Treatment of Psychological Disorders

Insight Therapies


Psychoanalytic theory focuses on generating insight into unconscious motivations and unhelpful defense mechanisms.

Psychoanalysis, the first of the insight therapies to treat mental illness, began with Joseph Breuer and Sigmund Freud. In insight therapy, clinicians promote awareness of the thoughts, beliefs, and feelings causing negative behaviors. Once people see they have control of their behavior, they will be better able to make changes. Psychoanalysis emphasizes the importance of uncovering unconscious motives and desires and defense mechanisms used to protect against unconscious conflicts. Freud identified three parts of the mind: the id, the source of mental energy and the seat of sexual and aggressive drives; the ego, the persona presented to the world; and the superego, the conscience. Anxiety arises when people are torn between the desires of the id and the morality of the superego. As a result, the mind uses unconscious defense mechanisms, such as denial or regression, to cope with anxiety and protect the ego's self-image. For example, a person with a substance abuse problem may deny that their drug use affects their ability to parent. An elementary school student upset by the death of a pet may regress to an earlier developmental stage, returning to outgrown behaviors such as thumb sucking and sleeping with the lights on. Freud used free association and dream analysis to bring these defense mechanisms into conscious awareness. These techniques were intended to provide insight into the origins of problems and to alleviate the associated conflict or anxiety.

Free association is a therapeutic technique used to uncover unconscious content by having the client say whatever comes to mind without self-censoring. The psychoanalyst reads a list of words, and the client immediately responds with the first word that comes to mind. The psychoanalyst then studies these comments to understand unconscious motivations. Dream analysis is a therapeutic technique used to uncover unconscious content by interpreting symbols within dreams. An analyst encourages the client to keep a dream log and then interprets the events and characters within the dream. Freud coined the term resistance to describe the unconscious tendency to slow down the progress of therapy to avoid facing painful conflicts. He also observed the phenomenon of transference, a process in which a client unconsciously begins interacting with the analyst as if the analyst were a figure from the client's past or present. For example, a client may assume the analyst has the same negative perceptions of them that their father has expressed or may react to the analyst in the same way they react to their spouse.

Modern psychoanalysis, which recreates Freud's techniques, is costly and lengthy. True psychoanalysis requires multiple sessions each week for years. Few therapists use this approach. However, many psychodynamic therapists use elements of psychoanalysis in their approach. Psychodynamic therapy refers to any treatment approach that explores the impact of unconscious processes on current emotions and behaviors. For example, a psychodynamic therapist may help a client develop insight into how unmet childhood needs have been manifesting themselves in unconscious defense mechanisms.

Although many of Freud's theories were not scientific and could not be tested, outcomes of psychodynamic therapy can be tested. Current evidence suggests that psychodynamic therapy has a slightly better impact on treatment outcomes than waitlist conditions (delayed or no treatment). However, for most disorders there are now more effective talk therapy approaches or medications. The umbrella term psychotherapy is a generic term for any form of talk therapy intended to alleviate mental distress. Psychoanalysis is one form of psychotherapy. Psychotherapy also includes a wide range of other approaches. Some approaches are loosely structured, such as supportive approaches, in which therapists provide empathy and a chance to talk about problems. Other psychotherapy approaches are more highly structured. Structured forms of psychotherapy are often guided by treatment manuals that give therapists guidelines for teaching a specific set of skills. Structured approaches include problem-solving therapies intended to help clients cope with life challenges actively by identifying a possible solution, implementing it, and then evaluating the outcome. Interpersonal therapy is also a structured type of psychotherapy. It targets disorders such as depression by helping clients strengthen relationships and identify sources of support. Cognitive-behavioral therapy involves teaching clients skills for recognizing and changing negative thoughts, as well as strategies for changing unhelpful behaviors.

Treatment Effects

Not all treatments work equally well. In a study aggregating data from many large depression treatment studies, structured skill-building approaches such as problem-solving, cognitive-behavioral, and interpersonal therapies offered more symptom relief than supportive and psychodynamic approaches.

Humanistic Approaches

Humanistic therapy provides nonjudgmental support and genuine empathy in a client-directed process.

Humanistic therapies emphasize a person's capacity to grow and change. American psychologist Carl Rogers introduced client-centered therapy (also called person-centered therapy) in the 1940s and 1950s. In client-centered therapy, the therapist provides empathy and emotional support while the client directs the therapeutic process. In contrast to psychodynamic therapy, which is guided by the therapist, Rogers believed therapy should be a client-directed process aimed at allowing the client to lead the conversation.

Rogers considered the difference between people's self-image and the realistic feedback they received from others as the principal cause of anxiety. To reduce clients' defensiveness, Rogers believed therapists needed to give their clients unconditional positive regard, nonjudgmental acceptance and support of clients regardless of what they say or do. He also encouraged therapists to practice active listening, a technique in which a therapist restates a client's feelings back to them. In active listening, the therapist uses mirroring statements, such as "I hear you saying that …" to ensure they are understanding the client's concerns. Rogers emphasized empathy, authenticity, and emotional support to engender healthy psychological change. Client-centered therapists also seek to help their clients understand the client's own feelings by identifying themes that can be used as stepping-stones to insight.

Fritz Perls, a German-born psychiatrist, developed a form of humanistic therapy called gestalt therapy. Gestalt therapy encourages clients to focus on what is presently occurring in their lives without focusing on past events. Gestalt means "whole," with gestalt therapy focusing on every aspect of a person: body, mind, and soul. Gestalt therapists bring the past into the present to help clients improve their self-awareness and realize the ways in which their behavior influences situations. For example, a therapist may role-play a previously upsetting experience with a client and then discuss how the experience makes the client feel right now. By reenacting an event and becoming attuned to one's feelings, clients can begin to understand how their reactions shape what happens to them. Compared to client-centered therapy, gestalt therapy involves the use of more active exercises during therapy sessions. For example, in the empty chair technique, clients face an empty chair and imagine that a person they are feeling frustrated or hurt by is in that chair. They have a conversation with that person, expressing their thoughts and feelings. Then they may switch places, playing the role of that other person in order to better understand that person's perspective.

Existential therapy is based on the premise that people can maintain their freedom, even in the most extreme circumstances, by choosing how they will respond to their situation. It is grounded in a belief that life has no inherent or objective meaning. Rather, humans have a sacred duty to assign a meaning to life and their own individual actions. One important figure in the school of existentialist psychology is Viktor Frankl, who survived imprisonment in a Nazi concentration camp and wrote about how his ordeal informed his beliefs. Frankl called his approach logotherapy, which stresses humankind's relentless search for meaning and a sense of purpose. Existential therapists use techniques from client-centered therapy such as empathy and unconditional positive regard. However, their sessions are likely to include more emphasis on spiritual questions and facing the universal reality of death.

Client-Centered Therapy

Client-centered therapy, developed by psychologist Carl Rogers, uses authenticity, empathy, and unconditional positive regard to build a strong therapeutic relationship.