with the person who has been the object of the anger, the depressed person
may attempt to express his or her anger and to try to work out their differences. As a
19.5 Treatment Principles 235

therapist, it is better to recommend that the patient heal the angry feelings before
thinking of confronting the caregiver. It is not uncommon for patients, as they become
more aware of and comfortable with their true feelings, to do so anyway. Occasionally,
this works out in a positive way and can help greatly to resolve the depression. On
the other hand, it is more likely that the caregiver will remain as unwilling now to
take responsibility for having done any wrong as long ago. In another twist, the
patient may express the anger in a way that makes him or herself look like the one
who is unhealthy, thereby giving the parent an easy path to blaming the patient.
Ultimately the goal of work with angry affect is the now-familiar healing in a
context of connection.

Key Points
• Grief is a healthy response to serious loss. It is the means by which we come
to accept life without the person, concept, or object we no longer have.
• Much of the experience of grief (and depression) can be explained as shut-
ting down of the SEEKING system; that part of our emotional apparatus
that attaches to whatever goals the mind sees as important.
• The study of depression is made more difficult by using a broad definition
of major depression and by the influences of corporate interests in promot-
ing drug treatment for all forms of depression while covering up its
problems.
• Depression and grief both turn our biology upside down, as well as giving
a sense of eternal hopelessness. If we take away these common elements,
what is left are the essential aspects of each condition.
• The unique component of depression is an entrenched dysfunctional pat-
tern, the product of the nonconscious problem solver trying to deal with an
unsolvable, impossible dilemma in which any direction we take leads to an
unacceptable result.
• Depressive EDPs solve the problem of having vital needs that are unac-
ceptable to the people with whom we have an essential connection. We
cannot sacrifice either, so the mind turns its anger to punishing the self.
• With the most serious depression, treatment usually starts with the biologi-
cal aspects using medication. Following that, or simultaneously, we can
approach the psychotherapy.
• Cognitive therapies approach the depressive EDP from the behavioral
direction by working on self-destructive behavior and thoughts. This is
usually the most accessible at first.
• Approaching depression from the emotional direction focuses on helping
the patient understand that the impossibility that once applied to the situa-
tion is no longer valid and that the answer is that affect and action are sepa-
rate. It is safe and moral to feel, even if the feeling is anger toward an
important figure. As affects come to consciousness, they can heal like other
emotions, by extinction or reconsolidation.
236 19 Involuntary Symptoms: Grief and Depression

References
1. Freud S. Mourning and melancholia (1917). In: Strachey J, ed. and trans. The standard edition
of the complete psychological works of sigmund freud. Vol.14. London: Hogarth; 1957.
p. 237–260.
2. Global depression drug market poised to surge from USD 14.51 billion in 2014 to USD 16.80 bil-
lion by 2020 – marketresearchstore.com. GlobalNewswire. 2016. https://globenewswire.com/
news-release/2016/05/10/838292/0/en/Global-Depression-Drug-Market-Poised-to-Surge-
from-USD-14-51-Billion-in-2014-to-USD-16-80-Billion-by-2020-MarketResearchStore-
Com.html. Accessed 22 Sept 2016.
3. Gort G. Pathological grief: causes, recognition, and treatment. Can Fam Physician. 1984;30
914–16, 919–20, 923–4
4. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE,
Wang PS. The epidemiology of major depressive disorder: results from the national comorbid-
ity survey replication (NCS-R). JAMA. 2003;289(23):3095–105.
5. Klein M. Notes on some schizoid mechanisms. In: Envy and gratitude and other works 1946–
1963. London: Hogarth Press and the Institute of Psycho-Analysis; 1946. p. 1975.
6. Lorenz K. On aggression (1963). 2nd ed. New York: Routledge Classics; 2002. p. 201.
7. Marcus M, Yasamy MT, van Ommeren M, Chisholm D, Saxena S. Depression: a global pub-
lic health concern. WHO Department of Mental Health and Substance Abuse. 2012. http://
www.who.int/mental_health/management/depression/who_paper_depression_wfmh_2012.
pdf. Accessed 22 Sept 2016.
8. Panksepp J, Biven L. The archaeology of mind: neuroevolutionary origins of human emo-
tions. Norton Series on Interpersonal Neurobiology. 1st. New York: W. W. Norton & Company;
2012. p. 108.
9. Penn E, Tracy DK. The drugs don’t work?: antidepressants and the current and future pharma-
cological management of depression. Ther Adv Psychopharmacol. 2012;2(5):179–88.
Involuntary Symptoms:
Anxiety-Related Problems 20

Anxiety, panic, obsessive-compulsive disorder (OCD), and somatization

(preoccupation with physical symptoms), the 13th group of EDPs, all represent
unwelcome intrusions into consciousness that can and do ruin the quality of life
for many individuals. Because the ways to approach these various symptoms are
largely the same, they are brought together in this chapter. The main commonal-
ity is that each one becomes an intense preoccupation and leads the individual to
focus on how to eliminate the uncomfortable feeling. The more success there is
at controlling the symptom, the more sensitive the person becomes and the worse
it gets.
Like the other involuntary symptoms, anxiety, panic, OCD, and somatization
have a major genetic component. Some people are predisposed to have higher levels
of anxiety or fear than others. OCD is related to hyperactivity in the part of the brain
that is responsible for error detection. One can imagine that there might even be an
evolutionary advantage to this heterogeneity. Human social groups benefit from
those who are fearless but also from those who put their energy into avoiding trou-
ble and checking for errors.

20.1 Two Layers of EDP

What the affect avoidance model brings to work with anxiety-related problems is
recognition that two layers of EDP are involved. On the surface, the patient’s con-
scious focus is on how to eliminate the uncomfortable feeling. This is an example of
“simple avoidance,” a conscious, voluntary attempt to eliminate an uncomfortable
affect. On a deeper level, as with depression, anxiety-related symptoms can also be
seen as entrenched dysfunctional patterns that work to block affects that are even
more deeply dreaded than the symptom itself.

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_20
238 20 Involuntary Symptoms: Anxiety-Related Problems

20.1.1 The Surface Layer EDP

Most of the current discussion of anxiety-related problems and their treatment

focuses on the surface layer. The fairly recent finding showed that when patients use
simple avoidance to try to eliminate their anxiety, it gets worse. One reasonable
explanation is that the patient’s intense preoccupation increases attention paid to the
symptom, which increases sensitivity to the symptom along with the sense that it is
intolerable and must be eliminated at any cost.
When patients try to eliminate anxiety or other intrusive symptoms, they do so, as
in other instances of simple avoidance, by adopting dysfunctional behavior patterns
in their lives. For example, generalized anxiety patients may become dependent on
sedative drugs. Agoraphobic patients become restricted to their homes. OCD patients
spend hours with rituals, and somatizing patients go from doctor to doctor seeking
reassurance that they are healthy. Not only are these avoidance patterns costly and
destructive, but, as stated above, they also put the patient in a vicious cycle by increas-
ing sensitivity to the worry and anxiety, which worsens the condition.
The treatment that has been most talked about recently is cognitive-behavioral
therapy. The original form of CBT focused exclusively on unhealthy thinking and
behavior. In terms of the affect avoidance model, this is the behavioral pathway to
treating an EDP. More recently, CBT has begun to embrace the emotional pathway
as well. By adopting a two-pronged approach, cognitive-behavioral therapy is in
line with the affect avoidance model as described in Part I of this book. Using the
traditional behavioral approach, CBT tries to help the patient let go of irrational
automatic thoughts and dysfunctional behavior patterns. This means recognizing
and letting go of irrational thoughts that justify the anxiety or other symptoms. It
also means letting go of behaviors that restrict the patient’s lifestyle in order to con-
trol anxiety and symptoms. Such behaviors include, for example, staying at home,
performing rituals, or making excessive visits to physicians.
In addition to working with thoughts and behaviors, CBT has more recently
adopted another strategy that approaches the EDP from the emotional direction.
This is called exposure. Exposure has been used extensively to help heal and detox-
ify the painful affects associated with trauma. In this procedure, the patient is helped
to bring the uncomfortable feeling into the room, fully activated, and to face the
feeling so it can heal. Whether recognized or not, this is done in a context of con-
nection. As we have seen multiple times, this combination of juxtaposing con-
sciously activated affects with a context of connection is the key to emotional
healing by extinction and/or reconsolidation.
Thus, in working with anxiety-based symptoms, cognitive therapists approach
only the EDP layer of simple avoidance, that is, the patient’s conscious attempts to
eliminate the uncomfortable affect. However, in doing so they acknowledge both
the importance of dealing with the avoidant behavior and the affect that is being
avoided. Furthermore, recent treatment recommendations focus on specific ways to
detoxify the affect.
What is especially remarkable about these treatments is that they are not only
effective, but they have also been shown to change brain neurochemistry and
20.1 Two Layers of EDP 239

functioning in ways that are often similar to drug treatment. This will be discussed
further in the section on OCD. Thus, in a context where CBT addresses both the
behavioral and emotional aspects of an EDP, science shows that measurable brain
changes are produced.
Perhaps the reason these beneficial effects are the first to have been demonstrated
biochemically is due to the marked contrast between the state of mind of a patient
trying desperately to control anxiety-related symptoms versus the relative calm of a
patient who has learned skills to cope with the anxiety and heal its emotions.
Patients’ preoccupation with anxiety and the escalating intensity of the feeling that
it must be controlled have a powerful destabilizing effect on the mind. As therapy
begins to normalize emotional functioning, then neurophysiological parameters
begin to go back toward normal.

20.1.2 The Deeper Layer of EDP

Much of the current excitement about treatment is focused on the voluntary surface
layer. In some patients it is possible that an overactive anxiety system is simply
generating meaningless fears and that the mind reflexively seeks to find an explana-
tion. On the other hand, these irrational worries, like all products of the mind, usu-
ally have symbolic meaning. Exploration of patients’ explanations regularly does
yield likely chains of cause and effect. The affect avoidance model points the way
to understanding the symptom as a manifestation of the mind’s drive to protect the
individual from troublesome emotions.
In Jack’s case, for example, the panic attack did not come from nowhere. It could
be seen as a product of a control structure, programmed to signal the impending
threat that Jack’s longing for support was about to break through into conscious-
ness. In other words, anxiety (or worry) entering into consciousness represents the
mind’s efforts to cope with a deeper threat by generating an unpleasant product that
demands action on the part of the patient.
This view of the mind producing intense anxiety and worries gives a slightly dif-
ferent face to the nonconscious problem solver. Here, rather than appearing as the
creative inventor of strategies for avoiding feelings, the problem solver, guided by
genetic proclivities, seems programmed to produce simpler, more stereotyped reac-
tions. Among these are blooms of mental concern, such as exaggerated versions of
simple anxiety, worries about illnesses or accidents, worries about loss of control,
concern about the reactions of others, and sometimes simply annoying repetitive
mental contents.
The one thing all these products do is to mobilize the patient’s conscious desire
to somehow make the worry go away. Looking at this natural desire as part of a
programmed dance, it actually accomplishes quite a bit. First, an increasing preoc-
cupation with the symptom distracts the patient from any awareness of deeper emo-
tional happenings. Jack was distracted from distress about his new responsibilities
as a father and in a new job. Second, the patient’s loss of control over his or her own
mental life leads to a pulling away from normal functioning and generates in others
240 20 Involuntary Symptoms: Anxiety-Related Problems

a lowered level of expectation. Specifically in Jack’s case, this meant a few days off
from work and attention from his wife that his conscience wouldn’t let him ask for.
In general, anxiety-related symptoms reduce the stresses of functioning and increase
support from others.
A third group of effects that come out of anxiety-related symptoms can be seen
as a symbolic solution to a problem. An example we have already looked at is how
anorexia nervosa seems to use control of the appetite for food as a symbolic equiva-
lent to controlling the more truly troublesome need for primitive, all-encompassing
nurturing. By mastering an appetite it can control, the mind symbolically seeks to
gain mastery over one that is beyond its ability.
Not infrequently, the therapist can develop a hypothesis that the specifics of a
particular anxiety or worry represent such a symbolic pseudosolution to a problem.
For instance, Jack’s panic focused on the message that he might be having a heart
attack that would prevent him from fulfilling his responsibilities. His seeking medi-
cal help was a pseudosolution to a real problem. Some other examples: An obses-
sive fear of losing control by picking up a kitchen knife and accidently hurting a
family member might be a symbolic way of expressing (and focusing on trying to
control) angry impulses toward those whom the patient is supposed to cherish. Fear
of having contracted AIDS from a masseuse could be an expression of guilt over
comfort-seeking sexual behavior and, at the same time, express a wish to be bedrid-
den in a hospital, relieved of responsibility, and surrounded by nurturing healthcare
staff.
These cause and effect relationships are hypotheses. As indicated earlier, they
cannot be proven directly because we don’t have access to the complex thinking of
the nonconscious problem-solving mind. On the other hand, using our usual confir-
matory indicators, subjective resonance, indirect inference based on examining
mental inputs and outputs, and results of treatment, we can gain some degree of
confidence that a hypothesis is likely to be true.
Thus, each of these complex symptoms not only mobilizes a layer of simple
avoidance but can be seen as a sign that the mind as control structure is experi-
encing distress. Following genetically as well as historically determined pat-
terns, the mind is doing its best to alert the patient, to seek immediate relief, and
possibly to act out a symbolic solution to the problem. In this way, this second,
deeper layer of entrenched dysfunctional pattern can be viewed as yet another
attempt to protect the individual that has become dysfunctional. Once again, the
signal that triggers the first layer of EDP is the anticipation of a troublesome
affect.
Treatment for this layer of EDP involves building a partnership with the
patient to explore and make meaning. Meanings at this level are very individual
and idiosyncratic, and, because they may not be expressed directly, the methods
of unstructured psychotherapeutic exploration as described in Part II are espe-
cially applicable. These are quite different from the more structured approaches
used for the top layer of EDP, where the goal is to develop general skills for
coping with anxiety and worry. Treatment principles will be discussed further
below.
20.2 A Brief Catalog of Anxiety-Related Syndromes 241

20.2 A Brief Catalog of Anxiety-Related Syndromes

In the following sections we will look at some of the anxiety-related problems that
patients bring to treatment. As indicated above, each type of problem has the same
two layers of avoidance. On the surface, each one becomes a preoccupation that
motivates the patient to use simple avoidance to control the symptom and block the
uncomfortable feelings. On a deeper level, in each one, the mind can be seen as
responding to an inner threat by generating an uncomfortable and highly mobilizing
symptom.

20.2.1 Anxiety

According to Wang, 3.1 percent of the US population experience generalized anxi-

ety disorder, meaning that they experience at least 6 months of preoccupation with
exaggerated or unrealistic worries within a given year [4]. Of these, about 1 percent
suffer severely. As mentioned, there are clear genetic and family contributions.
Patients may experience a free-floating anxiety but are also likely to focus on some
particular worry. When one worry is resolved, another is likely to take its place as a
source of concern. Patients can usually see that their worries are more intense than
warranted by reality. For example, a patient might worry about driving off a bridge
into water below, even though this is exceedingly unlikely to happen. Worries are
typically about accidents, finances, health, employment, and relationships.
Phobias are actually more prevalent than generalized anxiety disorder and repre-
sent a variation on the same theme. Here, the fear is associated with some specific
object or situation. Fears can be very general as in agoraphobia, fear of being out in
public, or social anxiety, where the fear is of social encounters that might lead to the
feeling of embarrassment.
A two-layer EDP structure is well represented here. Preoccupation with anxiety
and how to avoid it take up the patient’s attention and draw it away from whatever
deeper concern might have triggered anxiety in the first place. Preoccupation with
eliminating the discomfort sets off a vicious cycle that tends to make the anxiety
progressively worse. Treatment aimed at the surface layer has a more rapid effect
than working to understand the deeper layer. Results are more dramatic but in the
long term may fail to resolve underlying distress.

20.2.2 Panic

In our culture, we don’t differentiate much between anxiety and panic, except that
panic seems more acute. In fact, panic actually relates to a distinct emotional system
other than the fear system, which is responsible for other forms of anxiety. In mam-
mals, according to Jaak Panksepp [3], panic is associated with the experience of
aloneness, where anxiety represents more general fear. The case of Jack, already
explored elsewhere, is a typical example of this symptom.
242 20 Involuntary Symptoms: Anxiety-Related Problems

The experience of a panic attack is extremely distressing. Many patients are liter-
ally afraid that they are dying. Even with reassurance, they usually have an intense
desire never to experience one again. The result is that panic attacks, like anxiety
and phobias, become a preoccupation. Since they are unpredictable and take the
patient by surprise, motivation is maximized to avoid repeating the experience.
Patients restrict their lives to avoid another panic attack, and, as in other anxiety-
related problems, focus on avoiding the symptom tends to make it worse.
Exploration of the deeper layer of avoidance usually uncovers something seri-
ously out of balance in the patient’s life. Along with work on the surface layer to
help reduce the patient’s preoccupation with avoiding recurrence, exploration of
important stresses should be a regular part of the therapist’s approach. The presence
of recognizable and treatable life stresses is usually not difficult to discern.

20.2.3 Obsessions and Compulsions

Patients experience a feeling of needing to take some action in order to control anxi-
ety. The actions suggested by the mind tend to be repetitive rituals providing only
the illusion of protection. In addition, some patients experience intrusive thoughts
or other mental contents such as songs. Even without rituals, excessive concern
about getting something just right can be a manifestation of obsessive-compulsive
disorder (OCD).
Like anxiety, obsessive-compulsive disorder has an important biological compo-
nent; however, in this case, the specifics are distinct from pure anxiety. Areas in the
brain—prefrontal orbital cortex, cingulate gyrus, caudate nucleus, and basal gan-
glia—link together to perform the function of error detection and checking [2]. To
simplify an area of ongoing research and discovery, when these areas are overactive,
the result is some form of obsession or compulsion. These circuits are sensitive to
decreased levels of serotonin and tend to calm with serotonin-enhancing drugs such
as the selective serotonin reuptake inhibitor (SSRI) antidepressants.
OCD is particularly interesting to therapists because this is the first area where
science has confirmed that psychotherapy can accomplish the same biochemical
changes that medication can. Cognitive-behavioral therapy focused on helping the
patient to tolerate anxiety and not to perform rituals has been shown to produce the
same biochemical effects as SSRI medications [1].
OCD has a very wide range of seriousness, going from extreme disability to mild
annoyance. Treatment aimed at the surface layer, helping the patient tolerate anxiety
and refrain from performing rituals, is highly desirable but for many patients diffi-
cult to achieve. The urge to perform the ritual is intense, and the anxiety experienced
by not doing so can be extremely compelling.
In serious OCD, the relief obtained with medication is dramatic enough and the
side effects mild enough that most patients seek drug treatment, hopefully along
with efforts to address the surface layer of EDP as described above.
20.2 A Brief Catalog of Anxiety-Related Syndromes 243

As with other anxiety-related symptoms, what science has not been able to do is
to understand or predict the content of each individual’s symptoms. Viewing the
obsessions and compulsions as EDPs and exploring their functioning for affect
avoidance are likely to yield a hypothesis about the specifics. Exploration of this
deeper layer of affect avoidance is a slower process with less direct benefits in
reducing symptomatology. On the other hand, diligent work to help the patient
engage more effectively in life can be of lasting usefulness and can support efforts
to manage the surface layer.

20.2.4 Somatization

Somatic symptoms are included in this chapter because they have so much in com-
mon with other anxiety-based symptoms. Especially in medical settings, a signifi-
cant percentage of patients express concerns and distress about physical symptoms
that do not have a medical basis. The current DSM-V appropriately lumps these
problems together under the general term “somatic symptom disorder.” They belong
together because therapy is aimed at the surface EDP, the debilitating preoccupation
with eliminating the symptom, rather than the symptom itself. Below are some of
the variations on this type of symptom:

• Pain, bowel dysfunction, and other physical symptoms that can’t be explained or
treated as medical illness
• Intense preoccupation with symptoms that are interpreted as possibly indicating
a serious medical problem, like cancer
• Neurological dysfunction with no physiological basis (conversion)
• Preoccupation with a body characteristic or defect seen as intolerable (body dys-
morphic disorder)

Like the other anxiety-based problems, especially obsessions and compulsions,

these symptoms aren’t under voluntary control, and trying to eliminate them makes
them worse. Consequently, treatment mainly focuses on the preoccupation. As with
OCD, exploratory psychotherapy aimed at helping patients understand and resolve
deeper EDPs and improve their engagement in life can be of significant long-term
benefit.
In these cases, especially where there are somatic symptoms like pain, there is
a special trap for therapists. Suggesting to the patient that a more exploratory
psychotherapy can help with the somatic symptom sets up treatment as a promise
of relief. As is now familiar, such a promise will increase the patient’s focus on the
expected relief: “When is the pain going to go away?” Predictably, this has the
effect of increasing the preoccupation and worsening the pain. For this reason, it
is very important for the therapist not to overpromise results from exploratory
work.
244 20 Involuntary Symptoms: Anxiety-Related Problems

20.3 Treatment Principles

20.3.1 Trying to Control Anxiety Makes It Worse

As reviewed now several times, any attempt to control anxiety or to eliminate intru-
sive thoughts or symptoms will make the problem worse. Short-term success leads
to increased sensitivity to anxiety and even greater preoccupation with symptoms.
This phenomenon is consistent with the affect avoidance model, which predicts that
attempts to eliminate avoidance strategies will be experienced as removal of a layer
of protection and will force the nonconscious problem solver to redouble its efforts.

20.3.2 Medication Treatment

Medication treatment is aimed at supporting the patient’s already intense (and coun-
terproductive) efforts to eliminate the uncomfortable feeling. In general this is exactly
what we don’t want to do because it increases the preoccupation and decreases any
motivation to learn to cope with anxiety or other symptoms. Furthermore, and per-
haps unfortunately, alcohol and sedative medications do an excellent job of eliminat-
ing anxiety. In the short run, they go right to the fear system and turn it off. Sedative
medications such as clonazepam and alprazolam bring rapid and powerful relief.
Success in avoiding anxiety leads to worsening of the problem.
In addition, medication can exacerbate the problem in some new and unique
ways. By eliminating the conscious experience of anxiety as an affect, antianxiety
medications remove an opportunity for the healing actions of extinction and recon-
solidation. Healing of emotions only happens when they are activated, and the drugs
block that. One of the benefits of learning to cope is that the patient allows him or
herself to experience regular doses of anxiety in a context of connection where they
can heal. Furthermore, when the mind focuses on medication as “the solution” for
anxiety, there is little chance of the patient investing significant energy into learning
psychological coping skills. A third new problem generated by antianxiety medica-
tion is habituation and physical dependence. Over a few weeks, the brain becomes
accustomed to the drug and compensates for its presence. This results in the drug
being less effective at the original dose. The patient asks for a dose increase, which
works, but deepens the physical dependence. Finally, when the drug must be
reduced, the withdrawal effect is none other than intense anxiety along with insom-
nia and a risk of seizures.
SSRI antidepressants, while less effective, can also suppress anxiety along with
other emotions and obsessions. Because they are not physically addictive in the
same way as the sedatives described above, they are very popular treatments. They
are, indeed, less problematic, but these too tend to increase the patient’s focus on
eliminating the affect and can increase preoccupation with the symptom rather than
reducing it.
Typically, unless the patient is making progress in other areas of coping, over
time, the SSRI antidepressants lose some of their effectiveness. Once again doses
20.3 Treatment Principles 245

are often increased until side effects become problematic. Some patients remain on
them, while others decide that the benefits do not outweigh the negative aspects.
These drugs also have withdrawal effects. After being on SSRI drugs for some
months, even with a tapering dose, many patients experience an exaggerated level
of emotion and irritability lasting a few weeks.
With patients and their families, it is hard to argue that the drugs don’t have any
benefit. What may be the most workable strategy is to stabilize the dose and choice
of medication so that the drug treatment is no longer a preoccupation but more of a
background fact. At that point the focus can be drawn more to developing coping
skills and exploring emotional issues.
Having said these negative things about medication, in an immediate crisis or
with patients whose problems are mainly situational––say loss of a job––these med-
ications can be very helpful, especially if anxiety or symptoms threaten to interfere
with vital functioning or result in overall disability. A pragmatic approach is to
weigh benefits against potential problems.

20.3.3 The Behavioral Approach to the Preoccupation

As indicated above, one of the two approaches of CBT and other therapies for
anxiety-related symptoms is to work with the avoidance pattern itself. This means
helping the patient to let go of the preoccupation by showing the irrationality of the
automatic thoughts and helping the patient develop skills to tolerate the anxiety and
symptoms. The goal is to stop the destructive cycle of trying to control the symp-
tom. Here are the main strategies:

• Examine helper EDPs in the form of automatic thoughts that provide illogical
justifications for worry and anxiety. Examining the irrationality and exaggera-
tions in these thoughts helps to reduce anxiety. This is classic CBT.
• Learn that anxiety is a normal function of the brain that is sometimes misguided
but not inherently harmful.
• Learn the harmfulness of trying to eliminate the symptom.
• Practice relaxation techniques including muscle relaxation and breathing
exercises.
• Distract oneself with positive activities, especially social ones.

20.3.4 The Emotional Approach to Preoccupation

As emphasized in the affect avoidance model, like every EDP, the top layer in
anxiety-related symptoms––that is, the patient’s preoccupation with avoiding anxi-
ety or distressing mental contents––has two approaches, the behavioral and the
emotional. In the last section, we looked at the behavioral approach. Now we turn
to the emotional approach. The new discovery for the behavioral world is what
traditional therapy has known since the beginning that painful affects heal when
246 20 Involuntary Symptoms: Anxiety-Related Problems

actively experienced in a context of connection. In behavioral terms, this is called

exposure. It was perhaps in the field of trauma that behaviorally oriented therapists
learned most clearly that experiencing affects was essential for long-term benefit.
Acquiring coping skills was not enough to bring relief to people suffering from the
intense affects of trauma. As discussed earlier, exposure means experiencing the
affect in a conscious, visceral way, in a context of safety and connection, so that
either extinction or reconsolidation or a combination of both is possible. Exposure
for war trauma may mean listening to battle sounds. For the very individual horrors
of anxiety-related symptoms, exposure mainly means imagining in a vivid way, just
what it would be like, minute by minute, to go through the patient’s most dreaded
situation.
Thus, in working with people who suffer from anxiety-related symptoms, the
emotional approach is essentially to expose the patient to their “worst-case sce-
nario.” “What if your hand did slip and grab the knife? What would you do?” “What
if you were having a heart attack?” “What if you did step into an airplane?” “What
if you were up in front of a room full of people?” When the patient opens his or her
mind to the dreaded possibility, then affects are activated and healing can take place.
If the patient is not ready or able to take on the whole experience, then exposure
to small increments can help to break down the process. This is similar to “desensi-
tization” but not the same. In the original desensitization protocol, patients were
taught to experience the affect and then go through a cycle of relaxation. The relax-
ation often reduced the activation of the affect to the point where healing did not take
place. As a result, the procedure was not very effective and was largely discredited.
In spite of problems with desensitization, the principle of breaking down experi-
ences into smaller, more tolerable “chunks” is valid. Thus, with the airplane exam-
ple, the patient might first imagine approaching an airplane, then stepping inside,
then having the doors close, and then being in a seat with the seat belt fastened.
Fortunately, imagination is often as effective as actually experiencing the situation.
Sometimes, though, the actual experience, when it can be recreated, adds a dimen-
sion of realness that brings out affects that would otherwise not be experienced.
The result of this renewed interest in emotional healing is that a great deal of
energy is being put into teaching therapists and patients the value of facing affects
and allowing them to heal.

20.3.5 Mindfulness Helps

Along with the discovery of exposure as a way of healing affects, a renewed empha-
sis on emotion in therapy has brought with it a rediscovery of the Buddhist practice
of mindfulness, discussed in Chap. 6. Mindfulness is a way of looking at one’s own
experience as if from outside, seeing it as something transient rather than being
caught in the moment. Whether this is done through meditation or within the con-
text of the therapeutic relationship, the calm perspective one finds is very close to
the healing combination, mentioned so often in this book, of gaining a sense of
perspective by seeing oneself through the eyes of an empathic witness. Whether
20.3 Treatment Principles 247

meditating alone but feeling connected or in the context of a relationship, the result
is that the magic of emotional healing (by extinction or reconsolidation) takes place
naturally and automatically when the uncomfortable affect enters consciousness.

20.3.6 Healing the Deeper Layer of EDP

In working with the deeper layer where the symptom is generated, only one of the
two pathways is available. Because the mind generates anxiety and intrusive
thoughts automatically and completely outside voluntary control, then the behav-
ioral approach is not possible. We can’t stop the mind from producing anxiety and
worries. What is left is to identify the avoided emotional issues and to address them
by bringing triggering affects to consciousness where they can heal.
In the case of Jack, this would mean helping him to become aware of and to feel
his yearning for support. With his strong value system telling him that he should
never have such feelings, this level of awareness and conscious activation will take
a long time and a good deal of psychotherapeutic work to achieve. Jack’s case illus-
trates exactly the difficulty of activating such feelings to the point where healing is
possible. It also hints at the kind of thoughtful exploratory psychotherapy that would
be required to accomplish such healing.
As stated in Chap. 9, the roadmap for such exploration is in the patient’s mind,
which means there is no easy formula. Each patient is different even though the
symptoms might be in the same category. The therapist must partner with the patient
to clarify what inner affect avoidance might be causing the nonconscious mind to
inflict such uncomfortable symptoms on the patient. Essentially, that means explor-
ing the inner workings of the patient’s mind to the point where affects come to the
surface and are experienced as less threatening than they once were. The guidance
in Part II is intended to help with this process.

20.3.7 Time Sometimes Heals

In our society, partially driven by the need to maximize stockholder’s profit and
partly as a feature of our culture, treatment is often expected to be brief and focused.
Practice over several decades shows that in a portion of cases, improvement takes
place on a much larger scale of time. A performer, well known in her time, when
interviewed on television, described crippling stage fright when she was young. She
related that at times she would have to leave the stage to pull herself together and
then would return to perform. The interviewer asked her if she still experienced
anxiety. The answer was an offhanded “no.” Apparently with no special effort, her
performance anxiety resolved itself.
Such a story is not uncommon and makes sense in that each time the individual
experiences anxiety and does not do anything to suppress it, there is some degree of
healing. Even if there was a deeper layer of unresolved affect, that too might have a
chance to heal over time.
248 20 Involuntary Symptoms: Anxiety-Related Problems

The end result is that more often than is generally recognized, people suffering
from anxiety and related symptoms may experience improvement, though over a
much longer time than they or their therapist might expect.

Key Points
• Anxiety-related symptoms consist of unwelcome anxiety, worries, and
other mental contents that intrude into consciousness and motivate the
patient to try to eliminate them.
• General anxiety, focused anxieties, panic, obsessions, compulsions, and
somatic symptoms, such as psychogenic pain and hypochondria, are
discussed together because their treatment is similar.
• Looking at these symptoms from the point of view of the affect avoidance
model, each has two layers of EDP. The surface layer is one of simple avoid-
ance, where the patient is intensely preoccupied with trying to eliminate the
unwanted symptom. The deeper layer is what produces the symptom in the
first place.
• The patient’s simple avoidance generates a vicious cycle that paradoxically
makes the symptom worse over time. Arresting this cycle is the goal of
most current treatments.
• Medication treatments are aimed at eliminating the uncomfortable symp-
tom. As such, they have the problem of augmenting the patient’s own
efforts at avoidance, which tend to be counterproductive and to work
against psychotherapy. On the other hand, the effectiveness of medications
does make them useful when functioning is threatened or psychological
treatment is too slow to be tolerated.
• CBT and other treatments approach the surface layer by both the behav-
ioral and the emotional approaches. The behavioral one is to teach the
patient how to cope with the symptom without letting it become a preoc-
cupation. The emotional approach is using exposure and mindfulness to
detoxify the uncomfortable affect.
• Treatment for the deeper layer cannot be approached behaviorally because
the avoidance strategies are entirely nonvoluntary. On the other hand, treat-
ment can approach this EDP layer by using psychotherapeutic exploration
to bring affects to consciousness where healing in a context of connection
can happen.

References
1. Baxter LR, Schwartz JM, Bergman KS, et al. Caudate glucose metabolic rate changes with
both drug and behavior therapy for obsessive-compulsive disorder. Arch Gen Psychiatry.
1992;49:681–9.
2. Maia TV, Cooney RE, Peterson BS. The neural bases of obsessive-compulsive disorder in chil-
dren and adults. Development and Psychopathology. 2008;20(4):1251–83.
References 249

3. Panksepp J, Biven L. The archaeology of mind: neuroevolutionary origins of human emotions.

Norton Series on Interpersonal Neurobiology. 1st. New York: W. W. Norton & Company; 2012.
p. 341.
4. Wang PS, Lane M, Olfson M, Pincus HA, Wells KB, Kessler RC. Twelve month use of mental
health services in the United States. Arch Gen Psychiatry. 2005;62(6):629–40.
Involuntary Symptoms: Trauma
and Dissociation 21

Trauma and dissociation are combined as EDP number 14. Since the introduction of
the healing mechanisms of extinction and reconsolidation in Chap. 5, trauma has
been our main model for how painful feelings can be detoxified. Now it is time to
discuss how trauma produces EDPs. The critical question we did not ask before is
how emotions resulting from trauma can be locked away, outside of consciousness,
but potentially available to be processed in therapy years, and even decades, later.
The answer is the last of our involuntary symptoms, dissociation. For the sake of
simplicity, we will define dissociation clinically as the mind’s capacity, when
severely threatened, to create reversible barriers between areas of mental function-
ing and content. The reason dissociation is important is that the mind uses it as a
form of overload protection to keep feelings and facts out of consciousness that are
too intense or threatening to be processed at the time.
Much of the lasting damage from trauma is the result of dissociation. Facts and
feelings that are too much to deal with are put behind a mental barrier. There, they
are no longer available to consciousness but are able to cause problems. In contrast,
when the affects and their surrounding truths are kept in consciousness and pro-
cessed soon after a trauma, then the trauma heals and causes much less lasting harm.
On the other hand, when feelings and facts remain walled off, they begin to produce
the symptoms of post-traumatic stress disorder, or PTSD. This is why we look at
trauma and dissociation in the same chapter.

21.1 Taking the Mystery Out of Dissociation

Over the years, the mental health field has tended to ignore dissociation or treat it as
something mysterious. More recently, a renewed focus on trauma has brought back
interest in and research on dissociation, but many of the discussions continue to
miss or downplay its central importance in PTSD and related conditions. The mis-
diagnosis of dissociation, unfortunately, remains more common than correct identi-
fication and treatment.

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_21
252 21 Involuntary Symptoms: Trauma and Dissociation

When a disaster strikes, we see television images of people who appear dazed but
manage to carry out necessary functions. Their cognitive abilities are intact; how-
ever, their feelings are gone. This is dissociation. The mind, more in some individu-
als than others, has the capacity to split off from consciousness, mental contents that
are too disturbing to handle. As in people’s reaction to disaster, the most common
element of experience that is dissociated is emotion.
One woman discovered that her husband was having an affair. She found herself
feeling strange, not like herself. She complained to her doctor, who sent her to a
therapist. Over the next year, the therapist and several other mental health practitio-
ners diagnosed anxiety, depression, and personality problems. None of the medica-
tions she was given helped, nor did the therapy have an effect on her symptom.
What was missed was the fact that she was in a dissociated state and had lost access
to her normal emotions. With careful exploration, her feelings became less threaten-
ing, and she began to recover them along with her familiar sense of self.
In psychogenic amnesia, the memory of whole experiences or periods of time
can be dissociated as well, where an entire event becomes locked away somewhere
in the mind and not available to recall. Other mental contents and functions can be
dissociated. Depersonalization is the feeling that the self is not real. Derealization is
a feeling that the whole world is not real. Both of these represent barriers between
consciousness and familiar perceptions of reality. Conversion reactions such as psy-
chogenic paralysis or blindness also seem to be related. Here a portion of normal
functioning is separated from conscious control.
Severe trauma, usually in early life, can result in multiple personalities, offi-
cially, dissociative identity disorder. This is a condition where dissociative barriers
separate areas of functioning large enough to constitute separate personalities.
Later, when triggered by specific circumstances, particular units of functioning tend
to take over consciousness and control the person’s activities.
Once acquired as a mental capacity, dissociation is entirely automatic. It tends to
happen repeatedly with major stress. Just as automatic is the dissolution of dissocia-
tive barriers. There is no simple way to make patients come out of dissociated state,
so the main thrust of treatment is to create conditions where this will be likely to
happen. What is required is to create a new context where the mind “feels safe”
enough to reopen access to the dissociated mental contents or functioning.

21.2 PTSD and Dissociation

The four main symptoms of PTSD are each related to dissociation:

• Emotional numbing in relation to the trauma. People act like zombies, able to
perform whatever functions they must, but with a barrier between consciousness
and the intense emotions that have been generated by traumatic events.
• Intrusive memory fragments or “flashbacks.” Unintegrated, disconnected sen-
sory elements cross the barrier and break into consciousness, causing intense
distress. This form of awareness does not lead to healing but appears to represent
momentary failure of the dissociative barrier.
21.4 The Nature of Dissociation 253

• Avoiding reminders of the trauma. Patients go to great lengths to avoid reminders

that threaten to dissolve barriers and bring threatening facts and affects back into
consciousness.
• Increased vigilance or arousal. Patients are unable to recover a relaxed state even
when the danger has passed because the trauma has been locked away and not
yet processed.

The presence of a barrier to consciousness does not prevent the toxic affects of
trauma from causing problems. Sufferers from PTSD undergo a great deal of dis-
tress and disability. If and when they are able to access their feelings and the related
circumstances (in a context of safe connection), then, as is familiar to us, they
become able to take in an outside perspective on their experience and healing takes
place.

21.3 Complex Trauma

Before continuing, the subject of complex trauma is often talked about by profes-
sionals and needs to be distinguished from dissociation. Complex trauma refers to
all the effects of trauma other than PTSD and dissociation. Abuse, neglect, and other
threats to the emotional and physical needs of children have profound effects on
their growth and development. These have already been alluded to in the discussion
of nonverbal schemas in Chap. 14. Many of the distortions of complex trauma are
due to nonverbal schemas developed during early life to try to manage the painful
affects associated with basic needs not being met. Bessel van der Kolk’s book The
Body Keeps the Score [4] is a good resource for learning more about trauma.
The other main area where trauma does damage beyond PTSD is in the develop-
ment of unhealthy internalized values and attitudes that lead to inappropriate shame
and guilt coming from the conscience. As in the case of Jack, who was neglected
and mistreated, faulty values and attitudes are internalized and continue to do dam-
age over the years. The low self-esteem and inappropriate shame that are often
associated with adult trauma are examples of this phenomenon. These are discussed
in Chap. 17.
For the most part, then, the concept of complex trauma refers to nonverbal sche-
mas and unhealthy internalized values formed as a result of maltreatment. How to
help patients with those components of trauma is discussed in the sections of this
book devoted to those specific EDPs. For the remainder of this chapter, we will
focus on dissociation as a separate entrenched dysfunctional pattern, one that starts
out as a necessary protection but later becomes a severe liability.

21.4 The Nature of Dissociation

The exact mechanism of dissociation is not known. In the instance of the numbing
of feelings, research has shown that the cerebral cortex sends inhibiting signals to
the emotional brain [3]. Other types of barriers have not been as clearly explained.
254 21 Involuntary Symptoms: Trauma and Dissociation

The wide variety of contents that can be dissociated suggests that this ability is
extremely flexible. Dissociation can take place in seconds and then dissolve in sec-
onds, which suggests that it is based on nerve signals rather than hormones or other,
slower brain processes. Research has shown that some people are genetically more
capable of dissociating than others. Children who experience early stress from
abuse may learn to dissociate and often become more adept than others at using this
defense against overwhelming affects. One girl recalled learning to dissociate while
she was being molested. She focused on a spot on the ceiling and suddenly found
herself looking down dispassionately at the child (herself) on the bed as if she was
an uninvolved observer.

21.5 Multiple Personalities

Officially named “dissociative identity disorder,” chronic, repeated abuse can result
in multiple dissociative barriers between parts of the personality. Usually a severely
abused child’s mind tries to wall off incompatible parts of experience. One part
might be an innocent and defenseless child; another is a fearless protector; and a
third has formed an alliance with the abuser. A child’s mind could not integrate
these three extreme and incompatible versions of the self, yet they each have an
essential role in survival. Even the innocent child functions to preserve intact as
much of the original self as possible. One way to allow each part of the self to func-
tion as needed without being overwhelmed by their differences is through the for-
mation of dissociative barriers. The result is the appearance of multiple separate
personalities and the ability to switch instantly from one to another as circumstances
dictate.
Anna O., discussed in Chap. 5, the first patient reported on by Freud and the
inventor of modern talk therapy, suffered from multiple personalities. In her ses-
sions of “chimney sweeping,” she would change into a different personality [1] and,
in that state, would remember and reexperience traumatic events in her life. As she
did so in a context of safety and empathic connection, the affects were detoxified
and her somatic symptoms resolved.
We can call this condition a “disorder,” but entrenched dysfunctional pattern is a
better term because it takes into account that dissociation, even in this extreme form,
starts out as a necessary and helpful protection. Only later does it become a
problem.
Some therapists have raised objections to the possibility of multiple personali-
ties. Perhaps this is because they misunderstand the term as meaning different peo-
ple are occupying the same brain. A more accurate description would focus on
dissociative barriers dividing up a single mind. In fact, all people have different
sides of themselves. For example, when we attend funerals we are nothing like who
we are at a celebration. Unlike most of us, who are aware of changes in our person-
ality, the barriers that create multiple personalities can be completely opaque or
allow only partial awareness of what is on the other side of the barrier. We could
diagram the condition like this (Fig. 21.1).
21.5 Multiple Personalities 255

“Main”
personality

Identified
Fierce with
protector perpetrator

Observer

Innocent child

Fig. 21.1 Dissociation barriers between parts of whole personality

Healing traumatic affects is only part of the treatment for people with multiple
personalities. Modern treatment starts with the need to establish safety. Different
parts of the self may interpret the treatment situation in different ways. Some may
be adamant about never going near the feelings. Others may see the therapist as a
potential perpetrator. Yet others may be allied with the abuser and see therapy as
something to be resisted. Among this discord, there is generally an even deeper
desire to find relief. These patients are often extremely dedicated to the work of
therapy. The issues brought by each part need to be taken seriously and worked with
as with other EDPs.
Once safety is established, the second phase of treatment is to address painful
affects and memories. This healing is the same as with other traumatic affects and
will be detailed further below.
The third phase of treatment is helping different parts to understand and appreci-
ate each other and to help all of them digest and make sense of the events that have
marked their life. In many cases different parts of the self will come to accept that
switching from one to the other according to the situation is not the best way to live.
They may come to believe that they will function better as a whole with the skills of
each part.
If so, then well-established parts will have to work out significant differences in
their value systems before becoming integrated becomes possible. Patients tend to
resist pressure from therapists about blending parts into a whole. Most want to make
their own decisions about this. Different parts can integrate one at a time or as a
group. The actual mechanism of integration is automatic and, like dissociation, can
256 21 Involuntary Symptoms: Trauma and Dissociation

happen in a brief moment. The end result has immediate access to the skills, knowl-
edge, and memories of the parts that were separate a few seconds before. How this
works is not known, but, like dissociation itself, the process is clearly one of infor-
mation processing, not hormones or other more gradual change mechanisms.
For more information about the treatment of DID, dissociative identity disorder,
the Sidran Foundation has an excellent and highly responsible website giving con-
temporary resources.

21.6 Treatment Principles

As with the other EDPs in this catalog, the treatment of trauma and dissociation is
vast and is the subject of many books, articles, and conferences. What are presented
here are a few highlights to point the therapist in helpful directions.

21.6.1 The Flight–Fight Cycle

Peter Levine, the originator of somatic experiencing therapy, brings an important

perspective to trauma and dissociation [2]. He points to the way herd animals deal
with the attack of a predator. When the predator is nearby, say a lion, the herd
becomes anxious and keyed up. When the lion attacks, they run at full speed in a
classic flight mode. The lion singles out one of the herd and pursues that one mem-
ber. The rest of the herd continues to run for a while and then slows and stops, with
much remaining nervous energy. Finally they settle down to grazing again until the
next attack. This cycle is repeated many times in the course of a year, with no visible
damage to the survivors.
What is different about trauma is that this natural cycle is interrupted at some
point. Levine specializes in situations where unresolved physical and emotional
trauma are frozen in the body. It is as if a movement to escape or fight back had been
stopped in midstream. Until the mind gains access to that moment of freezing, then
the trauma remains unresolved. In a similar way, dissociation freezes the emotional
processing of the event. Suddenly, the mind’s circuit breaker trips, and processing
of the event stops. In this way, trauma can be thought of as a cycle of emotional
processing interrupted. What treatment seeks to do is to reopen the sequence so that
normal processing can resume.

21.6.2 Accessing Dissociated Facts and Feelings

The central work of treatment for dissociation is inviting the patient to explore and
bring to consciousness the traumatic experiences and feelings that have been buried.
Several measures can be reassuring to the nonconscious problem solver, who is still
responding to the concerns of long ago. Reassuring and safe exploration of material
around the traumatic usually lead to gaining more access. EMDR treatment breaks
21.6 Treatment Principles 257

down affects that are too large to be dealt with into smaller portions. A therapist–
guide who is empathically attuned both to the traumatic feelings and the anxiety
involved in their exploration provides a sense of safety. Some therapists use hypno-
sis to gain access to dissociated emotions and experiences. When a traumatic expe-
rience is locked into the body, Levine’s somatic experiencing therapy specializes in
helping patients access these stuck points.
While a positively reassuring approach helps a still-frightened inner child to feel
safe, the absence of negative factors is important as well. Since abuse is usually
coercive, then using pressure of any kind tends to re-create the frightening aspects
of the original experience. Authoritarian manners may remind the patient of an
abuser. This can elicit cooperation, but if it does, it is out of fear and tends to
reawaken wariness. As stated above, at some point in treatment the child within usu-
ally expects the therapist to have motives and characteristics in common with the
perpetrators of abuse. It is important for the therapist not to be shocked or put off by
this kind of perception but to help the patient deal with those concerns.
When trauma from wars, disasters, and assaults occurs later in life, the psyche is
often more fully developed and robust. Bringing back memories and emotions can
be approached using the more powerful techniques of exposure therapy. Where
exposure to reminders of trauma can be overwhelming to a frightened inner child,
sensory reminders such as sounds and images can be helpful to an adult having
trouble accessing emotions.

21.6.3 Basic Healing

As explained in Chap. 5, dissociation creates a situation that is especially favorable

to healing by reconsolidation, which is permanent, as opposed to extinction, which
requires repetition and is not permanent. The reason is that dissociation essentially
hides the experience away for years. The usual minor alterations of the memory that
take place with each instance of recall do not happen. When the event is finally
brought to light, the intensity and freshness of recall are very close to the original
experience. This high level of activation, along with full empathic attunement on the
part of the therapist, creates precisely the conditions necessary for healing by recon-
solidation. This type of healing takes place remarkably rapidly for whatever portion
of the affect is brought to consciousness at that time.

21.6.4 Building a Perspective and Narrative

When all aspects and portions of affect have been explored and healed, patient and
therapist will naturally begin to use the perspective gained to form a narrative of the
experience. This perspective will help the patient to make sense of what has happened
and to identify further damage, such as the two types of EDPs described in complex
trauma. Seeing nonverbal schemas and distorted internalized values in a more accurate
light will help the patient begin to take back his or her power and to work on those EDPs.
258 21 Involuntary Symptoms: Trauma and Dissociation

Key Points
• The belated healing of traumatic experiences taught us about extinction
and reconsolidation. Now we turn to dissociation, the mechanism by which
the mind is able to split off these experiences for many years.
• Dissociation is the mind’s capacity, when severely threatened, to create
reversible barriers between areas of mental functioning and content.
• Dissociation is a common protective strategy that explains the symptoms of
post-traumatic stress disorder (PTSD), as well as depersonalization, dereal-
ization conversion, psychogenic amnesia, and multiple personalities.
• Dissociation and complex trauma are two distinct results of trauma. In this
chapter we deal with dissociation, but complex trauma is covered in sec-
tions of the book covering nonverbal schemas and internalized values.
• Multiple personalities, officially dissociative identity disorder, is demysti-
fied in that it is a natural result of early and lasting dissociative barriers
between incompatible parts of the personality that are nonetheless neces-
sary for survival.
• Treatment of multiple personalities focuses first on safety, then on healing
traumatic experiences, and finally on helping distinct parts of the person to
appreciate one another and to work together.
• Treatment of dissociative states in general hinges on helping the inner
mind feel safe enough to let go of barriers to consciousness. Then emotions
become affects and can heal.
• As with other emotional healing, part of the process is gaining perspective,
which leads to a narrative that makes better sense of the trauma.

References
1. Jones E, Trilling L. The life and work of Sigmund Freud. New York: Doubleday; 1961. p. 152.
2. Levine PA, Frederick A. Waking the tiger: healing trauma. 1st ed. Berkeley: North Atlantic
Books; 1997. p. 15.
3. Sierra M, Berrios GE. Depersonalization: neurobiological perspectives. Biol Psychiatry.
1998;44:898–908.
4. van der Kolk B. The body keeps the score: brain, mind, and body in the healing of trauma. 1st
ed. New York: Penguin Books; 2015.
Going Forward
22

The field of psychotherapy is at a very exciting stage. So much new scientific

knowledge is developing that therapists of all persuasions must open their minds to
new ideas. There is an increasing body of knowledge of how the mind/brain is
directed by emotions connected to a powerful motivational system. Mechanisms of
change are being elucidated so that therapists can begin to incorporate these expla-
nations into their ideas of change.
All this new wisdom is pushing us out of our silos toward a more universal
understanding of psychology. Therapists and researchers are now seeking common
ground. The affect avoidance model offers a simple, coherent framework for psy-
chopathology, within which these new insights can be brought together. In provid-
ing this, it has something to offer for new therapists, seasoned ones, researchers,
teachers, and the field in general.

22.1 For the New Therapist

The next time we encounter a new patient, there are a series of steps to take. Here is
a summary, according to the affect avoidance model:

1. We take the time we need to assess where the patient is now (point “A” in Chap.
9 on forming a hypothesis). Identify strengths and all that is dysfunctional or
could be better in the patient’s encounters with life. This includes both the patient’s
views and our own observations. This is the starting point for our work.
2. Next we look to where the therapy is leading (point “B”). It may not be possible to
see all the way to the end point, but having a direction will help us know what to
do next. Pay close attention to what the patient wants because that is the source of
the motivation and energy to do the work of change. At the same time, we need to
form our own opinions about what might lead to a more satisfying life. We don’t
want to impose our ideas, but sometimes therapists can see positive opportunities
that patients can’t now but may see later. In addition, we want to be alert to the
desires and goals of the child within, since those too carry a large amount of energy.

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9_22
260 22 Going Forward

3. Then we want to understand what forces stand in the way of progress from point
A to point B. This is the dread of uncomfortable feelings anticipated in the course
of making changes. Knowing point A, point B, and what resistance will be
encountered, we now can define the therapeutic work to be done.
4. The three elements of the work diagram will begin to give us an outline of the
layers of entrenched dysfunctional patterns and how to approach replacing them
with healthier ways of functioning.
5. Knowing the changes that need to take place and the sources of resistance, we
can now home in on just what change processes are going to be most accessible
and how to approach them. Do we want to approach uncomfortable feelings
first? Will it be easier to seek behavior change? Or are there ways to skirt around
problems that will have to be tackled more thoroughly later?
6. Having identified the change processes that come next, we can select the tools
from the many we have encountered that will be optimal for the work to be done.
7. Finally, we set about using the empathic attunement that has grown naturally out
of the listening and interaction that have been part of doing the assessment. We
now put the relationship to work to collaborate on a plan and develop a working
partnership to begin doing the work.

That, in a nutshell, is how the affect avoidance model approaches psychotherapy

using tools and methods from the full range of invention and experience embodied
in the psychotherapy traditions.

22.1.1 Psychotherapy Is Still Best Learned Experientially

Becoming skilled will take practice. It will also require a lot of discussion with more
experienced supervisors and peers who will come up with ideas that we haven’t
thought of. Each session and each intervention are an opportunity to learn. It is
invaluable to keep forming hypotheses. How will the patient react? What is going
on here? Each of these hypotheses will shape the next intervention and will frame
our observation of the results. As we gain hundreds and then thousands of observa-
tions of what we think and what actually happens, we will continue to sharpen our
ability to understand. This is the process of becoming an excellent therapist.
Malcom Gladwell writes that mastering a complex art takes 10,000 h of practice
[1]. What is most gratifying about psychotherapy is that after 40,000 h, you will still
be learning and each new patient will be vastly different from anyone you have seen
before. Psychotherapy may be stressful at times, but, unless some kind of resistance
is preventing the empathic connection, it never gets boring.

22.2 For the Seasoned Practitioner

What the affect avoidance model has to offer for experienced therapists is a concep-
tual framework into which already acquired skills will fit but one that also extends
into areas that one hasn’t learned or been exposed to yet.
22.3 For Knowledge Seekers and Researchers 261

The cognitively oriented therapist will gain a basis for bringing emotion into
focus as part of the process of helping patients make cognitive and behavioral
changes. The affect avoidance model will enhance appreciation and precise under-
standing of the struggles that patients go through in the process of letting go of the
irrational ways they cling to.
The psychodynamic therapist will find an increased appreciation for the impor-
tance of behavior change in bringing emotions to the surface and in moving from
insight to lasting change.
The “third wave” and experiential therapist will find a generally comfortable
conceptual environment for working with early, automatic, nonverbal schemas and
trauma. In addition, the affect avoidance model will point the way to understanding
and working with avoidance patterns derived from later developmental eras, such as
hidden agendas and guilty quests.

22.3 For Knowledge Seekers and Researchers

One of the greatest handicaps for research has been selection of patient groups. The
most common and standard way of doing so is along diagnostic lines. As we have
seen with depression, official diagnoses, even when applied strictly, end up creating
very mixed cohorts of patients where important but specific cause-and-effect rela-
tionships can be blurred and lost.
The affect avoidance model is intended to divide psychopathology along more
natural cleavage planes so that people struggling with the same type of EDP may
have more in common than those who carry the same overall diagnosis. Human
psychology, being what it is, is the surface layer that determines what is available
for observation. For that reason, identifying the most accessible and surface EDP is
not only good for treatment but also holds promise for research.

22.3.1 Some Specific Questions for Investigation

The affect avoidance model itself is built on a hypothesis that is subject to testing.
The model holds the notion that all the pathology that is treatable with psychother-
apy is the result of the mind’s natural programming to avoid painful, uncomfortable,
or overwhelming affects. This is consistent with a great deal of observed reality but
could turn out to be untrue in certain circumstances. An example is addiction, where
a component of pleasure seeking does seem to be operative at least partially in par-
allel with avoidance of pain.
Even if incomplete in some instances, the affect avoidance model highlights
distinctions that have rarely been examined in a research context. In particular, the
model differentiates problems that result from values internalized in the con-
science (those that produce inappropriate shame and guilt) from problems arising
from faulty beliefs. The latter appear more in the form of hidden agendas. When
this distinction is made, then it becomes apparent that changing values is much
harder and slower than changing erroneous beliefs. A valuable area for research
262 22 Going Forward

would be to explore by what mechanisms values are so much more resistant to

change than beliefs.
Another area for investigation, now that science has provided clear differentia-
tion between extinction and reconsolidation, would be identifying which mecha-
nism is operating in various clinical situations. Also, it would be interesting to see if
there are any other change mechanisms yet unknown.
Finally, perhaps the richest area for investigation would be which treatment tools
and approaches are most helpful for specific types of EDPs in patients with particu-
lar characteristics. The EDP concept allows for sharp distinctions of different types
of EDPs and therefore a better chance of showing differences in the effectiveness of
various treatment strategies.

22.4 For Students and Teachers

Until recently, psychotherapy has been organized, taught, and practiced like the
intellectual pursuits of the Middle Ages. A thousand years ago, schools grew up
around the thinking of a few wise and innovative scholars who taught their disciples
what they believed. One school competed with others, and the emphasis was on dif-
ferences rather than the similarities between alternative approaches. Students
avoided feelings of insecurity by emphasizing the purity of their allegiance to the
founder. Practices tended to become more rigid over time rather than more inclusive
and flexible.
What made this way of learning necessary was that the theoretical basis of each
school was a matter of conjecture and belief rather than scientific verification. The
belief that depression was due to an excess of black bile (dating back to classical
Greece) was a matter of belief, not verification. As an example from our field,
Freud’s notion of a sexual drive and a death wish was similarly based on an elegant
conjecture but not subject to verification. Some wisdom was based on observation.
Freud observed the healing of emotions (catharsis = reconsolidation) when patients
brought repressed material into consciousness. Similarly, the pioneering cognitive
therapists, Ellis and Beck, observed accurately that irrationally negative thoughts
led to negative emotions and actions. At least at first the Freudian school sought to
“make the unconscious conscious” so that healing could happen. The cognitive-
behavioral school sought to correct irrational thoughts and beliefs. However, in both
cases there was no overarching framework, no roof under which both sets of (cor-
rect) observations could be brought together. They remained isolated observations,
each one connected to a different and incompatible goal of therapy. Psychoanalysis,
seeking to bring material to consciousness, focused on free association. CBT, seek-
ing to correct the irrational, focused on structured sessions examining thoughts and
beliefs so they could be resolved.
Yet, seen in the light of the affect avoidance model, both of these activities can
work together to help patients understand what affects they are running from, how
their nonconscious problem solver is working to protect them, and how letting go of
irrational patterns may be stressful but will lead to healing dreaded affects and trad-
ing dysfunctional patterns for better ones.
22.4 For Students and Teachers 263

22.4.1 Today’s Teaching Model

The current standard teaching model for psychotherapy is to expose young students
to a variety of traditional schools and ask them to make a personal choice to focus
on one school and learn it thoroughly, ignoring the others. Such choices, made
mostly on the basis of the influence of a teacher or mentor, are forced on students
long before they possess any rational basis for making such a decision. Later, the
majority of therapists, coming to experience the clinical limitations of their “home”
school, begin to branch out and learn techniques from other schools. As long as the
theories of each school were incompatible, there was little choice but to approach
learning in this way. Students had to become familiar and comfortable with some
way of understanding what was happening, and no one theory was able to accom-
modate the wisdom of the others.
This is extraordinarily wasteful, not to mention limiting. No one school is excel-
lent at treating all kinds of EDPs. The current standard is to spend precious time and
energy on having students learn a single theory that applies best only to certain
kinds of patients. Then they start from the beginning to learn another incompatible
theory for a different set of patients. This double (or more) teaching and learning are
inefficient. Then there is still the problem of the student having to approach each
patient using a different school and theory or to invent a personal way of assimilat-
ing incompatible theories into the same treatment. A few pioneers, like Paul Wachtel
[2], have proposed roadmaps for doing this, but, until a more unifying framework is
adopted, each therapist is left to learn multiple theories and to find his or her own
path to stitching them together.

22.4.2 Moving Out of the Middle Ages

Today, with the advances of science, we are beginning to be able to make much
more accurate, direct observations to correlate clinical observation with brain activ-
ity. The inclusion of affect and attachment as subjects of interest along with cogni-
tion is particularly important in building an overall picture of how the mind
functions. These new observations need an overall theory to tie them together. The
affect avoidance model offers a starting point for conceptualizing how the human
mind, as a control system programmed by evolution, can produce psychological
dysfunction on a regular and predictable basis and how those dysfunctions can be
resolved.

22.4.3 We Can’t Afford to Waste Resources

We live at a time where a vast number of people in the developing world are moving
from survival to seeking a better quality of life. As they do so, psychological dys-
function becomes one of the greatest sources of suffering and destructiveness. As
mentioned in Chap. 19, the World Health Organization has said that depression is
the world’s number one cause of disability [3]. These changes are taking place
264 22 Going Forward

largely in the developing world. Countries with the least resources will be experi-
encing the greatest challenges to their mental health systems. Therefore, it is critical
that we simplify training in psychotherapy and to stop wasting energy and resources
on infighting between schools. In developing countries as well as developed ones,
students are exposed to a wide variety of techniques and approaches. They need a
coherent framework within which they can place all that they learn and benefit from
all the wisdom they are able to absorb rather than having to choose one approach
and abandon what they have learned about others.

22.5 Conclusion

It is hoped, then, that the affect avoidance model will provide a robust and flexible
framework to help move the field further away from warring camps and toward a
common collaboration. A unifying basis and common concepts can help accelerate
the movement that has already begun, joining affective neuroscience with clinical
practice. The EDP concept makes clear the relationship between emotion-oriented
interventions and those directed at irrational thought and behavior. Furthermore, by
identifying the EDP as the basic unit of pathology, we can go beyond case diagnosis
to bring greater precision to the way we match techniques to each problem module.
There is no time to lose as emotional dysfunction continues unabated, resources
remain constrained, and ever greater numbers of people identify the need for
psychotherapy.

References
1. Gladwell M. Outliers: the story of success. New York: Little, Brown and Company; 2008.
2. Wachtel P. Therapeutic communication: knowing what to say when. 2nd ed. New York:
Guilford Press; 2013.
3. Marcus M, Yasamy MT, van Ommeren M, Chisholm D, Saxena S. Depression: a global public
health concern. WHO Department of Mental Health and Substance Abuse. 2012. http://www.
who.int/mental_health/management/depression/who_paper_depression_wfmh_2012.pdf.
Accessed 22 Sept 2016.
Index

A AEDP. See Accelerated experiential dynamic

Accelerated experiential dynamic psychotherapy (AEDP)
psychotherapy (AEDP), 167 Affect avoidance, 19–20, 22–23
Acceptance and commitment therapy (ACT), Affect avoidance model, 1–3, 19, 25–26, 28,
23, 27, 28, 167, 170, 175 34–35, 114, 128, 237, 259–261
Acting out pattern, 46, 172–173 Affect-avoiding behavior patterns, 45
treatment principles, 173 ‘Affect’ word usage, 20
treatment resources, 173 Agitated depression, 230–231
Active therapist communication, arguments Ainsworth, Mary, 169
for, 153–154 Alcoholism, 184
ADD. See Attention deficit disorder (ADD) American Freedom of Information Act, 224
Addictions, 47, 183 Amnesia, psychogenic, 252
alcoholism, 184 Amygdala, 10, 23, 28, 29, 42, 52, 53, 169
behavior pattern, 184 Anger, 197–198
codependency, 185–186 as avoidance, 198
family disease, 185 as social tool, 198
role of value systems, 184–185 Angry enabling, 76
secondary psychopathology, 184 Anorexia nervosa, 185, 240
treatment principles Anti-craving medication, 188
anti-craving medications, 188 Antidepressant, 226
controlled use, 186–187 SSRI, 242, 244–245
external motivation, 187 tricyclic, 232
leverage, 187–188 Antidepressant medication, 232
motivational interviewing, 189 Anxiety, 241
outside help, 187 healthy, 199
positive prognostic signs, 190 simple, 199
12-step groups, 189–190 as social signal, 200
therapist role, 188 Anxiety-related syndromes
Addiction therapist, 217 anxiety, 241
ADHD. See Attention deficit hyperactivity compulsions, 242–243
disorder (ADHD) obsessions, 242–243
Adjustments panic, 241–242
therapist, 158–159 somatization, 243
treatment, 157–158 treatment principles
Adolescence behavioral approach to
developmental arrest in, 180 preoccupation, 245
developmental challenges, 88–89 control, 244
Adulthood, developmental challenges, 89 emotional approach to preoccupation,
Adult temper tantrums, 146–147 245–246

J. Smith, Psychotherapy, DOI 10.1007/978-3-319-49460-9
266 Index

Anxiety-related syndromes (cont.) developmental arrest, 178–180

healing, 247–248 guilty quest, 176–178
medication treatment, 244–245 hidden agendas, 173–175
mindfulness, 246–247 nonverbal schemas, 167–171
Anxious/ambivalent children, 158 reenactment, 171–172
Anxious-preoccupied style, 169 simple avoidance, 166–167
Arrested development, 46 Behavioral therapy, 2
Attachment pattern, and therapeutic cognitive, 10, 16, 26–27, 35, 65, 96,
relationship, 169–170 199–200, 238
Attachment style, 169 dialectical, 23, 27, 28, 167, 170, 173, 194
adapting to, 158–159 Behavior change
Attachment theory, 2 elements, 160–161
Attention deficit disorder (ADD), 24 generic talk therapy conduction, 123
Attention deficit hyperactivity disorder homework as, 160–161
(ADHD), 200 Behavior pattern, affect-avoiding, 45
Attention, mind emotional, 102 Biological dysregulation, 227–228
Attitudes, 204, 211 Biological motivation, 73
Authority, therapist, 157–158 Borderline pathology, 85
Automatic thoughts, 32, 47, 193, 246 Boundary violations, 127
Autopilot, 173 Bowen, Murray, 75
Avoidance and commitment therapy Bowl, John, 27, 169
(ACT), 166 Brain regulation, 24
Avoidance, anger as, 198 Buddhist meditation, 149
Avoidance patterns, 32, 41–42
childlike plans, 33–34
inherently dysfunctional patterns, 33 C
threatening situation, 33 Catharsis, 55
Avoidant behavior pattern, 165 CBT. See Cognitive-behavioral therapy (CBT)
acting out, 172–173 Childlike behavior, 142, 143
developmental arrest, 178–180 Childlike plan, 141
guilty quest, 176–178 avoidance pattern, 33–34
hidden agendas, 173–175 Civil disobedience, 212
nonverbal schemas, 167–171 Codependency, addiction, 185–186
reenactment, 171–172 Cognitive-behavioral strategy, 233
simple avoidance, 166–167 Cognitive-behavioral therapist, 229
Avoidant children, 159 Cognitive-behavioral therapy (CBT), 10, 16,
Avoiding thoughts, 217 26–27, 35, 65, 96, 199–200, 238
Avoiding uncomfortable feelings, 25 Cognitively oriented therapist, 261
Cognitive therapist, 217, 228, 238
Cognitive therapy, 2, 63, 205, 215, 217–218
B Coherence therapy, 175
Beck, Aaron, 168 Communication, active therapist, 153–154
Behavior Compassion, inner child, 149
childlike, 142, 143 Complex trauma, 253
destructive, 183 Compulsions, 48, 242–243
dysfunctional, 30, 45–47, 165, 216 Conscience-based emotion, 47, 57, 193,
potential, 30–31 203–204
self-destructive, 146 adult internalization, 209
Behavioral approach aware of, 205
to depression, 233 electric fences, internal, 208–209
to preoccupation, 245 internalization, 208
Behavioral avoidance patterns, 165 of values, 207–208
acting out, 172–173 justice system, 205–206
Index 267

neurophysiology, 204–205 recognize, 179

pathology, 206 shame about immaturity, 179
resistance to change, 209 thought of immaturity, 178
self-contradictory values, 210 treatment principles, 179–180
of shame/guilt, 31–32 Developmental challenges, 82
treatment principles adolescence, 88–89
civil disobedience, 212 adulthood, 89
education, 211 attachment and separation, 83
modeling positive values and crime and punishment, 85–86
attitudes, 211 later childhood, 88
new values vs. old ones recover, 211 old age, 90
tread lightly, 210–211 power struggles, 84–85
working with shame, 212 rules, 86
unhealthy values, 209–210 self-other differentiation, 82–83
Conscience-based feelings, 166 someday, 87
Conscious decision-making, 155 young adulthood, 89
Consciousness, 34, 51, 218 Developmental theory, 79–80
Containment, inner child, 147–148 Dialectical behavior therapy (DBT), 23, 27,
Corrective emotional experience, 149–150 28, 167, 170, 173, 194
Countertransference, 135, 136 Disorganized children, 159
Crime and punishment, 85–86 Dissociation, 48–49, 251–252
Cyclical therapy, 37, 123 multiple personalities, 254–256
nature of, 253–254
PTSD and, 252–253
D treatment principles
Danger becomes irrelevant avoidance accessing dissociated facts and feelings,
pattern, 33 256–257
DBT. See Dialectical behavior therapy (DBT) flight–fight cycle, 256
Depersonalization, 252 healing, 257
Depression, 2, 48, 223 perspective and narrative, 257
agitated, 230–231 Dissociative identity disorder, 254
behavioral aspect of, 228–229 Drug abuse, 180
emotional aspect of, 229–230 Duvarci, Sevil, 54
financial influences, 225 Dysfunctional avoidance mechanism, 23
grief, 231 Dysfunctional behavior, 30, 45–47, 165
major, 224 potential, 216
melancholic (see Melancholic depression) Dysfunctional thoughts, 218
milder, emotional components of, 230 Dysregulation, 227–228
miscellaneous symptoms, 232
narcissistic/antisocial personality, 231
treatment principles, 232 E
antidepressant medication, 232 Ecker, Bruce, 55, 175
behavioral approach, 233 EDPs. See Entrenched dysfunctional patterns
emotional approach, 233–235 (EDPs)
psychotherapy, 233 EFT. See Emotion-focused therapy (EFT)
unhealthy lifestyle, 231 EMDR. See Eye movement desensitization
Derealization, 252 and reprocessing (EMDR)
Destructive behavior, 183 Emotion, 20, 27. See also Conscience-based
Detachment with love, addiction, emotion
186, 188, 189 healing of, 244
Detoxification, 20, 26, 29, 58, 96, 111 as helpers, 194–195
Developmental arrest, 178 negative, 23
in adolescence, 180 primary, 31, 47, 193
268 Index

Emotional activation, 155 generic talk therapy conduction, 120–121

Emotional approach initial assessment conduction, 102
to depression, 233–235 negative, 21, 22
to preoccupation, 245–246 therapist, 135–136
Emotional arousal, using language to uncomfortable, avoidance of, 25
regulate, 155 Freud, Sigmund, 22, 171
Emotional attention, mind, 102
Emotional healing, 61, 96, 123
ubiquity of, 62–63 G
Emotional relationship, 171, 173 Gender, 135
Emotional stakes, 173 Generic talk therapy conduction, 111–112
Emotion-focused therapy (EFT), 23, 27, behavior change, 123
167, 170 discovery, 123
Emotion-heightening words, 156 emotional healing, 123
Emotion-lowering words, 156 ending a session, 121–122
Emotion-regulating schemas, 169 feelings, 120–121
Empathic confrontation, 170 intervention, 115–116
Empathy, 129, 130 long-term resistance, 122–123
Enabling, 76 phases of therapy, 122
Entrenched dysfunctional patterns (EDPs), responsibility of a therapist, 112–113
2, 3, 23, 25, 32, 34, 79–81, 111, successful change, 124
119, 141, 143, 203 therapist guidance through
activation of, 165 questioning, 112
advantages, 13–15 therapist’s first priority, 115
catalog of, 45 therapist’s second priority, 118–119
deeper layer, 239–240 three-step formula, 116–118, 120
healing, 247 value of listening, 119–120
dysfunctional behavior, 45–47 Gladwell, Malcom, 260
function, 26 Greenberg, Leslie, 27
helpers, 47 Grief, 231
involuntary, 65 healthy response, 221–222
structure of, 28–30 pathological, 222–223
surface layer, 238–239 sadness and, 195–196
symptoms, 48 SEEKING System, 222
anxiety-based, 48–49 Group treatment, 180
Epigenetics, 24 Guilt, 47, 57–58
Expectation and motivation, 68 conscience-based emotions of, 31–32
Experiential therapist, 261 vs. shame, 206–207
Exposure therapy, 53–54 Guilty quest, 46, 176
External motivation, 187 helpful readings, 178
Extinction, 29, 53–54 someday and dimension of time, 177
Eye movement desensitization and treatment, 177
reprocessing (EMDR), 57, 63, 87, principles, 177
160, 167, 196, 212, 256–257

H
F Hands-off technique, 144
Fear Healing, 52–53, 56, 57, 247–248
reactions, 54 anxiety-related syndromes, 247–248
working with, 179 beyond trauma, 57
Fearful-avoidant pattern, 170 attachment, 58
Feelings ideas, 58
accessing dissociated facts and, 256–257 pride, guilt, and shame, 57–58
conscience-based, 166 psychological development, 58
Index 269

dissociation, 257 concept history, 143

in EMDR, 63 containment, 147–148
emotional, 61, 96, 123 corrective emotional experience, 149–150
ubiquity of, 62–63 manipulative patient, 148
of emotions, 244 recognize, 144–145
trauma, 255, 257 schema therapy, 148
Healthy anxiety, 199 self-sufficient patient, 148–149
Healthy thoughts from unhealthy, 218 therapeutic failure, 145–146
Hebb, Donald, 43 Internal electric fences, 208–209
Helpers, 31, 47 Internal tension, 74
emotion as, 194–195 Intrusive thoughts, 216
thoughts as, 215–217 Involuntary EDPs, 65
Helplessness, 197
Hidden agendas, 46, 58, 173–174
recognizing, 174–175 J
treatment, 175 Justice system, conscience, 205–206
principles, 175
Homework, as behavior change, 160–161
Hopelessness, 197 K
Hopes Kandel, Eric, 43
and motivation, 68 Kant, Immanuel, 168
and SEEKING system, 69–70 Klein, Melanie, 230
Human psyche, 183

L
I Later childhood, developmental challenges, 88
Ideals, 204 Leverage, 71, 187–188
Identity disorder, dissociative, 254 Limited reparenting concept, 148, 170
Immaturity Linehan, Marsha, 37
shame about, 179 Long-term potentiation (LTP), 43
thought of, 178 Löwel, Siegrid, 43
Impulses, 31, 47, 200–201
Influencing thoughts, 216, 217
Inherently dysfunctional avoidance pattern, 33 M
Initial assessment conduction, 95 Mahler, Margaret, 64
arriving at an agreement, 108 Main, Mary, 169
assembling the data, 103–105 Major depression, 224
building a hypothesis, 105–106 Maladaptive nonverbal schemas, 168–169
chief complaint, 100–101 Mania, 230–231
feelings, 102 Marriage, 173
following leads, 99–100 Medication
formula for, 97–98 anti-craving, 188
formulating questions, 99 antidepressant, 232
listening, 102 Melancholic depression, 225–226
for style and content, 98–99 biological dysregulation, 227–228
making a plan, 106–108 bipolar illness, 226–227
patient’s mind, 100 unique aspects of, 226
spiral organization, 101 vicious cycles, 227
trauma and substance abuse, 103 Memory, 42–43
working with uncertainty, 96–97 procedural, 30, 32, 44–45, 58, 125, 141,
Inner child, 141–143 142, 168, 188, 231
accepting unmet needs, 147 traumatic, 64
adult temper tantrums, 146–147 Mental pathology, 13, 17, 19, 20, 23
compassion, 149 Metacommunication, 117
270 Index

Milder depression, emotional components Norcross, John, 66

of, 230 Nucleus accumbens, 73, 183
Miller technique, 185, 189
Mind
as control structure, 20–22 O
emotional attention, 102 Obsessions, 48, 242–243
Mindfulness, 51, 63–64, 153, 167, 219, Obsessive-compulsive disorder (OCD),
246–247 237, 238, 242
Modular therapy, 17, 37, 106, 165 Oppositional defiant disorder, 2
Motivation, 67 Outside motivation, 70
biological, 73
eliciting expectations, 68–69
expectations, 68 P
external, 187 Panic and anxiety, 199
hopes, 68–70 Panic attack, 7, 8, 10–11
inner child, 69 Panksepp, Jaak, 20, 69, 204, 241
location of the problem, 68 thinking, 231
outside, 70 Pascual-Leone, Antonio, 178
patient’s complaint, 67–68 Pathological narcissism, 84–85
pleasure role in, 23 Patient
positive, 74 internalizing vs. externalizing, 159
positive emotion role in, 23 and therapist, agreement between,
timing and, 73 132–133
Motivational interviewing (MI), 133, 154, Patient motivation
173, 185, 189, 218 deciding to quit, 72
Motivator, therapist as, 73–74 internal resistance to change, 73
Multiple personalities, 254–256 missing sessions, 72
Penfield, Wilder, 43
Personality, 8–9
N multiple, 254–256
Nader, Karim, 54 narcissistic/antisocial, 231
Narcissism, pathological, 84–85 Personality disorder, 30, 170
Narcissistic personality disorders, 84 narcissistic, 84
Negative emotion, 23 Phobias, 241
Negative feeling, 21, 22 Physical boundary violations, 127
Neurophysiology, of conscience, 204–205 Piaget, Jean, 79, 168
Nonconscious problem solver, 30, 113, 154, Pleasure, role in motivation, 23
165, 168, 184, 188, 217 Positive emotion, role in motivation, 23
helpers, 31 Positive motivation, 74
conscience-based emotions of shame Post-traumatic stress disorder (PTSD),
or guilt, 31–32 96, 252–253
primary emotions and impulses, 31 Potential behavior, 30–31
thoughts, 32 dysfunctional, 216
potential behaviors, 30–31 Pride, 57–58
symptoms, 32 Primary emotion, 31, 47, 193
Nonverbal schemas, 45–46, 167–168, Procedural memory, 30, 32, 44–45, 58, 125,
179–180 141, 142, 168, 188, 231
attachment patterns and therapeutic Prohibitions, 204
relationship, 169–170 Protections become problem, 32–34
general considerations, 171 Psyche, 183, 184
personality disorders, 170 Psychoanalytic dictum, 112
pre-attachment, 169 Psychodynamic approach, 3
schema therapy, 170–171 Psychodynamic theories, 1–2
sensorimotor schemas, 168–169 Psychodynamic therapist, 217, 261
treatment resources, 170 Psychodynamic therapy, 27, 170, 172
Index 271

Psychogenic amnesia, 252 Simple avoidance, 45, 166–167, 237

Psychological dilemma, 230 Skinner, B.F., 22, 23
Psychological pathology, 20 Snapping: America’s Epidemic of Sudden
Psychotherapy: A Practical Guide Personality Change (Conway and
(Einstein), 1 Siegelman), 207
Psychotherapy integration, 17 Social isolation, 184
PTSD. See Post-traumatic stress disorder Social signal, anxiety as, 200
(PTSD) Social tool, anger as, 198
Punishment, crime and, 85–86 Society for the Exploration of Psychotherapy
Integration (SEPI), 4
Solo meditation, 63, 65
R Somatization, 48, 243
Rationalization, working with, 81–82 Spontaneous thoughts, 246
Reality, 153–154 Substance abuse, 103
Reconsolidation, 29, 51, 54–56 Supportive therapy, 156–157
Reenactment, 46, 171–172
treatment principles, 172
treatment resources, 172 T
Rehabilitation programs, 188 Tactical retreat, 117
Relational therapy, 170 Talking therapy
Repetition, 56–57 arguments for active therapist
Resistance, 102 communication, 153–154
Rogers, Carl, 149 liabilities of more, 154–155
Rollnick technique, 185, 189 pros and cons of less, 154
some goals furthered by, 155
traditional, 35
S Tara Brach, 149
Sadness Teaching model, psychotherapy, 263
and grief, 195–196 Tears
and tears, 195–197 of protest, 196–197
Schema therapy, 148, 170–171 and sadness, 195–196
Schore, Alan, 204 Tension, internal, 74
SEEKING system, 222, 225 Therapeutic relationship
hopes and, 69–70 achieve empathy, 129
Selective serotonin reuptake inhibitor (SSRI) agreement between patient and therapist,
antidepressants, 242, 244–245 132–133
Self-blame, 185 attachment patterns and, 169–170
Self-condemnation, 86 attunement, 129
Self-contradictory values, 210 boundaries, 126–127
Self-control, 208 effective boundary management, 127–128
Self-destructive behavior, 146 eliciting feedback, 130–131
Self-other differentiation, 82–83 empathy, 130
Self-punishment, 86 exceptions, 129–130
Self-sufficiency, 7, 208 flexibility, 128
Sensorimotor schema, 167–169 frame, 128
SEPI. See Society for the Exploration of goals of termination sessions, 138
Psychotherapy Integration (SEPI) matching culture, religion, and
Sexual orientation, 135 spirituality, 134–135
Sezgin, Betul, 134 matching gender and sexual
Shame, 47, 57–58, 166 orientation, 135
conscience-based emotions of, 31–32 matching stages of change, 133–134
vs. guilt, 206–207 maximum empathy, 131–132
working with, 179, 212 optimal expectancy, 131–132
Shapiro, Francine, 63 terminating, 138
Simple anxiety, 199 working alliance, 137
272 Index

Therapist ideas, 58
authority, 157–158 pride, guilt, and shame, 57–58
communication, arguments for active, psychological development, 58
153–154 treatment principles
feelings, about patients, 135–136 accessing dissociated facts and
frame as a variable, 161 feelings, 256–257
as motivator, 73–74 building a perspective and
and patient, agreement between, 132–133 narrative, 257
role, 125–126 flight–fight cycle, 256
Thinking healing, 257
Panksepp, 231 Traumatic memories, 64
wishful, 185 Tricyclic antidepressants, 232
young and adult, 81
Third wave therapist, 261
Third wave therapy, 23, 35, 172, 199–200 U
Thoughts Uncertainty, working with, 96–97
automatic, 32, 47, 193, 246 Uncomfortable feelings, avoidance of, 25
avoiding, 217
dysfunctional, 218
as helpers, 215–217 V
influencing, 216, 217 Values, 204
intrusive, 216 Van der Kolk, Bessel, 154
spontaneous, 246
treatment principles, 219–220
consciousness raising, 218 W
distinguishing healthy thoughts from Wachtel, Paul, 37, 263
unhealthy, 218 Wishful thinking, 185
mindfulness, 219 Witness, 64–65
resistance, 218–219 Working
Timing, and motivation, 73 with fear, 179
Traditional psychodynamic therapy, 27 with shame, 179, 212
Traditional talking therapy, 35
Transference, 141, 142
Trauma, 103, 251 Y
complex, 253 Young adulthood, developmental
healing beyond challenges, 89
attachment, 58