Finding a Therapist: Theoretical Orientation

TL;DR: All psychotherapists do their work based on one or more theories about humans and how to help them. You don’t need to know the theories, but, at the very least, know they exist. Most importantly, be wary of therapists who aren’t able to talk about what informs their work!

To begin this series on finding a therapist, I thought I’d talk about theoretical orientation. That’s quite a mouthful, yes? In a nutshell, a psychotherapist’s theoretical orientation is the underlying theory that informs how a therapist thinks about how humans operate and, based on that information, how the therapist can go about helping people. An even simpler way to describe this might be to say that we’re talking about the psychotherapist’s “approach.” (In reality, this is simplifying things quite a lot, but it’s probably good enough for the topic at hand.)

To the uninformed eye (or even an informed one), this may not look like it makes much of a difference. Let’s say you’re a fly on the wall, watching a therapy session with a therapist who says they work “psychodynamically.” If you fly into another therapy room to check out a session with a therapist who says they they are “humanistic,” they might look pretty similar. (Not sure how all these voyeuristic flies are getting in the therapy rooms, but you get the idea.) For sure, there are times when psychotherapeutic “interventions” (the way the therapist interacts with/responds to the patient) appear very similar. In this case, both sessions might look to your tiny fly-eyes like two people having a meaningful dialogue of some kind.

Now, I don’t want to get too lost in the trees with definitions of the theories themselves. There are actually a lot of resources online to learn about those. (A decent, reliable starting point might be here.) The point is that a psychotherapist’s choice of intervention will be informed by their theoretical orientation. Think of it as the why behind what they do. And, even if both of these two hypothetical therapists say some of the same things in session (what they say), the reasons for doing so (the why part) might be a bit different.

Much of the time, you may not notice or care about your psychotherapist’s underlying theories. For decades, there have been many studies and arguments about which ingredients make therapy “work” and which ways of doing therapy are better than others. Ultimately, we’ve come to find that the therapeutic relationship is what matters most, though it is not the only thing that matters. (If you’re interested in reading about therapeutic relationships, this online article is a good, straightforward read.) Nevertheless, the psychotherapist’s assumptions about what makes people tick, how problems can arise, and how to address them will inevitably influence therapy. If you’re seeing a therapist who works very strictly using certain methods (e.g., “pure” DBT, strictly manualized CBT, or some psychoanalysts), the effects will be more noticeable. I find this to be more rare among my own colleagues, finding that many psychotherapists are a little more “go with the flow” in conversation, making the differences between them more subtle. They will be there, though.

Now that I’ve said all this (and haven’t bothered to provide you with any actual details about the different theories out there), what is the actual point? Do I think you should go out and do a bunch of research on the main theoretical orientations? Not at all. It’s the psychotherapist’s job to really understand them. But I do think it’s helpful to have some notion in a broad brushstrokes kind of way when someone tells you how they work. At the very least, it’s good to know that there are differences. That knowledge can help you ask informed questions.

At this point, I’d like you to move in a little closer. I’ve got something really, really important to say about all this. Just scooch in a bit. Comfy? Excellent. Here it is: be wary of psychotherapists who can’t tell you what their theoretical orientation even is. To be fair, maybe some people will need the question to be asked differently. You could try things like, “Could you tell me how you work? What your underlying assumptions are?” You could ask things about what motivates people or how they believe people get better through therapy. But I personally get very worried about psychotherapists who can’t identify what informs their interventions or (even more worrying) don’t know and/or believe that they have any kind of theory beneath it all. Everyone has this. Everyone. Not knowing what it is or believing one does not work from one or more theories is just winging it, and that has the potential to be dangerous.

Last thing I’ll say about this is that there’s a difference between not knowing one’s theoretical orientation and working from several. Being an “integrative psychotherapist” is a thing! That means the therapist knowingly and (mostly) deliberately chooses interventions from a variety of theories and/or methods. And that can be very creative and skillful on the part of the therapist. In all honesty, intuition and creativity are helpful assets in a psychotherapist. People who have a lot of experience can sometimes “just do the work” without saying to themselves, “Now I’m going to use an intervention from an existentialist perspective.” But the difference between using intuition and just winging it is that the intuitive and experienced therapist can probably point out what they were up to after the fact. Just saying, “I don’t know. I just do therapy” is not a very professional approach. Incidentally, we used to use the word “eclectic,” but that fell out of vogue. It is now considered a negative thing, because it is assumed to mean “winging it.” If someone freely admits to this, however, give them the benefit of the doubt and ask them some questions to see whether they really are flying by the seat of their pants or if they might actually be conscientiously integrating more than one way of doing things.

So, that’s all I have to say about that. I hope you found this helpful. I, myself, am a psychoanalytically-oriented psychotherapist who integrates interventions and ideas from Acceptance and Commitment Therapy, as well as existential philosophy. If that sounds like a good combination for you as a therapist — or if you have any questions about any of this — feel free to contact me. I am available for telepsychology in forty-three states, and in-person in my home area of Kitsap County, Washington. I hope to hear from you.

Dr. A.