An Overview of Treatment Approaches

An Overview of Treatment Approaches


The modern history of treatment for psychological and psychiatric problems is often viewed as beginning with the work of Freud in the late 19th and early 20th centuries. After a brief stay at the Salpêtrière studying the work of the neurologist Martin Charcot, renowned for his work on the uses of hypnosis for “hysterical” conditions (Charcot & Goetz, 1987), Freud returned to Vienna where he began using hypnosis with patients. Within a few years, Freud abandoned hypnosis in favor of encouraging patients to freely share their thoughts (“free association”) as a means of revealing unconscious psychological material (Freud, 1929). This led to the eventual development of psychoanalysis as a comprehensive theory of mental illness and a treatment approach.

The practice of psychoanalysis soon came to dominate the landscape of mental health care in much of the world but was not without its detractors. Among the criticisms levelled against psychoanalytic theory were the difficulty in empirically substantiating many of its claims, the variety of unconscious structures to which problems were being attributed, and the unobservable nature of core psychoanalytic constructs.

These criticisms, and others, contributed to the rise of behaviorism. Watson and Wolpe, early champions of the behaviorist approach, drew on animal research, such as the work of Pavlov, showing that responses to stimuli can be learned (“conditioned”) through experience (Wolpe & Plaud, 1997). They emphasized focusing on processes that can be empirically studied in laboratory settings and applied learning principles to humans. In Watson’s seminal case of Little Albert, a new fear was induced in a child by pairing a previously not frightening stimulus with a loud noise (Watson & Rayner, 1920). Mary Cover Jones demonstrated that fears can be removed through gradual exposure to a fear-inducing stimulus (Jones, 1924), and Wolpe applied the procedure clinically with the addition of progressive relaxation, laying the foundation for many current behavioral treatment interventions (Wolpe, 1958, 1961).

In the second half of the 20th century, a renewed focus on the not directly observable mental processes that impact psychological problems came about through the development, and eventual integration with behavioral approaches, of cognitive therapy (Beck, 1963). Underlying this focus on cognition were the assumptions that human beings respond to mental representations of events, rather than to the events themselves, that learning is mediated by mental processes of cognition, and that individuals form and maintain a cognitive style that
impacts their learning and their susceptibility to psychological problems. Cognitive therapy aims to identify and modify such problematic thought patterns. The integration of cognitive and behavioral treatment strategies is generally referred to as cognitive behavioral therapy or CBT.

CBT itself has continued to evolve in recent decades. This process has included the expansion of CBT, as treatment protocols have been developed and studied for more and more mental health conditions, as well as the addition of various treatment components that draw from other areas. In particular, a group of interventions (often referred to as the third wave of behavioral treatment) emphasizes mindfulness, acceptance, and relationships—factors that do not feature in “classic” CBT (Hayes & Hofmann, 2017). Prominent in this group are acceptance and commitment therapy (Hayes et al., 2011), dialectical behavior therapy (DBT) (Linehan et al., 1999), and mindfulness-based therapies (Khoury et al., 2013).

Alongside the evolution of behavioral and cognitive approaches, the second half of the 20th century also saw the rise of family therapy as a theoretical and applied discipline. Ackerman is often credited with having published the first paper to explicitly describe treating an entire family unit (Ackerman & Sobel, 1950). Much of the early work in family therapy focused on the role of family and relationships in schizophrenia, which led to the now discredited concept of the “schizophrenogenic mother”—one who through aloofness, rejection, and guilt alongside a passive and ineffective father, was thought to induce schizophrenia in her children (Seeman, 2016). Though such direct cause and effect pathways are no longer thought to link parental behaviors and child mental illness, family therapy remains a prominent approach to treating mental problems.


Psychodynamic Approaches

Psychodynamic treatment is a broad concept that describes a variety of specific treatment interventions that share certain underlying principles and assumptions (Luyten et al., 2015). Among these are an emphasis on internal and unconscious conflicts between aspects of the patient’s psyche; the view that mental problems stem from experiences early in life; the view that individuals develop “defenses” or processes that emerge to reduce the distress caused by the internal conflicts; the assumption that problematic dynamics will emerge and play out in the patient-therapist interactions and relationship; and the belief that achieving insight into the previously unconscious conflicts is a key to achieving therapeutic success. Psychodynamic therapies have their root in Freud’s psychoanalysis but have evolved to encompass a range of specific therapies with unique theoretical and practical characteristics. Among the schools of psychodynamic therapies are, in addition to Freudian analysis, Ego Psychology (Wallerstein, 2002), Object Relations (Klein, 1984), and Self Psychology (Kohut, 1971).

The high degree to which psychodynamic treatments are tailored to individual patients generally precludes the kind of step-by-step manualization of treatment protocols that is typical in some other forms of therapy (e.g., CBT). This necessitates a particularly high level of trust in the therapist on the part of the patient, and a particularly strong emphasis on the therapeutic alliance. Patients in psychodynamic therapy are generally encouraged to speak freely and without self-censorship as a means of revealing unconscious material, and special emphasis is placed on verbalizations relating to feelings of the patient toward the therapist.

Although much of psychodynamic therapy has focused on adults, there is also a long and rich history of psychodynamic treatment for pediatric patients, often with an emphasis on the use of play. Play therapy interprets the child’s verbal and nonverbal behavior during play, similar to the open and uncensored speech in treating adults. Freud first introduced the concept of using play as a therapeutic tool with children in his seminal description of Little Hans (Young-Bruehl, 2007). Through this and other work (mostly with adults), Freud developed several theories, eventually arriving at a sexual drive theory that posits the existence
of sequential psychosexual stages of development. Each of the oral, anal, phallic, and genital stages is accompanied by developmental challenges for the child. Each challenge must be successfully resolved before advancing to the next stage to avoid the development of neurotic “fixations” that cause regression to the unsuccessfully completed stage during times of stress throughout life. Further advances, expansions, and competing psychodynamic approaches for treating children have been developed over the many decades since Freud disseminated his ideas, with prominent figures in the field including Anna Freud, Melanie Klein, and Donald Winnicott. Although psychodynamic treatment tends to be more client-focused than symptom-focused, specific psychodynamic interventions have been developed for certain problems including trauma.

Cognitive Behavioral Approaches

CBT is the most widely studied psychological treatment and encompasses a large number of specific interventions for a wide range of problems, with certain shared features and underlying principles. Cognitive behavioral therapies are generally focused and pragmatic, emphasizing symptom reduction through problem solving and skill building rather than the discovery of root etiologic causes of the patient’s problems. Cognitive behavioral therapies assume that problems develop at least in part through learned experience and treatment is generally informed by functional analysis of causal pathways linking thoughts, emotions, and behavior. Functional analysis involves a systematic attempt to identify the antecedents (both environmental and internal) of problematic behavior patterns (Mash & Wolfe, 2019). CBT tends to be relatively brief, with many interventions having a typical length of between 10 and 20 sessions, although both shorter and longer protocols exist and are in common use.

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Jun 19, 2022 | Posted by in PSYCHOLOGY | Comments Off on An Overview of Treatment Approaches
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