When therapy stops working ?

Why understanding your past does not always mean you are free from it

After one of the most significant expansions in the use of psychological care in recent history, why are so many people still struggling?

I invite you to pause and reflect on the central issue of healing for those who have experienced trauma and carry the remnants of their past into their present lives.

1What the Pandemic Brought Into the Therapy Room?

Since the pandemic, Americans have participated in psychotherapy and other mental health care at elevated levels. In one large study of commercially insured U.S. adults, mental health service utilization was 38.8% higher by August 2022 than before the pandemic, alongside a dramatic shift toward telehealth delivery.

Since the beginning of the pandemic, I estimate that I have spent more than 7,000 hours in psychotherapy sessions and psychological consultations . And even today, stories connected to that period continue to find their way into the consulting room regardless of their current circumstances and mental health conditions .

Many came into therapy in the wake of sudden panic attacks and anxiety. Many sought help, unable to bear loneliness. Some lost their romantic relationships. Others started experiencing high levels of stress in their relationships, and they parted ways, even losing their livelihood in the middle of the pandemic. Many sought help because they either started using substances, drinking heavily, and/or relapsed in their recovery, resulting in poor anger management, sometimes emotional and physical abuse. Many coped with grief after losing their loved ones.

I myself did my grief work after the passing of my mother, who was ill for a long time, but the lockdown prevented me from participating in her last rites. I received immense support and care to grieve. I did not feel alone. I paused all my activities for a couple of weeks . Wait a minute. I am going to be brutally honest with you. I thought that, having done hundreds of hours of psychotherapy, real inner work, I had attained moksha, liberation from the pain of the past. But the passing of my mother in the middle of the pandemic brought out a stunning truth about my childhood: there was a “big part” of me that was still grieving the absence of my mother from the age of 6 to 17.

Yes, I have done the grief work, but my accomplishments as a professional and my effectiveness as a healing professional were not the ultimate closure. There is nothing called closure in grief.

I was surprised that my personal story and the work that I started undertaking with the utmost sense of responsibility brought me into direct contact with many others. While these experiences have been extremely hard for many individuals, couples, and families, some embraced their initial healing journey for the very first time in their lives. Some, for the very first time, started seeing a connection between pandemic-related anxiety and the emotional burden they had been carrying for decades. It was also painful for many to enter into grief.

It’s important to note that many of us understand our history, our ruptures, and past relationships, but still we are unable to break free from the past. People may not be manifesting their past troubled relationships or major interpersonal crises with their ex-employer because they’d done therapy, felt stable, and were ready to move on. In the case of work-related issues, they believe 4–5 EAP sessions worked magic for them to prepare for a new life. Of course, every mindful personal work creates emotional safety, but it’s important to reflect on, “How come I suddenly reacted the way I reacted 10 years ago?”

You thought you’d done several hours of anger management, but when you least expected it, you happened to crumble under pressure. In spite of the regulation and stabilization people experience, they lose it, and it robs them of their capacity to live and to assure themselves of safe practices and relationships.

What I notice is that many understand their childhood and their relationships clearly. Many of them come to seek psychological consultations and psychotherapy today not knowing what’s been going on, and for many, there is a growing sense of awareness about what went wrong. This is a significant observation across the chronological milestones. I am amazed at this evolution, understanding, and awareness of many. My amazement stems from the lack of awareness and understanding I carried for many years, which resulted in self-condemnation.

I admit I could not recognize my triggers and patterns before I spent a long time in therapy. In contrast, many I meet today recognize their triggers and patterns. They are able to recognize their voices of self-condemnation and self-blame and talk about the consequences of toxic relationships in their lives. Many of them have a language for what happens internally, while others learn to name their triggers and get in touch with their deeper emotions once they feel emotional safety in the presence of a healing professional. In spite of their efforts to heal , restore and move , something remains unchanged . I invite you to reflect on this critical issue in regards to healing and recovery through psychotherapy .

As a budding clinician, I even thought of changing my profession because it was a lot of inner work that I carried home from every clinical case.

2. What Does It Mean for Therapy to Work?

This brings me to a question I have wrestled with both personally and professionally: What do we really mean when we say therapy is working, or that it has stopped working?

Many of your familiar with the common structure and process of ‘ good enough ‘ therapy . Psychotherapy many a times starts with or without a medical evaluation of psychiatric assessment , but psychotherapy is expected to develop assessment for short term therapy and long term therapy , it develops short terms goals and long term goals respectively, but I wonder how far psychotherapy addresses more fundamental and unspoken questions, because many expect that after therapy they should no longer experience panic attack , anxiety , repeat an old relational pattern, lose their temper, feel grief intensely, or become triggered by events they thought they may not occur again . They have carry failed expectations from previous therapy sessions or there were missteps or lack of clarifications by the previous psychologist or other therapists . Sometimes , the central theme of my initial session included uncomfortable questions “I thought I had dealt with this. Why am I back here?”.

3. When There Are No Easy Answers

A clinician should not be in a hurry to answer “why” questions. Premature intellectual work to deal with a pain point can sabotage the therapeutic connection. I am ready and eager to sit there. I will not run away from their “why” questions. I know many questions do not have immediate answers or final answers in therapy and after therapy, but questions carry much more than questions. I am more keen on going to the underground of many unsettling questions. However , therapy must offer immediate ‘ emotional safety, which is the corner stone for building the work , if not therapy work might swept away from the sand with the incoming streams of waters .

I recall many years ago, while on call with a leukemia patient who had two questions for me in the ICU: “Am I going to die?” The other question was about his strange relationship with his younger sister. They had stopped talking to each other seven years ago, yet he had a question: “Can my sister be with me now?”

I felt helpless and filled with pain and sorrow with the former, but for the latter, I requested the ICU in charge to let his waiting sister join him in this terminal stage, and I witnessed therapy working.

Was therapy working there? If so, at what level was therapy unfolding for them?

Let’s remember something fundamental: therapy is more of a process than content. If nothing was cured, recovered, explained, resolved, or intellectually understood, in what sense might something therapeutic have happened? This is a critical piece in therapeutic work.

In this process, many unsettling dimensions can and will emerge. There are many questions and long-held assumptions: Can therapy help me live without anxiety because I’ve done a few hours of therapy? Will I ever lose my temper? Now I understand that my current conflict with my partner comes from childhood. Will I repeat those patterns? Will I be able to forgive my partner for his physical and emotional abuse because I’ve done therapy now?

It’s natural to have these survival questions hounding you while embarking on therapy. It’s not your fault. Are these questions inviting us to consider something else while attending therapy sessions?

Perhaps before asking when therapy stops working, we first need to understand what we have been asking therapy to do.

Perhaps the more difficult question is not whether therapy worked, but what we expected it to remove from our lives. Did we expect never to feel anxious again? Never lose our temper? Never to be reminded of an old wound? Never to grieve again?

My own journey has taught me to be cautious about such conclusions. Some of what I thought I had worked through returned to meet me again, not necessarily in the same way, and not necessarily asking the same thing from me.

Maybe healing is not always measured by what no longer hurts.

Perhaps before asking when therapy stops working, we first need to understand what we have been asking therapy to do.

Part 2 will follow on Wednesday.

We will explore what happens when understanding ourselves is no longer enough, and what this may guide us in the deeper work of therapy , consistency , emotional safety, psychological agency, growth and wellbeing .

Reference

Cantor, J. H., McBain, R. K., Kofner, A., Hanson, R., & Stein, B. D. (2023). Telehealth and in-person mental health service utilization and spending, 2019 to 2022. JAMA Health Forum, 4(8), e232645.