What Is Psychotherapy?
According to the book History of Psychotherapy: Continuity and Change, attempts to assist people using talking psychotherapy-like approaches or techniques can be traced back to ancient cultures. The formal term psychotherapy was developed from an English psychiatrist named Dr. Walter C. Dendy who described his talking therapy treatment approach in the 1880s.
The person most often credited with being the founder of modern psychotherapy is Sigmund Freud. Freud was a neurologist who became interested in treating hysteria (a presentation of neurological paralysis or other symptoms that had no physical cause) and other issues by first using hypnosis and then later using a “talking cure” that led to an understanding and realization (catharsis) by his patients. Freud’s application of psychotherapy, psychoanalysis, was much longer in duration and required more frequent weekly visits than the psychotherapy that is commonly practiced today. However, Freud’s influence on psychotherapy remains very substantial even though many of his major propositions are no longer used by the majority of practicing therapists.
What Distinguishes Psychotherapy from Other Treatments?
One of the major psychological associations in the country, the American Psychological Association, formally distinguishes psychotherapy from other forms of intervention in that it requires the application of a formally trained professional therapist who uses various techniques that are based on psychological principles to assist an individual or a group of people with their problems or goals. The term formally trained professional therapist insinuates that the individual has received some type of advanced education and has some type of designation as being certified as proficient and qualified to apply these principles. In most states, this qualification is in the form education and formal licensing. The formal licensing of the therapist requires that the individual receives some form of professional training in therapy (e.g., in psychology, social work, counseling, etc.) and demonstrates their qualifications to practice therapy by means of having a degree and then by passing a formal licensing examination.
Psychotherapy is a collaborative effort by one or more therapists and one or more clients in therapy to achieve a set of predefined goals.
Typically, these goals involve having a person change their behavior, attitudes, or thinking processes, or relieving some form of distress. Given the formal definition of psychotherapy, a number of interventions, such as social support groups (e.g., 12-Step groups like Alcoholics Anonymous), are not actually formal psychotherapy techniques or applications of psychotherapy because these types of interventions do not use trained licensed professional therapists, even though individuals who participate in these interventions may feel they are “therapeutic.”
The difference between a formal definition of psychotherapy and something being “therapeutic” is based on a professional definition of a formal process (therapy) and the subjective feeling that occurs when an individual feels that a certain experience has benefited them (something being described as “therapeutic”). Any number of experiences can be described as “therapeutic,” including exercise or even watching a movie or film, whereas psychotherapy describes a formal process that is administered by a trained therapist.
The American Psychological Association reports that there are several hundred different types of psychotherapy being practiced. As it turns out, the majority of the forms of psychotherapy that are currently being practiced can be traced back to one or more of several major schools of thought or paradigms that have dominated clinical psychology since its inception. Most forms of psychotherapy that are considered to be empirically validated forms of intervention (backed by sufficient, reliable, and valid research studies) either stemmed from one of these paradigms or a combination of more than one of these paradigms.
Sigmund Freud is the founder and originator of the psychodynamic paradigm and psychodynamic therapy. The majority of the current forms of psychodynamic therapy are substantially different than Freud’s original approach; however, some therapists still adhere strictly to Freud’s psychoanalysis.
Freud believed that experiences that occurred in early childhood were the most important driving factors of later behavior. Freud also believed that the major driving forces associated with behavior were largely based on unconscious mental processes that we are not directly aware of. The major foundation of a person’s preferences, dislikes, fears, etc., were based on these unconscious processes that in large part were formed in early childhood. This is one of the major tenants of Freudian theory that still receives some recognition today: the notion that childhood experiences can be important in determining adult behavior. However, even the current psychodynamic paradigm recognizes that the full personality structure of the individual may not largely be formed until later in life, whereas Freud’s notion was that the structure of an individual’s personality was complete before the individual was 10 years old.
Freud and his daughter Anna Freud are also responsible for the development of the notion of defense mechanisms, such as denial, repression, rationalization, and many others. These defense mechanisms are often used to protect an individual from anxiety associated with certain realizations about themselves. Many of Freud’s other ideas have been modified substantially, and his emphasis on urges related to sexuality have been largely replaced by other types of drives and urges.
The basic approach to treatment in the psychodynamic school is to help an individual become aware of their own unconscious sources of discomfort or dysfunctional behavior and to understand how these were developed as a function of their early experiences and how they are maintained. Helping an individual achieve insight into their own reasons for their behavior and then helping them readjust their attitudes is often the goal of psychodynamic therapy.
In many instances, certain forms of psychodynamic therapy have been combined with some of the other paradigms to address specific issues, such as panic disorder or depression. The use of a pure psychodynamic approach for the treatment of a substance use disorder is relatively rare these days; however, a number of psychodynamic principles regarding motivation and factors that drive behavior are combined with other paradigms in the conceptualization of substance use disorders. One such factor is the notion of defense mechanisms that was originally proposed by Freud. Another factor is the emphasis on how experiences in early childhood can affect later behavior.
The Behavioral Paradigm in Psychology
The behavioral paradigm, or behaviorism, grew out of experimental psychology and initially relied heavily on the use of experiments with animals to develop its theories. Whereas Freudian approaches believe that all behavior is based on unconscious drives and motivations, behaviorists believe that behavior is a function of the conditions that are present before the organism acts and the results of the organism’s action (the antecedents and consequences of behavior). Thus, the most famous acronym in behaviorism, ABC (Antecedents – Behavior – Consequences), sums up the foundation of nearly every approach to behaviorism. The conditions preceding a behavior dictate what type of behavior will occur in an individual, and the consequences of one’s behavior will help determine whether that behavior will be repeated or not be repeated in the future.
Different schools within the paradigm focus on different types of antecedents or consequences in order to explain, produce, or even change certain behaviors in an individual. The most famous behaviorist of all, B.F. Skinner, developed very complicated theories of behavior based on the notions of altering the consequences for specific behaviors (using reinforcement and/or punishment). As a result of the work by theorists like Skinner, a number of behaviorally based therapeutic techniques also attempt to assist an individual in altering or changing their behavior by concentrating on changing the antecedents or consequences of their actions.
The drug Antabuse, which produces severe physical reactions of nausea in individuals who drink alcohol, is based on the principle from the behavioral paradigm of aversion therapy. Aversion therapy is based on the Skinnerian principle of punishment, which in this case applies a noxious condition as a consequence of one’s behavior, and this noxious condition reduces the probability that the individual will repeat the behavior (that the individual will drink alcohol).
- The criminal justice system also applies the notion of aversion therapy (behavioral change based on punishing unwanted behaviors) in cases of certain individuals with substance use disorders who may end up being punished or sanctioned for operating an automobile under the influence of alcohol or some other drug. Other applications of behavioral therapy are extremely useful in the treatment of substance abuse, but most of these concentrate more on reinforcing positive behaviors as opposed to attempting to punish unwanted behaviors.
There are a number of techniques from the behavioral paradigm that are combined with other paradigms, including diaphragmatic breathing, progressive muscle relaxation, exposure techniques, etc., that are useful in the treatment of different issues, including substance use disorders.
The Cognitive Paradigm
The cognitive paradigm developed as a direct reaction to the behavioral paradigm. The behavioral paradigm under leaders such as B.F. Skinner and John Watson made the assertion that all behaviors were a function of their antecedents and/or consequences. The behavior paradigm gave little or no emphasis to thinking processes; in fact, many of the supporters of the behavioral paradigm referred to the brain as a “black box,” meaning that the processes that occur in the brain cannot be observed directly, and that only observable behavior should be considered in developing theories and treatments. The cognitive paradigm was fostered by researcher Edward C. Tolman who demonstrated that even rodents who were deprived of food or water made “cognitive maps” of their environment and learned where to find needed resources without undergoing any form of reinforcement.
Cognitive psychology is concerned with the thinking and reasoning processes that occur in individuals. Cognitive therapy is concerned with helping an individual to become aware of and to change certain types of beliefs, attitudes, thoughts, judgments, problem-solving methods, etc., that drive dysfunctional or unwanted behaviors, such as depression or even substance use/abuse. The cognitive school of psychology has become one of the most influential paradigms related to psychotherapy, and a number of different types of cognitive therapies and Cognitive Behavioral Therapies (where cognitive techniques and behavioral techniques are combined) currently dominate most of the formal treatment approaches used in psychotherapy today.
Some of the major names in cognitive therapy and Cognitive Behavioral Therapy include Aaron Beck (cognitive therapy), Albert Ellis (Rational Emotive Behavioral Therapy or rational therapy), and Marcia Linehan (Dialectic Behavior Therapy). Other well-known techniques that are based on cognitive principles or cognitive-behavioral principles include Motivational Interviewing, exposure therapy, and Contingency Management. All of these techniques have empirically validated uses for the treatment of substance use disorders.
The Humanistic Paradigm
As a result of the rather impersonal approaches used in the psychodynamic paradigm and the behavioral paradigm, a number of individuals in the field of psychology began to explore issues that concentrated on issues associated with feelings of security, goals, striving to better oneself, and connecting with others. The humanistic paradigm got its start with the theories of the psychologist Abraham Maslow and his famous depiction of the hierarchy of human needs. This conceptualization, currently still popular but revised by numerous other theorists, discusses behavior based on factors that go beyond the conceptualizations of Freud and Skinner.
The individual who developed therapeutic principles based on the notions of Maslow and others is Carl Rogers. Rogers believed that individuals were motivated to achieve their potential in a number of other areas but were often thwarted by their perceptions of what others believe that they “should be” doing. Rogers’s approach to therapy was to help individuals free themselves of their perceptions based on the opinions of others and to strive to be the best person they could possibly be. This approach was one of honesty and acceptance in therapy, and Rogers was the first major therapist to perform research on the effectiveness of psychotherapy.
In addition, the main principles of Rogers’s humanistic approach to therapy (client-centered therapy) are often referred to as important components of the common factors of therapy, meaning that these principles/factors are part of the core principles that make any form of psychotherapy effective. These include such things as the therapist being honest and genuine with the client, accepting the client for who they are, and giving the client unconditional positive regard (meaning that the therapist values the client despite all of the client’s issues and perceived imperfections).
While many of the specific techniques used in humanistic therapy may be a bit too soft to deal with serious substance abuse issues or serious psychopathology, the common factors of therapy as described by Rogers can be applied over all therapeutic paradigms and approaches. These factors are important components that help to produce positive outcomes in any form of psychotherapy.
The Biological Paradigm
Biological psychology is often considered to be the fifth major paradigm in psychology. Biological approaches are typically explained as the ones that are used by psychiatrists (e.g., medications). However, in all current conceptualizations of therapy, a number of aspects of biology are incorporated into treatment, such as the breathing techniques, relaxation, visualization, a sense of belonging, and treatments to address anxiety, depression, and even substance use disorders.
Basic Approaches over All Paradigms
Psychotherapy is often performed on a singular individual or on a group of individuals. Conveniently enough, the general terms for these designations are:
- Individual psychotherapy: This is psychotherapy performed on one person in a session, usually by one therapist. Individual psychotherapy has the advantages of being more personal, more focused on the specific issues of the individual, and far more confidential as only the therapist and the client are aware of what goes on in sessions.
- Group psychotherapy: This is psychotherapy performed on more than one person in a session by at least one therapist. Group psychotherapy offers individuals a chance to learn from others, get different perspectives, and, in some cases, experience issues that would not be brought up in individual sessions. Group therapy includes marital therapy, family therapy, and specialized groups of individuals with the same or similar issues that are treated by one or more therapists. Group therapy is a common approach used in the treatment of substance use disorders.
Empirical research has provided evidence that both group and individual psychotherapy are effective in treating a number of issues, including issues with substance use disorders. Some types of psychotherapy, such as Dialectic Behavior Therapy, require that clients attend both individual and group sessions, and some substance use disorder treatment programs often have the same requirement.
Does Psychotherapy Work?
Yes, psychotherapy does work. Psychotherapy of all types and based on all formal paradigms is effective in treating a number of different issues; however, psychotherapy is not a passive process. What this means is that individuals in therapy actually have to participate and do the work involved in order for psychotherapy to be effective.
Psychotherapy is not some form of magical cure where an individual lies on a couch and talks away while the therapist sits back and listens, as is often depicted in many films. Instead, it’s an interactive process where a therapist and client work together on focused goals. Therapists use specific techniques based on the type of therapy they are trained in, the type of problems being addressed, and individual differences in clients. Clients are expected to apply the principles learned in therapy and are often given homework assignments.
Certain types of psychotherapy are preferred for certain types of conditions. Most sources suggest using some form of Cognitive Behavioral Therapy in the treatment of substance use disorders; however, there is evidence that the use of psychodynamic principles and humanistic principles can also be effective in the treatment of substance abuse.
Psychotherapy is the preferred treatment for a number of different disorders, including substance use disorders. However, psychotherapy is not considered to be the primary treatment for some very serious mental health disorders, such as schizophrenia or bipolar disorder. Instead, most sources suggest that the main treatment for these disorders consists of medications and that psychotherapy be used as an adjunctive treatment to help with issues regarding adjustment, modifying certain behaviors, developing support, and as an opportunity to provide education and instruction to individuals.