by Robert Duff
In a typical individual therapy session, you will sit down with your therapist and generally talk about nothing important for a few minutes. This part is important to just ease the tension and transition into a therapeutic environment. You might talk about movies you’ve seen, the weather, or whatever bullshit pops into your head. After the small talk, they will usually ask you if there are any really important updates that they should know about. Life changes and that sort of thing. From there, it depends on the type of therapy that you are getting. Some modes of therapy will review homework, challenges, assignments, or experiments from the previous session before diving into new content. Others will simply wait for you to speak your mind and follow your lead. What you talk about depends on your particular issues and the theoretical orientation of the therapist. Sometimes, it’s a place to just get all of that shit off of your chest that you’ve been keeping in all week. Friends and family are great, but they biased and there is always some inherent risk to telling them things. With a mental health professional, they will hear you out and be on your team no matter what you tell them. They are there to support you and try to gently guide you on your quest.
The term that we use in the field to describe the opinion that therapists have toward their clients is called “unconditional positive regard.” That means that they are always on your side. It does not mean that they will agree with everything you say, but they will not think less of you for saying it. You do not need to worry about scaring them away or making them think you are an idiot for saying the things on your mind. It’s an inherently one-sided relationship. That doesn’t mean that your therapist will be completely blank and inactive. Not by any means. It just means that you are both there for you. It’s different from a friendship, because a therapist should not be pushing their own agenda or looking for you to reciprocate the support. They are there for you because they care and it is their job. Some people make the mistake of feeling guilty, because they come in every week and lay all of this crap on their therapist and feel like the therapist has to just take it without getting anything back in return. While it is true that your shrink is in the business of hearing you out and taking in your thoughts and emotions, they certainly do get something back in return. This is perhaps a bit of a generalization, but most therapists get into the field for a reason. It is inherently rewarding to be able to help other people. As a therapist, you also have the opportunity to learn about such a wide variety of life experiences by having people be so open and honest with you. It’s a very uniquely rewarding job, and you don’t need to worry about your therapist. Let them worry about helping you become your best self.
At first, it can be a little weird to have a time-limited conversation about your life. Usually when you have these sorts of candid conversations, they are with friends and can go on for any amount of time. In the case of therapy, you will be sticking to a schedule. So usually, you will be hypersensitive to the time for the first few sessions. Eventually, you get the feel for it and it won’t feel like a limitation. Most good therapists are able to guide the conversation in a way that fits nicely within the timeline. That means that they will not open up a huge can of worms that causes you to unravel emotionally right at the end of the session. No one wants you to walk out of the room a complete wreck. It can also be a bit awkward to have someone taking notes while you talk. Not all therapists write notes during sessions, but many do. Don’t worry about this. It’s not like they are making a binding contract based on the words that you have said. More likely they are just jotting down notes to themselves regarding what you said so that they don’t have to rely on their memory when going back later to write session notes. Sometimes they also may write down a small note to come back to a topic so that they don’t have to interrupt you when you are in the middle of saying something.
For instance, you might be talking about your experience over a holiday and say something like, “It was pretty much what I expected. Everyone came over for dinner and it was just super awkward. John was there, which I definitely did not expect after last year- so that made things worse. I guess it wasn’t all bad, though. Dinner tasted great, and I got to see some people in the family that actually seem to understand me. I tried to just hang out with them for most of the night and pretend like the rest of the family wasn’t staring at me with judging eyes.” During this story, your therapist wouldn’t want to interrupt. In order to be fully present in what you are saying, they might just jot down a couple quick notes to come back to such as “John last year?” or “family who understands vs doesn’t?” This would allow them come back later and learn more about your experience by asking something like, “I’m glad your holiday wasn’t all bad. You did a good job of finding some positive aspects. Do you mind if I ask about something you mentioned in there? Well, you said that there are some people in your family who just seem to ‘get it’ better than others. What do you think they see or know about you that helps them understand?” It may seem like they are mentally checking out when they are writing something down instead of paying attention to you, but in reality it is probably helping them stay more present in what you are saying.
I talked a bit about individual therapy, so let me talk about some of the other lesser known formats. If you are having relationship issues with your spouse or significant other, you might find yourself in couples therapy. This is different from being in individual therapy and occasionally bringing your significant other in for a session to help round things out. That method of bringing a third person into individual therapy every once in awhile is called having “collateral” sessions. Couples therapy is a bit different, because you are both there from the start, and it’s the relationship rather than either of you individually that is being worked on. You will definitely address individual issues as they relate to the relationship, but the “identified patient” is the both of you together. If you are experiencing depression that isn’t leading to major difficulties in the relationship, you are probably not going to engage in couples therapy. However, since depression is one of those problems that seems to generate a bullshit vortex and suck other people into it, there is a significant chance that there are also some issues going on in lover-land. If that is the case, it is important to know a few things about couples therapy.
You are allowed to be in individual therapy as well as couples therapy, but probably not with the same therapist. Most good therapists try to avoid the situation where they are more aligned with one partner than the other and will not do couples therapy with someone that they see in individual therapy. Can you imagine being in the therapist’s shoes and hearing all of one partner’s closest held secrets, fears, and wishes, and then being expected to not let those influence their opinion when seeing both partners at the same time? Not possible. That said, it is pretty common for partners to have individual therapy on their own as well as couples therapy with a separate provider. This way, you can work on the nitty gritty personal stuff in individual therapy and then bring that growth to the table and try to make relationship gains in couples sessions. Just like any therapy format, the way sessions go will be partially dictated by the therapists particular theoretical orientation and approach to treatment. In general, there will be more active strategies employed where you practice skills that will be helpful in your relationship. This might involve practicing different types of communication, expressing concerns in a safe space, or going through exercises in session to address particular issues within the relationship. It’s an amazing tool that is available to you. If you are really feeling like you are still in the trenches of depression, it is okay to focus on yourself first, but being open to couples treatment at some point can go a long way toward rectifying some of the damage that may have been done during the rough periods.
Another type of therapy you may have heard of is family therapy. Before you go any further, you should go on Youtube and look up the classic clip from the Simpsons about family therapy. It doesn’t have anything to do with what I’m going
to say here, but it’s hilarious and you deserve a laugh. ANYWAY, family therapy is much like couples therapy in that the “identified patient” typically is the family unit rather than a particular individual. There are many different types of family therapy out there and to be honest, it’s not my area of specialty. I can hold my own in family sessions, but that is ALL some people do. I would suggest that you find someone that specializes in family therapy if you are interested in pursuing this avenue of treatment. It should say on their website or their page on therapy search engines whether this is their bread and butter. In general, family therapists think of psychological issues as resulting from problems in the system of a family. That means that your depression isn’t just an isolated problem, but it’s influenced by other factors within that wonderful group of assholes that you call a family. If you have depression, you probably recognize that family often knows the exact right buttons to push when they want to send you from 0 to 100 on the depression and irritation scale in the blink of an eye. They are also sometimes the exact people you need on your side to beat this thing. In those moments where they look at your eyes you can see a glimmer of understanding and unconditional love, you can feel a trickle of hope drip into your iced over veins. Maybe they can help you get through it.
The actual in-session work is more in line with couples therapy than individual therapy. The therapist will probably have you work on concrete skills and possibly even reenact situations that happened at home to suggest alternative approaches. I won’t lie. Family therapy sessions can be tough, especially if your family environment is a place where feelings aren’t exactly talked about in the open. The therapist will encourage each member of the family to be present and involved in treatment. Usually when there is some resistance there to start with, that is an indication that you are on the right track. It’s like when you really don’t want to check your bank account… that’s probably the exact time that you need to be checking your balance. To this point, family therapy will often involve a little more introduction and guidance at the start. We don’t really expect families to just sit down and “1 2 3 GO!” Instead, the therapist will talk a bit about what to expect from therapy, how they work, and typically guide families as much as needed through those initial stages. It’s worth mentioning here that both couples therapy and family therapy also involve intake sessions and are sometimes longer than the standard therapeutic hour to make time for all of the work that needs to be done.
So, let’s get back to talking about therapy in general. Just like I have presented you with many different strategies and approaches for fighting back against your depression, therapists that you encounter will have their own particular theoretical orientations that lead to different styles of treatment. A theoretical orientation basically just refers to which school of thought guides your understanding about the source of psychological issues and how they are healed. There are more orientations than I can go into here. Seriously, there are fat textbooks full of them. That said, I want to at least introduce you to a few of the key players.
Probably the most well-known type of therapy is cognitive behavioral therapy, or CBT. You might already be familiar with this approach, especially if you are from the United States. It’s definitely one of the more prevalent forms of therapy out there, and for good reason. Its efficacy has been supported through countless important pieces of research. If you have already read through my chapter on adjusting your thinking patterns, you already have a pretty good primer for CBT. The roots of CBT actually come all the way back from stoic philosophy, but you might be more familiar with some of the founding fathers of formal cognitive treatment such as Aaron Beck or Albert Ellis. The cognitive behavioral approach assumes that most psychological issues arise from faulty patterns in our thinking, which can be “unlearned” through a scientific approach to examining our assumptions and automatic responses to situations. A CBT-oriented therapist will help you to identify the patterns in your thinking that get you into trouble to help you stop being such a dick to yourself. They will often engage in something called “collaborative empiricism.” That means that you will both put on your scientist hats and dive into your problems together. You will not take your asshole brain at its word. Instead, you will treat the things that it automatically tells you as hypotheses. They are interesting ideas that can either be proven or disproven by examining the evidence. You will work together to find those delicious little nuggets of evidence and apply them to your working hypothesis to see if you really need to be feeling so terrible.
This is definitely one of the more active psychotherapy approaches. There will probably be more structured activities that could involve worksheets or even workbooks so you can develop and internalize a step-by-step process for addressing your unhelpful thinking patterns. Trigger warning: you might even get homework *GASP*. Don’t worry, these are not like school homework assignments. They are most likely things like filling out a thought log or doing behavioral experiments in your life. To challenge those negative assumptions that you have. In most cases, CBT will focus less on the past than present issues. The past is considered to be important due to the ways in which it might influence our current patterns of thinking and behavior. For instance, it may be useful to look back at early instances of learning, when you may have been taught that a particular distorted way of thinking was appropriate. You most likely won’t focus quite so much on things like deep-seated parental issues or unconscious motivations. I’ll offer a word of warning here: CBT is effective, but it can also be a bit challenging. A good therapist will help tailor the treatment to you as a person, but in some cases, old school cognitive therapists can come off as a little harsh. The reason for this is that they’re in the business of challenging you and pushing you to not trust your automatic thoughts and instead go where the evidence leads you. This can sometimes be annoying if you don’t like to be contradicted or challenged on your thoughts. Even if you have a pretty thin skin, I would still suggest that you give CBT a fair shot. Like I said, most shrinks these days try to be legitimately helpful and find something that works for your particular personality.
Another common type of treatment for those of you that might want to dive a bit deeper and scour your psyche for the roots of your current issues would be psychoanalytic or psychodynamic therapy. I’d be surprised if you haven’t heard of Sigmund Freud at this point. He’s the grandfather of this approach. If that puts a bad taste in your mouth, just know that we have come a long way since his time. Freud was a brilliant man, but he was also a fuckin’ weirdo. The type of therapy that he originated is called psychoanalysis. This is that classic caricature you may have seen in movies or cartoons where someone is lying down on the couch and free associating while the creepy white dude with the pipe and notepad sits silently behind them. There aren’t so many therapists who still offer hardcore 3-times-a-week psychoanalysis these days, though they do exist. The more modern version of this (that has a little more structure and a lot more research support) is called psychodynamic treatment. Same roots, just updated to fit with modern times… much more palatable to most people.
In psychodynamic treatment, you will probably look quite a bit more at relationships, especially early relationships that shaped your ways of relating to other people and the world around you. Yes, that probably means Mom and Dad. You will likely dive into all of that stuff that happened during your formative years. That’s one of the main distinctions between psychodynamic treatment and more present-focused approaches like CBT. With this type of therapy, there is the assumption that a portion of the iceberg that is your psyche lies beneath the surface. You can expect to work toward uncovering and becoming more aware of subconscious tendencies and wishes that are playing out and influencing your daily life. I consider psychodynamic treatment to be an insight oriented treatment. This means value is placed on uncovering the origins of the issues that are currently causing you so much grief, and there’s an assumption that understanding where the issues came from serve
s as a means to heal and protect.
The actual in-session work will probably be somewhat less structured than CBT. You won’t be doing quite as many worksheets or homework assignments, and instead your therapist will be a gentle guide to support you and offer interpretations as you begin to peel back the layers of your psychic onion. A psychodynamic therapist may also draw your attention to patterns that are playing out between the two of you in the moment as a parallel to what goes on in the rest of your life outside of treatment. The idea is that we fall into certain relational patterns that tend to continue in different facets of our life. Many people turn to a psychodynamically oriented interpretation of events when they consider someone in an abusive relationship. For the non-therapist, the most common interpretation of that situation is that they were in an abusive relationship with one of their parents and continue to play out that relationship with other people throughout their life. Don’t be turned off by the ancestry of psychodynamic treatment being a little weird. As you can see by that example, it sometimes makes a lot of sense to consider your difficulties through this lens.
Like I said before, those are a couple of the main players in the field of psychotherapy right now, but there are SO many more. You might run into approaches like dialectical behavior therapy, strategic solution-focused therapy, gestalt therapy, family systems therapy, or interpersonal therapy. They all have their unique features and merits. Many modern approaches blend aspects from different theoretical orientations. A therapist that uses an approach that combines several types of treatment is called “integrative”, or “eclectic”. Sometimes the word eclectic is avoided, just because the connotation in the United States is that an eclectic person is probably strange. Currently, integrated approaches to psychotherapy are more common than pure single-theory approaches and that is perfectly alright. In fact, there is some research that suggests that as therapists practice and become masters of their craft, they naturally begin to drift toward a similar, more integrated approach that combines the most useful aspects from the different theoretical orientations out there.
