This post is about the concepts of “bottom up,” “top down,” and how they relate to the art of communicating with the inner self, where problem patterns are formed and hopefully exchanged for healthier ones. I’ll start by putting these things in some perspective, then look at two clinical examples and some lessons we can take from them.
Three change mechanisms
In these posts, I have talked about three foundational change mechanisms of psychotherapy: extinction, memory reconsolidation, and new learning. When we talk about new learning, that is, learning new patterns through repetition, the mechanism is long term potentiation in which “neurons that fire together wire together.” That’s the kind of learning that Pavlov described and the focus of classical learning theory. It is also what is generally referred to as “top down.” That’s because we start with conscious awareness and push the information down into the automatic parts of the mind. However, “top down” has a fairly bad reputation in the world of psychotherapy because it often fails to reach the limbic system where emotion rules, and the entrenched maladaptive patterns we most want to change are set in motion. Trying to use this approach for therapy is more of a brute force operation and often fails.
Extinction is a change mechanism in which the cortex learns that old patterns of response, such as fear, are no longer needed, then sends inhibitory signals to the limbic areas, suppressing the inappropriate response. What it doesn’t do is turn off the danger signal (typically activation in the amygdala, which I’ll call “limbic emotion”). Because the call for a response remains active, the old, unhealthy pattern eventually returns. Thus, the benefit of extinction is temporary. Since it originates in the cortex, we can call this change mechanism "top-down," but it is noteworthy that it operates on the limbic system, so technically it is partially bottom-up.
That leaves memory reconsolidation as the quintessential “bottom up” change mechanism, operating when relevant limbic neural networks are active, but disconfirmed by new information. This change process only works when the new information finds its way to the limbic areas where problem patterns get started. The juxtaposition of neural activation and disconfirming information, (further helped by sleep), leads to rapid, essentially “one and done” change to the implicit logic that formerly determined the need for a protective response. The change is permanent, with no need for further reinforcement, though clinical experience says it may be only partial, and that associated habitual behavior patterns still may need to be changed.
In the same week I encountered two examples that shed light on the complexities of these informational events in actual practice. They are best understood as a conversation with the inner self, the automatic, emotion-based, survival-oriented, information processing function residing primarily in the limbic domain.
In one, a client who had been heavily abused and rejected throughout his childhood remains “braced” against further aggression, accompanied by constant muscle tension resulting in severe chronic pain. A combination of talk and body work had helped to coax tender and young emotions to the surface at times, but mostly in relation to others’ pain, not his own. The bracing and muscle tension had not budged with a year of concentrated work. What we realized was that his inner self (also known as the unconscious or the id) had quietly compromised with the therapeutic team, giving us the emotion we wanted, but only in a few islands of safety. Overall, he refused to let go of his tense and self-protective stance. Yes, he had shared affect, but no, the treatment was no closer to the goal of pain relief.
The adult client and I realized that the inner self would have to “buy in” to the need for vulnerability in spite of his vivid anticipation of painful attacks. Being frozen in time, the inner mind did not differentiate between past and present danger. For all practical purposes they were the same. The young inner self was far from ready to risk any such peril.
In previous posts, I have talked about the art of psychotherapy. A big part of that art is understanding and using multiple channels to converse with the inner self. What model might we follow? Is like getting a wild animal to eat out of one’s hand? Is it how a parent communicates with a small and frightened child? The core issue seems to be safety and trust. Why would a child put his or her life in the hands of a relative stranger? Steadiness, authenticity, and consistency are qualities that convey safety, but our inner client is not so easily convinced. In the therapeutic relationship, with the stakes being life and death, even a hint of inauthenticity will block readiness for risk. Any fissure in the therapeutic relationship will need to be repaired before progress can be made. The situation reminds me of Hiroo Onoda, the Japanese Soldier who held out until 1974, believing Japan was still engaged in WWII. He only let go when his commanding officer came in person and ordered him to stand down.
So my client’s inner self will need to be convinced that it is safer and better to drop his vigilance and risk being overpowered and hurt yet again. In my experience, the process is more like seduction than convincing. As the limbic system evaluates subtle signs of danger and safety, it is anticipation of relief from loneliness and tension that leads to letting go. The interaction looks more like surrender than calculation. It’s more like “OK, what the hell” than “I guess it’s safe.” Top-down convincing doesn’t have much impact in the limbic system, but instinctive needs do. For the deer in the forrest, it is hunger and desire for food that eventually overcomes vigilance. Think of the elements that lead a reluctant child to succumb to sleep. In Internal Family Systems therapy, the therapist might ask the hold-out firefighter how it would feel to take a break from defending the inner family. While trust is needed, it seems that the pull of comfort, relief, and a sense of connection are the elements that lead to surrender.
Safety and seduction are positive elements, but we also need to be fully respectful of the client’s deepest emotional dread. Onoda’s dread was the shame of disobeying an order. For my client it was the intolerable dread of being humiliated and abused one more time.
A second case
This time, the dread was loss of connection, in other words, attachment trauma. It came from the experience of a narcissistic mother who was supremely capable of withdrawing warmth and signs of attachment. She would withdraw emotionally at the slightest hint of strength on the part of her daughter. As a result, the child learned in a deeply entrenched pattern, to “fawn,” that is, to act submissive in the face of anything in the other person that looked like power. It cost her dearly in her life and career, but her inner mind held onto that safety measure with a tenacity that reflected the life-and-death experience of losing mother’s attachment, starting from when she was barely old enough to talk.
She had been through many therapists over the years. Each had noticed her submissiveness, and recognized it as a problem. Some had advocated a top-down approach. “Just don’t do the behavior.” The more subtle technique of suggesting an avatar as a model for healthy behavior also failed to work. From the inner self’s point of view, the therapists were using their power to demand that she go unprotected in the face of deadly danger. Furthermore, their willingness to use power on her was a confirmation that they could not be trusted. As if to prove that the inner self was right, her failure to change eventually led the therapists to lose patience and “go cold” on her, exactly what her mother had done years before.
Talking to the inner self
The lesson is that personifying the inner self may not seem “scientific,” but it is far more accurate than any jargon-ridden theory. What we need to do is follow a model based on interaction between parents and children. We know that, at the extremes, parents who are excessively overpowering fail, as do those who do not exercise their authority. Somewhere in the middle, parents need to win battles when it is necessary, but understand and be willing to concede when they can. The resulting implicit learning for the limbic child is that the world is a safe, reasonable place and the issue is how to thrive, rather than how to survive. That gives us a benchmark, a starting point in our conversation with the inner self.
But reasonableness and safety aren’t enough. There has to be something to go to. What that is may vary with the specifics but when the fears are most profound, authentic human connection may be the only thing strong enough to lead the inner self to face the most dreaded limbic emotion. Just as we now know young children can’t survive emotionally cold orphanages without damage, clients with attachment trauma can’t get well in a sterile, detached therapy. They need us, not only to behave in predictable and trustworthy ways, but also to allow ourselves to become attached. Only then, can the inner self develop the kind of trust needed to allow the pull of a safe connection to lead it out of it's cave.
Jeffery Smith MD
PS: A reader asked two questions:
1. How does one show genuine attachment? Answer: You don't. It happens by itself and shows itself. That's what authenticity does beyond our control.
2. How do I protect my own emotional wellbeing? That is harder. It starts with clear boundaries, but powerful emotions reside here. This is what personal therapy is for. Perhaps the most important thing I could say is that self honesty and willingness to admit errors are the keys to knowing if one has issues. They are also the keys to repair or limitation of damage if the therapist's issues do intrude.
Photo Credit: Nuno Alberto, Unsplash