Psychotherapy is a formal intervention that relies on a formally trained professional therapist to utilize techniques that have their foundation in psychological principles in order to assist a person or group of people in dealing with certain problems or reaching certain goals, according to the American Psychological Association, the foremost organization of professional psychologists in the United States. This is a rather broad-based and overly simplified definition of what psychotherapy does and leaves quite a bit of leeway for the actual types of interventions used in psychotherapy; however, there are some restrictions that apply to the delivery of psychotherapy. Based on this formal definition of psychotherapy, there are several points that need to be made:
- Formally trained professional therapist: This specification indicates that psychotherapy is performed by someone with specialized training. In most states, the specialized training consists of postgraduate work in an area of psychology, counseling, social work, or related field in order to obtain licensure. The prospective therapist then must pass some formal evaluation, such as a licensing evaluation, in order to be deemed capable of performing psychotherapy.
- Techniques that have their foundation in psychological principles: This indicates that the techniques used in the delivery of therapy have some sort of basis that comes from the field of psychology. Typically, accepted types of therapeutic techniques need to be empirically validated (subjected to controlled research studies in order to verify their effectiveness), originate from some established psychological principle or set of principles, and be behaviorally based in the sense that they require a person to somehow alter someone’s behavior, way of thinking, etc., as opposed to using medications or other types of interventions.
- To assist a person or group of people in dealing with certain problems or reaching certain goals: Psychotherapy has specific goals in mind when it is implemented. These goals may consist of changing behaviors, working out problems, dealing with certain issues, etc., and as a result of this part of the definition, it is clear that for the individual to be engaged in psychotherapy, there must be a purpose for the intervention. Psychotherapy is not a fishing expedition where the therapist and client set out to find something to change; instead, it is a targeted intervention directed at resolving existing problems or reaching certain goals.
Given the general and formal definition stated above, psychotherapy can be separated from a number of other similar interventions. For example, 12-Step groups and other types of social support groups are not technically forms of psychotherapy because they do not utilize the expertise of a formally trained therapist and often do not apply interventions based on psychological principles. Typically, these groups organize individuals with similar problems, and they meet in order to provide support and guidance.
A number of different types of complementary and alternative therapies would not be defined as types of psychotherapy, such as art therapy, yoga therapy, etc., because these are sometimes not delivered by formally trained professional therapists who utilize psychological principles; in some cases, they may be. Obviously, psychiatrists who administer medications are not practicing psychotherapy. Some psychiatrists are trained in formal psychotherapy techniques and sometimes actually perform psychotherapy; however, according to the American Psychiatric Association, the practice of psychiatrists doing psychotherapy has significantly diminished since the use of psychoactive medications, such as antidepressants, anxiolytic drugs, antipsychotic drugs, etc., became the standard of psychiatric practice.
Many of Freud’s beliefs and principles have been disconfirmed or significantly altered today; however, his contribution to psychotherapy remains.
The book History of Psychotherapy: Continuity and Change is an excellent source to understand the history of psychotherapy and the different paradigms in psychotherapy today. According to the book, the term psychotherapy was actually developed from an English psychiatrist, Dr. Walter C. Dendy, who in the 1880s used a talking approach in treating his patients that he termed “psycho-threpeia.” Dr. Dendy’s influence on the field of psychotherapy is basically restricted to this small footnote regarding the origin of the term. It is widely acknowledged that the neurologist Sigmund Freud is the founder of modern psychotherapy.
Freud became very interested in the treatment of hysteria, which was the presentation of some type of a neurological issue in an individual, such as blindness, paralysis, or loss of some other function that had no apparent physical cause. Working with a number of other individuals, such as the French physician Jean-Martin Charcot, Freud first began using hypnosis to treat these patients but later abandoned hypnosis in favor of a talking approach that became the forerunner of all modern forms of psychotherapy. Many of his basic core beliefs are still held by nearly every therapist to this day, including:
- The notion that things that happen to people as children can deeply affect them as adults
- The observation that often the reason people act in certain ways is not as apparent as it seems on the surface
- The idea that people often use certain types of psychological defense mechanisms in order to protect themselves from their true feelings
- The concept that getting people to talk about their feelings and beliefs can help to understand and treat them
While these principles seem rather elementary by today’s standards, in Freud’s time, they were groundbreaking. Freud is responsible for these types of core principles associated with psychotherapeutic interventions and for a number of different techniques, therapeutic approaches, and theories of behavior that are still relevant today.
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Types of Psychotherapy
According to the American Psychological Association, there are literally hundreds of different approaches and types of psychotherapy being practiced today. Many of these approaches have a number of similarities (some are so similar that they are basically indistinguishable from one another), whereas others have significant differences. Despite the increasing number of different types of psychotherapy, all forms of psychotherapy can be categorized according to five or six basic paradigms (schools or models of thought) that have been driven in the field since psychology was recognized as a specific scientific discipline. A brief description of these basic paradigms follows.
This is the paradigm or school of thought that was originated by Sigmund Freud. The terms psychoanalytic and psychodynamic are often used interchangeably in describing this paradigm. This paradigm has undergone a number of significant modifications and consists of a number of different types of approaches that are all founded on the same general formulations that began with Freud’s conceptualization of human behavior.
The first conceptualization that Freud made based on his study of hysteria was that a great deal of the behavior that people engage in occurs at a level below conscious awareness (Freud’s unconsciousness). In his typography of the mind, Freud defined three basic components: consciousness (what we are directly aware of at the moment), pre-consciousness (we may not be directly aware of these beliefs, thoughts, etc., at the moment but we can bring them into the consciousness if we so choose), and unconscious portion of the mind that represents the largest portion of the human mind and is responsible for driving the majority of our actions. Mental events that occur at the unconscious level cannot be brought to the surface by the individual without professional assistance and are often produced in an individual’s behavior in symbolic ways.
There are a number of different theoretical constructs, conceptualizations of personality, and other principles associated with different subtypes of psychodynamic theories, but most modern forms of the psychoanalytic paradigm still hold to the notion that unconscious behavioral processes are a significant contributor to a number of behavioral issues. The goal of the psychoanalytic paradigm is to bring these unconscious events, motivations, and memories to the surface through therapy, and this helps individuals understand themselves and alter whatever issues they are having.
Traditionally, psychoanalysis was lengthy (often requiring participation in therapy several times a week over a period of years) and expensive; however, many of the modern manifestations of the psychodynamic paradigm are more focused and time-limited. Psychodynamic therapy has been successfully utilized to treat individuals with substance abuse issues by helping them understand the motivations for their behavior and reorganizing them.
This paradigm grew out of experimental psychology and the use of animal models of behavior to attempt to understand human behavior. The most well-known proponent of the behavioral paradigm is B.F. Skinner. Skinner developed a theory of operant conditioning that described how learning and behavior occur as a result of the consequences of behavior. Applied to psychotherapy, the behavioral paradigm is only concerned with addressing the behavior that one wishes to change. Unlike its predecessor, the psychodynamic paradigm, the behavioral paradigm is not concerned with mental events. Instead, behavior is directly approached, and the attempts to get an individual to change are focused on what they do as opposed to what they think or feel.
While the behavioral paradigm by itself has a number of limitations for psychotherapy, it does offer many useful techniques that can be combined with other principles from other therapeutic paradigms. One of the most commonly applied behavioral therapeutic techniques is the notion of exposure therapy for individuals with issues with anxiety. Exposure therapy aptly describes the technique in simple terms; you simply expose the individual to the anxiety-provoking stimulus until they are no longer afraid of it. This can be done in a number of ways, such as developing a list of anxiety-provoking situations/stimuli that bother the person. The person then starts with exposure to the situation that provokes the least amount of anxiety, and once they have mastered that, they move up the list to the next level. This way, the person can comfortably be exposed to events/stimuli in a hierarchical fashion, such that they can master their issues with anxiety at a comfortable level. Obviously, this form of therapy needs to be implemented by a trained professional. Many therapeutic techniques used in a number of different treatments today have significant ties to the behavioral paradigm.
The cognitive paradigm developed as a reaction to behaviorism’s ignoring mental events. The cognitive paradigm addresses thinking processes, such as reasoning, attitudes, beliefs, etc., and how they affect behavior. Cognitive therapy has a number of different approaches that all basically help an individual to identify thoughts or beliefs that result in different types of distress or dysfunction, objectively help the person analyze the origin of these thoughts or beliefs, challenge them, and then help the individual to change these thoughts and beliefs to more realistic ones that are functional for them. Cognitive therapy is one of the major components of the treatment for depression.
Most cognitive-driven therapeutic approaches today are described as cognitive-behavioral approaches that combine the principles from cognitive therapy with many of the techniques used in behavioral therapy. Cognitive Behavioral Therapy is an umbrella term for a number of different therapeutic approaches, including such well-known therapies as Motivational Interviewing, Rational Emotive Behavior Therapy, Dialectic Behavior Therapy, etc. In addition, Cognitive Behavioral Therapy is generally recommended as the primary psychotherapy approach for the treatment of individuals with substance use disorders.
Theorists like Abraham Maslow and therapists such as Carl Rogers objected to the rather mechanistic approaches favored by Freud in the psychodynamic paradigm and Skinner in the behavioral paradigm. The humanistic paradigm was developed to identify the specific types of experiences, motivations, and associations that are unique to people. The humanistic paradigm is more interested in the subjective feelings and experiences of the individual than in the overall effects of a type of intervention on a group of people (something that would be favored by the behavioral paradigm).
The famous psychotherapist Carl Rogers developed a humanistic therapy he referred to as client-centered therapy that focused on the unique experiences of the individual, their motivations and drives, and the relationship of the therapist and client in order to effect change. Interestingly, Carl Rogers was also the first therapist to actually apply formal research methodology to psychotherapeutic outcomes. Many of Rogers’s core principles to his client-centered therapy are still considered to be goal components of successful therapeutic outcomes and all therapeutic paradigms today (the idea of the importance of the relationship between the client and therapist, the notion that both the therapist and client need to be honest and genuine, and the notion that the therapist should hold an unconditional positive regard for the client, such that they accept the client as a worthwhile person at all times).
The biological paradigm in psychology was primarily concerned with understanding the relationships between the brain and human behavior. This paradigm is the one that is still favored by the majority of practicing psychiatrists who most often administer medications or even psychosurgery to clients as opposed to formal psychotherapy; however, in recent years, it has also gained momentum in psychotherapy. Principles such as neuroplasticity, the notion that the brain changes in response to experience, are becoming more popular in different psychotherapeutic settings. A number of different techniques from behavioral therapy, cognitive therapy, and even Cognitive Behavioral Therapy are being applied as methods to “rewire” or “retrain” the brain.
A more recent phenomenon in the field of psychology has been the appearance of theorists who combine different paradigms to develop integrative theories of behavior. As it turns out, many psychotherapists today do the same thing. Instead of strictly practicing within the framework of one type of therapy or therapeutic paradigm, many psychotherapists combine different paradigms, such as the psychodynamic paradigm in the cognitive paradigm, psychodynamic principles with Cognitive Behavioral Therapy, the humanistic paradigm with the psychodynamic paradigm, etc., in order to draw on the strengths of each paradigm and develop a more effective therapeutic process.
Paradigms in psychology may be combined with techniques from other fields, such as art or music in the delivery of music therapy or art therapy. The notion of a holistic treatment attempts to treat individuals in therapy from a perspective of all valid paradigms and approaches. Sometimes, this is referred to as a biopsychosocial model. This approach attributes the interaction of biologically based treatments, psychologically based treatments, and social/logically based principles (e.g., cultural, socioeconomic, familial approaches, etc.) as the most complete overall approach to help an individual reach their goals.
Group or Individual?
Psychotherapy is typically practiced in two situations: individual or group therapy. In individual therapy, a single individual is typically treated by one therapist. Individual therapy offers several advantages.
- The treatment focuses on the individual’s problems.
- There is a high level of confidentiality, as only the therapist and client know what occurs in sessions, and the therapist is bound by ethical principles not to discuss these issues outside of the therapeutic situation except with other colleagues for advice or in specific instances.
- The treatment is organized, can be tailored to the needs of the person, and focused on specific concrete goals.
Group therapy occurs when more than one person is treated by one or more therapists in the same sessions. Groups can be as small as two individuals, though they often include many more than this. The optimal number is generally considered to be 9-12 members, but many groups have 20 or more members. Group therapy offers a number of advantages as well.
- Individuals learn from both the therapist and the experience of others with similar problems.
- Individuals in therapy do not feel alone in their problems and get support from one another in groups.
- The therapy is often more flexible and broader.
Nonetheless, both group and individual therapy are generally considered to be equally efficacious in their treatment outcomes. In some specific instances, individuals may be more suited to attend groups, and in others, they may find individual sessions more productive. For example, a married couple experiencing issues would be better suited for group therapy, whereas an extremely introverted person with a number of issues related to anxiety may initially find that individual therapy better suits their needs. However, either type of therapy can work for anyone and for almost any particular issue. Individuals with substance use disorders typically find that there are advantages to both individual therapy and group therapy; often, in the early stages of treatment, they attend both.
Effectiveness of Psychotherapy
According to The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work, psychotherapies from all the different paradigms have sufficient evidence to indicate that they are efficacious for a number of different problems. The specific paradigm used often depends on the particular problem being addressed, such as most sources recommending some type of Cognitive Behavioral Therapy be used in the treatment of substance use disorders. Nonetheless, there is sufficient evidence to indicate that the use of some types of psychodynamic therapy, behavioral therapy, or humanistic therapy also have treatment utility for substance use disorders, and combining principles from the humanistic paradigm with behavioral therapy or Cognitive Behavioral Therapy increases the effectiveness of these approaches.
As it turns out, many times, the use of psychotherapy is the chief treatment approach for issues with substance abuse, certain types of anxiety disorders, depression, etc. The use of medications alone for many of these issues is not sufficient to fully treat them. On the other hand, there are a number of conditions where psychotherapy is not considered to be the main treatment approach but instead can be used as an adjunctive or additional form of treatment, such as the treatment of those with schizophrenia or bipolar disorder.
Whenever the effectiveness of any psychotherapeutic approach is discussed, it is important to note that psychotherapy is a collaborative process between the therapist and the client. Psychotherapy is not a passive form of treatment where the therapist is required to do all the work and the client benefits from the therapist “changing them.” Clients in therapy need to be motivated, follow through on assignments, and honest with the therapist regarding their issues.