What is Psychotherapy?

Psychotherapy, Psychoanalysis, Academic

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Dr. Salih Murat Paker – Clinical Psychologist – Psychotherapist – May 2022

In the broadest and most general sense, psychotherapy can be defined as psychological practices conducted by a professional with the necessary training to reduce or alleviate the psychological distress or difficulties experienced by individuals or groups. These practices do not involve overtly biological interventions (e.g., medication, electroconvulsive therapy, surgery). Psychotherapy was long referred to as “talk therapy,” but this definition has largely been abandoned, as advancements in the field have demonstrated that psychotherapy involves dynamics far beyond talking. Additionally, methods such as body-oriented therapies, which focus more on bodily sensations or movements than verbal communication, have been developed.

Scope

Psychotherapy can address all forms of psychological difficulties. To briefly summarize the most common ones: anxiety, stress, phobias, depression and other mood disorders, personality issues, relationship problems, adjustment difficulties, challenges arising from traumatic experiences, eating disorders, addictions, psychosis, self-awareness, and maturation. As psychological symptoms become more severe, biological interventions like medication can complement psychotherapy as a primary or secondary treatment. However, the majority of those who seek professional help for psychological difficulties can recover sufficiently without needing medication, relying solely on psychotherapy. Nonetheless, psychiatric medication use is much more widespread today than psychotherapy. Three main reasons are often cited for this:

  1. The strong lobbying power of the pharmaceutical industry,
  2. The prevailing expectation in popular culture for easy and quick fixes, and psychotherapy being perceived as a lengthy and challenging process,
  3. In most countries, the lack of sufficient public funding for psychotherapy makes it relatively expensive and difficult to access, often due to a shortage of professionals.

Despite these factors, it is evident that psychotherapy usage is steadily increasing worldwide.

History

We know that shamans, religious figures, and doctors have used traditional psychological healing methods based on mechanisms such as catharsis (emotional release), persuasion, dream interpretation, fortune-telling, and prayer for thousands of years. Modern scientific psychotherapy, however, is generally acknowledged to have begun at the end of the 19th century with Freud and psychoanalysis. Although there are significant differences between traditional methods and modern psychotherapies regarding understanding, theory, explanatory frameworks, and practices, the central importance of the relationship between the therapist (or “healer”) and the client is a common focus.

Science or Art?

In the more than a century-long history of modern psychotherapy practice, whether psychotherapy is a scientific or creative activity has been frequently debated. It must be acknowledged that psychotherapy, with all its different schools, has been rigorously researched using scientific methodology, with efforts made to identify which methods, factors, and processes are most effective. These findings have continuously developed and altered psychotherapy’s theoretical and practical aspects. In this sense, psychotherapy is a serious field of scientific research, continuously informed by scientific studies.

However, no matter how much science informs psychotherapy, what therapists do in the therapy room is not a scientific activity. In addition to their scientific knowledge, the therapist brings their human self into the process, developing a special relationship with the client. This process is most comparable to artistic creation. Utilizing their knowledge, emotions, and intuitions, the therapist creates and recreates a therapeutic relationship unique to the client and the therapist.

Diversity

The first notable feature in the field of psychotherapy is its vast diversity, which can be examined along several dimensions:

Diversity of approaches/schools:

Hundreds of different approaches have been defined in psychotherapy. These approaches formulate the human mind, personality structure, developmental processes, the formation of psychopathology, therapeutic transformation processes, and therapy techniques in various ways. Although some schools may fade away over time, primary schools have continued to evolve, adapt, and interact with one another. These schools can be grouped under seven main headings, each with multiple branches and hybrid approaches beneath them:

  • Psychoanalytic / Psychodynamic Approach: At the end of the 19th century, Freud introduced the first modern psychotherapy approach. This approach argues that psychological issues stem from emotional processes such as fear, anxiety, and desire that have been repressed, dissociated, or pushed into the unconscious. Thus, the goal of therapy was to resolve these processes, making them conscious by utilizing the dynamics within the therapeutic relationship to develop insight.

Psychoanalytic approaches, which significantly influenced the cultural life of the modern world, dominated the psychotherapy field until the late 1950s, evolving into multiple branches. However, their popularity waned with the development of other approaches, listed below. Since the 1990s, the psychoanalytic approach has experienced a revival due to a “relational revolution” within the field of psychoanalysis, and it has become more open to interaction with other psychotherapy schools.

While gaining insight into unconscious processes remains important in the relational psychoanalytic approach, the primary focus is on providing corrective emotional experiences through implicit relational learning within the therapeutic relationship. This allows clients to develop new relational patterns with themselves and the world.

  • Cognitive-Behavioral Approach: This approach holds that psychological problems arise from dysfunctional learned behaviors and thinking patterns and aims to correct them through a new learning process.
  • Humanistic Approach: This approach, which includes branches like Gestalt Therapy, Existential Therapy, and Client-Centered Therapy, emphasizes the belief that humans are inherently good, possess free will, and strive to realize their potential, though they may become alienated from their true nature due to obstacles encountered in life.
  • Systemic Approach: Often used in couples and family therapy, this approach views social groups as more than just the sum of individuals, emphasizing the dynamics of the larger system and the roles and functions individuals take within it.
  • Body-Oriented (Somatic) Approach: This approach focuses on the idea that some psychological processes are inaccessible through language and can only be addressed through bodily sensations and movements. It is often used in the context of traumatic stress and anxiety issues.
  • Eclectic Approach: Therapists using this approach pragmatically select techniques from different schools according to the client’s needs without adhering to a single theoretical framework.
  • Integrative Approach: In this approach, therapists combine more than one school, usually emphasizing one while synthesizing elements of others into a comprehensive theoretical and practical framework.

Therapists are expected to have received adequate training in at least one school. While many fanatic factions in each school may look down on other approaches, more open-minded groups are open to dialogue and integration. Regardless of their theoretical orientation, most therapists today feel the need to work more flexibly, eclectically, or integratively in practice.

Diversity in Intervention Channels:

Each therapeutic approach employs four main channels, to varying extents, through which it establishes a therapeutic connection with the individual’s psychological state:

  • Affect – the emotional world
  • Cognition – the cognitive/thought-belief world
  • Behavior – the observable world of behavior
  • Body/Sensation – the world of sensations

All these intervention channels correspond to different layers/structures in the central nervous system (the brain) and are, therefore, intricately interconnected. However, since the early days, therapeutic approaches have debated which intervention channel(s) should take precedence or be most effective in a given situation. These theoretical and practical distinctions remain subjects of intense discussion.

Diversity in Client Types:

Therapy clients can be individuals, couples, small social groups (such as families), or larger groups brought together due to common problems or experiences (usually between 5 and 15 people). As the number of clients in a group increases, two therapists often prefer to manage the process together.

Diversity in Age Groups:

Psychotherapy with appropriate adjustments can be applied to every age group. Therapy for infants must inevitably involve “mother-infant therapy,” focusing on the relationship between the two. Therapy with children is often conducted through games that enable meaningful engagement with the child. While therapy with adolescents, adults, and the elderly has similarities, each requires distinct expertise due to inherent differences.

Diversity in Duration and Frequency:

Depending on the therapeutic approach, the client, and the problem, the duration and frequency of therapy can vary greatly. Therapy lasting less than a year is generally considered short-term, while more extended therapies are considered long-term. Some structured short-term therapies have a predetermined number of sessions, whereas open-ended therapies that last several years are common. The more complex and deep-rooted the issue (most problems involve the entire personality structure), and the more profound and lasting the desired transformation, the longer the therapy will take. In this sense, psychotherapy is a demanding endeavor; seemingly simple, easy, and quick solutions are often temporary and deceptive.

Individual and couple therapy sessions typically last 45-50 minutes, whereas family and group therapy sessions may last 90-120 minutes, depending on the group size. Although there are exceptions, the duration of sessions in a particular therapy remains consistent. Session frequency is typically once a week, though more frequent sessions (up to 3-4 times a week) may sometimes be necessary. Sessions less frequent than once a week are rare, generally deemed insufficient for therapeutic change, and more characteristic of psychological counseling rather than psychotherapy.

Diversity in Clinical Settings:

Psychotherapy can take place in various settings, including private offices, hospitals (outpatient or inpatient), clinics, prisons, infirmaries, and even outdoor environments. Depending on the situation, therapy can be conducted face-to-face or online. Regardless of the setting, the therapeutic environment must be as safe, respectful, quiet, and private as possible.

Diversity in Problems:

Therapy can focus on all psychological difficulties, from the simplest to the most complex. Even when there are no significant issues, people may seek therapy to understand themselves better, mature, or improve their quality of life. This spectrum is vast. For instance, in the psychoanalytic school, becoming a therapist requires undergoing long-term personal therapy to confront one’s psyche.

People:

Beyond all these dimensions, the most significant diversity in psychotherapy lies in the variety of individuals seeking therapy. No matter how many diagnostic categories are used, each person who comes to therapy is unique. No two cases of panic disorder are identical, and no two cases of depression or borderline personality disorder are the same. Symptoms may be similar, but the meanings attributed to those symptoms, their functions, the contexts in which they emerge and persist, and their place within the overall personality structure vary immensely.

Similarly, no two therapists, even from the same specific school, are precisely the same. Each therapist is unique. When we consider all of this, the goal of psychotherapy is not to treat a particular complaint, diagnosis, or illness; instead, it is to engage in a unique therapeutic relationship between a client with specific complaints and a therapist, both of whom are one-of-a-kind. In this relationship, particular techniques are used. Still, the process primarily relies on the implicit healing quality of the therapeutic relationship itself (I will address the qualities of the therapeutic relationship in another article).

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