The 20th century has been called ‘the century of psychiatry’, and in many ways one could read that as ‘the century of psychotherapy’. A hundred years ago, at the onset of World War I, psychotherapy had touched the lives of only a tiny number of people, and most of the population had simply never heard of it. Since then it has reached into almost every aspect of our lives—how we treat the mentally ill, how we understand our relationships, our appreciation of art and artists, and even how we manage our schools, prisons, and workplaces. Our culture has become one quite obsessed with understanding how people feel and our daily language is peppered with psychotherapy language.
What does the future hold? Have we witnessed the flowering of a cultural movement that is tied to just one unique time and place, or is it a fundamental step forward in human thinking and relationships? In our increasingly global world will it spread ever more widely or perhaps fade away altogether? Have the various changes in its practice made it more relevant to modern man or less so? Will the enormous advances in medicine, neuroscience, and psychology, and our move into the digital age of social media, render it obsolete?
How we judge psychotherapy’s future will probably reflect what we think of it now: as a profound breakthrough in understanding ourselves and a step forward in social evolution, or as simply one among many technical procedures to reduce distress and improve human well-being. Reducing distress is certainly not a trivial achievement, but it does not satisfy psychotherapy’s strongest advocates—they believe it has irrevocably changed the way we see the world and how we behave. From a different perspective, psychotherapy has been criticized right from the beginning for having ‘cult-like’ and religious overtones.
We have roughly divided psychotherapy’s century into two halves. Up to the 1960s it was either psychoanalysis or one of its modifications. Therapies were verbal, protracted, and intensive, drawing on a detailed theory of unconscious forces. Understanding was the key to recovery. Later therapies have been much more experiential. Understanding remains important, but the process of psychotherapy and the therapeutic relationship have come to the fore. Some people are struck by the similarities between these psychotherapies and some by their differences. Are they adaptations of the same basic model or new and original approaches? It is a bit like deciding whether a glass is half full or half empty. Therapists usually stress the differences and the unique therapeutic mechanisms in their approach. Psychoanalysts and CBT therapists have traditionally had very little positive to say about each other’s practice.
You may have found yourself drawn to one or other specific therapy. Alternatively you may come to the conclusion that they have more elements in common than divide them. The latter perspective is probably how we view things. Yes, CBT is undoubtedly radically different in tone, duration, and immediate focus from psychoanalysis. But both work by helping troubled individuals understand better the mental mechanisms that have caused and sustain their problems.
One thing the psychotherapies share is that they have all expanded their reach. The threshold for seeking psychotherapy or counselling has steadily lowered over the decades, and our demand for it seems inexhaustible. Their goals have also expanded—from just the reduction or removal of symptoms, towards self-fulfilment and well-being.
We can be certain that psychotherapy will undergo changes in both theory and practice. What is impossible to foresee is precisely where these changes will occur. The trend towards shorter, more structured and democratic therapies seems inexorable, but radical changes may come out of the blue. Will they come from developments such as computer science, or perhaps from other cultures than the Judeo-Christian origins of most current therapies? Prediction is a risky business.
It is easy to forget that psychotherapy originated within medicine, and that most of the early pioneers were doctors. They used psychotherapy to treat psychological disorders, but that did not mean that they ignored physical factors. The importance of biological considerations has waxed and waned but they never disappeared, and the medical hold on psychotherapy dominated until the 1970s. Some psychotherapies, especially in the Americas, were even restricted to medical practitioners, and departments of psychiatry were dominated by psychoanalysis. Since then psychologists and other non-medical practitioners have increasingly become the main force in providing counselling and psychotherapy. They now also lead most of the research and development.
Psychoanalysis paid a high price for its early dominance and undeniable hubris in the US, where it is now almost totally excluded from mainstream medicine. It has been replaced by an equally inflated and exaggerated reliance on pharmacological treatments. Outside the psychiatric mainstream however, psychotherapy remains widely available and very vigorous. In Europe, it always played a much smaller part in public psychiatry, and its rise and fall has therefore been nowhere near as dramatic. In the UK it is not the availability and influence of psychotherapy that has changed, so much as the type of psychotherapy and who delivers it. Now it is often provided by psychologists and is almost exclusively CBT. In parts of the UK CBT may be the only psychotherapy available in the National Health Service. A much wider range of psychotherapies is readily available in private practice and in other European countries.
One of the reasons for psychotherapy’s fading influence within medicine has been the increasing importance given to research findings. Medicine now sees itself as an evidence-based practice, rigorously assessing and comparing the effects of different treatments. Randomized controlled trials (RCTs) are considered the strongest test of a treatment. In an RCT patients are randomly allocated to either treatment A or treatment B (often a placebo, or dummy treatment), with neither the clinician nor the patient knowing which. The outcome is usually measured by an independent researcher. You can see how this provides very strong evidence, but also why it is incredibly hard to do in psychotherapy. It is almost impossible for patients, therapists, or researchers to be ‘blind’ to the treatment. Treatment also depends on sustained motivation by both therapist and patient. It is not like simply swallowing a pill, and there is bound to be variation in how individual therapists work.
Despite this many RCTs have been conducted in psychotherapy, although until more recently psychoanalysts have been unenthusiastic and generally uncooperative. The length of psychoanalysis clearly makes such trials particularly difficult, but the resistance also reflects many analysts’ doubts about the research approach itself. After analysis a patient may be ‘sadder but wiser’—is this better or worse? Such concerns are not unique to psychoanalysis. Much medical research has to make do with what can be measured, but the rewards of such pragmatism in terms of improved treatments are very obvious.
There are published trials in most of the psychotherapies, although the volume in CBT is dramatically greater. This does not mean that there is no research evidence that psychodynamic therapies also work, far from it. As research findings change rapidly, we will restrict ourselves to describing some well-established findings here. Today’s cutting-edge results may be tomorrow’s discounted news.
Overall the research confirms that most psychotherapies improve outcomes for patients compared to similar patients without therapy (usually those still on the therapy waiting list). Some studies have pitted one type of therapy against another but these are a minority. A surprising but consistent finding is that there is not that much specificity about the therapy (IPT is about as good as CBT, which is about as good as CAT, and so on). The evidence supports the importance of the quality of the therapy relationship and therefore of the so-called ‘general factors’ we have already discussed: genuineness, empathy, and non-possessive warmth. It is not quite that simple, however.
How, and by whom, therapy is conducted also seems to matter. More experienced therapists achieve better results, which is perhaps not surprising. However, therapists who stick closely to their model (whichever it is) also do measurably better. These two findings can seem contradictory. We might assume that more senior therapists get better results by being more flexible, but this is clearly not the full answer. Sticking to the model, to the agreed procedures if you will, and attending to the state of the therapy relationship, is what helps most.
While the body of research in psychotherapy is positive overall and generally points to equivalence, with skilled and thorough therapists getting broadly similar improvements, there are exceptions. Not only has more research been conducted with CBT, but it has demonstrated a clear superiority over dynamic therapies for some disorders. Often this is when the CBT therapists have adapted and refined their approach in a clearly targeted manner for individual conditions. These include depression, anxiety and panic disorders, and eating disorders.
So overall it is wrong to say, as many of its critics do, that there is no evidence that psychotherapy works. There is evidence. However, there is nowhere near enough. More good quality research is sorely needed if psychotherapy is to command continuing confidence and ensure public investment.
While psychotherapy (especially psychoanalysis) has been in and out of favour in health care, it has kept going strong in our broader culture. Indeed, it is so strong that people often complain about excessive ‘psychobabble’ in public discourse. This is now being challenged by the rise of ‘biobabble’, which attempts to explain just about every possible human quality or behaviour with either evolutionary psychology or the neurosciences: ‘we are hard-wired to … ’, ‘your brain tells you to … ’, etc. Freudian language has been toned down, and some dated ideas on sexuality have long been abandoned. Stripped of their exaggerated language, analytic and psychotherapeutic ideas continue to permeate both high culture (such as the visual arts, novels, and the theatre) and popular culture (such as television, film, and the press). The language of emotional trauma, conflict, and defences frames our stories, with endless speculation about flawed relationships and human tragedies.
Psychotherapy and counselling are widely available for Westernized elites everywhere in the world. In the developing world it is less clear if these approaches are really accepted or relevant, even in adapted forms. Counsellors and psychotherapists are routinely confronted with the question of the cultural relevance and application of psychotherapy in our multicultural societies. Virtually every European country has around 10–15 per cent of its population born abroad, many with both a different mother tongue and a different set of values. In multicultural capital cities such as London or Copenhagen migrants can constitute half the population. There are some uncomfortable truths about access to psychotherapy. Wherever accurate figures on ethnicity are kept, ethnic minority populations are always over-represented as psychiatric patients but strikingly under-represented in counselling and psychotherapy services. They have more illness but get less psychotherapy. Can that be fair?
Much soul-searching goes into trying to understand this phenomenon. It was once thought that the higher rates of psychiatric diagnosis were due to misdiagnosis, but we now know this is not so. Being a migrant, especially a disadvantaged one, is highly stressful and causes more breakdowns. Those subject to such stresses should have a greater, not a lesser, need for psychotherapy, so why are they not getting it?
Two possible explanations exist with no clear answer. The first is that health-care staff fail to identify emotional and psychological problems in individuals with a different cultural heritage. They simply don’t spot the cues. One example is that depressed patients with Pakistani and Indian backgrounds usually complain of tiredness and aches and pains, but only very rarely of sadness. Most counselling and psychotherapy services strive to be accessible to people from different cultures. They publicize their services in local places of worship and social centres, produce leaflets and posters in a range of languages, and provide interpreter services. This can reduce the barriers to access, but it does little to address the second possible explanation of the low uptake—that psychotherapy may not appear relevant or acceptable.
Whole books exist on how to provide culturally sensitive and effective counselling and psychotherapy. They debate whether to adapt practice, or keep faithful to the model but simply try harder. All agree that counsellors should find out about their clients’ heritage and ask questions when unsure. White therapists should also be alive to the impact of their own ethnicity and to the power differentials in the relationship. Psychotherapy evolved in a privileged, white European and American environment, so they are at risk of taking its cultural assumptions too much for granted. Most black and Asian therapists have been sensitized to these concerns, which are now important components in most psychotherapy trainings.
A recurring question is whether to match the ethnicity of counsellor and client. If there is a common language this makes obvious sense, but otherwise opinions are divided. A therapist from the same background is likely to have a surer grasp of particular pressures and concerns, but she may have blind spots for just that reason. What if the problem lies in managing relationships with the mainstream culture? Or might a unique, personal concern get obscured by a focus on cultural issues?
Several psychotherapy services are run by counsellors from ethnic minorities specifically for their own communities. These fill an important gap but have not increased the overall take-up. There is also an uncomfortable concern that some form of service ‘apartheid’ could develop. As with women-only services, there is also a risk that problems will become externalized, creating a ‘them and us’ mentality shared by client and counsellor. This forges an immediate and strong bond, but could impede the examination of overall personal relationships in all their complexity and contradiction. Discussing these issues requires treading carefully to avoid opinions being tainted (or being thought to be tainted) with racism. There is no shortage of cultural imperialism in the history of psychiatry.
We gave a very broad definition of psychotherapy at the start of this book: the deliberate use of a special, agreed relationship established between a trained practitioner and a patient to obtain relief from emotional suffering. This definition goes way beyond the practices we have traced from Freud in 19th century Vienna. Doing these different approaches full justice is not feasible in this short book. We shall restrict ourselves to some observations on how Western psychotherapy has adapted to other cultures, and been influenced by them.
These influences are not new. Eastern mysticism influenced Carl Jung at the very beginning of psychoanalysis. Currently, mindfulness-based cognitive therapy draws heavily on Buddhist thinking and practice. This focus on being aware of, and accepting the present moment and freeing yourself from past experience and future ambitions has been a persistent influence from Eastern philosophy. It is in striking contrast to the Freudian obsession with understanding and changing. At the time Freud was working in Vienna, Zen Buddhist exercises were used in Japan specifically to demonstrate how neurotic problems were absurd and inconsequential. In a worldview that discourages individualism, the patient was helped to ‘let nature take its course’. Fritz Perl’s gestalt therapy in the 1940s and 1950s embodied much of the same approach, although derived from European existentialism.
Think how different the Eastern emphasis on living vividly in the moment is to Freud’s deferring of gratification. Some non-Western patients, less wedded to extreme individualism, often also want a more directive approach. They are happier to be instructed what to do, rather than be endlessly encouraged to decide for themselves. This difference is not just a reflection of a more hierarchical society. In much of the world people consider themselves first and foremost as a member of a family or a group, rather than as an individual. We Westerners are the odd ones out, and probably only for the last three or four centuries. Our psychotherapy embodies this view. For us, relationships are something we choose to engage in. They are important, but the starting point is always the individual. For most of the world the group we belong to (family or clan) is the starting point, more important than any individual ambition or career. The Zulu word ubuntu perhaps best conveys this. Widely used throughout Africa, the commonest translation is ‘being a person through other people’ or ‘I am because we are’. It emphasizes the non-negotiable interdependence of all humans. We cannot be meaningfully understood as isolated individuals.
This fundamental difference in what it means to be a person has posed a massive challenge to counselling and psychotherapy, to which it is only now slowly responding. Will psychotherapy continue to evolve and adapt to this wider, more communitarian worldview? Or might globalization undermine the collectivism that has characterized much of the world up until now? Will it generate the same problems of extreme individualism, alienation, conflict, and isolation that we are so familiar with in the West, and with it a need for ‘Western’ psychotherapy?
Freud believed that advances in medicine would eventually do away with the need for psychotherapy completely. He certainly got that wrong. Psychotherapy and counselling have continued to flourish despite medicine advancing by leaps and bounds. Cutting-edge medical and cognitive neuroscience research is now confirming many of the underlying processes of psychotherapy and its benefits.
Some of the biological mechanisms that mediate relationships generally, and psychotherapy in particular, are now being identified. One striking example is the hormone oxytocin, the so-called ‘bonding hormone’. Oxytocin is released both during breastfeeding and at orgasm. As well as promoting the flow of milk it has a direct and measurable effect on the mother’s mood, generating a sense of contentment. If you give women or men oxytocin (it is absorbed easily in a nasal spray) they almost immediately report feeling contented. Even more striking, it makes them feel more positive towards whoever they are with at that moment—like the spell cast on the sleeping Bottom in Shakespeare’s A Midsummer Night’s Dream! The nursing mother is biologically confirmed in her attachment to her baby, and sexual partners have their relationship strengthened and deepened by a chemical swirling round in their blood. So our observations that the contentment and holding in psychotherapy allow us to experience those around us more positively may partly work through biological processes. This will come as no surprise to body psychotherapists.
Modern neuroscience has brought overwhelming confirmation of the unconscious mind. Experiments with computer images that last for microseconds show that our thinking, feeling, and behaviour are profoundly affected without us being in the least aware of what did it. These are not just trivial or nerdy effects. A subliminal computer image, or even word, can measurably change our view of whether someone is trustworthy or threatening. There is a certain poetic justice that this evidence for Freud’s theory comes from ultra-scientific psychologists, most of whom would be deeply sceptical of everything he stood for. Neuroscience demonstrates just how widespread and essential unconscious processes are for healthy functioning. We simply could not get by without them. The Nobel Prize-winning psychologist Daniel Kahneman’s book Thinking, Fast and Slow repeatedly confirms that we make the vast majority of our decisions using unconscious (often called intuitive) thinking. It is the rule rather than the exception.
Brain imaging has even begun to confirm physical effects of psychotherapy. Modern scanning techniques are extremely precise, so that differences in brain tissue size of less than a cubic millimetre can be measured. There are now a number of of studies measuring parts of the brain before and after psychotherapy. One of the earliest, in 1992, showed that treating depressed patients with either Prozac or CBT led to an equal increase in the volume of the caudate nucleus. Various parts of the brain (the amygdala, the hippocampus, and the frontal lobes) have been studied, as have various psychotherapies. Positive changes in one or other of these structures have been reported for most therapies. There is great excitement in this area of research, and we can expect many more findings. Some will undoubtedly be red herrings, but overall they do seem to confirm that there really is an interaction between the mind and the brain. This interaction goes both ways, and psychotherapy can influence it.
We hope this book has given you a sense of the richness and variety of psychotherapy. Human beings have always wanted to find meaning in their lives and to understand themselves and each other. The last century has seen a systematic attempt to understand our problems and to find specific ways of helping both those with severe disturbances and those with more common life-problems.
Psychotherapy and counselling occupy an uncomfortable place in modern medicine. They benefit from the enormous power of the scientific method to clarify their processes and to find ‘what works for whom’. Yet this scientific approach feels at odds with their spirit. Science measures what we have in common and ignores what makes each of us different. We have to be treated as ‘cases’ to advance scientific knowledge, but none of us wants to be treated as ‘a case’ in our own therapy. What matters to us is the unique, personal experience of transformation that comes from two individuals working together. These two are not simply interchangeable with any other two other individuals.
Luckily researchers are becoming more skilled at making the necessary adaptations to test psychotherapy processes without losing this essence. Such research has confounded the sceptics and confirmed that psychotherapy does work. It does help people to change and get better, it is not just a matter of time healing. This research has also consistently shown that the quality of the therapy relationship is of essential importance, and how crucial training and skills are.
We now have a range of therapies from which to seek help. They are no longer an exclusive and expensive prerogative of the ultra-rich and the intellectual. Most therapists are registered with professional bodies, which provides reassurance about their training and skills, although you need to check. As the stigma about psychological problems and their treatment has receded, people now talk openly about their therapy, and can recommend who and what helped and what did not. Psychotherapy may be challenging, but it needn’t be feared and its results can be life changing. We believe it will be here for the foreseeable future.