TIFT #132: Report from Istanbul

This year's annual conference of SEPI, the Society for the Explanation of Psychotherapy Integration, was held in Istanbul under my chairmanship. It was energetic. It covered every aspect of psychotherapy. It embodied every point of view. Thoughtful contributions came from around the world. And I was pushy about wanting to make it an inflection point, a fulfillment of Marvin Goldfried’s 41 year call for a consensus on the scientific foundations of all psychotherapies.

Why am I pushy? Why do many people still resist? Is there a better way to turn a corner in our field? Is my campaign working?

About ten years ago, I was deeply distressed by reports of poorly conducted therapy coming to my then blog for consumers. Stories kept coming of therapists, ranging from benign good listeners who left the client feeling better but unchanged, all the way to disasters, where clients who finally dared to tell their therapist about their strong transferential feelings, were summarily escorted out of the clinic and told never to return. That was when I decided to focus the rest of my career on helping therapists use better understanding of processes to know what to do next. The name of my blog changed to “Tuesday Is For Therapists,” TIFT.

To be truly satisfying and useful, an explanation should, as Descartes pointed out, rest on a solid foundation. Instead, explanations of psychotherapy are given in terms belonging to that therapy’s own conceptualizations. In other words, they were self-referential. Psychodynamic therapy explains that it aims to help clients resolve conflicts between ego, id, and superego, concepts that belong to those therapies alone. Behavioral therapies say therapy corrects irrationality, based on learning theory, but tends not to ask or answer why.

These theories were edifices built with no foundation other than their own ground floor. Compare that with biology, built now on an increasingly detailed understanding from DNA on up and chemistry, built on principles like electron rings and the positive and negative attractions in protein structures.

I wrote in 2004 that psychotherapy made use of at least two change processes that were distinctly different from one another. My hunch was that there were probably just a few processes in play. When I stepped back to look at the broad range of clients I had worked with and problems they had brought, one thing stood out. Each of the problem patterns I had seen could be explained as avoidance of some dreaded emotion. That was similar to Hayes’ Experiential Avoidance, but different. Hayes was talking about conscious avoidance, and I knew from my psychodynamic background and experience that, in many of my clients, the dread was not of anything conscious. Rather, there were powerful nonconscious emotions driving strenuous efforts to avoid them. Consciousness avoidance happens, too, but the broader and deeper forces exist in a realm outside of direct awareness.

Not only was it important to understand and teach basic processes, but I began to realize that the field would have difficulty accepting explanations based on foundational mechanisms. Too many careers had been built on one therapeutic tradition or another. The way to change the field would be to give younger therapists powerful ideas based on science from within and and outside our field to explain, in satisfying and useful ways, what was going on and what needed to happen next. In short, I wanted to formulate and teach the infrastructure applicable to all therapies. This would not conflict with or contradict traditional thinking because existing theories have little to say about underlying mechanisms. Rather, it would support them by showing just how they work. A detailed understanding could even lead to refinements in existing technique. The best innovations in medicine are increasingly coming out of detailed knowledge of processes and mechanisms. Why couldn’t we do this for psychotherapy? When I ran for President of SEPI, it was on a platform that included both support for diverse techniques and approaches as well as using fresh science to move towards fulfilling Dr. Goldfried’s call and quest.

The theme of this year’s conference, “Integrative Foundations of Psychotherapy” was chosen to reflect the belief that it is, at last, time for SEPI’s eternal exploration to be transformed into a harvest of foundational principles along with a wide range of fresh ideas to bridge across specific therapies.

That sounds pushy, and maybe it is, but I believe the future of psychotherapy rests on coming out of the age of incompatible and competing therapies. The foundations I’m talking about consist of three pillars of science. Each one is relatively uncontroversial and together they do not compete with existing conceptualizations because they explain therapy at a lower level. The three pillars are still compatible with traditional ideas like the ego, superego, and id, as well as with learning theory, at least the multi-faceted and varied understanding of learning that is known today.

In my Presidential Address at the conference, I told the group that, like Ulysses, I would take them on an odyssey, visiting three “strange lands,” each representing one of the three pillars of science. Upon returning home, I promised that our home would be the same, but that we would see it with fresh eyes following our voyage.

An odyssey to three strange lands

The first, not-very-controversial, “strange land” was the evolution of the human brain and of our way of surviving as a species. From earlier mammals, we have inherited a subcortical, survival-oriented brain that operates autonomously and outside of consciousness and has evolved to support the preservation of our species under widely varying conditions. The human experience places new demands on old systems in that our survival now depends, not on flight, fight, and freeze, but on maintaining cohesiveness within increasingly complex social structures. In response to those demands, evolution has largely kept the old survival systems, including motivation and emotion, but has added a new innovation, conscious thought. This “fancy add-on,” with its precise logic and reasoning, now has some ability to edit our instinctive aims. As often happens in biology, the two systems compete and balance each other. The older, subcortical “thinking fast” influences the conscious one by generating bodily affects as well as projecting thoughts, feelings and impulses into consciousness. The newer one, “thinking slow,” then has the ability to weigh future consequences, pros and cons, and other subtleties, along with modest powers to override our “basic instincts.” With that principle we set sail for our next destination.

The second island of not-so-controversial science was the land of “survival circuits,” named by LeDoux and picked up by Steven Hayes as sources of maladaptive patterns. These are the nonconscious schemas, embodying associative, pattern-matching logic, that determine what the subcortical, survival-oriented brain determines to be threatening, and the similar logic that determines the response. The schemas that have been studied in the greatest detail are those involved in the “learned fear paradigm.” In addition to their neurochemistry, computational neuroscience has shown how “predictive coding” performs pattern matching between current inputs and past experience by repetitively comparing inputs with “priors” and, each time, making adjustments to reduce the degree of mismatch or “prediction error.” In particular, emphasis was placed on the way the brain signals danger. The brain’s alarm is neural activation, well known to neurophysiologists. These activations are what trigger the selection of a response, including those outdated patterns of response that psychotherapy targets for change.

The crucial insight is that those alarm signals are fundamentally emotional. That is, they consist of “proto-emotions.” They are not consciously knowable, any more than we can know the inner experience of a cat or dog, or even a baby crying, but they are outwardly manifested by bodily affects such as growls, tears, or changes in breathing. For us clinicians, those are our best indicators that subcortical threat processing is actively going on. These are the inner emotions that our maladaptive response patterns are designed to avoid and suppress. In this land we found that the architecture of the subcortical threat processing system consists of three elements, a threat detection schema, an alarm signal consisting of proto-emotions, and a response selection schema that determines the response transmitted to the body and to consciousness. Understanding that architecture points directly to what psychotherapy is designed to accomplish, that is, changing the programming or functioning of the two schemas.

From this detailed look at the neurophysiology of threat processing, our voyage took us to a final adventure in the “land of change.” There we learned that just two mechanisms are known to be able to alter the functioning of the subcortical schemas. As I have repeated in this blog, the first is extinction, named by Pavlov, using cortical learning to send inhibitory impulses to subcortical structures such as the amygdala, where problem responses can be blocked. Because the driving proto-emotion is not suppressed, the old response may eventually return, making this mechanism largely temporary. On the other hand, the second change mechanism of memory reconsolidation appears to be the only one capable of bringing about enduring change to the content of the nonconscious schemas. In clinical practice it is hard to tell whether the change happening before us is “transformational” and due to memory reconsolidation or temporary due to extinction. The strongest evidence for memory reconsolidation is when changes turn out to be transformational, that is, not requiring further effort, repetition, or reinforcement. There, memory reconsolidation is the only known mechanism and, at present, it is understood down to a molecular level, with further research actively elucidating more details.

Returning home with new vision

Returning “home,” what we knew about psychotherapy has not changed. Psychotherapy theories are like origin stories. They satisfy the need to know where human irrationality comes from, but, of necessity, they are inventions of their founders, trying to explain what they observed at a time when underlying mechanisms were not known. What’s different now is that we have science independent of our field on which to build an understanding of the action of psychotherapy. The sciences of evolution, of threat processing, and of how nonconscious schemas can be rewritten can be brought to bear on how the tools of every therapy, words, nonverbal communication, and relationship, are able to transform lives. Those explanations don’t replace what we already know, they confirm it and add a new dimension of support from relatively independent sources.

By approaching the infrastructure of psychotherapy, not only is it possible to focus in on the level of detail, but it becomes possible to identify the specific active ingredients in every therapy. How do they activate outdated response patterns? How do they deliver disconfirming information to those subcortical structures where the schemas reside? And how do they promote a third change process, helping our clients learn new response patterns or adapt old ones to the point where they are internalized and available to the subcortical mind? By focusing on specific points where therapy accomplishes these aims, we can hope to improve technique as well as matching it to the client and situation. And none of this changes what we already know. Home still looks like home, but we can see it with fresh eyes.

Is that too pushy?

One conference attendee questioned my pushiness, saying he felt pressured to adopt these ideas. I think that comes from an old habit of treating each new therapy and theory as a smorgasbord dish. If there is an alternative to this underlying science, it would need to be a scientific basis other than the evolution of human threat processing. 

Why is it important for our field to find consensus? We are under intense fire. There is another origin story to explain human irrationality and it is backed by vast amounts of money. It says that human irrationality arises because of problems in genetics and biology. It says that we can bypass psychotherapy and seek quicker, cheaper, and more profitable cures by using biological treatments like medication, transcranial magnetic stimulation, and psychedelics. Each of them may have uses, but they do not replace what we do. Our ability to argue for the importance of psychotherapy is seriously undermined by our divisiveness. It will help us to join together, to coalesce around the transformative changes that come from the intelligent use of words, nonverbal communication and relationship in helping our client’s inner minds process ongoing experience in new ways.

The conference presentations

Richard Lane’s keynote address laid critical groundwork by opening attendees eyes to the subcortical mind’s internal working models and how avoidance of unconscious but intolerable emotional experiences is embodied in the development of each person’s ways of coping. When these are maladaptive, memory reconsolidation is the mechanism underlying the “corrective emotional experiences,” that allow updating of the old working models to enable improvements in social adaptation and well-being, regardless of the therapeutic modality chosen.

Adding riches of energy and enthusiasm, our local host, Tahir Ozakkas rallied his remarkable following of Turkish trainees, teachers, and therapists, to add, not only memorable presentations in English, but many in Turkish, too, making the conference a multicultural event. Not only that, but he brought together volunteers to record every session, translators to provide simultaneous translation between Turkish and English, and a setting that was elegant, comfortable, and thoroughly conducive to lively exchange at every coffee break. With his team they published in both Turkish and English a book of abstracts of all presentations and will be making available video recordings of the presentations through SEPI’s website, www.sepiweb.org.

Over 100 English language presentations provided both reinforcement of the foundational story, and added new and widely varied “golden nuggets” to help further the effectiveness of integrative psychotherapy and training. A brief summary of topics included:

• Integration of therapies
• Teaching & training
• Formulation
• Relationship patterns
• Neuroscience and Psychotherapy
• Deliberate Practice
• Measurement
• Public Policy & Ethics
• Child development & treatment
• Arts therapy & dreams
• Attachment & development
• Trauma & dissociation
• The body
• Social media, technology, and AI
• Personality
• SEPI’s regional networks
• Professional wellbeing
• Culture 

The boat ride

You had to be there. The Bosporus at night is an unbelievable sight and I can’t describe the dancing. You can take in some of the energy from the conference video soon to be posted HERE.

Is my campaign working?

This year has been for me one of breakthrough events. It has seen the publication in the Journal of Psychotherapy Integration the article that establishes the intellectual basis of my argument (2025). I hope the conference will represent a turning point and galvanize leadership from what President Elect Designate,  Jeffrey Magnavita calls "SEPI’s braintrust.” And my new book, How Psychotherapy Works: Navigating the Therapeutic Space with Confidence, is, at last, in the hands of the publishers, to come out sometime in the spring. It is designed as a companion for therapists seeking clarity about what is going in in their work, combining the science of change with a feeling for how the inner, nonverbal mind thinks and can become a partner in healing and growth.

Reference

Smith, J. (2025). Psychotherapy integration from the bottom up: A unifying, science-based view of psychotherapy’s infrastructure. Journal of Psychotherapy Integration. Advance online publication: https://dx.doi.org/10.1037/int0000371

Jeffery Smith MD