The Seven Tasks of Psychotherapy


Of course, what all therapies seek is change, but change what? Most of the popular traditions focus the one way people change, but, by my count, there are seven. For both patient and therapist, knowing how each is distinct can sharpen our focus and help us see our own change processes unfold.

Neurophysiologists believe that change really occurs in the connections between neurons. They are also beginning to map out how different functions of the mind have different locations and work somewhat differently. Just as computers store information in different places such as your hard drive, a memory stick, or the volatile memory that was holding your essay when the power went out, your brain does, too.  So it is not a surprise that change processes are not all the same.

1.  The first is the transformation that happens when we tell someone about our painful feelings. It is so common that we may take this near-miraculous process for granted. People who have suffered major trauma don’t. They know that it can be the most challenging kind of change to undergo because you have to face the painful feeling and experience it’s full depth before the transformation can happen. Freud called this change catharsis, and I personally don’t think there is a better term, even though most of the time it is far from dramatic. This kind of change happens in every therapy session, not to mention every day of our lives.

2.  Stop running from your feelings. Avoidance becomes automatic. Most of the time we are barely aware that we do it. Humans are very good at avoiding the very thing we need most:  To go through feelings.  We need a therapist to hold up a mirror revealing how we have been avoiding. For example staying too busy can be one way. Rationalizing our misery is another. Even feelings like anger can cover up sadness we dread even more. The mind has any number of tricks but once we know about them, we can begin to choose to face our feelings and heal.

3. The third task is gaining knowledge of ourselves and how we manage to keep our misery intact. Changing our mind happens instantly when we are exposed to new facts, so changing our understanding and awareness should be the easiest to achieve. Unfortunately our tricks for avoidance may get in the way. As we let go of avoidance and heal painful feelings, new knowledge will begin to come into view.

4.  Changing dysfunctional values and beliefs is one of the hardest tasks. We all have values, attitudes, ideals and prohibitions. We are proud of our values, and defend them to the death. To a large extent, they form our unique identity. They also serve to help us resist temptation, which is why they are partially independent from the self and particularly hard to change. Unfortunately, we can also have values that are contradictory and even downright dysfunctional. For example, you might feel that you have to do everything perfectly. If so, there is another part of your mind that feels you should enjoy the fruits of life as much as others with lower standards. But you never arrive at perfection so you are not allowed to enjoy anything. The two values, perfection and enjoyment, are incompatible and no matter which way you go, there is a loud complaint. People who have suffered early trauma know that the experience causes internalization of negative attitudes about the self.  You have to fight to accept that you are as good as anyone else. These are two of many situations where values need to change. This kind of change requires energy, focus, hard work and time. Cognitive-behavioral therapy (CBT) specializes in bringing these “core values” to light and changing them.

5. The fifth task is to restart arrested development. In a way, humans are like plant spores. When conditions are not good, our development can be put “on hold.” More often than generally realized, we may carry some very “young” characteristics and reactions. For example caretakers sometimes give to others what they are still wishing for themselves. Fortunately, all that may be required for development to resume is a feeling of safety and connection. When this happens, as it often does in therapy, the path of psychological development can be picked up where it was left off regardless of chronological age. Just as in childhood, growth and development happen when we try out new behaviors and go through the feelings of anxiety, vulnerability and strangeness that accompany them.

6. Changing behavior patterns: As behaviors are repeated, they become habits and take on a life of their own. Even though their bad consequences are clear, it becomes automatic or nearly so to follow them again and again. These behavior patterns may be the primary impediments to change. For example, moving directly from impulse to action will consistently avoid the step of feeling. Similarly, acting habitually like a second class citizen can make a negative attitude toward the self appear to be an established fact. Behavior patterns can also include not doing something. A person who never says “thank you,” may be avoiding acknowledgement of the need for others. Lives that have been damaged by addictions and other compulsive behaviors can only begin to be repaired when the behavior is stopped.

7. Reevaluate secret wishes and dreams. This change process is the core of psychoanalysis. By age five, as I see it, we have enough grasp of time to solve the problems of the present by dreaming of a better future. Sometimes these dreams are experienced as shameful and unacceptable. They are not given up but buried, waiting for eventual fulfillment. Blocked by fear and guilt, out of conscious awareness, they wait and search for opportunity. Intensive therapy is calculated to call out these wishes and plans, which usually involve the therapist. Their coming to light is often stormy and difficult, but the end result is a chance to reevaluate goals that date back to a much earlier age, a chance to seek fulfillment of those aspects that are consistent with adult life and to let go of those that are not. This is classic “neurosis.” How do you know if you have neurosis? See my post “OMG Do I Have Neurosis?” below.

At any time in therapy, the work will be focused on one or two, maybe three of these processes or tasks. As you become more aware of just which ones you are addressing, you will be more attuned to the best tools to use and how your efforts should be directed. Furthermore, you will be able to monitor your progress by observing moments of change as they happen.

In order to help with your observation, we have developed the Scarsdale Psychotherapy Self-Test (SPST). Click the link at the right and rate the sixteen items that reflect how well your therapy is working. It is a tool for thinking about and evaluating therapies of all kinds. In addition you will be able to enter your ratings and receive a confidential report of how your therapy compares with others from our database. These seven tasks are the basis of the book I am working on, so I will value your feedback and ideas. Please use the comment link below.


  • Change- the only constant in our lives, yet people cling onto the known when change can lead them down the pathway to success and happiness. Why is it people continue to do the same things and expect to get different results? The therapist must reach out and gently build a relationship with the client until they can help them find a way of changing their behaviour pattern without infringing on their core values.

  • I lately came across your blog and have been learning along. I believed I would leave my 1st comment. I do not know what to say except that I have loved reading. Fine weblog. I will keep visiting this blog very often.

  • “secret wishes and dreams … are not given up but buried, waiting for eventual fulfillment. … Intensive therapy is calculated to call out these wishes and plans, which usually involve the therapist. Their coming to light is often stormy and difficult … ”

    I was on the point of despair when I wrote the following to my therapist. But I think you have helped me to understand what is happening – thank you:

    I am trying so hard to make myself understood. I’ll give it one more shot and then I will give up – I am too weird to be comprehensible.

    I am talking about a fundamental biological need – the human need to feel felt. Here is my understanding of it (and it could be incorrect, of course). Feelings are signals of need – feelings can tell us we have some kind of need. It is a basic biological process – all life forms have some kind of sensory mechanism so that they can survive their environment (so that they can meet their needs) by responding to their sensations/feelings.

    Therefore, sensing feelings is the step that precedes having our needs met. It is vital for survival.

    As young helpless infants, we are dependent on adults to meet our needs. It is necessary for our feelings to be sensed by others, in order for the adult to be attuned to the needs of the infant. If the infant experiences that attunement through appropriate responses from the adult, the infant becomes confident that her needs will continue to be met and she feels secure because she is understood.

    Even though we grow up and are no longer dependent on others to meet our needs, we still need to feel felt – we are programmed to seek the experience of being felt by others … to want to share our feelings with others, and to experience attunement and empathy from others.

    Therefore, having others understand our feelings is hard-wired and remains a life-long desire. It is vital for mental health.

    But what if the (programmed) desire for intimacy and attunement is fraught with panic because it always seemed to lead to painful feelings? Not only did I feel isolated and disconnected because attempts to connect were thwarted, but I would take action to disconnect and isolate myself because attempts to connect would also inevitably lead to suffering (just letting someone become close would sooner or later end in disaster). Yet I would always be drawn back a little ways, only to flee again at the first sign of not being understood properly (which is the signal that things are about to go awry).

    So that is what I am doing right now. I am fighting the urge to flee. I have come full circle yet again, having first been lulled into a sense of trust and positive-thinking, only to slump into despair when it seems it is impossible to make myself understood, like the child who only wanted to share her happiness and was made to feel like a really awful person.

    I think that you can sense that I am feeling a particular feeling, but I don’t think you can understand the whole picture of it, what it means to experience that feeling in that particular context, what effect it has on me in the way I relate to others. I could be completely wrong and attributing things to you that really belong to the way my parents treated my feelings … having no understanding of how I experienced their actions … projecting onto you a blankness about what I experienced. But that is what I am sensing. A blankness.

    I know that I make it very difficult because when I am with you, part of me is always blocking you out to some extent, and that blocks out the communication that would help you to understand. I sit there and defend myself from you by shutting you out, but all the while I am silently pleading with you to help me … I don’t know any other way.

    And I don’t know how much more of this I can take … I am so close to wanting to end it again.

    • Dear Reader,

      Your letter is really powerful. I completely agree with you that having someone feel what we feel is a fundamental need and the basis of much of the healing that happens in therapy. In therapy, especially when the things we wish for may be impossible, being understood in a feeling way is good enough for healing to take place.

      In my regular website, in the first chapter of the course, I talk about “catharsis,” which is just what you are talking about. It is also central in the book I am working on, but, unfortunately that is not ready for publication.

      Another writer who understands what you are experiencing is Diana Fosha. In her book, The Transforming Power of Affect, chapters 4 and 5 she gives a good description of how problems like yours get started and some about what to do.

      I am very glad that my blog has been of help and wish you the best with your therapy.

      Yours, Jeffery Smith, MD

  • Thanks Jeffery

    I have been in psychotherapy for two years and have tried so very hard to make myself understood the whole time. It is more than seeking catharsis for me – it is also the “secret wishes and dreams … [that] are not given up but buried, waiting for eventual fulfillment” you wrote about.

    My emotional needs as a child were not understood or were ignored by my parents, and so I yearn for signs of understanding from my therapist about the effect that has had on me in the way I relate to others (panic and fleeing to retreat into isolation and disconnection), just as I silently yearned for signs of understanding from my father as a child (at some point, I must have given up on my mother as a source of comfort and help) … please make it stop, please understand what it is doing to me. Silent pleading. Powerlessness.

    Perhaps thinking about the “secret wishes and dreams … [that] are not given up but buried, waiting for eventual fulfillment” will help to empower me, or at least keep me going. I will try. After all, it’s signs of understanding that I yearn for … surely that can be fulfilled.

  • First off, how do I sign up to follow your blog?

    Second, may I have permission to post parts of your blog on my blog ( I have posted a number of blogs related to psychotherapy and feel your information would be of value to my readers.

    Patrick Day

    • Dear Patrick, Yes, you have my permission to publish parts of my blog on condition that you link to the blog itself. Thanks. I’ll put yours in my favorites, too. JS

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