Remembering some of my weirder moments in therapy. Presents an overview of CBT, DBT, psychodynamic therapy, and EMDR. Addresses how to know which one is right for you and asks four key questions to consider before booking your first session.
Contains a directory of searchable provider listings from several national mental health organizations to help you find a suitable clinician.
In this scene from Dune, a 2021 movie based on Frank Herbert's astoundingly imaginative sci fi novels, Timothée Chalamet's character Paul of House Atreides must stick his hand in a box that produces tremendous pain - comparable to that caused by holding one's arm in a blazing fire. If he so much as moves a finger, a Bene Gesserit hag will kill him with the poisoned gom jabbar needle that she is holding to his neck. In case you're wondering, I'm mentioning this because I once went to a psychiatrist who used a similar method to measure distress tolerance (except with ice and minus the gom jabbar).
Meet 65% Executive Dysfunction Tessa
Three statistics to set the scene:
͎• 92% of American adults prefer to date someone who has undergone therapy*
͎• 22.8% of American adults had some form of mental illness in 2021
͎• 75% of people who undergo therapy have some positive effects
*If you’ve ever lived in NYC, you know that it’s 99.99% there
So, therapy works. Therapy is important. But anyone who has ever worked in the medical field knows that psych attracts a… unique… set of practitioners.
A quick story because I need to unburden myself. I was once in an inpatient addiction treatment center in Delray Beach, Florida, which is a bougie area that became the recovery capital of the U.S. and the relapse mecca of the universe during the rehab craze of the 2010s. This facility was located in a beautiful area with designer McMansions crammed in next to each other along a system of labyrinthine canals so that they could all be considered “waterfront property.”
For whatever reason, the patient set at this treatment facility was mostly young, gorgeous people (cue: insecurities about my physical appearance).
Now, every treatment center has a no-fraternization policy because burying one's sorrows in another patient's orifices is seldom a sustainable recovery plan.
At Palm Partners, there was endless drama around staff discovering 2 a.m. laundry room liaisons or dinnertime hookups in storage closets. I suppose that these relationships were inevitable, especially considering that we played co-ed beach volleyball in skimpy swimsuits every afternoon - what did they think would happen? It would have made good reality TV, honestly.
Anyway, on account of the enthusiastic enforcement of its no-fraternization rule, we patients gave Palm Partners a new slogan, “Palm Partners: Where your palm is your partner, and your finger is your best friend.” I’ll let that sink in for a moment.
To its credit, the facility offered a variety of treatment options, including some complementary and alternative methods like Kundalini yoga, sober raves, and sweat lodges.
Its head psychiatrist was a short, mischievous-looking man with hair sprouting from his nose and ears; he looked like a dwarf from an Eastern European fairy tale. The first time that I saw Dr. L, I arrived outside his office five minutes early. I didn’t see anyone to greet me, so I knocked on the door. There was no response, so I opened it a crack.
Inside, I saw a fellow patient named Tessa. She was a coltish, straw-blonde girl from Jersey, and she was wearing a green Ninja Turtles outfit with a backpack for a shell. We referred to her as 65% Executive Dysfunction Tessa due to the unfortunate results of a brain scan undertaken to try to determine why she had absolutely, positively no filter on what came out of her mouth. I should probably mention that Tessa was sitting on the ground in front of Dr. L, who was in a standard office chair with his computer propped up on a small table to his left.
“Oh, hey, Brian; I wish you weren’t gay so I could f*ck you,” Tessa called. "I'll be here for another few weeks, looks like; they say that if you're from Jersey, they automatically keep you for double the time."
“Be with you in one moment,” Dr. L greeted me.
A few minutes later, Dr. L ushered me into his office and invited me to take a seat. There were maybe eight different options arranged in a rough semicircle around his own chair, including a loveseat, a stool, a desk-chair with an L-shaped armrest / work surface, and a spinny office chair.
I thought about the desk, but I didn't want Dr. L to think that I was asserting my studiousness to try to impress him or something. Instead, I selected the most unremarkable option, a black, sled-base chair that would have been at home in any office or waiting room. Is he going to think that I don’t want him to know anything about me? That I’m resistant to opening up or dishonest? Dr. L turned to his computer to type a note as I cursed fate for not giving me Tessa's executive dysfunction superpower ("F*ck you and your C-list cliche of a psychological experiment," I imagined telling him).
Five minutes later, I plunged my right arm into an icy bath that Dr. L’s assistant had brought in. I kept my hand there until cold had become searing pain and my entire arm was shaking spastically. Anyone who has ever read Dune will understand the Bene Gesserit stress test parallel running through my mind. When I gave in and withdrew my hand from the ice bath, half-expecting the sinister prick of the poisoned gom jabbar, I knew that I hadn't lasted very long; my nerves were hypersensitive from coming off of benzos and opiates, which made ordinary tasks like shaving and brushing my teeth very uncomfortable.
“Can we do it again with music?” I asked as I flexed my fingers, enjoying the tingle as my arm returned to room temperature.
“Sure,” Dr. L responded with raised eyebrows.
I put my AirPods in and selected “Layla” on my iPod, skipping to the hauntingly beautiful electric guitar / piano solo that dominates the second half of the song. This time, as I held my hand in the ice bucket, I fit my pain into the spaces between the notes, tucking it in between E-flats and C-sharps, under codas and in the pregnant pauses between chords. I subtly undulated the muscles and tendons of my hand and forearm in rhythm with the ups and downs of the tune until they became too frozen to feel.
I outlasted the fiery pain phase and entered a state of partial dissociation, in which my vision blurred and I couldn’t feel my arm or hand hardly at all. My whole limb all the way up to the shoulder felt like it was floating, and still the melody cradled me. I gave a surprised jerk when Dr. L instructed me to withdraw my arm.
“Any longer and it could cause some damage,” he explained. “I’m writing in my notes that you show some distress intolerance, but that it is well-compensated-for with coping skills like music…”
Dr. L was trying to assess whether I could tolerate physical discomfort as well as a “normal” person. In this case, he was evaluating this with a physical distress test - whose results, interestingly, closely parallel those of mental ones for a given individual, providing one example of the brain processing physical and mental pain in a unified way. I knew where he was going with this: Dr. L was using this test to determine whether he should approach treating me through the lens of DBT or CBT.
Without a little background knowledge, I would have been bewildered. Moreover, I wouldn’t have been able to talk to Dr. L about my own priorities in a way that meshed with his approach. When it comes to treatment, it pays to do your own research* before you engage with the medical system.
*It's me; I'm your research.
Untangling the Therapy Alphabet: CBT, DBT, Psychodynamic, and EMDR
Take a simple issue like anxiety. You decide to meet with four different therapists specializing in four different methods:
͎• The psychotherapist is probably going to talk to you about when in your life anxiety started becoming an issue; they are also likely to be interested in how your parents and other key figures from childhood dealt with their own anxiety and whether you felt safe at home and school growing up
͎• A DBT practitioner is going to teach you to put your face in ice water to calm your heartrate during anxiety attacks
͎• A CBT-based therapist is going to examine the irrational thought patterns that magnify and sustain your anxiety and teach you to create an adaptive mental narrative to counter them
͎• Someone using EMDR is going to select the most disturbing images, thoughts, and memories that provoke your anxiety and present triggering stimuli while having you focus on a counternarrative and watch the therapist move his finger from side to side
So, four different therapeutic approaches, four entirely different experiences as a patient.
Most therapists employ eclectic methods, and as I mentioned above, if you don’t understand their theoretical framework, you’re not going to be able to track your own progress and advocate for yourself effectively.
Alright; let’s get down to the nitty gritty.
Cognitive Behavioral Therapy is probably the broadest and most widely used of the therapeutic lenses that I’ll talk about today. Basically, CBT helps you to identify maladaptive thought patterns (see infographic on cognitive distortions below).
As an example, consider negative internal monologues that magnify and catastrophize anxiety, such as “Oh my God, my heart's racing, my blood pressure's going to spike and I’m going to die.” CBT corrects cognitive distortions that make mountains out of molehills (“My boss just told me that there are corrections needed on my project; I’m going to lose my job, and I won't be able to get another because I won't have a good reference, then I won’t be able to pay my rent, so I’m going to end up homeless").
I’m using hyperbolic examples, but hopefully you get my drift. CBT teaches you to recognize maladaptive thought patterns that produce and feed into negative emotions.
It also gives you practical skills to deal with the problems in your life. If you’re having marital issues, for example, your therapist might model a conversation with your spouse in which he or she plays your partner. The two of you will reenact a typical argument and then model a different set of responses that could shift it in a more positive direction (switching roles is fun with this kind of exercise, too).
If you’re experiencing depression, anxiety, or other symptoms that are magnified by negative thought patterns, CBT is likely the way to go; CBT is great when thought dominates feeling. Almost all therapists will have some grounding in this therapeutic approach, which was formally developed in the 1960s but draws on techniques and theories that existed long before.
CBT teaches us how to reframe our thoughts to avoid cognitive distortions that produce depression, anxiety, and maladaptive behaviors. I am a proficient catastrophizer; small setbacks act as kindling that my mind uses to create vast apocalyptic forest-fires as I'm up at 3 a.m. worrying about my future. I never have a simple cavity; I suffer from painful oral bone infections that will lead to endocarditis necessitating valve replacement, which will reduce my lifespan to 3-5 years. CBT techniques help me to walk that thinking back and reframe life situations in a more balanced way. Infographic from mentalhealthathome.org.
Dialectical Behavioral Therapy is an outgrowth of CBT specifically designed for people with Borderline Personality Disorder (described in my PSA on Cluster B disorders). It’s been used for a variety of other diagnoses, as well.
Basically, if you’re someone who sometimes gets so swept up in their emotions that thought becomes almost irrelevant, DBT is for you.
Many addicts suffer from severe mental and physical distress intolerance, and DBT can help with multiple aspects of addiction. For example, DBT groups taught me meditative exercises to manage my withdrawal symptoms.
Dialectical refers to a back-and-forth; it has to do with reconciling opposites. DBT is meant to shift patients away from black-and-white thinking about the people and situations in their lives. It helps us to understand that two opposite things can co-exist and both be valid.
Like CBT, DBT has a module focused on effective communication. As I mentioned above, it also emphasizes mindfulness methods such as breathing exercises and other tools descended from Eastern spiritual traditions.
If you have a Cluster B diagnosis or you're hotblooded, irrational, and impulsive due to your addiction or other mental health problems, DBT is a godsend. For people who struggle with these issues, CBT won’t be very effective because in the fury of the moment, emotions override thought for many people, especially those with severe anxiety, depression, and PTSD.
See the following chart for a helpful comparison of CBT and DBT.
This chart is reproduced from simplypsychology.org, which has some good mental health-related resources.
Psychodynamic therapies are often used for people without mental health diagnoses ("normies") and patients who are seeking insight into why they feel and act the way that they do. Emphasis is placed on the context in which you developed your patterns of thought and feeling; you’re likely to be asked about what home life was like growing up, how you felt about school, how you related to elders / authority figures, and what some of your key early memories are (both positive and potentially traumatic).
Your therapist will help you to uncover far-reaching beliefs that were ingrained in you during development and that might have become subconscious, which are still influencing how you think and act in the present (for example, ideas like “I’m not good enough” or “Everybody’s out to get me” or “I’ll never find real love”).
Again, the psychodynamic approach is focused on developing insight. This therapeutic mode is less likely to employ direct, practical behavioral methods such as dunking your face in ice water to calm anxiety or snapping a rubber band on your wrist to stop an intrusive thought. The premise is that heightened awareness will naturally give rise to change. From this perspective, understanding your past is the key to controlling your destiny.
Psychodynamic theory developed out of Freudian theory and other talk-therapy-oriented schools of thought. It retains their focus on how profoundly early life experiences influence later mental health and behavior.
Finally, EMDR, which stands for Eye Movement Desensitization and Reprocessing, is worth mentioning because I have seen it produce positive results for other addicts, including a fellow patient who was a State Trooper whose job involved investigating violent crimes against children. After twenty-five years on the job, this man was deeply traumatized by the remains of child victims and other horrifying sights that had been indelibly imprinted on his mind; he told me that EMDR helped him more than any other therapeutic technique or medication that he had tried.
During EMDR, you will be asked to evaluate beliefs connected with traumatic moments in your past (for example, perhaps “I am ruined” connected with a sexual assault). You will formulate a more positive cognitive response, e.g., “I’m a resilient person who is on a positive path in life, and I control my own destiny." After being shown a traumatic trigger, you will focus on the positive thought as your therapist presents a stimulus that initiates side-to-side eye movement, such as a finger moved back and forth in front of your eyes.
It’s theorized that this lateral eye movement triggers reprocessing of trauma by both hemispheres of the brain, which allows the brain to bypass “stuck” or “broken” neural networks and form new ones that respond more effectively to trauma-associated pain and anxiety.
EMDR is used for people with PTSD, intrusive thoughts, anxiety, dissociative disorders, eating disorders, and substance abuse problems. There is some controversy over its efficacy and potential dangers, but if you have a few unforgettable traumatic moments or intrusive thoughts that dominate your internal life and trigger negative episodes, EMDR is certainly worth looking into.
Let's take a moment to review. if you’re someone whose negative thoughts generate anxiety and depression, CBT is probably the way to go. If you’re dealing with emotional overload and need to re-center your mind and body, check out DBT. If you’re interested in gaining insight into your past and how it is producing your present, psychodynamic approaches are likely to be of use. Finally, EMDR is based on reprocessing of key traumatic moments and intrusive thoughts, so if you’re someone dealing with PTSD that is possibly related to a substance abuse or eating disorder, I’d recommend looking into EMDR.
Key Questions to Consider Before Your First Therapy Session
I’ve put together a list of questions that I think anyone entering therapy should consider before they make that first set of calls.
1. What mental health diagnoses have I been given? Are there any undiagnosed conditions that I suspect that I might have? Are there any problems with my physical health that could be influencing my mental health?
2. What issues in my life do I want to work on?
For example, “I want to improve my marriage,” “I want to feel less anxious,” “I want to cut down on my drinking.”
3. What therapeutic modalities am I interested in?
Not all therapists will be trained in DBT and EMDR, but most will have some grounding in psychodynamic approaches and CBT. Ask about what workbooks and other materials are used; competent therapists will have an organized approach in applying each therapeutic modality.
Remember that only a physician (typically a psychiatrist), certain midlevels (Nurse Practitioners or Physician Assistants), and in some states, clinical psychologists with PhDs and Psy Ds can prescribe mental health medicines. I recommend seeking out a PhD-level clinical psychologist whenever possible, but due to insurance limitations and a dearth of providers, this can be challenging.
If you're in standard inpatient or outpatient therapy, your counselor likely has an associate’s degree in counseling or substance abuse treatment. If you’re dealing with a Credentialed Alcohol and Substance Abuse Counselor (CASAC), you need to figure out whether they have sufficient training in any of these therapeutic approaches and seek help from someone else if they don’t. Licensed Clinical Social Workers (LCSWs) are master's-degree-level professionals who are often wonderful to turn to, and they tend to be more prevalent in addiction treatment contexts.
4. How many sessions does your insurance typically cover? How much time per week or month can you devote to therapy?
Make sure to budget time outside of your sessions to reflect on what you've learned, practice new techniques, and complete "homework." It’s important that you and your therapist come up with a plan of attack after one or two sessions to make sure that you have defined, measurable goals that will be addressed during your time together.
Here are some resources for finding therapists specializing in different approaches and populations:
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