An Overview of the Psychotherapies

Background

Clinicians half-jokingly assert that the number of psychotherapies in existence might exceed the number of psychotherapists in practice. Each session, even of manual-driven psychotherapies, is unique. Many factors (e.g., patient characteristics, patient preferences, therapist's training, therapist's theoretical perspective, time in therapist's career, insurance or funds available for therapy, time available for therapy) determine how the therapist and the patient proceed.

Much psychotherapeutic activity can occur during a 20-minute psychopharmacological follow-up appointment or during the brief chat between a psychiatrist and a patient before electroconvulsive therapy (ECT), or during a visit to an empathic primary care physician (PCP). However, in this chapter, we define psychotherapy as the beneficial process that is embedded in the verbal interaction between a professional psychotherapist and a patient or patients.

The kinds of psychotherapy described in the literature probably number in the hundreds. This overview will focus (somewhat arbitrarily) on 10 common types of psychotherapy for adults based on theory, technique, length, and patient mix. A section on psychotherapy for children and adolescents follows.

Psychodynamic Psychotherapy

Psychodynamic psychotherapy has the longest organized tradition of the psychotherapies. It is also known as psychoanalytic psychotherapy or expressive psychotherapy. This psychotherapy can be brief or time-limited, but it is usually open-ended and long-term. Sessions are generally held once or twice per week, with the patient being encouraged to talk about “whatever comes to mind.” This encouragement has been termed the fundamental rule of psychotherapy. The therapist, consequently, is usually non-directive but may encourage the patient to focus on feelings about “whatever comes to mind.” The therapist is empathic, attentive, inquiring, non-judgmental, and more passive than in other kinds of psychotherapies. The goal of psychodynamic psychotherapy is to recognize, interpret, and work through unconscious feelings that are problematic. Often unconscious feelings are first recognized in transference phenomena. Many psychodynamic psychotherapists choose to ignore positive transference phenomena, but interpret negative phenomena. For example, the patient may express the wish to be the therapist's friend. The focus would be on the patient's disappointment and frustration that a friendship cannot occur rather than a focus on the depth of the patient's longing for a friendship with the therapist. The psychotherapist deliberately avoids answering most questions directly or revealing personal information about himself or herself. This strategy, referred to as the abstinent posture, promotes the emergence of transference phenomena. The abstinent posture leaves a social void that the patient fills with his or her imagination and projections, allowing the therapist access to the patient's unconscious. The patient will get in touch with intense feelings that have been suppressed or repressed. Catharsis is the “letting go” and expression of these feelings.

At least six major theoretical systems exist under the psychodynamic model; these are summarized in Box 10-1 .

Psychoanalysis is an intensive form of psychodynamic psychotherapy; several of its characteristics are summarized in Box 10-2 . The time and financial cost of psychoanalysis generally puts it out of range for many patients. To date, there is no persuasive evidence that psychoanalysis is more effective than psychodynamic psychotherapy. However, there is emerging evidence that psychodynamic psychotherapy is effective for a number of diagnoses.

Cognitive-Behavioral Therapy

Cognitive-behavioural therapy (CBT) is emerging as a widely-practiced psychotherapy for depression, anxiety disorders, and other psychiatric and medical diagnoses. CBT represents a merger of the pioneering work of Aaron Beck (who first developed cognitive therapy for depression in the mid-1960s) and the work of Joseph Wolpe (who, in 1958, described a behavior therapy, reciprocal inhibition, for anxiety disorders).

CBT is built on the assumption that conscious thoughts, feelings, and behaviors interact to create symptoms. In contrast to the psychodynamic model, unconscious inner conflicts and early relationships are considered less important than here-and-now conscious awareness of thoughts, feelings, and behaviors. The therapeutic sessions are structured and collaborative. The therapist defines the goals and methodology of therapy and teaches the patient to observe the interaction of feelings, thoughts, and behaviors. Commonly used cognitive-behavioral techniques are summarized in Box 10-3 . There is considerable research supporting the effectiveness of CBT for a number of disorders.