(And should we all be considering it really?)
I’m going to have to be really transparent here. I have changed my stance on this and I only came to realise that I had changed my stance on it, about 6 months ago. Historically I have very much been of the opinion that for some people therapy is fundamental, for others potentially helpful and for others completely superfluous. So what changed?
Although my realisation that my position had changed, was a gradual one, the actual position changing probably coincided quite specifically with one thing. And that was my learning and starting to use more regularly Eye Movement Desensitisation and Reprocessing – often and more easily referred to as EMDR. EMDR was developed by a psychologist called Francine Shapiro in 1987 quite accidentally when she realised that she felt less negative emotions about difficult memories when her eyes were moving side to side. Shapiro tested this hypothesis out with other people, finding that eye movement had a desensitising effect, but alone were not sufficient for comprehensive therapeutic effects. Shapiro went on to add other therapeutic elements including cognitive components, developing EMD and then later EMDR. What EMDR involves, in a nutshell, is identifying an agreed, emotionally distressing target and attending to this target in brief sequences while simultaneously focussing on an external stimulus. This is often therapist directed eye movements from side to side (i.e. following the therapist’s fingers) but it can also involve tapping. It is hypothesised that this “bilateral stimulation” allows access to and desensitisation of distressing memories and material that have been locked in due to the brain’s automatic defence mechanisms.
It was originally developed and assessed for use in people with post-traumatic stress disorder (PTSD) and established a compelling peer-reviewed evidence base. When I first learnt EMDR, my principal method of working with PTSD had been to use trauma-focussed cognitive behavioural therapy (tCBT). This also has a very good evidence base, demonstrating a significant reduction in flashbacks and other characteristic trauma symptoms. I actually remember remarking with a fellow EMDR trainee and friend at the time that I would probably still use tCBT for PTSD as it is so comprehensive and I must admit, I was sceptical of EMDR. I mean let’s face it, it can seem really odd.
However, once I started using it, I quickly realised that I was unlikely to use tCBT as my first option ever again and quickly EMDR instilled itself into my practice for people presenting with other issues including depression, low self-esteem and even obsessive-compulsive disorder (OCD). And guess what? It worked! And what I mean by that is, I witnessed people turning towards issues and memories that they had kept at bay for years and years (sometimes decades) and experiencing substantial changes in the way they related to themselves as a result of these experiences. By default, we as humans, tend to personalise a lot and with that comes a lot of automatic self-blame. In CBT, when we create comprehensive longitudinal formulations, we make some important links between our present, sometimes relatively unconscious beliefs and the things we have experienced in our lives, including our childhood and adolescence. The problem I have quite often found when doing these longitudinal formulations is that we are also exceptionally quick to dismiss the pain or impact of our own experiences. That is to deny ourselves the acknowledgement of the emotions we felt at the time. And what happens then?
Well, as research increasingly finds in many different ways, our emotions are physiological events in the body. When we suppress or deny them, they don’t just dissipate. There are many and varied ways suppressed emotions can impact us including numbing our physical and emotional feelings, increasing reactivity or sensitivity, running down our immune system and causing/exacerbating pain. I’m re-reading The Body Keeps The Score by Bessel Van Der Kolk at the moment, and this book really expertly shows the many ways that our minds and bodies are interlinked through our emotional experiences.
In EMDR, we are able to bypass our “rational brains” that are so eager to dismiss our experiences (in mistaken efforts to protect us), and we are able to turn towards and recognise how those experiences shaped us. How those moments of hurt, dismissal, fear and whatever else, penetrated deep within us and manifested themselves in different ways. I’ve witnessed some drastic and humbling moments of realisation in my clients and seen how these have been so transformative to them.
So how has this changed my perspective on therapy? The truth is that we all have lives made up of many little and (for some) large traumas. What differs amongst us is the extent to which we recognise them and the extent to which we allow ourselves to process them. I have to be honest and self-disclose that for most of my adult life I have thought that for me therapy would be a nice luxury, but not necessary. I’ve got this! I know therapy after all. And to some degree, that’s valid. I don’t believe my life would have necessarily fallen apart without therapy, although at the time I sought it out, I definitely felt that it was cracking substantially. But this comes back to a fundamental cognitive trap that we humans often fall into, which is all-or-nothing thinking. Just because I wouldn’t completely drown in despair, doesn’t mean that I wouldn’t do unhelpful things for myself that could ultimately be avoided or minimised with a bit more insight and change in my affective state and relationship with myself. And given the choice, what would you choose? You can stay the same, with unknown potential blind spots and unhelpful patterns or you can gain more self-knowledge and compassion which can serve future you no end of dividends?
You may be surprised (or not) to hear that there will be a substantial amount of people that would choose the first option. Something I hear again and again, as well as have felt myself, is the fear of opening a Pandora’s Box. What if one thing leads to another, which opens another, and before you know it, it’s all completely overwhelming? This is a completely understandable worry. There are of course many, many unhelpful, underskilled therapists out there, or even just therapists that are not well-matched with the individuals they end up seeing as clients. Therapeutic alliance refers to the quality of the relationship between therapist and client, and a good therapeutic alliance is characterised by trust, warmth, reciprocity and collaboration. When matched with a sufficiently skilled therapist with who you feel comfortable, therapy should match a pace that feels right to you. In my opinion, particularly as I step more into private practice, this is one of the more subtle and tricky skills of delivering therapy; opening things up too quickly can feel overwhelming, whilst going too gradually, can feel stagnant and unproductive. Balancing therapy progression should very much be informed by how the client feels and also goals set at the start of therapy. This brings us back to the issue at hand. If I have no clear goals for therapy, is there any point to it?
Models of therapy like CBT were developed on presentations with diagnostic criteria, such as depression and anxiety disorders (e.g. social phobia or health anxiety, etc). It was therefore very much developed to address a clear presenting problem. However, the wider therapeutic principles of identifying sore sports, themes of thinking, the more subtle challenges and stepping back to unpack and better understand them, can still very much be applied when there are no standout goals or clear directions for “progress”. Therapy is quite often a pooling of jigsaw puzzle pieces and a gradual sifting of them until you are ready to slot them into their places. For some people, just the experience of telling their story and gaining an insight into their own feelings and perceptions helps shift trajectories that they were set in.
Common myths people often have about therapy include:
- I need to be really distressed or anxious
- I need to have had a lot of bad things happen to me in my life
- You have to talk about the worst things that have happened to you in therapy
- Therapy is just about talking about childhood and bringing things up again
- Therapy can make me feel instantly better just by talking
None of these are true. I have worked with clients who generally feel ok but are aware that they have some sensitivities they can’t really understand (e.g. really not liking it when people interrupt them or feeling crushed at criticism). I have had clients with really fortunate lives generally but who feel overwhelmingly sad or numb or anxious. I have worked with people coming from war zones and focussed on their present-day work issues instead. For some people, exploring childhood is an important part of the process, for others, it may not be as key or need as much time. I do think it’s worth acknowledging the role of our backgrounds, but the extent to which we do this will vary from client to client.
In terms of therapy being a magic cure just by talking… of course, it is not. Deciding to go to therapy can be such a big decision and with that can come big expectations. Often the beginning part of therapy is the process of getting the jigsaw pieces out of the box. It can take a while to sift through the pieces and organise them and even longer to feel like they are slotting into place. I have sat across from many a person who has felt upset with themselves for “not feeling better yet” after 8 sessions of CBT. This in itself is a curious thing to explore, telling of the pressures that we automatically place on ourselves (and perhaps others), which can cause substantial resistance and with it, distress and/or frustration. Sometimes these people have persevered and been glad that they did, others may have ended therapy thinking “therapy is not for me”. But was it not for them? Or did it not perform as expected? Was it the expectations that got in the way and did those expectations manifest in other ways in life that remained obscured to them?
As I finish writing this, I must acknowledge my own bias. I am a therapist who has had a positive experience of therapy (although I have also had negative experiences). So maybe it is a no-brainer that I think everyone can benefit from therapy, although this was not always my stance. What I will say is that sometimes, people mourn the lessons they were not privy to sooner. In life generally, adopting open curiosity can help us figure out what our own needs are and how we may best serve ourselves and others. Why not adopt this approach with therapy?
If you have experiences and thoughts you’d like to share, please do leave a comment or contact me on @the_health_psychologist_ Instagram account where I will be exploring this topic further with the community there.