Therapy

Are You Ready for a Universal Model of Psychotherapy?

We describe a common infrastructure that underpins all schools of psychotherapy.

Posted Nov 19, 2020

Photo by Possessed Photography on Unsplash
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Source: Photo by Possessed Photography on Unsplash

Ben Johnson and I wrote an article two years ago proposing a universal model of psychotherapy including the pathology we aim (primarily) to change and the mechanisms by which psychotherapeutic change can take place. The article in its present form (revised after one round of peer review) just passed 800 reads on ResearchGate, though we have not yet found a publisher.

What is the use of developing a universal model?

The article describes the common infrastructure that underpins essentially all schools and orientations of psychotherapy.

  • Having a common model makes teaching and learning simpler and more efficient.
  • Conceptualizing the common infrastructure provides a kind of Rosetta Stone to translate between seemingly incompatible constructs belonging to diverse schools of therapy.
  • The model describes components of psychotherapy theory that have historically been the least thoroughly described, and thereby supports, rather than challenges existing schools and techniques.

The Affect Avoidance Model in brief

The core concept of the model is the hypothesis that entrenched maladaptive patterns of response (EMPs), which are the primary targets of psychotherapy, are universally triggered by deep emotions located mainly in the limbic system. These deep emotions are essentially always of negative valence because that is how the brain signals threat and EMPs constitute protective responses to threat. In other words, the problems psychotherapy aims to change represent some form of “coping gone awry.”

This brief statement requires a bit of explanation. First, in the article, we call them EDPs, with the “D” standing for dysfunctional. The Convergence SIG of SEPI has settled on EMP, where the “M” is for maladaptive to emphasize their evolutionary purpose. Otherwise, the two are the same.

Furthermore, the avoidance of deep emotions comes in many forms. The most primitive are responses like freezing, depression, and panic, which have evolved far up the evolutionary tree before humans or even primates existed. Next are responses that become embedded in attachment patterns and personality traits. These are often responses to adverse conditions during the first years of life. They may have a genetic component as well as representing adaptation to the human environment. The avoidance strategies they represent often reflect the limited cognitive abilities of very young children. Third, are problems resulting from developmental deficits. Development is the result of experience and developmental deficits are often the result of a lack of exposure to important experiences. The result is a failure to develop important skills. The absence of an adaptive response or the resultant expression of a more primitive response (for example the emotional breakdown of a borderline patient) is, in fact, a form of entrenched maladaptive response.

Further along the developmental scale come an impressive variety of automatic thoughts, feelings, impulses to act, and visceral changes, any of which can secondarily trigger the consciously chosen avoidance patterns that are the targets of CBT. In this way, the wide variety of maladaptive responses that can be addressed in psychotherapy can all (we believe) be explained as the mind’s attempts to mitigate threats through avoidance of the mind’s proxy for danger, namely, deep emotions of negative valence.

For clinicians, the best indicator we have of the activation of deep emotions is affect, defined as conscious feeling accompanied by visceral changes. For this reason, we have called the model the “Affect Avoidance Model.” This is important because, as it turns out, change in existing maladaptive patterns requires that the triggering emotions must be activated. More on this below.

Now that we have a universal description of the pathology that is the primary target of psychotherapy, we can look further at the characteristics of EMPs. Most important, as implied by the word “pattern,” these problem responses tend to be repeated. The implication is that they must therefore be stored in memory, mainly implicit memory and we can describe psychotherapy as an operation aimed at replacing old patterns stored in memory with new ones learned through experience or conscious learning.

As it happens, this is where notions from the world of psychotherapy converge with recent neurophysiology. Detailed studies of the learned fear response, among others, show, so far, that there is only one known mechanism for modifying already laid down patterns of appraisal and response. That mechanism is memory reconsolidation, which happens when the old pattern is neurologically activated in a context where new information contradicts what is predicted. This converges precisely with what Alexander and French described in their analysis of the Corrective Emotional Experience, as well as many other formulations of therapeutic change. An old response is elicited in a context where new information such as the surprising response of the therapist, contradicts what is expected. The new information can be experiential but can also consist of newly acquired skills, sometimes learned through cognitive acquisition as well as experience.

It is also important to note that, while memory reconsolidation is currently the only known mechanism for changing existing patterns, the mechanism of extinction may also play a role in therapy. This pathway is neurophysiologically distinct from memory reconsolidation in that response patterns are not changed but are blocked by inhibitory signals sent from the cortex to prevented their outward expression. This inhibition is temporary and must be reinforced if it is to be maintained. It may play a significant role in psychotherapy but is distinct from change due to memory reconsolidation in that the latter is rapid, permanent, and does not require effort to maintain.

What the Affect Avoidance Model means to the clinician

For us clinicians, this means we have just a few objectives to pursue, which we can do using techniques from many sources.

  1. Support activation of relevant deep emotions as evidenced by affect.
  2. Simultaneously help the patient to experience or learn surprising new information relevant to the maladaptive pattern being targeted.
  3. Help regulate arousal within an optimal window as required for change.
  4. Support motivation to do the taxing work of change.
  5. Maintain the therapeutic relationship, which plays a vital role in all of the above.

What do you think?

We would love to hear what our readers think of this model and the role a universal model of psychotherapy might play in our field.

—Jeffery Smith, M.D.

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References

Smith, J.S., Johnson, B.N. The Affect Avoidance Model: An Integrative Paradigm for Psychotherapy (Major Revision, Final) 2018. Full text available at: https://www.researchgate.net/publication/325871396_The_Affect_Avoidance_Model_An_Integrative_Paradigm_for_Psychotherapy_Major_Revision_Final