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Are You Truly Getting “Therapy”?


therapy versus counseling

Mental health is a hot topic and people are much more familiar with psychology concepts and open to seeking therapy than they may have been in the past. I find, however, that there are still many misconceptions about therapy that get in the way of people being able to live their best lives.

 

Among adults, many people will say that they are “in therapy” but as they describe it, I get the sense that they are not having the experience that I would expect. Often, I meet children who have been in play therapy for a year, but their parents are questioning whether they made much progress during that time.

 

I’m going to make a distinction here between two different approaches:

 

Supportive Counseling

 

Supportive counseling is appropriate for people who need support through a life stressor: normal grieving, divorce (for the adult or child), roommate disputes, problems with a family member, etc. The job of the therapist is to listen, display empathy and validation, reflect back what the client says, and maybe provide some basic advice or coping skills. This approach is often based on the work of Carl Rogers. In research, supportive counseling or “treatment as usual” would be used as the control group compared to more “active” treatments.

 

Psychotherapy

 

Psychotherapy is based on a particular theory of human behavior. Cognitive-behavioral and psychodynamic therapies are the most common approaches. The intent is to treat a mental health condition/diagnosis or problem area (such as social skills, pain, or relationship issues). Psychotherapy will often have a foundation of supportive counseling but adds to it by teaching certain skills or using therapeutic approaches proven to be helpful for particular problems. Within psychotherapy, there are treatments that have been found through research to be more effective (AKA, they work better) than others, and we would call these empirically supported treatments (ESTs). Using ESTs, the therapist should provide evidence-based care, which means they select the best treatment considering the research, the patient’s unique cultural variables, and their own clinical judgment. My Ph.D. is in Clinical Psychology and the “psychotherapy” approach is in line with my work.

 

Based on these categorizations, so far, nothing is wrong. There are two distinct approaches to supporting human beings with their emotional health. The problem is when there is a mismatch between the needs of the patient/client and the approach of the provider/therapist.

 

Let’s say we have a young adult, Olivia, who has been restricting her eating. She has lost a few pounds and spends a lot of her day counting calories, looking in the mirror to judge her appearance, and weighing herself.

 

Olivia does not want to admit this, but she starts to be scared that she has an eating disorder and decides to begin therapy. She calls her insurance to ask who is covered and she conveniently finds a therapist down the street from her apartment. As she Googles the therapist’s profile, she is thrilled to see that she is also a young adult and that they both love cats.

 

Olivia begins therapy. She loves getting a space to talk about her life and her past. She often finds that she and her therapist have conversations like they are truly friends. Her therapist has advised that Olivia tell herself positive affirmations such as “I am powerful” every morning in the mirror. Olivia loves this time in the morning, and it is convenient because she needs to check herself anyway for signs of fat on her stomach.

 

Six months into therapy, Olivia is so happy to have such a strong connection with her therapist, but she continues to lose weight. She is spending more and more time checking herself in the mirror, researching new diets, and running on her treadmill. Olivia works from home and she is getting so distracted by her eating and body-related behaviors that she often does not complete her job tasks for the day. One day, Olivia faints, and she realizes that things might be worse than she has been willing to admit.

 

The problem here is that Olivia needs psychotherapy but she is receiving supportive counseling.

 

Olivia’s counseling is not designed to treat her complex symptoms, which are impacting her physical health and work. In this example, Olivia may have anorexia nervosa, and top priority should be placed on regaining weight and decreasing behaviors that are interfering with this. An appropriate treatment might be the Maudsley approach, CBT-E, or another evidence-based therapy for eating disorders.

 

Like Olivia, I have found that many people have mental health conditions that require treatment through psychotherapy but they are actually in supportive counseling. And why would they know the difference? This is complex stuff that most people and even medical providers often do not understand. We certainly don’t expect people to perfectly diagnose themselves before entering treatment.

 

For someone who might be questioning whether they are in supportive counseling or psychotherapy, I would recommend a quick Google search (don’t get stuck on this!) to help identify the problem area. Is it depression or relationship problems or OCD or seeking a diagnosis of autism? This makes a big difference in terms of the type of treatment and provider that will be necessary.

 

For adults, APA Division 12 hosts a directory of all of the evidence-based therapies for specific mental health conditions. For children, APA Division 53 hosts a similar directory.

 

For example, let’s say a parent is concerned that their child has Obsessive-Compulsive Disorder (OCD) and they have been in counseling for a year with no improvement. They would find that the treatment with the most effectiveness for OCD is called Exposure and Response Prevention (ERP), a type of cognitive-behavioral therapy. Then, they could ask their current counselor if the approach they are using is ERP. If it is not and the provider is not at all familiar with OCD, hopefully through their Googling, the parent would encounter the International OCD Foundation (IOCDF), which has a lot of quality information and a directory of therapists who provide ERP. They could consult with this professional to see if psychotherapy is recommended.

 

I’m putting myself at risk of all the online trolling for this post. Some might argue on the semantics or fundamentally disagree with my categorization, calling me biased. I can see the comments now (“You’re an elitist psychologist!”).

 

I am willing to risk this because, in my opinion, these are incredibly important differences that can keep people stuck in suffering and potentially be life or death. My passion is helping people find treatment that can be absolutely life-changing! Recovering from a mental health condition can lead to amazing things people may not have thought even possible while in the middle of their distress. As a therapist, I am so humbled when I am able to see someone’s (or a whole family’s) journey from despair to joy. It is possible to heal and grow in ways someone might have never expected.

 

I hope you find this article helpful and I will continue to post content to help navigate the very confusing mental health care system!


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