V.

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.

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. 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.

A.2.

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.

A.3.

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.

A.4.

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.

A.5.

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.

B.

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.

B.1.

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).

B.2.

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:

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

B.3.

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:

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.

C.

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.

C.1.

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:

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.

C.2.

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.

C.3.

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.

C.4.

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.

C.5.

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.

D.

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.

D.1.

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.”

D.2.

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.

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.

E.1.

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.

E.2.

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.

F.1.

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.

F.2.

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.

G.1.

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.

G.2.

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.

G.3.

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.