The Nuts and Bolts of Therapy

What is this thing called therapy?

According to Hollywood, a therapist is either a professorial type sitting behind a desk who makes snap judgments about the hapless client, or an ethically challenged man or woman who becomes sexually involved with the individual seeking help. (The movies in which the latter scenario develops, such as The Prince of Tides, Final Analysis, Basic Instinct, and Mr. Jones, among others, rarely mention that in real life such behavior could cost the therapist his or her license.)

And of course there are the neurotic Woody Allen-type characters who spend years of three-hours-a-week-on-the-couch in psychoanalysis...and are still crippled by anxiety or end up dating their stepdaughters.

Radio shows in either real life ("Dr. Laura"— the doctorate, by the way, is in physiology, not a mental health field) or fantasy (television's Frasier) also add grist to the mill of expectations about therapy. A few sentences about a problem and the caller is spoon-fed (or sometimes force-fed) advice from the host and, often, other callers.

It's no wonder that people are sometimes confused about what therapy really is. Read on, then, for a more accurate picture of therapy — what it's like, how it works, and who can benefit.

You don't have to have a mental illness or even a clear idea of what your problem is initially in order to seek and benefit from therapy. In fact, many people enter therapy, or it's suggested to them by their physician, friends, family, or coworkers, because they're unhappy and don't know why...or if they do know why, they see no way to change.

First, let's define some terms. When I mention therapy, I'm talking about psychotherapy -- therapy of the mind (or soul, if one considers the original Greek meaning of "psyche"). Webster's dictionary defines psychotherapy as "the treatment of mental or emotional disorder or of related bodily ills by psychological means."

Some people use the words "therapy" and "counseling" interchangeably, although counseling is technically defined by Webster as "giving advice....as a result of consultation" and usually involves more of a sense of "professional guidance," while psychotherapy could be viewed as a process in which the therapist helps clients make their own decisions.

A lot of people, of course, would prefer that someone just give them advice — tell them what to do to get out of the situation or state they're in. But humans are complicated beings, and it's usually not that easy. Remember the saying "Give a man a fish and he'll eat for a day; teach a man to fish and he'll eat forever?" Counseling tends to hand the person the fish, while therapy teaches him to fish. While sometimes handing a man a fish may be just what he needs, at other times a careful assessment is needed to make sure fish is really what he needs, and that there will be no allergic reactions.

When you meet with a therapist, he or she will ask you to talk about yourself, what brings you in to see him or her, and what your goals are. The therapist will ask questions to elicit your personal, social, and physical history, including your current issues, problems, and symptoms. The initial session with a therapist helps him or her to get a complete picture of you and your life. Since we humans are pretty complex, that process can sometimes take two or three sessions or more. Psychotherapy sessions usually run from 45 minutes to an hour each. Occasionally the therapist may ask you to take some psychological tests, which are traditionally administered by a psychologist or under a psychologist's supervision. Such tests can give the psychologist or therapist more insight into your personality, coping styles, and moods.

The psychotherapy process is one in which a variety of approaches and techniques may be used to help the client identify problem patterns and behaviors and experiment with change. Talking is usually an important part of psychotherapy, as it helps the individual — and, of course, the therapist, who can't read minds! — become aware of problems, conflicts, and possible solutions. The very act of talking about oneself and one's life for an hour is often itself therapeutic, as it forces the individual to sit and contemplate what's going wrong in his or her life, which he or she may not have the time or inclination to do otherwise. The therapy office can be a safe place in which the client can talk, rant, rave, puzzle, laugh, and cry while knowing that information will be held confidential and the therapist will be nonjudgmental.

Other approaches used in therapy may include art, journaling, and recommended readings (bibliotherapy). Some therapists are trained in the use of Eye Movement Desensitization and Reprocessing (EMDR) or energy psychology modalities, relatively new techniques that can help people resolve traumatic experiences and free up areas in which they feel "stuck." Sometimes medication will be recommended, and the therapist will refer the client to a physician to prescribe and monitor the medication while the client continues seeing the therapist for psychotherapy. In other instances, a client may already be on psychiatric medication prescribed by his or her physician, but wants to directly address his or her problems with the goal of learning new coping skills and eventually discontinuing the prescribed medication.

Regardless of the techniques or modalities employwed, the foundation of psychotherapy is the therapeutic relationship -- the connection between client and therapist. So it's important to work with a therapist with whom you feel comfortable. (If you don't feel comfortable with anybody, then pick a therapist with whom you feel the safest.)

How do you find a therapist? Although you can open up the Yellow Pages, look under "Psychologists" and start calling while hoping you find someone you like without traveling too far down the alphabet, it's usually better to ask someone you trust to give you names of therapists they recommend. You can ask a friend or family member who's been in therapy. Your physician can also refer you. Or you can call your state's psychological association (usually listed in the phone directory of your state's capitol city). Other options include contacting the psychology department of a local university or college, or the psychiatry or social work department of a nearby hospital, to ask for a referral. Your county may also have a community mental health center that can be a resource. In contacting a psychiatry department or community mental health center, be sure to emphasize that you are looking for psychotherapy rather than medication. Many psychiatrists are primarily trained to prescribe and monitor medication and other biologically or medically oriented treatments, such as electroconvulsive ("shock") therapy, rather than provide psychotherapy. Medication management sessions will usually be shorter (15 to 30 minutes each) and less frequent than psychotherapy sessions (once a month or every few months, rather than weekly).

There are several different kinds of therapists. A psychologist has a doctoral degree in psychology that includes three to four years of clinical training in addition to course work, and has completed a year-long internship and an additional year of supervised postdoctoral training. Psychologists are qualified to assess, diagnose, and treat psychological, emotional, and personality problems and the psychological and behavioral aspects of medical conditions. A Licensed Professional Counselor (LPC has at least a master's degree— sometimes a doctorate — in psychology. Some individuals with master's degrees in psychology are licensed as psychological examiners or psychological assistants and practice under the supervision of a psychologist (except when doing vocational or career testing or counseling, which they can do independently). A Licensed Clinical Social Worker (LCSW) has a master's degree in social work and two years of post-degree supervised clinical experience. A psychiatrist has a general (non-specialized) M.D. degree and three to four years of postdoctoral clinical training in psychiatry. As mentioned earlier, contemporary psychiatry tends to conceptualize psychological and emotional conditions as diseases or illnesses with biological origins. Some psychiatrists are well-trained as psychotherapists, while others are not. All psychiatrists are trained and licensed to prescribe medication.

If you plan to use your insurance to reimburse some of the costs of therapy, you will need to check with your insurance or managed care company to see if they limit who you can see. Most managed care companies and many insurance companies have a list of therapists for whose psychological services they will reimburse. (Call the number listed on your insurance card for information.) If such is the case, you can ask them to refer you to someone and "authorize" or "precertify" the treatment — which simply means they agree that the psychological treatment is "medically necessary" according to their criteria and in accordance with your insurance benefits. If you want to see a particular therapist and he or she is not on the "provider panel" (list of "approved" therapists — meaning those who have agreed to accept the company's reduced rates and paperwork requirements), ask about out-of-network benefits. Sometimes a company will pay a lesser amount — say, 50 percent of the therapist's fee instead of the usual 80 pecent) for services provided by a therapist who isn't on their panel. That means your co-payment (the amount you would be responsible for after insurance pays) would be higher than if you saw an in-network therapist, but you might choose to do so in order to see a particular therapist.

There are costs as well as benefits to involving your insurance or a managed care company in your therapy. [See What You Should Know About Using Health Insurance for Psychotherapy or Psychological Consultations for a discussion of these pros and cons.] One benefit, of course, is that insurance may pay for a significant percentage of the costs of therapy. Managed care companies will frequently argue that their screening process ensures the level of competence of the therapists on their panel. But being licensed by the state also ensures a level of competence and protection for the consumer, and there are many qualified therapists who refuse to work with managed care because of concerns about patient confidentiality, excessive paperwork and treatment authorization procedures, and poor reimbursement rates. [Since initially publishing this article in 1997, I have become one of those therapists.]

In order for an insurance company to reimburse for treatment, it will need to know a diagnosis (an official label for what's troubling you) and the dates, charges, and services provided. The company frequently will also want to know details about your condition and treatment. Many therapists are uncomfortable releasing such detailed information, because they have no control over how the information will be used. In other words, they can no longer guarantee your confidentiality once an insurance or managed care company is involved. You have a right to know what kind of information your insurance or managed care company may ask for, and what information your therapist gives them. You can then decide whether the benefits of using insurance or managed care outweigh the costs.

If you decide to engage in therapy and find a therapist you like, how long the therapy lasts will depend on you and your therapist if you are paying for your treatment yourself. If you use your insurance, the insurance or managed care company will probably authorize only a few sessions at a time, requiring your therapist to justify further sessions as "medically necessary." Short-term therapy is generally less than 20 sessions, and many people feel significantly better after as few as 12 sessions.

Traditionally, the therapist and client meet once a week for 45 minutes to an hour; however, you can discuss a different schedule with your therapist if you think that might work better for you. Longer-term therapy can last a year or more of weekly sessions, and is usually necessary when the client needs time to open up in therapy or when a longer period of time is needed to process problems and possible solutions or practice coping strategies. People who have been severely hurt, betrayed, or abused by others, for instance, often need time to develop trust that the therapist won't be just another person to betray them.

Sometimes therapy sessions will be held weekly for a while and then be tapered down to every two weeks, once a month, etc. until therapy is finally terminated or regular sessions are no longer scheduled, with the understanding that the client can contact the therapist to schedule further sessions on an "as needed" basis.

Therapy can be costly in terms of time, energy, and money, especially if you choose to or need to pay for it out-of-pocket. But the possible benefits — improved quality of life, decreased stress, and more satisfying relationships —can be priceless. Think of it as an investment in yourself.