We provided a broad overview of psychotherapies in the Talk Therapy chapter. We showed you what therapy can look like. We described general categories of talk therapies and their goals, and how to use them as part of your living treatment plan.
This appendix provides an overview of several commonly-used, evidence-based talk therapies. Consider it a starting point used to discover which therapies might be helpful for you.
Most therapeutic modalities are applied to many different problems and illnesses, while some only work in specific situations. As with any treatment, your therapist should use them in a way that fits your overall treatment goals. You should also regularly measure your progress toward those goals during a course of therapy.
There are many more talk therapies than we cover here. The Psychology Today and GoodTherapy websites describe many types of therapies:
https://www.psychologytoday.com/types-of-therapy
https://www.goodtherapy.org/learn-about-therapy/types
CBT is a short-term, goal-oriented collection of psychotherapeutic techniques. It is based on the premise that your thoughts, feelings, and behaviours all affect each other. Changing unhealthy patterns in the way you think (thoughts) or behave can positively influence your mood (feelings).
Learning and practicing CBT techniques help you “rewire” your brain, building new connections between neurons. Imaging studies have observed brain changes as a result of CBT. Practicing is key, so active participation both during and between sessions (i.e., homework) is crucial. It is a very well-studied therapy that can be as effective as medication in some situations. Often, a combination of CBT and medication is optimal.
There are dozens of different CBT techniques. You need to choose the right techniques to use and the right thoughts or behaviours to work on. Two people suffering from depression, who undergo CBT, may work on completely different things using completely different techniques. CBT techniques have been successfully applied to a vast range of symptoms, e.g., depression, panic, compulsions, insomnia, binge eating, pain. We’ll now briefly examine three categories of CBT techniques.
Changing the way you think is called cognitive restructuring. Like most people, you likely have thoughts that automatically pop into your mind at different times. Some may be distorted and not based on reality, e.g., “I am worthless.” These can negatively affect your mood and behaviour. CBT techniques help you identify these thoughts, challenge them, and replace them with balanced alternatives based on reality. With practice, these changes become ingrained. Gradually, these changes in your thoughts improve your mood and change your behaviour. Breaking down this process:
Thought records and mood logs capture automatic thoughts for analysis.
Automatic thoughts are examined for a wide range of logical errors called cognitive distortions, e.g., all-or-none thinking, overgeneralization, jumping to conclusions.
Evidence both for and against automatic thoughts is collected and reviewed.
Based on refuting cognitive distortions, assessing evidence, or other techniques like pros-and-cons, more balanced thoughts are generated.
As cognitive restructuring helps to change automatic thoughts, exposure helps to change automatic behaviours like avoidance. People avoid things that may contribute to their anxiety. The anxious mind overestimates the negative consequences of being around people or objects, in situations, or doing activities. Exposure makes you repeatedly face the things you’ve been avoiding. Your confidence increases each time you successfully expose yourself to a trigger. This decreases your avoidance and positively affects your thoughts, mood and anxiety.
For exposure activities to be successful, you start with less anxiety-provoking situations, and gradually introduce situations associated with increasing anxiety. For example, addressing a phobia of snakes might involve reading about snakes, then looking at pictures of snakes, holding a toy snake, looking at a small snake at a pet store, and several more steps before eventually holding a snake. Exposure can be done via:
facing the object, situation or activity in real life, known as in vivo exposure;
imagining an object, situation or activity, known as imaginal exposure;
bringing on physical sensations associated with the anxiety (e.g., shortness of breath) when the object, situation or activity is not present, known as interoceptive exposure; and
using other techniques, e.g., virtual reality.
When you are emotionally overwhelmed, you’re less likely to take part in activities that you enjoy. You tend to isolate and detach from others. You avoid things that will likely improve your mood. You’d rather stay in bed. Your symptoms worsen, leading to more avoidance—a vicious circle.
Behavioural activation forces you to do things that you enjoy, to eventually improve your feelings and thoughts. Some notable aspects:
Activities are rigidly scheduled, usually on a weekly basis, and defined very precisely; you can easily say if you’ve completed an activity or not.
Detailed planning helps avoid relying on motivation; in fact, you’re using behaviour to improve motivation and not vice versa.
Activities are chosen that are consistent with your values and are important to you (not others), bringing pleasure or a sense of accomplishment.
Mood charting helps identify activities that you enjoy and to monitor your mood between activities.
As with exposure, you start with smaller and less intimidating activities, gradually progressing to activities that you are more strongly compelled to avoid.
Several other therapeutic skills and techniques are commonly used, either standalone or incorporated into CBT or other therapies.
Mindfulness is a broad set of practices that help you remain in the here-and-now and decrease your baseline stress level. Adapted from Buddhist meditation practices, many modern forms of mindfulness have good clinical evidence supporting them. Typical mindfulness exercises include forms of meditation, visualization, body scans, and being in the present when performing activities like eating. These exercises teach and enhance five core skills:
Observe. Notice things that are happening both inside and outside you.
Describe. Organize and convey what you are aware of at the moment.
Detach. Allow thoughts, feelings, memories and sensations to simply be present without becoming absorbed in mental evaluation—“letting go.”
Self-compassion. Practice acceptance, care and kindness to yourself. Accept yourself, flaws and all.
Act mindfully. Act with intention, reflecting your beliefs and principles in the present moment.
Mindfulness is a general skill applied to many illnesses and often combined with other therapies. Notable variations include mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR).
These are the fancy terms for reading and using self-help materials. Psychoeducation helps you understand your illness and learn techniques to improve your symptoms. Reading this book is a good example. You can find many good books on almost any mental health topic. Workbooks (and to some degree, apps for various devices) also provide exercises to help practice different techniques. Though primarily a solo form of therapy, treatment providers can play valuable roles, recommending resources, encouraging you, and monitoring your progress to help you stay engaged, accountable, and on track.
A wide range of practices can help you relax and decrease stress. They are often incorporated into psychotherapy programs. These help a variety of physical and mental health problems. Many of the mindfulness techniques promote relaxation. Other examples include deep breathing, biofeedback, meditation, yoga, massage, acupuncture, reflexology, T’ai chi, Qigong, flotation therapy, and taking a walk in the park. Admittedly, we may be stretching the boundaries of talk therapy pretty far with some of these.
Here, we note some of the other more commonly used therapies. Remember that these are only a small fraction of those available, and each therapy has many variations.
Problem-solving therapy uses a cognitive-behavioural approach to help you learn and improve problem-solving skills. It also helps increase your optimism and acceptance to enhance your problem-solving and healthy coping. This therapy has been widely applied to a variety of stressors and psychological problems.
In PST, you define problems, come up with potential solutions, decide amongst the alternatives, and then implement and evaluate the chosen solution. You explore practical barriers to problem-solving (e.g., ambiguity or conflicting goals), negative problem-solving styles (e.g., avoidance or impulsivity) and other mental obstacles (e.g., cognitive overload, poor motivation, decreased emotional regulation).
Interpersonal psychotherapy helps you understand the connection between the onset and fluctuation of your symptoms and a recent challenge in your life, e.g., relationships. You use that information to find ways of dealing with the life challenge, thereby improving your symptoms. Therapists offer support and ideas for change. IPT is usually highly structured, with a course of therapy usually lasting 12-16 weeks. IPT can help with:
grief and loss;
interpersonal role disputes, typically conflict with another person leading to tension and distress;
life changes and role transitions, such as losing a job, the birth of a child, starting a new relationship; and
challenges with interpersonal skills that make it difficult to start or sustain relationships.
IPT is most often used for forms of depression and bipolar disorders. Interpersonal and social rhythm therapy (IPSRT) is a notable variation.
ACT is a short-term, practical, down-to-earth form of therapy. It combines mindfulness with tools to modify behaviour.
When faced with negative experiences that you can’t change (e.g., illness, end of a relationship), ACT encourages you to accept reality without analyzing or trying to control the situation. Struggling often leads to overreaction, obsession, and avoidance. ACT teaches you how to observe your current reaction and gain control over it. Through a series of skills and strategies, you learn to identify and then choose alternative ways of reacting that are consistent with your values. You set goals and commit to your chosen set of actions. So:
Accept your reactions and be present.
Choose a valued direction.
Take action.
Like CBT, ACT has been widely used to treat many different illnesses.
DBT is a multifaceted program used to help those who frequently experience intense emotion, which can lead to impulsive behaviour, self-harm, and substance use. It was initially designed to treat borderline personality disorder but has been used, in whole or in part, for depression, PTSD, binge eating and addiction.
A full DBT program is typically one year long, mixing individual and group psychotherapy and skills training. Many smaller programs focus on specific subsets and skills. Several individual skills and techniques developed within DBT, e.g., grounding techniques, have also been incorporated into other therapies.
Like ACT, DBT begins with accepting emotions and situations. It then proceeds through the process of change. Tools, techniques and coping skills are divided into four modules:
mindfulness (observe and describe emotions, withholding judgment, focus);
interpersonal effectiveness (assertiveness, communication);
distress tolerance (grounding, relaxation, self-soothing, distraction); and
emotional regulation (understanding emotion, problem-solving, health).
Psychodynamic therapy is a form of insight-oriented psychotherapy. Here, you explore your past to gain a better understanding of your current behaviours in order to change them. Its focus on the past separates it from most modern therapies that are entirely forward-looking. It is a modern evolution of Freudian psychoanalysis.
Full psychodynamic therapy is extremely open-ended, wide-ranging, and lengthy. Short-term variations are briefer (weeks or months versus years), more focused, and thereby more practical for most people. While few therapists practice pure psychodynamic therapy, many incorporate some aspects and interpretations into more eclectic mixtures of therapies when treating various symptoms. Psychodynamic concepts are also used by therapists when formulating a patient’s presentation.
Supportive psychotherapy aims to improve symptoms via a therapist’s positive, respectful and optimistic engagement with you. This general approach increases your comfort in sharing personal information and reduces your anxiety. It can help boost your self-esteem while developing new skills to address symptoms. Therapists commonly:
demonstrate support, acceptance, and warmth toward you;
emphasize how they will work collaboratively with you;
are optimistic and hopeful that your goals will be met;
help you normalize, clarify or reframe experiences in a more positive light;
respect your defences and boundaries;
offer advice and teach you new skills; and
focus on your strengths and give positive feedback on growth.
Humanistic therapies help you to identify and fulfill your unique purpose and potential as a whole individual. They take a holistic approach rooted in personal self-awareness and experience in the present moment, not the past. The therapist’s role is to create a positive and empathetic environment for you to share feelings; they do not act as an authority figure.
Common variations of these therapies include client-centred therapy, existential psychotherapy, and Gestalt therapy.
EMDR was designed to treat posttraumatic stress and has been applied to help deal with other distressing life events. Some memories can remain unprocessed due to the distress present at the time of the event. They stay stored in your brain as raw emotion and are not incorporated into the complex structure of your personal story. Future events that are in some way associated with the unprocessed memory cause you to respond as you did to the original event.
An EMDR therapist helps you reprocess those original distressing unresolved memories. They ask you to remember the unprocessed memory and focus on an external stimulus that the therapist provides. Your eyes move side-to-side, following the horizontal movement of the therapist’s finger (hence the name of the therapy). The therapist then asks you to shift your thoughts to more positive ideas or images. This helps weaken the strong negative associations of the original memory.
While there’s little understanding of how bilateral stimulus helps (other stimuli are also used), the therapy can effectively help you deal with past trauma.
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