Psychotherapy

From Wikipedia, the free encyclopedia

Contents 1 History 2 General issues 3 Specific schools and approaches 3.1 Psychoanalysis 3.2 Medical and non-medical models 3.3 Cognitive therapy 3.4 Expressive therapy 3.5 Adaptations for children 4 The therapeutic relationship 4.1 Confidentiality 5 Effectiveness and criticism 6 Client Views and Concerns 7 References 7.1 Psychodynamic schools 7.2 Humanistic schools 8 See also 8.1 Related topics 8.2 Related lists

Psychotherapy is an interpersonal, relational intervention used by trained psychotherapists to aid clients in problems of living. This usually includes increasing individual sense of well-being and reducing subjective discomforting experience. Psychotherapists employ a range of techniques based on experiential relationship building, dialogue, communication and behavior change and that 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, artwork, drama, narrative story, or therapeutic touch. Psychotherapy occurs within a structured encounter between a trained therapist and client(s). Purposeful, theoretically based psychotherapy began in the 19th century with psychoanalysis, scores of other approaches have since developed and continue to be created.

Therapy is generally used to respond to a variety or specific or non-specific manifestations of clinically diagnosable crises. 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.

There are several main systems of psychotherapy:

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

See the list of psychotherapies for more.

[edit] History

See also Timeline of psychotherapy and Eastern & middle eastern influences

In an informal sense, psychotherapy can be said to have been practiced through the ages, as individuals received psychological counsel and reassurance from others. Purposeful, theoretically-based psychotherapy was probably first developed in the middle east during the 8th century by the Persian physician Rhazes who was at one time chief physician of the Baghdad hospital. Serious mental disorders, however, were generally treated in the West as demonic or medical conditions requiring punishment and confinement, until the advent of moral treatment approaches in the 18th Century. This brought about a focus on the possibility of psychosocial intervention - including reasoning, moral encouragement and group activities - to rehabilitate the "insane".

Psychoanalysis was perhaps the first specific school of psychotherapy, developed by Sigmund Freud and others through the early 1900s. Trained as a neurologist, Freud began focusing on problems that appeared to have no discernible organic basis, and theorized that they had psychological causes originating in childhood experiences and the unconscious mind. Techniques such as dream interpretation, free association, transference and analysis of the id, ego and superego were developed.

Many theorists built upon Freud's fundamental ideas, including Anna Freud, Alfred Adler, Carl Jung, Karen Horney, Otto Rank, Erik Erikson, Melanie Klein, and Heinz Kohut and often 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. Sessions tended to number in to 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 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 the lifespan, 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 (eg 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 enquiry.

A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based in existentialism and the works of Abraham Maslow and his hierarchy of human needs, he brought Person-centered psychotherapy into mainstream focus. Rogers' basic tenets were unconditional positive regard, genuineness, and empathic understanding, with each demonstrated by the counselor. The aim was to create a relationship conducive to enhancing the client's psychological well being, by enabling the client to fully experience and express themselves. 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 1960s, Albert Ellis developed Rational Emotive Behavior Therapy (REBT). Around the same time, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included short, structured and present-focused therapy aimed at changing a person's distorted thinking, by contrast with the long-lasting insight-based approach of psychodynamic or humanistic therapies. Cognitive and behavioral therapy approaches were combined during the 1970s, resulting in Cognitive behavioral therapy. Being oriented towards symptom-relief, collaborative empiricism and modifying peoples core beliefs, the approach 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.

Counseling methods developed, including solution-focused therapy and systemic coaching. Postmodern psychotherapies such as Narrative Therapy and coherence therapy did not impose definitions of mental health and illness, but rather saw the goal of therapy as something constructed by the client and therapist in a social context. Systems Therapy also developed, which focuses on family and group dynamics—and Transpersonal psychology, which focuses on the spiritual facet of human experience. Other important orientations developed in the last three decades include Feminist therapy, Brief therapy, Somatic Psychology, Expressive therapy, and applied Positive Psychology.

[edit] General issues

Psychotherapy can be seen as an interpersonal invitation offered by (often trained and regulated) psychotherapists to aid clients in reaching their full potential or to cope better with problems of life. Psychotherapists usually receive a benefit or remuneration in some form in return for their time and skills. This is one way in which the relationship can be distinguished from an altruistic offer of assistance.

Psychotherapy often includes techniques to increase awareness for example, or to enable other choices of thought, feeling or action; to increase the sense of well-being and to better manage subjective discomfort or distress. Psychotherapy can be provided on a one to one basis or in group therapy. It can occur face to face, over the telephone or the internet. Its time frame may be a matter of weeks or over many years. It can be seen as ultimately about agency and the meaning of life. Psychotherapy can also be seen as a social construct that cannot occur in a power vacuum nor without reference to semiotics (meaning systems and symbols) - irrespective of how practitioners may describe their work. or research its effects. 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".

Psychotherapists employ a range of techniques to influence or pursuade the client to adapt or change in the direction the client has chosen. These can be based on clear thinking about their options; experiential relationship building; dialogue, communication and adoption of behavior change strategies. Each is 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, artwork, drama, narrative story, or therapeutic touch. Psychotherapy occurs within a structured encounter between a trained therapist and client(s). Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.

Psychotherapists are often trained, certified, and licensed, with a range of different certifications and licensing requirements in every jurisdiction. Psychotherapy may be undertaken by clinical psychologists, social workers, marriage-family therapists, expressive therapists, trained nurses, psychiatrists, psychoanalysts, mental health counselors, school counselors, or professionals of other mental health disciplines. Psychiatrists have medical qualifications and may also administer prescription medication. The primary training of a psychiatrist focuses on the biological aspects of mental health conditions, with some training in psychotherapy. Psychologists have more training in psychological assessment and research and, in addition, 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 (LPCs) generally have special training in career, mental health, school, or rehabilitation counseling. Many of the wide variety of training programs are multiprofessional, that is, psychiatrists, psychologists, mental health nurses, and social workers may be found in the same training group. Consequently, specialized psychotherapeutic training in most countries requires a program of continuing education after the basic degree, or involve multiple certifications attached to one specific degree.

[edit] Specific schools and approaches

Main article: list of psychotherapies

[edit] 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.

[edit] 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.

[edit] 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.

[edit] 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.

[edit] 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 ^[1][2][3], which is an evidence-based family-based treatment approach.

[edit] 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:

Outside 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.

[edit] Confidentiality

Further information: client confidentiality, and physician-patient privilege

Confidentiality is an integral part of the therapeutic relationship and psychotherapy in general.

[edit] Effectiveness and criticism

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. ^[10]

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.

As early as 1952, in one of the earliest studies of psychotherapy treatment, Hans Eysenck reported that 2/3rds of therapy patients improved significantly or recovered on their own within two years, whether or not they received psychotherapy. ^[11]

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" ^[12]. 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,
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."

Critics of psychotherapy are skeptical of the healing power of a psychotherapeutic relationship.^[13] 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. ^[14]

Critics note the many resources available to a person experiencing emotional distress: the friendly support of friends, peers, family members, clergy contacts, personal reading, research, and independent coping-- indicating that psychotherapy is inappropriate or unneeded by many. These critics note that humans have been dealing with crisis, navigating problems and finding solutions long before the advent of psychotherapy.

[edit] Client Views and Concerns

This section may contain original research or unattributed claims. Please help Wikipedia by adding references. See the talk page for details. This article has been tagged since March 2007.

Sometimes, clients can end up feeling much worse after therapy than before they started not because the therapist is a bad apple, but because therapy itself can cause problems. Feeling worse as a result of therapy can mean almost anything from a minor deterioration in emotional well-being to a sense of desperation, sometimes even to the point of suicide.

Everyone's therapy experience is different, and just as there are very many things that people can find helpful about therapy, there are also many things that people find unhelpful and sometimes terribly damaging. There is much that can go wrong in everyday therapy, even with a good and conscientious therapist who is following correct procedure. The profession often 'explains away' or dismisses these problems as insignificant or part of the process, but the increasing number of books and articles written by clients shows that therapy does indeed have many serious dangers which urgently need to be addressed.

Some common problems

First, many clients experience very strong emotions towards their therapists. Sometimes, these are feelings of obsession, love, and/or sexual attraction (even where this goes against the client’s normal sexuality). This can happen to anyone, including clients who are in extremely happy, loving, stable relationships with their partners, and people who are not normally highly emotional.

Clients are not usually forewarned about this, but it is common. Some schools of therapy refer to it as 'transference' and believe it to be emotions that are 'transferred' from another person in the client's life (for example, a parent). Other schools do not see it in this way. Some schools deliberately encourage these feelings because they are seen as a key to the client 'working through' emotional issues.

These emotions can be overpowering and have a huge effect upon the client's life. His or her other relationships can suffer – sometimes irretrievably. He or she can find it impossible to function normally and live for the hour per week that he or she spends with the therapist. Clients have been known to be so overwhelmed by such feelings that they experience panic attacks, breakdowns, severe depression and other traumatic effects, both during the therapy and after it has ended. The feelings can be brief but can also persist for years.

Therapists say that it is only in unusual cases that the feelings become that strong. They also say that staying in therapy is the best way to deal with them, and that 'working through' the feelings usually causes them to subside. But experts are now saying that it is much more common than the therapy world is prepared to admit (or indeed knows – some clients go through all that pain without telling their therapist). It is also a phenomenon which is not really understood, and if the feelings do become unmanageable, there is little or nothing in the therapist's training to help.

Similarly, clients often become extremely dependent upon their therapist. It is generally accepted that there is something about the nature of therapy that seems to make such dependence much more likely than in other types of relationship. Again, this can place a huge emotional burden upon clients and their families, and usually, a huge financial burden too. Clients can literally feel unable to make simple decisions without talking things through with the therapist. Some clients find that life outside of the therapy room feels insignificant and meaningless. This can have a devastating and humiliating effect on the client’s personal, social and working life. Again, clients are not usually forewarned of this possibility, and little is known about how to prevent it or to curtail it when it happens.

The client’s handle on reality can be severely affected by therapy. Some forms can encourage clients to question themselves to such an extent that they can lose a clear sense of identity, self-belief and confidence in their own judgement. Many people believe that there is a brainwashing element to therapy, sometimes even resembling a cult, and that this can override clients' normal judgement and self-sufficiency.

Many clients, former clients, sociologists and social commentators have warned that therapy can convince clients that their perfectly normal human feelings and behaviours are malfunctions – signs of mental ill health, instability or 'disordered personality'. Believing oneself to be ill or not functioning adequately can be extremely upsetting, and can even become a self-fulfilling prophecy. It also seems that therapy’s focus on the past, and/or negative experiences, and/or on the client’s own internal world can be most unhelpful for some clients, because it surrounds them in despair when what they need might be to put the past behind them, look at positives or focus outwards.

Nobody really knows whether talking about one’s problems at all is going to be helpful for an individual. Nobody knows whether bringing deep emotions and memories to the surface is going to make someone's life better or considerably worse. Therapy has become such a big part of our society that it is hard to believe that it isn’t scientifically proven. In fact, most research suggests that almost as many people (50% as opposed to 65%) feel helped by sitting in a room talking to someone generally as do when sitting in a room talking to someone who is deliberately 'doing therapy'. Research has failed to show any real difference in effectiveness between any of the different forms of therapy (and there are many of these, and they are very different from each other). In fact, bizarrely, research has repeatedly shown that people feel helped more by people who are not fully trained, than by people who are. Nobody can explain this.

Of course, many clients do not suffer in any of these ways and there are lots of people who say that therapy changed their life for the better – or even saved it. An awful lot of good can come out of therapy. But problems are far more common, and sometimes far more serious than anyone cares to admit, and there is very little support out there for people who suffer from therapy.

Resources

Books written by clients provide the best insight into the dangers of therapy. The profession can be defensive and reluctant to accept the problems and often tries to explain away the negative effects, either blaming the client’s individual therapist for making mistakes, or blaming the client for being resistant or inappropriate for therapy in some way. Leading books written by clients include:

• Shouldn’t I Be Feeling Better by Now? Client Views of Therapy a collection of client accounts edited by Yvonne Bates.
• Folie à Deux: Experience of One-to-One Therapy by Rosie Alexander.
• Falling for Therapy: Psychotherapy from a Client’s Point of View by Anna Sands.
• The website therapybreakdown.com provides free support for people who have concerns about their therapy, including links to many other useful resources and links.

[edit] References

• 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)

[edit] Psychodynamic schools

• Bateman, Anthony; Brown, Dennis and Pedder, Jonathan (2000). Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice. Routledge. ISBN 0-415-20569-7. 

• Bateman, A.; and Holmes, J. (1995). Introduction to Psychoanalysis: Contemporary Theory and Practice. Routledge. ISBN 0-415-10739-3. 

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

[edit] Humanistic schools

• Schneider (et al), Kirk (2001). The Handbook of Humanistic Psychology. SAGE Publications. ISBN 0-7619-2121-4. 
• Rowan, John (2001). Ordinary Ecstasy. Brunner-Routledge. ISBN 0-415-23632-0. 

[edit] See also

[edit] Related topics

Counseling Main article Counselling with disambiguations Counselling psychology Clinical psychology Anti-psychiatry Psychiatry Psychology Defence mechanism

Mental health Mental health professional Neurosis Psychosis Social work

[edit] Related lists

• List of psychotherapies
• Therapy List
• Important publications in psychoanalysis and psychotherapy
• Timeline of psychotherapy
• Special:Whatlinkshere/Counselling psychology Links into Counseling Psychology
• Special:Whatlinkshere/Clinical psychology Links into Clinical Psychology