Kick the tires and light the fires, problem officially solevd!
- 1 Definition
- 2 Etymology
- 3 Forms
- 4 Systems
- 5 History
- 6 General concerns
- 7 Specific schools and approaches
- 7.1 Psychoanalysis
- 7.2 Gestalt therapy
- 7.3 Group psychotherapy
- 7.4 Medical and non-medical models
- 7.5 Cognitive behavioral therapy
- 7.6 Behavior therapy
- 7.7 Body-oriented psychotherapy
- 7.8 Expressive therapy
- 7.9 Interpersonal psychotherapy
- 7.10 Narrative therapy
- 7.11 Integrative psychotherapy
- 7.12 Hypnotherapy
- 7.13 Adaptations for children
- 7.14 Confidentiality
- 8 Criticisms and questions regarding effectiveness
- 9 References
Psychotherapy is the treatment of mental and emotional disorders through the use of psychological techniques designed to encourage communication of conflicts and insight into problems, with the goal being relief of symptoms, changes in behavior leading to improved social and vocational functioning, and personality.
It is an intentional interpersonal relationship used by trained psychotherapists or it is personal counseling with a psychotherapist to aid a client or patient in problems of living.
It aims to increase the individual's sense of their own well-being. Psychotherapists employ a range of techniques based on experiential relationship building, dialogue, communication and behavior change and that are designed to improve the mental health of a client or patient, or to improve group relationships (such as in a family).
Psychotherapy may also be performed by practitioners with a number of different qualifications, including psychiatry, clinical psychology, clinical social work, counseling psychology, mental health counseling, clinical or psychiatric social work, marriage and family therapy, rehabilitation counseling, music therapy, occupational therapy, psychiatric nursing, psychoanalysis and others. It may be legally regulated, voluntarily regulated or unregulated, depending on the jurisdiction. Requirements of these professions vary, but often require graduate school and supervised clinical experience.
Psychotherapy is an English word of Greek origin, deriving from Ancient Greek psyche meaning "breath; spirit; soul" and therapia ("healing; medical treatment").
According to the Oxford English Dictionary, psychotherapy first meant "hypnotherapy" instead of "psychotherapy". The original meaning, "the treatment of disease by ‘psychic’ [i.e., hypnotic] methods", was first recorded in 1853 as "Psychotherapeia, or the remedial influence of mind". The modern meaning, "the treatment of disorders of the mind or personality by psychological or psychophysiological methods", was first used in 1892 by Frederik van Eeden translating "Suggestive Psycho-therapy" for his French "Psychothérapie Suggestive". Van Eeden credited borrowing this term from Daniel Hack Tuke and noted, "Psycho-therapy … had the misfortune to be taken in tow by hypnotism."
The psychiatrist Jerome Frank defined psychotherapy as the relief of distress or disability in one person by another, using an approach based on a particular theory or paradigm, and a requirement that the agent performing the therapy has had some form of training in delivering this. It is these latter two points which distinguish psychotherapy from other forms of counseling or caregiving.
Most forms of psychotherapy use spoken conversation. Some also use various other forms of communication such as the written word, artwork, drama, narrative story or music. Psychotherapy with children and their parents often involves play, dramatization (i.e. role-play), and drawing, with a co-constructed narrative from these non-verbal and displaced modes of interacting. Psychotherapy occurs within a structured encounter between a trained psychotherapist, and client(s). Purposeful, theoretically based psychotherapy began in the 19th century with psychoanalysis; since then, scores of other approaches have been developed and continue to be created.
Therapy is generally used in response to a variety of specific or non-specific manifestations of clinically diagnosable and/or existential crises. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers). However, the term counseling is sometimes used interchangeably with "psychotherapy".
While some psychotherapeutic interventions are designed to treat the patient using the medical model, many psychotherapeutic approaches do not adhere to the symptom-based model of "illness/cure". Some practitioners, such as humanistic therapists, see themselves more in a facilitative/helper role. As sensitive and deeply personal topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality. The critical importance of confidentiality is enshrined in the regulatory psychotherapeutic organizations' codes of ethical practice.
There are several main broad systems of psychotherapy:
- Psychoanalytic - it was the first practice to be called a psychotherapy. It encourages the verbalization of all the patient's thoughts, including free associations, fantasies, and dreams, from which the analyst formulates the nature of the unconscious conflicts which are causing the patient's symptoms and character problems.
- Behavior Therapy/applied behavior analysis focuses on changing maladaptive patterns of behavior to improve emotional responses, cognitions, and interactions with others.
- Cognitive behavioral - generally seeks to identify maladaptive cognition, appraisal, beliefs and reactions with the aim of influencing destructive negative emotions and problematic dysfunctional behaviors.
- Psychodynamic - is a form of depth psychology, whose primary focus is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. Although its roots are in psychoanalysis, psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis.
- Existential - is based on the existential belief that human beings are alone in the world. This isolation leads to feelings of meaninglessness, which can be overcome only by creating one's own values and meanings. Existential therapy is philosophically associated with phenomenology.
- Humanistic - emerged in reaction to both behaviorism and psychoanalysis and is therefore known as the Third Force in the development of psychology. It is explicitly concerned with the human context of the development of the individual with an emphasis on subjective meaning, a rejection of determinism, and a concern for positive growth rather than pathology. It posits an inherent human capacity to maximize potential, 'the self-actualizing tendency'. The task of Humanistic therapy is to create a relational environment where this tendency might flourish. Humanistic psychology is philosophically rooted in existentialism.
- Brief - "Brief therapy" is an umbrella term for a variety of approaches to psychotherapy. It differs from other schools of therapy in that it emphasizes (1) a focus on a specific problem and (2) direct intervention. It is solution-based rather than problem-oriented. It is less concerned with how a problem arose than with the current factors sustaining it and preventing change.
- Systemic - seeks to address people not at an individual level, as is often the focus of other forms of therapy, but as people in relationship, dealing with the interactions of groups, their patterns and dynamics (includes family therapy & marriage counseling). Community psychology is a type of systemic psychology.
- Transpersonal - Addresses the client in the context of a spiritual understanding of consciousness.
- Body Psychotherapy - Addresses problems of the mind as being closely correlated with bodily phenomena, including a person's sexuality, musculature, breathing habits, physiology etc. This therapy may involve massage and other body exercises as well as talking.
There are hundreds of psychotherapeutic approaches or schools of thought. By 1980 there were more than 250; by 1996 there were more than 450. The development of new and hybrid approaches continues around the wide variety of theoretical backgrounds. Many practitioners use several approaches in their work and alter their approach based on client need.
- See the list of psychotherapies for an extended list of individual psychotherapies.
In an informal sense, psychotherapy can be said to have been practiced through the ages, as individuals received psychological counsel and reassurance from others. Philosophers and physicians from the Hellenistic schools of philosophy and therapy practised psychotherapy among the Ancient Greeks and Romans from about the late 4th century BC to the 4th century AD. The Greek physician Hippocrates (460– 377 BC) viewed mental illnesses as phenomena that could be studied and treated empirically. Purposeful, theoretically-based psychotherapy was probably first developed in the Middle East during the 9th century by the Persian physician and psychological thinker, Rhazes (AD 852-932), who was at one time the chief physician of the Baghdad hospital. At that time in Europe, serious mental disorders were generally treated as demonic or medical conditions requiring punishment and confinement until the advent of moral treatment approaches in the 18th Century. This brought about a focus on the possibility of psychosocial intervention - including reasoning, moral encouragement, and group activities - to rehabilitate the "insane".
Psychoanalysis was perhaps the first specific school of psychotherapy, developed by Sigmund Freud and others through the early 20th century. Trained as a neurologist, Freud began focusing on problems that appeared to have no discernible organic basis, and theorized that they had psychological causes originating in childhood experiences and the unconscious mind. Techniques such as dream interpretation, free association, transference and analysis of the id, ego and superego were developed. Starting in the 1950s Carl Rogers brought Person-centered psychotherapy into mainstream focus. Many theorists, including Anna Freud, Alfred Adler, Carl Jung, Karen Horney, Otto Rank, Erik Erikson, Melanie Klein, and Heinz Kohut, built upon Freud's fundamental ideas and often formed their own differentiating systems of psychotherapy. These were all later categorized as psychodynamic, meaning anything that involved the psyche's conscious/unconscious influence on external relationships and the self. Sessions tended to number into the hundreds over several years.
Behaviorism developed in the 1920s, and behavior modification as a therapy became popularized in the 1950s and 1960s. Notable contributors were Joseph Wolpe in South Africa, M.B. Shipiro and Hans Eysenck in Britain, and John B. Watson and B.F. Skinner in the United States. Behavioral therapy approaches relied on principles of operant conditioning, classical conditioning and social learning theory to bring about therapeutic change in observable symptoms. The approach became commonly used for phobias, as well as other disorders.
Some therapeutic approaches developed out of the European school of existential philosophy. Concerned mainly with the individual's ability to develop and preserve a sense of meaning and purpose throughout life, major contributors to the field in the US (e.g., Irvin Yalom, Rollo May) and Europe (Viktor Frankl, Ludwig Binswanger, Medard Boss, R.D.Laing, Emmy van Deurzen) attempted to create therapies sensitive to common 'life crises' springing from the essential bleakness of human self-awareness, previously accessible only through the complex writings of existential philosophers (e.g., Søren Kierkegaard, Jean-Paul Sartre, Gabriel Marcel, Martin Heidegger, Friedrich Nietzsche). The uniqueness of the patient-therapist relationship thus also forms a vehicle for therapeutic enquiry. A related body of thought in psychotherapy started in the 1950s with Carl Rogers. Based on existentialism and the works of Abraham Maslow and his hierarchy of human needs, Rogers brought person-centered psychotherapy into mainstream focus. The primary requirement of Rogers is that the client should be in receipt of three core 'conditions' from their counsellor or therapist: unconditional positive regard, also sometimes described as 'prizing' the person or valuing the humanity of an individual, congruence [authenticity/genuineness/transparency], and empathic understanding. The aim in using the 'core conditions' is to facilitate therapeutic change within a non-directive relationship conducive to enhancing the client's psychological well being. This type of interaction enables the client to fully experience and express themselves. Others developed the approach, like Fritz and Laura Perls in the creation of Gestalt therapy, as well as Marshall Rosenberg, founder of Nonviolent Communication, and Eric Berne, founder of Transactional Analysis. Later these fields of psychotherapy would become what is known as humanistic psychotherapy today. Self-help groups and books became widespread.
During the 1950s, Albert Ellis originated Rational Emotive Behavior Therapy (REBT). A few years later, psychiatrist Aaron T. Beck developed a form of psychotherapy known as cognitive therapy. Both of these included generally relative short, structured and present-focused therapy aimed at identifying and changing a person's beliefs, appraisals and reaction-patterns, by contrast with the more long-lasting insight-based approach of psycho-dynamic or humanistic therapies. Cognitive and behavioral therapy approaches were combined and grouped under the heading and umbrella-term Cognitive behavioral therapy (CBT) in the 1970s. Many approaches within CBT were oriented towards active/directive collaborative empiricism and mapping, assessing and modifying clients core beliefs and dysfunctional schemas. These approaches gained widespread acceptance as a primary treatment for numerous disorders. A "third wave" of cognitive and behavioral therapies developed, including Acceptance and Commitment Therapy and Dialectical behavior therapy, which expanded the concepts to other disorders and/or added novel components and mindfulness exercises. Counseling methods developed, including solution-focused therapy and systemic coaching.
Postmodern psychotherapies such as Narrative Therapy and Coherence Therapy did not impose definitions of mental health and illness, but rather saw the goal of therapy as something constructed by the client and therapist in a social context. Systems Therapy also developed, which focuses on family and group dynamics—and Transpersonal psychology, which focuses on the spiritual facet of human experience. Other important orientations developed in the last three decades include Feminist therapy, Brief therapy, Somatic Psychology, Expressive therapy, applied Positive psychology and the Human Givens approach which is building on the best of what has gone before. A survey of over 2,500 United States therapists in 2006 revealed the most utilized models of therapy and the ten most influential therapists of the previous quarter-century.
Psychotherapy can be seen as an interpersonal invitation offered by (often trained and regulated) psychotherapists to aid clients in reaching their full potential or to cope better with problems of life. Psychotherapists usually receive remuneration in some form in return for their time and skills. This is one way in which the relationship can be distinguished from an altruistic offer of assistance.
Psychotherapists and counselors often require to create a therapeutic environment referred to as the frame, which is characterized by a free yet secure climate that enables the client to open up. The degree to which client feels related to the therapist may well depend on the methods and approaches used by the therapist or counselor.
Psychotherapy often includes techniques to increase awareness and the capacity for self observation, change behavior and cognition, and develop insight and empathy. A desired result enable other choices of thought, feeling or action; to increase the sense of well-being and to better manage subjective discomfort or distress. Perception of reality is hopefully improved. Grieving might be enhanced producing less long term depression. Psychotherapy can improve medication response where such medication is also needed. Psychotherapy can be provided on a one-to-one basis, in group therapy, conjointly with couples and with entire families. It can occur face to face (individual), over the telephone, or, much less commonly, the Internet. Its time frame may be a matter of weeks or many years. Therapy may address specific forms of diagnosable mental illness, or everyday problems in managing or maintaining interpersonal relationships or meeting personal goals. Treatment in families with children can favorably influence a childs development, lasting for life and into future generations. Better parenting may be an indirect result of therapy or purposefully learned as parenting techniques. Divorces can be prevented, or made far less traumatic. Treatment of everyday problems is more often referred to as counseling (a distinction originally adopted by Carl Rogers) but the term is sometimes used interchangeably with "psychotherapy". Therapeutic skills can be used in mental health consultation to business and public agencies to improve efficiency and assist with coworkers or clients.
Psychotherapists use a range of techniques to influence or persuade the client to adapt or change in the direction the client has chosen. These can be based on clear thinking about their options; experiential relationship building; dialogue, communication and adoption of behavior change strategies. Each is designed to improve the mental health of a client or patient, or to improve group relationships (as in a family). Most forms of psychotherapy use only spoken conversation, though some also use other forms of communication such as the written word, artwork, drama, narrative story, or therapeutic touch. Psychotherapy occurs within a structured encounter between a trained therapist and client(s). Because sensitive topics are often discussed during psychotherapy, therapists are expected, and usually legally bound, to respect client or patient confidentiality.
Psychotherapists are often trained, certified, and licensed, with a range of different certifications and licensing requirements depending on the jurisdiction. Psychotherapy may be undertaken by clinical psychologists,counseling psychologists, social workers, marriage-family therapists, adult and child psychiatrists and expressive therapists, trained nurses, psychiatrists, psychoanalysts, mental health counselors, school counselors, or professionals of other mental health disciplines.
Psychiatrists have medical qualifications and may also administer prescription medication. The primary training of a psychiatrist uses the ' Bio-Psycho-Social' model, medical training in practical psychology and applied psychotherapy. Psychiatric training begins in medical school, first in the doctor patient relationship with ill people , and later in psychiatric residency for specialists. The focus is usually eclectic but including biological, cultural, and social aspects. They are advanced in understanding patients from the inception of medical training . Psychologists spend their early years in school receiving more training intellectually and in psychological theory used for, in part, psychological assessment and research, and have in-depth training in psychotherapy but psychiatrists have far more clinical experience with people at the end of formal training. MDs tend to lag behind psychologist in academic knowledge as the are entering residency training . Over the years psychologists gain clinical experience and MD's usually improve in intellectually so that a kind of equality in competence occurs . Today there are two doctoral degrees in psychology , the PsyD and PhD . Training for these degrees overlap but the PsyD is more clinical and the Phd stresses research and is ' more academic ' . Both degrees have clinical education components, Social workers have specialized training in linking patients to community and institutional resources, in addition to elements of psychological assessment and psychotherapy. Marriage-family therapists have specific training and experience working with relationships and family issues. A licensed professional counselor (LPC) generally has special training in career, mental health, school, or rehabilitation counseling to include evaluation and assessments as well as psychotherapy. Many of the wide variety of training programs are multiprofessional, that is, psychiatrists, psychologists, mental health nurses, and social workers may be found in the same training group. All these degrees commonly work together as a team , especially in institutional settings . All those doing specialized psychotherapeutic work, in most countries require a program of continuing education after the basic degree, or involves multiple certifications attached to one specific degree , and 'board certification' in psychiatry . Specialty exams are used to confirm competence or board exams with psychiatrists .
Specific schools and approaches
Psychoanalysis was developed in the late 19th century by Sigmund Freud. His therapy explores the dynamic workings of a mind understood to consist of three parts: the hedonistic id (German: das Es, "the it"), the rational ego (das Ich, "the I"), and the moral superego (das Überich, "the above-I"). Because the majority of these dynamics are said to occur outside people's awareness, Freudian psychoanalysis seeks to probe the unconscious by way of various techniques, including dream interpretation and free association. Freud maintained that the condition of the unconscious mind is profoundly influenced by childhood experiences. So, in addition to dealing with the defense mechanisms used by an overburdened ego, his therapy addresses fixations and other issues by probing deeply into clients' youth.
Other psychodynamic theories and techniques have been developed and used by psychotherapists, psychologists, psychiatrists, personal growth facilitators, occupational therapists and social workers. Techniques for group therapy have also been developed. While behaviour is often a target of the work, many approaches value working with feelings and thoughts. This is especially true of the psychodynamic schools of psychotherapy, which today include Jungian therapy and Psychodrama as well as the psychoanalytic schools.
Gestalt Therapy is a major overhaul of psychoanalysis. In its early development it was called "concentration therapy" by its founders, Frederick and Laura Perls. However, its mix of theoretical influences became most organized around the work of the gestalt psychologists; thus, by the time 'Gestalt Therapy, Excitement and Growth in the Human Personality' (Perls, Hefferline, and Goodman) was written, the approach became known as "Gestalt Therapy."
Gestalt Therapy stands on top of essentially four load bearing theoretical walls: phenomenological method, dialogical relationship, field-theoretical strategies, and experimental freedom. Some have considered it an existential phenomenology while others have described it as a phenomenological behaviorism. Gestalt therapy is a humanistic, holistic, and experiential approach that does not rely on talking alone, but facilitates awareness in the various contexts of life by moving from talking about situations relatively remote to action and direct, current experience.
The therapeutic use of groups in modern clinical practice can be traced to the early 20th century, when the American chest physician Pratt, working in Boston, described forming 'classes' of 15 to 20 patients with tuberculosis who had been rejected for sanatorium treatment. The term group therapy, however, was first used around 1920 by Jacob L. Moreno, whose main contribution was the development of psychodrama, in which groups were used as both cast and audience for the exploration of individual problems by reenactment under the direction of the leader. The more analytic and exploratory use of groups in both hospital and out-patient settings was pioneered by a few European psychoanalysts who emigrated to the USA, such as Paul Schilder, who treated severely neurotic and mildly psychotic out-patients in small groups at Bellevue Hospital, New York. The power of groups was most influentially demonstrated in Britain during the Second World War, when several psychoanalysts and psychiatrists proved the value of group methods for officer selection in the War Office Selection Boards. A chance to run an Army psychiatric unit on group lines was then given to several of these pioneers, notably Wilfred Bion and Rickman, followed by S. H. Foulkes, Main, and Bridger. The Northfield Hospital in Birmingham gave its name to what came to be called the two 'Northfield Experiments', which provided the impetus for the development since the war of both social therapy, that is, the therapeutic community movement, and the use of small groups for the treatment of neurotic and personality disorders. Today group therapy is used in clinical settings and in private practice settings. It has been shown to be as or more effective than individual therapy.
Medical and non-medical models
A distinction can also be made between those psychotherapies that employ a medical model and those that employ a humanistic model. In the medical model the client is seen as unwell and the therapist employs their skill to help the client back to health. The extensive use of the DSM-IV, the diagnostic and statistical manual of mental disorders in the United States, is an example of a medically-exclusive model.
The humanistic model of non medical in contrast strives to depathologise the human condition. The therapist attempts to create a relational environment conducive to experiential learning and help build the client's confidence in their own natural process resulting in a deeper understanding of themselves. An example would be gestalt therapy.
Some psychodynamic practitioners distinguish between more uncovering and more supportive psychotherapy. Uncovering psychotherapy emphasizes facilitating the client's insight into the roots of their difficulties. The best-known example of an uncovering psychotherapy is classical psychoanalysis. Supportive psychotherapy by contrast stresses strengthening the client's defenses and often providing encouragement and advice. Depending on the client's personality, a more supportive or more uncovering approach may be optimal. Most psychotherapists use a combination of uncovering and supportive approaches.
Cognitive behavioral therapy
Cognitive behavioral therapy refers to a range of techniques which focus on the construction and re-construction of people's cognitions, emotions and behaviors. Generally in CBT the therapist, through a wide array of modalities, helps clients assess, recognize and deal with problematic and dysfunctional ways of thinking, emoting and behaving.
Behavior therapy focuses on modifying overt behavior and helping clients to achieve goals. This approach is built on the principles of learning theory including operant and respondent conditioning, which makes up the area of applied behavior analysis or behavior modification. This approach includes acceptance and commitment therapy, functional analytic psychotherapy, and dialectical behavior therapy. Sometimes it is integrated with cognitive therapy to make cognitive behavior therapy. By nature, behavioral therapies are empirical (data-driven), contextual (focused on the environment and context), functional (interested in the effect or consequence a behavior ultimately has), probabilistic (viewing behavior as statistically predictable), monistic (rejecting mind-body dualism and treating the person as a unit), and relational (analyzing bidirectional interactions).
Body-oriented psychotherapy or Body Psychotherapy is also known as Somatic Psychology, especially in the USA. There are many very different psychotherapeutic approaches. They generally focus on the link between the mind and the body and try to access deeper levels of the psyche through greater awareness of the physical body and the emotions which gave rise to the various body-oriented based psychotherapeutic approaches, such as Reichian (Wilhelm Reich) Character-Analytic Vegetotherapy and Orgonomy; neo-Reichian Alexander Lowen's Bioenergetic analysis; Peter Levine's Somatic Experiencing; Jack Rosenberg's Integrative body psychotherapy; Ron Kurtz's Hakomi psychotherapy; Pat Ogden's sensorimotor psychotherapy; David Boadella's Biosynthesis psychotherapy; Gerda Boyesen's Biodynamic psychotherapy; etc. These body-oriented psychotherapies are not to be confused with alternative medicine body-work or body-therapies that seek primarily to improve physical health through direct work (touch and manipulation) on the body because, despite the fact that bodywork techniques (for example Alexander Technique, Rolfing, and the Feldenkrais Method) can also affect the emotions, these techniques are not designed to work on psychological issues, neither are their practitioners so trained.
Expressive therapy is a form of therapy that utilizes artistic expression as its core means of treating clients. Expressive therapists use the different disciplines of the creative arts as therapeutic interventions. This includes the modalities dance therapy, drama therapy, art therapy, music therapy, writing therapy, among others. Expressive therapists believe that often the most effective way of treating a client is through the expression of imagination in a creative work and integrating and processing what issues are raised in the act.
Interpersonal psychotherapy (IPT) is a time-limited psychotherapy that focuses on the interpersonal context and on building interpersonal skills. IPT is based on the belief that interpersonal factors may contribute heavily to psychological problems. It is commonly distinguished from other forms of therapy in its emphasis on interpersonal processes rather than intrapsychic processes. IPT aims to change a person's interpersonal behavior by fostering adaptation to current interpersonal roles and situations.
Narrative therapy gives attention to each person's "dominant story" by means of therapeutic conversations, which also may involve exploring unhelpful ideas and how they came to prominence. Possible social and cultural influences may be explored if the client deems it helpful.
Integrative psychotherapy is an attempt to combine ideas and strategies from more than one theoretical approach. These approaches include mixing core beliefs and combining proven techniques. Forms of integrative psychotherapy include multimodal therapy, the transtheoretical model, cyclical psychodynamics, systematic treatment selection, cognitive analytic therapy, Internal Family Systems Model, multitheoretical psychotherapy and conceptual interaction. In practice, most experienced psychotherapists develop their own integrative approach over time.
Hypnotherapy is therapy that is undertaken with a subject in hypnosis. Hypnotherapy is often applied in order to modify a subject's behavior, emotional content, and attitudes, as well as a wide range of conditions including dysfunctional habits, anxiety, stress-related illness, pain management, and personal development.
Adaptations for children
Counseling and psychotherapy must be adapted to meet the developmental needs of children. Many counseling preparation programs include courses in human development. Since children often do not have the ability to articulate thoughts and feelings, counselors will use a variety of media such as crayons, paint, clay, puppets, bibliocounseling (books), toys, board games, et cetera. The use of play therapy is often rooted in psychodynamic theory, but other approaches such as Solution Focused Brief Counseling may also employ the use of play in counseling. In many cases the counselor may prefer to work with the care taker of the child, especially if the child is younger than age four. Yet, by doing so, the counselor risks the perpetuation of maladaptive interactive patterns and the adverse effects on development that have already been affected on the child's end of the relationship Therefore, contemporary thinking on working with this young age group has leaned towards working with parent and child simultaneously within the interaction, as well as individually as needed.
Confidentiality is an integral part of the therapeutic relationship and psychotherapy in general.
Criticisms and questions regarding effectiveness
Within the psychotherapeutic community there has been some discussion of empirically-based psychotherapy, e.g.
Virtually no comparisons of different psychotherapies with long follow-up times have been done. The Helsinki Psychotherapy Study is a randomized clinical trial, in which patients are monitored for 12 months after the onset of study treatments, of which each lasted approximately 6 months. The assessments are to be completed at the baseline examination and during the follow-up after 3, 7, and 9 months and 1, 1.5, 2, 3, 4, 5, 6, and 7 years. The final results of this trial are yet to be published because follow-up evaluations continued up to 2009.
There is considerable controversy about which form of psychotherapy is most effective, and more specifically, which types of therapy are optimal for treating which sorts of problems. Furthermore, it is controversial whether the form of therapy or the presence of factors common to many psychotherapies best separates effective therapy from ineffective therapy. Common factors theory asserts it is precisely the factors common to the most psychotherapies that make any psychotherapy successful: this is the quality of the therapeutic relationship.
The dropout level is quite high; one meta-analysis of 125 studies concluded that the mean dropout rate was 46.86%. The high level of dropout has raised some criticism about the relevance and efficacy of psychotherapy.
Psychotherapy outcome research—in which the effectiveness of psychotherapy is measured by questionnaires given to patients before, during, and after treatment—has had difficulty distinguishing between the success or failure of the different approaches to therapy. Those who stay with their therapist for longer periods are more likely to report positively on what develops into a longer-term relationship. This suggests that some "treatment" may be open-ended with concerns associated with ongoing financial costs.
As early as 1952, in one of the earliest studies of psychotherapy treatment, Hans Eysenck reported that two thirds of therapy patients improved significantly or recovered on their own within two years, whether or not they received psychotherapy.
Many psychotherapists believe that the nuances of psychotherapy cannot be captured by questionnaire-style observation, and prefer to rely on their own clinical experiences and conceptual arguments to support the type of treatment they practice.
In 2001, Bruce Wampold of the University of Wisconsin published the book The Great Psychotherapy Debate. In it Wampold, a former statistician who went on to train as a counseling psychologist, reported that
- psychotherapy is indeed effective,
- the type of treatment is not a factor,
- the theoretical bases of the techniques used, and the strictness of adherence to those techniques are both not factors,
- the therapist's strength of belief in the efficacy of the technique is a factor,
- the personality of the therapist is a significant factor,
- the alliance between the patient(s) and the therapist (meaning affectionate and trusting feelings toward the therapist, motivation and collaboration of the client, and empathic response of the therapist) is a key factor.
Wampold therefore concludes that "we do not know why psychotherapy works".
Although the Great Psychotherapy Debate dealt primarily with data on depressed patients, subsequent articles have made similar findings for post-traumatic stress disorder and youth disorders. There have also been studies of Panic Disorder, where treatment effectiveness is measured in the abatement of panic attacks. Psychoanalytic psychotherapy has been found to be as effective as Cognitive Behavioral Therapy for immediate relief and more effective over the long term 
Some report that by attempting to program or manualize treatment, psychotherapists may be reducing efficacy, although the unstructured approach of many psychotherapists cannot appeal to patients motivated to solve their difficulties through the application of specific techniques different from their past "mistakes."
Critics of psychotherapy are skeptical of the healing power of a psychotherapeutic relationship. Because any intervention takes time, critics note that the passage of time alone, without therapeutic intervention, often results in psycho-social healing. Social contact with others is universally seen as beneficial for all humans and regularly scheduled visits with anyone would be likely to diminish both mild and severe emotional difficulty.
Many resources available to a person experiencing emotional distress—the friendly support of friends, peers, family members, clergy contacts, personal reading, healthy exercise, research, and independent coping—all present considerable value. Critics note that humans have been dealing with crises, navigating severe social problems and finding solutions to life problems long before the advent of psychotherapy. Of course, it may well be something in the patient that does not develop these "natural" supports that requires therapy.
Further critiques have emerged from feminist, constructionist and discursive sources. Key to these is the issue of power. In this regard there is a concern that clients are persuaded—both inside and outside the consulting room—to understand themselves and their difficulties in ways that are consistent with therapeutic ideas. This means that alternative ideas (e.g., feminist, economic, spiritual) are sometimes implicitly undermined. Critics suggest that we idealise the situation when we think of therapy only as a helping relation. It is also fundamentally a political practice, in that some cultural ideas and practices are supported while others are undermined or disqualified. So, while it is seldom intended, the therapist-client relationship always participates in society's power relations and political dynamics.
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