When something no longer feels manageable

People usually come to therapy because something in their life no longer feels manageable. Often, they are struggling with debilitating symptoms - whether depression, anxiety, panic attacks, eating disorders, exhaustion...

More often still, the reason people come for therapy is less clearly defined, and things simply feel off. This is in fact, a very common presentation. So often I hear "I should be happy. I have everything I thought I wanted - but I'm not." This way of narrating one’s difficulties is particularly striking as the pain seems compounded: there is the initial pain of something feeling off, amplified by the additional pain (guilt, shame?) of feeling that one does not have the right to suffer as everything “seems well”.

Some describe finding themselves repeating the same painful relationship patterns, struggling to make decisions, or feeling as though they have become a stranger to themselves. Some come because life has begun to feel flat or devoid of meaning, even if they cannot yet put it into words.

More often than not, by the time a person walks through the door, therapy is not the first thing they've tried.

We often ignore a problem, hoping it will pass. We try to make sense of it on our own. We take the advice of friends and loved ones. We read books, listen to podcasts, perhaps even convince ourselves we simply need to try harder. And sometimes that is enough. It works. We figure it out. And sometimes, despite all of our best efforts, we find ourselves feeling increasingly stuck.

So what actually happens in therapy?

Learning to listen

The first thing we do is listen.

I deliberately say we, because although I listen carefully to the person sitting in front of me, I am also inviting them to begin listening to themselves in a new way. Therapy is not simply about telling a story; it is about paying attention to the story as it is being told. Listening not only to what is being said, but also to how it is being said, what seems to carry emotion, what appears almost in passing, and what seems difficult to put into words.

"I hadn't realised I'd just said that."

Those moments of recognition, of hearing oneself differently, or even hearing some parts of one’s own story for the first time, are often the start of therapy.

One of the elements that continues to surprise me is how often insight comes not from me saying something particularly clever in session, but from simply reflecting back something the patient has just said. A sentence they themselves spoke only moments before can suddenly sound different when it is gently highlighted. It is not uncommon for someone to pause and say, "I hadn't realised I'd just said that," or sometimes, "I don't even know why I said that."

Listening to the symptoms, and beyond

Of course, we also listen to the symptoms that brought the person into therapy. By the time most people come to their first session, they are dealing with symptoms so incapacitating that they represent a crisis.

When the time is right, with an equally genuine interest, we explore the broader context in which this suffering is expressed. Where is the person in their life? How did they get there? What are they proud of? What are they afraid of? What has shaped them? How did they experience love? Success? Failure?

Together, we are building a picture of the person as a whole.

The patterns that begin to emerge

This process usually unfolds over the first two or three sessions. Gradually, an understanding of the person’s functioning begins to emerge and can be discussed and explored.

Sometimes, maybe often, patterns can be identified in the way a person relates to others. For instance, many people describe themselves as people-pleasers. Others describe themselves as successful and driven, yet chronically overworked and unable to slow down. Some find themselves endlessly doubting themselves in relationships. Others feel that, no matter what they achieve, they are never quite good enough, and that the people around them somehow confirm this impression.

Identifying these patterns is important. We become interested in understanding how these ways of being came to make sense. More often than not, they have a history. They have been shaped, often quite understandably, through significant relationships and life experiences.

What may feel like an irrational or counterproductive way of living today often reveals itself to have been a remarkably sensible adaptation at an earlier point in someone's life—often their childhood.

Listening to what remains unspoken

Also, sometimes what is most interesting is not what a person says about themselves, but what never seems to find words.

For instance, a person may speak for an hour about conflict without ever mentioning anger. Yet the anger can often be sensed in the room. It may permeate the person's tone of voice, the way their body tenses, their account of events, and their relationships, while never once being put into words. The question then becomes: why is this feeling so difficult to name? What made it dangerous, unnecessary or impossible to recognise?

And if that anger cannot be consciously owned, what happens to it instead? Where does it go?

The same questions can be asked of many other experiences. Sometimes it is not anger that has gone underground, but ambition, competitiveness, grief, dependency, vulnerability...

For various reasons, different parts of ourselves can come to feel irrelevant, forbidden, or simply too risky to acknowledge.

Making sense of suffering

As we begin to understand both the patterns that are lived out repeatedly and the experiences that remain hidden, another picture begins to emerge. We start to see the conflicts between different parts of the person.

One part may long for closeness while another may fear dependence. One part may strive relentlessly for success while another may believe they will never be good enough. One part may long to express anger while another has learned that anger threatens love or safety.

And where we find unnamed conflict, we often begin to understand suffering.

Appreciating the intelligence of symptoms

It is here that symptoms begin to make sense.

This is perhaps one of the biggest misconceptions about psychotherapy. We often think of symptoms as problems to be eliminated as quickly as possible.

Therapy invites a different question: what problem is this symptom trying to solve?

I do believe symptoms make sense. Not because they are pleasant or desirable, but because they represent the mind's attempt to resolve a conflict that has not yet found another expression. They are an imperfect solution, one that often creates suffering of its own, but a solution nonetheless.

A different way of thinking

Understanding what is being communicated through symptoms does not make anxiety, depression or panic disappear overnight. But it does gradually change the way we relate to them. Instead of asking only, "How do I get rid of this?", we begin asking, "What might this be trying to tell me?"

Perhaps that is where therapy truly begins—and where change becomes possible.