How Psychotherapy Works

A brief history of psychotherapy

The diagnosis and treatment of mental illness date back to ancient Greece. However, psychotherapy as a method of treatment did not become prominent until the late 19th century, largely due to the work of neurologist Sigmund Freud, the “father” of psychoanalysis. Freud posited that anxious and depressive symptoms could be eliminated via a “talking cure,” by which patients uncovered repressed thoughts and memories.

While Freudian thought continues to influence modern, psychological theory, psychotherapy has also greatly changed since the turn of the century, resulting in various, sometimes even contrasting, approaches to treatment. Given this development, it’s no wonder people are often skeptical of psychotherapy, and wonder if/how it works.

Evidence that “just talking” makes you feel better

One thing that has changed significantly since the time of Freud is the amount of scientific evidence that exists in support of psychotherapy. While much of this research focuses on behavioral treatments (Cognitive-Behavioral Therapy, or CBT, being one), there is a growing body of literature that suggests that traditional “talk therapy” is just as, if not more effective at alleviating symptoms than other forms of treatment, including medication (Shedler, 2010).

For example, in 2006, in a study led by Allan Abbass at Dalhousie University, psychoanalytic psychotherapy was three times more effective than medication in reducing symptoms of depression, anxiety, and other stress-related and psychological ailments (Abbass et. al., 2006). Perhaps more striking, Abbass found that the benefits patients received from psychotherapy persisted and expanded even after patients ceased treatment (Abbass et. al., 2006).

A series of studies at Penn State in 1996 showed that insight-based psychotherapy led to significant reductions in symptoms and improvements in the functioning of depressed patients, especially when the alliance between patient and therapist was strong (Castonguay et. al., 1996). This is why I counsel my patients to meet with several therapists before choosing one.

How the “talking cure” works

Human beings, and the brains that govern their thought, emotion, and behavior, are complicated. Moreover, as previously mentioned, there are almost as many psychotherapeutic approaches as there are psychological disorders. Although neuroimaging has allowed scientists to begin to map brain function and pathology, much is unknown about how different treatments help people to recover from illnesses like depression, anxiety, and PTSD. However, researchers and practitioners of psychotherapy seem to agree on several key ideas:

  • Psychotherapy allows patients to explore and express the emotions that are causing distress or dysfunction and teaches them new, more effective ways of dealing with these emotions.
  • Psychotherapy helps patients to identify recurring themes in thinking and behavior and change self-defeating cognitive and behavioral patterns.
  • Psychotherapy may lead to structural changes in the brain.

Possible biological underpinnings

Neurobiological research has demonstrated structural changes in the brain change in response to experience (Doidge, 2007). Dr. Susan Vaughn, psychiatrist and instructor at Columbia College, argues in her book The Talking Cure that psychotherapy works by providing an experience that effectively alters patients’ cerebral cortices. The cerebral cortex is the outermost “layer” of the brain and is comprised of a complicated web of interconnecting neural cells that govern how we process and retain information and experiences. Neurons form connections based on how often they fire simultaneously. As Vaughn puts it, “neurons that fire together, wire together.” A simple example of this is the association most people make between peanut butter and jelly. Because peanut butter and jelly are often mentioned or experienced together, the neuronal network that encodes the mental representation of “peanut butter” is activated alongside the neuronal network that encodes the representation of “jelly.” Over time, the two do not need to actually coexist (in the form of a sandwich, say) for the mention of one to elicit thoughts of the other.

Vaughn posits that the cerebral cortex functions as a “story synthesizer” that integrates and makes sense of patients’ experiences. Sometimes these stories include “false connections” or problematic themes—for example, irrational phobias. Psychotherapy teaches patients to “rewrite” their life histories, a potential “rewiring” of neural connections that corresponds with a reduction in depressive or anxious symptoms (Vaughn, 1997). As she surmises, “True brain training requires focused attention to recognizing and challenging the associations your life experiences have led you to construct.”


Abbass AA, Hancock JT, Henderson J, Kisely SR. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004687. DOI: 10.1002/14651858.CD004687.pub3

Castonguay, L. G., Goldfried, M. R., Wiser, S. L., Raue, P. J., & Hayes, A. M. (1996). Predicting the effect of cognitive therapy for depression: A study of unique and common factors. Journal of Consulting and Clinical Psychology, 64, 497–504. doi:10.1037/0022-006X.64.3.497

Doidge, N. (2007) The brain that changes itself. New York, NY: Penguin Books.

Sheldon, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109.

Vaughn, S.C. (1997) The Talking Cure. New York, NY: Henry Holt and Company.