Pop culture portrays therapy in a way that usually misses the mark ... by a lot. Let's demystify the idea of going to therapy with a down-to-earth overview of what types of therapy there are and which problems they can help with.
When someone says they’re going to therapy, what comes to mind?
Perhaps you imagine them lying on a couch, the way they do in cartoons, while a serious-looking man in a sweater vest and glasses takes notes, pausing once in a while to ask, “And how does that make you feel?”
Or perhaps you think of that scene in Good Will Hunting, where Robin Williams’ character, a therapist, keeps repeating "It's not your fault" until his patient breaks down and cries in his arms.
What pop culture gets wrong about therapy
In real life, therapy doesn't look like it does on TV or in movies. At least not the vast majority of the time.
People don’t lie down anymore; they sit in chairs or on sofas and face their therapist so they can engage in a collaborative dialogue. We therapists also understand that cornering a patient and forcefully and repeatedly insisting they change their mind about something they believe is not effective.
Therapists in real life do not and should not date their clients. This is a big ethical no-no.
And most importantly, therapists in real life do not and should not date their clients. This is a big ethical no-no. Clients are vulnerable to exploitation in this type of relationship. It always blows my mind when movies and TV shows make it seem normal, and even romantic, when therapists and their clients start flirting!
Maybe our imaginations run wild about what happens in therapy because it seems so mysterious. I mean, what do two strangers talk about for a whole hour, week after week? Does therapy really help anyone? Do therapists say wise things that magically heal people? Why pay a therapist when you could just talk to friends about your problems?
No wonder so many people are either hesitant to try therapy or give up after trying one session. They have no idea what to expect, which means they might also have no confidence that it’s going to work. Often, people are either convinced that therapy is all just a scam or they go into it expecting a miracle cure, only to be disappointed when they don’t find The Answer right away.
I've seen patients make life-changing decisions, repair damaged relationships, overcome fears, and learn to value themselves.
This is such a shame, because therapy really can help. We know from plenty of research that psychotherapy is effective for:
- Alleviating depression, especially when added to antidepressant medication
- Decreasing symptoms of anxiety disorders and obsessive-compulsive disorder (OCD)
- Helping people overcome trauma
- Improving quality of life in general
In my clinical experience, I've seen patients make life-changing decisions, repair damaged relationships, overcome fears that were keeping them from living to the fullest, and learn to value themselves in a way they never knew existed.
So let’s demystify therapy. The more you understand what it’s all about, the more likely that you’ll take advantage of this potentially life-changing experience.
Today’s episode will be a broad overview of different types of therapy and how to know which to look for. In next week’s episode, I’ll zoom into cognitive-behavioral therapy, often the most effective and least expensive option for people with psychological symptoms. The episode after that will walk you through a super-practical guide to finding a therapist, including information about insurance coverage and costs.
Let’s dive in.
3 reasons for seeking therapy
First, I don’t want to assume that everybody has the same ideas about why therapy exists.
For individuals, therapy is about working collaboratively with a professional who is trained in psychology to improve functioning. (And "what therapy is about" is such a big topic that we’ll have to stick with talking about individual psychotherapy today and save group and couple's therapy for another time.)
I tend to think of three major reasons for doing psychotherapy:
1. Getting emotional support during a difficult time
Leaving home for the first time, grieving a death, adjusting to a serious diagnosis, losing a part of your identity, losing a relationship ... I can’t think of a single person in my life who has completely avoided all of those lemons life hands us.
Sometimes, we can't lean on the people we’re close to.
Friends and family often provide the much-needed emotional support we all need in times of hurt. But sometimes, we can't lean on the people we’re close to because they’re the cause of the hurt, or maybe they’re hurting too much themselves, or there is awkwardness or secrecy that prevents us from pouring out our hearts to them.
Supportive psychotherapy can help. No matter what type of specific treatments therapists are trained in, we all get a solid grounding in being really good at empathizing, listening, and not being judgmental (at least while we’re on the job). Sometimes, that little bit of common humanity is all you need to get through a rough patch.
2. Gaining insight about the self or about a specific life problem
Sometimes, what we need is a little more specific.
Maybe you’ve been doing some self-reflection and noticed that you always have trouble making decisions. Why? What are you afraid of?
Or maybe the latest in a string of explosive breakups hurt more than usual and you’re wondering why you always end up with people who are terrible for you.
Sometimes a fresh, objective perspective can help you notice patterns you didn’t notice before.
Or maybe you’re trying to decide whether you should have kids or not, and you’ve exhausted all of your pros and cons list-making abilities without getting to the root of why this question tortures you so much.
A therapist may be able to help you untangle some yarn. Sometimes a fresh, objective perspective can help you notice patterns you didn’t notice before. Like the fact that you reject people before they've a chance to reject you, leading you to miss out on vulnerable but meaningful connections.
Or a therapist can use their knowledge and experience to catch red flags. Like connecting the dots between your inability to relax with some troubling ways you describe your parents.
Or if you’re stuck in a seemingly impossible decision, a therapist might be able to ask a few key questions from angles you hadn’t considered to shed new light. Like wondering if you’d leave your relationship if you had a magic self-esteem wand.
3. Reducing psychological symptoms that get in the way of your life
Of course, on top of normal life stressors and emotional hangups—and who doesn’t have those?—some of us also have psychological disorders or symptoms.
Our brains can get stuck in ways of thinking, feeling, and doing that are unhelpful.
Psychological symptoms are anything that you often think, feel, or do that gets in the way of you living a fulfilling life. This could be feeling sad or unmotivated most of the time, not being able to sleep well, acting as if food were an enemy instead of a pleasure, not being able to leave the house without checking the lock multiple times, dreading social interactions, not feeling confident enough to stand up to bullies, or being so impulsive that you’re losing money and friends. Our brains can get stuck in ways of thinking, feeling, and doing that are unhelpful.
Some psychotherapies are specifically designed to address these problems. They work by taking psychological science—what we know about how the brain works—and turning it into teachable skills for improving our machinery. It’s the same idea as how physical therapists turn their knowledge of how muscles and bones work into exercises to help you heal and strengthen them. Healthy ways of thinking, relating, and behaving can be strengthened too!
Different types of therapy and how they help
Just as not everyone needs the same things from therapy, not all therapy looks the same. I won’t get into the history of how all the different branches of psychotherapy evolved. I just want to share the main categories of which psychotherapies you can find today.
Generally, supportive therapy refers to therapy that meets the first type of goal we talked about above—getting through a difficult time.
Supportive therapy tends to not be very structured or goal-oriented. The therapist usually follows the client’s lead and provides what they need in the moment. This might be simply having a nonjudgmental place to cry and an empathic ear to hear their story.
For people who have depression, supportive therapy can be helpful, especially because a big chunk of why people’s depression gets better with therapy is from “non-specific factors” like trusting the therapist, feeling heard, and feeling like someone cares.
If your depression (or other challenges like impulsivity, anxiety, or body image issues) has been around for a while, or it’s hard to pinpoint any temporary event that’s causing it, then you may need something more focused than supportive therapy.
Psychoanalysis, psychodynamic therapy, and insight-oriented therapy
These are the “old school” therapies, evolved from Sigmund Freud’s theories of the unconscious in the late 1800s. The main idea is that we have unconscious drives versus conscious thoughts, and when there are conflicts between the two, we have mental health problems.
The therapy process is meant to “liberate” the unconscious through the therapist’s guidance, often by examining unmet needs from childhood. They can be helpful for the second reason for psychotherapy I mentioned—gaining insight about the self.
Psychoanalysis is meant to 'liberate' the unconscious through the therapist’s guidance, often by examining unmet needs from childhood.
This type of therapy is usually long-term, meaning it lasts months to years, though a short-term version can be used as an add-on to antidepressant drug therapy.
Research shows that psychoanalysis has, on average, small to medium effects for improving symptoms and functioning, but is not as effective when compared to other therapies that are designed to treat specific mental disorders.
Cognitive-behavioral therapies (CBT)
Cognitive-behavioral therapies are designed to treat specific symptoms like social anxiety, depression, insomnia, tinnitus ... the list goes on. We keep inventing new CBTs for various psychological and physical problems.
CBT therapies are very good at alleviating psychological disorders and symptoms.
Some components and variations of CBT are called “cognitive therapy,” “exposure therapy,” “exposure and response prevention,” and so on. But what they all have in common is that they're based on the science of how our brains work, and they teach patients skills to re-train their brains for better functioning.
These treatments are very good at addressing the third reason for therapy—to alleviate psychological disorders and symptoms. I particularly recommend CBT (and its variants) to people who struggle with anxiety disorders, lingering effects of psychological trauma and PTSD, obsessive-compulsive disorder (OCD), and insomnia. You may be surprised at how quickly your symptoms can change!
CBTs are usually short-term, ranging from about 4 to 20 sessions, depending on the client’s symptoms and unique needs. Next week, we’ll zoom in on CBT and look at some examples of just what happens during this type of therapy.
I know the name sounds very hippie, but third-wave psychotherapies are really just variations on CBT with an added central component—mindfulness.
Third-wave psychotherapies are great for people who are emotionally struggling with situations outside of their control
These therapies also alleviate psychological symptoms, but there’s more emphasis on acceptance, life values, and whole-person health. Some well-known third-wave psychotherapies are Acceptance and Commitment Therapy and Mindfulness-Based Stress Reduction. These are great for people who are emotionally struggling with situations outside of their control—chronic illness or stress, fertility problems, estranged relationships, burnout, or just the general sense that life feels like a struggle and happiness seems hard to reach.
Another type of third-wave therapy is Dialectical Behavior Therapy (DBT), of which I’m a big fan. This is an intensive form of CBT (with mindfulness as one of several central foundations) for people who struggle with a combination of big mood swings, chronic life drama, and self-esteem issues.
Other types of therapy
Often, therapists will guide you along a few different roads because each of them contributes to the journey.
You may hear about other schools of thought or other types of therapies, like humanistic or experiential, person-centered therapy, EMDR, contingency management, narrative, expressive, transpersonal ... there are lots of fancy names. But I’ll level with you right now: All of these are variations on one of the main categories we covered today. They’re all just different roads to Rome with different names. Often, therapists will guide you along a few different roads because each of them contributes to the journey.
You may have noticed that I tend to emphasize CBT and its variants more than other types of psychotherapy. That’s because the CBTs are the most supported by psychological science. This is not to say that other forms of therapy aren't helpful! I myself have received insight-oriented psychodynamic therapy and found it to be very helpful for some specific personal questions.
In my work as a clinical psychologist, I have provided supportive therapy to many. But in terms of the most good for the most people for the least cost to patients and society … so far, the CBTs are winning. That’s why I want to tell you a lot more about CBT next week and offer some examples of what actually happens in a CBT therapist’s office. You can subscribe to my newsletter to make sure you don't miss the follow-ups!