For the Therapy-Curious: 5 Things That Happen in Therapy

Every time I meet with a prospective psychotherapy client I’m reminded that, for many people, therapy is still a mysterious and often stigmatized process. While the conversation around mental health has become increasingly mainstream, unknowns still remain about the activity of therapy itself. What is expected of me as a client? What should I look for or expect in a therapist? What do we do in therapy? How long does it last?

Here are a few things that I tell people when they inquire about the therapeutic process.

1. Therapy is descriptive and exploratory. Much of the early stages of therapy are about describing what is going on for an individual. What are we feeling right now? What are our dominant or persistent thoughts? What recent events have transpired? What kinds of relationships are we involved in? We often come into therapy without a real map of what’s wrong or even what the issue is. We feel off or stuck or abnormal but don’t necessarily know what the cause is or what to do about it. This early stage is like detective work. I often use the analogy of untangling a ball of yarn, pulling different strings from our lives to sort out and clarify key areas of concern. Is my romantic relationship the most pressing right now, or is it my workplace stress? Maybe it’s managing pressure from old friends or family? By tugging at each string we can see what the priority in therapy should be, where we want to begin our work, and also the relationship between different elements in our lives (I notice that my workplace stress has affected my marriage, for example).

2. Therapy is about clarifying wants and needs. The descriptive phase often leads us to important questions concerning our wants and needs. Indeed, one of the fundamental (and surprisingly difficult) questions that appears in therapy is ‘What do I want?’ We often go about our lives without actively thinking about our wants. What do I want or need from a romantic partner? What kind of work am I excited about? What kind of life do I want to live? What kind of person do I envision being? In therapy, we can discover wants that we had not articulated or even known. Sometimes we uncover wants that have been suppressed by necessity, life’s duties or obligations, or forbidden from being expressed. Sometimes we need to express wants that we are ashamed of or that we know cannot be realized (or wants that we would be afraid to come to life). Naming these wants and their obstacles, what stands in the way of our wants, is important in this process. Wants to give us maps in therapy and can often shape the direction of therapeutic treatment. Are we trying to find ways to actualize these wants and needs, or are we reconciling ourselves to loss and disappointment from impossible wants?

3. Therapy is about situating ourselves in our family history. An important component in therapeutic exploration and treatment is in understanding our family system. As a therapist, I always begin with a genogram or family tree to find out where a client comes from and where they are situated in their family system. This is valuable information for both the therapist and the client and again shapes the direction of our work together. This work intersects with the question of wants and needs as we frequently inherit scripts from our families. For example, my parents valued financial security over all other values and so this too has become an anxious priority for me. Part of the work here is in untangling what is truly mine (my wants, my desires) and what are hand-me-downs. While sometimes our desires and values are congruent with our family of origin, often they are not. This friction can be a source of great anxiety, stress, and even depression for many clients. Untangling the family knots is a good early starting point in therapy.

4. Therapy is about strategies for living. It is rare that I have a session with a client that doesn’t involve what to do about therapeutic detective work and exploration. For example, I have discovered that I dislike my job and want to quit but feel powerless (and financially compelled) to stay. What do we do now? We often come to a point in therapy where it is appropriate to discuss strategies or approaches for resolving these dead ends or impasses. There are too many strategies to list here, but the world of psychotherapy is not short of approaches for helping us make decisions, cope, or manage symptoms that we live with. I often present strategies as a buffet that a client can take or reject. A client may be inclined to fill out homework sheets tracking their anxieties on a weekly basis, for example. Or they may benefit from mindful breathing exercises to help alleviate the pressures of uncertainty and doubt. I frequently hand out homework about ineffective communication strategies for couples. Strategies are tools and tools can make us feel active and empowered in our therapeutic work, engendering autonomy in our pursuit of mental health.

5. Therapy is about relationships. Regardless of modality, strategy, or approach, therapy is fundamentally about a relationship between therapist and client. Research consistently shows that it is the relationship in psychotherapy that matters most in client success, building a safe and trusting container to discuss and work out our most difficult issues and concerns. The relationship is the architecture of therapy and the ground upon which all therapeutic progress is built. It is the security of the relationship that can repair past hurts or traumas and provide a place for new growth and experiments of the self.