How Therapy Works
by Tori Olds, Ph.D.
The article below describes the science behind personal growth, attachment theory, and the therapeutic process. It begins with a brief overview of attachment theory (which studies the impact of early family relationships), specifically looking at how childhood experiences influence how our brains become wired. Next it explores ways we can rewire our brains as adults through healthy relationships (including our relationship with ourself, which can be developed through mindfulness and self-compassion). The aim here is to achieve neural integration–or the ability to have both our thinking and feeling parts of our brains working at the same time. This type of integration is key to resilience, emotional balance, aliveness, and the capacity for empathic connection and self-compassion.
My therapeutic approach is largely based on attachment theory. Attachment theory was developed by John Bowlby in the 60’s, but attachment theory has more recently gained prominence, largely due to exciting developments within the field that shed light on how attachment (i.e. early childhood) experiences impact brain development. Attachment theory explores the critical importance of an infant’s early experiences with caregivers in terms of forming later patterns of relating that include one’s sense of self (e.g., “I received lots of love, so I must be lovable”), expectations of others (e.g., “If I express need, I will be disappointed/punished”), and strategies for handling relationships (e.g., “I can’t expect consistent care from others, so I will learn to take care of myself”).
Children have little other choice than to base their understanding of reality, and their strategy for dealing with that reality, on what they experience at home. According to attachment theory, it is during the first years that children learn what to expect from other human beings. This is very important because social relationships are so critically important to living. Because humans have a much better chance of surviving (and reproducing) in a group, we are literally wired to need relationships–for our sense of safety, for our psychological and physical health, and for our ability to find meaning. This wiring explains why so much of our sense of well-being is dependent on our relationships and why coming from a family that instills negative expectations of others (and the subsequent maladaptive strategies) can be so debilitating.
Because relationships are key to survival, a great deal of the brain is dedicated to monitoring and engaging in social behavior (determining safety or danger, expressing warmth or threat, etc.). Allan Schore, who writes about attachment theory and the brain, describes how the right hemisphere is more heavily involved in interpersonal processes. It is also the side of the brain that develops more actively in the first two years. During this time the brain is extremely plastic, with neuronal pathways being laid down and strengthened (or, without use, atrophying). This is a concept that some of my clients have found surprising. It would be easy to assume that the brain is pretty much fully-structured at birth (like the hands and feet). But in fact, attachment theory tells us that experience works alongside genetics to determine how the brain is wired. Because so much of the right brain is molded during the first two years, this period is particularly critical in terms of learning how to trust and relate to other people. Reading social cues, having empathy, even being able to like others and ourselves, is based on how the brain is wired. Although this wiring is largely determined by how one was related to as a child, corrective experiences in adulthood (such as therapy) can fortunately modify brain wiring as well, which I will say more about later.
Attachment Theory and the Brain
A new focus of attachment theory is the study of how attachment experiences impact the brain. This work has been largely pioneered by a psychiatrist named Daniel Siegel, whose work many Austin therapists, psychologists, and educators have grown interested in over the last 10 years. Building largely on attachment theory, Siegel developed a field called Interpersonal Neurobiology, which addresses how the brain is wired through past experiences and how new experiences can help rewire the brain. In the last few years, interest in attachment theory and interpersonal neurobiology this field has rocketed, I believe because Siegel’s work confirms what psychologists have always known–that early relationships are important–while helping us understand why they are important from a biological point of view. Although specific knowledge of the brain may not be essential for therapy or counseling, I have found it extremely helpful to orient clients to some of the general principles that Siegel (and Allan Schore, Steve Porges, among others) have discovered. There is something helpful about conceptualizing our behavioral/emotional problems as glitches in our nervous system. Looking at attachment theory and the brain can decrease shame (since it illustrates that our vulnerabilities aren’t “on purpose”) and be empowering (since understanding the science behind what we are experiencing can help us make shifts).
Because the field of Interpersonal Neurobiology and other advances in attachment theory are so groundbreaking, there is a tremendous amount of excitement about it in the therapeutic community. A number of approaches to therapy, including the ones I most heavily draw from– AEDP for individuals and Psychobiological Couples Therapy for couples–incorporate attachment theory into their techniques. Another theory that has informed my work and thinking, Systems Centered Therapy, provides all the experiences that we now know are needed to create secure attachment and change the brain. I feel very lucky to have started my career during a time when the therapy community is so energized by these ideas.
Let me say more about Interpersonal Neurobiology teaches us and how it relates to attachment theory. According to Siegel, how the brain becomes wired is largely based on social stimuli involved in care-taking (such as smiles, cooing, being rocked or held), that activate certain neuronal patterns. For instance, if a baby cries and then is picked up and soothed, the brain is learning how to move from a state of upset to a state of calm. Since “neurons that fire together wire together,” this soothing allows neuronal pathway to form such that different areas of the brain can calmly work together to deal with upsetting emotions in the future. On the other hand, if a baby cries and is ignored, or even punished, then the baby learns that emotion simply leads to disappointment, isolation, or a feeling of overwhelm. These experiences teach the brain to identify emotion as threatening. When a brain perceives threat, it naturally moves toward states which are defensive by nature. Depending on the level of threat, the brain moves into either hyperarousal known as anxiety (our heart pumping so we can fight or flee) or hypoarousal known as depression or collapse (the defensive maneuver of playing dead). In other words, when our parents’ response or lack of response makes us experience emotion as bad or scary, then our brain learns to respond to feeling by going into the defensive posture of either anxiety or depression.
During early experiences with emotion, the brain also learns ways of dealing with emotion that are interpersonal. As attachment theory teaches us, when parents are available, attuned, and non-intrusive, children are able to use them for emotional regulation. This type of support patterns the child’s brain toward healthy independence (where they can care for themselves, but also allow others to care for them when needed). When parents are inconsistent, a child might learn to cling to his or her loved one’s to get what she needs, thereby engraining a style of relating (in attachment theory this is called an “attachment style”) that is very sensitive to abandonment or withdrawal and often manifests as anger or clinging (in attachment theory this is called an ambivalent attachment style). On the other hand, a child may feel so neglected that he or she “gives up” on others and shuts down their need for support–to the point where it can be difficult to receive connection or support later in life (in attachment theory this is called an avoidant or dismissing attachment style). For these individuals, it is approach, not withdrawal, that activates discomfort. Though these adaptations may be necessary during childhood, they can create notable problems later on, particularly in committed relationships. For people who did not have positive experiences of being regulated by their caretakers, it may be more difficult for them to effectively use others when dysregulation occurs. In couples counseling, teaching partners to successfully use one another for regulation is a key to therapy and can often make the difference between a safe, healing relationship, and an unsafe, damaging (or distant) one.
Emotional Regulation: Before I go on, let me say more about the concept of emotional regulation versus dysregulation, since it is one that is often the focus of therapy. Emotional dysregulation is the word used to describe a state in which the brain is having difficulty keeping emotion at a manageable level. It is extremely common (in fact, all of us get dysregulated at times). A person might be too “low” (collapsed, despairing, shut-off from feelings) or too “high” (flooded, agitated, overwhelmed). Building on this idea, Seigel has described emotional resilience as the ability to maintain a balance between states of chaos and rigidity. Chaos and rigidity are on opposite sides of a continuum in terms of brain state, and have to do with a lack of integration between parts of the brain.
Two types of integration are important in the brain: horizontal integration (between the right and left hemispheres) and vertical integration (between higher and lower centers). If either is missing, then chaos or rigidity occurs. Chaos occurs when the brain centers in charge of emotional response (in the mid and lower as well as right brain) fire without modulation by the more calming and “thinking” (upper and left) parts of the brain. This happens when a person becomes flooded or overwhelmed with emotion. In these states of chaos, I try to bring the client back into a window of emotional tolerance by helping bring “higher” brain functions back on-line, thereby shoring up his/her sense of safety, structure, and stability. The therapist’s presence alone can act as a stabilizing force, particularly if they guide the client toward self-compassion. Also, because the language center is in the left hemisphere, simply naming what one feels can activate the left brain, and thereby help create order out of chaos.
In contrast, rigidity occurs when the left and higher brain’s analytical functions are activated with minimal input from the feeling, intuitive, empathic functions of the brain. People who tend towards rigidity often describe themselves as being too much “in their head.” They are able to rationally analyze a problem, but may have difficulty knowing what they feel or want, or lack a gut sense of what is right for them. In this case, a psychologist’s active support helps clients to access feelings they may have been ignoring or avoiding, and to do so with self-compassion.
Most of my clients tend toward either rigidity or chaos. It is also common to move between both states–perhaps getting overwhelmed when emotion comes up (chaos) to the point that one shuts down and becomes defended (rigidity). Obviously, the experience of chaos is very unpleasant and inhibits daily functioning. It is difficult to think straight, for instance, when we are very anxious or angry. For people who have trouble with chaos, it is as if the emotions “hijack” them–taking them somewhere unpleasant and where they have little control. These people may get stuck in feelings that they don’t know how to process to completion and by which they therefore feel disempowered. Rigidity, on the other hand, means loosing track of one’s emotions altogether or having little sense of one’s true self. While rigidity has the advantage of muting negative feelings, it has the disadvantage of muting positive feelings as well, including the feelings of connection and intimacy. I would describe these two extremes as two sides of the same coin, since people who cut off their feelings usually do so because they fear being overwhelmed by them.
In order for an individual to have more emotional resilience, self-compassion and flexibility, new neuronal connections need to be forged inside the brain such that soothing and organizing functions can come online when things are too chaotic, and enriching functions can come online when things are too rigid.
How therapy helps
So how does therapy help with these issues? Therapy works (in part) by providing an individual the experience of first being aware of the emotion (by slowing down and sidestepping defenses) and then moving through the emotion without getting too dysregulated by it. Hopefully the therapists’ presence, tracking of the process, and ability to stay regulated themselves in the face of strong feelings can help clients pace, ground, and contain their experience with self-compassion. Think of how much learning can take place in these moments! Firstly, the brain is learning how to “ride the wave” of emotion. To use this metaphor, when someone is learning to surf, the more he/she practices it, the more it becomes engrained in the body–so that the body knows how to stay on top of the wave without thinking. That is because new neuronal connections have been formed in his/her brain. In a similar way, the body/brain needs to learn how to move through emotions in a smooth, manageable way that is not too intense (chaotic), without being too flat (rigid) either. In this metaphor rigidity might look like not getting in the water in the first place, while chaos would be having the waves crash on top of you.
Secondly, the therapeutic process should help the brain learn that it can be safe to share one’s self with others and that it can be helpful, even deeply satisfying, to do so. On this more subjective level, many of my clients have described the experience of having their real feelings, even painful ones, as beautiful. They say that it lends a sense of connection with me–another person (which we are predisposed to enjoy), as well as a deep sense of connection with themselves. This experience isn’t only on the level of intellectual insight (though often insights come out of this process); it is an experience of finally truly being with one’s self. Just this week I had a client tearfully tell me at the end of a session that she felt she had just experienced a “home-coming.” She did this by attuning to and listening to what was “inside.”
“Inside” might sound like a mysterious place, but as a therapist I try to make it a bit more concrete. I primarily do this by orienting clients toward the sensations in their body. The body, after all, is where we “feel” our feelings—just like we would a belly-ache or many other biological processes. Slowing down to check in with our physical experience is a concrete way to begin gaining awareness of our emotions. Any way we can tune into ourselves, in fact, can help with this process. We can listen to the nature of our thoughts, take note of our energy level or where we are holding tension, identify impulses, notice our breathing or heart-rate, pay attention to sensations of emotion—there are many ways to tune into one’s self. Paying attention to the body is a great place to start because inputs from the body come up first to the right brain and then to the left. This “up and over” motion fosters both vertical and horizontal integration.
Making the Implicit Explicit
The body also provides information that is more difficult to “analyze.” I’ve heard many clients say they’ve sought counseling because analyzing themselves hasn’t been very helpful. On the other hand, simply paying attention to ourselves can be very fruitful and give us a more honest picture. To clarify, the left brain is great at confabulating (coming up with fictitious answers, like “I snapped at you because xyz…”), while the body, on the other hand, doesn’t lie. When we listen to the body (in other words—the right brain), we have realizations that feel “true”—like a gut sense or a knowing. These are usually more accurate and helpful. Allan Schore believes the information held in the right hemisphere is comparable to what has traditionally been called the unconscious. As therapists have always believed, making this kind of implicit information more explicit is very important. I like to think of this right brain information as the “raw data” about our experience that the left brain can then take and analyze. Without this raw data, the left brain creates likely, but not necessarily accurate, explanations.
Building on this idea, many of my clients have found the concept of implicit memory very helpful in understanding their experience. Implicit memory occurs when we are remembering something from the past without the sensation of remembering (in other words, we have no idea we are having a memory). The most extreme version of this is a flash-back. A flash-back happens when the brain remembers a traumatic event without the person knowing that it is just a memory. A person having a flash-back isn’t aware that he or she is remembering something from the past–rather, it feels as if the past experience is happening again in the present. This is because the brain processes information differently during particularly stressful (or traumatic) moments. More specifically, the overwhelming experience fails to be encoded into the part of the brain that is usually in charge of remembering, so that when it is recalled later, we don’t know we’re having a memory.
A similar process can occur for people who had stressful experiences during childhood. When these experiences are remembered implicitly, people can re-experience a certain feeling that they had during childhood without realizing that the feeling relates to the past. Rather, they believe they are having a feeling in relation to the present. This can be very confusing, leading people (and their loved ones) to wonder at the severity of their reaction. For instance, let’s say a woman had a history of being demeaned by her father. When her husband gives her feedback, it is quite possible for the memory of being demeaned as a child to be triggered on an implicit level. If so, then she would suddenly re-experience painful feelings she had during childhood, and believe they were in response to her husband’s behavior. This might cause her to believe her husband meant to demean her. When members of a couple are aware of one another’s implicit memories, they can more easily understand, and deal with, their partner’s surprising emotional reactions. This is something addressed in couples counseling.
Making sense of implicit memories is another important reason for listening to the body/right-brain. To summarize, being able to know ourselves and our emotional world, without being overwhelmed with all the feelings that live there, allows for a sense of aliveness, richness, and self-understanding. Being present with the “realness” of this experience, while being able to contain and make sense of it, is what makes the counseling process empowering and healing, not to mention insight-producing.
If “being present with” sounds a little “woo-woo” or vague, let me explain further by introducing the concept of mindfulness. Mindfulness is a process of observing one’s experience, in the moment and without judgment. This means just noticing what you are noticing without trying to change it or criticize yourself for it–and ideally having self-compassion. Yes, this is similar to the idea of meditation, and is not a new concept. What is new is the understanding of how practicing mindfulness changes the brain, increasing frontal lobe activity, growing cells in areas like the hippocampus, and strengthening the insula (which facilitates compassion). While therapists can’t measure those physical changes during counseling, what counselors can see is clients being able to find equanimity and strength in the face of difficult feelings.
This strength is gained because the various parts of clients brains are learning to work together in an integrated, harmonious way. When therapists help clients be mindful of their feelings, they are allowing the emotional centers of the brain to be stimulated, while at the same time using other areas as well.
Related to mindfulness is the process of introceptive attention, or turning one’s attention away from outward stimuli toward inward stimuli. A new study highlights how holding internal attention strengthens the brain. Tuning our awareness to our internal experience can be frightening in that it is likely to make us more aware of avoided emotions. This is why it can be useful to have external support when we are learning to feel the fullness of our feelings. A psychologist’s or another person’s presence can provide a containing function. It is easier to calmly face and master difficult states when we feel we are not alone.
Having the chance to observe one’s feelings and experience while staying calm and rational allows both feeling and thinking centers to be activated at once–linking them in partnership. This is why children’s brains become more integrated when they are able to turn to their parents for support. For example, say that a six-year-old boy is upset because he got teased at school. He comes to his mother in tears, unable to deal with his feelings by himself. His mother takes him onto her lap, soothing him through her closeness, vocal tone, warmth, and touch. His brain has a chance to practice moving from a state of dysregulation to one of regulation (and as we know, practice grows neuronal connections). Additionally, the mother whispers to him, “I know; it is so upsetting to be teased. It really hurts. It’s natural to cry about it, and maybe that will help you feel better.” Her words activate the more thinking, understanding frontal part of his brain–not in a way that shuts down his feelings, but in a way that allows him to think and feel at the same time. The more he has this type of support, the less scary emotions will feel (in fact, they can be linked to the very positive experience of love and connection!) and the less likely that he will become confused and flustered by emotions as an adult (or need to shut them down entirely).
Rewiring the Brain
Although the brain becomes less changeable as a child grows older, even in adulthood there is the possibility for change (without which, counseling would be useless). As I said, experience is a powerful way to rewire the brain. The brain is particularly receptive to change when emotion is being experienced. A negative example of this would be trauma. We all know that powerful, traumatic events can affect a person’s future ability to regulate emotion, feel safe, and perhaps even connect with others. That is because strong emotion primes the brain for learning (as if the emotions signal that something important is going on, so the brain should “listen” and adapt accordingly). A positive interaction with a psychologist, then, can be seen as the opposite of a traumatic event, as it can be a powerful, yet positive experience–one of being cared for. The process of being helped, seen, and accepted in places of pain can rewire the brain, allowing the mind to realize that emotions can be safe and that there is no need to “freak-out” in the face of them. This understanding increases one’s ability to recover from difficult emotions, as well as relate to others in healthy ways. In case you ever wondered, this fact is why therapists are known for wanting clients to feel their feelings more fully. Many people assume that the purpose of encouraging feeling is purely cathartic. But in fact, without the experience of emotion, the brain changes very little (for reasons I just described). Of course it changes some–when we learn a new piece of information, for instance, new neuronal connections must be made. But only when we allow the actual neural nets associated with our painful patterns to fire can they begin to rewire in new and integrated ways.
Markers of Change
Related to the discussion of change, there seem to be two particularly powerful markers of change. One indicator is the ability to tell a coherent and meaningful story of one’s own life and how one developed into the person one is today. For people who have had to defend against their experience, they often lack access to the right-brain information/memory/processing that would give their story a sense of “realness,” and emotional coherence. I am amazed by how often people come into my office and say they don’t remember their childhoods much at all. When a psychologist helps you construct a more complete understanding of your life, it requires participation from so many parts of the brain that, again, integration is fostered.
A second indicator of growth is the ability to be in a state of mindfulness, as described above. To say a bit more, being mindful is similar to being a good parent to one’s self, to have our own attention and self-compassion. It is soothing knowing we are being paid attention to without judgment, for both children (who often calm down as soon as someone is there for them) and adults. In many ways mindfulness is about learning to have a positive, caring relationship with ourselves where we are willing to “show up” and notice what is going on for us with self-compassion.
For those of you who are interested in a more in-depth understanding of mindfulness and the brain (as well as attachment theory), I highly recommend Seigel’s book Mindsight. Obviously this is a skill that can be practiced in therapy, but mindfulness can also be practiced on one’s own. I often recommend that my clients have a daily mindfulness practice, even if just a few minutes before they go to bed. This process simply includes paying attention to whatever they notice inside without judging it. Doing a body-scan (taking one’s attention slowly through the body to see how each part feels) can be very helpful. (Some examples can be streamed here or here). Researchers have found that mindfulness practitioners have a thicker middle prefrontal cortex–an area that is key in “regulating the body, attuning to others, balancing emotions, being flexible in our responses, soothing fear, and creating empathy, insight, moral awareness, and intuition” (p. 9 in Seigel’s book Mindsight). In fact, engaging in 30 minutes of meditation practice for 8 weeks has been shown to change the brain.
Above I described mindfulness as learning to be a good parent to one’s self–in other words to pay attention to one’s experience without judgement. A good parent, however, does more than simply not judge their children. They care for them–offering love and kindness. I therefore try to help my clients learn self-compassion as self-compassion is an incredibly powerful tool for healing. Self-compassion is correlated with about every imaginable positive health outcome. Self-compassion in fact has all the benefits of having a positive self-image, and yet is even more powerful because it is not based on judgement. Unlike self-esteem, which has the tendency to abandon us just when we need a boost (in other words, during times of failure), self-compassion is a more consistent source of support. There are a number of ways people can learn self-compassion through therapy. The first is simply by templating an attitude of kindness from the therapist’s caring presence. The second is the learn about how the mind (and brain) works, thereby developing self-compassion through the discovery that our struggles are not intentional, but can be understood in scientific terms. The third way that therapy can help clients develop self-compassion is through offering a chance to contact one’s deeper self. When we view ourselves more clearly, it is difficult not to have self-compassion. We are all doing our best, after all.
Role of the Therapist
Because of the reasons noted above, counseling with me (and other emotionally-focused therapists or psychologists), is less content-driven (discussing events or receiving advice), and more about tracking one’s moment-to-moment experience in the room with me. I italicized “with me” because often having someone actively attune to and track our states and feelings is a new experience, and one that is critical to healing. This kind of interaction can link the experience of emotion with the experience of safety and connection (so that they become associated in the brain). It also templates a way of relating to one’s self and one’s feelings that is marked by curiosity and compassion–similar to the idea of security in attachment theory. When others treat us with caring (or, using the language of attachment theory, with attunement), it helps us relate to ourselves in positive ways as well. (The reverse, as we too painfully know, can also be true…).
I recommend group therapy as an adjunct to individual work for nearly all of my clients (or sometimes as an alternative to individual work for people who are looking for a lower cost form of treatment). Given all the information presented above–particularly on attachment theory–the reasons group therapy is so effective may already be clear. As attachment theory teaches us, human relationships are such an impactful part of our lives–affecting the very functioning of our brains! Group therapy feeds our right-brains, giving us a place to practice skills such as resonating with others, relating in deeper ways, and, to use an attachment word, co-regulating (when two minds come together to make an emotional experience more manageable and less lonely). Group is also a place to understand our reactions to others and our relational patterns (defenses, roles we take on, imbalances in giving or receiving etc.). Spending 90 minutes every week with a group of people who are all interested in expressing their real feelings and exploring whatever reactions they notice in the moment is enriching and transformative–almost a type of mindfulness, but in this case practiced in a group where it is enriched by people’s responsiveness.
For individuals who are part of a committed relationship, couples counseling cannot only help heal the relationship, but the individuals in the relationship as well (again, think attachment theory). If you are planning to begin counseling, I would consider starting with couples therapy even over individual therapy (assuming one’s partner would be willing to be engaged in the process with you). I advise this because people are only with their therapists typically for one hour a week, whereas they are with their partners for many hours a day. I therefore see no reason for couples not to engage in their therapeutic journey together (if they can). In this case, the therapist can coach each partner in learning to provide their partner with positive, safe experiences of connection in states of distress, which has the potential to be even more healing than when the psychologist provides that caring because our partners are often the people we feel safest with and closest to (and when this is not the case, that is a good reason in itself to start couples counseling!). It is wonderful when couples can tackle problems together, rather than simply sending one member to deal with his or her “own issues” alone. Choosing a couples therapist grounded in attachment theory can be helpful. According to attachment theory, even individuals with insecure attachment histories can develop “earned security” together as a couple.
- Shortened version of article Tori wrote on therapy with young adults for a local professional group therapy journal
- Tatkin’s Description of the Wecome Home Exercise–I mentioned that I am in a study group with Dr. Stan Tatkin, who has a practice in L.A. Below is a YouTube video he made describing the “Welcome Home Exercise” which I often use in my practice. (As an aside, Dr. Tatkin is willing to spend an entire weekend working with an out-of-town couple. For couples looking for more immediate change, I recommend considering flying out to see him).