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How to Engage in Meaningful, Successful Psychotherapy

Posted Aug 27 2009 11:38pm
More people than ever before are seeking professional counseling services. Thankfully, the stigma of seeing a mental health professional is waning and people are becoming better educated regarding the various options available to them. Needless to say, psychotherapy can be extremely helpful and--assuming there are no major contraindications (see below) and the client-therapist relationship is a good fit--it is almost always a good idea if a person is at all interested in it. Unfortunately, a trial of psychotherapy can also result in disappointment and/or even greater confusion. This article discusses how to embark upon meaningful, successful psychotherapy by setting goals, avoiding pitfalls and engaging your therapist.

Pick the right therapist. Because the start of a successful psychotherapeutic endeavor begins with the therapeutic relationship itself, selecting the right therapist is of paramount importance. This not only gets you off to a good start, but will prove absolutely vital to your ultimate success. It is a complicated issue, and there are no guarantees, but it is the sine qua non of engaging in successful therapy. It is also one of the most uncertain tasks, especially when practical considerations such as geographical location, availability and cost come into play.

A therapist is not a friend. Therapists and clients do not, and should not, socialize outside of scheduled appointments. While many clients want to become friends with their therapists and even understandably consider themselves to be on friendly terms, it is never appropriate for a degreed professional to seek personal validation and social enjoyment by dropping his professional role and adopting the client as a friend. This is not only counterproductive, it is unethical. Similarly, a therapist is not a parent, a therapist is not a policeman, and a therapist is not a personal savior.

A good therapist is well-trained, experienced, non-judgmental, empathetic, unbiased, open to feedback, transparent (honest, upfront and sincere), and directive when you need it or ask for it. She is there to facilitate your growth and to help you help yourself and solve your own problems; she is not there to take charge or solve them herself. See my previous article, "How to Pick a Good Therapist", for some general guidelines in making this selection.

More specifically, the type of therapist you choose to see may depend upon your particular concerns. There are therapists who specialize in a host of specific conditions, such as chemical dependency counselors and other addictionologists, relationship counselors, therapists who specialize in eating disorders, forensic psychologists, and others. Within these groups there may be further differences, as various therapists subscribe to various forms of therapy, based on one school of thought or another. For example, there are cognitive-behavioral therapists, interpersonal therapists, psychoanalysts and other psychodynamic therapists, group therapists, hypnotherapists, faith-based counselors, etc. A discussion of all of the available forms of talk therapy is well beyond the scope of this article, but see below for some links to organizations that can provide additional information.

Manage your expectations. The degree of satisfaction we come to derive from any given venture depends in large measure upon our expectations going in. When expectations are excessively high, this can be a setup for disappointment. Conversely, when expectations are unreasonably low, this can sabotage the process by preventing us from adequately investing of our time and energy. Decide what you are looking for and identify any reservations you might have, and discuss this openly at your first visit. Managing expectations involves being in touch with why you are seeking counseling in the first place. Perhaps you were referred by someone else, but in that case you should especially do some soul-searching and ask yourself why (or even whether) you agree that professional assistance is the best next step.

Once you have reconciled yourself to the notion of conferring with a professional counselor, ask yourself: are you needing someone who is going to employ a highly directive approach, an active therapist who will ask a lot of close-ended questions, challenge your previously held assumptions, supply expert advice and give you "homework assignments?" Or are you more interested in someone who will mainly listen, someone to whom you can reveal and with whom you can discuss things you might not yet be able to share with family and friends, a person who can remain objective and who can provide you with a safe forum in which to explore how you truly feel about your situation, as well as give you time to weigh your options in a non-threatening environment? Both approaches are valid and alternately warranted, depending upon the given circumstances. A good therapist is flexible and can provide both.

Frequency. At your first visit you will also need to determine the frequency of visits. Once-a-week, hour-long sessions are standard, but in some cases your therapist may initially recommend twice-weekly sessions, until the crisis has passed and your situation has stabilized somewhat. Rarely, if ever, are more frequent visits called for (traditional psychoanalysis is an exception, but the goal of analysis per se is not really what this article is about). If a person needs to see a mental health professional more than twice a week to function and to stay safe, a brief course of hospitalization is often indicated.

Duration. Therapy can be brief, short-term or long-term. Certainly some individuals have done well to remain in therapy for years with one or more providers, but most practitioners agree that a principal goal of psychotherapy is to foster autonomy and to sufficiently improve a client's situation and symptoms such that she no longer requires frequent, ongoing sessions. To the extent that this is so, from the beginning there is at least the implication of an eventual endpoint, although the exact duration of treatment is not typically discussed or determined at the outset (with the exception of some forms of highly structured brief therapy).

In some cases in which a client has developed a good working relationship with a certain therapist, he may resume weekly or biweekly sessions only during difficult or particularly symptomatic periods and otherwise suspend regular sessions in the interim. Other clients may graduate to monthly visits and remain on that "maintenance" schedule over the long term, to stay on track; this is particularly appropriate for individuals who are in the later phases of recovery from substance abuse or some other form of addiction as a means of relapse prevention, to compliment involvement in a community-based twelve-step program.

Once you have voiced your preferences and agreed upon a general plan for treatment, the next order of business is to focus on what needs to be "fixed." Enrolling in professional psychotherapy is not a casual decision for most people, and so the reason for investing what could be a significant amount of time, money and energy needs to be made explicit. If you are not exactly sure, then this is an excellent opportunity to have that discussion with your new therapist and it will also give you something to report back to the person who initially referred you.

Identify target symptoms. Sometimes the goal of therapy involves understanding and controlling specific target symptoms, such as panic attacks, crying spells, or feelings of hopelessness, helplessness and/or worthlessness. Identifying target symptoms early on is especially important when therapy is a means by which to determine whether or not you should consider a trial of psychotropic medication. One of the things an experienced therapist can tell you is whether or not she feels you might be suffering from a physical condition the cause of which is biological and that you would benefit from a consultation with a doctor who can prescribe medication.

Or, when therapy is part of a multidisciplinary approach in which you are already taking a psychotropic medication, focusing on the reduction or the elimination of your target symptoms in therapy is an effective way of making sure your treatment is well-rounded. Sometimes medications reduce symptoms to the extent that you are then able to accomplish the work you need to do in psychotherapy. Conversely, psychotherapy can always go beyond what the medications are designed to do by assisting you in taking personal inventory and effecting change that ensures your long-term well-being in a way that has more to do with your environment, your relationships, your attitude and outlook on life, and your lifestyle choices. There is a lot of research that indicates that patients do better with a combination of medication and psychotherapy than with medication alone.

Set goals. Beyond defining your immediate needs, the best way to evaluate the outcome of therapy in the long-run is to establish concrete, realistic goals that you hope to achieve and setting a timeframe for reaching (or at least reexamining) those goals. Timeframes, of course, should be flexible and subject to adjustment, as becomes necessary; although certainly in real life, decisions may have to be made and certain problems dealt with in a timely manner, there are never any "deadlines" in therapy beyond which personal growth cannot occur. And while you will want to have thought this through a bit before your first consultation with a new therapist, determining all of your goals is not something you have to have accomplished prior to that first visit. Proper goals evolve over time and your therapist should actively engage you in determining what they are and modifying them as you go along, as appropriate. Whatever else, don't be shy about discussing the treatment plan. How will progress be measured?

Seek to understand. Concrete goals are a good idea, but remember also that the lasting benefits of therapy involve more than having simply put out fires and surmounted specific obstacles. Life is full of trials and there will always be something else to negotiate. What enduring lessons has therapy taught you? For example, one goal might be: "Deciding by the end of the fiscal year whether or not to offer my resignation at work," but this decision could also be paired with gaining a broader, further-reaching insight, such as, "Understanding why I become so frustrated at work and why I resent my supervisor," and ultimately, "Am I satisfied with my chosen profession and will I feel fulfilled doing this for the rest of my career?" Or, alternately, a person might be confronted with the decision, "Do I want to try to salvage my marriage?" and at the same time come to consider questions like, "Have I approached my current and previous relationships in a healthy and compassionate manner? If not, why not?" and, "What do I really need in a long-term companion?"

A perfectly valid, if somewhat more ambiguous, goal for therapy is to answer questions such as these and to come to know oneself better in the process. Of course, with questions like these, it may be that at the outset of therapy you won't even know which ones need answering. Often one of the long-term benefits of psychotherapy is discovering the important questions in your life, and working to resolve them is one of the rewards, even when some of them do not necessarily have definitive, absolute answers, because life circumstances do change, and we evolve as individuals.

Be honest with your therapist. There are many ways to sabotage your efforts in therapy, both purposely and inadvertently. Perhaps the most common is not being completely honest with your therapist. There are two ways to be dishonest in treatment, and thereby to cheat yourself of the full benefit of therapy. One way is to lie or distort the truth. This we do on purpose, and there are many reasons for it, all of which seem like a good idea at the time, but of course lying only detracts from the usefulness of therapy. But examined logically, lying to your therapist is pretty pointless. Remember that your therapist is like your lawyer; she is your advocate, and is not there to judge. She is also bound by the ethical guidelines of her profession, which includes strict confidentiality. There are only a few instances in which confidentiality can be violated (see clients' rights, below), so unless you know for a fact that "anything you say can and will be used against you in a court of law," the urge to deceive your therapist is at best irrational, at worst self-defeating.

The other way to be dishonest is through blatant omission: holding back the truth or the whole truth, often due to feelings of guilt or embarrassment. Sometimes what we don't reveal is more misleading than the little white lies we are apt to tell. Though it may be difficult, do yourself a favor and try your best to tell the whole truth and nothing but the truth. I promise you will get so much more out of therapy! Not having to worry about censoring yourself with your therapist is one of the great benefits of the professional therapeutic relationship; it is one of the things that makes it so unique and that gives it the power to be so helpful to you.

Being completely honest and relaxed can be incredibly liberating and highly therapeutic in itself, but understandably this may be something you will only slowly gain comfort with over time, as you come to better know and trust your therapist. That's perfectly natural. Just don't be afraid to admit to your therapist when the time comes that you may have failed to mention something important early on, or even that you gave an untruthful answer before, because you were unsure. Many times a client will come to feel comfortable fully confiding in his therapist, but then worries about courting the therapist's disapproval because he was not honest the entire time. Believe me when I say that a compassionate, competent therapist will not take it personally and would much rather prefer knowing what she needs to know to best counsel you as soon as you are comfortable enough to reveal it. Better late than never. Unfortunately, when it is part of a client's avoidant personality, sometimes a client feels so guilty about having lied that he can't bring himself to set the record straight, and therapy is then corrupted by an unnecessary tension and the added stress of having to avoid what may be at the heart of the matter.

If this happens to you, trying writing your therapist a brief note explaining why you felt you couldn't be entirely honest before and ask for her assistance in moving through this unexpected roadblock. Remember that in therapy everything is fair game and, inasmuch as it provides added insight into the nature of the way in which you tend to relate to other people and what it says about your emotional sensibilities, many times the therapeutic process and relationship itself needs to be the focus of the discussion for a while to achieve the personal growth that is one of the goals in therapy.

Be honest with yourself. Sometimes you can't be honest with your therapist because you're not being entirely honest with yourself. Denial, rationalization, and intellectualization are some of the defense mechanisms we use to protect ourselves from the sometimes unpleasant truth. Being honest with oneself is perhaps more easily said than done, but like seeking to understand, it is a valid work-in-progress and something an astute therapist will encourage and remind you to do from time to time. As clients, we rely upon the professional's objectivity and impartiality to help us see ourselves more accurately.

Engage your therapist. Therapy is not a monologue (again, with the exception of classical psychoanalysis; Freudian analysis is a form of therapy with many extremes). Instead, psychotherapy should be a dialogue between client and therapist, so don't be shy about asking questions, providing critical feedback, and even challenging your therapist's assumptions if they don't make sense to you or you fundamentally disagree. Your therapist may have training and experience and some measure of objectivity on his side, but he is not infallible. Not only that, but it is in the exchange of ideas with a therapist that some of the most important discoveries take place. Remember that neither you nor your therapist know everything that is going on with you at the start of therapy, or for that matter, at any point along the way. An active, vibrant discussion keeps the lines of communication open, prevents misunderstandings, spontaneously gives rise to new hypotheses worth exploring and at the very least, assures you that you are being heard.

Don't sabotage treatment. I've already talked about how anything less than complete honesty can detract from and even derail treatment, and I mentioned how low expectations and skepticism can sabotage you before you even get started, but nothing wrecks the entire process more completely and permanently than abruptly walking away from therapy because of a momentary flash of emotion. Sometimes it's anxiety, usually it's anger or hurt feelings, but it's always a bad idea if you do it without first signaling your intention and scheduling at least one final session to discuss your reasons for doing so. It could be that you are justified in your decision, and that terminating therapy is actually the right thing to do, whether you take a break from it completely or find a new therapist with whom to work, but if you act impulsively and you don't process it with your therapist before you abandon treatment, you might miss the opportunity to either clarify a simple misunderstanding, or else, at the very least, speak your mind and leave the therapist with something to think about for his next client. Especially if you are motivated by anger to "fire" your therapist, give yourself some time to calm down and give your therapist the opportunity to refer you to someone else so you can continue to work on your issues. Remember that therapy is for your benefit, not your therapist's, and you should never make decisions about your treatment based on hard feelings aroused in you by something your therapist said, or something he did or didn't do.

The other possibility is that you are feeling vulnerable or threatened precisely because you are getting somewhere in treatment. Therapy is not always comfortable, and it can actually be a bit stressful or even daunting at times, depending on the strength and nature of your defense mechanisms. Particularly if you want to quit altogether, ask yourself if you are not avoiding moving through and dealing with something difficult or painful.

Know your rights. Because getting the most from psychotherapy requires a certain piece of mind (for example, regarding the legal limits on confidentiality), familiarizing yourself with y our rights as a therapy client can be an important part of committing to the process, especially if you are new to it.

Confidentiality. The law in all 50 States protects the privacy of communications between a client and a psychotherapist, but there are limited situations in which a therapist is permitted or required to disclose information without your consent. These are situations involving certain court proceedings when a judge issues a subpoena, if you file a complaint or lawsuit against your therapist and the therapist has to defend herself, specific diagnostic and treatment information as requested by your insurance company in order to authorize payment for services rendered, situations involving the potential abuse of a child, or an elderly or disabled person, or if you make a serious threat of homicide against a specific person, and you have every intention of actually carrying out that threat, the therapist may be required to notify the potential victim directly and contact law enforcement. Depending on the law, minors who are not emancipated may also have their treatment record subject to review by their parents; it is best for teenagers to come to a clear understanding with their therapists regarding what information, if any, will be shared with their parents without their explicit prior consent. Parental involvement in therapy is extremely important, but a therapist should also be sensitive to the fact that a lack of confidence can seriously undermine the therapeutic process as well.

Protected Health Information. You have the right to examine and/or receive a copy of your clinical record, if you request it in writing and pay for it, but your therapist has the prerogative to refuse the request on clinical grounds, or to release to you a redacted copy of her notes, whose decision you then have the right to appeal. This is based on the fact that professional records can be misinterpreted and/or upsetting to untrained readers and can actually do psychological harm to the client.

Although you have a legal right to request a copy of your therapy record, I generally advise against it on therapeutic grounds. I myself frequently make observations and other notations in a patient's chart that would not necessarily be therapeutic for him to read verbatim himself, and that in a few cases might actually be detrimental to progress in therapy, or even downright psychologically harmful. Any helpful observations, insights and interpretations that should be communicated will be brought up by a deft therapist in session when the time is right, and in such a manner that is measured and most appropriate, with the client's well-being and best interests in mind.

If you need records sent to your doctor or another provider, it is best to sign a release of information form and have your therapist mail or fax the records directly to that professional. In some instances where it was necessary for me to release records directly to a patient and I had concerns about what the patient or the patient's family might read there, I sat down with the patient to review specific portions of the record with him. A debriefing session of this kind can easily be incorporated into your final visit if you are moving or terminating treatment for some other reason and you need direct access to your record.

Contraindications. Finally, there are a few circumstances in which engaging in psychotherapy is not a good idea at the time. These all involve periods during which the potential client is too sick to engage in healthy, conducive talk therapy, including periods of detoxification from drugs or medicines, episodes of acute psychosis (when a person’s reality testing is impaired), and during a severe major mood episode. Acutely manic individuals do poorly in therapy and therapy should be deferred or suspended until symptoms come under control on medications. Similarly, if an episode of depression is especially severe, talk therapy is relatively contraindicated until medical treatment has a chance to work. A seriously disturbed mood will contaminate the therapeutic process; patients who are deeply depressed are often incapable of formulating positive interpretations and of envisioning a better future. All therapy may accomplish for these individuals at these times is to induce a great deal of painful, mood-congruent and ultimately harmful ideations and helpless conclusions. It is better to wait until the client is physically capable of fostering hope and of feeling empowered before proceeding to introspect and problem-solve.

International Society for Interpersonal Psychotherapy

National Association of Cognitive-Behavioral Therapists

American Psychoanalytic Association

American Psychological Association

Read this: Current Psychotherapies

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