All good psychotherapists want to help clients think about their lives in new ways and find solutions to the problems that plague them. In this section, we will consider the major schools of psychotherapy. To illustrate the philosophy and methods of each one, we will focus on a fictional fellow named Murray. Murray is a smart guy whose problem is all too familiar to many students: He procrastinates. He just can’t seem to settle down and write his term papers. He keeps getting incompletes, and before long the incompletes turn to Fs. Why does Murray procrastinate, manufacturing his own misery? What kind of therapy might help him? Watch Therapies in Action 2 for an overview of techniques that are available to mental health professionals.

Sigmund Freud was the father of the “talking cure,” as one of his patients called it. In his method of psychoanalysis, which required patients to come for treatment several days a week, often for years, patients talked not about their immediate problems but about their dreams and their memories of childhood. Freud believed that intensive analysis of these dreams and memories would give patients insight into the unconscious reasons for their symptoms. With insight and emotional release, he believed, the person’s symptoms would disappear.

Freud’s psychoanalytic method has since evolved into many different forms of psychodynamic therapy, all of which share the goal of exploring the unconscious dynamics of personality, such as defenses and conflicts. Proponents of these therapies often refer to them as “depth” therapies because the purpose is to delve into the deep, unconscious processes believed to be the source of the patient’s problems rather than to concentrate on “superficial” symptoms and conscious beliefs. One modern psychodynamic approach is based on object-relations theory, which emphasizes the unconscious influence of people’s earliest mental representations of their parents and how these affect reactions to separations and losses throughout life.

A major element of most psychodynamic therapies is transference, the client’s transfer (displacement) of emotional elements of his or her inner life—usually feelings about the client’s parents—outward onto the analyst. Have you ever responded to a new acquaintance with unusually quick affection or dislike, and later realized it was because the person reminded you of a relative whom you loved or loathed? That experience is similar to transference. In therapy, a woman might transfer her love for her father to the analyst, believing that she has fallen in love with the analyst. A man who is unconsciously angry at his mother for rejecting him might become furious with his analyst for going on vacation. Through analysis of transference in the therapy setting, psychodynamic therapists believe that clients can see their emotional conflicts in action and work through them (Schafer, 1992; Westen, 1998).

Today, most psychodynamic therapists borrow methods from other forms of therapy. They are more concerned with helping clients solve their problems and ease their emotional symptoms than traditional analysts were, and they tend to limit therapy to a specific number of sessions, say, 10 or 20. Perhaps they might help our friend Murray gain the insight that he procrastinates as a way of expressing anger toward his parents. He might realize that he is angry because they insist he study for a career he dislikes. Ideally, Murray will come to this insight by himself. If the analyst suggests it, Murray might feel too defensive to accept it.

Clinical psychologists who practice behavior therapy would get right to the problem: What are the reinforcers in Murray’s environment that are maintaining his behavior? “Mur,” they would say, “forget about insight. You have lousy study habits.” Clinicians who practice cognitive therapy would focus on helping Murray understand how his beliefs about studying, writing papers, and success are woefully unrealistic. Often these two approaches are combined.

Behavioral TechniquesBehavior therapy is based on principles of classical and operant conditioning. Here are some of these methods (Martin & Pear, 2014):

1. Exposure. The most widely used behavioral approach for treating fears and panic is graduated exposure. When people are afraid of some situation, object, or upsetting memory, they usually do everything they can to avoid confronting or thinking of it. Unfortunately, this seemingly logical response only makes the fear worse. Exposure treatments, either in the client’s imagination or in actual situations, are aimed at reversing this tendency. In graduated exposure, the client controls the degree of confrontation with the source of the fear. Someone who is trying to avoid thinking of a traumatic event might be asked to imagine the event over and over, until it no longer evokes the same degree of panic. A more dramatic form of exposure is flooding, in which the therapist takes the client directly into the feared situation and remains there until the client’s panic and anxiety decline. Thus a person suffering from agoraphobia might be taken into a department store or a subway, an action that would normally be terrifying to contemplate.

2. Systematic desensitization. Systematic desensitization is an older behavioral method, a step-by-step process of breaking down a client’s conditioned associations with a feared object or experience (Wolpe, 1958). It is based on the classical-conditioning procedure of counterconditioning, in which a stimulus (such as a dog) for an unwanted response (such as fear) is paired with some other stimulus or situation that elicits a response incompatible with the undesirable one. In this case, the incompatible response is usually relaxation. The client learns to relax deeply while imagining or looking at a sequence of feared stimuli, arranged in a hierarchy from the least frightening to the most frightening. The hierarchy itself is provided by the client. The sequence for a person who is terrified of spiders might be to read the classic children’s story Charlotte’s Web, then look at pictures of small, cute spiders, then look at pictures of tarantulas, then move on to observing a real spider, and so on. At each step, the person must become relaxed before going on. Eventually, the fear responses are extinguished.

   In a growing specialty called cybertherapy, some behavior therapists have developed virtual reality (VR) programs to desensitize clients to various phobias, notably of flying, heights, spiders, and public speaking, and to help clients reduce anxiety (Gregg & Tarrier, 2007; Jacob & Storch, 2015; Wiederhold & Wiederhold, 2000.) Others are experimenting with VR to treat combat veterans who are suffering from intractable posttraumatic stress symptoms. In a program called Virtual Iraq/Afghanistan, vets get a combination of exposure and desensitization (Rizzo et al., 2015b). They wear a helmet with video goggles and earphones to hear the sounds of war, and then play a modified version of the VR game Full Spectrum Warrior adapted to the Iraq experience (S. Halpern, 2008; Rizzo et al., 2015a).

   

3. Behavioral self-monitoring. Before you can change your behavior, it helps to identify the reinforcers that are supporting your unwanted habits: attention from others, temporary relief from tension or unhappiness, or tangible rewards such as money or a good meal. One way to do this is to keep a record of the behavior that you would like to change. Would you like to cut back on eating sweets? You may not be aware of how much you are eating throughout the day to relieve tension, to boost your energy, or just to be sociable when you are hanging out; a behavioral record will show just how much and when you eat. A mother might complain that her child “always” has temper tantrums; a behavioral record will show when, where, and with whom those tantrums occur. After the unwanted behavior is identified, along with the reinforcers that have been maintaining it, a treatment program can be designed to change it. For instance, you might find other ways to reduce stress besides eating, and make sure that you are nowhere near junk food in the late afternoon, when your energy is low. The mother can learn to respond to her child’s tantrum not with her attention (or a cookie to buy silence) but with a time-out, banishing the child to a corner where no positive reinforcers are available.

4. Skills training. It is not enough to tell someone “Don’t be shy” if the person does not know how to make small talk with others, or “Don’t yell!” if the person does not know how to express feelings calmly. Therefore, some behavior therapists use operant-conditioning techniques, modeling, and role-playing to teach the skills a client might lack. A shy person might learn how to converse in social settings by focusing on other people rather than on his or her own insecurity. Skills-training programs have been designed for all kinds of behavioral problems: to teach parents how to discipline their children, impulsive adults how to manage anger, autistic children how to behave appropriately, and people with schizophrenia how to hold a job. These skills are also being taught in virtual worlds, such as Second Life. After face-to-face sessions with a therapist, the client creates an avatar to explore a virtual environment and experiment with new behaviors; the therapist can monitor the client’s psychological and even physiological reactions at the same time.

A behaviorist would treat Murray’s procrastination in several ways. Monitoring his own behavior with a diary would let Murray know exactly how he spends his time, and how much time he should realistically allot to a project. Instead of having a vague, impossibly huge goal, such as “I’m going to reorganize my life,” Murray would establish specific small goals, such as reading the two books necessary for an English paper and writing one page of an assignment. If Murray does not know how to write clearly, however, even writing one page might feel overwhelming; he might also need some skills training, such as a basic composition class. Most of all, the therapist would change the reinforcers that are maintaining Murray’s “procrastination behavior”—perhaps the immediate gratification of partying with friends—and replace them with reinforcers for getting the work done.

In the 1960s, humanist psychologists rejected the two dominant psychological approaches of the time, psychoanalysis and behaviorism. Humanists regarded psychoanalysis, with its emphasis on dangerous sexual and aggressive impulses, as too pessimistic a view of human nature, one that overlooked human resilience and the capacity for joy. And humanists regarded behaviorism, with its emphasis on observable acts, as too mechanistic and “mindless” a view of human nature, one that ignored what really matters to most people—their uniquely human hopes and aspirations. In the humanists’ view, human behavior is not completely determined by either unconscious conflicts or the environment. People are capable of free will and therefore have the ability to make more of themselves than either psychoanalysts or behaviorists would predict. The goal of humanist psychology was, and still is, to help people express themselves creatively and achieve their full potential.

Humanist therapy, like its parent philosophy humanism, starts from the assumption that human nature is basically good and that people behave badly or develop problems when they have been warped by self-imposed limits. Humanist therapists, therefore, want to know how clients subjectively see their own situations and how they construe the world around them. They explore what is going on “here and now,” not past issues of “why and how.”

In client-centered (nondirective) therapy, developed by Carl Rogers, the therapist’s role is to listen to the client’s needs in an accepting, nonjudgmental way and to offer what Rogers called unconditional positive regard. Whatever the client’s specific complaint is, the goal is to build the client’s self-esteem and self-acceptance and help the client find a more productive way of seeing his or her problems. Thus, a Rogerian might assume that Murray’s procrastination masks his low self-regard and that Murray is out of touch with his real feelings and wishes. Perhaps he is not passing his courses because he is trying to please his parents by majoring in prelaw when he would secretly rather become an artist. Rogers (1951, 1961) believed that effective therapists must be warm and genuine. For Rogerians, empathy, the therapist’s ability to understand what the client says and identify the client’s feelings, is the crucial ingredient of successful therapy: “I understand how frustrated you must be feeling, Murray, because no matter how hard you try, you don’t succeed.” The client will eventually internalize the therapist’s support and become more self-accepting.

Existential therapy helps clients face the great questions of existence, such as death, freedom, loneliness, and meaninglessness. Existential therapists, like humanist therapists, believe that our lives are not inevitably determined by our pasts or our circumstances; we have the free will to choose our own destinies. As Irvin Yalom (1989) explained, “The crucial first step in therapy is the patient’s assumption of responsibility for his or her life predicament. As long as one believes that one’s problems are caused by some force or agency outside oneself, there is no leverage in therapy.” Yalom argues that the goal of therapy is to help clients cope with the inescapable realities of life and death and the struggle for meaning. However grim our experiences may be, he believes, “they contain the seeds of wisdom and redemption.” Perhaps the most remarkable example of a man able to find seeds of wisdom in a barren landscape was Viktor Frankl (1905–1997), who developed a form of existential therapy after surviving a Nazi concentration camp. In that pit of horror, Frankl (1955) observed, some people maintained their sanity because they were able to find meaning in the experience, shattering though it was.

Some observers believe that all therapies are ultimately existential. In different ways, therapy helps people determine what matters to them, what values guide them, and what changes they will have the courage to make. A humanist or existential therapist might help Murray think about the significance of his procrastination, what his ultimate goals in life are, and how he might find the strength to reach them.

Murray’s situation is getting worse. His father has begun to call him Tomorrow Man, which upsets his mother, and his younger brother, the math major, has been calculating how much tuition money Murray’s incompletes are costing. His older sister, Isabel, the biochemist who never took an incomplete grade in her life, now proposes that all of them go to a family therapist. “Murray’s not the only one in this family with complaints,” she says.

Family therapists would maintain that Murray’s problem developed in the context of his family, that it is sustained by the dynamics of his family, and that any change he makes will affect all members of his family (Nichols, 2012). One of the most famous early family therapists, Salvador Minuchin (1984), compared the family to a kaleidoscope, a changing pattern of mosaics in which the pattern is larger than any one piece. In this view, efforts to isolate and treat one member of the family without the others are doomed. Only if all family members reveal their differing perceptions of each other can mistakes and misperceptions be identified. A teenager, for instance, may see his mother as crabby and nagging when actually she is tired and worried. A parent may see a child as rebellious when in fact the child is lonely and desperate for attention.

Family members are usually unaware of how they influence one another. By observing the entire family, the family therapist hopes to discover tensions and imbalances in power and communication. A child may have a chronic illness or a psychological problem, such as anorexia, that affects the workings of the whole family. One parent may become overinvolved with the sick child whereas the other parent retreats, and each may start blaming the other. The child, in turn, may cling to the illness or disorder as a way of expressing anger, keeping the parents together, getting the parents’ attention, or asserting control (Cummings & Davies, 2011).

Even when it is not possible to treat the whole family, some therapists will treat individuals in a family-systems perspective, which recognizes that people’s behavior in a family is as interconnected as that of two dancers (Bowen, 1978; Cox & Paley, 2003; Ram et al., 2014). Clients learn that if they change in any way, even for the better, their families may protest noisily or may send subtle messages that read, “Change back!” Why? Because when one family member changes, each of the others must change too. As the saying goes, it takes two to tango, and if one dancer stops, so must the other. But most people do not like change. They are comfortable with old patterns and habits, even those that cause them trouble. They want to keep dancing the same old dance, even if their feet hurt.

When a couple is arguing frequently about issues that never seem to get resolved, they may be helped by going together to couples therapy, which is designed to help couples manage the inevitable conflicts that occur in all relationships. One of the most common problems that couples complain about is the “demand–withdraw” pattern, in which one partner badgers the other about some perceived failing, demanding that he or she change. The more the badgering partner demands, the more the target withdraws, sulks, or avoids the subject (Baucom et al., 2011; Christensen & Jacobson, 2000). Couples therapists generally insist on seeing both partners, so that they will hear both sides of the story. They cut through the blaming and attacking (“She never listens to me!” “He never does anything!”), and instead focus on helping the couple resolve their differences, get over hurt and blame, and make specific behavioral changes to reduce anger and conflict.

Many couples therapists, like some cognitive therapists, are moving away from the “fix all the differences” approach. Instead, they are helping couples learn to accept and live with qualities in both partners that aren’t going to change much (Baucom et al., 2011; Hayes, 2004). A wife can stop trying to turn her calm, steady husband into a spontaneous adventurer (“After all, that’s what I originally loved about him; he’s as steady as a rock”), and a husband can stop trying to make his shy wife more assertive (“I have always loved her remarkable serenity”).

Family and couples therapists may use psychodynamic, behavioral, cognitive, or humanist approaches in their work; they share only a focus on the family or the couple. In Murray’s case, a family therapist would observe how Murray’s procrastination fits his family dynamics. Perhaps it allows Murray to get his father’s attention and his mother’s sympathy. Perhaps it keeps Murray from facing his greatest fear: If he does finish his work, it will not measure up to his father’s impossibly high standards. The therapist will not only help Murray change his work habits, but will also help his family deal with a changed Murray.

The kinds of psychotherapy that we have discussed are all quite different in theory, and so are their techniques (see Review16.2). Yet in practice, many psychotherapists take an integrative approach, drawing on methods and ideas from various schools and avoiding strong allegiances to any one theory. This flexibility enables them to treat clients with whatever methods are most appropriate and effective. In an Internet-based survey of more than 2,400 psychotherapists, two-thirds said they practice cognitive-behavioral therapy and that the single most influential therapist they followed was Carl Rogers and that they often incorporate ideas of mindfulness and acceptance (Cook, Biyanova, & Coyne, 2009).

The life narrative, the story that each of us develops to explain who we are and how we got that way, is important (McAdams & McLean, 2013). All successful therapies share two key elements: They are able to motivate the client into wanting to change, and they replace a client’s pessimistic or unrealistic narrative with one that is more hopeful and attainable (Howard, 1991; Schafer, 1992).