Harvard Women's Health Watch

Psychotherapy at midlife

It's never too late to benefit from talk therapy.

By midlife, you've probably spent years thinking of yourself as a certain kind of person — outgoing or introverted, high-strung or easygoing, optimistic or pessimistic. You may have become accustomed to certain roles and styles of communication in your relationships and certain ways of coping with stress. Even if you're dissatisfied with those roles and your patterns of coping aren't working so well anymore, you may think it's too late or too bothersome to question your perceptions or seek changes in important relationships.

But a woman at midlife today can usually expect to live several more decades. Instead of thinking of retirement, many women are starting a new job or planning for an extended work life. Older women are less inclined to stick with a troubled marriage and are more likely than men to initiate a divorce. Midlife is an important stage of development with unique challenges. It's not too late for women to reap the benefits of change by seeking the help they need to gain greater satisfaction in their lives.

One avenue to change is psychotherapy. At any time of life, successful psychotherapy can heighten your awareness and insight into your actions, thoughts, and feelings and help you learn and practice more effective ways of thinking and behaving. Either alone or combined with medication, psychotherapy is valuable in treating a wide range of mental health conditions. But even if you're not trying to solve a fixed psychological problem, psychotherapy may provide help in challenging situations or guidance in creating a happier or more fulfilled life.

Choosing psychotherapy

There are many theories and styles of psychotherapy, but the two most popular forms are psychodynamic therapy and cognitive behavioral therapy.

Psychodynamic therapy recognizes that past experiences and feelings of which you're not consciously aware can influence your present emotional well-being and ability to function. Through regular discussions with a therapist, you can gain insight into your motivations and conflicts and learn more productive ways to cope with them. Cognitive behavioral therapy is less concerned with the past and unconscious feelings and instead concentrates on ways to change harmful thinking and behavior, such as smoking, procrastination, or phobias. (For more information about these therapies, go to www.health.harvard.edu/womenextra.)

Which works best? There's no simple answer. Just as many kinds of aerobic exercise can help you achieve cardiovascular fitness, many types of therapy can help you understand yourself better, relieve bothersome symptoms, and change habits that aren't good for you. You may do better with one type than with another, or you may find that a blended approach, drawn from different schools of psychotherapy, suits you best. Although most therapists emphasize one type of intervention, a good therapist often incorporates elements of others as well. Your regular participation in the process is more important than the type of therapy you choose. Most important of all is the match, or rapport, between you and your therapist.

How do you decide if you need therapy?

The hardest question is the first — do I need help? Sometimes the answer is clearly yes. Certain symptoms indicate a serious psychological disorder that requires professional evaluation. These include excessive rumination, loss of contact with reality, and extreme periods of high and low moods.

But you don't need to know exactly what the problem is before seeking help. Midlife women seek therapy for reasons that range from painful emotions to difficult life events. It's enough to feel lost or "stuck," or to be worried about a feeling, thought, behavior, or situation.

"If you're feeling depressed, panicky, or anxious, have a problem you can't solve, or are getting into trouble with your work or relationships, it's useful to get a consultation with someone who has mental health training," says Dr. Malkah Notman, clinical professor of psychiatry at Harvard Medical School.

Women sometimes feel ashamed that they can't solve a problem on their own, or with the help of friends. Friends and family can be an important sounding board and source of support when problems arise. But eventually, repeated conversations about a problem that has you stuck can be a drain on friendships and relationships. Without training in therapy, your friends and family can't be expected to recognize psychological problems or evaluate their seriousness. For relief from serious conditions like major depression, panic disorder, and anxiety disorders, you will often need professional help.

Is it time for couples counseling?

There are often good reasons for a couple to re-evaluate their relationship in midlife. A therapist can help a couple improve communication or address longstanding interpersonal issues that may not be acutely troubling yet still stand in the way of a happier partnership. A therapist can also provide guidance as couples face common mid- to late-life issues, such as redefining life goals, changing careers or financial circumstances, caring for aging parents, negotiating relationships with adult children, and adjusting to physical, cognitive, or psychological changes.

Working on a marriage or any committed relationship can provide physical as well as psychological benefits. For example, researchers have found that people in satisfying marriages have a lower risk for cardiovascular disease than those in unsatisfying marriages.

Psychotherapy and physical changes at midlife

Women often benefit from professional help in adjusting to the physical changes and challenges of aging, including the following:

Perimenopause. Women seem to have an increased susceptibility to depression and other mood symptoms during perimenopause — the years leading up to menopause, when hormone levels are in flux and periods are irregular. Findings from the Study of Women's Health Across the Nation showed a peak in major depression during the menopausal transition — that is, perimenopause and the first two years after periods end — even after correcting for other factors such as hot flashes and previous depression. The reasons for this increased risk aren't entirely clear and will require more research.

Eating issues. It's well known that the risk for eating disorders is high in adolescence, a time of rapid body changes. But there's increasing awareness that women at midlife can also face anorexia, bulimia, or other problems with food or body image in response to changing bodies and life circumstances.

Sexual concerns. With age, women may experience diminished sexual desire and arousal, discomfort during intercourse, or a need to adjust to sexual problems — their own or a partner's. Some sexual issues (for example, diminished lubrication) are physical in origin, but a biological fix is unlikely to help unless psychological and relationship issues are addressed as well. A psychotherapist experienced in working with sexual issues can help you explore all these matters as well as provide specific education and advice about maximizing satisfaction in your sex life.

Alcohol and drug use. Women who are depressed, grieving, or even simply adjusting to common midlife transitions are at increased risk for harmful use of alcohol. During therapy, you may find that you are using alcohol or drugs as self-medication for symptoms of depression or anxiety. With support and more appropriate treatment for the underlying problem, you should be able to cut down on your alcohol or drug use. Or you may discover that substance use itself is the main problem that needs to be addressed. Here, too, psychotherapy may help.

Chronic illness. Psychotherapy and support groups can not only help with the difficult problem of emotional adjustment to illness and disability, they can also improve the physical functioning of people with chronic illness. For example, several studies have shown that adding psychotherapy to standard treatments for type 2 diabetes can improve blood sugar control and drastically reduce the risk for complications. In depressed people with arthritis, treatment with psychotherapy, psychiatric medication, or both reduced pain and improved the ability to function.

Where do I start?

You can go directly to a psychiatrist, psychologist, or other therapist. (Many different mental health practitioners in addition to psychiatrists and psychologists offer psychotherapy, including licensed clinical or independent social workers, marriage or family counselors, psychiatric nurses, clinical nurse specialists, and trained members of the clergy.) If you're not sure whether you might benefit from therapy, you might first consult your primary care physician, a religious advisor, or someone at a mental health clinic or employee assistance program.

How do I find a therapist?

If you have a friend or family member who is finding psychotherapy helpful, ask whether her or his therapist (who may prefer not to work with you because of the connection) could recommend someone for you. Your primary care physician may be able to recommend a mental health professional, or you can contact one affiliated with your insurance plan. Collaboration between your physician and the therapist is especially important if you are being treated for another illness, or if you might need medication as well as psychotherapy.

Some people meet with several therapists before making the commitment to work with one. Even the most highly recommended person may not be the right match for you. Beginning therapy is often daunting and uncomfortable, but if a therapist's demeanor or office set-up puts you off, don't waste your time trying to make the situation work.

Body and mind

Some medical disorders have psychological symptoms. For example, an overactive thyroid can make you irritable, depressed, and anxious; an underactive thyroid can also cause depression. It's easier to treat these symptoms if their medical basis is recognized. Otherwise, psychotherapy won't relieve even the psychological symptoms, and failure to treat the medical condition could be dangerous.

If you consult your primary care physician about a psychological problem, a physical exam and testing can rule out a medical disorder. If you go directly to a psychotherapist who isn't a physician, she or he should keep in mind the possibility of medical problems.

What should I expect?

At your first meeting, the therapist will ask about your personal history, relationships, and specific concerns, and possibly give you a psychological test. You should ask the therapist about her or his experience and preferred approach to problems like yours, what to expect during therapy, and how your progress will be monitored. It's good if the therapist can describe the merits and drawbacks of different types of therapy, including ones she or he doesn't do.

After the evaluation, you may or may not be given a specific diagnosis. Ideally, therapy should take into account the condition being treated, the therapist's philosophy, and the patient's preferences.

You should be able to work out within a few sessions whether you will be able to confide in this person. When you talk, the therapist's questions and comments should let you know you're being heard and understood. A therapist's questions or suggestions may challenge your current perspective, but they should seem sensible. She or he should be supportive but willing to confront you in order to encourage change when necessary.

Will my insurance help pay?

You may be hesitating to pursue psychotherapy because of the cost. But most private insurance, Medicare, and managed care plans provide some coverage for psychotherapy from licensed providers. Moreover, since 2008, insurers have been required to provide equal coverage for mental and physical illnesses. In managed care, you may need to choose from a specific list of therapists.

Before you speak with a therapist, find out about your insurance coverage, and don't hesitate to raise payment issues. With a therapist who is outside your insurance plan, you may be able to arrange less frequent visits or take advantage of a sliding fee schedule.

Lower-cost psychotherapy may also be available through your employee assistance program or a community mental health center that receives government or other funding.