Psychotherapy – confusing diversity

What psychotherapy is not

Even when separated from psychological help, psychoanalysis, coaching, support through friends or organised specialised forms of support (sometimes mistakenly included in the area of treatment, which they are not), psychotherapy is still an immensely diverse field.

The most typical/common therapy: individual therapy

The meeting of one patient with his regular therapist (i.e. individual therapy) is the most typical (most common) and oldest form of therapy, which is sometimes extended to include a psychiatrist who administers pharmacotherapy (even if the psychotherapist in charge is a trained physician and psychiatrist).

New options: various variants of group and complex therapy

Numerous variants of group psychotherapy which have evolved in the recent decades can be divided according to the aforementioned duration, group composition variations and the characteristics of the patients in the group (there are the so-called homogeneous groups of people of the same gender, age and diagnosis or heterogeneous mixed groups). In the world of psychotherapy there are also groups whose membership remains unchanged throughout their duration (the so-called closed groups, nowadays this solution is less popular), groups whose composition varies subject to the decision of therapists (a semi-open group changes when one patient leaves the group and another one joins in and is introduced to its rules by senior group members, which is the most common option) or groups that spontaneously change their composition in situations when, for example, new group members enter the group (open groups, more common in addiction treatment). 

Difficult terminology

Theoretical approaches have different names, which can be difficult to understand without preparation. The term cognitive refers to conscious mental activities, and psychodynamic, dynamic and analytical are close but not synonymous concepts. Moreover, there are hybrids such as cognitive-behavioural psychotherapy or less known cognitive-analytic, both of which are abbreviated (CBT - cognitive-behavioural therapy and CAT - cognitive-analytic therapy). Within the so-called third wave of cognitive behavioural therapy, new proposals appeared, such as dialectical behavioural therapy (DBT), acceptance and commitment therapy (ACT) or schema therapy (ST).

Psychodynamic foundations

One of the most important aspects is the recognition of the existence of the unconscious part of the human psyche by schools of (psycho)analytic and (psycho)dynamic therapies. In consequence, the emphasis needs to be placed on working with phenomena within this field and on the border with consciousness, on the psyche defence mechanisms and on transference and counter-transference processes (to put it simply - on powerful emotions in the patient-therapist relationship).

Cognitive foundations

Cognitive and cognitive-behavioural therapies do not take in to account the abovementioned assumptions about the unconscious. In principle, they do not deal with a part of the related processes between the patient and the therapist. Instead, they focus on the patient’s misconceptions and falsified knowledge, of which the patient can be made aware and which are detected and verified by the therapist, as the causes of the condition (for example, the belief in achieving a very high material, educational and social status before the age of 25 as a prerequisite for the patient’s good self-esteem). However, recent trends in cognitive therapy recognize the so-called ‘tacit knowledge’, ‘deep beliefs’ and other constructs related to those applied in the psychoanalytic approach. A cognitive behavioural therapist works using discussion, training, and tasks.

The foundations of systemic family and couple therapy

The perspective of therapies in the systemic approach, predominant in the area of treatment for couples, families and to a large extent children and adolescents, is completely different. They assume that only the contact with the couple or the entire family (living together) enables the comprehensive diagnosis of the situation of these two people or the family. 

Proponents of this approach often prefer to work (as do most group therapists) in pairs (two therapists with a couple or family) or even in larger teams, allowing or even requiring observers present behind a one-way mirror or a camera system (obviously, after the notification of the patients and with their consent). Such a different technique is a result of the difference in the perspective - the disorder is not seen as a condition of the individual (unlike in other non-systemic therapies) but of the couple or the entire family. It can be said that, as a consequence of these assumptions, the formal reason for signing up for the therapy in not the patient but the family or the couple. Because of such differences, it is called systemic therapy and not psychotherapy.

Conclusion

It should be emphasized that the major reason why there is so much diversity and individuality in the field of psychotherapy is the fact the patients and therapists (therapeutic dyads) are so individual. This, obviously, makes it extremely difficult to generalise about the progress and effectiveness (or in other words: the process and its efficiency) of psychotherapy, but it is a subject worthy of a separate discussion.

However, the diversity of psychotherapies is fully justified for at least two reasons. Just like in medicine one disease can be treated with different drugs selected for a given patient, different psychological disorders may sometimes require different psychotherapeutic procedures, e.g. cognitive-behavioural therapy is more often applied in the case of simple phobias, while personality disorders require intensive psychodynamic psychotherapy.

Acknowledgements: The author would like to thank Professor Krzysztof Rutkowski for his valuable comments concerning this text.

Reference literature

1. Richard F. Summers, Jacques P. Barber. Psychodynamic Therapy. A Guide to Evidence-Based Practice. Guilford Press, 2009. ISBN 9781606234433
2. Jerzy Aleksandrowicz. Psychoterapia. Poradnik dla pacjentów. Wydawnictwo Uniwersytetu Jagiellońskiego. Kraków, 2004. ISBN 978-83-233-1890-3
3. Danuta Mazgaj, Dorota Stolarska. Model terapii nerwic na oddziale dziennym. Psychiatria Polska 1994; 28(4): 421–430.
4. Jerzy Aleksandrowicz. Psychoterapia medyczna. Warszawa: Wydawnictwo Lekarskie PZWL; 1996.
5. Kodeks Etyczny Psychoterapeutów Polskiego Towarzystwa Psychiatrycznego [The Code of Ethics of the Therapists of the Polish Psychiatric Association –] http://www.psychoterapiaptp.pl/Kodeks-etyczny.html [access date 22 June 2021].

 About the author

Jerzy A. Sobański, MD-PhD – psychiatrist and psychotherapist, assistant professor at the Faculty of Psychotherapy of the Jagiellonian University Medical College. For two decades he has been teaching psychotherapy to students of medical and postgraduate programmes. He has authored publications on the psychopathology of anxiety disorders and the effectiveness of psychotherapy. He is deputy chief-of staff of the bimonthly ‘Psychiatria Polska’ and secretary of the Edititorial and Publishing Committee of the Polish Psychiatric Association. He earned his doctoral degree in medical sciences from the Medical Faculty of the Jagiellonian University Medical College.