Q&A The Nature of Change

Dialogue #2 The Nature of Change

Dr. Leanne Domash: The book came out of the question – why is it so difficult to change. How do we begin to understand this? Doing this work we often encounter how difficult it is for patients and for ourselves to modify how we deal with dysregulated affect or avoid repeating behaviors that don’t work.

Dr. Efrat Ginot: A better understanding of the neuropsychology of unconscious processes clearly shows the roots of entrenched emotional, cognitive and behavioral patterns. Such encoded patterns occur from the very beginning and engage all facets of our functioning. They are the product of an ongoing interaction between the individual and the environment. From the very beginning the brain/mind learns how to adapt, how to make meaning of affects, interactions and events, and how to maintain the sense of wellbeing through defenses. For example, with reinforcement, such learning – especially within the intersubjective field – will become a pattern of relating. Once a pattern is established, it tends to guide our perceptions and reactions, especially in situations similar to the original one

I am not talking here about stimulus-response learning in a simplistic sense. The encoded patterns are complex, nuanced and spread out. Emotional memories, interpersonal experiences, our unconscious interpretations of events, unconscious associative learning, and many “conclusions” as to our self-worth coalesce into unconscious maps. In essence, an unconscious map reflects every child’s attempts to give meaning to what is happening inside and out. A punitive parent’s behavior, for example, will still be justified. The child has no capacity yet to see the parent with the needed clarity and with a reality-bound perspective. A part of the child, as Braten said, is always immersed in the parents’ self-states, identifying with them and imitating them. As a result, negative feelings such as shame and humiliation experienced by the child, will be perceived by him as emanating from him and not the result of the parent’s verbal shaming. We often see this in patients who in states of dysregulation revert to very negative emotions and narratives about their self-worth.

Dr. L.D. But why are they so entrenched?

The general answer lies with evolutionary pressures for adaptation and the ways that these demands shaped the way our brain/mind works. Prior to full consciousness, as some neuroscientist believe, it was important for early humans to rely on quick responses, on memories that guided them without much effort or thought. It was important to act quickly. As a result, the brain developed the propensity toward the automatic enactment of established learned patterns. As we know, the prefrontal cortex is relatively new, while the subcortical regions establish and enact all learned patterns automatically and out of awareness. In addition, all learned patterns are embedded in early emotions emanating from subcortical regions. Emotional memories make a stronger impact and strong emotions strengthen encoded maps.

Dr. L.D.: In the book you put the unconscious on a flexibility/rigidity continuum. Is this a characteristic of unconscious processes that explains our obstacles to sustained change? Is it more difficult for some people than for others? 

We need to remember here that we cannot talk about the unconscious without its relationship to consciousness. A person that displays seemingly rigid patterns of behaviors, for example, repeating the same interpersonal mistakes, is most likely guided by a rigid unconscious system which interprets reality only according to what it knows. A rigid system does not learn from reality and does not take different or new elements into account; influenced by subcortical regions that in turn affect the prefrontal cortex and its capacity for flexible judgment, it mainly relies on familiar systems. Deconstructing such a way of seeing the world, understanding it and being mindful of it is certainly one of the more important therapeutic goals.

L.D. Yes, it seems to me that this applies to one of the goals of therapy– helping people become more adaptive to changing circumstances. How is this achieved in therapy?

E.G. If we identify and define change as the ability to modify the ways we automatically organize the world, the way we can regulate affect and challenge distorted narratives about ourselves, therapy is among the few human endeavors that can achieve it.

Almost every form of therapy sees change as its goal. Psychoanalysis has focused on interpretations and insight that we now know may not enough. Although most therapeutic approaches offer rich internal and interpersonal experiences, a more advanced understanding of the brain/mind indicates that undergirding the patient’s ability to attain and sustain emotional and behavioral change is the ability to engage in of reflective awareness – what used to be called the observing ego. Based on what we know, however, this observation is not just a momentary insight; such a process is not sufficient to induce change in very stable neural circuits.

What seems to enhance the process of change is active reflection on affect and behavior in real time. The more a patient becomes aware of her emotional, cognitive and interpersonal patterns, the more her psychic flexibility and behavioral grow. Such active engagement with one’s reflective awareness needs to occur both within sessions and in life outside of them. Encouraging the patient to reflect in real time in moment of dyregulation, giving her homework, addresses one of the fundamental obstacles to change. Namely, without continual practice it’s hard to shift established patterns. To strengthen the flexible arm, we have to pause before the automaticity takes over. This is a taxing and difficult process because it involves the necessity to experience one’s feelings and negative cognitions about the self while at the same time not acting on them in the usual way.

LD: Can you give me an example of a patient’s newfound ability to pause, experience and reflect?

EG: This ability to stop and reflect is the beginning of a complex process of change. As we saw, one of the hallmarks of brain processes is the tendency to perceive, think, feel and act according to established patterns. For example, Ms. A often feels slighted in in large groups. Somehow, she leaves such a gathering feeling certain that the hostess or other friends were not very warm to her. She often feels rejected by others. Without ever questioning the certitude of her feelings and thought, A, Is convinced that unless her friends pay full attention they are being dismissive of her. She is often disappointed with them saying to herself that she would never be so unfeeling; she would make sure everybody feels very welcome.

Of course A. is reacting to real stimuli in the environment, the hostess is busy attending to many things and people, and others may not be as attentive as A. would have liked. But without reality-bound perspectives, A.’s interpersonal entanglements and internal torment are determined by an internal map and the perceptions, emotions and they cognitive conclusions it automatically triggers. Without a greater awareness of the relational origin for such perceptual tendencies A. most likely will continue to feel convinced of the rightness of her emotional reactions interpretations of events. We can see in this case, how “homework” might help A. reflect on her emotional state when in an actual party.

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