Therapy

How Does Change Happen in Therapy? It’s More Than an Exercise in Talking

Learn to take risks and do things differently in the service of your values.

Posted Feb 12, 2021 | Reviewed by Lybi Ma

Siphotography/iStock
Source: Siphotography/iStock

When my client Eli* first came to therapy, I saw right away he was a talker. He would saunter into our sessions with cool hipster confidence, flashing me a smile. He was wicked smart and charismatic, and quite good at analyzing himself and his relationships. Often he made me laugh out loud. His well-developed narratives were full of causal patterns, flowing gorgeously from his lips. Lots of words, lots of content, all very captivating.

But Eli wasn’t really doing therapy with me.

You might think: Well, isn’t that what people are supposed to do in therapy? It’s the “talking cure” after all. I hear you. That’s what I did in my own therapy for many years. I thought therapy was reflecting out loud, making conceptual connections with the help of the therapist. And I had this belief: these insights would organically lead to some kind of meaningful change in my life. 

Only they didn’t.

I wish one of my therapists had explained to me: change requires more than just “talk” – it involves doing something different within yourself, with your therapist, and out in the world. 

Talking the Talk, But Not Walking the Walk

Let’s take a closer look at Eli. He came to therapy longing for a committed relationship, but in our first session acknowledged with an ironic smile that he is a serial dater of attractive but unavailable men. It was clear from his work as an engineering manager at a tech firm that he was quite skillful at identifying and analyzing problems. It was no surprise that he understood his own dynamics quite well at an intellectual level, and he was masterful at talking about them. But I could see underneath the talk, he was in pain. And he was puzzled why he couldn’t change his patterns.

Eli was raised by his single, hard-working mother. Because she was focused on meeting their basic needs, she was rarely around and had little bandwidth for a child’s usual struggles (not to mention his emerging sexual identity). Eli learned to shove down his feelings and amp up his entertaining personality to get his mom’s attention. These coping behaviors helped him to maintain a vital, thin thread of attachment to his only parent. Reflecting on this as an adult, Eli knew that he kept others at a distance. What he had trouble noticing were the moments when he was actually distancing. And he had no idea how to engage others differently to form more authentic, deeper relationships. 

This was clear to me during our sessions. Eli would say he keeps people at arm’s length, while at the same time not realizing that he was doing this with me. He would tell me familiar stories about his history that explained why he was wary of others, but he didn’t know how to open up and share that pain with me in real-time, in a vulnerable way. Even when he would talk about emotional things, he would do it in a way that was in control and detached—keeping it light, story-telling with his witty humor. Eli wasn’t consciously avoiding. These protective behaviors had emerged long ago and were now deployed automatically, even though they were no longer adaptive. Therapists call these “defenses” or “safety behaviors” or simply “avoidance.” Regardless of the name, these behaviors functioned to keep Eli in his safe-zone. No emotional risk-taking happening during this therapy hour. 

The result on my side of the therapeutic relationship was that I liked and admired Eli very much, but it was hard to get in close. 

How Eli was acting with me in therapy was, of course, a reflection of how he acted with others in his life. He had gregarious friendships, but no one really knew his interior. When someone he was dating started to really like him or he felt a growing attachment, he would back off. And he maintained a superficial relationship with his mom, who was still living but sick with multiple sclerosis. Surrounded by many people in his life, Eli was quite lonely.                     

Change required Eli to do more than just see his patterns. He needed to overcome his avoidance and do something new, starting with me. He needed to learn how to walk the walk of genuine intimacy

Tension Between Old and New Learning

Although the details of Eli’s life are unique to him, at a more fundamental level, Eli was stuck for the same reason we all get stuck. There is a fundamental tension between what we “know” based on our past (old learning), and what we might discover if we step outside of that into (new learning). Eli’s history with his mom was thoroughly encoded into various sensory, emotional, cognitive (beliefs), and behavioral systems in his brain. These networks “fired together” as he moved through his childhood and then “wired together” across his memory systems. This is how Eli’s past was consolidated into a subtle but ever-present distrust of others at varying degrees of awareness. 

Sammie Chaffin/Unsplash
Source: Sammie Chaffin/Unsplash

For Eli to update his old learning, I couldn’t just tell him “I am someone you can be real with” or “try to trust your new partner.” Words can’t touch lived experience. This is the reason merely talking about one’s experience or returning to well-worn narratives in therapy is generally weak medicine. For Eli to learn at every level of his nervous system that there might be people he can form emotionally close relationships with, he needed to risk engaging me and others in new ways. This meant bravely facing possible judgment, rejection, abandonment. Opening up thus felt to Eli like leaping from his safe, solid base across a chasm of uncertainty without knowing how to stick the landing.

You can see Eli’s dilemma. And why engaging in new ways takes courage. 

Therapists work to create safety with the client for this very reason. We strive to create a trusting relationship to help clients open up to what feels threatening or painful within themselves (new internal behaviors), and to risk engaging us and others in new and healthier ways that feel risky (new interpersonal behaviors). We are there as the client approaches the edge of what feels like a cliff—anxiety alarm blaring—and then leaps. Now it’s true that sometimes the feared outcome happens; to engage means being willing to accept this possibility and the difficult feelings that come with it. But often the outcome is surprising and transformative, disconfirming what the brain expects based on the past. Therapists call this a “corrective emotional experience.” Regardless of the outcome, taking a risk in the service of one’s values is always empowering and builds inner trust, integrity, and meaning.

Walking the Walk: Learning to Engage in New Ways

John Hain/Pixabay
Source: John Hain/Pixabay

Here’s what I did with Eli.

In session, I would interrupt Eli as he would wax poetic about how others aren’t really interested in him, and ask him to notice what was happening between us: did he feel my genuine curiosity in this moment? I invited him to risk sharing parts of himself he normally hid—what he feared and longed for, his shadow sides he felt shame about. Then I asked him to observe my response: Did I judge and pull back, or listen and strive to meet him there? I encouraged him to slow down and actually feel the anxiety, hurt, and loneliness that would arise as he leaned in (a difficult skill, and topic for another blog post). And as he started to move into that risky space, he kept seeing that I would stay with him. Together we created moments of profound connection that began to heal Eli’s painful isolation, soften his distrust, and give him a template for forging true intimacy. 

But it was also important that Eli generalize this experience to his life outside our sessions. Each week he and I formulated “homework”—experiments of how he might open up with others. For example, when Eli went on a date or spent time with friends, he would practice asking for what he needed, taking in the care that was offered, and expressing himself in more genuine and vulnerable ways. He told a man he was dating that he was looking for something more serious. And he started calling his mom more, letting her into his world. And together we would track and process what happened. Others surprised him by opening up themselves, inviting more emotional connection. Soon he was feeling a deeper sense of connection and belonging. And while he was rebuffed by one potential partner, he was eventually able to get into a healthy, committed relationship. 

A little interlude here about psychotherapy approaches, for the curious. Psychodynamic and emotion-focused approaches have honed relational work in session (what’s happening between the client and the therapist, sometimes called transference work). Cognitive and behavioral approaches are skillful at helping the client engage in new ways outside the session (exposures, “behavioral experiments,” putting values into action instead of avoiding), and also turning these behaviors into skills and habits. Both in-session and outside-session engagement facilitate experiential learning (i.e., learning from doing, as opposed to academic or conceptual learning). And both are essential for deep and sustained growth. 

Now, here’s where “talk” can productively consolidate new learning. After Eli would take a risk with me or others, we would closely observe what happened, putting words to his experience. We were integrating the information to update his beliefs, helping Eli form more flexible and helpful narratives to keep doing what was most important to him. Effective therapy is this on-going dialectic between acting in new ways, and then languaging what happens into our conceptual models to support more on-going meaningful engagement.

I remember a moment with Eli after working together for a while. He was telling me a funny anecdote about his new relationship—how the two of them were kayaking on the bay and tipped over. Eli was still a riveting story-teller, but as he was talking, he suddenly paused, letting the vulnerable feelings arise. He then shared with me his astonishment and joy that he had finally found love, his fear of possible loss, and a growing confidence that even with heartbreak, he knew how to do this again. 

*Eli is a composite client, with all identifying information removed or changed to maintain privacy. 

References

Burch, G.F., Giambatista, R., Batchelor, J.H., Burch, J.J., Hoover, J.D. & Heller, N.A. (2019). A meta‐analysis of the relationship between experiential learning and learning outcomes. Decision Sciences Journal of Innovative Education, 17: 239-273.

Elliott, R., Greenberg, L.S. & Lietaer, G. (2004). Research on experiential psychotherapies. In M.J. Lambert (Ed.), Bergin & Garfield‘s Handbook of Psychotherapy and Behavior Change, 5th ed. (pp. 493-539). New York: Wiley

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20–35.