By what mechanism is talk therapy supposed to be effective?
May 17, 2014 7:32 PM   Subscribe

I have a fair bit of experience with getting talk therapy of the open-ended type, sometimes for long periods. It doesn't seem to ever have resulted in any change in my attitudes or behavior patterns. What's more, I don't understand how it theoretically could result in this, either generally or with a specific issue I've been dealing with (procrastination/self-discipline). Explain/exemplify?

Over the years I've seen a number of therapists for various reasons -- six altogether, if I'm counting right, for periods ranging from a few weeks to over a year. It's always been talk therapy of the unstructured type (rather than practical/goal-oriented modalities like CBT). My therapists have generally been highly intelligent, well-respected professionals. I keep going because I like having someone to talk to regularly in this way, but I've never felt that I've changed in any way as a result of therapy, and I'm not sure by what mechanism this is supposed to happen.

The idea seems to be largely to acquire insight into the underlying causes of one's difficulties. But I'm a very introspective, analytical person, and I'm always thinking about these questions as it is, so nothing a therapist has said has ever been major news to me; and even if it was, so what? How is insight supposed to translate into changed behavior?

For example, take one of the main things I'm struggling with right now, which is a difficulty with persevering on self-directed projects (both practical things like academic writing and hobbies like music). I could expatiate at length about the psychological and historical reasons for this (e.g. fear of criticism rooted in childhood relationships, etc.); it's something I've thought about a lot. When I talk about it with my current therapist (and it's been basically the same with past therapists), I feel like she more or less says back to me the same things I've been saying to her, just in different vocabulary. Sure, there have been one or two sessions that I've come out thinking "Oh yeah, she's right: I hadn't thought of the connection between current behavior X and childhood caregiver interaction Y", or "Hmm, word X is a slightly better way to think about this issue than word Y which I've been using", or things like that. But those are just more "insights" to add to my analytical dossier, and meanwhile I keep acting in the same ineffective ways I've always acted.

I know a lot of people who swear by talk therapy, and I don't think they're all self-deluding. So I'm thinking that maybe this type of therapy is just not suited for my particular issues, or else not suited to my particular personality (or else that I just haven't found the right therapist, but this strikes me as less likely given that I've seen half a dozen who have all been pretty different form each other in personality and general approach). But I don't have a good sense of how this process is theoretically supposed to work. If you understand this, please explain? And especially, if you've had experience with talk therapy that actually led to a change in rooted behavior patterns, please describe how this happened?

(Just to anticipate some possible replies: I've brought up this question with my current therapist and some previous ones, but I've never gotten a satisfactory response. I know that there are other modalities like CBT which might be more effective for things like procrastination, but I'm not asking for alternative suggestions, and I don't want to focus on that particular issue -- it's just an example.)
posted by zeri to Grab Bag (24 answers total) 24 users marked this as a favorite
In my personal experience, in talk therapy my therapist was there to shed light on the issues I brought up and to suggest different interpretations, or different modes of thinking and acting.

And for some people that's enough. For others, awareness is only the first step and it's completely possible to go about your life, aware of what you're doing, but not changing. (Raises hand)

Being aware of something and changing it are two different things. I too got fed up with talk therapy because I felt like even though it was cathartic and I'd feel momentarily happier and more relaxed, we were just going over the same things and they didn't "stick" after I left the office. Now I've been in CBT and it's much better. But the responsibility is on me to follow up with my actions and words after I have a session, with various habits, exercises, routines. So it's been more "work" than talk therapy and I'm having to spend more time on it. I feel more empowered though because the focus is not on "magical smart therapist that explains things to me" but on my own construction of habits and activity patterns. It is slow going but I am seeing some results, and I'm hopeful for the future.

[I know you don't want recommendations and I don't know if CBT is for you or suggesting you'd have the same experience! Just sharing my own experiences.]
posted by rogerrogerwhatsyourrvectorvicto at 7:44 PM on May 17, 2014

From the American Psychological Association:
Q. How exactly does psychotherapy help people?

A. Patients often come to psychotherapy with explanations for their difficulties that leave them feeling that the distress will continue indefinitely. Every treatment provides an explanation for the distress that is adaptive — that is, the patient understands that he or she can do something to improve his or her situation. This leads the patient into healthy actions in that the psychotherapy improves some aspect of their lives, whether it is thinking more positive thoughts, creating better relationships, more appropriately expressing emotions, or enacting other positive changes. The critical aspect is not which treatment a person receives but rather that the patient believes this particular treatment is effective and works collaboratively with the therapist.
posted by capricorn at 7:45 PM on May 17, 2014 [5 favorites]

Why therapy works depends on whom you ask. That it generally does work is, judging from hundreds of studies made over decades, fairly indisputable.

But I'll try to jot down in highly simplified manner a couple of possible mechanisms of change.

Relational: By building a strong, empathetic rapport with a therapist, patients may feel understood and cared for. This alone helps, because to be understood and cared for is probably a basic human need. Such a relationship may also help build new models in the patient's mind for how to interact with people in healthier ways. It may help the patient see themselves in a new, more positive light, based on the way their therapist sees them, and thus give them a greater sense of efficacy and self-worth. From the relationship, the patient may also learn by imitation, treating the therapist as a kind of role model.

Insight: People often have distorted views of problematic areas in their life. These distortions can serve important emotional purposes, but they can also obscure things. Therapy can help point out these distortions and the purposes they serve or served. This can create new ways of seeing the current situation, the past, and the future. Therapists can also point out habitual mode and means of distortion, and perhaps connect them with plausible causes. This can be make it easier to change those modes. In particular, therapy can be very helpful in assessing how one relates to people in recurring patterns, often dysfunctional patterns.
posted by shivohum at 7:55 PM on May 17, 2014 [8 favorites]

If you're like me, you might feel like you need someone holding you accountable to actually change in your daily life? I used to ask my therapist for "homework" and she would give it to me. That helped me feel like I was changing "in real life," not just having insights in therapy and going right back to the same old habits the minute I walked out.
posted by drjimmy11 at 8:49 PM on May 17, 2014 [3 favorites]

"Homework" as in, she would give me some task or activity to try in daily life, and I would have to report back if I did it and how it went.
posted by drjimmy11 at 8:50 PM on May 17, 2014 [1 favorite]

The idea seems to be largely to acquire insight into the underlying causes of one's difficulties.

Not only, and sometimes not at all. For people dealing with current or past traumas, a therapist can serve as a helping witnesses, "people who help [trauma survivors] to recognize the injustices they suffered, to give vent to their feelings of rage, pain and indignation at what happened to them." Therapists can help clients spot and change cognitive distortions that are getting in the way of successful relationships, careers, or study. Most crucially, in my opinion, therapists can help clients get in touch with their emotional life and learn to balance their emotional, intellectual, physical, and spiritual selves.

In my experience, clients who are analytical often benefit most profoundly from therapy that works to open up their emotional experiences, moving them out of their heads and into their hearts/guts. In my experience, clients who are analytical are often most resistant to this type of therapy and write it off as slow, superficial, or "woo." Analytical clients are also often very, very good at keeping their therapists up in their own heads rather than engaging at a heart/emotional level, and so therapist and client often end up spinning their wheels.
posted by jaguar at 9:33 PM on May 17, 2014 [8 favorites]

If you're also getting medication, it helps the psychiatrist to observe you talking for an hour in order to see if the medication is having an effect.
posted by Chocolate Pickle at 9:33 PM on May 17, 2014

And especially, if you've had experience with talk therapy that actually led to a change in rooted behavior patterns, please describe how this happened?

As a client (and a very analytical person myself), the biggest break-through I had was by beating the hell out of chair with a plastic kid's baseball bat. It was one of the first times I actually let myself tap into the anger I had been suppressing with intellectual mumbo-jumbo.
posted by jaguar at 9:37 PM on May 17, 2014 [1 favorite]

Just to add a little note to show how therapists might help you with the problems you've specifically mentioned:

One approach some therapists might take to a problem of procrastination is that maybe you don't really want to do the thing. So then the question becomes: why are you trying to make yourself? What forces within you are pushing and pulling you in contrary directions and why?

Or therapists might look at your pattern of constantly changing therapists and ask: is there something within you that is using the process of constantly changing therapists and turning the question of therapy into an academic investigation as a way of delaying and resisting change?

I don't know if either of these things is going on your case, but a good therapist might look into them as possibilities, and that could reveal interesting things about you and help you move in a positive direction.

Finally, therapy may work better for some people at higher frequencies. You might consider finding a reputable psychoanalytic institute getting a referral to a trained psychoanalyst. Often, the most powerful things can happen when you go in 2-5x a week. It seems like a lot, but if you think about it, it's really not much time at all for someone to get to know another human being in real depth from scratch. It also helps them see how you react to new events in your life as they happen.
posted by shivohum at 9:39 PM on May 17, 2014 [1 favorite]

I've had talk therapy that helped for some problems, and CBT that helped for some problems. It not working for you doesn't mean they aren't a good therapist or it's not a worthwhile type of therapy, but it does mean that therapy isn't working for you.
posted by Sequence at 9:41 PM on May 17, 2014

Even the most generous statistics for talk therapy only show it to be effective 80% of the time. You could just be in the unfortunate 20%.
posted by Violet Hour at 10:12 PM on May 17, 2014

I'm a therapist but not yours. If you feel therapy isn't changing you--It doesn't seem to ever have resulted in any change in my attitudes or behavior patterns--this is something you need to talk to your therapist about. That you remain in a relationship with this person and don't feel helped is something you need to explore. That in itself says something very important about you.

You say "I've never gotten a satisfactory response." yet you have not pressed for one. Why is that? Are you being polite? Therapy isn't about being polite. Express how you feel. Insist on getting an answer that you don't feel is an evasion.

CBT includes a lot of useful perspectives but it remains someone else telling you how to live. Ultimately, you need to be making your own decisions. You are the authority on your life. If you hesitate to exert that authority, you need to understand why.
posted by Obscure Reference at 1:16 AM on May 18, 2014 [5 favorites]

th: Have you thought about that issue?
me: yep
th: i mean - have you really *really taken it apart and looked at it all logically?
me: oh yeah - very much so
th: so you understand it thoroughly from a few points of view?
me: i'm really good at deconstructing issues like that
th: ...and how's that approach workin out?


me: wha...rrriiiigggghhhht.

Nthing learning how to *get out of your head* can be the hurdle. *Action-not-thinking* is a valuable way ahead that I would only have come by through therapy.
posted by j_curiouser at 1:16 AM on May 18, 2014 [6 favorites]

For me, talk therapy helped because it helped me to finish telling and re-telling the stories about myself that I'd gotten hung up on. Somehow, explaining everything to an authoritative listener let me feel like I was done and did not have to revisit some stuff anymore. Also, telling the same authoritative listener some things that I had thought but never said really allowed me to feel and then move past some very painful emotions. And organizing these stories helped me to see some patterns and also some inconsistencies that helped me to think about myself differently. I didn't feel that my therapist was a Super Genius Who Had All The Insights - although he really had a couple of pretty startling insights about my family - more that he was an intelligent, experienced listener who was on my side but would not let me off the hook. My problems were mostly about causing myself pain and stress, not so much "I can't finish projects" or "my relationships never last".

The main upshot of therapy for me was to feel better about myself. This has had small results elsewhere - better sleep, somewhat better eating, calmer on the job, made some low-key long term plans - but has not been about small bad habits very much.

I could certainly see that if you came in with "I want to stop doing X" or "I have this problem in relationships" and you had a particular idea why you had that problem, talk therapy wouldn't do much for you except possibly very incidentally. I don't think it would have done much for me except that my problems were much more narrative problems.
posted by Frowner at 5:27 AM on May 18, 2014 [3 favorites]

In my experience (and the experience of some of my friends, who are really similar to me, in a lot of ways) the main benefit of therapy has been to challenge some fundamental, unquestioned assumptions made by me, my family, and the people in my profession about human nature, the virtue of hard work, the meaning and consequences of mistakes, etc. I, too, am very analytical, and have picked at this stuff in my own head for a long time, but my thinking tends to settle into well-worn ruts that lead to non-optimal behaviors. A therapist, to me, is an objective outside observer who can point out out a questionable assumption that I've never questioned before. That can change my perspective and jar me out of the ruts—if I'm able to take the insight out of therapy and into day-to-day life. If I say, "That's interesting," and push it away and don't think about it until the next session, I don't tend to make any progress. If, instead, when I find I'm in the old familiar rut, I can say, "What light does the current situation shed on my assumptions?" that's when I see the process working effectively.
posted by BrashTech at 6:34 AM on May 18, 2014 [1 favorite]

One thing that can be helpful to effect change is exploring what's called the "negative transference," that is, the feeling that the therapist is a disappointment -- in other words, exactly the feeling that prompted you to ask your question.

You find an "expert," you go to sessions, using your valuable time, and you pay a lot of money to someone, and you find that they are limited in what they can do for you. This replicates the limits of your prior relationships, particularly with parents, and the disappointments you may have felt because of those limitations. It's complicated, because some therapists are better than others, and some are a better fit for you than others, so you can easily think that that's the problem -- and you may be right -- but the problem also may be that you have bumped into that wall where you need to to face your feelings about other people not measuring up to what you would like them to be.

Intellectual insight, as you've discovered, only goes so far to effect personality change. The deeper and more lasting changes come about by facing how you feel about the therapy and therapist and by risking sharing those feelings with the therapist -- and then you have to be lucky enough to be working with a therapist who is willing and able to work with your feelings of disappointment and not just volley them back at you. The more recent versions of psychodynamic therapy are called "relational" -- which understands that there is a two-way street going on where both patient and therapist need to be open about their feelings toward each other -- so that your therapist "should" not try to veer away from what you're expressing here, your feelings of confusion and disappointment and that the therapy isn't changing you as deeply as you want it to -- but, rather, "should" get into it with you and then, probably, relate some of those feelings to feelings you've had about other people in your life.

In other words, the disappointment and questioning about "what's going on here? is this all there is? why am I still alone in the sense of not really being touched emotionally by this experience with this therapist?" would be presumed to exist in other areas of your life.

Basically, when you get "stuck" in therapy, which is the sort of feeling you are expressing in your question, you can take that stuckness as a representation of having reached a place, a kind of "node", that parallels where you are stuck in the non-therapy parts of your life, so this is a really good place to stop and dig IN, rather than just think, "oh, this is sort of okay, but I thought it would be so much better."

That *in itself* is an example of the kind of "pattern of thought" that some posters are referring to. The problems are not just outside the therapy office -- they pop up *inside* the therapy office as well, and that's where you can begin to look at them, but that's also where it's terribly difficult to look at them -- which is why, if you (and the therapist) can get into it, it can be so valuable.

***I am not your therapist***, but if a patient of mine expressed that kind of disappointment in the therapeutic process, I would question the part where you say it's sort of okay with you, you like having someone to talk to, etc., and reflect back how sad that must feel, and how you feel that maybe you shouldn't even be wanting more, let alone demanding more, and what is *that* about? How much do you think you can have? etc.
posted by DMelanogaster at 4:44 PM on May 18, 2014 [4 favorites]

To continue:

you have a problem with procrastination/self-discipline. How could therapy help you with this? By helping you define what is procrastination for you? What is procrastination? Procrastination is delaying. Why are you delaying? What are you anticipating? Getting "into" something. What does it mean to get "into" something? what do you fear? what are the feelings that you need to avoid, and why must you avoid them? What are you protecting in yourself by avoiding those feelings?

We know on a practical level that it's self-sabotaging, on the one hand, to avoid working on things, but if we presume that procrastination is also a (not terribly adaptive) way that you are trying to protect yourself from feeling things that are painful for you to feel then we need to ask, "what *are* those feelings, and why do you feel them?"

Is it fine when you accomplish something, finally, or is that a disappointment? is it worth it to you not to procrastinate? it must feel great to the person who is walking on burning coals to reach the end, when he no longer has to walk on burning coals, but who takes it upon himself to walk on burning coals in the first place? If doing things feels like walking on burning coals to you, of course you're going to procrastinate! but what are the coals, and why are they red-hot?

Practical solutions like "oh you'll feel so much better when you get to work," Or "once you get into it you'll be okay" are fine for friends to tell you, or self-help books...but when you are in the state when you are procrastinating, that's all there is for you at the time, avoiding walking on those coals. So that's what you have to present to the therapist to be explored in depth. But they ARE hot coals, you are not "wrong." (that's the difference between psychodynamic and cognitive-beahvioral therapy)

Are there things you're thinking and feeling when you're in therapy sessions with the therapist that you're delaying telling her? are you procastinating there too, because you want to avoid pain? what kind of pain is that?

what are you afraid of?

These are the questions and the issues that come up in therapy and your responses to those questions (and really they are responses, not "answers". There are no right "answers," there are only more feelings, more subjectivity) will be the path toward seeing more aspects of yourself, and it's that expansion of your own feelings, sometimes in awareness, something not in awareness as we normally think of awareness, are the way that therapy can help.

(This is psychodynamic therapy I'm talking about. Cognitive-behavioral therapy is more like school. They want to tell you that the way you feel isn't really "rational" and you should start thinking about things in others ways. It's more didactic and prescriptive (and superficial). But people love it because we're taught that there are formulae for "fixing" things and you are essentially another "thing" in the world with "patterns" that can be corrected.)
posted by DMelanogaster at 5:14 PM on May 18, 2014 [6 favorites]

Two books that helped me understand therapy: The gift of therapy by Irving Yalom and How psychotherapy really works by Willard Gaylin.
posted by SyraCarol at 6:21 PM on May 18, 2014 [3 favorites]

Response by poster: Thanks, all. To be perfectly honest, what these answers are collectively making me think is that talk therapy probably just isn't something that's likely to ever be very helpful for me -- at least not in the sense of facilitating practical changes in behavior, as opposed to just providing regular emotional support when I need it, which of course is valuable in itself. Questions like

why are you trying to make yourself? What forces within you are pushing and pulling you in contrary directions and why?

What does it mean to get "into" something? what do you fear? what are the feelings that you need to avoid, and why must you avoid them? What are you protecting in yourself by avoiding those feelings?

are more or less the kind that my current therapist asks, and we can happily spend 50 minutes dissecting and anatomizing them. I have lots of answers. It's never led to anything.

My previous therapist, by contrast, was very much the emotion-centered type that jaguar describes. In those sessions I often did get in touch with powerful emotions that I wouldn't otherwise feel. Sometimes I'd just come in and cry. It felt really good, but the patterns that were making me unhappy in the first place stayed the same.

I think part of the problem is that I have some kind of resistance to trying to make active changes in my life with the help of therapy. (My last therapist used to give me homework, but I never did any of it; then we'd talk about why I hadn't done it, and the cycle would continue.) It's like I'm coming in expecting the therapist to wave a magic wand and change my personality, though I know perfectly well that that's not going to happen. I'm sure that passivity/resistance in itself could be investigated ad nauseam. But as j_curiouser says, and how's that approach workin out? Well, it isn't -- that's exactly where I'm coming from with this question.
posted by zeri at 7:48 PM on May 18, 2014

It's like I'm coming in expecting the therapist to wave a magic wand and change my personality, though I know perfectly well that that's not going to happen. I'm sure that passivity/resistance in itself could be investigated ad nauseam.

Another benefit to therapy is that it can serve as a safe rehearsal space for trying out new behaviors. Rather than analyzing why you're not changing, what would happen if you changed the way you acted in therapy? Rather than passively waiting for the therapist to fix you, what would happen if you spent those 50 minutes being active in the moment -- pushing yourself as hard as you can to solve your own problems, to find your own inner guidance, to experience what it's like to take charge of your life even in the presence of someone regarded as an "expert"? What would happen if you told your therapist that you're sick of waiting for them to solve your problems and that you're pissed off at them for not being able to do so?

If therapy works to hold you accountable, it's worthwhile to think about how you can use that to make those changes you want to make.
posted by jaguar at 7:58 PM on May 18, 2014 [1 favorite]

In other words, just because it's called "talk therapy" doesn't mean that the only thing required of you is talking about your problems!
posted by jaguar at 8:00 PM on May 18, 2014 [1 favorite]

are more or less the kind that my current therapist asks, and we can happily spend 50 minutes dissecting and anatomizing them. I have lots of answers. It's never led to anything.

This is not necessarily supposed to be a matter for "discussion." Yes, of course you can fritter away an hour "discussing" things, because sometimes "discussion" is a way of avoiding really looking at things.

Perhaps, for instance, like in this very thread. You came in with doubt about the utility of therapy, and you -- surprise, surprise -- came out with the doubt confirmed. The answers merely acted to confirm the impossibility for you of getting use out of therapy. I don't get the sense that you are seeing a lot of the nuance and variation in these answers, but are mostly picking out what confirms your opinion. Maybe this is because of what you call your "resistance"?

Anyhow, I'd reiterate the idea of finding a good psychoanalytic institute and getting a referral to a trained and experienced psychoanalyst.

They are going to be the ones best trained to deal with your kind of "passivity/resistance," as you put it.

Commit to doing therapy at least 2x/week and give it a full year before judging it. That would be my recommendation.
posted by shivohum at 8:24 PM on May 18, 2014 [1 favorite]

Best answer: My last therapist used to give me homework, but I never did any of it; then we'd talk about why I hadn't done it, and the cycle would continue.

This is the root of the problem right here. You can talk about homework, about what homework is supposed to do for you, about why you didn't do the homework, and then talk about more homework... but the change in behavior and habits and attitudes comes from actually doing the work that is meant to be practice in making the change.

Right now, it sounds like you're not fully engaging - you are taking lack of change as confirmation of the fact that things aren't changeable. But that's sort of like needing a pen, seeing one across the room -- and then determining that you'll never write anything down because that pen is not in your hand right now. You talked about walking over to pick it up, but then you didn't do, and so here you are, pen-less forever.

You have to do the work. Not just look at the problem, or investigate it, or label it -- you have to practice the change by taking action until the changed behavior is the habit.
posted by dryad at 7:07 AM on May 19, 2014

Just to second dryad - you sound a lot like I feel on the days I think about stopping therapy. I feel like I've done a lot of good work, covered a lot of ground, done some deep thinking, don't have much more to think about... then she says one thing that shifts my perspective and takes me into new territory and uncovers the next thing I need to work on. But it's up to me to follow that lead and decide if/when/how we're going to go there. I sometimes think really good therapy should come with an ad like a vintage poster: "Surprise twists!" - "Unexpected turns!" - "You'll never believe what happens next!"
posted by Wyeldfire at 1:06 PM on May 20, 2014

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