Common Issues and Themes in Therapy & Tools That Can Help
Hollywood movies love to portray therapy as very dramatic. Often, a client is getting regular therapy from a psychiatrist (a prescriber of medicine) or Freudian analyst (therapist sits behind client lying on a couch), both of which rarely happen anymore. Sometimes in these dramatizations, the client has the poor boundaries (like Jack Nicholson's character shown above, or Bill Murray's character in What About Bob?), but most of the time, it's actually the therapist who is depicted with really poor boundaries (see: The Departed, Prince of Tides, Antwon Fisher, Deconstructing Harry, Prime, Basic Instinct ... I could go on).
Therapy in reality typically begins with basic questions and clear-cut problems. And the boundaries on both sides of the couch, so to speak, are almost always much, much better in real life (don't believe the movies, please!). Following you'll find information about the most common therapeutic themes, presenting issues, diagnoses - whatever is getting in your way in life and you're ready to address. Within the text you'll find links to areas of this website that contain a tool or strategy for dealing with a symptom, or you will find external links to the most credible online resources I have found and use. *And I've said it before, but I'll say it again: this website is not a substitute for therapy and is not intended to be used to diagnose mental illness or respond to crisis.* See my CONTACT page for three links to crisis support.
Depression. This typically comprises not just sadness but also: loss of interest or pleasure, insomnia, inexplicable fatigue, loss of appetite, stress eating, irritability, foggy thinking, low self-esteem, and/or thoughts of self-harm or suicide. Depression is diagnosed when several of the above symptoms have happened at least some of the time in the past two weeks, so it is actually quite easy to meet the criteria. And similarly, once you have gone two weeks without most of these symptoms, you are no longer "clinically depressed." Depression can be diagnosed as mild, moderate, or severe. It can be so severe that some people experience psychosis, meaning they are disconnected from reality (seeing or hearing things others don't, being paranoid, acting in a hostile or bizarre manner, etc).
Most people who are depressed want to make the feelings go away, which is completely normal; however, it can be important first to reflect on the contents of your mind. What are you thinking about - someone who died, disappointed you, something that "failed"? Do you tend to feel "not good enough," like you're always doing something wrong, that you're unloved, or that life is simply too sad or hard? If you stop to journal or meditate on what you are thinking, you will very likely uncover some relief (an insight or possible solution), and/or some beliefs. Beliefs are thoughts about reality. It's important to distinguish these from the world of facts. Facts can be objectively confirmed (2+2=4, the Earth is round, humans have heads, cats are nocturnal, etc). To challenge your thoughts and weed out the facts from the beliefs, use the CBT strategy of Socratic questioning. To try to change some beliefs about yourself, see this blog post. To cope with symptoms by trying to do something different, try one or several activities from this list of 15 coping strategies or from these three tried and true strategies.
Anxiety. This includes generalized anxiety, social anxiety, Obsessive-Compulsive Disorder (OCD), and panic attacks. Anxiety symptoms can include frequent worry, difficult-to-control worry, overthinking/racing thoughts, overwhelm, tense muscles, and difficulty concentrating. Anxiety with panic can include some symptoms of anxiety, hypervigilance and/or physical symptoms like sweating, feeling faint, heart palpitations, and the fear of fainting or dying from these symptoms. Social anxiety is the fear of being judged (openly or secretly), criticized, or humiliated by other people, and often causes social withdrawal and feelings of loneliness. OCD can involve only obsessional thoughts (germaphobia, perfectionism, fear of having certain thoughts) or can include compulsions (excessive cleaning, washing, tapping, checking, counting, or arranging).
There are different strategies for dealing with anxiety depending on the type, so please see the links above for online resources - an especially good one is www.anxietycanada.com, because there is not only information for adults and teens but also worksheets and plans for dealing with each different type of anxiety. In fact, because that website is SO good, I won't list a bunch of strategies that are specific to each type here. What you can do on this website is check out my list of 15 coping strategies, or try looking into ASMR for an interesting look at a new type of stress relief.
Work stress. Pretty self-explanatory, work stress is a very common theme for people who want to talk to a therapist. Sometimes, just talking about what is going on and problem-solving where appropriate can be what is needed. Keep in mind that talking about a problem without moving on to problem-solving (i.e. just complaining) is not advised. If you don't start eventually to think about what is in your power to change, this can cause you to feel powerless, and you might only focus on the problem and make it bigger or worse than it was (or is). In a few cases, it can lead or point to obsessional thinking, which is a type of anxiety that requires more than "talk therapy" to resolve.
You may want to talk to a therapist because you're adjusting to a new job, staff changes, changes in your own duties, layoffs, or a difficult supervisor or coworker. Other times, more reflection and planning may be needed as you might feel a lack of purpose from what you are doing to make a living or contribute to your household or family. This is a common type of problem that can be resolved if you have friends or family to talk to, but many people seek out therapy with this presenting problem because 1) it's an easier and less personal problem to start with - you have something else going on but you want to ease into that or build trust with a therapist first, or 2) it can be helpful to problem-solve with a therapist because they aren't friend or family and have no personal stake in what decisions you make; 3) sometimes, people feel like friends and family have "their own stuff going on" and they feel like they would be burdening them. While I discourage the "I don't want to be a burden" mentality, I understand it, and it is simply a very common part of any presenting issue.
Trauma. The most common diagnosis I would treat here is post-traumatic stress disorder or PSTD, but I may also work with people who have childhood trauma/abuse, and relationship or domestic abuse, which don't necessarily meet the criteria of PTSD, which includes experiencing a situation that felt potentially life-threatening and several long-lasting symptoms such as flashbacks and nightmares of the event, hypervigilance, insomnia, irritability, avoidance of similar situations or reminders, or forgetting the incident entirely. (Again, this is not a comprehensive list of criteria and not intended as a diagnostic tool, but you can see here for full list.)
It is very important to treat trauma disorders therapeutically, and I believe this is among the most important to treat in a therapy setting with a qualified specialist in trauma. This could be a psychologist who does psychotherapy, or it could be someone like me, who is a masters-level clinician who is trained with strategies like EMDR (Eye Movement Desensitization and Reprocessing). Coping tools for use outside of therapy are very similar to those listed in the depression and anxiety sections above. This short .pdf is a nice list of tools, and you may also want to learn this grounding tool that I use quite often both with kids and adults.
Relationship problems. While I generally don't do couples therapy, I do see some couples when a relationship issue comes up with an individual client. It can be difficult to move forward sometimes without bringing in a significant other because that the other person is needed to clear something up or to make an agreement with me and the client. Also, I have had more than a few clients come because their spouse or partner have told them, "YOU are the problem," and that they (the spouse/partner) will not go to therapy because they don't need it, don't like therapy, don't think it will help, can't be bothered, blah, etc. Usually, they are people who have never seen a therapist, don't believe in therapy (for themselves), had a bad experience with a therapist (understandable - not all therapists are good at what they do), or have been told that going to couples counseling will bring up more problems.
One thing I do most often with couples is work on communication and conflict resolution via a SPACE CONTRACT. This is not a contract about outer space, but rather an agreement to take space from each other to defuse or de-escalate an argument. Generally, we write down three things in this contract: 1) a code word that will be used to put the agreement into effect (usually a silly word or phrase like "pink martini" or "rhinoceros"), 2) how much time will each person be expected to completely avoid each other and go do something to calm themselves (NOT think up better arguments), and 3) that each person agrees to come back to try again. * *Follow-up is arguably (no pun intended) the most important AND most often forgotten aspect of conflict resolution.
For a free online workbook that you and your spouse or partner may work on together, click here.
LGBTQIA. This can include sexual preference or orientation (lesbian, gay, bisexual, asexual, pansexual), gender identity, gender dysphoria, non-identification with binary ("M or F") gender, intersex (or abiguous genitalia), and queer/questioning. The most common presenting issue I see is identification as transgender.
Being transgender is a topic that is finally gaining more attention and understanding, but we still have a LONG way to go. For the time being, the therapy world uses the diagnosis of gender dysphoria to provide treatment. This means that a person has a "strong, persistent feelings of identification with the opposite gender and discomfort with one's own assigned sex that results in significant distress or impairment" (www.psychologytoday.com). People sometimes use the shorthand of MTF (male to female) or FTM (female to male) to describe gender identification that is opposite to the gender they were assigned at birth. Other times, this is too categorical, as people may be gender fluid, non-binary, simply uninterested in labels - see this GLAAD reference guide for more definitions and helpful guidance. Sometimes, a person is seeking gender-confirmation surgery, and they are coming to me for a letter of reference for their doctor stating that they have been diagnosed with gender dysphoria so surgery is recommended. It's not exactly that simple, though. Non-gender-conforming people do not all want (or need) surgery.
Most of the time, I meet with children, teens, or adults who identify as transgender (genderqueer, nonbinary, fluid, etc) because not conforming to society's standards and biases can be hard. It can be downright terrible. The suicide attempt rate for people within the trans spectrum is much higher than in the general population - this article abstract reports it as 32-50% of the transgender/non-binary sample, which included people from several countries. So, when we meet, I consider one of my most important tasks is that of being as informed as possible in order to be as understanding as possible, because this is not typically what people come across in daily life. What I have been struck by in working with transgender-identified people in the past ten years, is that most people just want a regular life. They don't necessarily want to be an advocate, educate people, or call out their gender identification all the time.
While I don't have a lot of coping resources specifically for identifying as transgender or non-binary, many of the exercises linked in the depression and anxiety sections above could be helpful, as they address stress, loneliness, self-reflection, and coping in general.