Psychological therapy or “psychotherapy” is the name for ‘talking’ treatment designed to alleviate emotional problems or disability, by treating a person’s psychological conflict or distress. It is to the mind what physiotherapy (termed “physical therapy” in the USA) is to the physical body.
A brief overview of types of psychotherapy and their clinical settings:
Psychological therapy or “psychotherapy” is the name for ‘talking’ treatment designed to alleviate emotional problems or disability, by treating a person’s psychological conflict or distress. It is to the mind what physiotherapy (termed “physical therapy” in the USA) is to the physical body. There are a very large number of schools of psychotherapy, each with their own training schemes. Psychotherapeutic treatments are delivered by practitioners from many professional backgrounds; for example psychology, psychiatry, nursing, and other allied health professions. Specific training enables people to qualify as specialist adult or child psychotherapists, and they may deliver treatments to patients in some NHS settings in the UK. Talking therapies can be powerful, for good and ill. They use time and resources and have to be compared to doing nothing (the ‘test of time’, during which many conditions get better naturally) and other treatments. Research can be done even though a personal relationship between two unique individuals sits at the heart of the therapeutic encounter.
The earliest form of psychotherapy was psychoanalysis, developed in the late nineteenth and early twentieth centuries by Sigmund Freud. Adaptations of Freudian theory by other analysts, such as Carl Jung and Melanie Klein, subsequently modified psychoanalytic theory and its practice. Jungian psychology and Kleinian theory was developed out of clinical experience with patients suffering from psychoses as well as the neuroses in which Freud tended to specialise. Classical psychoanalytic therapy involves frequent sessions, eg daily or three times weekly, over a period of years. This is not usually available on the NHS, but may be offered through private practice in the UK.
Psychodynamic psychotherapy is a modern derivative of psychoanalysis, and continues to be practised in NHS and private healthcare settings. In the NHS psychodynamic therapy is usually time-limited and may be quite brief in duration, eg measured in weeks or months rather than years. Again, there are many different schools of psychodynamic psychotherapy, but they all draw upon aspects of psychoanalytic theory, where there is an emphasis on the relevance of the unconscious and on the importance of childhood experiences in shaping human motivation and behaviours. These are manifest in the therapeutic relationship and can be worked with in the transference between patient and therapist. All of these forms of therapy are sometimes grouped together and referred to by the shorthand term exploratory therapies.
Another major strand of psychological therapy is behaviour therapy, which developed from the mid twentieth century. This focuses explicitly on human behaviours and draws upon experimental psychology: the late nineteenth century discoveries of classical conditioning by Ivan Pavlov, B.F. Skinner’s later development of learning theory known as operant conditioning, and, in the 1970s, Alfred Bandura’s application to human behaviours in the form of social learning theory.
Cognitive behaviour therapy, usually abbreviated to CBT, is the most common form of psychotherapy in today’s NHS. It is based on the work of Aaron Beck, a psychiatrist and psychoanalyst who developed a theory describing how thoughts, feelings and behaviours influence each other. CBT focuses on challenging and changing irrational beliefs that are thought to drive problems with mood and behaviours. As with the psychodynamic therapies, various schools of cognitive behaviour therapy exist, and these are sometimes loosely referred to as the prescriptive therapies, to contrast with the so-called exploratory therapies. Neither of these labels is very satisfactory, since therapies based on cognitive psychology aim to explore human motivation and behaviour as much as the psychodynamic therapies do, albeit using differing methods and with differing emphases.
In present day clinical practice, as opposed to research or specialist training settings, these therapeutic modalities are frequently not delivered in their pure “textbook” form. Instead, a skilled and experienced therapist can draw upon a number of theoretical models to deliver an individually tailored approach to suit a patient’s problems and her/his capacity to engage in the therapy and work with the material. This kind of approach is commonly called eclectic therapy, and is often used by NHS clinical psychologists. A related but significantly different way of working therapeutically is to employ an integrative approach, where elements of certain models of therapy are intentionally combined in a recognised manner that can be manualised and reliably replicated for clinical supervision and research purposes. Some examples of integrative therapies are cognitive analytic therapy (CAT), dialectical behaviour therapy (DBT), psychodynamic-interpersonal therapy (PIT).
Counselling is also a form of psychological therapy, and, as with those modalities grouped together as the psychotherapies, it takes many forms, using different approaches and sometimes designed to address specific issues, eg bereavement. The basis of all counselling is a personal contract between patient (usually referred to as the client) and therapist (counsellor), to meet regularly and to address whatever concerns have been brought to the therapeutic space. Many forms of counselling owe their origins to the work of Carl Rogers, who developed his ideas of client-centred therapy in the 1940s, as an alternative to the traditional psychoanalytic emphasis on interpretation of underlying conflicts. He described three core conditions of empathy, congruence and unconditional positive regard, as the basis of his therapeutic approach.
Systemic psychotherapy is another strand of psychological therapy. It is based upon systems theory, and again there are a number of different schools under this broad umbrella. The emphasis here moves from the individual to the wider system, and looks at how problems can be addressed by making changes in the relationships and behaviours that an individual engages with, rather than the focus remaining upon the person who has presented with a problem. The various schools of family therapy have in common a systemic understanding of human relationships, as does couples therapy. Family therapy in NHS settings is most usually found in the psychiatric setting of Child And Adolescent Mental Health Services (CAMHS), eg in eating disorders services. Its schools include structural family therapy, developed by Salvador Minuchin, strategic family therapy, and narrative family therapy.
Group therapy treats the individual using a group setting in place of an individual patient/client and therapist dyad. There are, again, many types of group psychotherapy, many of which are provided in the NHS, where they may be short-term or longer-term (meaning up to two years usually).
Group analysis traces its origins to the work of psychoanalysts like Michael Foulkes, and also Wilfred Bion, who worked with traumatised World War II veterans as part of the Northfield Experiments, and later at the Tavistock Clinic. Bion’s work was notable in developing the idea of therapy “by the group,” a notion distinct from the treatment of individuals who happened to be treated together in a group. He described three types of dysfunctional groups, which he termed basic assumption groups. Any interpretations made by the group therapist are focused on how the whole group is functioning, rather than on the individuals within it.
Other types of group therapy include the many different types of groups that put together individuals who share a common problem, such as alcohol or other substance dependence, or bereavement, or depression, so that members can give peer support to each other and learn strategies for managing their problems from other group members. These groups are described as having a focus but included in this category are many diverse types of group and therapeutic method.
All psychological therapies involve some form of combination of acceptance and validation with challenge and exploration. Difficulties may arise if ‘affirmation’ is taken literally to imply that no form of challenge or exploration of the presenting issues or problems is to be used in therapy. (See FAQ: What is Conversion Therapy?)