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Psychotherapy

From Wikipedia, the free encyclopedia

Abridged by Don Morgan, Ph.D.

Psychotherapy is a range of techniques based on dialogue, communication and behavior change 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 psychotherapies use only spoken conversation, though some also use various other forms such as writing, artwork or touch.  Psychotherapy involves a therapist and client(s) — and in family therapy, several family members — who discuss the issues to discover underlying problems and find constructive solutions.
Psychotherapy addresses diagnosable mental illness and everyday problems in relationships or meeting personal goals. Treatment of everyday problems is also referred to as counseling.  Often, the terms are used interchangeably.
Psychotherapeutic interventions often follow the medical model of "illness – cure."  Humanistic therapists see themselves in an educational or helper role. All therapists are required to respect client confidentiality.

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 (Rosenzweig, S. (1936). "Some implicit common factors in diverse methods in psychotherapy". Journal of Orthopsychiatry 6: 412-415.)  Accordingly, most contemporary schools of psychotherapy focus on the healing power of the therapeutic relationship.
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, “The Client as a Common Factor: Clients as self-healers”, Hubble, Duncan, Miller: The Heart and Soul of Change, 91-131).  Outside of therapy, people rarely have a friend who will truly listen to them for more than 20 minutes. (Stiles, W. B. (1995). “Disclosure as a speech act: Is it psychotherapeutic to disclose?”, J. E. Pennebaker: Emotion, Disclosure, and Health, 71-92.)  Further, friends and relatives often are involved in the problem and therefore do not provide a "safe outside perspective" which may be required.

Effectiveness

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.
In "The Great Psychotherapy Debate (2001University of Wisconsin-Madison) Bruce Wampold reported that a positive working alliance with the client is much more important than techniques used used.

General description

Psychotherapy is restricted to conversations and practitioners do not have to be medically qualified, but do receive some medical training. 
Not all psychotherapists are psychologists.  Others with varying degrees of training are social workers, marriage-family therapists, expressive 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 have much more training in psychotherapy and psychological assessment.  Psychologists are required to take frequent continuing education classes to retain their licenses.  Social workers have specialized training linking patients to community and institutional resources.  Marriage-Family Therapists have training similar to the social worker, with specific training working with relationships and family issues.  Licensed professional counselors (LPC's) have training in career, mental health, school, or rehabilitation counseling. 
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 practitioners. 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 (Antidepressant drug trials: fast track to overprescription? Wikipedia 3-16-2006).  Drugs and psychotherapy combined are more efficacious than either treatment alone in treating persons with mental illness.
Seven main systems of psychotherapy:

History

Most psychotherapies are direct descendants of psychoanalysis, branched off of areas of psychoanalysis, or developed in reaction to psychoanalysis.   Therefore, when describing the history of psychotherapy, most traditionally start with Freud who is credited with being the first to use dialogue as a therapeutic tool.

Psychoanalysis

Sigmund Freud noticed neurological problems in patients such as blindness, paralysis and anorexia with no apparent physical cause.  He looked to the mind for answers.  Freud opened a private practice from 1886 until 1896, treating mostly women with symptoms of hysteria. Using dream interpretation, free association, transference and analysis of the id, ego and superego, his colleagues developed a system of psychoanalysisAlfred Adler, Otto Rank, and Carl Jung formed their own systems, all later termed 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 effective at treating personality disorders and mood disorders. However, these methods require hundreds of sessions over a period of several years.
Contemporary psychodynamic approaches retain Freud's emphasis on sexuality, aggression, and mental conflict, and believe that psychotherapy is most effective when it leads to increased self-knowledge. Other current psychodynamic approaches—such as object-relational—prefer techniques designed to change the patient's habitual patterns of living by building authentic supportive relationship with the analyst to help the patient learn new ways of relating to others.
While behavior is often a target of the work, many approaches value working with feelings and thoughts. This is especially true of the psychodynamic schools, which include Jungian therapy and Psychodrama.  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.

Cognitive

Cognitive therapy appeared in the 1940s.  Albert Ellis developed Rational Emotive Behavior Therapy (REBT).  Common features included short, structured and present-focused therapy aimed at changing a person's distorted thinking. Being oriented towards symptom-relief, collaborative empiricism and modifying people’s core beliefs, this is often the preferred method of treatment for depression, substance abuse, anxiety disorders, eating disorders and phobias.  Cognitive behavioral therapy involves recognizing distorted thinking and learning to replace it with more realistic ideas, and is common where the therapy is subject to demands of insurance companies with a financially limited commitment.

Humanistic

Carl Rogers became interested in existentialism. The works of Abraham Maslow and his hierarchy of human needs became his main focus.  He brought Person-Centered Psychotherapy into the mainstream.  Rogers' technique of active listening is considered fundamental to most counseling styles, and is included in virtually every counselor preparation program.  His basic tenets were unconditional positive regard, genuineness, and empathic understanding.  These tenets were necessary and sufficient to create a relationship enhancing the client's psychological well being, enabling clients to fully experience themselves.  Others like Fritz and Laura Perls followed with Gestalt therapy. Eric Berne founded Transactional Analysis.  These fields are known as humanistic psychotherapy.

Existential

Existential psychotherapy is mainly concerned with the individual's ability to preserve a sense of meaning and purpose in the face of limitations of a mortal existence (i.e. ageing, death, ultimate aloneness, having sole responsibility for our actions, choices and freedom).  Existential philosophy celebrates the uniqueness and multi-dimensional nature of the individual.  Therefore each therapist's stance varies according to his or her life experiences, personality and interpretation of the philosophy.  The uniqueness of the patient-therapist relationship forms a vehicle for therapeutic enquiry.  Practitioners' formulations of theory range from descriptive phenomenology to creativity and awareness development.  Some practitioners combine psychoanalytic (e.g. defenses versus unconscious death anxiety) with the humanistic model.  Contributors include Rollo May, Viktor Frankl, Ludwig Binswanger, Medard Boss, and R.D.Laing, previously accessible through the complex writings of existential philosophers (e.g. Soren Kierkegaard, Jean-Paul Sartre, Martin Heidegger, Friedrich Nietzsche).

Behavioral

Behavioral therapy (B.F. Skinner) relies on 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.  Newer forms of behavior therapy (such as Acceptance and Commitment Therapy) focus on thought, showing that behavior therapy focuses on more than publicly observable behavior.  B. F. Skinner was named Humanist of the Year in 1972 by the American Humanist Association, indicating that behavior therapy is compatible with humanistic philosophy (Epstein, R. 1997. Skinner as self-manager. Journal of applied behavior analysis 30: 545-569)
Behavior therapists 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.  Conditioning techniques are the treatment of choice for phobias and fetishes, including systematic desensitization, flooding, counterconditioning, exposure, and aversive conditioning. Sometimes hypnosis and biofeedback are used as well.
Behavior therapy has been effective in treating eating disorders.  Increasingly, counselors 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. (Thomson, C.L.; Rudolph, L.B., and Henderson, D. (2004). Counseling children, 6th ed., Belmont, CA: Brooks/Cole Thompson)
A "third wave" of cognitive and behavioral therapies includes 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 takes from one to five sessions using any of the above approaches and narrative therapy, reverse psychology, solution-focused therapy and systemic coaching to help clients identify occasions when their stated problem(s) are less dominant in their lives, and adjust relationships that motivate problematic behavior.  Employee Assistance Programs are geared to provide brief assessments and interventions intended to fulfill clients' needs in a few sessions.  Community mental health centers offer Brief Counseling to new clients in order to encourage greater self-reliance and to discourage dependence on a therapist.

Expressive therapy

Expressive therapy uses artistic expression as its core means of treating clients. Therapeutic interventions include dance therapy, drama therapy, art therapy, music therapy among others.  Expressive therapists believe the most effective way of treating a client is through the expression of imagination in a creative work and integrating and processing the issues raised in the act.

Post-modern therapies

While sharing similarities to brief counseling and humanistic therapies, postmodern psychotherapy includes narrative therapy, coherence therapy, and social therapy from a post-modern epistemology. These therapies do not impose definitions of mental health and illness, but rather see the goal of therapy as something constructed by the client and therapist. They are aware of the client’s role in actively constructing his or her reality, and challenge the premise that the individual behaving-being is the fundamental ontological unit.

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 client’s own natural process draws them to a fuller understanding of themselves. An example would be gestalt therapy.
Uncovering psychotherapy emphasizes clients finding insight into the roots of their difficulties (classical psychoanalysis).  By contrast, Supportive psychotherapy stresses strengthening clients' defenses, providing encouragement, and advice.  Depending on the individual client's personality, a supportive or uncovering approach may be optimal.  Most therapists use both uncovering and supportive approaches.

Adaptations for children

Children do not have the ability to articulate thoughts and feelings.  Psychotherapy must be adapted to the developmental needs of children using crayons, paint, clay, puppets, bibliocounseling (books), toys, etc.  The use of play therapy is often rooted in psychodynamic theory, but other approaches such as Solution Focused Brief Counseling may also use play.  It is often necessary to work with the child’s caretaker. Theraplay facilitates a healthier relationship between parent and child using structured play.  Children who have experienced chronic early maltreatment resulting 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. (Becker-Weidman. Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. 23(2), April 2006;  Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9 and Becker-Weidman, A, (2006b) Dyadic Developmental Psychotherapy: a multi year follow-up. in Sturt, S., (ed) New Developments in Child Abuse Research. NY: Nova)


 
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