Much of What Is Called Therapy Is Not Psychotherapy
Real psychotherapy isn’t about “being helpful.” It’s something else.
Editorial note: After thoughtful discussion in the comments, I’ve revised the title to better reflect the argument I am making. The text of the essay is unchanged.
“Few therapists act like therapists because it is hard to do… the vast majority act like guidance counselors, friends, older siblings, doctors, cult figures, kindergarten teachers, mentors, or advisers. These aberrations are all easier than therapy.”
—Michael Karson“All people have experience helping others before they enter professional training. We have called this pre-training period the Lay Helper phase.”
—M.H. Rønnestad & T.M. Skovholt
When people think about getting help in psychotherapy, they naturally draw on their experiences of “help” in everyday life—and assume the same applies in therapy. But real psychotherapy isn’t about being “helpful” in everyday, commonsense ways. It is something else entirely.
Therapy trainees generally bring that mistaken assumption to their early therapy work (the notable exceptions are trainees who have had their own in-depth psychotherapy). They try to be “helpful” in familiar ways, offering support, encouragement, validation, and advice. It feels caring and compassionate but leaves underlying psychological patterns untouched.
They act like friends, teachers, or coaches—well-meaning, but unequipped to tackle the ingrained psychological patterns that lead people to relive the same unhappy outcomes time and again. They are in the lay helper phase. Their intentions are good—but if commonsense help and support were enough to change dysfunctional patterns, psychotherapy would be unnecessary.
As Otto Kernberg reminds us: “Psychotherapy starts where common sense ends.” To progress beyond the lay helper phase and become real psychotherapists, trainees must unlearn conventional ways of “helping” and learn something entirely new.
Real psychotherapy requires more than helpfulness, kindness, and good intentions.
Sadly, many therapists never leave the lay helper phase. Their patients may like them and even feel helped, but they do not change in meaningful ways. The same self-defeating patterns repeat. Therapists who have never been exposed to real psychotherapy often don’t realize they’re not providing it.
After years of doing “not therapy” and calling it therapy, these therapists may become invested in thinking of themselves as experts. Their early misconceptions about psychotherapy weren’t challenged during training and were often reinforced by teachers and peers.
Once they’ve built careers and professional identities on misconceptions, they need to defend and justify them. Instead of being open to learning another way, they may dismiss or attack what they don’t understand.
It’s the Dunning-Kruger effect: people don’t know what they don’t know. They can recognize differences in skill below their own skill level, but not above it.
Real psychotherapy requires more than helpfulness, kindness, and good intentions. It requires expertise, discipline, the courage to face what we’d rather avoid, and the skill to help our patients do the same.
That is why meaningful psychotherapy is increasingly rare.
Related Essays
Getting Started in Psychotherapy: A Guide for Patients (and Their Therapists) (September 3rd, 2025)
What Every Therapist Needs to Find Out in the First Session (October 7th, 2025)
Why Psychotherapy Gets Stuck (January 19th, 2026)
More writing, interviews, and related work on my Linktree.
I have been sitting with this piece and the responses to it.
I find myself curious about your data here. Are you drawing primarily from personal clinical experience, consultation work, research, or some combination of all three? I ask with genuine interest. Those of us who supervise and mentor clinicians are often looking at similar questions from different vantage points, and clarity about what informs a claim helps move the conversation forward.
Many of the clinicians I mentor are actively seeking what you describe as “real psychotherapy.” They are not trying to be friends, coaches, or influencers. They are trying to understand transference, enactment, resistance, and what it actually requires to sit with another human being without rushing toward reassurance or advice. What they often lack is not seriousness or commitment, but training environments that make this kind of work sustainable. High caseloads, brief treatment models, productivity demands, insurance constraints, and limited access to their own long-term therapy all shape what early career clinicians can and cannot practice.
This is where I find myself wanting more context in essays like this. Naming a problem without engaging the realities of contemporary training and practice risks turning a complex professional landscape into a simple character judgment about individual therapists. It can land less as an invitation to deepen the work and more as a sweeping indictment of a field that is already under strain. Many clinicians are practicing inside systems that reward speed, manualization, and symptom reduction. They are trying to learn depth work in environments that often do not support it.
In my consultation groups, there is real hunger for rigorous, relational, psychodynamic, and integrative thinking. There is also humility. Most newer clinicians know they are still learning. They want supervision that challenges them and frameworks that move beyond surface-level “helping.” They are asking serious questions about what psychotherapy actually is and how to do it responsibly.
So I am interested in continuing this conversation with attention to both skill and structure. What does it take to train therapists well right now? What conditions allow clinicians to move beyond the “lay helper” phase you describe? And how do we talk about standards while also acknowledging the systems shaping contemporary practice?
These feel like worthwhile questions for the field to keep engaging together.
I’m still stunned by the fact that many of my peers during training had not had any psychotherapy themselves, nor was it insisted upon by the (prestigious) university. I’ve learned as much from the two excellent psychotherapists who’ve treated me over the last 20 years as I did /do from years of training and ongoing supervision.