How do you actually do the work in therapy?
December 2, 2019 4:10 AM   Subscribe

Trying a new therapist for the umpteenth time. I don't want to just have (expensive) cathartic chats every week, but apart from committing to doing any homework the therapist may give me, what does actually "working hard" or "doing the work" in therapy look like?

My previous therapist was person-centered, a modality I now realize doesn't work for me -- it's completely led by the client and non-directive. The therapist would say "I can't do this work for you" -- which I understand. But I entered therapy feeling very lost and stuck. This style of therapy felt like everything was up to me but I didn't know how to begin, and the therapist wasn't going to offer suggestions because that isn't how they work.

They also would note how negative I was about things: I'd mention things I could try, or that had been suggested I try, and I'd be skeptical about them. The therapist pointed out this was self-sabotage/self-fulfilling prophecy, etc. Fair enough. But then they'd say "So nothing is going to work, you've already decided that, you just think that it doesn't matter because things will fail anyway. It's very hard to work with clients who are so negative." And... okay, but that kind of pessimism is part and parcel of depression, isn't it? I felt like I was being penalized for not being able to start pulling myself out of it, but without being offered tools by my therapist to do so.

I now have a new therapist (I've seen her once). She's said that she will challenge me and she will be directive. This sounds like what I need. But apart from doing any exercises or things she says, how else can I do the work in therapy (and outside of the sessions themselves)? I feel like I want to really try but I don't know what to do. I've had some experience with CBT and DBT in the past, so I have some understanding of what therapy homework might look like in that sense. But what else?

Yes, I'll ask my therapist. But for those of you who've gone through grueling therapy stints, where you felt like you were really working your ass off and committing to going through the crap in order to make it out the other side, what did that look like? How did you do it? What did you do? How did you get yourself to stick to it?
posted by diffuse to Health & Fitness (18 answers total) 30 users marked this as a favorite
Do the exercises your therapist gives you, even when you're deeply skeptical they'll work. Be honest about your negativity and skepticism with your therapist, but don't let that be the end oF the conversation. Take the time in between sessions to note how you're implementing their strategies and sift out exactly what makes you so frustrated. There's a wide gulf between "I hated those guided meditations you gave me; I don't see how it could work anyway" and "I've been doing those guided meditations every day, but I get really frustrated with them, especially when they ask me to visualize something. I get so focused on picturing every detail and then I get angry that I can't do it right that I finish them feeling worse than before." The second one gives specific insights into your thoughts that the therapist can work with, while the first statement closes down any path to further conversation.
posted by lilac girl at 4:20 AM on December 2, 2019 [13 favorites]

For me it has meant a lot of journaling about the issues I was talking through in therapy and trying to pay more attention to my internal reactions to things. Sometimes, reading recommended books.
posted by bunderful at 5:14 AM on December 2, 2019 [1 favorite]

Get a notebook. Make notes: at least before and after sessions, but ideally also in response to any exercises. Dump that stuff from out of your head when it's fresh. You might not need or want to refer back to what you've written but it will give you a better sense of how you're responding.
posted by holgate at 5:15 AM on December 2, 2019 [4 favorites]

i'm on the notebook bandwagon. but also, it helped me to switch from CBT to DBT, which is more skills focused. for me, just talking it out isn't enough - i need some very concrete coping skills, as it turns out. so it might help to do whatever exercises they give you, even if it feels weird.
posted by megan_magnolia at 5:33 AM on December 2, 2019 [2 favorites]

Honestly for me it's pushing myself to say the things I used to censor. And then my therapist connects the dots between things where I couldn't see the connections.
posted by wellred at 5:56 AM on December 2, 2019 [20 favorites]

Oh yeah. Piggy-backing off of wellred, it's also, maybe even mostly, doing my best to be honest in therapy. Sometimes this means writing down things that are difficult to bring up outside of session, and then handing the paper to my therapist.

And in general, for me growth has meant accepting responsibility - a word I have a lot of baggage around. I prefer thinking in terms of "how am I response - able in this situation? i.e., how am I able to respond?"
posted by bunderful at 6:05 AM on December 2, 2019 [6 favorites]

Specifically about the negativity: consider trying to explore your negative reactions to your therapist's ideas differently, if you end up having those negative reactions like last time.

So if your therapist suggestions that you try something, and your first reaction is why that won't work, you can try noticing and processing that reaction, but making a commitment to trying that idea anyway.

So a script could be something like, "When you suggest I talk to my mom about what happened, my first reaction is to think why I can never talk to her about that. I'm only thinking of the ways that might not work. Can we spend some time exploring how I can reframe this idea?" Or something like that?

It's true that you might get more out of therapy this time if you find a way to say yes to more of the therapist's insights and suggestions.
posted by latkes at 6:11 AM on December 2, 2019

what did that look like?

Journalling, in three ways:
- thoughts and feelings
- keeping a list of what I wanted life to be like, what I wanted
- checking in with that list weekly against the thoughts/feelings part, like, did I experience one less meltdown at the thought of Christmas?

Saying yes, and doing the things. One example was that my therapist at one point suggested yoga. I was all like, what does yoga have to do with anything? When I finally did it, it altered my life in about 8 classes.

Committing, due to my personal issues, to being as present in my life as possible.

How did you do it? What did you do?

Set specific goals and took one step at a time. As an example, I was abused outside in a wooded environment. For years standing under a tree made me feel sick. But I also like trees and nature and had good memories too. I wanted to be able to enjoy the woods. I wrote that down. I practiced ways to stay present and then when it was the right time (no commitments for a few hours, distracting and fun activity later in the day) I stood under trees and did that...probably 40-50 times. Now I go camping with joy.

There was no magic formula though. My therapist gave me the grounding exercises and helped me set the goal, but only I could go stand under the tree.

How did you get yourself to stick to it?

I stopped seeing my pessimism and my belief that I personally am too smart/too different/too far gone for stupid therapy exercises/techniques in self-help books/ideas from others to work for me.

I did them when I didn't believe in them. And then I did them again, and again. Not all of them worked, but a surprising number did eventually become useful.
posted by warriorqueen at 6:29 AM on December 2, 2019 [7 favorites]

Nthing journaling. I was very resistant to it at first, but it works wonders. When I'm anxiety-spiraling it acts as an outlet so the spiral has somewhere to empty out to, and doesn't keep swirling over and over again in my mind.

For me, the hardest work was (is) not avoiding feelings/emotions. Actually feeling them, naming them, giving myself the time to really process and listen to what they are trying to tell me. For some people this comes really easily. For me, it's work. I am so uncomfortable having emotions. It's much easier to say "I feel like crap and have all this going on, but I don't have time to deal with it right now, time to shove the feelings down and put them in a box so I can get on with my life." It's so hard, and I won't lie, I hate it most of the time. I keep at it because I see how it really does help avoid sudden hysterical crying jags (hey, it turns out those emotions don't really go away! they call it "bottling up" for a reason), and I can see my support network strengthening as I am able to open up and share more with people.

I also have some reading lists. Sometimes, we will work on specific skills together, and then I get an assignment to practice it, and then at the next sesh we talk about how it went.

After writing this out, this feels like it's too personalized and nothing here may apply to you, so I hope it's helpful and what you're looking for.
posted by Sparky Buttons at 7:41 AM on December 2, 2019 [1 favorite]

Yes, I'll ask my therapist. But for those of you who've gone through grueling therapy stints, where you felt like you were really working your ass off and committing to going through the crap in order to make it out the other side, what did that look like? How did you do it? What did you do? How did you get yourself to stick to it?

Sometimes it was trusting the process. I liked my therapist and we connected well. So when she would suggest things to try for intractable issues I was having and my first thought was OH HELL NO, I tried it anyhow. Some of the stuff worked well (getting more distance from my online life, taking more time for myself even when it felt wrong/bad) and some of the stuff didn't work for me (some of the readings she suggested, a few other modalities that I wasn't interested in) and over time, things started to change.

Of course, as things changed I also became very aware of some other things that needed to happen and so there is a Sisyphean feel to some of this (oh hey I worked out some shit with my outdated view of my parents and now I really need to address how that has fucked up my other relationships). I think for some people the goal is not to be in therapy anymore. For me to goal is to know I have this one avenue of untangling some of the knots that make my life harder than it needs to be.

So, in answer to your question, some of it is literally trust in the process and some of it is being honest about the things that need to happen and the problems you have doing what needs to be done. It's easy, super easy, to go to a therapist, go through the motions and be like "It's not working, I don't feel better!" and part of the process is taking responsibility for the things you CAN do to help the process along and knowing that, ultimately, it's in your hands.
posted by jessamyn at 9:20 AM on December 2, 2019 [6 favorites]

apart from committing to doing any homework the therapist may give me, what does actually "working hard" or "doing the work" in therapy look like?

It looked like being open, honest, and uncensored with my therapist about what was happening in my life at any given time. I wouldn't go to a physical doctor for an ailment and then not tell them about my symptoms, so it made no sense to me to do that for my mental healthcare.

It looked like always having given a certain thought ahead of time about what I wanted to discuss with her instead of just showing up (and I'm talking just a few lines jotted down in my phone, it's not like I ever wrote paragraphs ahead of time unless I really wanted to). It meant a certain level of awareness in between sessions where I noticed patterns in my own behavior, my feelings around stuff I was struggling with, crappy or thought-provoking incidents from the past week, identified areas I wanted to be better at, and making a mental or physical note to discuss at the next meeting. It meant connecting the dots when ideas discussed in the actual therapy played out in my daily life away from my therapist's office, and discussing with her what happened as a result.

It looked like giving everything my therapist suggested an honest go even if I was dubious about its merit, and being politely frank with her when a certain technique just was not resonating with me, and we'd pivot to something that did and it was fine. That too is important information for them to have.

As jessamyn said, I have witnessed many, many people who consider simply showing up to appointments to be "doing the work" and don't put any effort beyond that and so remain "stuck" for literally years. The work is everything ELSE that happens in between the sessions and how you notice, process, and respond to it. Only speaking for myself, I had no problem sticking with it because I knew instinctively that life did not have to be as hard as it was and that therapy could only be an improvement. My goal, if you can call it that, was just for things to not be so hard and to suck less than they did, and that (rather low) baseline was pretty easy to accomplish within just a few months – 15-20 sessions sounds about right to establishing that critical foundation if you are committed to it, but also know that this is a lifelong process and not necessarily a linear one. I thought of it a lot like how I approached sleep training my kid, where the goal was not to go straight to sleeping 12 hours at a stretch but for each night to be incrementally better than the one before. I started therapy three years ago (went regularly for awhile and now just drop in whenever I feel the need) and just last week had a critically important, relationship-altering (in a good way) conversation with my mom that I had always envisioned having but NEVER in a million years thought we'd be able to, and I know beyond a shadow of a doubt that everything I learned from therapy led up to that moment. That's the kind of stuff I live for. That's why I go.
posted by anderjen at 10:31 AM on December 2, 2019 [5 favorites]

Nthing a lot of what has been said but especially what wellred said first. When I was in therapy the hardest, most grueling work I did was to DROP. MY. SHIELDS!

I put those defenses up to protect myself. With really good reasons. Being honest and, just as importantly, forthcoming with someone felt like an unacceptable vulnerability. I had to keep redirecting myself away from being glib and self censoring.

Also, I started taking notes like I actually wanted to pass the class. Notes on meds, notes on what we talked about in sessions, notes about what I want to talk about in sessions. And, while I never could get into journaling in the way I imagined it would be, when a therapist asks me to track my feelings I can AT LEAST do a sort of ship's log impression: "day 23, wind nor'easter at 12 knots, depression/anxiety 3/10, slept 6 hours, ate a whole bowl of oatmeal".
posted by Horkus at 12:35 PM on December 2, 2019 [5 favorites]

I'd mention things I could try, or that had been suggested I try, and I'd be skeptical about them. The therapist pointed out this was self-sabotage/self-fulfilling prophecy, etc.

A lot of my work was trying these things anyway. Whether they were successful or not was beside the point, it was the orientation towards trying new things that was key. Finding the energy and motivation to do this was extremely difficult when I was depressed, but then finding the energy and motivation to do therapy was as well.

There’s a lot of other work I’ve done in therapy, but trying those stupid things for no goddamn reason has pretty much been the hardest so far.
posted by Tell Me No Lies at 12:52 PM on December 2, 2019

There's a very old self-help book called "I'm ok, you're ok" and the takeaway I still have from it about 25 years later is the "yes, but..." game. People give me advice that I have asked for, and I'd say "yes (good idea), but (I can't do that because I'm a special snowflake)."

So not every one of my therapists had ideas that worked for me, but some did when I least expected to, for example:
Riding the wave of anxiety. You don't need to know why you're anxious (in fact, you've struggled with identifying reasons all your life), so ride it, like you're a surfer on a wave... which neatly fit into some ACT therapy about "examining the feelings in my body like a scientist". This practice turns my mind from fearful to analytical, and not the type of analysis (why so fearful) which has no answer, but an opportunity to use a different part of my brain at identifying the physical experience adrenaline gives me.

Another suggested I deliberately put myself in difficult (for me) circumstances, so as horrifying as my social anxiety made it, I went travelling in NZ with a bunch of strangers. There were some really difficult moments, like being asked to tell the busload of strangers who I am, and getting lost one night in the caravan park and unable to find my tent, but as horrible as some aspects were, I learned that I was capable of being friendly with strangers and coping with the unexpected.

My earliest therapy (80s) was all "what's happened to you that damaged you so much?" And I became annoyed at rehashing childhood abuse. Talking about it the first few times was cathartic but it didn't change my behaviour or thinking like the 10 cognitive distortions of CBT.

It takes practice to remember to use these tools, but they have had a massive impact on my life, in that I don't inflame my own anxiety but manage it. So I guess I'm saying, do the homework means starting and keeping on with a gratitude journal or a positive actions log, it means listening to the self-check soundfile on a regular basis, it means looking for your own behavioural and cognitive bad practices, and trying out your therapist's suggestions multiple times.

I will say I did refuse the therapy that involved my therapist pummeling me with a sponge hammer, and as an atheist, I never did go to church.
posted by b33j at 1:23 PM on December 2, 2019 [3 favorites]

Journaling -writing my feelings and not censoring myself

I did artistic stuff too, and i am not an artist. I drew pictures. I also cut out pictures and words magazines and made collages about how i felt or about a specific thing from my past.

Thinking a lot outside of therapy. A lot of personal examination
posted by ChristineSings at 6:43 PM on December 2, 2019

Came in to say: be radically honest. About your intentions. What you thought other people were thinking. What you want them to think of you. What made you feel defensive. What made you angry. Where other people seem to break the rules. When you wanted to make others feel bad or expose them. Give voice to it all.

Then, follow the therapists questions without resorting to glib answers. What would it take to have a positive intention?

Notice times when therapy is making you feel uncomfortable and give voice to that too.
posted by St. Peepsburg at 7:54 PM on December 2, 2019 [2 favorites]

For me, it was building trust. I described it as letting that wall come down. This is an ongoing thing with me in relationships. When I left my therapist last year, my wall had come back up and I wasn't open to what she was saying to me. Taking a break was doing work. I'm a people pleaser, so saying I don't want to come was a big thing.

I've gone back in the last couple months on urging from my psychiatrist because of a health scare and a traumatic procedure. I'll probably only go a few more times since I'm in a good place. But being able to trust she'd be there for me was a big deal.
posted by kathrynm at 4:55 AM on December 3, 2019

But then they'd say "So nothing is going to work, you've already decided that, you just think that it doesn't matter because things will fail anyway. It's very hard to work with clients who are so negative."

Jesus, this is hot fucking garbage. This person needs a therapist.

What I would like to have heard from a therapist is something like, "I understand you've tried this action in the past, and you're probably right about its effect. But I want you to try again, and when you're headed into the interaction, pay attention to how you're feeling. What physical symptoms do you note? Don't try to control them, just recognize them. Then, give yourself the gift of actually trying this thing again. Maybe pretend you're an anthropologist reliving something you read about, and you're going to see if you can make things happen differently. If it goes south the way you expect it to, pay attention to how you feel then. Do you feel discouraged? Angry? Sadness? What else? Once you're done with this interaction, write down as much as you can about how you felt throughout, bring it back, and we'll talk about the next steps." To me, that's actionable work.
posted by disconnect at 9:47 AM on December 3, 2019 [4 favorites]

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