This year has seen publication of 25 issues of “Tuesday is for Therapists.” With each issue, I, myself, learn and make use of these nuggets in my own practice. I hope they are as useful to my readers.
I have one wish for my readers. Please share your questions and clinical conundrums. I am always happiest to respond to reader queries and problems. That keeps the discussion focused on real life clinical issues. Just be sure that you disguise any client information, as this blog is open to anyone.
Here are this year’s posts with a brief synopsis.
Following the dread is a technique I use every day now. I ask my clients to focus on what it is they most dread. “You are anxious about X, but what is your picture of what would happen? How would it affect you? What makes you dread that outcome so terribly?” Eventually the inquiry leads to activation of the dreaded emotion, itself. That is the first requirement for clinical memory reconsolidation.
The next TIFT followed up with a catalogue of things people dread, such as dread of failing to grow into one’s potential, dread of being caught by surprise, and terrors from so far back that they have no verbal expression. The important point is made that “the dread” is the same phenomenon as the limbic activation that triggers all the maladaptive response patterns that are what psychotherapy seeks to help people trade for better ones.
This post showed how clinical memory reconsolidation provides a universal explanation for how psychodynamic, cognitive-behavioral, and “third wave” therapies actually achieve change. It also introduces the idea that, with a clear picture of how change happens, we can focus concretely on how best to meet the conditions for change. The post also introduced “nonspecific” but important aims of therapy, including arousal regulation, safety, support for motivation, and a positive alliance.
Deeper than it might appear, this post personifies our instinctive, danger-oriented mammalian mind as the “nonconscious problem solver,” and shows how multiple protective patterns are organized in layers like the defenses in a medieval castle. The threat that a layer will be breached triggers development and activation of a new layer. Unlike the DSM, this architecture shows how multiple Entrenched Maladaptive Patterns are separate but related and ultimately organized around a core dread.
This was the post from 2016 that put the HowTherapyWorks blog on the map. It attracted a following who had experienced powerful attachment to their therapist. Many found their attachment hard to talk about and scary to mention to their therapist. Too often, therapists’ handling of these feelings was disastrous. This is what opened my eyes to the need for more and better therapist training. Subsequent posts and selected stories were published in the eBook, “Attachment to Your Therapist: A Conversation,” available in the “Store” and on Amazon.
Childhood temper tantrums are important to understand for many reasons, especially because they are prototypical of adult problems and how they resolve. This post shows how they relate to adult therapy. It’s a nugget well worth taking in. The hallmark is self-defeating or ineffective behavior that doesn’t respond to therapeutic efforts. The answer for adults is the same as for small children.
Why is our field still divided into competing camps? The post outlines how understanding the universal infrastructure that explains the action of all therapies can lead to the demise of silos and facilitates choosing techniques from a range of options, based on the needs of the specific client and situation rather than on a pre-set method determined by the brand of therapy.
Close observation of the need for closeness and its grip on motivation is vital for good clinical work. The post starts with co-dependency and moves on to the developmental point of view that therapy can help clients become comfortable with a looser closeness and tolerate a middle ground, where separate thinking and free will are no longer threats to connection.
Joining a systems-view of marriage with an appreciation of individual dynamics, the post suggests that the “nonconscious internal problem solver” instinctively seeks to solve marital tension by “getting the other to…” In individual therapy, as one partner becomes able to engage in a compassionate relationship with the self, “I statements” become more comfortable and the marriage begins to unlock and function better.
This essay on anger started with my wondering why fathers are so often angry at their “lazy” children. It’s hard being a father (or mother) and seeing one’s children giving themselves an easy path naturally generates anger. The post goes on to discuss the instinctive tendency to act on anger and how anger can be handled such that it can heal and resolve.
Few doubt that there is a crisis in adolescent mental health. This post looks at it from a developmental point of view, suggesting that today’s culture makes it easy for young people to veer away from the kinds of engagement with life that lead to development of healthy strengths. Instead, young people may find it easier and more comfortable to avoid just those encounters that lead to growth. Once the pattern of avoidance is established, the bias continues, and a deepening sense of immaturity discourages further engagement.
I reported on a summit on trauma with Bessel Van der Kolk and other leading lights. The gist was about seeing how healing needs to take place within the self who was hurt and frozen in time. This means that effective work with survivors of early trauma must address the inner child on their turf in a way that “gets through.” We need to overcome the shame that often inhibits both communicating with the inner self and working with experiences that are held in the body and deep in the limbic system.
When clients are in a state of dysregulation, therapeutic work stops until there is a change of state. Dysregulation can be seen as a failure of coping and a loss of control, but it can also be described as reverting to primitive patterns of coping similar to those of the temper tantrum. From this point of view, what we do to bring about re-regulation amounts to helping the client move physiologically from isolation and disconnection to social engagement. When that happens, we return to more usual psychotherapeutic techniques. Healing moments again become our clinical focus.
It’s always a pleasure to respond to therapists’ description of their most intractable situations. This one involved a trauma survivor who just could not find peaceful sleep. As it turns out, the problem was not simply that he was afraid of being retraumatized, but that experiencing one more assault was an absolute red line. Since there could not be any absolute protection, the hypervigilance could not resolve. The “antidote” in this case, and in other common types of dread, was for the inner child to become ready to accept the possibility that, while a new trauma could happen, it could be survived.
Aimed especially at psychiatry residents and the teaching of psychotherapy, this post examines in detail how the three required therapies, CBT, Psychodynamic Therapy, and Supportive Therapy are fundamentally the same. They each follow a different path to the healing moment, that is, the essential final pathway to enduring change. It’s a detailed look at how these three therapies actually do the same few things.
The material in this blog has been labeled as “reductionistic.” This post argues that looking closely at the infrastructure that governs the action of all therapies in no way undermines, oversimplifies, or invalidates the subtlety or sophistication of existing theories. Instead, it provides a kind of “Rosetta Stone” to bring all therapies under one roof and adds support for the wisdom accumulated by so many wise therapists over the past 140 years.
The image of the dog at the top of this post was intended to make the point that our own limbic system is very similar to that of our pooch. Furthermore, that limbic system is both the source of the problems therapy can treat as well as the place where therapeutic change needs to take place. This post highlights the fact that activation of alarm centers in the amygdala is no different from the emotion we infer in our dog. It goes on to look at the subtle relationship between limbic emotion and conscious affect and the role of affect in therapy.
The author had the pleasure of reading Richard Schwartz’s eye-opening textbook of Family Systems Therapy. Like many “brand” therapies, FST competes by emphasizing its differences compared to other therapies. This post looks at it as one more approach to the same problems and processes, but with a very positive and helpful way of characterizing the entrenched maladaptive patterns that bring clients to treatment. The concepts of exiles, managers, and firefighters are invaluable!
Continuing an exploration of Internal Family Systems Therapy, this post looks at the idea of the “Self,” as an unerring source of clarity about what the client truly needs. I’m not fully convinced, but the approach is solidly humanistic and gives a chance to look at how a client-therapist partnership should work.
Listening to adult clients struggle to find their way later in life, it is valuable to realize that our most powerful motivation comes from the inner, childlike self. The corollary is that we had better not ignore the inner child’s will. Attempts to manhandle our decisions are doomed, as motivation soon wilts. Instead, we need to explore and honor the childhood dreams and plans that have been pushed aside, allowing them to come to light again and begin to be shaped by adult reality into the kinds of “passion” that actually do lead to satisfying adult lives.
Much has been written about why researchers and clinicians pass like ships in the night. This post suggests that a significant factor is that they have markedly different standards of proof. Lucid clinicians seek “the preponderance” of all the available evidence, while researchers wait until they have proof “beyond reasonable doubt.” The result is a culture gap in whch they have a good deal of difficulty listening to one another.
Instinctively, we know that making our clients aware of their inner emotional life is valuable, but why? In response to Richard Lane’s excellent article on the role of emotional awareness in therapy, the post suggests that awareness is the embodiment of the kind of “illumination” that fulfills the second requirement for memory reconsolidation. It’s the “antidote” to the inner mind’s maladaptive meanings that allows them to be rewritten.
If you haven’t read this one, you must! It’s a carefully reasoned, highly positive pathway out of the mess the world is in, and it centers on the things we therapists know about how life needs to be lived.
Returning to the clinical, this post examines the channel by which therapy delivers the “antidote” that provides required illumination allowing maladaptive patterns to be rewritten. The idea is that the presence of affect not only shows what’s going on in the limbic system, but also means the limbic system is open to receiving new illumination, conveyed from consciousness downward.
The author has often used the term “accurate empathy,” but it has sometimes been misunderstood. It’s not that I mean anything different from Carl Rogers, when he coined the term. Rather, my use implies a lot more about what accurate empathy does to contribute in multiple ways to promoting those healing moments that are at the core of what we all seek to make happen.
I hope you enjoy these 2022 posts and those from years past. Please notice that they remain “nondenominational” and are consistent with the theme that all therapies really do the same few things. With them, I hope to share with my colleagues and readers that therapy wars should be declared over, and it’s time to appreciate how understanding the universal infrastructure of change can sharpen our practice regardless of training or orientation.
And please don’t forget to comment and to share your questions and clinical dilemmas as the basis for further discussion.
Jeffery Smith MD
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