What we do in therapy

The following is a point of view written by Serge Prengel. 

The giant “pause” that we are going through due to COVID has been an opportunity to reflect on what our basic assumptions are as to what we do and why we do it. I am sharing my thoughts with you in the hope that they will stimulate you to formulate your own.

What is it that we aim to achieve in therapy? Often, but not always, the desired outcome is lasting sustainable change. For the purpose of this article, I will be assuming that this is the desired outcome.

How do we accomplish that? I see therapy as a transformative experience, which leads the client to learn new patterns of responding to life’s interactions.

We can conceptualize this as a rewiring of neural circuits. If we were able to see the wiring, we would presumably notice the change. In any case, the transformation is not an abstraction. We can very much see it in the way it manifests. Essentially, the client is now reliably able to be responsive, rather than reactive, in situations that were triggering them.

The notion of responsive vs reactive has a correlate in which circuit of the autonomic nervous system is involved. Under threat, the ANS networks are activated in a specific order, ranging from most sophisticated to most primitive (Polyvagal Theory).

These self-states are readily observable phenomena: in the course of therapy, we can track the client’s somatic experience to monitor where they are on this roadmap. We can also coach the client to improve their somatic awareness.

Within this framework, the notion of “meaning“ is not a philosophical concept: it reflects the experience we have of a given circuit in the ANS. That is, in dorsal vagal mode, the experience is that of an overwhelming threat. In sympathetic mode, it is that of fighting or fleeing a threat. In social engagement mode, we have access to many more nuances of meaning.

Looking at change within the context of the autonomic nervous system reminds us that what we are dealing with is the human ability to manage interaction. This is a relational perspective, as opposed to a “one-person psychology”. Hence the following implications:
– We therapists are not outside observers but human beings engaged in an interactive process with our clients. Tracking our inner experience is a necessary part of this process.
– The therapeutic interaction requires fostering the safety and relationality that facilitate the social engagement mode, where experience can be assimilated.
– The changes will only be lasting to the extent that external factors, such as family pressures, or social pressure, are addressed.

Posted by Serge Prengel