Which therapy is best suited to me?

There are many different models of therapy and different ‘flavours’ of each model. As a Clinical Psychologist, I am trained in the two major models, cognitive (CBT) and psychodynamic (in my case, Kleinian object relations).

There are some fundamental aspects of therapy that apply to every session with any patient, particularly the capacity to take an open, non-judgemental stance and work within professional best-practice guidelines. But the choice about which model to use depends on the patient’s needs and capacities and the therapist’s training. This fictitious example might illustrate how CBT and psychodynamic therapy can be used differently.

A client says her problems are that she is worrying a great deal. We talk a little about what that feels like and she gives an example: on the bus on the way home from work, she starts to think about all the jobs she has to do when she gets home. Her mind races, finding one challenge after another, finding a problem for every solution, she starts to feel a little claustrophobic. She notices a knot in her stomach and wonders whether people notice she is stressed. When she gets home, she focuses on completing all chores but, when she finally gets to bed, she struggles to get to sleep as her mind is still racing.

From a CBT standpoint, it could be understood like this:

We think of her experience in four domains: thoughts, emotions, symptoms and behaviours. The patient is evidently vulnerable to frequent, negative thoughts and appraisals about her situation. Those thoughts are negative but automatic, associated with her bus journey home. The emotion triggered appears to be fear (that she won’t complete chores at home), prompting symptoms of mild nausea (a result of the surge in stress hormones adrenaline and cortisol) and the behaviour is disrupted sleep.

I may suggest she keeps a thought diary on her journey, jotting down what is going through her mind. That reveals a repetitive theme “I won’t be able to complete all the tasks at home and the house will be chaos”. We identify ways of challenging those thoughts. Perhaps establishing what “chaos” would actually look like (and perhaps finding “chaos”though not desirable, is not disastrous).

She notices that when she thinks about home she often clutches her bag tightly. That behaviour may be triggered by her anxiety but is also sustaining it by keeping her muscles tense. (Internal dialogue: “You can’t be relaxed, look how tense your shoulders are!”) So, we might add a behavioural component so the next time she notices she is clutching her bag she will consciously relax her grip and allow her shoulders to drop. (Updated internal dialogue: “Maybe you’re not that tense after all, look how relaxed your shoulders are!”)

We might schedule some worry time for part of the journey (immerse yourself in worry for 15 minutes then shift your attention elsewhere with a grounding technique or safe-place imagery). Then reduce 15 minutes to 10. Then 5.  After a few sessions, she has reached her goal of getting off the bus without feeling nauseous. After a few weeks, her sleep has improved. The focus of our work then shifts to sustaining this new pattern, anticipating challenges ahead and managing the, inevitable, occasional relapses.

A psychodynamic approach, from the same start point, might look like this:

The key tools of psychodynamic work are interpretation and transference. Interpretation involves not hearing just what a patient is saying but also asking the question what else could it mean? Is it an unconscious metaphor for a more fundamental motive? Why is this on her mind now? What drives underlie this behaviour?

Transference requires the therapist to be aware of the emotions stirred up in the room between the therapist and the patient. Tuning in to a kind of emotional resonance.

As we explore her experience, we can see the bus carries her between her work life and home life so it is a physical transition between her two biggest roles: colleague and mother. It is also the source of some internal dissonance as she battles to reconcile these apparently contradictory drives to achieve and to nurture. She says she feels she is not doing either very well and feels trapped in others’ expectations, hence the claustrophobia. In the session, I am aware she takes up very little space in the room, perches on the edge of the chair. I ask if there are some people or memories that make her feel small. She remembers an elderly relative once saying that women could have a career or children but not both and part of her still feels she is being greedy by wanting both. So she tries to stifle that sense of greed by being small. It may be anger that is making her clutch her bag so tightly, not fear.

As she develops an understanding of how her lifespan experience has shaped her emotional world, she can begin to let go of her anger toward an elderly relative and not be so troubled by a greedy desire to have it all but cherish the different roles she can move between.

By exploring her experience in a safe, non-judgemental environment she has developed a richer understanding of her lifespan influences and so nurtured a more compassionate view of herself. She feels a little more at ease. Her sleep is improved.