The Shrink Rap

Therapy 101: Twin Cities therapists talk about what to
expect from your time on the couch
by Jennifer Franklin

Exactly what happens in a therapist's office? Years of navel-gazing introspection on a couch, like Woody Allen in Annie Hall? A quick-as-wink diagnosis from a wittier-than-thou psychiatrist like TV's favorite shrink-jock, Frasier Crane? Or a groovy, avant-garde therapist who's crazier than his patients, á la Ally McBeal?

None of the above, actually.

While therapists can't magically make your problems disappear in one session - in real life, unlike television, it takes time for a therapist to get to know you and to put an effective treatment plan together - very few will suggest that you spend decades in therapy, either. The trend is toward therapy that helps effect fairly immediate change and improvement. And guess what? The success of the results is up to you. Patient, heal thyself - sort of.

How long will this take?

There's an old joke about therapy: How many psychiatrists does it take to change a light bulb? Only one, but the light bulb really has to want to change. The joke refers to patients who used to spend years, even decades, with a Freudian psychoanalyst, peering into their subconscious and substantially remolding their personalities.

Today, although some patients look to therapy to make sweeping changes, most expect therapy to focus on particular, finite emotional symptoms that hinder their daily lives. Weight loss, mood swings, insomnia, and frustration, for example, can actually be common signals of deeper issues such as anxiety, depression, and relationship conflicts. To alleviate the symptoms, plus work to resolve the root causes, therapy usually includes a combination of behavioral-action-changing and cognitive-thought-changing techniques.

Combining these techniques helps therapists demonstrate tangible, quantifiable results to both the patient and the managed care provider. Since the coverage offered by managed care and insurance providers is usually limited to somewhere between 10 and 30 sessions, therapists are conscious of how quickly results need to occur. It is easier for a therapist to prove short term therapy results - that a client is less worried, sleeps better, or is able to overcome a phobia - than it is to describe the results of long-term therapy: major, positive shifts in personality issues.

"I believe most people are not looking to change their personality," says Glenn Hirsch, Ph.D., assistant director of the University of Minnesota Counseling and Consulting Service. "There isn't a lot of long-term psychotherapy being done. Insurance isn't paying for it. However, research shows that a combination of medication and cognitive/behavioral therapy has a very good outcome. People find it very effective. Cognitive/behavioral therapy looks at more immediate concerns."

On the other hand, for people who have the time, money and inclination, long-term therapy has the potential to yield amazing transformations. Some troubling symptoms and phobias can signal more serious, underlying problems that may have started early in life and may be lingering in the unconscious. Therapists can treat symptoms in the short term, but many say that new problems will crop up as others get resolved because the root cause has not been addressed.

"Depression or anxiety are really just symptoms of other things going on internally," says Colin Hollidge, Ph.D., a clinical psychologist and licensed social worker in private practice at The Aslan Institute in Eagan. "I see insight therapy (often requiring long-term therapy) as an opportunity to really start heading down the road to personal growth. I see people for brief periods of time, but that's really only time enough to work on one symptom, such as why are they avoiding intimacy with their partner, or why are they thinking very critically of themselves. Often people have tried already to alleviate symptoms, but the underlying issue keeps popping up. They need to really want to look inside and explore. But to really organize your internal world differently, that is a longer journey."

And a journey that most insurance and managed care providers are unwilling to pay for you to take.

How does therapy work?

A good therapist will want to try to get a good understanding of where you are mentally- and will ask about your physical health, as well. Some therapists use diagnostic tools, such as the Minnesota Multiphasic Personality Inventory or the Meyers-Briggs Type Indicator, in addition to talking with the client.

"Assessment is very important," says Mary Ellen Jaehne, clinical associate director at the Hamm Clinic in St. Paul. "You have to know going into [therapy] what will be the best course of action. We look at each situation differently. Two people who have the same symptoms might need different kinds of therapy."

"An evaluation might take time," says Jim Ayers, Ph.D., clinic director of the Walk-In Counseling Center in South Minneapolis. "But that's what you need to individualized the therapy. It's not a cookie-cutter approach."

Therapists assert that the most important component in any therapy is often the relationship between the therapist and the client. By forming a trusting bond with another person, clients are able to work on their problems, correct old patterns and change the course of their personal history.

Forming a new, healthy relationship can be so transformational, some therapists say, that it can actually change the neurons in your brain. "The brain develops chemically and our biochemistry can change with our relationships, and how we think about ourselves," says Hollidge. "Experiencing a new kind of relationship can actually change your brain's soft wiring."

"The relationship between the therapist and the client is a major factor in how successful the treatment is," agrees Steve Sandage, Ph.D., a licensed psychologist with Nystrom & Associates in New Brighton. "We all have mental scripts as to how we think relationships are supposed to go, and it is through the relationship with the therapist that we can begin to change those scripts. People have a change in relational experience."

Creating a new way to relate to others could happen on your own, but it's likely to be a hit-or-miss, trial-and-error process. Experimenting with new ways of communicating and behaving is generally more successful with the guidance of a therapist who is trained to listen and doesn't bring his or her own baggage and personal issues to the table.

"The therapist is removed from your personal life," says Ayers. "Most of the people you would talk to about your intimate thoughts and feelings are the very people involved in the problem." They can't be objective, and they can't always help, he says. "What we're finding more and more is that the therapeutic relationship itself is curative," says Hollidge. "And relationships take time to develop."

What about medication?

In the past few decades, great strides forward have been made in understanding how the brain's biochemistry affects mood and perception. Fifty years ago, psychoactive medicines and treatments were prescribed mostly for acute illnesses, such as schizophrenia and manic depression, and carried harsh side effects. Today, many new medicines are being developed for depression, anxiety, obsessive-compulsive disorder, and other non-acute problems. These new medications have milder side effects than predecessors and can produce dramatic results when used in conjunction with talk therapy, say mental health professionals.

Sometimes clients can benefit from taking an antidepressant or an anti-anxiety medication, for example, so that they are better able to focus on the issues that therapy addresses. "There's a point where [a patient has] a biochemical sensitivity such that talk alone is not enough," says Ayers.

"Biology and therapy work hand in hand," says Dr. Charles Schulz, head of the Psychiatry Department at the University of Minnesota Medical School. Medication, says Schulz, can help patients get better enough to have more effective results with therapy. Neither works as well alone, he says. "I tell the [medical students] that if medications were that good by themselves, we'd just mail them to patients. On the other hand, talk therapy alone with a major depression or bipolar disorder is not nearly as effective."

What should I do, Doc?

One word of advice: Don't expect any. People often want advice from their therapist, but no good therapist will give it. The therapist's purpose is to help a client gain insight, not to tell a client what to do.

"Often people ask me for advice, and of course that's not what they need," says Hollidge. "You're going to learn a lot more about yourself in relationship with me than anything I can tell you."

What your therapist will do is work with you to establish a plan of action for you to take in your life, and the two of you will revisit it from time to time to see how you feel you're progressing.

"I help clients establish goals at the beginning of our work together," says Hirsch. "Therapy won't be effective if it's simply my agenda. My approach is to evaluate together every five to 10 sessions and look at how it's working. And I encourage my clients to be direct with me if they feel it's not working."

Finding a therapist

"Talk is about listening," says Ayers. The [therapist] ought to be a very attentive listener. People have a sense of when they're connected, a sense of feeling "I can talk to this person."

Start out by asking some questions. Although it may feel awkward, you should feel free to ask therapists about their training and credentials, their theoretical orientation toward therapy, what they feel is a reasonable time frame for your therapy, and what they expect to accomplish.

"For people considering therapy, I tell them to try to feel comfortable asking questions or even interviewing the therapist," says Sandage. "I know it's difficult, but if they feel the freedom or confidence to do that, it's a good start. Clients who work with the therapist right away to help set the tone and agenda of their therapy seem to have greater success."

Paying for therapy

Mental health has been making the news lately in more ways than one. Minnesota's senior senator, Paul Wellstone, is co-sponsor of the Mental Health Parity bill in Congress, which aims to make insurers cover mental health treatment the same as they cover physical health treatment.

Minnesota has had mental health parity laws since the late 1980s that managed care professionals say are already stringent. "People shouldn't underestimate the coverage [already] available to them, and at reasonable rates," says Dr. Elliot R. Phillips, medical director for behavioral health at Medica. Phillips says a treatment method such as cognitive/behavioral therapy is more likely to be paid for by insurance companies and managed care organizations because it yields greater measurable evidence that it is actually helping a patient improve. The vast majority of therapy clients are greatly improved in 25 or fewer sessions, says Phillips, and that is money well spent. "If a person doesn't see someone [for help] and has a crisis situation and goes into an inpatient faculty for even one night's stay, it's more expensive than if they had just gotten outpatient treatment," he says.

Longer-term therapy that may last months or years, however, is a self-pay proposition in the eyes of almost all insurance companies and managed care organizations, "We won't pay for enrichment, just as we won't pay for a membership to a health club on the physical side," says Phillips. "If you feel fine, but want to feel better, you'll have to pay for it."

"You develop ways of coping that don't really help," says Steve Sandage, Ph.D., a licensed psychologist.  "The longer you organize your life around maladaptive coping skills, the harder it is to undue."

Am I cured?

Mental health professionals often see people make dramatic changes for the better during therapy. But, warns Ayers, don't expect your problems to be solved over night.

"Sometimes people try to make too many changes too quickly and they get hopeless and discouraged," he says.

"We do see movement from here to there," says Jaehne. "The whole goal is for the person to see improvement in their lives. Their symptoms improve, their mood improves, they gain new insight." 

That's Life

Should you hang in there and be philosophical about that bad day (week, month, year...), or would therapy help?

Seeking therapy doesn't mean you're crazy - in fact, it likely means just the opposite. "It's the healthiest people who walk through our doors," says Cathy Plessner, associate director of operations at the Hamm Clinic in St. Paul.

If you think you may benefit from talking to a mental health professional, that's one good sign that you probably ought to try. Many of the classic signs that you might need therapy are easy to dismiss or to confuse with other sorts of problems. Symptoms such as overeating, insomnia, anxiety, or fighting with your spouse are things almost everyone experiences from time to time. However, say mental health professionals, if you find that symptoms linger, or that your work or personal relationships are suffering, it could be time to see a professional.

People often try to resolve personal problems themselves. But this can actually cause bigger problems. "People have really creative attempts to repair what is going wrong in their lives," says Colin Hollidge, Ph.D., a licensed social worker in Eagan. "They self-medicate or avoid relationship. These are ways that they adapt to what's bothering them."

"You develop ways of coping that don't really help," says Steve Sandage, Ph.D., a licensed psychologist.  "The longer you organize your life around maladaptive coping skills, the harder it is to undue."

"If you find yourself having a real sense of distress, if you're asking how much is too much, then I'd say it's time to go talk to someone," says Glenn Hirsch, Ph.D., assistant director of the University of Minnesota Counseling and Consulting Service.

Signs That Therapy Might be of Help to You:

• Significant weight gain or weight loss
• Feeling sad and hopeless for weeks or even months on end
• Extreme feelings of happiness, sadness, or anger, or sweeping mood swings
• Insomnia or excessive sleeping
• Problems at work: truancy, low productivity, inability to concentrate, not getting along with co-workers
• Problems in personal relationships: fighting with your spouse, yelling at your children, sexual problems
• Becoming isolated: not going out with friends, not wanting to leave the house or get out of bed
• Suicidal thoughts
• Being physically, emotionally, and/or sexually abused or abusive
• Self-medicating: using drugs, alcohol, gambling, sex, or other behaviors inappropriately
• Not getting pleasure out of things you usually enjoy, like time with family and friends, work, recreation, food, and sex
• An increasing sense that you are unable to manage your fears, anxieties, frustrations, or sadness
• A feeling that you just aren't able to cope