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The Basics of Therapy

What Psychological Therapy Is, What It Aims to Achieve, and How It All Works in the Brain

By Gulce SakalliogluPublished 5 years ago 23 min read
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At one point or another, we are all likely to face difficulties in our lives that are seemingly too complicated to overcome by ourselves. This might be an isolated incident that we encounter, such as losing a job, which perhaps triggered a set of overwhelming emotions like self-doubt and shame that engulfs us. Or it might be a general sense of sadness and loss of motivation that seems to linger, no matter what we do, which makes it difficult to get out of bed each morning. When such a situation arises, seeking help from a therapist could be a great option; to not only solve present problems, but to also foster a deeper understanding of ourselves and our minds, which will enable us to be more competent in dealing with similar problems in the future.

However, when there is no shortage of myths and misconceptions surrounding psychotherapy, many people elude the option all together. Whether it’s due to fear of the unknown, thinking that therapy is useless, or that going to therapy is a sign of weakness, not seeking help can easily become a self-destructive cycle, causing us to feel stuck and helpless, while simultaneously perpetuating our difficulties. Even when one decides to try out psychotherapy, the decision to seek help from a therapist is daunting by itself for many. With the endless options for different types of therapies and countless therapists to choose from, the decision of settling to one becomes even more overwhelming.

In order to tackle these issues, my aim here is to first explain what therapy actually is, and what it aims to achieve. Next, I will explain how therapy works from a scientific standpoint, outlining the actual mechanisms of change elicited by therapy on the level of brain connectivity, and behavior, in hopes of clarifying some doubts you might have about what makes therapy effective. Finally, I am going to talk about from whom you can seek therapy, and some factors to bear in mind when choosing a therapist. These will hopefully help clear the air about some common misconceptions, giving you an idea of what to expect from psychotherapy, and will help you get started in the process from an informed stance.

What is psychotherapy, and what does it aim to achieve?

First things first, what is psychotherapy? We have all seen the image of a therapist in movies or TV shows, overlooking their client who is lying on a couch, incessantly asking what their childhood was like. In reality, this hardly encompasses the true extent of what therapy is–though the couch situation might actually come up, but that is for another article.

Psychotherapy, therapy, or talking therapies all refer to a broad range of methods used to tackle the emotional, behavioral and cognitive difficulties that people face in their day-to-day lives. These might include dealing with feelings of depression, sadness, stress, anxiety, or grief, tackling social difficulties, coping with chronic illness, addictions, and countless other problems that trouble a person and interfere with their daily functioning and quality of life. Though therapy might be a necessary part of recovery for serious illnesses such as post-traumatic stress disorder, you certainly don't have to have a problem that lies out of ordinary human experience, or be "mentally ill" to benefit from therapy; in fact, most of what therapy addresses are the rather typical human experiences and difficulties, which most of us are never fully isolated from.

In working through these challenges, the essence of therapy is the relationship between the client and the therapist, which is referred to as the “therapeutic alliance.” The pair collaborate to solve current difficulties in the client’s life, by enabling them to understand their inner emotional world, while promoting coping skills that act as tools to help them work through other, or similar, problems they might encounter in the future. The aim here is not to have you dependent on a therapist forever, but to endow you with skills that can help you stand strong in the face of turmoil. The specific goals of therapy will be dictated by what you want them to be; you might want to address a particular issue that has been bothering you recently, or to go on a journey of self-discovery with no pre-set rules; either way, this will be up to you, and what you want to gain out of therapy.

This all sounds swell, but how is it actually achieved in the setting of therapy? The main pillar of therapeutic techniques is simple; talking. The idea is to create a safe space for the client to express their thoughts, worries and emotions, and work through them with an empathetic, and competent professional. The content of what you will be talking about largely depends on the type of therapy; each take a primary focus on different aspects of the client’s life. So whether you delve into distant childhood memories, or simply talk about your present life events, this will be determined by the modality adopted by your therapist. Regardless of these differences, as a common ground, you should expect a good level of self-disclosure and honesty, which might be intimidating for most. Revealing aspects of our self puts us in a vulnerable situation, so it might not always come easy. But recognizing that it is a necessary part of change, and knowing that your therapist will not judge you in the same way a random stranger might, rather that they are there to understand, and to help with whatever it is that you bring to therapy, could give a sense of much needed comfort.

To ease your mind even more about sharing the deepest parts of yourself with someone else, it is useful to bear in mind the rule of confidentiality that every single licensed therapist has to abide by; what you share in the setting of therapy is between you and your therapist. So, you are truly in a place where you can be present as you are, without having to filter thoughts or emotions. Which is, when you think about it, a rather freeing concept considering how much we have to adjust and amend ourselves to the expectations of society in our daily lives.

Yet, there are a few exceptions to this rule that might arise in extreme situations, which I feel obligated to mention regardless. If you are in great danger of committing suicide or harming someone else, or if your safety is severely threatened by another person, your therapist might inform other professionals to ensure everyone’s wellbeing. This is very, very rare in the day-to-day setting of the therapy, and the therapist will have to proceed with absolute caution in pursuing such a route, as, if deemed unnecessary or unethical, this will result in the therapist losing their license, and possibly not being able to ever work as a therapist again. Even when the therapist decides they need to notify someone of such a situation, they will not be able to share any details of what you told them in the setting of the therapy that doesn't concern the imminent danger, so it is safe to assume that, as a rule of thumb, what you say in therapy is confidential.

How does therapy work?

So, how is talking through your problems supposed to actually help solve them? After all, if you are miserable at your job, or stuck in a toxic relationship, therapy can't go out and effectively change those things by itself. The answer here is that it doesn't change your life by changing your circumstances, it does so by changing the way you relate to them.

As humans, we are creatures of habit. Our brains function in ways that aim to conserve our mental energy as much as possible. So, most of our brain functions; our thought patterns, feelings, reactions are automatic processes, similar to reflexes. They are based on our previous life experiences, and on our disposition as a person. Instead of thinking "what do I do now?" in every novel situation, your brain tends to implement strategies that it previously acquired in similar situations, saving you some time and cognitive effort. This is not only a conceptual phenomenon, but a biological one. There is a famous saying in neuroscience that goes "neurons that fire together, wire together," and here's how it works.

https://www.altamirarecovery.com/clinical-care/neuroplasticity-recovering-brain/

Neurons are the cells in our brain and nervous system, which are responsible for carrying information throughout the human body. They allow information we receive from the outside world (such as vision, touch, smell) to be relayed to the brain; and they allow communication between different brain parts, organizing their functioning. This is achieved through the electrical and chemical signals, which are transmitted among neural networks. When the same neuron pathways are activated over and over again, it becomes easier and more likely for them to keep repeating this pattern. This mechanism underlies learning, and it is where the saying comes from; neurons that repeatedly communicate and transmit signals between each other solidify their connection–or they wire together. In contrast, the connections that are not maintained fade away, just as muscles in your body deteriorate if you don't use them.

A simple analogy in understanding how this works is to picture a forest with many hiking trails. The most commonly followed trail will consequently be the most evident, as many venturers stomped on the dirt and grass on the way, making it more visible; and the next hiker will also be more likely to follow that trail, because it is more convenient. On the other hand, the paths that aren't taken are slowly covered by fallen leaves and debris, and for someone to choose to take those routes would require a step outside the norm, and an effective decision to do so. This applies to how we acquire and internalize habits of thought, behavior, and emotions–what we have repeated before, we are likely to repeat again.

This mechanism is essential for our brains to function efficiently, and to master different skills, but what if the patterns we internalized have become dysfunctional and harmful to our wellbeing? We then need to change these patterns and re-learn some of our habits, a process enabled by what is called neuroplasticity.

Neuroplasticity refers to the capacity of the brain to form and strengthen new connections between neurons upon learning. It also encompasses how some abilities that are lost due to traumatic brain injury can be recovered, or compensated for. Neuroplasticity is the primary mechanism of action for therapy. Therapy encourages new ways of relating to our experiences by changing the meaning they signify to us. We make attributions to events and create narratives of our lives, and the following experiences that seem to fit into that narrative are dealt with using previously acquired strategies, both emotionally and behaviorally. It takes effective action to change those narratives, and this is where neuroplasticity fits into the workings of therapy.

Let's consider an example of how therapy might allow the reattribution of meaning to an experience, and how the brain utilizes this to come up with new strategies, and learn them over time, creating new "default" settings. For instance, if you repeatedly felt that your boss is critical and unappreciative of your work, the narrative your brain will come up with is something along the lines of "my boss thinks that I can't do my job right," or, "my boss is an awful person who is out to get me." These generalized negative statements will likely be upsetting, and make you feel incompetent in your work, taking a toll on your self-confidence. You will probably also resent your boss, because they will now be the person responsible for eliciting those unwanted feelings over and over again. It would come as no surprise if you start feeling less motivated about your job as a consequence, and over time, might even become miserable in your workplace. As these patterns are perpetuated, the next time your boss criticizes you, the same train of thought and accompanying emotions will be triggered, becoming more solidified with each repetition. Your brain will also take similar experiences as evidence for the schemas you formed regarding your boss and your work, and it will get to a point where you start expecting a negative reaction from your boss no matter the circumstances. When you expect a certain outcome from a situation, your brain is likely to fall into what is called confirmation bias. This is the tendency of the brain to pay more attention to evidence that supports your beliefs, and ignore the ones that do not match the existing schemas. Going back to the example of the critical boss, this would mean that you will have a tendency to ignore, or forget the times, where your boss might, in fact, praise you or compliment your work. So, it would take a lot of conscious effort to break out of this worldview, and this is where the reattribution of meaning comes into play. When your boss offers you criticism, what would happen if you consider this as an attempt to improve the quality of your work, or as a sign that your boss believes in you enough that they might be expecting more from you, and pushing you to get there? Now, it might take some convincing to actually believe this after holding onto many negative emotions about your past experiences, but just for the sake of a thought experiment, presume for a minute that you do believe that this is the situation. You still might be a bit frustrated that you have to redo some of your work, but it is much less likely that this new belief will result in the same loss of confidence, and feelings of resentment towards your boss. When the negative fog of emotions are lifted, this will enable you to see subsequent events under a more objective light. You might even notice those times when your boss approved of you, and begin striving to excel rather than sulk in your misery, and refuse to engage with your work. And when you repeat this new pattern over and over again, your brain will learn that there is an alternative way to respond to the same triggering events, and new connections between the parts of your brain that induce thoughts and emotions will start to form. The part of the process that therapy will support you in, is considering alternative attributions to events, and helping you to accept them as the reality, or at least a version of it. This might call for resolving the emotional tension you could be holding onto, especially around sensitive subjects that we might have suffered plenty from. And if you held certain beliefs for a very long time, you might find it very difficult to even come up with alternative explanations, because what you believe has been your reality for so long. But when there is an objective third party, who is willing to listen to you, evaluate situations, and possibly uncover why you might have such strong beliefs about a certain situation, it becomes easier to tackle, and to change them to a less dysfunctional, yet still realistic version. This, in a nutshell, is how therapy promotes neuroplasticity. It is not a passive process that simply will occur on its own; it will take work, and it might test your will at times, but if the usual habits of your brain haven't been serving you well, there is no reason not to challenge them, just to see what happens.

Brain Connectivity and Therapy

Unlike neurological conditions, which arise from a dysfunction of specific brain parts, psychological conditions arise from dysfunctions in the connections between brain parts. Consider depression and anxiety as an example; the most common psychological difficulties in the general population. These disorders alter the functioning of three main brain parts: the amygdala, the hippocampus and the prefrontal cortex. Let's take a look at how these brain parts function in relation to one another.

https://acmwb.com/2018/02/09/stop-your-brain-from-being-hijacked/

First, the amygdala, which is a primitive brain part responsible mainly for emotions, survival instincts, and memory. When you are faced with a threat, your amygdala sends danger signals to your brain that help you respond accordingly, for instance to fight or to flight. The amygdala works together with the hippocampus (which is responsible for long-term memory) in regulating the storage of emotionally significant events into our memory. Specifically, the amygdala tells the hippocampus how emotionally charged a memory is, which influences how the hippocampus stores this information. In turn, the hippocampus creates representations of the event–what the emotional trigger signifies to you–which later on affects how the amygdala will be triggered when faced with similar events. So if an event was deemed life threatening, the amygdala would be more likely to be activated when faced with a similar threat. In the midst of all of this, the prefrontal cortex serves a regulatory function. The prefrontal cortex is responsible for what are commonly referred to as "high-order" brain functions such as reasoning, language and planning; and it has an executive function, so it coordinates how different parts of the brain operate, like a conductor of an orchestra. Normally, the prefrontal cortex suppresses the function of the amygdala when the perceived threat has been evaded and the signals are no longer relevant. In turn, when the amygdala is fired up, it interferes with the functioning of the prefrontal cortex. Evolutionarily, when you're in a life threatening situation, the idea is to run first and think later, so your brain conserves its limited and valuable cognitive capacity by inhibiting the slow and complicated processes of the prefrontal cortex, which consumes a lot of this mental energy. Think of it this way; if you're a prehistoric human running away from a saber-toothed tiger, it doesn't serve you well to be thinking about whether you should go left or right, hide or climb, or frankly try to make any decision at all, which will most likely be slowing you down. Instead, your brain puts you in survival mode, which shuts off the decision-making functions, and directs all of its energy to keeping you alive; in this case, through making you feel immense fear, which makes you run like hell.

So, what happens to these brain parts and their connectivity in depression or anxiety? The amygdala becomes overworked; where it's supposed to give signals only when faced with actual threats or sad events, it becomes activated in a variety of situations; it overreacts, so to speak. For instance in anxiety, you might be worried about whether you will be able to finish an assignment on time in reality, but your brain starts interpreting this as you being in a life or death situation. This interferes with the hippocampus, which might fail to store information to your long-term memory, and become more inclined to store negative events as it often receives signals to do so from the amygdala. And since the amygdala interferes with the functioning of the prefrontal cortex, it can't do its job in regulating these processes as well as it should, which perpetuates this vicious cycle as the amygdala is left unchecked. So you become more likely to have adverse emotional reactions, and less likely to rely on your "check-mechanism." This even leads to structural changes in the brain; people with depression and anxiety have an enlarged amygdala and decreased volumes of the prefrontal cortex and hippocampus, which fits rather appropriately into the analogy of the muscles in the body–as they are used less they literally shrink.

How does therapy address this situation, then? Therapy deals with this faulty mechanism by promoting the functioning of the prefrontal cortex. By encouraging you to reason, to monitor, and to take control of your emotional experiences, the executive part of your brain is activated, which inhibits the strong emotional responses delivered by the amygdala. So the next time you encounter a stressful deadline, even if your gut reaction is to panic, the tactics you learned in therapy might help you change your relationship to your emotion, reason your emotional experience and reassure yourself, allowing you to be in control. This falls in line with the previously discussed reattribution of meaning, which basically makes your prefrontal cortex take active charge. Consequently, this allows the hippocampus functions to return to normal as well, so you won't be remembering as many negative events that might be used as evidence that perpetuates your difficulties. For instance, in the case of depression, your tendency before therapy might be to interpret a minor setback in the workplace as "I'm a failure, I mess everything up"; but the representation of your error when changed to "I made a mistake, it's okay and I know what to improve next time" becomes a lot less threatening and will not be encoded under the over-generalized, negative self-representation memories in your brain. This also means that you will be less likely to be overly critical of yourself the next time you make a mistake, because the hippocampus will not be "filing" this memory under emotionally-charged events that the amygdala should be wary of. These changes elicited by therapy are long-lasting, internalized, and have behavioral implications that keep promoting these adaptive mechanisms.

In contrast to the top-down mechanism of action in therapy where executive functions are promoted, which then naturally control emotional reactions; antidepressants, which are commonly prescribed alongside therapy approach this mechanism bottom-up. They inhibit the amygdala from over-working, which leaves room for the prefrontal cortex to gain its function back, and breaks the person out of this cycle. This is not to say that one approach is better than the other; in some cases antidepressants are a necessity for a person to feel just okay enough to begin working on the goals of therapy, but it is important to note that they are not identical in how they promote positive change.

Who can administer therapy?

If you do decide to try out therapy, the question then becomes from whom can you seek help? There are many different professionals who can administer therapy such as clinical psychologists, psychiatrists, counsellors, social workers, family therapists, and psychiatric nurses. Who you refer to will largely depend on what your needs are, and the setting of therapy that you choose to go to. For instance, you might refer to your school’s counsellor if you are a college student, or you might choose to get in touch with a social worker if your financial situation doesn’t allow funding therapy, or you might seek a family therapist if you are recently going through a divorce, and want to make sure that this event is processed by your children in an adaptive manner. The choice depends on your circumstances, but it is important to note that if you’re experiencing hallucinations or delusions (persistent, unusual beliefs such as being targeted by the CIA), your first course of action should be to seek the help of a psychiatrist, who will be able to help stabilize your condition with the necessary medical interventions.

There is often confusion about what the job description of psychiatrists and psychologists entail, and how they differ. Very basically, psychiatrists go through medical training, which enables them to give their clients prescription medication such as antidepressants. Psychologists do not have this authority, and when they see it necessary to put their clients on antidepressants or other psychotropic medication, this will always be done in collaboration with a psychiatrist. As for administering therapy, the differences cannot be outlined in terms of the professions as a whole, but rather on the personal qualifications of the therapists. Some psychiatrists do not administer therapy at all, and choose to stay involved only with the medical aspect of the clinical care pathway, and some go through similar certification programs as psychologists to get licensed in specific modalities of therapy. So when it comes to administering therapy, do not fall into the preconception that since psychiatrists are trained medical professionals they are for certain more competent in delivering psychological care; the ability to give therapy comes from training in a plethora of domains, and a typical psychologist might have more clinical experience with regards to therapy than a psychiatrist. Again, the key here is individual qualifications and work experience.

Regardless of who you choose to see as your therapist, the single most important factor is whether the person you seek help from is actually licensed to administer therapy. Many countries such as the USA and UK have very strict laws on the minimum requirements to become qualified; therapists need to obtain a doctorate degree in specific accredited courses and complete numerous other trainings specific to the modality of therapy they choose to administer. This, unfortunately, is not the case in many other countries where the rules and regulations are not clearly defined, and the consequences of promising to deliver therapy when you’re not authorized to do so are minimal, to say the least. Sadly, this often means that the responsibility falls on the client to ensure that what they are promised is indeed what is being delivered. There is no shame in asking about your therapist’s qualifications, in fact it is an absolute necessity, and your right to do so, in order to save yourself some valuable time and money that you will be dedicating to therapy. Your therapist will not be offended that you asked either, they will likely be impressed by your sense of responsibility, and will–hopefully–gladly explain their credentials to ease your mind of any questions you might have. Hence, it is useful to familiarize yourself with the specific laws and regulations in your country, so you know what the standards of the industry are, and to do your research on your therapist before you commit.

I would also like to briefly touch on how there sometimes might be more insidious instances of failure to hold up with these credibility standards in the industry. Stretches of the title of “therapist” or “clinical psychologist” are commonly adopted by lines of work such as life coaches, which is not only unethical, but also endangers the credibility of a profession they simply are not truly a part of. This is not to say that their work is not of value, in fact, aspects of what a life coach would help you with are engrained in parts of psychotherapy as well, but it is not nearly the entirety of what therapy is supposed to be. Regardless, if you find that seeing a life coach helps you, you are more than entitled to do so. Simply ensure that they are merely promising to be a life coach, and offer you guidance in some aspects of your life, not to deliver a specific therapy, which, in reality, takes years of training and supervised clinical work to actually be accredited to do so.

Conclusions

The note that I would like to end on here is that there really is no shame in asking for help. Just as you would work on your physical wellbeing, it is essential to ensure that our mind is taken care of as well, and sometimes it may not a one-person job, and that's okay. You don't have to suffer in solitude; with the help of a competent professional, you can not only overcome difficulties, but also experience great self-understanding and compassion. Actively working on our problems is daunting to say the least, but it is surely a journey worth taking. Everyone deserves a chance to improve their quality of life, and with the availability of as powerful a tool as therapy, why not utilize it?

Sources

APA. (n.d.). Understanding psychotherapy and how it works. Retrieved.

Gonçalves, Ó F., & Perrone-Mcgovern, K. M. (2014). A neuroscience agenda for counseling psychology research. Journal of Counseling Psychology, 61(4), 507-512. doi:10.1037/cou0000026

Linden, D. E. (2006). How psychotherapy changes the brain – the contribution of functional neuroimaging. Molecular Psychiatry, 11(6), 528-538. doi:10.1038/sj.mp.4001816

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About the Creator

Gulce Sakallioglu

Master's student in mental health and newbie yoga teacher, writing about all things 'well-being'.

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