What Therapy is Really Like

If you do any streaming at all, you’ll know that therapy has become a lot more popular. In 2024, 14% of U.S. adults said they had received counseling or therapy from a mental health professional in the previous year. In 2019, that number was 9.5%.

You can see the change pretty easily. There are therapists everywhere, along with online therapy platforms, mental health apps, podcasts, books, coaches, influencers and a million opinions about what the rest of us should be doing to become our “best selves.”

I’m a therapist, so obviously I’m in favor of therapy. I’m also a little skeptical of the current mental health and wellness zeitgeist. Not everything that makes you feel better is therapy, and not every difficult feeling needs to be fixed, processed or turned into a personal growth opportunity.

Therapy is more complicated than that.

The NYT offered four things to consider before starting therapy. I agree with the basic premise, but after spending a fair amount of time on both sides of the therapy room, there are a few things I’d add.

1. The relationship matters more than you think

There are a lot of therapy modalities. CBT, EMDR, ACT, IFS, psychodynamic therapy and plenty of others. Many are useful and have good research behind them. It makes sense to look for someone with experience treating the particular problem you’re dealing with.

But I wouldn’t spend too much time trying to find the perfect modality.

Irvin Yalom, the psychiatrist and psychotherapist whose writing has influenced generations of therapists, wrote about this a lot. His phrase, “It’s the relationship that heals,” comes from Love’s Executioner, where he calls it his “professional rosary.”

There’s quite a bit of research behind the idea, too. The quality of the therapeutic relationship is consistently associated with better outcomes across different kinds of psychotherapy.

This makes sense when you think about what therapy actually asks you to do. You’re sitting with another person and, eventually, telling them things you may not have told anyone else. You need to trust them enough to be honest. You need to feel that they’re paying attention. You need to be able to tell them when you’re annoyed with them or when you think they’ve completely missed the point or aren’t fully present.

That last part is very important.

A therapist can have every certification imaginable and still not be clicking for you. The relationship is not some nice extra that comes along with the treatment. It is a big part of the treatment.

2. Therapy is not about advice

This comes up all the time. Clients ask us what they should do. Should I take this job? Should I move? Should I talk to my sister? Should I leave my marriage? Should I stay with my spouse?

I understand the impulse. When you’re confused, sometimes you want someone who knows what they’re doing to just tell you what to do.

But that’s not really our job.

And this is where I think it’s important to distinguish therapy from life coaching without taking anything away from educated coaches who are staying in their lane. Therapists are trained and licensed to provide mental health treatment. Life coaching is a different profession with a different scope. They shouldn’t be treated as interchangeable.

Therapy is also not about having a therapist make your decisions for you.

A good therapist shouldn’t give you a steady supply of advice. We’re supposed to help you figure out what you think, what you feel, what you want and why you keep getting stuck in the same places.

We all have our own answers. Unfortunately, they can get buried under family expectations, fear, other people’s opinions, old habits and the stories we’ve been telling ourselves for years. Sometimes the hardest part is figuring out which voice is actually yours.

3. It’s supposed to be a little uncomfortable

This is something I wish people knew before their first appointment.

Therapy can feel awkward.

You’re meeting a stranger and then, over time, you’re expected to talk about your childhood, your marriage, your sex life, your parents, your anger, your insecurities, the thing you did that you’re embarrassed about or the thing someone did to you that you’ve never quite gotten over.

You may spend the first few sessions wondering what your therapist thinks of you. You may find yourself telling a story and suddenly realize that you’ve never actually said it out loud before. You may cry when you absolutely did not intend to cry.

None of that necessarily means something has gone wrong.

You’re getting used to the idea of telling your innermost thoughts to someone who was a stranger a few weeks ago. That takes time.

Therapy is also supposed to uncover things that are uncomfortable. If every session leaves you feeling reassured, validated and completely certain that everyone else is the problem, I’d have some questions about that.

That doesn’t mean therapy should feel bad or that you should stay with a therapist who makes you feel unsafe, dismissed or misunderstood. There’s a difference between productive discomfort and a bad therapeutic fit.

4. You actually have to participate

We can ask good questions, notice patterns, offer perspective, teach you skills and help you see something you’ve been avoiding. We can’t do the work for you.

You also don’t have to arrive at your first appointment knowing exactly what you need. Most people don’t. Sometimes figuring out what’s wrong is part of why you’re there.

What helps is being willing to be honest, including when the honest answer isn’t particularly flattering.

Maybe you’re contributing to the relationship problem you came in to complain about. Maybe the thing you thought was making you miserable isn’t actually the thing that’s bothering you. Maybe you’re asking your therapist for advice because you already know the answer and don’t want to be responsible for making the decision yourself.

Those are useful things to discover.

Therapy isn't supposed to make you feel good all the time

I realize that sounds like an odd thing for a therapist to say, especially at a time when mental health has become part of the wellness industry and everyone seems to have a morning routine, a therapist, a meditation app and a favorite word for their “journey.”

There is nothing wrong with wanting to feel better. That’s one of the reasons people come to therapy.

But therapy is not a weekly appointment where someone tells you that your feelings are valid and sends you home feeling better about yourself.

Sometimes you will feel better. Sometimes you’ll feel worse before you feel better. Sometimes you’ll be annoyed with your therapist. Sometimes you’ll realize that the problem isn’t quite what you thought it was.

And sometimes you’ll have to sit with something for a while before you know what to do about it. That’s what doing the work looks like.

The best therapist for you may not be the person with the most impressive website or the most fashionable therapeutic modality. It may be the person you eventually trust enough to tell the truth to, including the truth you don’t particularly like.

I think that’s an accurate description of good therapy.