The Real Reason Therapy Works

“It’s the relationship that heals, the relationship that heals, the relationship that heals—my professional rosary.”

– Dr. Irvin D. Yalom, from Love’s Executioner 


There’s an underlying mechanism behind why therapy is so reliably effective, despite a wide variety of contradictory methodologies and professional techniques: relationship.

This basic mechanism somehow seems both obvious and clandestine, but it’s not really either.

The concept of ‘relationship’ as the primary mechanism for healing is not simplistic, nor is it esoteric or complex:

The power of relationship – one in which there’s full trust and no ‘personal’ judgment, and in which there’s a deep understanding of problems – is in itself fundamentally therapeutic. It’s a state of consistently relating your life experience with another. It’s a genuine human bond based in familiarity, shared awareness, and care.

Obviously therapy works for a lot of reasons. The title of this post is admittedly simplistic. But the general concept – the ongoing relationship serves as the primary therapeutic mechanism – tends to apply in some significant way to just about everyone, and understanding this can be very helpful for healing.

To be clear, therapy is absolutely necessary for a lot of people. There are certainly elements beyond the trusting relationship that are attributable to healing. But the genuine establishment and development of a constructive relationship is what often serves as the ultimate healer. Moreover, the sense of relationship is the primary healer, the sense that one is being related to — the sense of being felt and understood and validated with consistent attention.

There’s a lot of smoke and mirrors in psychotherapy (often unintended, to be fair), a lot of methods and techniques and systematic applications and analytical styles and so forth of which patients might assign responsibility for their therapy’s effectiveness, when really the mechanism of healing is mainly just the establishment and development of a *genuine sense of relationship, including the sense of ability to relate to one’s self, to cohere one’s thoughts and feelings and experiences.

*While a “genuine sense of relationship”, as in directly experiencing a deeper human bond and feeling personally understood and accepted, is of utmost value for therapeutic healing, it’s also probably the main reason why most people don’t need therapy: healthy relationships help prevent psychological dysfunction. Oftenfor people who are otherwise psychologically stable, the development of relationship is what is fundamentally lacking, and thus the absence of a sustained meaningful bond with another person is the primary element – possibly the only element – that’s preventing them from being on a level of psychological health and well-being that wouldn’t necessitate therapy. And the lack of bond is most often directly or indirectly attributable to an undeveloped, underdeveloped, or diminished bond with one or both parents (or with primary caretakers).

Another Dr. Yalom quote from Love’s Executioner:

“Though the public may believe that therapists guide patients systematically and sure-handedly through predictable stages of therapy to a foreknown goal, such is rarely the case: instead…therapists frequently wobble, improvise, and grope for direction.”

This exemplifies the idea that technical psychological maneuvering is not often the primary mechanism of healing, or at least not necessarily the actual driver of change. Rigid psychotherapeutic game plans aren’t very effective, or at least aren’t reliable.

Regardless of the content of conversation, patients mostly figure out what they need to do – the therapist is mostly there to be inquisitive, engaged, suggestive, and supportive. The therapist serves as a guide, accompanying the patient on a difficult emotional journey, pointing him or her in the right direction towards mental health.

As therapy begins, ‘relationship’ quickly evolves to become the most necessary mechanism for effective therapy (especially for “hard cases” of longer term therapy).

If a therapist has impeccable professional judgment and knows the right questions to ask and is thus masterful in developing a genuinely trusting relationship with patients, then he or she will be a much more effective therapist – much more effective in actually healing the patient.

Yet another quote from Dr. Yalom:

“The psychotherapist’s single most valuable practical tool is the “process” focus. Think of process as opposed to content. In a conversation, the content consists of the actual words uttered, the substantive issues discussed; the process, however, is how the content is expressed and especially what this mode of expression reveals about the relationship between the participating individuals.”

(Sometimes the **specific content of professional questioning, suggestion, and psychoanalysis is the primary mechanism for healing – the actual driver of change. But usually the specific content is supplemental. Usually the sense of relationship is the real reason why healing takes place.)

Final quote from Dr. Yalom:

“The drama…(or, for that matter, any therapeutic-cathartic or intellectual project) is healing only because it provides therapist and patient with some interesting shared activity while the real therapeutic force—the relationship—is ripening on the tree.”

Please note:  One implication of this post is that therapy may not be necessary for some people, particularly for those who have access to healthy relationships and also have the willingness and ability to establish, develop, and engage them. Of course therapy is certainly necessary for many people, as it is certainly effective in a variety of ways for a variety of people. But the primary reason why it works so reliably across the board is than most people think.

**To elaborate on “specific content”, I should note that this term essentially refers to the substance of conversation. It refers to the helpful statements or questions initiated by the therapist, including all professional perspective and logical framing of situations, rational inquiry and theoretical structure, and any type of directive empowerment accompanying individualized problem solving. Obviously specific conversational content plays a role in healing – it’s why some people can significantly benefit from only one or two sessions of therapy. But particularly for longer term and/or intensive psychotherapy, it is supplemental to the core element of relationship.