TIFT #55: De-Confusing Psychotherapy

Psychiatry residents are required to learn three therapies, CBT, Psychodynamic therapy, and Supportive therapy. While the goal is to gain a broad knowledge, incompatibility among these therapies leads to a lot of confusion. It doesn’t have to be that way because they do the same things in different ways. De-confusing is just a matter of finding the deeper principles underlying all three approaches.

Why is our field divided into silos

Our field developed long before we had enough understanding of human evolutionary origins and the working of the brain to glimpse the underlying developmental and neurophysiological principles that make psychotherapy possible. Those principles are only now coming into focus. As an overview, let’s look at them one at a time.

Evolution:

Now we know that the human mind represents a further development of a mammalian brain that evolved to make predictions of and respond to opportunities and dangers. Basic responses were built in, but further along in evolution, the need to adapt to rapidly changing conditions led to the ability to learn response patterns from experience. As life has gotten more complex, mismatches between instinctive patterns and those learned early in life collide more often with adult circumstances.

In the age of reason, scientists and philosophers were enthralled with mastering the world through conscious logic. Victorians tried mightily to tame the “beastly” remnants of our mammalian mind. Freud and Watson inherited some of those traditions. As a result, they each had a somewhat negative view of irrationality and of our “baser” instincts.

Today, we have a more loving relationship with the parts of our minds that operate more like those of our mammalian ancestors. We are more accepting of the reality that our unconscious mind functions hand in hand with our logical mind. We also accept that they can disagree and that one or both can lead us astray, sometimes in ways that cause immeasurable pain and suffering.

With this perspective, we can view psychotherapy as a broad array of means for helping people heal and grow by trading in maladaptive response patterns for better ones. What follows is a brief sketch of a more universal way to look at what psychotherapy can do and how it works.

The secret role of emotion in therapeutic change:

It’s secret because this part is crucial but often not fully appreciated. Emotion has long been recognized as necessary for change but only now do we know fully why. Emotion is at the center of all response patterns, healthy and unhealthy. Why is that? Because limbic emotion is how the brain flags circumstances that need a response. Opportunities and threats are triaged for different responses according to the emotions that represent them. If you think about it, it’s a marvelous system. Emotion is the universal currency that allows the mind to compare apples to oranges. When different survival-related needs conflict, the kind and intensity of emotion provides a basis for deciding which to pursue.

To put it more technically, the mind is constantly scanning inner and outer environments for opportunities and threats. The main way it has of giving us the result of these predictions is by activating emotional neurons in the limbic system. It is that emotion that triggers further calculation to determine the best response. Significantly, emotion is also what leads to the motivations required to make sure a response is carried out and completed.

That’s part of the central importance of emotion. The other part, also little recognized, is the role of emotion in fundamental change processes. To explain, let’s look at the neurophysiology of change.

The Corrective Emotional Experience

Research on learned fear has identified and characterized two and only two basic change mechanisms. They are known as extinction and memoryreconsolidation. Remarkably, the conditions required for them to happen are essentially the same. These two mechanisms, along with new learning, account for the effectiveness of psychotherapy regardless of brand or orientation.

Using terminology from Alexander and French, let’s call the basic change paradigm the “corrective emotional experience.” We could just as well call it mindfulness or conflict resolution, acceptance, or even becoming rational, but the corrective emotional experience combines each of the necessary elements.

Three things are required for change to happen. First, the old, maladaptive pattern has to be in an active state. What that means is that the mind is in a state of readiness for the predicted danger. Ready for what? To unleash a protective response. This whole series of events is automatic and usually outside of consciousness. So how can we tell that this condition has been met? The answer comes in the form of a second requirement, affect.

Affect means conscious feelings that are accompanied by bodily changes, such as tears, hair on end, heart beating fast, etc. The bodily changes are automatic and involuntary. They are what tell us that deep limbic emotions have been energized, which implies that neural pathways that have led to appraisal of danger must also be in an active state. Thus, affect is critical as our clinical confirmation that the first requirement has been met.

The third requirement is simultaneously experiencing or knowing something new and surprising that conflicts with the old pattern and corrects it. I call this the “antidote,” because it has to be quite specific to clash with the old pattern in a way that permits change.

In the case of one of the two change mechanisms, extinction, the cortex learns to suppress the maladaptive response. Unfortunately, appraisal of the threat remains unchanged and ready to be activated. The result is that eventually the inhibition fades and the old response pattern returns, so the benefit is not permanent. The other mechanism, memory reconsolidation, causes the neurons and pathways leading to the old response to be re-written in line with the new information, resulting in change that is enduring and does not require further reinforcement.

Antidotes come in different forms and means of delivery. Healthy experiences, insights, and corrective ideas are woven through every therapy, ready to serve as antidotes for the many maladaptive interpretations and responses of which the mind is capable. In addition, sometimes there is no old pattern to change, but only a new pattern to learn. That, too, is taken care of by new information and experiences that therapy can bring.

Putting these new ideas to work

Now let’s make use of these modern ways of looking at the mind and how old, maladaptive patterns can change. First we’ll apply them to psychodynamic therapy, then to CBT, and finally to Supportive therapy. 

Psychodynamic Psychotherapy De-Confused

The central theory of psychodynamic therapy is that three agencies of the mind, the id, the superego, and the ego sometimes come into conflict. Therapy is aimed at resolving these conflicts, usually in favor of the ego, which is in better contact with the real world.

From our modern point of view, we can see that the id is not some nasty homunculus seeking self-centered pleasures. Rather it is a collection of instinctive responses triggered by anticipation of uncomfortable emotions and shaped by past experience. Psychotherapy seeks to help our patient trade those maladaptive responses for better ones. As stated above, for change to take place, the old response needs to be in an active state, as signaled by affect. This activation happens naturally through the therapeutic process, set in motion by techniques such as verbal exploration, relational interaction, and behavior change. Using the old terminology, when the id is involved, the dreaded emotions are likely to be fear, loss, or rage. Emotions like shame or guilt suggest involvement of the superego or conscience.

Critics of psychodynamic therapy have complained that the id and the superego don’t exist. That argument becomes irrelevant when we identify how maladaptive patterns are established and stored in memory, how certain circumstances can cause them to be triggered, and how they can be changed. 

More modern views of psychodynamic therapy emphasize the role of the relationship. Change requires not only activating deep emotions, but also the presence of new, surprising information and experiences. Beyond insight and interpretation, the therapeutic relationship, among other benefits, is often, in itself, the source of that new information. Acceptance, clear boundaries and other healthy responses provide surprising new experiences. Those new experiences combine with activation of deep emotions related to old expectations and the path to change is opened.

De-Confusing CBT

CBT originated as a way to bring about change without having to drag the patient through an exploration of the past. As in the nineteenth century, irrationality was the enemy. Non-rational thoughts lead to maladaptive behavior. Eliminating those automatic thoughts logically leads to things getting better. Protocols were developed to make patients more aware of their irrationality and to replace old thoughts with new, rational ones. It was assumed that, as patients learned more rational ways of thinking, their functioning would improve.

Based on long-established principles of behaviorism, CBT tended to avoid asking why people have irrational thoughts in the first place. When the question of their origin comes up, they are often described simply as “learned.” More recently, there has been a growing interest in understanding why, even if that has little impact on treatment protocols. From our integrative point of view, we can see that irrational thoughts and core values are dynamic products of the threat-avoiding function of the human mind. 

For example, an automatic thought like “I’m just a loser, I’ll never get better,” can be seen as the mind’s attempt to avoid uncomfortable emotions associated with change. If the situation is hopeless, then why do anything different? Looking under the hood, we can see that change is being appraised as a threat, which means the old emotions are indeed in an active state. Now the therapist works to motivate the patient to take the emotional risk of adopting a more hopeful outlook and experiencing some success. These new experiences provide surprising new information which contradicts the old pattern of hopelessness and inaction. In this way, the protocols of CBT have created yet another version of the corrective emotional experience, in which the old pattern can be modified in the light of new experience.

More recently, CBT has embraced the idea of exposure to uncomfortable feelings as a pathway to change. The theory is that emotions can be detoxified by “processing.” That processing consists of activating the old, dreaded emotions. The safe context of the therapeutic relationship provides the antidote, showing that the danger is over now. The three conditions for change are met and the patient moves towards greater health. Once again understanding the universal neurophysiology of change tends to erase the apparent differences between therapies.

De-Confusing Supportive Therapy

Supportive therapy came out of the idea that some patients could not cope with the “blank canvas” that was part of psychoanalysis, but could still benefit from talk therapy. First, let’s look at the historical roots of that blank canvas. In the nineteenth century scientists, including Freud, believed in the objectivity of the scientist. When he observed that “making the unconscious conscious” led to resolution of symptoms, he was talking about trauma patients like Anna O., who had dissociated her traumatic experiences. When their painful emotions were brought to consciousness, there was an almost miraculous healing. What Freud neglected to notice was the importance of his own presence. The warm and understanding presence of another human provided the antidote to his patient’s terrible memories. Minimizing the importance of his own compassion, Freud continued to follow the idea that the analyst needed to withhold expressions of emotion or support in order to avoid suppressing or distorting transference reactions.

Today, few therapists believe in the therapist’s objectivity, but the prohibition against “gratifying” the patient’s needs remains influential and confusing. This old tradition lies at the heart of the false dichotomy between supportive therapy and uncovering therapy. All therapy is supportive, but how and when we provide the support should be attuned to the needs of the patient.

Transference responses, given time for them to develop, are not fragile. To the contrary, they are remarkably robust. Perhaps the best proof that transference reactions cannot be suppressed comes from marital therapy.  Spouses make no effort effort to present a blank slate or avoid gratifying wishes, yet the majority of marital problems come directly from transference-type reactions. Any marital therapist will confirm that they are far from easy to modify or suppress. In individual therapy, if anything, it is the frequency of sessions and the duration of treatment that bring out responses derived from early relationships. So the blank slate has an impact, but is not the thing that makes the therapy work.

If the blank slate is not a critical element in the action of the therapy, then how should we look at the issue of support? A simple answer comes from observing parenting. As a child develops, the role of parents needs to evolve. A parent refusing to tie the child’s shoelaces too early would be cruel. A bit later, when the child has learned the skill, tying them would be infantilizing and stunt the acquisition of new abilities. In therapy, it is no different. Timing is critical. At the right time, our support and guidance may encourage growth, but if timed wrong, it can be infantilizing. Furthermore, patients have areas where they are more competent than others. Like parents, one of our jobs is continuously to evaluate our role in supporting specific changes and growth.

One place where techniques of supportive therapy make a lot of sense is in patients who tend to become psychotic under stress. Where personal boundaries are fragile, support, if too personal, can be a threat to the patient’s sense of self. Keeping stress out of a toxic zone might mean a subtle mixing of supportiveness with respect for boundaries. Even fragile patients can, if supported wisely, grow by engaging in new experiences. They are more likely to do so in an atmosphere of positive helpfulness.

Conclusion

This is only a brief summary of universal principles. With a little more detail, they create a kind of Rosetta Stone, essentially bringing all effective therapies under one big roof. At that point, as I have stated before, we naturally pay more attention to matching technique with the needs of the patient and the moment and less to the brand of therapy. In this way, we come to follow process rather than set methods.

Jeffery Smith MD

Photo credit:   Uday Mittal, Unsplash