Psychotherapy

B

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.

Managed healthcare, which became widespread in the United States in the 1980s and 1990s, has further driven the movement toward shorter therapies. To provide mental healthcare 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 a set fee 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.

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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.

IV

Education and Training of Psychotherapists

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. They then 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.

Most 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.

V

Types of Psychotherapy

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.

A

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.

A

1

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, which can become costly. Classical psychoanalysis is not typically covered by insurance plans with managed mental healthcare. Therefore, relatively few individuals choose this intensive and long-term therapy.

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