Sometimes the world of psychological therapy can seem like a complex, tangled web. Such therapies include, but are not limited to: psychodynamic (or psychoanalytic) psychotherapy, cognitive analytic therapy (CAT), cognitive behaviour therapy (CBT), dialetical behaviour therapy (DBT), compassion focussed therapy (CFT), acceptance and commitment therapy (ACT), transactional analysis (TA), family therapy (systemic, structural, problem-based, behavioural), multi-systemic therapy (MST), mentalisation based therapy (MBT), narrative therapy, rational emotive behaviour therapy (REBT), humanistic psychotherapy, Gestalt psychotherapy, interpersonal therapy (IPT).. and this isn’t even touching the surface.
In the middle of all that confusion, each kind of therapy purports an ‘evidence base’ (alongside the comments of critics of this ‘evidence base’). And that ‘evidence base’ consist of different types of therapies for different types of problem.
There are, however, a comforting number of overlaps in therapies. For example, most therapies examine people’s way of looking at the world. This may be ‘cognitions’, ‘beliefs’, or stories. In types of therapies that involve more than one person, clients may be asked what they believe someone else is thinking, too, or differences and similarities in opinion may be explored.
Therapies also look at the things that we do. What we ‘do’ could mean something as simple as what we eat and when we go to bed, or as complex as how we deal with difficult interpersonal situations and ‘act out’ different feelings. Naturally, therapies also address how we feel. The aim, usually, is to try to support us to feel better. Sometimes (not as often) the focus may be how our feelings interact with others around us, and their feelings.
Most therapies try to identify patterns or ways of being that are causing distress, and support someone to change these patterns. Changing these patterns may involve adding in something different, or removing something that seems harmful. Most therapies will also place someone in the context of their personal history (that is, what things were like for you when you were growing up) in order to understand how and why you came to be where you currently are. Less often, wider social history is brought into account.
One of the biggest differences between types of therapy is the values base behind it, and how distress is understood. For example, cognitive approaches emphasise how we might change unhelpful thinking patterns, and generally assume that thoughts and interpretations lead onto feelings. Psychodynamic approaches emphasise earlier life and exploring the unconscious world through symbols, metaphor and hidden expressions . Narrative approaches look at how our self-stories can become saturated with the bad and the problematic, and seeks to enrich our stories to include more robust positives as part of the full spectrum of ourselves.
Some therapies focus more broadly on leading a life that we value, such as ACT and existential/humanistic approaches. Other approaches, such as systemic and narrative approaches, more closely examine the stories we tell and the meaning we make of life – and how we can make fuller, richer sense of ourselves and our lives.
This leads on to one of the fundamental ways that therapies differ – the way that they understand relationships, and people’s context. Most of the therapies mentioned in the first paragraph of this article are based on an individual, the idea being that an individual has the power to change themselves and their life. Indeed, once one has identified the problems and gained more ‘insight’ that should support them to change. This is largely part of western culture, and the western individualised way of looking at people.
However, as the late psychologist David Smail wrote about extensively, people are often pushed into having ‘insight’ rather than ‘outsight’. That is, people look inwards and (some argue) are therefore subtly blamed for distress that is caused by distal factors such as economic depression, war, poverty, overconsumption of idealised media lifestyles, sexism, racism, homophobia, inequality, and so on.
Smail argued, essentially, that most people do the best they can with what has been given to them – and, if anything, we should appreciate the myriad of creative ways that people find to try to make their way in life rather than labelling them ‘dysfunctional’. He saw the (limited) role of therapists primarily as ‘being with’ people who are in distress and supporting them through this, rather than trying to change people who fundamentally have little power against huge outside forces.
Systemic and community approaches tend to see people as a product of, and part of, their social context and culture. It’s not just about what is wrong with ‘you’, but how people relate to each other in light of certain problems. This is important when we consider that distress is not necessarily an individual ‘mental illness’ but actually a social and cultural phenomenon.
Take the popular example of the thing we call ‘depression’. We know that a valued social life is important for wellbeing, and to have compassionate, understanding others around us will alter whether we are likely to become ‘depressed’ or not. But, additionally, whether someone is ‘depressed’ or not depends on social understandings. In our culture we may feel ‘depression’ is sadness without immediately identifiable, rational, ‘reason’, whereas similar responses to immediate job loss, bereavement or breakup can get different and less pathologising reactions.
Even therapy is dependent on its relational context. We know that the biggest in-therapy factor that affects the outcome is one’s relationship with a therapist. Martin et al (2000) conducted a meta-analysis and found that the quality of the ‘therapeutic alliance’ is more important than the technique and orientation of the therapist. This can be seen as positive news. It implies that the most important thing is to have a therapist that one is able to work with – this may include taking part in a therapy that fits with your values.
So what might be helpful? The following paragraph offers some hints about what to consider, and you can find the acronyms at the start of this article.
Do you feel your thinking patterns are especially problematic, or do you get stuck in cycles of reacting? Maybe go with CBT. Are you more concerned with finding feelings difficult to tolerate, or are you an ‘overthinker’ already? If so, DBT, CFT and ACT might prove helpful. Are your life stories primarily negative, and do you get ‘stuck’ in one aspect of yourself or your life? Narrative and humanistic approaches could support you. Are you concerned with repeating patterns of relationships in your life? Perhaps CAT or psychodynamic will be suitable.
Your ‘problem’ will no doubt be important to the people who care about you too, so if you’d like to group together to make meaning, come up with ideas, and create change, systemic approaches may well be for you (and for those close to you). Additionally, systemic approaches (alongside compassionate therapies) may help shift the self-blame that so many of us are burdened with.
There are networks both online and offline for people who reject the notion of having an individual ‘problem’, such as Madness in America, liberation and some community psychologies, and Mad Pride. The Social Materialist Manifesto of Distress (Midlands Psychology Group, 2012) highlights how we need to go further to understand distress as a socially created being. Community approaches, community activism, and political change may play a greater part in understanding problems and distress than any kind of therapy.
Whilst therapy can be a confusing world, it may also be a hopeful world in that there will be ‘something for everybody’. If one type of therapy hasn’t ‘worked’ for you, that’s okay, and it’s certainly not something you should blame yourself for. There are plenty of ways of understanding distress, and plenty of therapies (or communities) that are available to address different kinds of problem. That is, if after reading this you still feel like you need ‘therapy’ after all.