Environmental humanities employs humanistic questions about
meaning, culture, values, ethics, and responsibilities to address
pressing environmental problems. The environmental humanities aim to
help bridge traditional divides between the sciences and the humanities,
as well as between Western, Eastern, and Indigenous
ways of relating to the natural world and the place of humans within
it. The field also resists the traditional divide between "nature" and
"culture," showing how many "environmental" issues have always been
entangled in human questions of justice, labor, and politics.
Environmental humanities is also a way of synthesizing methods from
different fields to create new ways of thinking through environmental
problems.
Emergence of environmental humanities
Although
the concepts and ideas underpinning environmental humanities date back
centuries, the field consolidated under the name "environmental
humanities" in the 2000s following steady developments of the 1970s,
1980s, and 1990s in humanities and social science fields such as
literature, history, philosophy, gender studies, and anthropology. A
group of Australian researchers used the name "ecological humanities" to
describe their work in the 1990s; the field consolidated under the name
"environmental humanities" around 2010. The journal Environmental Humanities was founded in 2012 and Resilience: A Journal of the Environmental Humanities in 2014, indicating the development of the field and the consolidation around this terminology.
Dozens of universities offer PhDs, Masters of Arts degrees,
graduate certificates, and Bachelor of Arts degrees in environmental
humanities. Courses in environmental humanities are taught on every continent.
The environmental humanities did not just emerge from Western
academic thinkers: indigenous, postcolonial, and feminist thinkers have
provided major contributions. These contributions include challenging
the human-centered viewpoints that separate "nature" and "culture" and
the white, male, European- and North American-centric viewpoints of what
constitutes "nature"; revising the literary genre of "nature writing"; and creating new concepts and fields that bridge the academic and the political, such as "environmental justice," "environmental racism," "the environmentalism of the poor," "naturecultures," and "the posthuman."
Connectivity ontology
The environmental humanities are characterised by a connectivity ontology and a commitment to two fundamental axioms relating to the need to submit to ecological laws and to see humanity as part of a larger living system.
One of the fundamental ontological presuppositions of environmental humanities is that the organic world and its inorganic parts are seen as a single system whereby each part is linked to each other part. This world view in turn shares an intimate connection with Lotka's physiological philosophy and the associated concept of the "World Engine". When we see everything as connected, then the traditional questions of
the humanities concerning economic and political justice become enlarged, into a consideration of how justice is connected with our transformation of our environment and ecosystems.
The consequence of such connectivity ontology
is, as proponents of the environmental humanities argue, that we begin
to seek out a more inclusive concept of justice that includes non-humans
within the domain of those to whom rights are owing. This broadened
conception of justice involves "enlarged" or "ecological thinking",
which presupposes the enhancement of knowledge sharing within fields of
plural and diverse ‘knowledges’. This kind of knowledge sharing is
called transdisciplinarity. It has links with the political philosophy
of Hannah Arendt and the works of Italo Calvino.
As Calvino put it, "enlarge[s] the sphere of what we can imagine". It
also has connections with Leibniz's Enlightenment project where the
sciences are simultaneously abridged while also being enlarged.
The situation is complicated, however, by the recognition of the fact that connections are both non-linear and linear.
The environmental humanities, therefore, require both linear and
non-linear modes of language through which reasoning about justice can
be done. Thus there is a motivation to find linguistic modes which can
adequately express both linear and non-linear connectivities.
Axioms
According to some thinkers, there are three axioms of environmental humanities:
The axiom of ecological kinship, which situates humanity as a participant in a larger living system; and
The axiom of the social construction of ecosystems and ecological
unity, which states that ecosystems and nature may be merely convenient
conceptual entities (Marshall, 2002).
Putting the first and second axioms another way, the connections
between and among living things are the basis for how ecosystems are
understood to work, and thus constitute laws of existence and guidelines
for behaviour (Rose 2004).
The first of these axioms has a tradition in social sciences (see Marx, 1968: 3). From the second axiom the notions of "ecological embodiment/ embeddedness"
and "habitat" have emerged from Political Theory with a fundamental
connectivity to rights, democracy, and ecologism (Eckersley 1996: 222,
225; Eckersley 1998).
The third axiom comes from the strong 'self-reflective' tradition
of all 'humanities' scholarship and it encourages the environmental
humanities to investigate its own theoretical basis (and without which,
the environmental humanities is just 'ecology').
Some theorists have suggested that the inclusion of non-humans in the
consideration of justice links ecocentric philosophy with political
economics. This is because the theorising of justice is a central
activity of political economic philosophy. If in accordance with the
axioms of environmental humanities, theories of justice are enlarged to
include ecological values, then the necessary result is the synthesis of
the concerns of ecology with that of political economy: i.e. political
economic ecology.
Energy systems language
The question of what language can best depict the linear and non-linear causal connections of ecological systems appears to have been taken up by the school of ecology known as systems ecology.
To depict the linear and non-linear internal relatedness of ecosystems
where the laws of thermodynamics hold significant consequences (Hannon
et al. 1991: 80), Systems Ecologist H.T. Odum (1994) predicated the Energy Systems Language on the principles of ecological energetics.
In ecological energetics, just as in environmental humanities, the
causal bond between connections is considered an ontic category (see
Patten et al. 1976: 460). Moreover, as a result of simulating ecological
systems with the energy systems language, H.T. Odum made the
controversial suggestion that embodied energy could be understood as value, which in itself is a step into the field of Political Economic Ecology noted above.
Ecocriticism is the study of literature and ecology from an interdisciplinary
point of view, where literature scholars analyze texts that illustrate
environmental concerns and examine the various ways literature treats
the subject of nature. It was first originated by Joseph Meeker as an idea called "literary ecology" in his The Comedy of Survival: Studies in Literary Ecology (1972).
The term 'ecocriticism' was coined in 1978 by William Rueckert in
his essay "Literature and Ecology: An Experiment in Ecocriticism". It takes an interdisciplinary point of view by analyzing the works of
authors, researchers and poets in the context of environmental issues
and nature. Some ecocritics brainstorm possible solutions for the correction of the
contemporary environmental situation, though not all ecocritics agree
on the purpose, methodology, or scope of ecocriticism.
In the United States, ecocriticism is often associated with the Association for the Study of Literature and Environment (ASLE), which hosts a biennial conference for scholars who deal with
environmental matters in literature and the environmental humanities in
general. ASLE publishes a journal—Interdisciplinary Studies in Literature and Environment (ISLE)—in which current international scholarship can be found.
In
comparison with other 'political' forms of criticism, there has been
relatively little dispute about the moral and philosophical aims of
ecocriticism, although its scope has broadened from nature writing,
romantic poetry, and canonical literature to take in film, television,
theatre, animal stories, architectures, scientific narratives and an
extraordinary range of literary texts. At the same time, ecocriticism
has borrowed methodologies and theoretically informed approaches
liberally from other fields of literary, social and scientific study.
Cheryll Glotfelty's working definition in The Ecocriticism Reader is that "ecocriticism is the study of the relationship between literature and the physical environment", and one of the implicit goals of the approach is to recoup professional
dignity for what Glotfelty calls the "undervalued genre of nature writing". Lawrence Buell defines "'ecocriticism' ... as [a] study of the
relationship between literature and the environment conducted in a
spirit of commitment to environmentalist praxis".
Simon Estok noted in 2001 that "ecocriticism has distinguished
itself, debates notwithstanding, firstly by the ethical stand it takes,
its commitment to the natural world as an important thing rather than
simply as an object of thematic study, and, secondly, by its commitment
to making connections".
More recently, in an article that extends ecocriticism to
Shakespearean studies, Estok argues that ecocriticism is more than
"simply the study of Nature or natural things in literature; rather, it
is any theory that is committed to effecting change by analyzing the
function–thematic, artistic, social, historical, ideological,
theoretical, or otherwise–of the natural environment, or aspects of it,
represented in documents (literary or other) that contribute to material
practices in material worlds". This echoes the functional approach of the cultural ecology
branch of ecocriticism, which analyzes the analogies between ecosystems
and imaginative texts and posits that such texts potentially have an
ecological (regenerative, revitalizing) function in the cultural system.
As Michael P. Cohen has observed, "if you want to be an
ecocritic, be prepared to explain what you do and be criticized, if not
satirized." Certainly, Cohen adds his voice to such critique, noting
that one of the problems of ecocriticism has been what he calls its
"praise-song school" of criticism. All ecocritics share an
environmentalist motivation of some sort, but whereas the majority are
'nature endorsing', some are 'nature sceptical'. In part this entails a shared sense of the
ways in which 'nature' has been used to legitimize gender, sexual and
racial norms (so homosexuality has been seen as 'unnatural', for
example), but it also involves scepticism about the uses to which
'ecological' language is put in ecocriticism; it can also involve a
critique of the ways cultural norms of nature and the environment
contribute to environmental degradation. Greg Garrard has dubbed 'pastoral ecology' the notion that nature undisturbed is balanced and harmonious, while Dana Phillips has criticised the literary quality and scientific accuracy of nature writing in The Truth of Ecology. Similarly, there has been a call to recognize the place of the environmental justice movement in redefining ecocritical discourse.
In response to the question of what ecocriticism is or should be,
Camilo Gomides has offered an operational definition that is both broad
and discriminating: "The field of enquiry that analyzes and promotes
works of art which raise moral questions about human interactions with
nature, while also motivating audiences to live within a limit that will
be binding over generations". He tests it for a film adaptation about Amazonian deforestation.
Implementing the Gomides definition, Joseph Henry Vogel makes the case
that ecocriticism constitutes an "economic school of thought" as it
engages audiences to debate issues of resource allocation that have no
technical solution. Ashton Nichols
has recently argued that the historical dangers of a romantic version
of nature now need to be replaced by "urbanatural roosting", a view that
sees urban life and the natural world as closely linked and argues for
humans to live more lightly on the planet, the way virtually all other
species do.
The interdisciplinary nature of Ecocriticism and Islam as well as
their mutual interest in nature led to the coinage of Islamecocriticism
in 2021. Islemecocriticism is fully introduced by ISLE: Interdisciplinary Studies in Literature and Environment in "Islamecocriticism: Green Islam Introduced to Ecocriticism." The article is shortly followed by a thorough representation of
Material Islamecocriticism in "Matter Really Matters: A Poetic Material
Islamecocritical Reading of Inanimateness Animism" which appeared in Kritika Kultura.
In literary studies
Ecocritics investigate such things as the underlying ecological
values, what, precisely, is meant by the word nature, and whether the
examination of "place" should be a distinctive category, much like
class, gender or race. Ecocritics examine human perception of wilderness,
and how it has changed throughout history and whether or not current
environmental issues are accurately represented or even mentioned in
popular culture and modern literature. Not only do ecocritics determine
the actual meaning of nature writing
texts, but they use those texts for analyzing the practices of society
in relationship to nature. They also critique visions that are
human-centered and man/male centered. Scholars in ecocriticism engage
in questions regarding anthropocentrism,
and the "mainstream assumption that the natural world be seen primarily
as a resource for human beings" as well as critical approaches to
changing ideas in "the material and cultural bases of modern society." Recently, "empirical ecocritics" have begun empirically evaluating the influence of ecofiction on its readers and the prevalence of environmental narratives in popular media. Other disciplines, such as history, economics, philosophy, ethics, and
psychology, are also considered by ecocritics to be possible
contributors to ecocriticism.
While William Rueckert may have been the first person to use the term ecocriticism (Barry 240) in his 1978 essay entitled Literature and Ecology: An Experiment in Ecocriticism, ecocriticism as a movement owes much to Rachel Carson's 1962 environmental exposé Silent Spring.
Drawing from this critical moment, Rueckert's intent was to focus on
"the application of ecology and ecological concepts to the study of
literature".
Ecologically minded individuals and scholars have been publishing
progressive works of ecotheory and criticism since the explosion of
environmentalism in the late 1960s and 1970s. However, because there was
no organized movement to study the ecological/environmental side of
literature, these important works were scattered and categorized under a
litany of different subject headings: pastoralism, human ecology, regionalism, American Studies etc. British marxist criticRaymond Williams, for example, wrote a seminal critique of pastoral literature in 1973, The Country and the City.
Another early ecocritical text, Joseph Meeker's The Comedy of Survival
(1974), proposed a version of an argument that was later to dominate
ecocriticism and environmental philosophy; that environmental crisis is
caused primarily by a cultural tradition in the West of separation of
culture from nature, and elevation of the former to moral predominance.
Such anthropocentrism
is identified in the tragic conception of a hero whose moral struggles
are more important than mere biological survival, whereas the science of
animal ethology, Meeker asserts, shows that a "comic mode" of muddling
through and "making love not war" has superior ecological value. In the
later, "second wave" ecocriticism, Meeker's adoption of an
ecophilosophical position with apparent scientific sanction as a measure
of literary value tended to prevail over Williams's ideological and
historical critique of the shifts in a literary genre's representation
of nature.
As Glotfelty noted in The Ecocriticism Reader, "One
indication of the disunity of the early efforts is that these critics
rarely cited one another's work; they didn't know that it existed...Each
was a single voice howling in the wilderness." Nevertheless, ecocriticism—unlike feminist and Marxist
criticisms—failed to crystallize into a coherent movement in the late
1970s, and indeed only did so in the US in the 1990s.
In the mid-1980s, scholars began to work collectively to establish ecocriticism as a genre, primarily through the work of the Western Literature Association in which the revaluation of nature writing as a non-fictional literary genre could function. During the late-1980s poet Jack Collom was awarded a 2nd National Endowment for the Arts grant, for his ground-breaking work in this emerging genre. Collom taught an influential Eco-Lit course at Naropa University in Boulder, Colorado, for nearly two decades. In 1990, at the University of Nevada, Reno,
Glotfelty became the first person to hold an academic position as a
professor of Literature and the Environment, and UNR, with the aid of
the now-retired Glotfelty and the remaining professor Michael P. Branch,
has retained the position it established at that time as the
intellectual home of ecocriticism even as ASLE has burgeoned into an
organization with thousands of members in the US alone. From the late
1990s, new branches of ASLE and affiliated organizations were started in
the UK, Japan, Korea, Australia and New Zealand (ASLEC-ANZ), India
(OSLE-India), Southeast Asia (ASLE-ASEAN), Taiwan, Canada and
continental Europe. The emergence of ecocriticism in British literary
criticism is usually dated to the publication in 1991 of Romantic Ecology: Wordsworth and the Environmental Tradition by Jonathan Bate.
Ecocriticism’s second wave emerged in the 2000s through a more
complex understanding of the overall history of global environmentalism
and environmental justice. According to Lawrence Buell,
former Harvard professor and proponent of ecocriticism, the second wave
of ecocriticism aligns with public health environmentalism, with ethics
and politics that are sociocentric rather than ecocentric. The second
wave not only considers rural landscapes or wilderness, but also
landscapes of urban and industrial transformation. It is inspired by
writers such as Charles Dickens, who wrote about Victorian-era public
health concerns, and the American novelist Upton Sinclair, as well as by global activists, such as Ken Saro-Wiwa, who was executed for his protests against ecological devastation in Nigeria, and Michiko Ishimure, who wrote about Minamata disease and the effects of mercury poisoning.
The second wave of ecocriticism distinguishes itself from the first
wave by prioritizing the exploration of issues such as environmental
resource distribution, environmental justice, minority and socioeconomic
impacts related to environmental circumstances. A representative of
second-wave ecocriticism is the 2002 Environmental Justice Reader: Politics, Poetics, and Pedagogy.
Recent eco-critical scholarship has seen issues concerning
eco-anxiety, veganism, and activism take precedence. Scholars are now
starting to take into consideration the impact of the Covid-19 pandemic
on environmental activism and the climate crisis more broadly. In their
2022 Special Issue for Green Letters entitled 'A New Poetics of
Space', the co-editors, Lucy Jeffery and Vicky Angelaki, remark: 'We
hope that through the analysis of the act of walking in the creative
arts we can understand our role in shaping the environmental state in
which we find ourselves. Throughout this volume we ask: is there a way
yet to describe how our attitude towards our being in the environment
has shifted since the Covid-19 pandemic?' This scholarly volume is evidence of a current trend in eco-critical
scholarship to explore the impact of the twenty-first century's
technological developments, societal shifts, environmental challenges,
and political situation through the perspective of creative works that
are concerned with the poetics of space, health, and the environment
(both urban and rural).
Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for
individual adults, families, or children and adolescents. Some types of
psychotherapy are considered evidence-based for treating diagnosed mental disorders; other types have been criticized as pseudoscience.
There are hundreds of psychotherapy techniques, some being minor
variations; others are based on very different conceptions of
psychology. Most approaches involve one-to-one sessions, between the client and therapist, but some are conducted with groups, including couples and families.
It has shown general efficacy across a range of conditions, although its efficacy
varies by individual and condition. While large-scale reviews support
its benefits, debates continue over the best methods for evaluating
outcomes, including the use of randomized controlled trials versus individualized approaches. A 2022 umbrella review of 102 meta-analyses found that effect sizes for both psychotherapies and medications were generally small, leading researchers to recommend a paradigm shift in mental health research. Although many forms of therapy differ in technique, they often produce similar outcomes, leading to theories that common factors—such as the therapeutic relationship—are key drivers of efficacy. Challenges include high dropout rates, limited understanding of mechanisms of change, potential adverse effects, and concerns about therapist adherence to treatment fidelity. Critics have raised questions about psychotherapy's scientific basis, cultural assumptions, and power dynamics, while others argue it is underutilized compared to pharmacological treatments.
Definitions
The term psychotherapy is derived from Ancient Greekpsyche (ψυχή meaning "breath; spirit; soul") and therapeia (θεραπεία "healing; medical treatment"). The Oxford English Dictionary
defines it as "The treatment of disorders of the mind or personality by
psychological means...", however, in earlier use, it denoted the
treatment of disease through hypnotic suggestion. Psychotherapy is often dubbed as a "talking therapy" or "talk 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.
The American Psychological Association adopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed by American psychologist 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—which Frank regarded as forms of persuasion and rhetoric. 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.
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.
Delivery
Psychotherapy may be delivered in person (one on one, or with couples, with families, or, in groups) or via telephone counseling or online counseling (see also § Telepsychotherapy). There have also been developments in computer-assisted therapy, such as virtual reality therapy
for behavioral exposure, multimedia programs to teach cognitive
techniques, and handheld devices for improved monitoring or putting
ideas into practice (see also § Computer-supported).
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.
Some therapeutic settings use digital tools to help with session
documentation. Ambient systems, for example, employ speech recognition
that captures clinician–patient dialogue and generates draft notes for
later review. These tools, offered by various vendors including Twofold
Health, must comply with privacy and security requirements such as those
set out in HIPAA.
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. In addition to the training, many
countries require psychotherapist to register with a professional body
in order to be permitted to offer services.
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 specialty 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
training is completed at a postgraduate level, often at a master's
degree (or doctoral) level, over four years, with significant clinical supervision
and clinical placements. Mental health professionals that choose to
specialize in psychotherapeutic work also require a program of
continuing professional education after basic professional training.
A listing of the extensive professional competencies of a
European psychotherapist was developed by the European Association of
Psychotherapy (EAP) in 2013.
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. In some
countries psychotherapists are required by law to be mandated reporters.
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 training. The
titles that are protected also vary. The European Association for Psychotherapy
(EAP) established the 1990 Strasbourg Declaration on Psychotherapy,
which is dedicated to establishing an independent profession of
psychotherapy in Europe, with pan-European standards.[28] 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 labor 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, cognitive behavioral therapy,
and systemic therapy meet the requirements of German health insurance
companies, mental health professionals regularly opt for one of these
four 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
recognised 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 licence, 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. Counsellors 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 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 of psychologists 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".
Canada
Regulation of psychotherapy is in the jurisdiction of, and varies among, the provinces and territories.
In Quebec,
psychotherapy is a regulated activity which is restricted to
psychologists, medical doctors, and holders of a psychotherapy permit
issued by the Ordre des psychologues du Québec, the Quebec order of
psychologists. Members of certain specified professions, including social workers, couple and family therapists, occupational therapists, guidance counsellors, criminologists, sexologists, psychoeducators,
and registered nurses may obtain a psychotherapy permit by completing
certain educational and practice requirements; their professional
oversight is provided by their own professional orders. Some other
professionals who were practising psychotherapy before the current
system came into force continue to hold psychotherapy permits alone.
On 1 July 2019, Ontario's Missing Persons Act came into effect,
with the purpose of giving police more power to investigate missing
persons. It allows police to require (as opposed to permit) health
professionals, including psychotherapists, to share otherwise
confidential documents about their client, if there is reason to believe
their client is missing. Some have expressed concern that this legislation undermines
psychotherapy confidentiality and could be abused maliciously by police, while others have praised the act for how it respects privacy and includes checks and balances.
On the 13th of October 2025, the National Standards for Counsellors and Psychotherapists entered the counsultation stage.The
standards define career stages that have specified requirements in the
level of education, training and experience expected of counsellors or
psychotherapists at each level. These stages are mapped to the Australian Qualifications Framework.
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.
Hippolyte Bernheim and his colleagues in the "Nancy School" (Ambroise-Auguste Liébeault, Henri-Étienne Beaunis, and Jules Liégeois) 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 van Renterghem 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 the right of the 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 the 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.
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
receive 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.
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. Contemporary integrative models increasingly emphasize identifying and
modifying recurrent cognitive, emotional, and interpersonal patterns,
combining techniques from cognitive-behavioral, psychodynamic, and
attachment-based frameworks. 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 Jean-Martin Charcot
in 1885, is often considered the father of modern psychotherapy. His
methods included analyzing his patient's dreams in search of important
hidden insights into their unconscious minds. 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 tool set of
ordinary clinical practice. They are not just medications, they
additionally help to understand complex conduct.
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.
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.
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.
Humanistic Psychodrama (HPD) is based on the human image of humanistic psychology. So all rules and methods follow the axioms of humanistic psychology.
The HPD sees itself as development-oriented psychotherapy and has
completely moved away from the psychoanalytic catharsis theory. Self-awareness and self-realization are essential aspects in the
therapeutic process. Subjective experiences, feelings and thoughts and
one's own experiences are the starting point for a change or
reorientation in experience and behavior in the direction of more
self-acceptance and satisfaction. Dealing with the biography of the
individual is closely related to the sociometry of the group.
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 1998–99. 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 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.
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 reconstruction 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.
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.
Exposure and response prevention (ERP) is primarily deployed by therapists in the treatment of OCD.[99] The American Psychiatric Association
(APA) state that CBT drawing primarily on behavioral techniques (such
as ERP) has the "strongest evidence base" among psychosocial
interventions.[100]
By confronting feared scenarios (i.e., exposure) and refraining from
performing rituals (i.e., responsive prevention), patients may gradually
feel less distress in confronting feared stimuli, while also feeling
less inclination to use rituals to relieve that distress. Typically, ERP
is delivered in "hierarchical fashion", meaning patients confront
increasingly anxiety-provoking stimuli as they progress through a course
of treatment.
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 psychotherapy is a form of therapy that utilizes artistic
expression (via improvisational, compositional, re-creative, and
receptive experiences) as its core means of treating clients. Expressive
psychotherapists 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. This may include techniques such as affect labeling.
Expressive psychotherapists believe that often the most effective way
of treating a client is through the expression of imagination in
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" through 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.
Psychedelic therapy are therapeutic practices involving psychedelic drugs, such as LSD, psilocybin, DMT, and MDMA. In psychedelic therapy, in contrast to conventional psychiatric medication
taken by the patient regularly or as needed, patients generally remain
in an extended psychotherapy session during the acute psychedelic
activity with additional sessions both before and after in order to help
integrate experiences with the psychedelics. Psychedelic therapy has been compared with the shamanic
healing rituals of indigenous people. Researchers identified two main
differences: the first is the shamanic belief that multiple realities
exist and can be explored through altered states of consciousness, and
second the belief that spirits encountered in dreams and visions are
real. The charitable initiative Founders Pledge has written a research report on cost-effective giving opportunities for funding psychedelic-assisted mental health treatments.
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.
Psychotherapy needs to be adapted to meet the developmental needs of
children. Depending on age, it is generally held to be one part of an
effective strategy to help the needs of a child within the family
setting. Child psychotherapy training programs necessarily include courses in human development.
Since children often do not have the ability to articulate thoughts and
feelings, psychotherapists will use a variety of media such as musical
instruments, sand and toys, crayons, paint, clay, puppets,
bibliocounseling (books), or board games. The use of play therapy is often rooted in psychodynamic theory, but other approaches also exist.
In addition to therapy for the child, sometimes instead of it,
children may benefit if their parents work with a therapist, take
parenting classes, attend grief counseling, or take other action to resolve stressful situations that affect the child. Parent management training is a highly effective form of psychotherapy that teaches parenting skills to reduce their child's behavior problems.
In many cases a different psychotherapist will work with the care taker of the child, while a colleague works with the child. Therefore, contemporary thinking on working with the younger age group
has leaned towards working with parent and child simultaneously, as well
as individually as needed.
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:
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.
Telepsychiatry can be effective in treating people with mental
health conditions. In the short-term it can be as acceptable and
effective as face-to-face care. Research also suggests comparable therapeutic factors, such as changes in problematic thinking or behaviour.
It can improve access to mental health services for some but
might also represent a barrier for those lacking access to a suitable
device, the internet or the necessary digital skills. Factors such as poverty that are associated with lack of internet access are also associated with greater risk of mental health problems, making digital exclusion an important problem of telemental health services.
During the COVID-19 pandemic mental health services were adapted to telemental health in high-income countries.
It proved effective and acceptable for use in an emergency situation
but there were concerns regarding its long-term implementation.
Effects
Efficacy
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 group includes patients on a waiting list, or those
receiving some kind of regular non-specific contact or support.
Researchers must consider how best 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 several formal frameworks for evaluating whether a
psychotherapist is a good fit for a patient. One example is 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
increasingly believe that evidence-based approaches are appropriate to
their methods and assumptions, and have increasingly accepted the
challenge to implement evidence-based approaches in their methods.
A pioneer in investigating the results of different psychological therapies was psychologist Hans Eysenck, who argued that psychotherapy does not produce any improvement in patients. He held that behavior therapy
is the only effective one. However, it was revealed that Eysenck (who
died in 1997) falsified data in his studies about this subject,
fabricating data that would indicate that behavioral therapy enables
achievements that are impossible to believe. Fourteen of his papers were
retracted by journals in 2020, and journals issued 64 statements of
concern about publications by him. Rod Buchanan, a biographer of
Eysenck, has argued that 87 publications by Eysenck should be retracted.
The response rate of psychotherapy varies, no reliable changes due to psychotherapy can be found in up to 33% of patients.
Comparison with other treatments
Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions. A 2022 umbrella review of 102 meta-analyses found that most effect sizes
reported for both psychotherapies and pharmacotherapies, compared to
treatment-as-usual or placebo, were small for most disorders and
treatments, and concluded that a "paradigm shift in research" was needed
to advance the field and improve treatment strategies for mental
disorders.
One line of research consistently found that supposedly different
forms of psychotherapy show similar effectiveness. According to the
2008 edition of 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 stated that "little evidence suggests that any one
treatment 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.
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.
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.
Adverse effects
Research on adverse effects
of psychotherapy has been limited, yet worsening of symptoms may be
expected to occur in 3% to 15% of patients, with variability across
patient and therapist characteristics. Potential problems include deterioration of symptoms or developing new symptoms, strains in other relationships, social stigma, and therapy dependence. 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.
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.
Mechanisms of change
It is not yet understood how psychotherapies can succeed in treating mental illnesses. 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.
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.
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.
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