Because there is so much confusion about the multitude of modalities and differences among clinicians providing psychotherapy, the following will briefly describe some common approaches, rooted in psychoanalytic origins, with a focus on the unique contributions of the systemic perspective of marriage and family therapy training. This will also describe some distinctive features of the multiple licenses associated with mental healthcare including those earned by physicians and psychologists, and the master’s level curriculum leading to licensure in professional counseling, addiction counseling, social work, and marriage and family therapy. It will conclude with overarching questions relevant to clinicians of described educational and training backgrounds, evoking further thoughts for a multi-disciplinary approach.
Clinical approaches to psychotherapy: Distinctive features, common ground
While the sheer number of approaches to psychotherapy can be confusing, choosing among an array of specialty-trained clinicians presents another challenge. Physicians and psychologists earn doctorates. Generally speaking, family therapists, social workers, and counselors earn master’s degrees (though it is estimated that 20% of MFTs hold doctorate degrees). Each degree emphasizes differing bodies of knowledge, approaches, and areas of expertise. Physicians understand mental health through a predominantly medical lens with goals of elucidating a diagnosis for treatment with a robust biological focus. In the biopsychosocial formulation that all practitioners consider, physician training is also immersed in the realm of histology, anatomy, physiology, pathophysiology, and medicine, including primary and critical care. Training leads to an understanding of psychiatric diagnoses integrated with neurological and other medical illnesses, a unique focus on biological etiologies, and the implications of the full range of treatment choices. The latter includes monitoring and treating for medication side effects, idiosyncratic responses, possible allergic reactions, interactions with other medications and medical illnesses, and unwanted effects accompanying some classes of psychotropics. Training includes in-depth exposure to inpatient and outpatient practice through clerkships with subspecialty tracks available.
Medical approach
The medical approach to mental health, initiated in the neurologist Freud’s concepts of psychoanalysis, has been largely subsumed by medication management beginning with the serendipitous discovery of the efficacy of chlorpromazine for the treatment of psychosis. In the 1970s and ‘80s, enthusiasm for psychotropics essentially sidelined psychoanalysis as a primary and, in some minds, relevant treatment approach. While still offering training in psychotherapy, emphasis remains on medication as a primary treatment by many psychiatrists (Nemeroff, 2020). Some mental illnesses require medication for effective treatment—mood stabilizers for a range of bipolar disorders, and the medical treatment of psychosis, for example. Medication can help with depression and anxiety, alone or in conjunction with psychotherapy, and ADHD is ideally approached with both medication and psychotherapy.
After training, approximately 10% of psychiatrists go on to offer psychotherapy in addition to treatment with medication. Among these clinicians, there is also a subset that considers the meaning that medication holds for individuals from a perspective firmly rooted in psychoanalytic thinking (Mintz, 2020). This offers a powerful combination for mental health treatment. In some practices, psychiatrists collaborate with or refer out to psychotherapists, where collaboration offers the advantage of consistency in case conceptualization, thereby more effectively protecting client trust across multiple clinicians.
Psychologists
Psychologists have the option of applying formal evaluation and testing via sophisticated and statistically validated assessment tools due to extensive training in a doctoral program. These include assessments for cognitive ability, projective tests exploring motives, needs, and assumptions, personality, and diagnostic tools to assist in sorting out complex presentations including ADHD, anxiety, depression, and others. Psychology focuses on diverse inputs described in developmental, relational, cognitive, emotional, and behavioral domains. In addition to the medical diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders (DSM), psychologists also reference the Psychodynamic Diagnostic Manual (PDM) and the International Classification of Disease (ICD) which offer developmental, psychodynamic, and medical and mental health perspectives. Psychotherapy treatment uses the full spectrum of available frameworks in which to specialize including an eclectic approach which blends useful aspects of different theoretical approaches according to unique client need. Collaboration with psychiatry integrates medication management in this treatment frame.
Master’s level clinicians. Master’s-level clinicians include several areas of focus: general counseling, addiction counseling, social work, and marriage and family therapy (MFT). While there are common factors in each degree, they do differ in important ways. Social work focuses on community resources, social justice, and advocacy. Training offers a robust approach to systemic injustices woven into American society including the school to prison pipeline (American Bar Association, 2023; DuVernay, 2016), variables of poverty, access to healthcare, education, and other essential services.
Addiction counseling focuses on disordered substance use and process addictions with attention to underlying physiology and effective approaches including motivational interviewing (MI) and cognitive behavioral therapy (CBT), for example. It also focuses on family systems as they apply to addictions, and particularly how this perspective contributes to illness and recovery (Reiter, 2019).
Marriage and family therapists also learn common theoretical approaches but in a context of the underlying systems into which families organize. This informs conceptualization of presenting problems and can be uniquely leveraged for healthy change. On an opposing end of the spectrum compared to the medical lens seeking to elucidate a treatable diagnosis, MFTs focus on contributions to relational distress where the relationship is the focus of the work and conceptualized as the client. This is a critical perspective in work with families that struggle with illnesses like addictions, including eating disorders, which often require a cooperative, intensive, multi-disciplinary approach for successful treatment. This is the systemic perspective where the patient cannot be optimally treated without incorporating an understanding of family dynamics and how systems work (Bitter, 2021). This also encapsulates the power and utility of collaborative practice.
Identifying what is being protected and how, or the rules guiding the system, facilitates a strategy towards durable transformation.
The overarching impact of a systemic perspective. Systemic impact is best summarized by the concept of circular causality, and MFTs are uniquely trained to leverage this towards effective and healthy change. Specifically, mechanisms of homeostasis or resistance to change are built into the family system, and by definition, these resist the change stated in the goals of therapy. An intimate understanding of these concepts and how they unfold in relationships can help mitigate the frustration of working towards change that is protected against via mechanisms not specifically addressed by other theoretical approaches. Identifying what is being protected and how, or the rules guiding the system, facilitates a strategy towards durable transformation. It is not uncommon to hear the observation that couples in therapy “tried that for a while, but it didn’t really work,” and this often reflects a failure to address systemic factors obstructing change as well as the underlying meaning and purpose of behaviors in interaction (Johnson, 2020; Seigel, 2023).
Systemic concepts distinguish between a fundamental change in the rules of the system versus how those rules are navigated, called second-order and first-order change, respectively. For example, a first-order change might reluctantly accommodate some of a child’s interests, even if they do not align with what parents conceptualize for their child’s future. In this view, it might be expected that the child will come around eventually to conform to parental wishes, which are still considered a priority. By comparison, parents can fully reprioritize by shifting importance to the child’s strengths and increasingly articulated desires for future goals. The first-order change in this example allows for some latitude while asserting parental control. Second-order change shifts to an entirely different approach by supporting the child’s input as they grow and mature. The rules have fundamentally changed from parents as decision-makers to parents as guides.
Underlying rules are both intergenerational and cultural, and they are frequently outside of overt awareness. Consider two parents growing up in very different systems and the conflict this might generate due to unarticulated expectations. For example, in one household of origin, children are indulged completely until pre-adolescence, after which the stance changes to expectations of a more mature individual. In another household, strict formal rules apply from birth. Imagine the conflict when these differing assumptions around child rearing collide, particularly with poorly-defined parameters of disagreement. Also, consider children growing up in an environment that radically differs from their parents’ experiences, and which can introduce conflict in expectations from both sides. This can lead to feelings of betrayal and torn loyalties, and it necessitates finding ways to blend differing values. Identifying and exploring underlying rules can clarify contributions to conflict, which then reveals new pathways for change.
The stability of a system is supported by both positive and negative feedback loops which uphold the governing rules, and which can be interrupted if recognized. Interdependence, mutual influence, family life cycles, recursive relationships, attachment theory, social learning, and cultural impacts are additional concepts routinely integrated into a systems approach. Organization into sub-systems with boundaries—permeable, rigid, or adaptive—further expands the lens. Compare the role of parent and child in a family with appropriate hierarchy and boundaries versus a system in which roles are reversed. The concept of a parentified child is contextualized by an understanding of healthy subsystems and how to engage this towards problem-solving. Additionally, as mentioned above, patterns of relating are carried through generations, sometimes leading to conflict as each new generation develops their own family system. Once overt and covert inherited rules are identified and understood, these can be explored for change in the contemporary situation, often contributing to relief from chronic conflict.
The concept and use of an identified patient frequently leveraged to utilize insurance benefits which does not otherwise support family therapy in the United States system of reimbursement, can sometimes inadvertently serve to maintain the status quo. For example, frustrated parents can mistakenly understand their family’s problems to revolve solely around the behavior of a troubled child. Recognition that the behavior of children sometimes reflects conflict within the family system can facilitate more effective work. For example, this can uncover triangulation or the pulling for a third party to join into a two-person conflict. If this originates in conflict between the parents, the child may be reacting to that conflict or may even be pulled in by one or more family members for relief from anxiety with tension effectively transferred to the child. Revealing this to the parents in a way that they can hear empowers them to engage in healthy change rather than remaining stuck in a repetitive cycle. If everyone in the family believes the child is the sole problem, rather than part of a complex relational interplay, the underlying conflict is less likely to be effectively changed.
Conclusion
In the context of the distinctive formal training backgrounds and modalities engaged by psychotherapists, uniformly relevant questions arise in discussing the efficacy, utility, and perceived acceptability of psychotherapy. Multiple studies support the efficacy of common modalities rooted in psychoanalysis and its sibling psychodynamic psychotherapy, including CBT, MI, trauma modalities, the systemic perspective, and iterations of the above repackaged for specialized trainings. Why and how does therapy work? What are the goals of therapy, and does this depend on modality—to relieve symptoms, solve problems, change personality? Why does it feel so vulnerable to reach out for these services even in a context of significant and long-term unrelieved struggle? It is not unusual for people to present in times of acute crisis and after dissolution of relationships, job loss, inability to stop drinking, or tolerating unacceptable circumstances, instead of seeking help earlier. These are questions considered by therapists of all educational and training backgrounds and perhaps suggest a common ground from which to meet and further the efficacy and approachability of our field.
Maire Daugharty, MD, LMFT, LPC, LAC, is an anesthesiologist and psychotherapist with expertise in couple therapy, phase of family life transitions, and professional work-life balance. She is the owner and clinician at Physician Vitality Services, a speaker with expertise on professional well-being, and a Professional member of AAMFT serving as a member-at-large on the Board of the Rocky Mountain Regional Interest Network.
American Bar Association. (2023). https://www.americanbar.org/groups/diversity/racial_ethnic_justice/projects/school_to_prison/statistics/
Bitter, J. R. (2021). Theory and practice of couples and family counseling, third edition.
DuVernay, A. (Director). (2016). 13th [Film]. Netflix.
Johnson, S. M. (2020). The practice of emotionally focused couple therapy, third edition. Routledge: New York.
Mintz, D. (2022). Psychodynamic psychopharmacology. American Psychiatric Association.
Nemeroff, C. B. (2020). The state of our understanding of the pathophysiology and optimal treatment of depression: Glass half full or half empty? American Journal of Psychiatry, 177(8), 647-734.
Reiter, M. D. (2019). Substance abuse and the family, second edition. Routledge: New York.
Seigel, J. P. (2023). Object relations couple therapy. Lebow, J. L. & Snyder, D. K. (Eds.) Clinical handbook of couple therapy, sixth edition. (pp. 151-174). The Guilford Press.
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