This is a book I had to write, and that did a lot to shape the way it emerged. My father was a professor at Stanford, but never published. I did not want to be an academic, like him, so I went to medical school to become a therapist. But, perhaps out of a drive to fulfill his dream, against my own resistance, I had to write. Experience with early trauma and with addiction led me to a passionate focus on how people change.
When I first encountered the effects of severe, early life trauma, my residency had left me completely unprepared except for requiring me to buy Freud’s complete works. Trying to deal with trauma, before it was recognized as common, I fell upon Freud and Breuer’s account of Anna O, which described exactly what was happening in sessions with my patient. When she was able to communicate to me her emotional experience (in a context of connection and empathic attunement), in a matter of hours her visceral pain was reduced to a dull ache.
This was no less astounding to me than it must have been to Freud, seeking a more satisfactory way to deal with the hysteria that was rampant in the late 19th century. This was not the catharsis that has been vilified and which almost made Nancy skip my book. It was a powerful and profound change process made clear and visible by the particular circumstances of the therapy.
For my patient as for Anna O., terrible emotional wounds had been split off from consciousness, and therefore from any healing, by profound dissociative barriers. In both treatments, after work to establish a strong therapeutic connection, the barriers suddenly fell away, exposing raw feelings for the first time in a new and entirely different context. These circumstances made possible the observation of healing that was rapid, profound, permanent, and maintained without effort.
I, too, have wrestled with the word catharsis. I raised it in a question and answer session at the Boston Trauma Conference, and heard that it was a word to avoid. Yet, out of respect for Freud’s pioneering and accurate observation, I didn’t want to abandon the term. In the end, I decided to risk disapproval and go ahead. Today, I don’t use it much, for reasons I’m about to explain.
Catharsis and the New Science of Reconsolidation
In 2004, I wrote an article published in the Journal of the American Academy of Psychoanalysis entitled “Reexamining Therapeutic Action Through the Lens of Trauma.” I described catharsis in detail along with another change process, the modification of internalized superego templates. It was only after the publication of How We Heal and Grow that I learned about reconsolidation, the neurophysiological basis of catharsis. I was fascinated to find out that reconsolidation had first been described in the literature in the same year as my original paper, 2004.
This was after the publication of my book, and there was still a certain amount of controversy, but today I am sure that reconsolidation is the neural mechanism of the catharsis I have often witnessed. For anyone not familiar with reconsolidation, when fear memories (and other memories as well) are re-activated by remembering, for a period from about 10 minutes later till about 3 hours later, those memories remain volatile and subject to reconsolidation either to their original form if reconfirmed, or, if the context is different, to being erased. I have a blog post (“Emotional Healing: Erase Your Triggers”) at www.howtherapyworks.com describing this in more detail with references. Thus, the field now has a new name, reconsolidation, to describe the phenomenon of catharsis. It is not as evocative, but the unfortunate connotation is no longer there to cause trouble.
I have come to believe in the importance of the body in therapy but consider myself a beginner at tapping into this area directly. I had long ago realized that EMDR was a way of structuring and facilitating catharsis, and use it from time to time. On the other hand, words remain my native language. I find them amazingly flexible and evocative to help my patient and I get ever closer to the realities of experience, both in body and in mind.
Since writing How We Heal and Grow, I have learned a lot more about somatic psychotherapy. I saw Peter Levine speak and later took a brief class with two of his students. I posted on that, too, “PTSD: A New Way to Look at Healing.” And I read Bessel van der Kolk’s ground breaking, The Body Keeps the Score. I love watching Dr. Levine work and am increasingly incorporating the idea of using action to contradict the mind’s misconceptions.
I hope I can make more progress in absorbing the wisdom of somatic psychotherapy so I can incorporate it more authentically into the next edition and into the textbook on psychotherapy that I am currently writing to be published by Springer.
The “Affect Avoidance Model” of Psychopathology and Psychotherapy
Circling back to the book as a whole, as I struggled to understand how people change and how to communicate that knowledge to students I had, in the back of my mind, the idea that someday I would see the whole picture. One day, I would be able to pull all my experience and knowledge into one simple, non-denominational model of how all psychotherapies work. It started with the idea that therapy should be taught as processes rather than techniques. Gradually the change processes gelled into only a few, though the problems they dealt with were many.
The book began as a handout for my psychotherapy classes. Then, since I don’t like jargon, it made sense to make write for a general readership. It was only as I wrote that that the big picture began to emerge out of the fog of implicit knowledge. Today, I have a name for the model: The “Affect Avoidance Model” of psychopathology and psychotherapy. Stated very briefly, I have come to think that all the pathology we seek to resolve in psychotherapy is the result of attempts to avoid painful, overwhelming or uncomfortable feelings. When we attempt to let go of or change the vestiges of those now-dysfunctional coping strategies, we run into the scary anticipation that we will encounter the very feelings we had sought to avoid. As we face all those feelings in a context of safety and attunement, they heal through reconsolidation and our natural resistance to change gives way to more satisfying patterns of living. The model is described in more detail under the “About” tab on my website.
So, Nancy, thank you so much for your lovely review and for the opportunity to address what may be my primary readership, therapists who are open to learning anything and everything about how to help our patients.
Jeffery Smith MD