In Treatment (How Therapy Works)

Well - I started this blog series with the intent of an every other week schedule, and I’m already well off track. Life gets away from you sometimes, right? 

This blog post I feel like has been marinating in me for a while, as I had watched the latest season of “In Treatment,” a show that focuses on a therapist, and it had stirred some more challenging reflection. I really enjoy this show as entertainment, (truly, it is fun to watch), but I also feel like it portrays therapy in a way that feels a bit off. Don’t get me wrong, there are many wonderful moments in this show that do happen in therapy, but the overall presentation of how a therapy conversation unfolds is just – not how it usually goes. I’ll try to explain what I mean. 

In the fourth episode of the show, the main actor for this season, Uzo Adoba, portraying Brooke Lawrence, tries to explain therapy to a new teen patient. She says it’s about being genuine or authentic. And I would say that her portrayal of that authenticity is delightful to watch. She is wonderfully real and that is a critical ingredient to successful therapy. Now, I like this idea of authenticity - I think this is a good place to start in therapy. Many, not all, but many of our mental health issues do stem from our struggle with the false self - the self we think we should be, versus our genuine inner voice. However, where I struggle with this in this show is the way in which watching a therapy session with the actors can feel like watching a chess or checkers game, where the therapist is advancing some insight into some harmful pattern in the client’s life or thinking, and the patient tries to resist those insights. You see this all through the series, from the way the therapist Paul, in the first three seasons, battles with his clients to now Brooke in her back and forth with clients. Don’t get me wrong, it’s often fun to watch and there are moments where the show flips the script in entertaining ways, but this kind of tense push and pull, while it can happen here and there, isn’t the main way a session plays out. 

What am I trying to say? I think this is why this post took me a while to write, because it requires that I attempt to answer the question of how therapy works. The fun thing you learn in this field is that it’s not an exact science. There are now literally hundreds of theories of how therapy works, and each theory tries to distinguish itself as better than others through research. One curious fact that has arisen out of the research is the method doesn’t matter as much as what we’ve now come to call the “common factors” of therapy success. These factors include things like the therapist’s warmth or empathy, their ability to be genuine, their belief in the efficacy of the therapy, paired with the client’s commitment to change and belief in the therapy. When these factors are present, people get better. 

This helps me begin to think about how I think therapy can help someone. Those above common factors, which are predictive of therapy success, provide a setting that facilitates certain relational moments that help us heal. For instance, when a therapist is warm and empathetic, a person can feel cared for and safe from harm to their sense of self. This safety allows the person to lower their defenses and think, talk and process aspects of their life that they are typically afraid to think about for fear of judgment. This relational space then lets the client develop awareness into patterns in their life that may contribute to the difficulties that brought them to therapy. 

But the above is only one way that the presence of an empathetic connection with a therapist can help. Another way is that a client can be resisting certain parts of their experience, like the experience of a particular emotion, because they have learned to expect judgment if they feel that emotion. Let’s say, for example, a child was raised by a parent who was very fearful and anxious. The client may then learn that expressing adventuresome or curious feelings is met with anxiety by their parent, so they learn to suppress those key parts of the self. In therapy, in the presence of empathy, a perhaps now adult client may begin to express and feel some curious or adventurous feelings, because they feel safe in the relationship. This aspect of their experience that was blocked may have contributed to feelings of sadness, or conversely, when they felt a little bit of adventuresomeness in themselves, they may actually then become anxious. 

Now, to bring it back to my thoughts on the show. There are many moments in therapy where I might begin to notice a pattern with a client like the ones I described above. Maybe I notice they become sad or anxious whenever they start to think about taking a risk. If I’ve established trust and a connection with that client, I might reflect back what I’ve noticed and be curious with them about what it might mean. What I would avoid, in most instances, is to push a fully fleshed out interpretation of this pattern, its origins and its consequences onto a resistant client. This would often erode safety and push the client to further repress or avoid those aspects of their experience. Ultimately, it might stunt or slow the process of therapy. 

I think in my first blog post of this series, I mentioned that tv shows often speed up the process of therapy to make it more entertaining. I think that is fundamentally what I struggle with in watching “In Treatment.” The process of therapy is sped up and it highlights tension in order to provide entertainment. Rather, in the presence of a secure and caring connection with a therapist, a person can find their way to insights into these patterns, and with that new awareness, begin to experiment with new ways of navigating their life authentically. I would even say, sometimes, the client knows the answer to the question before the therapist does! That can be really fun to see unfold too. I think I’ll leave this here, but before I conclude I do want to say that this was just perhaps one dimension or set of examples of how therapy works. There is much more to say here, and it’s being ok with that incompleteness, that helped me write this little window into how I think therapy works.