Guidance on how to get the most out of your counseling sessions by starting with how to find the right therapist for you.
A path to mental health, a partnership, a means of seeing yourself in a truer light—at its best, psychotherapy can be all these things. The medical community has held psychotherapy in varying levels of regard over the years. But a growing body of research suggests that talk therapy, when done well, can be as effective as medication in treating depression.
Various studies—including a 2004 overview of 16 clinical trials, published in the Archives of General Psychiatry—have found that many people do best with a combination of the two. The antidepressant works on the chemical roots of depression so you feel well enough to fully participate in therapy; the therapy provides practical tools to manage the illness and reduce the odds of a relapse.
A combination of psychotherapy and medication helped Ted D. regain his life.
“In 1995, I had a depression that grew so severe, I had to quit teaching for a semester,” says Ted, who was an English instructor at Red Deer College in Alberta at the time. A psychiatrist prescribed medication, which Ted found to be “an immediate help.” The two also began meeting regularly for intensive talk therapy.
Ted initially saw the psychiatrist daily, scaling back as he began feeling better. After four months of treatment, he was well enough to return to work.
With his psychiatrist’s help, Ted says, he came to understand that patterns of negative, cyclical thinking were part of his disease.
“I would go round and round on an issue, almost obsessively. In therapy, I learned how to break that kind of cyclical thinking. I also learned how to manage the depression, how to deal with episodes and how to make sure they stayed minor.”
Find a good fit
If you have a cavity, you go to a dentist; if you have a broken bone, you get it set by an orthopedist. But if you need psychotherapy, there are many choices: psychiatrists, psychologists, licensed clinical social workers, and mental health counselors. To complicate matters, it’s fairly common to see a psychiatrist who handles your medications and a second practitioner who delivers therapy.
No matter what type of professional you end up with, you’ll be giving that therapist your trust, your time, and, in many cases, a good chunk of money. So you want to find someone who is qualified, dedicated and makes you feel comfortable, and that usually takes some shopping around.
Ask the experts: A good place to start is to ask one of your physicians, whether a primary care doctor or a specialist, for recommendations. Trusted friends may also have good leads. Community mental health organizations and support groups can be valuable resources. National mental health organizations frequently post online referral lists.
Test the waters: It’s worth meeting with a few potential candidates, says Jeanne Watson, PhD, an associate professor in counseling psychology at the Ontario Institute for Studies in Education of the University of Toronto. “Get a good fit with someone you feel comfortable and safe with, so you will be able to engage in the deep emotional processing required.”
Think nuts and bolts: There are also practical considerations. Is the person credentialed? Does the type of therapy he practices meet your needs? Will he accept your insurance plan, and is he available at times and days convenient to you?
Play critic: Decide if the therapist’s style suits you. “You want someone who is neutral and nonjudgmental,” says Maureen Empfield, MD, a psychoanalyst who practices in Mount Kisco, New York, and has written about treating depression. “That’s critical. It’s a safety zone—there is no judgment. It also has to be somebody who lets you explore what’s going on and points you in certain directions.”
Give it time: If you’ve made little progress after a reasonable number of sessions, or you’re not growing more comfortable with the therapist, it’s probably time to look for someone else. But before you do, Watson recommends first sharing your concerns with the therapist.
“If the therapist is willing to adjust and work with you to find a better fit, that is someone worth hanging on to for a while,” says Watson, who maintains a part-time private practice in Toronto. “But if the person criticizes you or blames you, it’s probably not going to work out.”
Stick with it
Dropping out of therapy altogether because of a bad experience with one therapist can be short-sighted. Gyl W. of Texas, went through years of therapy before she found a therapist who gave her what she was seeking—the tools to build a happier life.
Gyl, director of public policy at Mental Health America of Texas, a mental health advocacy and educational organization, remembers having her first depressive episode in grade school. But it wasn’t until she graduated from college that she sought mental health counseling.
In therapy, I learned… how to manage the depression, how to deal with episodes and how to make sure they stayed minor.
Although Gyl was severely depressed at the time, that first therapist never discussed medication as an option. Later, when Gyl became so ill that she had to drop out of graduate school, another therapist did refer her to a medical doctor for antidepressants.
When Gyl was coping with a divorce, she saw a therapist who was a good listener and empathetic. But that wasn’t enough.
“I just kind of vented,” recalls Gyl, who wanted to do the deep therapeutic work that leads to positive life changes. “All she could do was reassure me.”
Gyl didn’t give up on therapy, however, and her perseverance paid off. For the past nine years, she has been engaged in cognitive behavioral therapy with a counselor who pushes her to be an active participant.
“He gives me homework and handouts. He identifies patterns of negative self-talk and perfectionism,” says Gyl, 45. “He’ll ask me questions like, ‘If you felt better, what would it look like?’”
Do the work
Good therapy involves more than just sitting in a chair and having someone tell you what to do. It calls for hard, sometimes painful, work: Recognizing destructive patterns, learning the skills to change them and putting those skills into practice day in and day out.
For example, homework is an essential component in cognitive behavioral therapy (CBT), currently the most widely used—and most scientifically researched—form of talk therapy. The therapist typically assigns tasks or writing exercises that address behaviors or patterns of thinking identified during sessions.
Homework could involve any activity that “extends the learning process, such as making a phone call you have been avoiding, talking to a friend, or getting out of bed,” explains Leslie Sokol, PhD, a psychologist in private practice and director of education at the Beck Institute for Cognitive Therapy and Research outside Philadelphia.
People [with anxiety disorders] tend to over-predict risk. Therapy helps them see the real evidence of risk and gives them coping tools.
Or it could be a more involved task, she says, like writing down what you’ve accomplished for the week that you thought you couldn’t.
“The real reason CBT works is that you are helping people change their beliefs,” says Steven D. Hollon, PhD, a professor of psychology at Vanderbilt University in Nashville, Tennessee.
A 2005 study led by Hollon found that CBT may be especially effective in preventing relapse. Preventing recurrence is key, as the likelihood of a relapse increases dramatically with each episode of depression. For example, after a first episode, there is a 50 percent chance of relapse; after the second episode of depression, the rate shoots up to 70 percent.
The study looked at what happened after people with depression stop treatment. In the group of people who had been treated only with cognitive behavioral therapy, the relapse rate was surprisingly low—just 31 percent.
CBT is now the first line of treatment for most anxiety disorders, says David Dozois, PhD, an associate professor in the psychology department at the University of Western Ontario. “People [with anxiety disorders] tend to overpredict risk,” Dozois says. “Therapy helps them see the real evidence of risk and gives them coping tools.”
Move forward
The work of therapy can be challenging, but ideally it brings long-term benefits: “It empowers the individual to acquire the skills necessary to be their own therapist long into the future,” says Leslie Sokol.
How do you know when it’s time to say goodbye to your therapist? It’s over when the client and therapist agree the objectives have been met, says Maureen Empfield.
“The doctor doesn’t come in and suddenly announce, ‘You’re cured,’ ” she explains. “Usually the patient reaches a point where things are going smoothly.”
But therapy does not have to end completely.
Although Ted D. and his psychiatrist are in different cities—Ted, 70, now runs his own writing and editing service in Saskatchewan—he still periodically contacts her by email, phone, or even in person when he needs extra support.
He recognizes the monumental role the right therapist can fill in a time of darkness and seemingly limited possibilities.
“She helped me in every possible way,” says Ted. “It was the classic role of a therapist—she helped me find out what was wrong, learn ways of dealing with it and moved me toward independence.”
Maximize the benefits
To enjoy long-term benefits from therapy, it’s necessary to be a partner in the process, says Leslie Sokol, PhD, a psychologist in private practice and director of education at the Beck Institute for Cognitive Therapy and Research outside Philadelphia.
To build a strong partnership, the therapist needs to establish rapport with the client, demonstrate an understanding of the client and his issues—and provide a strategy to move forward in therapy, Sokol says.
The therapist can’t do it alone, however. If a patient is “not engaged or invested in treatment goals, or willing to play their part in working toward change, treatment will be compromised,” she adds.
Beginning the work of therapy while in the midst of an immobilizing depression can feel like trying to run a race wearing 50-pound shoes. But there is a common misperception, says Sokol, that you have to feel like doing something in order to do it. In reality, she says, “You have to put action before motivation.”
It’s also important to set some general goals you want to accomplish with the therapist. Articulating why you are in therapy—“I don’t like the way I feel,” for example, or, “My family needs me”—is helpful, too.
Same goal, different approaches
There are many types of talk therapy. Here are some of the disciplines that research shows to be effective in treating depression and/or anxiety:
Cognitive behavioral therapy helps people recognize distorted thinking and unhelpful behaviors and modify them using various techniques taught in therapy. CBT emphasizes problem-solving in the present. It is generally brief, between 12 and 20 sessions, although people coping with more complex issues may require months of therapy.
Dialectical behavior therapy combines behavioral therapy with mindfulness practice (attention to the moment, observing without judgment). The term “dialectical” refers to a process of synthesizing opposites. In DBT, the therapist validates the client while simultaneously encouraging change. The therapist points out unhealthy behaviors, then teaches skills to better react in similar situations. DBT involves both individual sessions (to learn skills such as mindfulness and regulating emotions) and group therapy (to practice those skills).
Group therapy brings together people with the same or similar disorders to talk out their problems under the guidance of a trained mental health practitioner. (This is different from a support group, which can be led by a professional facilitator or by group members.) Attendees find companionship, emotional support, and insight from shared experiences.
Interpersonal psychotherapy is a short-term therapy (usually up to 20 sessions). The therapist identifies significant life events that may feed into depression, such as a geographical move, marital discord, birth of a child or longstanding grief. Therapist and patient then work on specific problems with the overall goal of alleviating depressive symptoms and improving relationships.
Psychodynamic psychotherapy focuses on helping the client gain greater self-awareness and better understanding of problem behaviors by exploring how unconscious emotions and motivations can influence actions. This is partly accomplished through using the developing therapeutic relationship to gain insight into problematic relationship patterns in the patient’s life.
Psychoanalytic psychotherapy delves into the patient’s unconscious to better understand the origins of self-destructive personality traits, difficulties in relationships, or disturbances in mood and self-esteem. As the patient talks freely, the analyst looks for clues in subjects the patient avoids, repetitive behavior patterns and how the patient relates to the therapist.
Printed as “Talking up Talk Therapy,” Summer 2010
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