TIFT #39 Psychotherapy's Near Surrender

We've almost given up on theory and it matters

Joseph Priestly, a British clergyman and scientist was a believer in the then-current theory of phlogiston, which explained why putting a jar over a burning candle put out the flame. The flame was believed to produce phlogiston, and when the air inside the jar became saturated with the substance, the fire would go out. 

In 1774, two years before the Declaration of Independence, he told the famous chemist, Lavoisier, about an experiment in which he produced a substance that did the opposite. His new,"dephlogisticated air" actually promoted burning under the jar. Lavoisier seized upon the new type of air and cleverly renamed it “oxygen.” Unlike Priestly, who clung to the Phlogiston theory, Lavoisier realized the revolutionary implication that fire does not increase phlogiston, rather, it consumes oxygen. When the oxygen is depleted, the flame goes out.

It took a while for the scientific world to accept Lavoisier’s fresh explanation of combustion, but eventually, it became the accepted paradigm to explain the chemical process of oxidation, more commonly known as burning. Why hasn't the science of psychotherapy progressed similarly towards a commonly accepted explanatory core?

We, like Priestly, continue to cling to old theories

The sad thing about our field, psychotherapy, is that so many of us have given up on finding a universal explanation of how therapy does its work of modifying maladaptive response patterns. I recently mentioned the idea of “theoretical integration,” meaning just such a universal explanation, and a senior researcher laughed. When the subject comes up in the literature, a common conclusion is that we’ll have to keep on exploring and debating (forever). In other words, the field has largely capitulated.

We have mostly given up on the ideal of finding a core explanation of how therapy really works. Instead, we cling to a plurality of explanations. They are not factually incorrect, but like phlogiston they represent our pioneers' best efforts in the absence of knowledge of the underlying core principles. The problem is that each theory applies to one orientation or school of therapy and they are deeply incompatible with one another.

The theory behind classical CBT, for example, says that that irrational thoughts, learned at some point, cause maladaptive responses, and that changing the thoughts is the way to modify responses. How can we square that explanation with the idea from the psychodynamic camp that conflict between unconscious agencies (which CBT doesn’t recognize) cause maladaptive responses, whose resolution leads to clinical improvement.

The problem is that the theories are self-referential. They explain the treatment in terms derived from the method, not independent of it. CBT theory arises from the observation that talking people out of their irrational ideas leads to change. Psychodynamic theory derives from the equally true, but incompatible discovery that making the unconscious conscious can lead to resolution of conflict and to cure.

Modern schools are not so different. Mindfulness-based treatments demonstrate that gaining a larger perspective on emotional distress results in being able to tolerate what was once intolerable. From this observation, one can derive yet another theory that avoidance of distressing experiences (Experiential Avoidance) is the cause of trouble, and that helping people tolerate them is the cure.

Should we just keep on debating? Doing so is an exercise in futility, a conversation of the deaf. Protagonists repeat their formulations but have no place for those of the other camps. There is no meeting of the minds, and the field has largely given up on doing better. So sad!

Do we have a choice?

This situation is no one's fault. Lack of understanding of the basic functioning of the nervous system made psychotherapy's universal core elements unreachable. Just as explaining the inheritance of genetic traits required the discovery that genetic information was encoded in DNA, understanding how repeated maladaptive patterns of response might be modified had to wait for the discovery that such patterns are encoded in neural networks that fire together. But that time has arrived and we do have a choice. Today, we have the ability to rebuild our understanding of therapeutic action. We can do so, based on the fact that repeated maladaptive patterns are held as encoded information and that, based on current research, there are a very limited number of pathways by which existing patterns of response can be modified.

Stated a different way, what has been relatively absent from existing theory is the infrastructure, the core mechanisms underlying familiar change processes. In the absence of a known infrastructure, explanatory theories had to be invented. Like the theory of phlogiston, they had to rely on constructs that seemed plausible, but had little basis other than fitting with the observations of their inventors. Only now, do we have a more universal and independent ability to explain the infrastructure behind the vast accumulation of examples of how words and relational interaction can result in enduring change.

So the answer is, yes. Today, we have the tools to build a core set of constructs to explain in independent terms how talk and relationship do what they do. A few have soldiered on with the idea that a core paradigm might be possible. Marvin Goldfried  (2019) called for such a paradigm and in 2020, the executive committee of SEPI, the Society for the Exploration of Psychotherapy Integration, chartered its Special Interest Group (SIG) on Convergence (with outside science).

For a succinct presentation of one version of such a theory, please see the most recent version of an infographic, developed in consultation with members of the SIG and aimed at describing such an infrastructure in an accessible format. 

How a universal explanation changes practice

As we make second-to-second clinical decisions psychotherapy, it turns out that theory actually does make an important difference. As we navigate the therapeutic space, we generally have an objective in mind. We might be trying to help our client see the irrationality of their thinking or change it. We might be trying to help them become aware of a previously unconscious wish. We might seek to help our client experience an avoided emotion. We might be attempting to bring to our client a bigger perspective or “reframe” an understanding. In each case, the therapist has a goal, and most of the time, the goal is dictated by a theory. We may have learned the theory long ago and since forgotten, but what remains is a method. Too often, psychotherapy is practiced by following a method, limited in its ability to take into account myriad factors that affect outcome.

The impact of having a core understanding is that we can visualize a specific change process and to follow its unfolding. As indicated in the infographic, the essence of our work boils down to three core processes. One is New Learning in which the client becomes aware of and practices alternative ways to respond. The other two, Extinction and Memory Reconsolidation are the only known mechanisms by which expression of existing maladaptive patterns can be modified. Remarkably, they have essentially the same two clinical requirements. One is to reactivate the old, maladaptive pattern with affect and the other is to expose the client to new, surprising information with which to update the response pattern or the appraisal that led to it. When these requirements are met, as they are in the “Corrective Emotional Experience,” updating of existing patterns is set in motion.

Thus, the therapist might focus at a particular moment on of how an old pattern might be activated or how to facilitate exposure to new, more satisfactory information. The tools available for each of these tasks are as varied as the 500+ schools of therapy that have been described. Should I use a two-chair exercise or would I do better to explore in words? Should I instruct? Should I use socratic questioning? Do I assign an exercise or do I wait for my client to discover? Focusing on basic change requirements, it becomes natural to choose tools according to the needs of the individual client, the circumstances of the moment, and the therapist’s personal repertoire. Beyond clinical benefits, this broader view of therapeutic action can facilitate training in multiple techniques without having to become a disciple of each new therapy.

Following process rather than method feels subtly different. It feels free, yet precise. It encourages observing the results of each intervention and taking note of those that work best. To be complete, as indicated in the infographic, there are additional facilitative tasks such as arousal regulation, relationship management, and support for motivation, which, at times may also dictate our focus. Taken together, these moment-to-moment objectives are determined not by method, but by the desire to support the three foundational processes, New Learning, Extinction, and Memory Reconsolidation. 

Incompatibility has been raised as an objection to the mixing of techniques, however, those fears are based on method, not an understanding of process. With an understanding of core processes we can consider techniques in the same way we do medications and other medical treatments, by weighing benefits against side effects and risks. For example, an earlier post, TIFT #37, on changing thought and behavior, suggests specific liabilities that go with using more active interventions. Weighing pros and cons of a given intervention gives a reality-based route to good clinical decision making.

Jeffery Smith MD

Reference

Goldfried, M. R. (2019). Obtaining consensus in psychotherapy: What holds us back?. American Psychologist, 74(4), 484.

Smith, J. S. (2021) The Common Infrastructure of Psychotherapy. Downloadable PDF infographic. 

Photo credit, Engin Yakurt on Unsplash.