Psychotherapy

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Psychotherapy (also called psychological therapy, talk therapy, or just therapy) is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.

There are hundreds of psychotherapy techniques, some being minor variations; others are based on very different conceptions of psychology. Most involve one-to-one sessions, between the client and therapist, but some are conducted with groups, including families.

Psychotherapists may be mental health professionals such as psychiatrists, psychologists, mental health nurses, clinical social workers, marriage and family therapists, or professional counselors. Psychotherapists may also come from a variety of other backgrounds, and depending on the jurisdiction may be legally regulated, voluntarily regulated or unregulated (and the term itself may be protected or not).

Definitions

"Psychotherapy" is described as the "art of curing mental diseases,"[1] 1892, or "the treatment of mental or emotional disorder or of related bodily ills by psychological means.[2] The word is derived from Ancient Greek psyche (ψυχή meaning "breath; spirit; soul") and therapeia (θεραπεία "healing; medical treatment").

Psychotherapy is often dubbed as a "talking therapy" or "talk therapy," referring to the way therapy sessions are often conducted by talking "with a trained therapist in a safe and confidential environment to explore and understand feelings and behaviors and gain coping skills."[3] However, not all forms of psychotherapy rely on verbal communication.[4] Children or adults who do not engage in verbal communication (or not in the usual way) are not excluded from psychotherapy; indeed some types are designed for such cases.

The American Psychological Association adopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed in 1990 by American psychologist John C. Norcross[5]:

Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions, and/or other personal characteristics in directions that the participants deem desirable.[6]

Psychiatrist Jerome Frank defined psychotherapy as a healing relationship using socially authorized methods in a series of contacts primarily involving words, acts and rituals—which Frank regarded as forms of persuasion and rhetoric.[7]

Historically, psychotherapy has sometimes meant "interpretative" (i.e. Freudian) methods, namely psychoanalysis, in contrast with other methods to treat psychiatric disorders such as behavior modification.[8]

Some definitions of counseling overlap with psychotherapy, particularly in non-directive client-centered approaches.[9]

Psychotherapy may address spirituality as a significant part of someone's mental / psychological life, and some forms are derived from spiritual philosophies, but practices based on treating the spiritual as a separate dimension are not necessarily considered as traditional or 'legitimate' forms of psychotherapy.[10]

History

Baquet scene with many people sitting and standing around a large table for "animal magnetism" treatment

Psychotherapy in some form can be said to have been practiced through the ages, as medics, philosophers, spiritual practitioners, and people in general used psychological methods to heal others.[11]

In the Western tradition, an influential movement was started by Franz Mesmer (1734–1815) and his student Armand-Marie-Jacques de Chastenet, Marquis of Puységur (1751–1825). Called Mesmerism or animal magnetism, it had a strong influence on the rise of dynamic psychology and psychiatry as well as theories about hypnosis.[12][13]

In 1853, Walter Cooper Dendy introduced the term "psycho-therapeia" regarding how physicians might influence the mental states of patients and thus their bodily ailments, for example by creating opposing emotions to promote mental balance.[14] Daniel Hack Tuke wrote about "psycho-therapeutics" in 1872, in which he also proposed making a science of animal magnetism.[15]

Hippolyte Bernheim and colleagues in the "Nancy School" further developed the concept of "psychotherapy" in the sense of using the mind to heal the body through hypnotism.[16] Charles Lloyd Tuckey's 1889 work popularized the work of the Nancy School in English.[17] Also in 1889 a clinic used the word in its title for the first time, when Frederik van Eeden and Albert Willem van Renterghem in Amsterdam renamed theirs "Clinique de Psycho-thérapeutique Suggestive" after visiting Nancy.[16]

Thus psychotherapy initially referred to "treatment of diseases by "psychic" methods (mainly hypnotism)."[1]

Group photo 1909 in front of Clark University. Front row: Sigmund Freud, Granville Stanley Hall, Carl Jung; back row: Abraham Brill, Ernest Jones, Sandor Ferenczi

Sigmund Freud visited the Nancy School and his early neurological practice involved the use of hypnotism. However following the work of his mentor Josef Breuer—in particular a case where symptoms appeared partially resolved by what the patient, Bertha Pappenheim, dubbed a "talking cure"—Freud began focusing on conditions that appeared to have psychological causes originating in childhood experiences and the unconscious mind. He went on to develop techniques such as free association, dream interpretation, transference, and analysis of the ego, superego, and id. His popular reputation as the father of psychotherapy was established by his use of the distinct term "psychoanalysis," tied to an overarching system of theories and methods.[16]

Many others, including Alfred Adler, Carl Jung, Karen Horney, Anna Freud, Otto Rank, Erik Erikson, Melanie Klein, and Heinz Kohut, built upon Freud's fundamental ideas, often developing their own systems of psychotherapy. These were all later categorized as psychodynamic, meaning anything that involved the psyche's conscious/unconscious influence on external relationships and the self.

Behaviorism developed in the 1920s, and behavior modification as a therapy became popular in the 1950s and 1960s. Notable contributors were Joseph Wolpe in South Africa, M.B. Shapiro and Hans Eysenck in Britain, and John B. Watson and B.F. Skinner in the United States. Behavioral therapy approaches relied on principles of operant conditioning, classical conditioning, and social learning theory to bring about therapeutic change in observable symptoms. The approach became commonly used for phobiass, as well as other disorders.

Some therapeutic approaches developed out of the European school of existential philosophy. Concerned mainly with the individual's ability to develop and preserve a sense of meaning and purpose throughout life, major contributors to the field, including Rollo May), Viktor Frankl, and R.D.Laing, attempted to create therapies sensitive to common "life crises" springing from the essential bleakness of human self-awareness, previously accessible only through the complex writings of existential philosophers such as Søren Kierkegaard, Jean-Paul Sartre, Gabriel Marcel, Martin Heidegger, and Friedrich Nietzsche.

A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based on the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centered psychotherapy into the mainstream. The primary requirement was that the client receive three core "conditions" from his counselor or therapist: unconditional positive regard, sometimes described as "prizing" the client's humanity; congruence [authenticity/genuineness/transparency]; and empathic understanding. This type of interaction was thought to enable clients to fully experience and express themselves, and thus develop according to their innate potential.[18] Others developed this approach: Fritz and Laura Perls created Gestalt therapy and Eric Berne founded transactional analysis. Later these fields of psychotherapy would become what is known as humanistic psychotherapy.

During the 1950s, Albert Ellis originated rational emotive behavior therapy (REBT). Independently a few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included relatively short, structured, and present-focused techniques aimed at identifying and changing a person's beliefs, appraisals, and reaction-patterns, in contrast to the more long-lasting insight-based approach of psychodynamic or humanistic therapies. Beck's approach used primarily the socratic method, and both Beck and Ellis cited aspects of the ancient philosophical system of Stoicism as a forerunner of their ideas.[19]

Cognitive and behavioral therapy approaches were increasingly combined and grouped under the umbrella term cognitive behavioral therapy (CBT) in the 1970s. Many approaches within CBT are oriented towards active/directive yet collaborative empiricism (a form of reality-testing), and assessing and modifying core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders.

Delivery

Psychotherapy may be delivered in person (one on one, or with couples, or in groups) or via telephone counseling or online counseling.

Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story, or music. Psychotherapy with children and their parents often involves play, dramatization (role-playing), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting.[20]

Developments in computer-assisted therapy include as virtual reality therapy for behavioral exposure, multimedia programs to teach cognitive techniques, and handheld devices for improved monitoring or putting ideas into practice.[21]

Regulation

Psychotherapists include mental health professionals like psychologists and psychiatrists; professionals from other backgrounds (family therapists, social workers, nurses, etc.) who have trained in a specific psychotherapy; or (in some cases) academic or scientifically trained professionals.

Psychiatrists are trained first as physicians, and as such they may prescribe prescription medication. Specialist psychiatric training begins after medical school in psychiatric residencies: however, their specialty is in mental disorders or forms of mental illness. Clinical psychologists have specialist doctoral degrees in psychology with some clinical and research components. Other clinical practitioners, social workers, mental health counselors, pastoral counselors, and nurses with a specialization in mental health, also conduct psychotherapy. Many of the wide variety of psychotherapy training programs and institutional settings are multi-professional. In most countries, psychotherapy training is completed at a postgraduate level, often at a master's degree (or doctoral) level, over four years, with significant supervised practice and clinical placements. Mental health professionals that choose to specialize in psychotherapeutic work also require a program of continuing professional education after basic professional training, such as psychoanalytic training.[22]

As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of client confidentiality—and the limited circumstances in which it may need to be broken for the protection of clients or others—is enshrined in the regulatory psychotherapeutic organizations' codes of ethical practice.[23] Examples of when it is typically accepted to break confidentiality include when the therapist has knowledge that a child or elder is being physically abused; when there is a direct, clear and imminent threat of serious physical harm to self or to a specific individual.

Types

Numerous types of psychotherapy have been designed for individual adults, families, or children and adolescents. There are hundreds of psychotherapy techniques, some being minor variations; others are based on very different conceptions of psychology.[24]

There are many types of psychotherapy, but generally they fall into four major categories: psychodynamic psychotherapy, cognitive therapy or behavior therapy, humanistic therapy, and integrative psychotherapy.[25]

Psychotherapies can also be categorized by whether they involve individual one-to-one therapy sessions, or group psychotherapy, including couples therapy and family therapy.[26]

Therapies may also classified according to their duration; a small number of sessions over a few weeks or months may be classified as brief therapy (or short-term therapy), others, where regular sessions take place for years, may be classified as long-term.

Psychodynamic

Psychodynamic therapy, or Insight-oriented psychotherapy, focuses on revealing or interpreting unconscious processes. These applications of depth psychology, of which Psychoanalysis is the oldest and most intensive form, encourage the verbalization of all the patient's thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the nature of the past and present unconscious conflicts which are causing the patient's symptoms and character problems.

There are six main schools of psychoanalysis, which all influenced psychodynamic theory: Freudian, ego psychology, object relations theory, self psychology, interpersonal psychoanalysis,[27] and relational psychoanalysis.[28]

Cognitive-behavioral

Main article: Cognitive behavioral therapy

Behavior therapies use behavioral techniques, including applied behavior analysis (also known as behavior modification), to change maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others. By nature, behavioral therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behavior ultimately has), probabilistic (viewing behavior as statistically predictable), monistic (rejecting mind-body dualism and treating the person as a unit), and relational (analyzing bidirectional interactions).[29]

Cognitive therapy focuses directly on changing the person's thoughts, in order to improve their emotions and behaviors.

Cognitive behavioral therapy (CBT) attempts to combine the above two approaches, focused on the construction and reconstruction of people's cognitions, emotions, and behaviors. Generally in CBT, the therapist, through a wide array of modalities, helps clients assess, recognize and deal with problematic and dysfunctional ways of thinking, emoting, and behaving.

Humanistic

Main article: Humanistic psychology

Humanistic psychotherapies, also known as "experiential," are based on humanistic psychology and emerged in reaction to both behaviorism and psychoanalysis, being dubbed the "third force." They are primarily concerned with the human development and needs of the individual, with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology.[30] Some posit an inherent human capacity to maximize potential, "the self-actualizing tendency"; the task of therapy is to create a relational environment where this tendency might flourish.[31]

Humanistic psychology includes several approaches to counseling and therapy. These include the existential psychology of Rollo May, person-centered or client-centered therapy developed by Carl Rogers, Gestalt therapy developed by Fritz Perls, transactional analysis developed by Eric Berne, marital counseling, and family therapy.

The general aim of humanistic therapy is to give a holistic description of the person. By using phenomenological, intersubjective and first person categories, the humanistic psychologist attempts to glimpse the whole person and not just fragmented parts of the personality.

Such therapy also seeks an integration of the whole person, referred to as self-actualization by Maslow. According to humanistic thinking, each person already has inbuilt potentials and resources that might help them to build a stronger personality and self-concept. The mission of the humanistic psychologist is to point the individual in the direction of these resources. The therapist is, in some circumstances, closer to a guide than to a clinician. However, in order to actualize hidden potentials the person might have to give up the safety of a particular stage of the personality in order to embrace a new and more integrated stage. This is not a simple or easy process, as it might include confronting new life-choices or redefining one's view of life. Humanistic psychology views psychological instability and anxiety as normal features of human life and development that can be worked through in therapy.


Person-centered therapy, also known as client-centered, focuses on the therapist showing openness, empathy and "unconditional positive regard", to help clients express and develop their own self.[32]

Humanistic Psychodrama (HPD) is based on the human image of humanistic psychology.[33] So all rules and methods follow the axioms of humanistic psychology. The HPD sees itself as development-oriented psychotherapy and has completely moved away from the psychoanalytic catharsis theory.[34] Self-awareness and self-realization are essential aspects in the therapeutic process. Subjective experiences, feelings and thoughts and one's own experiences are the starting point for a change or reorientation in experience and behavior in the direction of more self-acceptance and satisfaction. Dealing with the biography of the individual is closely related to the sociometry of the group.[35]

Gestalt therapy, originally called "concentration therapy", is an existential/experiential form that facilitates awareness in the various contexts of life, by moving from talking about relatively remote situations to action and direct current experience. Derived from various influences, including an overhaul of psychoanalysis, it stands on top of essentially four load-bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom.[36]

A briefer form of humanistic therapy is the human givens approach, introduced in 1998 –99.[37] It is a solution-focused intervention based on identifying emotional needs—such as for security, autonomy and social connection—and using various educational and psychological methods to help people meet those needs more fully or appropriately.[38][39][40][41]

Integrative

In practice therapy is often not of one pure type but draws from a number of perspectives and schools—known as an integrative or eclectic approach.[42][43]

Integrative psychotherapies involve the integration of elements from different schools of psychotherapy in the treatment of a client. Integrative psychotherapy may also refer to the psychotherapeutic process of integrating the personality: uniting the "affective, cognitive, behavioral, and physiological systems within a person".[44]

Integrative psychotherapy is an attempt to combine ideas and strategies from more than one theoretical approach.[45] These approaches include mixing core beliefs and combining proven techniques. Forms of integrative psychotherapy include multimodal therapy, the transtheoretical model, cyclical psychodynamics, systematic treatment selection, cognitive analytic therapy, internal family systems model, multitheoretical psychotherapy and conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time.

Other

Systemic
A group therapy session

Systemic therapy seeks to address people not just individually, as is often the focus of other forms of therapy, but in relationship, dealing with the interactions of groups, their patterns and dynamics (includes family therapy and marriage counseling). Community psychology is a type of systemic psychology.

The term group therapy was first used around 1920 by Jacob L. Moreno, whose main contribution was the development of psychodrama, in which groups were used as both cast and audience for the exploration of individual problems by reenactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the US, such as Paul Schilder, who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably Wilfred Bion and Rickman, followed by S. H. Foulkes, Main, and Bridger. The Northfield Hospital in Birmingham gave its name to what came to be called the two "Northfield Experiments", which provided the impetus for the development since the war of both social therapy, that is, the therapeutic community movement, and the use of small groups for the treatment of neurotic and personality disorders. Today group therapy is used in clinical settings and in private practice settings.[46]

Expressive


Expressive psychotherapy is a form of therapy that utilizes artistic expression (via improvisational, compositional, re-creative, and receptive experiences) as its core means of treating clients. Expressive psychotherapists use the different disciplines of the creative arts as therapeutic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy, writing therapy, among others.[47] This may include techniques such as affect labeling. Expressive psychotherapists believe that often the most effective way of treating a client is through the expression of imagination in creative work and integrating and processing what issues are raised in the act.

Postmodernist

Also known as post-structuralist or constructivist. Narrative therapy gives attention to each person's "dominant story" through therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful. Coherence therapy posits multiple levels of mental constructs that create symptoms as a way to strive for self-protection or self-realization. Feminist therapy does not accept that there is one single or correct way of looking at reality and therefore is considered a postmodernist approach.[48]

Transpersonal

Transpersonal psychology addresses the client in the context of a spiritual understanding of consciousness.[49] Positive psychotherapy (PPT) (since 1968) is a method in the field of humanistic and psychodynamic psychotherapy and is based on a positive image of humans, with a health-promoting, resource-oriented and conflict-centered approach.

Hypnotherapy

Hypnotherapy is undertaken while a subject is in a state of hypnosis. Hypnotherapy is often applied in order to modify a subject's behavior, emotional content, and attitudes, as well as a wide range of conditions including: dysfunctional habits,[50][51][52][53][54] anxiety,[55] stress-related illness,[56][57][58] pain management,[59]Template:Unreliable source?[60] and personal development.[61]Template:Unreliable source?[62]

Computer-supported

Research on computer-supported and computer-based interventions has increased significantly over the course of the last two decades.[63][64] The following applications frequently have been investigated:

  • Virtual reality: VR is a computer-generated scenario that simulates experience. The immersive environment, used for simulated exposure, can be similar to the real world or it can be fantastical, creating a new experience.[65][66]
  • Computer-based interventions (or online interventions or internet interventions): These interventions can be described as interactive self-help. They usually entail a combination of text, audio or video elements.[67][68]
  • Computer-supported therapy (or blended therapy): Classical psychotherapy is supported by means of online or software application elements. The feasibility of such interventions has been investigated for individual[69] and group therapy.[70][71]

Telepsychotherapy

Telepsychiatry or telemental health refers to the use of telecommunications technology (mostly videoconferencing and phone calls) to deliver psychiatric care remotely for people with mental health conditions. It is a branch of telemedicine.[72][73]

Telepsychiatry can be effective in treating people with mental health conditions. In the short-term it can be as acceptable and effective as face-to-face care.[74]

It can improve access to mental health services for some but might also represent a barrier for those lacking access to a suitable device, the internet or the necessary digital skills. Factors such as poverty that are associated with lack of internet access are also associated with greater risk of mental health problems, making digital exclusion an important problem of telemental health services.[74]

During the COVID-19 pandemic mental health services were adapted to telemental health in high-income countries. It proved effective and acceptable for use in an emergency situation but there were concerns regarding its long-term implementation.[75]

Evaluation

There is considerable controversy about whether, or when, psychotherapy efficacy is best evaluated by randomized controlled trials or more individualized idiographic methods.[76]

One issue with trials is what to use as a placebo treatment group or non-treatment control group. Often, this group includes patients on a waiting list, or those receiving some kind of regular non-specific contact or support. Researchers must consider how best to match the use of inert tablets or sham treatments in placebo-controlled studies in pharmaceutical trials. Several interpretations and differing assumptions and language remain.[77] Another issue is the attempt to standardize and manualize therapies and link them to specific symptoms of diagnostic categories, making them more amenable to research. Some report that this may reduce efficacy or gloss over individual needs. Fonagy and Roth's opinion is that the benefits of the evidence-based approach outweighs the difficulties.[78]

There are several formal frameworks for evaluating whether a psychotherapist is a good fit for a patient. One example is the Scarsdale Psychotherapy Self-Evaluation (SPSE).[79] However, some scales, such as the SPS, elicit information specific to certain schools of psychotherapy alone (e.g. the superego).

Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice. Psychodynamic therapists increasingly believe that evidence-based approaches are appropriate to their methods and assumptions, and have increasingly accepted the challenge to implement evidence-based approaches in their methods.[80]

A pioneer in investigating the results of different psychological therapies was psychologist Hans Eysenck, who argued that psychotherapy does not produce any improvement in patients. He held that behavior therapy is the only effective one. However, it was revealed that Eysenck (who died in 1997) falsified data in his studies about this subject, fabricating data that would indicate that behavioral therapy enables achievements that are impossible to believe. Fourteen of his papers were retracted by journals in 2020, and journals issued 64 statements of concern about publications by him. Rod Buchanan, a biographer of Eysenck, has argued that 87 publications by Eysenck should be retracted.[81][82][83][84][85][86][87]

Outcomes

Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.[88][89]

One line of research consistently finds that supposedly different forms of psychotherapy show similar effectiveness. According to The Handbook of Counseling Psychology: "Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments". The handbook states that there is "little evidence to suggest that any one psychological therapy consistently outperforms any other for any specific psychological disorders. This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes".[90]

Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.[91][92]{{ safesubst:#invoke:Unsubst||date=__DATE__ |$B=

}}[93][94]

Outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalize from them to practicing therapists.[92][95]

However, specific therapies have been tested for use with specific disorders,[96] and regulatory organizations in both the UK and US make recommendations for different conditions.[97][98][99]

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 five years long-term psychotherapy and psychoanalysis gave greater benefits. Several patient and therapist factors appear to predict suitability for different psychotherapies.[100]

Meta-analyses have established that cognitive behavioural therapy (CBT) and psychodynamic psychotherapy are equally effective in treating depression.[101]

A 2014 meta analysis over 11,000 patients reveals that Interpersonal Psychotherapy (IPT) is of comparable effectiveness to CBT for depression but is inferior to the latter for eating disorders.[102] For children and adolescents, interpersonal psychotherapy and CBT are the best methods according to a 2014 meta analysis of almost 4000 patients.[103]

Mechanisms of change

It is not yet understood how psychotherapies can succeed in treating mental illnesses.[104] Different therapeutic approaches may be associated with particular theories about what needs to change in a person for a successful therapeutic outcome.

In general, processes of emotional arousal and memory have long been held to play an important role. One theory combining these aspects proposes that permanent change occurs to the extent that the neuropsychological mechanism of memory reconsolidation is triggered and is able to incorporate new emotional experiences.[105][106][107][108]

Adherence

Patient adherence to a course of psychotherapy—continuing to attend sessions or complete tasks—is a major issue.

The dropout level—early termination—ranges from around 30% to 60%, depending partly on how it is defined. The range is lower for research settings for various reasons, such as the selection of clients and how they are inducted. Early termination is associated on average with various demographic and clinical characteristics of clients, therapists and treatment interactions.[109][110] The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.[111]

Most psychologists use between-session tasks in their general therapy work, and cognitive behavioral therapies in particular use and see them as an "active ingredient". It is not clear how often clients do not complete them, but it is thought to be a pervasive phenomenon.[109]

From the other side, the adherence of therapists to therapy protocols and techniques—known as "treatment integrity" or "fidelity"—has also been studied, with complex mixed results.[112] In general, however, it is a hallmark of evidence-based psychotherapy to use fidelity monitoring as part of therapy outcome trials and ongoing quality assurance in clinical implementation.

Adverse effects

Research on adverse effects of psychotherapy has been limited, yet worsening of symptoms may be expected to occur in 3% to 15% of patients, with variability across patient and therapist characteristics.[113][114][115] Potential problems include deterioration of symptoms or developing new symptoms, strains in other relationships, social stigma, and therapy dependence.[116] Some techniques or therapists may carry more risks than others, and some client characteristics may make them more vulnerable.[114] Side-effects from properly conducted therapy should be distinguished from harms caused by malpractice.[116]

General critique

Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.[117]


Some critics are skeptical of the healing power of psychotherapeutic relationships.[118][119][120] Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners,[121] instead favoring either nonprofessional help[121] or biomedical treatments.[122] Others have pointed out ways in which the values and techniques of therapists can be harmful as well as helpful to clients (or indirectly to other people in a client's life).[123][124][125]

Many resources available to a person experiencing emotional distress—the friendly support of friends, peers, family members, clergy contacts, personal reading, healthy exercise, research, and independent coping—all present considerable value. Critics note that humans have been dealing with crises, navigating severe social problems and finding solutions to life problems long before the advent of psychotherapy.[126]

On the other hand, some argue psychotherapy is under-utilized and under-researched by contemporary psychiatry despite offering more promise than stagnant medication development. In 2015, the US National Institute of Mental Health allocated only 5.4% of its budget to new clinical trials of psychotherapies (medication trials are largely funded by pharmaceutical companies), despite plentiful evidence they can work and that patients are more likely to prefer them.[127]

Further critiques have emerged from feminist, constructionist and discourse-analytical sources.[128][129][130] Key to these is the issue of power.[129][131] In this regard there is a concern that clients are persuaded—both inside and outside the consulting room—to understand themselves and their difficulties in ways that are consistent with therapeutic ideas.[119][129] This means that alternative ideas (e.g., feminist,[132] economic,[133] spiritual[134]) are sometimes implicitly undermined.[135] Critics suggest that we idealize the situation when we think of therapy only as a helping relationship—arguing instead that it is fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified, and that while it is seldom intended, the therapist–client relationship always participates in society's power relations and political dynamics.[119][136][137] A noted academic who espoused this criticism was Michel Foucault.[138][139][140]

Notes

  1. ↑ 1.0 1.1 psychotherapy (n.) Etymology Online. Retrieved February 16, 2024.
  2. ↑ psychotherapy Merriam Webster. Retrieved February 16, 2024.
  3. ↑ Psychotherapy National Alliance on Mental Illness (NAMI). Retrieved February 16, 2024.
  4. ↑ "Talk Therapy" The American Heritage® Dictionary of the English Language (2018). Retrieved February 16, 2024.
  5. ↑ John C. Norcross, An eclectic definition of psychotherapy. In Jeffrey K. Zeig and W. Michael Munion (eds.), What is psychotherapy? Contemporary perspectives (San Francisco, CA: Jossey-Bass, 1990, ISBN 978-1555422837), 218-220.
  6. ↑ American Psychological Association Recognition of Psychotherapy Effectiveness {{webarchive|(Approved 2021). Retrieved February 20, 2024.
  7. ↑ Jerome D. Frank, and Julia B. Frank, Persuasion and Healing: A comparative study of psychotherapy (Johns Hopkins University Press, 1993, ISBN 978-0801846366).
  8. ↑ Richard L. Gregory (ed.), Oxford Companion to the Mind (Oxford University Press, 2004, ISBN 978-0198662242).
  9. ↑ Greg Mulhauser, History of Counselling & Psychotherapy Counselling Resource (December 20, 2014). Retrieved February 20, 2024.
  10. ↑ Vijoy K. Varma and Nitin Gupta, Psychotherapy in a Traditional Society: Context, Concept and Practice (Jaypee Brothers Publishers, 2008, ISBN 978-8184482362).
  11. ↑ Sharon G. Mijares (ed.), Modern Psychology and Ancient Wisdom: Psychological Healing Practices from the World's Religious Traditions (Routledge, 2003, ISBN 978-0789017512).
  12. ↑ Henri F. Ellenberger, The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry (New York: Basic Books, 1981, ISBN 978-0465016730).
  13. ↑ Grant J. Rich and Uwe Gielen (eds.), Pathfinders in International Psychology (Charlotte, NC: Information Age Publishing, 2015, ISBN 978-1681231433).
  14. ↑ Stanley W. Jackson, Care of the Psyche: A History of Psychological Healing (Yale University Press, 1999, ISBN 978-0300076714).
  15. ↑ Daniel Hack Tuke, Illustrations of the Influence of the Mind upon the Body in Health and Disease: Designed to elucidate the action of the imagination (Kessinger Publishing, 2007 (original 1972), ISBN 978-0548104163).
  16. ↑ 16.0 16.1 16.2 Sonu Shamdasani, 'Psychotherapy': the invention of a word History of the Human Sciences 18(1) (February 2005):1–22. Retrieved February 20, 2024.
  17. ↑ C. Lloyd Tuckey, Psycho-Therapeutics Or Treatment By Sleep And Suggestion (Kessinger Publishing, 2010 (original 1889), ISBN 978-1162929156).
  18. ↑ Saul Mcleod, Person-Centred Therapy and Core Conditions Simply Psychology, December 20, 2023. Retrieved February 21, 2024.
  19. ↑ Daniel Robertson, The Philosophy of Cognitive-Behavioural Therapy: Stoicism as Rational and Cognitive Psychotherapy (Routledge, 2019, ISBN 978-0367219147).
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References
ISBN links support NWE through referral fees

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