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A Guide to Why Therapy Works

Understanding how psychotherapy works helps you choose the best therapist.

Key points

  • Nathaniel Hawthorne described the qualities of a good therapist almost 175 years ago.
  • Hawthorne described what patients need to bring to therapy to get maximum benefit.
  • Good treatment requires many abilities: marketing is not one of them.

I recently discovered the clearest and most concise explanation of why good psychotherapy works. Surprisingly, it was written in 1850, by Nathaniel Hawthorne, six years before Sigmund Freud was even born.

Taken from Chapter 9 of The Scarlet Letter (with outdated language paraphrased) this is what Hawthorne had to say:

A person of skill, a kind and friendly physician/therapist, strives to go deep into a patient’s heart, delving among his/her principles, prying into recollections, and probing everything with a cautious touch, like a treasure seeker in a dark cavern. Few secrets can escape an investigator who has opportunity and license to undertake such a quest and skill to follow it up. A person burdened with a secret should especially avoid the intimacy of a therapist if the latter contains such sagacity [discernment and judgment] and intuition, if the therapist shows no intrusive egotism nor disagreeable prominent characteristics, if the therapist has the power borne within to bring his/her mind into affinity with a patient’s that this last shall unawares have spoken what he/she imagines only to have thought, if these revelations be received without tumult and acknowledged not so often by an uttered sympathy as by silence and here and there a word to indicate that all is understood, if to these qualifications of a confidant be joined the advantages afforded by recognized character as a physician/therapist, then at some inevitable moment will the soul of the sufferer be dissolved and flow forth in a dark but transparent stream, bringing all its mysteries into daylight.

That is almost all both patient and therapist need to know. Each idea Hawthorne presents has a great depth of meaning. The following highlight some of the most important points:

First, the character of physicians and therapists is of paramount importance. Many things are demanded of people undertaking therapeutic treatment, but marketing is not one of them. Psychotherapists must be:

  • Skilled: This means trained by seasoned teachers with high standards.
  • Kind and Friendly: This means therapists must make people feel welcome within the limits of being a patient. It does not mean being a personal friend, which risks losing objectivity.
  • Deeply Curious: Psychotherapists need to keep asking hard questions that are guided by their training and experience.
  • Sensitive: Each patient has their own pacing and delicacies of feeling that need to be respected.
  • Capable of Intimacy: This means the ability to stay present and in contact during difficult feelings.
  • Intuitive: The ability to grasp a patient's meaning without conscious reasoning.
  • Serene: This means being a calm witness even as a patient's feelings are in tumult.
  • Not Egoistic: Your therapy is not your therapist’s show. Therapists need to get their own wants and needs taken care of outside of time spent with patients.
  • Empathetic: This means bringing one’s mind into affinity with a patient’s mind. Therapists need to feel empathy for patients’ suffering, which is not the same as sharing that suffering, as much as it means sensing and caring about the full depth of another’s aching, fear, anger, doubts, and grief.
  • Responsive: Therapists must know how to quietly communicate their understanding.

This list is not exhaustive, despite already posing a rigorous challenge. No therapist perfectly masters all these required characteristics. But every good therapist strives to embody each one to the extent of their capability.

Second, people who hope to get the maximum benefit from therapy need to be open to the following:

  • Accepting the Patient Role: The ancient meaning of “patient” is “sufferer.” One source of our suffering comes from having to admit we need help. Accepting the patient role means acknowledging your pain and seeking help to heal your wounds.
  • License: People need to trust the therapist enough to give their therapist license to probe and explore their basic beliefs and recollections.
  • Heart: Therapy explores emotions even deeper than a patient’s reason.
  • Patience: A good therapist follows threads into unknown parts of a patient’s psychology and continues to follow up on clues to find what lies in the dark corners of the mind.
  • Intimacy: Entering into an intimate relationship with your therapist is essential for the full benefit of the work you have entered into. Intimacy is measured by the degree of vulnerability each patient can bear.
  • Transparency: Patients become far more transparent with their therapist than vice versa. Only in this way can your therapist remain dispassionate enough to focus from moment to moment on what best helps treatment succeed.
  • Uncontrolled Mysteries: When the realities within your mind find a voice, you need to be open to whatever it may say. The calm presence of a good therapist is often the balm needed to tolerate the truths that can change your life for the better.

Anyone familiar with the 12-Step program of Alcoholics Anonymous understands the similarities between doing a fearless inventory of one’s defects of character (Step 4) and sharing this inventory with another trusted person (Step 5). Multiple other traditions, such as the Catholic practice of confessing one’s sins to a trusted priest, also share similarities. But nothing I have ever read expresses the core of changing your life through psychotherapy better than Hawthorne’s words.

It is so odd, so ironic, that the “doctor” pretending to have these qualities in The Scarlet Letter turned out to be the apotheosis of deviousness and evil. This simply reinforces my long-held belief that the best way to choose therapists is through personal referrals from trusted friends. You want to find a therapist who does more than try to “perform” the qualities listed above. You want someone who embodies these qualities. To discern whether you have found that person, you need to trust your gut. It has to feel right when looking into the eyes of the person you are permitting to lead you on a journey into your unseen depths.

To find a therapist near you, visit the Psychology Today Therapy Directory.

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