Introduction
Psychotherapy is an interpersonal relationship in which clients present themselves to a psychotherapist to gain some relief from distress in their lives. It should be noted that although people who seek psychological help are referred to as “clients” by a wide range of psychotherapists, this term is used interchangeably with the term “patients,” which is traditionally used more often by psychodynamically and medically trained practitioners. In all forms of psychotherapy, patients or clients must tell the psychotherapist about their distress and reveal intimate information for the psychotherapist to be helpful. The psychotherapist must aid clients in the difficult task of admitting difficulties and revealing themselves, since a client’s desire to be liked and to be seen as competent can stand in the way of this work. The client also wants to find relief from distress at the least possible cost in terms of the effort and personal changes to be made, and therefore, clients often prevent themselves from making the very changes in which they are interested. This is termed resistance, and much of the work of the psychotherapist involves dealing with such resistance.
The goals of the client are determined by the type of life problems that are being experienced. Traditionally, psychotherapists make a diagnosis of the psychiatric disorder from which the client suffers, with different disorders presenting certain symptoms to be removed for the client to gain relief. The vast majority of clients suffer from some form of anxiety or depression, or from certain failures in personality development, which produce deviant behaviors and rigid patterns of relating to others called personality disorders. Relatively few clients suffer from severe disorders, called psychoses, which are characterized by some degree of loss of contact with reality. Depending on the particular symptoms involved in the client’s disorder, psychotherapeutic goals will be set, although the client may not be aware of the necessity of these changes at first. In addition, the diagnosis allows the psychotherapist to anticipate the kinds of goals that would be difficult for the client to attain. Psychotherapists also consider the length of time they will most likely work with the client. Therefore, psychotherapeutic goals depend on the client’s wishes, the type of psychiatric disorder from which the client suffers, and the limitations of time under which the psychotherapy proceeds.
Another factor that plays a major role in determining psychotherapeutic goals is the psychotherapist’s theoretical model for treatment. This model is based on a personality theory that explains people’s motivations, how people develop psychologically, and how people differ from one another. It suggests what occurred in life to create the person’s problems and what must be achieved to correct these problems. Associated with each theory is a group of techniques that can be applied to accomplish the goals considered to be crucial within the theory used. There are three main models of personality and treatment: psychodynamic therapies, behavioral therapies, and humanistic therapies. Psychodynamic therapists seek to make clients aware of motives for their actions of which they were previously unconscious or unaware. By becoming aware of their motives, clients can better control the balance between desires for pleasure and the need to obey one’s conscience. Behavioral therapists attempt to increase the frequency of certain behaviors and decrease the frequency of others by reducing anxiety associated with certain behavior, teaching new behavior, and rewarding and punishing certain behaviors. Humanistic therapists try to free clients to use their innate abilities by developing relationships with clients in which clients can be assured of acceptance, making the clients more accepting of themselves and more confident in making decisions and expressing themselves.
Most psychotherapists use a combination of theories, and therefore of goals and techniques, in their practice. These “eclectic” therapists base their decisions about goals and techniques on the combined theory they have evolved or on a choice among other theories given what applies best to a client or diagnosis. It also appears that this eclectic approach has become popular because virtually all psychotherapy cases demand attention to certain common goals associated with the various stages of treatment, and different types of therapy are well suited to certain goals and related techniques at particular stages.
Therapeutic Relationships
When clients first come to a psychotherapist, they have in mind some things about their lives that need to be changed. The psychotherapist recognizes that before this can be accomplished, a trusting relationship must be established with clients. This has been termed the therapeutic alliance or a collaborative relationship. Establishing this relationship becomes the first goal of therapy. Clients must learn that the therapist understands them and can be trusted with the secrets of their lives. They must also learn about the limits of the therapeutic relationship: that the psychotherapist is to be paid for the service, that the relationship will focus on the clients’ concerns and life experiences rather than the psychotherapist’s, that the psychotherapist is available to clients during the scheduled sessions and emergencies only, and that this relationship will end when the psychotherapeutic goals are met.
The therapist looks early for certain recurring patterns in what clients think, feel, and do. These patterns may occur in the therapy sessions, and clients report about the way these patterns have occurred in the past and how they continue. These patterns become the focal theme for the therapy and are seen as a basic reason for the clients’ troubles. For example, some clients may complain that they have never had the confidence to think for themselves. They report that their parents always told them what to do without explanation. In their current marriage, they find themselves unable to feel comfortable with any decisions, and they always look to their spouse for the final say. This pattern of dependence may not be as clear to the clients as to psychotherapists, who look specifically for similarities across past and present relationships. Furthermore, clients will probably approach the psychotherapist in a similar fashion. For example, clients might ask for the psychotherapist’s advice, stating that they do not know what to do. When the psychotherapist points out the pattern in the clients’ behavior, or suggests that it may have developed from the way their parents interacted with them, the psychotherapist is using the technique of interpretation. This technique originated in the psychodynamic models of psychotherapy.
When clients are confronted with having such patterns or focal themes, they may protest that they are not doing this, find it difficult to do anything different, or cannot imagine that there may be a different way of living. These tendencies to protest and to find change to be difficult are called resistance. Much of the work of psychotherapy involves overcoming this resistance and achieving the understanding of self called insight.
One of the techniques the psychotherapist uses to deal with resistance is the continued development of the therapeutic relationship to demonstrate that the psychotherapist understands and accepts the client’s point of view and that these interpretations of patterns of living are done in the interest of the achievement of therapeutic goals by the client. Humanistic psychotherapists have emphasized this aspect of psychotherapeutic technique. The psychotherapist also responds differently to the client from the way others have in the past, so that when the client demonstrates the focal theme in the psychotherapy session, this different outcome to the pattern encourages a new approach to the difficulty. This is called the corrective emotional experience, a psychotherapeutic technique that originated in psychodynamic psychotherapy and is emphasized in humanistic therapies as well. For example, when the client asks the psychotherapist for advice, the psychotherapist might respond that they could work together on a solution, building on valuable information and ideas that both may have. In this way, the psychotherapist avoids keeping the client dependent in the relationship with the psychotherapist as the client has been in relationships with parents, a spouse, or others. This is experienced by the client emotionally, in that it may produce an increase in self-confidence or trust rather than resentment, since the psychotherapist did not dominate. With the repetition of these responses by the psychotherapist, the client’s ways of relating are corrected. Such a repetition is often called working through, another term originating in psychodynamic models of therapy.
Psychotherapists have recognized that many clients have difficulty with changing their patterns of living because of anxiety or lack of skill and experience in behaving differently. Behavioral therapy techniques are especially useful in such cases. In cases of anxiety, the client can be taught to relax through relaxation training exercises. The client gradually imagines performing new, difficult behaviors while relaxing. Eventually, the client learns to stay relaxed while performing these behaviors with the psychotherapist and other people. This process is called desensitization, and it was originally developed to treat persons with extreme fears of particular objects or situations, termed phobias. New behavior is sometimes taught through modeling techniques in which examples of the behavior are first demonstrated by others. Behavioral psychotherapists have also shown the importance of rewarding small approximations to the new behavior that is the goal. This shaping technique might be used with the dependent client by praising confident, assertive, or independent behavior reported by the client or shown in the psychotherapy session, no matter how minor it may be initially.
Alleviating Distress
The goals and techniques of psychotherapy were first discussed by the psychodynamic theorists who originated the modern practice of psychotherapy. Sigmund Freud and Josef Breuer are generally credited with describing the first modern case treated with psychotherapy, and Freud went on to develop the basis for psychodynamic psychotherapy in his writings between 1895 and his death in 1939. Freud sat behind his clients while they lay on a couch so that they could concentrate on saying anything that came to mind to reveal themselves to the psychotherapist. This also prevented the clients from seeing the psychotherapist’s reaction, in case they expected the psychotherapist to react to them as their parents had reacted. This transference relationship provided Freud with information about the client’s relationship with parents, which Freud considered to be the root of the problems that his clients had. Later psychodynamic psychotherapists sat facing their clients and conversing with them in a more conventional fashion, but they still attended to the transference.
Carl R. Rogers is usually described as the first humanistic psychotherapist, and he published descriptions of his techniques in 1942 and 1951. Rogers concentrated on establishing a warm, accepting, honest relationship with his clients. He established this relationship by attempting to understand the client from the client’s point of view. By communicating this “accurate empathy,” clients would feel accepted and therefore would accept themselves and be more confident in living according to their wishes without fear.
Behavioral psychotherapists began to play a major role in this field after Joseph Wolpe developed systematic desensitization in the 1950s. In the 1960s and 1970s, Albert Bandura applied his findings on how children learn to be aggressive through observation to the development of modeling techniques for reducing fears and teaching new behaviors. Bandura focused on how people attend to, remember, and decide to perform behavior they observe in others. These thought processes, or “cognitions,” came to be addressed in cognitive psychotherapy by Aaron T. Beck and others in the 1970s and 1980s. Cognitive behavioral therapy became a popular hybrid that included emphasis on how thinking and behavior influence each other.
In surveys of practicing psychotherapists beginning in the late 1970s, Sol Garfield showed that the majority of therapists practice some hybrid therapy or eclectic approach. As it became apparent that no one model produced the desired effects in a variety of clients, psychotherapists used techniques from various approaches. An example is Arnold Lazarus’s multimodal behavior therapy, introduced in 1971. It appears that such trends will continue and that, in addition to combining existing psychotherapeutic techniques, new eclectic models will produce additional ways of understanding psychotherapy as well as different techniques for practice.
Bibliography
Garfield, Sol L. Psychotherapy: An Eclectic Approach. New York: John Wiley & Sons, 1980. Focuses on the client, the therapist, and their interaction within an eclectic framework. Written for the beginning student of psychotherapy and relatively free of jargon.
Goldfried, Marvin R., and Gerald C. Davison. Clinical Behavior Therapy. New York: Holt, Rinehart and Winston, 1976. An elementary, concise description of basic behavioral techniques. Includes clear examples of how these techniques are implemented.
Goldman, George D., and Donald S. Milman, eds. Psychoanalytic Psychotherapy. Reading, Mass.: Addison-Wesley, 1978. A very clear, concise treatment of complicated psychodynamic techniques. Explains difficult concepts in language accessible to the layperson.
Norcross, John C., and Marvin R. Goldfried, eds. Handbook of Psychotherapy Integration. 2d ed. New York: Oxford University Press, 2005. Filled with suggestions for therapists on ways to incorporate various therapeutic approaches in their client treatment. In addition, this resource provides the history of eclectic therapy, helpful to students.
Phares, E. Jerry. Clinical Psychology. 4th ed. Pacific Grove, Calif.: Brooks/Cole, 1997. An overview of clinical psychology that includes excellent chapters summarizing psychodynamic, behavioral, humanistic, and other models of psychotherapy. Written as a college-level text.
Rogers, Carl R. Client-Centered Therapy. 1951. Reprint. Boston: Houghton, 1965. A classic description of the author’s humanistic psychotherapy, originally published in 1951, that is still useful as a strong statement of the value of the therapeutic relationship. Written for a professional audience, though quite readable.
Teyber, Edward. Interpersonal Process in Psychotherapy: A Guide to Clinical Training. 5th ed. Belmont, Calif.: Thomson-Brooks/Cole, 2006. An extremely clear and readable guide to modern eclectic therapy. Full of practical examples and written as a training manual for beginning psychotherapy students.
Wolpe, Joseph. The Practice of Behavior Therapy. 4th ed. Boston: Allyn & Bacon, 2008. Written by the originator of behavioral psychotherapy. Introduces basic principles, examples of behavioral interventions, and many references to research. Initial chapters are elementary, but later ones tend to be complicated.
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