A mindful Approach: Broadening the base of ‘therapies’

A mindful Approach: Broadening the base of ‘therapies’


Mental-health care has come a long way since the remedy of choice was trepanation — drilling holes into the skull to release “evil spirits.” Over the last 30 years, treatments like cognitive-behavioral therapy, dialectical behavior therapy and family-based treatment have been shown effective for ailments ranging from anxiety and depression to post-traumatic stress disorder and eating disorders.

What is therapy?

Therapy is a scientifically proven process that teaches you how your mind works. It helps you navigate your feelings, build better behaviors, and relate to your thoughts differently so you can live the life you want. Therapists who use clinically-proven techniques like Cognitive Behavioral Therapy (CBT) work with you to set goals, track progress, and measure results. They teach you skills to build emotional resilience so you can eventually leave therapy and manage on your own. Therapy is a high-value–but temporary–investment in yourself.

A young woman came to see me on the recommendation of her physician. “I don’t know what she thinks you can do for me,” she said. “I just can’t get myself to do what I need to do. Maybe some cognitive therapy – something that would change my thinking. Maybe that would help.”

I asked her to tell me in her own words why her doctor had referred her to me. “I don’t have any energy. There’s nothing wrong with me physically. I was depressed for awhile, but I’m not anymore. But she thought it might help me to talk to someone. I don’t need longterm psychotherapy to understand myself. I just need someone to help me change my thoughts.”

The trouble is, surprisingly few patients actually get these kinds of evidence-based treatments once they land on the couch — especially not cognitive behavioral therapy. In 2009, a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders. One survey of nearly 2,300 psychologists in the United States found that 69 percent used C.B.T. only part time or in combination with other therapies to treat depression and anxiety.

C.B.T. refers to a number of structured, directive types of psychotherapy that focus on the thoughts behind a patient’s feelings and that often include exposure therapy and other activities.

Shedler, who is an associate professor of psychiatry at the University of Colorado School of Medicine and director of psychology at the University of Colorado Hospital Outpatient Psychiatry Service, describes fascinating research evidence that “psychodynamic therapy alleviates symptoms as effectively as newer, more targeted therapies” (like cognitive behavioral therapy).

He also offers evidence “that people who receive psychodynamic therapy actually continue to improve after therapy ends – presumably because the understanding they gain is global.” In other words, this kind of therapy helps us learn about ourselves in such a deep and broad way that we can utilize our understanding in a variety of situations; and further, that with the help of therapy, we also learn how to continue to learn more about ourselves even when we are no longer seeing our therapist.

Shedler says that people often shy away from psychodynamic psychotherapy because they assume that it won’t help them with their immediate problems and they fear that they will have to make a commitment to years of expensive, time-consuming and unproductive “navel-gazing.” He suggests that this is partly the fault of those of us who practice this kind of therapy. We shun research and fail to explain what we are doing. I would add that we also fail to tell our clients that they should start to feel some relief fairly quickly, and that if they are not feeling better, it may be that we’re not helping them get to something important in the work. Nor do we always explain, as Shedler does in a beautiful example, why talking about what is happening between therapist and client is an important – sometimes crucial -part of the work.

I encourage you to read Shedler’s article yourself; but as an appetizer, I offer this brief highlighting of some of his points:

 Psychodynamic therapy as practiced today is not your father’s psychoanalysis. For one thing, Shedler says, clients “do not lie on a couch free-associating as an inscrutable therapist silently looks on, nor must they commit to four or five sessions a week for years on end.”

 In this kind of therapy clients get an opportunity to explore and broaden the range of feelings that they are comfortable with. This exploratory process not only helps a person understand subtle and often unnoticed emotions, but also helps them begin to manage strong and often uncomfortable feelings more effectively.

 Research confirms that psychodynamic psychotherapy is highly effective. For example, Shedler writes, “One major study found an ‘effect size’-a measure of treatment benefit – of 0.97” for psychodynamic psychotherapy. “For CBT (cognitive behavioral therapy), 0.68 is a typical effect size. For antidepressant medication, the average effect size is 0.31.”

 Shedler describes seven features that researchers have found contribute to the power and effectiveness of psychodynamic psychotherapy: “exploring emotions, examining avoidances, identifying recurring patterns, discussing past experience, focusing on relationships, and examining the patient/therapist relationship.”

Obviously, of course, not all psychodynamic psychotherapists are created equal. It is important, when looking for someone to help with your problems, to get recommendations from people you trust, to interview several different therapists, to ask about their training, and finally, to trust your instinct. (For more specifics, check out my post on choosing a psychotherapist). But if you decide to go with a psychodynamically-oriented psychotherapist and friends or family tell you there’s no evidence that it works, give them a copy of Shedler’s article.

As for the client I described at the beginning of this post, after we had been working together psychodynamically for several months, she came into my office and said, “You know, I am starting to feel better.” I told her I was glad and asked if she had any thoughts about what had contributed to the change. “I think it helps to talk about things to someone who listens and doesn’t tell me what to think. You’re always asking me to try to put into words what I think about something. And that helps me think about what I’m feeling, too. And somehow, that’s helping me to feel better.”

Have you ever had these thoughts about therapy?

  • Therapy doesn’t work.
  • Therapy is not for me–it’s for people with serious mental health issues.
  • Talking to someone about my problems won’t help me.
  • I can fix the problem myself.
  • Once I start going to therapy, I’ll have to go forever.

Many people have had these same thoughts, but they’re not true! And worse, these misconceptions prevent people from enjoying the positive, life-changing benefits that therapy brings.

Myth: Therapy doesn’t work.

For all the good therapy does for people, it certainly has a bad rap.

A founder once shared a story of his time spent living on an island in the South Pacific, where diabetes was becoming a dangerous epidemic. The cycle, he said, went like this: people distrust Western Medicine, so they don’t go to the doctor in the early stages of the disease. By the time they visited a doctor, a once-treatable foot ulcer would have spread so much that the only treatment option available was to amputate the leg. The misconception spread among the community that a visit to the doctor led to severe consequences like a leg amputation, so people would only visit the doctor as the very last resort.

A similar cycle spreads misconceptions about therapy. Many people (wrongly) think that therapy is only for people with severe mental health issues or people at the brink of collapse. Or, they assume that therapy is a glamorous hobby of the rich, who pay professionals to listen to their problems but not to actually help solve them. These are the kinds of stories about mental health that permeate the media. Too often, these stories are the only information people have about therapy, since public discussion about therapy and mental health is rare.

So, when someone does take the leap to go to therapy, and has a bad experience, it’s easy for them to assume that all therapy is useless, just like the island residents in the earlier anecdote thought that going to the doctor would lead to bad things like foot amputations. It’s silly when you think about it; if you went to a bad dentist, you wouldn’t assume that going to the dentist was a waste of time. You’d find a better dentist! But many of us don’t approach therapy with the same expectations.

The truth about therapy is that it really works. Scientific studies consistently show that behavioral and emotional interventions work as well, if not better, than medication to treat anxiety, depression, and mental health issues like OCD. Therapy that teaches you skills, like CBT, will leave you with long-term, healthy coping strategies that you can use when issues pop up.

At Kip, our therapists practice CBT as well as feedback-informed treatment (FIT) which makes therapy even more effective. In FIT, therapists gather data and patient feedback regularly so that they can see what’s working, what isn’t working, and then iterate on treatment plans as quickly as possible. Therapists can’t promise cures or cookie-cutter solutions, but good therapists get you results.

Myth: I don’t need therapy–I can fix it on my own.

At some point, you have experienced stress, felt anxious, overwhelmed, sad, or depressed. No one is immune to these common, human conditions. Sometimes, we can work these issues out on our own by changing our lifestyles, reading books, taking classes, or through talking with friends, family members, or mentors. Other times, we notice patterns that we haven’t been able to change on our own, or issues start to overwhelm us and negatively affect our lives, relationships, and work. In severe cases, anxiety, depression, and stress can put our health and lives at risk.

Therapy is often the fastest, most effective route to overcome emotional and behavioral issues that keep you from living the life you want. Sometimes, you can get better on your own, but in most cases you’ll get better results, faster, with a therapist. Professionally certified therapists are experts in how humans process thoughts and emotions. Whether you want to learn tools to manage stress, build skills to be a better leader, or treat clinical depression, they’ll help you do that. A good therapist is like a coach–a coach for your mind.

Myth: Therapy is for people with serious mental health issues. I’m not broken enough to go.

Therapy is obviously useful in severe situations, but it’s also incredibly valuable as a method to treat moderate conditions and build positive mental health habits. If you approach mental health with a preventative care mindset, you can catch and treat downward trends in your emotional well-being before they become bigger problems.

There are many ways to change how you think, feel, and act but therapy is usually the quickest, most effective, safest route to do it. Also, if you catch issues early, they may need less work and care to be resolved. Therapy is for everybody and can help you anytime you’re working through a behavioral or emotional issue.

There are some situations in which you should definitely consider therapy:

  • When your thoughts, feelings, or behaviors hold you back from living a normal life (e.g. you’re not sleeping; you’re avoiding things you normally like doing).
  • When your mental health is causing physical harm (e.g., you’re binging; you’re suicidal)
  • When your time is valuable and you need to improve your performance quickly to meet professional goals (e.g. you’re a founder; performance issues put your job at risk)

Much like you would consider working with a personal trainer to get in good physical shape, you can work with a therapist to improve your mental fitness. You’ll treat existing issues while you also build emotional resilience, which will leave you better prepared to handle whatever situations life throws at you. Consider the parallels between therapy and personal training:

A professional trainer creates an effective training program to get your body in shape. It’s designed just for you. Your trainer teaches you proper form for each exercise to optimize results and also avoid injury during one-on-one sessions. They make it clear that change comes from routine daily effort; you have to work out, rest, and eat right every day to get in good physical shape, in addition to going to personal training sessions. The time you spend with a personal trainer is not the cure; it’s the combined effort of those sessions plus the work you do outside of sessions which get results.

A professional therapist works in a similar way. They create an effective training program for your mind that is designed just for you, with your specific goals in mind. Your therapist spends time in session to identify the thoughts, feelings, and behaviors that shape your life. They’ll listen for patterns to figure out what’s working, what’s not, and come up with a plan that will help you make positive changes. You’ll learn valuable insights about how your mind works in session and also gain skills that will help you make it work better. Your therapist makes it clear that change comes not just from going to therapy, but also from spending time practicing the skills that you learn in session. You’ll leave therapy when you’re in a positive state of mind, with the tools to manage negative feelings when they crop up and to make positive changes effectively and safely.

Myth: It’s a waste of time to lay on a couch, talk about my feelings, and replay my childhood.

Therapy gives you a safe space to talk freely and process your emotions, but a good therapist doesn’t listen just to make you feel heard. They’re looking for patterns in how your mind works and how they can help you make it work better. Therapy should involve learning skills and building tools to manage your thoughts, feelings, and behaviors. Talking about your feelings is simply part of the process.

Eventually you’ll leave therapy with the ability to recognize patterns in yourself and to make changes on your own using the skills you learned in sessions. For example, say you go to a therapist to manage anxiety. Your therapist will help you determine what triggers your anxiety, which could be a behavior such as drinking coffee or an unhelpful thought like, “I’m not good enough.” They’ll teach you ways to catch your unhelpful thoughts and correct them before they impact your feelings. They might also teach you deep breathing exercises to calm down anxiety in the moment and ask you to make lifestyle changes to lower your anxiety overall, such as switching from coffee to tea and exercising daily. You can practice these skills for the rest of your life, whenever anxiety rears its head.

Myth: Once you start therapy, you have to go forever.

Good therapy has an end date. Therapy can be temporary because it teaches you tools that last forever. A good therapist wants you to get better and leave therapy, and will teach you skills so that you can ‘be your own therapist’ when you’re on your own.

Therapy should always have a goal. When your therapy goal is met, you will naturally phase out of therapy. You might not know what that goal is when you first enter therapy and in those cases you and your therapist will figure out goals together.

At Kip, our therapists practice evidence-based techniques designed to be shorter-term treatment methods. You should start seeing progress after just a handful of visits with your therapist. As you make progress, your therapist will move you from weekly sessions to bi-weekly sessions to (eventually) sessions just once a month. Sometimes you feel worse before you feel better–that’s normal. So is seeing your therapist more than once a week in the beginning or booking extra sessions during hard weeks. When it feels right, whether you’re at your goal or have nailed down the routine to get there, you’ll stop seeing your therapist all together, save for a booster session here and there. It’s hard to put an exact number on sessions, but most people on Kip go for 10–20 sessions.

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