TIFT #128: One Big Therapy

My plan for bringing the many therapies under one roof took a huge step this week, and another step is coming soon. I think it is time to explain. This week, the academic paper that lays the foundation was published in the Journal of Psychotherapy Integration (Smith, 2025). As of now, it is available to all as an open-access PDF. The other step is a new book for trainees and others who are not committed to a singe therapy or way of understanding what’s going on. That will be out soon. The title is “How Psychotherapy Works: Navigating the Therapeutic Space with Confidence.” But let’s step back a bit and look at the whole picture.

The problem

Our field has been severely hobbled by its divisiveness into competing therapies. The reason this has not been seen as a shocking failure is that most of us have given up on really integrating the various therapies. However, the current state of affairs is shocking. It has given biological therapies a huge advantage, even though they are often not as effective as psychotherapy. It has created confusion among clients and trainees alike, where each therapy promises to be the one answer when it is not. It is unfairly confusing for learners because they are expected to align themselves with one therapy or orientation long before they are in a position to make an informed choice. They only find out later that the therapy they have chosen may not be the best for every client and every situation. They wonder if another approach might be better, but face the daunting prospect of investing years in learning another in depth. So they go to conferences and workshops that give only a taste of something different, and, too often, end up with seat-of-the-pants decision making or just being a good listener.

Why we are in this situation

Every science started out like this. In the middle ages and renaissance, no one knew the foundational principles, so one person’s theory was as good as another’s. The idea that matter was made of earth, air, fire, and water was elegant and clear, but it wasn’t true. Little by little starting in the enlightenment, principles were found that had explanatory power and applied to multiple situations. A recent example is the DNA code. Understanding how the characteristics of species are encoded and carried has given a tremendous boost, making it possible for example, to understand the similarities and differences between plants and animals and humans.

Psychotherapy, on the other hand, was left behind, with little understanding of why people are irrational or how they change. Unlike chemistry and even evolution, the underlying principles were not known. Every therapy had to invent its own version of what it treats and how it works. Theories have been stated in terms that make sense within that therapy’s set of constructs but don’t make sense to followers of another approach. The farthest apart are the behavioral world and the psychodynamic world, to the point where finding unity has all but been abandoned. As a solution, a series of unifying principles have even been proposed, but they, too, are in competition. Psychotherapy is all about mindfulness, or it’s all about the autonomic nervous system, or it’s about attachment and relationship, or it’s about trauma. These are all important, but no one idea explains the whole story of how psychotherapy works.

Good news

The best news is that over the 130 or so years that professional psychotherapy has been practiced, techniques have been honed by intuition and experience to the point where they work remarkably well. Each school, within its own world, has explored what it is best and how best to apply its constructs. It is no surprise that, when they are compared, diverse therapies are about equally effective. The results have been so impressive that they have led to a false satisfaction with the status quo. For me, this is not satisfying at all, but further suggests that on some deeper level, they are actually doing the same few things

Turning Points

My interest turned a corner when I published a paper (Smith, 2004) describing two distinct change processes with different time courses and characteristics. One was the kind of transformative change described in Louis Castonguay and Clara Hill’s 2012 edited book, Transformation in Psychotherapy: Corrective Experiences Across Cognitive Behavioral, Humanistic, and Psychodynamic Approaches. It was rapid, dramatic, and permanent, and seemed to require both recall of emotional events and the client taking in a new experience or perspective on what had happened. The other change process is still interesting, but beyond the scope of this post.

The next key event was in 2015, when readers of my blog began reporting therapeutic disasters. Way too many therapists were not equipped to deal with the intense attachments my readers were describing. I decided then to turn my blog towards helping therapists rather than speaking directly to clients. I renamed my posts, “Tuesday is for Therapists,” TIFT.

A second event happened the same year. At the Psychotherapy Networker conference, I heard about memory reconsolidation, a mechanism by which schemas laid down outside of consciousness could be changed rapidly and essentially permanently. In a flash (by that evening I was reading Bruce Ecker’s book, “Unlocking the Emotional Brain), I realized that this was the mechanism I had seen in action from early in my career. I already knew about extinction, so now I had at least two known change mechanisms that could explain what happens in psychotherapy.

How to change a profession?

Helping people change is one thing, but how might it be possible to move an entire profession, especially one where different therapies continue to be ensconced in silos and compete for the title of “best in show.” I joined SEPI, the Society for the Exploration of Psychotherapy Integration, where others like myself were also unsatisfied. As I began to talk about what I had learned about change mechanisms, I realized that it was going to be an uphill battle.

The problem seemed to be that many of the influential people were in academia, where a career requires specialization. Some were committed professionally to one of the competing silos and others were held back by a standard of proof appropriate for a mature science, but not for building a new theory. That’s when I realized that the answer would need to be carrying a message to younger therapists and those who wouldn’t be satisfied until they got to the very bottom of how psychotherapy works.

I would use my medical background to make more accessible the underlying neurophysiological mechanisms, and I would use my interest in the information processing of the nonverbal, nonconscious mind/brain to follow the flow of information leading to human irrationality. Attention: When I say information, I don’t mean words. Here I mean connotations, feelings, images, experiences, bodily sensations, that is, “anything that can be described in poetry.” Those are the kinds of information the nonconscious mind works with and the kinds that are involved in producing the problems psychotherapy treats and in the processes by which psychotherapy can bring about change.

Flip the mind

Another hurdle was “conscious-centric” thinking. We are all familiar with our own minds, but only the conscious part. Since Descartes, we have had a love affair with our ability to reason, and have neglected the inner mind, the part that Panksepp has shown is very similar to the mind of your dog and has a far greater influence on our motivation and decisions than many are willing to admit. That is the basic mind, the one that has been keeping the human race going for thousands of years. It is at its best when surviving an attack by predators using simple solutions like fight, flight, and freeze. When humans switched from survival by physical fighting to surviving by means of social cohesion, the original, basic, subcortical mind began to struggle with complexities like balancing love for friends with hate for enemies. That’s when having a cortex and the ability to reason became important, giving us the power to make subtle decisions like who is a friend and who is not.

What I learned form working with people with addictions is that the original, subcortical inner mind is remarkably powerful. I saw how clients in early recovery could have a full conscious commitment to staying sober, but their inner mind would manipulate them until they relapsed. It would give them automatic thoughts justifying a relapse in the most seductive ways. “Just have a little,” “No one will know,” “I have to get some sleep.” The inner mind would send up a feeling, an uneasiness or sense that something was missing. Of course the answer was to use. If they still resisted, then an impulse would catch them by surprise, bypassing reason, as they accepted a “friendly” offer. The inner mind showed the breadth and depth of its power to influence conscious decision making. No wonder self control is a real challenge for humans. In my view, the conscious cortex has only a modest ability to “edit” the motivations and goals of the more basic, inner mind.

Since I was never a specialist and because the door of my practice is open to whoever comes, I gained a wide perspective on the kinds of problems people bring to psychotherapy. What came clear was that the ones therapy could help with are the inner, nonconscious mind’s attempts to solve serious problems. They are solutions that may have worked in the beginning but have become outdated and maladaptive. As they appear in therapy, it is often possible to form an educated guess about the problem or challenge they were designed to solve, the strategies they used, and why the same inner mind viewed therapeutic change as the loss of a vital protection, leading to resistance to therapeutic change. The more I thought about it, the more clear it became that all the problems psychotherapies are designed to treat have the same profile. A group of us from SEPI, including Andre Marquis and Gregg Henriques, called them entrenched maladaptive patterns, EMPs.

Three change mechanisms

I’m going to skip ahead here. The steps are in the new paper referenced below. If the inner mind is holding schemas with programming to identify threats and to decide how to deal with them, then there aren’t many options left for how to help the inner mind launch a new, more satisfactory solution.

1. Block the maladaptive pattern from being put into action.

2. Change the programming (held in procedural memory schemas) so the same inputs lead to a different pattern of response, including the automatic thoughts, feelings, and impulses that are projected into consciousness.

3. But there is still a missing piece. What if the client doesn’t have a better response available? It will have to be learned and practiced, so that makes a third required change process.
   
   Three candidates for these change functions have already been identified and extensively researched. Extinction is known to use cortical learning to generate inhibitory signals to block the expression of a pattern of response. Memory reconsolidation opens a 5 hour period during which the old programming can be replaced. And new learning with practice allows clients to add new response patterns to their repertoire of available responses.

Three final clinical objectives

Here are three clinical objectives that, when achieved, result in fulfilling the conditions for the above change mechanisms.

1. Help the client use new learning to add new, improved responses when needed. The most common new solution is acceptance because accepting is something the inner mind often works fiercely to avoid.

2. Bring relevant affect into the room. This is one of the “common factors,” and it is so because affect signals that the inner mind has been activated neurologically, a requirement for both extinction and memory reconsolidation.

3. Deliver disconfirming information. The easy part is teaching the mostly-conscious cortex to initiate extinction causing the maladaptive response to be inhibited. The problem is that this tends to be temporary and the old pattern eventually returns. The more interesting part is enduring, transformative change via memory reconsolidation, where disconfirming information must be delivered to the nonverbal, subcortical inner mind. This is where schemas are re-programmed either not to identify a threat or to deal with it using a new strategy.

Together these three change mechanisms and the three final clinical objectives that allow them to operate are enough to explain how psychotherapy works, regardless of brand or orientation. It is also how we can explain the importance of the relationship oriented common factors.

Common Factors

Remember that the term, EMP, a universal definition of what psychotherapy is designed to change, starts with “entrenched.” That means hard to change. As mentioned earlier, the inner mind’s survival mission sees letting go of an old but vital protection as a serious threat. It uses the tools at its disposal to counter the threat, that is to resist the pull of therapy. In doing so, it uses the same tools it uses to maintain an addiction or to make sure we eat enough to survive the famine that might start tomorrow. And, as we have seen, those tools are powerful. How, then, can we prevail?

As emphasized in Castonguay and Hill’s volume, the answer is common factors, that is, the strength of the therapeutic relationship. It is our direct or implied commitment to the client’s wellbeing that supports clients’ resolve and motivation to overcome their inner resistance to new behaviors and changed ways of thinking.

How does the relationship help accomplish the three therapeutic objectives listed above? Taking the emotional risk of trying out a new behavior is a powerful way to provide disconfirming information in an experiential form. The success of the new response pattern is living proof that the new way is superior. Similarly, consciously adopting a different perspective or point of view, one such as mindfulness, works as an imaginal experience. It tempts the inner mind to re-evaluate the contents of the old schemas. That is one more type of disconfirming information.

There is one clinical caveat. When the inner mind uses shame as a deterrent to the adoption of new behaviors, for example, assertiveness when the old pattern has been fawning, the result of the client’s behavior change will not be happiness, but a burst of intense shame. We need to anticipate that and help the client be ready to understand that the shame is not because they have done something terrible but that the inner mind is trying its best to ensure safety by re-establishing the old response. (This, by the way, is the other, more difficult change process, discussed in my 2004 paper.)

Where this all leads

The pathway to one big psychotherapy is clear. The action of any therapy can be explained by its ways of achieving the three final clinical objectives listed above. Those three objectives: 1) Learning new ways of thinking and acting; 2) Activating the old pattern as indicated by the presence of affect in the room; and 3) The delivery (in nonverbal terms to the subcortical inner mind) of disconfirming information, lead to fulfillment of the clinical requirements for the three change mechanisms listed earlier. In addition the function of the relationship-oriented common factors is to support the client’s willingness and ability to overcome the entrenchment, or resistance to change, inherent in the inner mind’s outdated solutions to once-serious problems.

Finally, as described above, the nonconscious inner mind, where the action of psychotherapy mainly takes place, responds to a different form of communication compared with conscious reasoning. As indicated above, it processes nonverbal information in the form of connotations, feelings, images, experiences, bodily sensations, that is, “anything that can be described in poetry.” Speaking that language is the art of psychotherapy, and that requires us to use not only our reasoning, but our intuition and empathy as well.

One big therapy with many techniques

By assembling a framework that is relatively simple, easily observed, and not in conflict with existing ideas, one big therapy becomes accessible to anyone open to a fresh way of thinking. Doing so can clarify what all therapies have in common and how each therapy’s constructs and techniques embody the same three objectives. With that perspective, it becomes natural to anticipate which of many techniques may be the best fit for a given client, therapist, and situation. It also becomes clear whether and where there may be incompatibilities between techniques. Thus, the mixing of techniques, a central goal of the psychotherapy integration movement, can be done coherently, based on predicting and observing the results of our interventions.

Where next

This is a quick summary of the article mentioned at the outset. I hope readers will want to see the argument in its peer-reviewed form. It is available to all as a PDF, downloadable at https://psycnet.apa.org/fulltext/2026-48751-001.html. In addition, a new book, “How Psychotherapy Works: Navigating the Therapeutic Space with Confidence” will soon be available as a companion to any practice.

Jeffery Smith MD

References

Castonguay, L. G., & Hill, C. E. (Eds.). (2012). Transformation in psychotherapy: Corrective experiences across cognitive behavioral, humanistic, and psychodynamic approaches. American Psychological Association.

Ecker, B., Ticic, R., & Hulley, L. (2024). Unlocking the emotional brain: Memory Reconsolidation and the Psychotherapy of Transformational Change. Taylor & Francis.

Smith, J. (2025). Psychotherapy integration from the bottom up: A unifying, science-based view of psychotherapy’s infrastructure. Journal of Psychotherapy Integration. Advance online publication. https://dx.doi.org/10.1037/int0000371

Photo Credit: Andrej-Lisakov, Unsplash