Therapeutic Intent

© 2021 Richard John Kosciejew. All rights reserved.

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Published by AuthorHouse 06/18/2021

ISBN: 978-1-6655-2976-1 (sc)

ISBN: 978-1-6655-2988-4 (e)

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Freud was born in Freiburg, now Príbor Czech Republic, on May 6, 1856, and educated at Vienna University. When he was three years old, his family, fleeing from the anti-Semitic riots then raging in Freiburg, moved to Leipzig. Shortly thereafter, the family settled in Vienna, where Freud remained for most of his life.

Although Freud’s ambition from childhood had been a career in law, he decided to become a medical student shortly before he entered Vienna University in 1873. Inspired by the scientific investigations of the German poet Goethe, Freud was driven by an intense desire to study natural science and to solve some of the challenging problems confronting contemporary scientists.

In his third year at the university Freud began research work on the central nervous system in the physiological laboratory under the direction of the German physician Ernst Wilhelm von Brücke. Neurological research was so engrossing that Freud neglected of the prescribed courses and as a result remained in medical school three years longer than was required normally to qualify as a physician. In 1881, after completing a year of compulsory, military service, he received his medical degree. Unwilling to give up his experimental work, however, he remained at the university as a demonstrator in the physiological laboratory. In 1883, at Brücke’s urging, he reluctantly abandoned theoretical research to gain practical experience.

Freud spent three years at the General Hospital of Vienna, devoting himself successively to psychiatry, dermatology, and nervous diseases. In 1885, following his appointment as a lecturer in neuropathology at Vienna University, he left his post at the hospital. Later the same year he was awarded a government grant enabling him to spend 19 weeks in Paris as a student of the French neurologist Jean Charcot. Charcot, who was the director of the clinic at the mental hospital, the Salpêtrière, was then treating nervous disorders by the use of hypnotic suggestion. Freud’s studies under Charcot, which centred largely on hysteria, influenced him greatly in channelling his interests to psychopathology.

In 1886 Freud established a private practice in Vienna specializing in nervous disease. He met with violent opposition from the Viennese medical profession because of his strong support of Charcot’s unorthodox views on hysteria and hypnotherapy. The resentment he incurred was to delay any acceptance of his subsequent findings on the origin of neurosis.

Freud’s first published work, On Aphasia, appeared in 1891; it was a study of the neurological disorder in which the ability to pronounce words or to name common objects is lost as a result of organic brain disease. His final work in neurology, an article, ‘Infantile Cerebral Paralysis,’ was written in 1897 for an encyclopaedia only at the insistence of the editor, since by this time Freud was occupied largely with psychological rather than physiological explanations for mental illnesses. His subsequent writings were devoted entirely to that field, which he had named the psychoanalysis in 1896.

Freud’s new orientation was heralded by his collaborative work on hysteria with the Viennese physician Josef Breuer. The work was presented in 1893 in a preliminary paper and two years later in an expanded form under the title Studies on Hysteria. In this work the symptoms of hysteria were ascribed to manifestations of undischarged emotional energy associated with forgotten psychic traumas. The therapeutic procedure involved the use of a hypnotic state in which the patient was led to recall and reenact the traumatic experience, thus discharging by catharsis the emotions causing the symptoms. The publication of this work marked the beginning of psychoanalytic theory formulated on the basis of clinical observations.

During the period from 1895 to 1900 Freud developed many of the concepts that were later incorporated into psychoanalytic practice and doctrine. Soon after publishing the studies on hysteria he abandoned the use of hypnosis as a cathartic procedure and substituted the investigation of the patient’s spontaneous flow of thoughts, called free association, to reveal the unconscious mental processes at the root of the neurotic disturbance.

In his clinical observations Freud found evidence for the mental mechanisms of repression and resistance. He described repression as a device operating unconsciously to make the memory of painful or threatening events inaccessible to the conscious mind. Resistance is defined as the unconscious defence against awareness of repressed experiences in order to avoid the resulting anxiety. He traced the operation of unconscious processes, using the free associations of the patient to guide him in the interpretation of dreams and slips of speech. Dream analysis led to his discoveries of infantile sexuality and of the so-called Oedipus complex, which constitutes the erotic attachment of the child for the parent of the opposite sex, together with hostile feelings toward the other parent. In these years he also developed the theory of transference, the process by which emotional attitudes, established originally toward parental figures in childhood, is transferred in later life to others. The end of this period was marked by the appearance of Freud’s most important work, The Interpretation of Dreams (1899). Here Freud analysed many of his own dreams recorded in the 3-year period of his self-analysis, begun in 1897. This work expounds all the fundamental concepts underlying psychoanalytic technique and doctrine.

In 1902, Freud was appointed a full professor at Vienna University. This honour was granted not in recognition of his contributions but as a result of the efforts of a highly influential patient. The medical world still regarded his work with hostility, and other compositions were in the writings, that Freud attributively gave by his exploration and research. The Psychopathology of Everyday Life (1904) as this contribution, and others, like the Sexual Theory (1905), only increased this antagonism. As a result Freud continued to work virtually alone in what he termed ‘splendid isolation.’

By 1906, however, a small number of pupils and followers had gathered around Freud, including the Austrian psychiatrists William Stekel and Alfred Adler, the Austrian psychologist Otto Rank, the American psychiatrist Abraham Brill, and the Swiss psychiatrist’s Eugen Bleuler and Carl Jung. Other notable associates, who joined the circle in 1908, were the Hungarian psychiatrist Sándor Ferenczi and the British psychiatrist Ernest Jones.

Austrian doctor Sigmund Freud spent many hours refining his theories in this study of his home in Vienna, Austria. Freud pioneered the use of clinical observation to treat mental disease. The publication of The Interpretation of Dreams in 1899 detailed his technique of isolating the source of psychological problems by examining a patient’s spontaneous stream of thought.

Increasing recognition of the psychoanalytic movement for making it possible for the formation in 1910 of a worldwide organization called the International Psychoanalytic Association. As the movement spread, gaining new adherents through Europe and the United States. Freud was troubled by the dissension that arose among members of his original circle. Most disturbing was the defection from the group of Adler and Jung, each of whom developed a different theoretical basis for disagreement with Freud’s emphasis on the sexual origin of neurosis. Freud met these setbacks by developing further his basic concepts and by elaborating his own views in many publications and lectures.

After the onset of World War I Freud devoted little time to clinical observation and concentrated on the application of his theories to the interpretation of religion, mythology, art, and literature. In 1923 he was stricken with cancer of the jaw, which necessitated constant, painful treatment in addition to many surgical operations. Despite his physical suffering he continued his literary activity for the next 16 years, writing mostly on cultural and philosophical problems.

When the Germans occupied Austria in 1938, Freud, a Jew, was persuaded by friends to escape with his family to England. He died in London on September 23, 1939.

Freud created an entirely new approach to the understanding of human personality by his demonstration of the existence and force of the unconscious. In addition, he founded a new medical discipline and formulated basic therapeutic procedures that in modified form are applied widely in the present-day treatment of neuroses and psychoses. Although never accorded full recognition during his lifetime, Freud is generally acknowledged as one of the great creative minds of modern times.

Among his other works are Totem and Taboo (1913), Ego and the Id (1923), New Introductory Lectures on Psychoanalysis (1933), and Moses and Monotheism (1939).

Carl Gustav Jung (1875-1961), the Swiss psychiatrist who founded the analytical school of psychology, and had broadened of Sigmund Freud’s psychoanalytical approach. Jung also interpreted the mental and emotional disturbances as an attempt to find personal and spiritual realization and undivided wholeness.

Born on July 26, 1875, in Kesswil, Switzerland, the son of a Protestant clergyman, Jung developed during his lonely childhood an inclination for dreaming and fantasy that greatly influenced his adult work. After graduating in medicine in 1902 from the universities of Basel and Zürich, with a wide background in biology, zoology, paleontology, and archaeology, he began his work on word association, in which a patient’s responses to stimulus words revealed what Jung called ‘complexes’, - a term that has since become universal. These studies brought him international renown and led him to a close collaboration with Freud, and with the publication of Psychology of the Unconscious (1912; trans. 1916), however, Jung declared his independence from Freud’s narrowed sexual interpretation of the libido by showing the close parallels between ancient myths and psychotic fantasies. By explaining human motivation in terms of a larger creative energy he gave up the presidency of the International Psychoanalytic Society and confounded a movement called analytical psychology.

During his remaining 50 years Jung developed his theories, drawing on a wide knowledge of mythology and history: Travelling to diverse cultures in New Mexico, India, and Kenya, particularly were the dreams and fantasies of his childhood. In 1921 he published his major work, Psychological Types (trans. 1923), in which he dealt with the relationship between the conscious and unconscious and proposed the well-known personality types, being the extrovert and introvert. He later made a distinction between the personal unconscious, or the repressed feelings and thoughts developed during an individual’s life, and the collective unconscious, or those inherited feelings, thoughts, and memories shared by all humanity. The collective unconscious, according to Jung, is made up of what he called ‘archetypes,’ or primordial images. These correspond to such experiences as confronting death or choosing a mate and manifest themselves symbolically in religions, myths, fairy tales, and fantasies.

Jung’s therapeutic approach aimed at reconciling the diverse states of personality, which he saw divided not only into the opposites of introvert and extrovert, but also into those of sensing and intuiting, and of feeling and thinking. By understanding how the personal unconscious integrates with the collective unconscious, Jung theorized, a patient can achieve a state of individuation, or wholeness of self.

Jung wrote voluminously, especially on analytical methods and the relationships between psychotherapy and religious belief. He died on June 6, 1961, in Küsnacht.

Alfred Adler (1870-1937), an Austrian psychologist and psychiatrist, born in Vienna, and educated at Vienna University, after leaving the university he associated with Sigmund Freud, the finding founders of the psychoanalysis. In 1911 Adler left the orthodox psychoanalytic school to found a neo-Freudian school of the psychoanalysis. After 1926 he was a visiting professor at Columbia University, and in 1935 he and his family moved to the United States.

In his analysis of individual development, Adler stressed the sense of inferiority, rather than sexual drives, as the motivating force in human life. According to Adler, conscious or subconscious feelings of inferiority (to which he gave the name inferiority complex), combined with compensatory defence mechanisms, is the basic cause of psychopathological behaviour. The function of the psychoanalyst, furthermore, is to discover and rationalize such feelings and break down the compensatory, neurotic will for power that they engender in the patient. Adler’s works include The Theory and Practice of Individual Psychology (1918) and The Pattern of Life (1930).

Jean Martin Charcot (1825-1893), the French neurologist, considered the father of clinical neurology, born in Paris, and educated at the University of Paris. In 1856 he was appointed the physician to the Central Bureau of Hospitals. In 1860 he became a professor of pathological anatomy in the faculty of medicine at the University of Paris. Two years later he joined the staff of the Salpêtrière Hospital, and he opened the most highly regarded neurological clinic of his day. He specialized in the study of hysteria, locomotor ataxia, hypnosis, and aphasia. Cerebrospinal sclerosis was named Charcot’s disease after him. Achieving international fame, Charcot became an honorary member of the American Neurological Association in 1881. He attracted pupils and scientists from all over the world. His most celebrated pupil was Sigmund Freud.

Wilhelm Reich (1897-1957), the Austrian psychoanalyst and biophysicist, once associated with Sigmund Freud’s Viennese clinic, he broke with Freud’s movement and later immigrated to the United States, where he taught at the New School for Social Research in New York City from 1939 to 1941. By this time Reich had developed his theory of an ‘Orgone’ energy, postulating that this energy permeates the universe and that humans must release it through sexual activity if they are not to develop neuroses. In 1942 he founded the Orgone Institute and invented an ‘Orgone box’ to aid in energy release; however, he was found guilty of fraudulent claims for his methods and sentenced to two years in a federal penitentiary, where he died. For Wilhelm Reich, his literary contributions to psychology are still the subject of a great deal of controversy.

Like Jung, the Austrian physician Alfred Adler believed that Freud overemphasized the importance of sexual and aggressive drives. Adler was particularly interested in sibling relationships, birth order, and relationships with parents. He would ask patients about their early memories and use this information to analyse their attitudes, beliefs, and behaviours. He helped his patients by encouraging them to meet important life goals: love, work, and friendship.

For Adler and modern therapists’ who drew principle from his work and gathered interests in others and participation in society are important goals of therapy. Alderian therapists see therapy in part as educational, and they use a number of innovative action techniques to help patients change mistaken beliefs and interact more fully with family members and others.

Humanistic therapies focus on the client’s present rather than past experiences, and on conscious feelings rather than unconscious thoughts. Therapists try to create a caring, supportive atmosphere and to guide clients toward personal realizations and insights. Clients are encouraged to take responsibility for their lives, to accept themselves, and to recognize their own potential for growth and change.

The length of therapy depends on the severity of the problem and on a client’s ability to change and try new behaviours. Because humanistic therapies emphasize the relationship between client and therapist and a gradual development of increased responsibility by the client, these therapies typically take of a year or two in weekly sessions.

Three of the most influential forms of humanistic therapies are existential therapy, person-centred therapy, and the Gestalt therapy.

Based on a philosophical approach as peoples and existence, that existential therapy deals with important life themes. These themes include living and dying, freedom, responsibility to self and others, finding meaning in life, and dealing with a sense of meaninglessness. More than other kinds of therapists, existential therapists examine individuals’ awareness of themselves and their ability to look beyond their immediate problems and daily events to problems of human existence.

The first existential therapists were European psychiatrists trained in the psychoanalysis who were dissatisfied with Freud’s emphasis on biological drives and unconscious processes. Existential therapists help their clients confront and explore anxiety, loneliness, despair, fear of death, and the feeling that life is meaningless. There are few techniques specific to existential therapy. Therapists normally draw on techniques from a variety of therapies. One well-known existential therapy is logo therapy, developed by Austrian psychiatrist Viktor E. Frankl in the 1940s (logo is Greek for meaning).

Viktor Frankl (1905-1997), the Austrian psychiatrist who developed a form of existential psychotherapy which came to be known as logo therapy. Logo therapy is based on Frankl’s theory that the underlying needs of human existence are to find meaning in life (logo is a Greek word for ‘meaning’).

Born in Vienna, Austria, Frankl was educated at the University of Vienna, where he earned a medical degree in 1930. In 1942 Frankl and his family, who were Jewish, were arrested by the Nazis and imprisoned in concentration camps. Frankl’s mother, father, brother, and pregnant wife were all killed in the camps. Frankl spent the next three years at Auschwitz, Dachau, and other concentration camps. During his imprisonment, Frankl helped despairing prisoners maintain their psychological health. He also recorded, on stolen bits of paper, his theories and experiences, which he later employed in his books. After his release, Frankl returned to Vienna and became the professor of neurology and psychiatry at the University of Vienna Medical School, a position he retained for the rest of his career.

In his most recognized and best-known book, ‘Man’s Search for Meaning’, in which the introduction to logo therapy (1962, translated into English, 1970), for which of Frankl described how he and other prisoners in the concentration camps found meaning in their lives and summoned the will to pull through. The remainder of the book outlines the theory and practice of logo therapy. In addition to its influence on the field of psychotherapy, Man’s Search for Meaning found an enormous readership among the general public. By the time of Frankl’s death, it had sold more than 10 million copies in 24 languages. Frankl published 31 other books on his psychological theories.

Between the 1940s and 1950s the American psychologist Carl Rogers developed a form of psychotherapy known as a person-centred therapy. This approach emphasizes that each person has the capacity for self-understanding and self-healing. The therapist tries to demonstrate empathy and true caring for clients, allowing them to reveal their true feelings without fear of being judged.

Person-centred therapy, originally called client-centred therapy, is perhaps the best-known form of humanistic therapy. American psychologist Carl Rogers developed this type of therapy of the 1940s and 1950s. Rogers believed that people, like other living organisms, are driven by an innate tendency to maintain and enhance themselves, which in turn moves them toward growth, maturity, and life enrichment. Within each person, Rogers believed, is the capacity for self-understanding and constructive change.

Person-centred therapy emphasizes understanding and caring rather than diagnosis, advice, and persuasion. Rogers strongly believed that the quality of the therapist-client -relationship influences the success of therapy. He felt that effective therapists must be genuine, accepting, and empathic. A genuine therapist expresses true interest in the client and is open and honest. An accepting therapist cares for the client unconditionally, even if the therapist does not always agree with him or her. An empathic therapist demonstrates a deep understanding of the client’s thoughts, ideas, experiences, and feelings and communicates this empathic understanding to the client. Rogers believed that when clients feel unconditional positive regard from a genuine therapist and feel empathically understood, they will be less anxious and more willing to reveal themselves and their weaknesses. By doing so, clients gain a better understanding of their own lives, move toward self-acceptance, and can make progress in resolving a wide variety of personal problems.

Person-centred therapists use an approach called active listening to demonstrate empathy - letting clients know that they are fully listening to and understood. First, therapists must show through their body position and facial expression that they are attentively concerned, - for example, by directly facing the client and making good eye contact. During the therapy session, the therapist tries to restate what the client has said and seeks clarification of the client’s feelings. The therapist may use such phrases as ‘What I hear you saying’ and ‘Your feeling like’ The therapist seeks mainly to give reflection of the client’s statements back to the client accurately, and does not try to analyse, judge, or lead the direction of discussion.

Client: I always felt my husband loved me. I just don’t understand why this happened.

Therapist: You feel surprised by the fact that he left you, because you thought he loved you. It comes as a real surprise.

Client: M-hm. I guess I haven’t really accepted that he could do this to me. A big part of me still loves him.

Therapist: You seem to still be hurting from what he did. The love you have for him is so strong.

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

Gestalt is the German word referring to wholeness and the concept that a whole unit is more than the sum of its parts. Gestalt therapy was developed in the 1940s and 1950s by Frederick (Fritz) Perls, a German-born psychiatrist who immigrated to the United States. Like person-centred therapy, Gestalt therapy tries to make individuals take responsibility for their own lives and personal growth and to recognize their capacity for healing themselves. However, Gestalt therapists are willing to use confrontational questions and techniques to help clients express their true feelings. In the following example, the therapist helps the client become more aware of her own behaviour and her responsibility for it:

Client: You know, you just can’t do anything right in today’s world.

Therapist: Please repeats the phrase for using the word I instead of you.

Client: I can’t do anything right, it seems.

Therapist: Would you change the word can’t, to won’t?

Client: I won’t do anything right.

Therapist: What won’t you do that you want to do?

The general goal of Gestalt therapy is awareness of self, others, and the environment for bringing about growth, wholeness, and integration of one’s thoughts, feelings, and actions. Gestalt therapists use a wide variety of techniques to make clients more aware of themselves, and they often invent or experiment with techniques that might help to accomplish this goal. One of the best-known The Gestalt technique is the empty-chair technique, in which an empty chair represents another person or another part of the client’s self. For example, if a client is angry at herself for not being kinder to her mother, the client may pretend her mother is sitting in an empty chair. The client may then express her feelings by speaking in the direction of the chair. Alternatively, the client might play the role of the understanding daughter while sitting in one chair and the angry daughter while sitting in another. As she talks to different parts of herself, differences may be resolved. The empty-chair technique reflects Gestalt therapy’s strong emphasis on dealing with problems in the present.

Behavioural therapies differ dramatically from psychodynamics and the humanistic therapies, and behavioural therapists. Each do not explore an individual’s thoughts, feelings, dreams, or past experiences. Rather, they focus on the behaviour that is causing the distress for their clients. They believe that behaviour of all kinds, both normal and abnormal, is the product of learning. By applying the principles of learning, they help individuals replace distressing behaviours with more appropriate ones.

Typical problems treated with behavioural therapy include alcohol or drug addiction, phobias (such as a fear of heights), and anxiety. Modern behavioural therapists work with other problems, such as depression, by having clients develop specific behavioural goals - such as returning to work, talking with others, or cooking a meal. Because behavioural therapy can work through nonverbal means, it can also help people who would not respond to other forms of therapy. For example, behavioural therapists can teach social and self-care skills to children with severe learning disabilities and to individuals with schizophrenia who are out of touch with reality.

Behavioural therapists begin treatment by finding out as much as they can about the client’s problem and the circumstances surrounding it. They do not infer causes or look for hidden meanings, but rather focus on observable and measurable behaviour. Therapists may use a number of specific techniques to alter behaviour. These techniques include relaxation training, systematic desensitization, exposure and response prevention, aversive conditioning, and social skills training.

Relaxation training is a method of helping people with high levels of anxiety and stress. It also serves as an important component of some other behavioural treatments.

In one type of relaxation exercise, people learn to tighten and then relax one muscle group at a time. This method, called progressive relaxation, was developed in the 1930s by American physiologist and psychologist Edmund Jacobson. At first, the therapist gives spoken instructions to the client. Later the client can practice more freely in the relaxation exercises at home using a tape recording of the therapist’s voice. The following example, adapted from Jacobson’s work, illustrates a brief relaxation procedure:

Just settle back as comfortably as you can, close your eyes, and let yourself relax to the best of your ability. Now clench up both fists tighter and tighter and study the tension as you do so. Keep them clenched and feel the tension in your fists, hands, forearms, now relax. Let the fingers of your hands become loose and observe the contrast in your feelings, and now let yourself go and try to become more relaxed all over. Take a deep breath, Just let your whole body become more and more relaxed.

Another relaxation technique is meditation. In meditation, people try to relax both the mind and the body. In many forms of meditation, people begin by sitting comfortably on a cushion or chair. Then they gradually relax their body, begin to breathe slowly, and concentrate on a sensation - such as the inhaling and exhaling of breath - or on an image or object. In Transcendental Meditation, a person does not try to concentrate on anything, but merely sits in a quiet atmosphere and repeats a mantra (a specially chosen word) to try to achieve a state of restful alertness.

Systematic desensitization, a procedure developed by South African psychiatrist Joseph Wolpe in the 1950s, gradually teaches people to be relaxed in a situation that would otherwise frighten them. It is often used to treat phobias and other anxiety disorders. The word desensitization refers to making people less sensitive to or frightened of certain situations.

In the first step of desensitization, for the therapist and client establish an anxiety hierarchy - a list of fear-provoking situations arranged in order of how much fear they provoke in the client. For a man afraid of spiders, for example, holding a spider may rank at the top of his anxiety hierarchy, whereas seeing a small picture of a spider may rank at the bottom. In the second step, the therapist has the client relax using one of the relaxation techniques described above. Then the therapist asks the client to imagine each situation on the anxiety hierarchy, beginning with the least-feared situation and moving upward. For example, which may at first be the imaginary, by seeing a picture of a spider, then imagine seeing a real spider from far away, then from a short distance, and so forth. If the client feels anxiety at any stage, he or she is instructed to stop thinking about the situation and to return to a state of deep relaxation. The relaxation and the imagined scene are paired until the client feels no further anxiety. Eventually the client can remain free of anxiety while imagining the most-feared situation.

Asking a client to encounter the feared situation is a technique called in vivo exposure. For the man who is afraid of spiders, a therapist might arrange to go to a park or zoo where visitors can touch large spiders. The therapist would model for the client how to approach a spider and how to handle it. The therapist may also encourage the man to walk gradually closer to the spider, reinforcing his progress with praise and reassurance as he does so. The goal for the therapist and patient would be for the man to pick up the spider.

Problems are rarely as clear and simple as fear of spiders. Therapists may spend considerable time deciding on appropriate goals, which ones to pursue first, and then reevaluating or changing goals as therapy progresses. Systematic desensitization typically takes from 10 to 30 sessions, depending on the severity of the problem. In vivo therapies are more direct and may take less time.

Exposure and response prevention is a behavioural technique often used to treat people with obsessive-compulsive disorder. In this technique, the therapist exposes the client to the situation that causes obsessive thoughts, but then prevents the client from acting on these thoughts. For example, to treat people who compulsively wash their hands because they fear contamination from germs, a therapist might have them handle something dirty and then prevent them from washing their hands. Therapists have also experimented with exposure and response prevention to treat people with Bulimba nervosa, an eating disorder in which people engage in binge eating and afterward force themselves to vomit or, more occasionally, take laxatives. The therapist feeds the bulimic patients small amounts of food but prevents them from binging, taking laxatives, or vomiting.

Behavioural therapists occasionally use a technique called aversive conditioning or aversion therapy. In this method, clients receive an unpleasant stimulus, such as an electric shock, whenever they perform some undesirable behaviour, for example, therapists treating patients with alcoholism may have them ingest the drug disulfiram (Antabuse). The drug makes the patients violently sick if they drink alcohol. Many therapists have found that aversive conditioning is not as effective as other behavioural techniques, and as a result, they use this technique very infrequently. For some problems, however, aversive conditioning can work when all other techniques have failed. For example, therapists have found that immediate application of an unpleasant stimulus can eliminate self-mutilation and other self-destructive behaviours in children with autism.

Social skill training is a method of helping people who have problems interacting with others. Clients learn basic social skills such as initiating conversations, making eye contact, standing at the appropriate distance, controlling voice volume and pitch, and responding to questions. The therapist first describes and models the behaviour. Then the patient or client’s practices the behaviour skits on which role-playing are placed to exercise, in that which the therapist watches the exercises and provides constructive criticism only to further their modelling. Therapists often conduct this kind of training with groups of people with similar problems. Social skill training and often can help people suffering with schizophrenia and function more easily to public situations, in reducing their risk of relapse or re-hospitalization.

One popular form of social skills training is assertiveness training, another technique pioneered by Joseph Wolpe. This technique teaches people, often those who are shy, to make appropriate responses when someone does something to them that seem inappropriate or offensive or violates their rights. For example, if a woman has trouble saying no to a coworker who inappropriately asks her to handle some of his job responsibilities, she may benefit from learning how to become more assertive. In this example, the therapist would model assertive behaviour for the client, who would then role-play and rehearse appropriate responses to her coworker.

Cognitive therapies are similar to behavioural therapies in that they focus on specific problems. However, they emphasize changing beliefs and thoughts, rather than observable behaviours. Cognitive therapists believe that irrational beliefs or distorted thinking patterns can cause a variety of serious problems, including depression and chronic anxiety. They try to teach people to think in more rational, constructive ways.

In the mid-1950’s American psychologist Albert Ellis developed one of the first cognitive approaches to therapy, rational-emotive therapy, now commonly called rational-emotive behaviour therapy. Trained in a psychoanalysis in the 1940’s, Ellis quickly became disillusioned with psychoanalytic methods, viewing them as slow and inefficient. Influenced by Alfred Adler’s work, Ellis came to regard irrational beliefs and illogical thinking as the major cause of most emotional disturbances. In his view, negative events such as losing a job or breaking up with a lover do not by themselves cause depression or anxiety. Rather, emotional disorders result when a person perceives the events in an irrational way, such as by thinking, ‘I’m a worthless human being.’

Although rational-emotive behaviour therapists use many techniques, the most common technique is that of disputing irrational thoughts. First the therapist identifies irrational beliefs by talking with the client about his or her problems. Examples of irrational beliefs, according to Ellis, include the idea that unhappiness is caused by external events, the idea that one must be accepted and loved by everyone, and the idea that one must always be competent and successful to be a worthwhile person.

To dispute the client’s irrational beliefs and longstanding assumptions, rational-emotive behaviour therapists often use confrontational techniques. For example, if a student tells the therapist, ‘I must get an A on this test or I will be a failure in life,’ the therapist might say, ‘Why must you? Do you think your entire career as a student will be through if you get a B?’ The therapist helps the client replace irrational thoughts with more reasonable ones, such as ‘I would like to get an A on the test, but if I don’t, I have strategies I can use to do better next time.’

Like Ellis before him, American psychiatrist Aaron T. Beck became disenchanted with the psychoanalysis, finding that it often did not help relieve depression for his patients. In the 1960s Beck developed his own form of cognitive therapy for treating depression, and later applied it to other disorders. In Beck’s view, depressed people tend to have negative views of themselves, interpret their experiences negatively, and feel hopeless about their future. He sees these tendencies as a problem of faulty thinking. Like rational-emotive behaviour therapists, practitioners of Beck’s technique challenge the client’s absolute, extreme statements. They try to help the client identify distorted thinking, such as thinking about negative events in catastrophic terms, and then suggest ways to change this thinking. The following example illustrates how a cognitive therapist might challenge a client’s absolute statement. For which is the following:

Client: Everyone at work is much smarter than I.

Therapist: Everyone? Every single person at work is smarter than you?

Client: Well, maybe not. There are a lot of people at work I don’t know well at all, but my boss seems smarter: She seems to really know what’s going on.

Therapist: Notice how we went from everyone at work being smarter than you to saying just your boss.

Cognitive therapists often give their clients homework assignments designed to help them identify their own irrational patterns of thinking and to reinforce what they learn in therapy. For example, clients often keep a daily log in which they write down distressing emotions, the situation that caused the emotions, their thoughts or thinking patterns, or whether the thoughts were of a reality orientation or simply distorted or not, and the alternative ways to handle the drama in a therapeutic situation.

Helping individuals change problematic behaviours, thoughts, or feelings is not an easy task. Therapists have tried many creative approaches to help patients, some of which do not fall neatly into the major categories of psychodynamics, humanistic, behavioural, or cognitive inclinations. Two such therapies still in use today are transactional analysis and reality therapy.

In the 1950s and 1960s Canadian-American psychiatrist Eric Berne developed a form of therapy he called transactional analysis. Although trained in the psychoanalysis, Berne felt that the complexity of psychoanalytic terminology excluded patients from full participation in their own treatment. He developed a theory of personality based on the view that when people interact with each other, they function as either a parent, adult, or the child, for example, he would characterize social interactions between two people as parent-adult, parent-child, adult-child, adult-adult, and so forth depending on the situation. He referred to social interactions as transactions and to analysis of these interactions as transactional analysis.

In therapy, which is often conducted in groups, patients learn to recognize when they are assuming one of these roles and to understand when being an authoritarian parent or an impulsive child is appropriate or inappropriate. In addition to identifying these roles, clients learn how to change roles in order to behave in more desirable ways.

American psychiatrist William Glasser developed reality therapy in the 1960’s, after working with teenage girls in a correctional institution and observing work with severely disturbed schizophrenic patients in a mental hospital. He observed that psychoanalysis did not help many of his patients change their behaviour, even when they understood the sources of it. Glasser felt it was important to help individuals take responsibility for their own lives and to blame others less. Largely because of this emphasis on personal responsibility, his approach has found widespread acceptance among drugs - and alcohol-abuse, counsellors, correction workers, school counsellors, and those working with clients who may be disruptive to others.

Reality therapy is based on the premise that all human behaviour is motivated by fundamental needs and specific wants. The reality therapist first seeks to establish a friendly, trusting relationship with clients in which they can express their needs and wants. Then the therapist helps clients explore the behaviours that created problems for them. Clients are encouraged to examining the consequences of their behaviour and evaluate how well their behaviour helped them fulfil their wants. The therapist does not accept excuses from clients. Finally, the therapist helps the client formulate a concrete plan of action to change certain behaviours, based on the client’s own goals and ability to make choices.

Currently, many therapists describe their approach as eclectic or integrative, meaning that they use ideas and techniques from a variety of therapies. Many therapists like the opportunity to draw from many theories and not limit themselves to one or two. Most therapists who adopt an eclectic approach have a rationale for which techniques they use with specific clients, rather than just choosing an approach randomly or because it suits them at the time.

One of the most influential eclectic approaches is cognitive-behavioural therapy. Other eclectic approaches use other combinations of therapies.

There are almost no pure cognitive or behavioural therapists. Usually therapists combine cognitive and behavioural techniques in an approach known as cognitive-behavioural therapy. For example, to treat a woman with depression, a therapist may help her identify irrational thinking patterns that cause the distressing feelings and to replace these irrational thoughts with new ways of thinking. The therapist may also train her of the relaxation techniques and have in trying new behaviours that help her become more active and less depressed. The client then reports the result’s reciprocally back to the therapist.

Fulfilling-behavioural therapy has rapidly become one of the most popular and influential forms of psychotherapy, in part because it takes a relatively short period of time compared to humanistic and psychoanalytic therapies, also, because of its ability to treat a wide range of problems. Sometimes cognitive-behavioural therapy takes only a few sessions, but, to a greater extent, it often extends for some 20 or 30 sessions more than four to six months. The length of therapy usually depends on the severity and number of the client’s problems.

Some therapists have one particular way of understanding clients - that is, they adhere to one theory of personality - but use many techniques from a variety of theories. Other therapists may understand clients for using two or three theories of personality and only use techniques to bring about change that is consistent with those theories. Some therapists have combined psychodynamics and behavioural therapies in ways to help their clients deal with fears and anxieties, but also to understand and especially to remember their referential causalities.

Therapists may use different approaches to treat different problems. For example, a therapist might find that clients who are grieving over the loss of a spouse may respond best to a humanistic approach, in which they can share their grieving and their hurts with the therapist. However, the same therapist may use a cognitive-behavioural approach with a person who reports being anxious most of the time.

All of the individual therapies can also be used with groups. People may choose group therapy for several reasons. First, group therapy is usually less expensive than individual therapy, because group members share the cost. Group therapy also allows a therapist to provide treatment to more people than would be possible otherwise. Aside from cost and efficiency advantages, group therapy allows people to hear and see how others deal with their problems. In addition, group members receive vital support and encouragement from others in the group. They can try out new ways of behaving in a safe, supportive environment and learn how others perceive them.

Groups also have disadvantages. Individuals spend less time talking about their own problems than they would in one-on-one therapy. Also, certain group members may interact with other group members in hurtful ways, such as by yelling at them or criticizing them harshly. Generally, therapists try to intercede when group members act in destructive ways. Another disadvantage of group therapy involves confidentiality. Although group members usually promise to treat all therapy discussions as confidential, some group members may worry that other members will share their secrets outside of the group. Group members who believe this may be less willing to disclose all of their problems, lessening the effectiveness of therapy for them.

Groups vary widely in how they work. The typical group size is from six to ten people with one or two therapists. Often two therapists prefer to work together in a group so that they can respond not only to one person’s issues, but also to discussions between group members that may be occurring quickly. Some groups are open or drop-in groups - new clients may join at any time and members may attend or skip whatever sessions they desire. Other groups are closed and admit new members only when all members agree. Regular attendance is usually required in these groups. In closed groups, both the therapist and group members will ask a member to provide an explanation for missing a meeting.

When forming a group, therapists try to make clear to potential participants the goals of the group and for whom it is appropriate. Therapists will often screen potential participants to learn about their problems and decide whether the group is right for them. Sometimes therapists prefer diversity among group members in terms of age, gender, and problem. In other cases, therapists may limit membership in a group to individuals with similar problems and backgrounds. For example, some groups may form specifically for individuals who are grieving the loss of a loved one, individuals who abuse drugs or alcohol, people with eating disorders, people suffering from depression, or troubled elderly individuals.

The techniques used in group therapy depend largely on the theoretical orientation of the therapist. Humanistic therapists tend to respond to the feelings and experiences of other members. They may also interpret or comment on social interactions between group members. In cognitive-behavioural groups, group members try to change their own thoughts and behaviours and support and encourage other members to do the same. Psychoanalytic groups focus on childhood experiences and their impact on participants’ current behaviours, thoughts, and feelings.

Psychodrama, the first form of group therapy, was developed in the 1920s by Jacob L. Moreno, an Austrian psychiatrist. Moreno brought his method to the United States in 1925, and its use spread to other parts of the world. Participants in a psychodrama interact, are often on a real stage and with props - as a means of heightening their awareness of them. The therapist serves as the director, suggesting how participants might act out problems and assigning roles to other group members. For example, a woman might reenact a scene from her childhood with other group members playing her father, mother, brother, or sister. Groups who use the psychodrama may do so weekly or simply as a one-time demonstration.

A self-help group, or the support group involves people with a common problem that meet regularly to share their experiences, support each other emotionally, and encourage change or recovery. They are usually free of charge to interested participants. Self-help groups are not strictly considered psychotherapy because they are not led by a licensed mental health professional. However, they can serve as an important source of help for people in emotional distress.

There are thousands of self-help and support groups in the United States and Canada. The oldest and best known is Alcoholics Anonymous, which uses a 12-step program to treat alcoholism. Other groups have formed for cancer patients, parents whose children have been murdered, compulsive gamblers, battered women, obese people, and many other types of people.

Family therapy involves the participation of one or more members of the same family who seeks help for troubled family relationships or the problems of individual family members. Typical problems that bring families into family therapy are delinquent behaviour by a child or adolescent, a child’s poor performance in school, hostilities between a parent and child or between siblings, and severe psychological disturbance or mental illness in a parent or child.

One of the most influential forms of family therapy, family systems therapy, views the family as a single, complex system or unit. Individual members are interdependent parts of the system. Rather than treating one person’s symptoms in isolation, therapists try to understand the symptoms in the larger context of the family. For example, a boy who begins picking fights with classmates might do so to get more attention from his busy parents. Therapists work from the rationale those current family relationships profoundly affect, and are affected by, an individual family member’s psychological problems. For this reason, most family therapists prefer to work with the entire family during a session, rather than meeting with family members individually.

In most family therapy sessions, the therapist encourages family members to air their feelings, frustrations, and hostilities. By observing how they interact, the therapist can help them recognize their roles and relationships with each other. The therapist tries to avoid assigning blame to any particular family member. Instead, the therapist makes suggestions about how family members might adjust their roles and prevent future conflict.

Couples therapy, also called marital therapy or marriage counselling, is designed to help intimate partners improve their relationship. Therapists treat married couples as well as unmarried couples of the opposite or same sex. Therapists normally hold sessions with both partners present. At certain times during therapy, however, the therapist may choose to see the partners individually.

Couples may seek therapy for a variety of problems, many of which concern a breakdown of communication or trust between the partners. For example, an extramarital affair by one partner may cause the other partner to feel emotional pain, anger, and distrust. Some partners may feel distant from one another or experience sexual problems. In other cases, one or both partners may have psychological problems or alcohol or drug problems that negatively affect their relationship.

The techniques used in therapy vary depending on the theoretical orientation of the therapist and the nature of the couple’s problem. Most often, therapists focus on improving communication between partners and on helping them learn to manage conflict. By observing the partners as they talk to each other, the therapist can learn about their communication patterns and the roles they assume in their relationship. The therapist may then teach the partners new ways of expressing their feelings verbally, how to listen to each other, and how to work together to solve problems. The therapist may also suggest that they try out new roles. For example, if one partner makes all of the decisions in the relationship, the therapist may encourage the couple to try sharing decision-making power.

Because most couple’s therapists also have trained in family therapy, they often examine the influence of the couple’s relationships with parents, children, and siblings. Psychoanalytically oriented therapists may focus on how the partners’ childhood experiences affect their current relationship with each other. For couples who cannot work through their differences or reestablish trust and intimacy, separation or divorce may be the best choice. Therapists can help such partners separate in constructive ways.

Some psychotherapists specialize in working with children. Therapists deal with children who are anxious, depressed, or have difficulty getting along with others at home or school. Some children have psychological problems resulting from family issues such as divorce, new stepparents, single-parent homes, death of a parent or sibling, being homeless, or being raised in an alcoholic family. Other children have emotional problems related to physical disabilities, learning disabilities, or attention-deficit hyperactivity disorder.

Play therapy is a special technique that therapists often use with children aging from two through 12. For children, play is a natural way of learning and relating to others. Play therapy can help therapists both to understand children’s problems and to help children deal with their feelings, behaviours, and thoughts. Therapists may use playhouses, puppets, a toy telephone, dolls, bandboxes, food, finger paints, and other toys or objects to help children express their thoughts and feelings. In addition to projecting a caring and gentle manner, therapists who work with children are trained to understand and interpret children’s nonverbal and verbal expressions.

For most people, psychotherapy involves a common sequence of events: Finding a therapist, assessing the problem, exploring the problem, resolving the problem, and terminating therapy. Sometimes therapy will end prematurely, before the problem is resolved. For example, the therapist or client may move to a new city.

When someone has a personal problem and seeks help from a therapist, the individual may turn to a variety of people to obtain a referral - of a friend, a pastor or rabbi, or a family physician. Phone books list associations of psychologists, psychiatrists, and social workers that can also provide referrals to therapists. As noted earlier, however, some health insurance plans may restrict a person’s choice of a therapist.

When prospective clients call a therapist for an appointment, they may discuss several aspects of therapy. One concern of availability - is that the therapist takes upon new patients? Are their hours when both patient and therapist can meet? Another issue is fees. Both therapists in private practice and those in community mental health agencies have to negotiate fees depending in part on the client’s health insurance plan, as for some agencies do not require health insurance and have very low fees or a sliding scale that sets fees depending on the ability of the client to pay.

During the first meeting, clients try to explain their problems to the therapist. The therapist usually asks about the nature of the problems, what may make the problems better or worse, and how long the problems have existed. For many therapists, hearing details, even small ones, help them to assess the problems and to decide the best form of treatment. Some therapists collaborate with clients in deciding the goals of therapy and what treatment methods will be used. Assessment does not stop with the first session, but continues through therapy. Occasionally, goals of therapy change upon assessment of new issues or problems.

During therapy, the client sits across from the therapist - except in classical psychoanalyses, in which the client lies on a couch. The specific nature of the discussions between therapist and client differs greatly depending on the therapist’s theoretical orientation. Some therapists are interested in unconscious forces and the early childhood years of the client (as Psychodynamic therapy), others in actions of the client (behavioural therapy), and others in the client’s thinking patterns (cognitive therapy), and yet others in all or some of these aspects. Therapists often take notes during a session or make notes after the session has ended. Sessions typically last from 45 to 50 minutes, although therapists may hold longer sessions during the initial stages of treatment. Clients typically meet weekly with the therapist, although some may meet twice a week or more.

When does therapy end? Clients and therapists discuss this issue together and determine when it is best to stop. Ideally their decision depends on their judgments about the client’s degree of progress and improvement. Some clients may find that therapy does not seem to be making progress, and may decide to change therapists. However, the cost of therapy may also factor in the decision to terminate the therapy. Managed-care companies generally place limits on the number of sessions they will subsidize to between 15 and 20. Some therapists, especially those in private practice, may arrange to go beyond these limits by negotiating a fee that the client will pay for services. In other cases, the therapist may refer the client to other mental health agencies that have lower fees and do not require insurance. At the end of therapy, the therapist may schedule a follow-up session several months later to check the client’s progress. Also, the therapist and client agree on what to do if the client’s problems recur.

Almost since the inception of psychotherapy, therapists and their clients have asked, ‘Does it work? Does psychotherapy help person resolve their problems, feel better, and change the way they deal with other people?’ Therapists and clients are not the only ones asking these questions. In recent years, the agencies that fund mental health services - health insurance companies, health maintenance organizations, and government organizations - have increased their scrutiny of the effectiveness of various psychotherapies in an effort to contain costs.

Measuring the effectiveness of psychotherapy is an extremely complex task. In asking psychotherapists or their clients, as to ‘How helpfully has therapy, was?’ the answer does provide some information about how therapists and their clients perceive therapy. However, it does not answer the question of whether psychotherapy is effective because both therapists and clients have vested interests in believing that therapy succeeded. Therapists want to uphold their professional reputation and sense of competence, and clients want to feel that their investment of time and money has been worthwhile. Because of these biases, most studies of effectiveness rely on other evaluations of a client’s improvement: psychological tests given before and after treatment, report from the client’s friends and family, and reports from impartial interviewers who do not know the client or whether the client received any therapy.

In 1952 the British psychologist Hans Eysenck reviewed the results of 24 studies of psychotherapy and came to a controversial conclusion: Although two-thirds of the patients who received psychotherapy showed improvement, a roughly equal proportion of patients who had been on a waiting list for therapy improved with no treatment. According to Eysenck, the patients on the waiting list showed spontaneous remission - recovery without treatment. Although researchers soon exposed flaws in his analysis and problems with the original studies, Eysenck’s findings touched off hundreds of new studies on the effectiveness of psychotherapy.

By 1980 American researchers statistically combined the results of 475 studies on psychotherapy outcomes using a technique known as meta-analysis. Their study found that the average psychotherapy recipient showed more improvement than 80 percent of untreated individuals. Later studies have confirmed that overall that psychotherapy is better than no therapy at all. Furthermore, it appears at least as effective as drug treatment for most psychological problems. However, psychotherapy is not effective for everyone. About 10 percent of people who receive psychotherapy show no improvement or actually get worse.

Researchers have also studied how quickly people improve with psychotherapy. One analysis, which reviewed data from more than 2,400 psychotherapy patients, found that 50 percent of people receiving once-a-week psychotherapy showed significant improvement after eight sessions, or two months. After six months, or 26 sessions, about 75 percent of people show improvement. However, most people required about a year of psychotherapy for relief from severe symptoms, such as feelings of worthlessness.

Are some types of psychotherapy more effective than others? This question has been hotly debated for decades, and research on p this issue present many difficulties. In conducting studies that compare different therapies, researchers seek to make sure that each treatment group is as similar as possible. For example, researchers may limit the groups to people with the same severity of depression. In addition, within each treatment group, researchers try to make sure that therapists are using the same techniques and are trained similarly. However, patients do not come to therapy with simple problems that fit easily into studies. Furthermore, therapists of the same theoretical orientation may vary in their techniques and in the skillfulness with which they apply them.

Because of these problems, there is no conclusive answer about which type of therapy is best. Most studies have failed to demonstrate that any approach is superior to another. The meta-analysis of 475 studies mentioned earlier, for example, found that psychodynamics, humanistic, behavioural, and cognitive approaches were all equally effective. In the 1990s a major study by the National Institute of Mental Health correlated by comparisons the effectiveness as graded through the cognitive-behavioural therapy, interpersonal psychotherapy is a form of short-term Psychodynamic therapy which is focussed on social relations, as well as drug therapy for people with depression. The comparative study found that all three types of treatment helped individuals become, as to a lesser extent less depressive. Furthermore, no one method was significantly more effective than the others.

Some researchers suggest that all therapies share certain qualities, and that these qualities account for the similar effectiveness of therapies despite quite different techniques. For instance, all therapies offer people hope for recovery. People who begin therapy often expect that therapy will help them, and this expectation alone may lead to some improvement (a phenomenon known as the placebo effect). Also, people in psychotherapy may find that simply being able to talk freely and openly about their problems helps them to feel better. Finally, the support, encouragement, and warmth that clients feel from their therapist some boundred allowances of which they are caringly respected, which may positively affect their mental health.

Although different therapeutic approaches may be equally effective on average, mental health researchers agree that some types of