What Happens in Psychotherapy?

What does psychotherapy do and how does it do that? Good questions, and even some therapists might have a hard time answering them. Of course, some of the goals are obvious: reduce depression, have better relationships, eliminate anxiety, enjoy your life more, and stop worrying. But what are the elements that get you there? I’ll give you a sense of some of the factors that permit those goals to be achieved.

1. Trust. Many people entering treatment have trust issues: they trust too easily or not at all, usually the latter. Trust will start with the relationship between you and the therapist. Simple things: does he listen? Does he understand? Does he seem interested and dedicated? Is he dependable? Does he care? If the answers to these questions are “yes,” then it will be a bit easier to begin to trust others. The experience of a benign relationship with one person can open you to the possibility that this experience can be achieved elsewhere in your life.

2. Validation. Many people coming into psychotherapy having been told that they should “get over it,” that they “shouldn’t feel that way,” that they shouldn’t complain or “whine;” or having been ignored, dismissed, or criticized too often when trying to express themselves. Some folks believe feelings are unimportant; others might state that it is not “masculine” to feel too much, and so forth. As a result, many new patients have so buried their feelings that they are alienated from themselves and don’t know whether it is appropriate to think or feel as they do. A good therapist creates a safe place for talking about such things (trust again), and gives the person a sense that there is value in what they feel and think. Over time, this action, by itself, can help improve self esteem and reduce sadness and alienation.

3. Grieving. If one has not had supportive relationships (with people who are both trustworthy and validating), the sense of loss or absence contributes to sadness, and sometimes to depression. The relationship with the therapist allows you to express the emotions related to loss (both sadness and anger) to someone who listens patiently and shows concern. As you process those feelings of loss, your sadness should gradually diminish. The therapist serves as a witness and again, as someone who validates your pain. Grieving in isolation too often contributes to the feeling of disconnection and alienation from the world. Grieving with someone who cares reconnects you to one of the things that can be good in life: human contact.

4. Learning new things. Any good therapist needs to provide some guidance and tools that enable change. This might come in the form of helping you learn and practice new social skills (including acting these skills out with the therapist), assisting you in changing how you think (cognitive restructuring) that helps you reduce self-defeating thoughts, training in how to be assertive (again with role playing in the therapy session), or meditation.

5. A change in perspective. A good therapist will provide you with new ways of thinking about the world and about your life. Since he can see you from the outside, he is more likely to see you in a way that you cannot see yourself.

6. Facing things, not avoiding things. We all practice avoidance some of the time, and some of the time it is a useful thing. Unfortunately, many of us practice it all too much. We distract ourselves from pain and avoid challenging situations. We can use food, TV, shopping, sex, drugs, alcohol, the internet, and computer games to get us away from whatever it is we can’t handle. We worry about problems rather than coming up with a plan of action and taking them on. We don’t ask out the pretty girl for fear of rejection, or say “no” to people who want to befriend us for the same reason. We stay at a “dead-end” job because of our insecurities. And, of course, unhappiness is the result.

A therapist can assist you in identifying the patterns of avoidance, help you to gradually become able to tolerate anxiety (by use of such things as cognitive restructuring, role playing or meditation) and give you tasks that gradually increase in difficulty so that you reduce avoidance and begin to take action that works.

7. Acceptance. By acceptance I am referring to acceptance of the nature of life and the discomfort that comes with living; acceptance of the fact that being open to life allows you to experience satisfaction and joy, but also opens you to pain; and awareness of the temporary nature of most of that discomfort. The more that you take life on its terms, the less you will be trapped by it.

Remember playing with the Chinese Finger Puzzle as a kid, the cylindrical woven structure made of bamboo, open at both ends? You put your two index fingers into it, but when you pulled hard to get your fingers out, you became more stuck. Only by releasing the tension and moving your fingers toward the center of the device, did it collapse and no longer held you tight. Life is a lot like that to the extent that we must stop engaging in behaviors that only make us more “stuck.”Acceptance allows you to free yourself, at least somewhat, from what is distressing about life.

8. Valued Action. If you are caught in the struggle with your emotions, or focused on avoidance of pain, what is good in life will be hard to achieve. Therapy can help you to think about the life you would like to lead, the life that is consistent with your values, and help to relieve you of the habits that keep you so wound-up that you don’t have time to think about what it is you would really like to do, and what it is that would lead you to a sense of satisfaction and accomplishment. What is your true self? Therapy can help you find out and encourage that person to exist in the world.

The description I’ve given you is based, in part, on my experience in life and training, especially training in such therapeutic approaches as cognitive behavior therapy (CBT), mindfulness-based behavior therapy, Acceptance and Commitment Therapy (ACT), and psychodynamic psychotherapy. Other therapists may have a different view of what is important and how to help you get to the point that your life is more satisfying and less fraught with depression, anxiety, or chronic relationship problems. But here, at least, I hope that I have given you some sense of direction and some reason to be hopeful about the possibility of change in your life.

What To Do When Therapy Doesn’t Help


Therapy doesn’t always help. That doesn’t mean that it can’t help and that a second chance isn’t indicated. But, it does mean that you will need to ask yourself a few questions about what is going wrong.

There are several possibilities:

1. Misdiagnosis. If, for example, you have an alcohol or drug problem, but the therapist wasn’t told about it or didn’t realize its significance, treatment is almost certain to fail. Similarly, if you have a Bipolar (manic-depressive) Disorder that goes untreated (these can be difficult to diagnose), it will be hard to profit from therapy. I have seen many adults, for example, who have the inattentive form of ADHD and have never been diagnosed and treated for the condition, even though they have seen more than one therapist.

2. Insufficient motivation. Have you been giving therapy your best effort? Do you go to sessions religiously? Do you follow through on any “homework” assignments that you and the therapist discuss? If you are not adequately open and dedicated to getting better, then treatment is likely to fail. Defensiveness in the treatment process and inconsistent attendance are major problems. With respect to lack of effort, the old joke goes: “How many therapists does it take to change a light bulb?” Answer: “One, but the light bulb has to want to be changed.”

3. The therapist/patient match. Do you feel comfortable with the counselor? That doesn’t mean that therapy will never make you uncomfortable (change isn’t easy and it is often painful), but it does mean that the therapist is someone you can trust, who is sincere, and who is competent. Does the therapist have sufficient understanding of your life circumstances? This doesn’t necessarily mean that he has lived through a similar situation or has an identical background, gender, age, or religion; but he will need to understand where you are coming from.

4. The tempo of therapy. Does the therapist push too hard? Do you find yourself too often overwhelmed by the issues and feelings being stirred up in your sessions? Or perhaps, do things seem to go too slow? Are the sessions becoming boring and unproductive?

5. Activity level of the therapist. Is the counselor too active and probing for you? Does he seem to have a plan and a direction for your treatment (he should)? Is he too controlling, seeming to follow an agenda that is inflexible and ignores what you need? Or, alternatively, is he too passive, simply waiting for you to talk about whatever you want, regardless of how far afield this might lead the treatment?

6. Is the therapist too friendly? Does he want (or is he open to) a friendship or anything other than a therapeutic relationship (he shouldn’t be). Or, is he too distant and uninvolved?

7. Type of therapy. Therapists are not all equally comfortable and competent at the multiple types of treatment available. Some problems have been subjected to well-documented and researched treatments (Obsessive Compulsive Disorder, for example). If your therapist is using the wrong treatment approach, you are not likely to benefit as much as you could.

8. Medication. Would you do better if you were on medication? If you are on medication, might you improve more with a different medication?

9. The therapist’s problems. Does the therapist seem stable? Does he act in an inappropriate way in the sessions? Does he become angry and critical? Is he judgmental rather than supportive? Does he talk about his own current problems?

If you are still in therapy and you have concerns about its effectiveness or any of the issues mentioned above, it is usually best to voice those issues to your counselor. He should not only be open to hearing what you have to say, but want to be responsive.

Therapists are not mind readers and won’t always figure out what you are thinking or worried about unless you say it. Do your homework and try to find out what therapeutic approaches might be more appropriate for you (your therapist should be able to describe at least some alternatives).

If he cannot provide you with the kind of treatment you are asking for, he should be able to come up with some very good reasons for what he is doing. Should those reasons be unconvincing, perhaps a second opinion is indicated and he should be open to this idea, as well. If you remain sure that this therapist is not the right one for you, getting a referral from him to someone else is entirely appropriate.

If, on the other hand, you have had unsatisfying experiences in therapy before and are not now in treatment, but are thinking of trying again, make sure that you have attempted to investigate your potential new therapist’s background and experience. Also, when you talk to him on the phone, ask about his therapeutic approach. If you do decide to see him, talk about the things that didn’t work in previous therapy attempts, as well as those that did.

Be as informed as you can be. Unlike brain surgery, you aren’t going to be passive and unconscious during treatment. You are going to participate and interact with someone who, you hope, is well-trained and dedicated and compassionate. Evaluate what is going on in treatment in an open and thoughtful way; collaborate with the therapist.

You will be glad you did.

The Red Woman by Neuthaler is the name of the above image, sourced from Wikimedia Commons.