Last week’s newsletter 👉 Pain: Is it All In Your Head?
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The stigma around psychotherapy seems to be lifting. More of my patients are embracing it. But some of them have even spent years, even decades, with the same therapist, without noticeable improvements in their lives (and health).
Sure, it can be hard to see small changes in ourselves. Witnessing the evolution of our own thoughts, feelings and behaviors can be like watching grass grow. But therapy isn’t always a slam dunk either. Writer Susan Dominus explores these issues in her latest piece in the New York Times, “Does Therapy Really Work? Let’s Unpack That.”
So, why doesn’t therapy always work? When does it? Is there a “right” or “wrong” kind of therapy? Based on what I see in my own practice, there are myriad reasons why therapy doesn’t “work.”
My advice for anyone in therapy and still feeling stuck? Ask yourself these six questions:
Are you giving it enough time? Therapists aren’t magicians! They need time to establish rapport, build trust, and help patients challenge (and cope with) unpleasant thoughts, feelings and behaviors.
Are you being honest? Therapists can only work with the story that their patient tells them. If we insist on sticking to an internal narrative that leaves out key components, we aren’t giving the therapist the material they need to help us. For example, consider a patient whose husband has threatened divorce. In therapy, she blames him for their broken marriage. Yet she leaves out an important detail: her alcohol abuse. Withholding this information with the therapist impairs impairs their joint ability to work on her anger issues and the relationship itself.
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Are you ambivalent about being in therapy in the first place? When a therapist hears, “My [spouse/parent/doctor] made me come here,” it doesn’t bode well. Therapy is unlikely to work when it is presented as a requirement or even a threat in a relationship.
Are you willing to make changes? It’s difficult to make progress if the patient uses therapy as a dumping ground, only to complain about what bothers them and/or seek validation. The patient needs to be open to envisioning and executing on change.
Has your therapist established trust, rapport and a sense of safety? Patients need to feel that they are being heard and understood—not judged or shamed—otherwise progress will be nearly impossible.
Does your therapist appropriately push you? It’s not always appropriate to push the patient (for example, a patient who is in the throes of grief), but supportive therapy alone is unlikely to move the ball down the court. Therapy isn’t supposed to be a cozy home; it’s a place to train your brain.
The route to success in therapy is a heck of a lot shorter when:
The patient is in therapy because they want to be there and they are motivated to try to feel better.
The patient is willing to be vulnerable, to accept help, and to make changes.
There is a good rapport between the patient and the therapist.
Neither the therapist nor the patient sees their relationship as a friendship. Both are willing not to be liked and are also willing to show their “unlikeable” sides.
The therapist is willing to be firm and direct, while ALSO being empathetic and supportive.
One of my therapist colleagues says that patients should see some results in 3 to 5 visits. If not, it may be time to reassess the patient-therapist relationship: what’s working and not working on both sides. That’s the piece of advice I gave my patient who I described in the video above.
Ultimately, the “best” style of therapy—whether it’s psychodynamic, cognitive behavioral, trauma-informed, or EMDR—is the one you best connect with.
Therapy’s success is founded on a relationship where you can honestly assess your interior world and the facts of your life—and your willingness to accept the things you cannot change in order to gain agency over the things you can.
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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.