A Short Introduction to Psychotherapy

Christine Lister-Ford

• Publisher: SAGE Publications Ltd
• Year: 2007
• ISBN:
  9781446222584
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychotherapie

A Short Introduction to Psychotherapy is an accessible guide to the field for anyone embarking on training or simply interested in finding out more about psychotherapy.

Mapping the development and dimensions of contemporary practice, the book explores:

"the origins of psychotherapy

"its applications in terms of modalities, settings and client populations

"central theoretical concepts

"the nature of training and career paths for qualified practitioners

"main critiques, both from within and outside psychotherapy.

A team of well-known and highly-regarded contributors examine issues which have particular bearing on psychotherapy today. This includes the changing roles for psychotherapists working in primary and secondary care and the demand for practice to be more ?evidence-based?.

A useful summary is provided of existing research into the efficacy and effectiveness of psychotherapy. Looking ahead, the book also examines the future of psychotherapy and considers the effect that the proposed statutory registration will have on the field.

Christine Lister-Ford is a Director of the Northern Guild for Psychotherapy where she leads the MSc in Integrative Psychotherapy. Previously she sat on the Governing Board of the United Kingdom Council for Psychotherapy for 7 years. She has chaired International and European Training Standards groups over a 15 year period. Her previous publications include Skills in Transactional Analysis Counselling & Psychotherapy (SAGE, 2002). She is a member of the editorial boards of several psychotherapy journals.

1

AN HISTORICAL OVERVIEW OF PSYCHOTHERAPY

SARAH HAMLYN

Early views of mental illness

Since the earliest recording of human culture there has been evidence of human mental and emotional distress and also ways to explain and alleviate it. Responses have ranged from demonisation and execution to some form of ‘treatment’. Hippocrates in the third century BC considered that mental distress must have a physical cause. However, the predominant view in most cultures has been to define mental disturbance in terms of spiritual distress and the task of healing it has been seen as belonging to the realm of priests and of shamans who used trance states to effect emotional healing, for example through ‘soul retrieval’ (Ingerman, 1991).

The predominant Christian view of mental distress has been to regard it as caused by evil spirits, or as possession by demons. From the thirteenth century, the inquisition of the Catholic church defined people with deviant behaviour as possessed or as witches, and persecuted them. In 1487 Malleus Maleficarum (The Witch Hammer) was published. It attributed abnormal behaviour to satanic influences and specified the diagnosis, behaviour, trial and punishment of witches and provided a basis for the torture of people with deviant behaviour. Loss of reason was seen as a key diagnostic feature, and many hundreds of thousands of mentally disturbed individuals (suffering from what we would now think of as psychosis, and even depression) were tortured and put to death. Most of those who suffered were female and the authors of Malleus Maleficarum considered that ‘All witchcraft comes from carnal lust, which in women is insatiable’ (Tallis, 1998: 5).

It is also likely that some early Christian visionaries and saints suffered from mental illness. For example Joan of Arc may well have suffered auditory hallucinations. Interestingly she was both burned as a witch and, later, sanctified by the church – perhaps an indicator of the ambivalent and confused view of mental disturbance. The last execution of a witch took place in Switzerland as late as 1782 and it was around this time that more humane views of mental illness were emerging.

The beginnings of care and treatment

In Europe, alongside the religious view, there has also been the approach of containing the mentally ill. In 1247 the priory of St Mary of Bethlehem was founded in London. It later became known as Bethlehem Hospital (or ‘Bedlam’) and from as early as 1377 it was used to house ‘distracted persons’. Treatment there was nevertheless based on the idea of possession by demons, resulting in the punitive and neglectful treatment of inmates.

At the time of the renaissance there is evidence of debate as to whether mental disturbance was a spiritual or a physical and medical problem. A well-known example of this may be found in Shakespeare’s Macbeth (published in 1599). The doctor observes Lady Macbeth’s troubled sleep-walking and responds:

‘This disease is beyond my practice …

… Unnatural deeds

Do breed unnatural troubles; infected minds

To their deaf pillows will discharge their secrets.

More needs she the divine than the physician’ (Macbeth, V. i.)

thus placing mental disturbance firmly in the hands of spiritual care. He also suggests that problematic or traumatic events can lead to mental distress. When the doctor reports to Macbeth he receives the challenge:

Cure her of that.

Canst thou not minister to a mind diseas’d,

Pluck from the memory a rooted sorrow,

Raze out the written troubles of the brain,

And with some sweet oblivious antidote

Cleanse the stuff’d bosom of that perilous stuff

Which weighs upon the heart? (Macbeth, V. iii.)

However, the doctor washes his hands of the problem:

Therein the patient

Must minister to himself (Macbeth, V. iii.)

Although Macbeth is clearly articulating the idea that mental distress has a cause and potentially a cure, this was, at the time Shakespeare wrote, a novel idea and the doctor here evidently does not regard healing the mind as within the province of medicine and science. The implication is that talking (confession) with a priest is what is needed, and that there is no magic pill to cure such distress. This debate is still current, and while we now have effective psychotropic medications, the role of human relationship and contact through talking is acknowledged by both medicine and religion as being highly important in resolving distress and maintaining well-being.

In 1586, just 13 years before Macbeth was written, the first medical book about mental illness, the Treatise on Melancholy by a physician called Timothie Bright, was published. It contained descriptions of what we would now call depression or mood disorder, and may well have been a source for Shakespeare, particularly for Hamlet. In 1632 came the publication of Burton’s Anatomy of Melancholy, and this included both descriptions and treatments (diet, exercise), based on earlier medical views. Burton wrote in order to relieve his own melancholy and considered it possible to alleviate this distress.

Despite these acknowledgements of the role of treatment, the predominant approach to mental distress continued to be incarceration and physical restraint. Patients might be chained or manacled, and treatments included blood-letting, whipping and immersion in cold water. Furthermore, in the seventeenth century the behaviour of mentally deranged people was considered amusing and Bethlehem Hospital was open to the public who could take a tour and view the inmates as a form of entertainment. John Evelyn described a visit in his diary in 1657: ‘several poor miserable creatures in chains; one of them was mad with making verses’. Hogarth’s 1735 picture of Bedlam shows the kind of scene these tourists might have observed. Mental illness was still viewed as a kind of degeneracy, and the picture was intended as a moral lesson warning against debauched behaviour.

Later in the eighteenth century the idea that people suffering mental distress needed humane care began to emerge. Public visiting to Bedlam was curtailed in 1770, although it continued in some form into the nineteenth century. The first-ever law to ensure the humane care of people with mental illness was passed in Tuscany in 1774, and in 1792 the first humane care for people with mental illness in the UK was provided by William Tuke, a quaker, who founded the York Retreat. Here patients were less restrained and confined, a healthy diet was provided and treatment included giving patients activities such as farm work (the beginnings of occupational therapy). Similarly, in 1794 Pinel introduced humane care at the asylum of La Bicêtre in Paris. He took the view that:

The mentally sick, far from being guilty people deserving of punishment are sick people whose miserable state deserves all the consideration that is due to suffering humanity. One should try with the most simple methods to restore their reason. (cited in Tallis, 1998: 8)

Pinel in his Medico-Philosophical Treatise on Mental Alienation or Mania (1801) developed what he called ‘traitement moral’, which involved talking gently with the patient, offering warmth, and restoring hope – elements that research now demonstrates are central to effective psychotherapy.

The emergence of psychological diagnosis and treatment

In 1766 Franz Anton Mesmer published his ideas about what he called ‘animal magnetism’, seeking to account for mental disturbance as a result of physical forces. His ‘animal magnetism’ may best be understood as a kind of ‘life force’ and he conceived illness as an interruption of the natural flow of this ‘subtle fluid’. His treatment system, known as mesmerism, was a precursor of hypnosis, which in turn influenced the development of psychological treatment and particularly psychoanalysis (Ellenberger, 1970).

During the nineteenth century the medicalisation of mental illness progressed as modern scientific medicine evolved. The idea that mental problems may have physical causes was supported by the development of microbiology (for example the connection between syphilis and the mental condition of ‘general paresis’), establishing a trend of seeking physical and biological causes for emotional problems. This approach was reversed through the work of Charcot (1882) who, at the Salpêtrière hospital in Paris, began to look at psychological causes for physical symptoms. He believed he had identified a condition he called ‘hystero-epilepsy’, based on a group of patients who appeared to have both epileptic symptoms and ‘hysteria’. It emerged that the epileptic convulsions were the result of suggestion and induction (hypnotism) due to the fact that these apparently ‘hysteric’ patients were placed on the same wards as the epileptics. Once these patients were separated from the epileptics, and their initial concerns (for example, distress, anxiety, family conflicts) were individually explored, their epileptic symptoms disappeared. Charcot developed treatment based on counter-suggestion to address what we would now call conversion disorders. The focus on the symptoms was redirected to looking at real-life concerns with a focus on solving these problems.

Sigmund Freud and psychoanalysis

Charcot’s lectures and demonstrations of his new hypnotic treatment were attended by the young Sigmund Freud, around 1885. Freud, who had specialised in neurology, had begun to be interested in hypnotism and psychological treatment. Contact with Charcot further developed Freud’s interest in psychology and the nature of neurosis which in turn led to his development of psychoanalytic theory and practice.

Sigmund Freud (1856–1939) emerged in the context of the nineteenth-century post-enlightenment preoccupation with the development of rationality and science. Religion, spirituality and romanticism were equally powerful aspects of his culture, however they were being scrutinised and questioned with a scientific eye. The publication of Darwin’s The Origin of Species in 1859 represented an unprecedented upheaval in Western culture as beliefs about God and the nature of human beings were radically called into question. In focusing on human psychology, Freud was grappling with understanding scientifically the nature and workings of the human soul. Science was moving into the domain of human emotional and mental suffering, which had hitherto been configured in spiritual terms, as soul-sickness; and into the domain of healing, which had been the preserve of pastoral care.

Psychotherapy emerged as the child of religion and science, and Freud, as a doctor and as a Jew, held within himself the tensions of the relationship between these ‘parents’. Although Freud was not a practising Jew, and indeed viewed religious belief as a form of neurosis (Linke, 1999) the religious/spiritual core of Judaism is inevitably a part of his heritage and its influence may be discerned in the evolution of psychotherapy. Given his medical training, Freud was concerned to establish the scientific credibility of psychological treatment, and specifically psychoanalytic theory. He faced the perennial problem of translating clinical experience with unique, individual patients into empirically valid theory and practice. The tension between the art of the healing relationship and scientific accountability is as evident in Freud’s work as it is in current debates about the evidence base for psychotherapy.

So Freud sought to locate his theories in a medical model of sickness and treatment. Initially he collaborated with Breuer, using hypnotic techniques to work with patients who suffered with hysterical conversion symptoms. Freud’s early theory (1895) was based on the case of ‘Anna O’, a patient of Breuer, and a number of women with similar difficulties (Freud and Breuer, 1895/1974). Anna O suffered from a range of physical symptoms for which no physical cause could be found, and also had mood swings and a form of hallucination. She named the treatment ‘the talking cure’ because it involved her entering a hypnotic state, in which she would speak about her symptoms and make links between specific symptoms and feelings, previous occurrences, and ultimately specific forgotten emotionally traumatic events from her past. Once these links were identified, the symptoms disappeared (Freud and Breuer, 1895/1974). The hypothesis was that traumatic events had been repressed into the unconscious mind, and the hysterical symptoms were signalling their presence. By retrieving and ‘talking them away’ the symptoms could be resolved. Later, instead of hypnosis, Freud developed the technique of ‘free association’, in which the patient lies on a couch and verbalises whatever thoughts come into their mind, without censoring or seeking logical connections. From these beginnings he developed key concepts including the role of the unconscious mind, the idea of defences, particularly repression and resistance, and the role of analysis or interpretation.

Freud’s efforts to work within a scientific paradigm led him to seek ‘objectivity’ and this may lie behind his approach of making the therapist the neutral ‘scientific instrument’, the blank screen, which receives the productions of the patient: ‘the physician should be opaque to the patient and, like a mirror, show nothing but what is shown to him’ (in Tallis, 1998: 41).

The concept of the unconscious mind was also explored by other students of Charcot, notably Janet, whose L’Automatisme psychologique published in 1889 pre-dates Freud. However Freud developed this idea, formulating a cohesive (albeit complex and evolving) theory of the unconscious mind, and this is perhaps his greatest contribution, both to psychotherapeutic theory and to human culture and self-understanding. Freud formulated a theory of mental difficulty that accounted for overt mental (and sometimes physical) symptoms as being related to aspects of experience that have, because of their traumatic nature, been split off from conscious awareness and repressed so that they are held in the unconscious mind.

The idea that hysterical symptoms and neuroses had their roots in sexuality had existed since ancient times, when it was believed that they were caused by the movement of the uterus around the body. Although this view was discredited, many doctors, including Charcot and Breuer, held the view that sexuality was nevertheless in some way relevant for their patients. In the nineteenth century, female sexuality, if its existence was acknowledged at all, tended to be seen as unacceptable and problematic. Thus it was revolutionary for Freud to move away from the trauma theory described above and develop his theory of the role of libido (sex drive) in human psychological functioning. It was in keeping with the cultural norms of the time for Freud to hypothesise that psychopathology must arise from the repression of sexual needs and feelings.

Freud noted that many of his patients reported sexual experiences from childhood, and he initially took these to be factual memories. However he eventually abandoned this view and developed his theories of infantile sexuality and psychosexual development (1905). This theory was only slightly less shocking in his day than the idea that adults were sexually abusing children in their care. More recently Freud has been criticised for defining his patients’ reports as fantasy and denying the possibility that real abuse might have taken place (e.g. Miller, 1981/1985).

Freud developed the notion of the pleasure principle – the drive for pleasurable sensation, and he focused specifically on sexual or sensual pleasure. He considered that, in normal development, the infant’s pleasure focus was initially oral, that it then develops and shifts to an anal focus as the child gains control of bodily functions, and then to a phallic/genital focus at around three to six years of age. In relation to this he also identified what he called the Oedipal phase, in which the child’s sexual focus is on the opposite gender parent, and reaches a crisis as the child, fearful of reprisal from the same gender parent, gives up and represses the sexual focus on the opposite gender parent. This repression is seen as part of normal development and enables the child to move into the next developmental phase, latency, and then to normal sexual maturity. Freud’s theory was coloured by the gender perceptions of his day, and was much more clearly articulated in relation to male children than females.

His theory of psychopathology focused on the idea that for some reason the child gets stuck or fixated in her or his negotiation of the early developmental stages, so that the progress towards sexual maturity is interrupted and arrested. In adult life these unresolved fixations may emerge such that unacceptable infantile wishes and urges intrude into the adult consciousness. This generates anxiety and then a need to defend against both the anxiety and the infantile material, processes that may become evident as neurotic symptoms.

Much of Freud’s work focused on treatment approaches, including the...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Information on the Editor and Contributors
• Introduction
• 1 An Historical Overview of Psychotherapy
• 2 Psychotherapy Applications
• 3 The Evidence Base of Psychotherapy
• 4 Critiques of Psychotherapy
• 5 Psychotherapy in the NHS
• 6 Training for a Career in Psychotherapy
• 7 Future Trends and Developments
• References
• Index