So, let me ask, I've asked a few people what brought you here. Anybody else would like to come up to the microphone and say what made, what attracted you to this session? Hi, I'm a medical director for an inpatient mental health unit. I see a lot of trauma victims and I, sometimes patients aren't ready for a healing moment, but sometimes they really are. And so that's what brought me here. Great. Okay. That's, that's wonderful. Let's see. Well, we got a couple, somebody else, couple of minutes to go. I've heard, I've heard that it would be helpful. I think that idea of, of creating a healing moment instead of having to wait for it. I think that resonated with quite a few people. Raise your hand if that was one of the things that made you think of coming here. Great. Okay. That's good. Any other, any other focus? All right. Well, so we, we have an hour and a half and I think that, I think we're going to have a significant amount of time for questions and there's, there's plenty more to say. So I, so I hope you'll save up your questions if they're, if they're pertinent to the present. Let's, let's try being interactive and we'll see how that works. So, all right, well, it's, it's, we're just about on. So I'll, I'm Jeffrey Smith and I'm the leader of the Psychotherapy Caucus and anybody who's interested in psychotherapy, all you have to do to join our group, which is now numbers somewhere in the 1200s, is go to your profile on the APA website and look for interests and you just tick the box that says you're interested in psychotherapy and boom, you are then part of the list serve and you can, you can adjust that so that you get, you get every once in a while a bunch of emails or you get them as they, as they come out. I do announcements there and, and then people talk about all kinds of things on that, on that list serve. So anybody who's not a member, how many of you are on the list serve of the Psychotherapy Caucus? Okay. Well, good. One person. So please do join. It's, it's a wonderful organization because we have no budget. We get, every year we get a room like this and, and that's about all we get in terms of support. We're a special interest group, so we get to do whatever we want and, and that's really, that's really a nice advantage. So I'm going to start with my origin story, I guess. I finished residency a very long time ago and pretty soon after finishing residency, I was in my first job and I saw a patient who had been terribly abused in early life by her psychotic mother who was, it was sexual abuse, a bizarre sort of stuff, and I only knew it in, in very general terms and it took, she was so horrified by, by the events that had taken place and she also was dissociative. So it took us four years of work to develop trust and deal with some of her, of her anger and things like that until she finally one day recalled what had happened and in two prolonged sessions we processed that. How did we process it? She was, she was going through it as if it was happening in the present, here and now, and I would say something like, I'm over here, or something very benign just to remind her that we were still in the present, that we weren't completely back to her early life. She was in her, in her forties by that time. And to my amazement, at the end of these, of these two sessions, all of these terrible memories were, were nothing but a dull ache. It wasn't, it wasn't terrifying anymore. It wasn't something that she was, was horrified to even think of. It just was that. And that was permanent. You, you knew it at the time but there wasn't any, any further concern about it. We went on and there were some other incidents that were, that were healed in a similar way. So I think of that as emotional healing. Those were really major healing moments. And I came through a very psychoanalytic program at Einstein at the time and we, they didn't teach us anything about trauma because trauma was for military psychiatrists and, you know, real psychiatrists didn't, didn't worry about those shell shock and things like that. And the textbook at the time said, incest is an exceedingly rare phenomenon. That that was, that was in the early seventies. So, so what did I do? I saw this trauma patient. Well, I figured out that, that all those books on my shelf from Freud, if I looked at the first couple of books, they had stuff about working with trauma survivors. And Freud was a good trauma therapist and he wrote well, he really, it's an intermediate guide to trauma therapy. And Freud described the healing moment. He said, if you have the patient, if you, if the patient describes their, their painful experiences with affect, then lo and behold, something happens and, and it all withers away and the symptoms that are derived from that experience go away and everything's going to be okay. And he called that catharsis. Catharsis is this word that kind of picks up the drama. And the real reason for the drama is because he was working with dissociative patients at that time. And dissociative patients remember nothing and then all of a sudden they remember everything. So that creates these dramatic kinds of moments. Freud missed one thing. He was a Victorian. And as a Victorian, Freud didn't think that, that the doctor was, he thought the doctor was an objective observer and not a participant. And so what he missed was the importance of his own presence in the healing moment. And we'll get to that. So so I was so taken by that that then I tried that same method on the patient's low self-esteem. And guess what? We talked about her low self-esteem. We talked about how she felt crummy and like she wasn't worthy and she was guilty. Nothing happened. It didn't work. So I said to myself, you know, there must be two healing processes here. There's more than one anyway. And that started me on a career long interest in change processes. And that's what gets us to here. In 2004, I wrote a paper about these two processes. The one for trauma healing and the one for values and things like self-esteem. And it was only until about five years ago, I was at a social worker conference and somebody talked about memory reconsolidation. And it hit me like a bomb. All of a sudden, I was hearing the neurophysiology that helped to understand what created that healing moment. And so that's what propelled me to talking about this and teaching it and being here today. So let's move along. Let's see if the clicker works. There we go. So I get royalties from books and I get fees from online training. We just finished a 10 session training for residents and fellows in psychiatry. But those things do not have anything to do with this talk. So the biggest problem in psychotherapy for most of our history has been the lack of underlying basic science. Nobody knew really how psychotherapy works. And so as a result, then each, well, let's go on here. So first I want to make the point that psychotherapy is about changing things in the mind. What's the mind? The mind is, if we think of this brain as an organ for processing information, then the mind is the information processing. It's the content and how that content is handled. And that was something nobody knew anything about. And so the best they could do was to invent some kind of an explanatory set of concepts and then try to get as many disciples as possible and do some RCTs to demonstrate that their method is better. And so how psychotherapy works and with anything else, you really want to know that before you're going to try to intervene. But in our field, we just didn't have the information. And the problem with these theories that exist currently that you're hearing about every day is that they're self-referential. If you're, let's say a psychodynamic therapist is talking with a behavioral therapist, the behavioral therapist says, well, what is it that you're trying to do with your psychotherapy? And the psychodynamic person says, oh, well, we're resolving intrapsychic conflicts between the id and the ego and the superego. And the behavior says, hmm, id, I've never seen one of those. Can you show me an id? And that's the problem, is that each theory is self-contained and that's the way the schools of philosophy were in the Middle Ages. It hasn't advanced, but for a good reason, because the science didn't exist at the time. And in fact, the science we're going to be talking about hasn't really been available until neurophysiologists began to discover this in the year 2000. So it's very recent. So let's see. Did I miss something there? No. And this divisiveness that we have in this old-fashioned organization of our field really causes a lot of problems. The theories, as somebody mentioned in the audience before we started, they're really complicated. I had one senior colleague who said to me, yeah, you know, I learned a whole lot of stuff and read all those papers about psychodynamic therapy, and I couldn't really remember that stuff when I was practicing. So in the end, I'm just a good person and a good listener. And that's not good enough. We want to do better than that. And then there's too many therapies. So if one of them is limited and you want to go beyond one therapy, then you're going to have to learn a whole other one. And how many are you going to learn? There's too many. So we wind up being good, nice people and good listeners. Somebody called that, how you doing therapy? You know, how you doing today? And then we're just going to have a nice conversation and nothing is going to change. There's another blockage. There are lots of policymakers and teachers who have been doing things the way they've always been doing them, and they're perfectly satisfied with that. That makes a great academic career. And you get along. And why should you change? So there's some resistance. And the biggest problem in the things that we're going to be talking about is that most people don't know that such a thing exists. And so we had a session recently at CEPI, the other organization that I belong to, and one guy was going to be talking about the big picture, about how therapy deals with society and marriages and more things besides the individual and biology and stuff. So I said, okay, he's doing this and I'm going to do this. I'm going to talk about what's underneath. So what we need is we need a basic science of mind. And that's the thing that is actually beginning to be possible. And actually, this is part of an insidious plan that I have. I think if we teach enough people, enough young people, the basic science behind psychotherapy, then they're not going to be that interested in becoming disciples of this school or that school because they're going to understand how all of these schools are doing the same few things. So this basic science of mind, let's call it the common infrastructure of psychotherapy. And as I said, it's all based on post-year 2000 science. It explains why people have the problems that we have. Why do human beings act in all the crazy, self-defeating ways that we do? We'll point to the precise conditions that allow change to take place, and that's how we're going to make these healing moments. We're going to focus on process, not method. The audience mentioned that without even me prompting her. And the beauty of what I'm talking about is that this is not a new therapy. This is not competitive with anything else you've heard. It's supportive of existing therapies and theories. We're just going to be filling in a gap that essentially every therapy has, the gap of not knowing on a detailed level how it actually works. And what makes this possible are three threads of science. The first one is evolution, and we're going to use the theory of evolution to understand why people have the problems that psychotherapy can address. Second, we're going to look at the neurophysiology of the limbic system and specifically how those problem patterns that people exhibit to us, how they get triggered. And then finally, we're going to look at what's recently been discovered, which is the neurophysiology of how change actually takes place and how we can engineer or we can support the change process. So we're going to look at how to explain how words and relationship support specific change mechanisms. As a preview, I'm going to tell you that at least for now, basically, we've got three change mechanisms that we work with. So that's not going to be too complicated. So let's start with evolution. First thing that evolution tells us now, and if you think, put yourself in the Victorian era when people were just enthralled with rational thought. It was just incredible what human beings could do with their brain. And nobody was thinking except for Freud, who had the courage to say, no, that's not all the information processing that's going on in the brain. There's stuff that's going on behind the scenes. Well now, you don't have to be a Freudian to know that unconscious information processing is really important. In fact, probably handles a lot more of the work than our conscious logic. So the brain is an information processing organ. It works mostly outside of consciousness. And it was architected, it has evolved for a purpose. The brain is an organ that's there for our preservation of our species, which means survival and procreation. And how does the mind process information so as to promote procreation and survival? It looks for threats, and it tries to predict threats, and it tries to predict and identify opportunities so that we can take advantage of the opportunities and in some way mitigate the threats. And it turns out that the problems that psychotherapy treats are essentially all triggered by the prediction of a threat. You can argue that maybe people start out using drugs because it feels good, but eventually by the time it's a problem, it's pretty much is their use is to deal with a threat. So that's a little bit arguable, but the vast majority of problems, if you trace them back, their actual origin is something that was appraised as a threat. Now I'm going to go back up to the red letters there, recurrent maladaptive patterns. You see, if you ask what is the definition of what psychotherapy treats, if you go out there and ask that question, almost everybody will tell you what it treats in the terms of their own specific therapy. There has not been any concept. So a few of us at CEPI, the Society for the Exploration of Psychotherapy Integration, got together and we thought about, is there a way we could characterize the things that psychotherapy treats? Well, psychotherapy works on the mind. Psychotherapy is there to change patterns in the mind, patterns in the way the mind identifies threats and deals with them. What we came up with was the idea of recurrent maladaptive patterns. That descriptive phrase covers a vast majority, a vast range of things from psychogenic pain to Oedipus complexes. All of those things really amount to maladaptive patterns that people have. That's one of the things when we do psychotherapy that we're going to want to identify very early on. It turns out if I were talking a lot more about them, I would tell you that they actually are arranged in sort of layers like the defenses of a medieval castle. You start with, there's the earliest one and then the most recent ones. Resistance in therapy is actually another kind of recurrent maladaptive pattern because the mind doesn't like to give up its survival mechanisms. If you say, hi, I'm your therapist and I'm going to take away your defenses, the mind says, uh-oh, this is not good and it's going to start to resist. I want you to realize also, and this will help you in your work, that the mind identifies a threat and then it comes up with a response. Those responses have to go from the computer to actually something happening out there in the world. There has to be a transfer from identifying the threat and designing a response to actually putting a response into effect. Those responses have just a few products. We can think of the mind as having some products. One product are bodily changes. That might be the hair on your arm standing up or your heart beating a little faster or breathing faster or it might be an involuntary vocalization. Those are very important things that the mind puts out as part of our response repertoire. But also, the mind does some other things. It puts out thoughts. Cognitive behavioral therapists call them automatic thoughts and psychodynamic therapists call them free associations. But those are the thoughts that our mind pops into our head. The way I became familiar with this was working with alcoholics. When you see an alcoholic in early recovery, they've decided that they're not going to drink for today. Then the idea pops into their mind that maybe you're not an alcoholic. Just as they're walking by a liquor store and bang, they've gone and bought a bottle of liquor. That started to help me understand how the mind, in this case, thinks that drinking is synonymous with survival. The mind uses all of its power to get the alcoholic to do what the mind thinks he's supposed to do. That is to go and get some alcohol. Thoughts are very important products that are designed to advance whatever it is that your mind thinks you need to be doing. There are other kinds of thoughts. Once we have this brain, of course we use it for all kinds of crazy things and fun things that don't have anything to do with survival, but I'm not talking about those. We're talking about therapy, which is really dealing with maladaptive patterns, with recurrent maladaptive patterns. Then the mind produces feelings. We have feelings. They're complicated things, but they're very important. There are some different kinds of them, but they too are products of the mind trying to get us to do what we need to do. We have impulses, like the alcoholic has the impulse to go right into the liquor store. Finally, there are actions. Some actions are semi-voluntary. Some of them are not voluntary, but action is certainly another large realm of what the mind gets us to do, sometimes through the influence of thoughts, feelings, and impulses, and sometimes more directly. That's a little bit of a picture of what evolution is beginning to tell us, how the mind is really different from what they thought in the 19th century as an organ of elegant prose and logic. It's really a survival organ. I also want you to realize that this is an area where we're talking about basic science, and there actually is a remarkable animal model that has produced tremendously detailed and interesting scientific results that explain change processes. And the paradigm that's been used and that's produced a lot of this really wonderful science is the learned fear paradigm. And that, just to simplify, I'm not going to get into, you know, operant conditioning and all that stuff. We don't need that. If you ring a bell and then give an electric shock, then whether it's a human or an animal, we're anticipating that. The mind is working hard to be ready to brace yourself for that shock that's coming or to run away or something like that. So we've now learned a response pattern to deal with, to mitigate that, the threat of that shock. And then what happens in this paradigm, you keep on ringing the bell, but you don't give the shock anymore. And what happens? Well, we all know after a while, the animal or the person says, eh, you know, I guess the shock is done. I'm not going to worry about it anymore. And the response goes away. And now that response, before this response goes away, during that period, before it goes away, before change happens, we are looking at a recurrent maladaptive pattern because it's maladaptive. You don't need to be all braced when there's going to be any shock. So we have an actual recurrent maladaptive pattern that we can see in animals and it works just the same in humans. And so we can put electrodes in different places in the brain and figure out exactly how that's happening and what chemical processes are involved in detail. And so we have a real basic science that's going to help us understand how we get from ringing the bell and no shock, but the person is all worried, to ringing the bell and no shock and no response. That is a change process and it's going to turn out to be the same kind of change process that we want to do in psychotherapy. So now we're going to talk a little bit about the second thread of science and I'm going to focus in particular on the narrow part of that hourglass there. The organization of the mind, if we look at it in terms of identifying a threat and doing something about it. So it's kind of an hourglass in the sense that the appraisal, the process of taking information from outside, from inside, from the past and putting all that together and figuring out whether we're dealing with a threat or an opportunity or nothing. That is an extremely complicated process and it involves, it diffuses through the brain, it involves multiple sites and there are lots of people who are doing work now to understand which parts of the brain it operates in. As a clinical therapist, we don't need to know all of that. It's interesting, but it's not really vital to us. And in the same way, the lower part of the hourglass is how the mind comes up with what would be the right thing to do. Is it better to flight or fight or freeze or do something else? And that's a very complicated set of calculations also and one that the mind does. And again, we don't need to know that so well, though it's good to know what the end products are, as we just talked about, because when you know those products, then you can keep an eye out for them as you're working. Okay, now we get to the middle of the hourglass and that's where the triggering happens for the response. Now, if you think about it, so we have this computer that's taking all kinds of data and crunching it and going back and forth and figuring out is there a threat or not. How does that computer signal that yes, there is a threat and we better do something about it? Does it have a siren that goes off? Nope, we don't have any of those in the brain. Are there any LEDs in there? Maybe there's LEDs that flash. Nope, no LEDs. Anybody got an idea of how the brain signals that there is a threat that we need to do something about? Visual cues like we see? I think so. Say it loud. Visual cues we sense with our senses that there's something dangerous. If I understood you right, my hearing is not perfect, I'm sorry. I think I heard the amygdala. I was saying visual cues like visually we see there's danger or with our senses. This all is happening, that's a good thought, but this is all going on outside of consciousness automatically. And this is where you've all heard about the amygdala. Let's use that because neurophysiologists will tell you that the amygdala is not everything. There's other centers in the limbic system that operate in similar ways. And so I'm not going to get into the complexity of it, but more in the functional operation of it. But we'll use the amygdala for an example, that when the mind identifies a threat, there's a little neural network in the amygdala that lights up. Those neural networks are nerve cells that are connected by synapses and they have a tendency to fire at the same time as a unit together. So one of those neural networks in the amygdala then fires and says, be afraid, this is something to be afraid of. And that's what triggers then the development of a response. And so we have a chain of events, but it's very complicated over here at the beginning, it's very complicated at the end. And in the middle, it's fairly simple and it can be studied. And the signals are pretty quiet. So it's hard to be precise with scans, and I'm not super knowledgeable about that. But I know also there are people who put electrodes in these specific areas and can see what's going on. And that's how neurophysiologists have been able to identify exactly that it's this. This is the sine qua non. It's the one necessary step in the chain of events that leads to a recurrent maladaptive pattern. Now, I'll tell you, it's a little more complicated than that because sometimes some of the calculation of whether there's a threat goes on upstream of the limbic system. But the last calculations that finally say, okay, we got to worry about this, that takes place in the limbic system. I also want to say a couple more things about that. Let's see, how are we doing here? Good. So... I lost my train of thought. Well, I'm going to skip ahead a little bit. So there's the response. If we think of this as a computer, as a kind of a system, how many of you know what the difference between negative feedback and positive feedback loops? Okay. And positive feedback is when you're talking in the microphone and the thing starts to scream. They're unstable. And negative feedback loops are stable because the thing that triggers the response, you make sure that the response then goes back and modulates the thing and downgrades the thing that triggered it. And that's how the brain works. That's how the mind works when it's dealing with threats. It sends signals that it does things in the world through those products that then cause a downregulation in the signaling that says we better do something about this, it's dangerous. And that's kind of important because in animals, and this is just interesting, in animals generally there's a one-to-one correspondence between the threat and the signal in the limbic system that says we better do something about it. And so if the response is aimed at quieting down the limbic system, that means flight or fight or whatever you're supposed to do, and it does a pretty good job of matching the response to the threat. Okay, now let's look at humans. How about the human who suffers from PTSD because of an assault? And that person doesn't want to experience the pain that's coming out of that signal that there's a danger there. They don't want to feel those horrible feelings again. And so what do they do? They go and they start drinking. And pretty soon they're alcoholic and they're out there stumbling around in the middle of the night in a bad part of town. And guess what? They've done nothing at all to take care of the danger of an assault. Instead, they've killed the messenger instead of worrying about the message. And in many instances, this is one of the ways that coping goes awry. And that's another, I mean, coping gone awry is another way of saying recurrent maladaptive patterns. And those are the things that psychotherapy can treat. All right, I lost track of whatever it was I wanted to say, but okay. So now let's talk a little bit about affect. Psychotherapists have had a lot of trouble with this because we humans are conscious of our feelings, and yet we see things in animals that we identify as feelings, but animals don't presumably have the same kind of consciousness, and so they all argue about it. But we as therapists and clinicians, we don't really need to be so worried. The definition of affect is bodily changes. Remember those bodily changes that are products of the mind that's coming up with a response to a threat? And when those are combined with conscious awareness and conscious feeling, which is much more complicated, you know, feeling involves identifying it with words. Some people are better at identifying their feelings than other people. And sometimes things go on in the limbic system that we're not conscious of at all. So definition of affect is bodily changes with conscious feeling. And then there's something that I'm going to call limbic emotion. I'm going to call that little triggering activation that goes on in the limbic system, the thing that sets off the whole chain of responses, I'm going to call that limbic emotion because when you look at an animal or a baby, you say they're having a feeling. The animal's tail goes down and the dog is shivering, you say the dog is afraid. So we're not going to argue about what the dog might be conscious of. What we're going to know is that in the limbic system, there's been an activation and that's produced some bodily changes as a product. And the way we know that it's fear is because we have similar bodily changes and we identify those as fear. So we, using our empathy and our motor neurons and all of that, we identify the dog or the baby as having a feeling. But what's really going on is limbic emotion is the trigger for recurrent maladaptive patterns. So limbic emotion is a word, I'm just going to use it here, I'm coining that word to describe this triggering because the triggering is so important when we come to change. And so for purposes of clinicians, affect then is our indirect indicator that the limbic system is active. And that will turn out to be extremely important when it comes to creating a healing moment. So just to be complete here, I really want to talk about memory reconsolidation, but I need to remind you that there are two other significant change processes that go on. And these are the last of the three threads of science. So the first and the longest identified change process that is relevant to psychotherapy is extinction. That was observed by Pavlov a very long time ago. And what happens there, it turns out when the neurophysiologists got to looking, using the learned fear paradigm, got to looking at exactly what was going on, it turns out what happens in extinction is over on the red on the right in the slide, is the cortex figures out that the shock isn't going to happen and I'm okay. And the cortex starts to send inhibitory signals into the limbic system and those signals inhibit the response. But they don't inhibit the appraisal, the identification, the limbic emotion that's identifying a threat. And the problem with that is that it's not permanent. So when you try to do extinction, you have to keep reinforcing it where eventually because the limbic emotion, remember that's the activation of those few neurons that trigger a response, that limbic activation is still happening. And even though you've suppressed the response, the activation is still saying, hey, there's a problem here. There's something dangerous that could happen. And so eventually the old fear response comes back. So there's a disadvantage. And this is... So when the federal government says there are a few approved treatments for PTSD for military veterans, one of them is based on the theory of extinction because that's really all that was available at that time. And so veterans are brought into an office and they're exposed to, let's say, battle sounds or something like that and have to go through their terrible experiences over and over and over because extinction works with repeated experiences. And little by little, then the inhibitory... The mind learns that the war is over and it's not dangerous anymore. And pretty soon those inhibitory signals start coming and you get a reasonable degree of improvement. However, you remember the experience that I told you about early on of the patient who just in two sessions, and those two sessions were looking at different facets of her traumatic experience and kind of one at a time, what did it feel like? What were your feelings about your mother? How did you come to blame yourself for it? Things like that. So it really took pretty much one time, one repetition for that healing moment to happen. And that's because we were working with a different change mechanism. Now, the conditions for them are very similar and this is an area for research. The only research I know about it is that if you repeat a safety signal over and over and over again, then you tend to get extinction. If you do it just once with intensity, it's more likely to produce what we'll get to second, the second of the change mechanisms, memory reconsolidation. But otherwise the conditions are going to turn out to be very similar and we'll get to those in just a minute. So memory reconsolidation, I think of as kind of the queen of change processes in psychotherapy. You'll understand why as we go forward. But it's the one that I think Freud was talking about when he talked about catharsis. It's the one that I experienced with my patient many years ago. And it's the one that we want to have happen in those aha special moments that many methods of psychotherapy produce. But generally they're things that just happen, that you kind of wait for it to happen rather than actually being able to make it happen. And finally, there are some processes, some change processes like habits, for example. Typically, let's say if somebody has a deep down misunderstanding of how life works, a schema, and we manage to change that schema through memory reconsolidation, they're still going to have a lot of habits, of habits that depend on that perception of the world. And like, you know, I walk like this and things that you're going to need to learn a new way that's going to override the old habit. And so that's kind of classical learning as learning theory describes it, where we learn something new that outcompetes the old way of operating. So that is a significant part of psychotherapy. But I think it's not the thing that really is operating in these special healing moments that we like so much. So just some pioneers in the field to recognize. Bruce Ecker was, I think, the first one really to say that memory reconsolidation is entirely relevant to psychotherapy. And he's been evangelizing that quite strongly. Aram Nader is the lead author of the first publication in the year 2000, and then with some more detail in 2004, to describe how memory reconsolidation is definitely distinct and sort of opposite to extinctions. In fact, if one happens, the other is not likely to happen. So they're sort of mutually exclusive. And Richard Lane is a psychiatrist at the University of Arizona who's done a lot of research on memory and also written some very important papers and a book on how memory reconsolidation is relevant to many different schools of therapy. So now let's talk about the clinical requirements. So here I'm talking about memory reconsolidation and extinction. But I'm mostly focused on memory reconsolidation. The way I'm going to put it, there's three requirements for this to happen. And this is the piece that I want you to take out of here and use in your clinical practice. So the first thing is that you need activation of the old pattern. In other words, when the mind thinks, uh-oh, there's something bad that's going to happen here. Like, uh-oh, if I tell my therapist about this shameful thing that I did, then the therapist is going to suddenly turn red in the face and throw me out of the office. You know, horrors. And so that is an activation. How do we know there's activation? Well, we went over that before. The indirect indicator that there's activation in the limbic system is affect. And we all know that. As therapists, we know instinctively when we see tears or when our patient starts to fidget. We know something's going on that's important, and we tune in on that. And we just sense that that's important. In fact, there's a huge body of research that says that emotion that affect experience during sessions correlates very strongly with a positive outcome of therapy. So that's the first requirement. And the second requirement is disconfirming information. Some piece of information that when it connects with the places where the threat is being identified and says, no, that's not a threat, it's really okay. And when that happens, when there's a collision between disconfirming information and the original appraisal of a threat, then what happens is, as you've all probably heard, the neural networks, those synapses that join those cells together to make them fire as a unit, get readjusted, reconfigured, because they become volatile for a period of about four to six hours. They become volatile and able to be changed. So the synapses are adjusted, and then the signals come into the amygdala that says, you know, we think there might be a threat here. And the amygdala says, no, not really. I'm not worried about it. And there's no response, because that's where, back on the earlier diagram, you remember memory reconsolidation, cut the chain at the level of the limbic emotion. Is all of this clear? Is everybody clear about what I'm saying? Okay, good. Now, so it's the collision between disconfirming information and the activated original perception that triggers the volatility and allows this new information to overwrite the old in the memory cells. Yes, okay. So the collision between disconfirming information and the original appraisal in the limbic system, and this may operate in other areas of the brain as well, but within the limbic system, that collision creates what neurophysiologists call a prediction error. The brain is very sensitive to when I think something, and then there's something else that tells it, no, that's not true. Brain is very much tuned into prediction errors. They're important. And in this case, prediction error seems to be the thing that triggers the memory volatility and the possibility over a period of four to six hours of those adjustments, of those synapses being readjusted so that they no longer process the same information in the same way. They now process the inputs in a different way and come out with a different conclusion. And so, you know, if you re-traumatize somebody, you're just going to reinforce the old conclusion. But if you have new disconfirming information, then that's going to change things, okay? And now I put the third one, the third requirement is affect. And there's a reason for that. So affect is only, it's not really a requirement, except that's our clinical indicator that the activation, that requirement number one has been met. But it also tells us something else, I think. And this is not neurophysiology, it's not research, but the way I think about it as a clinician is that when we've got affect, the channel is also opened from consciousness down to the limbic system where the change needs to take place. Because if we have new information that's just held on an intellectual level and it doesn't trickle down to the limbic system, it's not going to do anything. We all know that. So we need a two-way channel. The limbic system sends us into consciousness, the fact that there's things going on that are of an emotional nature and we have affect, and we need to be able to send new disconfirming information down into the limbic system where it's going to change the configuration of neural networks and memories and change the way the mind appraises, the way the mind processes that information so that we can change the response pattern. So affect is necessary, but necessary only really as an indicator that the channel is open. I also, just for the sake of completeness, just like I mentioned that there are three different change processes, there are also nonspecific factors that are not part of these change processes, but they're also important. Number one is arousal regulation, because we all know that when people are so highly aroused, then they're not going to learn anything new. These subtle change processes aren't going to happen. And so we need to pay attention to arousal regulation, and you all know that there are many methods for doing that, not just breathing, but simply being there and not freaking out is one of the most powerful ways to regulate aroused people. The second one is motivation. There are some therapy traditions that don't talk very much about supporting the patient's motivation, but actually that's a part of every clinician's toolbox and a part of what we always do. We point out how much better you are now than you were two years ago, or we talk about what the goals of therapy are. And so we do a lot of subtle things, and we might as well say it out loud, because it really is important. The going gets tough sometimes. It's hard work and you have to kind of go against your instincts and try out behaviors maybe that are unfamiliar and uncomfortable in order to make progress in psychotherapy. And so motivation is important. Safety is really critical, and I think that I had a blog for a long time that became sort of ground central for people who had intense attachments to their therapist. And any number of times people would write in and they'd say, I told my therapist I had these feelings about him, and the next thing that happened is a security guard came and ushered me out of the clinic. You know, awful, terrible disasters. And so I think we need to pay attention to not only giving our clients the impression that they're in a safe place, but we also have to make sure it really is safe. And sometimes people are going to try new behaviors that involve some level of risk. We need to inform them about the risk. So just a reminder that safety is part of our job as physicians and as psychiatrists. And finally, the relationship I think of as the Swiss army knife of psychotherapy, because the relationship supports arousal regulation, it supports motivation, it supports a sense of safety, and it also is an important source of information for this process of memory reconsolidation. So now I want to go back as I promised that I wouldn't forget this, and I'm remembering it fortunately. The disconfirming information that we send, this comes in a wide variety of different kinds, and you wouldn't necessarily realize. We'll think of three kinds of disconfirming information. So the obvious one is cognitive. It's like we're reframing is an example of disconfirming information, right? Or explaining or looking at the origin of something. So we do a lot of things to help people be aware and understand on a cognitive level, and that frequently forms the disconfirming information that creates a healing moment. The second kind of disconfirming information is nonverbal, and that is when it's just your presence or your tone of voice or the fact that you're tuned in and you really get it, that the person perceives that you're right there with them. And that is disconfirming information for many of our patients who've come from situations where they didn't have that kind of responsiveness. So that is, you know, just like your computer doesn't care whether it's processing an image or a sound or a set of numbers or words, the mind doesn't really care what kind of information it's processing. It's all kept in these clumps of nerve cells called neural networks. That's how the mind holds information, and that's where we need to make changes happen. So that's two kinds of information, and then there's a third. I've been working with a patient recently who was grossly overpowered and controlled by both of her parents, really, and she learned to kind of give up her power. She learned to disempower herself and did that very easily throughout her life, and she wouldn't claim any kind of power at all. We talked about this a lot, and one day she came in and she said, you know what, I joined a boxing club. And you know, this is a third kind of disconfirming information, because for her, when she lands a punch on the heavy bag, that's telling her limbic system that it's okay to have power. That's disconfirming information. So physical information is also really important, and that's something that's not generally built into psychotherapy, but increasingly therapists, especially in the trauma area, are becoming aware that bodily information is part of what's going on here. And again, the brain doesn't really care what kind of information it is. So those are examples of three different kinds of information. Let's see. Wait a minute. There we go. Okay. So now we have activation, disconfirmation, and affect, and those are the requirements for memory reconsolidation and, incidentally, for extinction as well. And let's map those to just a few. For example, and we can, I hope, have some questions and some discussion about how it may fit with other ones, because the marvel when you have a new theory is when you realize that it's starting to generate predictions that actually come true. When Einstein's theory, you know, a few years later, people would suddenly say, hey, wait a minute, that explains this and that, that Einstein hadn't thought of at all. Well, in our case, we've been gathering data for 100 years, and so when we now have a new way to explain what it's doing, it's kind of reassuring that the explanation turns out to correspond to the things that we already know clinically. And so let's look at some different therapies and therapeutic situations. Some people feel that the corrective emotional experience, and I'm thinking of Marvin Goldfried, who is one of the pioneers in psychotherapy integration, says that the corrective emotional experience is really the core change process in psychotherapy. Well, what happens, this was described by Alexander in French in 1946, and they said that the corrective emotional experience is when the patient has an expectation of something is going to go a certain way in the therapy, and then it goes in a radically different way. So like, for example, you know, you're going to throw me out of the room when you hear this, and then the therapist says, no, you know, I really understand. You didn't have any other choice. And that's disconfirming information, and that's what makes the corrective emotional experience, except for the word emotional, which also says, then, that there's affect. So Alexander in French's description of the corrective emotional experience corresponds very closely to the requirements for memory reconsolidation. And that's used to, well, let's see, let's go on. So here's one that's a little more modern. How many of you were thinking that memory reconsolidation and mindfulness are really the same thing? Anybody have that idea? Well, they are. If you think about it, when we use mindfulness clinically, let's say with somebody who's been traumatized, what mindfulness is all about is when you're meditating, when you're sitting there with a painful experience, you get these feelings. You get this sense of foreboding, let's say. And that's an indication, that's affect, that self-centered kind of experience that people have when they're dealing with something that's uncomfortable. And they're not really seeing it from outside. They're just seeing it from within their own experience. And then what mindfulness does is says, well, you know, why don't you think about that in a larger perspective? You know, maybe this is just one of those things that happens. And that's part of the flow of life. Oh, yeah. That's disconfirming information. And so mindfulness is all about having a larger perspective that alters the self-centered experience of affect in relation to something uncomfortable that floated into the person's mind. And if you look back at kind of the descriptions of mindfulness, it really is all about that bigger, more global perspective that alters the self-centered feeling somebody has. Was there a hand? Okay. All right. Insight and interpretation. So I looked up the other day, I looked up academic articles on the timing of interpretations. And I found a beautiful article, I don't remember the author, but a classic author and a beautiful paper that described the subtlety of figuring out when to time an interpretation. And I can't remember what it said, but it was really, really, it was subtle and it was quite nice. And bottom line was, you have a feeling, you have a hunch that it's the right time and you go for it. But we know, now that we know something about memory reconsolidation, we can do better. Because now we know that in interpretation, one of the functions of interpretation is to provide disconfirming information. And so when are you going to want to provide disconfirming information? When it comes at the same time as there's affect. And now affect comes with, the reason it's affect has a conscious component is because the conscious component tells us what the person has a feeling about. The person, let's say they're talking about that, my dad died and suddenly I felt like I had to be the man of the family. And you see that the person's face changes and they're obviously having some kind of affect with that. Well, that's a time to then say, you know, wow, that was really tough. And I totally understand that it was scary because you weren't sure that you were going to be able to rise to the occasion. You were only 10 years old. And so we provide then some disconfirming information at the time when we notice that there's activation and the information has to correspond to whatever it was that was causing the activation of affect. So we can't just have any old interpretation with any old affect. It really needs to match up in order to be relevant and go through that process of rewriting the neural networks. And in a similar way, insight also, when somebody says, oh, yes, I understand, and they have greater insight, then they, you know, memory reconsolidation isn't always something that happens in a clinical setting. It may be that the person realizes or maybe they see something on YouTube and it suddenly clicks with them and at a time when they're feeling something, and then you're going to have a healing moment anyway. And then correcting core beliefs in for our cognitive behavioral colleagues, we're doing the same thing. We may be doing more of, since the design of cognitive behavioral therapists tends to be oriented towards the extinction process, but I think very often it creeps into the territory of memory reconsolidation as well. Because when you identify some maladaptive thoughts, that's telling us that those thoughts bubble up from somewhere. And when that thought comes up with affect, then, and you provide some disconfirming information, you're creating a healing moment again. Or let's say you identify a maladaptive behavior and as a cognitive therapist, you say to your patient, you know, I think it would really help you to practice changing that behavior. And the person says, oh, oh my God, what do you mean? I'm going to have to change my behavior. Boom, we've got affect. So now we have affect and they're imagining themselves doing a different behavior and maybe in a context where the new behavior is clearly going to be more satisfactory and work better, then we've created a healing moment. So these things happen all the time. There also is evidence that after you have a healing moment, the reconsolidation works better if you sleep afterwards. So that good night's sleep after the session. Some people are talking about even advocating a nap after a psychotherapy session in order to consolidate what has been learned and what's taken place. So that really covers, this is not all that complicated. So I want you to be aware of what's going on, aware of affect as an indicator that there's an opportunity for change and thinking about what kind of disconfirming information you're going to need to supply. And so this is a summary slide then indicating the four nonspecific factors on the left, the three change mechanisms that we talked about on the right, and a little diagram with those three requirements for memory reconsolidation and extinction, the activation of old patterns, disconfirming information, and the presence of affect. So yes, what I want you to take away then is thinking about that special confluence of events, of affect indicating an activation of limbic emotion and providing disconfirming information that's going to be able to change the memory cells that are holding that old information. And this is, it's consistent with any therapy you want to name, you know, schema therapy and emotion focused therapy and all of them. So I'm going to stop here and we have a good amount of time for questions and discussion and we can get down to some specifics. So thank you very much and we'll move on to the questions. And if you'd like to know more, let me just say that I do a blog, I'm now on number 77, every two weeks, sort of an essay on some aspect of psychotherapy. And the thing that's unique about these is that you can't identify what school of therapy I'm talking about. They're compatible with any school. So you're welcome to subscribe to those. And my website is howtherapyworks.com. You'll also get an infographic and I have a free ebook there and lots of other materials and things that pertain to this way of approaching therapy with the knowledge of the common infrastructure. So thank you very much and let's go on to questions. Yes, you mentioned affect is a bodily changes with conscious feeling, is it correct? Correct. So I have a question. Let's say I am in a therapy with a 24 years old girl who talk about the trauma that she had and then she start to grab a napkin and start to cry. While crying, she also start to smile. So I wondering how you tease it up about this paradoxical type of expression of affect. Wait a minute, she starts to cry and then what? And then while she was talking about the trauma, she also intermittently would smile. Okay. Well, I think that what I like to say is that the things you don't know are more interesting and more important than the things you do know. So now we have something we don't know, which is why is she smiling while she's talking about trauma? And I'm not sure about exactly why that might be. I would then be asking myself, does she smile when she's uncomfortable or is there something else? So what we know is that the mind may be processing different things at the same time and coming out with responses. So one response is the smile response, and there's a whole process of triggering and a causation for that smile response. And then there's a response. So we can certainly ask and maybe develop a working hypothesis about why it is that she smiles. My starting point would be thinking maybe this is a person who has a habit that when she's uncomfortable, then she smiles. And maybe that goes back to something in her past where she learned to do that. Who knows? Thank you. Yes. Thank you very much for giving me another way of thinking about some patient material. I wonder how you would approach this. I have a patient that I've been working with for many years. Really, it's a trauma case, someone who had an affair and ended up getting extorted as well as sexually and physically abused within the affair. When it finally came to light, her husband decided to stay with her. And even though I've been working with her over many years now, what is confounding the work is that this very prolonged case in the courts. Courts that have refused to take up her case, courts that have diminished the charges and the constant appeals that the perpetrator continues to seek. So all the while in therapy that I'm trying to change the memory, we've got these forces outside of the work that continues to confound it, including her husband who says he's supportive, but when he gets angry with her, he has a few choice names that he bestows upon her. Yeah. Oh my, that's a horrible problem. I have a saying for myself that as long as litigation is pending, then no change is going to take place in psychotherapy. It's not absolute, but it really, really is because the mind is focusing on the future benefit that the litigation is going to fix everything. And in a similar way, medication often works that way too. When alcoholics now come out of rehab with medications that are supposed to, that if you give them to 100 alcoholics, they'll drink less than the control group, but the mind thinks that medication is going to do all the hard work so they don't go to the AA meetings and the things they really need to do. So this is another one where I think the mind locks onto a goal and it's very hard to change that. So I don't really know a good answer to that. It's really, really unfortunate and it's a terrible thing about, I think, about the courts. So what I say to people who've been traumatized is I really hope that you will think about retribution as a gift to society and it's something that you only should do when you've completely made peace with what happened and you resolved it emotionally and now you're kind of detached and you realize that it's gonna cost you a tremendous amount to enter into litigation emotionally and in every other way and that is something that you're giving to society to eliminate this perpetrator. It's not gonna solve any of your emotional feelings to have that court verdict. Just a secondary thought about this during the pandemic when we reverted to virtual sessions, the affect of processing was really hampered by that screen effect, even though it was something I've known for years. Me too. On the other hand, I think the way I explain the fact that virtual sessions have been found to be fairly effective is that human beings are so good at overcoming barriers to making a connection that we somehow managed to do it in spite of the limitations of the video setup. So I have a couple of cases myself, one in London and another one in Canada where we make do with that and it seems to work okay, but it definitely is not the ideal. Thank you. Yes. I have two questions. Number one, do you think psychotherapy really is an art or a science? That's number one. Number two, I wanna know how do you feel about the concept of empathy in psychotherapy and how significant that is in the cohort work? Okay, well, first, is it an art or a science? Well, playing the violin, how many people think that playing the violin is an art? Okay, or even singing is an art, but if you ask any singing teacher, they'll tell you that I teach a whole lot of things about the science of how the vocal cords work or in the violin, how your bow produces sounds on the strings and so on and how the strings are tuned to different frequencies and so on. So there is a science and sometimes the science really helps us to perform the art in a way that's more effective. And the other question was, wait a minute, I lost track of it, I'm sorry. The role of empathy. The role of empathy. Absolutely. One of the ways that I like to talk to beginning therapists is about accurate empathy. That's a term from, what's, I'm sorry, I lost, I lost track of the guy, but anyway, accurate empathy means that you're not just a nice person that, oh, I'm so sorry you're crying, that I can see you must be hurting, but actually understanding the current context of the emotion and the reason that the current context is interpreted as it is that produces that emotion. So you need to know sort of the past background as well as the current context and you want to be precisely accurate about understanding just what is going on in that feeling. And so if we set our minds to doing that, to achieving accurate empathy, then that really takes us in all the right directions to be able to know what is the disconfirming information that might actually make a difference. I'll give you a quick example of a piece of disconfirming information. I had a guy who was a military veteran and he was braced all the time and carried weapons with him because he was worried at any time there could be a terrorist attack and any time he'd see somebody in a loose-fitting coat, then he'd wonder if there was an AR-15 underneath there. And so the disconfirming information was to talk about the pros and cons of being ready for anything at any time, that if you put all of your energy into being fully ready for anything, any bad thing that might happen, you don't have any life left. And so what I said to him is, maybe what you need to do is to think about, oh well, that what if something bad happened and you had to say, I wasn't prepared, but if I was gonna be prepared, I would have no life left. So oh well, that's just the way life goes. So that was a piece of disconfirming information that happened to be appropriate for this gentleman who was thinking that you really do have to be ready for anything, any time. Question. Yes, hi. Thank you very much for this beautiful talk. I'm a resident of psychiatry in the Netherlands and currently I'm working with the mentalized-based treatment. And one of the things that I have with my patient is that sometimes I feel like, is there something else going on as well, like autistic spectrum disorder? Because I can't reach really to the effect. And is there something you have, like experience with autistic patients and is psychotherapy also for them or is this a disorder that we can say should be actually excluded from psychotherapy? It's a really good question. I think that, I know for myself, I really feel badly that it took me a long time to start to be sensitive to autism spectrum in my patients. And I think it's really unfortunate because I would say in my caseload, maybe 5%, something like that. I have two of them currently in my caseload. And so I think it's extremely important. One of the cases that I feel really wonderful about was a woman who was treated as schizophrenic and given all kinds of antipsychotic medications. And she acted crazy because she didn't know what else to do. And it was quite obvious that she was autistic. And she then gradually began to embrace the diagnosis and avail herself of resources that are available. And she has a nice boyfriend and a good job and they love her at her work. She does a really good job. So, you know, that wasn't, I wasn't trying to bring about very much in the way of therapeutic change, but more what I would call counseling, which is sometimes part of what we do. And counseling to help her feel better about herself, understand herself as neurodiverse and see the good sides of it as well as the disadvantages of it and so on. So I think it's very important to be tuned in. Dealing with the affects of autistic people is tricky. They tend to be, in my experience, intellectually quite rigid. They'll get an idea and they just won't budge from it. And it's very hard to talk them into anything if they don't agree. And the usual things that we use, you know, people are, we have a relationship and people want to get close to us. They want to be on the same wavelength with us. And that's a really positive factor in doing psychotherapy and the motivation. And that doesn't really operate the same way with people who are autistic. And so you just, you know, your personal influence is not gonna be as good a tool as it is with your other patients. I was wondering about, you mentioned that case example of someone who was kind of over-controlled by parents and then disempowered themselves. And I have a patient who I think is in a similar confirmation and also is on the autism spectrum. So there's levels of complications. The father's a pediatric neurosurgeon. The mom's an international lawyer. The patient is a graduate in physics and is just like directionless in life because she can't, she just doesn't, so she's super depressed. And anyway, so I think like her doing something that would solidify in her mind that like she is in the driver's seat of her own life would be really helpful. Is it best to tell someone that, like why that intervention? Like you should, you know, here's a recommendation. Why don't you try boxing or riding a horse because I want you to experience this? Or am I supposed to let her figure that out? Okay, wow. So the last two of my blogs, one of them is posted now and it is one that describes the difficulty of exactly that problem. And the one that's going up shortly, it already went out to the subscribers, is about what to do about it. They're long, they're complicated. And I think that what we basically want to do is we want to support, well, let me stop all of that and go back a little bit because if there's one thing I can say to you that besides studying the neurophysiology of change, the one thing that I would want you all to be most curious and most interested in is psychological development. The title of the first of those two blogs was that immaturity doesn't have a DSM code. And yet immaturity is one of the most important things that we deal with in our work. And when we see people with developmental problems, then I say that's great because now we're paddling downstream because development just, all it requires is that you try out some new behaviors and some new ways of looking at things. And pretty soon you've acquired new skills that you didn't have before. And so catching up with development is a lot easier than undoing some maladaptive pattern that you've had for a long time. But understanding maladaptive patterns as patterns that originated at a certain point in development helps us a lot to understand that sort of the cognitive operations that were going on at the time that were limited by cognition. So I wanted to say that about development, that it's super important. With adolescents, then you're trying to help them move along towards having, my definition of adulthood is the subjective sense of full ownership of your own life. And that's what we're moving towards. And people go through a phase of doing, of defying their parents because they're really fighting with themselves. They really have a profound ambivalence about wanting to grow up and not wanting to grow up. And so we wanna support the healthy moves, but also be aware that it's pretty easy to get into a place where the, if you're too strong in pushing the positive, your patient may then go and report all of this to their parents and they're gonna fire you as the therapist, you know? So, and that's the other side of the ambivalence coming in. So anyway, I recommend those two blog posts. Those say a lot more than I can say in a couple of minutes. And just keep your eye out for number 77. It's coming shortly. Number 76 is up already at howtherapyworks.com. Okay, thanks. Yes. She was first. Oh. Um, I was about to speak and then I noticed this is the first workshop this week where one group of, one sex predominates. Usually they're men and women. And there's not been any other group I've been in where most of the people are women. And I just don't know what that means, but it's interesting to observe. Maybe they identify with healing moments? I just, I don't know. Interesting, yes. You can come up with stereotypes of sensitivity or whatever. But what I was gonna ask about, in terms of being in relationship with a patient for a while, what is, what would you suggest about personal information that you share? Or how much do you include about your own life? And when you're doing therapy with people over a long time, information can leak and, does it, what the boundaries should be? Or does it depend on the patient? Or, it's complicated. That question keeps coming up. I've heard it in several different sessions. And so I guess it's something that people do think about quite a bit. I like to self-reveal. I'm kind of a ham and I like to be seen. And I know that sometimes that's not so good. So what I notice is that if I put in a little too much information about me, the people are bored. They don't wanna know. It's not about them. So patients are really interested about them. And if there's something that you can bring up that's actually going to help them understand about themselves, then, and that's going to be useful in providing some disconfirming information, then I think that's a good criterion for revealing something. And if it's, if not, then don't do it. There's a lot of information that you can say about within the therapy. When you say that, it makes me feel like I wanna go to sleep. That's different from saying I'm in the process of divorcing my wife or something like that. So there's a big difference between things that situate you in the world outside versus things that are about the therapy. But I have this fairly extensive online presence and some patients look up my blog and some people actually subscribe to it and follow it. And it doesn't seem to cause much trouble. I haven't seen a lot of trouble from it so far. But the blog really is talking about clinical things and it's not personal in that sense. But they do know that I have a life out there. I sometimes think there's information and then there's too much information. Exactly, that's a good way to put it. There's information and there's too much. Yes, in the back. I wonder what your recommendation is. I supervise resident psychotherapy and I'm seeing more and more cases being brought where the patient is a daily consumer of cannabis. In the past, it's been alcohol. My training always was you really can't do this kind of work if you are constantly intoxicated. But now we're seeing the so-called psychedelic enhanced psychotherapy. So I'd be interested in your perspective. Well, it feels to me like coming into a movie after it's already started. My father was a professor of philosophy and humanities at Stanford. And he was very interested in psychedelics in the 50s. And that's when psilocybin and LSD were around and he was quite enthralled with that. And they were trying to use that to treat alcoholics and all kinds of things. And it didn't do much and wound up getting turned into a criminal activity. So I started out with an attitude that, oh God, this is. But so I think in general with medications, if the emotions are so overwhelming that the person can't function, then that's a time for medication. And I suppose that cannabis works as well. I do have very strong feelings about cannabis because I've seen so many adolescents who's, and nobody talks about this or very few people whose emotional growth and development stops dead when they start smoking pot on a regular basis. It just quits. And so they don't learn their identity. They don't earn impulse control. They don't have their own values. They don't learn to have deep relationships. All of the important things that you acquire as an adolescent, they don't get. And when they're 25 and they finally get sick of it, then you're starting with a 14 year old and you're working on the development. So I have a kind of a dim view and I just say to people, and does it have an effect on therapy sessions? I heard a reasonably good discussion about that the day before yesterday that it probably is not good. Basically, I think that's the takeaway that it makes people just not care that much about things. And so they're not as engaged in the process. The psychedelics, the way I think about psychedelics is that they're very similar to a revival meeting. I read early on a book that was extremely influential for me about how people internalize values and it's called Snapping. And it's about sudden change in people and how they can have an experience where they suddenly, it feels very physiological. There are a lot of bodily changes that go on and they've come out with a whole new set of values and join a cult or something like that. Or it's same thing works in brainwashing. So I think that psychedelics kind of reshuffle the cards and allow them to come back together, usually in the same old configuration. But I did have one patient who was a creative guy who couldn't finish his film project and was inhibited. And we were just about to the point where he was really ready to understand that his sense of unworthiness was needed to be replaced with something better. And he went and had one of those ayahuasca sessions and came back and finished his film project and he was okay. So I think we had done all the preparatory work for him to benefit from that reshuffling of the cards. So my guess is that that stuff maybe works occasionally, but most of the time it's a wow experience and then you're gonna come back to where you were before. Thank you. Well, thank you again. I really appreciate the kind of skeleton of organization to how to think about this. I have kept one psychotherapy patient, although I'm working in the inpatient mental health unit. This is a patient who's about 30 years old, was really verbally abused, observed physical aggression, stepfather against her mother. Locked her in the attic and her brother for a long time. She witnessed shortly after her mother was murdered by the stepfather, observed her mother dead. And so a lot of trauma. She locked herself metaphorically in the attic for years and now she's trying to come out. And so your description of this kind of activation as she tries to grow in her relationship with her partner, as she tries to grow at work, it's exciting. And I can recognize from what you said, this kind of disconfirmation that she's presenting to me. So she's had success and then, and then she had some not successful at work and in her relationship. She had some what? She had a couple of experiences, both at work and at home, where someone complained about something that wasn't true. Yeah. Okay. So, and she was able to recognize that that was not true. This is a behavior pattern she's used to, people yelling at her for something that she didn't do or wasn't responsible for. And when I approached her about it, it seemed like she wasn't wallowing in it. It seemed like she could recognize it for what it was untrue, both at work and at home. But her response was, no, I'm actually wallowing this. I can't get out from under it. So she started the session recognizing successes. Then she mentions these two examples at work and at home. And I didn't know what to do. Well, my word for that is backlash. That when people do something against their own internalized values, they feel shame or guilt about it. And very often in therapy, we're helping people to do things that are healthy when they have internalized attitudes that are unhealthy. And so the woman who joined the boxing club, after she did that, she had a terrible backlash. There was a period where she thought, oh my God, I'm worthless. I need to kill myself and things like that. So it was really dramatic. And we had to then go back and try to help her repair that, which ultimately worked out. But I think you've done a wonderful job with your patient that she's trying these new things and development involves the same change process. You know, when you do something that you haven't done before and it's successful, you have an activation of your anxiety. And at the same time, you have disconfirming information that says, no, this is okay. It actually works. But the superego gets involved and that's a whole nother conversation about this superego. I use the word superego because it's much better than the word conscience. Conscience is a value laden word, but superego is not. It's a good scientific word that talks about the function in the brain to keep us on the straight and narrow because sometimes the conscience gets the wrong idea about what the straight and narrow is. And it might be, you know, devaluing yourself. She seemed really uncomfortable and that's what I recognize. You're really uncomfortable recognizing that these two different people were saying things about her that she knew were not true. And maybe just sitting there with her in that. I think I would be exploring those internalized sense and attitude that she's always wrong and how it's uncomfortable to actually acknowledge that she's right. I'm not 100% sure if that's what's going on, but it sounds like it. I think so. Yep. Thank you. Being a clinician is fun, right? Okay, I think we're out of time and thank you very much for your attendance.

therapeutic approaches

emotional trauma

healing moments

memory reconsolidation

psychotherapy

amygdala

emotional responses

affect

extinction process

mindfulness

cognitive interventions

trauma processing

therapy effectiveness