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The treatment of mental and emotional disorders through the use of psychological techniques designed to encourage communication of conflicts and insight into problems, with the goal being relief of symptoms, changes in behavior leading to improved social and vocational functioning, and personality growth.
psychotherapeutic psy'cho·ther'a·peu'tic (-pyū'tĭk) adj.Any treatment or therapy that is primarily psychological in nature. In recent years, counseling also has been included in this categorization.
Psychodynamic therapies
Historically, psychoanalysis—created by Sigmund Freud—has played an important role in the growth and development of psychotherapy. Central to Freud's theories was the importance of unconscious conflicts in producing the symptoms and defenses of the patient. The goal of therapy is to help the patient attain insight into the repressed conflicts which are the source of difficulty. Since patients resist these attempts bring to consciousness the painful repressed material, therapy must proceed slowly. Consequently, psychoanalysis is a long-term therapy requiring several years for completion and almost daily visits. Since Freud's time, there have been important modifications associated with former disciples such as Alfred Adler and Carl Jung. Self psychology and ego psychology are among more recent emphases. However, the popularity of psychoanalysis has waned. See also Psychoanalysis.
Experiential therapies
A number of related therapies are included in this group. Probably best known was the patient-centered therapy of Carl Rogers appearing in the 1940s. In Rogers' therapy, a major emphasis is placed on the ability of the patient to change when the therapist is empathic and genuine and conveys nonpossessive warmth. The therapist is nondirective in the interaction with the patient and attempts to facilitate the growth potential of the patient. Other therapeutic approaches considered as experiential include Gestalt therapy, existential approaches, and transpersonal approaches. The facilitation of experiencing is emphasized as the basic therapeutic task, and the therapeutic relationship is viewed as a significant potentially curative factor.
Cognitive, behavioral, and interpersonal therapies
In behavioral therapies, therapists play a more directive role. The emphasis is on changing the patient's behavior, using positive reinforcement, and increasing self-efficacy. More recently, cognitive therapies such as those of A. T. Beck have tended to be combined with behavioral emphases. The cognitive-behavioral therapies have focused on changing dysfunctional attitudes into more realistic and positive ones and providing new information-processing skills. See also Cognition.
Most of the developments in interpersonal therapy have occurred in work with depressed patients. The goal of interpersonal therapy (a brief form of therapy) is centered on increasing the quality of the patient's interpersonal interactions. Emphasis is placed on enhancing the patient's ability to cope with stresses, improving interpersonal communications, increasing morale, and helping the patient deal with the effects of the depressive disorder. See also Personality theory.
Eclectic and integrative therapies
The largest number of psychotherapists consider themselves to be eclectics. They do not adhere strictly to one theoretical orientation or school but use any procedures that they believe will be helpful for the individual patient. Eclecticism has been linked with the development of a movement for integration in psychotherapy. The emphasis in this new development is on openness to the views of other approaches, a less doctrinaire approach to psychotherapy, and an attempt to integrate two or more different theoretical views or systems of psychotherapy.
Group, family, and marital therapy
Most psychotherapy is conducted on a one-to-one basis—one therapist for one patient—and the confidentiality of these sessions is extremely important. However, there are other instances where more than one patient is involved because of particular goals. These include marital, family, and group therapy. Outpatient groups have been used for smoking cessation, weight loss, binge eating, and similar problems as well as for what were traditionally viewed as psychoneurotic problems. Inpatient group therapy was frequently employed in mental hospital settings.
There has been research on the combined use of medication and psychotherapy. In general, where two highly successful treatments are combined in cases with depressive or anxiety disorders, there appears to be little gain in effectiveness. However, in several studies of hospitalized patients with schizophrenia where individual psychotherapy has been ineffective, a combination of psychotherapy and medication has produced better results than medication alone. See also Affective disorders; Psychopharmacology; Schizophrenia.
Any of a large number of related methods of treating mental or emotional disorders by psychologic techniques rather than by physical means.
Definition
Psychotherapy can be defined as a means of treating psychological or emotional problems such as neurosis or personality disorder through verbal and nonverbal communication. It is the treatment of psychological distress through talking with a specially trained therapist and learning new ways to cope rather than merely using medication to alleviate the distress. It is done with the immediate goal of aiding the person in increasing self-knowledge and awareness of relationships with others. Psychotherapy is carried out to assist people in becoming more conscious of their unconscious thoughts, feelings, and motives.
Psychotherapy's longer-term goal is making it possible for people to exchange destructive patterns of behavior for healthier, more successful ones.
Different Approaches to Psychotherapy
The psychodynamic approach was derived from principles and methods of psychoanalysis, and it encompasses psychoanalysis, Jungian analysis, Gestalt therapy, client-centered therapy, and somatic or body therapies, among
| TYPES OF PSYCHOTHERAPY | |||
| Type | Description | Disciplines | Proponents |
| Psychodynamic | Based on psychoanalysis, the psychodynamic approach believes behavior and personality stem from the unconscious wishes and conflicts from childhood. | Psychoanalysis, Jungian analysis, Gestalt therapy Client-centered therapy, and somatic or body therapies | Sigmund Freud, Carl Jung, Alfred Adler, Erich Fromm, Karen Horney, Erik Erikson, and Frederick (Fritz) Perls |
| Behavioral | Encompasses various behavior modification techniques and theories | Assertiveness training/social skills training, operant conditioning, hypnosis/hypnotherapy, sex therapy, systematic desensitization, etc. | Joseph Wolpe |
| Cognitive | Focuses on the influence thoughts have on behavior | Rational-emotive therapy and reality therapy | Albert Ellis, William Glasser |
| Family systems | Believes behavior in influenced by family dynamics and attempts to modify relationships within the family | Family therapy | Murray Bowen |
other forms of psychotherapy. Psychoanalysis is therapy based upon the work of Austrian physician Sigmund Freud (1856–1939), and those who followed, Carl Jung, Alfred Adler, Erich Fromm, Karen Horney, and Erik Erikson. The basis of psychoanalytic therapy is the belief that behavior and personality develop in relation to unconscious wishes and conflicts from childhood. Gestalt therapy, developed by Frederick (Fritz) Perls, emphasizes the principles of self-centered awareness and accepting responsibility of one's own behavior. Client-centered therapy was formulated by Carl Rogers, and it introduced the idea that individuals have the resources within themselves for self-understanding and for change. Part of this concept is that the therapist exposes his or her own true feelings and does not adopt a professional posture, keeping personal feelings unclear. Somatic or body therapies include: dance therapy, holotropic breathwork, and Reichian therapy.
The behavioral approach encompasses various behavior modification techniques and theories, including assertiveness training/social skills training, operant conditioning, hypnosis/hypnotherapy, sex therapy, systematic desensitization, and others. Systematic desensitization was pioneered by Joseph Wolpe, after he became frustrated with psychoanalysis. This therapy is a combination of deep muscular relaxation and emotive imagery exercises, in which the client relaxes and the therapist verbally sets scenes for the client to imagine. These scenes include elements of the client's fears, building from the smallest fear toward the largest fear, and the therapist monitors the client and introduces the scenes, working to maintain the client's relaxed state.
The cognitive approach stresses the role that thoughts play in influencing behavior. Rational-emotive therapy and reality therapy are both examples of the cognitive approach. Rational-emotive therapy was pioneered by Albert Ellis in the mid-1950s. This therapy is based on the belief that events in and of themselves don't upset people, but people get upset about events because of their attitudes towards the events. Ellis's therapy set out to change people's attitudes about events through objective, firm direction from the therapist and talk therapy. Reality therapy, developed by William Glasser, is based upon the idea that humans seek to satisfy their complex needs, and the behaviors they adopt are to accomplish that satisfaction. In Glasser's theory, some people usually fulfill themselves and are generally happy, while others are unable to fulfill themselves and get angry or depressed.
The family systems approach includes family therapy in several forms and is the attempt to modify relationships within the family. Family therapy views behaviors and problems as the result of family interactions, rather than as belonging to a family member. One theory, developed by Murray Bowen, has become its own integrated system with eight basic concepts, including differentiation of self and sibling position. This system attempts to help an individual become differentiated from the family, while remaining in touch with the family system.
In the practical application of these approaches, psychotherapy can take many forms. Some of the most commonly practiced forms include:
All forms of psychotherapy require an atmosphere of absolute mutual trust and confidentiality. Without this total safety, no form of therapy will be successful.
Origins
Psychotherapy had its beginnings in the ministrations of some of the earliest psychologists, priests, magicians, and shamans of the ancient world. They attempted to determine the causes of the person's emotional distress by talking, counseling, and educating, and interpreting both behavior and dreams. Many of these practices became suspect as the work of charlatans, and fell into disrepute over the centuries. There was little change or progress in the treatment of mental illness over the centuries that followed.
Austrian physician Franz Anton Mesmer (1734–1815) began using what he termed magnetism and both the power of suggestion and hypnosis in 1772. Mesmer's treatments, too, fell into disrepute after his theories were rejected by a medical board of inquiry in 1784. Then, nearly a century later, Mesmer's ideas were rediscovered by French neurologist Jean-Martin Charcot (1825–1893). Dr. Charcot used suggestion and hypnosis for treating psychological difficulties at Salpêtrière Hospital in Paris in the late nineteenth century. Mesmer is now known as the Father of Hypnosis.
In the late nineteenth and early twentieth century, Austrian physician Sigmund Freud studied Charcot's work, and came to believe that hypnosis was less a treatment for mental illness than a means of determining its underlying cause. Freud used hypnosis as one means of uncovering the often traumatic, not consciously recalled memories of his neurotic patients just as he used their dreams to evaluate their mental conflicts. He later abandoned hypnosis because he did not induce successful trances in his neurology patients. His The Interpretation of Dreams, published in 1899, made the point that a person's dreams were actually a window into the inner, un-known mind—the royal road to the unconscious. He used the information he obtained not only to help his patients, but also to collect data that eventually helped verify some of his psychodynamic assumptions.
Sigmund Freud theorized that the human personality is composed of three basic parts, the id, the ego, and the superego. The id is defined as the most elemental part, the one that unconsciously motivates people toward fulfilling instinctive urges. The ego is more related to intellect and judegment. It arbitrates between the internal, usually unrecognized desires all human beings have and the reality of the external world. The superego, unconscious controls dictated by moral or social standards outside of ourselves, is probably most easily described as another name for the conscience.
Freud believed that mental illness was the result of people being unable to resolve conflict, or inadequate settlement of disharmony among the ego, superego, and id. To deal with these internal psychic conflicts, people develop defense mechanisms, which is normally a healthy response. The defense mechanisms become harmful to mental health when overused, or used inappropriately. Freud further postulated that childhood psychic development is primarily based upon sexuality; he divided the first eighteen months of life into three sexbased phases: oral, anal, and genital.
Freud's earliest students, including Carl Jung and Alfred Adler, came to believe that Freud had overestimated the influence sexuality had on psychic development, and found other influences that helped to shape the personality. In the late 1800s and into the twentieth century, 1904 Nobel Prize winner Ivan Petrovich Pavlov pioneered the research that would later result in behavioral therapies, such as the work of American behaviorist Burrhus Frederic Skinner. And in the 1930s, American psychologist Carl Ransom Rogers began his school of psychology that emphasized the importance of the relationship between the patient (or client, according to Rogers) and the therapist in bringing about positive psychic change.
Primal therapy, developed by Arthur Janov in the 1960s, is based upon the assumption that people must relive early life experiences with all the acuity of feeling that was somehow suppressed at the time in order to free themselves of compulsive or neurotic behavior. Primal therapy was a cathartic approach that many therapists now believe can impede progress because a person can become addicted to the release (even "high") associated with the catharsis and seek to keep repeating it for the momentary satisfaction. Transactional analysis, based on Eric Berne's work, came into favor in the 1970s, and supposes that all people function as either parent or child at various times, and teaches the person to identify which role he or she is filling at any given time and to evaluate whether this role is appropriate.
Benefits
The generally accepted aims of psychotherapy are:
Though there are no definitive studies proving that all five of these goals are consistently realized, psychotherapy in one form or other is a component of nearly all of both in-patient and community based psychiatric treatment programs.
Description
Classic Freudian psychotherapy is usually carried out in 50-minute sessions three to five times per week. The patient lies on a couch while he or she talks with the therapist. Freudian therapy characteristically requires ongoing treatment for several years, though in Freud's era it did not. Most other forms of individual psychotherapy, including Jungian, counseling, humanistic, Gestalt, or behavioral therapies, are carried out on a weekly basis (or more frequently, if necessary), in which the person meets with his or her therapist in the therapist's office, and may or may not continue for longer than a year.
Group therapy is held in a variety of settings. A trained group therapist chooses the people that presumably would benefit and learn from interactions with each other. The size of a group is usually five to 10 people, plus a specially trained therapist who guides the group discussion and provides examination of issues and concerns raised.
Child psychotherapy is done for the same reasons as adult psychotherapy—to treat emotional problems through communication. The obvious difference is that child psychotherapy must acknowledge the child's stage of development. This means that the therapist may use different techniques, including play, rather than only talking to the patient.
A newer direction in the treatment of mental disorders is the use of brief psychotherapy sessions, often combined with medication, to treat neurotic conditions. Another short-term psychotherapy is often termed crisis intervention, and is used to aid people in dealing with specific crises in their lives, such as the death of a loved one.
Research & General Acceptance
Psychotherapy, in its many forms, has been accepted and used throughout the world for more than one hundred years. It is normally covered as a valid treatment of mental disorder by both public and private health insurers. Because the various types of psychotherapy have different aims, and mental illnesses usually do not have absolute measurable signs of recovery, evaluating psychotherapy's effectiveness is difficult. As a general rule, the majority of people who undergo treatment with psychotherapy can expect to make appreciable gains. Studies have revealed, however, that not everyone who goes into therapy will be helped, or helped as much as others, and some will even be harmed.
Training & Certification
Though the actual clinical practice of psychotherapy is very much the same among disciplines, therapists come from a variety of different fields, including medicine, psychology, social work, and nursing.
Psychiatrists are required to complete four years of medical school and one year of internship, followed by a three-year residency in psychiatry. In order to be a psychoanalyst, a minimum of three years further training at a psychoanalytic institute is necessary, along with personal ongoing analysis.
Psychologists earn a Ph.D. in clinical psychology followed by a year of supervised practice, and additionally may take specialized training at a specific psychotherapeutic school, including therapy for themselves.
Social workers who specialize in mental health must earn a master's degree or doctorate before being allowed to practice.
Psychiatric nurses generally earn a master's degree and practice in hospitals or community mental health centers.
Most states in the United States require a license to practice as a psychotherapist, and by law in the majority of the states, they are accountable only to the other members of their profession.
Resources
Books
Clayman, Charles B., M.D. American Medical Association Home Medical Encyclopedia. New York: Random House, 1989.
Coleman, James C. Abnormal Psychology and Modern Life. Glenview, Illinois: Scott, Foresman and Company, 1972.
Engler, Jack, and Daniel Goleman. The Consumer's Guide to Psychotherapy. New York: Simon & Schuster, 1992.
Taber, Clarence Wilbur. Taber's Cyclopedic Medical Dictionary. F. A. Davis Co., 1997.
Other
American Group Psychotherapy Association. "About Group Psychotherapy." http://www.agpa.org (1999).
CNN. "A Century Later, Science Still Grapples with Freud." http://www.cnn.com.
Electric Library. "Group Psychotherapy." http://www.encyclopedia.com (1999).
Lucidcafe. "Sigmund Freud, Austrian Originator of Psycho-Analysis." http://www.lucidcafe.com.
[Article by: Joan Schonbeck]
For more information on psychotherapy, visit Britannica.com.
Behavior therapy aims to help the patient eliminate undesirable habits or irrational fears through conditioning. Techniques include systematic desensitization, particularly for the treatment of clients with irrational anxieties or fears, and aversive conditioning, which uses negative stimuli to end bad habits. Humanistic therapy tends to be more optimistic, basing its treatment on the theory that individuals have a natural inclination to strive toward self-fulfillment. Therapists such as Carl Rogers and Abraham Maslow used a highly interactive client-therapist relationship, compelling clients to realize exactly what they are saying or how they are behaving, in order to foster a sense of self-awareness. Cognitive therapies try to show the client that certain, usually negative, thoughts are irrational, with the goal of restructuring such thoughts into positive, constructive ideas. Such methods include Albert Ellis's rational-emotive therapy, where the therapist argues with the client about his negative ideas; and Aaron Beck's cognitive restructuring therapy, in which the therapist works with the client to set attainable goals. Other forms of therapy stress helping patients to examine their own ideas about themselves.
Psychotherapy may be brief, lasting just a few sessions, or it may extend over many years. More than one client may be involved, as in marriage or family counseling, or a number of individuals, as in group psychotherapy.
Bibliography
See S. L. Garfield and A. E. Bergin, ed., Handbook of Psychotherapy and Behavior Change (4th ed. 1993); A. Roth et al., What Works for Whom?: A Critical Review of Psychotherapy Research (1996); W. Gaylin, Talk Is Not Enough: How Psychotherapy Really Works (2000).
Psychotherapy is a method for the treatment of psychological problems, which are often expressed somatically.
Therapies can be classified following various models. In the cathartic model, the patient is urged to speak, in order to expel or get rid of his suffering. The therapist favors the act of communication over the content of what is expressed. In the reparative model, the therapist tries to help the patient by bringing love and understanding to cancel out the prejudice he has been victim of or to make up for some internal deficit. With the educational model, the therapist guides the patient in the "right" direction, advising him as to his life choices. He "corrects" the mistakes of nature, parental education, or social environment.
Freud demarcated himself dramatically from hypnosis and cathartic post-traumatic abreaction in developing an original psychotherapeutic dimension, centered on the exploration of the unconscious, the study of psychic functioning and intrapsychic conflicts, and transference-counter-transference relation (Ellenberger, 1970). He emphasized psychic reality understood through the reality of narrative. Accordingly, the psychotherapy to be discussed here is psychoanalytic psychotherapy, situated within the context of the theory, technique, and framework of psychoanalysis.
The term psychotherapy surfaced for the first time in 1872, while the term psychoanalysis came to be known only in 1896. But it wasn't until 1905, in his article "On Psychotherapy" (1905a [1904]) that Freud clearly distanced himself from hypnosis by opposing the cathartic method to the analytic method. For a number of decades, he had used the terms psychoanalysis and psychotherapy interchangeably, but shortly before 1920 he abandoned the term psychotherapy definitively, qualifying his method from then on as psychoanalysis. This abandonment occurred after the defections of Alfred Adler, Wilhelm Steckel, and Carl G. Jung and, in a second stage, his differences with Otto Rank and Sàndor Ferenczi. In effect, some of those in Freud's circle were advocating a more active attitude on the part of the psychoanalyst to accelerate the psychoanalytic process as well as to shorten its duration. A reaction was not long in coming: Ernest Jones and Edward Glover emphatically denounced any deviation from a traditional treatment, and any psychotherapeutic approach, such as a return to pure suggestion of the preanalytic period (Robert Wallerstein). This traditional position was the "official" one of the psychoanalytic movement for a very long time. Nevertheless, in the 1950s the term psychoanalytic psychotherapy gained currency among psychoanalysts themselves, who came to believe that certain changes had to be made in the framework of the classical psychoanalytic model, which was not appropriate for the psychopathology of some patients.
As of 2005, questions about the differences between psychoanalytic psychotherapy and psychoanalysis are still posed in terms of process: how, for example, could the psychoanalytical process be influenced by reworking the framework? The face-to-face position implies seeing the analyst, being able to observe his gestures and unconscious corporal reactions, to hang onto his every word and look into his eyes. Likewise, not being seen by the analyst can result in the patient's feeling lost, cast into the abyss, or on the contrary allow him to feel emotions that would be blocked by a face-to-face expression. However, these differences in formal framework (frequency of sessions, face-to-face or couch-armchair, more or less active position of the psychoanalyst, etc.) are insufficient, in themselves, to characterize the type of process underway. In any event, according to René Roussillon (1986), a psychoanalytic approach can only explore certain portions of the psyche. Even where the choice of the framework (psychotherapy or psychoanalysis) favors a psychoanalytical approach, this is not always necessarily the same one. Finally, the psychotherapeutic process is characterized by a transference of partial objects to the psychoanalyst while, in the psychoanalytical process, these partial transferences would be worked through until there was a full development of the transference neurosis.
Other authors have brought out differences in therapeutic aims. Ideally, in psychoanalysis the framework should allow exploration of the patient's unconscious with the psychoanalyst following the patient as far as he is able to go. According to this very strict definition, psychoanalysis does not, a priori, aim at a therapeutic goal. Instead, the therapeutic result emerges from the psychoanalytic process. By contrast, psychotherapy does imply a goal: to diminish the suffering of the patient, allowing him to return to work, and so on. However, these differences are not always so clear-cut in the reality of practice among psychoanalysts and psychotherapists. Whatever technique is chosen, standard treatment or face-to-face, the psychoanalyst has a "psychoanalytic function," so that any psychotherapeutic approach undertaken by the psychoanalyst involves psychoanalytical work.
Psychotherapy cannot be isolated from its social context. After the Second World War, the development of social health care programs allowed compensation for psychiatric care and the establishment of a variety of facilities for the treatment of specific pathologies. Many of the professionals practicing in these institutional settings were trained in psychoanalytic psychotherapy by psychoanalysts working in the field, or else were educated in teaching institutes that structured their curricula in accordance with psychoanalytic psychotherapy. These professionals engaged in personal psychoanalytic work without, necessarily, matriculating in the training courses of psychoanalytic societies; but very often a veritable analytical process developed with patients that they were treating in their institutions.
Accordingly, the wish of Freud (1919a [1918]) has been fulfilled, "to alloy the pure gold of analysis freely with the copper of direct suggestion" (p. 168) to create "a psychotherapy for the people" (p. 168), and to alleviate a greater portion of "the vast amount of neurotic misery which there is in the world" (p. 166), which the small number of psychoanalysts cannot greatly affect. Clearly Freud wanted to see the traditional treatment adapted to treat a greater number of patients as soon as "the conscience of society will awake" (p. 167). The concern to preserve psychoanalytic thought in some institutional form has led national societies of psychoanalytic therapy to create organizations like the European Federation for Psychoanalytic Psychotherapy (EFPP).
Psychoanalysis and psychoanalytic psychotherapy, and their particular adaptations (child psychoanalysis, group psychoanalysis, analytical psychodrama, psychoanalytical couple or family therapy, etc.) constitute a "psychoanalytic field," very different in nature from therapeutic techniques. The latter, basically anti-analytic, may be considered as "an ensemble of ready-made counter-transference approaches meant to function as institutional defenses, as a system of alleviating anxieties prompted by the relation to the other," representing "group-oriented ideologies" (Roussillon, 1986).
The psychoanalytical approach often requires much time since it favors the process rather than the suppression of symptoms, which is the case with non-analytical therapeutic techniques. In the interest of budgetary considerations, social agencies that reimburse psychic treatment try to limit its duration or the amount of compensated sessions, or else to favor approaches that aim to eliminate symptoms very quickly, without taking account of their function in the overall psychic economy of the patient. The psychoanalytical approach runs the risk of losing its liberty and revolutionary quality in submitting overly to social constraints. Countries that seek to integrate the psychoanalytic approach in the master plan of their treatment policies risk making it shed its special and irreverent identity, becoming increasingly therapeutic, in the sense of "suppressing symptoms" (Frisch, 1998). The notion of conflict, central in psychoanalysis, has consequently been introduced in the psychoanalytic movement on issues relating to its future and its identity: it must either evolve toward isolation to maintain its purity (psychoanalysis), or adapt to social constraints to survive (psychoanalytical psychotherapy), but at the risk of losing its soul.
Bibliography
Ellenberger, Henri F. (1970). The discovery of the unconscious. The history and evolution of dynamic psychiatry. New York: Basic Books.
Freud, Sigmund. (1919a [1918]). Lines of advance in psycho-analytic therapy. SE, 17: 157-168.
Roussillon, René. (1986). Préface, in M. Berger (Ed.), Entretiens familiaux et champ transitionnel. Paris: Presses Universitaires de France.
Wallerstein, Robert S. (1995). The talking cures. New Haven, CT, and London: Yale University Press.
Further Reading
Bergman, Anni. (2002). Changing psychoanalytic psychotherapy into psychoanalysis. International Journal of Psychoanalysis, 83, 245-248.
Kernberg, Otto. (1999). Psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy. International Journal of Psychoanalysis, 80, 1075-1092.
Stone, Leo. (1954). The widening scope of indications for psychoanalysis. Journal of the American Psychoanalytic Association, 2, 567-594.
Wallerstein, Robert S. (1989). Psychoanalysis and psychotherapy: An historical perspective. International Journal of Psychoanalysis, 70, 563-592.
—SERGE FRISCH
The use of the techniques of psychology or psychiatry or both to treat mental and emotional disorders. The term includes psychoanalysis, as well as other forms of psychological therapy.
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Psychotherapy is an interpersonal, relational intervention used by trained psychotherapists to aid clients in problems of living. This usually includes increasing individual sense of well-being and reducing subjective discomforting experience. Psychotherapists employ a range of techniques based on experiential relationship building, dialogue, communication and behavior change and that are designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family).
Most forms of psychotherapy use only spoken conversation, though some also use various
other forms of communication such as the written word, artwork, drama,
Therapy is generally used to respond to a variety of specific or non-specific manifestations of clinically diagnosable crises. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers) but the term is sometimes used interchangeably with "psychotherapy".
Psychotherapeutic interventions are often designed to treat the patient 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. Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.
There are several main systems of psychotherapy:
In an informal sense, psychotherapy can be said to have been practiced through the ages, as individuals received psychological counsel and reassurance from others. Purposeful, theoretically-based psychotherapy was probably first developed in the Middle East during the 9th century by the Persian physician Rhazes, who was at one time the chief physician of the Baghdad hospital. In the West, however, serious mental disorders were generally treated as demonic or medical conditions requiring punishment and confinement until the advent of moral treatment approaches in the 18th Century. This brought about a focus on the possibility of psychosocial intervention - including reasoning, moral encouragement and group activities - to rehabilitate the "insane".
Psychoanalysis was perhaps the first specific school of psychotherapy, developed by Sigmund Freud and others through the early 1900s. Trained as a neurologist, Freud began focusing on problems that appeared to have no discernible organic basis, and theorized that they had psychological causes originating in childhood experiences and the unconscious mind. Techniques such as dream interpretation, free association, transference and analysis of the id, ego and superego were developed.
Many theorists, including Anna Freud, Alfred Adler, Carl Jung, Karen Horney, Otto Rank, Erik Erikson, Melanie Klein, and Heinz Kohut, built upon Freud's fundamental ideas and often 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. Sessions tended to number into the hundreds over several years.
Behaviorism developed in the 1920s, and behavior modification as a therapy became popularized in the 1950s and 1960s. Notable contributors were Joseph Wolpe in South Africa, M.B. Shipiro and Hans Eysenck in Britain, and B.F. Skinner in the United States. Behavioral therapy approaches relied on principles of operant conditioning, classical conditioning and social learning theory to bring about therapeutic change in observable symptoms. The approach became commonly used for phobias, as well as other disorders.
Some therapeutic approaches developed out of the European school of existential
philosophy. Concerned mainly with the individual's ability to develop and preserve a sense of meaning and purpose
throughout life, major contributors to the field (e.g., Irvin Yalom,
A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based in existentialism and the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centered psychotherapy into mainstream focus. Rogers' basic tenets were unconditional positive regard, genuineness, and empathic understanding, with each demonstrated by the counselor. The aim was to create a relationship conducive to enhancing the client's psychological well being, by enabling the client to fully experience and express themselves. Others developed the approach, like Fritz and Laura Perls in the creation of Gestalt therapy, as well as Marshall Rosenberg, founder of Nonviolent Communication, and Eric Berne, founder of Transactional Analysis. Later these fields of psychotherapy would become what is known as humanistic psychotherapy today. Self-help groups and books became widespread.
During the 1950s, Albert Ellis developed Rational Emotive Behavior Therapy (REBT). A few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included short, structured and present-focused therapy aimed at changing a person's distorted thinking, by contrast with the long-lasting insight-based approach of psychodynamic or humanistic therapies. Cognitive and behavioral therapy approaches were combined during the 1970s, resulting in Cognitive behavioral therapy. Being oriented towards symptom-relief, collaborative empiricism and modifying peoples core beliefs, the approach gained widespread acceptance as a primary treatment for numerous disorders. A "third wave" of cognitive and behavioral therapies developed, including Acceptance and Commitment Therapy and Dialectical behavior therapy, which expanded the concepts to other disorders and/or added novel components.
Counseling methods developed, including solution-focused therapy and systemic coaching. Postmodern psychotherapies such as Narrative Therapy and coherence therapy did not impose definitions of mental health and illness, but rather saw the goal of therapy as something constructed by the client and therapist in a social context. Systems Therapy also developed, which focuses on family and group dynamics—and Transpersonal psychology, which focuses on the spiritual facet of human experience. Other important orientations developed in the last three decades include Feminist therapy, Brief therapy, Somatic Psychology, Expressive therapy, and applied Positive psychology.
A survey of over 2,500 US therapists in 2006 revealed the most utilised models of therapy and the ten most influential therapists of the previous quarter-century.[1]
Psychotherapy can be seen as an interpersonal invitation offered by (often trained and regulated) psychotherapists to aid
clients in reaching their full potential or to cope better with problems of
Psychotherapy often includes techniques to increase awareness for example, or to enable other choices of thought, feeling or action; to increase the sense of well-being and to better manage subjective discomfort or distress. Psychotherapy can be provided on a one to one basis or in group therapy. It can occur face to face, over the telephone or the internet. Its time frame may be a matter of weeks or over many years. It can be seen as ultimately about agency and the meaning of life. Psychotherapy can also be seen as a social construct that cannot occur in a power vacuum nor without reference to semiotics (meaning systems and symbols) - irrespective of how practitioners may describe their work or research its effects. Therapy may address specific forms of diagnosable mental illness, or everyday problems in relationships or meeting personal goals. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers) but the term is sometimes used interchangeably with "psychotherapy".
Psychotherapists employ a range of techniques to influence or pursuade the client to adapt or change in the direction the client has chosen. These can be based on clear thinking about their options; experiential relationship building; dialogue, communication and adoption of behavior change strategies. Each is designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family). Most forms of psychotherapy use only spoken conversation, though some also use various other forms of communication such as the written word, artwork, drama, narrative story, or therapeutic touch. Psychotherapy occurs within a structured encounter between a trained therapist and client(s). Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.
Psychotherapists are often trained, certified, and licensed, with a range of different certifications and licensing requirements in every jurisdiction. Psychotherapy may be undertaken by clinical psychologists, social workers, marriage-family therapists, expressive therapists, trained nurses, psychiatrists, psychoanalysts, mental health counselors, school counselors, or professionals of other mental health disciplines. Psychiatrists have medical qualifications and may also administer prescription medication. The primary training of a psychiatrist focuses on the biological aspects of mental health conditions, with some training in psychotherapy. Psychologists have more training in psychological assessment and research and, in addition, 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. Marriage-Family Therapists have training similar to the social worker, and also have specific training and experience working with relationships and family issues. Licensed professional counselors (LPCs) generally have special training in career, mental health, school, or rehabilitation counseling. Many of the wide variety of training programs are multiprofessional, that is, psychiatrists, psychologists, mental health nurses, and social workers may be found in the same training group. Consequently, specialized psychotherapeutic training in most countries requires a program of continuing education after the basic degree, or involve multiple certifications attached to one specific degree.
In the psychotherapeutic community there has been discussion of evidence-based psychotherapy, e.g.[2].
Virtually no comparisons of different psychotherapies with long follow-up times have been carried out. [3] The Helsinki Psychotherapy Study [4] is a randomized clinical trial, where patients are monitored for 12 months after the onset of study treatments, of which each lasted approximately 6 months. The assessments are to be completed at the baseline examination and during the follow-up after 3, 7, and 9 months and 1, 1.5, 2, 3, 4, 5, 6, and 7 years. The final results of this trial are yet to be published since follow-up evaluations will continue up to 2009.
Psychoanalysis was the earliest form of psychotherapy, but many other theories and techniques are also now used by psychotherapists, psychologists, psychiatrists, personal growth facilitators, occupational therapists 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.[citation needed]
Gestalt Therapy is a major overhaul psychoanalysis. In its early development it was called "concentration therapy" by its founders, Frederick and Laura Perls. However, its mix of theoretical influences became most organized around the work of the gestalt psychologists; thus, by the time Gestalt Therapy, Excitement and Growth in the Human Personality (Perls, Hefferline, and Goodman) was written, the approach became known as "Gestalt Therapy."
Gestalt Therapy stands on top of essentially four load bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom. Some have considered it an existential phenomenology while others have described it as a phenomenological behaviorism. Gestalt therapy is a humanistic, holistic, and experiential approach that does not rely on talking alone, but facilitates awareness in the various contexts of life by moving from talking about situations relatively remote to action and direct, current experience.
The therapeutic use of groups in modern clinical practice can be traced to the early years of the 20th century, when the American chest physician Pratt, working in Boston, described forming 'classes' of fifteen to twenty patients with tuberculosis who had been rejected for sanatorium treatment[citation needed]. The term 'group therapy', however, was first used around 1920 by Jacob L. Moreno, whose main contribution was the development of psychodrama, in which groups were used as both cast and audience for the exploration of individual problems by reenactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the USA, such as Paul Schilder, who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably Wilfred Bion and Rickman, followed by S. H. Foulkes, Main, and Bridger. The Northfield Hospital in Birmingham gave its name to what came to be called the two 'Northfield Experiments', which provided the impetus for the development since the war of both social therapy, that is, the therapeutic community movement, and the use of small groups for the treatment of neurotic and personality disorders.
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 the client 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 client's 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 the client's insight into the roots of their difficulties. The best-known example of an uncovering psychotherapy is classical psychoanalysis. Supportive psychotherapy by contrast stresses strengthening the client's 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 use a combination of uncovering and supportive approaches.
Cognitive behavioral therapy focuses on modifying everyday thoughts and behaviors, with the aim of positively influencing emotions. The therapist helps clients recognise distorted thinking and learn to replace unhealthy thoughts with more realistic substitute ideas. This approach includes Dialectical behavior therapy.
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 therapeutic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy, writing 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.
Integrative Psychotherapy represents an attempt to combine ideas and strategies from more than one theoretical approach.[5] These approaches include mixing core beliefs and combining proven techniques. Forms of integrative psychotherapy include Multimodal Therapy, the Transtheoretical Model, Cyclical Psychodynamics, Systematic Treatment Selection, Cognitive Analytic Therapy, Internal Family Systems Model, and Multitheoretical Psychotherapy. In practice, most experienced psychotherapists develop their own integrative approach over time.
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.
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 [6]). Accordingly, most contemporary schools of psychotherapy focus on the healing power of the therapeutic relationship.
This research is extensively discussed (with many references) in Hubble, Duncan and Miller (1999)[7] (quotes in this section are from this book) and in Wampold (2001) [8].
A literature review by M. J. Lambert (1992) [9] 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 (1999) [10] note that:
Outside of therapy people rarely have a friend who will truly listen to them for more than 20 minutes (Stiles, 1995)[11]... 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.
