Therapy: The rough guide

Psychologists do psychological therapy. No surprises there. But like much of our work, it’s poorly-understood by those not in the business (in my experience, it’s often poorly understood by our colleagues). Here’s a quick run-down of the three major types of therapy we do. There are plenty of variants, but these are the Big Three:

Cognitive-behavioural therapy:

The big one. The one that is currently in vogue. The one that the government likes and that the overwhelming majority of services provide, in some form or another. People talk about ‘having CBT’ or ‘wanting CBT’ but they’re rarely familiar with the fundamentals. The fundamentals, then, are these: CBT looks at the link between cognitions (thoughts) and behaviours (how we act). This relationship is considered in the context of feelings and specific situations. As an example, you fail a piece of academic work (situation). You think ‘God, I’m such a failure’ (cognition). You might feel, understandably,  worthless. You might then cancel your evening out with your friends, sit in your room by yourself and mope over it (behaviours). This is something a lot of us will have done, in some form or another, but it’s not an especially helpful response. If this is a one-off response, it might not affect your live particularly negatively but if it’s an entrenched pattern, these negative thinking styles (to use the CBT lingo) might start to have a huge effect on you and your functioning. CBT aims to try to identify these patterns and look at the evidence for the thoughts. In this example, then, are you truly a failure? What’s the evidence for that? What’s the evidence against it? If the evidence for the statement is outweighed by the evidence against it, can we re-evaluate the statement? If so, how does that change the way you feel about yourself? Are you still worthless? Finally, you look at the effect of the behaviour. Drowning your sorrows on your own may work in the short-term; it’s probably not going to feel such a good idea in the long-term, even if the long-term is the next morning.

CBT is a structured treatment programme and is designed to help the person seeking treatment to become their own therapist. You will be expected to complete ‘homework’ between sessions to practice the skills you’ve learned and build confidence in your own ability to make progress. A good rapport with the therapist is importance; dependence on them is discouraged.

There is some good evidence for CBT for some problems, but it doesn’t work for everyone. Nevertheless, when it does work, it can work very well indeed.

Systemic therapy:

A fancy way of saying (usually) ‘family therapy’, systemic therapy thinks about ‘systems’ generally taken to mean family systems. The theory is that we don’t exist in isolation, we’re not islands, so there’s little merit in treating people as though problems exist solely ‘within’ them. We exist in families and communities and societies and all of these are crucial to our emotional wellbeing. Systemic therapy aims to make the unspoken spoken; to break down the walls of silence, denial and lies that characterise so many families and which can be so destructive. The therapist often sees members of the family individual and the conducts joint sessions (not dissimilar to couples’ therapy). Family work such as this is commonplace in child and adolescent services but sadly lacking in general adult services, almost as though we cease to have families when we hit eighteen. I have a real fondness for family work; I think it can do wonderful things and it’s an enormously interesting way to work. Crucially, it takes the problem out of the person – they stop being ‘a person with …’ and become ‘a person who lives in a system which results in …’. The distinction is subtle but vital. I am not there to pathologise the people who come and see me, nor am  I there to stigmatise. There are plenty of others who are all too willing to do that. I am there to help them break the cycles which imprison them.  Externalising problems is a key part of that.

Psychoanalytic therapy:

The oldest therapy on the block and one commonly held to be about nothing but sex. Sadly that’s not quite true. I confess, though, that I’ve never quite understood why Freud et al. have such a bad press. The roots of psychoanalysis are over a hundred years old; of course some of the ideas will seem peculiar to us now. The fact is that Freud was one of the first people in modern times to fully recognise that the things we experience in early life will have significant bearing on us later life. In essence, he realised that the child was the father of the man, an idea that few people would disagree with. There are some bits which seem less credible through 21st century lenses, but that’s a luxury Freud didn’t have. Also, he was a very good, engaging, witty writer and in my book that wins you brownie points. But I digress. The fundamentals of his ideas are these:

We are driven by unconscious desires (the id) which seek nothing but pleasure. This isn’t a helpful way to live because no one will like you. So we also have an ego which helps us to act in ways which are socially appropriate. The id tells you to grab all the roast potatoes at Sunday dinner; the ego tells you to only take four and then to go back for seconds if there are any. The superego is where we derive our sense of morality.

In addition to all this, psychoanalysis suggests that development occurs through stages and that successful resolution of those stages is necessary to be able to function well. Key to this is the notion of attachment. Babies, for example, are entirely dependent on other for survival and to them, with their undeveloped brains, anything unpleasant – hunger, cold, pain – is essentially a threat to life. The baby can’t survive without the assistance of another, so it screams and screams until someone removes the threat by soothing them, feeding them, etc. With time, the child learns that their unpleasant emotions can be dealt with and that they are not necessarily fatal and, as they get a little older, they learn to comfort themselves (typically, this is seen through the medium of a grubby old teddy or a revolting blanket which parents desperately try to wash while the child is napping). Eventually, they become able to regulate their own emotions without the help of these external agents. But for some people, there was no one to soothe them when they wept; no one to make them feel safe. They had no ‘attachment figure’ to cling on to, to make them feel secure. That child may grow up less able to manage their emotions and a whole raft of problems may arise as a result – difficulties in relationships are most common, and these will likely impact on all areas of life.

Psychoanalytic therapy aims to make links between the present and the early life and to help the person understand why they are what they are. The approach used differs depending on the school of thought of the therapist (Freudian, Jungian, attachment-based), but it is usually relatively long-term therapy and delves rather more into the mind than most other approaches. No therapy is easy, but psychoanalytic work can be some of the most challenging because it encourages you to face parts of your personality and history that you may rather forget or ignore (repression is another classic Freudian idea). Psychoanalysis has many critics, but I think it’s important that the essence of it is not derided – it contains many ideas which we now regard as self-evident but which were truly radical when they were first formulated.

The application of the main models of therapy in mental health services:

So those are the main schools of thought in contemporary psychology. But, in the event you require psychological input, which are you most likely to get? At present, CBT is the most likely, partly because there is a good deal of evidence for it. Increasingly, provision of mental health services is being driven by evidence, and with the cuts in funding, we are being encouraged to use approaches which have a good evidence bas,e partly so that we can derive maximum value for money. Whilst this seems sensible, it’s also led to a situation where we might not have the resources to provide a broader range of interventions. CBT is manualised, which means that conducting research into its effectiveness is relatively easy. Psychoanalysis, in contrast, is esoteric and much harder to to evaluate. As a result, there’s little research to back the model up and it has fallen out of favour. It’s also a longer, more intensive therapy and, as I said, the focus is on providing shorter treatments such as CBT.

I should probably add that all psychological therapy has one thing in common: it can be tough. We will ask you to do things which might scare you and we will encourage you to talk about things which are difficult. We don’t do this to be sadistic; we do it because we think it is important, but a good therapist will never ask you to do something you don’t want to. As I always say to the people who come to me, I might ask you to do things that are hard but  I will never ask you to do something unless I genuinely believe it will help, nor will I ask you to do anything I wouldn’t do myself.

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