Psychotherapy

For the academic journal, seePsychotherapy(journal).

"Therapy session" redirects here. For the music albums, seeTherapy SessionandTherapy Sessions.

Psychotherapy
MeSH	D011613

Psychotherapy(alsopsychological therapy,talk therapy,ortalking therapy) is the use ofpsychologicalmethods, particularly when based on regularpersonal interaction,to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual'swell-beingandmental health,to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships andsocial skills.Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are consideredevidence-basedfor treating some diagnosedmental disorders;other types have been criticized aspseudoscience.

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 withgroups,includingfamilies.

Psychotherapists may bemental health professionalssuch 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 thejurisdictionmay be legally regulated, voluntarily regulated or unregulated (and the term itself may be protected or not).

Definitions

The termpsychotherapyis derived fromAncient Greekpsyche(ψυχήmeaning "breath; spirit; soul" ) andtherapeia(θεραπεία"healing; medical treatment" ). TheOxford English Dictionarydefines it as "The treatment of disorders of the mind or personality by psychological means...", however, in earlier use it denoted the treatment of disease through hypnotic suggestion.Psychotherapy is often dubbed as a "talking therapy" or "talk therapy", particularly for a general audience,though not all forms of psychotherapy rely onverbal communication.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.

TheAmerican Psychological Associationadopted a resolution on the effectiveness of psychotherapy in 2012 based on a definition developed by American psychologistJohn C. Norcross:"Psychotherapy is the informed and intentional application ofclinical methodsandinterpersonal stancesderived 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 ".Influential editions of a work by psychiatristJerome Frankdefined 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 ofpersuasionandrhetoric.Historically, psychotherapy has sometimes meant "interpretative" (i.e.Freudian) methods, namelypsychoanalysis,in contrast with other methods to treat psychiatric disorders such as behavior modification.

Some definitions ofcounselingoverlap with psychotherapy (particularly in non-directive client-centered approaches), or counseling may refer to guidance for everyday problems in specific areas, typically for shorter durations with a less medical or "professional" focus.Somatotherapyrefers to the use of physical changes as injuries and illnesses, andsociotherapyto the use of a person's social environment to effect therapeutic change.Psychotherapy may addressspiritualityas 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.

Delivery

Psychotherapy may be delivered in person (one on one, or with couples, or in groups) or viatelephone counselingoronline counseling(see also§ Telepsychotherapy).There have also been developments in computer-assisted therapy, such asvirtual reality therapyfor behavioral exposure, multimedia programs to teach cognitive techniques, and handheld devices for improved monitoring or putting ideas into practice (see also§ Computer-supported).

Most forms of psychotherapy use spokenconversation.Some also use various other forms of communication such as the written word,artwork,drama,narrativestory or music. Psychotherapy with children and their parents often involvesplay,dramatization (i.e. role-play), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting.

Regulation

See also:Psychologist § Licensing and regulations,Counseling psychology § Counseling ethics and regulation,Psychiatrist § Professional requirements,Health professional requisites,Social work § Qualifications,andMental health professional § Professional distinctions

Psychotherapists traditionally may bemental health professionalslike 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. Psychiatristsare trained first as physicians, and as such they may prescribeprescription medication;and specialist psychiatric training begins after medical school in psychiatric residencies: however, their specialty is in mental disorders or forms of mental illness.Clinical psychologistshave 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 often 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.

A listing of the extensive professional competencies of a European psychotherapist was developed by the European Association of Psychotherapy (EAP) in 2013.

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 ofclient 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.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.

Europe

As of 2015, there are still a lot of variations between different European countries about the regulation and delivery of psychotherapy. Several countries have no regulation of the practice or no protection of the title. Some have a system of voluntary registration, with independent professional organizations, while other countries attempt to restrict the practice of psychotherapy to 'mental health professionals' (psychologists and psychiatrists) with state-certified training. The titles that are protected also vary.TheEuropean Association for Psychotherapy(EAP) established the 1990 Strasbourg Declaration on Psychotherapy, which is dedicated to establishing an independent profession of psychotherapy in Europe, with pan-European standards.The EAP has already made significant contacts with the European Union & European Commission towards this end.

Given that theEuropean Unionhas a primary policy about the free movement of labor within Europe, European legislation can overrule national regulations that are, in essence, forms of restrictive practices.

In Germany, the practice of psychotherapy for adults is restricted to qualified psychologists and physicians (including psychiatrists) who have completed several years of specialist practical training and certification in psychotherapy.As psychoanalysis, psychodynamic therapy, and cognitive behavioral therapy meet the requirements of German health insurance companies, mental health professionals regularly opt for one of these three specializations in their postgraduate training. For psychologists, this includes three years of full-time practical training (4,200 hours), encompassing a year-long internship at an accredited psychiatric institution, six months of clinical work at an outpatient facility, 600 hours of supervised psychotherapy in an outpatient setting, and at least 600 hours of theoretical seminars.Social workersmay complete the specialist training for child and teenage clients.Similarly in Italy, the practice of psychotherapy is restricted to graduates in psychology or medicine who have completed four years of recognised specialist training.Sweden has a similar restriction on the title "psychotherapist", which may only be used by professionals who have gone through a post-graduate training in psychotherapy and then applied for a licence, issued by theNational Board of Health and Welfare.

Legislation in France restricts the use of the title "psychotherapist" to professionals on the National Register of Psychotherapists,which requires a training in clinical psychopathology and a period of internship which is only open to physicians or titulars of a master's degree in psychology or psychoanalysis.

Austria and Switzerland (2011) have laws that recognize multi-disciplinary functional approaches.

In the United Kingdom, the government andHealth and Care Professions Councilconsidered mandatory legal registration but decided that it was best left to professional bodies to regulate themselves, so theProfessional Standards Authority for Health and Social Care(PSA) launched an Accredited Voluntary Registers scheme.Counseling and psychotherapy are not protected titles in the United Kingdom. Counsellors and psychotherapists who have trained and qualify to a certain standard (usually a level 4 Diploma) can apply to be members of the professional bodies who are listed on the PSA Accredited Registers.

United States

In some states, counselors or therapists must be licensed to use certain words and titles on self-identification or advertising. In some other states, the restrictions on practice are more closely associated with the charging of fees. Licensing and regulation are performed by various states. Presentation of practice as licensed, but without such a license, is generally illegal.Without a license, for example, a practitioner cannot bill insurance companies.Information about state licensure of psychologists is provided by theAmerican Psychological Association.

In addition to state laws, the American Psychological Association requires its members to adhere to its publishedEthical Principles of Psychologists and Code of Conduct.TheAmerican Board of Professional Psychologyexamines and certifies "psychologists who demonstrate competence in approved specialty areas in professional psychology".

Canada

Regulation of psychotherapy is in the jurisdiction of, and varies among, the provinces and territories.

InQuebec,psychotherapy is a regulated activity which is restricted to psychologists, medical doctors, and holders of a psychotherapy permit issued by the Ordre des psychologues du Québec, the Quebec order of psychologists. Members of certain specified professions, includingsocial workers,couple and family therapists,occupational therapists,guidance counsellors,criminologists,sexologists,psychoeducators,and registered nurses may obtain a psychotherapy permit by completing certain educational and practice requirements; their professional oversight is provided by their own professional orders. Some other professionals who were practising psychotherapy before the current system came into force continue to hold psychotherapy permits alone.

On 1 July 2019, Ontario's Missing Persons Act came into effect, with the purpose of giving police more power to investigate missing persons. It allows police to require (as opposed to permit) health professionals, including psychotherapists, to share otherwise confidential documents about their client, if there is reason to believe their client is missing.Some have expressed concern that this legislation undermines psychotherapy confidentiality and could be abused maliciously by police,while others have praised the act for how it respects privacy and includes checks and balances.

History

See also:History of psychotherapyandTimeline of psychotherapy

Psychotherapy 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.

In theWestern tradition,by the 19th century, amoral treatmentmovement (then meaning morale or mental) developed based on non-invasive non-restraint therapeutic methods.Another influential movement was started byFranz Mesmer(1734–1815) and his studentArmand-Marie-Jacques de Chastenet, Marquis of Puységur(1751–1825). Called Mesmerism or animal magnetism, it would have a strong influence on the rise ofdynamic psychologyand psychiatry as well as theories abouthypnosis.In 1853,Walter Cooper Dendyintroduced 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.Daniel Hack Tukecited the term and wrote about "psycho-therapeutics" in 1872, in which he also proposed making a science ofanimal magnetism.Hippolyte Bernheimand colleagues in the "NancySchool "developed the concept of" psychotherapy "in the sense of using the mind to heal the body throughhypnotism,yet further.Charles Lloyd Tuckey's 1889 work,Psycho-therapeutics, or Treatment by Hypnotism and Suggestionpopularized the work of the Nancy School in English.Also in 1889 a clinic used the word in its title for the first time, whenFrederik van Eedenand Albert Willem van Renterghem inAmsterdamrenamed theirs "Clinique de Psycho-thérapeutique Suggestive" after visiting Nancy.During this time, travellingstage hypnosisbecame popular, and such activities added to the scientific controversies around the use of hypnosis in medicine.Also in 1892, at the second congress of experimental psychology, van Eeden attempted to take the credit for the term psychotherapy and to distance the term from hypnosis.In 1896, the German journal Zeitschrift für Hypnotismus, Suggestionstherapie, Suggestionslehre und verwandte psychologische Forschungen changed its name to Zeitschrift für Hypnotismus, Psychotherapie sowie andere psychophysiologische und psychopathologische Forschungen, which is probably the first journal to use the term.Thus psychotherapy initially meant "the treatment of disease by psychic or hypnotic influence, or by suggestion".

Freud, seated left of picture with Jung seated at the right of the picture. 1909

Sigmund Freudvisited the Nancy School and his earlyneurologicalpractice involved the use of hypnotism. However following the work of his mentorJosef 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 theunconscious mind.He went on to develop techniques such asfree association,dream interpretation,transferenceand analysis of theid, ego and superego.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, and by the effective work of his followers in rewriting history.Many theorists, includingAlfred Adler,Carl Jung,Karen Horney,Anna Freud,Otto Rank,Erik Erikson,Melanie KleinandHeinz Kohut,built upon Freud's fundamental ideas and often developed their own systems of psychotherapy. These were all later categorized aspsychodynamic,meaning anything that involved thepsyche'sconscious/unconsciousinfluence on external relationships and the self. Sessions tended to number into the hundreds over several years.

Behaviorismdeveloped in the 1920s, andbehavior modificationas a therapy became popularized in the 1950s and 1960s. Notable contributors wereJoseph Wolpein South Africa,M.B. ShapiroandHans Eysenckin Britain, andJohn B. WatsonandB.F. Skinnerin the United States.Behavioral therapyapproaches relied on principles ofoperant conditioning,classical conditioningandsocial learning theoryto bring about therapeutic change in observable symptoms. The approach became commonly used forphobias,as well as other disorders.

Some therapeutic approaches developed out of the European school ofexistential 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 thepatient-therapist relationshipthus also forms a vehicle for therapeutic inquiry. A related body of thought in psychotherapy started in the 1950s withCarl Rogers.Based also on the works ofAbraham Maslowand hishierarchy of human needs,Rogers broughtperson-centered psychotherapyinto mainstream focus. 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]; andempathic understanding.This type of interaction was thought to enable clients to fully experience and express themselves, and thus develop according to their innate potential.Others developed the approach, likeFritzandLaura Perlsin the creation ofGestalt therapy,as well as Marshall Rosenberg, founder ofNonviolent Communication,andEric Berne,founder oftransactional analysis.Later these fields of psychotherapy would become what is known ashumanistic psychotherapytoday. Self-help groups and books became widespread.

During the 1950s,Albert Ellisoriginatedrational emotive behavior therapy(REBT). Independently a few years later, psychiatristAaron T. Beckdeveloped a form of psychotherapy known ascognitive 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, by contrast with the more long-lasting insight-based approach of psychodynamic or humanistic therapies. Beck's approach used primarily thesocratic method,and links have been drawn between ancientstoicphilosophy and these cognitive therapies.

Cognitive and behavioral therapy approaches were increasingly combined and grouped under the umbrella termcognitive behavioral therapy(CBT) in the 1970s. Many approaches within CBT are oriented towards active/directive yet collaborativeempiricism(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. A "third wave" of cognitive and behavioral therapies developed, includingacceptance and commitment therapyanddialectical behavior therapy,which expanded the concepts to other disorders and/or added novel components andmindfulnessexercises. However the "third wave" concept has been criticized as not essentially different from other therapies and having roots in earlier ones as well.Counseling methods developed includesolution-focused therapyandsystemic coaching.

Postmodernpsychotherapies such asnarrative therapyandcoherence therapydo not impose definitions of mental health and illness, but rather see the goal of therapy as something constructed by the client and therapist in a social context.Systemic therapyalso developed, which focuses on family and group dynamics—andtranspersonal psychology,which focuses on the spiritual facet of human experience. Other orientations developed in the last three decades includefeminist therapy,brief therapy,somatic psychology,expressive therapy,appliedpositive psychologyand thehuman givensapproach. A survey of over 2,500 US therapists in 2006 revealed the most utilized models of therapy and the ten most influential therapists of the previous quarter-century.

Types

See also:List of psychotherapies

There are hundreds of psychotherapy approaches or schools of thought. By 1980 there were more than 250;by 1996 more than 450;and at the start of the 21st century there were over a thousand different named psychotherapies—some being minor variations while others are based on very different conceptions of psychology, ethics (how to live) or technique.In practice therapy is often not of one pure type but draws from a number of perspectives and schools—known as anintegrativeoreclecticapproach.The importance of thetherapeutic relationship,also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy.Common factors theoryaddresses this and other core aspects thought to be responsible for effective psychotherapy. Sigmund Freud (1856–1939), a Viennese neurologist who studied withJean-Martin Charcotin 1885, is often considered the father of modern psychotherapy. His methods included analyzing his patient's dreams in search of important hidden insights into their unconscious minds. Other major elements of his methods, which changed throughout the years, included identification of childhood sexuality, the role of anxiety as a manifestation of inner conflict, the differentiation of parts of the psyche (id, ego, superego), transference and countertransference (the patient's projections onto the therapist, and the therapist's emotional responses to that). Some of his concepts were too broad to be amenable to empirical testing and invalidation, and he was critiqued for this by Jaspers. Numerous major figures elaborated and refined Freud's therapeutic techniques including Melanie Klein, Donald Winnicott, and others. Since the 1960s, however, the use of Freudian-based analysis for the treatment ofmental disordershas declined substantially. Different types of psychotherapy have been created along with the advent of clinical trials to test them scientifically. These incorporate subjective treatments (after Beck), behavioral treatments (after Skinner and Wolpe) and additional time-constrained and centered structures, for example, interpersonal psychotherapy. In youth issue and in schizophrenia, the systems of family treatment hold esteem. A portion of the thoughts emerging from therapy are presently pervasive and some are a piece of the tool set of ordinary clinical practice. They are not just medications, they additionally help to understand complex conduct.

Therapy may address specific forms of diagnosablemental illness,or everyday problems in managing or maintaininginterpersonal relationshipsor meeting personal goals. A course of therapy may happen before, during or afterpharmacotherapy(e.g. takingpsychiatric medication).

Psychotherapies are categorized in several different ways. A distinction can be made between those based on amedical modeland those based on ahumanistic 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 theDSM-IV,the diagnostic and statistical manual of mental disorders in the United States is an example of a medically exclusive model. The humanistic or non-medical 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. The therapist may see themselves as a facilitator/helper.

Another distinction is between individual one-to-one therapy sessions, andgroup psychotherapy,includingcouples therapyandfamily therapy.

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

Some practitioners distinguish between more "uncovering" (or "depth") approaches and more" supportive "psychotherapy. Uncovering psychotherapy emphasizes facilitating the client's insight into the roots of their difficulties. The best-known example is classical psychoanalysis.Supportive psychotherapyby contrast stresses strengthening the client's coping mechanisms and often providing encouragement and advice, as well as reality-testing and limit-setting where necessary. Depending on the client's issues and situation, a more supportive or more uncovering approach may be optimal.

Humanistic

Main article:Humanistic psychology

These psychotherapies, also known as "experiential",are based onhumanistic psychologyand 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 onsubjectivemeaning, a rejection ofdeterminism,and a concern for positive growth rather thanpathology.Some posit an inherent human capacity to maximize potential, "theself-actualizingtendency "; the task of therapy is to create a relational environment where this tendency might flourish.Humanistic psychology can, in turn, be rooted inexistentialism—the belief that human beings can only find meaning by creating it. This is the goal ofexistential therapy.Existential therapy is in turn philosophically associated withphenomenology.

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 ownself.

HumanisticPsychodrama(HPD) is based on the human image of humanistic psychology.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. 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.

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.

A briefer form of humanistic therapy is thehuman givensapproach, introduced in 1998–99.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.

Insight-oriented

Main article:Insight-oriented psychotherapy

Insight-oriented psychotherapiesfocus on revealing or interpretingunconsciousprocesses. Most commonly referring topsychodynamic therapy,of whichpsychoanalysisis the oldest and most intensive form, these applications ofdepth psychologyencourage the verbalization of all the patient's thoughts, includingfree 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,andrelational psychoanalysis.Techniques for analyticgroup therapyhave also developed.

Cognitive-behavioral

Main article:Cognitive behavioral therapy

Behavior therapiesusebehavioraltechniques, includingapplied behavior analysis(also known asbehavior modification), to change maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others.Functional analytic psychotherapyis one form of this approach. 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).

Cognitive therapyfocuses directly on changing the thoughts, in order to improve the emotions and behaviors.

Cognitive behavioral therapyattempts to combine the above two approaches, focused on the construction and reconstruction of people'scognitions,emotionsandbehaviors.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.

The concept of "third wave" psychotherapies reflects an influence ofEastern philosophy in clinical psychology,incorporating principles such asmeditationinto interventions such asmindfulness-based cognitive therapy,acceptance and commitment therapy,anddialectical behavior therapyforborderline personality disorder.

Interpersonal psychotherapy(IPT) is a relatively brief form of psychotherapy (deriving from both CBT andpsychodynamicapproaches) that has been increasingly studied and endorsed by guidelines for some conditions. It focuses on the links betweenmoodand social circumstances, helping to build social skills and social support.It aims to foster adaptation to current interpersonal roles and situations.

Exposure and response prevention(ERP) is primarily deployed by therapists in the treatment ofOCD.TheAmerican Psychiatric Association(APA) state that CBT drawing primarily on behavioral techniques (such as ERP) has the "strongest evidence base" among psychosocial interventions.By confronting feared scenarios (i.e., exposure) and refraining from performing rituals (i.e., responsive prevention), patients may gradually feel less distress in confronting feared stimuli, while also feeling less inclination to use rituals to relieve that distress. Typically, ERP is delivered in "hierarchical fashion", meaning patients confront increasingly anxiety-provoking stimuli as they progress through a course of treatment.

Other types includereality therapy/choice theory,multimodal therapy,and therapies for specific disorders includingPTSDtherapies such ascognitive processing therapy,substance abusetherapies such asrelapse preventionandcontingency management;andco-occurring disorderstherapies such as Seeking Safety.

Systemic

Main article:Systemic therapy

Group therapy, Ukraine

Systemic therapyseeks 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 (includesfamily therapyandmarriage counseling).Community psychologyis a type of systemic psychology.

The termgroup therapywas first used around 1920 byJacob L. Moreno,whose main contribution was the development ofpsychodrama,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 asPaul 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, notablyWilfred Bionand Rickman, followed byS. H. Foulkes,Main, and Bridger. TheNorthfield Hospitalin 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, thetherapeutic communitymovement, 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.

Expressive

Main article:Expressive therapy

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 modalitiesdance therapy,drama therapy,art therapy,music therapy,writing therapy,among others.This may include techniques such asaffect 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 aspost-structuralistorconstructivist.Narrative therapygives 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 therapyposits multiple levels of mental constructs that create symptoms as a way to strive for self-protection or self-realization.Feminist therapydoes not accept that there is one single or correct way of looking at reality and therefore is considered a postmodernist approach.

Other

Transpersonal psychologyaddresses the client in the context of a spiritual understanding of consciousness.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.

Hypnotherapyis undertaken while a subject is in a state ofhypnosis.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,anxiety,stress-related illness,pain management,and personal development.

Psychedelic therapyare therapeutic practices involvingpsychedelic drugs,such asLSD,psilocybin,DMT,andMDMA.In psychedelic therapy, in contrast to conventionalpsychiatric medicationtaken by the patient regularly or as needed, patients generally remain in an extended psychotherapy session during the acute psychedelic activity with additional sessions both before and after in order to help integrate experiences with the psychedelics.Psychedelic therapy has been compared with theshamanichealing rituals of indigenous people. Researchers identified two main differences: the first is the shamanic belief that multiple realities exist and can be explored through altered states of consciousness, and second the belief that spirits encountered in dreams and visions are real.The charitable initiativeFounders Pledgehas written a research report on cost-effective giving opportunities for funding psychedelic-assisted mental health treatments.

Body psychotherapy,part of the field ofsomatic psychology,focuses on the link between the mind and the body and tries to access deeper levels of the psyche through greater awareness of thephysical bodyandemotions.There are variousbody-orientedapproaches, such as Reichian (Wilhelm Reich) character-analyticvegetotherapyand orgonomy; neo-Reichianbioenergetic analysis;somatic experiencing;integrative body psychotherapy;Ron Kurtz'sHakomipsychotherapy; sensorimotor psychotherapy; Biosynthesis psychotherapy; and Biodynamic psychotherapy. These approaches are not to be confused withbody workor body-therapies that seek to improve primarily physical health through direct work (touch and manipulation) on the body, rather than through directly psychological methods.

Some non-Westernindigenoustherapies have been developed. In African countries this includes harmony restoration therapy, meseron therapy and systemic therapies based on theUbuntu philosophy.

Integrative psychotherapyis 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 includemultimodal therapy,thetranstheoretical model,cyclical psychodynamics, systematic treatment selection,cognitive analytic therapy,internal family systems model,multitheoretical psychotherapyand conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time.

Child

Main article:Child psychotherapy

Psychotherapy needs to be adapted to meet the developmental needs of children. Depending on age, it is generally held to be one part of an effective strategy to help the needs of a child within the family setting.Child psychotherapy training programs necessarily include courses inhuman development.Since children often do not have the ability to articulate thoughts and feelings, psychotherapists will use a variety of media such as musical instruments, sand and toys, crayons, paint, clay, puppets, bibliocounseling (books), or board games. The use ofplay therapyis often rooted inpsychodynamic theory,but other approaches also exist.

In addition to therapy for the child, sometimes instead of it, children may benefit if their parents work with a therapist, take parenting classes, attendgrief counseling,or take other action to resolve stressful situations that affect the child.Parent management trainingis a highly effective form of psychotherapy that teaches parenting skills to reduce their child's behavior problems.

In many cases a different psychotherapist will work with the care taker of the child, while a colleague works with the child.Therefore, contemporary thinking on working with the younger age group has leaned towards working with parent and child simultaneously, as well as individually as needed.

Computer-supported

See also:Online counselingandUse of technology in treatment of mental disorders

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

• Virtual reality:VRis a computer-generated scenario that simulates experience. The immersive environment, used for simulatedexposure,can be similar to the real world or it can be fantastical, creating a new experience.
• Computer-based interventions (oronline interventionsorinternet interventions): These interventions can be described as interactive self-help. They usually entail a combination of text, audio or video elements.
• Computer-supported therapy (orblended therapy): Classical psychotherapy is supported by means of online orsoftware applicationelements. The feasibility of such interventions has been investigated for individualand group therapy.

Telepsychotherapy

This section is an excerpt fromTelepsychiatry.[edit]

Telemental health session

Telepsychiatryor telemental health refers to the use oftelecommunicationstechnology (mostlyvideoconferencingand phone calls) to deliverpsychiatric careremotely for people withmental health conditions.It is a branch oftelemedicine.

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.

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 necessarydigital skills.Factors such aspovertythat are associated with lack of internet access are also associated with greater risk of mental health problems, makingdigital exclusionan important problem of telemental health services.

During theCOVID-19 pandemicmental health services were adapted to telemental health inhigh-income countries.It proved effective and acceptable for use in an emergency situation but there were concerns regarding its long-term implementation.

Effects

Evaluation

There is considerable controversy about whether, or when, psychotherapy efficacy is best evaluated byrandomized controlled trialsor more individualizedidiographicmethods.

One issue with trials is what to use as aplacebotreatment group or non-treatmentcontrol 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 inplacebo-controlled studiesin pharmaceutical trials. Several interpretations and differing assumptions and language remain.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.

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).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.

A pioneer in investigating the results of different psychological therapies was psychologistHans Eysenck,who argued that psychotherapy does not produce any improvement in patients. He held thatbehavior therapyis 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.

Outcomes in relation with selected kinds of treatment

Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.A 2022 meta-analysis of meta-analyses found that effect sizes reported for both psychotherapies and pharmacotherapies, compared to treatment-as-usual or placebo, were small for most disorders and treatments, and concluded that a "paradigm shift in research" was needed to advance the field and improve treatment strategies for mental disorders.

One line of research consistently found that supposedly different forms of psychotherapy show similar effectiveness. According to the 2008 edition ofThe Handbook of Counseling Psychology:"Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments".The handbook stated that "little evidence suggests that any one treatment consistently outperforms any other for any specific psychological disorders".This is sometimes called theDodo bird verdictafter a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes.

Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known ascommon factors theory;for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.

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 thereplicationof research results and the ability to generalize from them to practicing therapists.

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

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.

Meta-analyses have established thatcognitive behavioural therapy(CBT) andpsychodynamic psychotherapyare equally effective in treating depression.

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.For children and adolescents, interpersonal psychotherapy and CBT are the best methods according to a 2014 meta analysis of almost 4000 patients.

Mechanisms of change

It is not yet understood how psychotherapies can succeed in treating mental illnesses.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 ofemotional arousalandmemoryhave 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 ofmemory reconsolidationis triggered and is able to incorporate new emotional experiences.

Adherence

Patientadherenceto 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.The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.

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.

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.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 onadverse effectsof 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.Potential problems include deterioration of symptoms or developing new symptoms, strains in other relationships, social stigma, and therapy dependence.Some techniques or therapists may carry more risks than others, and some client characteristics may make them more vulnerable.Side-effects from properly conducted therapy should be distinguished from harms caused by malpractice.

General critiques

Some critics are skeptical of the healing power of psychotherapeutic relationships.Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners,instead favoring either nonprofessional helpor biomedical treatments.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).

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.

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 USNational Institute of Mental Healthallocated only 5.4% of its budget to new clinical trials of psychotherapies (medication trials are largely funded bypharmaceutical companies), despite plentiful evidence they can work and that patients are more likely to prefer them.

Further critiques have emerged fromfeminist,constructionistanddiscourse-analyticalsources.Key to these is the issue ofpower.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.This means that alternative ideas (e.g., feminist,economic,spiritual) are sometimes implicitly undermined.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.A noted academic who espoused this criticism wasMichel Foucault.

See also

• Improving Access to Psychological Therapies– United Kingdom initiative to improve access to psychological therapiesPages displaying wikidata descriptions as a fallback
• List of psychotherapy journals
• Physical therapy– Profession that helps a disabled person function in everyday life
• Psychosomatic medicine– Interdisciplinary medical field exploring various influences on bodily processes

Further reading

• Bartlett, Steven J. (1987).When You Don't Know Where to Turn: A Self-diagnosing Guide to Counseling and Therapy.Contemporary Books.ISBN9780809248292.
• Bloch, Sidney (2006).Introduction to the Psychotherapies(4th ed.). Oxford University Press.ISBN0198520921.
• Carter, Robert T., ed. (2005).Handbook of Racial-Cultural Psychology and Counseling.OCLC54905669.Two volumes.
• Corey, Gerald (2015).Theory and Practice of Counseling and Psychotherapy(10th ed.). Cengage Learning.ISBN9781305263727.
• Cozolino, Louis (2017).The Neuroscience of Psychotherapy: Healing the Social Brain(3rd ed.). National Geographic Books.ISBN9780393712643.
• DeBord, Kurt A.; Fischer, Ann R.; Bieschke, Kathleen J.; Perez, Ruperto M., eds. (2017).Handbook of Sexual Orientation and Gender Diversity in Counseling and Psychotherapy.American Psychological Association.ISBN9781433823060.
• Foschi, Renato; Innamorati, Marco (2023).A Critical History of Psychotherapy.Routledge, Taylor & Francis.ISBN9781032364025.Two volumes.
• Hofmann, Stefan G., ed. (2017).International Perspectives on Psychotherapy.Springer.ISBN9783319561936.
• Jongsma, Arthur E.; Peterson, L. Mark; Bruce, Timothy J. (2021).The Complete Adult Psychotherapy Treatment Planner(6th ed.). John Wiley & Sons.ISBN978-1118067864.
• McAuliffe, Garrett J., ed. (2021).Culturally Alert Counseling: A Comprehensive Introduction(3rd ed.). SAGE Publications.ISBN9781483378213.
• Prochaska, James O.; Norcross, John C. (2018).Systems of Psychotherapy: A Transtheoretical Analysis(9th ed.). Oxford University Press.ISBN9780190880415.
• Rastogi, Mudita; Wieling, Elizabeth, eds. (2005).Voices of Color: First-Person Accounts of Ethnic Minority Therapists.ISBN0761928901.
• Slavney, Phillip R. (2005).Psychotherapy: An Introduction for Psychiatry Residents and Other Mental Health Trainees.JHU Press.ISBN0801880963.
• Wampold, Bruce E. (2019).The Basics of Psychotherapy: An Introduction to Theory and Practice(2nd ed.). American Psychological Association.ISBN9781433830198.