Below two seasoned psychologists debunk common myths about psychotherapy and offer pointers on making the most out of therapy.

Misconceptions and Concerns About Psychotherapy

According to Ryan Howes, Ph.D, psychologist, writer and professor in Pasadena, California, “Some clients expect their therapists to give them direct advice, telling them who to date and what to study and when to break up.” It’s easy to think this way considering that TV therapists dole out advice without hesitation. “But most therapists resist giving advice because they believe it’s better for the client to learn to solve their own problems,” he says.

Clients also worry about what others will think. They wonder what’ll happen if their co-workers or friends find out they’re going to therapy. They might automatically assume others will think they’re “weak, flawed [or] crazy,” comments Chicago psychologist and life coach John Duffy, Ph.D. In reality, though, “More often than not, people tend to be very supportive,” he says. Plus, it’s up to you who you tell about your therapy, and confidentiality laws protect your privacy.

The therapy process itself can get confusing. According to Duffy, people might have questions like: “Is it brainwashing? Will it change my personality? What if focusing on my problems will make them worse, not better?”

These myths and concerns stem from various sources, including therapists themselves. Howes says: “…no two therapies/therapists are alike, the media does a lousy job of portraying realistic therapy, many people are still too ashamed to talk about it and therapists don’t always do a good job of teaching clients the best ways to get the most from their therapy.”

How to Make the Most of Therapy

1. Do your homework.

Be a discerning consumer by doing your research. Therapists “have different approaches, and come from different schools of thought,” Duffy says. For instance, you might learn the differences between treatment approaches, such as cognitive-behavioral therapy and psychodynamic therapy, he says.

2. Ask for referrals.

“It is difficult to determine on paper or via a website who will work for you,” Duffy says, “So ask around.”

3. Consider expertise.

“If you are seeking a therapist for a teenager, for instance, you probably want to avoid the therapist who focuses on couples work,” Duffy explains. Similarly, if you know your diagnosis, see someone who specializes in that disorder.

4. Be open to change and the process.

Change is hard. And it’s a pivotal part of therapy. As Duffy says, “By definition, therapy is a change process, and it will and should foster a bit of discomfort. This is not a bad thing.”

Engaging fully in therapy increases the chances of its effectiveness, he says. Think of it this way: “In order to get a different result, you’ll probably need to try a different approach,” Howes says.

So trust the process. “Some of the techniques therapists use — like the empty chair, reflective listening and thought stopping — can seem corny at first, but many people find them effective.” And keep in mind that some issues will require bigger changes than you initially thought, he adds.

5. Limit the process.

Another way to foster change is to remember that the therapeutic process doesn’t go on forever. “That is, if we think therapy has no end, we may put off the changes we want and need to make. If we know we’re working together for about 6, or 12 or even 20 weeks, that timing provides a context for us to think about and enact change,” Duffy says.

6. Make therapy part of your life.

Many people expect change to happen from an hour a week at the therapist’s office, Duffy points out. But “…in order for the process to foster real change, a great deal of the work has to take place outside of the therapy room.”

This “might range from a simple meditation to a significant change in work habits to ending a dysfunctional relationship.”

In other words, “Therapy is one of those ‘you get out of it what you put into it’ activities,” Howes says. He suggests “Keep a journal, show up to appointments on time, read books about your issue, do your homework and dive in.”

The key, Duffy says, is to hold yourself accountable for this outside work.

7. Be brutally honest.

For instance, whether you have positive or negative feelings about your therapist, don’t be afraid to bring them up, Howes says. In fact, “…this sort of discussion can provide some of the best results therapy has to offer.”

Consequently, he says, “Whether you’re talking about yourself, your past, your ‘craziest’ thoughts or the relationship with the therapist, brutal honesty is the quickest route to results.”

8. Realize that “things can get worse before they get better,” Howes says.

“After a few sessions of poking around in a person’s psyche, we’ve opened several cans of worms and it can feel overwhelming,” he says. It’s not uncommon that “…people come in to work on one problem and soon realize they have four.”

9. Talk about challenges regarding therapy.

Therapy requires resources, namely time and money, which as Howes says, “are increasingly hard to come by.” Also, some people might not have access to community resources or a good support system. Then there are also what Howes refers to as “backseat drivers,” “well-meaning loved ones who try to tell [clients] what to talk about in therapy, ask a million questions about it or even poke fun at them for being in therapy.”

Many clients don’t bring up these issues to their therapists. Instead, they might suddenly stop therapy or keep getting stressed out. Howes emphasizes the importance of talking to your therapist about these concerns, because together you can brainstorm solutions.

In general, therapy offers many benefits, whether you’re struggling with mental illness, a difficult life transition or other concerns. According to Howes, therapy is an opportunity “to try new things. It’s a place for thinkers to try feeling, busy people to practice slowing down, non-confrontational people to be assertive, people pleasers to practice thinking only about themselves, and cut-and-run people to learn the art of a healthy goodbye.”

He concludes, “It’s like taking a college course where you are the topic. Make the most of it!”

Photo by Code Pink, available under a Creative Commons attribution license.

Although the approaches are often seen as distinct, in the implementation and even theoretically there is often overlap. Rigidly adhering to one way of thinking or approaching therapy often limits results and misses the whole picture, and may result in an approach that feels foreign or false to the patient.

The psychodynamic approach focuses on understanding where the patient’s problems or symptoms came from. The therapist helps the patient recognize how the past is repeated in the present.

Attachment theories have become more popular recently as new research emerges. These approaches use empirically-based and neurobiological research to understand problematic relationship styles. Scientific studies on attachment have found that issues in adult relationships can be reliably predicted from objectively identifiable, early patterns of attachment between parents and children. Therapists using attachment-based approaches aim for healing unconscious psychological and biological processes in the brain and promoting the development of higher-level capacities. Such capacities include the ability to recognize and reflect upon what is happening in one’s own mind and the minds of others, and sort out one from the other.

This approach to therapy is also particularly helpful for teaching parents ways to react that optimize children’s psychological and brain development and improve parent-child relationships.

Cognitive-behavioral approaches emphasize learning to recognize and change maladaptive thought patterns and behaviors, improve how feelings and worries are handled, and break the cycle of dysfunctional habitual behaviors. This perspective helps people see the connection between how they think, what they tell themselves, and the feelings and actions that follow.

Interpersonal approaches emphasize identifying and understanding self-defeating patterns in relationships, figuring out why a particular situation is happening in a particular context, changing patterns that don’t work and developing healthier ones. In this approach, relationships and the here-and-now are the focus.

Systemic approaches understand problems in a contextual framework and focus on understanding and shifting the current dynamics of relationships, families, and even work settings. The roles and behaviors that people take on in a particular family or context are understood to be determined by the unspoken rules of that system and interaction among its members. Change in any part of the family system or group is the route to changing symptoms and dynamics, whether or not the “identified patient” is specifically involved in those changes. In this type of therapy, the “identified patient” in a family – the one seen by family members as having the problem — is viewed by the therapist as part of a larger system that is creating or sustaining this problem. This approach can be particularly useful when one member of a family seems resistant to therapy or to change; it opens up other avenues for intervention.

Other therapeutic approaches are centered around self-expression, with therapy providing a safe and private place to express feelings, confusion, worries, secrets and ideas.

In general, regardless of the therapist’s preferred way of working, people find therapy to be most useful when therapists are responsive, engaged, and offer feedback.

Many people who have been in therapy or have interviewed different therapists report better results when they like and feel comfortable with a therapist experienced in their particular issue. In addition, some of what makes a good match has to do with “chemistry.” Chemistry involves more subtle factors such as the therapist’s personality and whether he or she is someone in whom the client would want to talk and confide.

For those who are new to therapy, this article provides a general understanding. Those who have had therapy before may find additional understanding here about what worked or didn’t work in their earlier experience. If you’re very familiar with the therapy process, this article touches on some of its subtleties.

To get the best results, it’s helpful to follow a few basic principles:

• Choose a therapist with whom you feel comfortable
• Define your goals
• Reveal yourself, and voice your concerns
• Apply yourself
• Understand the psychotherapy framework

Choosing a Therapist

Research on psychotherapy outcomes tells us that the most powerful factor to assist healing is the quality of the relationship you have with your therapist. [1] Addressing sensitive personal issues with a therapist can be difficult, bringing up intense feelings, thoughts and memories. When you choose a therapist, your ability to disclose sensitive material and work on it openly is greatly enhanced if you feel comfortable with the therapist and can establish a trusting relationship with him or her. You also want to feel secure in the therapist’s skills, competence, and approach to your needs — a nice person without these qualifications won’t get you the best results.

For these reasons, I recommend that you don’t settle for the first therapist you meet if you don’t feel the potential to form a strong healing alliance. As you get into the work, feel free to ask your therapist about your treatment plan and progress. If you aren’t happy with her or his approach or with the results you’re getting, voice your concerns early, as discussed below.

Define Your Goals

I once heard a saying that if you don’t know where you’re going, that’s where you’re going to get. (Maybe someone who reads this will know the source of that saying. If so, please let me know!) There are definite reasons why you’re seeking psychotherapy. A good therapist will ask the necessary questions to help you express your goals. But it’s also helpful to clarify them for yourself and even write them down and bring them into session. A clear understanding of your goals will give you a way to track your progress in reaching them and will assist the therapist in formulating a treatment plan.

Sometimes the goal can be more generalized, such as personal growth, more inner peace or greater passion for living. This type of overarching goal is still very useful, and is usually addressed by long-term, in-depth therapy.

Occasionally I find that clients start by asking me to address goals that are not the core of their issues. They may feel uncomfortable admitting the core problem, such as an addiction, an extramarital affair, uncertainty about sexual identity, a source of guilt, and so on. One of the benefits of good psychotherapy is the ability to tolerate intense feelings without falling apart or acting on them. Your therapist may be able to help you do so more comfortably than you think.

People with borderline personality disorder tend to have unstable and intense relationships, and may unconsciously exploit and manipulate others. They may find it difficult or impossible to recognize the effects their behavior has on other people, to put themselves in other people’s shoes and to empathize with others.

Mentalization is the capacity to understand both behavior and feelings and how they’re associated with specific mental states, not just in ourselves, but in others as well. It is theorized that people with borderline personality disorder (BPD) have a decreased capacity for mentalization. Mentalization is a component in most traditional types of psychotherapy, but it is not usually the primary focus of such therapy approaches.

In mentalization-based therapy (MBT), the concept of mentalization is emphasized, reinforced and practiced within a safe and supportive psychotherapy setting. Because the approach is psychodynamic, therapy tends to be less directive than cognitive-behavioral approaches, such as dialectical behavior therapy (DBT), another common treatment approach for borderline personality disorder.

In someone with BPD, the difference between the person’s inner experience and the perspective given by the therapist (or others), as well as the person’s attachment to the therapist (or others), often leads to feelings of bewilderment and instability.

Unsurprisingly, this leads to more, rather than less, problems in the person’s life. It has been proposed that people with BPD have hyperactive attachment systems as a result of their history or biological predisposition, which may account for their reduced capacity to mentalize. They would be particularly vulnerable to side-effects of psychotherapeutic treatments that activate the attachment system.

Yet without activation of the attachment system, people with BPD will never develop a capacity to function in a healthy manner in the context of interpersonal relationships.

Mentalization, like socialization or public speaking, is a skill which can be readily learned. People who undergo MBT will find that their therapy experience focuses on learning and practicing this skill in the context not only of their social relationships with others, but also directly with their therapist.

Since this internal split determines the nature of the patient’s perceptions, it leads to the chaotic interpersonal relations, impulsive self-destructive behaviors, and other symptoms of BPD. The internal split is based on a model of the mind in which early affectively-charged experiences are cumulatively internalized over time in the individual’s mind and become established in the individual’s psychological structure as “object relations dyads” – units which combine a specific representation of the self and a specific representation of the other linked by a specific affect.

Different dyads represent different images of the self and of the other connected by different affects. These dyads are not exact, accurate representations of historical reality, but tend to represent extreme images and affects. In the course of psychological development, these separate dyads become integrated into a unified whole with a more mature and flexible sense of self and others in the world. However, in borderline individuals, these separate dyads do not become integrated in this way. Instead, dyads associated with sharply different affects exist independently from one another and determine the lack of continuity of the borderline patient’s subjective experience in life.

An obvious question is why this integration does not take place in individuals with BPD. TFP posits a multifactorial explanation in which elements of biologically-determined temperament and of environment combine to maintain this split psychological structure. In over-simplified terms, internal representations of frustrating others in relation to a helpless deprived self are totally split off from internal representations of gratifying others in relation to a satisfied self.

These opposite images are imbued with intense affects, both hateful (in association with the first internal representation), and loving (in association with the second). While the patient has no conscious awareness of this split internal world (and his or her ability to identify with either side of it at different moments in time), this structure underlies and determines the symptoms mentioned above, such as chaos in interpersonal relations, emotional lability, black-and-white thinking, anger, and proneness to lapses in reality testing. In psychodynamic terms, this split internal structure corresponds to the syndrome of identity diffusion and use of primitive defense mechanisms. In more phenomenological terms, this psychological structure results in an individual going through life with a subjective experience that is fragmented, discontinuous, rigid and impoverished.

Several different approaches to brief psychodynamic psychotherapy have evolved from psychoanalytic theory and have been clinically applied to a wide range of psychological disorders. There is a body of research that generally supports the efficacy of these approaches.

Psychodynamic therapy is the oldest of the modern therapies. (Freud’s psychoanalysis is a specific form and subset of psychodymanic therapy.) As such, it is based in a highly developed and multifaceted theory of human development and interaction. This chapter demonstrates how rich it is for adaptation and further evolution by contemporary therapists for specific purposes. The material presented in this chapter provides a quick glance at the usefulness and the complex nature of this type of therapy.

History of Psychodynamic Therapy

The theory supporting psychodynamic therapy originated in and is informed by psychoanalytic theory. There are four major schools of psychoanalytic theory, each of which has influenced psychodynamic therapy. The four schools are: Freudian, Ego Psychology, Object Relations, and Self Psychology.

Freudian psychology is based on the theories first formulated by Sigmund Freud in the early part of this century and is sometimes referred to as the drive or structural model. The essence of Freud’s theory is that sexual and aggressive energies originating in the id (or unconscious) are modulated by the ego, which is a set of functions that moderates between the id and external reality. Defense mechanisms are constructions of the ego that operate to minimize pain and to maintain psychic equilibrium. The superego, formed during latency (between age 5 and puberty), operates to control id drives through guilt.

Ego Psychology derives from Freudian psychology. Its proponents focus their work on enhancing and maintaining ego function in accordance with the demands of reality. Ego Psychology stresses the individual’s capacity for defense, adaptation, and reality testing.

Object Relations psychology was first articulated by several British analysts, among them Melanie Klein, W.R.D. Fairbairn, D.W. Winnicott, and Harry Guntrip. According to this theory, human beings are always shaped in relation to the significant others surrounding them. Our struggles and goals in life focus on maintaining relations with others, while at the same time differentiating ourselves from others. The internal representations of self and others acquired in childhood are later played out in adult relations. Individuals repeat old object relationships in an effort to master them and become freed from them.

Self Psychology was founded by Heinz Kohut, M.D., in Chicago during the 1950s. Kohut observed that the self refers to a person’s perception of his experience of his self, including the presence or lack of a sense of self-esteem. The self is perceived in relation to the establishment of boundaries and the differentiations of self from others (or the lack of boundaries and differentiations).

Each of the four schools of psychoanalytic theory presents discrete theories of personality formation, psychopathology formation, and change; techniques by which to conduct therapy; and indications and contraindications for therapy. Psychodynamic therapy is distinguished from psychoanalysis in several particulars, including the fact that psychodynamic therapy need not include all analytic techniques and is not conducted by psychoanalytically trained analysts. Psychodynamic therapy is also conducted over a shorter period of time and with less frequency than psychoanalysis.

Introduction to Brief Psychodynamic Therapy

The healing and change process envisioned in long-term psychodynamic therapy typically requires at least 2 years of sessions. This is because the goal of therapy is often to change an aspect of one’s identity or personality or to integrate key developmental learning missed while the client was stuck at an earlier stage of emotional development.

Practitioners of brief psychodynamic therapy believe that some changes can happen through a more rapid process or that an initial short intervention will start an ongoing process of change that does not need the constant involvement of the therapist. A central concept in brief therapy is that there should be one major focus for the therapy rather than the more traditional psychoanalytic practice of allowing the client to associate freely and discuss unconnected issues. In brief therapy, the central focus is developed during the initial evaluation process, occurring during the first session or two. This focus must be agreed on by the client and therapist. The central focus singles out the most important issues and thus creates a structure and identifies a goal for the treatment. In brief therapy, the therapist is expected to be fairly active in keeping the session focused on the main issue. Having a clear focus makes it possible to do interpretive work in a relatively short time because the therapist only addresses the circumscribed problem area.

The number of professionals who practice an exclusive form of psychodynamic therapy today is a small percentage of psychotherapists. Many psychotherapists use components of psychodynamic theories, however, in their formulation of a client’s issues, while employing other types of psychological techniques (most often, cognitive-behavioral techniques) to affect change in the individual.