PSYCHOTHERAPY: WHAT IT IS, AND WHAT IT IS NOT
by Mark Chrisinger, LCMHC
PSYCHOTHERAPY: WHAT IT IS, AND WHAT IT IS NOT
by Mark Chrisinger, LCMHC
Here I want to give some basic definitions of what therapy is and what therapy is not. I am not going to get into the many kinds of theoretical approaches to therapy—e.g., psychoanalysis, person-centered, cognitive-behavioral, DBT, EMDR, ERP, etc.—but am going to focus on what therapy is in general, regardless of theoretical orientation. I am hoping to add articles in the future to help differentiate the common types of therapy and also understand when it does and does not matter what kind of therapy you receive.
I’ll begin with a brief list of what I think therapy is and what it is not, and then I’ll go into greater detail on each point.
What therapy is:
an interaction between two human beings
a series of collaborative therapist-client interactions intended to assess and remediate the client’s specific psychological problems using psychological theories of human functioning and change
a care-providing relationship between a licensed therapist and a client or patient
a confidential relationship in which the therapist is required to protect the client’s information (with some exceptions: see below and here)
(as it exists in current society) a business relationship between a service provider (individual or business) and client
a secular approach to healing that can incorporate religious strengths
What therapy is not:
a passive treatment
a socially embedded relationship
a guru-disciple relationship
the only way to address psychological problems
a solution to all of life’s problems
a magical cure
a philosophy or religion
an easily defined thing!
Let’s go into each of these points in greater detail.
Therapy is an interaction between two human beings. If you go to therapy, you're just going to meet with another person and talk with that person for an hour. It's as intimidating or not as intimidating as that. For people who find the prospect of talking to anyone for an hour intimidating, I will add that most therapists are practiced and natural non-judgmental listeners who make the process as gentle as possible.
Therapy is a series of collaborative therapist-client interactions intended to assess and remediate the client’s specific psychological problems using psychological theories of human functioning and change. There are several important points in this definition. First of all, therapy is a collaboration. You come to the table with skills, strengths, and essential knowledge (about yourself) that need to be applied to assessing and treating the issues you are seeking help for. Your collaboration in conceptualizing your issues and potential solutions to those issues is absolutely necessary, because you are the expert on yourself. The therapist’s expertise is only useful insomuch as you are participating in the process. That being said, it's not like you need to write a thesis on yourself and present it to the therapist. Your contribution will come naturally from your personal experience and motivations and doesn't require anything more than being active in the process.
Second, part of therapy is assessing your presenting concerns. Typically, assessment is directed toward classifying your presenting symptoms as meeting or not meeting criteria for various mental disorders, but on a more important level it involves creating a well-informed, sound conceptualization of your psychological patterns, identifies unhealthy patterns, and creates a plan for modifying those unhealthy patterns to restore optimal psychological functioning.
Third, therapy applies psychological principles to help you resolve the issues you are facing. This means that the therapist helps you to build a conceptual model of why you are experiencing your particular issues, what expectations you might have for change, and what you might do to bring about change. This begins with the initial conceptualization and then is applied directly with interventions intended to remediate the symptoms or behavioral patterns. The psychological principles used depends on your therapist’s theoretical approach. Usually it matters less what the theoretical approach is and more that the conceptualization makes sense to you and your therapist in a way that allows you to collaborate.
Finally, therapy is a series of interactions, meaning it almost always requires multiple sessions to have any effect. The frequency and duration of therapy can vary significantly depending on the issue.
Therapy is a care-providing relationship between a licensed therapist and a client or patient. The goal of the institution of psychotherapy is to provide you with legitimate care for psychological issues from an appropriately credentialed individual. Therapists are trained and licensed in their profession (typically counseling, social work, psychiatry, psychology, addictions counseling, or marriage and family counseling), and they are held to a standard of care and professional responsibility in helping you. An important point here is that the therapist’s professional role creates a protective boundary around the therapeutic relationship and focuses the interaction on providing you with mental health care.
Therapy is a confidential relationship in which the therapist is required to protect the client’s information. One of the most important aspects of therapy is the privacy of the interaction. Confidentiality laws differ from state-to-state, but in North Carolina a therapist can only breach confidentiality if they believe you are at risk of harm to self or others; you direct the therapist to share information; the therapist is ordered by a judge to do so; or you say something to indicate a child, elderly person, or dependent adult is at risk of abuse. See more about confidentiality and HIPAA here.
Therapy is a business relationship between a service provider and client. Much to its institutional detriment or benefit, depending on who you talk to, therapy is provided as a service for a fee in its current form in the United States. The client may pay the fee, an insurance company may pay it, or the therapist may be reimbursed through institutional or other subsidy. Regardless, the therapist is making a livelihood by providing the service of therapy. This does not mean that therapists don’t do pro bono work, are motivated strictly by financial concerns, or have no altruistic intentions, but it does create another boundary around the therapeutic interaction. As it exists now, therapy is in a fundamental way an exchange of services, and without that exchange the therapeutic relationship would not exist. I will be writing more about the problem of money and therapy in another article.
To further reflect on these last three observations about the nature of therapy, it’s important to note that there are essential professional roles and boundaries associated with any therapeutic relationship, and recognizing those limitations can clarify your expectations around therapy. Not acknowledging boundaries and roles can sometimes lead to confusion and issues in fully opening up to the therapeutic experience. For instance, sometimes being the recipient of help is a difficult position for the client to be in, because the immediate social exchange feels so unequal, and this may motivate the client to try to help the therapist in return. This can take the form of wanting to talk about the therapist’s life, wanting to entertain the therapist with good stories, wanting to give the therapist gifts, or even withholding difficult material to spare the therapist emotional labor. I think it can be helpful for the client to express gratitude when this natural impulse arises, but it is also helpful to remember the fundamental boundaries that effectively balance the relationship: the therapist is rewarded by doing their work well (by helping you) and through monetary compensation.
Another difficulty of the therapeutic relationship that boundaries can help with is expecting more from the therapist than what can be provided. Therapy requires you to open up about the most intimate parts of your emotional life, and this means your therapist ends up knowing you and being close to you in an emotionally intimate way—but, as confusing as it is to the human brain, your therapist is still not your friend and can’t be. There is no way for the bond to be truly mutual and extend beyond the professional relationship while maintaining the integrity of the professional relationship. This does not mean your therapist does not care for you or like you. It just means there is no way to be your friend and protect your confidentiality, deliver professional mental health care, and make a living. All the boundaries of the therapist-client relationship create limitations on what therapy can and cannot do, and they exist for the benefit of both the client and the therapist.
Therapy is a secular approach to healing that can incorporate religious strengths. Like medicine, therapy is fundamentally secular or empirical in nature. It has to be this way so that we can serve all kinds of people using effective techniques that don’t rely on aspects of experience we don’t all agree exist. On the other hand, therapy is fundamentally humanistic and incorporates your strengths into the therapeutic work. So if religion is important to you, religion is going to be part of the therapy, and your therapist is not going to convert you to a non-religious attitude.
Therapy is not a passive treatment. Psychotherapy is not like taking medication or getting massage therapy where you benefit from taking the treatment and showing up. Showing up is helpful and can be a big step in making progress, but you have to be actively involved in therapy for it to work. I think sometimes people take the advice "go to therapy" too literally, and they just go to therapy with the idea that they are doing something beneficial. But there's nothing magical about sitting in the same (real or virtual) room as a therapist. You have to be motivated to grow and learn for growth and learning to occur.
Therapy is not a socially embedded relationship. This means the therapeutic relationship exists outside of the normal context of social relationships. As mentioned above, while you do need to get along with your therapist through a social medium (talking), your therapist can’t be your friend like your friend is your friend—and that’s good thing. Your friend might be a good friend, but that doesn’t mean they won’t sometimes share what you’ve said with someone else, judge you, or turn the conversation from your needs to their own needs. Your therapist refrains from all of these social behaviors. The information you share is private, you are listened to non-judgmentally (for the most part), and the therapist doesn’t use the social opportunity to talk about their own problems.
Therapy is not a guru-disciple relationship. Your therapist might know a lot of things, have seen a lot of things, have experienced a lot of things—but your therapist is not a guru, sage, saint, oracle, or magician. Just like your mechanic or dentist, your therapist is a normal person who has knowledge and resources to help you with specific problems—and that’s it.
Therapy is not the only way to address psychological problems. People get better and grow outside of therapy all of the time—thank god! Therapy is not the solution to every psychological problem for every person. It is often helpful for people under the right circumstances, but it is not the only or best solution. Medication, exercise, positive social supports, self-reflection, meditation, yoga, being in nature, participation in one’s religious/spiritual tradition, and other activities can all be effective ways of addressing issues, alleviating symptoms, and growing personally.
Therapy is not a solution to all of life’s problems. This builds on the previous point, but it means more specifically that sometimes your problem is totally conditional: not having enough money, loneliness, a terrible living situation, a poorly matched domestic partner, insufficient medical care, etc. These are problems that are best solved pragmatically by changing the conditions that create the problem. Sometimes psychological factors create these situations or become barriers to changing the conditions, and therapy can help with that, but sometimes you just need a better job, a car, the right medical care—and we can waste our time analyzing your dreams for the secret reason you’re in this situation, but in the end there’s nothing for it but to change what needs to change.
Therapy is not a magical cure. This might seem obvious, but it is important to note that there are no magical cures out there. Sometimes we want a miraculous resolution of symptoms, but most of the time it is just not possible. For instance, it is generally accepted by therapists that it is not possible for or even expected of a normal human being to be free from anxiety or stress, much less a person who is wired to be over-anxious. When we treat anxiety, in fact, we focus on experiencing and tolerating anxiety rather than making it go away. Most of the effect of therapy is in learning to relate to symptoms in a way that causes less suffering, and symptom resolution is usually a side-effect of this more important goal. Therapy is an effective treatment for a variety of mental health concerns, but it won’t wash your suffering away like stains in a laundry detergent commercial.
Therapy is not a philosophy or religion. In reflecting on this issue, I got so long-winded I decided I’d write another article on it later—but the short version of my point here is that the therapist does not provide solutions to the fundamental problems of life in the way that religion or philosophy do. Religions give direct answers to questions about the nature of reality, the nature of the human being, the nature of truth, and the nature of good and evil. Therapy does not do that.
Finally, therapy is none of what I have described above! In the end, what therapy is or is not cannot be defined as within the box or without the box so easily. Each therapy session might have components of what I've described above, but each session will always be unique. In fact, it's pretty much guaranteed that therapy is going to bring up things neither of us could have imagined as being central to your therapeutic process. My idea of what can help you is going to change as I work with you, just as your idea of what you need will change.
There you have it—what therapy is and is not. The definition of what is and is not extends infinitely, and hopefully I will be able to clarify and qualify with further articles in the future.
Questions or comments? Contact me at: mark@markchrisingercounseling.com