How does therapy actually work?

[Music] Welcome back to Psychedelic Therapy Frontiers, the podcast devoted to exploring the frontiers of psychedelic medicine and what it takes to cultivate a healthy mind, body, and spirit. I'm Dr. Steve Thayer, and today, my co-host Dr. Reed Robinson and I try to answer the provocative question: How does therapy actually work? As is typical for Reed and myself, we have a pretty meandering conversation and cover a lot of topics. We discuss how mental illness is defined, different psychotherapy approaches, common aspects to all psychotherapy approaches. We talk a little bit about how psychedelics might actually accelerate progress in therapy, and we discuss whether or not artificial intelligent therapy programs are going to steal our jobs in the future, and so much more.

I wanted to take a second here in this intro and just thank all of you who have emailed us your questions and episode suggestions, those of you who comment on our YouTube videos, and who've left us reviews on the Apple Podcast platform. In particular, we read all this stuff, folks, and I've got to tell you, some of those reviews have made my day. Some of you are very generous and enjoy the show, and that means the world to me. So, if you'd like to email us, you can email us at psycfrontiers@novamind.ca. If you'd like to follow Reed and myself on Instagram, you can find Reed at @interspacedoctor and myself at @drsteventhayer. Without further delay, please enjoy today's episode.

Yay, yay! We are back. A message to our editor, Jamie: We should start the podcast with the yays. I think that was adorable. I hope this makes it into the podcast too. We are back with myself, Dr. Steve Thayer. I am here with the... I was going to say intrepid, but I used intrepid last time for Paul. So, what should I use to describe you? The just painfully handsome Reed Robinson. I have our customary awkward intro. Today, we are going to talk about psychotherapies. I have a question for you, Reed. Um, does psychotherapy work?

Well, if it worked beautifully all the time, we wouldn't have this podcast. No, would we? Or jobs. Um, but I'm a big therapy fan. Uh, but I don't, I'm going to [Music] pass on answering that and suggest that you tell us first, what the heck therapy is. We could probably have a ping pong match of obnoxious ontological questions like, well, that really depends. What do we mean by mental health condition or mental illness? We could rename the podcast to "That Depends." [Laughter] "That Depends" with Reed and Steve. Yeah, I like it. One of our many podcast ideas.

Yeah, so whenever I think about like, does psychotherapy work? What is psychotherapy? I'm always tempted to drill down to what I think is the question under the question, and that is like, uh, how is it that we know that we're struggling psychologically? And like, because how we define it probably dictates how we try to help. You don't have to have, um, that big of a psychological struggle to warrant therapy. You could be doing therapy like before entering a marriage or relationship proactively, or you could be doing therapy to, in theory, to get to know yourself, right?

I know. Yeah, so that, I mean, that does beg the questions that we started with, like, well, if that's the case, what is it, right? Yes. And what's the difference between therapy and something like life coaching? Like, when, when you and I both did our training, different paths up this mountain, right? But we both were told, do some therapy so you know what it's like before you start dishing it out. And we did. And I know I didn't go in with a, with a problem list or a problem. I went in just with openness, curiosity. Yeah. And then, and then the blank slate just sat there and stared at me awkwardly.

What kind of therapy did you? I, I chose a psychodynamic psychotherapy because I was really intrigued. Not a formal analyst, because I didn't have an hour, two, five days. Yeah, yeah. Although that is intriguing. Um, yeah, but, uh, no, it was a great dynamic process and, um, I learned a ton from it and, and she was amazing. It was like an archetypal, um, intimidating, silver-haired woman who was an awesome therapist.

Well, yeah, this, this sort of brings up more questions in my mind, like, does therapy work? What is therapy? It depends on therapy. Can be so many different things. And like you were saying, it can be for so many different things as well. We've talked a lot on the podcast in previous episodes about how we define mental health conditions or mental illnesses. We've talked about the strengths and limitations of the DSM, the Diagnostic and Statistical Manual for Mental Disorders. Diagnosticals, the diagnosticals, the diagnosticals of Narnia. Um, but yeah, I think you can go to therapy because you're curious, you want to do some introspection, some self-betterment. You can go to therapy because you have a hard time getting out of bed in the morning, you're so depressed. I mean, you can go to therapy because, um, you're super anxious and it's making your hair fall out. Like, there's, there's a lot of, I have androgenic alopecia. It wasn't from stress, at least I don't think so. Anytime I make a hair comment, I'm suddenly conscious that I'm very bald.

But did you go to therapy for, not for the baldness, but I've been to therapy for many other things. Like you said, uh, we were encouraged to go and sort of get a flavor of what it's like to be on that side of the couch. But yeah, I, I think I went to my first therapist in college when I was an undergraduate, and he was a disciple of of Albert Ellis. So he did REBT, Rational Emotive Behavioral Therapy. [Music] Ellis was a contemporary, like Aaron Beck, you know, the guy that, uh, basically created Cognitive Behavioral Therapy. Fritz Perls, maybe? Or his Perls, does Perls predate those guys? Well, I mean, a little older. Beck just passed away a couple of years ago, right? It is nice. Yeah, yeah. So lots of, lots of different ways to define psychotherapy. I'm wondering how we could get down to brass tacks and the basics. So, let's put aside my distracting comment about you can go to therapy when nothing's wrong. And just, let's assume we all have stuff to work on, and we bring it to therapy. So, one, one thing I like to look for in the therapy room is not only entrenched patterns, but entrenched patterns that are maladaptive. And so that's kind of a key, uh, signal that I'll go for. It's maladaptive, meaning it's not serving you well in your life. Because you might be flying off the handle every time someone cuts you off when you're driving home from work, and you keep going to jail because you get out of your car with a baseball bat, right?

I like the term adaptive, maladaptive, because, you know, it implies that, you know, we're responding to a stimuli one way or the other, either adapting to the pressure that that stimuli puts on us, or we're not adapting. We've engaged in a behavioral pattern that doesn't help us survive and thrive. Kind of, kind of like an evolutionary take on whether or not this is a problem, aka our reactions and responses that get us into trouble in life, right? That could be mild, quiet, subtle trouble. It could be big trouble. Yeah.

Another term that's often used is functional or dysfunctional. Yeah. Right. Do your worries, are your reactions helping you function? Are they helping you function in the major areas of your life, like your work, your family, your schooling, your self-care, health? Or are they causing dysfunction? Yeah. And so after, after looking for the entrenched maladaptive patterns, you know, often in therapy, well, you tell me, is we'll go looking for where they came from and why. Yeah, the origin stories. And different kinds of therapy will focus more or less on those origins. You know, therapies like Cognitive Behavioral Therapy, excuse me, are famous for not really focusing too much on the origin stories. I mean, we want to have the context, um, but the idea is that you don't necessarily, at least from those perspectives, you have to have to, you don't always get it, you don't always find the origin. Whereas something like psychoanalysis, you know, you're working, working on those origins and trying to heal from that place so that whatever's going on now, the entrenched maladaptive thinking patterns, behavioral patterns, feeling patterns, sort of fix themselves once you fix it from the starting block. And it reminds me of that saying that we've used on the podcast before, and probably said, we want to make a shirt out of it, is: "When it's hysterical, it's historical." Meaning your responses, these deeply entrenched patterns that are maladaptive and cause a response that gets you into trouble. If it's a big response, a big reaction, a hysterical one, and there's a pretty good chance it dates back to your childhood or some early life event or events that entrenched itself as a pattern, right?

So therapy, like following that thread, therapy is a relationship that you engage in with a trained professional who will provide you certain basic things. Basic things meaning things like compassion, listening, non-judgment, empathy, confidentiality, a plan, a structure, some predictability, some consistency, right? A lot of these things that you wouldn't get by default talking to just anybody else. And so they're going to provide you that container, and within that container, you can do some exploring of the past, and then you can work directly on these patterns. [Music] That's sort of that off the top of my head definition of what a therapeutic relationship might be. And the relationship piece, I think, is key because it's that whole idea that we may need to tease apart in this episode of transference and countertransference. But but putting that aside for a moment, is like, a lot of the time in therapy, we're, we're not just talking about the patterns and the responses, but we're especially looking for ways they show up in the interaction. Like, if someone gets triggered in the therapy room, that's ripe for here-and-now work, or that is a lot easier to work with than just remembering something from a week or a year ago, right?

And, you know, we didn't intend for this episode to be a master class on every therapeutic approach that's out there, because there are hundreds. Please, no. But I think a lot of them will take advantage of these, what you call the here-and-now interactions and the transference or countertransference to help a person. Because, you know, another way to think of the therapy relationship is a laboratory. It's a little social microcosm, right? And in that microcosm, you have a person who is totally committed and dedicated to you and helping you overcome your challenges, who is also a human being. So, like, I can get triggered by my clients, but, you know, we've structured and we've been trained to structure the relationship such that we can identify those triggers in ourselves and put them aside or use them as tools. Right? If this client is annoying me, it's quite possible that they have that effect on other people in their lives. They might have something to do with why their relationships aren't super good, or they feel rejected. So you can use that data, you can use yourself as a tool as a therapist, with great caution and attention paid towards not getting, getting yourself in the way of the therapeutic process, right? Or projecting your own. Right, exactly.

Yeah, I had one of my supervisors in graduate school said, Steve, if you want to be a good therapist, you have to take care of your own first. And by taking care of. Yeah, he didn't mean like you have to become a fully actualized ubermensch. Like, you don't have to be a perfect person, but you have to develop a type and a level of awareness so that you can tell, you can tell if an emotional trigger in yourself is your stuff, or is it like, we were talking about, something that is would be a reasonable reaction, uh, that anyone in that person's life would have. And then you can use it as sort of an emotional tuning fork. Like, oh, this, this person's giving off a frequency that they probably give off a lot in their life. Let me help them develop awareness around that. Let me help them then make some changes around that pattern. Yeah.

That's, I like that. And it reminds me of one of the most common, um, signposts of transference that I'll look for, or that I've, I guess I've encountered in these therapy dialogues, is when a client is relying on you as a therapist to fix something in their lives. It, uh, reminds me of like, in childhood, kids often, you know, in the earlier stages, especially, don't solve their own problems. They'll turn to mom and dad to help them fix it or tell them how, even if they could figure it out on their own. And if a client is relying on you, and you have that, that transference elicits something in you, you can be like, ah, they're looking to me as the grown-up to fix something. And then the, "don't get in the way" part is, don't just reactively jump in and fix it like you might with your little, little kids.

Yeah, and it is something that, like we were saying, requires a lot of, uh, self-awareness as a helper, because, you know, maybe you were drawn to this work because you like helping people, or you were put in a helping role when you were a kid. Yeah. So you might feel this drive to jump in and sort of help them, fix them, rescue them. And that's what we were talking about here, when you need to know the difference between your stuff and what's being evoked by the client's stuff, because you could then, you know, actually do some harm, or at least not be very helpful, if, yeah, you give in to that, you know, emotionally immature defense mechanism or a maladaptive pattern of them just wanting people to come rescue them by trying to rescue. Should I stay or should I go? Tell me. Right, right. Yeah. That's a tricky part because you do have a lot of clients show up, say they're in a relationship quagmire, and say you have an opinion, a strong one. What do you do with that?

Well, yeah, and it's, and, you know, some of that depends on the type of therapy you're doing. I've certainly had mentors and supervisors say, never render an opinion. Don't. I've had supervisors forever, never ask a question out of therapy. Right. Yeah. Uh, rendering opinions is, is, uh, perilous these days. But, um, yeah, I mean, again, depends on the approach. Like, they never asked a question was, uh, something I got from a supervisor once, but he was a Rogerian, disciple of Carl Rogers, right? Rogerian client-centered therapy, which its style is typically based on the assumption that if people are given this loving container with somebody who's a good reflective listener, they will move toward health on their own. They will, they will follow this natural human tendency towards self-actualization. All you need to do as a therapist, quote unquote, all you need to do as a therapist is provide for them unconditional positive regard and empathy.

That does bring up one of my favorite mechanisms of change, though. And I do like to put aside the alphabet soup of flavors of therapy and try to look for the common themes or the underlying mechanisms of how they work. And one of them that's really stood out to me as one of the top few most important and useful is the corrective emotional experience. And it, a lot like you said, in that loving container, or you have someone there who's helping you figure it out instead of bolting or reacting in a maladaptive way to you, or jumping in and fixing everything so you don't have to. Yeah, maybe we can give our listeners an example of a corrective emotional experience. This is one of the things we love about psychedelic-assisted psychotherapy, by the way, which we can meander into that topic, is its ability to provide corrective, powerful corrective emotional experiences. But yeah, what might be a good example of a corrective emotional experience for somebody in therapy?

You're scared to share something that you find very shameful with your therapist because when you share it with your mom, she jumps on it and you get shamed, maybe. Yeah, and criticizes you. But then when you bring it up, you muster up the courage to bring it up in that safe container, therapy room, and they don't react negatively. They actually hold it in love. That's a corrective emotional experience. And you're laying down these new neuronal pathways of healing. And it might take a few of those. But but I can tell you, there's nothing like the presence of a supportive other to help you heal some of these, um, deep wounds of trauma, shame, and, um, things of the past. Yeah. Yeah.

And like you were saying, that that falls into the category of of what we, what we in the research literature at least call common factors. Right? There's specific factors for when we're trying to test which psychotherapies work best and for which problems. There's a set of variables that are present in just about all the therapeutic approaches, and we call those the common factors. Right? And having an empathic listener is one of those common factors. You'd be hard-pressed to find a therapy that doesn't involve some degree of empathic, reflective listening. And then having a corrective emotional experience is also pretty much universal, regardless of what kind of, at least it's on the menu. It's one of the things you're trying to help a person experience, regardless of which alphabet soup combination you tend to practice.

And when I did, uh, Emotion-Focused Therapy training with Les Greenberg, that was one of the key tools of one of the two ways of transforming emotion with emotion was through corrective emotional experiences. And because there's this interpersonal soothing, because it corrects these tightly held false pathogenic beliefs, like, oh, I thought they were going to throw me out of the room when I shared that, and they didn't, and they actually still care about me. One of the things I really like about that therapy, EFT, and IFS, is its Internal Family Systems. IFS is, it's provides not only interpersonal, what did you call it? Interpersonal healing. Soothing. Neurobiology. Yeah. Well, it causes, it also causes intra-personal soothing, right? You have, within the self, you have different parts. In EFT, you have like, usually it's two-chair work. You go back and forth between chairs where you represent parts of you that have this relationship internally, and then you sort of navigate collaboration instead of conflict within your parts, and sometimes in relationship to important people in your life, right?

Yeah, it's either living people, but sometimes it can be really powerful for people who are no longer in your life, but you still carry them. You have this archetype or a representation of them that, yeah, you carry around with you, like with your parents, for example. Yeah, unresolved grief. That's complicated. Yeah. So, that many roads lead to this, this realm of corrective emotional experience. Other common factors are things like the working alliance. How much do you trust your therapist? And how much do you feel like that you and your therapist are working toward a goal that you've both agreed to? And how effective do you think the things, the conversations that you're having, the interventions that the therapist is recommending, how effective do you believe they are? We even have measures to measure these kinds of things in psychotherapy outcome research, like the Working Alliance Inventory is probably one of the most common ones.

And this highlights for me one of the kind of theories I like of how the human mind works that helps in the therapy room, in psychedelic therapy as well, is the, that we're prediction machines. We have these, what you could call a hierarchical coding mechanism in our heads that tries to predict what's going to happen out there in this world of uncertainty and takes in sensory inputs bottom-up, assigns this hierarchy of predictions. And when you have a corrective experience, you were expecting something to happen, something else that didn't happen, something else did. Especially if it's like a soothing, internally soothing, interpersonally soothing, uh, corrective experience, then you start to rewire that pathway so you can not predict that the world is going to hurt you every time, right?

And like you mentioned, it takes, it can take a while for that software program to get updated and changed. Another way to describe this process is it's learning, right? We were alert, we had, we had come to some conclusions based on, you know, the way we were treated when we were young, some salient, perhaps traumatic experiences we had early on in life, and we've developed this expectation, like you were saying, of the world. And then when you're given data that doesn't jive with that expectation, you can then update, like you were saying, to me, that's, you know, it's a, it's a one way of describing how human beings can learn. So a corrective emotional experience is a learning experience. And there's a lot of ways we teach in therapy, but yeah, it goes by many terms, I guess. And looking at it through Pavlov's lens of extinction, or, you know, if you remember, if for anyone who's had psychology classes, back to psych 101, the Pavlovian dogs and the bell making them salivate. If you just stop ringing the bell, that pattern of, "hear bell, saliva occurs," that pattern will start to fade gradually, or it could be kind of replaced with a different response. But learning occurs, yeah.

And we have entire therapeutic approaches based on these principles of learning, on operant and classical conditioning. Yeah. The idea that if you are rewarded for a certain pattern of behavior, that pattern of behavior is likely to persist. If you're punished as a result of that behavior, it's less likely to persist. It's not so cut and dry, but it's kind of dry for some things, like if you've ever trained a dog or a small human, you know, a child. Yeah, they respond to these interventions, these learning strategies. And let's look at, like, uh, combat-related PTSD as an example. You know, you have, uh, um, someone who's say, lost a limb in the service in a war, and, you know, every time they hear a loud noise, it lights off the amygdala alarms, thinking you're back there, and there's an explosion, and you're not safe. But if you can use that extinction, like you were saying, to elicit a response, or get triggered a little bit, manageably, on purpose, in a safe, supported environment, then all of a sudden, your cortex and your amygdala can kind of reintegrate and learn that it's safe, even though there was a loud noise, right? Yeah. Yeah.

So, back, you know, we, I guess we sort of answered the question, but does therapy work? Yes, for some people, some of the time, for certain conditions, in some ways. And this, what you did, the example you gave, is a great example of how therapy can quote unquote work. It can change that conditioned relationship in your mind. And, you know, the research we mentioned on here often maps is, uh, phase three data now that's coming out. Yeah, they, they released half of it so far. Yeah. But at least the phase two data was really, really promising with respect to MDMA-assisted therapy for PTSD in providing those corrective emotional experiences. Because they're, they're escorting these trauma survivors into their trauma, right, into the memory of their trauma, and they're able to sit with it in a non, you know, activated state. So instead of what they would normally feel, right, this central nervous system activation, panic, fear, flashbacks, they can be with it in in the MDMA state, the more loving state. And I remember hearing Rick Doblin talk about what, you know, it's rudimentary, but this is probably generally what's happening in the brain, they think with MDMA, where it calms down the amygdala, that sort of fear center. Yeah. It increases connectivity between the prefrontal cortex and the hippocampal regions, so you're getting better memory retrieval and better learning as a result of memory retrieval. And increases activity in the prefrontal cortex, so you can make more rational sense of what's going on. And your mind is awash with all the great fun neurotransmitters like oxytocin, dopamine, serotonin.

No, I think that's a really good point because when you're looking at deeply entrenched maladaptive patterns, I think there are two ways, two main ways to address them. And extinction, um, isn't the most effective, like the most quickest way to do it. It takes time to relearn those. Whereas the other path, you could call like memory reconsolidation. It's more of how MDMA-assisted psychotherapy is working. You've got the trigger, you've got the response, you've got this awareness of of the situation that it's safe, and you have a window of opportunity to work in to lay down the new memory tracks of or reconnect those disconnected pathways of of, you know, safety.

And we don't want to overstate these results either. Like, this is not, you take an MDMA pill, have a trip for 10 hours, and congratulations, you're cured. This is in the context of, in case people who don't know, like, yeah, this is in the context of 40, 40 plus hours of psychotherapy, at least two, maybe three medicine sessions. Three in the PTSD studies, right? And, uh, you know, you hear, at least I heard some anecdotal reports that from the therapists who have run these trials, that a lot of these people struggled hard in between sessions. They required a lot of support. You can almost predict, like, we get asked a lot about psychedelics, obviously, and you can almost predict, uh, who's going to have a difficult experience versus whose is less likely to be so. Because if, if you've had decades of of really, you know, tragically unfair, dramatic things happening, you know, there's a very good chance that that stuff is going to come to the surface during psychedelic experiences, including MDMA-assisted psychotherapy. And that's why we do it, right? You know, to work with it. But but that's also why it's really important to pay attention to those set and setting factors and the preparation phase and what happens next. And it's why we take psychedelic use so seriously. Because certainly, there are good arguments to be made about the free consciousness movement and being able to alter your consciousness if you want to without permission from, you know, the big brother or the government or whatever. But you can wander into this territory, ill-prepared territory of psychedelic medicine, psychedelic substances, and, and it can stir a lot of those things up that you're talking about and can be really, really destabilizing. So, you know, using these powerful tools in the context of a trained professional, um, a very supportive environment, something we are constantly advocating for.

You know, I just have this urge to debate everything you say, even though I really agree with that, just because. Play the devil's advocate. No, I'm just thinking of, uh, it's easy for the pendulum to swing too far in any direction, right? Of like, you're not ready for trauma work because you're not perfectly stable and one zillion percent supported. Um, I just was having this meandering thought of, uh, what happens in, like, the Zen view of awakening? We talked about awakening recently. You could be walking along and have a sudden awakening, and life just gets wild and weird. But, um, and then what do you do with it? And that can be healing. It can be dramatic. Yeah. We've said on the podcast multiple times that healing can be disruptive. And we certainly don't want to try to avoid the disruption because the disruption is part of the like, the active ingredient. Yeah. You shake it up like a snow globe so you can, um, you know, reset some of that, some of those patterns. Yeah. Absolutely.

So, um, cognitive dissonance seems relevant to this discussion. Because I don't know that term. I've just always loved for some strange reason, because you've got, um, this tension between your old prediction mechanisms and then this new corrective experience or this awareness you have of, oh, maybe not everyone is out to get me, or maybe I'm not totally unworthy of love. Um, and then you've got this tension that you might call cognitive dissonance. And then therapy involves, how do we work with that? Right?

Yeah, if, if you hearken back, if you took one to a cognitive science class in school, human beings are driven to resolve this dissonance one way or another because it is so uncomfortable psychologically. And a lot of times, what they do, so let's say dissonance is caused by old beliefs being confronted with new data, and you're resisting updating the software, like we've been talking about. I'm going to torture this metaphor to death, but do it. Um, and that resistance causes the friction. So you can do one of two things. You can update your beliefs, you can submit to the new data and say, okay, I guess I was wrong. I was wrong when I thought that I was a terrible person, and I have this therapist telling me I'm not. Oh, maybe, maybe she's right. Maybe I need to update my. Or you can reject the data. Ignore spam folder. Exactly. Delete. And then you're further entrenched, right? Yeah. If the new data is the accurate, and some, some conditions like that are highly, you know, deeply entrenched, they've been there for a long time. You almost expect that, um, when some new sensory data comes in, which it always does, evidence to the contrary of your tightly held prior beliefs or predictions, when it doesn't match, some patterns get really good at just rejecting the new data. And that's where I think psychedelics come in, and where your "shake it up" or "chaos" comment comes in really handy. Is, um, in this idea of the free energy principle. I love that we can bring kind of all these different disciplines and theories of the mind and a little bit of splash of physics into into the equation. Because the free energy principle, or the entropic brain theory, suggests that, yeah, we can, we can melt those patterns through psychedelics or other ways, right? And then we can more consciously reconstruct them. Yeah. It makes the, the brain more plastic, malleable. Like the, uh, the term out of Carhartt Harris and colleagues at Imperial College was Rebus, or Relaxed Belief Under Psychedelics. And using a metaphor of like, taking a psychedelic medicine is like heating up metal so you could bend it, shape it, and then as it cools down, uh, you know, working in that therapeutic process and the therapeutic integration, you can shape it more consciously into more adaptive patterns. It's one of the things that had me so excited about psychedelic medicine when I first, you know, started researching and learning about it, because as a therapist, I noticed how challenging that was for myself and my clients to heat up the mind sufficiently that it could be malleable in this way. Because, you know, we also have these interesting terms in the therapy profession, uh, where people resist change, right? There's resistance, or there's defense mechanisms, where people argue for their limitations. There's ways that people, even though it's not working for them, want to stay in their patterns. Or "having is evidence of wanting" is another fun catchphrase that we sometimes use. If you argue for your self-defeating, self-limiting beliefs, you get to keep them. Yay, yay. And, you know, if you say these things to people sometimes, the, they are, you know, gives them a little bit of an insight. But normally it's like, okay, screw you, whatever, that doesn't help, you're just being mean. So, yeah, we typically don't throw that in people's faces.

What's the, the role of being mean in therapy? That's actually a good question. Uh, we, there's this fun, I think it's fun, at least maybe because I'm mean, but, uh, this fun intervention called paradoxical intention. Where, you know, let's say somebody trying to give a good example of this, somebody says, yeah, you know, I'm just not really, I'm not a very impressive person. And you say, yeah, you are. You're kind of the worst person ever. Like, you, you're, you're woefully unimpressive. I mean, worse than unimpressive. And most people kind of catch on to what you're doing. But it's like, no, well, I mean, I'm bad, but I'm not not that bad. And then they, they sort of back off from the extreme thinking a little bit. That could be mean, I guess. Yeah.

I remember the first time I saw that in action in EFT chair work, some of the advanced moves like taking people into the gutter to retrieve the deep and rooted shame and play it out, work with it. You don't want to finish that chair exercise or leave it unfinished. Yeah, that's like open psychological surgery that you need to wind down and get to the, the corrective healing side of the coin, right? Yeah. I think sometimes, you know, I really loved your question about being mean, because, you know, depending on the culture you grew up in, there are, there are different expectations around niceness and politeness. Like, oh, we don't, we don't say those things. We don't actually tell the truth to each other. How are you feeling? Oh, fine. You know, like, oh, you look great. Or, you know, there's, there's varying degrees to which we are painfully honest with one another. And a lot of people like therapy because their therapists are sort of brutally honest with them. Yeah. You know, not that I love Dr. Phil, because I don't actually, but he had this, because I don't actually, but he had this fun catchphrase, like, "How's that working for you?" You know, people would say, well, this and this, and there's like complaining. And okay, well, how's that working for you? And it is, it's like cold water in the face. It's like, oh, it's not working for me, actually. Yeah. You don't want to beat around the bush or, um, or contribute to someone staying stuck for sure. And we do have to check that, that our own people-pleasing, our own tendency to be over-agreeable. Yeah. Especially in therapy, because I've heard time and time again how clients, you know, I, I really rely on my therapist to tell it like it is, or like to tell me the truth. And that is, like we were saying last time, you know, one of the greatest gifts we can give another human is to be truthful, right? And sometimes when I'm talking to a client about the relationship, like it's the intake session, and we're talking about expectations, I might say, it's my objective is not to make you like me. My objective is not to be your buddy. Um, we'll probably tell me things you'll never tell anybody else, and I'll probably say things to you that you will never hear anybody else say to you. And sometimes they're going to not feel good. But remember, the objective isn't to make you feel good, right? Sometimes they'll say, I don't want you to feel better, I want you to feel better. I want you to learn how to feel in a better, more efficient, more healthy way. Yeah. Fun again. More fun catchphrases. But yeah, it usually sort of, it just sets, that's the stage for a different kind of interaction, a different kind of relationship. Because sometimes, pretty often, you do have to feel worse in some ways before you feel better. You've got to bring the stuff up to be able to work with it, or the only way out is through, right?

Yeah, I mean, avoidance is at the root of a lot of what makes us suffer perpetually. All the entrenchment you were talking about is, is because of, for, for one reason or another, and we all do it, I know I certainly do, um, is attributable to our tendency to avoid what is hard and void, what is difficult. And so, when in the skills department, I think, another common theme I'm, I'm seeing at least in the therapies I like, is the, um, learning how to self-observe and learning to be self-aware, learning to stay present with the discomfort. Because how are you going to do this work of extinction or memory reconsolidation otherwise, even with the presence of a supportive other therapist, right? And some therapies are, are structured more around trying to occasion insight, self, like self-knowledge, like you're talking about, or insight. And, you know, based on the idea that if, if with insight, a person will then make changes, like with a greater self-knowledge, they are then better equipped to make changes. Yeah. And then there are other theories of change or therapeutic approaches that would say insight's actually not as important as just better conditioning. But, you know, like most things in the world, I think the truth lies somewhere in between. I think most effective therapies are going to involve, you know, certain types of insight, that's going to promote certain types of insight, it's going to have corrective emotional experiences, like you talked about, it's going to have those other common factors that we discussed, the safe container of being seen, being heard, being understood, being validated. Because you look at the more modern mindfulness-based therapies, the so-called third wave therapies. I mean, if you go way back to Victor Frankl's writings on logotherapy, yeah, like between, uh, stimulus and response, that's your chance to decide how you act. And you do have to bring some awareness or put some space in there, or else you're reacting automatically based on your patterns, right?

I like that way of conceptualizing change in psychotherapy. Like, you can think of therapy in that way as like physical therapy. Sometimes I like to make the comparison to physical therapy. Yeah, it's practice. You're, you're moving an injured joint through range of motion. And, you know, if, if you didn't learn to tolerate the discomfort, you might continue to just react to the presence of discomfort, and then you might brace, you might hold that joint still, and then you lose function, right? You might not be in as much pain, but then it's not as functional, and then your freedoms are limited because you can't do as much as you would have been able to if you had gone through the discomfort and, and then, and it granted you options. So there's that black box between stimulus and response that I think, as you're probably getting to the idea that, like mindfulness-based approaches and others can help you, I don't know what you would say, but like widen that time or that time in which you are volitional, you have the opportunity, the chance, the skill, the ability to then decide instead of reacting according to conditioning. Yeah. Because we, if we use a therapy example, take binge eating disorder, for example, or where you have something might trigger an urge. It might be a stressful situation, a negative emotion might trigger an urge to engage in using food to self-soothe. And some people are prone to have that spin out of control, that we call a binge episode. And then there's a lot of discomfort after. There's some shame. There's even some loss of control during. But but one intervention that has been striking to me to watch, and it's not always easy in the real world, is just putting some space in between stimulus and when your response, even. And how, when you respond, even if it means setting a timer and say, for the next five minutes, I am not, whatever happens, I am not starting a binge episode. And then that gives you a little time to go phone a friend, you know, go down your list of other, other paths, right?

Yeah, that sort of trots into the, the world of just, of habit change, right? And all this stuff is a giant Venn diagram, burn all over laps. Right? We're just jumping around the Venn circles. Yeah. Yeah. It's what happens when you spend years packing a lot of stuff in your brain, and then it just sort of is leaking out in random ways. But that's another name for the podcast, "Leaky Brain." Maybe. But yeah, it's, you're, you're changing the relationship between the cue and the behavior, right? So you've got this, in case of binge eating, maybe it's an emotional cue, or maybe it's an environmental cue. This is the same for addiction, the same for most habits, right? Lots of good books on habits. One I really like is called "Atomic Habits" by, uh, James Clear. That's a good one. Another one, "The Power of Habit" by Charles Duhigg. Two non-mental health professionals who just wrote really good, good books about habit. Um, but you have this habit loop, right? There's the cue, and then depending on who's loop you're looking at, it's the, the craving, yeah, and then the routine, or the, the actual behavior itself, which leads to a reward, which reinforces the connection between the cue and the behavior, the cue and the craving. So, I hear you saying, you know, let's, let's calm down, let's create some space before we just impulsively and reflexively engage in the behavior. And that gives us the chance, the opportunity to do these other things, which will hopefully weaken the connection between the maladaptive behavior and the cue, and strengthen a connection between the cue and maybe a more adaptive coping skill, like phone a friend.

And the frequency and severity of the pattern, and how maladaptive it really is, helps determine the level of intervention needed. Right? I mean, this all may sound obvious, but I would just like, even for my own purposes, to like walk through it out loud. Taking another example of say, bulimia nervosa. I know I'm using eating disorder examples here because that's a field I tend to focus on a lot. Is bulimia nervosa, where there's binge-purge cycles. And if someone is binging and purging multiple times a day, and to the point where even their laboratory values might be thrown off, you know, potassium out of whack or something like that, sometimes an intervention, a big corrective emotional experience intervention, is needed. Or some might need to go into a treatment center for a few weeks where you can't engage in those patterns because you're surrounded by environmental supports and the supportive presence of others. So that pattern can go down a few notches with extinction and reconsolidation, and then you can, uh, reintegrate back into your own environment where those triggers were previously too much for you to handle on your own.

I'm glad you're bringing up those examples because, you know, we, when you talk about habit change, you can talk about things that seem so, um, what would be the right word? Uh, like not as serious. I can't think of a fancy word, but like not as serious, meaning, oh, I just, maybe I, New Year's resolutions, yeah, like I've got this bad habit around not exercising or whatever. Between that and something like an opiate addiction or an eating disorder where you might need to go into a center like you're describing more than once. You know, these are, you, you called them intractable earlier. That's like, that's a good word to describe some of these problems. There's nothing weak about that, not one bit. Like that's a, that's a courageous act because, you know, what, like we all are in this same kind of habit loop together where sometimes you just can't think yourself out of it. And the difference is just that some of those patterns and maladaptive responses were just more dangerous that, uh, showed up in someone's life for whatever reason.

It makes me wonder because I'm not very familiar with the research. It makes me wonder about what is ibogaine doing when people go to New Mexico and they're getting ibogaine treatment for some of the most intractable patterns that people people can have, like an opiate addiction or alcoholism. What's it doing that helps? That gives it so like this promising efficacy in helping people break these patterns?

I could try to comment on the, what, not so much the why, but I remember when I started working with ayahuasca in the jungle, there was a good friend who was really well-versed in iboga, who had traveled and spent a lot of time with the Dweety tribes and sat in on a lot of indigenous use and ceremonial use of that. And I was just asking him and a number of others their their experience of how did ibogaine or iboga feel versus ayahuasca. And first of all, ayahuasca is more often thought to help you move stuck emotions. And then, and there's a lot of overlap on these Venn circles as well. And then ibogaine or iboga is more likely to show you your patterns, give you a view of them, and then change them. And it happens to kick the cravings out of people on things like opiates and nicotine. Kick the cravings out. That's just so interesting. Yeah. I can't wait for more research on this because I had, speaking to somebody who had one of those ibogaine experiences, and she described it as, like defragging. Can we used to have to defrag our computers? And we're in that, like defragmentation program. And she was like, it literally felt like it was scanning the lines of code one by one, and it would find something that was a broken line of code and deleting it. And it just, it's really fun, like metaphors and visions and experiences on stuff like ayahuasca and ibogaine. Machine elves defragging your brain. Who wouldn't want that? I certainly do.

I don't know, the machine elf thing still, uh, creeps me out a little bit. I mean, like, just the term. You mean machine elves isn't a lovely term that inspires like sugar plum fairies? Now it is kind of terrifying, right? I'm thinking of like a.

Steampunk Lord of the Rings. I don't know that I would love an encounter with the machine elves, but in people's experiences, they do show up in a number of ways. They, like, they're often called entities, or it could be like a psycho-spiritual entity or being. Yeah, this is where we kind of wander into some really fun territory, the trans-personal territory, and kind of a speculative territory. Like, what, what is it that we are experiencing, especially when it's there are some common experiences? This entity experience is really common on, on DMT-containing psychedelics, and it's often, you know, they're often at the periphery. They often have sort of a playful, feminine energy. Like, there are these fun commonalities that we see in these experiences. Like, what is it? What are we accessing, if anything?

Oh, it's fascinating, the, the commonalities, like you said, and the varieties of the psychedelic experience in general. Um, seeing the patterns or signatures that each type of medicine has, like whether you're doing geometry, yeah, doing a psilocybin dosing session, or an ayahuasca journey, or Iboga. You know, they're, they're distinct but overlapping. Like we saw in that research that compared LSD and psilocybin, and people weren't that good at telling them apart. Yeah, distinct but overlapping. And, you know, to tie it back into our just general therapy conversation, that's, you could say the same thing about a lot of psychotherapeutic approaches. There are things that make them distinct, and those things maybe make them certain ones better for certain conditions than others. Like, you know, OCD and phobias tend to respond pretty well to exposure and response prevention, or just, uh, you know, on the, the sort of conditioning behavioral approaches, as opposed to insight-oriented therapies. I know plenty of people with OCD who have tremendous insight into the fact that their obsessions and compulsions are irrational. For example, but knowing that they're irrational often does nothing to help you change those patterns. It's more that corrective emotional experience that you get by exposing yourself to the condition that you're afraid of, and then enough times, frequently enough, to update your brain. Like, hey, you actually, you know, your mother's back doesn't shatter when you step on a crack. Like, let's step on some cracks and we'll call mom. We need to, we need to change this. And it's not like that, not until repeated exposure does those things update. So, yeah, certain approaches work better for certain kinds of problems.

And because that's a good point, I was just going to ask you in the spirit of practicality, so we're not just waxing philosophical on this stuff. What do you tell people when they ask about how to find the right therapist? Yeah. Oh my gosh, and I get that question probably every week. Who do I go to? Like, sorry, everyone's full, right? That's a problem across the entire nation, unfortunately. But about robots? Well, we've talked a lot about that, Reid. Like, it's, there's some interesting data out there about AI therapists. A lot of it's not data, a lot of it's just sort of case studies in Silicon Valley trying to take over the psychotherapy world. I think they should be called coaches, but the coaches are not gonna like that. No, I mean, I just, I just think it, it fits more in that realm. And I love coaching too. I did have a client who used one of these apps, and, you know, the app was programmed, I wouldn't call it AI, it was more just kind of a procedural chatbot. But yeah, you know, she would, she would type in like, how are you feeling this morning? And she'd do a little journaling, and then it would say, oh, and it would look for certain words, the occurrence of certain words, right? I forget like the natural linguistic programming or something like that. There's a way that it'll scan your text, and if it detects sadness, it might say, sorry to hear that, tell me more. And there's plenty of dystopian movies if you want to watch that will freak you out about this. Like, her, uh, with Joaquin Phoenix, but yeah, um, or Ex Machina has another one that was wild. Yeah. But this is a client who had a really hard time talking to me. I mean, I, I saw her every week for a long time. She had really serious OCD and and really significant, um, social anxiety. And so sometimes periods of silence of like 20 minutes where just she was trying, but she just couldn't. And so I'd have her journal, and she'd bring in these like long journal pages that was so insightful, and there was so much that she had to say. Um, arguably, she got more out of the, the robot than she did out of our sessions. At least she was able to talk and process more. The combination of the two helped a lot. Like, yeah, she'd bring in her insights, and we'd go through them. But I'm a, I'm a big fan of that approach. Like, we talk about this a lot with our clinicians in clinics, is why don't we do more CBT-I for insomnia, an evidence-based approach that's not a medication intervention when we're dishing out all these meds? Kind of a pet peeve of mine. But it's hard to find someone who's just going to give you CBT for insomnia in a structured way routinely when there's a therapist shortage and all these, this alphabet soup of therapies to to learn and and navigate as a client or as a therapist. So I like having these approaches where it can be manualized in a workbook or in an app, and you have your, your skilled, supportive psychotherapist, and you have a coach. Yeah, why not? Yeah, I think the apps are good in as much as they, they bring supportive content to people who might not be able to access support otherwise. I don't think they are 100% like a one-to-one replacement of what you could get from actually meeting with a human being and getting psychotherapy, especially if you're gonna do something really intense and complicated like EMDR or something like that, psychoanalysis. Yeah, um, like chess. But your question was like, how, how would I answer that question? Like, yeah, that people often ask, how do I find the right therapist? How do I know who might the right therapist for me is? Um, the grammar of that sentence fell apart. Good. Yeah. But like, I think honestly, it's really hard to predict. There are certain factors, like when we study this, that people are generally more comfortable with. And this is a generalization, but generally more comfortable with people of the same gender, similar background, or at least gender identity, similar backgrounds, especially if your background is one of a minority in whatever culture that you're in. Um, because they just, they tend to feel like there might be a shared understanding of this person. They get me. Yeah. And they get me is something you really want to feel when you're with a therapist. Yeah. It takes a lot of that hopelessness out of the equation, right? So that's something to think about. A lot of, we therapists have just profiles online nowadays. You can even see reviews for therapists, but read those with a grain of salt. [Music] So, and then finances is always often a really, really big challenge for people. So sometimes we're limited to people, if we have insurance, who are on, America at least, on our insurance panel. I think you can overthink the question too much as well. As a risk, and you can bypass the work by jumping from one therapist to the next. That's something I've seen way too many times. Is I say, when you embark on a course of therapy, commit to yourself that unless there's XYZ huge egregious, uh, you know, errors in in the process, then stick with it. Give it a chance of X number of sessions, because if you're getting your buttons pushed, that might just mean it's working, right? Yeah. I, it's, people ask me like, how many sessions should I try? And it's, I mean, I can throw an arbitrary number at you, but do it. Really, it's, it's, uh, you should have at least, should I encourage you to have at least one, um, tense interaction with your therapist where you confront them about your concerns, like, hey, I don't think this is working, or whatever, before you decide to go to somebody else. And see how they handle that, because, you know, not every therapist will handle that well. Remember, therapists are people, and just like there are good carpenters and bad carpenters, there are good therapists and shitty therapists. Yeah. Um, so it's not that you have to stay with your therapist because we're telling you to try to see it through, but, um, get, play with it a bit. Like, give them a chance. See if, how they handle that. And if your trust in them builds and grows, then it's a good sign that you ought to stick with them. Yeah, I like that. And that's, that's an approach I've almost insisted on in a number of settings where I've supervised clinicians and people are doctor or therapist shopping. Is like, put it right back into the therapy room. You too, I would have a frank discussion about it before we're even going to consider that. Right. Yeah. And I'll say, some, some of the best therapy outcomes I've had with clients have been after several, um, like therapeutic relationship repairs. Where I've said something. I remember one client came to me and said, uh, I was really offended when you yawned in our session. And, uh, of course, I, my, in my all, all my parts get activated. I'm thinking, well, I was tired, or do people just yawn? Come on, right? I'm getting a little defensive inside. Um, but because I'm a trained therapist, damn it, I did not get defensive in the interaction, and I reacted in a very, you know, therapist type of way. And she trusted me so much more after that interaction. We were able to do a lot of really interesting work about why she felt the way she did in response to my yawn, and where else does she feel that way in her life. And, but if I just said, you're right, I tend to yawn, I have sleep apnea, I can't promise I'm not gonna yawn, you might have to find a different therapist. Or if she just had gone home and being like, he yawned, he's probably bored, he doesn't like me, and never came back, then we wouldn't have been able to experience the improvements that she experienced as a result of continuing therapy after that. A corrective emotional experience. There you go. Yeah. Yeah. So sticking with it long enough to see whether or not it's going to help is advisable.

The combination of therapy and medications, as people are, things people often ask about. We're talking about, you know, how does therapy work? Does it work? We could easily have an episode on antidepressants or psychotropic medications with the same question. One thing I will say is that most of the research suggests that the combination of the two is more effective than either one by themselves, depending on the condition. Is that your understanding too, Reid? That if it's combining the right psychotropic med with the right therapist is kind of the best? Yeah, it's always, it's always my default answer. That's an easy one. Which one should I do? Meds or therapy? Or medicine, therapy? It's always either start with therapy, and then if you need meds, keep the therapy going. Or if you're on meds, do medicine, therapy. Is that a common? I mean, I know several psychiatrists, but is that a common belief among the psychiatrists that you roll with? Start with therapy? Well, it's a good question. I think there may be that belief in most. But when the rubber meets the road in the real world, and you're faced with finding a therapist who's available and accessible and affordable to the client, then, um, you might be dishing out meds way more or way sooner than you'd like to, because of that. Yeah, a real-world systems problem, right? Yeah. And I've noticed a pattern in some clinicians, you know, where psychiatrists or other prescribers of psychotropic meds, if they encounter a roadblock or just clients not making a lot of progress, then it's maybe you should try therapy. And then on the therapist side, you know, not making progress, maybe you ought to be on some meds. Yeah, I've seen that pattern sometimes, which, you know, maybe it's an indication that both would be better. Yeah. Because if you look at one of the more common conditions in mental health, ADHD, you know, which back when I started in this field, the prevalence rate was cited at around like 5%, and now more recently, it's above 10%. 10.5%. Yeah. Um, and climbing. But, you know, and that's another rabbit hole we'll avoid. But we may have covered on another episode, an episode called ADHD. Yeah, go look at it. Yeah. But, uh, the, I think the ideal path would be to, even though stimulants work really well, some of the best response rates we find still, I would much rather start a client, kid or adult, on psychotherapy. But where do you find a psychotherapist who's going to focus on ADHD, who's available and covered by insurance? Your insurance, right? It's difficult. It's difficult. And I know, of course, we would be the people to ask these questions, and it would, we would love to have really, really clear answers for the people in our lives, for our clients, for people listening. But there's a huge butt coming up. But these are just the, this is the reality of mental healthcare in America right now. It's really difficult to find the specialist that you want at the price you can afford with the availability that works for you. Yeah. And this, it's well said, and it, it brings to mind that there are two forces at play. Like, one, the stigma is reducing, and people are being more vulnerable around their mental health and more willing to address it, less shame around asking for help in that way, which I think is is amazing. And also, in this difficult time we live in, and when people are turning towards their, working on their mental health more, we have a shortage in the profession, you know? Yeah. Yeah, a shortage of mental health professionals. Um, you know, being a mental health professional is hard. It, uh, isn't incredibly lucrative for most of us. You know, like a lot of helping professions, you know? Yeah. And so you have this sort of increased supply, or excuse me, um, it's an increasing supply, but it's not increasing fast enough to meet the demand. Yeah. And I, back to the analogy you brought up of physical therapy, I've used that time and time again, that, you know, healing or recovery from whatever the struggle is, is a lot like physical therapy, and it takes, you know, repetitive, consistent visits and a lot of practice in between. And then you won't see the results necessarily overnight, right? And it does take patience. It is one of the reasons we are so attracted to psychedelic-assisted psychotherapy, or I should say, one of the reasons we were so attracted. Is I think it has the potential to address this from at least one angle, because, you know, some of the preliminary data suggests that, um, you can get there faster with psychedelic-assisted psychotherapy. And by there, I mean, you're well enough that you might not need further intervention, that you're well-resourced enough that you can, you know, go it on your own. So that's one of the ways, at least Reid and I are trying to approach this problem, is as we both research and provide psychedelic-assisted treatment, is just trying to help people with a powerful treatment so they don't need as much. Yeah, accelerated courses of therapy. Yeah.

Well, anything else about why psychotherapy works, uh, how it works? Uh, of course, as usual, our podcast has been exhaustive. We have covered in every single point that is possible to cover. Hopefully, you can detect my irony in my voice. But yeah, anything you think is noteworthy that we ought to, you know, as we talk about, uh, these patterns and how we have corrective emotional experiences to heal those old wounds and lay down new predictions, or when we have memory reconsolidation or extinction of patterns, it just reminds me of this overarching goal is not to just fix those in the therapy room, but help the client learn, develop the skills and confidence to correct and self-correct themselves throughout their lifetime. Yeah. Yeah, I like that. Yeah, I mean, and what is the expectation going into therapy? It's a good life. A mentally healthy life is not one free from discomfort. You know, if anything, it's one where you feel equipped to navigate discomfort such that you can live a life that is meaningful, a life that is filled with love and freedom and peace of mind and aliveness. Um, and if you can do that, then you're gonna live pretty good, pretty pretty decent life. So to that end, we will continue to do our work as mental health professionals. And for those of you listening who are in the profession, thank you for all your dedicated work and for listening. And for those of you who aren't, we love you. Thank you for being here, our loyal listeners and fans. Good chat, Steve. Good job. Good intro and closing. Thank you. Yes. Not too painful. You can cut that out if you want. Whatever. Every time Reid compliments, maybe we should, we should do a highlight reel. Copy paste it. There we go. All right. Okay. See ya. Thank you, dear listener, for listening. It means a lot to me. Psychedelic Therapy Frontiers is brought to you by NovaMind, a mental health company that specializes in psychedelic medicine and research. You can learn more about NovaMind's mission to increase access to legal, safe, and evidence-based psychedelic medicine at novamind.ca. If you like what you heard, please subscribe to the podcast on whatever platform you're using to listen or watch. Also, if you're feeling generous today, please leave us a glowing review on Apple Podcasts, Stitcher, or wherever you like to listen. If you'd like to reach out to us with questions, suggestions, scathing criticisms, etc., please email us at psychfrontiers@novamind.ca. Thanks again. The content of this podcast does not constitute medical advice or mental health treatment. Please consult a medical or mental health professional if you believe you are in need of mental health treatment.