A couple of weeks ago I attended the annual conference of the Association for Psychological Science (APS). APS was founded twenty years ago by psychologists and neuroscientists who were dismayed by trends in the American Psychological Association (APA). The APA had lost its old single-minded focus on the search for empirically based answers to psychological questions. This may have followed from the fact that the APA’s membership encompassed an ever-larger percentage of practicing psychologists with many immediate, practical concerns. Yet it is these very clinicians who are in such dire need of empirically validated procedures. For example, a common clinical procedure, assumed to be therapeutic, is catharsis. Yet the recent APS conference offered still more evidence that in many if not most instances, catharsis can be harmful rather than helpful. This is a point of view that I had personally expressed in a number of my own publications. Rather than walking away pleased at confirmation of what I had already concluded, I was dismayed by the realization that this newer literature with its important findings was not well known in the clinical community. I thought it might be time to summarize this newer, empirical literature on the effects of the expression of emotion, and on the frequently negative consequences of catharsis, while offering a concise description of the validated alternative procedures.
There are four closely related axioms that can be abstracted from the empirical studies on emotion and its expression. They each offer implications for treatment, or even how individuals should deal with their own experiences of emotional trauma.
1) Expression of strong negative emotions usually enhances the strength of these emotions and keeps them in focus, as opposed to dissipating them. Overt emotional expression, like other behaviors, carries self-defining information. That is, if you see yourself trembling, you’ll be convinced that you are afraid. Screaming will have the same effect. Expressing how frightening it is adds confirmation. Most of us have observed somebody “working himself into a frenzy.” But because of the impact of psychoanalytic thinking in our culture, we assume that catharsis has the effect of dissipating emotion, rather than recognizing the common experience (now supported by research), that fully expressing strong negative feelings will, more often than not, increase the feelings.
2) Given one encounters a distressing experience, focusing on the discomfort will make it worse. Noel-Hoeksema is famous, at least in some circles, for developing the concept of rumination. After a negative experience, asking “what am I feeling”“ ”why am I feeling this?” “What does this mean?’ “How long will this last?’ will prolong the experience. This type of rumination will lead to even more rumination. Changing the focus, being involved in anything that can otherwise engage you, whether sports, other challenges, or other issues in one’s life, can break the cycle. Sometimes the discomfited individual lacks the ability to change focus to something else. In such cases, even keeping the negative event in focus, the ruminating individual can be helped and encouraged to describe the negative event from a third party perspective. Choose a proper alternative perspective, with less negative implications. Describing, contemplating, and appreciating the event from this other perspective, the hurting individual can find a step by step retreat from the purely negative tone of the ruminative cycle.
3) Depression is partly defined by, and largely maintained by, self-focus. Changing to an external focus will help. Helen Mayberg has achieved recognition for deep brain stimulation of Brodman’s area 25 to relieve symptoms of depression. While nobody knows what function Brodman’s area 25 actually subserves, Mayberg’s patients report that when Mayberg turns off this area in the brain, they want to do something. One patient said that if he were home he would clean out the garage. A crucial difference between cleaning out the garage and being depressed is the presence of external focus ─ operating on the world rather than observing one’s feelings.
4) Positive affect is just as important for well-being as an absence of negative emotion. Barbara Fredrickson has explored the benefits of positive affect on health and cognition. Recent research finds that externally focused positive emotion, such as occurs with loving/kindness meditation, has a more powerful effect on health than self-focused positive emotion (hedonism or pride). The work on positive affect is very consistent with Fava’s recommendation to find traits in others that please you and focus on things for which you are grateful as a mechanism for treating depression (Journal of Personality, 2009).
In summary, following trauma, do not focus on the discomfort, do not focus on one’s self other than for positive assessments, and the experience should be reframed so that it is seen in a less negative light. Assuming the presence of therapists, the therapists should be assisting the clients in identifying positives in their daily lives. Identifying personally embraced goals and developing active behavioral strategies for achieving these goals is a useful practical road to shifting the focus away from internal focusing. A seeming contradiction to this advice is seen in the empirically supported technique involving extinction of fear (usually called re-exposure therapy, or flooding). Extinction of fear entails exposing the client to the terror-eliciting stimuli and then waiting the requisite 15 minutes for the terror to dissipate while no actual disaster occurs. But outside of war, extreme fear is not a frequent source of trauma and precipitant to seeking help. There is little evidence that extinction works well with other emotions. And extinction of fear through forced exposure is not really an example of the cathartic method, in that instead of the client emoting, the client remains passive while exposed to the stimuli associated with the trauma.
So why is it that the assumption that the mere expression of emotion is helpful, is still so widely embraced? Freud’s perspective was based on views on energy that were just beginning to be fully appreciated and fully utilized at the turn of the century (1900 not 2000): energy can be converted from one form to another but energy can neither be created nor destroyed. This physical principle was applied to human emotions and formed the basis for the catharsis hypothesis: emotion is trapped in the body where it causes symptoms, and is expunged or dissipated if externally expressed. But as previously discussed, that is seldom what occurs, and Freud’s view of emotion fails to comport with contemporary views of emotion: emotional reactions are determined by how one appraises the situation and/or by which situation one chooses to focus on or appraise. If there is a simple bottom line to this literature, it is that in order to ameliorate distress; quickly find something else to think about. For the longer term, change how you view the situation.
A final note on this issue. Since catharsis frequently prolongs emotional upset, and is frequently utilized, harm is being done. Yet we all believe in the first principle of doing no harm. Hopefully, disabusing the mental health community of the idea that catharsis is generally a good thing, may help us to follow the widely approved maxim: do no harm. Confusion on this topic should no longer be tolerated.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.