What can be developed in in-depth psychotherapy?
Most people who seek out a psychologist do so because they are feeling unwell. Perhaps they are experiencing overwhelming anxiety, persistent depression, or relationships that repeatedly fall into the same destructive patterns. This is completely natural—suffering is what drives us to seek help, and alleviating symptoms is an important part of any psychotherapy.
But there is a dimension to more in-depth psychotherapy that is not always discussed, and which I think more people should be aware of: the possibility of developing abilities and qualities in oneself that change how one lives, not just how one feels.
Symptom relief—reducing anxiety, sleeping better, stopping avoidance—is often the first step. But in longer-term psychotherapy, both individual and group, something else begins to happen. You change not only by getting rid of what is troubling you, but by growing as a person. It can be difficult to put into words what that means. In this post, I want to try to do just that.
Beyond the symptoms
American psychoanalyst Nancy McWilliams has formulated ten signs that psychotherapy is moving in the right direction. She calls them "vital signs" – much like pulse and blood pressure are vital signs for physical health. What makes her list interesting is that it goes far beyond the question of whether the patient has gotten rid of their symptoms. It's about what it means to grow as a person.
I will go through these ten signs and explain what they can mean in practice. This is not a checklist—it is more of a map of possibilities that in-depth psychotherapy can open up.
Honoré Daumier - circa 1865
1. A more secure foundation to stand on
The first sign is about attachment—the ability to trust that other people can be reliable and present. Many of us carry experiences that have made us suspicious of closeness, or overly dependent on it. In psychotherapy, you have the opportunity to experience a relationship that is reliable and consistent, often in a way you have not experienced before. Over time, that experience is internalized and influences how you relate to other relationships in your life.
2. Being able to hold on to yourself and others
This is about what is known as object constancy and self-constancy—the ability to maintain a coherent image of yourself and the important people in your life, even when your emotions fluctuate. Without this ability, a minor disappointment can suddenly make someone you love feel like a complete stranger, or cause you to lose all confidence in yourself after a single mistake. In therapy, you develop the ability to hold the whole picture—to be angry with someone you love without losing that love.
3. A stronger sense of being the one who acts in your own life
Many people who seek therapy describe a feeling that life just happens to them. They react, adapt, survive—but rarely feel that they are actually in control. In psychotherapy, a sense of agency often develops, of being the one who makes decisions and shapes their own life. This does not mean that you suddenly control everything, but that you feel you have a choice and that your actions matter.
4. A more realistic and stable self-esteem
There is a big difference between inflated self-esteem and genuine self-confidence. Many people swing between thinking very highly of themselves and thinking they are completely worthless. In-depth psychotherapy helps self-esteem move toward something more realistic—a stable sense that you have both strengths and weaknesses, and that you can accept both. This kind of self-esteem is not as dramatic, but it is clearly more reliable.
5. Greater resilience and ability to manage emotions
Life inevitably involves setbacks, losses, and disappointments. The question is not whether difficult things will happen, but how well you are equipped to deal with them. In therapy, you develop the ability to regulate your emotions—to experience strong inner states without being overwhelmed by them, to distinguish one emotion from another, and to use your inner feelings as information rather than as threats.
6. Being able to reflect on oneself and understand others
This is the ability to pause and observe your own inner life with curiosity rather than automatically—and to imagine how other people experience the world. In psychology, this is sometimes called mentalization. It is an ability that fundamentally changes relationships, as it makes it possible to meet conflicts with understanding rather than reactivity.
7. Feeling at home both in community and in solitude
Some of us are so attuned to the needs of others that we lose touch with ourselves in relationships. Others protect themselves by withdrawing and never really letting others in. Psychotherapy often helps to find the balance—to be able to be close without losing yourself, and to be able to be alone without feeling abandoned.
8. A deeper sense of being alive
This is perhaps the most elusive sign, and the one that interests me the most. It's about vitality—not just existing, but actually feeling real.
Donald Winnicott wrote about the difference between living and merely existing. In his article on the mirroring function of the mother, he describes how even as infants we are dependent on being seen and mirrored in order to develop a sense of being real. When a child sees itself reflected in its mother's face and is met with a response that matches its own experience, the feeling of "I exist, I am real, my inner life has meaning" is established. But if this mirroring is absent—if the child instead encounters an absent or unresponsive gaze—it may grow up with a sense of unreality, as if life is happening behind a glass pane.
Many people live with this feeling without knowing that it can be changed. They function, they perform, they fulfill their commitments—but they don't really feel like they are living. This can manifest itself as a chronic emptiness, a lack of spontaneity, or a feeling of always being "outside" of life.
In psychotherapy that truly reaches deep down, people sometimes begin to feel more alive and energetic. It is difficult to describe exactly what this means, but it can be seen from the outside in the way they talk about their everyday lives, in how they react in the room, in flashes of spontaneity and presence that were not there before. It is as if they begin to live within themselves instead of observing themselves from the outside.
9. The ability to accept, forgive, and feel gratitude
Acceptance does not mean giving up or thinking that everything is fine as it is. It is about being able to see reality without distorting it—being able to acknowledge what has happened, both the good and the painful, without getting stuck in bitterness. Forgiveness is not about excusing other people's behavior, but about freeing yourself from the burden of unforgiveness. And gratitude—not the forced kind, but the kind that grows naturally—can fundamentally change your relationship with life.
10. The ability to love, work, and play
Finally, what Sigmund Freud once described as the goal of psychotherapy: to be able to love and work. McWilliams adds a third dimension—to play. This involves being able to engage in relationships with openness and generosity, to invest in meaningful work with perseverance and joy, and to be playful—not taking oneself too seriously, being spontaneous, and tapping into one's own creativity.
What does this mean for you?
If you recognize yourself in any of the abilities I have described—if you feel that you lack any of them, or that you have them to a limited extent—it may be comforting to know that change is possible. It is not a question of willpower or self-help. It is about working with another person or a group, over time, in an environment where you can explore yourself in the presence of others.
That is what deep psychotherapy is all about. Not just getting rid of what hurts, but also gaining access to more of yourself.
If you would like to learn more about how this might work in practice, schedule a complimentary phone call and we can discuss your situation.
