One of the best-known tools in mental health is talk therapy. It goes by various names: therapy, psychotherapy, counselling, analysis, and many more. As with so many aspects of mental health, you likely have an idea of what therapy entails. Yet, most people don’t know how to tell the different forms apart, how to choose between them, how they work, or how they can help.
You may have already tried therapy and found it didn’t help. Don’t skip this chapter. There are hundreds of different therapies. Some therapies are more general and can help with a wider range of problems; others are useful only in specific situations. Is therapy right for you? It depends on your problem. Someone saying that therapy will solve your mental health problem—not knowing what it is—makes no sense.
There are many types of therapies, but far more therapists. Each uses a different set of therapies, putting their unique spin on each one. Success depends on the right therapy used in the right way for the right problem. Some problems won’t respond to any therapy, while others are well suited to many forms of therapy.
In this chapter, we’ll give you a very broad overview highlighting the diversity of therapy. You’ll get a sense of what therapy can and can’t do for your mental health. We’ll also identify a few common types of therapies that have good clinical evidence to support them. More are described in Appendix B. In the process, you’ll learn some of the questions to ask as you explore what might be right for you.
In the following chapter, we’ll discuss how to find the right therapist. Therapy is less regulated and standardized than, for example, pharmaceutical treatments. Be warned that the “experts” you meet may not know what techniques would be helpful in your situation.
Gone are the days where a Freud-like psychoanalyst pensively sits back in their chair while you lay on a long couch. Ditto for interpreting ink blots. Sure, you’ll find these still used today but very rarely. Therapy today can take on all kinds of different forms:
Therapy may be delivered one on one, therapist and patient. A therapist may also work with two people (not necessarily romantically linked), a few more people (such as a family), a small group, or even quite large groups.
The therapist may be a trained mental health professional such as a psychiatrist, psychologist, clinical counsellor, or a psychiatric nurse. They may be a social worker or a religious leader. They may even be a peer in your workplace, a close family member, or an empathetic friend. In some therapeutic interactions, none of the participants has any mental health or therapy training at all. This is not uncommon in groups that follow a particular structure or set of rules. Others can be even more laissez-faire.
Therapy may occur in an office, a living room, a classroom, a community centre, a library, a yoga studio, a hospital, or a mental health clinic. It may take place over the telephone with a worker at a crisis centre, during a Skype video chat with a faraway therapist, or while alone with a workbook or an iPhone app.
Therapy may be a brief, one-time conversation, or a monthly two-hour meeting. It may be one hour a week for a couple of months, or several hours a few days a week, possibly for years. It can follow a consistent schedule and frequency or may vary with circumstances.
Counsellors, psychologists, and other providers employ many different therapy techniques. Some of these have been studied extensively and have good evidence behind them. Others have been the topic of fewer studies but are commonly used and effective. Still others may be more obscure, novel, or fringe; perhaps helpful for some people, perhaps not. In practice, most providers draw from several different techniques, choosing what they feel is appropriate given your situation. Relatively few are purists who strictly adhere to a single methodology.
As with all things mental health, there is no one-size-fits-all solution when it comes to therapy. If you’re sick and someone tells you that, “You should take something for that,” it leaves more questions than answers. Sick with what? What medicine? Prescription, over-the-counter, herbal? How will it help? Who should I get it from? Hearing “you should go talk to a therapist” should prompt similar questions. What problem needs fixing? What technique should be used? How will it help? Who should I talk to?
Any therapy you choose should help you achieve the goals described in your living treatment plan. You need to ask questions up front to see if it’s right for you and track your progress during treatment (we’ll discuss managing therapy shortly). All therapies presumably aim to make things better. You need to narrow down your choices to find the type of therapy that best fits your situation. This can be very difficult, especially on your own, so ask your doctor or others you trust for help.
There are as many ways to categorize types of therapy as there are people writing about them. We won’t abandon that tradition here. We’ll discuss four general approaches to therapy, with the goal of helping you pick which might fit your situation. The approaches are practical advice, skills and techniques, depth, and eclectic. Keep in mind these are our terms. There is always considerable overlap in any categorization.
Practical advice helps you through situations you’re facing right now.
When you’re having difficulty with a situation at home, work, or elsewhere, a therapist can help you deal with the problem and move forward. Experiencing grief due to a death in the family? Struggling to cope financially after a job loss? Overwhelmed juggling too many responsibilities? Not sure how to respond to bullying at work? Don’t know what to say to your teenager? Need help making a stressful decision about your relationship?
A therapist can help you identify the cause of your distress and what to do about it. They can help you find alternatives, pros and cons, and see things from different perspectives. They may even role-play situations with you to increase your confidence. Sometimes, talking things out with someone who is not directly involved is all you need.
Though highly trained professionals may be better at providing this support, they’re not the only ones who do. Support can also come from volunteers at a mental health support telephone line or others with mental illness in a peer support group. It can come from friends and family.
Finding better ways to deal with your current situation may even help you in the future. But that isn’t the goal. Therapy providing practical advice is all about working through struggles you’re dealing with in the present.
Is what you’re going through now a one-off situation? Focused practical advice might be just what you need. Do similar problems seem to keep cropping up for you again and again? Practical advice may get you through the current round. But, you’ll need something more if you don’t want to end up back at square one next time.
The second general category of talk therapy teaches you skills and techniques. These help you gain control of overwhelming emotions and longstanding distorted thoughts. These worsen when you have a mental illness. You learn skills and techniques to apply to a current stressor. This helps in the short term. Over time and with practice, you confidently use the skills or techniques in various situations that you later face.
In these types of therapies, the therapist or provider acts as a teacher. Given individual situations are not the focus but only serve as examples used to apply the skill, these skills and techniques can be taught to several people at once. Groups can be offered relatively affordably and are often supported by governments or other organizations. In a group, you learn from others experiencing similar problems and realize you’re not alone. Other categories of talk therapies are less suited to group delivery.
There are many different types of skills or techniques. A few prominent examples are described here:
Grounding Techniques. When you are very overwhelmed or panicked, your brain flips into a basic fight-or-flight mode. Your heart beats faster, your breathing quickens, you feel pumped up and full of adrenaline. Other parts of your brain fade deep into the background, including those that control reasoning and problem solving. Grounding techniques are simple exercises that switch your brain out of fight-or-flight mode. This, in turn, reactivates your ability to problem solve and think through your situation.
Mindfulness. Many people go through life on autopilot, jumping from one task to the next. You may be constantly distracted by things around you, other people, or notifications from your phone. Those things in themselves can increase stress. Mindfulness is a set of meditative practices that encourage you to be present and more aware of how you’re feeling. Among other benefits, mindfulness helps you lower your baseline level of stress and anxiety. You’ll likely deal with a stressful situation far better if you’re relaxed to start with, instead of almost at the point of snapping. You’ll be able to respond instead of just react. Scientific studies have shown multiple mental and physical health benefits of living mindfully.
Cognitive Behavioural Therapy (CBT). One of the most-studied therapies, CBT in its various forms is a collection of skills that help you improve emotional reactions, and change thoughts and patterns of behaviour. It teaches you questions to ask yourself when placed in a difficult situation, and methods you can use to approach and break down problems. With continued practice, automatic but unhelpful thoughts, feelings, and behaviours are gradually replaced by more constructive ones. Extensive data, including from advanced brain imaging techniques, have shown that over the long term, CBT often results in improvement comparable to medications.
Dialectical Behavioural Therapy (DBT). Intense emotion can lead to impulsive behaviour, self-harm, and substance use. DBT is a multifaceted program to help those who frequently experience such emotion. It was initially designed to treat borderline personality disorder but has been used, in whole or in part, for many other disorders including depression, PTSD, binge eating, and addiction. DBT programs interweave aspects of all three of the previous skills and techniques, plus many others.
The skills themselves are general and can be applied to many situations. The trick is learning how to apply the skill or technique to new situations you encounter (and remembering to do so). As part of learning, you work through exercises or scenarios where you try to apply the technique. With practice, doing this becomes ingrained. However, learning the skill in session and then immediately forgetting it won’t be of much help.
We’re calling the third category of talk therapies depth therapies. They help you develop a better understanding of yourself, based on past events and experiences. You learn how your past has influenced your current thoughts and behaviours. With this new self-knowledge, you construct a new and healthier approach to future events and circumstances.
In depth therapies, a therapist helps you identify and process past events and themes that make up your current psyche. They then help you build up a new foundation. This is what most people initially think of when you mention therapy (couches, cigars, and similar clichés optional). Depth therapies are very much geared toward improving your future situation. Digging into your past usually leaves you feeling worse before you feel better.
Psychoanalysis, as exemplified by people such as Freud and Jung, started in the late 1800s. It has branched into many, many approaches and schools of thought. Today, there are huge variations, some of which have been well studied. Thankfully, many modern forms are also far less time-intensive. They are practiced almost exclusively one on one, are generally not amenable to groups, and do not aim to provide practical advice.
The final category of talk therapy is eclectic therapy. This category is a mix of the previous three categories. Therapists who don’t focus exclusively on a particular type of therapy often practice some form of eclectic therapy. They mix techniques to meet your needs, and share some common characteristics:
The tone of the therapy is generally positive. Therapists encourage you and help build your confidence. You achieve this through quick, identifiable progress with current problems and stressors.
They take into account key events and broad themes from your past. They don’t delve as far as depth therapies, so are less time-consuming. Therapists may use techniques such as short-term psychodynamic therapy to capture and frame themes. They help you gain insight into why you think and act the way you do.
After identifying particular problems or behaviours, you can be taught specific skills and techniques such as mindfulness or CBT to address them. Eclectic therapies help clients identify and replace unhealthy coping strategies with healthier behaviours.
They do not follow a strict formula or lesson plan like in CBT.
You may have a sense of which of the four approaches is right for you. How do you know what specific therapy to choose? While some therapies are specific to an illness such as trauma, many others, such as CBT, can be applied to a broad range of illnesses. If someone suggests that a certain therapy technique is best for you, how do you know if that’s true?
One starting point is asking what therapies are recommended in the clinical guidelines for your illness. Clinical guidelines are broad-based consensus documents that gather and evaluate the evidence for various treatments of a particular illness.
As an example, for psychological treatment of acute major depressive disorder, the 2016 CANMAT1 guidelines recommend the following:
First line (most evidence for effectiveness):
Second line:
Third line:
Most reputable therapists should be able to point you toward relevant clinical guidelines or describe how the treatments they offer fit within those guidelines. It never hurts to ask someone else, such as your family doctor, if the guidelines and the suggested therapy seem legitimate.
You’ll find sources to locate guidelines in Appendix A, and brief descriptions of many common therapies in Appendix B.
Talk therapy can be time-consuming and costly. Some people continue in therapy for years on end, with no real improvement. Even if you’re working with a skilled therapist, you still want to make sure what you’re doing is actually helping.
Managing talk therapy goes back to your living treatment plan. After all, talk therapy is one of several types of interventions to treat your symptoms and accomplish your goals. You may make great progress in therapy. But does it improve your life in the ways that you’ve identified as important? When deciding to pursue therapy, make sure to answer some key questions:
What do you hope to achieve from this therapy? What are your goals? How will it improve your current situation? Your ongoing mental health symptoms? How will you know whether it is working?
What should you expect if you pursue this therapy? What happens during sessions? What about between sessions? How long would it likely take to see changes? How big would any improvement be? Do these fit with your overall treatment goals?
Can you get the most from this therapy at this point? If learning skills and techniques, are you having concentration problems? If delving into your past, do you have the emotional strength required, or will it just cause you to panic? If not, what else could you do first to prepare?
Is a good, well-qualified therapist for this type of therapy available? Affordable? A good fit for your particular needs and situation?
What other treatment options are available to you? Is pursuing this therapy the best option at this time? Can other treatments be pursued at the same time?
Working with a therapist will often span many sessions, over weeks, months, or even years. Identify specific evaluation points. At those times, measure your progress against your goals, expectations, and symptoms. Discuss your progress with your therapist. Don’t continue indefinitely with a therapist who no longer meets your needs.
As always, share your treatment plan with your therapist as well as all your other treatment providers. You want everyone to understand your overall goals and how their piece fits into the complete picture.
There are hundreds of different types of therapies. They can be delivered individually or in a group, and provided by a range of professionals or none at all.
We categorize therapies as offering practical advice for current problems, teaching skills or techniques, and depth therapies that explore issues from your past. Most therapists combine these into an eclectic mix to suit their clients.
Clinical guidelines help identify a set of therapies to consider for a particular illness. Some therapies are more generally applied than others.
Therapy should be managed in the context of your living treatment plan. What are your goals? How and when will you evaluate your progress?
The Canadian Network for Mood and Anxiety Treatments publish a variety of treatment guidelines, as well as other research.
https://canmat.org↩
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