Take our Do I Need Therapy?

Find a therapist near me

Psychotherapy has been practiced now for a little more than a century.

Psychotherapy is helpful for most people.

Psychotherapy is as much about acceptance as change.

"We cannot change anything unless we accept it."

"The curious paradox is that when I accept myself just as I am, then I can change."

"Freedom from suffering requires accepting rather than resisting reality."

“How many psychotherapists does it take to change a light bulb? Answer: Only one. But the light bulb has to really want to change."

--An old psychotherapy joke

What is psychotherapy? Such a seemingly simple, straightforward question. Something those who have never personally experienced this enigmatic, mysterious process are understandably curious about. (Perhaps sufficiently curious to be reading this article right now.) But, strangely enough, it remains a profound question even for those that have at some time been psychotherapy patients or clients. And, if truth be told, this is still an open and hotly debated question even among professional providers of psychotherapy: clinical psychologists, psychiatrists, clinical social workers, marriage and family therapists, counselors, and other licensed mental health professionals who have spent years studying, practicing, teaching and, in many cases, receiving psychotherapy themselves.

Indeed, depending upon whom you ask, the definition and description of psychotherapy can vary wildly--which all contributes to the swirling cloud of confusion and controversy still surrounding psychotherapy more than a century since Sigmund Freud formulated the prototypical form of psychotherapy he called psychoanalysis. But, despite these discrepancies, according to some recent studies, psychotherapy has proven to be effective and helpful for approximately 80% of those who try it. But how exactly does it work?

One of Freud’s original therapeutic techniques was called “free association,” in which the patient is asked to recline on a comfortable couch and say out loud whatever thought, memory, emotion or image comes to mind in the moment. Let’s try a little free association experiment right now: When you think of psychotherapy, what image comes immediately to mind? For most people, this question conjures up something like this: A neurotic, anxious patient prone on the couch (or sometimes seated in a chair), and a detached, aloof, bespectacled, scholarly-looking psychotherapist, pen and notebook in hand, mostly silent but at times offering terse interpretations related to the patient's parents and childhood, punctuated with the occasional "Uh-huh" and the hackneyed question "How did that make you feel?" or something similar. How does that caricature of psychotherapy comport with your own fantasy?

In reality, much has changed about psychotherapy over the past century--both for better and for worse. And much remains the same. Most psychotherapy today tends to be briefer and more pragmatically symptom-focused, foregoes the iconic Freudian couch in favor of sitting face-to-face (or, as Jung once described it, “knee to knee”), is more interactive and collaborative, less authoritarian, more humanistic, cognitive, or behavioral, and not uncommonly complemented by some sort of psychiatric medication. Fascinatingly, despite the Victorian chauvinism initially leading the psychotherapy field to be dominated by men, there has been a seismic shift in recent decades: Today the majority of psychotherapists (an estimated up to 75%) are women. It has also become a huge industry. The use of online therapy globally, a relatively recent and revolutionary post-pandemic development in the delivery of psychotherapy services, will likely exceed $65 billion annually. Psychotherapy, whether conducted in-person or online, has also become expensive, sometimes prohibitively so, though many health insurance companies now at least partially cover it, making it more accessible.

To be sure, twenty-first century consumers of psychotherapy present somewhat diverse symptoms and struggle with different conflicts and issues than did those back in Freud's day. Such things change, at least to some extent, with the current times and cultural zeitgeist. Yet, they still, like each of us, must contend with the colossal complexities and perplexities of the human condition, come to grips with the daunting existential facts of life, and deal with the immense challenges of living in these trying, tumultuous, bewildering, and sometimes overwhelming post-pandemic times. One big secret here is that there really is no such thing as generic "psychotherapy" per se. When someone says they have been in psychotherapy, or practice psychotherapy, the reality is that his or her experience with and perception of therapy may differ radically from another person's.

To speak about psychotherapy generically is a little like speaking of ice cream: Today, there are at least as many types of psychotherapy out there as there are different flavors of ice cream. (Incredibly, there are an estimated 400-500 different types of psychotherapy being practiced today!) One can be said to like ice cream, but all that tells us is that they consume something sweet, creamy, ice-cold, and delicious. Yet we all know that vanilla, chocolate, strawberry, butter-pecan, chocolate-chip, pistachio or green tea ice cream are quite different from each other and that any single flavor of ice cream does not necessarily suit everyone's taste. So it is with psychotherapy.

Take our Do I Need Therapy?

Find a therapist near me

Even psychotherapists of the same theoretical school or orientation will differ significantly in how and what they actually practice. Psychotherapy is not something consistently or reliably uniform, predictable, and predetermined, despite recent efforts by some to mechanistically manualize and standardize it. Rather, it is an archetypal healing process that is, at its best, re-invented with each new patient, each practitioner, and for and by each new generation. No two courses of psychotherapy will ever look exactly the same. Nor should they. But, given these subtle (or sometimes not so subtle) disparities in the way it is practiced, its myriad theories, goals, and methods, this still begs the basic question: What is the essence of psychotherapy?

For most people, the key word they associate with psychotherapy is “change.” Psychotherapy patients, we presume, must obviously change their aberrant or self-defeating behavior, their negative attitude, their irrational thinking. This is, of course, typically true. But here is another secret: What if I were to tell you that psychotherapy is at least as much about acceptance as change?

When Freud made the oft- cited yet mostly misunderstood statement that the purpose of psychoanalysis is to transform neurotic human "misery into common unhappiness," he was certainly speaking of change. Freud's statement on the purpose or goal of psychoanalysis may seem cynical to some. But when seen in the light of his own prolonged personal suffering from oral cancer during the last decades of his life and how he stoically and courageously confronted that excruciating fate, it is a mature and sobering commentary on the absolute necessity of unequivocal acceptance. Rather than reflecting his pessimism about the human condition, as some mistakenly conclude, Freud's comment recognizes the incontestable need for heroic acceptance of physical, psychological, and spiritual suffering, and the high price we pay for attempting to avoid or deny life's tragic aspects. But how is even such seemingly modest change accomplished in psychotherapy?

So many of the changes that occur in the psychotherapy patient can best be described as a gradual, subtle, and sometimes imperceptible process of acceptance: Acceptance of the stark existential facts of life: suffering, disease, death, aloneness, loss, tedium, meaninglessness, anxiety, insecurity, uncertainty, absurdity, and of the perennial problem of evil. Acceptance of painful past trauma and its powerful and pervasive impact in adulthood. Acceptance of ourselves as we are, and for who we really are, rather than who we ourselves or others wish us to be. Accepting and compassion for others. Indeed, not infrequently, some symptoms initially presented by the patient or client at the outset of psychotherapy slowly disappear or diminish in intensity secondary to, or as a consequence of, this crucial and indispensable process of acceptance.

Diamond, S.A. (1996). Anger, madness, and the daimonic: The psychological genesis of violence, evil, and creativity. SUNY Press.

© Psychology Today