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How to choose a therapist? Part 7

Theoretical Orientation

A therapist's orientation (orientation for short) refers to the underlying philosophy and theory that guides how they understand people and approach their challenges. You could think of this as a compass that orientates the therapist to where they are and where they are headed. How they understand your issues, their idea of health, and the route they follow all depend on their theoretical orientation. For example, a medical orientation encourages the practitioner to identify symptoms (e.g. depressed mood) that diagnose an underlying disease (e.g. depression) which can be medically treated (e.g. antidepressants); whereas a psycho-dynamic approach might aim to understand the psychological dynamics at play (e.g. let's see if we can understand your unhappiness). Most training programs will focus on one orientation but introduce trainees to a range of them. To properly master an orientation takes decades, and few therapists manage to learn master more than one.  Therapists are usually happy to answer questions about their orientation (especially at the beginning), and so you can feel free to do so. Apart from helping to inform you, exploring your interest can form a fruitful part of the therapeutic process.   No one orientation is better than the rest, and there is often considerable overlap between them despite the different language they use to describe similar things. This does not mean that they are all the same or that they are all equally appropriate in all instances, since each has its emphasis and goals. For example, short-term, symptom-focused approaches help you quickly address specific things while longer-term, more intensive approaches aim for lasting, broader change. Also, you will find that each therapist is unique, and it is not unusual to see two therapists with the same orientation work in remarkably different ways. The therapies that have grown from the more established orientations are described below. There are many more than those listed here, but these are the most widely practiced. The therapies rather than the actual orientations are defined because this site aims to meet the needs of therapy seekers rather than therapists. There is no intention to exclude any orientations, and if you notice that an important one is missing and would like to submit an explanatory paragraph that is in line with the others, we would happily consider including it. 

Cognitive Behavioral Therapy (CBT)

Cognitive behavioral therapy (CBT) offers a practical and measurable approach to therapy. It holds the premise that what we believe, the way we think and the behaviors we have learned perpetuate (if not cause) the emotional difficulties we experience (e.g. you might feel depressed because you believe you are bad). Thus, changing the way you think and act can change the way you feel. CBT helps by providing a combination of education, structured interventions and directions that target specific symptoms. You might be taught how to identify the negative automatic thoughts that undermine your mood, and be asked to do homework, e.g. keep a thought diary. In the case of phobias, a person might be called upon to face their fears in a systematic and graded way while being taught relaxation techniques. 

This approach is concrete, hands-on, and appeals to one's common sense. You don't need to have undergone decades of study to understand its core principles. It is easily written into manuals, and its definable and measurable goals provide useful direction in what can be a rather fuzzy world. These features also make it easy to research, and many studies have confirmed that CBT effectively and efficiently reduces specific symptoms in a range of conditions.  In the last few decades, CBT has begun to incorporate mindfulness and acceptance into its paradigm. Some practitioners see this as an evolution, shifting CBT's emphasize from reducing and managing dysfunctional thinking styles, towards embracing the value of acceptance and moving forward or letting go. Some of those advocating this shift critique the traditional cognitive focus on changing dysfunctional thinking as potentially counterproductive. These practitioners incorporate aspects of eastern thought that aim to embrace contradiction and acceptance as a way of life. Mindfulness and Dialectical Behavioral Therapy are two examples. CBT is a good first port of call, especially in defined instances of phobia, OCD, depression, social anxiety and panic. It is less useful when aims are less circumscribed, e.g. wanting to develop maturity and depth, or seeking insight into interpersonal or self-defeating patterns, etc. Psychoanalysis 

Psychoanalysis is a sophisticated body of theory and practice that has evolved in different directions over more than a century. The theory is dense, complicated and intimidating but, once you grasp its core concepts, it's also quite simple and straightforward. Some of its grounding ideas include the recognition that we don't always know or understand our motives, that we try to avoid painful feelings, that our wishes frequently conflict and that we can confuse parts of our fantasies with reality. Added to this is the understanding that many of our actions, language and dreams communicate more than we realize. This might sound a bit odd, but it's no more esoteric than when we interpret our partner forgetting our birthday. 

Psychoanalysis proper is carried out several times per week over several years. Free association (saying all that comes to mind without censorship) forms the cornerstone of this technique. The analyst and patient are encouraged to listen to the patient's associations with care and curiosity. Both parties then gradually develop a profound understanding of the patient, how they came to be who they are, and how they play a role in the difficulties that they face. This can lead to greater levels of emotional maturity and deep personal change.  The long-term and unstructured nature of this practice has historically made it difficult to research. Fortunately, the number of high-quality research trials supporting psychotherapies based on the principles of psychoanalysis is mounting.  Conducting a psychoanalysis is an advanced skill. Training as a psychoanalyst involves undergoing a full personal analysis (usually four times weekly for years), performing closely supervised work with patients, and completing a demanding theoretical program. It is impractical to incorporate more than a basic introduction when training psychologists, psychiatrists, social workers, etc. For this reason, treat much of what you read about psychoanalysis online with caution.  Psychoanalysis is a good choice, particularly if you have tried other routes, are struggling with long-lasting difficulties, are naturally drawn to this way of thinking, or are a psychotherapist wanting to deepen your work with your patients. Psychodynamic Psychotherapy

Professionals from various backgrounds often hold a psycho-dynamic orientation, including many psychologists, psychiatrists, social workers, occupational therapists and even nurses. Psychoèdynamic psychotherapy (sometimes called insight-oriented therapy) applies the same theories as psychoanalysis but in a distilled, less intensive and more pragmatic way. Therapists working from this perspective tend to talk more than psychoanalysts, but also guide their patient towards recognizing their defenses, conflicts and interpersonal patterns, and how their past experiences influence the present. 

The relationship with the therapist in the 'here and now' is frequently used as a valuable source of information and taken as a site where the patient's (and therapist's) patterns play out live. Witnessing yourself repeating the same patterns in therapy that brought you to therapy, or noticing how you start to see your therapist in the same way that you tend to see other important people, is a compelling way to discover your contribution to things.  Psycho-dynamic psychotherapy is particularly useful with interpersonal difficulties and in working on how you relate to yourself and your emotions. A successful, long-term psychodynamic therapy should produce internal changes that continue to develop long after the therapy ends. This approach is a good first port of call for a broad range of difficulties especially if you are open to a longer-term process. Narrative Therapy 

The narrative method of therapy works with the way a person tells the story of their lives. People are thought to hold a narrative of their lives that foregrounds certain details at the expense of others, i.e. it's one version of a life story that potentially keeps you stuck by leaving out details that might change things significantly. A narrative therapist might help their patient to find alternative ways to see their lives that are less saturated with difficulties and impossibilities, and more open to potential and success.  Narrative therapists view problems as separate from people. As such, they work with clients to help them separate themselves from their problems and to develop tools and resources to address the problems that they are experiencing.  A narrative therapist considers the client to be the ultimate expert on their life and views the role of therapist to be more of a curious, investigative reporter assisting the client to make discoveries through different types of interviewing questions. Humanistic Existentialism A wide range of therapies is underpinned by a humanistic or existential orientation. These approaches foreground human experience rather than dynamics, symptoms or diagnostic categories. The difficulties people present are taken as an expression of their inability to live in an authentic, meaningful and self-guided way. Therapy guides the person towards growth by promoting self-understanding, self-awareness, and acceptance of personal responsibility and free will. Although humanistic and existential approaches are often grouped, they emphasise different things. 

Humanistic approaches view people as inherently good and innately capable of directing their lives and relationships in ways that are healthy and meaningful to self and other. People fail to do this only because they hold conscious assumptions that inhibit them from acting as their true self. Therapy overcomes these blocks to living in an actualised way by promoting growth rather than cure.  Existentialism also holds that the individual is a conscious, free, self-directed actor, but it emphasises the need to find philosophical meaning in our lives. From this perspective, the problems we face stem from the challenge to live a meaningful life given the context of essential loneliness, isolation, despair and the inevitability of death. Living authentically and creatively offers a means to overcome this and accept that we are each responsible for finding meaning in our lives, no matter what circumstances we face.

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