How Does Psychotherapy Work?
Emotions reflect our ability to subjectively experience states of our nervous system. These states, which we describe with words such as elation, fear, shame, love, and rage, are experienced as either good or bad, leading us to approach or avoid other people or specific situations. Attempts to avoid or escape painful, intense, or frightening feelings plays a major role in psychological dis-ease, anxiety, depression, and mental illness.
Assistance with experiencing and tolerating increasing levels of positive and negative feelings is a vital component of both good parenting and psychotherapy. The gradual increasing tolerance for stress builds our brains, expands the organization of emotional and cognitive integration, and creates networks in the brain to help regulate emotions.
Emerging from childhood with an ability to experience a range of emotions and tolerate stress serves as a means of brain growth and continued development throughout life. However, when parents fail to provide adequate assistance in making sense of emotions, the brain organizes a variety of coping strategies and defense mechanisms. These strategies and defenses vary in the degree to which they are successful in reducing anxiety.
The neural connections in the brain that result in defenses shape our lives by selecting what we approach and avoid, where our attention is drawn, as well as the assumptions we use to organize our experiences. Our brain then provides us with rationalizations and beliefs about our behaviors that help keep our coping strategies and defenses in place. These brain structures can, on the one hand, lead to psychological and physical health, or, on the other, to problematic symptoms and disability.
Psychotherapy provides a safe place in which to explore any unintegrated and dysregulating/upsetting thoughts and feelings that lead to problematic symptoms, unhappiness, and dissatisfaction with life. The process involves exposing clients to the unintegrated and upsetting thoughts and feelings and at the same time offering the tools and nurturance with which to integrate painful feelings and experiences.
As in development, the repeated exposure to stress in the supportive interpersonal context of psychotherapy results in the ability to tolerate increasing levels of arousal (intensity of feelings). This process reflects the building and integration of brain circuits and their increasing ability to regulate emotions.
In this process, the therapist plays essentially the same role as a parent, who provides and models the regulatory functions of the brain. As feelings are repeatedly brought into the therapy relationship and managed through a variety of stabilizing mechanisms, the client gradually internalizes these skills while simultaneously sculpting the neural structures necessary for improved regulation of emotions.
As in childhood, the repeated cycle of attunement, rupture of attunement, and its reestablishment gradually creates an expectation of reconnection with a nurturing figure. The expectation of relief in the future enhances the ability to tolerate more intense emotions in the midst of a stressful moment.
One of the goals of therapy is to shift a client’s experience of anxiety from an unconscious trigger resulting in avoidance into a conscious trigger for curiosity and exploration-using anxiety as a compass to help guide him or her to the unconscious fears and anxieties. Becoming aware of anxiety is followed with an understanding of what we are afraid of and why. The next step is to move toward the anxiety with an understanding of its meaning and significance. In this way, anxiety becomes woven into a conscious narrative-something that makes sense to us-as opposed to being an unconscious trigger for avoidance.
Deprivation and/or chronic stress during childhood increases the chance of simultaneous damage to the brain and the use of unhelpful or maladaptive defenses. With increased nurturance and support, physical comfort and soothing talk with caretakers, stress hormone levels decrease and the brain is better able to integrate all kinds of experience.
Through psychotherapy and self-reflection, most of us become aware that we seem to shift back and forth among different perspectives, emotional states, and the way we use language. We are all aware of the voices we hear and the conversations we carry on within us as we struggle with the weighty issues of our lives, or even to decide something as simple as where to go for dinner. This internal dialogue, guiding our thoughts and behaviors, often departs from what we say socially. In other words, some of the negative things we say to ourselves we would never say aloud. This internal language serves as a way of maintaining preexisting attitudes, behaviors, and feelings, based on the supportive or critical voices of our parents. Most of our ongoing internal dialogue is habitual and continues to keep us in the mode in which we have been shaped, which is quite often limiting and constricting, preventing us from living as fully and freely as we might otherwise live.
Much of therapy consists of examining and attempting to understand this internal dialogue. This process expands perspective on many of the unconscious aspects of the self. In therapy, a language of self-reflection is either enhanced or created for the first time. As this language is expanded and reinforced, clients learn that they can first evaluate and then choose whether to follow their thoughts or what others expect of them (instead of reacting unconsciously).
There is an increasing experience of having feelings about thoughts and thoughts about feelings, rather than having feelings completely dominate one’s experience, or vice versa, having thoughts (rationality) completely dominate one’s experience. Feelings and thoughts can be more integrated so that both aspects of brain function can balance and enrich one’s life, allowing one to live and move about more freely in the present and be less ruled by the past.
