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In This Chapter:

Catharsis Heals Painful Feelings

Internalization Sets Values, Attitudes, etc.

Distinct Early Life Origins

Catharsis and Internalization at Work in Healing and Growth

*Reference to original article with detailed coverage of this topic.

Chapter 1: How People Change:

Two Irreducible Change Processes*

Breuer's experience with "Anna O." gave psychotherapy its first glimpse of healing. As the patient talked and her doctor listened, she re-experienced events and the emotions that accompanied them. After each session, the conversion symptoms associated with the traumas she recounted resolved permanently. As Breuer described his case to his friend, Sigmund Freud, the latter was excited because the treatment represented an alternative to the hypnotic suggestion that was the standard of the day. Freud recognized a more natural therapy with superior results. He called the healing process, "Catharsis." The academic community has largely abandoned this term, however, it remains accurately descriptive of what we have all experienced, so I have chosen to resume its use.

Catharsis

Those who have studied the healing of painful emotions and trauma have realized that processing or healing painful emotions is the same whether the emotions come from old events or current ones. This healing is familiar to all of us. When we experience something painful, the act of sharing it with a friend or family member provides remarkable relief. Sometimes one time is enough, and sometimes, we need to explore different aspects or levels of depth of the experience. Each sharing, initiates healing for that part of the experience. There is common agreement that the necessary ingredients are telling and feeling. In addition, patients and lay people are aware that having a trusted person as a witness is a also a key part of the process. Scientists have had some trouble accepting this latter component, perhaps because it takes away from "objectivity." Though scientists have been reluctant to recognize the importance of an empathically attuned other, practically every sientific description of healing does include the presence of such a person. In the discussion of childhood origins below, I will show why the other person is necessary.

The notion that healing of painful emotions is "structural" is supported by the fact that unprocessed emotions can, and frequently are, held for decades or even a lifetime until they are subject to catharsis.

 

Internalization

Work with trauma survivors shows that catharsis, alone, is not enough. When painful memories have healed, survivors still suffer from bad feelings about themselves. A universal part of early life trauma is the internalization of negative attitudes towards oneself. These attitudes are easily explained as a survival mechanism. Children "identify with the agressor," that is, they adopt attitudes "in sync" with those of their abusers in order to maintain a connection with someone. This is not a surprise because we know that, under stress, even adults experience a powerful need for human connection. What is remarkable is that these negative attitudes, once internalized, are powerful and resistant to change even when the trauma is long over. It is this resistance to change that strongly contrasts with the rapid action of catharsis and suggests an entirely different mechanism.

Examination of this phenomenon has convinced me that the mechanism of internalization in trauma is the same as that which gives us a conscience and our sense of pride and shame. In psychoanalytic terms, this means that the mechanism of traumatic internalization is the same as that of the formation of superego values and prohibitions. For example, we learn to control our bowels early in life and to feel shame when we fail. Many years later, in old age, when involuntary incontinence occurs, we still feel the shame we learned as children. The internalization of childhood values, prohibitions, etc. has similar lasting power and presumably the same mechanism as the traumatic internalization of low self-esteem. Furthermore,he process of internalization of new, positive attitudes in therapy will be seen once again to have the same characteristics.

Therapy with trauma survivors shows that the negative attitudes are not actually removed. They are layered over with new, positive ones rather than eliminated. For this reason, unlike catharsis, the the healing is not always permanent. There remains a susceptibility to re-activation of negative attitudes under adverse conditions. The therapeutic process is easier if there is a history of positive experiences prior to trauma. Awakening these earlier positive attitudes is much easier than building them anew. Where do the new, positive values come from in therapy? Just as with the internalization of childhood values and that of traumatic ones, the healthy positive attitudes and values come from an important person. Typically the source is the patient's perception of the values represented by the therapist and the therapy. Once again, the impetus for internalization is the need to reinforce and assure an important human bond, the bond with the therapist.

 

Early Life Origins of Catharsis and Internalization

The ability to utilize the mechanism of catharsis begins at 9 months of age when the infant (according to Daniel Stern) is able to sense and reciprocate empathic attunement in the mother. When the toddler falls, her first action is to make eye contact with her mother. Depending on the mother's reaction the child will get up and go on playing, or will begin to cry. The child utilizes the mother's affective attunement to regulate her own emotions. This major mechanism for regulating affect continues to be useful throughout life. As adults, when we encounter adversity, the presence of an understanding witness has a powerful healing action. The same mechanism is at the core of catharsis, making it possible for the sharing of painful experience with an empathically attuned other to bring permanent healing to the distress of emotional trauma.

According to Allan Schore, the mechanism of internalization does not become available till age 18 months. At that age the neurological development of the prefrontal cortex makes the emotion of shame available. It is shame that allows the child, for the first time, to have an internal feedback system to control his or her own behavior. By controlling his or her behavior, the child can avoid painful experiences by pleasing important others. This new self control would not be possible without the internalization of templates of behavior. This is the first use of internalization. As the conscience or superego develops, attitudes, values, prohibitions and ideals become lasting elements of the personality. Their resistance to change that gives the personality it's powerfully enduring quality. The mechanism that allows for the formation of these important mental contents is the same one that later causes internalization of negative attitudes in trauma and positive ones in psychotherapy.

The separate origins and functions of Catharsis and Internalization confirm and highlight the need to view them separately as we seek to understand what is going on at any moment in psychotherapy.

 

Non-Structural Change Mechanisms

In Chapter 10, on Behavior and Cognition, more attention will be paid to two change processes that are important, but not structural. Ideas are subject to almost instantaneous change. They are fluid, and change spontaneously without resistance.

When we see evidence that an idea we hold is not correct, then we "change our minds." The process is fluid and effortless. Ideas and thoughts are not entrenched, and are not resistant to change unless there are feelings or values, etc. holding them in place. Note that the word "cognition" is not employed here. Cognition is a much broader term covering such mental contents as non-verbal cognition as well as the formulation and storage of values and attitudes, the subjects of internalization. Therefore, in discussing those mental contents that are volatile and easily changed, the word "idea" is more accurate.

Behavior patterns, or habits, like ideas, are also "fluid" in that they tend to change by themselves without effort. However, they are "viscous." They slide from one configuration to another more slowly than ideas. Behavioral schemas change gradually with repetition, rather than instantly. We often "practice" new behavior patterns or schemas in the course of learning new skills or unlearning bad habits. This kind of learning is closer, if not identical to what Learning Theory has so thoroughly described. However, they are not structural. When no longer useful, they gradually extinguish. Behavior patterns that become entrenched are those that are supported by values or feelings. When the values and feelings are modified through catharsis and internalization, then the behavior patterns tend to change. A conscious effort to change behavior patterns may also de-stabilize feelings and values, bringing them into question. Thus, behavior change also has an important role in therapy, but is not considered structural. All structural change comes down to healing of feelings through catharsis and modification of values, attitudes, etc. through internalization.

 

Two Mechanisms For Structural Change

Catharsis is responsible for the detoxification of painful affects. Internalization is responsible for the acquisition of new attitudes, values, ideals, etc. Together the two mechanisms explain the known effects of psychotherapy in all its varieties. This is a strong statement. The support for this view is woven into the rest of this website, however a some examples of different types of healing and change will help to show how it might be true.

Before moving on to examples, it is important to note that, in cognitive-behavioral circles, the word "desensitization" would be used in place of catharsis. I have avoided the word desensitization because it generally connotes a repetitive process. According to my own and many others' observations, cathartic healing is a rapid process that does not necessarily require repetition. I believe the idea of repetition is a hold over from learning theory, and is not necessary for catharsis. Other than that, the two concepts describe the same phenomenon. I don't believe there is any real difference.

Similarly, those of a cognitive-behavioral bent, might want to substitute "clarification of incorrect cognitions" for the term "internalization." I believe that the concept of internalization is more faithful to the semi-permanent quality of internalized values. Again, I believe that the two concepts actually refer to the same clinical phenomenon. Now a few examples:

Trauma: The action of Catharsis and Internalization are found in their most pure forms in the treatment of trauma, where the healing of painful affects and the modification of internalized negative attitudes covers a large part of the work. Much of the time in trauma work, the therapy is focused on one process or the other, catharsis, or the revision of pathological internalizations. However, in cases of complex PTSD, working with problems of trust may bring the two healing modes together. As the patient takes emotional risks, it is catharsis that softens the fear of betrayal. At the same time, the patient internalizes positive attitudes towards the other person and towards the experience of needing, where previously, any temptation to depend on an other would have caused feelings of shame. Simultaneous catharsis of painful feelings and internalization of new attitudes is typical of the therapeutic action involved in the resolution of personality disorders as well as trauma.

Depression: Cognitive therapy was originally developed as a treatment for depression. Depressed patients, like trauma patients, show a preponderance of negative internalized attitudes towards the self. Whether these are resolved through persistent, patient interpretation or by cognitive interventions is of little importance. In either case, the resolution of the negative attitudes that characterize depression uses the mechanism of internalization. Secondarily, when the patient begins to adopt new attitudes and behaviors, an initial sense of shame or guilt can be expected as the old negative values are violated. Resolution of these painful feelings takes place quite automatically, but again involves the mechanism of catharsis.

Internal Conflict Resolution: In psychodynamic terms, the resolution of internal conflict will require both catharsis and internalization. Conflicting goals or values will require new internalizations to modify the ones that are least in tune with healthy life. Again, as in depression, change brings uncomfortable emotions, whose resolution through catharsis is a central part of "working through." Similarly, prohibited oedipal wishes may require both internalization of new values, as well as cathartic healing of feelings of shame and loss before infantile wishes can be grieved and eventually relinquished. Here again, both processes typically work in tandem.

Transference Resolution: Finally, the resolution of the transference is largely a job for cathartic healing. As the patient finds him or herself experiencing inappropriate feelings toward the therapist, it is the presence of a non-judging, empathic therapist/witness that can make the experience tolerable and allow healing to take place.

 

*This material was originally published in greater detail in the following article:

Jeffery Smith, MD, (2004) "Reexamining Psychotherapeutic Action Through the Lens of Trauma" Journal of the American Academy of Psychoanalysis, 32(4), 613-631.