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Addiction, anxiety, mental health.

How do we address our traumas?

And how do we begin to move forward?

The path to healing and understanding is through candid conversation.

I'm Aisha Sultan, and this is Things We Don't Talk About.

So you've decided to get help.

It may have taken years to get here.

Maybe it took courage you weren't sure that you had.

Then you have to search for a therapist, which can be another process.

And what actually happens when you're in that first session?

There's so many different approaches to therapy, and it can sound like a list of unknown abbreviations.

Will your therapist be using a modality like CBT, DBT, EMDR, or IPT?

What does any of this mean?

And how do you know what's right for you?

For the nearly 60 million Americans living with a mental health condition, taking that first step is hard enough.

Figuring out what comes next shouldn't feel so hard.

Today, we're going to be cutting through some of this confusion.

Three different therapists will join us and break down some common approaches to treatment, what they are, how they work, and who they're best suited for.

Right now, I'm joined by Julie Probus Shad, a licensed clinical social worker who can explain a few of these therapeutic approaches.

Hi, Julie.

Hello, thank you for having me.

Absolutely.

Okay, so tell me what a therapeutic approach to therapy even means.

A lot of people think talking to therapy is like talking to a good friend who's just going to listen to you without any judgment.

How is therapy different?

So therapy is different in many ways.

Probably the first way is a therapist is an objective observer who doesn't have the bias that might come with friends and family.

So that's one thing.

The other thing is is that a therapeutic approach is an approach that means there will be change.

So we're not talking only about talking about what brings you in.

We're going to have plan and goals and methods to get to where you want to go.

So therapeutic approaches are about change.

So those methods that you're talking about, and some of those abbreviations that I said earlier, how are they different?

And tell me about the ones that you have found that have been really helpful to people.

- Okay, so there are many different approaches.

Today I'll be talking mostly about eye movement desensitization and reprocessing, and dialectical behavior therapy.

So that's EMDR and DBT.

- Okay.

I have no idea what that means right now.

- Okay, you will, you will.

So when a client comes in, the therapist along with the client collaborates.

So first we assess, what are they here to resolve?

What would they like to change or improve?

And during that assessment, we begin to determine in collaboration with the individual, what technique or tools we might use.

So if we were going to use DBT, which is Dialectical Behavior Therapy, we might have a client who has a very hard time calming their own nervous system, feels distressed frequently, have something called cognitive distortions where they have negative core beliefs that we know aren't true but feel true to them.

- Okay, okay.

And so when you, what does it mean to like do DBT with another person?

Yeah, so what it would mean to use DBT with a client, for example, is we're going to see what are the areas that are most impacted in their life.

And then we're going to use primary tools.

So first of all, we're going to teach them mindfulness techniques.

How do you be in the present moment instead of fearful or anxious about the future or looping and stuck in the past?

So that's the number one tool is wise mind.

How do we work with a wise mind?

So many people don't know they have a wise mind that we just have to access it.

And then we're going to teach them distress tolerance skills.

So when our nervous system gets activated by something that causes us fear or anxiety, oftentimes we think we just have to run with those feelings in our body.

- Like we're upset and we just need to react to that.

- Right, we just wanna react.

So DBT is a way to help people learn to pause and respond.

And then teaches very specific tools about how do you calm your nervous system?

How do you have emotional regulation?

And oftentimes people weren't taught this in childhood.

And so they are imagined they should just have this skill, but they don't.

But the good news is, is that we're lifetime learners and we can learn these skills.

- Oh, that's great.

And so how does that look different than EMDR, which you mentioned earlier?

- Okay, so EMDR was originally founded for post-traumatic stress disorder, which originally was with veterans from Vietnam.

And what we found is that EMDR, eye movement desensitization and reprocessing, works for many problems, not only severe traumatic stress disorder, but also recent traumas.

So essentially with EMDR, what we do is, so originally it was follow my fingers, which was the eye movement.

But what we do is we activate a memory network.

So we wanna know what is the worst part of the memory.

And then we get the emotions, the body sensation, and the negative belief that goes with that memory.

And we add something called bilateral stimulation, which can be tapping.

- Okay.

- And that activates the whole brain.

Usually when we're dealing with trauma, we're only dealing with the part of our brain where the trauma gets stuck in a fragmented form.

- Okay.

- And language and other skills are actually locked out from that trauma network.

So with EMDR, we light up the memory network, we access where the trauma lives, and then with the bilateral stimulation, we begin to get access to language, which is in a different part of the brain, as well as just the tapping alone sets off something called the parasympathetic response system, which is a fancy way of saying it just calms your nervous system.

So suddenly you have access to what you always knew, but couldn't link in because it was locked out.

So from what I'm understanding here, a therapist who uses EMDR or is skilled in it can help you relive or walk through a traumatic incident or memory that feels very emotionally triggering to you in some way, you have strong emotion attached to it, can guide you through that along with some tapping or bilateral movement and ask you guided questions so you can process that memory through your body in a different way with different beliefs.

Is that right?

- That's exactly right.

The one caveat I would say is the good news about EMDR is you don't have to relive the entire experience.

We actually don't want you to.

We want to just tackle the worst part and get stuck.

We say the neurons that fired and wired together at the time of the incident or incidents, we want to calm your nervous system and give you access to your natural ability to heal.

So we don't have to relive it.

We just want to go to the worst part and then reprocess it.

That is fascinating.

And I think it's helpful for people to know that these techniques and therapies that you're talking about, they have a body of research behind them.

So it's not just like someone thought up a bunch of ideas and they think it works.

There's actually research with people who've been through these therapies who feel much better, whose lives are going much better.

Isn't that right?

- It is so correct.

And evidence-based treatments are imperative.

We really want to give our clients the best care.

And we do that by having evidence.

So what I will say is EMDR and DBT were both founded around the same time in the late 1980s.

- Oh, so they've been around for a long time.

- Yeah, they've been around for a very long time.

And they are two of the most researched modalities that there are.

- Wonderful.

Thank you so much for coming on the show and explaining these things.

And it's something that if you're thinking about therapy, you can ask a therapist about if they're trained in this, if they use it, and if they think it would be appropriate for you.

- Thank you so much for having me.

- Welcome back.

Now we're joined by Monique Gill, a licensed professional counselor at Washington University Medicine.

Hi, Monique.

- Hi, how are you?

- Great.

So people talk a lot about CBT these days.

It's something I hear a lot of conversation around.

So can you help us understand what that is a little bit better?

- Yeah, so cognitive behavioral therapy is a therapy that helps individuals figure out their connection between the thoughts, feelings and behaviors.

It's really helpful when you're feeling anxiety, maybe you're feeling stress or just everyday challenges in your life.

- Okay, so I'm gonna use a personal example and you tell me how CBT would work in that situation.

Let's say I come to you because I am feeling really anxious and really sad about my father who hasn't been well for a long time and has recently started hospice care.

And I'm just like so distressed about that.

How would a CBT approach look like in a situation like that?

Well, first, in the beginning, you would provide psychoeducation on what automatic thoughts are.

So what the theory is, is that we have thoughts that pop into our head automatically.

And sometimes those thoughts can be helpful, and sometimes they may be unhelpful.

So we'll go through those automatic thoughts, and then we will talk about unhelpful patterns.

So you would educate the person on, are you thinking something is a worst case scenario?

Are you thinking very black and white about the situation?

So what are some of those thoughts?

And then you're actually having them provide evidence for, in support of a thought or evidence against that thought.

- Okay.

- So it's really a way of figuring out, is this thought helpful?

Do we have evidence about it?

Are we forecasting into the future?

- So it sounds like it's sort of like helping the person logically understand their own thoughts about it.

Like for me, I feel like what makes me so upset is that I feel like my father's suffering and it's very painful.

I feel very helpless to help him or to do anything about it.

So that's my thought.

- And so what's important also in CBT is also think about how calming strategies can help with that and how do you problem solve.

And so in the process of going through your thoughts, you say, "Hmm, what am I feeling connected to that thought?"

And then, "Well, how am I behaving?"

And so, a part of CBT is saying, "If we have this thought and challenge it," and then if it's like, "Well, I get really anxious," it's like, "Let's calm and say, are we forecasting into the future or are we thinking the worst-case scenario?

What are some other ways we can think about this situation that might be more helpful to our anxiety about the distress?"

Amy Quinton If I'm able to think differently about a situation, will that change how terrible I'm feeling about it?

No, it won't change it, but it might help you find... Part of what is also is just going out and maybe doing activities that might calm it.

So, like, if you're feeling very distressed right before you go see your father, you might say, "Hey, let's do some behavior activation."

So maybe we need to go take a walk beforehand or take a walk afterwards.

We call it cognitive restructuring.

So you go through the thought and you say, what are some different ways to think about this situation that would be more helpful?

And so it's called cognitive restructuring.

So maybe the thoughts then are contributing to my, I'm gonna enjoy this time with my father.

And so, 'cause it's not thinking of the worst case scenario, you think about all the memories you have with your father.

And so, and then that brings a different feeling that comes up.

So you're thinking about things that will produce a different feeling.

- Okay, so what is that connection between our thoughts and our feelings?

Because sometimes I feel like I can think one way, but I still feel differently.

Like I can intellectually feel like I accept something, I'm at peace with something, but my body is still like upset, you know, feels dysregulated.

So what is that connection?

I think people do struggle with that.

Yeah, so we are beings that are all connected with the three.

And so sometimes you don't even notice it.

And so part of the education is that what are those feelings?

So we call it emotion identification.

So once you identify those emotions and then you share, oh, this is what I'm thinking about this.

And so it's not that it takes those emotions away.

It's very, in CBT, we definitely validate those emotions.

We normalize those emotions.

But at the same time, you're saying like the distress is coming from maybe this, what's not on cover.

- So are you feeling distressed because you're having a fear?

And so let's talk about that fear.

And is the fear rooted in something that we know or is it a fear of something that we don't know?

And so you really, you're questioning around, you're having more questions around the thought that then you're hoping then gives you a better sense of what that feeling is.

So if you're feeling anxious, say that's fine to be anxious.

And also is this anxious feeling helping in the situation or is that anxious feeling taking away from the situation in terms of the time you're spending with your father?

- I mean, how long does it take to work through all of this?

- When you're in a CBT intervention, it varies.

There's no automatic, it can take anywhere from six to 20 sessions.

Sometimes people start to feel relief in the first couple.

It's created to be very time-oriented, so it's not endless therapy, but also it's not a quick fix.

And so you wanna definitely spend time really getting to know those thought logs.

We call them thought logs, and so you track it every day.

And so when you have the thought log, you remember, when I had this thought, this is what my mood was like.

And so then you say, okay, and now I'm making the connection.

I'm thinking this, and my mood is low that day.

Let's now try to think about what other thoughts and what other behaviors we can do in terms of now producing when I was in a good mood.

I was in a good mood when I visited my father.

But what were you thinking at the time when you were visiting?

Were you thinking these happy thoughts?

Were you thinking happy memories?

Interesting.

Now, what do you wish people knew about CBT that a lot of people don't know?

That is very structured.

And so if you're looking for something that is very, like guidance is provided, it's skill-based.

And so when you leave in that first couple of sessions, you're going to have a skill.

The skill has to be practiced, like with anything.

If you're learning a new instrument or you're playing a new sport, it doesn't, you know, you have to continue to practice it.

And even though you're feeling well, it doesn't become automatic until you spend a lot of time with your therapist, providing that feedback, you bring in the challenge and then we work through that challenge each time.

Oh, that's so interesting.

So it's something that the person has to have a commitment, not just to sharing, but also making certain changes in the way you think.

- Yeah, changing the way you think and also, again, with the way you're behaving too, because it can all be connected.

If you are eating a certain food that is unhealthy, you have to start with that behavior, like how do you eat healthier and then you feel good?

So you might also have to start with a behavior that can then kind of jumpstart you into having a better mood and also then you say, oh, now I think better about myself because actually I did an activity that made me feel better.

Oh, okay.

So does a person need to know when they come to a therapist, like, I want you to take this approach, or does the therapist figure that out and say, this is what I think is going to work for you?

So it's very important for the therapist and the client to work collaboratively together to figure out what the best approach is.

And so when they come in, they provide the challenge and you kind of provide the education around these are the different modalities that can be used.

And then together you both agree on what is the next best step.

- Oh, okay, okay.

So you don't necessarily need to have it figured out before you come talk to someone.

- Absolutely not.

You don't need to have it figured out.

You work on it together and that education piece is so key because everyone is different.

Everyone responds to something different.

And so it's important to figure out what you respond to in terms of the different modalities that are presented.

- How quickly do you know whether something is working or whether you have to switch to a different strategy?

- And so that does, it's tricky because you wanna give it an opportunity to work.

And so you have to spend some time going through the techniques and if something, that's why it's important to bring in the challenges and going through the challenges.

And if you both agree like this still isn't working, then you might have the conversation about is it the way that it's being delivered?

Is it the way that it's being practiced in between?

And so then if you've kind of ruled out all of those factors, then it might be a determination like, okay, maybe we should try something different.

- Okay, great, wonderful.

Thank you so much for coming and sharing information about this.

I'm sure it's gonna be helpful to many people who are watching.

- Thank you.

♪♪ - Now we're joined by Shannon Lenze, a clinical psychologist at Washington University Medicine, who's going to explain yet another type of therapeutic approach to us.

Hi, Shannon.

- Hi, thank you for having me.

- Absolutely, so tell me what IPT is.

- Sure, IPT, or interpersonal psychotherapy, is a type of psychotherapy that was developed in the late 1960s, early 1970s, and it's really focused on relationships with other people.

So no matter what the cause of the mental health condition might be, it happens in an interpersonal context.

Our friends, family, and community are important to us.

- So how, like if someone has depression or anxiety, how do you apply a relationship lens to their problem?

- Sure, as an IPT therapist, I would be asking a lot of questions about who are the important people in your life?

Who are the people who are closest to you?

Who are people who are important to you but maybe not so close?

Have there been any changes in those people?

How often are you talking to them and are they contributing to the problem?

Or maybe these people are people you can lean into more for support.

- And then how does learning about those relationships help the person feel better about their problems?

- So we would think about, are there difficulties in the relationships that if we can work through these difficulties by working on better ways of communicating, maybe asking for help, if we can get some support from these people, maybe we can feel better about ourselves and better in our functioning.

- Sometimes though, like you might want to fix certain things about the relationship, but the person around you may not, or they have a very different view on that relationship.

So all you have control over is yourself.

You don't have control over how they're gonna react.

So how does that work in an IPT approach?

- That's a really good question.

That's exactly right.

Sometimes what we want in the relationship is very different from what the other person wants in the relationship.

And the challenges we see are very different from what the other person thinks.

So the therapist is going to work with that person to try to uncover what's in your control, what are the things that you can change about the way that you're communicating, how maybe might you deliver some education to the person that you're in the relationship with about what you're going through and what your needs are?

And sometimes the therapist might work with the person to say, is this a person that you want to continue to have a relationship with?

Right.

So sort of coaching what those conversations can look like, and then sort of guiding what that relationship might be healthiest for you.

Yes.

To continue.

Okay.

And so, you know, we've heard about several different ways of approaching therapy, but how does a therapist decide which of these approaches to use with a person?

Yes.

So that's kind of a million dollar question.

We don't exactly know what's the best fit for any person when they come into the door.

So we do a lot of talking with them to try to figure that out.

And it's really important that the therapists work collaboratively with that person to try to say, is it a problem in your thinking?

Or is it a problem with relationships?

What's going to be the best fit for you?

And then are like, how do you know which therapists use what type of approach or what they're trained in or what they're comfortable with?

You can always ask the therapist if they have a specific technique or modality that they're trained in or they prefer to use.

Other therapists are very integrative or eclectic, we call it.

They use a little bit of this and a little bit of that.

- Okay, great.

And is there something that's in common of all the different approaches we've talked about?

Like certain things that run through all of the approaches?

- Yes, yes.

So we use a lot of different letters, but at the end of the day, the thing that's most important about therapy is the relationship between the person and the therapist.

We know that that's the bread and butter.

It runs across all of the different therapy alphabet soup is that relationship piece.

- And how do you know if therapy is working for you?

- Hopefully you feel it.

So sometimes-- - You feel better.

- Yes, sometimes you feel worse before you feel better.

When we're asking a person to make change, especially if I'm thinking about IPT and I'm asking my client to make changes and nobody else is making changes that can upturn the apple cart sometimes.

But with the help of your therapist, they can guide you through it and ultimately the goal is to be feeling better.

- Right, and does it also make you feel more in control of like, like we're always gonna have stressors and things that happen, but maybe it returns the sense of like, well, I can handle some of this stuff a little better, I don't have to feel so overwhelmed or so anxious or so sad about this all the time.

- Yes, it can give you that sense of control.

It can give you some skills that you feel confident that I know I'm feeling this way now, but I know what to do.

It can also empower you.

I'm feeling this way now, but I actually feel like I have the confidence to go and make a change and do something different.

- And so this is gonna seem like a strange question, but if someone really has never done therapy before and they're maybe just Googling names or asking friends and family, "Oh, do you have a good therapist?"

How do they know if that relationship is gonna work for them?

Are there signs, are there questions they should ask on the phone before they even come in for an appointment?

- You can ask questions just to get an understanding of how comfortable does this therapist seem to be with me over the phone.

We use our gut a lot.

Do I feel comfortable talking to this person?

Is this person listening to me or are they just talking at me or over me?

Sometimes people have preferences.

They want a therapist that looks like them or is from the same culture.

And so you can ask those questions as well.

- Or has familiarity with how your cultural situation might be affecting what you're going through.

- Exactly, exactly.

- Right.

Oh, that's great.

And what do you feel like are some of the most common hurdles or obstacles people face when they decide they're gonna wanna do therapy?

- It can be a challenge to find a therapist.

So we think about challenges on multiple levels.

Does that therapist take insurance?

Is that therapist affordable?

Is it easy for me to get to that therapist?

Does the therapist offer only in-person appointments or is the therapist available by telemedicine or video conferencing?

Does the therapist do phone sessions?

So there's a lot of different questions you can ask to see how approachable or available that is.

- Right, right.

And like, right, if you can afford it, if you can get there, how accessible it is, and then how that relationship comes together.

And typically in your practice and the teaching that you do with other therapists, which approaches have the most evidence of success with people in like the shortest amount of time?

Because a lot of times people, they wanna see results and maybe they have a limited amount of funds and a limited amount of time.

So can you share a little bit about that?

- Oh gosh, we have almost 600 evidence-based different types of psychotherapies.

- Wow.

- So to say one is better than the other, I would be doing everybody a disservice.

- Wow.

- It really depends on what you're looking for, what your therapist is comfortable doing.

All of this has been around for a long time and has decades of research behind it.

- You know, I think that's also interesting because I was saying this earlier that people might have the misconception that it's just like someone listening to you.

So how is it different than just having a friend listen to you?

Yes, the listening part is important.

I think what the therapist adds on top of that is that outsider perspective, where I'm listening to you, but I'm listening for, is there something that I can help you to change?

Whereas friends and family might just be.

Yeah, that person is a bad person.

They're not pushing you or challenging you or or, asking you to think about things in a different way or behave in a different way.

Right.

And, you know, sometimes when you see a person that you love that's very sad or very hurt, our inclination is just to try to make them feel better by saying whatever or fixing the situation for them.

Yes, rather than like helping them figure out why they might be doing certain things over and over, or feeling a certain way over and over, or why they're stuck.

Yes.

So I was going to ask you about that.

Are there people who, like, fail at therapy and just get stuck and they don't make progress?

And why does that happen?

I don't want to say anybody fails if therapy, it's that the therapy, that particular therapy didn't work for them.

Okay.

And there's likely another approach that will work better.

Sometimes it's a bit of trial and error.

We have to, it's hard for us to know, as a therapist, what's gonna work best and fastest for any one person once they come in.

- And what should a person do to prepare and come in to get the best outcome out of it?

- I think a willingness to just talk about themselves.

Sometimes that's hard for us to talk about ourselves or to really share with a stranger.

Yeah, our personal stories.

And so I think you do have to have that.

Even if it's just a little bit of willingness to open up just a little bit and get your foot in the door and give it a try.

Right.

I mean, I think that it can feel scary and it can feel unnerving, one, to talk to a stranger, but also to talk about things that are very personal and might be painful to talk about.

But as someone who has done therapy myself, I can say it was so worth it.

I felt so much better after.

And that's why I wanted to have a conversation so people can learn more about it and feel more comfortable.

So thank you so much for the work that you do and for coming on and telling us more about this.

Thank you.

♪♪ - This program is funded in part by the following.