Near-death studies

From Wikipedia, the free encyclopedia

Near-death studies is a field of psychology and psychiatry that studies the physiology, phenomenology and after-effects of the near-death experience (NDE). The field was originally associated with a distinct group of North American researchers that followed up on the initial work of Raymond Moody, and who later established the International Association for Near-death Studies (IANDS) and the Journal of Near-Death Studies. Since then the field has expanded, and now includes contributions from a wide range of researchers and commentators worldwide.

Near-death experience

The near-death experience is an experience reported by people who have come close to dying in a medical or non-medical setting. The aspect of trauma, and physical crises, is also recognized as an indicator for the phenomenon. According to sources it is estimated that near-death experiences are reported by five percent of the adult American population. According to IANDS, surveys (conducted in USA, Australia and Germany) suggest that 4 to 15% of the population have had NDEs. Researchers study the role of physiological, psychological and transcendental factors associated with the NDE. These dimensions are also the basis for the three major explanatory models for the NDE. 

Some general characteristics of an NDE include subjective impressions of being outside the physical body; visions of deceased relatives and religious figures; transcendence of ego and spatiotemporal boundaries. NDE researchers have also found that the NDE may not be a uniquely western experience. Commentators note that several elements and features of the NDE appears to be similar across cultures, but the details of the experience (figures, beings, scenery), and the interpretation of the experience, varies between cultures. However, a few researchers have challenged the hypothesis that near-death experience accounts are substantially influenced by prevailing cultural models.

Elements of the NDE

According to the NDE-scale a near-death-experience includes a few, or several, of the following 16 elements:

1. Time speeds up or slows down.
2. Thought-processes speed up.
3. A return of scenes from the past.
4. A sudden insight, or understanding.
5. A feeling of peace or pleasantness.
6. A feeling of happiness, or joy.
7. A sense of harmony or unity with the universe.
8. Confrontation with a brilliant light.
9. The senses feel more vivid.
10. An awareness of things going on elsewhere, as if by extrasensory perception (ESP).
11. Experiencing scenes from the future.
12. A feeling of being separated from the body.
13. Experiencing a different, unearthly world.
14. Encountering a mystical being or presence, or hearing an unidentifiable voice.
15. Seeing deceased or religious spirits.
16. Coming to a border, or point of no return.

In a study published in The Lancet van Lommel and colleagues  list ten elements of the NDE: 

1. Awareness of being dead.
2. Positive emotions.
3. Out of body experience.
4. Moving through a tunnel.
5. Communication with light.
6. Observation of colours.
7. Observation of a celestial landscape.
8. Meeting with deceased persons.
9. Life review.
10. Presence of border.

After-effects

According to sources the NDE is associated with a number of after-effects, or life changing effects. The effects, which are often summarized by researchers, include a number of value, attitude and belief changes that reflect radical changes in personality, and a new outlook on life and death, human relations, and spirituality. Many of the effects are considered to be positive or beneficial.van Lommel and colleagues conducted a longitudinal follow-up research into transformational processes after NDE's and found a long-lasting transformational effect of the experience.

However, not all after-effects are beneficial. The literature describes circumstances where changes in attitudes and behavior can lead to distress, psychosocial, or psychospiritual problems. Often the problems have to do with adjustment to the new situation following a near-death experience, and its integration into ordinary life. Another category, so-called distressing or unpleasant near-death experiences, has been investigated by Greyson and Bush.

Explanatory models

Explanatory models for the phenomenology and the elements of the NDE can, according to sources, be divided into a few broad categories: psychological, physiological, and transcendental. Agrillo, adopting a more parsimonious overview, notes that literature reports two main theoretical frameworks: (1) “biological/psychological” interpretation (in-brain theories), or (2) “survivalist” interpretation (out-of-brain theories). The research on NDEs often include variables from all three models. In a study published in 1990, Owens, Cook and Stevenson presented results that lent support to all of these three interpretations.

Each model contains a number of variables that are often mentioned, or summarized, by commentators: 

Psychological theories have suggested that the NDE can be a consequence of mental and emotional reactions to the perceived threat of dying, or a result of expectation. Other psychological variables that are considered by researchers include: imagination; depersonalization; dissociation; proneness to fantasy; and the memory of being born.

Physiological theories tend to focus on somatic, biological or pharmacological explanations for the NDE, often with an emphasis on the physiology of the brain. Variables that are considered, and often summarized by researchers, include: anoxia; cerebral hypoxia; hypercarbia; endorphins; serotonin or various neurotransmitters; temporal lobe dysfunction or seizures; the NMDA receptor; activation of the limbic system; drugs; retinal ischemia; and processes linked to rapid eye-movement (REM) sleep or phenomena generated on the border between sleep and wakefulness.

A third model, sometimes called the transcendental explanation, considers a number of categories, often summarized by commentators, that usually fall outside the scope of physiological or psychological explanations. This explanatory model considers whether the NDE might be related to the existence of an afterlife; a changing state of consciousness; mystical (peak) experiences; or the concept of a mind-body separation.

Several researchers in the field, while investigating variables from all three models, have expressed reservations towards explanations that are purely psychological or physiological. van Lommel and colleagues have argued for the inclusion of transcendental categories as part of the explanatory framework. Other researchers, such as Parnia, Fenwick, and Greyson, have argued for an expanded discussion about the mind-brain relationship and the possibilities of human consciousness.

Research - history and background

Individual cases of NDEs in literature have been identified into ancient times. In the 19th century a few efforts moved beyond studying individual cases - one privately done by Mormons and one in Switzerland. Up to 2005, 95% of world cultures have been documented making some mention of NDEs. From 1975 to 2005, some 2500 self reported individuals in the US had been reviewed in retrospective studies of the phenomena with an additional 600 outside the US in the West, and 70 in Asia. Prospective studies, reviewing groups of individuals and then finding who had an NDE after some time and costing more to do, had identified 270 individuals. In all close to 3500 individual cases between 1975 and 2005 had been reviewed in one or another study. And all these studies were carried out by some 55 researchers or teams of researchers.

Research on near-death experiences is mainly limited to the disciplines of medicine, psychology and psychiatry. Interest in this field of study was originally spurred by the research of such pioneers as Elisabeth Kübler-Ross (psychiatrist) and Raymond Moody (psychologist and M.D.), but also by autobiographical accounts, such as the books of George Ritchie (psychiatrist). Kübler-Ross, who was a researcher in the field of Thanatology and a driving force behind the establishment of the Hospice System in the United States, reported on her interviews for the first time in her book "On Death and Dying. What the dying have to teach doctors, nurses, clergy, and their own families"(1969). Raymond Moody, on the other hand, got interested in the subject at the start of his career. In the mid-seventies, while doing his medical residency as a psychiatrist at the University of Virginia, he conducted interviews with Near-Death Experiencers. He later published these findings in the book Life After Life (1976). In the book Moody outlines the different elements of the NDE. Features that were picked up by later researchers. The book brought a lot of attention to the topic of NDEs.

The late seventies saw the establishment of the Association for the Scientific Study of Near-Death Phenomena, an initial group of academic researchers, including John Audette, Raymond Moody, Bruce Greyson, Kenneth Ring and Michael Sabom, who laid the foundations for the field of Near-death studies, and carried out some of the first post-Moody NDE research. The Association was the immediate predecessor of the International Association for Near-death Studies (IANDS), which was founded in the early eighties and which established its headquarters at the University of Connecticut, Storrs. This group of researchers, but especially Ring, was responsible for launching Anabiosis, the first peer-reviewed journal within the field. The journal later became Journal of Near-Death Studies.

However, even though the above-mentioned profiles introduced the sucject of NDE's to the academic setting, the subject was often met with academic disbelief, or regarded as taboo. The medical community has been somewhat reluctant to address the phenomenon of NDEs, and grant money for research has been scarce. However, both Ring and Sabom made contributions that were influential for the newly established field. Ring published a book in 1980 called Life at Death: A Scientific Investigation of the Near-Death Experience. This early research was followed up by new book in 1984 by the title Heading Toward Omega: In Search of the Meaning of the Near-Death Experience. The early work of Michael Sabom was also bringing attention to the topic within the academic community. Besides contributing material to academic journals, he wrote a book called Recollections of Death (1982) which is considered to be a significant publication in the launching of the field.

As research in the field progressed both Greyson and Ring developed measurement tools that can be used in a clinical setting. Greyson has also addressed different aspects of the NDE, such as the psychodynamics of the experience, the varieties of NDE, the typology of NDE's and the biology of NDE's. In addition to this he has brought attention to the near-death experience as a focus of clinical attention, suggesting that the aftermath of the NDE, in some cases, can lead to psychological problems. 

The 1980s also introduced the research of Melvin Morse, another profile in the field of near-death studies. Morse and colleagues investigated near-death experiences in a pediatric population. They found that children reported NDE's that were similar to those described by adults. Morse later published two books, co-authored with Paul Perry, that were aimed at a general audience: Closer to the light: learning from children’s near-death experiences (1990) and Transformed by the light: the powerful effect of near-death experiences on people’s lives (1992). Another early contribution to the field was the research of British Neuro-psychiatrist Peter Fenwick, who started to collect NDE-stories in the 1980s. In 1987 he presented his findings on a television-program, which resulted in more stories being collected. The responses from Near-death experiencers later served as the basis for a book published in 1997, "The Truth in the light", co-authored with his wife Elizabeth Fenwick. Co-operating with other researchers, among others Sam Parnia, Fenwick has also published research on the potential relationship between cardiac arrest and Near-death Experiences.

Early investigations into the topic of near-death experiences were also being conducted at the University of Virginia, where Ian Stevenson founded the Division of Personality Studies in the late sixties. The division went on to produce research on a number of phenomena that were not considered to be mainstream. In addition to near-death experiences this included: reincarnation and past lives, out-of-body experiences, apparitions and after-death communications, and deathbed visions. Stevenson, whose main academic interest was the topic of reincarnation and past lives, also made contributions to the field of near-death studies. In a 1990-study, co-authored with Owens & Cook, the researchers studied the medical records of 58 people who believed they had been near death. The authors judged 28 candidates to actually have been close to dying, while 30 candidates, who merely thought they were about to die, were judged to not have been in any medical danger. Both groups reported similar experiences, but the first group reported more features of the core NDE-experience than the other group.

Recently, the work of Jeffrey Long has also attracted attention to the topic of NDE's in both the academic, and the popular field. In 2010 he released a book, co-authored with Paul Perry, called Evidence of the Afterlife: The Science of Near-Death Experiences. In the book Long presented results from research conducted over the last decade. Research has also entered into other fields of interest, such as the mental health of military veterans. Goza studied NDE's among combat veterans. She found, among other things, that combat soldiers reported different, and less intense near-death experiences, compared to NDErs in the civilian population.

The first decades of Near-death research were characterized by retrospective studies. However, the 2000s marked the beginning of prospective studies in the field, both on the European and the American continent. 

In a study from 2001, conducted at Southampton General Hospital, Parnia and colleagues found that 11.1% of 63 cardiac-arrest survivors reported memories of their unconscious period. Several of these memories included NDE-features. This study was the first in a series of new prospective studies using cardiac arrest criteria, and it was soon to be followed by the study of van Lommel and colleagues, also published in 2001. Pim van Lommel (cardiologist) was one of the first researchers to bring the study of NDE's into the area of Hospital Medicine. In 1988 he launched a prospective study that spanned 10 Dutch hospitals. 344 survivors of cardiac arrest were included in the study. 62 patients (18%) reported NDE. 41 of these patients (12%) described a core experience. The aim of the study was to investigate the cause of the experience, and assess variables connected to frequency, depth, and content.

Prospective studies were also taking place in the U.S. Schwaninger and colleagues collaborated with Barnes-Jewish Hospital, where they studied cardiac arrest patients over a three-year period (April 1991 - February 1994). Only a minority of the patients survived, and from this group 30 patients were interviewable. Of these 30 patients 23% reported an NDE, while 13% reported an NDE during a prior life-threatening illness. Greyson conducted a 30-month survey of patients admitted to the cardiac inpatient service of the University of Virginia Hospital. He found that NDE's were reported by 10% of patients with cardiac arrest and 1% of other cardiac patients.

In 2008 the University of Southampton announced the start of a new research-project named The AWARE (AWAreness during REsuscitation) study. The study was launched by the University of Southampton, but included collaboration with medical centres within the UK, mainland Europe and North America. The object of the study was to study the brain, and consciousness, during cardiac arrest, and to test the validity of out of body experiences and reported claims of lucidity (the ability to see and hear) during cardiac arrest.

The first clinical paper from this project, described as a 4-year multi-center observational study, was published in 2014. The study found that 9% of patients who completed stage 2 interviews reported experiences compatible with NDEs.

Psychometrics

Several psychometric instruments have been adapted to near-death research. Ring developed the Weighted Core Experience Index in order to measure the depth of NDE's, and this instrument has been used by other researchers for this purpose. The instrument has also been used to measure the impact of near-death experiences on dialysis patients. According to some commentators the index has improved consistency in the field. However, Greyson notes that although the index is a pioneering effort, it is not based on statistical analysis, and has not been tested for internal coherence or reliability. In 1984 Ring developed an instrument called the Life Changes Inventory (LCI) in order to quantify value changes following an NDE. The instrument was later revised and standardized and a new version, the LCI-R, was published in 2004.

Greyson developed The Near-Death Experience Scale. This 16-item Scale was found to have high internal consistency, split-half reliability, and test-retest reliability and was correlated with Ring's Weighted Core Experience Index. Questions formulated by the scale address such dimensions as: cognition (feelings of accelerated thought, or "life-review"), affect (feelings of peace and joy), paranormal experience (feelings of being outside of the body, or a perception of future events) and transcendence (experience of encountering deceased relatives, or experiencing an unearthly realm). A score of 7 or higher out of a possible 32 was used as the standard criterion for a near-death experience. The scale is, according to the author, clinically useful in differentiating NDEs from organic brain syndromes and nonspecific stress responses. The NDE-scale was later found to fit the Rasch rating scale model. The instrument has been used to measure NDE's among cardiac arrest survivors, coma survivors, out-of-hospital cardiac arrest patients/survivors, substance misusers, and dialysis patients.

In the late 1980s Thornburg developed the Near-Death Phenomena Knowledge and Attitudes Questionnaire. The questionnaire consists of 23 true/false/undecided response items assessing knowledge, 23 Likert scale items assessing general attitudes toward near-death phenomena, and 20 Likert scale items assessing attitude toward caring for a client who has had an NDE. Knowledge and attitude portions of the instrument were tested for internal consistency. Content validity was established by using a panel of experts selected from nursing, sociology, and psychology. The instrument has been used to measure attitudes toward, and knowledge of, near-death experiences in a college population, among clergy, among registered psychologists, and among hospice nurses.

Greyson has also used mainstream psychological measurements in his research, for example The Dissociative Experiences Scale; a measure of dissociative symptoms, and The Threat Index; a measure of the threat implied by one's personal death.

Near death studies community

Research Organizations and Academic locations

The field of near-death studies includes several communities that study the phenomenology of NDE's. The largest of these communities is IANDS, an international organization based in Durham, North-Carolina, that encourages scientific research and education on the physical, psychological, social, and spiritual nature and ramifications of near-death experiences. Among its publications we find the peer-reviewed Journal of Near-Death Studies, and the quarterly newsletter Vital Signs. The organization also maintains an archive of near-death case histories for research and study.

Another research organization, the Louisiana-based Near Death Experience Research Foundation, was established by radiation oncologist Jeffrey Long in 1998. The foundation maintains a web-site, also launched in 1998, and a database of more than 1,600 cases, which is currently the world's largest collection of near-death reports. The reports come directly from sources all across the world.

A few academic locations have been associated with the activities of the field of near-death studies. Among these we find the University of Connecticut (US), Southampton University (UK), University Of North Texas (US)  and the Division of Perceptual Studies at the University of Virginia (US).

Conferences

IANDS holds conferences, at regular intervals, on the topic of near-death experiences. The first meeting was a medical seminar at Yale University, New Haven (CT) in 1982. This was followed by the first clinical conference in Pembroke Pines (FL), and the first research conference in Farmington (CT) in 1984. Since then conferences have been held in major U.S. cities, almost annually. Many of the conferences have addressed a specific topic, defined in advance of the meeting. In 2004 participants gathered in Evanston (IL) under the headline:"Creativity from the light". A few of the conferences have been arranged at academic locations. In 2001 researchers and participants gathered at Seattle Pacific University. In 2006 the University of Texas MD Anderson Cancer Center became the first medical institution to host the annual IANDS conference.

The first international medical conference on near-death experiences was held in 2006. Approximately 1.500 delegates, including people who claim to have had NDEs, were attending the one-day conference in Martigues, France. Among the researchers attending the conference were anaesthetist and intensive care doctor Jean-Jacques Charbonnier, and pioneering researcher Raymond Moody.

Relevant publications

IANDS publishes the quarterly Journal of Near-Death Studies, the only scholarly journal in the field. The Journal is cross-disciplinary, is committed to an unbiased exploration of the NDE and related phenomena, and welcomes different theoretical perspectives and interpretations that are based on scientific criteria, such as empirical observation and research. IANDS also publishes Vital Signs, a quarterly newsletter that is made available to its members and that includes commentary, news and articles of general interest.

One of the first introductions to the field of near-death studies was the publication of a general reader: The Near-Death Experience: Problems, Prospects, Perspectives. The book was published in 1984 and was an early overview of the field. In 2009 Praeger Publishers published the Handbook of Near-Death Experiences: thirty years of investigation, a comprehensive critical review of the research carried out within the field of near-death studies. 2011 marked the publication of Making Sense of Near-Death Experiences: A Handbook for Clinicians. The book is a multi-author text which describes how the NDE can be handled in psychiatric and clinical practice.

Recognition and criticism

Skepticism towards the findings of near-death studies, and the validity of the near-death experience as a subject for scientific study, has been widespread. According to Knapton, in The Daily Telegraph, the subject was, until recently, considered to be controversial. Both scientists and medical professionals have, in general, tended to be skeptical. According to commentators in the field the early study of Near-death experiences was met with "academic disbelief". Acceptance of NDE's as a legitimate topic for scientific study has improved, but the process has been slow. According to literature "psychiatrists have played a role in the recognition of the “near-death” phenomenon as well as popularization of the subject and subsequent research". 

Skeptics have remarked that it is difficult to verify many of the anecdotal reports that are being used as background material in order to outline the features of the NDE.

Internet Infidels paper editor, and commentator, Keith Augustine has criticized near-death research for oversimplifying the role of culture in afterlife beliefs. He has also exposed weaknesses in methodology, paucity of data, and gaps in arguments. Instead of a transcendental model of NDE's, which he does not find plausible, he suggests that NDE's are products of individuals' minds rather than windows into a transcendental reality. His criticism has been answered by Greyson who suggests that the materialist model favored by Augustine is supported by even fewer data than the "mind-brain separation model" favored by many researchers within the field of near-death studies. 

The findings of NDE research has been contested by several writers in the fields of psychology and neuroscience. Susan Blackmore has contested the findings of NDE research, and has instead argued in favour of a neurological explanation. Psychologist Christopher French has reviewed several of the theories that have originated from the field of Near-death studies. This includes theories that present a challenge to modern neuroscience by suggesting a new understanding of the mind-brain relationship in the direction of transcendental, or paranormal, elements. In reply to this French argues in favor of the conventional scientific understanding, and introduces several non-paranormal factors, as well as psychological theory, that might explain those near-death experiences that defy conventional scientific explanations. However, he does not rule out a future revision of modern neuroscience, awaiting new and improved research procedures. 

Jason Braithwaite, a Senior Lecturer in Cognitive Neuroscience in the Behavioural Brain Sciences Centre, University of Birmingham, issued an in-depth analysis and critique of the survivalist's neuroscience of some NDE researchers, concluding, "it is difficult to see what one could learn from the paranormal survivalist position which sets out assuming the truth of that which it seeks to establish, makes additional and unnecessary assumptions, misrepresents the current state of knowledge from mainstream science, and appears less than comprehensive in its analysis of the available facts."

Martens noted the "lack of uniform nomenclature", and "the failure to control the studied population with an elimination of interfering factors", as examples of criticism directed towards near-death research. 

But criticism of the field has also come from commentators within its own ranks. In an open letter to the NDE community Ring has pointed to the "issue of possible religious bias in near-death studies". According to Ring the field of near-death studies, as well as the larger NDE movement, has attracted a variety of religious and spiritual affiliations, from a number of traditions, which makes ideological claims on behalf of NDE research. In his view this has compromised the integrity of research and discussion.

Psychotherapy (updated)

From Wikipedia, the free encyclopedia

Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior and overcome problems in desired ways. 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. Certain psychotherapies are considered evidence-based for treating some diagnosed mental disorders. Others have been criticized as pseudoscience.

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.