Mental health Updated January 2026

How to choose the right type of therapy

From Freud's couch to FDA-approved psychedelics, therapy has evolved dramatically. We compared seven major approaches—their origins, evidence, and who they're best for—so you can make an informed choice.

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Key finding

There's no universally "best" therapy—but there are best matches

CBT has the largest evidence base (2,000+ trials), but that doesn't mean it's right for everyone. DBT is the gold standard for borderline personality disorder. EMDR rivals CBT for trauma. Ketamine works within 24 hours for treatment-resistant depression. The best therapy depends on your condition, preferences, and access.

Note: This guide is for educational purposes. It doesn't replace professional assessment. If you're in crisis, contact the 988 Suicide & Crisis Lifeline (call or text 988) or go to your nearest emergency room.

At a glance

Therapy Best for Timeline Evidence
Talk therapy Depression, personality patterns Months to years Good
CBT Depression, anxiety, OCD, phobias 6-20 weeks Excellent
DBT BPD, chronic suicidality, self-harm 6+ months Excellent
EMDR PTSD, trauma 8-12 sessions Strong
Somatic Trauma with body symptoms Variable Emerging
Ketamine Treatment-resistant depression 4-12 weeks Good
Psychedelics TRD, PTSD (clinical trials) Variable Emerging

The therapies, compared

Talk therapy (psychodynamic)

Good evidence

Historical origins

Founded by Sigmund Freud in the 1890s. The term "psychoanalysis" was introduced in 1896, and Freud's The Interpretation of Dreams (1900) marked the formal beginning of the field. Emerged during a period of growing interest in how unconscious processes shape behavior.

How it works: Explores unconscious patterns—often rooted in childhood—that influence present behavior. Uses the therapeutic relationship itself as a tool for insight. Key concepts include defense mechanisms, transference, and the id/ego/superego framework.

The evidence: Jonathan Shedler's 2010 meta-analysis in American Psychologist established psychodynamic therapy as evidence-based, with adequate effect sizes for depression and anxiety. Benefits often continue growing after treatment ends—a "sleeper effect" not always seen with other therapies.

Best for

  • • Depression and anxiety
  • • Personality patterns
  • • Relationship issues
  • • Those seeking deep self-understanding

Limitations

  • • Less effective for OCD, PTSD
  • • Long duration and higher cost
  • • Less structured than CBT
  • • Harder to measure progress

Key sources:

• Shedler (2010): "The Efficacy of Psychodynamic Psychotherapy" — American Psychologist

Cognitive behavioral therapy (CBT)

Excellent evidence

Historical origins

Developed by Aaron Beck, MD in the 1960s at the University of Pennsylvania. Beck, a trained psychoanalyst, noticed that depressed patients had streams of automatic negative thoughts. He developed a structured approach to identify and challenge these thought patterns.

How it works: Based on the principle that thoughts, emotions, and behaviors are interconnected. Identifies distorted thinking patterns (catastrophizing, black-and-white thinking, etc.) and replaces them with more balanced thoughts. Present-focused, goal-oriented, and typically includes homework.

The evidence: The most studied therapy, with over 2,000 clinical trials. A 2006 meta-analysis of 16 rigorous meta-analyses found large effect sizes for depression (g=0.71), generalized anxiety, panic disorder, social phobia, and PTSD. CBT is somewhat superior to antidepressants for depression and has better long-term durability.

Best for

  • • Depression and anxiety
  • • OCD, phobias, panic disorder
  • • Sleep issues, PTSD
  • • Those wanting structured, time-limited treatment

Limitations

  • • May not address deep unconscious patterns
  • • Requires active engagement and homework
  • • Can feel mechanical for some
  • • Less effective for personality disorders

Key sources:

• Butler et al. (2006): Meta-analysis of 16 meta-analyses — Clinical Psychology Review

• Beck Institute: Training and research center

Dialectical behavior therapy (DBT)

Excellent for BPD

Historical origins

Created by Dr. Marsha Linehan at the University of Washington in the late 1980s. Developed specifically for chronically suicidal individuals with borderline personality disorder—patients considered "untreatable" at the time. Linehan later publicly disclosed her own BPD diagnosis, helping reduce stigma.

How it works: Combines CBT techniques with acceptance, mindfulness, and dialectics (balancing change with validation). Four skill modules: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance. Full DBT includes individual therapy, skills groups, phone coaching, and therapist consultation teams.

The evidence: Eight published RCTs demonstrate efficacy for BPD. A two-year trial showed DBT patients were half as likely to attempt suicide as those in community treatment. 71% of patients with comorbid PTSD no longer met PTSD criteria after DBT with prolonged exposure protocol.

Best for

  • • Borderline personality disorder
  • • Chronic suicidality, self-harm
  • • Severe emotion dysregulation
  • • Eating disorders, substance use

Limitations

  • • Long commitment (6+ months minimum)
  • • Requires multiple components (often unavailable)
  • • Expensive due to complexity
  • • May be overkill for less severe cases

Key sources:

• Linehan et al. (2015): "DBT for high suicide risk in BPD" — JAMA Psychiatry

• Peter Attia's Episode #219 with Shireen Rizvi on DBT

EMDR (eye movement desensitization and reprocessing)

Strong for trauma

Historical origins

Discovered by Francine Shapiro, PhD in the late 1980s. While walking in a park, Shapiro noticed that moving her eyes back and forth seemed to reduce the disturbance of troubling memories. She systematized this observation into a formal therapy protocol and published her PhD thesis in the Journal of Traumatic Stress in 1989.

How it works: An eight-phase treatment using bilateral stimulation (eye movements, tapping, or sounds) while processing traumatic memories. Based on the Adaptive Information Processing model—the idea that psychopathology stems from inadequately processed traumatic memories that get "stuck."

The evidence: 24 randomized controlled trials support its efficacy for trauma. Recognized as a best practice by the VA, Department of Defense, WHO, and International Society for Traumatic Stress Studies. Systematic reviews show EMDR is equivalent to trauma-focused CBT approaches like prolonged exposure.

The eye movement controversy: Critics note that studies comparing EMDR to fixed-eye-gaze conditions found no difference—suggesting the eye movements may not be the active ingredient. The therapy likely works through exposure and cognitive elements rather than bilateral stimulation specifically.

Best for

  • • PTSD (primary indication)
  • • Single-incident trauma
  • • Complex trauma
  • • Those wanting faster trauma processing

Limitations

  • • Eye movements may not be essential
  • • Limited evidence for anxiety, panic
  • • Less effective within 1 month of trauma
  • • Requires trained specialist

Key sources:

• de Jongh et al. (2024): "State of the Science: EMDR Therapy" — Journal of Traumatic Stress

• EMDR Institute: Training and resources

Somatic therapy (somatic experiencing)

Emerging evidence

Historical origins

Developed by Peter A. Levine, PhD over 40+ years of trauma work. His book Waking the Tiger: Healing Trauma popularized the approach. Emerged from observations of how animals in the wild naturally recover from life-threatening events through instinctive bodily responses.

How it works: A body-oriented approach based on the idea that trauma gets "stored" in the nervous system, not just the mind. Uses attention to internal bodily sensations (interoception), body position (proprioception), and kinesthetic awareness. Aims to release protective freeze/fight/flight responses that remain trapped after trauma.

The evidence: A 2021 scoping review found initial but promising evidence for treating PTSD. However, only 5 studies met scientific rigor standards, and 2 of those lacked adequate control groups. The research is genuinely promising but requires more unbiased RCTs before drawing firm conclusions.

Best for

  • • PTSD and complex trauma
  • • Trauma with physical symptoms
  • • Those who've struggled with talk therapy
  • • Body-aware individuals

Limitations

  • • Limited rigorous evidence
  • • "Body-stored trauma" concept debated
  • • Practitioner training varies widely
  • • Some practitioners use touch (boundary concerns)

Key sources:

• Scoping review (2021): Somatic experiencing effectiveness — PMC

• Somatic Experiencing International

Ketamine therapy

Good evidence

Historical origins

Ketamine was first synthesized in 1962 and FDA-approved for anesthesia. Over the past 15+ years, research has focused on its rapid-acting antidepressant effects. In 2019, the FDA approved esketamine (Spravato) for treatment-resistant depression. In January 2025, the label was expanded to allow esketamine as monotherapy (without a required oral antidepressant).

How it works: Blocks NMDA glutamate receptors, triggering downstream effects on neuroplasticity. Unlike SSRIs, which take weeks to work, ketamine shows antidepressant effects within 24 hours. It's administered via IV infusion (off-label) or nasal spray (FDA-approved esketamine).

The evidence: 70% of treatment-resistant depression patients improved with esketamine plus oral antidepressant vs. 50% without. Over 50% show significant symptom reduction within 24 hours. Repeat doses maintain benefits for 2+ months. Emerging evidence for alcohol use disorder (86% maintained abstinence in one 2025 study).

Best for

  • • Treatment-resistant depression
  • • Acute suicidal ideation (rapid response)
  • • Failed 2+ antidepressant trials
  • • Chronic pain (emerging)

Limitations

  • • Expensive; often not covered by insurance
  • • Dissociative side effects during treatment
  • • Abuse potential (Schedule III)
  • • Limited long-term safety data

Key sources:

• Yale Medicine: How ketamine helps depression

• Vekhova et al. (2025): Ketamine clinical trials review

Psychedelic-assisted therapy (psilocybin, MDMA)

Emerging evidence

Historical origins

Psilocybin has been used in Mesoamerican indigenous ceremonies for centuries. Modern psychiatric research began in the 1950s-60s but halted after prohibition. MDMA was synthesized in 1912 and used therapeutically in the 1970s before becoming Schedule I. Both have seen a research renaissance since the 2010s, with FDA granting "breakthrough therapy" designations.

How it works: Psilocybin activates serotonin 5-HT2A receptors, promoting neuroplasticity and disrupting the default mode network (associated with rumination). MDMA increases empathy, emotional openness, and trust—combined with psychotherapy to process traumatic memories. Both require trained therapist support and preparation/integration sessions.

The evidence: Preliminary 2025 data shows 71% of PTSD patients experience lasting relief with MDMA-assisted therapy; 58% achieve depression remission with psilocybin at 12 months. As of April 2024, 134+ psilocybin trials are registered across 54 potential indications. However, the FDA denied MDMA approval in August 2024 citing data reliability concerns, requesting additional trials.

Legal status (January 2026): Psilocybin remains Schedule I federally. California AB 1103 (effective January 1, 2026) fast-tracks psychedelics research for PTSD/depression. New Mexico has legalized a regulated market. Access is currently limited primarily to clinical trials.

Best for

  • • Treatment-resistant PTSD
  • • Treatment-resistant depression
  • • End-of-life anxiety
  • • Those open to novel approaches

Limitations

  • • Limited access (mostly clinical trials)
  • • Legal restrictions in most states
  • • Likely expensive when commercialized
  • • Not suitable for psychosis history

Key sources:

• FDA (2023): Draft guidance for psychedelic clinical trials

• 2025 Clinical Outcomes Review

How to choose

Key factors to consider when selecting a therapy approach

Start with your primary concern

Depression or anxiety

CBT is the default first choice—widest evidence, most accessible, fastest

PTSD or trauma

EMDR or trauma-focused CBT; somatic if body symptoms are prominent

Borderline personality disorder

DBT is the gold standard—specifically designed for this

Treatment-resistant depression

Ketamine for rapid response; psychedelics if eligible for trials

Chronic suicidality or self-harm

DBT—the only therapy specifically developed for this population

Deep pattern exploration

Psychodynamic therapy if you have time and seek self-understanding

Consider your constraints

  • Time: CBT and EMDR are typically 8-20 sessions. DBT and psychodynamic therapy take months to years.
  • Cost: CBT is most widely covered by insurance. Ketamine and psychedelics are expensive and often not covered. DBT is expensive due to multiple components.
  • Access: CBT therapists are most common. DBT requires specialized training and team structure. Psychedelics are mostly limited to clinical trials.
  • Style preference: Want structure and homework? CBT. Want to explore your past? Psychodynamic. Want body-based work? Somatic or EMDR.

The therapeutic relationship matters most

Research consistently shows that the quality of the therapeutic relationship—feeling understood, safe, and connected with your therapist—is one of the strongest predictors of outcome, regardless of modality. If a therapy isn't working after 6-8 sessions, it may be worth trying a different therapist or approach.

Our take: Don't agonize over picking the "perfect" therapy. Start with what's accessible and evidence-based for your condition. Pay attention to how you feel with your therapist. Be willing to switch if it's not working.

A note on insurance and access

Under the Affordable Care Act, all ACA-compliant plans must cover mental health treatment including psychotherapy. Parity laws require that mental health benefits can't have more restrictive limits than medical/surgical benefits. In practice, you'll typically pay a copay or coinsurance.

What's typically covered: CBT, DBT, psychodynamic therapy, EMDR (all with in-network providers). Telehealth is widely covered.

What's often not covered: Ketamine infusions (IV ketamine is off-label), psychedelic therapy (experimental), and some specialized somatic therapy practitioners. Esketamine (Spravato) nasal spray may be covered for treatment-resistant depression.

Primary sources

Key publications and resources we drew from for this guide

Butler et al. (2006)

CBT meta-analysis of meta-analyses

Shedler (2010)

Psychodynamic therapy efficacy

Linehan et al. (2015)

DBT for high suicide risk in BPD

The Drive #219

Peter Attia on DBT

Additional sources

Change log

  • January 2026: Initial publication