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.