Psychotherapy means different things to different people. Literally it means ‘treatment of the mind’, though it can be read as ‘treatment by the mind’. I will use this second understanding (otherwise all psychiatric activity would be psychotherapy and we would be no further forward). In this chapter psychotherapy will include any deliberate, structured use of the relationship between a therapist and patient to help that patient to change or better understand his or herself. Psychotherapy is usually conducted by talking, hence the current expression ‘talking treatments’, but in some therapies words are not the crucial element and in some the ‘dialogue’ is internal.
How is psychotherapy different from normal kindness?
Much of what characterizes psychotherapy characterizes normal life. We all try to help our friends and family by being supportive and talking things through when they are upset. Many asylum doctors spent time in supportive conversations with their patients aiming to calm them and restore reason. This was broadly psychotherapeutic in aim. What is special about psychotherapies, however, is that there is an explicit agreement, almost a contract, between patient and therapist to set time aside to concentrate on it. They also follow a known and agreed approach, with clarity about what will happen and how long it will take.
The National Health Service in England calls psychotherapy ‘talking treatments’ or ‘psychological treatments’ to avoid old sectarian arguments about what is ‘true’ psychotherapy. It has a rather helpful hierarchy:
Type A comprises simple psychotherapeutic understanding employed during any treatment (e.g. counselling and support from a doctor prescribing antidepressants).
Type B involves dedicated sessions devoted exclusively to psychological understanding and emotional support. These use general psychotherapeutic principles but don’t follow a strict theory or have a prescribed number of sessions. An example would be a nurse having regular meetings with a depressed patient on the ward to talk through her situation.
Type C treatments are ‘psychotherapy proper’. Here the therapist has a recognized psychotherapy training and there is a clear, shared undertaking to pursue a specified course of that psychotherapy.
I’ve laboured this because some of the older psychotherapies are more evident in Type A and Type B treatments and are overlooked when not used as ‘proper’ Type C psychotherapies.
Sigmund Freud and the origins of psychoanalysis
No story of psychotherapy can ignore Sigmund Freud. Love him or loathe him, he is a towering figure who has radically altered not just psychotherapy but how much of the Western world thinks. We met him in Chapter 2, forced to leave his research and make a living for himself in private practice in Vienna. Most of his clientele was ‘neurotic’ and most was female. The commonest problems he saw were either ‘neurasthaenia’ (lack of motivation, mild depression) or a series of ostensibly physical complaints (paralyses, pains, seizures, etc.) for which there was no identifiable physical cause. Before reaching Freud they would have been subject to exhaustive medical examinations and treatments without benefit.
In over 50 years and 24 volumes of writing, Freud’s ideas changed significantly and they are sometimes contradictory. The outline that follows is, of necessity, simplified and partial but there are many detailed and accessible introductions (e.g. Anthony Storr’s Freud: A Very Short Introduction).
Freud’s thinking was heavily influenced by the scientific models that surrounded him. Darwin’s Origin of Species had located mankind squarely in the natural world (not a special divine creation) so the mind became a legitimate subject for scientific investigation. The laws of thermodynamics (which gave rise to much of 20th-century physics) dominated scientific thinking then. These proposed that energy is never lost – simply transformed. Nineteenth-century Europe was economically booming; its industry driven by mechanical innovations such as trains, factory presses, ships’ engines, all based on harnessing ‘conserved energy’. Whether water, steam, or internal combustion engines, they all demonstrated the enormous power of damming up energy and channelling its escape through a restricted outlet. Freud’s ideas of the human mind are shot through with this metaphor – whether blocked instinctual drives or repressed memories, he believed our greatest destructive and creative achievements stemmed from forces denied their natural release.
The unconscious and free association
If the laws of energy conservation applied to the mind then new ideas and feeling had to come from somewhere. Freud observed the impact of releasing ‘unconscious’ forces after visiting the French neurologist Charcot who used hypnosis to cure hysterical disorders such as fits or mutism. Freud initially found hypnosis and suggestion successful with many of his patients but the results were only temporary. He encouraged them, under hypnosis, to recall the events leading up to their illness and concluded that traumatic memories were the cause of many of their maladies.
His conclusion from this was that patients are unaware of much of their ‘thinking’ – that some mental processes were unconscious. The harder one tried to remember the harder it got. Freud responded with the technique of ‘free association’ – encouraging the patient to stop trying to remember and instead say whatever came into their mind. Through these ‘random’ remarks, supplemented by recounting dreams, repressed thoughts leaked out in obscure ways (you can almost see him imagining steam driving pistons). The analyst used his own unconscious to ‘listen’ to these remarks, detecting patterns and so directing the patient to the source of their troubles. Hence a ‘Freudian slip’ is when someone reveals their true thoughts by mistake. Freud became obsessed with the need not to interfere with this free association. The ‘blank screen’ therapist should reveal nothing about themselves, often sitting behind the patient and never answering questions or giving reassurance. It is hard to imagine, looking at the picture of his consulting room, and knowing about the controversy that accompanied him throughout his life, how Freud could ever believe he was a blank screen.
Nineteenth-century bourgeois Vienna was a very inhibited society. Not surprisingly many of the unconscious conflicts that Freud uncovered were sexual. Initially he believed that his patients had been sexually abused but he changed to a belief that these descriptions were more often fantasies and wish-fulfilments. He went on to propound his theory of infantile sexuality – that even very small children have strong ‘sexual’ feelings about their parents. This, of course, caused uproar, and in many circles still does. The language is clumsy but the ideas do help make some sense of the intense and powerful dynamics children set up in families. The Oedipus Complex is his most famous construct. Freud proposed that at about 3 years old the young boy desires his mother and sees his father as a rival for her affections (based on the Greek myth of Oedipus who killed his father and married his mother). Put like that it is pretty unhelpful, but it is an insightful way to understand how some people never learn to share important relationships. In the process of striving for exclusive intimacy they destroy what they want most. It made sense of many of the patients Freud saw (as it does even today).
8. Freud’s consulting room in Vienna c.1910 with his famous couch. The room is packed with evidence of Freud’s preoccupation with ancient Egypt and mythology
Ego, id, and superego
Freud originally believed that the conscious mind was entirely rational and contrasted with the more primitive, less logical, unconscious mental processes. This may explain some of the exaggerated terminology he used when discussing it. However he was struck by the brutal, punitive consciences of some of his patients. How could something as noble as conscience drive a patient to suicide through guilt? His solution was to describe the conscience as derived from both conscious thoughts and also from powerful unconscious remnants of parental and social demands. His map of the mind expanded from two areas (unconscious and conscious) to three. He called the primitive unconscious the id (‘it’), the conscious mind the ego (‘I’) and the conscience the superego (literally ‘over I’). All of these terms are now in common use.
Early psychoanalysis was about enabling the patient to discover repressed conflicts. Initially Freud and his growing band of colleagues thought that this was sufficient. However, as analyses got longer and more complex, analysts encountered ‘resistance’ where patients appeared to block change using various psychological defence mechanisms. One of the most troublesome ‘resistances’ for Freud was that patients kept falling in love with him (or at the least seeing him as a father figure). At one level this helps – if the patient likes you they are more likely to do what you ask. However, these strong feelings (he called them ‘transference’ because he thought they were transferred from important figures in the patient’s past life) made the exploration of free association almost impossible. Having initially seen transference as exclusively a problem Freud began to exploit it in the analysis. This ‘analysis of defence mechanisms’ became an essential part of the treatment.
There were certainly many blind alleys in Freud’s work – no surprise in a man who wrote so much. He made us aware of the power of unacknowledged thoughts and how the past can continue to haunt lives. Perhaps more importantly he showed that a brave attempt to confront and understand the origins of the misery (not simply to offer support and comfort) can lead to real liberation and relief. He also (against his own wishes, no doubt) showed how an honestly entered reflective human relationship can itself be the tool for recovery from quite severe mental illnesses.
Freud was a pessimist (particularly after the carnage of the First World War) and never promised happiness. The aim of psychoanalysis, he wrote, was to help a patient ‘to work and to love’. No more, no less. The rigidity and grandiosity of many of his successors has tarnished his reputation. His claims to have been a scientist are questionable and his treatment, psychoanalysis, is under siege for its failure to prove effectiveness. However, he has probably contributed as much to understanding and tolerance in the care of the mentally ill as any other individual. His insistence on taking the patient’s past seriously and his vivid metaphors for mental processes appeal to therapists and patients alike. They have formed the basis for a humane working relationship for which he deserves more credit than is currently his lot.
Freud collected about him a glittering band of followers. As often with such creative groups there were tensions, conflicts, and schisms. Several took the approach in differing directions and their individual fames have waxed and waned. Probably Carl-Gustav Jung (1875–1961) has had the most lasting influence. While Freud called himself a ‘Godless Jew’ with little sense of the spiritual or transcendent, Jung’s theories were more mystical. They included such constructions as a racial unconscious with ‘archetypes’ (symbolic figures which we all share). Jung also emphasized the importance of opposites in the human personality and how a ‘shadow self’ develops from aspects of our personality that we fail to acknowledge. Jung probably suffered a psychotic breakdown himself and drew on some of these deeply irrational experiences. Unlike Freud he believed that therapy could promote deep personal fulfilment and his approach is attractive to those who work with very ill patients and in artistic circles. Jung’s most persisting contribution, however, is probably his elaboration of the introvert and extrovert personality types. These have entered common language and are in daily usage by millions unfamiliar with even his name.
Psychoanalysis was closely associated with Jewish practitioners in its infancy and became a target for Nazi persecution in the 1930s. As a result most practitioners had to leave and most moved to the US, England, and South America. In all of these places their work and teaching came to have an enormous influence on psychiatry – much more than in their native German-speaking countries.
The Second World War put extra demands on psychoanalysts who turned their attention to traumatized soldiers and, surprisingly, the understanding of organizations (in particular the army). Out of this arose group analysis and group therapies where patients were treated in small groups of 5–8 so that they benefited from solidarity and support as well as insight. Group work led to the development of the therapeutic community (see Chapter 3) where analytical and psychological insights are applied to running a unit (rather than individual treatments). This informal, communal approach (with staff and patients sharing many of the tasks of running the place) was called ‘sociotherapy’ and has become a standard feature of modern psychiatric practice, drug rehabilitation units, and some prisons.
The endlessness of classic psychoanalysis (often taking several years at three to five sessions a week) has been strongly criticized. It is prohibitively expensive and many believed that shorter therapies would focus the mind better and improve outcomes. Typical ‘short-term’ therapies now last three to six months with weekly sessions of an hour. Interpersonal therapy focuses on relationships and cognitive analytical therapy uses specific exercises like letter writing and prescription of homework as part of the treatment. While still maintaining strict professional boundaries therapists are increasingly more active.
These are usually called ‘psychodynamic’ psychotherapies because they attribute such importance to dynamic interactions between the past and the present and between conscious and unconscious processes. The individual’s life story, their ‘narrative’, is central to understanding and resolving their problems. All require the therapist to hold back from giving too much direct advice so that the patient can, with guidance, find their own solutions. These therapies are routinely combined with other psychiatric treatments (antidepressants, hospital care, etc.).
Non-specific factors in psychotherapy
Most psychodynamic psychotherapists are intensely loyal to their model, convinced of the specificity of their treatment. Unfortunately the evidence is against them. There is depressingly little research into psychodynamic psychotherapies (unlike cognitive behavioural therapies) but what there is makes interesting reading. Experienced therapists who follow their training closely do much better than novices, or those who apply their model loosely. However, which model doesn’t seem to matter so much – they are all about equally effective. Most of this research confirms the crucial importance of establishing a good therapeutic relationship.
The qualities of a good therapist transcend the different schools of thought. The essential ingredients are accurate empathy (the therapist must really understand what the patient is going through, it is not enough just to feel sorry for them),unconditional regard (the therapist has to like and respect the patient, you can’t do therapy with someone you really dislike), and non-possessive warmth (the therapist must be able to show warmth without making the patient feel beholden to them). These insights are particularly useful in psychiatric practice. Matching patients and therapists really does matter – not all of us can get on with everyone. To work with violent or sexual offenders, for instance, requires a particularly tolerant and forgiving individual.
Existential and experimental psychotherapies
Several schools of psychotherapy have evolved which utilize the techniques of psychodynamic psychotherapy without accepting the theory. Existential psychotherapy, as its name suggests, makes no assumptions about what people ‘should be like’ but focuses on helping the patient express their identity in their own chosen way. Existential psychotherapies have some affinity with Jungian approaches and have become more popular as society becomes less rigid and conformist.
Freud’s patients usually knew what their families and society expected of them and were anguished because they could not achieve it. In the early 21st century we are more likely to experience aimlessness and emptiness rather than guilt at not living up to expectations. Alienation and confusion are now the dominant complaints so psychotherapies have become more structured to provide boundaries and containment.
These more here-and-now therapies blend imperceptibly into the personal growth movement. It can be difficult sometimes to decide whether a gestalt therapy or encounter group is a treatment to reduce suffering or an exercise to increase personal happiness and fulfilment. Perhaps it doesn’t matter what the purpose is so much as who gets it. There can be little doubt that depressed and demoralized psychiatric patients benefit greatly from activities such as these which improve general morale and self-esteem. In the treatments of self-harming young women, addressing self-esteem directly may be one of the most effective interventions.
Psychodynamic psychotherapies are currently under attack in psychiatry. They are criticized for inadequate research to establish that they really do work. Also, the requirement for therapists to undergo treatment themselves and to continue with supervision throughout their professional lives compromises objectivity and smacks of a ‘cult’ rather than a profession. Some research has been conducted in the short-term dynamic therapies and their results are generally good. However, more detailed studies to identify which aspects are effective, and which redundant, remain to be done. The opportunity may even have passed. So many of the core features of psychodynamic psychotherapy are now absorbed into routine care (the Type A and B treatments referred to above) that their contribution as specific treatments may be difficult to isolate and evaluate.
The strength of criticism is not surprising as psychoanalysis really did oversell itself. In America (North and South) between 1940 and 1970 it virtually drove all other thinking out of mental health care – most people thought that a psychiatrist was a psychoanalyst. Psychotic patients, for whom analysis had little to offer, were neglected, as were the basic skills of diagnosis and treatment. Critics accused American psychiatry in this period, with its high status and expanding workforce, of simply turning its back on the severely mentally ill and on science altogether. President Kennedy tried to refocus the profession in the early 1960s but without success and it required the pharmacological revolution to achieve it.
A more scientific and self-critical psychiatry, obliged to establish itself with hard won research data, has taken its revenge on psychoanalysis (and some would say is now making many of the same mistakes – Chapter 6).
The newer psychotherapies and counselling
The last 40 years have seen the development of a whole series of new psychotherapies that are radically different. They pay far less attention to understanding the past. The therapists are usually more directive – they give instructions and opinions, not just further encouragement to the patient to continue reflecting. Many involve specific exercises and ‘homework’ that is reviewed in sessions. They last months not years. The psychotherapist acts much like any other mental health professional and avoids the mystique surrounding psychodynamic therapists.
Person-centred (often called Rogerian) counselling is one such approach. The distinction between counselling and psychotherapy is variable and unclear. Counselling is often offered at times of personal crisis to people we would not usually consider as ‘ill’. Its aims are more modest than those of formal therapies. It draws on the characteristics of a good therapist outlined above, and provides a ‘safe space’ for the individual to explore their concerns. Here the therapist is non-directive. They rarely give opinions or advise the patient what to do or think, and often simply repeat the patient’s last phrase as encouragement to continue reflecting. Counselling is a skill highly prized by many mental health professionals and clearly valued by patients.
Family and systems therapies and crisis intervention
Family therapies have become very important in the treatment of psychiatrically ill children. Family therapists generally avoid implying a role for the family in causing the illness (see Chapter 5), but sometimes it is impossible for a patient to get better unless the family changes its way of responding. In anorexia nervosa, for instance, a family may have become so anxious about their daughter’s illness that they cannot allow her the freedom to take necessary risks and so mature. They may need help to back off and contain their anxiety. Sometimes the same can occur with adult patients where family therapy often helps couples shift the balance in their relationship. Family therapy usually relies on a ‘systems’ approach where the whole family is the focus, not the individual members.
‘Behavioural family management’ using a problem-solving approach helps families of schizophrenia patients. Patients break down more often if they live in highly emotional families – especially where there is tension and criticism. It may be very difficult for the family to avoid this, so the treatment is aimed at identifying flash-points in the relationships and finding alternative solutions (e.g. going into another room rather than arguing back). This has been shown to reduce breakdown rates by almost as much as medicine, but is protracted and difficult to do.
Crisis therapy is in here with systems therapies because it deals with immediate issues. You don’t have to dig around in crisis or family therapy – it’s all there in front of you. Crisis therapy is dramatic, often ultra short-term, and handles strong emotions, often with limited attention to their origins. While the family therapies are generally well established there remain doubts about crisis therapy. Some researchers suggest, for example, that debriefing after trauma can even make things worse. Presumably it interferes with the healthy processes of forgetting distressing events.
Behaviour therapy principles are about as different from psychodynamic psychotherapy as it is possible to be. They are based on learning theory which made a virtue of removing ‘consciousness’ from the equation – change is explained by reflex learning. Behaviour therapy is indelibly associated with B. F. Skinner who demonstrated that you could train rats in quite complex behaviours simply by rewarding the behaviour you wanted (‘operant conditioning’) or, alternatively, ‘punishing’ the behaviour you wanted to stop. Behaviour is ‘shaped’ in small steps, one at a time. The unique aspect of behaviour therapy is that it is irrelevant whether the subject agrees or even knows what is going on – the learning is completely unconscious.
Behaviour therapy can be staggeringly effective – think how easy it is to ride a bike and yet you probably have never ‘consciously’ learnt. You just tried it and each time it started to go wrong your body compensated, and now you are supremely skilled. Behaviour therapy works like that. It has proved particularly effective in treatments for individuals with learning disabilities and with children. A simple example of operant conditioning is the bell-and-pad system for nocturnal enuresis (bed wetting). A bell rings as soon as the pad gets wet, waking the patient. Over time he starts to wake up when his (it is usually his) bladder is full, as that sensation becomes associated with the bell and being woken. This successful treatment is widely used despite contradictory beliefs that bed wetting is either evidence of neurotic problems or, the opposite, that it is predominantly genetic.
Behaviour therapy is extensively used for phobias and for obsessive compulsive disorders. The patient is gradually exposed to the feared stimulus (e.g. a dirty hand for someone with obsessions about germs) while restricting avoidance and monitoring anxiety to ensure it remains tolerable. In practice behaviour therapists still take detailed histories because, without a good therapeutic relationship, patients drop out of treatment.
Cognitive behavioural therapy
Cognitive behavioural therapy could be considered a sophisticated extension of behaviour therapy, although it could also be viewed as an adaptation of psychodynamic psychotherapy. It lies somewhere between the two. It was developed by an American psychiatrist, Aaron Beck. He was a psychoanalytically trained psychiatrist who found a proportion of patients did not benefit from his psychoanalysis. On the whole they were people who valued mastery of their symptoms more than understanding them. His exploration, particularly of depression, convinced him that it was unconscious and pathological thoughtsas much as feelings that were trapping his patients. He developed a therapy to enable patients to identify ‘automatic negative thoughts’ (self-critical, self-defeating beliefs and conclusions) and to train them in how to challenge and contradict them.
His method emphasized ‘Socratic Dialogue’. Socrates believed that all you needed to teach truth was to keep asking the right questions and people found the answers within. Whenever the patient expresses a pathological doubt – e.g. ‘I got it wrong at work today. There’s no future for me’, the therapist asks them to explain it – ‘Explain to me why there is no hope.’ He contrasts the thoughts with the reality of the situation – ‘Explain how it is that you’re still being promoted at work then, despite these mistakes?’ CBT is now an essential part of psychiatric practice and training and is a standard ingredient in the treatments of depression and anxiety. It is also being increasingly used in a whole range of disorders including schizophrenia with intractable hallucinations or delusions and also physical disorders with a significant psychological component.
It may not be psychiatry, but the self-help movement has grown out of the psychotherapy tradition. Alcoholics Anonymous, Weight Watchers, The Depression Alliance, have all begun to apply what they have learnt, and more. Accurate empathy and unconditional regard – who better than someone who has been through it? Who less likely to condemn than someone with the same problems? Non-possessive warmth – what better source than shared suffering and real fellow-feeling? Self-help groups constitute a folk movement of our times which relieves distress and isolation and reduces stigma. Self-help books and computer programmes are increasingly available for common disorders like anxiety and depression. It is too early to judge their impact but they certainly get the popular vote.
After 200 years of psychiatry it seems strange for psychotherapy to be restricted to its own short chapter. Can it really be considered independent from psychiatry or psychiatry independent from it? Psychotherapy has been a defining characteristic of the psychiatric craft – just as a surgeon operates, a radiographer reads x-rays, an obstetrician delivers a baby. Asylum doctors of 150 years ago spent time talking with distressed patients to bring understanding, comfort, and relief. In the second half of the 20th century this personal relationship was why most staff came into the profession. Yet as we start the 21st century psychiatry and psychotherapy are increasingly considered as parallel activities. Is psychiatry changing fundamentally? Time will tell if they are to grow together again or to continue to pursue increasingly independent paths. Some of the forces driving these changes will occupy us in succeeding chapters.