Hey all! This is a deep dive episode that was prompted by an email question that I got. In this episode, I talk about the different types of therapy that are available. Of course, I don’t cover every single one, but I describe some of the types of therapy that you are most likely to encounter including:
- Psychoanalysis and psychodynamic therapy
- Cognitive Behavioral Therapy
- Dialectical Behavior Therapy
- Family Systems Therapy
- Integrative or Eclectic Therapy
Listen on iTunes or view the transcript of this episode below!
I was wondering if you can explain the difference between psychotherapy and psycho analysis and when each is preferred.
To be clear, psychoanalysis is one form of psychotherapy. Psychotherapy is the broad umbrella term to describe all of the different therapeutic treatment methods that I will be talking about here. Therapy and psychotherapy generally mean the same thing when you are talking about it in this context. Psychotherapy is simply therapy for your psyche just like physiotherapy is therapy for your body. In the US therapy, psychotherapy, and counseling generally refer to the same thing. Counseling tends to have a connotation that the person is a therapist with a master’s level degree rather than a psychologist with a doctorate, but that’s not necessarily always the case.
So psychoanalysis. This is one that many people have heard of because it comes from Sigmund Freud. He is largely credited with establishing psychoanalysis as a set of therapeutic skills in the late 1800s. There are many other people who took these theories and created treatment approaches from them. The modern type of therapy that is more commonly practiced that comes from this tradition is called psychodynamic therapy.
Psychoanalysis focuses heavily on the unconscious and attempting to bring the drives, desires, and wishes of the unconscious to the surface. Practitioners believe the bringing the unconscious into one’s conscious awareness helps to liberate them from the effects of the issues caused by these underlying drives. There is also a heavy emphasis placed on the past. The theory is that early experiences, even ones that are not within someone’s memory shape their development.
Traditional psychoanalysis is intense and its rare that clinicians practice it these days. The classic picture of a person lying on the couch and talking about their mom – that’s from psychoanalysis. Traditionally, people would come in for hour long sessions multiple times per week. There was a heavy focus placed on the analyst being a blank slate and hardly present. The thought is that this will allow the person to better access their unconscious.
As I said, the more common type of therapy that you will see these days is called psychodynamic therapy. This type of therapy is much more reasonable in the requirements. Typically once-weekly sessions and there are even brief forms that are research supported. There is still a focus on unpacking early experiences and developing insight into the way the past has shaped the present. There is also often a focus on the interpersonal dynamics that play out between the therapist and the client. There’s a concept called transference, which basically says that clients will often project elements of other important people in their life onto the therapist. This is analyzed and worked with. The way that I often describe it is that the transference relationship provides the opportunity for a correcting emotional experience. You can sort of have a do over and find a way past that relational hangup.
Overall, psychoanalysis and psychodynamic therapy are considered depth-based approaches, which means that the primary focus isn’t trying to solve the day to day issues and provide immediate coping skills. The emphasis is on developing insight into how these issues came to develop. Psychoanalysis has been controversial throughout the years, mainly because Freud was a fuckin’ weirdo. Just know that modern psychodynamic therapy is totally valid and research supported for a variety of conditions. In fact, there is some research to suggest that insight-oriented therapies like this provide longer-lasting change that can actually increase after therapy is finished.
Cognitive Behavioral Therapy (CBT)
This is one that many have probably heard of. It’s probably the most common form of therapy in the US. CBT is a much more present-oriented therapy. It’s very active. It involves exercises, homework, and practicing strategies to help with coping. It’s called cognitive-behavioral because it focuses on thoughts and behaviors.
There is this concept called the cognitive triad or the cognitive triangle. I tend to call it the tri-force because I’m a dork. But basically it has thoughts, feelings, and behaviors. They all influence each other. Your thoughts and interpretations of a situations heavily influence the way that we end up feeling about a given situation. In turn, that will cause you to behave a certain way.
For instance if you ask your partner how they are and they say “fine” your thoughts and interpretations will matter a lot. If try to read their mind and think that they are lying and they aren’t actually okay, that will make you feel bad and you will probably annoy them by continuing to pester them for the “truth”.
In CBT you will often go through common irrational thinking patterns and use different exercises to catch yourself and rely more on your logical brain. It’s a very verbal form of therapy that tends to work well for people that are looking for an active approach that provides some immediate tools that they can use.
Dialectical Behavior Therapy (DBT)
DBT is a newer form therapy that was designed for treatment of bordeline personality disorder. It is still used primarily for that purpose, but it has strong research support for PTSD, mood disorders, and even some eating disorders.
Basically, DBT is used to help people recognize their emotional triggers and identify which coping skills are most applicable. It can be thought of as a modified form of cognitive behavioral therapy. A couple primary skills involved in DBT are distress tolerance and mindfulness.
I’ve talked about mindfulness many times in various content of mine, but basically it comes from the Buddhist tradition and helps you learn how to be focused on the present moment and less judgmental of your thoughts and feelings. Something that is characteristically very tough for people with mental illness. Often it’s a battle between the past and the future and the present moment gets caught in the crossfire.
Distress tolerance is particularly important in things like borderline personality disorder because one of the characteristics of that issue is strong emotional reactivity. Through acceptance, self-soothing activities, and distraction, DBT teaches you to better tolerate strong emotions rather than turning to unhelpful things like cutting, drug use, or destroying relationships.
DBT is often an intensive treatment that they use in hospitals or partial hospitalization programs. It can be done individually, but it quite often done in a group context. There is a heavy emphasis on learning. Some people have a hard time tolerating DBT because it can feel like a class sometimes. There will be handouts, assignments, and lessons involved. The research on it is great, though. It’s really the treatment of choice for borderline and other issues that may involve very strong emotions.
Eye Movement Desensitization and Reprogramming (EMDR)
EMDR is another controversial one. It’s controversial because it involve some pretty unusual (and woo-y) techniques. There is also a subset of people who practice EMDR who really really strongly advocate for it and have almost a religious devotion to the techniques.
I don’t mean to shit on EMDR because it works. EMDR is one of the most effective forms of treatment for trauma. It’s considered a treatment of choice for PTSD. Basically, person who developed the approach noticed that here eyes moved rapidly when she was recalling a traumatic memory and then she found that when she tried to control this and intentionally move here eyes back and forth, she experienced less intensity.
The theory is that bilateral stimulation of the brain, either by moving the eyes rapidly back and forth, tapping on alternating sides of the body, or using some other device like a light bar to cause back and forth stimulation to both hemispheres of the brain. This does not have adequate research support – there are many conflicting findings and bad studies that have been conducted.
It seems to be that the effectiveness of EMDR has a whole lot less to do with the bilateral stimulation and more to do with the fact that people are getting exposure to their traumatic memories instead of avoiding them. The base structure of EMDR is that the clinician has the person recall aspects of their traumatic memory while engaging in these bilateral stimulation activities.
Repeated exposure to the traumatic memories without negative coping and avoidance strategies is what seems to really make a difference for people.
Our memories are alive. They aren’t like a permanent record that plays back a copy of what happened. Humans actually have super unreliable memories. Every time we recall a memory, we put it back into our memory storage in a slightly different way. Treatment of trauma exploits this weakness to help you store traumatic memories in a less threatening way.
Even though the research doesn’t necessarily support the bilateral stimulation thing, I still like EMDR. I think that the different bilateral techniques serve as a good container for doing the exposure work. It’s a good distraction, just like bouncing a ball or playing tetris or something like that.
If you go into a therapist’s office and they say “Okay we are going to dive into the traumatic memory of what happened to you” that is pretty freaky and you might shut down. If they instead say, okay check out this bar. There’s a light that goes back and forth. I want you to follow that with your eyes. Now I’m going to ask you a couple questions… That might be a better way to ease into the process.
Of the research that is positive on EMDR, the thing that might actually be helpful about these exercises is not that they stimulate both sides of the brain, but they can overload your working memory. Working memory is the skill you use for mental arithmetic. When you hold information in your mind temporarily, manipulate it, and then produce some sort of outcome. We have a limited working memory capacity and when your traumatic memory is competing for real estate with the exercises that you are doing, it seems to help you store those memories in a less immediate and threatening way.
I mentioned Tetris earlier – there is actually some research that indicates that puzzle games can have the same effect. They tax your visual working memory and if you play them after a trauma, they can help you avoid storing the memory in a threatening, traumatic way.
Many approaches can be used for individual, couples, family, or groups. For instance you can certainly do psychodynamic therapy or CBT with families. However, family systems therapy is a type of therapy specifically designed for family therapy.
Family systems therapy focuses on the family as an emotional unit.
Rather than looking at one person as the problematic one, it looks at each person as part of the overall system and that holds that the dysfunction lies within the system. Each person is looked at in relation to the overall system.
In this approach, you might make a genogram to look at relationships and roles within the larger family. Sessions often have exercises or activities to practice or play out scenarios. Family members may even be encouraged to switch roles to get a better understanding of the way conflict plays out within a system. There are many different subschools within family systems therapy and they all have slightly different approaches, but they hold the same fundamental tenants.
Again they don’t identify one person as the problem. They look at the family dynamics themselves. Maybe someone is acting out, but what other parts of the family system are prompting them to act out and what reaction happens within the system when that acting out occurs? This is a strength and also a criticism of the approach. The practitioners tend to remain very neutral. Sometimes infuriatingly neutral. To some that can seem like they may ignore obvious issues that come from one specific element within the system.
I do like this approach, though. It’s a good way of forcing everyone in the family to take responsibility and it becomes the goal of the family to improve rather than the goal to be to fix someone so they can stop ruining the family.
Eclectic or Integrative
The last approach that I am going to mention here is eclectic, or as I prefer to call it, integrative psychotherapy. This is the approach that I use. It basically means that you integrate various aspects from different psychotherapy approaches to craft a system that works for you. There is some pretty convincing research that indicates that most “master therapists” tend to converge on a similar model that uses the most helpful elements from various types of therapy after they practice for long enough.
There is a theory that there are some common factors that really make the most different in therapy. Funny enough, things like the relationship between the client and therapist and expectations for therapy seem to make up a huge chunk of what actually creates change in therapy and the actual techniques that are used are just one part of the puzzle.
For my personal approach, I tend to blend CBT and psychodynamic treatment. At the start of treatment, I tend to focus on education and empowering the person to understand what is playing out. I also tend to give some immediate coping strategies and techniques from the CBT tradition to help the person get some immediate control and relief.
As the opportunity provides, I always want to be looking for moments of insight to help the person understand the origins of their issues. In my opinion, which is based of of clinical experience and research – its important to arm someone with tools, but also provide some depth to treatment going back to the past and looking at the underlying issues because that sort of provides an armor to help avoid relapse in the future and creates enduring change. I also tend to integrate elements from other approaches like mindfulness to help people learn to tolerate their own internal experience better. That seems to amplify the gains that are made through CBT treatment.
These are definitely not all of the types of therapy out there. There are many. These are just a few of the most common ones. Others types of therapy you might hear about would be Acceptance and Commitment Therapy, Interpersonal therapy, pure behavioral therapy, or solution-focused therapy.
Therapy is effective. Many people don’t understand how talking with someone can help, but it does. The research is good on therapy outcomes, which is why insurance companies continue to cover it.
If you want to learn more about how to find a therapist, I have a blog post and a video about it here.
Thanks for listening!
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