“It is nice to have somewhere to talk about my problems, but is that the point of therapy?”
“I mean, I like my therapist, but I have no idea what she means when she tells me ‘I made progress today.’”
“If I’m walking out of therapy feeling worse, does that mean it’s not helping me?”
As a psychiatrist, these are some of the frustrations I often hear in my office. For me, these conversations either occur while I am trying to encourage people to try therapy, or while I am trying to advocate for them to stick with therapy.
It’s very common for people to question the efficacy of psychotherapy. The thing about therapy is, it doesn’t work the way, say, a medication might, where when you have symptoms, you take a drug targeting those symptoms, and hopefully, after some amount of time, those symptoms go away. Therapy is more about taking the time to look for and treat the source of the wound.
It can be hard to understand what therapy is targeting, or how it is doing so. It’s not as clear when it “works” or does not work, or if you are getting better after some amount of time. Therapy comes with a pretty strong sense of the unknown for a lot of people, and it can be uncomfortable to put your trust in a seemingly vague, non-linear process.
For any of you doubting the process or feeling like you’re in a state of confusion (or simply waiting it out with your therapist and hoping to have an epiphany!), I want to help clarify the nuances of improvement and success in psychotherapy.
Hopefully, this way, you will know what to ask your own therapist, as well as what to look for in your own experiences moving forward.
So, what does success look like in therapy?
Part of what makes success in therapy so difficult to measure—or even explain—is the fact that success means different things to different providers, in different kinds of therapy, and for different diseases or purposes.
“This question is complicated because it is individually defined and depends on the therapy modality. There are over 200 classified mental health conditions and some clients [even] initiate psychotherapy [simply] for self-enhancement,” Kristine Luce, Ph.D., a psychologist and clinical associate professor in the department of psychiatry and behavioral science at Stanford University School of Medicine, tells SELF.
There are approximately 14 recognized types of mental health professionals who are trained to provide various therapies or counseling in the U.S., she notes. So, there are probably thousands of iterations and possible responses to this Big Question (which is why I asked some fellow mental health professionals to weigh in on this topic too).
Also, the answer for any one person in therapy greatly depends on what they sought treatment for (their health and personal history, symptoms, goals for treatment, background) and who they are receiving treatment from (how they were trained, what kind of therapy they practice, and what they might look for in a patient for improvement). For example, measuring success in cognitive behavioral therapy for social anxiety would look very different than the metrics for success in couple’s therapy for marital discord.
Goals and successes in psychotherapy can also change over time, as therapy itself is a very dynamic process.
Like the conversations in any relationship, what gets discussed in therapy initially might be more surface level until the individual gets more comfortable. A person’s goals might also start off as more surface level (e.g. “I want to sleep better”). But what comes out over time through your work together could be a deeper, causal understanding of these symptoms (think: “I am not sleeping because I experienced a trauma and am having nightmares from it”), which in turn, could alter the goals for therapy, what improvement would look like, and might even change the type of therapy someone receives.
The therapist also learns a lot about their patient from the behaviors, patterns, and thoughts they exhibit in session, which can dictate what “success” looks like. Those 50ish minutes serve as a mini model of how the patient acts in the real world. By observing the patient over time, and coming to know them, a therapist will only better be able to point out what they witness or make interpretations of what these behaviors or thoughts might mean.
For instance, a therapist might notice you change the topic every time your partner is mentioned. After seeing this a few times, a therapist might say, “I notice that every time I ask about your partner, you change the topic,” which can open the conversation up for discussion on the meaning behind this and might, in the future, allow for greater awareness or understanding. The patient may have previously been completely unaware of these behaviors, thoughts, or interpersonal patterns—so this type of awareness, insight, or behavioral modification that might be considered a “success” in therapy would be kind of unexpected and hard to predict upfront.
There are a few common ways to assess your progress in therapy.
Ultimately, successful therapy means that your symptoms seem better managed or are decreasing, and you feel like you’re accomplishing your current goal(s) or raising your self-awareness outside of therapy. But let’s unpack this some more.
If you went into therapy symptomatic, like to deal with anxiety issues, you can look at whether your symptoms have decreased, or if they are interfering with your day-to-day activities less frequently. For example, you might feel less anxious, you might have less frequent panic attacks, or you might be sleeping more hours a night.
Sometimes therapists will use objective measurements in session to help monitor symptoms and clearly demonstrate improvement. A common example of this is a scale used to assess the improvement or worsening of depression called the Patient Health Questionnaire (PHQ-9).
You can, however, easily track your symptoms on your own outside of session. You might do this by ranking your anxiety each day on a scale of one to 10, and tracking that. Or, if it applies to you, you could also keep track of the number of panic attacks you have, how long they last, and how distressing they are on a scale of one to 10. (This information also helps you and your therapist better understand the context of your symptoms and look to establish triggers or patterns when you get worse or better.)
Keep in mind that this will not be perfectly linear, and sometimes you can have bad days or even weeks. The dips or plateaus you might witness as you track your symptoms do not mean your progress has stalled or therapy is not working. It’s more important to pay attention to the greater trends and not obsess over the details of the day to day changes.
Another measure of success is behavioral change. Luce notes, “Because of the disorders I treat and the therapies I use, I am generally measuring progress by behavior change—decreasing binge eating and purging for bulimia, increasing social or performance tasks for social anxiety.”
For a person with depression, for instance, behavioral changes that may be noticeable include getting up and out of bed more often, the ability to socialize and not isolate, and/or, depending on severity, the ability to function through daily tasks like showering, eating, and getting dressed more regularly and consistently. Behavioral change is by no means easy, but it does feel like a success when it is attained and gradual improvements are noticeable.
But keep in mind that not all progress will be obvious and tangible.
Other “metrics”—like developing your self-awareness and insight—are measures that probably bother patients the most because they feel less tangible. Say you’re receiving therapy that’s insight-oriented: Success would mean that your insight has deepened. In other words, you understand yourself, your feelings, and your behaviors more than you did before therapy started.
Another helpful measure to look at is whether you’re actually implementing the mental health tools you’re learning. “You also know therapy is working if you are doing the skills you have learned in session outside of session and seeing that it works or helps,” Jessica Dyer, LCSW, staff counselor at Washington University in St. Louis, tells SELF. This might feel similar to behavior change but tends to be a bit less objective. “Therapy [might be] working if you are able to set better boundaries, trust yourself and your decisions without reassurance seeking, validate yourself and others, or prioritize your needs and demands in a more balanced way,” Dyer continues, adding that she’ll sometimes even require patients to track specific things outside of session that can increase awareness about their own improvement.
For example, Dyer might have a patient do a “diary card” every day between sessions in which she has them track multiple emotions, behaviors (self-harm, suicidality, other problematic behaviors impacting one’s quality of life), their interactions with others (e.g. who they lost their temper with), and what skills they used in the moment (e.g. deep breathing instead of self-harming). In these instances, awareness itself—of a thought, feeling, or behavior—can be a marker of success.
Additionally, therapy may be working if you feel you do not need to be seen as regularly, your problems do not feel as urgent, or you generally feel better able to cope on your own. But it is important to realize that it can take a long time to accomplish one’s goals. “Many people are surprised by how long it can take to accomplish the goals they have for therapy,” Riley Cropper, Ph.D., a clinical psychologist at Stanford University, tells SELF. “So you may not reach that goal right away, but if you feel that you are making progress toward it, that is a good sign.”
And, surprisingly, sometimes feeling worse is actually a measure of success.
Without sounding cliché, you will often feel worse before you feel better. Luce notes, “Change is hard and can hurt. Good therapy doesn't always feel good because it often requires patients to look at and change long standing patterns of behavior.” Therapy also requires patients to deal with everything they have been avoiding (topics, emotions, people), and that can cause a “spike in painful emotions,” Dyer says—and you don’t want this to discourage you from continuing treatment.
The end goal for therapy is also not simply to “be happy” and never experience other emotions, like sadness or anger. “Progress in therapy loosely means you are allowing yourself to observe and experience all your emotions,” Dyer says. “Getting to a perpetual state of happiness is not reality. Happiness is one emotion of many. You also can’t feel happiness and not feel pain.”
It’s perfectly acceptable to ask your therapist what progress might look like for you.
Given how challenging and broad it is to define and measure success in therapy, it’s a good idea to discuss your specific treatment goals with your therapist upfront, and ask lots of questions moving forward.
First, you’ll of course discuss with your therapist what brings you there, and what your specific goals might be. (If you’re not totally sure, that’s also OK, and your therapist will help you talk through these things.)
Then, ideally at the outset of therapy, the individual (or family, couple, organization, etc.) and provider also mutually agree upon a definition of progress that both parties can evaluate over time. I suggest going as far asking your therapist directly: How will I know if this is working or if I am improving?
Cropper says, “As a provider, there are many times where I use measures of different symptoms to gauge how the patient is doing or if they are improving, but I also aim to check in with the patient directly and have a conversation about whether the treatment is helpful or if there are aspects that are working for them and others that are not.”
And if, as your time in therapy goes on, you're unsure about what your therapist is talking about when they say things like, "This was great progress today," it doesn’t hurt to ask them straight up what they mean by that.
“You want to be on the same page as your provider, especially when it comes to the goals for treatment and the progress you're making,” Cropper says. Also, she adds, “If they are making comments about you making progress and you do not feel like you are, I encourage you to ask what they are basing this on. Therapy can be difficult and uncomfortable so you may not always feel like you're improving or making progress, and this is why it is important to check in with your provider about your goals and progress throughout the course of treatment.”
As therapists, we also try to be mindful of the words we use, and even the nods or body language we exhibit. We know everything is analyzed and interpreted by a patient and do our best to consider what a patient might think about a reaction before we do or say something. We try not to give validation or encouragement by accident.
We are also humans, and even though we do try to think about what we do or say, we’re not always perfect. So if your therapist says something (or perhaps nods at something) and you’d like to know why, always ask. You want to build a therapeutic relationship where asking questions and asking for clarification or more explanation feels safe and normal. That might take some time, but it should exist. Perhaps that, too, is a measure of a successful therapy.
Jessica A. Gold, M.D., M.S., is an assistant professor in the department of psychiatry at Washington University in St Louis. Find her on Twitter @drjessigold.