En español | This too shall pass, goes the old adage. But when life takes a challenging turn, it can be hard to take things in stride. Perhaps you're feeling persistently irritable (a frequent sign of depression) or experiencing the stress that often comes from caring for an elderly parent. Maybe your marriage is in a rut or you're grappling with a major life change, such as adjusting to retirement or an empty nest. And then there is the coronavirus pandemic, which for many people has inspired feelings of grief, anxiety and helplessness.
For whatever reason, if you're depressed, anxious, worried or out of sorts, and it's taking a toll on your life, it may be time to turn to therapy to help you cope.
There are a range of approaches to therapy, but many therapists combine elements from two schools: cognitive behavioral therapy and psychodynamic therapy. Before you look for a therapist, it pays to understand these two approaches.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) is a directive therapy, which means the therapist leads the process, teaching patients how to develop effective ways of coping with a range of problems, including depression, anxiety and panic disorders. “Cognitive behavioral therapy is based on the idea that the person is having difficulties because of faulty thinking and behaviors,” says Burton Hutto, a psychiatrist and director of the Crisis Stabilization Inpatient Unit at the University of North Carolina, Chapel Hill, School of Medicine.
These “cognitive errors” or distorted thinking often manifest in self-criticism or guilt. “You may catastrophize situations, tending to imagine the worst or overestimate the likelihood of something bad happening,” says Lynn Bufka, associate executive director for practice research and policy at the American Psychological Association (APA). “For example, you might think, ‘It's all my fault,’ or ‘I never do anything right.'”
How CBT works
CBT, Hutto says, helps you identify and change those negative thought patterns and behaviors that are wreaking havoc on your well-being. “You try to get a more realistic view of what's going on,” Bufka says. “Someone who is really anxious about the coronavirus might be convinced that they're going to get it and are going to die. That's a possibility, but it's not necessarily true.” CBT also helps you recognize and accept events that are beyond your control.
The therapy is structured and focused: You set a plan with the therapist at the beginning of the session. “Because there's an agenda on what you're going to accomplish, it's a shorter-term therapy that typically doesn't last much more than six months,” Hutto says. Patients learn coping techniques during sessions, such as learning practical, more productive ways to respond to distressing or anxiety-provoking situations or feelings (deep breathing exercises, for example). “There's also homework,” Hutto says. “For example, keeping track of thoughts, feelings and situations, then discussing them in the following therapy session."
While CBT concentrates on the here and now, psychodynamic therapy (PDT) is an exploratory therapy that delves deep into the past and your unconscious to help you gain insight and get to the root of your problems. The idea here is that most people's thoughts, feelings, behaviors and the choices they make are tied to earlier (sometimes forgotten) experiences. By becoming aware of connections, you may find it easier to break unhealthy patterns. For example, Bufka says, “a significant loss as a child may contribute to current fears about losing a loved one.”
Another part of PDT involves focusing on the role that repressed emotions and experiences play in our problems. “It looks more at the unconscious — how thoughts and feelings, that are out of our awareness, are making us sabotage ourselves or repeat negative patterns,” says Eric Sherman, a therapist in private practice in New York City and Montclair, N.J. Put another way: It sets out to make the unconscious conscious.
One technique is dream analysis, based on the idea that the mind is less guarded when we're slumbering, making it easier for repressed ideas to emerge. PDT may also be more broadly focused, Hutto says: “If you feel like you have a nice life, but you're just not happy and don't know why you can't be satisfied, you might use therapy to understand yourself and build your capacity for gratitude and acceptance.”
How PDT works
PDT is nondirective and unstructured. “The patient is encouraged to take the lead by talking freely about whatever is on his or her mind,” Hutto says. “It's the therapist's job to organize the information over time, looking for patterns and themes.”
In CBT, the therapist is like a teacher or coach; here, the patient sets the agenda. In PDT, the patient is on a journey, with the therapist pointing out things along the way. PDT can be short-term, long-term or open-ended. “Some people get out of it what they want within months, others within a couple years,” Hutto says. “And there are those who decide to continue for many years, in a more supportive way.”
Understanding different kinds of therapists
The sheer number of types of therapists — beyond whether they specialize in CBT or PDT — can be daunting. Here's how to make sense of the field. First of all, “psychotherapist” is basically a blanket term for any trained professional who treats people for emotional problems or mental health issues. This includes psychiatrists, psychologists and clinical social workers.
Psychiatrists and psychologists
A psychiatrist has attended medical school and has an M.D. Since they have medical training, psychiatrists — unlike psychologists — can prescribe medication. Typically, a patient receives “split treatment,” with a psychiatrist handling the management of medication and a psychologist providing talk therapy, though some psychiatrists also practice psychotherapy. A psychologist has a doctorate in psychology, which can result in a Ph.D. (with a focus on research) or a Psy.D. (concentrating primarily on talk therapy).
Clinical social workers
These therapists typically have a master's degree. “When some people hear ‘social worker,’ they think of professionals who work in hospitals, helping with transition care, for example,” Bufka says. “But there is a segment of social workers who are trained to provide psychotherapy.” Social workers may be an LCSW (licensed clinical social worker), LICSW (licensed independent clinical social worker) or LSW (licensed social worker).
There's no evidence that one kind of provider is better than another. “A person's professional degree doesn't really tell you what level of therapy training they've had,” Hutto says. “Therapists can have very different levels of training, ranging from almost none to many years of supervised casework.” A licensed marriage therapist may have 10 years of training, he says, while a psychiatrist could have had minimal therapy training. “You might think the psychiatrist, with his or her medical degree, would be the ‘better’ expert. But in fact, the other person is the therapy expert.” It just depends.
One thing that may affect your decision: money. Fees often reflect a therapist's degree. “The fee of a social worker would typically be less than a typical psychiatrist or even a psychologist,” Hutto says. “In fact, a licensed clinical social worker, with 25 years of experience providing therapy, may charge only half of what a newly trained psychologist does."
How to find who's right for you
"A good way to find the appropriate person is to get a referral,” Sherman says. “Your doctor, a close friend or family member who sees a therapist might be able to recommend someone.” Or you can do some digging on your own. Psychology Today's Find a Therapist, the APA's Psychologist Locator, or ZenCare (a therapist database) are terrific resources. Type in your zip code and you'll find a list of professionals near you. Refine your search by clicking on treatment methods (CBT, PDT, etc.), specialties (such as emotional problems, life transitions or marital problems), age group specialization (seniors, for example), qualifications and years in practice, or cost per session.
Another way to go: Narrow the prospects based on your insurance. “If you have private insurance, Medicare or Medicaid, contact them to find in-network providers,” Hutto says. “You can cross-match that with, say, the Psychology Today list.” After you've pared down your search, interview potential therapists by giving each one a call or requesting a free consultation. (Keep in mind, right now most therapists are conducting sessions over the phone or via teletherapy because of the coronavirus lockdown.)
Questions to ask a candidate
Ask about their credentials and their training, related to your specific problem, and what their approach to therapy might look like, Hutto says. Let them know why you'd like to see them ("I've been really depressed,” or “I'm having a difficult time dealing with retirement"). You want to get a sense that they're a good fit, Sherman says: “You're going to open up to this person, share things that are tough to talk about, and be vulnerable, which is not an easy thing to do. You want to think, ‘This is a person who I can unburden myself to — someone who can create a safe space for me.'”