What goes on in the process of psychotherapy?
Psychotherapy is not an esoteric, undefinable process. It is not magic or mumbo jumbo. It is, in fact, a rather rational and accessible process. Let us describe some of what happens when you go into a therapist’s office.
Before you get there, of course, you have typically made an appointment either with the practitioner or through his or her secretary. (“Drop-in therapy” is unusual these days.) You will have probably been asked if you have mental health insurance, and either you or the therapist (or secretary) will have checked to see what your coverage is. Some people, however, either do not have insurance, or choose to pay for the services out of pocket. Hopefully, you will have arrived early enough to fill out some paperwork and not feel too rushed.
When you first walk into the therapist’s consulting room, he or she will have you sit down and, after very brief pleasantries, without much ado will ask you to say why you have come in for the appointment. “What brings you in today?” “How can I help you?” “Tell me what’s going on in your life that you decided to get some help.” These are some of the types of initial questions you will probably be asked. Since you will typically have filled out an intake form, the counselor may glance at it and comment on your “presenting problem”. ”It looks like you’ve been having some marital problems (or feeling depressed etc., etc.)”
Then it’s your turn to unload! Maybe you’ve been waiting for this opportunity for a long time and here’s your chance to get a lot of “stuff” off your chest. Or, for some people, it may be difficult to really get into the nitty-gritty of the problem so fast, and it will take some time (sometimes many sessions, in fact) to get down to the real problem. The client may want to “feel you out”, to test the therapist to see how they react to some of the less scary issues they may have. This is very normal. If the therapist “passes” the tests of trust and safety, only then will the client then get into what really brought them in for counseling.
Types of Therapies
While there is a wide variety of therapeutic approaches used today, each with its own name and methodology, in point of fact the vast majority of therapies can be divided into three broad categories: Psychodynamic, Behavioral and Cognitive. In this section we will also discuss two other therapeutic adjuncts, hypnosis and psychotropic medication.
1. Psychodynamic therapies derive their origins from the work of Sigmund Freud. We will not delve into the details of Freud’s original work, nor of the myriad variations on his theory of psychoanalysis, but rather summarize the basic tenets and techniques of his work and how psychodynamic therapists generally function in today’s world.
The underlying basis of Freudian (and all psychodynamic) theory is that many of our behaviors, both normal and abnormal, are either caused by or influenced by unconscious factors. In fact, it was Freud who first pointed out the existence and importance of unconscious motivation in our lives. The (in?)famous Freudian slips we all make are an everyday example of how unconscious feelings and thoughts can affect our behavior. Calling our new girlfriend by our ex’s name is an all too common example of this phenomenon. “Forgetting” to do an errand that we didn’t want to do in the first place is another common example.
In the realm of psychological problems, our unconscious rears its head in many different ways. As a child, if our father had been an angry, punitive person, we might have repressed (“forgotten”) much of the trauma he caused us, but in a relationship with our bosses, or teachers, or anyone in a position of authority we might have a deep seated fear, mistrust, hostility or even rage that can rear its head in often self destructive, self-sabotaging ways. Unless this is pointed out to us (by a therapist or another wise person in our lives) we could go on this way for years or decades “replicating” these patterns. A psychodynamic therapist would attempt to give us insight into these patterns and help us understand whence they come.
In psychodynamic approaches the role of insight is paramount. In order to really change behaviors and feelings, we must understand their source. The “aha!” moment where things become clearer is seen as pivotal in this process. As a patient you might discover, for example, that one of the reasons you have such a mistrust of men is that when you were a child you overheard your parents arguing about an alleged affair your dad had, and your mom yelling in tears, “I will never again trust you or any man!” You might have repressed this memory, as we often do with sad or scary early memories, but its effect stayed with you at an unconscious level. Other examples of early repression can include child molestation or child abuse, which can stay with us for our whole lives and affect how we interact with people in close and intimate relationships.
The humanistic or existential therapy approaches, while different in many important ways, are classified under the psychodynamic rubric, as they approach the therapeutic enterprise from the perspective of helping the patient understand more of how they function and emphasize the importance of insight in their methodologies. The humanistic approach focuses on reinforcing the client’s importance as a unique and valuable human being, while the existential approaches emphasize the importance of our ability to make choices in our lives, and that we do, in fact, have control over our inner thoughts, feelings and behaviors.
2. Behavioral therapies are concerned with the current relationship between our behaviors and feelings and with events in our environment that reinforce how we feel and what we do. Generally, behavioral therapists don’t care a whole lot about historical information. They want to know what we are feeling now, how we are acting now, and what is maintaining these behaviors. While psychodynamic therapies have their Freud, the behaviorists look to Ivan Pavlov and B.F. Skinner as their patron saints.
You have probably heard of Pavlov’s famous dogs. To make a long story short, Pavlov hooked up some hungry dogs to a device that could blow meat powder into their mouths. Every time the dogs received the meat powder, they would hear a musical tone. They quickly learned to associate the presentation of food with the sound of the tone. Lo and behold, just as they would salivate upon getting the food, they began to salivate when the tone sounded. This is called “classical conditioning.”
There is of course a great deal more to this process, but one can see that much of what Pavlov demonstrated with dogs applies to the learning and unlearning of human behavior. Think of how we associate the smell of perfume with romantic thoughts and how alluring it can be. Think of how we feel when we hear the sounds of our alma mater on a Fall Saturday afternoon (or any time for some people). Think of how we can feel scared when we hear a voice that reminds us of someone in our past who hurt us or scared us. Notice how a young child reacts when he learns to associate getting a shot with the sight of the doctor or nurse. These are all examples of classical conditioning.
One technique that has been developed based on the principles of classical conditioning is called “systematic desensitization.” This is often used with great efficacy to deal with specific phobias, such as fear of flying, fear of closed spaces (claustrophobia), freeway phobias, or fear of heights (acrophobia). To summarize briefly, the patient is put in a completely relaxed state (generally lying down) and listens to the therapist describe scenes related to his or her phobia in a gradually progressive manner, going from least anxiety provoking to most scary. Some therapists make a recording of the session, which the patient can take home and listen to on their own. The idea is to pair the previously anxiety-provoking scene with a state of total relaxation. Just like Pavlov paired the tone with the meat, the patient learns to associate the previously scary stimulus with the mellow, relaxed state of mind he or she is in while listening to the tape. And it really works!
Some 50-60 years ago, B.F. Skinner developed the other major theory of learning, called “operant conditioning.” Skinner’s laboratory animals were white rats, which were put into a contraption call the Skinner Box in which there was a lever attached to a device that, when depressed, would release a pellet of food. Press the lever, and get the food. The food is called the “reinforcement” and as soon as the rat discovered that there was a relationship between pressing the lever and getting food, its frequency of bar pressing behavior would increase exponentially. Give a baby an m&m and watch him smile. That’s reinforcement! Pay someone well to do a job and watch his productivity increase. Reward your spouse with a hug and a kiss and watch them be more likely to be nice to you in return. Examples of reinforcement abound, as you can easily imagine.
In therapy, operant conditioning is used in many different ways, from providing simple reinforcement of kids to do their chores (e.g., more TV or more PlayStation time) to more subtle but very powerful “techniques” like teaching spouses to be more appreciative of each other in order to “reinforce” the behaviors they are trying to change.
3. The third major category of schools of psychotherapy is the Cognitive/Behavioral approach, most notably associated with the work of Aaron Beck and Albert Ellis. As with the first two schools, Cognitive/Behavioral Therapy (CBT) is a rubric under which many different cognitive approaches can be included. However, we can provide a useful summary of the major tenets of this widely used approach below. In fact, there are probably more therapists today who call themselves Cognitive/Behavioral Therapists than any other approach. There are many reasons for this: one is that the methods used are often very effective and efficient in terms of how long it takes to get measurable results; and second, because of the efficiency factor, many insurance companies like to encourage therapists to use what they consider to be cost effective methods, and might be more likely to authorize more sessions to treat the client. (This is an example of insurance companies reinforcing therapists.)
According to the Cognitive Psychology approach, our behaviors, our feelings and our thoughts are all integrally related. The connection among these three components of our personality is called the “Cognitive Triad.” How we feel affects how we think, which, in turn, affects how we act; further, how we act also affects our feelings and our thoughts. Think about it for a moment. When we are depressed we usually tend to think the worst thoughts: things will go from bad to worse, nothing is going right, others don’t like or appreciate me, I don’t like myself, etc. These negative feelings and negative thoughts often result in behaving in ways that tend to exacerbate our depression, like overeating, sleeping too much (or too little), sometimes abusing alcohol or other drugs, stopping whatever exercise we had been doing, acting in angry or insensitive ways to those we love, and the like. It is a vicious cycle, one that continues its downward spiral due to the interconnection among the three components described above: thoughts, feelings and behavior.
With this in mind, a CBT therapist will attempt to intervene into this cognitive triad wherever they can gain entrance, and try to change the self-defeating system. For instance, they often work with irrational or self-defeating thoughts and teach the client how their thinking is taking them down the wrong road. Some of the ways we tend to “think wrong” include “catastrophizing” (making a relatively minor disappointment into a life-changing catastrophe); and “overgeneralizing” (going from a specific negative experience and thinking that “no one in the world likes me”). Some cognitive therapists point out irrational thinking such as “I must be liked by everyone.” Or “…if I fail this test it will mean I won’t be a success in life.”
The type of thinking described above is all too pervasive in our culture. We learn early on to be self-critical and think the worst, which leads to sadness and depression, and then, as described above, to various kinds of self-sabotaging behaviors. It is the role of the Cognitive/Behavioral therapist to point out where our thoughts, feelings and behaviors are self-defeating and to help us relearn them in more positive, productive ways. The technique of “reframing” is often used to help people process events in a more positive way. The oft-used cliché “we can’t change reality but we can change how we view reality” is an example of cognitive reframing.
Other therapy adjuncts:
Hypnosis (from the word “hypnos” which means sleep in Greek) has been used as a therapeutic technique in both the psychodynamic and cognitive/behavioral modalities.
Within the psychodynamic perspective, hypnosis is used to help with problems related to early childhood traumas and early memories. One technique, called “age regression”, enables the client to re-experience things that happened as far back as ages four or five—or, in some cases, even earlier. In a deep hypnotic state the client feels as though he or she is actually much younger than they are and thus is able to re-process experiences that occurred many years or decades earlier. This can be a very powerful experience for the client, and must be handled with care and sensitivity by the therapist, especially with issues such as early physical or sexual abuse.
Within the cognitive/behavioral perspectives, hypnosis can be used to reduce or eliminate unwanted behaviors such as smoking or overeating. The client is given suggestions that they will have the strength to resist the particular behavior and when they do, that they will feel better and better about themselves. In other words, there will develop an association between the target behavior (e.g., resisting smoking) and the positive reinforcement of feeling good about themselves. As part of this approach, the client is given suggestions that they will develop positive thoughts concerning the behaviors they are trying to change. Note that in this approach, as with all behavioral methods, there is little interest in developing insight, personal understanding or emotional growth. In other words, change the thoughts and change the behavior, and you’ve solved the problem.
Psychotropic Medications. “To medicate or not to medicate…that is the question” that clients often ask on their journey through psychotherapy. It is a profound and important question for clients suffering from severe depression, anxiety and many other issues.
The first thing to know about psychotropic drugs is that only a licensed medical doctor (MD) can prescribe any type of medication. An experienced psychologist will have had the opportunity of working with many patients who are taking psychotropic medications and will be able to track their progress, including unwanted side effects that may occur in some cases. Many non-medical therapists (psychologists, social workers, and marriage and family therapists) are able to discuss the pros and cons of medication with their clients and then refer them to their primary doctor or a psychiatrist to let them make a decision. Here is a “short course” on some of the most commonly prescribed psychotropic medications for depression and anxiety:
Antidepressants: The most widely prescribed antidepressants these days are called SSRI’s, which stand for Selective Serotonin Reuptake Inhibitors. The interested reader can Google SSRI’s to obtain a deeper understanding of what they are and how they work, but here is a short version: We all have billions of nerve cells or neurons in our brains. The spaces between all of these cells are called the synapses. Traveling among these neurons are three neurotransmitters: Serotonin, Dopamine and Norepinephrine. Researchers have found that when there is too much or too little of any of these neurotransmitters the person may develop any number of psychological symptoms, including depression or anxiety. The SSRI medications generally prevent the “reuptake” or absorption of serotonin by the nerve cells, thus ensuring that there will be a sufficient amount of this crucial chemical in the synapse.
The first SSRI to hit the market was Prozac in the late 1980’s. Since then many others have been introduced, including Zoloft, Paxil, Celexa, Lexapro and Cymbalta. Other similar medications (SNRI’s or Selective Norepinephrine Reuptake Inhibitors) are Welbutrin and Effexor. It is very difficult to predict which of these medications will work best for any given patient, as the effects of any kind of medication are the result of the interaction between the chemistry of the drug with the chemistry of the patient’s body.
For most patients there are very few side effects to these drugs and in fact many people report no unwanted side effects whatsoever. Some people, however, report initial dry mouth, a little trouble falling asleep for a few nights, minor headaches and minor nausea. The vast majority of these people report that the negative side effects decrease and go away within a few days. For a small minority of patients the side effects persist and they should of course consult their physician. They typically try another one of the medications; if they still have the negative side effects, they may not be good candidates for psychotropic meds.
It should also be noted that a small minority of patients report agitation as a result of these meds. In these cases they should consult their doctor and will probably be told to discontinue the meds immediately. Finally, some patients experience a decrease in libido with SSRI’s. For men, this may include delayed ejaculation or a loss of sexual interest, and for women there can also be a decrease in sexual interest, as well as more difficulty in experiencing orgasm. To reiterate the caveat at the top of this section, the medical doctor is always the person in charge of both prescribing and discontinuing any type of psychotropic medication.
Anxiolytics (antianxiety medications): The most well known of the anti-anxiety drugs (called benzodiazepines) is Valium. It has been around for many decades and was routinely prescribed by physicians for many years without realizing its highly addictive nature. Indeed, we unwittingly created many thousands of Valium addicts during the 1970’s and 1980’s. The well known book, “I’m Dancing As Fast As I Can” was a profoundly personal account of one woman’s struggle to detox from her Valium habit.
Over the last 20 years, other benzodiazepines were introduced such as Xanax, Ativan and Klonipin. The “benzos” are widely prescribed to treat anxiety disorders these days, despite the danger of addiction. The good news is that they work immediately and they work well. The bad news is that they work immediately and they work well. They have their place in the armamentarium of psychological interventions, but need to be used carefully and with the knowledge that there is always the possibility that the patient could become habituated to the drug and have difficulty getting off of it. Other benzodiazepines, such as Ambien and Halcion, are also widely used as sleep aides.
One final thought on anti-anxiety drugs: A drug called Imipramine has been used with great effectiveness to prevent panic attacks from happening before they even start. Rather than a secondary prevention drug (like the anti-anxiety drugs such as Xanax), this is a primary prevention medication that gives the patient the security that he or she will not have to be fearful of having even the beginnings of an anxiety or panic attack.
(There are, of course, many other medications used to treat emotional and mental problems, including psychotic disorders, bipolar disorder, attention deficit hyperactivity disorders and many others. The reader is referred to medicines such as Tegretol, Lithium, Seroquel, Risperdal, Adderall and Ritalin for information on other medications used these days to treat psychological disorders.)
The decision whether to use a psychotropic medicine is often not an easy one to make. Many people are “anti-medication” and are resistant to putting any kind of drug into their body. Others are “gung ho” for meds and can’t wait to try to newest drug to ameliorate their personal problems. The decision is always a personal one and needs to be made with care and respect for the patient’s feelings and attitudes. It should be thoroughly discussed with the therapist, but the ultimate decision whether to prescribe or not rests with the patient’s primary doctor or psychiatrist.
It should be clear that each of the therapeutic schools described above has its own philosophy and methodologies of helping people solve their life’s problems It is also important to note that there is no one approach that is best for all people. In fact, in my 40 plus years as a practicing therapist, the single most important thing I have learned is that to be truly helpful as a therapist, one must have the ability to provide a variety of therapy methods to our clientele, as what works for one person may well not work for the next. And what is effective in solving certain kinds of problems is simply not useful in dealing with others. Let me give you some examples of this:
If a person has been experiencing severe anxiety or panic episodes, rather than focusing many sessions on uncovering why they developed these symptoms (the psychodynamic approach), it is often more effective to treat the symptom immediately in order to reduce the pain they are experiencing (the behavioral method), and only then to look at historical factors that may have contributed to the problem. In this situation one could employ different forms of systematic desensitization, hypnotic induction techniques, and relaxation training, to name a few. As mentioned above, in these situations the therapist may make a CD or tape recording of the relaxation session for the patient to take home and listen to on their own. They then have their own “portable therapist” available when needed.
Another example: The patient presents with feelings of depression, emptiness, feelings that life is meaningless and “anhedonia” (inability to get pleasure out of anything in life). This person is of course suffering from clinical depression, and presents a very different challenge than the anxious individual described above. For many depressed patients (though not all, of course), either a psychodynamic or a cognitive approach is needed. They will not be “cured” in one or two sessions, though they can begin the road to recovery even after the initial session and begin to develop hope that things will change. We know that having hope is often a powerful first step in turning around even the most profound depression.
One final example of how different problems need different therapy approaches: A person says that “everyone in my family (or at work) says I have a short temper.” He or she describes many examples of unpleasant encounters with others, when tempers flare, nasty things are said, hurtful accusations are hurled back and forth, etc. In these cases, of course, we are looking at therapy approaches that involve anger management techniques, teaching the person how to handle frustrations in more effective ways. Providing coping skills in this area can be “lifesaving” in terms of preventing marriages, family relationships, and workplace problems from dissolving, with often disastrous consequences. Anger Management generally falls under the category of cognitive behavioral approaches.
From these brief examples, it should be clear that different problems, life experiences, and cultural parameters need to be respected when deciding on a therapy method. The more experience a therapist has, the more nuanced he or she becomes in choosing a therapy “technology” or approach to utilize with the wide variety of people who come for help.
As an interested reader, you might Google psychological issues that relate to the problems you are experiencing. These days, as you know, there is information on every topic under the sun, and it can often be helpful to know more about the latest thinking in these areas. General headings to check out would be: Depression, Anxiety, Panic Disorder, Anger Management, Marital Counseling, Phobias, Workplace Stress, Stress Management, Smoking Cessation and Parenting Skills.
When I was a graduate student back in the 1960’s (I was very young!) I learned about a study comparing therapists of different orientations with therapists with more and less years of practice. The results stick with me to this day: The research found that therapists with many years of practice were more similar to each other in their approach than, for example, a young Freudian and an older Freudian. In other words, as we get more experience under our belts, therapists tend to become more similar in their ways of dealing with and understanding people.
What this means is not that different techniques do not matter. They certainly do. Rather it means that what is most important in becoming a competent therapist is the attitude that no one technique has a monopoly on the truth. We need to understand and know many of the wide variety of techniques and technologies out there to be of most help to you, when you trust us at one of the most important junctures in your life: when you are asking a professional therapist to take care of you and guide you in a time of great personal need.