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.

A.

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.

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.

, 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.