How Therapy Works, Redux
Recently, I revisited the question of how therapy works. Here’s what I came up with:
Over the past year I’ve really come to see therapy as involving two tiers: 1) symptom relief; and 2) beyond symptom relief. The language isn’t the most elegant, but hopefully you get the idea.
Clients enter therapy because something hurts. Perhaps they feel as if they are about to buckle under the weight of an oppressive depression. Or maybe they feel consumed with the kind of worry that sinks its teeth in and doesn’t let go. Others have had their hearts broken, their trust betrayed, their sense of the world turned upside down. No matter what the presenting problem, there is a common denominator – pain – that calls out to be soothed. Typically, this pain manifests itself in the form of symptoms: restless sleep, crying, worry thoughts that circle and circle and circle. Clients come in and say, “I want to feel better.” “I can’t stand this anymore.” The promise of symptom relief constitutes the first tier in therapy. And, depending on the particular client, it can involve different components. We work together to alleviate suffering in the moment, with the hopes of creating space for the second tier of therapy.
After clients have experienced some measure of relief from symptoms, when they have breathed a sigh of relief, no matter how small, there is the possibility of moving beyond symptom relief toward other tasks, including making sense of the pain and experiencing healing. We all, over time, develop habits of thought, feeling, and behavior that work to varying degrees of success. Many of these habits or patterns get laid down early in life. More often than not they work for awhile (i.e., are adaptive), and then they don’t, because of changing circumstances or new challenges, or because their usefulness has been outgrown.
A part of the second tier of therapy is about helping clients to increase awareness of these patterns, so that they get to know the ins and outs of how they operate and potential reasons why. Helping clients to step outside themselves allows them to develop new relationships with their problems, and ultimately, themselves. Instead of blindly repeating the same patterns over and over, we can develop space to do things differently.
Sometimes doing things differently is literally about doing things differently, changing behavior – saying “no” instead of “yes,” or pursuing a dream career, or ditching a toxic relationship. Or it can come in the form of changed thoughts, for example through noticing and challenging persistently negative thought patterns. Perhaps in a more subtle way, in can also involve changed emotions. Evoking and exploring emotion in sessions, within the context of a caring therapeutic relationship, can allow clients to experience resolution of previously “stuck” feelings; it can help them to feel differently about themselves and others. Raising awareness allows for different possibilities to emerge. That, in a nutshell, is how I believe therapy works.