Psychotherapeutic Approaches 10/17/2019

Psychotherapy has a rich history and many traditions. Each school of thought draws from generations of theorists and practitioners. Over the past 40 years, there has been a growing movement to evaluate the effectiveness of therapy in general and specific models in particular. The expanding body of evidence has been helpful to confirm the long-standing belief that therapy has an essential role in the treatment of mental illness.

Yet there are still complexities the literature struggles to grapple with or quantify. For example, it is challenging to predict how a patient will “connect” or “fit” with a therapist, whether the patient is “ready” to change, or if the therapist can shape the therapy to meet specific needs. The field of social work has developed the “Ecological model”, which draws into focus the importance of family and community supports, which have predominant impact on identity and self-esteem.

These factors highlight the difficulty in identifying the “right therapy” or avoiding the “wrong therapy”. In fact, it likely takes time and careful evaluation of individual outcomes to really know whether a therapy is helpful for any one person. But we can rely on the literature and our understanding of different mental health challenges to guide our choices.

Cognitive Behavioral Therapy (CBT) is an effective, time limited approach recommended for the treatment of depression, anxiety, and trauma in adults, adolescents and children. CBT draws from behaviorist traditions, neuroscience and more recent studies of therapy. The core theory of CBT holds that thoughts, feelings and behaviors are separate entities, each impacting the other. Whereas psychodynamic therapy (which draws from Freudian traditions) might focus on talking about the past, CBT aims to increase awareness of current thoughts, feelings and behaviors, at the same time encouraging new thoughts and behaviors, which ultimately positively impact emotions. Using the concept of psycho-education (teaching about relevant components of wellness and mental illness, as well as about CBT itself), homework (assigning handouts or other projects to work on during the week) and skills building, the CBT therapist will work with patients to challenge thoughts and behaviors.

Dialectical Behavioral Therapy (DBT) can be effective at reducing self-harm, managing emotional dysregulation and improving interpersonal efficacy. DBT draws from CBT, eastern approaches to wellbeing and mindfulness, makes use of individual and group therapy, skills training, and “In-the-Moment Phone Coaching”. Developed by Marsha Linehan, the approach encourages therapists and patients to acknowledge and grapple with contradictions inherent to the life and treatment of patients with chronic self-harm. The “dialectic” is a bringing together of two opposite extremes. Linehan exemplifies this, “accepting patients just as they are within a context of trying to teach them to change”. This approach has been conventionally associated with treatment of borderline personality disorder, but it is appropriate to refers teens and youth with self-harm, mood swings and behavioral outbursts (not due to developmental delay, bipolar disorder or psychotic illness) to DBT groups or therapists. DBT is available at private programs as well as at Rady Central Outpatient Clinic.

Psychodynamic Psychotherapy applies to therapies that draw from Freudian theories. There is a common misconception that these approaches remain stuck in outdated views of human development. On the contrary, psychodynamic approaches have grown and shifted and can be effective for treatment of mood disorder, trauma and other challenges. Another misconception is that psychodynamic approaches must include analysis, a technique in which the patient lies on a couch and free associates. In fact, analysis is increasingly rare.

Psychodynamic approaches have contributed greatly to our understandings of mental health, wellness and treatment. While there are notable differences between approaches, most psychodynamic therapies draw from the “tripartite model” of the mind – that our sense of self, executive functioning and thinking (ego), our primal impulses (ID) and our understandings of moral standards (Superego) co-exist and interact to create our personality and lived experience. Therapists work with patients to better understand how these parts of our experience interact and get in the way.   There is evidence support the efficacy of these approaches. There are certain psychodynamic approaches that are time limited, but this can be difficult to access in the general community. We typically turn to CBT first, as it is time limited, more often covered by insurance, and more available in various communities.

Linehan, M (1993). Cognitive-Behavioral Treatment of Boderline Personality Disorder. The Guilford Press 1993

Williams, K. and Crandal, B (2015). Modular CBT for Children and Adolescents with Depression. A Clinician’s Guide to Individualized Treatment. New Harbinger Publications 2015.




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