Affective Neuroscience in Psychotherapy, Francis Stevens (2021)
Affective Neuroscience
Two Pathways
The affective primacy hypothesis holds that we can have an emotion without cognitive processing, while the cognitive processing hypothesis holds that we cannot have an emotion without cognitive processing. Stevens that “neither cognition nor affect is the brain’s primary response.” Rather, the brain has two systems for evaluating stimuli.
Steven supports the two-pathway theory, which posits that a region of the thalamus (the pulvinar) has a pathway to the amygdala that allows for “rapid processing… before conscious awareness” and also a pathway to the cortex that allows for cognitive processing. “Neuroimaging studies demonstrate that when stimuli are presented in a rapid fashion where individuals have no conscious perception of what they are seeing, limbic areas like the insula and amygdala are activated.” “In an evolutionary context, having two systems for brain processing makes sense; one can quickly detect threatening stimuli, and the other can make more adaptive long-term judgments.”
Triune Brain Theory
This theory holds that the brain can be divided into three sections that illustrate the evolution from reptiles (brainstem and cerebellum) to mammals (limbic system) to humans (neocortex).
Neocortex. The neocortex has four major lobes: (a) the prefrontal cortex (PFC) “is involved in complex thinking and judgment,” (b) the parietal lobe [like pariah-tal] “is involved in sensory and motor processing” and “gives us a sense of where our body is in space,” (c) the occipital lobe [like oxygon] processes visual information, and (d) the temporal lobe is involved in language and memory.
Limbic System. The limbic system is subcortical (beneath the cortex) and contains (a) the amygdala, (b) hippocampus, and (c) basal ganglia [basil, gang-lia]. Some say that the (d) insula and (e) anterior cingulate cortex [sing] (ACC) are part of the limbic system while others say they’re their own system. Dogs have a limbic system, and they can remember people and places and can express emotions. However, because they do not have a developed neocortex, the brain region “involved in making judgments, executive functioning, and critical thinking. If we leave the house, our dogs don’t know if we are going away for a week’s vacation or just out to get the mail. They react with the same disappointment, as they are unable to regulate emotion by comprehending the experience with neocortical thinking. Our dogs are capable of learning through reinforcement and punishment.” (3) The neocortical brain can “outsmart itself when it comes to responding to the more primitive emotional brain. Over-reliance on cognitive in the face of emotional problems may be one example.”
Brainstem and Cerebellum. The cerebellum and brainstem. The brainstem contains (a) the midbrain, (b) pons, (c) medulla oblongata. The brainstem and cerebellum are “responsible for a lot of autonomic motor functioning,” e.g., walking, riding a bicycle. “Initially learning to walk or ride a bicycle is very hard and uses multiple brain regions, but once we learn the complex motor movements, the cerebellum is largely responsible for carrying out these behaviors without much conscious thought.” These regions control other autonomic nervous functions that we have little control over, e.g., breathing, natural reflexes.
Brain Networks
Many neuroscientists are increasingly thinking in terms of brain networks. “Brain networks contain several brain areas that typically operate in tandem for a certain purpose, as opposed to a single brain area completing a task”...
Emotional Awareness and Mindfulness
Mindfulness does two important things. First, it “helps us to recognize and connect with our body and feelings.” The first step to solving a problem is to understand the problem, and in this way, mindfulness helps with this. Often patients ignore their problems and only reach out to a therapist when their feelings “reach a crescendo that they can no longer ignore.” Second, mindfulness “helps us see feelings as part of us but not all of us, an important emotion regulation skill.”
Dehaene et al. argue that things can become conscious in one of two ways. Bottom-up awareness occurs when a stimulus is especially strong. Some patients need the stimulus to be incredibly strong to gain their awareness, e.g., a panic attack or suicidal feelings. Top-down awareness occurs when the individual chooses to direct his attention on something.
There are two components to awareness of our inner experience, interoceptive awareness and feelings awareness. “Interoceptive Introspective awareness is the awareness of internal body states,” e.g., heart rate, body temperature, feelings of hunger. “Feelings awareness involves your ability to understand and think about emotion. For example, our interoceptive awareness would notice when we are tired, while our feeling awareness would recognize that we are grumpy likely because we are tired.”
It’s possible to “have interoceptive awareness without feeling awareness, but it’s hard to have feeling awareness without interoceptive awareness.” The lack of feeling awareness is called alexithymia. Interoceptive awareness and alexithymia are predictive of panic disorder.
Sometimes Stevens has patients with stress set a timer to go off every two hours. When the timer goes off, they are to then ask themselves, “How do I feel?” or “What is my stress level?” “This is all developing mindfulness, and after a few weeks, the patient no longer needs the timer.”
Mindfulness helps us to gain awareness of our problems but doesn’t solve our problems. “I like to point out to patients that the original emotion that is causing distress is still there. The patient is now more aware of their feelings with mindfulness and can separate themselves from their feelings with mindfulness; however, typically the emotion is still left unchanged.”
If a patient is resistant to mindfulness, Stevens will have him journal about his feelings. “I am careful to describe that the journaling should not be about the content of their day, but their experience of their day: what stood out to them and how did it make them feel? I tell them to try not to think too much, because too much subjective judgment stops the free flow of feelings.” “Another idea is to have them set an alarm to go off every few hours to go on their phones and write down their feelings.”
If a patient is really struggling to access his emotions, Stevens will facilitate somatic experiencing. Here he references the resources on Peter Levine’s website. “The goal is through increasing self-awareness of your body, you will eventually increase emotional awareness.” Second, he will use guided meditation, “often bringing the patient back to a time when they did feel an emotion.”
Emotional Validation
After recognizing our emotions, we need to validate them. “Validation is telling ourselves that our feelings are real and true. Many patients will often say, ‘I shouldn’t be feeling this way.’ There is no right or wrong way to feel. Invalidating your feelings creates confusion because it’s a movement away from the self.” Stevens often tells his patients, “We cannot control our feelings, only how we react to our feelings.”
Repressing or suppressing our feelings “take both an emotional and cognitive toll. Franchow and Suchy (2015) show that individuals who suppress their emotions show deficits in executive functioning, working memory, and processing speed.” Geraerts et. al (2006) showed that in the long-term repression does not reduce emotional pathology. Hu et al. (2014) found that “the suppression of emotions is negatively correlated with indicators of mental health.” Beblo et al. (2012) found that “individuals with mental illness are often afraid of their feelings and suppress emotions because they become too overwhelmed by them.”
Feeling Crazy. We often invalidate a feeling because it “doesn’t seem relevant to the current situation.” We might label such a feeling “crazy.” It’s important to remember that emotions “can be stored like memory.” “If you’ve ever asked yourself, ‘Why am I so upset about this?’ the emotion is probably not related to the current context, but the context has evoked an old emotional experience.”
“Our anger could be triggered by subliminal stimuli; and not wanting to be angry about nothing, we find some small thing in our environment to which we can attribute our anger. However, attributing our anger to this small thing is crazy, because it doesn’t relate to our anger… Because we often cannot understand why we feel the way we do, we wrongly label the emotion as the problem, when instead the real problem is the lack of understanding.”
Attribution Error. We “consistently provide a rationale for our feelings even though the rationale we provide is often wrong.” Forgas (1998) showed that we tend to attribute the behavior of other people to their personalities and the behavior of ourselves to the situation. “Our mistakes are outside of our control, while others’ mistakes are a deficit of character.” “For example, if we are late to work, we attribute our lateness to traffic or challenges getting out of the house, whereas if our co-worker is late, we’ll assume that they’re not that conscious of time, which is a dimension of their personality.”
Caregiver Attunement. According to Erikson, if a child’s basic needs are not met, that child will not develop trust. Emotional attunement is “the reflective practice of recognizing another’s emotions and reflecting that emotion back.” Emotional attunement begins with babies and their caregivers looking at each other. “When we tell a friend we had a bad day, we don’t want to get a smile or puzzled look back; we want to see that friend frowning, demonstrating that they recognize and validate our emotional experience.” An example of emotional attunement is Ed Tronick’s still face experiment.
Dimberg, Thunberg, and Elmehed (2000) found that “when presented subliminally with faces, we unconsciously mimic those facial expressions, suggesting that in some ways we may be innately programmed to validate each other’s feelings.” Mimicking other people’s expressions allows us to understand how they feel. “Interference with mimicry through biting a pen or chewing gum impairs our ability to recognize emotions.” “This ability to recognize the emotions of caregivers quickly and effectively may be evolutionarily adaptive for survival.”
When parents invalidate their children’s experience — e.g., “It’s not that bad” or “You’ve got nothing to complain about” — the child’s experience is invalidated. When children are invalidated over time, they “lose touch with their experience, which makes them lose touch with themselves. This then causes the child to rely on external mechanisms of value. If a child is not able to validate their own experience, this prevents them from valuing their feelings. Then in absence of self-knowledge, the child starts to construct their sense of self, based upon what the world around them values and not on what they value. They end up living a life motivated by what they think will bring them value, but not necessarily what they value, and in the process of doing this, they continue to invalidate themselves. Emotional maltreatment trains the child to live for someone else’s needs and not their own.”
Responding to Emotions. Imagine a child falls on the playground and is “mildly hurt.” The child then looks at his mom. The mom can respond in different ways. (1) The mom can get anxious and overreact, causing the child to overreact. (2) The mom sees “no major physical trauma” and “waves it off and tells the child to go back to playing.” (3) The mom goes over to the child and asks, “Are you okay?” She “attunes to the child’s experience, provides emotional or physical reassurance, and then encourages the child to keep playing.” Each response shapes “the child’s approach to their emotions.” (1) The child “will learn that any emotional discomfort is distressing. Through vicarious learning, they may learn to start to panic in response to their own feelings; therefore, emotional struggles of any kind will be difficult.” (2) The child “will learn to disregard their feelings; they won’t become emotionally distressed by upsetting feelings, but they may start to invalidate or avoid their own emotions.” (3) This “helps the child to recognize and validate their feelings.” The mom “acknowledges the child’s feelings, the expresses the feelings back with their own facial expression, an act of emotional validation, and then helps the child to regulate the feeling by expressing a warm smile or offering a hug, and finally, the caregiver encourages the child to keep playing and not let the emotional scare inhibit their fun.”
Braunstein, Gross, and Ochsner write about implicit emotional regulation in which “emotions are regulated in the absence of direct cognitive intervention. When children have their emotions validated and regulated from infancy, they learn to self-regulate and validate their emotions without conscious thought. The best way to build implicit emotional regulation among children is “role modeling strong emotional skills in yourself.”
“Emotional validation like mindfulness still does not fix the upsetting emotion, but it helps to stop the bleeding, so to speak. If patients can learn to validate their own emotions, they start to feel more grounded and stop getting frustrated with themselves for the way they feel.” In therapy, validating feelings can also occur through mimicry, which is an implicit form of implicit emotional regulation. “Just like the child that fell off the swing, you feel upset with them and for them, while slowly expressing through your emotions that it will be okay.”
Self-Compassion
After a patient can validate his emotions, you should help them practice self-compassion. Neff and Germer (2017) define self-compassion as “being touched by and open to one’s own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one’s suffering and to heal oneself with kindness. Self-compassion also involves offering nonjudgmental understanding to one’s pain, inadequacies, and failures, so that one’s experience is seen as part of the larger human experience.” There are three components of self-compassion: (1) mindfulness, (2) common humanity, which “helps us to normalize our feelings and not to assume that we are the first and only individual to struggle with these emotions,” (3) self-kindness, “which takes a non-judgmental stance toward the self.”
Primary and Secondary Emotions. “Secondary emotions are symptomatic emotions that result from the avoidance of a primary emotion. Individuals can also have tertiary emotions, resulting from the secondary emotions.” Example: Someone is sad (primary emotion), and he then feels ashamed that he’s sad (secondary emotion); whenever something happens that could evoke my shame, I get anxious (tertiary emotion). “Enacting self-compassion for one’s anxiety may help them to recognize their shame, further self-compassion for shame could help them accept their sadness, and self-compassion for their sadness may result in self-acceptance and amelioration of their sadness. Once this sadness is accepted, the shame and anxiety that resulted from avoiding the sadness disappear.”
When we see someone else in distress, we can either experience empathic concern or personal distress. “Empathic concern has been referred to as compassion, while personal distress results in feeling alarmed, worried, disturbed, and so on.”
Recently, people like Paul Bloom have challenged the value of empathy. There are two types of empathy: cognitive empathy, “which is the ability to understand another’s experience through perspective-taking,” and affective empathy, “which is feeling someone’s emotion.” Affective empathy is different than emotional contagion; with the former “you recognize the emotion is coming from outside yourself, whereas with emotional contagion you don’t know the source of the emotion.” Affective empathy does not always lead to more pro-social behavior, as we can become overwhelmed and develop compassion fatigue. Some studies show that the key is having the optimal level of affective empathy: “too little and there is no motivation to help; too much and the individual is overwhelmed by feelings rendering them unable to direct resources to others in need.” Practicing self-compassion can help us to avoid burnout.
Understanding Emotion
“Once we have recognized, validated, and provided self-compasison for our feelings, the next step is to try to understand them.
Knowing that we have two brain systems — the limbic system’s feeling brain and the prefrontal cortex’s thinking brain — helps us to understand how we can desire two contradictory things. “Accepting this conflict may be difficult because the brain does not like contradictory states (see cognitive dissonance theory, Festinger 1957). Yet if we can accept this conflict, it allows us to recognize more thoughts and feelings, and in doing so a decision can be made.”
Emotional Arousal. Carrier and Greenberg (2010) found that “a moderate level of arousal is best for therapeutic outcomes.” Yerkes and Dodson (1908) found that “performance is maximized when physiological or mental arousal is at a moderate level. Too high and the participant is bored and not engaged in the task, too high and the participant is too overwhelmed to perform at their best. This is why we like to play sports against someone around our own level.” In therapy, too little emotion “could mean the patient is not engaged or avoiding something. Too much emotion and the patient is too overwhelmed, unable to apply new coping mechanisms or take time to learn from their feelings. A strong therapist should be up-regulating and down-regulating a patient’s emotion to maintain a moderate level of arousal.”
Emotional Regulation (Ways to Down-Regulate Emotions)
Physiological Interventions
“Deep breathing encourages slower breaths and helps restore oxygen to the body, which is quickly being used by the active sympathetic nervous system… Regular practice of being aware of one’s breathing and regulating breathing to a consistent rate will prevent future instances of an exaggerated sympathetic nervous response when the patient feels excess emotion.”
“Muscle relaxation exercises where the patient learns to recognize and control the tightness or looseness of their muscles can be helpful. Stress is often associated with muscle tension and learning how to relax muscles helps regulate the sympathetic nervous system. To help a patient learn mastery over the tension in their muscles I often have patients tense and relax different muscles within the body.”
“If the flight or fight response, the body is on high alert, any method that can be employed to mitigate the response can be helpful. For example, lying down is a physical position not associated with the flight or fight response; having a patient lie on a couch can send a counter signal to the brain that they are safe. Playing relaxing music might be another example.”
Cognitive Interventions
“While I don’t believe thoughts can cause a primary or original emotion, thoughts can contribute to the reinforcement of secondary emotions.” For example, if you’re anxious “because you are worried about losing a job and you think of all the bad things that will happen as a result, you will have more negative feelings, reinforcing the anxiety. Perhaps some things might be worthy of consideration, but for the most part excessive thinking is called rumination and it’s not good. Replaying bad events in your head only makes you feel worse; accepting the experience, validating it, and providing compassion for yourself is a much better use of your brain, instead of trying to go back and undo the past.”
Cognitive reappraisal can be helpful for “not overly personalizing events.” Stevens will “quickly examine the situation with the patient, make a judgment, and let it go.” It is generally helpful to help suicidal patients down-regulate their emotions. “Once I’ve validated their feelings, I find it extremely important to engage cognitions, to help patients remember that emotions are ephemeral, that these feelings will not last.”
Working with Specific Emotions
Anger
“Anger is a feeling we get when something is not as we expect it to be, and we typically want to act on it.” “Sometimes our anger is just a normal response. When someone hurts us, it’s natural to feel anger. This often signals to us that we need a stronger boundary. Telling someone it is not okay to call you hurtful names would be an example of setting a boundary.” We need to communicate our boundaries, and when they “get repeatedly crossed, it is also important to set a consequence for when the boundary is not respected.” It’s important not to misattribute where anger is coming from — e.g., a present situation or something that happened in the past.
Forgiveness
“To let go of anger, the person who did the harm must be forgiven.” We can be reluctant to forgive because “holding on to one’s anger can act as a useful form of self-protection.”
Abandonment and Loneliness
“Abandonment occurs when we’ve been neglected in some way. We feel left out by others.” When we feel abandoned, the best thing for us is to get someone’s support. However, many who have experienced abandonment have learned to shut others out. “Loneliness is often a feeling we experience when we are afraid to express vulnerability around others.” Some believe that the feeling of loneliness “is a built-in evolutionary mechanism to improve the survival of the organism; if left alone, they are more vulnerable to environmental hazards.” Overcoming loneliness may require one to “face fears of vulnerability and abandonment around others.”
Sadness
“Feeling sad is often the result of loss, such as a close relationship, and sadness is a normal healthy response. The purpose of sadness: “I tell my patients that acknowledging sadness prevents suffering. Sometimes individuals encourage each other to get over or move past their sadness, but this is not always healthy because it can lead to avoiding grief or even worse, shame about the feeling of sadness.” “By not accepting sadness (primary emotion) we are pushing away a feeling that wants to arise. This tension between wanting to feel sad and pushing down the feeling results in depression. In Buddhism, this is referred to as suffering. We cannot avoid sadness as individuals, but we can avoid suffering by accepting our feelings.
Stevens replaces “grief” for “depression” in the Kubler-Ross model of loss and grief. “Grief, although commonly associated with the loss of something that one had before, can also be related to the loss of a future that never occurred. Some individuals may feel grief about never having gotten married, having children, or any expectation that never came to fruition.”
Fear and Anxiety
“Fear associations or memories have been shown to be the strongest and most stable of conditioned associations, which from a survival standpoint have obvious benefits.” “Patients will often report to me that they are still afraid of the airplane crashing despite contrary knowledge. However, I often find this to be an attribution error. Often what patients are really afraid of is their own emotional reaction. In this sense, they are afraid of being afraid.”
Desire and Compulsion
Why do we sometimes desire things that are harmful for us? The answer is that “wanting (desire) and liking are separate brain systems. The wanting system does not accurately predict the current value, utility, or enjoyment for a given behavior.” The wanting system involves the MCL/dopamine circuit, and dopamine “influences our brain to make choices that have been rewarding in the past, even if they are no longer currently rewarding.” Anselme and Robinson (2016) “suggest that the subcortical MCL operates below conscious awareness, which helps explain why it can be so difficult to control our desires.”
OCD — obsessive thoughts “influence the MCL, which then rewards obsessive behaviors with a dopamine response. Individuals with OCD typically recognize the irrationality of their behavior but feel compelled to act. In doing so, they receive dopamine, which in turn lowers anxiety, and the individual feels a temporary relief.” The goal in OCD treatment is to manage “the desire to engage in the compulsive behavior. Once the patient can manage the desire without engaging in the compulsion, the dopamine reinforcement loop ceases. The desire to engage in compulsive behavior is similar to the desire to take an unnecessary drug.”
“When working with patients that engage in unhealthy behaviors like smoking or eating excessive junk food, I try to help patients recognize the wanting or craving desire that occurs in relation to these substances.” Stopping the behavior immediately “can be overwhelming and often will set the patient up for failure. Each additional failure makes the patient feel more hopeless about quitting. I explain to these patients the goal is more about managing the desire or craving than changing the behavior; the stronger we can get at managing the desire, the more likely we are not to engage in the unhealthy behavior.” He tells patients that when they get the desire, they should initially wait one minute until they indulge. “After a week or two, we double the time to two minutes, then five minutes, and so on.” “During each period, the patient is learning how to regulate their desire.”
“Another common pathology related to dopamine is engaging in unhealthy or abusive relationships.” “The wanting of the past love or whatever previous value existed from the relationship prevents them from terminating the relationship.” Relinquishing “desires or wants can also involve an additional component of grief.”
Disgust
“Disgust has roots in avoidance of toxins like spoiled food or feces, but it has come to be associated with lapses in morality. References of disgust are often made toward aspects of sex. Even off-color jokes about race, religion, or sexuality are often said to be disgusting.” Zhong and Liljenquist (2006) found that “when subjects were asked to recall unethical behaviors from their past, they then went on to purchase more cleaning products, indicating people associate moral transgressions with dirtiness.” “Disgust is also related to shame.” Ginger-Sorolla and Espinosa (2011) found that “when participants are shown angry faces, they feel more guilt, and when they are shown more disgusting faces, they feel more shame.”
Gratitude
“Having gratitude can help balance negative perspectives and help patients find meaning in their negative feelings. For example, when a patient feels sad about a loss, I will sometimes point out that their investment in an object or relationship had value. As much as the loss hurts, it’s important to honor the meaning and value of what was lost.” If someone feels anxious about an upcoming performance, Stevens points out that this means that the individual wants to perform well and that he can feel gratitude for this.
Self-Conscious Emotions, including Shame
Self-conscious emotions are not innate. “These emotions involve a cognitive appraisal of self: pride being a positive view of self; shame being a negative view of self.” These emotions can help us regulate our social behavior; e.g., “feelings of embarrassment or guilt may help to regulate future behavior, especially for adhesion to social norms.” In guilt, “people judge their behavior; in shame, people judge themselves as bad.”
“Guilt motivates one toward behavior change, whereas shame results in a denial of self and reduced action for behavior change.”
Notions of Self
Attachment Styles. Avoidant individuals are less aware of their feelings, while anxious individuals are more aware of their feelings but have more difficulty controlling their feelings.
Personality Disorders. Personality disorders can be conceptualized as “an adaptive response to the environment, which is no longer adaptive.”
Affect Reconsolidation
“Memory reconsolidation is the process of updating and changing memories when they are recollected.” Stevens often refers to this as “affection reconsolidation” because “in the practice of psychotherapy, it’s not the nature of the memory that is changing but the emotions surrounding the memory.” Memory reconsolidation is different than extinction, as “memory reconsolidation rewrites the original memory, whereas in extinction a new memory is formed, and no change to the original memory occurs.” Whereas with extinction the original memory can be spontaneously recovered, this does not happy with memory reconsolidation since “the original memory is changed or reconsolidated.”
Step #1: We must reactivate the client’s old memory. Step #2: We must “provide a new healthy experience within which to recode the old memory. Without this, the old memory can just be reinforced.”
The key to memory reconsolidation is to have just the right level of prediction error. When we remember an event, “the hippocampus interacts with neocortical areas, creating a spiderweb of linkages associated with that memory, and we have a prediction or predictions of what will happen based on that memory. These predictions represent what is likely to happen given past experiences. Sometimes the predicted outcome of the choice doesn’t match the actual outcome, and this is called prediction error.”
Example #1: I used to see my friend Dave and called him Chad. “The memory of Dave’s face was associated with the name Chad, and I kept predicting that Chad was this face’s name.” When I did this, “I received an uncomfortable puzzled look from Dave. This mismatch between the expected response (smile) from Dave and the actual response (puzzled look) resulted in a prediction error. After a few prediction errors, I learned to reconsolidate or re-associate the memory of Dave’s face with the name Dave, and the problem stopped.” Too little prediction error, and there is no memory change: “Dave politely smiles when I call him Chad, and I continue to associate Dave’s face with the name Chad.” Too little prediction error, and an entirely new memory is formed.
Example #2: I visit my old high school, which activates old memories. I go to where the math room used to be and see that it’s now an art room; prediction error or mismatch occurs. If there’s just the right level of prediction error, “the old/original memory becomes updated. The math room is now the art room stored in my memory. My memory changes to this room being where I took art classes, not math classes, when I was in high school.”
Example #3: A client felt unloved by his parents. When that old memory is activated, he must also experience “a felt sense of love.” But the prediction error cannot be too great. Stevens tries to find this balance by explaining that “the lack of love they feel is a lack of self-love. Maybe their parents didn’t love them, which is bad, but worse is now that patient doesn’t love themselves. I match the feelings of the patient not loving themselves when their parents didn’t love them (old memory) with the patient currently loving themselves. This seems to create the optimum prediction error for therapeutic change.” Sometimes if the therapist tries to do this by loving the patient himself, the mismatch is too great, and the patient might think, “You’re only doing this because it’s your job.”
Two Pathways
The affective primacy hypothesis holds that we can have an emotion without cognitive processing, while the cognitive processing hypothesis holds that we cannot have an emotion without cognitive processing. Stevens that “neither cognition nor affect is the brain’s primary response.” Rather, the brain has two systems for evaluating stimuli.
Steven supports the two-pathway theory, which posits that a region of the thalamus (the pulvinar) has a pathway to the amygdala that allows for “rapid processing… before conscious awareness” and also a pathway to the cortex that allows for cognitive processing. “Neuroimaging studies demonstrate that when stimuli are presented in a rapid fashion where individuals have no conscious perception of what they are seeing, limbic areas like the insula and amygdala are activated.” “In an evolutionary context, having two systems for brain processing makes sense; one can quickly detect threatening stimuli, and the other can make more adaptive long-term judgments.”
Triune Brain Theory
This theory holds that the brain can be divided into three sections that illustrate the evolution from reptiles (brainstem and cerebellum) to mammals (limbic system) to humans (neocortex).
Neocortex. The neocortex has four major lobes: (a) the prefrontal cortex (PFC) “is involved in complex thinking and judgment,” (b) the parietal lobe [like pariah-tal] “is involved in sensory and motor processing” and “gives us a sense of where our body is in space,” (c) the occipital lobe [like oxygon] processes visual information, and (d) the temporal lobe is involved in language and memory.
Limbic System. The limbic system is subcortical (beneath the cortex) and contains (a) the amygdala, (b) hippocampus, and (c) basal ganglia [basil, gang-lia]. Some say that the (d) insula and (e) anterior cingulate cortex [sing] (ACC) are part of the limbic system while others say they’re their own system. Dogs have a limbic system, and they can remember people and places and can express emotions. However, because they do not have a developed neocortex, the brain region “involved in making judgments, executive functioning, and critical thinking. If we leave the house, our dogs don’t know if we are going away for a week’s vacation or just out to get the mail. They react with the same disappointment, as they are unable to regulate emotion by comprehending the experience with neocortical thinking. Our dogs are capable of learning through reinforcement and punishment.” (3) The neocortical brain can “outsmart itself when it comes to responding to the more primitive emotional brain. Over-reliance on cognitive in the face of emotional problems may be one example.”
Brainstem and Cerebellum. The cerebellum and brainstem. The brainstem contains (a) the midbrain, (b) pons, (c) medulla oblongata. The brainstem and cerebellum are “responsible for a lot of autonomic motor functioning,” e.g., walking, riding a bicycle. “Initially learning to walk or ride a bicycle is very hard and uses multiple brain regions, but once we learn the complex motor movements, the cerebellum is largely responsible for carrying out these behaviors without much conscious thought.” These regions control other autonomic nervous functions that we have little control over, e.g., breathing, natural reflexes.
Brain Networks
Many neuroscientists are increasingly thinking in terms of brain networks. “Brain networks contain several brain areas that typically operate in tandem for a certain purpose, as opposed to a single brain area completing a task”...
Emotional Awareness and Mindfulness
Mindfulness does two important things. First, it “helps us to recognize and connect with our body and feelings.” The first step to solving a problem is to understand the problem, and in this way, mindfulness helps with this. Often patients ignore their problems and only reach out to a therapist when their feelings “reach a crescendo that they can no longer ignore.” Second, mindfulness “helps us see feelings as part of us but not all of us, an important emotion regulation skill.”
Dehaene et al. argue that things can become conscious in one of two ways. Bottom-up awareness occurs when a stimulus is especially strong. Some patients need the stimulus to be incredibly strong to gain their awareness, e.g., a panic attack or suicidal feelings. Top-down awareness occurs when the individual chooses to direct his attention on something.
There are two components to awareness of our inner experience, interoceptive awareness and feelings awareness. “Interoceptive Introspective awareness is the awareness of internal body states,” e.g., heart rate, body temperature, feelings of hunger. “Feelings awareness involves your ability to understand and think about emotion. For example, our interoceptive awareness would notice when we are tired, while our feeling awareness would recognize that we are grumpy likely because we are tired.”
It’s possible to “have interoceptive awareness without feeling awareness, but it’s hard to have feeling awareness without interoceptive awareness.” The lack of feeling awareness is called alexithymia. Interoceptive awareness and alexithymia are predictive of panic disorder.
Sometimes Stevens has patients with stress set a timer to go off every two hours. When the timer goes off, they are to then ask themselves, “How do I feel?” or “What is my stress level?” “This is all developing mindfulness, and after a few weeks, the patient no longer needs the timer.”
Mindfulness helps us to gain awareness of our problems but doesn’t solve our problems. “I like to point out to patients that the original emotion that is causing distress is still there. The patient is now more aware of their feelings with mindfulness and can separate themselves from their feelings with mindfulness; however, typically the emotion is still left unchanged.”
If a patient is resistant to mindfulness, Stevens will have him journal about his feelings. “I am careful to describe that the journaling should not be about the content of their day, but their experience of their day: what stood out to them and how did it make them feel? I tell them to try not to think too much, because too much subjective judgment stops the free flow of feelings.” “Another idea is to have them set an alarm to go off every few hours to go on their phones and write down their feelings.”
If a patient is really struggling to access his emotions, Stevens will facilitate somatic experiencing. Here he references the resources on Peter Levine’s website. “The goal is through increasing self-awareness of your body, you will eventually increase emotional awareness.” Second, he will use guided meditation, “often bringing the patient back to a time when they did feel an emotion.”
Emotional Validation
After recognizing our emotions, we need to validate them. “Validation is telling ourselves that our feelings are real and true. Many patients will often say, ‘I shouldn’t be feeling this way.’ There is no right or wrong way to feel. Invalidating your feelings creates confusion because it’s a movement away from the self.” Stevens often tells his patients, “We cannot control our feelings, only how we react to our feelings.”
Repressing or suppressing our feelings “take both an emotional and cognitive toll. Franchow and Suchy (2015) show that individuals who suppress their emotions show deficits in executive functioning, working memory, and processing speed.” Geraerts et. al (2006) showed that in the long-term repression does not reduce emotional pathology. Hu et al. (2014) found that “the suppression of emotions is negatively correlated with indicators of mental health.” Beblo et al. (2012) found that “individuals with mental illness are often afraid of their feelings and suppress emotions because they become too overwhelmed by them.”
Feeling Crazy. We often invalidate a feeling because it “doesn’t seem relevant to the current situation.” We might label such a feeling “crazy.” It’s important to remember that emotions “can be stored like memory.” “If you’ve ever asked yourself, ‘Why am I so upset about this?’ the emotion is probably not related to the current context, but the context has evoked an old emotional experience.”
“Our anger could be triggered by subliminal stimuli; and not wanting to be angry about nothing, we find some small thing in our environment to which we can attribute our anger. However, attributing our anger to this small thing is crazy, because it doesn’t relate to our anger… Because we often cannot understand why we feel the way we do, we wrongly label the emotion as the problem, when instead the real problem is the lack of understanding.”
Attribution Error. We “consistently provide a rationale for our feelings even though the rationale we provide is often wrong.” Forgas (1998) showed that we tend to attribute the behavior of other people to their personalities and the behavior of ourselves to the situation. “Our mistakes are outside of our control, while others’ mistakes are a deficit of character.” “For example, if we are late to work, we attribute our lateness to traffic or challenges getting out of the house, whereas if our co-worker is late, we’ll assume that they’re not that conscious of time, which is a dimension of their personality.”
Caregiver Attunement. According to Erikson, if a child’s basic needs are not met, that child will not develop trust. Emotional attunement is “the reflective practice of recognizing another’s emotions and reflecting that emotion back.” Emotional attunement begins with babies and their caregivers looking at each other. “When we tell a friend we had a bad day, we don’t want to get a smile or puzzled look back; we want to see that friend frowning, demonstrating that they recognize and validate our emotional experience.” An example of emotional attunement is Ed Tronick’s still face experiment.
Dimberg, Thunberg, and Elmehed (2000) found that “when presented subliminally with faces, we unconsciously mimic those facial expressions, suggesting that in some ways we may be innately programmed to validate each other’s feelings.” Mimicking other people’s expressions allows us to understand how they feel. “Interference with mimicry through biting a pen or chewing gum impairs our ability to recognize emotions.” “This ability to recognize the emotions of caregivers quickly and effectively may be evolutionarily adaptive for survival.”
When parents invalidate their children’s experience — e.g., “It’s not that bad” or “You’ve got nothing to complain about” — the child’s experience is invalidated. When children are invalidated over time, they “lose touch with their experience, which makes them lose touch with themselves. This then causes the child to rely on external mechanisms of value. If a child is not able to validate their own experience, this prevents them from valuing their feelings. Then in absence of self-knowledge, the child starts to construct their sense of self, based upon what the world around them values and not on what they value. They end up living a life motivated by what they think will bring them value, but not necessarily what they value, and in the process of doing this, they continue to invalidate themselves. Emotional maltreatment trains the child to live for someone else’s needs and not their own.”
Responding to Emotions. Imagine a child falls on the playground and is “mildly hurt.” The child then looks at his mom. The mom can respond in different ways. (1) The mom can get anxious and overreact, causing the child to overreact. (2) The mom sees “no major physical trauma” and “waves it off and tells the child to go back to playing.” (3) The mom goes over to the child and asks, “Are you okay?” She “attunes to the child’s experience, provides emotional or physical reassurance, and then encourages the child to keep playing.” Each response shapes “the child’s approach to their emotions.” (1) The child “will learn that any emotional discomfort is distressing. Through vicarious learning, they may learn to start to panic in response to their own feelings; therefore, emotional struggles of any kind will be difficult.” (2) The child “will learn to disregard their feelings; they won’t become emotionally distressed by upsetting feelings, but they may start to invalidate or avoid their own emotions.” (3) This “helps the child to recognize and validate their feelings.” The mom “acknowledges the child’s feelings, the expresses the feelings back with their own facial expression, an act of emotional validation, and then helps the child to regulate the feeling by expressing a warm smile or offering a hug, and finally, the caregiver encourages the child to keep playing and not let the emotional scare inhibit their fun.”
Braunstein, Gross, and Ochsner write about implicit emotional regulation in which “emotions are regulated in the absence of direct cognitive intervention. When children have their emotions validated and regulated from infancy, they learn to self-regulate and validate their emotions without conscious thought. The best way to build implicit emotional regulation among children is “role modeling strong emotional skills in yourself.”
“Emotional validation like mindfulness still does not fix the upsetting emotion, but it helps to stop the bleeding, so to speak. If patients can learn to validate their own emotions, they start to feel more grounded and stop getting frustrated with themselves for the way they feel.” In therapy, validating feelings can also occur through mimicry, which is an implicit form of implicit emotional regulation. “Just like the child that fell off the swing, you feel upset with them and for them, while slowly expressing through your emotions that it will be okay.”
Self-Compassion
After a patient can validate his emotions, you should help them practice self-compassion. Neff and Germer (2017) define self-compassion as “being touched by and open to one’s own suffering, not avoiding or disconnecting from it, generating the desire to alleviate one’s suffering and to heal oneself with kindness. Self-compassion also involves offering nonjudgmental understanding to one’s pain, inadequacies, and failures, so that one’s experience is seen as part of the larger human experience.” There are three components of self-compassion: (1) mindfulness, (2) common humanity, which “helps us to normalize our feelings and not to assume that we are the first and only individual to struggle with these emotions,” (3) self-kindness, “which takes a non-judgmental stance toward the self.”
Primary and Secondary Emotions. “Secondary emotions are symptomatic emotions that result from the avoidance of a primary emotion. Individuals can also have tertiary emotions, resulting from the secondary emotions.” Example: Someone is sad (primary emotion), and he then feels ashamed that he’s sad (secondary emotion); whenever something happens that could evoke my shame, I get anxious (tertiary emotion). “Enacting self-compassion for one’s anxiety may help them to recognize their shame, further self-compassion for shame could help them accept their sadness, and self-compassion for their sadness may result in self-acceptance and amelioration of their sadness. Once this sadness is accepted, the shame and anxiety that resulted from avoiding the sadness disappear.”
When we see someone else in distress, we can either experience empathic concern or personal distress. “Empathic concern has been referred to as compassion, while personal distress results in feeling alarmed, worried, disturbed, and so on.”
Recently, people like Paul Bloom have challenged the value of empathy. There are two types of empathy: cognitive empathy, “which is the ability to understand another’s experience through perspective-taking,” and affective empathy, “which is feeling someone’s emotion.” Affective empathy is different than emotional contagion; with the former “you recognize the emotion is coming from outside yourself, whereas with emotional contagion you don’t know the source of the emotion.” Affective empathy does not always lead to more pro-social behavior, as we can become overwhelmed and develop compassion fatigue. Some studies show that the key is having the optimal level of affective empathy: “too little and there is no motivation to help; too much and the individual is overwhelmed by feelings rendering them unable to direct resources to others in need.” Practicing self-compassion can help us to avoid burnout.
Understanding Emotion
“Once we have recognized, validated, and provided self-compasison for our feelings, the next step is to try to understand them.
Knowing that we have two brain systems — the limbic system’s feeling brain and the prefrontal cortex’s thinking brain — helps us to understand how we can desire two contradictory things. “Accepting this conflict may be difficult because the brain does not like contradictory states (see cognitive dissonance theory, Festinger 1957). Yet if we can accept this conflict, it allows us to recognize more thoughts and feelings, and in doing so a decision can be made.”
Emotional Arousal. Carrier and Greenberg (2010) found that “a moderate level of arousal is best for therapeutic outcomes.” Yerkes and Dodson (1908) found that “performance is maximized when physiological or mental arousal is at a moderate level. Too high and the participant is bored and not engaged in the task, too high and the participant is too overwhelmed to perform at their best. This is why we like to play sports against someone around our own level.” In therapy, too little emotion “could mean the patient is not engaged or avoiding something. Too much emotion and the patient is too overwhelmed, unable to apply new coping mechanisms or take time to learn from their feelings. A strong therapist should be up-regulating and down-regulating a patient’s emotion to maintain a moderate level of arousal.”
Emotional Regulation (Ways to Down-Regulate Emotions)
Physiological Interventions
“Deep breathing encourages slower breaths and helps restore oxygen to the body, which is quickly being used by the active sympathetic nervous system… Regular practice of being aware of one’s breathing and regulating breathing to a consistent rate will prevent future instances of an exaggerated sympathetic nervous response when the patient feels excess emotion.”
“Muscle relaxation exercises where the patient learns to recognize and control the tightness or looseness of their muscles can be helpful. Stress is often associated with muscle tension and learning how to relax muscles helps regulate the sympathetic nervous system. To help a patient learn mastery over the tension in their muscles I often have patients tense and relax different muscles within the body.”
“If the flight or fight response, the body is on high alert, any method that can be employed to mitigate the response can be helpful. For example, lying down is a physical position not associated with the flight or fight response; having a patient lie on a couch can send a counter signal to the brain that they are safe. Playing relaxing music might be another example.”
Cognitive Interventions
“While I don’t believe thoughts can cause a primary or original emotion, thoughts can contribute to the reinforcement of secondary emotions.” For example, if you’re anxious “because you are worried about losing a job and you think of all the bad things that will happen as a result, you will have more negative feelings, reinforcing the anxiety. Perhaps some things might be worthy of consideration, but for the most part excessive thinking is called rumination and it’s not good. Replaying bad events in your head only makes you feel worse; accepting the experience, validating it, and providing compassion for yourself is a much better use of your brain, instead of trying to go back and undo the past.”
Cognitive reappraisal can be helpful for “not overly personalizing events.” Stevens will “quickly examine the situation with the patient, make a judgment, and let it go.” It is generally helpful to help suicidal patients down-regulate their emotions. “Once I’ve validated their feelings, I find it extremely important to engage cognitions, to help patients remember that emotions are ephemeral, that these feelings will not last.”
Working with Specific Emotions
Anger
“Anger is a feeling we get when something is not as we expect it to be, and we typically want to act on it.” “Sometimes our anger is just a normal response. When someone hurts us, it’s natural to feel anger. This often signals to us that we need a stronger boundary. Telling someone it is not okay to call you hurtful names would be an example of setting a boundary.” We need to communicate our boundaries, and when they “get repeatedly crossed, it is also important to set a consequence for when the boundary is not respected.” It’s important not to misattribute where anger is coming from — e.g., a present situation or something that happened in the past.
Forgiveness
“To let go of anger, the person who did the harm must be forgiven.” We can be reluctant to forgive because “holding on to one’s anger can act as a useful form of self-protection.”
Abandonment and Loneliness
“Abandonment occurs when we’ve been neglected in some way. We feel left out by others.” When we feel abandoned, the best thing for us is to get someone’s support. However, many who have experienced abandonment have learned to shut others out. “Loneliness is often a feeling we experience when we are afraid to express vulnerability around others.” Some believe that the feeling of loneliness “is a built-in evolutionary mechanism to improve the survival of the organism; if left alone, they are more vulnerable to environmental hazards.” Overcoming loneliness may require one to “face fears of vulnerability and abandonment around others.”
Sadness
“Feeling sad is often the result of loss, such as a close relationship, and sadness is a normal healthy response. The purpose of sadness: “I tell my patients that acknowledging sadness prevents suffering. Sometimes individuals encourage each other to get over or move past their sadness, but this is not always healthy because it can lead to avoiding grief or even worse, shame about the feeling of sadness.” “By not accepting sadness (primary emotion) we are pushing away a feeling that wants to arise. This tension between wanting to feel sad and pushing down the feeling results in depression. In Buddhism, this is referred to as suffering. We cannot avoid sadness as individuals, but we can avoid suffering by accepting our feelings.
Stevens replaces “grief” for “depression” in the Kubler-Ross model of loss and grief. “Grief, although commonly associated with the loss of something that one had before, can also be related to the loss of a future that never occurred. Some individuals may feel grief about never having gotten married, having children, or any expectation that never came to fruition.”
Fear and Anxiety
“Fear associations or memories have been shown to be the strongest and most stable of conditioned associations, which from a survival standpoint have obvious benefits.” “Patients will often report to me that they are still afraid of the airplane crashing despite contrary knowledge. However, I often find this to be an attribution error. Often what patients are really afraid of is their own emotional reaction. In this sense, they are afraid of being afraid.”
Desire and Compulsion
Why do we sometimes desire things that are harmful for us? The answer is that “wanting (desire) and liking are separate brain systems. The wanting system does not accurately predict the current value, utility, or enjoyment for a given behavior.” The wanting system involves the MCL/dopamine circuit, and dopamine “influences our brain to make choices that have been rewarding in the past, even if they are no longer currently rewarding.” Anselme and Robinson (2016) “suggest that the subcortical MCL operates below conscious awareness, which helps explain why it can be so difficult to control our desires.”
OCD — obsessive thoughts “influence the MCL, which then rewards obsessive behaviors with a dopamine response. Individuals with OCD typically recognize the irrationality of their behavior but feel compelled to act. In doing so, they receive dopamine, which in turn lowers anxiety, and the individual feels a temporary relief.” The goal in OCD treatment is to manage “the desire to engage in the compulsive behavior. Once the patient can manage the desire without engaging in the compulsion, the dopamine reinforcement loop ceases. The desire to engage in compulsive behavior is similar to the desire to take an unnecessary drug.”
“When working with patients that engage in unhealthy behaviors like smoking or eating excessive junk food, I try to help patients recognize the wanting or craving desire that occurs in relation to these substances.” Stopping the behavior immediately “can be overwhelming and often will set the patient up for failure. Each additional failure makes the patient feel more hopeless about quitting. I explain to these patients the goal is more about managing the desire or craving than changing the behavior; the stronger we can get at managing the desire, the more likely we are not to engage in the unhealthy behavior.” He tells patients that when they get the desire, they should initially wait one minute until they indulge. “After a week or two, we double the time to two minutes, then five minutes, and so on.” “During each period, the patient is learning how to regulate their desire.”
“Another common pathology related to dopamine is engaging in unhealthy or abusive relationships.” “The wanting of the past love or whatever previous value existed from the relationship prevents them from terminating the relationship.” Relinquishing “desires or wants can also involve an additional component of grief.”
Disgust
“Disgust has roots in avoidance of toxins like spoiled food or feces, but it has come to be associated with lapses in morality. References of disgust are often made toward aspects of sex. Even off-color jokes about race, religion, or sexuality are often said to be disgusting.” Zhong and Liljenquist (2006) found that “when subjects were asked to recall unethical behaviors from their past, they then went on to purchase more cleaning products, indicating people associate moral transgressions with dirtiness.” “Disgust is also related to shame.” Ginger-Sorolla and Espinosa (2011) found that “when participants are shown angry faces, they feel more guilt, and when they are shown more disgusting faces, they feel more shame.”
Gratitude
“Having gratitude can help balance negative perspectives and help patients find meaning in their negative feelings. For example, when a patient feels sad about a loss, I will sometimes point out that their investment in an object or relationship had value. As much as the loss hurts, it’s important to honor the meaning and value of what was lost.” If someone feels anxious about an upcoming performance, Stevens points out that this means that the individual wants to perform well and that he can feel gratitude for this.
Self-Conscious Emotions, including Shame
Self-conscious emotions are not innate. “These emotions involve a cognitive appraisal of self: pride being a positive view of self; shame being a negative view of self.” These emotions can help us regulate our social behavior; e.g., “feelings of embarrassment or guilt may help to regulate future behavior, especially for adhesion to social norms.” In guilt, “people judge their behavior; in shame, people judge themselves as bad.”
“Guilt motivates one toward behavior change, whereas shame results in a denial of self and reduced action for behavior change.”
Shame’s purpose is to provide “a delusional sense of control when one has no control.” We see this in abused children “who falsely believe that they are bad and if they can be good, then they will not get abused. This creates the basic notion that the self is bad.” In other words, shaming themselves creates a false sense of control that allows them to not feel helpless.
Jealousy and Envy
Both jealous and envy are similar; “both are unpleasant feelings of wanting what someone else has. Envy typically involves wanting what someone else has, while jealousy is more likely to involve another person who is a potential threat to an existing relationship. For example, an individual may become jealous of a sibling when that sibling receives praise from a parent; the jealous individual fears the praise because it could be a threat to the relationship with that parent.”
Envy can be either benign or malicious. “Benign envy would involve admiration, looking up to someone, or having great respect for another.” Malicious envy “is wanting something from someone which you cannot have, and this is associated with resentment toward another.” If we believe we can achieve the thing we desire, the envy is benign. “We may then look up to the successful/envied individual as a model for our own behavior.” If we don’t believe we can obtain “the desired object or situation, then the envy is malicious. In this case, it may seem unfair that someone has more than we do, and this typically results in anger or discontenment. With malicious envy, there is a desire to sabotage or damage the envied individual.”
“Jealousy is often tied to social exclusion.” Even “when individuals claim to be jealous of someone else’s status, qualities or achievements, the underlying fear may be that if they don’t possess such things and they will be less desirable and socially isolated because of this insufficiency. Jealousy appears to be related to and mediated by self-esteem,” as “if an individual has a strong sense of self-esteem, events that might evoke jealousy may not result in a strong jealous feeling.”
Jealousy and Envy
Both jealous and envy are similar; “both are unpleasant feelings of wanting what someone else has. Envy typically involves wanting what someone else has, while jealousy is more likely to involve another person who is a potential threat to an existing relationship. For example, an individual may become jealous of a sibling when that sibling receives praise from a parent; the jealous individual fears the praise because it could be a threat to the relationship with that parent.”
Envy can be either benign or malicious. “Benign envy would involve admiration, looking up to someone, or having great respect for another.” Malicious envy “is wanting something from someone which you cannot have, and this is associated with resentment toward another.” If we believe we can achieve the thing we desire, the envy is benign. “We may then look up to the successful/envied individual as a model for our own behavior.” If we don’t believe we can obtain “the desired object or situation, then the envy is malicious. In this case, it may seem unfair that someone has more than we do, and this typically results in anger or discontenment. With malicious envy, there is a desire to sabotage or damage the envied individual.”
“Jealousy is often tied to social exclusion.” Even “when individuals claim to be jealous of someone else’s status, qualities or achievements, the underlying fear may be that if they don’t possess such things and they will be less desirable and socially isolated because of this insufficiency. Jealousy appears to be related to and mediated by self-esteem,” as “if an individual has a strong sense of self-esteem, events that might evoke jealousy may not result in a strong jealous feeling.”
Notions of Self
Attachment Styles. Avoidant individuals are less aware of their feelings, while anxious individuals are more aware of their feelings but have more difficulty controlling their feelings.
Personality Disorders. Personality disorders can be conceptualized as “an adaptive response to the environment, which is no longer adaptive.”
Affect Reconsolidation
“Memory reconsolidation is the process of updating and changing memories when they are recollected.” Stevens often refers to this as “affection reconsolidation” because “in the practice of psychotherapy, it’s not the nature of the memory that is changing but the emotions surrounding the memory.” Memory reconsolidation is different than extinction, as “memory reconsolidation rewrites the original memory, whereas in extinction a new memory is formed, and no change to the original memory occurs.” Whereas with extinction the original memory can be spontaneously recovered, this does not happy with memory reconsolidation since “the original memory is changed or reconsolidated.”
Step #1: We must reactivate the client’s old memory. Step #2: We must “provide a new healthy experience within which to recode the old memory. Without this, the old memory can just be reinforced.”
The key to memory reconsolidation is to have just the right level of prediction error. When we remember an event, “the hippocampus interacts with neocortical areas, creating a spiderweb of linkages associated with that memory, and we have a prediction or predictions of what will happen based on that memory. These predictions represent what is likely to happen given past experiences. Sometimes the predicted outcome of the choice doesn’t match the actual outcome, and this is called prediction error.”
Example #1: I used to see my friend Dave and called him Chad. “The memory of Dave’s face was associated with the name Chad, and I kept predicting that Chad was this face’s name.” When I did this, “I received an uncomfortable puzzled look from Dave. This mismatch between the expected response (smile) from Dave and the actual response (puzzled look) resulted in a prediction error. After a few prediction errors, I learned to reconsolidate or re-associate the memory of Dave’s face with the name Dave, and the problem stopped.” Too little prediction error, and there is no memory change: “Dave politely smiles when I call him Chad, and I continue to associate Dave’s face with the name Chad.” Too little prediction error, and an entirely new memory is formed.
Example #2: I visit my old high school, which activates old memories. I go to where the math room used to be and see that it’s now an art room; prediction error or mismatch occurs. If there’s just the right level of prediction error, “the old/original memory becomes updated. The math room is now the art room stored in my memory. My memory changes to this room being where I took art classes, not math classes, when I was in high school.”
Example #3: A client felt unloved by his parents. When that old memory is activated, he must also experience “a felt sense of love.” But the prediction error cannot be too great. Stevens tries to find this balance by explaining that “the lack of love they feel is a lack of self-love. Maybe their parents didn’t love them, which is bad, but worse is now that patient doesn’t love themselves. I match the feelings of the patient not loving themselves when their parents didn’t love them (old memory) with the patient currently loving themselves. This seems to create the optimum prediction error for therapeutic change.” Sometimes if the therapist tries to do this by loving the patient himself, the mismatch is too great, and the patient might think, “You’re only doing this because it’s your job.”
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