What is Therapy?

This blog was originally posted on Therapy Route

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From the outside, therapy looks little different to any other conversation between two or more people. There is however, more to therapy than meets the eye. 

What is therapy?

Unlike the supportive conversations that you hopefully have with your loved ones, therapy discussions are structured by trained therapists according to principles scientifically demonstrated to be helpful. This involves far more than talking about your problems in the hope that someone will listen and offer practical solutions or reassurance. Of course, therapy can include these aspects, but therapists aim to achieve lasting growth by helping you find ways of seeing, thinking and feeling that leave you more capable and prosperous.

There are many forms of psychotherapy and they differ in a variety of ways, but they also share a great deal in common. All therapists aim to provide a safe, confidential, non-judgmental, consistent, reliable and accepting encounter with a helpful human being. Therapy is designed so that you and your internal life take centre stage.

You are the one who shares personal details about your life, while the therapist works to help you to understand the situation you face and to be as open as possible. This includes the therapist refraining from sharing their political, religious, moral or any other views that might make it more difficult for you to be yourself. 

Some forms of psychotherapy involve a meeting between one patient and one therapist, while others involve more, e.g. group or couples therapy. Sessions are usually less than one hour but it is not unusual for initial assessment sessions (or groups) to be scheduled for longer. This is because assessments sometimes require many questions to be asked, whereas subsequent sessions might be less structured. 

Does therapy work?

Yes! Therapy does work. Research has shown that people who attend therapy are more likely to be better off than those who don’t. This finding has been repeatedly confirmed and researchers are now turning their attention from asking “Does therapy work?” to the more complex issue of “Which therapy works best for whom and under what circumstances?” 

Apart from the obvious expected benefits like feeling and functioning better, therapy can also improve relationship skills and work performance, and reduce the number of times a person sees a doctor or is admitted to hospital.

Some issues that therapy is known to be helpful for include:

• Addictions
• Anxiety
• Depression
• Emotional crises
• Low self-esteem
• Obsessive-compulsive disorder (OCD)
• Personality disorders
• Phobias
• Post-traumatic stress disorder (PTSD)
• Relationship and family problems
• Schizophrenia

What to expect

No two therapists are the same, not even two therapists working under the same professional title, using the same orientation and applying the same techniques. The good thing about this is that you don’t need to write off an entire approach if you are unfortunate enough to have had a bad experience with one therapist. Try someone else; you might be pleasantly surprised. 

There are some things that you can expect from most therapists. Most will want to meet once or twice weekly for under an hour (45 – 50 minutes). During this time, you will probably do much of the talking as your therapist works to understand the nature of your difficulties. Think of these meetings as an opportunity for the two of you to get to know each other a bit and decide if this relationship will work.

Some therapists will approach these initial (and perhaps later) meetings in a structured way, asking questions and gathering details about what brings you. Others might follow your lead and quietly form an impression of how to be helpful. At the end of your first session, some will invite you to return to continue where you left off, while others may have already formulated clear ideas about how to proceed. Neither approach is better or worse; the important thing is that the two of you are starting to clarify your expectations, establish a good rapport and build a connection. 

It’s understandable to want a professional who will tell you how to go about fixing things, but this is rarely the best approach. As the word suggests, psychotherapy is a therapy of the mind. The aim is to help you to change internally so that you can live more productively. Having a therapist solve problems for you or tell you what to do ‘out there’ feels nice, but it is a red flag and fosters dependence. Be prepared for the process to unfold gradually, to work together with your therapist, and to take risks as you feel ready and able to. This includes things like being open to feeling vulnerable, acknowledging the part you might be playing in something, or allowing yourself to trust your therapist. 

Working towards trust is an important part of most psychotherapies. You probably sought help because you have been suffering. Therapy involves talking about this and so stirs up painful memories, feelings of frustration, and sometimes shame-filled disclosures. A good therapist will guide you through this and will understand that this is difficult and takes time. Feel free to let them know how you are feeling, even if this involves your negative or positive feelings towards them. It’s okay to have mixed feelings about therapy and to let your therapist know if you have doubts about the sessions. 

How long does therapy last?

The length of therapy will depend on a few factors including your therapist’s talent, your goals, the type of difficulties you are working with, and your level of commitment to the process.

Therapies that aim to reduce one symptom (e.g. fear of flying) or that have a clear, focused goal (e.g. teaching relaxation techniques) are usually shorter-term (months) than those aiming for broader, less defined changes (years). Examples of the latter include aiming for greater emotional maturity or deeper interpersonal relationships. Also, some difficulties are easily addressed while others prove difficult to change and sometimes form part of a severe and chronic condition.  

The length of therapy often has little to do with what is needed and might be prescribed by practicalities such as finances and clinic policies. In instances where a therapy is cut short because of financial and policy restraints, it is helpful to think of your therapy as one step along a journey that may need to be revisited from time to time. Don’t blame yourself if you aren’t well at the end of a limited service, or relapse shortly after that; time limits are often based on available resources and not on what’s in the best interest of each person’s situation.

It is acceptable to participate with your therapist in setting goals and establishing the type of work that you are looking for. This is also something that is likely to change over time, and you can feel confident about revisiting these issues as and when needed.

Getting the most out of psychotherapy

As with most things in life, the more you put in, the more you will get out. In therapy, this refers to how often you attend, how engaged you are during the sessions, and then how hard you work on the issues that brought you to therapy between the sessions. The time you spend with your therapist is important and can provide a large part of what you need, but you will probably discover that being in therapy often means thinking about things in new ways for much of the time, including between the sessions.

The two most important things you can do to get the most out of therapy are: 1. be open with your therapist, and 2. attend the sessions. Being open is something many of us find more difficult than we would like. Even people who seem to be publicly open about the most personal things are often quite reluctant to talk about a host of ordinary things that would surprise you.

A significant part of many therapies is having the opportunity to share things with another human being that you would find difficult to tell your closest loved ones. This can be for a whole range of reasons, but shame and embarrassment are the most common. Openness is a quality best worked towards gradually. Blurting out all your secrets can be counterproductive since it might leave you feeling terrible, and this approach probably won’t change much.

Change comes from getting to a place where you trust your therapist enough to risk telling them. Repeatedly discovering that they aren’t driven away is transformative and can alter how you start to relate to yourself. In instances where it’s just too difficult to be open, the best strategy is to be open about why it’s too difficult. That way you are starting to understand what holds you back, while letting your therapist know that there is more and that you will get there in due course. 

Attendance is also very important. You aren’t in therapy if you aren’t in the room as agreed. This may seem an obvious point, but it is a frequent stumbling block to true progress. This is quite understandable: therapy can be painful at times and often involves confronting things that you might be trying to avoid. Attending regularly is the best way forward because it allows you to develop trust more easily, it prevents your session time from being hijacked by the need to update your therapist on recent news, and it helps you build momentum and pick up from where you left off. When you find yourself not wanting to go to a session, try to reflect on why. Could it be that the last one was hard? Did you leave a little angry with the therapist, or is there something you know you need to talk about but don’t want to? These are all good things to work through together with your therapist.

Remember: frequency, regularity and continuity are required to achieve depth.

You should also know that attending therapy, while most definitely a valuable and positive step, is not enough to lead to a healthy and reasonably happy life by itself. You will still need to work towards having the basics in place. These include eating properly, staying fit, socialising, keeping intimate, loving relationships, participating in productive activities, resting, having sex, taking the time to play, etc. etc. etc. Of course, it might be because you are unable to do these things that you are in therapy; unfortunately, the one doesn’t replace the need for the other. 

Try to take as much control of your therapeutic process as possible. For example, if someone plans to help you pay the account, still have the account sent to you and arrange for the money to be paid through you to the therapist. Similarly, do call your therapist yourself if you need to cancel, move a session or find yourself in crisis. Therapies that are carried out in this way are more successful because the patient practices taking responsibility, and the therapy is less likely to be hijacked or seem as though another person (e.g. Dad) is pushing the agenda. 

How to tell if therapy is working

This can be a difficult question to address because we all have different ideas about what ‘working’ means. Some enter therapy hoping to eradicate their need for others. Since humans are more like pack animals than lone leopards, this is not possible. The therapist might feel things are proceeding well if the person starts to understand their aversion to neediness, but the person may see this as a failure. Agreeing on clear goals (e.g. date more) makes it far easier to evaluate how things are going, but circumscribed goals rarely do justice to the complexity of living. In fact, many people only realise what they wanted out of the therapy quite some way into it. Also, different kinds of difficulties respond to therapy in different ways, so it isn’t always possible to sketch out clear guidelines regarding how to tell if things are going well. 

Having said that, there are ways to tell if things are working out or not. You should have a gradually deepening sense that the therapist you are working with is engaged with and interested in you. As time goes on, they should appear to be reliable and consistent, and they should be developing an understanding of the challenges you face. Your sessions should not frequently be rescheduled and cancelled by your therapist, and you can expect that them to remember at least the main elements of your story. 

Many people will start to feel better soon after entering a psychotherapy process. Taking steps towards changing in positive ways and finally having someone listen with sincere interest is uplifting by itself. Lasting change takes a little longer, but you should soon notice that you start to think a little differently about your life. These small changes are usually accompanied by a sense of hope, but some can also be quite painful. For example, it might initially hurt if you have been getting into trouble because you have found it difficult to think about certain things, and you have now found the courage to start doing so.

Progress in therapy is rarely one straight line upwards. As with climbing a mountain, you may find yourself descending into small valleys even though the overall trajectory is up. Don’t be discouraged; this is normal. Setbacks are an opportunity to learn something. The whole picture is what’s most important. Therapy is not easy; some patterns have been in place for decades, and it takes some effort and patience to shift them. A more productive and fulfilling life is possible.

Questions to help evaluate how therapy is progressing

• Are you socialising more or at least feeling less isolated?
• Is it any easier to be productive?
• Do you feel more connected to yourself or others?
• Have you been able to broach topics in therapy that you never thought you would?
• Do you like yourself more?
• Can you have more fun than before?
• Is hope a little more present? 
• Do you notice any areas improving in your life?  E.g. work, love, play?
• Are you more honest with yourself?
• Do you feel challenged to grow?
• Have other people’s actions started to make more sense?
• Are you feeling better or more confident?

Assessing doubts about therapy

Sometimes doubts are no more than a sign of the typically mixed feelings that come about while doing something uncomfortable. Sometimes they are the expression of similar doubts that block you in your other intimate relationships. Unfortunately, they can also be a sign that something is wrong with the fit between you and the therapist.

Start by asking yourself the following questions:

• Is this a familiar feeling that causes you to hold back from relationships generally, and is it something you would like to work through?
• Does your therapist appear to accept, empathise with, or care about your situation?
• Is it clear that the therapy is about you and your life rather than the therapist’s?
• Do they seem to want to understand?
• Are they working to make it easier for you to share difficult things?
• Do they respond thoughtfully and non-defensively when you talk about your doubts?

Answering “No” to the above questions may suggest that it’s time to move on to someone else. If you find yourself in the same situation repeatedly, it may be worth considering the role you play.

When is it time to end therapy?

There are three points at which it is worth considering stopping your therapy: 

1. You have met your goals 
2. The cost outweighs the benefit
3. Something is going wrong.

The first of these is easy enough but requires that either your therapist or you had the foresight to establish clear and measurable goals at the start. Maybe you wanted to date more, perhaps you had a fear of flying, or it could be that you wanted therapy to help you to get through the first anniversary of a loved one’s death. These are all definable and measurable goals, and it’s easy to tell if they have been met. If they have, you can either bring therapy to an end or set new goals and continue.

Many people, however, enter psychotherapy with less measurable goals. They might sense that they are easily offended, intolerant of intimacy, or want to understand why they experience life differently to others, sabotage their success, or choose unavailable people. There are countless examples of situations like these, and while some do offer clear endpoints, many have the potential to lead to long-term therapies that end when the therapist or patient or both decide that it’s time to call it a day. 

The decision to end often comes down to an assessment of whether the benefit continues to outweigh the costs, i.e. are you still making good progress or finding help? Assuming the therapy is affordable and providing value, there is no inherent reason you should end it. Emotional growth and development unfold over time, and some have found integrating psychotherapy over the course of their lives enormously enriching. Of course, you may not want to do this, and there is nothing wrong with that either. But there is no need to end therapy out of fear you might become dependent, or fear that being in therapy proves you are weak. Well-trained therapists know how to establish a long-term therapeutic relationship that breeds independence and strength rather than dependence and weakness. This is one reason they don’t tell you what to do and encourage you to find your own solutions. 

Unfortunately, therapy doesn’t always end because things have gone well and your goals have been reached. Sometimes it must stop because things have gone or are going wrong. It might be that the therapy frame has become eroded. The frame includes all the things that distinguish being in psychotherapy from having a friend who is also a psychotherapist. This includes the rules that structure the engagement, e.g. who’s there to get help, the length and frequency of sessions, who speaks first, whether meetings can be rescheduled, whether contact is avoided outside of sessions, etc.

An eroded frame will render the therapy ineffective. It is always the therapist who works to maintain the frame, but it is sometimes the patient who must call it a day if the therapy relationship has turned into something else. 

Signs that your therapy has an eroded frame include: your therapist telling you their difficulties; holding long, unscheduled telephone conversations; meeting casually outside the therapy room; spending therapy time catching up on each other’s lives; and flirting (or worse) with each other. Ending a therapy that has reached this point can be especially painful since you may have developed a strong bond with your therapist by then. Try not to let this prevent you from moving on to the real help you need. It is unethical for a therapist to allow the frame to erode; consider reporting them to their respective licensing authority.

Here are a few other signs that indicate things are not going well in your therapy: a clear sense that the therapist is uncomfortable about discussing what troubles you (e.g. sex); having the therapist dismiss each of your concerns or worries; finding that your therapist needs constant reassurance or admiration; being subject to your therapist’s agenda (e.g. applying pressure to attend their expensive workshops); and finding that the therapist pushes their moral view, tells you how to live your life or speaks more than they listen. 

The ending of a therapy can be a surprisingly emotional time. It is not unusual for symptoms to return around the time, and many people find that they doubt whether they are ready. This is quite reasonable, and things do usually settle down again. For many, this will have been the most open and supportive relationship they have ever had. It is not uncommon to have told your therapist more intimate things than any other person before. There is a good chance that you formed an important and powerful bond with your therapist and this can make saying goodbye quite challenging, since it involves facing genuine loss. 

When you do decide that it is time to end, it is wise to set a future date for the last session and then to use the run-up time to properly say goodbye, and process the feelings that saying goodbye can evoke. This is particularly useful if you tend to dismiss goodbyes or minimise loss, because it can help you to hold onto the good of the experience you have had by allowing you to face the end in an authentic way. The length of this ending period should be proportional to the duration of the overall therapy; a week or two for short-term work and possibly many months for therapies that have lasted years.