Psychotherapy is the treatment of psychological problems through confidential verbal communications with a mental health professional. All psychotherapies offer hope that a problem will improve, present new perspectives on the problem, and encourage an empathic relationship with a therapist. The approach a psychotherapist uses depends on his or her theoretical orientation. Types of approaches include psychodynamic, cognitive, humanistic, and behavioral.
All of the many psychodynamic therapies derive from the treatment called psychoanalysis, which Sigmund Freud developed and used in the late 1800s and early 1900s. (See Chapter 13 for more information on Freud and his theory of psychoanalysis.)
Psychoanalytic treatment focuses on uncovering unconscious motives, conflicts, and defenses that relate to childhood experiences. Freud believed that people experience anxiety because of conflicts among the id, ego, and superego. To manage these conflicts, people use defense mechanisms, which can often be self-defeating and unsuccessful at fully controlling anxiety.
In the traditional form of psychoanalysis, clients meet with a psychoanalyst several times a week for many years. The psychoanalyst sits out of view of the client, who sometimes lies on a couch.
Some techniques commonly used in psychoanalysis include free association, dream analysis, and interpretation:
- Free association: Psychoanalysts encourage clients to say anything that comes to mind. Clients are expected to put all thoughts into words, even if those thoughts are incoherent, inappropriate, rude, or seemingly irrelevant. Free associations reveal the client’s unconscious to the psychoanalyst.
- Dream analysis: Dreams also reveal the subconscious. Clients describe their dreams in detail, and the psychoanalyst interprets the latent content, or the hidden meaning, of these dreams.
- Interpretation: A key technique in psychoanalysis, interpretation refers to the psychoanalyst’s efforts to uncover the hidden meanings in the client’s free associations, dreams, feelings, memories, and behavior. Psychoanalysts are trained to make interpretations carefully and only when a client is ready to accept them. Ideally, such interpretations increase the client’s insight .
Three important concepts involved in psychoanalysis are transference, resistance, and catharsis:
- Transference refers to the process by which clients relate to their psychoanalysts as they would to important figures in their past. Psychoanalysts usually encourage transference because it helps them to uncover the client’s hidden conflicts and helps the client to work through such conflicts.
Example: A client who is resentful about her mother’s authority over her might show angry, rebellious behavior toward the psychoanalyst.
- Resistance refers to the client’s efforts to block the progress of treatment. These efforts are usually unconscious. Resistance occurs because the client experiences anxiety when unconscious conflicts begin to be uncovered.
Example: Resistance can take many different forms, such as coming late to sessions, forgetting to pay for sessions, and expressing hostility toward the psychoanalyst.
- Catharsis is the release of tension that results when repressed thoughts or memories move into the patient’s conscious mind.
Example: Jane has a repressed childhood memory of being punished by her father after walking into her parents’ bedroom while they were having sex. This memory comes into her conscious mind while she is undergoing psychotherapy. Subsequently, she feels a release of tension and is able to relate the incident to her current aversion toward sex.
Current Psychodynamic Therapies
Today, the classical form of psychoanalysis is rarely practiced. Psychodynamic therapies, however, are widely used for treating the full range of psychological disorders. Psychodynamic therapies differ in their specific approaches, but they all focus on increasing insight by uncovering unconscious motives, conflicts, and defenses.
Interpretation and the concepts of transference and resistance are important features of psychodynamic therapies. Unlike traditional psychoanalysts, psychodynamic therapists usually sit face-to-face with their clients. Sessions typically occur once or twice a week, and treatment usually does not last as long as psychoanalysis.
Cognitive therapies aim to identify and change maladaptive thinking patterns that can result in negative emotions and dysfunctional behavior. Psychologist Aaron Beck first developed cognitive therapy to treat depression, although cognitive therapies are now used to treat a wide range of disorders. Beck’s cognitive therapy helps clients test whether their beliefs are realistic.
Cognitive therapists such as Beck believe that depression arises from errors in thinking. According to this theory, depressed people tend to do any of the following:
- Blame themselves for negative events. They underestimate situational causes.
- Pay more attention to negative events than to positive ones.
- Are pessimistic.
- Make inappropriately global generalizations from negative events.
Cognitive Therapy Techniques
Cognitive therapists try to change their clients’ ways of thinking. In therapy, clients learn to identify automatic negative thoughts and the assumptions they make about the world. Automatic thoughts are self-defeating judgments that people make about themselves. Clients learn to see these judgments as unrealistic and to consider other interpretations for events they encounter.
Whereas insight therapies focus on addressing the problems that underlie symptoms, behavior therapists focus on addressing symptoms, which they believe are the real problem. Behavior therapies use learning principles to modify maladaptive behaviors. Many therapists combine behavior therapy and cognitive therapy into an approach known as cognitive-behavior therapy.
Behavior therapies are based on two assumptions:
- Behavior is learned.
- Behavior can be changed by applying the principles of classical conditioning, operant conditioning, and observational learning. (See Chapter 7 for more information.)
Behavior therapies are designed for specific types of problems. Three important types of behavior therapies include systematic desensitization, aversion therapy, and social skills training.
Systematic desensitization is a treatment designed by the psychologist Joseph Wolpe. It uses counterconditioning to decrease anxiety symptoms. This therapy works on the assumption that anxiety arises through classical conditioning. That is, a neutral stimulus begins to arouse anxiety when it is paired with an unconditioned stimulus that evokes anxiety.
Example: A person might develop a fear of high places after experiencing an avalanche on a mountain trail. The avalanche is the unconditioned stimulus, and any high place becomes the conditioned stimulus, producing anxiety similar to that evoked by the avalanche.
Systematic desensitization aims to replace the conditioned stimulus with a response, such as relaxation, that is incompatible with anxiety. If psychotherapists can teach their clients to relax whenever they encounter an anxiety-producing stimulus, the anxiety will gradually decrease.
Systematic desensitization involves a series of steps, which occur over several therapy sessions:
- The therapist and client make up an anxiety hierarchy. The hierarchy lists stimuli that the client is likely to find frightening. The client ranks the stimuli from least frightening to most frightening.
- The therapist teaches the client how to progressively and completely relax his body.
- Next, the therapist asks the client to first relax and then imagine encountering the stimuli listed in the anxiety hierarchy, beginning with the least-frightening stimulus. If the client feels anxious while imagining a stimulus, he is asked to stop imagining the stimulus and focus on relaxing. After some time, the client becomes able to imagine all the stimuli on the hierarchy without anxiety.
- Finally, the client practices encountering the real stimuli.
In aversion therapy, a stimulus that evokes an unpleasant response is paired with a stimulus that evokes a maladaptive behavior.
Example: A therapist might give an alcoholic a nausea- producing drug along with alcoholic drinks.
Therapists use aversion therapy to treat problems such as deviant sexual behavior, substance abuse, and overeating. One major limitation of this type of therapy is that people know that the aversive stimulus occurs only during therapy sessions. Aversion therapy is usually used in combination with other treatments.
Social Skills Training
Social skills training aims to enhance a client’s relationships with other people. Techniques used in social skills training include modeling, behavioral rehearsal, and shaping:
- Modeling involves having clients learn specific skills by observing socially skilled people.
- Behavioral rehearsal involves having the client role-play behavior that could be used in social situations. The therapist provides feedback about the client’s behavior.
- Shaping involves having the client approach progressively more difficult social situations in the real world.
Humanistic therapies are derived from the school of humanistic psychology (see Chapter 13). Humanistic therapists try to help people accept themselves and free themselves from unnecessary limitations. The influence of humanistic therapies led to the use of the term clients, rather than patients, in referring to people who seek therapy. Humanistic therapists tend to focus on the present situation of clients rather than their past.
The best-known humanistic therapy is client-centered therapy.
Client-centered, or person-centered, therapy was developed by the psychologist Carl Rogers. (See Chapter 13 for more information on Carl Rogers.) It aims to help clients enhance self-acceptance and personal growth by providing a supportive emotional environment. This type of therapy is nondirective, which means that the therapist does not direct the course and pace of therapy. Client-centered therapists believe that people’s problems come from incongruence, or a disparity between their self- concept and reality. Incongruence arises because people are too dependent on others for approval and acceptance. When people have incongruence, they feel anxious. They subsequently try to maintain their self-concept by denying or distorting reality.
In client-centered therapy, people learn to adopt a more realistic self-concept by accepting who they are and thus becoming less reliant on the acceptance of others. To do this, therapists have to be genuine, empathic, and provide unconditional positive regard, which is nonjudgmental acceptance of the client. Client-centered therapists use active listening to show empathy by accurately mirroring, or reflecting, the thoughts and feelings of the client. They help the client to clarify these thoughts and feelings by echoing and restating what the client has said.