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What is it?

Psychotherapy, treatment of psychological distress with techniques that rely heavily on verbal and emotional communication and other symbolic behaviour.

Psychotherapy differs in two ways from the informal help one person gives another. First, it is conducted by a psychotherapist who is specially trained and licensed or otherwise culturally sanctioned. Second, psychotherapy is guided by theories about the sources of distress and the methods needed to alleviate it. Because communication is the primary means of healing in most forms of psychotherapy, the relationship between the therapist and patient, or client, is much more important than in other medical treatments. The therapist's personality influences the patient and may be used quite deliberately to achieve therapeutic ends.

Attempts to ameliorate emotional and mental disorders through psychological means date from ancient times. Throughout most of history these efforts have been grounded in religious and magical beliefs. Attempts to base psychotherapeutic practices on scientific principles date from the mid-18th century, when the Austrian doctor Franz Anton Mesmer used a form of suggestion called animal magnetism. Neuroses were treated in the 19th century with such physical agents as water or painful electrical currents, both of which also depended for effectiveness on the use of suggestion. Hypnotism as a method of suggestion for alleviating certain psychological disturbances reached its height late in the 19th century, as practised by the French neurologist Jean Martin Charcot at the Salpêtrière Hospital in Paris.

Psychoanalytic Psychotherapy

Stimulated by Charcot's demonstrations of the therapeutic value of hypnosis, the Austrian doctor and founder of psychoanalysis, Sigmund Freud, used the hypnotic state, not for the purpose of suggestion, but to uncover painful and forgotten memories in his neurotic patients. By this technique, he not only attempted to help his patients but also collected the data from which he formulated psychoanalytic theory. Freud believed that during the course of a person's development unacceptable sexual and aggressive drives are forced out of consciousness. These repressed urges, constantly striving for release, are sometimes expressed as symptoms of neurosis.

Freud thought that such symptoms could be eliminated by bringing the repressed fantasies and emotions into consciousness. He first used hypnosis as the means of gaining access to the unconscious. He soon abandoned the technique, however, in favour of free association, a method in which patients were asked to report whatever thoughts came to their minds about dreams, fantasies, and memories. By interpreting these associations Freud helped his patients gain the insight into their unconscious that he believed to be curative.

Later he placed great value on what could be learned from so-called transference, that is, the patient's emotional response to therapists, which in Freud's view reflected earlier feelings towards the patient's family members. Free association and transference reactions are still central features of Freudian psychoanalysis sessions, which can take place from three to five times a week.

Divergent Psychoanalytic Schools

Some of Freud's most gifted followers disagreed with him on important aspects of theory and therapeutic technique and subsequently founded schools of their own.

Jung

Perhaps the most influential was Carl Gustav Jung, a Swiss psychiatrist, who believed that Freud overemphasized sexual instincts as a source of behaviour. Jung thought that nonsexual potentials within the person must be realized, or neuroses will develop. Jungian therapists attempt to help patients recognize their own inner resources for growth and for dealing with conflict. They see patients frequently at first, then weekly for a period of months or years. Techniques for solving immediate problems are varied and pragmatic. Dreams and art are used to draw out the patient's associations to the unconscious images that Jung believed are shared by all.

Adler

Another of Freud's students to break with him was the Austrian psychologist Alfred Adler, who also minimized the importance of instinctual sexual drives in behaviour. He believed that the smallness and helplessness of children produce feelings of inferiority in them. In reaction to these feelings, many people strive for superiority. Countering this search for power and significance is the quality of what he called social interest, that is, empathy and identification with other people. According to Adler, psychological disorders result from a faulty way of living, including mistaken opinions and goals and underdeveloped social interest. The therapist's job is to reeducate patients-to convince them of their errors and to encourage them to develop more social interest.

Fromm, Horney, and Erikson

Several of Freud's followers elaborated theories of neuroses that emphasized the role of social and cultural influences in the formation of personality. These so-called neo-Freudians include Erich Fromm, Karen Horney, and Erik Erikson. All three emigrated from Germany to the United States in the 1930s.

Fromm believed that the fundamental problem confronted by everyone is a sense of isolation deriving from the individual's separateness. The goal of life and of therapy, according to Fromm, is to orient oneself, establish roots, and find security by uniting with other people while remaining a separate individual.

Horney believed that neurotic behaviour blocks a person's inherent capacity for healthy growth and change. The job of therapy, in her view, is to disillusion the patient of such defence blockages, that is, to identify and clarify them, and then to help the patient mobilize innate constructive forces for change.

Erikson, like Horney, was convinced that human beings are capable of growth throughout their lives. Guiding such change is the person's ego, which can develop in a healthy way when given the right environment. Failing that, a person can acquire through therapy the basic trust and confidence needed for a healthy ego. Unlike traditional psychoanalysts, Erikson, who began practice as a child analyst, usually worked with a patient's family while treating the patient.

Humanistic Psychotherapy

Begun as reaction against psychoanalytic psychotherapy, humanistic therapies are based on views of human nature that emphasize the human potential for goodness.

Carl Rogers

The oldest of the humanistic therapies is the client-centred psychotherapy of Carl Rogers, an American psychologist. Rogers believed that people, like other living organisms, are driven by an innate tendency to maintain and enhance themselves, which in turn moves them towards growth, maturity, and life enrichment. Within each person, Rogers believed, is the capacity for self-understanding and constructive change. In therapy this capacity can be realized with the help of a therapist who has certain essential qualities.

Rogers attached more importance to the therapist's attitudes than to their technical training or skills. He used the word client instead of patient to indicate that the treatment is neither manipulative nor medically prescriptive. Accurate and sensitive understanding of the client's experiences and feelings is paramount, because it helps the client focus on the experience of the moment. A second important quality in a therapist is unconditional positive regard, that is, a nonjudgemental caring for the patient. Genuineness, or an absence of sham, is a third quality that Rogers felt was essential in a therapist.

Rogers described the treatment process itself as the client's reciprocation of the therapist's attitudes. Because the therapist listens, the client learns to listen to ever more frightening thoughts and feelings until he or she reaches a stage of self-acceptance where change and growth are possible.

Gestalt Therapy

Another humanist approach, Gestalt therapy, was developed by Frederick S. (Fritz) Perls, a German-born former psychoanalyst. Perls believed that modern civilization inevitably produces neurosis, because it forces people to repress natural desires and consequently frustrates an inherent human tendency to adjust biologically and psychologically to the environment. Neurotic anxiety results; in order for a person to be cured, unmet needs must be brought back to awareness. Disavowing the psychoanalytic tradition, Perls believed that intellectual insight is powerless to change people. Instead he devised exercises designed to enhance the person's awareness of his or her emotions, physical state, and repressed needs, as well as physical and psychological stimuli in the environment. Gestalt therapy is conducted with both individuals and groups, typically in once-a-week sessions lasting up to two years.

Behaviour Therapy

In contrast to most other forms of psychological therapy, behaviour therapy is not based on a theory of neurosis. Rather, it is the application of the methods of experimental psychology to the problems of an individual who comes for treatment. Behaviour therapists, who are usually psychologists, are not directly concerned with underlying psychological forces. Instead they focus on the behaviour that is causing distress for their clients. They believe that behaviour of all kinds, normal and maladaptive, is learned according to specifiable principles. These principles have been studied extensively-in Russia, for example, by Ivan Pavlov, and in the United States by B. F. Skinner. Behaviour therapists believe that these same learning principles can be used to correct troublesome behaviour.

Regardless of the specific technique they later use, behaviour therapists begin treatment by finding out as much as they can about the client's problem and the circumstances surrounding it. They do not infer causes or look for hidden meanings; rather, they concentrate on observable and measurable phenomena. On the basis of this behavioural analysis, they formulate hypotheses about the circumstances creating and maintaining the problem. They then set out to alter the circumstances, one by one, and observe whether the client's behaviour changes as a result.

Desensitization

Of the many techniques used by behaviour therapists, one of the oldest and most common is systematic desensitization, a procedure developed by the South African psychiatrist Joseph Wolpe. Used for treating symptoms caused by excessive anxiety, this method calls for helping the client to relax and then, gradually, to approach the situations or objects that are feared.

Cognitive Approaches

Recently, behaviour therapists have begun to give more attention to the influence of thought on behaviour, spurred by such thinkers as the American psychologist Albert Bandura. Cognitive behaviour therapy uses the behavioural approach to change beliefs and habits of thought that appear to be the source of the client's distress.

Similar cognitive approaches have been devised by therapists who were trained in psychoanalysis but who become disenchanted with its theories and techniques. The oldest is the rational-emotive therapy of the American psychologist Albert Ellis, who believes that irrational beliefs and illogical thinking are the cause of emotional disturbances. In his treatment he confronts patients with their irrationality and encourages them to work vigilantly at replacing it with more reasonable thoughts and emotions.

A related technique, which has shown promise in the treatment of depression, was developed by the American psychologist Aaron T. Beck. He believes that depressed people tend to have negative conceptions of themselves, to interpret their experiences negatively, and to view the future with hopelessness. He sees these tendencies as basically a problem of faulty thinking. His treatment techniques, like strictly behaviourist approaches, are aimed at correcting the problem directly rather than understanding its possible origins in the past.

Group Therapy

Because it requires fewer therapists, group psychotherapy is less expensive than individual therapy. It may offer other advantages as well, such as demonstrating to patients that their problems are not unique. In group treatment, interactions among group members are considered the main source of change and cure; the therapist's job is to encourage and control these interactions.

Origins

Group therapy originated in Europe and the United States in the early part of the 20th century. In Europe group psychotherapy was first used by Jacob L. Moreno, a psychiatrist who had his patients act out their problems as a means of heightening their awareness of them. Moreno's "psychodrama" spread to other parts of the world and it is used for treating both neurotic and psychotic patients and also for training mental health professionals.

Many forms of group psychotherapy are practised today, and most of the theoretical orientations found in individual psychotherapy are also represented in group work. In addition, group therapy is conducted at the psychological growth centres that are part of the human potential movement. Many therapists see their patients both individually and in groups.

Family Therapy

One special type of group treatment is family therapy. Adler had worked with whole families in the 1930s, but not until the early 1950s did therapists begin treating families instead of individuals. They and their successors work from the rationale that current family relationships profoundly affect, and are affected by, an individual family member's psychological problems. Rather than explore the inner conflicts of individuals, family therapists try to promote interactions among family members, thereby enhancing the well-being of each.

New Approaches to Psychotherapy

In the late 1960s and the 1970s, a large number of new psychotherapeutic methods were devised and promoted. Many, like the earlier humanistic therapies, were born out of dissatisfaction with psychoanalytically oriented psychotherapy, which was considered too costly, too time consuming, and élitist. Some critics also believed that psychoanalytic practices were too intellectualized and rational, overly preoccupied with the past, and unnecessarily committed to preserving the Western values of individualism, achievement, and productivity. In reaction, they developed methods that emphasize emotion over reason and the present over the past and future. Others who became dissatisfied with psychoanalysis, such as Ellis and Beck, turned in a different direction and placed even more emphasis on the power of reason to overcome emotional disturbance.

Among controversial methods to have attracted public interest are primal therapy, which was devised by the American psychologist Arthur Janov, and transactional analysis, based on the work of Eric Berne. In primal therapy, patients are encouraged to relive early experiences with an intensity of feeling that had been suppressed at the time. Janov believes that such cathartic reactions free the patient from compulsively neurotic behaviour. Transactional analysis is based on the theory that a person, when interacting with others, functions as either parent, adult, or child. In therapy, usually conducted in groups, patients are taught to recognize when they are assuming one of these roles and to understand when being an authoritarian parent or an impulsive child is appropriate and to act as an adult as much of the time as possible.

Brief Psychotherapy and Crisis Intervention

Another recent trend in psychotherapy is the use of brief methods, often to help people deal with crises. These brief psychotherapies were developed partly as a result of dissatisfaction with the length of psychoanalytic therapies, which sometimes continue for many years, and partly in light of a growing understanding of the human response to crises. At critical times in life, such as after the death of a loved one, people are more susceptible to change, for better or worse. Intervening at these times not only can help them overcome the crises but may also help them to become stronger psychologically than they were before the crises.

Two major types of brief psychotherapy are practised. One type, directed at suppressing anxiety, uses supportive techniques such as reassurance, suggestion, manipulation of the environment, and medications. The other type, which uses techniques that provoke anxiety, is directed at disrupting a patient's usual neurotic defences so that change can occur. Psychoanalysis is itself an example of such an anxiety-provoking technique; as conducted by Freud, psychoanalysis was much shorter (less than a year) than is usual today.

Child Psychotherapy

Psychotherapy with children is guided by the same frames of reference used in adult psychotherapy, with the important difference that child therapists must constantly keep in mind the developmental stage of their patients. Techniques also differ. What talk is to adult therapy, play is to child therapy. Whether the therapist's orientation is psychoanalytic or behaviourist or focuses on the family as a system, the actual technique used is likely to involve play with clay, dolls, and other toys. The use of play as a means of communicating with a child in therapy was first developed by the psychoanalysts Anna Freud and Melanie Klein.

The Therapist

Psychotherapists come principally from the fields of medicine, psychology, social work, and psychiatric nursing. Their training is remarkably different, considering that their actual clinical practice may be quite similar.

Psychiatrists are doctors. In many countries, they attend medical school for a number of years, then complete a period of clinical training. They are then trained in psychiatry during a residency period lasting around three years. Psychoanalysts undergo further training of three years or more at a psychoanalytic institute. They are also required to undergo a personal analysis themselves.

Psychologists usually earn a Ph.D. degree in clinical psychology and undergo a year of supervised therapeutic practice before they are considered fully trained. Social workers specialize in mental health and earn master's or doctoral degrees before practising. Some psychologists and social workers, like psychoanalysts, take further training in an institute devoted to a particular psychotherapeutic school, and many undergo therapy as well. Psychiatric nurses usually hold master's degrees and practise primarily in hospitals.

Evaluation

The various types of psychotherapy have different goals, ranging from the psychoanalyst's ambition to alter basic personality structure and deal with existential dilemmas-problems of existence-to the behaviour therapist's more practical contention that the job of therapy is to relieve distressing symptoms. For that reason, each method of treatment must be judged against its own goal.

It is easier to measure whether a symptom has disappeared than it is to measure more far-reaching psychotherapeutic goals. Not surprisingly, behaviour therapy and other more directive, limited types of therapy are supported by evidence that is considered more scientifically valid than that used to defend psychoanalysis and related methods.

One trend has been to move away from the case histories that were once used as testimonials for a particular method and to judge treatments instead by criteria that would be applied to the evaluation of a new drug. Typically, large samples of patients receiving a standardized version of a treatment are compared with other patients who receive another treatment or no therapy at all. The goal of these investigations is to pinpoint which type of treatment is best suited for a given type of patient. This degree of specificity has so far eluded researchers, with one exception: behaviour therapy seems most effective in the treatment of phobias.

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