Understanding Psychotherapy: 

How To Choose The Type of Psychotherapy & Psychotherapist
That Is Best For You

Janice E. Cohen, M.D.

Why is understanding psychotherapy important and how can it help patients?

As an experienced and well-trained psychotherapist, it is humbling to admit that there are no conclusive studies demonstrating the superiority of one type of individual psychotherapy over another nor what combination of factors determine whether a particular type of psychotherapy is effective for a particular individual.

I received comprehensive training in many psychotherapies (e.g., cognitive behavioral, psycho-dynamic, supportive, family, and play) during my psychiatry residency and carried an unusually large caseload of child and adult psychotherapy patients throughout. I feel very lucky in this regard, as I completed my training several years before competency standards for psychotherapy for psychiatric residents were finally established.

Despite my extensive training in psychotherapy, as I left residency I had no plan on how to select from, apply or integrate the many diverse types of psychotherapy that I had learned and practiced during my training. I found that there was very limited or contradictory information regarding which types of psychotherapy were most effective overall and how particular forms of psychotherapy might be more effective for certain groups of individuals with similar problems.

As I worked to develop my own personal approach from different models, I would often ask patients what type of psychotherapy they had done in the past, what aspects had helped them the most, and what others had not. I found that most of my patients did not understand the fundamental differences between major types of psychotherapy and could not describe the type of psychotherapy that they had done. Nevertheless, they could articulate very well specific components of past psychotherapy treatment that had or had not worked for them and what characteristics they hoped to find in their next therapist.

The outcome of this process was the development of my own approach, and with it a conceptual framework for understanding the essential domains of psychotherapy and the fundamental differences among those being practiced (including my own). Over the past 7 years, this conceptual framework has proven invaluable to both my patients and myself. My patients feel that understanding the rationale and content of what we do in psychotherapy helps to engage them and provides them with a tool that allows them to guide the work. They also feel that understanding what we are doing in psychotherapy (within the larger holistic and rehabilitative context in which I practice) makes them more educated as consumers and better advocates for themselves and their families in obtaining effective mental health care.

What is Psychotherapy and does it work?

Most psychotherapies are fundamentally talk therapies (e.g., psychodynamic or insight oriented, cognitive behavioral, supportive, spiritual). These are in contrast to non-verbal or creative and expressive modalities such as music, dance, theatrical, writing (e.g. poetry) and art therapies (i.e., painting/drawing, crafts, jewelry making). Other non-verbal therapies include play therapy (e.g. toys, dolls, sports, games of all types). Play therapy is typically geared towards young children and people with cognitive deficits that interfere with their verbalizing their thoughts and feelings. Behavioral therapies focus on modifying people's behaviors. Such behavior therapies are based upon the principles of classical conditioning developed by Ivan Pavlov and operant conditioning developed by B.F. Skinner. They can be linked to talk therapies (i.e., cognitive behavioral therapy) or focus exclusively on affecting peoples behaviors through techniques such as positive reinforcement and systemic desensitization.

There are randomized, double-blinded, controlled clinical trials that show the "efficacy" (i.e. when things work in controlled or laboratory settings) of certain forms of psychotherapy. There are other studies that demonstrate the effectiveness (i.e., when things work in real world settings) of these and other various forms of psychotherapy. Some individual psychotherapies have structured tools for assessment and some have manuals for the specific process and content of the psychotherapy itself. Psychotherapies that are manualized or highly structured tend to have more and better evidence to support their efficacy (e.g., cognitive behavioral therapy). This is, in large part, because only a specific and well-defined intervention can be properly studied in a clinical trial. However, there are recent meta-analyses (combined analysis of many separate studies) of psychodynamic psychotherapy showing outcomes better than placebo or no treatment and results reportedly comparable to other forms of psychotherapy.

What types of Psychotherapy are being offered and practiced?

Even among psychotherapists who practice the same type of psychotherapy, there may be significant variation in practice among therapists. Modifications and combinations of different forms of psychotherapy are also constantly being developed and promoted. Such approaches may be described by the name of the therapist who developed the approach (e.g., Freudian, Jungian). Other forms may have names that do not necessarily describe the primary model or type of therapy that the new variant is based upon, but rather one small aspect of it, such as the time frame (e.g., Brief), the life domain constituting the focus of the therapy (e.g., Interpersonal), the theoretical framework about the mechanism of the cure (e.g., Insight-oriented), or the subjects for whom the therapy is designed (e.g., individual, family, couples, group). Some psychotherapies are named by a word whose definition describes the goal (e.g., Gestalt = completeness, wholeness) or the theoretical focus of the therapy (e.g., cognitive behavioral).

It is very common for therapists to describe the type of psychotherapy that they do as eclectic, which means that they combine a variety of different types of psychotherapy in their own particular way. Some therapists use the lack of conclusive evidence in support of one approach over another to promote a very general process or set of guidelines. Some rely on a discrete body of evidence that supports their one particular approach. Still others may practice a certain type of psychotherapy based on personal preference or the type in which they have received the most training.

Only in 2004 were competency standards for psychotherapy training adopted as requirements for psychiatric residency programs. That means that recently trained psychiatrists (graduates from psychiatric residency training programs who are already M.D.s) will often have training in multiple types of psychotherapy, which is often not the case for those who trained before 2004. However, even those trained in multiple approaches may favor or feel more competent in one approach versus another and it can take a period of time following training to find one's own personal approach to integrating different types of psychotherapy. The Accreditation Council for Graduate Medical Education lists as a requirement for psychiatric residency training: "applying supportive, psychodynamic, and cognitive-behavioral psychotherapies to both brief and long-term individual practice, as well as to assuring exposure to family, couples, group and other individual evidence-based psychotherapies."

From 1985-2000, the biological model and treatments (i.e., medication) became the predominant focus of scientific psychiatric treatment in residency programs, replacing the historic mainstay of psychiatric treatment: psychodynamic psychotherapies based on Freudian Psychoanalysis. Until the development of cognitive behavioral therapy (CBT), psychoanalysis and its many offshoots and hybrids constituted the foundation of most psychotherapy practiced in the United States. In many parts of the country, this is still the case, even though CBT hybrids and spin-offs have gained prominence at various institutions where psychodynamic psychotherapy was previously the exclusive form practiced (e.g., UCSF/Langley Porter Psychiatric Institute).

What is Talk Psychotherapy?

I like to define individual psychotherapy broadly in the most simple way - as any type of treatment for emotional or psychological problems based on an exchange of words and a special relationship between the therapist and the person seeking help. The therapist is typically a mental health professional with special training, but not always, such as in the case of a priest who provides couples therapy in the form of pastoral counseling.

What are the main types of Talk Psychotherapy and the differences between them?

I view and understand different types of psychotherapy on a continuum, a concept that was first introduced to me by Raymond Hoffman, M.D.. Dr. Hoffman was my main psychotherapy supervisor during my psychiatric residency training and he had a very broad and unique combination of skills. He was a certified psychoanalyst, an instructor at my psychiatric residency program at University of Maryland at Baltimore, and the medical director of the community clinic where I trained. It was he who first introduced this concept to me, one that I have developed and used ever since. As reflected by the ACGME guidelines, I likewise consider supportive, cognitive behavioral, and psychodynamic psychotherapy the three main forms of psychotherapy.

On the psychotherapy continuum, supportive therapy sits at one end and psychoanalysis at the other. Cognitive behavioral and modified psychodynamic/insight oriented psychotherapies lie somewhere in between. Over the years, I have come to understand the differences and similarities among various psychotherapies in terms of five domains. These include:

  1. the time frame(s) on which the therapy is focused: the past, the present or the future,
  2. the role and level of activity of the therapist and the type and degree of their participation/communication in the process,
  3. the average duration of the treatment,
  4. the theoretical or scientific assumptions about how the therapy works to heal or cure the individual and how closely the process is aligned with whatever models have been formally studied, and
  5. what the actual content/work of the therapy entails and where the focus of the treatment is (office vs. out-of-office).

What is Supportive Psychotherapy?

Supportive therapy entails exactly what it describes: support for the person in whatever area they may need it. This could mean emotional support and encouragement, social support such as enlisting family members and friends to assist the client; problem-solving or decision-making support; medical support such as medication or a physical examination; practical supports such as transportation or helping someone care for themselves, their home or their children; or legal support in dealing with criminal or financial matters or assistance in obtaining health care or disability benefits.

Supportive therapy is often the type of therapy that is provided to people who are in crisis or having acute problems. It is also provided to people, who may not be in crisis, but may not have the capacity or desire to gain insight into the nature of their problems or to develop particular skills to manage their problems. The time frame in which the therapy is focused is the present and immediate future (next few days or week). For people who are in crisis, the duration of treatment is typically short, a few weeks to no more than a few months. For those who are not in crisis, but may have chronic problems, therapy or treatment can be ongoing and is ideally titrated to the needs of the individual. An example of the latter are clients in a community clinic who have a case manager, therapist or psychiatrist who works with them over many years.

In all supportive therapy, the therapist is very active and offers a significant amount of guidance, advice, and structure, all considered essential to the approach and treatment. The theoretical assumption regarding how supportive therapy works is simple. The person either articulates their immediate needs or problems and/or the person's needs are assessed by the therapist. The therapist then works in a collaborative way to effectively address the person's needs in ways most appropriate for the individual. For someone in crisis the work typically involves identifying and setting up structures and supports that the patient will need outside of the clinic setting to stabilize them and maintain their safety and functioning. If the patient is not in crisis and the work is more focused on ongoing issues, the content of therapy will involve goal-setting, help with cognitive and skills development and the provision of appropriate resources and referrals to help the patient achieve their goals.

What is Psychoanalysis and Psychodynamic or Insight-oriented Psychotherapy?

At the other end of the continuum is Freudian Psychoanalysis or psychoanalytic psychotherapy, upon which all psychodynamic or insight-oriented (these are just different names for the same thing) therapies are based. The time frame is the past and particularly early childhood. In pure psychoanalysis, the therapist is completely behaviorally inactive, with the three principles of the psychoanalyst being anonymity, neutrality, and abstinence. The theory behind how this approach works posits that through the process of free association and transference, the patient displaces onto therapist their unconscious conflicts, feelings and thoughts related to important people from their childhood (particularly the opposite sex parent). Through this process and aided by periodic interpretations by the therapist who is actively listening, the patient gradually gains conscious insight into their dysfunctional and destructive patterns and defenses and is cured of their neuroses.

Newer models of psychoanalysis describe the "joint creation of transference" between the patient and therapist where the therapist is not expected to be totally inactive or anonymous. In classical psychoanalysis, the patient typically sees the therapist for at least two and up to five sessions per week and for 10 years or longer. Currently, 50 minute to 1 hour weekly or bi-weekly sessions for several months up to several years is the common range of duration of treatment for insight-oriented psychotherapies. The variants and offshoots of psychoanalysis may differ considerably and include Jungian psychoanalysis and psychodynamic psychotherapies that integrate or are based on object relations theory and self-psychology.

What is Cognitive Behavioral Therapy?

Cognitive Behavioral Therapy (CBT) lies in between psychodynamic and supportive psychotherapies. The time frame is the past, but the primary focus is to understand how the past influences the person's present. The past is most important in the beginning of treatment in identifying each person's automatic (and unconscious) negative core beliefs. This approach assumes that people's negative repetitive emotional states and unproductive behaviors are hard-wired and result from current life situations that trigger one's automatic negative thoughts and a perceived threat or danger, which leads to a cascade of negative emotional states that often follow. The cure involves many techniques and interventions designed to 1) Teach people to recognize and stop these automatic thoughts before they get out of control, 2) provide people skills and training to replace their negative irrational thoughts with positive rational ones, and 3) to help people modify their negative behaviors/reactions to situations. Insight is not seen as the cure, but rather cognitive restructuring (rewiring so to speak) using one's conscious mind. In this approach, the therapist is very active and the work collaborative.

In formal individual CBT, after a core belief analysis, each session may be organized according to a formal structured interview. Some therapists practice a less structured form of CBT, but generally apply the same principles and techniques. The role of the therapist in CBT is to help the person develop and practice cognitive skills and approaches with a strong emphasis on self-help homework assignments outside of the office. The duration of therapy tends to be short to intermediate duration, 12-24 weeks, although for individuals with personality disorders or ongoing need for support, CBT is typically lengthier, involving 1-3 years.  For people with personality disorders, individual therapists may require that the person also participate in Dialectical Behavioral Therapy, a manualized 6-8 month CBT-based skills training group developed by Marsha Linehan.  For people with substance use disorders, individual therapists may require that the person also participate in a substance abuse treatment program or group.

The following chart compares the types of psychotherapy on the five domains noted earlier.

 

DOMAINS TYPES OF PSYCHOTHERAPY
Supportive Cognitive Behavioral Psychodynamic/Psychoanalytical
Time Frame in which therapy is focused Present and immediate future Past experiences that influence present thoughts and behaviors, then a focus on the present and future Past, typically early childhood.
Role and level of activity of therapist Most intense and active in terms of providing concrete advice and guidance/ content focus are supports outside of the office Active, collaborative relationship with patient. Therapist helps in providing structure. Large emphasis on homework with a focus on implementation of skills outside of therapy and office Ranges from inactive (neutral, abstinent, anonymous in psychoanalysis) to more active and interactive in more modern psychodynamic approaches. Therapeutic relationship and work in session is considered primary.
Duration of treatment Can vary, very brief if focused on a person in crisis and ongoing for people with chronic or sustained illnesses Brief to intermediate Typically long-term (one year to many years) although Brief Psychotherapy is a psychodynamic psychotherapy and is typically 12 weeks or less.
Theoretical/scientific assumptions or models regarding how the therapy works Common sense - people in crisis need individualized supports and assistance including hope/confidence they can get through the crisis, on-site supervision, help with food, clothing, shelter, transportation, medical care, medications, hospitalization, coordination of care, time off from work or school Past trauma or negative experiences lead to automatic negative thoughts (hard-wired reactive negative thoughts and emotions) triggered by situations in the present. Cognitive restructuring is accomplished through bringing to rational conscious awareness reactive thinking and patterns. Treatment involves stopping negative thoughts, cycle of of negative emotions and behaviors. People learn to replace negative ways of thinking and behaving with positive ones. Through the process of free association and transference, the patient displaces onto the therapist their unconscious conflicts, feelings and thoughts related to important people from their childhood (particularly the opposite sex parent). Through this process and aided by periodic interpretations by the therapist who is actively listeningŁ, the patient gradually gains conscious insight into dysfunctional and destructive patterns and is cured of their neuroses.
The content/work that the therapy actual entails Clinical and non-clinical supports and interventions in the community, office, clinic and/or home. Structured or non-structured individual office-based psychotherapy with significant ongoing homework outside of session. May involve parallel group CBT (e.g. DBT). May also involve treatment outside of the office (e.g. working with a patient who is a hoarder at their home). Regular individual psychotherapy with a focus on the relationship between the therapist and the patient and what happens in the session.

 

What are some non-pharmacological complimentary treatments used in conjunction with talk therapies?

There are many non-verbal treatments besides medications that may be effective and used in conjunction with talk therapies. Such distinct modalities include herbal psychoactive preparations (e.g., St. John's Wort), Eye Movement Desensitization and Reprocessing (EMDR), Meditation, Hypnotherapy, nutritional supplements (e.g., Omega-3 fatty acid supplementation), Light therapy, and Biofeedback. Use and implementation of lifestyle interventions (aerobic exercise, good nutrition, adequate restorative sleep, creative activities, spiritual pursuits) can also be important adjunctive treatment in effective psychotherapy.

Are there other services that can be effectively integrated with and complement talk therapies?

Many rehabilitative services that were developed in the public sector for people with severe and/or chronic psychiatric illnesses can be beneficial to individuals at all levels of illness severity, including those with developmental disorders. These include supported education, employment and housing, family psychoeducation and therapy, vocational rehabilitation, social skills training and integration, and self help and peer support groups. Individuals, especially those with learning and developmental disorders, may also benefit from time management and organizational skills training, sensory integration therapy, speech therapy, behavioral coaching and therapies, as well as social thinking training. Helping a disabled person obtain benefits and special or reasonable accommodations through their academic institution or place of employment can also be very beneficial.

References

  1. Accreditation Council for Graduate Medical Education
    1. Program Requirements for Residency Training in Psychiatry  Approved: February, 2000, Effective: January, 2001; Minor Revision Approved: September 2004, Effective: November 12, 2004
    2. Program Requirements for Graduate Medical Education in Psychiatry Approved: September 12, 2006, Effective: July 1, 2007; Revised Common Program Requirements Effective: July 1, 2007; Approved Minor Revision: February 12, 2008; Effective: April 12, 2008; Editorial Revision: July 1, 2009
  2. Validity of Controlled Clinical Trials of Psychotherapy: Findings From the NIMH Treatment of Depression Collaborative Research Program, Ablon JS, Jones EE, Am J Psychiatry 2002; 159 (5):775-783.
  3. The Heart and Soul of Change: Delivering What Works in Therapy, Barry L. Duncan, Scott D. Miller, Bruce E. Wampold, Mark A. Hubble, Editors, American Psychological Association, 2010.
  4. Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis, Leichsenring F, Rabung S, JAMA. 2008; 300(13):1551-1565.

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