How does therapy work?

I often use “Castaway,” the Tom Hanks movie as a reference for how the counseling journey may go for some clients. In the movie, the first act shows a man working in a shipping company. After his airplane crash lands on an uninhabited island, he is left to learn how to fend for himself. Those familiar with trauma, depression, substance use recovery, and so on, will recognize the desperation of those first 24 hours. The audience witnesses Tom Hanks’ character learn the basics — where do I sleep? Where do I get water, food? Is anyone coming for me?

After the movie establishes Tom Hanks learning to get his basic, daily needs met, the movie flashes forward to showing a lean, tan, fit man who has mastered his life on the island. This can be like the first phase of therapy, going from “I’m in a crisis” to “I was in a crisis.” For example, a client coming to see me may have just discovered an affair, lost their partner, lost a job, is finally realizing that they have “crash landed” into a deep depression. There is sometimes a progression, back-and-forth, between the overwhelm of the trauma itself, being “in” the depression to such an extent that there are no words for it, and then “I’m still feeling it, it’s still there, but…” Going from “I just crash landed” to “I’ve mastered this” is a gradual one, and it often feels like a back-and-forth, two steps forward, one step back. Particularly in clients’ lives who experience trauma, or those who are born into un-safe systems and environments, there is no linear progression as in a well-told story or screenplay. The experience of the audience watching “Castaway” was a scene ends, and another one begins with the island-savvy man bending the island to his will. The difference for some clients is, they are more likely to look back after a season of therapy to find the island onto which they crash landed has been integrated into their life — it may start to feel safe, like “home.”

What can sometimes happen when a client reaches that point in their life — “I’ve mastered this” — is some begin to say, “It’s time for me to get off the island.” Tom Hanks’ character, stranded on the island for a couple of decades, develops his skills, strengths, supports, resources on the island to where he could have survived there relatively comfortably for the rest of his days. For some people, this can mean developing the skills to manage trauma triggers more effectively, to where they are not disrupting work, family, relationships, school, etc. I’ve sat with clients who begin to ask, does it ever go back to the way it was before? Before the accident, the divorce, the diagnosis.

Referring again to the movie, Tom Hanks does get off the island. The therapeutic picture of this is similar to the characters’ — change is uncertain, risky, and it requires a lot of preparation. He goes to great lengths to secure a way “off the island,” to the best of his ability, and he is saved by a ship who happens to cross the path of his raft. On the mainland, he finds that the job he once had doesn’t exist anymore. His wife, thinking he had died, moved on and married someone else. He notices mundane things have changed, like his old football team, friends, and so on. Essentially, he gets off the island and finds that the whole world he had left behind was changed, and as importantly, he finds that he had changed, too. For the character in this film, there was no “going back” because that world, that life, those relationships didn’t exist anymore, and the subject of these relationships (Tom’s character) had been fundamentally altered by that experience.

For a client navigating life after a trauma, this movie captures the experience in a painful way. There’s the crisis at the start, sometimes brief, sometimes ongoing — those moments when you’re just trying to survive. Then, there’s the integration of the crisis experience, the mastery of that state of being. Depressed, and finding some enjoyment sometimes. Betrayed, and learning to trust again. Then, there’s the external change. I’m going to “get off this island.” Sometimes that takes the form of internal change, developing new habits of thought or giving space for uncomfortable emotions. Other times, it’s external, like changing out of a toxic workplace, changing careers altogether, starting or ending a relationship. Finally, “arriving” at the change in the context of therapy doesn’t usually mean arriving. What trauma, depression, addiction do is change a person, and the world in which they find themselves. In the therapeutic relationship, this can mean, we explore together what it means now that you are this new, whole, healthy, integrated person.

And finally, you may “arrive” back on the mainland, and find that there are still crisis moments, parts of you still trying to survive, some sense of “am I still crash landed, alone, and struggling?” and maybe grasping at meaning and purpose in this new life is leading to new sources of internal tension. Life still may be a bit messy. The point here being, “Castaway” is not a blueprint so much as an illustration of the concepts that may come up in therapy. One’s healing journey is rarely linear, nor so clear in the development and resolution of a crisis.

In a nutshell:

First 24-48 hours — Crisis work
The first week (ongoing) — Skill development
Basic needs, 8 hours of sleep, 3 meals a day, relative sobriety
The next phase (as indicated) — Making a change
Work, life, family, home, self, what can be changed? What do you want to be different?
What do you want to keep the same? Internally, externally, with yourself and others?
The final phase — The big questions
Who am I? What is my purpose? To whom do I belong?

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