Nuts and bolts of effective psychological therapy from a patient's point of view.

July 10, 2006 7:31 AM

How much, and in what way, does psychological therapy reduce problematic patterns of behaviour and thought? How can I, as a patient, make the process work for me? Layperson's eye view sought.

I'm looking for the nuts and bolts, from a patient's point of view, of if and how therapy works to diminish problems. I will be seeking therapy to address several issues: anxiety and depression which manifests itself in a lack of focus and productivity and just a general upsettedness that is very disruptive to my Better Half; a lot of anger over issues past and present that can manifest in a welter of shame and rage over an issue that took place years ago; and a powerful insecurity that is also very disruptive to my Better Half. How does it work, thera-peers? How long does it take to make an appreciable difference in life-limiting problems? What do you bring to the table with the therapist, how do you and s/he discuss the issue, and what's learned/changed when you leave? What can I do to prepare to be best disposed to using the professional's intervention effectively? Conversely, what should I avoid and watch out for in order to maximise my effective use of this resource? How can I stay committed/consistent?
Online resources towards learning about these issues are welcome.
I have not started therapy yet so advice in selecting a therapist and pre-therapy preparation is also welcome. I am in the UK.

posted by By The Grace of God to health & fitness (18 comments total)

It takes awhile to feel better through therapy - months even. Sometimes, when you are discussing really difficult subjects, you may even feel a little bit worse at the time. But over time, addressing these things and exploring them with a professional can help you face things you weren't facing, and find ways to handle your feelings that are more constructive than what you had previously done.

Two things I have had to remind myself to do to make therapy more productive:

- Be honest no matter what.
- If you "blank" on things that have bothered you outside of the office, write some notes or a list of things that you feel you want to discuss later.
posted by tastybrains at 7:38 AM on July 10, 2006

My layman's opinion is that therapy allows one to bring attention on problems and their root causes that they normally remain ignorant of.

In many cases this ignorance is difficult if not impossible to recognize on one's own. A therapist is an unbiased third-party that can repeatedly and skillfully direct your attention until your ignorance of the root cause is dispelled.

So what's important? I guess trust, honesty and a willingness to face potentially difficult and frigthening surprises, would go a long way to facillitating change and healing.
posted by lyam at 7:45 AM on July 10, 2006

Follow-up on honesty: How do you get yourself to say the really embarrassing things that you can barely admit to yourself? Heck that sounds hard. Thinking back to the times years ago when I did therapy that was always the toughest bit.
posted by By The Grace of God at 7:49 AM on July 10, 2006

Cognitive behavioral therapy helped me lose about 40 pounds. I think flexibility is key--setting minor goals. If I was told I had to use the same habits I use now when I started, I would have quit right away. On the other hand, being willing to do some things you don't want is also key. It's definitely easier to give in to temptation rather than use restraint but I know the latter is better for me in the end. Taking it slowly is always good.
posted by clairezulkey at 8:19 AM on July 10, 2006

You just have to remember that the therapist has likely heard it all before. What's embarrassing to you is something he or she has encountered before and so won't be surprised or mocking or horrified or whatever. (If you are a female, compare this to a visit to the gynecologist.)

The first time you say something out loud that you may have only thought before can be hard, but it gets easier. And really, no one can help you if you aren't honest with them, or with yourself. Try it first with something relatively minor, and it will get easier with time.

The real benefits (IMO) of therapy come after you've been going for a while, and the therapist has come to a better understanding of your history, your current situation, and your personality. At that point he or she can finally start connecting the dots for you, and help you recognize patterns. Then the real changes can begin.

In addition to writing things down outside of therapy that you would like to discuss, I also find it helpful to do a quick "debriefing" soon after a session. I try to write down any particular points or suggestions the therapist made, to make things easier to remember. It can be easy to only think about those issues during an actual session, and find that your daily routine of life gets in the way of any serious pondering, which is important to the process.
posted by SuperSquirrel at 8:23 AM on July 10, 2006

Naturally I'm speaking only from my personal experience, but I recently "graduated" therapy after 2 1/2 years. It does take time, and echoing what SuperSquirrel said, I did a lot of writing down things to take in and discuss with my therapist. I also did a lot of writing for therapeutic purposes... just getting down my thoughts and feelings helped a lot.

As for me, I had one major issue and a lot of little issues. I can't say it will work this way for everyone, but once I resolved that major issue, everything else improved dramatically. All the little issues were so much easier to deal with, my self esteem went way up, and that was the point at which I told my therapist I thought I could do without therapy. I'm now 4 months out and doing great.

Again echoing the others... I'm not sure exactly how therapy worked for me, but it took a long time and being gut-wrenching honest. You have to be open with your therapist if you want it to work.
posted by IndigoRain at 8:35 AM on July 10, 2006

Therapy works well and quickly for most people who go into it wanting to change. The evidence for this is more than compelling, it's completely settled. The same evidence suggests that all types of therapy work about equally well. The conservative estimates have a <5 % variation in outcome based the of therapy (cbt, behavioral, insight oriented) engaged in.

That said, probably the most important client-side information to come out of the big meta-analyses is that some therapists practicing some therapies are better for some patients at some times. When you couple this with the data that says that therapy works well and relatively quickly (on the order of a couple of months, not many months or years), patients who want to get the most out of therapy should:

1) have a broad (and a specific) sense of what they want to work on:
make yourself a list, and be as specific as possible. The dirty secret of therapy is that behavioral change comes through behavioral change, which insight may be crucial for, but the more you know about what you want to change the more you will be able to successfully address it;

2) have a sense of how they know things will be working:
Ask youself how you'll know when things have begun to change, and when they've changed enough. Frequently this is part of a conversation one might have with a partner, and therapists should ask if other people are noticing change. The more forthright you are about these kinds of things the more likely you are to be successful, as it can be easy to feel like you're gaining all kinds of insight while the people around you see the same old you;

3) have had conversations about both of these things with the therapist:
there are many different kinds of therapy, and as many kinds of therapists. Your's needs to know what you consider success in therapy and needs to know how you'll measure that. Not only is that only fair, it will help the right therapist to better help you;

4) make sure that the therapist's way of working is compatible with their own:
related to #3. How do you tend to think about your issues right now? Do you think insight into your problems will help you? Do you want to do homework when away from therapy? Do you want a regimented plan from your therapist about what to do when you encounter situation X? All of these things are handled differently in different styles of therapy. Since all therapy works about as well as all other therapy (despite some misleading studies to the contrary, and most definitely despite a raft load of anecdote), it behooves you to choose a method that complements your own view of your consciousness, identity and personality.

5) make sure that the therapist knows that outcome (not process) is the most important measure of therapeutic success:
This is a big one, perhaps the biggest. For too long therapy has been long on process and has assumed that good process (a good fit between therapist and patient) would lead to good outcomes as a matter of course. The opposite appears to be true. It's hard to have good outcomes without a good therapuetic fit, but easy to have good process without any outcome. Hence people in therapy for years and years. There was recently a study published in Psychotherapy (Fall '05, I think) which showed that people who liked their therapists often stayed in therapy for as much as a year even when they thought it was not helping them at all. So, if you want results you have to make sure your therapist knows that and is ready to provide them. (Not incidentally, early change in therapy predicts later change: if you haven't started to see results by, say, session 6 you ain't likely to see those missing results at session 60.)

I think, unfortunately, that patients (as well as therapists) face a culture of therapy that implicitly assumes that longer is better and change is subtle and almost magical. This isn't a nefarious position, but one based on a sincere belief that length and depth in therapy are the same thing, and hence a position based on the best of intentions. The research is quite explicit now, though, that change is change, not insight, and that outcomes need to be worked toward explicitly.

6) have ongoing conversations about what's working and what isn't in therapy:
Let the therapists you're interviewing know what you want and expect, and hopefully they will check back in with you about it. If not, you need to bring it up: this is working for me, this isn't, I want to focus on this, I really don't think my mother matters that much in this instance.

7) be prepared to suggest changes, up to and including changing to another therapist, if things aren't going as hoped:
If you're going to be a good consumer of therapy you need to be prepared to demand the things that any consumer should, and be prepared to leave if things are not working out. This is not to say that one should leave therapy if the therapist talks about something unpleasant which you'd prefer not to discuss. One of the reasons for going to talk with a professional is that a therapist may see a larger picture of your life, with more connections, than you do, and you should be prepared to honestly evaluate the things they have to say and adjust your expectations accordingly. However, if you want to stop smoking and after eight months and 30 hour long conversations about that particular day you shat your pants as a twelve-year-old you now smoke more, well then, it's time to move on.

Finally, and I'm sorry this is so long, I think that one of the disturbing insistences of our culture is that everything needs to come out in order for us to do better. In terms of trauma and talking about trauma this is an especially pervasive position. The truth is, though, that what needs to come out is what's bothering you and getting in your way. Recent research from the WTC, for instance, suggests that those who talked least to "trauma debriefers" have alower incidence of PTSD. There's other research that suggests that if you're basically doing ok in life, and have no specific problems to address, going to therapy actually makes people less happy. I'm obviously a proponent of psychotherapy, and I think it's very, very useful, but also that it's a treatment and not a panacea. Good luck, you'll do fine. My email is in my profile if you would like to email me.

[for meta-analyses of therapies' efficacy, both absolute and relative, see Wampold, The Great Psychotherapy Debate. For more on the specifics of patient-therapist interaction specifcally geared to change see The Heroic Client.]
posted by OmieWise at 8:37 AM on July 10, 2006 [41 favorites]

Well, knowledge is power. We often lack knowledge of troubling or unhelpful behavior patterns and attitudes we hold that may be obvious to a skilled and trained listener, who can help us see and understand these patterns and attitudes. At least, that's been my experience. I'm currently seeing an excellent psychiatrist who asks very trenchant questions. When I answer these questions, I often realize things about myself I never realized before. I like the problem-solving aspect of this. Some therapists, on the other hand, are more in the realm of emotional support, which is fine if that's what you need. Sometimes you need to try a lot of therapists before you find a good one.
posted by scratch at 8:41 AM on July 10, 2006

One thing that I've gathered from fictional treatments of therapy, as well as confirmation from friends who have been in (I have not), which I have not seen anyone mention here yet, is that one of the very useful things you get from therapy is that you learn how to talk about the inside of your head, and the way your thinking works, clearly, and as objectively as is practical.

Part of this comes from the 'honesty' thing, but I think part of it is simply learning the language.

Whorf's hypothesis seems pertinent.
posted by baylink at 9:37 AM on July 10, 2006

Another thing to keep in mind with therapy is that not all methodologies will work well with a given person or situation - that's part of why there are so many.

For example, someone who is very rational, logical,a nd results oriented would most likely not benefit from Jungian psychology, which is aimed at analyzing deep, often mythological themes in a person's life.

A lot of it depends on your goals and your nature. If you like breaking things apart, setting small goals, thinking through problems and solving them, then Cognitive/Behavioral is probably one of your best bets. If you tend to avoid things and have somewhat amorphous fears, Rational-Emotive is probably better (the methodology has to do with putting yourself in awkward situations so you can survive them and realize it's ok). If you have a religious or mythological bent, Jungian psychology might be a better choice. If the core of your problem seems to be insecurity and a need for rational reassurance, then Rogerian psychology might be a good choice.

As for how much and in what way, that's much harder to say since it varies so widely from person to person. I found that more than solving my immediate problems (though it did serve as a pressure valve for me during a rough time), my years in Jungian therapy gave me skills for dealing with trauma and difficulty on my own - a framework, if you will, for how I cope best with trials.
posted by Deoridhe at 11:38 AM on July 10, 2006

It doesn't always take a long time. I had therapy for a very specific problem, and I already knew what the problem was so I didn't need to go through a period of denial or embarrassment or anything like that. I had two hour-long sessions with some sort of an assistant who had some training but was not a licensed psychologist (who prescreened patients for the free clinic that provided my therapy) and then I had hour-long sessions with the psychologist, once a week for about a month and a half. She gave me homework - some writing assignments and some breathing exercises to do when I got upset. Then I moved, and I didn't pick it up again, but the problem has pretty much gone away by continuing to use the behavioural modification tools she walked me through.

I think it takes as long as it needs to - you may not need years or you might, it's very individual.
posted by joannemerriam at 12:01 PM on July 10, 2006

OmieWise, that's some really good advice about how to approach therapy.

I've had a lot of psychological problems, and they came out at a fairly young age, so I've basically spent most of my life in therapy of some sort or another. But until about a year ago, almost all of it got me nowhere at all. I had a very passive attitude to the whole undertaking-- which probably had something to do with being a kid when I first started doing therapy-- and I tended to just go in and be like, "Here I am. Fix me. Solve my mystery." I didn't have any idea what I wanted, except to be happier and more normal and get people off my back. I didn't participate, I didn't say, "These are the ways in which I want my life to be better." And nothing changed for me, for years.

But as I got older, and as I talked to more people about the good and bad experiences they've had with mental health care, I decided that I needed to change my style. I started out by dumping a therapist I'd been seeing for a year and felt was a dingbat but had kept going to out of a misguided sense of obligation. I shopped around and found a therapist I really liked, and I cannot stress enough how much of a difference that made for me. Do what it takes to find a counselor you can have a real connect with.

Before I even started sessions with the new shrink, I sat down and made out a list of my problems, as I understood them. I made note of how they interfered with my life, and what I would like to see changed. When I went in for therapy I brought the list, and told the counselor exactly what I wanted to see happen. I think this method worked out very well, because it kept us focused on improving my life, which is really what therapy should be doing for you.

I also went in prepared and willing to work hard. When my therapist gave me activities to do and made suggestions for things I could try out, I really did it, and I really tried hard to make it work. It was hard at first to make myself stick to all this stuff, as I am generally a flaky kind of person, but the payoff was massive. I have really made a comlete turn-around in my mental state, and it's the most wonderful thing. A year ago, I was spending my days in hiding in bed, obsessively planning my own suicide. Today, I am, for the most part, a functional and hopeful person.

I wish you lots of luck.
posted by bookish at 1:17 PM on July 10, 2006

The major lessons I took from my experience with therapy:

1) Early gains are predictive of future gains. If you work with someone for a few months and don't feel like you're succeeding in any of the changes you want to make, look at your therapy from the ground up. Maybe you aren't focusing on the right questions, or maybe you aren't clicking with your therapist.

2) Don't be afraid to change therapists if you don't click with yours. Make an honest attempt to work with the therapist you pick, and if you don't feel like things are working, discuss that with them. You're not beholden to stay with your therapist forever though.

One of my biggest challenges with therapy, which I never adequately resolved, was how to make it work schedule-wise with my job. Most therapists work Monday through Friday, as do I, which meant I had to go straight from therapy to work. I was dealing with some pretty painful issues and a deep depression, and that made the mental transition from therapy to work very difficult. Also, my work environment was extremely unsupportive and I could not lot it be known that I was in therapy lest it be held against me. If this is an issue for you, I recommend discussing coping strategies with your therapist as early as possible so that it does not interfere with your ability to stay committed to therapy.
posted by rhiannon at 1:23 PM on July 10, 2006

wow.

You guys are awesome. Thank you for sharing all of this information.

I'm going to bookmark this thread and come back to it, as I get going on this. I'll mark best answers as I go.
posted by By The Grace of God at 2:28 PM on July 10, 2006

To second three things:

From scratch: We often lack knowledge of troubling or unhelpful behavior patterns and attitudes we hold that may be obvious to a skilled and trained listener, who can help us see and understand these patterns and attitudes.

From SuperSquirrel: The real benefits (IMO) of therapy come after you've been going for a while, and the therapist has come to a better understanding of your history, your current situation, and your personality. At that point he or she can finally start connecting the dots for you, and help you recognize patterns.

I don't know if the "real" benefits come later, but therapy has only gotten more and more useful for me.

Also, be yourself. I had a therapist who mostly listened and asked questions, so I just talked a lot in the beginning. Then I started asking what she thought about things, and the whole situation started getting more interesting. The more proactive you are about what you want to get out of it, the better:

From bookish: I sat down and made out a list of my problems, as I understood them. I made note of how they interfered with my life, and what I would like to see changed. When I went in for therapy I brought the list, and told the counselor exactly what I wanted to see happen.... I went in prepared to work hard.
posted by salvia at 2:48 PM on July 10, 2006

Whorf's hypothesis seems pertinent.

And completely debunked by linguists and psychologists in any kind of strong form that would be relevant to this thread.
posted by advil at 3:05 PM on July 10, 2006

I know nothing about theories or hypotheses or what have you, but I do have a ton of experience with therapists and therapizing.

First off, it's hard as hell finding "the right" therapist. It's actually kind of like dating. I lived in Juneau, which is basically an island, and went through all of the city's therapists until I found a pediatrician I felt safe talking to. He helped me a lot more than any shrink would have. You wouldn't settle on a house or a car or a mate, don't settle on a therapist.

Second, buy a notebook that's specifically for your therapy. Write down everything. Take notes before, during and after sessions. And then write down what you feel and/or think about the notes. Share them with someone you trust if you need to.

Third, and this sounds obvious, be prepared for change. A lot of people go to therapy hoping that they can be "fixed" and stick to the same patterns. It's not true. Also, because you change, others will have to change as well. Talk about this with your S.O., family and close friends. Some might not like the change and try to get you to revert back to your old behaviors and thought processes. Be prepared for this.

Therapy is a shitload of hard ass work. It's physically and mentally draining. When you start dredging up the scary stuff, it can be tempting to stop. Think up some rewards you can give yourself for keeping at it.

I wish you well.
posted by hercatalyst at 5:02 PM on July 10, 2006

Also, my work environment was extremely unsupportive and I could not lot it be known that I was in therapy lest it be held against me. If this is an issue for you, I recommend discussing coping strategies with your therapist as early as possible so that it does not interfere with your ability to stay committed to therapy.

One coping strategy: simply saying "I must leave every Thursday by X time because I have a medically necessary appointment that I must make by Y. Every other evening, my schedule is flexible." No need to elaborate further. It's medical in nature and therefore, none of their goddamned fucking business. Just assert your right to get the medical treatment you need. If you were getting dialysis, you wouldn't have to do a song and dance routine to leave on time, would you?

(Yes, I did have this issue too. Yes, I'm still pissed off about it.)
posted by jason's_planet at 9:55 PM on July 10, 2006 [1 favorite]