What Is Therapy?

One of the toughest interview questions I've ever had to answer while applying for a job as a therapist is, "How would you define therapy?" 

I don't remember what I said last time I was asked this in an interview (although I did get the resulting job, yay!), but it was probably something jumbled and full of disclaimers about the process of working together with a professional to change your thoughts, feelings, and behavior and improve your life. 

That's not bad as far as on-the-fly definitions of therapy go, but I think I can get a bit more specific. One place to start would be talking about some of the many different processes that go on in a therapeutic relationship.

In psychology we talk about content versus process--content is what you say or do, and process is the function that it's serving, how it's actually working in the moment. For instance, the content of my communication with you might be, "Wow, it must be difficult to be away from your kids so much." But depending on the context--the situation I say it in, the tone I use, and so on--the process might be anything from validating you and comforting you during a difficult time in your life to actively trying to make you feel guilty for being away from your kids so much.

Process is a huge component of therapy and it's something we therapists call attention to a lot. For instance, if a client always redirects from a particular topic, or asks for the therapist's opinion about their outfit, we might ask what's going on there--what the process is.

Likewise, to understand what therapy actually is, it might be helpful to get familiar with some of the processes that happen during it. Here I've listed some common ones, along with how they relate to your treatment and how a skilled therapist might go about making them happen.

Establishing a therapeutic alliance is not something Anya has difficulty with. I mean, look.

Establishing a therapeutic alliance is not something Anya has difficulty with. I mean, look.

1. Building rapport.

The therapeutic alliance refers to the strong, trusting working relationship that's supposed to develop over time between you and your therapist. Research shows that this relationship is one the strongest predictors of success in therapy--stronger than the amount of experience the therapist has, or the specific methods they use. In order to get a good start developing a strong therapeutic alliance, therapists engage in rapport-building--the process of helping you trust and open up to them. They might do this by expressing empathy when you share your struggles, relating their own experiences or stories as appropriate, or asking you questions to show that they care and are interested to know more about you.

Which brings us to...

2. Gaining knowledge about you.

In order for therapists to help you effectively, they have to know a lot about you--your goals, your most private struggles, your identity, your relationships with others, and so on. That's why therapy always starts with some sort of intake process in which you may fill out lots of paperwork or answer lots of questions. Good therapists realize that this process can be pretty stressful, so we try not to overload you with never-ending interrogations at the beginning (or at any stage). However, a lot of therapists' questions, especially at the beginning of treatment, are for the purpose of learning more about you.

3. Validating emotions.

Therapists often validate clients' emotions by empathizing ("Sounds like you were pretty mad at your friend for forgetting your birthday"), normalizing ("You know, a lot of people would feel the same way in your situation"), or literally just directly validating ("Yup, that's legit"). Validating clients' emotions is an important part of building rapport, but it also serves its own purpose--people start to feel better if they can accept their emotions and view them as valid rather than shaming themselves for their emotions and trying to change them in counterproductive ways. When a therapist validates your emotions, they're telling you that it's okay to feel that way--even if there may have been better ways to react to that emotion.

4. Educating you about mental health.

The jargon-y term for this is "psychoeducation," and it's a big part of what therapists do. Knowing that, for instance, heavy marijuana use can increase anxiety and paranoia, or that people on the autism spectrum often have difficulty managing physical sensations, or that people with what's called atypical depression can take advantage of the fact that their mood lifts in response to increased activity or socializing, can make a huge difference in your treatment. Good therapists try to stay up-to-date on research and can tell you the best and latest info about what to expect with a particular diagnosis or how best to manage it.

5. Suggesting coping skills.

A big part of the reason many people go to therapy is, of course, to learn better coping skills. While therapy is intended to help reduce your symptoms, you may still need good coping skills to manage them--and besides, those changes won't happen right away and sometimes a bandaid solution is what's called for. Therapists work with you to help you figure out ways to deal with painful thoughts and feelings. While you might already know some things that work for you (even if you struggle with putting them into practice), they can also suggest things you may not have thought of. Some unusual coping skills my clients and I have worked out together: using a chatbot programmed by the client's partner to remind them to track their symptoms, turning on the AC a few hours before bed, exploring Tumblr as a way to connect to others with similar identities.

6. Helping you reframe things and think differently.

Reframing is a tool from cognitive behavioral therapy that helps people change the way they think about things. All of us sometimes get stuck in unhelpful ways of thinking about ourselves or situations that we're in, and sometimes it takes a therapist to point out new ways of thinking about it.

For instance, many of my clients who have struggled with substance addiction in the past feel ashamed of it and believe that it makes them weaker than others. I often reframe their struggle for them by pointing out that recovering from substance abuse is really difficult and that this makes them anything but weak. If anything, they probably have wisdom to share with others who haven't gone through that experience. Of course, reframing things in that way doesn't magically fix the fact that people who have struggled with addiction are stigmatized, or that recovery is a daily struggle. But if you work on reframing some of your thoughts, they can become less painful over time.

7. Pointing out patterns and habits.

Sometimes it takes a compassionate outside perspective to realize that you tend to make the same mistakes, assumptions, dating choices, and so on time and time again. Sometimes this can lead you to a deeper realization about yourself--for instance, many people learn in therapy that they have a pattern of sabotaging their relationships or goals because of insecurities they have. Other times, there isn't necessarily an underlying reason why you behave that way, but noticing the fact that you do can help you release yourself from that behavior. 

8. Encouraging mindfulness and introspection.

Mindfulness may be a buzzword these days, but it simply means paying attention to what's going on in or around you without judging it and without trying to change it. Easy to practice and difficult to master, it's the foundation of most evidence-based approaches to improving mental health--because they all require paying attention to how you're feeling without jumping to possibly-harmful attempts to change how you're feeling. Introspection is a sort of mindfulness because it involves noticing your internal states--thoughts, feelings, beliefs, fears, hopes--and labeling them with words, something that doesn't come naturally to everyone. 

9. Teaching social skills.

If you have ADHD, autism spectrum disorder, or borderline personality disorder--or sometimes even if you don't--learning effective social skills might be a component of your therapy. It's important to note that there's a painful history there with folks on the autism spectrum being put into programs that teach all kinds of messed up stuff under the guise of "social skills," but that's not what I'm talking about. Therapy can help you learn how you come across to others and how to change that if you're not happy with it. It's also great for practicing effective communication skills and learning how to read social cues better.

10. Reducing harm.

Harm reduction is a term that comes from substance abuse treatment. It emphasizes helping people make choices that keep them safer than they would've been otherwise, even if they are unable to completely stop engaging in a risky behavior. One of the prototypical examples of this is needle exchange programs, which allow people who use injection drugs to bring used needles to dispose of and receive clean ones to use, reducing the risk of transmitting infections. 

Many people find the idea of harm reduction disturbing because it feels to them like "condoning" or "encouraging" risky behavior. However, harm reduction is based on the fact that people who are determined to do stuff like using drugs or having sex with strangers will do so no matter what--so why not help them do it in a safer way.

Harm reduction includes not just needle exchange but things like providing condoms to populations at risk of STI transmission (such as college students or men who have sex with men), helping people who aren't ready to stop self-harming find safer ways to do it, and creating a safety plan with someone who is engaging in survival sex. If you're doing something that's potentially risky, your therapist may work with you to find less risky ways of doing it.

11. Motivating valued living.

In Acceptance & Commitment Therapy (ACT), my preferred approach, values are the things that are most important to you in life--things that you pursue whether or not they bring you any additional gain or advantage. For instance, my values are having caring, supportive relationships with people; learning new things; engaging with the natural world; being part of a community; and quite a few other things. That means that pursuing these things makes my life feel meaningful to me, even if I'm not always successful at specific goals.

Whether or not your therapist practices ACT, they will probably eventually focus on helping you live a meaningful life. Only you get to decide what that looks like. But what we can all agree on is that acting purely on impulse or in reaction to others, bouncing around from situation to situation without really knowing why, and feeling stuck in meaningless or painful life paths are all barriers to lasting mental health. That's why helping people understand what their values are and act in accordance with them is a component of many types of therapy.

The processes I've listed here are probably just a few of the countless ways that therapy can happen. This article focused on processes that the therapist facilitates; in a future article, I'll talk about what that actually looks like on your end, as the client.