TIFT #67: Becoming a Better Therapist

The second day of 2023 seems like a good time to think about becoming an even better therapist. We all have doubts and areas where we can grow. In this post, I’ll share some possible directions for deepening our understanding and practice. 

My training, like that of most of us, was all about applying concepts and methods belonging to just one kind of therapy, in my case, psychodynamic. I can remember dutifully making  my interpretations and hoping they would help. It wasn’t until a couple of years out of training that I finally knew the method worked. That was encouraging, but soon I was confronted with problems for which my training was entirely inadequate: trauma and then addiction. In the late 70s, trauma was considered of interest only to military psychiatrists, while addiction was far from the mainstream and barely respectable.

My transformation as a therapist began when a client experienced a major healing moment that I now recognize as memory reconsolidation. During four years of intensive therapy, detailed memories of early life trauma had remained dissociated and inaccessible. Finally, she was ready. In the course of two extended sessions, the memories came to light in detail. What was most remarkable was that re-experiencing and sharing each facet with full emotion led to permanent change. What she had most dreaded was now no more than a dull ache. This was exactly what Freud had described in his early writings on trauma. He had called it “catharsis.” The only difference between Freud’s description and my experience was that he had neglected his own role in the process. In contrast, I felt intuitively that my presence as an empathic witness was somehow essential.

What brought this healing moment into sharp focus was wanting to help the same client with the chronic low self-esteem that most trauma survivors experience. I tried the same empathic listening and nothing happened. There was no catharsis. A flash bulb went off in my mind. The mechanisms of healing for traumatic memories and for low self-esteem had to be entirely different. Were there yet more fundamental pathways for healing? How, exactly did these two work? From that time on, my focus moved to understanding and observing change processes and how I could support them. 

Most of our field is still based on following methods

The big question was how does therapy really work? Crazily, this is still the biggest mystery in the field, but only because the good news hasn’t spread. Until the 21st Century, no one really knew, so every therapy had to invent its own explanations, usually based on concepts that belonged to that therapy alone and made little sense to disciples of other approaches. There were consequences. Schools of therapy competed, based on who could gather the most disciples or the best looking statistics. Rather than cooperating, they emphasized their differences and told followers that they should not listen to those from the other camps or mix techniques. These turf wars have limited therapist’s ability to adjust to different clients and situations and slowed learning from the wisdom in other therapies, not to mention creating a huge amount of confusion for both therapists and clients.

Becoming a better therapist

The solution is for us to become “lucid therapists,” having a firm grasp on a framework that brings all therapies under one roof and begins to explain fundamentally how clinical actions support change. As we increasingly make use of a universal perspective, we’ll find that we can further refine the old, intuitively-based methods. Here’s an example. Now I know that the abstract concept of “timing of an interpretation” is really about noticing the presence of affect, our best indicator that the channel from cortex to limbic system is open. With the channel open I can choose words that will travel down and illuminate the old pattern with new meaning.

Making the leap from adhering to a method to becoming a student of process is the key to transforming not only one’s personal practice, but the broken politics of psychotherapy as well. As we pay more attention to process, “branded” therapies and the exclusivity of their methods fade in importance. Instead, we find ourselves focused on optimizing our use of a widening range of tools to bring about the elements involved in each change process.

In this post, I’d like to suggest a few areas I think are particularly ripe for deepening our understanding. They are areas where I think today’s training is sometimes lacking and that can yield important rewards in the effectiveness of our work. At the end, I’ll also suggest an overall framework, a “nondenominational,” 21st Century picture of why and how humans develop maladaptive patterns and the foundational ways therapy can change them and improve our quality of life.

Learn about different ego states and inner children

Most therapies proceed as if adult humans are unitary. The fact that our name remains constant supports that fiction, but the truth is that many if not most of the problems psychotherapy aims to address are the direct result of our switching into patterns from earlier times and circumstances. What makes those patterns troublesome is that they are “frozen in time.” They were developed long ago to deal with emotionally threatening situations and remain unchanged because letting them go is perceived by the inner mind as re-exposing us to danger. When our clients are in the middle of one of those responses, they are, for practical purposes, functioning as a child who has not yet completed integration with the adult self. We need to recognize and take into account this functional split. When we address that child client as if they were adult, guess what happens? It’s the same as if we spoke to an actual child in adult terms, meaningless and irrelevant to the child. Have you ever told a small child that “monsters don’t exist?” (Small children don't possess the concept of zero or absence.) It's ships passing in the night. Is this common in therapy? Yes, it is very common, so one way to be a better therapist is learning more about how children think and how to help them grow.

How do these inner children get better? Just like real children. First they have to feel safe (which can be a major task in itself), and then, a little at a time, they need to take risks and go through emotions. Even if the therapist is warm and supportive, the host adult will need to learn not to be ashamed of their own inner child.  Then the child can start to grow to the point of being ready to integrate with the adult self. It’s our job to provide support and guidance to help them do the daunting emotional work. The more we know about development, the better we will be at relating to the stuck inner children we encounter in our offices.

Learn how the conscience is unique

There is a lot of talk these days about shame, but much of it fails to take into account how the conscience, the source of internally generated shame, really works. Understanding the conscience can be a real help doing therapy. I wrote at the beginning of this post about the low self-esteem that usually accompanies trauma. In fact, it comes from the conscience, the aspect of the mind that acts as a self-contained reward and punishment center. The reward is pride and the punishments are feelings of shame and guilt. By the way, those emotions are different from other emotions in that they originate in the cortex, not the limbic system (though they may end up there). And those rewards and punishments are always based on the individual making a judgment. Shame may look like a learned response but what is learned (or more accurately internalized) is a value, attitude, ideal or prohibition. The mind compares reality with the internalized rule and, depending on which side we find ourselves, produces a sense of pride or, alternatively, one of those painful, punishing negative emotions.

What this means for the clinician is that trying to heal emotions of  inappropriate shame or guilt without changing the internalized value won’t last. Values are inherently hard to change. Most therapies mix them up with other kinds of mental contents and assume that changing them is easy. In fact, values are probably indelible; the evidence is that low self-esteem can so easily return. Change involves activating healthier values to override the inappropriate ones. To activate healthy values, we need to help our client be very clear that they have internalized something pathological from someone who should not be trusted, and, most important, to start behaving in ways that are contrary to the internalized attitude. Note that here is a place where improved understanding shows how therapies that prohibit “telling clients what to do” can be counterproductive. Thus, one more way to be a better therapist is to recognize internalized values and give them the respect of knowing that changing them requires internalizing new values or awaking older, healthy ones, and that that is a slow and hard process.

Learn that a lot of the “pathology” we see is really arrested development

I’m back on the subject of development. How much of adolescent trouble is being diagnosed as anxiety or depression, when it is really arrested development? How often is it that the young person who can’t launch has some sense of how far behind they are and how scary and hard it will be to catch up? They understandably want to escape, and it’s so much more comfortable for young people and families to give the problem a diagnostic label and seek one miracle cure after another.

Adolescents aren’t the only ones. My definition of adulthood is “having a subjective sense of full ownership of one’s own life.” When our clients can’t stop looking outside themselves for the source of their trouble and what needs to change, it is a good clue that they may not have fully achieved that major developmental step. While we may be uncomfortable with the idea of an adult who hasn’t finished “growing up,” clients are often quite receptive. Besides, it is easier to grow new skills and mastery than to have first to let go of negative patterns from the past.

Learn in detail about “clinical memory reconsolidation”

Maybe the thing that can bring the most benefit in 2023 is to become a master of the healing moment. Those are the moments that Alexander and French called “Corrective Emotional Experiences” and that many people call mindfulness. They are the moments when the mechanism of memory reconsolidation allows old patterns to be re-written permanently in limbic memory so that we no longer dread things that once seemed too terrible to get near. They are also moments when old assumptions about life can suddenly be seen in a bigger context, where they lose forever the deep sense of truth they once had.

Every therapy has a way of recognizing these moments, but most are limited to waiting for them to happen. We can do far better when we understand the elements. First the old pattern needs to be awakened in the limbic system. The way we know that is happening is affect, those involuntary bodily signs that emotion is going on deep down. Then there needs to be illumination in the light of a larger perspective. That can be the warmth and calm communicated nonverbally by the attuned therapist, or it can be more of an idea, such as that “it’s not your fault.” The two elements, activation of the old pattern and illumination in the light of a new perspective, have to take place at a moment when the channel between consciousness and limbic neurons is open. And, by the way, science also seems to be saying that sleep over the next few hours can cement the change.

The better we get at encouraging activation of old patterns and helping to provide illumination from new ones, the more effective we become at supporting enduring change by the mechanisms of memory reconsolidation.

Understanding how therapy really works

I said I would talk at the end about an overall framework. Each of the areas I have outlined above can be placed in a universal framework relevant to every therapy. If you don’t possess such a framework, I would be glad to share the one I use. I’ve boiled it down in a newly revised infographic and eBook. For your copy, Click here. or the red button below.

My own new year’s resolutions are to learn more about just how the body keeps the score. It seems to involve our human ability to inhibit natural responses, which become frozen. I’ll also be working on how values change and on the details of the healing moment. I hope 2023 will be a year of abundant personal growth for each of you in both your work and life.

Jeffery Smith MD

Photo credit:  Weston M. Unsplash