Psychotherapy: major psychotherapeutic approaches

01Common factors and supportive therapy

Psychotherapy treats mental disorder through a structured relationship with a trained therapist, using talk, reflection and practice between sessions. There are hundreds of named therapies, but they fall into a few families, and they share more than their founders admitted.

What every therapy shares

In 1936 Saul Rosenzweig noticed that different therapies seemed to work about equally well, and quoted the Dodo in Alice in Wonderland, "everybody has won, and all must have prizes"; the idea became known as the Dodo bird verdict. Jerome Frank later named the common factors of all healing practices: an emotionally charged, confiding relationship, a healing setting, a rationale that explains the patient's suffering, and a procedure in which both take part.

On one influential reading of the evidence, common factors account for more of the benefit than the differences between specific techniques; this is still debated, and specific methods clearly matter for some disorders, above all exposure in anxiety and OCD.

Supportive psychotherapy

Supportive therapy relies on the common factors without trying to change deep patterns. The therapist listens, validates, gives information and advice, encourages problem solving and strengthens the patient's healthy defences and coping. It is the backbone of good psychiatric follow-up, suits patients in crisis, with severe or chronic illness, or who cannot use exploratory therapy, and is the active comparison in many trials. Counselling, in the person-centred tradition of Carl Rogers, is similar and is used for milder depression, adjustment and bereavement.

02Psychodynamic therapy

From Freud to modern practice

Sigmund Freud, a Viennese neurologist, developed psychoanalysis from the 1890s. He proposed that much of mental life is unconscious, that symptoms express unresolved conflicts rooted in childhood, and that bringing them into awareness relieves them.

Freud's followers changed the theory. Anna Freud catalogued the defences; Melanie Klein, Donald Winnicott and the object-relations school focused on early relationships; John Bowlby's attachment theory gave the field testable research. Classical psychoanalysis, on the couch four or five times a week for years, is now rare. Psychodynamic psychotherapy is face to face, weekly or twice weekly, often time-limited to six months or a year, and more active; brief forms last about 16 sessions.

Defence mechanisms

Defence mechanisms are unconscious ways of protecting the self from anxiety, painful feelings or unacceptable impulses. Everyone uses them; they become a problem when they are immature, rigid or used to excess. They are usually ranked from immature to mature, after George Vaillant; the three levels below simplify his scheme, which also has a psychotic level.

Transference in therapy

Transference and countertransference are the working tools of dynamic therapy: the patient's feelings towards the therapist repeat older relationships, and the therapist's own reactions are information. The therapist interprets these patterns gently, linking past, present and the relationship in the room. Psychodynamic therapy has trial evidence in depression, some anxiety disorders and personality disorders, and remains widely practised in Germany, France and Italy; in Germany, psychodynamic and analytic therapies are funded by statutory health insurance alongside CBT and, since 2020 for adults, systemic therapy.

03Cognitive behavioural therapy

The cognitive model

Cognitive behavioural therapy (CBT) combines behaviour therapy, built on learning theory from the 1950s, with Aaron Beck's cognitive therapy of the 1960s. Its premise is that it is not events themselves but how they are interpreted that shapes feelings and behaviour, and that thoughts, emotions, bodily sensations and actions maintain one another in vicious circles.

Beck described the cognitive triad of depression, negative views of the self, the world and the future, held at three levels:

Cognitive distortions

How CBT is done

CBT is structured, time-limited, usually 6 to 20 weekly sessions, and collaborative. Each session sets an agenda, reviews homework and works on a current problem. The therapist uses guided discovery and Socratic questioning, not persuasion, to help the patient examine the evidence for a thought, and the patient keeps thought records and tests predictions in behavioural experiments. Progress is tracked with scales such as the PHQ-9.

Behavioural activation treats depression by the behavioural side alone. Depression leads to withdrawal and avoidance, which remove the activities that bring pleasure and achievement, which deepens the depression. The patient monitors activity and mood, then schedules valued activities step by step. In the UK COBRA trial, behavioural activation delivered by junior mental health workers was as effective as CBT from experienced therapists, and cheaper.

Exposure treats anxiety. Avoidance and safety behaviours relieve anxiety in the short term but keep the fear alive, because the patient never learns that the feared outcome does not happen.

1. 1

   Explain

   Share a model of how avoidance and safety behaviours maintain the fear.
2. 2

   Build a hierarchy

   List feared situations from mild to severe, rated by expected anxiety.
3. 3

   Face it

   Enter each situation, starting low, and stay until the anxiety falls or the prediction is disproved, without escaping or using safety behaviours.
4. 4

   Repeat

   Practise often, between sessions, in many settings, and move up the hierarchy.
5. 5

   Prevent the response

   In OCD, exposure to the trigger is paired with not performing the compulsion: exposure and response prevention.

Exposure can be graded, or intense and prolonged from the start (flooding), in the imagination or in real life. In specific phobia a single session of about three hours, developed in Sweden, is often enough.

04Third-wave therapies

The third-wave therapies keep the behavioural tradition but change the patient's relationship with thoughts and feelings rather than their content, through acceptance, mindfulness and values.

DBT roughly halved suicide attempts compared with treatment by community experts in a two-year trial. MBCT reduced relapse in an individual patient data meta-analysis, and in a large UK trial it protected about as well as maintenance antidepressants. Schema therapy did better than transference-focused psychotherapy in a Dutch trial in borderline personality disorder.

05Other therapies

Interpersonal psychotherapy

Interpersonal psychotherapy (IPT), developed by Gerald Klerman and Myrna Weissman in the 1970s for depression, links the onset of symptoms to current relationships. It lasts 12 to 16 weekly sessions in three phases. The patient is given the sick role, depression is explained as an illness, and one focus is agreed and worked on:

IPT is about as effective as CBT in depression, including in adolescents and around childbirth, and is used in bulimia and in bipolar disorder as interpersonal and social rhythm therapy.

Family and systemic therapy

Systemic therapy treats the family, not one member, as the unit: symptoms are understood in terms of patterns, roles and communication in the system. Major schools came from Europe as well as America, notably the Milan school of Mara Selvini Palazzoli. Family therapy is the first-line treatment of anorexia nervosa in children and adolescents. In psychosis, family intervention is psychoeducational: it lowers expressed emotion and relapse. Couples therapy helps depression when the relationship contributes to it.

Group therapy

Groups treat several patients together and use the group itself as a therapeutic agent. Irvin Yalom described its therapeutic factors, among them hope, universality (finding that others share the problem), learning from others, altruism, cohesion and catharsis. Groups range from psychoeducation and CBT groups to psychodynamic group analysis and residential therapeutic communities. Patients who cannot tolerate a group, such as those who are acutely paranoid or unable to keep its rules, are not suited.

EMDR

Eye movement desensitisation and reprocessing (EMDR), developed by Francine Shapiro in the late 1980s, asks the patient to hold a traumatic memory in mind while following the therapist's finger from side to side, or with other bilateral stimulation, until the memory loses its charge. It works about as well as trauma-focused CBT in post-traumatic stress disorder, and WHO and NICE recommend it, but whether the eye movements add anything to the exposure it contains is disputed.

Mentalisation-based therapy

Mentalisation is the capacity to understand one's own and others' behaviour in terms of thoughts, feelings and intentions. Anthony Bateman and Peter Fonagy in London proposed that it fails under emotional stress in borderline personality disorder, rooted in insecure attachment. Mentalisation-based therapy (MBT), about 18 months of individual and group sessions, helps patients stay curious about minds when emotions run high. It has randomised trial support and is widely used in the UK, Scandinavia and the Netherlands.

Other approaches a student meets include cognitive analytic therapy (a brief UK integration of cognitive and psychodynamic ideas), solution-focused therapy, motivational interviewing for substance use, and compassion-focused and metacognitive therapy.

06What works for what

Most first-line psychological treatments are similar across European guidelines; the details below follow NICE.

07Delivery

Demand for therapy far exceeds the number of therapists, so services are organised to treat as many people as possible with the least intensive treatment that works.

1. 1

   Step 1, recognise

   Assessment, information, active monitoring and self-help in primary care.
2. 2

   Step 2, low intensity

   Guided self-help, digital CBT with support, psychoeducational groups, delivered by trained practitioners in a few short sessions.
3. 3

   Step 3, high intensity

   Individual CBT, IPT, behavioural activation, counselling or couples therapy from qualified therapists, often with drugs.
4. 4

   Step 4, specialist

   Complex, severe or risky problems in secondary care: specialist therapies, crisis care, inpatient treatment.

In stepped care, patients start at the lowest suitable step and move up if they do not improve; in matched care, they start at the step that fits their severity. England's NHS Talking Therapies programme, launched in 2008 as Improving Access to Psychological Therapies, treats hundreds of thousands of people a year this way, with about half recovering, and reports outcomes for every patient.

Guided self-help, a book or programme with brief support from a practitioner, works better than unguided self-help, which most people abandon. Internet-delivered CBT with therapist support works about as well as face-to-face CBT for depression and anxiety disorders; Sweden has offered it in routine care since 2007, and in Germany approved digital therapy apps can be prescribed and are paid for by health insurance.

08Harms of psychotherapy

Therapy that is powerful enough to help is powerful enough to harm, and harms are less often recorded than drug side effects.

Practices that try to change a person's sexual orientation or gender identity, so-called conversion therapy, are ineffective and harmful, and several European countries have banned them, among them Malta, France, Belgium, Spain and Portugal, and Germany for minors and for adults pressured or deceived into them.

Harms are reduced by careful assessment, a clear rationale and consent, monitoring outcomes every session, supervision, and asking patients directly about negative effects.