Psychotherapy

Psychotherapy is the  treatment of individuals with emotional problems, behavioral problems, or mental illness primarily through verbal communication. In most types of psychotherapy, a person discusses his or her problems one-on-one with a therapist. The therapist tries to understand the person’s problems and to help the individual change distressing thoughts, feelings, or behaviors.

People often seek psychotherapy when they have tried other approaches to solving a personal problem. For example, people who are depressed, anxious, or have drug or alcohol problems may find that talking to friends or family members is not enough to resolve their problems. Sometimes people may want to talk to a therapist about problems they would feel uncomfortable discussing with friends or family, such as being sexually abused as a child. Finding a therapist to talk to who is knowledgeable about emotional problems, has patients’ best interests at heart, and is relatively objective can be extremely helpful.

Psychotherapy differs in two ways from the informal help or advice that one person may give another. First, psychotherapy is conducted by a trained, certified, or licensed therapist. In addition, treatment methods in psychotherapy are guided by well-developed theories about the sources of personal problems.

At one time the term psychotherapy referred to a form of psychiatric treatment used with severely disturbed individuals, whereas counseling referred to the treatment of people with milder psychological problems or to advice given on vocational and educational matters. Today the distinction between psychotherapy and counseling is quite blurred, and many mental health professionals use the terms interchangeably. Psychotherapists and counselors often treat the same kinds of problems and use the same set of techniques.

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PROBLEMS TREATED WITH PSYCHOTHERAPY

Psychotherapy is an important form of treatment for many kinds of psychological problems. Two of the most common problems for which people seek help from a therapist are depression and persistent anxiety. People with depression may have low self-esteem, a sense of hopelessness about the future, and a lack of interest in people and activities once found pleasurable. People with anxiety disorders may feel anxious all the time or suffer from phobias, a fear of specific objects or situations. Psychotherapy, by itself or in combination with drug treatment, can often help people overcome or manage these problems.

People experiencing an emotional crisis due to marital problems, family disputes, problems at work, loneliness, or troubled social relationships may benefit from psychotherapy. Other problems often treated with psychotherapy include obsessive-compulsive disorder, personality disorders, alcoholism and other forms of drug dependence, problems stemming from child abuse, and behavioral problems, such as eating disorders and juvenile delinquency.

Mental health professionals do not rely on psychotherapy to treat schizophrenia, a severe mental illness. Drugs are used to treat this disorder. However, some psychotherapeutic techniques may help people with schizophrenia learn appropriate social skills and skills for managing anxiety. Another severe mental illness, bipolar disorder (popularly called manic depression), is treated with drugs or a combination of drugs and psychotherapy.

III

TRENDS IN PSYCHOTHERAPY

Before 1950 psychoanalysis was virtually the only form of psychotherapy available. In traditional psychoanalysis, patients met with a therapist several times a week. Patients would lie on a couch and talk about their childhood, their dreams, or whatever came to mind. The psychoanalyst interpreted these thoughts and helped patients resolve unconscious conflicts. This type of therapy often took years and was very expensive.

Over the next several decades the field of psychotherapy and counseling expanded enormously, both in the number of approaches available and in the number of people choosing to enter the profession. Variants of psychoanalysis emerged that focused more on the patient’s current level of functioning and required less time in therapy. In the 1950s and 1960s therapists began using behavioral and cognitive therapies that focused less on the inner world of the client and more on the client’s problem behaviors or thoughts.

As the number of approaches to therapy grew throughout the 1960s and 1970s, the practice of psychotherapy and counseling spread from hospitals and private psychiatric offices to new settings—elementary schools, high schools, colleges, prisons, mental health clinics, military bases, businesses, and churches and synagogues. With more opportunities for individuals to receive help for their problems, and with more affordable treatments, psychotherapy has become increasingly popular. Although a reliable count of the number of people who receive psychotherapy is difficult to obtain, researchers estimate that 3.5 percent of women and 2.5 percent of men in the United States receive psychotherapy in any given year.

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Attitudes Toward Psychotherapy

The increased availability and use of psychotherapy has led to more positive attitudes toward mental health care among the general public. Before the 1960s, people often viewed the need for psychotherapy as a sign of personal weakness or a sign that the person was abnormal. Those who received therapy seldom told others about their treatment. Since then the stigma attached to psychotherapy has decreased significantly. It is now common for people to consider seeing a therapist for an emotional problem, and recipients of therapy are more willing to disclose their therapy to friends. Today psychotherapy is a topic of immense public interest. In the scientific community and in the media, people assess methods of therapy and debate which approaches are best for particular problems and disorders.

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Brief Therapy and Managed Care

One of the strongest trends in psychotherapy in recent years has been the shift toward short-term treatment, or brief therapy. Rather than spending years in therapy, clients receive treatment over the course of several weeks or months. Brief therapies usually focus on the client’s specific problems and may make use of techniques from a variety of theoretical orientations. Brief approaches to therapy evolved in part from consumer dissatisfaction with the length, scope, and cost of psychoanalysis and similar approaches. With extensive publicity about short-term therapies, many consumers have come to expect faster treatment for mental health problems than in the past.

, which became widespread in the United States in the 1980s and 1990s, has further driven the movement toward shorter therapies. To provide mental health care at lower costs, managed-care firms, such as health maintenance organizations (HMOs), limit the number of therapy sessions that they will pay for during a year for each insured person. Typical managed-care firms allow up to 20 sessions per year, but some allow as few as 8 sessions per year. Case reviewers for the managed-care company decide how many sessions of therapy each person should receive. Usually a case reviewer will authorize only a small number of sessions at first. If the therapist and client wish to continue beyond this number, the therapist must get approval from the case reviewer for additional sessions. If the client wishes to continue after reaching the maximum, he or she must pay the full cost of therapy.

Other managed-care companies pay therapists a set fee to meet with a client for up to a specified maximum number of sessions depending on the nature of the problem, free of interference from case reviewers. For example, a managed-care firm may pay a therapist $200 to hold up to eight sessions with a person. If the client uses all eight sessions, the therapist normally loses money. But if treatment stops after two or three sessions, the therapist makes a profit. This relatively new system is controversial because it creates a financial incentive for the therapist to shorten the length of treatment.

Managed care has affected the practice of psychotherapy in other important ways. Rather than selecting a therapist based on personal referrals, people enrolled in managed-care plans must select from a list of therapists provided by their managed-care organization. Clients cannot be assured of complete confidentiality because therapists must provide case reviewers with treatment plans and details of progress. Increasingly, managed-care companies are reluctant to authorize more than several sessions of psychotherapy, favoring drug treatment instead.

Critics argue that managed-care companies have embraced a “quick fix” mentality that pushes short-term therapy even when long-term therapy may be more appropriate. Others note that managed care has brought greater accountability to the profession of psychotherapy, forcing therapists to justify the effectiveness of their treatment approach. In the late 1990s most Americans with health insurance were enrolled in plans with managed mental health care.

IV

EDUCATION AND TRAINING OF THERAPISTS

Psychotherapists and counselors come principally from the fields of psychiatry, psychology, social work, and psychiatric nursing. Their training is quite different, considering that their actual therapeutic techniques may be quite similar.

Psychiatrists are physicians who specialize in the treatment of psychological disorders. They attend medical school for four years to earn an M.D. (doctor of medicine) degree. Then they receive training in psychiatry during a residency of three or four years. They differ from other therapists in that they can prescribe medications, such as antidepressants and antianxiety drugs.

Clinical psychologists and counseling psychologists have a Ph.D. (doctor of philosophy) or Psy.D. (doctor of psychology) degree that requires four to six years of graduate study. They work in settings such as businesses, schools, mental health centers, and hospitals. Licensing requirements vary in the United States, but most states require psychologists to have postdoctoral training.

Psychiatric social workers have a master’s degree in social work (M.S.W.), usually requiring two years of graduate study. They may work in mental health agencies or medical settings practicing individual therapy or family and marital therapy. Psychiatric social workers make up the single largest group of mental health professionals. Licensing requirements vary in the United States.

Psychiatric nurses are registered nurses who usually have a master’s degree in psychiatric nursing. They often work in a hospital setting conducting individual or group therapy with patients under the supervision of a psychiatrist.

Psychoanalysts specialize in psychoanalysis. Although anyone may use the title of psychoanalyst, those accredited by the International Psychoanalytic Association are usually psychiatrists, psychologists, or social workers who have completed six to ten years of psychoanalytic training. They are also required to undergo a personal analysis themselves.

All but a few states license professional counselors, usually under the title of licensed professional counselor or licensed mental health counselor. The National Board for Certified Counselors offers certification for counselors who have a minimum of a master’s degree and who meet the organization’s professional standards.

Members of the clergy—priests, ministers, and rabbis—usually take courses in counseling and psychology as part of their seminary training. Some ministers specialize in pastoral counseling, working with members of a congregation who are in distress.

Any person, even one with no training, can legally use the title of therapist, psychotherapist, or other titles not covered under licensing and certification laws. Therefore, clients should ask therapists who practice under such titles about their academic and professional training.

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TYPES OF THERAPY

Psychotherapy encompasses a large number of treatment methods, each developed from different theories about the causes of psychological problems and mental illnesses. There are more than 250 kinds of psychotherapy, but only a fraction of these have found mainstream acceptance. Many kinds of psychotherapy are offshoots of well-known approaches or build upon the work of earlier theorists.

In individual therapy, a patient or client meets regularly with a therapist, typically over a period of weeks or months. The methods of therapists vary depending on their theory of personality, or way of understanding another individual. Most therapies can be classified as (1) psychodynamic, (2) humanistic, (3) behavioral, (4) cognitive, or (5) eclectic. In the United States, about 40 percent of therapists consider their approach eclectic, which means they combine techniques from a number of theoretical approaches and often tailor their treatment to the particular psychological problem of a client.

Forms of therapy that treat more than one person at a time include group therapy, family therapy, and couples therapy. These therapies may use techniques from any theoretical approach. Other forms of therapy specialize in treating children or adolescents with psychological problems.

People seeking help for their problems most often select individual therapy over group therapy and other forms of therapy. People may prefer individual therapy because it allows the therapist to focus exclusively on their problems, without distractions from others. Also, individuals may desire more privacy and confidentiality than is possible in a group setting. Sometimes people combine individual therapy and group therapy.

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Psychodynamic Therapies

Psychodynamic therapies are those therapies in some way derived from the work of Austrian physician Sigmund Freud, the founder of psychoanalysis. In general, psychodynamic therapists emphasize the importance of discovering and resolving internal, unconscious conflicts, often through an exploration of one’s childhood and past experiences. Although psychoanalysis is the best-known form of psychodynamic therapy, theorists have developed many other psychodynamic therapies, some very different from Freud’s original techniques.

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Classical Psychoanalysis

Freud developed the theory and techniques of psychoanalysis in the 1890s. He believed that much of an individual's personality develops before the age of six. He also proposed that children pass through a series of psychosexual stages, during which they express sexual energy in different ways. For example, during the phallic stage, from about age three to age five, children focus on feelings of pleasure in their genital organs. At this time, according to Freud, boys become sexually attracted to their mothers and feel hostility and jealousy toward their fathers. Similarly, girls develop sexual feelings toward their fathers and feel rage toward their mothers. In Freud’s view, such innate sexual and aggressive drives cause feelings and thoughts that the person regards as unacceptable. In response, the individual represses these feelings, driving them into the unconscious mind. In the process, three basic personality structures are formed: the id, the ego, and the superego. The id represents unchecked, instinctual drives; the superego is the voice of social conscience; and the ego is the rational thinking that mediates between the id and superego and deals with reality. These three systems function as a whole, not separately. Id forces are unconscious and often emerge without an individual’s awareness, causing fear, anxiety, depression, or other distressing symptoms. Freud used the term neurosis to refer to such symptoms.

In psychoanalysis, Freud sought to eliminate neurotic symptoms by bringing the individual’s repressed fantasies, memories, and emotions into consciousness. He placed particular emphasis on helping patients uncover memories about early childhood trauma and conflict, which he regarded as the source of emotional problems in adults. At first, he used hypnosis as a way to gain access to a person’s unconscious. Later he developed free association, a method in which patients say whatever thoughts come to their minds about dreams, fantasies, and memories. The analyst’s interpretations of this material, Freud believed, could provide patients with insight into their unconscious—insight that would help them become less anxious, less depressed, or better in other ways.

Freud also placed great value on what could be learned from transference, the patient’s emotional response to the therapist. Freud believed that during therapy, patients transfer repressed feelings toward their family members to their relationship with the therapist. Transference exposes these repressed feelings and allows the patient to work through them. Free association and transference are still central features of Freudian psychoanalysis.

In traditional or classical psychoanalysis, the patient lies on a couch and the therapist sits out of sight of the patient. This practice is intended to minimize the presence of the therapist and allow the patient to engage in free association more easily. Classical psychoanalysis requires three to four sessions of therapy each week for several years. At a rate of $100 or more per session, three sessions per week costs more than $15,000 per year. Classical psychoanalysis is not typically covered by insurance plans with managed mental health care. Therefore, relatively few individuals choose this intensive and long-term therapy.

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Contemporary Psychoanalysis

In contemporary forms of psychoanalysis, the duration of therapy is often shorter—between one and four years—and meetings may take place one or two times a week. Other psychoanalytically oriented therapists work in a brief format of 30 sessions or less. The patient sits on a chair across from the therapist rather than lying on a couch. Modern psychoanalysts tend to focus more on current functioning and make less use of free association techniques.

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Neo-Freudian Therapies

Several of Freud's followers developed new theories about the causes of psychological disorders. Three important neo-Freudians were Erich Fromm, Karen Horney, and Erik Erikson, who emphasized the role of social and cultural influences in the formation of personality. All three emigrated from Germany to the United States in the 1930s. Their theories have influenced modern psychodynamic therapists.

Fromm believed that the fundamental problem people confront is a sense of isolation deriving from their own separateness. According to Fromm, the goal of therapy is to orient oneself, establish roots, and find security by uniting with other people while remaining a separate individual.

Horney departed from Freud in her belief in the importance of social forces in personality formation. She asserted that people develop anxiety and other psychological problems because of feelings of isolation during childhood and unmet needs for love and respect from their parents. The goal of therapy, in her view, is to help patients overcome anxiety-driven neurotic needs and move toward a more realistic image of themselves.

Erikson extended Freud's emphasis on childhood development to cover the entire lifespan. Referred to as an ego psychologist, he emphasized the importance of the ego in helping individuals develop healthy ways to deal with their environment. Often working with children, Erikson helped individuals develop the basic trust and confidence needed for the development of a healthy ego.

Other psychoanalytic therapists focused on how relationships develop between the child and others, especially the mother. British pediatrician Donald Winnicott and Austrian-American pediatrician Margaret Mahler were known as object-relations analysts because of their emphasis on the child’s love object (such as the mother or father). They and other object-relations therapists, such as Austrian-born British psychoanalyst Melanie Klein, helped patients deal with problems that arose from being separated inappropriately or at too early an age or from their mothers.

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Jungian Therapy

Unlike the psychoanalytic therapists, Swiss psychiatrist Carl Jung developed a very different system of therapy. He had worked closely with Freud, but broke away totally from Freud in his own work.

Jung created a school of psychology that he called analytical psychology. He felt that Freud focused too much on sexual drives and not enough on all of the creative instincts and impulses that motivate individuals. Whereas Freud had described the personal unconscious, which reflected the sum of one person’s experience, Jung added the concept of the collective unconscious, which he defined as the reservoir of the experience of the entire human race. The collective unconscious contains images called archetypes that are common to all individuals. They are often expressed in mythological concepts such as good and evil spirits, fairies, dragons, and gods.

In general, Jungian therapists see psychological problems as arising from unconscious conflicts that create disturbances in psychic energy. They treat psychological problems by helping their patients bring material from their personal and collective unconscious into conscious awareness. The therapists do this through a knowledge of symbolism—not only symbols from mythology and folk culture, but also current cultural symbols. By interpreting dreams and other materials, Jungian therapists help their patients become more aware of unconscious processes and become stronger individuals.

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Adlerian Therapy

Like Jung, Austrian physician Alfred Adler believed that Freud overemphasized the importance of sexual and aggressive drives. Adler was particularly interested in sibling relationships, birth order, and relationships with parents. He would ask patients about their early memories and use this information to analyze their attitudes, beliefs, and behaviors. He helped his patients by encouraging them to meet important life goals: love, work, and friendship.

For Adler and modern therapists who draw from his work, interest in others and participation in society are important goals of therapy. Adlerian therapists see therapy in part as educational, and they use a number of innovative action techniques to help patients change mistaken beliefs and interact more fully with family members and others.

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Humanistic Therapies

Humanistic therapies focus on the client's present rather than past experiences, and on conscious feelings rather than unconscious thoughts. Therapists try to create a caring, supportive atmosphere and to guide clients toward personal realizations and insights. Clients are encouraged to take responsibility for their lives, to accept themselves, and to recognize their own potential for growth and change.

The length of therapy depends on the severity of the problem and on a client's ability to change and try new behaviors. Because humanistic therapies emphasize the relationship between client and therapist and a gradual development of increased responsibility by the client, these therapies typically take a year or two of weekly sessions.

Three of the most influential forms of humanistic therapy are existential therapy, person-centered therapy, and Gestalt therapy.

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Existential Therapy

Based on a philosophical approach to people and their existence, existential therapy deals with important life themes. These themes include living and dying, freedom, responsibility to self and others, finding meaning in life, and dealing with a sense of meaninglessness. More than other kinds of therapists, existential therapists examine individuals' awareness of themselves and their ability to look beyond their immediate problems and daily events to problems of human existence.

The first existential therapists were European psychiatrists trained in psychoanalysis who were dissatisfied with Freud's emphasis on biological drives and unconscious processes. Existential therapists help their clients confront and explore anxiety, loneliness, despair, fear of death, and the feeling that life is meaningless. There are few techniques specific to existential therapy. Therapists normally draw on techniques from a variety of therapies. One well-known existential therapy is logotherapy, developed by Austrian psychiatrist Viktor E. Frankl in the 1940s (logos is Greek for meaning).

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Person-Centered Therapy

Person-centered therapy, originally called client-centered therapy, is perhaps the best-known form of humanistic therapy. American psychologist Carl Rogers developed this type of therapy in the 1940s and 1950s. Rogers believed that people, like other living organisms, are driven by an innate tendency to maintain and enhance themselves, which in turn moves them toward growth, maturity, and life enrichment. Within each person, Rogers believed, is the capacity for self-understanding and constructive change.

Person-centered therapy emphasizes understanding and caring rather than diagnosis, advice, and persuasion. Rogers strongly believed that the quality of the therapist-client relationship influences the success of therapy. He felt that effective therapists must be genuine, accepting, and empathic. A genuine therapist expresses true interest in the client and is open and honest. An accepting therapist cares for the client unconditionally, even if the therapist does not always agree with him or her. An empathic therapist demonstrates a deep understanding of the client's thoughts, ideas, experiences, and feelings and communicates this empathic understanding to the client. Rogers believed that when clients feel unconditional positive regard from a genuine therapist and feel empathically understood, they will be less anxious and more willing to reveal themselves and their weaknesses. By doing so, clients gain a better understanding of their own lives, move toward self-acceptance, and can make progress in resolving a wide variety of personal problems.

Person-centered therapists use an approach called active listening to demonstrate empathy—letting clients know that they are being fully listened to and understood. First, therapists must show through their body position and facial expression that they are paying attention—for example, by directly facing the client and making good eye contact. During the therapy session, the therapist tries to restate what the client has said and seeks clarification of the client’s feelings. The therapist may use such phrases as “What I hear you saying is…” and “You’re feeling like…” The therapist seeks mainly to reflect the client’s statements back to the client accurately, and does not try to analyze, judge, or lead the direction of discussion. For example:

Client: I always felt my husband loved me. I just don’t understand why this happened.
Therapist: You feel surprised by the fact that he left you, because you thought he loved you. It comes as a real surprise.
Client: M-hm. I guess I haven’t really accepted that he could do this to me. A big part of me still loves him.
Therapist: You seem to still be hurting from what he did. The love you have for him is so strong.

Many therapists, not just those of humanistic orientation, have adopted elements of Rogers’s approach.

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Gestalt Therapy

Gestalt is a German word referring to wholeness and the concept that a whole unit is more than the sum of its parts. Gestalt therapy was developed in the 1940s and 1950s by Frederick (Fritz) Perls, a German-born psychiatrist who immigrated to the United States. Like person-centered therapy, Gestalt therapy tries to make individuals take responsibility for their own lives and personal growth and to recognize their capacity for healing themselves. However, Gestalt therapists are willing to use confrontational questions and techniques to help clients express their true feelings. In the following example, the therapist helps the client become more aware of her own behavior and her responsibility for it:

Client: You know, you just can't do anything right in today's world.
Therapist: Please repeat that phrase using the word I instead of you.
Client: I can't do anything right, it seems.
Therapist: Would you change the word can't to won't?
Client: I won't do anything right.
Therapist: What won't you do that you want to do?

The general goal of Gestalt therapy is awareness of self, others, and the environment that brings about growth, wholeness, and integration of one’s thoughts, feelings, and actions. Gestalt therapists use a wide variety of techniques to make clients more aware of themselves, and they often invent or experiment with techniques that might help to accomplish this goal. One of the best-known Gestalt techniques is the empty-chair technique, in which an empty chair represents another person or another part of the client’s self. For example, if a client is angry at herself for not being kinder to her mother, the client may pretend her mother is sitting in an empty chair. The client may then express her feelings by speaking in the direction of the chair. Alternatively, the client might play the role of the understanding daughter while sitting in one chair and the angry daughter while sitting in another. As she talks to different parts of herself, differences may be resolved. The empty-chair technique reflects Gestalt therapy’s strong emphasis on dealing with problems in the present.

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Behavioral Therapies

Behavioral therapies differ dramatically from psychodynamic and humanistic therapies. Behavioral therapists do not explore an individual’s thoughts, feelings, dreams, or past experiences. Rather, they focus on the behavior that is causing distress for their clients. They believe that behavior of all kinds, both normal and abnormal, is the product of learning. By applying the principles of learning, they help individuals replace distressing behaviors with more appropriate ones. See Behavior Modification.

Typical problems treated with behavioral therapy include alcohol or drug addiction, phobias (such as a fear of heights), and anxiety. Modern behavioral therapists work with other problems, such as depression, by having clients develop specific behavioral goals—such as returning to work, talking with others, or cooking a meal. Because behavioral therapy can work through nonverbal means, it can also help people who would not respond to other forms of therapy. For example, behavioral therapists can teach social and self-care skills to children with severe learning disabilities and to individuals with schizophrenia who are out of touch with reality.

Behavioral therapists begin treatment by finding out as much as they can about the client's problem and the circumstances surrounding it. They do not infer causes or look for hidden meanings, but rather focus on observable and measurable behaviors. Therapists may use a number of specific techniques to alter behavior. These techniques include relaxation training, systematic desensitization, exposure and response prevention, aversive conditioning, and social skills training.

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Relaxation Training

Relaxation training is a method of helping people with high levels of anxiety and stress. It also serves as an important component of some other behavioral treatments.

In one type of relaxation exercise, people learn to tighten and then relax one muscle group at a time. This method, called progressive relaxation, was developed in the 1930s by American physiologist and psychologist Edmund Jacobson. At first, the therapist gives spoken instructions to the client. Later the client can practice the relaxation exercise at home using a tape recording of the therapist’s voice. The following example, adapted from Jacobson’s work, illustrates a brief relaxation procedure:

Just settle back as comfortably as you can, close your eyes, and let yourself relax to the best of your ability … Now clench up both fists tighter and tighter and study the tension as you do so. Keep them clenched and feel the tension in your fists, hands, forearms … Now relax. Let the fingers of your hands become loose and observe the contrast in your feelings … Now let yourself go and try to become more relaxed all over. Take a deep breath … Just let your whole body become more and more relaxed.

Another relaxation technique is meditation. In meditation, people try to relax both the mind and the body. In many forms of meditation, people begin by sitting comfortably on a cushion or chair. Then they gradually relax their body, begin to breathe slowly, and concentrate on a sensation—such as the inhaling and exhaling of breath—or on an image or object. In Transcendental Meditation, a person does not try to concentrate on anything, but merely sits in a quiet atmosphere and repeats a mantra (a specially chosen word) to try to achieve a state of restful alertness.

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Systematic Densensitization

Systematic desensitization, a procedure developed by South African psychiatrist Joseph Wolpe in the 1950s, gradually teaches people to be relaxed in a situation that would otherwise frighten them. It is often used to treat phobias and other anxiety disorders. The word desensitization refers to making people less sensitive to or frightened of certain situations.

In the first step of desensitization, the therapist and client establish an anxiety hierarchy—a list of fear-provoking situations arranged in order of how much fear they provoke in the client. For a man afraid of spiders, for example, holding a spider may rank at the top of his anxiety hierarchy, whereas seeing a small picture of a spider may rank at the bottom. In the second step, the therapist has the client relax using one of the relaxation techniques described above. Then the therapist asks the client to imagine each situation on the anxiety hierarchy, beginning with the least-feared situation and moving upward. For example, the man may first imagine seeing a picture of a spider, then imagine seeing a real spider from far away, then from a short distance, and so forth. If the client feels anxiety at any stage, he or she is instructed to stop thinking about the situation and to return to a state of deep relaxation. The relaxation and the imagined scene are paired until the client feels no further anxiety. Eventually the client can remain free of anxiety while imagining the most-feared situation.

Asking a client to encounter the feared situation is a technique called in vivo exposure. For the man who is afraid of spiders, a therapist might arrange to go to a park or zoo where visitors can touch large spiders. The therapist would model for the client how to approach a spider and how to handle it. The therapist may also encourage the man to walk gradually closer to the spider, reinforcing his progress with praise and reassurance as he does so. The goal for the therapist and patient would be for the man to pick up the spider.

Problems are rarely as clear and simple as fear of spiders. Therapists may spend considerable time deciding on appropriate goals, which ones to pursue first, and then reevaluating or changing goals as therapy progresses. Systematic desensitization typically takes from 10 to 30 sessions, depending on the severity of the problem. In vivo therapies are more direct and may take less time.

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Exposure and Response Prevention

Exposure and response prevention is a behavioral technique often used to treat people with obsessive-compulsive disorder. In this technique, the therapist exposes the client to the situation that causes obsessive thoughts, but then prevents the client from acting on these thoughts. For example, to treat people who compulsively wash their hands because they fear contamination from germs, a therapist might have them handle something dirty and then prevent them from washing their hands. Therapists have also experimented with exposure and response prevention to treat people with bulimia nervosa, an eating disorder in which people engage in binge eating and afterward force themselves to vomit or, more occasionally, take laxatives (see Bulimia). The therapist feeds the bulimic patients small amounts of food but prevents them from binging, taking laxatives, or vomiting.

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Aversive Conditioning

Behavioral therapists occasionally use a technique called aversive conditioning or aversion therapy. In this method, clients receive an unpleasant stimulus, such as an electric shock, whenever they perform an undesirable behavior. For example, therapists treating patients with alcoholism may have them ingest the drug disulfiram (Antabuse). The drug makes the patients violently sick if they drink alcohol. Many therapists have found that aversive conditioning is not as effective as other behavioral techniques, and as a result, they use this technique very infrequently. For some problems, however, aversive conditioning can work when all other techniques have failed. For example, therapists have found that immediate application of an unpleasant stimulus can eliminate self-mutilation and other self-destructive behaviors in children with autism.

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Social Skills Training

Social skills training is a method of helping people who have problems interacting with others. Clients learn basic social skills such as initiating conversations, making eye contact, standing at the appropriate distance, controlling voice volume and pitch, and responding to questions. The therapist first describes and models the behavior. Then the patient or client practices the behavior in skits or role-playing exercises. The therapist watches the exercises and provides constructive criticism and further modeling. Therapists often conduct this kind of training with groups of people with similar problems. Social skills training often can help people with schizophrenia function more easily in public situations and reduce their risk of relapse or rehospitalization.

One popular form of social skills training is assertiveness training, another technique pioneered by Joseph Wolpe. This technique teaches people, often those who are shy, to make appropriate responses when someone does something to them that seems inappropriate or offensive or violates their rights. For example, if a woman has trouble saying no to a coworker who inappropriately asks her to handle some of his job responsibilities, she may benefit from learning how to become more assertive. In this example, the therapist would model assertive behavior for the client, who would then role-play and rehearse appropriate responses to her coworker.

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Cognitive Therapies

Cognitive therapies are similar to behavioral therapies in that they focus on specific problems. However, they emphasize changing beliefs and thoughts, rather than observable behaviors. Cognitive therapists believe that irrational beliefs or distorted thinking patterns can cause a variety of serious problems, including depression and chronic anxiety. They try to teach people to think in more rational, constructive ways.

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Rational-Emotive Behavior Therapy

In the mid-1950s American psychologist Albert Ellis developed one of the first cognitive approaches to therapy, rational-emotive therapy, now commonly called rational-emotive behavior therapy. Trained in psychoanalysis in the 1940s, Ellis quickly became disillusioned with psychoanalytic methods, viewing them as slow and inefficient. Influenced by Alfred Adler’s work, Ellis came to regard irrational beliefs and illogical thinking as the major cause of most emotional disturbances. In his view, negative events such as losing a job or breaking up with a lover do not by themselves cause depression or anxiety. Rather, emotional disorders result when a person perceives the events in an irrational way, such as by thinking, “I’m a worthless human being.”

Although rational-emotive behavior therapists use many techniques, the most common technique is that of disputing irrational thoughts. First the therapist identifies irrational beliefs by talking with the client about his or her problems. Examples of irrational beliefs, according to Ellis, include the idea that unhappiness is caused by external events, the idea that one must be accepted and loved by everyone, and the idea that one must always be competent and successful to be a worthwhile person.

To dispute the client’s irrational beliefs and longstanding assumptions, rational-emotive behavior therapists often use confrontational techniques. For example, if a student tells the therapist, “I must get an A on this test or I will be a failure in life,” the therapist might say, “Why must you? Do you think your entire career as a student will be through if you get a B?” The therapist helps the client replace irrational thoughts with more reasonable ones, such as “I would like to get an A on the test, but if I don't, I have strategies I can use to do better next time.”

D2

Beck’s Cognitive Therapy

Like Ellis before him, American psychiatrist Aaron T. Beck became disenchanted with psychoanalysis, finding that it often did not help relieve depression for his patients. In the 1960s Beck developed his own form of cognitive therapy for treating depression, and later applied it to other disorders. In Beck’s view, depressed people tend to have negative views of themselves, interpret their experiences negatively, and feel hopeless about their future. He sees these tendencies as a problem of faulty thinking. Like rational-emotive behavior therapists, practitioners of Beck’s technique challenge the client's absolute, extreme statements. They try to help the client identify distorted thinking, such as thinking about negative events in catastrophic terms, and then suggest ways to change this thinking. The following example illustrates how a cognitive therapist might challenge a client’s absolute statement.

Client: Everyone at work is smarter than me.
Therapist: Everyone? Every single person at work is smarter than you?
Client: Well, maybe not. There are a lot of people at work I don't know well at all. But my boss seems smarter; she seems to really know what's going on.
Therapist: Notice how we went from everyone at work being smarter than you to just your boss.

Cognitive therapists often give their clients homework assignments designed to help them identify their own irrational patterns of thinking and to reinforce what they learn in therapy. For example, clients often keep a daily log in which they write down distressing emotions, the situation that caused the emotions, their thoughts at the time, whether the thoughts were distorted or not, and alternative ways of thinking about the situation.

E

Other Therapies

Helping individuals change problematic behaviors, thoughts, or feelings is not an easy task. Therapists have tried many creative approaches to help patients, some of which do not fall neatly into the major categories of psychodynamic, humanistic, behavioral, or cognitive. Two such therapies still in use today are transactional analysis and reality therapy.

E1

Transactional Analysis

In the 1950s and 1960s Canadian-American psychiatrist Eric Berne developed a form of therapy he called transactional analysis. Although trained in psychoanalysis, Berne felt that the complexity of psychoanalytic terminology excluded patients from full participation in their own treatment. He developed a theory of personality based on the view that when people interact with each other, they function either as a parent, adult, or child. For example, he would characterize social interactions between two people as parent-adult, parent-child, adult-child, adult-adult, and so forth depending on the situation. He referred to social interactions as transactions and to analysis of these interactions as transactional analysis.

In therapy, which is often conducted in groups, patients learn to recognize when they are assuming one of these roles and to understand when being an authoritarian parent or an impulsive child is appropriate or inappropriate. In addition to identifying these roles, clients learn how to change roles in order to behave in more desirable ways.

E2

Reality Therapy

American psychiatrist William Glasser developed reality therapy in the 1960s, after working with teenage girls in a correctional institution and observing work with severely disturbed schizophrenic patients in a mental hospital. He observed that psychoanalysis did not help many of his patients change their behavior, even when they understood the sources of it. Glasser felt it was important to help individuals take responsibility for their own lives and to blame others less. Largely because of this emphasis on personal responsibility, his approach has found widespread acceptance among drug- and alcohol-abuse counselors, corrections workers, school counselors, and those working with clients who may be disruptive to others.

Reality therapy is based on the premise that all human behavior is motivated by fundamental needs and specific wants. The reality therapist first seeks to establish a friendly, trusting relationship with clients in which they can express their needs and wants. Then the therapist helps clients explore the behaviors that created problems for them. Clients are encouraged to examine the consequences of their behavior and to evaluate how well their behavior helped them fulfill their wants. The therapist does not accept excuses from clients. Finally, the therapist helps the client formulate a concrete plan of action to change certain behaviors, based on the client’s own goals and ability to make choices.

F

Eclectic Therapy

Currently, many therapists describe their approach as eclectic or integrative, meaning that they use ideas and techniques from a variety of therapies. Many therapists like the opportunity to draw from many theories and not limit themselves to one or two. Most therapists who adopt an eclectic approach have a rationale for which techniques they use with specific clients, rather than just choosing an approach randomly or because it suits them at the time.

One of the most influential eclectic approaches is cognitive-behavioral therapy. Other eclectic approaches use other combinations of therapies.

F1

Cognitive-Behavioral Therapy

There are almost no pure cognitive or behavioral therapists. Usually therapists combine cognitive and behavioral techniques in an approach known as cognitive-behavioral therapy. For example, to treat a woman with depression, a therapist may help her identify irrational thinking patterns that cause the distressing feelings and to replace these irrational thoughts with new ways of thinking. The therapist may also train her in relaxation techniques and have her try new behaviors that help her become more active and less depressed. The client then reports the results back to the therapist.

Cognitive-behavioral therapy has rapidly become one of the most popular and influential forms of psychotherapy, in part because it takes a relatively short period of time compared to humanistic and psychoanalytic therapies, and also because of its ability to treat a wide range of problems. Sometimes cognitive-behavioral therapy takes only a few sessions, but more often it extends for 20 or 30 sessions over four to six months. The length of therapy usually depends on the severity and number of the client’s problems.

F2

Other Eclectic Approaches

Some therapists have one particular way of understanding clients—that is, they adhere to one theory of personality—but use many techniques from a variety of theories. Other therapists may understand clients using two or three theories of personality and only use techniques to bring about change that are consistent with those theories. Some therapists have combined psychodynamic and behavioral therapies in ways to help their clients deal with fears and anxieties but also understand their causes.

Therapists may use different approaches to treat different problems. For example, a therapist might find that clients who are grieving over the loss of a spouse may respond best to a humanistic approach, in which they can share their grieving and their hurts with the therapist. However, the same therapist may use a cognitive-behavioral approach with a person who reports being anxious most of the time.

G

Group Therapy

All of the individual therapies can also be used with groups. People may choose group therapy for several reasons. First, group therapy is usually less expensive than individual therapy, because group members share the cost. Group therapy also allows a therapist to provide treatment to more people than would be possible otherwise. Aside from cost and efficiency advantages, group therapy allows people to hear and see how others deal with their problems. In addition, group members receive vital support and encouragement from others in the group. They can try out new ways of behaving in a safe, supportive environment and learn how others perceive them.

Groups also have disadvantages. Individuals spend less time talking about their own problems than they would in one-on-one therapy. Also, certain group members may interact with other group members in hurtful ways, such as by yelling at them or criticizing them harshly. Generally, therapists try to intercede when group members act in destructive ways. Another disadvantage of group therapy involves confidentiality. Although group members usually promise to treat all therapy discussions as confidential, some group members may worry that other members will share their secrets outside of the group. Group members who believe this may be less willing to disclose all of their problems, lessening the effectiveness of therapy for them.

G1

Format of Group Therapy

Groups vary widely in how they work. The typical group size is from six to ten people with one or two therapists. Often two therapists prefer to work together in a group so that they can respond not only to one person’s issues, but also to discussions between group members that may be occurring quickly. Some groups are open or drop-in groups—new clients may join at any time and members may attend or skip whatever sessions they desire. Other groups are closed and admit new members only when all members agree. Regular attendance is usually required in these groups. In closed groups, both the therapist and group members will ask a member to provide an explanation for missing a meeting.

When forming a group, therapists try to make clear to potential participants the goals of the group and for whom it is appropriate. Therapists will often screen potential participants to learn about their problems and decide whether the group is right for them. Sometimes therapists prefer diversity among group members in terms of age, gender, and problem. In other cases, therapists may limit membership in a group to individuals with similar problems and backgrounds. For example, some groups may form specifically for individuals who are grieving the loss of a loved one, individuals who abuse drugs or alcohol, people with eating disorders, people suffering from depression, or troubled elderly individuals.

The techniques used in group therapy depend largely on the theoretical orientation of the therapist. Humanistic therapists tend to respond to the feelings and experiences of other members. They may also interpret or comment on social interactions between group members. In cognitive-behavioral groups, group members try to change their own thoughts and behaviors and support and encourage other members to do the same. Psychoanalytic groups focus on childhood experiences and their impact on participants’ current behaviors, thoughts, and feelings.

G2

Psychodrama

Psychodrama, the first form of group therapy, was developed in the 1920s by Jacob L. Moreno, an Austrian psychiatrist. Moreno brought his method to the United States in 1925, and its use spread to other parts of the world. Participants in psychodrama act out their problems—often on a real stage and with props—as a means of heightening their awareness of them. The therapist serves as the director, suggesting how participants might act out problems and assigning roles to other group members. For example, a woman might reenact a scene from her childhood with other group members playing her father, mother, brother, or sister. Groups who use psychodrama may do so weekly or simply as a one-time demonstration.

G3

Self-Help Groups

A self-help group or support group involves people with a common problem who meet regularly to share their experiences, support each other emotionally, and encourage change or recovery. They are usually free of charge to interested participants. Self-help groups are not strictly considered psychotherapy because they are not led by a licensed mental health professional. However, they can serve as an important source of help for people in emotional distress.

There are thousands of self-help and support groups in the United States and Canada. The oldest and best known is Alcoholics Anonymous, which uses a 12-step program to treat alcoholism. Other groups have formed for cancer patients, parents whose children have been murdered, compulsive gamblers, battered women, obese people, and many other types of people.

H

Family Therapy

Family therapy involves the participation of one or more members of the same family who seek help for troubled family relationships or the problems of individual family members. Typical problems that bring families into family therapy are delinquent behavior by a child or adolescent, a child’s poor performance in school, hostilities between a parent and child or between siblings, and severe psychological disturbance or mental illness in a parent or child.

One of the most influential forms of family therapy, family systems therapy, views the family as a single, complex system or unit. Individual members are interdependent parts of the system. Rather than treating one person’s symptoms in isolation, therapists try to understand the symptoms in the larger context of the family. For example, a boy who begins picking fights with classmates might do so to get more attention from his busy parents. Therapists work from the rationale that current family relationships profoundly affect, and are affected by, an individual family member’s psychological problems. For this reason, most family therapists prefer to work with the entire family during a session, rather than meeting with family members individually.

In most family therapy sessions, the therapist encourages family members to air their feelings, frustrations, and hostilities. By observing how they interact, the therapist can help them recognize their roles and relationships with each other. The therapist tries to avoid assigning blame to any particular family member. Instead, the therapist makes suggestions about how family members might adjust their roles and prevent future conflict.

I

Couples Therapy

Couples therapy, also called marital therapy or marriage counseling, is designed to help intimate partners improve their relationship. Therapists treat married couples as well as unmarried couples of the opposite or same sex. Therapists normally hold sessions with both partners present. At certain times during therapy, however, the therapist may choose to see the partners individually.

Couples may seek therapy for a variety of problems, many of which concern a breakdown of communication or trust between the partners. For example, an extramarital affair by one partner may cause the other partner to feel emotional pain, anger, and distrust. Some partners may feel distant from one another or experience sexual problems. In other cases, one or both partners may have psychological problems or alcohol or drug problems that negatively affect their relationship.

The techniques used in therapy vary depending on the theoretical orientation of the therapist and the nature of the couple’s problem. Most often, therapists focus on improving communication between partners and on helping them learn to manage conflict. By observing the partners as they talk to each other, the therapist can learn about their communication patterns and the roles they assume in their relationship. The therapist may then teach the partners new ways of expressing their feelings verbally, how to listen to each other, and how to work together to solve problems. The therapist may also suggest that they try out new roles. For example, if one partner makes all of the decisions in the relationship, the therapist may encourage the couple to try sharing decision-making power.

Because most couples therapists also have training in family therapy, they often examine the influence of the couple’s relationships with parents, children, and siblings. Psychoanalytically oriented therapists may focus on how the partners’ childhood experiences affect their current relationship with each other. For couples who cannot work through their differences or reestablish trust and intimacy, separation or divorce may be the best choice. Therapists can help such partners separate in constructive ways.

J

Child Therapy

Some psychotherapists specialize in working with children. Therapists deal with children who are anxious, depressed, or have difficulty getting along with others at home or school. Some children have psychological problems resulting from family issues such as divorce, new stepparents, single-parent homes, death of a parent or sibling, being homeless, or being raised in an alcoholic family. Other children have emotional problems related to physical disabilities, learning disabilities, or attention-deficit hyperactivity disorder.

Play therapy is a special technique that therapists often use with children aged 2 to 12. For children, play is a natural way of learning and relating to others. Play therapy can help therapists both to understand children's problems and to help children deal with their feelings, behaviors, and thoughts. Therapists may use playhouses, puppets, a toy telephone, dolls, sandboxes, food, finger paints, and other toys or objects to help children express their thoughts and feelings. In addition to projecting a caring and gentle manner, therapists who work with children are trained to understand and interpret children’s nonverbal and verbal expressions.

VI

THE PROCESS OF PSYCHOTHERAPY

For most people, psychotherapy involves a common sequence of events: finding a therapist, assessing the problem, exploring the problem, resolving the problem, and terminating therapy. Sometimes therapy will end prematurely, before the problem is resolved. For example, the therapist or client may move to a new city.

When someone has a personal problem and seeks help from a therapist, the individual may turn to a variety of people to get a referral—a friend, a pastor or rabbi, or a family physician. Phone books list associations of psychologists, psychiatrists, and social workers that can also provide referrals to therapists. As noted earlier, however, some health insurance plans may restrict a person’s choice of therapist.

When prospective clients call a therapist for an appointment, they may discuss several aspects of therapy. One concern is availability—is the therapist taking on new patients? Are there hours when both patient and therapist can meet? Another issue is fees. Both therapists in private practice and those in community mental health agencies have to negotiate fees depending in part on the client’s health insurance plan. Some agencies do not require health insurance and have very low fees or a sliding scale that sets fees depending on the ability of the client to pay.

During the first meeting, clients try to explain their problems to the therapist. The therapist usually asks about the nature of the problems, what may make the problems better or worse, and how long the problems have existed. For many therapists, hearing details, even small ones, helps them to assess the problems and to decide the best form of treatment. Some therapists collaborate with clients in deciding the goals of therapy and what treatment methods will be used. Assessment does not stop with the first session, but continues through therapy. Occasionally, goals of therapy change upon assessment of new issues or problems.

During therapy, the client sits across from the therapist—except in classical psychoanalysis, in which the client lies on a couch. The specific nature of the discussions between therapist and client differs greatly depending on the therapist’s theoretical orientation. Some therapists are interested in unconscious forces and the early childhood years of the client (psychodynamic therapy), others in actions of the client (behavioral therapy), others in the client’s thinking patterns (cognitive therapy), and yet others in all or some of these aspects. Therapists often take notes during a session or make notes after the session has ended. Sessions typically last from 45 to 50 minutes, although therapists may hold longer sessions during the initial stages of treatment. Clients typically meet weekly with the therapist, although some may meet twice a week or more.

When does therapy end? Clients and therapists discuss this issue together and determine when it is best to stop. Ideally their decision depends on their judgments about the client’s degree of progress and improvement. Some clients may find that therapy does not seem to be making progress, and may decide to change therapists. However, the cost of therapy may also factor in the decision to end therapy. Managed-care companies generally limit the number of sessions they will subsidize to between 15 and 20. Some therapists, especially those in private practice, may arrange to go beyond these limits by negotiating a fee that the client will pay for services. In other cases, the therapist may refer the client to other mental health agencies that have lower fees and do not require insurance. At the end of therapy, the therapist may schedule a follow-up session several months later to check the client’s progress. Also, the therapist and client agree on what to do if the client’s problems recur.

VII

EFFECTIVENESS OF PSYCHOTHERAPY

Almost since the inception of psychotherapy, therapists and their clients have asked, “Does it work? Does psychotherapy help people resolve their problems, feel better, and change the way they deal with other people?” Therapists and clients are not the only ones asking these questions. In recent years, the agencies that fund mental health services—health insurance companies, health maintenance organizations, and government organizations—have increased their scrutiny of the effectiveness of various psychotherapies in an effort to contain costs.

Measuring the effectiveness of psychotherapy is an extremely complex task. Asking psychotherapists or their clients, “How helpful has therapy been?” is only a start. The answer does provide some information about how therapists and their clients perceive therapy. However, it does not answer the question of whether psychotherapy is effective because both therapists and clients have vested interests in believing that therapy succeeded. Therapists want to uphold their professional reputation and sense of competence, and clients want to feel that their investment of time and money has been worthwhile. Because of these biases, most studies of effectiveness rely on other evaluations of a client’s improvement: psychological tests given before and after treatment, reports from the client’s friends and family, and reports from impartial interviewers who do not know the client or whether the client received any therapy.

A

Overall Effectiveness

In 1952 British psychologist Hans Eysenck reviewed the results of 24 studies of psychotherapy and came to a controversial conclusion: Although two-thirds of patients who received psychotherapy showed improvement, a roughly equal proportion of patients who had been on a waiting list for therapy improved with no treatment. According to Eysenck, the patients on the waiting list showed spontaneous remission—recovery without treatment. Although researchers soon exposed flaws in his analysis and problems with the original studies, Eysenck’s findings touched off hundreds of new studies on the effectiveness of psychotherapy.

In 1980 American researchers statistically combined the results of 475 studies on psychotherapy outcomes using a technique known as meta-analysis. Their study found that the average psychotherapy recipient showed more improvement than 80 percent of untreated individuals. Later studies have confirmed that overall, psychotherapy is better than no therapy at all. Furthermore, it appears at least as effective as drug treatment for most psychological problems. However, psychotherapy is not effective for everyone. About 10 percent of people who receive psychotherapy show no improvement or actually get worse.

Researchers have also studied how quickly people improve with psychotherapy. One analysis, which reviewed data from more than 2400 psychotherapy patients, found that 50 percent of people receiving once-a-week psychotherapy showed significant improvement after eight sessions, or two months. After six months, or 26 sessions, about 75 percent of people show improvement. However, most people required about a year of psychotherapy for relief from severe symptoms, such as feelings of worthlessness.

B

Comparing Different Psychotherapies

Are some types of psychotherapy more effective than others? This question has been hotly debated for decades, and research on this issue presents many difficulties. In conducting studies that compare different therapies, researchers seek to make sure that each treatment group is as similar as possible. For example, researchers may limit the groups to people with the same severity of depression. In addition, within each treatment group, researchers try to make sure that therapists are using the same techniques and are trained similarly. However, patients do not come to therapy with simple problems that fit easily into studies. Furthermore, therapists of the same theoretical orientation may vary in their techniques and in the skillfulness with which they apply them.

Because of these problems, there is no conclusive answer about which type of therapy is best. Most studies have failed to demonstrate that any one approach is superior to another. The meta-analysis of 475 studies mentioned earlier, for example, found that psychodynamic, humanistic, behavioral, and cognitive approaches were all about equally effective. In the 1990s a major study by the National Institute of Mental Health compared the effectiveness of cognitive-behavioral therapy, interpersonal psychotherapy (a form of short-term psychodynamic therapy that focuses on social relations), and drug therapy for people with depression. The study found that all three types of treatment helped individuals become less depressed. Furthermore, no one method was significantly more effective than the others.

Some researchers suggest that all therapies share certain qualities, and that these qualities account for the similar effectiveness of therapies despite quite different techniques. For instance, all therapies offer people hope for recovery. People who begin therapy often expect that therapy will help them, and this expectation alone may lead to some improvement (a phenomenon known as the placebo effect). Also, people in psychotherapy may find that simply being able to talk freely and openly about their problems helps them to feel better. Finally, the support, encouragement, and warmth that clients feel from their therapist lets them know they are cared about and respected, which may positively affect their mental health.

Although different therapeutic approaches may be equally effective on average, mental health researchers agree that some types of therapy are best for particular problems. For panic disorder and phobias, behavioral and cognitive-behavioral therapies seem most effective. Behavioral techniques, often in combination with medication, are also an effective treatment for obsessive-compulsive disorder, post-traumatic stress disorder, generalized anxiety disorder, and sexual dysfunction. Cognitive-behavioral, psychodynamic, and humanistic approaches all provide moderate relief from depression.

C

The Therapist-Client Relationship

Mental health professionals agree that the effectiveness of therapy depends to a large extent on the quality of the relationship between the client and therapist. In general, the better the rapport is between therapist and client, the better the outcome of therapy. If a person does not trust a therapist enough to describe deeply personal problems, the therapist will have trouble helping the person change and improve. For clients, trusting that the therapist can provide help for their problems is essential for making progress.

The founder of person-centered therapy, Carl Rogers, believed that the most important qualities in a therapist are being genuine, accepting, and empathic. Almost all therapists today would agree that these qualities are important. Being genuine means that therapists care for the client and behave toward the client as they really feel. Being accepting means that therapists should appreciate clients for who they are, despite the things that they may have done. Therapists do not have to agree with clients, but they must accept them. Being empathic means that therapists understand the client’s feelings and experiences and convey this understanding back to the client.

In helping their clients, all therapists follow a code of ethics. First, all therapy is confidential. Therapists notify others of a client’s disclosures only in exceptional cases, such as when children disclose abuse by parents, parents disclose abuse of children, or clients disclose an intention to harm themselves or others. Also, therapists avoid dual relationships with clients—that is, being friends outside of therapy or maintaining a business relationship. Such relationships may reduce the therapist’s objectivity and ability to work with the client. Ethical therapists also do not engage in sexual relationships with clients, and do not accept as clients people with whom they have been sexually intimate.

D

Cultural Factors

As more immigrants to the United States and Canada have entered therapy, psychotherapists and counselors have learned the importance of taking a client’s cultural background into account when assessing the problem and determining treatment. Scholars recognize that most psychotherapies are based on Western systems of psychology, which stress the desirability of individualism and independence. However, cultures of Asia and other regions commonly emphasize different values, such as conformity, dependency on others, and obeying one’s parents. Thus, techniques that might be effective for someone from North America, Europe, or Australia might be inappropriate for a recent immigrant from Vietnam, Japan, or India. In order to provide effective treatment, therapists must be aware of their own cultural biases and become familiar with their client’s ethnic and cultural background.