Counseling Approaches

So you think you want to visit a therapist. After looking at the names your insurance company gave you, or the listings in the phone book, how do you choose? One option might be to discover what type of training your future counselor possesses.

Realistically, there are hundreds of different approaches to psychotherapy. Depending on the problem, one orientation might be better than another, so to help you in your decision making, let me briefly describe the major counseling approaches.

Psychodynamic Theory is the granddad of psychotherapy. Founded by Sigmund Freud, almost all forms of therapy reflect some of his ideas. In its purest form the goal is a major personality change. Among other things, counselors trained in this model use insight, or the understanding of ones own psychological processes. Here’s how it works. The therapist uses techniques such as free association, where the client is asked to “say whatever comes to your mind, thoughts, feelings, fantasies, memories or dreams from the night before.” Then the therapist interprets what has been disclosed to help uncover unconscious thoughts, patterns or ways of coping.

For example, if I remember a dream where I am falling, the therapist and I might explore what meaning this holds for me, where this meaning originally entered my consciousness, how it effects my life today and what I can do about it now. I don’t always need to suffer the consequences of my metaphorical falling.

As you might imagine, to change an entire personality is neither short term, nor inexpensive. Intensive therapy requires the client to meet with the therapist three to five times a week. For moderately intensive therapy the client and therapist meet one to three times a week, often for several years. And just for the record, don’t count on your insurance covering much of the cost. They are most interested in crisis intervention, not giving your personality a major overhaul.

Behavioral Therapy, on the other hand, is typically short term, and insurance companies love it. Behavioral therapists begin with a careful analysis of the problem behavior, and an examination of the symptoms and thoughts associated with it. Then a program is developed to reinforce desired behaviors, and eliminate the undesired ones.

So let’s say that while I was driving one day I was unexpectedly hit from behind, and now I am afraid to drive. A situation that would normally be neutral (driving) is now causing me to have a fear response. To treat this fear behaviorally, I might be asked to imagine myself in a car, and then use relaxation techniques to calm myself down. Once I have mastered this, I might then just sit in a car in the driveway, and continue practicing relaxation for how ever long it takes until I can sit in the car relaxed. I would then progress to driving on an empty, quiet street, then to a busier street, and finally to driving on The 101 Freeway in rush hour traffic. In contrast to the psychodynamic therapist, the behavioral therapist is not interested in insights. The goal is simply to get back the behaviors I was missing (driving) in as short a time as possible.

Cognitive Therapies target the things we say to ourselves, and the assumptions we make, to identify irrational beliefs, and errors in thinking. I once knew a woman who was suicidal because she believed she had nothing to look forward to because her husband had an affair and was leaving her. She believed that she was nothing without her husband (irrational belief). After some discussion she remembered that she was not always happy when she was with her husband, they often fought, and since she could remember being somebody before she was married, it might be possible for her to be somebody after her divorce.

According to Gestalt Therapists losing touch with our emotions and our authentic “inner voice” leads to psychological problems such as anxiety and depression. Gestalt therapy is similar to psychodynamic therapy with one major exception, Gestalt therapists are interested in the “here and now” rather then the “there and then.” The goal is to help the client reunite with their “true self.” Gestalt therapy is extremely experiential, allowing the client to make his or her own interpretations. I recently had a client who was trying to decide if he should leave his job. I asked him to sit on one side of the sofa and talk from the part of him that wanted to stay at the job, then move to the other side of the sofa and talk form the part of him that wanted to leave. After doing this several times he was able to see for himself what was motivating his decision.

Unlike the individual types of therapy described above, Family Systems Theory highlights the idea that problems displayed by one family member often reflect problems in the entire family’s functioning. As an example, if someone calls me requesting counseling because of “difficulty with my spouse”, I typically like to see both people for couple’s therapy. My view is that it took two people to get to this “difficult” place, and ideally it will take two people to get out of it. Goals are set that meet the specific needs of each couple, but my experience has proven that some form of communication skills training is necessary, typically around communicating anger. The truth is that all couples are going to have disagreements; the healthy ones just learn how to fight well.

Good luck in choosing an appropriate therapist for your dilemma. Perhaps this quote by Freud himself will help.

“Psychiatry is the art of teaching people how to stand on their own two feet while reclining on couches.”