Levels of Therapy
Therapy can be compared to a tree with varying levels and depths. Are you working among the leaves at the top of the tree? Or somewhere deep down in the roots?
After a decade of working as a clinical psychologist, I think I finally have a clear idea in my mind of what therapy is and how we can conceptualize ways to access it. It always struck me as overwhelming to determine what kind of therapy someone should pursue with what kind of provider and in what context? Is there a difference between free short term therapy and expensive paid therapy? And what would fit someone best at what time in their life?
I think about this now in the form of a tree (similar to Dr. Gordon Neufeld's theories on attachment) and largely because I love trees and find them so inspirational.
The level of therapy you seek depends on your goals for therapy and at different stages in your life or for different concerns or challenges, you may choose to work at different levels of the tree.
The Levels of Therapy Tree
1. At the top of the tree, we have the beautiful leaves that are always changing color and moving and light - full of change. This is the level I think of with people looking for talk therapy - they just really need the non-judgemental, listening ear of a neutral person to help them identify the leaves and patterns of their thoughts, life stressors, and current challenges. This is the absolute starting point of any therapy relationship and is necessary in understanding current experiences and diagnosing ongoing problematic conditions and patterns of thoughts and behaviors. And if this is all you are seeking, any therapist (Psychologist, Counsellor, Mental Health Provider, Social Worker, etc.) can provide this service as everyone is trained in this as a baseline to building what we refer to as "rapport" or connection with clients.
2. Once the leaves have been explored and catalogued and the client feels connected with their therapist and truly understood, the next level deeper is the branches of the tree. To me, these represent the more enduring patterns of thought and behavior that reinforce the leaves and hold them in place. So when we engage in avoidance behaviors, shallow breathing, restriction of movement and social interaction, we maintain and keep unhealthy perspectives and thought patterns entrenched. This level is often where therapists will go next. They will identify branches that are unhealthy and need to be pruned (such as inactivity, avoidance behavior, unhealthy and abusive relationships, etc.) and what branches need to be grown and expanded (such as meditation practices, exercise, good social networks, sleep hygiene, etc.). This kind of therapy is often tool heavy and the therapist is providing activities, homework, and behavioral strategies to promote change at this level. Ideally, you will also be practicing these tools in session with your therapist.
3. The next level takes us into the trunk of the tree which includes working on underlying beliefs, values and perspectives that maintain and lock in the behavioral patterns of the branches. These include things like core values, biases and core beliefs such as “I am not good enough” or “I am stupid" or "I am loveable." This level of work is obviously deeper and can be a more long term prospect to shift. There are many different theories about how to shift these beliefs and it all depends on the way the therapist believes these difficulties develop. For example, some therapists are what we call "behaviorists" and they lean more towards engaging in behaviors that reinforce the belief we want to hold and extinguishing the ones that maintain the unhealthy one. Other therapists believe that if one focuses on where one is going and maintains healthy habits (e.g. Solution Focused Therapy and Positive Psychology), a person will naturally start feeling more positive in these beliefs. Others believe that you collect data that challenges these old patterns and reinforces new perspectives, then through repetition you can shift these underlying factors (e.g. Cognitive Behavioral Therapy). Still others are more humanistic and believe just having a connected, empathetic, and non-judgemental therapist to make space to explore these beliefs and their origins will produce change (e.g. Adlerian and Psychoanalytic therapies). And then there is a whole group of therapies that suggest that these beliefs and difficulties in the trunk are created and fed by a deeper system in the roots of the tree.
4. This brings us to the deepest level of therapy which targets the very roots of humanity and takes a developmental approach – that’s to say that the tree grew in a specific environment and adapted accordingly to survive. You cannot modify the more surface level difficulties without truly modifying the roots and the environment. These therapies are the more long term and enduring approaches as they strive to create true resilience and health in the system. As expected, this layer often exists largely out of our day to day awareness but through therapy, individuals learn to identify their deep seated patterns, triggers and needs so that they can gain some degree of healing and change in them. For example, Dr. Neufeld's attachment theories identify developmental needs that were not met for the child and continue to echo through the life of the adult until they are addressed. Developmental Eye-Movement Desensitization and Reprocessing (EMDR) is another route to changing these enduring patterns, especially for traumatic experiences. Sensorimotor Psychotherapy and other somatic approaches (Somatic Experiencing, trauma informed yoga, etc.) target the nervous system and the physically engrained behaviors that inform our thoughts and emotions, creating a ripple effect or shudder through the tree and all systems. Of course these approaches are more involved and longer term investments but they can result in broad reaching changes and healthier systems from the ground up so to speak.
Of course, this is just one approach to therapy and it is impossible to detail all of the types of therapy you could find advertised. Therefore when you are thinking about therapy, it may be beneficial to think about the level of therapy interests you most, what levels have been worked through already, how effective those approaches were, and what draws you and makes the most sense for your given situation.
The beautiful thing about human beings is that we are always growing and changing. Adapting our growth and our environment is always possible!
