The Therapeutic Philosophy
What is a Therapeutic Philosophy?
It is tough to articulate one’s therapeutic philosophy. After all, what is a therapeutic philosophy? It is an organizing principle, a lens that equips the therapist to provide a story to one’s experience, to answer the “how” and “why”, bridging the connection between what has happened, what is happening, and what is yet to happen. It is to assume that there is a structure to experience and that this structure abides by certain principles. It is a theory of motivation and the more that I have been practicing, reading, and living, the more I have come to view the Therapeutic Philosophy as a theory of Anxiety.
A theory is a model for something. We need theories to make sense of the world. It is what allows us to infer, predict, and understand. It is perhaps the greatest tool to humanity, that which relieves the Anxiety inherent to the unknown, through the imbued a sense of power, of agency.
Psychological and therapeutic theories abound. There is no shortage of conflicting and competing therapeutic modalities, each offering their own competing explanatory framework for the cause of psychological distress and subsequent prescriptions for well-being: cognitive distortions, polarizing “parts”, cognitive “fusion”, Magical Thinking, skills deficits, repression. The list is close to endless. The therapist is left with a seemingly overwhelming number of options to choose from. The disagreement and conflict among related therapeutic traditions is seemingly akin to the perennial conflicts between the great religions: each offers the way and the only way, and the way that pioneers of popular modalities are idolized is indicative of this fact. I have found it rather curious that there has been such controversy and conflict within the psychological and therapeutic field. It is no short a testament to both our collective creativity and–tragically–inability to understand ourselves. We seem to be blind to our own nature.
Perhaps the appeal of modalities lies in the promise of the “Answer”. There is some relief and comfort held in this promise. People want to know that there is an answer, a way out, a solution to their suffering, and therapists want to find that answer, both for their clients and themselves. The objectification and pursuit of this elusive answer, I believe, is reflective of our deep rooted desire to seek certainty, of our collective vulnerability (anxiety) and our inherent discomfort with confusion. There is no doubt that the therapeutic realm has suffered from “second hand smoke” from the physical sciences, as evidenced by the therapist's requirement to justify the need for treatment to lovely insurance panels through diagnosis and rigorous treatment plans. There is something comforting and reassuring and being able to label and identify something. It gives us something to do about it.
Yet, among all the seemingly different ways to understand the human experience, we have to plant our flag in the ground somewhere. As such, therapists tend to specialize in modalities practiced by those they admire or those they themselves resonate with—modalities that provide them with a sense of comfort and security. In this way, the specialization of the therapist is largely indicative of their psychology.
Therapeutic Techniques and My Developments as a Therapist
My trainings and specializations in Anxiety, OCD, and PTSD are reflective of both my early experiences as a therapist—first joining a trauma-informed private practice—my early experiences with anxiety (namely social and performance anxiety), and my resonance, as an early therapist, with the related treatment approaches, primarily CBT (Cognitive Behavioral Therapy). I was, no doubt, allured by the promise of “The Answer.” I remember reading one of my first books on psychology as a late teenager, at the suggestion of a counselor of mine at the time—Feeling Good by Dr. David Burns. I will never forget the feeling of astonishment, relief, and almost euphoria at the knowledge that there was not only someone who had dedicated nearly an entire book to the topic, but that there was a reliable reason—a mechanism—behind my suffering and behind that of those I cared about.
There was a way out, a cure, a hope for relief and lasting well-being at the hands of the omniscient “Other.” Identify my “negative, self-defeating thoughts,” identify the distortions, and then challenge and replace them with more reasonable and realistic ones so as to put the lie to the former: the Triple Column Technique. If only I could see the world as it was, then I’d be free from suffering. There was something comforting in this promise and in the act of doing this exercise, as it encouraged the idea that relief was within my control. Yet, it always felt anticlimactic. This speaks to my naivety at the time. It was, no doubt, foolish to believe that I could reframe my deep-seated social anxieties after just five minutes of completing a worksheet. This is not to discount the value and impact of such an exercise, especially in times of overwhelm or crisis. I remember being in my early 20s, getting my heart broken by someone I thought I loved, breaking down, and pulling out my phone to do the Triple Column Technique. I needed relief. I needed to see—to know—that what I was feeling and thinking about myself and my future prospects was disillusioned, that it was not the world. Anything to take the blame off reality, which was too overwhelming to bear.
Unknowingly at the time, I was operating under the assumption that CBT and its related techniques could provide an escape hatch from all of my suffering—that my anxiety, stuttering, and social insecurities were reflective of something being “wrong,” and that these experiences were within my conscious control to eliminate. I realize now how tragically hopeful this expectation was. It never could have occurred to me that, in fact, yes—people can be that scary; that heartbreak simply hurts and there is no way around it; that these experiences—pain and suffering—are part of living, inseparable from the fabric of being.
There is, no doubt, a distinction between the “neurotic” and the “human” dimensions, as Viktor Frankl articulated, and parsing out this difference is a large component of the therapeutic process. This is captured beautifully in “Ilomilo” by Billie Eilish: “The world is a little blurry. Or maybe it’s my eyes.” There is perhaps something more comforting in the neurotic—in it being one’s “eyes”—as it affords a sense of agency. There is something deeply terrifying in accepting that it—whatever “it” is—could be the world. It signals something that is, and has always been, fundamentally true but was too overwhelming to acknowledge. Perhaps the “blurring” itself is the very shield that protects us from seeing that which is too overwhelming to see.
We cannot escape the confines of our existence. Our bank accounts, unfortunately, have a decimal. Our bodies are bounded, finite, and vulnerable to illness and injury at every moment. Those we love are always and forever “out there,” vulnerable to everything that “out there” has to offer. It seems that we are each trapped, held hostage to the very forces of nature—of existence—that we so desperately seek respite from. Given this state of affairs, it is—on the contrary—nothing short of bizarre that we are not anxious all of the time. It almost seems insulting, the promise that one could “outthink” or reframe away one’s anxiety—a testament to our hubris, to think that we can transcend our captors. After all, how many times has completing a worksheet—be it for school or any other learning endeavor—reliably and sustainably led to a lasting change in how one perceives oneself and the world?
I do want to acknowledge that there is a canary in the coal mine here, and my intention is not to discount or discard the philosophical underpinnings and techniques that CBT has to offer. It is one of the most effective and well-researched therapeutic modalities we currently have. How we perceive the world largely—if not entirely—defines the core of our being. Yet, I am trying to point out that there is a fundamental limit, an upper bound, to the amount of relief and insight that any direct therapeutic technique—be it reframing, cognitive restructuring, or emotion regulation skills—can provide. The emphasis on conscious reframing, I believe, confuses the cause for the symptom. It neglects function and implicitly identifies the protector as the culprit. After all, why do cognitive distortions exist? There must be something deeper, something more fundamental, underlying what brings dis-ease.
What is my Therapeutic Philosophy?
Of course, people aren’t anxious all the time. This is a mystery in my eyes. How might this be? How could this be?
I have recently been influenced by the central thesis put forth by Irvin Yalom in Existential Psychotherapy: namely, that anxiety is inherently woven into the fabric of being by virtue of the “givens” of existence—our vulnerability to and inescapability from death; the inherent loneliness of existence—the fundamental experiential bridge that will forever lie between I and You, and the ensuing sense of vulnerability that brings; the fundamental responsibility we bear for our own experience; and the challenge of cultivating meaning despite these realities: Death, Isolation, Freedom, and Meaninglessness, respectively.
For Yalom, these existential givens are the central causes of anxiety; they are what we feel anxious about when we feel anxious. Not only that, but the objects of our anxiety (our fears) are manifestations, symbols, archetypes, and representations of underlying fears of Death, Isolation, Meaninglessness, and Freedom (another essay would be warranted to further explain exactly how each of these manifests, as it is beyond the scope of this current exploration). This highlights a rather interesting distinction betweenAnxieties and anxieties, the former being the central source of our discontent, providing the subtextual meaning for the latter, which are symbols of the former. The existential perspective argues that there is a specific meaning to Anxiety, that it has its roots in experiential truths. Not only that, but there is a psychological and developmental “timeliness” to understanding and grappling with these givens, such that there are moments when we are or aren’t ready to do so. Denial, according to Yalom, is essential for psychological development and is an adaptive, organic, and unconscious mechanism that shields inherent Anxiety from conscious awareness before full psychological maturity. Problems arise not from “dysfunction,” but when these organic and adaptive defenses that shield fundamental anxiety break down, leading to rigid, inflexible, growth-inhibiting psychological modes of functioning.
The implication is profound: dis-ease arises not from “pathology,” but from a breakdown in unconscious defense structures. This idea has been deeply influential for both my personal and professional perspectives on mental health, in that it collapses the distinction between “normal” and “abnormal” to one of degree of defensive functioning, instead of categorical differences between fundamentally “healthy” and “pathological” individuals. The tragic paradox of the predicament that we so often find ourselves in is that the very defenses that, in their collapse or overextension, originally functioned to fend off fundamental anxiety, thwart the very sources of emotional well-being that we seek, for the cost of such would entail having to confront our existential situation, from having to confront our Anxiety. Yalom quotes Otto Rank: “We refuse the loan (life) to avoid the debt (death).” Anxiety relieves itself. The distress we feel inherent in our defenses protects us from confronting some deeper, more uncomfortable truth or reality. Recovery isn’t one of escape from, but escape into; that is, only when we can turn toward our anxiety and fully and consciously accept all of the potential meanings that our anxiety presents to us can we hope to find long-lasting relief.
This perspective is but one among many that offers explanatory power for why we feel the way we feel. It also does not directly change or diminish the utility of conventional techniques and modalities. Cognitive reframing, DBT skill-building, and EMDR remain warranted and necessary for specific experiences and presentations, and proper medication management is always a part of an effective treatment plan. We can’t outrun our biology, unfortunately. Yet, it points to an often unrecognized, deeply resonant, and unifying “matter of fact” of our psychological experience: that we and those we love are subject to death; that our time is finite; that we must, on some level, venture through this world alone; that we are ultimately the only ones who can live our lives; and that we seek to find and create meaning despite these facts in an uncertain world. The existential perspective adds a piece to this thing that is the human puzzle, making available certain information and meanings that would otherwise be unavailable.
And so at the end of this exploration, I surmise I could sum up my part of my current therapeutic philosophy as follows:
There are certain givens to our existence that are inherently terrifying.
In the absence of premature exposure or environmental stress, adaptive, necessary, unconscious, denial-based defense mechanisms naturally develop to shield fundamental anxiety and set the foundation for healthy psychological development.
Due to either premature exposure or environmental stress, these natural, denial-based defenses collapse, resulting in ineffective modes of coping with fundamental anxiety, which inhibit growth and psychological flexibility.
The therapeutic environment serves as a kind of microcosm to cultivate awareness, understanding, and acceptance of one’s defensive structures and to facilitate and potentiate alternative modes of being through a safe, trusting relationship.
The psychological freedom and respite that one seeks, in the presence of defense breakdown, arises when one willingly acknowledges and accepts that very terror that is a part of the very thing one desires.
An interesting implication is that it may be that some degree of mental health comes at the expense of psychological safety. It may be that the impermanence and finitude of the world necessitate it as such.