Resolution, Not Conflict

The guide to problem-solving.

I Know I Need Therapy Help, but Is My Therapy Working?

How can you assess if your therapy and therapist are good fits for you?

Is therapy working? Is this the right therapy help for me?
Is therapy working? Is it the right therapy help for me?
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Is your therapy working?  Personal problems, and marriage problems as well, can feel quite distressing.  Professional therapy help can soothe your stress, much like seeing a dentist can ease a toothache and an orthopedist can reset broken bones.  At the same time, therapists and psychotherapy methods can vary widely in their effectiveness.  It's important to be able to asses if the therapy help you are receiving is likely to prove genuinely helpful for you

Here’s two perspectives.  The first, offering a client’s perspective, is from a young adult friend who wrote to me about his therapy experience.  His thoughts started me thinking about this topic. Thank you M.S. for your permission to include your writing in this article. 

The second perspective is from my own experience as a therapist, enhanced by findings from therapy outcome research.

A client’s perspective on assessing if therapy was working

Regarding my experience with a therapist in New York—I refer to him as Dr. Dee (I forget his real name)—I hope my assessment is of some use to other therapists and patients.

After shopping around for a therapist in New York for approximately a month I decided to see Dr. Dee. I liked his calm and collected demeanor, and at the time his dead-pan expression made me feel quite comfortable. We set up a schedule and I started seeing him once a week. At the time I was recently separated from my wife and having emotional issues in a new relationship. I was suffering from depression, anxiety, and general lack of motivation while holding a sales job in a very dynamic company in Manhattan.

As is customary, Dr. Dee started by asking me what brought me to his office. He would ask questions that made me start talking and for much of the session I would give endless rambling answers to his questions. I found talking very relaxing and often times he would have to stop me when our time was up. Initially, I thought I had made the right choice. However, by the fourth session I felt like my sessions with him were nothing more than a quick fix that made me feel better, perhaps through some kind of vocal-catharsis. I had no sense of direction regarding our progress. None had been discussed. There was no road-map of any kind and it seemed to me we would just have these long talks without trying to achieve a specific goal. If there was a strategy in his mind I had no access to it. There was no sense of direction within each session either. I would leave his office feeling somewhat lighter but the feeling only lasted a few hours and by that evening I would usually be in the same place I was in right before I saw him.

Just like it is important for a surgeon to give the patient some sense of the surgery before operating—what they're removing, how they hope the patient will feel after the surgery, the aim of the procedure—I feel it would have helped if Dr. Dee had told me what my procedure was going to be like and what we were trying to achieve. While it is important to be on the road to recovery, I feel it is just as important to have some sense of an itinerary and the direction that road will take. Otherwise one feels one is on a merry-go-round, an exhilarating ride no doubt, that gives you a sense of movement but never takes you much further from where you started. 

Perhaps there is something to be said for not marking out the journey and letting the mind wander but I feel in this day and age, when so much of our lives are goal-oriented, from the entertainment we choose to the education we invest in, that serious activities surrounding mental health and general well-being should at least incorporate some of that attitude. Otherwise, therapy sessions run the risk of being perceived as casual endeavors, like a drive around the block, rather than a serious voyage to a new world.

Second Perspective: A clinician’s viewpoint on assessing if your therapy is working well for you.

I very much agree with MS tht it is important to know if the therapy help you are getting is a therapy that is working well for you.  Therapy is expensive, a major investment in both money and time.  In addition, people would not make that investment if they did not have a serious desire to get their problem solved.  So here’s nine suggestions on how to assess if the therapy help road you are on is likely to get you where you want to end up.

1. Do you feel that your therapist understands what you are going to treatment to accomplish?  If not, start your next session by re-clarifying your treatment goals with your therapist.  Therapy is more likely to feel like it is working if you and your therapist are both rowing in the same direction.

Research on "goal consensus" in therapy has indicated that therapists and clients who clearly agree on what they are trying to accomplish definitely do have higher odds of reaching these goals. My friend M.S. who wrote his perspective above hit the bullseye when he identified this factor as having been key to his dissatisfaction with his therapist.

2. Do you feel satisfied that your therapist has explained how the therapy method that you are undergoing will help?  How it will fix the problem you are there to fix?  If not, ask for an explanation.  If the explanation does not feel sufficient, ask for further information.  

Therapy outcome research has shown that lack of understanding of how a therapy is supposed to be helpful often leads clients to drop out prematurely from therapy.

3. Do you have a nagging feeling that there may be other treatment options?  Are there other kinds of therapy help that might be more appropriate for dealing with your problem? 

Research by Michael Lambert has found that about 8% of clients in therapy actually deteriorate from their treatment.  

If you are uncertain about the effectiveness for you of the therapy help you have been getting, you might ask your therapist what alternative treatment methods could be effective for your particular problem so that you can make an informed choice.

Note that Lambert's research also has shown that virtually all therapists think that they are above average in their capabilities, and that their way of doing therapy is the best.  Still, your therapist should be able to inform you of treatment options. 

One further caution with regard to choice of therapy methods.  If your problem involves relationship issues, be sure that both of you go for treatment together.  For married people in particular, when one person goes alone to therapy the odds go up that the marriage will end.  When both spouses see separate therapists the odds of a divorce zoom further upward.  The best marriage therapy format therefore usually is one therapist who works with the couple and who also works as needed with each individual. This policy is fairly standard for therapists who work within a family-systems treatment orientation.

4. Does your therapist begin each session by asking you what you want help with that day so you decide together what to focus your therapy hour on? 

If not, you can begin thinking ahead of each session what you would like to use that session to accomplish, and then share that goal when you first sit down to talk.  As my friend above so clearly realized, if you don't know where you are heading the odds that you will get there become slim. 

Here are seven potential goals to help you choose a session focus:

  1. Digest and learn from a specific upsetting interaction that happened the prior week
  2. Make a plan of action to prepare for a challenge that you see ahead
  3. Ease a negative feeling you have been experiencing such as anxiety, anger or depression
  4. Improve a relationship at home or at work
  5. Understand how experiences earlier in your life have been affecting how you handle situations that you are facing now
  6. Understand the source and remove a self-defeating belief (e.g., “I can’t possibly succeed…”)
  7. Understand the origin and remove a self-defeating habit (e.g., eating excessively or quickness to anger).

5. Do you leave each session feeling that your time and money have been well-spent?  One way to assess the value of any particular session is to look back on it in order to articulate what you accomplished. What was your take-home? What about your therapy was working well for you?

Many therapists end each session with a session summary. I defintely aim to save time at the end of the session to look back and sum up, and succeed in doing this at least at the end of most sessions.  If your therapist does not routinely review the session at the end, request a summary.  Starting your review with 5 to 10 minutes left will give you time to consolidate and reinforce what you have gained.

It's helpful also to look by the end of the session at any unfinished pieces that you will want to explore further next session, and to tell your therapist of anything in the session that did not work for you.

6.  How far do you think you have come in solving your problems?  If you think of therapy help as a journey from San Francisco to New York, where are you so far?  If your progress thus far is unclear to you, ask your therapist to share his/her view. 

7.  Are you clear what your role needs to be for the therapy to feel that it is working effectively?  If not, ask your therapist if and how you could do something additional that would accelerate your treatment.

8.  What skills have you learned so that your treatment gains will hold?  For instance, have you been depressed?  Depression is triggered by giving up in a situation in which there is something you want but are unable to get.  Have you been learning to speak up more effectively about your concerns?  When therapy is working the best, gains from insight generally also need to be consolidated with new habits.

In couples therapy for instance, gaining new skills for communication that stays harmonious, for collaborative shared decision-making, for eliminating arguments, and for augmenting the positives the two of you give each other is especially vital for gains that will last.  If your therapist does not feel qualified to coach you in these skills, be sure you take a marriage education course to augment your therapy work.  Take this free quiz if you would like to determine if a skills course would be helpful for you.

9. How optimistic did you feel about your treatment after the first several sessions?  Therapy outcome research by researcher Michael Lambert has indicated that if clients do not feel that they have gained significant help within the first several sessions, the odds slide downward that the therapy will conclude with a successful outcome.  

In sum...

The moral of the story: Listen to your inner voices. Odds are that there is a small voice within you, or maybe even a loud one, that, especially in answering the questions above, is telling you whether your particular therapist and therapy treatment method are a good match for your needs.  Want to know if your therapy is working and if it's the right kind of therapy help for you?  Listen up! 

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Denver psychologist Susan Heitler, PhD specializes in helping couples to build strong and loving marriages via her clinical work, her books, and her online alternative to couple therapy  for singles who want to become more marriage-ready, for partners, and for married folks who want to upgrade their relationship.

Susan Heitler, Ph.D., is the author of many books, including From Conflict to Resolution and The Power of Two. She is a graduate of Harvard University and New York University.

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