Introduction to Psychotherapy
"Psychotherapy" is an umbrella term that describes the use of psychological methods to help a client overcome distressing thoughts, feelings, and behaviors.
Discuss the history, goals, and types of psychotherapy
- The purpose of psychotherapy is to explore thoughts, feelings, and behaviors with the goal of problem -solving or achieving higher levels of functioning. Psychotherapy aims to increase the individual's sense of their own well-being.
- One of the earliest forms of psychotherapy was psychoanalysis, created by Sigmund Freud in the late 19th century. Psychoanalysis aims to help clients gain insights about unresolved issues from the past.
- The type of psychotherapy used is often dependent on the the individual, their particular situation, and the problems from which they are suffering. Common types of psychotherapy include psychodynamic, humanistic, behavioral, cognitive, cognitive-behavioral, group, and a number of others.
- Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions; however, some criticize its effectiveness in favor of biomedical models.
- classical conditioning: The use of a neutral stimulus, originally paired with one that invokes a response, to generate a conditioned response.
- determinism: The doctrine that all actions are determined by the current state and immutable laws of the universe, with no possibility of choice.
- free association: A technique used in psychoanalysis in which patients are invited to relate whatever comes into their minds during the analytic session and to not censor their thoughts.
- operant conditioning: A technique of behavior modification, developed by B. F. Skinner, that utilizes positive and negative reinforcement and positive and negative punishment to alter behavior.
"Psychotherapy" is an umbrella term that describes the use of psychological methods, particularly when based on regular personal interaction, to help a person change and overcome problems in desired ways. Other terms that can be used more or less interchangeably with the term "psychotherapy" include "counseling" and "therapy." Psychotherapy is defined by the interaction or treatment between a trained professional and a client, patient, family, couple, or group. The problems addressed are psychological in nature and can vary in terms of causes, influences, triggers, and resolutions.
History of Psychotherapy
It can be said that psychotherapy has been practiced through the ages, as medics, philosophers, spiritual practitioners, and others used psychological methods to heal people. In the Western tradition, by the 19th century a mental-treatment movement (then referred to as "moral treatment") developed based on certain therapeutic methods. 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.
In the late 1800s, Sigmund Freud (now known as the father of psychotherapy) developed psychoanalysis, an early Western form of psychotherapy. Psychoanalysis is based on overcoming the desires and negative influences of the unconscious mind. It encourages patients to use free association as a way to come to insights about unresolved issues from the past that are resulting in emotional or behavioral problems in the present.
Trained as a neurologist, Freud began focusing on problems that appeared to have no discernible organic basis; he theorized that they had psychological causes originating in childhood experiences and the unconscious mind. Techniques such as dream interpretation, free association, transference, and analysis of the unconscious mind were developed. Many theorists, including Anna Freud, Carl Jung, and Erik Erikson, built upon Freud's fundamental ideas and developed their own systems of psychotherapy. These were all later categorized as psychodynamic
, meaning any approach that focused on the psyche's conscious and unconscious influences on the self and external relationships.
Behaviorism and behavioral therapy developed in the 1920s, relying on principles of operant conditioning, classical conditioning, and social-learning theory to bring about therapeutic change in observable symptoms. The approach became commonly used to treat phobias, as well as other disorders.
Goals of Psychotherapy
The purpose of psychotherapy is to explore thoughts, feelings, and behaviors with the goal of problem-solving or achieving higher levels of functioning. Psychotherapy aims to increase the individual's sense of their own well-being. Psychotherapists employ a range of techniques based on experiential relationship-building, dialogue, communication, and behavior change that are designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family). During psychotherapy, an individual will often talk with a trained professional about how they feel, think, and react to challenges in life, with the ultimate goal of resolving or reducing negative symptoms of an emotional or mental health problem.
Types of Psychotherapy
Many forms of psychotherapy use spoken conversation; others use various other forms of communication such as the written word, artwork, drama, storytelling, or music. Psychotherapy occurs within a structured encounter between a trained therapist and a client. Depending on the individual and the types of symptoms they are experiencing, a particular method of psychotherapy may be employed. For instance, psychotherapy with children and their parents often involves play, role-play, and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting. Common types of psychotherapy include the following.
The primary focus is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. Although its roots are in psychoanalysis, psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis.
This form is explicitly concerned with the human context of the development of the individual with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. It posits an inherent human capacity to maximize potential.
These methods focus exclusively on behaviors, or on behaviors in combination with thoughts and feelings that might be causing them. Those who practice behavioral therapy tend to look more at specific, learned behaviors and how the environment has an impact on those behaviors. Two primary types include operant conditioning and classical conditioning.
Cognitive and Cognitive Behavioral Therapy (CBT)
Cognitive therapy seeks to identify maladaptive cognitions (thoughts), appraisals, beliefs, and reactions, with the aim of influencing destructive negative emotions. CBT combines cognitive therapy and behavioral therapy to address maladaptive cognitions as well as dysfunctional behaviors.
In this type of therapy, one or more therapists treat a small group of clients together as a group.
Recently, many practitioners have begun to take what's known as an eclectic approach, meaning they combine aspects of multiple types 0f therapies. This approach can be useful in that is uses the techniques and theories that work best in a specific patient's scenario, rather than sticking solely to the methods of one discipline.
Other Approaches to Therapy
There are a number of other approaches to psychotherapy as well. For instance, eye-movement desensitization and reprocessing (EMDR)
alleviates symptoms for individuals who have experienced severe trauma. Body-centered therapies
focus on the links between the mind and the body in order to access greater awareness of the physical body and the emotions.
Medical vs. Humanistic Model
A distinction can 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 the client regain health. The extensive use of the DSM-5 (the Diagnostic and Statistical Manual of Mental Disorders) in the United States comes out of the medical model. The humanistic
or non-medical model,
in contrast, strives to depathologize 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.
Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions. One line of research consistently finds that different forms of psychotherapy show similar effectiveness. Further analyses seek to identify the factors that various psychotherapies have in common that seem to account for this; for example, the quality of the therapeutic relationship, the interpretation of the problem, and the confrontation of painful emotions. However, specific therapies have been tested for use with specific disorders, and regulatory organizations in both the UK and the 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 after five years, long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies.
Some are skeptical of the healing power of a psychotherapeutic relationship. Some dismiss psychotherapy altogether in favor of 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 people clients are in relationships with—critics point out that people have, after all, been weathering crises long before psychotherapy was introduced.
Introduction to Biomedical Therapies
Biomedical therapies involve the use of medication and/or medical procedures to treat psychological disorders.
Evaluate the efficacy of various types of biomedical therapies
- Biological therapies approach psychological disorders as having biological causes and focus on eliminating or alleviating symptoms of psychological disorders. The mind and body are viewed as connected: poor physical health leads to poor mental health, and vice versa.
- Biomedical therapies and psychotherapy are often used in conjunction with one another to treat the whole person. For many, biomedical approaches can help enhance the effectiveness of psychotherapeutic approaches.
- "Pharmacotherapy" refers to the use of medications in biomedical treatment. Medications exist in four classes: antipsychotics, antidepressants, anti-cycling agents, and hypnoanxiolytics.
- Electroconvulsive therapy (ECT) involves using an electrical current to induce seizures in the brain in order to help alleviate the effects of certain severe mental disorders.
- Psychosurgery is a type of neurosurgery in which a small piece of brain is destroyed or removed. Today it is rarely used, and only for particular mental illnesses.
- Two ways in which biological therapies are studied are through efficacy research and effectiveness studies.
- placebo: A simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient.
- efficacy: Ability to produce a desired amount of a desired effect.
- schizophrenia: A psychiatric diagnosis denoting a persistent, often chronic, mental illness affecting behavior, thinking, and emotion.
Two types of therapy are psychotherapy and biomedical therapy. Both types of treatment help people with psychological disorders such as depression, anxiety, and schizophrenia. Psychotherapy
is a psychological treatment that employs various methods to help someone overcome personal problems, or to attain personal growth. Biomedical therapy
involves medication and/or medical procedures to treat psychological disorders.
Biomedical therapies approach psychological disorders as having biological causes and focus on eliminating or alleviating symptoms of psychological disorders. The mind and body are viewed as connected; poor physical health leads to poor mental health, and vice versa.
Biomedical therapies and psychotherapy are often used in conjunction with one another to treat the whole person. Not all individuals will require biomedical therapy; however, for some, biomedical approaches can help enhance the effectiveness of psychotherapeutic approaches. For example, an individual with schizophrenia who is bombarded with visual or auditory hallucinations may find it difficult to focus in psychotherapy; with medication, the individual's hallucinations can be eliminated or reduced to a level that allows the individual to benefit from psychotherapy.
Types of Biomedical Therapies
"Pharmacotherapy" refers to the use of medications in biomedical treatment. Medications exist in four classes: antipsychotics, antidepressants, anti-cycling agents, and hypnoanxiolytics. In general, the effectiveness of medications is upwards of 80%, but some of the medications also contain serious side effects. Once the medication is discontinued, symptoms often return; however, prolonged use can lead to other problems.
Different types and classes of medications are prescribed for different disorders. A depressed person might be given an antidepressant, a bipolar individual might be given a mood stabilizer, and a schizophrenic individual might be given an antipsychotic. These medications treat the symptoms of a psychological disorder; they can help people feel better so that they can function on a daily basis, but they do not cure the disorder. Some people may only need to take a psychotropic medication for a short period of time. Others, with severe disorders like bipolar disorder or schizophrenia, may need to take psychotropic medication continuously for effective symptom management.
Antidepressants: Biomedical therapies, such as the use of the antidepressant Zoloft, can be effective in reducing the symptoms of individuals with certain mental illnesses so that psychotherapeutic interventions can be more effective.
Another biologically based treatment that continues to be used, although infrequently, is electroconvulsive therapy (ECT; formerly known by the unscientific name "electroshock therapy"). It involves using an electrical current to induce seizures in the brain in order to help alleviate the effects of certain mental conditions, such as severe forms of depression or bipolar disorder. The exact mechanism is unknown, although it does help alleviate symptoms for people with severe depression who have not responded to traditional drug therapy (Pagnin, de Queiroz, Pini, & Cassano, 2004). About 85% of people treated with ECT improve (Reti, n.d.). However, the memory loss associated with repeated administrations has led to it typically being implemented as a last resort (Donahue, 2000; Prudic, Peyser, & Sackeim, 2000). A more recent alternative to ECT is transcranial magnetic stimulation
(TMS), a procedure approved by the FDA in 2008 that uses magnetic fields to stimulate nerve cells in the brain to improve depression symptoms; like ECT, it is used when other treatments have not worked (Mayo Clinic, 2012).
Psychosurgery, also called neurosurgery for mental disorder (NMD), is the neurosurgical treatment of mental illness. Psychosurgery has always been a controversial medical field. Some countries have abandoned psychosurgery altogether; in others (the US and the UK, for example) it is only used in a few centers on small numbers of people with depression or obsessive-compulsive disorder (OCD). In some countries it is also used in the treatment of schizophrenia and other disorders.
Psychosurgery is a collaboration between psychiatrists and neurosurgeons. During the operation, which is carried out under a general anesthetic, a small piece of brain is destroyed or removed. The most common types of psychosurgery in current or recent use are capsulotomy, cingulotomy, subcaudate tractotomy, and limbic leucotomy. About a third of patients show significant improvement in their symptoms after the operation. Advances in surgical technique have greatly reduced the incidence of death and serious damage from psychosurgery; the remaining risks include seizures, incontinence, decreased drive and initiative, weight gain, and cognitive and affective problems.
Two ways in which biological therapies are studied are through efficacy research
and effectiveness studies.
Placebo -controlled randomized clinical trials, using strict exclusionary criteria when selecting subjects, have traditionally been used to study a psychiatric medication's efficacy (i.e., the ability of the medication to treat the condition better than placebo under controlled conditions). For example, studies comparing an antidepressant to a placebo may use an eight-week double-blind parallel design and include subjects with major depression, but without any other medical or psychiatric comorbidities.
Effectiveness studies, on the other hand, are often larger, naturalistic studies that attempt to approximate "real-world" conditions by studying patients who may have psychiatric and medical comorbidities and by relying on broader outcome measures for assessing response. These studies may compare outcomes of treatment with multiple medications. Effectiveness studies are complementary to understanding drug efficacy.
Influences of Culture and Gender in Psychotherapy
Cultural and gender norms significantly shape how mental illness as well as therapy and various other treatment methods are perceived.
Analyze how culture and gender can influence the therapy process
- Those who favor multicultural therapy models focus on cultural specificity—that therapy should be adapted to various cultures due to differing cultural norms, expectations, and identities.
- Those who argue for culturally specific therapy point to differing standards across cultures for what is deemed normal and what is psychopathological. In some cultures, for example, hallucinations are not seen as a mental illness.
- The majority of standards for what is normal or pathological are determined by European-American psychology—universal models are based on these standards. Advocates of cultural specificity argue that this reflects a power imbalance which denies individuals culturally appropriate care.
- Various cultural groups communicate in different ways. A number of research studies have also found gender to be an important factor in how an individual communicates.
- The way men and women are socialized in Western countries determines how they will express themselves, how they will experience and express their emotions, and what is considered normal or abnormal.
- pathological: Relating to, amounting to, causing, or caused by a physical or mental disorder.
- multicultural: Relating or pertaining to several different cultures.
A number of psychologists argue for integrating cultural and gender sensitivity into the therapy process because of the significant influence that such factors can have on therapy. Those who favor multicultural therapy models
focus on cultural specificity—that therapy should be adapted to specific cultures due to differing cultural norms, expectations, and identities. Proponents of multicultural models contend that psychological processes are not universal, but culturally specific.
Those who believe in culturally specific treatment
point to differing standards across cultures for what is deemed normal and what is deemed abnormal, or psychopathological. In some cultures, for example, hallucinations are considered a form of spiritual communication; those who experience hallucinations are respected or even revered, rather than labeled "crazy."
Those who support cultural specificity also point to the problem of power in defining what is normal or pathological. The majority of "universal" standards for what is deemed normal or pathological are determined by European-American psychology. These standards hold a great deal of power, yet are very biased, since they come almost entirely from a European-American perspective. Advocates of cultural specificity argue that this reflects a power imbalance which denies many individuals culturally appropriate care.
Cultural Influences on Therapy
Culture and gender can influence the therapy process in a number of ways. For example, different cultural groups communicate in different ways. African-Americans have been found to use significantly more non-verbal communication and non-verbal cues. If a Caucasian therapist is trying to encourage a client to communicate verbally in a session, the therapist may misunderstand the non-verbal communication cues given off by a client of another race. Culture will also influence factors such as how trust is built in the therapeutic relationship, how help-seeking behavior manifests (or doesn't manifest, or how quickly), how therapy is viewed (for instance, if being in therapy is considered stigmatizing or shameful), how emotions are expressed, what is considered appropriate to discuss or express, and many other factors.
The Sociocultural Model and Multicultural Therapies
The sociocultural perspective looks at you, your behaviors, and your symptoms in the context of your culture and background. As our society becomes increasingly multiethnic and multiracial, mental health professionals must develop cultural competence, which means they must understand and address issues of race, culture, and ethnicity. They must also develop strategies to effectively address the needs of various populations for which Eurocentric therapies (therapies with a strong European or Western bias) have limited application. For example, a counselor whose treatment focuses on individual decision-making may be ineffective at helping a Chinese client with a collectivist approach (or more group-based approach) to problem-solving (Sue, 2004).
This sociocultural perspective integrates the impact of cultural and social norms, starting at the beginning of treatment. Therapists who use multicultural therapy work with clients to obtain and integrate information about their cultural patterns into a unique treatment approach based on their particular situation. This approach also examines how certain ethnicities in the United States are less likely to access mental health services than their White middle-class American counterparts. Barriers to treatment include lack of insurance, transportation, and time; cultural views that mental illness is a stigma; fears about treatment; and language barriers.
Gender and Therapy
A number of research studies have also found gender to be an important factor in how an individual communicates. The ways in which men and women are socialized in Western countries determines how they will express themselves, how they will experience and express their emotions, and what is considered normal or abnormal. For instance, aggression in men is somewhat normalized in the United States, but it is generally considered problematic or a sign of "imbalance" in women. At the same time, people raised as female are encouraged to talk about feelings (such as sadness, love, hurt, fear) much more than males are; those raised as male are often taught to repress these feelings or keep them hidden. Symptoms of depression will often manifest very differently between men and women due to how each gender is socially taught to channel their emotions (for instance, depression in men will often manifest as increased irritability or anger). If a therapist fails to take into account the differing ways in which males and females are socialized, and how this manifests psychologically, they might misunderstand and misdiagnose what a client is encountering.
Depression and gender: This statue by Antun Augustincic depicts a woman who is depressed. Due to gender socialization, men and women may express depression differently, which is an important consideration when planning a course of therapy.
Research Methods for Evaluating Treatment Efficacy
Several research methods can be used to evaluate which therapeutic approaches are the most beneficial under which circumstances.
Describe the research methods and criteria that are used to determine the effectiveness of therapy
- Researchers who assess therapy are interested in areas such as whether or not counseling is effective, under what conditions it is effective, and what outcomes are considered effective—such as symptom reduction, behavior change, or quality-of-life improvement.
- Topics commonly explored in the study of the counseling process and outcome include therapist variables, client variables, the counseling or therapeutic relationship, cultural variables, process and outcome measurement, mechanisms of change, and process and outcome research methods.
- When assessing the effectiveness of therapy, researchers often rely on mixed methods, or both quantitative and qualitative designs. Each type of data provides different forms of information, together providing a fuller evaluation of the therapy.
- Quantitative methods include randomly controlled clinical trials, correlational studies over the course of counseling, or the use of inventories to track a client's progress throughout the course of treatment.
- Qualitative methods may involve conducting, transcribing, and coding interviews or therapy sessions; analysis of single counseling sessions or counseling cases; or reported observations made by the therapist.
- A randomized controlled trial (RCT) is a type of scientific experiment that is often used to test the efficacy or effectiveness of various types of medical intervention.
- Meta-analyses can be thought of as "conducting research about previous research" in order to gain a better understanding of the effectiveness of different therapeutic approaches.
- quantitative: Of a measurement based on a number or numerical value, rather than on a quality.
- qualitative: Of a measurement, description, or distinction based on a characteristic, rather than on a quantity.
- attachment style: Based on Bowlby's attachment theory, which describes the dynamics of long-term relationships between humans; there are four main styles of attachment—secure, anxious-preoccupied, anxious-avoidant, and fearful-avoidant.
- subjective: Formed, as in opinions, based on a person's feelings or intuition, not on observation or reasoning; coming more from within the observer than from observations of the external environment.
- meta-analysis: Any systematic procedure for statistically combining the results of many different studies.
The Importance of Evaluation
Assessing the effectiveness of therapeutic interventions is important for determining which therapies are the most beneficial, and for which types of disorders and/or individuals. Researchers who assess therapy are interested in areas such as whether or not counseling is effective, under what conditions it is effective, and what outcomes are considered effective—such as symptom reduction, behavior change, or quality-of-life improvement.
Variables That Influence Treatment
Topics commonly explored in studies of counseling processes and outcomes include therapist variables, client variables, the counseling or therapeutic relationship, cultural variables, process and outcome measurement, mechanisms of change,
and process and outcome research methods.
Therapist variables include the characteristics of the therapist, the techniques of the therapist, therapist behavior, theoretical orientation, and training. The characteristics of the therapist can include the therapist's gender, race, sexual orientation, culture, biases, personality, etc. The techniques of the therapist include the ways in which the therapist approaches the therapy sessions.
Client characteristics, such as help-seeking attitudes and attachment style, have been found to be related to seeking out counseling, expectations of counseling, and outcomes. Educating clients about expectations of counseling can improve client satisfaction and outcomes.
The Therapeutic Relationship
The therapeutic relationship is defined as the feelings and attitudes that a client and therapist have toward one another and the manner in which those feelings and attitudes are expressed. The amount of trust or distrust
that a client has toward the therapist can have an impact on the outcome of therapy. The therapeutic relationship has been found to predict treatment adherence and outcomes across a range of client diagnoses and treatment settings. A positive relationship between the therapist and the client based on trust and confidence often leads to a good working alliance, in which the therapist and client can agree on tasks and goals for therapy.
Approaches to Measuring Therapeutic Outcomes
When assessing the effectiveness of therapy, researchers often rely on mixed-method designs, which means using both quantitative and qualitative designs. Unfortunately, a number of theoretical models used in therapy, such as interviews and observations, lack quantitative data to support their effectiveness and rely solely on qualitative data. Ideally, therapies should use mixed methods to provide both quantitative and qualitative data. Each type of data provides different forms of information, together providing a fuller evaluation of the therapy.
Quantitative vs. Qualitative Methods
Quantitative methods include randomly controlled clinical trials, correlational studies over the course of counseling, and laboratory studies about specific counseling processes and outcome variables. One way of gathering quantitative data is through the use of inventories. For example, the Outcome Questionnaire-45
is a 45-item self-report measure of psychological distress; the Beck Depression Inventory
specifically measures depression; and the Quality of Life Inventory
is a 17-item self-report measure of life satisfaction. These types of inventories can be given at the beginning of treatment when a client enters therapy and then again at some point near the end. The differences in scores can then be examined to determine if the quality of life has improved, if the distressing symptoms have decreased, and other factors that indicate the effectiveness of the therapeutic approach.
Qualitative methods may involve conducting, transcribing, and coding interviews; transcribing and/or coding therapy sessions; analyzing single counseling sessions or counseling cases; or using observations made and reported by the therapist. Qualitative data can provide subjective information that cannot be measured or effectively captured by quantitative methods. Many psychotherapists believe that the nuances of psychotherapy cannot be captured by quantitative, questionnaire-style observation, and prefer to rely on their own qualitative clinical experiences and conceptual arguments to support the type of treatment they practice.
Randomized Controlled Trial
Flowchart of a randomized controlled trial : In a randomized controlled trial, people are randomly assigned to different groups that are receiving different treatment or no treatment at all, in order to study the effects of various treatment interventions.
A randomized controlled trial (RCT) is a type of scientific (often medical) experiment, where the people being studied are randomly allocated to one or another of the different treatments under study. Often, people will be randomly allocated to an "intervention" group (for example, those that receive the medication being studied) and a "non-intervention" group (those that do not receive the medication, or receive a placebo instead). The RCT is often considered the gold standard for a clinical trial. RCTs are often used to test the efficacy or effectiveness of various types of medical intervention and may provide information about adverse effects, such as drug reactions. Random assignment of intervention is done after subjects have been assessed for eligibility and recruited, but before the intervention to be studied begins.
A meta-analysis comprises statistical methods for contrasting and combining results from different treatment-focused studies in the hope of identifying patterns among study results, sources of disagreement among those results, or other interesting relationships that may come to light in the context of multiple studies. Meta-analysis can be thought of as "conducting research about previous research" in order to gain a better understanding of the effectiveness of different therapeutic approaches. Many meta-analyses have been used to explore the effectiveness of psychotherapy. For example, one large-scale study that examined 16 meta-analyses of cognitive behavioral therapy (CBT) reported that it was as effective as, or more effective than, other therapies in treating post-traumatic stress disorder (PTSD), generalized anxiety disorder, depression, and social phobia (Butlera, Chapmanb, Formanc, & Becka, 2006). Another meta-analysis found that psychodynamic therapy was also as effective at treating these types of psychological issues as CBT (Shedler, 2010).
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