Effective psychologists are flexible and knowledgeable in a variety of perspectives and modalities. They use an integrative or multi-dimensional approach, actively tailoring sessions to their patient’s needs, symptoms, personality, and mood. Being ruled by one perspective, way of thinking or diagnostic label limits what therapists notice, and leads to interventions that patients experience as artificial, forced, and alienating.
Therapy should be delivered actively and in a personal way with a responsive, collaborative, respectful therapist who is fully present in the here-and-now with the person in front of them. It is not about applying techniques or formulas. It should not feel stale or rote. Helpful therapy is both experiential and practical, and should move the patient in some way, and not be just intellectual.
There are many therapy approaches, referred to as modalities or orientations. But what do these labels actually mean and how do they translate into what a therapist actually says and does in their sessions with patients?
This article is a guide to some popular approaches, specifically, psychodynamic and attachment-based therapies, acceptance and commitment therapies, interpersonal therapies, systemic approaches. Though the approaches may be represented and seen by the public as distinct, they are broad categories, and there is a lot of overlap among them both in theory and practice. There are also other popular approaches that are not covered here, some of which are centered around coaching, self-expression and personal growth.
How The Personality Of The Therapist Shapes Therapy Approach
Therapy unfolds within the landscape of an interpersonal relationship. For example, two therapists who practice the same type of therapy deliver it differently, since a therapist’s approach is filtered through the lens, personality and voice of the therapist. The relational dynamics that emerge between therapist and patient further shape the interaction. It’s no surprise, then, that research finds the personal match between therapist and patient impacts treatment outcome more than the therapist’s stated orientation.
Where a therapist trained as well as their intellect, cognitive style, defenses, and personality all play a role in determining their choice of approach.
For example, certain approaches lend themselves to a more formulaic and emotionally distant format, not requiring the therapist to access their own emotions or tune in to their mental state. Staying more emotionally distant in the interactions may work with certain problems (for example phobias) and personalities. But, patients in this type of therapy report feeling treated generically as a “patient” or an object rather than a person.
Alternatively, some types of therapy require the therapist to show up more fully as a real person and be more emotionally involved and vulnerable. Therapists using these approaches feel less psychologically shielded, and less emotionally separated, from the patient.
In these more dynamic interpersonal orientations, the therapist’s authentic engagement is essential for healing a patient’s underlying, and often unconscious, emotional experience during treatment.
The therapist’s attunement and the therapy relationship are used as a vehicle to understand the patient, in the service of creating a reparative experience that impacts their neurophysiology and psychology.
However, regardless of their orientation, therapists who are tuned in, emotionally intelligent, and interactive are not only preferred by patients but get better results.
Popular Approaches
Psychodynamic approaches focus on understanding and identifying the origin of the patient’s issues or symptoms. In this type of therapy, the therapist helps the patient recognize recurring patterns of behavior in which the past is reexperienced and recreated in the present, often without awareness. Patients come to understand the nature of the templates or maps for relationships formed in childhood that were adaptive at the time but are now unconsciously and maladaptively replayed with their spouse, children, and often authority figures.
Psychodynamic Approaches Informed by Attachment Research
Therapy approaches informed by attachment theories and “mentalizing”—the ability to recognize and understand one’s own and others’ mental states, are broadly considered to fall under the psychodynamic category. This perspective has become more popular as research emerges on the importance of a therapist’s capacity to mentalize because it is relevant to patient improvement.
Mentalizing is related to the ability to reflect, psychological-mindedness, and perspective-taking. This capacity is not limited to the cognitive or intellectual component. It includes the ability to make sense of behavior, to interpret both heart and mind in oneself and others and see the link between mental states, feelings, and behaviors. This is the opposite of “mind-blindness.”
Being able to understand one’s own and other’s mental states enables people to manage conflict and get along better in their relationships.
When therapists possess this skill, regardless of their theoretical orientation, patients are more likely to develop it and transform problematic attachment patterns, a particularly important capacity for parents.
Parents with insecure or anxious attachment patterns who have the capacity to mentalize are able to protect their children from the negative effects of these attachment patterns and optimize brain development.
Research on attachment has found that symptoms in adult relationships can be reliably predicted from early patterns of attachment between parents and children. Therapists using attachment-based approaches work within a framework of carefully attuned listening and responding aimed at healing unconscious, psychological, and biological processes in the brain and promoting the development of higher-level capacities. Such capacities include the ability to recognize and reflect upon what is happening in one’s mind and the minds of others, and sort out one from the other, which has been described as “seeing oneself from the outside and others from the inside.”
Cognitive-Behavioral Approaches (CBT)
Cognitive-behavioral approaches emphasize learning to recognize and change maladaptive thought patterns and behaviors, improve how feelings and worries are handled, and break the cycle of dysfunctional habitual behaviors. This perspective helps people see the connection between how they think, what they tell themselves in their inner dialog, and the feelings and actions that follow.
Cognitive Restructuring
Cognitive restructuring or reframing, an intervention in CBT, can be helpful to incorporate into many therapy orientations because it helps people view things from a different perspective that allows them to not only feel better but also make more adaptive decisions about what to do.
However, cognitive-behavioral approaches that follow a manual can limit the deeper emotional and interpersonal healing required for many issues and can be off-putting or trigger resistance in certain patients.
Acceptance and Commitment Therapy (ACT)
Acceptance and commitment therapy (ACT, pronounced like the word “act”), a 3rd wave mindfulness approach that does not involve meditation), offers an alternative.
This orientation is particularly effective in addressing avoidance, emotion dysregulation, and self-defeating behaviors, including internal distress caused by punitive and shaming inner dialogs.
At the heart of ACT is the idea that people assign arbitrary and negative meaning to their mental and emotional states and that it is the overreaction to their inner states: thoughts and feelings that lead these states to become paralyzing. These judgments and reactions to thoughts, feelings, and behaviors transform internal states into something unbearable, triggering punishment, shame, and avoidance.
ACT teaches people to observe their thoughts and feelings from a distance and recognize them as separate from who they are, rather than taking them literally as facts or predictions. By stepping back and taking perspective, while having thoughts and feelings, patients gain the space to develop greater awareness and tolerance of their inner world. ACT interventions foster flexibility and can help break the cycle of self-defeating behavior, shame, and the need to escape.
A key part of ACT strategy involves identifying and bringing into focus what truly matters to the patient. The goal is to help people act more in line with their values and take charge of their decisions.
Unlike formalized cognitive behavior therapy, ACT therapy is not one size fits all. Rather than trying to change thinking patterns and seeing them as symptoms, the philosophy here is to teach people to experience their thoughts and feelings differently so that they do not have to escape them.
Interpersonal and Relational Approaches
Interpersonal and relational approaches emphasize identifying and understanding (self-defeating) patterns in relationships, figuring out why they are happening now, given a particular context or relationship, and how to change patterns that do not work and develop healthier ones. This approach focuses on active problem-solving and understanding what is happening in relationships, including the here and now of therapy.
Systemic Approaches
Systemic approaches take an even wider lens, understanding problems within their contextual framework, with a focus on understanding and shifting the dynamics of relationships, families, and even work settings. The roles and behaviors that people take on in a particular family or context are understood as determined by the unspoken rules of that system at large and the interplay of how everyone interacts. Change in any part of the system is the route to changing symptoms and dynamics, whether or not the “identified patient” is specifically involved in those changes. In this type of therapy, the “identified patient” in a family—the one seen by family members as having the problem—is viewed by the therapist as part of a larger system that is creating and/or sustaining this problem. This approach can be particularly useful when one member of a family seems resistant to therapy or to change because it opens up other avenues for intervention.
The bottom line is that patients have very different experiences and outcomes with different therapists. In general, people find therapy most useful when therapists are responsive, warm, engaged, and offer feedback, regardless of the therapist’s orientation.
Certain basic conditions should be met in terms of training and experience when choosing a therapist. Orientation does matter, particularly in terms of how it’s applied and whether a particular orientation lends itself to your issues. However, the personality and personal qualities of the therapist are intermingled with their orientation and should override orientation preference when there is not the right personal match.
How To Tell If It’s a Good Match
Many people who have been in therapy report that they feel most comfortable and have better results when there is a good personal match. When someone strongly prefers a certain gender or cultural match, they do better in treatment when this preference is honored, if possible without compromising the other important factors.
Whether the match is good can be determined by whether you like and feel comfortable with the therapist and of course whether the therapist has experience, training, and successful outcomes in treating your issues. In addition, a key part of what makes a good match has to do with “chemistry.” Chemistry involves more subtle factors such as the personality style of the therapist, voice and manner and its intuitive feel to the patient. Is this someone with whom you would want to talk and confide? Do they seem like they care?
The bottom line is that patients have very different experiences and outcomes with different therapists. Therefore, if you are new to therapy, or have not had a productive experience, consult with more than one therapist and have a conversation.
