What is therapy?

One thing that I think keeps people away from therapy is a lack of knowledge about the topic. Media depictions of a person laying down on a couch while a somewhat cold and distant therapist asks them pointed questions have led to many people having a mistaken view of what therapy is and how the whole process works. This post is intended as a bit of a lesson on how counselling functions in the modern age. If you feel like you need help, but you’re unsure if therapy is the right answer, read on!

First off, there are a lot of different forms of therapy, so this post cannot be an exhaustive list of how every different modality would treat every different problem. Rather, this piece will focus on the things most forms of therapy share. I’ll also include a little bit about the style of therapy I use (CBT) to give examples of how certain issues would be treated by a very common style.

So you need help, you schedule an appointment with a counsellor, and you show up for your session. What happens next? You’ll sit down with a therapist in a quiet, private setting. Generally, the first thing that is done is going over the counselling consent form. The therapist will explain to the client about the confidentiality of counselling, the situations where that confidentiality would have to be broken, how records are kept, as well as fees and payment options. The client is given a chance to bring up any questions or concerns they may have with any parts of the consent form, and the counsellor tries to answer these questions. The client and counsellor sign the form.

Next, the counsellor will ask the client to tell them about why they’re seeking counselling. The first one to two sessions, sometimes more, are devoted to exploring the issues the client is experiencing. Together, the counsellor and client explore whatever it is that has the client seeking help. What emotions is the client experiencing? What sorts of physical reactions? How do they react to troubling situations? What do they think about them? What are the client’s strengths and who can they draw support from? What are areas that need improvement to promote better functioning? Some kinds of therapists will focus entirely on the present issues, while others will want to explore the client’s past in order to see how certain patterns of behavior have developed.

While this is happening the counsellor will be trying to empathize with the client, to make them feel heard and understood. The counsellor uses deliberate active listening skills to make sure they understand what the client is experiencing as best they can. This in itself can sometimes be a moving experience, since many of us are unused to someone really listening to us and showing genuine care and concern.

It should be noted here that this is the point where the goals for counselling should be discussed. In some situations it will be fairly obvious, but it should be made concrete. What would the client like to be able to do that they cannot do now? What specific areas of their life would they like to see improvement? How would we know that this improvement had happened? Having clear, defined goals for therapy help to ensure that the counsellor orients sessions directly to the issues most important to the client. The therapist does not impose their own ideas of what would be good for the client, but instead explores what the client wants to achieve in therapy.

As the counsellor and client begin to get a good sense of the problem, the counsellor will begin to use interventions in sessions. These can vary wildly between different types of therapy and what interventions the counsellor chooses to use largely depend on the specific client problem. In CBT, we often look at the thoughts a client has about the issue they’re seeking help with. We check to see if these thoughts are true, or if they’re affected by our biases. We might come up with experiments to test a person’s beliefs, or cooperatively come up with new, more adaptive thoughts, or reframe very negative thinking in a more positive way. Also, we’ll be looking at the behaviors that a client uses in their life. Are these behaviors helpful, and if not, what new behaviors could be tried that might help? These sorts of interventions will often be paired with techniques that allow a client to calm their body down from a very elevated state.

That explanation was very simplistic of course, and every different style of therapy will have different sorts of interventions that they would use in specific circumstances. Interventions will be used and the client’s difficulties will be monitored. What works, and what doesn’t? There is often some trial and error here, as something which helps one client may prove ineffective with another. The client brings in new situations as they pop up in their lives and works with their therapist about how to handle them. As therapy progresses, the goal is for the client’s symptoms or difficulties to reduce over time, until such point as the client is ready to leave therapy and function independently. Hopefully the client is also learning skills to help them when similar issues come up in the future so that they become more resilient.

Let’s give a hypothetical example to show how this might work from a CBT perspective. Sam seeks out therapy to help deal with his anxiety. He gets extremely anxious in social situations and is having difficulty functioning in university, often retreating to his dorm room and skipping classes. As mentioned, for the first couple of sessions Sam and his therapist explore the problem. How does Sam experience this anxiety? Why is he feeling this way? What are his thoughts around it? What behaviors does Sam use to help? Are these behaviors helpful?

Over time it becomes clear that Sam feels judged when he is surrounded by other people. He thinks that people are watching and being critical of the things he does, which causes him to become very self-conscious and anxious. This has resulted in Sam withdrawing from every situation involving other people that he can. Because he now has very little contact with other people, he never gets to challenge the thoughts he has about this situation, which has caused his anxiety to worsen over time.

Together with his therapist, Sam starts to examine the thoughts he has about other people. He feels certain that people have focused on him in public. They examine situations where Sam felt like this and look for alternative explanations. Over time, Sam begins to feel less certain about this belief, but the issue is still present.

They also examine Sam’s behaviors. In this case he has withdrawn in order to avoid the anxiety. Sam recognizes that this is not a helpful strategy, but feels like he doesn’t have any other options. The counsellor introduces some breathing techniques which allow Sam to control his anxiety somewhat, though it is not a perfect solution.

As Sam’s anxiety lessens slightly because of therapy, he begins to return to classes with a smaller number of students, which feel safer than his larger classes. As a way to test his beliefs, Sam sits to one side where he can see the whole class and pays attention to the other students. He makes a mark on the corner of his book every time someone looks at or seems to be paying attention to him.

Sam quickly realizes that hardly anyone is paying attention to him. Testing his beliefs quickly falsifies them, and in their next session Sam and his counsellor focus on creating a new thought to replace the thought that Sam has disproven. They decide that instead of ‘everyone is focusing on me’, Sam now thinks ‘people are generally focused on themselves or people they know, or their teacher’. Sam begins to do more around other people, and although he still experiences some anxiety, he uses the breathing techniques and new thoughts he has worked on in therapy. He gradually gets to the point where he is living life normally again, and finishes therapy.

Now, it would be easy to look at this and think ‘that’s an unrealistic example, surely nobody would believe something like that!’. First, you’d be surprised. We all have cognitive biases and habitual ways of thinking, and in someone who is experiencing psychological distress these biases are often amplified. Secondly, of course it was a simple example, this is supposed to be a blog post, not a novel. In reality, people’s issues are usually more complicated than a single mistaken belief and one behavior that contributes to the problem. This example is just meant to demonstrate what therapy looks like from a CBT perspective so you can get a sense of how therapy functions in practice.

Hopefully this post has cleared up some misunderstandings about what therapy is these days. Across all different types of therapy, the goal is to empower the client and help them deal with the issues that they want help with. If you’re dealing with serious issues in your life and this sounds good, consider reaching out to a professional! We all need help sometimes.

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