People come to therapy either because unfortunate things have happened to them or because they are unhappy with themselves, or both. Let’s take a look at each of these situations:

Unfortunate Things Have Happened: Some people seek therapy because something fateful has happened in their lives: they’ve lost a spouse or a job, they’ve gotten in trouble with the authorities, they’ve failed at something they were trying to do, they’ve been given an ultimatum by someone who matters to them, a child has crashed and burned, someone they loved has died.

What they want from therapy is support and guidance, some comfort, help getting back on their feet. They aren’t interested in examining their childhoods -- the crisis is now and they want relief. Totally understandable.

If the problem is really not of their making, if the fates dealt them a bad hand, they may get back on their feet quickly with just a little help. A therapist may be able to help reassemble the pieces in short order. Sometimes therapies really can accomplish their goals in just a few sessions, sometimes in just a matter of months. Therapist and patient need to keep their focus.

But it’s more complicated if the problem really isn’t external – if the job was lost, or the coursework failed, or the relationship sabotaged, because stuff inside was keeping the person from functioning well. The therapist may have to start by helping his patient understand that the disaster wasn’t just a matter of bad luck or chance or the unkindness of strangers. If the patient and therapist can get there, then the hard work begins.

Life Doesn’t Go Easy: Others come for treatment because they’re unhappy with how they are functioning or feeling. They may be painfully depressed, or anxious, or guilty, or alone, or sad all the time. They may have difficulty managing relationships, or they may keep getting in trouble at work, or be unable to study, or be blocked in creative pursuits, or have trouble coping with a chronic illness, or be unable to have sex comfortably.

Problems of this sort have usually been going on for a time. They may have gotten worse recently, which has prompted thoughts of seeing a therapist. Medication may be very helpful, but it’s usually not enough by itself. Talking helps. It’s a very common experience for patients to feel, when therapy goes well, that the therapist is the first person that they’ve really been able to open up to, fully, and that that it’s the first time they’ve really felt understood.

How does psychotherapy work? Depends on who you ask. Let me tell you what, for me, a good therapy session is like:

First and foremost, it’s an open and honest conversation, a good talk. I feel it’s been a useful hour if we’ve been able to say the things worth saying to each other. And it’s not so easy to do that – we’re used to keeping our guard up for compelling reasons, because of our experiences of being hurt and used and misunderstood in the past. So it takes a while, and sometimes a substantial while, for us to build trust, to negotiate ways in which we can be really candid with each other.

Our past experiences shape us, and sometimes they take their toll. But it’s a great misunderstanding about therapy that the work is all about rummaging through the attics of our past. Therapists are only interested in the past as it is alive and kicking in the present. The ways of negotiating the world that we learned in childhood often became addictive. For better and for worse we connect in the ways that worked for us as children, even at great price to ourselves. That’s because the opposite of being loved isn’t being hated – it’s being treated as nonexistent – and so we accepted connection on the terms we could find. Therapy is about putting in question the roadmaps we’ve followed without hesitation and taken as set in stone.

In a good-enough therapy, more than anything else, we come to know ourselves better. Which can be extraordinarily useful. We don’t become different people, but we can develop second opinions about things we’ve taken for granted. (An example: It’s not just that I’m afraid of being embarrassed if I speak up. It’s also that I’m afraid of hurting you, and losing you.) Being able to entertain a second possibility offers us a measure of freedom, the chance to make a different choice. At least some of the time.

I think that my patients usually finish treatment with a different understanding of themselves, a different take on who they are and what’s made them that way, a fresh accounting in some regards, a self seen anew by virtue of having been refracted in our relationship.

I should add that I have had a few patients whom I have seen for many years of whom it might be said that they haven’t changed at all in that time, and yet for them the experience of being able to have a meaningful conversation each week has made their lives richer, the therapy session being an oasis in the desert, a pause in the deadened ritual, an hour of freedom.

The real difference between psychotherapy and psychoanalysis is how often we meet. Conventionally, being in psychoanalysis means having sessions four or five times a week, and being in psychotherapy means coming less often. Once-a-week treatment does run the risk of becoming the “news of the week in review.” By meeting more frequently, we can move beyond surface concerns and work at the underlying problems which interfere with connecting, loving, working, being expressive and creative, feeling better. It becomes safer to reveal yourself when you know that we can pick up the conversation tomorrow.

There’s a popular notion that more frequent treatment is for those who are more disturbed, that coming often must mean you’re “really sick.” But it’s actually the other way around. It takes a measure of personal strength to engage in a substantial treatment. Most of the people I’ve seen in psychoanalysis have been students or professionals with fully engaged personal lives. For stubborn inner problems, which have been years or decades in the fashioning, it may be that nothing less than an intensive treatment will make a difference. A maladaptive way of negotiating the world fashioned over a lifetime can’t be shifted quickly or easily.

“So am I signing on to do this for the next ten years?” I might be asked at this point. “Am I surrendering my life? Am I another perpetual patient like Woody Allen?” might be the private thought. (My first thought is: But think of all the great movies he made during those years of treatment.) What I’d say is this: You’re not signing on for life, you’re going to give it a try. If it doesn’t seem useful you’ll move on and try something else. And if it does feel helpful, it folds into your life like other useful activities which take time (working out at the gym, practicing at the piano, participating at the church, and so forth). Analysis makes heavy demands in time and money, and you’ll only stay with it if you sense that it’s become worth doing.

Couples usually come for help when they’ve reached a crisis point in their relationship. Often the problems have been long-standing, but now matters have taken a turn for the worse. If both members of the couple want to try to work things out, treatment helps. It’s usually possible to restore the relationship to the level at which it was functioning before the crisis (the affair, the loss of the job, the death of a parent, and so forth) in reasonably short order, a few weeks to a few months. To create a shift in the couple’s underlying long-term dynamics is much harder, and may take months or even years of work. But if both partners are motivated to change the relationship, there are prospects that therapy will improve things.

But some couples come for treatment with one partner dragging the other in tow. Sometimes the reluctant partner can be successfully engaged, and the treatment moves forward. At other times, that person has simply come in an act of angry compliance, and having paid his or her dues by doing so, doesn’t return. And occasionally one partner is towing in a spouse just to shame the person, and neither party really wants a stranger’s help. Rarely, one partner has actually signed off on the relationship; I’ve never seen such a person change course. It doesn’t necessarily mean that the marriage is over – some people need to be in a relationship with a person they can despise. But on the rare occasions when I’ve encountered this (perhaps a half-dozen times in the five hundred or so couples I’ve seen over the years), being in couple therapy is pointless – and I’ve said this.

For the well-intentioned couple who I think I can help, my goal is to help each person understand why the partner thinks and feels the way he or she does, based on the partner’s own life experience. A few years ago, I presented my thinking about what makes marriage work to an audience, and this is what I said:

Here’s a modest proposal. When you find your spouse taking a truly outrageous position, try to imagine, using all that you know about him, how he got there. You don’t need to agree with your spouse’s point of view, you can even continue to think that it’s ridiculous. But if you can understand that, for example, his upbringing gave him good reason to be totally paranoid when confronted with the request you just made, you make him human in your mind.

The second definition is “…vicariously experiencing the feelings, thoughts, and experience of another [without having it directly communicated].” In this definition I actually try to put myself in your shoes and imagine your experience. It’s the heart of what we do as therapists. And the mutual ability to be empathic in this sense is the single best criterion for a workable marriage. Being empathic doesn’t mean having the same point of view. Partners can disagree absolutely. What it means is having respect, taking the other seriously.

Couple therapy can also be quite useful in two other situations. Occasionally I’ve seen a couple who are contemplating either marriage or moving in to live together, who want to take stock of their situation before making a commitment. Meeting for a few sessions or a few months, they may be able to sort this out in a helpful way. And I’ve also seen couples who have decided to separate who want to find a way to work together to make the parting less acrimonious, or to help with planning for their children’s futures. Couple work can be vitally helpful in this regard.

In any event, a couple therapy is always a trial intervention. Some of the time individual work will be the best course for one or both partners to pursue, sometimes in concert with joint work and sometimes not. In the initial evaluation we try to sort out the question of which course of action offers the best prospects.

Most often couple therapy proceeds on a once-a-week basis, but some couples have found it useful to meet regularly for double sessions to have time enough to really have a chance to open up to each other. And I’ve occasionally seen couples more frequently, on one occasion actually meeting usefully three times a week for several years.

The first principle of family therapy is that everyone should be on equal footing and everyone’s ideas should be taken seriously. Sometimes parents see family therapy as a means for the therapist to help them manage their child, who is presented as the focus of the treatment. The child then sees the therapist as another adult in league with the parents to control the child’s behaviors. Enterprises of this sort are almost always unsuccessful.

But if the parents can genuinely view the treatment as a chance for all the family members to talk openly with one another, and to listen to each other, the experience can be eye-opening and constructive for all concerned. It’s usually best if all the people residing under the shared roof can come to the sessions, and sometimes it makes sense to include older children who live outside the home. When everyone takes part, there’s less scapegoating.
Over the years I’ve found it remarkable how open children can be in family sessions; parents may hear their children speak frankly with them about highly charged matters for the first time. I’ve heard children as young as three or four express themselves in ways that shed light for everybody. Some dramatically times in just a few sessions of this sort the family’s feeling about itself changes dramatically.

Medication can be quite helpful in alleviating conditions such as chronic anxiety, depression, insomnia, and attentional difficulties, among others. In some areas, most notably in the treatment of depression, the newer medications have substantially better side-effect profiles than those used in years past, which makes them much more tolerable to take. I’ve seen a wide variety in patients’ responses to medications, with some people getting dramatic relief and others not so much help. That being so, I’m up for giving drugs a try if my patient is of similar mind. Perhaps a third of my current patients are using medications.

On the other hand, medication is rarely sufficient as a treatment in itself. Talking is important too, and actually usually helps more. We need someone to sort out our thoughts and feelings with, to make sense of what’s going on in our lives, so that we can find ways to make things go better for us. That’s where dialogue makes a difference. Sometimes medications provide the sort of relief that actually helps the person to make better use of psychotherapy, and that can be worth consideration. And some of my patients have been opposed to using drugs, for a variety of reasons, and this can be a totally reasonable choice. We need to think about the alternatives together.