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.

"Adulting is Hard"

When my now 24 year old niece got her first job two years ago, she would often quip, “Adulting is hard, man!” We would all laugh with her taking in that light moment. But around me I can’t help notice that people ARE in fact struggling so much with life. A friend came over the other day and with his gaze transfixed to the floor, deep in thought, he said, “Life can be so boring. The same routine, wake up, go to work, come back, barely get any time with family, eat, sleep, repeat. It’s lonely, D,” he said.

I opened my eyes, ears, and heart to people around, including to my own self. What was happening to so many of us out there? Disconnected, isolated, lonely, dejected, overwhelmed, guarded, sad, distant people, with an empty, forlorn look in their eyes stared back at me.

Around this time, my closest friend from school sent me something to read titled, “Are we going through a friendship recession?” A survey done on the Americans revealed that there is in fact a friendship recession going on where the presence of close friends is declining and we have fewer people to rely on in times of crisis. The factors leading to this decline ranged from geographic mobility, increased responsibility towards child rearing, the increasing focus on a work centric culture and “workism,” overall breakdown of relationships which lead to separation of friend groups as well. In a country like India, you can add the additional responsibility of caregiving for aging parents to that list.

Has the pandemic added to this disintegration of meaningful connections? Just as I was pondering over this question, I got a new referral. “I want to know if I am an introvert and how I can change that?” As I went on an exploratory journey with this young man, working from home, he revealed that he was a lot more outgoing before the pandemic hit, but had become socially more anxious since he has been working from home since 2020, preferred to isolate himself, and couldn’t seem to voice an opinion when in groups. We explored relationship stresses resulting in mood disturbances which further made him isolate himself, distancing himself from the relationships that brought some comfort and respite.

Humans are wired to be social beings, and it has been known that friendships are crucial for overall well-being, physically, emotionally, spiritually, and here we are, crumbling under external factors and pressures which have not only hindered the maintenance of relationships, but we find ourselves perplexed at how do we even create new ones? The result of this decline is leading to what people identify as loneliness, boredom, sadness, running the same rat race, which further impacts overall health. We may not feel this, or realize the import of, but it’s eroding the fabric of our very selves.

The survey further showed that in 2021, 15% of men reported lacking a close friend versus only 3% in 1990, in a time of crisis 45% of men would have turned to a close friend for help in 1990, versus only 22% of them in 2021. Female friendships saw a different trend where during the pandemic it was reported that more than half of the women lost touch with their friends, implicating that for female friendships, in person physical contact may be more important, whereas for men it could be more technology driven.

The fear is that if this trend continues we would see isolated, atomized, island-like individuals who see life as a continuous struggle, posing challenges at every step, which adds to their level of suffering. The glass will always seem half full, which would further perpetuate sadness and ill-health.

On my birthday almost a month ago, I was soaking in so much love, blessings, and wishes from people in my life. What was most overwhelming, in a good way, were the people who reached out to me, who I would have expected to give up on me, because I had lost contact with them. You see, I am known to be an ostrich who buries her head in the sand when going through a difficult time, and I tune out the world while I work through whatever it is that caused me to derail. People who truly mattered, didn’t give up on me, and love shone through so brilliantly those few days. As I reflected some more, the strong influences of meaningful connections, vulnerability, belongingness, and love came to my mind as I was lifted out of the isolating vortex I had been finding myself in. The pick me up from all the calls and messages was weaving a magical charm.

We search for connection, to belong, to care, to be cared for, to love. Whether we realize it or not, it does seem to be a natural instinct, unless we put strong walls around to self-preserve. Love and belonging are touted to be irreducible needs for all individuals.

Why are we increasingly feeling this unshakeable sense of isolation and loneliness? Why does this feeling of belongingness to others seem so fractured? I realized that we have to belong to ourselves first as much as we need to belong to others, and that itself is suffering these days. How often are we willing to be open and vulnerable to others, where we own our authentic selves and are willing to share it with the world, fearlessly? How often are we content in our heart, spirit, and soul where we choose to look for that sacredness in being a part of something larger than life, or even in standing alone and burning through the fire, only to come out stronger on the other side?

We all have that one friend who never gives up on us, however out of touch we may be over months or even years. We can pick up from where we left, and we can be who we are; we don’t need to fit in, we don’t need to appease, we can just be. The beauty of such friendships is that we can be vulnerable, raw, and open, we can share the most uncomfortable feelings and yet we will feel safe. No facades, no pretences, just a beautiful melding of two hearts that shares the sorrows and doubles the joys. Are these relationships getting buried under the heavy stresses and strains of daily living? At the centre of loneliness we are denying ourselves of meaningful connections such as these; and of emotional intimacy, friendships, family gatherings, and even work connections, making us turn more and more inward, not necessarily in the most healthiest of ways.

The cycle gets perpetuated, of sadness, withdrawal from meaningful connections & activities, and sadness again and we find ourselves feeling like this state is unchanging, it is what it is.

But the antidote is in the problem itself. We have to acknowledge that it is important to actively work on friendships, even for an introvert like me, who is very content with a few close friends. Till the time we don’t set the intention, our actions won’t follow. Because like anything else, relationships require work, and effort and the outcomes are totally worth it. You never know who pulls you out of the slumps with a kind hug, a piece of advice, some humor, a compassionate sounding board, or just with some silly banter. And to be open, and willing to share, to belong to ourselves first, to see ourselves through the lens of compassion and kindness, to be raw yet be able to reach out to others in our lives.

Adulting IS hard. But maybe the way to make it easier is to also bring back the non-adult in us. To indulge in some fun and adventure, and bring back some spontaneity. To make friends without seeking anything or much out of them, because constant expectations weigh us down even more. To infuse more play into everything. To enjoy the pursuit of meaning as much as the pursuit of nonsense. As kids show us, it's the little stuff that we enjoy together that binds the big stuff -- like hearts and minds -- together, to weather the storms of time and adulting.