Michael J T Leftwich. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
The practice of psychotherapy (or just “therapy”) is a combination of science and art, and a skillful clinician can help people make adaptive changes and healthier choices, minimizing distress and dysfunction. Clinical and counseling psychologists receive specialized instruction and supervision in various types of therapy as an integral part of their graduate training. Once they complete their training and obtain a license to practice, they are uniquely qualified to apply existing theoretical principles and therapeutic techniques, as well as develop new methods and approaches designed to help people sort out problems and overcome roadblocks in their daily lives. There is no one “correct” method of therapy, in part because people are so complex to begin with, but also because varying settings, circumstances, presenting problems, client characteristics, and clinician personalities all interact to influence what might be effective. Regardless of therapeutic orientation or method of service delivery, a practicing psychologist who is well trained, thoughtful, and creative can have a very meaningful and lasting impact on clients’ lives, and enjoy a very rewarding career where the presenting problems and resultant solutions can be simply mind-boggling (e.g., Kottler & Carlson, 2003a).
Psychologists practice psychotherapy in many formats. Perhaps the most easily recognized format is individual therapy, where a clinician and a client (also sometimes called a patient or consumer) work together in one-on-one fashion. The targets in individual therapy are on the individual’s symptoms and difficulties, and many clients benefit from and enjoy the support and focused attention they receive from individual therapy sessions. Individual therapy is the oldest form of psychotherapy, although many things have changed since its formal introduction. Individual therapy is a fascinating and complex process, shaped by the interactions between the therapist and client, and one that changes with each new combination of elements. We have a solid research base to demonstrate that therapy is clearly more effective than doing nothing or being on a waiting list, but psychologists have long struggled to explain the critical and necessary components of therapy (e.g., Lambert, 2004; Miller & Rollnick, 2002). This is no easy task, in part because psychologists don’t always do a very good job of describing what they do, or actually doing what they say or think they do (Kottler, 2002).
Sometimes it is necessary or beneficial to include other people in the therapy process, and in those instances psychologists can utilize the formats of family therapy or group therapy. Family therapy, often found in combination with marital or couples therapy in many training programs and service agencies, is another format that has proved useful (e.g., Gladding, 2007; Goldenberg & Goldenberg, 2002). In family and couples therapy, the relationships, roles, and interaction patterns between the individuals are critical. In other words, it is the system or the relationship that is the client, and not just one person. When problems obviously extend beyond the individual and directly involve relationships with significant others, family therapy or couples therapy seems an obvious choice. There are clinicians who believe that all therapy is relationship therapy, even if it is not explicitly referred to as such. In family or couples therapy, the therapist(s) typically asks all members of the defined system to be present for sessions. There may be situations where psychologists choose to see members individually, but every member would likely be given equal time and would often be asked the same questions so the psychologists can get information from multiple perspectives. Two therapists (or cotherapists) may lead sessions to provide everyone with additional support and perspective. Having cotherapists lead sessions also provides the potential benefit of the psychologists directly modeling the basic elements of cooperative and respectful relationships for the members of the client system.
Group therapy is the third primary therapy format in use today, and it offers several potential benefits including reduced costs of services for consumers and highly efficient use of clinicians’ time (e.g., Corey, 2004). In group therapy, several individuals with similar presenting problems but varying backgrounds and experiences can come together to simultaneously receive and provide group support. This support and difference in perspective can lead people to try new things and face challenges they would have otherwise avoided. The roles and duties of group leaders or facilitators can vary greatly, but at the very least the leader is there to establish some basic ground rules and facilitate communication and participation. As in family therapy, it may be necessary or beneficial to have two psychologists serving as group cofacilitators. Over a relatively short period of time, what started out as a gathering of separate and unfamiliar personalities can become a very cohesive and supportive group serving as a catalyst for change, with each group developing its own unique characteristics and dynamics.
In addition to the therapy format, other practicalities such as session frequency and duration also may vary. It is not uncommon to meet once per week for approximately one hour (typically at least 50 minutes, with a few minutes for the clinician to write a progress note or prepare for the next session). More severe and chronic conditions may require multiple consultations per week, and in cases involving psychiatric inpatient hospitalization, therapeutic contact likely occurs on a daily basis. Family and Group sessions may last longer than individual sessions to account for the increased number of people involved, perhaps running one and one half to two hours each session. Session duration may also be affected by session frequency; clients traveling long distances may attend sessions scheduled every other week but for longer periods of time. As a client improves and progresses through the stages of treatment, the frequency and/or duration of sessions may decrease, ultimately leading to an occasional and brief contact (perhaps by phone) for purposes of follow-up on treatment outcomes. Finally, the clinician’s daily work schedule and time management skills are also important factors that cannot be overlooked when considering session frequency, session duration, as well as total number of clients (or caseload) to schedule.
Stages of the Therapy Process
The progression and pace of therapy varies, but there are some general stages that most clinicians can easily recognize, with the acknowledgment that therapy is indeed a process involving the evolution of a professional relationship. The stages are not absolute and frequently blend together or coincide with one another, but it is helpful to describe them as separate to get a feel for the different points of emphasis and tasks that a clinician might engage in.
The first stage is the introductory stage, and it is in this stage of therapy that the client and clinician get to know each other and build rapport. Trust, reliability, and sensitivity are especially crucial in the early stages of therapy, and often help set the stage for making and maintaining changes in later stages.
The second stage is the goal-setting stage, and it is during this phase that the psychologist and client work together to define the problem and its context, which in turn often shapes the potential interventions used to move clients toward solutions. Thorough assessments and accurate diagnoses are critical, but it is also important to understand the client’s views on what is happening and why. This not only helps the clinician understand the presenting problems more clearly but also could help prevent wasted time and effort by recognizing potential misconceptions about therapy and discrepancies between therapist and client goals (Kottler, 2002; Miller & Rollnick, 2002).
The third stage of therapy is the intervention stage, when the client and clinician work cooperatively to develop and implement plans to change problematic thoughts, behaviors, and feelings. The psychologist often thinks of each intervention as a single-case design of sorts, comparing baseline levels of symptoms and daily functioning to post-intervention levels to determine if there has been any improvement and if the client has achieved his or her original goals.
The fourth stage is the evaluation stage, when the client and therapist review progress and potential roadblocks. New goals and targets for change can be developed as needed, including plans for long-term maintenance and the transition out of therapy. It may seem strange to think that practicing psychologists are in the business of putting themselves out of business as quickly as possible, but that is the essence of effective psychotherapy. Those students who are interested in pursuing a career in psychology to practice therapy should not worry, however, as there will always be plenty of work to be found as long as people experience stress, transition, and difficulty coping. In addition, a clinician who gains a reputation as someone who works quickly, competently, and ethically will likely develop a referral base that will keep him/her in very high demand.
The final stage of therapy is the termination and follow-up stage, and it bears emphasizing that the word “termination” should not be interpreted too literally. Even after a client has reached a level of comfort that allows him/her to discontinue regularly scheduled therapy sessions, it is still necessary and important to follow up with clients to assess maintenance of change. It may also be necessary to be available in cases of relapse or regression and for checkups. Many people need to engage and reengage in the therapy process before they actually achieve their therapy goals (e.g., Prochaska & DiClemente, 1984), which almost always include maintenance of progress in addition to initial symptomatic relief.
There are more theories or perspectives on psychotherapy than can be reasonably covered in an entire textbook, let alone a single chapter, but the primary perspectives that helped lay the foundation for others and those that are ascribed to most frequently by clinicians will be briefly reviewed. The interested reader should see Kottler (2002) for a very good, integrative overview and suggestions for additional readings, as well as excellent resources such as Lambert (2004), which provide more thorough discussions of the history and the empirical support base for the application of psychological principles in the form of psychotherapy.
Psychotherapy most likely formally began with the work of Sigmund Freud and the Psychodynamic perspective. This approach evolved with the contributions of colleagues such as Carl Jung, Alfred Adler, Erik Erikson, and so on; in its purest or most traditional form it is sometimes called psychoanalytic psychotherapy. This approach emphasizes a person’s past and development, as well as ways developmental crises and themes from the past keep repeating themselves in a person’s current relationships and functioning. It also focuses on all the needs and drives that constantly push and pull us, as well as varying levels of awareness or consciousness that often create conflict within us. These dynamic forces and conflicts are primarily where the perspective gets its name, although the approach has come a long way from the image that many people have of a patient lying on a leather couch free-associating while the psychodynamic therapist listens in an attentive but somewhat aloof or detached fashion, picking and choosing key moments to interject interpretive statements or provocative questions. Resistance and transference are key concepts in traditional psychodynamic models, and techniques designed to reduce resistance, promote transference onto the therapist, and promote insight and catharsis play a primary role. In its traditional form (perhaps daily sessions over the course of several years), psychodynamic therapy was often extremely time-consuming and expensive, and current psychodynamic practitioners have had to adapt their methods into a much more brief and efficient form (e.g., Levenson, 1995).
Behavioral therapy (e.g., Kazdin, 2001) was the next primary movement, spearheaded by B. F. Skinner and others, such as Joseph Wolpe. Also called behavior modification or just behavior therapy, this perspective grew directly out of the traditions of behavioral learning theory and the work of key figures such as Ivan Pavlov, John B. Watson, E. L. Thorndike, and others. Behavior therapy deemphasized the relatively ambiguous, poorly defined, and often empirically untestable elements of the therapy relationship that psychodynamic theorists had simply come to accept as necessary. In their place, behavioral psychologists put very specific and systematic applications based on classical and operant conditioning, such as systematic desensitization and token economies. To psychology students, the characteristics and strength of the therapy relationship often seem lost in the shuffle of behavior therapy. However, most behavioral therapists today would point out that a strong, cooperative coalition is a necessary (but not sufficient) condition of any behavioral intervention. Performing a thorough functional analysis of the antecedents and consequences of target behavior(s) to design interventions is critical, as is enlisting the support of others (e.g., parents, spouses, or other members of a professional treatment team) who may be in a position to observe the behavior in context on a regular basis. Behavioral assessment and evaluation of the effectiveness interventions are integral components of behavior therapy. This emphasis on objective measurement and quantifiable behavior has served practicing psychologists well, and prepared an entire generation of psychologists for elements of accountability and outcomes-based treatments demanded by today’s managed care (e.g., Spiegler & Guevremont, 1998).
Client-centered (also sometimes known as Person-centered or Humanistic) psychotherapy is another primary theoretical orientation. Historians often describe it as the “Third Force” in psychology because of its influence and evolution, which occurred after the rise of Psychodynamic and Behavioral perspectives. Founded by such pioneers as Carl Rogers and Abraham Maslow, client-centered therapy focuses on individual growth and maximum potentials, and on the support and understanding that many people lack in their daily lives to achieve those goals. Being in touch with feelings and honest communication are points of emphasis, and humanists highlight specific traits and behaviors of the clinician (e.g., empathy and active listening) that can be taught to and practiced by clients to help them realize their potential, be more accepting of the self and others, and generally feel more at peace with the world around them. Much has been written about the concept of unconditional positive regard as it relates to client-centered therapy, but this is a concept that students can easily misunderstand. It is not blindly accepting everything a person does as positive. Rather, it involves acknowledging unconditionally the value of all human beings, especially when they make mistakes or poor choices, such that clients can see and learn firsthand the qualities of patience, support, acceptance, and even forgiveness that they may need to apply in their own lives.
Cognitive therapy is another popular perspective, developed by key figures such as Aaron Beck, Albert Ellis, and Albert Bandura. Beck and Ellis both developed methods of specifically dealing with maladaptive thought patterns that contribute to emotional distress and other dysfunctional behaviors (e.g., Beck & Freeman, 1990). Cognitive therapy identifies, challenges, and replaces these dysfunctional and illogical self-statements with more realistic statements that provide enough psychological breathing room for a client to try something different. This process takes practice and patience, and Beck and Ellis had very different methods of achieving similar goals. Ellis called his therapy rational emotive therapy (RET) or rational emotive behavior therapy (REBT). Some critics saw him as being very confrontational and at times even sarcastic in therapy demonstrations, yet he was still very effective and charismatic in his own way.
Psychologists often discuss the contributions of Bandura and his descriptions of social learning theory in the context of behavior therapy, but his inclusion of concepts such as modeling and vicarious learning as important avenues for behavior change help illustrate the natural blending of cognitive and behavioral perspectives. Many practitioners today would, in fact, describe themselves as Cognitive-Behavioral to reflect this ideal marriage of concepts and methods encompassing internal and external behaviors that are all valid targets for intervention.
The final perspective reviewed here is the Systemic perspective, and in reality it is actually a collection of very different theories. Because they all focus on patterns, symptoms, and dynamics of groups or systems, they are often treated as one broad category and discussed in the context of family or couples therapy and sometimes group therapy (e.g., Goldenberg & Goldenberg, 2002). Jay Haley, Salvador Minuchin, Virginia Satir, and Murray Bowen are highly recognizable names representing different systemic perspectives (strategic, structural, experiential, and transgenerational systems theories, respectively). Identifying symptoms or labeling problems within an individual, sometimes called scapegoating, is generally avoided because it puts too much emphasis on linear cause-effect models of dysfunction that are too simplistic to adequately account for the full spectrum of difficulties a family, a couple, or another meaningful group may be experiencing. Instead, the focus is on the roles, boundaries, and communication patterns between individual members of the system in question. The way the system responds to stress and change is also important, and feedback mechanisms and ways of maintaining homeostasis, or the status quo, are identified and modified as needed to help the client system adapt and evolve in a healthier manner.
There are entire training programs devoted to each primary therapeutic orientation and its variations. Many clinicians will develop an eclectic or integrative approach out of either experience or necessity (e.g., Kottler, 2002), even though they might identify easily with one or two specific orientations. One perspective is not superior to another, in part because many of them do essentially the same kinds of things even though the concepts have different labels and the techniques might vary. Additionally, there are qualities such as therapist personality and other nonspecific factors that play a key role in the effectiveness of psychotherapy, regardless of orientation and technique (Miller & Rollnick, 2002). However, that is not to say that theory is unimportant, because applying techniques without understanding and utilizing theory can be a step into uncharted and potentially dangerous waters. Understanding a theoretical orientation not only helps a clinician understand when to use a technique, and why, but also provides the tools necessary to develop new techniques and interventions uniquely suited to the client.
Because psychologists work with people who are in distress and are at a point where they may be least functional and most vulnerable, it is critical to have a clear set of professional guidelines designed to protect the public, the profession, and the professional. Human relationships involve sensitive issues and complex dynamics, and the therapy relationship is no exception. The American Psychological Association (APA) has a code of ethics that all psychologists should follow, and the code contains five general principles serving as guidelines that psychologists should aspire toward, as well as several more specific standards that deal specifically with the do’s and don’ts of providing psychotherapy and can serve as a basis for disciplinary action if violated (APA, 2002).
The five principles are beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity. The overarching theme of all five principles as they pertain to therapy is that the best interests of the client must be valued above all else, and psychologists should take proactive steps to ensure client rights and protections. There are 10 ethical standards, each one broken down into more specific elements, covering everything from conducting psychological research to resolving ethical conflicts within the profession. Several standards (e.g., Standard 4, which deals with privacy and confidentiality; and Standard 6, which discusses record keeping and fees) help clarify and define important elements of the practice of therapy, but the 10th and final standard deals specifically with the therapy relationship. The 10th standard clarifies appropriate boundaries of the professional therapy relationship, discusses the circumstances under which therapy should begin and end, as well as certain caveats when working with special populations (e.g., children) or in various modalities (i.e., individual, group, or family or couples therapy). The development and evolution of the APA code of ethics is a major step forward and an advantage for currently practicing psychologists. Incorporating this code into their day-to-day activities can help prevent serious problems and ethical dilemmas that even the most skilled clinicians had to deal with in the not-so-distant history of psychology (e.g., Kottler & Carlson, 2003b).
Psychotherapy can be extremely powerful and effective, and yet extremely elusive and difficult to deconstruct into its constituent elements. A career as a clinical or counseling psychologist providing therapy services in various settings can be extremely stimulating and rewarding, but also humbling and at times even mystifying. Part of the complexity can be attributed to the variety of perspectives and modes of service delivery. Despite these complications, the fact remains that combining the support and expertise of a competent psychologist, along with client characteristics such as positive expectations for change and symptom relief, has reliably produced a profound effect for many people and for many years. A practicing psychologist must be attentive, observant, open-minded, and possess good listening and communication skills to be effective. Being able to think critically and having the training and discipline to be systematic and objective are also prerequisite abilities. The process is a unique journey with each new client, which means that clinicians must also be flexible, adaptive, and practical. The interpersonal dynamics of a therapy relationship are complex, but using a theory to guide their actions and reasoning helps psychologists meld practice with science. Using the APA code of ethics to guide their behavior helps psychologists maintain appropriate boundaries, preserve professional integrity, and protect clients.