Why Therapy Works. Four Neuroscience Principles Behind Psychotherapy.

A love letter to therapy and therapists. On why therapy works and why you shouldn't let anyone tell you otherwise.

I am a therapist. I love my job. For me, it is the best job in the world.

Save one soul, save the world, they say. It really does feel that way sometimes. On a good therapy day, you know?

As of late, however, I have noticed therapy has been getting some bad press. A number of hit pieces. I know it might simply be a passing wave, and I know some people tend to write about what is likely to get them traction, but still, it makes me feel a little sad. I think it is because I feel sometimes people don’t understand what we do.

So here it is. My love letter to therapy and therapists. (And it comes with a neuroscience twist.)

Therapy Is NOT A Science. It’s An Art.

Therapy is not a science. How could it be? Therapy is an art. As such, it takes many forms, just as art does. It is fundamentally and inextricably intertwined with the person of the therapist, in the same way that art is with the artist.

Stripped to its essence, therapy is a place where one human soul meets another human soul. This is inscribed in the very root of the word psychotherapy itself: psyche (ψυχή meaning “breath; spirit; soul”) and therapeia (θεραπεία meaning “healing; treatment”) .

Only art, and not science, can measure up in that unfathomable equation. And some might say that some science is art, in which case there is a place where they all meet.

This discourse might come as surprise from someone who spends their time talking about neuroscience and psychotherapy. But this contradiction is only superficial.

Science, and particularly psychology and neuroscience, can inform and support therapy.

And this is true for some forms of therapy more than others as it is for some art forms. After all geometry, physics, maths, linguistics, acoustics can all support some forms of art.

I have written before about how I don’t believe that we need neuroscience to tell us what to do. But because that is what I spend my time thinking about, this will be the form my love letter to therapy takes.

Here goes.

Emotional Labour Is Labour

A fundamental flaw I observe in the reasoning of many therapy detractors is the implicit assumption that emotional work is not real work.

However, this is a misconception (albeit still a common one). Social neuroscience together with social baseline theory have demonstrated that the brain treats physical resources as interchangeable with the emotional resources of social support. As such, there is fundamentally no difference between someone fixing your pipes, delivering your groceries, teaching your children at school or helping you regulate your emotions. Yet it is rare for anyone to question whether the former are worthy of payment.

Emotional work is work, yet for much of history it has been taken for granted, unpaid and denied the status of legitimate work. It is high time this changed.

Additionally, emotional work is hard, and therapists are far from being the only unsang heroes of it. For most of part though, therapy it is ultimately a calling. A labour of love.

Emotional work is work. Don’t let anybody minimise what you do. Be a proud therapist (while also remaining a critical one).

Four Neuroscience Principles of Therapy

This list is by no means exhaustive, but it should be sufficient to put to rest any question whether therapy is an endeavour worth pursuing.

1. Memory Reconsolidation

Memories are not set in stone. Once formed, memories become malleable and can undergo a change every time they are retrieved (a fancy word for remembered). This process is called memory reconsolidation, as opposed to memory consolidation, which refers to the initial process of when the memory is ‘recorded’ or ‘stored’.

The process of reconsolidation was rediscovered in the early 2000s and has since become a thriving area of research within the neuroscience community.

I should say that memories themselves are not the problem in therapy. Rather, it is emotional memories - the emotional charge they carry - and how that often negative charge influences our future, the meanings we assign to events and to life itself. This emotional charge becomes intertwined with countless other neural networks of meaning and experience, shaping our understanding of what our life is about. Difficult memories can hold us back from growth, keep us living in fear, and make us unhappy, even as they try to protect us from harm.

While the details of the mechanisms and conditions of memory reconsolidation, as well as the precise ways to trigger it ‘surgically’, remain open to debate and ongoing research, there is no question that the process itself occurs. These important caveats set aside, memory reconsolidation stands as one of the major drivers of therapeutic change.

This process happens all the time, spontaneously or more intentionally triggered, in and outside of the therapy room. However, in the presence of safety, warmth, trust, and non-judgement and through the dedicated time for oneself with someone who is there to listen and support - all things that good therapy should provide, things can be said in the confines of the therapy room that not many other place or situation would tolerate. Emotions are re-lived and, in the process, transformed - often for the better.

Memory reconsolidation is why the talking therapy is more than just talking. What has happened cannot be changed but how we feel about it potentially can.

I wrote more about the nitty-gritty of the mechanisms of memory reconsolidation here.

2. Biobehavioural Synchrony

Biobehavioural synchrony is defined as alignment in time - in other words synchronisation - of biological and behavioural parameters during interpersonal interactions. Four aspects of bio-behavioural synchrony have been well-documented:

• Behavioural (synchronisation of body movements)

• Physiology synchrony (examples: heart rate coupling, pupil dilatation synchronisation)

• Endocrine synchrony (examples: coordinated cortisol stress response, coordinated oxytocin parent/child)

• Interbrain synchrony: the brain activities become aligned or “in sync”

Of course, biobehavioural synchrony is not something confined to the therapy room, but it also occurs there. The therapeutic space is a setting dedicated to focusing on the client and their inner world, where therapist and client sit together as though time has stopped, attending closely to the client’s experiences, torments, insecurities, emotional and body states. The therapist - including the regulation of their own nervous system - can serve as a template through which the client learns to ground, accept, and soothe themselves, by borrowing the therapist’s own ‘vibration’ or ‘energy’, to use those somewhat esoteric-sounding but, in this context, I think appropriate terms.

Biobehavioural synchrony is why the therapy is more than just talking. In the process and mostly out of awareness, as therapists we ‘lend’, so to speak, our own physiology, our own nervous system and as such the lending hand for our clients to hang on too, as they are walking some kind of tight rope in their lives. Through that process, they also learn to become better at it without our help.

I have written about biobehavioural synchrony and therapy here.

3. “Wordwork“: Benefits of Talking About Our Inner Life

Talking is not just ‘talking’. When people claim otherwise, they are essentially suggesting that talking is merely ‘producing sound with our mouths’ (or signs with our hands) and ‘exchanging information’.

There is however, a huge body of evidence to the contrary. For those interested, I recommend the book “MoreThan Words” , but I will limit myself to some points that to me seem the most compelling.

1. When we feel strong emotions, we don’t always see clearly how and what we feel exactly. Therapy provides the time, the place and an accountability person to to take the time and get clarity on it. In turn, by naming what we feel makes us better able to deal with these strong feelings. At the core of this is the idea of affect labelling and there is now a body of evidence about the benefits of naming emotions.

2. Talking is a booster of the executive function, helping us focus, take the better decisions and become more in control of our lives. In fact, some scientists think that talking, and not thinking, came first. Therapy provides a safe and dedicated space and time to do that.

3. When we talk about things in a considered way - which therapy through its core principles facilitates - we understand and make sense of things. ‘Making sense’ can lead to ‘changing sense’. ‘Changing sense’ can change our very emotions about something.

4. When we talk about difficult things, and by definition, that means we bring up difficult emotions, and yet are surrounded by a warm, safe, non-jugmental environment it can be a corrective experience, circling back to memory reconsolidation (see the beginning of this section).

Because talking is really much more than ‘just talking’, talking therapy is much more too.

I have written a little bit about the power of affect labelling here.

4. Priming For Attachment Security

Attachment is our primary strategy for social allostasis. As humans - children and adults alike - we cannot live without others. While we may have many connections to people around us, the ones who are meant to be there for us no matter what, are our attachment figures and our attachment network.

While the social neuroscience of attachment is still a developing field, we know that our complex neurobiology accounting for enormous intricacies of human social life has a special place for attachment system. As one of the primary mechanisms for our survival, attachment is hardwired in the brain.

However, not all of us, for various reasons, have developed the optimal attachment strategies to lead our lives by. One of the best gifts that therapy can give to the client is to shift their attachment towards more attachment security. While attachment security is not a sine qua non of a happy life (nothing is), the research has found times and times again the secure attachment to be a protective factor conducive to more thriving.

It would be overstating the importance of therapists as to say that they become replacements for attachment figures (and, in my opinion, they shouldn't), therapy - both as a practice and through the figure of the therapist - becomes an exercise in priming for attachment security. And helping someone live a life of not only surviving but thriving, that is something.

Attachment priming is why the therapy is more than just talking.

I have written (or, co-written rather) about attachment and its social, biological and neuroscience underpinnings many times. See here, here and here.

And So We Continue Our Labour Of Love…

There. I said it. My four big neuroscience principles of why therapy works.

Here I focused on the practice of therapy for life in general and not for a specific disorder or pathology per se. Life is a hard gig (no matter how the mavericks of positive psychology spin it). We all go through tough times.

Therapy, of course, is very effective in a number of specific disorders, and here is just one recent meta-analysis of therapy’s effectiveness - in case you are interested.

So, to all therapists out there, if sometimes you feel a little under the weather, as though your work doesn’t count, remember the list above.

If you can find it in you, then forgive the therapy detractors (I promise I will). For they don’t know what they’re saying.

What you do, day in and day out, might be invisible to the outside world (and is certainly invisible to the philistines of the human soul). But it makes a huge difference in people’s lives. And sometimes, it makes the difference between being and non-being. Save one soul, save the world.

We always want to make our profession better, more accountable, more effective. We never want to lose our critical sense. But all that said and done, the fundamental fact remains: therapy works. Don’t let anybody tell you otherwise.

As always, thank you for reading 🙏.

Because this is an opinion piece, I have substantiated my claims less than I usually would. However, these are all topics I write about regularly, and more extensive referencing can be found by following the links to posts on the specific neuroscience principles I discuss.