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Navigating the therapy world and not sure where to begin?
Many people are deterred from approaching therapy, and this is for various reasons. Some lack an understanding of what therapy is, and how it works, while others have no clarity on what the various approaches mean, and how the therapist would work with them.
Therapy is a very personal journey. Knowing the basics of each approach, reflecting on how you are living your life, & reflecting on which approach resonates with you is helpful, in identifying the right fit (therapist), and getting the right help (modality). I believe clients should feel empowered and autonomous in their journey, and they should make an effort to explore before engaging.
Is there such a thing as the best modality?
There have been numerous debates around which therapy approach is most effective, abetted by the IAPT placing some modalities above others. This has the effect of positioning therapy modalities in a hierarchy, viewing some as gold standard, panaceas and evidence based. Instead of it being helpful, it often creates more confusion to people who are unfamiliar of the therapy world, and places some therapy modalities at a disadvantage, not because they are ineffective.
The Layard report (2006) informed the reforming of the NICE Guidelines, which led to the adoption of short-term, manualised therapies in the NHS. While this was a cost cutting exercise, it also meant longer term therapies were marginalised, as they are costly, and seen as non-evidence based. Secondary questions on what is considered credible evidence arise, as most of this research came from Randomised Control Trials (RCTs), whose reliability, and credibility in researching talking therapies remains questionable (Hinshelwood, 2010) . Furthermore, some research has concluded that while short term therapy is beneficial, its benefits wear off in the medium-long term (Norcross, 2005)
Numerous research studies have concluded that in any therapy process, it is not the modality that lead to positive outcomes, but the relationship. Some of the research which supports the notion that the relationship between the therapist and client is the main ingredient in any successful talking therapy has been carried out by Blagys and Hilsenorth (2000); Leichsenring and Leibling (2007); Shedler, (2010); Norcross, (2011); Norcross and Wampold, (2011); Norcross and Lambert, (2019). This means that regardless of whichever modality one takes, the capacity to have a deep, and meaningful relationship, and an emotional (human) connection between therapist and client is key to that process. Norcross, (2011) considers having a real relationship, empathy, positive regard, congruence and genuineness as some of the core elements of a therapeutic relationship As humans, we have an innate need for safety & connection. This is central to any therapeutic, and meaningful therapy and is contrary to what is considered evidence based, therefore more superior.
Do we make the right fit?
There are many factors involved in considering who could make the right fit in therapy. I have encountered many people who have had negative experiences in therapy, and left feeling completely discouraged & put off therapy. Sadly the reason behind this disheartening experience was mainly due to simply the client and therapist not being the right fit. Many people approach therapy already aware of whether they want to work with a male/female therapist, LGBTQ therapist, White/Black/Asian/Mixed therapist, etc. Issues around class, culture, geographical location, and lived experiences are also central in choosing the right therapist. For example clients who have experienced discrimination in their lives will find it easier to have a therapist who can identify with their experiences; gay clients may want to work with a therapist who is from the LGBT community, and a White Middle class client may want to work with a therapist who can understand their world better. These are certainly not written rules, nor are they indicators of successful therapy. There are more nuances around this, which are beyond the scope of this short blog. Some clients have a preference for face to face sessions or online- vice versa & this will again impact on their choice of therapist.
To reiterate, it is the relationship, the connection, and feeling of safety that matters. Some clients are also unaware of the significance of working with a therapists who is accredited and registered with any of the psychotherapy accrediting bodies- UKCP, BPC, BACP, HPC, HPCP, NCS and other accrediting bodies which have ethical codes of practice for therapist, and regulate the profession. There are many people (unaccredited) claiming to be therapists and life gurus offering therapy, yet they are untrained to deliver therapy. This can be harmful.
Which approach do I choose?
What makes the best approach to therapy for anyone is determined by what one wants to get out of therapy, the nature of their difficulties, how one is living their day to-day life, & psychological mindedness. The commitment therapy is also key -whether the one wants short-term or long-term therapy- time, finances etc factored in.
Schools of Thought and Therapeutic Approaches
While therapy is a concept which binds the non-medical models of treatment of mental/emotional distress, and understanding the human mind, there are different schools of thought, orientation, and therapeutic approaches to therapy. These schools of thought have different philosophical underpinnings, and does have unique and specific language, concepts, and ideas to distinguish themselves epistemologically, and describing what they do. While these postulations are different, from a philosophical perspective, they are essentially describing the same thing-the human mind and understanding human suffering. There are a lot of parallels. Fundamentally, there are more similarities than differences within these schools of thought, and a lot of borrowing from each other.
Here are the main schools of thought and the breakdown and their approach to therapy.
1-Psychodynamic/Psychoanalytic
Based on the works of Austrian Neurologist Sigmund Freud (1856-1939), this approach places the relationship between therapist and client at the centre of the process. Psychodynamic psychotherapy seeks to enable the client to develop the capacity to reflect on their experiences & create an understanding of the unconscious drives behind certain behaviours, feelings, thoughts that may be causing their distress, making connections between the past and the present. Psychodynamic/ psychoanalytic clinicians’ work is inductive, and view the therapist’s role of interpreting the past in the present and meaning making as key. The therapy addresses the person as a whole, not simply their symptoms, but try to create an understanding of the root cause of the symptoms. Distress is alleviated by processing & developing self-awareness- insight oriented. Therapists pay attention to the real relationship and the transference (internalised relational patterns) which is a tool and informs the therapy. It is unstructured & a deeper way of working and one of the oldest forms of therapy. This is typically long term; however, one can also have short term psychodynamic counselling focusing on a specific issue.
2- Cognitive Behavioural Therapy
CBT is type of therapy which originates from the works of American Psychiatrist Aaron Beck (1921-2021). It is a type of therapy which combines Behaviourism and Cognitive Therapy. CBT as an approach seeks to help one create an understanding of how thoughts (cognitions), feelings/emotions, behaviours and the body’s physiological reactions are connected. By understanding these connections, one is able to disrupt whatever maintains a negative cycle, therefore undoing certain unhealthy patterns. CBT focuses on present day distress. Behavioural experiments & using the body to emotionally regulate, are key tenets of this approach. It is typically short term, structured, & very specific to a particular presenting problem. CBT therapy can be applied through a formulation approach, or protocol treatment which is manualised and follows specific guidelines. This is true for the treatment of some complex presentations such as eating disorders, OCD, certain phobias, and severe depression.
3- Humanistic/Person Centred
This type of therapy originated from the works of American Psychologist Carl Rogers (1902-1987). It places the client at the centre of the process, with the therapist guiding the client to discover their innate abilities, wisdom & creativity in order to reach their full potential. It is typically long term and unstructured. Transactional Analysis and Gestalt Therapy falls in the Humanistic approaches as well. They all place the human at the centre of their existence, and view them as capable of autonomously making changes to their lives.
4- Existential
This approach stems from the works of Philosophers Friedrich Nietzsche (1844-1900) and Danish Theologian Soren Kiekegaard (1813-1855). Other Phenomenologists such as Martin Heidegger (1889-1976) and much later Otto Ranks (1884- 1939) contributed to the theoretical principles of Existential therapy. It focuses on developing self-awareness, creating an understanding of one’s place in the world in relation to others & meaning making of one’s unique experiences in the context of life. Responsibly and freedom is key to this type of therapy. The therapist guides the client in their journey of self-discovery.
5- Integrative
Some therapists are trained to work pluralistically, which means they can integrate various models in their therapy. This is typically a combination of any 3 of the modalities between CBT, Existential, Psychodynamic, Gestalt, Transactional Analysis and Person centred. Cooper and McLeod (2007) view this pluralistic approach as beneficial as clients will benefit from a different therapeutic approach at different points in time. Since these therapists are trained in 3 different modalities, there are pros and cons, with regards to depth and breadth of their work.
Difference between Counselling and Psychotherapy
Although counselling and psychotherapy are terms used to define talking therapies, the main differences between counselling and psychotherapy is in the depth, breadth, and duration of the work. These concepts tend to be used interchangeably, which create more confusion on their meaning. Counselling is often short term, and focused on a specific issue, while psychotherapy is a deeper way of working, which attends to the person as a whole, helping them identify the root cause of their difficulties. Counsellors are typically trained at Diploma level, while psychotherapists tend to be Masters level going up. Psychotherapists can practice as counsellors, while counsellors can not deliver psychotherapy. There are current debates around professional titles (protected) and who can have certain privileges.
Couples Therapy
Couples Therapy is a form of therapy where the therapist works with a couple, or a pair in a relationship. The aim is not to address the individual pathology of each partner in isolation, but help the couple understand how it is impacting on the relationship. A lot of people present to individual therapy with relational issues with their partners. However, if they go into couples therapy, it helps the couple work through their issues together, and grow in parallel. What often happens is that when one partners goes into therapy, they begin to grow and mature emotionally, leaving the other partner behind. At times this is positive as the growing, and emotionally mature partner assist the less mature partner in their growth together. In other situations, the gap in emotional maturity becomes wider, which can aggravate the relationship further. This highlights the significance of partners considering couples therapy if they are having mainly relational issues. Many people have couples therapy adjunct to individual therapy. They would however not have the couples therapist giving them individual therapy concurrently.
Other Contemporary Therapy Modalities
- Dynamic Interpersonal Therapy (DIT) Time limited/Short term
- Cognitive Analytic Therapy (CAT) Time limited/Short term
- Interpersonal Therapy (IPT) Time limited/Short term
- Dialectic Behavioural Therapy (DBT) Time limited/Short term
- Emotional Freedom Therapy (EFT) Time limited/Short term
- Eye Movement Desensitisation and Reprocessing (EMDR) Time limited/Short term
- Attachment Based Therapy (ABT) Medium-Long term/Short term
Other Health Professionals
Clinical Psychologists
Clinical Psychologists are trained to deliver psychotherapy along with other specialist assessment, diagnosis, formulations, and treatment of psychological and behavioural problems. Psychology and psychotherapy training is different; psychotherapists are not trained to carry out specialist psychological assessments and diagnosis. Psychologists are typically trained at Doctoral level and this reflects their skill, and specialist roles in clinical practice. Although they are Doctors, Psychologists do not prescribe medication. Psychologists have a different Accrediting body (UK Context) and this is typically HCPC or BABCP.
Psychiatrists
Psychiatrists are medical trained doctors who specialises in psychiatry. Psychiatrists apply the medial model in their work, and they are prescribers of medication. They can assess, diagnose, and medically treat mental disorders. Not all psychiatrists are trained to deliver psychotherapy; it is an additional training they need to undertake. In order to practice as psychotherapists, they need to be registered with one of the psychotherapy bodies for them to practice as both psychiatrists and psychotherapists. Psychiatrists also provide other specialist psychiatric assessments and diagnosis of ADHD, ADD, Autism, Aspergers, Dyspraxia and other neurodivergences, which therapists are not trained to do. Psychiatrists are registered with the GMC, and other bodes for any specialisms they may have acquired.
Most therapists offer a free 10-15 minute call. Do request for one if you are unsure, and use it as a time to explore, assess, and evaluate things. Browse therapists websites, and familiarise yourself with how they work before arranging a consultation.
Remember therapist are human!
Blagys, M. D. and Hilsenroth, M. J. (2000) Distinctive features of short-term psychodynamic
interpersonal psychotherapy: A review of the comparative psychotherapy process literature. Clinical Psychology, Volume 7 (2): 167-188.
Strathprints Institutional Repository
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psychotherapy: Implications for research. Counselling and Psychotherapy Research,
7 (3). pp. 135-143. ISSN 1473-314
Cooper, Mick and McLeod, John (2007) A pluralistic framework for counselling and psychotherapy:
Implications for research. Counselling and Psychotherapy Research, 7 (3). pp. 135-143. ISSN
1473-314
Cooper, Mick and McLeod, John (2007) A pluralistic framework for counselling and psychotherapy:
Implications for research. Counselling and Psychotherapy Research, 7 (3). pp. 135-143. ISSN
1473-314
Cooper, Mick and McLeod, John (2007) A pluralistic framework for counselling and psychotherapy:
Implications for research. Counselling and Psychotherapy Research, 7 (3). pp. 135-143. ISSN
1473-314
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Norcross, J. C. (2011). Psychotherapy relationships that work (2nd ed.). New York, NY:
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conclusions and clinical practices. In J. C. Norcross (Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (pp. 423–430). Oxford University Press
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