Uncommon questions about therapy you’ve wondered but never asked - a Psychologist in Orange County answers
You’ve been kicking around the idea of going to therapy for a while, but you have so many questions about the nuts and bolts of what it is, how it could help, and what it looks like. You might even feel embarrassed by how basic these questions are. It seems like everyone just knows these things.
Let me tell you, they don’t!
The majority of people, even those who are highly educated or have been in therapy, do not know the answers to a lot of these seemingly basic questions. I draw on my extensive experience of doing therapy to answer questions you’ve always wanted to know but are too embarrassed to ask.
I’m a Psychologist in Orange County, and I’ve been providing psychotherapy, full-time, for over 12 years. I want to answer these questions because I have a passion for reducing the stigma and mysticism of therapy so that more people can benefit from it. Here we go.
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When it comes to mental health, there's no difference between the terms "therapy" and "psychotherapy". Both refer to the practice of meeting with a mental health professional for talk therapy to alleviate emotional and psychological symptoms. Though the word "therapy" is also used in other disciplines such as physical therapy and occupational therapy, in our present-day society, most people use "therapy" to refer to psychotherapy.
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All are mental health professionals. But they differ in their qualifications (i.e. education and training) and roles.
Psychiatrists (MD or DO) are medical doctors who specialize in mental health. They diagnose and treat complex mental illnesses through the use of medication to alter brain chemistry. In present-day, few Psychiatrists do talk therapy. Their primary role is medication management of complex and severe mental illnesses. Psychiatrists are the only mental health professionals who can prescribe medication. If medication is needed, it is typical for people to have a Psychiatrist (for medication management) + a therapist for talk therapy to change behaviors. The education for a Psychiatrist entails 4 years of a Bachelor’s degree, 4 years of medical school, and 4 years of residency in Psychiatry.
Clinical Psychologist (PsyD or PhD) is a doctor of Clinical Psychology who can evaluate, diagnose, and treat mental, behavioral and emotional problems with psychotherapy. They are also trained to provide psychological testing with treatment recommendations such as intelligence, personality, achievement, and neuropsychological testing. Their education entails 4 years of a Bachelor’s degree, 4-8 years to earn a doctorate degree + 1-2 years of post-doctoral supervised clinical experience.
LMFT is a Licensed Marriage and Family therapist. They have a Master’s degree in marriage and family therapy. They specialize in doing therapy/counseling with couples and families. Their education typically entails, 4 years of a Bachelor’s degree, 2-3 years to earn a Master’s degree + 1-2 years of supervised clinical experience.
LCSW is a Licensed Clinical Social Worker. They have a Master’s degree in social work and specializes in counseling of individuals and families with a wide range of social and emotional problems. Their education entails 4 years of a Bachelor’s degree, 2-3 years to earn a Master’s degree + 1-2 years of supervised clinical experience.
In present-day, Clinical Psychologists, LMFTs, LCSWs all do psychotherapy and are collectively referred to as “therapists”.
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These acronyms refer to ways a therapist works and their treatment approach to helping you resolve your struggles. CBT = Cognitive Behavioral Therapy; EMDR = Eye Movement Desensitization and Reprocessing; DBT = Dialectic Behavior Therapy; EFT = Emotion-Focused Therapy; ERP = Exposure Response Prevention. There are countless more acronyms for ways of working, but these are some of the common ones that you will see. Each one of these treatment approaches differs in their conceptualization of how problematic behaviors occur and the interventions necessary to bring about change. Most treatment approaches are highly procedural and require additional training to implement the interventions effectively.
It is not necessary to find a therapist who is trained in most or any of these approaches. Some therapists choose to specialize in treating a certain population or disorder. In this case, they need to pursue training in the treatment approach that is deemed most effective for that specialty. Some therapists choose to be more of a generalist. They could be equally effective as a therapist who pursued additional training. In therapy, the quality of the relationship between therapist and client is more important than the therapist’s training. I will explain more on this below.
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In my experience, people wait too long to get professional help. If you find yourself wondering if therapy could help, then it’s time. If you notice that friends or family are telling you to get therapy, then it’s time. I’ve never heard anyone say they regretted starting therapy early. On the contrary, I hear people tell me they wished they had gone to therapy sooner - to not have waited so long and “wasted time” feeling bad.
Behaviorally, it is time to get professional help when the thoughts or feelings you’re experiencing are affecting your sleep. Whether it be having a hard time falling asleep or staying asleep. Quality sleep is vital for your mind and body to function properly. Every aspect of your life suffers when sleep is poor. So when your negative thoughts and feelings are interfering with your ability to sleep and function, then it’s time to get professional help.
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Definitely! Therapy not only helps individuals feel better but can also save lives. I cannot count the number of times people have told me that I have saved their lives, how our sessions have brought them back from the brink of hopelessness, and from giving up on life.
As you can see from the answers above, there are several techniques for doing therapy, but research indicates that the most crucial factor in therapy success is the therapeutic alliance between the client and the therapist, not the specific techniques used.
What exactly is a therapeutic alliance? It is the positive connection or bond that one feels with their therapist. When you feel safe and comfortable talking to them, have confidence in their expertise and ability to assist you, trust that they care about you, and that you matter to them.
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It can be challenging to determine if therapy is effective. However, you can gauge its effectiveness by checking in on your thoughts and feelings. Are you reflecting on things discussed in the sessions? Did the therapist say something that resonated with you and your thoughts keep going back to it? Do you feel understood and acknowledged? Are you comfortable sharing things that are embarrassing or shameful? Are you being challenged or nudged by the therapist to take a different perspective on your firmly held beliefs?
At the end of a session, do you feel like you have gained something from it? It could be a different perspective on an issue, new things to try when a problematic situation arises, or a sense of not feeling so alone. Although therapy can be challenging and painful, if you feel hopeful and look forward to going back next week, it is a sign that therapy is working.
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When considering whether your therapist is a good fit for you, there are two things to keep in mind: how comfortable you feel talking to them, and how aligned you are with their approach.
As mentioned, the positive feelings you have for your therapist are the most important factor in determining whether therapy will be successful. Only you can make that determination based on how it feels to be in their presence. To help you decide, check in with your body and listen to your gut/intuition.
The topic of how your therapist works and their approach to change should be discussed during the phone consultation or in the first session. Although research shows that the therapist's approach is not the key ingredient to successful therapy, it's still important to be on board with their treatment approach.
For instance, I believe in treating the root cause(s) of symptoms, not just the symptoms themselves. My ultimate goal is for my patients to be symptom-free. I'm a good fit for someone who wants to understand the key players in their lives, the formative experiences that taught them "lessons" about themselves and the world, and the areas in life where these lessons are helpful or problematic. However, I may not be a good fit for someone who doesn't care about their past and only wants to focus on feeling better in the present.
You can usually determine whether a therapist is a good fit for you after the first session. If you're still unsure after the first session, it's probably not a good fit.
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Therapy can be quite expensive, with fees ranging from $80 to $350+ per session, depending on factors such as the therapist's licensure status, degree, expertise, and experience, as well as the geographic location. However, unlike other medical professions, therapists do not double-book their appointments. When you book a therapy session, the entire hour is reserved solely for you, with the therapist's undivided attention and care from the first minute to the last. This is in stark contrast to other medical appointments where you may only see the doctor for a small portion of the visit, and a paraprofessional does the rest. In most cases, you get to talk to the therapist directly from the first phone call.
Another reason why therapy can be costly is because of the nature of the work itself. It is a mentally and emotionally demanding profession that requires therapists to sit with people in their darkest hours as they recall painful experiences. Therapists use their hearts and humanity, in addition to their brains, to help people heal from their emotional wounds. This takes a significant toll on the therapist. A therapist who prioritizes their mental well-being will only see about 20-25 clients a week, allowing time for documentation and self-care activities, including their own therapy. (Click here to read more about the importance of therapists getting their own therapy.) By building in time for self-care behaviors, therapists can ensure that each person they treat gets their full attention and care. The session fee allows therapists to be the most effective in their profession, while also enabling them to pay their bills and make a living.
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Yes, you might experience an increase in symptoms before you feel better. I see this in people who have a history of trauma or abuse. They’ve spent years walling off painful experiences. To talk about them in therapy brings the memories and feelings to the forefront and could cause an increase in distress, temporarily. It’s important to remember that you will not be alone in your pain this time around. I tell my patients, “I will be with you, side by side, to help you feel your way through and out of the darkness.” For a lot of people, this increase in symptoms does not occur. Therapy is still hard work, eliciting discomfort and sadness at times, but manageable for people with the help of their therapist. The relief and healing resulting from therapy outweigh its temporary discomfort.
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In-person therapy is more powerful, in my professional opinion. No doubt, virtual therapy is convenient. I appreciate that virtual therapy eliminates barriers like travel time and lack of childcare, making therapy more accessible for people. It also has the added benefit of letting you work with a therapist you really want to see but are in a different part of your state. For example, I’m a Psychologist in Orange County, CA, but I have patients who live in San Diego, Los Angeles and the Bay Area.
These conveniences come at a cost though. The cost of information and connection. Talk therapy is not just about talking. We communicate through our body language, our nonverbal behaviors, and the micro-expressions in our faces. For example, through video, I cannot see a person’s bouncing knees or wringing hands when a particular topic comes up. The person might not be aware of such feelings associated with the topic or their unconscious display of anxiety in their bodies.
Here is another illustration from my practice of what gets lost in video. I have an exquisite ability to perceive the slightest change in someone’s facial expression. When I notice it, I always ask about the change I observed and it leads to meaningful dialogue about hidden feelings. In-person session enables me to pick up on the slightest nuanced shifts in emotions on someone’s face that video cannot capture. Consequently, I noticed I don’t make those observations as often when I do video sessions compared to in-person sessions. Also, I believe my calming presence is also more palpable and easily perceived in person than in video.
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The first session of therapy can differ from therapist to therapist. If you're unsure of what to expect, it's recommended that you ask the therapist during the free phone consultation. Knowing what to expect in the first session can help alleviate anxiety about that initial meeting. Some therapists may want to delve straight into the work and ask you to talk about what brings you to therapy, while others may choose to orient you to what therapy is and how it works, doing most of the talking instead. During the first session, the therapist should provide you with information about confidentiality, the limits of confidentiality, and office policies. However, the amount of time spent on these topics can vary depending on the therapist and when it is discussed.
In my practice, I aim for a balance of listening and talking during the first session. For people who've never been in therapy before, I allocate more time to explaining how therapy works, how I can help, and answering any questions they may have about what to expect.
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No! From the therapist’s perspective, there is no such thing as oversharing. I tell people, “I am interested in everything and anything that is on your mind.”
Over the course of 12 years of providing psychotherapy, I often hear people say to me, “I’ve never told anyone this.” Or “You’re the only person who knows this about me.” When done right, the therapy relationship is often the most emotionally intimate relationship you will have. For a lot of people, it is more intimate than a spousal, parent-child, best-friend, or sibling relationship.
Confidentiality is an important part that encourages this intimacy. For the most part, everything you say in therapy is confidential, except for four instances. The four limits of confidentiality are harm to self, harm to others, suspicion of child abuse, and suspicion of elderly abuse. If you share specific intent, plan, and means for how you want to hurt yourself or others, or any information that indicates abuse in children or the elderly, then the law requires therapists to break confidentiality and involve other people. Aside from that, everything you say in therapy is private and cannot be revealed to anyone without your consent.
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They are not supposed to. This is where it’s important to work with a well-trained therapist, experienced therapist. Very few things can shock an experienced therapist. They would know how to engage with you from a place of compassion and understanding instead of judgment.
In the event that you do feel judged, I encourage you to voice that feeling to the therapist right there in the session. This would be a great opportunity to see how the therapist handles feedback. You could say,
“I feel like you’re judging me right now.”
You want to hear the therapist say something like,
“Thank you for sharing that feedback with me. That can’t be easy to say as we don’t know each other well yet. I want to know more about what I said or did that made you feel unsafe. Can you tell me more please?”
You want someone who 1) acknowledges the courage it took to give that feedback, 2) owns their negative impact on you, even if it’s unintended, and 3) demonstrates curiosity about your feelings and encourages you to say more.
You do not want to hear the therapist say something like,
“No I’m not! I’d never do that; I’m a professional.”
I would not recommend working with a therapist who responds in a defensive indignant way to your feelings.
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The type of therapist you are seeing plays a significant role in the type of homework assigned. Cognitive Behavioral Therapists (CBTs) usually assign worksheets and writing exercises to record thoughts. However, most therapists, including myself, don't typically assign formal homework. Instead, we encourage you to apply the positive coping skills learned in your daily life between sessions. This could include prioritizing yourself, setting boundaries with others, trying out a self-care behavior, or intentionally changing the way you speak to yourself.
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When I hear this question, I think the person is telling me they’re in pain and would like assurances that there is “a light at the end of the tunnel". Let me assure you now. There IS a light at the end of the tunnel. You WILL get relief and feel better. But everyone’s tunnel is different. Some tunnels are longer than others. Some people get to where they want to be in 10 to 12 months, but others may take longer.
There is no one-size-fits-all treatment in psychotherapy. So it doesn’t make sense to put an arbitrary time limit for therapy. The speed at which a person heals depends on a variety of individual factors, such as their childhood experiences, current relationships, family support, culture, previous traumas, and motivation to change. Our main goal is to help you feel better as quickly as possible. Instead of focusing on the length of therapy, we prioritize checking in on how you feel. This is why it's crucial to work with a therapist who you feel comfortable with. It's important for you to be able to express any frustration, confusion, or disappointment if you feel like you're not making progress toward your goals.
As a private practitioner, I've received consistent feedback from clients that they feel better after their first session. They gain hope and confidence in the psychotherapy process and develop trust in me to guide them through their unique journey.