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What makes psychotherapy work?


There is debate about how therapy works and currently a lot more research identifying some of the ways it does. Much of this research suggests that the best outcomes in therapy are directly linked to the quality of the relationship between the two people in the room.


The person seeking therapy has to feel comfortable and safe, that the therapist can really be with them, that they feel listened to and acknowledged. Another important factor is the experience of an emotional bond, a sense that we can work together, a feeling that there is a potential for collaboration. Both the people involved also have to agree that the goals they have identified are both worthwhile and attainable. If there is any uncertainty, if the person seeking help isn’t sure about the professional integrity of the therapist or doesn’t quite feel safe, or if the therapist doubts the motivation of the person seeking help to change or to give it a go, then the relationship is quite likely to flounder.


I know from my own personal experience in therapy that on the occasions when I consistently felt that I was not being listened to by the therapist, I found it really uncomfortable. I was pretty inexperienced in the world of therapy then and so stuck it out longer than I should have. I can remember walking up to the therapy room with something of a sinking feeling but hoping that it was going to be ’good for me’. Finally, I took my courage in both hands and stopped going.  Sadly I couldn’t find the courage to explain to the therapist why. I went on to work with someone else and this time the experience was profound and transformational.


The, apparently simple, fact of hearing yourself say things, things that you might have never said out loud or to anyone else before, can be very moving.  Seeing how the other reacts, noticing that the world doesn’t end, realising that you won’t be judged stupid or foolish for saying those things helps us to think about our feelings and assumptions about ourselves in different ways.  The fact that there is someone else listening, being a witness to what you want to say is also very important. Talking to yourself outloud simply doesn’t have the same impact.


This relationship can  only develop when there is a sense of trust between the two people involved and this grows from a number of things. One aspect is quite visceral, there are some people in the world I feel instantly comfortable with and some I will never feel easy with.  I don’t know exactly what it is I am picking up on when I respond this way, but I do know this can get in the way of developing a good relationship.  Trust is also based on the therapist behaving in a trustworthy manner, respecting what I am saying and my responses, not judging me, being there when they say they will, not imposing their assumptions on me, and so on. 


Another key factor seems to be an agreement about goals; what have I come here for and what are we going to do together? This can support the feeling that the two people are linked in a shared enterprise, are working collaboratively-‘singing from the same song sheet’. Without this sense of common purpose it is very difficult to feel you are achieving anything together.


Cozolino, who writes a lot about therapy suggests that;  ‘As adolescents and adults we seek therapy because we find ourselves unable to form meaningful relationships, manage our emotions, or feel worthy of love. The reasons for our struggles often remain buried in networks of implicit memory, inaccessible to conscious reflection.  Psychotherapy guides us in a safe exploration of our early experiences and helps us create a narrative that associates these early experiences with the ways in which our brains and minds distort our current lives.   In the process our symptoms come to be understood as forms of implicit memory instead of insanity, character pathology, or plain stupidity.  This process  can open the door to greater compassion for oneself, openness to others, and the possibility for healing.’(Why Therapy works 2016) I find this description very helpful as it gives us both hope for the future and a sense of what is important in the present.


So the evidence of the research and my own experience, both as a  client and a therapist  is that therapy works. For are some people they may not be in the right space for it at the moment, and it is important to find the right person for you.And it requires the commitment of both the people involved  in terms of thinking about it and acting on what is discovered.