A Functional Neurology Perspective on the Concept of Stored Trauma with Dr. Matthew Tolstoy (Part 2) | E70

Can attachment theory influence concussion recovery, chronic pain, dysautonomia, and the success of rehabilitation? In Part 2 of this conversation, Dr. Ayla Wolf sits down with psychologist, somatic therapist, and Chinese medicine practitioner Dr. Matthew Tolstoy to explore how unconscious nervous system patterns shape the therapeutic relationship, why The Body Keeps the Score is often misunderstood, and how psychotherapy, EMDR, somatic therapy, and physical rehabilitation all work to influence the same underlying autonomic physiology.

If Part 1 introduced the foundations of attachment theory and the autonomic nervous system, this episode takes the conversation even deeper—into what actually happens inside the treatment room.

Dr. Tolstoy offers a rare behind-the-scenes look at the thought process of an experienced psychotherapist, explaining how clinicians create safety, build trust, and recognize when a patient's response to treatment may have less to do with the technique itself and more to do with deeply ingrained patterns of nervous system regulation. Together, we discuss why two patients with the same diagnosis can respond completely differently to the same intervention, how rehabilitation providers can thoughtfully introduce referrals for psychotherapy or somatic therapy, and why the therapeutic relationship itself may be one of the most powerful tools for healing. 

We also tackle one of the most misunderstood ideas in trauma therapy: "The Body Keeps the Score." Is trauma actually stored in the hips? Can emotions simply be "released" through bodywork? Or is something far more sophisticated happening within the nervous system? Dr. Tolstoy explains how unconscious protective strategies can manifest as chronic muscle tension, pain, and autonomic dysregulation—and why understanding the underlying neuroscience changes the way we think about healing. 

The conversation concludes with a fascinating discussion on the neuroscience of affect, emotion, and feelings, exploring how the unconscious brain continuously shapes our physiology, attention, and behavior long before we become consciously aware of what's happening.

In this episode, you'll learn:

•  How attachment theory influences the therapeutic relationship 
•  Why two patients with the same diagnosis may respond differently to treatment 
•  How to discuss psychotherapy with patients without implying "it's all in your head" 
•  When rehabilitation providers should consider referring for EMDR, somatic therapy, or psychotherapy 
•  What The Body Keeps the Score really means—and what it doesn't 
•  Why chronic muscle tension may represent protective nervous system strategies rather than "stored trauma" 
•  The neuroscience behind affect, emotion, and conscious feelings 
•  How unconscious survival programs shape physical symptoms and emotional regulation 
•  Why the therapeutic alliance is one of the strongest predictors of successful psychotherapy 
•  How awareness helps bridge subconscious autonomic patterns and intentional healing 

Perhaps the most important message from this conversation is that healing isn't simply about finding the right technique. Whether you're recovering through physical therapy, acupuncture, chiropractic care, psychotherapy, vestibular rehabilitation, or functional neurology, lasting change often begins when the nervous system feels safe enough to update the protective patterns it developed long ago. As Dr. Tolstoy explains, awareness doesn't eliminate unconscious programming—but it creates the opportunity for neuroplasticity, healthier autonomic regulation, and meaningful, lasting change.

Whether you're recovering from a concussion, living with chronic pain, navigating dysautonomia, or you're a healthcare professional interested in the intersection of neuroscience, psychology, and rehabilitation, this episode offers a thoughtful and eye-opening perspective on how the therapeutic relationship itself can become part of the healing process. 

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Medical disclaimer: this video or podcast is for general informational purposes only, and does not constitute the practice of medicine or other professional healthcare services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice diagnosis or treatment. Consumers of this information should seek the advice of a medical professional for any and all health related issues. 

Transcript

When The Body Braces To Cope

Dr. Matthew Tolstoy 0:00

Sometimes when that really helpless feeling that might be associated with my trauma shows up, that can feel very threatening and overwhelming. And my nervous system, reflexively, without any of my conscious input, it does not consult me in the process. It just says, whoa, that is too much. We are gonna just pull the plug on that. What can we do? And sometimes gripping in your psoas or gripping in your hip muscles is a way of toning that down because now all of a sudden I'm more in touch with my muscle tension as a way of controlling my sense of feeling than I am that helpless or fill-in-the-blank overwhelming negative feeling that might have just popped up a moment ago.

Welcome And Why This Matters

Dr. Ayla Wolf 0:42

Welcome to Life After Impact, the Concussion Recovery Podcast. I'm Dr. Ayla Wolfe, and I will be hosting today's episode where we help you navigate the often confusing, frustrating, and overwhelming journey of concussion and brain injury recovery. This podcast is your go-to resource for actionable information. Whether you're dealing with a recent concussion, struggling with post-concussion syndrome, or just feeling stuck in your healing process, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. This is part two of my conversation with Dr. Matthew Tolstoy. If you haven't listened to part one yet, I highly recommend starting there because we covered so much foundational material on attachment theory and how our earliest relationships shape the autonomic nervous system. In this episode, we take the conversation even deeper. Dr. Tolstoy really pulls back the curtain and gives us a glimpse into what it's like to be on the clinician's side of the treatment room. We talk about the things that physical medicine practitioners, counselors, somatic therapists, and other rehabilitation professionals are constantly thinking about, but that patients rarely get to hear. How do we create a sense of safety? How do we avoid saying something that could unintentionally activate a patient's nervous system or be taken the wrong way? And how do we recognize when a patient's response to treatment may have less to do with the technique itself and more to do with deeply ingrained patterns of autonomic regulation? I think it's rare to hear such an honest conversation about the therapeutic relationship itself. Whether you're a clinician or a patient, this episode offers a fascinating window into the complexity of healing and why understanding the person is often just as important as understanding the diagnosis. I hope you enjoy part two of my conversation with Dr. Matthew Tolstoy.

When A Referral Feels Risky

Dr. Ayla Wolf 2:55

Okay, so that brings me to the next question, which is that as a provider, when I see those red flags or when I feel, even when I feel like somebody's nervous system has been stuck in a loop that they just can't get out of for a long time. Um, and I feel like I I need to send them on to somebody else. A lot of times I don't really know what is the right referral. Like, should I send them to someone that does somatic body work? Should I send them to someone that does EMDR? Should I send them to a counselor or a psychotherapist? I think sometimes I really feel like I don't know which of these therapies is going to be a the one that resonates with you, or B, the one that is the thing that helps you to get to that next step where maybe your nervous system isn't stuck in this loop where every time you get stressed out, your next immediate response is to get nauseous and get a headache, or for example. I also think that sometimes the patient, when I bring up this idea of like maybe there's some other therapy to do, I don't want them to hear me say, I think this is all in your head and now you need to go to psychotherapy, because people are going to potentially misinterpret that, and that's not what I'm saying. So how would I, on my side of that equation, even have that conversation in a way that's maybe heard in a positive framework? Do you have any advice for me?

Dr. Matthew Tolstoy 4:25

Oh man, yeah, it's it's it really, this is such a great question because it is a tricky moment to navigate inside of the patient provider alliance to make a suggestion like this. And I do know many people on the rehab side of things who have made suggestions like this and it's really blown up. And so when you've had that happen, you go like, oh God, I better line up in my shot here a little bit more before I, you know, reach for something like this. So I think, you know, to speak to the two levels of questions here, like how how do you how do you even float this to somebody? That's one. And then also in the sea of all these different therapeutic providers, you know, who do I even send somebody to? Right.

Dr. Ayla Wolf 5:04

Two two huge questions,

How To Talk About Therapy

Dr. Ayla Wolf 5:06

yes.

Dr. Matthew Tolstoy 5:06

Yeah, yeah. Which is why I can understand why people just kind of go, ah, I don't know, and then don't make a call on that front because it feels super risky. So, all right, with this, with this conversation about how how do you how do you bring up to a to a physical medicine patient that you're wondering if there may be some level of emotional and relational regulation that is at play in a meaningful enough way in their case. Right. There's a lot of ways to have this conversation with somebody, but I think in particular, when you're coming from a rehab provider, a physical medicine provider first, the person already knows that there are things happening inside of them that are not under their conscious control. They do not necessarily consciously regulate their autonomic response or their response of muscle tension. And there's all these things that we're helping to educate them that, like, look, a lot of these things just reflexively happen inside of you. And what we're trying to do is give you experiences that shape the way those reflexes fire off so that they regulate in a new way that reduces your symptoms and it just makes life easier. We're doing the same thing with good psychotherapy. We're trying to address the things that, sure, yes, you are having a conscious experience of and like your thoughts matter, but also what we're really trying to address are the things that just reflexively happen inside of you that you don't choose. When we hear it's all in your head, we often think like you're deciding to do this. Um, it's because you're not wise enough, or like you don't, you know, you have all these irrational thoughts in your head, and that's what's ruining your life. And look, sometimes there are patients who have something like that, but the overwhelming majority is just simply the way these, as we've been talking, either attachment-related or emotional regulation issues come up, they really do have their hubs of control subcortically, subconsciously, and they become conscious, but we become conscious not at step one, but at step like 14. And part of what we're doing in psychotherapy is trying to wind the reel back to understand the sequence of associations that then led to a physiological change, that then led to a psychological experience, a felt experience of what happened, such that we can then give you experiences relationally through therapy, through whatever you're working on from a methodology standpoint, that begin to change this stuff that is not immediately under your conscious control. And so sometimes people who are coming from a physical rehab standpoint can kind of grasp that a little bit better and they will hear that not as you're a crazy person who needs to get psychological help because there's something severely wrong with you, as more of like all these treatments are pointed at the same thing. If the person is interested enough and, you know, potentially nerdy enough, you can share with them some of the literal brain pathways. It's like, look, look, look, this loop runs the same thing as emotional regulation as it does your baroreceptor reflex. They have influence on each other. And so I'm not trying to say that your psychological experience is symbolic and abstract and way over here. I'm trying to say that these reflexive responses to your sense of emotions and relationships might have a play here. And especially if you treat people who have had concussions or accidents or moments where something very intense happened very quickly and changed their life in a dramatic way, that is sometimes a more accessible ledge for them to understand what you're recommending versus, you know, go lay on a couch and talk to a stuffy guy in a tweed jacket about your mom. You know what I mean?

Dr. Ayla Wolf 8:46

Yeah. Yeah. It's essentially pointing out that there are many different avenues to address kind of the exact same physiology. Um and different people are trained to offer different pieces of that puzzle.

Dr. Matthew Tolstoy 9:00

Yes, exactly. I think I realized now I didn't answer that second part of your question about like, okay, well, who who do you who do you refer

Choosing Between Somatic EMDR CBT

Dr. Matthew Tolstoy 9:07

people to? And I remember um listening to when you had Dr. Antonucci uh on the pod is talking about how if you go see 100 chiropractors, you will see 200 methods of treatment. That there's a lot of art as well as science, psychotherapy training. That could be somatic experiencing, which is what I'm particularly trained in and involved with. Um that can be EMDR, because again, it's a very bodily oriented, reflexive pathway type of treatment that is going to work on the level of linking up information sharing between your subjective felt experience and what you're feeling inside of your body physiologically. If we're just doing, let's say, psychodynamic work that is a lot about relationships, it's a lot about the way attachment functions inside of us, that does have to do with a relationship with a therapist and can be very helpful. That might be one step removed, depending on, again, depending on the therapist's orientation. There are a lot of psychodynamic therapists, myself included, that have bodily training and there can be that. So it's not a writ large thing. But then if we think about this again from like a cognitive behavioral standpoint, where it's like, hey, look, your thoughts and your behavior are influencing your emotions, that might be even another step removed from like, hey, what's happening right now in your felt experience? I'm not directing you to fill out a worksheet to disconfirm your irrational thoughts so much in this patient. I'm more interested in what's happening right now inside your body when we talk about whatever the thing is that maybe happened. That might be a little bit more directed towards what some of these patients might need.

Dr. Ayla Wolf 10:48

Okay, got it. Which brings us to kind of our next topic, which is that we have this very popular book, The Body Keeps the Score. We have lots of people talking about this online. And I think one of the questions that we need to have here is that when we think about this idea of trauma being stored in the body, and we decide sometimes we oversimplify this concept to be like, oh, well, as a somatic therapist, if I just touch here, I can release this trauma. And so at what point are we overinterpreting the person's bodily response versus um not really appreciating how the nervous system is actually operating?

Dr. Matthew Tolstoy 11:34

Yeah. Yeah, this is this is a huge and important topic because again, the internet and social media has really gone through its body keeps the score era in the last whatever it's been, you know, maybe six

The Body Keeps The Score Misread

Dr. Matthew Tolstoy 12:47

or seven years in particular, it's become very, very, very popular. And we have a lot of people, because of the nature of somatic therapy, we have a lot of people who are psychotherapists who practice, and we have a lot of people who are not psychotherapists who practice somatic fill-in-the-blank release technique. And this can really get us into hot water a bit. And I'm a little bit sensitive to this because as somebody who started out as a physical medicine practitioner and then has, you know, transitioned and added in psychotherapy to what I do, um I know what it's like to be on both sides of this set of training. And I've also seen a lot of people who have been harmed by somatic, fill-in-the-blank practitioners who kind of poked around with people's trauma and because of a lack of awareness around certain types of relational dynamics, certain types of attachment-related things, really ended up re-traumatizing the person via this relational therapeutic experience that did not go well. And so it's a topic that I am particularly protective of because I just have had a lot of experience where I've seen how this can go wrong as well as how this can go right. So when we talk about the body keeping the score, what what what are we talking about? Because there can be these very powerful and meaningful experiences where you go to a yoga class and the instructor asks you to stretch and mobilize your joints in a particular way. And all of a sudden you're flooded with a very intense emotional experience. And afterwards you feel very different. And it's very meaningful and it's very impactful. Or again, you go to a body worker and they put their hands on you in a certain way, it creates a certain type of sensation. And again, an emotional experience comes online that then makes you feel very different afterwards. So, on like an experiential phenomenological level, it can feel very much like, oh, this trauma or this emotional experience was in my tissue, in my body a particular way. And when we did whatever intervention or activity, it like purged it from my experience and it like jettisoned it out of me, and now I feel better, which is a very understandable conclusion to come to when you just go through that experience. However, it misses how this is really organized inside of the nervous system in a larger, higher hierarchical way. And I think, in simplest terms, how we can talk about this is, you know, one of the things you hear a lot about on trauma, you know, trauma social media is that all trauma is stored in the hips, that there's something about the hips that is a magnet for trauma, and that when you've had trauma, it sort of somehow um embeds itself in the tissue of your hips, and you need to do X, Y, or Z mobilization. This is not true. Uh, this is not how this works. Experientially, it can feel that way. And here's the overlap between how it can experientially feel very true, but but um from a mechanistic standpoint is not actually true. How the trauma may or may not end up in your hips is like this. The body is a really interesting place for our felt experience because it's where we feel and have experience of emotion. We don't experience emotion in the mind, although the mind can generate emotional experience. How do you know you're feeling sad? How do you know you're feeling joyful? There are physiological sensations that signal a state shift that tell us that's how we're feeling. So the body is the first theater of experience where we register a felt sense of what's going on, right? And the body is really interesting where it's the place that we feel things, it's also the thing that we use to not feel things. And the way that we use the body to manage our physiological and emotional experience is often through something like muscle tension. Sometimes when that really helpless feeling that might be associated with my trauma shows up, that can feel very threatening and overwhelming. And my nervous system, reflexively, without any of my conscious input, it does not consult me in the process. It just says, whoa, that is too much. We are gonna just pull the plug on that. What can we do? And sometimes gripping in your psoas or gripping in your hip muscles is a way of toning that down because now all of a sudden I'm more in touch with my muscle tension as a way of controlling my sense of feeling than I am that helpless or fill-in-the-blank, overwhelming, negative feeling that might have just popped up a moment ago. So that habitual response can then show up as a muscle guarding tension in your hips. That then, when a provider or a yoga teacher, or you have an experience where you go in and you lessen that muscle tension, the feelings, the emotions and the affects that that muscle tension was guarding against now are able to reach higher levels of consciousness than they were before. And so then it can feel like, oh, when I do something to my hip, I feel my emotions, therefore it was trapped in my hip. It's like, well, no, your hip was playing a meaningful role in your emotional management strategy. And that's where it got stuck because your nervous system just figured out to do how to do that. For somebody else, it might be their jaw. For somebody else, it might be their neck, for somebody else, it might be wherever their system organizes something. That's what's happening rather than the tissue itself being like the store and processor of the trauma.

Dr. Ayla Wolf 18:30

So that makes perfect sense. And to me, it seems like an analogy would be sometimes if, for example, I had chronic back pain. And before I had my back surgery when I was living in chronic back pain, I then injured my brachial plexus. Well, my brachial plexus is coming into my spinal cord at a higher level than my low back pain is. And so then all of a sudden my brain says, well, now I'm only able to register this pain and not that pain. It's almost like the brain is saying, I'm paying more attention to this muscle pain than my feelings and emotions because that muscle pain is now the louder stimuli.

Dr. Matthew Tolstoy 19:12

Yes. Okay. Exactly. Exactly. It has a way of directing our attention away from something that feels more threatening than the brachial plexus pain. You know, there's there's sometimes like an organizing feature inside of our psychological defenses that tell us, um, hey, uh, solve this simpler problem. And when I say simpler, it just means something that I know how to be in relationship with that is still a bad time. I'm not happy about it. But I at least it's safer for me to be in shoulder pain than maybe to feel the depths of maybe that terror or the helplessness that was associated with, let's say, the event or something. And so when that does show up, the system goes, right, right, right, okay, okay, let me organize in relationship to this physical pain. I'm still having a miserable time. But this is easier than feeling the other thing. But again, nobody would consciously report this. This does not happen at the level of consciousness until we go back, slow things down, feel into what is actually happening for you moment to moment at the level of your sensations and emotions with a supportive other, like a therapist that you feel good enough about and trust. That's what then allows the system to be open enough to soften some of these defensive patterns, so that then we can learn how to be with what's under that in a way that doesn't feel as threatening, that then allows us to engage with it in a way that regulates it, metabolizes it, and then we have a new relationship to.

Dr. Ayla Wolf 20:43

That makes perfect sense. Thank you for that explanation. The this uh updated model of what the body keeps the score really means. Thank you for that.

Dr. Matthew Tolstoy 20:54

Yeah. Yeah, exactly.

Dr. Ayla Wolf 20:56

At this point, should we describe the difference between because you mentioned affect, emotion, and feelings. Is it worthwhile to talk about the difference between those?

Dr. Matthew Tolstoy 21:09

Sure. Yeah, I think I think it's really worth taking some time to talk about what we have uh neuroscientifically come to understand about emotional life and sequencing that really hasn't made it out into the public very much. We still have some very old ideas about what emotions are. And other than just being technically correct, which is fine or whatever, and especially if you're an academic person, but for the lay person and the and the average, you know, provider, what is important about understanding this is to just then understand what we're working on, you know, what are we treating, and to help me organize my experience of like, okay, what is happening here? And and to just feel more centered in what's going on. Because sometimes emotional experiences can just feel very disorienting and overwhelming to people. And then it can be very hard to understand like, what do I need to do and what is

Affect Emotion Feeling Explained

Dr. Matthew Tolstoy 22:00

happening? What's happening to me? And so I think defining these different stages of what produces our subjective emotional felt experience of what's happening to us can sometimes just help us feel more grounded and secure in our experience, even if it's still a hard time, right? And so I think if if we wind this back as far as we can and just think about like, isn't it kind of crazy that we have feelings? Right? Like we have subjective first-person experiences about what happened to us. And nature, in terms of evolutionary biology, doesn't keep things around that is not worth the glucose, I mean not worth the energy to run those circuits. Nature is very, very, very conservative and ruthless when it comes to natural selection and evolving out features inside of us. So just starting from the baseline here, isn't it wild? That nature has maintained inside of us emotions that can feel incredibly uncomfortable and that can make us feel like they derail our lives. And like, what is this about? That's a very good question. Right. So when we think about what this is about, is we think about what the function of emotion is, is it's related to getting our needs met in the world. We have systems of, again, affect, which is when we have these spontaneous appraisals about what's happening in the world, whether that's our internal world or the external world, there are events that happen that signal to us about whether things are good for our survival or bad for our survival. So when I feel hungry, something inside goes, This isn't great for your survival. And then it releases physiological and attention changes, what we focus on, how we feel, to then help us go get that need met. Because we've perceived something has changed meaningfully in our internal environment. We've been talking about attachment. There's also that perception of the external environment. Oh man, uh, my caregiver just did this thing that made me feel very rejected by them. That is not good for my survival. Let me do these things, let me change my physiology in this ways. Here's our callback to how that person learns through their attachment pattern. What do I do to solve this problem? And so emotion is the whole brain event below consciousness, above consciousness, that is coming up with an organized response to perceiving a need that has been activated. And inside of us, nature has programmed seven basic categorical emotions that are the largest categories of just what seems to, over the course of evolution, help us get our needs met.

Dr. Ayla Wolf 24:50

Are we talking inside out here?

Dr. Matthew Tolstoy 24:52

Yes, we're talking very much inside out. Exactly. And it really is like that. We have these like kind of little people inside of us that have these motivational states that get activated by patterns of change inside of us or outside of us, that then somebody takes over the control board and says, no, no, no, no, I know I'm the one to respond to this. Going with our hunger example, why is hangry a thing? When you get angry when you're hungry, is because the physiological and attentional state associated with hunger is more likely to motivate you and end in success, that you go get the berries, or you go catch the squirrel when you're angry versus filled with crippling grief. Crippling grief allows us to turn inwards, realize that we lost something important to our survival, and we really need to remember that losing this thing is not good for our survival. And so if we released that type of physiological, motivational, and attentional state when we're hungry, that just from an evolutionary standpoint is not going to be the thing that gets that need met. And so if we think about it, contained inside of our emotions are these action tendencies to move towards something to meet a need. And that those action tendencies get shaped by our relational experiences early in life, that get shaped by just what we've learned over time. And so we've talked about emotion, affect, and then lastly, feeling. Feeling is what we commonly think of as emotion, meaning just the first person feeling of what the impact is of our physiology changing and our attention changing and our appraisal about whether something is good or bad for our survival. That has a, what we call in the research like a qualia to it. It has like a felt sense of, again, when I'm hungry, my body's perceived this need, it releases an emotional state, it releases a physiological state where my heart rate speeds up and my muscles tense up. And that just has what we call the feeling and sensation of anger or whatever the state is that gets active. But it's attempting to get us in touch with a core need and then what we need to do about it. And the tricky thing about modern emotional experience is that because we live in a polite society that has all these rules, we oftentimes distance ourselves from the core emotional experiences that we have because they feel too risky. You don't want to flip out in the middle of Costco. You know, we know that that's just not societally appropriate, but our brainstem and less you're too same. Yeah, right, exactly. If you don't have a full cortex yet, you're two, you can flip out in Costco, that's okay. You know, when you're older and everything, like society just doesn't look super fondly upon that. And we've learned all these ways to inhibit and distance ourselves from those core feelings, which is understandable and often sometimes needed. Like we need to have restraint sometimes and then not act on our first impulse. However, if we get completely disconnected from that impulse and those emotional core states, it makes it very hard for us to even know what we need. How do we know? Because if I get really practiced and not really feeling my core feeling, but feeling like a secondary or tertiary feeling on top of the feeling, and I'm really connected to that, but I really don't have any access to what's happening underneath, it just makes it really hard to get my needs met. Because I keep acting on this inhibited, modulated, different feeling that I'm that I feel more safe to be in touch with, that I've learned is more safe to be in touch with. But then this is where I go about living my life in a way that kind of feels unsatisfying because I keep having these repeated experiences of just not being able to meet my needs by myself with other people, because I'm disconnected from that core emotional state that has what I need kind of contained inside of it.

Dr. Ayla Wolf 28:43

Yeah. And so it sounds like all of this, everything we're talking about, really comes down to this idea. Well, I don't want to oversimplify what we're talking about because we covered a lot of ground. What I want to say is that our unconscious programming really does run the show. And the more we can narrow the gap between our unconscious programming and our consciousness, the more we have an understanding of our tendencies, our behaviors, and how to maybe regulate them in a more intentional way.

Dr. Matthew Tolstoy 29:18

Yes, exactly. Exactly. It's when we think about emotional regulation and this gap between our immediate unconscious reactions to things and then our conscious experience of that. I think we have to appreciate how well, first of all, what we've come to learn about the brain is most of our mental and emotional life happens outside of consciousness. We can demonstrate this through fMRI studies, we can demonstrate

Closing The Gap With Awareness

Dr. Matthew Tolstoy 29:46

this through split brain research. There's a lot out there that we we kind of can't argue anymore. It used to be a big debate about the unconscious, the nature of the unconscious. Like there for a long time in the 70s, 80s, and so forth, before we got to fMRI studies, you know, is kind of a spooky concept, right? Like, oh, we have this thing inside of us that processes things and comes to conclusions and has procedures associated with stimuli that we are not in touch with at all, but that we feel a certain impact of. It's it's kind of, you know, it's a little creepy and it's a little spooky, and it's understandable that we've had feelings about that societally and academically over time. But it's pretty much a done deal now that we understand that the unconscious is real. It's where most of our pro most of our processing happens. And then the mind, the conscious mind is the last thing to know. But that conscious mind is also the thing that if we slow down and have enough support, we can go back and increase its influence on these downstream circuits. And what I think we have to appreciate is that when we have overwhelming emotional and affective experiences in life, and we all have them at some point in life, and I don't just mean traumatic experiences, but what we're talking about, you know, in infancy and young childhood related to attachment, we all have emotional experiences that at some point overwhelm us because we didn't have enough social support to be with those feelings. And look, there's some element of this that is just normal, and that's a part of being human. That's our lot in life. And some of it has to do with abuse, some of this, you know, there's a spectrum, but there's a sense of we get overwhelmed and then we develop these ways of keeping those experiences away from our conscious experience. Because when we have those experiences consciously, they made us feel too physiologically overwhelmed. And so then the nervous system goes, right, I can compartmentalize this, I can keep this over here. This is like what we're talking about with the hip tension analogy. If I have this muscle tension, it helps me not be as aware of, let's say, the physical sensations associated with this feeling. Or I have a way of just not feeling the emotions associated with that. Or the other way, I have no connection to my body at all. I feel really dissociated. I have all my mental life, but I don't have a sense of being felt and real. Because at some point in that person's life, it was too much to feel both of those channels at the same time. And so then it's adaptive strategy is like, look, we need to separate this in order to survive. And so that increases the gap between what's happening unconsciously and what's happening consciously. And like we said about the definition with emotion, having our needs contained inside of it. This is again, it makes it hard for us to know what to act on because we have a part in our appraisal system below consciousness that says, hey, hey, hey, uh, do not continue to send that fill-in-the-blank sensory or affective information further up the chain into awareness. Don't do that. And so it stops its serial processing sometimes at the level of the brainstem, sometimes at the level of the lower limbic system. And then there's this disconnection that then is part of how this system learns to not be overwhelmed by emotions, but then is also kind of at the root of why they come to psychotherapy.

Dr. Ayla Wolf 33:05

And also there's then an encoding that happens within the autonomic nervous system that is a physiological response that may not match what's happening consciously.

Dr. Matthew Tolstoy 33:15

Yes, exactly. Exactly. And so this is where we start to, when enough pressure gets put on the compensation model, it works, it works, it works until it doesn't work. And then people notice what their symptoms are. And like I said, that's why people show up to psychotherapy is because they're having a change in their life. Well, here, look, look, when we're talking about that separation, why it's in there is because it worked at a certain period of time in that person's life. It was the adaptive thing to do, to not be aware of the physical sensation or not be aware of the emotional state, or not be aware of what's happening relationally with a certain level of detail. It actually created stability and favored their survival. The problem is their life and their values and situation has now changed and is now less compatible with that defensive state. But the person doesn't even know that they're continuing to do this thing because it never reaches the level of consciousness without some help. And they go, why am I having such a bad time? I'm noticing X, Y, or Z. And then that's part of our process is trying to understand where that gap is between where the reflexive procedural responses are coming in, and then when consciousness shows up and how can we gently bring those two a little bit closer together, but this time bring it closer together with the support of another person. Because when you have the support of another person, the threat of whatever got pushed over there, you know, the br the brain is going, look, I put that over there for a reason. I don't go looking over there. But it's like, hey, but look, you have a relationship here with this experience now, with another person that is looking, that is holding that, that is with you. And that's a different, that's a different survival math than when they were likely overwhelmed by that experience and were also profoundly alone with that experience. And so now if we can update the person to let attention come to that emotional experience and all of the other associations in the body with it, but maintain a relationship with a safe enough other, that then changes the brain's predictive coding around what too threatening is versus a little risky, but safe enough to engage with. And then that's where the money is in the process. If we can spend time in that space, that's what allow th that's what allows things to eventually reprocess and not be managed in the same way. It lets that information flow and integrate with other higher order processing because it's not being flagged as overwhelming and dangerous.

Dr. Ayla Wolf 35:43

Okay. So I have one last question as we wrap up here. And I knowing that I'm gonna have you back on the show because we have a lot of other things to talk about. But if there was one maybe misconception about psychotherapy that is out there, what would that be? What would you want people to know that maybe they don't understand about psychotherapy in general? I know you already said you see 100 people, there's 600 different approaches or methods, but yeah.

Dr. Matthew Tolstoy 36:14

Oh man, my answer to this would be it would be it would be this. Going off of what you just said about there's 600 10 billion methods. How do I sort my way through this? How do I know therapy is working? What do I do? How do I not end up wasting my time? There's a bit of a secret in the psychotherapy world that is um something that how we all just kind of collude in the industry together to like keep it

What Actually Makes Therapy Work

Dr. Matthew Tolstoy 36:47

a secret from ourselves and other people. But there's very clear research, meta-analyses research over time that has been replicated, that for all of the different rigorously studied versions of psychotherapy, cognitive behavioral therapy, psychoanalytic, psychodynamic therapy, DBT, uh, supportive therapy, all these different types. When we look at them over time, they all seem to be equally effective. One is not better than the other. Again, for things that have been studied, there's a lot out there that doesn't have research. And so we can't necessarily say the same thing about them. But for a lot of methods that are that have been around for a couple decades and have been here enough to do randomized controlled trials, the actual technique and method accounts for about 5% of the positive effect of psychotherapy.

Dr. Ayla Wolf 37:40

Oh, I didn't think you were going to say that low of a number.

Dr. Matthew Tolstoy 37:43

Yeah. Can you see why we keep this a secret? No, we're not keeping it a secret because it means that we're all frauds. There's an interesting other data point that came from this research as what is doing the overwhelming majority of the work. Because psychotherapy has been, there's no doubt that in a statistically significant way it helps people. We hear the 5% technical data point, and we think, okay, this is all just made up. It's just placebo effect. No, no, no. We have tons of very well-controlled studies, tons of meta-analyses that say that good psychotherapy over time makes a difference in people's psychological growth. So, how do we square these two things? What is the factor that makes it work? And the factor that over and over and over again has shown to be the thing that matters the most is the sense of depth of the therapeutic alliance between you and the therapist. That matters a factor of a bajillion more than the specific technique. That's not to say that the technique doesn't matter, because now we get an overlap of factors. Is it the technique that mattered the most, or is it that the type of therapist that's attracted to that technique is maybe more likely to connect with you in a personal, meaningful, attachment-related way than the type of technique that CBT or whatever else kind of selects for? It's hard to say, like, well, was it CBT that helped you? Or after trying your, let's say, failed psychodynamic therapy with a psychodynamic therapist, you had great results with CBT. 5% of that might have been because CBT is great. The other huge impact leverage may have just been because the type of person with the type of interpersonal therapeutic style of CBT maybe matches your attachment style a little bit better. And this is what we're, this is what we're learning about like what matters in psychotherapy. And so the last thing that I want to say about what that means is that does not mean just simply liking your therapist more. That is a huge trap. There's there's the huge trap in psychotherapy of just simply validating and making somebody feel pumped up and good about themselves and just simply confirming everything that they do. This is not part of those technicalities and that has been researched in psychotherapy as effective. What a good therapeutic relationship means is just simply that you can be incredibly deeply honest with this person. You can survive having disconnect with them, moments when you get upset with them, moments when you can talk to them openly about when they said X, it really bothered you. And that enters the space. That's what sends really clear, if we want to talk about secure attachment signals, is that this relationship is deep and strong enough to hold my hardest emotional experiences. Not this is the safest, cushiest place I've ever been. Safety is unbelievably important. And it's not to be overlooked. But I'm saying when the relationship stops there or is purely organized around safety and validation and never moves past that in pacing, we don't get the depth of therapeutic relationship that is needed to really change and grow psychologically speaking. So when we say therapeutic alliance, it doesn't just mean my therapist is really nice and I feel comfy with them. It's that this is a really deep, rich experience, and I can just be my complete self with them in a way that I feel incredibly met and seen by this person.

Dr. Ayla Wolf 41:13

Yeah, that kind of reminds me of this idea there's so much going on on the part of the therapist that the other person doesn't even understand. And when I did EMDR, which I thought was very helpful, my EMDR therapist had all the things that he did as part of the therapy. And then it wasn't until I interviewed Dr. Michelle Morrissey, who actually teaches EMDR to EMDR providers, um, and specifically for people with brain injury, she has her advanced module that she teaches. It wasn't until I interviewed her for my podcast where she started talking about how EMDR works and the process that people, the therapists go through that I was like, I had no idea that that was all happening, you know, as I was doing this. And obviously, I guess the point I'm trying to make is that sometimes as the patient, you don't always understand the depth of what's happening on the other side. When when someone's really good at what they do, there's

What Therapists Track In Session

Dr. Ayla Wolf 42:16

a lot going on there that you are not aware of and you don't need to be aware of it.

Dr. Matthew Tolstoy 42:22

Yeah, exactly. You know, there's there's on the other side of the room in psychotherapy, a lot of what I'm, let's say, spending my attention focusing on and thinking about and engaging with with somebody in the room. Most of it I never comment on externally. Not necessarily in a way that's trying to like, you know, be behind the veil or, you know, like sort of hide something from the patient or anything, but just constantly listening and being with somebody and responding to them, knowing about their history, knowing about what their relational patterns are like, knowing that their relational patterns are going to organize themselves in the room with me in some way? And how can we then have an experience that broadens and is more exploratory and enriching together as these habitual patterns emerge between us? There's a way, do you talk more? Do you talk less? Does this person need you to step closer? Does this person need more space? Do they experience that space as abandoning? Different people, all of this means very different things. And so it's not just like, oh, when the person says something vulnerable, what you do first is you affirm it, and then you say, it's like, no, no, no, no, no. Like vulnerability, again, tying this back to what we were saying about attachment styles, a moment of vulnerability expressed by an avoidantly attached person is a very different relational moment between you and the therapist than somebody else who's anxiously attached. And therefore, then as the therapist, to engage with that person's vulnerability, it just means something very different. And so, yeah, we're thinking about that if that's your orientation in therapy. Those are the things that are all happening behind the scenes that may equate to the output of a subtle nod and uh yeah, as the intervention.

Dr. Ayla Wolf 44:24

Love it. Okay, I love that. All right. Well, what a great place to end with a subtle nod. Why don't you why don't you let people know where they can find you?

Dr. Matthew Tolstoy 44:35

Sure. Um I'm a I'm a little hard hard to find because I'm not on social media very much these days. Um, but you can find me at Matt Tolstoy. Uh I've been most active over the years on Instagram and threads. You can find me there, stuff that I've written about when it comes to therapy and rehab. Um, you know, my website is just you know mattolstoy.com. That has contact information there. Um I work with people both in person and online on this type of thing. So if this is resonating with you and you feel like um I could help you out, I'm happy to sort of talk to you about that. And uh yeah, those are the easiest ways to to get in touch.

Dr. Ayla Wolf 45:12

Okay. I will share all of that. And uh, we're definitely gonna have you back so that we can explore some other things we didn't even get to touch on today.

Dr. Matthew Tolstoy 45:21

Yeah, there's a lot. There's a lot that we can there's a lot that we can go in on, and uh that would be it'd be exciting. I'd love I'd love to come back.

Dr. Ayla Wolf 45:27

Perfect. Amazing. All right. Well,

Where To Find Dr Tolstoy

Dr. Ayla Wolf 45:30

thank you for your time.

Dr. Matthew Tolstoy 45:33

Of course. Thanks so much for having me here. It's always good to see you.

Dr. Ayla Wolf 45:38

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