How does Psychotherapy work?

By Joseph Sacks, LCSW

Are you an adult living with anxiety, depression, family conflict, or other mental health issues? Did you ever wonder how does psychotherapy work? How can very real, even physical, symptoms be relieved simply by talking to someone?

The truth is that psychotherapy is a medical treatment that can bring about a great reduction in the presence of emotional health problems as well as their effects.

How does psychotherapy work?

The first fact we need to understand is that mental health problems are not genetically or biologically-based! Instead they are caused when a person born with a sensitive temperament has experienced certain early childhood stressors. That's the simple truth. Problems in childhood are the real causes of emotional illness in adults. By the way, many people automatically assume that they had a perfectly happy childhood, and come to therapy reporting a trouble-free childhood, only to discover that their childhood actually involved difficulties that were repressed, causing painful memories to be overlooked and buried.

This is actually fantastic news! If I were to tell you that all emotional illness is in-born, there would be nothing you could do to prevent it, and little you could do to cure it, as you cannot change your genes and your biology. However since mental illness is really caused when healthy people are adversely affected by their environment, changing one’s emotional environment through psychotherapy can completely reverse the process and bring about a major cure. We need to simply recover from the mistakes made in our childhood.

In considering how does Psychotherapy work, we need to remember that emotional illnesses such as anxiety, depression, ADHD, OCD, schizophrenia and most others are actually natural responses to early childhood stress.

They are the by-product of the attempts of the body and mind to survive and resolve difficult trauma. It is critical to remember this point! Erroneously calling mental illness genetic makes patients feel naturally sick and defective, and prevents them from having hope to recover, but, understanding the true cause of your symptoms is immensely relieving, empowering and healing. What are the psychotherapy steps involved in this healing process?

Step one: Knowledge is Power!

All good treatment of emotional illness begins with what is called psychodynamic psychotherapy. This means we must fully understand what is causing our symptoms, to unravel, step-by-step, the chain of events that led to and generated the condition from which you may be suffering. 

This is done in therapy by first taking a detailed emotional history of your life, starting with your early childhood. Since the absolutely most important element in any child's life is his relationship with his parents or early caretakers, this history will focus on every detail of that relationship. How did his parents treat him? How did they speak with him and relate to him emotionally on a daily basis? How did they discipline him? How was the marital relationship between partners? Was there stress and conflict in the house? Did his parents suffer from emotional illness which they may have passed on, not genetically but in maladaptive behaviors expressed through the environment? It is important to note that we do not blame the parents for the problem, as they were usually loving and had good intentions. However we do attribute cause to them. That is, they unfortunately made mistakes which had a serious effect on the young child.

 This first step is purely intellectual. You need to get a concrete understanding of the events in your childhood, paying careful attention to any stressors, traumas, mistakes in child-rearing, or forms of abuse suffered, if any. Being ill and not understanding the reason makes the suffering much worse. But just understanding the reason behind your condition already brings tremendous relief.

Step two: understanding your emotional history

The next question we need to ask is how you felt during the various stages of your childhood? How did it make you feel when your parents had marital conflict? How did it feel to be partially abandoned or neglected by one parent? What about verbal, physical or emotional mistreatment such as frequent criticism? What emotions did this generate in you as a child? We must remember that as a matter of survival most painful emotions children experience are repressed, because a child is too emotionally fragile to handle them consciously. These repressed feelings are real and strong, and fester in your unconscious for the rest of your life, often generating mental illness. Therefore it is important to discover those repressed emotions, and to gain conscious awareness of them. What fears did you feel as a child? How were you shamed or embarrassed? And, most importantly, how were you angered? 

Anytime a person, including a child, is hurt, even through an innocent mistake, the automatic and natural human reaction is anger! If you were hurt or mistreated by someone in any way you will remain angry until those feelings are processed. If you're not aware of your anger, that means it must have been repressed. In addition, children are often made to feel it's unacceptable to express their anger. When anger is not expressed, it is usually repressed where it lingers for a lifetime and causes emotional health problems.


Step three: mourning and grieving your childhood trauma

Now we begin the most important step. When a loved one dies, people mourn and grieve. This is not just a reaction, it is a God-given process that actually allows you to heal from the trauma of the lost loved one. Many different cultures have different customs for mourning such as wearing black, wailing or crying. Reviewing these custom are very instructive. In one particular culture, when a loved one dies the bereaved spends an entire week at home, doing nothing but mourning, that is consciously and purposely thinking about his loss. All kinds of actions are taken to constantly keep his lost love one in the forefront of his consciousness, thus keeping his mind focused on his grief. While many visitors come over to comfort the mourner, it is customary for them to avoid talking to him about anything except his loss. That is, the way they comfort him is by keeping him thinking about his loss! 

This may actually seem counter-intuitive. One might reason, “Your loved one is gone, there is nothing you can do to bring him back, so you have to move on. You have to get over it. Go to work, keep busy, distract yourself.” One might think the bereaved should be cheered up and so helped to move on and get over it. However the wise custom just described teaches us that the opposite is necessary. You must spend an entire week deeply morning and grieving your loss by thinking about it and processing it as much as possible. That is the path to healing. By mourning deeply, you are assimilating the fact of your loss into your conscious awareness. This is extremely healthy. 

How does it work? When a person has a trauma for which he has not grieved and assimilated into his conscious awareness, he will temporarily forget his loss, at least at times. Then he will periodically and inevitably be reminded of it and since he was not truly conscious of it at every moment, that refreshing of his memory will be experienced anew as a traumatic event. Since it was not deeply assimilated into his consciousness, he will constantly be shocked by the thought, “Yes she's gone” and this will cause a physical and emotional trauma reaction. Over time this constant reaction generates mental health problems. So by trying to push the loss out of his mind he sets himself up to be re-traumatized every time he is reminded of it. But paradoxically, by purposely thinking about it and dwelling on it, by mourning and grieving, the memory becomes so etched into his consciousness that it can never surprise him and re-traumatize him. The fact “She’s gone” becomes as simple and obvious a fact as “I live in New York.” Therefore it can’t cause him any mental health problems.

As a personal example, my dear friend’s father tragically died very young. I paid a visit to comfort him and while there he asked me to pay a visit to his mother as well who was also deeply mourning. Unfortunately, I forgot to do so immediately and only remembered a year and a half later. But I said, “Better late than never” and I called up his mother and told her I would like to offer my belated condolences. Her reaction was amazing. She just said, “Oh my husband’s gone, but it’s fine now. I have a wonderful son to make up for it.” She did not accept my condolences at all because she absolutely did not need them. She was so completely healed from the trauma of her husband's loss that there were no more hurt feelings that needed to be consoled. There had been a huge response from her community, hundreds of people had comforted her and helped her to mourn and grieve during the year after her husband’s passing, therefore she was completely healed, needed no further mourning and suffered no more ill effects from her loss.

The loss of a loved one is tragic. However having gone through a troubled childhood is a much greater tragedy and trauma! It is devastating to the very fabric of your self. Therefore the most important part of healing mental illness is to mourn and grieve deeply the unfortunate events of your childhood. This is done after you have gained intellectual awareness of those events and their emotional effect on you. Childhood trauma that is not mourned sizzles in your unconscious and constantly re-traumatizes you, generating continuous mental health symptoms. The memories bubble up constantly and since they are ungrieved, they constantly shock you anew.

However since the truth of a tough childhood is a much greater tragedy and loss than the loss of a loved one, It will require more than just a few weeks of mourning. Furthermore the mourning must be somewhat gradual so as to not overwhelm you. I recommend to patients to start off with a period of time, lying on your pillow crying and grieving, “Why did it have to be that way? Why did they have to hurt me? How could they do that to me? Why didn't they take care of me? They hurt me so much, I suffered so much.” You must truly, deeply and consciously become aware of the monstrosity of the mistakes made to you in your childhood, as well as their effects on your life and how they generated your present emotional issues and all the deep problems that go along with them. You need to also do this in the presence of your therapist. His reflection of your experience will help you bring it into your consciousness. Becoming aware of childhood trauma is the greatest realization you will ever have in your life! It is further helpful to share this realization with friends and loved ones whom you trust, which is similar to a mourner being comforted by friends and neighbors.

The more you mourn the better, every bit helps, but after six months to one year you will begin to experience major relief.

Step four: processing your anger

As I said above, anger is an automatic human reaction to being hurt, therefore anyone who suffered child mistreatment is sure to have deep, buried angry feelings that are causing emotional disorders and disrupting his functioning. Therefore in addition to mourning you need to recognize and become consciously aware of your angry feelings. This is difficult because many people are not comfortable with blaming their parents for their problems. Therefore, as I said above, I need to advise you that we do not blame them. There is a difference between assigning blame and guilt on the one hand, and identifying causes on the other. We do not blame your parents for the mistakes they made, as they did the best they could, considering the difficulties that they undoubtedly experienced in their own childhoods. 

However we simply recognize cause; they were well-meaning and well-intentioned but unfortunately they made serious mistakes which caused you much suffering and trouble, and it is automatic that's such mistakes generate anger. The way to actually resolve and get over that anger is paradoxically to give it a voice, to recognize, feel, process and become aware of it. Therefore you must again rage into your pillow for a period of time. It sounds controversial, but you must engage in fantasies of justice being carried out to those that hurt you, at least in your mind. You need to imagine them paying for what they did, because only by truly recognizing the need for justice can you become aware of the truth of the effects of what was done to you and mourn, grieve and be healed. Again all this work needs as well to be done in the presence of your therapist.

Step five: seek an admission from those who hurt you

Parents, even of children who are adults, possess tremendous power to influence the psychological reality of their children. If a parent made mistakes raising their child and they refuse to admit and recognize their mistakes, that is they deny they ever made any, the child even as an adult will tend to deny the mistakes as well. No matter how much mourning and grieving he or she does, if there is no admission, in the back of his mind the patient will think: “Maybe they really didn't do anything wrong, maybe I was the bad one.” This will seriously impede his ability to mourn, grieve, express his anger and heal. Therefore if your parent is still alive it will be immensely helpful to ask them to recognize their errors, admit their mistakes and yes, to apologize. There need not be any kissing up or groveling, just a simple recognition of the truth. The parents’ admission is critical because it shatters the illusion that you had a perfect childhood.

However in order for this admission to be successful you need to approach it with great wisdom. You need to first mourn, grieve and rage for a period before approaching your parent. You must first process the trauma until it is somewhat resolved so that you can approach your parents in a calm non-adversarial manner, because if you feel the need to attack the parent they will just get defensive and will not admit anything. Next you need to explain to your parents how that which you are about to do will greatly benefit them. You have to show them how they will benefit, to explain to them that you would like to have a loving, warm and meaningful relationship with them and that there is something that they can do which will be immensely helpful for you, and will allow you to develop that immensely mutually beneficial relationship. Usually, when approached in this way parents are willing to help. If you suspect they might not be willing, then you need to wait and give them more time, and approach them some time later. When you feel the time is right you need to explain to them that although you recognize that they loved you and they did the best they could, they did unfortunately make some mistakes which had an effect on you, and it would be immensely helpful to you if they would admit and recognize their mistakes. Start off with one mistake and very calmly make them aware of it, and see their response. I know someone whose mother, in a five minute phone conversation admitted, “The truth is I just didn't know anything about parenting, and I'm sorry for the way I raised you. I'm sorry I hurt you. I hope you'll get better.” Just those few phrases were so immensely healing for that person and it resulted in a significantly stronger cure of his emotional illness and in addition resulted in the creation of a wonderful adult relationship between mother and child.

If the parent is unwilling to admit his mistakes it pays to wait and try again later. One should never give up hope for resolution with a parent, and one should never cut off the relationship. An admission is so valuable to your mental health that it is worth pursuing as long as the parent is alive.

If the parent is not alive, you need to imagine yourself having this conversation with him or her to such a deep extent that you can assume if he had been alive he surely would've admitted his mistakes. This will bring healing.

Step six: re-structuring your unhealthy thoughts

The above work is psychodynamic. This fifth step is called cognitive behavioral therapy or CBT, and may be undertaken gradually and concurrently with the above work. However there are many therapists who will advise you to do only CBT and not psychodynamic work, and that is a great mistake. CBT only works if you first understand where your emotional illness is coming from and have mourned and grieved for it.

How does psychotherapy work with CBT?

Childhood trauma creates many unhealthy and erroneous thought patterns. Take for example low self-esteem. If a child's parents fought often the child usually thinks: “They are fighting because I am bad, if I was better they would get along.” This creates deeply entrenched thoughts that “I am not worthy, I am no good” Any kind of mistreatment creates a similar response of low self-esteem. We need to cognitively challenge those thoughts by bathing them in the light of reason. We need to question, “Was it really your fault that your parents fought? Was it really a sign that you were no good?” We need to understand and recognize the truth that a child is born completely good and innocent and is at fault for nothing. We need to constantly review this thought and use it to challenge our thoughts of low self-esteem. If a child was criticized or put down by his parents we need to cognitively challenge the truth of those critical statements made by the parent. Were you truly so bad and worthy of criticism? Of course not! All children deserve to be treated with the upmost respect by their parents. Nothing is the child's fault. We need to go through all the unhealthy thought patterns in the adult mind and reframe them in the light of the psychodynamic truths of his history. Furthermore we need to emphasize the fact that you are not defective, there's nothing wrong with you, your symptoms are a normal and healthy reaction to childhood trauma.

For a discussion of a common pitfall of low self-esteem, click here.

One great technique was developed by Dr. Mayer Wickler of Brooklyn. The patient should journal two good things that he did each day. They should be meaningful accomplishments in therapy work, personal growth or acts of kindness he has done to his family and other people. At the end of the month he will have 60 good things recorded and he should review them intensely in therapy. This creates a tremendous cognitive challenge to feelings of low self-esteem as the person sees all the wonderful things that he has done. This can truly heal the lifelong wounds of childhood trauma.

See my helpful post: How to change negative thinking, here.

One more tip is to engage in bibliotherapy. Reading such great authors as Alice Miller, Susan Forward and Jonice Webb will be immensely helpful on your journey. I can recommend to you exactly with which books to start with.

However there is one more important thing to be aware of. You may not be ready to engage in the above work right away after starting therapy. You might be advised to first take months to just get to know your therapist, and receive support and validation of your feelings. Then wait until your childhood trauma becomes an issue that you feel a great desire to bring up, that the issue arises organically. That is a sign that you are ready for it. But if you explore your childhood too soon, you may be overwhelmed and it will prevent healing.

Now that you have a general answer to the question of how does psychotherapy work, never underestimate its great power.

Even schizophrenics and other psychotic individuals have been healed by it. It will take a bit of time, but you will see major improvement. It all depends on the extent of your childhood trauma, the depth of your emotional health symptoms, the skill of your therapist and most importantly, your bravery and willingness to embrace the truth and to truly heal. If the task seems overwhelming you should realize that you have many years of life left to live and a moderate period of time is not so great an investment, when you recognize that you'll be left with wonderful emotional health and interpersonal relationships for the rest of your life!

If you would like the guidance of a warm, empathetic psychotherapist to help show you how psychotherapy works, and to take you through this journey to healing, you may call me at 646-681-1707 for a free 15-minute consultation. I look forward to speaking with you!

For a discussion of the causes and treatment of perfectionism, click here.

For more information on perfectionism treatment, click here.