On multiple levels, I have grappled with the question of ‘if’ and then ‘how’ therapy works.
As a person in my 20s, reaching out for therapy at a vulnerable point in my life, I wondered if therapy ‘worked.’ I didn’t really see how talking was going to help anything, but I knew I felt pretty alone, and pretty stuck, and I didn’t know how to fix what was going wrong in my life. So, I went to my campus counselling centre and asked for help. I was one of the lucky ones. I got what I needed – a supportive connection to a trained therapist with the time and patience to let my story unfold, working on the layers of challenges I brought, as they emerged. Spoiler alert: it took more than five to six sessions, but more on that later.
As a new therapist in my late 20s, I was fascinated by the many schools and theories of counselling. I read broadly and sought to understand how to help my own clients (and, truth be told, how to understand myself). As it turned out, this attempt at a broad reading of the therapy literature was a confusing and at times overwhelming endeavour. While schools of therapy have been historically divisive, each wishing to lay claim to having found the pivotal solution to creating positive change in clients, the reality is that evidence does not support this claim (Wampold, 2015). I wholeheartedly agree with the statement of esteemed psychologist Marvin Goldfried in his 2003 article in celebration of the 25th anniversary of the journal Cognitive-Behaviour Therapy who stated: “the time has come when the contributions made by the different orientations need to be viewed as being complementary. Rather than continuing to maintain the adversarial stance that has characterized our field for so many years, I suggest that we strive to develop a more comprehensive and integrative perspective of the therapeutic change process.” This remains a significant work in progress with many camps in disagreement.
By the time I took on the role of Clinical Coordinator of Ryerson’s Centre for Student Development and Counselling seven years ago, a position from which I officially ‘retired’ in 2017, I knew therapy worked – research clearly supports the efficacy of psychotherapy in reducing symptoms of psychological pain (Hunsley, Elliot, & Therrien, 2013). However, I couldn’t say I knew why therapy worked, or how to predict which clients would respond to which interventions. This was a question my colleagues and I routinely contemplated as I led a team grappling, as is typically the case in mental health centres, with the challenge of how to match incoming clients with the form of assistance that might best fit their needs in a resource-strapped system.
Through my term as Clinical Coordinator, I maintained a central focus on the principle of equitable care over equal care with the aspirational goal of connecting each person attending our centre with the resources they needed – high intensity resources for some, and lower intensity resource for others, utilizing both university and surrounding community resources. While some centres have shifted to a principle of ‘equal care’ (everyone gets five to six sessions of care before discharge), at our centre, we view ourselves as one resource hub in a service-rich urban centre (with keen awareness that not all post secondary institutions have such resources at their doorstep). The catch? Some community-based services are not easily accessible, most specifically longer-term care options for students with more complex and/or long-standing mental health needs where free programs tend to have waitlists of more than a year, and regularly scheduled private therapy would be too costly.
In focusing on the premise of equitable care, we needed to shift our view to refer into community care those students whose needs could actually be met by high quality, accessible, community-based services (e.g. affordable and without wait times of 6-18 months). In the Greater Toronto Area, we can easily refer to private practice those students needing short term care who also have extended healthcare benefits – through the school or through their guardians. As it turns out this is a significant proportion of students seeking care on our campus. In addition, many students coming to our Centre do not need active and intensive psychotherapy (while many others do) in order to feel better and move forward. Through an evolution of “stepped care” models to our setting, we have arrived at a combination of single-session intervention, high quality referral (to local community therapists and to Student Affairs supports on campus), group psychotherapy, and medium and longer-term psychotherapy on site, seeking to match need to available resources more effectively, all while radically reducing wait times and maintaining high client satisfaction.
Through all of these experiences, I have remained curious about how to effectively and efficiently assist clients in healing sufficiently to prevent new symptoms from popping up as soon as old ones have been cleared. After all, if we as mental health providers can help ease someone’s pain faster, we should! In this instalment, we’ll build upon what we have been learning in the series to date to address the question of whether and why therapy works.
Therapy is, simply put, learning. It combines science and art, explicit and implicit learning, in support of human healing, growth, and the development of one’s full potential. My job is to help my clients feel and make meaning of their inner world in the context of their own lives, to teach the skills and foster circumstances that allow effective decision-making, to help clients to differentiate when to accept ‘what is’ and when to seek to change the context of their lives, seeking to live in and with a sustainable balance. In my experience, in order to achieve these goals, good therapy involves a few key ingredients spread over a few stages of treatment. In the beginning, it is important to start with a genuine and empathic therapist who is well trained, who listens intently, and who cares (after all, I’m not telling my secrets and hurts to someone who seems inauthentic, inattentive, or uncaring!).
A productive therapy starts with an opportunity for a client to share why they have come to therapy, their understanding of the problem, and what has lead to this point in their life. A good therapist will welcome a client’s thoughts and feelings, and will help a client to speak about their experience in a meaningful way, including identifying, understanding, feeling, expressing, and making meaning of the client’s own internal experience, not just “the facts” of the story. After listening and understanding a client’s concerns, a respectful and confident therapist will share their own opinions about what is happening in the client’s life, sharing their own understanding of their client’s challenges, strengths, and context, and based on this understanding, will lay out a plan of treatment for how to help a client to transform their experience through engaging in psychotherapy.
Moving into more active treatment stages, safety is important, and in part, this means being able to talk to a therapist without feeling numbed out, or overwhelmed by painful feelings. I often use a metaphor of a swimming pool when talking to clients about their feelings and internal experience. If we think of the water as someone’s internal sensations, feelings, and experience, then my job is not to push someone into the deep end before they know how to swim. That’s not helpful to anyone, and can indeed be harmful. Nor is it to ignore that we are standing on a pool deck. Rather, I work with clients to first explore the pool deck, identify the safety equipment, notice where the deep and shallow ends lie, slowly get used to the water, and develop any needed skills before swimming safely out to explore the deep end. Symptoms are often what keep us out of the pool and afraid of swimming in the first place. This process of ‘learning to swim’ may involve: learning new skills; developing a more balanced understanding of one’s history, strengths, and challenges; feeling truly and deeply heard, understood, and seen by another human being; and learning to build confidence, assertiveness, and self-compassion where previously there was fear, shame, loneliness, and avoidance. Finally, a good therapist will help to track when it is time to end the relationship, monitoring progress, continuously checking in on goals, and when the time is right, helping to create conditions for a good ending.
Recent advances in psychotherapy or ‘talk therapy’ research and neuroscience suggest that the ‘talking part’ is only one part of the solution – and it’s probably not the most important part. In his 2003 article, Goldfried references explicit and implicit learning systems, which are a helpful tool for organizing what is needed for talk therapy to be effective. Therapy can be viewed, fundamentally, as a dual process of explicit knowledge transfer, operating at the cognitive/rational level (teaching skills, providing information, imparting new conceptual frameworks for self-understanding) and implicit learning opportunities (operating at the level of our affective systems and automatic response tendencies). For a rather mind-blowing look at the impact of implicit learning in the physical realm, check out Dustin Sandlin riding the Backwards Brain Bike. Much like riding a bike, many of our emotional response patterns are implicit and automatic reactions that occur based on past learning. Rewiring these responses takes exposure, time, and a lot of wobbling!
Self: I’m having a great day! I felt anxious and tense this morning, listened to a meditation to soothe my nervous system, immersed myself in two hours of writing, got really excited in framing some conceptual arcs for finishing this blog, got hungry and tired, ate, set myself the goal of finishing off one particular section, and then took a break to go outside and enjoy nature. Loved this day!
Inner Critic: Yep. Pretty much!
While all therapies work with both explicit and implicit learning to some degree, their relative degree of focus on these two areas may vary both across therapy models, and indeed across practitioners. For example, some therapies have a heavy focus on teaching new coping tools and behaviours; this is especially true of cognitive therapies such as CBT (cognitive behavioural therapy), solution-focused therapy, and dialectical behaviour therapy, each of which focus primarily on the present or the ‘here and now.’ These therapies aim, broadly speaking, to help to correct bias in one’s thinking, to promote trying new behaviours, to help individuals understand what they are already doing well, and to understand their problems in new ways so that their actions change as a result. Through homework and application of this explicit knowledge, clients then have an opportunity for implicit learning, experiencing the results of new actions on multiple levels: cognitively (naming and making meaning of new outcomes following new behaviours), physiologically (having new mixtures of stress hormones and neurotransmitter combinations following novel responses to their new behaviours), and through interactions with mental health professionals who interact with their problems in new ways. By overcoming avoidance of certain actions and behaviours, clients expose themselves to new learning about what will actually happen in a given situation (as opposed to what they fear will happen), allowing them to build competence and confidence.
Some therapies, especially those that are psychodynamically oriented, focus more on insight, coming to understand past and present patterns in one’s life, exploring one’s emotional reactions, working in real-time to understand how one’s patterns may be playing out in current relationships, including the relationship with the therapist, and using all of this knowledge to make healthier choices going forward. In addition to a focus on explicit meaning making – coming to identify and understand patterns, and applying that linguistically-mediated knowledge to new life situations, implicit learning occurs in the interactions between client and therapist as the client’s nervous system reacts repeatedly to the attuned presence of the therapist. Outside of therapy, we expect implicit learning to follow as individuals experience new ways of being in old situations, including mindfully experiencing their and others’ reactions to these new responses.
Experiential therapies tend to focus on changing emotion with emotion, with a belief that by intentionally activating painful, old, stuck emotions in the present, we expose the underlying neural systems, including associated memories and response patterns to opportunities for new learning and change. Explicit teaching introduces clients to the importance of emotions and attending to their own experience. A high degree of focus is then placed on implicit learning – on increasing capacities and tendencies to be aware of one’s internal world, to live with awareness of one’s own body and feeling states, changing one’s internal world by reducing avoidance of what is going on inside one’s body and mind, observing changes, and maximizing coactivation of healthy experience alongside maladaptive stuck feelings, beliefs, and response patterns. To be transparent about my social location in the landscape of psychotherapies, it is with this last category that I have aligned my practice.
What are the common factors?
Wampold (2015) has proposed a contextual model of psychotherapy that nicely organizes our understanding of common factors underlying psychotherapy processes. According to Wampold, “[t]he three pathways of the contextual model involve: a) the real relationship, b) the creation of expectations through explanation of disorder and the treatment involved, and c) the enactment of health promoting actions. Before these pathways can be activated, an initial therapeutic relationship must be established.”
Meta-analyses (Wampold, 2015) of psychotherapy research data indicate that the majority of change in psychotherapy is predicted not by the specific model being used, or even the “active” ingredients of a given psychotherapy approach, but by a range of common factors including therapeutic alliance (the quality of the bond you experience with your therapist and your agreement on your goals and steps to achieve them), positive expectations that therapy will help (Price, Anderson, Henrich, and Rothbaum, 2008), therapist effects (such as the therapist having spent more time learning and practicing psychotherapy outside of their actual client work, greater skills in building alliance with a range of clients, and stronger facilitative interpersonal skills), and that the therapy in question provides a structured approach and encourages clients to engage in new and health-promoting behaviours. Pascual-Leone and Yeryomenko (2017) suggest that client experiencing should also be considered as a common factor. “Experiencing” refers to the client’s depth of emotional processing, both the degree to which a client is aware of internal experience such as feelings and physical sensations active in their body in the moment, and the client’s engagement in making meaning of and understanding this internal experience in relation to their own life.
To get what I mean by ‘experiencing,’ join me in this little thought experiment as we explore the difference between talking about feelings versus expressing feelings meaningfully. These are two quite different activities which activate different parts of the brain. Take a moment to imagine a time in your life when you felt hurt by someone’s actions – perhaps this was a fight with a partner, parent, or friend. Perhaps it was a disagreement with your boss that left you feeling misunderstood or undervalued. Imagine for a moment that you are talking to a close friend about this recent conflict. What would you say about the events? How would you describe what happened? Really bring this conversation alive in your imagination.
Pause for just a moment to identify what sensations and feelings you experience in your own body as you imagine talking to your friend in this way.
Now, take a moment and imagine the person you felt hurt by. Imagine how they look, what they might be wearing, their typical facial expression. Now imagine that you are expressing your feelings of hurt directly to the person you were in conflict with: telling a parent or partner how hurt you felt when they behaved in that way; telling a boss that you believed that their assessment was unfair and you wish to revisit the topic of your work.
Pause and notice what happens inside as you switch from imagining ‘talking about’ your feelings, to imagining expressing your actual feelings directly to the person you felt hurt by. For most individuals, feelings are stronger when we actually express what we are feeling to another (even in imagination), rather than ‘talking about’ our feelings. One is descriptive, the other expressive. You may also notice that you have different feelings in these two scenarios, for example, anger as you imagine talking to your friend about how hurtful your boss’ actions were to you, versus feelings of fear, or hurt when telling your boss how their actions impacted you.
Is there a common change process?
Just as there are different ways to learn to speak, read, and write effectively, there will certainly be multiple ways to learn to regulate and transform one’s internal emotional experience. While some educators believe that explicit learning of phonics and grammar is essential to linguistic development, what we see is that some individuals thrive without this explicit learning (which is absent in the predominant Ontario teaching curriculum), having a robust capacity to learn phonics and grammar implicitly through language exposure, while other students fall behind and require explicit learning to master the rules of language (whether or not these students are effectively identified and supported is another matter!). So too in therapy, clients will require different levels of intensity of treatment, with different foci, and different durations to master the basic skills and experiences required for emotional healing. This is one reason I have been a vocal advocate for equitable over equal care. Providing all incoming prospective clients with the same duration of treatment, and with similar tools, does not adequately support the diverse needs of our students.
Pascual-Leone (2018) has presented compelling preliminary research suggesting that there may be a common change process associated with psychological healing. This involves coming into contact with one’s experience, moving sequentially from experiencing and expressing secondary “global distress” (just feeling rotten without necessarily even knowing what one is feeling – it just feels bad; sometimes really, really bad!) into experiencing and expressing differentiated primary maladaptive emotions such as shame, fear, or blaming/rejecting anger, and then to experiencing adaptive emotions such as assertive anger, self-compassion, and grief related to past suffering.
Self: I feel sad sometimes when I think about past hurts. I’m sorry, critic, that you have had to hold on to those memories and the fear and shame they brought up for all of these years. How about we let them go together now? I know that you now know how to get my attention without scaring me, and I know how to listen and take care of things.
Inner Critic: I like that idea. It has been hard, and it feels good that you can pay attention now and know what you need in the moment to feel better – at least most of the time.
Pascual-Leone’s research provides preliminary evidence that this sequence appears to predict positive treatment outcomes across several therapy models and several categories of psychological difficulties (including anxiety, depression, and relational trauma). Some evidence suggests that focusing on expression of emotion as well as a client’s unmet needs for closeness (attachment needs) or for mastery (identity needs) appears to play a central role in decreasing initial client distress (Singh 2008, 2012). This is akin to the difference between feeling ‘lovable’ or acceptable to others, and feeling ‘good enough’ – both of which help to foster healthy relationships and appropriate self-confidence. Pascual-Leone likens the process of effective therapy, which tends to proceed in a non-linear, “two steps forward, and one step back” trajectory to helping clients complete “emotional push-ups,” increasing emotional flexibility, tolerance, regulation, and meaning-making across sessions.
Fundamentally, effective therapies help integrate our interoceptive, motoric, emotion, memory and rational/cognitive systems through helping people make sense of their internal worlds in meaningful ways and through trying out new behaviours and experiencing the results. All of this helps to rewire the brain, replacing longstanding problematic responses to old triggers (feeling repeatedly as though one did in past, in response to a difficult situation) with new responses that are relevant to the ‘here and now’ situation to which one is responding.
In my opinion, good therapy really is about having compassion for, protecting, and standing up for your inner child (SYTYCD fans, click here!) – or at least for the ‘younger’ parts of your self, encoded through earlier experiences in your own neural network, that continue to drive patterns of distress, pain, and hurt that underlie our “symptoms” and require healing to overcome. At times, this will also require explicitly teaching new world views, new skills, and new behaviours.
Join me in the next and final instalment when I will share my own journey of writing this series, analyzing the evolution of my own critical voice through the lens of emotion theory, and ending with some meta-processing or meaning-making, a unique stage in many experiential therapies.
Goldfriend, M. R. (2003). Cognitive–Behavior Therapy: Reflections on the Evolution of a Therapeutic Orientation, Cognitive Therapy and Research, February 2003, Volume 27, Issue 1, pp 53–69.
Hunsley, J., Elliot, K., & Therrien, Z. (2013). Canadian Psychological Association. (2013). The Efficacy and Effectiveness of Psychological Treatments [pdf]. Ottawa. Retrieved from https://www.cpa.ca/docs/File/Practice/TheEfficacyAndEffectivenessOfPsychologicalTreatments_web.pdf
Pascual-Leone, A. (March, 2018). How clients “change emotion with emotion”: A programme of research on emotional processing. Psychotherapy Research 28(2), p. 165-182.
Pascual-Leone, A., & Yeryomenko, N. (November, 2017). The client “experiencing” scale as a predictor of treatment outcomes: A meta-analysis on psychotherapy process. Psychotherapy Research 27(6), p. 653-665.
Price, M., Anderson, P., Henrich, C. C., & Rothbaum, B. O. (2008). Greater Expectations: Using Hierarchical Linear Modeling to Examine Expectancy for Treatment Outcome as a Predictor of Treatment Response. Behavior Therapy, Dec, 39 (4): 398-405.
Wampold, B. E (2015, Oct). How important are the common factors in psychotherapy? An update. World Psychiatry. 2015 Oct; 14(3): 270–277.