What to Do If Therapy Isn't Working

While in therapy, the question "Is this working?" might cross your mind more often than you’d expect. The psychological community has been debating the merits of evidence-based short-term methods versus long-term, open-ended therapy for a long time. Depending on your current needs, you might favor an evidence-based therapeutic method that will help you treat panic attacks, phobias, or acute anxiety, or you might prefer a practice-based psychodynamic method that will help you explore the early relationships and attachments, and their influence on your current condition.

Just like different therapists are attracted to different approaches and practice what resonates with their personality, clients do as well. It is less a matter of a therapeutic modality that you choose for yourself, as long as you are comfortable with it, see and feel results, and have a working connection with your therapist.

So, once you’ve chosen the fitting modality, found the right therapist, and sailed forward on your therapeutic journey, what are the signs that your therapy is not working?

1. Lack of therapeutic alliance

The main predictor of success in therapy is therapeutic alliance (1). A therapeutic alliance is a trust-based relationship between you and the therapist that advances your therapeutic goals. If you feel that therapeutic alliance is absent, or it has disappeared and you no longer trust your therapist, stop whatever you are working on to find out why it has happened. You are not wasting time by doing this; it is a part of therapy.
This temporarily caved relationship shows you something about what is going on and is, in and of itself, therapeutic. For example, your therapist might have said something that felt insensitive, or suddenly they have pushed you to do something you are not ready to do. While your first automatic reaction might be to never come again, it is these points of losing the connection and then reinstating it advance therapy.
If you, for whatever reason, are angry at your therapist, losing trust, or dissatisfied with something and it causes you to withdraw or leave, try to discuss it with them directly before you discuss it with anyone else. There is a high probability that the therapeutic alliance will be restored and you will be able to continue working on the relevant issues, while also incorporating overcoming this crisis.

2. You are feeling emotionally worse and your therapist is refusing to discuss it with you.

Therapy isn’t always a linear path to feeling better, and sometimes you might feel worse during therapy. This usually happens because long-suppressed emotions and memories come to the surface, and you need more energy to deal with them. These emotions might also scare you. This is entirely natural in therapy. As long as you have a working therapeutic alliance, you can discuss these acute emotions with your therapist. Oftentimes, it is unnecessary to discuss them right off the bat, but acknowledging that they are there and that you both haven’t lost focus on them is vital.

The issue here isn’t that you are feeling emotionally overwhelmed, the problem is when this feeling is ignored and unacknowledged. While one of your therapist's most crucial tasks is being attentive to your condition, do not delegate this responsibility to them completely. Be sure to speak up about the presence of negative feelings. If both you and your therapist acknowledge them and agree to tackle them later, you are on the right track.

3. Feeling unsafe

A therapeutic relationship is one of safety. Losing the feeling of safety stalls therapy and even undermines it. When people don’t feel safe, they tend to protect themselves, and, granted, if you feel unsafe with your therapist, you will be protecting yourself from them. Once this happens, you can no longer be honest about yourself. There are obvious signs of non-safety, of a therapist stalking you, abusing you emotionally, dismissing, or intimidating you.
There are other signs, which are non-obvious. One factor contributing to feelings of non-safety can be a dual relationship with your therapist. If the therapist is both your therapist and your friend, or your lover, the therapeutic boundaries blur and it might leave you confused, thereby sabotaging your therapy. These dual relationships can potentially lead to abuse, which is dangerous, especially if the subject of therapy is trauma.

4. Defining your real needs in therapy

Therapy can serve as treatment, especially during periods of crisis when you might feel that you are fighting to maintain your mental health. It can serve as a means of personal growth and motivation.
People often start therapy out of necessity because they need mental and emotional support. Later, they might continue therapy not because they need it, but because they want it.
Understanding your real needs helps you to adapt to therapy and influences the choice of therapist, modality, how seriously you approach therapy, the regularity of therapy, and so on. Knowing whether you are addressing urgent issues, exploring behavioral patterns, or just maintaining a space for self-reflection might guide your therapeutic success.

5. Are you making progress, and do you know how to define it?

Therapy occurs in phases. Sometimes the progress is astoundingly fast (often at the beginning), sometimes it is slow and sometimes it stalls. It is not always clear where we are making progress. For example, your initial goal might be to meet a new partner after a divorce. Instead, you’ve found yourself less angry with your teenage child. Whatever the progress is, it is important not to lose sight of it.

Positive dynamics in therapy can be observed if you feel better emotionally, your symptoms have subsided, you are more satisfied with your relationship, and you've become happier.
If, however, both you and your therapist believe that no progress is being made, don’t rush to terminate therapy. Discussing with your therapist why there is no progress is also a part of therapy.

A lack of progress in therapy might stem from avoiding unpleasant topics. If you feel that there is a topic that you are brooding on, but you and the therapist have created a “false positive” alliance of avoiding hard and emotionally laden topics, it might stall your therapy.

It needs to be noted that sometimes therapy in itself is not enough, and better results are reached together with psychiatric treatment.

Conclusion

Therapy is not about single-handedly carrying your burdens on either your or your therapist’s shoulders. Therapy is a joint venture between two motivated and willing parties. So, you are also in control of what you can influence in your therapy if you feel that it is not working for you, especially if it had been, and then stopped. I encourage you not to abandon therapy immediately but rather allow yourself to explore why it is not working. It might prove to be a valuable part of your therapeutic journey.

Bibliography:
Gabbard, G. O. (2007). Psychotherapy in psychiatry. International Review of Psychiatry, 19(1), 5–12.

Published by author on Psychology Today: https://www.psychologytoday.com/us/blog/the-psychology-of-relationships-and-emotional-intelligence/202503/what-to-do-if-therapy-isnt