A Buyer’s Guide to Psychotherapy

Let’s start with some statistics.  Referrals to psychologists almost doubled during the pandemic and have remained well above pre-pandemic levels, with most now preferring in-person sessions.  But most people have no or limited experience with either counseling (generally short-term and very focused) or psychotherapy (more broad-based, for more complex problems or issues).  So, where to start?

Bear in mind that there are many different approaches in psychotherapy (which is my focus in this blog) and that the process is not always successful. When therapy fails, one of the main reasons is a mismatch between the therapist’s approach and the client’s expectations.  To ensure a good fit, start by becoming familiar with the different approaches and by asking your prospective therapist questions before or during the first session.

But first, consider what you really need.  Are your problems just normal stressors that have been exacerbated recently?  If so, a few calls with a counselor through your organization’s Employee Assistance Program (EAP) might do the trick.  Are your problems severe enough to carry a diagnosis?  In that case, depending on the condition, you might need both psychotherapy and medication.  Your family doctor can help you make that determination. Still, there are also online sources that can assist, such as the websites for the Cleveland Clinic, Mayo Clinic, APA.org, Psychology Today, nimh.nih.gov, and samhsa.gov.

Once you’ve identified a prospective therapist, draft a list of questions, such as:

• Have you worked with clients with issues like mine before?
• What is a typical session like?
• What’s your style of helping like, more like directing or guiding, or just listening to help me get things off my chest?
• How often do you anticipate seeing me, for how long?
• How do I prepare for my first session?
• How will we evaluate success?
• What if I have questions between sessions?
• What are your fees, and do you accept insurance?
• What if we determine that we are not a good match?

Answers to these questions will help you get a sense of whether you and the therapist are thinking along the same lines from the start.

It might also help you to consider some of the broad-brush approaches that therapy can take.  Many therapists will tell you that they have an “eclectic” style, that they fit their therapeutic approach to the specific client and the client’s needs.  And that may be accurate. However, it’s difficult to be a true chameleon, and most will still generally follow one “school” or another. History books list many, but nowadays most therapists fall into one of four major groups.  Let’s briefly review them and what you can expect from each.

First, the dominant approach these days is called Cognitive-Behavior Therapy or CBT.  It has its roots in behaviorism and focuses on how behavior responds to external stimuli (Pavlov, Watson, Skinner – remember classical and operant conditioning from Psych 101?), but with the added insight that people can also think and use their thoughts to change their behavior.  CBT therapists are generally focused on problem-solving and goal-setting.  They’ll teach you how thoughts, behaviors, and emotions are all intertwined: changing how you think about your problems will get you to change your behaviors, and that will change how you feel.  They’ll have you doing homework, and they generally plan to work within a limited number of sessions.  You’ll do well with this method if you like structure and having a clear path.

Secondly, psychodynamic therapists are the direct descendants of Freud, Jung, and other late-19th- and early-20th-century psychoanalysts.  Their focus is on understanding how the issues that you may now be dealing with derive from early experiences, and how much of what we do stems from unconscious motivations.  Their goal, broadly, is to bring some of those unconscious conflicts to the surface and to increase self-awareness.  They’re big on interpretation.  They usually plan for therapy to take months, not weeks.  You’ll do well with them if you’re interested in understanding what drives you and if you can tolerate working without an evident structure.

Humanistic (person-centered) psychotherapists are the third force in American psychology, the historical alternative to the two above.  They see each person as unique and capable of achieving their goals, and they see their role as that of a facilitator, assisting and cheering you on your journey of self-discovery.  They see therapy as a collaborative endeavor.  They’ll do a lot of listening, and you’ll be in the driver’s seat, with the therapist as your co-pilot.

Finally, the fourth force -- family systems therapists, who focus on understanding and navigating the systems in which we operate.  They’ll spend time figuring out how your issues may fit in the context of the other significant people in your life, including but not limited to your family of origin.  They’ll explore what would happen to your relationships with your significant others if you were to make some changes, so that you can understand the repercussions of change.  They generally work with couples and families rather than individuals.

Which of these approaches might fit you best?

Research shows that they all work, but they arrive at the goal via different routes, and some work better than others, depending on the condition.  Both CBT and psychodynamic approaches do well with depression, anxiety, trauma, and stress-related conditions.  CBT usually works more quickly, but the changes brought about through psychodynamic approaches often continue to improve after therapy ends.  Humanistic approaches are best when focused on interpersonal or relationship issues (the therapist’s softer approach often works well) and for those coping with chronic medical conditions.  But note that eclectic therapists will borrow from this approach and adapt these techniques as they think best.  Family Systems therapy is broadly effective, but it does best with substance abuse disorders, child and family issues, and relationship problems, with problems that are clearly embedded in a broader context.

Contemplating psychotherapy can be foreboding. In fact, once you start, it can actually be enjoyable.  The opportunity to make desired changes in your life and feel yourself grow as a human can be exhilarating.  Many psychotherapists know this first-hand from having gone through the process, and many use therapy often as their lives shape-shift, requiring minor adjustments or major re-fittings.  Starting therapy for the first time can be a little scary.  Hopefully, the above will help you take a good first step, if it is one that you need or want to take. Enjoy the journey!