Therapy Needs Therapy

My husband shared this New York Times article with me this morning because it sounded like things I've said to him over the years…and I agree. I'm posting this in its entirety to honor and give credit to the author, but the last two sections are the ones I want to emphasize. For many years leaders in the field have said the relationship between therapist and client are the best predictors of successful outcomes. That is why I've always strived to create a welcoming and "homey" atmosphere in my office and approach each client or couple with warmth and acceptance. Only in a safe environment can we let our guard down so that real progress can be made. Thank you Daniel Duane for elegantly articulating this!

— Lynne Clifton, LICSW, PIP, Certified Gottman Therapist

1. The Therapy Crisis

I love being a therapist. I love being present for people over time, listening for mystery and pattern. I also know that psychotherapy done well can bring emotional freedom and even authenticity, that precious feeling of leading one's own life. But therapy needs a therapist of its own.

The profession has never been more self-assured. The old stigma has faded. Demand is high, thanks to nightmarish politics, digital isolation and TV shows like "Shrinking" and "Couples Therapy." But the work itself — the actual practice, in the room — faces relentless devaluation.

Companies like BetterHelp try to reinvent therapy as low-paid gig work: DoorDash for emotional support. A.I. start-ups raise many millions of dollars to create therapy-adjacent chatbots, as if whatever a human therapist does can be replicated by an algorithm utterly devoid of feeling, much less embodied experience.

It would be nice to blame opportunistic entrepreneurs, but we wouldn't be having this conversation if therapy itself were not a mess — or, rather, a Tower of Babel with hundreds of approaches based on contradictory theory and research, and no agreement on what even constitutes a good outcome.

To be fair, those hundreds of therapies mostly fall under one of three main tents — psychodynamic, existential humanist and cognitive behavioral (better known as C.B.T.) — plus a fourth that we might as well call influencer-driven because its unifying element is TikTok. But you would not believe the range of thinking underlying each.

Psychodynamic therapy, for starters, grows out of Freudian psychoanalysis, which remains the intellectual taproot of the entire enterprise. In Dr. Ogden's framing, therapy's power lies less in whatever knowledge it brings and more in the dreaming of one's un-dreamt dreams — ways of feeling more fully the half-digested experiences that lie walled-off somewhere inside ourselves.

At the opposite extreme, C.B.T., which gets by far the most research attention, grows out of early-20th-century studies of how positive and negative stimulus can modify behavior. And yet, the most influential innovation in the C.B.T. camp has been Acceptance and Commitment Therapy, based on the idea that trying to modify thoughts often backfires and that we should focus instead on whatever we value most.

2. The Problem With Therapy Research

Psychotherapy research is both helpful and not. Bruce Wampold, a co-author of "The Great Psychotherapy Debate," told me that the most durable finding is that talk therapy works — at least as well as antidepressants but often with longer-lasting benefit and fewer side effects. But research has also found that some therapists — "super shrinks," in the literature — were much better than others for reasons that did not correlate with whether they had a Ph.D. in psychology or a Masters in social work, their preferred theory of therapy, or even how long they'd practiced.

Still more confounding, studies repeatedly find that it barely matters for patient outcomes which of those hundreds of approaches a therapist claims to use. What matters vastly more is that a particular kind of relationship exist between therapist and client. This makes intuitive sense but may sound like saying that you shouldn't care if your doctor treats your sore knee with Adderall or rhinoplasty so long as you like her bedside manner.

Now for a big ray of sunshine. Therapy, at long last, may have a way out of its embarrassing identity crisis. It comes from a heady source: the neuroscience of predictive processing, which is perhaps best characterized as the study of how our brains construct reality. Throughout the psychotherapy community, there is audible excitement that predictive processing might give therapy its first unified field theory — a Rosetta stone for explaining what makes talk therapy work and how to know if you're getting the good stuff.

3. How Therapy Lost Its Way

The messy predicament of therapy dates back to the late 19th century, when the young Sigmund Freud became fascinated by physical ailments with seemingly psychological origins. Freud initially believed that bringing the unconscious to light would set us free. Over time, he noticed that even clients aware of their unconscious predilections kept manifesting the same lousy patterns in life.

Freud called this the repetition compulsion — or, alternately, the destiny neurosis. The entire subsequent history of psychotherapy can be viewed as one long effort to understand and disrupt this frustrating tendency. Why do we repeat harmful and hurtful emotional patterns even after we learn to recognize them? And how can we stop?

By the 1930s, therapists noticed that most approaches to therapy had similar effects. This came to be known as the Dodo Bird Verdict, borrowing from "Alice in Wonderland," in which the Dodo Bird says, after a foot race, "Everybody has won and all must have prizes!"

This "common factors" research produced a stable list of key elements: a therapist who displays genuine empathy while holding the client in unconditional positive regard; a client with a sincere desire to change and confidence in the therapist; and, between the two, a spirit of collaboration.

Still, the common factors might have gotten us moving in the same direction — if not for the collision with managed-care health insurance in the 1990s. This feedback loop led to the widespread misconception that only C.B.T. and its variants are supported by scientific evidence.

A study published in Lancet Psychiatry confirmed what almost anybody could have told you — that people don't seek therapy solely for relief from DSM-5 symptoms. They seek therapy for self-awareness and self-compassion, new perspective on their situation, adaptive new ways of thinking and better relationships.

4. How Neuroscience Can Help

Predictive processing is a vast field that draws on more than a century of philosophy, cognitive science and empirical research into neuroanatomy and electrophysiology.

The truth goes more like this: Our brains maintain an internal generative model of the world and use it, in every instant of life, to predict the imminent future as the future becomes the present. Importantly, though, we do not experience these predictions as predictions. We experience them as reality.

Consider the combat veteran who, after months of terrifying night operations, goes home to his family. Asleep one night in bed, the veteran is awakened by a soft noise. His brain, in choosing between memories of his beloved's footfalls and a midnight ambush, favors the latter. The veteran leaps out of bed, frightening not just his wife, but also his children. This happens again the next night and the next.

We can think of PTSD as an extreme version of a slippage that we all experience every day, especially in our social lives. For the rest of our lives, in every exchange with everyone who matters to us, our brains construct reality based on childhood experiences that we cannot even recall. The more threatened we feel, the more we perceive everything through the lens of our most frightened childhood selves.

5. A Unified Field Theory of Therapy

People seek therapy because something about their internal generative model keeps constructing reality in ways that cause trouble. Therapy, then, looks like a way of getting your predictive model to update. Predictive processing theory tells us that model updates depend upon two key factors: safety and precision.

Safety, in this context, means an environment of such emotional and physical security that a person can let her guard down, stop defaulting to old ways of seeing things and start recognizing her predictive errors. More than 50 years ago, Dr. Donald Winnicott called this a "holding environment" and described it as the sine qua non of effective therapy.

Predictive processing theory allows us to say that, so long as a given therapist and client have a genuine human relationship, emotional safety and a reliable method for generating — and resolving — flawed ways of modeling the world and self, they are probably on the right track. And if we can get it to work for the guy who keeps hearing an ambush when his wife stirs in the night, we can certainly be of use to people who want to understand themselves better, break free of whatever problematic beliefs hold them back, and enjoy lives that feel more authentically their own.