Cooking’s Not Therapy

I keep hearing it.

"Cooking is my therapy." "The gym is better than therapy." "My friends are my therapy." "My face in a bowl of pasta, binge-watching Breaking Bad for the eighteenth time, is my therapy."

Look. I get it. And there is a difference. A substantial one. The distance between something being therapeutic and something being therapy is the distance between staying afloat and learning to swim.

We are learning a new vocabulary our grandparents did not have. That is mostly a good thing. It is also a problem. Because the more fluent we become in the language of mental health, the easier it becomes to use that language as a substitute for actually doing the work.

The Continuum Nobody Tells You About

There's a useful frame for thinking about what is actually happening when we say a word like "therapy." Picture a continuum.

On one end, manualized therapy. Structured, evidence-based modalities like CBT or AEDP or family systems work. Delivered by someone with specific training. With a clear contract, a clear intention, and a clear end.

In the middle, heterogeneous therapy. Interventions that draw on multiple psychological approaches with the explicit goal of change or insight.

On the far end, therapeutic practice. The broader category of things that might feel therapeutic. Things that might leave you feeling lighter or clearer. But that were never contracted, intended, or structured to do the work of therapy.

Cooking dinner is therapeutic. Running is therapeutic. So is a good cry in the shower and a long phone call with someone who actually listens. None of these are therapy. The difference is not snobbery. It is the difference between a thing that helps you regulate and a thing that helps you change.

When we collapse that distinction, we tell ourselves we are handling it. We are not always handling it. Sometimes we are just running the same loop with slightly better lighting.

What the Data Actually Show

Here is where I want to be careful, because this is where most blogs, Instagram reels, and the glorified TikTok University on this topic either oversell or undersell.

The case for psychotherapy is, at this point, very strong. In the largest synthesis to date, a 2024 study published in World Psychiatry by Pim Cuijpers and colleagues pulled together 441 randomized controlled trials across eight major mental disorders, covering nearly 34,000 patients. Across the board, psychotherapy outperformed control conditions. For depression, response rates in therapy were 42 percent compared to 19 percent in control groups. For PTSD, 38 percent versus 10 percent. For OCD, 38 percent versus 5 percent. The relative risk of meaningful improvement was roughly two to nine times higher in treatment than in control across nearly every disorder studied.

That is the headline. Therapy works. It works better than nothing, it works better than placebo, and the effect holds up across decades of careful study.

But here is the second half of the sentence, and it matters. The response rates in treatment are modest. Most patients in psychotherapy do not hit full symptom reduction. The relative risk is impressive. The absolute rate of complete response is still under fifty percent for every disorder studied.

What that means, in plain language: therapy is the best tool we have, it reliably helps, and it is not magic. People who go to therapy expecting transformation in eight sessions are often disappointed. People who go expecting nothing are often surprised. People who never go because they have absorbed the cultural story that therapy probably won't work for them anyway are working from bad data.

Because here is what we also know. People consistently underestimate how well therapy works. They walk around with a quiet internal story that says therapy is for other people, or therapy is a luxury, or therapy is fine for venting but doesn't really change anything. That story is often a symptom of the very thing therapy would address. Depression itself tilts the lens toward pessimism. The illness argues against its own treatment.

That is a trap worth naming out loud.

So What Is Therapy, Actually, and What Does Success Look Like

Let me try to define both, because the rest of the piece depends on it.

Therapy is a structured, contracted relationship with a trained clinician, oriented toward change. The structure means there is a frame: a beginning, a middle, an end, regular sessions, clear roles. The contract means there is an explicit agreement about what you are working on and how you will know if it is working. The training means the person across from you has spent years learning how to track affect, formulate a case, hold ruptures without retaliating, and stay useful when the work gets hard. The orientation toward change means the goal is not to feel better in the next forty-five minutes. The goal is to be different in your life in ways you can measure.

That last part is where most people get lost, including, sometimes, therapists. Because success in therapy is not the absence of symptoms. Symptoms come and go. Success is measurable change against where you started, sustained across time, in a relationship where someone is actually tracking it with you.

This is where the work of Tony Rousmaniere, Scott Miller, Bruce Wampold, and Rodney Goodyear becomes useful. In their 2017 book The Cycle of Excellence, they pulled together decades of research on what actually makes therapy work and what makes therapists effective. Three findings are worth sitting with.

The first is that the field has been on a performance plateau for almost forty years. Despite the explosion of new therapy models, the average effectiveness of therapy has not meaningfully improved since the 1970s. About sixty percent of clients in clinical trials reach what researchers call recovery. Between five and ten percent get worse. Between twenty and sixty percent drop out before the work is done. These numbers have barely moved in a generation.

The second is that the variability between therapists is enormous. The most effective therapists, sometimes called supershrinks in the research literature, average roughly fifty percent better outcomes and fifty percent fewer dropouts than the field average. The least effective therapists produce, on average, no change or even worsen their clients. The school of therapy matters less than the person practicing it. Which means the choice of therapist is not a minor logistical detail. It is most of the work.

The third is the one that should change how you shop for a therapist. Experience alone does not make therapists better. Studies tracking therapists over time consistently find that what improves with experience is confidence, not competence. The therapists who actually get better are the ones who engage in what Anders Ericsson called deliberate practice. They track their outcomes. They get real feedback. They sit with their hard cases. They refine. They are willing to know when something is not working, and to change it.

So if you are looking for a therapist, or trying to evaluate the one you have, here are the questions that matter more than the framed degree on the wall.

Do they track outcomes in some structured way, even informally? Do they ask, regularly, whether the work is helping? Do they invite feedback about the relationship itself, including the ruptures? Do they have a supervisor or consultation group they are still learning from? Do they have a clear sense of what you are working on and how you will know it is changing?

If yes, you are in good hands. If no, you may be in a relationship that feels nice and produces very little.

Success in therapy, then, looks like this. You can name what you are working on. You can describe what is changing. You can tell, in your life, that you are different in ways that matter to you. And the person sitting across from you is tracking it with you, not just listening kindly.

Therapeutic practices give you a place to land. Therapy gives you a place to grow. The difference between them is the difference between feeling held and being changed.

The Schools Matter Less Than You Think

When patients ask me which kind of therapy is best, I have learned to slow down before I answer. Because the honest answer is that the intramural war between therapeutic schools is louder than the actual difference between them.

CBT, psychodynamic, humanistic, somatic, integrative, AEDP, Gestalt, interpersonal. When these are delivered with genuine therapeutic intent by a trained clinician, the outcomes are roughly comparable. What seems to matter most are the things that cut across orientation. The quality of the alliance between therapist and client. The collaborative shaping of goals and tasks. The therapist's ability to notice when something has ruptured and to repair it without retaliating. The presence of someone who is, in the language of the research, attentive, real, and empathic.

This is not the warm fuzzy version of therapy. This is what the data show actually moves the needle.

The same holds, more or less, for format. The evidence on group psychotherapy for anxiety disorders, for instance, shows large effects against no treatment and no significant difference compared to individual psychotherapy or medication. Group is roughly as good as individual, often for a fraction of the cost. The field could be using this better than it does.

The Friends and Faith Question

This is where I have to be most careful, because this is where I am most exposed.

When someone says "I don't need therapy, I have friends" or "I don't need therapy, I have church on Sunday," I hear something true and something incomplete.

The true part is well documented. Social support is protective. Religious and spiritual community is protective. People embedded in real relationships and meaning-making traditions tend to fare better across nearly every mental health outcome we can measure. This is not a small finding. It is one of the most robust findings in the entire field.

And there is more. When therapy itself is delivered in a way that takes a patient's religious and spiritual life seriously, the outcomes improve. In a recent meta-analysis of randomized controlled trials, psychotherapy that integrated religion and spirituality outperformed standard therapy for religiously affiliated patients, with moderate effect sizes on both symptoms and broader functioning. The lesson there is not that prayer replaces therapy. The lesson is that therapy that knows what your prayer life is, that can sit with your tradition rather than around it, does better work.

So the honest version of the friends and faith answer is layered. Your friends and your faith community can carry an enormous amount. They are protective, they are sufficient for many people much of the time, and they are not equivalent to clinical intervention for clinical-level distress. The trained clinician is not a better version of your friend. They are a different role. They have spent years learning how to track affect, hold ruptures without retaliating, formulate a case, and work with the parts of you that the people who love you have a stake in not seeing.

That is not a knock on your friends. It is the job description of a different relationship.

The Other Thing

Now. The reason we are even having this conversation is partly because therapy is genuinely hard to access.

A 2024 review in the Annual Review of Public Health by Chad Stecher and colleagues estimated the full economic burden of depression in the United States at 326 billion dollars in 2020. Of that, only about eleven percent was spent on treatment. The rest was absorbed by lost productivity, comorbidity costs, and the costs of suicide. The same review found that between a third and three-quarters of adults who meet criteria for depression in high-income countries receive no treatment at all. In low-income countries, the figure is around eight percent.

Some of this is cost. The average out-of-pocket price for a single hour of therapy in the United States runs between one hundred and two hundred and fifty dollars. Therapy is not a one-and-done. Multiply that by months. Multiply that against rent and groceries and a labor market that does not care about your sleep.

But cost is not the only barrier. Insurance panels pay clinicians so poorly and demand so much administrative blood that good therapists are quietly leaving the system. Networks are narrow. Wait lists are long. Community mental health clinics with predatory caseload demands burn out the people inside them. And the Stecher review also notes something counterintuitive worth sitting with: demand for mental health care is relatively inelastic. Meaning that even when the price drops, people don't rush in the way you might expect. Which tells us something important. The barriers are not only financial. They are also about stigma, about knowing where to go, about whether the space you would walk into would actually see you.

And here I want to make a harder claim than the usual one. Because the typical framing locates the access problem in the patient. The patient does not have insurance. The patient does not have time. The patient has stigma. The patient has not been educated about the value of treatment.

But a more honest framing locates a share of the responsibility in the field itself. Rachel Tambling, Kevin Hynes, and Carissa D'Aniello, writing in the American Journal of Family Therapy in 2022, made this case directly. They argued that the profession has historically trained therapists to believe that if a person really wanted help, they would come. Lack of help-seeking got read as lack of motivation. What Tambling and her colleagues called for instead was a shift toward seeing these so-called barriers as social determinants of health, and toward a model of shared responsibility between clients and providers. The work of demonstrating that the room is safe, that the field is worth walking into, that the clinician sitting across from you can actually see your race or your faith or your displacement, was treated as optional. It is not optional. The burden of access is not only on the person standing outside the door. Some of it is on the people inside who built the door.

So yes. When the actual door is this hard to walk through, of course people start calling other things therapy. It is not a failure of vocabulary. It is a workaround for a system that is not yet what it could be.

But here is where I want to be careful again. The workaround is not the same as the thing.

Cooking, the gym, friends, faith, long walks, the sauna, the journal, the run, the breath, the bowl of pasta. Keep all of it. These are not the protocol, but they are not nothing. They are how you stay regulated enough to live your life. They are how you survive the wait for an opening. They are how you sustain the work between sessions, after sessions, instead of sessions when there are no sessions to be had.

Just do not confuse them with The Work.

Where This Leaves Us

If the word "therapy" has started to mean everything, it has started to mean nothing. And the cost is not academic. The cost is that when we actually need the real thing, we might already have convinced ourselves we are doing it.

Therapeutic practices give us a place to land. Therapy gives us a place to grow.

The difference between them is the difference between feeling held and being changed.

Both belong in a life. They just deserve to be called by their right names.

Sources…um, because I keep things nerdy like that.🤓

Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., & Rosendahl, J. (2020). Efficacy of group psychotherapy for anxiety disorders: A systematic review and meta-analysis. Psychotherapy Research, 30(8), 965–982.

Bouwhuis-Van Keulen, A. J., Koelen, J., Eurelings-Bontekoe, L., Hoekstra-Oomen, C., & Glas, G. (2024). The evaluation of religious and spirituality-based therapy compared to standard treatment in mental health care: A multi-level meta-analysis of randomized controlled trials. Psychotherapy Research, 34(3), 339–352.

Cuijpers, P., Miguel, C., Ciharova, M., Harrer, M., Basic, D., Cristea, I. A., et al. (2024). Absolute and relative outcomes of psychotherapies for eight mental disorders: A systematic review and meta-analysis. World Psychiatry, 23(2), 267–275.

Rousmaniere, T., Goodyear, R. K., Miller, S. D., & Wampold, B. E. (Eds.). (2017). The cycle of excellence: Using deliberate practice to improve supervision and training. John Wiley & Sons.

Stecher, C., Cloonan, S., & Domino, M. E. (2024). The economics of treatment for depression. Annual Review of Public Health, 45, 527–551.

Tambling, R. R., Hynes, K. C., & D'Aniello, C. (2022). Are barriers to psychotherapy treatment seeking indicators of social determinants of health? A critical review of the literature. The American Journal of Family Therapy, 50(5), 443–458.