How to Ensure You're Receiving Effective Psychotherapy (video)

Transcript of video (please pardon the imperfect translation to written word):

Hi there, my name is Tim Holtzman. I'm the director of Winding River Therapy Services. We are a Berkeley Therapy Group. In this video today, I'm going to focus on helping you know when or when not you're receiving high-quality therapy. Before we begin, I'd like to give a quick disclaimer stating that I do my very best to base what I'm saying on research and base it on my direct experience of working with clients and seeing them grow and heal. Nevertheless, as an informed consumer, it's always your important duty to not just take what you're hearing at face value but to really feel into what you're hearing and ask yourselves the important questions, such as does this fit my experience? Does this feel true to me? Is what I'm hearing aligned with what I know is important for my health and well-being?

The first point I want to make is about making sure your therapist is able to keep you on core material. I'm going to define core material shortly, but beforehand, I want to first explain what therapy tends to look like for the most part in America. So for the most part, therapy tends to be you, the client, coming in and having a lot of freedom and independence to talk about whatever you want to talk about. Talk about the stressor of the week, talk about things that were hard for you during the week. And so, this does have a lot of healing potential, a lot of healing qualities to it, and it's especially important for folks that are dealing with immediate crises or high levels of stress in their life. And so, it's not that it's not important; it can be really useful. But the challenge is that for a lot of clients, they kind of get stuck in a cycle of coming in, sharing freely about whatever happened in their week, feeling some relief afterwards, and then coming back the next week and doing the same thing. The problem is that therapy needs to be able to keep you on what is probably the most important thing, which are your core wounds or your core material that keeps you stuck. It's almost like trying to pull weeds by just taking out the leaves or the stems without actually getting to the root.

So, core material is sort of the root, and let me give you some examples of this. For folks that have low self-esteem, that's the roots, and then some of the sort of leaves or branches would be the things that happen as a result of that low self-esteem. So in their day-to-day life, they may see themselves get into bad relationships or choose the wrong friends because they don't value honest or good people, or something like that. Or maybe they also choose jobs that aren't ideal for them because they don't have the self-esteem they deserve. Another example might be folks that see the world as very dangerous. Of course, you know, the world is dangerous in many ways, but then there are some folks that have an above and beyond view of the world being dangerous. And so when you have that core material, that core wound, you're going to see symptoms in your life such as maybe loneliness because you're not taking enough social risks, or maybe social anxiety because you're always anxious when you're around other people thinking the worst of them.

The important thing I want to say here in wrapping up is that we need therapists who are skilled enough to give the right amount of freedom but also skilled enough to make sure you're getting to that core material enough so that you actually can heal and do the deep root work.

The second point I want to make is how you, the client, can find therapies that are effective and do help you stay on core material. Traditionally, there are considered to be two different types of therapy. So the first type is talk therapy or traditional talk therapy. This is what we talked about earlier, where you come in and you share freely about what was going on in your week, and your therapist kind of listens, asks questions, provides feedback. And so, this can be highly effective, and it's shown through all kinds of research to be beneficial for most people. And some of the qualities you want to look for when you are trying to find the right talk therapist are pretty intuitive. You know, of course, you want to find someone who listens to you well and really understands what you're saying, someone who's kind and empathetic, someone who you trust enough to share vulnerable emotions with and to feel emotions with. And perhaps another telltale sign that I always like to think about is someone that you feel comfortable enough with to provide feedback to, because often the best forms of therapy or the best therapist-client relationships are ones in which you're able to co-create the therapy together, to kind of create the therapy in ways that work best for the individual client.

Now, these qualities I just laid out for you there are not just useful for traditional talk therapies, but they're also useful and important for the other category of therapy. The other category of therapy is what I refer to as exposure therapies and experiential therapies. They're not traditionally linked together, but they do have a lot of overlap, which you'll hear as I talk. So exposure therapy is the more traditional part here, the traditional part meaning that for over 30 years now they've been considered highly effective. They're often referred to as the gold standard for anxiety disorders and for traumas. And there's just a lot of research, probably more than any other therapy technique that exists. There are all kinds of well-designed studies with randomized controls. And so, you know, exposure therapy is a really good thing to look for, especially for some specific problems that you might be dealing with. You can research that more on your own. Now, with some of these exposure therapies and experiential therapies, I want to give you some of the more common ones that you'll hear. With exposure therapies, the more common ones are real-world exposure therapy, imaginal exposure therapy, exposure and response prevention. And then with experiential therapies, some of the more common ones you'll hear about are internal family systems or IFS. You also have Hakomi, you have EMDR, you have brain spotting, you got drama therapy, somatic experiencing, and AEDP. This are just to name a few. There's even more than that out there.

And so, with this second category of experiential therapies, what that means is that you're not just coming in and talking about what's going on in your life, talking about stuff that's out there, but you're actually coming into therapy and you're having an experience, perhaps a new experience that you haven't had before, such as feeling your emotions in different ways or being able to cope with emotions in different ways. Experiential therapies tend to be exercise-driven. So instead of just coming in and talking freely, your therapist might use the whole session or half the session to lead you through a specific exercise or technique where you're being exposed to your emotions, you're being exposed to pains in certain ways. And so, the thing about these types of therapies, both exposure therapies and experiential therapies, is that you are going to have to feel a certain amount of pain or a certain amount of emotion in sessions. This can be counterintuitive to a lot of people because they want therapy to relieve them, and to make them feel better. But unfortunately, the most healing does tend to happen when you are feeling some level of pain.

The analogy that's always useful is, you know, if you go to the gym and you're barely working out, you know, you're not feeling much pain, you're not feeling your muscles be stretched and kind of put to its limit, and same thing with therapies. If you know you're not feeling much pain in emotion, then you know you're probably not growing that much. So, we consider pain and emotion as a pretty good sign for the most part. You know, it's not always good, but you know, it generally is a good sign that you are stretching yourself in therapy. Now, with exposure and experiential therapies, they're not crude in a sense where you're just coming in and a therapist is making you look at hard stuff and making you feel a bunch of things. They're often very refined and very sophisticated. And, you know, because there are different kinds of different exposure and experiential therapies, you know, you might want to find one that's specifically suited for you. I want to give you an example of my favorite of the bunch, which is internal family systems or IFS.

So, with exposure therapies and experiential therapies in general, they try to be gentle and to kind of systemically or systematically lead you to feel different emotions. So you're not just going to get thrown in the deep end; you're going to be kind of led to feel some emotions, and then once you feel good about that, you can move on to some maybe some heavier emotions. And so, with internal family systems, say on the example we used earlier with low self-esteem, what we're going to do is we're going to first have you learn a pretty powerful technique to stay very grounded and stay very clearheaded and calm to begin with so that you can begin to look at hard material in your life with that grounded energy. And then, instead of just kind of tossing you into the deep end and having you look at some of your core material, your core wounds, we then have you first look at behaviors in your life that are protecting you or are sort of helping you prevent yourself from making mistakes that make you feel that pain of that low self-esteem. And so, it's a little bit easier in the beginning where you're kind of just getting to know you're protecting yourself against maybe I don't know taking a job that's going to be too hard for you or maybe trying things that you might fail at and then have to feel that low self-esteem. And so, you know, it's a sort of a very elegant way of helping you first clear out some of the first layer of clouds, and then when you feel more confident and even more grounded, we then bring you to core material, which is the actual low self-esteem itself and some of the experiences in your past that led to your low self-esteem. Most likely these core material or these core wounds started at a pretty early age, you know, really early or maybe semi-early in your teens. And, you know, most likely you know, maybe for low self-esteem, you maybe in kindergarten, you know, had a slight dyslexia or something like that, and you know, people noticed it a little bit, and they made fun of you, and you felt like you were really bad at things, and you took on this impression of yourself like, oh, I'm not worthy, I'm not good at stuff. And even though it was actually just a minor little quality of yours, you know, you're a kid and you blow it out of proportion, you take on this belief, and you get really scared, you get really hurt by it. And so, with elegant techniques like internal family systems, we help you relieve some of the pain you hold about those early experiences and begin to have new experiences of maybe feeling at peace when you're looking at those old experiences and then being able to feel more at peace and more confident about yourself in the therapy room and in your daily life. And so, the changes and the positive effects that can have on your life are huge.

The third point I want to make here is about regulation or physiological regulation. It is so, so key for therapy to know this concept. You know, a lot of therapy might aim to help you change behaviors or change your views of things, and you know, that could be helpful and all, but in order for therapy to truly be considered effective, therapy needs to help you be able to stay calm, focused, clear-headed in increasingly difficult situations throughout your life. And so, I want to bring your attention to this slide here, and if you have a look, you can see that there are really these two sides to it, with the middle being what we consider an optimal arousal zone. This is calm, cool, collected, connected, you know, you're able to feel and think simultaneously, feel empathy, be present, feel safe. And so, depending on the person and depending on the symptom, what happens is that something happens to us in life, maybe, you know, it's a hard conversation with a friend, or maybe it's, you know, we hit traffic on the way home from work. And depending on the person, they could go one of two ways, or they can switch off and go one way sometimes and the other way the other time. And those two ways are either what we call hyperarousal, which is the top area, or hypoarousal, which is the bottom area. And so, for the top area, we consider that a fight or flight response. It's related to the sympathetic nervous system, and it's really related to too much arousal. So you might feel emotionally overwhelmed, you might feel unsafe, impulsive, angry, defensive, racing thoughts. And then the other area, which, you know, again, if you have something hard in life happen, you might go into what is considered a hypoarousal zone, which is at the bottom. And this is about having too little arousal, and this is a parasympathetic nervous system response. And common effects of this would be flat, no energy, inability to think clearly, numb, collapsed feeling, disconnected without feelings.

Now, one of the unfortunate things about hypoarousal is that one might be having a ton of emotions or feeling a lot, but it's their external behavior that looks hypoaroused or the external behavior that looks like there's no arousal happening. And so really with these two areas that are outside of the window of Tolerance are is there're more around kind of what it looks on outside what their behavior looks like on outside but internally you know it could be more of a fight OR flight response or it could be more of a too little arousal response. Now, this is really important to understand, and I think you know it's worth taking some time to go over this a little more. And so when we come into therapy, you know, it could be useful to think about what situations make us fall out of our window or tolerance make us feel hyperaroused or hypoaroused and then to what degree do we shoot up. So we usually think about hyperaroused or hypoaroused on a scale of 1 to 10 with sort of one being low hyperarousal or low hypoarousal and then tend to be very high. So you want to think about things that trigger you in life like what are the context what are their situations how much you get triggered like to what degree and you also want to think about how long does it take to recover are you know at an eight for half an hour or an hour are you at a three for only 20 minutes and so that's another consideration and you also want to consider what is it that you do to recover faster and to get into your window of Tolerance faster. And so if you assess yourself on these dimensions before therapy and then you assess yourself after therapy, the goal would be that there is a clear difference. Maybe it's that you have less events that trigger you less situations that trigger you. Maybe it's that you still get triggered but you come down quicker or you get less intense. So these are a physiological assessment of how effective therapy is and you know. I'm not going to say that it's going to be easy to see significant changes but it certainly is possible over time. In order to know you're having effective therapy you want to be able to monitor your levels of regulation and to really see change over time. You can't expect quick changes because this is again a physiological system within your body um but you should see changes.

That's what I have for you today. I hope it was helpful. In closing I want to give a quick summary so what we talked about. Therapies can be classified into two different categories, the first being traditional talk therapy which is the therapy where you come in and you have a lot of freedom and flexibility to talk about whatever you'd like to talk about. There is a lot of research showing that it is helpful for most people. However it tends to be the most helpful for folks that are dealing with very stressful situations in their present or they're dealing with some kind of crisis and they just need a lot of space to talk freely about what's happening. The second category of therapies are exposure and experiential therapies and these therapies are more about the therapist leading you through things. They tend to be better for people that have a very targeted goal for therapy such as reducing social anxiety or reducing anxiety in relationships and these also tend to be better for folks that want to go to core material sort of themes or things that have happen to them in their life. Of course if therapy is successful and you're able to clear up that root, you can see system-wide changes in your life. You can see a wide range of positive effects that can be quite profound in some cases.

I want to leave everyone with a quick exercise if you have a pen and paper you can write down a couple questions and think about it on your own time. So these questions are geared towards helping you identify core material that you might want to work on in therapy. The first question is what patterns and themes have occurred in your life that deeply frustrate you or cause you pain. Maybe an example would be someone who's lost a lot of loved ones to death. If that happens to you multiple times it would make sense that maybe someone is grim or maybe afraid of losing other loved ones, That would be a theme that has happened to you and you know might be useful core material for therapy. Another question or the second question would be what are some of the biggest fears and avoiding behaviors you have in your life? Most of us humans have multiple fears or avoidance behaviors but I think for this question you want to consider what the most troublesome or bothersome ones are. Some examples might be... maybe you're someone who is afraid of planes or gets anxiety on planes. Or maybe you're someone who has problems with authority and gets really nervous around authority and so this again would be considered a theme.

Thanks again for stopping by if you want to stay in touch with future blog posts um you can find us online at WindingRiver PsychotherapyServices.com we specialize with online internal family systems therapy, with EMDR therapy, with couples therapy, and relationship therapy for individuals. We work mainly via online therapy. Thanks again and be well.