How is therapy effective when you (typically) only talk for one hour per week?
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The short answer is that [nobody knows the mechanism behind why psychotherapies are effective](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7180170/) [technical review]. They are consistently measured to be effective, however, and weekly sessions are measured to be a very effective frequency. It’s an empirically verifiable medicine with no decent theory behind it (and in medicine, this is [not unusual](https://www.sgu.edu/blog/medical/how-does-anesthesia-work/)).
There are many types of psychotherapy that meet in several different ways with different frequencies and different techniques. When you talk about most psychotherapies used clinically by trained doctors and professional therapists, they are [conclusively effective, though underutilized](https://www.apa.org/news/press/releases/2012/08/psychotherapy-effective) — with caveats that therapy should be consistent and that it is usually more effective in conjunction with other interventions. While consistency — regular timely attendance — is important, therapy can also be optimized for frequency of sessions.
Many studies have converged that weekly sessions are quite effective for a variety of disorders for most patients, but it has also been measured that [increased frequency of treatment can significantly increase effectiveness of psychotherapy in more severe cases in the first few months](https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-019-2214-4) [technical review]. So why don’t psychotherapists typically meet more than weekly? The limiting factor is often the limited availability of medical resources — too few and unevenly distributed doctors, MSW therapists, and the like.
(Note that I’m not sure to what extent you’ll accept an explanation of a mechanism for effectiveness. It is definitely known that psychotherapy alone will change brain chemistry, both temporarily and permanently. You can also pick out specific examples: it is clear that in certain elements of CBT it incorporates something like classical conditioning. But I think asking a question of “how it works” for a medicine in general usually expects a deeper response.)
(Note there was a famous 2018 review that suggested a range of psychotherapies were significantly less effective than believed. That review has been [countered in several re-reviews](https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/is-psychotherapy-effective-a-reanalysis-of-treatments-for-depression/5D8EC85B6FA35B5CEE124381F18E51B9), which is an interesting read overall. )
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