The rise of psychotherapy was one of the most striking features of the 20th century. What started as an obscure treatment for wealthy, intellectual neurotics in fin-de-siècle Vienna has changed not only the nature of psychiatric practice but how we understand ourselves. Psychotherapeutic language and thinking is now part of everyday life, and we hardly get through a day without using it: he ‘made a Freudian slip’, their relationship ‘is a bit Oedipal’, my ‘inferiority complex’ is showing. Counselling is now seen as a natural response to many of the problems in our lives.
Our parents’ image of a psychotherapist—if they had any at all—was probably that of a bearded psychoanalyst with his patient lying on a couch (see ). Psychotherapy is now much less exotic, encompassing marriage guidance, cognitive behaviour therapy (CBT), Alcoholics Anonymous (AA) meetings, group therapy, and much more. It is a very broad church, which has existed in the practice of traditional healers from long before Freud, indeed before psychiatry itself.
What links the sober psychoanalyst, the careful and scientific psychologist, and the mystical and dramatic shaman? At its most basic psychotherapy involves using an agreed relationship with specific characteristics, involving a trained practitioner and a patient, to obtain relief from emotional suffering. Most Western psychotherapies are based on talking and discussion. They aim for a very personal understanding of the origins and meaning of problems in order to remove symptoms and obtain relief. Not all emphasize understanding the causes; in fact, existential philosophies do quite the opposite. Some discourage such a search for unique personal meanings, and some psychotherapies rely on a dramatic discharge of emotion.
The core feature of any psychotherapy, however, is the relationship between a practitioner and a patient, a relationship which inspires hope for healing or change. Both need to share an understanding of the process and agree to work together within that relationship. Confidentiality is the norm, as therapy often involves exploring very personal thoughts and feelings which people may feel conflicted about or ashamed of. Psychotherapists are expected to be worldly-wise and tolerant. They will be familiar with the extremes of human experience, hard to shock, and slow to blame.
How long or how intensive psychotherapeutic treatment is can vary enormously—from a handful of meetings to the (now very rare) classical psychoanalysis of an hour a day, five days a week, for several years. Therapist training can also range from several years to shorter part-time courses. Psychoanalytic schools require an intensive, and expensive, personal analysis. Psychotherapies are sometimes called ‘talking cures’ or ‘psychological treatments’. These terms are used to distance current practice from psychoanalysis and its unscientific reputation, but they are too broad for our purpose. They lose the focus on the relationship and self-understanding of psychotherapy. For example, teaching someone about their illness and how to manage it (psycho-education) is technically a talking treatment, but it is not psychotherapy as we would understand it. We will retain the term psychotherapy to indicate the skilful and deliberate use of a specialized relationship to gain self-understanding and relief from troubling symptoms.
In Freud’s day, patients usually sought help for very severe, often dramatic, symptoms. His patients had to have a high level of education and drive to be taken on for psychoanalysis. Treatment was very intensive and rather intellectual. It delved into internal conflicts, making links between symptoms, unconscious wishes, and disturbing early experiences. By making these conscious (becoming aware of them) the patient could gain greater control. Current psychoanalytic practice focuses more on problems in relationships and self-fulfilment, and is sought by a much wider range of people. This is not surprising. Our happiness depends most of all on our relationships, so if they go wrong, we want to understand why and try to repair them.
Not only are those who seek psychotherapy now more varied, but it is provided in a much wider range of settings, including in family doctor practices and occupational health schemes. It is no longer restricted to ‘intellectuals’, and accepts patients with more pervasive difficulties, such as self-harm and substance abuse, as well as those from more disturbed or deprived backgrounds.
Much has been made of psychological mindedness (the ability to reflect and think about thoughts and feelings) as a requirement for psychotherapy. We think this is putting the cart before the horse. People often seek therapy precisely because they are not able to reflect on their lives in a psychological manner. Psychotherapy can provide the tools to develop this capacity. The popularity of the more transparent and ‘democratic’ recent therapies such as interpersonal therapy (IPT), solution focused therapy (SFT), and cognitive analytic therapy (CAT) (), and CBT (), testify to this trend, as does the increasing use of written aids and questionnaires.
Psychotherapy in the 21st century is more accessible and varied than it was a hundred years ago, and this book will reflect that scope—from the unique and specialized to the more generic and familiar. We will restrict ourselves to the forms of psychotherapy generally available for adults. Child psychotherapy is a very specialized activity with its own theories and practices, and neither of us is an expert in this field. While early psychoanalysis did not see older adults as suitable candidates for analysis, this view has changed, and many current psychotherapy models are suitable for this age group and for people with learning disabilities. Although there is a growing body of psychotherapy practice for these groups, we will not address them in this book.
Before we provide an outline of present-day psychotherapy, we think it might be helpful to trace its lineage and put it in its historical context.
Modern psychiatry began just over 200 years ago at the end of the 18th century. It is a product of the Enlightenment, when reason and logic triumphed over religious dogma. People began to trust their own experiences to understand the world around them. Two iconic events marked psychiatry’s beginning, one in France and one in England.
In Paris, in 1789 after the French Revolution, Philippe Pinel took charge of two enormous institutions and ‘struck off the chains from the insane’. He was convinced that their brutal treatment made their disturbances worse, rather than reduced them. In England at about the same time a Quaker family, the Tukes, were appalled at practices in their local madhouse. They established an alternative, the York Retreat, providing a calm and tolerant setting where patients were kept busy and constantly encouraged. Punishment and harsh treatments were expressly prohibited. They called this approach moral treatment.
The success of the York Retreat became world renowned. Along with Pinel’s fledgling attempts at the classification of mental illnesses, it formed the basis of modern psychiatry and the asylum movement that was to dominate it for the next century and a half.
At this time a remarkable individual, Anton Mesmer (1734–1815), was revolutionizing how we treat those who, although not ‘insane’, suffered from severe emotional problems. He used light hypnotism, which was originally called mesmerism after him. His treatment relied on powerful suggestion, using his force of personality. During sessions his patients often became overwhelmed by strong and inexplicable emotions, after which their symptoms might disappear. This looked very similar to the exorcisms used by the church, but Mesmer’s rejection of religious explanations was the turning point. His treatments initiated the rational investigation of psychological processes that we now take for granted.
Mesmerism rapidly evolved into deep hypnotism, where patients discovered hidden emotional conflicts during trance states. Along with post-hypnotic suggestion (following instructions of which one appears to be totally unaware), this obliged a rethink of the understanding of the mind in order to accommodate unconscious processes. Until then the mind was the sum of what you were conscious of thinking or feeling at any moment. René Descartes’ ‘cogito ergo sum’—I think therefore I am—conveys this view. Yet powerful forces and complex ideas were clearly in operation beyond the reach of our day-to-day awareness. Hypnosis had also demonstrated that such unconscious thoughts were involved in neuroses and could be used in their cure.
Hypnosis and suggestion became central to the treatment of neuroses in the early 19th century. While Mesmer relied on drama and showmanship, others were more reflective, recognizing the importance of trust and suggestibility in the process. By the 1850s hypnosis had fallen from grace, tainted by its association with spiritualism and fraud. It came back into favour with the work of Jean-Martin Charcot (1825–1893), a celebrated neurologist in Paris. Hysterical disorders were common at that time. They included paralyses, blindness, anaesthesias, strange movements, and even epileptic fits with no obvious physical cause. Charcot acquired an international reputation in treating hysterical seizures using hypnosis (see ). Freud, like so many aspiring neurologists, visited him and was very impressed.
Back in Vienna, Freud began to use hypnosis and suggestion to treat his neurotic patients. Despite some initial success he soon realized that powerful suggestion followed by emotional release did not always work. For many patients the detailed nature of their unconscious conflicts had to be understood. Initially he believed that neuroses were caused by childhood sexual abuse, which gave rise to memories that had to be kept unconscious because they were too distressing. Later he changed his opinion and came to believe that the abuse was imaginary, and that the neurotic symptoms really arose from unacceptable impulses and drives. Psychoanalysts created relationships with their patients, in which it was safe to dive deep into the unconscious and confront what previously had been too threatening. Unconscious processes had become firmly established as the source of neuroses, and the substance of psychotherapy.
In the first half of the 20th century, psychotherapy essentially meant psychoanalysis. There were various adaptations—shorter forms, group, and even institutional forms—but the basic principles were the same. Their aim was to guide the patient on a journey through their unconscious and to make links or ‘interpretations’ between experiences in earlier relationships and current problems. Other than during the two world wars, when it was conscripted to deal with shell shock and battle casualties, psychotherapy remained the preserve of the intellectual and the wealthy.
After World War II, society changed rapidly and new psychotherapies were developed to reflect this. Psychoanalysis had itself contributed to these changes, with its emphasis on the universality of emotional conflicts and complexes, and its demonstration of the benefits of emotional honesty. It now stressed the importance of early childcare and explored real relationships, not just painful memories. With an increasingly egalitarian society it became inevitable that such benefits should be made more widely available. Psychoanalytic psychotherapy responded with shorter and less intensive treatment regimes, once a week for a number of months rather than daily for several years. However, the changes soon to come were even more fundamental.
The problems we bring to psychotherapists (depression, anxiety, difficulties with relationships, and self-doubt) may not have changed that much. However, our expectations are now very different. The stiff upper lip has given way in a society that prizes emotional expression and self-revelation. People expect to be happy and they aspire to be so. The American Constitution promises ‘Life, Liberty, and the Pursuit of Happiness’, and most of us expect just that. This is very different to the world of duty and acceptance that had shaped Freud and his patients. He explicitly rejected happiness as a goal for therapy. For him, and his generation, the measure of good mental health was to be able ‘to love and to work’ (zu lieben und zu arbeiten). Indeed, he stated that the aim of psychoanalysis was ‘to transform neurotic misery into common unhappiness’! This clearly will not do for our modern tastes.
Personal fulfilment, self-expression, happiness, and control over our own fate are the reasons most of us now seek out psychotherapists. It is not just our aspirations that have changed. Modern society is more mobile and fragmented, with dispersed families often unable to provide support, and traditional religion playing a reduced role in giving comfort. Individuals now need help with coming to terms with themselves as much as they do with difficult relationships. Psychotherapy has changed and diversified to meet these needs.
In times of distress we need to be listened to and feel understood, and counselling provides a kindly and tolerant ear. Counselling has become available to those who would never have considered themselves as ‘neurotic’ or candidates for formal treatment with psychotherapy. It provides help for ordinary people facing problems in everyday life or in their relationships. Counselling was established by the work of Carl Rogers (). He called it client-centred or person-centred to emphasize its independence from rigid theories and dogma. It provides a calm, safe, and supportive relationship that allows self-reflection and emotional healing. Rogers recognized that simply having time to ponder your feelings and thoughts is enormously valuable in its own right.
The relationship between counselling and psychotherapy is complex and shifting and there is no simple, universally accepted description of their differences. People argue about whether it is a form of psychotherapy or a quite different activity altogether. It is generally less ambitious than psychotherapy, with its goals less fixed and the process more directed by the patient. In client-centred counselling the therapist resists imposing structure. Counselling speaks to a universal human need, as is shown both by the number who seek it out and the number who seek to practise it. People like counselling, and they like being counsellors. Many do it without payment in organizations such as the Samaritans and Relate. Training is variable but generally quite short.
Counselling is also an integral part of many wider treatment regimes. Drug and alcohol counsellors draw heavily on their personal experiences of addiction to guide clients and sustain hope. Traditional client-centred practice (‘how does that make you feel?’) often alternates with forceful challenges in such rehab programmes. In hospitals and self-help groups for patients with physical illnesses, counselling helps in managing the illness, coping with anger and distress, and reducing isolation and hopelessness. Counselling after personal trauma (such as assault or rape) and major disasters (such as train crashes or earthquakes) is also regularly offered.
There are some radically new psychotherapies. The most widespread and influential of these is CBT, which is outlined in detail in . CBT focuses directly on current thoughts and actions (hence ‘cognitive’ and ‘behavioural’) more than on feelings and personal history. It identifies unhelpful thinking patterns and challenges them utilizing specific techniques, often practised between sessions. The aim of therapy is more control and mastery than in-depth understanding. Treatments are usually weekly for twelve to twenty sessions, sometimes even fewer. The relationship is very equal and transparent, stressing collaboration, and is devoid of mystique.
CBT’s ‘technological’ quality is probably its most significant break with the past. Out goes the long training analysis and the mysterious and aloof manner. In comes the therapy manual and democratic engagement, with repeated exercises and measurement. CBT is probably now the most widely practised therapy in healthcare and has a strong evidence base for treating anxiety and depression. Its therapists see no conflict between ‘drugs’ or ‘therapy’, and are quite comfortable with ‘drugs and therapy’.
Sorting different therapies neatly into tidy boxes risks caricaturing them and oversimplifying. In truth there has been a steady process of development, refinement, and diversification of all therapies. Several have made radical changes in theory and practice, although clearly with links to psychoanalysis. Examples of this group (taken up in ) are IPT, DIT, and CAT.
Much of psychotherapy is directed at understanding the problems people have in relation to those around them. In individual psychotherapy the therapist has to rely on what the patient tells her, and this can be pretty one-sided. Several therapies have broken through this barrier, and involve relevant other people directly in the treatment. This can be by working with naturally occurring groups, such as in couples or family therapy, or by bringing together groups of individuals with similar problems, as in group therapy. We are social animals and we come alive in our relationships, so these psychotherapies can be dramatic and fast moving.
Family therapy was first used in the treatment of disturbed children and adolescents. Sometimes a child’s disturbance is a symptom of a wider family dysfunction which needs to change. Even where this may not be the case the whole family may be affected and need help, as when a child is gravely ill. Treatments can sometimes be very short, involving only a handful of meetings. Family therapy usually focuses on current relationships rather than digging into ancient history, and the emphasis is on the structure of the relationships. The same is true of couples and marital therapy. What is locking family members into sterile and repetitive conflicts? How can they escape to something more supportive and liberating?
Harnessing the power of the group has become a central plank in addictions treatment, such as in AA. Self-help organizations form the mainstay of support in alcohol and drug abuse worldwide, and they have spread to other addictions such as gambling.
Most therapy groups are composed of individuals with similar problems, but not all. The original group therapies brought together a range of individuals seeking self-understanding and change. Some groups are psychoanalytic in orientation, but most are more direct and exploratory. The group benefits from the variety of individuals and problems it contains, as members learn about themselves and experiment with new ways of relating and being.
All the newer psychotherapies are more active than psychoanalysis. Freud wanted to understand his patients’ mental processes and was keen to avoid contaminating them with his presence. This gave rise to the ‘blank screen’ therapist, who strove to reveal nothing about himself by word or deed. Later psychotherapists are less concerned about this and believe a well-timed active intervention can move things along. More interactive therapists are particularly needed with less ‘typical’ psychotherapy patients. The ‘right’ sort of psychotherapy patient was flippantly described as YAVIS—young, attractive, verbal, intelligent, and successful. Clearly not all who need psychotherapy fit this narrow caricature. Children, less introspective individuals, those with less education, and those with less self-confidence or motivation may need more active help.
Some therapies are based entirely on action, such as music therapy, dance therapy, art therapy, and drama therapy (). These activities may be healing in themselves. Intensely self-conscious children and adolescents can lose themselves in music or dance, freed temporarily from doubt and anxiety. Alternatively, the therapist may use the activity as a platform for exploration: ‘Tell me about your painting. Why such dark colours?’ ‘Hamlet’s speech seemed to stir you up—what do you think he was getting at?’
There is a wide range of therapeutic activities and exercises that overlap with psychotherapies. These include meditation, encounter groups, massage therapies, and more. Many are very sophisticated, and it can be very difficult to make a clear distinction between them and ‘psychotherapies proper’. How can we decide what is and is not a psychotherapy, and which to include in this book? We have relied heavily on ‘psychotherapies proper’ being individually tailored to each patient and their specific problems. Activities or exercises which are equally useful for anyone (such as yoga or meditation), while undoubtedly very good for us, are not included here.
Completely new psychotherapies have arisen to meet modern man’s sense of alienation. Existential psychotherapies, which are outlined in , reject preconceptions about how we ought to be. They aim to liberate us from what they see as a futile search for meaning. Having accepted the randomness, even absurdity, of the universe we must find fulfilment in our own unique existence. This ultra-modern emphasis on ‘being through becoming’ is derived from philosophers such as Kierkegaard, Buber, and Sartre, but is surprisingly close to therapies that draw on ancient Eastern philosophies.
Eastern thinking emphasizes the constancy of change and universal connectedness. Personal fulfilment and enlightenment come from self-awareness in the moment with the abandonment of desire. Several Western psychotherapies have incorporated such ideas. Jung wrote of the wholeness of existence and attaining integration by abandoning striving. Gestalt therapies work towards a sense of wholeness rather than concentrating on detailed concerns. One of the most rapidly spreading forms of cognitive therapy, mindfulness-based cognitive therapy (MBCT), draws heavily on Buddhism. Patients meditate and concentrate on the moment, practising tranquil self-awareness.
Current psychotherapies draw inspiration widely, well beyond psychoanalysis and standard psychological theories. Your choice of therapy may be based as much on your temperament and philosophy as your symptoms. The no-nonsense thrusting businessman may choose CBT or transactional analysis, while the more artistic individual might seek a Jungian analyst.
When you read articles comparing psychotherapy with antidepressants, they always list the side effects and risks for the pills. Psychotherapy is assumed to be risk free: ‘It may not always work, but it can’t do any harm’. This is not so. Any effective treatment carries risks. Longer psychotherapies carry a risk of overdependence or inertia. Issues can also be opened up which feel overwhelming and result in increased distress, perhaps with a retreat into alcohol or even self-harm. Good psychotherapists know this and carefully assess patients’ character strengths and supports as well as their problems before embarking on treatment.
Freud advised against psychoanalysis with psychotic illnesses or very severe depression, and most psychiatrists and psychotherapists would still agree. Exploratory psychotherapy is always unsettling to some degree, so balancing the potential benefits against the stress involved should never be neglected. If recovering from a severe mental illness, or alcohol or drug abuse, it may be best to wait.
Most countries are trying to develop formal registration for psychotherapists, to restrict membership to those with an adequate training and with clear procedures for excluding incompetent practitioners. However, it is an imperfect system and does not yet cover all psychotherapists. In addition, psychotherapy is not an official profession, so anyone can in theory call themselves a psychotherapist.
The privacy and confidentiality of psychotherapy can lead to a loss of perspective. Relatively minor problems can become magnified or, conversely, emerging issues can be missed because of the familiarity that comes with the relationship. The therapist’s personality can have profound effects, particularly if he or she is not fully aware of it. For this reason most psychotherapists regularly meet with another colleague for supervision, even long after they have finished their formal training.
There is also the rare risk of improper sexual conduct by therapists. The intimate and private nature of all medical practice brings such risks. This can be even more pronounced in psychotherapy where intimate wishes and longings are ventilated, and where dependent and anxious patients can come to idealize their therapists. Practitioners have always taken these risks seriously, hence the existence of rigorous professional codes with severe sanctions.
The best defence is to rely only on well-trained psychotherapists who are members of established professional associations. This guarantees not only their basic competence but also that they are in regular contact with colleagues. Isolation is the danger—psychotherapists go astray much more often when they work alone, especially in private practice. However, we should not exaggerate these risks. Most therapists have their networks and supervisors, so such incidents, while still indefensible, are very rare. Finding a good therapist is not that difficult if you take soundings and get advice. The following chapters will describe in more detail the thinking and practice of the most common psychotherapies and what kinds of problems they can help with.