Making Sense of Psychotherapy

Counseling or psychotherapy is a critical piece of comprehensive mental health care.  Studies have shown than for many conditions it can be at least as effective as medications and may have longer lasting benefits. Many primary care clinicians know that their patient is “in counseling” but often not much more than that.

The world of psychotherapy can be confusing with lots of different names and approaches that often borrow from each other.  Some schools of psychotherapy have good research support for specific disorders while for others there is less evidence.  The following is a brief description of some of the major types of therapy. 

Cognitive Behavior Therapy (CBT):  This form of psychotherapy is structured and generally focused on present symptoms.  It concentrates on how behaviors are learned and reinforced.  The cognitive aspect challenges patients to analyze and alter how they think about the world. This type of psychotherapy has a great deal of research in children to back its efficacy, particularly for problems such as oppositional defiant disorder, anxiety, and some aspects of ADHD.  Children often get homework assignments and parents are usually involved actively.

Exposure and Response Prevention (ERP) is a variant of CBT designed especially for obsessive-compulsive behavior.  Patients rate the intensity of their different compulsions and are supported in resisting them in session.  Its efficacy in pediatric populations is very good.

Dialectical Behavior Therapy (DBT):  This is another variant of CBT that combines traditional approaches with mindfulness training.  It was developed and tested in adults with self-injurious behaviors and has expanded since.

Applied Behavioral Analysis (ABA) is a type of behavioral therapy that is used mostly with autistic children.  It helps children learn and reinforce new skills and behaviors and has good evidence for its use. Discrete Trial Learning is a component of ABA.

Trauma-Based CBT is yet another variant of CBT specifically targeted for children with a history of trauma and PTSD.  There is strong evidence for its effectiveness and combines standard CBT with elements tailored at addressing past trauma once sufficient regulatory skills are in place.

Eye Movement Desensitization and Reprocessing (EMDR) is a type of PTSD treatment that combines CBT techniques with visually following repetitive actions.  It has been used primarily in adults.  While there are some studies showing its efficacy, the unique importance of the eye movements has been questioned.

Play Therapy attempts to work through patient conflicts in play or “displacement” rather than directly.  Younger patients often enjoy this type of work but parents sometimes feel excluded from the opportunity to be more involved in their child’s improvement. 

Psychodynamic Therapy is based on the premise that symptoms are related to unconscious defenses against basic impulses.  Despite its long history, there have been few controlled trials in children. 

Motivational Interviewing:  This type of therapy has been used most to treat substance abuse and can be very effective.  It focuses on advancing patients through progressive “stages of change” through collaborative, non-confrontational dialogue in contrast to older techniques that are more “interventional.”

Supportive Psychotherapy is probably the most widely practiced type of counseling in the area.  It tends to be less structured than CBT and can range widely based on the needs of the patient and style of the therapist.  While this type of counseling has helped many, more controlled research is needed.

It is often worthwhile to find out more about your patient’s counseling.  Some questions to ask include.

  1. What kind of therapy is it?
  2. How often do you meet?
  3. Are the parents involved?
  4. Is there homework to be done outside the session?
  5. Do you have a good connection with the therapist?

The therapist may also be a valuable collaboration resource to help with questions about diagnosis, when to refer to a psychiatrist, and when to consider medications.

Learning as much as possible about therapy resources in your area and working collaboratively with local counselors can really help distribute the responsibilities of mental health care and help build effective teams that can maximize your patient’s path towards wellness.

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