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Jeffery S. Smith M.D.
Jeffery S. Smith M.D.

Is Your Therapy Working as it Should?

Good therapy should feel like work that is paying off.

Brandon Baunach/Flickr (Modified) CC BY 2.0
Source: Brandon Baunach/Flickr (Modified) CC BY 2.0

Human dysfunction has staying power. If we enter psychotherapy, it is only when common sense, family, friends, and self-help resources haven’t been enough to overcome the problem. There must be something in us that resists our best efforts to change. What is it?

One of the most basic principles governing the way the brain works is that we (like all mammals) strongly work to avoid painful, overwhelming and uncomfortable feelings. Our brain is organized around opposites, things we seek out and those that we avoid. Circumstances associated with negative feelings are the ones we keep at a distance. So to stay out of trouble, we instinctively run from anything that will lead to a bad feeling. Of course we also seek out good feelings, but, as many have pointed out, the bias is towards the avoidance of the negative.

This system works very well overall, but has a few glitches. If a situation once caused pain, we never want to forget it, so our brain is set up to remember any signs that we are entering dangerous territory. But what if a situation was once dangerous and now is really good for us? Our brain still reacts as if life depended on keeping our distance. For example, being betrayed by caregivers in early life makes us skittish about trust and vulnerability, even though vulnerability is an essential part of healthy intimacy.

It may be hard to believe, but all the emotional problems that therapy can help with, first started out, as a means to avoid difficult feelings. This is a very broad statement, but please look at the sheet I have prepared showing the 12 ways we avoid feelings. [, see resources/free downloads] These 12 mechanisms cover all the problems that are amenable to psychotherapy and they make up most of the psychological problems that plague humans.

So it is that the invisible force working against positive change is simply the brain doing its job to keep as far away from troublesome feelings erroneously associated with healthy new ways of approaching life.

Why don’t we learn over time, that our brain's assessment of danger is wrong? Our brains are programmed under most conditions not to forget any possible danger. The exception is that if we re-experience the full intensity of the troublesome feeling in a context that shows us it is not really dangerous, then the old learning can change. As long as we successfully avoid getting near the feeling, the conditions for new learning are not met. We don't re-experience the feeling. In fact, by avoiding the feeling, we strongly resist opening ourselves to new learning. It’s a “catch 22,” where the conditions needed for change are the ones we most strongly avoid.

This is why good therapy should regularly feel uncomfortable if not frankly anxiety provoking. While it is good that therapists invite us to take healthy risks and change familiar but dysfunctional behaviors, we should also experience that doing so results in feeling better. We should be trying to let go of the status quo and to expose ourselves to what we have most dreaded. However we should only do so when we are as sure as we can be that the result will be positive.

Sometimes this is easier and sometimes it is harder. Taking a healthy risk often requires trust. If our trust has been damaged, then you may have to start with small risks of trusting and having a positive experience. Another factor that often holds us back is shame. Telling a therapist something we feel ashamed of is hard for all of us, but is one of the most positive things we can do. The things we don't want to disclose are usually the ones that, once out in the open, are most freeing.

Habits and behavior patterns can also be powerful ways to distance feelings. Ways we act without thinking often turn out to have started out as avoidance mechanisms that have since become unhealthy. Do you have any patterns that get in the way of your happiness or success? We often rationalize them or tell ourselves, “It’s just my way,” when they are really destructive. When we finally admit that they are unhealthy, our brain may come up with invisible resistance. Having honest, open conversation with a therapist can help identify these patterns and how best to change them.

Another resource is the Scarsdale Psychotherapy Self-Evaluation, (SPSE), an 18-item questionnaire that helps you identify areas of your therapy where there may be room for improvement.

Jeffery Smith, MD

About the Author
Jeffery S. Smith M.D.

Jeffrey Smith, M.D., teaches at the psychiatry residency program at New York Medical College.

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