Thoughts on the Therapeutic Process
Clients often enter therapy with a pressing matter or crisis - symptoms of depression have become debilitating, an affair has thrown a relationship into a tailspin, feelings of anger towards a loved one have reached a boiling point, they have been ordered to come, and so on. Clients enter treatment and want to feel better, to determine if a relationship with their partner can work, to get rid of hateful feelings. Most of the time, people hope for quick, orderly fixes. Almost all of my new clients, especially in today's day and age where we can get everything we want with the press of a button, often desire quick solutions to very complicated problems.
The Desire for Quick Fixes
All clients ask similar questions during the first session, and it is the therapists job to introduce them to how they work. For example, many ask, “Is it normal to feel ____?” “How do I stop feeling or acting ____?” “How many sessions until our relationship is fixed?” “What are the concrete steps to _____?”
These are perfectly sound questions and should be asked, but I am afraid the answer may be disappointing at first. A quick google search would want you to believe that “anxiety should be solved in 6 sessions” or “PTSD symptoms should disappear in 8 weeks if you follow this technique,” but these magical claims only leave clients confused and disappointed in the long run.
It is much more realistic to claim that lasting change starts to occur after about 6 months and, in some cases, may take years. All modalities of therapy show initial improvements in the early weeks which is likely due to the relief of finding someone who can help. But lasting change depends on two factors. One, the client’s unique needs. For example, someone with schizophrenia may require 8 years of regular treatment. Or, a client who has experienced complex childhood trauma may also need multiple years of regular treatment - and may require many different treatments throughout their lifetime. Two, the longterm change of therapy also depends on the effectiveness of the therapist over the course of treatment.
What Heals
One thing that virtually every school of therapy can agree on is that it is not worksheets or specific tips and tricks that heal (although these can be helpful), it is the relationship between you and an experienced, thoughtful and emotionally present therapist that heals. The best thing to heal problems that arose from difficult relationships (either to yourself, other people or the world) is a new, more healing relationship.
So, for example, let’s say someone comes into treatment and has never felt safe in the world, does not feel protected by authorities and does not feel cared for in intimate relationships. There are no short-cuts or ways of “optimizing therapy” that can supersede the need for these difficult feelings to arise in treatment, be explored and felt through, so that new emotions and patterns of interaction can be experienced and explored. The relationship experience with a therapist that allows you to live a more meaningful life takes time and concerted action to develop. Similar to how there are no “hacks” to getting in good physical shape quickly, the same is true for mental health.
How to get the most out of therapy
What does beneficial therapy look like for you? Well, it is different for everyone. There is bound to be some discomfort between you and the therapist at first since it is a new and deeply personal relationship that differs from normal social interactions. If the therapist is doing their job correctly they help orient you to the process and support you voicing your feelings of initial discomfort, and they attempt to address those feelings.
Trust and comfort are the two most important things that need to develop between you and the therapist. Some clients want their therapist to be warm initially but to others, an overly warm therapist can feel uncomfortable and untrustworthy. This is why honest communication about what is felt, thought and needed by you is imperative to the formation of a therapeutic alliance.
How to Create a Therapeutic Alliance
This is done by the patient honestly saying everything and anything (about themselves, people close to them, and their thoughts and feelings about the therapist) and trusting that the therapist will be able to handle the honesty and use it therapeutically. The therapist's role is not to always make you feel good, their role is to allow you to come into treatment exactly as you are with the sole focus of working with you to explore all the different parts of you.
For most people it is easy to say social niceties to the therapist “thank you for understanding me” or “I feel listened to in here” but it is very difficult to tell the therapist negative thoughts and feelings. It may take you a few sessions until you feel comfortable telling the therapist you feel angry towards them or that you do not feel this is progressing fast enough (both are inevitable feelings in therapy). You may be preoccupied with concern of hurting the therapist's feelings or perhaps with a fear the therapist will punish you in some way. If you do feel you have hurt the therapist or you are being punished - then say that too! But again, if you are feeling the need to filter yourself in therapy then this should be explored.
Therapy takes time. However, therapists do want you to progress as quickly as possible so that you can live a more meaningful and truer life to who you are. This can only happen if both you and your therapist do your parts and you are completely honest with thoughts and feelings as they arise in session.
Common Concerns
Clients often imagine they are uniquely bad, that the therapist will find them to be extraordinarily mentally ill, that the therapist will recommend institutionalization if the client is totally honest. Clients believe they have thoughts that they should not have or have feelings they think are despicable and should never be shared - but the truth is that those concerns are common and deeply human. It is hard to imagine an experienced therapist being surprised and unable to relate to something that you bring into the treatment room (we are all much more alike than different). It is a more common experience that after you start talking about yourself that the therapist thinks to themself, “My God, how did you preserve so many positive traits after experiencing all you have been through.”
What Comes Up in Treatment
Throughout treatment sensations, emotions, thoughts and actions are discussed and explored about you and between you and other people in your life. Strong feelings also develop towards the therapist, feelings that are reminiscent of feelings you may have for people close to you such as a parent, sibling, romantic partner, authority figure, etc. The beauty of the therapeutic relationship is that anything and everything (as long as you feel comfortable) can be talked about and explored through words. The clear boundaries of the therapeutic relationship (or what psychoanalysts call the “frame”) make it a safe playground where everything can be discussed (feelings of hate, love, thoughts about sex or violence, ambivalence, etc).
Relationships Repeat
Whereas in your personal life you may, for example, become overwhelmed with feelings of anger and distrust towards any parental / authority figure (a pattern you may find yourself reenacting with your parents, your boss, your romantic partner(s), etc) in therapy these feelings are likely to also be felt towards the therapist (and that is a good thing!). In the therapeutic relationship however, these things are slowed down and those patterns recognized, put into words and felt through (the feeling through these patterns being the most important aspect of treatment). This allows room for new emotional experiences to be created and felt into (perhaps you may notice yourself having less feelings of hatred / mistrust towards your therapist and more feelings of trust or love, and you may also notice this start to permeate your relationships outside of the treatment room). The goal is not to use the therapy as a substitute for getting needs met, however. It is a playground where complicated emotions and patterns can be explored and felt so that the client may improve their life outside of treatment. But again, these processes take time.
How to Choose a Therapist
The therapist is able to help because the therapist works with their own emotions and thoughts with the sole purpose of better understanding you and helping you explore patterns (both outside the treatment room and inside of it). Initially the therapist acts in ways that invite you (emotionally, cognitively and spiritually) into the treatment room. The therapist may not say much initially as they want to get “caught up” on what it means and feels like to be you. If the therapist initially talks too much, dominates the room with their own emotions or idea etc, then this makes it more difficult for the client to create a space true to them and their thoughts and feelings.
Ideally the therapist has read across a vast discipline of subjects and literature (of course in the psychological realm but also across a broad array of studies), has ample metaphors for understanding and working with the human mind and is in their own regular therapy so they can process their own emotions about their life so it does not interfere with the treatment in a negative way. It is also imperative for therapists to undergo their own supervision with trusted, experienced clinicians in the field (sometimes for multiple hours each week) to explore their thoughts and feelings about cases to make sure they are intervening in helpful ways with clients.
Concluding Thoughts
The work between therapist and client is often longer and slower than most people initially would like. People come to us in crisis, and we do use various techniques in the short-run that manage immediate symptoms and attempt to reduce immediate suffering. But that does not produce lasting change. Lasting change is accomplished through a deep, often difficult, healing relationship with another.
