How Therapy Works

From a nontherapist frequent patient

I am not any sort of therapist, psychiatrist, or mental health professional, and I am not basing this post on any sort of scientific evidence. I am, however, a mentally ill person who has been to a lot of therapists, and who knows a lot of people who have been to therapy, and I can generalize from my experiences.

There are two things you can get from therapy.

First, you can get a “manualized” therapy. “Manualized” means that it follows specific guidelines which say what you should do when— sometimes down to what specific things should happen in each session. Pretty much any therapy that has been studied in a randomized controlled trial is manualized, because they have to make sure that every therapist giving the therapy is giving the same therapy. There are many evidence-based manualized therapies for specific conditions: cognitive behavioral therapy for insomnia, phobias, or panic attacks; dialectical behavioral therapy for borderline personality disorder and chronic suicidality; exposure and response prevention for obsessive compulsive disorder; sensate focus for sexual issues.¹

You can usually do a manualized therapy to yourself by buying the manual therapists use and following the instructions. This isn’t exactly brain surgery. But most people find it easier to have a therapist. Therapists can answer questions, help you problem solve, and adjust the therapy to your specific situation. Also, frankly, a lot of manualized therapies suck to go through. If you’re an arachnophobe, sitting in the same room as a spider is terrifying. A therapist can provide emotional support and cheerleading, and also keep you from procrastinating and saying that you’re definitely going to sit in the same room as the spider next week.

It is surprisingly hard to find therapists who will give you a manualized therapy. Even if you look for someone who claims to specialize in cognitive behavioral therapy and social phobia, most of the time they will not give you the manualized therapy for social phobia. It is very possible to spend years in therapy with crippling insomnia and never have anyone suggest cognitive behavior therapy for insomnia. Most forms of manualized therapy have a website with a directory of trained providers (for example, here’s the one for cognitive behavioral therapy for insomnia); this is the best way I know of to get manualized therapy. However, you will often discover that there is no provider in your area, in which case you’re back to self-treatment.

Second, you can get generic therapy. Generic therapy is not really even medical at all. It’s just taking an hour a week to talk to a wise empathetic person who can provide a listening ear and an outside view on your problems. A lot of therapy techniques are just fancy-sounding words for normal advice. “Behavioral activation” is “you’ll feel better if you stop laying in bed all day and get out of the house” put in a way that doesn’t make the therapist feel embarrassed about how much time they spent in school to get this job.

A lot of people are going to object that that’s what friends are for. Well, sure! A lot of people get the same basic thing that therapy provides from their friends—or a life coach, a religious leader, or their grandma. But there are a lot of reasons you might prefer a therapist:

• You want someone who isn’t connected to your problems with all that entails: divided loyalties, giving advice that isn’t in your best interest because they want you to do something, fixed views of the situation they won’t change, projecting their issues all over you, etc.

• You have problems of the sort that people tend to freak out about (suicidality, self-harm, horrifying trauma, hearing voices) and want someone who has seen enough stuff that they’ll shrug it off.

• You’re talking about secret or shameful things (your sexuality, morally wrong things you’ve done, your doubts about God or your marriage, your mental illness) and want someone who will keep things confidential.

• You don’t want to worry about not being a burden or overtaxing your support people.

• Relatedly: your friends are burned out and want you to talk to someone else.

• You are spread too thin already and you want to get emotional support from someone who isn’t going to ask for emotional support back.

• You want to be confident that your therapist has a certain bare minimum competence level (i.e. they went to Being An Empathetic Person school and haven’t lost their license for misconduct) that is not guaranteed from friends, religious leaders, or life coaches.

• You want someone to hold you accountable and call you on it when you’re doing The Thing (deflecting from the issue, catastrophizing, projecting…) in a way that friends will often be too awkward to do.

• You don’t have any friends you can talk about your feelings with.

• Relatedly: Your friends share your blind spots, are very polite, or otherwise will not give you the painful but useful advice you need.

• Relatedly: Your friends have no idea what to do with feelings, are overly blunt, or otherwise will not give you the comfort and validation you need.

Another major advantage of therapists over friends is that therapists have a broader base of knowledge to draw from. Therapist school teaches therapists things, at least in theory, and if a therapist has been practicing for a while they’ll have seen many more and weirder situations than the average friend. It is a very unusual person who knows the intimate life details of dozens of people and can see how well their advice worked or didn’t work.

If you’re seeking out generic therapy, it is very important that you basically like, trust, and are comfortable with your therapist. Do not just keep going to therapy because therapy helps depression and this is therapy so it must be helping your depression, even though you hate your therapist and think she’s an idiot. It’s not like strep throat where the antibiotics work no matter how obnoxious your doctor is. The thing that makes generic therapy work is the relationship.

No relationship is perfect, and the therapeutic relationship is no exception. Maybe your therapist has annoying political views, but he mostly doesn’t bring them up and you can shrug it off when he does. (Or maybe you can’t shrug it off, and he’s not the therapist for you.) Maybe you don’t trust your therapist enough to tell him about your voice hearing, but as your actual problem is your divorce that doesn’t matter. (Or maybe you don’t feel safe around a therapist unless you’re able to share everything important about your life.) Maybe your therapist is super woo, but accepts it when you say “I’m not interested in trying Tarot to fix my problems.” (Or maybe that makes you distrust everything else he says too.)

What matters is your individual sense that this person is someone you can talk to who is on your side and who usually has pretty good advice.

1. It is very often possible to self-diagnose whether you need a manualized therapy. If you are irrationally terrified of something and it’s disrupting your life, try CBT for phobia. If you can’t go to sleep no matter how hard you try, try CBT for insomnia. If you sometimes have sudden and intense anxiety with physical symptoms like sweating or shaking or nausea or a racing heart, try CBT for panic attacks. If you can’t get turned on, can’t get hard, can’t come, come too quickly, or experience pain during sex, try sensate focus. If you have distressing intrusive thoughts that go away if you do a ritual except now you have to do the ritual all the time and it sucks, try exposure and response prevention. If you want to die all the time, try DBT.