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Finding Quality Psychotherapy – Moving Beyond Talk Therapy

Len Lantz, MD

Image: Psychotherapist by cvpericias (CC0)

Synopsis: Finding a good therapist can be difficult and stressful. It's hard to know from online ratings who the best therapists are in your community. If you desire the best treatment, read this article to learn about the core elements of excellent psychotherapy and how to find a good therapist.

BY LEN LANTZ, MD / 1.9.2020; No. 9 / 7 min read

Disclaimer: Yes, I am a physician, but I’m not your doctor, and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post might also contain affiliate links. Please click this LINK for the full disclaimer.

All therapy is the same, right?

Yes.

You thought I was going to say no. Keep reading and it will all make sense. The fact is, all good psychotherapy is the same, at least in its core elements. There is a massive variety in schools of thought and approaches in psychotherapy. It is not hard to find “true believers” who think that their form of psychotherapy is the best. It also is not hard to find individual therapists who believe that they have the perfect combination of therapeutic approaches, drawn from many different schools of thought, which make their approach unique and help them get superior outcomes. The reality is that when all of the different therapy approaches and their outcomes are studied in large meta-analyses, effective psychotherapy boils down to a few common elements. Someone is likely getting effective psychotherapy if they are able to confidently say:

  • “My therapist listens to me. We have a good connection/fit.”

  • “I believe my therapist can/is helping me.”

What does high-quality psychotherapy look like?

It is pretty easy to spot high-quality therapy. I would know that someone likely was receiving excellent therapy if they said the following:

  • “Well, I learned more about identifying my emotions and unhelpful thoughts.”

  • “I practiced skills for balancing out my thoughts and emotions.”

  • “I learned how to do deep breathing, progressive muscle relaxation and autogenic relaxation.”

  • “I practiced mindfulness exercises and I completed enough thought balancing logs that I can now balance out my thoughts in my mind and in the moment.”

  • “Well, I learned some skills.”

  • “My therapist had me working on things between therapy sessions.”

What does low-quality psychotherapy look like?

One of the least effective psychotherapy approaches is COW (crisis of the week) therapy or talk therapy. This usually involves the therapist asking you, “How was your week?” Unfortunately for some patients, that is the only question that ever gets asked or discussed – week after week for years. Other than one research article that found talk therapy to reduce suicidal ideation/risk, there is very limited research evidence to show that this type of therapy has substantial value or results in a meaningful outcome.

Unfortunately, talk therapy is what most people probably want when they go to see a therapist. There are a lot of therapists who only do talk therapy. Why? Well, if I wanted to go see a therapist, it might be because I was having a difficult situation in my life or trouble coping with a difficult situation. I might want to talk about it and see if I could get some ideas. Don’t get me wrong, this does have value, but it loses its value if therapy does not progress beyond this point and is continued week after week, month after month and year after year. You know that you are in trouble if your therapist does not give you things to work on between each session.

If you are looking for an effective, time-limited therapy where you can talk to an expert to get some ideas, consider looking into Interpersonal Therapy (IPT), discussed below.

Is therapy effective?

Psychotherapy is the foundation of the treatment of depression and anxiety. If a person has a serious mood disorder or anxiety disorder, they can benefit tremendously from therapy. Consider anxiety disorders. In nearly every study, Cognitive Behavioral Therapy (CBT) was more effective than medications in treating anxiety disorders. While it might be easier to take a medication, in therapy, you learn the skills to cope with anxiety and replace your unbalanced thoughts. Balancing your thoughts is essential, as unbalanced thoughts tend to escalate anxiety. Therapy teaches skills. Pills don’t.

Different forms of psychotherapy

Cognitive Behavioral Therapy (CBT): This form of therapy is similar to coaching because it is almost entirely focused on the here and now and on skills building. The types of skills that people learn in CBT include identifying the difference between thoughts and emotions, practicing coping skills/techniques for anxiety and other negative emotions and cognitive reframing, which uses thought logs to balance out thoughts, which in turn balance out emotions.

Dialectical Behavior Therapy (DBT): This is a form of CBT that focuses on helping people with suicidal thoughts and self-defeating behaviors. DBT helps people to radically accept themselves just as they are, while at the same time seeking positive change.

Interpersonal Therapy (IPT): This form of therapy is usually the most effective for people who are dealing with problems mainly focused on 3 different areas in their lives: loss/grief, relationship problems and role transitions. There also is a 4th area of focus on role deficits, which is less well defined. IPT can be very effective for the treatment of depression.

Acceptance and Commitment Therapy (ACT): This form of therapy is about action and uses a combination of CBT and behavior therapy. ACT focus on the use of acceptance and mindfulness strategies in combination with behavioral and commitment strategies to help people in different areas of their life where they want to see positive movement.

Exposure and Response Prevention (ERP): This form of therapy involves gradually exposing a person to the thing they fear so that the fear no longer rules their lives. Exposure and response prevention might not sound like fun but is one of the most effective strategies for addressing issues like phobias, panic attacks, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

Behavior Therapy: This broad term refers to a variety of therapies that are trying to change behavior, not thoughts, through systematic behavioral techniques. Behavioral therapies can vary quite a bit depending on the issue being treated.

Good therapy helps you become your own therapist

There are lots of things you can learn from therapy. You will know you are making progress when there are actual skills that you have practiced and learned. Doing a thought log on a piece of paper can feel slow and tedious the first time you do it, but by the time you have completed 20 to 40 paper-based thought logs, you will start to be able to balance out your thoughts in your head in the moment. When you recognize that you are stressed and have been holding your breath throughout the day and start doing some deep breathing, then you know you are making progress. When you have a history of mentally beating yourself up and you learn mindfulness, you can then recognize those negative thoughts earlier. Imagine being able to say to yourself, “Oh, that’s just a thought” or “There’s that old thought again” and then let it go and bring your focus back to the task at hand. Getting good therapy can feel a bit like you are becoming your own therapist because it is teaching you skills and building your confidence.

How often or how long should I go to therapy?

Good therapy is not “forever therapy.” All therapy should have a beginning, middle and end. Different forms of psychotherapy have different timelines for treatment. For example, cognitive behavioral therapy may involve 14, 16 or 20 sessions. In this form of therapy, skills-building activities are assigned between therapy sessions and the therapist acts as a coach. Because stages and activities in therapy are planned out in advance, there is an expectation for progress throughout treatment, and this progress can be measured in order to determine a logical time to end therapy. At that point, you have learned more about yourself, gained necessary skills and seen improvement in the thoughts, behaviors and emotions that brought you to therapy in the first place. It is very reasonable for you to ask your therapist, “How many sessions will we have?” or “How many weeks or months will our therapy last?” and expect a clear answer.

Sometimes you need to return to therapy for brief periods. You might hit a rough patch in life and know all the right skills and strategies but not utilize them. If that is the case, it is usually a good time for you to return to your therapist and rebuild sufficient motivation to do the things you need to be doing.

What if I live somewhere that doesn’t have high-quality therapy?

If you have high-speed internet or mobile coverage and a laptop or smartphone, you can access a licensed therapist in your state by video chat. These therapists have websites or apps that are similar to Facetime or Skype but have the necessary encryption and requirements for privacy.

There are other strategies that you can use for support, though they do not replace a therapeutic relationship. One option for people in Montana is Thrive for Montana, which has an online website for CBT-based skills building. Self-help workbooks can be effective as well. My favorite CBT workbook for adults is Mind Over Mood, which takes you from beginning to end in CBT strategies and practice.

How to find a therapist

The best strategy for finding a therapist is to talk to your primary care physician or your psychiatrist. It’s very difficult to determine online who would be an excellent therapist, but one helpful measure is whether or not the therapist advertising themselves lists research-proven, evidence-based psychotherapeutic approaches that they consistently follow. I often encourage people to try out a new therapist by seeing them for at least three sessions. At the end of the third visit I have them ask themselves two questions:

  • “Do I feel like this therapist understands me and listens to me?”

  • “Is this therapist helping me or do I believe that they can help me?”

If the answer to those two questions is yes, you are likely to make progress in therapy. If the answer to either one of those questions is no, you are unlikely to make progress in therapy and it will likely be a waste of your time and money.

Keep in mind that your therapist should have you working on something in your life or practicing a skill between therapy visits. If your therapist is not having you do this, you may want to talk with your therapist about this or consider moving on to someone new. Lastly, it would be helpful when working with a new therapist to ask them what type of treatment plan they would develop for you in terms of the progress that they would be looking for to determine when to end therapy and an estimated timeline for the duration of therapy.

Why do therapy?

I think the biggest reason that people avoid therapy is the time commitment. The second biggest reason is cost. I’m here to tell you that you are worth it. Ask someone who knows and cares about you. They are likely to tell you the same. Remember: pills don’t teach skills. A third reason people avoid therapy is that good therapy can be hard work. Well, a lot of good things in life take effort, time and determination. Therapy can be as effective as or more effective than medication for several mental health concerns. Why would you skip one of the most effective treatments available? Combining therapy with medication is usually more effective than either treatment alone. Why would you avoid therapy and deprive yourself of effective treatment – essentially only giving yourself half of the treatment with medication alone? Therapy can help you get to the root of your depression, anxiety and relationship conflicts. Finding a great therapist and making progress in therapy can transform your life.

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