The mind is like an iceberg, it floats with one-seventh of its bulk above water.
– Sigmund Freud
Because the need for therapy or counselling is often urgent and the result of a crisis, the referral may come from a family doctor or a friend who’s benefited from treatment. It may even happen through a random internet search, like the one that may have led you to this page. All of these routes to a particular therapist’s office involve some element of luck. But that also means, of course, that you could land up with a type of therapy that isn’t suitable for you, or you miss out on a type of therapy that could be more appropriate for your problem.
What I’d like to provide, in a broad way, is some information that will help you, the potential patient, to know what’s out there – what types of therapy are available and what kind of qualification does the person you might end up seeing, have.
Who offers therapy?
Therapy can be offered by:
- A psychiatrist
- A clinical psychologist
- A clinical social worker
Psychiatrists are medical doctors who specialize in a medically-based approach to mental problems. The treatment involves diagnosis and medication. Some psychiatrists have chosen to study further in a particular therapeutic paradigm and, in addition to medication, offer analysis or therapy, which can be Jungian or psychoanalytical.
Many psychiatrists work together with a psychologist wherein the psychiatrist is responsible for the medical treatment of the patient while the psychologist focuses on the psychological, emotional roots of the problem.
Psychologists are not medically trained and therefore do not prescribe medication. Their training is based completely in the human sciences field. But not all psychologists are the same. Under the umbrella of psychology you will find sub-categories, with each focusing on different forms of treatment.
The main three categories are:
- Clinical psychologist – they are specially trained to assist those with relatively serious forms of psychological or emotional distress and/or psychopathology, such as depression, eating disorders, schizophrenia, and so on.
- Counseling psychologist – they counsel people dealing with relatively minor challenges and developmental problems of everyday life, such as adolescent worry or peer group difficulties. They also focus on maximising personal skills, educational and career development, and how to effectively deal with one’s environment.
- Educational psychologist – they treat children (2–21 years) in order to aid their learning and development to fully-functioning, healthy and independent adults. They may do this through different types of therapy and parent guidance. They also assist with changes to family structure, trauma, behaviour modification, socialisation of children, coping strategies, and educational study skills and guidance.
Clinical social workers
As with psychologists, a clinical social worker’s training is also based in the human sciences field. They are adept at helping people work through their emotions, develop coping strategies, and adapt to their environments. However, they may also become involved in the client’s external environment by, for instance, calling employers or potential employers of a person who has special needs; or managing the case of an abused child, both assisting the child by way of counselling and helping the family navigate the legal and emotional processes.
(A summary of the scope of practice of these different sub-categories based on the South African HPCSA Health Professions Act, 1974 (Act No. 56 of 1974), can be found here.)
As you can see, although these three categories are all psychologist-related, the scope of practice varies, with one being focused more on learning development as opposed to more complex psychopathologies. The training of practitioners in these different categories is also vastly different, which makes it important when seeking a therapist to be aware of the type of training that the psychologist has undergone.
However, the challenge doesn’t end here! Within these categories lie more differences that could impact strongly on what therapy you find yourself in. Since I am a clinical psychologist, I will remain focused on this field.
The different approaches to therapy are very often the product of the particular university a therapist studied at. For example, Stellenbosch University focuses more on cognitive psychotherapy, while the University of Cape Town uses a more psychodynamic psychoanalytic approach. I will try to explain theoretically, in the briefest and simplest way, how different therapists may approach the same case. Let me exemplify these differences through the fictitious case of Mr Jones.
The case of Mr Jones
Mr Jones decided to see a therapist. This was an uncharacteristic decision for the very conservative man who rarely spoke about his emotional world and believed that all could be overcome with the right attitude. So what happened? One day, out of the blue, his wife of 30 years announced that she had been having an affair with his best friend Dan for the past two years and that she was leaving him. After much probing, she proceeded to confess that this was not the first affair she’d had and that, prior to her relationship with Dan, she’d had an eight-year affair with her married work colleague. These disturbing findings catapulted him into a deep depression from which he was unable to recover. He became tearful and prone to uncontrollable anger when provoked; in fact, he had been arrested by the police after a road-rage incident. Needless to say, this affected his work performance and his relationship with his children. The normally calm, accommodating person with an easy disposition became unrecognisable, both to himself and those who knew him, and was steadily getting worse. His children, friends, and work colleagues became increasingly worried about him and suggested that he speak to someone.
There are a number of ways of understanding and working with what Mr Jones is presenting.
The cognitive behavioral method would be to focus on helping him deal with his symptoms. He needs to accept what has happened, find ways to deal with his rage, grieve for the loss of his wife and express his emotions. In this case, the treatment would most likely be short-term and the therapist would try to equip the broken man with tools and mechanisms to work through and deal with his symptoms so that he can move forward with his life.
On the other hand, a psychodynamic, psychoanalytically trained therapist, such as myself, will focus more on what it was that brought Mr Jones to this point. How could he have been so blind to his wife’s infidelities for so long? What is there in his history that has led him to this desperate point? I would also assume that the rage and sadness he displays have probably been buried in his unconscious mind for a long time, longer than the years he’s been married to his wife, and have now erupted to the forefront. I would want to find out more about his background and who he is as a person so that we can both understand why he is where he is today.
In essence, I would see this terrible event as a wake-up call and also an opportunity for Mr Jones to ‘find out who he really is’. To achieve this he will need to do some soul-searching. This will happen through the dialogue between us and the exploration of his life, his childhood and his previous relationships.
This type of therapy is often longer-term, not because I would insist that Mr Jones stay in therapy for a particular period of time, but because the work that we will be doing will move far beyond the particular event that brought him to me.
Very often individuals choose to stay in therapy long after the bad feelings and crises have been resolved. It becomes a space where they can reflect on and investigate who they are, how they operate in the world, and what they really want and need in order to feel happy and fulfilled.
Therapy – be it long-term or short-term, behavioural or analytical, medication-based or not – is first and foremost a relationship between two people.
When people come to see me for the first time, one of the most important things we need to establish is how they feel about being with ME. Do I feel like the right person for them? Do they feel comfortable and safe with me?
You need to feel that there is some potential, at least, to develop a relationship with a particular therapist. If it doesn’t feel right, don’t force it; shop around and see a few other people first. Be serious about who you choose to work with. It’s important to find someone with whom you feel at ease and can trust.
When you find the right therapist, all the jargon falls away and therapy becomes an extended conversation offering you the power to change your life.