Therapeutic Modalities Explained: How to Find a Good Therapist, Part 2

Understanding differences in therapeutic modalities can help you choose a therapist whose approach aligns with your needs. Here, we'll explore the modalities that you are most likely to encounter. I will briefly explain their features, key concepts, and goals. These therapeutic modalities have both similarities and differences regarding the causes of patients’ difficulties. They use approaches and techniques based on these conceptualizations. 

Theories and Modalities: Differences Explained

Psychoanalytic/Psychodynamic Therapy:

Psychodynamic therapy originates from psychoanalysis, which is a more specific and intensive form of psychodynamic therapy. However, for the purpose of this guide, I will group psychoanalytic and psychodynamic therapy together, as their similarities outweigh their differences. 

Psychodynamic therapy can be deeply transformative by focusing on the underlying emotional roots of psychological distress. It helps patients explore patterns of thought, emotion, and behavior often outside of their awareness. Many of these patterns stem from past experiences, particularly early relationships. These unconscious patterns shape present-day relationships, choices, and emotional challenges. By addressing the root causes of emotional suffering, psychodynamic therapy fosters lasting change, rather than solely focusing on immediate symptom relief. In many cases, the benefits of this approach continue to grow even after treatment ends, as patients gain deeper self-understanding and greater emotional resilience.

Key Features of Psychoanalytic/Psychodynamic Theory:

In his excellent paper analyzing “The Efficacy of Psychodynamic Therapy,” Psychologist Jonathan Shedler, Ph.D., provides a clear overview of the key features of psychodynamic psychotherapy, outlined below:

1. Focus on affect and expression of emotion. 

• Here, the focus is on affect (i.e., emotion) rather than logic. Our emotions often dictate our ability to think logically and make good decisions. Psychoanalytic therapists help their patients put words to their full range of feelings, including fear, sadness, anxiety, joy, anger, excitement, shame, and grief. 

  
  

• Psychoanalysis recognizes that intellectual insight is not the same as emotional insight. Emotional insight refers to a deep understanding of one's thoughts, feelings, and behaviors. It is not just intellectual or cognitive awareness but also involves a personal, emotional connection to that understanding. For example, a person may intellectually understand that their fear of abandonment is linked to childhood experiences, but emotional insight would mean actually feeling the pain of that experience and recognizing how it influences their current relationships. Emotional insight is necessary for deeper, lasting change.

  
  

2. Exploration of attempts to avoid distressing thoughts and feelings.

• This is called resistance and it is employed by every single person to different extents. Some avoidance is conscious and some is unconscious. 

• Psychoanalytic therapists actively explore avoidances with their patients.

  
  

3. Identification of recurring themes and patterns.

• Psychoanalytic therapists explore recurrent themes and patterns in all aspects of patients’ lives. 

• Some people are aware of certain patterns and need help escaping their pull. Some are unaware of other patterns and need the help of a therapist to recognize, understand, and address them.

  
  
  
  

4. Discussion of past experience (developmental focus).

• Psychoanalytic therapists explore early experiences, relationships, and memories, understanding that these experiences shape the way we learn to interact with the world around us. 

• The goal is not to fixate on the past, but to see how our past affects our present, and to be able to free ourselves from the tethers that hold us back now.

  
  

5. Focus on interpersonal relations.

• Psychoanalytic therapists strongly focus on patients’ relationships and interpersonal experiences. 

• These include past relationships and current relationships, including the relationship between the patient and therapist (called the therapy relationship or therapeutic alliance).

  
  

6. Focus on the therapy relationship.

• Psychoanalytic therapists view the relationship between the patient and therapist as deeply valuable and emotionally charged. 

• They recognize that repetitive patterns in a patient’s relationships are likely to emerge within the context of the therapy relationship, providing a unique opportunity to explore those themes in the immediate experience of the current relationship. 

  
  

7. Exploration of fantasy life.

• Exploration of fantasy life is a key feature of psychoanalytic therapy. Fantasy life refers to freely occurring thoughts, including desires, fears, fantasies, dreams, and daydreams. When put into words, these fantasies provide rich insight into the individual’s internal world, how they make sense of information, and how they view themselves and others.

Key Concepts: 

Unconscious mind: The foundational concept of psychoanalytic theory and practice is that much of human behavior is influenced by unconscious processes, or processes that occur outside of our awareness. 

Defense mechanism: A key belief of psychoanalysis is that that there are unconscious psychological processes that protect a person from anxiety-producing thoughts and feelings. These attempts at self-protection, or defense mechanisms, often come with unintended negative consequences including various forms of self-sabotaging and relationship-interfering behaviors.

Goals:

Short-term goal: Provide symptom remission/relief. (i.e., feel less depressed, anxious, or paralyzed).

Long-term goal: Increase capacity to find greater satisfaction and meaning in life. Depending on the individual, this may mean forming and maintaining meaningful relationships, becoming more confident, learning to use one’s abilities and talents more effectively, and becoming more adaptable and flexible in the face of challenges and changes.

According to Shedler, psychoanalytic therapists believe that these goals can be achieved through the hard work of “self-exploration, self-reflection, and self-discovery that takes places in the context of a safe and deeply authentic relationship between therapist and patient.”  

Cognitive Behavioral Therapy (CBT):

Cognitive Behavioral Therapy is grounded in the understanding that our thoughts, feelings, and behaviors are interconnected. By identifying and challenging distorted thinking patterns, we can change the way we feel and behave. CBT is a structured, goal-oriented approach that focuses on the present. Through techniques such as cognitive restructuring, exposure therapy, and behavioral activation, individuals are empowered to overcome anxiety, depression, and a range of other mental health issues.

Key Features:

1. Structured and Goal-Oriented

2. CBT tends to be highly structured, with sessions following an agenda, and patient and therapist collaborating on specific goals.

3. Short-Term and Time-Limited

4. CBT tends to be short-term, typically lasting between 6-20 sessions. Many CBT clinicians also see patients long-term depending on their needs. 

5. Problem-Focused

6. CBT is focused on specific problems and emphasizes practical strategies and techniques to address these problems directly. 

7. Collaborative Approach

8. CBT is a collaborative process. The therapist acts as a guide, helping the patient understand and work through their issues.

Key Concepts:

Cognitive Restructuring: The therapist engages the patient in identifying and challenging unhelpful or distorted thoughts and replacing them with more balanced, realistic ones. 

Behavioral Activation: This technique encourages patients to engage in activities that they might otherwise avoid due to distorted thoughts or anxious feelings. The goal is to break the cycle of avoidance and inactivity. 

Exposure Therapy: Especially for anxiety disorders and phobias, exposure therapy involves gradually and systematically exposing a patient to a feared situation or object with the goal of reducing the associated anxiety over time. 

Skills Training: CBT often includes teaching specific skills, such as relaxation techniques, mindfulness, assertiveness training, and communication skills, depending on the issues presented by the patient. 

Homework Assignments: Patients are sometimes given homework assignments to complete between sessions. These may include writing in a diary, engaging in specific activities, or practicing the skills learned in session.  

Goals:

Change Negative Thought Patterns: By altering negative thought patterns that contribute to emotional distress, individuals can experience more positive emotions and behaviors. 

Modify Unhelpful Behaviors: The aim is to identify and change the specific behaviors that are contributing to the patient’s problems. 

Develop Coping Skills: This goal is to equip patients with practical skills and strategies that can be used to independently manage future challenges. 

Improve Emotional Regulation: The idea is that by changing negative or distorted thoughts and behaviors, a patient will improve their capacity to regulate their emotions, leading to a more balanced emotional state. 

Enhance Problem-Solving Abilities: Theoretically, learning to approach problems in a more systematic and effective way can increase a patient’s overall ability to manage life’s challenges.

Dialectical Behavior Therapy (DBT)

Dialectical Behavior Therapy was originally developed to treat individuals with borderline personality disorder and suicidal behaviors. DBT combines cognitive-behavioral techniques with mindfulness practices, emphasizing the balance between acceptance and change. Core components of DBT include emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness. DBT emphasizes that by learning these skills, individuals can manage intense emotions, build healthier relationships, and find a sense of inner peace. DBT is typically used for individuals who struggle with intense emotions, impulsive and dangerous behaviors, and severe difficulties in interpersonal relationships. 

Key Features:

1. Structured and Modular Approach

2. DBT has 4 core modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness (described in detail below). Each module targets specific skill sets that are typically practiced both in individual therapy and group skills training sessions. 

3. Validation and Change

4. Balancing acceptance with change is a hallmark of DBT. 

5. Comprehensive Treatment Format

6. DBT includes individual therapy, group skills training, and phone coaching. This holistic format offers constant support and skill-building for patients. 

7. Phone Coaching

8. DBT offers patients access to their therapists for real-time coaching between sessions. This feature helps individuals apply skills in challenging, real-life situations when they need immediate guidance.

Key Concepts:

Mindfulness: Central to DBT, mindfulness encourages individuals to become more aware of their thoughts, feelings, and bodily sensations without judgement. This helps individuals stay grounded in the present and manage overwhelming emotions.  

Distress Tolerance: These skills focus on tolerating and surviving crises without resorting to unhealthy behaviors. Techniques like self-soothing, distraction, and radical acceptance allow individuals to get through moments of intense emotional pain.

Emotional Regulation: DBT teaches skills to help patients identify and label emotions, reduce the impact of negative emotions, and increase positive emotional experiences.  

Interpersonal Effectiveness: This component focuses on improving communication and relationship skills. Patients learn how to assert their needs, set boundaries, and maintain healthy relationships while balancing their desires with the needs of others.

Goals:

Improve Emotional Regulation: A primary goal of DBT is to help patients manage and regulate their emotions more effectively, preventing overwhelming feelings from dictating behaviors.

Reduce Self-Destructive Behaviors: DBT aims to reduce harmful behaviors, such as self-harm, suicidal ideation, or substance abuse, by teaching healthier coping strategies.

Develop Interpersonal Skills: Improving relationships and communication is a key focus of DBT. Patients learn how to maintain stable, fulfilling relationships while reducing conflicts.

Enhance Distress Tolerance: DBT equips patients with tools to manage crises without making things worse, allowing them to face intense emotions or situations without resorting to harmful behaviors.

Increase Present-Moment Awareness: By developing mindfulness, patients can experience a greater sense of clarity and calm in their everyday lives, helping them respond more effectively to stressors.

DBT’s focus on balancing acceptance and change, teaching practical skills, and providing ongoing support makes it effective for individuals dealing with high emotional sensitivity, impulse control issues, and relationship problems.

Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT) is modern behavioral therapy that helps individuals live more fully by fostering psychological flexibility. The core of ACT involves learning to accept difficult thoughts and emotions, rather than struggling against them, and committing to behaviors aligned with personal values. ACT emphasizes that the goal is not to eliminate negative experiences but to change the relationship with them—viewing thoughts and feelings as natural parts of life that don’t have to dictate actions. By combining acceptance strategies with mindfulness and commitment to meaningful goals, ACT aims to reduce emotional suffering and promote a more fulfilling life. 

Key Features:

1. Psychological Flexibility

2. The primary aim of ACT is to enhance psychological flexibility—the ability to adapt and respond effectively to emotional experiences while pursuing meaningful goals. 

3. Acceptance Focus

4. ACT teaches patients to accept rather than avoid or suppress uncomfortable thoughts and feelings, recognizing that discomfort is a natural part of life.

5. Mindfulness-Based Approach

6. ACT uses mindfulness to encourage patients to stay present and fully engaged in the current moment, allowing them to observe their thoughts and emotions without becoming entangled in them.  

7. Values-Driven Action

8. ACT emphasized clarifying personal values and committing to behaviors that align with those values, which fosters a more purposeful and satisfying life. 

Key Concepts:

Acceptance: ACT encourages patients to accept painful or distressing thoughts and emotions, acknowledging that avoiding or fighting them often leads to more suffering.  

Cognitive Defusion: This concept involves learning to detach from unhelpful thoughts and viewing them as passing mental events rather than literal truths. This reduces the influence of negative thoughts on behavior. 

Values: ACT helps patients clarify their core values and guides them to act in ways that align with these values.   

Mindfulness: In ACT, mindfulness refers to the practice of being present and aware of one’s thoughts and feelings without judgement.  

Committed Action: ACT emphasizes taking concrete, committed steps towards value-driven goals, even in the presence of challenging emotions, thoughts, or external circumstances. 

Goals:

Increase Psychological Flexibility: The primary goal of ACT is to help patients become more adaptable in the face of emotional discomfort.

Reduce Experiential Avoidance: ACT seeks to decrease avoidance behaviors by helping patients accept difficult thoughts and emotions instead of trying to escape or control them. 

Align Behavior with Personal Values: A key aim is to guide patients to make choices and take actions that are consistent with their values.

Improve Present-Moment Awareness: By fostering mindfulness, ACT helps patients develop the ability to remain engaged in the present, improving emotional regulation and reducing reactivity to difficult experiences. 

Promote Long-Term Emotional Well-Being: ACT supports long-term emotional well-being by helping patients respond more effectively to emotional challenges and engage in behaviors that create lasting fulfillment

Eye Movement Desensitization and Reprocessing (EMDR)

Eye Movement Desensitization and Reprocessing (EMDR) is a therapy primarily used to treat trauma and post-traumatic stress disorder (PTSD). EMDR involves guiding the patient through recalling distressing memories while simultaneously engaging in bilateral stimulation, typically through guided eye movements. This process is believed to help the brain process traumatic memories and reduce their emotional intensity. 

Key Features:

1. Bilateral Stimulation:

2. The most distinctive feature of EMDR is the use of bilateral stimulation, which typically involves eye movements but can also include tapping or auditory tones that alternate between the left and right sides of the body. This stimulation is used while the patient recalls distressing memories. 

3. Structured Phases:

4. EMDR follows a highly structured protocol. The phases include preparation, memory desensitization, and installing positive beliefs. 

5. Minimal Verbal Processing:

6. Unlike most other forms of therapy, EMDR requires less verbal processing of emotions. The emphasis is more on reprocessing memories through the bilateral stimulation than on extensive discussion of the trauma. 

Key Concepts:

Bilateral Stimulation: As mentioned above, this is the central mechanism in EMDR. By engaging in eye movements, tapping, or auditory tones while recalling traumatic memories, the brain is believed to process these memories more adaptively, reducing their emotional charge.   

Desensitization: As the traumatic memory is reprocessed through EMDR, the goal is to reduce the intensity of the emotional and physiological response to the memory. Over time, the memory becomes less distressing.

Reprocessing: Integrating and reframing traumatic memories into a more adaptive perspective.

Goals: 

Alleviate Trauma-Related Symptoms: The primary goal of EMDR is to reduce the distress and symptoms associated with traumatic memories, such as flashbacks, nightmares, anxiety, and avoidance. 

Reprocess Traumatic Memories: EMDR aims to help individuals process traumatic experiences in a way that leads to healthier emotional and cognitive integration.

Foster Long-Term Health: EMDR not only seeks to reduce immediate symptoms but also promotes long-term healing by helping individuals integrate traumatic experiences into their overall life narrative in a healthy way.

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Conclusion - Therapy Modalities

Dr. Julian Rappaport | Psychologist in Raleigh, NC

These are some of the most prevalent and widely practiced therapeutic modalities. Each of these approaches offers distinct strategies and techniques for addressing psychological issues, reflecting their unique theoretical foundations and treatment goals. Understanding the differences between these therapies can be crucial in determining which approach might be the best fit for you. By exploring the specific features, concepts, and goals of various therapies, you can make an informed decision about which modality aligns with your personal needs and preferences. This knowledge empowers you to choose a therapy that not only addresses your current challenges but also supports your long-term emotional well-being and personal growth.

Resources:

Psychoanalytic/Psychodynamic

Leichsenring, F., & Rabung, S. (2008). Long-term outcomes of psychodynamic psychotherapy: A meta-analysis of randomized controlled trials. JAMA, 300(13), 1551-1565. https://doi.org/10.1001/jama.300.13.1551

Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98-109. https://doi.org/10.1037/a0018378

Summers, R. F., & Barber, J. P. (2010). Psychodynamic therapy: A guide to evidence-based practice. Guilford Press.

CBT

American Psychological Association. (n.d.). Cognitive behavioral therapy (CBT). APA. https://www.apa.org/therapy/cognitive-behavioral-therapy

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. International Universities Press.

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. https://doi.org/10.1007/s10608-012-9476-1

DBT

Linehan, M. M. (2015). DBT skills training manual (2nd ed.). Guilford Press.

Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40–51. https://doi.org/10.1016/j.brat.2014.05.005

Swales, M. A., & Heard, H. L. (2009). Dialectical behaviour therapy: Distinctive features. Routledge.

ACT

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2016). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). Guilford Press.

Harris, R. (2009). ACT made simple: An easy-to-read primer on acceptance and commitment therapy. New Harbinger Publications.

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner's treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. New Harbinger Publications.

EMDR

Shapiro, F. (2018). EMDR therapy: An overview of the model and its effectiveness. In E. A. R. Levinson (Ed.), Trauma and memory (pp. 1-16). Routledge.

van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Viking.

Wilson, S., & Becker, L. A. (2015). The effectiveness of EMDR for PTSD: A meta-analysis. Journal of Anxiety Disorders, 32, 51-57. https://doi.org/10.1016/j.janxdis.2015.01.009