Unlocking the emotional brain

a grand unified theory of therapy?

Preamble: The book Unlocking the Emotional Brain was published in 2012, and last year I helped one of the authors with research and editing for the second edition, which was just published earlier this summer. This essay is my attempt at describing what the book talks about and why it’s important.

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What happens in successful therapy? You talk to someone, have many hourlong conversations, and perhaps you cry a bunch—but what is actually happening that leads to you feeling better (and sometimes worse)?

Surprisingly, we don’t have a widely agreed-upon answer to this question. This is the study of “mechanisms of change” in therapy, and it’s something that psychologists (and more recently, neuroscientists) have been going back and forth about for over a hundred years. Some argue that the core mechanism of change in therapy is memory reconsolidation, in which you are updating past memories of traumatic experiences. Others argue that the core function of therapy is not to re-adjust traumatic memories, but to create new memories that compete with the older memories when determining behavior. Still other people frame psychological change primarily in terms of constructing and deconstructing personal narratives, or in terms of processing and better relating to your emotions.

This is where psychotherapists Bruce Ecker, Robin Ticic, and Laurel Hulley came into the picture and said: we know the fundamental process that takes place in successful therapy, across all the different therapy modalities, and we have the neuroscience to back it up. They wrote Unlocking the Emotional Brain (UTEB) to explain their theory. It’s a very bold agenda, and regardless of whether it ultimately succeeds, the book has had a fundamental impact on how I think about human psychology, and I think it can help everyone understand themselves better.

Subconscious beliefs dictate behavior

Here’s the gist of the theory behind UTEB. Inside our mind is a bunch of “schemas”—mental models we’ve formed of the world based on past experiences. Ecker and team believe that much of our behavior is dictated by these unconscious, emotional models of the world that we may have learned years in the past. For example, if you’re conflict-avoidant, the authors would argue there’s some implicit belief that drives that behavior: maybe you harbor a belief of the form “if I upset someone, they’ll hold a grudge against me forever.” Now, this might not be a conscious belief, but the idea is that this mental model is well-formed in your subconscious and guides your behavior without you even noticing it.

Unlike other therapies that might focus especially strongly on the past experiences that led to this belief, or unprocessed emotions that guide the belief, the authors of UTEB are primarily interested in the mental model itself, and how to uproot it. Any traumatic memories (say, of someone holding a grudge against you) might help you identify the problematic model, but the focus is on updating the mental model today, rather than marinating in the past. The authors believe that all successful therapy is ultimately about uprooting beliefs, and doing so in a visceral and decisive fashion.

Case study: anxiety at work

To help understand what it means to “uproot unconscious beliefs,” it’ll help to look at an actual case study of the process.

Consider the case of Richard.¹ Richard had paralyzing anxiety at work, particularly in the context of contributing to discussions. He was constantly blocked from speaking up in meetings, despite generally receiving positive feedback for his contributions. In order to uncover the “underlying emotional belief” that was causing this behavior, the therapist engaged in a visualization exercise with him, in which Richard was asked to imagine contributing to a team discussion without inhibition. When Richard imagined contributing to a meeting, this happened:

Richard: [Pause.] Now they hate me.

Therapist: “Now they hate me.” Good. Keep going: See if this really uncomfortable feeling can also tell you why they hate you now.

Richard: [Pause.] Hnh. Wow. It’s because… now I’m… an arrogant asshole… like my father… a totally self-centered, totally insensitive know-it-all.

Therapist: Do you mean that having a feeling of confidence as you speak turns you into an arrogant asshole, like Dad?

Richard: Yeah, exactly. Wow.

Now the therapist has helped Richard to identify the relevant “schema” in his mind: his anxiety is based on the belief that if he spoke up at work, he’d be hated. How do we update this mental model? The authors stress that you don’t just want to say: stop thinking that way. This is roughly the approach used in “counteractive” therapies like cognitive behavioral therapy (CBT), and it can work, but is harder to carry out for deeply held emotional beliefs. Instead, you want to treat the belief as valid and plausible to start (it had an adaptive purpose, after all), and then you want to present the mind with definitive evidence for why it’s not true.² You want to update the belief at an emotional level, rather than just an intellectual one.³

The usual way to do this is to induce a strong juxtaposition experience between the original belief and some experience that violates that belief. They had Richard do two things simultaneously: (1) bring to mind his intense anxiety at work, and (2) recall a recent experience in which he observed someone else contribute to a meeting without being hated or ridiculed.

Therapist: Mm-hm. [Silence for about 20 seconds.] So, how is it for you be in touch with both of these knowings, the old one telling you that anything said with confidence means being like Dad, and the new one that knows you can be confident in a way that feels okay to people?

Richard: It’s sort of weird. It’s like there’s this part of the world that I didn’t notice before, even though it’s been right there.

Therapist: I’m intrigued by how you put that. Sounds like a significant shift for you.

Richard: Yeah, it is. Huh.

Therapist: You’re seeing both now, the old part of the world and this other part of the world that’s new, even though it was right there all along. So, keep seeing both, the old part and the new part, when you open your eyes in a few seconds and come back into the room with me. [Richard soon opens his eyes and blinks a few times.] Can you keep seeing both?

Richard: Yeah.

Therapist: What’s it like to see both and feel both now?

Richard: [Pause, then sudden, gleeful laughter.] It’s kind of funny! Like, what? How could I think that?

By virtue of this visceral, emotional experience of the conflict between the belief that (1) “If I speak confidently people will hate me”, and (2) “when others speak confidently they are not hated”, Richard effectively rewired the part of his brain that held the first belief. The authors describe how after a few repetitions of this “juxtaposition experience,” Richard came back in future sessions and reported the total absence of his prior anxiety, to his immense relief.

Transformational change vs incremental change

One of the key theses of UTEB is that there are two categories of outcomes in therapy: transformational change and incremental change. Transformational change looks like the case above: a small number of sessions that target the root of an undesired symptom, and bring about lasting resolution of the symptom, with no relapse. Incremental change looks more like: going to therapy for months or years, and experiencing only minor improvements in symptoms, and suffering multiple relapses in the proceeding years.

Unfortunately, there is substantial literature suggesting that most of therapy falls under the latter bucket. As psychologist Jonathan Shedler puts it, “Empirical research shows that “evidence-based” therapies are weak treatments. Their benefits are trivial, few patients get well, and even the trivial benefits do not last.” It’s difficult to measure the effectiveness of therapy as a whole, and it has been the subject of contentious debate for decades, but the overall sentiment after thousands of studies and meta-analyses is that therapy definitely helps, but it doesn’t help that much.⁴

Ecker and team believe that therapy could be helping much more. And in their view one of the major trends holding the therapy world back is the widespread focus on counteractive approaches (i.e. suppressing the symptom rather than targeting its root cause). In their book, they make the claim that all transformational change in therapy involves a process of rewriting unconscious emotional beliefs, even when this is not what the therapist is explicitly trying to do. They document dozens of case studies from across different therapy schools to demonstrate their point (emotion-focused therapy, psychoanalysis, internal family systems, and many others).

But are all psychological problems really about updating beliefs?

Is there an unconscious belief that underlies depression, and eating disorders, and alcoholism? What about perfectionism, compulsive behaviors, or aggression? The view of the authors of UTEB is that all psychological problems—aside from ones that have clear biological causes like genetics or hormonal deficiencies—are in some way based upon unconscious emotional learnings, and as a result they can be resolved with the right “disconfirming” experiences. Here are just a few examples from the book of how symptoms can be driven by unconscious beliefs, and resolved quickly once the belief is uprooted:

• Ted, 33, has a problem of pervasive underachievement, unable to hold a job or relationship for longer than a few months. Ted also had a difficult relationship with his father, who was constantly mean and disapproving of him as a child. In the course of a few sessions, the therapist helps Ted uncover the belief: “if I succeed in life, my father will never know how terrible of a job he did parenting me; I have to do poorly so that he feels remorse.” They then update this belief by helping Ted realize that, given what he knows about his father, he will never get the remorse he’s looking for. Ted’s life then turns around: he enters a long-term relationship, completes vocational training and gets a job.

• Brenda is an aspiring stage performer, but has stage fright that paralyzes her at her weekly rehearsal. During therapy, Brenda identifies the feeling of stage fright with a childhood memory of her being terrified as her drunk father was driving her family. This experience engendered a belief that Brenda was powerless and stuck. Together, Brenda and the therapist do a “reenactment” of that childhood experience, in which Brenda assertively asks her father to stop driving, and she gets help from other adults. Brenda effectively updates the mental model that she was powerless in that situation, and this relieves her stage fright.

• Raoul came to therapy with excessive and unpredictable bursts of anger. Over a few sessions the therapist helped identify that the anger is triggered by instances of a shared agreement being violated, even very minor violations. They then uncover that Raoul’s anger was connected to an experience years ago in which a business partner had betrayed him. This betrayal had resulted in Raoul forming a number of unconscious beliefs, including “Breaking agreements ruins lives. Anyone who breaks an agreement with me doesn’t care about ruining me and is my enemy. Without my anger, I would feel powerless and defenseless against being betrayed again like that, so I need my anger.”

Do these examples generalize to all cases of (non-biological) symptoms? I’m of two minds about this: on the one hand, any given psychological problem can be stretched and squeezed to fit the narrative of “symptom-producing belief” and “disconfirming evidence which updates that belief.” At the same time, this model really is powerful, and does explain the vast majority of human behavior, whether it’s in the context of formal therapy or more mundane psychological problems. And the dozens of case studies in the book show that by targeting the mental model specifically, lasting change can be achieved very quickly.

Ecker and team’s sell is that this framework makes therapists more effective, because as a therapist you have a clearer picture of what exactly you’re trying to do (identify and update emotional learnings), regardless of the specific technique you’re using to do it. It’s ultimately a playbook for transformational change, which is sorely needed, because as we’ve covered, much of therapy today is not transformational.⁵

My personal takeaway from reading the book has been to be treat my own problems differently: to always try to identify the specific belief underlying my maladaptive behaviors, rather than immediately looking for ways to correct them. Sometimes merely bringing a belief to conscious awareness reduces its power over you, because you immediately see how it’s not always true. For example, I recently had an argument with a close friend that left me feeling very unsettled, and I got immense relief from recognizing an implicit belief: “I need this person to believe that I’m right, because I don’t have enough confidence in my own judgement.” Simply recognizing this implicit belief helped me get a bit of distance from it, and reduced the emotional weight of arguments with my friend.

Time will tell whether Unlocking the Emotional Brain will accomplish the tall order of unifying all the schools of therapy. In the meantime, it has done the best job I’ve seen at articulating a basic tendency of human psychology: a lot of problems you can’t seem to solve are secretly solutions you’ve adopted to problems you don’t want to admit to having.⁶ What’s profound about this is that once you’ve identified the “underlying” problem, solving the original problem becomes much easier. The best part of Unlocking the Emotional Brain is that it encourages an attitude we desperately need more of in our culture at large: we can solve our psychological problems, and we can solve them much more quickly and decisively than we think.

Thanks to Susie for feedback on earlier drafts.

1. Kaj Sotala also talks about this case in his blog post on the same book.

2. Something to keep in mind is that throughout this process, the therapist is not meant to have a strong agenda about what emotional beliefs are true or false. The whole point is to bring subconscious beliefs into conscious awareness, so that the patient can more thoroughly consider the validity of the belief. In some cases, you find that your unwanted behavior (say, anxiety) is premised on a mental model that you actually believe is true and useful, in which case the anxiety is no longer a problem—it’s just serving a purpose in line with your goals. (Example: a little bit of social anxiety around new people might help prevent you from saying something totally off-color.)

3. The distinction between a deeper “emotional” belief and a more surface-level “intellectual” one is important. If you take someone with chronic self-doubt, you could easily get them to rehearse the statement “I am capable,” but the question is whether they actually believe that. When you emotionally believe something, it’s no longer something you’re expending effort trying to convince yourself of—it feels obviously true.

4. For more on this, see this paper: “For over 40 years, the level of therapeutic improvement measured in randomized controlled trials (RCTs) and meta-analytic reviews has been a change of about one standard deviation in the mean score on outcome measures, typically representing a 20%–25% reduction in the measured strength of symptoms (Smith & Glass, 1977; Wampold & Imel, 2015), a quite mild effect (Shedler, 2015).”

5. Ecker and team also acknowledge that “updating emotional beliefs” isn’t always the best approach for a given problem: sometimes a given emotional belief is so deeply held and underlies so many behaviors that trying to uproot it suddenly can disrupt your entire way of life. If, for example, you entered into your current marriage and career primarily due to some belief in your unworthiness, uprooting that belief will have predictably bad consequences for your marriage and career. In such cases, the better approach is to target the belief in parts – in specific contexts, for example – before trying to uproot the whole thing.

6. Credit to David MacIver for this.