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Catharsis and internalization are also the final pathways for resolution of transference feelings and wishes. On the way to uncovering transference material, there may be affects of fear and shame, subject to cathartic detoxification. Internalized values may stand in the way of revealing affective content. These superego contents may need to be modified in order for the patient to tolerate awareness of prohibited thoughts. The uncovering eventually leads to more primary feelings and wishes that must be relinquished or modified. This latter operation is essentially a mourning process, and again utilizes the mechanism of catharsis to heal feelings of loss.

As my intellectual journey progressed I began to incorporate the new concepts in my teaching of psychotherapy to psychiatric residents. This brought me back to the therapeutic relationship and the still-nagging question of how important was the emotional connection to the patient. Intuitively I was sure that the empathic connection was a critical ingredient in catharsis, but I still did not have a satisfying explanation of why. In addition, the need for connection seemed to underly the mechanism of internalization. How were the two related? Was there one framework that would contain both?

Child Development

The logical place to look was early child development. The action of therapy must ultimately be rooted in early experience. Catharsis had to be built on a developmental foundation, as did internalization. Alan Schore (1994), writing on the development of affect regulation provided an epiphany. Schore does not say it explicitly, but there it was. Schore had brought together clinical observation and neuroscience in a way that showed why catharsis and internalization are different. Each has its origins at a different stage of development and plays a fundamentally different role in affect regulation.

The nine-month origin of catharsis:

First, the origin of catharsis was relatively obvious. At nine months, Daniel Stern (1985) documents the evidence for the emergence of "affect attunement." At this age, the child can first exchange looks with mother and make use of their shared emotional state for affective regulation. When the one-year-old toddler falls, he or she makes eye contact with the mother before "deciding" whether or not to cry. The mother's reaction helps regulate the child's affect.

It is a small step to think that we use this same mechanism throughout life. When we get bad news, we want to share it with someone we trust and feel close to. We do not do this for the advice we may receive. More fundamentally, we share because having an empathically attuned witness allows a basic affect regulating transformation to take place. This is the essence of catharsis. Just like the toddler, when we make an empathic connection in the context of an emotional experience, the painful feelings are detoxified.

Understanding catharsis in adults is somewhat more complex. As children develop, they no longer require the constant presence of a reassuring other person. This is presumably because there is gradual internalization of a sense of connectedness. It is through understanding the workings of this "context of connection" that we can now answer the question posed earlier: Does catharsis really require the presence of a witness?

"Context of Connection:" Why trauma treatment requires a witness

In life, it often happens that painful feelings are detoxified without any witness or sharing. Why, then, should the presence of an empathic other be necessary in the cathartic healing of trauma? The answer is that, under good conditions, we all carry an empathic other inside. Object constancy, which allows children to cope with physical separation, is thought to be made possible by internalization of the presence of the mother. On the other hand, many observers have pointed out that this internal presence is subject to disruption under stress. Throughout life, the internalized mother functions something like a rechargeable battery. When pain is minor, or while waiting to share with someone we trust, we are able to cope because we carry an inner sense of connection, of not being alone. Periodically, most of us still need to interact with those to whom we feel close in order to recharge our inner resource. I have used the phrase "context of connection" to describe the combination of inner and outer connections. When functioning adequately, this feeling of connection is in our contextual (or background) awareness and buffers our feeling reactions to events in the outside world. We can picture the context of connection thus:

Context of connection: Reassuring presence is both internal and external

Painful events that cause damage are "traumatic." These are almost always associated with a state of psychological aloneness for two reasons. First, trauma usually happens when we are alone since painful events, when experienced with someone we trust, are much less likely to be damaging. Second, whether the individual is physically alone or not, as indicated above, overwhelming terror or helplessness tends to disrupt the internal sense of connectedness. Putting the two factors together, emotional trauma is almost always associated with disruption of the context of connection.

In treatment, as the patient begins to relive the trauma, the sense of aloneness is almost inevitably part of the experience. Unless there is an empathic witness to re-establish a human connection, then exposure is re-traumatizing and catharsis does not take place. For this reason, whether explicitly stated or not, almost all treatments for trauma including exposure therapy, EMDR (Eye Movement Desensitization and Reprecessing, Shapiro, 1995) and psychodynamic therapy all include the presence of a therapist who listens, understands, and, is empathically attuned.

Behaviour regulation and internalization: The eighteen-month origin of shame

Now, internalization. Schore (1994) writes that, at about 18 months, the prefrontal cortex is mature enough to support the emotion of shame. Shore also reviews the evidence that, at that time, children begin to be able to internalize ideals. These new mental contents are stored in the right pre-frontal cortex. According to Schore, this "right hemispheric orbitofrontal affect regulator... is identical to the ego ideal, described in the psychoanalytic literature as a component of the superego." Shame is the feeling we get when we violate internalized prohibitions, values and ideals. Let us consider the relevance of these findings to the development of affect regulation in toddlers.

The one-year-old has little self-control. He lacks the ability to hold onto the parents' wish that the pots and pans should stay in the cupboards while mother is preparing dinner. Memory of consequences may be present, but is not very strong, and is of little help when mother is not physically present. It is only towards the end of the second year that the child first begins to be able to experience shame when he or she fails to conform. This painful emotion becomes a deterrent to bad behaviour. In order to anticipate mother's reactions, the child must carry internalized templates of acceptable behaviour. These are the precursors of the attitudes and values that make up the superego. Children will repeat to themselves, "No, no, not take pots out." as they struggle to internalize mother's value system. Now, for the first time, the child's self-control can begin to be independent of the parent's physical presence. Shame is not only experienced when mother scolds, but also when the toddler fails to meet his own internalized standards. Now, for the first time, the child has the capacity to prevent a painful scolding by carrying mother's values inside.

This new development in affect regulation is of tremendous importance. Prior to acquiring the ability to regulate behaviour, the child would "misbehave" and then have no option but to deal with the pain that resulted. The empathic connection with mother was the only way to soften the anguish, and at the dinner hour, mom might not be very empathic. Now, the child possesses a way to prevent pain by controlling his or her behaviour in the first place.

Putting catharsis and internalization together

Catharsis and internalization work together to regulate affect but operate at distinctly different points. Internalized values and prohibitions allow for control of behaviour, while catharsis utilizes empathic connection to process painful feelings when self control has failed.

Besides their role in affect regulation, they are also linked by their relationship to attachment bonds or "context of connection." To put them into one same framework, we can say that catharsis makes use of the context of connection while internalization helps to maintain it. Catharsis utilizes an empathic connection to heal painful affects. Internalization allows us to feel safely connected to our significant others by taking in their attitudes and values.

My work with trauma patients had highlighted the two change processes, and had helped to make it clear how different they were. Tracing their origins strengthened my conviction that they should be viewed as distinct. The crystal was cleaving smoothly and strengthened the impression that my understanding of the underlying structure was correct.

The next test would be to attempt to integrate the notion of catharsis and internalization as the fundamental processes of therapy with more traditional concepts of insight, interpretation and behaviour modification. In order to do this, we must revisit concepts of what psychotherapy tries to accomplish.

Continued on next page ...

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