Psychotherapy

What is it?

Psychotherapy, colloquially known as “talk therapy”, is a practice that has gained tremendous popularity in the last several decades. Used to achieve mental wellness, psychotherapy is being widely promoted nowadays by celebrities and personalities. From Michael Phelps to Oprah Winfrey, these figures are highlighting the importance of mental health. Through their platforms, they share the stories of many different people (including themselves) who go through mental and emotional struggles.

At its most basic level, psychotherapy is a practice that uses a conversation between a therapist and a patient to help the patient manage general emotional unrest or acute trauma. Depending on the degree and specialty, therapists can be psychiatrists, psychologists, social workers, or counselors.

While a wide range of techniques exist in psychotherapy, almost all types include developing a therapeutic relationship. Communicating and creating a dialogue and working actively on overcoming problematic thoughts or behaviors are core tenets of psychotherapy. These engagements can be short-term, dealing with immediate issues, or long-term, dealing with longstanding and more complex issues.

Core philosophy

It is up for debate how much psychotherapy falls into the category of alternative medicine. Some argue that mental health is one of the many fields long overlooked by conventional allopathic medicine, therefore it naturally falls more in the alternative field. Others say that the medical preparation of psychiatrists and psychologists makes this practice akin to more conventional medical fields.

The reality is that there is not a precise answer for this. In a similar way to naturopaths, some kind of therapists has the actual credentials to claim a conventional medical approach. However, the actual practice of psychotherapy is extremely more nuanced, and therefore, more difficult to measure in the same way other medical fields are.

Similarities with more traditional alternative medicine practices

As a matter of fact, a paper published by Michael E Hyland, a Professor of Health Psychology from the University of Plymouth shows just that. Mr. Hyland states that meta-analyses show that psychotherapy and alternative medicine are effective primarily or entirely due to contextual factors rather than the specific disease-treating factors suggested by the therapy.

Therapists, this paper says, use a variety of techniques ‘without necessarily subscribing to the theories that spawned them’. The name to this response is “technical eclecticism” or “integration”. In addition, none of the specific techniques are effective as the outcome depends on incidental (contextual) factors. These contextual factors include i) the relationship between the therapist and the patient, ii) the expectancy that the patient has a positive outcome and iii) the shared goals between the therapist and the patient.

Complementary and Alternative Medicine (CAM), like psychotherapy, involves specific and incidental factors. The specific factors are varied, often scientifically controversial, but are assumed not to be psychological in nature. CAM research, like psychotherapy, is dominated by the aim of demonstrating the efficacy of specific factors over incidental factors (placebo).

In psychotherapy, the biggest source of variability, the therapist, is so little understood. We do not know what makes a good therapist, other than using a tautological label, such as charisma. Nor do we understand how charismatic therapists have a therapeutic effect. One paramount motivation for carrying out research in CAM and psychotherapy is to establish the credibility of these therapies as an alternative form of medical treatment.

Types of psychotherapy

There are many types of psychotherapies. However, the most popular ones are:

  • Cognitive Behavioral Therapy (CBT): is a short-term, goal-oriented therapy that focuses on the link between our thoughts (cognition) and our actions (behavior). It is intended to help people change thought patterns that cause unhealthy, unproductive, or incapacitating behavior.

  • Psychodynamic Therapy: emphasizes how certain life events and relationships, both past and present, affect your current feelings, relationships and choices. Its goal is to help acknowledge and understand negative feelings and repressed emotions to resolve internal psychological conflicts.

  • Dialectical Behavior Therapy (DBT): it is a form of cognitive behavior therapy. Its primary aim is to give people the skills to regulate their emotions, handle stress in a healthy manner, and improve relationships, and live mindfully. It is especially helpful for people with seemingly uncontrollable, intense negative emotions or those who may incline toward self-harm.

  • Humanistic/Experiential Therapy: It focuses on a person’s individual nature rather than the collection of behaviors that makes up a specific psychological category. It emphasizes the whole person, especially their positive behaviors and their ability to grow and heal to find self-actualization.

In truth, therapists tend to combine different types during sessions, most commonly CBT and psychodynamic therapy, depending on the patient and the condition.

How psychotherapy works

Psychotherapy has a very hard time showing its efficacy in scientific trials – and has to plead that its results are too singular neatly to fit the models offered by statisticians. And yet, psychotherapy can be hugely effective, not by chance, but for three solidly-founded reasons:

  • Our unconscious feelings become conscious

A founding idea of psychotherapy is that we get mentally unwell because we are not sufficiently aware of the difficulties we have been through. In such cases, we can’t be healed simply through rational discussion because we can’t fathom what is powering our distress in the first place.

  • Transference

It is a term that describes the way, once therapy develops, a patient will start to behave towards the therapist in ways that echo aspects of their most important and traumatic past relationships. We transfer like this outside therapy all not the time, albeit not properly dealt with. Therapy is a controlled experiment that can teach us to observe what we’re up to and understand where our impulses come from.

  • The first good relationship

During sessions, you can feel your therapist as the first truly supportive and reliable person you’ve yet encountered. They become the good parent we so needed and never had. In their company, we can regress to stages of development that went wrong and relive them with a better ending.

History

Freud

While the healing effects of talking date thousands of years ago, the history of psychotherapy is relatively recent. Mindspace offers an overview of the history of psychotherapy, which starts with Sigmund Freud. He created a technique called psychoanalysis, which dominated the field for the first half of the 20th century. Psychoanalysis is an open-ended exploration of the unconscious.

By discussing whatever comes to mind, patients uncover the deep emotional conflicts, typically forged in childhood, that cause suffering in adulthood. The analyst says very little, except an occasional interpretation to guide the patient to deeper insights. Because the analyst participated very little in the sessions, he or she acted as a kind of blank slate onto which the patient projected all of his or her intra- and inter-personal conflicts.

The downsides to this approach were several. On the one hand, it provided limited practical tools to people suffering from well-defined psychological problems, like depression. On the other hand, there is little empirical evidence that it actually works in reducing symptoms. And since it is open-ended and non-structured, it can be costly and can go on for years with no resolution.

Behavior therapy

The return home of World War II veterans in the 1940s placed enormous pressure on the mental health field. People needed the development of effective short-term therapy to help major emotional adjustments.

At this time, Behaviorist researchers were sketching out the foundations of Learning Theory, including Classical Conditioning (Pavlov), Operant Conditioning (Skinner), and Systematic Desensitization (Wolpe). These ideas explained how contingencies and rewards in our environment shape our behavior and provided powerful tools to eliminate problem behaviors.

These principles were adopted by clinicians who rejected Freud’s elaborate psycho-babble and wanted a simpler and more practical approach to psychology. Behavior therapy continues to be practiced to this day and it can be very effective in treating some anxieties, phobias, and addictions. However, it is limited insofar as it does not address people’s thoughts and feelings.

Humanistic or Client-Centered Therapy

Carl Rogers was the one who put his patients’ experience at the forefront of the process of learning and change. Like the psychoanalysts, he was convinced that the therapeutic alliance was the key factor in therapy.

However, unlike the psychoanalysts, he believed that therapists should actively participate in clients’ self-exploration. By the 1950s, Rogers was beginning to have a profound and lasting impact on the way psychotherapists interact with their clients.

Cognitive Therapy

In the 1960s, Aaron Beck began to think about the human mind as a complex information-processing organ. He argued that the information in our minds has an important impact on how we feel in the present. Therefore, our thoughts, interpretations and perceptions of things in our lives influence our feelings and actions.

Beck developed Cognitive Therapy, a series of techniques designed to search and eliminate distorted, exaggerated or unhelpful cognitions that drag our mood down or stimulate fear and anxiety. Many behavioral therapists began incorporating these techniques and Cognitive Behavior Therapy (CBT) was born.

CBT is present-oriented and time-limited, often achieving significant symptom reduction in 8-12 weeks. It has an impressive record of rigorous scientific studies demonstrating its effectiveness and has been widely used in the last 20-30 years.

A new wave of CBT

Since the turn of the millennium, a group of more recent innovations has begun to shape the history of psychotherapy. While these new approaches share the same basic assumptions of traditional CBT, they have introduced the importance of Mindfulness and Acceptance.

  • Mindfulness-Based Therapies: referring to a state of mind, characterized by careful attention to the present moment, with a non-judgmental attitude. These therapies help clients bring greater awareness and clarity to their day-to-day lives. The most common Mindfulness-Based therapies include Kabat-Zinn’s Mindfulness-Based Stress Reduction and Zindel Seigal’s Mindfulness-Based Cognitive Therapy for Depression.

  • Acceptance and Commitment Therapy (ACT): developed by Dr. Stephen Hayes, ACT is designed to help clients learn to use acceptance-based (as opposed to control-based) strategies for coping with difficult experiences. Studies show that negative reactions to emotions amplify the negative emotion, making the problem worse. ACT therapists help clients develop skills to better accept their experience and work toward more effective ways of coping with and solving problems.

Benefits and uses

Psychotherapy can immensely improve a person’s quality of life. According to the American Psychological Association, about 75% of people who enter psychotherapy say they benefit from it, and research shows they’re better able to function in their day-to-day activities.

Here are a few of the ways going to therapy can boost a person’s overall mental health:

  • Overcome harmful behaviors: therapists help identify negative thought patterns and destructive behaviors and teach strategies to avoid them.

  • Identify triggers: many times negative behaviors come from triggers that provoke unpleasant feelings. In therapy, you learn to notice the triggers and to create strategies for controlling the response.

  • Learn healthy coping mechanisms: replacing ineffective or dangerous reactions with healthy, positive coping mechanisms can help manage emotions and stay productive.

  • Heal broken relationships: healthy interpersonal relationships are crucial to mental health. Therapy helps improve communication and resolve conflicts constructively, helping grow important relationships stronger.

  • Feel physically healthier: studies show that people who engage in psychotherapy end up encountering fewer medical problems.

  • Improve self-reliance: psychotherapy helps you develop problem-solving skills, build confidence and become more self-aware. This encourages you to take personal responsibility for your actions. You also learn to manage your mental health issues, now and in the future.

Who practices it

There are education options for people interested in conducting psychotherapy. A brief overview below:

Specialists with PhD degrees

  • Psychiatrists

Psychiatrists are trained medical doctors, and so they attend medical school and are trained in general medicine. After earning an MD, they practice four years of practice residency in psychiatry. Their experience typically involves working in the psychiatric unit of a hospital with a variety of patients. These patients vary from children and adolescents with behavior disorders to adults with severe cases of mental illness.

Psychiatrists are able to conduct therapy sessions and are allowed to prescribe medications that help in the patient’s treatment. They tend to be more involved with clients who require assistance in the form of prescriptions. To this end, psychiatrists usually work in tandem with psychologists and other therapists in situations where medications are required.

  • Psychologists

To put it simply, most psychologists have either a Ph.D. in psychology or a Psy.D., otherwise known as a Doctor of Psychology degree. To distinguish between the two, a Ph.D. is based on research towards a dissertation, while a Psy.D. is based more on clinical work.

While all of these tracks require a bachelor’s degree, some psychologist jobs (such as a school psychologist) can be obtained with a master’s degree without needing a higher degree.

Getting a Ph.D. or Psy.D. usually takes at least five years to complete. During this time there is generally a research or practicum component, and a required number of supervised clinical hours. This is the longest track to practicing as a therapist, albeit it opens up the door to work with patients in a variety of settings.

Specialists with Masters degrees

  • Licensed Clinical Social Workers

Licensed clinical social workers (LCSWs) usually complete two years of coursework beyond the undergraduate degree. It also often involves an internship and supervised experience directly in the field.

Individuals with a master’s in social work are often able to provide therapy to clients in a wide variety of settings and situations.

  • Licensed Professional Counselors

Becoming a licensed professional counselor can be an alluring alternative for others.. It requires a master’s degree in counseling.

The 60 credits required to complete the degree can take between two and three years. This is dependent on your schedule and the individual program. In many cases, you may also have to complete an additional 12 to 16 credit hours of training to become licensed in your state.

What to expect

When you decide to pursue psychotherapy, arranging your first appointment can be a daunting experience. From selecting the right provider to estimating your budget, it can be intimidating or off-putting for many. However, while kicking off a therapy journey needs a little bit of preparation, multitudes of individuals do it on a daily basis and you can do it too. Below are some key things to consider.

Finding the right therapist

Rather than having to rely on recommendations from friends and family, you can actually use the web where you will find thousands of options. Since mental health professionals are far more open to virtual sessions these days, it’s even easier to find someone you click with.

Maybe you feel more comfortable with a therapist that follows a specific psychotherapy type, or maybe you are more at ease with a therapist of a specific gender. Perhaps you might be looking for therapists who cater to specific communities, such as the LGBTQ+ community. What about specialized techniques? Websites like Psychology Today offer really useful tools to find the right therapist for you.

You can also search for clinical psychologists (with a ph.D. and/or Psy.D after their names), who have completed doctoral degrees. You can also find therapists with a minimum of a Master’s Degree. These credentials include LCSWs (licensed clinical social workers), LPCs (licensed professional counselors), MSWs (masters in social work), among others. If you think you may need a prescription, you can seek out a psychiatrist.

Once you’ve narrowed down the type of therapy and therapist you are looking for, you should check with your health insurer to see in-network and out-of-network benefits. Therapy sessions can be pricey with in-person sessions ranging from $150 to north of $300 per session. Psychiatrists almost always charge the most. Understanding your benefits will help keep your costs at check, particularly if the therapy sessions will be long-term.

Screening

It is always wise to pre-select a few therapists during the research phase. Try to select three to five options and contact them to schedule an introductory call. Most therapists are open to short phone conversations. During this conversation, you can express that you are in the process of selecting a therapist. You can express the pressing issues that you want to address and ask about their experience with these issues.

During these calls, you can get a sense of pacing, listening, and overall connection. You will know when you find someone you can feel comfortable speaking with. It is important to discuss logistics as well. Details include duration of sessions (anywhere 45 to 60 min), cost, confirm insurance affiliations, how they bill, etc. Once you select the right provider, it is time to make that first appointment.

The first appointment

A therapist is not going to label you with some kind of mental health diagnosis in your first appointment. They will need to get to know more about you first. During the first session, they will ask introductory questions to get to know you. The therapist will also ask the specific reason(s) why you decided to pursue therapy.

You will likely talk about your past and how and for how long your symptoms are manifesting today. It is important to remember you are in the driver’s seat and you can always break up with the therapist if they don’t work for you. Similarly important is to know that the information you share with the therapist is confidential by law. With the exception of some specific circumstances (for example when it involves harming yourself or others), all the information you share with the therapist is between you and the therapist.

The role of a therapist is to help you untangle the confusion and indecision you walked in holding. They will assist as you navigate new ideas and try on alternate ways of being. A good therapist will support your self-determination and leave you feeling more seen and understood.

Ongoing appointments

After the first session, the therapist will propose a cadence of sessions. They can go from multiple times a week to once a month or longer. Once a week is one of the most common cadences as this gives enough time for the therapist to get to know you and for you to work on changing your patterns.

While the long-term benefits of psychotherapy can be pretty substantial, it usually gets worse before it gets better. This is simply because you will be exploring head-on many issues that you knew were there but could not see them. Someone characterizes this as “finally materializing and putting a name to your invisible ghosts and fears so that you can ask them to leave.” It is not uncommon to be emotional during sessions, taking a temporary toll on your levels of energy.

Remember that therapists are trained to listen. They have seen and heard a wide range of problems, so don’t feel that they will be offended by or judgmental of the thoughts and emotions you articulate. And even if they are new for the therapist, they will have the tools to guide you through it.

You will likely be leaving each session with some thoughts or reflections from your own talking and from the guidance from the therapist. It is important you reflect on those and try to apply them or see them in your daily life. This is of huge importance for the long-term success of therapy.

Lastly, as you start feeling in a better mental state, allow yourself some time. As there are always areas of improvement, your therapist typically will not proactively cease the sessions. You will be the one who will feel this and when it happens, you can share this with your therapist.

Interesting facts

Psychotherapy is a fascinating topic that is gaining a lot of attention these days. Here are some interesting facts about psychotherapy, all of them sourced from NAMI (National Alliance on Mental Illness) and Mental Health America.

  • In 2020, approximately 47.6 million adults in the United States experience a mental illness. That is 18% of the U.S. adult population.

  • 1 in 25 adults in the U.S. experience a serious mental illness in a given year.

  • About 80% of Americans have experienced emotional abuse.

  • 90% of those who die by suicide have an underlying mental illness.

  • 56% of U.S. adults with mental illness have not received any treatment.

  • In the U.S. there is one mental health provider for every 504 people.

Closing statement

We live in a world that is increasingly complex, intense, and stressful. Most people, at some time or other in their lives, can make good use of psychotherapy as they map their course and steer their way through it.

Psychotherapy is a process of discovering a learning process. In it, the therapist and the client work together to discover what events, situations, and relationships, current or past, are creating uncomfortable feelings. Through collaboration and will, people acquire new effective ways of understanding and coming to terms with those experiences, creating a meaningful change in their feelings, behavior, and overall life outlook.