Therapy is a treatment intended to heal a disorder. That’s the medical perspective anyway, and it’s not wrong, but it’s maybe only part of the picture. Therapy frequently begins by addressing a primary complaint or problem in a collaborative relationship that grows over time. And during that time, while the client is assessing trustworthiness, the clinician continues to work towards an effective therapeutic alliance. How this exactly occurs depends a little bit on the lens through which one looks but a common factors approach observes that the relationship is the most important ingredient in therapy. Although all of this is true, it didn’t really make sense when I was initially curious about what really makes therapy work. First of all, what is the “work” of therapy? Isn’t it just two people talking, and eventually, someone’s depression or anxiety or anger gets better? And what does the collaborative process really mean? One’s talking, one’s listening, one takes notes, the other goes home to survive another week. What gives, what’s this really all about.
I think it’s hard to describe therapy because it is a different process for everyone. No one’s depression, anxiety, dissolving relationship, or sh*tty boss is the same. No one’s defining experiences are alike. Our expectations of life and of the people around us all differ and contribute to where and who we are. And all of that shows up in therapeutic work. We bring what’s on our mind to the therapy hour and talk about it, a therapist makes interventions, some subtle some obvious, and two things happen. We go home, and our minds continue to work on the issues, and our expectations begin to change over time. To really understand this, it’s helpful to understand how language develops in infancy.
Infants are born making similar sounds all across the globe. It is in interaction with another adult human being that a particular language’s unique facets develop out of those universal sounds. Some sounds are attended to, others ignored, and the baby is exposed to all of the sounds of language that eventually become part of the native tongue. The infant brain is wired to soak up and sort out language. Similarly, the infant brain soaks up expectations of important people based on experiences with an early primary caregiver; mom, dad, grandparent, or whoever fulfills that role. Infants who are denied regular, meaningful human interaction do not develop as has been formally observed and documented in multiple studies. At the most extreme end of the spectrum, these babies fail to thrive, and they die. Babies who do have adults to interact with grow up to reflect expectations learned in those earlier interactions. Because there is no explicit memory for this early foundational experience, much of our behavior is driven by assumptions for which we have no awareness. This is contemporarily described, in part, by attachment styles.
Inferences about early relationships can be made based on how we interact with others, especially those of importance like spouses or intimate partners. For example, when a conflict arises between you and someone you love, are you more likely to tackle it head-on, pretend it doesn’t exist, ignore it, hope it will go away, get very depressed or anxious, get angry, or insist on one outcome? Our typical response tells us a little bit about how we expect things to work out, and we often behave accordingly. Neuroplasticity plays a huge role in the observation that our underlying expectations, even those we are only vaguely aware of at best, can change. This is where the collaborative relationship comes in, as well as some of the work of therapy. As we are pitting our unexplored, implicit expectations against what we expect to be a wall of some sort, a consistent unexpected response begins to alter the tracks of our mind. Neurobiology has come a long way in explaining so many of the observations initially made by Freud a hundred years ago, and built upon by so many theoreticians since. Maybe we should talk more about this.
Maire Daugharty is an anesthesiologist.
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