Understanding Talk Therapy: Benefits, Risks and Enhancing Therapeutic Outcomes

Talk therapy is treatment that works through conversation with a trained therapist. This page covers both sides: what therapy can do, what can go wrong, how to judge whether the therapy you are in is helping, and what to do when it is not.

The plain definition, and a guide to the different types of talk therapy, are covered separately elsewhere on TherapyRoute. If you already have the gist and want to weigh it up, this page does that.

How often you go, and how long it takes

There is no single correct schedule. Weekly is the common arrangement, and a course of therapy is more often measured in months than in years.

Trial evidence gives a sense of scale. In a trial comparing once-weekly with twice-weekly psychotherapy for depression, the 191 patients who started treatment received a mean of about 17 sessions. In that trial there was no difference between the two frequency conditions in the total number of sessions.¹ The twice-weekly group finished sooner, and also showed a greater fall in depressive symptoms, less drop-out and a higher response rate.

Frequency can matter for some treatments. In a review of art therapy for anxiety in children and adolescents, twice-weekly sessions showed a more pronounced effect size than weekly sessions.² That finding belongs to that age group and that therapy. It does not settle the question for adults in talk therapy.

How much therapy you can reach may not be yours to decide alone. What is funded, and which therapies count, is set country by country. Under Australia's Medicare Benefits Schedule, a set range of psychological strategies is approved for use by eligible health professionals under the focussed psychological strategies items.³ Ask your therapist what applies where you live.

What talk therapy can do, and how well it works

For depression the international guidance is specific. The World Health Organization states that psychological treatments are the first treatments for depression. The same WHO fact sheet says psychological treatments can be combined with antidepressant medications in moderate and severe depression, and that antidepressant medications are not needed for mild depression.⁴

Different therapies can reach similar results. In borderline personality disorder, clinical trials show that methods based on very different theories can be effective.⁵ Gunderson and Links argue that the different evidence-based therapies for borderline personality disorder must share underlying processes that account for their similar profile of benefits.⁶

One of those shared processes appears consistently. The alliance between therapist and client is an important factor in successful therapeutic outcomes regardless of the modality of therapy.⁷ In plain terms, who you work with, and how you work together, affects the result whatever method is used.

Format matters less than people expect. The American Psychological Association reports that teletherapy delivered by telephone or videoconferencing has been shown to have similar outcomes to in-person therapy.⁸ Research on videoconferenced therapy points to the therapeutic approach, rather than the technological medium, as having the largest impact on the therapeutic relationship.⁹ TherapyRoute covers teletherapy on its own page.

The risks, stated plainly

Therapy is a treatment, and treatments carry risk. Researchers separate two kinds. A commentary on negative effects in psychotherapy separates deterioration, meaning a measured change in a negative direction, from adverse and unwanted events, which need not show up as increased symptomatology.¹⁰ So harm does not always show up as feeling worse.

Yalom notes that although most therapists help their clients, some therapists make some clients worse.¹¹

Therapy also simply fails to help some people. Miller and Rollnick report that motivational interviewing does not always help people change, and that its effects vary substantially across providers, sites and studies.¹² Motivational interviewing is one well-studied approach among many, and the pattern is not unique to it.

Other risks to know about before you start:

• Sessions can be distressing. Talking about painful material is uncomfortable, and that discomfort is real rather than proof you are doing it wrong.
• A poor fit with a therapist can stall the work.
• Confidentiality has limits. Those limits are set by law and by professional codes, and they are not the same in every country.
• Therapy may not be the right treatment for you, or not the only one you need.

Ask your own therapist, at the first session, what they would have to pass on and to whom. Rules written for another country will not answer it for you.

Feeling worse before feeling better

You will find pages saying that early distress in therapy shows the work is going well. Some call this "the therapeutic paradox" and present it as established terminology. It is not established terminology for that idea, and there is no research finding behind it.

Both readings can be true. Hard sessions are part of ordinary therapy. So are the early sessions of a treatment that is going wrong. What separates them is the pattern over weeks, not any single difficult hour.

Research on failed therapy found something specific. In a Norwegian study of therapies that failed, von der Lippe and colleagues found that rejection of the therapist's interventions predicted negative outcome most strongly and escalated with time, against a subtly hostile therapeutic climate.¹³ So the warning sign is not discomfort. It is escalation over time.

The therapist's side counts too. Reviewers of the countertransference research concluded that its principal effect is to strain the therapeutic alliance, and that an unrepaired strain is likely to have a negative impact on client outcome.¹⁴ The important word is unrepaired. Ruptures happen in good therapy. What matters is whether they get talked about and mended.

If your distress rises sharply between sessions, do not wait for the next appointment. Contact your therapist, your doctor, or your local emergency service.

What your therapist should set out at the start

Good therapy starts with an explicit agreement. Judith Herman writes that the therapy contract should be set out to the patient explicitly and in detail.¹⁵ It gives you something to judge against later, when you want to know whether the therapy is doing what it said it would.

Reasonable things to have covered at or before the first session:

• What you are working on, in your own words, and what would count as progress
• Roughly how often you will meet, and what happens if that needs to change
• Fees, cancellation, and whether there is any contact between sessions
• What your therapist would have to disclose, to whom, and in what circumstances
• Their training and registration, and which body they answer to

If a therapist will not discuss the last two, ask why.

How to tell whether your therapy is working

Two things are worth checking.

The first is the relationship. Successful therapists are described as understanding, accepting, empathic, warm and supportive.¹⁶ Those are reasonable things to expect, and to notice when they are missing.

The second is tracking. Routine process monitoring, where the alliance is measured session by session, has emerged as a promising approach to enhance therapy outcomes.¹⁷ Some therapists use short session-rating forms for exactly this. You can ask whether yours does.

A no to any row is worth raising in the room. It is not a reason to disappear from therapy without saying why.

Getting more out of your sessions

Preparation helps, and it need not be elaborate. Before a session it is usually enough to know the one thing you most want to use the time for. Some people keep a note during the week, because what felt urgent on Tuesday is hard to recall by Friday.

Say the awkward thing early. What you bring to the session shapes the work, and the material people hold back longest tends to be the material that matters most.

None of this is a rule. If keeping notes turns therapy into homework, stop keeping notes.

What to do when it is not working

Start by saying so, in the room. This is the step people skip, and it is the one with evidence behind it. A review of humanistic psychotherapy research found that seeking feedback from the client at regular intervals, and particularly once therapy has bogged down, improved the effectiveness of therapy.¹⁸

How your therapist responds matters. A conversation-analysis study of a single therapy session found that some therapist responses were endorsed by the client while others were rejected as inappropriate displays of understanding or empathy.¹⁹ If a response repeatedly feels wrong, say so rather than tolerate it.

A different approach may suit you better. A standard psychiatry text notes that behavioural treatment may not be appropriate for people who are not ready to change, or who would rather explore the historical origins of their problems than take action.²⁰ That is a mismatch, not a failure on your part. Cognitive behavioural therapy, psychodynamic therapy and mindfulness-based approaches all work through conversation in different ways. Others work through another medium: art therapy, music therapy, dance and movement therapy, and animal-assisted therapy.

Medication is a separate decision, taken with a prescriber rather than with a therapist who cannot prescribe. For depression, the World Health Organization guidance set out earlier on this page is the sensible starting point.

Changing therapist is a legitimate step and not a verdict on the last one. Stopping is too. Where a therapist is registered, there is a body that handles complaints about conduct, which is a different matter from a poor fit. Your therapist should be able to tell you which body that is.

Finding a therapist who fits

Fit matters. The alliance between you and your therapist, set out earlier on this page, is part of how therapy works.

If you are starting, or starting again, our guide to finding the right therapist covers what to look for and what to ask. You can search for a registered therapist in your own country through the TherapyRoute directory.

Team TherapyRoute

References

1. [1] The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients - The British Journal of Psychiatry - Cambridge Core. cambridge.org.
2. [2] Zhang B et al., The effects of art therapy interventions on anxiety in children and adolescents: A meta-analysis. Clinics (Sao Paulo) (2024). pmc.ncbi.nlm.nih.gov/articles/PMC11260852.
3. [3] Item 80110 - Medicare Benefits Schedule. www9.health.gov.au/mbs/fullDisplay.cfm.
4. [4] Depressive disorder (depression). who.int.
5. [5] Paris - Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice: Paris - Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice, Chapter 10 (pt 1).
6. [6] Gunderson & Links - Borderline Personality Disorder: A Clinical Guide (2nd ed, 2008): Gunderson & Links - Borderline Personality Disorder: A Clinical Guide (2nd ed, 2008), Generic Qualities of Effective Psychotherapies.
7. [7] Chapter 7, Brief Psychodynamic Therapy - Brief Interventions and Brief Therapies for Substance Abuse - NCBI Bookshelf. ncbi.nlm.nih.gov/books/NBK64952.
8. [8] Telehealth and telepsychology. apa.org. apa.org/practice/telehealth-telepsychology.
9. [9] Frontiers | Couples Therapy Delivered Through Videoconferencing: Effects on Relationship Outcomes, Mental Health and the Therapeutic Alliance. frontiersin.org.
10. [10] Rozental A et al., Negative effects in psychotherapy: commentary and recommendations for future research and clinical practice. BJPsych Open (2018). pmc.ncbi.nlm.nih.gov/articles/PMC6066991.
11. [11] Yalom - Theory and Practice of Group Psychotherapy: Yalom - Theory and Practice of Group Psychotherapy, THE IMPORTANCE OF GROUP COHESIVENESS (pt 1).
12. [12] Miller & Rollnick - Motivational Interviewing (4th ed, 2023): Miller & Rollnick - Motivational Interviewing (4th ed, 2023), 18. Studying Motivational Interviewing (pt 1).
13. [13] von der Lippe AL et al., Treatment failure in psychotherapy: the pull of hostility. Psychother Res (2008). pubmed.ncbi.nlm.nih.gov/18815994.
14. [14] Cain, Keenan & Rubin - Humanistic Psychotherapies: Handbook of Research and Practice (2nd ed, 2016, APA): Cain, Keenan & Rubin - Humanistic Psychotherapies: Handbook of Research and Practice (2nd ed, 2016, APA), Chapter 13 The Good Therapist: Evidence Regarding the Therapist’s Contribution to Psychotherapy (pt 3).
15. [15] Herman - Trauma and Recovery (2015): Herman - Trauma and Recovery (2015), Chapter 7: A Healing Relationship (pt 3).
16. [16] Mindfulness and the Therapeutic Relationship: Mindfulness and the Therapeutic Relationship, Epilogue.
17. [17] Kamp D et al., The additional value of self-reflection and feedback on therapy outcome: a pilot study. Front Psychol (2024). pmc.ncbi.nlm.nih.gov/articles/PMC11700981.
18. [18] Cain, Keenan & Rubin - Humanistic Psychotherapies: Handbook of Research and Practice (2nd ed, 2016, APA): Cain, Keenan & Rubin - Humanistic Psychotherapies: Handbook of Research and Practice (2nd ed, 2016, APA), Chapter 15 Toward a Research-Based Integration of Optimal Practices of Humanistic Psychotherapies (pt 5).
19. [19] Muntigl P, Managing Distress Over Time in Psychotherapy: Guiding the Client in and Through Intense Emotional Work. Front Psychol (2019). pmc.ncbi.nlm.nih.gov/articles/PMC7042173.
20. [20] Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2): Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 10th ed (2017, vols 1+2), 33.3: Behavior Therapy (pt 7).