Thinking About a Theory of Everything: For Therapists and Others Curious About Therapy Theory

Thinking About a Theory of Everything (20 min read). 

The audio version is episode 11 on Steps with Boone podcast (on all major streamers) or here: https://open.acast.com/public/streams/634b7a13a82792001234e124/episodes/644355e9dcef5900114e7d96.MP3

What's the Issue?

The world is in turmoil about mental health issues, as if they were a mysterious phenomenon with no solution. We’ve convoluted the investigation with scientifically unfounded theories about brain chemicals, DNA, and arbitrary diagnostic categories. We’ve developed hundreds of research-backed therapy approaches, and are no more effective as therapists than when we started psychotherapy 100 years ago. We’ve developed many medical approaches with many more on the rise (e.g., psychedelics), and yet the rate of mental illness increases. Maybe we’re missing something?

What Do We Know?

The world of psychology is going through a replication crisis, meaning that many of the research findings and theories from psychological research, including therapy outcome studies, are under question because new research does not support much of it and a closer look at the old research uncovers many flaws in methods (Tackett et al., 2019; Wiggins & Christopherson, 2019). Though distressing to the field as a whole, it has been helpful in that this has helped reveal the Common Factors. The Common Factors body of research has shown that the therapist-client relationship (aka, the "alliance") is the most important factor in therapy change. Specific techniques or models, when studied in aggregate, account for very little change (Cuijpers et al., 2019).

This is helpful because it lets us know that therapists should focus on relationships, rather than just trainings and certificates. However, it doesn’t explain why people get better due to the relationship or how therapists can develop better alliances and become better therapists. We have some evidence that certain therapist behaviors correlate with better outcomes (such as empathetic statements, seeking frequent feedback, and gathering outcome data (Chow, 2014)), but we don’t understand what leads therapists to perform those certain behaviors. We know what makes a therapist better than others, but that knowledge itself doesn't seem to make us better therapists.

There is also no unifying model of why people can experience healing from traditional/alternative medicine, placebos, or self-help books. Or, one that explains why group therapy has been shown to be as effective as individual therapy (Burlingame, 2023). Or, why many people do not benefit from scientifically-supported approaches. We just don’t know what makes people heal–only that, in talk therapy, the relationship has something to do with it. But, given the information we already have, we can piece together something that makes sense.

What is the Proposed Solution?

The only answer I can find on the table, and which relatively few therapists are discussing is:

Evolution

Or rather “The Theory” of Evolution, which posits that all organisms adapt to their circumstances to create the best chances of surviving and perpetuating their species. Given a few principles of biology and neuroscience, we find that this theory explains all of the presented issues, and provides simple (though not necessarily easy) solutions. Evolution is the science world's “Theory of Everything” that explains why all organisms are the way they are, but we have been reluctant to apply it to Homo sapiens.

When observing other animals, we find a simple mechanism for processing stress. Animals react to stress according to the data of previous experiences: Fight if the threat might be neutralized, Flight if the threat can be escaped, and Freeze if the threat is overwhelming or inevitable. When the threat is over, animals are able to stay present (mindful) and absorb the fact that the threat is over. They don’t get chronic PTSD, Anxiety, or Depression unless exposed to chronic trauma. They adapt their Fight/Flight/Freeze mechanisms to their environment. When their environment changes, they change relatively quickly to match–they can’t numb out or distract themselves from the present. As long as they aren’t threatened in this process, they work through unnecessary threat responses. A quick example:

A dog living with abusive owners develops an immediate Freeze response around them–it knows it will be hurt if it expresses anger or pain. It expresses anger at everyone else, as experience shows that aggression scares most people away.

When the dog is rescued, it uses its defense mechanisms with all new people. When it isn’t hurt or threatened for its aggressive or frightened behavior, it has new experiences showing that the people around it are different from its owners. Its defensive responses are no longer necessary, so they steadily diminish in a new environment. Its internal resources are diverted from defensive mechanisms to other functions like muscle growth, learning, and relationship building.

Humans are mammals. They heal on the same principles of adaptation. However, humans are more complicated. We hold the history of many more stimuli in our brains, and hold many more associations. And, we can create stimuli from within our own brains, which most other organisms can’t do. This makes creating a healing environment more difficult. Not only physically painful experiences activate our defensive responses, but misunderstandings, the future, and abstract concepts–things dogs don’t have the wiring to consider. 

The other complication is our ability to dissociate. Many mammals can dissociate, meaning they can turn off Fight/Flight/Freeze when it serves an adaptive purpose. Drawing from my horse-training experience, let’s consider what it means to “break” a horse. When it expresses anger or fear, it gets whipped or spurred. If it gets depressed and shuts down, it also gets whipped or spurred. For the horse to not incur pain, it must suppress its anxious and depressive responses while keeping access to body control and learning functions to appease its master. The solution? Dissociation. The horse is probably doing this unconsciously. But whether or not it’s unconscious, it’s just the adaptive thing to do. As long as training is maintained, the horse will dissociate from emotions while learning new tricks. But if you leave a horse in a natural environment, it will eventually revert to its natural functions. It recovers from its “breaking.” 

*Side note: This piece is not an argument against animal training. I don’t argue that dissociation is inherently wrong, and don’t posit that all training involves dissociative mechanisms.

Humans also dissociate involuntarily. This is the hallmark symptom of dissociative disorders, which are virtually all rooted in severe trauma. However, humans often dissociate voluntarily, which is one of the main reasons they can retain traumatic symptoms in non-traumatic environments. They do this through any activity that produces quick results in masking depressive or anxious responses (unpleasant/painful feelings). Stress eating, tv, games, phones, drugs, pornography, and gambling are common examples, but humans have many different strategies to distract themselves from natural emotions trying to run their course. People even do it in the middle of therapy sessions: talking in circles, going on tangents, or choosing to talk about less stressful things. They can even use therapeutic techniques–like thought-challenging exercises or positive thinking–to push emotions away with logic. (This “cognitive-behavioral dissociation” will be discussed later on).

So, even if the process of healing is natural, our human intelligence allows us to stop it, even to make our unnatural mechanisms automatic. However, interruption of natural processes tends to have negative side effects. Emotions don’t regulate to adaptive levels when they aren’t allowed to. It can get to a point where they actually cannot be processed naturally without a severe crisis ensuing (psychosis, suicidal ideation, etc.). We become dependent on our dissociative mechanisms because the alternative is overwhelming. 

For example: A teen boy, who is experiencing bullying and loneliness, begins playing video games more than usual to cope with his pain. The trauma builds up as he continues going to school, but rather than discharging the pain (he doesn’t even know how), he numbs through more video games. It gets to a point where the trauma buildup would evoke suicidal feelings, but he doesn’t even know they are there because he is checked out with gaming. When his parents finally start restricting his gaming, he is left alone to face the emotions, gets overwhelmed by the buildup, and threatens suicide. It’s gotten to the point where he actually feels he cannot live without the games, and he’s not wrong. If he doesn’t have safe people to help him through the initial wave of traumatic feelings, he might not survive.

Effective therapy doesn’t just reduce symptoms (which can be done with enough dissociation or drugs), but creates an environment where involuntary dissociation is no longer necessary, and challenges our urges to dissociate on purpose. Effective therapy uses the basic principle of evolution: that organisms can and will adapt to their circumstances for their best chances of survival.

But some might argue that evolution doesn’t apply because people often don’t adapt for their ultimate well-being; when left to their own devices, they hurt themselves. That makes sense, since people’s health often can decline for years if left unchecked. But that’s the condition isn’t it? Things will decline if nothing in the environment changes. People change when something happens that drives a new adaptation, or that allows for something better. Think of our gaming addict. If we take all things into consideration, we’d find that he is actually optimizing his health:

He is racking up trauma on a daily basis at school. He can’t tell his parents because they, in their kindest of intentions, try to make him feel better by giving him suggestions of things to do, or encourage him to “not worry about it,” which just makes him feel misunderstood and invalidated. He learns to stop talking to them because it only hurts more to do so, and he doesn’t want to express anger at them since he usually gets punished for doing so. Video games offer some respite from the pain. He has felt tempted to cut himself, to look at pornography, and to sneak Dad’s leftover back pain killers, but luckily the games provide enough relief, though only in ever-increasing doses. If he didn’t use games, he might have started dissociating involuntarily (which is harder to treat and comes with worse side effects), or he might have become suicidal more quickly, which might have been harder to detect and intervene with.

This boy adapted as well as he could to his circumstances. The change came when his parents, who reached a tipping point in their anxiety about his behaviors, got up the courage to set boundaries. Once the environment changed, the boy could adapt accordingly.

So how does therapy, or any treatment method, create a change in environment?

The therapist-client relationship predicts healing because it is a way to introduce safety. An observable fact in biology is that organisms divert resources to the functions most important to their survival according to surrounding stimuli. As long as basic needs are met, and no immediate threats are detected, animals heal, both physically and emotionally. This is why it doesn’t matter what research-backed therapy method is used; as long as the client buys into it and feels safe with the therapist, they’ll probably get better. The commonality between scientifically-supported models is that they all challenge clients or introduce a strenuous stimulus within an appropriate measure of safety. If an approach strains someone beyond their “window of tolerance” for stress, it will likely tend to induce shutdown and dropout from therapy. If it isn’t strenuous enough, it might feel good and safe, but produce no change.

This mechanism of safety introduction also explains why placebos or traditional methods work. As long as the person believes in and feels safe with the method, and a challenging stimulus is introduced (or allowed to remain), the amount of safety the method provides may reduce anxiety enough for healing to occur. This would explain why placebos usually don’t work as well as other methods, since a method is less likely to work with the general population if it doesn’t make sense to them (or appears too hokie or magical).

But empirical methods also don’t work with everyone because not everyone can buy in to the method. Some simply can’t understand them, which would happen especially if their logical functions are impeded by their illness. Some won’t feel that the method applies to them, such as those who are unable to effectively challenge their thoughts, which CBT requires. And some may not buy-in for reasons unrelated to the method itself.

Example: A woman raised in the slums seeks conventional medical help to quit smoking. Her trauma from parents, with police, and social workers makes her anxious around authority figures. She feels stressed by her doctor visits, and distrusts the information she receives about medical methods of quitting (which are supported by research). Her smoking slightly increases to cope with the stress. She visits an energy healer, who looks and sounds just like her loving grandmother. She feels safe and understood, and thus feels open to the healer’s scientifically-unsupported approach of “releasing the bad energy” that perpetuates the smoking habit. With this boost of confidence and reduction of anxiety with the feeling of support from a familiar person, the challenge of quitting becomes more manageable.

The principle of safety explains why self-help programs/books can be effective, and why group therapy can be as effective as individual. If the reader feels comfortable with the author’s style, understands what they are saying, and feels validated by the content, they will feel more equipped to face their stressors. If a client feels safe in the group, and is encouraged to engage in internal struggles with supportive people around them, the group becomes therapeutic.

*And just a brief comment on Strategic therapies, wherein change may occur through the induction of tension in the therapeutic alliance. The increase of safety comes in increasing the client’s sense of power and autonomy, that helps them make changes to spite the therapist. Though the therapeutic relationship wasn’t the mechanism of safety, safety was still introduced strategically.

* This discussion doesn’t seek to invalidate traditional/spiritual methods, it simply offers another explanation for those who don’t ascribe to spirituality.

This theory also partially explains the replication crisis. CBT is the therapy method with the most research backing. This is because it is highly operational (easy to turn into a step-by-step manual) and provides a direct linear rationale for treatment that appeals to many in Western society: if you do more positive behaviors and think more positive thoughts, you will feel better. It makes sense, so we’ve been using it and studying the outcomes for a long time. There’s an issue with outcome studies though. They are based on measures seeking objectivity, meaning they measure behaviors and frequency of feelings, on which diagnostic criteria are based. But, they can’t accurately capture a subjective experience. This means that outcome studies can show reductions in symptom scores, while not necessarily showing that clients are getting better. I’ve experienced this pattern frequently with my clients, with whom I use the same kinds of measures. Their subjective evaluation is often inconsistent with the outcome measures. Given this inconsistency, outcomes in research studies may be difficult to replicate, especially as we gain greater knowledge of dissociation, and as our culture encourages greater authenticity.

In particular, I have noted a link between increased dissociation and decreased symptoms, and vice-versa–more awareness of experience correlating with more symptomatic feelings and behaviors. However, the latter tends to precede progress, whereas the former tends to lead to a crisis, where the suppressed thoughts and feelings explode into awareness in destructive ways.

But what has been most disturbing is how some clients dissociate with skills previously learned in therapy, making themselves engage in “healthy behaviors,” and avoiding painful feelings with thought-stopping or challenging. They attribute progress they’ve made to these techniques, but actually have reduced awareness and authenticity. Yes, their numbers improved, but their health didn’t. At least, I would not consider the successful suppression of emotion that leads to a personal crisis (sometimes decades) down the line, or projection of symptoms onto others, as desirable adaptations. This pattern may help explain why cognitive-behavioral approaches show better short-term, but not long-term results compared to other approaches (Marcus et al., 2014).

I believe that an effective Theory of Therapy must account for the way that symptoms are reduced, not just that they are. It may be that dissociation is actually the best thing for someone to do in a particular circumstance, but it should be done deliberately if possible (“compartmentalizing,” we might say). We should not view a symptom reduction caused by unnecessary or involuntary dissociation as a win. But to change this view, we would need to overhaul the very definition of mental/behavioral health.

The Definition of Health 

Another reason the Theory of Everything has not already arisen is that there is no agreement on what it means to be healthy. According to CBT, you are healthy if you are thinking logically and functioning productively (but what if you still feel terrible?). In ACT, you are healthy if you are acting according to your beliefs (but what if your beliefs are antisocial, and you still feel terrible?). Solutions-Focused suggests that you do more behaviors that help you feel good, and less of what doesn’t. The long-term negative implications of this theory are obvious. And, these are some of the most common models therapists use!

Current diagnostic criteria mostly fail to recognize causes of symptoms, and don’t acknowledge their adaptive functions. According to criteria, our gaming teen has clinical depression, but our parents don’t have clinical anxiety due to their difficulty setting boundaries with their son, or inability to listen and validate feelings. The system is not seen as incompatible with emotional recovery, so the boy is seen as the problem. In a way, the diagnostic premise perpetuates mental illness in how it stigmatizes individuals.

This is a larger discussion, but I propose that a new definition of health both define an optimum state (such as, how much someone’s sympathetic nervous system is active), and define an environment where such a state is adaptive and possible. For example, it is adaptive to have a low heart rate and low muscle tension in a neighborhood of low-crime where all your basic needs are met, but not when you have gunshots going off at night and a corrupt police force primed to arrest you without a bribe.

Can we prove the Theory of Everything?

Evolution, on which all biological science is based, is not considered a scientific law because it can’t be proven. And that’s the issue with empirically-supported therapy: we don’t accept any idea as ethically viable unless it can be proven (or at least, reported to be clinically-proven in a reputable journal). We can prove that certain techniques work better than placebo or nothing through random control trials (RCTs). But we can’t prove why they work. For example, I can show that EMDR therapy reduces PTSD symptoms more than being on a waitlist, but I can’t prove with all certainty that it was the eye movements that made the change (as opposed to exposing yourself to stressful stimuli while regulating in a safe environment to build new associations, as is suggested as the mechanism for other therapies). Regardless, I can ethically use EMDR because my outcome studies show it does something. 

But I can’t apply the Theory of Evolution to an outcome study. Imagine I had one group receive therapy from therapists who treat according to the Evolutionary model, and other controls of therapists that don’t, and got better outcomes with the treatment group. I could only show that getting therapy from these evolution-minded therapists produces better outcomes, not that the theory is true. Maybe it’s the case that evolution-minded therapists carry a gene that gives them a propensity to believing the model, or that just makes them better therapists? Maybe I just recruited the best and brightest therapists I know to participate in the study? No matter how many factors I try to control, there would never be indisputable evidence. But what I haven’t found yet is a simpler (but still testable) theory.

So, to promote acceptance of this model, I’m counting on Occam’s Razor. I can’t prove it is true, but I can prove that it is very likely to be, and continuously rack up evidence that coincides with it, as has happened with Evolution. What makes evolution the simplest model to work from is that it always has a simple and workable explanation for why things change or don’t change. From what I understand of other therapy models, they don’t have a logical explanation at the end of asking “Why” something happened or didn’t, often with an underlying conclusion of “they were just ready”, or “they just weren’t motivated enough.”

The thing is, if you keep asking why and how, you must either come to a scientific conclusion-- “Something real and observable caused it”--or a non-scientific one, “It’s just how it is; something not-observable caused it.” And, if we claim to be scientific, we have no business dealing with non-scientific conclusions. It just makes sense that we would conceptualize changes in humans the same way we do with every other living thing, even if the theory behind that conceptualization can’t actually be “proven.”

Extra points:

-Medications: This theory doesn't argue for or against medications, but it offers ways to think about their effects. Medications change intensities of anxiety, depression, and dissociation, but we still don't know why or how or why the effects are different for everyone. We also haven't effectively determined whether you are feeling less distressed because you are more dissociated or because you are actually less distressed. People report all sorts of effects from medications. If it's working for you, use it. If not, try something else. But I will still assert that medications are useful only inasmuch as they increase your ability to confront your stressors, not avoid them.

-Medical mental illness: And what does this theory say about tumor or fever-induced mental illness? It recognizes their existence. If you have a tumor pushing on your amygdala, you might have excessive irrational anger. If you have inflammation cutting off circulation to your upper brain, you might feel depressed. These are real sources of symptoms, but much more rare as sources for most cases of mental illness. But the arguments for chemical imbalances and genetic causes are still not scientifically viable. If they were clear explanations for mental illness, the research would have shown that by now. I'm open to those findings in the future, but for now, I prefer the simple and practical explanation that accounts for past discrepancies in research findings and successful treatments today.

-Spirituality: Finally, I'd like to address how spirituality plays in. I consider myself highly religious AND spiritual, but I find that, whenever I treat someone as if their illness or hurtful behavior arises as an adaptation to their circumstances, rather than as a spiritual issue or character flaw, just as I would with a misbehaving dog or a depressed horse, then I feel less triggered by them, more compassionate, and more likely to be helpful to them. I believe that, whenever we try to attribute issues to someone's spirit, conscience, or other cause not explainable by science, then we are judging them, which is against my religious beliefs. I believe all living things are spiritual, but it is not my job to discern how much or how well that spirituality is playing out. Recently, someone asked me about how I thought demonic possession related to therapy. I don't know if I'm dealing with evil spirits in the therapy room. It certainly feels like it sometimes. But whether or not this person is bad or evil, or has a scientifically explainable mental illness, I can only help them if I refrain from judging them and help them feel unconditionally loved. The forces of pure love and safety treat both conditions.

References

Burlingame, G. M. (2023). The future of group therapy is bright!. International Journal of Group Psychotherapy, 73(1), 1-19.

Chow, D. (2014). The study of supershrinks: Development and deliberate practices of highly effective psychotherapists (Doctoral dissertation, Curtin University).

Cuijpers, P., Reijnders, M., & Huibers, M. J. (2019). The role of common factors in psychotherapy outcomes. Annual review of clinical psychology, 15, 207-231.

Marcus, D. K., O'Connell, D., Norris, A. L., & Sawaqdeh, A. (2014). Is the Dodo bird endangered in the 21st century? A meta-analysis of treatment comparison studies. Clinical Psychology Review, 34(7), 519-530.

Tackett, J. L., Brandes, C. M., King, K. M., & Markon, K. E. (2019). Psychology's replication crisis and clinical psychological science. Annual review of clinical psychology, 15, 579-604.

Wiggins, B. J., & Christopherson, C. D. (2019). The replication crisis in psychology: An overview for theoretical and philosophical psychology. Journal of Theoretical and Philosophical Psychology, 39(4), 202.