CBT? DBT? Psychodynamic? What type of therapy is right for me?
Psychotherapy is not one size fits all. From behavioural to gestalt therapies, which approach will work best for you depends on your needs and goals.
Since ancient times, cultures across the world have understood that human suffering can have psychological causes. At its core, psychotherapy is working with another person to help identify and address emotional challenges that matter to you. It involves trying to understand the source of those problems and coming up with ways to tackle them head-on.
Some therapists may take a particular approach to psychotherapy, like cognitive-behavioural or psychodynamic. As a child and adolescent psychiatrist who trains and consults with many other clinicians, I often find myself fielding questions about what type of therapy would be the best fit for a particular person.
It can be difficult to understand what therapists mean when they refer to these different techniques, and which is best for you. Learning about how each of the most common approaches to psychotherapy works may help clarify what you might expect from a particular session.
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is considered the gold standard in psychotherapy. Numerous clinical trials have found CBT to be effective for a spectrum of emotional health challenges, from anxiety and depression to addiction and schizophrenia.
CBT involves identifying, assessing and finding ways to push back on the negative thoughts that often underlie many negative feelings. For example, if I’m stuck thinking that I will definitely be unable to give a good presentation to my colleagues tomorrow, this can lead to feelings of anxiety and dread that fuel unhelpful behaviors like avoiding finishing up my preparation. A therapist might help me examine these thoughts by asking questions like, “Is this thought really accurate? Is this helpful right now in reaching my goals?”
Exploring the thoughts underlying negative feelings and behaviours doesn’t always feel like a very natural process. But with practice, usually in the form of “homework” to help you practice identifying and “talking back” to these negative thoughts, it can become second nature. Over time, CBT can help you to transition from the skewed lens of depression and anxiety to a more nuanced and balanced perspective on your daily life.
CBT can be brief (four to eight sessions) or intermediate (12 to 20 sessions) in length, but is not designed to be long term. The idea is to learn these adaptive skills in a quick, practical, “minds-on” way, then go out and use these strategies in daily life. Sometimes a refresher can help if you find yourself stuck in negative thought patterns again. But CBT has a great track record for long-term effectiveness over months and years.
Behavioural therapies encompass a number of treatments that focus on helping your body and brain build new connections through healthier behaviours. These connections are both psychological (developing healthier cognitive and emotional habits) and neurobiological (improved connectivity between brain regions involved in strong emotional responses).
For example, one form of treatment called behavioural activation seeks to lift mood by slowly increasing and reintegrating activities that are fun, physical, social or give a sense of achievement back into your daily life. It is often used as a component of CBT.
Physically, anything from taking a walk to incorporating the stairs in your daily routine is a great way to get your body and mind moving again. Socially, calling or texting an old friend may also help you gradually feel more connected and engaged with others. Simultaneously addressing both the psychological and behavioural sides of mental health can often synergistically kick-start progress towards feeling better overall.
If you have a particular phobia, a therapist might use graduated exposure to help you relearn how to tolerate the normal distress that can accompany uncomfortable experiences. The goal is not to eliminate all feelings of distress, but rather to relearn that your body and brain can withstand normal distress without shutting down. Eventually, you may be able to participate in an activity you’ve been avoiding, or directly engage with what you fear.
For example, if I’m struggling with a fear of needles, I would spend some time understanding the full range of the fearful responses I have to them. Thinking about needles makes me feel uncomfortable, seeing needles makes my heart race, and preparing to have my blood drawn makes me sweat and intensely want to avoid my appointment. Graduated exposure therapy would slowly but steadily introduce minimally distressing experiences (looking at pictures of needles) until my body and brain become accustomed to the fear response and return increasingly quickly to a normal state. This process, called habituation, can be practiced with increasingly distressing versions of your fear until you’re ready to tackle the full experience (getting blood drawn).
For children and families, behavioural modification is a generally brief (four to eight sessions) and problem-focused way to introduce more structure to parent-child interactions. This might involve creating a plan that establishes rewards to encourage positive behaviours, and consequences to discourage challenging behaviours.
If a family is working on improving respectful language in the home, for example, a parent might offer specific praise each time a child uses respectful language, strategically ignore minor disrespectful language, and establish predictable and consistent consequences for major disrespectful language.
Behavioural modification can also be useful for adults working to change specific challenging behaviours of their own. A typical example may be getting to watch an episode of a favourite TV show only if you’ve exercised that day.
Dialectical behavioural therapy
Often considered a type of CBT, dialectical behavioural therapy (DBT) is ideal for those who chronically struggle with managing their emotions. DBT focuses on learning skills to help you tolerate distress and navigate challenging interpersonal relationships.
One core skill of DBT is mindfulness. Mindfulness entails finding ways to “declutter” your mind from past emotional challenges and focus on what is happening in the moment. A common mindfulness strategy utilized in DBT is guided imagery. This involves repeatedly imagining a beautiful and relaxing physical environment, such as a beach, mountain meadow or cozy family kitchen, both to prevent and improve feelings of stress.
A common DBT strategy to tolerate emotional distress is sensory grounding. When you’re feeling overwhelmed, sensory grounding involves taking a step back and finding five objects you see in the physical environment, four objects you can touch, three sounds you can hear, two things you can smell and one thing you can taste. This gradual experience helps take the mind’s focus off an emotionally distressing experience to calm both body and mind.
DBT usually involves both individual and group sessions. While group sessions are often time limited (usually about six months), individual sessions sometimes can be longer term.
Psychodynamic psychotherapy starts with the framework that unconscious mental processes, such as denial or repression, regularly influence your thoughts, feelings and behaviours.
It uses the strong relationship built between you and your therapist to uncover these processes. The goal is to find functional ways of navigating interpersonal difficulties, trouble achieving personal goals or broader life dissatisfaction. Your therapist will likely help you explore your past experiences and relationships, looking for thought and behaviour patterns influencing the challenges you’re facing in the here and now.
Psychodynamic therapy is generally longer term, with weekly or more frequent meetings. While some patients can continue to have sessions indefinitely, most work with their therapists for several months to a year or more.
Gestalt and person-centered therapies
Gestalt and person-centred therapies are often referred to as humanistic psychotherapy. This model is generally centered on individual experiences and challenges, emphasizing that each person has a unique point of view.
Sessions are usually less structured and directive compared to other types of therapy. Rather than learning specific cognitive or behavioural skills, gestalt and person-centered therapies focus on exploring your current emotional state and identifying and working through your own identified goals with gentle guidance from your therapist.
For example, if I am struggling with depression related to a problematic relationship with my parents, a session might focus on better understanding the dynamics of this particular relationship and devising practical steps for possible ways to improve it.
Choosing the right therapy for you
In thinking about what kind of therapy you might benefit from most, consider how you tend to approach and solve problems in your daily life.
Are you someone who tends to be problem-focused and open to learning new skills? CBT may be a good fit for you. Do you like to understand why you respond the way you do to certain situations and enjoy finding root causes of the challenges you face? Psychodynamic therapy may be a better fit. Have you been avoiding a major challenge in your life and need some concrete way to feel better? A behavioural or DBT approach may better suit you.
Just as important as the type of therapy is how well you connect with your therapist. Finding a good match can be a challenge. A recommendation from people you know and trust, such as your friends or primary care provider, can help point you in the right direction. Your insurance company may also have a list of therapists who are covered in your plan. If you’re looking online, your local community may have a regional association of therapists, and some websites like Psychology Today have a searchable database of therapists. A number of telehealth platforms offer remote therapy as well.
Think about who you’d feel comfortable with, what you want to work on and what kind of work you want to do together. Communicate your needs and goals upfront in your first session with your prospective therapist. If you don’t feel like you have a good connection after the first few meetings, tell them your concerns and don’t be afraid to seek another therapist.
Ultimately, your therapist wants you to better understand yourself and grow in your ability to help yourself navigate all that lies ahead. DM/ML
Sourav Sengupta is an Associate Professor of Psychiatry and Pediatrics at the University at Buffalo.