What is psychotherapy? - Ranjan Patel, Psy.D. M.F.T. Psychotherapy and Mindfulness Training, Burlingame, San Francisco Bay Area, CA

Psychotherapy and Counseling Defined

Psychotherapy and counseling are synonymous terms to describe a professional relationship between a trained clinician and client (the “client” may be an individual, couple, family, or group). The initial task of the therapist and client is to jointly decide how best to address the client’s presenting problem(s), what avenues of exploration to take, interventions to be used, and to prioritize the urgency of issues. Most therapies, in some form or another, foster increased awareness or insight of the hidden and not so hidden parts of ourselves, including symptoms and defenses (the mechanisms that protect us from further pain). As we become more aware of our thoughts, feelings, actions, perceptions, and experiences, we tend to have greater acceptance, choice, and freedom in life – all of which contribute to a potent sense of well-being. An analogy of how this works: Ideally, we want a varied menu at a restaurant because it gives us more choices. Similarly, if we have a longer internal menu of perceptions, experiences, and the like, we end up with greater choices in life.

Contrary to popular opinion, psychotherapy is not advice giving or teaching, nor is it preaching. You can easily get advice from well-meaning friends, family, acquaintances and even from strangers and the media. You don’t need one more person telling you what to do or giving you a prescription for life. Rather, the goal of therapy is to re-discover your own voice to help guide you in the directions you need to go, and to cultivate trusting your own self more fully in order to make your own decisions. It is becoming more common for clients to inquire about “brief therapy”, mainly because HMO insurance companies prefer short-term therapy because it costs them less. Although consultation and Employee Assistance Program brief therapy (ranging from one to eight sessions) can be very effective for managing a crisis, it is usually not helpful for meaningful personality change or substantive solutions. Realistically, it makes sense that long standing, complex issues require longer-term therapy. “Longer-term” is relative in that you should see definite positive results in 15-30 sessions, and, by all means, if you see no change week after week, broach this with your therapist. He/she should be eager and willing to discuss problems with the therapy, explore alternative treatments, refer you to a more appropriate clinician, etc.

Myths and Questions about Psychotherapy

“Only sick people go to therapy.”A recent article in the American Journal of Psychiatry reports that only 2.4% of outpatient therapy clients were hospitalized with a severe diagnosis. By definition, people in outpatient therapy are higher functioning that an inpatient population, and rather than being “sick”, people who seek therapy for their problems tend to be more proactive and determined about insuring their well-being.

“Going to therapy is a sign of weakness.”On the contrary, asking for help reflects your strength and openness to exploring yourself and acknowledging problems. By going to therapy, you are indicating a readiness to change, and therapy builds on these internal resources you already possess. In fact, most therapists have been in long-term therapy!

“Therapy is all about blaming my parents.”Therapy is not about assigning blame to anybody. It is often helpful to more deeply understand your past within the context of your family in order to assess the effects on you today, so that you have more choices in life, feel better, reach your goals, improve relationships, etc.

“It will take years of therapy to see benefit.”A recent survey by Consumer Reports concluded that 53% of outpatient clients showed some improvement by the fifth session, 74% significantly improved by the 26th session, and 90 % were much improved by the 104th session. Statistics aside, in my experience, clients often feel better after the initial phone call to the therapist, which I think is a function of feeling hopeful about the future and relieved that he/she has taken action and the therapist now shares some responsibility, e.g. the client feels less alone by anticipating help. Realistically, you should see definite improvement from therapy in 10 to 20 sessions (for symptom reduction). For personality change, longer-term therapy is required.

“How can a stranger, who knows nothing about me, be helpful when my family and friends haven’t been helpful?”Friends and family, though well-intentioned, can give good advice and offer support, but they cannot be your therapist by virtue of your relationship with them – they are too close to you to function therapeutically, and they may also be part of the problem. In fact, it is unethical for therapists to treat friends and family for the same reason: it is a “dual relationship” and as such, non-therapeutic.

“My problems are because of my past; I can’t change my past, so how can therapy help me?”It is true that your objective past cannot be changed. Your subjective past, however, can be changed. By exploring your memories of, and relationship to, your history, you are effectively changing the past as it lives inside of you. Essentially, this is the “working through” process: to remember, relive experientially/emotionally, and explore/adopt alternative views of events. Doing this constitutes getting a fresh internal past – a reworking of your history.

“I’ve been to therapy before and it didn’t help, why should I try it again?”Several factors may have contributed to your last therapy experience:

The fit and dynamics between you and the therapist may not have been a good one; the quality of the therapeutic relationship is key to the change in therapy.
The specific interventions used may not have been appropriate, e.g. research has shown that for chronic anger and for certain personality disorders, cathartic methods (expressive techniques such a banging pillows) are contraindicated and often make the problem worse.
The therapist may not have had the experience, expertise, interest, etc. in working with your particular issues.
Perhaps you felt more afraid in the past, and found it safer to leave therapy rather than confront the pain. If so, it is understandable that you needed to protect yourself, and it’s especially courageous of you to think about trying it again now.

“I’ve tried self-help books, tapes, meditation, retreats, etc. and they didn’t help. How is therapy different?”

Books, lectures, workshops, etc. are valuable as general information and as resources to get you started on thinking about yourself in new ways. But they do not acknowledge who you are as an individual. Therapy accommodates for and responds to your unique personality, style, and needs so that a healing relationship can take place. No amount of seminar attendance and book reading can give you a custom made therapy tailored specifically for you. Because psychology as a discipline needs to legitimize itself as a science, it waxes on about “human nature”, as if the nature of humans is unified, and as though there are many similarities for us all as a species, the fact remains: there is no one in the world quite like you. You are like no other. The beauty of therapy is its unwavering commitment to help you discover your true self and be your personal best.

“Therapy is mystical mumbo jumbo.”

The process of psychotherapy should be coherent and lucid to you as your therapist clarifies the reasons for the steps you are taking and explains the rationale for exploring specific themes. If something does not make sense to you, feel free to ask your therapist to explain it. Therapy is not classroom learning, nor is it listening to advice or lecturing. The basic therapy process involves you talking as honestly and openly as possible (presenting internal and external data, so to speak) and the therapist gives his/her guidance and reflections about your content/context. You would again respond, verbally and/or non-verbally – this is the back and forth interpersonal exchange. Your conversations may explore everything from the meanings and dynamics between you and others, you and the therapist, you and the world, and of course, your relationship with yourself. You make the final decisions about what you want to broach in sessions, how far you want to go with it, and what you need to do in your life. You are the ultimate and final judge of your own truth.

“Maybe I’ll feel better without therapy . . . I’ll just wait and see.”

You may be right, you could feel better without professional help; in fact, it’s likely that you will get some relief simply as a function of time – we all have ups and downs over the course of days to months. Feeling temporarily better is not a substantive solution because you might be prey to the same problem(s) in the future. In therapy, you would proactively initiate strategies to not only effectively manage the present, but also to prevent the same issues from returning in the future. Just as a medical symptom responds better to prompt treatment, the same is true for a psychological symptom. Problems are often more easily dealt with if addressed earlier, before they build steam and gain momentum. It is natural to feel apprehensive about starting therapy; if you feel this, please do not think you need to handle it on your own or get over it before coming in. I encourage you to call me to talk about your apprehensions, fears, doubts, etc. so we can make this process as comfortable as possible for you.

“How will I know when to stop going to therapy?”

Remember, you are the final judge of what you need to do. Given this, you can stop whenever you want to, e.g. as in when you are not being helped despite your therapist’s and your best efforts. You have the right to ask your therapist to refer you to someone else.

You SHOULD immediately stop if the therapist is behaving inappropriately and unethically, e.g. want to socialize with you, confiding in you about his/her own problems, wanting to have sex with you, borrowing or lending money to you, etc. These are all boundary violations and ought to be reported to the therapist’s regulatory board.

There may be times when you want to leave therapy because it is too painful to talk about difficult things. This is normal and it’s best to talk to your therapist about your feelings without leaving (acting out). You and your therapist can then collaborate on ways to help the process feel safer while still making progress.

If you are inclined to leave therapy for other reasons, e.g. fee concerns, disliking the therapist’s style, not liking the therapist, or liking him/her romantically, etc. all of this and much more is grist for the therapy mill, so to speak. Your therapist should be happy to discuss your concerns at length. No topic is off limits for you to bring up in your therapy.

And finally, you are likely to want to stop therapy either when you feel you have reached your goals and wish to make no further changes or when you come to a point where you no longer want therapy for inner exploration or personal growth.

“Will therapy help me after I stop going to see the therapist?”

A 2008 study published in Journal of Cognitive/Behavioral Science vol 15 (2) 194-202, suggests that psychotherapy outcome (follow-up at 2 years) is dependent on whether clients continue using skills learned in therapy. Just as clients often do “homework” while in therapy, doing “afterwork” is crucial upon leaving therapy. If clients integrate their experience into their lives post therapy and practice what they’ve learned, they’re far more likely to keep improving and building on the already laid foundation. This is one of innumerable studies where clients are shown to maintain their progress after leaving therapy, e.g. a U.K. 2008 follow-up study from Counseling and Psychotherapy Research vol 8 (2), 80-84, reports clients as “significantly less distressed” 30 months after counseling. Regardless of type of therapy or orientation or any other variable, if the original therapeutic experience is a positive one, the client is likely to use it as a springboard. The mechanisms are debatable but the results are not.

Does Psychotherapy Work?