What is Psychotherapy? I Explain Why There Are Only Two Fundamental Types of Therapy | Therapy Guide |

Immediately when you begin to look for therapy, you will find yourself assaulted by acronyms: CBT, DBT, ACT, EMDR, IFS….

Although I will be going through many of these individually in another post, knowing more about them actually gets us no closer to understanding the experience of therapy. To do this, we need a more fundamental distinction. We can broadly say there are only two types of therapy:

Skills-Based Therapies and Developmental Therapies.

This distinction is more important than listing theoretical orientations. Fundamentally, patients don’t need to know how their therapist identifies as much as they need to know which of these two processes they are stepping into. Let’s take a look at these two approaches.  

https://x.com/KemtrupTweets first put forward this distinction in a series of tweets.

Techniques and Skills-Based Therapies

These therapies are highly structured and often manualised. Fundamentally, the relationship between therapist and patient is taken in the spirit of teacher and pupil. There may be some discussion about this; if so, it is more at the practitioner's discretion and has very little to do with the treatment.

Rather, the therapist takes up a position where they attempt to instruct the patient in a set of skills or some kind of technique. The patient practices this and is often given homework to do outside of sessions. This is CBT and the many variations it has spawned.

There is no deep investigation of the patient's inner world, no exploration of the relationship inside the room or in their life, no question as to why or how skills or techniques do not work beyond a rational motivation, no subjective inquiry, and no concern for unconscious or relational dynamics. Instead, there is a set of skills to teach, and they are offered up with an implicit assumption that the patient is a rational actor able to employ these techniques to alter their mind. 

Skills-based approaches are about training not meaning. 

You could think about it a bit like personal training or physiotherapy, whereby you arrive with a problem and the practitioner assesses what's wrong, gives you exercises, and helps you practice them. Another way to consider it is like having a coach guiding you through a self-help manual. The goal is to train behaviour, not to understand or create meaning.

Some techniques involve more than just learning. EMDR, for instance, isn’t self-help but a structured intervention. However, the principle is the same: something is done to the patient, or the patient is taught what to do. The therapist can be understood as a guide or a coach, not necessarily someone with whom the patient forms a deep, lasting relationship from which insight is gathered.

And because these therapies are structured, they are naturally time-limited. There is a plan, a set of steps, and an end goal.

Developmental Therapies

In contrast, a developmental therapy is what people typically imagine when they think of psychotherapy. The process is open-ended, non-directive, and involves the patient speaking what is on their mind. The therapist doesn’t impose a specific edict other than that the patient speak and the therapist listens, thinks, and works to understand the patient. The work isn’t about teaching a skill but about engaging in a relationship that allows for growth and helps foster development. The implicit assumption here is that emotional understanding helps and heals. 

In this kind of therapy, the patient’s psychological difficulties aren’t assumed to have a simple solution; the answer isn’t diagnosed and known at the beginning and then planned around, but rather emerges through the process of therapy itself. The approach isn’t to press for behaviour change but get closer to understanding psychological states. The therapist doesn't do something to the patient, but rather, they help create the conditions for the patient to develop. 

Because of this, developmental therapies are rarely time-limited in the same way. You can't predict how long it will take for someone to deeply understand something, nor how long it will take for real, internal change to occur. This has proved a challenge for researchers to capture as really we are in complexity theory here. Though many good studies do exist in order to demonstrate the effectiveness of developmental therapies, particularly psychodynamic.

Psychodynamic therapy, although individualised and complex to study, has a strong evidence base

Why This Distinction Matters

Most patients don’t have the language to ask whether a therapist practices a developmental or a skills-based approach. But this is the question they need to be asking. The different approaches and modalities are important, but this is the fundamental distinction: skills or developmental. In another post, I will go through various offerings and explain where they fall. 

However, some therapists claim to do both. In a sense, this is true: some skills-based therapists might have some relational reflections with their patients, or a developmental therapist might offer some skills or coping strategies. But really, in practice, therapy is either primarily an open-ended process with occasional techniques thrown in, or a structured and mapped-out intervention. And how your therapist has trained to do this or how they approach this does matter.

What is psychotherapy?

I think it is misleading to call both of these approaches psychotherapy, as they are fundamentally different. I think the general public assumes psychotherapy means the developmental type, the kind we see in films, the kind that shaped the field in the first place. What's often marketed as psychotherapy is something else: structured training, problem-solving, skill-building. This doesn’t mean it’s useless or bad, but just that it shouldn’t be confused with psychotherapy. It’s different.

At the very least, there needs to be better honesty and clarity about what is being offered. If the approach is teaching skills or techniques, better to call it that. If it’s developmental, call it psychotherapy. 

Further Reading

• Do I Need a Diagnosis to Start Therapy?

• Common Myths About Starting Therapy

• What is Psychodynamic Psychotherapy?

  
  

About the Author

I'm a psychodynamic psychotherapist working in the Tavistock Trauma Service, and a private practice in Hackney, East London, and online. I am a member of the British Psychoanalytic Council (BPC) and abide by their codes of ethics. I hold a Master’s degree with distinction and am a Clinical Fellow of the Neuropsychoanalysis Association, as well as a registered member of the British Association for Counselling and Psychotherapy (BACP)