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Structural change

The best phrase I have found to describe the goal of our work is that psychotherapy aims to modify "entrenched dysfunctional patterns of reaction." This phrase encompasses the broad range of pathology that is still within the scope of therapy. Something that happens only once would not constitute a pattern of reaction and would not be a reason for seeing a therapist. The patterns that are objects of concern are, of course, dysfunctional ones. Finally, if they do not resist change, then there is no need for seeing a professional, therefore the dysfunctional patterns that patients seek to change in therapy are those that are entrenched.

To say that a pattern is entrenched is the same as saying that it is structural. The two are synonymous, signifying mental configurations that do not change over time unless a specific change process causes their modification.

So far, we have discussed two healing processes, each of which is aimed at a different kind of structural change. Painful feelings can be held for decades with no detectable degradation until catharsis results in their permanent healing. Similarly, internalization pertains to those mental contents that are most resistant to change. Values, attitudes, prohibitions and ideals tend to stay in place throughout life without moving unless a concerted effort is made to bring about change. Examining other change processes in psychotherapy, we can then ask whether or not they bring about structural change.

Ideas, the mercurial mental contents

First there is a semantic problem to clear up. Therapists love the word cognition. Unfortunately, this word applies just as well to internalized values, attitudes, prohibitions, which behave very differently from ideas. Therefore, I will stay with the word, "idea" to signify those mental contents that are involved in conscious thought in general and insight and interpretation in particular.

The way ideas change is mercurial compared to the way internalizations are layered over with new ones. We might hold a childhood notion about how things work. When the evidence shows the contrary, our thinking changes instantly without resistance. Ideas, themselves, are not structural. When we run into resistance, it is not because the idea could not change instantly, but that there is an emotional investment in keeping a cherished idea intact. What is structural is the emotional investment. Psychotherapy aimed at changing the idea would have to aim at modifying the emotional investment. Thus, changing ideas is not an end point in therapy, but a step along the way, and sometimes a consequence of structural change.

An interesting example from practice dramatizes the fluidity and volatility of ideas. A patient who had been terribly traumatized by her psychotic mother had held the belief that she was, herself, responsible for her mother's illness. One day, her father, who had abandoned the family when the patient was eight, returned to find her in adulthood. In the course of conversation, he told the patient that her mother had been hospitalized before the patient was born. Instantly, the patient flew into an uncontrollable rage.

At that time, in therapy, we had been working on buried anger. My focus had been on clearing resistance to awareness of rage. In this moment, a new piece of information slipped by the patient's defenses, and suddenly changed her idea. Instantly, she knew that her self-blame was contradicted by the facts. The cognition switched and an avalanche of emotion poured out.

Change in an idea served to unblock the patient's affect, and was a necessary step, but could not be regarded as directly producing structural change. In subsequent sessions the release of emotion led to cathartic healing of the anger, which was permanent. In the chain of events, the final step was detoxification of rage through catharsis. That was the structural change.

To say it more simply, modification of ideas can be a destabilizer of defenses. A primary role of interpretation is the modification of ideas, often, as in this case, to destabilize defenses. Insight is the acquisition of new ideas. Like the interpretations that foster it, insight can be seen primarily as an agent for destabilizing defenses.

Behaviour patterns, the viscous mental contents

What about behaviour change? After all, behaviour patterns have lasting power, and both patients and therapists often focus on behaviour change as an immediate goal. Is behaviour change structural? Should this be considered another fundamental change process?

During residency, I lived in an apartment with an elevator and wool carpeting between the elevator and my door. Each winter, when I touched the metal door handle, I would receive an electric shock. With no special effort, I developed the habit of touching the door first with the back of my hand to discharge the shock. Each year in the humid, New York summer, I would forget my behaviour pattern, and, without realizing that I had changed, would reach for the knob with my open hand.

I could have made a conscious effort to change my behaviour, but this one changed without thought or effort. I concluded that behaviour patterns could have a kind of "fluidity." They are more resistant to change than ideas, but can flow from one configuration to another. Perhaps the appropriate word for this kind of movement would be "viscous." Viscosity indicates fluidity but with resistance to rapid change. Where catharsis and internalization are permanent and structural, behaviour patterns can be described as viscous, moving spontaneously in response to external and internal forces. Change of behaviour patterns would not qualify as a final pathway in structural change. However, like insight, behaviour change serves to destabilize defenses and set the stage for new internalizations and catharsis.

The role of behaviour change in therapy

As patients who had suffered trauma were teaching me about catharsis and integration, my career had taken me into the field of addiction. I quickly learned how behaviour change could be a destabilizer of emotions. I learned that abstinence, a radically new behaviour pattern, was the starting point for recovery from addiction. Even though patients and sometimes therapists wish that psychological change could lead to abstinence, it usually does not work. Abstinence, on the other hand, could be seen as a behaviour change that turns the psyche upside down. If the patient could come through a full year without relapse, then a tremendous amount of internal adjustment and development would usually take place. The power of self-help or therapeutic groups was in the way that exposed feelings could be shared and healed by catharsis. In addition, they provided a fellowship built around healthy values and attitudes that were internalized over time.

The impact of abstinence was more dramatic, but not different from the role of behaviour change in other psychotherapies. My psychoanalytically oriented training had initially taught me to be reluctant to recommend specific behaviours, but, emboldened by my experience with addiction, I found that behaviour change was a powerful tool for destabilizing entrenched defenses. Moreover, used with appropriate checks and balances, it did not have the negative effects on transference that I had been taught to anticipate.

In my practice of psychotherapy, suggesting behaviour change has since become as natural as making interpretations. Both served to destabilize entrenched systems so as to allow the power of catharsis and internalization to bring about fundamental and lasting changes.

Emotional activation, the common factor in all structural change

Since the "talking cure" was invented, there has been agreement in all camps that effective psychotherapy requires that emotions be aroused. This was obviously true for catharsis, and my exploration of internalization suggested the same requirement there as well. For catharsis, emotional activation means that you have gained access to the place where healing needs to take place. In the case of internalization, the emotions activated were the need for connection and the fear of losing it. Anxieties around connection or belonging constitute the triggers for internalization in general. The stance of "slight aloofness" or expectancy that fosters internalization, does so by implying possible loss of connection. Internalization in the midst of trauma, and cult conversions provided the most dramatic instances of how "attachment anxiety" is key in the process of internalization.


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