Psychotherapy and Relationship / Marriage Counseling

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Psychotherapy and Relationship / Marriage Counseling
Psychotherapy, Relationship Help & Marriage Counseling

Psychotherapy is broadly defined as the treatment of mental and emotional disorders or problems. Psychotherapy involves a process, a relationship between a patient/client and a therapist.


In This Article:

* What is psychotherapy?
* Insurance coverage
* Psychotherapy vs. counseling
* Which therapy is best?
* Types of therapy
* Couple, family and group therapy
* Mental health professionals
* Telephone and online therapy
* References and resources



We have probably all seen TV shows or movies in which a psychotherapist, psychiatrist, or marriage counselor is portrayed as a comedic character, or one who behaves in very unethical or inappropriate ways. There are also a few films or TV shows in which therapists are shown at their best. Over time, most people have come to realize that someone does not have to be "crazy" in order to go see a therapist. But understanding the different types of therapy and deciding which therapist to contact can still be confusing to many people.

Helpguide's series, Relationship Help: Communication Skills to Find and Keep a Healthy Exciting Love Relationship, is for women and men of all ages.
What is psychotherapy?

Psychotherapy is broadly defined as the treatment of mental and emotional disorders or problems. Psychotherapy involves a process, a relationship between a patient/client and a therapist. The therapist is usually someone trained to:

* Listen deeply
* Reflect empathically
* Offer insight
* Provide feedback
* Help the person explore alternatives
* Serve as a guide or companion on the journey of exploration into the depths of emotions and experiences.

Therapy sessions are usually 45-50 minutes in length, one or more times per week. The number of sessions depends on the types of difficulties experienced by the client – symptomatic relief can often be achieved in a few sessions, longer and more lasting changes in negative behavior patterns might take a year or longer, and depth life issues might require several years to overcome.

Many different goals have been identified by psychotherapists, such as:

* Developing insight into problems
* Learning to communicate more effectively
* Learning to resolve both internal and interpersonal conflicts
* Managing, reducing or relieving symptoms of emotional distress
* Changing behaviors to improve social, relational or vocational functioning
* Personal growth and development
* Reconstructing a life damaged by faulty early life experiences

Many different kinds of personal and interpersonal difficulties can be relieved through psychotherapy. The pages throughout Helpguide's Mental and Emotional Health section describe many of these disorders and offer specific suggestions for identifying and treating them. For example, see Helpguide's Relationship Help: Exploring the Deeper Issues Behind Success or Failure in Love Relationships to learn how the lessons of infant bonding can be applied to helping adult love relationships.

A few general guidelines for those new to treatment with a psychotherapist:

* Some psychological symptoms may be rooted in a physical problem, such as a tumor or problem with circulation. Before or early in therapy, also see a medical doctor to rule out any organic source for the problem being experienced.
* Therapy often has an early "honeymoon" effect of symptom relief. While this seems positive, do not stop treatment before addressing the sources of the problems, or they may soon return or be replaced by other difficulties.
* Like house remodeling, taking apart things that haven't worked well in one's life often makes them seem worse before they get better. When therapy seems difficult or painful, don't give up – discuss your feelings and reactions honestly with your therapist and you will move forward rather than retreat back to your old, less effective ways.

Which type of therapy is the best?

There is no one type of therapy that is the best, any more than there is one best style of car or one best kind of food. It depends on each person's individual needs and wishes. Some specific techniques have been found to be more useful than others in dealing with certain types of problems (such as phobias), but in general, research about the "best" model of therapy always reaches the same conclusion: the most critical factor is the relationship between the therapist and the client/patient. If you feel comfortable and trusting in that relationship, the model of therapy, like your car, is just the vehicle that will help you move ahead to lead a more fulfilling life, regardless of the circumstances that bring you to seek assistance.
Types of therapy

There are many types of therapy. Generally, they all seek to help people improve their lives. How they go about that depends on their different philosophies, or "theoretical orientation". Each type of orientation involves different ideas about what causes the pain in our lives, and what will help us heal and move forward in happier and more productive ways. Some examples of the focus of different orientations would be:

* Focus more on the past – family of origin, earlier life difficulties, how the present is rooted in past experience
* Focus more on the present – regardless of the past, what is happening in the here and now, what choices are being made, whether the results are satisfactory
* Focus on thoughts and behaviors – the ways we understand or interpret things that are happening in our lives, and what actions we take
* Focus on emotions – how we feel about the things that are happening in our lives
* Focus on the body itself – how the things happening in our lives show up as stress in physical armature and physical reactions.

Some of the more well-known psychotherapy approaches are summarized here.
Psychodynamic psychotherapy

Psychodynamic psychotherapy is used to help clients understand themselves more fully. The theory behind this approach is that our past – adverse childhood experiences or other unconscious conflicts – is the basis for problems that persist into adulthood, such as unusually low self-esteem, anxiety, or a feeling of being incomplete. Psychodynamic therapy presumes that some facets of our lives are hidden from us, in the subconscious mind, and that we use defenses to help keep us from experiencing the pain that would come from acknowledging elements from our past. Psychodynamic therapy can help to recognize and look behind these protective defense mechanisms, to bring the unconscious into conscious awareness, and to uncover and deal more effectively with neurotic conflicts.

The classic form of "talking therapy" is psychoanalysis, which has evolved into several modern branches, including self-psychology, object relations psychotherapy, intersubjectivity, and psychodynamic psychotherapy. In general, they all involve such typical constructs as:

* An orientation toward the past – childhood experiences, sexual feelings, fears, jealousies, relationships with parents, etc. – as the source of problems in the present
* Traditionally, a couch for the patient to lie on, with the therapist outside of the line of sight (however, most modern therapists now use chairs and sit face to face)
* The therapist (or analyst) as a blank screen – no personal photos or objects – to allow the patient to project any thoughts or conceptions onto the therapist (this is known as "transference")
* "Free association"– letting the mind wander aloud and seeing what connections arise
* Little interaction between the analyst and patient, until the analyst offers interpretations of what the patient is experiencing, and the reasons behind certain ideas or actions (although again, modern therapists often engage in greater interaction)
* Creating a safe space (or "holding environment") that allows the client to explore depth issues with as little fear as possible
* Long-term treatment, sometimes several times per week (although modern accommodations are often more brief)

Interpersonal psychotherapy

Interpersonal psychotherapy (IPT) is an approach based on the view that our current problems are maladaptive behaviors rooted in our previous interpersonal relationships. Personality is not a focus of this type of therapy, as it usually is with psychodynamic psychotherapy. Interpersonal psychotherapy generally targets these areas:

* Interpersonal disputes or difficulties (marital, family, work, or social)
* Role transitions (adapting to changes in social or occupational roles or other life circumstances)
* Grief and loss issues
* Interpersonal deficits

IPT is a short-term, highly structured approach that has been used to treat a wide range of issues, such as depression, eating disorders, and anxiety, all with an eye to the involvement of relationships in the past and present.

Interpersonal psychotherapy is also a broad term sometimes used in reference to many approaches that involve current issues related to interpersonal factors. Some of these therapeutic modalities are:

* Humanistic
* Gestalt
* Transactional Analysis (TA)

Most of these interpersonal therapies utilize such tools as:

* Active listening
* Clarification
* Communication exercises
* Role playing
* Encouragement of expression of feelings and affect
* Use of the therapeutic relationship as a model of healthy interactions

Cognitive-behavioral therapy (CBT)

Cognitive therapy involves identifying and changing harmful or ineffective thinking patterns. Behavioral therapy helps a client to recognize certain harmful or inappropriate behaviors that may be operating automatically, without awareness, and to substitute more helpful behaviors. Cognitive-behavioral therapy (CBT) uses a combination of both cognitive and behavioral therapy. CBT explores both thinking patterns and harmful or self-destructive behaviors that might accompany them. The therapy then combines changing the thinking patterns along with changing the behavior.

Cognitive-Behavioral Therapy is also known by the names given to it by certain well-known authors, such as Albert Ellis (Rational Emotive Behavioral Therapy – REBT), or David Beck (Feeling Good: The New Mood Therapy). In general, the approach taken is that events themselves do not cause our reactions. Rather, our thoughts – the meaning we give to external events – cause our feelings and behaviors. Thus, changing our thoughts will lead to changes in the way we feel or act.

CBT utilizes many "left brain" analytical, logical approaches, using such interventions as:

* Challenging negative thinking processes, for example:
- black and white thinking (the all or nothing version of reality)
- awfulizing (catastrophic thinking, where worries spin out to the worst possible outcome)
- minimizing (the tendency to act like certain important matters are not significant)
* Thought stopping (noticing when certain self-defeating thoughts are occurring and putting a mental stop sign on them)
* Automatic Thought Record (a log in which the person notes the triggers to reactions, automatic negative thoughts that arise in response to the triggers, challenges to the truth of these thoughts, and substitutions of more positive thoughts)
* Homework assignments to practice different ways of thinking and behaving
* Checklists and measurement scales (for depression, anxiety, etc.)

Cognitive-Behavioral Therapy has been researched in many different situations, and is often the treatment preferred for such conditions as:

* Phobias (excessive fear of specific objects or situations)
* Panic attacks and panic disorder
* Repetitive habits (Obsessive Compulsive Disorder)
* Anxiety
* Depression
* Eating disorders

Other psychotherapeutic modalities

There are many other therapy models, each of which has a somewhat different philosophy and approach. Some have evolved from the needs of economic realities, in finding ways to assist people with lower cost and time commitments. Others appeal to the interests of those with more time, who want to explore the meaning of their lives but without the main focus on the past. Some of the current therapies are:

* Existential
* Humanistic
* Brief, Solution-Focused
* Narrative

There are also many types of therapy that are considered alternative or complementary, or are focused on the creative arts or body rather than the more traditional talk therapies. See Helpguide's Treatment Options for more information.
Couples, families, or groups in therapy

Psychotherapy was developed as the "talking cure" and was originally always conducted with the doctor or therapist and one patient or client. However, as the practice evolved, it became apparent that there were circumstances in which it makes sense to include others:

* Relationship matters – it is logical to include family members when issues concern others in the family
* Financial reasons – it is less costly to participate in a therapy group than individual treatment
* Reduced isolation – it is helpful to meet other people who share similar concerns
* Therapeutic time constraints – it is more efficient use of some therapists' time to meet with groups of people who have similar issues than meet with them individually

Any of the theoretical orientations described above might be adapted to working with couples, families or groups. Some of the other approaches to those settings are described below.
Marriage (relationship) counseling

All couples have conflicts or disagreements at times. The difference between a happily married (or otherwise committed) couple and an unhappy union most frequently involves the ability to discuss and resolve those differences in a positive manner that respects the interests and needs of each individual.

Common unhealthy, damaging relationship communications usually include such interactions as:

* Hostility, or verbal or physical attacks on the other person
* Put-downs, name-calling or other contempt for the partner
* Dragging old information or experiences into a current argument
* Defensive responses
* Withdrawal from a disagreement
* Escalating negativity in the relationship

If an unsatisfying love relationship is a part of your problem mix, see Helpguide's series, Relationship Help: Communication Skills to Find and Keep a Healthy Exciting Love Relationship.

Some therapists have specialized training in marriage counseling. A marriage counselor usually sees both members of the couple together, though some will occasionally also see each person individually. The goals of a marriage or relationship counselor are generally to help the couple:

* improve communication patterns
* develop empathic, active listening skills
* improve problem-solving skills
* resolve conflicts in ways that meet the needs of both partners
* explore ways for old wounds (from this or previous relationships) to be healed
* if possible, find ways to stay together in a positive and mutually satisfying relationship
* if not possible to stay together, then to separate in a healthy and respectful way

There are also some reputable weekend seminars for couples, usually conducted through religious organizations. The best known of these is Marriage Encounter, which is intended to improve relationships that are not in serious jeopardy. Many different religions provide Marriage Encounter weekend retreats. A similar program for pre-marital couples is called Engaged Encounter. For those with more difficulties, another resource is Retrouvaille ("re-discovery"), organized by the Catholic Church, but conducted without regard to the religious beliefs of participants.
Family therapy

There are also some additional approaches that have evolved specifically for family settings, such as:

* Family Systems – views families as a system in which each member plays a role that serves to sustain the balance (homeostasis), regardless of whether family members are happy with the way things are (status quo); considers that a change in any one member will cause the entire system to have to change and readjust
* Bowenian Family Therapy – looks at the generational patterns that are handed down in families; how family members often form "triangles" in their relationships by pulling others into a matter that actually concerns two people; focus in treatment is on the marital dyad, regardless of the family's view about which child or adult is the "problem"
* Structural Family Therapy – looks at the generational alliances in families; seeks to strengthen the parental dyad in its managerial role in the family; focus in treatment is the entire family, with shifts in the structure of the interactions
* Experiential – looks at the rules and roles played by family members and how family members struggle if those rules and roles are either poorly defined or inflexible; emphasis on communication patterns; treatment involves the entire family and often incorporates role playing or other drama or art

Family therapy is often the most appropriate treatment for a child with behavioral problems. It is also helpful when a family member has a serious medical problem or mental condition such as bipolar disorder or schizophrenia.
Group therapy

Group therapy refers to therapy sessions that involve a group participating, instead of one-on-one interaction with a therapist. They are different from self help or peer support groups in that there is a professional therapist as the facilitator. Group therapy may have a theme or focus (such as a women's or men's group, or one for divorcing people or recovering alcoholics) or they may be open to a variety of participants. Some groups are time-limited (participants join for a specified period), while others are open-ended. Groups generally include 6-8 people who meet at a regularly scheduled time, often for about 2 hours. Membership may be open, with people coming and going over time, or they may be closed, with a particular group who work together over a longer period, sometimes many years.
Types of mental health professionals and finding a good therapist

This is a starting place to learn about some of the types of mental health professionals. Each profession has training programs where pre-licensed individuals provide services under the supervision and training of a licensed professional. Note that a master's or doctoral degree is awarded by a college or university, while a license is granted by a state, after the candidate has earned an appropriate degree, completed a required number of clinical training hours of experience, and passed a written and/or oral examination.

How do you know which type of therapist is right for you? One of the most common ways to find a therapist is to ask friends, colleagues, or an Employee Assistance Program (EAP) for recommendations. The descriptions below provide general information on types of therapists, and each section includes links to organizations that have lists of therapists by city, specialization, training, or other useful information. Just as the theoretical training of a given person may or may not determine a good "fit" for you, the best therapist may be the one with whom you feel comfort, confidence, and trust, regardless of degree or license. You may need to talk to a few therapists on the phone or meet for a brief session with more than one before you decide where to start.
Marriage and family therapist (MFT)

Marriage and Family Therapists are psychotherapists who treat persons involved in interpersonal relationships. They are licensed to diagnose and treat mental and emotional disorders within the context of marriage, couples and family systems, as well as assist clients in achieving more adequate, satisfying and productive marriage, family, and social adjustment. The practice also includes premarital counseling, child counseling, divorce or separation counseling and other relationship counseling. Most MFTs will work with same-gender as well as heterosexual couples, though some therapists have specializations with gay couples. Marriage and Family Therapists have graduate training (a Master's or Doctoral degree) in marriage and family therapy and at least two years of clinical experience, in addition to passing a licensing exam.
Social worker (MSW or LCSW)

Clinical social workers are the largest group of professionally trained mental health care providers in the United States. Licensed Clinical Social Workers (LCSW) have a Master's degree in social work (MSW) along with additional clinical training and passage of a licensing exam. They help people function the best way they can in their environment, deal with their relationships with others, and solve personal and family problems. About 40% of social workers practice psychotherapy. Others are case managers - they are involved in coordinating a range of needed services for a client, such as psychiatric, medical, legal, or financial services. They can specialize in many fields, including gerontology, mental health, hospital administration, healthy care, schools, child welfare agencies, criminal justice, and child or adult protective services.
Other Licensed Professionals

Each state has its own licensing boards for mental health professionals, each with its own requirements for coursework, clinically supervised practice prior to licensing, and examination process. Some of the common titles include:

* Licensed Professional Counselor (LPC)
* Licensed Mental Health Counselor (LMPC)
* Licensed Clinical Professional Counselor (LPCC)
* Licensed Clinical Mental Health Counselor (LCMHC)

Although most states require a Master's degree plus experience, there is no standardization across states in regard to these counselor designations. Some states have reciprocal acceptance of licenses if a therapist moves, while others, such as California, do not recognize LPCs and require additional training and supervision before eligibility for licensing. Check with your own state licensing commissions or boards to determine what kind of background and training is required for mental health professionals in your state.
Psychiatric nurses

A psychiatric nurse has a degree in nursing and is licensed as a registered nurse (RN); s/he also has additional experience in psychiatry. Advanced practice psychiatric nurses are registered nurses prepared at the master's level as a nurse practitioner or certified nurse specialist specializing in psychiatric-mental health care. Advanced practice psychiatric nursing roles embrace a variety of functions, which can include prescriptive practice of psychotropic medications; individual, group, and family psychotherapy; crisis intervention; case management; and consultation. They also have important functions in consultation to nurses in primary care and other medical settings who serve as first points of contact for many people seeking help.
Psychologist

Psychologists usually have a doctoral degree in psychology (Ph.D. or Psy.D.), and are often licensed in Clinical Psychology. Psychologists can do assessments to help evaluate people's mental health; they also can treat problems using psychotherapy. They often focus on treating particular populations, such as children, adolescents, children or adolescents in a school setting, older adults, or people with health issues. They can also specialize in what they would like to treat, such as the diagnosis and treatment of mental disorders, or problems of adjustment or life challenges, such as choosing a career or coping with marital problems. Or, they might specialize in performing assessments, such as personality testing or neuropsychological assessment.
Psychiatrist

A psychiatrist is a physician (M.D. or D.O.) who completed psychiatric residency training after four years of medical school. Psychiatrists specialize in the diagnosis, treatment and prevention of mental illnesses and substance abuse disorders. Many psychiatrists undergo additional training for specialization in such areas as child and adolescent psychiatry, geriatric psychiatric, forensic psychiatry, psychopharmacology, and/or psychoanalysis. Because they are medical doctors, psychiatrists can prescribe medication.
Psychoanalyst

A psychoanalyst is a mental health professional with additional training in psychoanalysis. Some psychoanalysts are also medical doctors, while others are not. As a therapy, psychoanalysis is based on the observation that individuals are often unaware of many of the factors that determine their emotions and behavior. Psychoanalytic treatment demonstrates how these unconscious factors affect current relationships and patterns of behavior, traces them back to their historical origins, shows how they have changed and developed over time, and helps the individual to deal better with the realities of adult life.
Telephone and online counseling

In the era of telecommunications and computers, there are now counselors who provide services by phone or email. Online counseling should probably not be considered a substitute for psychotherapy but may be a useful adjunct for some people. The advantages of such contacts are that they:

* Are available at all hours, worldwide
* Offer assistance to those who are unable or unwilling to seek such help in person
* May be a good introduction for someone who has never sought counseling and is "testing the waters" to see how it feels to discuss personal issues
* Are usually cost-effective (often charging about $1-2.00/minute, making a full 60-minute hour less expensive than a 50-minute in-person session might be).

But there are also many drawbacks to phone or online counseling:

* It is missing the "personal" interaction that is typically part of the healing process
* It is sometimes difficult to know if the provider is legitimate
* The provider cannot use visual cues (such as your facial expression or body posture) to get a more complete sense of your reactions and interactions
* It may be more difficult to clear up misunderstandings of what was meant by something said, on either side
* Insurance companies are unlikely to cover the costs
* There may be legal or ethical issues that are not adequately addressed for either party.

If you think you are interested in online or telephone counseling, it is advisable to go through a reputable organization to find a provider. At the very least, they will have screened their participants to assure they are properly licensed, and usually also require a resumé.

posted by Robert Heard at 8:39 AM