Psychotherapy

Psychotherapy

PSYCHOANALYSIS

BEHAVIORAL THERAPY

COGNITIVE THERAPY

HUMANISTIC THERAPY

OTHER PSYCHOTHERAPIES

BIOLOGICAL CONSIDERATIONS AND RESEARCH

BIBLIOGRAPHY

Psychotherapy is the treatment of mental illness, emotional difficulties, or behavioral problems through usually non-invasive psychological means. It is based on the premise that human psychological suffering can be alleviated by speaking and listening. At its core, psychotherapy involves the interpersonal interaction between a trained professional and a suffering individual. Collectively, the varied forms of psychotherapy are often referred to as “talking therapies.” The specific techniques used in any psychotherapy depend largely on the theoretical orientation of the psychotherapist. Most approaches to psychotherapy can be traced in origin to one of the following schools: psychoanalytic, behavioral, cognitive, or humanistic. In practice, however, much of what is called psychotherapy today involves an evolving, fluid, and personalized use of techniques that depend on the specific problem, the professional’s training, and the sufferer’s needs. The goals of all types of psychotherapy typically involve the reduction of symptoms (e.g., depression, anxiety), altering maladaptive patterns of living (e.g., alcohol abuse, compulsive gambling), and/or improvement in specific areas of life functioning (e.g., increased capacity for work, creativity, or relationships).

The advent of modern psychotherapy can arguably be attributed to the work of Franz Anton Mesmer (1734-1815). Though few, if any, of his ideas would be recognized today as sound practice, his work marked an important shift from religious theories and explanations of healing (i.e., exorcisms) to theories based on scientific understandings of the time. The trance-like state Mesmer induced in individuals (still known colloquially today as being “mesmerized”) was the precursor to hypnosis, a practice that French neurologist Jean-Martin Charcot (1825–1893) began using more specifically to treat patients with psychological difficulties. As a student of Charcot’s, Sigmund Freud (1856–1939) first began using hypnosis to treat patients before he abandoned it for what would later become his revolutionary method of psychoanalysis. Decades of theoretical evolution of psychoanalytic theory has spawned a vast array of psychotherapies.

Though a contemporary of Freud’s, Ivan Pavlov’s (1849–1936) work represents a different yet important developmental line in the understanding of human behavior and learning. Known for his work studying the reflexive behavior of dogs, Pavlov discovered how certain behavioral responses could be experimentally brought about, or “conditioned,” by pairing specific stimuli with other naturally occurring behaviors. This principle was used by American psychologists John B. Watson (1878–1958) and B. F. Skinner (1904–1990) in the clinical application of behaviorism, behavior therapy, and then to cognitive and cognitive-behavioral therapy. Historically, behavioral and cognitive psychotherapies have been viewed as an important counterargument to the earliest psychoanalytic ideas and techniques. In fact, the trailblazers of the behavior and cognitive psychotherapy movement, Albert Ellis (b. 1913) and Aaron Beck (b. 1921), both had early psychoanalytic training and interests.

PSYCHOANALYSIS

Developed by Sigmund Freud, psychoanalysis is often recognized as the first modern form of psychotherapy. It is based on the assumption that psychological symptoms are caused by unconscious conflict often rooted in one’s early childhood experience. The aim of psychoanalysis is to bring unconscious conflicts into conscious awareness through the processes of introspection, insight, and interpretation. In a collaborative effort, the patient and therapist examine and try to resolve these conflicts, freeing the patient to live a more adaptive, healthy, and fulfilling life.

Freud discovered that examining the unconscious required some special tools. Foremost of these was the process of “free association,” the uncensored report of all thoughts and fantasies, regardless of content. What seemed potentially irrelevant, tangential, or embarrassing to the patient was seen by Freud to have disguised connections and meanings that once understood would help reveal unconscious conflicts and reduce suffering. To promote free association, an analytic couch was often used, with the analyst sitting behind the couch and listening to the patient. Freud also viewed dreams as disguised and symbolic representations of unconscious conflicts, which could be useful in the psychoanalytic process. The interpretation of these conflicts brought about change, according to Freud.

As Freud’s understanding of psychoanalytic theory evolved he began incorporating such ideas as transference, resistance, and defensive mechanisms into his theory of cure. The practice of psychoanalysis continues to evolve today in ways that maintain, reject, and expand some of Freud’s original principles. Although traditional psychoanalysis (usually four to five appointments per week for several years) is not as popular as it was in the first half of the twentieth century, at the beginning of the twenty-first century it remains a sought-after treatment modality for some people. A more popular variant of psychoanalysis is face-to-face psychoanalytic psychotherapy, which uses many of the same principles as psychoanalysis but is less frequent (usually one to two appointments per week). In the psychoanalytic community, psychoanalysis is viewed as the treatment of choice for a wide range of psychological difficulties, including depression, anxiety, and personality disorders. Though the cost and length of treatment has been criticized as being prohibitive for many individuals, proponents of psychoanalysis and psychoanalytic psychotherapy argue that benefits are more comprehensive and longer lasting than other forms of treatment.

BEHAVIORAL THERAPY

Behavior therapy emphasizes the scientific understanding of observable behaviors, rejecting the importance of self-awareness, insight, and the unconscious as valued in psychoanalytic techniques. The goal of most forms of behavior therapy is to increase desired behaviors and decrease undesired ones. It is a collective group of therapeutic techniques based on systematically researched theories of learning and behavior. For example, Pavlov’s discovery of “classical conditioning,” or Pavlovian conditioning, led to an increased understanding of how certain behaviors could be learned. In his experiments with dogs, Pavlov found that the repeated pairing of a bell immediately proceeding the presentation of meat powder would eventually “condition” the dogs to salivate when the bell was later presented alone (without the meat powder). John B. Watson’s (1878-1958) famous “Little Albert” experiment demonstrated how fear of a non fear-inducing white rat could be conditioned in a toddler boy by the repeated pairing of a loud noise with a the presentation of the rat. While the increase of salivation in dogs or the induction of fear in infants are hardly desired outcomes of modern psychotherapeutic techniques, these principles of classical conditioning have had a far reaching influence on subsequent developments of different forms of behavior therapy.

“Systematic desensitization,” for example, is a behavioral therapy technique that uses principles of classical conditioning to help gradually alleviate specific phobias (e.g., fear of flying) or reduce the symptoms of certain anxiety disorders. “Flooding” (also called exposure therapy) is another form of behavior therapy used to help reduce anxiety by exposing an individual to a feared stimulus until the anxiety is extinguished. Though not commonly used in modern day, “aversion therapy” is a controversial behavior therapy technique that pairs unwanted behaviors with unpleasant results in order to reduce the behavior (e.g., pairing alcoholic beverages with a chemical substance that causes nausea). Other behavioral approaches involve principles of “operant conditioning” that Skinner was most noted for. Operant conditioning relies heavily on ideas of reinforcement and punishment in the service of increasing desired behaviors and decreasing unwanted behaviors.

Behavior psychotherapies tend to be directive, specific, and symptom focused. They are most popularly associated with the treatment of specific phobias, various anxiety disorders, or maladaptive behaviors (e.g., addictions, pedophilia). While research suggests that these techniques can be highly effective, especially in the short term, there is some debate as to how lasting the effects can be. A criticism of a strict behavioral approach to treatment is that it does not address underlying causes of the behaviors. The principles of behaviorism and behavioral psychotherapy are often used most successfully in conjunction with other theoretical approaches.

COGNITIVE THERAPY

Since the 1960s cognitive psychotherapy has been the predominant force in the treatment of many psychological difficulties. The basic assumption of all forms of cognitive therapy is that thinking impacts feeling. For example, cognitive therapists posit that an individual may be feeling depressed because of certain thoughts the person has (e.g., “I am not good enough”). In contrast to behaviorism’s focus on observable behaviors, the aim of cognitive therapy is to address, challenge, and alter maladaptive thoughts and cognitions. This can be done in many ways.

Developed by Ellis, Rational Emotive Therapy, also known as Rational Emotive Behavior Therapy, is a confrontational form of cognitive therapy that involves active and direct confrontation of an individual’s irrational beliefs. This type of intervention was intended by Ellis to be somewhat jarring to patients so as to highlight how individuals’ thoughts and beliefs were irrational appraisals of events that led to self-imposed suffering (e.g., depression, anxiety). As such, alleviation of symptoms came about by attacking these irrational thoughts directly.

Beck is known for developing a less confrontational, gentler approach to cognitive psychotherapy. Beck’s work, and many approaches that follow, focuses on correcting errors of reasoning called “cognitive distortions.” These distortions are said to create and maintain negative feelings such as anxiety or depression. For example, a young man engages in the cognitive distortion of catastrophizing (e.g., assuming the worst case scenario) when he believes that his public speaking will provoke unbearable anxiety and illicit embarrassing ridicule. In reality, however, the experience may just be uncomfortable. A cognitive therapist would address with this young man the distortions of his thinking. Other cognitive distortions include “overgeneralization,” “all-or-nothing thinking,” and “jumping to conclusions.” All of these distortions are automatic in nature and the process of cognitive psychotherapy works to reprogram these thoughts into more adaptive ones. Technically, cognitive psychotherapy tends to be directive with an emphasis on self-monitoring, problem solving skills, behavioral experiments, and improved decision making. Many cognitive therapists utilize homework assignments to encourage patients to continue monitoring their thoughts and feelings when outside the consulting room.

The term cognitive-behavioral psychotherapy is often used to describe the natural and practical mix of many of the cognitive and behavioral techniques described. In general, cognitive and cognitive-behavioral therapy utilize a much more structured and guided approach. It has proven to be a highly effective, efficient, and often time-limited treatment of many psychological disorders. Its structure also lends itself well to empirical investigation. Cognitive and cognitive-behavioral psychotherapy is the predominate form of psychotherapy being practiced in the United States today.

HUMANISTIC THERAPY

Having its roots in existential philosophy, humanistic psychotherapy is based on the ideas and practice of Abraham Maslow (1908–1970) and Carl Rogers (1902–1987). Often referred to as a “third force” of modern psychology and psychotherapeutic technique, humanistic psychotherapy represents an alternative to the larger psychoanalytic and cognitive-behavioral approaches. Both Maslow and Rogers focused on the ideas of psychological growth and deemphasized the notion of mental illness. Developed in the 1960s, humanistic psychotherapy posits that humans have an innate desire to maximizing personal growth and fulfillment, a goal termed by humanistic thinkers as “self-actualization.” The blocking of self-actualization is viewed by humanistic therapists as the source of psychological suffering.

Perhaps more than any other clinician, Rogers’s person-centered therapy illuminated the more universally practical components of psychotherapy, regardless of orientation. His focus on a genuine, empathic, and honest relationship between therapist and sufferer has been viewed as instrumental across many therapeutic disciplines. Humanistic psychotherapy tends to be non-directive. The humanistic psychotherapist focuses on the patient’s current feelings and experiences. The goal of Rogers’s type of psychotherapy is to listen in an empathic way that allows the patient to feel heard and understood. It was this understanding, Rogers believed, that helped patients navigate personal roadblocks and live more fulfilled and meaningful lives. Other important variants of humanistic psychotherapy were practiced by Rollo May (1909-1994), Victor Frankl (1905–1997) and James Bugental (b. 1915).

OTHER PSYCHOTHERAPIES

The various practices described share in common the most traditionally recognized form of psychotherapy: one trained professional listening and speaking with a suffering individual. There are, however, other forms of psychotherapy that deserve mention. As early as the 1940s, psychotherapy in a group setting was an accepted form of treatment.

The unique benefits of the interpersonal experience coupled with the increased patient-to-therapist ratio maintains group psychotherapy as a popular alternative to individual psychotherapy. Support groups led by lay persons or fellow suffers, such as Alcoholics Anonymous, remain a popular treatment choice for individuals. Specific psychotherapies have been designed to work with families, couples, or even in industrial settings. Play therapy is often a method used by practitioners working with children. There are also different forms of psychotherapy that involve the use of music or art. The variety of problems, populations, theoretical orientations, and modalities, coupled with each psychotherapist’s individual style, makes the number of different types of psychotherapy virtually endless.

BIOLOGICAL CONSIDERATIONS AND RESEARCH

The biological treatment of psychological distress has become inextricably linked to current ideas about psychotherapy. The 1950s marked an explosion of scientific research that led to new understandings about the connection between brain chemistry and psychological disorders. Most notably, the advent of psychotropic medication demonstrated that medicines could influence individuals’ thinking, feelings, and behaviors in ways that brought about relief of symptoms. This development has drastically changed the way people suffering from mental health issues receive treatment. Though it has not supplanted psychotherapy as a treatment modality, psychopharmacology has proven to be an important aspect of treating many disorders. Findings suggest that for most mental health issues, a combination of psychotherapy and medication is often more effective than either alone or none at all.

Critics of the biological approach often state that medication alone treats only symptoms and does not address underlying, more psychological causes, often leaving individuals dependent on medications to maintain a sense of mental health. The effectiveness and efficiency of symptom relief that some medication has demonstrated, however, solidifies the medical treatment of mental illness as an important modality that is here to stay. That said, new developments in neuroscience, brain imaging, and research techniques are beginning to demonstrate how psychotherapy alone can alter brain chemistry. This nascent line of research has begun focusing the historically fuzzy distinction between mind and body that has puzzled philosophers and scientists for thousands of years.

Psychiatry itself is a biologically oriented field. As compared to other mental health fields such as clinical psychology, counseling psychology, and social work, modern psychiatric training involves relatively little instruction or experience in the practice of psychotherapy. This has not always been the case. At the height of its popularity in the United States, psychoanalysis was practiced almost exclusively by psychiatrists. It was only in the late 1980s that psychologists, social workers, and counselors were first accepted into American psychoanalytic training institutes. Although some psychiatrists practice various types of psychotherapy as part of their profession, most do not and the balance of psychotherapy practice has shifted to non-medically trained professionals. As a medical profession with prescription privileges, however, psychiatrists are the most knowledgeable and well-trained in the area of psychotropic medication and the biological treatment of mental illness.

In the study of mental health treatment there is a growing call for the introduction and dissemination of psychotherapy approaches to be scientifically sound and have evidence-based proof of effectiveness. This comes from a social value of consumer protection as well as the financial pressures inherent in increasing health care costs. The structured nature of cognitive and behavioral psychotherapy techniques have made these forms of treatment better suited to traditional experimental designs and standardization, whereas the less structured and more individualized psychoanalytic and humanistic treatments present more complicated research challenges. This makes comparing the effectiveness of one type of therapy versus another understandably problematic. What constitutes proof is also a matter of debate among researchers, practitioners, and patients alike. While the scientific study of psychotherapy process and outcome likely will continue to illuminate and inform the public about treatment options, it is important to always consider the limitations of such research.

Debates between theoretical camps of psychotherapy have had a history of contention, each, at times, extolling the virtues of their own techniques and criticizing the deficits of the others. This debate has also been informative, propelling the understanding of what helps troubled people feel better. In some ways the debate is like the fable of the six blind men asked to describe an elephant to one another. Having only the sense of touch, one man described the smooth coolness of the ivory tusk, another the furrowed curve of the trunk; a third the wispy tuft of the tail, and so on. Each man could hardly believe that he was describing the same thing as the other.

SEE ALSO Anxiety; Classical Conditioning; Depression, Psychological; Emotion; Existentialism; Freud, Sigmund; Maslow, Abraham; Medicine; Mental Illness; Operant Conditioning; Pavlov, Ivan; Psychoanalytic Theory; Psychology; Psychoneuroendocrinology; Skinner, B. F.

BIBLIOGRAPHY

Beck, Aaron T. Cognitive Therapy and the Emotional Disorders. 1976. New York: International Universities Press.

Beck, Judith S. Cognitive Therapy: Basics and Beyond. 1995. New York: Guilford Press.

Frank, Jerome D., and Julia B. Frank. Persuasion and Healing: A Comparative Study of Psychotherapy, 3rd ed. 1993. Baltimore, MD: Johns Hopkins University Press.

Freud, Sigmund. New Introductory Lectures on Psycho-Analysis. 1933. New York: W. W. Norton.

McWilliams, Nancy. Psychoanalytic Psychotherapy: A Practitioner’s Guide. 2004. New York: Guilford Press.

Prochaska, James O., and John C. Norcross. 2006. Systems of Psychotherapy: A Transtheoretical Analysis, 6th ed. Pacifica Grove, CA: Thomson Brooks/Cole.

Rogers, Carl. On Becoming a Person. 1961. Boston: Houghton Mifflin.

Skinner, B. F. Science and Human Behavior. 1953. New York: Macmillan.

Yalom, Irivin D., and Molyn Leszcz. 2005. The Theory and Practice of Group Psychotherapy, 5th ed. New York: Basic Books.

Steven J. Hanley