Comfortably uncomfortable: An introduction to psychotherapy
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Mary:Welcome to Unraveling. This is a podcast that sees the world through the lens of mental health. I'm Mary Wilson, a journalist.
Kurt:And I'm Kurt White, a social worker and psychotherapist.
Mary:And Kurt, we've had some wonderful guests on our podcast. On each episode, we typically invite someone from the outside in. But today, we are talking to you, Kurt, our very own psychotherapist and social worker, and we're going to pepper you with some questions. To help me, we're bringing in our senior producer, Hans Buteau. Hi, Hans.
Hans:Hi. Thanks for, thanks for bringing me here. I have so many questions. You say it every episode, I'm a psychotherapist and social worker. I don't know what that means, So I'm excited to grill you on it.
Kurt:That's great. In retrospect, something I should have explained sooner probably, right? But no, I'm really glad to do this with you folks. It should be really fun to dive into all the questions you have about psychotherapy and how it works and what it is and who does it and how you find it and all that sort of stuff.
Hans:Mary, do you mind if I take the first question?
Mary:Go for it.
Hans:Great. Well, buckle up, Kirk, because here we go. What is the difference between a psychiatrist, a psychologist, a psychotherapist, a therapist, a counselor, a social worker, and then somebody like a bartender or a barber?
Kurt:Right. It does sound like a setup for a joke, doesn't it? It's the where they all walk into a bar. How could they know the difference?
Hans:That's right. Is it level of education? Is it like medication? What are the differences between all of those different things, and how should we think about them as we as we bring them onto the show and who they're talking about and what perspective they're coming from? But also if you wanted to seek the help of a mental health professional, who do you look for?
Hans:What what do those mean?
Kurt:Just as a caveat, my answer will be mostly the American answer to this. There are some international similarities and differences in the way that professions are divided and titles and licensure and scope of practice work that are sometimes interesting and surprising. And it's kind of interesting because sometimes there's a difference in scope. What can people do? What can this profession do?
Kurt:In training, sort of how did we learn to do the things that we're allowed to do as well as some overlap in scope. But there are also disciplines that have unique and different histories from one another. So psychiatry, these are doctors. Psychiatrists are medical doctors. They go to medical school.
Hans:So they could like also treat me at the ER or whatever.
Kurt:Yeah, they spend years after college just learning general medicine, They all of the study the chemistry and physiology of the body, the anatomy. They do rotations through various different specialties. And then at the
Mary:end of that, it's time to decide what do you specialize in, and they decide to apply to psychiatry residency programs. And then they match with the residency where they just study psychiatry for years, years more after medical school, and then they become psychiatrists after that. And certain specialties in psychiatry,
Kurt:like child adolescent psychiatry, forensic, There's a few others that are like an additional training, substance use. Sometimes they're usually requiring a fellowship year at sort of at the end of or after their residency training. And historically they were the superintendents of the psychiatric asylums, basically. Oh, wow. And they had a group together.
Kurt:This was way before residency programs. This was kind of as modern medicine was being invented, so was psychiatry being invented. And they got together and they had an organization of the superintendents. And that became actually the organization that is the American Psychiatric Association. And there's a history of doctors being interested in mental health problems, seeing mental health and substance abuse issues, substance use disorder issues as being related to medicine.
Kurt:Notably Doctor. Benjamin Rush, who was one of the signatories on the Declaration of Independence, for example, really described the problem of addiction, for example, in a way that really kind of resonates down through the years. Right? But he was not a psychiatrist because there wasn't such a thing as psychiatry yet. He was just a doctor being interested in the way that mental health problems work.
Hans:Is psychiatry different from psychology, and how is a psychiatrist different from a psychologist?
Kurt:Yeah. Psychology is its own whole thing, and that has its own complicated history. But modern psychology is often traced to William James, who wrote a book called Principles of Psychology. And he was sort of interested in the ways that, I don't know, not just personality, but the ways that people are put together. How the senses work?
Kurt:How does perception work? How does the mind work? And psychology is sort of the study of all of that, the study of psyche, the study of the mind.
Hans:Okay. And that's different from a psychiatrist because a psychiatrist is mind as a part of the body?
Kurt:Yeah. Their train their training would have been fundamentally in medicine first. Right? Medicine first. Medicine first.
Kurt:Psychiatry as a part of that, the mental health part of medicine. And psychology doesn't, they're not medical doctors. Psychologists at the doctoral level, we would call them doctor actually. Okay. But they haven't gone to medical school.
Kurt:Their doctorate is in well, it's in the philosophy of psychology, a PhD. And there are psychologists at the master's level that we wouldn't call doctor, but they have similar training. And this is an old profession, but not as
Hans:old, right? So the fundamentals of psychology is date us here. Put us
Kurt:in Yeah. That's in the late 1900s also. Okay. Yeah. Both of these things are kind of emerging in their modern form as we sort of get toward 1900 or so.
Kurt:So what was Freud? Freud was really neither thing. He was a medical person that would have studied neurology had it not been for the antisemitism of the time. And so he was interested in the mind and the practical problems of mental health in a way that we understand You know, people were coming to medical people with symptoms, and he was trying to understand those symptoms. And he hung around with people that were also trying to do that in various ways.
Kurt:Some people that were coming at it from like hypnotism and different methods like that. And he kind of invented a field of psychoanalysis. Psychoanalysis.
Hans:So he's a psycho analyst. He is. Which is different from a psychologist. Yeah.
Kurt:Psychoanalysts are historically mental health professionals in the sense that they they were usually trained in medicine and often psychiatry. There was a big fight that lasted until surprisingly recently, by the way, like the 1980s and even into the '90s, about whether or not psychiatrists had exclusive dibs on psychoanalysis and psychoanalytic training, or whether psychologists could get into that basically. Wow. And there was a giant lawsuit actually that went on for a long time where the psychologists were suing the psychiatrists for restraint of trade, for not letting them into the training institutes.
Mary:Wow.
Kurt:Wow. But there's also a history in psychoanalysis of what they call lay analysts, people who learn to do psychoanalysis, but without really having been to school to train in all of the things a mental health professional would train in. And one of my teachers, Jonathan Lear, was such a person. He was a philosopher and philosophy professor, but was also a lay analyst, meaning he went to an institute to train in psychoanalysis, and then did that but did not otherwise do mental health treatment.
Hans:I'm already tired. I'm laying on the floor at this point, but we have more to go.
Kurt:We have more to come.
Hans:What then is so what's a psycho therapist,
Kurt:which
Hans:is what you are. Right?
Kurt:I am. Yeah. I always say social worker and psychotherapist. And social work has its own history, by the way, I should say, that comes out of same kind of timeframe, turn of the century, where certain folks trying to provide help to others started doing that in various ways. And that often included talking to them and doing things that sort of began to resemble psychotherapy.
Kurt:And there was a sort of connection between the psychotherapy of the day and psychoanalysis and social work at that time, which developed over time. And then you also have mental health counselors, which sort of developed as a field kind of out of school counseling, but also sort of involved talking to people and helping them with their problems. And then, marriage and family therapists, and they have their own licenses. And then last but not least, drug and alcohol counselors. That has an interesting history too, because it kind of was a field that kind of invented itself.
Kurt:It came out of folks with addiction in recovery helping each other and then sort of developing that into a field that was recognized over time. And psychotherapy is the kind of overlap skillset of the ways that we talk to people with an intention to be helpful that is common to all of these things. There are some unique scope elements like things psychiatrists do, things that psychologists do mostly, that social workers don't do, things that social workers do. But all of us could be doing psychotherapy.
Hans:Oh, so if I were to reframe that another way, psychotherapy is an umbrella term that everybody fits into because everybody could sit you down on a couch, lay you back, and have you tell all of your problems.
Kurt:Yeah. The couch is sort of more associated with psychoanalysis these But but yeah, but, yes, you know, we could there's they don't have beads on the couch. We could use the couch if we wanted to, mostly we don't use the couch.
Hans:But Irrespective of education, of ability to prescribe. Because I'm imagining the medical doctors are the only ones who can prescribe because of their medical professional licenses. They can prescribe drugs. Right?
Kurt:Well, yes. Whether they're the only ones that can do it, that gets a little complicated too. In a couple of states, psychologists are allowed some prescribing privilege in this country around psychiatric medications themselves. But having not been to medical school, they usually have to do some additional scope of training related to that. And there are also folks that come out of the medical world that are kind of psychiatry adjacent, like psychiatric nurse practitioners or physician assistants that have prescribing privilege and may also do psychotherapy, depending on their training.
Kurt:They also can prescribe medicines for psychiatric drugs as well as other kinds of things. Remember that there weren't really many drugs to prescribe to people until about mid twentieth century, by the way. Oh, mean, it was sort of like, so the idea that like, if you look in early old records from the retreat, for example, like all of the meds are like things to help with constipation, you know, or things, you know, I mean, they're just like basic medical tinctures and things. They're not they're not there's no cure going on there. Kelli brothers.
Hans:That's a
Kurt:thing that develops in the twentieth century. Wow. Almost exclusively.
Mary:There's so many roles here. How does one find the person and the professional that they need to help them?
Kurt:Well, one of one of the things that most mental health professionals will do, especially if they're sort of hanging out a shingle to say that they're willing to help you, right? So if you sort of go to someone's the first thing they'll do is to assess, right? And that's part of the scope that most or all of these professions have, that they can diagnose, they can look at, they can talk to you and understand your problems in a common way with a common language that we all use. Happen to have it next to me here, but the Diagnostic and Statistical Manual of Mental Disorder. It sort of defines things in a way.
Kurt:So we're all using the same language across And all of these we all have an ethical obligation to try to tell people the things that we think can help them. And to do those things and mostly only those things, or if we're doing something else to tell people that we don't know if it'll help them or not, right? Sometimes we do that. And sometimes that can involve referring people to other services that they might benefit from, but which we ourselves don't provide. So hopefully like a lot of that gets sorted out just at the initial visit.
Kurt:And so I would sort of say to folks like, don't get too stuck on what door you knock on first if you're needing help. Knock on a door that seems reasonable. We could maybe get into what that means, but probably you're going to get some advice from there and then interrogate that, see, does it make sense to you? And that could involve some referrals. So like if I saw someone and they were very, very depressed in a way that I thought might benefit from medicine, I would probably talk to them at least about the idea of medicine, that that might help them also and wonder if a referral to a specialist would be an order or a lot of medicine prescribing in mental health is actually done at the primary care level.
Kurt:More than eighty percent actually is like just done that way. So it's, and psychiatric medicines are the most prescribed category of medicines in this country. Not true worldwide, but in this country that's true. So, you know, it might be that I could talk to their primary care and sort of consult with them about that, sort of say, yes, I think this person really does have this depression. I'm going to follow them for that.
Kurt:We'll do some psychotherapy that'll be helpful. They have you thought about a medicine and see what they say. They usually appreciate that. Being
Mary:the most prescribed class of drugs, do you see that as a positive thing that more people are seeking help and are going to therapy? Or do you think it's problematic in any way?
Kurt:Well, I mean, I think it's probably mostly a positive thing. I think it's I mean, we've sometimes in this show, we've tried to complicate the picture of things a little bit at the sort of social level. And if we say, and I've sometimes said, you know, if one person has a problem, one person has a problem, right? If two people do, two people do. But if everybody does, then maybe something's in the water, something's going on that's problematic, right?
Kurt:Why are we all depressed? At the same time, I think probably a lot of mental health problems are just kind of common problems, but it doesn't diminish the severity of them, right? Many terrible physical problems are also surprisingly common, right? I mean, people get sick with things. And, know, high blood pressure, diabetes.
Kurt:And so why should we be so surprised that people have mental health problems also? And certainly if any individual has them, I would hope that they would be getting all the treatment that might benefit them, or at least know about the treatment that benefits them. So generally speaking, I celebrate it. I do think that sometimes the world is a hard place to live and it's stressful and that there might be sort of like also other things we can do to look at that.
Mary:I might be an outlier in today's day and age. I've never actually gone to a therapy session unless this podcast with you counts,
Hans:Kurt, maybe. I mean, this is a big question.
Kurt:Yes. It's the name of it.
Hans:Is this therapy?
Kurt:That what a good question. Question.
Mary:So who should go to therapy?
Kurt:I think people mostly come to therapy after they've already tried a lot of other things. I think people would really it's a hard thing to do to go and sit and talk to someone who is a stranger to you about very personal matters, sometimes things that are hard to even talk to yourself about, much less talk to a stranger about. And there are hurdles to that, right? And it hurts to do it a little bit. But it also hurts not to do it.
Kurt:And people usually come when the calculus sort of shifts into like, I got to try something different than what I've done before. So we generally assume that if someone has showed up asking for help, regardless of how mild it might seem, that something has gone on, that they've had some internal kind of something that's led them there. And a lot of times that really is like problem that is a diagnosable problem, and a thing we could do something about, help people with, sometimes very discreetly and sometimes maybe in a more complicated way having to do with like their sense of themselves in the world and something longer. A lot of people will use therapy as needed, right? I mean, in a very kind of non stigmatized way, like hospice centers will often have a grief counseling sort of built into the sort of accessing hospice or something in a person's area, sometimes in a group setting, sometimes individually.
Kurt:When my mother was dying, I remember there was a social worker that sort of met with all of us, both individually and in a group and talked about it. And like, I thought it was very helpful. Things like that might happen to get and some people might have those encounters and not even think of it as therapy or something like that. Right?
Mary:And a first session, should someone expect to be sort of telling their life story, or what can they expect? And how honest does someone have to be for the therapy to work?
Kurt:Very good questions. I mean, the first yeah. The first session, partly because of this assessment process where we have to kinda we're strangers to one another. And I have to understand, first of all, are you safe? How bad is it and what's going on?
Kurt:What needs immediate attention? And then the sort of problem underneath that, which is what kind of thing are you suffering with or from, right? How do we understand it? And sometimes it takes asking a lot of questions to get at that. And so like the initial couple of sessions usually involve more questions being asked of you to get underneath that than might be true later.
Kurt:There's a kind of changing gears when you move from assessment to treatment, even though they are kind of like blended together a little bit. So yeah, I guess be prepared to answer a lot of questions about things. You can always not answer any question, you know, that's okay. But usually people do. They sort of, you know, if you're in for it, you know, we try to make people feel comfortable and share what's going on.
Kurt:How comfortable do you have to be or how, you know, how honest rather, how honest you have to be? I mean, I think there are usually things that people don't share sometimes for a long time. And of course, we don't know what people don't share ever also, right? But I've sometimes been surprised that sometimes people will tell me very important things long after I initially started working with them, right? And so it's sort of people will disclose at this pace of safety.
Hans:Comfort is a really interesting word that you let slip there and then tried to cover up, but I'm not going to let you. I'm not going to let you because as a parallel to what Mary's asking, should therapy be uncomfortable? Should therapy be comfortable? How do you know it's working? How do you know your therapist is good?
Hans:Do they make you feel good? Do they make you feel bad? Do they make you hate your parents? Is it your parents' fault? Why should I hate my parents?
Hans:I
Kurt:mean, you might say something more like comfortably uncomfortable or something like that. I I think it is ideally, there is a certain comfort to it, I think. But again, it kind of depends. I mean, I think like you could be in a kind of therapy where we're going to focus on, you know, let's take something kind of simple like fear of flying or something like that, something discrete, right? Now that kind of work involves putting people in touch with the fear of flying, right?
Kurt:And so that's uncomfortable. That's part of the model. Basically all of the different kinds of treatments you do for that involve trying to move closer to the thing you're afraid of so that the fear doesn't get in the way anymore. Different schools will have different ways of describing what that is and what's going on, but that's basically it for that kind of a problem. And then you might have like a longer term kind of issue.
Kurt:Like, oh my god, you know, I grew up in an abusive alcoholic family. I've got these kind of multiple and complex traumas maybe. And got And yeah, I'm afraid of flying, but I'm afraid of a thousand other things also. And I'm in this relationship that I sort of have mixed feelings about, and I don't know how to sort out my feelings. The person may be asking for help with all of that.
Kurt:And sometimes that involves a level of like complicated personal exploration where you have to kind of sort out your own feelings and thoughts. And that's not so easy to do. But it is good to do, right? I mean, people usually feel better after they do that. If you know that your feelings are your feelings, then you feel better about it, even when they're hard feelings to hold.
Kurt:That's my experience of it. And so there's a discomfort, but there can be a comfort also.
Mary:And after a therapy session, should you feel good? Should you feel sometimes are you crying? Does it just run
Kurt:the gamut? I think it runs the gamut. I think absolutely. I think generally speaking, if it's a longer term therapy, then I guess we would hope that people feel better after leaving more of the time than not. But sometimes it's a place where therapy can be, a place where you it has a kind of containment function, you know, where you come here to talk about hard things so that the rest of the time it's a little easier to live your life and you can metabolize some of those hard things.
Kurt:So you might leave here feeling like you've done a hard thing, maybe like worked out at the gym kind of hard. Like, does that feel good or does it feel bad? I mean, I don't know, it hurts, but maybe it hurts in a way that feels good and productive. Sometimes also there are like arcs of work that are just harder than others. And sometimes you get into a thing and it's gonna feel bad for a while.
Kurt:You may not feel better right after the session or the day after a session or the week after session. You may feel bad while you're in the middle of it, but there's something good on the other side of it.
Hans:I have a feeling that a big part of the education that you all go through is learning what are the boundaries? What are the ground rules? What are the things you that that you're that you have to do as a care provider? What are the things that you can't do as a care provider? What are the rights that somebody has walking into your door and sitting down, and then once they they've left?
Hans:And it's occurred to me that I've done a lot of therapy in my life, and I've never had that conversation where a therapist has outlined their rights and responsibilities and my rights and responsibilities. So, Kurt, I'm asking you to do that for me. Can you help me understand that? Because to Mary's point, if you're entering into this space, this weird, weird space, what can you expect from them, and what do they expect of you?
Kurt:Yeah. That's such a good question. And I wish more therapists did more of that explicitly because I do think people are a bit hungry for it. It's disorienting. It's a different kind of relationship.
Kurt:Even if you have experience with some therapy, what does this therapy be like and what should I expect? You know, you're different than my last therapist, but how are you both the same in terms of what you're doing? It gets into something that we would call like informed consent, informed consent for psychotherapy. And that really is a process that, you know, could be done. You could have some things written down.
Kurt:But I mean, to do it interpersonally, like by talking about things, like, hey, you're coming to me for help. That means that I'm going to ask you a bunch of questions and that we're going to try to talk about these things. And I'm going to tell you what you're doing and here's the ways that I work. And it should feel like this. And if it doesn't, we should talk about it.
Kurt:And I'll periodically ask you how it's going and that I really want to know. I might sometimes share some things about how I'm feeling related to what's going on in the room, but I'm not going to share a lot about my own personal life and history because it's not your problem, right? So different therapists set the boundary of disclosure differently. But we should talk about it so that people don't get confused about it. It's not friendship.
Kurt:You know, it's something other than that. You know, and that for the most part, like the relationship is constrained to the time that we've agreed to have together in the office. And concretely, like most therapies are like we sit across from one another or talk to each other. Or if you're a psychoanalyst, you lie down on the couch and I sit behind you or next to you or whatever it is. I had that, by the way.
Kurt:I mean, you know, that's not like, you know, we joke about that, but my analyst, he sat fully behind me. I couldn't see him, you know, five and a half years. So yeah, I mean, it still exists. Although there are other kinds of therapies, right, where you move around the room and you use a whiteboard and you graph something out and you look at this. Or, you know, where there's a sort of behavioral medicine has some sometimes people are touched, right?
Kurt:You know, where like but there's consent for that. Like, can I position? Sometimes it involves a sensor or something that measures how you're breathing or your heart rate or something like that. Or can I show you how to hold your shoulders so that you don't do this with you? And so there are some therapies that do that.
Kurt:Psychodrama sometimes involves some of that. Which we've
Hans:talked about on the show a few We've talked about
Kurt:on the show, right? So it And so
Hans:didn't even know it was a thing, yeah.
Kurt:Yeah. And it can be enormously helpful. But the hope would be that whatever you're doing, that there's a sort of consent for that. And that the person seeking help, the client, the patient, whatever we call that person, that their request for help is always at the center of it, right? That it never becomes about something that the therapist needs or wants that, you know, because then it's exploitative, right?
Kurt:People are in a very vulnerable state and there are bad therapists in the world that violate our codes of ethics and sort of cross boundaries with people and things like that. It's terrible when it happens. But there are rules about it, and it's often against the law depending on exactly what happens.
Hans:I have started I got a diagnosis of OCD, and I've been working through OCD therapy for a year just over a year now. And my OCD therapist, whom I adore, said something to me when we first started working together that I'd never had a therapist say to me, which was explicitly, she said, I will never, if we run into each other in public, because she's local, lives just not down the street, but close. She said if we ever run into each other in public, I will pretend not to know you. Mhmm.
Kurt:Yeah. Yeah.
Hans:I will respond if you approach me, but I will pretend we don't know each other, which is kind of an extension to the fact that she doesn't take insurance because there's a lot of people who don't want it reported in any way to to a medical establishment that they've got this sort of diagnosis because there could be implications for it. But that sort of, like, your secret is safe with me to the point where if we run into each other at the farmer's market, we don't know each other.
Kurt:Mhmm.
Hans:And that's that's a protection for me. Is that a common thing with a lot of therapies that it's it is that privileged of a space?
Kurt:Oh yeah, absolutely. Yeah. And that would be the usual, that's the usual advice I think most therapists would take. Like I won't, if you greet me, I'll say hello back, but I'm not going to acknowledge you in public that way, you know. And most of the time, even if you ran into a person and they approached you with somebody and said hello, and the person says, how do you know them?
Kurt:We still wouldn't, you know, we would just say, oh, you know, I don't know. Know each other from around town, you know, and the rest. And the person might then say, no, he's my therapist. You know? But, yeah, could they could do it, but we can't do it.
Kurt:Right.
Hans:It allows the patient to dictate the terms by which they are public about it or private about it. Right?
Kurt:That's right. That's right. Yeah. We get used to that. I live in a small town, and so it's nice to live 10 miles outside of town, you know, because at least I know.
Kurt:But even then, you know, you run into people and that sort of thing.
Mary:Even if it's a great therapist, when you're talking about the relationship, can there be a mismatch like any friendship or relationship where it's just not vibing, it's not working, and is that common? Does then the client say, you know, it's just not working. I'm gonna try someone else. Is that advisable?
Kurt:Oh, yeah. Absolutely. I I I think this sort of fit, you know, both in terms of, like, is what the person offering the kind of thing I'm looking for? Is it the right kind of therapy for the problem I have, right? That's one thing, right?
Kurt:And then the second is, do I feel like this is a person I can spend an hour a week with? There's a lot of people that are, I'm sure are great that I necessarily feel like I would look forward to spending an hour a week with. People I can imagine would feel that way about me. And that's fine, right? We all really just want folks to find someone that they really feel good about.
Kurt:And I would say, like, if you're not kind of clicking with someone in the first couple of meetings, you're probably not going to. Try a couple people. Shop around a little, and there's no rule against that. That's perfectly fine to do. Anyone that really discourages that, probably that'd be like a red flag anyway.
Kurt:Right? It's we want people to feel comfortable.
Hans:So, Kurt, I think a common refrain that I I hear in a joking way or maybe a little bit afraid way associated with, oh, I'm not going to a shrink, which, boy, we could talk about that term for a long time, is they're gonna tell me to hit my parents, and they're just looking for money. And they're gonna tell me I need to come five times a week for the rest of my life, and they're gonna charge me out the nose for it. Like, it's just it's a scam.
Kurt:Right. Right.
Hans:Yeah. So that's the impression I think some people have of therapy and the act of therapy. But is it for is it a forever thing? Do you just I'm now a person who goes to therapy? Is it discreet?
Hans:Does it end? How do you know you're done? How do you know it's, like, run its course? How do you finish therapy? Can you can you win therapy?
Kurt:Can you win therapy? Absolute well, I mean, I don't know if you can absolutely win therapy, but but you you definitely yeah. It's a good question. And it's a complicated one. How do you know when you're done?
Kurt:And it depends a little bit on like some of the answers that people will say are, well, did you come for? Right? And did you get what you came for? Sometimes that's not a bad starting point necessarily, right? If my hope was that I would be less anxious and have better relationships with the people I care about, do you have that?
Kurt:We should be checking in about that periodically. And if you do, then maybe it's time to think about stopping. That would be fine. Right? If it's about the sort of management or control of a particular symptom or something like that, Is it under control?
Kurt:Is it better? Are you less depressed? Sometimes things that are more complicated, like can lead into longer term kinds of things. And the therapy relationship can become an important relationship in a person's life, sometimes with multiple and different things being the focus at different times. But perhaps with periods of greater intensity of treatment and periods of lesser intensity or something like that.
Kurt:So some long term folks are, you know, are still sort of using therapy in sometimes more acute ways and less acute ways. And some people find that being in therapy over a longer period of time also helps to manage what are sometimes for them longer term issues, right? One problem that we have sometimes, just to take an example from medicine, is that we don't adequately differentiate acute and ongoing or chronic, I don't love the word chronic, but acute and chronic problems, right? So if you have like the flu, you know, you take, hopefully, that's just an acute problem. You get some treatment for the flu and the flu is gone, right?
Kurt:But if you have alcoholism, well, maybe you can stop drinking, but maybe there's a lot of work to do after you stop drinking also, right?
Hans:Yeah, yeah. You'll always have it.
Kurt:Yeah. You'll always have it. And it's not that you are cured or that something happened, but that there are different things that happened. Depression can be a long term problem in people's lives, for example. And one that is for some people, even gets more complicated at different periods of time or when different things crop up.
Kurt:The idea of using psychotherapy to help manage that is not always the worst idea in the world for folks. And for some people it's totally indicated above board if you're paying out of pocket worth the money. I will also say like a lot of people go to therapy and they go to people that do take their insurance. And there are a lot of people that do that. And so it is a more recognized covered benefit because of some federal laws, sometimes state laws that mandate that we have to treat this as a problem like we would treat other kinds of health problems.
Mary:Like other health problems in the medicine world, you know, sometimes you get a surgery and it makes things worse or it doesn't work. Is there ever a time when therapy can worsen someone's mental state? Does someone have to go to therapy because of therapy ever?
Kurt:Wow. Oh, that's bleak. It's a it's a good no. It's a good question. There are people that argue that in the informed consent process, that's part of what we should say to people actually.
Kurt:Is that part, what are the risks of therapy is that your problems might get worse? And some therapists don't like that because they say, well, you know, in general, that's not how it goes, you know? But individuals, that might be how it goes, you know? Or at least, and that could be like a temporary effect, right? You've opened something up and now it feels worse.
Kurt:But certainly that can sometimes cause a crisis. People can end up in acute states related to that. It's not the most common thing and we look out for it, but it can still happen. As well as just the idea that like sometimes mental health problems have their own things in the world that make them better and worse. We're not, the therapy doesn't control all of those things, right?
Kurt:So sometimes a person can be in therapy and then still life is hard. And even if the therapy is helpful, the things that are sort of pulling them in the other direction are stronger, whether they're internal or external things. But you know, it's sort of like there's a warning label on antidepressants that they can make suicidal thinking worse. We should take that seriously, right? We should always be watching for suicidal thinking.
Kurt:But like clearly there's a pretty good body of evidence that actually the medicines have an indication for a reason, right? That most of the people that take them feel less depressed, have less of that kind of problem, even when some people might have a different reaction to to them or something like that. So we you know, we'd be careful about it, but we're that would be probably looking for the atypical kind of reaction rather than the typical.
Hans:Kurt, this has been so much good stuff to think about, but it is very complicated. More complicated than I thought it was gonna be, and I felt like I knew something about it. It's a hard thing to explain. It's a hard thing to communicate. And I wanna put a hypothetical in front of you, because I'm actually experiencing this hypothetical in my real life.
Hans:But I think it's kind of a a way to summarize a lot of what we've just talked about, which is I have a friend slash family member in my life who I think would benefit from therapy. I would say that they are curious about it. Maybe even, oh, I should. Yeah. Oh, I should.
Hans:But like everything we've named, it's complicated to know where to start, who to reach out to, what the rules are, what the experience is gonna be like, all that sort of stuff. And it feels like all of those add up to just too many barriers for them taking action, to this thing they're curious about, they're open to, but, ugh, would you say to this person to tip the scales for them to taking the risk, to taking the action, to putting themselves out there, to trying to do this thing that we've all kind of agreed might benefit them?
Kurt:Yeah. And I can think of people like that, some of whom I will never convince also, And it's okay. It's not my life's mission to convince people to go to therapy. But I do think that there are times where you can kind of see that it would help somebody. And it really would, like, oh my goodness, like there's a kind of suffering you have, a kind of unhappiness in life that maybe you don't have to carry around.
Kurt:And I think therapy is often good for that. It can really help. A lot of the time therapy gets good reviews. You know what I mean? I mean, like if you go to people afterwards and ask them like, how was it?
Kurt:And then you go to the therapist and ask them, how do you think it went? The person receiving therapy almost always gives the better review of the two, right? Oh, They got even more from it than we would have guessed necessarily, right? And when you look at it and you study it, right, you say, well, the effect size is very large actually, right? It's not just that it helps.
Kurt:It helps a lot, actually. Sometimes for a thing to be helpful, it doesn't even need to help a lot, but it does. It helps people a lot. And so when you see somebody that's sort of like nervous about it, I can understand the nervousness, but I do sometimes have the wish like you do to sort of say, why not just try it? You know?
Kurt:How would you do that? I think probably to try to connect them to an individual therapist, like a particular person, rather than to the idea of therapy. Like, I know this person that I think has openings and might be good for you to talk to. Here's how they work. Can I help with that?
Kurt:And even if you don't know the therapist, a couple of personal recommendations offer to help, Offer to talk about it. And be specific about why you think so, right? I mean, nobody really, it's like being told you look sick or something. You know what I mean? It's like, yeah.
Kurt:But
Hans:that's true. That's a good analogy. Yeah.
Kurt:It's sort of like, no, no, sick here. No, I'm here. Fine. I'm not, I'm going figure this out. You know what I mean?
Kurt:I'm not Be specific about what you think might be able to be different and better in folks' lives. If you have a personal experience of that that's leading you to want to recommend this, share that personal experience. I have a different problem I've been struggling with, but I got help in this way. It was really helpful. It's a little weird at first, but, you know, you get really used to it.
Kurt:And then see what happens, I think. The more personal you can make the appeal and the more you can make the connection a human, you're connecting them to a human being that does this rather than to an idea or a concept or a set of names on a list that their insurance company gave them or something, that probably will help.
Mary:That's great advice, Kurt. Thank you so much for fielding so many of our questions.
Kurt:Yeah. Thanks, Kurt.
Mary:And Hans, I know you and I both have many more, so we'll have to do this again.
Kurt:Oh, yeah. Good. I had a lot of fun. I hope it was brought to you by Brattleboro Retreat. Our producers at Charts and Leisure are Andrew Adkin, Hans Buteau, and Jason Oberholzer.
Mary:And you can find us on social media by searching Brattleboro Retreat. Brattleboro Retreat is committed to exploring diverse perspectives on mental health. While we invite hosts and guests to share their insights, the views expressed are their own and do not necessarily reflect the policies or positions of the hospital or its staff.
