Psychotherapy

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Psychotherapy is an intervention technique that relies on interpersonal communication between a therapist and a client. Most forms of psychotherapy use only conversation, although some also use various other forms of communication such as the written word (journaling), art work (art therapy), or play (play therapy).

Therapy may address specific forms of diagnosable mental illness, or everyday problems in relationships or meeting personal goals. Treatment of everyday problems is more often referred to as counseling (a distinction originally enjoined by Carl Rogers), although that term is often used interchangeably with psychotherapy.

Psychotherapeutic interventions are often designed to treat the client within the context of the medical model, although not all psychotherapeutic approaches follow this model of "illness/cure". Some practitioners, regard themselves as more within an educational or helper role.

General description

Given that psychotherapy is restricted to conversations, practitioners do not have to be medically qualified, but a basic acquaintance with psychiatric and psychological considerations is typically a part of their training. In most countries, psychotherapists must be trained, certified, and licensed, with a range of different certification and licensing requirements in force internationally. Psychotherapists may be psychologists, social workers, marriage-family therapists, trained nurses, psychiatrists, psychoanalysts, mental health counselors, school counselors, or professionals of other mental health disciplines.

The primary training of a psychiatrist focuses on the biological aspects of mental disorders, with some training in psychotherapy. Psychologists usually have more training in psychological assessment and research and, in addition, from a moderate amount to a great deal of training in psychotherapy. Social workers have specialized training in linking patients to community and institutional resources, in addition to elements of psychological assessment and psychotherapy. Marriage-family therapists have training similar to the social worker, and also have specific training and experience working with relationships and family issues. Licensed professional counselors (LPC's) generally have special training in career, mental health, school, or rehabilitation counseling. Many family therapy training programs are multiprofessional, that is, psychiatrists, psychologists, mental health nurses, and social workers may be found in the same training group. In these approaches the family therapy session itself may be conducted by a multiprofessional team. Consequently, specialized psychotherapeutic training in most countries requires a program of continuing education after the basic degree.

Evidence of the effectiveness of certain psychoactive drugs, especially to treat serious depression, bipolar disorder, and schizophrenia, have led to a more widespread use of pharmaceuticals in conjunction with psychotherapy by medically qualified mental health nurse practitioners, psychiatrists, and in some states prescribing psychologists. These drugs are reported to have benefits for patients with ailments such as bipolar disorder, impulse problems, schizophrenia and obsessive compulsive disorder, but some in the therapeutic community fear that they may be over-prescribed.[1][1].

There are at least six main systems of psychotherapy:

History

Most psychotherapies are direct descendants of psychoanalysis, branched off of areas of psychoanalysis, or were developed in reaction to psychoanalysis. Therefore, when describing the history of psychotherapy, most traditionally start with Freud. Freud is credited with being the first to use dialogue as a therapeutic tool.

Psychodynamic

For more information, see: Psychoanalysis.

Although there are some bodies of thought in psychology without Sigmund Freud in their legacy, most can be traced back to his work starting in the 1880s in Vienna. Trained as a neurologist, Freud began noticing neurological problems in patients that had no discernible biological basis. Seeing blindness, paralysis and anorexia with no apparent physical cause, he looked towards the mind for answers. Finding some evidence that those who were mentally ill could exhibit physical symptoms, he discovered colleagues and teachers who were equally perplexed and interested in such matters like Josef Breuer and Jean-Martin Charcot.

Freud opened up a private practice in 1886 until 1896 that mostly treated women who showed symptoms of hysteria (which, at that time, was very loosely defined). Using such techniques as dream interpretation, free association, transference and analysis of the id, ego and superego, his colleagues developed a system of psychotherapy termed psychoanalysis. Students and colleagues of his such as Alfred Adler, Otto Rank, and Carl Jung became psychoanalysts themselves, and formed their own differentiating systems of psychotherapy. These were all later termed under a more broad label of psychodynamic, meaning anything that involved the psyche's conscious/unconscious influence on external relationships and the self. Psychodynamic psychotherapy and psychoanalysis are considered by some to be effective at treating certain mental disorders, such as personality disorders and mood disorders.

Contemporary Freudian approaches usually retain Freud's emphasis on sexuality, aggression, and mental conflict, and often prefer insight-oriented, uncovering psychotherapy to more supportive techniques. Contemporary Freudians, for the most part, continue to believe that psychotherapy is most effective when it leads to increased self-knowledge on the part of the patient. Other current psychodynamic approaches—such as object-relational and self-psychological approaches—prefer techniques designed to change the patient's habitual patterns of living by building an especially authentic or supportive relationship with the analyst that is believed to help the patient learn new ways of relating to others and to life in general.

The psychoanalytic community has recently begun to put extensive effort into researching the efficacy and process of psychoanalytic treatment.

Cognitive

As psychoanalysis and its influence spread throughout the world in the early 1900s, other ideas were brewing. Aaron T. Beck developed his own form of psychotherapy known as cognitive therapy in the 1940s. Similarly Albert Ellis developed Rational Emotive Behavior Therapy (REBT). The spectrum that soon became cognitive therapy involved some common features. These included short, structured and present-focused therapy aimed at changing a person's distorted thinking. Being oriented towards symptom-relief, collaborative empiricism and modifying peoples core beliefs, this is often the preferred method of treatment for depression, substance abuse, anxiety disorders, eating disorders and phobias. This method of treatment has been more extensively researched than most other types of psychotherapy.

Humanistic

For more information, see: Humanistic psychology.

Another body of thought in psychotherapy started in the 1950s with Carl Rogers, who became interested in existentialism. The works of Abraham Maslow and his hierarchy of human needs became his focus , and by the early [[1930s] hehad bro ught Person centered psychotherapy into mainstream focus. Rogers' basic tenets were unconditional positive regard, genuineness, and empathic understanding, with each demonstrated by the counselor. According to Rogers, these tenets were necessary and sufficient to create a relationship conducive to enhancing the client's psychological well being, by enabling the client to fully experience themselves. Others followed his mode of thinking like Fritz and Laura Perls in the creation of Gestalt therapy, as well as Marshall Rosenberg, founder of Nonviolent Communication. Later these fields of psychotherapy would become what is known today as humanistic psychotherapy. Rogers' technique of active listening is considered fundamental to most counseling styles, and is included in virtually every counselor preparation program.

Existential

Concerned mainly with the individual's ability to preserve a sense of meaning and purpose throughout life in the face of immutable biological limitations (i.e. ageing, death, ultimate aloneness, having sole responsibility for our actions, choices and freedom). Therapeutic stance is a combination of the psychoanalytic school (e.g., defences versus unconscious death anxiety) and the humanistic model. Major contributors to the field, including Irvin Yalom, Viktor Frankl and Rollo May, have attempted to create a therapy sensitive to common 'life crises' springing from the essential bleakness of human self awareness, previously accessible through the writings of existential philosophers such as Jean-Paul Sartre and Friedrich Nietzsche.

Behavioral

The rudiments of behavioral therapy begin in the 1920s, but its comprehensive form did not emerge until the 1950s and 1960s. The primary contributors were Joseph Wolpe in South Africa, M.B. Shipiro and Hans Eysenck in Britain, and B.F. Skinner in the United States.

Behavioral therapy approaches rely on principles of operant conditioning, classical conditioning and social learning theory. Drawing on principles of behaviorism, behavioral therapy often focuses on behaviors that are observable and measurable, rather than cognitions. However, newer forms of behavior therapy (such as Acceptance and Commitment Therapy)include a strong focus on thought . [2].

The behavior therapist may use operant conditioning techniques contingency contracts, self-management, shaping, behavioral momentum, token economies, response cost, and biofeedback. For social learning theory techniques, counselors may use modeling, behavior practice groups, and role playing. Often classical conditioning techniques are the treatment of choice for phobias and fetishes, and include techniques of systematic desensitization, flooding, counterconditioning, exposure, and aversive conditioning. Sometimes hypnosis or biofeedback are used to achieve relaxation as well.

Additionally, behavior therapy has been claimed to be effective in treating eating disorders. Behavior therapy is one of the most scientifically validated approaches because of its emphasis on measurable and observable results. Increasingly, counselors and researchers are incorporating behavior modification techniques with other approaches (eclectic or multimodal approaches), and develop behavioral definitions to measure psychological constructs such as depression, anxiety or anger [3].

A "third wave" of cognitive and behavioral therapies has been building and includes behavioral therapies such as Acceptance and Commitment Therapy and Dialectical behavior therapy. These newer forms of behavior therapy are gaining increasing evidence for their effectiveness and incorporate such techniques as acceptance, mindfulness, and values work.

Brief counseling

See also: Brief therapy

Brief Counseling can make use of any of the above psychotherapeutic approaches, but it also may involve specific techniques that have been shown to provide rapid relief for large numbers of people. Among these approaches are Narrative Therapy, reverse psychology, and Solution-focused Therapy. These practices help clients to identify those occasions when their stated problem(s) are less dominant in their lives.

Typically brief counseling takes from one to five sessions. Employee Assistance Programs are geared to provide brief assessments and interventions that often fulfill the clients' needs in just a few sessions. It is also not unusual for a community mental health center to offer Brief Counseling to all new clients in order to encourage greater self-reliance and to discourage dependence on a therapist. In such a context, self-help groups also play a role in aiding ongoing improvements in functioning.

Well-known writers/practitioners of brief counseling techniques are Bill O'Hanlon, Insoo Kim Berg, Michael White, Jeffrey Guterman, Paul Watzlawick, Jay Haley and Steve de Shazer.

Family therapy

Family therapy is sometimes seen as a subset of brief therapy, often imposing a limit of 20 sessions. It differs from individual therapy partly in that all members of the family are present. It differs from group therapy partly in that members are working on a single problem, rather than each working on his own separate problem.

Family therapy was originally conceived from several sources. Some therapists noticed that when one member of a family would get better, another would develop symptoms, suggesting that the family needed a sick member to maintain "homeostasis," or balance. Some therapists noticed peculiar interactions between hospital patients and their family members. Multi-family therapy was developed after therapists, who had called them together for an educational session regarding hospitalized family members, noticed their conversations after the session was over.

Types of family vary widely. Famous writers who have invented therapies give names to them, such as "systemic therapy" "family systems therapy," "Milan systems Therapy," "contextual therapy," "structural therapy," "strategic therapy" "solution-focused" therapy and others. Well-known names in the field are Jay Haley, Salvador Minuchin, Carl Whitaker, Murray Bowen, Ivan Bozormenyi-Nagy, Virginia Satir, Maria Selvini-Pallazoli and others.

Structural therapy concentrates on the organization of the family, in regard to hierarchy, and the concept of boundaries, separating the members or separating the family from the external world, such as rigid boundaries, clear boundaries, or permeable or diffuse boundaries. It also takes note of "triangulation," or bringing a third person or entity into an area of stress. The techniques are largely educative.

Strategic therapy addresses irrational components of the family and resistance to change, often making use of paradox to overcome resistance. Nearly all of the family therapies address the proneness of families to seek "homeostasis," or sameness to retain balance in the family. Each member sees his own behavior as a solution to problems, rather than as a problem, and fears the consequences of change.

Murray Bowen and Carl Whitaker may have distant family members flown in for a session, even if the client isn't in frequent contact with them. Whittaker makes use of absurdity, to cause people to think differently about their problem. Ivan Bozormenyi-Nagy writes of accounts family members keep in their heads, balancing mutual indebtedness as each of them sees it.

Early advocates for family therapy used to say that family therapy was more effective and faster than other therapies. Today, the view is that it is just as effective as other therapies, though it may be more moral. That is, individual therapy may help one person to get better, but allows another family member to develop a symptom to replace him in the family system. Family therapy can help a person to lose his symptoms, without passing his symptomatic condition to another family member.

Each type of family therapy may vary greatly from the others, and experience of a client with one form may not be experience with the next encountered. Some individual therapists, not understanding much about family therapy, may believe that it is for a particular type of people, or even for less serious cases, seeing individual therapy as the "real" therapy, and family therapy as just brushing up the edges, a completely erroneous conception.

Post-modern therapies

For more information, see: transpersonal psychology.

While sharing similarites to brief counseling and humistic therapies, post-modern therapies, including narrative therapy and social therapy are non-epistemelogical (i.e. non-truth referential) therapies that relate to the activity and not the content of what is said as the sin qua non of the therapeutic interaction. Post-modern therapies also challenge the premise of the individual, behaving being as the fundamental ontological unit.

Schools and approaches

Psychoanalysis

Psychoanalysis was the earliest form of psychotherapy, but many other theories and techniques are also now used by psychotherapists, psychologists, psychiatrists, personal growth facilitators and social workers. Techniques for group therapy have been developed.

While behaviour is often a target of the work, many approaches value working with feelings and thoughts. This is especially true of the psychodynamic schools of psychotherapy, which today include Jungian therapy and Psychodrama as well as the psychoanalytic schools. Other approaches focus on the link between the mind and body and try to access deeper levels of the psyche through manipulation of the physical body. Examples are Rolfing, Pulsing and postural integration.

Medical and non-medical models

A distinction can also be made between those psychotherapies that employ a medical model and those that employ a humanistic model. In the medical model the client is seen as unwell and the therapist employs their skill to help them back to health. The extensive use of the DSM-IV, the diagnostic and statistical manual of mental disorders in the United States, is an example of a medically-exclusive model. Therapists who do not accept the medical model must use the DSM for insurance purposes, and to fit into bureaucratic systems.

In the humanistic model, the therapist facilitates learning in the individual and the clients own natural process draws them to a fuller understanding of themselves. An example would be gestalt therapy.

Some psychodynamic practitioners distinguish between more uncovering and more supportive psychotherapy. Uncovering psychotherapy emphasizes facilitating clients' insight into the roots of their difficulties. The best-known example of an uncovering psychotherapy is classical psychoanalysis. Supportive psychotherapy, by contrast, stresses strengthening clients' defenses and often providing encouragement and advice. Depending on the client's personality, a more supportive or more uncovering approach may be optimal. Most psychotherapists utilize a combination of uncovering and supportive approaches.

An objection to the medical model is that physical illnesses are discrete entities. They can be described as to symptoms, causation, and appropriate cure. Psychological problems may get the same diagnosis because they have a similar look, though they may have different causes and require different treatments from one another. One can not say that a particular mental disorder is caused by a particular virus, for example.

The medical model also assumes a defect in the person. A metaphor might be made to a computer with hardware that functions perfectly, but software that malfunctions, or even to two computers that are functioning perfectly, but they begin to interfere with one another, reducing the function of both.

A person who has no defect but has life experiences resulting in depression might be treated with medication. The medication may reduce his symptoms, and he may even get better if he puts some time between the present and those life experiences. However, the medication does not cure the problem, considering that his brain matter has no defect in itself. A medical metaphor could be treating the foot for gout, when the problem is actually in the kidneys. So long as one's attention is attracted to the symptom only, he fails to treat the actual disorder.

An appropriate treatment would not be to treat him as if he were defective, but to treat his contextual predicament, either with individual talk therapy or through family therapy.

Some exception to this view is found in the cases in which there is an actual physiological difference causing a mental problem. Such cases include diagnoses of schizophrenia, bipolar disorder, ADHD and Altzheimer's disorder. These conditions involve actual differences in brain chemistry and structure, and are appropriately treated with medications.

Cognitive therapy

Cognitive therapy and cognitive behavioral therapy are kinds of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of mental disorder. It involves recognizing distorted thinking and learning to replace it with more realistic substitute ideas. This type of therapy is particularly common where the mode of psychotherapy is dictated by the demands of insurance companies who wish to see a financially limited commitment.

Expressive therapy

Expressive therapy is a form of therapy that utilizes artistic expression as its core means of treating clients. Expressive therapists use the different disciplines of the creative arts as therapuetic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy among others. Expressive therapists believe that often the most effective way of treating a client is through the expression of imagination in a creative work and integrating and processing what issues are raised in the act.

Adaptations for children

Counseling and psychotherapy must be adapted to meet the developmental needs of children. Many counseling preparation programs include a courses in human development. Since children often do not have the ability to articulate thoughts and feelings, counselors will use a variety of media such as crayons, paint, clay, puppets, books, toys, et cetera. The use of play therapy is often rooted in psychodynamic theory, but other approaches such as Solution Focused Brief Counseling may also employ the use of play in counseling. In many cases the counselor may prefer to work with the care taker of the child, especially if the child is younger than age four. Theraplay is an approach developed to facilitate a healthier relationship between parent and child that uses structured play. Children who have experienced chronic early maltreatment that results in Complex Post Traumatic Stress Disorder or reactive attachment disorder can be effectively treated with Dyadic Developmental Psychotherapy, which is an evidence-based family-based treatment approach.

Effectiveness

There is considerable controversy over which form of psychotherapy is most effective, and more specifically, which types of therapy are optimal for treating which sorts of problems. Psychotherapy outcome research - in which the effectiveness of psychotherapy is measured by questionnaires given to patients before, during, and after treatment - has had difficulty distinguishing between the success or failure of the different approaches to therapy. Not surprisingly, those who stay with their therapist for longer periods are more likely to report positively on what develops into a longer term relationship. Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice.

In 2001 Bruce Wampold, Ph.D. of the University of Wisconsin published "The Great Psychotherapy Debate." In it, Wampold, a former statistician studying primarily outcomes with depressed patients reported that (1) psychotherapy can be more effective than placebo (2) no one treatment modality has the edge in efficacy (3) factors common to different psychotherapies such as whether or not the therapist has established a positive working alliance with the client/patient account for much more of the variance in outcomes than specific techniques or modalities. Some report that by attempting to program or manualize treatment psychotherapists may actually be reducing efficacy, though the unstructured approach of many psychotherapists cannot appeal to patients motived to solve their difficulties through the application of specific techniques different from their past "mistakes."

The therapeutic relationship

Research has shown that the quality of the relationship between the therapist and the client has a greater influence on client outcomes than the specific type of psychotherapy used by the therapist (this was first suggested by Saul Rosenzweig in 1936 [4]). Accordingly, most contemporary schools of psychotherapy focus on the healing power of the therapeutic relationship.

This research is extensively discussed (with many references) in Hubble, Duncan and Miller (1999)[5] (quotes in this section are from this book) and in Wampold (2001) [6].

A literature review by M. J. Lambert (1992) [7] estimated that 40% of client changes are due to extratherapeutic influences, 30% are due to the quality of the therapeutic relationship, 15% are due to expectancy (placebo) effects, and 15% are due to specific techniques. Extratherapeutic influences include client motivation and the severity of the problem:

For example, a withdrawn, alcoholic client, who is "dragged into therapy" by his or her spouse, possesses poor motivation for therapy, regards mental health professionals with suspicion, and harbors hostility toward others, is not nearly as likely to find relief as the client who is eager to discover how he or she has contributed to a failing marriage and expresses determination to make personal changes.

In one study, some highly motivated clients showed measurable improvement before their first session with the therapist, suggesting that just making the appointment can be an indicator of readiness to change. Tallman and Bohart (1999) [8] note that:

[O]utside of therapy people rarely have a friend who will truly listen to them for more than 20 minutes (Stiles, 1995)[9]... Further, friends and relatives often are involved in the problem and therefore do not provide a "safe outside perspective" which may be required. Nonetheless, as noted above, people often solve their problems by talking to friends, relatives, co-workers, religious leaders, or some other confidant in their lives, or by thinking and exploring themselves.

Confidentiality

Confidentiality is an integral part of the therapeutic relationship and psychotherapy in general. For further discussion see Physician-patient privilege. Confidentiality varies widely by profession and condition, and certainly by state. In most states, child abuse must be reported to appropriate authorities. In some states drug counselors have greater rights of confidentiality than psychologists, social workers or counselors. Ministers and priests generally have little or no rights of confidentiality.

Criticism

Critics of psychotherapy are skeptical of the healing power of a psychotherapeutic relationship. Since any intervention takes time, critics note that the passage of time, without therapeutic intervention, can result in psycho-social healing despite the absence of counseling.

Critics note that there are other resources that are available to someone suffering: the friendly support of friends, peers, family members, clergy contacts, personal reading, research, and independent coping and so suggest that therapy is not necessary for everyone. These critics note that humans have been dealing with crisis, navigating problems and finding solutions since long before the advent of therapy.

The incoming president of the American Psychological Association, Ronald Levant, Ph.D., has assembled a task force to address current controversies in the field. Included are growing number of voices similar to David Burns, M.D. a psychiatrist who trains residents at Stanford University School of Medicine, "....there is a kind of narcissism in our field to say, 'I'm so great, I know what I'm doing,' and it puts us back 2,000 years to a time of cults, when every snake oil salesman's got something and the parade just goes on."

Criticism of Criticism

There have been hundreds of controlled studies in professional peer-reviewed journals demonstrating the efficacy of various types of psychotherapy and which control for maturation, or the passage of time. [10]

Any scientific study endeavors to control for extraneous variables wherever possible. Groups are compared that are alike in every known respect except for one. Groups are used in consideration that some variables are unknown, and if a variable exists in a group, it is likely to be cancelled out or averaged out by an opposite variable in individuals in the same group, or matched by a similar variable in other groups.

Thus, a study may match groups for length of time in therapy, external influences like finances or employment, marriage or divorce, marital status, age, race, gender, education, etc. Once known variables are counted, individuals are randomly assigned to groups, so that an individual of a given description has an equal chance of being in any group, having the same "experimental variable," such as type of therapy. Pre-therapy, individuals might be randomly assigned to one therapy or the other, and post-therapy, if there is an excess of people in a category such as age, random means would be used to remove a number of individuals.

One criticism of psychotherapy comes from a school of thought stating that there is no such thing as mental illness, and that mental illness simply means eccentricity, or varying from social conventions. This is countered by the fact that certain medications work for some diagnoses but not for others, suggesting a physical difference in brain physiology which responds to that medication. For example, lithium salts relieve the symptoms of bipolar disorder, but have no effect on the mental condition of persons without that disorder. The mentally ill often complain of their symptoms and request relief, indicating that this is not just a matter of disapproval of their behavior by society. Recent research has discovered a genetic difference between persons with schizophrenia and people without that disorder.

References

  1. Antidepressant drug trials: fast track to overprescription?. Retrieved on 2006-03-16.
  2. Epstein, R. (1997). "Skinner as self-manager". Journal of applied behavior analysis 30: 545-569. (PDF accessed June 27, 2006)
  3. Thomson, C.L.; Rudolph, L.B., and Henderson, D. (2004). Counseling children, 6th ed.. Belmont, CA: Brooks/Cole Thompson. 
  4. Rosenzweig, S. (1936). "Some implicit common factors in diverse methods in psychotherapy". Journal of Orthopsychiatry 6: 412-415.
  5. Hubble, Mark A.; Barry L. Duncan and Scott D. Miller (Eds) (1999). The Heart and Soul of Change: What Works in Therapy. American Psychological Association. ISBN 1-55798-557-X. 
  6. Wampold, Bruce E. (2001). The great psychotherapy debate. New Jersey: Lawrence Erlbaum. 
  7. Lambert, M. J. (1992). “Implications of outcome research for psychotherapy integration”, J. C. Norcross & M. R. Goldfried: Handbook of Psychotherapy Integration, 94-129. 
  8. Tallman, Karen; Arthur C. Bohart (1999). “The Client as a Common Factor: Clients as self-healers”, Hubble, Duncan, Miller: The Heart and Soul of Change, 91-131. 
  9. Stiles, W. B. (1995). “Disclosure as a speech act: Is it psychotherapeutic to disclose?”, J. E. Pennebaker: Emotion, Disclosure, and Health, 71-92. 
  10. Lambert, M., (2004), Bergin and Garfield's Handbook of Psychotherapy and Behavior Change, fifth edition, NY: John Wiley.