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Online Therapists

Photo of Michelle Tulik, MS, Pre-Licensed Professional
Michelle Tulik
Pre-Licensed Professional, MS
Verified Verified
Exton, PA 19341
Drawing from and utilizing Internal Family Systems (IFS), Shadow Work (Jungian), Dialectical behavior therapy (DBT), mindfulness, play therapy, and somatic interventions.
Do you often grapple with feelings of inadequacy and low confidence? Do you feel stuck and/or experience intense anxiety? Do you often feel detached? If you answered, "yes", to any of these prompts, please know I am here to support you. I help adults and children navigate life transitions, social anxiety, panic disorder, anxiety, depression, and self esteem issues. I also assist clients who have experienced past trauma and bring a compassionate, patient, warm, and nonjudgmental approach; viewing each client as a whole person, with past experiences shaping their present moment.
Drawing from and utilizing Internal Family Systems (IFS), Shadow Work (Jungian), Dialectical behavior therapy (DBT), mindfulness, play therapy, and somatic interventions.
Do you often grapple with feelings of inadequacy and low confidence? Do you feel stuck and/or experience intense anxiety? Do you often feel detached? If you answered, "yes", to any of these prompts, please know I am here to support you. I help adults and children navigate life transitions, social anxiety, panic disorder, anxiety, depression, and self esteem issues. I also assist clients who have experienced past trauma and bring a compassionate, patient, warm, and nonjudgmental approach; viewing each client as a whole person, with past experiences shaping their present moment.
(484) 260-3140 View (484) 260-3140
Photo of Linda Naylor Dench - Dench Counseling Sport & Wellness Centre, MA, PhD, LPC, RPT-S, Licensed Professional Counselor
Dench Counseling Sport & Wellness Centre
Licensed Professional Counselor, MA, PhD, LPC, RPT-S
Verified Verified
2 Endorsed
Allentown, PA 18103
Waitlist for new clients
I may draw heavily on Play Therapy, Sandtray, Expressive Arts, and games, or other specialties including Jungian Psychotherapy and Sport Psychology.
If you are anxious, having difficulty with relationships, depression, self-esteem, or wrestling with an addiction & would like help, let's talk. I have been a psychotherapist for thirty years, and work with children, adolescents, and adults. How long ago did your issue begin? Many people don’t know the root cause of their problem. You may be suffering in silence not knowing where to turn. Counseling can provide tools for surviving the emotional fall out from COVID-19, building happy, healthy relationships, managing stress & anxiety, appreciating your strengths, & feeling good about yourself.
I may draw heavily on Play Therapy, Sandtray, Expressive Arts, and games, or other specialties including Jungian Psychotherapy and Sport Psychology.
If you are anxious, having difficulty with relationships, depression, self-esteem, or wrestling with an addiction & would like help, let's talk. I have been a psychotherapist for thirty years, and work with children, adolescents, and adults. How long ago did your issue begin? Many people don’t know the root cause of their problem. You may be suffering in silence not knowing where to turn. Counseling can provide tools for surviving the emotional fall out from COVID-19, building happy, healthy relationships, managing stress & anxiety, appreciating your strengths, & feeling good about yourself.
(610) 365-4354 View (610) 365-4354
Photo of Mark E. Dean, MA,  , ATR, LPC, Licensed Professional Counselor
Mark E. Dean
Licensed Professional Counselor, MA, , ATR, LPC
Verified Verified
Fleetwood, PA 19522  (Online Only)
As a Jungian Psychoanalyst, I have 10 years of training in analytic practice.
My focus is helping you to discover your own unique pathway through the hardships and challenges that you are currently facing. This path is almost impossible to find on your own when you feel lost, confused, overwhelmed, and in pain. At such times one naturally feels broken, defective, and defeated by troubles that you have tried your best to understand and overcome. In every struggle however there lies a hidden possibility for growth and development that can lead to a renewed sense of meaning and well being. My work is to listen carefully to you, to come to understand your unique life, and how what you are struggling with actually makes perfect sense. By understanding your life and your struggle we can find what is needed to navigate through to a renewed sense of life and meaning.
As a Jungian Psychoanalyst, I have 10 years of training in analytic practice.
My focus is helping you to discover your own unique pathway through the hardships and challenges that you are currently facing. This path is almost impossible to find on your own when you feel lost, confused, overwhelmed, and in pain. At such times one naturally feels broken, defective, and defeated by troubles that you have tried your best to understand and overcome. In every struggle however there lies a hidden possibility for growth and development that can lead to a renewed sense of meaning and well being. My work is to listen carefully to you, to come to understand your unique life, and how what you are struggling with actually makes perfect sense. By understanding your life and your struggle we can find what is needed to navigate through to a renewed sense of life and meaning.
(610) 756-0983 View (610) 756-0983
Photo of Michelina Marsico, MA, ATR-BC, LPC, Licensed Professional Counselor
Michelina Marsico
Licensed Professional Counselor, MA, ATR-BC, LPC
Verified Verified
5 Endorsed
Harrisburg, PA 17112
I combine elements of CBT, mindfulness, spirituality, existential, and Jungian approaches but am ultimately a humanistic, client-centered clinician.
We all come into this world with a blank canvas. All of our experiences throughout our lives get added to it. Sometimes, like art, life gets messy, and there are too many layers to get through. I am here to walk alongside you as you scrape off and explore the layers in your life and learn to paint a clearer picture. You are the narrator of your own story. Every person has the ability to learn tools to adapt to the crazy changes in this world.
I combine elements of CBT, mindfulness, spirituality, existential, and Jungian approaches but am ultimately a humanistic, client-centered clinician.
We all come into this world with a blank canvas. All of our experiences throughout our lives get added to it. Sometimes, like art, life gets messy, and there are too many layers to get through. I am here to walk alongside you as you scrape off and explore the layers in your life and learn to paint a clearer picture. You are the narrator of your own story. Every person has the ability to learn tools to adapt to the crazy changes in this world.
(717) 621-3672 View (717) 621-3672
Photo of Alexei Soma, LSW
Alexei Soma
Licensed Social Worker, LSW
Verified Verified
1 Endorsed
Philadelphia, PA 19102
My first goal when working with a client is to create a space of absolute safety, a space where people feel at ease to share the fullness of their suffering, to share their hopes and their dreams. I use a whole-person approach and learn not just about a person’s pain but also about their strengths and their vision for a better future. Together, my clients and I create a healing field that allows their deepest knowledge to flower. We transform confusion into clarity and habitual patterns into fresh action arising out of wisdom.
My first goal when working with a client is to create a space of absolute safety, a space where people feel at ease to share the fullness of their suffering, to share their hopes and their dreams. I use a whole-person approach and learn not just about a person’s pain but also about their strengths and their vision for a better future. Together, my clients and I create a healing field that allows their deepest knowledge to flower. We transform confusion into clarity and habitual patterns into fresh action arising out of wisdom.
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Wellbrook Wellness @ Living Well Studios
Licensed Professional Counselor
Verified Verified
Paoli, PA 19301
Our holistic approach puts your whole being at the center of treatment by addressing your mental, emotional, physical and psychological-spiritual needs (meaning/purpose, transcendence, and peace of mind). The core of our mission begins with the recognition that psychological well-being requires learning how to develop greater awareness, self-compassion and commitment, and turning that effort into action. We are licensed professional therapists and wellness practitioners who specialize in providing integrative and innovative interventions to help you heal, evolve, and thrive. ​
Our holistic approach puts your whole being at the center of treatment by addressing your mental, emotional, physical and psychological-spiritual needs (meaning/purpose, transcendence, and peace of mind). The core of our mission begins with the recognition that psychological well-being requires learning how to develop greater awareness, self-compassion and commitment, and turning that effort into action. We are licensed professional therapists and wellness practitioners who specialize in providing integrative and innovative interventions to help you heal, evolve, and thrive. ​
(484) 998-1162 View (484) 998-1162
Photo of Maryrose Yerger, MS, Pre-Licensed Professional
Maryrose Yerger
Pre-Licensed Professional, MS
Verified Verified
1 Endorsed
Phoenixville, PA 19460
Now Accepting New Clients for July: Individuals, couples, and families- Therapy is a collaborative journey of discovery. It is my belief that our healing lies in the gifts we have yet to uncover. As we learned to exist in this challenging world, these gifts often became clouded or adapted to meet our survival needs. The weight of our past, the stress of our daily lives, and our fears for the future can begin to drag us down and dull our experience. Through a process that is gentle, intuitive and individually tailored my goal is to help you unearth your gifts so you can move through your life with more lightness and ease.
Now Accepting New Clients for July: Individuals, couples, and families- Therapy is a collaborative journey of discovery. It is my belief that our healing lies in the gifts we have yet to uncover. As we learned to exist in this challenging world, these gifts often became clouded or adapted to meet our survival needs. The weight of our past, the stress of our daily lives, and our fears for the future can begin to drag us down and dull our experience. Through a process that is gentle, intuitive and individually tailored my goal is to help you unearth your gifts so you can move through your life with more lightness and ease.
(215) 770-9024 View (215) 770-9024
Photo of Kelly Segaline, LPC, ATR-BC, Licensed Professional Counselor
Kelly Segaline
Licensed Professional Counselor, LPC, ATR-BC
Verified Verified
2 Endorsed
Newtown, PA 18940
If you are here because you are struggling with anxiety, eating disorders, low self-esteem, and life transitions there is a way out. If you are experiencing panic attacks and anxiety I can provide you the hope that you can heal. If you feel stuck in life, let's get unstuck. I work with those experiencing grief in relationships, loss of loved ones, pets, and autonomy. My clients are creative individuals who often take the world on their shoulders. I work with parents, partners, children, siblings, and professionals who need to be heard and seen.
If you are here because you are struggling with anxiety, eating disorders, low self-esteem, and life transitions there is a way out. If you are experiencing panic attacks and anxiety I can provide you the hope that you can heal. If you feel stuck in life, let's get unstuck. I work with those experiencing grief in relationships, loss of loved ones, pets, and autonomy. My clients are creative individuals who often take the world on their shoulders. I work with parents, partners, children, siblings, and professionals who need to be heard and seen.
(484) 562-4372 View (484) 562-4372
Photo of Samantha Lauren Blanchard, MA, LPC, ATR, Counselor
Samantha Lauren Blanchard
Counselor, MA, LPC, ATR
Verified Verified
1 Endorsed
Hawley, PA 18428
Life is a process & change isn't easy. We can all benefit from gaining new perspectives. While you don't have control of the cards you're dealt, your power lies in how you respond. In addition to talk therapy, I'm an art therapist & believe art offers a portal to embodying our most authentic self. Art therapy offers endless opportunities for expressing & working through internal issues, & processing/releasing what may be difficult to put into words. Life is full of lessons & we can choose to use the challenges & problems we face as opportunities to grow & evolve. Therapy can promote the hope & self compassion needed to rise & thrive
Life is a process & change isn't easy. We can all benefit from gaining new perspectives. While you don't have control of the cards you're dealt, your power lies in how you respond. In addition to talk therapy, I'm an art therapist & believe art offers a portal to embodying our most authentic self. Art therapy offers endless opportunities for expressing & working through internal issues, & processing/releasing what may be difficult to put into words. Life is full of lessons & we can choose to use the challenges & problems we face as opportunities to grow & evolve. Therapy can promote the hope & self compassion needed to rise & thrive
(272) 359-7643 View (272) 359-7643
Photo of Stephanie Pirozzi - Stephanie Brooks Pirozzi | Wellbrook Wellness, MA, LPC, Licensed Professional Counselor
Stephanie Brooks Pirozzi | Wellbrook Wellness
Licensed Professional Counselor, MA, LPC
Verified Verified
Malvern, PA 19355
“You’ve always had the power, you just had to learn it for yourself.” These famous words echo a universal truth; no matter what your life experience, personal power lies at the heart of who you are. As a holistic, strength-based therapist, I understand how all aspects of self - mind, body and essence - work together to access inner wisdom and inspire the best version of you. I work with adolescents, adults and families in the treatment of depression, anxiety, mood dysregulation, grief and relational problems to help identify and dismantle disruptive thought and behavior patterns that get the way of living your best life.
“You’ve always had the power, you just had to learn it for yourself.” These famous words echo a universal truth; no matter what your life experience, personal power lies at the heart of who you are. As a holistic, strength-based therapist, I understand how all aspects of self - mind, body and essence - work together to access inner wisdom and inspire the best version of you. I work with adolescents, adults and families in the treatment of depression, anxiety, mood dysregulation, grief and relational problems to help identify and dismantle disruptive thought and behavior patterns that get the way of living your best life.
(484) 218-5445 View (484) 218-5445
Photo of Jennifer M Matthes, LPC, ATR-BC, Licensed Professional Counselor
Jennifer M Matthes
Licensed Professional Counselor, LPC, ATR-BC
Verified Verified
2 Endorsed
Coopersburg, PA 18036
Waitlist for new clients
I provide art therapy services rooted in a holistic approach for individuals looking to experience a sense of wholeness. A new opportunity is available for outdoor walk & talk therapy, gardening, and more interactive approaches on an educational farm in Coopersburg! This lets us incorporate nature as a mirror to work with as we learn to love and connect to the natural parts of ourselves. The art process works in a similar way and is a great technique to express our feelings deeper. You do not need to be an artist to benefit from art therapy. I work with ALL ages and customize my techniques to be relevant to what season you are in.
I provide art therapy services rooted in a holistic approach for individuals looking to experience a sense of wholeness. A new opportunity is available for outdoor walk & talk therapy, gardening, and more interactive approaches on an educational farm in Coopersburg! This lets us incorporate nature as a mirror to work with as we learn to love and connect to the natural parts of ourselves. The art process works in a similar way and is a great technique to express our feelings deeper. You do not need to be an artist to benefit from art therapy. I work with ALL ages and customize my techniques to be relevant to what season you are in.
(267) 680-7276 View (267) 680-7276
Photo of Jennifer L Jeffers, MS, LPC, NCC, Licensed Professional Counselor
Jennifer L Jeffers
Licensed Professional Counselor, MS, LPC, NCC
Verified Verified
Philadelphia, PA 19144
I view psychotherapy as the ultimate practice of self-care. Sessions are a time to explore your inner self, your outer relationships, and evaluate how your past and present influence your future. I approach treatment though an existential, intersectional feminist, and person-centered lens – this means I consider gender, race, class, sexuality, belief, biology, ability, physicality, and life experiences during our work together.
I view psychotherapy as the ultimate practice of self-care. Sessions are a time to explore your inner self, your outer relationships, and evaluate how your past and present influence your future. I approach treatment though an existential, intersectional feminist, and person-centered lens – this means I consider gender, race, class, sexuality, belief, biology, ability, physicality, and life experiences during our work together.
(215) 598-6811 View (215) 598-6811
Photo of Megan Bousquet, MA, ATR, LPC, Licensed Professional Counselor
Megan Bousquet
Licensed Professional Counselor, MA, ATR, LPC
Verified Verified
4 Endorsed
Philadelphia, PA 19123  (Online Only)
Throughout a woman’s life there are many emotional shifts and it takes strength to reach out for support! I understand the many challenges and stress that sometimes might have you not feeling like yourself. Do you feel alone, anxious, tired, sad, angry, irritable, or stressed? I work with women who are experiencing anxiety, depressed mood, grief and loss, fertility, miscarriage, transition to motherhood, and other life changing events. I have specialized training in anxiety, maternal mental health (pregnancy, birth, postpartum, motherhood), child development, and eating disorders.
Throughout a woman’s life there are many emotional shifts and it takes strength to reach out for support! I understand the many challenges and stress that sometimes might have you not feeling like yourself. Do you feel alone, anxious, tired, sad, angry, irritable, or stressed? I work with women who are experiencing anxiety, depressed mood, grief and loss, fertility, miscarriage, transition to motherhood, and other life changing events. I have specialized training in anxiety, maternal mental health (pregnancy, birth, postpartum, motherhood), child development, and eating disorders.
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Photo of Josie Villamar, PhD, LPC, MFT, Licensed Professional Counselor
Josie Villamar
Licensed Professional Counselor, PhD, LPC, MFT
Verified Verified
1 Endorsed
Stroudsburg, PA 18360
My name is Josie Villamar; God has blessed me with a great husband and a beautiful family. I am an active member of my church, and I enjoy having quality time with my loved ones. I love people; cooking, reading, traveling, and I enjoy the wonders of God's nature and outside activities. I have been practicing for many years, and my education background includes a Doctorate degree in Christian Counseling, a Master's degree in Marriage and Family Therapy, a State certification as a Licensed Professional Counselor, and specialization and extensive training in Functional Family Therapy Approach.
My name is Josie Villamar; God has blessed me with a great husband and a beautiful family. I am an active member of my church, and I enjoy having quality time with my loved ones. I love people; cooking, reading, traveling, and I enjoy the wonders of God's nature and outside activities. I have been practicing for many years, and my education background includes a Doctorate degree in Christian Counseling, a Master's degree in Marriage and Family Therapy, a State certification as a Licensed Professional Counselor, and specialization and extensive training in Functional Family Therapy Approach.
(272) 203-1807 View (272) 203-1807
Photo of Kaitlin Staples Vigo, MA, ATR-BC, LPC, Licensed Professional Counselor
Kaitlin Staples Vigo
Licensed Professional Counselor, MA, ATR-BC, LPC
Verified Verified
1 Endorsed
Philadelphia, PA 19127
Are you tired of feeling stuck? Do you want to create changes that make your life feel more exciting, satisfying, fulfilling, purposeful, or sustainable? Maybe you’re experiencing a creative block, relationship stagnancy, grief and loss, job dissatisfaction, career choice difficulty, feeling uninspired by life, struggling with food or substances, etc. Maybe you're taking on some of life's biggest milestones: graduation, marriage, embarking on becoming a parent, etc.
Are you tired of feeling stuck? Do you want to create changes that make your life feel more exciting, satisfying, fulfilling, purposeful, or sustainable? Maybe you’re experiencing a creative block, relationship stagnancy, grief and loss, job dissatisfaction, career choice difficulty, feeling uninspired by life, struggling with food or substances, etc. Maybe you're taking on some of life's biggest milestones: graduation, marriage, embarking on becoming a parent, etc.
(215) 515-7579 View (215) 515-7579
Photo of Keisha Vuong - Bent Mountain Springs Counseling, LLC Keisha Vuong, MS, LPC, LPCMH, NCC, Licensed Professional Counselor
Bent Mountain Springs Counseling, LLC Keisha Vuong
Licensed Professional Counselor, MS, LPC, LPCMH, NCC
Verified Verified
5 Endorsed
Chadds Ford, PA 19317
I know the importance of building rapport and a therapeutic relationship “trust” with my clients. I take a non-judgmental supportive approach and have experience working with a diverse population of all ages. Together my goal is to help support you through the current challenges/struggles you face and to truly hear you and assist you in reaching a positive place.
I know the importance of building rapport and a therapeutic relationship “trust” with my clients. I take a non-judgmental supportive approach and have experience working with a diverse population of all ages. Together my goal is to help support you through the current challenges/struggles you face and to truly hear you and assist you in reaching a positive place.
(484) 209-5229 View (484) 209-5229
Photo of Nicole Goicuria, MA
Nicole Goicuria
MA
Verified Verified
2 Endorsed
Philadelphia, PA 19122
Hello! I am an art psychotherapist with over 16 years of experience trained in trauma therapy, IFS, PCIT and CBT. I offer traditional therapy services as well as trauma-informed intuitive counseling methods that can be customized to suit a wide range of mental health & wellness needs. I practice an intersectional and holistic approach to healing that I hope will provide you with a unique therapeutic experience that is both affirming and effective in helping you build a stronger connection to your intuition, access deeper insights, and cultivate more self compassion on your healing journey.
Hello! I am an art psychotherapist with over 16 years of experience trained in trauma therapy, IFS, PCIT and CBT. I offer traditional therapy services as well as trauma-informed intuitive counseling methods that can be customized to suit a wide range of mental health & wellness needs. I practice an intersectional and holistic approach to healing that I hope will provide you with a unique therapeutic experience that is both affirming and effective in helping you build a stronger connection to your intuition, access deeper insights, and cultivate more self compassion on your healing journey.
(215) 883-8249 View (215) 883-8249
Photo of Ashley Gavoni - Creative Arts in Healing, MA
Creative Arts in Healing
MA
Verified Verified
York, PA 17402  (Online Only)
Much of my experience is in working with clients in areas of anxiety management, mood management, social skills development, self-esteem, identity, emotional regulation, executive functioning, behavioral transformation, and trauma. I have 10+years experience in these areas as well as working with clients on the Autism Spectrum, ADHD, and other Pervasive Developmental Disorders. I believe in working with clients from a holistic viewpoint, attending to mind/body/spirit in order to support self exploration and understanding. We will work in some talk therapy techniques and possibly integrate other techniques.
Much of my experience is in working with clients in areas of anxiety management, mood management, social skills development, self-esteem, identity, emotional regulation, executive functioning, behavioral transformation, and trauma. I have 10+years experience in these areas as well as working with clients on the Autism Spectrum, ADHD, and other Pervasive Developmental Disorders. I believe in working with clients from a holistic viewpoint, attending to mind/body/spirit in order to support self exploration and understanding. We will work in some talk therapy techniques and possibly integrate other techniques.
(717) 678-7680 View (717) 678-7680
Photo of Lee Anne Englert, LPC, MA, Licensed Professional Counselor
Lee Anne Englert
Licensed Professional Counselor, LPC, MA
Verified Verified
Doylestown, PA 18901
Do Holistic and spiritual approaches to therapy appeal to you? Clients connect to my services because they want to work through their struggles from a body/soul/mind/emotion perspective. I guide couples and individuals in their quest to transform life's challenges into a tapestry of wisdom. I passionately embrace the depth of each person's journey to heal their past traumatic wounding and foster the development of true empowerment. Embracing the ancient teachings of shamanism, we will journey into non-ordinary realities where you will heal fragmented aspects and begin to know your true self.
Do Holistic and spiritual approaches to therapy appeal to you? Clients connect to my services because they want to work through their struggles from a body/soul/mind/emotion perspective. I guide couples and individuals in their quest to transform life's challenges into a tapestry of wisdom. I passionately embrace the depth of each person's journey to heal their past traumatic wounding and foster the development of true empowerment. Embracing the ancient teachings of shamanism, we will journey into non-ordinary realities where you will heal fragmented aspects and begin to know your true self.
(267) 863-4595 View (267) 863-4595
Photo of Mike Fogel, MA, ATR-BC, LPC, Licensed Professional Counselor
Mike Fogel
Licensed Professional Counselor, MA, ATR-BC, LPC
Verified Verified
Haverford, PA 19041
I am an art & play therapist & child-adolescent specialist who helps children and parents develop powerful coping skills to overcome challenges & succeed at home, school, & in relationships. Parents who engage me in therapy are looking for an effective therapist with whom their child will feel supremely comfortable & not resist. I know how children think & my waiting rooms, offices, & every move I make is designed to help children & teens enjoy therapy. I treat a range of emotional-behavioral challenges & have a sub-specialty in social skills groups for neurodiverse children. Located in Haverford, Paoli, Blue Bell, & Center City.
I am an art & play therapist & child-adolescent specialist who helps children and parents develop powerful coping skills to overcome challenges & succeed at home, school, & in relationships. Parents who engage me in therapy are looking for an effective therapist with whom their child will feel supremely comfortable & not resist. I know how children think & my waiting rooms, offices, & every move I make is designed to help children & teens enjoy therapy. I treat a range of emotional-behavioral challenges & have a sub-specialty in social skills groups for neurodiverse children. Located in Haverford, Paoli, Blue Bell, & Center City.
(484) 214-2612 x1 View (484) 214-2612 x1
Jungian Therapists

How does Jungian therapy work?

Jungian therapy, also called analytical psychology, focuses on a patient’s inner experiences and unconscious mind. Exploring a person’s unconscious mind can be achieved through several means, including the analysis of memories and dreams, and through physical exercises, such as art, dance, and word association.

How long does Jungian therapy last?

Jungian therapy is an intensive treatment type. Because its goal is to understand a person as a whole, including the unconscious aspects of them, treatment can range from months to years. Since patients learn the theory behind Jungian therapy during treatment, they can also practice its tenets throughout life after therapy sessions have completed.

Is Jungian therapy effective?

According to studies, many patients find success with Jungian therapy, and the century-old treatment has a devoted following. Researchers note that the therapy is particularly useful in improving relationships, self-esteem, anxiety, and depression. Improvements in problem areas seem to continue even after the end of Jungian therapy, as people are able to continue working on themselves using the tools they’ve learned during the treatment.

Is Jungian therapy evidence-based?

Jungian therapy is theory-based, derived from the theories of Carl Jung, a Swiss psychiatrist often called one of the fathers of psychology, along with Sigmund Freud. Jung developed his theories from observing the problems of patients, and developed many theories of how the mind works. Subsequent psychological research has determined that Jungian therapy can lead to significant improvement in most patients.