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One reason for the fragmentation of the psychotherapy field has been weakness in basic understanding of why maladaptive patterns are endemic to humankind and how psychotherapy can lead to trading them in for healthier ones. Each school has developed theory on these questions, but the theories tend to be stated in self-referential terms, that is, using concepts specific to that school and not accepted by proponents of another. This is problematic. One definition states that a theory is “a supposition or a system of ideas intended to explain something, especially one based on general principles independent of the thing to be explained” [my italics].
While progress has been made in studying psychotherapy in the aggregate, resulting, for example, in the identification of common factors, a more challenging issue has been finding a broadly acceptable paradigm for understanding individual irrationality. The 21st century has, at last, seen the development of several threads of science, some new and some older, that are converging to make this possible. A picture is emerging of why and how we are irrational and of precisely how psychotherapy works to foster change.
The purpose of this series of three posts is to suggest that our field is closer to consensus than is generally recognized regarding the infrastructure common to all therapies. The key to finding common ground is narrowing the inquiry to five foundational questions:
- What is psychotherapy primarily aimed at changing?
- What are the common characteristics of those problems?
- What are the fundamental pathways by which change takes place?
- What supporting conditions are needed for change to happen?
Today’s post seeks to bring together a view of what psychotherapy does, based on the most broadly accepted principles.
Psychotherapy is not aimed directly at ameliorating DSM disorders. Rather, it seeks to improve the way people adapt or respond to challenges in their lives. For example, we don’t seek primarily to change a tendency towards anxiety, but to help an individual respond in a healthier way to the experience of anxiety. Over time, the anxiety may diminish, but that is not our primary aim. As many have pointed out, we don’t simply try to suppress or eliminate maladaptive patterns; we work to help patients replace automatic responses with healthier or more satisfactory ones.
Gregg Henriques, in the previous post, provides a practical, precise, and universal definition of the units of pathology that are the immediate targets of psychotherapy. He calls them “Entrenched Maladaptive Patterns” (EMPs).
Using Gregg’s characterization of the problems psychotherapy addresses we can apply 21st Century concepts to further describe what they have in common and how they can be modified or exchanged. The two subsequent posts will give more detail, but for now, I summarize:
Entrenched Maladaptive Patterns (EMPs) are:
Purposeful: As architected by evolution.
Encoded: In the synapses that define neural memory structures.
Triggered: And driven by subcortical emotions.
Shaped: By the Bayesian Brain’s predictive coding.
Layered: From older and deeper to more recent and superficial.
They are replaceable via three known low-level mechanisms:
1) New learning, both experiential and ideational
2) Extinction, through cortical inhibition of responses
3) Memory Reconsolidation, allowing modification of memory structures
Supporting Conditions Include:
1) Modulation of arousal within an optimal window.
2) Support, implied or direct, for motivation to do the work and take emotional risks.
3) Safety, real and perceived
4) Relationship, a key component in most of the above.
It is important to be clear that the common infrastructure outlined in these posts does not replace or compete with the richness of thought, experience, and tradition that have developed in the many schools of therapy. Instead, we suggest that our understanding of underlying mechanisms and commonalities has, until recently, been limited by lack of knowledge in areas such as how information was stored in the brain, why humans act irrationally, and why and how information is extensively processed outside of consciousness. As multiple areas of science are converging on these questions, new light is shed and new questions raised about the action of psychotherapy. Perhaps most important, principles that only now are becoming clear, begin to provide a Rosetta Stone for translating between existing but self-referential theories. The following two posts will detail nine threads of science that support the above propositions.
What do you think?
[For a view of how this list applies to practice, see the SEPI Convergence SIG’s 2020 Poster, The Common Infrastructure of Psychotherapy]
—Jeffery Smith, M.D.
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