Mechanisms of Change

Why Therapy Works: Breaking Down the Process of Change

We often walk into the therapy space with an appropriate skepticism. How is this different than talking with a friend? How can a stranger advise me on how to live my life better? These are very valid questions. However, good therapy usually involves the client and therapist collaboratively identifying what needs to change in the client's life and why they are stuck where they are.

Once we identify the problem, we can employ different therapeutic approaches with specific mechanisms of change, designed to help the client become unstuck.

Mechanisms of Change Examples

• Insight - Sometimes, simply holding up a mirror to a client is enough to help them make all the changes they're seeking. I find this tool especially powerful during times of crisis, when emotions are high and clarity is harder to attain. A well-timed reflection can help clients recognize patterns or put a name to their pain.

  
  

  But as a therapist, I’m hesitant to rely heavily on insight. It can feel satisfying in the moment, but difficult to carry forward and turn into practical skills. Think back to watching a teacher solve a complex math problem on the board. In class, it feels approachable and often even intuitive. At home, faced with the same type of problem on your own, it often becomes overwhelming. Insight-based therapy can have that same gap: we understand something in session, but without practice or tools, it slips away when we need it most. Insight is woven into therapy, but it’s rarely the only driver of change.

• Exposure - Exposure is the biggest component of most evidence-based trauma treatments and often gets a bad rap. Trauma memories are often fragmented because the intense emotion leads to avoidance and suppression of the memory. Exposure therapy helps a person slowly and methodically piece the full story together. Over time, this repetition reduces the intensity of the memory, so it becomes more like other painful memories. It's something you can recall without reliving the experience. Imagine a scary movie. No matter how terrifying it is the first time, if I have you watch it a dozen times, start to finish, it won’t stay scary. You won’t like the movie, but you’ll be able to sit through it without the same rush of fear. Exposure doesn’t erase the past, but it reduces the intensity of the experience.

This is practical with physical avoidance as well. We can create a hierarchy of desired activities that progressively challenge you. If you want to be able to go to a concert, we might start you with going to the grocery store when it's more crowded than usual. Next, you might go to an outdoor event. We keep increasing the challenge of the assignment until you feel ready to attend the concert.

There are all sorts of ways to prepare and manage your emotions in the moment, but the key ingredient is exposure to what is feared. We find meaningful and practical experiences to ensure there is a reason to go through the challenge.

• Cognitive Restructuring - Applied poorly, this mechanism of change looks a lot like telling someone, "Have you tried being less depressed?" The real goal is examining how you talk to yourself by digging deep down to core beliefs. Cognitive restructuring is great for anxiety and depressive symptoms.

  
  

  Time for another metaphor! If you go to the optometrist to find what lenses work best, they’ll cycle through different options: “Is this clearer? Or this?” You are collaboratively exploring what feels right. Some lenses help you see the world more clearly and others distort things.

  
  

  In therapy, we do the same thing with your thoughts. We test them. We ask, “Does this belief help you? Does it reflect the full picture? What else might be true?” We introduce some flexibility to find gentler, more helpful ways to think through thoughts that show up while maintaining the accuracy of the statement.

  
  

  As a clinician, I usually lean more toward cognitive flexibility rather than cognitive restructuring. The main difference is that cognitive restructuring focuses on identifying and challenging distorted thoughts to replace them with more accurate ones, while cognitive flexibility is about learning to hold thoughts more lightly. It’s less about proving a thought wrong and more about expanding the range of possible perspectives, so you're not stuck reacting to a single interpretation. Both are effective, but usually for different types of people and for different occasions.

Behavioral Activation - This one is honestly one of my favorites. When we’re depressed, our worlds often shrink. We stop doing things we used to enjoy, and even basic routines can start to feel heavy. Behavioral activation is one of the most evidence-based ways to interrupt that cycle. Waiting to feel better before we start building pleasurable activities into our day often leads to a lot of waiting. And when the haze finally begins to lift, there’s often a mountain of rebuilding to face—which can overwhelm a fragile recovery.

This isn’t about forcing false positivity. It’s about exploring practical, meaningful, and/or enjoyable activities to gently reintroduce into your routine. That might look like getting out of bed to brush your teeth (practical), returning a text from a friend who’s checking on you (meaningful), or listening to your favorite songs (enjoyable). These actions may feel small, but they send an important message: you’re still here, and you’re still moving forward.

There are many more ways therapy can support change, but these are the ones I return to most often in my work. They’re powerful tools when used with your goals in mind.