Psychotherapy

The term psychotherapy refers to the use of psychological (as opposed to physical) treatments to improve physical and mental health by relieving symptoms, helping patients manage or adjust to stressors, decreasing distress, and enhancing well-being. To some practitioners psychotherapy is a science; to others it is more of an art form. An abiding belief in the value of talking about one’s concerns is a key premise shared by the thousands of psychotherapies and nearly as many theoretical perspectives.

Psychotherapy is typically conducted on a one-to-one basis, with an individual. Treatments for couples, families, and groups are also available. Psychotherapy is practiced throughout the world, with different types gaining popularity in different parts of the world.

Historical Overview of Psychotherapy

In Western cultures, at least four prominent schools of individual psychotherapy can be identified: psychoanalytic, behavioral, cognitive, and humanistic/existential. Psychoanalysis is the original “talking cure.” Joseph Breuer and Sigmund Freud developed it in 19th-century Vienna when they discovered that uncovering and talking about repressed intrapsychic conflict led to the removal of symptoms in hysterical patients. Psychoanalysis posits that human behavior is in part driven by unconscious wishes and conflicts often originating in early childhood, and that the work of therapy is to uncover and analyze patients’ intrapsychic conflicts. Freud refined the techniques of classical psychoanalysis in the early 20th century, and charismatic leaders such as Harry Stack Sullivan, Otto Kernberg, and Heinz Kohut subsequently developed numerous forms of psychodynamically oriented treatments. Because many of these leaders shared Freud’s disdain for empirical scrutiny, psychodynamically oriented clinicians were unprepared to respond to the demand for greater economic and scientific accountability in the 1980s.

The same was not true of behavior therapy. Derived from scientific research by I. Pavlov and B. F. Skinner on conditioning and how people learn, behavior therapy was developed and disseminated in the middle of the 20th century, most notably by Joseph Wolpe. Unlike their psychodynamically oriented colleagues, behavior therapists were interested in demonstrating scientifically the effectiveness of the treatment. Behavior therapists explain pathological behaviors as consequences of maladaptive learning and reinforcement systems, rather than unconscious dynamic conflicts. In psychotherapy, behaviorists work with patients to identify new behaviors to replace problematic ones, and to substitute new reinforcement systems that will maintain the new behaviors. So, for example, a behavior therapist might determine that a child who resisted going to school was having this behavior reinforced by parents giving the child more attention. Treatment would involve restructuring the reinforcement system to have parents give greater attention and other rewards to the child when he or she attends school.

Due largely to the pioneering work of Aaron Beck, cognitive therapy rose to prominence in the 1960s and preeminence in the mid-1970s. By the early 1980s cognitive-behavioral therapies, integrating behavioral and cognitive approaches, became influential. Solid empirical research documenting their effectiveness is perhaps the main reason why the number of clinical psychologists whose primary theoretical orientation is psychodynamic fell from 35% in i960 to half that in 1995. Cognitive and cognitive-behavioral therapies are concerned with the impact of patients’ thoughts and beliefs on their moods and behaviors. Cognitivists identify the automatic, negative thoughts and beliefs that patients have about themselves and others, and work to restructure thinking patterns in more appropriate and adaptive ways. A cognitive-behavioral therapist could, for example, assist a male patient who was depressed after not receiving a job promotion by identifying the negative thought patterns underlying the depression (“If I’m not promoted, I’m no good; I’ll never succeed at work”) with more adaptive ones (“I am a worthwhile person whether or not I have a job promotion; just because I wasn’t promoted doesn’t mean I’ll never have job success again”).

Carl Rogers and Victor Frankl, among others, propounded humanistic and existential therapies. In contrast to the relatively more disorder-focused approaches of psychoanalysis and behaviorism, proponents of humanistic and existential approaches strive to understand the whole person and to assist patients’ in their search for personal meaning, identity, or self-actualization. Therapists do not view themselves as authority figures; instead, the relationship with the client (not patient) is meant to be more egalitarian.

Conceptual Overview of Psychotherapy

Given the plethora of psychotherapies and theoretical perspectives, it is useful to think about psychotherapists as varying along three related dimensions: their conceptualization of the patient’s problem, psychological focus, and behavior in the session.

Perhaps the most salient conceptual dimension that distinguishes therapists is the extent to which they view the patient’s current presenting problem as emanating from earlier (often childhood) experiences. Another distinction concerns how literally the presenting symptom is conceptualized. Psychodynamic therapists may view a symptom such as anxiety as a symbolic expression of repressed emotional conflict, and they will attempt to uncover and help the patient work through the conflict. Cognitive therapists will conceptualize anxiety as fueled by maladaptive thinking, and they will help patients think about themselves as effective and powerful in a relatively benign world.

With respect to psychological focus, therapists differ in the relative emphasis placed on the patient’s thoughts, use of language, emotions, interpersonal relationships, behaviors, motives, and goals. The name of the psychotherapy often is derived from the psychological focus. For example, cognitive therapists focus on thoughts, behavior therapists concentrate on behavior, cognitive-behavior therapists attend to the thoughts that accompany particular behaviors, and psychodynamic therapists analyze the driving (or dynamic) unconscious wishes and conflicts behind behaviors and emotions.

Turning to in-session behavior, we can say that therapists differ in their level of activity, warmth, and attention to how they are perceived or treated by their patients. Active therapists dispense advice, reveal much of themselves, prescribe behavioral regimens, or assign homework, such as asking patients to maintain diaries or journals. Passive therapists say very little, never talk about themselves, and do not assign homework. That does not mean that they are less intellectually or emotionally engaged in the treatment.

Another in-session dimension concerns the therapist’s level of warmth or empathy. At one end of this spectrum, some therapists exude warmth and approach the patients with unconditional positive regard. At the other end, therapists could be confrontational or critical in an effort to help patients take a closer look at themselves. That does not mean that they like the patient less than therapists who display unconditional positive regard.

A third dimension concerns the extent to which the relationship between therapist and patient is analyzed or even discussed. Psychodynamic therapists pay very close attention to their patients’ emotional responses to them because those responses are thought to derive from deep-seated and often unconscious feelings about early caregivers in patients’ lives.

Other therapies do not make the therapeutic relationship a central concern.

Pragmatic Considerations in Psychotherapy

Therapies need to be tailored to the age, educational level, and cognitive status of the patient. Many psychotherapies require reasonably intact, adult-level cognition and are therefore not appropriate for children or for patients with cognitive impairment. The patient’s socioeconomic circumstance, notably his or her insurance coverage, is another important pragmatic consideration. In response to increasing economic constraints and calls for scientific accountability, there has been movement toward scientific study of briefer treatments (defined in terms of weeks or months) as opposed to longer-term therapies. Structured, or manualized, brief treatments for disorders such as acute depression and panic disorder have proven successful. However, as evidence mounts that therapy’s beneficial effects are often not sustained, longer-term maintenance therapies are now being used to maintain good mental health outcomes.

Who Practices Psychotherapy and Where?

Psychotherapy is practiced by individuals trained in a number of professional disciplines, including psychology, psychiatry, family medicine, nursing, education, social work, and theology. It is practiced in diverse settings, including schools and universities, places of worship, the workplace, primary care clinics, community mental health centers, psychiatric inpatient units of hospitals, and private offices.

Psychotherapy in the Context of Medical Treatment

Practitioners in virtually every medical specialty are potentially positioned to make referrals for psychotherapy. Primary care physicians often see patients with depression, anxiety, or multiple unexplained physical symptoms. Many will make a referral to a mental health professional only after conducting a course of psychotherapy themselves. Panic disorder patients will often present to a primary care physician or cardiologist before seeking help from a mental health professional. Surgeons may refer patients with posttraumatic stress disorder following a motor vehicle accident or other accidental injury. Many skin conditions, such as eczema or dermatitis, are stress responsive and may abate in response to stress-reducing treatments. Depression is not uncommon following myocardial infarction, coronary artery bypass graft surgery, or the diagnosis and treatment of many forms of cancer. These patients (and their spouses) may often benefit from psychotherapy. The advent of genetic testing may have solved a number of problems, but it has created others, some of which may be amenable to psychotherapy.

Effective Psychotherapy Treatments

As noted by Peter Nathan and Jack Gorman, research has identified a number of effective therapies for particular symptoms or disorders For example, cognitive-behavioral interventions can be used effectively in the treatment of ritualistic behaviors and thoughts associated with obsessive-compulsive disorder. Cognitive-behavioral interventions are also effective at improving body image in patients with body dysmorphic disorder, and decreasing the frequency of binge and purge behavior in patients with bulimia nervosa. Behavior therapies have proven effectiveness in treating several disorders commonly seen in medical settings, especially panic disorder with agoraphobia and sleep disorders. Cognitive-behavior therapy, psychodynamic therapy and interpersonal therapy have all been shown to be effective in treating some forms of depression.

Most of the rigorous studies and subsequent meta-analyses on treatments for mental disorders have been conducted on patients seen in the context of mental health care delivery settings, not medical settings. Research on the effectiveness of psychotherapeutic treatments for medical patients seen in medical settings will help advance the science and art of psychotherapy.