We’re getting therapy all wrong.
The turmoil of the past three years—pandemic, lockdowns, economic uncertainty, political upheaval, and that’s just a snapshot—did a number on our collective psyches. According to the CDC, between 2019 and 2021, the number of people who received mental health treatment in the U.S. went up across every demographic, everywhere in the country. And that’s hardly everyone who might benefit—according to some research, about 45% of people with a clinical-level mental health issues do not seek professional help.
There are many reasons people reject the idea of therapy, from seeing it as a sign of weakness, to believing their problems aren’t big enough to require professional help, to a lack of available of mental health services. But a reluctance to try talk therapy can also stem from a basic misunderstanding about how therapy is practiced in the modern day.
What people get wrong about talk therapy
Many people don’t seem to understand how therapy works. When they think of it, they picture a longterm, expensive relationship with an eccentric doctor in which childhood memories and traumas are dredged up week after week, with little tangible result. But the way talk therapy is typically practiced in 2023 bears little resemblance to the “lay on the couch and tell my about your mother” cliches of the past.
About 70% of therapists in the U.S. now practice “cognitive behavioral therapy” (CBT), an evidence-based, short-term process that isn’t concerned as much with complex theories of integrating the past with the present as it is with producing tangible results.
Where talk therapy comes from
Talking through your problems with a knowledgable guide dates back at least to the philosophical dialogues of the ancient Greeks, but its modern incarnation is largely the product of Sigmund Freud. Freud’s influence was so pervasive that a bespectacled man with a vaguely European accent and a cigar is still shorthand for the process, even though Freud’s been dead since 1939.
Freudian psychoanalysis, very broadly, holds that bringing the content of the unconscious mind into conscious awareness can lead to relief from psychological distress. It generally takes a long time—decades even—and has no clear definition of success, so it’s difficult to know whether it “works” or not, except on an anecdotal level.
As psychotherapy progressed, countless other theories and approaches sprung from Freud’s ideas, and they fell into two broad categories. Cognitive approaches may ignore or downplay strictly Freudian notions like the id and super-ego, but the basic concepts are similar to psychoanalysis: Our behaviors are rooted in our thoughts and feelings, so if we understand and master those, we can change our behaviors and find relief from our psychological problems.
Behaviorism, on the other hand, broadly holds that human behaviors are due to environmental conditioning only. The unconscious, and even the mind itself, aren’t worthwhile concepts, as they can’t be observed or studied. In other words, change what you do; don’t worry about how you feel or what you think.
Squaring the circle: Cognitive Behavioral Therapy
These two seemingly disparate approaches came together in the mid 1960s in the form of cognitive behavioral therapy, which holds that psychological problems are partly based on unhelpful ways of thinking and partly based on patterns of unhelpful behavior. These ideas aren’t at odds, as each of these drivers affect the another.
The role of the therapist in CBT
In many older forms of therapy, finding the right therapist for you can be essential, as the relationship between patient and doctor is a huge part of the process. With CBT, on the other hand, this is less of a concern. Instead of a confidant or confessor, the CBT therapist acts more as an organizer or coach, working with the patient to set specific personal goals and provide a strategy for achieving them. It’s more about problem-solving than personal growth, with a focus is on achievable, concrete steps instead of abstract ideas like fulfillment or happiness. Presumably, these come from acting in healthy ways.
CBT is focused on present problems, not past trauma
CBT generally isn’t as past-focused as many other forms of therapy, so it often doesn’t involved in-depth examinations of childhood (although it can help people overcome past experiences that are affecting how they behave in the present). For example, if you’re having trouble getting to work on time, a more cognitive-leaning form of therapy might suggest you examine how your parents discipline style relates to how your feel about deadlines now. CBT, on the other hand, might suggest you use mental strategies to help get you out the door earlier in the morning—or buy a new alarm clock.
CBT isn’t purely behaviorism though. It also focuses on recognizing distortions in thinking that may be influencing patients’ actions or causing distress. For instance, if you wake up every morning thinking, “I can never get to work on time,” CBT would help you see the error in that way of thinking and give you strategies for changing it—perhaps by trying to think instead, “Of course I can get to work on time.” (It often sounds dumb, because it’s so simple.)
CBT doesn’t take forever
Where many forms of talk therapy are open-ended and can go on for years or even decades, cognitive behavioral therapy is generally short-term. The course of treatment usually takes between six and 20 sessions, usually lasting an hour or so. Ideally, by the end of that time, patients are able to act as their own therapists, and use the tools they’ve learned to better navigate the world. So you won’t become that one friend who’s been in therapy for 18 years and still can’t hold down a job.
Is cognitive behavioral therapy effective?
No one kind of therapy is right for every person or every type of mental illness. There are a lot of approaches to talk therapy. For some, psychodynamic therapy, a longer term process centered on exploring past experiences, might be the right fit. Or you could consider Eye Movement Desensitization and Reprocessing Therapy which has shown great effectiveness for treating PTSD. You could take a spiritual approach. Or consider psychedelic therapy. Maybe a strictly pharmaceutical solution is the right move—plenty of people benefit from swallowing some Wellbutrin every morning and getting on with things, or combining drugs with talk therapy. You might even be able to find a strictly Freudian psychoanalyst out there, if you want to go retro.
But CBT is a good place to start. It’s become the most widely practiced form of therapy, particularly for treating depression and anxiety, largely because there is solid evidence it is effective. Other forms of talk therapy may work, but it’s often impossible to tell because they don’t include an objective way to measure success, whereas CBT has been tested within an evidence-based framework for decades. It’s been more rigorously studied than any other form of talk therapy, in fact, and has almost always shown to be more effective than its “competition.”
An evidence-based approach also means that therapy can be refined, and with a clear standard to measure it against—approaches like ACT (Acceptance and Commitment Therapy) use many of the techniques of CBT, but focus on mindfulness and acceptance of emotions, while keeping CBT’s action-oriented approach.
While no form of therapy is universal, if you’ve never tried talk therapy, or you’ve had a bad experience with another form of therapy in the past, CBT might provide the answers you’re looking for, or at least give you some strategies on how to find them. And you don’t have to tell anyone about your mother unless you want to.
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