Therapy Isn't Like Surgery

Someone wrote to me this week that despite quite a bit of therapy, most of her healing had happened on its own. Therapy, in her experience, had felt largely unnecessary; almost a graft onto a process that was already underway.

A comment on one of my posts pushed back harder. Couples therapy is a scam, she said: a way of keeping people stuck in relationships that should be over.

Both got me thinking.

I’ve been in this field long enough to know that some therapy is mediocre, and some therapists are poorly trained. Therapy isn’t immune to the same variations in quality as any other profession.

At the same time, these critiques miss something that’s probably more obvious from the therapist side: therapy isn't something that gets done to people. It's something people participate in, and the quality of that participation matters as much as anything the therapist does.

Decades of research suggest that what clients bring to therapy predicts outcomes more than any technique the therapist uses. *

Here are a few ways I’ve seen the client side play out.

– The articulate, self-aware client, who talks through their week with clarity, agrees with what needs to happen, does none of it, and returns the following week to do the same.

– Clients who are in so much pain that the gains are nearly invisible and unnecessary, for whom just staying in the room is progress.

– Those convinced therapy won’t help but who need to check the box, creating a self-fulfilling prophecy where expectation shapes engagement, and engagement shapes the outcome.

– Others have circumstances so unstable, such as a job loss, a sick parent, or a chaotic relationship, that treatment for the underlying condition becomes secondary to acute support.

– And some people simply struggle to form therapeutic alliance with the therapist, one of the strongest predictors of treatment outcome.

In couples work, these variables can double. When there are two people, there are two sets of expectations, two different capacities for alliance, and progress only happens if both partners are willing to fully engage. When one isn't, the work becomes something else: sometimes mediation, sometimes a reckoning.

And occasionally, it’s helping two people find their way to an ending with clarity, more quickly and with less damage than they’d have managed alone. That's not a scam either.

Good therapy creates the conditions for change. It opens a door. But what happens next depends on what clients bring to it: how willing they are to walk through, and what they do with the rest of their time outside the therapy hour. An hour a week of anything, without practice, has limits. My kid had years of guitar lessons. He still can't play.

So that may be what the skeptics are describing: the tool of therapy offered under the wrong conditions, or a door nobody walked through. Sometimes the therapist is the problem. Sometimes it's a bad fit between therapist and client. And sometimes it's the client.

*Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). Routledge.