Why Therapy Works
By Aletheia Team | Mar. 19
Recent decades have seen a surge in attempts to scientifically validate techniques and practices in psychotherapy, in order to hold psychotherapists accountable. This research - combined with pressures from managed care (insurance) and policy-makers to find the most effective and efficient treatments to promote and fund - has led the field to focus on promoting “evidence-based treatment”.
This project for evidence-based treatment is theoretically grounded in a medical model of clinical conceptualization, diagnosis, and treatment. It is presupposed that effective treatment is short-term, solution-focused, and oriented toward measurable treatment goals. The focus is largely on symptom reduction, and little attention is given to the patient’s overall life outside of the current symptoms. Many of these treatments become manualized, generalizing treatment approaches regardless of individual personality structure, unique idiosyncrasies, or clinical intuition of the therapist. The therapy relationship is seen as a necessary means to end - we need to have a solid enough rapport for the patient to trust our manualized treatment recommendations.
But this sidelining of the therapy relationship is being looked on with more and more suspicion. In 1999, the American Psychological Association commissioned a task-force to research the impact the therapeutic relationship has on the therapy process. Since that time, additional task forces have been established to continue the investigation of the therapeutic relationship, and the impact it has on therapy outcomes. In 2018, Norcross and Lambert published the research findings of a 30 year longitudinal study, delineating what works and what doesn’t in the therapy relationship. They conclude that therapists should “make the creation and cultivation of the therapy relationship a primary aim of treatment” and that therapists “are encouraged to concurrently use evidence-based relationships and evidence-based treatments adapted to the whole patient.”
The research is clear that the therapy relationship is central to successful therapy outcomes. This begs the question of what is happening in the therapy relationship that leads to healing, wholeness, and transformation. Psychologist and couples therapist Harville Hendrix has gifted the therapy field with an often-repeated adage: We are born in relationship, we are wounded in relationship, and we are healed in relationship. I would amend this adage to say that we are born in relationship, wounded in relationship, re-wounded in relationship, and healed in relationship.
We are Born in Relationship
Since the 1950’s, the field of attachment science has been investigating the impact that the mother-infant relationship has on the infant’s development and functioning. It has become clear that the stability (or instability) of the primary attachment relationship impacts not only the child’s way of relating to others later in life, but is crucial in the development of a stable sense of self, the ability to regulate strong or intense emotions, and the capacity to think and reflect about internal states.
With the advent of neuroscience, attachment scientists have accelerated their ability to assess the impact of relationships on human development. The entire field of interpersonal neurobiology (spearheaded by scientists such as Dan Siegel, Allan Schore, Louis Cozolino, and Bonnie Badenoch) is an interdisciplinary approach to investigating how relationships affect the development of the brain and the psyche.
While all metaphors are problematic, and especially those that relate a human person to a computer system, an illustration can be helpful:
A healthy infant is born with the primary neurological hardware intact. The infant’s brain is capable of regulating bodily functioning, receiving sensory input, and responding to that input. The motherboard is online. But the software is not yet developed. The software has to be downloaded, and this can only be done in relationship, initially with primary caregivers, and secondarily, with peers. Relational experiences provide the schematic for how neurons will network. Internal maps of self, others, and the world are “downloaded” from consistent, ongoing interactions with primary caregivers. We are literally ourselves because of others.
One of the (many) important factors that the attachment-bond contributes to is the ability to regulate emotion – what theorists refer to as affect regulation. Emotion is first experienced as a bodily sensation in an infant – hunger, fear, anger are expressed bodily. The attuned caregiver reflects the emotional experience back to the child, responds to the child’s need, and helps the child to regulate. With repeated, attuned responses from the parent, the child learns to understand its emotion (“I’m angry”), connect it to the stimulus or experience (“because the bottle is empty”) and regulate the emotion (“I know mom will feed me soon”). As the infant begins to acquire language, they become capable of expressing their emotional needs and experiences, but only if they received the right “software” to experience their emotion.
We are Wounded in Relationship
When attuned responsiveness is not offered, or is not offered consistently enough to be internalized, the infant does not have the software available to be able to read their own internal states. They will learn the language of emotion – anger, fear, sadness, shame, joy – but they won’t be able to adequately map that language on to their own internal experience. The emotion is too intense and too chaotic, or it is cut-off and repressed.
When emotion is not consistently reflected back, the infant never learns to understand it. When the infant is not soothed, they never learn to regulate their emotions. When the infant’s emotions are not responded to, they are never taught how to think about their emotional experience. In short, there’s a bug in the attachment system and that produces problems in the emotion regulatory system. We may be overwhelmed by emotion, or we may repress and cut-off our emotion. But what we cannot do is verbalize and address our emotion.
We are Re-Wounded in Relationship
When emotion cannot be verbalized or addressed, it doesn’t go away. Something has to be done with it. We either experience it in an unregulated, unreflective, and overwhelming way, or we defend against it in some way. Usually some mixture of both happens, and both produce symptoms.
As adults, we tend to repeat the patterns, themes, and emotional experiences of the past in our present relationships. The software we are running as adults still has the early-childhood bug in it. As we enter into new relationships, we have a hope that this one will be different. But we find ourselves stuck in the same patterns.
When we cannot reflect on, regulate, and address our emotional needs, we enact them instead. An infant doesn’t tell their parent that they are angry. They show them. As adults, we develop increasingly sophisticated ways to defend against our emotions. But if we cannot understand and articulate our emotional experiences and woundings, we are bound to enact them. If we can’t tell our loved ones what we are feeling, we will show them.
These repeated enactments tend to reinforce the initial wounds. For example, if I was abandoned as a child, I will unconsciously fear abandonment in my adult relationships. I will therefore cling, or hover, or overwhelm my loved ones out of a need to feel secure. Or I might test the relationship to see if they will stay, poking, prodding, and provoking unnecessary conflict to unconsciously see if the relationship will survive it. Or I may remain guarded, keeping myself from becoming too emotionally involved, so that when the assumed inevitable abandonment comes, it won’t hurt so much. I may do all three. These dynamics will eventually drive my loved one away from me. I will find myself feeling even more abandoned and double down on my defenses.
Unconscious, Relational Replications
It is essential to emphasize two points here. One, these processes are unconscious replications of past wounds. That does not simply mean we are not thinking about them, or are not aware of them. It means we cannot be aware of them in our present state. Our mind has organized itself around keeping the pain out of awareness. It is not a matter of developing self-reflective capacities and figuring out what is happening (though self-reflection is important), because the mind that is reflecting is a mind organized around keeping the pain out of awareness. In order to make the unconscious conscious, it takes an emotional experience. This is what has traditionally been referred to as insight. (More on that in the next section)
Two, these are relational replications. We have ways of interacting that pull others into these dynamics. In the example above, it is not just that my mind is participating in the repeated dynamics of abandonment. I interact with my loved ones in such a way that they are also participating, and doing so unconsciously.
For decades, these patterns of replication were known by clinical intuition alone. Current findings in neuroscience have helped explain how these patterns occur. Through complex neurological processes involving mirror-neurons and right-brain to right-brain communication (which is all happening unconsciously) we are pulling others into our dynamics, and are being pulled in by others. Thus, these patterns are taking place unconsciously in us, and in those to whom we are closest. And these dynamics are unconscious for both parties. This is important for therapy, because the therapist, being human, is not immune to being pulled into these replications.
We are Healed in Relationship
In the beginnings of modern psychotherapy, there was great emphasis placed on the therapist’s interpretations of psychological dynamics. If the therapist can analyze the patient’s dynamics as they are playing out in the treatment and come to an understanding of what is occurring unconsciously, then he or she makes an interpretation. The thought is that this will produce insight in the patient, bringing conscious awareness to unconscious dynamics, and freeing the patient from the patterns at play.
It was largely assumed that, in order to make accurate interpretations, the therapist or analyst was required to undergo their own treatment so that they may be free from their own dynamics. If an adequate treatment had not occurred, then the therapist may contaminate the treatment with their own dynamics. The therapist had to be healed and freed of their own dynamics to eradicate the vulnerability of being pulled into that of the patient.
In recent years, the optimistic assumption that the therapist can be freed from their own dynamics has been challenged. While the therapist’s own therapy remains essential in helping the therapist understand their own dynamics, and how those dynamics may impact treatment with their own patients, the assumption that the therapist can keep themselves from being pulled into their patients’ dynamics is no longer tenable. Therapists are still human, and relational dynamics are still operating at a largely unconscious level. Thus, the therapist can never assume that they have a full understanding of what is happening, nor should they be so confident that they are not in the midst of a replication or re-enactment with the patient.
Therapists can no longer assume that they can remain detached and objective. It is neither possible nor desirable for the therapist to remain on the sideline, analyzing and reflecting back what is being observed. We are in it. Our stories, patterns, histories, and relational dynamics are being pulled at by our patients’ stories, patterns, histories, and relational dynamics. And this is good news. Because the therapist’s self – the experience of being drawn in – is the most reliable tool a therapist has.
My friend and mentor, Bryan Nixon, writes “the therapist must be attuned not only to the story the client is telling and the emotions the client is experiencing in regards to their story, but also to the therapist’s own experience during each session. Why? Because the experience the therapist is having offers clues about what is being repeated from the client’s past.” The therapist’s experience of their own self, affect, and experience with the patient is the greatest entrance into exploring the patient’s story and repeated relational patterns.
Again, this is good news. We as therapists no longer have to work quite so hard to keep ourselves out of the room. Rather than having to analyze and observe from the sidelines, we are in the midst of the dynamics – participating, repeating, enacting. It feels difficult, as it requires that we become aware of our own vulnerabilities, emotional reactions, and relational wounds. But it is actually much less work to be in the midst of, rather than trying to stay above the relational fray. Therapy is at its best when the therapist and patient can catch themselves in the re-enactment. The unconscious becomes conscious, and the conversation moves forward. But it is not a cognitive process that brings the unconscious into consciousness. It is an emotional, relational experience.
The notion of therapist as expert, who dispenses tools, skills, or interpretations, must be done away with. As long as the therapist is attempting to maintain the expert role, they are working to remain above the fray. One cannot be both expert and participant at the same time. This is not to indicate that the therapist does not have expertise – they absolutely do. They maintain a mind about what is happening, and have expert training in conceptualizing how the current experience is a repetition.
But they cannot be certain of what is going on in the relational dynamics from within the relational dynamics themselves. Rather than interpret from the perspective of a passive expert, the therapist articulates his or her experience of the relationship with the patient. Articulation is not an interpretation, but an invitation. It invites the patient to co-explore together what might be unfolding.
When we begin to explore our relationship – what analysis calls “the intersubjective space” – we are stepping out of the repetition of the relational dynamic and are stepping into a third space where we can encounter each other and co-create something new. When we are in the intersubjective third space, we are able to become consciously aware of all of the dynamics, patterns, and wounds that we are participating in, and through those things becoming conscious, finally encounter one another in the fullness of our humanity.
It is by finding ourselves that we find each other – I cannot hope to genuinely encounter my patients if I am defended against my story, my affect, or my experience. But when I can locate myself within my story, my affect, and my participation in that of my patient, I am able to offer myself to my patient, and hopefully guide my patient and myself into a mutual recognition of ourselves and each other. We find ourselves in relationship with others.