When deciding on a psychological therapy you might like to know roughly what’s in store for you. Although they all involve talking to some degree, what you’ll talk about and what exercises you’ll be asked to engage in will differ. I would say they all have one major thing in common, and that is we don’t know exactly how they work, although each has a theory behind it, and some are more scientific than others.
As to which is better, there is a school of thought that they all do roughly the same thing and it doesn’t matter much, and it does seem that a good working relationship between the therapist and client is still the most important factor behind successful therapy. However, there is evidence out there suggesting some therapies are better for treating certain disorders, so receiving a good assessment by a competent clinician will help in your choice.
Often though, you’ll go to see a clinician after a recommendation or a search on the internet, and they will already have training in certain therapies, so it would be useful at that stage to know what they are offering. Here’s a quick run-down of the major therapy styles available in the Western world at least, in roughly chronological order of their development.
Insight therapies aim to help a client by improving their awareness and understanding of relevant aspects of their psychological functioning. With this increased insight the client is able to make positive changes to their life. I’m not formally trained in these therapies, but I know enough to pass on the basics.
Psychodynamic Psychotherapy, including Psychoanalysis (345 words)
The Austrian neurologist Sigmund Freud was a pioneer in developing a formal ‘talking cure’ for mental health problems, beginning in the late nineteenth century with psychoanalysis, and his body of work has been very influential on Western culture more generally. Psychodynamic theories and therapies were once dominant, but began to wane in influence from roughly the 1970’s. They nevertheless remain a significant alternative to the cognitive-behavioural therapies I’ll discuss later.
Psychodynamic psychotherapy presumes the existence of subconscious psychological processes, (including basic drives and motivations), that are thought to significantly influence our behaviour and psychological wellbeing. By identifying damaging processes and bringing these to light, the therapist hopes to release the client from their influence. These processes develop gradually throughout our lives, particularly in our impressionable childhood years, and are influenced heavily by interactions with our family. Consequently, there is a focus on the past, and on interpersonal relationships.
The therapist will look for subtle, often symbolic cues as to the source of distress and dysfunction, and may interpret dreams, which are a meaningful product of the unconscious mind (according to the theory).The relationship between the therapist and client is particularly important, as it represents a source of data, so-called ‘transference’, when the interpersonal patterns of the past are played out between the client and the therapist in the present.
Hence psychodynamic psychotherapists will generally take on a less active role, letting the client do most of the talking. And they are quite disciplined in their approach to therapy so that they don’t muddy the waters; for example they’ll typically maintain regular appointments at the same place and time, and will disclose relatively little about themselves in session.
The less active role of the therapist, and the rather ambitious goal of uncovering the unconscious mind means this therapy can be slow going, and that requires a substantial investment of time, and probably money. But you can expect to learn more about yourself in the process. It doesn’t have a strong scientific basis, although studies have shown it to be effective for a range of problems.
Humanistic Therapy (215 words)
Carl Rogers, who developed a humanistic ‘client-centred’ approach to therapy from the 1940’s to the 1980’s, is still thought of as one of the most influential of all clinicians. The humanistic approach was never taught to me formally in my clinical training, but his client-centred principles are infused in the way therapy is taught, and hence in the way most therapists work.
The client is presumed to have within them the ability to change for the better, and achieve personal growth. The therapist is led by the client, helping them to gain insight along the way. As in Psychodynamic Therapy, the client tends to do most of the talking; and the direction therapy takes depends on what issues or ideas the client brings to the table (…or chair, more commonly). The therapist uses active listening to reflect back the client’s own ideas in a way that promotes insight, treats the client with ‘unconditional positive regard’ to bolster their own self-regard, and shows empathy and understanding towards the client. Lovely stuff :-).
Humanistic psychology doesn’t really offer specific theories of mental disorders, and so a purely humanistic approach to therapy may not suffice for those in an acute stage of mental illness. It aims rather to promote personal growth, and to help people achieve their potential.
Cognitive & Behavioural Therapies
The psychological therapies in this category focus more on changing what you do, rather than building insight, (although increased knowledge and awareness is important still). Their development began in the 1950’s and has continued until the present day. They can be split into roughly three groups – Behaviour Therapy, Cognitive Therapy, (together, ‘Cognitive Behaviour Therapy’), and finally, the so-called ‘Third-Wave’ therapies.
Cognitive Behaviour Therapy (CBT; 530 words)
The main assumptions of CBT are that our thoughts, feelings and actions are interconnected, and hence changing one will lead to changes in the others, offering opportunities for targeted therapeutic interventions. The relationship between them is often portrayed by diagram below.
Whereas in psychodynamic theories the majority of important psychological processes are unavailable to our conscious awareness, CBT assumes that whilst much of our thinking may be automatic and out of awareness, with a little practice we can begin to notice our thoughts, and connect them with related feelings and actions. This allows us to consciously make beneficial changes to these processes. The therapist’s job is to help the client to develop the skills to identify and change the relevant processes, leading to improved psychological health, and providing additional coping skills for the future; when successful, the client becomes their own therapist.
Behavioural techniques were the first to be developed, and came with a fairly rigorous scientific backing (at least by psychological standards). Research has shown that certain habits of behaviour maintain psychological problems. For example, for those suffering from excess anxiety, consistently avoiding what they fear maintains this anxiety in the long run, as they never have the opportunity to disconfirm their expectations of threat. To address this, behavioural techniques for anxiety involve facing our fears (called exposure therapy). There are also behavioural techniques for depression, which aim to reverse corrosive patterns of withdrawal and social isolation. Behavioural techniques are widely used to manage behavioural problems in children, and adults in some cases, by manipulating the pattern of positive and negative consequences following targeted behaviours.
Cognitive techniques came later, and are premised on the idea that the way we feel is a direct result of our thoughts, specifically the way we appraise a situation. And although our perspective on the world is certainly influenced by our upbringing and events of the past, the focus of CBT is on the present, in that we can change how we presently think in order to improve our psychological condition. CT generally involves monitoring thoughts to identify patterns of thinking that are maintaining poor psychological health, and will then employ techniques to test the validity of these usually biased and unrealistically negative thoughts, thereby weakening their hold on our emotional health.
CBT is probably the most well researched psychological therapy, and there is a fair bit of evidence supporting its effectiveness. It is also quite targeted and can be effective in a relatively short time, (weeks or months, sometimes even just one session for simpler problems like specific phobias eg, spiders). It requires more effort from the client though, who is generally set homework tasks, and we need to repeatedly use skills to get them to a point where they are effective. Treatments like exposure therapy are potentially very effective, but only if you can talk someone into doing them: facing our fears is not, at first, a pleasant experience (although it can be very empowering once accomplished). And the cognitive techniques use our conscious thinking to challenge ingrained ways of seeing the world, which can be quite a big ask for some people, especially those who are not psychologically minded.
Third Wave Therapies (515 words)
These therapy styles came to prominence in the 1990s (give or take), and are generally influenced by Eastern philosophies. Whereas the CT in CBT asks us to change the content of our thoughts, which leads to a change in how we feel and act, these therapies ask us to change the way we relate to our inner psychological world. Many promote acceptance of our thoughts and feelings by learning to view them as merely psychological and physical events that we can choose not to engage with, if it is unhelpful to do so. We learn not so much to change our psychology, as to live with it.
Mindfulness Based Stress Reduction (MBSR) was one of the earlier therapies to adapt certain meditation techniques into a psychological therapy. This particular therapy is generally conducted in a group format, and is almost entirely based on applications of Mindfulness. Mindfulness practice is quite experiential, as you can’t really understand what it is without doing it. MBSR uses mostly meditation exercises.
All of the other third-wave therapies I mention below include some concept of Mindfulness.
Dialectical Behaviour Therapy (DBT)
This therapy was developed in response to the specific needs of a particular clinical group, but is now used more widely. It combines pretty pragmatic behavioural techniques with Mindfulness and other skills-based practices. DBT therapists are often more forthcoming in style, may disclose more about themselves, and will sometimes be available to consult with their clients out of session (often to coach people through crises). Some therapists use DBT techniques to supplement their main therapy modality, but this won’t be the full DBT experience.
Acceptance and Commitment Therapy (ACT)
As the name suggests, ACT promotes acceptance of our psychological experience, and asks the client to commit to living life according to what they most value. In ACT, the therapist will help the client to see that the way they have struggled to manage their symptoms so far has not helped, and may even be making things worse. They then make use of a range of analogies and other techniques, such as Mindfulness, to help the client accept their negative thoughts and feelings, and re-focus on living a meaningful life, taking some of their symptoms along for the ride! Although symptom reduction is not the aim of ACT, the paradox of acceptance is that by not trying to reduce symptoms we no longer fuel them, and they may subside as a result.
Metacognitive Therapy (MCT)
This therapy focusses not on managing symptoms directly, but on managing what we think about our symptoms, and how we respond to those symptoms. It has elements in common with ACT, although acceptance itself is not a central theme. Many of the techniques are designed to change the processes of thinking without necessarily changing the content of thinking. It nevertheless aims to challenge unhelpful thoughts about our own symptoms, such as worrying about how we worry too much, which only adds to the worry (and don’t I know it!). It also uses analogies, visualisation techniques, attention training, and a more specific concept of Mindfulness (without the meditation practice).
A Couple of Others (130 words)
Still quite new, Schema Therapy combines the focus on thinking from Cognitive Therapy, with the past focus and longer term approach of Psychodynamic Therapy. The CT part of CBT focusses (at least initially) on individual thoughts identified by the client, but recognises that these thoughts come from ‘core beliefs’ that we hold about the world. Schemas are collections of core beliefs on related topics, and so represent maps or blueprints of our life. Schema Therapy aims to improve our psychological health by re-programming these schemas, re-drawing the maps in our mind in a sense. It can be quite experiential, dealing with significant memories and themes from a client’s life.
Interpersonal Psychotherapy (IPT)
This cognitive-behavioural therapy is an evidence-based treatment for depression, and focusses on the interpersonal aspects of this disorder.