Therapy is generally employed in response to a variety of specific or non-specific manifestations of clinically diagnosable and/or existential crises. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers). However, the term counseling is sometimes used interchangeably with "psychotherapy".
Whilst some psychotherapeutic interventions are designed to treat the patient employing the medical model, many psychotherapeutic approaches do not adhere to the symptom-based model of "illness/cure". Some practitioners, such as humanistic therapists, see themselves more in a facilitative/helper role. 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 confidentiality is enshrined in the regulatory psychotherapeutic organisations codes of ethical practice.
There are dozens of approaches, which continue to be developed around the wide variety of theoretical backgrounds. Many practitioners use several approaches in their work and alter their approach based on client need.
In an informal sense, psychotherapy can be said to have been practiced through the ages, as individuals received psychological counsel and reassurance from others. Purposeful, theoretically-based psychotherapy was probably first developed in the Middle East during the 9th century by the Persian physician and psychological thinker, Rhazes, who was at one time the chief physician of the Baghdad psychiatric hospital. In the West, however, serious mental disorders were generally treated as demonic or medical conditions requiring punishment and confinement until the advent of moral treatment approaches in the 18th Century. This brought about a focus on the possibility of psychosocial intervention - including reasoning, moral encouragement and group activities - to rehabilitate the "insane".
Psychoanalysis was perhaps the first specific school of psychotherapy, developed by Sigmund Freud and others through the early 1900s. Trained as a neurologist, Freud began focusing on problems that appeared to have no discernible organic basis, and theorized that they had psychological causes originating in childhood experiences and the unconscious mind. Techniques such as dream interpretation, free association, transference and analysis of the id, ego and superego were developed. Many theorists, including Anna Freud, Alfred Adler, Carl Jung, Karen Horney, Otto Rank, Erik Erikson, Melanie Klein, and Heinz Kohut, built upon Freud's fundamental ideas and often formed their own differentiating 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. Sessions tended to number into the hundreds over several years.
Behaviorism developed in the 1920s, and behavior modification as a therapy became popularized in the 1950s and 1960s. Notable contributors were Joseph Wolpe in South Africa, M.B. Shipiro 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 phobias, 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 (e.g., Irvin Yalom, Rollo May) and Europe (Viktor Frankl, Ludwig Binswanger, Medard Boss, R.D.Laing, Emmy van Deurzen) 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 (e.g., Søren Kierkegaard, Jean-Paul Sartre, Gabriel Marcel, Martin Heidegger, Friedrich Nietzsche). The uniqueness of the patient-therapist relationship thus also forms a vehicle for therapeutic enquiry. A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based in existentialism and the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centered psychotherapy into mainstream focus. Rogers's primary requirement is that the client should be in receipt of three core 'conditions' from their Counselor; unconditional positive regardalso sometimes described as 'prizing' the person or valuing the humanity of an individual, congruence [authenticity/genuineness/transparency], and empathic understanding. The aim in using the 'core conditions' is to facilitate therapeutic change within a non-directive relationship conducive to enhancing the client's psychological well being. This type of interaction enables the client to fully experience and express themselves. Others developed the approach, like Fritz and Laura Perls in the creation of Gestalt therapy, as well as Marshall Rosenberg, founder of Nonviolent Communication, and Eric Berne, founder of Transactional Analysis. Later these fields of psychotherapy would become what is known as humanistic psychotherapy today. Self-help groups and books became widespread.
During the 1950s, Albert Ellis originated Rational Emotive Behavior Therapy (REBT). A few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included generally relative short, structured and present-focused therapy aimed at identifying and changing a person's beliefs, appraisals and reaction-patterns, by contrast with the more long-lasting insight-based approach of psychodynamic or humanistic therapies. Cognitive and behavioral therapy approaches were combined and grouped under the heading and unbrella-term Cognitive behavioral therapy (CBT) in the 1970s. Many approaches within CBT was oriented towards active-directive collaborative empiricism and maping, assessing and modifying clients core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders. A "third wave" of cognitive and behavioral therapies developed, including Acceptance and Commitment Therapy and Dialectical behavior therapy, which expanded the concepts to other disorders and/or added novel components and mindfulness exercises. Counseling methods developed, including solution-focused therapy and systemic coaching. Postmodern psychotherapies such as Narrative Therapy and coherence therapy did not impose definitions of mental health and illness, but rather saw the goal of therapy as something constructed by the client and therapist in a social context. Systems Therapy also developed, which focuses on family and group dynamics—and Transpersonal psychology, which focuses on the spiritual facet of human experience. Other important orientations developed in the last three decades include Feminist therapy, Brief therapy, Somatic Psychology, Expressive therapy, and applied Positive psychology. A survey of over 2,500 US therapists in 2006 revealed the most utilised models of therapy and the ten most influential therapists of the previous quarter-century.
Psychotherapy can be seen as an interpersonal invitation offered by (often trained and regulated) psychotherapists to aid clients in reaching their full potential or to cope better with problems of life. Psychotherapists usually receive remuneration in some form in return for their time and skills. This is one way in which the relationship can be distinguished from an altruistic offer of assistance.
Psychotherapy often includes techniques to increase awareness, for example, or to enable other choices of thought, feeling or action; to increase the sense of well-being and to better manage subjective discomfort or distress. Psychotherapy can be provided on a one-to-one basis or in group therapy. It can occur face to face, over the telephone, or, much less commonly, the Internet. Its time frame may be a matter of weeks or many years. Therapy may address specific forms of diagnosable mental illness, or everyday problems in managing or maintaining person relationships or meeting personal goals. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers) but the term is sometimes used interchangeably with "psychotherapy".
Psychotherapists employ a range of techniques to influence or persuade the client to adapt or change in the direction the client has chosen. These can be based on clear thinking about their options; experiential relationship building; dialogue, communication and adoption of behavior change strategies. Each is designed to improve the mental health of a client or patient, or to improve group relationships (as in a family). Most forms of psychotherapy use only spoken conversation, though some also use other forms of communication such as the written word, artwork, drama, narrative story, or therapeutic touch. Psychotherapy occurs within a structured encounter between a trained therapist and client(s). Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.
Psychotherapists are often trained, certified, and licensed, with a range of different certifications and licensing requirements depending on the jurisdiction. Psychotherapy may be undertaken by clinical psychologists,counseling psychologists, social workers, marriage-family therapists, expressive therapists, trained nurses, psychiatrists, psychoanalysts, mental health counselors, school counselors, or professionals of other mental health disciplines. Psychiatrists have medical qualifications and may also administer prescription medication. The primary training of a psychiatrist focuses on the biological aspects of mental health conditions, with some training in psychotherapy. Psychologists have more training in psychological assessment and research and, in addition, in-depth training in psychotherapy. Social workers have specialized training in linking patients to community and institutional resources, in addition to elements of psychological assessment and psychotherapy. Marriage-Family Therapists have specific training and experience working with relationships and family issues. A Licensed Professional Counselor (LPC) generally has special training in career, mental health, school, or rehabilitation counseling to include evaluation and assessments as well as psychotherapy. Many of the wide variety of training programs are multiprofessional, that is, psychiatrists, psychologists, mental health nurses, and social workers may be found in the same training group. Consequently, specialized psychotherapeutic training in most countries requires a program of continuing education after the basic degree, or involves multiple certifications attached to one specific degree.
In practices of experienced psychotherapists, therapy will not represent pure types, but will draw aspects from a number of perspectives and schools.
Psychoanalysis was developed in the late 1800s by Sigmund Freud. His therapy explores the dynamic workings of a mind understood to consist of three parts: the hedonistic id (German: das Es, "the it"), the rational ego (das Ich, "the I"), and the moral superego (das Überich, "the above-I"). Because the majority of these dynamics are said to occur outside people's awareness, Freudian psychoanalysis seeks to probe the unconscious by way of various techniques, including dream interpretation and free association. Freud maintained that the condition of the unconscious mind is profoundly influenced by childhood experiences. So, in addition to dealing with the defense mechanisms employed by an overburdened ego, his therapy addresses fixations and other issues by probing deeply into clients' youth.
Other psychodynamic theories and techniques have been developed and used by psychotherapists, psychologists, psychiatrists, personal growth facilitators, occupational therapists and social workers. Techniques for group therapy have also been developed. While behaviour is often a target of the work, many approaches value working with feelings and thoughts. This is especially true of the psychodynamic schools of psychotherapy, which today include Jungian therapy and Psychodrama as well as the psychoanalytic schools. Other approaches focus on the link between the mind and body and try to access deeper levels of the psyche through manipulation of the physical body. Examples are Rolfing, Bioenergetic analysis and postural integration.
Gestalt Therapy is a major overhaul of psychoanalysis. In its early development it was called "concentration therapy" by its founders, Frederick and Laura Perls. However, its mix of theoretical influences became most organized around the work of the gestalt psychologists; thus, by the time Gestalt Therapy, Excitement and Growth in the Human Personality (Perls, Hefferline, and Goodman) was written, the approach became known as "Gestalt Therapy."
Gestalt Therapy stands on top of essentially four load bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom. Some have considered it an existential phenomenology while others have described it as a phenomenological behaviorism. Gestalt therapy is a humanistic, holistic, and experiential approach that does not rely on talking alone, but facilitates awareness in the various contexts of life by moving from talking about situations relatively remote to action and direct, current experience.
The therapeutic use of groups in modern clinical practice can be traced to the early years of the 20th century, when the American chest physician Pratt, working in Boston, described forming 'classes' of fifteen to twenty patients with tuberculosis who had been rejected for sanatorium treatment. The term group therapy, however, 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 USA, 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.
A distinction can also be made between those psychotherapies that employ a medical model and those that employ a humanistic model. In the medical model the client is seen as unwell and the therapist employs their skill to help the client back to health. The extensive use of the DSM-IV, the diagnostic and statistical manual of mental disorders in the United States, is an example of a medically-exclusive model.
The humanistic model in contrast strives to depathologise the human condition. The therapist attempts to create a relational environment conducive to experiential learning and help build the client's confidence in their own natural process resulting in a deeper understanding of themselves. An example would be gestalt therapy.
Some psychodynamic practitioners distinguish between more uncovering and more supportive psychotherapy. Uncovering psychotherapy emphasizes facilitating the client's insight into the roots of their difficulties. The best-known example of an uncovering psychotherapy is classical psychoanalysis. Supportive psychotherapy by contrast stresses strengthening the client's defenses and often providing encouragement and advice. Depending on the client's personality, a more supportive or more uncovering approach may be optimal. Most psychotherapists use a combination of uncovering and supportive approaches.
Cognitive Behavioral Therapies (CBT) are a group of therapies that generally focus on the construction and re-construction 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 thinking, emoting and behaving.
Behavior Therapy focuses on modifying overt behavior and helping clients to achieve goals. This approach is built on the principles of learning theory including operant and respondent conditioning, which makes up the area of applied behavior analysis or behavior modification. This approach includes Acceptance and Commitment Therapy, Functional Analytic Psychotherapy, and Dialectical behavior therapy. Sometimes it is integrated with cognitive therapy to make cognitive behavior therapy
Expressive therapy is a form of therapy that utilizes artistic expression as its core means of treating clients. Expressive therapists 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. Expressive therapists believe that often the most effective way of treating a client is through the expression of imagination in a creative work and integrating and processing what issues are raised in the act.
Narrative therapy gives attention to each person's "dominant story" by means of 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
Integrative Psychotherapy represents an attempt to combine ideas and strategies from more than one theoretical approach. 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.
Within the psychotherapeutic community there has been some discussion of empirically-based psychotherapy, e.g.
Virtually no comparisons of different psychotherapies with long follow-up times have been carried out. The Helsinki Psychotherapy Study is a randomized clinical trial, in which patients are monitored for 12 months after the onset of study treatments, of which each lasted approximately 6 months. The assessments are to be completed at the baseline examination and during the follow-up after 3, 7, and 9 months and 1, 1.5, 2, 3, 4, 5, 6, and 7 years. The final results of this trial are yet to be published since follow-up evaluations will continue up to 2009.
Counseling and psychotherapy must be adapted to meet the developmental needs of children. Many counseling preparation programs include courses in human development. Since children often do not have the ability to articulate thoughts and feelings, counselors will use a variety of media such as crayons, paint, clay, puppets, bibliocounseling (books), toys, et cetera. The use of play therapy is often rooted in psychodynamic theory, but other approaches such as Solution Focused Brief Counseling may also employ the use of play in counseling. In many cases the counselor may prefer to work with the care taker of the child, especially if the child is younger than age four.
With children the approach is sometimes more easily accepted if tools are used. For example, a book about a difficult situation that someone else must negotiate that is similar to the child's situation. This approach can bring down a child's defenses regarding a difficult issue. There are also other tools that can be of use. The Challenge Software Program uses common everyday animated scenarios combined with games to illustrate the internal conflicts a child may experience when trying to process events. The way the child processes the event has a great deal to do with what the outcome will be.
This research is extensively discussed (with many references) in Hubble, Duncan and Miller (1999) (quotes in this section are from this book) and in Wampold (2001).
A literature review by M. J. Lambert (1992) estimated that 40% of client changes are due to extratherapeutic influences, 30% are due to the quality of the therapeutic relationship, 15% are due to expectancy (placebo) effects, and 15% are due to specific techniques. Extratherapeutic influences include client motivation and the severity of the problem:
In one study, some highly motivated clients showed measurable improvement before their first session with the therapist, suggesting that just making the appointment can be an indicator of readiness to change. Tallman and Bohart (1999) note that:
There is considerable controversy over which form of psychotherapy is most effective, and more specifically, which types of therapy are optimal for treating which sorts of problems.
The dropout level is quite high, one meta-analysis of 125 studies concluded that mean dropout rate was 46.86%. The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.
Psychotherapy outcome research—in which the effectiveness of psychotherapy is measured by questionnaires given to patients before, during, and after treatment—has had difficulty distinguishing between the success or failure of the different approaches to therapy. Not surprisingly, those who stay with their therapist for longer periods are more likely to report positively on what develops into a longer term relationship. Of course, this suggests that some "treatment" may be open-ended with concerns associated with ongoing financial costs.
As early as 1952, in one of the earliest studies of psychotherapy treatment, Hans Eysenck reported that two thirds of therapy patients improved significantly or recovered on their own within two years, whether or not they received psychotherapy.
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. This means that "if you believe you are doing some good, you are," a conception of dubious merit.
In 2001 Bruce Wampold of the University of Wisconsin published "The Great Psychotherapy Debate. In it Wampold, a former statistician who went on to train as a counselling psychologist, reported that
Although the Great Psychotherapy Debate dealt primarily with data on depressed patients, subsequent articles have made similar findings for post-traumatic stress disorder , and youth disorders
Some report that by attempting to program or manualize treatment psychotherapists may actually be reducing efficacy, although the unstructured approach of many psychotherapists cannot appeal to patients motived to solve their difficulties through the application of specific techniques different from their past "mistakes."
Critics of psychotherapy are skeptical of the healing power of a psychotherapeutic relationship. Since any intervention takes time, critics note that the passage of time alone, without therapeutic intervention, often results in psycho-social healing. Social contact with others is universally seen as beneficial for all humans and regularly scheduled visits with anyone would be likely to diminish both mild and severe emotional difficulty.
Many resources available to a person experiencing emotional distress—the friendly support of friends, peers, family members, clergy contacts, personal reading, research, and independent coping—-present considerable value, suggesting that psychotherapy is often inappropriate or unneeded. 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.
Some psychotherapeutics have answered to scientific critique saying that psychotherapy is not a science since it is a craft.However, participation with a craft customarily lacks such common iatrogenic potential.
Further critiques have emerged from feminist, constructionist and discursive sources. Key to these is the issue of power. In this regard there is a concern that clients are persuaded—both inside and outside of the consulting room—to understand themselves and their difficulties in ways that are consistent with therapeutic ideas. This means that alternative ideas (e.g., feminist, economic, spiritual) are sometimes implicitly undermined. Critics suggest that we idealise the situation when we think of therapy only as a helping relation. It is also fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified. So, while it is seldom intended, the therapist-client relationship always participates in society's power relations and political dynamics.