Monday, June 13, 2022

What type of therapy is best for you?: a theoretical model breakdown

The search for a therapist can be long and full of jargon. Resumes have lists of trainings, websites have unfamiliar acronyms, and even Psychology Today has a section for treatment approach. Most will try and guess the meanings from context, skim Wikipedia pages, or skip over these altogether. Still, clients and friends alike ask me how to tell what theoretical model is the best. And, as with so many things, my response is: it depends on who you are and what you're looking for.

For starters, I often find it works best to find a model that operates differently from how you naturally approach problems. For example, if you tend to take a very direct problem solving approach, seeing a therapist who mostly works from a solution-oriented model might feel redundant. On the other hand, you don't want something so far out of your comfort zone that it isn't doable. Therapy may feel like work, but it should be the kind of work you're willing to do. Some people care a lot about the research and evidence behind certain theories and techniques. In my breakdown below, I'll start by talking about the most common and most evidence-based models, before going into the rest. It's worth keeping in mind that just because a model isn't evidence-based doesn't mean it isn't going to work! Some of these are harder to research by nature, some struggle to get funding, and others are too new to have much research behind them. My advice is to not let whether something is evidence-based or not put you off. You may find that what works for you in therapy is very different from what you'd expect.

Cognitive and Behavioral

The most evidence-based model is Cognitive Behavioral Therapy, with related models like Dialectical Behavioral Therapy closeby. CBT's numbers-based system for evaluating emotions makes its results easy to quantify and therefore study. CBT examines the way our thoughts affect our emotions, which in turn affect our behaviors. This can work well for people who get so stuck in their emotions that it's hard to look at things more logically. However, since CBT is so commonly used, there's a good chance that those who have found therapy unhelpful have encountered this model before. Many clients with previous therapy experience have said that therapists suggest things they already do, like reframing negative thoughts, or writing a list of pros and cons to make a decision. CBT works well enough for standard levels of anxiety and depression, as well as circumstantial stressors. However, if you're dealing with more complex issues such as trauma or addiction, I'd highly recommend finding a therapist with training that applies CBT to your specific issue. 

A couple of related models build on the CBT framework. Mindfulness-Based Cognitive Therapy adds mindfulness to cognitive work, both as a way of better noticing thoughts and feelings, and as a way of approaching them nonjudgmentally. If these are issues for you, mindfulness might help. Mindfulness in general is a concept therapists use in many different models, but you probably most often see it named as such when incorporated into theories like this. In Dialectical Behavioral Therapy, mindfulness is foundational. Though DBT also builds on CBT, it focuses less on reframing thoughts and more on regulating emotions. While CBT works well on its own for those whose problems are more emotional than behavioral (depression, anxiety), DBT was created specifically for clients with Borderline Personality Disorder, making it good for those with complex trauma, a pattern of interpersonal difficulties, and high reactivity or impulsivity. However, it's also helpful for fluctuating emotions (bipolar, depression), eating disorders, and substance abuse. This is because it focuses in developing skills that help notice, tolerate, manage, and describe difficult emotions. Basically, DBT teaches clients to build up a sense of internal emotional structure. If you find yourself in crisis mode often, struggle to manage strong emotions, or just want to feel like less of a mess, DBT may be a good fit. It's worth noting that DBT-informed talk therapy is different from a full DBT program at a clinic; DBT programs are more geared to high-risk individuals.


While the CBT-based models focus on thoughts and logic, Humanistic models tend to focus more on emotions. In particular, they focus on a person's individual nature, including their identity and strengths. The simplest example of this is Client-Centered Therapy, where the client leads the discussion and the therapist listens, reflects, and provides support. While this alone can work well for building self confidence and allowing clients to take up space if they struggle to otherwise, most therapists integrate this with other types of therapy. It's worth noting that some see this as part of a therapist's personal style -- some therapists tend to listen and reflect, and others are more directive. Similarly, Solution-Oriented Therapy focuses on setting goals and solving problems. While this can address simpler stressors, it isn't going to help on its own for psychiatric concerns. Like Client-Centered Therapy, it can be used with other theories, or function as a style of therapy.

Other humanistic models are more specific to root causes behind the difficulties that bring clients in to therapy. Existential therapy looks at the search for meaning in life in a way inspired by philosophy. This can help with depression, grief, loneliness, and generally feeling stuck in life. Though philosophy fans may be those most drawn to this, I'd probably recommend it more to people who struggle to examine themselves in this way, since for them this would be an area for growth. Meanwhile, Experiential Therapy uses roleplay and re-enactment to bring the emotions present from past situations to the surface. In doing so, this helps make bottled up emotions easier to see and process, and can work as an outlet. Gestalt Therapy similarly uses re-enactment, but the focus is more on what's going on in the moment. Classic Gestalt exercises involve things like writing a letter or speaking to an empty chair, as a way of getting out and thus becoming more aware of thoughts and feelings. In contrast, an Experiential exercise might involve art, acting, or guided imagery, with the focus on a particular past event and the associated emotions. The different focuses mean they work for different issues, with Gestalt working well for things like anxiety, depression, and grief, while experiential works for trauma and behavioral issues. For those who prefer traditional talk therapy, these models may push on or expand comfort zones, with Experiential work straying a little further from the typical two person conversation. And, it's worth keeping in mind that not every session is necessarily going to involve one of these exercises. Most therapists will check in about things like level of comfort and willingness to do certain exercises, since we understand they can feel strange, vulnerable, embarrassing, and a little silly. However, if you enjoy self-exploration, there is a lot to gain from expanding your comfort zone.

Newer models

As cultural perspectives shift, so too do therapeutic models. These newer therapies are often collectively called Postmodern theories. Often these link to the different ways people see themselves and the world. One example is Narrative Therapy, which works on separating clients from their problems by changing their perspective of self. This idea is very reminiscent of person-first language in that it insists a client is not, for example, "an anxious person", but "a person who struggles with anxiety". The work itself comes from deconstructing the stories we tell ourselves about ourselves, editing how we tell some parts, and highlighting things that may get left out. This ties in with ideas about subjective truth. Issues best fit for Narrative Therapy are usually long term patterns with recurring themes, like social anxiety or apathetic depression. While this model may appeal to readers by name alone, more important is that the model fits in with how the client sees the world.

Another Postmodern theory is Internal Family Systems, or parts work. This theory looks at the self as one that contains many individual parts, each with their own functions. A simplified version of parts work is shown in the movie Inside Out, which depicts emotions as actual characters. However, parts aren't always emotions, and a single emotion can have many parts associated with it. These parts can be wounded, suppressed, or overburdened, and this is where a client's difficulties are seen to come from. However, these parts all have purposes. IFS is called this because the ideal is to have parts that work together, like an internal family, all functioning as one harmonized system. This can work well for anxiety disorders, OCD, trauma, and depression. In particular, IFS can help if you notice having conflicting thoughts or feelings a lot, as this suggests the conflict is between two or more parts. IFS is still new enough that it isn't always taught in graduate school, so if you're looking for an IFS therapist, it makes a huge difference to make sure they're trained in it.

Older models, revisited

You may notice that I haven't covered the father of psychology: Freud. The stereotype of lying down on a couch and talking about your mother is called psychoanalysis, and is far less common than it used to be. More commonly, you'll find Psychodynamic Therapy, where clients are given space to freely speak about feelings with the aim of gaining awareness about emotions, behaviors, and relationships. What it takes from psychoanalysis is the aim to bring awareness to the origins of long term problems, including any related repressed feelings. It's worth noting that traditional psychoanalysis was long and intense, and while some therapists do brief Psychodynamic Therapy, most often treatment is longer term.

Perhaps the biggest revision of an older model is Attachment Theory, which looks at the attachment made between child and parent and how this affects relationships later on in life. Though stemming from older models, Attachment Theory has a lot of evidence and studies to back it up, showing how unstable parental bonds can become unstable relationships later in life. While a more traditional version of this may focus on the client-therapist relationship as a way of learning healthy relationships, many who primarily use other models will call themselves Attachment-based or Attachment-informed, showing that they use the Attachment model to inform their work, even if their actual therapeutic approach is different. Attachment work is most helpful for those with a pattern of relationship difficulties, romantic or otherwise.

Holistic models: beyond talk therapy

As with any field, there are many therapeutic models that are considered more alternative. Though less evidence-based, they can work well with long term therapy and personal work. Therapists can combine these techniques with other, more evidence-based systems. However, it's worth noting that these aren't usually taught in grad school. Some grad programs focus on alternative therapies, but if you're seeking therapy that largely focuses one of these styles, I'd recommend finding a therapist who either went to a school that taught it or has gotten a credential or license in the specific technique. Many therapists will have such credentials listed on their website, but if not, it's worth asking.

Creative therapies are probably the most well known of these. With some basis in psychoanalysis, these therapies use different forms of expression to examine thoughts, feelings, and experiences that clients might not have the words for or find hard to talk about. Because of this, some of these techniques are often used with children, particularly kids who are shy or struggle to put words to their experiences. These techniques are also often brought up in groups. It can be easier for groups to discuss things like art and music, because it feels less vulnerable than speaking directly about difficult feelings and experiences. 

Art therapy, the most well known of these, is the label used for two different techniques in this category. More traditional, psychoanalytic art therapy involves giving prompts and analyzing the results, like having a kid draw a picture of their family. There's also expressive art therapy, which tends to be more freeform, with clients free to depict feelings and experiences in myriad ways, both abstract and symbolic. The therapist may ask questions while you create, like about what colors you choose, or just observe and save discussion for after. Dance therapy works similarly but with freeform movement, sometimes guided by prompts and sometimes using free association. Here the therapist may observe, mirror the client's movements, or draw the client's attention to things like posture, body parts, and breath. Music therapy can involve listening to, singing, or creating music with instruments. The focus can be specific songs or tunes, with discussions of feelings and memories that come up, or on using instruments and vocals to express whatever comes up, and provide catharsis. Though these techniques can feel intimidating, especially for those who don't have creative hobbies, it's important to note that no experience or talent is necessary. Creation here is a way of getting out what's inside, so it can be examined, and thus it doesn't actually matter how "good" the result is.

Another angle often taken up by some therapists is spiritual. Religious counselors can draw from their religious beliefs, ideally if this is shared with the client. The most common I've seen is Christian and Buddhist perspectives. Outside of organized religion is Transpersonal therapy, which addresses spirituality more generally. This looks at things like wisdom and finding meaning, and could be a better fit for those who are more spiritual than religious. Transpersonal therapists see the client as the expert on their relationship with spirituality, so they function more like a copilot than a guide. Transpersonal therapy is more of a lens than a technique, so it is usually very personalized to the client; this can involve mindfulness practices, journaling, breathwork, creative therapies, movement, and more.

The mind-body connection is explored further in somatic therapy. This most often involves noticing how the body responds during psychological work, but can also involve movement, postures, and other experiential techniques. This is often used for trauma work, and can be particularly helpful for those who notice physical symptoms coming up from mental health issues, such as chronic pain. If this is what you're dealing with, it's important to see a doctor first to be sure that the issue isn't medical in nature.

One of the newest alternative therapies is EMDR, which stands for Eye Movement Desensitization and Reprocessing. This involves using eye movement (usually watching something move back and forth) to desensitize traumatic memories and reprocess them, separating out strong emotions and strengthening positive beliefs and feelings. The full process takes place over many sessions and can involve discussing memories, analyzing negative and positive thoughts and feelings, dealing with strong emotions, and noticing feelings, thoughts, and sensations linked with stressors. Though it's primarily used for trauma work, even other diagnoses such as anxiety, phobias, and depression can have roots in traumatic or stressful memories. EMDR is somewhat controversial because its mechanism of action is unclear, but it is highly evidence-based. Many of the techniques used in EMDR draw from CBT, psychoanalysis, somatic therapy, and even some humanistic techniques. EMDR is a complex modality with a specific process, and can involve digging into the depths of the mind, so it is very important that the therapist have the appropriate training and certification.

Multi-modal therapy

Many therapists will refer to themselves as eclectic or integrative therapists. This usually means that they adapt their style to the needs of the client, depending on the problem, goals, and the client's personality. This may include trying different techniques, using specific therapies with specific types of clients (ie DBT for bipolar, Gestalt for grief), or combining approaches to create something new. As a result, it's hard to say this style does or doesn't work for particular clients. Drawing from different sources allows the focus to change as the client's life changes. You can start by dealing with something acute like panic attacks, then move into examining long term patterns of anxiety, before moving on to self-exploration and finding purpose, and all with different approaches. Therapists who practice multi-modally will often list out which modes they draw from the most. If you read this far and found it difficult to choose one, finding a therapist familiar with some or all might be a good call. Above all, make sure that whoever you work with is someone you trust. While trust is important for any client-therapist relationship, drawing from multiple models relies more on client feedback than sticking to just one. In this sense, you need to trust your therapist's ability to guide you, their judgment on what may and may not work, their understanding of you and your situation, and their ability to take whatever feedback you can give them.

Ultimately, the connection between therapist and client correlates with good results in therapy far more than use of any specific theory. A client can't feel safe with a therapist who makes them uncomfortable, and can't be challenged in an environment that bores them. Feeling heard and understood is such a base-level human desire that it can be easy to overlook how much of a difference it can make on the therapeutic process, but on some level, this need is often what drives us to seek therapy in the first place.

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