There are over a thousand different psychotherapy techniques,
some being minor variations, while others are based on very different
conceptions of psychology, ethics (how to live), or techniques. Most
involve one-to-one sessions, between client and therapist, but some are
conducted with groups, including families. Psychotherapists may be mental health professionals
such as psychiatrists, psychologists, clinical social workers, marriage
and family therapists, or professional counselors. Psychotherapists may
also come from a variety of other backgrounds, and depending on the jurisdiction may be legally regulated, voluntarily regulated or unregulated (and the term itself may be protected or not).
Definitions
The term psychotherapy is derived from Ancient Greek psyche (ψυχή meaning "breath; spirit; soul") and therapeia (θεραπεία "healing; medical treatment"). The Oxford English Dictionary defines it now as "The treatment of disorders of the mind or personality by psychological methods..."
The American Psychological Association adopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed by John C. Norcross: "Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances
derived from established psychological principles for the purpose of
assisting people to modify their behaviors, cognitions, emotions, and/or
other personal characteristics in directions that the participants deem
desirable". Influential editions of a work by psychiatrist Jerome Frank
defined psychotherapy as a healing relationship using socially
authorized methods in a series of contacts primarily involving words,
acts and rituals—regarded as forms of persuasion and rhetoric.
Some definitions of counseling
overlap with psychotherapy (particularly in non-directive
client-centered approaches), or counseling may refer to guidance for
everyday problems in specific areas, typically for shorter durations
with a less medical or 'professional' focus. Somatotherapy refers to the use of physical changes as injuries and illnesses, and sociotherapy to the use of a person's social environment to effect therapeutic change. Psychotherapy may address spirituality
as a significant part of someone's mental / psychological life, and
some forms are derived from spiritual philosophies, but practices based
on treating the spiritual as a separate dimension are not necessarily
considered as traditional or 'legitimate' forms of psychotherapy.
Historically, psychotherapy has sometimes meant "interpretative" (i.e. Freudian) methods, namely psychoanalysis, in contrast with other methods to treat psychiatric disorders such as behavior modification.
Psychotherapy is often dubbed as a "talking therapy", particularly for a general audience, though not all forms of psychotherapy rely on verbal communication.
Children or adults who do not engage in verbal communication (or not in
the usual way) are not excluded from psychotherapy; indeed some types
are designed for such cases.
Delivery
Psychotherapy may be delivered in person (one on one, or with couples, or in groups), over the phone, via telephone counseling, or via the internet.
It has not been established whether the effectiveness of
psychotherapy administered online, over video chat for instance, is
comparable to that delivered within in-person meetings: Clear, consistent trends from empirical research are lacking regarding the efficacy of online therapy - Australian Counselling Association.
The Victoria Government's Health Agency has awarded no mental
health app with scores greater than 3 stars out of 5 for effectiveness.
One reason for this is that online Cognitive Behavioural Therapy
programs have poor "adherence" compared to face-to-face programs. That
means that many users do not "stick to" the program as prescribed. They
may uninstall the app or skip days, for instance.
Treatments duration
Experts
suggests that those who have had two depressive episodes in recent
years, or three episodes over their life, have to get treated on an
ongoing basis to prevent recurrent depression: At
least 60% of individuals who have had one depressive episode will have
another, 70% of individuals who have had two depressive episodes will
have a third, and 90% of individuals with three episodes will have a
fourth episode. - American Psychological Association.
Regulation
Psychotherapists traditionally may be: mental health professionals
like psychologists and psychiatrists; professionals from other
backgrounds (family therapists, social workers, nurses, etc.) who have
trained in a specific psychotherapy; or (in some cases) academic or
scientifically-trained professionals.
Psychiatrists are trained first as physicians, and—as such—they may prescribe prescription medication;
and specialist psychiatric training begins after medical school in
psychiatric residencies: however, their speciality is in mental
disorders or forms of mental illness. Clinical psychologists have specialist doctoral degrees in psychology with some clinical and research components. Other clinical practitioners, social workers,
mental health counselors, pastoral counselors, and nurses with a
specialization in mental health, also often conduct psychotherapy. Many
of the wide variety of psychotherapy training programs and institutional
settings are multi-professional. In most countries, psychotherapy
trainings are all at a post-graduate level, often at master's degree (or
doctoral) level, over a 4-year period, with significant supervised
practice and clinical placements. Such professionals doing specialized
psychotherapeutic work also require a program of continuing professional
education after the basic professional training.
There is a 2013 listing of the extensive professional
competencies of a European psychotherapist, developed by the European
Association of Psychotherapy (EAP).
As sensitive and deeply personal topics are often discussed
during psychotherapy, therapists are expected, and usually legally
bound, to respect client or patient confidentiality. The critical
importance of client confidentiality—and
the limited circumstances in which it may need to be broken for the
protection of clients or others—is enshrined in the regulatory
psychotherapeutic organizations' codes of ethical practice.
Examples of when it is typically accepted to break confidentiality
include when the therapist has knowledge that a child or elder is being
physically abused; when there is a direct, clear and imminent threat of
serious physical harm to self or to a specific individual.
Europe
As of
2015, there are still a lot of variations between different European
countries about the regulation and delivery of psychotherapy. Several
countries have no regulation of the practice, or no protection of the
title. Some have a system of voluntary registration, with independent
professional organizations. While other countries attempt to restrict
the practice of psychotherapy to 'mental health professionals'
(psychologists and psychiatrists) with state-certified trainings. The
titles that are protected also varies. The European Association for Psychotherapy
(EAP) established the 1990 Strasbourg Declaration on Psychotherapy,
which is dedicated to establish an independent profession of
psychotherapy in Europe, with pan-European standards. The EAP has already made significant contacts with the European Union & European Commission towards this end.
Given that the European Union
has a primary policy about the free movement of labour within Europe,
European legislation can overrule national regulations that are, in
essence, forms of restrictive practices.
In Germany, the practice of psychotherapy for adults is
restricted to qualified psychologists and physicians (including
psychiatrists) who have completed several years of specialist practical
training and certification in psychotherapy. As psychoanalysis,
psychodynamic therapy, and cognitive behavioral therapy meet the
requirements of German health insurance companies, mental health
professionals regularly opt for one of these three specializations in
their postgraduate training. For psychologists, this includes three
years of full-time practical training (4.200 hours), encompassing a
year-long internship at an accredited psychiatric institution, six
months of clinical work at an outpatient facility, 600 hours of
supervised psychotherapy in an outpatient setting, and at least 600
hours of theoretical seminars. Social workers may complete the specialist training for child and teenage clients.
Similarly in Italy, the practice of psychotherapy is restricted to
graduates in psychology or medicine who have completed four years of
recognized specialist training.
Sweden has a similar restriction on the title "psychotherapist", which
may only be used by professionals who have gone through a post-graduate
training in psychotherapy and then applied for a license, issued by the National Board of Health and Welfare.
Legislation in France restricts the use of the title
"psychotherapist" to professionals on the National Register of
Psychotherapists,
which requires a training in clinical psychopathology and a period of
internship which is only open to physicians or titulars of a master's
degree in psychology or psychoanalysis.
Austria and Switzerland (2011) have laws that recognize multi-disciplinary functional approaches.
In the United Kingdom, the government and Health and Care Professions Council
considered mandatory legal registration but decided that it was best
left to professional bodies to regulate themselves, so the Professional Standards Authority for Health and Social Care (PSA) launched an Accredited Voluntary Registers scheme.
Counseling and psychotherapy are not protected titles in the United
Kingdom. Counselors and psychotherapists who have trained and qualify
to a certain standard (usually a level 4 Diploma) can apply to be
members of the professional bodies who are listed on the PSA Accredited
Registers.
United States
In
some states, counselors or therapists must be licensed to use certain
words and titles on self-identification or advertising. In some other
states, the restrictions on practice are more closely associated with
the charging of fees. Licensing and regulation are performed by the
various states. Presentation of practice as licensed, but without such a
license, is generally illegal. Without a license, for example a practitioner cannot bill insurance companies. Information about state licensure is provided by the American Psychological Association.
In addition to state laws, the American Psychological Association requires its members to adhere to its published Ethical Principles of Psychologists and Code of Conduct. The American Board of Professional Psychology examines and certifies "psychologists who demonstrate competence in approved specialty areas in professional psychology".
History
Psychotherapy can be said to have been practiced through the ages, as
medics, philosophers, spiritual practitioners and people in general
used psychological methods to heal others.
In the Western tradition, by the 19th century, a moral treatment movement (then meaning morale or mental) developed based on non-invasive non-restraint therapeutic methods. Another influential movement was started by Franz Mesmer (1734–1815) and his student Armand-Marie-Jacques de Chastenet, Marquis of Puységur (1751–1825). Called Mesmerism or animal magnetism, it would have a strong influence on the rise of dynamic psychology and psychiatry as well as theories about hypnosis. In 1853 Walter Cooper Dendy
introduced the term "psycho-therapeia" regarding how physicians might
influence the mental states of sufferers and thus their bodily ailments,
for example by creating opposing emotions to promote mental balance. Daniel Hack Tuke cited the term and wrote about "psycho-therapeutics" in 1872, in which he also proposed making a science of animal magnetism. Hippolyte Bernheim and colleagues in the "Nancy School" developed the concept of "psychotherapy" in the sense of using the mind to heal the body through hypnotism, yet further. Charles Lloyd Tuckey's 1889 work, Psycho-therapeutics, or Treatment by Hypnotism and Suggestion popularized the work of the Nancy School in English. Also in 1889 a clinic used the word in its title for the first time, when Frederik van Eeden and Albert Willem in Amsterdam renamed theirs "Clinique de Psycho-thérapeutique Suggestive" after visiting Nancy. During this time, travelling stage hypnosis became popular, and such activities added to the scientific controversies around the use of hypnosis in medicine.
Also in 1892, at the second congress of experimental psychology, van
Eeden attempted to take the credit for the term psychotherapy and to
distance the term from hypnosis.
In 1896, the German journal Zeitschrift für Hypnotismus,
Suggestionstherapie, Suggestionslehre und verwandte psychologische
Forschungen changed its name to Zeitschrift für Hypnotismus,
Psychotherapie sowie andere psychophysiologische und psychopathologische
Forschungen, which is probably the first journal to use the term. Thus psychotherapy initially meant "the treatment of disease by psychic or hypnotic influence, or by suggestion".
Freud, seated left of picture with Jung seated at right of picture. 1909
Sigmund Freud visited the Nancy School and his early neurological practice involved the use of hypnotism. However following the work of his mentor Josef Breuer—in particular a case where symptoms appeared partially resolved by what the patient, Bertha Pappenheim, dubbed a "talking cure"—Freud began focusing on conditions that appeared to have psychological causes originating in childhood experiences and the unconscious mind. He went on to develop techniques such as free association, dream interpretation, transference and analysis of the id, ego and superego. His popular reputation as father of psychotherapy was established by his use of the distinct term "psychoanalysis", tied to an overarching system of theories and methods, and by the effective work of his followers in rewriting history. Many theorists, including Alfred Adler, Carl Jung, Karen Horney, Anna Freud, Otto Rank, Erik Erikson, Melanie Klein and Heinz Kohut,
built upon Freud's fundamental ideas and often developed their own
systems of psychotherapy. These were all later categorized as 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 John B. Watson 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, Rollo May) and Europe (Viktor Frankl, Ludwig Binswanger, Medard Boss, R.D.Laing, Emmy van Deurzen)
attempted to create therapies sensitive to common "life crises"
springing from the essential bleakness of human self-awareness,
previously accessible only through the complex writings of existential
philosophers (e.g., Søren Kierkegaard, Jean-Paul Sartre, Gabriel Marcel, Martin Heidegger, Friedrich Nietzsche). The uniqueness of the patient-therapist relationship thus also forms a vehicle for therapeutic inquiry. A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based also on the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centered psychotherapy
into mainstream focus. The primary requirement was that the client be
in receipt of three core "conditions" from his counselor or therapist:
unconditional positive regard, sometimes described as "prizing" the
client's humanity; congruence [authenticity/genuineness/transparency];
and empathic understanding.
This type of interaction was thought to enable clients to fully
experience and express themselves, and thus develop according to their
innate potential. 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 originated rational emotive behavior therapy (REBT). Independently a few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy.
Both of these included relatively short, structured and present-focused
techniques aimed at identifying and changing a person's beliefs,
appraisals and reaction-patterns, by contrast with the more long-lasting
insight-based approach of psychodynamic or humanistic therapies. Beck's
approach used primarily the Socratic method, and links have been drawn between ancient stoic philosophy and these cognitive therapies.
Cognitive and behavioral therapy approaches were increasingly combined and grouped under the umbrella term cognitive behavioral therapy (CBT) in the 1970s. Many approaches within CBT are oriented towards active/directive yet collaborative empiricism
(a form of reality-testing), and assessing and modifying core beliefs
and dysfunctional schemas. These approaches 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 and mindfulness
exercises. However the "third wave" concept has been criticized as not
essentially different from other therapies and having roots in earlier
ones as well. Counseling methods developed include solution-focused therapy and systemic coaching.
Postmodern psychotherapies such as narrative therapy and coherence therapy
do not impose definitions of mental health and illness, but rather see
the goal of therapy as something constructed by the client and therapist
in a social context. Systemic therapy also developed, which focuses on family and group dynamics—and transpersonal psychology, which focuses on the spiritual facet of human experience. Other orientations developed in the last three decades include feminist therapy, brief therapy, somatic psychology, expressive therapy, applied positive psychology and the human givens
approach. A survey of over 2,500 US therapists in 2006 revealed the
most utilized models of therapy and the ten most influential therapists
of the previous quarter-century.
Types
Overview
There are hundreds of psychotherapy approaches or schools of thought. By 1980 there were more than 250; by 1996 more than 450;
and at the start of the 21st century there were over a thousand
different named psychotherapies—some being minor variations while others
are based on very different conceptions of psychology, ethics (how to
live) or technique. In practice therapy is often not of one pure type but draws from a number of perspectives and schools—known as an integrative or eclectic approach. The importance of the therapeutic relationship, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy. Common factors theory
addresses this and other core aspects thought to be responsible for
effective psychotherapy.
Sigmund Freud (1856–1939), a Viennese neurologist who studied with
Charcot in 1885, is often considered the father of modern psychotherapy.
His methods included analyzing dreams for important insights that lay
out of awareness of the dreamer. Other major elements of his methods,
which changed throughout the years, included identification of childhood
sexuality, the role of anxiety as a manifestation of inner conflict,
the differentiation of parts of the psyche (id, ego, superego),
transference and countertransference (the patient's projections onto the
therapist, and the therapist's emotional responses to that). Some of
his concepts were too broad to be amenable to empirical testing and
invalidation, and he was critiqued for this by Jaspers. Numerous major
figures elaborated and refined Freud's therapeutic techniques including
Melanie Klein, Donald Winnicott, and others. Since the 1960s, however,
the use of Freudian-based analysis for the treatment of mental disorders
has declined substantially. Different types of psychotherapy have been
created along with the advent of clinical trials to test them
scientifically. These incorporate subjective treatments (after Beck),
behavioral treatments (after Skinner and Wolpe) and additional
time-constrained and centered structures, for example, interpersonal
psychotherapy. In youth issue and in schizophrenia, the systems of
family treatment hold esteem. A portion of the thoughts emerging from
therapy are presently pervasive and some are a piece of the
armamentarium of ordinary clinical practice. They are not just
medications, they additionally help to understand complex conduct.
Therapy may address specific forms of diagnosable mental illness, or everyday problems in managing or maintaining interpersonal relationships or meeting personal goals. A course of therapy may happen before, during or after pharmacotherapy (e.g. taking psychiatric medication).
Psychotherapies are categorized in several different ways. A distinction can be made between those based on a medical model and those based on 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. The humanistic or
non-medical model in contrast strives to depathologise the human
condition. The therapist attempts to create a relational environment
conducive to experiential learning and help build the client's
confidence in their own natural process resulting in a deeper
understanding of themselves. The therapist may see themselves as a
facilitator/helper.
Another distinction is between individual one-to-one therapy sessions, and group psychotherapy, including couples therapy and family therapy.
Therapies are sometimes classified according to their duration; a
small number of sessions over a few weeks or months may be classified
as brief therapy (or short-term therapy), others where regular sessions take place for years may be classified as long-term.
Some practitioners distinguish between more "uncovering" (or "depth")
approaches and more "supportive" psychotherapy. Uncovering
psychotherapy emphasizes facilitating the client's insight into the
roots of their difficulties. The best-known example is classical
psychoanalysis. Supportive psychotherapy
by contrast stresses strengthening the client's coping mechanisms and
often providing encouragement and advice, as well as reality-testing and
limit-setting where necessary. Depending on the client's issues and
situation, a more supportive or more uncovering approach may be optimal.
Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story or music. Psychotherapy with children and their parents often involves play,
dramatization (i.e. role-play), and drawing, with a co-constructed
narrative from these non-verbal and displaced modes of interacting.
There are also different formats for delivering some therapies, as well as the usual face to face: for example via telephone or via online interaction. There have also been developments in computer-assisted therapy, such as virtual reality therapy
for behavioral exposure, multimedia programs to each cognitive
techniques, and handheld devices for improved monitoring or putting
ideas into practice.
Humanistic
These psychotherapies, also known as "experiential", are based on humanistic psychology
and emerged in reaction to both behaviorism and psychoanalysis, being
dubbed the "third force". They are primarily concerned with the human
development and needs of the individual, with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. Some posit an inherent human capacity to maximize potential, "the self-actualizing tendency"; the task of therapy is to create a relational environment where this tendency might flourish. Humanistic psychology can in turn be rooted in existentialism—the belief that human beings can only find meaning by creating it. This is the goal of existential therapy. Existential therapy is in turn philosophically associated with phenomenology.
Person-centered therapy,
also known as client-centered, focuses on the therapist showing
openness, empathy and "unconditional positive regard", to help clients
express and develop their own self.
Gestalt therapy,
originally called "concentration therapy", is an
existential/experiential form that facilitates awareness in the various
contexts of life, by moving from talking about relatively remote
situations to action and direct current experience. Derived from various
influences, including an overhaul of psychoanalysis, it stands on top
of essentially four load-bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom.
A briefer form of humanistic therapy is the human givens approach, introduced in 1998/9.
It is a solution-focused intervention based on identifying emotional
needs—such as for security, autonomy and social connection—and using
various educational and psychological methods to help people meet those
needs more fully or appropriately.
Insight-oriented
Insight-oriented psychotherapies focus on revealing or interpreting unconscious processes. Most commonly referring to psychodynamic therapy, of which psychoanalysis is the oldest and most intensive form, these applications of depth psychology encourage the verbalization of all the patient's thoughts, including free associations,
fantasies, and dreams, from which the analyst formulates the nature of
the past and present unconscious conflicts which are causing the
patient's symptoms and character problems.
There are six main schools of psychoanalysis, which all influenced psychodynamic theory: Freudian, ego psychology, object relations theory, self psychology, interpersonal psychoanalysis, and relational psychoanalysis. Techniques for analytic group therapy have also developed.
Cognitive-behavioral
Behavior therapies use behavioral techniques, including applied behavior analysis (also known as behavior modification), to change maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others. Functional analytic psychotherapy
is one form of this approach. By nature, behavioral therapies are
empirical (data-driven), contextual (focused on the environment and
context), functional (interested in the effect or consequence a behavior
ultimately has), probabilistic (viewing behavior as statistically
predictable), monistic (rejecting mind-body dualism and treating the person as a unit), and relational (analyzing bidirectional interactions).
Cognitive therapy focuses directly on changing the thoughts, in order to improve the emotions and behaviors.
Cognitive behavioral therapy attempts to combine the above two approaches, focused on the construction and re-construction of people's cognitions, emotions and behaviors.
Generally in CBT, the therapist, through a wide array of modalities,
helps clients assess, recognize and deal with problematic and
dysfunctional ways of thinking, emoting and behaving.
The concept of "third wave" psychotherapies reflects an influence of Eastern philosophy in clinical psychology, incorporating principles such as meditation into interventions such as mindfulness-based cognitive therapy, acceptance and commitment therapy, and dialectical behavior therapy for borderline personality disorder.
Interpersonal psychotherapy (IPT) is a relatively brief form of psychotherapy (deriving from both CBT and psychodynamic approaches) that has been increasingly studied and endorsed by guidelines for some conditions. It focuses on the links between mood and social circumstances, helping to build social skills and social support. It aims to foster adaptation to current interpersonal roles and situations.
Other types include reality therapy/choice theory, multimodal therapy, and therapies for specific disorders including PTSD therapies such as cognitive processing therapy and EMDR; substance abuse therapies such as relapse prevention and contingency management; OCD therapies such as exposure and response prevention; and co-occurring disorders therapies such as Seeking Safety.
Systemic
Systemic therapy
seeks to address people not just individually, as is often the focus of
other forms of therapy, but in relationship, dealing with the
interactions of groups, their patterns and dynamics (includes family therapy and marriage counseling). Community psychology is a type of systemic psychology.
The term group therapy 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 US, 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. Today group therapy is used in clinical settings
and in private practice settings.
Expressive
Expressive therapy is any 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.
Postmodernist
Also known as post-structuralist or constructivist. Narrative therapy
gives attention to each person's "dominant story" by means of
therapeutic conversations, which also may involve exploring unhelpful
ideas and how they came to prominence. Possible social and cultural
influences may be explored if the client deems it helpful. Coherence therapy posits multiple levels of mental constructs that create symptoms as a way to strive for self-protection or self-realization. Feminist therapy
does not accept that there is one single or correct way of looking at
reality and therefore is considered a postmodernist approach.
Other
Transpersonal psychology addresses the client in the context of a spiritual understanding of consciousness. Positive psychotherapy
(PPT) (since 1968) is a method in the field of humanistic and
psychodynamic psychotherapy and is based on a positive image of humans,
with a health-promoting, resource-oriented and conflict-centered
approach.
Hypnotherapy is undertaken while a subject is in a state of hypnosis.
Hypnotherapy is often applied in order to modify a subject's behavior,
emotional content, and attitudes, as well as a wide range of conditions
including: dysfunctional habits, anxiety, stress-related illness, pain management, and personal development.
Body psychotherapy, part of the field of somatic psychology,
focuses on the link between the mind and the body and tries to access
deeper levels of the psyche through greater awareness of the physical body and emotions. There are various body-oriented approaches, such as Reichian (Wilhelm Reich) character-analytic vegetotherapy and orgonomy; neo-Reichian bioenergetic analysis; somatic experiencing; integrative body psychotherapy; Ron Kurtz's Hakomi psychotherapy; sensorimotor psychotherapy; Biosynthesis psychotherapy; and Biodynamic psychotherapy. These approaches are not to be confused with body work
or body-therapies that seek to improve primarily physical health
through direct work (touch and manipulation) on the body, rather than
through directly psychological methods.
Some non-Western indigenous
therapies have been developed. In African countries this includes
harmony restoration therapy, meseron therapy and systemic therapies
based on the Ubuntu philosophy.
Integrative psychotherapy is an attempt to combine ideas and strategies from more than one theoretical approach. 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, multitheoretical psychotherapy and conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time.
Child
Counseling and psychotherapy must be adapted to meet the
developmental needs of children. It is generally held to be one part of
an effective strategy for some purposes and not for others.
In addition to therapy for the child, or even instead of it, children
may benefit if their parents speak to a therapist, take parenting
classes, attend grief counseling, or take other actions to resolve stressful situations that affect the child. Parent management training is a highly effective form of psychotherapy that teaches parents skills to reduce their child's behavior problems.
Many counseling preparation programs include 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, board games, etc. 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. Yet, by doing so, the counselor risks the
perpetuation of maladaptive interactive patterns and the adverse effects
on development that have already been affected on the child's end of
the relationship.
Therefore, contemporary thinking on working with this young age group
has leaned towards working with parent and child simultaneously within
the interaction, as well as individually as needed.
Computer-supported psychotherapy
Research on computer-supported and computer-based interventions has
increased significantly over the course of the last two decades. The following applications frequently have been investigated:
- Tele-therapy / tele-mental health: In teletherapy classical psychotherapy is provided via modern communication devices, such as via videoconferencing.
- Virtual reality: VR is a computer-generated scenario that simulates experience. The immersive environment, used for simulated exposure, can be similar to the real world or it can be fantastical, creating a new experience.
- Computer-based interventions (or online interventions or internet interventions): These interventions can be described as interactive self-help. They usually entail a combination of text, audio or video elements.
- Computer-supported therapy (or blended therapy): Classical psychotherapy is supported by means of online or software application elements. The feasibility of such interventions has been investigated for individual and group therapy.
Effects
Evaluation
There is considerable controversy about whether, or when, psychotherapy efficacy is best evaluated by randomized controlled trials or more individualized idiographic methods.
One issue with trials is what to use as a placebo treatment group or non-treatment control group.
Often this is patients on a waiting list, or people receiving some kind
of regular non-specific contact or support. One issue is the best way
to match the use of inert tablets or sham treatments in placebo-controlled studies in pharmaceutical trials. Several interpretations and differing assumptions and language remain.
Another issue is the attempt to standardize and manualize therapies and
link them to specific symptoms of diagnostic categories, making them
more amenable to research. Some report that this may reduce efficacy or
gloss over individual needs. Fonagy and Roth's opinion is that the
benefits of the evidence-based approach outweighs the difficulties.
There are formal frameworks for evaluating a psychotherapist fit
for a particular patient, for instance, the Scarsdale Psychotherapy
Self-Evaluation (SPSE).
However, some scales, such as the SPS, elicit information specific to
certain schools of psychotherapy alone (e.g. the superego).
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. Psychodynamic therapists in
particular believe that evidence-based approaches are not appropriate
to their methods or assumptions, though some have increasingly accepted
the challenge to implement evidence-based approaches in their methods.
Outcomes in relation with selected kinds of treatment
Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.
One line of research consistently finds that supposedly different
forms of psychotherapy show similar effectiveness. According to The
Handbook of Counseling Psychology: "Meta-analyses of psychotherapy
studies have consistently demonstrated that there are no substantial
differences in outcomes among treatments". The handbook states that
there is "little evidence to suggest that anyone psychological therapy
consistently outperforms any other for any specific psychological
disorders. This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes".
Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.
It should be noted that outcome studies have been critiqued for
being too removed from real-world practice in that they use carefully
selected therapists who have been extensively trained and monitored, and
patients who may be non-representative of typical patients by virtue of
strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalize from them to practicing therapists.
However, specific therapies have been tested for use with specific disorders, and regulatory organizations in both the UK and US make recommendations for different conditions.
The Helsinki Psychotherapy Study was one of several large
long-term clinical trials of psychotherapies that have taken place.
Anxious and depressed patients in two short-term therapies
(solution-focused and brief psychodynamic) improved faster, but five
years long-term psychotherapy and psychoanalysis gave greater benefits.
Several patient and therapist factors appear to predict suitability for
different psychotherapies.
Meta-analyses have established that Cognitive Behavioral Therapy
(CBT) and psychodynamic psychotherapy are equally effective in treating
depression.
A 2014 meta analysis over 11,000 patients reveals that
Interpersonal Psychotherapy (IPT) is of comparable effectiveness to CBT
for depression but is inferior to the latter for eating disorders.
For children and adolescents, interpersonal psychotherapy and CBT are
the best methods according to a 2014 meta analysis of almost 4000
patients.
Mechanisms of change
Different
therapeutic approaches may be associated with particular theories about
what needs to change in a person for a successful therapeutic outcome.
In general, processes of emotional arousal and memory
have long been held to play an important role. One theory combining
these aspects proposes that permanent change occurs to the extent that
the neuropsychological mechanism of memory reconsolidation is triggered and is able to incorporate new emotional experiences.
Adherence
Patient adherence to a course of psychotherapy—continuing to attend sessions or complete tasks—is a major issue.
The dropout level—early termination—ranges from around 30% to
60%, depending partly on how it is defined. The range is lower for
research settings for various reasons, such as the selection of clients
and how they are inducted. Early termination is associated on average
with various demographic and clinical characteristics of clients,
therapists and treatment interactions. The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.
Most psychologists use between-session tasks in their general
therapy work, and cognitive behavioral therapies in particular use and
see them as an "active ingredient". It is not clear how often clients do
not complete them, but it is thought to be a pervasive phenomenon.
From the other side, the adherence of therapists to therapy
protocols and techniques—known as "treatment integrity" or
"fidelity"—has also been studied, with complex mixed results.
In general, however, it is a hallmark of evidence-based psychotherapy
to use fidelity monitoring as part of therapy outcome trials and ongoing
quality assurance in clinical implementation.
Adverse effects
Research on adverse effects
of psychotherapy has been limited for various reasons, yet they may be
expected to occur in 5% to 20% of patients. Problems include
deterioration of symptoms or developing new symptoms, strains in other
relationships, and dependency on the therapist. Some techniques or
therapists may carry more risks than others, and some client
characteristics may make them more vulnerable. Side-effects from
properly conducted therapy should be distinguished from harms caused by
malpractice.
General critiques
Some critics are skeptical of the healing power of psychotherapeutic relationships. Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners, instead favoring either nonprofessional help or biomedical treatments.
Others have pointed out ways in which the values and techniques of
therapists can be harmful as well as helpful to clients (or indirectly
to other people in a client's life).
Many resources available to a person experiencing emotional
distress—the friendly support of friends, peers, family members, clergy
contacts, personal reading, healthy exercise, research, and independent
coping—all present considerable value. Critics note that humans have
been dealing with crises, navigating severe social problems and finding
solutions to life problems long before the advent of psychotherapy.
On the other hand, some argue psychotherapy is under-utilized and
under-researched by contemporary psychiatry despite offering more
promise than stagnant medication development. In 2015, the US National Institute of Mental Health allocated only 5.4% of its budget to new clinical trials of psychotherapies (medication trials are largely funded by pharmaceutical companies), despite plentiful evidence they can work and that patients are more likely to prefer them.
Some Christians, such as theologian Thomas C. Oden,
have argued that successful therapeutic relationships, based on true
acceptance of the client as a human being without contingency, require a
theological assumption, an ontological acceptance of God.
Further critiques have emerged from feminist, constructionist and discourse-analytical sources. Key to these is the issue of power.
In this regard there is a concern that clients are persuaded—both
inside and outside the consulting room—to understand themselves and
their difficulties in ways that are consistent with therapeutic ideas. This means that alternative ideas (e.g., feminist, economic, spiritual) are sometimes implicitly undermined.
Critics suggest that we idealize the situation when we think of therapy
only as a helping relationship—arguing instead that it is fundamentally
a political practice, in that some cultural ideas and practices are
supported while others are undermined or disqualified, and that while it
is seldom intended, the therapist–client relationship always
participates in society's power relations and political dynamics. A noted academic who espoused this criticism was Michel Foucault.
