The Music Theory of Psychotherapy
As a white dude in his early twenties with a penchant for melancholy, at some point, I had to learn guitar. This seems to be genetic destiny for my people, like how homing pigeons instinctively know how to find True North. At some point our DNA activates and we know that the world must hear our feelings, that there are women out there who need guitar played at them. (Academic sidenote: scientists believe it’s the same gene that’s now being activated and leading guys to start podcasts.)
Mercifully for the world, I wasn’t much good. I just never had the knack. My total lack of musical education as a child left me completely adrift in the swirl of melody and rhythm, let alone finger placement. I learned some chords, I learned all the songs you’re assuming I learned (yes, those ones), and I learned scales.
At first, scales seemed like the magic formula. Once you had scales, you could “jam” with people. The fantasy of kicking off my flip-flops, flashing my hemp necklace, and being welcomed into the brotherhood of chill dudes had never seemed so close. Here’s the problem: I often couldn’t identify what key the music was in, and even if I could, I still had to contend with rhythm. For the uninitiated, a “key” in music identifies the frequency cluster around which the notes revolve so they sound coherent and, well, good together. Rhythm is the speed at which the music progresses so that people can play together at the same pace. (In case you needed my whiteness bona fides, here I am feeling the need to define “rhythm” to the reader, implying that I was ignorant of it at the time.) Getting either wrong is jarring, strident, and most assuredly not chill, despite your dope hemp necklace and rainbow flip-flops.
No matter how good you are at playing scales—no matter how fast, technical, and confidently you can rip through a pentatonic scale or Phrygian dominant scale—if you don’t know what key you’re in, you’re hosed. If you don’t know the meter you’re playing in, you’re hosed. In order to jam, you need to know the key, the meter, and what the song wants or needs. So knowing a scale is great, but it’s just a small piece of the picture that requires holistic awareness. Conversely, even if you aren’t great at scales, but you know the key and the meter, you can probably add something pretty cool and earn the much-sought-after slow head nod from the chill guy jam session.
I’m telling you this because learning psychotherapy today feels remarkably similar to my guitar disaster. And just like my musical education, the therapy world has gotten obsessed with the wrong thing entirely.
Lost in the Alphabet Soup
To learn to become a therapist now is to approach a swirling array of acronyms, each purporting to be the way to “heal trauma.” These acronyms, completely inscrutable to a beginner, don’t become much clearer once you learn what they stand for. IFS stands for “Internal Family Systems,” a name that suggests you’ll be working through your internalized family relationships but actually approaches each individual’s disparate thoughts and motivations as an encapsulated inner family. ACT, perhaps the most cleverly named of the bunch, stands for “Acceptance and Commitment Therapy”—the implication being that other therapies somehow don’t focus on acceptance or commitment. EFT sits at the unfortunate center of a theoretical turf war and could mean either “Emotional Freedom Technique” or “Emotion Focused Therapy.”
Patients entering therapy, and new therapists alike, would naturally assume that these theories account for major differences in therapeutic outcomes, just as antibiotics and Tylenol give you completely different effects. It would seem obvious that since the therapy world invests so heavily in producing these different techniques, the return must be enormous in terms of reducing human suffering. And it would stand to reason that the proliferation of new techniques reflects a linear march of progress—that as we understand the mind better, new and refined techniques emerge that produce better and better results.
This is all, mostly, crap.
The therapy world’s obsession with techniques is missing the point, what actually makes therapy work, and how both therapists and patients can focus on getting better results. Because when we get this wrong, people get mediocre therapy and therapists waste their time learning techniques when they could focus on improving their actual game.
The Do Do Bird Effect
Time and time again, in large meta-analysis after large meta-analysis, research shows that the type of therapy doesn’t matter. They all show roughly equivalent outcomes. This is not some esoteric secret among academics. The American Psychological Association reviewed the data and released a statement noting that all evidence-based therapies are roughly equivalent. This is known as “The Do Do Bird Effect,” named after the race scene in Alice and Wonderland. The Do Do bird was tasked with judging the race, got distracted, and then declared everyone equal winners.
That’s not to say there aren’t differences in clinical outcomes—there absolutely are. However, they lie in other areas. Individual therapists vary wildly in their impact on patient outcomes, but it doesn’t seem to matter as much what techniques they’re using. Meanwhile, the much-vaunted strength of the therapeutic alliance has been identified as the major factor predicting how successful therapy will be.
Unfortunately, while these findings are well-known and widespread in the therapy world, therapists continue to produce and learn new techniques. There are several reasons for this.
First, most people don’t know an alternative model exists and thus remain stuck with techniques. Second, therapists are incentivized financially to produce techniques—becoming a technique trainer, or even a creator, is how you ascend to the ranks of alpha therapist, finally pay off your student loans, and maybe even get a vacation home. Third, universities and academics like studying techniques because they’re discrete, observable, produce more acronyms, and lend themselves to short studies that satisfy the publish-or-perish culture. Finally, real-life therapy is confusing. There are a million different variables at any given time. It’s hard to know what to attend to, what causes what, and how to help. So techniques offer some sort of structure.
But none of this helps patients all that much.
There is a better model out there. It’s the result of 50 years of clinical research, integrates neuroscience and evolutionary theory, and harmonizes many disparate and seemingly contradictory ideas in psychotherapy. I’ll expand upon its facets in future posts, but for now I want to propose that the power lies in discerning and embodying the correct healing attitude—unique for each patient—over any specific technique.
The Key is the Right Key
I’m assuming you know how I’m going to bring the metaphor from the beginning back here.
Learning techniques in therapy is like learning scales. They’re great, but they’re woefully incomplete. Just as a guitarist needs to read the room before choosing their scale, therapists need to read their patient before choosing their approach.
Let’s say we have a patient who comes in with heavy drinking, a lot of marital conflict, and who was recently mugged—now they’re having nightmares and feeling jumpy at night. This sounds like a real case. In a university setting, this person would have been eliminated from a trauma study because they have the “confounding variables” of substance abuse and marital conflict.
So where do we start? Maybe our therapist just took an EMDR training and they hone in on the mugging. Cool, cool, cool, but even then there are factors to consider. First, how does the person coming to therapy experience the therapist offering this technique to them? Do they like the authoritative tone of an expert offering them a solution? Or do they bristle at a jargon-laden explanation that, frankly, defies common sense from some bearded idiot in a stupid sweater?
Also, before we even start, is that actually what the person says they want to work on? What if they want to focus on their marital conflict? And should you trust them? What if they have a history of ignoring obvious problems until they’re too far advanced? And now what if they both have authority problems AND they ignore problems and they tell you they want to focus on things that don’t seem as pressing?
I’m suggesting, along with a lot of research, that the key to successful therapy is first understanding the rhythm and the key you’re playing in, followed then by the scales and techniques. The rhythm and the key of therapy is the type of relationship this person needs in order to feel emotionally safe, cared for, and supported.
The tragedy here is that many therapists haven’t been offered in-depth training about how to identify the correct, personalized attitude to adopt for each individual patient. So we’re stuck with an epidemic of therapists out there just playing EMDR at patients. (I’m not trying to pick on EMDR here—it could be CBT, psychoanalysis, ACT, etc.)
But there’s a better way—one I’ll explore in detail in Part 2, where we’ll dive into an in-depth, fictionalized but realistic case example that shows what this looks like in practice.
