Demystifying Therapy: What's a Theoretical Orientation?

Finding a therapist who is a good match for you can sometimes feel like a very mysterious process. Of course, as in any relationship, some sort of undefinable chemistry is part of what helps you know that you feel good speaking to this person as opposed to someone else. But then there are other factors such as clinical style and theoretical orientation which both influence how the therapist is going to work with you.

Most seeking therapy wind up with someone who was recommended to them by a friend, doctor, or other practitioner. Few patients actually call up a prospective therapist and ask what clinical theory she uses.

One of my passions as a clinician is helping to demystify the therapy process and assisting consumers to become more informed about therapy–both the process and the choices they have. If you have heard the term “theoretical orientation,” but never knew what it meant, this blog entry should help to clear up some of the confusion.

Okay Then, So What is a Theoretical Orientation?

As part of the training to become a therapist, we are introduced to different theories that offer different understandings about how a person’s problems develop and how those problems can be solved. These concepts about the development of problems and how they are best resolved are called a therapist’s theoretical orientation. It is the basic guiding principle in organizing a treatment and wil provide information on how a therapist is likely to interact with you.

It is always appropriate to ask a therapist questions about her or his training, experience, and the theoretical orientation(s) she uses in her work. Consider your own preferences and style and think about whether your therapist’s approach will fit for your goals and vision of therapy.

Here are some of the more common theoretical orientations which you are likely to encounter, along with descriptions of how they may influence the therapy.

Cognitive-behavioral therapy

Cognitive-behavioral therapy (or CBT) posits that behaviors and beliefs are responsible for the development of a client’s presenting problem. A CBT therapist will usually help their client to identify, challenge, and adjust maladaptive beliefs and behaviors. They will work with a client to identify negative or less-useful automatic thoughts, sometimes using charting tools like Thought Records. This kind of therapy can be more structured and directive and can include homework assignments such as tracking moods, recording thoughts, feelings, and behaviors, and even exposing oneself to situations that cause anxiety both in and out of sessions. The therapist will also teach the client breathing and relaxation techniques that can be practiced in-session, and used out of session. You can find out more about CBT from the National Association of Cognitive Behavioral Therapists.

Dialectical Behavioral Therapy

Dialectical Behavioral Therapy (or DBT) was originally pioneered by Marsha Linehan as a treatment for Borderline Personality Disorder, but it has also proven effective for a range of other problems. It is not a theoretical orientation, but a treatment approach that you may hear about. It utlizes focused CBT techniques to increase a client’s mindfulness, interpersonal effectiveness, emotional regulartion, and distress tolerance.

EMDR

Eye Movement Desensitizing and Reprocessing (or EMDR) is another treatment protocol that isn’t really a theoretical orientation. It utlizes bilateral stimulation, usually through eye movements, tapping, or audio stimuli, that is most frequently used to treat trauma, but which can also be used to treat anxiety or other troubling and intrusive thoughts. The therapist will apply the bilateral stimulation while having a client re-imagine painful or troubling events in her life. The therapist will walk the client through a standard set of questions during the therapy. Research has indicated that EMDR helps to integrate these  painful memories, allowing clients to experience shifts in meaning and feel relief or “clearing,” of the painful memories.

Family therapy

Family therapy, sometimes called family systems therapy, works with couples, families, and/or children and looks at problems in the context of a family system, viewing the entire family as the therapy client. Usually the family comes in together, although different subsets of the family may come in seperately or together, over time, in order to improve the overall functioning ofthe family unit. There are many different models of family therapy that utilize different approaches. The goal of treatment is to decrease distress in the overall family system and improve relationships. Therapists who practice family therapy are likely to examine different patterns of interaction and invite family members to try new behaviors in order to alter the system.

Feminist therapy

Feminist therapists are less focused on particular therapeutic techniques and are more focused upon connection between sex, gender, sexuality, race, ethnicity, religion, age and other categories which may influence a person’s experience in the world. Therapists who practice feminist therapy will try to create an egalitarian relationship between themselves and their client.

Gestalt therapy

Gestalt therapy, developed by Fritz Perls, is an experiential, existential therapy focusing on the present moment and what is perceived and felt. The therapy helps put clients in touch with their feelings and behaviors and how they affect how a client behaves. There is more focus on process and less focus on content.

Humanistic approaches

Humanistic therapy tends towards optimism. The theory is predicated on the belief that people have a natural inclination to strive toward self-fulfillment. the goal is to help patients self-actualize through self-examination, self-mastery, and creative expression. Freedom of choice or “self determination,” is a core value of the treatment. Humanistic therapists use open-ended responses, reflective listening and tentative interpretations to help their clients develop self-understanding, acceptance and actualization.

Integrative therapy

Some therapists will describe their practice as integrative, meaning that they use a number of different theories and interventions with the clients they see. If a therapist says she is integrative, ask her which specific theories she integrates into her practice. You may even want to ask her how and when she makes the choice to utilize different techniques.

Narrative therapy

Narrative therapy was developed by Michael White and David Epston and it examines the “storying,” of people’s lives. A Narrative therapist understands a person’s problems as the consequence of their getting stuck in “a problem-saturated story,” and only attending to the details that confirm this story. Narrative therapists help their clients to deconstruct problem-saturated narratives, re-author their experiences, and develop new (preferred) alternate stories.

Narrative therapists also view problems as separate from people with their own agendas and strategies, and work with clients to help them to also separate themselves from problems, developing tools and resources to fight the problem.  A narrative therapist considers the client to be the ultimate expert of her life and views the role of therapist to be more of a curious, investigative reporter assisting the client to make new discovers through different types of interviewing questions.

Psychodynamic

Psychodynamic or insight-oriented therapy looks at how the unconscious influences a person’s thinking and behavior. The goal is to bring self-awareness and understanding to a person, helping them understand how unresolved conflicts from the past may be influencing them in the present, replicating unwanted patterns in current relationships. Often these patterns may even be replicated and explored in the actual therapy relationship. Psychodynamic therapy grew out of Psychoanalytic theory and can be either brief or longer-term.

Psychoanalytic

Psychoanalytic therapy (or psychoanalysis) focuses is usually a long-term, intensive therapy focusing on the client’s unconscious, unresolved conflicts from childhood, seeking to help the client become freed from these unexamined barriers. Psychoanalytic therapy utilizes free association, exploration of dreams, and interpretations of the client’s transference and resistance in order to bring this unconscious material into the client’s conscious awareness. Psychoanalytic practitioners may listen carefully while maintaining a neutral position, only offering insights when it seems that a unique moment is presenting itself. They will clarify and confront a client’s defenses and wishes.

Some Last Words on Theory

Now that you have an overview of some the main theories most practitioners use, it’s good to remember that regardless of theory, all therapists differ. Two therapists utlizing the same exact theory may still think and respond differently to the same client bringing with the same issues. Ultimately, you still need to meet with a therapist face-to-face in order to know for sure if she’s the right therapist for you.

There are also other factors to consider when choosing a therapist, and I will write more about these factors in the future.