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One-on-One Therapy: Psychodynamic, Cognitive, and Behavioral Methods
Abnormal Psychology · Chapter 24: Therapeutic Approaches in Mental Health PracticeSection 24.1 · lesson 90 of 9716 min · free with a free account
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In this lesson
The individual modalities - compared and integrated, not re-taught.
- Describe the major individual modalities, and what each takes as its target
- Compare their evidence, stating the common-factors and specific-ingredients positions fairly
- Explain how treatment is selected, and what predicts outcome
- Describe what a clinician does when therapy isn't working
Transcript
Everything said in the video, section by section (2,109 words). Read along, or search it.
Therapeutic Approaches in Mental Health Practice
One-on-One Therapy
Chapter twenty-four turns to treatment, and this first section covers one-on-one therapy. It describes the major individual modalities, and what each takes as its target. It compares their evidence, and states the common-factors and specific-ingredients positions fairly. And it explains how treatment is selected, what predicts outcome, and what a clinician does when therapy is not working.
Before You Begin
How Therapies Work - Not How to Deliver Them
This material is educational. It describes how therapies work and how they compare. It is not a training manual. It is not a basis for self-treatment, and it is not a basis for treating anyone else. Psychotherapy is delivered by trained, supervised practitioners. Anyone seeking therapy should approach a qualified professional.
What Individual Psychotherapy Is
A Structured Professional Relationship
Psychotherapy is a structured professional relationship, entered into for agreed purposes, in which specified methods are used to address a difficulty the person has brought. Three contrasts sharpen the definition. It is not advice. The aim is not to tell the person what to do. It is not friendship. The relationship is one-directional in its focus, and bounded in time and place. And it is not coaching. It addresses difficulty and distress, rather than performance, and it answers to a clinical evidence base. The four models this chapter draws on were taught in full in chapters four through seven. So this section compares and integrates them, rather than re-teaching them. Every description is at the level of what an approach targets, and what its evidence supports.
The Therapeutic Frame
A Working Part of the Treatment
The therapeutic frame is the set of arrangements within which the work happens. A regular time, a consistent place, and an agreed length. Stated confidentiality, and its limits. And clear boundaries on the relationship. It is easy to mistake all this for administration. It is not. The frame is a working part of the treatment. Because it is reliable, a person can raise material they have not raised anywhere else. Departures from it are clinically informative, not merely inconvenient. That is why psychodynamic practice, as section four point four described, treats them as material. The frame is also the structure within which the ethical obligations of section twenty-four point five operate. A treatment without a frame is not a more relaxed treatment. It is one in which nobody can tell what is happening.
Figure 24.1.1 - From Assessment to Plan
The Step Most Often Skipped
The sequence from section ten point one governs treatment selection. Assessment produces a formulation, and the formulation produces the plan. The step most often skipped is the middle one. A diagnosis alone does not determine an approach. Two people with the same diagnosis may have entirely different maintaining processes. One may be avoiding. One may be appraising catastrophically. One may be caught in a relational pattern that keeps reproducing itself. The treatment that fits follows from that, rather than from the label. A plan built straight from the assessment, along the dashed route, will fit the diagnosis rather than the person. That is the practical meaning of the claim that formulation does work that classification does not.
Table 24.1.2 - The Modalities (1)
They Differ More in Target Than in Use
Here are the individual modalities compared. Read the second column, for what each approach treats as the thing to change. Notice that the approaches differ more in their target than in the conditions they are used for. Psychodynamic approaches target unconscious conflict, and recurring interpersonal patterns. Classically open-ended, contemporary forms are time-limited. Their strongest evidence is for some depressive and personality presentations, in shorter-term forms. The limitation is weaker controlled evidence overall, and less availability. Behavioral approaches target avoidance, and reinforcement contingencies. They are structured and time-limited, with practice between sessions. Exposure-based work for anxiety-related conditions is among the strongest evidence in the field. They suit less well when the difficulty is about meaning, rather than behavior. Cognitive and cognitive-behavioral approaches target appraisal, and the behavior that maintains it. They are structured and agenda-led, with homework. They have the broadest evidence base across presentations. They are weaker where distress reflects an accurate appraisal of real adversity.
Table 24.1.2 - The Modalities (2)
Experience, Growth, and Relationships
Third-wave approaches target a person's relationship with their experience, rather than its content. They are structured, and often skills-based. Their evidence is strongest for emotion-regulation difficulties, and some chronic presentations. They are newer, with a smaller, less mature evidence base. Humanistic and person-centered approaches target the conditions under which a person can move on, on their own terms. They are non-directive, and the relationship itself is the method. The relationship conditions are themselves well supported. But the constructs are harder to operationalize, and there is less outcome evidence. Interpersonal therapy targets current relationships, role transitions, grief, and disputes. It is time-limited and focused, with its strongest evidence in depressive presentations. It is narrower in application. Two more families belong here in outline. Systemic and family-informed individual work brings a relational lens to work with one person, covered in section twenty-four point two. And trauma-focused approaches have good evidence for post-traumatic presentations, from section eleven point four. No procedural content appears in this course.
Integration and Eclecticism
Reviewable - or Not
Most clinicians draw on more than one model, and there are two ways of doing so. Principled integration combines approaches on the basis of a coherent account of what is being targeted, and why. The components fit a single formulation. Unsystematic eclecticism selects techniques on the basis of familiarity or intuition, without any such account. The distinction matters practically, not aesthetically. An integrated treatment can be reviewed when it is not working, because there is a rationale to examine. An eclectic one cannot, because there is nothing to check against.
The Dodo Bird Verdict
Everyone Wins - or Do They?
One of the field's most persistent findings is the dodo bird verdict. The name comes from a story in which all the runners win, and all must have prizes. Bona fide therapies, delivered competently by people who believe in them, produce broadly comparable outcomes for many conditions. At full strength, the claim is that differences between named approaches are far smaller than their proponents assume. Comparisons that seem to favor one approach usually reflect the allegiance of the researchers, rather than the method. The counter-evidence is also strong. For particular conditions, particular approaches outperform others. Exposure-based work in anxiety-related conditions, from section five point four, is the clearest case. A comparison across all conditions can conceal genuine differences within specific ones. And if two approaches both contain the active element, finding them equivalent is not evidence that the element does not matter. This section does not resolve the debate. You should be able to state both positions in their strongest form, and notice which one a given piece of writing has assumed.
Common Factors and Specific Ingredients
Where Outcome Comes From
Common factors are the elements shared by all therapies. The therapeutic alliance, the person's expectancy of benefit, a credible rationale for what is happening, and effects due to the individual therapist. The evidence that these account for a substantial share of outcome is good. Section seven point two set out the humanistic contribution to establishing it. Specific ingredients are the elements particular to an approach. Evidence for effects beyond common factors is strongest where a mechanism is well specified, and the condition well defined. Diagrams that divide outcome into shares are illustrative. They show the shape of a disagreement, not a settled finding. But note the band that is easy to overlook. A substantial share of what happens to people in treatment is due to their circumstances, their relationships, and events outside the room. That is not a deflating observation. It is the reason section twenty-four point four treats housing, income, and social conditions as clinical matters, rather than context.
Table 24.1.4
Predictors of Outcome - Several Within a Service's Control
This table sets out the predictors of outcome. Read the third column, because several of the strongest predictors are things a service controls. A stronger therapeutic alliance predicts better outcome, across approaches. So measure it early, and treat a poor alliance as a clinical problem, rather than a difficult person. Attendance predicts outcome, and dropout is the most common reason treatment fails. So reduce practical barriers, and contact people who miss appointments, rather than discharging them. Readiness at the outset predicts engagement, as section eighteen point four described. So work with ambivalence, rather than requiring it to be resolved first. Outcomes vary substantially between therapists, more than between approaches. So use supervision and outcome feedback, and take that variation seriously, rather than treating it as noise. And housing, income, safety, and relationships constrain what treatment can achieve. Address them directly where possible. They are not outside the clinical remit.
Dose and Delivery
Early Gains, Remote Options, Guided Self-Help
On dose and duration, improvement is greatest early. Gains continue with further sessions, at a diminishing rate. More sessions help, and each one helps a little less than the last. No numbers are given here. The relationship differs by condition, and the figures quoted are often more precise than the evidence supports. Therapy can be delivered face-to-face, remotely, or through guided self-help, where a person works through structured material with clinician support. Remote delivery is broadly comparable to face-to-face for several presentations. But engagement and dropout differ, some people suit it less well, and digital-first provision raises equity questions, taken up in section twenty-four point four. Guided self-help is best understood as a genuine treatment step within stepped care, not a holding position. And the word guided is doing the work. The evidence for supported self-help is considerably better than for unsupported material.
In the Clinic
Matching the Approach - and the Person
Selection has two halves, and clinicians tend to attend to only one. The first half is what the evidence supports for this presentation. The second is what fits this person. What they have tried before, and how it went. What they think would help, what they can commit to, and what they will actually do between sessions. Imagine offering a structured cognitive-behavioral course to someone who has already completed two, and found them mechanical. That choice is defensible on the first half, and a poor one on the second. Preference is not a courtesy here. It predicts engagement, and engagement predicts outcome.
Non-Response and Deterioration
Therapy Doesn't Just Help or Do Nothing
Some people do not improve in therapy, and a smaller number deteriorate during treatment. Both facts are reliably established. And both are under-attended in training, where the unspoken assumption is that therapy either helps, or does nothing. The principal response is routine outcome monitoring. That means measuring outcome session by session, and feeding the results back to the clinician. Its evidence is strongest exactly where it is most needed. For people who are not improving, whom clinicians are otherwise poor at identifying. Section ten point four supplies the measurement standards, and section twenty-four point four the service-level argument.
When Therapy Isn't Working
3 Explanations, 3 Different Actions
When therapy is not working, there are three candidate explanations, and they call for different actions. The model may be wrong for this difficulty. Then the formulation needs revisiting. The fit may be wrong. The approach, the therapist, or the timing. Then something about the arrangement needs to change. Or the delivery may be at fault, through drift from the approach, missed sessions, or an alliance problem nobody has addressed. Concluding that the person is unmotivated is not a fourth explanation. It is the failure to consider the first three.
In the Clinic
A Review Planned From the Start
The most common error is continuing unchanged, and hoping. The second most common is discharging the person, and calling it non-engagement. What helps is a review that is planned from the start, rather than improvised at the point of frustration. That means an agreed point at which progress is examined against the formulation, with the three candidate explanations considered explicitly. And it means asking the person directly what they think is happening. People are frequently right about this. Asking is both a good source of information, and an intervention in the alliance.
Contraindications and Sequencing
A Statement About Order
Psychological therapy is not always the first thing to do. Where there is acute risk, immediate safety and clinical management come first, as section twelve point four described. In acute psychosis, from section nineteen point five, stabilization comes before psychological work aimed at appraisal. In severe undernutrition, from section sixteen point one, nutritional restoration is the precondition for psychological work, not an alternative to it. None of these says that therapy does not help. Each one is a statement about order.
Summary
Formulation, Fit, and Monitoring
To summarize. Individual psychotherapy is a structured professional relationship, with agreed goals, conducted within a frame that is part of the treatment. Selection runs from assessment, through formulation, to plan. The formulation, not the diagnosis, determines the approach. The modalities differ chiefly in target. Most clinicians integrate, and principled integration differs from eclecticism in being reviewable. The dodo bird verdict and the specific-ingredients position are both strong, and the debate is unresolved. Common factors account for a substantial share of outcome, and so do circumstances outside therapy. Alliance, engagement, readiness, therapist effects, and outside circumstances predict outcome, and several are within a service's control. And some people do not improve, while some deteriorate. The response is routine monitoring, and three candidate explanations, none of which is about the person.
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