How do you choose among hundreds of available therapies—offered by psychiatrists, psychologists, social workers, and counselors—to help you conquer painful feelings, unbearable anxiety, dysfunctional relationships, or out-of-control behavior? What are the sessions like? How will you know if your therapy is working and when it is time to stop? Veteran medical journalist Carl Sherman gives you the tools to make smart decisions about getting professional help.
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From the Trade Paperback edition.
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DO YOU NEED THERAPY?
Things aren't going well. You leave for work with a sense of dread and come home half-dead with fatigue. You fight incessantly with those you love-or can't find anyone to love. The toll of smoking or excessive drinking is obvious, even to you, but you keep on doing it.
Maybe something happened to knock you off balance. You lost your job a month ago, and now it's hard to get up and get dressed. A friend is terminally ill, and you can't put thoughts of him out of your mind. Since that emergency landing at O'Hare, every business trip gives you nightmares.
Or there's nothing really wrong, nothing you can put a finger on. But one day you realize that you've been struggling through the motions in a miasma of low-level discomfort and dissatisfaction. Whatever you do doesn't seem like the right thing, and none of it gives much pleasure.
What are you going to do? There's no shortage of books to tell you how to heal whatever ails you, no lack of talk-show gurus with wise advice on everything from beating the blues to finding lasting love or the job of your dreams. Maybe you've assembled your own little arsenal of strategies that help when the burdens get heavy and the skies refuse to brighten: taking a long, strenuous walk, a hot bath, a vacation. Volunteering at a soup kitchen. Cultivating your garden.
Friends and family are an age-old source of solace in times of trouble. Human beings are essentially social creatures; we need each other, and a sympathetic ear, an encouraging word can work wonders. It's been shown that simply having a confidant-someone you can trust to listen and care-reduces stress, eases anxiety, and lifts mood.
But sometimes the usual fixes just don't work; you know you've got a problem, and it's not about to go away. And the question comes up, moves up rapidly from the back of your mind (or perhaps it's suggested-diplomatically or otherwise-by a friend or loved one): should you go for therapy?
What Is Psychotherapy?
We all know what therapy is-until we try to pin it down, and realize how many very different things have come to carry the label. "Therapy" can last six weeks or six years. It may involve two people-you and the therapist-or your whole family, or even a group of strangers. You may talk about today's crisis or last night's dreams, or events you can scarcely remember. You may be encouraged to keep a diary of your thoughts, or to free-associate. To pound pillows or to take pills.
What do they all have in common? No matter what particular form therapy takes, the essence is an ongoing relationship. Researchers who seek to find what makes therapy successful return again and again to that central fact: whatever else happens, the closeness and trust between patient and therapist-what is called the "therapeutic alliance"-is a key factor. It even appears to be important when medication is the main treatment.
Therapy is a unique type of relationship, and what makes it valuable is what sets it apart from friendships, working partnerships, family connections, and love affairs. Its purpose is well defined: understanding and change. It comes into being, that is, to help you identify and understand dysfunctional ways of thinking, feeling, and acting, and to generate more productive and satisfying ways of thinking, feeling, and acting.
Friends and family members want to help us when we're in distress, and the advice they offer (with or without solicitation) can be useful. But the kind of counsel you'll get from a therapist is different. Rather than being simply instructive ("Here's what you ought to do"), it's likely intended to be a catalyst, to quicken your own ability to work things out.
Perhaps the most essential difference between therapy and other significant relationships is a matter of balance. You and the therapist are collaborating on a single project: helping you deal with your problems and achieve the changes you want. There is no other agenda.
This makes it very different from even close, supportive friendships in which you pour out your troubles and get a sympathetic ear and even useful feedback. Eventually, your friend will get bored, or tired, or simply need to talk herself. The essence of friendship is mutuality: you meet each other's needs. In therapy, your needs are what matter. The word itself, therapy, comes from a Greek word meaning "to serve." You receive the service-of being listened to, understood, helped-not out of friendship, love, or altruism, but for a fee. Crass as it sounds, this is a strength of therapy-there are no strings attached.
Another essential quality of therapy is safety. If it works well, you can be yourself, say what you feel, reveal your fantasies, fears, and aspirations, without repercussions. The therapist's professional role includes receiving your disclosures without moral judgment or rancor. You won't be ridiculed, censured, or resented-not when you speak, not a week or a year later. Can your best friend, spouse, or parent offer this guarantee?
You can say whatever you need to and know it will go no further. Confidentiality is a key component of the therapeutic relationship, as it is in certain religious settings. With the exception of certain well-defined circumstances (to be discussed fully later), the therapist is bound by ethics, and by law, to reveal nothing that transpires during your sessions. The communication, in fact, is privileged, which means that the therapist cannot be required (again, with exceptions) to reveal what you've said, except under court order.
Part of the safety zone in which therapy takes place is its reliability. It generally happens at the same place and at the same time, and follows a predictable format. It isn't contingent on your performance-the therapist won't get up and leave if you fail to keep her entertained or to live up to her expectations. Even intimate relationships can be jeopardized when one of the partners goes through personal changes ("You don't seem like yourself"), but in therapy, change is the whole point.
In addition to everything else, therapy is an educational experience. Some therapists actually describe what happens as a kind of learning, and compare their role to that of a teacher or coach. But even when this isn't explicit, any kind of effective therapy leads you to step back and reconsider what you may have always taken for granted, to try out new ways of looking at yourself, your emotions, and your world.
Who Needs Therapy?
There's little doubt that many people could use professional help. Nearly a half-century ago, when epidemiology in this area was somewhat less rigorous than it is today, one study found that 81.5 percent of the population of Manhattan had "signs and symptoms of mental distress."
Using more precise definitions, the 1999 U.S. surgeon general's mental health report suggested that in the course of a year 22 to 23 percent of Americans have a diagnosable mental disorder-that's 44 million troubled people. Most suffer from some form of depression or anxiety severe enough to cause marked distress or interfere with work or personal life. A 1993 study by the National Advisory Mental Health Council found that nearly one American in ten experienced significant functional impairment due to emotional ills-their problems made it truly difficult to go about their daily lives.
"Just as practically no one gets through life without a physical ailment, very few can without significant psychological ailments, conflicts, and stresses," says Jeffrey Binder, Ph.D., director of doctoral and master's clinical training at the Georgia School of Professional Psychology in Atlanta.
An identifiable crisis, loss (of a job, romantic partner, or close relative), or trauma propels many people into therapy. For others it's the culmination of a lengthy process; the problem is long-standing, and now the time seems right. Symptoms, like anxiety or difficulty concentrating, have become severe enough to interfere with your life. Perhaps your work is suffering.
"The key idea is perception," says Sharon Hymer, Ph.D., a clinical psychologist practicing in New York City. A family conflict may have been simmering for years, or a romantic disappointment may be just the latest act of a long-running drama. But on top of that, there's a feeling of demoralization. "People go to therapy when they perceive themselves in a crisis that they can't resolve by themselves and with the help of friends." (The kindling of hope, experts say, is often the first big benefit of effective therapy.)
Feeling you are out of your depth is a key indicator that it's "time to ask for some help," advises the American Psychological Association. Think of therapy when you feel trapped, with nowhere to turn, when it seems that things aren't getting better, when worry becomes chronic and never leads to any answers, or when emotional unease spills over and affects the way you eat or sleep, or takes a toll on your job or personal life.
Psychiatrists often treat those at the more seriously ill end of the spectrum. The American Psychiatric Association lists marked personality change, extreme highs and lows, excessive anxiety, anger, hostility, or violent behavior as indications for a prompt consultation. Thoughts (or talk) of suicide are a warning that immediate help is needed.
The mind and body are closely connected, and some signs that therapy may be helpful are physical. Unexplained, often vague symptoms-fatigue, frequent headaches, backaches, or other troublesome pains, frequent digestive upset, even pesky skin conditions-can reflect depression, anxiety, or a burnout level of stress. Such problems may accompany emotional distress or take their place. When a thorough medical work-up finds nothing, consider a psychological explanation.
On the other hand, a life-threatening illness such as cancer or heart attack, or a painful chronic condition like arthritis, often outstrips one's ability to cope. Psychotherapy doesn't take the place of medical care, but it can supplement it: in fact, substantial data suggests that people with serious illness do better physically if they take effective steps to deal with the emotional turmoil it creates.
While there's little solid data on just who seeks therapy and why, a widely cited 1995 survey by Consumer Reports found that nearly half of four thousand readers who went for professional help were "in considerable pain." Besides mental disorders like anxiety and depression in their various forms, the motivating forces included family or sexual problems, work woes, stress-related symptoms, problems coping with grief, and difficulties with alcohol or drugs.
Most significant emotional problems, however, remain untreated. The surgeon general's report noted that only one third of people with a diagnosable condition were getting any sort of help with it, and just over half of these were in treatment with a specialist such as a psychologist or psychiatrist. You may be in serious distress; you've done what you can to make things better, and it hasn't been enough. Your work, family life, or friendships are somewhat the worse for wear. Yet you hold back. You just can't take the next step toward getting help.
Why does this happen so often? For one thing, there's a persistent notion that we should be able to do it on our own, that it's shameful to need help. Some people fear that they'll give up control of their lives by submitting to the influence of someone with a sophisticated knowledge of human nature, or coerced into taking drugs. Or that they'll be "homogenized" by therapy, lose their individuality, become some sort of processed clone. They think that therapy must be a lengthy process that inevitably requires rehashing all of childhood and opening up a Pandora's box of repressed impulses. Or that nothing will really help-their problems are so hopeless that they are beyond therapy.
And there's stigma. Although much progress has been made in recent years, a lot of baggage still attaches to mental health problems-the idea that anyone who seeks therapy is "crazy" or "disturbed," somehow damaged or less than whole.
Many such attitudes come from images of therapy and therapists promoted in our culture. We laugh at endless analysis à la Woody Allen and set box office records to see movies featuring a Hannibal Lecter-type psychiatrist who is as expertly manipulative as he is malevolent. (Some psychiatrists have described the Lecter portrayal in The Silence of the Lambs as "devastating to the profession," and expressed concern that such images may prevent potential patients from getting the help they need.)
The best way past these obstacles is information. Learning, for example, that an explicit goal of good therapy is to help you become more individual and creative, not less so. That many effective kinds of therapy focus on the present and pay little attention to ancient history. That the "nothing will help" feeling is itself a symptom of emotional trouble (specifically, depression), not a realistic appraisal.
One last barrier to seeking therapy is simply not knowing how. What do you do to find a therapist? How can you ensure that he is competent, qualified . . . right for you? Is there reason to believe his approach is likely to be helpful? The aim of this book is to assist you in this quest.
What People are Saying About This
This book reflects wide and current knowledge of...the world of psychotherapy. Its information about online resources (including weblinks) is exhaustive and highly accessible. No other book addressing this topic offers as much to the computer-literate reader.--Jerilyn Ross, M.A., L.I.C.S.W. Author, Triumph Over Fear
(Sherman's) wonderfully warm and insightful guide...provides practical, step-by-step advice that will be an invaluable source of information to patients and their families for years to come.--David L. Ginsberg, M.D. Director, Outpatient Psychiatry, Tisch Hospital
A must read for anyone considering treatment...Easy to read, thorough, balanced and informative, it is also a valuable reference for physicians and psychotherapists to give to their patients.--Eva Ritvo, M.D., Director Continuing Professional Education University of Miami, Department of Psychiatry and Behavioral Sciences
How To Go To Therapy is superb...Concise and extremely well-written, this authoritative guide should become the standard book for anyone thinking of going into therapy. What an excellent, much needed book!--Edward Hallowell, M.D., author of Human Moments, Connect, and Driven to Distraction
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