This post picks up from TIFT #42 and TIFT #43, on "the dread," that is, what the mind most wants to avoid. Humans are really strange creatures. Our mammalian friends avoid pain for good reason, because pain acts as a proxy for some threat to survival. Humans avoid discomfort just because it feels bad. Have you noticed how often people put off needed healthcare for fear of unsettling news. And PTSD sufferers will go to extraordinary lengths to avoid emotions associated with distant trauma. This may seem quite natural, but let’s think about it from the point of view of evolution.
From very far back in evolution, the vertebrate central nervous system included alarm neurons which, when activated, signaled danger and the need for some form of evasive action. This was a great advance because a central alarm system makes it possible to compare apples and oranges, that is, vastly different kinds of threats, so as to prioritize the response. An example would be hunger at the same time as the smell of a predator. The alarm of hunger is softer and less insistent than the alarm raised by the predator, so running wins over seeking food. This remarkable system persists today when we face competing imperatives, shaping both split second decisions and long term choices.
For social mammals like ourselves, dangers to the social fabric are thrown in with the physical threats, making use of the same systems for registering danger through painful and uncomfortable alarm signals and launching actions calculated to mitigate the threat.
We might wonder what signals are employed by the mammalian alarm system. Does it set off flashing lights or generate a verbal report? The midbrain possesses neither lightbulbs nor words. What is most intriguing, is that the substance of our alarms, like those of our animal friends, can be though of as emotion. Detection of a danger sets off an emotion and the emotion is what triggers a response. I’ll explain more below.
Limbic emotions and the alarm system
While the limbic system has multiple parts and not all alarm signals arise in the same structures, the popular understanding of the amygdala is representative. Activation of certain neurons in the amygdala is equivalent to signaling that, as a result of complex information processing, the brain has detected a threat. These activations then trigger responses designed to do something that will ultimately calm down the alarm.
We humans inherit the same system, but with a twist. Both consciously and unconsciously, we are often more concerned with the emotion than the threat, itself. But before we go further into that peculiarity, we need to look into the nature of the emotions that constitute an alarm.
Neurophysiologists have had a raging debate. Some, like the late Jaak Panksepp, argue that animals experience emotions much the same as we do. Others like LeDoux, hold that we really can’t tell what animals feel because their emotions take place deep in the midbrain limbic system. Furthermore, they have no way to convey to us what they feel. One of the arguments is that, while our limbic structures are closely analogous to the dog's, our conscious feelings don't necessarily correspond to what is going on in our own limbic system. We can have limbic activation similar to a dog’s but without conscious awareness. At other times, we may report feeling something, but not have any corresponding limbic activation. Our conscious feelings, with their associations and added meaning, are both complex and variably related to limbic activity.
What we do know is that when the dog’s tail stops wagging and it begins to shiver, we recognize fear while researchers measure activation of limbic alarm structures. We also know that when we experience what we recognize as fear, analogous limbic structures are likely to be active in a way similar to the dog’s.
Just to mix things up, I’ll offer another source of observation. Infant humans have an active limbic system (we could call it the mammalian mind), which comes online quite a bit earlier than the cerebral cortex. Babies clearly have intense and varied emotions, which are very important sources of information for parents. We “read” their emotions, but infants are not that different from Rufus. If we can’t know what our dog is feeling, then how can we know what our own baby is feeling? Technically, we can’t, for the same reasons as with the dog. But who cares! We need to "know" the baby's emotions, and we don’t worry about the technicalities. Only later, do we teach the child to give words to what it is feeling.
De-confusing Emotions using the concept of affect
The word affect turns out to be very helpful in this discussion. It has been given different definitions, but the one I find most useful is the combination of conscious feeling along with involuntary bodily responses. When we therapists see tears, gasps, changes in breathing, etc, we know instinctively that something “real” and important is going on emotionally. Those bodily response are set off by the same limbic emotional centers that are indicators of threats and opportunities. So when we observe a conscious feeling accompanied by bodily changes, that is, affect, we can safely conclude that we are seeing an indirect indication that limbic structures have been activated.
And when a baby “shows emotion” what that means is that the baby is exhibiting bodily changes indicative of deep limbic emotional activation. Similarly, the dog’s sinking tail and trembling limbs are indicators of activation in neurological structures closely analogous to the baby’s and to ours. The only difference is that babies and other mammals, with the possible exception of some primates, are unable to put their consciousness into symbolic form. And while we’re on the subject of consciousness, it is not nearly as absolute as many have thought, but operates more like a special compartment separated by a flimsy and variable curtain, showing us what the brain thinks is important for us to know at any given moment.
You can see, then, why I consider affect to be so important for the therapist. The bodily changes tell us that something important is going on, and give some hints about what it might be. The words are equally important because they articulate much more precisely the circumstances that led to deep activation of limbic emotions. We need both to gain "accurate empathy." Affect is also our indirect clinical indicator and guide to the deep activation of the limbic neurons that trigger those entrenched maladaptive patterns (EMPs) that are the primary focus of our psychotherapeutic efforts. That’s why “affect avoidance model” is the phrase I use for a way of understanding our maladaptive avoidance responses, how we can track them, and how they can be modified.
Avoiding the threat or the emotion?
Here is where it gets curious. Through millions of years of evolution of central nervous systems, negative limbic emotions have functioned, for all intents and purposes, as equivalent to threats. Activation meant the brain was predicting something dangerous and the emotion triggered an avoidance response. The package delivery person arrives and the dog barks.
But humans have the capacity to understand time. When the PTSD sufferer remembers events from years past, the memory is almost as painful as when the events took place. He or she may do costly or even damaging things so as to avoid re-experiencing those painful emotions. Similarly, humans may imagine the pain of possible future bad news about a medical test and avoid taking the test, all the while knowing that early treatment can be life saving. Other examples are drowning our sorrows in alcohol or using isolation to avoid discussing a painful subject. All are examples of responses that have little to do with the threat, and everything to do with emotions that we may dread but that do not actually represent a threat.
A possible alternative explanation might be that the mammalian mind is not sophisticated enough to understand that the threat is no longer present. Could the mind of the ex-soldier be operating as if the threat of war were still present? Perhaps that is true in the case of PTSD, where loud sounds might trigger a war-related response. But there are too many instances where it seems that painful emotions are simply avoided because they are painful or uncomfortable.
Implications for therapy
This observation has critical implications for our profession. Our field’s one greatest discovery over the past 50 years is that, for painful emotions that don’t signal real danger, avoidance makes them worse. The reason this is important is that we now have a better way to cope with painful emotions: healing them for good. If you are familiar with what I’m about to say, you can skip it, but here is a brief summary.
In psychotherapy, the final common pathway to healing is usually for our client to face their painful emotions in a context of connection and empathy. Within that phrase are contained the two essential conditions required for memory reconsolidation to do its work of re-configuring neurons permanently so the emotional response can “heal,” or lose it’s toxicity. The first requirement is activation of those deep limbic emotions signaling a threat. The way we know that condition has been fulfilled is by affect. The second requirement, at the same time, is introduction of an “antidote,” a piece of surprising experience or information that tells the person the perceived threat is no longer dangerous. When the threat is the affect, itself, then the most common and important antidote is the same thing that soothes humans throughout life: The calm presence of an empathically connected other. Picture someone who has just received a cancer diagnosis. What is most soothing and reassuring is not the idea that “we’re going to fight this,” or a possible cure, but the presence of someone who understands us empathically and is not personally overwhelmed. That is a language our mammalian brain, like the dog’s, is designed to receive far more efficiently than anything intellectual.
This juxtaposition of affect and antidote describes the basic healing moment in so many therapeutic traditions. It is embodied in exposure therapy, in every mindfulness-based therapy, in experiential therapies, and in those “moments of meeting” described by the Boston Change Process Study Group in relation to psychodynamic therapies. Just to put a cherry on top, it’s what cements the important moments in psychological development, when facing a new and challenging experience triggers alarms. At those times, we instinctively understand the need for a calm but empathic other, as when we support a child going to school for the first time or an adolescent going off to college. Empathic understanding is transmitted automatically and subliminally to the mammalian brain signaling that “it’s going to be alright.”
So humans don’t respond only to threats and danger, even of the social kind, but also to uncomfortable emotions, themselves. Avoiding painful emotions is often maladaptive, but it can also be a defining feature of our experience. For good or ill, it is a central part of our humanness that we pursue good feelings and avoid negative ones.
Jeffery Smith MD
Thank you for reading and please consider contributing an anonymous and disguised description of your most difficult case for discussion of relevant principles.