Tag Archives: Cognitive behavioral therapy

Psychotherapy: Have The Issues Changed Much in 30+ Years?

Someone asked me if the problems people come to see me about have changed much over the course of my practice.  I had to think about it, but the answer I gave is basically “no”.   The externals or presenting problems can look very different and how people approach things and what they look for in the way of solutions has changed.  We live in a high stress world but in my view the underlying issues are essentially the same.

The only real difference that I can pinpoint is that people are more open in talking about certain things.  A good example is that people are less reluctant to talk about sexual issues.  Sex in general is talked about more openly.   Sexual orientation and identity are no longer taboo topics.  Adoption and fertility issues are talked about more openly.   Addictions too are not hidden or denied as much.  As a culture I think we are more open and accepting – at least in my neck of the woods.  And so because the culture in general has changed, there is very little that is off limits.  Topics that used to be considered shameful or impossible to even mention, are talked about.  That is not to say that people don’t feel shame and pain.  They do.  But at least the world gives them permission to speak.  I consider that one of the most positive outcomes resulting from the diversity and transparency in our modern world.

Most people can talk about what was once off limits even if it is hard to open up and takes a while.  But the underlying problems regarding relationships, intimacy, self-esteem, trauma, abuse, feelings of loss of control, depression, anxieties, self- hatred –  the list can go on – those remain much the same.  We are all creatures of the human condition and so the problems we experience in our core are still the same.  It’s one of the reasons I believe in psychotherapy.  It’s a methodology that can hopefully reach us in that core.

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The Prevalence of Social Anxiety

Scratch the surface and there it is.  Social anxiety is much more prevalent than people realize.  I hesitate to use the word ‘disorder’ because many people who suffer from it don’t meet the DSM criteria.  In more lay man’s terms they would be considered painfully shy.  Saying one is very shy seems more acceptable than saying they have ‘social anxiety disorder’.  Severe shyness is often something that’s been there since childhood.

In my practice over the years, I would say that more than a third of those I see have social anxiety in varying degrees, even if never diagnosed.  Many are able to hide it so well, no one would ever know.  They are good actors & often that helps.  But more often they are avoiders, afraid to deal with the world. Then there are those with more overt symptomatology who suffer from panic attacks, are almost are unable to speak, shake visibly, and will actually faint if the stress is enough.  Medication has been very helpful for some as well as psychotherapy along with the use of CBT.  In my practice I have noticed it gets significantly better but it rarely goes away completely.

Most people have a certain amount of anxiety in obvious situations like making a speech or meeting new people or confronting a difficult situation.  But for people who have social anxiety, the triggers are not necessarily visible.  They can be afraid to make phone calls, get on a bus or walk down the street for fear they may meet someone, talk with shop clerks, have difficulty going out in general, and without a drink or two, barely function in social situations.  It may not always be apparent, but inside they are struggling.   They are severely self-conscious.  I believe that many alcoholics suffer from social anxiety and that that may be a contributing factor to their disease.  Intimacy and social anxiety is another difficult combination.  Meeting people is hard enough for those who suffer from it, but add the pressure of relationship, and the situation can become impossible.  Loneliness and social anxiety are not strangers.

Over the years I have noticed that not only is the anxiety itself dehabilitating, but the shame and judgments that accompany it make it much more painful and problematic.  Often those who suffer from it consider themselves, wimps, cowards and just plain stupid for not being able to do things that seem to come so easily for others.  Self-hatred & self-criticism are very common.  They are aware that most of the fear is irrational and hate themselves for not being able to overcome it.  It constricts their lives and they feel they are at fault.  Consequently the self-hatred is continually reinforced, and that makes the anxiety even worse.  It’s bad enough to have it to begin with, but with the added  constant erosion of self-image, the pain is that much greater.

Unfortunately, like most things, intellectual knowledge does not always help with how one feels.  Most social phobics have been chipping away at their self- esteem for a long time.  These judgments about themselves can feel like a religion.  In their core they know how bad they are. It’s a long standing belief system that has offered a certain amount of protection & explanation for their plight.  That makes it harder to help alleviate the anxiety.   Acceptance is the friend of someone with social anxiety.  It takes away the added burden of self-hatred which in turn makes life easier.  Getting to a place of acceptance is very difficult for most.  There are usually some very unrealistic fantasies about what they would be like if they weren’t so shy. But it is the first step in the healing process.  Liking oneself better usually is.

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The Changing Face of Psychotherapy

Many years ago when I first started out in the field it was not uncommon for people to be in psychoanalysis or psychotherapy 3 – 4 times per week.  These days someone coming even 2 times per week is rare.  This change is partly because of the intrusion of insurance into medical treatment of all kinds.  Insurance controls what services are reimbursed and the frequency of visits, tests, etc.  This is especially true for mental health services, often considered by many as the stepchild of medicine.  Few can afford to see a psychotherapist more than weekly.

We can blame insurance companies & say “they’re the culprits”.  Insurance companies are offering less and reimbursing less for services they do approve, making it harder to get needed mental health services.  But this change is also because of the availability of different forms of psychological treatment, including medication, the difficulty in providing studies which can ‘prove’ the efficacy of psychotherapy, and the evolving nature of our culture at large.

The popular culture has become one of ‘quick fixes’, a ‘just do it’ mentality, and one of instant gratification.  Medication has changed the way people deal with issues. They often look first to a pill to solve their problems.  I have said before that I believe in medication.   But it’s not the magic answer and it is not right for all.   Studies have shown that medication in combination with psychotherapy is most effective.  But just as important a factor is that people are less willing to ‘go deep’.  And I don’t know if that’s all negative.  Sometimes Cognitive Behavioral Therapy – CBT makes a dent and I use it.  But there is a vast difference between knowing something intellectually & have it filter down into emotional understanding.  There are many who know the right ways they should think but can’t make the switch even with workbooks and reminders.  Then there are those who don’t make the effort because of underlying issues that stand in the way.  Our quick fix society wants to believe that these things work, but in my experience they are an aid for some but definitely not for all.  Just like medication, there is no magic.  I often say that if there was a magic pill or if I had a magic wand I would use it & find another line of work.

My friend reminds me that readers today have very short attention spans – no more than a paragraph for a blog.  I don’t know if that’s true or not but, there is definitely a trend toward shortening all aspects of communication.  I don’t know if that is good or bad or just a fact of the modern world and our busy lives.  The jury is out.  But it has certainly affected the practice of psychotherapy from the time I began working.

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