TIFT #23 Focus and Direction in Therapy

tift Aug 03, 2021


How do you tell your patients what you aim to do and how it will work? The old-fashioned answer was that it depended on what therapy you were practicing. Times are changing. Today, we are more likely to try to match the therapy to the patient, but that only highlights the confusion in our field. Therapists are exposed to a multiplicity of different approaches, each one saying it is the best and offering its own incompatible explanation of why and how therapy works. So, what do we say to our patients at the beginning of treatment? Do we propose free association? Exploring the relationship? Correcting irrational thoughts? Finding acceptance? Changing patterns of behavior? Which might be best for a given patient? How might we decide? What paradigm do we choose?

Why the Question is Important

We all see patients who have worked with another therapist. Much of the time the experience is very positive, but too often, therapy has dragged on with little change. It is my impression, and one of the main reasons behind TIFT, that today’s theories and explanations are too complicated, and therapists are exposed to too many approaches, each with its proprietary explanations. Too often, I think, the result is that therapists quit trying to understand and revert to being just nice people. Then the formidable power of affect avoidance guides both to a comfort zone with no focus or direction and little net change. 

Patient Preferences

People demonstrate sharp differences in what they need when they receive a serious medical diagnosis. Some want to know all about the illness, while others may prefer to put their care in the hands of someone with a top reputation, or with whom they feel a personal connection. Therapy patients want a practitioner who “gets” them, someone who is tuned in to their individuality and feelings, but they differ sharply on other dimensions like structure or flexibility. Some want their therapist to follow a set protocol and an end point, while others might be more comfortable with a therapy that evolves. Another important dimension is how personal they would like the therapist to be versus a more authoritative or distant stance. Do they prefer an evidence-based therapy or a warm hearted human?

All of us are capable of some range of adjustment, though we generally have our own comfort zone. Knowing and accepting one’s own characteristics and capacity for adjustment will help in making good matches and avoiding bad ones. From there, we can listen carefully to our patient’s personal preferences and ideas of how therapy is supposed to work.

Help from the common infrastructure

All therapies employ the same three underlying change mechanisms and four facilitating factors,** but they don’t share the same concept of what patient and therapist are supposed to be doing. Beyond personal preference, what is needed is a more basic clarity about how all therapies work. Then our explanation as well as our approach can be tailored to the patient’s needs and preferences. By diving down to the level of the common infrastructure of psychotherapy we can hope to see that the contradictions are more apparent than real.

The most crucial element is characterization of Entrenched Maladaptive Patterns (EMPs) as the basic units of pathology and the primary targets of our work. If we know what we are trying to change and how change works, then it should be much easier to clarify the focus and direction of a given psychotherapy. In doing this, I will to resort to what might be though of as a bit of trickery. 

The trick is to focus on how therapy addresses pathology while sidestepping the domain of health. Why? Compared with emotional health in humans, pathology is rigid, simple, restrictive, and often predictable. On the other hand, health has infinite variety and individuality. Health is fresh, constantly growing, and full of surprises. To put it simply, EMPs arise from the mind’s having evolved as an organ of survival, oriented towards coping with threats. However, our survival-oriented brain is good for so much more. What evolution shaped long ago for survival in a changing environment turns out now to be even more useful as an organ of creation. This was fleshed out in the Zoom meeting with Marvin Goldfried and Gregg Henriques described in TIFT #18. What we were able to agree on had to do with pathology. Meanwhile, at the end of the discussion, Gregg pointed out that important parts of psychology remains elusive and resistant to consensus. That is largely the realm of health. So for the sake of making a very complex subject understandable, I have skirted the complexity of health by defining it operationally as any response pattern that might be more desirable to the patient than another, presumably less adaptive one. In this way, limiting our view of therapy to helping patients trade away their maladaptive patterns allows us a far greater level of precision and specificity in describing our focus and direction.

Common Functioning of EMPs

EMPs have in common that they represent means for avoiding painful, uncomfortable or overwhelming core emotions. Those core emotions are not conscious feelings, but the deep activation of the limbic areas we have in common with other mammals. This activation is what triggers automatic patterns including EMPs. Some of these, such as anxiety, are shaped by evolution of mammals long before humans. Other EMPs are derived from coping strategies learned during our extended development, helpful at one time, but no longer so.

This means that EMPs have two components. The first is a pattern of appraisal identifying an actual or predicted threat. The result of this complex computational process is triggering a negative core emotion. Often these deep emotions are passed up to consciousness and manifested (with more complexity) as feelings. The threat could be imminent danger, but it can also be failure to meet a need or even an important goal. Thus, every EMP can be seen as having an interpretation of inputs leading to a negative core emotion as part of its structure.

The other component of every EMPs is an avoidance strategy, in broad terms, a pattern of behavior aimed at blocking the threat. Interestingly, this avoidance can be aimed at preventing something bad from happening but can also be aimed at suppressing the emotions that represent the endpoint of appraisal and the mind’s way of signaling the presence or prediction of a threat. This avoidance strategy is a pattern that can involve thoughts, impulses, feelings, actions, and bodily responses. When there is a consciously chosen response to an automatic thought or feeling, that, too, is part of the avoidance strategy.

Two Aims of Therapy: Emotion vs Behavior

To restate, every unit of pathology (EMP) treatable in psychotherapy has both a triggering core emotion related to a perceived threat, and a protective behavior pattern aimed at mitigating the threat and reducing or eliminating the emotion. This implies that there are two ways to approach helping people with troublesome EMPs. We can either work with the emotion or the avoidance strategy, whichever is more accessible at the time.

What we all know as clinicians is that sometimes our patients immediate suffering is related to painful emotions and sometimes it is from consequences of the avoidance. To put it in simpler terms, we humans instinctively avoid painful emotions by doing unhealthy things, even when it would be better to share them in a safe and supportive context. Sometimes in therapy the maladaptive avoidance pattern is more accessible and becomes the focus of our work. At other times, the triggering emotion is accessible and processing the emotion becomes our focus. At the level of the common infrastructure of psychotherapy, it’s that simple.

In Practice

If the painful emotion is the main concern of the patient or is relatively accessible, then we want to address that, first by bringing arousal into a workable window of intensity, then encouraging the patient to experience the problematic feeling while experiencing or being exposed to a new perspective or context of connection that softens the appraisal of danger and calms the emotion. That’s how we apply extinction or memory reconsolidation to the healing of emotions.

On the other hand, when the feeling is not accessible, our goal is primarily to help our patient let go of the unhealthy avoidance pattern. Psychodynamic therapists call these defenses while behaviorally oriented therapists call them irrational thoughts and behavior. 

Success in eliminating avoidance patterns of thought, behavior, feeling, etc. is likely to bring to the surface precisely the emotions that were being avoided. Thus made accessible, feelings again become available as targets of our work.

Statements of focus and direction

So now we can say that, taking into account the patient’s preferences and expectations, the aims that shape our focus and direction are helping patients experience of difficult emotions in a healing context and helping them become more aware of their avoidance patterns and motivated to change them. Let’s look at some typical clinical situations.

When emotion is more accessible:

  •  “You may have a genetic predisposition (to anxiety or depression), but I think there are also factors we could learn about that will help you heal these emotions. I’d like us to try listening to and understanding the unconscious part of your mind where this might be coming from.” Note: Exploration is a basic way to activate the maladaptive pattern while shedding new light on it.
  •  “Those are very distressing feelings. I’d like to hear more about what happened.” Note: Show, don’t tell is sometimes the best way.
  •  “I’m sorry to hear, but I know that experiencing and sharing your feelings will help you feel better.”
  •  “Research has shown that identifying and changing some problem ways of thinking can help you feel better. I’d like us to follow some steps and I’ll suggest homework so you can make progress between sessions.”

When voidance is more accessible:

  •  “Let’s work on helping you change this behavior by identifying the triggers and practicing healthier patterns until they are automatic. If that stirs up feelings, we’ll work with them, too.”
  •  “I think this pattern is there for a reason. I’d like to help you work on changing the pattern, but at the same time, I think it will help us if we can understand how it got that way and what is sustaining it.”
  • "Research has shown that learning to cope with these feelings will do more to help you than trying to eliminate them. I'd like to help you learn some effective techniques for doing just that."
  •  “Let’s explore the goings on in your unconscious mind which seems to be the source of your trouble.”
  •  “I think there are hidden things going on that are undermining your satisfaction in life. I believe the best way to work together will be an open-ended exploration. In short, we’ll try to understand what makes you tick.”

Excessive arousal needs to be regulated first:

  •  “Let’s work on helping you deal with overwhelming emotions first. Then we will be able to work on the issues behind them. I want to introduce some techniques that may be new to you.”


In my practice, I don’t have a set way of explaining focus and direction. It comes out differently every time, depending on a sense of the patient’s style and expectations as well as the work I anticipate us doing. Is there a general statement that might apply in a wide variety of situations? Here is one,  but even this one is biased towards open and flexible as opposed to structured: 


"A growing body of research and opinion are converging on the idea that the unconscious mind, in its efforts to protect us, can initiate less than ideal patterns of response including some designed to avoid painful feelings that need to heal. Exploring those patterns and working with the feelings provides a flexible and effective way to bring to the surface the things that need to be healed and to put in perspective patterns that don't fit with living a more satisfying life."


** Click here for Graphic Summary of 3 Change Mechanisms and 4 Facilitative Factors.


Jeffery Smith MD

Photo by: paul-skorupskas-unsplash, Unsplash.

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