I sometimes tell clients that I can be remarkably patient with change. I have worked with people who made enormous changes very quickly, and I have worked with people whose progress happened in inches over a period of years. I am genuinely okay with both. What matters to me is not the speed of change, but whether we are actually doing therapy, whether something, however small, is beginning to move.

That distinction matters because therapy is hard, and change is rarely linear. People have setbacks. Couples have a wonderful week and then fall directly back into the argument they have been having for fifteen years. Someone can understand a pattern intellectually long before they are able to respond differently when they are tired, scared, angry, or hurt. None of that makes me think therapy isn't working, and none of it makes me impatient with the people sitting in my office.

What concerns me is something different. It is when, after a meaningful period of time, we are essentially having the same conversation we had at intake. The same problems are occurring at home, the same explanations are being offered for them, the same partner is waiting for the other one to change, and the things we discuss in therapy never quite make it out of the therapy room. At that point, I think we have an obligation to stop and ask a harder question: What exactly are we doing here?

Showing Up for Therapy Is Not the Same as Doing Therapy

Making an appointment is important. Coming back the next week is important. Being honest with your therapist is important, and having a strong relationship with your therapist matters enormously. But attendance, by itself, is not change.

Research has consistently found an association between the therapeutic alliance and treatment outcome. One large meta-analysis by Flückiger and colleagues examined 295 studies involving more than 30,000 patients and concluded that the findings “confirm the robustness of the positive relation between the alliance and outcome.” In other words, the relationship between therapist and client matters a lot. But a good therapeutic relationship exists in service of the work. Feeling understood by your therapist cannot be the only thing that happens there.

The same principle becomes particularly interesting in couples therapy, because there isn't just one therapeutic relationship in the room. Research involving 1,545 couples found that the therapeutic alliance was significantly related to outcome, and that more split or unbalanced alliances were associated with poorer outcomes. The researchers also emphasized something couples therapists see every day: the extent to which partners agree about the problem and value working together toward shared goals matters. Couples therapy, by its nature, asks people who may profoundly disagree with each other to begin collaborating on creating something different.

And "different" does not have to mean dramatic. It might mean that the person who usually leaves the room stays for another two minutes. It might mean catching one criticism before saying it, asking one curious question instead of defending, or initiating affection when you normally wait for your partner to do it first. Sometimes I am looking for changes so small that no one outside that relationship would even notice them. But those small changes tell us something important: we are no longer simply rehearsing the problem.

Therapy Can Accidentally Become Part of the Problem

There is a concept in family systems work called isomorphism. Put simply, patterns have a way of repeating themselves across systems. The dynamic that exists at home can eventually begin showing up in therapy, too. And if we aren't paying attention, therapy itself can become incorporated into the very pattern we are supposed to be changing.

Imagine a relationship in which one person has been saying for years, "Something has to change," while the other person agrees in the moment but ultimately does very little differently. They come to therapy. Now one partner says in my office, "Something has to change," the other partner agrees that something has to change, I help them identify what needs to change, and then they go home and nothing changes. They return the following week, or two weeks later, and we do it again.

We can do that for a surprisingly long time and call it couples therapy. Everyone is showing up. Everyone may even be sincere. The couple gets to say, "We're working on our marriage," and perhaps they are spending considerable time, money, and emotional energy doing so. But structurally, we may have recreated exactly what happens at home: there is a great deal of discussion about the problem and very little willingness to do something different about it.

At some point, continuing that process without naming it is not particularly therapeutic. In fact, I worry that it can reinforce the existing system. Now, instead of simply being stuck, we are stuck and going to therapy. The presence of a therapist can create the appearance that something is being addressed when the more difficult reality may be that one or both people are not yet willing to make the changes the relationship requires.

Coming to Therapy Is Already an Admission That Something Isn’t Working

There is something implicit in the decision to seek therapy that I think is worth saying out loud. Making that first appointment usually means acknowledging that whatever you have been doing has not been sufficient. Maybe it worked once and doesn't anymore. Maybe it has never worked particularly well. Either way, if the old way were working, you probably wouldn't be sitting in my office.

That means therapy eventually has to ask something of you. It may ask you to tolerate anxiety rather than organize your life around avoiding it. It may ask you to have a conversation you have been putting off, set a boundary you are frightened to set, listen to something you don't want to hear, or consider that your partner's experience can be valid even when you remember the event differently. It may ask you to stop doing something that has protected you for decades because that same protection is now costing you intimacy.

None of those things are easy. In fact, sometimes resistance to change is the most understandable thing in the room. The behavior causing trouble today often developed for a very good reason somewhere else, and good therapy should be interested in that reason rather than simply demanding that the behavior disappear. Understanding why something is difficult, though, is different from deciding that because it is difficult, it never has to change.

I Don't Require Big Change. I Do Require Movement.

I want to be very clear about this, because I would never want a struggling client to read this and think, I'm not getting better fast enough. My therapist is going to give up on me. That is not what I mean. Some of the work I respect most has been done by clients who struggled mightily to make changes that probably looked very small from the outside.

Sometimes progress is messy. Sometimes we spend weeks figuring out what happened after an experiment went badly. Sometimes someone does the new thing once and then cannot do it again for a month. Sometimes the progress is simply that a person recognizes the cycle twenty minutes after it happened instead of three days later, and eventually twenty minutes becomes five minutes, and five minutes becomes recognizing it while it is happening.

That is work. That is movement. That is a person beginning to develop the capacity to do something other than what they have always done. I can be enormously patient with that process because there is evidence that something is happening.

What I am much less willing to do is conduct the same session indefinitely. If months have passed and we are still receiving essentially the same report we received at intake, I am going to talk about that. I may recommend that we change our approach, increase or decrease the frequency of treatment, bring in another kind of support, or reconsider what our goals actually are. And sometimes I will say that I don't think continuing therapy with me is clinically useful and recommend another provider or another course of action.

Sometimes One Person Is Doing the Work and the Other Isn't

This becomes particularly important in couples therapy because progress does not always stall equally. Sometimes one person is changing. They are regulating differently, communicating differently, becoming more accountable, setting boundaries, reaching for their partner, or working hard to understand their contribution to the relationship. And the other person simply isn't.

That is not something I can fix for the couple. I cannot make an adult become more empathic, more accountable, more affectionate, less defensive, more engaged, or more willing to examine themselves. I can create conditions that make those things more possible, and I can help someone understand what gets in the way. But eventually, willingness belongs to the person whose willingness is required.

When that happens, the lack of movement becomes important information for the partner who is working. The question may gradually shift from "How do we get my partner to change?" to "What does it mean for me if my partner is not willing to change?" Those are profoundly different questions, and sometimes the second question becomes the beginning of very important individual therapy.

It doesn't necessarily mean the relationship has to end. It does mean we have to stop pretending that the relationship we hope to have and the relationship that actually exists are the same thing. Sometimes one of the most painful tasks in therapy is helping someone see their relationship as it is today, rather than continuing to make decisions based on who their partner might someday become. That clarity can lead to a boundary, a different way of participating in the relationship, a separation, or occasionally the very change that years of pleading could not produce.

Therapy Is an Investment

Therapy costs money. It costs time. It requires people to arrange childcare, leave work, sit in traffic, rearrange evenings, and spend an hour talking about things they might much rather avoid. In couples therapy, there are two people's resources being spent, and often an entire family's future is implicated in the work.

I take that seriously. I don't think my responsibility as a therapist is fulfilled simply because I provided a thoughtful hour and everyone scheduled another appointment. Part of my job is to keep asking whether the treatment is accomplishing something and whether what we are doing together still makes sense. Sometimes the ethical and clinically appropriate thing to do is to acknowledge that it doesn't.

That does not mean therapy failed. Sometimes discovering that a person does not currently want what therapy would require of them is useful information. Sometimes discovering that your partner has no intention of participating differently in the relationship is heartbreaking information, but useful information nonetheless. And sometimes ending a treatment that has become stagnant creates room for a different kind of work to begin.

So, Am I the Therapist for You?

If you are frightened of change, that's okay. If you know you need to change but have no idea how, that's exactly the kind of thing therapy is for. If you've tried repeatedly and keep falling back into the same pattern, I don't consider that unwillingness. And if your progress is happening in tiny increments, I am probably going to notice those increments and help you build on them.

You also don't have to come into therapy already knowing whether you want to stay married, leave your marriage, forgive someone, set a boundary, change careers, confront something painful, or make some other enormous decision. Ambivalence is human, and good therapy has plenty of room for it. Sometimes part of the work is simply understanding yourself, your relationship, or the choices in front of you well enough to know what you want to do next. Not knowing yet is very different from being unwilling to do anything differently.

But eventually, therapy has to move beyond talking about why things are the way they are. Insight matters, but insight without any willingness to experiment with different behavior has limits. At some point, we have to take what we understand in the therapy room and see whether we can do something different with it outside the therapy room. We may do it imperfectly, inconsistently, awkwardly, and in very small increments, but we have to begin.

So, no, I don't need you to change quickly. I don't need you to make dramatic progress every week, and I certainly don't need you to make the choices I would make for you. I can sit with uncertainty, setbacks, fear, resistance, and very slow movement for a long time when we are genuinely working with them.

But if what you want is a place where you can continue doing exactly what you have always done, while adding a therapist to the room, I am probably not the therapist for you. Therapy is, at its heart, an acknowledgment that something isn't working and an invitation to find out what could be different. Eventually, we have to be willing to accept that invitation.