What are psychotherapy ‘modalities’?

“Researchers studied client outcomes based on self-reported measures and found that the single largest factor in the client’s view of therapeutic success was the relationship. Modality of the therapist was not found to be significant. So prioritise speaking to a few different therapists to see who feels like a good fit and inspires confidence that they can hold you.”

The origin of psychotherapy as a practice and academic field

Psychotherapy originated with Sigmund Freud in the early 1900’s. Many have heard of Freud, and he is, rightly, a polarising figure due to some of his ideas, especially regarding sexuality, though it’s important to consider the time and context. He was one of the first to sit with patients over periods of time, talking to try and understand what was happening to make them feel mentally unwell. In the early days, ‘patients’ may have spent hours with a psychoanalyst - who would have tried to understand the unconscious processes driving their behaviour, by offering interpretation of what the patient was unable to consciously accept and was thought to be the basis of their mental suffering. Freud devised the concept that as humans, we have a subconscious. The concept of talking therapy, and that our past lived experience can inform our present without us consciously thinking about it, are still key pillars of psychotherapy today.

At present, therapy has broader appeal, with many reaching out for support as they meet a multitude of challenges in life and want to understand more about who they are, what has shaped them, how to achieve their goals in life or be in healthy relationship with others, and what they really want from life. The language for many practitioners has shifted to clients, to indicate a less medicalised view. The ultimate aim of therapy is also a personal decision.

Many different ‘types’ of therapy, theories about how to practice and how it works, and the role of the therapist exist today. This allows client choice but can be confusing to navigate. So the below hopes to offer a helpful reference guide to some of the terms you might come across.

Modalities

Over time, different voices emerged in the psychotherapy field - either to build on, or in opposition to, the theories that came before. This proliferation is still happening. You may see on therapy directories or in therapist’s bios different terms that attempt to convey some of the theories and approaches that they draw on in their practice. Below is a definition of some of those key ‘modalities’, some of their core concepts and what differentiates them from other schools of thought.

Psychodynamic

The therapist draws on what might be happening in the unconscious, what defence mechanisms our mind is employing to protect us that are keeping us stuck in some way, focuses quite a lot on early development and childhood relationships that might inform how we are in relationship today. Feelings towards the therapist are thought to be transference, projections of these early caregiver relationships that can be explored. Conceptualised the mind as the part that has impulses (id), the ‘ego’ that moderates our behaviour and character, and the ‘super ego’ that considers cultural and moral expectations. Freud considered some tensions and frustrations of patients to be the result of moral pressures supressing human desires and motivations.

Person-centred

Often considered ‘opposite’ to psychodynamic, person-centred therapy was devised by Carl Rogers, an American who believed perhaps with more positivity that people have an innate desire to grow, develop and be ‘good’ but need the right supportive conditions. The focus of the therapist’s role is to provide unconditional positive regard, understand the client’s ‘frame of reference’ (how they experience the world) and through inviting compassionate enquiry, allow space for the client to reflect and develop themselves. Some find person-centred to be ‘non-directional’ - that the therapist doesn’t offer different perspective, challenge or ask questions in a way that can be guiding but instead holds space for the client to self-guide.

Gestalt

Gestalt therapy is largely underpinned by the idea that we focus on something in our mind and follow it through to resolution but if something disturbs this cycle we can be left with unresolved material, or ‘unfinished business’. Unlike psychodynamic, gestalt practitioners focus on how these past conflicts are impacting us in the present by working in the here-and-now. So the therapist might work ‘relationally’ to invite your awareness towards how you are relating to one another in the therapy room and experiment with trying something different. Often uses ‘experiments’ or play in an attempt to resolve these, role playing a conversation with someone, for instance.

Transactional analysis

Looks at patterns of relating by conceiving relationships as a series of reciprocal interactions. One of the most popular models from TA is known as functional ego states. This considers our ‘modes of being’ as Parent (controlling / nurturing), Adult and Child (free / adapted). These can be our internal state (For example: I don’t want to go to do the exam, my Inner Child would rather stay outside and play, my Adult is nervous of not performing, and my Parent is saying I have to in order to get the qualification which will benefit me in the long run and offering some reassurance that my performance will be acceptable). Or between people, if an adult acts from a Child place, we might find ourselves responding from our Parent mode.

CBT, DBT and ACT

Cognitive behavioural therapy (CBT) considers that how we think about a situation drives our behaviour and response and this is the most important part of making change. CBT is prevalent because the therapist can set tasks for the client to complete in their own time, making it a uniform/repeatable, more measurable and cost effective way of supporting clients that is then widely used across the NHS. Extensions to this include dialectical behavioual theory. Acceptance and Commitment therapy (ACT) offers a framework to consider a thought, validate the emotion, consider evidence and our values, and then decide to act or respond in line with our beliefs and values. These approaches incorporate mindfulness and being aware of how we think, can increase agency. Some criticisms of these approaches are that it can entrench the idea that there is something ‘wrong’ with the client and they should be able to simply ‘think their way out of it’, without addressing the underlying causes or conditions that led to the individual adapting in the ways they have.

Trauma-informed

This is an approach rather than a modality in its own right, though it draws on research of neuroscience and physiology to understand the impact that severe mental distress (e.g. accidents, natural disasters, assault, abuse, sexual trauma, time spent in conflict zones) or gaps in relational development (neglect, abuse - either acute or more subtle) can have on us as people. Aims to equip people with ways to manage their psychosomatic symptoms (e.g. ongoing anxiety), understand and make meaning of what has happened to have a coherent narrative, and live a life free of fear or shame, with healthy relationship patterns.

There is a separate blog post on this coming soon with more detail of key theories.

Internal family systems (IFS)

This is more of a theory than a whole modality but you often see it listed on directories. IFS is a fairly new framework to consider the ‘parts’ of us that exist within a system that might help us understand ourselves. Offers a way to explore how we hold sometimes contradictory views, behaviours and responses to situations and a way to validate that we may have vulnerabilities and can chose to respond with compassion and maturity. For example, to protect an anxious or vulnerable part, we may become very managerial to try and control and reduce uncertainty, or we may rebel and create problems elsewhere to distract us (drugs, alcohol, relationship dramas).

Existentialism

Focuses on the view that for humans, life is finite. We lose people we love and we ourselves will die some day too. The fact that we are mortal and life will end is in direct tension with our survival instincts. Existential therapy considers this contradiction, as well as other paradoxes in life, alongside theories of change and identity. It also examines autonomy or self-determinism versus ‘fate’, and ponders the questions of what makes a life well-lived. An existential view on change might say, for example, that we cannot know in advance how we will feel about having children because once we’ve had them, we will be a different person with a different set of preferences than we are today. In other words, we will change with life’s changes and so learning to embrace change is more important than the decision itself.

There are others too!

Integration

The body of work that now informs the profession is enormous and had become highly fragmented and full of confusing names, leading many to call for ‘integration’ - a unifying view of what psychotherapy is, how it works and how we can evidence effectiveness with research. To confuse things further, there are multiple views of how to integrate.

You may see the terms Humanistic or Integrative.

Humanistic tends to be a blend of theories primarily based in person-centred philosophy.

Integrative is a blend developed by practitioners who will have an evolving view of their integrative framework and draw on multiple theories in a way that feels relevant to their practice and client groups.

One proposed way of integrating is to look for commonalities. Another is to look at effectiveness of therapy across modalities, to understand if one is better than the other. Researchers studied client-outcomes based on self-reported measures, and found that the single largest factor in the client’s view of therapeutic success was the relationship. Modality of the therapist was not found to be significant. So prioritise speaking to a few different therapists to see who feels like a good fit and inspires confidence that they can hold you.

In therapy literature, this shift was so large that it became titled, ‘the relational turn’. Thought turned to how the therapist was in relationship with the client, even if they didn’t explicitly disclose information about themselves. How the individual therapist relates based on their lived experience, who they might represent, their identity, context, power and difference, came to the fore. Today, psychotherapy trainings require therapists to attend weekly therapy for a minimum of four years throughout the course and join group sessions, to understand themselves and their own relating patterns. This clear sense of what is mine, what is yours, and what is ours in the co-created relationship or therapeutic space has become a central premise of safe practice. A relational practitioner will consider how they feel with the client, thoughts that might pop into their mind, as useful information and may bring it into the session - for example, ‘How is it telling me that? Especially given that we have a different racialised experience’. Trying to equalise power, to ensure that the client is given choice, that the therapist’s working thoughts and suggestions are shared lightly for the client to consider and accept or reject are also components to consider here.

Another form of integration that I tend to work with, is pluralism - this involves working with different strands and offering clients choice to see what resonates for them. This sits most naturally for me as I’ll share relevant theories based on what material clients bring, and how they respond.

All of this can feel quite dense and academic, which is partly why the MSc/Advanced diploma and psychotherapy route takes longer. Though some of the core questions for therapists are, ‘how do I effect change for people and ensure the validity of my work?’ and ‘how do I practice in a way that feels true to me and is backed by research and theory?’

What’s in a title?

Psychotherapist is not a protected term in the UK. This means that legally, anyone can advertise as one. However there are professional bodies, the two major ones in the UK being the UKCP or BACP, who impose ethical standards, handle complaints, accredit training courses and audit therapist’s recordkeeping and continuous professional development requirements.

There is a separate blog article on the difference between psychotherapist, psychotherapeutic counsellor, counsellor, psychiatrist, and psychologist terms that you can read here.

Why did I chose an Integrative training?

I think that most people want to feel a warmth and confidence with their chosen therapist, rather than having any in-depth interest in all of the theory outlined above! So I think a solid grounding in theory across many schools of thought offers a varied and well-rounded understanding that allows me to be flexible to people’s needs. I offer therapy in a way that feels authentic to me, and offer my whole presence and experience in the service of the client so I don’t change dramatically between clients but can draw on different theory and frameworks that might be helpful.

Summary

Every individual and their set of circumstances is unique, and so it every therapeutic relationship. Whatever their theoretical orientation, psychotherapists should act ethically, with compassion and humility. We are trying to work things out too. Often, people expect therapists to offer advice, tell them what to do, or have a solution. The reality is, that life and relationships are complex, that often there is no simple resolution or clear ‘right and wrong’. We are trying to figure it out together and hold multiple truths, and uncertainty. Therapy is as much an art as it is a science. Though there are safeguards in place, such as supervision, reflective practice and ongoing professional development - and a competent therapist should be able to explain their ‘working out’ to you. Therapists can offer helpful frameworks, a different perspective, and we have likely seen aspects of these challenges or circumstances before.

If you feel unsafe, judged or like your therapist isn’t listening to you, or you don’t feel you can be fully open or understand the direction of the work - talk to them and please consider working with someone else if that conversation doesn’t bring you comfort or clarity.

Hopefully this article has helped demystify some of the terminology you might come across.