Psychotherapy
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Psychology |
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MeSH | D011613 |
Psychotherapy (also psychological therapy, talk therapy, or talking therapy) is the use of
There are hundreds of psychotherapy techniques, some being minor variations; others are based on very different conceptions of psychology.[3] Most involve one-to-one sessions, between the client and therapist, but some are conducted with groups,[4] including families.
Psychotherapists may be
Definitions
The term
The
Some definitions of
Delivery
Psychotherapy may be delivered in person (one on one, or with couples, or in groups) or via telephone counseling or online counseling (see also § Telepsychotherapy).[15] There have also been developments in computer-assisted therapy, such as virtual reality therapy for behavioral exposure, multimedia programs to teach cognitive techniques, and handheld devices for improved monitoring or putting ideas into practice (see also § Computer-supported).[15][16]
Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story or music. Psychotherapy with children and their parents often involves play, dramatization (i.e. role-play), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting.[17]
Regulation
Psychotherapists traditionally may be
A listing of the extensive professional competencies of a European psychotherapist was developed by the European Association of Psychotherapy (EAP) in 2013.[20]
As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of client confidentiality—and the limited circumstances in which it may need to be broken for the protection of clients or others—is enshrined in the regulatory psychotherapeutic organizations' codes of ethical practice.[21] 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.[22] The European 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.[23] The EAP has already made significant contacts with the European Union & European Commission towards this end.
Given that the European Union has 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.
Legislation in France restricts the use of the title "psychotherapist" to professionals on the National Register of Psychotherapists,[30] 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.[31]
Austria and Switzerland (2011) have laws that recognize multi-disciplinary functional approaches.[citation needed]
In the United Kingdom, the government and Health and Care Professions Council considered mandatory legal registration but decided that it was best left to professional bodies to regulate themselves, so the Professional Standards Authority for Health and Social Care (PSA) launched an Accredited Voluntary Registers scheme.[32][33][34][35][36] 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.[37] Without a license, for example, a practitioner cannot bill insurance companies.[38] Information about state licensure of psychologists is provided by the American Psychological Association.[39]
In addition to state laws, the American Psychological Association requires its members to adhere to its published Ethical Principles of Psychologists and Code of Conduct.[40] The American Board of Professional Psychology examines and certifies "psychologists who demonstrate competence in approved specialty areas in professional psychology".[41]
Canada
Regulation of psychotherapy is in the jurisdiction of, and varies among, the provinces and territories.
In
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.[43][44] Some have expressed concern that this legislation undermines psychotherapy confidentiality and could be abused maliciously by police,[45] while others have praised the act for how it respects privacy and includes checks and balances.[46]
History
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.[47][48]
In the
Some therapeutic approaches developed out of the European school of
During the 1950s,
Cognitive and behavioral therapy approaches were increasingly combined and grouped under the umbrella term
Types
There are hundreds of psychotherapy approaches or schools of thought. By 1980 there were more than 250;[63] by 1996 more than 450;[64] 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.[65][66] In practice therapy is often not of one pure type but draws from a number of perspectives and schools—known as an integrative or eclectic approach.[67][68] The importance of the therapeutic relationship, also known as therapeutic alliance, between client and therapist is often regarded as crucial to psychotherapy. Common factors theory addresses this and other core aspects thought to be responsible for effective psychotherapy. Sigmund Freud (1856–1939), a Viennese neurologist who studied with Jean-Martin Charcot in 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 of mental disorders has 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 diagnosable
Psychotherapies are categorized in several different ways. A distinction can be made between those based on a
Another distinction is between individual one-to-one therapy sessions, and group psychotherapy, including couples therapy and family therapy.[69]
Therapies are sometimes classified according to their duration; a small number of sessions over a few weeks or months may be classified as
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 psychotherapy by 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.[70]
Humanistic
These psychotherapies, also known as "
Person-centered therapy, also known as client-centered, focuses on the therapist showing openness, empathy and "unconditional positive regard", to help clients express and develop their own self.[75]
Humanistic Psychodrama (HPD) is based on the human image of humanistic psychology.[76] 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.[77] 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.[78]
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.[79]
A briefer form of humanistic therapy is the human givens approach, introduced in 1998–99.[80] 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.[81][82][83][84]
Insight-oriented
There are six main schools of psychoanalysis, which all influenced psychodynamic theory:
Cognitive-behavioral
Cognitive therapy focuses directly on changing the thoughts, in order to improve the emotions and behaviors.
The concept of "third wave" psychotherapies reflects an influence of Eastern philosophy in clinical psychology, incorporating principles such as meditation into interventions such as mindfulness-based cognitive therapy, acceptance and commitment therapy, and dialectical behavior therapy for borderline personality disorder.[65]
Interpersonal psychotherapy (IPT) is a relatively brief form of psychotherapy (deriving from both CBT and psychodynamic approaches) that has been increasingly studied and endorsed by guidelines for some conditions. It focuses on the links between mood and social circumstances, helping to build social skills and social support.[90] It aims to foster adaptation to current interpersonal roles and situations.
Other types include
Systemic
The term
Expressive
Expressive psychotherapy is a form of therapy that utilizes artistic expression (via improvisational, compositional, re-creative, and receptive experiences) as its core means of treating clients. Expressive psychotherapists use the different disciplines of the creative arts as therapeutic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy, writing therapy, among others.[97] This may include techniques such as affect labeling. Expressive psychotherapists believe that often the most effective way of treating a client is through the expression of imagination in creative work and integrating and processing what issues are raised in the act.
Postmodernist
Also known as
Other
Transpersonal psychology addresses the client in the context of a spiritual understanding of consciousness.[99] Positive psychotherapy (PPT) (since 1968) is a method in the field of humanistic and psychodynamic psychotherapy and is based on a positive image of humans, with a health-promoting, resource-oriented and conflict-centered approach.
Hypnotherapy is undertaken while a subject is in a state of hypnosis. Hypnotherapy is often applied in order to modify a subject's behavior, emotional content, and attitudes, as well as a wide range of conditions including: dysfunctional habits,[100][101][102][103][104] anxiety,[105] stress-related illness,[106][107][108] pain management,[109][unreliable source?][110] and personal development.[111][unreliable source?][112]
Some non-Western
Integrative psychotherapy is an attempt to combine ideas and strategies from more than one theoretical approach.[122] These approaches include mixing core beliefs and combining proven techniques. Forms of integrative psychotherapy include multimodal therapy, the transtheoretical model, cyclical psychodynamics, systematic treatment selection, cognitive analytic therapy, internal family systems model, multitheoretical psychotherapy and conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time.
Child
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.[123] Child psychotherapy training programs necessarily include courses in human 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 of play therapy is often rooted in psychodynamic 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, attend grief counseling, or take other action to resolve stressful situations that affect the child. Parent management training is 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.[124] 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.[125][126]
Computer-supported
Research on computer-supported and computer-based interventions has increased significantly over the course of the last two decades.[127][128] The following applications frequently have been investigated:
- Virtual reality: VR is a computer-generated scenario that simulates experience. The immersive environment, used for simulated exposure, can be similar to the real world or it can be fantastical, creating a new experience.[129][130]
- Computer-based interventions (or online interventions or internet interventions): These interventions can be described as interactive self-help. They usually entail a combination of text, audio or video elements.[131][132]
- Computer-supported therapy (or blended therapy): Classical psychotherapy is supported by means of online or
Telepsychotherapy
Telepsychiatry or telemental health refers to the use of telecommunications technology (mostly videoconferencing and phone calls) to deliver psychiatric care remotely for people with mental health conditions. It is a branch of telemedicine.[136][137]
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.[138]
It can improve access to mental health services for some but might also represent a barrier for those lacking access to a suitable device, the internet or the necessary digital skills. Factors such as poverty that are associated with lack of internet access are also associated with greater risk of mental health problems, making digital exclusion an important problem of telemental health services.[138]
During the COVID-19 pandemic mental health services were adapted to telemental health in high-income countries. It proved effective and acceptable for use in an emergency situation but there were concerns regarding its long-term implementation.[139]Effects
Evaluation
There is considerable controversy about whether, or when, psychotherapy efficacy is best evaluated by
One issue with trials is what to use as a
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).[143] 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.[144]
A pioneer in investigating the results of different psychological therapies was psychologist
Outcomes in relation with selected kinds of treatment
Large-scale international reviews of scientific studies have concluded that psychotherapy is effective for numerous conditions.[8][22]
One line of research consistently finds that supposedly different forms of psychotherapy show similar effectiveness. According to The Handbook of Counseling Psychology: "Meta-analyses of psychotherapy studies have consistently demonstrated that there are no substantial differences in outcomes among treatments". The handbook states that there is "little evidence to suggest that any one psychological therapy consistently outperforms any other for any specific psychological disorders. This is sometimes called the Dodo bird verdict after a scene/section in Alice in Wonderland where every competitor in a race was called a winner and is given prizes".[152]
Further analyses seek to identify the factors that the psychotherapies have in common that seem to account for this, known as common factors theory; for example the quality of the therapeutic relationship, interpretation of problem, and the confrontation of painful emotions.[153][154][page needed][155][156]
Outcome studies have been critiqued for being too removed from real-world practice in that they use carefully selected therapists who have been extensively trained and monitored, and patients who may be non-representative of typical patients by virtue of strict inclusionary/exclusionary criteria. Such concerns impact the replication of research results and the ability to generalize from them to practicing therapists.[154][157]
However, specific therapies have been tested for use with specific disorders,[158] and regulatory organizations in both the UK and US make recommendations for different conditions.[159][160][161]
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.[162]
Meta-analyses have established that
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.[164] For children and adolescents, interpersonal psychotherapy and CBT are the best methods according to a 2014 meta analysis of almost 4000 patients.[165]
Mechanisms of change
It is not yet understood how psychotherapies can succeed in treating mental illnesses.[166] Different therapeutic approaches may be associated with particular theories about what needs to change in a person for a successful therapeutic outcome.
In general, processes of emotional arousal and memory have long been held to play an important role. One theory combining these aspects proposes that permanent change occurs to the extent that the neuropsychological mechanism of memory reconsolidation is triggered and is able to incorporate new emotional experiences.[167][168][169][170]
Adherence
Patient
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.[171][172] The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.[173]
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.[171]
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.[174] In general, however, it is a hallmark of evidence-based psychotherapy to use fidelity monitoring as part of therapy outcome trials and ongoing quality assurance in clinical implementation.
Adverse effects
Research on adverse effects of psychotherapy has been limited, yet worsening of symptoms may be expected to occur in 3% to 15% of patients, with variability across patient and therapist characteristics.[175][176][177] Potential problems include deterioration of symptoms or developing new symptoms, strains in other relationships, social stigma, and therapy dependence.[178] Some techniques or therapists may carry more risks than others, and some client characteristics may make them more vulnerable.[176] Side-effects from properly conducted therapy should be distinguished from harms caused by malpractice.[178]
General critiques
Some critics are skeptical of the healing power of psychotherapeutic relationships.[179][180][181] Some dismiss psychotherapy altogether in the sense of a scientific discipline requiring professional practitioners,[182] instead favoring either nonprofessional help[182] or biomedical treatments.[183] 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).[184][185][186]
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.[187]
On the other hand, some argue psychotherapy is under-utilized and under-researched by contemporary psychiatry despite offering more promise than stagnant medication development. In 2015, the US
Further critiques have emerged from
See also
- Improving Access to Psychological Therapies – United Kingdom initiative to improve access to psychological therapies
- 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
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TFT, a treatment applied to mood, anxiety, and trauma-related disorders, is a prime example of practice founded on pseudoscience.
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Though there are hundreds if not thousands of different kinds of psychotherapy, in many ways some are quite similar—they share some common factors.
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Further reading
- Bartlett, Steven J. (1987). When You Don't Know Where to Turn: A Self-diagnosing Guide to Counseling and Therapy. Contemporary Books. ISBN 9780809248292.
- Bloch, Sidney (2006). Introduction to the Psychotherapies (4th ed.). Oxford University Press. ISBN 0198520921.
- Carter, Robert T., ed. (2005). Handbook of Racial-Cultural Psychology and Counseling. OCLC 54905669. Two volumes.
- Corey, Gerald (2015). Theory and Practice of Counseling and Psychotherapy (10th ed.). Cengage Learning. ISBN 9781305263727.
- Cozolino, Louis (2017). The Neuroscience of Psychotherapy: Healing the Social Brain (3rd ed.). National Geographic Books. ISBN 9780393712643.
- 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. ISBN 9781433823060.
- Foschi, Renato; Innamorati, Marco (2023). A Critical History of Psychotherapy. Routledge, Taylor & Francis. ISBN 9781032364025. Two volumes.
- Hofmann, Stefan G., ed. (2017). International Perspectives on Psychotherapy. Springer. ISBN 9783319561936.
- Jongsma, Arthur E.; Peterson, L. Mark; Bruce, Timothy J. (2021). The Complete Adult Psychotherapy Treatment Planner (6th ed.). John Wiley & Sons. ISBN 978-1118067864.
- McAuliffe, Garrett J., ed. (2021). Culturally Alert Counseling: A Comprehensive Introduction (3rd ed.). SAGE Publications. ISBN 9781483378213.
- Prochaska, James O.; Norcross, John C. (2018). Systems of Psychotherapy: A Transtheoretical Analysis (9th ed.). Oxford University Press. ISBN 9780190880415.
- Rastogi, Mudita; Wieling, Elizabeth, eds. (2005). Voices of Color: First-Person Accounts of Ethnic Minority Therapists. ISBN 0761928901.
- Slavney, Phillip R. (2005). Psychotherapy: An Introduction for Psychiatry Residents and Other Mental Health Trainees. JHU Press. ISBN 0801880963.
- Wampold, Bruce E. (2019). The Basics of Psychotherapy: An Introduction to Theory and Practice (2nd ed.). American Psychological Association. ISBN 9781433830198.