Understanding “Therapy,” How It Works and When to Seek It
Therapy is undeniably growing in the US. The behavioral therapy market is growing 8% a year, and the online therapy market is growing 31% a year. Yet most people can’t agree on what exactly “therapy” is, who can call themselves “therapists” and how it works. In this piece, I’ll explain a way to think about therapy that has been fruitful for many people and supported by many practitioners.
The many roles of a modern talk therapist
When we talk about “therapy,” we’re referencing behavioral therapy, not physical therapy, speech therapy or other therapeutic methods. Behavioral therapy – sometimes called psychotherapy, talk therapy, or counseling – is ”meeting with a trained professional to take care of your mental and emotional health”.
Interestingly enough, non-behavioral therapies are usually interventions. They are actions taken to improve a situation, especially a medical disorder. As interventions, it’s understood when to seek out these therapies and when the therapy has successfully been completed. For example, people seek out physical therapy during the recovery from an injury, and stop once they regain proper physical capability.
But in the US, behavioral therapies have become a lifestyle for many people. This is because in addition to offering interventions for acute behavioral health issues, talk therapists are being relied on to play multiple roles:
- A listening ear for venting
- A journal for reflecting
- A coach for goal setting and planning
- An accountability partner for keeping you on track
- A confidant to trust
Issues we see with overloading talk therapists with these multiple roles:
- Supply crunch – there aren’t enough trained, professional therapists for increasing demand. One (largely unaddressed) contributing factor is that therapists spend a lot of time on these additional roles that don’t have to be played by therapists. Licensed, professional therapists are most differentiated for rigorous interventions and passing off the other roles to others would improve the supply crunch.
- Efficacy – in negotiations, “good cop, bad cop” (a psychological tactic that involves one person being friendly and the other being forceful) is much more effective when played by two people, rather than one. Similarly, certain roles (such as Coach and Accountability Partner) can be more effective when played by separate people since the nature of these roles are in stark contrast; a Coach meets with you when you’re feeling optimistic and motivated to help you set goals, while an Accountability Partner keeps you accountable when you’re feeling pessimistic and unmotivated.
- Consumer education – without a clear understanding of what roles a talk therapist can play and when to seek out these roles, people are left unsure how to make the most of therapy. This lack of understanding prevents people who are interested in mental health support from seeking out therapy, and also causes people who start therapy to have unproductive sessions and churn before seeing progress (30% of people drop out of talk therapy before seeing results).
Understanding psychotherapy as an intervention
We believe trained, professional therapists are uniquely qualified to provide interventions for acute behavior health issues. So we typically wait to recommend therapy until we see criteria that justify an intervention. And when we do so, it’s very helpful for people we work with to have an understanding of the different types of psychotherapy.
Context: The brain is a prediction machine
Brain researchers have long understood that the brain collects lifelong emotional learnings. Pavlov famously demonstrated over a century ago that mammalian brains learn to associate experiences with pleasant sensations or painful sensations. And this makes sense from an evolutionary biology perspective, because being able to develop models of the world that help you quickly identify what experiences to seek and what to avoid increases your chance of survival.
Once encoded neurochemically, these emotional learnings operate outside of awareness, yet control our behavior and state of mind. And interestingly, scientists have demonstrated they don’t fade out over time; they aren’t supposed to, because the brain needs to be prepared throughout a lifetime.
However, not all learned patterns are correct or generalizable. (Pavlov’s dogs would continue to salivate when they heard the sound of a bell, even without the pairing of food). And this similarly applies to more complex human behavior.
We’ve come to see that all issues come from unresolved trauma. We add the asterisk because “trauma” is a stigmatized term associated with terrible, unfortunate life experiences. What we mean by “trauma” is any learned emotional response that turns out to be unproductive (e.g. Your parents were only excited when you placed first in youth sports, so you learned that perfectionism is essential to be worthy of love).
Because these emotional learnings don’t fade out over time, an intervention is needed to resolve them. And because emotional learnings are outside of awareness, it requires thoughtful and careful intervention to bring them into awareness, understand them, and improve them.
Goals of Therapy: Coping vs Resolving
Because resolving emotional learnings is difficult for both therapists and clients, many therapies take a rather opposite strategy of trying to help a person get away and disconnect from both the negative responses as well as the underlying material generating the responses. These are coping mechanisms and can be useful to manage symptoms, but should not be misconstrued as fundamental fixes.
e.g. Anger management techniques, relaxation techniques, soothing techniques.
e.g. Identifying and avoiding triggers for painful reactions.
Other therapies try to resolve negative responses, often by counterintuitively heading directly toward and into the underlying material to understand it and unlearn negative reactions and thought patterns.
e.g. Coherence therapy, Internal family systems, Psychedelic-assisted therapies, and other Experiential therapies.
Resolving Unproductive Emotional Learnings
Therapies that seek to resolve unproductive emotional learnings share a common underlying structure that relates to “memory reconsolidation.”
First, let’s explain memory consolidation. Memory consolidation is the process by which a change in the nervous system is caused by memorizing something. This is how emotional learnings become neurochemically encoded into the brain.
According to the memory reconsolidation view, memories are susceptible to change each time they are retrieved. The brain can use new learning to directly update and re-encode old learnings. No other framework can produce these markers of erasure where symptoms disappear, underlying emotional activation ceases, and these changes persist permanently and without active effort.
The following three-step process for leveraging memory reconsolidation can be seen in a number of effective psychotherapy techniques:
Step 1: Discover an underlying emotional learning and bring it into awareness
Well-trained talk therapists can help you identify specific emotional learnings that underly and control the negative response you’re seeking to resolve.
Again, emotional learnings are models of the world that you learned through an emotional experience and generalized. (e.g. Your parents were only excited when you placed first in youth sports, so you learned that perfectionism is essential to be worthy of love).
By bringing a target emotional learning into awareness and articulating it in words, its neurochemical encoding in your brain becomes susceptible to necessary change.
Step 2: Replace the emotional learning with a healthier counter-learning.
Talk therapists then guide you to identify experiences in your life that contradict the target emotional learning. (e.g. Instances where you didn’t achieve a perfect result but were still validated and appreciated by others). Using your own personal knowledge and experience to disconfirm the mental model you carry is fundamentally different from just relying on positive thinking; it takes personal experience to rewrite your memories and emotional learnings.
While holding multiple juxtapositions between the target emotional learning and your disconfirming experiences, you’re encouraged to recognize the prediction error your brain was making. The goal is to achieve an “A-ha moment” where you realize your brain incorrectly generalized an emotional experience into a faulty model of the world! This creates a counter-learning that directly re-writes the target emotional learning.
The goal is not to invalidate the experience that caused the target emotional learning, but rather invalidate the prediction error and faulty generalization your brain was making.
Step 3: Handle possible consequences of this nullifcation and erasure
Sometimes, these faulty generalizations and prediction errors are a defense mechanism (e.g. if you were abused as a child and generalized that all parents abuse their children, that generalization helps prevent you from feeling betrayed or wronged by your parent). So when a faulty generalization is erased and nullified, a possible consequence is experiencing the uncomfortable truth you were shielded from (e.g. your parent hurt and betrayed you, and you in fact did not deserve that treatment).
- This requires a few additional sessions with a professional talk therapist to process both this recognition and the grieving that accompanies it.
Another possible consequence is experiencing feelings of loss: lost time, lost potential and lost shared reality from years of operating under a faulty generalization and model of the world.
- This also requires a few additional sessions with a professional talk therapist to process both this recognition and the grieving that accompanies it.
It requires special skills and training to empathetically and safely guide someone to bring suppressed emotional learnings into awareness, understand them and replace them with healthier emotional learnings.
Thus, of all roles therapists are asked to play, we believe the area where licensed professional talk therapists are most differentiated and important is resolving unproductive emotional learnings that are outside of awareness yet control so much of our behavior and state of mind.
Understanding this model of how therapy works makes it more clear when therapy should be used. When making big life decision, uncovering and resolving emotional learnings can help when you’re trying to uncover your internal values in the face of biased external advice and when you’re curious whether your intuition is a sincere belief or a defensive narrative.
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