The key to undoing psychotherapy’s divisiveness and silos is understanding the healing moment at the core of every therapy. You could call it a “moment of meeting” or an “ah-hah” moment, or a successful exposure session. What our field doesn’t know yet is how they are all the same. I’ve talked before about the three essential elements of the healing moment:
- First, activation of the deep limbic emotions that signal danger and are the triggers for those maladaptive responses that, directly or indirectly, bring clients to therapy.
- Second, the “antidote,” new and surprising information that contradicts the original response and which can be cognitive or experiential.
- And third, the presence of affect, that is, conscious feeling accompanied by bodily changes like tears, change in breathing, etc.
Today’s post is an attempt to dig deeper into the last element, and especially awareness of the affect being felt. Yes, awareness helps shape conscious motivation, but what about awareness being needed for change in entrenched response patterns? For a long time, I have wondered why conscious awareness seems so important. Like all of us, I work constantly to gain understanding, myself, and to help clients become aware of their emotional responses and what they mean.
I’m not alone. Richard Lane, Les Greenberg, and colleagues, in the lead article of the June issue of SEPI’s Journal of Psychotherapy Integration, summarize the research and give support for the importance of emotional awareness: “These findings indicate that trait emotional awareness of the client may be a powerful variable that influences psychotherapy outcome. To date, however, the reasons for this association have not been established.”
They are correct that the reasons have not been established, but as clinicians, it helps to be able to picture how and why emotional awareness might be instrumental in bringing about therapeutic change. Let's try to build a working model.
What if a client was expressing grief about a lost relationship. We know we need to give her time to stay with the feeling, and we know that our empathy, in itself, furnishes the antidote. In this case it's a larger perspective on the loss, in contrast with her immediate internal experience. But instinctively we know that, as the feeling begins to lose intensity and the client’s thoughts begin to go elsewhere, we need to elicit the precise meaning of the loss. “You cherished that relationship…” We are looking for words to allow us into the personal meaning of the loss. What we are hoping to achieve is accurate empathy. Empathy is a natural human response, but for it to be fully effective we need a precise understanding of the context surrounding the emotion.
Generating an effective antidote
If we skipped the deeper inquiry and satisfied ourselves with knowing only that she is sad, her tears would soon dry up and the client would go on talking, but my instinct says that no healing would have taken place. The mind’s many defenses soon come to bear, nudging her feeling back out of painful immediacy. “Yes it was sad, but life must go on,” she might say.
Without us “really understanding,” the client will not experience the empathic connection. The therapist’s response will be a nice pat on the back, but not touch the point of pain. Thus, accurate empathy in the therapist is necessary for the healing moment to take place. In other words, the therapist is usually the source the antidote. And the antidote must be authentic to do its work of providing a larger perspective by which the original response can be modified.
Getting the antidote from therapist to client
For the antidote to get where it is needed, it must still travel from the therapist’s mind to the client’s. That is an automatic mammalian communication, based as much on facial expression and body language as it is on words. It is the “moment of meeting” championed by the Boston Change Process Study Group. At that moment, both participants know they understand each other. The antidote has traveled intact from therapist to client.
Transporting the antidote to where it is needed
Where does the antidote do its work? That work is memory reconsolidation and it operates primarily deep in the limbic areas of the brain. That’s where the “all clear” signal meets the old alarm signal and resets the system, such that the same inputs no longer trigger a full-on alarm. In the case of the lost relationship, the antidote is the affective expression of therapist’s point of view that losses happen and are part of life.
Just as transmission upward from limbic emotional areas to consciousness is variable and uncertain, so is transmission downward from consciousness to the midbrain where the limbic system resides. It is only too easy for half of the information to be lost when the content is stripped of emotion and becomes intellectual. Then we know the antidote will not penetrate to where change takes place. Only when the emotion is palpable “in the room,” can we have some confidence that the new perspective will have reached its destination. Under those conditions, synapses can be permanently reconfigured and the dire response softened to the point where loss is taken as a painful event in the course of life, eventually to be healed.
This makes sense, but raises the question of two-way communication along nerve pathways. On a micro level, nerve communication is one-way, but we also know that the brain’s channels of communication are based on networks of neurons, not individuals. They are naturally two-way. For example the function of appraisal of circumstances is “non-linear,” that is, it involves a great deal of two-way communication to check what is expected against what is sensed and vice versa until the best fit emerges.
About the Journal of Psychotherapy Integration article
Dr. Lane’s excellent article shows in detail and with examples how, based on foundational processes, Cognitive Therapy, Psychodynamic Therapy, and Emotion Focused Therapy lead to the same result, the one described here. Importantly, it also points out Les Greenberg’s distinction between primary emotions and those emotions that serve defensive purposes. Primary emotions are those basic and authentic responses described here and subject to the therapeutic healing, while defensive emotions serve protective functions such as covering up even more threatening emotions, discouraging behaviors (shame), and manipulating others.
Where are we now?
Dr. Lane, himself (personal communication), agrees that this is plausible as a working hypothesis. Having an explanation gives us confidence in our insistence on emotional awareness, as well as an understanding of the critical importance of healing moments in which conscious affect meets accurate empathy. And, finally, it clarifies the importance of both accurate understanding and affect in the two-way empathic communication at the center of the healing moment.
Jeffery Smith MD
Lane, R. D., Subic-Wrana, C., Greenberg, L., & Yovel, I. (2022). The role of enhanced emotional awareness in promoting change across psychotherapy modalities. Journal of Psychotherapy Integration, 32(2), 131.
Photo credit, Asley Batz, Unsplash
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