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Can therapy help people change? A therapist’s perspective

How Do People Change?

Spring, 2018 Mary Fitzgibbons, Ph.D.

Why would someone spend money on therapy? It can be costly if you do not have insurance coverage and it can be emotionally painful. Generally, by the time someone makes the effort to find a therapist who they believe and hope that they can trust and who will help them in resolving their issues, they are experiencing a fair amount of pain and/or inner turmoil. Most clients come into a therapeutic setting with varying amounts of hope and confusion. Their medical doctor may have prescribed different types of treatments. One, of course, is prescription drugs. But many feel that medications is not be the only option. Referrals to therapy are becoming more common, but that can be problematic.

What kind of therapy is needed? What is going to work? Choosing from the different types of therapy can be difficult, such as Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT) or Emotionally Focused Therapy (EFT). There are many other psychological treatments, but for each person, the question remains, “What is going to help me change?” While each therapeutic theory has pros and cons, it is essential that the therapist be clear as to how he or she will approach the therapy. This is because it is the therapist’s job to help the client create change, and that change should be lasting change. This would be very difficult to do if the therapist did not ultimately come to a belief as to how this should be done. Hoping that this theory or that theory may work but not being sure is akin to going to a surgeon for a hip operation and the surgeon only questioning which procedures will be most effective only as he begins the surgery.

\One of the better known therapies today is Cognitive Behavioral Therapy (CBT), which is derived from behavioral and cognitive psychology. The purpose of CBT is to address current issues by developing good coping strategies. One of the ways CBT does this is by changing thoughts and cognitions, beliefs and attitudes. The purpose is to treat specific problems, so it becomes a problem-focused, action-oriented approach. The focus of CBT is to help the client challenge his or her beliefs and replace present ways of thinking, which may include overgeneralizations, self-defeating thoughts, and/or the tendency to minimize the positives and maximize the negatives, with more realistic and balanced ways of thinking. The therapist and client work together to develop strategies and goals that will help the client achieve some resolution of the problems. The goal is to decrease the symptoms presented by the client. CBT advocates say that it is effective in treating depression and anxiety, along with Obsessive-compulsive Disorder, Post-Traumatic Stress Disorder, and aggression and conduct Disorder in children and youth.

There are certain clients that can be very difficult to treat. Dialectical Behavior Therapy was created with the express purpose of working with “non-motivated” patients. Some of these people were raised in severely invalidating families and as a result a trust level with the therapist is difficult to achieve. DBT aims to make the therapist an ally to the client. The focus of the therapist is to accept and validate the client’s feelings. It is the therapist’s role to confront the client when the latter’s feelings are maladaptive. This theory draws from other traditions such as CBT and assertiveness training. The therapist and client address the client’s issues on a hierarchical basis, moving from the most serious behaviors such as self- injurious or suicidal ideation to quality of life issues. The client is taught various skills and often group therapy is used to hone these skills. Mindfulness is an important component of CBT theory, in that it helps individuals accept and tolerate the strong and difficult emotions that challenge them. This contributes to helping the client emotionally regulate emotions.

DBT is often used in cases of depression or Borderline Personality Disorder. Many clients may assume that most therapeutic theories focus on emotion. In fact, many people hesitate before they see a therapist because they fear is that “I’m going to feel feelings I don’t want to experience,” or, “I’m afraid if I feel those negative feelings and if I express them,  I’ll never be all right again.” While this may sound like an exaggeration, it is often the reason people hesitate or refuse to begin therapy. It would surprise many people that emotion has not been the central aspect in most therapeutic models until the relatively recently. Behavior and cognition had been the focus in the past. Yet when we look at making changes in our life, the reason for wanting to change is often that we are not happy with the way we are feeling. We may be sad because a valued relationship is ending. Or we may feel helpless because our child is making risky decisions and we are at a loss as to how to deal with that. No one feels the need for therapy unless they are feeling sad, frightened, angry, helpless or depressed and, most importantly, they do not know how to handle these emotions so that they feel better. It is all about feelings.

While many therapies discuss emotions, the emphasis is not focused on changing those emotions. Most therapists acknowledge that they may use various techniques from different therapy theories. While this is true for many of us, this author would like to share what she has found to be an effective theoretical model in her years of doing therapy It is called Emotionally Focused Therapy (EFT). EFT is based on the premise that emotions are connected to human needs and, when we work through these emotions, problematic emotional states and interpersonal relationships can be changed. EFT is based on empathic attunement. That is, the therapist “gets” the client and is attuned to the client. Clients feel as though they are understood by their therapist. The emphasis is on engaging the client in an emotional experience that is in the present – what is going on with me right now? The theory is that we become more likely to change only after we can access the most primary emotion that we are experiencing. For example, Jane is angry because it seems as though a couple of her good friends aren’t including her in their regular nights out. She flies off the handle with others at the least provocation. Her anger is always present. After her sessions with her EFT therapist, she is able to access her deeper feelings of being truly sad because she has never felt as though she was special to anyone. The therapist, in this process, is validating the negative feelings that she entered into therapy with which is called a secondary emotion but then is able to reprocess her deeper feelings (her sadness) which are called primary emotions. Within EFT, this is what creates the change.

There are some key elements that are critical in creating this change in EBT. The creator of EBT  believed that the relationship between the client and therapist was critical to the therapeutic process: there must be a trustworthiness between the two. The client has to have the sense that the therapist sees the value in the client and the therapist understands the client. The attachment process is a crucial component to EBT. This refers back to the original relationship between mother and child. If this bond does not develop securely in infancy and early childhood, it will have serious emotional ramifications at a later time. This is often the basis of the emotional issues that we may have twenty or thirty years old. For example, Tom’s mother had a serious illness following his birth. For a number of months, she was unable to hold him or feed him. Though no one’s fault, Tom developed an insecure attachment style. This meant that he was never secure or safe in his attachment relationships, such as with a partner or close friends. He becomes highly anxious when he realizes that a relationship is falling apart. However, in order to resolve this anxiety, he must allow himself to experience the emotion in order to change. It is through the therapeutic process that he begins to be able to develop a sense of safety and security in his serious relationships.

The focus of the EFT therapist is on the present. While the issue may have begun in the past (Tom’s lack of early nurturing from his mother) the present feelings are what the therapist deals with. It is a highly experiential approach. The client becomes aware of his deepest primary feelings and how he experiences them. The EFT therapist will help the client not only identify the emotion but where this feeling is being felt in the body. It is in this experiential process that people change. This is because change comes about when one emotion replaces another emotion. Tom goes from feeling anxious to being secure and confident in the relationship. The reason that the EFT approach is effective, in this therapist’s experience, is that long-lasting change does not come about when a  therapist attempts to change the patient’s thought patterns. It is the emotions that must change. This may be a more difficult process, but it is longer lasting. When EFT achieves its goals, the emotional changes are longer lasting and become a part of the client’s emotional fabric.

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Dr. Mary Fitzgibbons is a licensed psychologist and the Director of West County Psychological Associates. Before beginning her career as a psychologist, Dr. Fitzgibbons was in education for 20 years, in both elementary and secondary levels.