| HISTORY
The
origins of psychotherapy as we know it today can unquestionably be traced to
the work of Sigmund Freud, who practiced psychoanalysis in Vienna from the
1880s to the 1930s. He introduced the idea of the unconscious mind, and tried
to uncover buried motives for the disturbed thoughts, feelings, and actions of
his patients by allowing them to talk freely.
In
around 1914, a pupil of Freud, Carl Jung, broke away from his mentor to develop
his own brand of analytic psychotherapy, based on the idea of a human drive
toward an inner world of wholeness.
Another
influential psychoanalyst was Melanie Klein. Between World Wars I
and
II, she carried out research into infant behavior, believing that young
children's relationships with the outside world are at least as formative as
their struggles to come to terms with their own bodies. Klein's theories about
how children learn to think influenced many psychoanalysts.
During
the first half of the 20th century, "behavioral" psychologists, such
as John Watson and Burrhus Frederic Skinner, criticized the psychoanalysts'
emphasis on the unconscious. They claimed that such unconscious states of mind,
which could
not
be measured, were irrelevant, while hunger and other biological triggers
"conditioned" predictable behavior that could be unlearned or
corrected by therapy.
In
reaction to the behaviorists' theories of negative "conditioning" and
the clinical nature of Freudian psychoanalysis, psychologists Abraham Maslow,
Carl Rogers, Fritz Perls, and others developed a "humanistic"
approach to therapy, focusing on the positive, rather than the dysfunctional,
aspects of behavior. By the 1960s, techniques such as encounter groups were
being used to encourage "personal growth" and help people realize
their "human potential."
While
psychoanalysis remained popular in central Europe and on the East Coast of the
US, the "personal growth movement" burgeoned on the West Coast, and
the work of therapists such as Virginia Satir and Milton Erickson proved to be
a major influence on developing techniques for brief psychotherapy. By the
1970s, psychotherapy and its sister therapy, counseling, were becoming established
outside the US. Today many doctors refer patients to various types of
psychotherapists and counselors, or even employ them in their practices.
KEY PRINCIPLES
For
many people, the existence of the "unconscious" remains
controversial. Analytic and psychodynamic therapies are based on the theory
that memories and feelings become "repressed," or forgotten, and
therefore disturb the mind and body. These approaches usually involve
encouraging clients to talk about their experiences and vent emotions that have
been repressed, while congnitive and behavioral therapies do not deal with the
unconscious at all. The client usually initiates the dialogue and decides what
is talked about.
Trained
practitioners should be able to identify the importance not only of what
clients say, but what they do not say, and suggest links between present
behavior and past events. Most practitioners will have undergone therapy as
part of their training, and even when qualified they should receive regular
supervision from another practitioner. While the distinctions between
practitioners may be blurred (particularly in the case of psychotherapists and
counselors), they can usually be categorized as one of the following:
Psychoanalysts: Practitioners train
for 5-7 years at a recognized institution, following the teachings of Sigmund
Freud, Carl Jung, or Melanie Klein. Some may also have a medical degree.
Psychologists: After taking a
science-based university degree, studying the mind and behavior, practitioners
choose a branch of psychology in which to specialize. Personal therapy is not always
part of their training.
Psychotherapists: Practitioners usually
train for four years with a recognized organization, but do not necessarily
have a degree. They may specialize in a variety of techniques (see below).
Counselors: While some counselors
may receive only a few weeks training, the better ones have 2-3 years training
and work under supervision.
Both
psychotherapists and counselors may use a variety of approaches, including
psychodynamic as well as humanistic.
EVIDENCE & RESEARCH
Psychological
therapies are difficult to research. Not only are the methods diverse but they
rely on theories about the human condition that are impossible to prove
scientifically. Often it is the skill of the practitioner, rather than the type
of therapy, that determines a successful outcome. Behavioral and cognitive
therapies have been widely evaluated - for example, studies published in the Journal
of Consulting and Clinical Psychology in the 1990s - have been shown to be
effective for anxiety, phobias, mild to moderate depression, relationship
problems, and sexual dysfunctions.
In
1994, the British Journal of Psychiatry published research suggesting
that cognitive therapy was more effective for panic attacks than either
conventional medication or relaxation techniques. When the results of such
studies are compared, clients are generally found to have benefited from
treatment in the long term, although no technique seems more effective than
another. Less research evidence is available for longer-term psychoanalytic
therapies, but some studies indicate that there is little change even after the
third year of treatment.
MEDICAL OPINION
Doctors
do not doubt the value of good listening skills and communication, particularly
where there has been loss or trauma. Giving patients the emotional help they
need can be distressing for practitioners and patients alike, and most doctors
stress the need for formal training. Many doctors use trained counselors in
their practices, and forms of brief psychotherapy are widely available. The
medical profession, however, is skeptical of more extreme theories and
therapies.
CONSULTING
A PRACTITIONER
There
are many reasons why you may consult a psychotherapist or counselor: a life
event may have triggered powerful emotions, or you may be distressed for
reasons that you do not comprehend. The inability to make a major decision may
be affecting your life, or you may have a history of relationship problems and
wish to understand why.
It
can be difficult to decide which type of therapy to choose, particularly as
many practitioners adapt a range of approaches. Try to be as clear as possible
about what you want to be doing differently at the end of treatment.
The
initial consultation is a chance to see if you feel comfortable with the type
of therapy and the practitioner. You will be asked to explain why you think you
need help, and the practitioner will decide whether she can help you. Some
practitioners offer the first consultation without charge, particularly if
therapy is likely to be long term. It is important to be able to talk freely to
your practitioner, so if you cannot do so on your first visit, do not hesitate
to find someone else. Always ask how long therapy is likely to last, and if
there will be regular progress reviews.
FORMS
OF THERAPY
Psychoanalysis,
psychodynamic therapies, and counseling rely on the verbal communication of
thoughts and emotions. Behavioral and cognitive therapies help to change
habitual actions or perceptions by offering positive ways of behaving and
thinking. The humanistic psychotherapies retain ideas from all of the above but
focus on a creative awareness of the present.
PSYCHOANALYSIS
The
essential premise of psychoanalysis is based on the work of Freud. The
unacceptable feelings of early childhood are said to be banished to the
unconscious mind, but to continue to influence thoughts, emotions, and
behavior. "Repressed" feelings may surface later in life as
conflictions, anguish, depression, or anxiety, or express themselves through
dreams and creative activities.
The
client-analyst relationship is taken as a reflection of previous significant
feelings and relationships which the analyst interprets and gradually helps
make acceptable to the client's conscious mind. You lie on a couch or sit in a chair and
talk about whatever comes to mind. Treatment is aimed at encouraging the
"transference" onto the analyst of feelings about figures in your
life, and then trying to identify these feelings. Patients undertaking psychoanalysis
are usually suffering high levels of distress, and treatment may be a lengthy
process, consisting of as many as three or five 50-minute sessions a week for
2-5 years.
JUNGIAN
ANALYTIC PSYCHOTHERAPY
Carl
Jung believed in a human drive toward "individuation," a spiritual
quest to get in touch with the "collective unconscious," the
myth-inspiring level of mind shared by the whole human race. He developed a
form of psychoanalysis in which clients examine past experiences in order to
confront deep-seated personal issues affecting their identity. Transference is
a crucial element, and the therapy may bring about profound changes. Jung
suggested that we have aspects of ourselves that we find unacceptable, and that
it is this "shadow," which is repressed, that has to be
"integrated" if we are to find our true self. One or two weekly
sessions are needed for at least six months, and a two-year course of treatment
is the norm.
PSYCHODYNAMIC
THERAPY
This
therapy works with the unconscious mind, exploring connections between past and
present life events and making use of transference, but emphasizing change and
development. If you have a history of broken relationships, for example, you
might examine possible formative childhood experiences. Knowing why difficulties
are occurring can free you to make changes. Treatment is traditionally
open-ended, but therapy for a core issue can be short-term work involving
15-40 sessions.
CHILD
THERAPY
For
severe problems, such as child abuse or autism, a child psychotherapist would
use a psychoanalytic approach to help the child make sense of relationship
experiences and learn from them. This is usually one-to-one, but includes
group and family work. For less severe problems, such as bedwetting, a child
counselor or play therapist may work with children singly or groups, often
using play - this can be the easiest way for children to express themselves.
GROUP
THERAPY
Group
work can include psychoanalytical, behavioral, and humanistic approaches. It is
helpful for people who find it difficult to relate to others, and is also used
to treat addiction. You meet in small groups over several months to share
experiences and feelings. A practitioner acts as a "facilitator" to
interpret group dynamics and help you express your feelings and insights.
FAMILY
THERAPY
Family
therapy explores the interactions between family members. Because the earliest
relationships we form are those within the family, the attitudes and habits
developed at this time can have a powerful influence on our patterns of
behavior later in life. In a dysfunctional family, one member sometimes becomes
disturbed or ill when they try to express something that they feel they cannot
mention to the others. When the whole family sits down together with a
practitioner, issues that affect each member, such as lack of communication,
can be discussed without targeting any one person. For this reason, the therapy
needs the cooperation of everyone in the family to be successful. Family
therapy has proved particularly helpful in treating young anorexics. The course
is often brief, perhaps between 10 and 20 sessions of 50 minutes' duration.
COUNSELING
Counseling
usually focuses on specific problems, such as bereavement or job loss, rather
than deep-seated personal issues. A counselor is supportive and skilled in
listening, and will prompt you to talk freely, but will probe less deeply into
personal problems than a psychotherapist, and offer little or no direct advice.
Instead, your thoughts and feelings are reflected back to you to increase your
self-awareness. The counselor also helps you to look at your situation from
different perspectives in order to gain fresh insights and find your own
solutions. If you are depressed or lack confidence, you may feel encouraged to
stand up for yourself, or you may learn to express difficult emotions, such as
anger, sadness, or fear.
Training
for counselors is usually shorter and less academic than for psychotherapists,
and a good counselor should know when to refer you for more expert treatment.
The boundary between counseling and psychotherapy can be difficult to define.
Some "psychodynamic counselors" may offer what others call
psychotherapy, while a psychotherapist in a private practice may be called a
counselor when working in a medical setting. Specialized counselors are often
available for marital and sexual problems and bereavement crises, and many
doctors now have counselors attached to their practice. A course of counseling
should take weeks or months rather than years.
MARRIAGE
COUNSELING
Dealing
with marital or relationship problems, this type of counseling aims not so much
to restore the relationship as to help couples understand the nature of their
difficulties, and decide what action can be taken in the future. You can see a
counselor individually, as a couple, or in a supportive group setting. As
counseling often explores deeper psychological problems, the counselor may
refer you to a psychotherapist or sexual counselor. Counselors work with all
couples, including unmarried or gay partners. Sessions are usually 50 minutes
weekly and may continue for several months.
SEXUAL
COUNSELING/ PSYCHOSEXUAL THERAPY
Known
by both names, this therapy is used specifically to help people with sexual
problems that may be causing relationship difficulties. The counselor helps
couples improve their verbal and physical communication, and advises on common
problems, such as impotence, difficulties in achieving an erection or becoming
aroused, and premature ejaculation. Other sex-related conditions that may
benefit from counseling and psychotherapy include vaginismus (muscle tension
preventing penetration) and painful intercourse, loss of libido, failure to
reach orgasm, dislike of sex, and fertility issues. You may seek advice singly
or as a couple. Weekly sessions of 50 minutes continue for weeks or months.
SOLUTION-FOCUSED
BRIEF THERAPY
This
counseling therapy promotes positive change rather than dwelling on past
problems. The counselor encourages you to focus positively on things that you
do well - to set yourself goals and work out how to achieve them. For example,
you may be asked the following: "If a miracle happened and all your
problems were resolved, what would be different about your life?"
Practitioners claim that clients can make worthwhile progress in as little as
three or four sessions.
BEHAVIORAL
THERAPY
At
the end of the 19th century, Russian scientist Ivan Pavlov discovered that
animals learn to associate certain situations with reward or punishment. This
led to the premise that behavior is learned in response to past experiences and
can be unlearned, or reconditioned, without analyzing the past for reasons why
the pattern had formed. You are taught to change certain unwanted habitual
actions or emotions through mental and physical exercises, including punishment
and reward strategies, employed to lever you out of destructive patterns of
behavior. The therapy works well with some stress related illnesses,
compulsive and obsessive behavior, irrational fears, phobias, and addictions.
For example, if you have a fear of flying you are taught relaxation methods,
offered information about aerodynamics, encouraged to visit an airport, and
then eventually accompanied on a flight.
COGNITIVE
THERAPY
Cognitive
therapy takes a positive view of the power of the mind to influence behavior.
It is based on the theory that previous experiences may adversely affect your
self-perception, and condition your attitudes, emotions, and ability to deal
with certain situations. By learning to identify, question, and change negative
or self-denigrating thoughts, it is possible to alter habitual responses and
behavior. If you are pessimistic or depressed, for example, you are encouraged
to view situations from different perspectives rather than always interpreting
everything in the same gloomy way. Weekly sessions of 50 minutes may continue
for several months.
COGNITIVE
ANALYTICAL THERAPY
Combining
cognitive therapy and psychotherapy, this approach encourages you to draw on
your own resources to acquire the skills to change destructive patterns of
behavior. Negative ways of thinking and behaving are explored with a psychotherapist.
Treatment is structured and directive, and takes place over 16 weekly sessions
of 50 minutes, involving diary keeping, progress charts, and diagrams that
explain the destructive emotional cycles in which you may be trapped. There is
a follow-up session three months later.
COGNITIVE
BEHAVIORAL THERAPY
Pioneered
by clinical psychologists in the 1960s, this approach combines cognitive and
behavioral techniques. For example, relaxation techniques may be taught
alongside ways to change your thoughts and expectations. It has proved
effective in treating stress-related ailments, phobias, obsessions, eating
disorders, and, in conjunction with drug treatment, major depression. Treatment
may involve as few as 10-15 weekly sessions of 50 minutes' duration, with
"homework" that may include practicing a certain skill or focusing on
something that arouses anxiety.
PERSONAL
CONSTRUCT THERAPY
Developed
by psychologist George Kelly in 1955, this approach helps you restructure
perceptions of yourself and so change your outlook. A questionnaire helps
analyze your view of the world, and techniques may include pretending for a
week to be a fictional character who views the world differently. Weekly
50-minute sessions may continue for several months.
THE
12-STEP PROGRAM
Originally
developed in the US in the 1930s to treat alcohol dependency, this cognitive
behavioral technique is now used for any addictive behavior, from recurring
problems when forming relationships to drug abuse. Within the support of a
group, the steps teach you new ways of behaving and thinking about yourself and
your life. The first step is to admit to the problem, while the final step
includes a pledge to help others in the same situation. Weekly sessions may
continue for years or for life.
BRIEF
THERAPY
Treatment
by this cognitive behavioral approach consists of three one-hour sessions with
one follow-up session three months later. In the first stage, the practitioner
helps you to establish the nature of the problem; over the next two sessions,
you look at strategies to resolve it. You are expected to act on these
strategies in the three months before the follow-up session. This therapy can
be effective in treating certain clearly defined problems linked to stress and
anxiety, such as panic attacks.
NEUROLINGUISTIC
PROGRAMMING (NLP)
Combining
cognitive behavioral techniques with ideas from humanistic psychotherapy and
hypnotherapy, NLP was developed in the 1970s by American psychotherapists John
Grinder and Richard Bandler. It works on the theory that life experiences, from
birth onward, program the way you see the world. A practitioner, who may be a
psychotherapist or counselor, helps you discover how you have learned to think
and feel so that you can take control of your actions. You are taught to
consciously change your patterns of speech and body language in order to
communicate better and bring about personal change. NLP even claims a "ten
minute phobia cure." The length and number of sessions vary, but are
usually brief compared to other approaches.
HUMANISTIC
PSYCHOTHERAPY
Embracing
many techniques that sprang from the "personal growth movement" of
the 1960s, humanistic psychotherapy owes much to American psychologist Abraham
Maslow. It invites people to explore their feelings and take responsibility for
their thoughts and actions. Emphasis is not on dysfunctional behavior or
neuroses, but on self-development and achieving one's highest potential
("high-level wellness"). Many humanistic therapies are based on a
"client-centered" or "nondirective" approach, which assumes
that people know best how to deal with their personal problems, and the
practitioner offers clients a nonjudgmental "space." Humanistic therapies
such as psychosynthesis can also be described as "holistic," since
patients use the "whole self' including their creative instincts to
explore and resolve personal issues.
GESTALT
THERAPY
Gestalt
therapy was developed in the 1960s by German psychoanalyst Fritz Perls. Its
name is from the German for "organized whole," reflecting Perls's
belief that the human response to experiences is a totality of thoughts,
feelings, and actions. You gain self-awareness by analyzing your behavior and body
language, and giving expression to any feelings you may be repressing.
Treatment consists of one-to-one or group sessions, and often includes acting
out scenarios and dream recall. Sessions are held weekly, and practitioners
claim that benefits can be felt after a few months' treatment.
TRANSPERSONAL
THERAPY
Like
Jungian therapy, this approach explores aspects of the mind that unite
humanity,
such as myth, spirituality, birth, and loss. It utilizes the human capacity to
develop "inner vision" and create stories and meaningful rituals that
enable people to "transcend" themselves and feel "in
touch." Sessions are one-to-one or in groups, and may be long term.
PSYCHOSYNTHESIS
Sometimes
called the "psychology of the soul," psychosynthesis was developed by
an Italian psychiatrist, Dr. Roberto Assagioli, early in the 20th century. It
aims to integrate, or "synthesize," the level of consciousness at
which thoughts and emotions are experienced with a higher, spiritual level of
consciousness. Through painting, movement, writing, and other techniques, you
learn to recognize and value different facets of your personality.
Psychosynthesis is helpful for people seeking a new, more spiritually oriented
vision of themselves. The work can be one-to-one or in groups and continue over
a long period.
TRANSACTIONAL
ANALYSIS
The
premise of transactional analysis - first outlined in the 1960s by Canadian
psychiatrist Eric Berne - is that everyone has a child, adult, and parent self
within them, and in each social interaction, one self predominates. By learning
to recognize these roles, you can choose which one to adopt and so change your
behavior. The therapy has given rise to the term "inner child," used
to describe unfulfilled needs neglected or frustrated during childhood.
One-to-one or group sessions of short- (six sessions) or long-term treatment
are used.
PSYCHODRAMA
This
therapy was devised in the 1920s by Jacob Moreno, an Austrian psychoanalyst.
You act out inner conflicts, rather than talking about them, giving vent to
feelings that are hard to express in everyday life. Therapy takes place in
groups, in which members take turns acting out their personal dramas on a
"therapeutic stage." The first scene usually focuses on present
issues, and subsequent scenes trace the problems of the "protagonist"
back to childhood experiences. Other group members play key characters in the
protagonist's life. The practitioner acts as "facilitator," guiding
the action and
helping
members share their feelings. Several psychodramas may be required to achieve
results and extreme emotions may be released in the process. Groups may meet
weekly or over a weekend.
PRIMAL
THERAPY
Based
on the theory that suppressed birth or infancy traumas can resurface as
neuroses, primal therapy grew out of the work of American psychologist Arthur
Janov in the 1960s. It aims to take you back to the "primal scene,"
where trauma can be reexperienced in a cathartic way, often resulting in what
is called the "primal scream." Therapy may last several years.
REBIRTHING
Emotional
or physical traumas during birth are said to create feelings of separation or
fear later in life. This therapy, developed in the 1970s, uses breathing
techniques to release tension and help you reexperience traumatic emotions.
Skilled counseling is important, and ten individual or group sessions may be
recommended.
PRECAUTIONS
•
When choosing a practitioner ask about training and qualifications, and whether
he or she belongs to a professional body (see page 318).
• It is essential to trust your practitioner.
Remember that you are paying for treatment and are entitled to stop therapy
whenever you wish.
• Avoid psychoanalysis, psychotherapy, or
counseling if you have any psychotic illness, such as schizophrenia or manic
depression.
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Compatibility
