Module 70 – Introduction to Therapy, and Psychodynamic and Humanistic Therapies

The long history of efforts to treat psychological disorders has included a bewildering mix of harsh and gentle methods. Well-meaning individuals have cut holes in people’s heads and restrained, bled, or “beat the devil” out of them. But they also have given warm baths and massages and placed people in sunny, serene environments. They have administered drugs and electric shocks. And they have talked with their patients about childhood experiences, current feelings, and maladaptive thoughts and behaviors.

Reformers Philippe Pinel and Dorothea Dix pushed for gentler, more humane treatments and for constructing mental hospitals. Since the 1950s, the introduction of effective drug therapies and community-based treatment programs have emptied most of those hospitals.

Introduction to Therapy

Today’s therapies can be classified into two main categories. In psychotherapy, a trained therapist uses psychological techniques to assist someone seeking to overcome difficulties or achieve personal growth. Biomedical therapy offers medication or other biological treatments.

Many therapists combine techniques. Jamison received psychotherapy in her meetings with her psychiatrist, and she took medications to control her wild mood swings. Many psychotherapists describe themselves as taking an eclectic approach, using a blend of psychotherapies. Like Jamison, many patients also can receive psychotherapy combined with medication.

Let’s look first at the psychotherapeutic “talk therapies.” Among the dozens of types of psychotherapy, we will look at the most influential. Each is built on one or more of psychology’s major theories: psychodynamic, humanistic, behavioral, and cognitive. Most of these techniques can be used one-on-one or in groups. We’ll explore psychodynamic and humanistic therapies in this module, and behavior, cognitive, and group therapies in Module 71.

Psychoanalysis and Psychodynamic Therapy

Sigmund Freud’s psychoanalysis was the first of the psychological therapies. Few clinicians today practice therapy as Freud did, but his work deserves discussion as part of the foundation for treating psychological disorders.

Goals

Psychoanalytic theory presumes that healthier, less anxious living becomes possible when people release the energy they had previously devoted to id-ego-superego conflicts (see Module 55). Freud assumed that we do not fully know ourselves. There are threatening things that we seem to want not to know - that we disavow or deny. “We can have loving feelings and hateful feelings toward the same person,” notes Jonathan Shedler (2009), and “we can desire something and also fear it.”

Freud’s therapy aimed to bring patients’ repressed or disowned feelings into conscious awareness. By helping them reclaim their unconscious thoughts and feelings and giving them insight into the origins of their disorders, he aimed to help them reduce growth-impeding inner conflicts.

Techniques Psychoanalysis is historical reconstruction. Psychoanalytic theory emphasizes the formative power of childhood experiences and their ability to mold the adult. Thus, it aims to unearth one’s past in hope of unmasking the present. After discarding hypnosis as an unreliable excavator, Freud turned to free association.

Imagine yourself as a patient using free association. First, you relax, perhaps by lying on a couch. As the psychoanalyst sits out of your line of vision, you say aloud whatever comes to mind. At one moment, you’re relating a childhood memory. At another, you’re describing a dream or recent experience. It sounds easy, but soon you notice how often you edit your thoughts as you speak. You pause for a second before uttering an embarrassing thought. You omit what seems trivial, irrelevant, or shameful. Sometimes your mind goes blank or you find yourself unable to remember important details. You may joke or change the subject to something less threatening.

To the analyst, these mental blocks indicate resistance. They hint that anxiety lurks and you are defending against sensitive material. The analyst will note your resistances and then provide insight into their meaning. If offered at the right moment, this interpretation - of, say, your not wanting to talk about your mother - may illuminate the underlying wishes, feelings, and conflicts you are avoiding. The analyst may also offer an explanation of how this resistance fits with other pieces of your psychological puzzle, including those based on analysis of your dream content.

Over many such sessions, your relationship patterns surface in your interaction with your therapist. You may find yourself experiencing strong positive or negative feelings for your analyst. The analyst may suggest you are transferring feelings, such as dependency or mingled love and anger, that you experienced in earlier relationships with family members or other important people. By exposing such feelings, you may gain insight into your current relationships.

Relatively few U.S. therapists now offer traditional psychoanalysis. Much of its underlying theory is not supported by scientific research (Module 56). Analysts’ interpretations cannot be proven or disproven. And psychoanalysis takes considerable time and money, often years of several sessions per week. Some of these problems have been addressed in the modern psychodynamic perspective that has evolved from psychoanalysis.

Psychodynamic Therapy Therapists who use psychodynamic therapy techniques don’t talk much about id, ego, and superego. Instead they try to help people understand their current symptoms. They focus on themes across important relationships, including childhood experiences and the therapist relationship. Rather than lying on a couch, out of the therapist’s line of vision, patients meet with their therapist face to face. These meetings take place once or twice a week (rather than several times per week), and often for only a few weeks or months (rather than several years).

In these meetings, patients explore and gain perspective into defended-against thoughts and feelings. Therapist David Shapiro (1999, p. 8) illustrates with the case of a young man who had told women that he loved them, when knowing well that he didn’t. They expected it, so he said it. But later with his wife, who wishes he would say that he loves her, he finds he “cannot” do that - “I don’t know why, but I can’t.”

Therapist: Do you mean, then, that if you could, you would like to?

Patient: Well, I don’t know.... Maybe I can’t say it because I’m not sure it’s true. Maybe I don’t love her.

Further interactions reveal that he can’t express real love because it would feel “mushy” and “soft” and therefore unmanly. He is “in conflict with himself, and he is cut off from the nature of that conflict.” Shapiro noted that with such patients, who are estranged from themselves, therapists using psychodynamic techniques “are in a position to introduce them to themselves. We can restore their awareness of their own wishes and feelings, and their awareness, as well, of their reactions against those wishes and feelings.”

Psychodynamic therapies may also help reveal past relationship troubles as the origin of current difficulties. Jonathan Shedler (2010a) recalls his patient Jeffrey’s complaints of difficulty getting along with his colleagues and wife, who saw him as hypercritical. Jeffrey then “began responding to me as if I were an unpredictable, angry adversary.” Shedler seized this opportunity to help Jeffrey recognize the relationship pattern, and its roots in the attacks and humiliation he experienced from his alcohol-abusing father-and to work through and let go of this defensive responding to people.

Interpersonal psychotherapy, a brief (12-to 16-session) variation of psychodynamic therapy, has effectively treated depression (Cuijpers, 2011). Although interpersonal psychotherapy aims to help people gain insight into the roots of their difficulties, its goal is symptom relief in the here and now. Rather than focusing mostly on undoing past hurts and offering interpretations, the therapist concentrates primarily on current relationships and on helping people improve their relationship skills.

The case of Anna, a 34-year-old married professional, illustrates these goals. Five months after receiving a promotion, with accompanying increased responsibilities and longer hours, Anna experienced tensions with her husband over his wish for a second child. She began feeling depressed, had trouble sleeping, became irritable, and was gaining weight. A therapist using psychodynamic techniques might have helped Anna gain insight into her angry impulses and her defenses against anger. A therapist applying interpersonal techniques would concur but would also engage her thinking on more immediate issues-how she could balance work and home, resolve the dispute with her husband, and express her emotions more effectively (Markowitz et al., 1998).

Humanistic Therapies

The humanistic perspective (Module 57) has emphasized people’s inherent potential for self-fulfillment. Like psychodynamic therapies, humanistic therapies have attempted to reduce growth-impeding inner conflicts by providing clients with new insights. Indeed, the psychodynamic and humanistic therapies are often referred to as insight therapies. But humanistic therapy differs from psychoanalytic therapy in many other ways:

• Humanistic therapy aims to boost people’s self-fulfillment by helping them grow in self-awareness and self-acceptance.
• Promoting this growth, not curing illness, is the focus of therapy. Thus, those in therapy became “clients” or just “persons” rather than “patients” (a change many other therapists have adopted).
• The path to growth is taking immediate responsibility for one’s feelings and actions, rather than uncovering hidden determinants.
• Conscious thoughts are more important than the unconscious.
• The present and future are more important than the past. The goal is to explore feelings as they occur, rather than achieve insights into the childhood origins of the feelings.

Carl Rogers (1902-1987) developed the widely used humanistic technique he called client-centered therapy, which focuses on the person’s conscious self-perceptions. In this nondirective therapy, the therapist listens, without judging or interpreting, and seeks to refrain from directing the client toward certain insights.

Believing that most people possess the resources for growth, Rogers (1961, 1980) encouraged therapists to exhibit acceptance, genuineness, and empathy. When therapists enable their clients to feel unconditionally accepted, when they drop their façades and genuinely express their true feelings, and when they empathically sense and reflect their clients’ feelings, the clients may deepen their self-understanding and self-acceptance (Hill & Nakayama, 2000). As Rogers (1980, p. 10) explained,

Hearing has consequences. When I truly hear a person and the meanings that are important to him at that moment, hearing not simply his words, but him, and when I let him know that I have heard his own private personal meanings, many things happen. There is first of all a grateful look. He feels released. He wants to tell me more about his world. He surges forth in a new sense of freedom. He becomes more open to the process of change.

I have often noticed that the more deeply I hear the meanings of the person, the more there is that happens. Almost always, when a person realizes he has been deeply heard, his eyes moisten. I think in some real sense he is weeping for joy. It is as though he were saying, “Thank God, somebody heard me. Someone knows what it’s like to be me.”

“Hearing” refers to Rogers’ technique of active listening - echoing, restating, and seeking clarification of what the person expresses (verbally or nonverbally) and acknowledging the expressed feelings. Active listening is now an accepted part of therapeutic counseling practices in many high schools, colleges, and clinics. The counselor listens attentively and interrupts only to restate and confirm feelings, to accept what is being expressed, or to seek clarification. The following brief excerpt between Rogers and a male client illustrates how he sought to provide a psychological mirror that would help clients see themselves more clearly.

Can a therapist be a perfect mirror, without selecting and interpreting what is reflected? Rogers conceded that one cannot be totally nondirective. Nevertheless, he believed that the therapist’s most important contribution is to accept and understand the client. Given a nonjudgmental, grace-filled environment that provides unconditional positive regard, people may accept even their worst traits and feel valued and whole.

If you want to listen more actively in your own relationships, three Rogerian hints may help:

1. Paraphrase. Rather than saying “I know how you feel,” check your understanding by summarizing the person’s words in your own words.
2. Invite clarification. “What might be an example of that?” may encourage the person to say more.
3. Reflect feelings. “It sounds frustrating” might mirror what you’re sensing from the person’s body language and intensity.