By Bart Pawlik, Clinical Psychologist
It can be confusing as a client seeking out what psychologist to engage with and what therapy to pursue. There’s a barrage of acronyms: CBT, ACT, EMDR, DBT.
As a psychologist, we get so familiar with these that they are like our ABCs, yet it’s easy to forget that someone might not know what were talking about, yet alone why it matters. And this is important when someone is spending their time and money to engage in therapy, as well as potentially confronting difficult emotional stuff in the hope of feeling better.
The goal of this is to help you become an educated consumer, so that you can have an understanding of what different therapies might have in common, what differentiates them – and how that might be relevant for you in trying to think, feel and act better.
Now, you might like to think of emotional health like ‘fitness’ – and the different therapies like fitness programs.
When deciding to look after one’s physical health, we might be decided between CrossFit, yoga, Brazilian jiu jitsu, powerlifting, bodybuilding, marathon running, dancing, etc. etc.
Yet why exactly are there so many different therapies?
Uncommon Factors in Therapy
When it comes to therapies, different approaches focus on ‘levelling up’ different mental health skills. You can think of it like a character sheet in a role playing game or video game.
If you only have a certain amount of skill points to invest, you can’t max everything out; likewise, there’s only so much time we have in therapy – and in life. Yet, we don’t need to max out all skill points to beat the game, we might invest them in becoming a swordsman, then manage to beat every boss; or, we could invest them in magic, and still beat every boss!
If you take for example Cognitive Therapy, there is a really big focus on training our awareness to notice our ‘negative automatic thoughts’ – our habitual mental chatter that can derail our mood and self-esteem.
We then work at learning skills and strategies to change these. We take negative, distorted our outdated views of ourselves, the world or other people, then endeavour to craft beliefs that are realistic, helpful and flexible. While traditional cognitive therapists might say that the magic is in the belief changes, in my experience as a psychologist people often make ‘meta-shifts’, where they stop listening to their negative mental chatter in general. If we strongly believe one negative thought, then have the insight it isn’t the whole truth: that opens up the possibility that other negative thoughts might be misguided too.
Behavioural Therapy – and Behavioural Activation – on the other hand, do exactly what the name suggest: focus on behaviours. It’s possible that thoughts are not focused on much at all and aren’t given much importance, but people are consistently encouraged and supported to uproot unhelpful behaviours and engage in activities that align with their values and goals.
In practice, most of the time these two approaches are integrated into Cognitive Behavioural Therapy – the most researched therapy – and these two strategies are combined.
Acceptance and Commitment Therapy doesn’t spend time ‘challenging’ thoughts, like Cognitive Therapy does. It instead focuses on mindfulness and ‘cognitive diffusion’ strategies to learn to take a step back from thoughts: seeing a thought as just a thought, a word, a series of sounds, a habit. We can even thank our mind for the input, then focus on working towards value-driven behaviours.
Dialectic Behaviour Therapy has a big emphasis on emotional regulation strategies, helping people build, practice and reinforce a huge toolkit of coping strategies to manage difficult emotions.
The list goes on. You can see that there might be a lot of different skills or practices that benefit mental health. And the different therapies each teach and emphasize a more narrow range of skills. You don’t need them all, you just need enough – and a few of the right one’s – to overcome your challenges and better your mental health.
In reality mental health seems to function in terms of ‘upward spirals’ and ‘downward spirals’. When someone is thinking negatively, their mood deteriorates, then they might start doing less, which makes themselves feel worse, causing more negative thoughts…. and so on. I think of different therapeutic skills as ‘levers’ that we can pull.
We don’t need to pull every single one, however it’s likely that pulling any lever will cause a ripple effect on the others. For example, research has found that doing simple, pure Behaviour Therapy – where thought aren’t targeted at all – people end up changing their beliefs in helpful ways!
Many of these things are connected, which brings us to the next section.
Common Factors in Therapy
You can think of mental health as a diamond with different facets and edges. The different therapies might focus on one corner, really polishing and shining that; other aspects of wellbeing might be towards the back, they might not be spoken about as overtly, but they’re still there. Okay, that’s not the best metaphor – I’m working on that one!
I’ll return to the exercise analogy. It’s less important for someone’s physical health what the exact exercise routine they’re engaging in ; it’s more important that they are consistently engage in regular movement. I think most of us can agree that whether someone is doing hot yoga or HIIT workouts, it’s much better for one’s physical health than being a couch potato. They are both moving their bodies, breaking some kind of sweat and getting their heartrate up. Exercise in general causes a cascade of helpful biological events.
Now, regardless of the type of therapy someone is engaging with, they are engaging in the therapeutic process, which is unique and has a lot in common regardless of the therapist’s approach. It’s a space with trained, supportive psychologist or therapy professional. The focus is completely on you, the client.
And regardless of what the therapy might call it, when you strip away the jargon and the specialised language, a lot of what good therapists do is similar across the different ‘schools of therapy’.
Most therapy is aimed at helpful and positive change. Different therapies focus on these things to difference extents, but the typical aims are:
- Changing unhelpful beliefs to helpful beliefs
- Changing unhelpful behaviours to helpful behaviours
- Changing unhelpful focuses to helpful focuses
- Changing unhelpful relationship patterns to helpful relationship patterns
And most therapies contain opportunities to create and experience the following themes:
- Having a safe space to discuss difficult issues
- Experiencing ‘unconditional positive regard’ from a therapist
- Working with someone who’s job is to understand
- Making sense of current problems
- Understanding self and challenges by connecting the dots in one’s life history
- Building self-compassion and self-acceptance
- Exposure to challenging thoughts and feelings, in a supportive environment, allowing the brain to ‘process’ them
- Creating an environment to see things in new ways
As long as someone is engaging in an evidence-based therapy with a competent therapist they click with, it’s likely much more important that someone is in therapy, rather than what therapy they are receiving. In the same way, it’s often more important that people simple get off the couch and move, rather than them having a 100% optimized and perfect exercise routine absolutely tailored to them. Also, there are 1000s of weightlifting routines, but, at the end of the day, people who lift heavy things get strong.
I mentioned the importance of upward and downward spirals before, so it’s sometimes hard to untangle. We know that therapy works. We know lots of different therapies works. And people, in a supportive environment, with a trained and empathetic therapist, motivated to work on their problems, tend to make changes: and those changes tend to impact lots of other areas of their psychology and brain.
Psychotherapy Client’s Preferences
Two psychologists, Cooper and Norcross, were researching psychotherapy clients’ preferences and found four main dimensions (there are others, but we will focus on these for brevity):
- Therapist directiveness – client directiveness
- Emotional intensity – emotional reserve
- Past orientation – present orientation
- Warm support – focused challenge
In our Adelaide psychology clinic, we actually ask people about these in our intake forms to try and help 1) match people with the appropriate psychologist, and 2) inform their psychologist about these preferences.
Now, these factors might be influenced by an individual psychologists style or personality. However, it’s clear to me that different therapies tend to emphasize or encourage different aspects of these continua.
There’s something called ‘Person-centred therapy’, which is very non-directive. It lets the client take the lead, so to speak, with the therapist aiming to listen carefully, understand precisely and reflect skilfully. The therapist will aim to ask questions that are helpful. It can lead to feeling very understood and supported, as well as insights naturally emerging. However, for someone who wants overt instruction and direction, it can be frustrating. The service Lifeline is largely based around this approach.
Dialectical Behaviour Therapy can be very structured – with the therapist deciding what is worked on and setting clear boundaries are what is and isn’t expected. There is a big focus on building skills, so it wouldn’t be the best fit for someone who wanted a lot of space to talk and explore their thoughts, feelings and memories at length.
Schema Therapy is an approach that works with complex or chronic life challenges, usually that people have had for years – our core ‘life patterns’ that are getting in the way of us flourishing. It uses techniques that tend to generate a lot of emotional intensity. This can lead to big emotional shifts and cathartic moments, but it can be too much for someone just looking for practical, non-nonsense skills and techniques.
Solutions Focused Therapy, Problem Solving Therapy and Strategic Psychotherapy, on the other hand, all take a pragmatic approach, which resonates in their names. There may not be any need for big expressions of emotions in order for people to benefit.
Psychodynamic or Psychodynamic Therapy unashamedly focuses on people pasts. These therapies really emphasise the role that someone’s developmental history – the things that happened when they were younger – shape and play a role in people’s enduring challenges.
Cognitive Behavioural Therapy, typically takes a very ‘here and now approach’. The idea is that, while understanding is helpful, we don’t need to work out ‘why’ or ‘when’ a problem started: we can understand it, treat it, work through it and overcome it in the present. It’s more likely that you will be asked what negative thoughts and experiences you’ve had in the past week, rather than when you were growing up.
As you might be able to guess from my words above, Schema Therapy and Person-Centred Therapy highlight the importance of warm support. Cognitive Behavioural Therapy and Dialectical Behaviour Therapy can lean into focused challenge.
It’s not that any of the above are good or bad, better or worse. It is about matching someone’s wants, needs and preferences.
To return to my fitness analogy, sometimes the best fitness program is the one that someone sticks to, because for whatever reason, it resonates with them. One person doing slow yoga may find it deeply relaxing and soothing, while another person might be restlessly craving more intensity. One person doing powerlifting might find the long breaks between sets boring, whereas another might relish the challenge of challenging themselves on the heavy sets.
It’s also about the therapy that makes sense to you and that you will stick with.
As well as potentially the one that meets your needs.
Though, I can’t help but to add a little psychologist’s caveat here: sometimes what people want isn’t what they need. I know that might be a risky thing to say. It can be presumptuous to assume we know more about someone’s experience than themselves. However, there might be times where a personal trainer or physiotherapist might be getting someone to do something they don’t really want to: but they know it will be damn good for them. Likewise, in therapy sometimes we do go to challenging places. For example, almost all evidence-based approaches to trauma have an exposure component, which means talking about the bad thing and processing it in some way. People hate this, it feels awful; though, it also helps people heal.
And so – beyond the approach and your preferences – it’s important that you find a psychologist that you feel safe enough with that you trust their judgement, while they are also listening to you and respecting any boundaries. You also should understand any rationale given for why you might be invited to do something that might be against your preference, like talk about a difficult emotion – or change a behaviour.
It’s teamwork.
The Impact of A Psychologist or Therapist
Therapy is weird. And unique. And powerful. It’s not like a pill – it’s dependent on another person: the therapist.
As a therapist myself that can be a little strange to acknowledge; but, it’s true.
We know from the scientific literature, as well as experience, that different therapists can have different results.
Diagnoses, Treatments and the Development of Psychotherapies
It makes sense that many therapies were originally developed to target specific problems.
The psychiatrist Aaron Beck originally developed Cognitive Therapy when he was working with people with depression. He noticed how many ‘negative automatic thoughts’ people were having when they were depressed, which they didn’t always share with their therapist – and sometimes were barely aware of themselves.
Marsha Linehan was the psychologist who invented Dialectical Behavioural Therapy – she specifically was working with people who were self-harming. It makes sense there’s such a strong focus on emotional regulation, behavioural change – and also emphasizing safety and boundaries in therapy.
Jeffrey Young invited Schema Therapy by searching for what could help people who hadn’t responded to Cognitive Behavioural Therapy. Often these were people who had complicated pasts, challenging childhoods – or who had experienced various kinds of developmental trauma. This led him to bring in more of a ‘past focus’ and more ‘experiential’ or emotionally.
Often therapies developed for one population are then tried successfully for others. CBT has evidence for treating a huge range of mental health conditions. DBT has been studied for things other than self-harm and Borderline Personality Disorder. Schema Therapy has even been found to be helpful for people in a forensic context!
Overall, many therapies have been born out of clinicians and scientists – psychologists in the therapy room and those in the lab – trying to make sense of specific challenges and then create the best way to help people with them.
In reality, a lot of things work for a lot of people. Though, in the field of psychotherapy, it’s best practice to offer people an ‘evidence based therapy’ for the specific challenge they are experiencing. This means that there has been a sufficient amount of scientific research for THAT therapy for THAT problem that we can be confident that the approach is going to benefit the average person.
What therapy should I get?
In reality, it’s common that most therapists are trained in multiple types of therapies. Please don’t agonize over the number of therapies I’ve mentioned! It’s typically not up to the client to pick the therapeutic approach. A good therapists will do an assessment and pick an evidence-based approach that seems to be an appropriate fit. And, they will refer you on to an appropriate provider if they aren’t trained to help you with your specific challenges.
You actually don’t need to know about all of these options to benefit from therapy.
Many therapists are also eclectic in some way, in that they will pick the strategies that they fill will be most helpful to a client with what they’re experiencing. Life is complicated. Life happens, things change.
It’s useful to have a few arrows in the quiver in case the first one misses. If someone doesn’t respond to cognitive behavioural therapy, schema therapy might be worth trying.
It’s even possible to benefit from therapy without knowing exactly what approach the therapist was using. In the same way, someone could do a workout without knowing it was HIIT – High Intensity Interval Training – and it would still do them good. (As a side-note, with the ethics of ‘informed consent’, a psychologist should explain a intended therapy rationale to you as a client!)
And so, you can book in for an assessment with a psychologist, then ask them what their ideas are, what approach they would recommend – and if they can do it or refer you to a colleague.
However, if you want to do some more research yourself, you might like to look at lists of evidence-based approaches if you know you have a specific mental health diagnosis. If you don’t have a diagnosis, you can look for challenges that are similar.
For example, you might not have Social Anxiety Disorder, but if you feel embarrassed or self-conscious more often than you would like, you might benefit from approaches focused on helping people with social anxiety.
You can also think in terms of what you would prefer in regards of directiveness, warmth, emotional intensity, and present-past orientation – and try and match that to a therapists approach. That could even be a set of questions you ask the psychology practice’s admin team on the phone or in the e-mail: you can invite them to help you match with a psychologist that might be a good fit.
You can also upskill and educate yourself by reading quality information about different therapies. You can read information on reputable websites; or seek out books. A part of why therapy works is because it makes sense to you – and that predicts you sticking with it. If you read a book about Acceptance and Commitment Therapy and you feel it helps you have a lot of little ‘aha’ or ‘lightbulb’ moments, then it could be a great idea to research ‘psychologists near me’ that practice that.
You can also reach us at Mind to Mind!
We have helpful admin staff who are studying psychology, as well as a team of psychologists in Adelaide with a diverse range of skills. If you’re unsure, we can walk you through your options – or book you in for an initial assessment with one of our psychologists to work out the best approach for you.
Best of luck growing!
