Psychotherapy

Psychotherapy is a set of techniques intended to improve mental health, emotional or behavioral issues in individuals, who are often called "clients". These issues often make it hard for people to manage their lives and achieve their goals. Psychotherapy is aimed at these problems, and attempts to solve them via a number of different approaches and techniques; commonly psychotherapy involves a therapist and client(s), who discuss their issues in an effort to discover what they are and how they can manage them. Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client privacy and client confidentiality. See therapeutic frame for more.

General description
Given that psychotherapy is restricted to conversations, practitioners do not have to be medically qualified. In most countries, however, psychotherapists must be trained, certified and licensed with a range of different licensing schemes and qualification requirements in place around the world. Psychotherapists may be psychologists, social workers, trained nurses, psychiatrists, psychoanalysts, counselors, or professionals of other mental health disciplines. Psychiatrists' training focuses on the prescription of medicines, with some training in psychotherapy. Psychologists have special training in psychological assessment and research in addition to psychotherapy. Social workers have special training in linking patients to community and institutional resources in addition to psychotherapy. Licensed Professional Counselors have special training in career, mental health, school, and rehabilitation counseling.

Recent trends in drug development to treat chemical imbalances have led to a more wide spread use of pharmaceuticals in conjunction with psychotherapy by medically qualified mental health nurse practitioners, psychiatrists, and in some states prescribing psychologists. While having benefits for patients with ailments such as bipolar disorder, impulse problems, schizophrenia and obsessive compulsive disorder, drugs of late have begun to be used as a 'quick fix' and are gaining less favor in the therapeutic community.

There are at least six main systems of psychotherapy:
 * Psychodynamic,
 * Cognitive ,
 * Humanistic/supportive
 * Behavioral,
 * Brief therapy (sometimes called "strategic" therapy),
 * Systemic Psychotherapy (including family therapy & marriage counseling).


 * For an idea of the range of different kinds of psychotherapies, see the list of psychotherapies.

History

 * For a comprehensive view of the different kinds of psychotherapies, see the List of psychotherapies. 
 * For a view of the development of psychotherapy see the Timeline of Psychotherapy history

Most psychotherapies are either direct descendants of psychoanalysis, or their founders started out in areas of psychoanalysis before developing their own theories. Therefore, when describing the history of psychotherapy, most traditionally start with Freud.

Psychoanalysis
Although there are some bodies of thought in psychology without Sigmund Freud in their legacy, most can be traced back to his work starting in the 1880s in Vienna. Trained as a neurologist, Freud began noticing neurological problems in patients that had no discernible biological basis. Seeing blindness, paralysis and anorexia with no apparent physical cause, he looked towards the mind for answers. Finding some evidence that those who were mentally ill could exhibit physical symptoms, he discovered colleagues and teachers who were equally perplexed and interested in such matters like Josef Breuer and Jean-Martin Charcot.

Freud opened up a private practice in 1886 until 1896 that mostly treated women who showed symptoms of hysteria (which, at that time, was very loosely defined). Using such techniques as dream interpretation, free association, transference and analysis of the id, ego and superego, his colleagues developed a system of psychotherapy termed 'psychoanalysis'. Students and colleagues of his such as Alfred Adler, Otto Rank and Carl Jung became psychoanalysts themselves, and formed their own differentiating systems of psychotherapy. These were all later termed under a more broad label of 'psychodynamic', meaning anything that involved the psyche's conscious/unconscious influence on external relationships and the self. Psychodynamic psychotherapy and psychoanalysis are considered to be particularly effective at treating certain mental disorders, such as personality disorders and mood disorders.

Current psychodynamic approaches continue to develop and change. Contemporary Freudian approaches usually retain Freud's emphasis on sexuality, aggression, and mental conflict, and often prefer insight-oriented, uncovering psychotherapy to more supportive techniques. Contemporary Freudians, for the most part, continue to believe that psychotherapy is most effective when it leads to increased self-knowledge on the part of the patient. Other current psychodynamic approaches -such as object-relational and self-psychological approaches- prefer techniques designed to change the patient's habitual patterns of living by building an especially authentic or supportive relationship with the analyst that is believed to help the patient learn new ways of relating to others and to life in general.

The psychoanalytic community has recently begun to put extensive effort into researching the efficacy and process of psychoanalytic treatment.

Cognitive
As psychoanalysis and its influence spread throughout the world in the early 1900s, other ideas were brewing. Aaron T. Beck, following schooling at Brown University and Yale Medical School developed his own form of psychotherapy known as cognitive therapy in the 1940s. Similarly Albert Ellis, a student at Columbia University developed Rational Emotive Behavior Therapy (REBT). The spectrum that soon became cognitive therapy involves some common features. These included short, structured and present focused therapy aimed at changing a person's distorted thinking. Being oriented towards symptom-relief, collaborative empiricism and modifying peoples core beliefs, this is often the preferred method of treatment for depression, substance abuse, anxiety disorders, eating disorders and phobias. This method of treatment is known for having been more extensively researched than most other types of psychotherapy.

Humanistic
Another body of thought in psychotherapy started in the 1950s with Carl Rogers. Rogers, who went to Columbia University just like Albert Ellis, earned a PhD while simultaneously becoming interested in existentialism, the works of Abraham Maslow and his hierarchy of human needs. By the early 1930s he had finished his doctoral work and had brought Person centered psychotherapy into mainstream focus. Rogers' basic tenets were unconditional positive regard, genuineness, and empathic understanding, with each demonstrated by the counselor. According to Rogers, these tenets were both necessary and sufficient to create a relationship conducive to enhancing the client's psychological well being, by enabling the client to fully experience themselves. Inspired by Rogers, others followed his mode of thinking like Fritz and Laura Perls in the creation of Gestalt therapy. Later these fields of psychotherapy would become what is known as humanistic psychotherapy today.

Behavioral
The rudiments of behavioral counseling begin in the 1920s, however its comprehensive form did not emerge until the 1950s and 1960s. The primary contributors were Joseph Wolpe in South Africa, M.B. Shipiro and Hans Eyseneck in Britain, and B.F. Skinner in the United States.

Behavioral counseling approaches rely on principles of operant conditioning, classical conditioning and social learning theory. Drawing on principles of behaviorism, behavioral counseling focuses on behaviors that are observable and measurable, rather than cognitions. Note that B. F. Skinner was named Humanist of the Year in 1972 by the American Humanist Association, indicating that behavioral counseling is considered compatible with humanistic philosophy as well (Epstein, 1997).

The behavioral counselor may use operant conditioning techniques contingency contracts, self-management, shaping, behavioral momentum, token economies, response cost, and biofeedback. For social learning theory techniques, counselors may use modeling, behavior practice groups, and role playing. Often classical conditioning techniques are the treatment of choice for phobias and fetishes, and include techniques of systematic desensitization, flooding, counterconditioning, and aversive conditioning. Sometimes hypnosis is used to achieve relaxation as well.

Additionally, behavioral counseling has been effective in treating eating disorders. Behavioral counseling is the most scientifically validated approach because of its emphasis measurable and observable results. Increasingly, counselors and researchers are incorporating behavior modification techniques with other approaches (eclectic or multimodal approaches), and develop behavioral definitions to measure psychological constructs such as depression, anxiety or anger (Thompson, Rudolph, & Henderson, 2004).

Brief counseling
Also see: Brief therapy

Brief Counseling can make use of any of the above psychotherapeutic approaches, but it also may involve specific techniques that have been shown to provide rapid relief for large numbers of people. Among these approaches are Narrative Therapy and Solution-focused Therapy. These practices help clients to identify those occasions when their stated problem(s) are less dominant in their lives.

Typically brief counseling can take from one to five sessions. Employee Assistance Programs are geared to provide brief assessments and interventions that often fulfill the clients' needs in just a few sessions. It is also not unusual for a community mental health center to offer Brief Counseling to all new clients in order to encourage greater self-reliance and to discourage dependence on a therapist. In such a context, self-help groups also play a role in aiding ongoing improvements in functioning.

Well-known writers/practitioners of brief counseling techniques are Bill O'Hanlon, Insoo Kim Berg, Michael White, Jeffrey Guterman, and Steve de Shazer.

Schools and approaches
Psychoanalysis was the earliest form of psychotherapy, but many other theories and techniques are also now used by psychotherapists, psychologists, psychiatrists, personal growth facilitators and social workers. Techniques for group therapy have been developed.

While behaviour is often a target of the work, many approaches value working with feelings and thoughts. This is especially true of the psychodynamic schools of psychotherapy, which today include Jungian therapy and Psychodrama as well as the psychoanalytic schools. Other approaches focus on the link between the mind and body and try to access deeper levels of the psyche through manipulation of the physical body. Examples are Rolfing, Pulsing and postural integration.

A distinction can also be made between those psychotherapies that employ a medical model and those that employ a humanistic model. In the medical model the client is seen as unwell and the therapist employs their skill to help them back to health. In the humanistic model the therapist facilitates learning in the individual and the clients own natural process draws them to a fuller understanding of themselves. An example would be gestalt therapy.

Some psychodynamic practitioners distinguish between more uncovering and more supportive psychotherapy. Uncovering psychotherapy emphasizes facilitating clients' insight into the roots of their difficulties. The best-known example of an uncovering psychotherapy is classical psychoanalysis. Supportive psychotherapy, by contrast, stresses strengthening clients' defenses and often providing encouragement and advice. Depending on the client's personality, a more supportive or more uncovering approach may be optimal. Most psychotherapists utilize a combination of uncovering and supportive approaches.

Cognitive behavioural therapy is particularly common where the mode of psychotherapy is dictated by the demands of insurance companies who wish to see a financially limited commitment.

A computer program called ELIZA has been built to perform an automated and extremely simplified version of Rogerian psychotherapy.

There is considerable controversy over which form of psychotherapy is most effective, and more specifically, which types of therapy are optimal for treating which sorts of problems. Psychotherapy outcome research -in which the effectiveness of psychotherapy is measured by questionnaires given to patients before, during, and after treatment- has had difficulty distinguishing between the different types of therapy. Many psychotherapists believe that the nuances of psychotherapy cannot be captured by this type of research, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice.

Therapeutic Relationship
Research has shown that the quality of the relationship between the therapist and the client has a greater influence on client outcomes than the specific type of psychotherapy used by the therapist (this was first suggested by Saul Rosenzweig in 1936). Accordingly, most contemporary schools of psychotherapy focus on the healing power of the therapeutic relationship.

This research is extensively discussed (with many references) in The Heart and Soul of Change: What Works in Therapy, Mark A. Hubble, Barry L. Duncan, Scott D. Miller (Eds), American Psychological Association (1999) ISBN 155798557X (quotes in this section are from this book) and in "The great psychotherapy debate" by Bruce Wampold (2001).

A literature review by M. J. Lambert (1992) estimated that 40% of client changes are due to extratherapeutic influences, 30% are due to the quality of the therapeutic relationship, 15% are due to expectancy (placebo) effects, and 15% are due to specific techniques. Extratherapeutic influences include client motivation and the severity of the problem:

For example, a withdrawn, alcoholic client, who is "dragged into therapy" by his or her spouse, possesses poor motivation for therapy, regards mental health professionals with suspicion, and harbors hostility toward others, is not nearly as likely to find relief as the client who is eager to discover how he or she has contributed to a failing marriage and expresses determination to make personal changes.

In one study, some highly motivated clients showed measurable improvement before their first session with the therapist, suggesting that just making the appointment can be an indicator of readiness to change. Tallman and Bohart note that:

''[O]utside of therapy people rarely have a friend who will truly listen to them for more than 20 minutes (Stiles, 1995)... Further, friends and relatives often are involved in the problem and therefore do not provide a "safe outside perspective" which may be required. Nonetheless, as noted above, people often solve their problems by talking to friends, relatives, co-workers, religious leaders, or some other confidant in their lives, or by thinking and exploring themselves.''

Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy. Journal of Orthopsychiatry, 6, 412-415

Lambert, M. J. (1992). Implications of outcome research for psychotherapy integration. In J. C. Norcross & M. R. Goldfried (Eds), Handbook of Psychotherapy Integration (pp. 94-129)

Stiles, W. B. (1995). Disclosure as a speech act: Is it psychotherapeutic to disclose? In J. E. Pennebaker (Ed.), Emotion, Disclosure, and Health (pp. 71-92).

Tallman, Karen, and Arthur C. Bohart (1999). The Client as a Common Factor: Clients as self-healers. In Hubble, Duncan, Miller (Eds), The Heart and Soul of Change (pp. 91-131)

Asay, Ted P., and Michael J. Lambert (1999). The Empirical Case for the Common Factors in Therapy: Quantitative Findings. In Hubble, Duncan, Miller (Eds), The Heart and Soul of Change (pp. 23-55)

Wampold, B. E. (2001). The great psychotherapy debate. New Jersey: Lawrence Erlbaum.

Criticism
Critics of psychotherapy suggest that the passage of time contributes significantly to psycho-social healing. After a difficult personal event, the friendly support of friends, peers, and family members; clergical contacts; and personal reading, research, and independent coping are all likely contributors to improvement should the person have those resources at hand. Contemporary use of simple questionnaires to report on personal function and feeling cannot be easily isolated from a variety of other valuable, more accessible, and less expensive tools that have been in place long before psychotherapy or psycho-active pharmaceuticals.

Related lists

 * Important publications in psychoanalysis & psychotherapy

Psychodynamic schools

 * Anthony Bateman, Dennis Brown, Jonathan Pedder Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice; Routledge; ISBN 0415205697; June 2000


 * Bateman, A. & Holmes J. Introduction to Psychoanalysis: Contemporary Theory and Practice; Routledge; ISBN 0415107393; 1995


 * Ellenberger, Henri F., The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry, Basic Books 1970

Humanistic schools

 * John Rowan; Ordinary Ecstasy: Brunner-Routledge; ISBN 0415236320; March 2001

General

 * Thomson, C.L, Rudolph L.B., & Henderson, D. (2004). Counseling children. (6th ed.). Belmont, CA: Brooks/Cole Thompson.

Behavioral

 * Epstein, R. (1997) Skinner as self-manager. Journal of applied behavior analysis. 30, 545-569. Retrieved from the world wide web on June 2, 2005 from http://seab.envmed.rochester.edu/jaba/articles/1997/jaba-30-03-0545.pdf