Types of Therapies

Theoretical Orientations and Practices of Therapists

July 21, 1995. By: John M. Grohol

From: http://psychcentral.com/therapy.htm

There are probably hundreds of different types of theoretical orientations and techniques that therapists use nowadays in the field of psychotherapy. You, as a consumer of mental health services, want an overview, however, of these types of approaches to therapy and practice. Luckily, you've turned to the right place. In this document, I will review the main schools of theory and the techniques they utilize in practice. Granted, such an overview is going to miss a lot and generalize even more (something my professors back in graduate school would kill me for!), but I feel information is important. I will, therefore, try and be mildly objective and unbiased in my presentation, when possible. Be aware that any therapist, no matter what their background or training actually is, can say they practice or subscribe to any of the below major schools of thought in psychology; a therapist's educational degree is no guarantee of any one theoretical or treatment orientation.

Four schools of theory and therapy will be examined here: Psychodynamic (and psychoanalytic); Cognitive-behavioral (and behavioral); Humanistic (and existential); and Eclectic. The parentheses indicate theories that are also covered in the same section, but only in passing or in conjunction with the other school; most are somewhat interchangeable. Note that although I don't have any current plans to add any other types of therapy and theories here right now (such as interpersonal, gestalt, or family systems), that may change at some point in the future. Before we begin this journey together through education, let me warn you that this article is not a scholarly, objective, dry, journal piece. (If you are a colleague of mine and don't like some things I've said about the school of theory or therapy you subscribe to, I'll apologize at the onset here and save you from having to write me about it!)

PSYCHODYNAMIC (and psychoanalytic) THEORY AND THERAPY

This is one of the oldest theories of psychology in which patients are viewed within a model of illness or "what is lacking." Individuals are seen as being made up from a "dynamic" that begins in early childhood and progresses throughout life. This psychodynamic way of thinking is generally a watered-down offshoot of the more conservative and rigid psychoanalytic school of thought. Psychoanalysis emphasizes that all adult problems' roots can be traced back to one's childhood. Few therapists can afford to practice strict psychoanalysis anymore and it is typically found nowadays only in the hands of psychiatrists, who have spent extraordinary amounts of personal time being analyzed themselves and attending a psychoanalytic institute. When people think of a "shrink," they probably imagine this type of therapy.

Therapists who subscribe to this theory tend to look at individuals as the composite of their parental upbringing and how particular conflicts between themselves and their parents and within themselves get worked out. Most psychodynamic therapists believe in the theoretical constructs of the ego (a mediating sort of force, like a referee), a superego (what is typically referred to as your "conscience," as in, "Your conscience tells you not to smoke!"), and an id (the devil inside us all that says, "Go ahead, what can it hurt?"). These constructs go to make up your personality and the role of the unconscious is emphasized. In other words, what you don't know can hurt you. And more often than not, it does. Since an adult's development to his present personality structure is viewed in terms of whether he or she successfully maneuvered through the psychosexual stages of childhood, you, as an adult, are likely completely unaware of how you are screwed up. And, according to much of psychodynamic theory I've been exposed to, almost everyone in the world can be viewed as only one degree or another of "bad." Human nature, viewed through the psychodynamic context, is decidedly negativistic.

Mental illness is a result of an unsuccessful progression through childhood development (e.g.- stuck in the "anal" stage), which in turn, has resulted in problems with the balance of your personality structure (the ego, superego, and id). The unconscious motives for most human behavior are sex and aggression. For example, perhaps the superego is much stronger than it should be and the ego is unable to always counteract its demands for strict, rigid, moralistic, and "right" answers to life... That person might be viewed as someone who is a perfectionist, clean, etc. You get the picture. But remember, this is all unconscious, as are all the unresolved childhood conflicts, so the person is not readily aware of why they are the way they are. That's what therapy is for!

In therapy, psychodynamic therapists tend to emphasize the important of the "frame," insight, and interpretations. Though not necessarily in that order. The "frame" of therapy exists in all theoretical orientations - to be fair - but it is usually emphasized to a great degree in psychodynamic therapy. The frame is the therapeutic setting and boundaries, such as the meeting time, length of time of each session (almost all therapy sessions are 50 minutes long), how payment is handled, how much self-disclosure the therapist makes, etc. Anything that disrupts this "frame" can be interpretable by some dynamic therapists (and most psychoanalytic therapists). If you cancel an appointment, it means something greater than your car broke down. There is some truth to this, as I've said, but not to the degree it is usually emphasized here. Since the basis of psychodynamic therapy is transference (where the patient projects his or her feelings about another person in their lives, typically one of their parents, onto the therapist), the frame is more important here. It means that the patient might be engaging in some sort of transference that needs to be examined by the therapist and interpret, if necessary.

Interpretations are what psychodynamic and psychoanalytic therapists do best (next to listening). As I noted above with regards to the canceled appointment, the therapist's reading into your actions more than really is there could be considered an interpretation. Interpretations are exactly that -- offering a reason or explanation to the patient about that person's behaviors, thoughts, or feelings. If an interpretation is done right, and usually after a fair amount of time in therapy, it leads to the patient's "insight," where the patient now understand the unconscious motivation that was making that person act, react, feel, or think in a certain manner. Other therapists make interpretations as well, but psychodynamic therapists do this best. That is their main weapon in their arsenal of therapeutic techniques, and the most powerful in almost all of therapy. Unfortunately, a lot of interpretations and insight don't necessarily lead to any changes in behaviors, thoughts, or feelings. Especially if done badly. This is why it would be important to see an experienced and long-practicing psychodynamic therapist if you were to seriously consider this modality of treatment. While historically, psychodynamic therapy would typically be lengthy (and in psychoanalytic therapy of days-since-past, you would meet with the therapist 3 or 4 days every week!), this is no longer the case with the advent of short-term psychodynamic theories and therapy methods. The research backing for this modality of treatment is still a little sparse and leaves much to be desired.

COGNITIVE-BEHAVIORAL (and behavioral) THEORY AND THERAPY

It is not really fair to lump these two together like this, but I did it anyway. Why? Because I'm trying to save space and time. Cognitive-behavioral theory emphasizes the cognitions or thoughts a person has as an explanation as to how people develop and how they sometimes get a mental disorder. Many types of theories in psychology could fit under this broad category, and it would be difficult to do them all justice, so I'm just going to focus on some of general points of them all.

Cognitive-behaviorists generally believe in the role of social learning in childhood development, and the ideas of modeling and reinforcement. People's personalities come from these experiences in which they are involved in critical learning, identification of appropriate (and inappropriate) thoughts and feelings, and imitation of these behaviors, thoughts, and feelings. So, in other words, if your parents act like snooty, uptight individuals all their lives, and treat other people with little dignity or respect, you, as a child, would learn to do much of the same thing. If your parents don't cry when they're emotional, you may also learn to hide your feelings and not cry when you're emotional. Children learn by observing and imitating. This is social learning theory. There's also a lot of discussion about how a human's innate drives and habits affect all of this, but we won't get into all that. Save to say that there is such a belief that it is these innate drives which underlie the motivation of human behavior.

Dysfunction (a nice term for "messed up") is a natural offshoot of this theory then. If your drives aren't properly reinforced and developed through proper and healthy social interactions, then you may learn unhealthy (or dysfunctional!) ways of coping with stress or life problems. Or, alternatively, somewhere the individual learned certain patterns of thinking which are either irrational or unhealthy, likely reinforced (unwittingly) by a parent or significant person in the child's development. If you grow up in a maladaptive or unhealthy environment, or you don't learn, for whatever reasons, proper coping skills, you can have mental disorder problems later on in life. Despite the negative-soundingness of this, the fact is that in this theory, humans are viewed as basically neutral. It is the environment and the other people they grow up with which shapes a person into a healthy or unhealthy human being.

Cognitive-behavioral therapy, in a nutshell, seeks to change a person's irrational or faulty thinking and behaviors by educating the person and reinforcing positive experiences that will lead to fundamental changes in the way that person copes. For instance, a person who might get depressed over the way their life is going right now may begin a downward spiral into thinking negativistic and irrational thoughts, as taught (or not taught) to that person in his or her upbringing. This only reinforces the depressive feelings and lethargic behaviors. Many people expect that therapy would try and attack feelings, to change them. Well, some cognitive-behavorial therapies do (e.g.- RET), but not in general. In general, feelings will only change after your thinking and behaviors have returned more to "normal" (whatever the heck that is!). So cognitive-behavioral therapists will work on helping the patient identify irrational thoughts, refute them, and help the patient change useless or frustrating and unproductive behaviors (through techniques such as modeling, role play, and reinforcement strategies). Therapists working with this type of therapy are generally more directive than psychodynamic therapists, and act as much as teachers, sometimes, as therapists. Therapy is generally short-term (which, in our field, means anywhere from 3-9 months, or roughly 10-35 sessions).

As you can probably begin to pick up on, cognitive-behaviorists use a wide variety of techniques, which are usually dependent, to some degree, on the patient's presenting problem. For instance, such a therapist would not use the same exact techniques to help someone who is suffering from a fear of heights than someone who is suffering from depression. The underlying theory is likely similar though. Cognitive-behavioral therapy has had some of the greatest success in research with a wide variety of disorders, from phobias to anxiety to depression. For instance, see my article on depression for some of this information. This therapy is one of the few empirically validated therapies on the market today. Does that mean it will work for you? Not necessarily, but it's probably worth your effort to try it out.

HUMANISTIC (and existential) THEORY AND THERAPY

I don't pretend to understand the underlying basics of this theory, except that it views human beings as basically good and positively, with the freedom to choose all of their actions and behaviors in their lives. What motivates behavior is "self-actualization," of the desire to always seek out to become something more of oneself in the future. Because an individual can be conscious of his or her own existence under this theory, that person is also fully responsible for the choices they make to further (or diminish) that existence. Responsibility is a key ingredient of this theory, for all humans are responsible for the choices they make in their lives, with regards to their emotions, thoughts, and behaviors.

Pretty tough stuff, eh? Yes, it is, because it says, in effect, that no matter what kind of childhood you suffered through, no matter what your life experiences, you are ultimately in charge of how you react to those experiences and how you will feel. No blaming it on the parents here! There are a number of major conflicts that also tend to need attention, according to this theory. These generally involve the struggle between "being" and non-being (life versus death, accepting parts of yourself, but not other parts, etc.), being authentic versus being "fake" or "fraudulent" in your day-to-day interactions with yourself and others, etc. This theory tends to emphasize these epic but philosophical struggles within oneself.

Therapy tends to emphasize these struggles and the individual that comes into therapy as being a unique person who views life in such an idiosyncratic way that it would be nearly impossible to try and fit them into any one specific developmental or other theory. It emphasizes the individualism of everybody and seeks to work with that individual's strengths and weaknesses as they apply to their particular problems. It also seeks to help the individual find themselves and their own answers to the philosophical struggles mentioned above, since no two people's answers are going to be alike. The therapist is there more as a guide, than as a teacher or authority figure, to help the patient learn more about themselves and what it means to be on this planet for such a very short time. Therapy can last anywhere from a few weeks to a few years, although it tends toward the longer end, since its focus is much broader than most other therapies here.

ECLECTICISM THEORY AND THERAPY

Of course I saved the best for last. Some of my colleagues are probably saying, "Hey, eclecticism is neither a theoretical orientation or therapy!" I'd say they're wrong, but I'm too modest and subtle for such an absolute statement. Oh, what the hell, You're wrong! There are many forms of eclecticism, but for you, the gentle reader, it is not really important to know or understand the differences between them all. I'll tell you what most therapists use in the field of psychology today... It's a pragmatic approach to therapy, meshing all of the above approaches together to fit the individualistic human being that sits before them for the first time with their particular problem.

Unfortunately, since it is based upon individualism and pragmatism, many people confuse it with confusion itself. Good eclecticism is neither messy nor confused. For example, a typical eclectic approach in therapy is to view an individual from a psychodynamic perspective, but to use more active interventions, such as you might find in a cognitive-behavioral approach. That is, believe it or not, eclecticism. Most forms of this therapy are much more subtle and less distinct than that. For instance, I tend to view individuals who come into my office as much as through the patient's own eyes as possible, imagining their worldview and the system that goes to make up their problems. I look at things not only from what might be reinforcing unhealthy behaviors (behaviorism), but also unhealthy thoughts (cognitive), and how these all relate together to go and make up the individual human being sitting in front of me (humanistic). In eclecticism, there is no one right or guaranteed way of approaching any given problem. Each problem is tainted and changed by that individual's own history and way of viewing or perceiving his or her own problem. Therapists are flexible, working as a teacher for one patient, as a guide for another, or as a combination of all of the above for yet another.

Eclectics use techniques, as mentioned above, from all schools of therapy. They may have a favorite theory or therapeutic technique that they tend to use more often or fall back on, but they are willing and often use all that are available to them. After all, the key here is to help the patient as quickly and as effectively as possible. Not to pigeon-hole them into some set way of looking at all people, whether it works for them or not. For instance, I have seen a lot of patients in which psychodynamic therapy techniques would have been useless and ineffective, because of time and verbal limitations (psychodynamic therapists basically agree that it is a most useful therapy for those who are more verbally-able, although the time 'constraint' can be argued). If I only practiced in that one vein (or, arguably in any one vein), I would automatically be excluding helping a lot of people.

Well, there it is. Remember, I've generalized a lot here and have not really been fair to the individualistic way therapy is done by individual therapists. That was not the point of this article. It was, instead, to give you a broad overview and basic understanding of these major schools of thought in psychology. Most therapists in the field today subscribe to some version of eclectic therapy; ask your therapist what theoretical orientation they subscribe to. It could lead to an interesting discussion. And remember, there is no "right" or "wrong" way in which to do therapy (at least of this date). You need to find what works best for you.