How does therapy really work? Depending on your school of thought, it has something to do with insight, identifying feelings, changing thought patterns, experimenting with new behavior, feeling understood—or all are promoted by a good therapist. Is it possible, however, to reduce these elements to their essence and produce a model that is not only helpful to therapists but to patients?
Two psychoanalysts from San Francisco, Joseph Weiss and Harold Sampson, have done just that. Drawing on 50 years of innovative research, much of it published in two books and dozens of articles, Weiss and Sampson developed a powerful model of the process of healing and change. As is true with all models, it is based on a particular theory of the mind: To elicit change, one must have a clear idea of what needs changing and how that thing works.
Weiss and Sampson introduced the concept of pathogenic beliefs to describe the building blocks of all psychopathology, i.e. what needs to change. Their use of the term “beliefs” isn’t meant to convey something abstract and intellectual, but rather early childhood constructions of reality that are shot through with intense emotion. Beliefs, in Weiss and Sampson’s usage, refer to acquired perceptions about how the world and people “work” and also how they’re supposed to work. In other words, in the young child’s mind, the way things are is also the way things are supposed to be. Going outside the familiar or violating these strictures threatens to disrupt the child’s relationships with his or her family.
By “pathogenic,” Weiss and Sampson refer to the ways that some beliefs, while feeing “normal,” interfere with healthy developmental aims and goals such as autonomy, competence, success, love, and intimacy—things we all seek to acquire from childhood onward. Weiss and Sampson call such beliefs “pathogenic” because, by interfering with normal and healthy developmental strivings, they create suffering.
Examples of pathogenic beliefs abound and, from the outside, often seem to take the form of “if-then” relationships. For example one might grow up feeling that if one exhibits too much strength, then one’s caregivers will be hurt, or expressing too much dependency will cause one’s caretakers to feel drained and, thus, withdraw. Or a child might infer that a parent’s depression was caused by that child’s angry feelings, or that his or her wish to be special and understood caused a parent to become irritable or angry.
This focus on parents isn’t about blame, but the result of a simple and universal fact: Parents have an awesome authority to define what children grow up feeling to assume is normal, as well as the way things are “supposed to be.” Parents and families, in other words, define reality and morality. It is because of the profound dependence that children have on parents that the latter’s personalities, reactions, moods, emotional presence or absence, empathy (or lack thereof), have such an impact and are so crucial in development. The need for safe attachment trumps everything else. It is in this context that pathogenic beliefs are formed.
Children don’t always correctly perceive or these “if-then” connections. The minds of children are usually egocentric and not infrequently draw conclusions that are false. For example, I’ve had many patients over the years who have secretly held themselves responsible for a parent’s or sibling’s death or illness. Moreover, there are many times when a parent’s temper, withdrawal, or depression has nothing to do with the child, but that the child associates with his or her own feelings and behavior (e.g. “my pushing my mother away in an effort to become more independent made my mother depressed and withdrawn). Often, of course, the child’s inferences are correct, but certainly not always. Either way, the connections are made and a very particular sense of reality is formed.
The suffering that our patients come to us to alleviate is based on pathogenic beliefs. For example, one of my patients kept shooting himself in the foot at work when it came to promotions because of the pathogenic belief that he wasn’t supposed to be more successful than his father. Another kept stirring up conflict in her marriage because of an unconscious loyalty to her mother who had a tumultuous and unhappy marriage. In this case, the pathogenic belief was that she wasn’t supposed to be happier in love than her mother and, if she was, her mother would feel betrayed and abandoned. And still another patient stayed in a bad relationship for years because of his pathogenic belief that he was omnipotently responsible for wife’s welfare and that, should he separate from her, she would go to pieces and it would be his fault.
It didn’t matter that the parents of these patients. The context, in other words, in which these pathogenic beliefs were formed, might no longer exist. As we grow up, we internalize and continue to repeat what we experienced and learned as children. Moreover, sometimes our pathogenic beliefs are confirmed by the realities we create. The male patient who kept sabotaging himself at work chose a company that made promotions difficult. The woman in the bad relationship had chosen a man with whom it was easy to argue and feel persecuted. And the man “stuck” in his marriage out of guilt did, in fact, choose a woman who was quite emotionally impaired and dependent. While these adult environments confirmed pathogenic beliefs, they didn’t create them. Sometimes the world reinforces our worst fears and inhibitions. However, it’s harder to change the world if one doesn’t change the pathogenic beliefs that are being reinforced.
If the world confirms one’s pathogenic beliefs, then it’s the job of therapy to disconfirm them. And that’s just what Weiss and Sampson argue that occurs in every good and successful psychotherapy. Therapy is nothing but a process by which people acquire insights and experiences that counteract their pathogenic expectations of the way their world is and the way it’s supposed to be. Weiss and Sampson’s description of the exact process by which this occurs is another thing that marks their approach as unique.
Patients, they assert, come into therapy with a conscious or unconscious wish to master their more troubling pathogenic beliefs. For example, a man enters therapy, unhappy in his marriage because he’s so shut down, and wants to master the problem of his withdrawal. It emerges that his withdrawal and apparent stoicism is based on the pathogenic belief that his wife doesn’t really care about his feelings and that it’s shameful for a man to express them. This perception or expectation originated in a family in which this patient, as a child, painfully experienced his parents as preoccupied and disinterested in what he thought and felt. He grew up feeling that this was the way the world worked, despite the pain it caused. He learned early on not to ask for much empathy, even as he suffered from its absence.
Despite these convictions, he comes for help because he wants to overcome his problem and learn to be more expressive and intimate. The problem is that, at the same time, he doesn’t feel safe enough to simply relinquish the defenses of a lifetime. He worries that if he shows too much of these forbidden needs to his therapist, much less to anyone else, that their responses will repeat the neglect and rejection of his parents. Early experiences will be confirmed and he’ll be made to feel terrible again. So, he wants to get better but his pathogenic beliefs interfere.
The therapist’s job is to disconfirm this man’s pathogenic beliefs in whatever way works. For example, the therapist might help explain to this particular man how he came by his problem honestly, how it arose from his childhood experiences through no fault of his own, and how it is probably not any longer an accurate inference about himself or others. Understanding and insight are powerful ways to disconfirm pathogenic beliefs. In addition, the therapist might go out of his or her way to demonstrate a special interest and non-judgmental curiosity about the patient’s inner world, emphasize the importance of the patient’s selfish needs, and thereby disconfirm in the therapy the painful belief that no one is really interested in him. The therapist might encourage the patient to gradually take the insights and corrective learning acquired in the consulting room and start to apply them in situations outside the therapy--for example, in his marriage--to learn the extent to which his pathogenic beliefs are really accurate. To the extent that they are not accurate, the pathogenic belief is weakened.
This example is but one of an almost infinite variety of clinical situations, each one of which involves different pathogenic beliefs and a different route to helping the patient disconfirm them. One patient of mine had a very weak mother and grew up feeling guilty about being separate and strong. It was important that I not only helped her understand these dynamics, but that I helped provide experiences in which she could be strong and independent with me, responding in ways contrary to her experience of her mother. I would make a point of being non-defensive, sometimes pushing back in a good-natured way, other times giving her a lot of space, letting her come and go, and all the time looking for ways that she might understand and experience that her pathogenic belief was wrong. I would point out how selective she was in looking for experiences outside the therapy that confirmed her guilt about being assertive, ignoring the ones that accepted or even celebrated this part of her, and encouraged her to test this out even more in the world.
Every patient is different. The therapist has to tailor his or her approach in very particular patient-specific ways, not bound by theories or generalizations about proper “technique.” The only relevant question is, does it work and is the patient getting steadily better? If so, the therapist is on the right track and if not, the therapist is missing something. Very few theories emphasize such an approach. Psychotherapists have a habit of thinking more about principles and theories than outcomes. One school argues that therapists ought to primarily focus on what is going on between the therapist and patient. Another promotes the notion that too many explanations or education in therapy necessarily contribute to the patient avoiding feelings. Still another teaches that if one uses logic to change people’s thought patterns, their emotions will follow. Finally, some schools of thought advocate simple listening, empathy, and mirroring the patient’s experience back to him or her.
All of these approaches are appropriate in some situations. All are completely wrong in others. To the extent they they define an “approach,” they are too often theory-driven and ignore the many exceptions to the rules they suggest. They suffer from the fact that they are not singularly attentive to the fact that a patient’s responses to interventions, whether he or she feels safe enough to explore issues more deeply, and whether or not he or she is getting better, are the only things that matter. There are very few generalizations that one can make about how a therapist should and shouldn’t work (other than legal and moral strictures against exploiting a patient). Weiss and Sampson’s approach, while certainly resting on a theory, is unique in that they teach therapists that if we’re “off,” we can see it in the patient’s responses and make mid-course corrections, that if our diagnosis of their core pathogenic beliefs is correct, an attitude of “whatever works” should prevail, without regard to any special “technique,” in disconfirming these beliefs. Every other generalization about therapy has too many exceptions to be useful.
Psychotherapy is often made to seem too complicated. Surely therapists bring intuition, training, and skill born of experience to the task. Patients would feel gypped and outraged if this were not the case. And the process itself might take a long time—after all, it took a long time to cement one’s pathogenic beliefs, they’re often reinforced, and at least they provide a sense of continuity, predictability and real or imagined safety. But the fundamentals of how therapy works are relatively simple. Therapists combine insight and new experience to disconfirm a patient’s pathogenic beliefs. How this is done is completely dependent on the particularities of the patient.