What Do People Actually Find Helpful in Therapy?

When people consider therapy, they often imagine talking about their problems and receiving professional advice. Perhaps the therapist will explain why they feel the way they do, suggest what to change, or teach them how to cope better. Advice and psychological knowledge can certainly be useful. But research into what clients themselves experience as helpful in psychotherapy suggests a more complex picture.

Irvin Yalom's early research into therapeutic factors in group psychotherapy found that patients valued experiences such as gaining a deeper understanding of themselves, expressing previously unspoken feelings, discovering how they affect other people, feeling accepted, and learning new ways of relating. Direct advice was not among the experiences they valued most highly.

Although Yalom in research studied group psychotherapy practice, his findings raise a broader and still relevant question:

What actually helps us change in therapy?

Understanding yourself

Most of us have explanations for why we are the way we are. Today, we may even arrive in therapy knowing about attachment styles, trauma responses, boundaries or emotional regulation. We may know that we are afraid of rejection, have difficulty saying no, or repeatedly become involved with emotionally unavailable people.

But knowing something about yourself is not quite the same as understanding yourself.

Understanding becomes more personal and immediate. Why is another person's disappointment so difficult for me to tolerate? What happens just before I withdraw from someone I love? Why do I say yes while feeling no? What am I protecting when I become silent and dissangaged?

Therapy can create the time and relationship in which these questions are explored rather than answered too quickly. Self-understanding does not necessarily give us a final explanation of who we are. It can, however, make our own experience less invisible to us.

Discovering the parts of yourself you find difficult to accept

One of the highly valued experiences in Yalom's early patient research concerned recognising and accepting previously unknown or unacceptable aspects of oneself. This is an important qualification to the popular idea of “self-discovery”. What we discover in therapy is not always something we like.

We may encounter our jealousy, dependency, resentment, need for approval, wish to control, fear of intimacy or capacity to hurt other people. We may discover that something we have always attributed to others also involves us.

Self-acceptance does not mean approving of everything we do. Sometimes the opposite is true: acknowledging an uncomfortable part of ourselves makes it possible to take responsibility for it. What remains unacceptable to us often has to remain hidden. And what remains hidden can be remarkably powerful.

Saying what has been difficult to say

Yalom used the term catharsis for another therapeutic factor: expressing feelings that have previously been held back. There are many things people find difficult to say in ordinary relationships. We may be ashamed of them, afraid of hurting someone, or worried about what another person will think of us. Sometimes we have not spoken because we ourselves barely understand what we are feeling.

Therapy can become a place where a person says, perhaps for the first time: I am jealous. I am angry with my child. I feel alone in my relationship. I am frightened of ageing. I don't know whether I love my partner anymore. I need other people much more than I want anyone to know.

The therapeutic value is not simply “getting it off your chest”. Something also happens when another person hears what has been difficult to say and remains present. We may begin to hear ourselves differently too.

Learning how other people experience you

Yalom called another important therapeutic process interpersonal learning. All of us have an idea of what we are like in relationships. That idea does not always correspond to other people's experience of us.

A person may experience themselves as caring while others sometimes experience their care as control. Someone may see themselves as independent while people close to them experience them as unreachable. Another may try very hard never to burden anyone and then wonder why they feel alone.

Psychotherapy offers an unusual opportunity because a relationship is happening in the room while it is being talked about. A therapist might notice that whenever disagreement appears, the client quickly changes the subject. Or that they apologise after expressing anger. Or that they repeatedly ask what the therapist thinks before saying what they themselves think.

Such moments can make an interpersonal pattern visible in a way that explanation alone cannot.

Experiencing a relationship differently

We do not leave our relationship history outside the therapy room. If disagreement once threatened connection, disagreeing with a therapist may feel dangerous too. If being loved meant being easy and undemanding, a person may try to become a “good client”. If closeness has previously involved intrusion or control, even genuine interest from another person can feel uncomfortable.

This means that therapy can offer something beyond talking about relationships. It can become a place where a relationship is experienced differently.

A person may disagree and discover that the relationship survives. They may say, “I don't think you understood me,” and find that the other person is willing to listen. They may express anger without being rejected, or depend on another person without losing all sense of themselves.

Such experiences do not erase the past. But they can introduce another possibility for how a relationship can be.

Feeling accepted without having to present only your acceptable self

In group psychotherapy, Yalom described cohesiveness as an important therapeutic factor: the experience of belonging, being accepted and feeling valued within the group. Individual psychotherapy is different, but acceptance remains central to the therapeutic relationship.

Many of us have learned to present particular versions of ourselves: competent, reasonable, independent, helpful, undemanding. The parts that do not fit this identity may be carefully concealed.

Therapeutic acceptance does not mean that everything a client does is approved or left unchallenged. Rather, difficult aspects of a person's experience can be approached without immediately rejecting the person who has them. Sometimes being met this way by another person makes it possible to become more curious, and less defensive, towards oneself.

Realising that your experience is human

Yalom called this universality. In group therapy, people can directly discover that others have fears, thoughts and feelings similar to their own. This can be particularly powerful when someone has spent years believing that a certain experience proves there is something fundamentally wrong with them.

Individual therapy cannot reproduce this in exactly the same way. Yet people can still discover that jealousy, ambivalence, dependency, loneliness, fear of death, resentment towards someone they love or uncertainty about the life they have chosen are not uniquely shameful experiences.

This is different from being told, “Everyone feels that way.” That response can minimise someone's experience. Universality allows for something subtler: my experience is uniquely mine, but I am not alone in being human enough to have it.

Finding more room to choose

This may be one of the less visible benefits of psychotherapy. Much of what we do in relationships happens quickly. We feel threatened and withdraw. We anticipate rejection and reject first. We fear disappointing someone and immediately agree. We feel hurt and attack.

When a pattern becomes more visible, a small space can appear between what we feel and what we do. In that space there may be another possibility.

I can say that I am hurt instead of attacking. I can ask instead of expecting another person to guess. I can remain in a difficult conversation instead of disappearing. I can tolerate someone's disappointment without immediately abandoning my own position.

These may look like small changes. In a person's life, they can be substantial.

Accepting what therapy cannot fix

Psychotherapy is often described in the language of change. But not everything in human life can be changed. We cannot alter our past. We cannot guarantee that people will love us or remain with us. Every important choice closes off other possibilities. We cannot completely protect ourselves from loss, illness, ageing or death.

These concerns are particularly important in existential psychotherapy. Sometimes therapy is not about finding a better strategy for solving a problem. It is about recognising that something is not a solvable problem at all.

There can be an important difference between what needs to be changed and what needs to be grieved, accepted or learned to live with. Acceptance in this sense is not resignation. When we see more clearly what is outside our control, we can also ask more seriously what remains ours to choose.

So, is therapy mainly about getting good advice?

Probably not. Yalom's early research should be interpreted carefully. His original work concerned group psychotherapy, involved relatively small samples, and should not be treated as a universal ranking of what every client needs. Different therapeutic approaches, difficulties and people require different things.

But one aspect of his findings remains particularly thought-provoking: clients placed considerable value on insight, emotional expression and interpersonal learning, while direct guidance was valued less highly.

Later psychotherapy research has also repeatedly found an association between the quality of the therapeutic alliance and treatment outcomes. A large meta-analysis by Christoph Flückiger and colleagues, covering more than 30,000 clients, found a consistent relationship between therapeutic alliance and psychotherapy outcome.

This does not mean that the relationship is the only thing that matters, nor that therapeutic methods are irrelevant. It does suggest that psychotherapy is difficult to reduce to an expert telling another person what to do.

Sometimes a good piece of advice is exactly what we need. At other times, the more important question is why we cannot do what we already know would be good for us.

What people may find helpful in therapy

There is no single therapeutic experience that will matter equally to everyone. But Yalom's work gives us useful language for some of what may happen:

understanding ourselves more deeply, expressing what has remained unspoken, seeing how we affect other people, experiencing acceptance, recognising recurring relationship patterns, trying new ways of relating, finding hope, taking greater responsibility for our choices, and accepting some of the limits of being human.

Perhaps this is why psychotherapy can be difficult to explain to someone who has never experienced it. Its value may not lie only in what the therapist tells us.

Sometimes it lies in what becomes possible to see, say and experience in the presence of another person – and in what we then begin to do differently outside the therapy room.

Sources and further reading

Yalom, I. D., & Leszcz, M. (2020). The Theory and Practice of Group Psychotherapy (6th ed.). Basic Books.

Yalom, I. D. (1980). Existential Psychotherapy. Basic Books.

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340.

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