I'm exploring versions of therapy other than traditional in-person therapy because there are barriers that prevent people from receiving traditional in-person therapy as a treatment for their mental illness:
Therapy is expensive.
There's a shortage of therapists.
In a previous article, we proposed solutions to these problems for traditional in-person therapy.
My hope is that there are different versions of therapy (other than traditional in-person therapy) that might be able to avoid these problems altogether.
The ultimate goal is to make sure that all U.S. adults with a mental illness have access to effective mental health care.
In this article, we define psychotherapy and attempt to isolate the main elements that make traditional in-office psychotherapy an effective treatment for mental illness.
This will serve as a jumping-off point to determine if different versions of therapy can be effective insofar as they include the main elements of traditional in-office psychotherapy that make it effective.
What is psychotherapy?
"Psychotherapy is a collaborative treatment based on the relationship between an individual and a psychologist. A psychologist provides a supportive environment that allows patients to talk openly with someone who is objective, neutral, and nonjudgmental. Most therapy focuses on individuals, although psychotherapists also work with couples, families, and groups."
"Psychotherapy, or talk therapy, is a way to help people with a broad variety of mental illnesses and emotional difficulties. Psychotherapy can help eliminate or control troubling symptoms so a person can function better and can increase well-being and healing."
"Psychotherapy (sometimes called “talk therapy”) is a term for a variety of treatment techniques that aim to help a person identify and change troubling emotions, thoughts, and behavior. Most psychotherapy takes place with a licensed, trained mental health professional and a patient meeting one-on-one or with other patients in a group setting."
"Psychotherapy, also called talk therapy or usually just "therapy," is a form of treatment aimed at relieving emotional distress and mental health problems. Provided by any of a variety of trained professionals—psychiatrists, psychologists, social workers, or licensed counselors—it involves examining and gaining insight into life choices and difficulties faced by individuals, couples, or families."
"Therapy (or psychotherapy, sometimes called talk therapy) is the process of working with a licensed therapist or counselor to develop positive thinking and coping skills to treat specific mental health conditions like depression or anxiety, trauma, or simply the daily human challenges we all face."
What does a therapist actually do?
Lori Gottlieb, a psychotherapist and author of Maybe You Should Talk to Someone, was interviewed for a Berkeley magazine article.
The interviewer asked, "You write a lot about listening to what’s not being said and slowing down the process in the therapy room. Why is that important?"
And this was Gottlieb's answer:
"We don’t get enough of that in the outside world—to just have someone listen to us. So, when people think about what therapists do, it sometimes seems like a superhuman feat.
Or course, therapists are not just listening. There are so many misconceptions about therapy that I was trying to get rid of in this book; one of them is that a therapist is just going to listen to you and then you leave. That’s not true—it’s a very active process. We’re making eye contact; we’re letting silences breathe. We’re letting people pause, so they can hear themselves think and let themselves feel—something people normally cover up with words or a phone or a screen. The relationship between the therapist and the client is an extremely rich, emotional experience."
The interviewer also asked, "Many people think of therapists as akin to medical doctors—people who diagnose and offer advice. But your book speaks to the importance of listening more and letting people struggle to find their own answers. Why that approach?"
Gottlieb's answer:
"We all have answers within ourselves, but sometimes we need a guide to help us find them. That’s what the best therapy does: It gives you agency over your own life. So many times, people come in and they say, 'Tell me what to do.' And that’s not very helpful, because we want to help you learn to trust yourself, to understand why some of the choices you’ve made before haven’t worked out the way you wanted them to. What are your blind spots? What are the ways you keep shooting yourself in the foot?
So many times, people will make choices that basically guarantee their unhappiness. And they don’t see that they’re doing that. So, they feel like they can’t make decisions for themselves. But what they need is someone to help them see themselves more clearly so that they can make better decisions."
Talkspace, a company that offers online therapy via messaging, phone, and video, asked therapists what they do. These were their answers:
“A therapist serves as an authentic, genuine, empathic individual who is unbiased, supportive, and, can provide objective, nonjudgemental guidance, assisting clients with desired changes as well as achieving their maximum self.”
— Kate Denihan, Talkspace Therapist
“A psychotherapist is someone who helps others find their strengths and courage to confront and make sense of difficult emotions and experiences so they can learn and thrive in their lives.”
— Shannon McFarlin, Talkspace Therapist
“A psychotherapist is someone who offers support, positive regard, compassion, guidance, a level of accountability, advocacy at times, a listening ear and sound clinical advice.”
— Candice Christiansen, CMHC
“A clinically trained helper who uses an integrative approach to help others heal.”
— Shannon Battle, LPC
“To me a psychotherapist is an objective sounding board, a perspective shifter, game changer, a truth teller.”
— Erika Martinez, Psy.D.
Talkspace also provides "a list of common services" offered by therapists:
Listening
Analyzing present issues
Analyzing the influence of the past on the present
Comforting clients
Helping clients without the kind of a bias a friend or family member might have
Diagnosing mental health conditions
Reducing symptoms of mental illness
Helping clients manage symptoms of mental illness
Helping clients change maladaptive behaviors and thinking patterns
Helping clients understand themselves and other people
Teaching emotional, cognitive and communication skills
Teaching clients how to effectively resolve emotional, relational and professional conflicts
Guiding clients through crises such as breakups, abuse, suicidal thoughts, grief, trauma, infidelity, sexual assault and more
Teaching clients how to improve current relationships and build new ones
Teaching clients self-help skills such as deep breathing, meditation, thinking exercises and more
Offering non-directive advice and suggestions (depending on the therapist)
Referring clients to psychiatrists, mental health facilities or medical professionals if necessary
Helping clients learn to love and accept themselves
Reducing the stigma and shame of mental illness and therapy
Four main elements of psychotherapy
Based on the above research, there seem to be four main elements of psychotherapy:
Listening
Remembering, reminding, repeating
Analysis
Teaching
Listening
Humans are social creatures. Studies show that talking to others increases our well-being. But a lot of Americans say they have "no one with whom they discuss important matters."
One of the main benefits of therapy is just having someone to talk to.
And therapists are actually good at listening. They are "objective, neutral, and nonjudgmental." They are comforting, compassionate, and supportive.
For these reasons, therapists are better listeners than friends or family members who might be unable to listen to you objectively without bringing their own biases and judgments to the conversation.
Remembering, reminding, repeating
A good therapist isn't just listening without remembering anything you say.
They'll remember what you say and remind you, maybe even repeating back your exact words from before.
Sometimes, this will help to illuminate patterns or inconsistencies in your thinking.
Analysis
Analysis is one step further than just reminding and repeating.
Once a therapist has listened to you for some time, they might begin to draw conclusions about "what's actually going on."
This doesn't necessarily mean that the therapist will come right out and tell you their conclusions. As Gottlieb said, "We all have answers within ourselves, but sometimes we need a guide to help us find them."
Teaching
A therapist has knowledge of various mental illnesses and the skills that are helpful in reducing symptoms.
Once a therapist has listened enough to draw conclusions about what's going on, they can make recommendations, give advice, and teach skills to increase your well-being.
Which elements of psychotherapy are responsible for its effectiveness?
In 2012, the American Psychological Association (APA) did an extensive review of psychotherapy research studies and found the following:
"The general or average effects of psychotherapy are widely accepted to be significant and large."
"The results of psychotherapy tend to last longer and be less likely to require additional treatment courses than psychopharmacological treatments."
"For most psychological disorders, the evidence from rigorous clinical research studies has shown that a variety of psychotherapies are effective with children, adults, and older adults. Generally, these studies show what experts in the field consider large beneficial effects for psychotherapy in comparison to no treatment, confirming the efficacy of psychotherapy across diverse conditions and settings."
"In studies measuring psychotherapy effectiveness, clients often report the benefits of treatment not only endure, but continue to improve following therapy completion."
Sources for the research studies can be found here.
It's proven that psychotherapy is effective, but why?
What exactly does a therapist do that reduces symptoms of mental illness and helps people to feel better?
Is it just the objective listening? Or, are the emotional, cognitive, and communication skills that therapists teach essential to the effectiveness?
Does psychotherapy have to happen in person in order to be effective? Or, can therapy via messaging, phone, and video be just as effective?
Does the therapist need to be another person? Or, can you be your own therapist?
Does the therapist need to be a human? Or, can your therapist be an AI robot?
I am not aware of research that isolates the specific elements of psychotherapy that are responsible for its effectiveness. However, if we can reproduce all or most of the main elements of traditional therapy in different versions of therapy, then it is likely that the different versions will also be effective.
Different versions of therapy
I think the main elements of traditional in-person psychotherapy can be reproduced in different versions of therapy.
These are the different versions of therapy I have in mind so far:
Online therapy
Community therapy
Self therapy
AI therapy
These different versions will not be the exact same as traditional in-person therapy and it's possible that the differences will result in decreased effectiveness, compared to traditional in-person therapy.
For example, AI therapy will be administered by a computer rather than a human. Is the human element part of what makes traditional therapy effective?
Self therapy will be administered by yourself rather than another person. Is the other-person element part of what makes traditional therapy effective?
Conclusion
There are different versions of therapy (other than traditional in-person therapy) that might be able to avoid the barriers that prevent U.S. adults with a mental illness from receiving therapy.
Further research is needed to determine which alternate version of therapy will be the most effective, especially when compared to the effectiveness of traditional in-person therapy.
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