I’m writing today on how therapists can gain clarity about client problems and how to help clients trade maladaptive patterns for better ones. Toward that end, I am sharing five critical questions developed in our Psychotherapy Coaching Community to trace, step by step, a path from the problem to its solution.
EMPs, Entrenched Maladaptive Patterns
By this time, most readers are familiar with the one jargon term I actively use, Entrenched Maladaptive Patterns (EMPs). The reason for such a term is that even today, every therapy has its own idea of what problems it treats and they are generally incompatible. That’s why a group of us at SEPI, the Society for the Exploration of Psychotherapy Integration, coined a term to encompass all the problems (or subunits of pathology) that psychotherapy aims to address.
Any client can have multiple EMPs, though they are usually organized like the defenses of a medieval castle around one central issue with layers of protection. Each layer arises when there is a threat that the one below will fail. In clinical practice, we are usually dealing with one at a time, and that is generally the most immediately troublesome or the one most accessible to change.
Here are the five questions aimed at helping therapists gain a full understanding of each problem and clarity about what to do to help.
Question One: What is the maladaptive pattern
It may seem obvious, but it is essential to identify together just what pattern of thinking, feeling, behavior, or body regulation is the most troubling. From far back in the history of medicine, the traditional term is the “chief complaint.” It is the main cause of pain or discomfort and, consequently, the client’s main source of motivation. That motivation is what will provide the energy and drive to support investment in the work of psychotherapy.
In thinking about principles that apply universally to all the problems we work with, it is helpful to have a catalog of different kinds of pathology. Some of these have biological aspects but all of them involve coping gone awry, that is, the mind’s efforts at protection from conditions appraised as threatening. The latter are what psychotherapy aims to address.
An informal list of EMPs found in practice:
- Anxiety and OCD
- Attachment problems
- Personality distortion
- Compulsive behaviors
- Maladaptive traits
- Failure to develop
- Relational troubles
- Responses to trauma
- Experiential avoidance
- Resistance to anticipated change
With any EMP, we seek first to describe the pattern and how it causes distress or dysfunction. Examples might be finding fault with a relationship just as it begins to get serious. Or it might be feeling low self-esteem for no good reason. It could be putting up roadblocks to healthy behaviors, or even avoiding therapeutic homework. Of course we need to be careful and in sync with our client when we label a pattern as something that needs to change. Maybe the homework was not really effective, or maybe there was another EMP, such as a reaction to authority that stood in the way of doing the homework. That is an example of how identifying problem patterns is not always obvious. As a result, our ideas need to be tentative and open to revision as we go along.
Question Two: What challenging circumstance does this pattern aim to solve?
This question is probably going to be a guess, but it will be helpful. It is a matter of “reverse engineering,” figuring out from the solution what problem it was trying to address. One important factor will be the point in time and level of development when the solution was first invented. Some, like depression, probably go back far before our species evolved. Others, like attachment styles, may date to the earliest years of life. Problems related to adult trauma may come from much later in life. At each point, we can envision what resources were available and that will help in understanding how the mind approached the problem.
Psychotherapy aims to work with problems that are not easy or trivial to change, that is, entrenched. What makes the mind resist change is that it is programmed to hold tightly to patterns that deal with serious threats. We can think of those serious threats as “challenging circumstances.” To be more technical, they are circumstances experienced on a limbic level as threats to our evolutionary goals Whether shared with the client or not, our observation and thinking are sharpened by seeking to understand the specific threat a pattern was designed to deal with, even if the best we can do is to hold an open question.
Question Three: What is the dreaded limbic emotion
Remarkably, it is possible to say that the aim of every entrenched maladaptive pattern is to quiet or eliminate negative emotions in the limbic system. The reason is that those limbic emotions are the brain’s way of signaling that a threat requires a response. Every protective response, maladaptive or not, is initiated by activation of limbic emotion. (The differences between limbic emotion and conscious emotion have been discussed in TIFT #84.) Essentially, limbic emotion can only be identified indirectly by the clinician when it “resonates” with conscious thoughts, or triggers some observable response. Fortunately, unlike many constructs in psychotherapy, with research instruments this one can be detected in the brain, so it is a real and measurable phenomenon.
For neurophysiologists, limbic activation (or emotion) is simply the firing of a few neurons in limbic structures like the amygdala. For us clinicians, it is far more specific and nuanced. As we seek accurate empathy (TIFT #65) we try to understand just how the inner mind is interpreting a situation and what makes it come to the conclusion that a threat must be acted upon. At the center of that inquiry is the dreaded limbic emotion the client’s inner mind is focused on quieting.
Some of the most potent forms of dread are helplessness, hopelessness, powerlessness, and not knowing. These have troubled humankind forever, and have spurred many maladaptive patterns. But there are many other sources of dread. If we think of addiction, the dread might be the sensations of withdrawal, or it might be a deep feeling of something missing that must imperatively be soothed. The possibilities are very broad, but every maladaptive pattern is triggered by the presence or anticipation of a dreaded limbic emotion.
Two specific types of dread are worth mentioning because they are less obvious. One is the terrible limbic emotion associated with a prediction of not having the the resources to cope with a challenging circumstance. Lack of adequate resources is as important a source of dread as the magnitude of the challenge. The other is being “caught off guard.” Once again the human mind spends a great deal of energy monitoring and predicting possible threats. When prediction fails, that, too is accompanied by intense limbic emotion and is likely to generate a powerful response such as cries of distress or strong internal shame.
Question Four: What is the target rule behind the dread?
Surrounding the dreaded limbic emotion are three components of logic that appear to take place in limbic structures such as the amygdala. To better picture this logic, it helps to think of the rules of grammar, held unconsciously and in nonverbal form, ready to shape the words we speak. The first kernel of logic is that which identifies the circumstance as a threat requiring action. The second is the best strategy to mitigate the threat. And the third is rapid analysis of our ability to succeed in overcoming the threat. Our efforts at supporting memory reconsolidation are specifically aimed at rewriting those rules or units of logic.
This logic, called “implicit learning” by Bruce Ecker, is retained as “procedural memory.” In general, as with grammar, it is possible to translate such nonverbal principles into words. Examples might be “avoid success to prevent dreaded feelings that go with being criticized.” A more complex rule might be, “The way to calm dreaded emotions of despair about not being loved is to wait and hope to find someone you will be able to change from ungiving to warm and generous by showing them their faults.” The situation changes a bit when the maladaptive pattern is supported by a biological predisposition, as in agoraphobia. The maladaptive rule might simply be, “Avoid the dreaded fear by not going out.” Each of these rules functions to sustain a maladaptive pattern of response.
Question Five: Identify a more satisfactory therapeutic antidote.
The antidote is new, surprising information that reaches the limbic system to disconfirm limbic logic and provide a new way to interpret and respond to the circumstances. Providing this communication turns out to be complex and is a major part of the art of psychotherapy.
Let’s step back a bit. The most salient common feature of all EMPs, is that they ultimately amount to avoidance of specific limbic emotions that the mind identifies as representing a threat. In providing an antidote, we are telling the limbic mind there is a better way to interpret what is going on and/or a better way to respond. The limbic mind is a skeptical consumer, at best, generally preferring to stick to what is old and familiar, even if it has disadvantages. Our communication will need to present a compelling story.
The big news we bring is that acceptance of past circumstances, even though painful, is almost always better than continuing the avoidance. But there are different ways to avoid. Some strategies for avoidance are associated with ongoing discomfort and costs, while for others, the cost and disadvantages may be less apparent. We can divide avoidance strategies into three flavors, depending on how clear it may be to the client that change will be beneficial.
The most common kind of avoidance requires continuous work to keep the dreaded limbic emotion at bay. PTSD sufferers may work tirelessly to keep from being reminded of the dreaded trauma. Those who have experienced deprivation early in life may remain on a continuing quest to find a substitute for the primal love or attention that was missed. Others may work to control neediness or overcome some weakness or shortcoming. When the avoidance requires continuous tension or vigilance, the therapist has an advantage in that the acceptance we propose tempts the limbic self to end a painful and laborious struggle. In this sense, therapy can be seen as finally ending a stress cycle that has been prolonged for years. The client is finally able to resolve the issue and put the past behind them.
However, another group of solutions for avoiding painful limbic emotions involve “structural” changes to the personality. Arrested development in some area of functioning is an example. When this becomes an accepted personal characteristic, it no longer causes ongoing discomfort or instability. It may deprive the individual of significant advantages in life, but those have long since been accepted and no longer cause tension. In this flavor of avoidance, the therapist may have more difficulty clarifying the benefits of facing painful feelings in order to change. Another example of this “structural” type of avoidance is the adoption of a value system that circumvents limbic emotion. A client may, for example, come to value self-sufficiency so as not to experience the pain of being left on their own at some point in development. That, in itself is experienced as a positive attribute and does not involve ongoing stress.
The third flavor of maladaptive avoidance applies to both categories above. The adopted strategy may have troublesome side effects that can be engaged as motivation for change. In the example immediately above, placing a high value on self-sufficiency can rob the individual of the chance for healthy interdependent relationships. It can discourage those who might want to support our client and leave them isolated and lonely. In practice it will be apparent that many strategies for avoidance of negative limbic emotions have additional, costly side effects.
In the end, each person’s challenges and solutions are unique and have different ongoing costs and side effects, possibly even benefits. When we, as therapists, think about more satisfactory alternatives, it is critical to be aware of how they look through the eyes of our client and their limbic self. From the client’s perspectives health may or may not appear so advantageous. There are even times when the “healthy” alternative is simply not attractive enough for the client to be willing to do the work of changing.
Communicating with the limbic self
Even when change is clearly in the client’s best interest, communicating the antidote is part of the art of psychotherapy. That communication needs to be in terms that can be taken in by the limbic system. I’m going to limit the discussion here to a few main points, because it is a major subject in itself.
First, the therapeutic relationship is critical. If the therapist is not trusted or if the suggestion of an alternative triggers resistance, that will have to be dealt with before the antidote and its value can be taken in.
Second, medical care has historically had a bias towards the negative. Helping clients choose to work towards health often requires a focus on the positive. We may need to paint a picture of what they can hope to attain or remind them of their own positive experiences. We do want to be careful not to build unrealistic expectations, but hope is one of the most important and powerful factors in human motivation.
In this communication, the critical information typically travels from the therapist’s limbic system (the source of imagination) to the therapist’s consciousness, then across the gap to the client. Next, it passes from the client’s consciousness to the client’s limbic system. There are enough steps and pitfalls that we need to use all our intuition and skill in shaping these communications. Here are some of the types of information that carry our message of health and hope:
- Cognitive: The classic “interpretation” is an idea, as is the CBT version of “correcting a cognitive distortion.” This intellectual communication is not so well adapted to the needs of limbic processing, but it may still be important in creating a framework for the message.
- Nonverbal: Aspects such as tone of voice, facial expression, body language, etc. can be the main channel of communication of a feeling or emotion, especially one that is reassuring.
- Circumstantial: These can include the office or setting, but also the timing and events outside the therapy that affect how communication is received.
- Relational: Even if the relationship overall is good, a temporary misattunement, especially during a critical communication, might trigger mistrust or a guardedness that could get in the way of information being received.
- Bodily: Phisical action can be the missing ingredient in the client’s communication between their consciousness and their limbic system.
When thinking about how to open our client’s eyes to a new and healthier way to respond to the old cues, we must work with our client to discover the unique, personal combination of inputs that will lead to disconfirmation of the old and eager acceptance and rewriting of the old implicit learning.
With practice, these five questions naturally lead to developing hypotheses that will help focus our work towards change. Of course these hypotheses are only that, subject to refinement and even abandonment in favor of better ones. What’s important is that the five questions form a direct path from a costly maladaptive response to one that may spell the end to a long and painful stress cycle and the beginning of a more satisfying life.
Jeffery Smith MD
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