Psychological therapy, or psychotherapy, is an interaction between a socially sanctioned clinician and someone suffering from a psychological problem, with the goal of providing support or relief from the problem. Currently, over 500 different forms of psychotherapy exist. A survey of 1,000 psychotherapists asked them to describe their main theoretical orientation (Norcross, Hedges, & Castle, 2002; see FIGURE 15.1). Over a third reported using eclectic psychotherapy, a form of psychotherapy that involves drawing on techniques from different forms of therapy, depending on the client and the problem. This allows therapists to apply an appropriate theoretical perspective suited to the problem at hand, rather than adhering to a single theoretical perspective for all clients and all types of problems. Nevertheless, as FIGURE 15.1 shows, the majority of psychotherapists use a single approach, such as psychodynamic therapy, humanistic and existential therapies, or behavioral and cognitive therapies. We’ll examine each of those four major branches of psychotherapy in turn.

Psychodynamic psychotherapy has its roots in Freud’s psychoanalytically oriented theory of personality. Psychodynamic psychotherapies are therapies that explore childhood events and encourage individuals to use the understanding that results to develop insight into their psychological problems. Psychoanalysis was the first psychodynamic therapy to develop, but it has largely been replaced by modern psychodynamic therapies, such as interpersonal psychotherapy.

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Psychoanalysis

As you saw in the Personality chapter, psychoanalysis assumes that people are born with aggressive and sexual urges that are repressed during childhood development through the use of defense mechanisms. Psychoanalysts encourage their clients to bring these repressed conflicts into consciousness so that the clients can understand them and reduce their unwanted influences.

Traditional psychoanalysis involves four or five sessions per week over an average of 3 to 6 years (Ursano & Silberman, 2003). During a session, the client reclines on a couch, facing away from the analyst, and is asked to express whatever thoughts and feelings come to mind. Occasionally, the therapist may comment on some of the information presented by the client but does not express his or her values and judgments. The stereotypic image you might have of psychological therapy—a person lying on a couch talking to a person sitting in a chair—springs from this approach.

The goal of psychoanalysis is for the client to understand the unconscious in a process Freud called developing insight. Some key techniques that psychoanalysts use to help the client develop insight include free association, in which the client reports every thought that enters the mind and the therapist looks for recurring themes, and dream analysis, in which the therapist looks for dream elements that might symbolize unconscious conflicts or wishes. Psychoanalysts also assess the client’s resistance, or a reluctance to cooperate with treatment for fear of confronting unpleasant unconscious material. For example, the therapist might suggest that the client’s problem with obsessive health worries could be traced to a childhood rivalry with her mother for her father’s love and attention. The client could find the suggestion insulting and resist the interpretation, which might signal to the therapist that this is indeed an issue the client could be directed to confront in order to develop insight.

Over time and many therapy sessions, the client and psychoanalyst often develop a close relationship. Freud believed that the development and resolution of this relationship was a key process of psychoanalysis. Transference is an event that occurs when the analyst begins to assume a major significance in the client’s life and the client reacts to the analyst based on unconscious childhood fantasies. Successful psychoanalysis involves analyzing the transference so that the client understands this reaction and why it occurs.

Beyond Psychoanalysis

Although Freud’s insights and techniques are fundamental, modern psychodynamic treatments differ from classic psychoanalysis in both their content and procedures. One of the most widely used psychodynamic treatments is interpersonal psychotherapy (IPT), a form of psychotherapy that focuses on helping clients improve current relationships (Weissman, Markowitz, & Klerman, 2000). Rather than using free association, therapists using IPT talk to clients about their interpersonal behaviors and feelings. The therapists pay particular attention to the client’s grief (an exaggerated reaction to the loss of a loved one), role disputes (conflicts with a significant other), role transitions (changes in life status, such as starting a new job, getting married, or retiring), or interpersonal deficits (lack of the necessary skills to start or maintain a relationship). The treatment assumes that, as interpersonal relations improve, symptoms will subside.

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Modern psychodynamic psychotherapies such as IPT also differ from classical psychoanalysis in the procedures used. For starters, in modern psychodynamic therapy, the therapist and client typically sit face-to-face. In addition, therapy is less intensive, with meetings often occurring only once a week and therapy lasting months rather than years. In contrast to classical psychoanalysis, modern psychodynamic therapists are more likely to offer support or advice in addition to interpretation (Barber et al., 2013). Therapists are also now less likely to interpret a client’s statements as a sign of unconscious sexual or aggressive impulses.

Although psychodynamic therapy has been around for a long time and continues to be widely practiced, there is relatively little evidence for its effectiveness. Moreover, there is some evidence that some aspects of psychodynamic therapy may actually be harmful. For instance, research suggests that the more a therapist makes interpretations about perceived transference in the client, the worse the therapeutic alliance and the worse the clinical outcome (Henry et al., 1994). Psychodynamic therapy is not as widely used as it once was, but many psychologists still use it in practice, and many people say that they find it helpful.

Humanistic and existential therapies emerged in part as a reaction to the negative views that psychoanalysis holds about human nature. Humanistic and existential therapies share the assumption that psychological problems stem from feelings of alienation and loneliness, and that those feelings can be traced to failures to reach one’s potential (in the humanistic approach) or from failures to find meaning in life (in the existential approach). Although interest in these approaches peaked in the 1960s and 1970s, some therapists continue to use these approaches today. Two well-known types are person-centered therapy (a humanistic approach) and gestalt therapy (an existential approach).

Person-Centered Therapy

Person-centered therapy (or client-centered therapy) assumes that all individuals have a tendency toward growth and that this growth can be facilitated by acceptance and genuine reactions from the therapist. Psychologist Carl Rogers (1902-1987) developed person-centered therapy in the 1940s and 1950s (Rogers, 1951). Person-centered therapy assumes that each person is qualified to determine his or her own goals for therapy, such as feeling more confident or making a career decision, and even the frequency and length of therapy. In this type of treatment, the therapist tends not to provide advice or suggestions about what the client should be doing, but instead paraphrases the client’s words, mirroring the client’s thoughts and sentiments (e.g., “I think I hear you saying …”). Person-centered therapists believe that with adequate support, the client will recognize the right things to do.

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Person-centered therapists should demonstrate three basic qualities. The first is congruence, which refers to openness and honesty in the therapeutic relationship. For example, the same message must be communicated in the therapist’s words, the therapist’s facial expression, and the therapist’s body language. Saying “I think your concerns are valid” while smirking would simply not do. The second quality, empathy, refers to trying to understand the client by seeing the world from the client’s perspective, which enables the therapist to better appreciate the client’s apprehensions, worries, or fears. The third quality is unconditional positive regard, which entails providing a nonjudgmental, warm, and accepting environment in which the client can feel safe expressing his or her thoughts and feelings.

The goal is not to uncover repressed conflicts, as in psychodynamic therapy, but instead to try to understand the client’s experience and reflect that experience back to the client in a supportive way, encouraging the client’s natural tendency toward growth. This style of therapy is reminiscent of psychoanalysis in its way of encouraging the client toward the free expression of thoughts and feelings.

Gestalt Therapy

Gestalt therapy was founded by Frederick “Fritz” Perls (1893–1970) and colleagues in the 1940s and 1950s (Perls, Hefferkine, & Goodman, 1951). Gestalt therapy has the goal of helping the client become aware of his or her thoughts, behaviors, experiences, and feelings and to “own” or take responsibility for them. Gestalt therapists are encouraged to be enthusiastic and warm toward their clients, an approach they share with person-centered therapists. To help facilitate the client’s awareness, gestalt therapists also reflect back to the client their impressions of the client.

Gestalt therapy emphasizes the experiences and behaviors that are occurring at that particular moment in the therapy session. For example, if a client is talking about something stressful that occurred during the previous week, the therapist might ask, “How do you feel now as you describe what happened to you?” Clients are also encouraged to put their feelings into action. One way to do this is the empty chair technique, in which the client imagines that another person (e.g., a spouse, a parent, or a co-worker) is in an empty chair, sitting directly across from the client. The client then moves from chair to chair, alternating from role-playing what he or she would say to the other person and how he or she imagines the other person would respond. Gestalt techniques are often used in counseling or “life coaching” to help people prepare for new job or family situations (Grant, 2008).

Unlike the talk therapies described earlier, behavioral and cognitive treatments emphasize actively changing a person’s current thoughts and behaviors as a way to decrease or eliminate the patient’s psychopathology. In the evolution of psychological treatments, clients started out lying down in psychoanalysis, then sitting in psychodynamic and related approaches, but they are often standing and engaging in behavior-change homework assignments in their everyday lives in behavioral and cognitive therapies.

Behavior Therapy

Whereas Freud developed psychoanalysis as an offshoot of hypnosis and other techniques used by other clinicians before him, behavior therapy was developed based on laboratory findings from earlier behavioral psychologists. As you read in the Psychology: Evolution of a Science chapter, behaviorists rejected theories that were based on “invisible” mental properties that were difficult to test and impossible to observe directly. Behaviorists found psychoanalytic ideas particularly hard to test: How do you know whether a person has an unconscious conflict? Behavioral principles, in contrast, focused solely on behaviors that could be observed (e.g., avoidance of a feared object, such as refusing to get on an airplane). Behavior therapy is a type of therapy that assumes that disordered behavior is learned and that symptom relief is achieved through changing overt maladaptive behaviors into more constructive behaviors. A variety of behavior therapy techniques have been developed for many disorders, based on the learning principles you encountered in the Learning chapter, including operant conditioning procedures (which focus on reinforcement and punishment) and classical conditioning procedures (which focus on extinction). Here are three examples of behavior therapy techniques in action:

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Cognitive Therapy

Whereas behavior therapy focuses primarily on changing a person’s behavior, cognitive therapy focuses on helping a client identify and correct any distorted thinking about self, others, or the world (Beck, 2005). For example, behaviorists might explain a phobia as the outcome of a classical conditioning experience such as being bitten by a dog, where the dog bite leads to the development of a dog phobia through the association of the dog with the experience of pain. Cognitive theorists might instead emphasize the interpretation of the event and focus on a person’s new or strengthened belief that dogs are dangerous to explain the fear.

Cognitive therapies use a technique called cognitive restructuring, a therapeutic approach that teaches clients to question the automatic beliefs, assumptions, and predictions that often lead to negative emotions and to replace negative thinking with more realistic and positive beliefs. Specifically, clients are taught to examine the evidence for and against a particular belief or to be more accepting of outcomes that may be undesirable yet still manageable. For example, a depressed client may believe that she is stupid and will never pass her college courses—all on the basis of one poor grade. In this situation, the therapist would work with the client to examine the validity of this belief. The therapist would consider relevant evidence such as grades on previous exams, performance in other coursework, and examples of intelligence outside school. In therapy sessions, the cognitive therapist will help the client to identify evidence that supports—and fails to support—each negative thought in order to help the client generate more balanced thoughts that accurately reflect the true state of affairs. In other words, the clinician tries to remove the dark lens through which the client views the world, not with the goal of replacing it with rose-colored glasses, but instead with clear glasses. Here is a brief sample transcript of what part of a cognitive therapy session might sound like.

In addition to cognitive restructuring techniques, which try to change a person’s thoughts to be more balanced or accurate, some forms of cognitive therapy also include techniques for coping with unwanted thoughts and feelings, techniques that resemble meditation (see the Consciousness chapter). One such technique, called mindfulness meditation, teaches an individual to be fully present in each moment; to be aware of his or her thoughts, feelings, and sensations; and to detect symptoms before they become a problem. In one study, people recovering from depression were about half as likely to relapse during a 60-week assessment period if they received mindfulness meditation-based cognitive therapy than if they received treatment as usual (Teasdale, Segal, & Williams, 2000).

Cognitive Behavioral Therapy

Historically, cognitive and behavioral therapies were considered distinct systems of therapy. Today, most therapists working with anxiety and depression use a blend of cognitive and behavioral therapeutic strategies, often referred to as cognitive behavioral therapy (CBT). In contrast to traditional behavior therapy and cognitive therapy, CBT is problem focused, meaning that it is undertaken for specific problems (e.g., reducing the frequency of panic attacks or returning to work after a bout of depression), and action oriented, meaning that the therapist tries to assist the client in selecting specific strategies to help address those problems. The client is expected to do things, such as engage in exposure exercises, practice behavior change skills or use a diary to monitor relevant symptoms (e.g., the severity of a depressed mood or panic attack symptoms). This is in contrast to psychodynamic or other therapies in which goals may not be explicitly discussed or agreed on and the client’s only necessary action is to attend the therapy session.

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Cognitive behavioral therapies have been found to be effective for a number of disorders (Butler et al., 2006), including unipolar depression, generalized anxiety disorder, panic disorder, social phobia, posttraumatic stress disorder, and childhood depressive and anxiety disorders (see the Hot Science box).

It is natural to think of psychopathology as an illness that affects only the individual. Yet each person lives in a world of other people, and interactions with others may intensify and even create disorders. A depressed person may be lonely after moving away from friends and loved ones, or an anxious person could be worried about pressures from parents. These ideas suggest that people might be able to recover from disorders in the same way they got into them—not just as an individual effort, but through social processes.

Couples and Family Therapy

When a couple is “having problems,” neither individual may be suffering from any psychopathology. Rather, it may be the relationship itself that is disordered. Couples therapy is when a married, cohabitating, or dating couple is seen together in therapy to work on problems usually arising within the relationship. For example, a couple might seek help because they are unhappy with their relationship. In this scenario, both members of the couple are expected to attend therapy sessions, and the problem is seen as arising from their interaction rather than from the problems of one half of the couple. Treatment strategies would target changes in both parties, focusing on ways to break their repetitive dysfunctional pattern.

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There are cases in which therapy with even larger groups is warranted. An individual may be having a problem—say, an adolescent is abusing alcohol—but the source of the problem is the individual’s relationships with family members; perhaps the mother is herself an alcoholic who subtly encourages the adolescent to drink and the father travels and neglects the family. In this case, it could be useful for the therapist to work with the whole group at once in family therapy—psychotherapy involving members of a family. As in couples therapy, the problems and solutions are seen as arising from the interaction of individuals in the family rather than simply from any one individual.

Group Therapy

Taking these ideas one step further, if individuals (or families) can benefit from talking with a psychotherapist, perhaps they can also benefit from talking with other clients who are talking with the therapist. This is group therapy, a technique in which multiple participants (who often do not know one another at the outset) work on their individual problems in a group atmosphere. The therapist in group therapy serves more as a discussion leader than as a personal therapist, conducting the sessions both by talking with individuals and by encouraging them to talk with one another.

Why do people choose group therapy? One advantage is that attending a group with others who have similar problems shows clients that they are not alone in their suffering. In addition, group members model appropriate behaviors for one another and share their insights about how to deal with their problems. Group therapy is often just as effective as individual therapy (e.g., Jonsson & Hougaard, 2008). So, from a societal perspective, group therapy is much more efficient.

Group therapy also has disadvantages. It may be difficult to assemble a group of individuals who have similar needs. This is particularly an issue with CBT, which tends to focus on specific problems such as depression or panic disorder. Group therapy may become a problem if one or more members undermine the treatment of other group members—for example, by dominating the discussions or by making others in the group uncomfortable (e.g., attempting to date other members). Finally, clients in group therapy get less attention than they might in individual psychotherapy.

Self-Help and Support Groups

An important offshoot of group therapy is the concept of self-help groups and support groups, which are discussion groups that are often run by peers who have themselves struggled with the same issues. The most famous self-help and support groups are Alcoholics Anonymous (AA), Gamblers Anonymous, and Al-Anon (a program for the family and friends of those with alcohol problems). Other self-help groups offer support to people with mood disorders, eating disorders, and substance abuse problems. In fact, self-help and support groups exist for just about every psychological disorder. In addition to being cost-effective, self-help and support groups allow people to realize that they are not the only ones with a particular problem and give them the opportunity to offer guidance and support to each other based on personal experiences of success.

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In some cases, though, self-help and support groups can do more harm than good. Some members may be disruptive or aggressive or encourage one another to engage in behaviors that are countertherapeutic (e.g., avoiding feared situations or using alcohol to cope). People with moderate problems may be exposed to others with severe problems and may become oversensitized to symptoms they might not otherwise have found disturbing. Because self-help and support groups are usually not led by trained therapists, mechanisms to evaluate these groups or to ensure their quality are rarely in place.

AA has more than two million members in the United States, with 185,000 group meetings that occur around the world (Mack, Franklin, & Frances, 2003). Members are encouraged to follow “12 steps” to reach the goal of lifelong abstinence from all drinking, and the steps include believing in a higher power, practicing prayer and meditation, and making amends for harm to others. A few studies examining the effectiveness of AA have been conducted, and it appears that individuals who participate tend to overcome problem drinking with greater success than those who do not participate in AA (Fiorentine, 1999; Morgenstern et al., 1997). However, several tenets of the AA philosophy are not supported by the research. We know that the general AA program is useful, but questions about which parts of this program are most helpful have yet to be studied.

Considered together, the many social approaches to psychotherapy reveal how important interpersonal relationships are for each of us. It may not always be clear how psychotherapy works, whether one approach is better than another, or what particular theory should be used to understand how problems have developed. What is clear, however, is that social interactions between people—both in individual therapy and in all the different forms of therapy in groups—can be useful in treating psychological disorders.