What happens in therapy

People who come to therapy for the first time often aren’t quite sure what to expect from the process. They are curious and sometimes a bit anxious. Perhaps their knowledge of therapy comes from scenes in movies or on TV, which usually involves someone lying on a couch while a bespectacled therapist takes notes on a pad. Dramatic enactments of therapy range from fairly accurate to wildly off the mark. And by the way, most clients don’t lie down, and a lot of therapists, myself included, don’t take notes (except on the initial session).

So what does happen in therapy? Of course, every client and every session is unique, but there are some common themes. But before we talk about that, let’s start with another question: Why do people come to therapy? The short answer is this: painful feelings. No one comes to therapy because they’re too happy. They seek help because of sadness, or anxiety, or guilt, or shame, or anger, or depression, or any combination of these. Something in their life needs to change.

Often, contacting a therapist is in itself an act of courage. There are several reasons why one might find the prospect of seeing a therapist a daunting one. Many people have been taught to believe that therapy is only for “crazy people,” and seeing a therapist is tantamount to admitting you are crazy. Several clients have told me, “My family doesn’t believe in therapy.” Yet here they are in my office, in spite of such teachings, ready to give it a try. I applaud their courage.

Another reason is that most people realize on some level that, deep down, they are carrying a lot of pain. Therapy might bring it up, where they can actually feel it. Nobody in their right mind relishes the prospect of doing something that could really hurt. In the same way someone might avoid going to the dentist or engaging in physical therapy for a wound that is on the mend, the potential client might balk at anything that is going to stir up emotional pain. This makes perfect sense. We are biologically programmed to avoid pain. However, there are times and situations where we might recognize facing a little pain now might result in a lot less pain down the road. That’s why people do scary things like go to the dentist, or the physical therapist, or the psychotherapist.

Here’s what happens in a typical first session in my practice: the client comes in and sits down, and we make a little small talk for a minute or two. Then we start getting down to business. In the first session, I try to gather as much information as possible about the client’s life situation. (This is when I take notes.) We discuss the “presenting problem,” which is the issue that prompted the client to seek assistance; where and with whom the client lives; their work and financial situation; level of social support; past and current family relationships; physical health; hobbies and interests; any history of trauma; substance use or abuse; and the client’s perceived strengths and weaknesses, among other things. This can take up several pages of notes. 

The actual process of “doing therapy” has not yet begun in earnest, although many people find they feel much better after an initial session, because they have taken an important first step, and gotten a few things off their chest in the process. At the end of session, we will talk about the client’s goals for therapy, which is usually some variation on, “I want to be a happier person,” which is an excellent goal.

In subsequent sessions, the client and therapist will talk in greater detail about some of the things the client discussed in the first session. Often, topics come up that weren’t talked about earlier. The point of all this talking is to give the client an opportunity to express feelings. It is a common misconception that the client’s task is to give as much detail as possible, so that the therapist will understand her or him better. While it is important for the therapist to have a good understanding of what happened in the client’s life, that’s not really what promotes healing. The real task of therapy is to give voice to your feelings.

To illustrate this, I’m going to provide an example from my own life. The year was 1996, and I was a junior social work major in college. I was also going through a divorce. We had married in 1994, had a pretty good first year and then things fell apart. I had spent the next year trying to salvage what was ultimately a doomed relationship, and it was far and away the most painful thing I had ever experienced. Not surprisingly, I was depressed.

Seeing as I was in school to learn to be a therapist and the university offered a free counseling service to students, I figured I should go talk to someone. At the time, I thought I had a pretty good understanding of what this whole therapy thing was about. As it turns out, I didn’t know doodly-squat.

When I went in for my intake session, I remember thinking that I was going to be a stellar client. I would go in there and dazzle my therapist with how much useful information I gave them, while at the same time proving just how smart I was. So that’s what I did. I sat down with the intake therapist, a nice guy who was probably just a little older than me, and he conducted what is called a psychosocial assessment. It consisted of a lot of questions about my current and past life situation, like I described above. It was a typical first session.

After about half an hour of me giving the therapist a treasure trove of clinical detail, he finally stopped taking notes and gave me a quizzical look.

“Do you see what you’re doing?” he asked.

I was perplexed. “What am I doing?”

“You’re giving me all this great clinical detail,” he said, “and you’re not allowing yourself to feel anything.”

And then, much to my embarrassment, I burst into tears.

In that moment, I learned a valuable lesson, one that they had yet to teach me in class: it’s all about the feelings. I realized that giving the therapist all this information wasn’t going to help me if I continued suppressing the profound sadness that brought me there in the first place. For that, I will always be grateful.

For the next several months, I saw the therapist on a weekly basis. There were times when I didn’t want to get into the pain, and I kept it about surface-level stuff. If I had been paying for the sessions, I might have worked harder. Eventually, I reached a place where we were doing more chatting than actual therapy, so I stopped going. I was still sad, but things were better. It helped.

Since then, I have tried to do for my clients what that therapist did for me, which was to provide a safe, supportive environment for men and women to take the lid off their feelings, to remove the mask, to become emotionally honest. That is the first core task of therapy. Feelings are like living things, trapped inside of us, and they all want the same thing: they want out. They want their freedom. We can give it to them, but we can’t do it and remain emotionally detached at the same time. We have to feel it. A little pain now means less pain down the road.

Giving voice to painful feelings, also known as grief work, is hard for two reasons. One, it hurts. Two, virtually everyone has been culturally conditioned to believe that certain feelings are bad, or wrong, or “weak.” Nothing could be further from the truth. Feelings are morally neutral, but most of us were taught that we shouldn’t have certain feelings. All this does is create unwarranted guilt which causes us to suppress the “bad” feelings. This is one of the reasons most of us have stuffed down a great deal of pain by the time we become adults.

In the course of growing up, the people whose job it is to raise us and love us are going to hurt us too. They usually don’t mean to, but they hurt us all the same. Deep down, we feel anger and disappointment, but often we invalidate our own feelings by letting them off the hook with statements like, “They did the best they could.” This may or may not be true, but it doesn’t change the fact that we suffered. The subtle message of, “They did the best they could,” is, “and therefore, I shouldn’t have any hard feelings.” But we do have hard feelings, whether we like it or not. We can suppress those feelings, or we can give them a voice and let them out.

There is a second core task of therapy: challenging faulty beliefs that maintain feelings of unwarranted guilt and shame. At the heart of virtually all depression, and a great deal of anxiety, is a deep-seated belief that says, “There is something wrong with me,” or, more succinctly, “I’m bad.” This is a belief that no one is born with. It is acquired, it is taught. It’s a message that is delivered by people who don’t know how to deal with their own unhappiness. The belief that one is bad makes it very difficult to be a reasonably happy person. It also sets up a vicious cycle that goes like this: A person learns to believe she is bad, which causes her to be chronically unhappy, which in turn is interpreted as further evidence there is something wrong with her, which makes her more unhappy, and so on, like a feedback loop. It’s not easy to break that cycle. It takes time and effort, a lot of which takes place in therapy.

When it comes to challenging faulty beliefs, cognitive-behavioral therapy can be quite effective. This type of therapy examines the role of our thoughts on our mood and behavior. If you could print out all the thoughts you had in the course of a day, and examine them, there’s a pretty good chance that a lot of your thoughts would be factually incorrect. This is particularly true for thoughts you might have about yourself. For instance, upon making a mistake, instead of a thought that says, “Well, I made a mistake,” which is perfectly true, you might have a thought that says, “I’m an idiot.” The number of exaggerated insults we hurl at ourselves can be quite high. Most of these go unnoticed by our conscious mind, but there’s a part of us that hears such statements, and reacts to them by feeling guilty and sad. Among people who struggle with depression, negative self-talk is usually extensive. Both cognitive-behavioral therapy and mindfulness (which are closely related) helps us to identify and challenge such thoughts, although in different ways. I will examine the similarities and differences of cognitive-behavioral therapy and mindfulness in my next article.

One thing cognitive-behavioral therapy is not good for is grief work, which consists mostly of giving voice to feelings. CBT can be quite helpful at clearing up a lot of misconceptions and unnecessary guilt and shame, which can make grief work easier, but grief itself isn’t based on a cognitive error. The only cure for grief is to grieve. Time alone may not be sufficient. 

Of course, there are a lot of other aspects to therapy besides grieving and challenging faulty beliefs, but those two are almost always present. Often, the presenting problem might not have anything to do with either of those things — at least, not on the surface. However, people often find in the course of doing therapy that they are carrying a lot of pain that they weren’t really aware of, and that they have a lot of negative self-talk as well. Not everyone is ready to deal with this right away, and so some people will discontinue therapy without getting much of a resolution. Over time, some of those people will come back when they are ready, and others won’t, which means they are likely to carry that pain until the end. The good news is, it’s never too late to heal, as long as you are alive.

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