You’re looking for a therapist. You do some google searches, you check out yelp. You find a therapist who is collaborative and has a warm and nonjudgmental approach. You’re intrigued. You keep scrolling. Just below the inspirational Carl Jung quote and right before the lotus graphic, you hit the section where the therapist tells you about their ‘orientation’ as a clinician. First of all, what does ‘orientation’ even mean? Maybe it will make sense if you keep reading? Nope. Plus, what’s with all the acronyms? CBT? DBT? EFT?…WTF?
While this list is in no way exhaustive, here is a brief explanation of some of the most commonly used therapy terms. If you have a term that you’re curious about that isn’t covered, leave me a comment and I’ll do my best to add it.
As human beings, we are born helpless and completely at the mercy of our caretakers. We have strong, neurological wiring that motivates us to attach to our biological parents, regardless of how good they are at parenting. In fact, the biological urge to win the love of a birth parent is so strong that we choose a dismissive or abusive birth parent over a kind, attentive surrogate caretaker. Especially in childhood, but throughout our lives, the way our caretakers treat us shapes how we see ourselves, which plays an integral role in how we make our way in the world. We also lean on our early attachment figures to show us how to make sense of the behavior of others, and how we should respond when people behave a certain way toward us. Thus, our early attachment figures have a strong impact on how we see ourselves, how we see the world; and thus, the thoughts, feelings and actions that comprise our identity.
Because our primary relationships and early experiences are incredibly influential over who we become, a lot of work for adult clients entails identifying, examining, challenging and rewiring some of thoughts, feelings and behaviors that spring from the formative relationships we have with our caregivers. While each human is complex and we don’t all fit into one box; extensive observation and study has yielded four attachment styles that are commonly referred to in psychology:
Secure attachment. My early caretakers safely and consistently met my needs. As an adult, I enter into relationships expecting people to meet my needs and treat me well, but I will walk away from a relationship where I am not treated as I deserve to be treated.
Anxious-avoidant attachment. My early caretakers frequently denied or invalidated my needs. In response, I learned to hide them at an early age. As an adult, I am often unaware of how much I need to connect with others. When I do get close, I become anxious and feel that I’m better off alone, or that I should hide deep or unfavorable emotions from my partner in order to avoid rejection, which makes even my close relationships distant in certain ways.
Anxious-resistant attachment. My caretakers were inconsistent in meeting my needs, which has made very reactive when I perceive that I will be abandoned or let down. As an adult, I am clingy and needy. I become upset or angry when I sense that I might be abandoned or when I feel that someone has neglected me for too long.
Disorganized attachment. My caretakers were sometimes threatening to my safety when I tried to get my needs met. As an adult, I am both drawn to and scared of close relationships; thus, I may behave in erratic and disorganized ways when I become close to other people.
The impact of attachment lasts far beyond childhood, as it provides a template for how we conduct adult relationships. When we suffer from some degree of insecure attachment or begin a relationship with someone who is insecurely attached, we may experience strong and unpleasant reactions when our partners unwittingly do or say something that we associate with a negative or painful aspect of a primary attachment relationship. For example, an avoidant adult may have been dismissed when they showed too much emotion, leading them to withdraw from their partner when they become overwhelmed or triggered. If that partner is resistant in their attachment, they may become clingy and aggressive when the sense their partner withdrawing, leaving the avoidant partner feeling cornered. Ironically, their goals are the same: to prevent rejection or abandonment. Unfortunately, the way they’ve learned to get this mutual need met is completely contradictory and explosive, causing conflict in the relationship.
Because our drive to bond with and be shaped by our caretakers is embedded in our biology, the validity of attachment theory is becoming increasingly neurobiological, not just observational. In fact, advancements in neuroscience have shown us that our primary attachment wiring (e.g. conclusions we made about ourselves in our primary attachment relationships) is activated when we pair bond with romantic partners. This is known as adult attachment, which (unsurprisingly) plays a key role in couples therapy. Consequently, while it may seem a bit psychodynamic (don’t worry, I’ll get to that term eventually) to explore your childhood in therapy, “what gets in early, gets in deep.” Thus, attachment is an important piece of the puzzle when figuring out how to build a future that isn’t driven by your past.
CBT (Cognitive Behavioral Therapy):
Before Beck’s method of CBT took the therapy world by storm, analyzing what happened to you (V1.0 = Psychoanalysis, V2.0 = Psychodynamic) was the predominant modality of the day. Don’t get me wrong, understanding how we come to suffer is important; however, if “knowing is half the battle,” the other half is doing what it takes to change the thoughts, feelings and behaviors that are causing distress. Luckily, the relatively healthy brain can be re-wired if we change the thought patterns, emotions and behaviors that construct our daily lives. Thus, CBT focuses on helping the client to:
Identify and dispute unrealistic or counterproductive thoughts;
Question and challenge the unpleasant emotions associated with these thoughts; and,
Execute a behavioral plan that will weaken the negative, cognitive circuitry that has been identified, while simultaneously rewiring those same, thinking, feeling and doing systems to better serve our health and happiness.
CBT is awesome and I use it all the time; however, it can prove insufficient when trauma is involved or when your client is a kid or young adult and doesn’t have a fully formed neocortex. Here’s why. When we are not traumatized, we can easily keep all three parts of our triune brain (reptilian, mammalian and neocortex) online. When we have suffered trauma, our neocortex (rational brain) is often pushed offline when our older brains (reptilian in conjunction with mammalian) get triggered. What’s more, our neocortex isn’t fully developed until we’re 26; so, younger clients may not have the neocortical firepower necessary to execute a complex CBT plan.
Either way, there are many instances in which we are simply not able to identify and challenge a negative thought, much less update our behavioral response to it. In cases of trauma, we often need to identify, externalize and process the emotional landmine that causes our triune brain to scramble, before we can enjoy the rewiring benefits that CBT can provide. For children and adolescents, we need to focus on distress tolerance and emotional regulation before pushing for drastic, behavioral change.
DBT is perhaps the most comprehensive modality available. Developed by the amazing Marsha Linehan, PhD, ABPP to treat some of the most challenging mental illnesses (like Borderline Personality Disorder); DBT is so effective at fomenting lasting, positive change because it accesses and helps the client to re-wire all three layers of the triune brains. The result is integration; meaning, what the way a client thinks aligns with how they feel and is supported by what they do.
If practiced as it was intended to be practiced, DBT is very comprehensive, extolling both individual psychotherapy and group skills training. Since we become who we are in relationships, we also change through positive relationships. Thus, the individual and social focus of DBT is especially effective and comprehensive. The core skills that clients learn via DBT therapy are:
Thus, DBT helps you to:
Understand what is going on inside your body and mind;
Develop the skills necessary to become less reactive to the negative thoughts, feelings and behaviors that are causing you to suffer; and,
Tolerate the distress that has caused you to engage in negative coping behaviors to lessen the pain (e.g. using a drug, cutting, withdrawing socially, etc).
Once these skills are in place, DBT therapists encourage you to apply them in relationships with others, which is both healing and preventative of future distress.
One of my favorite conceptualizations within DBT it the assertion that it can be simultaneously true that we are doing the best that we can with the tools we currently have, but that we can also do better in the future. Biologically, this is absolutely true. Who we currently are is the result of our biology, our experiences and our environment; however, if we come to understand how these factors have shaped us thus far and how we want to change; if we can handle the corresponding distress, we can absolutely change the way we engage with ourselves, with others and with our environment. These changes will, in turn, change our brains.
EBP (Evidence Based Therapy):
You down with EBP; Yeah you know me!
If you see that a therapy modality is “evidence-based,” it means that multiple studies have shown that; when effectively applied, the given therapy has driven a positive outcome (e.g. changes in mood, a reduction in the abuse of a substance, etc). Until recently, the majority of the measurement of this efficacy relied on observed or reported changes in mood and behavior. Now that brain imaging is getting better, we can actually start to see how therapy is changing the brain.
EFT (Emotionally Focused Therapy):
Sue Johnson (who is an absolute boss in the couples therapy world) developed EFT based on years of clinical experimentation, observation and optimization. Add an extra “F” to make it Emotionally Focused Family Therapy and you can apply it to families, too. While we have seen how EFT has helped couples through observation for years; more recently, FMRI (Functional Magnetic Resonance Imaging) technology has shown that EFT can indeed help to rewire the interpersonal neurobiology that gets triggered when we form deep relationships. Pretty cool, huh? So, how does it work?
Well, as I’ve said before, we are wired to seek deep, trusting, interpersonal bonds with a close-knit group of family and friends. As social primates, our very survival depends on successfully integrating into our tribe. We lean on our parents (primary attachment figures) to learn how we must behave to get others to love us and care for us. Later in life, when we couple up, we tend to use what we’ve learned from those early relationships to relate to our partner. If the way we learned to relate to others is incompatible with the way our partners learned to connect in their family of origin, emotionally infused conflicts tend to arise. What’s more; if our primary attachment relationships involve trauma (like neglect, lack of attunement or abuse); the resulting fear and hurt may bubble up when we interact with our partner. Because our survival response (fight, fight and freeze) is literally wired in to our social engagement system, we often become reactive, angry, sad or disconnected when triggered by an adult partner, even if they are not the original source of the trauma or hurt.
Sue Johnson frames the interactional patterns that exist between a couple as “the dance.” If the current dance contains missteps that are driving the couple apart, EFT therapists aim to identify the unhealthy aspects of the current dance and frame them as the shared enemy of the couple’s ability to connect with each other. To change the steps of the dance to make them better, the couple must identify the unmet need to that is inspiring each misstep before working together to re-choreograph the dance to get that need met in a healthier way.
Psychodynamic therapists help clients to explore how their early-life experiences may have led to the consequent emotions and beliefs that govern their lives. Once the client understands how they have come to feel, think and behave in ways that are causing them distress, they are then empowered to change those patterns in a way that will help them reach their goals.
In my opinion; psychodynamic work is an important component of the work with each client, but it isn’t a complete solution in-and-of-itself. I say this because I know plenty of people who come to understand why they are distressed, but experience little-to-no relief from their symptoms. Here’s why. While knowing engages our neocortex, it does little to influence or limbic system and our reptilian brain. Changing requires a rewiring of the triune brain, which is precisely what the most effective therapeutic modalities can accomplish if the right practitioner is there to guide the client through the work.
Anyone who dismisses the fact that we can feel unsafe without being in a hurricane, a war zone or a pit of alligators simply doesn’t understand how the brain’s threat system works. You see, the majority of the default circuitry in our reptilian brain sounds an alert when another human enters our space. Why? Because the biggest threat to an alligator for the first 18-months of life is another alligator. Since many of us have to work together, early mammals developed a direct line from our threat system to our social engagement system. This extra circuitry keeps our threat system online for humans who are not in our tribe, for alligators, heights, and fires; however, it overrides our danger alert system when we are in the company of family members and members of our tribe.
Just a few thousand years ago (e.g. a hot minute in evolutionary terms) we used to sing with, dance alongside and share stories with “other” humans to bond us and make us feel safe in their presence. Not anymore. In today’s world, on a daily basis, we walk past, drive alongside, work with and work for people we’ve never met before or will see again. Thus, we are frequently feeling not-so-safe in the presence of others. If we’ve experienced trauma, our fight, flight and freeze response can be triggered far quicker than those who haven’t been traumatized, as our brain is great at machine learning and will adapt to monitor for threat in the future if it has been threatened in the past. Thus, creating safety means putting the brain in an environment where it does not become so triggered that it pushes the neocortex offline and simply executes the survival response it has learned until the threat passes. For many of us, that means retreating to a place where people look like us, sound like us and reflect our worldview.
Descartes really set us back with this concept of a mind-body divide. While we are one, complete system; in Western societies especially, we’ve done a lot to encourage people to disconnect from the sensations and wisdom of their body; and thus, from themselves. Somatic interventions focus on using physical tools like breath and touch to create safety, relieve stress, gain insight and feel better. This isn’t hippie B.S. In fact, the field is championed by a bunch of medics and biological anthropologists who have come to understand how our oldest brain (the reptilian brain) works with our mammalian brain (e.g. the social brain) and neocortex (e.g. the rational brain) to execute the sympathetic (upregulate) and parasympathetic (downregulate) systems that make us feel horrible or pretty darn good. As fancy primates, human beings can get these systems revved up based on social traumas or painful memories (whether implicit or explicit). As such, somatic work is very important when healing trauma, as the fight, flight and freeze systems go from 0-to-Overwhelm in trauma survivors very quickly. Thus, it is imperative to give people the somatic tools to help them feel safe as they process their trauma.
Somatic work is not just for the traumatized. There is so much we can do to reset, nurture and improve the integration of our many parts, both inside and outside of therapy. When you dig into Yoga, for example, you see a lot of empirically validated tools to improve wellbeing. Just opening up a yoga session with an “Ooommmmmmmmm” of the right frequency will reset the balance between the sympathetic and parasympathetic nervous system. Turns out, if we’ve been doing it for thousands of years, it probably helps. So, next time someone tells you that something is “psychosomatic,” give them a quizzical look and say: “Isn’t everything?”
Transference and countertransference hail back to Freud. While he got a lot wrong (like assuming that everyone wanted to replace their same-sex parent and marry their opposite-sex parent); Freud’s observation that there was a lot going on outside of our conscious mind was genius, as was the hypothesis that early experiences play a big role in shaping who we become.
Transference refers to a client transferring a feeling they have toward a significant person in their life (past or present) on to the therapist. Countertransference refers to the therapist’s reaction to the client’s behavior. We now know that there are two pathways from the limbic brain to the neocortex (e.g. the rational brain), when something is personal, and a completely different pathway when it isn’t. To provide an example: An economist may build a well researched and rational model to predict what investments will pay off in the next, 18-months, but refuse to act on their own research when it is time to put their money on the line.
People who have witnessed domestic violence, experienced physical, emotional, and/or sexual abuse, suffered neglect, experienced war or survived a disaster are often traumatized. Because we are wired to survive as members of a social group, our defensive brain (which contains the famous fight, flight or freeze response) has developed a direct pipeline to the interpersonal neurobiology that comprises our social engagement system. Consequently, how we are treated (and how those around us are treated) can trigger a 300 million-year-old system of survival that causes a zebra to run from a lion or a possum to play dead when faced by a predator.
Because we are wired to make it work with our caretakers and we are deeply motivated to protect our tribe, the emotions tied to the memories of trauma are often so strong that our newest, rational brain becomes overwhelmed when they are triggered, rendering it incapable of placing these memories in an explicit and cohesive narrative of our personal experience — hence trauma-related memories being so foggy and disorganized. Thanks to both observation and an increasingly detailed understanding of how the triune brain reacts to complex trauma (e.g. sustained childhood abuse) or single episode trauma (e.g. a car accident as an adult); we now understand that we must slowly titrate a client’s exposure to trauma memories in order to process them. The wonderful trauma healer Babette Rothschild concocted the perfect analogy for trauma processing: It is like opening a coke bottle that has been shaken up after a long car ride. You don’t just wrench the cap off, you slowly loosen it, release a bit of pressure; wait, loosen a little more; wait and then loosen a little more.
If you’ve come across a term that you’d like me to write about, or you are confused/intrigued by something I haven’t covered here, please leave me a comment and I’ll do my best to add it into this post.
© Galyn Burke, 2018