Jeffery Smith

A Developmental Primer

It is particularly important for therapists to understand a few critical junctures in psychological development. The chapter covers the role of shame in obscuring the mix of adult and childlike thoughts typical of humans, how developmental challenges are successfully and unsuccessfully traversed, and how EDPs often bear the stamp of the period at which they are first formed. Early thinking is mixed with more mature thinking, and therapists do well to learn to perceive the difference. Healing of developmental arrest comes from undertaking, at whatever age, the challenges that were previously avoided. From there, the chapter covers 11 major points of challenge in development that are relevant to psychotherapy, starting from the first years of life and ending with old age.

The Second Helper: Conscience-Based Emotion

This chapter focuses on pride, shame, and guilt, conscience-based emotions that constitute the second of the three helpers that influence us to do what our nonconscious problem solver deems necessary to avoid painful feelings. Conscience-based emotions are always the result of judgments made according to values held in the conscience. These values can be positive and can help maintain behavior that is good for us, but they can also be dysfunctional and result in inappropriate pride, shame, and guilt. Unhealthy values are especially common as a way of coping with abuse and neglect. Therapy must work to bring healthy values to the fore, where they can override unhealthy ones. Healthy attitudes modeled by the therapist, encouragement to identify appropriate feelings, and, most of all, behaving in ways that go against unhealthy values are the keys to positive change.

Layers of Pathology

This chapter dives right into a common clinical situation. As we grapple with the complexity of a real patient, it becomes clear that dividing psychopathology into units will help clarify just what is happening with the patient and what to do. Looking into the nature of these units, we can see where thoughts, behavior, and emotions connect. The example of Jack explores how this way of looking at psychotherapy helps integrate techniques from different traditions and can be applied to the full range of problems addressable through psychotherapy.

Involuntary Symptoms: Grief and Depression

This chapter begins a series on involuntary symptoms, the last group in our catalog of EDPs. Here we look at grief and depression. While grief is normal and healthy, and depression is not, they have much in common. We examine those common aspects, and, then, imagining them removed from the picture of depression, we focus on the essential and unique qualities of that condition. What stands out is that depression can be seen as an EDP in which the nonconscious problem solver is trying to cope with an impossible choice, one in which a vital need comes into conflict with a human connection we must protect. The solution is to turn the resulting anger against the self.

Building and Maintaining the Therapeutic Relationship

The role of the therapist is best defined by what we are not: parents, friends, or exploiters. Beyond that, our role is to maximize empathy to help heal painful feelings and let go of EDPs that block access to those feelings that need to heal. Boundaries establish limits that let us know what would take us out of our proper role. The frame is the set of policies and habits that create a consistent background to support the therapeutic interaction. The ideal relationship is very attentive and not intrusive or critical. Breaks are inevitable, as are emotional reactions on both sides that must be managed. The partnership should be a positive experience, and getting feedback from the patient ensures that it is. Gaps in important characteristics such as religion and sexual orientation, if not matched, require that the therapist’s efforts at understanding be accepted by the patient. Eventually goals are reached or costs outweigh further benefits and therapy comes to an end. This is an opportunity to explore feelings that otherwise are likely to remain hidden.

The First Helper: Emotion

The first of three types of helpers is introduced. One of the main functions of emotion is to influence free will toward the choice to implement actions deemed by the nonconscious problem solver as important for survival. Various emotions are examined, and for each one, how it can come to fulfill various functions. Treatment starts with identifying the specific function of the emotion. If healing by extinction or reconsolidation is available, that is the preferred step. Beyond that, emotions working as EDPs are dealt with in treatment according to their specific action.

A Context of Connection

The context of safety and empathic connection inherent in a well-maintained therapeutic relationship provides the disconfirmation of danger necessary for emotional healing. The process involves a two-way information exchange identical to that between a mother and a toddler who has fallen. In mindfulness meditation, it appears that healing takes place without the presence of a witness, but a closer examination suggests that the mental state achieved by the meditator may actually put the individual in a context of connection with an internalized presence. When the goal is behavior change, a context of connection is a regular and important part of the coaching role of the therapist as the patient traverses the stages of change.

The Affect Avoidance Model

The affect avoidance model, introduced in this chapter, provides an overall framework for understanding how mental pathology treatable in psychotherapy can be explained as natural avoidance of dreaded emotions. Complex problems can be simplified by dividing them into units consisting of entrenched dysfunctional patterns, EDPs, each one designed to avoid a dreaded affect. Starting with an original troublesome emotion, each layer or module covers up feelings from the layer below. Treatment usually starts with the most accessible EDP, either by the emotional route, detoxifying the painful affect, or by the behavioral route, replacing dysfunctional avoidance patterns. For each module, treatment can begin with either route and can make use of techniques chosen pragmatically from a wide variety of contemporary therapies. Success with either approach often opens the way for work from the other route, creating a circular pathway to resolution of problems.

The Third Helper: Thoughts

Spontaneous thoughts comprise the third type of helper used by the nonconscious problem solver to influence our choices so that we implement avoidant behaviors. These thoughts are not obviously different from healthy ones. Studying the thoughts of recently recovering addicts shows that they are crafted with the same intelligence as the rest of patient’s thoughts and produced on the spot for maximum influence. The best ways to recognize them are to ask where the thought leads and to share them with a trusted other who does not have our blind spots. The mind is likely to resist challenge to such thoughts, so that tact and sensitivity are required.

Conducting Generic Talk Therapy

Once the initial assessment has been made, we continue to build a picture of how to conduct a generic, unstructured therapy. After transferring the conversation to the patient, we can focus on the therapist’s number-one job, following the flow of information. This leads to a three-step dance in which we intervene only when some resistance begins to interfere with the flow. When this happens, we change the focus to the inhibiting dysfunctional pattern, an EDP that has been triggered. Its exploration usually leads to resolution and continuation of the flow of information. Beyond this simple alternation between free flow of conversation and exploration of resistance, there are times when the therapist should take the initiative in showing how to articulate feelings and uncover EDPs. Next, the chapter explores cycles within the therapy and concludes with the question of whether there might be ways to do better in discovering issues, seeking emotional healing, and fostering behavior change. The answer, in the context of the affect avoidance model, is to look at specific EDPs, as will be done in Part III.