Which type of psychotherapy?

Choosing a psychotherapist is like shopping for a mattress.  Every store has its own house brand, so it's almost impossible to find the exact same product at different stores.  Briefly trying a mattress in the store feels awkward, and in any case says almost nothing about long-term comfort or support.  The "fit" is very personal and subjective, so friends and online reviewers provide little guidance.  And it's an expensive long-term investment, so making a mistake can be costly and very regrettable.

The analogy doesn't stop there; I'll torture it for one more paragraph.  Will you select a firm mattress that is good for your back, or a soft one that feels better in the moment?  Is it smart to choose the least expensive model, or to pay more for quality?  Is this a mattress just for you, or will your partner be sharing it with you?

Ok, I'm done.  There are a bewildering number of psychotherapists out there, with different letters after our names and different ways of describing what we do.  Ultimately I can't advise you about which mattress to buy, or which therapist to see.  But I can help you ask the right questions.

Level of training

In California, a "psychotherapist" may practice without any degree or license whatsoever.  There is no legal standard that defines a psychotherapist.  In contrast, titles like social worker, psychologist, and psychiatrist are tightly regulated.  They imply years of formal coursework and supervised training experience.  How much formal training?  A rough guideline is that social workers, marriage and family therapists (MFTs), and most psychiatric nurses have masters degrees, whereas most clinical psychologists and all psychiatrists have doctoral degrees.  The real life situation is more complicated, as many mental health professionals (MHPs) take additional workshops and other training that is not reflected in the degree after their names.  Perhaps the ultimate example of this is psychoanalytic training, an intensive multiyear education open to experienced MHPs with any terminal degree.

Differences in disciplines

At the risk of overgeneralizing, clinical social workers and MFTs tend to think in terms of social and family systems, i.e., the way people relate to one another.  Dysfunctional patterns are identified: when a person is being scapegoated, or someone is demanding attention from others, or there is a shared family secret.  There is relatively less emphasis on unconscious processes in the individual, nor on cognitive distortions or pathogenic beliefs.  Such therapists may be particularly skilled in working with couples or families, and are often the most knowledgable about public agencies and supportive resources (daycare, shelters, job training, etc).

Clinical psychologists are uniquely trained to administer and interpret psychological tests, such as IQ tests, personality tests, Rorschach inkblots, and so forth.  Doctoral-level (PhD or PsyD) psychologists have the most formal psychotherapy training of any MHP degree; PhDs also receive significant research experience.  Traditionally, psychologists came from an academic, experimentalist foundation, and as a result favored cognitive and behavioral treatments over psychoanalytic ones.  This is no longer true as a rule, and psychologists may be found who practice the full range of psychotherapy approaches.

Psychiatrists are physicians (MDs) who specialize in mental disorders, much as a dermatologist specializes in skin disease, or a cardiologist in heart disease.  Psychiatrists are the only MHPs who can prescribe medication (aside from psychiatric nurse practitioners, who can do so without physician supervision in 21 states, California not included), and are also best equipped to differentiate medical conditions that only appear psychiatric. Traditionally, psychiatrists emphasized psychoanalytically derived therapy.  This has changed in recent decades, with a marked de-emphasis on providing any psychotherapy at all: most American psychiatrists mainly prescribe medication.  Those who still offer in-depth psychotherapy in addition to, or sometimes instead of, medication tend to be found in major urban centers such as New York, San Francisco, and Boston.

Treatment philosophy

The major divide in psychotherapy today is between the psychoanalytically-derived therapies, which I will call dynamic therapy, and the cognitive and behavioral psychotherapies, which I will abbreviate CBT.   Dynamic therapy can be traced back to Freud, but has evolved significantly in the century since psychoanalysis was first developed. Its fundamental premise is that certain unacceptable thoughts and feelings lie outside our conscious awareness, yet affect our conscious feelings and behavior.  Psychotherapy aims toward insight ("making the unconscious conscious") and/or toward providing a healing therapeutic relationship that allows the psyche to recover naturally from past trauma and to develop more mature functioning.  Dynamic therapy is unscripted, exploratory, and unique for each individual.  It maximizes spontaneous, uncensored expression.

CBT is rooted in the experimentalist tradition of academic psychology, although it is noteworthy that Aaron T. Beck, the father of cognitive therapy, started out as a psychiatrist and psychoanalyst.  Fundamental premises of CBT are that feelings follow thoughts, and that unhealthy thoughts can be unlearned and replaced by healthier alternatives.  Patients are directed to take note of their thoughts by keepings weekly logs or "thought records."  The therapist reviews these records with the patient during their session, highlighting pathogenic (unhealthy) beliefs and self-statements that lead to symptoms, and proposing healthier alternatives.  CBT is more structured than dynamic therapy, and more directly symptom-focused.  While many CBT therapists accept the existence of the dynamic unconscious, it plays little or no role in treatment.

Although a MHP's degree hints at the type of psychotherapy he or she conducts, it is best to ask.  There are clinical social workers trained in psychoanalysis, psychologists who conduct family therapy, and psychiatrists who offer CBT.

How to choose?

If your main concern is fast relief of specific symptoms, CBT (and possibly medication) is the way to go.  This is especially true if you seek the reassurance of a concrete plan, and are allergic to meandering conversations, double meanings, symbolism, and the like.  CBT is particularly effective for obsessive-compulsive symptoms (including OCD proper), panic attacks, and various phobias such as fear of flying.  It is best suited for symptoms that are relatively well-defined and non-mysterious.  There are many more research studies showing the effectiveness of CBT, as compared to dynamic therapy.

In contrast, dynamic therapy is the better choice when problems are vague, obscure, and hard to characterize.  Examples include inexplicable self-defeating behavior, failure to fulfill one's potential, identity issues, ongoing dissatisfaction or struggles with romantic partners, and conflicts over competition or recognition.  Dynamic therapy is best suited for those who seek self-understanding, who can engage with puzzling uncertainty, and for those who were traumatized, neglected, or abused very early in life.  Dynamic therapy goes beyond symptom relief and aims for increased contentment and satisfaction with life generally.  Although there are more research studies supporting CBT, the effect size (amount of improvement) in studies of dynamic therapy is often greater.

Fortunately, dynamic therapy and CBT are not as mutually exclusive and incompatible as their partisans imply.  Many experienced therapists combine dynamic and cognitive techniques, customizing their work with each individual.