Why Does Therapy Work? It’s Not Why You Think

We Are Relational

“The self is a network of impressions that we form about ourselves in the context of our relationships with others.” - F. Perlman & J. Frankel

We are born into a relational context that shapes both how we see and how we show up in the world. My mentor, psychologist, Roy Barsness, who was on Ep. #3 of my podcast,  often says that, “We are formed in relationship, harmed in relationship, and healed in relationship.” I first heard him speak some version of these words 16 years ago when I was in grad school to become a therapist. His words rang deeply true for me then and have become the foundation of how I view my work as a therapist. 

When we are first born, long before we have the ability to have cognitive thoughts or express anything on a verbal level, we begin to navigate the world by way of our experience. Experience that is rich with physical sensations (warm, cold, wet, soiled, hungry, full, tired, etc), and unformulated emotional sensations known as affect states. The way that these physical and emotional states begin to take on meaning is largely relational, based on how the parenting figures respond to these various states. It is not until a later stage of development that children are able to have thoughts about or verbalize the meaning they take away from each encounter. 

Based on the consistency and types of early experiences we have early on, we all develop a specific attachment style. For example: 

If the parenting figures are relatively well attuned to the baby and these states and can respond and engage with warmth, care, and attentive love on a fairly consistent basis, over time the child will develop a secure attachment. This attachment becomes part of the lens through which they will see the world and relationships with as they grow and develop. Children with a secure attachment tend to view the world as a relatively safe place and develop a healthy sense of autonomy while also trusting that their needs will be met when they arise.

If the parenting figures are consistently not attuned to the various states of the child, or are dismissive and inattentive, then the child will likely develop an avoidant attachment and as they grow and develop they come to have no expectation that their needs matter or will be met in relationships. They are the self-sufficient, go-it-alone types.

A child whose parenting figures are either enmeshed with the child, not consistently available, or are overly anxious will often create an anxious-ambivalent attachment in the child. As this child grows and develops they come to believe that the world is not a safe place. They tend to be more clingy, maybe even fearful of their own needs because they can sense the distress their needs provoke in the parenting figures and are less willing to explore the world around them. 

Parenting figures who have significant unresolved grief or trauma of their own may find themselves in a direct conflictual relationship with their child’s needs on a regular basis. Over time the child will have both the desire to be soothed by the parenting figures, but will also feel fear about seeking the soothing that they need. This is known as a disorganized attachment and can be seen in the tendency of the child to become easily overwhelmed and space-out, dissociate, or freeze like they are stuck and don’t know what to do.

Our attachment style and developmental wounds move with us through the various stages of human growth and development and expand out from our family of origin relationships into the types of relationships we form in other social, educational, work, and romantic contexts. Based on our particular attachment style and the timing and types of developmental wounds we experience, we also begin to push parts of ourselves down into our unconscious that don’t serve to help us get our basic needs met. This is known as the psychological idea of repression. 

For example, say you grew up in a family where there was a parent who punished or shamed you every time you expressed anger. You quickly learned that anger is not a welcome emotion and to express it can, in fact, create a great deal of pain for you. So anger got split off from your consciousness and got pushed down into your unconscious. When anger came up your automatic unconscious pilot took over and based on your particular attachment style, your conscious expression took a different, more acceptable form. Initially this defense was useful in that it served as a protection and survival strategy because the absence of anger meant that you were more likely to avoid shame and punishment from the parent who couldn’t tolerate your anger. The problem is that there is a shadow side to every survival strategy. Things that served us to some level in our childhood don’t always serve us well as adults. Additionally our survival strategies often operate just outside of our awareness. This means that we are not usually thinking, “Hmm, I feel anger coming up for me so I should push it down so that I can feel safe.” Instead, the survival strategies are put into action by a type of autopilot response. This autopilot is directed by our unconscious.

We Have An Unconscious

“Until you make the unconscious conscious, it will direct your life and you will call it fate.” - Carl Jung

I’ve mentioned this idea of the unconscious several times, but what do I mean by that? Simply put, the unconscious is the part of us that is not accessible to our conscious minds, yet still has a significant impact on our emotions, thoughts, behaviors, and relationships. For example, we actually need the energy of our anger if we are going to be able to establish healthy boundaries in the various relationships we have. Anger helps us to recognize that something is not right and compels us to take action to change it. If our survival strategy automatically shuts our anger down then we will not be able to create the boundary and, in fact, may not even recognize that there is a problem requiring a new boundary.

Whichever attachment style and subsequent survival strategies we take on as children tend to get deeply embedded in our unconscious, always running in the background of our lived experiences (like an operating system in a computer). These patterns follow us through the various stages of psychological growth and development and show up again and again in our relationships. 

We Repeat the Past in the Present

“The past is never dead. It’s not even past.” - William Faulkner

Freud famously described this as a repetition compulsion, meaning that we tend to unconsciously repeat traumatic scenarios from the past again and again. The themes, emotional experiences, woundings that we lived through in the past get enacted in our present relationships. This unconscious cycle tends to deepen our wounds, defenses, and survival strategies. 

Have you ever asked yourself the question, “Why do I always end up in relationships or situations like this? I swore that after the last time I would never be in a relationship with someone like that again, and yet, here I am. In the same situation in spite of my best efforts to create different boundaries. Why does this keep happening?” 

Or maybe you are someone who views yourself as having done a lot of your own personal work to overcome your patterns and heal your past wounds. You notice that this has certainly impacted the way you live your life. Maybe you have become better at recognizing and valuing your own needs, are better at self-care and setting healthy boundaries. Then you go home to your family of origin for a visit, maybe it’s the holidays. You find yourself feeling dumbfounded that even though you’re in your mid-thirties and have done all of this personal healing work and swore to yourself that you were going to show up different with your family this time, however, in spite of all of that, you suddenly feel like you’re 15 years old again and unable to find your hard-earned voice when you are back in the gravitational pull of the family dynamic. You repeated your pattern again! 

You promised yourself that you were going to be more assertive this visit. Maybe say no a time or two. Maybe confront your relative when they make that offensive comment that they always make. But alas, you froze, fell back into your passive or avoidant role and in spite of your best efforts, could not get your voice to move from your head through your vocal chords and out of your mouth. By the end of the trip you feel stuck, exhausted, angry with yourself, and wondering what  just happened. You feel defeated like some hidden force hijacked your mind, emotions, and body during the visit. To be clear, that is exactly what happened. The hidden force is your unconscious grabbing the wheel from you and steering you back into the old pattern. While you are able to use your new skills, meditations, and self-care to show up differently in most of your life, something about that visit home was too overwhelming and overpowering. 

Your nervous system got overwhelmed and sent you into a fight, flight, or freeze response bypassing your best intentions and activating all of your old defenses and survival strategies. 

What does this mean? Are we just stuck and destined to always repeat the past? I think this is where Carl Jung is really helpful. He proposed that there is a prospective function to these unconscious repetitions of the past. Your unconscious is not simply trying to hijack you and hold you back, but rather that the unconscious is actually trying to help you move forward and heal. Each repetition is a clue pointing to some part of you that still needs some care, curiosity, and exploration. The prospective function is a rehearsal for the future, not just a repetition of the past. 

The unconscious is working to make itself known through these repetitions of the past, in the present, so that the original wound can be worked through consciously to a different outcome in order to find healing, integration, and open up new possibilities for the future. Each repetition is a new opportunity for the pattern to be discovered in the relational space between two people. The dilemma is that the unconscious is so good at creating the repetition that it often leads to the same outcome, reinforcing the wound while activating the subsequent defenses and survival strategies. This leads us to foreclose on our curiosity and say things like, “Well, this is just the way that I am.” This mindset leaves us feeling hopeless that anything will ever change.

What Does All of This Have to Do With Therapy?

“We always live something together with our patients while we try to get in touch with the truths of the session.” - Galit Atlas

Many clients assume that the therapist is the expert with the answers while they are the one with the problem to be fixed. The reality however, is that therapy is far more dynamic than that. It is an evolving relationship between the therapist and the client. It is literally two human beings sitting in a room trying to connect with one another. The focus is on the client but the humanity, attachment style, defenses, and survival strategies of the therapist are in the room as much as those of the client are. 

In fact, in 2018 The American Psychological Association published an article that combined decades worth of research to demonstrate that the determining factor of whether or not therapy will be effective and lasting is the quality and engagement of the relationship between the therapist and the client not in the particular technique used. Let that sink in for a moment. 

Patterns of relating that formed during childhood and have been reinforced during one’s life will inevitably repeat between the therapist and the client. As mindfulness expert, Jon Kabat-Zinn says, “Wherever you go, there you are.”  In other words, we take our patterns into every relationship that we have. The therapy relationship is no different. For this reason, when therapists choose to take their own medicine by remaining committed to their own healing and ongoing evolution it helps the therapist gain a better understanding of their own inner landscape. This is critically important so that the therapist does not unconsciously project their own unresolved issues onto their client and attempt to fix them in their client instead of doing their own work. 

It is startling how many therapists go all the way through grad school, some even going on to complete a doctorate degree, but have never been in their own personal therapy and often choose to stop receiving supervision once they attain their full license.

Therapists must be able to accept and get curious about their own internal experience as it relates to the client because something of the client's problematic past is being recreated in the present in the space between the client and the therapist. If the therapist ignores their experience and tries only to focus on the content and story the client is bringing then they are going to miss what is taking shape in the process of the developing relationship. It’s that classic metaphor of the iceberg. The content is the tip of the iceberg; the part that is above the surface of the water and visible. The process is the remaining majority of the iceberg and exists just beneath the surface of the water, initially out of sight. Therapists can become bewitched by the content because it is the easiest to think about, categorize, offer solutions for, and honestly, remain detached from. In other words, the therapist can stay defended and hidden if they are exclusively focusing on the content being presented. They can ignore the fact that they are an active participant in what is unfolding in the room. To explore the unfolding process requires more of the therapist. It demands that the therapist pay attention not only to the details being presented but also that they train themselves to notice the more subtle clues that exist in the actual felt experience they are having in the moment.

The therapist is not simply an objective observer with tools and solutions, but rather is dynamically involved in an ever unfolding relational matrix with the client. In fact, the self of the therapist IS the greatest tool any therapist has access to. What do I mean by that? Again, I am saying that the therapist must be attuned not only to the story the client is telling and the emotions the client is experiencing in regards to their story, but also to the therapist’s own experience during each session. Why? Because the experience the therapist is having offers clues about what is being repeated from the client’s past. 

Of course, the therapist should not just assume that their experience in the moment is the answer to exactly what is being repeated and then prescribe that to the client. Instead, the therapist may choose to courageously and vulnerably bring this to the client so that the two can sort it out together. By doing this, the therapist invites the client to participate by offering their own experience of both what the therapist is saying as well as adding their own differing thoughts, emotions, and sensations into the mix. In this way neither the therapist nor the client is the exclusive expert with the answers. Rather, both parties hold crucial clues as to what is trying to be worked out, and each is invited to add their ingredient to the stew while also wrestling with the ingredient that the other offered. The expertise actually exists in the evolving relationship between both people.

The experience of the therapist includes things like their own reveries, musings, thoughts, images, memories, and bodily sensations as they arise with the client. The work of the therapist is to make space for their entire experience without dismissing them as existing only within themselves or hiding behind a technique. The therapist is able to cultivate a mindedness that wonders, “What might this experience I’m having tell me about what is taking shape between me and the client?” And then must work to find a way to articulate their experience and invite the client to “work it” with them in a type of co-metabolization and exploration. Thus allowing for the unconscious to begin to emerge in the space between client and therapist where it can begin to be narrated, take on meaning, and ultimately integrated. 

The unconscious of the client and that of the therapist are co-creating a relational dynamic between the two of them. The truly transformative act of therapy is when the therapeutic couple eventually catch themselves in the repetitive enactment of the past. This allows for the unconscious pattern to become conscious, at which point they can slow it down, explore it with intention, and ultimately stop the repetitive cycle by working it through to a different outcome. It is in the relational space of working the enactment through together as co-participants rather than therapist-as-expert, that the process of gaining new insight, experiencing healing of past wounds, and transformation of unconscious survival strategies occurs, thus allowing for new possibilities for a more integrated, vibrant, and authentic future. Indeed it is true that we are formed in relationship, wounded in relationship, and healed in relationship.