How Does Psychotherapy Work?

Montage by Victor Bloomberg, March 20, 2023

Psychotherapy – Sometimes it is Not Useful

Psychotherapy can come up short – it can be almost healing but not quite. A reason could be that we haven’t figured out what the client needs (at that moment.) In that case, our actions as a therapist can miss the mark. We might understand the client’s need in the moment, but we pick the wrong tool for the work being done. Sometimes, a therapist can make an error. There are two kinds: omission and commission. Omission is leaving something out or not doing what needs to be done. Commission is putting something where it doesn’t belong, doing the wrong thing or doing it too soon. As you read the comments by psychotherapists who did fabulous work, flip it around. Envision an opposite story and you can imagine a therapist’s mistakes.

Psychotherapists Give Examples of Good Work

Often a session with me begins with a version of this question, “What is your goal for today?” I like the sports definition of “goal”. It means that you’ve scored. 

When a session is nearing its finish, I ask something like “Was today’s work useful to you?” I like the word “work” because it points to sustained effort and dignity. “Useful” reminds us that the purpose is to make progress. Often a client says, “I feel better” or “I’ll be thinking about what you said” or “I’m going to use this worksheet” and so on.

It is common for a client to tell me that it was special or different for them to share and not get blowback like shame or guilt or advice that’s a put-down. A psychotherapist described this clinical respect: 

My client needs my nonjudgmental acceptance, professionalism and being able to hold their issues without imposing my own issues on them. My knowledge and expertise on personality styles and knowing realistic expectations for this person given the way they are wired. Knowing what is the reasonable goal for someone who’s wired the way they are. A consistent presence so they know what they’re going to walk into from one week to another. They probably have enough of not knowing what to expect in their lives with other people.

Psychotherapists often talk about learning new skills, gaining insight, improving self-image, etc. A psychotherapist put it this way:

I think about my individual clients and how each person has different needs. With some people, I don’t talk very much. They just need to talk and be listened to. Some people have a problem to solve, so we talk together about what’s available to them, and share ideas. Sometimes people just want to talk about what they notice about their feelings. For some people, their history is important, because it helps me understand how they got to where they are. For some people, it doesn’t matter how they got to where they are. They just want relief in the present time. 

We also say that therapy can be a healing experience. I really like the empathy in this psychotherapist’s reflection:

It’s always really amazing to me that people change because they forgive themselves. They can love themselves. It starts with the therapist’s empathy towards the person’s dilemma. And I explain it back, supporting that part of them that was hurt or mistreated, and that they haven’t shut off themselves. The therapist needs to be able to know where the patient is stuck or hurt in their development, and then to gently focus on that. Make it more meaningful, change the meaning of it, and the experience of it for the person. So like lots of abused women will start to feel badly about their inner child, they start to feel sorry for the little girl that used to be, and then slowly they can empower the woman they are now. 

Are We Making Progress or Going Round-and-Round?

Short-term, time-limited therapy is provided through an Employee Assistance Program, an insurance company authorization, etc. A goal for the session is especially useful for brief therapy. The challenge of time-limited therapy is that we don’t know if the progress is sustained. 

Whenever a client makes the decision about scheduling the next session, sustained effort becomes possible. I begin a session by asking, “Where do you want to start today?” Sometimes it takes courage (to continue in the face of fear) and dedication (in spite of uncertainty.) A psychotherapist gave me an example:

The client who I’ve had for a while is depressed and says, “If things don’t get better, at some point I’m going to kill myself.” The client is very successful in their career, but incredibly lonely and unhappy. In sessions he was often telling me about their life, but kind of apathetic. I just felt like we were stalling. We were going in circles. There was mind awareness, but no heart awareness. I used Telehealth to push and push and push and push and push. And this person got angry, screaming at me via Telehealth, “Why isn’t anything changing? I’m paying you. Why isn’t this changing? Why, why, why, why?” Just like crying and screaming. And I let them go and, of course, was trying to soothe them. I never felt connected to this person and I can connect with a lot of people via Telehealth, but can’t feel connected to this person. And they’re circling, not connecting and all of a sudden, I felt all of their emotions and they were connecting with me. We talked, “Why is it that you can’t connect in your relationships? What is it? What does it look like to connect with people?” And that was after working for this person for two years in-person. I honestly feel like they’re so guarded. I think it was really a safe way of doing it via Telehealth. And from there they are making a lot of changes in their life and how they connect with people and what they do. I’m looking forward to seeing where it’s going to go. 

There are different ways to explain what happened. I’ll share mine.

The Fight-Flight-Freeze response to danger (real or imagined) releases molecules such as adrenalin, cortisol and histamines. We clench-up readying for action. The tension peaks, climaxes. The client had been repeatedly responding to therapy with the Fight-Flight-Freeze response. The therapist’s non-threatening way contrasted sharply with the painful sensations the client was feeling. The therapist persisted in a respectful manner. There came to pass a paradoxical moment for the client: intense personal pain in the presence of a therapist whom he (intuitively) trusted to provide safety. At that moment, healing occurred: emotions were released along with molecules that calmed (i.e., endorphins, dopamine, oxytocin.) The client relaxed and thought freshly (freed from some toxicity of the past injury.) I call this Emotion Surfing because we ride a wave to a shoreline of rest.

You can read more about the nature of healing in What is Transformative Psychotherapy? Read about different kinds of healing in Intro to Psychology. 

Emotion Surfing versus the Merry-Go-Round

The “incredibly lonely and unhappy” client asks “Why isn’t this changing?” A simple answer is that three of the instinctual Five-F’s (fight, flight and freeze) were activated whenever the client’s past injuries were stirred up. The clinician reported, “All of a sudden I felt all of their emotions and they were connecting with me.” 

Here is an explanation. The safety, respect and trust nurtured by the psychotherapist provided enough contrast to the survival instincts. The contrast permitted Emotion Surfing. How can we tell whether the client is surfing (healing) or on a merry-go-round that activates pain signals stored in the body?

The Merry-Go-Round

The survival instincts (fight, flight and freeze) are activated repeatedly during therapy. You can see it when a client talks, but it’s been said before and there’s no insight. Emotions are released and the client says something like, “This isn’t helping.” 

The contrast (re-experienced past injury while being connected to present-time safety) is not achieved. The contrast is a paradox. The person feels pain from the past – it hurts but there is not new damage. In absence of the split attention (here-and-now alongside there-and-then,) therapy becomes repetitive. It doesn’t go anywhere. There is no progress. It is like being on a merry-go-round. The person on the merry-go-round hangs on for dear life – this is not fun. 

You can see clenched facial muscles or hands. Sometimes the clenched muscles aren’t visible (such stomach or toes.) Facial or limb muscles can be so chronically clenched they seem to express the client’s personality. Sometimes the ready-for-injury is expressed by the client’s patterns of thinking and reactions that flow from them. The client might argue against nonexistent criticism, assume the worst, and so on. A person might think they are sick or defective when in fact they are a unique individual within a bell-shaped curve (that represents possibilities within our human community.)

Emotion Surfing

My model is similar to a sexual response cycle (Cleveland Clinic, 2017). The sexual response cycle (excitement, plateau, orgasm, and resolution) provides insight into the waves of all emotions. The wave pattern is similar for laughing, crying, yelling, etc. The results of the waves differ radically based upon whether the experience is accepted or rejected. Metaphorically, acceptance yields an orgasm and rejection produces a spasm, regardless of the emotion. We ride a merry-go-round of emotions only to experience spasms again and again. The alternative is emotion surfing.

Here’s what I see when the client is surfing emotion waves: When they are done their body language is open, their face is relaxed and their comments are fresh, new. They express insight. They are unclenched.

(Read more about Emotion Surfing in When Do Emotions Injure or Heal?)