Psychotherapy. Psychotherapy is the term applied to a wide variety of efforts to foster personal growth and behavioral modification by treating mental and emotional maladies through the use of conversations between therapists and patients designed to disclose inner conflicts and yield psychological insights. Several elements that lent credence to such talking cures were deeply rooted within American culture. Not only did “folk psychology” promote the value of talking things over with a trusted confidant, but nineteenth‐century theological and philosophical discussions of human nature emphasized the importance of the mind as a causal agent in self‐fashioning. Still, the birth of psychotherapy as a set of determinate ideas and clinical procedures awaited the discovery of the “subconscious” by the French psychopathologist Pierre Janet and others in the 1880s and 1890s and the use of a variety of techniques—hypnosis, suggestion, and the like—based on persuasion and the “re‐education” of those suffering psychological distress.
European‐based psychotherapeutic ideas and strategies initially encountered fierce resistance from the American medical community. Notwithstanding their inability to discern a physical cause for numerous forms of mental distress and their disturbingly low rate of success in treating those disorders, American physicians continued to attribute
mental illness to organic rather than psychological causes. During the late nineteenth and early twentieth centuries, however, several developments converged to foster interest in psychotherapy. Within the larger culture, many Americans became enthralled with
Christian Science, New Thought, the Episcopalian‐based Emmanuel movement, and other groups that dissented from “medical materialism.” At the same time, a small but influential group of neurologists, psychiatrists, and psychologists centered in the
Boston area—including James Jackson Putnam, Morton Prince, Boris Sidis, Adolf Meyer, William
James, and G. Stanley
Hall—began to assign great significance to psychological factors in the cause and treatment of hysteria, anxiety, depression, and a variety of other maladies. During the first decade of the twentieth century the prestige of these individuals, coupled with the desire of many physicians to compete more effectively with what William James termed the “mind‐cure” movement, helped to give psychotherapy a foothold within American society.
Freudianism in America.
One beneficiary of Americans' increasing tendency to look favorably on psychotherapy was the Austrian physician Sigmund Freud. In Freud's exposition of “depth psychology,” the powerful, amoral “drives” residing in the unconscious—most notably the sexual drive, which he termed the libido—played a central role in motivating human behavior. Freud also held that these drives prompted human beings, often in their early years, to generate ideas and wishes so radically at odds with the standards they embraced in their conscious minds that they “repressed” them. This psychic defense mechanism, however, was not always successful; and when repressed material did surface, it was capable of causing a wide variety of mental and behavioral disorders. The appropriate therapy for such disorders, Freud maintained, was analysis: a series of sustained discussions with a trained analyst, during which patients could bring repressed material fully to light and integrate it into the conscious mind. Eventually, some patients would even achieve insight into the motives that had led to the initial repression.
After 1909, the year that Freud delivered a series of lectures at Clark University in Worcester, Massachusetts, psychoanalysis not only took root in the United States, but also evolved considerably. This is partly because Freud himself continued to modify his views and partly because many professed Freudians altered his emphases. In the process of “Americanizing” Freud, proponents of psychoanalysis muted the conflict between the individual and society and downplayed the master's emphasis on sexuality, aggression, and the centrality of infancy and childhood in the psychological lives of human beings. They also tended to focus more on the role of the ego—the conscious self—and the external environment and less on the intractability of the unconscious. By the early 1940s these views had become institutionalized in a neo‐Freudian movement. Karen Horney, Harry Stack Sullivan, Erich Fromm, and other neo‐Freudians highlighted the importance of anxiety and the role of interpersonal relationships in personality development.
The Rise of Psychological Counseling.
Freudianism often receives the lion's share of attention in historical treatments of psychotherapy, and indeed prior to 1945 most of the psychotherapists in private practice and many of the best‐known treatment centers, such as the Menninger Clinic in Topeka, Kansas, were psychoanalytically oriented. Nevertheless, throughout the twentieth century psychoanalysis remained a relatively minor component of the broader psychotherapeutic enterprise. Many people found both the cost and the time involved in analysis prohibitive. In addition, for much of the twentieth century, analysts, like the institutes where they were trained, remained concentrated almost entirely in a relatively few large urban areas. Although the medical profession worked assiduously to secure a monopoly on psychoanalytic practice, this effort did not extend to psychotherapy as a whole. The realization quickly spread that psychotherapeutic skill did not require a medical degree, and during the 1920s and 1930s; practitioners in university counseling centers and community‐based child‐guidance clinics provided psychotherapy to their clients. The clergy, who were beginning to receive formal training in pastoral counseling, increasingly practiced psychotherapy as part of their vocational effort to cure souls. In fact, prior to
World War II, ministers may have provided more hours of therapy in America than all other professional groups combined.
Before 1941, however, few Americans were inclined to describe conversations with their clergy or the other varieties of counseling to which they were exposed as psychotherapy. Rather, most tended to stigmatize psychotherapy as a clinical treatment used exclusively with “crazy people.” World War II, however, proved to be a watershed in both the availability and the popularity of therapy. The sheer number of war‐related mental disorders made it necessary to bring a growing number of clinical psychologists, who had previously worked in institutional settings assisting educators, physicians, and business executives with aptitude and personality tests, into the counseling setting.
Post‐World War II Trends.
After the war, clinical psychologists continued to practice psychotherapy. Indeed, during the second half of the twentieth century the number of professionally trained psychotherapists—psychiatrists, clinical psychologists, marriage and school‐guidance counselors, clinical social workers, and clergy who provided counseling—increased dramatically. By the 1990s, depending on one's criteria for training and licensure, between 100,000 and 250,000 psychotherapists were practicing in the United States.
World War II also helped to democratize psychotherapy. The vigorous campaign of psychiatrists to screen the population for military fitness, coupled with the numerous instances of psychological disturbance associated with the war, suggested that many “normal” people could profit from therapy. In turn, psychotherapy lost much of its stigma. At the same time,
health insurance increasingly included coverage for therapeutic practices. By 1990 approximately a third of all Americans had received psychotherapy at some point in their lives.
Post‐World War II psychotherapeutic theories and practices varied enormously. Between 1945 and 1970 ego
psychology continued to dominate American psychoanalysis. Subsequently, however, many analysts in the United States, influenced especially by British “object relations” theory and the “self psychology” of Hans Kohut, tended to focus on issues relating to representations of self and object and the relationship between them. Within the larger realm of psychotherapy, eclecticism reigned. In the quarter century after 1945, humanistic psychology, most notably the non‐directive, “client‐centered” practice of Carl Rogers and the “self‐actualization” theory associated most closely with Abraham Maslow, became increasingly influential. Humanistic psychologists, who regarded the self as the ultimate source of values, insisted on the ability of individuals to achieve self‐determination. Personal growth, rather than mental stability, they maintained, constituted the appropriate goal of human life. Even after the mid‐1970s, when mainstream psychological theory began to move away from humanistic psychology, the importance of choice and the desirability of growth continued to be emphasized within therapeutic circles.
Criticism of Psychotherapy and the Pharmacological Challenge.
Criticism of psychotherapy intensified even as its popularity increased. In 1952, for example, the eminent British experimental psychologist Hans Eysenck denied that there was persuasive evidence of psychotherapy's value. Other psychologists and cultural critics echoed this charge. People of the left assailed psychotherapy for fostering adjustment to a corrupt and inhumane status quo, while critics on the right charged that it fostered a victim mentality. The assaults on psychoanalysis, and particularly on the legitimacy of Freudian theory and practice, became so intense as the twentieth century ended as to constitute almost a cottage industry.
Perhaps the most serious post‐1970 challenge to psychotherapy came from pharmacology. A growing number of newly developed drugs treated not only major mental illnesses but also less serious conditions that in previous years would have prompted people to enter therapy. Mood‐altering drugs such as Prozac enjoyed great popularity. Whether drugs served as an appropriate substitute for psychotherapy or simply alleviated symptoms while leaving the underlying causes of mental distress untreated remained a point of controversy.
Notwithstanding the hostility of critics and the presence of alternative approaches, many Americans continued to look to psychotherapy not only as a means of grappling with acute emotional and mental distress but also as a route to self‐knowledge and personal growth. So popular and persuasive did psychotherapy's approach to the human condition become that a number of observers characterized late‐twentieth‐century America as a “therapeutic society.”
See also
Health and Fitness;
Intelligence, Concepts of;
Medicine: From the 1870s to 1945;
Medicine: Since 1945;
Menninger, Karl and William;
Mental Health Institutions;
Pharmaceutical Industry;
Religion;
Sexual Morality and Sex Reform.
Bibliography
Nathan G. Hale Jr. , Freud and the Americans: The Beginnings of Psychoanalysis in the United States, 1876–1917, 1971.
Morris N. Eagle , Recent Developments in Psychoanalysis: A Critical Evaluation, 1987.
John C. Burnham , Paths into American Culture: Psychology, Medicine, and Morals, 1988.
John C. Burnham , Psychology and Counseling: Convergence into a Profession, in The Professions in American History, ed. Nathan O. Hatch, 1988, pp. 181–197.
Donald K. Freedheim, ed., History of Psychotherapy: A Century of Change, 1992.
Nathan G. Hale Jr. , The Rise and Crisis of Psychoanalysis in the United States: Freud and the Americans, 1917–1985, 1995.
Ellen Herman , The Romance of American Psychology: Political Culture in the Age of Experts, 1995.
Eric Caplan , Mind Games: American Culture and the Birth of Psychotherapy, 1998.
Jon H. Roberts
