How People Change In Therapy
by Janis Rosenberg

People come to therapists, doctors, religious counselors, gurus, and other kinds of healers with the belief that something in their life isn’t working. They want to change their beliefs, low self-esteem, tendency toward bad relationships, lack of confidence, or unhealthy lifestyle. They want to change their life and their outlook on life.

In my twenty-three years as a psychologist in private practice, I have often asked myself how I can help people find their way to change. My first supervisor in graduate school told me, a total neophyte therapist, that by the end of the year, she wanted me to be able to tell her how therapy works to help people change. This is the central question that has guided me—how can I help others to heal.

My clients come to therapy after living for years with the hurtful of effects of abuse, negative relationships, and other traumatic life events. They desperately want to be able to deal with life’s blows with equanimity, and release fear and shame.

If you ask people what helped you change in therapy, they make say it the relationship with someone they could trust or learning new more adaptive ways of thinking and feeling from the therapist.

Jim Johnson is a physical therapist who works with injured patients who need to feel motivated to heal. He talks about steps to motivate change in his book The Sixty-Second Motivator. Two factors are needed to have the motivation to change. One is believing that it is very important to change behaviors. If there is high importance that is personally meaningful to you to give you something you really want, you are more prone to change the behavior. The second factor is having the tools, skills and knowledge to change. Someone who wants to stop smoking has to be very motivated, but also needs the appropriate tools, whether it’s medication, hypnosis, or a group support.

If you ask clients about motivation to change, they may say they really want to change, but feel stuck in negative patterns of shame, self-doubt, and hopelessness. The belief that you can’t change deters the process of change. If a therapist tries too hard to motivate the client, the client may feel more shame.
I have had the experience of urging clients to do things outside of therapy to change, especially those who are withdrawn in depression. I may suggest that they reach out to others, attend support meetings, consider antidepressant medication or exercise. Some clients are not ready for this, since they need me be in the dark place with them, while still complaining about how terrible it feels.

I have also had the opposite happen, but this happens when the client is more open to change. So the question is, how does a person open to change?

Clients who make significant life changes often start not knowing what their goals are or what path they want to take to change. Let’s say Jim starts therapy because his significant other has many complaints about his depressed, unmotivated mood and lifestyle. At the time he starts, he might just want his partner to be less critical and more satisfied with him. After some time exploring his feelings in therapy, he is able to gain the confidence in himself to make significant changes in his life and relationship. But how does this happen, when at the start the waters are so murky and motivation and goals aren’t clear?

Working through the causes and triggers for shame can move the stuck negative beliefs so people can find their way “out of the hole.” The therapist has the important role of cheerleading to increase the client’s confidence or help them find the belief that they deserve a loving relationship or have the ability to get the better job or try harder in school.

Our caring for the client, plying out the resistant parts and helping her believe in herself creates change.

What happens in the brain from trauma to bring people to the hopeless, devastated place where they don’t feel capable of change? They are coming to us hoping for us to change them, yet telling us all the reasons they aren’t capable, it’s too hard, they are not good enough, smart enough, strong enough to change.

One client had been unable to work because of traumatic flashback memories of his childhood where he was neglected by parents, beaten by bullies, and frightened most of the time. Teaching him to calm himself somatically and processing traumatic memories using EMDR have helped him live more in the present, but it seems to be more the strength of our relationship, his trust in my explanations, that have helped him.

In his article, “Change or Die” in Fast Company Magazine, Alan Deutchman talks about how we fight change, even in a health crisis. “Severe heart disease is among the most serious of personal crises, and it doesn’t motivate—at least not nearly enough. Nor does giving people accurate analysis and factual information about their situations. What works? Why, in general, is change so incredibly difficult for people? What is it about how our brains are wired that resists change so tenaciously? Why do we fight even what we know to be in our own vital interests?”

Dr. Dean Ornish, who motivates heart patients to make radical change, believes you have to appeal to people’s emotions, to reframe their ideas of themselves to believe that they can have joy, not through fear of death. Fear isn’t a good motivator, joy is. He also found that radical, sweeping, comprehensive changes are often easier for people than small, incremental ones. “People need to make big changes to get immediate rewards, whether in health, weight loss or gains in physical ability. Then they see that the changes are worth it. It’s a paradox, that big changes are eaiser for people to make than small ones.” For example, patients often stop taking a cholesterol-lowering drug, he says, because they don’t actually see the changes or feel better.” (Fast Company)

While this may be true for physical changes, many clients are too unsure of themselves to embrace sweeping emotional or relationship changes. They need to take it a step at a time.

In spiritual circles, the Law of Attraction, which was highly touted in the book and film The Secret, claims that if you believe you can have something good in your life, you will have it. If you order something good off the cosmic menu and put your high vibrational attention on it, the universe will deliver it. Some believe that God, or “the universe” is delivering, but it may be that positive belief in the self motivates you to do the work to get the degree, the job, the good relationship.

One area where we can see people change is the recovery movement. People may have to “hit bottom”, but Anonymous groups using the Twelve Step model of recovery support groups has helped many people let go of various addictions, from drinking and drugs, to food, sex, gambling, debt, and even cluttering. Coming out of isolation and seeing others who have recovered, and then sharing publicly about the secret places of dysfunction can bring about change. Others may use faith in religion or God to change or improve their lives.

So how do clients change in therapy?

What I came to realize in my years as a helper is that there is something about the relationship with a safe, trustworthy, understanding therapist that helps promote change. Psychoanalysts call it transference and focus on interpreting the patient’s reactions to the therapist. Meta-analyses of therapy outcome research from the famous Smith and Glass study show that it’s the relationship that matters to clients, no matter which style of therapy the therapist claims to use.

Clients learn to be more accepting of who they are in the present, when they explore the past with the therapist explaining why they turned out like they are. When parents shame and blame the child, the child internalizes the inner badness and carries it.

“It is better to be a sinner in a world full of saints that a saint in a world full of sinners.” Ronald Fairbairn, famous Object Relations Theorist, explained how the child takes on the badness of the negative relationship with the parent, thus protecting the parent’s goodness, since s/he needs to believe the parent is good enough to take care of her. Often this is carried through life, with client being afraid to say anything negative about their parents, even after they have died. Taking on less of this burden and learning to have compassion for the self is an essential part of healing.

One client I saw for many years used to leave the session in a hurt, angry huff if she felt that I wasn’t with her or was not getting her. I would try to get her to come back and see what happened. One day when this happened again, I took her hand and apologized for being ahead of her. I said it was my mistake for trying to being ahead of where she needed me to be. She called this her “Helen Keller moment,” meaning that she got it that it isn’t always her fault, her responsibility, if things don’t feel good in a relationship.

I have seen change occur in group therapy, as well as in individual therapy. I lead groups for compulsive overeaters. Often change is easier to see in groups, if there are profound or moving moments where members either confront or support each other. One client was able to give up a serious eating disorder because of the concern of group members, even though we had been working individually on this destructive behavior. She was able to take in the concern of the other client even more than she could from me.

Both in groups and with individual clients, working on boundaries teaches clients it’s okay to say no, not do things, give too much away, or worry so much about others’ opinions, or work so hard.
People change when they learn from a credible source that conflicts with others can be worked through, needs can be expressed and often met, concerns about personal image can be less pervasive, and feelings can be tolerated and understood. Learning to regulate the physical manifestations of mood and find a grounded place to calm down or energize can be very helpful.

The suggestion of new ideas by believable sources, i.e., the therapist or other group members who have conquered an obstacle can help increase motivation to change and model the tools for change.

Even though all the theories, methods, and techniques that therapists learn are helpful, I have come to believe that there is something more that happens in therapy. We can see that therapy creates a safe relationship with a trusted expert, fosters self-acceptance and self-awareness, and offers tools for changing beliefs, habits, and patterns. But there is something more that seems more spiritual or even magical with the exchange of energy, commitment, trust, words and emotions.

That thing that happens when “two or more are gathered” seems to occur when there is genuine caring, cheerleading, enthusiasm, pride, nurturance and even love. Ronald Searles, in his famous article “Love in Countertransference” believed that you had to truly love clients for them to change, kind of like being the good parent they didn’t have. There is truth in this.

Jim Johnson P.T. "The Sixty-Second Motivator." Dog-ear Publishing, 2006
Alan Deutschman. “Change or Die” in Fast Company Magazine. May 2005.

Janis Rosenberg, Ph.D., is a clinical psychologist in private practice in Culver City. Visit her at: www.janisrosenberg.com