Misplaced Pages

Revision as of 16:25, 28 November 2006

Psychotherapy is a range of techniques which use only dialogue and communication and which are designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family). Most forms of psychotherapy use only spoken conversation, though some also use various other forms of communication such as the written word, art work or touch. Commonly psychotherapy involves a therapist and client(s) — and in family therapy several family members or even other members from their social network — who discuss their issues in an effort to discover underlying problems and to find constructive solutions.

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

Psychotherapeutic interventions are often designed to treat the patient in the medical model, although not all psychotherapeutic approaches follow the model of "illness/cure". Some practitioners, such as humanistic schools, see themselves in an educational or helper role. Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.

General description

Given that psychotherapy is restricted to conversations, practitioners do not have to be medically qualified, but to guarantee the medical safety of psychotherapy, a basic acquaintance with psychiatric and psychological considerations is typically a part of their training. In most countries, however, 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 wide spread use of pharmaceuticals in conjunction with psychotherapy by medically qualified mental health nurse practitioners, psychiatrists, and in some states prescribing psychologists. While having benefits for patients with ailments such as bipolar disorder, impulse problems, schizophrenia and obsessive compulsive disorder, drugs of late have begun to be used as a 'quick fix' and are gaining less favor in the therapeutic community.. Research reveals that both drugs and psychotherapy combined are more efficacious than either treatment alone in treating persons with mental disorders.

There are at least seven main systems of psychotherapy:

• Psychodynamic,
• Existential,
• Cognitive ,
• Humanistic/supportive
• Behavioral,
• Brief therapy (sometimes called "strategic" therapy, solution focused brief therapy),
• Systemic Therapy (including family therapy & marriage counseling).

See the list of psychotherapies for more.

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.

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 from 1886 until 1896. It 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 to be particularly effective at treating certain mental disorders, such as personality disorders and mood disorders. However, these methods require hundreds of sessions over a period of several years.

Current psychodynamic approaches continue to develop and change. 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, following schooling at Brown University and Yale University Medical School developed his own form of psychotherapy known as cognitive therapy in the 1940s. Similarly Albert Ellis, a student at Columbia University 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 is known for having been more extensively researched than most other types of psychotherapy.

Humanistic

Another body of thought in psychotherapy started in the 1950s with Carl Rogers. Rogers, who went to Columbia University, earned a PhD and simultaneously became interested in existentialism. The works of Abraham Maslow and his hierarchy of human needs became his main focus of concentration. By the early 1930s he had finished his doctoral work and had brought 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 both necessary and sufficient to create a relationship conducive to enhancing the client's psychological well being, by enabling the client to fully experience themselves. Inspired by Rogers, 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 as humanistic psychotherapy today. Rogers' technique of active listening is considered fundamental to most counseling styles, and is included in virtually every counselor preparation program.

Existential

Template:Noncompliant Concerned mainly with the individual's ability to preserve a sense of meaning and purpose throughout the lifespan in the face of immutable biological limitations of a mortal existence (ie ageing, death, ultimate aloneness, having sole responsibility for our actions, choices and freedom). Existential philosophy began in Europe and celebrates the uniqueness and multi-dimensional nature of the individual and therefore each therapist's therapeutic stance varies according to his/her life experiences, personality and interpretation of the philosophy. The uniqueness of the patient-therapist relationship thus also forms a vehicle for therapeutic enquiry. As such, there can be no orthodoxy of existential psychotherapy and practitioners' formulations of theory range from descriptive phenomenology to creativity and awareness development, with some practitioners combining theory from the psychoanalytic school (e.g. defenses versus unconscious death anxiety) with the humanistic model. Major US contributors to the field (e.g. Irvin Yalom, Rollo May) and Europe (Viktor Frankl, Ludwig Binswanger, Medard Boss, R.D.Laing, Emmy Van Deurzen) have attempted to create therapies sensitive to common 'life crises' springing from the essential bleakness of human self awareness, previously accessible through the complex writings of existential philosophers (eg Soren Kierkegaard, Jean-Paul Sartre, Gabriel Marcel, Martin Heidegger,Friedrich Nietzsche).

Behavioral

The rudiments of behavioral therapy begin in the 1920s, however 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 and show that the idea that behavior therapy focuses only on publicly observable behavior is inaccurate. Note that B. F. Skinner was named Humanist of the Year in 1972 by the American Humanist Association, indicating that behavior therapy is considered compatible with humanistic philosophy as well.

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 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 .

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

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, solution-focused therapy and systemic coaching. These practices can help clients identify occasions when their stated problem(s) are less dominant in their lives, and adjust relationships that motivate problematic behavior.

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 such as supportive therapy.

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

Post-Modern Therapies

While sharing similarities to brief counseling and humanistic therapies, postmodern psychotherapy, including narrative therapy and social therapy are non-epistemological (i.e. non-truth referential) therapies that relate to the activity and not the content of what is said as the essential ingredient of the therapeutic interaction. Post-modern therapies also challenge the premise of the individual, behaving being as the fundamental ontological unit.

Schools and approaches

A complete list of psychotherapies is also available.

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.

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.

Cognitive therapy

Cognitive behavioural therapy is a kind of psychotherapy used to treat depression, anxiety disorders, phobias, and other forms of mental disorder. It involves recognising 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, bibliocounseling (books), toys, et cetera. The use of play therapy is often rooted in psychodynamic theory, but other approaches such as Solution Focused Brief Counseling may also employ the use of play in counseling. In many cases the counselor may prefer to work with the care taker of the child, especially if the child is younger than age four. 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 questionnaire-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 single treatment modality has the edge in efficacy, and (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, although 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 ). 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) (quotes in this section are from this book) and in Wampold (2001) .

A literature review by M. J. Lambert (1992) 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) note that:

utside of therapy people rarely have a friend who will truly listen to them for more than 20 minutes (Stiles, 1995)... 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.

References

1. "Antidepressant drug trials: fast track to overprescription?". Retrieved 2006-03-16.
2. Epstein, R. (1997). "Skinner as self-manager" (PDF). Journal of applied behavior analysis. 30: 545–569. (PDF accessed June 27, 2006)
3. Thomson, C.L. (2004). Counseling children (6th ed. ed.). Belmont, CA: Brooks/Cole Thompson. {{cite book}}: |edition= has extra text (help); Unknown parameter |coauthors= ignored (|author= suggested) (help)
4. Becker-Weidman. Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. 23(2), April 2006
5. Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
6. Becker-Weidman, A., (2006b) Dyadic Developmental Psychotherapy: a multi year follow-up. in Sturt, S., (ed) New Developments in Child Abuse Research. NY: Nova
7. Rosenzweig, S. (1936). "Some implicit common factors in diverse methods in psychotherapy". Journal of Orthopsychiatry. 6: 412–415.
8. Hubble, Mark A. (1999). The Heart and Soul of Change: What Works in Therapy. American Psychological Association. ISBN 1-55798-557-X. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
9. Wampold, Bruce E. (2001). The great psychotherapy debate. New Jersey: Lawrence Erlbaum.
10. Lambert, M. J. (1992). "Implications of outcome research for psychotherapy integration". In J. C. Norcross & M. R. Goldfried (ed.). Handbook of Psychotherapy Integration. pp. 94–129.
11. Tallman, Karen (1999). "The Client as a Common Factor: Clients as self-healers". In Hubble, Duncan, Miller (ed.). The Heart and Soul of Change. pp. 91–131. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: multiple names: editors list (link)
12. Stiles, W. B. (1995). "Disclosure as a speech act: Is it psychotherapeutic to disclose?". In J. E. Pennebaker (ed.). Emotion, Disclosure, and Health. pp. 71–92.

• Asay, Ted P., and Michael J. Lambert (1999). The Empirical Case for the Common Factors in Therapy: Quantitative Findings. In Hubble, Duncan, Miller (Eds), The Heart and Soul of Change (pp. 23-55)

Psychodynamic schools

• Bateman, Anthony (2000). Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice. Routledge. ISBN 0-415-20569-7. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

• Bateman, A. (1995). Introduction to Psychoanalysis: Contemporary Theory and Practice. Routledge. ISBN 0-415-10739-3. {{cite book}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)

• Ellenberger, Henri F. (1970). The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. Basic Books.

Humanistic schools

• Schneider , Kirk; et al. (2001). The Handbook of Humanistic Psychology. SAGE Publications. ISBN 0-7619-2121-4. {{cite book}}: Explicit use of et al. in: |last= (help)
• Rowan, John (2001). Ordinary Ecstasy. Brunner-Routledge. ISBN 0-415-23632-0.

See also

Related topics

Related lists

• List of psychotherapies
• Important publications in psychoanalysis and psychotherapy
• Timeline of psychotherapy

External links

• Coalition for Marriage, Family and Couples Education
• General Psychotherapy Information
• Types of Counselling & Psychotherapy
• Marriage Counseling & Family Therapy Resources
• Depression and Bipolar Support Allinace Depression and Bipolar Support Alliance
• Twelve Stages of Classical Adlerian Psychotherapy

• Mental health
• Psychotherapy
• Psychology