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- Also see Psychotherapy (disambiguation)
Psychotherapy is a set of techniques intended to improve mental health, emotional or behavioral issues of individuals, group, or family interactional climates. Mental health problems can include psychological, social and somatic dimensions, which often make it hard for people to manage their lives and achieve their goals. Psychotherapy is aimed at these problems, and attempts to help people to solve them via a number of different approaches and techniques.
The term counseling is often used interchangeably with psychotherapy. It was originally adopted by Carl Rogers to distinguish his work from the more medically oriented psychotherapy but the difference has become blurred among lay people. Generally, counseling deals with ordinary every day problems and issues, while psychotherapy generally deals with deeper mental and emotional problems. Psychotherapy requires more intense training than counseling, and often tends to involve an longer commitment for the patient. (But see: brief, or strategic, therapy). In this article the term can be taken to be the same as psychotherapy.
Psychotherapeutic interventions are often designed to treat the client in the medical model, although not all psychotherapeutic approaches follow the model of "illness/cure". Some practitioners, such as humanistic schools, see themselves in an educational or helper role.
To emphasize the voluntary, free agency, consumer orientation of people seeking psychotherapy, they are often called clients, but psychotherapy as a method of treatment is regulated, at least in most Western countries, by the laws concerning patients and their rights. Commonly psychotherapy involves a therapist and client(s) — and in family therapy several family members or even other members from their social network — who discuss their issues in an effort to discover the underlying problems and to find constructive solutions. Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client confidentiality.
- 1 General description
- 2 History
- 3 Schools and approaches
- 4 Therapeutic Relationship
- 5 Criticism
- 6 See also
- 7 Related lists
- 8 References
- 9 Introductory books
- 10 Further reading
- 11 External links
Given that psychotherapy is restricted to conversations, practitioners do not have to be medically qualified, but to guarantee the medical safety of psychotherapy, a basic acquaintance with psychiatric and psychological considerations is typically a part of their training. In most countries, however, psychotherapists must be trained, certified, and licensed, with a range of different certification and licensing requirements in force internationally. Psychotherapists may be psychologists, Clinical Mental Health Practitioners, social workers, trained nurses, psychiatrists, psychoanalysts, mental health counselors, school counselors, or professionals of other mental health disciplines.
The primary training of a psychiatrist focuses on the biological aspects of mental disorders, with some training in psychotherapy. Psychologists and Clinical Mental Health Practitioners usually have more training in psychological assessment and research and, in addition, from a moderate amount to a great deal of training in psychotherapy. Social workers have specialized training in linking patients to community and institutional resources, in addition to elements of psychological assessment and psychotherapy. Licensed professional counselors(LPC's) generally have special training in career, mental health, school, or rehabilitation counseling. Many family therapy training programs are multiprofessional, that is, psychiatrists, psychologists, mental health nurses, and social workers may be found in the same training group. In these approaches the family therapy session itself may be conducted by a multiprofessional team. Consequently, specialized psychotherapeutic training in most countries requires a program of continuing education after the basic degree.
Evidence of the effectiveness of certain psychoactive drugs, especially to treat serious depression, bipolar disorder, and schizophrenia, 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.. Research reveals that both drugs and psychotherapy combined are more efficacious than either treatment alone in treating persons with mental disorders.
There are at least six main systems of psychotherapy:
- Cognitive ,
- Brief therapy (sometimes called "strategic" therapy, solution focused brief therapy),
- Systemic Therapy (including family therapy & marriage counseling).
- For an idea of the range of different kinds of psychotherapy, see the list of psychotherapeutic approaches.
- 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
When describing the history of psychotherapy, given the influence of psychoanalysis in the XX century, it is still traditional to start with the Viennese physician Sigmund Freud, albeit what is still considered valid today of his theorization is not his own original produce and what is really new has been definitely disconfirmed from research[How to reference and link to summary or text]. While many psychotherapies are direct descendants of psychoanalysis, other founders started out in areas of psychoanalysis before rejecting it and developing their own theories, in search of more viable and effective alternatives. Many more developed their ideas in a completely independent way and different methods. There are many bodies of thought in psychology without Sigmund Freud in their legacy, albeit many professionals still believe that they can be traced back to his work starting in the 1880s in Vienna. Moreover, while Freud is credited with being the first to use dialogue as a therapeutic tool, he was not. Given the importance given today to the empirical scrutiny of any theorization, specially when used to provide services to public, it looks more opportune to begin with the more scientifically sound approaches.[How to reference and link to summary or text]
- Main article: Psychoanalysis
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. Although, it requires hundreds of sessions over a period of several years.
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.
Behavioral approaches developed separately from psychoanalysis and drawing from concepts and theories emerging from scientific work being done in the XX century in different fields of cognitive and behavioural sciences, such as animal, social, cognitive, or experimental psychology, and ethology. These theories and concepts were developed mainly in laboratories or research fields. These researches included such individuals as the Nobel prize winner I. Pavlov, or the highly influential psychologist B.H. Skinner, the proponents of psychotherapy approaches did have initially more influence in the academic environments rather than on the public at large. Moreover, the empirical attitude to check the validity of observations against factual evidence which distinguishes the scientific enterprise, and the needed critical attitude which feeds discussions among researchers, reduced the impact on western culture of the ideas emerging from their studies.
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. Shapiro and Hans Eysenck 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).
Aaron T. Beck, following schooling at Brown University and Yale University Medical School developed a form of psychotherapy, drawing from concepts and methods already used in behavior therapy, which he called cognitive therapy in the 1960s.
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.
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.
Existential psychotherapy is concerned mainly with the individual's ability to preserve a sense of meaning and purpose throughout the lifespan in the face of immutable biological limitations of a mortal existence (ie ageing, death)and issues associated with human self awareness (ultimate aloneness, having sole responsibility for our actions, choices and freedom). Therapeutic stance is a combination of the psychoanalytic school (eg defences versus unconscious death anxiety) and the humanistic model. Major contributors to the field (eg Irvin Yalom) have attempted to create a therapy sensitive to common 'life crises' springing from the essential bleakness of human self awareness, previously accessible through the complex writings of existential philosophers (eg Jean-Paul Sartre, Friedrich Nietzsche).
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.
Schools and approaches
A complete list of psychotherapies is also available.
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.
Medical and non-medical models
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. The extensive use of the DSM-IV, the diagnostic and statistical manual of mental disorders in the United States, is an example of a medically-exclusive model.
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 a kind of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of mental disorder. It involves recognising distorted thinking and learning to replace it with more realistic substitute ideas. This type of 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.
Expressive therapy is a form of therapy that utilizes artistic expression as its core means of treating clients. Expressive therapists use the different disciplines of the creative arts as therapuetic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy among others. Expressive therapists believe that often the most effective way of treating a client is through the expression of imagination in a creative work and integrating and processing what issues are raised in the act.
Adaptations for children
Counseling and psychotherapy must be adapted to meet the developmental needs of children. Many counseling preparation programs include a courses in human development. Since children often do not have the ability to articulate thoughts and feelings, counselors will use a variety of media such as crayons, paint, clay, puppets, bibliocounseling (books), toys, et cetera. The use of play therapy is often rooted in psychodynamic theory, but other approaches such as Solution Focused Brief Counseling may also employ the use of play in counseling. In many cases the counselor may prefer to work with the care taker of the child, especially if the child is younger than age four. Theraplay is an approach developed to facilitate a healthier relationship between parent and child that uses structured play. Children who have experienced chronic early maltreatment that results in Complex Post Traumatic Stress Disorder or reactive attachment disorder can be effectively treated with Dyadic Developmental Psychotherapy , which is an evidence-based family-based treatment approach.
- Main article: Evaluation of outcome in 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 success or failure of the different approaches to therapy. Not surprisingly, those who stay with their therapist for longer periods are more likely to report positively on what develops into a longer term relationship. Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice.
In 2001 Bruce Wampold, Ph.D. of the University of Wisconsin published "The Great Psychotherapy Debate." In it Wampold, a former statistician studying primarily outcomes with depressed patients, reported that (1) psychotherapy can be more effective than placebo, (2) no single treatment modality has the edge in efficacy, and (3) factors common to different psychotherapies, such as whether or not the therapist has established a positive working alliance with the client/patient, account for much more of the variance in outcomes than specific techniques or modalities. Some report that by attempting to program or manualize treatment psychotherapists may actually be reducing efficacy, although the unstructured approach of many psychotherapists cannot appeal to patients motived to solve their difficulties through the application of specific techniques different from their past "mistakes."
- Main article: 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.
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.
- Important publications in psychoanalysis & psychotherapy
- List of psychotherapies
- Timeline of psychotherapy
- Antidepressant drug trials: fast track to overprescription?. URL accessed on 2006-03-16.
- Becker-Weidman. Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. 23(2), April 2006
- Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
- Becker-Weidman, A., (2006b) Dyadic Developmental Psychotherapy: a multi year follow-up. in Sturt, S., (ed) New Developments in Child Abuse Research. NY: Nova
- Anthony Bateman, Dennis Brown, Jonathan Pedder Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice; Routledge; ISBN 0415205697; June 2000
- Bloch S (ed.) (1979) An Introduction to the Psychotherapies. OUP: Oxford
- Brown D & Pedder J (1991) Introduction to Psychotherapy (2nd edition). Tavistock: London
- Casement P (1986) On Learning From the Patient. Tavistock: London.
- Casement P (1991) Further Learning From the Patient. Tavistock: London.
- Hughes, P (1999) Dynamic Psychotherapy Explained Routledge: London
- Malan D H (1979) Individual Psychotherapy and the Science of Psychodynamics. Butterworths: London.
- Storr A (1979) The Art of Psychotherapy. Secker & Warburg and Heinemann: London
- 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.
- Cozoli, L.J. (2002) The neuroscience of psychotherapy: building and rebuilding the human brain. New York : Norton. ISBN 0393703673
- 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
- Freud S (1985) (edited A Freud) The Essentials of Psychoanalysis. Penguin: London.
- Freud S (1962) Two Short Accounts of Psychoanalysis. Penguin: London
- Hobson R F (1986) Forms of Feeling: The Heart of Psychotherapy. London. Tavistock
- Klein M (1988) Envy and Gratitude Virago: London
- Klein M (1988) Love, Guilt and Reparation Virago: London
- Sandler J, Dare C & Holder A (1973) The Patient and the Analyst: The Basis of the Psychoanalytic Process. Maresfield Reprint: London
- Winnicott D W (1971) Playing and Reality Pelican: Harmondsworth
- John Rowan; Ordinary Ecstasy: Brunner-Routledge; ISBN 0415236320; March 2001
- Thomson, C.L, Rudolph L.B., & Henderson, D. (2004). Counseling children. (6th ed.). Belmont, CA: Brooks/Cole Thompson.
- 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
- American Counseling Association
- American Psychological Association
- American Mental Health Counselors Association
- British Association for Counselling and Psychotherapy
- Counselling Directory
- Counselling Directory UK
- Types of Counselling & Psychotherapy from CounsellingResource.com
- UK Council for Psychotherapy
- European Association for Psychotherapy
- European Body Psychotherapy (Europäische Vereinigung Körperpsychotherapie)
- International PSY Congresses
- Twelve Stages of Classical Adlerian Psychotherapy
- Yalom's psychotherapy.net
- Social Anxiety.com
- Counselling Services UK
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