“Do I have to lie on a couch?”
“You’ll need to scooch your chair closer, I’m afraid,” she said.
I was sitting opposite my former therapist in her tiny attic office, our knees almost touching. What I remember most about this therapy, apart from her chairs, was how she would share so much about herself during our sessions trying perhaps, I thought, to forge a connection with me.
By contrast, years later, in a different room, a very dissimilar former therapist chose to sit much further away and said virtually nothing except with her eyes which, now and again, would linger on the couch opposite.
“Do I have to lie on it?” I wondered, “For this therapy to work?”
Sometimes I did lie down on it and stared upwards with my eyes half-open, trying to verbalise whatever was running through my mind. An oddly freeing sensation.
***
With all the kinds of therapy on offer, it can be hard to know which to choose. There are certainly differences between them, mostly theoretical ones. I personally think that therapy types can vary along two main axes or continuums.
The first ranges from a preference to address issues largely relating to the here and now all the way along to those largely relating to the there and then.
The second ranges from a preference to having a profound relational connection with one’s therapist all the way through to preferring an impartial clinical diagnosis and some symptomatic treatment.
Wherever they lie, all psychotherapies leave plenty of room for interpretation. There might not even be that much between them when it comes to their healing potential. Though some may be more useful for certain kinds of problems[1].
The most well-known, commonly practised talking therapies include psychodynamic, cognitive-behavioural, and humanistic types.
Psychodynamic therapies, rooted in Freud and others’ theories, tend to highlight the importance of the unconscious mind and early childhood experiences. Classical techniques include ‘free association’ either in a chair or on a couch, with the therapist’s role being one of an interpreter of possible motivations, dreams or fantasies, or parts of ourselves we may cherish, despise, or are blissfully unaware of.
Cognitive-behavioural therapies, originating in behaviourism and cognitive psychology, tend to focus on identifying and changing unwanted thought patterns and behaviours. Therapies such as CBT are usually highly structured, directive, goal and time-focussed. Techniques include noticing and reframing negative thinking patterns, trialling alternative responses, and combatting stress.
Based on the so-called ‘Third Force’ of humanistic psychology, humanistic approaches such as Person-Centred therapy espouse the view that everybody has an inborn ability to heal themselves given the correct ‘core conditions’ of empathy, congruence and unconditional positive regard[2]. A person-centred therapist aims to provide these to their clients in a non-directive way (unlike cognitive behavioural therapy), and in a way which is client-led (unlike classical psychoanalytic therapy).
Integrative psychotherapy combines elements from these and other approaches in an effort to avoid a “one size fits all” approach. Integrative therapists draw on their own blend of theories and techniques that they feel are most suitable for the client and their issues. They try to remain adaptive throughout the therapeutic process. Integrative therapies can take many different forms but also uphold the idea of the client’s innate self-healing capacity as well as the transformative power of empathy.
Almost without exception and across the board, the therapeutic alliance (or helping relationship between therapist and client) is agreed upon as supremely important when it comes to effectiveness. Sometimes, this alliance has different names or shapes – such as transference in psychodynamic therapies or collaboration in CBT. Whilst terminologies, techniques, and the self-appointed role of the therapist may differ, all approaches aim to provide a supportive environment within which people can grow and make meaningful changes.
If you’re thinking of entering therapy yourself, or perhaps considering learning or training as a therapist, it’s worth considering what shape of therapy best lines up with your needs and your views about human problems.
For example, does the problem you’re thinking about correlate with something occurring right now such as a crippling fear or phobia? Or does it feel connected to something that may have been going on slowly and in a more complex way, perhaps since childhood?
Someone struggling with intrusive thoughts who finds themselves going to extreme lengths to avoid unpleasant beliefs or feelings might benefit from an approach directed towards thoughts, behaviours and beliefs, such as CBT.
On the other hand, someone who is tortured by their paradoxical-seeming feelings of tenderness and rage towards a loved-one may benefit from a therapy encouraging a deepening awareness of the unconscious mind, such as psychodynamic therapy.
Benefits could also be seen from choosing an integrative therapeutic approach in which these and other ‘lenses’ can be drawn on at different times for different reasons.
[1] McAleavey, A., & Castonguay, L. M. (2015). The process of change in psychotherapy: Common and unique factors. In O. C. G. Omar, A. Pritz, & B. Rieken (Eds.), Psychotherapy research: Foundations, process, and outcome (pp. 293–310). Springer.
[2] Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Houghton Mifflin.