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How Does Therapy Work?

No one knows for certain, although there are many theories. The good news is that research shows that, much of the time, therapy does work.

Now, here comes the long answer: There are, in my view, three essential and interrelated components of therapy. The focus of therapy can shift among these three aspects from session to session, or even in a single session.

The first component is what usually brings someone into therapy in the first place: one’s current life and situation. That may include work or career, or school, and it may be satisfactory and fulfilling or fraught with difficulties. It also includes one’s home life, whether married, living with a partner, with or without children, ending a painful relationship, starting a new one, or alone and yearning for more. Friendships—or the lack of them—and relationships to various family members also comprise one’s current life. Although there are other aspects to therapy, they always relate back to what is actually happening in one’s life.

In order to understand where someone’s difficulties come from and what to do about them, it is critical to look at the past. Although getting lost in an exploration of childhood seems almost like a cliché about therapy, it truly is a critical component. Otherwise, we would be operating in a vacuum, with no way to comprehend the reason for what is happening. While I am not a Freudian, I do believe that we all have an unconscious: conflicts and defenses that we are not aware of. To a large degree, my job is to listen. Part of my job is to listen for what someone is trying to tell me without even knowing it, and to bring what is unconscious into awareness, so that person can have more choices. Without that awareness, you might find yourself in that same painful situation over and over again. This is called the “repetition compulsion.” People are compelled to repeat what has not been resolved. Sometimes it happens over and over again throughout one’s life, and sometimes everything seems fine for a while until a change like a new relationship, marriage, or job stress brings out what seems to be a new problem. Usually, this traces back to a relationship or situation in childhood, and part of the way to change this futile repetition is to identify, understand, and feel the source.

Note that an intellectual understanding is not enough. One has to actually feel the feelings that may have been blocked long ago. One of the things that is special about therapy is that one can feel those feelings, not alone, but with the support of a compassionate witness. Generally, when someone gets hurt as a child, there is no one there to really help them through it. This is one of the ways that therapy is healing.

Another and perhaps more powerful way, and the third component of therapy, is the actual relationship between the patient, or client, and the therapist. When people come for therapy, they are looking for help, often concrete advice, and don’t necessarily think in terms of starting a relationship. But effective therapy is just that: a genuine, albeit unusual and even contrived, but real relationship between two human beings. That is one reason why one predictor of successful therapy is therapist-patient “match”—that is, finding a therapist with whom one can feel some sort of connection. Although therapy is a professional relationship with specified boundaries, it is very different from one’s relationship to an accountant, an attorney, or even a physician. In all those cases, as long as one is not repulsed by the professional, the relationship is not terribly important to the outcome. Your accountant can do your taxes and your physician can treat your headache whether you like them or not, and if you find yourself annoyed with them, the best thing to do is find someone else. Not so in therapy.

The therapeutic relationship is key because whatever one is struggling with in the “real” world will come up in therapy. Someone who has trouble getting close to anyone will have trouble getting close to a therapist. Someone who is mistrustful will have difficulty trusting the therapist. Someone who feels unlovable and rejected will feel hurt and rejected by the therapist. Just what sort of issue will come up in the relationship may be evident early in therapy, or it may take some time. What is important is that whatever it is, when it does come up, there is a unique opportunity to understand it and work through it with the therapist that one does not have with a friend, family member, boss, or spouse. At times, this can be a difficult period in therapy, and often one has the urge to quit just when major change might occur if one can stay with it.

It is the interwoven combination of these three components that is the fabric of therapy. And they are indeed connected. If you suddenly have a problem with your therapist that mirrors the problem you have with your boyfriend, which has threads of the trouble you had with your mother, it is an opportunity to work all that through and have a chance to live differently, healthier, happier.

How long does therapy take?

Good question. No good answer. Insurance companies would like it to take 6 sessions, or 20, or whatever their accountants have come up with lately, having nothing to do with how therapy really helps people. I have seen people resolve their problems in as little as one session, others over the course of many years, and everything in between. It varies as widely as people’s experiences, feelings, and difficulties vary. Generally, it takes about 6 months to 2 years to make a deep or significant change.