How does quality psychotherapy actually work?
- yourlistener249
- Jun 18
- 5 min read
Welcome to the April 2025 edition of the Your Listener Counselling newsletter! This month, I will introduce how psychotherapy works and describe some important qualities of good therapy. Given the vast number of therapeutic approaches and the variability in the quality of delivery, it is understandable that people may be confused about what to expect in therapy. Here, I aim to settle as much of this confusion as possible, while bringing attention to some common mistakes in therapeutic practice.
First, we must understand that psychotherapy is based on a scientific concept known as "reification", meaning that it involves treating something abstract or theoretical as if it is physical and can be experienced by the senses. Our thoughts, feelings (collectively known as "mental processes"), and their interaction with the body are the abstract events. We definitely know that our mental processes are real, but due to how the mind works, it is common for people to struggle to describe them, and we could not work with them unless we assigned them qualities and treated them as if they were physical and could be changed. In reality, we could argue that every mental process and changes in same are controlled by physical brain activity — as I often quip, just ask yourself if a person could think and feel with their brain removed. But psychotherapy usually is not practiced from the reference point of neurology. Instead, psychotherapy essentially works on the power of suggestion. When the client believes in the process and undertakes the involved exercises and routines, the changes in their mental processes and behaviours (actions) which they deliberately make have a reciprocal influence on each other. This equips the client to cope with challenges so that they become less of an impediment, or the changes may self-perpetuate so that they become habits that replace their previous functioning. As such, a number of factors must be present for therapy to be effective.
The client must be able to make sense of how the therapy explains and treats their problems. There are numerous psychotherapeutic approaches from both different and related schools of thought, and many of them could be effective in treating a single problem if they are delivered well. A known mistake is for therapists to try to force their preferred framework to explain a client's problems, which is often not only nonsensical to the client, but also feels rather abrupt. If we were to immediately tell a depressed client that their problem is their unconscious sexual attraction to their mother, there is a good chance that they would not return for another appointment. We would likely achieve the same result if we were to immediately lecture the client on how depression happens when we make the wrong choices. Many therapists dogmatically maintain, as is dictated by their favourite approach, that "only the here-and-now matters", without regard for the client's history. Regardless of a client's knowledge of psychology, they will often recognise when we have made these mistakes. Remember that psychological theories are invented by humans in an attempt to explain the basal workings of nature; no human nor creation of same has the ability to dictate those workings simply by conceptualising them in a given manner (this is a shortcoming of reification).
Hence, competent therapists treat therapeutic approaches as sets of tools rather than self-sufficient laws. This means using the client and their needs to guide which techniques we use. We first explore the client's concerns, ask questions, and establish their history, context, and their goals for therapy. History is important, as many problems are most credibly attributed to past experiences. It is concerning when therapists take what their clients tell them on face value without asking questions about what is unsaid. Perhaps they fear taking emotional tangents, or have been taught by their systems that asking about traumatic events could harm the client. Regardless, an effective therapist supports the client to complete their contextual story, explore their past experiences, and learn about themselves — remember that while the client is an expert on themselves, the therapist's expertise is on the workings of the mind, and the client is trusting us to teach them what they do not yet know. Once done, we explore the psychological theories that best explain the development of the problems in question, in language and at a pace appropriate for the client. Again, we must not exclude educating our clients on the nature of their problems and how the therapy is meant to help. If someone does not understand "why", then understanding "how" will be unnecessarily difficult. We then suggest a therapeutic approach and explain its purpose, and we conduct it with the goal of teaching the client accessible strategies, in the form of actions they can take regularly, to help them address their problems and achieve their goals. This is done with constant consultation with the client about how they feel about the therapy, and if any changes must be made to make it more relevant or accessible to them.
Also critical are the therapist's qualities. The therapist must first and foremost be sincere. As obvious as it is that this should not be so, too many personal experiences and accounts relayed to me have involved therapists being unaware (or aware, even more frighteningly) that they present to their clients as dismissive, patronising, or accusatory. We must also be relatable and have human qualities. While psychotherapists must be calm and objective, it is too common for them to not demonstrate appropriate emotional responses to clients' experiences, challenges, or sensitive issues, appearing indifferent or disconnected and ignoring the opportunity to empathise. I imagine this is because we are taught to be "unbiased" and not to "collude" with clients. But to work with people, we must have the wisdom and nuanced judgement to know when to be partial to a particular idea because it holds intrinsic truth, and not doing so would constitute ignorance of the client's struggles. To the client who has struggled with social services, we may sigh and respond: "I know the system's a nuisance! I'm frustrated for you too." To an abuse story, we may respond with: "what a nasty thing to say! I'm sorry you had to endure that." There are also opportunities to share humour with clients. None of this permits being unrestrained and impulsive in our communication, nor feigning empathy, and we can not provide absolute rules for when certain responses are acceptable or not. When we choose to be helping professionals, we must accept that we rely on our own care, nuanced judgement, and healthy emotional boundaries.
Being a counsellor can be a complex endeavour, and rigid rules are insufficient — one must have fine judgement and be constantly adapting to even a single person's changing needs. We must present to our clients as human first and foremost, and take it upon ourselves to help them learn as much as they can about themselves so that they can address the challenges they face in the process of living the lives they want, as independent people.