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Why Psychotherapy Trainees Need
an Updated Framework
Jeffery Smith MD
We all wish we could base technique on knowing precisely how therapy works.
As much as Freud, Watson, and many successors have wanted that, the best
anyone could do was to explain therapy with invented constructs, internally
coherent, but incompatible with one another. Formulations of therapeutic action
have included such concepts as “making the unconscious conscious,” “correcting
irrational thoughts,” “resolving intrapsychic conflicts,” “processing emotion,”
“changing emotion with emotion,” etc. Each one claims to have the key to
therapeutic success, yet none is clearly superior. All have limitations, and learning
more than one is both inefficient and confusing.
What if some easily teachable science explained what underlies all therapies
and, in doing so, confirmed existing clinical wisdom, while making clear how and
why psychotherapy actually does work?
What psychotherapy aims to change
A universal explanation of psychotherapeutic action is impossible without a
clear and unitary idea of what we are aiming to change. Fortunately, a modern
view of the mind is clarifying. A good definition of mind is the computational
activity of the brain. Today it is hardly controversial to describe the human mind
as a computational organ evolved to identify opportunities and threats and to
generate responses aimed at mitigating the threats and taking advantage of the
opportunities. Responses to threats tend to follow past experience and are not
infrequently less than ideal. Those maladaptive responses that are not easily
changed are the primary targets of psychotherapy. A group of colleagues and
myself have coined the phrase, “entrenched maladaptive patterns” to describe
these subunits of pathology. They consist of products of mental computation
including 1) bodily changes, such as tears; 2) involuntary actions; 3) spontaneous
thoughts; 4) conscious feelings; and 5) impulses to act. In addition, these five
products, generated automatically and outside of consciousness, can influence the
individual towards voluntary choices that may, themselves, be maladaptive.
Maladaptive products of the mind are what psychotherapy aims to change.
Psychotherapy is not designed to change biologically based tendencies such as
predilections for depression, anxiety, psychosis, mood instability, etc. Recent
discoveries such as epigenetics show that psychotherapy can have an effect on
biology, but that is not what primarily guides our efforts. Rather, therapy aims to
modify the mind’s calculated responses to appraised circumstances, internal and
external. The first aim of psychotherapy can be stated universally as “changing the
mind’s entrenched maladaptive patterns of response.”
What we aim to change converges with recent science
Fortuitously, among the problems therapy aims to treat are models that have
long been under the scientific microscope. The learned fear paradigm has been
studied extensively in humans and other mammals. Experiments start with a
learned response to some noxious stimulus in association with a benign signal such
as a bell. When the bell continues to ring, while the noxious stimulus is withdrawn,
humans and other mammals predictably continue to exhibit the fear response,
which is now inappropriate. That response, now maladaptive, meets the definition
of an entrenched maladaptive pattern. Research has recently made important
strides in explicating both how these responses originate and three mechanisms by
which they can be modified.
Fortuitously again, in contrast to the complexity of much brain pathology, the
central mechanisms involved in triggering and modification of threat responses are
relatively simple and accessible for study. In the mammalian nervous system, the
need for a response is signaled by neural activity located in specific parts of the
limbic system such as the amygdala. Modification of this responsiveness can be
accomplished by three known mechanisms. One, first described by Pavlov, is
“extinction” in which the cortex learns to send inhibitory signals to those limbic
areas where the response is initiated. Unfortunately, since extinction alters only the
response and not the danger signal, the benefit is temporary and old patterns tend
to return. A more recently elucidated mechanism, “memory reconsolidation”
involves rewriting the limbic procedural memory responsible for identifying and
signaling a threat. With this modification, the signal triggering a specific response is
permanently attenuated or eliminated. (Lane 2020) A third mechanism is learning
a new response pattern, competitive with the old maladaptive pattern. Among the
three, the most definitive change mechanism, memory reconsolidation, is of
particular interest for psychotherapy because the conditions it requires turn out to
correspond quite closely to what psychotherapy already does.
Art and science
It is noteworthy that recent advances in general medicine depend on an ever
deeper understanding of pathophysiology. Science seeks out the perfect molecule
for a given illness. The case of psychotherapy is different in that we are dealing
with the processing of information. Each individual’s pathology is unique because
no two lives have collected the same data. In other words, every entrenched
maladaptive pattern is crafted by the individual’s mind and represents a unique
illness. The curative element is not a molecule but a packet of new information
specific to each individual and each maladaptive pattern. Even when informed by a
better understanding of change mechanisms, finding the right message and
delivering it in the right way at the right time is where art and intuition will always
enter into psychotherapy. Therapists may take common patterns into account but
what makes treatment effective is the precision and specificity of the disconfirming
information or experience that allows enduring change to take place.
Science and clinical wisdom inform each other
The science of memory encoding, elucidated in the second half of the last
century, explains the critical fact that words, images, concepts, schemas, emotions,
etc. are all treated in the mind as information. They are all encoded in neural
networks and enter equally into the mind’s computations. Freud and Breuer (1893)
wrote, “We found to our great surprise at first, that each individual hysterical symptom
immediately and permanently disappeared when we had succeeded in bringing clearly to light the
memory of the event by which it was provoked and in arousing its accompanying affect…” What
they missed was the importance of the nonverbal information embodied in the
safety and comfort of the therapeutic relationship. That nonverbal content was the
new information that contradicted the dread that trauma patients carry in relation
to painful experiences (Smith, 2004)
The science of memory reconsolidation describes three requirements that,
together, serve to confirm and clarify the essence of how psychotherapy works.
First, confirming Freud’s 1893 observation, the limbic neurons responsible for
triggering the old, maladaptive pattern must be in an active state, as indicated by
the presence of affect. The second requirement, that of exposure to disconfirming
information, is embodied in many kinds of interventions including interpretation,
correcting irrational cognitions, and the nonverbal communication of an empathic
witness. A third requirement is that the disconfirming information must be
delivered in a form compatible with the language of limbic areas where triggering
takes place. The resulting collision of information (prediction error) initiates
memory volatility for a few hours, allowing rewriting of neural networks in line
with the new information. This combination of events, affective activation
juxtaposed with exposure to disconfirming information, turns up in essentially
every form of psychotherapy and provides a kind of Rosetta Stone to link
incompatible conceptualizations to universal neurophysiological infrastructure.
Diverse therapies meet requirements for memory reconsolidation
Often cited is Alexander and French’s description of the “corrective emotional
experience” (Goldfried, 2019), in which an old pattern collides with a disconfirming
experience. Similarly, exposure therapy requires activation of an old pattern along
with words and experiences that disconfirm the sense of dangerousness.
Transference activates maladaptive patterns and its resolution involves
internalizing new information about relationships. Even correcting irrational
cognitions with more accurate information may involve more than placing a new
version of reality into memory.
But memory reconsolidation is not proven
True, this framework is not proven by the evidential standard of research,
“beyond reasonable doubt.” But that is not the standard of clinical practice. In
practice, where restricted lengths of treatment, pure populations, and narrow
questions of research are often not applicable, the appropriate standard is “the
preponderance of the evidence.” There, as Bruce Ecker (2022) has pointed out,
years of accumulated instances of rapid, permanent change have no other known
explanation than memory reconsolidation. The theory is dually supported by the
basic science of learned fear and 120+ years of accumulated clinical experience,
where widely varying techniques fulfill the known requirements for the mechanism
of memory reconsolidation.
How this science can improve technique
Much of psychotherapy training involves applying a method and waiting for
results. By understanding the underlying processes and their requirements, it
becomes natural to seek the best way to activate an old pattern, the optimal
formulation of disconfirming information, and the right timing to allow a new
narrative to reach those limbic neurons where change is required. Instead of
waiting for change to happen, it becomes increasingly feasible to design the
therapeutic experience. Where all existing therapies have limitations, this
framework makes it rational to draw from the tools and techniques of multiple
therapies to better match therapeutic interventions to the unique situation.
How an explanatory framework improves training
In addition to improving technique, possessing a universal framework makes
training more efficient. Concepts from different brands of therapy are naturally
placed within one, easily recalled framework. Too many therapists, confused by
overly complex formulations, tend to resort to being no more than good listeners.
Less confusion means a greater likelihood of visualizing and supporting specific
change processes during sessions. That takes therapy beyond common factors to
individualized objectives and pathways to change.
Returning to the universal definition of what psychotherapy aims to change,
distinguishing the mind’s subunits of pathology and understanding relevant change
processes can significantly help psychotherapists of tomorrow be better armed to
meet the vast, worldwide morbidity arising from entrenched maladaptive patterns
generated by the human mind.
The framework referred to is described in more detail on the Convergence
and Integration in Psychotherapy blog and embodied in posts and a new, online
course available on Dr. Smith’s website, Howtherapyworks.com
References:
Ecker, B, & Vaz, A. (2022) Memory reconsolidation and the crisis of
mechanism in psychotherapy. New Ideas in Psychology. August 2022.
Goldfried, M. (2019) Obtaining consensus in psychotherapy: What holds us
back? The American psychologist May, 2019.
Freud, S. and Breuer, (1893) Preliminary Communication, The Standard
Edition, Vol. 2, Hogarth Press, London, 1955, p. 6.
Lane, Richard & Nadel, Lynn, Eds. (2020) Neuroscience of Enduring Change:
Implications for Psychotherapy, Oxford University Press.
Smith, Jeffery (2004) Reexamining psychotherapeutic action through the lens
of trauma, J Am Acad Psychoanalysis Dynamic Psychiatry. 32(4):613-31.
Author Bio
Jeffery S. Smith, M.D. is Clinical Professor of Psychiatry at New York Medical
College, Leader of the Psychotherapy Caucus of the American Psychiatric
Association, and President Elect of SEPI, the Society for the Exploration of
Psychotherapy Integration. He is a clinician in private practice, author, and trainer
of psychotherapists through the website, Howtherapyworks.com.
