Schools and Approaches to Psychotherapy
Summary and Keywords
There are many approaches to psychotherapy, commonly called “schools” or “theories.” These schools range from psychoanalytic, to variations of insight- and conflict-based approaches, through behavioral and cognitive behavioral approaches, to humanistic/existential approaches, and finally to integrative and eclectic approaches. Different and seemingly new approaches typically have been informed by older and more established ones. For instance, cognitive behavioral therapy (CBT), one of the more widely used approaches, evolved from traditional behavior therapy but has become sufficiently distinct by adding its own complex variations so as functionally to represent an approach of its own.
New approaches abound both in number and in complexity. Modern clinicians have had to become increasingly widely read and creative in trying to understand the ways in which patients may be helped. The sheer number of approaches, which has climbed into the hundreds, has challenged the field to find ways of ensuring that the treatments presented are effective. The advent of Evidence Based Practices (EBP) throughout the healthcare fields has placed the responsibility on those who advocate for particular types of treatment scientifically to demonstrate their efficacy and effectiveness. While this movement has brought standards to the field and has offered some assurance that psychotherapy is usually helpful, there remains much debate about whether the many different schools produce different results from one another. The debate about how best to optimize positive effects of psychotherapy continues, and there remain many questions to be asked of psychotherapy theories and of research on these approaches.
Keywords: psychotherapy theories, schools of psychotherapy, history of psychotherapy, approaches to psychotherapy, behavior therapy, psychodynamic psychotherapy, cognitive psychotherapies, humanistic psychotherapies, integrative psychotherapies
The Beginnings of Psychotherapy Schools
Psychotherapy as a behavioral health intervention arose in the early 20th century, from a theoretical foundation stemming from both philosophy and empirical medicine. Its inception was groundbreaking and forced a shift in the prevailing medical paradigm. Since then, five paradigm transitions or “waves” have occurred (e.g., Öst, 2008), each precipitated by a new view of change that challenged the ones that came before. Thus, psychoanalysis, the first formal psychotherapy or “school,” challenged the prevailing medical/biological perspective and, in turn, was challenged by behavior therapy, the second school to evolve. Behavior therapies, in turn, were challenged by the humanistic/existential school, which in turn was challenged by the emergence of the cognitive/cognitive behavioral school. The fifth and most recent transition is urging the field toward integration among the other schools.
Sigmund Freud developed psychoanalysis. He posed its value on the basis of case analyses (Norcross, VandenBos, & Freedheim, 2011). Theoretical and technical arguments about technique and value arose and persisted among Freud and his students, resulting in a vast number of alternatives to Freud’s form of psychoanalysis and psychodynamic therapy. Gradually, additional variations emerged that fractured psychoanalysis and moved some to turn to a view different than that of Freud.
In the absence of an objective behavioral science in this early period, the value of one approach over another hinged on who could make the most cogent and persuasive rational arguments. The subjectivity inherent in these analyses resulted in the development of different models of treatment (Consoli, Beutler, & Bongar, 2017; Norcross et al., 2011).
In the mid-20th century, science became acknowledged as an arbitrator of disagreements and introduced empirical research to psychotherapy. Scientific influence was first noted with an accumulation of studies about therapist and patient effects on outcomes, and later as a concentrated assessment of the role of different theoretical models and interventions in evoking measured change. Since the 1990s, the many approaches to psychotherapy have acceded to accepting strict rules of evidence by which to identify treatments whose efficacy warrants the support of public funds (Norcross, Beutler, & Levant, 2006). Today, major behavioral health groups have composed lists of empirically supported treatments in order to inform the public about what brands of psychotherapy can be scientifically shown to be effective (Castonguay & Beutler, 2006; Consoli et al., 2017; Norcross, 2011, 2014). These lists are composed of psychotherapy brands that have accumulated at least two randomized studies, each of which has demonstrated that the particular treatment being touted is more effective in treating a particular patient group than either an untreated group of similar patients or a group of those receiving a placebo treatment (Beutler, 2009). The brand names of the treatments that earned the right to be called “empirically supported” are associated with one or another theory of change that has characterized the five transition periods since the time of Freud.
Contemporary Views of Schools and Approaches
In spite of the relatively finite lists of effective treatments or schools, which usually contain fewer than 200 empirically defined approaches, there continues to be a larger number of psychotherapy schools that have eschewed scientific evidence as the best criteria of their value. This latter group may number as many as 1000 major and minor varieties of psychotherapy (Beutler, 1991).
Many fledgling clinicians encounter challenges when reconciling the differences among the many schools, not to mention the differences in the ways that they are validated. Implicitly, the different theories each view their own approach as more effective than others, leading to many overt arguments over the “best” theoretical model to utilize. Competition among different theoretical orientations has an extensive history, but if one can set aside this competition for a moment, we can learn much from the unique contributions of each of the schools making up the waves of historical evolution (Consoli et al., 2017).
The contemporary psychotherapies occupying the five waves of the field’s evolution can be distinguished from one another by the particular change mechanisms proposed, the methods used to effect change, and the explanatory constructs evoked to explain their effects. For instance, historically (Norcross et al., 2011), the psychoanalytic and psychodynamic approaches pursue and underline the roles of hidden motives and internal conflicts in the course of psychological symptoms (Karon & Widener, 1995).
Behavioral approaches, in contrast, alert us to the environmental factors by which one’s behavior is shaped according to perceived consequences and rewards in the external environment (Consoli et al., 2017).
The humanistic approaches reinforce the belief that psychological disturbances are the products of an individual’s internalization of attitudes, evaluations, and criticisms from early experience with significant others (Krug, 2017).
Cognitive-behavioral schools (e.g., Beck, 2006; Meichenbaum, 1995) view psychological symptoms as a product of core cognitions, which may include dysfunctional beliefs that then contaminate and distort one’s social interactions and internal perceptions.
Norcross (2014) notes that the approaches that are clustered under integrative therapies are even more varied than those clustered in the other categories. The approaches in this integrative group agree substantially on two principles: a) all therapies work with some people, but not with all; and b) if the treatment can be modified or tailored to fit the unique patient, the benefits of the psychotherapy can be expected to increase.
In the following paragraphs, we will describe the nuances that differentiate the various approaches, with the intent of providing a more coherent understanding of the many conditions that can evoke change and of fostering an increased dialogue about the unique contributions of each of the schools of psychotherapy.
Psychoanalysis and Psychodynamic Psychotherapy
The classical perspective of psychotherapy that was developed by Freud and his followers views psychic conflicts as the essence of neuroses. These telling conflicts exist as one tries to balance one’s impulses or wishes with personal or extant societal mores. The term “psychodynamic” refers to the active interchange that is used to manage these conflicts when they are at odds with one another (Freud, 1933; Pilecki, Thoma, & McKay, 2015). The urges/wishes and expectations often occur outside of one’s awareness, in what Freud described as the unconscious. Psychodynamic/psychoanalytic approaches emphasize the role of unconscious and other internal processes in the development both of normal personality and neurosis (Pilecki et al., 2015). Freud (1923) viewed this struggle as one that existed between an unconscious set of innate and primal urges, which he called the id, and an equally unconscious and rigid view of morality, which he called the superego. Behaviors and symptoms were described as the results of this struggle between the instinctual urges/wishes one possesses, and the defenses against those instincts.
The result of this struggle was the development of a psychic mediator, the ego, from which conscious action and realistic behavior is initiated. Internal conflicts among one’s id-based desires and impulses and the social/parental demands of the superego are the cornerstone of psychodynamic psychotherapy. Resolving such psychic conflict is the primary aim of the psychodynamic psychotherapies and is seen as an essential component of achieving symptomatic relief (Simmonds, Constantinides, Drapeau, & Sheptycki, 2015).
Within the psychodynamic tradition are three applications: psychoanalysis, psychodynamic psychotherapy, and supportive psychotherapy (Betan & Binder, 2017). Psychoanalysis is the most intensive variety of psychodynamic treatment and typically takes place over several years. In this process the patient and analyst focus on uncovering one’s historical and repressed experiences as well as one’s unconscious wants and urges. In contrast to normal forgetting or lack of attentiveness (i.e., the preconscious), repression is an unconscious process. The most widely used techniques for uncovering these unconscious processes include free association, dream analysis, and interpretation. These techniques are embedded in a “corrective emotional experience” in which the analyst and the analysand form a set of new expectations and correct unconsciously driven symptoms.
Psychoanalytic psychotherapy focuses on a more limited set of objectives than psychoanalysis (Betan & Binder, 2017). The analytic process and techniques used are similar to psychoanalysis, but the focus is not on revisiting the remote past of one’s development. Usually psychoanalytic psychotherapy focuses on the years of social development, or early adolescence to young adulthood (Karon & Widener, 1995). Here one attempts to assign problematic social responses to a particular, historical, root experience in one’s social development. The therapist encourages both an uncovering process and the cementing of a set of new expectations and need systems.
Supportive psychotherapy is usually conducted within a short-term (i.e., fewer than 10 sessions) framework and focuses on adapting to or resolving current life functions and struggles with minimal attention to the unconscious (Betan & Binder, 2017). The analytic couch is often replaced with a chair, and concepts of social development and “normal” interpersonal and social struggles dominate the conversation.
The psychoanalytic approach to psychotherapy began as an attempt to treat what was then referred to as hysteria, which would later be transformed into the more generalized concept of neurosis (Freud, 1989). Freud’s initial theoretical assumption was that neuroses resulted directly from repressed memories of traumatic childhood sexual experiences which now were stored in one’s unconscious. Shortly after publishing his treatise The Aetiology of Hysteria (Breuer & Freud, 1955), Freud changed his view of childhood sexuality and became convinced that the sexual experiences fostering hysteria were seldom instances of actual sexual encounters, but were developmentally based on sexual wishes and fantasies.
“Defense mechanisms” were introduced by Freud as a means of understanding an individual’s particular attempt to mediate the conflict between unconscious sexual and aggressive urges based in the id, and the demands of a restrictive morality, the superego (Gold & Striker, 2017; Karon & Widener, 1995). These defense mechanisms served to keep unwanted impulses and thoughts out of consciousness and to translate them and their associated behavior into more socially acceptable expressions. Freud promoted “free association” as a way to tap into the unconscious.
Through his work with patients using free association, Freud postulated that ongoing and unresolved intra-psychic struggles resulted in recurrent patterns of behavior, symptoms, and interpersonal events. The repetitive behaviors arising from these recurring struggles were categorized as “psychic determinism.” Recurring behavioral patterns were determined by past conflict rather than present behavior alone, and thus were deemed “neurotic.” One’s progress was noted as one’s behavior became less patterned and more responsive to current environments.
Contemporary Variations of Psychoanalysis and Psychoanalytic Therapy
There are many contemporary variations of psychodynamic and psychoanalytic therapies (e.g., Boesky, 2008; Brenner, 2002; Bromberg, 1998). These contemporary variations of psychoanalytic psychotherapy continue to focus on the central role of unconscious processes, as in classical psychoanalytic theory. However, they also allow for a larger role for preconscious and environmental forces (Betan & Binder, 2017). Therapy from the perspective of these theories encourages conflicts to be expressed, while also helping an individual to become aware of both environmental and intra-psychic factors that are distorted in the unconscious. Exploring underlying conflicts and their relationships to the formation of various symptom profiles remains an important focus of contemporary psychodynamic therapists. Pursuing an understanding of conflictual undercurrents with the patient is thought to help prevent “symptom substitution.” Symptom substitution is assumed to be a danger when the direct treatment of symptoms is provided, but without addressing the deeper causes. Under these circumstances, symptomatic improvement is thought to lead to the formation of new symptoms (Kazdin, 1982).
In many contemporary psychoanalytic approaches, one’s internal conflicts are represented by maladaptive interpersonal behaviors (Malan, 1979). The “triangle of insight” describes the interplay among three components about which the therapist and patient seek understanding. The triangle of insight seeks psychic relief by understanding these components as applied to the process of transference itself. Transference is the process of expecting, from a person in the real world, the behaviors and attitudes of those that exist primarily in the patient’s unconscious, past relationships. The component factors in this triangle include: (1) one or more significant figures in the patient’s current life; (2) a transferential ascription of one’s feelings and beliefs earned in childhood to contemporary people and things in the present; and (3) a childhood that included dysfunctional and damaging relationships, whose nature and meanings are now repressed (Menninger, 1958). The expectations built from past, damaging relationships are misattributed to those in one’s current life; the resulting distress is relieved when one understands this transferential process.
One’s drive to seek insight is illustrated by the interplay of a second triangle, the “triangle of conflict.” The therapist and patient work to: (1) identify the relationship between impulses and feelings (I/F); 2), identify one’s defenses (D) against these impulses; and 3) assess the anxiety (A) that manifests when a defense is failing (Malan, 1976, 1979). The two triangles are considered to be interwoven and are used to guide the analysis of transference. This is done when a patient can come to understand his or her own personality and behaviors in life as these things are manifested or re-enacted in the therapeutic relationship. Therapeutic change occurs as the patient can begin to process and understand the relationship of the two triangles between and within each other.
Object Relations Theory
Object relations approaches are the most widely used within the larger contemporary psychoanalytic/psychodynamic community of schools (Norcross, VandenBos, & Freedheim, 2011). In contrast to other approaches, Object Relations models emerged from analysts who emphasize the role of social forces and attachments to others as the major driver in developing psychopathology. Object Relations theory and its variations are distinct from Freudian perspectives in that they deemphasize the role of unconscious processes in one’s functioning (e.g., Karon & Widener, 1995; Gold & Striker, 2017). This approach looks to attachment styles as central in forming psychopathology.
Though originally quite fragmented, Object Relations theory has become quite cohesive through the collaboration of analysts like Otto Rank and Sándor Ferenczi, who rejected the use of free association as the central tool of psychotherapy, given what they saw as its passive nature. The theorists both believed that psychotherapy could be far more efficient and goal-oriented than it traditionally had been. Rank (1929) emphasized the role of current relationships, an approach that is quite in contrast to the traditional perspectives, which focused primarily on relationships during childhood. Rank also contributed to work on the role of separation from one’s mother as a predictor of current interpersonal relationship, while deemphasizing the importance of sexualized relationships. Early disruptions to the process of connecting to a parental figure were posed to have lasting effects. Thus, much of the neurotic psychopathology observed among people could be understood in psychoanalytic circles by knowing how successfully the mother and the infant were in developing a nurturing bond. Failure in this relationship was thought by many to substantially affect both self-perception and transference attachments to others. Psychotherapy was designed to adjust to this disruption to the attachment process.
Contemporary object relations theorists attend specifically to the situations in which emotional struggles emerge, placing these struggles in juxtaposition to the nature of early attachment patterns. Interpretations revolve around the therapist-parent transference and are framed in a way that is designed to help patients through a corrective emotional experience wherein they receive, from both the therapist and the environment, the type of nurturance that they missed earlier in life. This nurturing process is thought to break down patient defenses against intimacy.
Contemporary Psychodynamic Psychotherapy
The psychodynamic approach to psychotherapy embodies at least four key features that distinguish it from other psychoanalysisbased treatment. First, psychodynamic therapists tend to be more focused on emotions, rather than on achieving simple insight. They seek to elicit and magnify patients’ affective experiences by exploring emotions, thus triggering both the defenses and the resulting anxiety, so that they may be eventually processed and interpreted in therapy.
Second, psychodynamic therapists often also work within a time-limited window (i.e., 12–16 sessions). The use of a time-limited style is based on the belief that one will strive to complete a task if a specific amount of time is provided.
Third, in contemporary psychodynamic therapy, the conceptualization of the patient often occurs in a more direct, time-limited manner than in psychoanalytic practice. Within a time-limited framework, therapists often adopt a conflict that forms a central focus that is addressed throughout the therapy. This focus is intended to expedite the therapeutic process by quickly identifying antecedents goals that are pertinent to the therapeutic process and concentrating efforts on a specific, core problem.
Fourth, patient suitability is emphasized when starting psychodynamic psychotherapy. A history of successful past relationships, the availability of current sources of social support, and the capacity for insight are conventional criteria for participation. The psychodynamic approach is not recommended for more severely impaired patients, given that a high level of insight is considered necessary.
Interventions in Psychoanalytic/Psychodynamic Psychotherapies
In contemporary psychoanalysis, psychoanalytic therapy, and Object Relations psychotherapy models, the role of the working alliance and transference are central. The term “working alliance” refers to the relationship between the therapist and the patient, and can be assessed using various self-reporting measurement tools. While different terms are frequently used to describe this process (e.g., therapeutic alliance, therapeutic relationship, transference relationship, etc.), a high degree of correlation exists among these definitions (e.g., Salvio, Beutler, Engle, & Wood, 1992). Common among the various views are a positive view of session quality by both patient and therapist, a collaborative attitude regarding goals, and positive views of the therapy processes (Kivlighan, Hill, Gelso, & Baumann, 2015).
Therapeutic relationships are also often infused with transference. Theorists of the psychoanalytic approach emphasize the analysis of such responses as a representation of one’s unconscious struggles with past authorities. Countertransference, or the psychoanalyst’s transference onto the patient, is also viewed as an essential means to the therapeutic process in contemporary psychoanalytic therapy.
Psychoanalytic psychotherapists, perhaps more than Object Relations theorists or psychodynamic therapists, view defense mechanisms as a focal point for facilitating change (Pilecki et al., 2015). Defense mechanisms are unconscious coping mechanisms that are used to avoid negative impulses or internal experiences. For example, a patient may use intellectualization as a way to talk about feelings and defend against directly experiencing such emotional states. Becoming aware of such avoidance is an integral part of the psychoanalytic approach.
Empirical research has had a large influence on the way psychodynamic psychotherapy is conducted, especially by focusing on short-term and goal-specific approaches. Research has made much less of a change on the practice of contemporary psychoanalysis than it has on psychodynamic psychotherapy. Psychoanalysis, and to a lesser extent Object Relations theorists, focus on the uniqueness of the individual over the systematic study of the psychodynamics independently. Of note, research has largely demonstrated that the efficacies of various psychodynamic/psychoanalytic approaches to psychotherapy are equal to one another, and very similar to other highly researched approaches representing other schools of psychotherapy (e.g., Pilecki et al., 2015).
Behavior therapy entered the psychotherapy dialogue as a paradigm shift, inserted into the conversation because of dissatisfaction with the status quo. This shift moved the field away from a preoccupation with past experience and emphasized current, observable behavior. Behavior therapy introduced three basic concepts to the therapist: learning by association (i.e., classical conditioning); learning by consequence (i.e., operant conditioning); and learning by observation (modeling).
As researchers began to apply the scientific method to the study of behavior in the mid-20th century, laboratory experiments began to focus on how observable behaviors could be manipulated and eventually shaped. This new-found area of pursuit shifted the focus of psychotherapy from primarily unobservable, internal constructs to observable behavior. This shift promoted psychology as a natural science (Thoma, Pilecki, & McKay, 2015), rather than a biological science. The behavioral movement increased in popularity during the 1950s, following a widespread interest in animal research. However, Ivan Pavlov’s interest in examining the digestive system of dogs is responsible for behaviorism’s appearance in the field (Baum, 2005) and proved to be the catalyst for his later exploration of animal reward processes.
Pavlov observed that when a piece of meat was placed in a dog’s mouth, the animal began to salivate, and that this salivation continue to occurr even in the absence of food, because the dogs learned to associate external stimuli, such as the sound of their owner’s footsteps, with the presentation of food. He concluded that this association occurred because of repeated pairings, which had eventually become associated with the subsequent presentation of meat.
Pavlov extended such findings to explore pairing different stimuli with food. His experiments led to what became classical conditioning, which can be understood as an associative learning process in which an organism elicits a response to a previously neutral stimulus, when presented under certain conditions. Pavlov also determined that under some circumstances, a pairing could produce experimental neuroses. This phenomenon occurred when a dog was unable to make the required distinction among the cues associated with pleasure and those that signaled the onset of discomfort. When the reinforced and non-reinforced stimuli were too similar for the dog to discriminate, the result was anxiety, avoidance, and negative behavior.
John Watson extended the study of Pavlov’s concepts of behaviorism to humans in his most prominent experiment involving an 11-month old infant by the name of “Little Albert.” He hypothesized that human behavior could be understood in terms of stimuli pairings, and argued that learned responses to particular stimuli could then be generalized to a wider context. In his experiment, Watson examined an infant’s fear response by presenting a child with a white, furry rat, paired with the sound of a loud banging noise. The child responded to the jarring noise with fear, and eventually learned to fear the rat because of its association with the sound. This fear was further generalized to other white, fluffy objects. Such findings demonstrated the ways in which humans are shaped by environmental factors.
In contrast to Pavlov’s and Watson’s views that association between an innately provoking stimulus and a neutral one was the key to learning, others came to view behavior change as a consequence of reward. Burrhus Fredrick Skinner extended Watson’s and Pavlov’s views of experimental neuroses by introducing a process he referred to as operant conditioning (Skinner, 1961). He posited that individuals learn to change their behavior depending on the desirability of the consequences. According to Skinner, whether an organism increases or decreases a certain behavior is contingent upon whether it receives a “reinforcement” (i.e., receiving a reward or avoiding an undesirable experience). Skinner and his students demonstrated that the scheduling of reinforcement, the use of both positive (i.e., reward) and negative (i.e., removing unpleasant consequences) reinforcement, and the use of combinations of classically and operantly conditioned behaviors could account for very elaborate variations of behavior among humans as well as animals.
Increased interest in this domain soon was introduced in psychiatric hospitals, where Skinner’s operant principles were applied through the use of token rewards which could be earned by exercising prosocial behaviors, and which could be exchanged for desirable merchandise.
In 1969, the study of behaviorism shifted following Albert Bandura’s research on social- cognitive processes. Demonstrations that people and other animals could learn to solve problems or gain skills by observing others doing so led to the development of methods to foster this process and translate it to the clinician’s office. Social skills training and the use of modeling prosocial behaviors were found to be effective in cultivating socially desirable behavioral responses.
Variations on these three breakthrough, behavioral themes have led to the development of Systematic Desensitization, Eye Movement Desensitization, Social Reinforcement Therapy, Covert Sensitization, Implosive Therapy, and many others that have been or continue to be used in clinical practice (Zinbarg & Griffith, 2008). Although classic behavioral approaches to psychotherapy persist, since their initial emergence they have been integrated with experiential, cognitive, and integrative models to advance the field in many ways.
Interventions in Behavior Therapies
Approaching psychotherapy from a behavioral framework begins with an assessment of precipitating antecedents and the consequences that are present when this behavior occurs (Farmer & Chapman, 2016). Behavioral assessments strive to understand an individual as a force interacting with the environment, rather than as an entity that is separate from the environment. Behaviorism formulates the individual’s specific problematic behavior in terms of antecedents and consequences, rather than as a list of specific diagnoses and “illnesses.” The individualized behavioral assessment informs the selection of intervention techniques, composed largely of changing the antecedents and consequences (i.e., reinforcements) to develop, increase, reduce, or remove the behaviors that provoke problems.
Specific interventions that have garnered particular attention within the various behavior therapy brands include prolonged exposure therapy, behavioral rehearsal, and behavioral activation. For example, a study on behavioral activation treatment for major depressive disorder was used to show that activating social behavior was effective in ameliorating depressive symptoms among both medicated and unmedicated patients (Cullen, Spates, Pagoto, & Doran, 2006). Similarly, prolonged cue exposure is useful in the treatment of individuals with substance-related problems, as well as those with bulimia nervosa and phobias (Toro et al., 2003).
The humanistic and existential school of psychotherapy represents a large collection of varying psychotherapeutic approaches that stem from a similar theoretical foundation based on concepts of human growth and achievement. The existential/humanistic movement, the “third wave” of paradigmatic shifts within psychotherapy, can be delineated into four broad groupings (Krug, 2017). These include: (1) Daseinanalysis, an approach which encourages clients to experience “Being,” a presentcentered perspective; (2) Logotherapy, the set of procedures developed by Victor Frankl which is designed to help clients discover meaning in their lives; (3) humanistic/existentialist therapy, which is an amalgamation of phenomenological “experiencing,” and which encourages patients to explore their “Growth Potential”; and (4) British Existentialism, especially as articulated by R. D. Laing, who strived to move the concept of treatment to a non-pathology-based psychotherapy.
As a group, the existential-humanistic therapies arose from dissatisfaction both with the original psychodynamic formulations and the narrow focus on overt behavior espoused by the behaviorists in the mid-20th century. Contemporary humanistic/existential therapists believe in both the importance of being centered in the present and the salience of encouraging full expression of human emotions. They identify individuals as being inherently good, or at least neutral, in nature, in contrast to the assumption that they are driven by id-based motives and unmodulated pursuit of pleasure. They hold the belief that an individual is always moving toward a sense of wholeness, unless he or she is blocked in this endeavor by fear or environmental obstacles (Watson, Goldman, & Greenberg, 2011).
The humanistic and existential approaches started in Europe and the United States in the early 1930s. By the 1950s and 1960s, humanistic and existential psychotherapy had begun to expand into a number of distinct subdivisions (Krug, 2017). The founders of the various approaches shared a discontent with what they believed were nomothetic and reductionist stances on the human experience among the other psychotherapies of the time (Watson, Goldman, & Greenberg, 2011).
Those who advocated for the humanistic and existential psychotherapeutic school wanted a more humane science and believed that the focus on overt and quantifiable behaviors discounted the role of subjective processes in human motivation and growth (Misiak & Sexton, 1973). Abraham Maslow is considered by some as the “father of American humanistic psychology.” In A Theory of Human Motivation (1943), Maslow conceptualized a self-actualization process in which one’s urge to experience and grow was a primary factor in one’s emotional and social development. He introduced a “hierarchy of needs,” that is, a theoretical framework illustrating that individuals strive progressively for things that fulfill the need to exist and thrive. In contemporary psychotherapy, the humanistic/existential movement has led to several widely used models of intervention and associated methods of research.
Contemporary Variations in Existential/Experiential Psychotherapy
Four frequently used variations of the existential/humanistic school of psychotherapy are widely practiced in contemporary society. These approaches varied vary from one another in the degree to which they emphasized: a) the power of adopting a subjective or phenomenological perspective, b) the innate drive to achieve self-actualization or growth, c) the power of self-determination and self-awareness, and c) the uniqueness of each individual (Watson, Goldman, & Greenberg, 2011).
Carl Rogers’s client-centered therapy, also referred to as the person-centered approach, aimed to fully understand the patient’s experience. The act of understanding led Rogers to take a non-directive and phenomenological approach so as to encourage self-exploration and understanding.
Rogers published his initial theoretical concepts in The Clinical Treatment of the Problem Child (1939), which marked his movement from the theoretical to the applied. The result of his subsequent research was published in his third book, Client-Centered Therapy (1951).
Rogers’ approach centered on the concept of self. Indeed, he postulated that one held many views of self, ranging from how one appeared to others to how one appeared to oneself, and to how one most desired to be. Those with emotional problems were viewed as having multiple fractured or discordant “selves.” As a therapist he sought to integrate these self-expressions into a coherent and progressive view of self and others. Rogers fostered the importance of the therapeutic relationship as the vehicle for this movement. He argued that the therapist was to convey empathy, positive regard, trustworthiness, and congruence—the necessary conditions to develop self-understanding and to achieve growth. Thus, it was the patient’s responsibility to perceive and accept these attributes of the therapeutic process and to let down barriers to growth. In his view, the innate drive toward self-actualization would move the patient to integrate various expressions of “self” if social obstacles to doing so were removed.
Eugene Gendlin (b. 1962) formulated the concept of experiencing, or guiding the patient through a therapeutic process of living in the moment and focusing on present experience while maintaining a person-centered stance. Later, Rice and Greenberg (1984) would incorporate the process of task-analysis into the experiential approach. Rice and Greenberg evaluated the patient’s processes in therapy, using micro-change events during psychotherapy as indicators that could be used by the therapist to guide the patient through the presenting issues of therapy. Carl Whitaker was the first to call the approach “experiential therapy,” emphasizing the role of the patient’s feelings and self-experience, rather than merely his or her intellect, as the catalyst of change in psychotherapy.
In modern experiential psychotherapy, it is common for a session to begin with the identification of a single problematic concern, and then to track one’s experience via problem-affective-emotional processing, in order to encourage a change in the patient’s conceptual understanding of the problem. Experiential therapists believe that identifying a “living scene” of powerful, present, and likely ignored or suppressed emotions and feelings at the beginning of a session initiates a deeper experience for the patient than a rational analysis might (Watson, Goldman, & Greenberg, 2011).
Fritz and Laura Perls developed the theoretical foundations of gestalt therapy in the 1940s and 1950s. Gestalt therapists work on three main tenets: (1) Field theory, or the concept that everything is relational and in a constant state of flux; (2) Phenomenology, the study of subjective experience and implicit meanings; and (3) dialogue, the open engagement between therapist and individual (Watson, Goldman, & Greenberg, 2011). Gestalt therapy, as practiced by modern psychotherapists, centers on patients’ experience of the self-regulating adjustments they make in the present moment to contain and “disown” relevant experience and emotions. The disowning of experience derives from the attributions given to the interplay among the environment, the therapeutic relationship, and social contexts.
Existentialism was introduced to psychiatry and psychotherapy in the late 1940s with the help of Paul Tillich’s philosophical writings (Misiak & Sexton, 1973; Rice & Greenberg, 1992). Rollo May and Adrian van Kaam, separately, then began to incorporate the assumptions of existentialism into psychotherapy, contrasting it with the classic Freudian approaches of the time. Centered on Heidegger’s (1927) concept of Dasein (existence), the founders of the approach conceptualized pathology as a result of patients’ connection to the world and their capacity for developing a loving relationship (Krug, 2017). May later incorporated the concept of patients’ relationship to themselves, a concept that was more than simply perceiving one’s self or acknowledging one’s view of oneself. The development of an integrated, emotionally based relationship with one’s self is referred to as “intersubjectivity” (Watson, Goldman, & Greenberg, 2011).
Contemporary schools of humanistic and existential psychotherapy incorporate a vast number of unique psychotherapeutic constructs and corresponding interventions. Though the various techniques that are embodied in humanistic and existential psychotherapy vary greatly, the approaches all share the same basic conceptual framework. As noted earlier, this framework is composed of four basic assumptions (Watson, Goldman, & Greenberg, 2011):
1. There is therapeutic value in focusing on the patient’s subjective experience (e.g., feelings, perceptions, values, goals, etc.). By consciously reflecting on their experiences, patient become aware of occluded experiences (Watson, Goldman, & Greenberg, 2011).
2. Individuals have an inherent growth or self-actualization tendency. This implies that individuals do not focus solely on maintenance, coping, and stabilization in life, but instead aspire to be different, to evolve, and to strive toward harmony and growth (Watson, Goldman, & Greenberg, 2011). Rogers referred to the innate tendency to seek this balance as a “biological imperative.”
3. Each individual is capable of self-awareness, self-determination, and choice. By identifying what resonates with them, patients learn how to respond to and communicate with others (Greenberg, Rice, & Elliott, 1993; Rogers, 1959). Taylor (1990) has noted that these qualities allow the patient to engage in a process of second-order valuing, meaning that the individual possesses and uses personal agency (the ability to choose) and a capacity for self-determination (the ability to alter one’s life course) (e.g., Fagan, 1974; May & Yalom, 1989; Perls, 1973; Taylor, 1990).
4. Each individual is a unique entity (Watson, Goldman, & Greenberg, 2011). A humanistic/existential therapist attempts to understand the subjective worldview of the patient without judgment, while also treating the patient with utmost respect and care (Rogers, 1959).
The goals of the variations in humanistic/existential psychotherapy will vary in their particulars, but they all center on facilitating some form of individual awareness. A phenomenological, discovery-orientated approach is commonly used to allow patients to be the experts on their own inner experience. This school uses a variety of techniques, all of which are focused on increasing personal awareness of experience, choice, and outcomes. These techniques include active listening, self-focusing, and one- and two-chair dialogues with parts of the self or with important others; all of these techniques convey empathy and sincerity (Krug, 2017).
While research is very active in the domain of existential/humanistic therapies, few evidenced-based treatments have emerged. This absence may largely be due to the relative emphasis on process rather than outcomes, and the suspicion that is attached to outcomes that reflect groups rather than individuals (Watson, Goldman, & Greenberg, 2011).
Cognitive psychotherapy is arguably the major psychotherapeutic treatment paradigm used by contemporary psychotherapists (Thoma et al., 2015). Temporally, it represents the fourth wave of psychotherapy. For the cognitive therapist, the road to change is through rational, organized thought. This practice focuses on cognitions, and actively examines the relationship between these cognitions and other current mental and emotional states.
Albert Ellis’s Rational-Emotive Therapy (RET) was a revolutionary approach that maintained that the mere act of being rational when approaching one’s problems could overcome whatever internal dynamics perpetuated these problems. Ellis sought to help individuals who had been indoctrinated by society to hold neurotic beliefs about their own dependency on others and their personal weaknesses, such as a belief that social regard is needed to survive. Ellis viewed the therapist as a counter- propagandist who carried the gospel of rationalism.
Although Ellis initiated the paradigm shift to rationality and thereby helped to promote the beginnings of cognitive work, Aaron T. Beck is often thought of as a father of cognitive psychotherapy (Thoma et al., 2015). Like Ellis, he viewed his work as being a way to counter the propaganda that had been transmitted to patients from their parents and an irrational environment.
Following his clinical psychiatry training in the 1960s, Beck began to examine psychoanalytic theory (Beck, 2006). He found that many patients who suffered from depression experienced such symptoms because of an inflated negative view of the self, the world, and their future. Cognitive therapy (CT) for depression emerged as the initial treatment manual, which eventually expanded to include variations of cognitive therapy for anxiety disorders, personality disorders, and all forms of situational problems. In contrast to other forms of cognitive behavioral therapy, which relied on education and teaching, Beck introduced the concept of the patient as a personal scientist. He emphasized the collaboration between patient and therapist and encouraged individuals to engage in Socratic self-dialogues by labeling dysfunctional and misleading cognitive distortions in their thoughts, and then implementing cognitive restructuring strategies to combat negative automatic thoughts. Furthermore, Beck encouraged individuals to complete homework assignments related to such cognitive challenges.
Part of Beck’s success and distinctiveness in applying CT can be attributed to his emphasis on the role of scientific inquiry as a means of testing and sharpening treatments for ameliorating specific symptom profiles. He constructed and validated the Beck Depression Inventory (BDI) as a means of evaluating treatment effectiveness among depressed patients and applied this measure in a series of clinical trials to determine treatment efficacy. Another component that led to Beck’s effectiveness is his view of cognitive therapy as an integrative process. Beck strove to incorporate efficacious elements from behavior therapy, such as, for example, his inclusion of techniques of behavioral activation, exposures, social skills training, and relaxation training.
Variations of Cognitive Therapy
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a variation of cognitive psychotherapy that developed from the intersection of cognitive and behavior theory. As the name suggests, cognitive behavioral therapy synthesizes a more cognitive-focused approach with behavioral interventions like those incorporated by Beck in CT (Thoma et al., 2015). CBT has emerged as an efficacious treatment approach for a wide range of psychological disorders and can be conceptualized as a broad, heterogeneous school of psychotherapy, under which other approaches we describe in this section are listed. These approaches include mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT).
Mindfulness-Based Cognitive Therapy
“Mindfulness” is an emerging construct that has been adopted widely by many within different modifications of the cognitive psychotherapy school. Mindfulness emphasizes focus, and is very much reminiscent of the present-centered focus of the humanistic/existential school. It serves as a means of breaking the patient’s concentration on external events and the patient instead to center attention on dysfunctional thoughts and associated feeling states. It also is applied, as are humanistic/existential therapies, as a means of motivating movement and centering the individual’s efforts.
Each of the variations of cognitive psychotherapy involves mindfulness exercises which are applied along with other interventions that encourage cognitive change. For instance, both ACT and MBCT utilize experiential focusing exercises to increase one’s awareness of automatic thoughts (Strosahl, Hayes, Wilson, & Gifford, 2004). Yet, ACT and MBCT emphasize different mechanisms and concepts as they address mindfulness; and such differences in inflection and application distinguish among the many cognitive behavioral approaches to psychotherapy.
As a stand-alone therapy, mindfulness practice involves an attitude of acceptance and non-judgemental awareness of the present moment. It entails learning to step away from one’s experience and to observe it closely and dispassionately, with a sense of neutrality or even acceptance. This addition to the CBT armamentarium of interventions incorporates principles of acceptance and non-judgemental awareness with the more traditional CBT educative and self-discovery approaches as a means of facilitating psychological health (Hayes, 2004; Huijbers et al., 2015; Jacobs & Antony, 2009). There is an increasing number of professionals who support the use of mindfulness exercises within the context of cognitive behavioral therapy, particularly when applied to clinical presentations of anxiety and depression.
Acceptance and Commitment Therapy (ACT)
One of the most popular variations of CBT is Acceptance and Commitment Therapy (ACT), which conceptualizes mental illness as arising from a form of experiential avoidance. Hayes (2004) describes ACT as a “rigorously behavioral” approach that is also based on empirical analyses of one’s cognitions. ACT aims to cultivate acceptance and mindfulness of what occurs in the streaming moments of one’s struggles. ACT focuses on changing one’s relationship to the thinking process itself through the use of role-playing, experiential exercises, and other tools that help one to step back from and experience the benefits of acceptance in vivo. Although mindfulness and acceptance serve as core components of ACT, they are not the end goal of this modality. Rather, mindfulness and acceptance are viewed as ways to help an individual become more engaged with life in a meaningful way. Research shows that ACT is helpful in treating disorders such as depression, anxiety, and chronic pain (A-Tjak et al., 2015).
Dialectical Behavior Therapy (DBT)
Another variation of CBT is DBT, which was originally intended for use with patients who are or have been suicidal and who exhibit traits of borderline personality disorder (Linehan & Heard, 1992). Although DBT emerged from CBT, it contrasts with both its format and its overarching treatment strategies. For example, DBT is typically a long-term treatment that involves both individual psychotherapy and intensive group therapy. As with CBT, DBT emphasizes mindfulness practice and cognitive analysis, but the CBT techniques are articulated in a way that is used to promote emotion-regulation strategies. Thus, thought-replacement strategies, along with mindful focus, are emphasized to help temper emotional intensity and to redirect emotion-laden impulses.
Within the broad category of cognitive psychotherapies, the particular interventions used or recommended at any point differ in part depending on the particular sub-model used. CBT proper relies on skill development; CBT-based mindfulness therapy uses cognitive focusing and present centering as primary interventions; the primary intervention for DBT is establishing structure and support; and the primary intervention in CT is challenging cognitive errors. In part, these variations reflect the diagnosis and severity of the patient’s problems. DBT is typically used with much more disturbed and fragmented individuals than CBT alone, for example. While CBT relies heavily on maintaining an empathetic, non-judgemental, supportive therapeutic rapport, this relationship is considered a means to implementing other strategies, rather than being a healing force in its own right. But, even this focus on relationship is a departure from the original CT and RET, where relationship was seldom discussed.
Regardless of the specific approaches used, CBT interventions as a group aim to explore various ways in which one thinks about and interprets life events. It is the external event by which one usually first seeks to disclose the perceived relationships among events, thoughts, and behavioral and emotional problems. That is, external events are often the easiest point at which to begin a process of analysis because many patients are able to describe these events in detail. As one advances in the therapy, more attention is directed to how thoughts themselves may stimulate other thoughts, and how one symptom often interacts with another to complicate the treatment.
Psychotherapy begins with psychoeducation, during which time the clinician speaks with the patient about his or her presentation of concerns, and explores what is known about such conditions. For example, when applied to a patient that experiences depression, the therapist may discuss how the individual’s symptoms relate to his or her illness, and what can be achieved through seeking therapy. The specific techniques used may include self-monitoring, self-instruction, role play, and education about the relationship between thought and action, as well as mindfulness exercises and homework. Tracking of progress and change is often supported through the use of worksheets such as thought records that help a patient to better recognize dysfunctional thought patterns and cultivate ways to challenge maladaptive core beliefs (Hawton, Salkovskis, Kirk et al., 1989). Socratic questioning remains a favorite procedure in CBT and CT to help uncover dysfunctional thoughts and inadequate coping mechanisms.
In many respects, CBT can be described as an approach that intends to empower patients, as individuals are taught to recognize and cultivate coping skills that can then be generalized to other areas of concern in their life (Meichenbaum, 1977).
Although CBT can be applied to different disorders, researchers support the conclusion that it is an especially effective treatment of depression and anxiety. There is some evidence that CBT’s emphasis on relaxation training and its focus on changing anxious or depressed thoughts may predict its degree of clinical effectiveness (Peris et al., 2015). Likewise, evidence suggests that, especially among youth with symptoms of anxiety, cognitive restructuring and exposure significantly decrease symptom severity and global dysfunction during treatment (Peris et al., 2015).
The fifth great paradigm shift is the movement toward integration among the previously identified schools. Although still in its infancy, integrative psychotherapies can be separated by the degree to which they focus on merging two or more theories of change versus assuming an atheoretical application of empirically derived methods (Norcross, 2011). Psychotherapy integration attempts both to draw upon other schools and approaches to enhance the effectiveness of psychosocial treatments (Norcross, Martin, Omer, Pinsof, Rapp & Raw, 1996), and to stand as an independent alternative to these schools (Beutler, Clarkin, & Bongar, 2000). Since its inception, psychotherapy integration has aimed to address the high level of dissatisfaction with single-school approaches (Goldfried & Norcross, 2005).
Among various surveys, some form of integration is ranked as either the most or second-most popular school identified and used in practice (Norcross, 2014). Indeed, while the average difference in outcomes among single-theory schools of psychotherapy is negligible (e.g., Wampold & Imel, 2015), there is accumulating evidence that the use of integrative principles may optimize the effects these treatments (e.g., Beutler, 2014; Beutler, Someah, Kimpara, & Miller, 2016; Beutler, Forrester, Holt, & Stein, 2013).
As psychotherapy continues to develop, so does the number of clinicians who support psychotherapy integration. An increasing number of psychotherapists recognize the inherent limiting factors associated with adopting a single theoretical orientation (Goldfried & Norcross, 2005). Lebow (1997) described this movement toward psychotherapy integration as a “revolution” within the field. This movement fueled the organization of the Society for the Exploration of Psychotherapy Integration (SEPI), as well as several renowned international journals, including the Journal of Psychotherapy Integration. Goldfried and Norcross (2005) argue that the roots of psychotherapy integration extend to the early 1900s, when suggestions about synthesizing various approaches to psychotherapy emerged in the literature. For instance, in 1932 the American Psychiatric Association highlighted similarities between Freud and Pavlov. Despite its early roots, psychotherapy integration has only recently captured the imagination of large numbers of practitioners.
Variations among Psychotherapy Integration Approaches
Goldfried and Norcross (2005) delineate four “routes” to integrative practice. These include technical eclecticism, theoretical integration, common factors, and assimilative integration. Despite their similarities, these paths utilize different means to traverse beyond the confines of unitary psychotherapy approaches with the goal of enhancing therapeutic efficacy, efficiency, and application. Although these pathways to integration are not mutually exclusive, each approach offers its own view of the objectives and means of effective psychotherapy.
Eclectic approaches have traditionally been identified as focusing on the selection of a variety of techniques that produce optimal change. Such an approach eschews theory as a guide to the selection of interventions in favor of relying on empirically defined relationships between techniques and outcomes. Thus, exposure may be recommended for phobia, cognitive change for depression, and relaxation for general anxiety. However, over time, psychotherapists have shifted their focus to approaches that favor fitting classes of procedures to patient factors that portend efficacy on the basis of empirically derived strategies or principles of change. Beutler’s (1983) development of Systematic Eclectic Psychotherapy is an example of such an eclectic approach.
Over time and with accumulating research, the eclectic aim of deriving menus of techniques has given way to other methods of integrating interventions. Technique- oriented eclectics have largely been subsumed as either common-factors theorists, theoretical integrationists, or assimilative integrationists.
The goal of theoretical integration is to synthesize the most effective components of therapy approaches into a new or different theoretical frame. Theoretical integration advocates for the amalgamation of two or more underlying theories and techniques of psychotherapy to produce change. Both Ryle, Poynton, & Brockman’s (1990) and Wachtel’s (1977) blending of cognitive and psychoanalytic approaches to psychotherapy are exemplary of this route. Rather than simply combining theories, theoretical integration aims to create an emergent theory that can direct future practice and related research. Unlike technical eclecticism, this approach is convergent in nature, focusing on theoretical commonalities rather than differences.
It is noteworthy that the term “integrative” is preferred over the term “eclectic” by most contemporary clinicians (Norcross, 2014), and this fact has resulted in the general demise of the use of the identifier adjective “eclectic.” Most treatments within the integrative/eclectic tradition now identify their approach as being some variation of integration or integrationism. This includes some “evolved” technical-eclectic approaches (e.g., Beutler, Clarkin, & Bongar, 2000) and modern Common Factors Eclectics (e.g, Lasky, Gurman, & Wampold, 2014).
Even as Freud’s version of psychoanalysis came under attack by many of his own students, early theorists began to note that the differences among approaches may be more apparent than real. Rosenzweig (1936) observed that outcomes were about the same regardless of the type of psychotherapy used. He posited that it may be the commonalities among approaches that account for change rather than their distinguishing theories or procedures. Rosenzweig drew the parallel between the null differences among the psychotherapies and the “Caucus Race” described by Lewis Carroll (1865) in his book Alice’s Adventures in Wonderland. If the reader will recall, after all the characters came to various calamities while in the race, the dodo bird proclaimed that “everyone has won, and all must have prizes.”
It was not until some years later, however, that the common factors approach made a significant and strong debut as an authentic approach to psychotherapy. Frank (1973) was one of several in the mid-1970s who asserted that psychotherapeutic schools may be equivalent because of their common rather than their distinctive qualities. It was certainly Frank who helped lead the movement to find these common factors (Goldfried & Norcross, 2005).
Common factors approaches seek to create efficacious treatments that are based on common denominators associated with therapy (Garfield, 1980; Goldfried & Norcross, 2005). To most common factors clinicians, this means that a good therapeutic relationship is the core contributor to change. Therefore, they urge therapists from all perspectives to emphasize the same contextual and relationship factors across approaches to optimize change (Lasky, Gurman, & Wampold, 2014; Wampold & Imel, 2015.
A variation on this theme that equates the therapeutic relationship to the common factors that provoke change is to identify common principles that have differential effects. This differential, principle-based view stands in contrast to the view that psychotherapies all work in the same relational environments and use the same parameters across models. In models that bridge between common factors and assimilative integration (see the next section), Prochaska and DiClemente (1982) and Beutler, Clarkin, and Bongar (2000) have empirically identified lists of operational principles, the application of which requires the use of distinctive classes of intervention for different patients.
In these models, the role of diagnosis is primarily in determining the level of patient impairment, based on which a differential treatment decision is made, or as an outcome variable that defines “improvement.” Instead of trying to fit different models of psychotherapy to patients with different diagnoses, these models identify characteristics shared by a cluster of interventions. Efficacy rates are found to be very good using this model (Beutler, Someah, Kimpara, & Miller, 2016).
The approach of identifying a common set of principles from which a particular structure or form of treatment can be individually tailored to each patient seeks to have have an advantage over the traditional “common factors” approach. The common factors view attempts to provide the same relationship and technical ingredients to all, whereas the common principles approach concentrates on fitting the therapy (including the relationship) to the patient using moderators of change.
Assimilation can be described as a stepping stone toward integration. As described by Goldfried and colleagues (2005), assimilative integration maintains grounding in one, particular domain of psychotherapy while also incorporating techniques and perspectives from other schools of practice. This approach helps to preserve the fidelity of a specific approach and also invites flexibility by melding practices from other systems. The most likely foundation theory on which to build an assimilative form of integration is probably cognitive therapy, given its popularity generally. Proponents of assimilation favor synthesis and argue that this assimilation should occur at both a theoretical level and application level.
Integrationists, when compared to those adherents of first, second, third, and fourth wave schools, are likely to use the broadest and most inclusive array of techniques to bear on psychotherapy change. At least two variations of integrationism have been recognized as representing “Empirically Supported Psychotherapies” and research supports them as producing moderate to strong effects with diverse populations. As a doctrinal point, practitioners of these approaches borrow freely from all other schools. In contrast, those who adhere to more doctrinaire schools may be more likely to dip from the pot of techniques if these techniques arise from a theory with which there are strong conceptual disagreements. In particularly, those whose allegiance is in common factors and assimilative approaches, borrow widely from different brands of psychotherapy to incorporate the most effective principles possible from various theories from which research evidence is available (e.g., Beutler, Clarkin, & Bongar, 2000; Prochaska & DiClemente, 1982).
A common value among clinicians using integrative approaches is the emphasis placed on research evidence. Although integrative practice has caught on strongly among practitioners, the faith in scientific evidence remains (Norcross, 2014). Yet, there are still divisions among the approaches as they look at different types of scientific data and weigh it differently. Some focus on integrating principles to match patients to treatments and other focus on common relationship qualities associated with change. On one hand the principle based integrationist may look in practice like a CBT therapist while a common factors integrationist may practice more like a humanist. Both views are supported by psychotherapy research, but it remains for integrationists to fully integrate among themselves.
From its inception, the nature of psychotherapy has stimulated the development of many different schools and approaches. Each of these schools have their own unique attributes, while it is also evident that there remains an element of overlap among different schools of practice. Research methods have improved greatly over the years, and findings have generally underlined the value of psychotherapy for many different kinds of people and problems. As a general rule, the dodo bird still rules (Wampold & Imel, 2015). However, better research methods and more sophisticated therapies may yet begin to show more specific effects. To date, the tendency for psychotherapy to be shrouded in complex and diverse theories has persisted in spite of this increasingly strong research tradition.
Indeed, from an examination of the various theories and schools, there are several conclusions that one may reach, and several related quandaries toward which research must be directed:
1. All major brands of psychotherapy have accumulated evidence that they work better than no treatment and, to a lesser extent, minimal treatment.
2. An examination of comparative research programs strongly suggests that most treatments within the various models obtain about the same effects as all others (“Everyone has won, and all must have prizes”).
3. The role of theory in guiding psychotherapy has not been particularly effective. Psychotherapy continues to be a field with more theory than can be supported by the accumulating research, and the results of this research continue to reveal few outcome differences among the theories.
To summarize, there are five broad divisions representing the evolution and current practice of psychotherapy as well as some of the major subdivisions of nuanced approaches. Indeed, he field is diverse and creative. But while research has improved and flourished, it continues to lag behind the theories that are offered for why it works, and it fails to reveal the superiority of any particular approach over another.
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