Two Different Things Called Therapy

Nobody tells you this, but there are two very different things that get called therapy.

Some therapy is what you might expect if you have seen movies like Ordinary People or shows like In Treatment or The Sopranos and infer that real therapy is based on a relationship of exploration like the ones depicted in these stories, but slower-paced and with less unrealistic drama. The therapist listens and tries to understand, occasionally offering their own ideas to engage or challenge, but remains focused on you and your thoughts.

Eventually, a real, authentic psychotherapy relationship develops that allows the patient to grow new capacities to think, feel, and act differently, which in turn means the patient begins to get well enough that they can manage their world and their feelings in a way that is better for them. Not with everything solved, but better. This sort of therapy is based on the empirically well-confirmed, common-sense idea that we grow our psychological capacities in relationships, and it is wrong to say it is outdated, unscientific, or only for the worried well.

A focus on you

Let’s call this classical idea of psychotherapy “developmental psychotherapy.” It’s often associated with terms like “psychodynamic, psychoanalytic, existential, and humanistic,” but these are just labels that anyone can apply to themselves. Really, you can only know that your therapy is developmental if you feel that the therapist is focused, primarily and above all, on you, especially your inner world. You will feel a developmental therapist to be exceptionally curious, humble, and radically open to everything you might say. Such a therapist will feel, to quote the psychoanalyst Michael Balint, “unobtrusive” with no agenda of their own to impinge on you.

Developmental therapy stands in contrast to an alphabet soup of therapies named with acronyms based on teaching skills, giving worksheets, and didactically explaining the psyche that works by performing techniques on the client instead. The list grows by the day: CBT, DBT, EMDR, REBT, MBSR, and so on. In these therapies, the therapist follows a manual of instructions, and the therapy is often meant to be brief and with a preset time limit—for example, 12 sessions. Moreover, all that’s required is a relationship that is professional, friendly, and open, like you would see in teaching or coaching, because it is the techniques and skills that do the work, not the relationship. Let’s call these skills-based therapies.

Often, these skills-based therapies are marketed as being more evidence-based than developmental therapy, but as fellow PT contributor Jonathan Shedler has argued, they are often not effective for many or only minimally effective for others. They’re a sort of weak tea for many, which could explain why, as we offer more and more of this kind of therapy to people, overall mental health is not improving.

Hopeful but difficult

The main advantage of developmental psychotherapy is that it is built on the idea that if you and your psychotherapist can form the right relationship, you can change and develop in more profound ways, but in ways that are harder to predict. Whether the therapy works doesn’t hinge on the efficacy of a technique done to you but on whether, over time, the psychotherapist can adapt to your developmental and psychological needs. This is hopeful and difficult at the same time.

Sadly, it seems that the waxing popularity of skills-based therapies has come at the expense of developmental therapy, which is waning. I see many people who feel as if they have tried therapy, and it has failed to help them change the way they want and need numerous times, but they were unaware that, really, they had never tried developmental psychotherapy at all, which offered them hope when they finally found it that anyone can develop and grow with the right adaptive partner.

To find a therapist near you, visit the Psychology Today Therapy Directory.