Approaches to Psychotherapy

Psychodynamic and Psychoanalytic Therapy

The primary focus of psychodynamic therapy is to uncover the unconscious content of a client’s psyche in order to alleviate psychic tension.

Learning Objectives

Discuss the goals, techniques, and efficacy of psychodynamic therapy

Key Takeaways

Key Points

  • Psychodynamics emphasizes systematic study of the psychological forces that underlie human behavior, feelings, and emotions and how they might relate to early experience. It is especially interested in the dynamic relations between conscious motivation and unconscious motivation.
  • Psychodynamic therapy is similar to psychoanalytic therapy, which is based on the idea that a person’s development is often determined by forgotten events in early childhood. Psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis.
  • Psychodynamic therapy works to uncover repressed childhood experiences that are thought to explain an individual’s current difficulties. There are several forms of psychodynamic therapy, such as interpersonal therapy (IPT) and person-centered therapy.
  • Sigmund Freud first used the term “psychodynamics” to describe the processes of the mind as flows of psychological energy in an organically complex brain. The idea for this came from his adviser, Ernst Brucke, at the University of Vienna.
  • Psychodynamic therapy uses free association and focuses on unconscious conflicts, defense mechanisms, transference, and current symptoms.
  • While the effectiveness of psychodynamic therapy is difficult to measure, several studies have indicated its usefulness in treatment. However, this form of therapy is often criticized for its lack of quantitative and experimental research.

Key Terms

  • countertransference: The transference of a therapist’s own unconscious feelings to his or her patient; unconscious or instinctive emotion felt towards the patient.
  • transference: The process by which emotions and desires, originally associated with one person, such as a parent, are unconsciously shifted to another.
  • libido: A person’s overall sexual drive or desire for sexual activity.
  • psychodynamic therapy: A form of depth psychology, the primary focus of which is to reveal the unconscious content of a client’s psyche in an effort to alleviate psychic tension.
  • free association: A technique used in psychanalysis in which patients are invited to relate whatever comes into their minds during the analytic session, and to not censor their thoughts.
  • defense mechanism: A psychological strategy used unconsciously by people to manipulate, deny, or distort reality in order to defend against feelings of anxiety or unacceptable impulses and maintain one’s positive sense of self.

Defining the Psychodynamic Approach

” Psychotherapy ” is an general term that encompasses a wide variety of approaches to treatment. One such approach is psychodynamic therapy, which studies the psychological forces underlying human behavior, feelings, and emotions, as well as how they may relate to early childhood experience. This theory is especially interested in the dynamic relations between conscious and unconscious motivation; it asserts that behavior is the product of underlying conflicts of which people often have little awareness. The primary focus of psychodynamic therapy is to uncover the unconscious content of a client’s psyche in order to alleviate psychic tension.

Comparing Psychodynamic and Psychoanalytic Therapies

Psychodynamic therapy is similar to psychoanalytic therapy, or psychoanalysis, in that it works to uncover repressed childhood experiences that are thought to explain an individual’s current difficulties. Psychoanalytic therapy is based on the ideas that a person’s development is often determined by forgotten events in early childhood, and that human behavior and dysfunction are largely influenced by irrational drives that are rooted in the unconscious.

In terms of approach, psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis; it adapts some of the basic principles of psychoanalysis to a less intensive style of working, usually at a frequency of once or twice per week. Compared to other forms of therapy, psychodynamic therapy emphasizes the relationship between client and therapist as an agent of change.

Core Characteristics of the Psychodynamic Approach

Psychodynamic theory emphasizes the systematic study of the psychological forces that underlie human behavior. It is especially interested in the dynamic relations between conscious motivation and unconscious motivation. In the treatment of psychological distress, psychodynamic therapies target the client’s inner conflict, from where repressed behaviors and emotions surface into the patient’s consciousness. All psychodynamic therapies have a core set of characteristics:

  • An emphasis on unconscious conflicts and their relation to development, dysregulation, and dysfunction.
  • The belief that defense mechanisms are responses that develop in order to avoid unpleasant consequences of conflict.
  • The belief that psychopathology develops from early childhood experiences.
  • The idea that representations of experiences are founded upon interpersonal relations.
  • A conviction that life issues and dynamics will re-emerge in the context of the client-therapist relationship as transference and countertransference.
  • The use of free association as a core method to explore internal conflicts. During free association, patients are invited to relate whatever comes to mind during the therapeutic session, without censoring their thoughts.
  • The focus on interpretations of defense mechanisms (often unconscious coping techniques that reduce anxiety arising from unacceptable or potentially harmful impulses), transference (a phenomenon in which a patient unconsciously redirects their feelings onto the therapist or another person), and current symptoms.

Types of Psychodynamic Therapy

There are several forms of psychodynamic psychotherapy, such as interpersonal therapy (IPT) and person-centered therapy.

IPT is a structured, supportive approach that strives to connect the external, such as interpersonal struggles, with the internal, such as an individual’s mood. IPT is particularly attentive to relationships and social roles. It is usually a time-limited treatment, typically lasting 12–16 weeks, that encourages the patient to regain control of mood and functioning.

Person-centered therapy is less structured and non-directive. Developed by Carl Rogers, this method of therapy proposes that the function of the therapist is to extend empathy, warmth, and “unconditional positive regard” toward their clients. By listening to and echoing back the clients’ own concerns, the therapist helps the client see themselves as another might see them. This can help them perceive inconsistencies or biases in their perceptions of the world and other people.

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Person-centered therapy: Person-centered therapy (PCT) is a type of psychodynamic therapy in which the client guides each session and the therapist provides unconditional positive regard. The goal of PCT is to provide clients with an opportunity to develop a sense of self wherein they can realize how their attitudes, feelings, and behaviors are being negatively affected.

History of Psychodynamic Therapy

Psychodynamic theory was born in 1874 with the works of German scientist Ernst von Brucke, who supposed that all living organisms are energy systems governed by the principle of the conservation of energy. During the same year, medical student Sigmund Freud adopted this new “dynamic” physiology and expanded it to create the original concept of “psychodynamics,” in which he suggested that psychological processes are flows of psychological energy (which he termed the “libido”) in a complex brain. Freud coined the term “psychoanalysis,” and related  theories were developed further by Carl Jung, Alfred Adler, Melanie Klein, Anna Freud, Erik Erikson, and others. By the mid-1940s and into the 1950s, the general application of the “psychodynamic theory” had been well established.

Efficacy of Psychodynamic Therapy

The effectiveness of strict psychoanalysis is difficult to gauge; therapy as Freud intended it relies heavily on the interpretation of the therapist and is therefore difficult to prove. The effectiveness of more modern, developed techniques of psychodynamic therapy can be more accurately gauged, however. Meta-analyses in 2012 and 2013 found evidence for the efficacy of psychoanalytic therapy; other meta-analyses published in recent years showed psychoanalysis and psychodynamic therapy to be effective, with outcomes comparable to or greater than other kinds of psychotherapy or antidepressant drugs.

In 2011, the American Psychological Association made 103 comparisons between psychodynamic treatments and non-dynamic competitors and found that 6 were superior, 5 were inferior, 28 showed no difference, and 63 were adequate. The study found that this could be used as a basis to make psychodynamic psychotherapy an “empirically validated” treatment. In 2013, the world’s largest randomized controlled trial on therapy with anorexia outpatients, the ANTOP study, proved modified psychodynamic therapy to be more effective than cognitive behavioral therapy in the long term.

In contrast, a 2001 systematic review of the medical literature by the Cochrane Collaboration concluded that no data exist demonstrating that psychodynamic therapy is effective in treating schizophrenia and severe mental illness, and cautioned that medication should always be used alongside any type of talk therapy in schizophrenia cases. The Schizophrenia Patient Outcomes Research Team in particular cautions against following a psychodynamic approach in treating cases of schizophrenia due to its lack of empirical support.

Criticisms of Psychodynamic Therapy

Psychoanalysis continues to be practiced by psychiatrists, social workers, and other mental health professionals; however, its practice is less common today than in years past. Psychodynamic therapy, in contrast, is still commonly used today.

A common critique of psychoanalysis is its lack of basis in empirical research and too much reliance on anecdotal evidence by way of case studies. Both psychoanalysis and psychodynamic therapies have been criticized for a lack of scientific rigor, sometimes even referred to as “pseudoscience.” A French 2004 report from INSERM said that psychodynamic therapy is less effective than other psychotherapies (including cognitive behavioral therapy) for certain diseases. It used a meta-analysis of numerous other studies to find whether the method was “proven” or “presumed” to be effective in the treatment of different diseases. Numerous studies have suggested that its efficacy is related to the quality of the therapist, rather than the particular school, technique, or training.

Behavior Therapy and Applied Behavioral Analysis

Behavior therapy is based on the idea that maladaptive behavior is learned, and thus adaptive behavior can also be learned.

Learning Objectives

Discuss the goals, techniques, and efficacy of behavior therapy and applied behavior analysis

Key Takeaways

Key Points

  • Behavior therapy stands apart from insight-based therapies (such as psychoanalytic and humanistic therapy) because the goal is to teach clients new behaviors to minimize or eliminate problems, rather than focusing on the unconscious mind.
  • Behavioral therapy is based on behaviorism, which defines itself by the belief that psychology should concern itself with the observable behavior of people and animals, rather than unobservable events that take place in their minds.
  • Behavior therapy uses a wide range of techniques to treat a person’s psychological problems; it is based largely on the theories of classical conditioning and operant conditioning.
  • Operant conditioning focuses on rewards and punishments, while classical conditioning works to pair a conditioned stimulus with an unconditioned stimulus, so that they may be associated in the individual’s mind.
  • Some of the better-known types of treatments are applied behavioral analysis, aversion therapy, systematic desensitization, exposure therapy, and modeling.
  • Behavior therapy has proven effective in many areas and has been used to address intimacy in couples, relationships, forgiveness, chronic pain, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia, and obesity.
  • Applied behavioral analysis (ABA) has been criticized for pathologizing and trying to “normalize” the behaviors of children with autism, in order to re-shape these behaviors to be more socially acceptable.

Key Terms

  • operant conditioning: A technique of behavior modification, developed by B. F. Skinner, that utilizes positive and negative reinforcement and positive and negative punishment to alter behavior.
  • classical conditioning: The use of a neutral stimulus, originally paired with one that invokes a response, to generate a conditioned response.

Defining the Behavioral Approach and Applied Behavioral Analysis

Behavior therapy is a treatment approach that is based on the idea that abnormal behavior is learned. It applies the principles of operant conditioning, classical conditioning, and observational learning to eliminate inappropriate or maladaptive behaviors and replace them with more adaptive responses. Behavior therapy methods sometimes focus only on behaviors, and sometimes on combinations of thoughts and feelings that might be influencing behaviors. Those who practice behavior therapy, known as behaviorists, tend to look more at specific, learned behaviors and how the environment has an impact on those behaviors. Behaviorists tend to look for treatment outcomes that are objectively measurable.

Behavior therapy stands apart from insight-based therapies (such as psychoanalytic and humanistic therapy) because the goal is to teach clients new behaviors to minimize or eliminate problems, rather than digging deeply into their subconscious or uncovering repressed feelings. The basic premise is that the individual has learned behaviors that are problematic and maladaptive, and so he or she must learn new behaviors that are adaptive.

Foundations

Behaviorism focuses on learning that is brought about by a change in external behavior, achieved through a repetition of desirable actions and the rewarding of good habits and the discouragement of bad habits. There are two basic theories of learning that build the foundation for behaviorism:

  • Operant conditioning is a type of learning in which an individual’s behavior is modified by its consequences; the behavior may change in form, frequency, or strength.
  • Classical conditioning is a form of learning in which a subject comes to respond to a previously neutral stimulus by continually pairing it with an unconditioned stimulus that elicits the desired response.

Operant Conditioning Approaches

Applied behavioral analysis (ABA) is a type of behavior therapy that uses the principles of operant conditioning; it is commonly used in the treatment of children with autism spectrum disorder (ASD). In this treatment, child-specific reinforcers (e.g., stickers, praise, candy, bubbles, and extra play time) are used to reward and motivate children with ASD when they demonstrate desired behaviors, such as sitting on a chair when requested, verbalizing a greeting, or making eye contact. Punishment such as a timeout or a sharp “No!” from the therapist or parent might be used to discourage undesirable behaviors such as pinching, scratching, and pulling hair.

The use of token economies is a behavior-therapy technique in which clients are reinforced with tokens that are considered a type of currency that can be exchanged for special privileges or desired items. Token economies are mainly used in institutional and therapeutic settings. Over time, tokens need to be replaced with less tangible rewards, such as compliments, so that the client will be prepared when they leave the therapeutic setting.

Contingency contracts are formal, written contracts between the client and the therapist. They outline behavior-change goals, reinforcements, rewards, and penalties for not meeting the terms of the agreement.

Modeling involves learning through observation and emulating the behavior of others. The modeling process involves a person being subjected to watching other individuals who demonstrate behavior that is considered adaptive and that should be adopted by the client. In some cases, the therapist might model the desired behavior; in other instances, watching peers demonstrate the behaviors may be helpful. The process is based on Albert Bandura’s social learning theory, which emphasizes the social components of the learning process.

Classical Conditioning Approaches

One commonly used classical conditioning therapeutic technique is aversive conditioning, which uses an unpleasant stimulus to stop an undesirable behavior. Therapists apply this technique to eliminate addictive behaviors, such as smoking, nail biting, and drinking. In aversion therapy, clients will typically engage in a specific behavior (such as nail biting) and at the same time are exposed to something unpleasant, such as a mild electric shock or a bad taste. After repeated associations between the unpleasant stimulus and the behavior, the client can learn to stop the unwanted behavior.

In exposure therapy, a therapist seeks to treat clients’ fears or anxiety by presenting them with the object or situation that causes their problem, with the idea that they will eventually get used to it. This can be done via reality, imagination, or virtual reality. A popular form of exposure therapy is systematic desensitization, wherein a calm and pleasant state is gradually associated with increasing levels of anxiety-inducing stimuli. Virtual reality exposure therapy uses simulations when it’s either too impractical or expensive to re-create anxiety-producing situations; it has been used effectively to treat numerous anxiety disorders such as the fear of public speaking, claustrophobia (fear of enclosed spaces), aviophobia (fear of flying), and post-traumatic stress disorder (PTSD).

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Virtual reality therapy: Virtual reality therapy provides realistic, computer-based simulations that involve watching others performing the desired behaviors.

Flooding is the general technique in which an individual is exposed to anxiety-provoking stimuli, while at the same time prevented from having any avoidance responses. It is often used to treat phobias, anxiety, and other stress-related disorders. For example, flooding might be used to help a client who is suffering from an intense fear of birds. The individual may be forced to stay in a room with a harmless bird for an extended period of time and over repeated sessions. The theory is that after a while, the individual will realize that nothing bad is happening and the fear response will diminish.

Relaxation training is a type of behavior therapy that involves clients learning to lower arousal to reduce their stress by tensing and releasing certain muscle groups throughout their body. Social skills training teaches clients skills to access natural reinforcers and lessen life punishment.

History of Behavior Therapy

The first use of the term “behavior modification” appears to have been by Edward Thorndike in 1911. His article “Provisional Laws of Acquired Behavior or Learning” makes frequent use of the phrase “modifying behavior.” Through early research in the 1940s and the 1950s the term was used by Joseph Wolpe’s research group. In general, behavior therapy is seen as having three distinct points of origin: South Africa (Wolpe’s group), the United States ( B. F. Skinner ), and the United Kingdom (Rachman and Eysenck). Each had its own distinct approach to viewing behavior problems. B. F. Skinner developed the idea of operant conditioning in 1937, when he tested the learning of rats through reinforcement and punishment in what is now called a Skinner box. Ivan Pavlov’s famous experiments with dogs provide the most familiar example of the classical-conditioning procedure.

Exposure therapy was first reported in 1924 by Mary Cover Jones, who is considered the mother of behavior therapy. Jones used exposure therapy with a boy named Peter to help him overcome his fear of rabbits. Thirty years later, Joseph Wolpe (1958) refined Jones’s techniques, giving us the technique of exposure therapy that is used today.

In the second half of the 20th century, many therapists coupled behavior therapy with the cognitive therapy of Aaron Beck and Albert Ellis, forming cognitive behavioral therapy (CBT).

Effectiveness of Behavior Therapy

Behavior therapy has proven effective in many areas and has been used to address intimacy in couples, relationships, forgiveness, chronic pain, anorexia, chronic distress, substance abuse, depression, anxiety, insomnia, and obesity. Behavioral applications to these problems have left clinicians with considerable tools for enhancing therapeutic effectiveness.

Many have argued that behavior therapy is at least as effective as drug treatment for depression, ADHD, and OCD. Two large studies done by the Faculty of Health Sciences at Simon Fraser University indicates that behavior therapy and cognitive-behavioral therapy (CBT) are equally effective for OCD. CBT has been proven to perform slightly better at treating co-occurring depression. Systematic desensitization has been shown to successfully treat phobias about heights, driving, and insects, as well as any anxiety that a person may have. Virtual reality treatment has been shown to be effective for a fear of heights; it has also been shown to help with the treatment of a variety of anxiety disorders. Applied behavioral analysis has been shown to be an effective tool and is a very common treatment approach for children with autism (Lovaas, 1987, 2003; Sallows & Graupner, 2005; Wolf & Risley, 1967).

Criticism of Behavior Therapy and Applied Behavioral Analysis

Applied behavioral analysis has been criticized for trying to “normalize” the behavior of children with autism; critics argue that children with autism express themselves in different ways that are not pathological, and that ABA pathologizes these behaviors and seeks to re-shape them into more socially acceptable behaviors. Other critics have argued that ABA and other behavior therapies are too rigid in their approach, and that effective treatment requires an acknowledgement of the subconscious as well as observable behaviors. Some have argued that certain types of behavior therapy may make a patient too dependent on external rewards rather than internal motivation to change. Finally, many have critiqued the use of punishment in certain forms of behavior therapy as inhumane.

Cognitive and Cognitive-Behavioral Therapies

Cognitive and cognitive-behavioral therapies address the interplay between dysfunctional emotions, maladaptive behaviors, and biased cognitions.

Learning Objectives

Discuss the goals, techniques, and efficacy of cognitive and cognitive-behavioral therapies

Key Takeaways

Key Points

  • Cognitive therapy seeks to help the client overcome distress by identifying and changing dysfunctional thinking, behavior, and emotional responses. This involves helping patients develop skills for modifying beliefs, identifying distorted thinking, and changing behaviors.
  • Cognitive-behavioral therapy (CBT) works to solve current problems and change unhelpful thinking and behavior. The basic tenet of CBT is that emotions occur because of our interpretation of an event, not because of the event itself.
  • Modern forms of CBT include a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, acceptance and commitment therapy, and dialectical behavior therapy.
  • Dialectical behavior therapy (DBT), originally developed to treat people with borderline personality disorder, combines basic cognitive-behavioral approaches (such as emotion regulation and reality testing) with acceptance approaches (such as distress tolerance and mindful awareness).
  • The modern roots of CBT can be traced to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two.
  • CBT has been shown to have effectiveness in the treatment of anxiety disorders, depression, eating disorders, personality disorders, psychosis, substance use disorders, and schizophrenia.
  • Critics argue that one of the hidden assumptions in CBT is that of determinism, or the absence of free will.

Key Terms

  • maladaptive: Showing inadequate or faulty adaptation to a new situation.
  • dialectical: Logically reasoned through the exchange of opposing ideas.

Defining the Cognitive-Behavioral Approach

Cognitive therapy (CT) and cognitive-behavioral therapy (CBT) are closely related; however CBT is an umbrella category of therapies that includes cognitive therapy. CBT is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors, and cognitive processes through a number of goal-oriented, systematic procedures. The category refers to behavior therapy, cognitive therapy, and therapies based on a combination of basic behavioral and cognitive principles and research, including dialectical behavior therapy.

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Basic tenets of CBT: The diagram depicts how emotions, thoughts, and behaviors all influence each other. The triangle in the middle represents CBT’s tenet that all humans’ core beliefs relate to themselves, others, or the future. Centered around that is a feedback loop between behavior, thoughts, and feelings, all of which are the target of CBT.

Cognitive Therapy

Cognitive therapy seeks to help the client overcome difficulties by identifying and changing dysfunctional thinking and behavior, as well as emotional responses. This involves helping patients to develop skills for modifying beliefs, identifying distorted thinking, relating to others in different ways, and changing behaviors. Treatment is based on collaboration between the patient and therapist and on testing beliefs.

At the core of cognitive therapy is the idea of cognitive biases, or irrational beliefs that cause distress in a person’s life. Some examples include:

  • Over-generalization: drawing general conclusions from a single (usually negative) event, such as thinking that making a single bad grade makes you a failure of a student.
  • Minimization and magnification: either grossly underestimating one’s own positive performance or overestimating the importance of a negative event.
  • Selective abstraction: occurs when a detail is taken out of context and believed while everything else in the context is ignored.
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Cognitive biases: Cognitive biases are maladaptive patterns of judgment, whereby inferences about other people and situations may be drawn in an illogical fashion. The example in this image depicts a common cognitive bias known as black-and-white thinking, in which someone may think in terms of false dichotomies of always/never or right/wrong with no room for grey areas in between.

These irrational beliefs take the form of automatic thoughts; cognitive therapy believes that patients suffering from mental illness can be helped if therapists challenge these irrational beliefs. In this way, cognitive therapy encourages people to see that some of their thoughts are mistaken. It has been found that by adjusting these thoughts people’s emotional distress can be reduced.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) works to solve current problems and change unhelpful thinking and behavior. The basic tenet of CBT is that emotions (both adaptive and maladaptive) occur because of our interpretation of an event, not because of the event itself. At its most basic level, it is a combination of cognitive therapy and behavioral therapy. While rooted in rather different theories, these two therapy types have been characterized by a constant reference to experimental research to test hypotheses. Common features of CBT procedures are a focus on the here and now, a directive or guidance role of the therapist, structured psychotherapy sessions, and alleviating patients’ symptoms as well as vulnerabilities.

CBT is one of the most widely researched and most effective treatments for depression, anxiety disorders, eating disorders, and substance abuse disorders. When someone is distressed or anxious, the way they see and evaluate themselves can become negative. CBT therapists and clients work together to see the link between negative thoughts and mood. This empowers people to assert control over negative emotions and to change the way they behave. CBT assumes that changing maladaptive thinking leads to change in affect and behavior. Therapists help individuals to challenge maladaptive thinking and help them replace it with more realistic and effective thoughts, or encourage them to take a more open, mindful, and aware posture toward those thoughts.

Modern forms of CBT include a number of diverse but related techniques such as exposure therapy, stress inoculation training, cognitive processing therapy, cognitive therapy, relaxation training, acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT), which is discussed in more detail below.

Dialectical Behavior Therapy

Dialectical behavior therapy (DBT) is a form of psychotherapy that was originally developed to treat people with borderline personality disorder (BPD). DBT involves a combination of standard cognitive-behavioral techniques (e.g., reframing, emotion regulation testing) with acceptance approaches (e.g., distress tolerance,  mindful awareness).

DBT research suggests that maladaptive behaviors (such as self-harm or attention-seeking) function to regulate negative emotions in individuals who lack emotion-regulation skills. Thus, from a DBT perspective, the behaviors that are considered maladaptive in BPD, in people with eating disorders, and in sexual abuse survivors, are negatively reinforced, as they function to regulate emotions and decrease feelings of distress. Consequently, helping clients to develop more adaptive strategies to cope with their emotions should help patients improve their maladaptive behaviors.

DBT includes learning a number of strategies that are directly focused on increasing patients’ skills to adaptively cope with strong urges and emotions. These strategies include mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness.

History of Cognitive-Behavioral Therapy

The modern roots of CBT can be traced to the development of behavior therapy in the early 20th century, the development of cognitive therapy in the 1960s, and the subsequent merging of the two. Groundbreaking work of behavioralism began with Watson’s and Rayner’s studies of conditioning in 1920. Behavioral-centered therapeutic approaches appeared as early as 1924 with Mary Cover Jones’s work on the unlearning of fears in children. These were the antecedents of the development of Joseph Wolpe’s behavioral therapy in the 1950s. During the 1950s and 1960s, behavioral therapy became widely utilized by researchers in the United States, the United Kingdom, and South Africa, who were inspired by the behaviorist learning theories of Ivan Pavlov, John B. Watson, and Clark L. Hull.

Cognitive therapy was developed by psychiatrist Aaron Beck in the 1960s. His initial focus was on depression and how a client’s self-defeating attitude served to maintain a depression despite positive factors in her life (Beck, Rush, Shaw, & Emery, 1979). One of the first forms of cognitive-behavior therapy was rational emotive therapy (RET), which was founded by Albert Ellis and grew out of his dislike of Freudian psychoanalysis (Daniel, n.d.). During the 1980s and 1990s, cognitive and behavioral techniques were merged into cognitive-behavioral therapy. Pivotal to this merging was the successful development of treatments for panic disorder by David M. Clark in the UK and David H. Barlow in the US. Over time, cognitive-behavioral therapy came to be known not only as a therapy, but as an umbrella category for all cognitive-based psychotherapies.

DBT is a modified form of cognitive-behavioral therapy that was originally developed in the late 20th century by psychology researcher Marsha Linehan to treat people who are chronically suicidal and those with borderline personality disorder (BPD).

Efficacy of Cognitive-Behavioral Therapy

In adults, CBT has been shown to have effectiveness and a role in the treatment plans for anxiety disorders, depression, eating disorders, chronic low back pain, personality disorders, psychosis, substance use disorders, and in the adjustment, depression, and anxiety associated with fibromyalgia and post-spinal-cord injuries. Evidence has shown CBT is effective in helping treat schizophrenia, and it is now offered in most treatment guidelines. Some meta-analyses find CBT more effective than psychodynamic therapy and equal to other therapies in treating anxiety and depression. However, psychodynamic therapy may provide better long-term outcomes.

In children and adolescents, CBT is an effective part of treatment plans for anxiety disorders, body dysmorphic disorder, depression and suicidality, eating disorders and obesity, obsessive-compulsive disorder, and post-traumatic stress disorder, as well as tic disorders, trichotillomania, and other repetitive-behavior disorders.

Criticisms of Cognitive-Behavioral Therapy

The research conducted for CBT has been a topic of sustained controversy. While some researchers write that CBT is more effective than other treatments, many other researchers and practitioners have questioned the validity of such claims. A recent meta-analysis revealed that the positive effects of CBT on depression have been declining since 1977. The overall results showed two different declines in effect sizes: 1) an overall decline between 1977 and 2014, and 2) a steeper decline between 1995 and 2014. Some critics argue that CBT studies have high drop-out rates compared to other treatments. At times, the CBT drop-out rates can be more than five times higher than those of other treatment groups.

Critics argue that one of the hidden assumptions in CBT is that of determinism, or the absence of free will, because CBT invokes a type of cause-and-effect relationship with cognition. Specifically, critics argue that since CBT holds that external stimuli from the environment enter the mind, causing different thoughts that lead to emotional states, there is no room in CBT theory for agency, or free will.

Humanistic Therapy

Humanistic therapy helps individuals access and understand their feelings, gain a sense of meaning in life, and reach self-actualization.

Learning Objectives

Discuss the goals, techniques, and efficacy of humanistic therapy

Key Takeaways

Key Points

  • Humanistic therapy adopts a holistic approach to human existence and pays special attention to such phenomena as creativity, free will, and human potential. It encourages self exploration and viewing oneself as a “whole person.”
  • In humanistic therapy, there are two widely practiced techniques: gestalt therapy (which focuses on thoughts and feelings here and now, instead of root causes) and client-centered therapy (which provides a supportive environment in which clients can reestablish their true identity).
  • Humanistic psychology developed in response to psychoanalytic theory and behaviorism. Among its earliest theorists were Abraham Maslow, emphasizing a hierarchy of needs and motivations, and Carl Rogers, who created the person-centered approach.
  • Humanistic therapy has been used to treat a broad range of people and mental health challenges, including depression, anxiety, relationship issues, personality disorders, and various addictions. However, it has been criticized for its lack of empirical evidence.

Key Terms

  • self-actualization: According to humanistic theory, the realization of one’s full potential; can include creative expression, a quest for spiritual enlightenment, the pursuit of knowledge, or the desire to give to society.
  • empathy: The capacity to understand another person’s point of view, or the result of such understanding.

Defining the Humanistic Approach

As a psychotherapeutic treatment approach, humanistic therapy typically holds that people are inherently good. It adopts a holistic approach to human existence and pays special attention to such phenomena as creativity, free will, and human potential. It encourages viewing ourselves as a “whole person” greater than the sum of our parts and encourages self exploration rather than the study of behavior in other people. Humanistic psychology acknowledges spiritual aspiration as an integral part of the human psyche and is linked to the emerging field of transpersonal psychology.

Goals of Humanistic Therapy

The aim of humanistic therapy is to help the client develop a stronger, healthier sense of self, as well as access and understand their feelings to help gain a sense of meaning in life. Humanistic theory aims to help the client reach what Rogers and Maslow referred to as self-actualization —the final level of psychological development that can be achieved when all basic and mental needs are essentially fulfilled and the “actualization” of the full personal potential takes place. Humanistic therapy focuses on the individual’s strengths and offers non-judgmental counseling sessions.

Approaches to Humanistic Therapy

Empathy is one of the most important aspects of humanistic therapy. This idea focuses on the therapist’s ability to see the world through the eyes of the client. Without empathy, the therapist is no longer understanding the actions and thoughts of the client from the client’s perspective, but is understanding strictly as a therapist, which defeats the purpose of humanistic therapy.

Another key element is unconditional positive regard, which refers to the care that the therapist needs to have for the client. Unconditional positive regard is characterized by warmth, acceptance, and non-judgment. This ensures that the therapist does not become the authority figure in the relationship, and allows for a more open flow of information, as well as a kinder relationship between the two. A therapist practicing humanistic therapy needs to show a willingness to listen and ensure the comfort of the client by creating an environment where genuine feelings may be shared but are not forced upon someone.

Types of Humanistic Therapies

In humanistic therapy, there are two widely practiced techniques: gestalt therapy and client-centered therapy.

Gestalt therapy focuses on the skills and techniques that permit an individual to be more aware of their feelings. According to this approach, it is much more important to understand what and how clients are feeling, rather than to identify what is causing their feelings. Previous theories are thought to spend an unnecessary amount of time making assumptions about what causes behavior. Instead, Gestalt therapy focuses on the here and now.

Client-centered therapy provides a supportive environment in which clients can reestablish their true identity. This approach is based on the idea that fear of judgment prevents people from sharing their true selves with the world around them, causing them to instead establish a public identity to navigate a judgmental world. The ability to reestablish their true identity will help the individual understand themselves as they truly are. The task of reestablishing one’s true identity is not an easy one, and the therapist must rely on the techniques of unconditional positive regard and empathy.

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Client-centered therapy: In client-centered therapy, a form of humanistic therapy, one of the goals is to establish a trusting relationship built on empathy and unconditional positive regard.

History of Humanistic Therapy

Humanistic psychology rose to prominence in the mid-20th century in response to the limitations of Sigmund Freud ‘s psychoanalytic theory and B. F. Skinner’s behaviorism. With its roots running from Socrates through the Renaissance, this approach emphasizes individuals’ inherent drive towards self-actualization, the process of realizing and expressing one’s own capabilities, and creativity.

Among the earliest approaches are the developmental theory of Abraham Maslow, which emphasizes a hierarchy of needs and motivations, and the client-centered therapy of Carl Rogers, which is centered on the client’s capacity for self-direction and understanding of his or her own development. The term “actualizing tendency” was also coined by Rogers and was a concept that eventually led Maslow to study self-actualization as one of the needs of humans. Rogers and Maslow introduced this positive, humanistic psychology in response to what they viewed as the overly pessimistic view of psychoanalysis; during the 20th century, humanistic psychology became known as the “third force” in psychology.

Efficacy of Humanistic Therapy

Humanistic therapy is used to treat a broad range of people and mental health challenges. It has been used in the treatment of schizophrenia, depression, anxiety, relationship issues, personality disorders, and various addictions, such as alcoholism. Many proponents advocate the idea that it can be useful and effective with any population; however, others have argued that it has limited effectiveness with individuals who have limited access to education. Certain studies suggest that humanistic therapy is at least as effective as other forms of psychotherapy at producing stable, positive changes over time for clients that engage in this form of treatment.

While personal transformation may be the primary focus of most humanistic psychologists, humanistic approaches have also been applied to theories of social transformation related to pressing social, cultural, and gender issues. In addition, humanistic psychology’s emphasis on creativity and wholeness created a foundation for new approaches towards human capital in the workplace, stressing creativity and the relevance of emotional interactions.

Criticisms of Humanistic Therapy

Critics have taken issue with many of the early tenets of humanistic psychology. As with all early psychological approaches, questions have been raised about the lack of empirical evidence used in research. Because of the subjective nature of the framework, psychologists worry about the fallibility of the humanistic approach. The holistic approach allows for much variation but does not identify enough constant variables to be researched with true accuracy. Psychologists also worry that such an extreme focus on the subjective experience of the individual does little to explain or appreciate the impact of society on personality development. The presence of such a dynamic view of personality also does not seem to account for apparent continuity in an individual’s persona over time.

Body-Oriented Psychotherapies

Body-oriented psychotherapies focus on the importance of working with the body in the treatment of mental health issues.

Learning Objectives

Discuss the goals, techniques, and efficacy of body-oriented psychotherapy

Key Takeaways

Key Points

  • Body-oriented therapies are based on the principles of somatic psychology, which involves the study of the body, somatic experience, and the embodied self, including therapeutic and holistic approaches to the body.
  • Eye movement desensitization and reprocessing (EMDR) is a psychotherapy technique discovered in 1987 by Francine Shapiro for use in the treatment of anxiety, stress, and trauma.
  • Light therapy consists of exposure to daylight or to specific wavelengths of light. It is used to treat certain sleep disorders and seasonal affective disorder.
  • Hypnotherapy is a form of psychotherapy used to create unconscious change in the patient in the form of new responses, thoughts, attitudes, behaviors, or feelings. Hypnotherapy is used to treat anxiety, depression, habit disorders, irrational fears, insomnia, and addiction.
  • Yoga involves holding stretches as a kind of low-impact physical exercise, and is often used for therapeutic purposes, such as relieving symptoms of stress and depression.
  • The review of outcome research across different types of body-oriented psychotherapy suggests positive results in the treatment of somatoform/psychosomatic disorders, schizophrenia, and depressive and anxiety symptoms.
  • As with many alternative therapies, body-oriented therapy is criticized for its lack of scientific validation and empirical evidence.

Key Terms

  • seasonal affective disorder: A form of depression associated with the lack of natural light during the winter months.
  • hypnosis: A trancelike state, artificially induced, in which a person has a heightened suggestibility and during which suppressed memories may be experienced.
  • somatic: Of or relating to the body of an organism.
  • bilateral: Involving both sides equally; often refers to involving both sides of the brain.

Defining the Body-Oriented Approach

Psychotherapists employ a range of techniques based on experiential relationship-building, dialogue, communication, and behavior change that are designed to improve the mental health of a client or to improve family or group relationships (such as in a family). In addition to the more common forms of psychotherapy (including humanistic, cognitive-behavioral, and psychodynamic approaches), there are several alternative, body-oriented therapies that serve specific purposes.

Body-oriented therapies, also referred to as body psychotherapies, are based on the principles of somatic psychology, which involves the study of the body, somatic experience, and the embodied self, including therapeutic and holistic approaches to the body. A wide variety of techniques are used in body-oriented therapies, including sound, touch, mirroring, movement, and breath. There is an increasing use of body-oriented therapeutic techniques within mainstream psychology (such as the practice of mindfulness), and psychoanalysis has recognized the use of such concepts as somatic resonance and embodied trauma. These alternative methods include (but are not limited to) eye movement desensitization and reprocessing (EMDR), light therapy, hypnotherapy, and yoga.

EMDR

Eye movement desensitization and reprocessing (EMDR) is a psychotherapy technique discovered in 1987 by Francine Shapiro for use in the treatment of anxiety, stress, and trauma. The goal of EMDR is to reduce the long-lasting effects of distressing memories by developing more adaptive coping mechanisms. The therapy uses an eight-phase approach that includes having the patient recall distressing images while receiving one of several types of bilateral sensory input, such as side-to-side eye movements. EMDR was originally developed to treat adults with post-traumatic stress disorder ( PTSD ); however, it is also used to treat other conditions.

Light Therapy

Light therapy (also known as phototherapy or heliotherapy) consists of exposure to daylight or to specific wavelengths of light using polychromatic polarized light, fluorescent lamps, or very bight, full-spectrum light. Light is usually controlled with various devices. The light is administered for a prescribed amount of time and, in some cases, at a specific time of day.

Hypnotherapy

Hypnotherapy is a form of psychotherapy used to create unconscious change in the patient in the form of new responses, thoughts, attitudes, behaviors, or feelings. Under hypnosis, a person experiences heightened suggestibility and responsiveness.

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Hypnotherapy: Hypnotherapy is different than the sort of hypnosis performed on stage. It is a form of psychotherapy used to create unconscious change in a person and can be effective in treating many disorders.

Yoga Therapy

Yoga as exercise or alternative medicine is a modern phenomenon that has been influenced by the ancient Indian practice of hatha yoga. It involves holding stretches as a kind of low-impact physical exercise, and is often used for therapeutic purposes. Yoga in this sense often occurs in a class and may involve meditation, imagery, breath work, and music.

History of Body-Oriented Therapy

Body-oriented therapies are based on the principles of somatic psychology, which was founded by Wilhelm Reich in the 1930s. Reich was the first person to bring body awareness systematically into psychoanalysis and also the first psychotherapist to touch clients physically. Reich’s work significantly influenced the development of body psychotherapy; several types of body-oriented psychotherapies trace their origins back to Reich, though there have been many subsequent developments and additional influences.

Efficacy of Body-Oriented Therapy

A review of body-oriented therapy research finds there is a small but growing empirical-evidence base about the outcomes of these approaches; however, it is weakened by the fragmentation of the field into different branches and schools. Research across eight different schools of body-oriented therapies suggests overall efficacy in symptom reduction, though more research is needed. The review of outcome research across different types of body-oriented psychotherapy concludes that the best evidence supports efficacy for treating somatoform/psychosomatic disorders and schizophrenia. There is also support for positive effects on subjectively experienced depressive and anxiety symptoms, somatisation, and social insecurity.

EMDR is commonly used in the treatment of psychological trauma, particularly post-traumatic stress disorder (PTSD) and complex PTSD (C-PTSD). Other body-oriented therapies can help a client to recover a sense of physical boundaries, thereby helping to reestablish trust after a traumatizing incident.

Light therapy is used to treat certain sleep disorders and can also be used to treat seasonal affective disorder. There is also some support for its use with non-seasonal psychiatric disorders and skin disorders such as psoriasis. Modern hypnotherapy is widely used for the treatment of anxiety, subclinical depression, certain habit disorders, irrational fears, insomnia, and addiction. Both the meditative and the exercise components of hatha yoga have been researched for both specific and non-specific health benefits. Hatha yoga has been studied as an intervention for many mental health conditions, including stress and depression. In general, it can help improve quality of life, but does not treat disease.

Criticisms of Body-Oriented Therapy

As with many alternative therapies, body-oriented therapy is criticized for its lack of scientific validation and empirical evidence. Many of the claims regarding the efficacy of body-oriented therapies are considered controversial due to lack of research. Many critics point to the fact that there is no clear explanation or evidence for how or why various body-oriented therapies work.

In addition, the importance of ethical issues in body-oriented therapy has been highlighted on account of the intimacy of the techniques used in several kinds of therapies. In particular, care must be taken when working with clients who have experienced trauma, especially when a body-oriented therapy involves touch by the practitioner.

Group Therapy

Group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together at the same time.

Learning Objectives

Discuss the goals, techniques, and efficacy of group therapy

Key Takeaways

Key Points

  • In the psychodynamic sense, “group therapy” specifically indicates a situation where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring, and examining interpersonal relationships within the group.
  • Dr. Irvin D. Yalom outlined key therapeutic principles, which are derived from reports of individuals who have undergone group therapy. These principles neatly summarize the benefits of group therapy.
  • Group therapy has proven to be very effective for the treatment of depression, traumatic stress such as PTSD, and sexual-abuse survivors.

Key Terms

  • psychodynamic: An approach to psychology that emphasizes systematic study of the psychological forces that underlie human behavior, feelings, and emotions, and how they might relate to early experience.
  • mentalization-based treatment: A psychiatric treatment model that combines individual and group therapy with case management.

Defining the Group-Therapy Approach

Group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together at the same time. Receiving therapy in a group changes the therapist-client relationship dramatically, and therefore affects outcomes. While group therapy is sometimes used alone, it is more often used as part of a greater treatment plan that may include one-on-one therapy and/or medication.

The term “group therapy” is sometimes loosely used to indicate any group of individuals that are experiencing and discussing distress (support groups, for instance). Group therapy can be based on any theoretical approach, from cognitive-behavioral to humanistic. However, in the psychodynamic sense, it specifically indicates a situation where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring, and examining interpersonal relationships within the group. In short, the interpersonal dynamics that play out in the group are reflections of what happens in real life.

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Group dynamics: The group context and group process is explicitly used as a mechanism of change by developing, exploring, and examining interpersonal relationships within the group and seeing them as reflections of what happens in real life.

Therapeutic Principles

Dr. Irvin D. Yalom outlined key therapeutic principles, which are derived from reports of individuals who have undergone group therapy. These principles summarize the benefits of group therapy:

  • Altruism: Group members share their strengths and experiences in order to help others. The experience of being able to give something to another person can lift the member’s self-esteem and help develop more adaptive coping styles and interpersonal skills.
  • Catharsis: The experience of relief from emotional distress through the free and uninhibited expression of emotion. When members tell their story to a supportive audience, they can obtain relief from chronic feelings of shame and guilt.
  • Cohesiveness: It has been suggested that this is the primary therapeutic factor from which all others flow. Because all members share a common goal, there is a shared sense of belonging, acceptance, and validation.
  • Corrective recapitulation of the primary family experience: Seeing the group as a family may help group members gain understanding of the impact of childhood experiences on their personality, and they may learn to avoid unconsciously repeating unhelpful interactive patterns in present relationships.
  • Development of socializing techniques: The group setting provides a safe and supportive environment for members to take risks by practicing interpersonal behavior and improving social skills.
  • Existential factors: Group therapy helps members realize that they are responsible for their own lives, behaviors, and decisions.
  • Imparting information: Group members report benefiting from sharing information about themselves and one another, such as personal experiences.
  • Imitative behavior: One way in which group members can develop social skills is through a modeling process, observing and imitating the therapist and other group members.
  • Instillation of hope: In a mixed group that has members at various stages of the treatment process, seeing members that are in later stages of coping or recovery may give hope to those in early stages.
  • Interpersonal learning: Group members achieve a greater level of self-awareness through the process of interacting with others in the group, who give feedback on the member’s behavior and impact on others.
  • Universality: Sharing an experience with a group helps people see that they are not going through something alone. It also serves to remove a group member’s sense of isolation, validate their experiences, and raise self-esteem.

History of Group Therapy

The founders of group psychotherapy in the USA were Joseph H. Pratt, Trigant Burrow, and Paul Schilder on the East Coast in the first half of the 20th century. After World War II, group psychotherapy was further developed by many therapists. In particular, Irvin Yalom’s approach to group therapy has been influential not only in the United States but across the world.

An early development in group therapy was the T-group or training group (sometimes also referred to as sensitivity-training group, human-relations-training group or encounter group). This is a form of group psychotherapy where participants (typically, between eight and 15 people) learn about themselves and about small-group processes in general through their interaction with each other. They use feedback, problem solving, and role play to gain insights into themselves, others, and groups. It was pioneered in the mid-1940s by Kurt Lewin and Carl Rogers and his colleagues as a method of learning about human behavior in what became the National Training Laboratories (now NTL Institute) in 1947.

Efficacy of Group Therapy

Group therapy has proven to be very effective for the treatment of depression and traumatic stress, such as that suffered by sexual abuse survivors and people with post-traumatic stress disorder (PTSD). There is also good evidence for effectiveness with chronic traumatic stress in war veterans. However, there is less robust evidence of good outcomes for patients with borderline personality disorder. These patients may require additional support beyond group therapy. This theory is borne out by the impressive results obtained using mentalization-based treatment, a model that combines group therapy with individual therapy and case management. Clinical cases have shown that the combination of both individual and group therapy is typically the most beneficial for most clients.

Criticisms of Group Therapy

As mentioned, the term “group therapy” is sometimes loosely used to include support groups and other non-psychiatric groups. Because of this, a person seeking the benefits of group therapy or a support group may have trouble distinguishing between the many options that exist. Someone looking for the help of a professional psychiatrist may not get the medical attention they need if they enter a more casual group. Additionally, group therapy alone may not be sufficient for some psychiatric disorders.

Other Approaches to Therapy

Expressive therapies use the creative arts as a form of therapy; systemic therapies emphasize the treatment of a system rather than an individual.

Learning Objectives

Discuss the goals, techniques, and efficacy of expressive and systemic therapies

Key Takeaways

Key Points

  • Expressive therapy is the use of the creative arts as a form of therapy; its use is predicated on the assumption that people can heal through the use of imagination and the various forms of creative expression.
  • Some of the most common types of expressive therapy are art therapy, dance therapy, music therapy, writing therapy, psychodrama, drama therapy, and expressive arts therapy.
  • Systemic therapy seeks to address people not only on the individual level, but also as people in relationships, dealing with the interactions of groups and their interactional patterns and dynamics. Systemic therapy should be distinguished from group therapy.
  • Family therapy, an important subset of systemic therapy, is a branch of psychotherapy  that works with families and couples in intimate relationships to nurture change and development.

Key Terms

  • psychodrama: Role-playing therapy in which patients can reenact, express, and dramatize portions of their lives.
  • systems theory: The interdisciplinary study of systems in general, with the goal of elucidating principles that can be applied to all types of systems at all levels in all fields of research.

Expressive Therapy

Expressive therapy, also known as expressive arts therapy and creative arts therapy, is the use of the creative arts as a form of therapy. Unlike traditional art expression, the process of creation is emphasized rather than the final product. Expressive therapy is predicated on the assumption that people can heal through the use of imagination and the various forms of creative expression.

Defining Expressive Therapy

“Expressive therapy” is a general term for many types of therapy. Some of the most common forms of expressive therapy are:

  • art therapy;
  • dance therapy, also known as dance/movement therapy;
  • drama therapy, or therapy through theater methods;
  • psychodrama, or role-playing therapy, where patients act out parts of their own lives to gain insight;
  • music therapy;
  • writing therapy, a term that may encompass journaling, poetry therapy, and bibliotherapy;
  • expressive arts therapy, an intermodal discipline where the therapist and client move freely between drawing, dancing, music, drama, and poetry.

However, there are many other types of expressive therapy in which creative work is used to promote healing. All expressive therapists share the belief that through creative expression and the tapping of the imagination, a person can examine the body, feelings, emotions, and his or her thought process. Although often separated by the form of creative art, some expressive therapists consider themselves intermodal, using expression in general, rather than a specific discipline, to treat clients, altering their approach based on the client’s needs, or through using multiple forms of expression with the same client to aid with deeper exploration.

History of Expressive Therapies

Only recently have the various forms of expressive therapy begun to be grouped together; however, forms of dance, music, and art therapy have all existed for a long time.

Music has been used as a healing implement for centuries. As early as 400 BC, Hippocrates played music for mental patients. Music therapy as we know it began in the aftermath of World Wars I and II, when, particularly in the United Kingdom, musicians would travel to hospitals and play music for soldiers suffering from war-related emotional and physical trauma.

Dance has been used as a healing ritual in the context of fertility, birth, sickness, and death since early human history, but the actual establishment of dance as a professional type of therapy occurred in the 1950s, beginning with future American Dance Therapy Association founder Marian Chace, who is considered the principle founder of dance therapy in the United States

Visual art used as a form of professional therapy began in the mid-20th century, arising independently in English-speaking and European countries. The British artist Adrian Hill coined the term “art therapy” in 1942, when he was recovering from tuberculosis in a sanatorium and discovered the therapeutic benefits of drawing and painting while convalescing. The American Art Therapy Association was founded in 1969.

Efficacy of Expressive Therapies

Music therapy has been used in the treatment of many psychiatric disorders. Music therapy is used with schizophrenic patients to ameliorate many of the symptoms of the disorder, and individual studies of patients undergoing music therapy have showed diminished symptoms (such as reduced flattened affect, reduced speech issues, and increased interest in external events). Music therapy has also been found to have numerous significant outcomes for patients with major depressive disorder. A systematic review of five randomized trials found that people with depression generally accepted music therapy, which was found to produce improvements in mood when compared to standard therapy.

Various hypotheses have been proposed regarding the mechanisms by which dance therapy may benefit participants. There is a social component to dance therapy, which can be valuable for psychological functioning through human interaction. Another possible mechanism is the music that is used during the session, which may be able to reduce pain, decrease anxiety, and increase relaxation. Since dance requires learning and involves becoming active and discovering capacities for movement, there is also the physical training that could provide benefits as well.

Studies have demonstrated the efficacy of art therapy, as applied to clients with memory loss due to Alzheimer’s and other diseases, stroke residuals, traumatic brain injury, post-traumatic stress disorder (PTSD), depression, dealing with chronic illness, and aging.

Criticisms of Expressive Therapy

The expressive therapies, because they are more recent than many types of therapy, have been relatively less studied and as such their mechanisms may not be well-understood.

Systemic Therapy

In psychotherapy, systemic therapy seeks to address people not only on the individual level, as had been the focus of earlier forms of therapy, but also as people in relationships, dealing with groups and their interactional patterns and dynamics.

Defining Systemic Therapy

Systemic therapy should be distinguished from group therapy: in group therapy, individuals with similar treatment needs meet with one or more therapists and gain additional benefits from the group setting. Systemic therapies, such as family and marital counseling, are designed to treat a system (such as a family unit or a couple) and its interactional patterns and dynamics.

Family therapy, an important subset of systemic therapy, is a branch of psychotherapy that works with families and couples in intimate relationships to nurture change and development. It tends to view change in terms of the systems of interaction between family members. It emphasizes family relationships as an important factor in psychological health. This type of therapy also includes marriage counseling. Family therapy uses a range of counseling and other techniques, including the following:

  • Structural therapy: identifies and re-orders the organization of the family system.
  • Strategic therapy: looks at patterns of interactions between family members.
  • Systemic or “Milan” therapy: focuses on belief systems.
  • Narrative therapy: restoring of dominant problem -saturated narrative, emphasis on context, separation of the problem from the person.
  • Transgenerational therapy: dealing with transgenerational transmission of unhelpful patterns of belief and behavior.

A family therapist usually meets several members of the family at the same time. This has the advantage of making differences between the ways family members perceive mutual relations, as well as interaction patterns in the session, apparent for both the therapist and the family.

History of Systemic Therapy

Systemic therapy has its roots in family therapy, or more precisely, family systems therapy, as it later came to be known. Early schools of family therapy represented therapeutic adaptations of the larger interdisciplinary field of systems theory, which originated in the fields of biology and physiology.

As a branch of psychotherapy, the roots of family therapy can be traced to the early 20th century, with the emergence of the child guidance movement and marriage counseling. There was initially a strong influence from psychoanalysis (most of the early founders of the field had psychoanalytic backgrounds) and social psychiatry, and later from learning theory and behavior therapy. Significantly, family therapists began to articulate various theories about the nature and functioning of the family as an entity that was more than a mere aggregation of individuals.

Efficacy of Systemic Therapy

According to a 2004 French government study, family and couples therapy was the second most effective therapy after cognitive-behavioral therapy. Of the treatments looked at in the study, family therapy was presumed or proven effective in the treatment of schizophrenia, bipolar disorder, anorexia, and alcohol dependency.

Family therapists tend to be more interested in the solving of problems rather than in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to place blame on one or more individuals, with the effect that for many families a focus on causation is of little or no clinical utility. It is important to note that a circular way of problem evaluation is used, as opposed to a linear route. Using this method, families can be helped by finding patterns of behavior, what the causes are, and what can be done to better their situation.

Criticisms of Systemic Therapy

Since issues of interpersonal conflict, power, control, values, and ethics are often more pronounced in systemic therapy than in individual therapy, there has been debate within the profession about the different values that are implicit in the various theoretical models of therapy, as well as the role of the therapist’s own values in the therapeutic process, and how prospective clients should go about finding a therapist whose values and objectives are most consistent with their own.[33][34][35] Specific issues that have emerged include an increasing questioning of the longstanding notion of therapeutic neutrality, a concern with questions of justice and self-determination, connectedness and independence, “functioning” versus “authenticity,” and questions about the degree of the therapist’s “pro-marriage” versus “pro-individual” commitment.