Behind Closed Doors – What Therapy Actually Looks Like

If you’re a fan of Mad Men, you’re probably familiar with the iconic image of Betty Draper lying on a couch narrating the details of her life to a therapist sitting behind her. Mad Men was set in the 60s and, like most of the show’s periodic details, this representation of therapy is pretty accurate for that time.

So how has therapy changed in the last 50 years?

The answer depends on whom you ask. Psychoanalysts, like the therapist in Mad Men, continue to focus on the analysis of a patient’s thoughts, fantasies, and dreams. They often do so through “free association” in which a patient is encouraged to relate anything that comes into their mind during the session. The therapist will then analyze the content of the patient’s thoughts looking for patterns that might indicate hidden or unconscious desires, memories, or emotions. In some ways, this might look similar to Betty Draper’s experience.

However, although psychoanalysis is frequently depicted on television and in the media, it actually makes up only a subset of the types of therapies offered today. Increasingly common are the more modern cognitive-behavioral therapies (CBT), which were popularized in the 80s. Cognitive-behavioral approaches have now become the gold-standard in the treatment of various disorders and problems.

Despite their growing popularity, cognitive-behavioral approaches are rarely represented in movies and television. Perhaps as a result, many of the patients I see presenting for therapy are often unsure of what to expect from CBT.

So how does CBT differ from other types of therapy, including psychoanalysis? As a CBT therapist, I thought I’d provide a snapshot of what CBT looks like in action:

1. You might discuss your past and childhood, but therapy will often focus more on your current relationships, behaviors, and symptoms. CBT approaches generally highlight the importance of challenging certain ways of thinking, and learning more effective ways of managing specific symptoms or issues.

2. There might be a couch in the office, but you probably won’t be lying on it. The relationship between you and the therapist is usually collaborative, meaning you both contribute to the conversation and work together to affect change. CBT approaches often seek to minimize any perceived power differential between patient and doctor, and to focus instead on establishing a collaborative relationship between equals.

3. You will learn new skills and ways of thinking. Most CBT approaches teach new ways of responding to symptoms or problems. Usually these skills are borne out of extensive research on how to most effectively manage specific issues.

4. Expect homework. Most CBT approaches operate under the assumption that if you keep doing what you’ve always done you’ll keep getting the same result. In other words, if you want a different outcome, you need a different approach. This assumption applies to everything from marital conflict to problems with binge eating. In CBT, you learn evidence-based techniques and strategies for addressing the things you hope to change; the expectation is that you experiment with these techniques and strategies outside of session.

5. Sessions are focused. In my sessions, we typically set an agenda with issues to cover during that session. The client suggests some, and I suggest some. Sometimes we get through all of the items on the agenda, sometimes we don’t. The aim is for us to process important issues and then determine how to most effectively resolve them.

6. There is an end in sight. Although some disorders or problems may take longer to treat, most of the cognitive-behavioral interventions are intended to be focused and time-limited. Some even have very specific treatment “doses.” For example, Mindfulness-Based Cognitive Therapy (MBCT) for depression is typically 8-weeks, while Dialectical Behavior Therapy (DBT) generally requires a 1 year commitment. This is VERY different from more traditional psychotherapy approaches in which clients often remained, or were encouraged to remain, in therapy for years.

7. Your therapist will collect data. CBT therapists often want to assess your progress over time to see if you are actually improving. They thus might ask you to complete questionnaires or self-report forms throughout the course of therapy. If your symptoms or problems are not responding to treatment, this might mean that the therapy is not working, or that another treatment approach could be worth considering.

Obviously the list of factors that differentiate CBT from other therapies goes on, but these are some of the most notable. If your CBT therapist isn’t doing all of the things on this list, don’t worry! This a list of generalities, not requirements. If there is something from the list that you think would improve the quality of your therapy, consider discussing it with your provider.