How does therapy actually work, how do you find a good one, and what’s the difference between counseling/therapy/psychiatrists/psychologists/etc.?
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Where are you? Where you live will affect these answers. A lot.
I’m going to vastly oversimplify how it works, but:
Me: shows up to therapy as a simmering cauldron of low self-esteem and negative self-talk
Therapist: gets me to talk about these things
Therapist: helps me explore where these things probably came from (i.e., formative years with fucked-up parents)
Therapist: validates that things were severely fucked-up; provides thoughts on how it could have been handled better (if you really trust and respect your shrink, this voice will eventually replace the shitty-parent voice in your head)
Me: continues week-by-week to report new stimulus from my life and how I am handling these things
Therapist: understands current course of action based on deep understanding of my past, continues to validate current feelings, but also suggests different ways to handle and interpret these things going forward
Me: very slowly learns a different way of thinking about life and about myself, and of handling the things the world throws at me
I really believe in therapy as a long-term iterative process. It doesn’t happen in a weekend workshop; you have to keep experiencing the world and give your brain the chance to assimilate the possibility of doing things differently.
Lots of good points here. I’d add one thing.
Therapy is work. Sometimes, it’s grueling work.
Think of it along the lines of physical therapy. Let’s say your arm’s all screwed up. Just showing up at the PT office isn’t going to magically fix anything. They’ll give you some guidance, in the form of exercises that kind of hurt. And you have to do them, over and over again. It’s not much fun. No ‘major break throughs’ will suddenly miraculously heal you.
Once I figured this out, I got a lot more out of therapy. It’s something you have to actively participate in, and it takes a long time. No miraculous healing here either.
People used to talk to me about therapy work when I was studying psychology and doing PhD. I never had any training in therapy during 6 years of psychology study. We were just doing experiments. We would touch on mental health and other issues, but usually it was through the lens of what does someone’s issues tell us about how mind actually works? So a psychologist is not always a trained therapist. I would be terrible at that too, I get social anxiety around someone in need. All psychologists from my uni who wanted to be therapists had to go to clinical psychology training and masters route, for actual application of knowledge and therapy skills.
Really simply, psychiatrists can prescribe medication and conduct therapy. Many choose to do brief sessions focused on medication and maintenance. Counselors and psychologists both conduct therapy but cannot prescribe. Counselors tend to get more training surrounding conducting therapy, but little on testing and research. Psychologists (PhD) are trained more heavily and conduct more testing and research than counselors. A psyD psychologist will likely have more therapy training than their phd cohorts but less research. Finding a good one is very specific to you. A different tool for every job. For instance, an individual who has strong insight and meta cognitive Skills could greatly benefit from straight forward CBT or ACT, whereas someone with more difficulty in this area might benefit more from say DBT or talk therapy. Even those examples are not catch all’s as every Person is different.
There’s already a lot of conversation on degrees and education, so I won’t focus on that much here. All I’ll say is that degree mostly tells you 1. how much research experience the person has (PhDs are research-heavy), which frankly has little to do with you in therapy, and 2. some insight into the therapist’s background (social workers look at social factors impacting mental health, marriage/family therapists use the whole family system in treatment, etc.)
Honestly speaking, your relationship with the therapist is the biggest driving factor for change. So, don’t focus too much on degree when looking for a therapist.
Finding a “good” therapist is all about finding a good fit for you. Some people scoff at the idea of Christian or religious therapy, but others would only feel comfortable with a therapist who shares their spiritual beliefs. Therapists with a strong background in research may be a good fit for clients with specialized and complicated problems (like multiple severe mental disorders), but typically wouldn’t serve diverse populations as well as social workers. So, your search should mostly focus on the therapist’s personality, with a little consideration for specialization.
Personality is basically random. It’s normal to “shop around” and see a few therapists before finding someone who you mesh with. Please remember to ask plenty of questions when you do this! Therapists understand that shopping around is a part of the process, and they don’t get offended by it. They want to help you find a good fit, too.
Specialization is easier to recognize. What’s important to note here is that certifications and trainings have nothing to do with the therapist’s degree, as they are acquired after graduation. The degree is foundational knowledge; the certification/training is specialization.
While not every problem needs a specialist, that information can be helpful to know. Psychology Today’s website is actually a great resource for looking up therapists in your area, and you can filter results by many things including the issue you want treated and the type of therapy used to treat it.
As a general rule, most therapists are experienced in Cognitive Behavioral Therapy (CBT) and Solution Focused Brief Therapy (SFBT). Trauma specialists are often trained in Eye Movement Desensitization and Reprocessing (EMDR) and, for youth, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Marriage Therapists typically pursue training in the Gottman Method and Emotionally Focused Therapy (EFT)/Emotionally Focused Couples Therapy (EFCT). Child therapists usually have training in things like Sandplay and other play-oriented methods. However, this barely scratches the surface of certifications so there are certainly other models that are useful with these problems.
Again, it’s the therapist’s individual personality/skills and their relationship with the client that makes therapy successful – the method that the therapist uses is pretty much secondary. And, honestly, very few therapists are “purists” – most would call their approach “integrative” which means that they pull skills and theories from multiple models (called “common factors”) into their work. Just focus on how you feel in the therapy room with them and they’ll figure out a treatment that works for you. That’s their job, after all.
Psychiatrist: a medical doctor (or nurse practitioner)–someone who can prescribes medication.
Psychologist: has a doctoral degree in psychology, provides talk therapy.
Therapist: provides talk therapy. Depending on your location, this term is not strictly legally regulated. In my experience, but almost all have some kind of license like “licensed clinical social worker (LCSW),” “licensed professional counselor (LPC),” etc. Those qualifications do have specific legal requirements, probably including a master’s degree and supervised work experience. I’d be reluctant to see a therapist who wasn’t certified or licensed in some way, partly because the certification implies that they have experience and partly because it requires them to follow a variety of ethical rules.
In my experience, people who are using medication don’t just see a psychiatrist–they’ll see a therapist or psychologist regularly for talk therapy, and see a psychiatrist less frequently when they need to adjust their meds or get new prescriptions.
Suggestions for finding a good one:
– Read up on some common treatment approaches (cognitive behavioral therapy, psychodynamic therapy, etc). If one sounds like a good fit for you, you can look for therapists who use that approach.
– Use listings on psychologytoday.com, your health insurance website, or similar sites to find local therapists (i like psychology today because it has more filtering options you can use to narrow down the options). Read the profile info to see if they specialize in the type of issue you’re trying to address or treatment approach you’re interested in.
– It can take a while to find a therapist who is a good fit for you. Don’t be afraid to try several. In my experience, maybe 30% of the therapists I’ve seen were (IMO) bad people (ethical issues, judgemental/not respectful, etc). Another 40% seem like they’re probably good therapists for other people, but their methods and personalities didn’t really click for me. The remaining ones were a good fit, and they were really helpful.
I’ve seen 5 therapists and two psychiatrists. Nothing they did ever helped me :/
Imo, for some people, therapy is a massive waste of time and money. And for many many people, medication will destroy your brain and life. I have tried 8 different meds, and to this day (I quit them all) I still don’t feel back to normal. I feel semi depersonalized because the drugs fucked me up permanently. I can’t focus and I get anxiety now. I’d be very very fucking careful if you are considering meds. I was ruined by them
Not sure if this was mentioned here, but there are also currently 5 states in the US in which Clinical Psychologists with a post doctoral degree in psychopharmacology can prescribe within the field of mental health (e.g. SSRIs, MAOIs, etc.)
This is an interesting (and for some people controversial) trend towards granting psychologists prescription privileges.
You’ve gotten a lot of great answers but I wanted to clarify what you mean by how does it work. Do you mean, how does it “fix” mental illness or struggles? If that’s what you mean, I’d love if you could provide more information about what your concern is if you have one or are asking for a friend. A lot of the comments gave great descriptions on the different modalities (approaches) of therapy but they still have some variation based on the issue being addressed (ie personality disorder, mood disorder, substance abuse, trauma, etc).
I wanted to address the middle part of your question. Some of what I’ll mention is a repeat of previous comments but it’s important enough to say again. If you’re asking because you or a friend/family member is considering treatment please consider the following:
-Finding a good fit is HARD. Even harder if you’re in distress. Don’t give up but more importantly don’t give in. If it’s not working that’s okay…therapists know that their work is incredibly subjective and will sometimes even refer you to a colleague they believe will be a better fit. In the end the effort is worth it.
-Don’t discount group therapy. For a lot of people it’s super uncomfortable at first and it takes awhile to acknowledge it’s helpful. For sure it’s not for everyone, but it’s not as awful as a lot of people assume it is.
-Most primary care providers will prescribe antidepressants if you’re experiencing mild-moderate symptoms. That being said, seeing a psychiatrist is definitely a better option if insurance covers it and/or you’ve got significant symptoms. I’ve compared it to this: if you occasionally have symptoms of asthma your PCP will likely run some tests, prescribe an inhaler and they’ll monitor you. If you have significant respiratory issues, they’ll refer you to a specialist who can ensure all aspects of the illness are being treated.
I hope you’re able to find the answers you need.
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