BERLIN — Psychotherapy is a personal journey. Patients bring their own problems and hopes, their strengths and struggles, and they meet therapists who have their own methods, personalities, and experience. They talk and listen, they practice, learn, and sometimes clash.
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That makes it hard to compare one person’s therapy experience with another’s. Still, many want to know what makes therapy effective, whether their therapist is right for them, and when it might be time to switch or stop altogether.
There are a few key conditions and qualities in therapy that patients should be aware of. For this article, German weekly Die Zeit spoke to experts who study the topic and have extensive experience treating patients.
What does a typical therapy process look like?
It usually begins with an initial consultation. Patients learn how their mental health issues are being assessed, what they can do on their own, whether they need help, and if psychotherapy is the right choice.
After that they have up to three trial sessions, a kind of testing phase. During these sessions, the therapist and patient see whether they click, whether the therapy format fits, and what expectations are in play. Sometimes they agree on goals upfront. Other times, those goals only come into focus later on.
Therapists should discuss and manage these expectations. Not all therapy is aimed at a cure. In some cases, disorders are chronic or so severe that simply maintaining stability or finding better ways to cope is a success.
Only then does the real therapy begin. Patients explore what lies behind their problems and symptoms, and how they might resolve them. They learn to break old patterns, manage conflict, and try new approaches. Maybe that means having a long-overdue conversation with their parents, stopping the constant self-blame, managing fear more effectively, or getting to the bottom of recurring relationship troubles.
“Roughly a third of patients report a clear improvement from therapy,” says Antje Gumz, a medical psychotherapist at the Berlin School of Psychology who researches what makes therapy effective. “Around a quarter drop out early, and in five to ten percent of cases, symptoms actually get worse.”
There are various forms of therapy. The German health insurance system covers four standard types: behavioral therapy, depth psychology-based psychotherapy, analytical psychotherapy, and systemic therapy.
The type of therapy may not play a huge role in the outcome,
but it still needs to suit the patient.
All four have proven effective in numerous studies. For certain disorders like obsessive-compulsive disorder or specific anxiety issues, cognitive behavioral therapy tends to be slightly more effective. But for others, like depression or personality disorders, all four approaches seem to work equally well.
The type of therapy may not play a huge role in the outcome, but it still needs to suit the patient. A mismatch increases the chance that someone will drop out. If you want to fix a practical issue, you might not get much out of psychoanalysis focused on childhood. On the flip side, behavioral therapy can feel shallow if you’re trying to unpack deeper emotional history.
Ideally, therapy ends when the initial goals have been reached. If the allotted sessions run out, therapy can usually be extended.
How can you tell if your therapy is working?
Ralf Dohrenbusch, a psychotherapist who has led the University of Bonn’s outpatient clinic for nearly 20 years, points to several signs. You have a good relationship with your therapist, feel understood, and generally enjoy going. You’re motivated to change and face your problems. You have meaningful or unexpected insights that you wouldn’t get from friends or family, and those help you grow.
“When therapy is going well, I notice I’m feeling better,” says Dohrenbusch. “I get more in touch with myself, my internal conflicts begin to untangle, and my symptoms start to fade, or at least I feel more able to manage them.”
If that’s not the case right away, patients should at least feel like therapy is addressing the right problems, says Gumz.
That said, progress rarely moves in a straight line. There are ups and downs. “Symptoms may temporarily worsen or stagnate,” says Gumz. That can be painful, but it’s often part of the process.
Confronting early trauma can hurt, but it can also be healing.
For example, if someone feels worthless, it might stem from childhood experiences, like being told repeatedly they were stupid. Therapy might involve writing a letter to their parents or doing a role-play exercise to see how cruel and baseless those comments were, and to realize that the low self-esteem has no real foundation. Confronting early trauma can hurt, but it can also be healing.
If therapy doesn’t seem to be helping and it’s not just because of emotional discomfort, patients should speak up, says Gumz. A good therapist will work through those fears and help resolve them. Research shows that resolving tension and conflict in therapy often leads to better outcomes.
Sometimes a rift or distrust, once addressed, can actually push the therapy forward.
Gerhard Zarbock, a psychologist and child and adolescent therapist in Hamburg, saw this firsthand. He had a patient who seemed uneasy from the start. When he brought it up, it turned out the patient’s abusive father had the same first name: Gerhard. “After we talked about it, the therapy really turned around,” Zarbock recalls. “Sometimes a rift or distrust, once addressed, can actually push the therapy forward.”
If everything feels too easy and superficial, that might also be a red flag, says Gumz. Good therapy stirs things up a bit. Therapists are emotionally engaged, and patients should feel the sessions are focused deeply on them. “They should feel seen and understood on a deeper level,” Gumz says.
What makes a good therapist?
One of the most important markers of quality is proper training. Licensed psychological or medical psychotherapists, as well as child and adolescent psychotherapists, have completed several years of post-graduate training. That’s not true for coaches, counselors, or alternative healers.
But therapists are people too, with different personalities and levels of competence. Some therapists (10 to 15%) consistently get better results than others. A therapist’s personal impact on outcomes is estimated at around 5 to 10%. Other factors — like the nature and severity of the disorder, and the relationship between therapist and patient — also play a major role.
So what else makes a therapist effective?
Specialization helps with more complex or rare conditions, like trauma, borderline personality disorder, or psychotic illnesses. But most therapists treat things like anxiety, depression, stress, or burnout without needing a specific focus.
Factors like age, gender, experience, or whether they have a medical or psychology background don’t affect quality, says Gumz, even though many patients assume they do.
The relationship between therapist and patient, the so-called therapeutic alliance, is one of the most important success factors.
But certain traits are helpful: being warm and respectful, having confidence in the process, being able to express and regulate emotions, and handling stress. Self-awareness and openness to feedback are also important. Patients benefit when therapists are reflective and culturally competent.
The relationship between therapist and patient, the so-called therapeutic alliance, is one of the most important success factors. When it’s strong, there’s mutual respect and shared goals. Even small things like similar speaking styles or body language can strengthen the bond.
A strong alliance makes you feel understood and hopeful. You develop fresh perspectives, appreciate the therapist’s calm and kindness, and believe together you can make progress, says Zarbock. If that’s missing, it may be worth considering a change.
Some women may not feel comfortable with male therapists. Some dislike seeing a therapist wearing flashy jewelry or designer clothes. Others might be put off by incense and crystals. If you’re not at ease, Zarbock advises speaking up — and looking for someone who’s a better fit.
When is it time to switch therapists?
Almost all therapy includes tough moments. “But if patients try to talk about their concerns and the therapist doesn’t respond, that’s a bad sign,” says Gumz. If therapy feels like a chore, if you can’t open up, or if you don’t feel hopeful, it might be time for a change.
Start by exploring your doubts together. Maybe you don’t like the approach or feel it’s not a good match. It’s the therapist’s job to address that. “If they can’t or won’t, that’s a valid reason to look for someone else,” says Gumz.
Changing therapists is better than quitting altogether, even if it means going back on a waiting list. And if it didn’t work out, don’t blame yourself, she says.
What should never happen in therapy?
Therapists shouldn’t bring their own personal problems into sessions. They can share experiences or feelings when it helps the relationship, but therapy should never become about them.
There are also clear boundaries that should never be crossed. Therapists must respect confidentiality, avoid flirtation, and never suggest meeting privately. Any inappropriate physical contact is grounds to end therapy immediately.
If something feels wrong, patients can report it. In Germany, there are Psychotherapists’ Chambers in each region, where experts can look into the situation and take action if necessary.
When should you stop therapy?
If you feel better before your sessions are finished, you can end therapy at any time. Just make sure to talk it over with your therapist and confirm that your issues have truly improved.
These questions can help:
What goals did I set at the beginning? Have I met them? What problems brought me to therapy, and how are they now? How did these issues affect my life, relationships, work, energy, and mood? What’s different today? How long have I felt better? What makes me confident this will last? Do I know what to do if symptoms return?
If issues come back and you want to continue therapy, you can start again. But in many cases, that won’t be necessary. Study after study shows that the benefits of therapy can last for years.
