Sadly, the field of psychotherapy is still mired in wars between different schools and factions. This post outlines a simple way for CBT therapists, experiential therapists, dynamic therapists, and even advocates of meditation to speak a common language. (Original photo by Exlibber on Flickr. Text added.)
Cognitive-behavioral therapists say theirs is “evidence-based.” Experiential therapists insist on the importance of feelings. Some psychodynamic clinicians focus on insight, while others see relationship as key. Meanwhile, advocates of mindful meditation are saying their practice is the universal helper. For consumers, this cacophony only promotes confusion, while new therapists and trainees are left wondering if the techniques rejected by their teachers might actually have something to offer. That is not all. Insurance companies and governments profit from our arguments by rejecting all but the least expensive treatments.
Meanwhile, John Norcross’s careful analysis of research indicates that only 8% of the effectiveness of psychotherapy can be explained by the particular therapy, while 16% depends on the therapist and the relationship.
The good news is that, spearheaded by the trauma field, we are all progressing gradually towards a better understanding of how all therapies actually work. When we focus on “common factors,” the differences between schools become less significant and we can focus more on how to help patients get from point “A” to point “B.” As the field stands today, there is a need for a sharper delineation of just what change processes are needed when and how to combine techniques in a coherent and effective way.
One observation that transcends therapeutic traditions is that, while it is human to behave in irrational and dysfunctional ways, it is also human to resist change, even when it is obviously for the good. People only come for therapy when ordinary willpower and support have proved insufficient. Psychotherapy can be defined as the use of a dialog and relationship to help patients overcome whatever it is that makes us resist change and revert to old, unhealthy patterns. Upon examination, the reason we resist is that the change (or its anticipation) brings up uncomfortable emotions. Both consciously and unconsciously, we humans naturally and strongly resist getting too close to difficult feelings.
Fortunately, two of the most important traditions in therapy have recognized this common factor. Freud regarded the resolution of “resistance” to be the essence of psychotherapy. Remarkably, cognitive-behavioral therapy uses the same word to describe the same phenomenon. Patients are often seen as resistant to changes in thinking and behavior that are necessary for progress. One of the skills of the therapist, whatever his or her persuasion, is coaxing the patient to take the risk of traversing difficult emotions in order to experience the benefit of change. Each therapy has a different way of doing this, but it may not be too difficult to achieve a consensus that having a good relationship, a clear rationale, and an empathic manner are predictive of success.
Even more remarkable, a closer look at resistance shows that the similarity is more than skin deep. In all forms of therapy, contemplating or making changes in irrational and dysfunctional patterns is associated with painful or uncomfortable feelings. Patients show resistance to this discomfort in two ways. One is conscious reluctance to change and the other involves thoughts that spontaneously enter our consciousness and work against change.
In CBT, patients produce “automatic thoughts.” The thrust of these thoughts is that they justify resistance to changes in behavior. For example, “catastrophization” serves to rationalize the status quo. “If I change, then something terrible will surely happen, so I won’t try anything new.”
In traditional therapies, the same thing happens, but with a twist. The aim of therapy is not so directly focused on behavior change. Rather it is to gain insight and acceptance of inner mental contents. The more therapy pushes for acceptance of inner reality, the more patients resist. Their “free associations” (the equivalent of automatic thoughts) manifest themselves as “defenses,” that is, distortions of thinking aimed at avoiding uncomfortable mental contents. For example, “denial,” which nicely blocks awareness of an inner feeling or reality. “I am not angry.”
So resistance in each kind of therapy takes a form designed to counteract the specific demands of that therapy. CBT patients’ automatic thoughts resist changes in thinking and behavior, and psychodynamic patients’ free associations resist acknowledging inner mental contents. The common denominator is that change brings discomfort and humans abhor discomfort.
If uncomfortable feelings are the cause of resistance, then the solution must be to process or detoxify those feelings. I hope we now have a basis for consensus that emotional processing of uncomfortable feelings represents a common pathway for both achievement and consolidation of positive change. When patients have trouble with resistance, it is emotional processing of uncomfortable feelings that allows humans to settle into healthier patterns. This effect is often referred to as “nonspecific factors,” vaguely related to the therapeutic relationship. It is my contention that the healing of painful and uncomfortable feelings is, in fact, very specific.
Fortunately, the field of trauma has recently made important strides in understanding just how painful and uncomfortable feelings are detoxified in therapy. Whether it is Freud’s catharsis or trauma researcher, Edna Foa’s, extinction, the same two elements come up over and over. For emotions to heal, two conditions are required:
A. Emotions must be activated. This involves both neural networks firing together and conscious awareness of feeling.
B. A context of perceived safety and empathic connection. (Even solo meditation brings a feeling of safety and empathic connection.)
Putting this all together, I would like to propose that we may be closer to a consensus on common factors in therapy than has generally been recognized. To summarize, it is not so difficult to argue that all therapies consist of techniques and approaches, whether directive or implied, that accomplish the following four tasks:
1. Helping patients let go of distorted patterns of thinking
2. Helping patients change unhealthy behaviors (including interpersonal ones)
3. Helping patients modify unhealthy values
Making these changes is self-reinforcing, that is, they lead to a more satisfying life. But changing so also exposes uncomfortable feelings which need to be processed. This may take place gradually and quietly so it seems like something “nonspecific” is operating. In other cases it is more obvious and dramatic. Either way, processing feelings is sometimes required for changes to be adopted, and at other times, changes already made bring out feelings that must be processed for the new patterns to become lasting. As indicated above, this processing requires activation of feelings in a context of safety and empathic connection. Thus, a positive therapeutic relationship contributes to 1, 2, and 3, but is essential for 4, namely:
4. Helping patients process painful and uncomfortable feelings.
A consensus that psychotherapy consists in those four tasks could move the focus of debate and research from comparing the global effectiveness of different therapies to optimizing the means of accomplishing each of the tasks for a particular patient in a given circumstance. From this point of view, it becomes clear that different pathologies place more or less emphasis on different tasks at different times. For example, for addictions and compulsive behaviors, change in behavior often must come first, while emotional processing happens gradually over years of growing “sobriety.” On the other hand, for trauma, emotional processing is often primary, while changes in thinking, behavior and values may happen on a slower time course. With anxiety, all four tasks may go hand in hand. Personality problems tend to involve a gradual acceptance of emotional contents along with subtle accompanying changes in relationships and behavior.
It is my belief that, with adoption of a simple common framework such as the one presented here, therapists from different backgrounds could turn to what we have in common and how best to tackle specific challenges rather than arguing about whose theory is correct or whose treatment is more “proven.”
Please note that How We Heal and Grow: The Power of Facing Your Feelings is an account of many kinds of change built on the integrated view of psychotherapy presented in this post. I welcome comments both from consumers and therapists.