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May 11, 2017
I’d like to discuss psychotherapy since there seems to be a lot of confusion about how it actually works. Ideally, psychotherapy is a process that will lead to positive changes in your emotions, behaviors, and thought processes (i.e., you will feel better) although in order to be effective this process requires commitment, time, and effort.
How does therapy help you feel better?
Initially therapy sessions focus on allowing you to elaborate on the details of your symptoms. When you begin therapy it can be difficult to identify and describe your symptoms. This can be due to the difficulties opening up, disclosing personal matters, and feeling comfortable with a therapist that you just met. You may also be confused about the problems that you are experiencing and have difficulties clarifying the exact nature of your symptoms. At this stage, the therapist’s role is to help you feel comfortable in this new setting and help you clarify the problems that you are experiencing. In and of itself, this initial process can be therapeutic. Simply by setting aside a regular time and space to discuss your issues will help you gain a better understanding of what is going on in your head. This is due to the fact that we often do not discuss and clarify these problems with our friends and family due to concerns that we will burden them with our problems, they will not understand the problems we have, or we are simply too embarrassed to discuss our problems with others. So, initially psychotherapy is a process where you develop a more coherent understanding of what’s going on inside your head, an improved ability to communicate your emotional states, and develop what we call a therapeutic alliance with the therapist. A therapeutic alliance is where you establish a connection with the therapist which allows you to feel hopeful that your problems can be resolved.
This is the initial stage of therapy although it is also a process that will be repeated throughout therapy. As you delve deeper into your symptoms and become aware of other issues, you and your therapist will need to spend time clarifying the details of each problem. If this stage goes well, you will feel that the therapist understands your problems and you will feel more comfortable disclosing your inner feelings and beliefs to the therapist. In an of itself, this initial process often leads to feeling better although this is just the beginning.
As treatment progresses, therapy will lead down several therapeutic paths. This includes: going into your past to determine the causes of your symptoms; identifying the details, context, and triggers to your symptoms: and identifying the thoughts and beliefs that you have that contribute to your symptoms.
Going into your past to determine the causes of your symptoms
Many people believe that psychotherapy consists solely of an analysis of your past in an attempt to understand how it created your current symptoms. Although this is part of what we do in therapy it is only one aspect of treatment. For example, if your parents were overprotective and worried excessively about the dangers in the world you may have internalized their fears and experience anxiety in many situations. This process of developing insight into the origin of your symptoms is often helpful since it helps us makes sense of the symptoms. Instead of feeling confused about our symptoms we begin to understand that they are there for a reason and are often related to the environment of our formative years. Although this type of insight will often help us feel better it can also make us feel worse — since we now know the origin of our symptoms but still cannot change them. So, insight is often a necessary but not sufficient part of therapy. As we say, it is important to look at the past but don’t stare.
Identifying the details, context, and triggers to your symptoms
Another avenue that will be explored in therapy is a more in-depth understanding of the details of your symptoms including how and when you experience them. This will often be done at the same time that we explore the past and is important in many ways. When we experience symptoms such as depression or anxiety there are many aspects to them that we do not comprehend which prevent us from taking actions that would help us feel better. For example, when we are depressed instead of doing something that would help us feel better, like socializing or going to the gym, we do things that make us feel worse, like siting on the couch binge watching TV. This makes us feel worse because we don’t understand why we are just sitting on the couch, knowing that it makes us feel worse, instead of taking actions that could help us feel better. Similar to exploring your past, understanding the conditions that lead these symptoms to arise as well as the full extent of the symptoms (e.g., binge watching TV) helps to de-mystify them. This new understanding leads to developing a sense that we can control our symptoms as well as a better understanding of the actions that would help us to do this. As we begin to accurately identify and understand the conditions where our symptoms arise they begin to lose some of their power over us. In some cases we can learn to tolerate and even ignore these symptoms to the point where they no longer bother us. In other cases we can learn to avoid or intervene in the situations that lead our symptoms to arise and thereby gain control and decrease the symptoms.
Cognitive Behavioral Therapy
At this point we get into a more active type of psychotherapy referred to as Cognitive Behavioral Therapy (CBT). Although most patients would like to jump right into this stage at the beginning, without developing the ability to identify symptoms accurately and explore the context of the symptoms this stage wouldn’t work. For example, I recently had a patient that complained of binge watching TV every night instead of being more socially active. She wanted to focus on this behavior in sessions and change it without discussing anything else. Within a few sessions we realized that she was so unhappy at her job that when she came home at night she had no energy to do anything else. Had we focused just on the binge watching behavior we would have missed the bigger problem. So, getting to the point where we can engage in a more active treatment such as CBT takes time although when we do it properly it can lead to big and sometimes unexpected changes for the better.
CBT is a modern type of psychotherapy that says if we change the way we think we can change the way we feel. Most of us can relate to this. If we spend our day saying negative things to ourselves (e.g., “I’m a loser”) we will begin to feel down. If we can identify and change the way we talk to ourselves we will begin to feel better. CBT does not delve into the past and is not concerned with how your problems developed. It focuses on changing the thoughts that are in your head in order to change the way you feel. It may sound easy but CBT is actually hard work and requires persistent effort. Patients often believe that psychotherapy involves attending sessions for one hour a week but CBT requires a lot more. This usually begins with reading books about CBT that are designed for the specific symptoms that you have. It also includes homework assignments to help you identify the thoughts in your head and the ways to change them. In CBT the therapist is like a coach that will educate you, guide you, and get you past any pitfalls, but you must do a lot work and the harder you work the more benefit you will get. At this point in therapy, if you are willing to put in the work, you will experience powerful and long lasting results but you have to put in the work. There are no short cuts. I like to compare it to going to the gym. If you go to the gym once you will gain nothing and even feel worse about yourself because you stopped going. If you go regularly it will be hard, uncomfortable, and challenging but after three to six months you will feel and look better. The same principals apply in therapy.
Many of you may read about therapy on-line or see it on TV. These depictions are rarely accurate. They usually imply that the hardest part of therapy is making the first appointment and after that your problems will magically go away. Although it can be difficult to start therapy, once you begin it is usually an ongoing process of ups and downs. Sometimes you will have “breakthroughs” and feel better and sometimes it will be difficult and uncomfortable.
One of the more intriguing things about psychotherapy is that there is no way to tell how it will unfold. This is the case for many reasons. Most notably, when patients begin therapy they are often confused and naive about their symptoms and have an erroneous understanding of what the problem is. Other times, patients present with significant and chronic issues that require changes in seemingly unrelated areas of their life before they are resolved. For example, the patient that was binge watching TV came to realize that it was her job that was draining all of her energy but changing jobs was not that simple. So we focused on changing the way she responded to the stressors at her job while she explored other career directions. Over time, her binge watching decreased even while she remained at her job. Unexpectedly, her boss noticed the change in her attitude and gave her a promotion (actually it was more of a lateral move) into a position that was more gratifying for her. She was now feeling energized by her career and felt even more energized by the fact that she had taken an active role in her career change. At this point she no longer mentioned her binge watching behavior and became more socially and physically active. This is one of numerous examples of how the ultimate resolutions in therapy are often unknown to us when therapy starts and often include the patient’s ability to elicit or respond effectively to unexpected events.
What does this all mean to you?
Over the years psychotherapy has become more and more acceptable as a way to deal with emotional problems. Although in the past there was a lot of negative stigma attached to therapy, at this time it is often seen as a sign of strength that you are seeking out the help that you need. In addition to the changing attitudes about therapy, therapy itself has become more effective. This has been greatly enhanced by the field of CBT which has focused on improving symptoms as quickly and efficiently as possible. In spite of all of these advances therapy continues to be hard work and requires a commitment as well as time.
If you’ve read this far the rest won’t seem like much of a surprise. If you are experiencing emotional, behavioral, relationship, or career problems, psychotherapy will help. In order for it to work you must make a commitment to change and make it a priority in your life. If you are thinking that something magical will happen in one or two sessions it will not. If you are thinking that the therapist will be able to explain all of your symptoms and provide an in-depth treatment plan in one or two sessions they will not. If you are unable for any reason to make a commitment to therapy due to time or money it will not work. If you want to feel better about yourself and make improvements in your life therapy can help. It will not help overnight but if you are willing to make the commitment to therapy for three to six months you will see changes in your symptoms, relationships, and overall emotional well-being.