My Top 10 Cornerstones of Successful Therapy

“Doc it feels like a fairy tale to me. How Rahul (names changed to maintain confidentiality) and I have come through such turbulent times and now we are in calm waters, back to how we were, maybe even better, before we went through the challenges of the past two years.” Shreya said this recently in a marital therapy session with the three of us present. They both expressed how grateful they were that I helped in so many ways. And I, like always, put the success of the sessions back onto the clients I work with, because it is their persistence, patience, strength, fortitude, and the sight of the goals despite the tough process that makes the journey meaningful for them and for me in a way. I have seen this more so for the couples I work with. If they know they want to make it work, they literally go through the fire and come out unscathed and happier on the other side, because there is so much at stake.

I will be honest. Therapy sessions are no cake walk when done right. It starts off with people feeling extremely vulnerable as they reach out for a person who they have to learn to trust with their inner most world. “How can I bare my anxieties, angst, frustrations, problems, my core to a person I just don’t know?” “Will I be judged for seeking out help?” “Am I so weak that I can’t deal with this on my own?” And yet they realize that the mounting burden of their miseries far outweigh the rawness they feel in their gut and they make that first contact with someone like me.

Healing is a journey whose trajectory is unknown. There is no straight line from point A to point B in most cases, I have seen. And using this example of the fairy tale, let me write about what actually goes on behind the scenes in therapy, what factors determine outcomes of those sessions, what about people like Shreya and Rahul who have gone through so much in two years makes them finally see the light at the end of a dark tunnel which often had obstacles thrown in the way too. These observations hold true for individual therapy as well as couples therapy and I may use examples of either/or as I write along.

Here are my “Top 10 recommendations for making therapy successful”

For what specific reason(s) am I seeking therapy? Am I on the same page as my partner on the aspects we need to work on? Is it improving communication and conflict management skills, building emotional intimacy, working through an incident (or a series) which caused the relationship to fracture, figuring out whether they have it in them to make the relationship work or should they part ways, parenting tips, or anything else that is unique to the couple’s relationship that warrants attention. In case goals are misaligned, well, then they work towards addressing that conflict first and be on the same page. 

When difficult conversations happen, they leave us rattled, undoubtedly. What was suppressed for long, emerges like a tempest at times, which one may not be braced for. One of the foremost things to do in therapy is to learn how to manage those emotional sweep-aways, be able to ground yourself, and to drop an anchor so that you are able to manage your thoughts and emotions and bring them to baseline while the work continues to be underway. These skills vary from mindfulness techniques, to setting boundaries, to communicating effectively, or to learn when to take a time out and reconvene at a later time, when the emotional surge has subsided. These are customized based on the individual’s preferences, their unique nature, and what they are willing to work with and build on.

One of my favorite memories of my childhood is when my mother would start knitting a sweater, and in preparation, she would make neat spheres of wool so that she could knit tangle-free. I would be asked to stand with my arms bent at the elbows, shoulder width apart with the wool wrapped around my hands while she lovingly sorted through the knots and tangles and made those spheres. Therapy is something like that. Sorting through tangles, with love and compassion, to wade through the mess, to get stuck at some point, and to focus with love and attention so that the mess eases out. When people are making progress, and there is often a small blip or a slight relapse, they panic. Bad days will happen even when therapy is progressing well, while the frequency and/or the severity may reduce but nevertheless blips are expected. If they take that in their stride, centre and ground themselves, it bodes well, but if they get distressed at yet another stressor adding to the burden, and that distress remains then precious time is lost. We all will have some bad days even when life is going well, so it’s best to just take that in our stride, and work through those difficult moments. It would be best if people can learn to rides these tides and stay focused on their goals, have trust in the process, and keep forging ahead. That’s how life is!

When a therapist facilitates sessions, there are interventions or suggestions that nudge people to deeper reflections, to face issues, which often entails stepping out of their comfort zones. When they trust the process, each other, and most importantly the therapist, when guards and facades are dropped, an inner transformation due to the collaborative work often emerges. I am forever grateful to those people, who have placed their faith, their lives, their inner worlds in my hands, and have walked along with me, unwaveringly with their hopeful sights on a better tomorrow. It makes it easier to navigate those moments when we as therapists have also been at the receiving end of anger, bitterness, harsh words, and other transference issues from clients.

Being honest not just with themselves, but with each other, and the therapist. There is truth to “Truth comes with a price,” “Truth is a bitter pill to swallow.” Clients often find it difficult to speak the truth for several fears: of hurting their partner, of being at the receiving end of their anger, of shame, of issues escalating manifold, or for fear of disrupting the peace and harmony that has evaded them so long. And so sensitive issues are often withheld which threaten the basic foundation of any relationship, let alone a therapeutic one. Transparency, honesty, and facing the truth rather than finding comfort in hiding behind it and delaying the inevitable revelation may seem a difficult path to traverse, but is the one to walk on for sure. When couples express their thoughts and emotions freely, without censoring anything, without walking on egg shells, and when they can patiently listen to and understand each other, is when lasting changes happen.

When we were at the depth of processing a very sensitive issue that had confronted Shreya & Rahul in the past, another major stressor showed up in their life, which again threatened to shake the foundation of their relationship. Conflicts escalated temporarily, and in their despair and while engaging in catharsis, they both asked if the relationship was worth the struggle they were finding themselves in. They then stepped back and saw that their emotions were ruling their thoughts and they again laid their eyes on the goal of making their relationship work because of the high value they both had in each other’s life and how they had shared dreams of raising a family together, parenting their two teenage kids, traveling the world, sharing interests and hobbies, being each other’s cheerleaders, supporting each other’s dreams, and just the simple fact that despite the challenges and incidents there was a whole lot of love they had for each other. When they were able to step away from seeing everything through the lens of their frazzled emotions, and saw what they were working towards, and what they would lose if they let go, they were back with a renewed commitment and a focus on working things through.  

Therapy isn’t about me wielding a magic wand, as most people think or ask me in jest. I like being redundant once my work is done which means that the people I work with have to learn the skills and do the deep work that therapy entails. They shouldn’t be seeing me for life. Therapy is a two-way street, and I like active participation of the clients because after all, it is their life that they are shaping. There are skills we like clients to learn, and however difficult they may seem, or whatever resistance shows up, if those learnings are indicated, then motivation must be built to imbibe them. While catharsis has its role in sessions, only engaging in that and not showing any visible shifts in well-being means that more work needs to be done. I have found the most successful outcomes in clients who take charge of their lives, assume responsibility for their actions, and are open to feedback.

One of the most challenging concepts that couples particularly struggle with is “agreeing to disagree.” They want their partners to see and endorse their point of view and it often culminates in two people trying to argue with each other in an endless loop, without putting their own agendas aside and listening and understanding effectively. It becomes a battle of the egos. Sometimes all we need to hear is, “It makes sense to me how you saw this, and what your perceptions and needs are. I get it. I can see why this can upset you.” Easier said than done, one might think, right? But why? It’s because we struggle with not being heard and our point of view being accepted. If one person wants to win, the relationship invariably loses. If we reach out and empathize with our partner, with a focus on hearing out each other, and reaching a resolution, we are looking at some good times. I have often noticed a softening when I hear someone say, “Do you think I understood what you were trying to say? If not, what do I need to know to understand your perspective better? And making sure that there is a deeper understanding and connect.

Why are we so afraid to look deep within, to see how events and generations and histories, and even our own thoughts, feelings, and actions have influenced us? Why are we afraid of looking at our scars and inner wounds and why do we not allow ourselves to look at our inner child with compassion and do the necessary work to heal? Therapy is akin to just tenderly taking care of a wound and healing it for good than just applying a band aid for a temporary fix. If we commit to dig deep to unearth what lies buried and  repressed that is causing angst in the here and now, we will move towards a longer lasting impact and a better, integrated self. Words that a former client said to me still ring in my ears, “Doc, band aids don’t fix bullet holes.”

We rarely give ourselves kudos for a job well done, for small wins that make a difference to our days and lives. Could we get out of bed and start our day without being engulfed with self-critical thoughts or bursting into a flood of tears? Did we manage to have an amicable, peaceful conversation about a stressor rather than getting into a heated argument? Did I enjoy going out with a friend rather than staying holed up at home feeling sad and depressed? These are small wins which cumulatively help us to reach towards our final goal/destination. Celebrate them!

Therapy needs to be owned by the people receiving it. If you are investing in your mental health, it will serve you well to take responsibility for it and to play your part in ensuring a successful outcome. When hearts and minds come together to heal, a wondrous metamorphosis happens. So, if you are considering investing in your mental health, do make a mental note of these pointers so that you come away healed and transformed. It can be magical that way.

Are You Moving Towards or Away From Your Best Self?

“What choice do I have but to live through this terrible time?” I have often heard, with a sigh of resignation, or even submission perhaps. It is often assumed that if adversity strikes us, especially if it is beyond our control, then we might as well just cave in, and wait for the difficult moment to pass, often plagued with severe bouts of anxiety and depression. The helplessness makes every moment even more heavy, like a burden you want to get rid of but it just clings on, the more you struggle. And so the loop of misery, despair, and a sense of powerlessness continues to dance to the most nerve jangling tunes.

There is an intervention from the therapeutic model of Acceptance & Commitment Therapy (ACT) called the choice point, credited to Dr. Russ Harris (2017)* which I love because of how it illustrates to someone that however difficult a situation may be, we DO have a choice in how we respond to it every moment. And that could make all the difference in our attempt to attain psychological equilibrium, to not just be functional, but also to be effective and live a life that is worth living.

I like roadmaps, and this is like one of them. Let me tell you how.

You want to visit your dear friend who you haven’t seen in years because she lives in another city. You have always valued this friendship and are now looking forward to seeing her, except she is in a part of town you have never driven to before. So you whip out Google Maps, plug in the address and off you go. In your mindful, attentive state, you keep following directions, making “towards” moves to the chosen destination. But when your mind veers off, or you take a call in the middle of the drive, you miss a turn here and there and end up making “away” moves which takes you away from your desired destination. Yet you persist, through traffic, rain, and masticating cows in the middle of the road, because you are so driven by the goal of meeting your cherished friend. It’s as simple as that.

The choice point is something similar. 😊

I’ll explain using an example of a wonderful woman I have the privilege of working with in therapy. No personal details are mentioned here to protect her identity and maintain confidentiality.

Maya (name changed) has been struggling with severe depression which has impacted her in all major life domains (personally where the self-critical thoughts “I’m not good enough,” “I’m worthless,” feelings of guilt, and lack of self-compassion made her spiral into a low sense of self-worth; interpersonally having withdrawn from friends and prefers being isolated; vocationally being unable to find the motivation to attend important meetings, increased absenteeism, procrastination, and an inability to focus). Her self-care routine had been severely affected, where insomnia struck, coupled with night eating syndrome, making her gain weight and further launching into more self-loathing. Her relationship with her husband and child was severely affected.

When someone is as depressed as Maya, not knowing where and how to begin piecing their lives can be a challenge. The inertia is like quicksand, making you feel like there is no coming up for air. And that’s where it starts with the most basic choices we start exerting.

Let me explain the concept behind the approach before I show you how Maya applied it.

Here’s how it starts. (The script is adapted from Dr. Harris’ work):

Every moment of every day, we are doing things: getting to work, taking care of family, watching Netflix, listening to music, doing some physical activity, engaging in a hobby…that’s what we humans do. We are interacting with life in some way or the other, even if it means wallowing in bed. Some things we do, or would like to do, that make us move towards the optimum life that we would like to lead – being in charge of ourselves, acting efficiently, behaving in accordance with the kind of person we would like to be – those are called “toward” moves.

There will be some things we do which take us away from the kind of person we would like to be, from the kind of life we would like to live, which make us act ineffectively, causing us distress which we may not be aware of, and those are called “away” moves.

When life is going well, things are easy and smooth, and our course is not strewn with obstacles, we get what we want, and it is so straightforward and easy for us to make towards moves. We act adaptively, we treat ourselves and others just right, and we engage in activities and with life that bring about optimal outcomes. But don’t we wish that life was a smooth sail all along? But the reality is, life just isn’t as rosy and easy most of the time, and it doesn’t work in accordance with our wishes and hopes all the time either. So as we go along, we are faced with difficult situations that bring us down, and all sorts of difficult thoughts and feelings arise.

Have you noticed how we get so easily “hooked” to these thoughts and feelings? We latch on to them, we get jerked and pushed around, the mind goes into a tizzy, and we go completely off track which then makes us do more away moves. The things we value doing fade away in the backdrop, and the thoughts and feelings take centre stage. Have you noticed, with those of us who have experienced any form of stress, anxiety, depression, trauma, addictions, that the basis of our distress is getting hooked to these difficult thoughts and feelings and doing away moves?

If we are mindful enough or build that self-awareness that we can unhook from these thoughts and feelings we tend to get back on track and lead our lives in a way that we value and cherish. We get back to behaving effectively, of relating to others, of living a life of purpose. And the more we do this, the better we get at living a good life.

And this is where I ask, when you are faced with all these difficult and challenging situations, and are being pulled apart by these sapping thoughts and feelings, you know we have a choice, right? A choice of how we will respond in this given situation. And the choice is between the following two: Would you like to unhook and do more towards moves? Or would you like to continue to feel overwhelmed and helpless, remain hooked and do away moves?

For most of us, who have rarely observed the impact of thoughts on ourselves and know that we can dive into interventions, it is easy to get hooked and as a result do more away moves. But we can develop unhooking skills, we can introspect and do some soul searching and get clarity on what truly matters to us, where our internal compasses point to, where our North star lies. Having this clarity about our lives makes it easier to keep reminding ourselves that we have to make towards moves. It gets easier and we become more hard wired to choose what will serve us better rather than what will take us apart.

And so we dive into skill building in our therapy sessions. We learn to identify our guiding values which motivate our behavior to lead a life we choose for ourselves. We learn unhooking skills that help us respond to difficult thoughts and feelings in an adaptive way, while we also focus on taking charge such as problem solving, action planning, (active) acceptance, surrender, being assertive, being self-compassionate, and whatever else your self-care tool kit needs based on your own unique situation.

You know, right? We have a choice to work situations through, either through trying to change it, or to respond to it by taking charge of what you can, by yourself. The more towards moves we make, the more our life is one of quality, meaning, purpose, and well-being. Happiness extends from all of this organically.

Back to Maya now.

I asked Maya what difficult situations, thoughts, and feelings was she experiencing. Relationship difficulties for the past 12 years were bogging her down. Her husband was dependent on alcohol, he was recently unemployed, and she had to bear responsibility for providing for her family which included her 8-year-old daughter. Her thoughts centred around feelings of hopelessness. “Things will never get better,” “What’s the point of living like this?” “I must be worthless to not receive the love I deserve.” “I am not good enough because I always get a raw deal in life.”

The associated feelings were of despair, sadness, crippling anxiety, anger, frustration, hopelessness, and helplessness. Which further led to “I don’t feel like doing anything.” “I don’t have the energy or the motivation to do something worthwhile.” The downward spiral continued.

The “away” moves were dancing to a nice tune: Absenteeism from work, emotional eating and binge drinking, demotivated to take care of her child, neglect of grooming, lying in bed all day, long tearful spells that often lasted for days.

We worked on discovering what truly mattered to Maya, what she deeply cared for in her heart. What kind of a person did she want to be? Who were the important people in her life and how did she want to relate to them? What strengths did she want to develop? What obstacles did she want to work through? What excited her about life? What did she want to do with the remaining time she had of her existence? Questions like these truly bring on some deep soul-searching.

She spoke about wanting to become better at managing her own emotions, of dealing with crises and bouncing back to life, of wanting to set effective boundaries so that she was not on the receiving end of abuse, of being a compassionate, caring, loving mother, of focusing on physical and emotional health and well-being. She wanted to stop the avoidance of feared situations, and become a better team player at work, and to show up, whatever distress and state of mind she may be in. Just. Show. Up.

The first priority was to learn “unhooking” skills and Maya and I worked on mindfulness activities that would aid in the process. She had a range to choose from, and we finally zeroed in on what would help her truly centre and anchor herself in the midst of an emotional storm. These were the first set of “towards” moves.

Maya started sleeping on time, and waking up on time, and started exercising 5 days a week, even if for 20 minutes to begin with. She realized how good the exercise felt and notched it up to 30-45 minutes. Getting her child ready and ensuring she attended the online classes on time became her next task, along with logging in to her work and taking accountability. She was beginning to take charge. The intention and action of taking charge, of believing in her own self and the importance of who she wanted to be, became excellent catalysts to bring the transformation. Bit by bit, step by step, Maya started recovering from her depression and taking effective action to manage her relationship with her husband. It still is work in progress for her.

In sessions Maya would often say that whenever she was faced with a difficult situation, thought or emotion, her default question to herself was, “I have a choice to respond to this situation so that I come out with an effective resolution. What “towards” moves can I make?” and that always spearheaded her taking charge. Small wins every day.

Then again, when you’re moving towards being your best self, there are no small wins, are there? :)

We find ourselves chained and restrained by our difficult thoughts and feelings and feel we have no control over them. “If only these thoughts would stop,” is what I would often hear as an earnest request in therapy. But these thoughts are relentless, and they plough and plunder, and that’s when I would like you to remind yourself: That you have a choice, to let go of the shackles that you find yourself bound with, to choose to respond effectively, to focus on your North star, to move towards the best possible version of yourself. You owe it to yourself!

(*Choice Point 2.0 is presented here and is credited to Dr. Russ Harris (2017), adapted from the Choice Point by Bailey, Ciarrochi, & Harris (2013), proponents of the Acceptance & Commitment Therapy (ACT).)