What Therapy is Best for Me: Exploring Alphabet Soup

By Aletheia Team | Jan. 15

Trying to find a good therapist can be difficult with so many licenses, trainings, and degrees. Many of us complicate the issue further by describing specific theoretical approaches or techniques, and adding trainings and specializations to our repertoire. Words like existential, psychodynamic, cognitive behavioral, mindfulness, attachment, or solution-focused densely populate therapists’ promotion of their work. Psychology Today lists sixty-eight approaches to counseling. You may have noticed the “alphabet soup” phenomenon as you search for the right therapist and wonder what all of the letters at the end of a therapist’s name mean.

While space only allows for so much to be identified and explained, we will try to tackle some of the more common themes of therapy marketing. First, we will summarize four traditions of psychotherapy that cover a large portion of theoretical orientations. These are not comprehensive nor universally accepted delineations. Rather, these categories provide a way of organizing large bodies of information. We will also look at a few more popular approaches that are either integrative (draw on more than one tradition) or not easily categorized.

The four primary traditions are psychoanalysis, behaviorism, humanism, and systemic therapy.

Psychoanalysis

Psychoanalysis is not only a theory of psychotherapy, but is an entire field of inquiry or discourse that was initiated by Sigmund Freud at the end of the 19th Century. Freud’s greatest contribution to psychology and philosophy is his concept of the unconscious. Freud’s conceptualization of the unconscious was not simply that there were elements within the mind that were outside of human awareness. Rather, he posited that the unconscious was full of active processes that were in conflict with each other, and that much of our conscious life was influenced by these unconscious conflicts. 

Freud’s method of psychotherapy focused on inviting the patient to “free associate” or report whatever came to mind unedited, exploring the patient’s feelings about the therapist (called transference), and making interpretations about what conflicts the analyst is observing within the patient. Much of Freudian psychoanalysis is caricatured: the patient lying on the couch, with an observing analyst sitting behind the patient, making small comments (mmhmmm) and talking about the patient’s mother. These caricatures poke fun at a particularly rigid, dogmatic, and arrogant form of psychoanalysis that was practiced in the United States in the middle of the 20th Century. But each of these elements are serious components of psychoanalysis. 

Most psychological theories since Freud are in some way a reaction to Freud. The history of psychoanalysis is a long and winding road of theorists arguing against particular tenets of Freud's thought while maintaining much of his framework. Many theorists outside of the psychoanalytic tradition were trained as analysts first, before making their modifications. Much of the last century of Western psychology has in some sense been contending with Freud. 

Even from within the tradition of psychoanalysis, there are regular tensions that have produced a number of discrete theories. Self psychology, ego psychology, and object relations therapy are examples of subcategories of psychoanalysis that therapists may claim. While these tensions are numerous, there are two that are of particular importance for psychotherapy today.

First, there is a tension between drive and relationship. Freud’s original theory claimed that people were primarily motivated by conflicts between base drives like sex and aggression (what Freud called the “id”) and what is socially acceptable (what Freud called the “superego”). The ego works to negotiate between these two driving forces, by keeping unacceptable drives for sex and aggression unconscious. 

This emphasis on drive theory was challenged early and often by theorists. By the middle of the 20th century, studies on attachment and infant-mother bonding offered a convenient discipline from which to challenge drive theory. The criticism was that while sex and aggression are present and kept unconscious, and that conflicts do exist, the primary drive within a human person is not base, animalistic drives, but a drive to connect and relate. While some psychoanalytic psychotherapists emphasize drive theory more than others, virtually all will have been impacted by relational, interpersonal, and attachment critiques. 

The second tension regards the role that the analyst or therapist plays in the treatment. Originally, Freud emphasized the anonymity and abstinence of the analyst. The analyst needed to be a blank screen onto which the patient (what Freud called the “analysand”) could project all of their past wounds, histories, and assumptions. This assumption was challenged often as well. Harry Stack Sullivan promoted an interpersonal approach to psychoanalysis in which the analyst was more active. Contemporary psychoanalysis, or relational psychoanalysis, takes this critique to the extreme, suggesting that the analyst/therapist and analysand/patient are both in a co-constructed enactment together and that the therapist can never be certain what is going on in the treatment. Emphasis is placed on exploring the relationship together, rather than interpreting it from an objective perspective. (For more information on relational psychoanalysis, see our blog post titled “Why Therapy Works”).

Psychoanalysis was traditionally conducted with 4-5 sessions a week, for multiple years. It also required extensive post-doctoral training for the therapist. As a way of adjusting to these limitations, theorists began to distinguish between psychoanalysis, and psychodynamic therapy - which is an application of psychoanalytic thought in a more flexible, clinical frame. Psychodynamic therapy may meet only once or twice a week, and may be more focused and structured. 

(Cognitive) Behaviorism

Behaviorism was in many ways a reaction against psychoanalysis. Wanting to avoid overly theoretical, intuitive, or subjective elements in psychoanalysis, behaviorism focuses on concrete, observable behaviors. As it relates to psychotherapy, behaviorism is often divided into three distinct phases or waves. 

First wave behaviorism focused on environment, stimuli, and resultant behaviors. A behavioral therapist is looking at the particularly troubling behavior, and trying to determine what in the environment is stimulating that behavior. If that stimuli can be changed, the behavioral change will follow. 

Central to first wave behaviorism is the idea of classical conditioning. Classical conditioning is illustrated by one of the most well-known psychological experiments in history. Ivan Pavlov famously rang a bell before feeding his dog. The dog became conditioned to expect food when hearing the bell, and would salivate in anticipation of being fed. The dog became so conditioned, that upon hearing the bell, the dog would salivate even when food was not present. Traditional behaviorists attempt to condition patients toward more adaptive behaviors, or de-condition them away from maladaptive ones. Exposure and response therapy (often utilized for OCD) and progressive desensitization (for anxiety and phobias) are examples of behavioral therapies.

The second wave of behavioral therapy was the merging of behaviorism with the cognitive sciences that were being developed in the 1960’s. Aaron Beck is widely considered the father of cognitive behavior therapy (CBT). The focus of CBT is to identify dysfunctional thought patterns and beliefs that have an impact on behavior. If the thought can be challenged and changed, then the behavior will also change. Behaviors are then adjusted to help reinforce the new, adaptive thought or belief. 

In the third wave, CBT methods are combined with mindfulness skills from Buddhism. The focus shifts from changing dysfunctional thoughts or behaviors to cultivating a mindful awareness of the thoughts, feelings, and behaviors in order to gain freedom from our firmly ingrained patterns. Third wave therapies are often known by their acronyms.

Dialectical Behavior Therapy (DBT) is one of the most well-known of the third wave CBTs. DBT focuses on the cultivation of mindfulness skills in order to better regulate emotions, tolerate increased distress, and be effective interpersonally. The therapeutic approach is largely educational - teaching skills and practicing skills. DBT is particularly popular in residential treatment settings (in part because the time limitations of residential treatment are conducive to educational therapy) and with personality disorders (DBT was initially developed to treat borderline personality disorder).

Acceptance and Commitment Therapy (ACT) focuses on increasing the acceptance of negative or distressing feelings, and moving toward valued behaviors. ACT has a number of protocols designed to target specific struggles.

Mindfulness-Based Cognitive Therapy (MBCT) makes mindfulness a central intervention in therapy. MBCT was developed based on the teaching of Jon Kabat-Zinn. It was developed initially for relapse prevention for depression.

Humanism

If psychoanalysis is a coherent tradition that has evolved over time, and behaviorism has three discreet waves, humanism is more of an umbrella term that covers a number of related, but independent movements. The uniting factor of all humanist psychologies is the rejection of the determinism and reductionism that was viewed as inherent in both psychoanalysis and behaviorism. 

Carl Rogers is perhaps the most well-known humanistic psychologist. The impact of his work is felt by all therapists, to the point that many training programs teach Rogerian thought as basic counseling skills. Rogers emphasized empathy, congruence, and unconditional positive regard as the essential elements of a humanistic therapy. If the therapist can provide these conditions in the treatment, then the client’s natural tendency towards health (what Rogers called “self-actualization”) will take over. Rogerian therapy is non-directive - meaning that the therapist asks open ended questions and encourages the client’s own self-exploration with empathy and openness, rather than directing the exploration.

Abraham Maslow is another well-known humanist. Maslow is most well-known for developing his hierarchy of needs. Maslow identified five domains of human needs that, he argued, are progressive and built upon each other. Physiological needs (food, clothing, shelter) have to first be met before we can move to higher order needs. Next, financial security and physical health contribute to a sense of safety. Once safety is acquired, we move into focusing on social belonging by fostering relationships with friends and family. When social belonging is achieved, we tend towards building up self-esteem by focusing on meaningful activities that allow for a sense of achievement, status, recognition, freedom, competence and self-mastery. Finally, we self-actualize by looking for meaning and purpose in life, looking for intimacy, and seeking happiness for our unique selves. 

Existential psychotherapy shares many of the same assumptions with humanism. One of the clear differences is that existentialism is much less optimistic about humanity. Where humanism focuses on esteem and self-actualization, believing that people have the answers within them, existentialism focuses on accepting the limitations - what existentialist psychologist Irvin Yalom calls “the givens of life.” 

Irvin Yalom identifies four givens that all humanity shares in: death, meaninglessness, isolation, and freedom. Existentialism assumes that humanity defends against these givens - we deny the inevitability of our death, we refuse to accept the lack of meaning in our lives, we work to convince ourselves that we are not alone, and we look to external sources for meaning, denying our own freedom. These denials and defenses against the inherent givens of existence creates a multitude of symptoms. It is by facing these givens and choosing to live a meaningful life despite them that we find health.

Gestalt therapy is another humanistic approach to human psychology. Gestalt therapy emphasizes the patient’s personal responsibility for their life, and identifies ways that people attempt to shirk that responsibility. Gestalt therapy focuses on the present moment experience of the patient, and the relationship between the therapist and the patient. Many techniques of Gestalt therapy are widely used by therapists regardless of their theory, especially in using “the empty chair” or “chairwork.” In Gestalt chair work, the patient sits in a chair representing a relationship or aspect of themselves and speaks from that perspective. Then the patient will sit in a second chair and speak from a different perspective. The goal is to explore different perspectives and self-states within the patient.

Systemic 

Systems thinking is the foundation of family therapy, and is largely associated with family therapy. In fact, it is nearly synonymous with family therapy. Systemic clinical thought began to differentiate itself from traditional (individual) psychotherapy in the early 20th century when psychiatrists (usually psychoanalysts) started seeing family members of their patient’s together. In 1942, the American Association of Marriage Counselors (which was a precursor to the current AAMFT) was founded as the first professional organization with an explicit systemic orientation. 

Numerous schools of thought have grown out of the systemic approach, but what generally unites them is the assumption that a patient’s struggle is served and sustained by the larger system(s) in which the patient is embedded. A systemic approach does not necessarily deny that there are intrapsychic (within an individual mind) factors at play in a given mental illness. But systems therapists are opting to view their patients through the lens of a system.

It is a common misconception that marriage and family therapists only treat families or couples and only treat them for marital or family conflicts and struggles. Early family systems theorists grew out of extreme mental health struggles (schizophrenia or chronic alcoholism). What makes systemic thinkers unique is not necessarily that they meet with multiple family members during a session, though they are probably more likely to do so than therapists of other theoretical orientations. What makes systemic therapy unique is that it is looking at how the patient’s struggles function within and are maintained by a system. 

As mentioned above, systems therapy and marriage and family therapy are nearly synonymous. Other forms of therapy, however, rely on systemic thinking. Feminist therapy looks at societal structures of power and oppression, zooming the systemic focus out to the larger cultural system. Narrative therapy focuses on how specific narratives within family and society have impacted the patient, and how re-narrating the lives of patients can liberate them from their struggles.

Other Therapies

The four traditions listed above outline a large portion of the theoretical frameworks from which therapists work. But not every therapy fits comfortably into these forms. 

There are a number of trauma-informed therapies that have become popular over the last couple of decades. Many of these therapies were fashioned out of the necessary pragmatism of the clinic - when things did not work to treat the trauma, therapists experimented. They documented their experimentation, reflected upon it, and developed a theory around what worked. 

Perhaps the most popular trauma-informed therapy is Eye Movement Desensitization and Reprocessing, or EMDR. EMDR was developed by Francine Shapiro in the 1980’s and 1990’s, particularly in her work with Vietnam veterans. EMDR encourages the patient to engage in troubling and triggering memories, scaling their distress and some form of bilateral stimulation as they reprocess the memory. Bilateral stimulation means some sort of small activity that engages both right and left hemispheres of the brain. Many therapists utilize lights that flash, tappers that vibrate in the patients’ hands, or simply encourage the patient to tap their hands on their knees or the arms of the chair. While we are still unsure of the mechanics of how this treatment facilitates integration of trauma, it is clear that EMDR is a viable option for trauma. It is also being applied in treating other struggles as well, including anxiety, OCD depression, dissociative identity disorder, and some forms of psychosis.

Another trauma therapy that has been gaining popularity in recent years is Internal Family Systems (IFS). Developed by Richard Schwartz in the 1980s, IFS posits the theory of multiplicity - each human being is a constellation of subpersonalities that have feelings, memories, and motivations. These subpersonalities, typically referred to as parts of self, or simply parts, get polarized with each other and create a lot of internal conflict. The IFS treatment focuses on understanding all of our parts, helping our parts interact more harmoniously with each other, trust the self more, and be more effective in accomplishing their goals, and increasing our access to ourselves. Initially born out of Schwartz’s work with eating disorders, IFS has been used in treating anxiety, depression, personality disorders, dissociative identity disorder, autism spectrum disorders, and many forms of trauma.

Somatic therapy or Somatic Experiencing (SE) is an approach to trauma therapy that focuses on bodily experiences in trauma. Coming out of the animal behavior research of Peter Levine, and the groundbreaking book, The Body Keeps the Score by Bessel Van der Kolk, Somatic Experiencing encourages the patient to focus on their body, experience their sensations, explore what the body naturally wants to do with the sensation, and bringing meaning to the sensation. 

Emotionally Focused Therapy (EFT) was originally developed by Sue Johson for the treatment of couples. EFT is an integrative approach to therapy that seeks to increase emotional vulnerability and foster deeper attachment between the couple. EFT has also been applied to family therapy as well as individual therapy. 

Jungian therapy is based on the work of Carl Jung, who was a contemporary of Sigmund Freud. Freud and Jung had increased conflict over their ideas, and eventually parted entirely. While Jung’s views overlap with psychoanalysis in many ways, the emphases are different enough that the two are considered separate schools of thought. Jung focused on dreams, symbolism, mythology, and religion to explore the common unconscious dynamics in all human beings (what he termed as the “collective unconscious”). Jung’s body of work is far too great to summarize for the current post, but therapy based on Jungian thought will typically be oriented to dream exploration, art therapy, or a unique blend of therapy and creative expression called Sandplay therapy. 

Multicultural therapy makes explicit the assumptions of Western psychology. Western psychology is based on white, European male understandings, which do not match the majority of the human population. Multicultural therapy looks to treat patients with therapeutic approaches that are more appropriate to the assumptions of the patient’s primary culture, and to be aware of how the therapist’s cultural assumptions may impact the treatment.

While the information provided in this post may be overwhelming, it is not necessary for a patient to know or understand any of this information before starting treatment. It can, however, help to have a reference for the most common types of therapy as you search for a new therapist. Many therapists may use the terms and approaches listed above in slightly different ways, so, as always, it is important to discuss this information with your therapist or potential therapist to get a clear understanding of what they mean by the terms.