How to Create Lasting Change (in Yourself): Lessons from the Greatest Psychotherapists
Bamboo Newsletter #41 (Revised)
How to Create Lasting Change (in Yourself): Lessons from the Greatest Psychotherapists
(above poster can be purchased on Etsy here—I receive no commission. LOL.)
(A quick shoutout to my daughter, Lauren, whose birthday is today, April 20. Happy Birthday, Lauren. I wish you health, happiness, love, and abundance.)
A blessing has been in front of my eyes for the last 18 months and I finally allowed myself to receive it. It is like the story Acres of Diamond in that I didn’t need to look elsewhere for opportunity, achievement, or fortune; all the resources were in my own backyard. Two weeks ago, after knowing her well for the last 18 months, I read Dr. Marilyn Montgomery’s book, Theories in Counseling and Therapy. Generally, speaking I would say that my eyes would gloss over and roll back at how boring (click for gif) this book sounds
.
However, I was trying to get a better understanding of where Clear Beliefs and RIM fit into the world of Therapy and Coaching. So, I was willing to take this dive into what I thought would be a yawner. I was quite mistaken. One of the things I learned from speed reading was to ask the questions that you want to be answered before you start reading. Dr. Montgomery in the introduction of her book has pointed out that the book is organized around some central questions that are intriguing to me:
What leads people to develop problems?
How can we best influence people to change lifelong dysfunctional patterns?
What makes changes last?
In answering these 3 fundamental questions by looking at how groups of theories answer these questions, I was able to quickly get a 30,000 ft. overview of the history of psychology and most importantly how some of the greatest psychologists answered the question: how do we create changes that last?
Coaching vs Therapy
If you have been following my recent newsletters, you will have noticed that I have moved out of traditional coaching, which focuses on the present and future. I am now including a person’s past history which is more in line with a therapeutic model which focuses on past, present, and future (most therapists mostly focus on past and present). I am not a therapist, however, I notice that when most people get stuck, it is as a result of some past issue that is preventing them from moving forward.
Why Do People Go to Therapist or Coaching? They Get Stuck
In her book, How To Do The Work: Recognize your patterns, Heal from your past, + Create yourself, Dr. Nicole LePera, who is known as the holistic psychologist, notes:
“Over my decade of work as a researcher and clinical psychologist, “stuck” was the word most commonly used by my clients to describe the way they felt. Every client came to therapy because they wanted to change….Unanimously, no matter their backgrounds, every client felt stuck—stuck in bad habits, damaging behaviors, predictable and problematic patterns—and it made them feel lonely, isolated, and hopeless.”
Dr. LePera goes on to say that often the clients knew what to do, and were able to take the first few steps to do, and despite knowing better, they felt ashamed that they could not do better. Still, others, had great transformative experiences in single sessions, e.g. using psychotropics like ayahuasca, but slide back eventually into unwanted behaviors. In other words, even those who knew what to do and were able to create change were not able to create changes that last.
This reminds me of myself and the pattern of ”create a life that is great and then life crashes”; repeat and do over and over again; aka Mark 0.0, Mark 1.0, Mark 2.0, and now we are on Mark 3.0 forever, after fixing the issues. LOL.
Holistic Psychology Solution to Creating Lasting Change
Dr. LePera’s realization was that in order to change you had to recognize your patterns (maladaptive behaviors), heal from the past (your core wounds, etc.), be your true self, and create the life you want. “To truly actualize change, you have to engage in the work of making new choices every day. In order to achieve mental wellness, you must begin an active daily participant in our own healing.” In other words, she discovered her own theory on what it takes to create lasting change.
While Psychotherapy was founded to help people who have a mental disease (i.e. can be classified and diagnosed according to the Diagnostics and Statistics of Mental Disorders (DSM-5) which was last updated in 2013), I believe many of the tools used by psychotherapists can be used to help “ordinary” people, get unstuck in their lives, which is what Dr. LePera has done.
Understanding the Various Theories to Create Lasting Change
Dr. LePera in her own travels has developed a formula called holistic psychology. How does that compare to all the other alternative psychology schools of thought?
It is answering a question like this where Dr. Montgomery’s book comes in extremely handy. Understanding the theories of counseling and therapy has a lot to offer! It answers the question of what happened to you, why this is happening now and it also helps to answer how to make changes to get unstuck and make the changes last. In other words, theories of therapy and counseling answer the crucial question of self-development: how do you make changes that last?
Theories on how to make changes last in humans are the history of psychotherapy. It is best understood through the great therapists through history that represented each theory. Dr. Montgomery’s book groups most therapy into 5 main categories: psychoanalytic, behavioral, humanistic, cognitive, and systemic. It also has 2 other categories—brief therapies and what I call Other (it calls it new theories. Lol)
Freud, Jung, and Psychoanalytical family
Therapy really came into its own with Sigmund Freud. Despite many of his theories being discredited, Freud nevertheless laid the framework of which therapy still rests today. Freud was really responsible for creating the therapist-to-client relationship and using analysis to help the patient recover himself.
At one point in the 1960s, psychoanalysts headed every major school and hospital in psychiatry. Psychoanalysis until the 1970s was open only to medical doctors and was thus only available from psychiatrists (vs a psychologist who had a Ph.D. in psychology) While they are more like feuding cousins vs a cohesive family, this group includes Alfred Adler, Carl Jung, Erich Fromm, and Wilhelm Reich.
I will conclude later in the article the main features of psychodynamics and why this is the foundation of most practices today regardless of what people actually say. The common attributes of the psychodynamic family were featured in an article by Jonathan Shedler in the American Psychologist Feb. 2010, titled The Efficacy of Psychodynamic Psychoanalyst:
“1. Focus on affect and expression of emotion. Psychodynamic therapy encourages exploration and discussion of the full range of a patient’s emotions. The therapist helps the patient describe and put words to feelings, including contradictory feelings, feelings that are troubling or threatening, and feelings that the patient may not initially be able to recognize or acknowledge (this stands in contrast to a cognitive focus, where the greater emphasis is on thoughts and beliefs; Blagys & Hilsenroth, 2002; Burum & Goldfried, 2007). There is also a recognition that intellectual insight is not the same as emotional insight, which resonates at a deep level and leads to change (this is one reason why many intelligent and psychologically minded people can explain the reasons for their difficulties, yet their understanding does not help them overcome those difficulties).
2. Exploration of attempts to avoid distressing thoughts and feelings. People do a great many things, knowingly and unknowingly, to avoid aspects of experience that are troubling. This avoidance (in theoretical terms, defense and resistance) may take coarse forms, such as missing sessions, arriving late, or being evasive. It may take subtle forms that are difficult to recognize in ordinary social discourse, such as subtle shifts of topic when certain ideas arise, focusing on incidental aspects of an experience rather than on what is psychologically meaningful, attending to facts and events to the exclusion of affect, focusing on external circumstances rather than one’s own role in shaping events, and so on.
Psychodynamic therapists actively focus on and explore avoidances.
3. Identification of recurring themes and patterns. Psychodynamic therapists work to identify and explore recurring themes and patterns in patients’ thoughts, feelings, self-concept, relationships, and life experiences. In some cases, a patient may be acutely aware of recurring patterns that are painful or self-defeating but feel unable to escape them (e.g., a man who repeatedly finds himself drawn to romantic partners who are emotionally unavailable; a woman who regularly sabotages herself when success is at hand). In other cases, the patient may be unaware of the patterns until the therapist helps him or her recognize and understand them.
4. Discussion of past experience (developmental focus). Related to the identification of recurring themes and patterns is the recognition that past experience, especially early experiences of attachment figures, affects our relation to, and experience of, the present. Psychodynamic therapists explore early experiences, the relation between past and present, and the ways in which the past tends to “live on” in the present. The focus is not on the past for its own sake, but rather on how the past sheds light on current psychological difficulties. The goal is to help patients free themselves from the bonds of past experience in order to live more fully in the present.
5. Focus on interpersonal relations. Psychodynamic therapy places heavy emphasis on patients’ relationships and interpersonal experience (in theoretical terms, object relations and attachment). Both adaptive and nonadaptive aspects of personality and self-concept are forged in the context of attachment relationships, and psychological difficulties often arise when problematic interpersonal patterns interfere with a person’s ability to meet emotional needs.
6. Focus on the therapy relationship. The relationship between therapist and patient is itself an important interpersonal relationship, one that can become deeply meaningful and emotionally charged. To the extent that there are repetitive themes in a person’s relationships and manner of interacting, these themes tend to emerge in some form in the therapy relationship. For example, a person prone to distrust others may view the therapist with suspicion; a person who fears disapproval, rejection, or abandonment may fear rejection by the therapist, whether knowingly or unknowingly; a person who struggles with anger and hostility may struggle with anger toward the therapist; and so on (these are relatively crude examples; the repetition of interpersonal themes in the therapy relationship is often more complex and subtle than these examples suggest). The recurrence of interpersonal themes in the therapy relationship (in theoretical terms, transference and countertransference) provides a unique opportunity to explore and rework them in vivo. The goal is greater flexibility in interpersonal relationships and an enhanced capacity to meet interpersonal needs.
7. Exploration of fantasy life. In contrast to other therapies in which the therapist may actively structure sessions or follow a predetermined agenda, psychodynamic therapy encourages patients to speak freely about whatever is on their minds. When patients do this (and most patients require considerable help from the therapist before they can truly speak freely), their thoughts naturally range over many areas of mental life, including desires, fears, fantasies, dreams, and daydreams (which in many cases the patient has not previously attempted to put into words). All of this material is a rich source of information about how the person views self and others, interprets and makes sense of experience, avoids aspects of experience, or interferes with a potential capacity to find greater enjoyment and meaning in life.”
In other words, psychodynamics focuses on both the cognitive aspects and the emotional aspects. It looks at the past for cause and the present patterns (past and present focus). It also focuses on relationships with self and others. It uses the therapist (transference) to help create examples of what a proper relationship to self and others might look like. It allows the free exploration of the conscious, unconscious, and spiritual. Later Wilhelm Reich also incorporated the body as a source of information for use in the psychodynamic family (though he was an exception).
Pavlov, Skinner and the Behavioral Approaches
The basic tenet of the behavioral approach comes from Pavlov’s dog experiment’s which we are all familiar with. If you ring a bell and feed a dog, the dog will eventually salivate when you ring the bell even though you don’t feed it. The methods of relaxation training, systematic desensitization, behavioral contracting, and assertiveness training all came out of this approach.
Carl Rogers, Gestalt therapy, and the Humanistic family
Humanist theories all share a core set of beliefs about human beings. All the approaches value a helping relationship that is kind and caring. Most therapists today, regardless of branch of therapy, probably apply some form of Carl Rogers client-centered approach
“In order to elicit the actualizing tendency, the qualities of the psychosocial environment play a crucial role. Both the growth process and the organismic valuing process require favorable conditions (Rogers, 1961) particularly the esteem of another person without conditions of worth (i.e., imposing external demands and pressures for one to be accepted). Conditions of worth are viewed as the source of psychopathology (Rogers, 1959, 1961). They refer to external demands of one’s worthiness, or the idea that one is only worthy of love and belonging once one has fulfilled certain demands. (from Frontiers in Psychology: “Organismic Valuing Theory For Well Being” by Mauer and Daukantaite)
From Wikipedia, under therapeutic relationships:
“In the Humanistic approach, Carl Rogers identified a number of necessary and sufficient conditions that are required for therapeutic change to take place. These include the three core conditions: congruence, unconditional positive regard, and empathy. Rogers (1957; 1959) stated that there are six necessary and sufficient conditions required for therapeutic change:
Therapist–client psychological contact: a relationship between client and therapist must exist, and it must be a relationship in which each person's perception of the other is important.
Client incongruence: that incongruence exists between the client's experience and awareness.
Therapist congruence, or genuineness: the therapist is congruent within the therapeutic relationship. The therapist is deeply involved, they are not 'acting' and they can draw on their own experiences (self-disclosure) to facilitate the relationship.
Therapist unconditional positive regard: the therapist accepts the client unconditionally, without judgment, disapproval or approval. This facilitates increased self-regard in the client, as they can begin to become aware of experiences in which their view of self-worth was distorted or denied.
Therapist empathic understanding: the therapist experiences an empathic understanding of the client's internal frame of reference. Accurate empathy on the part of the therapist helps the client believe the therapist's unconditional regard for them.
Client perception: that the client perceives, to at least a minimal degree, the therapist's unconditional positive regard and empathic understanding.”
Aron Beck, Albert Ellis, and the Cognitive Theories
Today, the gold standard of therapy is CBT (Cognitive Behavioral Therapy). Much of this is due to the work of Aron Beck on Cognitive therapy as we know it today. However, under this category is also rational emotive behavior therapy (REBT), multimodal, Adlerian, and reality therapy. Because cognitive deals with the mind, it is almost impossible to separate the “mind” from other families, so often cognitive therapies are integrated with some family therapies.
Albert Ellis was one of the first to emphasize trying to find shorter timeframes than undergoing the traditional analysis process (i.e. sessions for 5 years). He was never a medical doctor, though he did get a Ph.D. and did undergo training as a psychoanalyst even though he was originally excluded because he was not a doctor.
Perhaps this is why Ellis was able to move towards a more advice process vs passive process and focused his therapy to tackle “beliefs” as the main issue leading to people’s problems. As the website Albert Ellis.org explains:
But Ellis’ faith in psychoanalysis was rapidly crumbling. He discovered that when he saw clients only once a week or even every other week, they progressed as well as when he saw them daily. He took a more active role, interjecting advice and direct interpretations as he did when he was counseling people with family or sex problems. His clients seemed to improve more quickly than when he used passive psychoanalytic procedures. And remembering that before he underwent analysis, he had worked through many of his own problems by reading and practicing the philosophies of Epictetus, Marcus Aurelius, Spinoza, and Bertrand Russell, he began to teach his clients the principles that had worked for him.
By 1955 Ellis had given up psychoanalysis entirely, and instead was concentrating on changing people’s behavior by confronting them with their irrational beliefs and persuading them to adopt rational ones. This role was more to Ellis’ taste, for he could be more honest himself. “When I became rational-emotive,” he said, “my own personality processes really began to vibrate.”
Aron Beck would lead the way in changing cognitive thoughts in the style we know today.
Here is a typical playbook for helping kids with anxiety using CBT from Anxious Kids, Anxious Parents by Reid Wilson and Lynn Lyons. Parents can download a free ebook at www.playingwithanxiety.com that are stories to walk through and give kids examples of how to use CBT-based strategies to get through anxiety.
“Over time they will equip themselves with the core strategies to win:
· They know the important tasks that they want to accomplish.
· They remember past successes that can help them face new challenges.
· They expect worry to show up.
· They talk to their worries so that anxiety doesn’t run the show.
Mark: they know that their worry brain (the limbic brain or amygdala) is only telling them there may be danger and they can assess to let the worry brain know that it doesn’t have to add fuel i.e. flight or fight adrenaline to the situation i.e. stress, an overactive imagination (catastrophizing) or being too rigid (perfectionism).
· They step on into new situations.
· They are willing to feel unsure and uncomfortable along the way (Mark: teach courage)
· They use their breathing skills to support them.”
Systemic or Family Therapies such as Richard Schwartz’s Internal Family Systems
This family of therapies is unlike the others because rather than do the analysis from an individual’s perspective, the systemic theory focuses on the family etc. as a unit. In addition, there are other theories such as constructivist and narrative therapies. Internal Family Systems or IFS is one of the most well-known of these and helped spin-off the “inner child” and “inner critic” terms common in today’s coaching and therapy.
These theories understood that a person is not created in isolation. So it included relationships with ourselves and others. Often the inner critic is a parental voice. Often we adopt the critical voice in order not to prevent the critical parent from criticizing us. So the inner voice pre-empts the critical parent’s voice.
Instead of the critical parent needing to say: “Clean up your room”, we will have our inner critic say: “Clean up your room, you slob”. Now, just saying that to ourselves as a child was less painful than having our parents say that to us which would have threatened us to be “abandoned” by our parents (or so our childlike survival mind might have thought).
Many of us develop parts of our psyche which run our lives. These parts were developed in childhood using child-like strategies and often we become stuck when these strategies stop working in adulthood. By discovering and working with the part, we can change or diminish our role in our life.
Brief Therapies such as Ericksonian Hypnosis, DBT, and ACT
The standard psychodynamic session (Freud’s couch) would last 4 to 6 years of weekly sessions. Mind you, these people were really “mentally sick” people or people who wanted to undergo the analysis process. Nevertheless, people and the medical system started looking for faster solutions.
Ericksonian hypnotherapy is probably the most famous of these and actually leads to NLP, of which, Tony Robbins is the most famous student and the leader in self-development. Other therapies include EMDR (eye movement and desensitization reprocessing) which is one of the darlings of trauma therapy that has empirical evidence to support it.
Two other brief therapies of note are ACT and DBT. The following descriptions are quoted from an article from Blue River Strategies, “Thoughts in Coaching.”
DBT includes four sets of behavioral skills.
• Mindfulness: the practice of being fully aware and present in this one moment
• Distress Tolerance: how to tolerate pain in difficult situations, not change it
• Interpersonal Effectiveness: how to ask for what you want and say no while
maintaining self-respect and relationships with others
• Emotion Regulation: how to change emotions that you want to change
The term "dialectical" means a synthesis or integration of opposites. The primary dialectic within DBT is between the seemingly opposite strategies of acceptance and change. For example, DBT therapists accept clients as they are while also acknowledging that they need to change in order to reach their goals. In addition, all of the skills and strategies taught in DBT are balanced in terms of acceptance and change. For example, the four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness)”
Acceptance Commitment Therapy ACT).
In this therapy – clients are asked to examine and accept self and the emotions that arise – again – without judgment -- and in a way that allows a more objective view of the situation. Clients are not immediately asked or expected to shift emotions or shy away from thoughts coming up for them at the time of discomfort. It connects with behavior as part of the change action versus only thought that changes behavior.
“ Psychodynamic approaches that emphasize insight imply that a change in attitude will most likely result in a change in behavior. In contrast, pure behavioral approaches suggest that altering behavior does not demand a change in attitude. However, changing a behavior may eventually result in a change in attitude or emotion. Focusing on changing behavior regardless of accompanying emotion is the emphasis. Taking behaviorism a step further, ACT suggests that both behavior and emotion can exist simultaneously and independently. Acceptance has been described as the “missing link in traditional behavior therapy” (Jacobson & Christensen, 1996). ACT is part of a larger movement in the behavioral and cognitive realm, which includes the mindfulness approaches (Hayes, 2005).
Hayes (2006, 2005, 1994) has been credited as the founder of ACT as a contextual approach to treatment. He explores the paradoxes of context, such as separating words and actions, and distinguishing clients’ sense of self from their thoughts and behavior. For example, when a person doesn’t go to work because he or she is anxious about a confrontation with his or her boss, it is conceivable (and encouraged) that the individual can go to work while feeling anxious.)” [1]
ACT establishes psychological flexibility by focusing on six core processes:
1. Acceptance of private experiences (i.e., willingness to experience odd or uncomfortable thoughts, feelings, or physical sensations in the service of response flexibility)
2. Cognitive defusion or emotional separation/distancing (i.e., observing one's own uncomfortable thoughts without automatically taking them literally or attaching any particular value to them)
3. Being present (i.e., being able to direct attention flexibly and voluntarily to present external and internal events rather than automatically focusing on the past or future)
4. A perspective-taking sense of self (i.e., being in touch with a sense of ongoing awareness)
5. Identification of values that are personally important
6. Commitment to action for achieving the personal values identified
Cutting-Edge Therapies
I really call this all the others. For example, all the expressive therapies are included here such as music therapy, art therapy, drama therapy, etc. Also included are all the spiritual or shamanic therapies and feminist theories.
While completing my RIM Certification, a part of the process uses drama therapy. It was actually a great way to replay my core issue by acting it out and then playing out how I could be changed. I think the process is an interesting one and I just saw an episode on New Amsterdam (Netflix and NBC) that incorporated drama therapy for war vets suffering from PTSD.
Trends in Therapy
There have been a couple of trends which has changed therapy. The first has been healthcare costs towards quick and cost-effective solutions. So rather than treat the cause, therapy has moved towards treating the symptoms. This has increased the use of medicines for psychological issues. So if you are depressed, give you Prozac for the rest of your life. Quick and easy. It has also given rise to therapies that will treat the symptom. If the person has anxiety, you can teach them CBT and that treats the symptoms, though the root cause or belief remains. The person can function, however, the root cause to some degree will prevent the person from developing to their full potential.
The second major trend has been towards positive psychology. So prior to 1990, when Martin Seligman was elected to the American Psychologist Association, the entire movement of psychologists was how to fix people who were mentally ill. As Martin Seligman recounts in his biography, The Hope Circuit, psychology was about moving people from minus 3, or minus 2, or minus 1 to zero or neutral. Once they got them to neutral, the job of the therapist was technically done (and for sure managed healthcare would not pay for more). As Seligman noted, this emphasis on truly sick people, represented less than 10% of the population. He wanted to apply his knowledge to help the other 90% of the population to move from zero or neutral states to positive one, positive two, or positive three.
So with the rise of positive psychology, the therapist started to move into the realm of coaches and focused on how to make people happy, or authentically happy, and finally, Martin Seligman realized the goal was how to make people flourish—i.e. health, happiness, love, and abundance as I have previously defined.
So therapists are now moving into the realm of coaches i.e. the future and trying to help the other 90% with quick results and a move into the realm of what was traditionally the coaching model, a movement that started primarily because psychologists were not previously interested.
Coaches (and psychologists have always been there) have recognized that what get people stuck is due to their patterns and their past issues that need healing. Therefore, Coaches are now reaching back into the therapist’s playbook and using therapy-related tools to create the changes people need that lasts.
The Role of Neuroscience and Trauma
The 1990s was the decade of the brain. And since then, much more is known about how the brain develops via neuroscience and attachment theory, and what happens when that development is hindered in shock or developmental trauma.
It takes normally 20 to 30 years for this research to start being applied in the mainstream. Already, for those of you who are less than 40 years old, the term trauma-informed is fairly well known due to the ACE studies and the amount that is now coming out around developmental trauma.
The neurosciences have enabled us to understand that when the development of the brain is hindered, then lots of issues are presented not only in childhood but also in adults. This area falls under the older topic of psychodynamics i.e. look back to the history of the patient to understand what happened in order to figure out why the patient is like they are today. However, instead of theories involving Oedipus, we actually have real neuroscience driving an understanding of development and attachment theory.
Shock Trauma Therapy and Peter Levine
PSTD has driven significant research into shock trauma and much has been discovered about how to treat veterans. Today, Dr. Peter Levine is probably the leading therapist/neuroscientist who is demonstrating that a somatic approach produces the best results with trauma. Dr. Levine has shown via the Somatic Experience that in humans, trauma is held in the body. Using somatic (body) therapy, Levine has been able to help trauma victims complete the fight-flight response that most of us know.
In actual fact, in trauma, the human response is fight, flight, freeze, or fold. As written by Dr. Vander Kolk in the introduction to Dr. Levine’s book Trauma and Memory
“Peter understood that in order to resolve trauma, you have to deal with the physical paralysis, agitation, and helplessness, and find some way of taking bodily action to regain ownership of your life. Even telling the story of what has happened is a form of effective action, developing a narrative that allows you and those around you to know what has happened. Sadly, numerous traumatized people become stuck in their trauma and never have a chance to develop that essential narrative.”
Dr. Levine understood that trauma could not be dealt with only through cognitive approaches but needed a somatic approach, and that is why most CBT approaches to shock trauma have not been successful because CBT only addresses the mental aspects.
Developmental Trauma Dr. Bruce Perry, Gabor Mate, and Laurence Heller
Developmental trauma has the added issues of having an identity and attachment aspect to shock trauma. So unlike shock trauma, additional therapeutic tools are needed. This was recognized by those in the trauma field. Dr. Laurence Heller was a colleague of Peter Levine and developed an approach to developmental trauma that addressed using both a somatic experience and also a cognitive approach that dealt with the identity and attachment issues called NeuroAffective Relational Model or NARM.
Dr. Bruce Perry, the author of “The Boy Who Was Raised as a Dog”, has also been instrumental in child trauma therapy. His book recounts some of the most horrendous child abuse cases and examines what happened with the children and why some of them were able to be reformed, while others were not able to be reformed. His major thesis is that the younger we are able to meet the child’s needs, the better the child will develop properly. Even terrible abuses can be reversed if it is caught young enough, or the child had an initial 4 years of fundamental and loving brain development.
So Which Therapy is Most Effective?
Mark Manson, the author of The Subtle Art of Not Giving a F*ck, wrote a newsletter this week on that very topic.
“With so many approaches to therapy, a few decades ago, researchers rightly became curious about which therapies were the most effective, which ones worked. So they ran hundreds of experiments to measure which therapies produced the best results. And the answer will probably surprise you.
All of them did.
All of them work, to some extent. Pretty much every modality produces, on average, relatively similar results. All of them work decently but not perfectly. Some may work slightly better for certain problems than others (i.e., CBT seems to be marginally better for anxiety). But on the whole, just the fact you’re doing therapy has way, way, way more impact than the type you choose to do.
This is kind of stunning. Because it suggests that for all of the theorizing and frameworking over the last 150 years, from Sigmund Freud to Dr. Phil, the content of the therapy itself isn’t that important. In fact, dozens of studies have struggled to find much measurable benefit to the therapist’s training or credentials. Many studies show that people benefit speaking to amateurs just as much as they do professionals. So, not only does the modality seem to not matter, but the therapist’s credentials don’t even seem to matter that much either.
What’s important is simply getting a person in a room regularly to talk about their problems to another human being. That’s the 1% that drives 99% of the results. The value of therapy isn’t the therapy. It’s the context. It’s the environment. You’re paying to have a place to go where you can sort out your shit in front of someone and not be judged for it. Everything else—the fancy acronyms and degrees and frameworks—seems to merely be an excuse to get you into that room and into that social context.”
Well Not Really
We need to be careful of what works and doesn’t work in terms of definition. In the article, Efficacy of Psychodynamic Psychotherapy, Jonathan Shedler concludes:
“Empirical evidence supports the efficacy of psychodynamic therapy. Effect sizes for psychodynamic therapy are as large as those reported for other therapies that have been actively promoted as “empirically supported” and “evidence-based.” In addition, patients who receive psychodynamic therapy maintain therapeutic gains and appear to continue to improve after treatment ends. Finally, non psychodynamic therapies may be effective in part because the more skilled practitioners utilize techniques that have long been central to psychodynamic theory and practice. The perception that psychodynamic approaches lack empirical support does not accord with available scientific evidence and may reflect selective dissemination of research findings.”
Shedler’s examination shows that psychodynamic patients actually continued to improve AFTER the therapy which CBT didn’t improve as much. And this makes sense. Psychodynamic tries to fix the root cause, which ultimately, once fixed should show improvements in other areas as well. CBT focuses on fixing the symptoms as it is generally applied today. (Note that Aron Beck though knew you could fix the root cause because much of his work also centered around looking at core belief issues that caused the symptoms).
We have also seen that PTSD cannot be treated well by CBT and somatic processes have better success rates.
Using the Psychodynamic Framework
Shedler’s analysis goes on to show that yes, most techniques use a psychodynamic framework, so people should be getting results as if they were using this same framework.
The therapeutic model is comprised of three parts: the working alliance, the transference/counter-transference, and the real relationship. The working alliance is itself also composed of three parts: goals of the therapy, tasks to reach the goals, bond between therapist and client to work on goals and tasks. It has been noted that it working alliance i.e. goal, tasks, and bond which helps to determine the outcome of the relationship. When the therapist and clients have a high agreement in goals, tasks, and bonds, then the better chances of a positive income. If there is a low agreement, the worst the outcome.
Need Time for Change to Happen
Similarly, it has also been shown that most people leave therapy before 3 sessions because the working alliance was not operable. So therapy works when the model works when the working alliance works and people stay long enough for it to work.
All Roads Lead to Rome—Yes and No—Depending on Your Goal
Once you have a working alliance, you have a social engagement, and the means to which you reach your goals can differ according to therapy theory.
Then a behavior therapist would add certain aspects of behavior to this framework.
Similarly, given the psychodynamic framework, a CBT therapist would use CBT to help a client process certain aspects of cognitive behavior.
You might have Ellis with REBT, who given the psychodynamic framework, would instead of just asking questions, perhaps give advice and then use CBT to change different limiting beliefs of the therapist.
We then continue along on the process and notice that cognitive aspects alone don’t get all the results we need. Someone might use Internal Family Systems and work on a person with anxiety using CBT but uses IFS to work with the person’s strong Inner Critic.
A person who is suffering from anxiety, and a strong inner critic, may also have dysregulation. So we may need ACT or DBT to help that person to get in touch with his emotions. So now you could be addressing the cognitive, the relationships, and the emotional aspects.
Finally, we get to a person who suffers from all those things, but it resulted from trauma. They notice that while the client has some relief from anxiety, and better control of the inner critic, and better awareness of his emotions, the majority of these PTSD symptoms are still with him. So the therapist sends the person to Peter Levine, who works on a body, emotional, cognitive level to help right the symptoms of PTSD.
However, Dr. Deb Sandella and Lion Goodman notice that the patient is still not completely a fully functional adult because the person is dissociating and has distorted self-identities. They work with the patient using RIM and Clear Beliefs and get the patient back to his true self, integrated into control of his mind, emotions, and body.
Thus, we have fully integrated many different therapies to arrive at the ultimate goal, which is to have a person reaching transcendence or flourishing with élan vital. The person has become his true self. He then works with a coach to arrive at his mission and future life goals, emphasizing his values and strengths.
Finally, the person has healed his core wounds, trauma, developmental trauma, reverted to his true self, and is living his mission and moving towards his goals.
It should be noted that depending on the goals, certain therapies are better at reaching Rome. People with PTSD are better off with Peter Levine-based somatic integrated therapy vs. CBT alone.
When we transform a mind, body, and spirit that is dissociated and dysregulated with distorted self-identity and disrupted attachments, we create an evolved mind, body, and spirit that is calm, kind, and creative. We experience our true selves and Aliveness.
Therapy Works
Ultimately, therapy works. It is important that there is a working alliance i.e. agreement on the goals, tasks, and bond between the therapist and client. And the proper amount of time is given to create those changes.
It is also important to have various tools to help a client to create changes on a cognitive, emotional, physical (body), and spiritual level depending on the client's issues and goals are. Various tools have been devised to accomplish these objectives over the years.
It appears to me that there are some issues that need to be addressed on multiple levels. Essentially, something happened to the person in the past. Out of that issue, be it developmental trauma, shock trauma, or just erroneous thinking, the person’s psyche (self-identity) separates into his “true self” and his “false” self.
His false self is really a coping mechanism or adaptive behavior. So they could be controlling or perfectionists and may exhibit anxiety or depression or addictive behavior. In addition, the person develops certain beliefs and values about themselves from which they live. They can also develop various “parts” of themselves such as an inner critic, rebel child, defender, etc. that helps them to cope or be safe in the world.
These issues and states can leave a person with some degree of dissociation, dysregulation, distorted identities, ruptured attachment with himself and others, and disorganized and numerous other dysfunctions.
Because these adaptive behaviors, beliefs, parts are often developed earlier in life (often as children) or to cope with situations that are no longer how the world works, the individual is not able to live life later to his full capabilities. Often his capabilities have not yet been fully developed such as the ability to interact with people in a loving way or his beliefs are limiting such as “I am not enough” or his brain core networks have been shut down such as the inability to use his imagination fully. These then hinder the person’s ability to fully live to their potential and they often get stuck in life.
At that point, a therapist or coach is able to help the person to become consciously aware of the situations that have held him back. Once this has been discovered with various tools, the therapist or coach uses another set of tools to help the person get unstuck. The more levels clearing can be done i.e. on the mental, emotional, body, and spiritual, the more likely the past events will be cleared and the issue will be healed forever. Once healed, the person has new capabilities and insights to move past the current obstacles and to live his life in a more flourishing manner.
The role of having another human being (could be therapist, coach, parent, or friend), who can lovingly provide empathy and guidance (ala Carl Rogers) to another human being by guiding that person and teaching them self-awareness, self-efficacy, and the skills to process their thoughts, emotions, body and spiritual experiences, both past, present, and future, is the key to creating changes that last.
Once you have created the changes to be your true self, and living your life mission, this is how the world feels:
Action Items:
1. Are you taking an integrated approach to create changes that last?
2. Work with your coach to heal your core wounds and limiting beliefs, be your true self and live your life mission.