Is What You’re Doing Really Psychotherapy?

Ellis’s version of ABC to describe behavior was Activating Event, Belief, and Consequence. You open the fridge looking for OJ, find none (A), and feel crushed (C). Perhaps the belief that accounts for your feeling crushed was that your romantic partner doesn’t value you enough to leave you some juice. That might hurt, but would it crush you? Perhaps beneath that B is another B that nobody really loves you. That would be crushing. The hallmark of a useful speculation about a B, in my view, is that if you believed it, you’d also feel crushed (or you’d do whatever C you’re trying to explain). It’s only in cognitive-behavior therapy (CBT) that B’s are beliefs. Instead, B can just stand for “Between.” The idea of a Between honors the fact that we don’t all respond the same way to the same situations. Although ABCs unfold as such in life, in therapy the process usually goes C-A-B: some consequence is noted as interesting (an emotion, thought, or overt behavior); the therapist tracks down the activating event (if the C is something that happened in the session, the therapist has the advantage of closer access to the activating event); then the therapist works with the patient to understand the Between that connected the two.

The Between may be a thought or belief after all, but it may be self psychology’s organizing principle, system theory’s family pattern, behaviorism’s learning history, ego psychology’s unconscious conflict, and so on. I find verbal beliefs to be of limited use as Betweens; they are typically too generic (“I am unloved”) and convey too little information. Instead, a picture or a movie makes a better B. A picture might be the person’s image of himself as a pimply teen who just farted in class. This comes to him when he sees there’s no OJ, and he’s crushed. A movie might be a memory that plays in the background of his mom promising him a chocolate cake on his sixth birthday and then producing a box of cookies expecting him not to complain in front of his friends. The movie might be an old memory, a dream, a fantasy, or an event from the recent past. If you want to work with Betweens, you need a therapeutic frame that facilitates his disclosure of the image or the movie.

Not all therapies are about Betweens. There are also A therapies and C therapies. An A therapy solves the patient’s problem by changing the situation directly, such as removing temptation or avoiding “triggers.” A C therapy addresses unwanted consequences directly, rather than changing the person so they won’t occur as often. Drugs, meditation, and distraction are typical C therapies. When someone says that golf is her therapy, she means that it relaxes her, a C therapy, not that golf illuminates her old patterns and changes them. The great advantage of a C therapy is that you don’t have to understand what’s going on to treat a symptom. Someone with a fear of flying has to get on a plane for some reason; give him a beta blocker and let him go back to his A approach (if avoiding plane flights is not that great a burden). The great disadvantage of C therapies is that, unlike medicine where the symptom is always the bad guy, the problematic consequence of anxiety or depression may be the only thing motivating the person to improve herself or her situation. Remove the anxiety or depression with pills and you remove the motivation to make things better. You can’t tell the kind of therapy from the theoretical orientation of the therapist. Some behaviorists are trying to change the person via exposure, typically a B therapy; some psychoanalysts drift into advice-giving, typically an A or C therapy.

Psychologically-minded therapy is about Betweens, changing the person and not just the situation or the problematic outcomes. I call this “psychotherapy,” reserving other terms for A and C therapies. This is the kind of therapy that works best and longest (Shedler, 2010), but not always quickest. Such a therapy must be organized around a frame that enhances the reproduction of problematic patterns in the therapist’s office, what behaviorists have recently taken to calling “clinically relevant behaviors,” and what psychoanalysts have long called “transference.” The reason for the explicit and implicit rules of therapy is to enhance and to take advantage of patients’ tendencies to screw up the therapy in the same way they screw up other things.