How Basic Science Supports the Art of Psychotherapy

Science might seem to stand in contrast to the art of psychotherapy. To the contrary, a modern understanding of the science of psychotherapy helps us know better how to bring art into practice, whether in the context of a med check or in full-on psychotherapy. Here is how.

Problems of Mind

Psychotherapy helps patients trade “coping gone awry” for a better response to the same inputs. Those “entrenched maladaptive patterns” (EMPs) are products of the mind. What’s that? “The information processing function of the brain.” The human mind, like the minds of our mammalian ancestors, evolved to process all available data to predict opportunities and threats and generate species-preserving responses. Not all responses are optimal. Most of the information processing is automatic and goes on outside of consciousness. Responses are first seen as bodily changes like tears or adrenaline. Those are followed by spontaneous thoughts, impulses, and feelings, which can be maladaptive in themselves or can influence unhealthy choices. Recurrent maladaptive patterns of response are what psychotherapy seeks to rewrite.

What the Mind Dreads: ‘Limbic Emotion’

EMPs are put into action when triggered by activity in limbic locations such as the amygdala. Those are the mind’s signals that a response is required. They are also what the mind “dreads” and tries to attenuate. I call the triggering activation “limbic emotion” because affects, the bodily changes that are its immediate products, are the clinician’s best indirect indicators. Limbic emotion is a real phenomenon, measurable in the laboratory, and of central importance to therapists because it is the universal trigger for those patterns that cause so much human suffering and that psychotherapy is designed to treat.

The Implicit Logic Behind Limbic Emotion

Why discuss logic? The mind uses it to draw conclusions from data. This is different from conscious logic, so let’s look at how it works. Long before we learn about nouns and verbs, the mind figures out the rules of grammar and how to apply them. Not surprisingly, the mind does the same with dangers. Not only does it have expectations and rules to determine what might be a threat, but it simultaneously evaluates possible responses. When the mind appraises that we have enough strength to stop a threat from setting off limbic emotion, it stays calm. Implicit learning of what is dangerous and our assessment of the ability to cope are applied using associative logic, based on the strength of synaptic interconnections.

The ‘Data’ Processed in the Limbic System

Just as computers encode all kinds of information, sounds, numbers, words, and so on, as 1s and 0s, the mind uses neural networks, groups of neurons that tend to fire together, to store all kinds of information relevant to species survival. That means not just words, but tone of voice, atmosphere, context, ideas, faces, bodily movements, even the comparative logic that informs decisions. In short, the mind encodes an infinite variety of “data types” into neural networks, with each unit bearing associations to others.

How Can We Update Implicit Learning?

The only mechanism known to science that is capable of changing implicit learning permanently is memory reconsolidation. That mechanism has two requirements. First, the old implicit learning must be in an active state and, second, new, disconfirming information must generate a “prediction error,” putting the implicit learning into a volatile state, ready to be rewritten.

Here’s Where the Art Comes in

An important part of doing therapy is supplying the disconfirming information, expressed in terms that resonate in the deep recesses of the limbic system. Pharmaceutical advertisers know better than therapists the art of communicating with the limbic system. They use smiles, color, music, and a lilting voice to tell you a drug is safe and desirable but dry, abstract words to inform you of its dangers. They know which words will and won’t penetrate to the limbic system, importantly, the locus of much of our motivation and decision-making.

We can do better than that because we’re not selling anything. It starts by listening to the many languages of our patients. Our job is to help them let us into their unique personal world, where we can listen to what stirs their affect. It’s when we allow our own intuition and empathy to guide us in asking the right questions and truly listening that the full breadth of relevant information finds its way from the patient’s limbic system to our own. Rogers called it “accurate empathy.” Only then do our silences, tone of voice, words, gestures, images, body language, and much more make the passage into the patient’s limbic system in a way that surprises and creates prediction error. Those are “moments of meeting,” and that is the art of psychotherapy—what ultimately makes it possible to rewrite the old implicit learning into something much better. ■

Jeffery Smith, M.D., is a clinical professor of psychiatry at the New York Medical College, leader of APA’s Psychotherapy Caucus, and author of the website Howtherapyworks.com.