NEW YORK — When many people who have never been to therapy imagine the process, they see a scene from a Woody Allen movie.
A patient lies on a couch while a Dr. Freud-style psychiatrist sits across from them and writes notes on a pad, nodding and saying nothing.
In reality, there are many kinds of therapists and many styles of treatment, and most do not fit the stereotype.
From the range of practitioners who offer therapy to the host of styles, it can be hard to navigate the myriad of choices. As the latest segment of DNAinfo.com New York's multi-part series on understanding the process of therapy, we'll look at who therapists are and what kinds of therapy they offer. (For a look back at Part 1, on how to know if it's time for therapy, click here.)
The Therapeutic Relationship
Before getting into the breakdown of each type of therapy and therapist, I want to make it clear that while it’s important to feel comfortable with your choice of practitioner, at the end of the day it is the “therapeutic relationship” that is most critical.
Recent studies indicate that the strength of the alliance, or relationship between the therapist and client, is the greatest predictor of success, no matter what type of training or clinical approach is taken. As a result, it's incredibly important that you feel comfortable with the person sitting across from you in the therapy office. What I usually say to clients when they call me for a consult is: "you are a consumer in this process and you need to feel comfortable with me as we go forward."
Having said that, there is a difference between feeling uncomfortable with a therapist and uncomfortable in the process of therapy. Often times it is an important step to feel uncomfortable with provocative material as it comes up. This is different from feeling like you are not being “heard” in session, or being “judged.” In the end, it’s a balance between feeling comfortable with your therapist and feeling like the approach you are taking is helpful.
Knowing Your Choices
Therapy has become such a buzzword that sometimes it can be hard to know who is and isn’t a therapist. For example, while there are many psychotherapists who also promote themselves as life coaches, life coaching is not, by definition, therapy. It is your right as a consumer to ask a therapist what certifications, trainings, experience and approach they use in their practice.
In general, it’s not so much the credential. Rather, it’s what the practitioner’s experience and postgraduate learning encompasses. That informs the modality and the treatment that each practitioner uses, and that can help make the difference between someone you feel comfortable with and someone you have a hard time connecting to.
Among the health professionals who are specially trained and licensed or certified to treat people are the following:
• Psychiatrists (M.D.’s)
• Psychologists (PhD’s, PsyD’s)
• Licensed Clinical Social Workers (LMSW and LCSW’s)
• Licensed Mental Health Counselors (LMHC’s.)
• Marriage and Family Therapists (MFT’s)
• Creative Art Therapists (ATR’s, LCAT’s)
• Registered Nurses (RN’s)
Click here for a full list of mental health abbreviations.
While the specific requirements and accreditations vary by profession, possessing one of these certifications means that those practitioners have attained at least graduate level degrees.
The State of New York regulates and administers these licensures and there are legal, educational and ethical standards that practitioners must adhere to in order to retain their credentials. There are differences in curriculum and internships between all of these professionals. However, it is generally the post-graduate study and work that shapes how a therapist approaches their craft.
Keep in mind, not everyone finds that more years of education and training equals better care. One person might feel comfortable with a newly-graduated therapist, or even an intern, while someone else feels more at ease with a psychiatrist with an Ivy League pedigree, who’s been practicing for more than 30 years. Both can have a positive effect on a client’s life and it’s ultimately a decision for the client to make.
It is important to note that psychiatrists are the only ones in this group that can prescribe medication. Indeed, many psychiatrists will see patients for “medication management,” and not psychotherapy. Some practitioners have a combination of degrees and/or certifications.
For example, some MFT’s are also CASAC’s (Certified Alcohol and Substance Abuse Counselors), usually specializing in treating addictions. Some practitioners have training from psychoanalytic programs, which can include years of institute training, which means they are seeing patients with oversight by people with decades of experience and seniority.
“Institute training” usually lasts one to four years, includes coursework, supervised therapy, psychoanalysis for the student and a thesis.
Besides institute training, there are many specialties and approaches to therapy that therapists can pursue.
For example, I have training in Eye Movement Desensitization and Reprocessing (EMDR), which consisted of two weeks of intensive training followed by monthly supervision. It is a powerful “tool” in my practice, and many clients seek me out specifically due to this training.
What are the Most Common Therapy Approaches?
While there are an endless number of modalities and sub-specialties (and more added every few years), here are the two basic approaches:
Psychoanalysis/psychotherapy is based from the Freudian tradition and involves discussing how past experiences or pain, along with unconscious thoughts and beliefs, drive our level of functioning and happiness.
There are many different types of psychotherapy and psychoanalysis (see the link above), and these types inform the client and therapist on where the focus is. Cognitive and behavioral approaches focus less on past experiences and more on how your thoughts influence your behavior and your mood. It is a more structured approach, and usually requires the client to assist in the process by completing “homework” assignments, explicitly tracking moods, behaviors and thoughts.
Cognitive behavioral approaches tend to be more short-term, ranging anywhere from eight to 15 weeks, however both approaches can be either used for short or long-term treatment. While most therapists have a foundation in either psychodynamics or cognitive behavioral therapy, most therapists I know use an eclectic approach which weaves various techniques, trainings and experience in order to best serve their clients. It is important to note that not all therapy is individual.
Group therapy is very popular as it is usually lower cost per session, and tends to be focused around specific topics, such as “new mothers,” “partners of sex and love addicts,” “survivors of childhood sexual abuse,” and so on. Many clients in groups feel that the group provides an added layer of support around their issues. And then there is couples and family therapy, which involves some or all members of the family. Focusing on family or relationship problems, by definition it acknowledges that its not just the individuals in the family, but the unit as a whole that has to resolve the family dysfunction.
Where you go for therapy and how you come to that determination we’ll address in the next part of the series.