Psychotherapy Integration: The Least Sexy Aspect

Why the least sexy aspect of psychotherapy integration is the most important.

Posted Oct 22, 2020

Photo by Ricardo Gomez Angel on Unsplash
Source: Photo by Ricardo Gomez Angel on Unsplash

The fragmentation of the field of psychotherapy exists today for the same reason that schools of all the sciences existed in the Middle Ages. One school’s explanation was as likely to be true as that of the next. What do we really need to move our field to the next level? It’s simple. We need a universally accepted explanation of how therapy works.

Explanation means causation, not correlation, and how on earth are we going to establish that for such a complex endeavor? Well, the least sexy aspect is that before we try to explain how, we had better be clear about what. What, actually, is the target of psychotherapy. What is it that we are trying to change? That should be obvious but a universal answer has been elusive for two reasons.

Psychotherapy Treats Only Part of Mental Illness

Patients don’t care whether they suffer from steroid-induced mania or a reaction to their parent’s divorce. They don’t care whether their alcoholism was inherited or is related to war trauma. They don’t care and the diagnostic systems we use every day don’t either. But psychotherapy doesn't have such a wide scope. It aims primarily to change problems of the mind, not the brain. Yes, our interventions may have effects on many brain systems, but that is not what shapes our actions as therapists. We are working at changing the mind.

Does that mean we have to solve the mind/body problem? No. Contemporary neurophysiology makes it fairly clear that the brain is an information processing organ that performs calculations allowing us to select what evolution and experience “think” is the best response for any set of circumstances. Thus, the mind can usefully be defined as the “activity of the brain.” Psychotherapy works on responses produced by those mental calculations that turn out to be unhealthy or less satisfactory than other possible responses.

The Other Problem: Self-Referential Definitions and Explanation

That psychotherapy treats maladaptive responses should not come as any surprise to therapists. We have always known that, but if we ask a therapist what it is that therapy aims to change, we will get a different answer for every school. The problem is that existing descriptions of what psychotherapy aims to change are generally stated in terms limited to a particular school or orientation. They are self-referential. Cognitive therapists aim to change cognitions, while psychodynamic therapists try to resolve intrapsychic conflicts, and “third-wave” therapists seek to detoxify troublesome emotions.

Enter Convergence

That’s why such a non-sexy thing as a universal definition of problems of the mind that psychotherapy targets is so important, and that’s why the group of authors of this blog have agreed on the notion of EMPs, Entrenched Maladaptive Patterns. (See Henriques’ post, “On Adaptive and Maladaptive Patterns.”) Without a firm grip on what it is we are trying to change, we will never be able to achieve theoretical integration. With it, we can. As it turns out, this simple definition of the target of psychotherapy pays generous dividends. That definition, along with recent science in several fields, leads directly to the following principles:

  1. EMPs are stored in memory, and, so far, that narrows down change mechanisms to just three:  New learning by long-term potentiation, extinction of maladaptive responses by cortical inhibition, and memory reconsolidation, where information content is permanently altered.
  2. Neurophysiology today is leaning towards what I think of as an “hourglass” organization of mental processing. Circumstances are appraised and, through complex, non-linear calculations, predictions are made. These predictions narrow down to the activation of deep emotions with positive or negative valence. Those deep emotions (which are not always conscious) trigger the calculation of the “best” response and lead to the production of spontaneous actions, automatic thoughts, feelings, impulses, motivations, and physiological changes, some of which are maladaptive. All of these exert further influence on conscious choices, some of which are also maladaptive.

Seeing the target of psychotherapy in this way leads directly to a universal explanation of how therapy works, based on the three change mechanisms in #1 above. In order to support those change mechanisms, psychotherapy needs to:

  1. Activate relevant deep emotions as evidenced by affect (feeling combined with visceral changes) in a context that includes exposure to relevant new information.
  2. Expose the patient to relevant new information (including “information” that is relational and emotional), often at the same time that affects are in evidence.
  3. Support motivation to do the hard work of changing.
  4. Regulate arousal within an optimal window.

With this in mind, it becomes clear that irrational cognitions are the products of the mind’s automatic appraisal and response patterns, intrapsychic conflict is when the mind’s appraisal leads simultaneously to incompatible responses, and troublesome emotions are the end result of appraisal of some important threat. The self-referential explanations of various therapies and orientations make sense within the same framework. We hope this clarity helps to bring us together into one camp with a long history of inventing remarkable and effective therapeutic interventions.

We invite discussion, agreement, and disagreement.

—Jeffery Smith

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