The word “psychotherapy” – also called “counseling” or just “therapy” informally – often carries a lot of baggage. For some, psychotherapy conjures images of lying on couch while a silent observer takes notes, speaking only to explain the “deeper meaning” of something that is said. For others, what happens during psychotherapeutic treatment is a source of mystery and often carries a sense of stigma and a fear of being judged. Psychotherapy is less mystical than depictions in media would suggest: it is a collaborative process that involves you and a therapist working to understand how your mind works, address mental health symptoms that you may be experiencing (for example, depression or anxiety), change patterns of behavior and thinking that can cause suffering and difficulties, and improve your overall quality of life. Despite the availability of other treatment approaches, psychotherapy remains the gold standard for long-term emotional growth and can often be effective when other treatments have not. In some cases – for example, problems stemming from early childhood trauma, neglect or abuse by caregivers, and chronic problems in relationships – psychotherapeutic treatment may be more effective than other commonly available treatments.

In this post, we will discuss what psychotherapy is, attempt to “demystify” what occurs in the psychotherapy treatment room, provide an overview of commonly practiced forms of psychotherapy, and discuss what to expect when beginning psychotherapeutic treatment. If you are interested in beginning in exploring psychotherapeutic treatment, please request an initial consultation with Dr. Cole to discuss if psychotherapy might be a helpful approach for you.

What is psychotherapy?

Psychotherapy is a form of mental health treatment used by trained professionals to help individuals identify and change troubling thoughts, emotions, and behaviors. Psychotherapy can be administered by many different mental health professionals, including licensed professional counselors (LPCs), “master’s level” therapists (including masters of social work and masters of family therapy), psychologists, and psychiatrists. While many types – also called “modalities” – of psychotherapy are practiced today, they all share the same core principle of talking about thoughts, feelings, and experiences to alleviate emotional suffering.

Psychotherapy is more than “venting” about your problems to another person. While “venting” can provide relief in the moment, it rarely leads to long-lasting, meaningful change. Instead, psychotherapy involves you and a therapist discussing problems that you have in your life, working to understand what might be contributing to those problems, and exploring strategies for addressing those problems moving forward. This is done with a person (the therapist) with whom you do not have a personal relationship, allowing the therapist to be more objective when discussing your problems and providing you with greater psychological safety and privacy than what similar conversations with someone that you know personally might be able to provide. The therapist also brings significant experience and expertise in dealing with mental health symptoms and concerns, allowing him or her to offer different perspectives for thinking about and understanding your concerns while addressing those concerns with care and compassion.

At its core, psychotherapy provides a safe, confidential space where you and your concerns are the focus while the therapist acts as a skilled guide to help navigate the emotional difficulties that you are facing.

Who can benefit from psychotherapy?

Numerous research studies have shown that psychotherapy can be helpful for nearly all mental health problems. Prior to the introduction of psychiatric medications in the 1950s, psychotherapy was used exclusively to treat all mental health symptoms, including conditions that, in modern psychiatric practice, are generally not considered to be treatable with psychotherapy. Today, psychotherapy is typically paired with other treatment approaches – most commonly medications – to address symptoms, though many people prefer to use psychotherapy as a standalone treatment option.

Extensive research has shown that psychotherapy can be effective in the treatment of most psychiatric conditions, including major depressive disorder, anxiety disorders, obsessive compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and others. These studies typically evaluate the effectiveness of a specific form of psychotherapy in the treatment of a specific psychiatric condition, however all available evidence suggests that most psychotherapeutic modalities are effective for most mental health concerns.

For most psychiatric conditions, both psychotherapy and medication therapy can be effective in managing symptoms, and personal preference is the primary driver of which treatments are pursued. However, psychotherapy has unique advantages as a treatment over medication management, including:

1. The durability of treatment. Because psychotherapeutic treatment works to address ways of thinking that may contribute to the development of mental health symptoms, the benefits of psychotherapy persist after treatment has ended. By contrast, symptoms treated with medications are more likely to return after medication treatment is stopped.
   
2. The lack of side effects. Unlike medications, psychotherapy has very few side effects. Confronting painful thoughts or feelings can be distressing, but this distress is temporary. Otherwise, the most significant downsides of psychotherapeutic treatment are the time and financial investment required.

In some cases, medications can reduce symptoms and allow psychotherapeutic treatment to be more helpful. Medications and psychotherapy are often complementary, and many studies have shown that the best treatment outcomes are achieved when both forms of treatment are used together.

Ultimately, psychotherapy can be helpful for anyone who is interested in learning about themselves and their symptoms, open to thinking about their thoughts and feelings in new ways, and working to live a more emotionally satisfying life.

An overview of psychotherapeutic treatment

The various forms of psychotherapy are often described as branches of a large tree. While all use verbal communication to discuss and understand your emotional life and experiences, different forms of psychotherapy use different techniques and focus on different principles and ideas to effectuate change. Nearly all psychotherapeutic techniques share several core ideas:

1. Discussing your emotional and mental experiences provides an opportunity to understand those experiences. Having an understanding of why you might be feeling how you are feeling can be immensely relieving, even if factors contributing to those feelings cannot be changed.
   
2. The experience of being heard and taken seriously by another person can be inherently therapeutic. For many people, the experience of having troubling thoughts or behaviors that are handled carefully and compassionately is an experience that they have not had before, and this new experience can be eye-opening and facilitate new ways of thinking about emotional and life experiences.
   
3. Improved self-understanding and changes in how you think about your life better equip you to deal with challenges in the future. While psychotherapy often begins with the goal of addressing a specific problem or concern, the benefits of treatment are broadly applicable to other situations that may occur in the future, lessening emotional difficulties over the long-term.

Psychoanalytic psychotherapy, psychodynamic psychotherapy, cognitive-behavior therapy (CBT), dialectical-behavioral therapy (DBT), acceptance and commitment therapy (ACT), and nearly all other psychotherapeutic modalities are founded on these core ideas. Differences among these modalities lie primarily in how these ideas are put into practice and specific points that may be emphasized during the course of treatment.

Psychotherapies can be broadly divided into two groups: manualized psychotherapies and expressive psychotherapies. Manualized psychotherapies tend to be highly structured, utilize practical techniques for addressing problems, and focus on specific problems or symptoms. These modalities are sometimes “time-limited” – for example, a therapist may say at the start of treatment that he or she will meet with you for a set number of sessions – and often incorporate explicit homework that is worked on outside of session. These approaches are generally more focused on addressing symptoms directly rather than addressing underlying causes of symptoms, and this approach tends to be more beneficial for people with very specific problems that they would like to address and specific goals that they would like to achieve from treatment. For example, someone who experiences panic attacks and would like to reduce the frequency of these symptoms may benefit immensely from this approach. Common examples of this form of psychotherapy include cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT), and dialectical behavioral therapy (DBT).

Expressive psychotherapies, also sometimes called insight-oriented psychotherapies, on the other hand, tend to be less structured and more “open-ended.” These modalities generally are not time-limited, rarely utilize homework, and view a symptom or problem as occurring in a broader life context which is worth understanding and exploring. This approach tends to be more beneficial for people with broader problems that they would like to address or for those who want to better understand themselves and their minds. Compared to manualized psychotherapies, expressive psychotherapies tend to be broader in the scope of problems they address and involve longer courses of treatment. For example, someone who repeatedly struggles to form close, intimate relationships with others may benefit from this approach more than from manualized therapies. Common examples of these forms of psychotherapy include psychoanalytic psychotherapy and psychodynamic psychotherapy.

In real-world practice, most therapists do not rigidly follow a specific psychotherapeutic approach and usually incorporate techniques and ways of thinking about problems from multiple psychotherapeutic modalities throughout treatment. However, most therapists identify with a particular psychotherapeutic modality that heavily informs the way he or she thinks about and approaches the problems you are hoping to address.

What to expect from psychotherapeutic treatment

Psychotherapeutic treatment tends to progress in phases, with each phase having slightly different goals and approaches as the treatment moves forward. These phases should not be thought of as absolute but, instead, as a rough guideline for gauging how treatment is progressing. In many cases, treatment may return to a previous phase as your and your therapist’s understanding of your problems evolve.

A course of psychotherapy typically moves through the following phases:

Phase one: treatment initiation

Psychotherapeutic treatment begins with you and the therapist getting to know one another. Some therapists may begin with a formal “diagnostic interview,” which is a structured way of learning about your symptoms, your prior treatment history, and aspects about your life. Others may use a less structured approach and have you tell your story in the way that is most comfortable for you, allowing information to be revealed over time. In this phase, the therapist is learning about you and your symptoms and may begin developing ideas about how these problems came about and how to address them. The therapist will often ask more direct questions and focus on obtaining as much information as possible to set the stage for treatment moving forward. In some cases, a therapist may feel that he or she does not have enough clinical expertise to treat the concerns you would like to address or may feel that he or she is not a “good fit” for you. In these cases, the therapist should provide you with a referral to another clinician that may be better able to address your concerns.

Importantly, this phase is also an opportunity for you to see if the therapist is a “good fit.” Every therapist-patient pair is different, and a particular therapist’s “style” or approach may not be the best for you to get the most out of the experience. While beginning psychotherapeutic treatment can be uncomfortable, awkward, or even intimidating, treatment is unlikely to be helpful if you do not feel heard by the therapist or if you and the therapist cannot developing a good working relationship. I generally recommend that people commit to completing 4-6 sessions with a therapist before making a decision about not moving forward with treatment as, just like any relationship, it takes time for a therapeutic relationship to develop.

The length of the introductory phase can vary considerably. With structured psychotherapies that are problem-focused or time-limited, the introductory phase may last only a couple of sessions. With less structured psychotherapies or when the problems being addressed are more broad, this phase may last months or even years. Key goals of this phase are to ensure that you and the therapist understand your concerns as fully as possible and to develop a safe and comfortable therapeutic relationship for ongoing work. This phase can also be thought of as a trial for both you and the therapist to determine if ongoing treatment together is the best option for you and will often end with the therapist sharing with you his or her understanding of the problems you would like to address and his or her recommendations for treatment. However, therapists are constantly working to learn about and understand their patients, so this phase often continues in some form throughout the treatment.

Phase two: “working through”

“Working through” is a term that describes the process of addressing the concerns that brought you to treatment. There is significant variability in how this occurs. Manualized therapies tend to use more direct approaches: the therapist may provide specific techniques or advice for addressing symptoms, and some psychotherapeutic modalities utilize homework to address symptoms that is reviewed at the next session. Some of these therapies follow a set structure from session to session that is predictable and fairly rigid. Expressive psychotherapies, by contrast, do not typically follow a set structure, and individual sessions can vary significantly in what is discussed and the overall emotional “feel” of the session. Courses of treatment that address specific symptoms or have more narrow goals are often more structured while treatments that address more pervasive, chronic problems or have the goal of better understanding yourself are often more flexible and variable in their approach. The “style” of the therapist and the psychotherapeutic modality being utilized also shape the working through process.

A lot happens during this phase of treatment. In many cases, treatment follows a pattern of “two steps forward, one step back.” As your understanding of your symptoms and problems change, new symptoms or problems may come to the fore that need to be explored and worked through. New insights may also result in a desire to make substantive changes in your life, and making these changes can be quite difficult or painful in their own right. Often times, frustration about the therapeutic process itself can occur. How these problems are discussed and dealt with will depend on the specific therapist and approach, but “working through” is almost always an iterative process of identifying problems, understanding those problems, and exploring ways to address them. The process of “working through” may last a few months to many years, depending on the problems being discussed and the goals of your treatment.

In some ways, though, “working through” is never complete. We all experience ongoing difficulties and problems as we go about our lives, and new situations will occur that can challenge us emotionally. While psychotherapy cannot anticipate every problem you may face, a major gift of “working through” is being able to address these future issues more effectively than before beginning treatment.

Phase three: termination

Psychotherapy is not intended to go on in perpetuity, and the end of treatment is usually a sign that significant growth has occurred. How long a course of psychotherapy lasts varies significantly. Some psychotherapeutic approaches are highly structured and do not last longer than a set number of sessions; in these cases, when treatment will end is known from the start. Some forms of psychotherapeutic treatment are specifically designed to last no longer than 10-12 sessions. Other approaches are more open-ended, and a decision to end treatment is made collaboratively between you and the therapist. Factors that can affect the duration of treatment include the problems being addressed in treatment, your goals for what you would like to achieve during treatment, and the specific psychotherapeutic modality that is being used. In most cases, the decision to end treatment is influenced by balancing practical considerations – for the example, the cost and time required for ongoing treatment – with the degree of improvement in symptoms that has occurred.

“Termination” is the planned end of psychotherapeutic treatment. This ending can sometimes be difficult and painful, and some people may experience a return of symptoms as the end of treatment approaches. The termination phase provides time to discuss these feelings, address any ongoing concerns, and allow for closure. The termination phase may last no more than a couple of sessions for time-limited psychotherapies or several months for more open-ended approaches that have resulted in a long course of treatment. Key goals during termination include reviewing progress that has been made during treatment, exploring and preemptively addressing challenges that may occur after the end of treatment, and saying goodbye.

In some cases, psychotherapeutic treatment may end earlier than expected. The realities of life may cause you or the therapist to be unable to continue treatment for as long as had been planned. In these cases, you or the therapist should notify one another as soon as possible about the need to end treatment so that the end of treatment can be approached in an intentional way. Treatment that ends suddenly or unexpectedly can be painful for both you and the therapist; while this is unavoidable in some situations, abrupt termination should be avoided as much as possible.

Most therapists view termination as an end to treatment “for now.” Some therapists may recommend ongoing, but less frequent, meetings – sometimes referred to as “booster sessions” – while others might encourage you to return to treatment in the future if needed. The therapist’s approach to these situations is usually discussed during the termination phase.

Taking the first step

Making the decision to begin meeting with a therapist is not an admission of weakness or a sign of failure: it is an investment in your long-term wellness and mental health. Psychotherapy provides a structured, supportive environment to address the barriers standing between you and the life you want to lead. While the various psychotherapies differ in their approaches, the goals remain the same: facilitating the development of a more resilient, self-aware, and fulfilled version of yourself.

If you are interested in seeing if psychotherapy may be a helpful treatment option for you, please contact us or request an initial consultation to schedule an appointment to discuss your concerns.