Psychotherapy

There are many types of psychotherapy, and even many different approaches within the different "types." On this page, I describe some of the different types of psychotherapy I use, as well as what each type or approach means to me. I also describe the kinds of patients with whom I tend to use each type. Let's start though with some basic definitions and history.

What is psychotherapy?

Most people have heard of Sigmund Freud. Freud was the inventor of psychotherapy as a formal service/profession. Although not all of Freud's ideas have held up over time, the profession of psychotherapy would not be what it is today without Freud's influence. Freud practiced actively and began publishing about psychotherapy over 100 years ago. What most people do not know is that Freud was actually trained as a hypnotist, and it was from the practice of hypnotism that he developed the idea that people could be "cured" of mental health issues through talking. During Freud's early days, hypnotism had grown popular and showed scientists that the human brain could be convinced to think and behave in new ways simply through the influence of another person - in this case, the hypnotist. Freud began to wonder, though, if similar changes could be produced without hypnotism, if you could change a person's thoughts and behaviors through simple talking, without placing them into a hypnotic state. After decades of practice, Freud found out he was right, and he began further developing his "talking cure," which eventually came to be known as psychotherapy. So, at it's heart, psychotherapy simply refers to a set of techniques that one person can use (the therapist) to influence and change the behaviors of another person. However, another thing that Freud learned in his career, and something he published about extensively, was that with the power of psychotherapy also comes great responsibility. A true psychotherapist has to keep an unbiased view of our patient's overall mental health, and we have to avoid the pitfalls of causing unhealthy change or taking advantage of our patients. Truthfully, this is a common fear of potential therapy patients, and is one of the reasons people, for many years, grew to fear "shrinks" - worrying the doctor might take advantage, or, at best, may inadvertently make things worse.

This is why psychotherapy training takes so many years. A doctoral-level therapist trains for at least 5-6 years before they ever even begin to see patients on their own. It's through this training that not only we learn about all the different types of psychotherapy, but we learn about or own and others' psychologies and how they affect the work we do. We learn extensively about ethics and we are trained how to use psychotherapy ethically, minimizing the risk of harm to our patients. 

So, in sum, I would amend the above definition of psychotherapy ( "a set of techniques that one person can use to influence and change the behaviors of another person"). Instead, I would add that psychotherapy is a relationship between two or more people that results in therapeutic change for at least one of the people in that relationship. There are two really important parts to this definition. First, notice that therapy is a relationship. Relationships involve connection and responsibility. Psychotherapy does not work if there is no connection and if no one in the relationship takes responsibility for caring for that relationship. Second, therapy must be, by definition, therapeutic. In other words, we therapists cannot just go changing people all willy-nilly, causing them, like hypnotists who entertain, to go around quacking like a duck everytime someone says "Mommy." This would not be therapy. The change has to lead to some sort of outcome that benefits the patient's overall mental health in some meaningful way.

With this in mind, let's look next at the types of psycotherpay I practice, and what they mean to me.

Psychodynamic Psychotherapy

The psychodynamic approach to psychotherapy is the oldest and most theoretically complex of all orientations. Because of it's complexity, psychodynamic theory is difficult to describe in a brief form that's friendly for a website. Still, I'll spend the most time and space on this theory here in order to give it a fair review. Psychodynamic theory also represents the bulk of how I think and work as a clinician, and so I think in order for you to understand my professional style, a good review of psychodynamic theory is necessary. 

 

In a nutshell, psychodynamic theory is built upon a few major components. First, the human mind consists of several components, some of which we are aware (conscious) and some of which are resting below the surface of our awareness (preconscious and unconscious). These parts are constantly interacting with each other in a fairly fluid manner (they are dynamic). Second, psychodynamic theory believes that clinical symptoms arise in patients as a result of some unresolved psychological conflict. Thus, the way to treat clinical conditions is to find the source and then help resolve that conflict through psychotherapy. Third, unresolved conflicts almost always can be traced to developmental sources. In other words, psychodynamic theory places a high emphasis on exploring a person's childhood and extensive developmental history, with a primary goal of then helping the person resolve that conflict in a natural, healthy way. Fourth, resolving these conflicts frightens our minds, and the human mind naturally tends to resist attempts to bring these conflicts into conscious awareness. Humans exhibit reliable defense mechanisms to fight awareness of internal conflict. We do this because that conflict is either so far in our remote past that we have "forgotten" it or, more commonly, because no one has ever taught us how to access the conflict. Thus, another task of the psychodynamic therapist is to minimize unhealthy psychological defenses and teach patients how to access and therefore address important psychological conflict.

A full overview of all of the above would literally take years and several graduate level courses of advanced psychology to cover. For our purposes here, though, I think it may be helpful to review the different human psychological needs. All humans have basic psychological needs, which, ideally, we are able to resolve naturally across our development (most often with the help of our parents or some other older, wiser mentor). When these needs are not met, we experience the psychological conflict referenced above.

What are the basic human psychological needs?

The following needs are presented basically in the order of when they arise naturally developmentally, from the earliest need (present at birth) to the latest (which usually presents in adolescence through adulthood). One thing that is important to remember also is that healthy psychodynamics are all about balance. So, with all of the needs below, the ideal place for a human to be is right in the middle, neither having too much or too little off any one thing.

  1. Humans need to be free of pain. This is clear from birth. Babies cry when something is bothering them - they are hungry, dirty (diaper), uncomfortable, sleepy, bored, angry, in physical pain, lonely, etc. Ideally, we learn how to manage this pain early, with the help of our parents. Some of us learn how to manage some pain (e.g. hunger) but not others (e.g. lonely). Ideally, though, the first few years of our life are spent learning how we can meet our own need to be free of pain, both physical and psychological. Also, ideally, we learn that it is not possible to completely rid ourselves of pain, and thus it is futile to always avoid any pain. Instead, we just learn how to manage the inevitability of pain, to keep it at a healthy balance.

  2. Humans need to feel powerful/autonomous. Humans also need to feel like we have some control over our world. Though less clear as #1, you can also see evidence of autonomy even in babies - namely, they cry when they need something, and thus make someone respond to them. This response is the first sign to babies that we humans have some sort of control over our world. However, over time, ideally, we learn that we can't control everything. Thus, again, the goal is to achieve balance in feeling we have some control, but understanding the limitations of our power. 

  3. Humans need love. We need both to receive and to give love, and we need love to be unconditional. The love is, importantly, NOT about being free from pain. Although having someone take care of and nurture us from an early age often contributes to love, the need for love is not solely met by nurturance and having someone help us meet need #1 above. In other words, the need for love is bigger than, and independent from, the need to be free of pain. As we age, we learn about just how big love is. Furthermore, we learn about the imperfections of those who love us and of those we love. Ideally, we learn to manage these imperfections and still experience love. Things can go wrong, though, when we don't, which can lead to difficulties with trust, with learning to let oneself love others, with learning to love oneself, and with letting others love them.

  4. Humans need someone or something to love (called an "object" in psychodynamic terms). Not only do we need the feeling of love, as in #3, but we need something on which to place that love (an object). Most often, our first object is our parents, but anyone or anything can be an attachment object. The difference between #3 and #4 is clearer when we explore the fears that can arise from these needs. In #3 (need for love), a child may lie to get out of trouble because they fear their parent may get angry with them, which is a natural representation of a  mild loss of love, one that we all go through. In #4 (need for an object), a child may worry about something bad happening to someone they love. In this case, the child isn't worry about losing the love, they are worried about losing the object. Separation anxiety is the most common type of loss of object anxiety (but it's not the only type). In fact, you can see loss of object anxiety in lots of conditions. To resolve this need, humans need to feel that we have can actually produce, at will, an internal representation of an "object," which we can then keep with us even when the actual object is no longer with us.

  5. Humans need to be able to meet our own expectations for ourselves (superego need). Freud proposed three divisions of motivations in our mind, the id, the ego, and the superego (which are translated from Freud's original German terms Es, Ich, and Uber-Ich, meaning the "It", the "I," and the "Over-I"). Roughly (and this is an oversimplification), the Id is what we want, the Super-ego is what we are supposed to do, and the Ego works out the difference between the two. So, our superego need can be basically translated to our need to do what we feel like we are supposed to do in the world. When what we are doing and what we feel like we're supposed to be doing match, we end up much healthier, psychologically. When these don't match, there can be conflict. How we define what we're supposed to be doing changes over time. As children, most often our superego is based on what everyone else tells us is right. As we age, though, we learn that sometimes others don't give the best advice, and we become more reliant on our own, internal sense of what our purpose in life is. What's important is that the superego is always self-defined. In other words, this need is solely about our expectations for ourselves, and not about meeting others' expectation, except for when those two overlap (and they often do). 

  6. Humans need to feel like we can trust others and be free of unfair judgment by others. This unmet need often presents as persecutory anxiety - that is, fears about what others (non-attachment figures) think of you. As with all of the above, the goal of this need is healthy balance. Humans are social species and we should care to some extent about how our actions impact the broader social network in which we live. In would not be good for use to free ourselves completely of persecutory anxiety, because others do matter. However, at the other extreme is caring so much about what other's think that we become frozen in our own actions and sense of self. If left to run rampant, this anxiety can trigger a person to become unable to form an independent self, instead action only based off the approval of others.

  7. Lastly, humans need a consistent, integrated sense of self. This unmet need is often called disintegration anxiety. This is one more complex than all the others, but the best way to think of this need is to focus on our identity. A healthy identity is a flexible one in which all of our parts coalesce into a meaningful whole, like a jigsaw puzzle. The Self is the completed puzzle, and the pieces are the different parts of our identity that make us who we are. Sometimes, a person's identity can become fragmented, and we can't figure out how to put the puzzle together, which can then lead to other problems. At its extreme end, disintegration anxiety can even cause Dissociative Identity Disorder (formerly called Multiple Personality Disorder). More commonly, though, people just struggle to figure out who they are and how the different parts of who they are make sense together. 

With what types of patients do you use psychodynamic psychotherapy?

I apply psychodynamic theory as defined above to every patient I work with, but most of this happens behind the scenes. In other words, most patients don't notice I'm thinking about all of the above, and it's extremely rare that I use dynamic terminology with my patients, especially with children. Instead, dynamic theory - the needs-based approach in particular - influences how I go about choosing intervention targets within therapy. So, if I'm treating a child with, say, test anxiety, a major task is to find what unmet need is driving that test anxiety and intervene there. I find this works better than simply giving the child "in-the-moment" skills to manage test anxiety (although I will do that too). Instead, I work to treat the source, rather than the symptom.

Cognitive Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) is probably the best-researched approach to psychotherapy. As a result, it's the one that people ask for by name most often. Patients who do their research often find numerous recommendations within media and scientific literature about CBT being an evidence-based treatment for a wide range of mental health conditions. That's because CBT, by far, is the the most "researchable" approach to therapy. The theory is simple and linear. Here's the basic premise: clinical conditions present with symptoms that affect our thoughts, feelings, and behaviors. When intervening in these conditions, we are not very successful at directly changing feelings. When someone is depressed, we can't just say, "Be happy," and all of a sudden the person is magically cured toward happiness. So, we intervene, instead at thoughts and behaviors, which then have an indirect effect on emotions. This is CBT.

CBT focuses on the following pathway: there is an event, about which we have certain thoughts and to which we react with certain behaviors, and those thoughts and behaviors reliably predict certain emotions. CBT focuses on teaching people to develop patterns of thoughs and behaviors that reliably translate to healthy functioning. We know what leads to healthy functioning through research. We look at differences in thoughts and behaviors comparing people with a clinical disorder to those without. Once we know those differences, then we know where to intervene. It's that simple.

Because the theory is relatively simple, CBT lends itself extremely well to research. It's relatively quite easy to track changes in behaviors and thoughts and how these contribute to therapeutic changes in patients. So, this is why CBT has so much research. CBT is not, in my opinion, inherently better than other approaches to treating mental illness. It is, however, more reliable. In other words, CBT comes with a simple set of predictable "rules" for clinicians that make it easier to follow. As a result, people can be more easily trained in CBT. Furthermore, CBT comes with well-defined sets of "homework" that patients can implement in their everyday life - a form of "sefl-help." Dynamic theory, on the other hand, does not lend itself well to "self-help" in the majority of patients. So, CBT is most powerful to me in its structure and in its ability to be trained more quickly thank other approaches. 

I use CBT prinicples again in (nearly) every patient I work with in my practice. When I use CBT, I give patients concrete skills to practice at home in which they work on changing their thoughts and behaviors toward healthier outcomes.

Person-Centered Psychotherapy

Person-Centered Psychotherapy was most prominently developed and promoted by Carl Rogers, and so is often called a "Rogerian" approach to therapy. The theory is influenced heavily also by Abraham Maslow, who is best known for his "hierarchy of needs," at the top of which is "Self-Actualization." Simply put, Maslow's idea is that a person can't achieve optimal mental health until all their other, lower-level needs are met first. Person-centered therapy, then, focuses on the basic idea that in order for people to get better, you also have to treat and interact with them in certain ways. In fact, purists of the theory would say that if you treat a person with the basic features described below, they will essentially then have room and opportunity to cure themselves. Person-centered therapy, then, at its core, is about helping to remove barriers that get in the way of a patient's optimal functioning. 

 

Rogerian theory is a "positive psychology" approach too. It sees people as inherently good, rather than flawed, and believes that under the right conditions all humans will thrive. There are three key elements of person-centered therapy that a therapist is focused on enacting in order to promote opportunities for self-healing.

 

1) Congruence or genuineness. The main purpose of this element is to differentiate it from classic Freudian theory, which suggested that a therapist must be a "blank slate," and most carefully control his or her external reactions not to show internal feelings during therapy. Rogerian therapy promotes, instead, that a therapist must be genuine and allow his or her own internal feelings during a session to come out into the open, which then gives the patient space to heal. Rogers believed (and I share this belief) that patients can tell if you are not being genuine with them, which can then negatively impact the relationship. To be effective, a therapist has to be honest. 

2) Accurate empathy. A therapist must also connect accurately with clients, and should show that empathy readily in session. Empathy allows a patient to feel understood, and once a person feels understood, theoretically they can then make movements toward real change.

3) Unconditional positive regard. Being genuine and empathic aren't useful if you don't constantly keep a positive attitude toward the client. In other words, if a therapist genuinely dislikes a client and cannot find a way past that, he or she cannot be therapeutic, and should thus refer the client so someone who can maintain an unconditional positive regard. Personally, I would take it a step further and suggest that a therapist who cannot maintain unconditional positive regard has a training need that should be corrected through further training and continued development. In other words, it is not enough just to refer clients you don't like. You also have to learn, as a therapist, how to genuinely like everyone, even hard-to-like people. 

Given all of the above, it is important or all therapists to maintain close vigilance at all times over our own attitudes towards our clients and how those attitudes shape our interactions with them. As with all of the other theories above, person-centered psychotherapy shapes all of my work as a psychologist, and I use these idea with every client I see.

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