Does Psychotherapy Really Have a Common Infrastructure?

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Source: Photo by Susan Holt Simpson on Unsplash.

Most laypeople likely already know that all kinds of psychotherapy really do the same general thing. But many thoughtful professionals have concluded that true “theoretical integration” is a pipe dream that will never be realized. The closest conceptualization with wide acceptance is that of “common factors,” nonspecific conditions that correlate with therapeutic success, but which cannot be shown to cause success or explain it.

There is a reason for this professional pessimism. The only way to demonstrate that widely divergent therapies actually make use of the same infrastructure would be to show that they make use of common change mechanisms.

For the first 100 years that psychotherapy was practiced, neurophysiology had not advanced far enough to characterize fundamental mechanisms that might be responsible for causing change. Each therapeutic school or tradition developed its own metaphors to describe what was happening, formulated in terms unique to that particular tradition, which meant one school’s theories made no sense when seen through the lens of another’s.

For example, the phrase “resolution of transference” makes no sense to a therapist who is trying to “correct irrational cognitions,” and neither can be understood by one seeking to “change emotion with emotion.” Even more deeply it has been pointed out that each of these catchphrases has acquired additional subtleties of meaning within the community, further distancing any hope of real synthesis.

As Timothy Melchert (2016) and Marvin Goldfried (2019), among others, have pointed out, until we have a clear idea of exactly how therapy works, there is no way to translate from one incompatible set of ideas to another. The sad consequence is that our field remains stuck in the “preparadigmatic” phase of science, where schools compete with one another on grounds that seem more religious than scientific.

The Clarion Call of Neuroscience

Yes, it is true that for the first 100 years, it was not possible to make out even the outlines of how therapy works. However, our field is now over 120 years old, and in this century, neuroscience has finally begun to provide the building blocks from which we can describe and explore an infrastructure common to all therapies.

What Does Psychotherapy Treat?

This question might seem obvious. Every therapy declares that it treats problems represented in the DSM-V or ICD-10. However, if we are to have any hope of identifying the precise mechanisms involved in psychotherapy, we will have to narrow the scope of our inquiry. Most importantly, the standard diagnostic systems do not distinguish between problems of the mind and those of biology. This invites us into the murky territory of philosophers, trying to unravel the mind/body problem, but we can do better to approach it in a practical way.

The mind processes information about the outside world and the inner world, based on a combination of built-in patterns and patterns that have been learned during development. While psychotherapy can have profound and even lasting effects on the body and biology, our efforts as therapists are generally aimed at problems of information processing in which the mind produces a response that is less satisfactory than some other possible response. This is what led a few members of SEPI (the Society for the Exploration of Psychotherapy Integration) to develop a simple phrase to describe what we treat.

Psychotherapy helps people trade entrenched maladaptive patterns for more satisfactory ones. To unpack this, if the patterns that caused trouble were not entrenched, then professional services would not be required to help make changes. They are also maladaptive, meaning that they made sense as ways to cope with circumstances at some point in time, but are not optimally adaptive in the present context. Sometimes the context is far back in evolution, as in the case of panic attacks. In other cases, the context comes from some point in development when life circumstances, available skills, and resources were different from those of the present. Finally, the problems people bring to us are patterns that potentially might be repeated.

By identifying the targets of our efforts as entrenched maladaptive patterns (EMPs), we can focus more precisely on how information processing can be improved. Two areas of contemporary neuroscience make this possible.

Memory Science

The way the mind responds is strongly shaped by information held in the brain. Now we know how the brain encodes information, in the form of neural networks or pathways shaped by the presence and sensitivity of synapses. Clumps of nerve cells that tend to fire together define the many types of information held in the mind, including words, sensory impressions, feelings, a “look,” a golf swing, etc. Just as memory chips hold all the types of information stored in a computer, the brain uses the same technique to encode the many kinds of information that influence how inputs lead to responses.

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Encoding of information and its storage in memory is central to each of the three change processes described here. Learning can be experiential or cognitive and can consist of words, actions, emotions, or any other type of information. Neuroscience now tells us that the final common pathway for long-term memory storage is LTP, long term potentiation, meaning that synapses are adjusted so as to create neural networks. We can consider the learning of newer, healthier patterns as the first of three pathways by which psychotherapy can help people trade EMPs for improved patterns of response.

The Learned Fear Paradigm

The more recent crucial discovery of modern neuroscience is that there are just two known mechanisms by which existing maladaptive patterns can be modified. They are extinction, identified by Pavlov, but only recently elucidated in neurophysiologic detail, and memory reconsolidation, by which existing remembered information can be permanently modified. Both have been intensely studied in humans and other mammals in the experimental paradigm of learned fear, in which a “conditioned stimulus” is associated with a shock or other unpleasant experience. So far, these two mechanisms are the only ones capable of explaining how existing response patterns can be modified.

To summarize briefly, extinction happens when the sensory input that previously signaled the arrival of an unpleasant experience is now presented in the absence of anything unpleasant. After a number of repetitions, in the absence of the noxious component, the fear response fades or disappears. This turns out to be the result of inhibitory signals being sent from the cortex, such that the response is temporarily blocked. The original response tends eventually to return.

Memory reconsolidation happens when the original pattern is activated (also required for extinction), while the individual is exposed to new, unexpected and contradictory, information. Then, for a few hours, the retained memory becomes volatile and can be updated with the new information. This modification is permanent and does not require further effort or re-training in order to be maintained.

Remarkably, these two mechanisms are the only ones known to be able to change established patterns. Like LTP, they appear to be widely represented in the brain. For us, as students of the action of psychotherapy, it would be reasonable to consider adopting, as a working hypothesis, that these three mechanisms are generalizable to the full range of the action of psychotherapy. As if to encourage us in adopting that hypothesis, the conditions known to allow the three mechanisms to operate do, in fact, correspond to detailed observations of the elements required for effective psychotherapy. In abbreviated form those are:

1. Learning healthier response patterns.
2. Activating maladaptive patterns with associated emotions (as indicated clinically by affect, defined as conscious feeling accompanied by bodily changes).
3. Temporally associated exposure to unexpected information contradictory to the existing maladaptive pattern.

In addition, all therapies, explicitly or not, support four facilitative factors required for these change processes to proceed. They are:

1. Arousal regulation.
2. Support for patient motivation.
3. Safety and informed consent.
4. Maintenance of a positive therapeutic relationship.

Yes, the Common Infrastructure of Psychotherapy is “a Thing.”

These seven elements, taken together with the characterization of what psychotherapy aims to change, provide a framework robust enough to explain and support the full range of therapeutic techniques as well as providing a basis for research to determine which techniques work best under what conditions to accomplish the seven aims.

Furthermore, I agree with Melchert (2016) that learning this infrastructure at the beginning of psychotherapy is a needed transformation. Training based on a common infrastructure can help trainees to understand precisely how it is that diverse therapies accomplish the same seven aims. This naturally leads to seeing the collected wisdom of 120 years of psychotherapy experience as a treasure trove of techniques and ways of thinking, ready to be put to use in helping patients trade their entrenched dysfunctional patterns for more satisfactory ways of experiencing and responding to the events of life.

—Jeffery Smith, M.D.

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