Pulling Back the Curtain: What Therapy Is, How it Works, and What to Expect
Author: Dr. Colleen Lang, with contributions by Dr. Monica Shah
Therapy: what is it, really? What exactly does it “treat,” when emotions themselves feel so intangible and cloudy, a morass of intense but nonspecific sensations that just keep changing anyway…..? How is it that “talking” is what does the treating? And what is it that “therapists” know or have training in that qualifies and authorizes them to actually make something of this emotion morass to then bring us…..what? What are we supposed to expect from therapy anyway?!
Therapy is confusing and for some, even scary, because of how different it is from any other form of treatment we seek, and because of how what we seek treatment of also feels different. We go to medical doctors and specialists with more defined expectations of what we want and why. We want to make sure our bloodwork is within normal limits or we want to update our vaccines. We want to explore other options for our migraines, determine the nature of our coughs, screen ourselves for various forms of cancer.
But why would we go to therapy? Perhaps because we know we are in emotional pain; but how do we know how much anger or worry or sadness is too much? How do we know when the problems caused by our pain, in our relationships, or to our work or well-being, are big enough problems? And even when we do know why we want to go, we might not know (precisely) what to expect. For one, the goal is not always clear. Are we supposed to feel less anxious or less quick to anger? More successful in our work or our relationships? Is therapy supposed to help us feel more satisfied with our lives, more motivated to live them? Also, how does this work? In therapy, we can’t be diagnosed with an MRI or a biopsy; and when we are diagnosed, there is no medicine nor surgical procedure to bring relief. It’s TALKING that brings both the diagnosis, and the relief from it. It can also be daunting to reconcile the unknown ‘length of treatment.’ We are told by medical doctors and specialists exactly when our viruses will no longer be contagious, and when the medications we are prescribed can be expected to bring relief. But therapy? Who knows how long. In some cases, it could be years.
Perhaps the most challenging of the myriad questions that make up the dark curtain mystifying therapy: what exactly is our expected role in it? To show up each week and talk, sure, but exactly what and how much should be shared? How much is enough for our pain to be understood, and how much is too much to share? Therapy involves entering into a unique relationship with our providers: we have to be vulnerable in a radically different way; we have to talk about private and possibly embarrassing or even shameful things. We don’t often share details of our sex lives or the dark thoughts we harbor about our coworkers with our eye doctors or podiatrists, nor do we have to express feelings to them about how we feel in our relationships with them. But in therapy, we are supposed to, and then we are supposed to just trust that we will not be judged or rejected, and that doing this will somehow help?!
Because therapy being a mystery gets in the way of therapy being therapeutic, I want to pull back that curtain to reveal what it really is, foremost because I believe strongly in it, and want a light shone on its full brilliance and force. More immediately, though: whether you are in therapy now and have been for a while, or if you have been in the past and are considering starting again, or if you are thinking about it for the very first time, your own understanding of what it is and how it works, what to expect and what is expected of you, are the first steps to making it work.
To begin, the science. Cognitive Behavioral Therapy (CBT) is an umbrella term for therapies or interventions that are based upon the same well-established theories of learning and human behavior;, theories that provide the rationale and roadmaps for why and how we do what we do. First, CBT assumes the emotion system as comprised of transacting parts: our thoughts, our physiology, our behaviors. Second, CBT is based upon an understanding of human behavior as learned, maintained, and strengthened through the conscious and unconscious processes of stimulus-conditioning and reinforcement. Our emotion system, like any intricate and evolutionarily sophisticated system keeping us alive – our digestive systems, cardiovascular systems, immune systems – are driven towards the goal of survival. We need to feel our emotions, and we need our emotions to inform our thinking, our physicality, and our behavioral impulses, just like we need to feel every other sensation our human bodies produce: hunger, fatigue, arousal, pain, nausea. Like these sensations, our emotions are functional; they give us directions. When we are afraid, we run from threat; when we are sad, we mourn loss; and when we are angry, we protect our resources. However, what are normally a vital part of what it takes for us to survive, emotions, like other bodily systems, can easily go awry. As a consequence of biological vulnerabilities and environmental events that feed complex internalized systems of learning, emotions can be over- and under-reactive or can mis-signal, and the directions they come with can be misguided, inaccurate, and at times, even dangerous. We can feel afraid when it’s more dangerous to run; we can feel sad when we have far more than what has been lost, and we can feel angry when it’s not justified to fight. What’s more, the errant signaling of emotions through physiological sensation, thought, and behavioral impulse can be conditioned and rewarded, even outside of our conscious awareness, so that without knowing it’s happening and/or without skills otherwise, we can find ourselves stuck in intricate and tightly wound patterns of feeling and behaving, relying on ways of coping that offer relief in the short-term, but while adding to our buckets of problems and reinforcing emotional pain in the long-term.
As CBT therapists, we use TALKING to you and the WAYS we talk to you to try and understand all errant, intense, or difficult emotional and behavioral experiences. We use what you describe to us, and how you describe it, and then apply our knowledge of these well-established theories and principles of human emotion, learning, behavior, and motivation to identify and map out the ways that you are stuck. We contextualize these conceptualizations in your unique neuropsychological, cultural, developmental, and sociodemographic processes. We present all of this to you, often diagramming the transacting cycles we understand you to be tied up in. And then we offer you (often through teaching, sometimes with subtle suggestion, and sometimes with a kick in the ass -, all depending on how you uniquely learn) solutions for getting out; - strategies and skills that re-work your thinking, emotional intensity, and behavioral output. And we do this as a ‘work in progress,’ learning more together over time, so as to further evolve and deepen our understanding of your experiences and enrich the strategies we can suggest. As such, CBT is active, didactic, collaborative, and goal-oriented. It involves sometimes detailed questioning and analysis, confrontation, modelling and role-play, and modification of contingencies in our clients’ worlds to promote more effective behavior. It also involves validation, compassion, and empathy.
Where our work becomes most rich and complicated is where we best understand you as the humans we are, fundamentally defined within relationships. Feelings of sadness, anxiety, anger, shame, even when with strong biologic components, most commonly have their correlates in real, anticipated, or perceived interactions with other humans. We use dialogue - engagement with one another in conversation, yes, but more than that, the heart of our connection with each other - so that as participant observers in our relationships with you, we point out entanglements as they arrive between us and then guide you in enacting new patterns of new skills, with the hope of new experiences of how relationships and communication can be.
In summary, to best describe the work, we collaborate through conversations with you, looking at how your life experiences, particularly the most painful ones, have created learning histories, or sets of expectations, interpretations and sensitivities, which then predict thoughts and behaviors that are reinforced in myriad obvious and less obvious ways, to in turn strengthen and maintain these learning histories. The work, then, feels like that of untying knots, sometimes several knots, with the goal of helping you to become finally free, at your full and unhindered length, more open to enjoying the life we also help you build.
Now, turning to what is expected of you. Unlike any other experience, your task then, as the client, may be as daunting (if not more?) than ours: It is to share, yes – to share what we ask about. And more broadly, it is to take the risks of trying what we teach or suggest, against the fear you may have of shifting away from ways of thinking and acting that you have always known, that make you feel safe, in some ways, and that even work for you in others (in the short-term anyway). It is to take these risks under the graver risk of trusting us, trusting not only that we will be compassionate and present with the privileged access you allow us to your hearts and minds, but that we will direct you for good, and that our intentions in doing so are for care.
Where we are also ‘works in progress’ with you, in evolving and educative relationships with you, we will not take these risks lightly. We understand the bravery it takes to show up to us, and we also understand the pain it takes you to show up to us. We owe it to you to justify this bravery and give you hope in your pain. We also owe you our presence, non judgment, regard, and honesty. We owe the authority of our knowledge and training, while we also owe you the constant pursuit of unbiased listening. And in all of this, we will strive to be open and upfront about how and why it works, what we need from you and what you need from us, so that you can be confident that these risks are well-informed, and that the equal measures of science and heart that drive us, are not a mystery, but are instead very clear, and worth trusting.