Introduction
Psychotherapy (also psychological therapy or talking therapy) is the use of psychological methods, particularly when based on regular personal interaction with adults, to help a person change behaviour and overcome problems in desired ways. Psychotherapy aims to improve an individual’s well-being and mental health, to resolve or mitigate troublesome behaviours, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. There is also a range of psychotherapies designed for children and adolescents, which typically involve play, such as sandplay. Certain psychotherapies are considered evidence-based for treating some diagnosed mental disorders. Others have been criticised as pseudoscience.
There are over a thousand different psychotherapy techniques, some being minor variations, while others are based on very different conceptions of psychology, ethics (how to behave professionally), or techniques. Most involve one-to-one sessions, between the client and therapist, but some are conducted with groups, including families.
Psychotherapists may be mental health professionals such as psychiatrists, psychologists, mental health nurses, clinical social workers, marriage and family therapists, or professional counsellors. Psychotherapists may also come from a variety of other backgrounds, and depending on the jurisdiction may be legally regulated, voluntarily regulated or unregulated (and the term itself may be protected or not).
Refer to Group Psychotherapy.
Definitions
The term psychotherapy is derived from Ancient Greek psyche (ψυχή meaning “breath; spirit; soul”) and therapeia (θεραπεία “healing; medical treatment”). The Oxford English Dictionary defines it now as “The treatment of disorders of the mind or personality by psychological methods…”, however, in earlier use it denoted the treatment of disease through hypnotic suggestion.
The American Psychological Association adopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed by John C. Norcross: “Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviours, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable”. Influential editions of a work by psychiatrist Jerome Frank defined psychotherapy as a healing relationship using socially authorised methods in a series of contacts primarily involving words, acts and rituals – regarded as forms of persuasion and rhetoric.
Some definitions of counselling overlap with psychotherapy (particularly in non-directive client-centred approaches), or counselling may refer to guidance for everyday problems in specific areas, typically for shorter durations with a less medical or ‘professional’ focus. Somatotherapy refers to the use of physical changes as injuries and illnesses, and sociotherapy to the use of a person’s social environment to effect therapeutic change. Psychotherapy may address spirituality as a significant part of someone’s mental/psychological life, and some forms are derived from spiritual philosophies, but practices based on treating the spiritual as a separate dimension are not necessarily considered as traditional or ‘legitimate’ forms of psychotherapy.
Historically, psychotherapy has sometimes meant “interpretative” (i.e. Freudian) methods, namely psychoanalysis, in contrast with other methods to treat psychiatric disorders such as behaviour modification.
Psychotherapy is often dubbed as a “talking therapy”, particularly for a general audience, though not all forms of psychotherapy rely on verbal communication. Children or adults who do not engage in verbal communication (or not in the usual way) are not excluded from psychotherapy; indeed some types are designed for such cases.
Delivery
Psychotherapy may be delivered in person (one on one, or with couples, or in groups), over the phone, via telephone counselling, or via the internet.
The Australian Victoria state Government’s Health Agency has awarded no mental health app with scores greater than 3 stars out of 5 for effectiveness. One reason for this is that online Cognitive Behavioural Therapy programmes have poor “adherence” compared to face-to-face programmes. That means that many users do not “stick to” the programme as prescribed. They may uninstall the app or skip days, for instance.
Regulation
Psychotherapists traditionally may be: mental health professionals like psychologists and psychiatrists; professionals from other backgrounds (family therapists, social workers, nurses, etc.) who have trained in a specific psychotherapy; or (in some cases) academic or scientifically-trained professionals. Psychiatrists are trained first as physicians, and – as such – they may prescribe prescription medication; and specialist psychiatric training begins after medical school in psychiatric residencies: however, their specialty is in mental disorders or forms of mental illness. Clinical psychologists have specialist doctoral degrees in psychology with some clinical and research components. Other clinical practitioners, social workers, mental health counsellors, pastoral counsellors, and nurses with a specialisation in mental health, also often conduct psychotherapy. Many of the wide variety of psychotherapy training programmes and institutional settings are multi-professional. In most countries, psychotherapy training are all at a post-graduate level, often at a master’s degree (or doctoral) level, over 4 years, with significant supervised practice and clinical placements. Such professionals doing specialised psychotherapeutic work also require a programme of continuing professional education after basic professional training.
There is a 2013 listing of the extensive professional competencies of a European psychotherapist, developed by the European Association of Psychotherapy (EAP).
As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of client confidentiality – and the limited circumstances in which it may need to be broken for the protection of clients or others – is enshrined in the regulatory psychotherapeutic organisations’ codes of ethical practice. Examples of when it is typically accepted to break confidentiality include when the therapist has knowledge that a child or elder is being physically abused; when there is a direct, clear and imminent threat of serious physical harm to self or to a specific individual.
Europe
As of 2015, there are still a lot of variations between different European countries about the regulation and delivery of psychotherapy. Several countries have no regulation of the practice or no protection of the title. Some have a system of voluntary registration, with independent professional organisations, while other countries attempt to restrict the practice of psychotherapy to ‘mental health professionals’ (psychologists and psychiatrists) with state-certified training. The titles that are protected also vary. The European Association for Psychotherapy (EAP) established the 1990 Strasbourg Declaration on Psychotherapy, which is dedicated to establishing an independent profession of psychotherapy in Europe, with pan-European standards. The EAP has already made significant contacts with the European Union & European Commission towards this end.
Given that the European Union has a primary policy about the free movement of labour within Europe, European legislation can overrule national regulations that are, in essence, forms of restrictive practices.
In Germany, the practice of psychotherapy for adults is restricted to qualified psychologists and physicians (including psychiatrists) who have completed several years of specialist practical training and certification in psychotherapy. As psychoanalysis, psychodynamic therapy, and cognitive behavioural therapy meet the requirements of German health insurance companies, mental health professionals regularly opt for one of these three specialisations in their postgraduate training. For psychologists, this includes three years of full-time practical training (4.200 hours), encompassing a year-long internship at an accredited psychiatric institution, six months of clinical work at an outpatient facility, 600 hours of supervised psychotherapy in an outpatient setting, and at least 600 hours of theoretical seminars. Social workers may complete the specialist training for child and teenage clients. Similarly in Italy, the practice of psychotherapy is restricted to graduates in psychology or medicine who have completed four years of recognised specialist training. Sweden has a similar restriction on the title “psychotherapist”, which may only be used by professionals who have gone through a post-graduate training in psychotherapy and then applied for a licence, issued by the National Board of Health and Welfare.
Legislation in France restricts the use of the title “psychotherapist” to professionals on the National Register of Psychotherapists, which requires a training in clinical psychopathology and a period of internship which is only open to physicians or titulars of a master’s degree in psychology or psychoanalysis.
Austria and Switzerland (2011) have laws that recognise multi-disciplinary functional approaches.
In the United Kingdom, the government and Health and Care Professions Council considered mandatory legal registration but decided that it was best left to professional bodies to regulate themselves, so the Professional Standards Authority for Health and Social Care (PSA) launched an Accredited Voluntary Registers scheme. Counselling and psychotherapy are not protected titles in the United Kingdom. Counsellors and psychotherapists who have trained and qualify to a certain standard (usually a level 4 Diploma) can apply to be members of the professional bodies who are listed on the PSA Accredited Registers.
United States
In some states, counsellors or therapists must be licensed to use certain words and titles on self-identification or advertising. In some other states, the restrictions on practice are more closely associated with the charging of fees. Licensing and regulation are performed by various states. Presentation of practice as licensed, but without such a license, is generally illegal. Without a license, for example, a practitioner cannot bill insurance companies. Information about state licensure is provided by the American Psychological Association.
In addition to state laws, the American Psychological Association requires its members to adhere to its published Ethical Principles of Psychologists and Code of Conduct. The American Board of Professional Psychology examines and certifies “psychologists who demonstrate competence in approved specialty areas in professional psychology”.
Canada
Regulation of psychotherapy is in the jurisdiction of, and varies among, the provinces and territories.
In Quebec, psychotherapy is a regulated activity which is restricted to psychologists, medical doctors, and holders of a psychotherapy permit issued by the Ordre des psychologues du Québec, the Quebec order of psychologists. Members of certain specified professions, including social workers, couple and family therapists, occupational therapists, guidance counsellors, criminologists, sexologists, psychoeducators, and registered nurses may obtain a psychotherapy permit by completing certain educational and practice requirements; their professional oversight is provided by their own professional orders. Some other professionals who were practising psychotherapy before the current system came into force continue to hold psychotherapy permits alone.
Brief History
Psychotherapy can be said to have been practiced through the ages, as medics, philosophers, spiritual practitioners and people in general used psychological methods to heal others.
In the Western tradition, by the 19th century, a moral treatment movement (then meaning morale or mental) developed based on non-invasive non-restraint therapeutic methods. Another influential movement was started by Franz Mesmer (1734-1815) and his student Armand-Marie-Jacques de Chastenet, Marquis of Puységur (1751-1825). Called Mesmerism or animal magnetism, it would have a strong influence on the rise of dynamic psychology and psychiatry as well as theories about hypnosis. In 1853 Walter Cooper Dendy introduced the term “psycho-therapeia” regarding how physicians might influence the mental states of sufferers and thus their bodily ailments, for example by creating opposing emotions to promote mental balance. Daniel Hack Tuke cited the term and wrote about “psycho-therapeutics” in 1872, in which he also proposed making a science of animal magnetism. Hippolyte Bernheim and colleagues in the “Nancy School” developed the concept of “psychotherapy” in the sense of using the mind to heal the body through hypnotism, yet further. Charles Lloyd Tuckey’s 1889 work, Psycho-therapeutics, or Treatment by Hypnotism and Suggestion popularised the work of the Nancy School in English. Also in 1889 a clinic used the word in its title for the first time, when Frederik van Eeden and Albert Willem in Amsterdam renamed theirs “Clinique de Psycho-thérapeutique Suggestive” after visiting Nancy. During this time, travelling stage hypnosis became popular, and such activities added to the scientific controversies around the use of hypnosis in medicine. Also in 1892, at the second congress of experimental psychology, van Eeden attempted to take the credit for the term psychotherapy and to distance the term from hypnosis. In 1896, the German journal Zeitschrift für Hypnotismus, Suggestionstherapie, Suggestionslehre und verwandte psychologische Forschungen changed its name to Zeitschrift für Hypnotismus, Psychotherapie sowie andere psychophysiologische und psychopathologische Forschungen, which is probably the first journal to use the term. Thus psychotherapy initially meant “the treatment of disease by psychic or hypnotic influence, or by suggestion”.
Sigmund Freud visited the Nancy School and his early neurological practice involved the use of hypnotism. However following the work of his mentor Josef Breuer – in particular a case where symptoms appeared partially resolved by what the patient, Bertha Pappenheim, dubbed a “talking cure” – Freud began focusing on conditions that appeared to have psychological causes originating in childhood experiences and the unconscious mind. He went on to develop techniques such as free association, dream interpretation, transference and analysis of the id, ego and superego. His popular reputation as the father of psychotherapy was established by his use of the distinct term “psychoanalysis“, tied to an overarching system of theories and methods, and by the effective work of his followers in rewriting history. Many theorists, including Alfred Adler, Carl Jung, Karen Horney, Anna Freud, Otto Rank, Erik Erikson, Melanie Klein and Heinz Kohut, built upon Freud’s fundamental ideas and often developed their own systems of psychotherapy. These were all later categorised as psychodynamic, meaning anything that involved the psyche’s conscious/unconscious influence on external relationships and the self. Sessions tended to number into the hundreds over several years.
Behaviourism developed in the 1920s, and behaviour modification as a therapy became popularised in the 1950s and 1960s. Notable contributors were Joseph Wolpe in South Africa, M.B. Shipiro and Hans Eysenck in Britain, and John B. Watson and B.F. Skinner in the United States. Behavioural 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 life, 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 (e.g., 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 inquiry. A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based also on the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centred psychotherapy into mainstream focus. The primary requirement was that the client receive three core “conditions” from his counsellor or therapist: unconditional positive regard, sometimes described as “prizing” the client’s humanity; congruence [authenticity/genuineness/transparency]; and empathic understanding. This type of interaction was thought to enable clients to fully experience and express themselves, and thus develop according to their innate potential. 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 1950s, Albert Ellis originated rational emotive behaviour therapy (REBT). Independently a few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included relatively short, structured and present-focused techniques aimed at identifying and changing a person’s beliefs, appraisals and reaction-patterns, by contrast with the more long-lasting insight-based approach of psychodynamic or humanistic therapies. Beck’s approach used primarily the socratic method, and links have been drawn between ancient stoic philosophy and these cognitive therapies.
Cognitive and behavioural therapy approaches were increasingly combined and grouped under the umbrella term cognitive behavioural therapy (CBT) in the 1970s. Many approaches within CBT are oriented towards active/directive yet collaborative empiricism (a form of reality-testing), and assessing and modifying core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders. A “third wave” of cognitive and behavioural therapies developed, including acceptance and commitment therapy and dialectical behaviour therapy, which expanded the concepts to other disorders and/or added novel components and mindfulness exercises. However the “third wave” concept has been criticised as not essentially different from other therapies and having roots in earlier ones as well. Counselling methods developed include solution-focused therapy and systemic coaching.
Postmodern psychotherapies such as narrative therapy and coherence therapy do not impose definitions of mental health and illness, but rather see the goal of therapy as something constructed by the client and therapist in a social context. Systemic therapy also developed, which focuses on family and group dynamics – and transpersonal psychology, which focuses on the spiritual facet of human experience. Other orientations developed in the last three decades include feminist therapy, brief therapy, somatic psychology, expressive therapy, applied positive psychology and the human givens approach. A survey of over 2,500 US therapists in 2006 revealed the most utilised models of therapy and the ten most influential therapists of the previous quarter-century.
Types of Psychotherapies
Overview
There are hundreds of psychotherapy approaches or schools of thought. By 1980 there were more than 250; by 1996 more than 450; and at the start of the 21st century there were over a thousand different named psychotherapies – some being minor variations while others are based on very different conceptions of psychology, ethics (how to live) or technique.
In practice therapy is often not of one pure type but draws from a number of perspectives and schools – known as an integrative or eclectic approach. The importance of the therapeutic relationship, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy. Common factors theory addresses this and other core aspects thought to be responsible for effective psychotherapy. Sigmund Freud (1856-1939), a Viennese neurologist who studied with Jean-Martin Charcot in 1885, is often considered the father of modern psychotherapy. His methods included analysing his patient’s dreams in search of important hidden insights into their unconscious minds. Other major elements of his methods, which changed throughout the years, included identification of childhood sexuality, the role of anxiety as a manifestation of inner conflict, the differentiation of parts of the psyche (id, ego, superego), transference and countertransference (the patient’s projections onto the therapist, and the therapist’s emotional responses to that). Some of his concepts were too broad to be amenable to empirical testing and invalidation, and he was critiqued for this by Jaspers. Numerous major figures elaborated and refined Freud’s therapeutic techniques including Melanie Klein, Donald Winnicott, and others. Since the 1960s, however, the use of Freudian-based analysis for the treatment of mental disorders has declined substantially. Different types of psychotherapy have been created along with the advent of clinical trials to test them scientifically. These incorporate subjective treatments (after Beck), behavioural treatments (after Skinner and Wolpe) and additional time-constrained and centred structures, for example, interpersonal psychotherapy. In youth issue and in schizophrenia, the systems of family treatment hold esteem. A portion of the thoughts emerging from therapy are presently pervasive and some are a piece of the tool set of ordinary clinical practice. They are not just medications, they additionally help to understand complex conduct.
Therapy may address specific forms of diagnosable mental illness, or everyday problems in managing or maintaining interpersonal relationships or meeting personal goals. A course of therapy may happen before, during or after pharmacotherapy (e.g. taking psychiatric medication).
Psychotherapies are categorised in several different ways. A distinction can be made between those based on a medical model and those based on a humanistic model. In the medical model, the client is seen as unwell and the therapist employs their skill to help the client 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. The humanistic or non-medical model in contrast strives to depathologise the human condition. The therapist attempts to create a relational environment conducive to experiential learning and help build the client’s confidence in their own natural process resulting in a deeper understanding of themselves. The therapist may see themselves as a facilitator/helper.
Another distinction is between individual one-to-one therapy sessions, and group psychotherapy, including couples therapy and family therapy.
Therapies are sometimes classified according to their duration; a small number of sessions over a few weeks or months may be classified as brief therapy (or short-term therapy), others, where regular sessions take place for years, may be classified as long-term.
Some practitioners distinguish between more “uncovering” (or “depth”) approaches and more “supportive” psychotherapy. Uncovering psychotherapy emphasizes facilitating the client’s insight into the roots of their difficulties. The best-known example is classical psychoanalysis. Supportive psychotherapy by contrast stresses strengthening the client’s coping mechanisms and often providing encouragement and advice, as well as reality-testing and limit-setting where necessary. Depending on the client’s issues and situation, a more supportive or more uncovering approach may be optimal.
Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story or music. Psychotherapy with children and their parents often involves play, dramatisation (i.e. role-play), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting.
There are also different formats for delivering some therapies, as well as the usual face to face: for example via telephone or via online interaction. There have also been developments in computer-assisted therapy, such as virtual reality therapy for behavioural exposure, multimedia programmes to each cognitive techniques, and handheld devices for improved monitoring or putting ideas into practice.
Humanistic
These psychotherapies, also known as “experiential”, are based on humanistic psychology and emerged in reaction to both behaviourism and psychoanalysis, being dubbed the “third force”. They are primarily concerned with the human development and needs of the individual, with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. Some posit an inherent human capacity to maximise potential, “the self-actualising tendency”; the task of therapy is to create a relational environment where this tendency might flourish. Humanistic psychology can, in turn, be rooted in existentialism – the belief that human beings can only find meaning by creating it. This is the goal of existential therapy. Existential therapy is in turn philosophically associated with phenomenology.
Person-centred therapy, also known as client-centred, focuses on the therapist showing openness, empathy and “unconditional positive regard”, to help clients express and develop their own self.
Humanistic Psychodrama (HPD) is based on the human image of humanistic psychology. So all rules and methods follow the axioms of humanistic psychology. The HPD sees itself as development-oriented psychotherapy and has completely moved away from the psychoanalytic catharsis theory. Self-awareness and self-realisation are essential aspects in the therapeutic process. Subjective experiences, feelings and thoughts and one’s own experiences are the starting point for a change or reorientation in experience and behaviour in the direction of more self-acceptance and satisfaction. Dealing with the biography of the individual is closely related to the sociometry of the group.
Gestalt therapy, originally called “concentration therapy”, is an existential/experiential form that facilitates awareness in the various contexts of life, by moving from talking about relatively remote situations to action and direct current experience. Derived from various influences, including an overhaul of psychoanalysis, it stands on top of essentially four load-bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom.
A briefer form of humanistic therapy is the human givens approach, introduced in 1998-1999. It is a solution-focused intervention based on identifying emotional needs – such as for security, autonomy and social connection – and using various educational and psychological methods to help people meet those needs more fully or appropriately.
Insight-Orientated
Insight-orientated psychotherapies focus on revealing or interpreting unconscious processes. Most commonly referring to psychodynamic therapy, of which psychoanalysis is the oldest and most intensive form, these applications of depth psychology encourage the verbalisation of all the patient’s thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the nature of the past and present unconscious conflicts which are causing the patient’s symptoms and character problems.
There are six main schools of psychoanalysis, which all influenced psychodynamic theory: Freudian, ego psychology, object relations theory, self psychology, interpersonal psychoanalysis, and relational psychoanalysis. Techniques for analytic group therapy have also developed.
Cognitive-Behavioural
Behaviour therapies use behavioural techniques, including applied behaviour analysis (also known as behaviour modification), to change maladaptive patterns of behaviour to improve emotional responses, cognitions, and interactions with others. Functional analytic psychotherapy is one form of this approach. By nature, behavioural therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behaviour ultimately has), probabilistic (viewing behaviour as statistically predictable), monistic (rejecting mind-body dualism and treating the person as a unit), and relational (analysing bidirectional interactions).
Cognitive therapy focuses directly on changing the thoughts, in order to improve the emotions and behaviours.
Cognitive behavioural therapy attempts to combine the above two approaches, focused on the construction and reconstruction of people’s cognitions, emotions and behaviours. Generally in CBT, the therapist, through a wide array of modalities, helps clients assess, recognise and deal with problematic and dysfunctional ways of thinking, emoting and behaving.
The concept of “third wave” psychotherapies reflects an influence of Eastern philosophy in clinical psychology, incorporating principles such as meditation into interventions such as mindfulness-based cognitive therapy, acceptance and commitment therapy, and dialectical behaviour therapy for borderline personality disorder.
Interpersonal psychotherapy (IPT) is a relatively brief form of psychotherapy (deriving from both CBT and psychodynamic approaches) that has been increasingly studied and endorsed by guidelines for some conditions. It focuses on the links between mood and social circumstances, helping to build social skills and social support. It aims to foster adaptation to current interpersonal roles and situations.
Exposure and response prevention (ERP) is primarily deployed by therapists in the treatment of OCD. The American Psychiatric Association (APA) state that CBT drawing primarily on behavioural techniques (such as ERP) has the “strongest evidence base” among psychosocial interventions. By confronting feared scenarios (i.e., exposure) and refraining from performing rituals (i.e., responsive prevention), patients may gradually feel less distress in confronting feared stimuli, while also feeling less inclination to use rituals to relieve that distress. Typically, ERP is delivered in “hierarchical fashion”, meaning patients confront increasingly anxiety-provoking stimuli as they progress through a course of treatment.
Other types include reality therapy/choice theory, multimodal therapy, and therapies for specific disorders including PTSD therapies such as cognitive processing therapy and EMDR; substance abuse therapies such as relapse prevention and contingency management; and co-occurring disorders therapies such as Seeking Safety.
Systemic
Systemic therapy seeks to address people not just individually, as is often the focus of other forms of therapy, but in relationship, dealing with the interactions of groups, their patterns and dynamics (includes family therapy and marriage counselling). Community psychology is a type of systemic psychology.
The term group therapy was first used around 1920 by Jacob L. Moreno, whose main contribution was the development of psychodrama, in which groups were used as both cast and audience for the exploration of individual problems by re-enactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the US, such as Paul Schilder, who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably Wilfred Bion and Rickman, followed by S.H. Foulkes, Main, and Bridger. The Northfield Hospital in Birmingham gave its name to what came to be called the two “Northfield Experiments”, which provided the impetus for the development since the war of both social therapy, that is, the therapeutic community movement, and the use of small groups for the treatment of neurotic and personality disorders. Today group therapy is used in clinical settings and in private practice settings.
Expressive
Expressive psychotherapy is a form of therapy that utilises artistic expression (via improvisational, compositional, re-creative, and receptive experiences) as its core means of treating clients. Expressive psychotherapists use the different disciplines of the creative arts as therapeutic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy, writing therapy, among others. This may include techniques such as affect labelling. Expressive psychotherapists believe that often the most effective way of treating a client is through the expression of imagination in creative work and integrating and processing what issues are raised in the act.
Postmodernist
Also known as post-structuralist or constructivist. Narrative therapy gives attention to each person’s “dominant story” through therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful. Coherence therapy posits multiple levels of mental constructs that create symptoms as a way to strive for self-protection or self-realisation. Feminist therapy does not accept that there is one single or correct way of looking at reality and therefore is considered a postmodernist approach.
Other
Transpersonal psychology addresses the client in the context of a spiritual understanding of consciousness. Positive psychotherapy (PPT) (since 1968) is a method in the field of humanistic and psychodynamic psychotherapy and is based on a positive image of humans, with a health-promoting, resource-oriented and conflict-centred approach.
Hypnotherapy is undertaken while a subject is in a state of hypnosis. Hypnotherapy is often applied in order to modify a subject’s behaviour, emotional content, and attitudes, as well as a wide range of conditions including: dysfunctional habits, anxiety, stress-related illness, pain management, and personal development.
Psychedelic therapy are therapeutic practices involving psychedelic drugs, such as LSD, psilocybin, DMT, and MDMA. In psychedelic therapy, in contrast to conventional psychiatric medication taken by the patient regularly or as-needed, patients generally remain in an extended psychotherapy session during the acute psychedelic activity with additional sessions both before and after in order to help integrate experiences with the psychedelics. Psychedelic therapy has been compared with the shamanic healing rituals of indigenous people. Researchers identified two main differences: the first is the shamanic belief that multiple realities exist and can be explored through altered states of consciousness, and second the belief that spirits encountered in dreams and visions are real.
Body psychotherapy, part of the field of somatic psychology, focuses on the link between the mind and the body and tries to access deeper levels of the psyche through greater awareness of the physical body and emotions. There are various body-oriented approaches, such as Reichian (Wilhelm Reich) character-analytic vegetotherapy and orgonomy; neo-Reichian bioenergetic analysis; somatic experiencing; integrative body psychotherapy; Ron Kurtz’s Hakomi psychotherapy; sensorimotor psychotherapy; Biosynthesis psychotherapy; and Biodynamic psychotherapy. These approaches are not to be confused with body work or body-therapies that seek to improve primarily physical health through direct work (touch and manipulation) on the body, rather than through directly psychological methods.
Some non-Western indigenous therapies have been developed. In African countries this includes harmony restoration therapy, meseron therapy and systemic therapies based on the Ubuntu philosophy.
Integrative psychotherapy is an attempt to combine ideas and strategies from more than one theoretical approach. These approaches include mixing core beliefs and combining proven techniques. Forms of integrative psychotherapy include multimodal therapy, the transtheoretical model, cyclical psychodynamics, systematic treatment selection, cognitive analytic therapy, internal family systems model, multi-theoretical psychotherapy and conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time.
Child
Psychotherapy needs to be adapted to meet the developmental needs of children. Depending on age, it is generally held to be one part of an effective strategy to help the needs of a child within the family setting. Child psychotherapy training programmes necessarily include courses in human development. Since children often do not have the ability to articulate thoughts and feelings, psychotherapists will use a variety of media such as musical instruments, sand and toys, crayons, paint, clay, puppets, biblio-counselling (books), or board games. The use of play therapy is often rooted in psychodynamic theory, but other approaches also exist.
In addition to therapy for the child, sometimes instead of it, children may benefit if their parents work with a therapist, take parenting classes, attend grief counselling, or take other action to resolve stressful situations that affect the child. Parent management training is a highly effective form of psychotherapy that teaches parenting skills to reduce their child’s behaviour problems.
In many cases a different psychotherapist will work with the care taker of the child, while a colleague works with the child. Therefore, contemporary thinking on working with the younger age group has leaned towards working with parent and child simultaneously, as well as individually as needed.
Computer-Supported
Research on computer-supported and computer-based interventions has increased significantly over the course of the last two decades. The following applications frequently have been investigated:
- Tele-therapy/tele-mental health: In teletherapy classical psychotherapy is provided via modern communication devices, such as via videoconferencing.
- Virtual reality: VR is a computer-generated scenario that simulates experience.
- The immersive environment, used for simulated exposure, can be similar to the real world or it can be fantastical, creating a new experience.
- Computer-based interventions (or online interventions or internet interventions): These interventions can be described as interactive self-help.
- They usually entail a combination of text, audio or video elements.
- Computer-supported therapy (or blended therapy): Classical psychotherapy is supported by means of online or software application elements.
- The feasibility of such interventions has been investigated for individual and group therapy.
Effects of Psychotherapy
Evaluation
There is considerable controversy about whether, or when, psychotherapy efficacy is best evaluated by randomized controlled trials or more individualised idiographic methods.
One issue with trials is what to use as a placebo treatment group or non-treatment control group. Often, this group includes patients on a waiting list, or those receiving some kind of regular non-specific contact or support. Researchers must consider how best to match the use of inert tablets or sham treatments in placebo-controlled studies in pharmaceutical trials. Several interpretations and differing assumptions and language remain. Another issue is the attempt to standardise and manualise therapies and link them to specific symptoms of diagnostic categories, making them more amenable to research. Some report that this may reduce efficacy or gloss over individual needs. Fonagy and Roth’s opinion is that the benefits of the evidence-based approach outweighs the difficulties.
There are several formal frameworks for evaluating whether a psychotherapist is a good fit for a patient. One example is the Scarsdale Psychotherapy Self-Evaluation (SPSE). However, some scales, such as the SPS, elicit information specific to certain schools of psychotherapy alone (e.g. the superego).
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. Psychodynamic therapists in particular believe that evidence-based approaches are not appropriate to their methods or assumptions, though some have increasingly accepted the challenge to implement evidence-based approaches in their methods.
Outcomes in Relation with Selected Kinds of Treatment
Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.
One line of research consistently finds that supposedly different forms of psychotherapy show similar effectiveness. According to The Handbook of Counselling Psychology: “Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments”. The handbook states that there is “little evidence to suggest that any one psychological therapy consistently outperforms any other for any specific psychological disorders. This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes”.
Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.
Outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalise from them to practicing therapists.
However, specific therapies have been tested for use with specific disorders, and regulatory organisations in both the UK and US make recommendations for different conditions.
The Helsinki Psychotherapy Study was one of several large long-term clinical trials of psychotherapies that have taken place. Anxious and depressed patients in two short-term therapies (solution-focused and brief psychodynamic) improved faster, but five years long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies.
Meta-analyses have established that Cognitive Behavioural Therapy (CBT) and psychodynamic psychotherapy are equally effective in treating depression.
A 2014 meta analysis over 11,000 patients reveals that Interpersonal Psychotherapy (IPT) is of comparable effectiveness to CBT for depression but is inferior to the latter for eating disorders. For children and adolescents, interpersonal psychotherapy and CBT are the best methods according to a 2014 meta analysis of almost 4,000 patients.
Mechanisms of Change
It is not yet understood how psychotherapies can succeed in treating mental illnesses. Different therapeutic approaches may be associated with particular theories about what needs to change in a person for a successful therapeutic outcome.
In general, processes of emotional arousal and memory have long been held to play an important role. One theory combining these aspects proposes that permanent change occurs to the extent that the neuropsychological mechanism of memory reconsolidation is triggered and is able to incorporate new emotional experiences.
Adherence
Patient adherence to a course of psychotherapy – continuing to attend sessions or complete tasks – is a major issue.
The dropout level – early termination – ranges from around 30% to 60%, depending partly on how it is defined. The range is lower for research settings for various reasons, such as the selection of clients and how they are inducted. Early termination is associated on average with various demographic and clinical characteristics of clients, therapists and treatment interactions. The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.
Most psychologists use between-session tasks in their general therapy work, and cognitive behavioural therapies in particular use and see them as an “active ingredient”. It is not clear how often clients do not complete them, but it is thought to be a pervasive phenomenon.
From the other side, the adherence of therapists to therapy protocols and techniques – known as “treatment integrity” or “fidelity” – has also been studied, with complex mixed results. In general, however, it is a hallmark of evidence-based psychotherapy to use fidelity monitoring as part of therapy outcome trials and ongoing quality assurance in clinical implementation.
Adverse Effects
Research on adverse effects of psychotherapy has been limited for various reasons, yet they may be expected to occur in 5% to 20% of patients. Problems include deterioration of symptoms or developing new symptoms, strains in other relationships, and therapy dependence. Some techniques or therapists may carry more risks than others, and some client characteristics may make them more vulnerable. Side-effects from properly conducted therapy should be distinguished from harms caused by malpractice.
General Critiques
Some critics are sceptical of the healing power of psychotherapeutic relationships. Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners, instead favouring either nonprofessional help or biomedical treatments. Others have pointed out ways in which the values and techniques of therapists can be harmful as well as helpful to clients (or indirectly to other people in a client’s life).
Many resources available to a person experiencing emotional distress – the friendly support of friends, peers, family members, clergy contacts, personal reading, healthy exercise, research, and independent coping – all present considerable value. Critics note that humans have been dealing with crises, navigating severe social problems and finding solutions to life problems long before the advent of psychotherapy.
On the other hand, some argue psychotherapy is under-utilised and under-researched by contemporary psychiatry despite offering more promise than stagnant medication development. In 2015, the US National Institute of Mental Health allocated only 5.4% of its budget to new clinical trials of psychotherapies (medication trials are largely funded by pharmaceutical companies), despite plentiful evidence they can work and that patients are more likely to prefer them.
Some Christians, such as theologian Thomas C. Oden, have argued that successful therapeutic relationships, based on true acceptance of the client as a human being without contingency, require a theological assumption, an ontological acceptance of God.
Further critiques have emerged from feminist, constructionist and discourse-analytical sources. Key to these is the issue of power. In this regard there is a concern that clients are persuaded – both inside and outside the consulting room – to understand themselves and their difficulties in ways that are consistent with therapeutic ideas. This means that alternative ideas (e.g., feminist, economic, spiritual) are sometimes implicitly undermined. Critics suggest that we idealise the situation when we think of therapy only as a helping relationship – arguing instead that it is fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified, and that while it is seldom intended, the therapist-client relationship always participates in society’s power relations and political dynamics. A noted academic who espoused this criticism was Michel Foucault.
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