Psychotherapy: A Very Short Introduction

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ACCOUNTING Christopher Nobes

ADVERTISING Winston Fletcher
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ANGELS David Albert Jones
ANGLICANISM Mark Chapman
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THE BEATS David Sterritt
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BIOGRAPHY Hermione Lee
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THE BOOK OF MORMON Terryl Givens
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BUDDHIST ETHICS Damien Keown
CANCER Nicholas James
CAPITALISM James Fulcher
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CLASSICS Mary Beard and John Henderson
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THE COLD WAR Robert McMahon
COLONIAL AMERICA Alan Taylor
COLONIAL LATIN AMERICAN LITERATURE Rolena Adorno
COMEDY Matthew Bevis
COMMUNISM Leslie Holmes
COMPLEXITY John H. Holland
THE COMPUTER Darrel Ince
CONFUCIANISM Daniel K. Gardner
THE CONQUISTADORS Matthew Restall and Felipe Fernández-Armesto
CONSCIENCE Paul Strohm
CONSCIOUSNESS Susan Blackmore
CONTEMPORARY ART Julian Stallabrass
CONTEMPORARY FICTION Robert Eaglestone
CONTINENTAL PHILOSOPHY Simon Critchley
CORAL REEFS Charles Sheppard
CORPORATE SOCIAL RESPONSIBILITY Jeremy Moon
COSMOLOGY Peter Coles
CRITICAL THEORY Stephen Eric Bronner
THE CRUSADES Christopher Tyerman
CRYPTOGRAPHY Fred Piper and Sean Murphy
THE CULTURAL REVOLUTION Richard Curt Kraus
DADA AND SURREALISM David Hopkins
DARWIN Jonathan Howard
THE DEAD SEA SCROLLS Timothy Lim
DEMOCRACY Bernard Crick
DERRIDA Simon Glendinning
DESCARTES Tom Sorell
DESERTS Nick Middleton
DESIGN John Heskett
DEVELOPMENTAL BIOLOGY Lewis Wolpert
THE DEVIL Darren Oldridge
DIASPORA Kevin Kenny
DICTIONARIES Lynda Mugglestone
DINOSAURS David Norman
DIPLOMACY Joseph M. Siracusa
DOCUMENTARY FILM Patricia Aufderheide
DREAMING J. Allan Hobson
DRUGS Leslie Iversen
DRUIDS Barry Cunliffe
EARLY MUSIC Thomas Forrest Kelly
THE EARTH Martin Redfern
ECONOMICS Partha Dasgupta
EDUCATION Gary Thomas
EGYPTIAN MYTH Geraldine Pinch
EIGHTEENTH-CENTURY BRITAIN Paul Langford
THE ELEMENTS Philip Ball
EMOTION Dylan Evans
EMPIRE Stephen Howe
ENGELS Terrell Carver
ENGINEERING David Blockley
ENGLISH LITERATURE Jonathan Bate
ENTREPRENEURSHIP Paul Westhead and Mike Wright
ENVIRONMENTAL ECONOMICS Stephen Smith
EPIDEMIOLOGY Rodolfo Saracci
ETHICS Simon Blackburn
ETHNOMUSICOLOGY Timothy Rice
THE ETRUSCANS Christopher Smith
THE EUROPEAN UNION John Pinder and Simon Usherwood
EVOLUTION Brian and Deborah Charlesworth
EXISTENTIALISM Thomas Flynn
EXPLORATION Stewart A. Weaver
THE EYE Michael Land
FAMILY LAW Jonathan Herring
FASCISM Kevin Passmore
FASHION Rebecca Arnold
FEMINISM Margaret Walters
FILM Michael Wood
FILM MUSIC Kathryn Kalinak
THE FIRST WORLD WAR Michael Howard
FOLK MUSIC Mark Slobin
FOOD John Krebs
FORENSIC PSYCHOLOGY David Canter
FORENSIC SCIENCE Jim Fraser
FOSSILS Keith Thomson
FOUCAULT Gary Gutting
FRACTALS Kenneth Falconer
FREE SPEECH Nigel Warburton
FREE WILL Thomas Pink
FRENCH LITERATURE John D. Lyons
THE FRENCH REVOLUTION William Doyle
FREUD Anthony Storr
FUNDAMENTALISM Malise Ruthven
GALAXIES John Gribbin
GALILEO Stillman Drake
GAME THEORY Ken Binmore
GANDHI Bhikhu Parekh
GENES Jonathan Slack
GENIUS Andrew Robinson
GEOGRAPHY John Matthews and David Herbert
GEOPOLITICS Klaus Dodds
GERMAN LITERATURE Nicholas Boyle
GERMAN PHILOSOPHY Andrew Bowie
GLOBAL CATASTROPHES Bill McGuire
GLOBAL ECONOMIC HISTORY Robert C. Allen
GLOBAL WARMING Mark Maslin
GLOBALIZATION Manfred Steger
GOD John Bowker
THE GOTHIC Nick Groom
GOVERNANCE Mark Bevir
THE GREAT DEPRESSION AND THE NEW DEAL Eric Rauchway
HABERMAS James Gordon Finlayson
HAPPINESS Daniel M. Haybron
HEGEL Peter Singer
HEIDEGGER Michael Inwood
HERODOTUS Jennifer T. Roberts
HIEROGLYPHS Penelope Wilson
HINDUISM Kim Knott
HISTORY John H. Arnold
THE HISTORY OF ASTRONOMY Michael Hoskin
THE HISTORY OF LIFE Michael Benton
THE HISTORY OF MATHEMATICS Jacqueline Stedall
THE HISTORY OF MEDICINE William Bynum
THE HISTORY OF TIME Leofranc Holford-Strevens
HIV/AIDS Alan Whiteside
HOBBES Richard Tuck
HORMONES Martin Luck
HUMAN EVOLUTION Bernard Wood
HUMAN RIGHTS Andrew Clapham
HUMANISM Stephen Law
HUME A. J. Ayer
HUMOUR Noël Carroll
THE ICE AGE Jamie Woodward
IDEOLOGY Michael Freeden
INDIAN PHILOSOPHY Sue Hamilton
INFORMATION Luciano Floridi
INNOVATION Mark Dodgson and David Gann
INTELLIGENCE Ian J. Deary
INTERNATIONAL MIGRATION Khalid Koser
INTERNATIONAL RELATIONS Paul Wilkinson
INTERNATIONAL SECURITY Christopher S. Browning
IRAN Ali M. Ansari
ISLAM Malise Ruthven
ISLAMIC HISTORY Adam Silverstein
ITALIAN LITERATURE Peter Hainsworth and David Robey
JESUS Richard Bauckham
JOURNALISM Ian Hargreaves
JUDAISM Norman Solomon
JUNG Anthony Stevens
KABBALAH Joseph Dan
KAFKA Ritchie Robertson
KANT Roger Scruton
KEYNES Robert Skidelsky
KIERKEGAARD Patrick Gardiner
KNOWLEDGE Jennifer Nagel
THE KORAN Michael Cook
LANDSCAPE ARCHITECTURE Ian H. Thompson
LANDSCAPES AND GEOMORPHOLOGY Andrew Goudie and Heather Viles
LANGUAGES Stephen R. Anderson
LATE ANTIQUITY Gillian Clark
LAW Raymond Wacks
THE LAWS OF THERMODYNAMICS Peter Atkins
LEADERSHIP Keith Grint
LINCOLN Allen C. Guelzo
LINGUISTICS Peter Matthews
LITERARY THEORY Jonathan Culler
LOCKE John Dunn
LOGIC Graham Priest
LOVE Ronald de Sousa
MACHIAVELLI Quentin Skinner
MADNESS Andrew Scull
MAGIC Owen Davies
MAGNA CARTA Nicholas Vincent
MAGNETISM Stephen Blundell
MALTHUS Donald Winch
MANAGEMENT John Hendry
MAO Delia Davin
MARINE BIOLOGY Philip V. Mladenov
THE MARQUIS DE SADE John Phillips
MARTIN LUTHER Scott H. Hendrix
MARTYRDOM Jolyon Mitchell
MARX Peter Singer
MATERIALS Christopher Hall
MATHEMATICS Timothy Gowers
THE MEANING OF LIFE Terry Eagleton
MEDICAL ETHICS Tony Hope
MEDICAL LAW Charles Foster
MEDIEVAL BRITAIN John Gillingham and Ralph A. Griffiths
MEMORY Jonathan K. Foster
METAPHYSICS Stephen Mumford
MICHAEL FARADAY Frank A. J. L. James
MICROBIOLOGY Nicholas P. Money
MICROECONOMICS Avinash Dixit
THE MIDDLE AGES Miri Rubin
MINERALS David Vaughan
MODERN ART David Cottington
MODERN CHINA Rana Mitter
MODERN FRANCE Vanessa R. Schwartz
MODERN IRELAND Senia Pašeta
MODERN JAPAN Christopher Goto-Jones
MODERN LATIN AMERICAN LITERATURE Roberto González Echevarría
MODERN WAR Richard English
MODERNISM Christopher Butler
MOLECULES Philip Ball
THE MONGOLS Morris Rossabi
MORMONISM Richard Lyman Bushman
MUHAMMAD Jonathan A. C. Brown
MULTICULTURALISM Ali Rattansi
MUSIC Nicholas Cook
MYTH Robert A. Segal
THE NAPOLEONIC WARS Mike Rapport
NATIONALISM Steven Grosby
NELSON MANDELA Elleke Boehmer
NEOLIBERALISM Manfred Steger and Ravi Roy
NETWORKS Guido Caldarelli and Michele Catanzaro
THE NEW TESTAMENT Luke Timothy Johnson
THE NEW TESTAMENT AS LITERATURE Kyle Keefer
NEWTON Robert Iliffe
NIETZSCHE Michael Tanner
NINETEENTH-CENTURY BRITAIN Christopher Harvie and H. C. G. Matthew
THE NORMAN CONQUEST George Garnett
NORTH AMERICAN INDIANS Theda Perdue and Michael D. Green
NORTHERN IRELAND Marc Mulholland
NOTHING Frank Close
NUCLEAR POWER Maxwell Irvine
NUCLEAR WEAPONS Joseph M. Siracusa
NUMBERS Peter M. Higgins
NUTRITION David A. Bender
OBJECTIVITY Stephen Gaukroger
THE OLD TESTAMENT Michael D. Coogan
THE ORCHESTRA D. Kern Holoman
ORGANIZATIONS Mary Jo Hatch
PAGANISM Owen Davies
THE PALESTINIAN-ISRAELI CONFLICT Martin Bunton
PARTICLE PHYSICS Frank Close
PAUL E. P. Sanders
PEACE Oliver P. Richmond
PENTECOSTALISM William K. Kay
THE PERIODIC TABLE Eric R. Scerri
PHILOSOPHY Edward Craig
PHILOSOPHY OF LAW Raymond Wacks
PHILOSOPHY OF SCIENCE Samir Okasha
PHOTOGRAPHY Steve Edwards
PHYSICAL CHEMISTRY Peter Atkins
PLAGUE Paul Slack
PLANETS David A. Rothery
PLANTS Timothy Walker
PLATO Julia Annas
POLITICAL PHILOSOPHY David Miller
POLITICS Kenneth Minogue
POSTCOLONIALISM Robert Young
POSTMODERNISM Christopher Butler
POSTSTRUCTURALISM Catherine Belsey
PREHISTORY Chris Gosden
PRESOCRATIC PHILOSOPHY Catherine Osborne
PRIVACY Raymond Wacks
PROBABILITY John Haigh
PROGRESSIVISM Walter Nugent
PROTESTANTISM Mark A. Noll
PSYCHIATRY Tom Burns
PSYCHOLOGY Gillian Butler and Freda McManus
PSYCHOTHERAPY Tom Burns and Eva Burns-Lundgren
PURITANISM Francis J. Bremer
THE QUAKERS Pink Dandelion
QUANTUM THEORY John Polkinghorne
RACISM Ali Rattansi
RADIOACTIVITY Claudio Tuniz
RASTAFARI Ennis B. Edmonds
THE REAGAN REVOLUTION Gil Troy
REALITY Jan Westerhoff
THE REFORMATION Peter Marshall
RELATIVITY Russell Stannard
RELIGION IN AMERICA Timothy Beal
THE RENAISSANCE Jerry Brotton
RENAISSANCE ART Geraldine A. Johnson
REVOLUTIONS Jack A. Goldstone
RHETORIC Richard Toye
RISK Baruch Fischhoff and John Kadvany
RIVERS Nick Middleton
ROBOTICS Alan Winfield
ROMAN BRITAIN Peter Salway
THE ROMAN EMPIRE Christopher Kelly
THE ROMAN REPUBLIC David M. Gwynn
ROMANTICISM Michael Ferber
ROUSSEAU Robert Wokler
RUSSELL A. C. Grayling
RUSSIAN HISTORY Geoffrey Hosking
RUSSIAN LITERATURE Catriona Kelly
THE RUSSIAN REVOLUTION S. A. Smith
SCHIZOPHRENIA Chris Frith and Eve Johnstone
SCHOPENHAUER Christopher Janaway
SCIENCE AND RELIGION Thomas Dixon
SCIENCE FICTION David Seed
THE SCIENTIFIC REVOLUTION Lawrence M. Principe
SCOTLAND Rab Houston
SEXUALITY Véronique Mottier
SHAKESPEARE Germaine Greer
SIKHISM Eleanor Nesbitt
THE SILK ROAD James A. Millward
SLEEP Steven W. Lockley and Russell G. Foster
SOCIAL AND CULTURAL ANTHROPOLOGY John Monaghan and Peter Just
SOCIALISM Michael Newman
SOCIOLINGUISTICS John Edwards
SOCIOLOGY Steve Bruce
SOCRATES C. C. W. Taylor
THE SOVIET UNION Stephen Lovell
THE SPANISH CIVIL WAR Helen Graham
SPANISH LITERATURE Jo Labanyi
SPINOZA Roger Scruton
SPIRITUALITY Philip Sheldrake
SPORT Mike Cronin
STARS Andrew King
STATISTICS David J. Hand
STEM CELLS Jonathan Slack
STRUCTURAL ENGINEERING David Blockley
STUART BRITAIN John Morrill
SUPERCONDUCTIVITY Stephen Blundell
SYMMETRY Ian Stewart
TEETH Peter S. Ungar
TERRORISM Charles Townshend
THEATRE Marvin Carlson
THEOLOGY David F. Ford
THOMAS AQUINAS Fergus Kerr
THOUGHT Tim Bayne
TIBETAN BUDDHISM Matthew T. Kapstein
TOCQUEVILLE Harvey C. Mansfield
TRAGEDY Adrian Poole
THE TROJAN WAR Eric H. Cline
TRUST Katherine Hawley
THE TUDORS John Guy
TWENTIETH-CENTURY BRITAIN Kenneth O. Morgan
THE UNITED NATIONS Jussi M. Hanhimäki
THE U.S. CONGRESS Donald A. Ritchie
THE U.S. SUPREME COURT Linda Greenhouse
UTOPIANISM Lyman Tower Sargent
THE VIKINGS Julian Richards
VIRUSES Dorothy H. Crawford
WITCHCRAFT Malcolm Gaskill
WITTGENSTEIN A. C. Grayling
WORK Stephen Fineman
WORLD MUSIC Philip Bohlman
THE WORLD TRADE ORGANIZATION Amrita Narlikar
WORLD WAR II Gerhard L. Weinberg
WRITING AND SCRIPT Andrew Robinson

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Tom Burns and Eva Burns-Lundgren
PSYCHOTHERAPY
A Very Short Introduction
 Great Clarendon Street, Oxford, OX2 6DP, United Kingdom
Oxford University Press is a department of the University of Oxford. It furthers the University’s
objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a
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© Tom Burns and Eva Burns-Lundgren 2015
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First edition published in 2015
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Published in the United States of America by Oxford University Press 198 Madison Avenue, New
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ISBN 978–0–19–968936–1
ebook ISBN 978–0–19–100358–5
Printed in Great Britain by Ashford Colour Press Ltd, Gosport, Hampshire
Contents

Preface
List of illustrations
1 What is psychotherapy and who is it for?
2 Freud and psychoanalysis
3 Post-Freudians: moving towards the interpersonal
4 Time-limited psychotherapy
5 Counselling
6 Cognitive behaviour therapy
7 Family, group, and interactive therapies
8 Psychotherapy now and in the future

References
Further reading
Index
Preface

Psychotherapy, psychology, and psychiatry

What is the difference between psychotherapy, psychology, and psychiatry?
Most people find them hard to distinguish, which isn’t surprising. The terms
seem to be used interchangeably about the same activities, and some people
describe themselves as practising more than one. Many psychologists and
psychiatrists are also psychotherapists, and there are even the odd
individuals who are all three. There are already Very Short Introductions
(VSIs) on psychology and psychiatry, so we should start by distinguishing
these subjects and explaining what this VSI to psychotherapy will add.

Psychology is the science of mental processes and behaviour. It uses all the
standard scientific methods of observation, experimentation, and theory
development. It isn’t even restricted to humans—many psychologists study
animal behaviour, both for its own sake and also to model human thinking.
Psychologists examine emotions, perceptions, thoughts, etc., and
increasingly use very high-tech equipment such as computers and brain
scanners. Some ‘clinical’ psychologists work in health services and apply
what they learn from their science to help people with problems.

Psychiatry is a medical discipline. Psychiatrists first train as doctors with

the full range of exposure—general practice, surgery, obstetrics, etc. When
qualified they then specialize in psychiatry, which is defined as the
diagnosis and treatment of mental illness. While modern medicine is very
‘scientific’, it is not first and foremost a science. It uses several sciences
such as physiology, genetics, and biochemistry to advance its knowledge
and practice, but its fundamental approach is observational, not theory
driven. Psychiatrists do not start from experiments or theories but from the
problems people bring to them, which they then attempt to categorize and
find treatments for. Psychiatry is firmly wedded to the ideas of diagnosis
and treatment, although mental illness, and in particular the boundary
between health and illness, are often very controversial.

Psychotherapy is a form of treatment for emotional and psychological

problems that is based on talking and understanding. It relies on two
(sometimes more) individuals exploring the problems the patient or client
brings. The aim is to gain greater understanding of the problems and better
ways of dealing with them. Many psychotherapists use psychiatric
diagnoses and the term ‘patient’, but they think more in terms of personal
problems and identity. They do not prescribe medication. Like medicine,
psychotherapy is not primarily a science, but more a skills-based
profession, which uses various theoretical concepts to understand human
experience and development. Like medicine, it also consists of many
different approaches and techniques, and this book will describe and discuss
those that are most significant.

The growth of psychotherapy

Roy Porter, a historian of medicine, called the 20th century ‘the century of
psychiatry’. He could just as well have called it ‘the century of
psychotherapy’. In the period of these hundred years both have transformed
from obscure, minor activities to topics of enormous public interest and
investment. Psychiatry now accounts for about one-fifth of all medical costs
throughout the world. Psychotherapy before World War I was an exotic
practice restricted to rich intellectuals and their psychoanalysts. The war
changed all that. Psychological treatments for emotional disorders altered
psychiatric practice fundamentally and began to change society’s thinking.
By the mid-20th century, psychotherapy had become a constant feature in
artistic and cultural debate, but more importantly it had become recognized
as an effective treatment for a wide range of emotional and interpersonal
problems.
Psychotherapy is now widely available—not just within psychiatry and not
just for mental illness. Psychotherapists are to be found in hospitals,
schools, universities, prisons, and increasingly in some enlightened
workplaces. People seek their help for longstanding problems, but also for
crises and relationship difficulties.

Psychotherapy or psychotherapies?
Psychotherapy has never stood still. It has not only expanded its range and
extent, but there have been exciting and lasting changes in its practice. The
traditional psychoanalytic psychotherapy described at length in Chapter 2
dominated the earlier years, but various styles and adaptations evolved up
until World War II. The Nazis’ persecution of the Jews (almost all the early
psychoanalysts were German-speaking Jews such as Sigmund Freud) drove
psychotherapists abroad to the US, South America, and the UK. The result
was a variation in practice in different societies and the beginning of
radically different ways of thinking (see Chapter 3). Since the war we have
witnessed the establishment of time-limited therapies (Chapter 4), the
exponential growth of counselling, psychotherapy’s less formal relative
(Chapter 5), and more recently the rapid development of a strikingly
different approach called cognitive behaviour therapy (CBT, Chapter 6). As
psychotherapeutic thinking became bolder it began to escape its traditional
one-to-one format and experimented with group and interactive therapies
(Chapter 7).

Just how different are these therapies from each other, and how much are
they variations on the same theme? Is counselling just another form of
psychotherapy, or is it something quite new and different? In writing a book
like this we have described the differences, so that you can get a sense of
the range. Many practitioners insist that they are radically different from
each other, but we are not convinced. Our view is that they have more
factors in common than separate them. All have the same starting point in
their commitment to help fellow human beings who are struggling with
distressing problems. All assume that things can get better, and that an
honest, reliable, and tolerant relationship can provide a setting for change.
Lastly, all are based on some form of belief that what matters in our lives is
not simply what happens to us, but crucially what we make of it and how
we deal with it, often based on mental processes we may only be dimly
aware of. Psychotherapy aims to bring these processes into clear
consciousness—to help us make sense of them and take more control of our
lives.

Gender and terminology

It struck us in writing this book just how skewed the sexual representation
was. More women seek psychotherapy than do men, and many more
psychotherapists are women than are men. Yet when we were writing about
who developed this or that psychotherapy, or who wrote what, it has tended
to be dominated by men. We believe this is a historical legacy of the
discrimination that characterized professional and educational opportunities
in previous generations. We predict that any book covering the same ground
in fifty years time will be peppered with creative women writers and
scientists.

Gender stereotypes have played a significant (and not especially

honourable) role in psychiatry’s history, so this is not unimportant. In the
text we wanted to avoid the clumsy his/her but were not happy with just
using ‘he, him, his’ throughout. Redressing the balance by always using
‘she, her, hers’ seemed equally artificial. We have opted to simply vary the
gender in a random way. There is no hidden pattern in it, so don’t try and
work it out!

You can please some of the people some of the time

…
Psychotherapy is an intellectually vibrant activity. It never stands still and is
full of debate and disagreement. Psychotherapists are committed people
who have undertaken long and demanding trainings, and who almost
invariably are very passionate about their work. Any book that sails a
middle course in describing them risks offending everyone. We have
ensured that each of these chapters has been read by at least a couple of real
experts in their areas. Invariably they have thought that we did not accord
their therapy type quite enough space or importance. That is the nature of
the beast. We both have our own specific therapy trainings (Eva in
cognitive analytic therapy, and Tom in group analysis), so we know how
they felt. However, our job has been to try and give you a balanced
overview and we hope that we have. We have chosen to describe some
therapies in more detail where we feel they illustrate underlying principles
particularly well, not necessarily because they are the most important
approaches.

A final word of warning. This is not a self-help book. There are plenty of
those around and many are excellent. This VSI may help you decide which
of the various types of psychotherapy appeals to you if you are thinking of
seeking help. But that is all it can do. Psychotherapy, and particularly
counselling, is now much more accessible and the old stigma that used to be
attached to seeking such help is, mercifully, shrinking fast. So if you are
thinking of talking things over there is absolutely nothing to be lost by
making the move, and it could make all the difference. A good place to start
is usually to discuss matters with your family doctor, or to access the
websites of reputable psychotherapy organizations. Currently,
psychotherapy registration is not statutory in most parts of the world, but
responsible therapists would welcome you enquiring into their level of
training or accreditation. We would recommend meeting with two or three
therapists for assessment sessions before making a final decision on whom
to see. Psychotherapy is a very personal business, and the ‘fit’ between you
and your therapist will play a crucial role both for the experience and for
the outcome of the process.
List of illustrations

1 The traditional bearded

analyst
© www.CartoonStock.com

2 Une leçon clinique à la

Salpêtrière, Andre Brouillet,
1887. Jean-Martin Charcot
using hypnosis to demonstrate
hysteria
© Hulton Archive / Getty Images

3 Freud’s consulting
room
© Archive Photos / Getty Images

4 Triangle of persons

5 Triangle of conflict

6 The mandala—an Eastern

spiritual symbol of the
universe and wholeness
© The Art Archive / DeA Picture
Library / V. Pirozzi

7 A shell-shocked soldier
© Jack Sullivan / Alamy
 8 A CAT diagram

9 The three possible roles

or ‘ego-states’

10 Pavlov’s dog
and conditioning
© Robert Leighton / The New Yorker
Magazine / Conde Nast

11 The Greek philosopher,

Socrates
‘Hutchinson’s History of the Nations’,
1915 (litho), Heath, Dudley (20th
Century) / Private Collection
© Bridgeman Images

12 A family tree or ‘genogram’

13 Emotional baggage
© Cartoon by Carl D’Agostino,
carldagostino.wordpress.com
Chapter 1
What is psychotherapy and who is
it for?

The rise of psychotherapy was one of the most striking features of the 20th
century. What started as an obscure treatment for wealthy, intellectual
neurotics in fin-de-siècle Vienna has changed not only the nature of
psychiatric practice but how we understand ourselves. Psychotherapeutic
language and thinking is now part of everyday life, and we hardly get
through a day without using it: he ‘made a Freudian slip’, their relationship
‘is a bit Oedipal’, my ‘inferiority complex’ is showing. Counselling is now
seen as a natural response to many of the problems in our lives.

Our parents’ image of a psychotherapist—if they had any at all—was

probably that of a bearded psychoanalyst with his patient lying on a couch
(see Figure 1). Psychotherapy is now much less exotic, encompassing
marriage guidance, cognitive behaviour therapy (CBT), Alcoholics
Anonymous (AA) meetings, group therapy, and much more. It is a very
broad church, which has existed in the practice of traditional healers from
long before Freud, indeed before psychiatry itself.

What links the sober psychoanalyst, the careful and scientific psychologist,
and the mystical and dramatic shaman? At its most basic psychotherapy
involves using an agreed relationship with specific characteristics,
involving a trained practitioner and a patient, to obtain relief from
emotional suffering. Most Western psychotherapies are based on talking
and discussion. They aim for a very personal understanding of the origins
and meaning of problems in order to remove symptoms and obtain relief.
Not all emphasize understanding the causes; in fact, existential philosophies
do quite the opposite. Some discourage such a search for unique personal
meanings, and some psychotherapies rely on a dramatic discharge of
emotion.

1. The image of the traditional bearded analyst with the mittel-European accent sitting behind
the couch dominated our view of psychotherapy for many decades

The core feature of any psychotherapy, however, is the relationship between

a practitioner and a patient, a relationship which inspires hope for healing or
change. Both need to share an understanding of the process and agree to
work together within that relationship. Confidentiality is the norm, as
therapy often involves exploring very personal thoughts and feelings which
people may feel conflicted about or ashamed of. Psychotherapists are
expected to be worldly-wise and tolerant. They will be familiar with the
extremes of human experience, hard to shock, and slow to blame.

How long or how intensive psychotherapeutic treatment is can vary

enormously—from a handful of meetings to the (now very rare) classical
psychoanalysis of an hour a day, five days a week, for several years.
Therapist training can also range from several years to shorter part-time
courses. Psychoanalytic schools require an intensive, and expensive,
personal analysis. Psychotherapies are sometimes called ‘talking cures’ or
‘psychological treatments’. These terms are used to distance current
practice from psychoanalysis and its unscientific reputation, but they are too
broad for our purpose. They lose the focus on the relationship and self-
understanding of psychotherapy. For example, teaching someone about
their illness and how to manage it (psycho-education) is technically a
talking treatment, but it is not psychotherapy as we would understand it. We
will retain the term psychotherapy to indicate the skilful and deliberate use
of a specialized relationship to gain self-understanding and relief from
troubling symptoms.

Who is it for?
In Freud’s day, patients usually sought help for very severe, often dramatic,
symptoms. His patients had to have a high level of education and drive to
be taken on for psychoanalysis. Treatment was very intensive and rather
intellectual. It delved into internal conflicts, making links between
symptoms, unconscious wishes, and disturbing early experiences. By
making these conscious (becoming aware of them) the patient could gain
greater control. Current psychoanalytic practice focuses more on problems
in relationships and self-fulfilment, and is sought by a much wider range of
people. This is not surprising. Our happiness depends most of all on our
relationships, so if they go wrong, we want to understand why and try to
repair them.
Not only are those who seek psychotherapy now more varied, but it is
provided in a much wider range of settings, including in family doctor
practices and occupational health schemes. It is no longer restricted to
‘intellectuals’, and accepts patients with more pervasive difficulties, such as
self-harm and substance abuse, as well as those from more disturbed or
deprived backgrounds.

Much has been made of psychological mindedness (the ability to reflect and
think about thoughts and feelings) as a requirement for psychotherapy. We
think this is putting the cart before the horse. People often seek therapy
precisely because they are not able to reflect on their lives in a
psychological manner. Psychotherapy can provide the tools to develop this
capacity. The popularity of the more transparent and ‘democratic’ recent
therapies such as interpersonal therapy (IPT), solution focused therapy
(SFT), and cognitive analytic therapy (CAT) (Chapter 4), and CBT (Chapter
6), testify to this trend, as does the increasing use of written aids and
questionnaires.

Psychotherapy in the 21st century is more accessible and varied than it was
a hundred years ago, and this book will reflect that scope—from the unique
and specialized to the more generic and familiar. We will restrict ourselves
to the forms of psychotherapy generally available for adults. Child
psychotherapy is a very specialized activity with its own theories and
practices, and neither of us is an expert in this field. While early
psychoanalysis did not see older adults as suitable candidates for analysis,
this view has changed, and many current psychotherapy models are suitable
for this age group and for people with learning disabilities. Although there
is a growing body of psychotherapy practice for these groups, we will not
address them in this book.

Before we provide an outline of present-day psychotherapy, we think it

might be helpful to trace its lineage and put it in its historical context.

Psychotherapy before the discovery of the

unconscious
Modern psychiatry began just over 200 years ago at the end of the 18th
century. It is a product of the Enlightenment, when reason and logic
triumphed over religious dogma. People began to trust their own
experiences to understand the world around them. Two iconic events
marked psychiatry’s beginning, one in France and one in England.

In Paris, in 1789 after the French Revolution, Philippe Pinel took charge of
two enormous institutions and ‘struck off the chains from the insane’. He
was convinced that their brutal treatment made their disturbances worse,
rather than reduced them. In England at about the same time a Quaker
family, the Tukes, were appalled at practices in their local madhouse. They
established an alternative, the York Retreat, providing a calm and tolerant
setting where patients were kept busy and constantly encouraged.
Punishment and harsh treatments were expressly prohibited. They called
this approach moral treatment.

The success of the York Retreat became world renowned. Along with
Pinel’s fledgling attempts at the classification of mental illnesses, it formed
the basis of modern psychiatry and the asylum movement that was to
dominate it for the next century and a half.

At this time a remarkable individual, Anton Mesmer (1734–1815), was

revolutionizing how we treat those who, although not ‘insane’, suffered
from severe emotional problems. He used light hypnotism, which was
originally called mesmerism after him. His treatment relied on powerful
suggestion, using his force of personality. During sessions his patients often
became overwhelmed by strong and inexplicable emotions, after which
their symptoms might disappear. This looked very similar to the exorcisms
used by the church, but Mesmer’s rejection of religious explanations was
the turning point. His treatments initiated the rational investigation of
psychological processes that we now take for granted.

Mesmerism rapidly evolved into deep hypnotism, where patients discovered

hidden emotional conflicts during trance states. Along with post-hypnotic
suggestion (following instructions of which one appears to be totally
unaware), this obliged a rethink of the understanding of the mind in order to
accommodate unconscious processes. Until then the mind was the sum of
what you were conscious of thinking or feeling at any moment. René
Descartes’ ‘cogito ergo sum’—I think therefore I am—conveys this view.
Yet powerful forces and complex ideas were clearly in operation beyond the
reach of our day-to-day awareness. Hypnosis had also demonstrated that
such unconscious thoughts were involved in neuroses and could be used in
their cure.

Exploring the unconscious and the birth of

psychoanalysis
Hypnosis and suggestion became central to the treatment of neuroses in the
early 19th century. While Mesmer relied on drama and showmanship,
others were more reflective, recognizing the importance of trust and
suggestibility in the process. By the 1850s hypnosis had fallen from grace,
tainted by its association with spiritualism and fraud. It came back into
favour with the work of Jean-Martin Charcot (1825–1893), a celebrated
neurologist in Paris. Hysterical disorders were common at that time. They
included paralyses, blindness, anaesthesias, strange movements, and even
epileptic fits with no obvious physical cause. Charcot acquired an
international reputation in treating hysterical seizures using hypnosis (see
Figure 2). Freud, like so many aspiring neurologists, visited him and was
very impressed.
2. Une leçon clinique à la Salpêtrière, Andre Brouillet, 1887. Jean-Martin Charcot (1825–1893),
the famous Parisian Neurologist, using hypnosis to demonstrate hysteria. Freud visited him and
copied his methods

Back in Vienna, Freud began to use hypnosis and suggestion to treat his
neurotic patients. Despite some initial success he soon realized that
powerful suggestion followed by emotional release did not always work.
For many patients the detailed nature of their unconscious conflicts had to
be understood. Initially he believed that neuroses were caused by childhood
sexual abuse, which gave rise to memories that had to be kept unconscious
because they were too distressing. Later he changed his opinion and came
to believe that the abuse was imaginary, and that the neurotic symptoms
really arose from unacceptable impulses and drives. Psychoanalysts created
relationships with their patients, in which it was safe to dive deep into the
unconscious and confront what previously had been too threatening.
Unconscious processes had become firmly established as the source of
neuroses, and the substance of psychotherapy.

In the first half of the 20th century, psychotherapy essentially meant

psychoanalysis. There were various adaptations—shorter forms, group, and
even institutional forms—but the basic principles were the same. Their aim
was to guide the patient on a journey through their unconscious and to make
links or ‘interpretations’ between experiences in earlier relationships and
current problems. Other than during the two world wars, when it was
conscripted to deal with shell shock and battle casualties, psychotherapy
remained the preserve of the intellectual and the wealthy.

After World War II, society changed rapidly and new psychotherapies were
developed to reflect this. Psychoanalysis had itself contributed to these
changes, with its emphasis on the universality of emotional conflicts and
complexes, and its demonstration of the benefits of emotional honesty. It
now stressed the importance of early childcare and explored real
relationships, not just painful memories. With an increasingly egalitarian
society it became inevitable that such benefits should be made more widely
available. Psychoanalytic psychotherapy responded with shorter and less
intensive treatment regimes, once a week for a number of months rather
than daily for several years. However, the changes soon to come were even
more fundamental.

Psychotherapy in the present day

The problems we bring to psychotherapists (depression, anxiety, difficulties
with relationships, and self-doubt) may not have changed that much.
However, our expectations are now very different. The stiff upper lip has
given way in a society that prizes emotional expression and self-revelation.
People expect to be happy and they aspire to be so. The American
Constitution promises ‘Life, Liberty, and the Pursuit of Happiness’, and
most of us expect just that. This is very different to the world of duty and
acceptance that had shaped Freud and his patients. He explicitly rejected
happiness as a goal for therapy. For him, and his generation, the measure of
good mental health was to be able ‘to love and to work’ (zu lieben und zu
arbeiten). Indeed, he stated that the aim of psychoanalysis was ‘to
transform neurotic misery into common unhappiness’! This clearly will not
do for our modern tastes.

Personal fulfilment, self-expression, happiness, and control over our own

fate are the reasons most of us now seek out psychotherapists. It is not just
our aspirations that have changed. Modern society is more mobile and
fragmented, with dispersed families often unable to provide support, and
traditional religion playing a reduced role in giving comfort. Individuals
now need help with coming to terms with themselves as much as they do
with difficult relationships. Psychotherapy has changed and diversified to
meet these needs.

Counselling
In times of distress we need to be listened to and feel understood, and
counselling provides a kindly and tolerant ear. Counselling has become
available to those who would never have considered themselves as
‘neurotic’ or candidates for formal treatment with psychotherapy. It
provides help for ordinary people facing problems in everyday life or in
their relationships. Counselling was established by the work of Carl Rogers
(Chapter 5). He called it client-centred or person-centred to emphasize its
independence from rigid theories and dogma. It provides a calm, safe, and
supportive relationship that allows self-reflection and emotional healing.
Rogers recognized that simply having time to ponder your feelings and
thoughts is enormously valuable in its own right.

The relationship between counselling and psychotherapy is complex and

shifting and there is no simple, universally accepted description of their
differences. People argue about whether it is a form of psychotherapy or a
quite different activity altogether. It is generally less ambitious than
psychotherapy, with its goals less fixed and the process more directed by
the patient. In client-centred counselling the therapist resists imposing
structure. Counselling speaks to a universal human need, as is shown both
by the number who seek it out and the number who seek to practise it.
People like counselling, and they like being counsellors. Many do it without
payment in organizations such as the Samaritans and Relate. Training is
variable but generally quite short.

Counselling is also an integral part of many wider treatment regimes. Drug

and alcohol counsellors draw heavily on their personal experiences of
addiction to guide clients and sustain hope. Traditional client-centred
practice (‘how does that make you feel?’) often alternates with forceful
challenges in such rehab programmes. In hospitals and self-help groups for
patients with physical illnesses, counselling helps in managing the illness,
coping with anger and distress, and reducing isolation and hopelessness.
Counselling after personal trauma (such as assault or rape) and major
disasters (such as train crashes or earthquakes) is also regularly offered.

CBT and focused therapies

There are some radically new psychotherapies. The most widespread and
influential of these is CBT, which is outlined in detail in Chapter 6. CBT
focuses directly on current thoughts and actions (hence ‘cognitive’ and
‘behavioural’) more than on feelings and personal history. It identifies
unhelpful thinking patterns and challenges them utilizing specific
techniques, often practised between sessions. The aim of therapy is more
control and mastery than in-depth understanding. Treatments are usually
weekly for twelve to twenty sessions, sometimes even fewer. The
relationship is very equal and transparent, stressing collaboration, and is
devoid of mystique.

CBT’s ‘technological’ quality is probably its most significant break with the
past. Out goes the long training analysis and the mysterious and aloof
manner. In comes the therapy manual and democratic engagement, with
repeated exercises and measurement. CBT is probably now the most widely
practised therapy in healthcare and has a strong evidence base for treating
anxiety and depression. Its therapists see no conflict between ‘drugs’ or
‘therapy’, and are quite comfortable with ‘drugs and therapy’.

Sorting different therapies neatly into tidy boxes risks caricaturing them and
oversimplifying. In truth there has been a steady process of development,
refinement, and diversification of all therapies. Several have made radical
changes in theory and practice, although clearly with links to
psychoanalysis. Examples of this group (taken up in Chapter 4) are IPT,
DIT, and CAT.

Group and family therapies

Much of psychotherapy is directed at understanding the problems people
have in relation to those around them. In individual psychotherapy the
therapist has to rely on what the patient tells her, and this can be pretty one-
sided. Several therapies have broken through this barrier, and involve
relevant other people directly in the treatment. This can be by working with
naturally occurring groups, such as in couples or family therapy, or by
bringing together groups of individuals with similar problems, as in group
therapy. We are social animals and we come alive in our relationships, so
these psychotherapies can be dramatic and fast moving.

Family therapy was first used in the treatment of disturbed children and
adolescents. Sometimes a child’s disturbance is a symptom of a wider
family dysfunction which needs to change. Even where this may not be the
case the whole family may be affected and need help, as when a child is
gravely ill. Treatments can sometimes be very short, involving only a
handful of meetings. Family therapy usually focuses on current
relationships rather than digging into ancient history, and the emphasis is on
the structure of the relationships. The same is true of couples and marital
therapy. What is locking family members into sterile and repetitive
conflicts? How can they escape to something more supportive and
liberating?

Harnessing the power of the group has become a central plank in addictions
treatment, such as in AA. Self-help organizations form the mainstay of
support in alcohol and drug abuse worldwide, and they have spread to other
addictions such as gambling.

Most therapy groups are composed of individuals with similar problems,

but not all. The original group therapies brought together a range of
individuals seeking self-understanding and change. Some groups are
psychoanalytic in orientation, but most are more direct and exploratory. The
group benefits from the variety of individuals and problems it contains, as
members learn about themselves and experiment with new ways of relating
and being.

Interactive therapies
All the newer psychotherapies are more active than psychoanalysis. Freud
wanted to understand his patients’ mental processes and was keen to avoid
contaminating them with his presence. This gave rise to the ‘blank screen’
therapist, who strove to reveal nothing about himself by word or deed. Later
psychotherapists are less concerned about this and believe a well-timed
active intervention can move things along. More interactive therapists are
particularly needed with less ‘typical’ psychotherapy patients. The ‘right’
sort of psychotherapy patient was flippantly described as YAVIS—young,
attractive, verbal, intelligent, and successful. Clearly not all who need
psychotherapy fit this narrow caricature. Children, less introspective
individuals, those with less education, and those with less self-confidence
or motivation may need more active help.

Some therapies are based entirely on action, such as music therapy, dance
therapy, art therapy, and drama therapy (Chapter 7). These activities may be
healing in themselves. Intensely self-conscious children and adolescents can
lose themselves in music or dance, freed temporarily from doubt and
anxiety. Alternatively, the therapist may use the activity as a platform for
exploration: ‘Tell me about your painting. Why such dark colours?’
‘Hamlet’s speech seemed to stir you up—what do you think he was getting
at?’

There is a wide range of therapeutic activities and exercises that overlap

with psychotherapies. These include meditation, encounter groups, massage
therapies, and more. Many are very sophisticated, and it can be very
difficult to make a clear distinction between them and ‘psychotherapies
proper’. How can we decide what is and is not a psychotherapy, and which
to include in this book? We have relied heavily on ‘psychotherapies proper’
being individually tailored to each patient and their specific problems.
Activities or exercises which are equally useful for anyone (such as yoga or
meditation), while undoubtedly very good for us, are not included here.

New ideas and psychotherapy’s horizons

Completely new psychotherapies have arisen to meet modern man’s sense
of alienation. Existential psychotherapies, which are outlined in Chapter 5,
reject preconceptions about how we ought to be. They aim to liberate us
from what they see as a futile search for meaning. Having accepted the
randomness, even absurdity, of the universe we must find fulfilment in our
own unique existence. This ultra-modern emphasis on ‘being through
becoming’ is derived from philosophers such as Kierkegaard, Buber, and
Sartre, but is surprisingly close to therapies that draw on ancient Eastern
philosophies.

Eastern thinking emphasizes the constancy of change and universal

connectedness. Personal fulfilment and enlightenment come from self-
awareness in the moment with the abandonment of desire. Several Western
psychotherapies have incorporated such ideas. Jung wrote of the wholeness
of existence and attaining integration by abandoning striving. Gestalt
therapies work towards a sense of wholeness rather than concentrating on
detailed concerns. One of the most rapidly spreading forms of cognitive
therapy, mindfulness-based cognitive therapy (MBCT), draws heavily on
Buddhism. Patients meditate and concentrate on the moment, practising
tranquil self-awareness.

Current psychotherapies draw inspiration widely, well beyond

psychoanalysis and standard psychological theories. Your choice of therapy
may be based as much on your temperament and philosophy as your
symptoms. The no-nonsense thrusting businessman may choose CBT or
transactional analysis, while the more artistic individual might seek a
Jungian analyst.

Risks in psychotherapy
When you read articles comparing psychotherapy with antidepressants, they
always list the side effects and risks for the pills. Psychotherapy is assumed
to be risk free: ‘It may not always work, but it can’t do any harm’. This is
not so. Any effective treatment carries risks. Longer psychotherapies carry a
risk of overdependence or inertia. Issues can also be opened up which feel
overwhelming and result in increased distress, perhaps with a retreat into
alcohol or even self-harm. Good psychotherapists know this and carefully
assess patients’ character strengths and supports as well as their problems
before embarking on treatment.

Freud advised against psychoanalysis with psychotic illnesses or very

severe depression, and most psychiatrists and psychotherapists would still
agree. Exploratory psychotherapy is always unsettling to some degree, so
balancing the potential benefits against the stress involved should never be
neglected. If recovering from a severe mental illness, or alcohol or drug
abuse, it may be best to wait.

Most countries are trying to develop formal registration for

psychotherapists, to restrict membership to those with an adequate training
and with clear procedures for excluding incompetent practitioners.
However, it is an imperfect system and does not yet cover all
psychotherapists. In addition, psychotherapy is not an official profession, so
anyone can in theory call themselves a psychotherapist.

The privacy and confidentiality of psychotherapy can lead to a loss of

perspective. Relatively minor problems can become magnified or,
conversely, emerging issues can be missed because of the familiarity that
comes with the relationship. The therapist’s personality can have profound
effects, particularly if he or she is not fully aware of it. For this reason most
psychotherapists regularly meet with another colleague for supervision,
even long after they have finished their formal training.

There is also the rare risk of improper sexual conduct by therapists. The
intimate and private nature of all medical practice brings such risks. This
can be even more pronounced in psychotherapy where intimate wishes and
longings are ventilated, and where dependent and anxious patients can
come to idealize their therapists. Practitioners have always taken these risks
seriously, hence the existence of rigorous professional codes with severe
sanctions.

The best defence is to rely only on well-trained psychotherapists who are

members of established professional associations. This guarantees not only
their basic competence but also that they are in regular contact with
colleagues. Isolation is the danger—psychotherapists go astray much more
often when they work alone, especially in private practice. However, we
should not exaggerate these risks. Most therapists have their networks and
supervisors, so such incidents, while still indefensible, are very rare.
Finding a good therapist is not that difficult if you take soundings and get
advice. The following chapters will describe in more detail the thinking and
practice of the most common psychotherapies and what kinds of problems
they can help with.
Chapter 2
Freud and psychoanalysis

Almost all modern psychotherapies owe their origins to Freud and

psychoanalysis, although listening to psychotherapists talk you could be
forgiven for not believing it. Psychotherapists are a fractious bunch, given
to arguing over fine points of theory and splitting into ever-smaller schools
of thought. This ought not to surprise us. Psychotherapy is a very personal
activity. You have to be fully engaged in it to do it well, so it is difficult to
be dispassionate.

Throughout this book we describe how various therapies differ from one
another, so that you can get a grasp of them. In truth they have much more
in common. What can seem to be very diverse practices, using strikingly
different languages, often draw on a common set of processes and lead to
similar outcomes.

Psychoanalysis is no longer the commonest, nor indeed the dominant,

psychotherapy, but it has a unique place in its history and development.
Psychoanalytic principles and practices have influenced virtually all
subsequent therapies. Getting a grasp of them will help you to understand
what follows, so we will describe them in considerable detail. Let us begin
with the remarkable man who started it all.

Sigmund Freud (1856–1939)

Sigmund Freud was born in Freiberg, in what is now the Czech Republic, to
a Jewish wool merchant and his much younger third wife who doted on her
son. From the age of nine he lived in Vienna, at that time the liberal and
cosmopolitan capital of the Austro-Hungarian Empire. The studious and
talented Freud excelled at his schooling and became a doctor and
subsequently a neurologist, carving out a promising career as a researcher.

He met his future wife, Martha Bernays, in 1882 and promptly became
engaged. He needed to earn a decent salary to get married so he took a
clinical post in the Vienna General Hospital. He managed to continue
researching part time, and published on the properties of cocaine and on
some neurological disorders. All neurologists, then as now, are regularly
confronted with the puzzle of whether a patient’s symptoms result from
nerve damage or from underlying psychological problems. Neuroses,
especially hysterical disorders as they were called then, produced a range of
apparently inexplicable and disabling physical symptoms such as paralyses,
weaknesses, pains, and fits.

Married in 1886, Freud established a private practice specializing in

neurotic patients, many with these hysterical disorders. He lived and
worked in the same spacious apartment for forty-seven years until he was
driven out by the Nazis in 1938. By that time he was a very sick man and
died in London a year later. A very domestic individual, Freud was sober
and predictable in his habits, invariably dressed in a tweed suit. His only
obvious vice was smoking cigars, which eventually caused his fatal cancer
of the mouth. He was inordinately proud of his six children, particularly his
youngest daughter Anna, who became a noted child analyst.

In 1885–6 Freud spent four months visiting the world renowned Jean-
Martin Charcot in Paris. Charcot specialized in distinguishing hysterical
from epileptic fits and used hypnosis to induce and control the seizures.
Freud was very impressed, and on his return to Vienna began to use
hypnosis in his practice.

Psychoanalysis begins to take form

Freud’s use of hypnosis continued for some years. He would put his patient
into a light trance and, placing his hands on their temples, suggest that their
symptoms were becoming weaker or that power was slowly returning to a
paralysed limb. However, in 1896, along with Joseph Breuer, he published
five detailed case histories, Studies in Hysteria. In these they used hypnosis
not so much to cure the disorder but to gain an understanding of it, to reveal
the underlying neurotic conflicts.

Freud’s attention had moved from removing symptoms to trying to

understand the causes behind them. This preoccupation was never to leave
him, and it has remained central to most psychotherapy practice. Freud was
not the first to recognize the role of the unconscious in neuroses, but he
stands out because of his total commitment to identifying the causes of the
symptoms. He was committed to honesty and insisted on sharing the
unvarnished truth with his patients. Psychoanalysis aimed to explore
unconscious mental processes. What were its tools?

Free association and dream interpretation

Abandoning hypnosis, Freud began to encourage his patients to relax and
say whatever came into their minds. To help them relax they lay on a couch,
and he sat just out of view (see Figure 3). Uncomfortable or disturbing
thoughts and feelings—which had been actively suppressed in the
unconscious mind—could then bubble up, evading the usual controls. He
called this process free association. A similar process occurs during sleep
when repressed thoughts make their way into consciousness, albeit
exotically disguised in dreams.
3. Freud’s consulting room around 1910. Patients would have no chance of being unaware of
Freud’s personality and interests when lying in this room

Freud called what we remember on waking the dream’s manifest content.

The dream’s real meaning, its unconscious latent content, has been distorted
in its journey to consciousness by several recognizable processes. These
include condensation when a single image serves to convey a number of
different concerns, or symbolization when a vivid image stands for an
unacceptable preoccupation. One rather hackneyed example is dreams of
trains being understood to symbolize sexual intercourse. Analysis was
needed to uncover the latent content.

Searching out the clues to neurosis revealed in dreams and free associations
remained the basis of all Freud’s subsequent work. He believed that nothing
was ever truly forgotten, and that nothing was ever just coincidence, hence
the ‘Freudian slip’. Everything had a meaning, and that meaning could be
uncovered by analysis. Over his lifetime Freud radically changed many of
his ideas about mental mechanisms, the origins of neurotic symptoms, as
well as practical aspects of psychoanalysis. However, he never deviated
from his search to understand and uncover unconscious conflicts.

The most distinctive feature of psychoanalysis is the interpretation. An

interpretation is when the analyst helps make the link between unconscious
meaning and motivation, conscious experience, and behaviour. Clarifying
these links promotes insight into the previously obscure origins of current
difficulties. The patient can then respond more rationally to issues in her
life.

Infantile sexuality
Freud initially believed that the hysterical disorders in his women patients
were the result of sexual abuse in childhood, often by their fathers. Over
time he came to doubt this explanation. He concluded that these stories of
abuse arose from fantasies, from the child’s desire for an intense, intimate
relationship with her father. To explain this he proposed that right from
birth we have strong instinctual (sexual) drives, which he called the libido.

Freud proposed that the libido developed through several stages

culminating in the Oedipus complex. Around the age of three to five years
the child struggles to have an exclusive and intense relationship with the
parent of the opposite sex and experiences the other parent as a rival. This
rivalry and jealousy generates the Oedipal triangle.

Freud believed that it was possible to become stuck at any of several earlier
developmental stages, and that this would prevent healthy maturation. He
saw the successful resolution of the Oedipal triangle as essential for mature
sexuality. This was necessary for forming realistic and affectionate adult
relationships, and to tolerate sharing. Those who did not resolve it were
trapped into seeking unrealistic, exclusive, and oversexualized
relationships.

Mental structures: the ego, id, and super-ego

Freud became interested in the mental structures that shaped and modified
these strong instinctual drives. He believed they arose in the primitive and
chaotic unconscious mind—what he called the id (‘it’ in Latin). They both
influenced and were controlled by the more rational conscious mind, the
ego (‘I’ in Latin). Freud proposed a third structure, the super-ego, for our
self-critical and controlling behaviour—our conscience.
He initially thought the super-ego was derived from our parents. However,
the scathing self-criticism he observed in severely depressed patients made
him question its rationality. His solution was to conclude that while it was
derived from the ego (representations of our parents and upbringing), it was
powered by the id, which contributed its primitive intensity. Many analysts
(such as Melanie Klein) now believe that this intensity is because the
Oedipal conflict actually takes place much earlier. Consequently, the super-
ego acquires some of the characteristics of the fearsome monster of a small
child’s nightmares, rather than just an overly strict parent.

Freud’s final addition to mental structures was the concept of defence

mechanisms. These are our mental mechanisms to deal with unwelcome
unconscious thoughts and feelings on a day-by-day basis. Unlike the
repression in neurosis, these do not require constant energy to hold the
threatening thoughts and feelings out of consciousness. Defence
mechanisms become stable parts of the personality—reliable, automatic
ways of dealing with uncomfortable issues as they arise. Defences include
denial (as in the alcoholic who bluntly insists he has no problem),
projection (where an angry person claims he is ‘just fine’ but everyone
around them is furious), and splitting (which deals with complex
relationships by making one person the good guy and the other the villain).

Exploring defence mechanisms became an important part of

psychoanalysis. Initially they were seen simply as a resistance to analysis,
which had to be overcome to get to the underlying conflicts. They later
came to be seen as key features of a patient’s character whose
understanding was helpful in its own right.

A particular aspect of treatment that troubled Freud was when patients

idealized him, especially when they declared they had fallen in love with
him. He called this transference, believing it was the transfer of emotions
from previous important relationships on to the current therapeutic one. He
initially saw it simply as resistance, but over time came to believe it is an
essential part of treatment—a vital route into the unconscious.

Transference analysis is now a central feature of all psychoanalysis. It uses

the patient’s responses to the therapist as a guide to how they experience
their other relationships and themselves. It also includes analysing counter-
transference, the feelings evoked in the therapist by the patient.
Interpretations which link the transference relationship with the patient’s
life situation and simultaneously with important past experiences are
considered to be the most potent. Counter-transference work enables
psychoanalysts (and psychoanalytic therapists) to work with adults who are
less verbal, or even young children seen with their parents.

The spread of psychoanalysis

All the early analysts in Vienna were Jewish (Carl Jung in Switzerland was
the first non-Jewish practitioner). The rise of Nazism in the 1930s forced
them to leave for the US, the UK, and South America, where they
established many psychoanalytic institutes. Theories developed and
disagreements lead to splits. The most acrimonious was the early departure
of Carl Jung, whose thinking (see Chapter 3) had always incorporated
spiritual dimensions. This grated with Freud’s more reductionist emphasis
on the role of sexuality. Numerous other ‘schools’ of psychoanalysis have
developed, many long-since faded away.

In the US the ‘neo-Freudians’ and ‘ego-psychologists’ established a strong

presence, with figures such as Karen Horney, Erich Fromm, Alfred Adler,
and Harry Stack Sullivan. They proposed a broader understanding of the
origins of neuroses, emphasizing the role of culture and social influences. In
the UK Melanie Klein’s approach effectively bypassed the ego to interpret
primitive emotions and fantasies right from the start. She was also one of
the first to use psychoanalysis with children.

More recently, the French psychoanalyst and philosopher Jacques Lacan

has profoundly influenced psychoanalysis in much of continental Europe
and Latin America. A prodigious intellectual, Lacan’s writings are
incredibly difficult to understand and some of his practice eccentric. For
instance, his analytical ‘hour’ always started late and lasted only as long as
he thought it useful or productive.

Psychoanalytic training
Psychoanalysis is very strict about who can call themselves analysts and
about what training and supervision is required. In the 1920s Carl Jung
insisted that analysts should have their own training analysis. Nowadays the
training is demanding, involving several years of training analysis,
attendance at seminars, and close supervision of early treatments. This
protracted and expensive training is thought by some to make analysis too
rigid and inhibit originality. It certainly makes analysis expensive.

Being in analysis: once a week or every day?

Few analysts see all their patients five days a week. It is neither affordable
nor compatible with modern lives. Most patients have one or two sessions a
week. Some analysts consider this an unavoidable compromise, and that
difficult patients still need a ‘full analysis’. The majority have adapted to
less frequent sessions and consider the advantages to probably outweigh the
disadvantages. The experience may not be so intense, but it focuses the
minds of both partners and allows time to reflect and reality-test between
sessions.

Some time ago we both shared a flat in south London with a trainee analyst.
He headed off before seven in the morning to Hampstead, five mornings a
week, for his analysis. He then came back to his full-time job as a
psychiatrist, before returning to Hampstead to his patients or seminars every
evening, to come home exhausted at nine or ten at night. We often joked
with him that he could not have anything to speak about in his sessions
other than the analysis itself and the traffic jams between us and
Hampstead! His experience was that this very intensity allowed him to
delve deeper into personal understanding without daily life intruding too
much. This ‘time out’ from normal life, inhabiting a different mental zone,
is undoubtedly a special quality of a full analysis. But what should one
expect from weekly analytic treatment, often called psychoanalytic or
psychodynamic psychotherapy?

The first sessions

The first session will be devoted to finding out why you have come. The
therapist will introduce herself and explain that she is there to listen to you.
She will work with you to help you understand your problems better, so that
you can find solutions to them. She will usually outline how the process
works and give you some idea of what to expect. Sessions are likely to last
an analytic hour (50 minutes) and to be at a regular time each week. The
50-minute hour gives the therapist time between patients to write notes and
ensures that each session starts on time.

Analytic therapies use punctuality and regularity to provide a sense of

structure and security around what can be an emotionally harrowing
process. Regularly coming late or missing sessions will be seen as evidence
of resistance—that you are trying to avoid painful issues. Analytic
psychotherapists are strict with all routines and boundaries and rarely
permit contact between sessions. Even if you are very upset at the end of a
session you will be encouraged to contain your emotions until the next one.
Living with, and trying to understand, powerful feelings is part of the
treatment.

Most therapists will offer a small number of exploratory sessions before

you both decide whether or not to continue. Your therapist is likely to be
relatively silent, but that does not mean that she is not listening. Everything
said in the room is confidential. Confronting painful issues can temporarily
increase distress rather than reducing it, and it is important to stay engaged.
That the analyst does not rush to comfort you does not mean at all that she
is indifferent, but rather that she wants you to have time to better understand
what is going on. All that is expected of you is to try and be as honest as
possible.

Having outlined the process the therapist will encourage you to talk about
your problems. ‘Tell me in your own words what is going on in your life
and why you are here. Just describe it, don’t try to explain it, and take your
time.’ Many people find this first session highly emotional, often bringing
an enormous sense of release, with words and emotions flooding out. The
therapist will not interrupt much in the first session. This is not a time for
detailed clarification but for getting an overview; your emotions are as
much a part of this as your story.
Therapists usually take care to wind up the first session in good time. This
allows them to summarize and discuss with you any thoughts they have
about what you have said, for example:

The relationship you describe with your partner seems to be burdened with anger, possibly
carried over from your disappointment with your father. You have shown me how upsetting it
remains for you, and that probably needs to be better understood. We will need to continue
with this next time.

This reviewing also allows time for you to move back out of the
emotionally intense world of psychotherapy and prepare to face the
everyday world as you step outside. Do not be surprised though, if you do
not get any clever summary or psychological ‘diagnosis’. Many therapies
have identified assessment sessions, but analytic therapy has a much more
open-ended approach to how long treatment will last and what will be
worked on.

Free association, interpretation, and working through

In psychoanalytic therapy you will remain very much in the driving seat.
The therapist will not tell you what you should or should not talk about.
Free association (saying whatever comes into your mind) is still the
cornerstone of the treatment. This is matched by the analyst’s free-floating
attention to themes that emerge in what you choose to talk about. You are
nowadays more likely to sit in a chair and face your therapist than lie on a
couch. You will also be encouraged to report and discuss your dreams.

Analysts believe nothing you say is random. It is all important and it stems
from the preoccupations that are troubling you, but which you may be
trying to avoid. The meaning will become clear in time, as long as you are
patient and do not rush it. This sounds self-indulgent and easy but it is not.
Most of us can find the apparent lack of structure very stressful initially,
and want the therapist to be more directive. Very often in the beginning we
experience our mind as being totally blank. The analyst may reply that it is
almost impossible ‘not to think’, we should just take time, and the thoughts
will surface.
Analytic psychotherapy is based on the premise that if we understand what
is going on in our minds, then we have the possibility to change it—in
Freud’s words, ‘where id was, ego shall be’. So analysis aims above all else
for self-understanding, for insight. Over time the therapist will increasingly
make interpretations to promote insights. Imagine describing the surprising
anger you felt when your partner forgot your birthday:

It was ridiculous. I know he has been very busy, and I know he loves me, but when he sat
there chattering away and clearly had completely forgotten I felt hate, real hate. I wanted to
scream at him or pack my bags and leave. Yet he is considerate and affectionate and I knew
perfectly well he had been preoccupied with the house repairs. How could I feel such hate
over something so trivial?

The therapist might link this to your earlier descriptions of a sense of

neglect when you were growing up:

This sounds very similar to how you described feeling left out and ignored by your father
when your sister was ill. How hurtful it felt, yet because of the worry about your sister you
could not have a tantrum or tell your dad. Could there be a link with that pain and not just the
forgotten birthday?

Interpretations help us recognize how our responses (whether thoughts,

feelings, or actions) are so damaging or distressing. This is because they
relate not just to what is happening now but also to earlier, unresolved, and
formative experiences. They are rarely blinding flashes of insight that
instantly clear away the fog of neurosis. They have to be repeated, building
up a richer understanding of what are well-entrenched, complex patterns of
thought and behaviour. The most effective interpretations are believed to be
those that illuminate the similarities between important past relationships
and current experiences in both your day-to-day life and in what is going on
in the analysis itself—the transference. Such triangular interpretations (see
Figure 4) are sometimes called mutative interpretations because of their
power to stimulate change.

Using such links there is the possibility of working through the pain of past
experiences—coming to terms with them and moving on. Working through
is the main task of therapy; more time-consuming and less glamorous than
the interpretations, but essential for personal growth and healing. In
working through, the transference relationship to the analyst assumes a
central role. Old feelings of anger, despair, rejection, or resentment that
have festered under the surface for decades are reignited and experienced in
the room. The analyst is the object of these feelings and must withstand
them, neither retaliating or wilting under their attack, nor rushing to remove
discomfort.

4. Triangle of persons

The concerned but relatively reserved manner that analysts adopt, the blank
screen, makes it possible to project transferred emotions on to them.
However, they should be blank but not absent—without trust and a sense of
security in the relationship such projection would be altogether too
frightening to engage in. The relationship must have enough depth for these
storms to be both weathered and confronted while new patterns are evolved.
Working through enables us to make the hugely important shift from
understanding the problem intellectually (‘I see that this has upset me
because I tend to believe that nobody is capable of helping me’) to really
feeling it (‘I really did feel unloved and unsupported—yet now I sense that
people in my life can help me’).

Analysis of defences
Latterly, analytic therapists have focused more on helping us understand our
habitual defence mechanisms—the patterns we regularly use to deal with
things that would otherwise make us uncomfortable. So rather than going
straight for the troubling conflicts underlying our neurotic problems, they
may examine our routine ways of dealing with these uncomfortable issues.
The two are not mutually exclusive and most therapists will do both.
Sometimes work on defence mechanisms is needed in order to get to the
underlying conflicts. A patient may, for instance, routinely intellectualize
their problems, denying the emotional impact of them:

5. Triangle of conflict

I realize that he has been too busy to remember my birthday; he’s been altogether far too
busy. I just got a bit irritated because I worry he is not looking after himself enough and
allowing time for himself.

Several sessions may be needed to understand the origins of this intellectual

defence and the underlying conflict or feelings (see Figure 5).

When is enough? The ending of therapy

Traditional psychoanalysis can go on for years. There is no fixed limit—
you carry on until the work is finished. Woody Allen once quipped after
seeing his analyst for fifteen years, ‘I’ll give it one more year and then I’ll
go to Lourdes’. Most analytic therapy nowadays is time-limited, although
not a rigidly fixed number of sessions.

The analyst David Malan, who inspired the triangles used in Figures 4 and
5, pioneered a sharply focused thirty-session analysis, sometimes referred to
as ‘short-term psychodynamic psychotherapy’. However, it is more likely
that at the start you and the therapist will agree to see each other for a
defined period, say once a week for twelve months, and then review.
Having an end in sight right from the beginning focuses the mind and
avoids coasting along with no sense of urgency. Too much urgency,
however, would inhibit the free-floating exploration essential to
psychoanalytic work, so a balance has to be struck. A year seems a long
time at the start, although it may not feel like that as the time approaches.
The ending of therapy is often experienced as its most productive period.

Ending can be painful, even if the therapy has done its work—perhaps
especially if it has. Strong feelings about the therapist are common, often of
an idealizing nature, as they have been experienced as understanding and
tolerant. The goal in analysis is to end with a balanced view of the therapist
—neither all-knowing and wise, nor cold and insensitive. Achieving such a
neutral appraisal while continuing to separate is difficult, so a ‘wobble’ is
common towards the end. The gains may seem to be lost and symptoms
may suddenly recur. This is a sign that the work of ending is underway, not
a reason to delay it or to prolong therapy.

Who benefits most from psychoanalytic

psychotherapy?
Those who go into analysis or psychoanalytic psychotherapy, particularly in
private practice, are a highly self-selected group. This is a form of therapy
that appeals broadly to those who are interested in the life of the mind or
their internal world for its own sake. They may want increased self-
understanding almost as much as they want relief from symptoms. It would
be wrong to believe that you have to be some sort of intellectual to benefit,
but the therapy is challenging and does require intellectual curiosity. It is
best suited to those with difficulties in relationships in general rather than
one relationship in particular, or with a gnawing dissatisfaction with their
lives rather than isolated anxiety attacks. Psychoanalytic psychotherapy is
certainly no quick fix. It is not for the impatient, but it can undoubtedly turn
lives around when it works.
Chapter 3
Post-Freudians: moving towards
the interpersonal

The early development of psychoanalysis was a period of intense

intellectual ferment. Freud’s ideas were evolving rapidly and he collected a
glittering group of followers. Initially they were all men; creative, self-
confident, and argumentative. They rapidly began to generate their own
ideas, often falling out with each other, and several split from Freud. The
first to leave the group was Alfred Adler, but the most acrimonious and
influential split was with Carl Jung.

Carl Gustav Jung

Jung was the first non-Jewish psychoanalyst and the first one not from
Vienna. He lived in Switzerland working as a psychiatrist with Manfred
Bleuler, the psychiatrist who introduced the term schizophrenia. Jung was
twenty years younger than Freud, tall and wealthy, and their relationship
was very intense until it soured.

Jung had always been somewhat mystical. Unlike Freud he came from a
religious family, and his earliest interest had been in paranormal
phenomena. He eventually fell out with Freud over what he saw as Freud’s
excessive emphasis on the role of the sex drive, but also more generally as a
reaction to Freud’s unremittingly rational approach. Jung was
fundamentally a romantic individual who believed that analysis had the
potential to bring patients to an emotionally richer, more spiritual state.

Jung’s constant striving for something more, and his dissatisfaction with the
mundane, characterized both his thinking and his life. He broke sexual
boundaries with patients and during a particularly turbulent period he
probably tipped over into a brief psychosis. Despite all this (or perhaps
because of it) he was enormously productive and creative. He introduced
the concepts of introvert and extrovert, but he is probably best known for
his ideas on symbolism.

Jung took a radically different approach to the unconscious material that

patients reported in their analyses. He was one of the few early
psychoanalysts who worked in a psychiatric hospital, and had noticed
similarities with the hallucinations described by psychotic patients. He
observed regularly recurring images of easily identified figures, such as that
of a wise old man, a warm motherly figure, God, and the Devil. Freud
thought of these as distortions caused by neurotic conflicts, but Jung
believed they were fundamental to human thinking. He called them
archetypes, and believed that they could be found in all cultures and all
times. He concluded that we access them from a collective unconscious, a
folk memory that we are all born with and which shapes us.

Prominent archetypes include the anima (the feminine side of men), the
persona (the face we present to the world), and the imago (our ideal self).
The shadow is particularly important in Jungian thinking. It contains all our
most shameful and frightening experiences, thoughts, and feelings—those
that we keep hidden both from ourselves and from others. Jung thought that
our shadow grew stronger and more threatening the longer it was ignored
(like Oscar Wilde’s ageing portrait of Dorian Gray). For us to develop
healthily it needed to be brought into the daylight and confronted.

Jungian psychotherapy is called analytical psychology to distinguish it from

psychoanalysis. It is shorter, usually with weekly sessions for a year or so,
and there is no analytical couch. Therapist and patient sit facing each other
and therapy is much more focused on the here-and-now. Analytical
psychology aims for integration of the personality, aspiring to a harmony
which accepts inherent contradictions rather than striving to reduce or
eradicate them. As in classical analysis, the initial sessions involve an
exploration of early experiences, and dreams are also taken very seriously.
However, this early exploration is soon brought to bear in understanding
current experiences and problems. In sharp contrast to psychoanalysis,
dreams are taken at face value with no tortuous extraction of latent from
manifest content.

While Freud was fairly modest in his aims for therapy (‘to convert your
neurotic anxiety into day-to-day misery’), Jung believed it could make us
better people. His emphasis on personal integration, his preoccupation with
symbols and Eastern mysticism (see Figure 6), and his tolerance of
uncertainty, have meant that Jungian psychotherapy is particularly attractive
to creative and artistic individuals and also to people later in life.

Freud thought that we become less able to utilize psychotherapy with

increasing age, because we become more rigid. Jung, on the contrary,
believed that the wealth of life experience older people bring makes them
eminently suitable for psychotherapy. Jungian psychotherapy provides
opportunities to make sense of life and come to terms with ourselves and
our approaching mortality. Because of its tolerance of ambiguity and
mystery, it is often experienced as richer and more tolerant than analysis.

Alfred Adler and the neo-Freudians

Alfred Adler was one of Freud’s original inner circle. Although also a
Viennese Jew he was very different from Freud. He came from a large
Hungarian family (Vienna was still the capital of the Austro-Hungarian
Empire) and was short and physically unimposing. His politics were radical
and his personal habits chaotic. His lasting contribution to psychotherapy is
the inferiority complex. He also thought that Freud overemphasized the
sexual, and believed that what drove most of us was a struggle to overcome
a sense of personal inferiority, whether real or imagined.
6. The mandala—an Eastern spiritual symbol of the universe and wholeness. Jung wrote in his
memoirs: ‘I sketched every morning in a notebook a small circular drawing … and discovered
what the mandala really is: … the Self, the wholeness of the personality, which if all goes well is
harmonious’

Adler was very energetic and forthright. He actively spread his ideas
throughout workers’ education movements, schools, and various other
institutions. He situated the patient firmly as a whole person in his social
context, and believed that you had to understand this context in order to
understand the individual. He often interviewed family members and
encouraged frank exchanges between them. Many of his ideas about social
inclusion and the power imbalances in society (especially that between the
sexes) seem strikingly modern. He saw neurotic symptoms as barriers to
achievement and self-fulfilment, and would often start his therapies with the
question ‘If you didn’t have this problem, what would you be doing?’

Neo-Freudians
Adler moved to the US in 1930 and was followed by many Jewish
psychoanalysts fleeing the Nazis. These arriving analysts were exposed to a
dramatically different lifestyle in America and were taken aback by it. The
impact of culture and the wider society on them and on their patients was
revelatory. The effects of society and culture in shaping patients’
aspirations, their values, and also their neuroses could not be ignored. Neo-
Freudian practice and writing embraced a broader, more interpersonal,
perspective.

This attention to social factors in psychotherapy was not a trivial departure.

Karen Horney, an early member of the group, challenged the entrenched
gender stereotypes of psychoanalysis, as have many feminists since. She
attacked its prejudices against women and the demeaning concept of ‘penis
envy’. She even argued that male ambition and competitiveness were
themselves a form of envy, an envy of women’s innate creativity in giving
birth. The shift in thinking was profound.

Psychotherapy was becoming firmly located as an interpersonal activity. Its

focus was moving to the current interactions between the patient and the
individuals who mattered to them. Painful memories from the family past
were no longer the whole story. Just as a patient’s relationships determined
their well-being, so their interaction with the therapist became key to
successful psychotherapy. These interactions were seen as agents of change
in themselves, not simply tools to understand intrapsychic events. Another
in this group, Harry Stack Sullivan, declared that psychotherapy should
‘focus on the interactional, not the intrapsychic’. Therapists should pay
attention to the real events in their patients’ lives (which he called
‘problems in living’), not just to patients’ interpretations of them. For later
existential therapists such as Irving Yalom (Chapter 5) the relationship itself
came to be seen as curative.

Erik Erikson
The neo-Freudians had initiated a process that would, in time, lead to
counselling and person-centred therapy. Erik Erikson helped set this
transformation on its way by radically rethinking the maturational crises we
experience in our lives. He proposed that we continue to face new
challenges to our sense of identity throughout our lives, calling them the
eight stages of development. Problems can arise at any of these stages, even
if earlier ones have been resolved perfectly well. For example, Erikson
believed that we can develop serious psychological disturbances when
confronted by a crisis such as a serious illness, despite having been
perfectly well adjusted previously. This is in stark contrast to traditional
analytical thinking where such late-onset psychological crises are explained
as reactivations of unresolved earlier conflicts.

Erikson, despite his name, was also a German-speaking Jewish analyst from
Vienna. He was tall, blond, blue-eyed, and had been taunted from an early
age from both sides (Aryans about his Jewishness, Jews about his Aryan
looks). His work reflects this experience. His eight stages in life each
present us with a potential identity crisis (Box 1). Each of these identity
crises contains two opposites that have to be recognized and accepted, with
both making their unique contribution to who we are.

Box 1 Erikson’s stages of psychosocial (ego) development

 Completed Failed Age
Trust Mistrust 0–1
years
Autonomy Shame 1–3
years
Purpose–initiative Guilt 3–6
years
Competence–industry Inferiority 6–11
years
Fidelity–identity Role confusion 12–18
years
Intimacy Isolation 18–35
years
Generativity Stagnation 35–64
years
Ego integrity Despair 65 years
onwards

Obviously these ages are just rough indications. Erikson’s stages provide a
structure for understanding problems that takes age and experience into
consideration, and even later challenges and stages have been added more
recently to his original eight in response to working with our increasingly
ageing population. Erikson did believe, like Freud, that getting stuck in
personal development later in life was more likely if earlier conflicts had
not been resolved. However, he also believed we could break down later in
life, even if all the earlier conflicts had been surmounted. For instance, a
successful and well-balanced man who has been enormously productive in
his career might still struggle with the end of that career. His ‘generativity’
may become eroded by the ‘stagnation’ in his leadership position.

Daniel Stern, an American analyst and researcher, came to an intermediate

position, based on close observations of mothers and babies. He described
different domains in the development of our sense of self. He viewed each
of these domains as tasks for life that are never fully resolved, and so we
revisit them repeatedly. Like Erikson, he also stressed the importance of
attending to the ‘present moment’, in therapy as in all our relationships.

Shell shock in World War I

There is a clear intellectual thread running from Jung to the neo-Freudians.
Practice steadily shifts away from a tight focus on what is going on in the
patient’s mind and its origins in very early experiences. The interest settles
more on what is happening right now, both between the patient and the
therapist, and also more widely in the patient’s life. These were, however,
not the first variations in Freudian practice. During World War I,
psychotherapy came into its own during the treatment of shell-shocked
soldiers (Figure 7), although the military psychiatrists using it did not have
much time left over for writing up their theories.

World War I produced an enormous number of psychological casualties.

This was mainly because of its special nature—months of waiting around in
trenches, always on edge for the next sniper bullet or shell to land. Most
soldiers had only a limited education and were psychologically
unsophisticated. Many developed what we now easily recognize as
hysterical disorders—uncontrollable shaking, paralyses, and nightmares
that made them unfit to fight. These conditions became severe and chronic
because they were unable to make the link between the onset of their
symptoms and the very understandable terror they were experiencing.

A slimmed down and modified Freudian approach was rapidly developed

for treating shell shock. This abandoned Freud’s sexual theorizing and
focused on emotional conflict. Symptoms originated from the soldier’s
sense of duty and his ‘unacceptable’ (and thus repressed) desire to escape
the horror of his current situation. Like the later neo-Freudians, the army
doctors worked towards rapidly uncovering these repressed desires and
fears. However, they were not interested in, nor did they have time for, fine
details. They relied heavily on their status and force of personality to
reassure and encourage their patients, often using simple hypnosis to
strengthen suggestions. An important feature of this rough and ready
psychotherapy was normalizing the experience for the soldiers and
protecting their self-respect.

7. The great numbers of soldiers who developed shell shock in the trenches demonstrated that
psychological stress could cause breakdowns and psychological treatments were needed to help
them

This down-to-earth and more supportive analytic relationship features

widely in novels, but has received relatively little attention in
psychotherapy literature. It demonstrated a pragmatic and self-confident
approach by doctors familiar with Freud’s and Jung’s psychodynamic
thinking.
Attachment theory
A similar leap forward occurred after World War II, with the creation of
attachment theory, proposed by John Bowlby. Bowlby was an analyst
familiar with the work of leading animal behaviourists. He had been sent
away early to boarding school by his rather cold, upper-class family, and
was acutely sensitive to the importance of separation for young children. He
undertook groundbreaking investigations into the lives of displaced children
in the aftermath of the war.

In his highly influential book Maternal Care and Mental Health, Bowlby
stressed the importance of a consistent and warm early bond with the
mother for emotional development. His insights have revolutionized the
care of children in day nurseries and hospitals across the world. He
emphasized the importance of the quality of this real relationship rather
than the infant’s fantasies about it—such as the real experience of
abandonment, deliberate or otherwise—and this initially made him
unpopular with analysts.

His concept of secure and insecure attachments, which provide us with

internal working models for subsequent relationships, is now widely
accepted. The sense of security experienced in therapy is now seen as a
reparative experience, one that has some potential to make up for an earlier
inadequate attachment. It sees the secure attachment to the therapist as a
healing factor in its own right. Cure does not come exclusively from
intellectual insights enabling the working through of earlier conflicts. These
conflicts may simply lose some of their power as a direct consequence of
this new healing experience.

Donald Winnicott was a prominent psychoanalyst and paediatrician who

also linked actual events and experiences in real relationships with our
personal development. He introduced two influential new ideas. The first
was that of the good-enough mother. She should not be too perfect or there
would be no scope for spontaneity and change. Equally, she should not be
too chaotic or there would not be sufficient security and containment for
emotional growth. Being ‘good enough’ means accepting those natural
flaws and minor failures, which we all need to learn to tolerate and master.
His second idea was the false self that a child might develop in response to
a mother or carer whose own needs are too strong and intrusive. If this
happens then a false self, which is often overly mature and seemingly self-
confident, is presented to the world like a shield. A consequence is that the
true self becomes isolated from experience and is deprived of opportunities
to develop fully.

These developments may seem a bit academic, but they have had an
enormous influence on psychotherapy and more widely on how we manage
our personal and family relationships. What is characteristic of all of them
is the elevation of the importance of real experiences in the process of
psychotherapy. The reality of the mothering experience matters as much as,
if not more than, any fantasies and conflicts surrounding it. What sort of life
the patient is living now also matters—whether or not she has the potential
to establish and maintain close and fulfilling relationships.

Lastly, the tone of the psychotherapy matters, not just its success in the
technicalities of uncovering conflicts or interpreting defences. The
psychoanalyst Nina Coltart stressed how ‘people not only like, but need, to
tell their stories, especially to an attentive listener equipped with certain
skills’, someone who ‘listens in a particular way’. Freud believed that the
analyst should be a neutral figure, and that any transference was to be
understood and interpreted away. Now it is no longer considered a failure of
therapy if the patient comes away with a fond memory of the process and a
genuine affection for their analyst.

Psychotherapy has moved permanently away from the caricature of an

exciting, intellectual detective story, tracking down and unearthing the
hidden cause of problems. The relationship itself matters. The therapy
relationship is usually experienced as warm and positive, but it is most
emphatically not just that. The therapist’s job is to use it to work with
relationship patterns and behaviours, many of which may be quite painful.
Analysts still insist that the treatment should not be too comfortable—
patients have to confront difficult issues. However, virtually all
psychotherapists now recognize that the quality of the relationship matters
in its own right and is a major part of the cure. In all of the therapies
described in the following chapters you will see this understanding run
through their practice.
Chapter 4
Time-limited psychotherapy

Early psychoanalytic treatments were often brief. Freud treated two of his
most famous patients over a very short period: ‘Dora’ only for eleven
weeks and the ‘Rat Man’ for eleven months. He saw the composers Bruno
Walter and Gustav Mahler for only six and four session each. Some of his
contemporaries attempted to develop shorter treatments as well as varying
the analytic technique to make it more active.

Despite this, psychoanalysis demonstrated a remorseless lengthening.

Further innovations, such as the development of the transference neurosis
and regression, required extensive working through. The passive analytic
stance increased the risk of dependence in longer therapies. Psychoanalytic
training added a further pressure by requiring extensive personal analysis
and lengthy training cases. Brief therapies are also more demanding to
conduct, and their greater turnover of patients adds to professional
uncertainty. Brief therapy came to be seen as second best or inferior.

In recent decades interest has grown in the development of shorter or time-

limited psychotherapies. Originally initiated by psychoanalysts, this
development has been accelerated by accumulating evidence for the
effectiveness of time-limited therapies, especially CBT. It had regularly
been observed how change occurs most often either in the early stages of
therapy or when the end is in sight, but that focus can be lost in the middle
stages. This also contributed to the drive for shorter therapies.
Cost-effectiveness pressures and the need to provide evidence-based
treatments identified, for example, by NICE (National Institute for Clinical
Excellence) in its guidelines for the UK’s health services, have coincided
with demands from patients for shorter treatments. For many of us,
therapists and patients alike, short-term therapies are now the treatments of
choice, rather than a necessary compromise. The IAPT programme
(Improving Access to Psychological Therapies) in the UK, which offers
short-term, mainly CBT-based therapies, has consolidated this development.
A number of time-limited psychotherapies have emerged with increasing
evidence for their effectiveness but also with plenty of ‘sibling rivalry’. Let
us start by outlining what they have in common.

Common features of brief psychotherapies

‘Psychotherapy should be as short as possible and only as long as the
patient really needs it’ writes Angela Molnos. The aim of therapy is ‘to
create a special place in which the past can appear in the here-and-now, a
space in which past emotional conflicts are re-lived and understood with
clarity, and in which new solutions to old problems are found’. Common
factors include weekly, face-to-face sessions with a more active therapist,
and with a clear focus on problem patterns as they present. Depending on
whether the therapy is more psychodynamic or cognitive in nature, the use
of transference will vary, as will the emphasis on problem solving. Dynamic
approaches are more likely to pay attention to attachment and loss during
the ending of the therapy. Therapies also vary in how much they follow a
detailed manual outlining practice. CBT practitioners often value them,
whereas brief psychodynamic therapists rarely rely on them.

The shortening in brief therapies is most noticeable in the early sessions.

Patterns of thinking and feeling are identified and are challenged very early
on. Problematic personal and interpersonal patterns do not require much
digging to find—if we only look carefully, they are there in all our
interactions. The therapist may notice how the person enters the room
(striding in or shuffling, looking the therapist in the eye or avoiding her
gaze, talking non-stop or having to be drawn out) and feed this back. Such
habits reflect the person’s lived experience, and how this shows in the
present provides food for thought. Observations like these lie at the core of
the therapeutic process, and are returned to regularly.

To illustrate these points and give a flavour of brief or time-limited

therapies, we describe three common, but distinct forms. IPT was devised
specifically for depression. CAT is an integrative approach, combining
cognitive understandings and techniques within a more analytic framework.
SFT is an active approach, which engages people’s inbuilt ability to find
solutions. As Chapter 6 is devoted to CBT, it will not be included here.

We find that making a distinction between brief therapies and time-limited

ones is helpful. Brief therapies usually last for one year or less but there is
quite a degree of flexibility. In time-limited therapies the number of
sessions or the length of therapy is explicitly determined at the outset. Most
time-limited therapies are also brief but they do not necessarily have to be.

Interpersonal psychotherapy (IPT)

IPT was developed in the US in the 1980s by Myrna Weissman and John
Markowitz, specifically for people with depressive illness. It has been
shown to be very effective with patients who are either not helped by
medication, or are unwilling to take it. The term ‘illness’ is used quite
deliberately here. A central feature of IPT is explaining that the patient is
suffering from a medical illness, thereby giving her temporary relief in the
‘sick role’. This reduces self-blame and guilt, and helps patients to accept
that they are not at fault for feeling the way they do. It also confirms that
this is a well- recognized and treatable condition, and thus helps to instil
hope. IPT also includes psycho-education about the illness and its various
treatments as part of the protocol.

Despite its very medical language IPT insists that mood and life situation—
and especially relationships—are closely interrelated. Patients are helped to
make links between life events and the onset of their depression. IPT has an
explicit relationship focus, and the patient’s aims for therapy are usually
linked to bringing about changes in their relationships. Therapy is based on
common therapeutic factors such as developing a strong treatment alliance
and emotional engagement, so that patients can feel understood and
supported during a difficult phase in their lives. However, the therapy
relationship is not explored in any detail as in psychodynamic therapy.

IPT links the emergence of depression to commonly occurring and

disturbing life events. These are grouped as losses (or bereavement) such as
the death of someone close, role transitions such as significant changes or
life upheavals, or role disputes which are conflicts or struggles with
important people. IPT goals are to reduce or remove depressive symptoms,
to improve interpersonal functioning, and to resolve interpersonal problems.
The therapist pays particular attention to how patients communicate their
needs and feelings to others. They also help patients to repair their social
supports, which are often lost in the withdrawal from contact so common in
depression.

IPT is limited to between twelve and sixteen sessions, and is highly

structured with a defined beginning, middle, and end. The therapist and
patient start by conducting an interpersonal inventory. This lists in detail
the important relationships in the patient’s life, such as with partners,
parents, or children. They examine the emotional quality of these
relationships with close attention to the feelings both within and between
the people involved. They will explore patterns of interaction and
communication, especially if conflicts are experienced. Does the other
person, such as a partner, help the patient manage better or actually make
the problem worse? The therapist will use all indications, in both verbal and
non-verbal communication, to establish possible links between the
relationships and the onset of symptoms. Together therapist and patient try
to understand the ‘why now?’ while also identifying any underlying
personal vulnerabilities or predispositions. The goal of the beginning phase
is to create a joint formulation of the problem—what may have caused it as
well as what keeps it going. A common pattern is a vicious cycle of
depression leading to lowered self-esteem, resulting in social withdrawal, in
turn leading to loneliness and increased depression. We all recognize what it
is like to feel miserable, embarrassed, or ashamed and so not to want to
trouble others. The result is that we don’t make that call to a friend or ask
for help.
The work of the middle stage will depend on which of the three possible
areas has been agreed in the beginning phase: losses, role transitions, or role
disputes. With losses the therapist will help the patient describe in detail the
actual death: what happened, whether it was expected or not, what the
funeral was like, and any rituals involved. They will focus on any feelings,
particularly when these were negative or ambivalent. Patients often need
special help to think and talk about the loss and any associated difficult
memories, about what they miss, and how to begin to move forward. For
one patient this had become a seemingly overwhelming task, after the
sudden death of her ‘perfect’ husband. He had been the one to take
responsibility for comforting and supporting her in all aspects of life—
practical, interpersonal, and emotional. Suddenly she was deprived of it all,
with few psychological tools for managing the catastrophic fall-out. How
could she even begin to admit to any angry or mixed feelings towards this
paragon?

For role transitions, the therapy starts by identifying which spheres of life
are affected. These can include work roles or social roles such as moving
home or the children leaving, or they can be biological to do with health or
ageing. What often matters most is whether the transition was planned,
whether it was wanted or not, and whether it was accompanied by a loss of
support. The therapist helps the patient recognize the feelings connected to
the transition, particularly any sense of loss. The patient’s capacities and
resources are not neglected—both internal and external strengths are
identified. Opportunities arising from the change are sought which might
require learning new skills or managing new challenges. Learning how to
assert needs and preferences, or even taking risks, can be part of this
process.

A communication analysis often has a central place in role disputes or

conflicts. This carefully explores what the patient wishes for, and whether it
is reasonable and realistic. Time is spent understanding what she wants to
say, how she says it, how this comes across to others, and whether it is
understood by them. A withdrawn woman, used to taking a back seat in the
family, thought resentfully that others should be able to ‘read her mind’.
She therefore failed to spell things out, or else she tended to say things in
such a soft voice that they didn’t hear it or take it seriously. The therapist
will help the patient make potential links with symptoms. Any mismatch
between what the person had aimed for and the actual interpersonal
outcome is carefully discussed. Different ways of communicating can be
explored by brainstorming or role plays, always encouraging the patient to
come up with ideas herself and try them out. Although IPT does not use
homework as such, the patient might be encouraged to rehearse and practise
things between sessions.

The end phase of therapy focuses on reviewing and consolidating any gains,
and if necessary making contingency plans for the future. As the ending is a
transition in itself, some of the skills learned earlier can be applied to it.

As with most therapies, the initial model has been refined by experience
and research. Dynamic Interpersonal Therapy or DIT is a recent such
development in the UK, which lasts for sixteen sessions. It is an approach to
IPT which combines an interpersonal focus with a more psychoanalytic
stance, following a clear manual through the different stages of therapy. It
uses interpretations of unconscious feelings and reactions in combination
with what is known as mentalization. This comprises techniques to enhance
the patient’s capacity to reflect on her own states of mind, and through this
to better understand what others might be feeling or thinking. By becoming
more aware in this way she can improve her ability to understand and
manage relationships.

Cognitive analytic therapy (CAT)

CAT was first developed in the 1980s in the UK by Dr Anthony Ryle, a
general practitioner working with students in a university setting and later
in adult mental health services. His initial aim was to create a common
language for the psychotherapies. He was frustrated with psychoanalysis
for its resistance to research, and with behaviour therapy for its
reductionism. CAT takes psychiatric diagnoses and individual presenting
problems seriously, but quickly moves to address the difficulties behind
them. It focuses on the sense of self, often negative or fragmented, which is
trapped by unhelpful relationship patterns.
CAT is a time-limited therapy, usually sixteen weekly sessions with one
follow-up at three months. For more complex difficulties, this can be
extended to twenty-four sessions with additional follow-ups. Like most
brief therapies, CAT is an interactive model, based on collaboration and
joint exploration. The model shares the analytical interest in exploring the
early roots of interpersonal difficulties and the need for all of us to have a
sense of our own story or narrative. It tries to understand how we have
arrived at this point in our lives and what keeps us here, even—or
especially—when the personal cost is high.

A joint reformulation of the patient’s narrative, and the core patterns

emerging from it, is expressed in the form of a letter, derived from the
discussions in the first few sessions. This is initially brought in draft form,
written by the therapist, and read out aloud by her. A common reaction to
hearing the letter is a sense of being validated, as if troubles have been
witnessed or acknowledged. The letter summarizes the person’s life
experiences and lays out the conclusions she has drawn from them. These
conclusions are usually about her sense of personal value, about her
relationships and how to deal with feelings and conflicts that emerge within
them. The patient takes the draft letter away, rereads it, and brings it back
with any amendments necessary to truly reflect their experiences. Once
agreed, it becomes a shared basis for the remainder of the therapy and,
indeed, for beyond therapy. Both parties can refer back to it at any time, and
it helps them keep on track as therapy progresses. One patient took to
keeping it in her bedside table and would read it to herself during times of
stress, or to remind herself of how to act and think differently when falling
back into old coping strategies.

A second function of the letter is to jointly identify a couple of main or

target problems to focus the therapy on, plus unhelpful patterns or
procedures stemming from attempts to solve these problems. Such
procedures often end up as problems in their own right. A young woman
brought back her letter with big, dirty footprints all over it, after leaving it
on the staircase in her shared house. This spoke volumes of her tendency to
let people ‘walk all over her’, while she attempted to fit in with everyone, in
order to feel accepted and valued.
The main part of the therapy then involves exploring and understanding the
various ways in which such unhelpful interpersonal patterns (known in CAT
as reciprocal roles) manifest themselves. It includes paying attention to how
the person treats herself, whether through self-neglect or overindulgence, or
in more extreme self-harming ways. It will especially note when these
patterns repeat themselves in the therapy relationship.

The patient and therapist together then look for exits or alternative ways of
self-management and of interacting with others, and will use the therapy
relationship or transference in this process. Change moments often come
when a familiar interpersonal pattern is reactivated in a session, but
accompanied by a new way of being or relating. This challenges the
person’s familiar expectations and habits. A common example is to expect
rejection or criticism after having been angry with the therapist in a session
or after revealing what were believed to be shameful secrets.

The main difference from IPT lies in the way these patterns are outlined
very explicitly in CAT, especially in the form of a diagram, which the
therapist and patient draw up together (see Figure 8). This identifies the
interpersonal patterns that most commonly occur in the patient’s life,
including how these are linked. Such a visual representation helps her take a
step back from the overall picture and develop what is called an observing
eye (or ‘I’), aiming for a more integrated sense of self. With this overview
she can start to join up the dots, see a fuller picture, and get a different
perspective on herself. The diagram can also help the person recognize
patterns or voices that have been handed down through the generations and
help them find their own, authentic voice through dialogue with the
therapist.

The diagram uses the person’s own words as much as possible, and the
therapist will take care to build on their strengths and ‘push where it
moves’. The aim is to enhance the patient’s (self-)reflective capacity and to
gradually make the tools for this her own. Anthony Ryle wrote, ‘what the
person can do with the therapist today, s/he will do on her own tomorrow’.
As with CBT, the patient is helped to become aware of their thought and
behaviour patterns and to devise homework tasks. These usually involve
small steps to break unhelpful patterns such as beginning to say no to others
or creating time for self-care.

8. With the help of this CAT diagram the patient could see how her attempts to feel better
about herself just led back to old, unhelpful patterns

Difficulties may emerge towards the end of therapy, often relating to past
losses or unresolved separations. These will have been identified and
anticipated in the early letter or in the diagram, which helps to address
reactions to the ending, such as anger or sadness. The ending is also
attended to by the patient and therapist each writing a goodbye letter. This
is a letter to the other person, but also an opportunity to summarize the
therapy. It covers what has been gained and learned, but also openly
acknowledges missed opportunities, and realistically predicts challenges
ahead. It is a chance to say a ‘fare well’ or an explicit ‘goodbye’, rather than
repeat painful ‘byes’ of the past.

Solution-focused therapy (SFT)

SFT has links with Ericksonian thinking, and was developed by Steve de
Shazer in the US during the 1970s. He noticed that clients seemed more
energized when talking about solutions to their problems and how they
would like their future to be, rather than analysing past difficulties. A
central feature of the model is its non-pathologizing stance. It identifies
healthy aspects of the person’s experience that can be used, and it
underscores that they already have resources to draw on. Therapy becomes
a process of mobilizing and building on these to resolve problems, always
with an eye to the future. A refreshing change if you have felt mired in
problems for a long time! The focus in SFT is on ‘competences rather than
deficits, strengths rather than weaknesses, possibilities rather than
limitations’. SFT can be very brief, often just three to six sessions.

SFT seeks solutions which ‘fit the client rather than the problem’. In this it
is very like IPT and CAT, but it is more explicitly directed towards solutions
for the future rather than linking with the past. SFT uses a number of
specialized techniques referred to as skeleton keys. One is inviting people to
become aware of exceptions, times when they succeeded in solving their
problems. It also involves identifying and mobilizing the client’s personal
and social resources, and imagining how they would like their future to be.
This might include asking the miracle question discussed below, but mainly
uses small, manageable steps when trying to change.

Personally relevant and realistic goals are generated. These are very
concrete and require specific actions, rather than being vague formulations
expressed in negative terms, such as wanting ‘not to feel depressed any
more’. The aim is for ‘good enough’ or satisfactory outcomes, with agreed
ways of recognizing when these are achieved. Links are made between
outcomes and what clients have done differently, so that they can take credit
for their own achievements. Problems are discussed openly, with the
therapist taking their share of responsibility. The therapist might ask
questions such as ‘What have I missed?’ or ‘What needs to happen today?’

SFT pays very close attention to the use of language. Questions are usually
framed positively: ‘What are your best hopes for this session?’ ‘What are
you already doing that is helpful?’ ‘How will you know that today has been
helpful?’ This engages the person in examining their expectations and their
own role in changing. Questions cover how the person will know when
things are getting better or how many sessions are needed.

The miracle question, a striking SFT technique, goes something like this:

Imagine that while you are asleep tonight a miracle occurs, and when you wake the problem
you have told me about has disappeared. You are now problem free. However, because you
have been asleep you won’t know that the miracle has happened. What will you notice when
you wake up that shows you things are different?

You are encouraged to ask yourself about the experience, again using
positive language: ‘What will I be doing differently?’ ‘What will I be
saying?’ ‘How will it affect my life?’ ‘How would I know that?’ ‘What will
others notice and how will they describe it and react?’ ‘What else will be
different?’ ‘And what else … ? And what else … ?’

An angry young student regularly sabotaged himself by missing course

deadlines, getting into drunken fights, and generally underperforming,
rather than stand up to his father and challenge what he saw as high family
expectations. Via the ‘miracle’ he might allow himself to enjoy doing well.
The therapy focuses on how this will manifest itself, not on wishful
thinking. What will the person be doing and thinking differently, and what
are they doing now that will move them towards this ‘miracle’ scenario? So
our student might identify how he was speaking more openly to his parents,
that he was getting support from his brother in this, that he had cut down on
his drinking, and that it had made a difference to his girlfriend.

SFT therapy sessions use scaling. So in relation to the miracle question the
therapist might say: ‘If on a scale of 1 to 10, 10 means you have already got
there, and 0 means you haven’t even started, where would you say you are
today?’ If the young man thinks that he is on a 3, he might review with the
therapist what he did to get there, and what he needs to do to get to point 4
before next week. Scaling can be used at any time during or between
sessions. One can rate where one was before, what one did to get from there
to here, what are realistic hopes, what might sabotage change, and how to
prevent this. SFT always uses positive questions, such as ‘What makes me
hopeful that I will move up the extra two points?’

Much of the work in SFT takes place between sessions using tasking or
homework assignments. These involve thinking about the change you
desire and the actions needed to achieve it. It means trying out and
practising new skills independently and in the contexts where they belong.
Some homework simply involves observational tasks, such as noticing
things that already work well or keeping notes of positive changes. These
can then be combined with behavioural tasks—doing things differently,
such as saying no rather than giving in. Similarly, cognitive tasks will
provide alternatives to negative thinking habits, such as ‘Today I didn’t let
my worry stop me from going to the shops on my own’ rather than ‘I will
never get back to having an independent life’. Using rituals or metaphors
that mark a new stage or symbolize the achievement of a task can boost
morale and give a sense of achievement.

As in all time-limited or brief therapies, the ending of therapy will have

been on the agenda right from the start. SFT differentiates explicitly
between treatment goals and life goals. Without this any therapy can
become overextended, invite dependency, and unwittingly undermine the
self-confidence and self-reliance that has been built up. Unlike in CAT, SFT
clients will determine when therapy should end, and SFT therapists find
that most opt for a brief input. The ‘good enough’ outcome between
‘miracle’ and the status quo is identified early, and anticipated in detail,
including how it will be recognized if and when it is achieved. It is then
time to stop.

What these and other brief or time-limited therapies share is the sense that
because time is at a premium, every session counts. Both parties have to
make active use of the time available to them. A focus is created at a very
early stage, and the patient or client plays an active role in addressing their
difficulties, both within and between sessions. There is also an unspoken
belief that once people begin to do things differently, those around them
will respond differently, and therefore much of the working through will
occur naturally within these relationships. Obstacles in this process can be
anticipated in the therapy, and new alternatives practised. In this way, the
therapy quickly starts to look towards the future and draws on the person’s
own resources. This in itself reduces the risk of dependency with its
potential to undermine confidence, and represents one of the major
advantages of time-limited psychotherapy.
Chapter 5
Counselling

Many more of us will see a counsellor than ever be treated by a

psychotherapist. Family doctor surgeries, colleges and schools, and many
workplaces now employ counsellors. How is counselling different from
psychotherapy? The word has several meanings—from a careers counsellor
who advises on jobs, to being ‘counselled’ (told off) about work
performance. In this book counselling refers to a confidential relationship
between a client (the term preferred by counsellors, rather than patient) and
an individual who is trained to listen attentively and who will try and help
you improve things through support and understanding. What is the
difference, then, between counselling and psychotherapy? This is a good
question, but one that is not easy to answer. The boundaries are blurred and
no definition pleases everyone. However, there are some recognizable and
useful differences.

Overall, counselling is less formal than psychotherapy, and the relationship

between counsellor and client more equal. The word counselling itself is a
bit less ‘threatening’ and therapists working in schools or colleges are often
referred to as counsellors to reduce anxiety about going to see them.
Counselling also tends to be shorter, often just half a dozen sessions. It is
rarely more than once a week and is usually less expensive. Most
counselling training focuses predominantly on the use of counselling skills
and on building the therapeutic relationship rather than on any complex
model of mental functioning. It is generally less theory-laden. This does not
mean there are no guiding principle, or that counsellors make it up as they
go along, but you are unlikely to have a sense that a specific interpretation
of your problems is imposed on you or on the process. As with
psychotherapy, counselling can focus on specific symptoms or on more
general problems of living. There are times when counselling is preferable
to more formal psychotherapies, as in coping with acute and overwhelming
events such as a bereavement or a relationship break-up.

Initially there was no training requirement for counsellors. Individuals with

a wide experience of human life and with a warm and tolerant personality
simply ‘became’ counsellors. Although still very variable in length and
intensity, training requirements are becoming more formalized. Many
counsellors in the UK are registered with the British Association of
Counselling and Psychotherapy (BACP), although they are not required to
be. To be registered they need to have completed a recognized training
course, many of which require them to have spent some time in counselling
themselves. They must have a supervisor with whom to discuss practice and
keep up to date with their subject. The BACP was originally the British
Association of Counselling, but it added Psychotherapy in 2000 as
counselling training became more sophisticated. The name in itself is
emblematic of the overlap between counselling and psychotherapy, which
we have outlined. Let us start with the fundamentals of counselling practice,
before describing some approaches in more detail.

Rogerian or client-centred counselling

Whatever they are called (existential, rational emotive, problem-based)
most counselling draws on the core tenets of Carl Rogers’ client-centred
approach. Carl Rogers (1902–1987) was an American psychologist and
psychotherapist who reacted against the pessimistic view of human nature
that dominated psychotherapy during his training. He rejected its excessive
focus on symptoms and disorders, basing his approach on humanism and
existentialism. Humanism emphasizes the basic goodness and positive
striving of all individuals, while existentialism teaches that the meaning of
our lives lies in what we do with them. To be what he called fully
functioning we continually have to make choices, and making choices is
inherently stressful. Rogers concluded that the only one who could know
what was right for an individual was that person himself. In client-centred
counselling, the client is always the real expert whose judgement should be
trusted when things are unclear.

The titles of Rogers’ most influential books (On Becoming a Person and A
Way of Being) demonstrate his outlook and underscore his fundamental
principle of counselling. Counsellors have to embody the counselling
process; it is not a technique to be learned but a philosophy to be embraced
and lived. Counsellors must accept the basic value and goodness of
everyone (including themselves) and recognize the healing power of self-
awareness and human relationships in the conduct of their daily lives.
Without this their counselling would be a hollow sham. Rogerian
counsellors disapprove of technique and explanations, relying instead on
their style of relating and on clarification.

The core conditions

Rogers believed that certain core features of the counselling relationship
were responsible for healing. Of the original conditions, he described three
that have become accepted as the basis of all psychotherapies. Two of the
others are so self-evident they are hardly mentioned. One of these is that
there has to be a psychological contact, a real relationship, which fully
engages both counsellor and client—one that they are both aware of.
Counsellors allow a greater degree of self-disclosure, acknowledging the
feelings in the room, and may sometimes share aspects of their own
experience, such as a bereavement. In drug and alcohol counselling services
an openly acknowledged history of addiction is often a requirement. The
second ‘self-evident’ condition is to communicate this engagement and
understanding to the client. It is no use having all this commitment if the
client remains blissfully ignorant of it. What, then, are the three core
conditions for successful counselling and psychotherapy?

Congruence or genuineness
This means that the counsellor is fully engaged both in himself and in the
relationship. Rogers originally used ‘congruence’ to convey that the
counsellor’s personality matched (was ‘congruent with’) her behaviour in
the session. She is not putting on a professional front, so can legitimately
draw on her own experiences in the therapy. The declared aims of the
counselling—those agreed by counsellor and client—then really are shared
objectives. Congruence is now more often described as genuineness or
authenticity. The three core conditions will vary in intensity over time, but
genuineness is a precondition for the other two. A counsellor who denies
that she is anxious in a session, while her body language clearly
demonstrates she is, will find it hard to help a client to be honest.

Empathy
The counsellor has to gain an understanding of what the client is going
through, emotionally as well as intellectually. Empathy means being able to
feel what the other person is experiencing. It is not the same as sympathy,
which is to feel for their plight. Accurate empathy is a core skill in all
therapy. We need to be able to ‘get under the skin’ of our patients and to see
the world through their eyes. Empathizing with a client means acquiring an
‘as if’ experience of what they are going through, not sharing it directly.
The therapist does not have to be personally anguished to empathize—in
fact this could be most unhelpful.

Establishing empathy often requires clarifying emotions. Rogerian

counsellors frequently repeat the clients’ comments (mirroring), often with
a questioning tone to encourage them to tease out what exactly they are
experiencing. What matters is that the client, not the counsellor,
understands. This mirroring of the client’s utterances has at times led to a
cruel and dismissive caricature of Rogerian counselling, in which such
repetition is presented as purely reflex:
CLIENT: I feel awful.
COUNSELLOR: You feel awful.
CLIENT: It’s hopeless. I’m going to end it all.
COUNSELLOR: You feel hopeless. You’re thinking of ending it all.
CLIENT: I’m jumping out of the window!
 COUNSELLOR: You’re jumping out of the window!

Of course it is not at all like this. Mirroring and clarification are active
processes to deepen understanding, without which change cannot take place
or freer and healthier choices be made.

Unconditional positive regard (respect)

It is difficult to imagine helping someone in counselling or psychotherapy if
you actively dislike them. Rogers believed that you have to have a real
desire for your client to do well, and to genuinely respect their struggle. At
the very least you should not find yourself disapproving of them, and
certainly not express such disapproval. This may seem a counsel of
perfection, as we all have our prejudices. The need to believe in people’s
fundamental goodness does not mean that counsellors are always ‘warm
and cuddly’. The clarification employed to deepen empathy often requires
asking hard questions and making uncomfortable observations.

Unconditional positive regard sounds very daunting so is now usually

called respect. You can have a positive regard for someone despite finding
some of their behaviour off-putting. Most therapists have strategies for
maintaining this distinction, just as clergymen profess to ‘love the sinner
but hate the sin’. Counsellors who really cannot warm to a client may refer
them on to a colleague, whereas a psychoanalyst is more likely to see such
feelings as important counter-transference clues to be worked with.

As in the later psychotherapies, the relationship itself has a central

importance in counselling. It is not simply a framework for exploring the
patient’s internal life, but a curative force in its own right. Many counsellors
distrust theories and concepts such as the Oedipus complex, archetypes, or
maladaptive schemas. The client is the only one who can answer the ‘why’,
and remains the final expert.

However, the nature of the counselling relationship carries some specific

risks. Because it is less structured and theory-bound, and because the
training is usually shorter, things can go wrong. A naïve counsellor may
blur professional boundaries too much and risk becoming overinvolved
with their client, or become swept up in the suffering. Self-disclosure (‘I
recognize how this feels, my own brother died suddenly when I was
young’) can be very powerful, but it can also derail the treatment. It could
overburden clients who may feel they then have to care for their counsellor.
Regular supervision is necessary to manage this tricky balance, particularly
if the counsellor has no other professional background (nurse, social
worker, psychologist) where supervision is an established practice. The
BACP has been at the forefront of developing codes of ethics and practice
to address these risks. We will now describe some specific counselling
approaches.

Existential therapy
Person-centred counselling derives its thinking in great part from existential
philosophy. Existentialists believe that what matters is what we do, rather
than who or what we are. It is our own actions (our existence) rather than
some preconceived view of human nature (an essence) that is important. We
constantly create our identity rather than being determined by it, and our
lives are driven by motives rather than causes. Every choice we make
defines us, and we have no option but to continually make choices.
Existentialists emphasize that we are active agents in the world, not objects,
so therapists strive strenuously to avoid objectifying or categorizing the
patient. They emphasize a mutually interacting relationship, focused on the
here-and-now and an immediate relationship with the world.

The American existentialist-humanistic approach

The first form of existential therapy was developed by Ludwig Binswanger
in the 1930s and is now mainly of historical interest. The existentialist
approach lives on in humanistic counselling and psychotherapy. Rollo May
and his enormously influential pupil Irving Yalom shifted the focus to a
consideration of the individual’s subjective reality; that is, how the client
experiences his own world. This deviates from the hard-line existentialist’s
insistent focus on interaction with the outside world. Their approach
focuses back on to the client’s inner life and emotions.
In contrast to Freud’s rather dour pessimism, Yalom brings a sunny
Californian positivity and optimism. He encourages the client to stay with
their emotions and confront the defences they have erected to protect
against life’s complexity: ‘feel the fear and carry on’. Like Rogers, Yalom
encourages therapists to be open to the client, and he repeatedly insists that
‘it is the relationship that heals’. Increased self-understanding may be
helpful, but it is not enough, nor is it the crucial ingredient. The vital
ingredient is the relationship itself.

This existential-humanistic approach re-engages with the unconscious, but

it is warmer and more directive than psychodynamic counselling. It is
concerned with the present and the future, rather than with the past.

Therapy focuses on four core existential concerns: death, freedom,

isolation, and meaninglessness. Counselling approaches for the physically
and even terminally ill have been extensively developed. Despite this
apparently morbid preoccupation, the tone of existentialist-humanistic
counselling is inexorably upbeat. Complaints of ‘can’t’ are reframed as
‘won’t’. In his 1980 book Existential Therapy, Yalom exhorts the client to
repeat regularly to himself or herself the following statements:
Only I can change the world I have created
There is no danger in change
To get what I want I must change
I have the power to change

The British existential school

In contrast to the sunny, Californian optimism of the American
existentialist-humanists, the British existential therapy school assumes that
‘life is an endless struggle’. Developed and popularized by the Dutch
psychotherapist Emmy van Deurzen, this approach links back to traditional
existentialism. It focuses on the immediate relationship with current reality
rather than the intrapsychic, subjective world of the patient. It continues to
emphasize the importance of an ‘authentic’ relationship, and rejects the
trappings of formal psychotherapy and of diagnoses and classification. It
construes patients’ problems in terms of being ‘clumsy at living’. True to its
existentialist roots it is relentlessly descriptive rather than explanatory. The
aim of therapy is to form a clearer awareness of experience rather than try
to explain it. In this it takes from Rogerian therapy, and in practice it is very
non-directive and democratic. It re-emphasizes ‘being with the patient’. Its
radical and anti-authoritarian (anti-expert) stance makes it very attractive to
those who might have difficulty tolerating a more paternalistic or
establishment approach.

Transactional analysis (TA)

TA is a very accessible theory of human interaction that is used by many
integrative or eclectic counsellors. It was introduced in 1964 by Eric Berne
in his bestselling book Games People Play. TA focuses on how we
communicate with others, and it replaces the three familiar Freudian levels
of super-ego, ego, and id with the mental states parent, adult, and child.
Berne shared Rogers’ and Yalom’s broadly optimistic view of human nature
and of our capacity to find success and happiness. Well-balanced
individuals behave as adults and treat those around them as adults. This was
captured in the title of one of the most successful TA books, I’m OK, You’re
OK.

Berne’s approach achieved instant popularity, not only through his easily
grasped structure of the parent, adult, and child roles, but via his description
of a series of ‘games’ with catchy titles. The ‘games people play’ are based
on the various permutations of the three roles (I act like a child that forces
you to act as a parent, I act as a parent forcing you to respond as a child,
and so on). Our tendency to fall into these roles in different situations will
depend on our own issues (see Figure 9). We may feel driven to exploit the
child role when we feel particularly insecure, or perhaps the parent role
when we want to avoid the intimacy that can come from adult sharing.
9. The three possible roles or ‘ego-states’

The most famous of these games is the ‘yes, but’ gambit, which is very
familiar not only to counsellors and therapists but surely to us all. The client
describes a problem that is troubling her, but when the counsellor points to
an obvious solution this is countered with an explanation of why it will not
work:
CLIENT: People dismiss me, even when they know I’m right, because I’m a scruffy dresser
and they are all snobs.
COUNSELLOR: What would it be like for you to ensure that when you are going to those
sorts of meetings you put on a suit? You don’t have to wear one all the time.
CLIENT: If I weren’t myself, if I had to put on a show, then it would all be a waste of time
and I wouldn’t care if they agreed.

On the face of it this is a reasonable adult-to-adult discussion about identity

and integrity. However, the counsellor might note that the patient is using a
victim-child state to engage the therapist’s parent role. The conversations
people engage in are built up of transactions which can be analysed in this
way. The most complex transactions occur when there is a deliberate or
unconscious difference between the overt social exchange (what is said)
and the covert psychological intent (what is meant). These are referred to as
ulterior transactions and need careful unpicking.

The most obvious strength of the TA approach is its common-sense quality.

We can all grasp the three roles, and once the games are pointed out they
are very easy to recognize. Counselling, of course, goes beyond simply
‘spotting’ games or the roles being used. It is the task of understanding why
and how the client uses them with certain individuals and in specific
circumstances that matters.

Drug and alcohol counselling

There is no recognized model for drug and alcohol counselling, but
counselling is used extensively throughout such services. The practice is
very widespread indeed, which should come as no surprise. It takes real
commitment and energy to get off and to stay off drugs or alcohol—to ‘kick
the habit’. The initial phase of getting off drugs or alcohol under medical
supervision is now fairly straightforward, but staying off is anything but.
This is where counselling comes in. Staying off requires radical changes in
lifestyle, giving up something that used to provide the pattern for your
existence, moving away from a familiar social circle of other drinkers and
addicts, with few other supports.

Alcoholics Anonymous (AA) is the most widespread system worldwide to

support sobriety in alcoholics, and its offspring Narcotics Anonymous (NA)
helps drug users stay ‘clean’. Its twelve steps approach is not, in itself, a
model of counselling but a structure, both social and psychological, to help
the addict embark on a new life. AA insists that with no ‘cure’ for
addiction, you have to renew a commitment to abstain ‘one day at a time’.
AA has quite a religious feel to it, with regular meetings where members
ritually acknowledge their problems: ‘My name is Janet and I am an
alcoholic’.

Most services for addicted individuals go beyond supervised withdrawal

and support from AA or NA meetings, and they also offer counselling. This
aims to help the recovering addict understand the personal issues that may
have driven them to drugs or alcohol and, just as importantly, those that
keep them stuck in their habit. What emotional pain was the drug blunting?
What failed relationships did the intoxication obscure? What made sobriety
unbearable? In addiction circles the language is often quite dramatic:
‘demons’ rather than complexes, ‘self-destruction’ rather than risk-taking.
But the issues are the same. Unresolved feelings, painful memories, low
self-esteem, and disturbing ruminations make it harder to get off and stay
off drink or drugs and to build new relationships.

As we have mentioned, there is no unique theoretical model of counselling

for addictions—person-centred counselling is the most common approach.
It often comes with strict rules on abstinence as a condition of attendance.
Blunt confrontations are common, which can seem quite brutal to outsiders,
although addicts often welcome them. They are only too familiar with their
evasions and have extensive experience of ‘fooling’ previous counsellors.
Many services insist that the counsellors are themselves recovered addicts
who are familiar with such self-deception and so don’t pull their punches
when pointing it out.

Psychodynamic counselling
Distinguishing psychodynamic counselling from client-centred counselling
is fairly easy, but distinguishing it from psychodynamic psychotherapy is
not so straightforward. This is probably where the boundary between
counselling and psychotherapy is the least clear. Many counsellors describe
themselves as psychodynamic, so being clear what it is, and the difference
between them, is worth some effort. While retaining many of the core
features of counselling outlined at the beginning of this chapter,
psychodynamic counsellors base their practice on traditional
psychodynamic or psychoanalytic theory. They focus on helping the client
become aware of unconscious conflicts and making sense of them, often
using interpretations (see Chapter 2). The aim in psychodynamic
counselling is ‘to make the unconscious conscious’—Freud’s ‘where id
was, ego shall be’. Once the client is properly aware of the unconscious
forces shaping their experiences and behaviour, they can start to sort
themselves out.

Psychodynamic counsellors are much more likely than client-centred

counsellors to respond to a question with another question or an
interpretation. Their aim is to uncover underlying issues. For instance, if a
client comments that their counsellor looks under the weather, the Rogerian
is likely to encourage them to explore in more detail their experience of that
concern. The psychodynamic counsellor, however, may seek out underlying
anxieties or hostilities: ‘perhaps you think that the problems you have been
sharing are too much for me and I am not coping?’

Psychodynamic counsellors pay particular attention to containing clients’

distressing experiences, often rephrasing them so the client can confront
them safely. The active emotional engagement buffers the pain of these
experiences so that they can be carefully examined. This is often referred to
as holding, a concept described by the analyst Donald Winnicott. It implies
that the strength of the relationship is such that it can contain intense
experiences that would otherwise be overwhelming.

By holding, and reflecting back a somewhat more manageable version of

the client’s conflicts, the counsellor provides the opportunity to find an
alternative way forward. The experience itself is partly curative. The
presence of a trained person who is able to withstand such stresses can be
used to explore and replay old conflicts and find new solutions. Unlike most
other counsellors, psychodynamic counsellors allow a degree of regression
and for clients to become more dependent so that they can explore their
more child-like feelings and impulses.

In practice, psychodynamic counselling can be quite long term—many

months or even a year or two. It is also rather more formal, being strict
about times and self-disclosure. The client is no longer the sole expert on
their inner life, although clarifying it is very much a collaborative exercise.

Telephone counselling
The Samaritans in the UK and their sister organizations across the world
have long demonstrated the value of fast access by telephone, and now
often by e-mail, to a sympathetic listener. They provide an opportunity to
express and share acute distress rather than simply soldiering on or
resorting to drastic acts such as self-harm or suicide attempts. The
telephone service Child Line in the UK offers similar opportunities to
children who experience neglect or abuse. In our age of the Internet and
Skype the lessons learned from these services have been taken on board by
counsellors and psychotherapists. In very dispersed communities such as
rural Australia it is now possible to have quite extensive tele-counselling or
tele-psychotherapy.

The relationship between counselling and

psychotherapy
The outline of the counselling approaches in this chapter demonstrates how
complex the relationship is between counselling and psychotherapy.
Counselling is not just some watered down or cheap alternative to
psychotherapy. From Rogers on it has forged its own theoretically coherent
and individual path. While it has learned from the more established
psychotherapies, we have also highlighted some of its own unique
contributions. These arose out of its more equal relationship and more
obviously shared experience. In turn these insights have fed back into the
practice of the formal therapies. Perhaps more importantly, it has made a
supportive space for self-reflection a realistic proposition for the majority of
us.
Chapter 6
Cognitive behaviour therapy

CBT is very different to the other therapies covered in this book, so this
chapter is also going to be different. Like the therapy itself it will have lots
of structure and lots of lists. CBT emphasizes thinking and thoughts. The
underlying premise is that ‘faulty’ thinking gives rise to anxiety and
depression rather than the other way round. CBT is the product of bringing
together the strengths of behaviour therapy and those of cognitive therapy.

Behaviour therapy is exactly what the name implies. It was a radical

departure from psychoanalysis with its emphasis on unconscious motivation
and symbolization, and it simply tried to help the patient alter their
behaviour. It is ultimately derived from the work of the Russian
psychologist Pavlov and his experiments with his dogs. Pavlov discovered
how behaviours could be ‘conditioned’ by associating them with stimuli,
such as making his dogs salivate at the sound of a bell after getting them
used to the bell being rung before food was delivered (see Figure 10).

The most famous (or perhaps infamous) exponent of this learning theory
was B. F. Skinner, who believed that all behaviours were learned by this
process of association. Skinner invented a special cage for rats which
became known as a ‘Skinner box’. In this they were either rewarded with
food or punished with electrical shocks when they performed specific
actions, and they demonstrated remarkably quick learning. His conclusion
was that any behaviour, whether in a rat or a human, could be trained by
‘reinforcing’ it with positive stimuli (rewards), or extinguished by
associating it with negative stimuli (an unpleasant taste, a small electric
shock). In clinical practice relaxation was most often used as the positive
stimulus to enable patients to confront feared situations, usually in a
stepwise manner. Behaviour therapy is particularly successful in phobias
(simple phobias such as fear of spiders and also in more complex phobias
such as agoraphobia) and in sexual therapies. ‘Aversive’ behaviour therapy,
where unwelcome behaviours are associated with unpleasant stimuli (e.g.
alcohol with a nausea-inducing drug), has been less influential.

10. Behaviour therapy derives from learning theory and the conditioned reflexes that Pavlov
noticed when his dogs associated the bell before feeding with the food itself

Behaviour therapies are nowadays more likely to be considered as a routine

treatment rather than as a psychotherapy. It is a fine distinction and one can
argue both ways. However, they do generally lack the specific, highly
personal relationships we associate with psychotherapy, so will not be dealt
with in any detail in this book. However, that is not to dismiss them. They
still play an important role in child psychiatry and in some services for
individuals with learning disabilities.

Cognitive therapy was developed in the 1960s by Aaron Beck in America.

He was struggling to help some of his patients who did not respond well to
his analysis. They appeared to value self-mastery much more than self-
understanding: control of their symptoms rather than understanding or
insight. ‘Cognition’ is usually defined as the mental process of acquiring
knowledge and understanding through thought, experience, and the senses.
The focus in cognitive therapy is therefore on our patterns of thinking and
‘knowing’ things, which is often based on unquestioned assumptions.
Beck’s change of focus provided a radical shift, which eventually led to the
development of CBT.

The underlying philosophy of CBT was propounded by the Ancient Greek

philosophers, the Stoics. They believed that happiness depends not on what
happens to us but on what we make of it. We call a Stoic someone who
seems able to shrug off life’s misfortunes and still remain contented and
productive. So CBT does not dwell on the difficulties of your childhood or
subsequent traumas, but on what you have made of them and how you are
coping now. It focuses on the present. It insists that you are in charge and
can make choices, and it is overwhelmingly interested in what you think.

CBT therapists are not naïve about this focus on thinking. They know that
thinking, feeling, and behaviour (indeed even physical health) are all
interconnected and continually influence each other. There are constant
feedback loops between them. However, CBT emphasizes how thinking
drives emotions, and it selects thinking as the point in the system where
change can most effectively be achieved. Sessions are consequently very
different from most other therapies, but before describing that practice it
helps to understand some of the theory.
 Box 2 Three layers of thinking
1. Negative automatic thoughts

2. Underlying assumptions

3. Core beliefs (schemas)

Here comes the first list of three. CBT theory identifies three layers of
thinking to address (see Box 2). The first is negative automatic thoughts,
below this our underlying assumptions, and then at the very fundamental
level our core beliefs often called schemas. Most CBT will concentrate on
negative automatic thoughts and only dive deeper during more complex and
protracted therapies.

Negative automatic thoughts

We are continually making judgements about what is going on around us.
We know from cognitive neuroscience that the vast majority of these
judgements are instantaneous and unconscious. We respond accurately to
our environment without being aware of the cues we receive, or of the
assumptions about them that condition our responses. In a crowded bar we
move away from someone staggering without even noticing we are doing it,
never mind being aware of why. We have registered subconsciously that
they may be drunk, and we know from long experience to be wary of
intoxicated people. We make such judgements and assumptions all the time,
instantaneously, without being aware of them. We have to, there are too
many to be made. Were we to consider them all consciously we would be
completely paralysed by indecision.

When we are stressed our assumptions can become more rigid and negative
—we easily assume the worst. We are unaware of this happening but it
affects what we do, and soon also how we feel, so we may become anxious
or depressed and not be sure why. We are unaware of how such automatic
thoughts can cause and maintain anxiety and depression.
CBT aims to help us identify and then challenge these negative automatic
thoughts. The processes used are called Socratic questioning and
collaborative empiricism. Essentially it starts with a simple question: ‘What
is going through your mind right now?’ Clarifying and challenging
thoughts, collaborative empiricism, involves three further questions:

1.Is there any evidence for this thought?

2.Are there other ways to understand what is happening?
3.What are the implications of thinking this way?

Underlying assumptions
These assumptions shape the way we understand how the world works.
They are the maxims, or principles, we apply in managing our everyday
lives. They state a consequence to an action, which we believe to be
inevitable. ‘If I do this then this will happen.’ ‘I should do this because … ’
‘Unless I do this then … ’ ‘I must do this or … ’ These assumptions
underlie the negative automatic thoughts, and Beck highlighted three that he
regularly encountered:
I am nothing unless I am loved—acceptance
I am what I accomplish—competence
I cannot ask for help—control

Core beliefs (schemas)

These are the fundamental beliefs we hold about ourselves, which shape
who we feel we are. They are often paired so that for each important belief
we also hold its mirror opposite in balance. When stressed we all too easily
lose sight of our positive self-belief and focus on its opposite. A successful
professional may for example usually think of herself as hard working and
reliable. However, under pressure she switches to believing she is a fraud
who gets by on the absolute minimum and will be found out. We don’t have
core beliefs about every tiny detail of our lives, only those aspects that are
important to us. Again there is a CBT rule of three (see Box 3).
 Box 3 The CBT rule of three

1. Beliefs about ourselves

2. Beliefs about others

3. Beliefs about the world

Only in very protracted (schema-based) CBT are core beliefs addressed

directly. Therapists usually rely on the work on negative automatic thoughts
to influence negative core beliefs.

CBT practice
The immediately striking thing about CBT is that it is short, sometimes
very short. Beck recommended between four and fourteen weekly sessions
for anxiety states, although most therapies hover between six and twenty
sessions. You also usually know exactly how long it is going to take right
from the start. Many services are very strict about how many sessions are
offered. The IAPT service (see Chapter 5) offers four to six sessions.

CBT is very structured and pretty prescriptive. Therapists are taught in

great detail about its specific procedures and individual components. They
may even use a manual outlining them, sometimes giving the order in
which they should be applied. CBT therapists consider this open and
transparent approach to be an important strength of their model. There is no
mystique, and patients are encouraged to read up about the various
practices. Being well-informed improves collaboration and reduces
misunderstandings.

Socratic dialogue
Socrates was a Greek philosopher whose teaching consisted of asking
questions (see Figure 11). He believed that we already know the answers
we seek but need help in finding them. This process came to be known as
Socratic dialogue. You are the one who has the automatic thoughts and only
you can identify them (think back to Carl Rogers’ client-centred approach
in Chapter 5).

11. Socrates was a Greek philosopher known to us through the writings of Plato. Socrates was
so influential that he was condemned to death by drinking hemlock for ‘corrupting the minds
of the youth of Athens’ by his teaching. His method used probing questioning to bring out
knowledge

The therapist’s function is to help you do this using careful questioning. She
will insist on clarity, especially in distinguishing thinking from feeling. It is
remarkable how often we say ‘I feel’ when we mean ‘I think’. If we say ‘I
feel that the banking crisis is now resolving’ we hardly register that what
we mean is we think the banking crisis is now resolving. We may also have
feelings about it, perhaps relief or anger that it was allowed to happen, but
that is a different matter from our thoughts.

There are many techniques for identifying and clarifying automatic

thoughts. Insisting that patients answer with statements rather than
hypotheses is important in the early stages:
THERAPIST: What were you thinking just then?
CLIENT: It was probably something about how my wife would react to my leaving my job.
 THERAPIST: That’s a speculation about what you might have been thinking, what was the
exact thought?
CLIENT: OK, I thought she would consider me stupid and impulsive.

Asking patients to describe the worst potential outcomes from their current
train of thought is also used:

What’s the worst thing you think would happen if your wife thought you were being
impulsive? Do you think she would despise you or perhaps even leave you?

Getting patients to recall distressing recent events (imagery) also sharpens

awareness of the associated thoughts. Sometimes the therapist may be fairly
sure what the patient is thinking, because they have come across it in many
previous patients. In CBT the therapist can suggest this as a possibility
(although not a certainty)—something that other therapists might be very
reluctant to do.

Collaborative empiricism
Once negative automatic thoughts have been identified they need to be
tested and examined. This is referred to as collaborative empiricism. It is
called empirical because it tests ideas in practice rather than in theory, and
collaborative because therapist and patient do it together. For example, a
patient reports a setback: ‘It was disastrous, a hopelessly public screw-up.
Nobody will ever take my opinions seriously again.’ The therapist
encourages him to think through the evidence for and against this belief.
She may ask him to give examples of when his opinion has been ignored
and when it has not. The patient is encouraged to find examples of how
people have recently followed his advice and taken him seriously.
Collecting such evidence can demonstrate that the negative automatic
thought is grossly exaggerated, if not downright wrong. Catastrophizing is a
common feature in automatic thinking. There may indeed have been a price
paid for some mistake, but it does not mean everything is lost, despite how
it may feel. Introducing shades of grey into such black-and-white thinking
characterizes collaborative empiricism.

The distinction between identifying and testing automatic thoughts can be

less clear in practice. An example is getting patients to think through the
pros and cons of individual thoughts and defining the terms they use more
clearly. Doing this both refines and simultaneously tests these thoughts.
Patients often apply more severe standards to their own behaviour than to
that of others. This can be exposed by asking them to apply what they have
just said about themselves to others: ‘Would you judge your wife that way?’
‘Would you bring up your children to believe that?’

In all CBT exercises thoughts are treated as hypotheses to be tested, not

incontrovertible facts. Testing them in the session can demonstrate this, but
the most powerful test is to try them out in reality. Such behavioural
experiments are part and parcel of CBT. They will be considered more in
the next section about homework, which is where they are usually
conducted.

Collaborative empiricism has two functions. The first, and most obvious, is
to identify, test, and modify negative automatic thoughts. The second is to
teach the patient to become his own therapist. The process of questioning
matters as much as the answers. Learning to recognize and test
dysfunctional thoughts and internalizing this process is held to be
responsible for CBT’s long-term effects. You are no longer a passive victim
of your thinking.

Homework
With so few sessions it is important to make every one count. In dynamic
psychotherapy holding on to an emotion or thought until the next session
can be important learning in itself, but CBT therapists don’t want patients to
keep things on hold for a week. They want them to work on what they are
learning, to practise and test it out between sessions. Therapists encourage
clients to keep putting into practice what they learn in sessions and so
devise homework tasks. The end of each session is used to review what has
been learned and to plan together how to practise it before the next session.
Most homework consists of deliberately trying out feared actions to learn
their real consequences, but there is a whole range of possible tasks.
Many cognitive homework tasks are things you can do alone. One is simply
to read and learn more about your problems and the possible treatments.
CBT therapists strongly encourage self-education and may suggest chapters
from specific books, especially CBT self-help books. Another is writing,
usually writing a daily thought record. This records the occurrence of
negative automatic thoughts, noting their context and perhaps how you
challenged them. Listening again to tape-recorded sessions is particularly
useful, as it isn’t always easy to take in everything during a session.
Remembering upsetting events in great detail, visualizing them happening
(imagery), can feed back into the next session. Listening to recorded
sessions or writing down your thoughts also helps get over the shyness of
early psychotherapy.

Behavioural homework is generally the more powerful challenge. After all,

this is real empiricism—testing out what happens in the real world, not in
your imagination. Behavioural experiments test out individual automatic
thoughts. Imagine you have identified a powerful negative automatic
thought during a session: ‘Any doubt I express indicates incompetence and
people at work will despise me.’ You then find some situations at work to
practise saying ‘I’m really not sure what is best here’, and observe (and
then write down) what the response is. Most likely it is something like:
‘Yes, I know, it is a tricky one. I’m never entirely sure myself.’ This
experience is much more powerful than just imagining it. Often one has to
work up to such experiments one step at a time. Confidence improves with
each success. Activity scheduling in depression can act in the same way, as
completing small, defined tasks chips away at the belief that they ‘can’t do
anything at all’.

CBT homework is agreed between patient and therapist. It is not like school
where the teacher sets the same homework for the whole class. CBT
homework, especially behavioural experiments, has to be very specific. It
must cover the where, when, and how, not just the what. It is specific to the
issues under examination and is negotiated and usually written down. Often
the tasks are practised in the session: ‘OK, we have agreed on what you are
going to say at work, try it out on me first.’ The homework experiences are
reviewed in the following session.
The structure of CBT sessions
So far we have focused on the content of CBT sessions, but CBT has a
well-developed structure which is also important for its success. CBT
therapists always start with a careful formulation of your problems in the
assessment session. As with everything else in CBT there is nothing secret
about it and your therapist will share it with you. Because CBT is brief, the
formulation must include an agreement on what will be worked on. The
formulation takes account of the past, but in shorter, simpler CBT therapies
past experiences take a back seat to what is going on now. In more
extensive therapies for complex problems understanding the past may be
crucial to properly understanding current concerns, and the formulation will
take account of this. If there are more problems than can be addressed in the
time available, the formulation will prioritize them.

Individual sessions are also structured. They start with a review of the
previous session and any homework. An agenda is set for the session,
agreeing what will be worked on. Towards the end of the session what has
gone on will be reviewed and summarized. Homework for the upcoming
week will be negotiated and agreed. All this sounds businesslike and very
hard work, but as with all therapies the CBT therapist is closely attuned to
how the patient is feeling. Also, as with everything in CBT, these are joint
decisions and not simply imposed on you.

All therapies aim to bring lasting change. CBT helps you to learn the
techniques that make you your own therapist, so that you can continue
practising what you have learned. Having one or more ‘booster’ sessions
after the therapy ends is common, sometimes the final sessions are spaced
out with longer intervals between them. Negative thoughts are not abolished
by CBT—we all have them. However, CBT should make you much better
at dealing with them. Some falling off of improvements is inevitable after
almost any therapy, and CBT therapists warn patients that it will happen. A
review session between a month and three months after finishing can serve
to re-energize and fine tune the self-therapy. It also helps make the point
that the work goes on long after the therapy ends.
CBT therapists rely heavily on measurement. They use questionnaires in
their work to measure symptoms and track changes. These include scales
for specific disorders (obsessive compulsive disorder, eating disorders,
etc.), but anxiety and depression ratings are the ones most widely used.
Scales are generally completed at the start and again at the end of therapy,
to assess the outcome, but sometimes they are used to track changes during
treatment. Filling out such questionnaires is more often a useful exercise in
itself, training the patients to make judgements about degrees rather than
catastrophize.

The role of research

CBT has been notable among the psychotherapies in its wholehearted
embrace of rigorous scientific testing of its effects. This follows logically
from its approach. Just as the therapy tests the real effects of negative
thoughts, so practitioners want to test the real effects of the treatment. CBT
is the most scientifically investigated psychotherapy, with literally dozens
of careful studies. Specific modifications for different disorders have also
been tested, including CBT for eating disorders, for different anxiety
disorders, personality difficulties, and sexual disorders.

CBT’s engagement with research reflects its underlying empirical approach,

but is also due to mainly being championed by clinical psychologists who
have a very scientific training. One result is that in many publicly funded
services it may be the only psychotherapy available. This is a pity, and
doubly so. First because the evidence for non-CBT therapies does suggest
that they are also effective, although there are far fewer studies. Second, it
is a pity because CBT does not suit everyone, nor does it always work. No
therapy suits everyone. Drop out rates are quite high in CBT, so where are
these patients to look for further help? CBT’s overwhelming lead in
research is somewhat demoralizing for non-CBT therapists. However,
failing to conduct research is not really a long-term option in our modern,
evidence-based world.

Specialized CBT
Because the different components in CBT practice are so well described,
they can be mixed and matched to different clinical needs and can be
‘branded’ for them. This can involve relatively minor, but highly effective,
changes in practice such as that developed for eating disorders. CBT-E as it
is called (the E stands for enhanced, not eating) is used with patients
suffering from both anorexia nervosa and bulimia. It lasts for twenty
sessions, forty for underweight patients, and requires from the outset that
the patient tries to eat regularly and that they be weighed at each session. It
downplays the examination of automatic thoughts, focusing more on the
responses to change in behaviour and weight. Neither the dietary diary nor
taped sessions are used, as they have been found to encourage unhealthy
rumination. This is an example of CBT adapted and shaped to a specific
clinical problem, rather than a major departure in practice.

Mindfulness-based cognitive therapy (MBCT) and dialectical behaviour

therapy (DBT) go well beyond adaptation and add a range of novel
practices. While DBT is a very specialized and restricted treatment, MBCT
is increasingly widespread and popular. It has been shown to be particularly
effective in reducing the risk of further relapses in people who have had
several episodes of depression.

Mindfulness draws on Buddhist ideas of ‘being in the moment’ and the

practice of meditation. Patients reduce the impact of negative thoughts by
developing metacognition—being able to create a distance from which to
think about their thinking. In practice this means recognizing a negative
automatic thought as just that: a thought that one has which one can either
accept or reject. There is no obligation to respond to it, it is enough simply
to note it. Using mindfulness techniques of being in the moment, devoid of
past and future, produces a more serene, non-judgemental state.
Mindfulness training consists of eight weekly two-hour classes, with a one-
day event halfway through. It prescribes guided meditation for extended
periods between sessions and developing a mindfulness approach in all
aspects of daily life.

DBT, although it includes mindfulness practices, is almost the polar

opposite in tone. It was developed for very troubled people whose lives
were in chaos and who often self-harmed. It is very intensive and quite
forceful. Weekly individual CBT sessions target reducing self-harm and
developing skills to minimize risk and stress. It is called ‘dialectical’
because it has two competing elements, mindfulness versus confrontation.
The latter involves learning how to regulate powerful feelings and tolerate
distress.

CBT has a very different feel and a different ethos to the other
psychotherapy and counselling approaches we have covered so far. It is
much more structured and predictable. Some patients react against what
they experience as a rather mechanical quality, far removed from
explorations of personal narrative and sense of self. Others, however,
welcome this clarity and structure. Longer and more complex CBT
treatments often concern themselves with relationships and blur the sharp
distinctions from more dynamic approaches, particularly when applied by
more senior practitioners. Be that as it may, CBT is a radical departure
which has changed the face of psychotherapy. It is still a relatively young,
vigorous, and expanding innovation, and a Very Short Introduction devoted
entirely to the subject is soon to be published. It will be fascinating to see
how CBT looks in ten to fifteen years’ time.
Chapter 7
Family, group, and interactive
therapies

We have described various individual therapy approaches in which the

patient’s or client’s descriptions of relationship and interpersonal problems
are explored. However, there are a number of therapies that work directly
with these problems, not just through the patient’s recall. Some, such as
couples and family therapy, directly involve all the individuals affected.
Group therapy offers direct opportunities for feedback in interactions with
others, with constructive challenges in the here-and-now on how to go
about things differently. There are also more interactive therapies such as
art and music therapy, which can be provided either with groups or
individuals. These particularly suit patients who are less clear about what
their problems are, or who might struggle to express them verbally.

There are countless variations of these more active therapies. In this chapter
we will describe the practice of systemic family therapy, couples therapy,
and group therapy, which are now widely established. We will also briefly
introduce the practice of psychodrama, art therapy, and music therapy.

Systemic family therapy

 Freud is all nonsense; the secret of neurosis is to be found in the family battle of wills to see
who can refuse longest to help with the dishes.

Julian Mitchell, quoted by Robin Skynnerin

One Flesh, Separate Persons

We are all born into ‘the hands of others’, the cradle of the family. Salvador
Minuchin, an influential early family therapist, describes families like this:

In all cultures, the family imprints its members with selfhood. Human experience of identity
has two elements: a sense of belonging and a sense of being separate. The laboratory in which
these ingredients are mixed and dispensed is the family, the matrix of identity.

Robin Skynner wrote that the best way to learn how to create a happy and
healthy family was to have been born into one. That way we learn how to
‘find satisfaction in harmonious relationship to one another’. Aware of the
enormous creative potential of the family it is not surprising that, when it
becomes disordered, it possesses an equal potential for destruction.

Family therapy is often used when the referred patient is a child or

adolescent. Originally, family therapists perceived the child’s disturbance
more as a marker of a family disturbance, but this is no longer necessarily
so. A referral for family therapy does not imply that the family is
considered responsible for the patient’s problems, more a recognition that
severe emotional problems can, and do, involve everyone in the family. For
example, the families of younger patients with anorexia nervosa are usually
offered therapy, and this has been found to be helpful. Nobody really knows
what causes an individual girl to become anorexic, but a severe, life-
threatening illness in a young person is bound to disrupt any family. Few
who work with anorexia nervosa believe that the family ‘causes’ anorexia,
and the therapy is aimed at finding ways to cope with the disorder for all
involved.

The same would apply when the identified patient is seen by an adult
mental health team, whether dealing with the painful consequences of a
psychotic disorder in a member of the family or when an ‘adult child’ has
become ‘stuck’ at home.

When families are struggling to find a healthy balance, systemic family

therapy offers them an opportunity to take a step back and think together. It
provides a chance to review patterns that might have become fossilized and
find ways to renegotiate and change them. Family therapy aims to
understand and intervene in the whole relationship context, rather than just
with the problems of the member initially identified as the patient. Freeing
up patterns at an early stage can bring prompt relief for all involved. Such
freeing up can also prevent family members being burdened with restrictive
family ‘scripts’ or myths.

Family therapy aims to improve the family’s capacity to communicate

clearly and openly with one another, exposing it to new perspectives and
ideas. It is not so preoccupied with specific solutions for specific problems
—problems arise constantly in all families—but with changing the family’s
style of interacting and operating. Family dynamics are immensely
powerful, so the therapy aims to channel this energy in a more healthy
direction. Clarifying communication clears away obstructions to the
developmental stages that all families have to go through, and so allows its
members to grow and move on.

Family therapists are very active and use a number of tried and tested
‘tools’. One is the genogram (see Figure 12). This is a family tree, usually
drawn up at the beginning of therapy. It outlines diagrammatically all the
family members and their relationships to each other, and usually covers the
last three generations. This helps the family see itself in context and with a
wider perspective. Intergenerational patterns can emerge with startling
clarity in this shared exercise.
12. A family tree, or ‘genogram’, used in family therapy to demonstrate recurring family
patterns. In this example we can see repeated broken relationships and also possible additional
pressures on Simon as the only male offspring

Examining the genogram helps the family and the therapists to undertake
what is called a script analysis. This is rarely done in a particularly formal
manner, but involves working out the rules, spoken or more often unspoken,
that govern how they relate. Four family ‘scripts’ are usually identified: the
circumstantial script is what all the members know about their family
history, and on which they base their overall behaviour; the assumptive
script describes beliefs about, and emotional attitudes towards, their roles,
both within the family and in the outside world; the delivered script is what
they actually say to one another, the words they use to convey these
assumptions; and finally the subscript is what we hold back from
expressing, whether deliberately or not. This nevertheless continually
affects our interactions, and all the more powerfully so for being unspoken.

In family and group therapies the participants are both agents and
observers. So while the mother and her son Simon may be at loggerheads in
a session over his recent truancy, the father and his sister Naomi observe
how they constantly interrupt one another, ramping up the tension despite
their best efforts to calm the situation down.
Collaborative team working is another striking feature of systemic family
therapy, usually with two therapists working together. In some settings
other members of the team may watch from behind a two-way mirror, even
phoning in advice to the therapists! Obviously this only happens with the
full agreement and consent of the family, and mainly in training settings.
However, it demonstrates a remarkable break with psychotherapy’s usual
insistence on intimacy and confidentiality. So why does it happen? Family
scripts can be inordinately powerful, with a whole set of well-entrenched
routines devoted to keeping things as they are. It takes intense, concerted
effort for therapists to get into this system enough to obtain a good grasp of
it. Yet they also have to remain something of an outsider to be able to
‘shake it up’ and create new experiences and a space to reflect. Conjoint
work ensures that therapists can be both agents and observers. It also means
that their working relationship can model more constructive and less
defensive ways of interacting, such as when they ask each others’ opinions
or discuss their different experiences of what is going on.

Family therapists demonstrate a stance of neutrality by seeking out the

views of each family member and taking them equally seriously. They often
use a circularity of enquiry, turning to each member of the family
individually as well as addressing the family as a whole. In the mother and
son scenario outlined above, the therapists might try and loosen the
stalemate as follows:
TO FATHER: How do you think your wife feels when she’s going on at Simon?
TO SIMON: While you’ve been having these school problems, have you noticed any other
changes in the family?
TO NAOMI: What do you think happens to Simon when he has these rows with your mum?
TO MOTHER: If this were a stage with characters in a play, where do you think Naomi feels
herself to be at the moment?
TO THE WHOLE FAMILY: What are things like for you as a family at the moment? How
would you like it to be? What would you each need to do differently to get there? Who would be
most likely to try it out?

Here we can see similarities with solution-focused therapy, and many

aspects of family scripts have an overlap with the reciprocal roles of CAT
(see Chapter 4). In common with most psychotherapy approaches,
therapists aim to help reframe difficulties. Family therapists are known for
their irreverence and tend to do this in a playful manner, where family
members often find themselves laughing out loud. The aim is to show that
rather than keep repeating ‘more-of-the-same’ sequences, things can be
done differently, while not trying to achieve any ‘right’ way to do them.

Many things happen all at once in family therapy, and each member may
have a different experience of it, so family therapists often write therapeutic
letters in which they summarize what went on in the session. With the
agreement of the family, these letters can also be a way of involving and
communicating with other systems engaged with the family, such as school
or a nursing team. This is particularly important as other professionals may
inadvertently be maintaining or exacerbating a family’s difficulties. Their
responses, while entirely well-intentioned, may get in the way of change. A
school nurse trying to support Simon by allowing him off lessons might
need to understand that him telling his mother each evening that he had
been in the sick bay was getting in the way of them getting to the root of
their difficulties. Systemic work sometimes involves bringing more distant
family members or other professionals into the sessions.

Couples therapy
Couples and marital therapy are more commonly available than family
therapy. RELATE (previously called the Marriage Guidance Council) is
best known in the UK for this, but almost all countries have similar
organizations. The approach is very similar to family therapy, although it is
not so common to have two therapists. Where there are, they are usually
one man and one woman, and their collaboration in the sessions acts as a
potent modelling experience.

Problems in relationships can have their roots in difficulties each partner

may have had earlier in their lives. Institutions such as the Tavistock Centre
in London employ a psychodynamic approach to understanding how this
impacts on the couple in the present, but couples therapy usually restricts
itself to altering the style of communication and focuses more on the
present and the future. Couples, like families, have no shortage of
grievances about each other, and the therapy has to get beyond the ‘blame
game’. The therapy often uses homework exercises—‘get a babysitter, go
out to somewhere you like, just the two of you’—to review in the next
session. Sometimes prescribing what not to do is more important: ‘talk for
an hour planning a holiday together without mentioning the last two
disasters’. This approach is used extensively in sex therapy, where
prohibiting intercourse for a set period can remove inhibiting performance
anxiety or prevent tensions building up. This can free up the warmth and
intimacy that is needed for eventually making love and enjoying it.

Group therapy
As its name implies, group therapy involves several people together. Unlike
family therapy these individuals do not generally know each other before
coming to the group. Groups usually consist of between six and eight
members plus the therapist (two co-therapists is quite common). They meet
in the same place at the same time, usually for about ninety minutes once a
week. The emphasis is on what goes on in the group, and members are
asked not to meet outside. If they do meet (which almost invariably
happens), they should be sure to report it back.

Group therapy is traditionally composed of individuals with a range of

problems—anxiety, depression, phobias, relationship difficulties, etc. This
range of problems and individuals (men and women, different ages, varying
life experiences) makes the group a microcosm of ordinary life. It means
that the full range of possible difficulties and conflicts is likely to occur in
the group over time.

Therapists have to balance the diversity needed to provide a rich experience

with ensuring that the group members have enough in common to gel. It is
particularly important not to have one or two members who are clearly
outliers. You don’t want a single retired member in a group of twenty-year-
olds, or someone with a dramatically different level of education or income
to the rest of the group. It should be a spread of life-experience, not a
random hotchpotch.

Not all groups are drawn from such a diverse population. Groups are also
used extensively for individuals who share a similar problem such as eating
disorders, addiction, or depression. Their advantage is that they can learn
about different ways of coping. They are very supportive, as members
realize they are not alone with their difficulties and can identify with each
other’s struggles. They can also be challenging, as members will know all
the tricks and be able to confront the person using them.

Group analysis applies psychoanalytic principles within the group. This

involves a blank screen therapist who interprets emerging themes in terms
of unconscious processes, including an exploration of group transference. It
was one of the earliest group therapies, and established the basic
expectations. These include the size of the group, with members sitting in a
circle so that they can easily see each other, the duration of therapy (usually
between one and two years), and the concept of what is called a slow-open
group. Only rarely in analytic groups do members all start and finish at the
same time—most join ongoing groups. As well as being practical, this has
several real advantages for patients, such as being able to observe how other
members deal with the end of their therapy before doing it yourself.
Turnover needs to be modest so that group members can gain trust in each
other and have the opportunity to pursue issues for a decent length of time.

Overall, however, the only predictable feature of group therapy is that it

involves a group of people. Other than a belief that more can be learned by
sharing and in the importance of confidentiality and boundaries, there is no
single theory or set of rules or practices. Groups can range from an
analytical group for well-heeled intellectuals through to structured CBT
groups for psychopaths in high-security prisons. Having said that, most
group therapy encompasses a common set of processes.

Group processes
Irvin Yalom, a leading exponent of group psychotherapy, identified three
underlying assumptions in group therapy. First, the central importance of
interpersonal relationships for a robust sense of self. Second, that we can
develop less distorted and more gratifying relationships through corrective
emotional experiences. And finally, that the social microcosm of a group
provides an ideal setting for relearning. As in life around us, group
members will sooner or later recreate the same interpersonal universe they
have always inhabited. A patient, abandoned by her mother and adopted
into a high-achieving family with two children, had always felt of less
value, that she was never going to fit in or be good enough. Finding it hard
to trust relationships, she attacked them, creating the very rejection she
feared. On joining a group she was antagonistic, instigated rows, and was
often on the verge of leaving the group. Only this time round she was able
to observe and change old patterns by using feedback from the other group
members.

Group therapy offers an opportunity to get a better alignment between how

we see ourselves and how we actually come across and are experienced by
those around us. As Robert Burns put it, ‘Wad some power the giftie gie us,
to see ourselves as others see us.’ A corrective emotional experience
requires a new experience which is emotionally vivid, and where the
emotions are clearly expressed. In a safe and supportive group feelings like
anger or dislike can be expressed and feedback given honestly and openly.
The ceiling doesn’t fall in after all, the anticipated catastrophe does not
materialize, and relationships are not destroyed. The second, and crucial,
aspect of the experience is its cognitive processing, when group members
can reflect on it. It is not enough just to feel something strongly, we need to
make sense of the experience and see how it could change our future
relationships.

Yalom also outlined several specific therapeutic factors in groups. These

vary for different group members and over time, but tend to reinforce each
other. Group cohesiveness is the foundation on which the group work rests.
It corresponds to the therapeutic relationship in individual therapy, but
includes the relationships of group members to one another, with the
therapist, and also to the group as a whole. It is what makes the group
attractive and keeps members attending, especially during the unfamiliar
early phase. It makes the group feel comfortable and welcoming, similar to
Carl Rogers’ unconditional regard. Therapists and members have to work to
sustain it. For the young adopted woman it made all the difference that she
was warmly welcomed, was helped to say something about herself early on,
and was not interrupted. Most importantly other group members found what
she said helpful and told her so.
Upon this solid platform rests a range of therapeutic factors. Installation of
hope arises from seeing that others with similar problems seem to be
overcoming them. Universality is the sense that ‘we’re all in the same boat’.
It reduces loneliness and shame, giving a sense of belonging to those who
might otherwise withdraw from social contact. Imparting of information,
such as the physical consequences of their habits in an eating disorder
group, can make a surprising difference. A lack of basic knowledge and
uncertainty are much more common than we often assume, and they make
us anxious and less able to cope. The act of giving advice or information
also demonstrates that others have our well-being at heart.

In groups, therapeutic activity does not originate from the therapist alone,
but occurs naturally between group members. The sense of altruism this
generates can be particularly therapeutic, as group members find they have
something to offer others rather than constantly feeling like they are a
burden. Collectively, these processes enable members to share events and
feelings they have rarely, if ever, told anyone about. Making such
revelations can constitute another therapeutic factor, the cathartic
experience.

13. We all bring our emotional baggage to therapy. In groups we are increasingly forced to
leave this outside the room in order to deal with relationships in the here-and-now
Group members invariably bring old family conflicts and historical
preoccupations into the group (see Figure 13), but the power of the group
lies in the melting pot of the here-and-now. This is where the real
interpersonal learning takes place. It is here that members become aware,
through feedback and self-observation, of what they do to others and how,
in turn, this rebounds on them. It is also where people can learn to see that
they have the power, and ultimately the responsibility, to do something
about it.

It’s not all hard work. The group is a place to experiment with new ways of
being and relating to others. These can be discovered by simply imitating
others or by becoming aware of new feelings and ideas in the group.
Groups provide an unparalleled opportunity to discover new and surprising
aspects of yourself and your abilities. Simply accepting an offer of a tissue
when talking about something upsetting can be liberating, just as finding
yourself doing the same for another group member can be cathartic.

The group therapist will always return the attention of the group to the here-
and-now, to the purpose of the group, and to the reason why each member
is there. In addition to attending to what is being said, he will notice how
things are expressed as well as enquiring into the why. With his experience
the therapist also listens out for what is not being said or is being avoided,
such as competitiveness or envy.

Interactive therapies
The therapies we will outline here occupy a special place in health services.
They are all registered therapies, but in practice they often straddle the
boundary between psychotherapy and a therapeutic activity. They may lack
the specific characteristics of psychotherapy, such as an explicit agreement
between a therapist and patient on the specific problems of an individual,
and a relatively formal and tailored plan based on a detailed assessment.
Obviously this is not a hard-and-fast divide—many psychotherapies are
fairly open-ended in their initial goals, and individuals often discuss in
detail what they want to gain from drama or music therapy, especially if
provided in specialist settings or in private practice. In our experience
however, it is rare for these therapies to be offered or sought independently
of other treatment programmes within general mental health services.

Psychodrama
Psychodrama was initially created by Jacob Moreno in the early 1900s. He
was equally frustrated with the overly formal, analytical approach of
psychoanalysis, and with the strictures of the drama and theatre of his day.
He stressed the need for spontaneity and improvisation to explore internal
conflicts and painful memories, and to resolve unfinished business.
Although it is group-based, psychodrama is essentially an individual
approach, with one protagonist taking centre stage in each session. The
group members are allotted different roles—for example, someone’s
powerful father figure—or act out different responses, such as one person
challenging and another being more submissive. It has been widely used to
explore family conflicts.

A typical session involves a number of people, helped by a ‘director’, to

enable the protagonist to enact emotionally important scenarios of his
choosing. After a warm-up to focus and enter a creative frame of mind,
scenes are acted out. The protagonist is centre stage, but he can also invite
others to take up his role (mirroring) or act as a double to put into words
feelings he may only be dimly aware of, or be avoiding. Role plays and role
reversals expand self-knowledge and perspective. The wind-up involves a
discussion in which all the participants offer observations from the
perspective of their allotted roles.

Drama therapy is a term used rather loosely to cover the use of drama to
promote emotional awareness and personal growth. There have been a
number of successful initiatives in prisons, as it recommends itself to men
who are not used to talking about their feelings. Plays usually touch on the
issues that matter powerfully to us, and often in dramatic and violent forms.
Both acting and watching allows prisoners to identify with, and express
their feelings through the actions of characters in a play.
Music therapy
Music therapy emerged in both the UK and the US in the aftermath of
World War II in treatment programmes for soldiers recovering from
physical and emotional injuries. It can be supportive and resource-building,
but in Europe it is primarily psychodynamic, with musical improvisation at
its core.

In a typical music therapy session therapist and client play together, in both
senses of the word. The therapist will encourage the client to express her
feelings through jointly creating music. Interacting with the therapist in this
process, the client will often reveal her patterns of relating, initially with no
need for words. No previous musical experience is needed. Instruments are
generally provided, such as piano, guitar, drums, or xylophone, which are
easy to use and highly expressive. The therapist is active and interactive,
inviting an inhibited individual to exaggerate and let go of their feelings, or
with others to contain and vary the expression of theirs. This can then be
further explored through role play and discussion. The aim is to gain a
fuller and less intellectual experience of the self, and to improve social
interaction.

Music, perhaps more than any other art form, has the capacity to affect our
emotions and mood. Even as infants we respond to the elements of music
(timbre, pitch, volume, rhythm), and these still affect us as adults. Music’s
capacity to link with our more primitive or freer responses is used to full
effect in music therapy. It is commonly used to help with communication
difficulties in autism and learning disabilities, in reminiscence and
orientation work with adults with dementia, with those recovering from
strokes, and also in child and adolescent settings.

Art therapy
Art therapy has its roots both in art and in psychotherapy. It is used in two
quite different ways, each prioritizing one of these origins. The first relies
on the healing power inherent in the creative act of simply making art. The
second uses the patient’s art as the basis for interpretation in a more
traditional psychotherapeutic format. What is created artistically is explored
to enhance self-awareness and insight. Art therapy originally drew directly
on psychoanalysis, but it became a profession in its own right in the mid-
20th century. It can be used with individuals or groups.

In an art therapy session the aim is not to produce beautiful art, but rather to
use a range of materials to create an image or a picture that speaks for an
experience or a feeling state. As with music therapy it removes the reliance
on words, but initially may have to overcome inhibitions: ‘I’m no good at
art’ or ‘I can’t draw’. After the creative part of a session, time is usually
spent discussing the personal meaning of what has been created or the
materials used. Over time, or through a sequence of images, new meanings
can be discovered or alternative feelings and identities experimented with.

All the interactive therapies we have described in this chapter make use of
direct interpersonal experiences. This makes it possible to bypass some of
the defences we described earlier, or at least for them to be identified and
worked with at an early stage and with real immediacy.

We started this book with formal psychoanalysis, and have moved through
time-limited therapies, CBT and counselling, to interactive therapies. We
hope we have provided an overview of psychotherapy in its many different
forms and current models. In the final chapter we will consider where
psychotherapy goes next, and the challenges it faces in that process.
Chapter 8
Psychotherapy now and in the
future

The 20th century has been called ‘the century of psychiatry’, and in many
ways one could read that as ‘the century of psychotherapy’. A hundred
years ago, at the onset of World War I, psychotherapy had touched the lives
of only a tiny number of people, and most of the population had simply
never heard of it. Since then it has reached into almost every aspect of our
lives—how we treat the mentally ill, how we understand our relationships,
our appreciation of art and artists, and even how we manage our schools,
prisons, and workplaces. Our culture has become one quite obsessed with
understanding how people feel and our daily language is peppered with
psychotherapy language.

What does the future hold? Have we witnessed the flowering of a cultural
movement that is tied to just one unique time and place, or is it a
fundamental step forward in human thinking and relationships? In our
increasingly global world will it spread ever more widely or perhaps fade
away altogether? Have the various changes in its practice made it more
relevant to modern man or less so? Will the enormous advances in
medicine, neuroscience, and psychology, and our move into the digital age
of social media, render it obsolete?
How we judge psychotherapy’s future will probably reflect what we think
of it now: as a profound breakthrough in understanding ourselves and a step
forward in social evolution, or as simply one among many technical
procedures to reduce distress and improve human well-being. Reducing
distress is certainly not a trivial achievement, but it does not satisfy
psychotherapy’s strongest advocates—they believe it has irrevocably
changed the way we see the world and how we behave. From a different
perspective, psychotherapy has been criticized right from the beginning for
having ‘cult-like’ and religious overtones.

Psychotherapy or psychotherapies?
We have roughly divided psychotherapy’s century into two halves. Up to
the 1960s it was either psychoanalysis or one of its modifications.
Therapies were verbal, protracted, and intensive, drawing on a detailed
theory of unconscious forces. Understanding was the key to recovery. Later
therapies have been much more experiential. Understanding remains
important, but the process of psychotherapy and the therapeutic
relationship have come to the fore. Some people are struck by the
similarities between these psychotherapies and some by their differences.
Are they adaptations of the same basic model or new and original
approaches? It is a bit like deciding whether a glass is half full or half
empty. Therapists usually stress the differences and the unique therapeutic
mechanisms in their approach. Psychoanalysts and CBT therapists have
traditionally had very little positive to say about each other’s practice.

You may have found yourself drawn to one or other specific therapy.
Alternatively you may come to the conclusion that they have more elements
in common than divide them. The latter perspective is probably how we
view things. Yes, CBT is undoubtedly radically different in tone, duration,
and immediate focus from psychoanalysis. But both work by helping
troubled individuals understand better the mental mechanisms that have
caused and sustain their problems.

One thing the psychotherapies share is that they have all expanded their
reach. The threshold for seeking psychotherapy or counselling has steadily
lowered over the decades, and our demand for it seems inexhaustible. Their
goals have also expanded—from just the reduction or removal of
symptoms, towards self-fulfilment and well-being.

We can be certain that psychotherapy will undergo changes in both theory

and practice. What is impossible to foresee is precisely where these changes
will occur. The trend towards shorter, more structured and democratic
therapies seems inexorable, but radical changes may come out of the blue.
Will they come from developments such as computer science, or perhaps
from other cultures than the Judeo-Christian origins of most current
therapies? Prediction is a risky business.

Psychotherapy in medicine and psychiatry

It is easy to forget that psychotherapy originated within medicine, and that
most of the early pioneers were doctors. They used psychotherapy to treat
psychological disorders, but that did not mean that they ignored physical
factors. The importance of biological considerations has waxed and waned
but they never disappeared, and the medical hold on psychotherapy
dominated until the 1970s. Some psychotherapies, especially in the
Americas, were even restricted to medical practitioners, and departments of
psychiatry were dominated by psychoanalysis. Since then psychologists and
other non-medical practitioners have increasingly become the main force in
providing counselling and psychotherapy. They now also lead most of the
research and development.

Psychoanalysis paid a high price for its early dominance and undeniable
hubris in the US, where it is now almost totally excluded from mainstream
medicine. It has been replaced by an equally inflated and exaggerated
reliance on pharmacological treatments. Outside the psychiatric mainstream
however, psychotherapy remains widely available and very vigorous. In
Europe, it always played a much smaller part in public psychiatry, and its
rise and fall has therefore been nowhere near as dramatic. In the UK it is
not the availability and influence of psychotherapy that has changed, so
much as the type of psychotherapy and who delivers it. Now it is often
provided by psychologists and is almost exclusively CBT. In parts of the
UK CBT may be the only psychotherapy available in the National Health
Service. A much wider range of psychotherapies is readily available in
private practice and in other European countries.

Psychotherapy research
One of the reasons for psychotherapy’s fading influence within medicine
has been the increasing importance given to research findings. Medicine
now sees itself as an evidence-based practice, rigorously assessing and
comparing the effects of different treatments. Randomized controlled trials
(RCTs) are considered the strongest test of a treatment. In an RCT patients
are randomly allocated to either treatment A or treatment B (often a
placebo, or dummy treatment), with neither the clinician nor the patient
knowing which. The outcome is usually measured by an independent
researcher. You can see how this provides very strong evidence, but also
why it is incredibly hard to do in psychotherapy. It is almost impossible for
patients, therapists, or researchers to be ‘blind’ to the treatment. Treatment
also depends on sustained motivation by both therapist and patient. It is not
like simply swallowing a pill, and there is bound to be variation in how
individual therapists work.

Despite this many RCTs have been conducted in psychotherapy, although

until more recently psychoanalysts have been unenthusiastic and generally
uncooperative. The length of psychoanalysis clearly makes such trials
particularly difficult, but the resistance also reflects many analysts’ doubts
about the research approach itself. After analysis a patient may be ‘sadder
but wiser’—is this better or worse? Such concerns are not unique to
psychoanalysis. Much medical research has to make do with what can be
measured, but the rewards of such pragmatism in terms of improved
treatments are very obvious.

There are published trials in most of the psychotherapies, although the

volume in CBT is dramatically greater. This does not mean that there is no
research evidence that psychodynamic therapies also work, far from it. As
research findings change rapidly, we will restrict ourselves to describing
some well-established findings here. Today’s cutting-edge results may be
tomorrow’s discounted news.

Overall the research confirms that most psychotherapies improve outcomes

for patients compared to similar patients without therapy (usually those still
on the therapy waiting list). Some studies have pitted one type of therapy
against another but these are a minority. A surprising but consistent finding
is that there is not that much specificity about the therapy (IPT is about as
good as CBT, which is about as good as CAT, and so on). The evidence
supports the importance of the quality of the therapy relationship and
therefore of the so-called ‘general factors’ we have already discussed:
genuineness, empathy, and non-possessive warmth. It is not quite that
simple, however.

How, and by whom, therapy is conducted also seems to matter. More

experienced therapists achieve better results, which is perhaps not
surprising. However, therapists who stick closely to their model (whichever
it is) also do measurably better. These two findings can seem contradictory.
We might assume that more senior therapists get better results by being
more flexible, but this is clearly not the full answer. Sticking to the model,
to the agreed procedures if you will, and attending to the state of the therapy
relationship, is what helps most.

While the body of research in psychotherapy is positive overall and

generally points to equivalence, with skilled and thorough therapists getting
broadly similar improvements, there are exceptions. Not only has more
research been conducted with CBT, but it has demonstrated a clear
superiority over dynamic therapies for some disorders. Often this is when
the CBT therapists have adapted and refined their approach in a clearly
targeted manner for individual conditions. These include depression,
anxiety and panic disorders, and eating disorders.

So overall it is wrong to say, as many of its critics do, that there is no

evidence that psychotherapy works. There is evidence. However, there is
nowhere near enough. More good quality research is sorely needed if
psychotherapy is to command continuing confidence and ensure public
investment.
Psychotherapy in culture
While psychotherapy (especially psychoanalysis) has been in and out of
favour in health care, it has kept going strong in our broader culture.
Indeed, it is so strong that people often complain about excessive
‘psychobabble’ in public discourse. This is now being challenged by the
rise of ‘biobabble’, which attempts to explain just about every possible
human quality or behaviour with either evolutionary psychology or the
neurosciences: ‘we are hard-wired to … ’, ‘your brain tells you to … ’, etc.
Freudian language has been toned down, and some dated ideas on sexuality
have long been abandoned. Stripped of their exaggerated language, analytic
and psychotherapeutic ideas continue to permeate both high culture (such as
the visual arts, novels, and the theatre) and popular culture (such as
television, film, and the press). The language of emotional trauma, conflict,
and defences frames our stories, with endless speculation about flawed
relationships and human tragedies.

Globalism and multiculturalism

Psychotherapy and counselling are widely available for Westernized elites
everywhere in the world. In the developing world it is less clear if these
approaches are really accepted or relevant, even in adapted forms.
Counsellors and psychotherapists are routinely confronted with the question
of the cultural relevance and application of psychotherapy in our
multicultural societies. Virtually every European country has around 10–15
per cent of its population born abroad, many with both a different mother
tongue and a different set of values. In multicultural capital cities such as
London or Copenhagen migrants can constitute half the population. There
are some uncomfortable truths about access to psychotherapy. Wherever
accurate figures on ethnicity are kept, ethnic minority populations are
always over-represented as psychiatric patients but strikingly under-
represented in counselling and psychotherapy services. They have more
illness but get less psychotherapy. Can that be fair?

Much soul-searching goes into trying to understand this phenomenon. It

was once thought that the higher rates of psychiatric diagnosis were due to
misdiagnosis, but we now know this is not so. Being a migrant, especially a
disadvantaged one, is highly stressful and causes more breakdowns. Those
subject to such stresses should have a greater, not a lesser, need for
psychotherapy, so why are they not getting it?

Two possible explanations exist with no clear answer. The first is that
health-care staff fail to identify emotional and psychological problems in
individuals with a different cultural heritage. They simply don’t spot the
cues. One example is that depressed patients with Pakistani and Indian
backgrounds usually complain of tiredness and aches and pains, but only
very rarely of sadness. Most counselling and psychotherapy services strive
to be accessible to people from different cultures. They publicize their
services in local places of worship and social centres, produce leaflets and
posters in a range of languages, and provide interpreter services. This can
reduce the barriers to access, but it does little to address the second possible
explanation of the low uptake—that psychotherapy may not appear relevant
or acceptable.

Whole books exist on how to provide culturally sensitive and effective

counselling and psychotherapy. They debate whether to adapt practice, or
keep faithful to the model but simply try harder. All agree that counsellors
should find out about their clients’ heritage and ask questions when unsure.
White therapists should also be alive to the impact of their own ethnicity
and to the power differentials in the relationship. Psychotherapy evolved in
a privileged, white European and American environment, so they are at risk
of taking its cultural assumptions too much for granted. Most black and
Asian therapists have been sensitized to these concerns, which are now
important components in most psychotherapy trainings.

A recurring question is whether to match the ethnicity of counsellor and

client. If there is a common language this makes obvious sense, but
otherwise opinions are divided. A therapist from the same background is
likely to have a surer grasp of particular pressures and concerns, but she
may have blind spots for just that reason. What if the problem lies in
managing relationships with the mainstream culture? Or might a unique,
personal concern get obscured by a focus on cultural issues?
Several psychotherapy services are run by counsellors from ethnic
minorities specifically for their own communities. These fill an important
gap but have not increased the overall take-up. There is also an
uncomfortable concern that some form of service ‘apartheid’ could develop.
As with women-only services, there is also a risk that problems will become
externalized, creating a ‘them and us’ mentality shared by client and
counsellor. This forges an immediate and strong bond, but could impede the
examination of overall personal relationships in all their complexity and
contradiction. Discussing these issues requires treading carefully to avoid
opinions being tainted (or being thought to be tainted) with racism. There is
no shortage of cultural imperialism in the history of psychiatry.

Psychotherapy in non-Western societies

We gave a very broad definition of psychotherapy at the start of this book:
the deliberate use of a special, agreed relationship established between a
trained practitioner and a patient to obtain relief from emotional suffering.
This definition goes way beyond the practices we have traced from Freud in
19th century Vienna. Doing these different approaches full justice is not
feasible in this short book. We shall restrict ourselves to some observations
on how Western psychotherapy has adapted to other cultures, and been
influenced by them.

These influences are not new. Eastern mysticism influenced Carl Jung at the
very beginning of psychoanalysis. Currently, mindfulness-based cognitive
therapy draws heavily on Buddhist thinking and practice. This focus on
being aware of, and accepting the present moment and freeing yourself
from past experience and future ambitions has been a persistent influence
from Eastern philosophy. It is in striking contrast to the Freudian obsession
with understanding and changing. At the time Freud was working in
Vienna, Zen Buddhist exercises were used in Japan specifically to
demonstrate how neurotic problems were absurd and inconsequential. In a
worldview that discourages individualism, the patient was helped to ‘let
nature take its course’. Fritz Perl’s gestalt therapy in the 1940s and 1950s
embodied much of the same approach, although derived from European
existentialism.
Think how different the Eastern emphasis on living vividly in the moment
is to Freud’s deferring of gratification. Some non-Western patients, less
wedded to extreme individualism, often also want a more directive
approach. They are happier to be instructed what to do, rather than be
endlessly encouraged to decide for themselves. This difference is not just a
reflection of a more hierarchical society. In much of the world people
consider themselves first and foremost as a member of a family or a group,
rather than as an individual. We Westerners are the odd ones out, and
probably only for the last three or four centuries. Our psychotherapy
embodies this view. For us, relationships are something we choose to
engage in. They are important, but the starting point is always the
individual. For most of the world the group we belong to (family or clan) is
the starting point, more important than any individual ambition or career.
The Zulu word ubuntu perhaps best conveys this. Widely used throughout
Africa, the commonest translation is ‘being a person through other people’
or ‘I am because we are’. It emphasizes the non-negotiable interdependence
of all humans. We cannot be meaningfully understood as isolated
individuals.

This fundamental difference in what it means to be a person has posed a

massive challenge to counselling and psychotherapy, to which it is only
now slowly responding. Will psychotherapy continue to evolve and adapt to
this wider, more communitarian worldview? Or might globalization
undermine the collectivism that has characterized much of the world up
until now? Will it generate the same problems of extreme individualism,
alienation, conflict, and isolation that we are so familiar with in the West,
and with it a need for ‘Western’ psychotherapy?

Neurosciences and psychotherapy

Freud believed that advances in medicine would eventually do away with
the need for psychotherapy completely. He certainly got that wrong.
Psychotherapy and counselling have continued to flourish despite medicine
advancing by leaps and bounds. Cutting-edge medical and cognitive
neuroscience research is now confirming many of the underlying processes
of psychotherapy and its benefits.
Some of the biological mechanisms that mediate relationships generally,
and psychotherapy in particular, are now being identified. One striking
example is the hormone oxytocin, the so-called ‘bonding hormone’.
Oxytocin is released both during breastfeeding and at orgasm. As well as
promoting the flow of milk it has a direct and measurable effect on the
mother’s mood, generating a sense of contentment. If you give women or
men oxytocin (it is absorbed easily in a nasal spray) they almost
immediately report feeling contented. Even more striking, it makes them
feel more positive towards whoever they are with at that moment—like the
spell cast on the sleeping Bottom in Shakespeare’s A Midsummer Night’s
Dream! The nursing mother is biologically confirmed in her attachment to
her baby, and sexual partners have their relationship strengthened and
deepened by a chemical swirling round in their blood. So our observations
that the contentment and holding in psychotherapy allow us to experience
those around us more positively may partly work through biological
processes. This will come as no surprise to body psychotherapists.

Modern neuroscience has brought overwhelming confirmation of the

unconscious mind. Experiments with computer images that last for
microseconds show that our thinking, feeling, and behaviour are profoundly
affected without us being in the least aware of what did it. These are not just
trivial or nerdy effects. A subliminal computer image, or even word, can
measurably change our view of whether someone is trustworthy or
threatening. There is a certain poetic justice that this evidence for Freud’s
theory comes from ultra-scientific psychologists, most of whom would be
deeply sceptical of everything he stood for. Neuroscience demonstrates just
how widespread and essential unconscious processes are for healthy
functioning. We simply could not get by without them. The Nobel Prize-
winning psychologist Daniel Kahneman’s book Thinking, Fast and Slow
repeatedly confirms that we make the vast majority of our decisions using
unconscious (often called intuitive) thinking. It is the rule rather than the
exception.

Brain imaging has even begun to confirm physical effects of psychotherapy.

Modern scanning techniques are extremely precise, so that differences in
brain tissue size of less than a cubic millimetre can be measured. There are
now a number of of studies measuring parts of the brain before and after
psychotherapy. One of the earliest, in 1992, showed that treating depressed
patients with either Prozac or CBT led to an equal increase in the volume of
the caudate nucleus. Various parts of the brain (the amygdala, the
hippocampus, and the frontal lobes) have been studied, as have various
psychotherapies. Positive changes in one or other of these structures have
been reported for most therapies. There is great excitement in this area of
research, and we can expect many more findings. Some will undoubtedly be
red herrings, but overall they do seem to confirm that there really is an
interaction between the mind and the brain. This interaction goes both
ways, and psychotherapy can influence it.

Conclusions
We hope this book has given you a sense of the richness and variety of
psychotherapy. Human beings have always wanted to find meaning in their
lives and to understand themselves and each other. The last century has seen
a systematic attempt to understand our problems and to find specific ways
of helping both those with severe disturbances and those with more
common life-problems.

Psychotherapy and counselling occupy an uncomfortable place in modern

medicine. They benefit from the enormous power of the scientific method
to clarify their processes and to find ‘what works for whom’. Yet this
scientific approach feels at odds with their spirit. Science measures what we
have in common and ignores what makes each of us different. We have to
be treated as ‘cases’ to advance scientific knowledge, but none of us wants
to be treated as ‘a case’ in our own therapy. What matters to us is the
unique, personal experience of transformation that comes from two
individuals working together. These two are not simply interchangeable
with any other two other individuals.

Luckily researchers are becoming more skilled at making the necessary

adaptations to test psychotherapy processes without losing this essence.
Such research has confounded the sceptics and confirmed that
psychotherapy does work. It does help people to change and get better, it is
not just a matter of time healing. This research has also consistently shown
that the quality of the therapy relationship is of essential importance, and
how crucial training and skills are.

We now have a range of therapies from which to seek help. They are no
longer an exclusive and expensive prerogative of the ultra-rich and the
intellectual. Most therapists are registered with professional bodies, which
provides reassurance about their training and skills, although you need to
check. As the stigma about psychological problems and their treatment has
receded, people now talk openly about their therapy, and can recommend
who and what helped and what did not. Psychotherapy may be challenging,
but it needn’t be feared and its results can be life changing. We believe it
will be here for the foreseeable future.
References

The triangles discussed in Chapter 2 were inspired by David H. Malan,

Individual Psychotherapy and the Science of Psychodynamics
(Butterworths, 1979).
In Chapter 3 we mention John Bowlby’s book Maternal Care and Mental
Health (Jason Aronson, 1977).
The Nina Coltart quotation in Chapter 3 is from The Baby and the
Bathwater (Karnac Books, 1996).
The Jung quotation in Chapter 3 is from his memoirs, Memories, Dreams,
Reflections (Pantheon Books, 1963).
The Angela Molnos quotations in Chapter 4 are from A Question of Time
(Karnac Books, 1995).
The Anthony Ryle quotation in Chapter 4 is from Anthony Ryle and Ian B.
Kerr, Introducing Cognitive Analytic Therapy: Principles and Practice
(Wiley, 2002).
The books by Carl Rogers mentioned in Chapter 5 are On Becoming a
Person (Houghton Mifflin, 1961) and A Way of Being (Mariner Books,
1980).
In Chapter 7 we refer to Robin Skynner’s One Flesh, Separate Persons:
Principles of Family and Marital Psychotherapy (Constable, 1976).
The Salvador Minuchin quotation in Chapter 7 is from Families and Family
Therapy (Tavistock Publications Limited, 1974).
Daniel Kahneman’s book, mentioned in Chapter 8, is Thinking, Fast and
Slow (Allen Lane, 2011).
Further reading

This book is only a brief overview of the main types of psychotherapy and
counselling. There are literally countless books on the subject at all levels
of complexity. Here we present a very limited list of books that we have
either found stimulating and informative, or which give an accessible
background to the issues raised.

Pat Barker, Regeneration, Penguin, 1991.

The first novel in her Regeneration Trilogy, describing the emotional
trauma and psychotherapeutic treatment of shell-shocked soldiers in
WW1. The central figures are the poets Siegfried Sassoon and Wilfred
Owen, as well as fictional characters.
Eric Berne, Games People Play: The Psychology of Human Relationships,
Penguin, 1964.
A short, engaging, and best-selling introduction to transactional analysis by
its originator. Still fresh, and with vivid descriptions of many of the
patterns we get stuck in.
Tom Burns, Psychiatry: A Very Short Introduction, Oxford University
Press, 2006.
An overview of psychiatry which helps place the development of
psychotherapy in its professional context.
Gillian Butler and Tony Hope, Manage Your Mind: The Mental Fitness
Guide, Oxford University Press, 2007.
An easy and practical guide to self-help using the whole range of
psychotherapy skills, with an emphasis on those used in CBT.
Gillian Butler and Freda McManus, Psychology: A Very Short Introduction,
2nd edition, Oxford University Press, 2014.
An authoritative introduction to psychology as a science and a profession.
Mick Cooper, Essential Research Findings in Counselling and
Psychotherapy: The Facts are Friendly, Sage, 2008.
A comprehensive and accessible summary of research findings and their
implications for psychotherapy practice.
Colin Feltham, What’s the Good of Counselling and Psychotherapy? Sage,
2002.
A series of perspectives on all aspects of psychotherapy, from target
problems and ethics through to its broader achievements.
Sue Gerhardt, Why Love Matters, How Affection Shapes a Baby’s Brain,
Brunner-Routledge, 2004.
An accessible, if detailed, interpretation of relevant recent findings in
neuroscience and psychology. Probably for the more committed reader.
Stephen Grosz, The Examined Life: How We Lose and Find Ourselves,
Chatto and Windus, 2013.
Tales drawn from the day-to-day practice of an experienced psychoanalyst,
which capture the essence of the analytic experience and the stories
people need to tell.
Jeremy Holmes, John Bowlby and Attachment Theory, Routledge, 1993.
An in-depth yet readable presentation of John Bowlby and his theories,
brought to life through vivid clinical vignettes by this prolific
commentator on psychotherapy.
Adam Phillips, Winnicott, Fontana Modern Masters, Fontana Press, 1988.
An introduction to the life and work of Donald Winnicott by a well-known
psychotherapist and essayist. Readers would benefit from prior
 background understanding of analytic concepts.
Anthony Roth and Peter Fonagy, What Works for Whom? A Critical Review
of Psychotherapy Research, Guildford Press, 1996.
A most comprehensive compilation of research evidence for
psychotherapies. Very authoritative but mainly for professionals.
Robin Skynner and John Cleese, Families and How to Survive Them,
Mandarin, 1984.
A best-selling self-help book co-authored by a psychotherapist and a
comedian. It takes the form of dialogues between the two and is both
educational and amusing.
Anthony Storr, The Art of Psychotherapy, 2nd edition, Butterworth
Heinemann, 1990.
A humane and profound account of the process of psychotherapy, mainly
aimed at those in training or in related fields.
Anthony Storr, Freud: A Very Short Introduction, Oxford University Press,
1989.
A comprehensive and readable account of the man and his developing
theories. It offers a nuanced critique rather than simply a chronological
outline.
Elizabeth Wilde McCormick, Change for the Better: Self-Help Through
Practical Psychotherapy, Sage, 2012.
A self-help book using easy conversational language, arranged around the
ideas of CAT. Relevant for anyone interested in how we become who
we are and how to improve things for our troubled selves.
Mark Williams, John Teasdale, Zindel Segal, and Jon Kabat-Zinn, The
Mindful Way Through Depression, Guilford Press, 2007.
A resource for learning about mindfulness drawing on meditative traditions
and cognitive therapy, complete with a CD of guided meditations.
Irvin D. Yalom, The Gift of Therapy: Reflections on Being a Therapist,
Piatkus, 2001.
An honest and engaging account of various aspects of the
psychotherapeutic process, reflecting Yalom’s respectful stance to his
patients and his work.
Index

A
action therapies 12–13
activity scheduling 82
addiction therapy 12, 68–9
Adler, Alfred 34–6
age groups 4
ageing 34
alcohol 68–9
altruism in group therapies 97–8
America 36
analytical psychology 34
anima 33
anorexia nervosa 88–9
archetypes 33
art therapy 101–2
asylums 5
attachment theory 41–2, 113
B
Beck, Aaron 74, 76, 77
behaviour therapy 72–4
behavioural experiments 82
bereavement 48
Berne, Eric 66
Binswanger, Ludwig 64
Bleuler, Manfred 32
Bowlby, John 41–2
Breuer, Joseph 18
brief therapies 44–6, 57
British Association of Counselling and Psychotherapy (BACP) 59
Buddhism 111
Burns, Robert 96

C
catastrophizing 80
catharsis 98
Charcot, Jean-Martin 6–7, 17–18
Child Line 71
children, attachment theory 41–2, 113
choices 64
client-centred therapy 60, 69, 78–9
cognitive analytic therapy (CAT) 50–4
cognitive behaviour therapy (CBT) 10–11, 45, 72–84
in medicine 106
research 108
specialisms 85–6
cognitive therapy 74
collaborative empiricism 76, 80–1
collaborative team working 91
Coltart, Nina 43
communication analysis 49
conditioning 72–3
core beliefs (schemas) 76–7
core conditions 61–3
counselling xvi, 9–10, 58–61
addiction 68–9
core conditions 61–3
psychodynamic 69–70
telephone 70–1
counter-transference 22, 63
couple therapy 11–12, 93–4
courses of CBT, length 77
courses of psychoanalysis
length 29–30
process 24–9
courses of treatment
frequency 23–4
length 3, 44–6
process 82–4
cultural relevance 109–11

D
daily thought records 81–2
defence mechanisms 21, 29
denial 21
depression 46–9, 82, 109
development of psychotherapy 104–5
diagrams in CAT 52–3
dialectal behaviour therapy (DBT) 85, 86
domains in development 39
drama therapy 99–100
dreams 18–19, 34
drugs 68–9
Duerzen, Emmy van 65
dynamic interpersonal therapy (DIT) 50

E
Eastern philosophies 13–14, 111–12
eating disorders 85, 88–9
effectiveness, research into 106–8
ego 21
ego-states 66–7
eight stages of development 37–8
empathy 61–2
ending therapy 30, 57
Erikson, Erik 37–9
ethnicity 109–11
existential therapy 63–4
British 65
existentialism 60
existentialist-humanistic approach 64–5

F
false self 42
family therapy 11–12, 88–93
feminism 36
free association 18, 26
Freud, Sigmund 3, 6–7, 8–9, 14, 17–22, 43
contrast with Eastern philosophies 111
future, focus on 54–7, 64–5

G
‘games people play’ 66–7
gender xvi–xvii, 36
genograms 89–91
genuineness 61
good-enough parenting 42
group therapy 11–12, 87–8, 94–9

H
happiness, pursuit of 8–9
helplines 70–1
holding 70
homework 56, 81–2
hormones, oxytocin 113
Horney, Karen 36
humanism 60
hypnosis 5–7, 18, 41
hysterical disorders 6, 17

I
IAPT programme 45
id 21
identity crises 38
imago 33
inferiority complex 35–6
interactive therapies 12–13, 99–102
interdependence 112
interpersonal inventory 47–8
interpersonal psychotherapy (IPT) 46–50
interpersonal relationships 96
interpersonal therapy 37
interpretation 20

J
Jewish psychoanalysts 22
Jung, Carl 13–14, 22, 23, 32–4, 35

K
Kahneman, Daniel 113
Klein, Melanie 21, 23

L
Lacan, Jacques 23
letters
in CAT 51, 53–4
in family therapy 93
libido 20
losses 48

M
Malan, David 30
mandala 35
Markowitz, John 46
maturational crises 37–8
May, Rollo 64
medical application 105–6
meditation 14
mental structures 20–2
mentalization 50
Mesmer, Anton 5–6
metacognition 85
migrants 109
mindfulness 85–6, 111
mindfulness-based cognitive therapy (MBCT) 14, 85
Minuchin, Salvador 88
miracle question 55–6
mirroring 61–2
Mitchell, Julian 88
Molnos, Angela 45
moral treatment 5
Moreno, Jacob 99
multiculturalism 109–11
music therapy 100–1

N
negative automatic thoughts 75–6, 79–80, 82, 85
neuroscience 112–14
neuroses
as barriers 36
physical manifestations 17
unconscious 7–8, 18–19
O
Oedipus complex 20
oxytocin 113

P
parent, adult and child roles 66–7
past experiences 27–8
patients 3–4, 12, 30–1
Pavlov, Ivan 72
Perl, Fritz 111
persona 33
Pinel, Philippe 5
Porter, Roy xiv
positive approach 64–5
present, focus on 98–9
professional bodies 59
professional standards 14–15
projection 21
psychiatry xiv–xv
psychoanalysis 7–8, 16, 18–31, 36
group therapy 95
in medicine 105–6
psychodrama 99–100
psychodynamic counselling 69–70
psychological mindedness 4
psychology xiii

R
randomized controlled trials (RCTs) 106–7
reciprocal roles 51
reinforcement, positive and negative 73
RELATE 93
relationship between therapist and patient 2–3, 7, 22, 28, 43
in counselling 60–3
relationship therapy 11–12, 93–4
relationships between members in group therapy 97–8
relationships in the patient’s life 47–8, 51–2
remote counselling 70–1
respect for clients 62–3
risks 14–15
Rogers, Carl 9, 59–63
role disputes 49
role play 100
role transitions 49
Ryle, Dr Anthony 50, 52

S
Samaritans 70
scaling 56
schemas 76–7
scientific research 84, 106–8
script analyses 91
self, false and true 42
self-awareness 13–14, 96
self-belief 77
self-management 51–2
sexual drives 20
shadow 33
Shazer, Steve de 54
shell shock 39–41
skeleton keys 54
Skinner, B. F. 72–3
Skynner, Robin 88
social withdrawal 47–8
Socrates 78–9
solution-focused therapy (SFT) 54–7
splitting 21
stages of development 37–8
Stern, Daniel 39
Stoicism 74
suggestion 6–7
Sullivan, Harry Stack 37
super-ego 21

T
tasking 56, 81–2
telephone counselling 70–1
terminology 108
therapists, core conditions 61–3
time-limited therapies 44–6, 50, 57
training for psychoanalysts 23
transactional analysis (TA) 66–7
transference 22, 27–8, 43
true self 42
Tukes family 5

U
ubuntu 112
unconditional positive regard for clients 62–3
unconscious
awareness of 69–70
collective 33
unconscious decision-making 113
unconscious neuroses 7–8, 18–19
underlying assumptions 76

W
Weissman, Myrna, 46
Winnicott, Donald 42, 70
World War I, shell shock 39–41

Y
Yalom, Irvin 64–5, 96–7
York Retreat 5
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VERY SHORT INTRODUCTIONS
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