Once you decide to start therapy, a new question appears: which kind? Cognitive behavioural, psychodynamic, systemic, humanistic, and within each of these, many more names. It can feel like you need to become an expert before you can even begin. The good news is that you do not.
In this article I want to give you a simple map of the main approaches, share what research says about choosing, and offer some questions to help you find a therapist who suits you.
A quick map of some main approaches
- Cognitive behavioural therapy (CBT): structured and goal-oriented, works with the links between thoughts, feelings, body and behaviour, often with exercises between sessions. More in Cognitive behavioural therapy.
- Psychodynamic therapy: explores unconscious patterns and how past relationships shape the present, usually less structured. More in Psychodynamic therapy.
- Systemic therapy: looks at problems in the context of relationships, often involving partners or family. More in Systemic therapy.
- Humanistic therapy: emphasises empathy, acceptance and personal growth, with a focus on present experience. More in Humanistic therapy.
Many therapists today combine elements from several approaches.
What research says about choosing
Several approaches work
For many common problems, different established approaches lead to similar results. A Cochrane review found that short-term psychodynamic therapies can help with a range of common mental health problems, although the quality of evidence varied (Abbass et al., 2014). Humanistic approaches such as person-centred therapy are also used for depression and other difficulties.
There are exceptions. For some conditions, specific methods have particularly strong evidence, for example exposure-based CBT for anxiety disorders, phobias and obsessive-compulsive disorder. If you have a specific diagnosis, it is worth asking which approach is recommended for it.
The relationship matters a lot
Across approaches, the quality of the relationship between client and therapist is one of the strongest predictors of good outcomes (Wampold, 2015). Therapists also differ from one another, even when they use the same method. In a study of CBT for panic disorder, therapists differed in their results, and the patient’s own contribution to the alliance played an important role (Huppert et al., 2014). In other words: who you work with matters as much as what method they use.
Your preferences matter
A meta-analysis found that clients who received the type of therapy they preferred were more satisfied, more likely to complete treatment and had somewhat better outcomes (Lindhiem et al., 2014). Your sense of what might suit you is valuable information.
In short
Choose an approach that makes sense to you and is suitable for your difficulties, and then pay close attention to whether you feel understood by the therapist.
Questions to ask yourself
- What do I want? Quick relief from a specific symptom, deeper self-understanding, help with relationships, or a mix?
- How do I like to work? With structure and exercises, or with open conversation?
- Does my problem involve other people? Then couples or family sessions, or a systemic approach, may help.
- What about language and culture? A therapist who understands your languages and background can make a big difference.
- What are my practical limits? Time, money, insurance and location.
Questions to ask a therapist
- How do you work, and why do you think it could help me?
- What does a typical session look like?
- How will we know if therapy is working?
- What is your experience with problems like mine?
- How long might therapy take, and what does it cost?
A good therapist will be happy to answer these questions, and to tell you honestly if another approach or professional might suit you better. More practical advice is in How to choose a therapist.
Signs that it fits
After two or three sessions, ask yourself:
- Do I feel listened to and taken seriously?
- Do I understand what we are working on?
- Can I say when something does not suit me?
- Do I feel a bit more hope or clarity, even if things are still hard?
If the answer is mostly no, it is fine to talk about it with your therapist, or to look for someone else. Changing therapists is common and can be a good decision.
Common worries when choosing
“What if I choose the wrong approach?”
For most everyday difficulties, several approaches can help, and good therapists adapt their work to the person in front of them. Choosing an approach is a starting point. If, after some sessions, it feels like the wrong fit, you can talk about it and adjust, or change.
“I don’t know what my problem is”
That is completely fine. Many people come to therapy with a feeling, more than a clear diagnosis: “Something isn’t right”, “I keep ending up in the same place.” Part of the first sessions is to understand together what is going on.
“I want to understand why, and I also want practical tools”
Many people want both. Integrative therapists combine insight-oriented and practical work, and CBT also includes looking at the history of patterns, just as psychodynamic therapy can include concrete steps.
“Does the therapist need to share my background?”
It is not necessary, and for some people it helps a lot, especially around migration, sexuality, religion or culture. What matters most is that the therapist is curious, respectful and willing to learn about your world.
If you still feel unsure
It is completely normal to read about five approaches and still not know which one is yours. Most people do not choose a method in the abstract. They choose a person, have a first conversation and notice how they feel afterwards. You can treat the first sessions as a trial: you are allowed to ask questions, to say what you need and to stop if it does not fit. Changing therapists is common and says nothing bad about you. If you are torn between two directions, you can tell a therapist exactly that. A good one will help you think it through, and will tell you honestly when another approach or another colleague might suit you better.
Cost and access
How you can access each approach depends on where you live. In some health systems, public insurance covers certain methods, most often cognitive behavioural therapy and psychodynamic therapy, while other approaches are mainly paid privately. It is worth checking what your health system or insurance covers, how long the waiting times are, and whether a therapist offers sessions online or in your language. If you live in Germany, the Therapy in Berlin section explains how this works there, for example in Does insurance pay for psychotherapy?
More about therapy with me.
References
- Abbass, A. A., Kisely, S. R., Town, J. M., Leichsenring, F., Driessen, E., De Maat, S., Gerber, A., Dekker, J., Rabung, S., Rusalovska, S., & Crowe, E. (2014). Short-term psychodynamic psychotherapies for common mental disorders. The Cochrane Database of Systematic Reviews, CD004687. https://doi.org/10.1002/14651858.cd004687.pub4
- Huppert, J. D., Kivity, Y., Barlow, D. H., Gorman, J. M., Shear, M. K., & Woods, S. W. (2014). Therapist effects and the outcome-alliance correlation in cognitive behavioral therapy for panic disorder with agoraphobia. Behaviour Research and Therapy, 52, 26–34. https://doi.org/10.1016/j.brat.2013.11.001
- Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: A meta-analysis. Clinical Psychology Review, 34(6), 506–517. https://doi.org/10.1016/j.cpr.2014.06.002
- Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270–277. https://doi.org/10.1002/wps.20238
This article is exploratory and meant for information and reflection. It cannot capture the full complexity of any individual situation, and your own experience may be different. It does not replace a diagnosis or treatment.
