Psychotherapy
Explained
What is psychotherapy?
Psychotherapy is essentially talking
therapy for emotional, behavioural, relationship or personality
problems. It involves a relationship with a therapist in which
those with problems can explore the nature of their difficulties
and possibly work towards change. There are many approaches
to psychotherapy and it is an area which continues to develop.
It may involve individual clients, groups, families or couples.
This information sheet describes some of the broad approaches
to psychotherapy but is not exhaustive.
What is the difference between psychotherapy and counselling?
The two terms are often used interchangeably
and have many similarities. The Irish Association for Counselling
and Psychotherapy describes counselling as an opportunity to
“discover the reason for negative feelings and to work
out ways of dealing with them” and “to express feelings
such as fear, suspicion and jealousy in a safe, supportive environment.”
Psychotherapists may be more highly trained than counsellors.
Counselling may more often occur in non-medical settings such
as schools. Psychotherapy may look at unconscious conflicts
and may be a more long term undertaking than counselling. Many
regard counselling as supportive psychotherapy.
Cognitive Behavioural Therapy
Cognitive therapy was developed by
Aaron Beck from his observation that many depressed people had
recognisable patterns of negative thinking such as feelings
of low self worth and personal failure. Behavioural therapy
involves modifying or stopping a particular behaviour. As many
psychological problems are complex, taking both behaviour and
cognitions into consideration can lead to greater success in
their resolution.
Cognitive
behavioural therapy aims to identify and change faulty patterns
of thinking or irrational beliefs that cause distress. The therapist
explores the relationship between thoughts and symptoms. In
tandem with this he or she attempts to alter maladaptive behaviour.
An example is a young man who, because he feels anxious and
fears scrutiny in public, withdraws and eventually avoids social
situations. The client and therapist work together to analyse
the cognitions that cause distress and lead to the avoidant
behaviour. Gradually they work towards altering the behaviour
and achieving a return to social situations. Similarly, in the
treatment of eating disorders, the therapy aims to alter thoughts
of distorted body image and the resulting extreme behaviour
to maintain low body weight.
Cognitive
behavioural therapy involves motivation. The therapist may ask
a client to do homework such as keep a diary of situations that
cause anxiety and to practise techniques learnt during therapy
sessions.
Family Therapy
People’s problems will often
impact on their relationships with those close to them. Likewise,
difficulties within an individual’s family can have a
negative impact on a person with a mental illness.
Family therapy aims to enhance communication
between family members and to cultivate the independence of
the individual with the family. It avoids apportioning blame.
In contrast to psychodynamic psychotherapy it tends to focus
on the present rather than the past and to promote action towards
change so that the distress of the family can be alleviated.
Family therapy may involve entire families with parents and
their young or adult children. It may involve some members of
a family or couples. Usually family therapists work in pairs
so that one therapist is actively involved in the sessions and
another co-therapist observes the interactions and communication
occurring in the session.
Group Therapy
The first therapeutic use of groups
can be traced back to the early 1900’s when an American
doctor arranged for groups of tuberculosis sufferers who had
been rejected for admission to sanatoria, to meet for education
and support. Subsequently their morale and physical well being
improved.
In group
therapy approximately 6 to 10 people meet with a therapist.
Some groups are formed with people with similar problems. Other
groups consist of individuals with a variety of difficulties.
The approach taken by the therapist can be psychodynamic or
operate on cognitive or behavioural lines. Group therapy can
offer individuals the support of others and the awareness that
others also suffer. Individuals influence groups and more particularly
groups influence individuals. In group therapy the therapist
directs the activities of the group in the way they offer alternative
behaviours and feedback to other group members. Interaction
between group members can be explored in the ways it may reflect
maladaptive relating styles or ways in which healthier styles
of relating can be practised.
Central to
group therapy is the commitment that individual members undertake
not to disclose anything that arises within the group outside
the group.
Psychodynamic Psychotherapy
The psychodynamic approach to psychotherapy
is one in which clients are helped understand their difficulties
in the context of their backgrounds, childhoods and development.
Central to psychodynamic psychotherapy is the relationship between
the therapist and client. The client may use patterns of relating
with the therapist that were present in significant past relationships.
The client arouses particular feelings in the therapist. Both
of these are studied by the therapist and can help investigate
the client’s problems. Psychodynamic psychotherapy stems
from the work of Sigmund Freud. To read more about Freud
click here.
What actually happens?
Most forms of psychotherapy involve
weekly sessions. After a therapist has done an individual assessment
he or she should be able to outline a treatment plan to a client
and within a few weeks be able to predict how long therapy is
likely to last. Some therapists use a variety of psychotherapeutic
techniques rather than focussing on one approach. The type of
problems an individual is experiencing determines the most appropriate
type of therapy and the duration.
For some, treatment is relatively
short-lived and lasts for 6 to 16 sessions. Others may remain
in psychotherapy for years.
Individual sessions usually last 50 minutes and take
place at the same time and place each week.
Some people may receive other treatments
in addition to psychotherapy, e.g. a person who is depressed
may be receiving anti-depressant medication from a general practitioner
or psychiatrist. The therapist does not get involved in this.
Psychotherapists are usually psychologists,
doctors, nurses, social workers or others who have attained
formal qualifications in psychotherapy.
Where can psychotherapy be received?
Unfortunately public psychotherapy
services are underdeveloped in this country and many people
receiving psychotherapy are paying for it themselves. It is
important that the person practising psychotherapy is qualified
to do so. Advice from a general practitioner can be sought about
psychotherapists practicing locally. The area psychiatric service
may be another way to source psychotherapy but availability
varies widely around Ireland.
Useful website addresses
Irish Association for Counselling
and Psychotherapy www.irish-counselling.ie
Psychological Society of Ireland
www.psihq.ie
Irish Council of Psychotherapy www.icpty.ie
Sigmund Freud
Psychodynamic psychotherapy stems
from the work of Sigmund Freud, who in the late nineteenth century,
discovered psychoanalysis. He became interested in the phenomenon
of hysteria, that is, the expression of psychological conflicts
and distress in physical terms. He studied this phenomenon while
on a scholarship in Paris, and when he returned home to Vienna,
started to see patients with hysterical symptoms (symptoms that
could not be explained by physical illness), initially by hypnotising
them. He found that when his patients were under hypnosis, they
began to speak freely about themselves, often about matters
that had not theretofore been accessible to consciousness. Freud
soon realised that the essential element in psychoanalysis was
speech, rather than hypnosis. When the person speaks freely,
without censorship, the unconscious emerges. The unconscious
for Freud, was what produced symptoms, slips of the tongue,
dreams and logical inconsistencies in the patient’s narrative.
The focus of psychoanalysis is therefore the unconscious and
its medium is speech.
Freud
found, through his clinical practice that the unconscious is
structured linguistically – that is, that symptoms have
a symbolic function. This is, of course, what makes us human;
we interact with the world in a symbolic way and our relationships
with others have a symbolic structure. The unconscious, therefore,
is not equivalent to animal instincts although it is often misunderstood
in this way. In the real Freudian sense, the unconscious is
not an entity or a location, but rather (and this is a simplification)
it is the subtext of speech which emerges only when we speak.
While the unconscious is implicated in all social relationships,
it is explicitly addressed in psychoanalysis. In psychoanalysis
the only rule is that of free association – the person
is instructed to speak about literally whatever comes into his
or her head, without censorship. Free association means that
the unconscious is more likely to emerge in speech – the
very fact that analysis is radically different from the usual
‘one-to-one’ relationship that characterises friendships,
business relationships, counselling, doctor-patient relationships
and so on, means that what is hidden can emerge. This is one
of the reasons that a couch is used in psychoanalysis. When
the client is lying on the couch, it is much harder to use defences,
to ‘interact’ with the analyst as one would with
a doctor, or with a counsellor; the client has only his/her
own speech to fall back on. The enterprise of psychoanalysis
is about putting into words what cannot be, or has not already
been, articulated. Symptoms are a way of saying something that
cannot be put into words; although psychoanalysis comes with
no guarantee of cure, it can allow unconscious ideas to be articulated
rather than being ‘acted out’ in the form of a symptom.
The position
of the analyst is therefore quite different from the popular
fantasy of a ‘therapist’ – the latter usually
involves someone with cast and intimate knowledge about the
patient, and who can tell the patient how to live his or her
life. The analyst, by contrast, has to maintain a position of
ignorance so that the client can come up with his/her own ‘answers’.
The analyst’s role is to facilitate the emergence of the
unconscious in the client’s discourse. If the analyst
assumes that they know all about the client, there is a risk
that the unconscious material will not emerge. The aim is not
so much for the client to ‘learn’ all about themselves,
or to gain ‘insight’, but to be less governed by
the unconscious repetition of pattern, relationships and so
on. In a good analysis, much of the material that has emerged
is in fact forgotten.
Psychoanalysis is in many ways radically
different from many of the popular psychotherapies available
nowadays – not least because its emphasis is not on ‘healing’
or wholeness, or even knowledge, but because it is concerned
with the inadequacies of language, and the failure of language
to symbolise experience. It might be said that, rather than
being a treatment for mental illness, it is an enterprise undertaken
in order to take responsibility for ones own life. This is not
a popular idea in a society where it is assumed that there is
an answer to every demand, and a cause and a cure for every
ill.
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