What am I supposed to be doing in therapy?
March 30, 2019 5:32 AM   Subscribe

So what is therapy for, exactly? (Please don't say "whatever you want it to be for".)

I've long struggled with depression and (I'm now realizing) social anxiety. The standard recommendation for these issues is always "therapy".

Thing is, I've tried therapy a few times – and it's been pretty much useless. I've never stuck with it for more than a few visits, and I know it can take some trial-and-error to find the right therapist – but the main problem is that I've never understood what I'm supposed to be doing in therapy. I'd go dutifully to this stranger's office, I'd tell them about my problems, and...this was supposed to help, somehow? Because it didn't.

Naively, I thought, "I'm obviously doing something wrong; hopefully this person can determine what it is, and tell me how to do it correctly". But the therapists I've seen have barely talked, let alone offered any kind of advice (beyond vague platitudes). Maybe I haven't given them enough to work with – but since I don't know what we're doing, I don't know what kind of material I need to give them. (Or maybe they've just been shitty therapists.)

People like to say "therapy can be whatever you want it to be". But, like...that obviously isn't true. Therapy can't teach me to make a souffle. Therapy can't help me with financial planning. I know this sounds naive, but...I literally don't understand what therapy is, as a process. I know that you go to an office, and complain about your problems, and maybe cry or fill out some worksheets...but it's really unclear to me what this is supposed to accomplish. (Maybe this is because I'm a dude, and have been socialized to be ignorant of my own emotional processes? I dunno.)

I'd like to give therapy another shot – but I really feel like I need to understand what I'm trying to accomplish first. I mean, on a high level, I'm trying to conquer my depression and/or social anxiety – but I need something more concrete and specific than that.

Maybe I need to figure out for myself what my concrete goal is? The problem there is: if I knew, I wouldn't have this dilemma in the first place.

Or, maybe figuring out a concrete goal can be my first goal for therapy? That...kinda seems reasonable?

(Part of the issue, perhaps, is that I don't trust other people easily. At all. Opening up to a stranger is, like, not a thing that I do. I scarcely open up to my closest friends. And an hour a week is nowhere near enough for me to warm up to someone.)

I dunno. I hope the question makes sense. Thanks!
posted by escape from the potato planet to Health & Fitness (19 answers total) 35 users marked this as a favorite
I like to think of a therapist as someone who gives me tools to manage my anxiety, or to try and understand interactions with other people, etc.

A former therapist insisted that I go walking every day. If I said it was too cold, she said, "put on a jacket!" That was my homework.

She recommended a hobby, I picked writing/journalling. That was my homework.

She helped me understand why certain family members, friends, former partners, acted the way they do and why the interactions were problematic. She also gave me validation that I wasn't just crazy, there was some dysfunction going on.

So you could ask questions, like "what causes my social anxiety? How can I manage it, or fix it?" It could be exercises, coping strategies, or even meds (mine referred me to a prescribing doctor, but after following the "homework," he said I didn't need the meds as long as I kept up with it).

I guess in my case, it was also having someone who was neutral, not a judgmental family member, giving me things to do, then knowing I would have to report my progress back to her, that helped. She was friendly, down-to-earth, and practical, with a good sense of humor. She could explain things clearly in a way that made sense to me.

Have had other therapists who gave out homework in the form of mental exercises, using worksheets (i.e., draw a box with 4 corners, each corner represents ways you might exit or escape the situation that might be unhealthy, such as too much time on the internet, drinking, unhealthy eating, isolating myself, etc. -- the answers are different for everyone, but it involved self-awareness to start, then ways to cope that are healthy, and ultimately address the problem). So that's the kind of therapist I like, not sure what it's called.
posted by Marie Mon Dieu at 5:53 AM on March 30, 2019 [10 favorites]

Best answer: Things I've done that have helped with that kind of situation
  1. Telling my therapist at the very beginning "I'd like you to take an active role. I'd like you to speak up when you have things to say instead of just listening." Some therapists still won't do that, but some will if they feel like they have your permission. (And of the therapists who won't do it, some will say "Yeah, that's not my style, let me refer you to someone else.")
  2. Telling my therapist "I feel like I have big problems I want to solve. I definitely don't just want to come in every week and tell you how my week went. I want to dig deeper, and I'm here because I don't know how to do that on my own."
  3. Being honest about how skeptical I was that therapy could help me at all.
  4. Saying to my therapist's face "I feel like you're doing XYZ and it pisses me off" when I felt like my therapist was doing XYZ and it was pissing me off.
  5. When there was something I didn't know how to open up about, saying "Hey, there's something I don't know how to open up about," even if I wasn't ready to go on and say what it was.
The thing about therapy is it works better when you talk about the shit that's actually on your mind, and not just the shit you feel like you're supposed to talk about. It sounds like what's on your mind is "UGH fuck this probably won't work and how the hell am I supposed to open up to this rando?" So, talk about that.
posted by nebulawindphone at 5:59 AM on March 30, 2019 [45 favorites]

Best answer: Oh also, when your therapist is doing something and you're not sure how it's supposed to help, you can ask them to explain/teach you how it's supposed to help. I have had great conversations with therapists that started with me asking a question like that, and them being like "Oh! Okay! So! There's this theory about how feelings/memories/relationships/whatever work that says X, and that makes me think it would help you to spend time thinking about Y, so I'm trying to help you do that." Again probably not every therapist is up for doing that, but I've actually had pretty good luck with it if I ask the question in a curious way and not a combative way.
posted by nebulawindphone at 6:09 AM on March 30, 2019 [6 favorites]

Think about what you want to change as a result of therapy. What skills do you want to gain? What situations do you want to handle differently?

Bring those skills and situations to your new therapist. Ask them to create a plan with you for improving those specific areas. Define with your therapist what success looks like. How will you know when you’re done solving these specific areas? Will you choose new areas to work on or will you take a break? Also ask your therapist how you will handle things getting or seeming worse.

Ask your therapist to describe their beliefs and methods about what success looks like for their clients. If that conversation feels good, then you have reason to keep going. I suspect you don’t want a therapist who says everyone has to go to therapy every week forever. Some WILL say that.
posted by bilabial at 6:32 AM on March 30, 2019 [3 favorites]

Would it work for you to think about therapy as a toolkit upgrade? You have a current set of tools for dealing with what you think is depression and social anxiety. As a dude socialized to be ignorant of his own emotional processes, you know your toolkit isn't sufficient for dealing with these issues...but you're also not sure what kinds of new tools you need for coping with the feelings they can raise. You said you have trouble opening up to a stranger, so I'll gently point out that this script is pretty much what you've just told me, a stranger.

It's fair to ask, up front, "What is your approach when clients identify depression and social anxiety as issues to work on?" and to say "I have trouble opening up to someone I don't know/I think I'd do best in conversation/'I need to develop some tools for when I'm having [x feelings]/My goal is to feel comfortable at a meeting with people I haven't yet met [or whatever specifics are appropriate here]."

I need to understand what I'm trying to accomplish first. I mean, on a high level, I'm trying to conquer my depression and/or social anxiety – but I need something more concrete and specific than that.
"I need new tools for identifying moments when depression and social anxiety and their attendant feelings want to run the show, and for responding to those moments in a different way." [Spitballing here; maybe writing something like this out with your specifics would help?]

I hope you find someone you can work well with.
posted by MonkeyToes at 7:43 AM on March 30, 2019 [3 favorites]

"I'm obviously doing something wrong; hopefully this person can determine what it is, and tell me how to do it correctly"

what happens when you ask them what the activity (not the theory!) of therapy is supposed to consist of, what do they say?

a good therapist will have an answer. it will not be identical to the answer another good therapist might give you.

a bad therapist will freak out invisibly and either say nothing, say a platitude that in no way addresses the question, or assume you must be asking a different question & try to answer whatever they imagine the other question to be.

a tolerable therapist will persistently answer the question "what do I do" as if you had asked "what is this for." this will not illuminate anything, but it is meant in good faith, which is something. the reason almost all therapists answer the practical question as if it is a theoretical one is because they either don't understand what you're asking or they don't have an answer.

do not trust random lay people who tell you confidently what happens in therapy; they do not know. they know what they, personally, have done; they know what their own therapists have done. but there is no accurate generic answer. never mind different methodologies and different philosophies; within a very loose framework of professional ethics, every therapist runs therapy as they please. and most therapists are not observed or recorded. so, a guess at what therapy is supposed to be like in the abstract will not tell you what this therapist is doing or what they expect you to do. only they, as specific individuals, can tell you that. and a lot of them cannot or will not.

(Maybe this is because I'm a dude, and have been socialized to be ignorant of my own emotional processes? I dunno.)

it is not because of that. I think more women are willing to give therapy an initial try and be outwardly compliant despite our instincts and private thoughts, out of hope more than faith. but we do not receive any secret gendered training in how therapy works.
posted by queenofbithynia at 7:49 AM on March 30, 2019 [4 favorites]

You know all those things you're not supposed to say to the people in your life because you'd hurt their feelings? You get to say those things to this impartial stranger, and they won't get upset or offended.

I swear I feel 20 lbs lighter coming out of a therapy session.
posted by hwyengr at 8:22 AM on March 30, 2019 [7 favorites]

Best answer: It takes a while to realize there is no magic healing switch that turns on in therapy and the therapist is not a guru. If you are going to regular psychodynamic, in-depth talk therapy, the goal is to recognize unconscious patterns of thinking and feeling, and how they connect to early experiences and relationships. This recognition or even moments of catharsis do not suddenly heal you unfortunately, although in the movies it often works that way. Instead, when you gradually start replacing unconscious patterns with conscious ones, you feel less jerked around by inner forces you don't understand, more able to make good choices. It is a slow process, sometimes, and it is really a practice of inner growth and a commitment to self-knowledge more than anything else. It has taught me enormously. I've learned to respect myself in ways I didn't think possible, and learned to choose healthier relationships, to relate to people with a better sense of what I need from them vs re-enacting what I needed in the past and could not get. It makes it easier to have relationships when you understand yourself. And for this you really need a therapist you can talk to comfortably, because a lot of the old stuff gets played out with them and they help you recognize it. For me, that's pretty much it. More like getting in shape by walking in the woods than like getting liposuction.
posted by nantucket at 8:47 AM on March 30, 2019 [4 favorites]

I find it pretty easy to open up to therapists and I've had a range of outcomes - some have been a good fit and it was helpful, some it was not helpful because they weren't really listening to me or couldn't relate to me.

I think it's reasonable to convey to a therapist during the first session a bit of your history, what's happening currently, and what you're hoping to explore. If it's a good fit they should be able to give some direction or share more about their experience/approach while also responding to where your conversations takes you.

Right now I'm seeing a psychotherapist instead of a clinical psychologist or a psychiatrist and I'm finding it much better for getting deeper into what I'd like to work on. I saw a university psychiatrist a decade ago for anxiety and panic attacks and received medication but not really any practices to try. I saw a couple of clinical psychologists and they weren't bad but I felt like I was sharing things and not getting much back in terms of better understanding myself or my patterns.
If it helps, my goal this time was to get help around grieving the sudden loss of my father, and that's turned into exploring my family history/trauma and myself to better understand myself and improve my well-being and relationships. I didn't say all of that on the first session but I shared quite a bit of my family history at a high level. After my first session the therapist gave me her opinion on what direction she thought the therapy could benefit me and it made sense to me and felt right. The therapist has consistently asked clarifying questions, suggested resources to look into, shared relevant information, and provided a supportive, caring, nonjudgmental environment so that the trust has increased and I can really open up. There's a good amount of back and forth even though I'm talkative. She gives me her opinion on certain situations I describe when I'm basically asking "what's going on here?" but not in a pushy way, just validates and fills out what seems to be going on, so that's very helpful as situations occur but the bigger thing I'm working on is the developing compassion for myself and my family members, and just understanding myself better so I can be more content, and it's been helpful.
posted by lafemma at 9:03 AM on March 30, 2019 [2 favorites]

Best answer: Therapists work differently and have different focuses, due both to their therapeutic orientations and just their personalities. I'm a more psychodynamic/humanist therapist but I use a lot of CBT techniques; my core treatment belief is that we're all doing the best we can with the tools we have, and we all want to get better, and sometimes we need to learn new tools (or forget old tools) in order to do that. Sometimes those "tools" are a worksheet. Sometimes those tools are learning how to sit with really uncomfortable feelings and not numb out. Sometimes those tools are learning to build a relationship with a human being (e.g., the therapist). Sometimes those tools are learning how to take all the thoughts inside your head apart and look at whether they're true or helpful. Sometimes ditto but with feelings. I like to think of the therapy hour as practice for real life -- an hour when the client gets to try stuff out in a nonjudgmental setting to see if maybe they could start using those tools in their daily life.

I struggle the most with clients who come and sit on the couch and expect me to wave a magic wand and fix them. It's frustrating for all the reasons you laid out, but the movement and direction needs to come from the client (and the suggestions to talk about how you don't know what to do are great!). The therapist is more of a coach/trainer than a surgeon; we don't go in and take out the depression, but instead we work with you to help you develop the skills that you personally need/want/value/use to make your life what you want it to be. Those skills, for a good therapist, are going to be very different between clients, because we all have different strengths and fears and vulnerabilities and traumas and goals.

It may be that simply learning to trust another human being and open up would be a great goal for you, as practice for learning how to do that in your daily life. Maybe something else would be more helpful. Clients build relationships with their therapists, and that process of relationship-building is healing in itself. The healing comes through the relationship, and your active participation in it, not just something the therapist does to you.
posted by lazuli at 9:18 AM on March 30, 2019 [10 favorites]

Lazuli's point above about therapeutic orientations is important. I'm not a therapist, but I'm married to one and so have absorbed a bit of knowledge by osmosis.

For example, consider something like ISTDP which has an emphasis on "short-term". This type of therapy is likely to look at something like depression as "the result of traumas, memories, and emotions that are too vivid and painful to emerge on a conscious level."

Something like ISTDP seeks to expose the client to hidden emotions "to the fullest extent in the shortest time possible." So in other words, this is not your garden variety "tell me how your week went".
posted by jeremias at 11:16 AM on March 30, 2019 [1 favorite]

Therapy is for working through your issues, the things that keep you from being your best self.
The job of the therapist is to facilitate that, and make it easier and more effective, by guiding you while you're doing this work.
posted by Too-Ticky at 3:07 PM on March 30, 2019

Fellow sufferer of depression and anxiety, still working on it but have done some some therapy.

The main technique my therapist used was to ask me to keep a mood log for a week, we discussed it to help me understand the thought-feeling link. For the following week, whenever I was feeling depressed, I had to write down my feelings and the associated thought, and practice re-framing it into a more positive though. Then write down my emotion afterword.
What I got out of it was that I would spend too much time dwelling on a thought, not that I can't occasionally be upset. So now once I feel that I've understood something, I try to put it aside, since continuing to think about it doesn't make it better but does make depressed. Sounds obvious now, but I'm not sure I could have easily figured it out on my own.

It felt active and concrete, and did help. I wouldn't say it was magic bullet, but a useful part of the skill set needed to manage my depression. Exercise and eating well is still the most effective thing for me, but not totally sufficient on its own.
posted by fruit sandwich at 4:39 PM on March 30, 2019 [1 favorite]

I used to worry a lot about why I was seeing a therapist. What is this for? Am I doing it right? Is she secretly judging me? Am I wasting my money? Is this a bunch of self-indulgent crap? What if I'm wasting a big opportunity to improve my life because I don't know how this works? Are there books I should be reading that will tell me how to Do Therapy Right?

Eventually I started to realize that I was probably asking all these questions because I tend to ask these sorts of questions about everything I do in life, and that this is why people sometimes make remarks like "wow, you seem like you have a lot of anxiety", and that in fact the condition of constantly being wound up in these sorts of doubts and uncertainties was the very problem of "anxiety" which had made me want to start working with a therapist in the first place.

What worked for me was to observe that my therapist consistently listened to me, showed that she understood where I was coming from, and in a quiet, nonthreatening, subtle way, occasionally made slightly enigmatic remarks which stuck with me and eventually led to little "aha!" moments where I started to understand my life better. I realized that these little realizations, which felt like I was having on my own, were allowing me to do a better job of living my life.

After that, I started to trust her more and let the process work without having to spend so much time understanding it. Why am I here? To pay this wise person listen to me talk about my life and have a helpful conversation, drawing from her years of experience and training, through which I slowly but steadily move toward a better, calmer, more fulfilling experience of life. Why is she here? Because she likes the work, and because I'm paying her for the time. I don't need to worry that I'm being selfish by talking about me all the time, because that's her job and she's getting compensated for it. I don't need to worry that I'm wasting my time in therapy, because she's seen it all before and she's always one step ahead of me, and she's good at offering me some options which allow me to pick out that next step and take it for myself.

It took a good long investment of time to get to the point that therapy really started to "work" in the way I had imagined it would, but that's because I had a lot of mistrust to overcome. I didn't know that mistrust was there, so I didn't realize it was going to take work to get through - but that was part of the process, too.

I don't know what your journey will be, but if you find someone you can have good conversations with, and you come away from most of those conversations thinking "hmm, that was interesting, and maybe I think I had a feeling about some of the things we talked about", then you're probably on the right track. I've been amazed to learn just how much *better* the experience of life can get than was apparent before I started out; perhaps you'll get to have some of the same experience of opening up and growing, and if that happens I think you'll be glad you stuck through the early confusion.
posted by crotchety old git at 5:48 PM on March 30, 2019 [4 favorites]

I have been to my share of therapists over the years for anxiety. I always make it clear at the beginning of every appointment that I need their active help in the forms of suggestions of things I can do/think/practice on my own. For example "I have anxiety about [recurring activity at work] and i could use some pointers on how to cope with that." Therapists who focus on specific modalities with CBT will have exercises you can do on your own and during the appointment.

That said, sometimes therapy just isn't what someone needs. It gets suggested so often here as though it's a perfect technique for everyone, but it just isn't. If your depression and anxiety aren't situational and you struggle every day, it might be time to try (or adjust) medication. My anxiety is 90% controlled with medication and I use therapy to help get through the remaining 10%. My depression is completely therapy-resistant, however, and I am working on finding medications that give me a better result.
posted by joan_holloway at 7:00 PM on March 30, 2019 [2 favorites]

Therapy is: doing something unfamiliar that you most likely find unpleasant, and doing it because you trust the person across from you enough that you believe you'll feel better after awhile if you just stick with it.
(this covers all modalities of psychotherapy)
(I am a therapist)
posted by Shusha at 7:06 PM on March 30, 2019 [2 favorites]

I've been in therapy on and off for decades. I think the most important thing a therapist can do is, when you mention something you're unhappy/uncomfortable with, they ask you what is it about that experience that makes you unhappy/uncomfortable. Basically, they can dig into your motivation for your feelings and behaviors. It helps you figure out why you're u/u which can hopefully lead to changing your thinking and resolving the issue.
posted by bendy at 7:47 PM on March 30, 2019

Unlike a lot of people here I haven't been to therapy for years and years with multiple therapists, so take my response with that in mind. I've been in successful therapy for about 2.5 years with my first and only therapist, and either I got incredibly lucky or I'm also doing my bit to let it work, I think it's both.

So, what's worked?

I have come to strongly agree that the therapeutic relationship is the lynchpin, and it requires trust and genuine empathic connection. In my case this is generated also by the conversation, my therapist talks a lot, he's constantly illustrating with examples and anecdotes, and I'm a good conversationalist too, this I know from life and friends, so we're a good match, talk is our medium.

What's the work I do? I lead, or atleast, I begin, I bring in what is stymying me, or saddening me, he takes and validates it, and gently challenges my inertia, I locate my stumbling blocks he helps me navigate them. He's also a cheerleader, and I can see his enthusiasm for changes in my life is real, and apart from being changes in my life they are professional validation for him.

You say on a high level you're trying to overcome depression and social anxiety, but how do you concretely do that? That's exactly the right question. Break it down more, to events and specific reactions. You have to analyze your life first and see what you would like to really do but are unable to. Say, for example, you would really like to start dating, or find a new job, or have a better relationship with your parents, or learn to play the piano. Or there's a past trauma that has stayed with you. Make it specific and take it to the therapist. Tell them you don't want a silent listener. That's the first thing I told mine within 10 minutes of meeting him.

Addressing the specific will radiate to the general and high level, because what is depression - first of all it's a spectrum - but it's specific things, for some it's an inability to get out of bed, for others broken communication with loved ones, even if it's a profound inertia, if it keeps you from brushing your teeth start with that, address its particular manifestation in your life, and if they are severe, perhaps medication could be useful if you haven't tried it already. Help the therapist by telling them what is bothering you or holding you back. If you went to a regular doctor and just said you had pain without being specific it would be impossible to make a diagnosis, therapists work in an inherently greyer zone.

Finally I'd say therapy is a partnership, and you are one half of it. Assess any potential therapist from that lens, will they make a good therapeutic partner, this doesn't mean it has to be smooth sailing, a good partner is any area of life will tell you hard truths with your best interest at heart, this is the same, but you have to commit to the relationship and to doing the work. Also ask around and see if group therapy might be good for you, seeing how others approach their problems might help and you might see your situation reflected in others and that's a source of validation too. Good luck!
posted by whatdoyouthink? at 10:33 AM on March 31, 2019 [1 favorite]

My answer here is similar to what I recently wrote on an earlier AskMeFi question.

Bottom line: If I had to live my life over again, I would have tried using a life coach as opposed to spending years in therapy. I feel like the therapy wasn't helpful -- with one exception, as explained below.

I found therapy to be largely useless. I spent years going to various therapists, but none of them really made much of a difference in my life, except for the last one I saw (who actually had the least amount of academic credentials). I was mostly a shut-in at the time, and he advised me to do some volunteer work. I resisted for a while and came up with lots of rationalizations why it would be a bad idea. But eventually I tried it. Doing the volunteer work initiated a cascade of positive events that lifted me out of my depression, got me a new job, and led to marriage with someone I met through volunteering.

When I look back on it now, I saw that a lot of my problems could have been addressed with practical, concrete changes. I had terrible sleeping habits and watched TV late into the night. I ate unhealthy foods and never exercised. The antidepressants I was taking made me fat and tired (I never did lose the weight after I quit them), and I should have ditched them much earlier than I did. I mismanged my money, didn't pay bills on time, didn't clean my apartment regularly, etc. The therapists had little to say about this stuff.

What I should have done is hired a good life coach, instead of spinning my wheels with a stream of over-educated therapists who had MD and PhD degrees but didn't really have anything practical to offer.
posted by akk2014 at 12:17 PM on March 31, 2019

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