You know, Herman, I was looking at some statistics the other day about how people search for mental health support, and it is fascinating how one acronym just completely dominates the landscape. If you look at any major health portal, university counseling center, or insurance provider, it is Cognitive Behavioral Therapy, or CBT, as far as the eye can see. It is the Google of the therapy world.
It really is the titan of the industry, Corn. Herman Poppleberry here, by the way. And you are right, CBT has become almost synonymous with psychotherapy in the public consciousness. It is the gold standard for a reason, but it is certainly not the only game in town. In fact, if you only look at CBT, you are missing out on about eighty percent of the fascinating evolution happening in the field right now.
Exactly. And that is actually what our housemate Daniel was asking about in the prompt he sent over this week. He was pointing out that while we often track the cutting edge of psychiatry and new medications, we tend to overlook the innovation happening in talk therapy itself. He called it the long tail of psychotherapy.
I love that framing. The long tail. It is a concept from economics, usually applied to how the internet allows niche products to find an audience. If CBT is the head of the curve, the blockbuster movie everyone sees, then there is this incredibly rich, diverse, and evidence based set of practices that follow it. Daniel wanted to know what these newer or less mainstream approaches actually look like and, crucially, what the evidence says about them as of February twenty twenty-six.
It is a great question because I think a lot of people feel like if CBT does not work for them, then maybe therapy just does not work for them. They feel like a failure because the gold standard did not click. But that is like saying if you do not like one specific genre of music, you do not like sound. So, let us dive in. Why did CBT get so big in the first place? We should probably establish the baseline before we look at the alternatives.
Right. To understand the innovations, you have to understand the incumbent. CBT really took off in the nineteen sixties and seventies with pioneers like Aaron Beck and Albert Ellis. The core idea is that your thoughts, feelings, and behaviors are all interconnected in a loop. If you change the way you think, you change the way you feel. It was revolutionary because it was short term, it was goal oriented, and most importantly for the medical establishment, it was manualized.
Manualized. That is a key word there. It means you can write down a protocol, right? Like a recipe.
Exactly. You can train a thousand therapists to follow the same twelve week protocol for depression. That makes it very easy to study in clinical trials. And because it was so easy to study, it racked up a massive amount of evidence. Insurance companies love evidence, and they love things that have a clear end date. So CBT became the default. But as we have moved into the mid twenty twenties, we are seeing the limitations of that highly structured, almost mechanical approach.
Which brings us to the first stop on our long tail tour. Daniel mentioned ACT, or Acceptance and Commitment Therapy. That is often called part of the third wave of behavioral therapy. How does that differ from the standard CBT approach of just challenging your thoughts?
This is where the shift really begins. If standard CBT is about challenging or changing the content of your thoughts, ACT is about changing your relationship to your thoughts. It was developed by Steven Hayes in the late nineteen eighties, but it really gained massive momentum in the last fifteen years. Instead of saying, this thought is irrational and I need to replace it with a rational one, ACT says, I am having the thought that I am a failure. It is just a thought. I do not have to fight it, but I also do not have to believe it.
So it is less about the content and more about the context?
Precisely. They use a term called cognitive defusion. Imagine you are wearing a pair of bright yellow sunglasses. Everything you see looks yellow. That is being fused with your thoughts. Cognitive defusion is taking the glasses off and looking at them. You realize, oh, the world is not yellow, I was just looking through these lenses. It uses what they call the Hexaflex, six core processes: acceptance, cognitive defusion, being present, self as context, values, and committed action.
I like that. It feels a lot more like mindfulness. But what about the commitment part of Acceptance and Commitment Therapy?
That is the engine. Once you stop wasting all your energy fighting your internal thoughts and feelings, what are you going to do with that energy? ACT asks you to identify your core values, what actually matters to you, and then commit to actions that align with those values, even if you are feeling anxious or sad while doing them. It is about psychological flexibility.
That seems like a big shift. In CBT, the goal is often to reduce the symptoms, like make the anxiety go away. In ACT, it sounds like the goal is to live a meaningful life even if the anxiety is still there.
You hit the nail on the head. And the evidence for ACT is incredibly robust now. As of twenty twenty-six, there have been over one thousand randomized controlled trials. It is particularly effective for chronic pain, where the goal is often management and quality of life rather than a total cure. It is also showing incredible results for workplace stress and even smoking cessation. It is a powerful example of how the field is moving toward flexibility rather than just symptom suppression.
Okay, so ACT is a big one. But Daniel mentioned the long tail. What about things that are a bit further out from the mainstream? I have been hearing a lot lately about Internal Family Systems, or IFS. It sounds almost like science fiction, the idea that we have multiple parts inside us.
Oh, IFS is the rising star of the twenty twenties. It was developed by Richard Schwartz. And while it might sound a bit out there, it is actually gaining huge traction in the trauma informed community. The core premise is that the mind is naturally sub divided into various parts, almost like a family system. You might have a part that is a perfectionist, a part that is a harsh critic, and a part that feels like a vulnerable child.
Right, we all say things like, a part of me wants to go to the party, but another part of me just wants to stay home and read.
Exactly. IFS just takes that intuition seriously. It suggests that there is no such thing as a bad part. Every part is trying to protect you in some way, even the ones that seem destructive, like an addiction or self harm. Those are often what they call protectors. They are trying to shield a more vulnerable, wounded part, which they call an exile.
So what does the therapy actually look like? Are you just talking to yourself?
In a way, yes. The goal is to get into a state of what Schwartz calls the Self, with a capital S. This is your core essence, which is characterized by the eight C's: calmness, curiosity, compassion, confidence, courage, clarity, connectedness, and creativity. From that place of Self, you can actually talk to these different parts, understand their roles, and help them unburden the pain they are carrying. It is deeply compassionate.
It sounds very different from the logical, structured approach of CBT. Is there actual evidence for this, or is it mostly anecdotal?
It is younger in terms of its research base, but it is catching up rapidly. The Substance Abuse and Mental Health Services Administration, or SAMHSA, has listed it as an evidence based practice. A landmark study in twenty twenty-one on IFS for rheumatoid arthritis showed significant improvements in physical symptoms and psychological self efficacy. More recently, in twenty twenty-four and twenty twenty-five, we have seen major studies focusing on IFS for complex PTSD showing that it can be more effective than traditional exposure therapy for some populations because it does not re traumatize the person.
That is an important point. Sometimes the long tail exists because the head of the curve, the standard CBT, does not work for everyone. I am curious about the interpersonal side of things. Most of what we have talked about is very internal. What about therapies that focus on our relationships with others?
That brings us to Emotionally Focused Therapy, or EFT. This was primarily developed by Sue Johnson, and it is based heavily on attachment theory. You know, the work of John Bowlby and Mary Ainsworth about how our early bonds with caregivers shape our adult lives.
Right, the idea that we are biologically wired for connection.
Exactly. EFT is most famous as a couples therapy, but it is also used for individuals, known as EFIT. The idea is that most of our distress comes from a sense of disconnection or insecure attachment. When we feel like our primary person is not there for us, we go into a state of primal panic. In couples, this often manifests as a cycle where one person pursues and the other withdraws.
I have seen that. One person is yelling because they want to feel heard, and the other person shuts down because the yelling feels like a threat.
Right. And standard therapy might try to teach them communication skills, like using I statements. But EFT says that is just putting a bandage on a geyser. You have to get to the underlying emotional attachment need. The therapist helps the couple identify the cycle and then express the deeper, more vulnerable feelings underneath, like, I am yelling because I am terrified that I do not matter to you.
And what is the evidence there? Because relationships are notoriously hard to measure.
EFT actually has some of the strongest evidence in the field for couples therapy. Research shows that about seventy to seventy-five percent of couples move from distress to recovery, and about ninety percent show significant improvement. And crucially, those results tend to be very stable over time. A study from twenty twenty-three even used brain scans to show that after EFT, the brain's threat response to physical pain was significantly reduced when holding a partner's hand. It literally changes how our nervous systems co regulate.
That is impressive. It makes me think about how much of our mental health is actually social health. But let us go even deeper into the long tail. What about things like Dialectical Behavior Therapy, or DBT? People often lump it in with CBT, but it feels like its own beast.
It really is. DBT was created by Marsha Linehan in the nineteen eighties specifically for people with borderline personality disorder, who were often considered untreatable by other methods. The word dialectical is the key. It refers to the tension between two seemingly opposite ideas: acceptance and change.
That sounds like a paradox. How do you do both?
That is the whole point of the therapy. You have to accept yourself exactly as you are in this moment, while simultaneously acknowledging that you need to change your behavior to reach your goals. DBT is incredibly structured. It involves individual therapy, but also a skills training group where you literally learn how to regulate your emotions, tolerate distress, and be mindful. It has four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
It is almost like a school for emotions.
It really is. And the evidence for DBT is gold standard level for self harm, suicidal ideation, and borderline personality disorder. But now, in twenty twenty-six, it is being used for all sorts of things, like eating disorders and treatment resistant depression. There is even a version called DBT for Adolescents that has been a game changer in high schools.
Okay, so we have covered ACT, IFS, EFT, and DBT. That is a lot of acronyms. But Daniel also asked about the innovation process itself. In medicine, we have these clear phases of clinical trials. How does a new talk therapy move from being an idea in a clinician's head to being something people can actually get covered by insurance?
It is a much messier process than drug development, Corn. Usually, it starts with clinical observation. A therapist sees a pattern in their clients and develops a new technique or framework. They might write a book or start training other therapists. This creates a community of practice.
But that is not evidence yet. That is just popularity.
Exactly. The next step is usually case studies and small pilot trials. If those look promising, researchers will conduct larger randomized controlled trials, or RCTs, comparing the new therapy to a control group, usually a waitlist or what they call treatment as usual. If the new therapy shows a significant effect, it starts getting published in major journals like the Lancet Psychiatry or JAMA Psychiatry. Eventually, meta analyses are done, which look at the results of many different studies together.
But here is the thing that always confuses me about therapy research. In a drug trial, you have a placebo. You give one person a pill with the chemical and another person a sugar pill. How do you have a placebo for talking?
That is the million dollar question. It is incredibly difficult. Most studies use what is called an active control. For example, they might compare the new therapy to a non directive supportive therapy, where the therapist is just kind and listens but does not use the specific techniques of the new model. This helps researchers figure out if the specific techniques actually matter, or if it is just the benefit of talking to a supportive human being.
And that leads us to one of the most famous and controversial ideas in psychotherapy research, right? The Dodo Bird Verdict.
Yes! I was hoping you would bring that up. For those who do not know, the Dodo Bird Verdict comes from a line in Alice in Wonderland: Everybody has won, and all must have prizes. In psychotherapy, it is the idea that all bona fide therapies are roughly equal in their effectiveness.
Which seems crazy if you think about how different they are. How can talking to your internal parts be the same as learning to challenge your cognitive distortions?
It is a huge debate. The proponents of the Dodo Bird Verdict argue that the specific techniques, the acronyms we have been talking about, actually only account for about fifteen percent of why people get better. They point to what are called common factors.
Like the relationship with the therapist?
Exactly. The therapeutic alliance is the single strongest predictor of success in therapy, across all models. Then you have things like therapist empathy, the client's expectations of getting better, and the fact that the therapist provides a coherent framework for understanding the client's problems. If you believe the framework, and you trust the therapist, you are likely to get better regardless of whether it is CBT or IFS.
So if the relationship is the main thing, does the specific type of therapy even matter? Why are we even bothering with this long tail?
Well, that is where the counter argument comes in. Critics of the Dodo Bird Verdict say that while all therapies might be equal on average, they are not equal for specific problems. For example, if you have a specific phobia of spiders, exposure therapy is clearly superior to just talking about your childhood. If you have borderline personality disorder, DBT has specific modules for distress tolerance that a general supportive therapy just does not have.
That makes sense. It is like saying all exercise is good for you, which is true on average. But if you want to run a marathon, you need a different training plan than if you want to win a weightlifting competition.
Perfect analogy. And that is where the innovation Daniel mentioned is really happening. We are moving away from the idea of one size fits all and toward a more precision medicine approach to psychotherapy. We are trying to figure out which specific processes work for which people. This is often called Process Based Therapy, or PBT. It is a movement led by Steven Hayes and Stefan Hofmann to move beyond the brands and focus on the underlying mechanisms of change.
So, what are some of the truly new things on the horizon? Beyond just the third wave? I have heard about things like MDMA assisted therapy or psilocybin therapy. Obviously, those involve drugs, but the talk therapy part of it is crucial, right?
Absolutely. That is actually one of the biggest areas of innovation right now. It is called psychedelic assisted psychotherapy. As of early twenty twenty-six, we are in a very interesting place. While the FDA had some setbacks with MDMA approval in twenty twenty-four, the research has continued to refine the therapy protocols. The drug is not the treatment on its own. It is a tool that opens a window of neuroplasticity and emotional openness. The actual healing happens in the therapy sessions before, during, and after the experience.
And what model of therapy do they use for that? Is it CBT?
Interestingly, it is often a blend of the long tail models we just discussed. They use a lot of Internal Family Systems and Acceptance and Commitment Therapy. The idea is to help the person stay with the experience, even if it is difficult, and then integrate what they learned into their daily lives. We are seeing people who have had treatment resistant PTSD for decades seeing massive improvements. It is a great example of how the long tail is merging with pharmacology.
That is incredible. But it also highlights something important. These therapies are often very intensive. They require a lot of time and specialized training. How do we make the long tail accessible to more people?
That is where technology and global health innovations come in. We are seeing the rise of digital therapeutics. These are not just apps that give you quotes. They are structured programs based on things like ACT or DBT that you can do on your phone. Some of them even use AI to provide feedback. In twenty twenty-five, we saw the first AI augmented therapy platforms that help therapists track the therapeutic alliance in real time.
I can hear some of our listeners cringing at the idea of an AI therapist.
And rightfully so. There are huge ethical and quality concerns there. But as a tool to augment human therapy, it has potential. Imagine if your therapist could assign you a module in an app that helps you practice the skills you talked about in your session. It bridges the gap between the once a week hour and the rest of your life.
It is like physical therapy. You see the professional once a week, but you have to do the exercises every day if you want to get better.
Exactly. And there is also a move toward what is called task shifting. This is especially important in parts of the world where there are very few trained psychologists. They train laypeople, like community members or grandmothers, to deliver basic versions of evidence based therapies. There is a famous project in Zimbabwe called the Friendship Bench, where grandmothers are trained to deliver a form of problem solving therapy on wooden benches outside health clinics.
I love that. It takes the elite, academic world of psychotherapy and brings it back to the community level. And it works, right?
It works incredibly well. The research showed it was more effective than standard care for depression and anxiety. It proves that while the technical details of the long tail are important, the human connection and the provision of a structured way to handle problems are the real magic.
So, if someone is listening to this and they are thinking, okay, I have tried CBT and it did not click for me, or I am just curious about these other approaches, how do they actually find them? It is not like there is a menu at the therapist's office.
It is getting easier. Most therapist directories, like the one on Psychology Today or specialized sites like the IFS Institute or the Association for Contextual Behavioral Science, now let you filter by the specific modality. You can search for someone who specializes in IFS or ACT. But my advice would be to look for someone who is what we call integrative or eclectic. These are therapists who have trained in multiple models and can tailor their approach to what you specifically need.
Like a chef who knows how to use different spices depending on the dish.
Exactly. You want someone who has a deep toolbox. And do not be afraid to ask a potential therapist during a consultation: What is your framework? How do you think people change? If they can only give you a vague answer, they might not be the right fit. A good therapist should be able to explain the evidence base for what they are doing.
That is a great point. I think we often treat therapy as this mysterious black box, but it is a service you are paying for. You have every right to understand the methodology.
And you should! Because when you find the right match between your personality, your problem, and the therapeutic model, that is when the real transformation happens. It is not just about feeling less bad. It is about gaining a new way of being in the world. We are seeing a shift toward what is called flourishing rather than just symptom reduction.
You know, talking about all this makes me realize how much the field has evolved just in our lifetimes. We went from the long, years-long process of psychoanalysis to the quick fix of CBT, and now we are landing in this more nuanced middle ground.
It is a maturation of the field. We are moving past the school wars where people would fight over which model was the best. Now, it is more about integration. How can we use the mindfulness of ACT, the parts work of IFS, and the relational depth of EFT to help this specific person sitting in front of us? It is a much more holistic view of the human experience.
It feels more humane. Less like fixing a broken machine and more like tending to a garden.
I love that. And the garden needs different things at different times. Sometimes it needs fertilizer, sometimes it needs pruning, and sometimes it just needs a lot of water and sun. The long tail of psychotherapy provides the different tools for those different needs.
So, to go back to Daniel's prompt, the long tail of psychotherapy is not just a collection of niche interests. It is the laboratory where the future of mental health is being built. Even if CBT remains the most popular, it is being constantly influenced and improved by these other models.
Absolutely. Innovation in talk therapy is just as vital as innovation in pharmacology. Because at the end of the day, we are social, storytelling animals. The way we talk about our lives and the way we relate to our own minds is the core of our experience. The evidence is clear: there are many paths to healing, and the long tail is where those paths are being mapped out.
Well, I think we have covered a lot of ground here. We have gone from the dominance of CBT to the psychological flexibility of ACT, the internal families of IFS, the attachment bonds of EFT, and the dialectics of DBT. We even touched on the future of psychedelic assisted therapy and the global impact of the Friendship Bench.
It is a pretty incredible landscape. And for anyone listening who wants to dive deeper, I highly recommend looking up some of the names we mentioned. Sue Johnson has some great books on EFT, and Richard Schwartz has written extensively about IFS. The resources are more accessible than ever before.
And if you are enjoying these deep dives into the weird and wonderful prompts our housemate Daniel sends our way, we would love it if you could leave us a review on your podcast app or on Spotify. It really does help other people find the show.
Yeah, it makes a huge difference. We love seeing the show grow and hearing from you all. We are always looking for new ways to explore the intersection of science, psychology, and the human experience.
You can find all our past episodes, including some where we touch on related topics like the history of psychiatry or the science of habits, at our website, myweirdprompts.com. We have an RSS feed there too if you want to subscribe.
This has been a great one, Corn. I always love geeky therapy talk. It is a field that is constantly surprising me with its creativity and its commitment to helping people.
Me too, Herman. Me too. This has been My Weird Prompts. Thanks for listening, and we will talk to you next time.
Goodbye, everyone! Keep exploring the long tail!
