Freud and psychoanalysis

A history of psychotherapy starts with none other than Sigmund Freud, the godfather of talk therapy. Freud created a technique known as psychoanalysis, which dominated the field for the first half of the 20th century. Psychoanalysis is an open-ended exploration of the unconscious. By discussing whatever comes to mind (free-association), patients uncover the deep emotional and conflicts, forged in childhood, that cause suffering in adulthood. The analyst says very little, except an occasional interpretation to guide the patient to deeper, more penetrating insights about themselves and their relationships with others. Because the analyst participated very little in the sessions, he or she acted as a kind of blank slate onto which the patient projected all of his or her intra- and inter-personal conflicts. As a result, much of the change and growth achieved in analysis achieved by working through these conflicts via the patient-analyst relationship, a.k.a the transference relationship. The nice thing about psychoanalysis is that it gives people an opportunity to work through deeper emotional problems in an open and unconstrained context. There are several downsides however, which are responsible for the decline of psychoanalysis in the later half of the 20th century: 1) it provided little practical tools to people suffering from well-defined psychological problems like anxiety and depression; 2) there is very little empirical evidence that it actually works in reducing symptoms or resolving these problems; and 3) because it is open-ended and non-structured, it can go on for years with no resolution and can be very costly.

Behaviour Therapy (The First Wave)

The return home of WWII vets in the 1940s placed enormous pressure on the mental health field to develop an effective short-term therapy to help major emotional adjustments the soldiers faced. At this time, Behaviorist researchers were sketching out the foundations of Learning Theory, including Classical Conditioning (Pavlov), Operant Conditioning (Skinner), and Systematic Desensitization (Wolpe). These ideas explained how contingencies and rewards in our environment shape our behaviour and provided powerful tools to eliminate problem behaviors. These principles were adopted by clinicians who were turned off by Freud’s elaborate psycho-babble and wanted an approach to psychology that was simpler, more practical, and lent itself better to rigorous, scientific study. Behavior Therapy emerged and continues to be practiced to this day. It is very effective for treating certain anxiety, phobias, and addictions. However, it is limited insofar as it does not address people’s thoughts and feelings. Other therapies soon filled that gap.

Humanistic or Client Centered Therapy

Carl Rogers, for one, was very interested in what his patients were saying! In fact, he put his patients’ experience at the forefront of the process of learning and change. Like the psychoanalysts, he was convinced that the therapeutic alliance (i.e. the relationship between the patient and therapist) was the key factor in therapy. However, unlike the psychoanalysts, he believed that therapists should actively participate in clients’ self-exploration, rather than commenting occasionally from a position of higher authority. He even preferred to call his patients ‘clients’ to emphasize the non-hierarchical relationship. For Rogers, the therapists role was to provided unconditional positive regard and follow clients’ lead as they pursue their own path to self-actualization. By the 1950s, Rogers was beginning to have a profound and lasting impact on the way psychotherapists interact with their clients.

Cognitive Therapy (The Second Wave)

In the 1960s, a new paradigm was shifting into place in psychology. Inspired by the advances in computing technology, psychologists began to think about the human mind as a complex information-processing organ – with the nervous system as the hardware and the mind as the software. Building on the work of Albert Ellis, Aaron (Tim) Beck began applying this model to the practice of psychotherapy. He argued that the information being processed in our minds (i.e. cognitions) has an important impact on how we feel in the present. So, our thoughts, interpretations, and perceptions of things in our lives influence our feelings and actions. Beck developed Cognitive Therapy, a series of techniques designed to “search and destroy” distorted, exaggerated, or unhelpful cognitions that drag our mood down or stimulate fear and anxiety. Many behavioural therapists began incorporating these techniques into their repertoire and Cognitive Behaviour Therapy (CBT) was born.

In CBT, the therapist is like a coach, guiding the client through a structured, goal-directed program aimed at reducing symptoms of psychopathology. CBT is practical, equipping clients with tools and strategies to manage their problems on their own. It is also present-oriented and time-limited, often achieving significant symptoms reduction in 8-12 weeks. Perhaps most importantly, CBT is an evidence-based treatment, meaning it has an impressive record of rigorous scientific studies demonstrating its effectiveness. As a result of these advantages, CBT has become the most widely-used approach to psychotherapy in the last 20-30 years.

The Third Wave of CBT

Since the turn of the millennium, a group of more recent innovations have begun to shape the history of psychotherapy. These new approaches share the basic assumptions of traditional CBT: dedication to scientific testing and focus on behavior and cognition in therapy. As such, they have been collectively described as the “Third Wave” of CBT. However, they have introduced the importance of Mindfulness and Acceptance.

1) Mindfulness-Based Therapies

Mindfulness refers to a state of mind, characterized by careful attention to the present moment, with a non-judgemental attitude. As has been known for thousands of years in eastern spiritual traditions, cultivating this state of mind through meditation helps reduce anxiety, lift mood, and promote health and well-being. It is only recently – thanks in part to the work of Jon Kabat-Zinn – that the practice of Mindfulness has reached the mainstream of Western psychological and medical best-practices. Mindfulness-based therapies help clients bring greater awareness and clarity to their day-to-day lives, which typically result in more effective coping and problem-solving for the challenges they face. The most common Mindfulness-Based therapies include Kabat-Zinn’s Mindfulness-Based Stress Reduction (MBSR), Zindel Seigal’s Mindfulness-Based Cognitive Therapy for Depression (MBCT). These therapies are structured, group-based programs and have taken root in most medical centers in North America and Europe. Mindfulness has exploded in popular discourse in recent years, due in part to the rapidly expanding clinical and neuroscience evidence for the benefits of meditation and the increasing media coverage of these findings.

2) Acceptance and Commitment Therapy (ACT)

ACT (pronounced as the work ‘act’) is a relatively new set of innovations to CBT, developed by Dr. Stephen Hayes. As the name implies, the techniques in ACT are designed to help clients learn to use acceptance-based (as apposed to control-based) strategies for coping with difficult experiences. Many of the problems people face in life stem from difficulty tolerating negative emotions (such as anxiety, fear, or sadness) and tend to avoid, repress, or attempt control them. A series of impressive studies has shown that these reactions actually amplify the negative emotion, thereby making the initial problem worse! So ACT therapists help clients develop skills to better accept their experience and work toward more effective ways of coping with and solving problems. Ultimately, the goal of ACT is to help clients move past preoccupations about mental health toward a focus on living by their most cherished values.

One of the biggest advantages of ACT is the strength of the evidence supporting it. Before presenting ACT to the public, Hayes dedicated many years to building a broad theoretical framework (Relational Frame Theory) and solid empirical foundation for the approach (Contextual Behavior Science). More recently, he and his team have conducted numerous randomized-controlled trials demonstrating the effectiveness of ACT techniques for a variety of psychological problems. ACT has really caught on recent years and is now widely considered at the cutting edge of Cognitive Behaviour Therapy.