Therapy Has All the Pieces

For as long as we've been able to think about our own experience, we've been trying to make meaning out of our suffering. It's the foundation of most religions, most philosophies, most of how we understand what it means to be human. We are the species that suffers uniquely, and the only species that knows it suffers, and we've spent thousands of years trying to decipher it. Maybe it’s a test, or a teacher, or the price of consciousness. It seems like it makes us deeper, or more real, or more human.

And through that deciphering and meaning making, the suffering has become a way we define what makes us…us. Our suffering becomes our identity. "I'm an anxious person." "I've always had a sensitive stomach." "I have ADHD." The suffering stops being something that's occurring and becomes who we are; a fixed trait, like eye color or height. And once that happens, the relationship to the problem fundamentally changes. You don't try to fix your eye color. You live with it. You work around it. Maybe you find a way to appreciate it.

And medicine, despite the research saying we are constantly changing, has been largely operating under the same model. That what our bodies are presenting in this moment is an immutable fact, and we must manage and work around it. Chronic diseases can go into remission but they are part of us forever, whether we like it or not. So they take the things that they see as their domain and they give them names - depression, Parkinson’s, ALS, fibromyalgia, IBS. And the diagnosis doesn't just describe what's happening, it defines what you are. For thousands of years, that was where the story ended. You suffered, it meant something, and it was yours to carry. Until one neurologist started wondering whether the patterns he was seeing in his patients were fixed features of who they were, or if they were possible something that had been learned instead. And this line of inquiry, looking at where our patterns come from, and if they are in fact changeable, led to the creation of a field that, without realizing it, got remarkably close to the answer of how to reverse chronic diseases.

Questioning the fixed identity

In Vienna in the 1890s, a neurologist named Sigmund Freud was trying to understand why some of his patients couldn't move their limbs despite having no physical injury, or why past experiences seemed to control present behavior in ways people couldn't explain or stop.

He started noticing things like a woman whose father died when she was twelve who would, twenty years later, still react to authority figures as if they might abandon her at any moment. A man who'd been humiliated in school would avoid situations as an adult where he might be judged, his body responding with a racing heart and shallow breathing as if the childhood classroom threat were happening now. Freud also noticed that talking about these experiences, bringing them into conscious awareness, sometimes helped. Not always, but often enough that he built an entire practice around it. He called these stuck patterns "repressions," believed they were buried in the "unconscious," and theorized that making them conscious through psychoanalysis would resolve the symptoms. We now know that he was seeing something real and physical: the threat circuit getting activated by cues in the present that matched patterns from the past, and the amygdala firing because something in the current situation pattern-matched to a previous threat, triggering the whole cascade even though the original danger was long gone.

So Freud built a model to explain what he was observing. The Oedipus complex, penis envy, id, ego, and superego battling for control, defense mechanisms, and psychosexual stages. In the absence of any established way to make sense of this, he created his own explanations to detail what he was observing. And because Freud was brilliant and persuasive, and because his observations about people getting stuck in past patterns were genuinely accurate, his model became the foundation of psychology for half a century. His educated guesses becoming dogma, as we have seen so many times before.

By the 1950s, a generation of researchers had been trained in Freudian theory, and many of them were starting to notice it didn't actually work very well. Psychoanalysis required years of expensive treatment, produced inconsistent results, and couldn't be tested scientifically because every failure could be explained away as resistance or insufficient analysis. It had become unfalsifiable—if you got better, psychoanalysis worked; if you didn't get better, you weren't ready to get better yet.

So in reaction to this unfalsifiable and not very effective framework, behaviorism came along. B.F. Skinner, Joseph Wolpe, and others said: forget the unconscious, forget Freud's model, forget everything that can't be directly observed and measured. Behavior is what matters and symptoms are learned responses to stimuli. Change the stimulus-response pattern and you change the behavior. And they were able to prove it too. Wolpe could take someone with a snake phobia and, through systematic desensitization, gradually exposing them to snake-related stimuli while they remained calm, eliminate the phobia in weeks instead of years. Skinner showed that you could shape behavior through reinforcement schedules, and that consequences determined what behaviors persisted.

The behaviorists were right that Freud's elaborate method was wrong. They were right that you could change emotional responses through learning. They were right that observable behavior mattered more than untestable theories about unconscious drives. But in their eagerness to reject Freud's unfalsifiable explanations, they threw out the baby with the bathwater and started a movement where thoughts and feelings got removed entirely from the field. Only what could be externally observed and measured, stimulus in, response out, counted as real.

What both sides were actually documenting was the same phenomenon from different angles. Freud had noticed that past experiences created patterns that activated automatically in the present. The behaviorists had discovered that you could change those automatic responses through repeated pairing of the trigger with a different outcome. Both sides observing our ancient learning system that could be updated through experience, but only under specific conditions.

By the 1960s, both approaches dominated different corners of psychology, with psychoanalysis mostly in universities and private practice, and behaviorism mostly in research labs and institutional settings. And this is when Aaron Beck, who had been trained as a psychoanalyst, was running experiments trying to validate Freud's theory that depression came from anger turned inward. He was using dream analysis to look for evidence of this repressed hostility. But what he kept finding instead was that his depressed patients had consistent patterns of negative thoughts about themselves, their experiences, and their future. The same patient who seemed fine discussing neutral topics would, when talking about their lives, automatically interpret everything through a lens of failure, inadequacy, and hopelessness. "I got a B on that test" became "I'm stupid." "My friend didn't call back" became "Nobody likes me." "This therapy session went well" became "I'm just fooling you, eventually you'll see I'm hopeless too."

Beck started calling these automatic negative thoughts, and documented how they preceded emotional shifts. A patient would be talking normally, then one of these thoughts would flash through their mind, often so quickly they barely noticed it, and suddenly their mood would drop, their posture would slump, and even their voice would change. It was as if the thought had triggered something physical. Which, of course, it had. What Beck was observing was the high road feeding the low road, thoughts activating the amygdala, triggering the threat cascade. But Beck didn't have that framework. What he concluded was that these distorted thoughts were causing the depression.

This became the foundation of Cognitive Behavioral Therapy (CBT). Beck identified common patterns of what he called cognitive distortions, like all-or-nothing thinking, overgeneralization, and catastrophizing. (Which if you look at this list, it’s exactly what your brain should be doing when it’s making quick real time threat assessments. When you’re threatened, that isn’t the time for nuanced thinking, it’s a time to make a quick decision so you can act. These are adaptive thought patterns when you’re in threat mode.) He then developed techniques to help patients identify and challenge these distorted thoughts. So for example if you notice yourself thinking "I'm a complete failure," you examine the evidence. Is that actually true? What evidence contradicts it? What would you tell a friend who said this about themselves? The idea was: fix the distorted thinking, and the emotions will follow.

This seems like it should work based on what we just established, right? Our ability to think threatening thoughts activates our pathostatic chemistry, so thinking different thoughts should turn it off. And it does help, a lot, when certain conditions are met. We'll go into this more in the next chapter, but the problem can sometimes be that these aren't conclusions someone reasoned their way into. They're conditioned associations that got wired into the threat circuit through repetition. Think about the woman who had an asthma attack from a paper rose as an example. Her brain had learned 'rose = danger' so thoroughly that the visual pattern alone triggered the cascade. The same thing happens with thoughts. When the threat circuit fires repeatedly at the same time you're thinking "nobody loves me" or "I'm a failure," those thoughts become part of the trigger pattern itself. Now the circuit triggers the thought, and the thought triggers the circuit. They're wired together, bidirectionally, reinforcing each other. You can't just reason with a conditioned response. And trying to talk yourself out of a threat loop that was learned through experience doesn’t always work. But you can use CBT techniques to update the prefrontal cortex response to this learned pattern.

What Beck had noticed was true; thoughts and emotions ARE connected. The high road does feed the low road. But people started to notice that this approach wasn't helping everyone; some patients were getting sicker and more stuck, so some therapists started to wonder: what if there was something going on in the body that talk therapy wasn’t addressing.

Trauma therapy is born

A psychiatrist named Bessel van der Kolk started documenting what he was seeing in his trauma patients. They would come in with histories of childhood abuse, combat exposure, assault, or loss, and just addressing their thinking patterns wasn’t working. They could challenge their thoughts all day long, "You're safe now, that was in the past, your reaction isn't logical", and their bodies were still reacting as if the threat were present. And Van der Kolk noticed these weren't just presenting as memories, they appeared to be full physiological states that got activated by present-moment cues. A combat veteran would hear a car backfire and his entire nervous system would shift before his conscious mind had time to register "that's not gunfire." A woman who'd been assaulted would feel a hand on her shoulder in a crowded room and her body would freeze, shut down, go numb, exactly as it had during the original attack. The past wasn't acting like the past in these people’s brains, it seemed more like it was encoded in the body, ready to replay at any moment.

Based on what they were seeing, that these past experiences seemed to be playing out in the present, they concluded that trauma was stored in the body, and that to heal, it needed to be somehow released, processed, or integrated. This idea resonated so much with people, finally there was a model that included more of what therapists were seeing in the therapy room, that the field exploded. Peter Levine developed Somatic Experiencing based on watching animals shake off their threat activation, theorizing that humans needed to discharge trapped survival energy. Pat Ogden created Sensorimotor Psychotherapy to help people complete defensive responses that had been interrupted. Richard Schwartz's Internal Family Systems noticed these activation patterns and came up with a model that theorized that we had parts inside of us carrying childhood wounds that needed to be unburdened.

All of these modalities were seeing the same thing: your threat system doing what it knows how to do. Firing the same patterns when triggered that it's been firing since the original event. These were conditioned threat responses, the same mechanism that gave the asthma patient a reaction to a paper rose, just playing out across different systems.

And it turns out that working with these threat responses, while they’re happening, is actually the key ingredient to reversing the engine driving pathostasis. We will look at the science around this in the coming chapters. The problem was that working with the body in this way, working with someone in these threat states, is only possible if the patient’s prefrontal cortex is online to drive the bus. To interpret what is happening alongside the 500 million year old threat response. And therapy saw this. If someone is fully stuck in threat mode, and no part of their thinking brain is online, no work can be done, and actually you can wire in more threat onto the old. So in response to this, in 1992, psychiatrist Judith Herman published "Trauma and Recovery," which established what became the standard trauma therapy approach: a three-stage model where establishing safety had to come first, before any trauma processing could begin. Herman wrote that 'the first task of recovery is to establish the survivor's safety - this task takes precedence over all others, for no other therapeutic work can possibly succeed if safety has not been adequately secured.'

And these preparation stages are essential to get patients ready to do the work so they don’t completely shut down. The only problem is when the safety requirement becomes a way to avoid activation all together rather than work with it. And because our entire culture is organized around one implicit message: don't feel bad, feel good. Medicine says reduce your stress, manage your symptoms, take something to feel better. Wellness says optimize, regulate, calm your nervous system. We do this socially too; we tell people to look on the bright side, we offer them a drink, we try to reason their pain into a lesson. The message from every direction is the same: the activation your body is producing is the problem, and the goal is to make it stop. So when therapists started working directly with these body-level threat responses and patients were getting intensely activated, sometimes the activation itself was seen as a threat, which can sometimes get in the way of doing the work necessary for healing.

Because if you see your activation is dangerous, you're adding a new threat on top of the original one. Your threat system gets activated, which is something that happens to every animal, every day, as a normal part of navigating life, but now you're afraid of that activation itself, which signals more danger to your amygdala, and on and on it goes. That activation of the threat circuit, which is the very thing that needs to happen for the pattern to update, is itself now a threat. Now you're not just afraid of the original trigger, you're afraid of being afraid. You're afraid of your racing heart, your shallow breathing, the physical sensations of activation. Which is actually one of the main reasons we get stuck in pathostasis in the first place, this feedback loop of activation causing activation. Because what is called retraumatization is actually just activating the threat circuit, which you need to do in order to update it. It becomes retraumatization when you do so without realizing that it’s safe and actually the goal - when you accidentally become really activated and then see that activation itself as dangerous, which adds more threat and trauma onto the old. The paper rose woman had a full asthma attack from a visual cue. That activation wasn't "re-asthmaing" her. It was her learned pattern expressing itself, and you can't change a pattern without activating it. The activation itself isn't dangerous; it’s actually the mechanism through which the learning happens.

Some therapy modalities do this explicitly. EMDR has you think about the traumatic memory while doing bilateral eye movements, which means you're activating the threat circuit on purpose while engaging your prefrontal cortex. Prolonged exposure therapy has you repeatedly revisit the trauma memory in detail until the activation decreases, to show your system that the expected catastrophe doesn't occur. Somatic approaches have you feel the body sensations associated with threat activation while you're actually safe.

These and other fields of psychology were doing ground breaking work. They were seeing something that medicine couldn’t: that this was happening not just in our 'thoughts', as though those were just floating in the ether, but in our brains and subsequently, our bodies. The therapy world had mapped out all the pieces needed to work with chronic disease. Therapy, the red headed step child of the medical world, actually got the closest of anyone to the actual mechanism that can address it all. Step back and look at the whole landscape of the work that the therapy world was doing, and the map is actually right there.

So let’s do that. Let’s take a step back and look at what the learning and behavioral research tells us about how these patterns actually update, and see if we can piece together the map that therapy was circling around.