HOW DOES PSYCHOTHERAPY WORK?
Learn about my approach
Psychotherapy works by literally, physically, changing your brain. Thoughts and emotional reactions are not simply abstract phenomena occurring somewhere in space. Instead, thoughts and emotions are actual physical events that take place amongst the billions of neurons within your brain. What this means is that past events and interactions with others, and our thoughts and emotions about these events, have left their mark in our brains. When you engage in psychotherapy, you are addressing the impact, on your brain, of certain aspects of your life, in a very specific, intentional, and physical way.
In the following paragraphs, I will attempt to offer a general introductory account of how psychological difficulties develop and how psychotherapy works. This description is based heavily on the Control-Mastery Theory of psychotherapy, initially developed by Joseph Weiss and Harold Sampson, and expanded upon by the San Francisco Psychotherapy Research Group (Formerly the Mount Zion Research Group. It is by no means intended to be an exhaustive or complete account of psychotherapy. My hope is that by providing this general description, the reader will gain some general understanding of how psychotherapy works and how I work as a therapist.
At the most basic level, we want psychotherapy to work on our “psychopathology”, which is just another way of saying that we want psychotherapy to work on the things that bother us psychologically. Psychopathology does not mean “crazy” or “insane.” Everybody has some degree of psychopathology at different times because everybody has things about themselves, the way they think, feel, and behave, that bothers them or creates problems for them. Furthermore, mental health is not static (unchanging), but instead fluctuates across the lifespan depending upon what is happening in our lives at any given time.
Psychological difficulties or "psychopathology" arise out of an interaction between our own personal genetic predispositions and our environment. By “personal genetic predispositions” I mean simply that some people are born a little more anxious than others, some are born more extroverted, some a little more reserved, etc. This is just their particular temperament. When I talk about “environment” I am simply acknowledging that humans undergo a learning process with regards to how the world works and how we should behave in it. Who we “become” is the result of our genetics interacting with our environment. This interaction between genetics and environment continues throughout our lifetime, but it is our earliest experiences of these interactions that lay the foundation for who we are, how we think and how we behave as adults. In summary, our early experiences combine with our genetics to co-create a structure, or template, for how we process information and how we respond to this information.
Starting with infancy, we are engaged in a social environment populated with parents, caretakers, siblings, etc. As infants and children, we are highly motivated to connect with, and to maintain our relationships with our caregivers. The consequences of failing to maintain these relationships as an infant and even as a young child would be catastrophic, and ultimately fatal. Gradually, through repeated interactions with caregivers, we learn how “to be” and how to behave. The cumulative result of these interactions is the development of foundational, firmly held beliefs about others, the world, and ourselves.
When interactions with caregivers are consistently predictable and nurturing, we learn that we can count on others to be there for us, to protect us, and that we have value as a person. We learn that there is some order in the world and that we have at least some control and power over what happens to us. However, when our interactions with caregivers are consistently negative, critical, abusive and traumatic, if we are regularly forgotten and neglected, we may develop a very different set of grim, negative beliefs about ourselves and the world. We may develop the belief that we cannot count on anyone to be there for us, that the world is a dangerous, unpredictable place. We may learn that we are of little value, and have little or no control or power in this world. Some of these beliefs may be conscious, but often they are unconscious.
In psychotherapy, we refer to these grim, trauma-based beliefs as Pathogenic Beliefs. What is important to recognize is that our beliefs, whether they are the more positive beliefs, or the more grim pathogenic beliefs, are “accurate” or “true” for the child who develops them. The nurtured child really does live in a predictable world where she is protected, has value, and some degree of control. The consistently criticized, abused, or neglected child really does live in a world that is unpredictable, chaotic, dangerous, and where she has little value. Whereas the nurtured child comes to expect respect, the abused child comes to expect disrespect.
The root of psychological difficulties
Pathogenic beliefs are deeply held, grim core beliefs about ourselves and the world. They are foundational and guide our thinking and behavior at an unconscious level. Pathogenic beliefs can develop as the result of a “shock” trauma (war, rape, natural disaster, etc.) or they can develop as the result of a “strain” trauma such as when parents are chronically critical or neglectful. However, pathogenic beliefs do not necessarily require abusive behavior to develop. For instance, a child whose father is chronically depressed or whose mother is constantly preoccupied with work, may develop the unconscious pathogenic belief that they are not worthy or deserving of attention or joy.
Pathogenic beliefs were once adaptive adjustments made by the patient in the service of protecting him/herself or loved ones. For example, the abused little boy who learns to keep himself quiet and small out of fear, was well served at the time, by his guiding belief that people (mommy and daddy) are unpredictable and dangerous. However, as an adult these beliefs do not serve him so well. Whereas his guiding beliefs formerly protected him by keeping him small and quiet, now they prevent him from pursuing romantic relationships; they prevent him from being promoted at work even though he may be genuinely attractive, interesting, talented and deserving. What’s more, this man is not even aware that he has the pathogenic belief that "I must keep myself small and quiet in order to avoid being abused or humiliated." All he may know is that things never seem to work out for him.
Pathogenic beliefs are like foundation of a house, upon which everything is built. The man from the above example may develop subsequent more conscious “explanatory” pathogenic beliefs to account for his unhappiness such as “I’m just a failure, God hates me, it is pointless to try, life is meaningless, etc.”But he does not really understand why he becomes paralyzed with anxiety, and speechless in the presence of an intelligent, attractive woman. Nor does he understand why he is continually passed over at work, while others receive promotions and salary increases. His firmly held pathogenic beliefs lead him to passively accept whoever or whatever comes along. Instead of actively pursuing a relationship with someone who would make him happy he continually dates women who are not good for him. Not surprisingly he feels unhappy, depressed, and bitter.
In psychotherapy patients work with the therapist to disconfirm their pathogenic beliefs.One way in which patients disconfirm pathogenic beliefs is by using insights gained from therapist interpretations during sessions. Another way patient’s work to disconfirm their pathogenic beliefs is by “testing” the validity of these beliefs in their relationship with the therapist. There are two forms of testing: transference testing and turning-passive-into-active testing. Both are described below.
HOW PATIENTS WORK IN PSYCHOTHERAPY
The disconfirmation of pathogenic beliefs
Transference testing comes from Freud’s observation that his patients tended to transfer the role of a parent or some other authority figure to the therapist. The idea of transference can sometimes feel a bit confusing, far-fetched, and even magical, as if the patient somehow believes the therapist is actually her father. However, all transference really implies is that we interact with others and expect others to interact with us in familiar ways.
For instance, if we come from a home and culture where it is common to greet others by shaking hands, then we will expect to shake the therapist’s hand. If we come from a home and culture where it is common greet others with a bow, then we may expect to bow and to be bowed to. In many ways, transference is about expectations for how we will be treated, and how others will respond to us. Further, we tend to not to pay much attention to these expectations, unless someone violates them by failing to respond in an expected way.
Transference testing with the therapist plays out in a variety of ways during therapy. For instance, consider a woman who was raised by a narcissistic and controlling father who frequently became wounded or angry whenever she attempted to assert herself by disagreeing or simply offering her opinion. As a child, this woman learned through repeated interactions, that to have an opinion and a voice of her own meant hurting her father or enraging him. Because she loved and needed her father, she adapted herself as a child, rarely speaking up or disagreeing. In therapy, this woman may engage in transference testing with the therapist by constantly deferring to the therapist, stating that she doesn’t know what to do, that she cannot make a decision, and asking the therapist to tell her what she should do and maybe even what she should talk about in therapy. In this case, it would be important for the therapist to recognize this woman’s history and to refuse to tell her what she should do or what she should talk about in therapy. By refusing to make the decision for this woman and in fact encouraging and valuing her ideas, the therapist conveys the message that she is capable of making her own decisions and that her doing so will not wound or enrage the therapist the way it did with her father.
Through this interaction, the therapist has taken a small step toward disconfirming the patient’s pathogenic belief that she must not speak up or assert herself lest she hurt or anger others. This and similar interactions will need to be repeated many times over, in different ways during the course of therapy in order to alter the very powerful learning that this woman has previously undergone. Her repeated experiences with her therapist of asserting herself and not being punished, but instead encouraged, will likely embolden her to begin asserting herself in other areas of her life such as with partners, family, work etc.
I want to reiterate that the above patient does not actually believe the therapist is her father, nor is she consciously trying to treat her therapist like her father. She has simply become accustomed to deferring to others due to an early, over-learned belief that she will either wound others or draw their anger, if she asserts herself. She may enter therapy very aware that she has a tendency to defer to others, or she may not.
Whereas transference testing places the therapist in the parental or authority role, turning-passive-into-active testing places the therapist in the patient’s childhood role. The patient then takes on the role of the parent. Once again, the patient does not actually believe she is the parent nor is she consciously attempting behave like the parent. Instead the patient is simply behaving in ways that she has seen other important figures from her life behave. It is simple learning and it is carried out automatically and unconsciously.
When a patient turns-passive-into-active, the patient is giving the therapist a taste of what it was like to be the patient as a child, and is testing to see if the therapist will be able to tolerate this in a healthy and assertive way. In the previous example of the woman with the narcissistic and controlling father, turning-passive-into-active testing would involve the patient attempting to exert control over the therapist in some way. For example, if the therapist disagrees with something this patient has said, the patient may respond by feeling very wounded and hurt. This might prompt the therapist to feel guilty and to want to agree with the patient in an attempt to make the patient feel better. However, to do so would be inauthentic on the part of the therapist, because the therapist is only agreeing with the patient to make the patient feel better, not because the therapist actually truly agrees. By respectfully, and yet firmly maintaining his or her own opinion, the therapist is modeling how to cope with and how to handle the narcissistic and controlling behavior experienced by this patient during her own childhood.
This interaction conveys to the patient that it is acceptable to have one’s own views and that the it is not one person’s responsibility to agree with another just to make him feel better. Another way to put this is that the therapists respectful assertive behavior models a new way or responding for the patient. This “passed test” is a small step towards ultimately disconfirming the patient’s pathogenic belief that she must adjust herself, her views and her opinions in order to avoid harming others or provoking their anger.
Regardless of whether the test is a transference or a turning-passive-into-active test, when a therapist passes a patient’s test, the patient experiences an increase in psychological safety. This is because the patient has been reassured that 1) the therapist will not treat the patient as the patient has been previously treated, and 2) the therapist knows how to handle and respond to the ways in which the patient has been previously treated. It is not enough to simply tell or explain this to the patient; it is a process that must be experienced and re-experienced again and again. The psychological safety of continuously being in the presence of somebody who will not hurt them and who also knows how to protect them, allows patients to explore, discuss, and face ideas and topics that may have previously been too painful, confusing, or frightening to address. The result is that patients begin to gain a greater sense of control and mastery in their lives allowing them to pursue previously elusive goals and dreams.
The successful therapeutic process
There is substantial scientific evidence that psychotherapy works. The above description addresses the process of psychotherapy in general. I have not addressed specific issues of concern (substance abuse, anger management, psychotherapy for men, etc) The reader can find more specific discussion of such issues in the services section of this website.
In our therapy sessions, we’ll work to solve current problems and improve positive thinking and behavior. The past is important, but only so far as it impedes the present and the future. I will help you “re-frame” your perceptions and provide you with valuable tools to cope with life’s obstacles. I’m confident you’ll find my personalized Individual Therapy beneficial and inspirational. Get in touch to book an appointment.