Maybe you’re struggling with depression, anxiety, substance abuse, stress, or some existential question, and you’re thinking about seeing someone about it.
Or maybe a friend or colleague recommended psychotherapy to you.
But what is psychotherapy? Sure, you’ve watched the movies and seen that same old image: the wise guru sitting calmly taking notes as the neurotic soul lies on the couch confessing his life story. The guru seems to know it all. The neurotic soul might or might not get better. How much of this is true? Read on to find out.
What is psychotherapy?
Psychotherapy is counseling or talk-therapy. In formal terms, it’s an intentional interpersonal relationship used by trained psychotherapists to help a person deal with their problems; talk-therapy aims to bolster the patient’s mental health. In terms for the rest of us, providers use talk therapy to help people overcome their problems.
Used with or without medications, it can be beneficial for almost all psychiatric conditions, ranging from mood disorders, attention problems, post-traumatic stress disorder, and addiction to psychosis and autism.
Psychotherapy can be done “individually” (one on one, where the therapist and patient work alone), or it can be done with couples, families, or groups of people with similar problems. This article is about individual therapy.
How does therapy work?
Talk-therapy starts with a psychiatric evaluation. The psychotherapist introduces themselves and asks lots of questions about your problems, life, past history, medical problems, medications, and symptoms. This interview usually takes one to two hours. Together you’ll arrange a plan of treatment, which often involves a number of weekly visits. Therapy might be limited to a few months or go on indefinitely, depending on your needs. The visits typically last one hour.
Often the therapist will focus on one or two major problem areas, which will be discussed during your appointments. These problems are different from person to person.
What types of therapy are there?
Psychotherapists use a range of techniques or types of therapy to bolster their patient’s well-being, ranging from exploring childhood experiences to studying problem thoughts. Here are some of the more common types.
Psychoanalysis was founded by Sigmund Freud in the late 1800’s. It was one of the first psychiatric treatments to use conversation and relationship between patient and professional as a means for gaining mental health – that is, for the first time in history, doctors actually sat down and talked their patients through their problems!
In this kind of therapy, the therapist, or psychoanalyst, meets with his patient five days a week. The patient lies on a couch and says whatever comes to mind. They’re encouraged to talk about their childhood and dreams.
It’s thought that this process of talking, called free association, helps the patient gains insight into themselves. This insight is cathartic, filled with lots of “ah-ha!” moments, and bolsters mental health.
Note that psychoanalysis isn’t very popular these days. Most insurance companies won’t pay for it because it requires many visits and can take years to see improvement. Yet psychoanalysis is popular in movies and TV shows, with the quiet Freud-like therapist and soul-bearing patient we all imagine when we think of psychotherapy.
Freud’s followers took psychoanalysis a step further and started their own flavor of psychotherapy, called psychodynamic psychotherapy. While there are many branches, they all share a few characteristics:
(1) they focus on past relationships, especially those from childhood, and how those relationships affect the present
(2) they’re based on the idea that we have an unconscious side to our personalities that influences our well-being
It’s thought that many of our problems stem from childhood, problems we’ve stuffed deep inside our unconscious, so the goal of therapy is to bring these issues to the surface where we can deal with them. This is done in the safety of a therapist’s office. Some types of psychodynamic therapy focus on defense mechanisms. Others are about internalized representations of early relationships.
While psychodynamic therapy deals with childhood experiences, cognitive therapy is about the here and now.
The basic premise is that our emotions are tied into what we think, that we can change our emotions and overcome troubling symptoms by changing our thought patterns. Learning to rewrite problem thoughts can take time and frequently involves homework. The person in therapy is asked to notice strong negative emotion when it occurs, then stop and examine their thoughts.
Here’s an example of a thought record. The patient failed a test and is dealing with the aftermath.
What emotion did you notice? I felt depressed and anxious all day.
What were you thinking when the emotion started? I failed that math test, which means I’m a failure and I’ll always fail everything.
What’s the evidence to support this thought? (1) I failed the test. (2) I’m not good at math. (3) I always did poorly in math at school.
What’s the evidence against this thought? (1) The exam only counts for 5% of the course, and I have the whole semester ahead of me. I can get help and study harder. I’m doing okay with the homework so far. (2) I may not be good at math, but I’m good at other things, like English, running, and drawing. I’m also a good wife and mother.
What’s a more realistic thought to replace what you were thinking? I might have failed that math test, but I’m doing okay with the homework, and I’ve got the whole semester to pick up my grades. Also, I’m good at many other things, things that are important to me. I’m not a failure.
How does this more realistic thought make you feel? I feel hopeful and more positive, less depressed. I’m still anxious, but not as much.
The premise of behavioral therapy is that we can change our emotions and overcome troubling symptoms by changing problem behaviors.
- Exposure therapy is a type of behavioral therapy used for phobias and obsessive compulsive disorder. It’s about facing one’s fears — with the assistance of a therapist. This usually involves relaxation exercises and approaching the feared object little by little.
- Behavioral activation therapy is used for severe depression and based on the idea that an increase in healthy activity helps mood.
Dialectical Behavioral Therapy (DBT).
Created for individuals with borderline personality disorder, DBT is a class about life. People with borderline personality tend to have unsafe behaviors, troublesome relationships, intense emotional responses, sensitivity to stress, and problems with identity.
The first focus of DBT is safety. It’s meant to diminish the rate of self-injurious behaviors. It also focuses on teaching the patient new social skills, stress tolerance, emotion regulation, and how to find their “Wise mind” through mindfulness exercises. DBT involves both individual therapy and group work. It requires homework.
Supportive therapy helps a person deal with tough life situations without delving into the past or scrutinizing thought patterns. This therapy helps the person function well now. It focuses on strength and coping skills. Supportive therapy helps during the more fragile moments of a patient’s life.
How does the counselor decide which therapy to use?
Therapists choose the type according to their own training and the patient’s thinking style & types of problems.
For example, cognitive therapy might be better for people who worry excessively over a certain thought, whereas psychodynamic therapy is preferable for those who wish to process a troubling childhood. A person with phobia might do better with exposure therapy than DBT. Someone with Schizophrenia who is currently hallucinating and confused would probably do best with supportive therapy.
How do I know if therapy is right for me?
Some of the signs that indicate psychotherapy might be helpful include:
- feeling sad and hopeless
- worrying excessively or feeling panicky
- having relationship problems or difficult life transitions
- struggling with an addiction
- experiencing obsessive compulsive disorder or phobias
- having anger management problems
- attention difficulties and you prefer to avoid medications
- feeling overwhelmed with life
To find a psychotherapist, do a search online, check with your health insurance, or talk to your primary care doctor for recommendations. Once you’ve chosen somebody, meet with them and ask about any concerns you might have.
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