It’s All In Your Head

By Jeff Levy

Illustration of human head with segmented descriptions of parts of brainI was talking with a colleague who recently completed her graduate degree in counseling.  We were discussing one of her cases—a young man who had experienced considerable trauma as a teenager.  Her client knew he had experienced the trauma, but didn’t have clear memories around it.  She was concerned about how much she needed to delve into his traumatic experiences in order to help him heal.

My colleague had taken a trauma course in graduate school, and said that it was one of her favorite classes.  Some of the content in the course, all of which seemed current and relevant, included the study of the neurophysiology of trauma and the impact of trauma on neurodevelopment.

“One of the things I remember so clearly, is my professor telling us not to do memory retrieval work,” she explained.  “He said that if a client doesn’t have specific memories, there is a reason, and we shouldn’t ‘poke the bear,’ so as to not accidentally implant or suggest memories.”

On one level, I agreed wholeheartedly with what her professor had shared.  At the same time, I was thinking about her case through a different lens.  “You’re already doing memory work,” I offered.  I could see her contemplating what I’d said, and trying to reconcile it with what her professor taught her.

“Watching the way your client walks into the room, the way he sits down, how he is breathing, the tenor and tone of his voice, changes in his facial expression….and even his breathing…is all memory work.”  I continued to talk about how our memories are not just pictures and narrative stories, but can also be physiological and emotional memories related to trauma or other aspects of our history.

In the graduate social work class I teach about trauma informed practice, one of the main content areas of the course is the study of trauma and the brain, including a discussion of brain structure and function, with a great deal of discussion about memory.  When teaching about the brain and memory, I talk about how psychotherapy is often about making implicit memories more explicit, and making explicit patterns more implicit.  And although I talk about this in the context of a trauma course, I believe it’s relevant to all the work we do as psychotherapists.

Sara is a 55-year-old financial advisor and one of my longer-term clients.  She has been seeing me because of relational difficulties both at work and in her personal life. When we began, we spent many hours talking about how worthless she felt, and how badly people treated her.  This manifest in numerous romantic relationships with women that ended because of emotional and/or physical abuse.  And at work, Sara experienced her bosses as unsupportive and unavailable, and her coworkers as untrustworthy and sabotaging.

A veteran of psychotherapy and a voracious investigative reader, Sara knew a great deal about the process of psychotherapy.  Early in our relationship, she vacillated between being angry with me if I was a few minutes late to start a session and frustrated when she knew more about a topic than I did.  She frequently canceled sessions.  Or when she arrived late and I told her I’d still need to end at the same time, our sessions were spent dealing with her feelings about me being unfair and uncaring.

There were also sessions spent talking about the logistics of her day or week, and then when I shared it was time for our session to end, she would share something deeply troubling for her.  Even as I tried to end the session, closing my notebook and sometimes standing up, Sara continued to talk, becoming more and more tearful.  I was almost never able to end sessions on time.

I had the urge to explain myself to help Sara understand the reasons for these boundaries around sessions.  The few times I attempted this, she only became more angry and shut down.  At one point, at the conclusion of a session, she tearfully and haltingly told me how disappointed she was with me.  “We don’t talk about the things that are really bothering me.  I don’t feel like I’m getting any better.”

One of the most difficult things to hear from a client is that I’m not helping, since that is the very foundation of the work we do, and certainly why I chose to do this work.  At the same time, I knew I couldn’t talk with Sara about her feelings in any depth at that moment.  First, because she shared it several minutes after the session had officially ended.  And second, because I needed to work through my own feelings before being able to be fully present to hers.

Understanding our Defaults

Back to my discussion with my students about making the implicit explicit, and the explicit implicit.  When we talk about implicit memory, we are typically talking about procedural memory, or thoughts, behaviors, and patterns in which we engage that are no longer conscious.  These thoughts and behaviors came to exist because we engaged in them enough times that they became a “default” way of moving through the world.  The more we repeat patterns, the more we reinforce the neural circuitry of those patterns.

For example, most of us learned to tie our shoes when we were little kids.  When we were first tying our shoes, we may have reminded ourselves (or one of our caregivers may have reminded us) to put one lace over the other, or to put one loop through the other loop, or to repeat in our minds what we had been taught in order to tie our shoes.  We had to engage in an explicit process to ensure our shoes were tied.  Explicit memory requires conscious thought; having to consciously think ourselves through tying our shoes based on our memories of what we were taught.

As adults, we probably don’t even think about tying our shoes anymore.  It happens automatically and doesn’t require our conscious attention.  The process of tying our shoes has become an implicit.  This kind of process also occurs when we learn to ride a bicycle and is one of the reasons you may hear people say:  “Once you learn how to ride a bike, you never “forget.”

This idea of implicit and explicit memory can be applied to almost all of our thoughts, feelings, and behaviors.  When we’ve experienced something enough times, we don’t have to explicitly recall our responses because those responses have become implicit, automatic, or unconscious.  So in many ways, the process of therapy is about making the implicit (or unconscious) ways we navigate the world more conscious (explicit), and then learning new ways to navigate the world (also explicit), until the new strategies have become automatic (implicit).

For Sara, her experiences of neglect and abandonment were so consistent and so profound that she had come to implicitly expect neglect in the context of almost all relationships. Her affective reactions to interactions with people were also implicit, with her frequently feeling abandoned and rejected, even when that was not the other person’s intent.  And with those beliefs and attributions occurring so automatically, a cycle came to exist that reinforced implicit memories Sara had developed about relationships.

Default Patterns in Relationships

At Sara’s next session, I began by asking if we could talk about what she’d shared as we ended our last meeting.  “I don’t really want to talk about it,” she said sharply.  “It’s over and there’s really nothing to talk about.”

I continued with trepidation:  “Might you be interested in some of what I was feeling as you were leaving?”

She clearly wasn’t expecting this question, and I could tell she was trying to decide if she wanted me to continue.  “OK.  “But I thought this whole thing is supposed to be about me!”

“This is about you,” I offered.  “And it’s about me.  In fact, it’s about our relationship with each other.  And I think there may be something that’s happening between us that happens in other relationships, too.”

This had Sara interested, since we’d not ever discussed our relationship so directly.  “You shared with me that I’m not asking the right questions, and you don’t think I’m helping you, right?”  She nodded.

I forged ahead.  “I was surprised when you shared that with me, because it’s not something you’ve said so directly to me in the past.”

“You should know those things,” she said with mild irritation.

“Exactly!” I said.  “You believe I should know things that maybe I can’t know because you haven’t told me.”

With more irritation and frustration, Sara responded loudly, “I have told you those things before!  You just don’t listen.”

I knew this was exactly where we needed to go, though a small voice of my own, coming from my own implicit memories whispered “See, you really don’t know what you’re doing!”

“Sara, do you think it’s possible you’re telling me how you feel and what you need, but maybe not in a way I understand?”

“Like how?,” she challenged.

“Well, I don’t think I really knew how disappointed you were in me and how much you felt like I wasn’t helping.  I absolutely want to know those kinds of things so that I can make the changes I need to make in our work together.”  This generated some conversation and eventually we got to the point where Sara also began to wonder how direct she had been with me about her feelings and about what she needed.

“I could be more direct?  Is that what you’re saying?  And you think I do this with other people too?”

More as a question than a definitive statement I  responded:  “Well, I wonder if this happens more than you’re aware of?  And if that’s the case, is it possible that other people are disappointing you and letting you down and they don’t know it?”  I was sure this was a therapy “light-bulb” moment.  I anticipated a revelatory response.

“I don’t know.  Probably not,” she countered.

We spent a number of weeks after that session continuing to talk about that one interaction when Sara told me I wasn’t helping her.  Slowly and eventually, we got to the place where she allowed herself to be curious about how she does or doesn’t ask for what she needs from people.

Sara saw some of the ways her childhood neglect resulted in knowing her needs would not be met and that it was safer to assume this in current relationships.  She spontaneously came to the conclusion that she didn’t ask for what she wanted because she knew she wouldn’t get it; that asking made her too vulnerable.  She saw that she was doing this with me, in therapy, as well.

We talked about how this was an unconscious pattern (an implicit behavioral and affective memory) for her, and one that was strengthened by years of practice in her relationship with her mother.

When we made this pattern more explicit, Sara and I were able to talk about explicitly testing this out in her relationship with me; asking more directly for what she wanted and needed, and seeing how I responded.  While there are still times Sara expresses disappointment in me, she is more direct and immediate about it, and we’re also able to talk about the extent to which she feels she was direct in asking from me what she wanted.

Can Fingers Remember?

When I was growing up, I took classical piano lessons from the time I was 7 until I graduated high school.  When I was 13 years old, my piano teacher held a recital for many of her students, and some of the students of other teachers with whom she worked.  It was the largest recital I’d ever played at with over 100 students and their families in attendance.   Although this was 45 years ago, I’ve replayed it many times.

When my name was called to come to the front of the room and play, I sat at the piano, rested my hands on the keys, closed my eyes for a moment, and then opened them to begin playing Bach’s First Invention.  We were not allowed to use music at this recital.  It was expected that each of us would have memorized what we would be playing.

I remember my heart racing while I watched my fingers move over the keys.  I was several measures into the piece when my right hand faltered and my mind went blank.  I started the piece over and got to the same place and faltered again.  I tried this four more times, each time stopping at the same place.

I felt everyone’s gaze and my legs begin to twitch, readying myself to run out of that room as quickly as I could.  I don’t know how I managed to start the piece one final time but as I approached the place where I had stopped six times previously, I heard my piano teacher from the back of the room:  “C!” she said loudly.  “The next note for your right hand is middle C.”  And as she said that, I consciously guided my thumb to middle C, and was able to finish the piece without any other disruptions.

For most of the time I took piano lessons, my teacher tried to explain the importance of not relying on “finger memory.”  She encouraged me to visualize the music as I was playing; to think about the key, the sharps/flats, and the time signature.  I was never particularly good with music theory, so while I nodded my head in acquiescence, I continued to memorize by playing something over and over and over again.

It’s All In Our Heads

Today, I understand my brain was creating procedural or implicit memory.  While my piano teacher referred to it as “finger memory.”  As a kid, I could never understand how my fingers could remember things!  I understand now, however, that she was really talking about not depending only on this implicit memory of my music.  She knew it was important to be able to have some explicit knowledge of the way a piece was written so that when my implicit memory somehow derailed, I could consciously (explicitly) re-rail myself.

When I talk to my students, to my colleagues, and to my clients, I return to this way of understanding our behavior.  We’re all comprised of implicit memories that guide us on a day-to-day basis.  We often enter therapy because these implicit patterns don’t serve us the way they used to.  And the process of therapy supports us in learning new (explicit) ways of moving through the world, practicing them in the context of therapy and in our relationships outside of therapy, until they become implicit, or the new “default.”

I’ll also be sure to share with my clients that when we hit bumps in the road, we may not be able to depend on these new implicit patterns to carry us through.  We may falter.  We may have to stop and start again.  But hopefully, as my piano teacher did so many years ago, we’ll hear a voice from somewhere, giving us an explicit reminder of what we need to do next.

And like I did 45 years ago, we’ll find that “middle C.”

“We, as human beings, are landed with memory systems that have fallibilities, frailties, and imperfections—but also great flexibility and creativity.”
Oliver Sacks

By Jeff Levy, LCSW, CTRS

Published on January 10, 2018