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Lucid psychotherapy contd ...
Recently, the blossoming field of neurophysiology has provided a possible explanation of the reason behind the need for emotional activation in structural change. It is very possible that emotional activation is a necessary key to the physiological means by which information content can be modified within the brain. The current consensus is that the most likely physical medium of long term memory is the neural network. Neural networks are groups of neurons within an anatomically connected matrix that tend to fire together. They do so because the synapses that connect them have functionally heightened sensitivity. Ideas, words, images, memories, atmosphere are all types of data thought to be stored in similar neural networks. The establishment or modification of information content is thought to rest on changes in the functional strength of specific synapses.
As explained by Joseph Le Doux, (1996), in 1949, Donald Hebb articulated the principle now known as "Hebbian plasticity," describing how the functional strength of neuronal connections can be enhanced by experience. "Neurons that fire together wire together." Specifically, if a "downstream" neuron happens, independently, to fire at the same moment that an "upstream" one is firing, then the synaptic connection between the two will be enhanced. The next time the upstream neuron fires, it will have gained in its ability to cause the downstream neuron to fire. The phenomenon is known as LTP, long term potentiation. Recent work has not only confirmed the principle, but elucidated the precise biochemistry. Even more recently, there is clinical evidence that this mechanism is relevant to psychotherapy. For example, enhancement of this very mechanism by the administration of d-cycloserine has been shown to improve the effectiveness of exposure therapy for social anxiety disorder (Hofmann, 2006).
The tantalizing hypothesis, then, is that the reason emotional activation is required for therapeutic change, whether it be catharsis or internalization, is that the relevant neurons must be actively firing for synaptic strengthening to take place.
In catharsis the change process would presumably be as follows: The neural network associated with a painful situation starts out with strong associations (meaning synaptic connections) to a neural network that signifies helplessness and danger. During cathartic healing, the neurons representing the pain are activated, but so is a neural network associated with the feeling of safety and comfort evoked by the empathic presence of the therapist. At that moment, a new association is established between the network representing the trauma and the network representing the safety of the therapeutic situation. Suddenly, pain and aloneness are welded together with safety and connection. The new sense of safety overrides the panic reaction that used to be triggered by the memory. This explanation has been articulated by a number of writers, notably Le Doux (1996).
Now, let us look at internalization. The patient is, in some degree, experiencing "attachment anxiety," or fear of losing the needed connection with the therapist. Simultaneously, there is an activation of networks representing the positive values and attitudes of the therapist. Through some form of information transfer, the values and attitudes of the therapist are now written indelibly into the superego where they become active as the current templates of self-esteem and desired behaviour.
Psychotherapy integration: building a toolbox
Having made behaviour change a regular part of my therapeutic armamentarium, I ventured further into cognitive-behavioural territory. There was more bounty to be harvested. Where psychodynamic therapy has relatively weak tools for changing defective internalizations such as the damaged self-esteem of my trauma patients, cognitive therapy is specialized for just this change process. As new tools became part of my daily repertoire, they became integrated into a whole that worked together.
No doubt following the path of many therapists, I had evolved a form of psychotherapy integration. My approach to psychotherapy now incorporated psychodynamic, behavioural and cognitive elements. Through experience, I had learned to manage these "incompatible" elements so as to prevent them from interacting negatively. An invitation to teach a course on "Combining Behavioural and Psychodynamic Techniques" pushed my interest in further developing the conceptual framework that can be found on the website: http//www.psytx.com.
How does this translate to day-to-day therapeutic work?
A male in his early sixties returned to therapy at the urging of his wife. He was angry and combative at home and at work, and had been unable to follow his physician's recommendations of exercise and weight loss following a heart attack. He had been in psychoanalytic therapy for 25 years until his doctor had died shortly after the patient's heart attack. During those years, he had been helped to marry and had prospered in his career. On the other hand, he would periodically have sessions where he went silent. His analyst would patiently wait till he spoke, and then wonder what emotional reaction had led to the silence. The patient would have no idea, and would eventually go on talking about something different. The patient improved overall, but this pattern never changed.
Early in his new round of treatment, I suggested that we focus on two behavioural areas, weight loss and exercise. This was shocking to the patient, as his previous therapist would never have made such a direct suggestion. He accepted the idea, but found that his eating became worse than ever, as did his lack of exercise.
We actively explored this reaction and gradually came to understand that being told what to do felt like being directed by his narcissistic mother. Intellectually, he knew that the goals were appropriate and reasonable but, emotionally, he reacted as if my suggestions reflected my agenda and not his. If he complied, he feared losing the essence of himself. If he objected, he feared rejection or abandonment. Given two unacceptable choices, he went silent. Over a period of a few months this transference paradigm became increasingly familiar. Without telling me, he had begun to exercise regularly. As the precise nature of his fears began to emerge, 1819we discussed the real life pros and cons of following my suggestions. This did not decrease the intensity of the fears, but made him more willing to consider going further with the suggested behaviour changes. As each incremental level of feeling came to the surface, cathartic healing allowed his fears of loss of self to be detoxified.
What happened in his treatment was not very different from any psychodynamically informed therapy. I believe that my willingness to make behavioural suggestions and actively explore the patient's thoughts speeded the process and opened up areas where the analysis had been stalled. At times, we used intellectual exploration, at times free association, and whenever feelings were available, catharsis.
Simultaneously, there was work going on in the area of internalization. Where the patient had built a value system to justify his fierce independence and contrarian ways, there was gradual change. He made progress in internalizing the value of receiving from others, such that he is less ashamed of feeling a need for the therapy and therapist and of his emotional needs within the marriage.
Lucid psychotherapy: Progress so far
It is time to stop for now, though the journey is by no means ended. In conclusion, I would like to summarize five clinical lessons that concretize what I have learned.
1. In the end, there are two kinds of structural change, catharsis and internalization. They work differently, have a different time course, and derive from different stages of development.
2. Catharsis is enhanced by close, empathic connection. Internalization is fostered by a stance of slightly aloof "expectancy." The immediate circumstances of the therapy dictate which aspect to emphasize. Patients instinctively understand that your shifting stance is necessary.
3. Interpretation and insight are not "structural" but lead to change in ideas, which is very helpful in destabilizing defenses and activating emotions.
4. Behavioural prescriptions are not directly structural, but do focus treatment, destabilize defenses and activate emotions. They are not inherently disruptive to the transference or the therapeutic relationship.
5. Healing and change happen in the moment. The bulk of our work is in preparing for these moments and destabilizing the structures that tend to prevent them from happening. Being conscious of moments of change has a subtle but very positive effect on therapy, making the process clearer, more focused and more effective.
About the author
Jeffery Smith is a native Californian, and graduate of Stanford University. He went to Medical School at UCLA and interned in Syracuse, New York in Internal Medicine. He completed psychiatric residency at Albert Einstein College of Medicine, Bronx, NY. In 1976, he began private practice in Scarsdale, NY. Smith was Chief Physician in the in outpatient clinic of Bronx Lebanon Hospital till 1980. It was there, in the outpatient clinic in 1977, that he became interested in the area of dissociation and what is now called dissociative identity disorder. He co-founded a professional study group on dissociation in the 1990s. In 1980, he went to Westchester Medical Centre and joined the faculty at New York Medical College. There, he was appointed director of Alcoholism Services, and in 1989 left to establish Cortland Medical, the first Evening Intensive Outpatient Programme for alcoholism in Westchester. In 1997, he co-founded AddictionResourceGuide.com, a website offering information on addiction treatment facilities.
He has continued as a volunteer teacher at New York Medical college and has taught courses on Psychotherapy Technique and Combined Psychodynamic and Behavioural Treatment in the residency. He has written and lectured on psychotherapy, dissociative identity disorder and addiction. His primary area of interest continues to be the process of change in psychotherapy. He recently established www.PsyTx.com, offering course material for psychotherapy teaching.