Could you benefit from talk therapy?

"Maybe you should consider seeing a therapist…"
By Harvard Health Publications

Every year, one in five adults in the United States experiences a mental disorder or an emotional problem serious enough to warrant treatment. Although psychotherapy is a cornerstone of psychological treatment, the initial suggestion — whether it comes from your physician, spouse, or best friend — can raise many questions. Are my loved ones tired of discussing my problems? Does my doctor think I’m crazy? Can talking really help? Would medicine work just as well? Will my insurance help pay? How do I find the right person to talk to? This article discusses how psychotherapy works in treating depression and other common psychological conditions.

What is psychotherapy?

Psychotherapy — often referred to as talk therapy — addresses troubling symptoms and emotions using psychological techniques rather than, or along with, medication or other physical approaches. There are many theories and styles of psychotherapy, but the two most popular forms are psychodynamic therapy and cognitive behavioral therapy.

Which works best? There’s no simple answer. Just as many forms of aerobic exercise can help you achieve cardiovascular fitness, many types of therapy can help you understand yourself better, change behavior that is wrong for you, and help relieve bothersome symptoms. You may do better with one type than with another, or find that a blended approach, drawn from different schools of psychotherapy, suits you best. Your regular participation in the process is more important than the type of therapy you choose. Most important is the match, or rapport, between you and your therapist.

Although most therapists emphasize one type of intervention, a good therapist can incorporate elements of others as well. Whatever approach the therapist adopts, she or he should develop a trusting alliance with you, suggest fresh ways for you to perceive your problems, and help alleviate your symptoms and your sense of isolation.

Psychodynamic therapy

Psychodynamic therapists believe that past experiences and feelings of which you’re not consciously aware can influence your present emotional well-being and ability to function. Through regular discussions with a therapist, you can gain insight into your motivations and conflicts and learn more productive ways to cope with them.

“Psychodynamic therapy can be very helpful if you feel like your life is repeating old patterns or you aren’t clear what direction you want to take,” says Harvard Medical School psychiatrist Margaret S. Ross, M.D.

The process of psychoanalysis developed by Sigmund Freud may be the most familiar form of psychodynamic therapy, but it’s not the most common. Psychoanalysis is designed to uncover the unconscious roots of your symptoms and help you apply this understanding to your current life. Classic psychoanalysis is time-consuming (it requires meeting several times a week, possibly for many years) and not widely used today. However, it’s still influential in the thinking behind much psychodynamic therapy, which can be short- or long-term, and may focus broadly or more narrowly on a particular issue or symptom.

Another common focus of psychodynamic therapy is an individual’s interaction with other people. Psychodynamic therapy can help you identify what you seek in a relationship (your needs), the healthy and unhealthy ways of meeting those needs, and ways to improve your ability to communicate. Such therapy can help people cope with the loss of a relationship, conflicts within relationships, or the demands of shifting roles (such as retirement or caring for a parent). One system of therapy with this emphasis, called interpersonal therapy, combines elements of psychodynamic therapy, cognitive behavioral therapy, and other techniques. Therapy is limited to three or four months and focuses on psychological difficulties sparked by recent conflicts or transitions. While not widely available, it is coming into more common use.
Selected resourcesAmerican Psychiatric Association 703-907-7300 http://www.psych.orgAmerican Psychological Association 800-374-2721 (toll free) Network 888-484-3727 (toll free) http://www.4therapy.comNational Mental Health Association Resource Center 800-969-6642 (toll free)

The cognitive behavioral approach

Cognitive behavioral therapy (CBT) is less focused on the underpinnings of feelings and instead emphasizes how to change the thoughts and behaviors that are causing problems. CBT can be used to alter difficult behaviors, such as smoking, procrastination, or phobias, and can also help address conditions such as depression and anxiety.

Cognitive behavioral therapists believe that you can change your feelings by changing your thoughts and actions. For example, you may have patterns of distorted thinking — excessive self-criticism or guilt, always anticipating the worst, attributing untoward motives to others — that make you vulnerable to feeling bad. CBT teaches you to recognize these patterns as they emerge and alter them. The “behavior” part refers to learning more productive responses to distressing circumstances or feelings — such as relaxing and breathing deeply instead of hyperventilating when in an anxiety-provoking situation.
Body and mindPsychological disorders have physical symptoms — fatigue is a hallmark of depression — and many medical disorders have psychological symptoms. For example, an overactive thyroid can make you irritable, depressed, and anxious; an underactive thyroid can make you depressed and slow-thinking. It’s easier to treat these symptoms if their medical basis is recognized. Otherwise, psychotherapy alone won’t relieve even the psychological symptoms, and failure to treat the medical condition can be dangerous.If you consult your primary care physician about psychological problems, a physical exam and testing can rule out a medical disorder. If you go directly to a psychologist, social worker, or other therapist who isn’t a physician, that person should keep in mind the possibility of medical problems and suggest a medical evaluation if appropriate.

Not going it alone

Most talk therapy involves one-on-one meetings with a psychotherapist, but other configurations can be helpful, too, depending on your needs.

Group therapy. Several people meet in regular sessions with a therapist. Interacting with others and hearing their problems can support your efforts to change and reduce your sense of isolation. Group therapy can be particularly helpful for people with difficulties in social interaction because it provides a place to practice and get feedback from others. A group may be organized around a single topic, such as anxiety, bereavement, or a medical condition — or it may be concerned with more general issues, on the understanding that most people cope with similar problems.

Before joining a group, you will be interviewed by the therapist and may be asked to commit to a certain number of sessions. Group therapy may be combined with individual sessions.

Family therapy. This involves the family unit. It’s usually brief and focused on problem solving. It can help families correct miscommunication, change dysfunctional patterns of blame, or adjust to altered circumstances, such as a chronic illness or adult children moving back home. It may be especially helpful when an individual’s psychological problem affects other members of the family.

Couples therapy. Also called marital therapy and marriage counseling, couples therapy focuses on your relationship with your partner. The process may be much like individual psychotherapy, or the couples therapist may act as a mediator, finding acceptable compromises when there is conflict. The therapist helps you and your partner examine your patterns of interaction and determine what changes are needed for each person to be satisfied.

Support groups. Support groups are usually organized around a specific issue, such as bereavement, a particular illness, divorce, or recovery from addiction. A professional usually does not lead them, and, strictly speaking, they are not a form of psychotherapy. But they can be extremely helpful for individuals or families confronting certain circumstances or striving to sustain healthy behavior changes. Like group therapy, support groups may be time-limited or ongoing. Insurance doesn’t cover all support groups.

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When is psychotherapy appropriate?

While medications are essential for the adequate treatment of certain mental disorders, such as schizophrenia, bipolar disorder, and severe depression, research shows that improvement is often greater when psychotherapy is added. By helping you understand and cope with the disorder, talk therapy can also help you stay in treatment and avoid relapse.

Anxiety disorders can be treated with psychotherapy, medication, or both. CBT is the most common treatment for phobias, that is, irrational fears of certain objects or situations.

If you have generalized anxiety or obsessive-compulsive disorder, CBT can help you learn to respond differently in situations that cause anxiety. A combination of psychotherapeutic approaches is required to help people with post-traumatic stress disorder (PTSD) come to terms with their trauma, losses, and painful memories.

Either talk therapy or medication can be used to treat mild to moderate depression, but combining them may be particularly effective. For example, researchers at the University of Pittsburgh School of Medicine found that when depressed people ages 60 and over received psychotherapy along with an antidepressant, they were symptom-free longer. Their quality of life and social interactions improved more than those of patients receiving either treatment alone.

Recent research comparing before-and-after brain scans of people being treated for depression suggests that medication and psychotherapy counter depression in different ways (Archives of General Psychiatry, January 2004). Among people receiving psychotherapy (as CBT), PET scans showed increased blood flow in the limbic, or “emotional,” system, and decreased activity in certain “thinking” areas of the brain. Subjects who took antidepressants showed different changes in the same brain regions. This may help explain why individual responses to treatment vary so much.

For seasonal affective disorder, a type of depression that recurs in the fall and winter, the standard approach is regular exposure to bright light. But new research indicates that CBT may work just as well, by helping patients revise their negative thoughts about the lack of light and learn ways to cope with winter darkness.

After diagnosing depression, a primary care doctor is more likely to prescribe an antidepressant, and a psychiatrist is more likely to recommend psychotherapy and an antidepressant. (A psychiatrist is also more likely to prescribe the antidepressant at the correct dose for you.) Your preferences should be considered. If your primary care physician prescribes an antidepressant, you can request a referral for psychotherapy, or wait to see how you respond to the medication, which may help you participate more effectively in talk therapy.

A psychiatrist may both provide psychotherapy and prescribe medication, but most psychotherapists cannot prescribe drugs. If you’re seeing a non-M.D. psychotherapist, she or he may recommend that you ask your physician about a prescription for an antidepressant. In that case, it’s important for the therapist and prescribing physician to collaborate in providing the best care for you.

Who offers psychotherapy?

Therapists differ in training, philosophy, and experience. When choosing a therapist, you may find that the “fit” is more important to you than the therapist’s specific discipline. Insurance companies usually restrict payment to practitioners licensed in your state.
• Psychiatrists are physicians who complete at least four years of psychiatric residency (in addition to four years of medical school). Psychiatrists can prescribe medication and hospitalize patients, if needed. This level of training is often essential in treating schizophrenia, bipolar disorder, and severe depression. A psychiatrist may offer psychotherapy or concentrate strictly on medical treatment. When looking for a psychiatrist, ask whether she or he performs psychotherapy and what type.

• Most clinical psychologists have doctoral level training (Ph.D. or Psy.D.) in clinical psychology. Psychologists receive extensive training in psychotherapy, but may have less experience than a psychiatrist in handling serious mental illnesses such as schizophrenia. A psychologist is not usually able to prescribe medication or admit someone to the hospital.

• Clinical social workers have master’s degree level training. While not all specialize in psychotherapy, many receive training in therapy and understanding how people function within their families and communities.• Marriage and family therapists are master’s level professionals trained to help with conflicts within marriages and families. They may have less training and experience in individual therapy. Psychotherapy is also available from other licensed mental health practitioners, including psychiatric nurses, clinical nurse specialists, and trained members of the clergy. Although it’s impossible to predict exactly how many therapy sessions you’ll need, it’s reasonable to ask a therapist for an estimate of how long therapy will take, and how and when she or he will evaluate your progress.


Last Updated: 08/04

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