CBT, psychodynamic, psychoanalytic, systemic: the four approaches compared

Anyone looking for psychotherapy in Germany quickly comes across terms like behavioural, psychodynamic, psychoanalytic or systemic. What is behind them, how well does each work, and what lasts longer? A clear overview that sticks to the research. And at the end, the question of why we chose the route through inner conflicts for MindMotion.

The four recognised approaches

German statutory health insurers pay for so-called guideline procedures. For a long time there were three: cognitive behavioural therapy (CBT), psychodynamic (depth-psychology-based) therapy and psychoanalytic therapy. The last two belong to the psychoanalytically grounded approaches. In November 2019, the Federal Joint Committee added systemic therapy for adults as the fourth approach¹; it has been covered since 1 July 2020². The approaches also differ in scope: long-term therapy for adults can last up to 48 hours (systemic), 80 hours (CBT), 100 hours (psychodynamic) or 300 hours (psychoanalytic)³.

How the approaches work

CBT starts with learning. A well-known example is exposure: someone afraid of being among people starts with a small group, then a larger one, step by step. Add to that testing distressing thoughts and tasks between sessions. The German-American psychologist Stefan Hofmann and his team reviewed more than 100 meta-analyses of CBT. The strongest support is for anxiety disorders, somatoform problems, bulimia, anger and stress⁴.

Psychodynamic therapy asks which inner conflict lies behind a situation that keeps repeating, for example between the wish for closeness and the fear of becoming dependent. Once you understand what drives you, you can choose anew. A meta-analysis by a Heidelberg group found a medium association between insight and outcome (r = .31), though the data do not prove cause and effect¹⁹.

Psychoanalytic therapy follows the same route, only broader and longer. It centres on the personality as a whole and recurring relationship patterns, which also show up in the relationship with the therapist.

Systemic therapy sees problems as part of a web of relationships. It can take place individually, in groups or with relatives¹. A meta-analysis led by the Marburg psychologist Martin Pinquart, with 37 trials, found better outcomes than no treatment, about as good as other established approaches, and fewer drop-outs¹⁶. In 2008, Germany’s Scientific Advisory Board on Psychotherapy considered its efficacy established mainly for mood disorders, eating disorders, schizophrenia and addiction¹⁷.

Above all approaches stands one key finding: the American psychotherapy researcher Bruce Wampold shows that common factors such as the working alliance, empathy and a coherent explanation of the problem contribute a lot to success, often more than the differences between methods¹⁸. More on this in What makes change work.

What effectiveness research says

The short answer: all four approaches work, and on average they are close. The Giessen research group led by Falk Leichsenring analysed 23 comparative trials with 2,751 people. Psychodynamic therapy was as effective as other established treatments, at the end of treatment and at follow-up⁸. For short-term psychodynamic therapy, a Cochrane review of 33 trials found clear effects on general symptoms, anxiety and depression; in the long term, results became less certain because few studies looked that far⁷.

CBT has the largest number of studies. The psychologist Steven Hollon and his team at Vanderbilt University describe its effects on depression and anxiety as lasting beyond the end of treatment⁵. In one meta-analysis, 39% relapsed after cognitive therapy compared with 61% after medication⁶. At the same time, 54% had another depressive episode within two years even after successful cognitive therapy⁶. Relapse is an issue with every method.

What lasts longer? The honest answer

This is where it gets interesting, and where we want to be especially precise. There are signs that changes arising from work on inner conflicts can keep growing after therapy ends:

• In 2010, the American psychologist Jonathan Shedler summarised the research. In one large meta-analysis, the effect of psychodynamic therapy was 0.97 and rose to 1.51 nine months or more after therapy ended⁹. Shedler reads this as therapy setting processes in motion that continue⁹.
• In the London Tavistock study led by Peter Fonagy, the difference at the end of treatment was not significant. Three and a half years after the start, it was clear¹³.
• In the Helsinki study, short therapies worked faster, longer psychodynamic therapy was ahead after three years, and psychoanalysis peaked after about five years¹⁴.

That supports our thesis, but it does not prove it. A meta-analysis led by Martin Kivlighan and Bruce Wampold examined exactly this question: do psychodynamic effects grow more after therapy than those of other approaches? The result: both were equally effective at the end and at follow-up¹⁰. In the German LAC study led by Marianne Leuzinger-Bohleber and Martin Hautzinger, with 252 chronically depressed people, symptoms kept improving over three years under both long-term psychoanalytic and long-term cognitive behavioural therapy, with no significant difference between them¹⁵. For long psychoanalytic therapy the picture is also disputed: Leichsenring and Sven Rabung found advantages for complex problems in 2008¹¹, while a 2012 meta-analysis led by Yolba Smit judged the evidence limited and conflicting¹².

Why MindMotion starts with inner conflicts

Many people experience the same difficulties in very different areas of life: at work, in their relationship, with friends. Advice for one situation then only solves that one situation. Our conviction: if you understand the inner driver that connects all these situations, you change not just one behaviour but the way you shape your life. It is a fascinating field, and it fits what the long-term studies suggest. How such patterns form is described in Inner conflicts and Why we keep falling into the same patterns.

The challenge: inner conflicts in an app

Honestly, we could have made it easier for ourselves. Behavioural ideas translate well into an app: task, exercise, next level. Inner conflicts, by contrast, are often not conscious, they show up between the lines, and in therapy they usually become tangible in the relationship with a person. An app cannot replace that. So this is how we built it:

• From outside to inside. You start with a concrete conflict in your daily life, not an abstract theory. How that works is shown in One conflict instead of a hundred.
• A chain you check. Wish, fear, protection and earlier experience become visible step by step. You confirm each link, soften it or discard it.
• Finely tuned feedback from AI. Several AI models work together: one recognises your spoken words, a language model summarises and asks back when something is unclear. Only when you say it fits do you move on.
• From understanding to action. Here we learn from CBT: every round ends with a concrete if-then plan and a weekly check.

Whether this works as well as we hope is something we keep testing with people who try the app. What an app can realistically do for change, and what not, we rated openly in What makes change work.

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