It's hard to imagine that less than a century ago, the "talking cure" — alleviating physical and emotional pain through talking — was a revolutionary idea. Now, with images of men in white coats and patients on couches stuck in our minds by Hollywood, psychotherapy has become a fixture of popular culture. But what exactly is psychotherapy and how is it used to treat mental illness?
Psychotherapy is a technical term defined in the mental health field as "any form of communication between a psychotherapist and a patient which involves a relationship between them for the purpose of remedying whatever disturbance, physical or psychic the patient brings for treatment." [Source: Nicholi] There are a variety of different kinds of psychotherapies which differ in intensity and duration. Three of the most common classifications are: individual, group, and pharmacological (drug). Different types of individual therapies include: psychoanalytical, behavioral, cognitive, and cognitive-behavioral. Differing types of group therapies include family therapy and psychodrama. And, quite recently, the types of pharmacological or drug treatments available to treat mental illnesses have resulted in four different classifications: antipsychotic agents, antimanic or mood-stabilizing agents, antidepressants, and antianxiety agents.
In order to better understand individual therapy, recall the popular image of the white-coated psychiatrist who was puffing his cigar and saying to his patient, "Well, tell me more about why you think your mother did that?" or "How did you feel?" Though these images were often exaggerated for comic purposes, there is some truth in this portrayal. Individual psychotherapy is most often associated with "psychodynamic" psychotherapy. Psychodynamic is an umbrella term for therapies which include psychoanalytical, cognitive, behavioral and cognitive-behavioral therapies. The founder of psychoanalytical therapy was the Viennese physician Sigmund Freud. The two main principles behind psychoanalysis are that [Source: Nicholi] we all have unconscious thoughts and when our unconscious and conscious thoughts are in conflict, emotional problems can result and, [Source: Gorman] early childhood experiences are critical in shaping our personalities, our unconscious thoughts, our emotions and our behaviors. [Source: Gorman]
Thus, the basic principle behind psychoanalysis is to make conscious what is unconscious through "free-association" therapy sessions. Particularly in psychoanalytical therapy, patients are asked to say whatever pops into their minds, which may also include dream interpretations. Psychoanalysis is most effective for treating personality disorders, neuroses and depression.
Behavioral, cognitive and cognitive behavioral therapies are more practically-oriented, individualized treatments for mental illnesses. Compared to the traditional psychoanalytical therapy, sessions are often much shorter in duration and focus on the present and the conscious. The main objective of the therapist is to help the patient identify faulty adaptations and change these adaptations through repeated behavioral changes. For example, in the treatment of the fear of heights, the patient must gradually climb a stair each day to become desensitized to her fear. Negative and positive reinforcements are often used in behavioral therapies.
The premise of cognitive therapy is that patients have negative thoughts throughout the day, which leads to unwanted behaviors and feelings. This habitual negative thinking must be altered in order for the patient to get well. First, the cognitive therapist helps the patient become aware of the negative thoughts and the habit of thinking this way and then he or she is asked to replace these thoughts with more positive, reinforcing feelings or behaviors. Gradually the patient is able to stop his or her negative pattern of thinking and use positive imagery to feel better. Cognitive therapists typically treat mild depression, anxiety and eating disorders.
Cognitive-behavioral therapy is exactly as it sounds. It is the combination of identifying negative thoughts and processes, as well as modifying negative feelings and behaviors. Cognitive-behaviorists believe that what has been learned can be unlearned. The cognitive-behavioral therapist will be very specific about what the problems are and provide specific homework assignments for the patient to practice in order to overcome ways of thinking and behaving. Cognitive behaviorists treat mild depression, anxiety, eating disorders, specific phobias (e.g., claustrophobia) and sexual disorders (e.g., premature ejaculation).
Choosing a Mental Health Provider
In choosing the right psychiatrist, psychotherapist or social worker, there are many avenues to pursue. Though many of us may feel scared or uncertain, one of the best ways to find a good mental health provider is to ask a trusted friend, relative or your family doctor. Other resources also include seeking a patient advocacy group (such as the National Alliance for the Mentally Ill), asking for referrals from an employee-assistance program, or calling a local medical school.
At the first meeting, the mental health provider should be clearly interested in your problem and not be distracted by phone calls, e-mails, etc. You are paying for his or her time and it should be entirely focused on you. During the first visit you will usually receive a diagnostic evaluation which includes questions such as: How long have you felt this way? Has your ability to sleep, eat, concentrate, work, etc. been affected? Have you ever considered suicide? Many mental health professionals will often diagnose you by using criteria outlined in the Diagnostic and Statistical Manual (DSM) by the American Psychiatric Association. By the end of the first session you should ask your therapist to provide you with a summary of the diagnostic evaluation and what type of therapy he or she would suggest. The key is to feel that you trust your therapist and that you can build a relationship working together to overcome your problems.
Group therapy, like individual psychotherapy, is intended to help people who would like to improve their ability to cope with problems in their lives. However, instead of a one-on-one meeting with a mental health professional, group therapy involves several individuals (usually six to eight) and a therapist or facilitator. The aim of group psychotherapy is to help solve emotional difficulties and to encourage the personal development of the participants in the group. One of the advantages of group therapy over individual therapy is that patients are able to develop more effective ways of relating interpersonally with others and to share their experiences with more than one person.
Group therapy also gives individuals a sense of hope and universality. The realization that one is not alone in dealing with the emotional upheavals of binge eating and then vomiting can be a relief for many eating disorder patients. Seeing those in the group who have learned to cope with their problems also provides hope and encouragement for participants. In addition, group therapy provides a means of getting direct advice from a "peer" or group member. Some people find that this is less threatening and more practical. By engaging in group therapy, many participants also develop socializing techniques by imitating behaviors of other group members which may help them better deal with their own, individual problems. Knowing that one belongs to a group or social network can be a powerful, confidence-building characteristic and offers the type of group togetherness that cannot be found in individual treatments.
There are different types of group therapy which include family therapy and psychodrama. Family therapy is usually used in the treatment of children, adolescents or young adults and is used when a patient's difficulties come from disturbed relationships within their family. Psychodrama is a form of group therapy originated by J.L. Moreno in which patients act out roles and characterizations in dramatic form on a stage. It encourages patients to communicate inner tensions, conflicts and feelings. [Source: Nicholi]
When choosing a group psychotherapist, look for a well-trained, reliable and ethnical professional. Reputable group therapists usually belong to professional associations such as the American Group Psychotherapy Association (AGPA). An experienced group therapist will interview you before you enter the group and will answer your questions about the process. Ask how many years of experience the therapist has and most importantly trust your instincts.
The third, and probably most common type of therapy is pharmacological or drug therapy. Millions of people are prescribed Prozac each year, with many citing the drug as a "miracle cure" for mild to severe depression. What exactly are the drugs available to treat mental illnesses? To understand how psychiatric drugs became so popular, it is useful to review their recent history. Many in field of mental health refer to the 1960s as a the era of a "drug revolution" in psychiatry. Before the 1960s, "talk therapy" was often the only mode of treatment. Barbiturates were often used for anxiety and very depressed patients were given shock treatments. By the early 1970s, however, four major classifications of psychiatric drugs were being prescribed in record numbers: antipsychotic agents, antimanic or mood-stabilizing agents, antidepressants, and antianxiety agents. [Source: Gorman]
Types of Psychiatric Drug Therapy
Types of Psychiatric Drug Therapy
- Antipsychotic agents treat psychosis and schizophrenia and include brands such as Thorazine, Risperdal and Haldol. Side effects of antipsychotic drugs can include low blood pressure, weight gain, constipation, dry mouth and blurry vision
- Antimanic or mood-stabilizing drugs are used to treat bipolar mood disorder, mainly manic-depression. Perhaps the most famous antimanic medication is lithium. Side effects of antimanic drugs can include weight gain, tremors, increased urination, and decreased thyroid function.
- Antidepressants. There are three types: (1) Tricyclic (examples: Elavil, Tofranil), (2) Monoamine oxidase(MAO) inhibitors (examples Nardil) and (3) Serotonin reuptake blockers (examples: Prozac, Zoloft and Paxil. Antidepressant side effects can include dry mouth, constipation, dizziness, weight gain, sexual problems and insomnia.
- Anxiety Disorders. The two types of drugs used to treat these conditions include (1) Benzodiazepines (examples: Valium, Xanax, Ativan) and (2) Non-benzodiazepines (example: BuSpar). Side effects of antianxiety drugs can include sedation and physical dependency.
If you are consulting a psychiatrist for drug therapy make sure you know your medical history in detail. Let him or her know of the medications you are currently taking and have taken in the past. It is also helpful to let the psychiatrist know your habits such as smoking, alcohol, exercise and diet. Some medications can be dangerous if combined. During the second visit tell the psychiatrist about any side effects or problems. Dose adjustments may be needed. During the next few weeks, keep in touch with your physician by phone and write down any side effects. Most psychiatric medications take from two to six weeks to become effective and the one month mark is a good time to reassess how you feel. Open communication with your doctor about your medications will enable him or her to help you find the most effective treatment.
The key to understanding which therapy is most effective for you is to realize which type of treatment you are most comfortable with. If you find that you are continually bombarded with negative thoughts throughout the day, which result in negative and sour moods throughout the week, perhaps individual cognitive therapy would be the best form of treatment. If, however, you are diagnosed with manic-depression, a severe type of disorder that requires medication, then medication may help quiet your manic thoughts and hallucinations. Whatever treatment you choose, realize that finding help either through one-on-one, group or pharmacological intervention will help you to achieve a better quality of life.
- Nicholi A, editor. The Harvard Guide to Psychiatry. Cambridge (MA): Belknap Press of Harvard University Press; 1999, p.415.
- Gorman J. The Essential Guide to Mental Health. New York: St. Martin's Griffin; 1996, p. 45.
ABOUT THE AUTHOR
Dr. Grace Tsai received her doctorate from the Johns Hopkins School of Public Health with an emphasis on Social and Behavioral Sciences. She investigated mental health issues in Asian and Asian American communities for her doctoral dissertation. She has served as a Psychiatric Epidemiologist in the Department of Mental Hygiene at Johns Hopkins. Dr. Tsai has also researched other mental health topics such as depression and suicide. She writes on mental health issues for various health organizations.