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Psychotherapy, History of: Psychiatric Aspects

Sidney Bloch and Edwin Harari, St Vincents Hospital, University of Melbourne, Melbourne, VIC, Australia
2001 Elsevier Ltd. All rights reserved.
This article is reproduced from the previous edition, volume 18, pp. 1248412491, 2001, Elsevier Ltd.


Psychotherapy has its origins in two healing traditions the magico-religious and the medico-scientic. It was with the
publication of Studies in Hysteria, by Josef Breuer and Sigmund Freud, and their concept of free-association the patient was
instructed to disclose whatever came into their mind while the therapist adopted an attitude of evenly-suspended attention
in listening to and interpreting the material that the latter was rmly launched. Freud revised his theories at numerous
points and many of his colleagues extended the boundaries of psychoanalytic thinking. But differences of opinion soon
surfaced, which led notable gures to evolve their own schools. Jung and Adler were two foremost dissidents in Europe,
Horney, Fromm, and Sullivan in the US, and Klein in Britain. Humanistically oriented schools became popular in the 1960s
and 1970s, mainly in the US. Among their chief features were challenging patients with the way they avoid emotionally
signicant matters in the here-and-now. Feminist-based psychotherapies evolved in the 1980s, reecting a range of opinion
from condemning Freud as a misogynist to appreciating his linkage of life experience, innate drives, and defenses in inu-
encing vulnerability. The second half of the twentieth century saw the evolution of treatments conducted with more than one
person: groups of strangers and families.
Although the therapy of stranger groups was experimented on early in the twentieth century, it was not until World War II
that major developments ensued. In the US, the move to the study of group process was spearheaded by social psychologists.
Paralleling the human potential movement in the 1960s, the group movement transferred its focus from group to personal
dynamics, and spawned the encounter movement. Formal group therapy under professional leadership then assumed a more
prominent role. Yalom pioneered the study of therapeutic factors specic to the group rather than transposing psychoanalytic
or other theories from the individual setting. Alongside this interest in group therapy came the idea of working with the
family. Many competing theories of how families become dysfunctional resulted, but principles of Systems Theory domi-
nated. Therapists also began to consider that families might be stymied by their interpretation of past experience. With the
narrative a family conveys about their lives regarded as a construction which organizes experience in particular ways, other
narratives are excluded. Systematic research in the psychotherapies was a low priority for decades. An impetus was Eysencks
critique of treatment as ineffective. Since then research has yielded much knowledge about whether psychotherapy works and
how it works.
Several reviews, including sophisticated methods such as meta-analysis, point to psychotherapy beneting suitably selected
patients. Research on comparative effectiveness has shown a consistent pattern that everyone has won and must have
prizes, a nding probably attributable to factors common to all approaches. Attention has also been devoted to the ther-
apeutic process, which has been shown to be as salient as that on outcome since only with the study of what occurs in
treatment can therapists appreciate factors accounting for improvement.

Psychotherapy the systematic application of psychological Labeling the phenomenon hypnotism, he proceeded to demon-
principles to accomplish symptomatic or more substantial strate its effectiveness in treating a range of conditions.
personality change has its origins in two healing traditions The doyen of French neurology, Jean Martin Charcot
the magico-religious and the medico-scientic (Bromberg, (183593), considered hypnosis a neurophysiological process,
1959). The idea that human experience is inuenced by and set about its study in states like somnambulism and
supernatural forces and that certain people have the power to hysteria. His pupil Pierre Janet (18591947) suggested that the
intercede with these forces dates back to antiquity. Shamans latter was brought about by weakening of a higher brain
and sorcerers have resorted to amulets, magical potions, and function, resulting in a constriction of consciousness. In this
incantations for centuries. They have also conducted exorcism dissociated state thoughts could not be integrated, and
and induced altered states of consciousness. symptoms were beyond the reach of consciousness.
With the Age of Reason, interest was aroused in the newly In an alternative explanation, Ambroise Liebeault
discovered phenomena of electricity and magnetism. Anton (18231904), and Hippolyte Bernheim (18401919) in France
Mesmer (17341815), a brash physician, drew on the latter when posited a narrowing of attention in hypnosis which rendered the
propounding his theory of animal magnetism. Since the body patient vulnerable to the therapists inuence by suggestion. Far
contained magnetic uid, and this could become disturbed, by from invalidating hypnosis, the power of suggestion could be
applying magnets to various parts a patient could be relieved of investigated scientically and accepted as a bona de therapy.
pain and other ailments. While Mesmers work was ultimately Freud (18561939) had studied briey with Charcot in
denounced by a Royal Commission and he was forgotten, the 188586 and became enthusiastic about new possible treat-
observation that his methods appeared to help patients ments for hysteria. Freuds mentor, a respected Viennese
continued to attract attention. James Braid (17951860), a Man- physician, Josef Breuer (18421925), had described the treat-
chester doctor, noted that he could induce a similar trance-like ment of a young woman who suffered from an array of marked
state by getting people to x their gaze on a luminous object. hysterical symptoms. Instead of suggesting disappearance of

502 International Encyclopedia of the Social & Behavioral Sciences, 2nd edition, Volume 19 http://dx.doi.org/10.1016/B978-0-08-097086-8.03047-6
Psychotherapy, History of: Psychiatric Aspects 503

the symptoms, Breuer had encouraged Anna O (the pseu- notable gures to leave the fold and to evolve their own models
donym given to her) to talk freely about her life under on which corresponding schools of therapy were established.
hypnosis. She did so and over time began to share memories Jung and Adler were two foremost European dissidents; Karen
about her fathers illness. Breuer noted that after each session, Horney, Erich Fromm, and H.S. Sullivan were pioneering neo-
his patient became less distressed and her symptoms improved. Freudians in the US; and W.D. Winnicott and Melanie Klein
Anna herself referred to this approach as her talking cure or were prominent in Britain (Mitchell and Black, 1995).
chimney sweeping; Breuer termed it catharsis. Whereas Carl Gustav Jung is perhaps the most critical dissenter since
Charcot had described physically traumatic events as possibly he was clearly being groomed to take over leadership of the
causal, in his hysterical patients, Breuer and Freuds interest psychoanalytic movement. But he was also celebrated because
focused on psychological trauma such as humiliation and loss. of his own contribution. Specically with regard to psycho-
Freud also became less keen on applying hypnosis. therapy, he advanced the notion of individuation the aim
Their volume, Studies in Hysteria, which included the case was to discover all parts of oneself and ones creative potential.
of Anna O., and four others treated by Freud himself, also Jung was less concerned than Freud with the biological roots of
contained ideas on defense mechanisms and an account behavior, especially infantile sexual development, but rather
of various techniques including suggestion, hypnosis, and emphasized social and cultural factors. The role of transference
catharsis. Most importantly, however, was the new concept of was replaced by a more adult type of collaboration.
free-association: the patient was instructed to disclose what- Furthermore, the unconscious for Jung is not merely the
ever came into their mind, without any censoring, while the repository of the individuals history but also a wider social
analyst adopted an attitude of evenly-suspended attention in history, a phenomenon Jung labeled the collective uncon-
listening to and interpreting the material. scious. He arrived at this notion through a study of myths,
On the basis of his subsequent self-analysis and further legends, and symbols in different cultures, in different epochs.
clinical experience, Freud elaborated his theory of infantile That these are shared by a variety of cultures is not fortuitous
sexuality. Sexual fantasies in young children centered around but reects cosmic mythical themes or archetypes, a salient
the triangular relationships of love and rivalry with their feature of mans collective history.
parents (the Oedipal complex). Promoting free association of Alfred Adler (18701937), a Viennese physician, was like
this theme, as well as of dreams, slips of the tongue, and other Jung a prominent dissenter. Adler joined Freuds circle in 1902
unconsciously-based thoughts, feelings, and fantasies, Freud but broke away to form his own school of individual
emphasized the centrality of the complex in the neuroses. psychology after 9 years. An important tenet concerns indi-
While catharsis and insight (making the unconscious con- vidual development. We begin life in a state of inferiority,
scious) seemed pivotal to therapy, Freud soon realized that weak, and defenseless, for which we compensate by striving for
other factors also operated, particularly the role of transference, power and by evolving a lifestyle to make our lives purposeful.
i.e., how feelings, thoughts, and fantasies stemming from The pattern that emerges varies and may include such goals as
childhood experiences and revived in current relationships are acquisition of money, procreation, high ambition, or creativity.
transferred onto the analyst. The drive for power and choice of lifestyle may, however, go
Interpretations were directed at this threefold nature of the awry in which case a neurosis results. A path is followed which
analytic experience. The therapists response to transference leads to ineffective efforts to cope with the feeling of inferiority
(countertransference) led to analysts having their own personal and assumption of a facade or false self.
therapy, the aim being to minimize it, and thus to be thor- Adler regarded therapy as a re-educative process in which
oughly objective in attending to the patients disclosures the therapist, who serves as model and source of encourage-
(Ellenberger, 1970). ment, engages in a warm relationship with the patient and
In summary then, psychoanalytic psychotherapy elaborated enables him or her to understand the lifestyle he/she has
the following processes: the patients unbridled disclosure of assumed. Unconscious determinants of behavior are less
whatever enters his or her mind free association; the trans- crucial than conscious ones and the term unconscious is used
ference of infantile and childlike feelings and attitudes to the only descriptively to refer to aspects of the person that are not
therapist which were previously directed to key gures in the understood by him.
patients earlier life; interpretation of the transference as well as Freuds insistence on innate drives and infantile sexuality
of defenses the patient applies to protect him/herself and the not only led to the schisms with Jung and Adler but also
resistance he/she manifests to self-exploration; and nally, the spurred a new generation of analytically oriented analysts to
repeated working through of the discoveries made in treatment. concentrate on interpersonal aspects of psychological experi-
The ultimate aim is insight with translation into corresponding ence. In the US, Sullivan pioneered the school of interpersonal
change in behavior and personality. psychiatry, in which the therapist adopted the role of partici-
pant observer in treatment, the transference providing one
opportunity to explore communication and its breakdown in
Variations on a Theme the patients interpersonal world.
We can consider the chief features in the approach of the
Freud revised his theories at numerous points in his long neo-Freudians by looking briey at Karen Horney
professional life. In addition, many colleagues extended the (18851952). She became disenchanted with Freuds rigid
boundaries of psychoanalytic thinking. But differences of focus on instinctual biological factors, arguing that cultural
opinion soon surfaced, some radical. The nature of psycho- factors were more salient, as reected in the differences in
analysis then, especially Freuds intolerance of dissent, led psychological development and behavior among different
504 Psychotherapy, History of: Psychiatric Aspects

sociocultural groups. Indeed, behavior regarded as normal in These models have implications for practice in that the
one culture could be viewed as neurotic in another. therapist expresses moment-to-moment empathic under-
In line with her emphasis on culture, Horney advanced the standing of the patients inner experiences and as this is
role of parental love in the life of a young child. Children repeated time and again the process promotes the evolution of
typically suffer anxiety, a consequence of feeling helpless in a coherent identity.
a threatening world. The child reared in a loving atmosphere Jacques Lacan (190181), the maverick French analyst,
succeeds in overcoming basic anxiety. By contrast, the deprived claimed a return to Freud, his early work in particular, but
child comes to view the world as cruel and hazardous. An through the prisms of semiotics and linguistics. These disci-
inevitable result is low self-esteem. plines, he contended, do not see language as a value-free means
The task of therapy is to examine the patients defective to express ideas and convey meaning but as a system of signs
patterns in relating to others. In part this is achieved through that communicate symbolically tacit rules and power arrange-
study of what transpires between patient and therapist. But ments. Language imposes on the child awareness of a sepa-
there is no emphasis on transference as occurs in Freudian rateness from its mother who represents a fantasized internal
analysis. Therapy aims to enable the patient to move with object (the imaginary mother), in whose eyes the child mirrors
others, by engaging in relationships which are reciprocal and itself in an attempt to achieve a state of psychological unity.
mutual. Another goal is greater self-realization, with freedom Lacans controversial proposals regarding variable duration of
from determined modes of thought and action. treatment and trainees themselves determining their compe-
While the neo-Freudians were establishing a new pathway tence to qualify as psychoanalysts led to his expulsion from
for psychoanalysis, a group was equally innovative in the UK the International Psychoanalytic Association, albeit with
and France. In the UK, Melanie Klein (18821960), a physician a dedicated following.
hailing from Berlin, concluded from her study of childrens play Humanistic experientially oriented schools of therapy
that the Oedipal complex, as described by Freud, was a late became popular in the 1960s and 1970s, mainly in the US.
expression of primitive unconscious anxieties which children Their chief features were: challenging patients with the way they
experienced in the rst 18 months of life. Given that these states avoid emotionally signicant matters in the here-and-now;
could be reactivated in adult life, Klein labeled them positions increasing awareness of nonverbal aspects of communication;
rather than stages of psychological development. She also sup- facilitating emotional arousal; and providing a forum in which
ported the move away from Freuds formulation of instincts and patients were encouraged to experiment with new behaviors.
psychosexual energy toward one of object relations, namely the Some of these schools have incorporated aspects of
representations of the perception and experience of signicant psychoanalytic theory. Transactional analysis, for instance,
others. Similarly, transference was to be understood not only as makes playful use of the concept of ego states, represented as
a repetition of past or current relationships, but as evidence of parent, adult, and child; primal scream therapy is predicated on
relational patterns in the patients current internal world. heightened arousal of the purported emotional trauma of
In tandem with Klein, other analysts in Britain proposed birth; and psychodrama encourages people to enact their
ways in which signicant early relationships, particularly conicts by personifying various roles in their psychological
between infant or young child and its mother, exerted lives.
a formative inuence on the developing psyche. John Bowlby The most inuential humanistic school has been the client-
(190790), in particular, observed that children who had centered therapy of Carl Rogers, although it has been absorbed
suffered a prolonged separation from their mother underwent into psychotherapy generally and not always with appropriate
a grief experience which predisposed them to a range of acknowledgment. Its premise is that if the therapist creates an
psychopathology in later life. Donald Winnicott (18961971), atmosphere that is nonjudgmental, empathic, and warm,
a pediatrician and analyst, proposed that a mothers attune- people can realize their potential for self-expression and self-
ment to her child, enabling him to feel psychologically held fulllment.
and understood, was an essential ingredient for a stable sense Feminist-based psychotherapies, still evolving since the
of self. The American psychoanalyst Heinz Kohut advanced 1980s, reect a range of opinion from those which condemn
a similar concept, but highlighted the place of empathy Freud as a misogynist who deliberately recanted his discovery
whereby the mother functions as a self object for the child. of the actuality of childhood sexual abuse, to those who
Wilfred Bion, a student of Klein, suggested that the analyst appreciate his linkage of life experience, innate drives, and
functions as a container into whom the patient projects their corresponding defense mechanisms in inuencing vulnera-
unprocessed feelings and experiences; the analyst returns them bility to psychopathology (Elliot, 1991; Appignanesi and
later in a form accessible to him to work on. This experience is Forrester, 1992). The latter point of view, echoing a broader
deemed to be crucial to the development of a persons ability to debate within psychoanalysis of the respective roles of internal
examine his or her own state of mind and that of others. and external reality, has led some feminist therapists to stress
Michael Balint, an analyst at the Tavistock Clinic, worked social reality, and others to stress physical reality.
along similar lines to Winnicott, focusing on the opportunity
for the patient to regress in the safety of the therapeutic rela-
tionship to a state of mind in which differentiating between The Development of Other Modes of Psychotherapy
patient and therapist may blur. The features of the encounter
its regularity, predictability, and the therapists empathic Our focus, hitherto, has been on psychotherapy of the indi-
attitude creates circumstances for such regression which can vidual patient. The second half of the twentieth century saw
then be used to examine and alter defense mechanisms. the evolution of treatments conducted with more than one
Psychotherapy, History of: Psychiatric Aspects 505

person: groups of strangers and families. In this section, we themselves emotionally from their families was impaired by the
provide a brief account of the development of these two consequences of unresolved losses, trauma, and other upheavals
modes. in the lives of parental and grand-parental generations.
Although therapy of stranger groups was experimented on Boszormenyi-Nagy and Spark (1984) also addressed this
early in the century, it was not until World War II that major transgenerational theme by describing how family relation-
developments ensued. The exigencies of war were the spur in ships were organized around a ledger of entitlements and
that the group format proved highly economical for dealing obligations which conferred upon each participant a sense of
with huge numbers of soldier-patients. The Northeld Military justice about their position. This, in turn, reected the experi-
Hospital in the UK was a center of remarkable innovation, led ence in childhood of neglect or sacrices for which redress was
by psychoanalytically oriented therapists like Wilfred Bion and sought in adult life.
S.N. Foulkes. Bions (1961) inuence pervaded subsequent Bowen also introduced the principles of Systems Theory
work at the Tavistock Clinic, while Foulkes (1965) was the into his work but it was Salvador Minuchin, working with
founding father of the Institute of Group Analysis (both in delinquent youth in New York, who highlighted the relevance
London). of systems thinking to their interventions. The youngsters often
In the US, the move to the study of group process was came from emotionally deprived families, headed by a demo-
spearheaded by social psychologists, particularly Kurt Lewin. A ralized single parent (most often the mother) who alternated
national center was established to train people in human between excessive discipline and helpless delegation of family
relations and group dynamics. Participants from diverse back- responsibilities to a child. Minuchins Structural Family
grounds studied group functioning in order to act more effec- Therapy deploys a series of action-oriented techniques and
tively in their own work settings. Paralleling the human powerful verbal metaphors which enable the therapist to join
potential movement in the 1960s, the group movement the family, and to reestablish an appropriate hierarchy and
transferred its focus from group to personal dynamics, and generational boundaries between the family subsystems
before long the encounter group movement had evolved with (marital, parent/child, siblings).
its thrust of promoting greater self-awareness and personal Another major development took place in Palo Alto,
growth. Encounter groups became widespread during the California, where a group of clinicians gathered around
1960s and 1970s but after an initial fervor, declined both in the anthropologist Gregory Bateson (1972) in the 1950s.
terms of membership and appeal. They noted that implicit in communication were meta-
Formal group therapy under professional leadership then communications, which dened the relationship between the
assumed a more prominent role. The most popular model was participants. Any contradiction or incongruence carried great
fathered by Irvin Yalom who drew upon an interpersonalist persuasive, moral, or coercive force and formed part of what
approach, one originally molded by Harry Stack Sullivan who they labeled a double-bind; they proposed this as a basis
proposed that personality is chiey the product of a persons for schizophrenic thinking.
interaction with other signicant people. Yalom pioneered the All these system-oriented views assume that the family is
study of therapeutic factors specic to the group rather than a system observed by the therapist. However, therapists are not
following the pattern of transposing psychoanalytic or other value-neutral. They may take an active role in orchestrating
theories from the individual setting. His Theory and Practice of change in accordance with a model of family functioning. Yet
Group Psychotherapy (Yalom, 1995) became exceedingly inu- these models ignore therapists biases as well as the relevance of
ential, attested to by the appearance of four editions. their relationships with families. This probably reected the
Constrained perhaps by Western medicines focus on the determination of some American family therapists to distance
individual patient, psychiatry was slow to develop an interest in themselves from psychoanalytic theory, and also led them to
the family (Gurman and Kniskern, 1991). Scattered through neglect the familys history, how it changed throughout the
Freuds writings are interesting comments about family rela- lifecycle, and the signicance of past traumatic and other
tionships and their possible roles in both individual develop- notable life events.
ment and psychopathology. His description of processes like In response to these criticisms there was a move away from
introjection, projection, and identication explained how the problem-focused approach which had characterized most
individual experiences could be transmitted across the gener- behavioral and communication views of psychopathology. The
ations in a family. Inuenced by the work in the UK of Anna Milan school (1980) whose founders were psychoanalysts
Freud, Melanie Klein, and Donald Winnicott, the child developed a new method of interviewing families in conjunc-
guidance movement developed a model of one therapist tion with observers behind a one-way screen formulating and
working with a disturbed child and another with the parents, then presenting to the family and therapist hypotheses about
most often the mother on her own. The two clinicians collab- their system.
orated in order to recognize how the mothers anxieties Family therapists also began to consider that families might
distorted her perception and handling of her child, which were be constrained from experimenting with new solutions because
added to the childs own anxieties. of the way they had interpreted their past experiences or
Things took a different turn in the US. There, Ackerman internalized explanatory narratives of their family, the experts,
(1958) introduced the idea of working with the family of or society at large. This led to a shift from considering the
a disturbed child using psychoanalytic methods in the 1950s. family as a social to a linguistic system.
An interest in working with the family, including two or more The narrative a family conveys about their lives is
generations, arose concurrently. Thus, Murray Bowen (1978) a construction which organizes past experience in particular
found that the capacity of psychotic children to differentiate ways; other narratives are excluded. When a family with an ill
506 Psychotherapy, History of: Psychiatric Aspects

member talks to a professional, conversations are inevitably minuscule. The attack led to much rancor and an extended
about problems (a problem-saturated description). The battle between the psychoanalytic and behavioral camps
participants ignore times when problems were absent or (Eysenck featured prominently in the latter). Fortunately,
minimal, or when they successfully conned problems to a positive repercussion was the sense of challenge experienced
manageable proportions. A different story might be told if they by the analytic group. They had been riding high for several
were to examine the context that might have led, or could still years, particularly in the US, and barely questioned whether
lead, to better outcomes. their concepts and practice required scientic appraisal. Thus,
A number of narrative approaches have applied these although Eysencks interpretation of the research literature was
concepts. Philosophically, they align themselves with post- awed and biased, he had stirred a hornets nest.
modernism, which challenges the notion of a basic truth Since the 1950s research has burgeoned and yielded much
known only by an expert. knowledge about whether psychotherapy works (outcome
Many criticisms of systems approaches have been leveled research) and how it works (process research). These develop-
including: ments were not without incident. Many therapists challenged
the relevance of conventional research methodology to
1. Disregard of the subjective and intersubjective experiences
psychotherapy. A key argument was that the encounter between
of family members.
therapist and patient is unique, involving two people in
2. Neglect of their history.
a complex collaborative venture, and cannot be subject to the
3. Denial of unconscious motives which affect relationships.
same form of scrutiny as occurs in the natural sciences. More-
4. Although family members are reciprocally connected, the
over, the latter approach is necessarily mechanistic and
power they exert on one another is not equal; this is high-
lighted in the violence against women and in child abuse.
There is merit to the argument but actual research practice
5. Inequality and other forms of injustice based on societal
reveals that methodology can accommodate, at least in part,
attitudes toward differences in gender, ethnicity, class, and
respect for the highly personal nature of psychological treat-
the like, are uncritically accepted as givens.
ment. Sophisticated statistical procedures can also contribute
6. Minimizing the role of the therapeutic relationship,
to maintaining an appreciation that many characteristics
including attitudes members develop toward the therapist
in both patient and therapist are relevant, and they cannot
and her feelings toward them.
be viewed as homogeneous groups. An illustration is the
This critique has led to growing interest in integrating multidimensional measurement of outcome. Instead of
systems-oriented and psychoanalytic ideas, particularly those restricting this to one or two variables only, several can be
derived from object-relations theory. One variant is John Byng- examined concurrently which together encompass the patients
Halls (1995) synthesis of attachment theory, systems-thinking, internal and interpersonal world, e.g., quality of life, self-
and a narrative approach. awareness, authenticity, self-esteem, target problems, and
A further criticism of systems-oriented approaches is that social adjustment.
they minimize the impact of external reality such as physical Another criticism of outcome research is examining effec-
disability or biological factors, in the etiology of mental tiveness without adequate treatment being given. Duration of
illness, and sociopolitical phenomena like unemployment, research-bound therapy in fact is often much briefer than in
racism, and poverty. One result is the psychoeducational customary practice because of funding constraints. A similar
approach, which has evolved in the context of the burden objection relates to the follow-up period usually set. A robust
schizophrenia places on the family and the potential for its test of effectiveness entails examining outcome one or more
members to inuence its course. This has led to a series of years following the end of therapy in order to judge clinical
interventions including educating the family about the nature, projects independent of the therapist.
causes, course, and treatment of schizophrenia; providing
them with opportunities to discuss their difculties in caring
for the patient, and to devise appropriate strategies; and The Effectiveness of Psychotherapy
helping them to resolve conict related to the illness, which
may be aggravated by the demands of caring for a chronically Several reviews have been conducted since the 1970s. A
ill person. sophisticated method meta-analysis which relies on
a rigorous statistical approach, points to psychotherapy overall
generating benets for patients who have been suitably
The Scientific Era selected. Encouragingly, better designed studies show positive
results more commonly than inadequate ones. In one trail-
Systematic research in the psychotherapies was a low priority blazing meta-analysis, levels of effectiveness were computed
for many decades; instead, practitioners interests focused on from 375 studies in which some 25 000 experimental and
theory and technique. Investigation of the subject only took off 25 000 controlled patients were tested (Smith et al., 1980). The
in earnest in the early 1950s. A notable impetus was the average patient receiving psychological treatment of one kind
critique by H.J. Eysenck (1952) in which he argued that the of another was better off than 75% of those who were
treatment of neurotic patients was no more effective than no untreated a clear demonstration of the benecial effects of
treatment at all. Two-thirds of both groups showed improve- treatment in general.
ment with time. In later reviews, Eysenck was even more With tens of schools available, many of them claiming
damning: the effects of psychoanalysis in particular were a distinctive approach, the obvious question arises as to
Psychotherapy, History of: Psychiatric Aspects 507

whether some are superior in producing benet. This question advent of recording techniques such as audio and video has
of comparative effectiveness is complicated in that not only facilitated studies of process and a wide range of observations
may schools be compared but also specic procedures such as of both verbal and nonverbal behavior, in both therapist and
setting a time limit or not or conducting therapy individually or patient and their interaction, have been made. One illustration
within a group. Notwithstanding these difculties, considering is the premise that a necessary condition for effective group
research on comparative effectiveness is worthwhile. Several therapy is group cohesiveness. It follows that anything
reviews show a consistent pattern that everyone has won and enhancing cohesiveness could be advantageous. Compatibility
must have prizes. This was of course the judgment of a race between members has been proposed as pertinent and indeed
handed down by the dodo bird in Alice in Wonderland. In the been shown to relate to cohesiveness. Group therapy therefore
psychotherapy stakes, it appears that everyone has won too, could conceivably be more effective if, in selecting members,
a nding probably attributable to factors common to all ther- compatibility were taken into account. For example, a patient
apeutic approaches. These factors, set out originally by Jerome incompatible with all his peers would presumably not be
Frank (1973), include a conding relationship with a helping placed in that group.
person, a rationale which provides an account of the patients Research on process has been shown to be as salient as that
problems and of the methods for remedying them, instillation on outcome since only with the study of what occurs in treat-
of hope for change, opportunity for success experiences during ment can therapists appreciate its inherent nature and the
treatment, facilitating emotion in the patient, and providing factors for optimal improvement of participants. Diligent
new knowledge, so promoting self-awareness. These nonspe- process research has provided solid foundations for establish-
cic factors comprise a signicant theme in psychotherapy; ing hypotheses about outcome.
they probably serve as a platform for benets from all We have dealt in general terms with the theme of psycho-
treatments. therapy research. The second half of the twentieth century has
Any consideration of effectiveness brings up the issue of been a fertile period and seen much achieved; to do it justice is
harm. In other words, treatment may be for better or for beyond our remit. The interested reader is recommended to
worse. After a long gestation, the concept of a negative effect consult the four editions of the Handbook of Psychotherapy and
attracted widespread attention from the 1970s (Hadley and Behavior Change (Bergin and Gareld, 1994) which has served
Strupp, 1976). A growing sense of condence perhaps the eld in distilling work done and providing a critique of its
permitted therapists to be more open to a potential harmful quality.
To distinguish between a patient becoming worse because
of their intrinsic condition or following an adverse life event, See also: Bowlby, John (190790); Freud, Sigmund
a negative effect has been dened as deterioration directly (18561939); Janet, Pierre (18591947); Jung, Carl Gustav
attributable to treatment itself. Such a causal link is difcult to (18751961); Klein, Melanie (18821960); Psychoanalysis,
prove but genuine negative effects certainly do occur. The History of; Psychological Treatment, Effectiveness of;
denitional difculty, however, leads to estimates of preva- Psychological Treatments, Empirically Supported.
lence ranging from rare to common. The type of therapy
appears to inuence the rate. Evidence points to worsening in
about 510% of cases in psychotherapy generally. The reasons
for deterioration are not well established although a common Bibliography
view is that patient factors probably contribute, particularly
selecting people for treatments for which they are unsuited. In Ackerman, N.W., 1958. The Psychodynamics of Family Life. Basic Books, New York.
this situation, rening assessment, thus enhancing clinicians Appignanesi, L., Forrester, J., 1992. Freuds Women. Basic Books, New York.
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