What is a Psychotherapist?
General Definition
Requirements for Graduate Education
Educational Levels
Licensing and Credentialing
Types of Psychotherapists
Theoretical Approaches
Where to Work
Payment Methods
GENERAL DEFINITION
The Greek word, "psycho" means "soul" or "spirit."
The Greek word, "therapeia," means "healing." The term "psychotherapist," then, when literally translated, means healer of the soul.
Today the word "psychotherapist" is used as a generic catch-all for many different disciplines and degrees. These practitioners help people who are unhappy, confused, angry, depressed, having marital trouble, having difficulty with their children, in need of career guidance, afraid, upset, hurt, or simply in need of an objective outsider as a sounding board for their thoughts. This help takes the form of talk therapy.
REQUIREMENTS FOR GRADUATE EDUCATION
Psychotherapists have all graduated from an accredited four-year college program followed by graduate school. In order to be accepted into graduate school, therapists must take the Graduate Record Examination, <http://www.ets.org> a standardized test developed by the Educational Testing Service.
This test, in combination with academic achievement in college, determines the likelihood of acceptance to graduate school. Different graduate schools have different standards for acceptance.
EDUCATIONAL LEVELS
There are two broad educational levels beyond college: the master's degree which is either one or two years and the doctoral degree which is anywhere from three to four years--or more. Although people might begin by getting a master's degree and then applying for further graduate study in a doctoral program, many schools accept students directly from college into a doctoral program.
Both master's and doctoratal programs entail most of these:
(1) courses on the field's history, philosophy, and methodology
(2) clinical training
(3) written papers that demonstrate special knowledge
(4) comprehensive tests
In all four of these areas, the work is normally more detailed, more demanding, more analytical, more specialized, and more comprehensive at the doctoral level.
Master's Degree
Master's degree programs may be completed in one or two years, depending on the requirements of the particular graduate school. The program may entail any of the following:
statistics
diagnostics
history of the profession
original readings by various leaders in the field
research methods
working within institutions (called a "practicum")
Clinical training requires time spent face-to-face working with "patients" or "clients." (Different orientations have different terms for those who seek their services, as we will see below.) In master's degree programs, this is usually accomplished by having students spend time in existing institutions such as schools, hospitals, and a multitude of community agencies, under the supervision of someone who works at that agency. The student is required to clock in a specific number of hours doing this in order to satisfy the clinical training requirement for the degree, state licensing requirements, and acceptance into professional organizations.
A master's degree programs usually require the writing of a master's thesis which is a lengthy research paper. There are two forms of research in science: One is a review of the literature and the other is an original study on a topic of interest. A review of the literature means going to the library and discovering what has been published previously on one's topic of interest. While this might not seem like originating something, many programs would consider the very act of bringing together information from various sources to be an acceptable form of research at a master's degree level.
Other programs require original research. This might entail observing a particular phenomenon and recording those observations, conducting interviews, or setting up a laboratory experiment.
Final testing at the master's level is usually comprehensive, meaning that it goes beyond the tests given at the end of each course. Rather, it is commonly one, rather lengthy test that includes material from all the courses in the program.
A typical example of a master's degree program is the one in Family Therapy at Nova Southeastern University (NSU) in Florida <http://shss.nova.edu/Academic_Programs/MastersPrograms/MSFT.htm> where students spend six trimesters (two years) in combined coursework and practicum work followed by a comprehensive exam. The clinical training entails 500 client-contact hours, half of which must be with couples and families.
In addition, the program requires that these client-contact hours are reviewed with a supervisor for 100 hours. This part of the process is called "supervision." Each field in psychotherapy requires this component and the supervisor must have the proper credentials to do so. In the case of Family Therapy illustrated above, for example, the supervisor must be certified by the state and also must be approved by the American Association for Marriage & Family Therapy.
Doctoral Degree
All of the above requirements would be true for the doctoral degree except that there is more included in each component of the program. The coursework contains material that is not taught at the master's level. This material may contain theoretical readings so that the student understands the underpinnings of the work rather than just knowing how to carry it out. It also may contain courses in supervision or teaching so as to prepare the clinician for leadership in the field upon graduation.
The clinical training will include more time spent in an outside facility and, in addition, as many as six semesters of supervised therapy done in the school's own health center. At the doctoral level, this supervision is often live, in real time, such as through a one-way mirror, with the ability to phone in comments to the therapist-in-training while the session is going on.
The written paper, or dissertation, will be more in-depth for the doctoral degree as well, most of the time entailing field research or a laboratory experiment that is original. This project could take a decade for a doctoral student to complete although that is very rare. The time frame for completion depends upon the nature of the study and the criteria of the dissertation committee that evaluates it. The dissertation committee is usually composed of professors in the student's department although outside experts may be included on occasion. It is the student who selects his or her dissertation committee.
The final test is generally comprehensive. Individual programs may not require this test because the student has already passed individual course tests, worked extensively in the clinic with people presenting real-life problems, and written a thorough dissertation.
As an example of the doctoral level requirements, see the website for Nova Southeastern University <http://shss.nova.edu/Academic_Programs/DoctoralPrograms/PhdFT.htm> and compare it to the one described above for a master's degree. At NSU, to earn the doctorate, students must complete four years of coursework beyond the master's that they have already attained. This includes a nine-month off-campus internship which follows three semesters of supervised work in the school's clinic. There are three comprehensive exams given at different times and four courses in research, both quantitative and qualitative, before dissertation work begins.
On the other hand, Harvard University <http://www.gsas.harvard.edu/programs_of_study/psychology_4.php> does not offer a masters degree in Psychology and does not require one for admission to its doctoral program in Psychology. Students are expected to complete the degree, which is oriented toward research, within five years. The clinical internship requirement is one year of supervised experience.
LICENSING AND CREDENTIALING
Each of the various disciplines that comprises psychotherapy is governed both legally and by the profession. Legal governance is by the state in which the practitioner lives. This is managed by the requirement of the state for the clinician to pass a licensing examination upon completion of final requirements by the school and to continue taking courses in the field each year to keep up with current information. These are called Continuing Education Units (CEUs).
In addition, each type of psychotherapist has an allegiance to and membership in an association made up of other therapists in his or her particular profession. Each of these associations has its own requirements for membership, set of ethical guidelines, and disciplinary procedures. When people satisfy the requirements for membership, they then receive a credential that states they hold such membership. The value of this credential lies in the respect the public has for the organization itself.
TYPES OF PSYCHOTHERAPISTS
Psychotherapists can be:
Psychologists
Social Workers
Mental Health Counselors
Marriage & Family Therapists
Pastoral Counselors
Psychiatrists
Psychologists
The most commonly known type of psychotherapist is the psychologist. This field falls into two broad types: clinical and counseling. While clinical psychologists are only at the doctoral level, counseling psychologists can be found at both the master's and doctoral levels.
There is a distinction in focus between these two types of psychologists as well, even when both types hold a doctoral degree. Clinical psychologists "tend to work with more seriously disturbed" people "whereas counseling psychology graduates work with healthier, less pathological populations and conduct more career and vocational assessment" (as reported in the PsiChi Honor Society Newsletter, Fall 2000, by Dr. John C. Norcross <http://www.psichi.org/pubs/articles/article_73.asp>).
The distinction between a more mentally healthy person and one who is less healthy (and therefore has pathology) comes from the fact that psychiatrists are medical doctors. Psychiatrists created a system of evaluating and judging levels of sickness in people. This makes sense because doctors normally see people who are ill, not well. The notion that a person must have something wrong with him in order to be at the doctor's office is called "the medical model." It postulates that when someone seeks help from a doctor--including a psychiatrist--there is pathology (sickness) to be found and it is the clinician's job to determine what it is.
The fact that clinical psychologists would follow the medical model arises from the history of this profession. Up until the turn of the last century, the focus of the profession was to study human behavior rather than to treat it. As soldiers returned from World War I, this ability to carefully examine people was called upon. Soldiers often had Post Traumatic Stress Disorder symptoms which were called "shell shock" at that time, and the Army wanted to know if psychologists would be able to develop a test to screen such people out before future service. It was about this time that the term "clinical psychology" was coined by Lightner Witmer, said to be the father of the profession, and their organization, the Association of Clinical Psychology merged with the American Psychological Association, receiving its own division. The historical stage was set, then, for this profession to have an orientation towards discovering pathology (Allessandri, 1995; Benjamin, 2005).
Counseling psycholgy developed differently.
Dr. John C. Norcross, who I have quoted above in describing the differences in practice between a clinical psychology and a counseling psychology orientation, goes on to explain that the theoretical orientation is different between clinical and counseling psychologists to some degree as well: "Clinical psychologists more frequently favored the behavioral and psychoanalytic (but not psychodynamic) persuasions, and counseling psychologists the client-centered and humanistic traditions." (See below for a discussion of these theoretical orientations.)
While it is possible to receive a master's degree in psychology, customarily psychologists work at the doctoral level. The doctoral degree psychologist may either be a Ph.D. or Psy.D. The Ph.D. has a more intensive research requirement while the Psy.D. is tailor-made for psychologists who want to focus on the treatment of people clinically. A person with a Ph.D. can do both clinical work and research.
The organization to which psychologists belong is the American Psychological Association (APA). <http://www.apa.org> The APA has 148,000 members. It contains 56 divisions from Society for General Psychology (1) to Trauma ( division 56) with Psychopharmacology and Substance Abuse in the middle (division 28). To learn more about the distinction between a pathologizing approach for clinical (and other) divisions and a non-pathologizing approach for counseling psychology, go to divisions 12 and 17, respectively. Read also a thorough review of counseling psychology in John M. Whiteley's article in The Counseling Psychologist, The Paradigms of Counseling Psychology (vol. 27, number 1, January, 1999, pages 14-31).
Psychologists were the frontrunners of psychological testing, a practice within clinical psychology in which diagnostic tests are given to people to determine what might be wrong with them; that is a specialty that other therapists do not share.(Division 5 - Evaluation, Measurement, and Statistics <http://www.apa.org/about/division/div5.html>). Many psychologists do their doctoral research on improving the accuracy of these tests.
Social Workers
The official website <https://www.socialworkers.org> describes the practice of social work as follows:
"Social work practice consists of the professional application of social work values, principles, and techniques to one or more of the following ends: helping people obtain tangible services; counseling and psychotherapy with individuals, families, and groups; helping communities or groups provide or improve social and health services; and participating in legislative processes. The practice of social work requires knowledge of human development and behavior; of social and economic, and cultural institutions; and of the interaction of all these factors."
This description demonstrates the emphasis on community and institutional work. The vast majority of social workers (SWs) have a master's degree. People with the doctoral degree (DSW) are additionally qualified to teach in a university or to serve as an administrator in a community setting (from Social Work Today, 2005 <http://www.socialworktoday.com/archive/swt_0705p12.htm>).
The organization to which social workers belong is the NASW, the National Association of Social Workers. With 150,000 members it may have the largest membership of the psychotherapy categories. Established in 1955, it was an amalgum of the American Association of Social Workers with Associations for Psychiatric SWs, Group SWs, Medical SWs, School SWs, and the Association for the Study of Community Organization.
Mental Health Counselors
Counselors typically have a master's degree. Professional counselors or mental health counselors are members of the American Counseling Association <http://www.counseling.org/>. Generally, a person who wished to pursue a doctorate in counseling would go into a counseling psychology program. These programs are found in both schools of education and psychology.
Indicative of the idea (discussed above in the psychology section) that counselors do not work with people suffering pathology, the online news for the American Counseling Association, ACA Today, recently ran stories with the following headlines: "When College Students Need Extra Help," "10 Steps for Improving Relationship Communications," "Helping Reduce the Trauma of a Family Move," and "Family Driving Vacations Don't Have to be Stressful." This non-pathologizing viewpoint helps to normalize the counseling process for clients who don't see themselves as sick--as well as for therapists who prefer not to view clients in that way either.
Counselors routinely work in private practice, schools, colleges, community agencies, hospitals, and government. For example, of the eleven journals in this field, aside from three that would be of general interest, there is Adultspan, which deals with aging, Counseling and Values, the official journal of the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC), the Journal of Addictions and Offender Counseling, two journals on employment or career counseling, and three journals for counselors in secondary schools and colleges.
The field of counseling is very active in attempting to have a positive impact on federal legislation regarding counselor reimbursement and funding to schools and other programs.
Marriage & Family Therapists
Marriage and family therapists (MFTs) could be called postmodern therapists. While they do work with both pathological and non-pathological populations, they prefer not to give diagnoses at all (except where required by insurance companies for reimbursement) and don't perceive of people, no matter what their symptoms, as "having" pathology.
As Edward Sampson (1993), a professor of psychology at California State Unviersity explains it in his book, Celebrating the Other, in labeling someone pathological, the one who does the labeling accrues power to himself and removes it from the other person.
Rather than to give people a diagnositc label, MFTs think of behavior as the product of the interaction between people's genetics and their environment. The behavior they exhibit is the solution they develop to conditions in their environment. The process by which people develop a response to their environment makes sense given the tools they had to work with (genetics) in combination with the total picture of that environment. The idea that a behavior--however odd ("pathological"), unusual, difficult to handle, or difficult to understand--would make sense and not be considered "sick" (given the person's history) is unique to the postmodern view that MFTs hold. This is a strength-based perspective of human nature. To distinguish this view from the medical model, MFTs refer to those who seek their services as "clients" rather than "patients."
The official statement of this position can be found on the website of their professional organization <http://www.aamft.org/index.asp> the American Association of Marriage & Family Therapists: "The development of the field of marriage and family therapy has included a tradition and perspective that eschewed the medical model. Historically, pathology or the diagnosis of an individual was not part of our field's heritage or practice. In light of this historical context, AAMFT never considered the possibility of making a statement that defined 'pathology.'"
Furthermore, diagnosis is not necessary for successful treatment. Again from the website, "Research indicates that marriage and family therapy is as effective, and in some cases more effective than standard and/or individual treatments for many mental health problems such as: adult schizophrenia, affective (mood) disorders, adult alcoholism and drug abuse, children's conduct disorders, adolescent drug abuse, anorexia in young adult women, childhood autism, chronic physical illness in adults and children, and marital distress and conflict."
Because state licensing laws require therapists to know and understand various standard aspects of therapy such as the use of diagnostic categories, all MFTs are trained to understand how to give psychological diagnoses. However, in creating a plan for therapy, they don't think in terms of "What's wrong with this person?" They think instead, "What strengths does this person have that I can build on?" and, "How can I understand his behavior and make sense out of it in the context of his life?"
MFTs may either have a master's degree or a Ph.D. Recently, programs have also added a doctorate in marriage and family therapy (DMFT) as a more clinical, less research-oriented degree.
Pastoral Counselors
The American Association of Pastoral Counselors <http://www.aapc.org/about.cfm> is a small (3,000) but growing force within psychotherapy. As their website states, "A national survey was conducted by Greenberg Quinlan Research, Inc. of Washington, D.C., to explore attitudes toward the role of spiritual values and beliefs in the treatment of mental and emotional problems. The report stated 'that an overwhelming number of Americans [69 percent] recognize the close link between spiritual faith, religious values, and mental health, and would prefer to seek assistance from a mental health professional who recognizes and can integrate spiritual values into the course of treatment.'"
In addition to seminary education, pastoral counselors must complete "at least 1,375 hours of supervised clinical experience (that is, the counselor provides individual, group, marital and family therapy) and 250 hours of direct approved supervision of the therapist’s work in both crisis and long-term situations" making them a highly-trained group of therapists.
Representing 80 different faiths, Pastoral Counselors may practice at the master's or doctoral levels.
Psychiatrists
Psychiatrists are on this list of psychotherapists in spite of the fact that they have a medical degree rather than a master's or Ph.D. Psychiatrists are doctors who have graduated from medical school and studied all the subjects that any medical doctor must such as obstetrics, cardiology and so on. This professional, however, chose as a specialty a field in medicine in which he or she could help to heal the types of problems that are listed at the beginning of this essay--anger, depression, confusion, and so on.
Psychiatrists, however, in the 21st Century, do not primarily address these problems through talk therapy. Rather, they write out prescriptions for medicines to take to alleviate the symptoms described above. They are included here because there are some--rare--psychiatrists who prefer to heal through talk therapy rather than through medicine. Those that prefer to follow the convention of offering prescriptions practice from a psychopharmalogical perspective.
The psychiatry profession originated and continues to develop the DSM, the Diagnostic and Statistical Manual of Mental Disorders <http://www.appi.org/dsm.cfx>. Historically, the DSM
began with two categories, neurotic and psychotic, but every decade or so, mental illnesses have been added. Currently, the DSM-IV is in use. Researchers explain that this is because greater knowledge about mental illness helps to refine its categories.
Currently, American Psychiatric Publishing, Inc. (APPI), a wholly owned subsidiery of the American Psychiatric Association, has a DSM library surrounding its most current version with 43 titles ranging from "A Research Agenda for DSM-V" and "Advancing DSM" to "Treatment Companion to the DSM-TR Casebook."
APPI notes on its website that its books are all peer-reviewed, with only 30 accepted for publication each year out of 200 applications. Once these titles are accepted, many have been reviewed by all major psychiatric journals as well as by the two highly respected general medical journals: the Journal of the American Medical Association and the New England Journal of Medicine <http://www.appi.org/aboutappi2.cfx>.
Further, APPI also states that its marketing efforts "are the most thorough of any in the field of psychiatry." This has paid off for the association and its members. As Paula Caplan, a Consulting Psychologist working with the DSM committee, noted in 1995 regarding the DSM, "A recent revision yielded more than a million dollars in revenue, since each time a new edition appears, libraries and many practicing therapists...have to buy the updated version" (p. xix).
Psychiatrists are members of the American Psychiatric Association <http://www.psych.org/>.
THEORETICAL APPROACHES
A number of differing approaches to therapy developed historically concurrently. There is a mix-and-match between professions and theories so that both mental health counselors and clinical psychologists might, for example, have a cognitive perspective while pastoral counselors and family therapists might both view a problem from family systems considerations. For this reason, this section presents theoretical approaches independently of which type of psychotherapist might use them. In fact, when therapists are polled, the most frequent response to the question, "Which theory do you follow?" is "eclectic" <http://www.psychotherapynetworker.com/index.php?category=magazine&sub_cat=articles&type=article&id=The%20Top%2010&page=1>.
Psychoanalytic
Sigmund Freud's turn-of-the century writings have not merely been the basis for psychoanalysis but have penetrated all domains of psychotherapy, literature, and vocabulary. His two great contributions were first, to make us aware of the unconscious aspects of our behavior, and second, he served as a role model for a successful therapist-patient relationship. This is evident in an excerpt from his paper comparing grieving with depression, "Mourning and Melancholia," first published in German in 1917 and translated into English in 1925:
"The melancholic displays something else besides which is lacking in mourning--an extraordinary diminution in his self-regard, an impoverishment of his ego on a grand scale. In mourning it is the world which has become poor and empty; in melancholia it is the ego itself. The patient represents his ego to us as worthless, incapable of any achievement and morally despicable; he reproaches himself, vilifies himself and expects to be cast out and punished. He abases himself before everyone and commiserates with his own relatives for being connected with anyone so unworthy. He is not of the opinion that a change has taken place in him, but extends his self-criticism back over the past; he declares that he was never any better. This picture of a delusion of (mainly moral) inferiority is completed by sleeplessness and refusal to take nourishment, and--what is psychologically very remarkable--by an overcoming of the instinct which compels every living thing to cling to life. It would be equally fruitless from a scientific and a therapeutic point of view to contradict a patient who brings these accusations against his ego. He must surely be right in some way and be describing something that is as it seems to him to be. Indeed, we must at once confirm some of his statements without reservation. He really is as lacking in interest and as incapable of love and achievement as he says. ... It may be, so far as we know, that he has come pretty near to understanding himself: we only wonder why a man has to be ill before he can be accessible to a truth of this kind" (Reproduced from a copy in the Library of the College of Physicians of Philadelphia by Merck Sharp & Dohme, 1972, p. 9).
Four aspects of this excerpt are noteworthy: first, his keen eye for detail which describes depression in fairly similar terms to those found in modern diagnostic books; second, his immediate acceptance of the person as is ("It would be equally fruitless from a scientific and a therapeutic point of view to contradict a patient who brings these accusations against his ego. He must surely be right in some way and be describing something that is as it seems to him to be. Indeed, we must at once confirm some of his statements without reservation."); third, his view that this behavior is an exception to normal behavior ("we only wonder why a man has to be ill before he can be accessible to a truth of this kind"); and fourth, this abnormal behavior is caused by activities going on beneath the surface ("his ego").
Regarding his ability to describe mental illness well (the first point, above), Freud, a medical doctor, is considered to be the first psychotherapist to not only attempt to classify pathological behavior, but to understand its causes.
The second aspect of the excerpt that is noteworthy, Freud's ability to connect with his patient is considered to be the most important quality for psychotherapists (Beutler, Machado, & Neufeldt, 1994). True, most people would want to persuade the patient that he is wrong and he is not as terrible a person as he thinks himself to be, but the brilliance in Freud's approach is precisely to do the opposite in order to convince the patient that he, the therapist, truly understands how he feels.
Regarding the third point, with few exceptions (such as postmodern MFTS), most psychotherapists subscribe to the view Freud expresses that there is such a thing as mental illness which is distinguished from normal behavior.
Finally, as to the fourth point highlighed from the excerpt, the role of unconscious factors such as the ego is widely accepted today throughout the psychotherapy field and is part of the layman's vocabulary as well.
Other psychoanalysts who had a profound impact on psychotherapy are: Erich Fromm <http://www.hrc.utexas.edu/multimedia/video/2008/wallace/fromm_erich.html>, Alfred Adler <http://ourworld.compuserve.com/homepages/hstein/>, Karen Horney <http://webspace.ship.edu/cgboer/horney.html>, Carl Jung <http://www.cgjungpage.org/>, Melanie Klein, Otto Rank <http://www.ottorank.com/>, Bruno Bettleheim <http://www.nybooks.com/articles/16807>, Harry Stack Sullivan <http://www.wawhite.org/history/brief_history_WAWI.htm>, and Karl Menninger <http://www.menningerclinic.com/about/early-history.htm>.
Behavioral
B.F. Skinner at Harvard published The Behavior of Organisms in 1938. He was doing research on how rats respond to pleasant or noxious stimuli, and, in the preface to the seventh printing in 1966, he stated, "The simplest contingencies involve at least three terms--stimulus, response, and reinforcer--and at least one variable (the deprivation associated with the reinforcer) is implied. This is very much more than input and output, and when all relevant variables are thus taken into account, there is no need to appeal to an inner apparatus, whether mental, physiological, or conceptual. The contingencies are quite enough to account for attending, remembering, learning, forgetting, generalizing, abstracting, and many other so-called cognitive processes."
Skinner is saying that one does not need to postulate a mind or mental proccesses to understand behavior because behavior is governed by the contingencies that precede and follow it. Although Skinner did not want to consider ideas, beliefs, and values as possible reinforcers, he recognized that most people do and wrote a very readable fictional book, Walden Two (McMillan, 1962) which does take values and beliefs into account as part of the reinforcement picture.
Soon, other researchers started applying the concepts of contingencies of reinforcement to schools, hospitals, prisons, and residential programs for juvenile delinquents. Teodoro Ayllon & Nathan Azrin described this application in The Token Economy (1960).
In spite of what may seem mechanistic in this approach, it is very powerful when used with children, especially in groups or children who may have lacked skilled discipline in earlier years. For that reason, behavior modification programs play a significant role in schools and parenting programs today. (See the Journal of Applied Behavior Analysis [JABA] archive which dates back to 1969 <http://www.pubmedcentral.nih.gov/tocrender.fcgi?journal=309&action=archive>.) In a 1993 review of the impact that JABA had on the therapy community over the 25 years of its existence, authors Victor G. Laties and F. Charles Mace note that such journals as J. of Consulting Psychology, J. of Autism & Developmental Disorders, J. of Learning Disabilities, J. of Speech & Hearing Disorders frequently cited its articles.
As the authors state, "Techniques and programs such as differential social reinforcment, token economies, prompt hierarchies, self-management, and effective and nonintrusive forms of time-out, have produced lasting changes in the delivery of psychological and educational services" (JABA, 26(4), p. 523, <http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1297881>). A quick look at the Summer 2008 titles for this journal <http://seab.envmed.rochester.edu/jaba/toc/cur/jabacurrent.php> shows that behavior modification is applied mostly to child-management issues.
Other well known behaviorists are Ivan Pavlov and John Watson of the 19th Century, Joseph Wolpe <http://findarticles.com/p/articles/mi_g2699/is_0006/ai_2699000655>, and Arnold Lazarus <http://findarticles.com/p/articles/mi_g2699/is_0005/ai_2699000528>.
Humanistic
Carl Rogers is considered one of the fathers of humanistic psychology. In his 1961 book, On Becoming a Person, he expressed his difficulty in finding an audience for his ideas since he felt caught between psychoanalysis and behaviorism: "I know I speak for only a fraction of psychologists. The majority--their interests suggested by such terms as stimulus-response, learning theory, operant conditioning--are so committed to seeing the individual solely as an object, that what I have to say often baffles if it does not annoy them. I also know that I speak to but a fraction of psychiatrists. For many, perhaps most of them, the truth about psychotherapy has already been voiced long ago by Freud, and they are uninterested in new possibilities (pp. vii-viii)." His concept was deceptively simple: Be a good listener and make the client central to the therapy process. He did not live to see that these principles would become the cornerstone of all good therapy regardless of theoretical orientation (Beutler, Machado, & Neufeldt, 1994).
Regarding client-centered psychology, Rogers explained, "In my early professional years I was asking the question, How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth (1961, p. 32)?"
Other noted humanist psychotherapists are: Abraham Maslow (1968), Victor Frankl (1959/1984), Sidney Jourard (1968), Rollo May (existential), Fritz Perls (gestalt), and Eric Berne (transactional analysis, 1964).
Humanistic psychology developed as an alternative way of perceiving human nature to both Freudianism and behaviorism. It is often referred to as the "third force" in psychology. More can be found about it at the Association for Humanistic Psychology<http://www.ahpweb.org/aboutahp/whatis.html>.
Cognitive
In 1961, Albert Ellis <http://nymag.com/nymetro/news/people/features/14947/> and Robert Harper published the book that would inaugurate cognitive therapy, The Guide to Rational Living. Their contention was that the choice of words that we use directs the way we feel. As an example, people often generalize without realizing it by saying such things as, "I can't stand her." Actually, the truth is that so-and-so bothers the speaker somewhat some of the time. The original statement is both an exaggeration and a generalization.
The authors describe the therapy process as follows: "When people say that 'That makes me anxious,' or 'You made me angry,' we help them see that 'I made myself anxious about that' and 'I angered myself about your behavior'" (p.xii). The authors thought of themselves as semanticists since they put such a heavy focus on words as the avenue to healing and they also classified themselves as humanists as distinct from behaviorists or Freudians (pp. ix-x). What Ellis and also Aaron Beck (below) would not realize then was the enormous influence that cognitive therapy would have on psychotherapy.
The other "father" of cognitive therapy is Aaron Beck <http://www.beckinstitute.org/FolderID/200/SessionID/%7B20510DC7-C0BB-45ED-809E-49FAA7E3DE18%7D/PageVars/Library/InfoManage/Guide.htm> whose approach paralleled the ideas of Ellis in that therapy contains "skills that involve identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors. . . Cognitive therapy helps people to identify their distressing thoughts and to evaluate how realistic the thoughts are. Then they learn to change their distorted thinking." He published Depression: Its Causes and Treatment in 1972.
Family Systems
Family systems is a unique approach to healing, built on the humanistic idea of understanding behavior from a non-pathologizing stance, while taking this point two steps further. First, as Salvadore Minuchen (1993) says, in contrast to his early training in individual therapy in which "We were deep-sea divers searching for motivation inside people," in working with whole families sitting together in a room, "We were suddenly unsure about the beginnings of behaviors or feelings since we could see them as responses to behavior or feelings of other family members, who were in turn responding to behaviors and feelings. We began to see all behavior as action, but aslo as reaction, a response that was also a point of departure" (p.29).
Second, the very act of having to juggle all the differing points of view, actions, and reactions of members of a family leads almost inevitably to call into question whose "reality" is the "right" one.
That is, the early family therapists noticed that when they would talk to only one member of a family, a particular incident would sound completely different than the way another family member would describe it. Not only would cause and effect become unclear, as Minuchen explains above, but truth itself would become perplexing.
As Caplan (1995) points out, "Ask ten people whether the object in the middle of your kitchen is a table and the chances are they will unaimously agree that it is. But ask ten people--even ten therapists--whether any particular person is normal and, if not, why they consider the person to be abnormal, and you will almost certainly get a large number of quite different replies" (p.34). This is because "normality is not real, like a table" (p. 34). Rather, as Edith Wyschogrod explains, normality is the result of what people think it is; it is arrived at by consensus, not objectively.
When members of a family present differing veiws of reality, it would not only be difficult for the therapist-as-outsider to choose which is the correct one, we can see that it would also be disrespectful for the therapist to believe one person in the family is "right" and the others, "wrong." Sampson (1993) stresses this point, saying, "For too long our major cultural and scientific views have been monologic and self-celebratory - focusing more on the leading protagonist and the supporting cast that he has assembled for his performances than on others as viable people in their own right. Time now to celebrate the other - not only to set the record straight but, of equal importance, to give voice, and in their own register and form, to those who have been condemned to silence" (p. ix).
We could say, then, that the family systems approach respects and gives voice to all views in the family and does not label any view as pathological. The therapist makes sense of family members' diverse views by recognizing the importance of history and context in how people develop. For example, Bradford Keeney (1983) explains, "To see a nagging husband without considering a withdrawing wife may lead to treating a 'nagger' rather than a nagging-withdrawing relationship system" (pp.37-38). Keeney's book is a tour-de-force in the science of logic as applied to clinical thinking.
For a grounding in this postmodern approach and/or its application to therapy, read also Gregory Bateson (1972); Kenneth Gergen (1991); Michael White & David Epston; Tom Andersen; Steve de Shazer; Luigi Boscolo, Gianfranco Cecchin, Lynn Hoffman, and Peggy Penn (1987); Paul Watzlawick, Janet Beavin Bavelas, and Don D. Jackson (1967); and Edith Wyschogrod (1990).
Other revolutionaries in the family therapy field are Virginia Satir <http://www.satirglobal.org/>, Murray Bowen (1988), Milton Erickson (1989), Jay Haley (1976), and Nathan Ackerman <http://www.abacon.com/famtherapy/profiles.html>.
WHERE TO WORK
Specialties also cut across clincial categories so that someone working in the corporate world could as readily be an industrial psychologist as an MFT. This is not as odd as it first seems considering that MFTs are highly familiar with how systems function. Families, after all, are systems. Thus, clinicians trained in the disciplines described above all could specialize and receive training targeted to working in:
1. school systems
2. agencies
3. hospitals
4. corporations
5. small business
6. the military
7. the legal system
8. private practice
PAYMENT METHODS
In the 1950s, therapy was the province of the weathly. They could visit the therapist several times a week for psychoanalysis, the method developed by Sigmund Freud, and pay for it out of pocket. Eventually, medical insurance carriers were willing to pick up the tab and had no strings attached. Thus, in the third quarter of the last century, psychotherapists did not have to explain to the insurer what they did to treat their patients and those patients were able to get the cost of their sessions fully covered by the insurance companies.
Thngs changed with the advent of Health Maintenance Organizations (HMOs). Because they were cost effective for employers, they had to scale back their benefits. This spawned an industry in which benefits administrators could be educated at the college-level without a background in any therapeutic discipline. They enforced company policy to limit numbers of visits and type of treatment. Clinicians found their income disappear while the quality of their work went down as well. They were compelled to spend an equal amount of time filling out paperwork for insurance companies or phoning them wanting to know why they hadn't gotten paid for therapy sessions. In compensation, they never had to advertise for clients as the insurance companies would send them a steady flow of people.
This is now changing once again with the increasing utility of the internet to reach people. Therapists who had no choice but to get reimbursement by insurance companies now have the flexibility to work independently. They may charge a high fee but use their discretion to take people in need at reduced rates in compliance with mandates to do so from the code of ethics of their professions. For the same reason, community mental health not-for-profit corporations may see an increase in usage because internet listings increase their visibility.
For these reasons, a person in need of psychotherapy services should not be put off by a high price tag or a lack of insurance. Such individuals should do a search for "free psychotherapy," or find the best therapists and ask them point blank for a price reduction. Some therapists have what is called a "sliding scale" which matches income with fee while others take a certain percentage of cases for a reduced price as a community service.
BIBLIOGRAPHY
Alessandri, M., Heiden, L., & Dunbar-Welter, M. (1995). History and Overview in L. Heiden & M. Hersen (Eds.), Introduction to clinical psychology. New York: Plenum Press.
Andersen, T. (1991). The reflecting team: dialogues and dialogues about the dialogues. New York: Norton.
Ayllon, T., & Azrin, N. (1968). The token economy. New York: Appleton-Century Crofts.
Bateson, G. (1972). Steps to an ecology of mind. New York: Paladin Books.
Benjamin, L. (2005). A history of clinical psychology as a profession in America (and a glimpse at its future). Annual Review of Clinical Psychology, 1, 1–30.
Berne, E. (1964). Games people play. New York: Ballantine.
Beutler, L. E., Machado, P. P., & Neufeldt, S. A. (1994). Therapist variables. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 229-269). New York: Wiley.
Boscolo, L., Cecchin, G., Hoffman, L., & Penn, P. (1987). Milan systemic family therapy: Conversations in theory and practice. New York: Basic Books.
Caplan, P. (1995). They say you're crazy: how the world's most powerful psychiatrists decide who's normal. New York:Perseus Books
de Shazer, S. (1985). Keys to solution in brief therapy. New York: Norton.
Ellis, A. & Harper, R. A. (1977). A new guide to rational living. No. Hollywood, CA: Wilshire Book Company.
Erickson, M. H. & Rossi, E. L. (1989). The February man: Evolving consciousness and identity in hypnotherapy. New York: Brunner/Mazel.
Frankl, V. E. (1959/1984). Man's search for meaning. New York: Washington Square Press.
Freud, S. (1917/1972). Mourning and Melancholia. Reproduced from a copy in the Library of the College of Physicians of Philadelphia by Merck Sharp & Dohme.
Fromm, E. (1947). Man for himself: An inquiry into the psychology of ethics. Greenwich, CT: Fawcett Premier
Gergen, K. J. (1991). The saturated self: Dilemmas of identity in contemporary life. US: Basic Books.
Glasser, W. (1975). Reality therapy: A new approach to psychiatry. New York:Colophon Books.
Haley, J. (1976). Problem-solving therapy: New strategies for effective family therapy. San Franscisco:Jossey-Bass.
Jourard, S. M (1968). Disclosing man to himself. New York: Van Nostrand Reinhold.
Jourard, S. M. (1971). The transparent self. New York: D. Van Nostrand.
Keeney, B. P. (1983). Aesthetics of change. New York: Guilford.
Kerr, M. E. & Bowen, M. (1988). Family Evaluation: An approach based on Bowen theory. New York: Norton.
Klein, M. (1975). Love, guilt and reparation: And other works 1921-1945, London: Hogarth Press.
Maslow, A. H. (1968). Toward a psychology of being. New York: D. Van Nostrand.
McNamee, S. & Gergen, K. J. (1992). Therapy as social construction. London: Sage.
Minuchin, S. (1993). Family healing: Tales of hope and renewal from family therapy. New York: Free Press.
Rogers, C. R. (1961). On becoming a person: A therapist's view of psychotherapy. Boston: Houghton Mifflin.
Sampson, E. E. (1993). Celebrating the other: A dialogic account of human nature. Boulder: Westview Press.
Skinner, B. F. (1938). The behavior of organisms: An experimental analysis. New York: Appleton-Century-Crofts.
Skinner, B. F. (1948/1962). Walden two. New York: Macmillan.
Watzlawick, P., Bavelas, J. B., & Jackson, D. D. (1967). Pragmatics of human communication. New York: Norton.
White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.
Whiteley, J. M. (1999). The paradigms of counseling psychology. The Counseling Psychologist, 27 (1), 14-31.
Wyschogrod, E. (1990). Saints and postmodernism: Revisioning moral philosophy. Chicago: Chicago University Press.
General Definition
Requirements for Graduate Education
Educational Levels
Licensing and Credentialing
Types of Psychotherapists
Theoretical Approaches
Where to Work
Payment Methods
GENERAL DEFINITION
The Greek word, "psycho" means "soul" or "spirit."
The Greek word, "therapeia," means "healing." The term "psychotherapist," then, when literally translated, means healer of the soul.
Today the word "psychotherapist" is used as a generic catch-all for many different disciplines and degrees. These practitioners help people who are unhappy, confused, angry, depressed, having marital trouble, having difficulty with their children, in need of career guidance, afraid, upset, hurt, or simply in need of an objective outsider as a sounding board for their thoughts. This help takes the form of talk therapy.
REQUIREMENTS FOR GRADUATE EDUCATION
Psychotherapists have all graduated from an accredited four-year college program followed by graduate school. In order to be accepted into graduate school, therapists must take the Graduate Record Examination, <http://www.ets.org> a standardized test developed by the Educational Testing Service.
This test, in combination with academic achievement in college, determines the likelihood of acceptance to graduate school. Different graduate schools have different standards for acceptance.
EDUCATIONAL LEVELS
There are two broad educational levels beyond college: the master's degree which is either one or two years and the doctoral degree which is anywhere from three to four years--or more. Although people might begin by getting a master's degree and then applying for further graduate study in a doctoral program, many schools accept students directly from college into a doctoral program.
Both master's and doctoratal programs entail most of these:
(1) courses on the field's history, philosophy, and methodology
(2) clinical training
(3) written papers that demonstrate special knowledge
(4) comprehensive tests
In all four of these areas, the work is normally more detailed, more demanding, more analytical, more specialized, and more comprehensive at the doctoral level.
Master's Degree
Master's degree programs may be completed in one or two years, depending on the requirements of the particular graduate school. The program may entail any of the following:
statistics
diagnostics
history of the profession
original readings by various leaders in the field
research methods
working within institutions (called a "practicum")
Clinical training requires time spent face-to-face working with "patients" or "clients." (Different orientations have different terms for those who seek their services, as we will see below.) In master's degree programs, this is usually accomplished by having students spend time in existing institutions such as schools, hospitals, and a multitude of community agencies, under the supervision of someone who works at that agency. The student is required to clock in a specific number of hours doing this in order to satisfy the clinical training requirement for the degree, state licensing requirements, and acceptance into professional organizations.
A master's degree programs usually require the writing of a master's thesis which is a lengthy research paper. There are two forms of research in science: One is a review of the literature and the other is an original study on a topic of interest. A review of the literature means going to the library and discovering what has been published previously on one's topic of interest. While this might not seem like originating something, many programs would consider the very act of bringing together information from various sources to be an acceptable form of research at a master's degree level.
Other programs require original research. This might entail observing a particular phenomenon and recording those observations, conducting interviews, or setting up a laboratory experiment.
Final testing at the master's level is usually comprehensive, meaning that it goes beyond the tests given at the end of each course. Rather, it is commonly one, rather lengthy test that includes material from all the courses in the program.
A typical example of a master's degree program is the one in Family Therapy at Nova Southeastern University (NSU) in Florida <http://shss.nova.edu/Academic_Programs/MastersPrograms/MSFT.htm> where students spend six trimesters (two years) in combined coursework and practicum work followed by a comprehensive exam. The clinical training entails 500 client-contact hours, half of which must be with couples and families.
In addition, the program requires that these client-contact hours are reviewed with a supervisor for 100 hours. This part of the process is called "supervision." Each field in psychotherapy requires this component and the supervisor must have the proper credentials to do so. In the case of Family Therapy illustrated above, for example, the supervisor must be certified by the state and also must be approved by the American Association for Marriage & Family Therapy.
Doctoral Degree
All of the above requirements would be true for the doctoral degree except that there is more included in each component of the program. The coursework contains material that is not taught at the master's level. This material may contain theoretical readings so that the student understands the underpinnings of the work rather than just knowing how to carry it out. It also may contain courses in supervision or teaching so as to prepare the clinician for leadership in the field upon graduation.
The clinical training will include more time spent in an outside facility and, in addition, as many as six semesters of supervised therapy done in the school's own health center. At the doctoral level, this supervision is often live, in real time, such as through a one-way mirror, with the ability to phone in comments to the therapist-in-training while the session is going on.
The written paper, or dissertation, will be more in-depth for the doctoral degree as well, most of the time entailing field research or a laboratory experiment that is original. This project could take a decade for a doctoral student to complete although that is very rare. The time frame for completion depends upon the nature of the study and the criteria of the dissertation committee that evaluates it. The dissertation committee is usually composed of professors in the student's department although outside experts may be included on occasion. It is the student who selects his or her dissertation committee.
The final test is generally comprehensive. Individual programs may not require this test because the student has already passed individual course tests, worked extensively in the clinic with people presenting real-life problems, and written a thorough dissertation.
As an example of the doctoral level requirements, see the website for Nova Southeastern University <http://shss.nova.edu/Academic_Programs/DoctoralPrograms/PhdFT.htm> and compare it to the one described above for a master's degree. At NSU, to earn the doctorate, students must complete four years of coursework beyond the master's that they have already attained. This includes a nine-month off-campus internship which follows three semesters of supervised work in the school's clinic. There are three comprehensive exams given at different times and four courses in research, both quantitative and qualitative, before dissertation work begins.
On the other hand, Harvard University <http://www.gsas.harvard.edu/programs_of_study/psychology_4.php> does not offer a masters degree in Psychology and does not require one for admission to its doctoral program in Psychology. Students are expected to complete the degree, which is oriented toward research, within five years. The clinical internship requirement is one year of supervised experience.
LICENSING AND CREDENTIALING
Each of the various disciplines that comprises psychotherapy is governed both legally and by the profession. Legal governance is by the state in which the practitioner lives. This is managed by the requirement of the state for the clinician to pass a licensing examination upon completion of final requirements by the school and to continue taking courses in the field each year to keep up with current information. These are called Continuing Education Units (CEUs).
In addition, each type of psychotherapist has an allegiance to and membership in an association made up of other therapists in his or her particular profession. Each of these associations has its own requirements for membership, set of ethical guidelines, and disciplinary procedures. When people satisfy the requirements for membership, they then receive a credential that states they hold such membership. The value of this credential lies in the respect the public has for the organization itself.
TYPES OF PSYCHOTHERAPISTS
Psychotherapists can be:
Psychologists
Social Workers
Mental Health Counselors
Marriage & Family Therapists
Pastoral Counselors
Psychiatrists
Psychologists
The most commonly known type of psychotherapist is the psychologist. This field falls into two broad types: clinical and counseling. While clinical psychologists are only at the doctoral level, counseling psychologists can be found at both the master's and doctoral levels.
There is a distinction in focus between these two types of psychologists as well, even when both types hold a doctoral degree. Clinical psychologists "tend to work with more seriously disturbed" people "whereas counseling psychology graduates work with healthier, less pathological populations and conduct more career and vocational assessment" (as reported in the PsiChi Honor Society Newsletter, Fall 2000, by Dr. John C. Norcross <http://www.psichi.org/pubs/articles/article_73.asp>).
The distinction between a more mentally healthy person and one who is less healthy (and therefore has pathology) comes from the fact that psychiatrists are medical doctors. Psychiatrists created a system of evaluating and judging levels of sickness in people. This makes sense because doctors normally see people who are ill, not well. The notion that a person must have something wrong with him in order to be at the doctor's office is called "the medical model." It postulates that when someone seeks help from a doctor--including a psychiatrist--there is pathology (sickness) to be found and it is the clinician's job to determine what it is.
The fact that clinical psychologists would follow the medical model arises from the history of this profession. Up until the turn of the last century, the focus of the profession was to study human behavior rather than to treat it. As soldiers returned from World War I, this ability to carefully examine people was called upon. Soldiers often had Post Traumatic Stress Disorder symptoms which were called "shell shock" at that time, and the Army wanted to know if psychologists would be able to develop a test to screen such people out before future service. It was about this time that the term "clinical psychology" was coined by Lightner Witmer, said to be the father of the profession, and their organization, the Association of Clinical Psychology merged with the American Psychological Association, receiving its own division. The historical stage was set, then, for this profession to have an orientation towards discovering pathology (Allessandri, 1995; Benjamin, 2005).
Counseling psycholgy developed differently.
Dr. John C. Norcross, who I have quoted above in describing the differences in practice between a clinical psychology and a counseling psychology orientation, goes on to explain that the theoretical orientation is different between clinical and counseling psychologists to some degree as well: "Clinical psychologists more frequently favored the behavioral and psychoanalytic (but not psychodynamic) persuasions, and counseling psychologists the client-centered and humanistic traditions." (See below for a discussion of these theoretical orientations.)
While it is possible to receive a master's degree in psychology, customarily psychologists work at the doctoral level. The doctoral degree psychologist may either be a Ph.D. or Psy.D. The Ph.D. has a more intensive research requirement while the Psy.D. is tailor-made for psychologists who want to focus on the treatment of people clinically. A person with a Ph.D. can do both clinical work and research.
The organization to which psychologists belong is the American Psychological Association (APA). <http://www.apa.org> The APA has 148,000 members. It contains 56 divisions from Society for General Psychology (1) to Trauma ( division 56) with Psychopharmacology and Substance Abuse in the middle (division 28). To learn more about the distinction between a pathologizing approach for clinical (and other) divisions and a non-pathologizing approach for counseling psychology, go to divisions 12 and 17, respectively. Read also a thorough review of counseling psychology in John M. Whiteley's article in The Counseling Psychologist, The Paradigms of Counseling Psychology (vol. 27, number 1, January, 1999, pages 14-31).
Psychologists were the frontrunners of psychological testing, a practice within clinical psychology in which diagnostic tests are given to people to determine what might be wrong with them; that is a specialty that other therapists do not share.(Division 5 - Evaluation, Measurement, and Statistics <http://www.apa.org/about/division/div5.html>). Many psychologists do their doctoral research on improving the accuracy of these tests.
Social Workers
The official website <https://www.socialworkers.org> describes the practice of social work as follows:
"Social work practice consists of the professional application of social work values, principles, and techniques to one or more of the following ends: helping people obtain tangible services; counseling and psychotherapy with individuals, families, and groups; helping communities or groups provide or improve social and health services; and participating in legislative processes. The practice of social work requires knowledge of human development and behavior; of social and economic, and cultural institutions; and of the interaction of all these factors."
This description demonstrates the emphasis on community and institutional work. The vast majority of social workers (SWs) have a master's degree. People with the doctoral degree (DSW) are additionally qualified to teach in a university or to serve as an administrator in a community setting (from Social Work Today, 2005 <http://www.socialworktoday.com/archive/swt_0705p12.htm>).
The organization to which social workers belong is the NASW, the National Association of Social Workers. With 150,000 members it may have the largest membership of the psychotherapy categories. Established in 1955, it was an amalgum of the American Association of Social Workers with Associations for Psychiatric SWs, Group SWs, Medical SWs, School SWs, and the Association for the Study of Community Organization.
Mental Health Counselors
Counselors typically have a master's degree. Professional counselors or mental health counselors are members of the American Counseling Association <http://www.counseling.org/>. Generally, a person who wished to pursue a doctorate in counseling would go into a counseling psychology program. These programs are found in both schools of education and psychology.
Indicative of the idea (discussed above in the psychology section) that counselors do not work with people suffering pathology, the online news for the American Counseling Association, ACA Today, recently ran stories with the following headlines: "When College Students Need Extra Help," "10 Steps for Improving Relationship Communications," "Helping Reduce the Trauma of a Family Move," and "Family Driving Vacations Don't Have to be Stressful." This non-pathologizing viewpoint helps to normalize the counseling process for clients who don't see themselves as sick--as well as for therapists who prefer not to view clients in that way either.
Counselors routinely work in private practice, schools, colleges, community agencies, hospitals, and government. For example, of the eleven journals in this field, aside from three that would be of general interest, there is Adultspan, which deals with aging, Counseling and Values, the official journal of the Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC), the Journal of Addictions and Offender Counseling, two journals on employment or career counseling, and three journals for counselors in secondary schools and colleges.
The field of counseling is very active in attempting to have a positive impact on federal legislation regarding counselor reimbursement and funding to schools and other programs.
Marriage & Family Therapists
Marriage and family therapists (MFTs) could be called postmodern therapists. While they do work with both pathological and non-pathological populations, they prefer not to give diagnoses at all (except where required by insurance companies for reimbursement) and don't perceive of people, no matter what their symptoms, as "having" pathology.
As Edward Sampson (1993), a professor of psychology at California State Unviersity explains it in his book, Celebrating the Other, in labeling someone pathological, the one who does the labeling accrues power to himself and removes it from the other person.
Rather than to give people a diagnositc label, MFTs think of behavior as the product of the interaction between people's genetics and their environment. The behavior they exhibit is the solution they develop to conditions in their environment. The process by which people develop a response to their environment makes sense given the tools they had to work with (genetics) in combination with the total picture of that environment. The idea that a behavior--however odd ("pathological"), unusual, difficult to handle, or difficult to understand--would make sense and not be considered "sick" (given the person's history) is unique to the postmodern view that MFTs hold. This is a strength-based perspective of human nature. To distinguish this view from the medical model, MFTs refer to those who seek their services as "clients" rather than "patients."
The official statement of this position can be found on the website of their professional organization <http://www.aamft.org/index.asp> the American Association of Marriage & Family Therapists: "The development of the field of marriage and family therapy has included a tradition and perspective that eschewed the medical model. Historically, pathology or the diagnosis of an individual was not part of our field's heritage or practice. In light of this historical context, AAMFT never considered the possibility of making a statement that defined 'pathology.'"
Furthermore, diagnosis is not necessary for successful treatment. Again from the website, "Research indicates that marriage and family therapy is as effective, and in some cases more effective than standard and/or individual treatments for many mental health problems such as: adult schizophrenia, affective (mood) disorders, adult alcoholism and drug abuse, children's conduct disorders, adolescent drug abuse, anorexia in young adult women, childhood autism, chronic physical illness in adults and children, and marital distress and conflict."
Because state licensing laws require therapists to know and understand various standard aspects of therapy such as the use of diagnostic categories, all MFTs are trained to understand how to give psychological diagnoses. However, in creating a plan for therapy, they don't think in terms of "What's wrong with this person?" They think instead, "What strengths does this person have that I can build on?" and, "How can I understand his behavior and make sense out of it in the context of his life?"
MFTs may either have a master's degree or a Ph.D. Recently, programs have also added a doctorate in marriage and family therapy (DMFT) as a more clinical, less research-oriented degree.
Pastoral Counselors
The American Association of Pastoral Counselors <http://www.aapc.org/about.cfm> is a small (3,000) but growing force within psychotherapy. As their website states, "A national survey was conducted by Greenberg Quinlan Research, Inc. of Washington, D.C., to explore attitudes toward the role of spiritual values and beliefs in the treatment of mental and emotional problems. The report stated 'that an overwhelming number of Americans [69 percent] recognize the close link between spiritual faith, religious values, and mental health, and would prefer to seek assistance from a mental health professional who recognizes and can integrate spiritual values into the course of treatment.'"
In addition to seminary education, pastoral counselors must complete "at least 1,375 hours of supervised clinical experience (that is, the counselor provides individual, group, marital and family therapy) and 250 hours of direct approved supervision of the therapist’s work in both crisis and long-term situations" making them a highly-trained group of therapists.
Representing 80 different faiths, Pastoral Counselors may practice at the master's or doctoral levels.
Psychiatrists
Psychiatrists are on this list of psychotherapists in spite of the fact that they have a medical degree rather than a master's or Ph.D. Psychiatrists are doctors who have graduated from medical school and studied all the subjects that any medical doctor must such as obstetrics, cardiology and so on. This professional, however, chose as a specialty a field in medicine in which he or she could help to heal the types of problems that are listed at the beginning of this essay--anger, depression, confusion, and so on.
Psychiatrists, however, in the 21st Century, do not primarily address these problems through talk therapy. Rather, they write out prescriptions for medicines to take to alleviate the symptoms described above. They are included here because there are some--rare--psychiatrists who prefer to heal through talk therapy rather than through medicine. Those that prefer to follow the convention of offering prescriptions practice from a psychopharmalogical perspective.
The psychiatry profession originated and continues to develop the DSM, the Diagnostic and Statistical Manual of Mental Disorders <http://www.appi.org/dsm.cfx>. Historically, the DSM
began with two categories, neurotic and psychotic, but every decade or so, mental illnesses have been added. Currently, the DSM-IV is in use. Researchers explain that this is because greater knowledge about mental illness helps to refine its categories.
Currently, American Psychiatric Publishing, Inc. (APPI), a wholly owned subsidiery of the American Psychiatric Association, has a DSM library surrounding its most current version with 43 titles ranging from "A Research Agenda for DSM-V" and "Advancing DSM" to "Treatment Companion to the DSM-TR Casebook."
APPI notes on its website that its books are all peer-reviewed, with only 30 accepted for publication each year out of 200 applications. Once these titles are accepted, many have been reviewed by all major psychiatric journals as well as by the two highly respected general medical journals: the Journal of the American Medical Association and the New England Journal of Medicine <http://www.appi.org/aboutappi2.cfx>.
Further, APPI also states that its marketing efforts "are the most thorough of any in the field of psychiatry." This has paid off for the association and its members. As Paula Caplan, a Consulting Psychologist working with the DSM committee, noted in 1995 regarding the DSM, "A recent revision yielded more than a million dollars in revenue, since each time a new edition appears, libraries and many practicing therapists...have to buy the updated version" (p. xix).
Psychiatrists are members of the American Psychiatric Association <http://www.psych.org/>.
THEORETICAL APPROACHES
A number of differing approaches to therapy developed historically concurrently. There is a mix-and-match between professions and theories so that both mental health counselors and clinical psychologists might, for example, have a cognitive perspective while pastoral counselors and family therapists might both view a problem from family systems considerations. For this reason, this section presents theoretical approaches independently of which type of psychotherapist might use them. In fact, when therapists are polled, the most frequent response to the question, "Which theory do you follow?" is "eclectic" <http://www.psychotherapynetworker.com/index.php?category=magazine&sub_cat=articles&type=article&id=The%20Top%2010&page=1>.
Psychoanalytic
Sigmund Freud's turn-of-the century writings have not merely been the basis for psychoanalysis but have penetrated all domains of psychotherapy, literature, and vocabulary. His two great contributions were first, to make us aware of the unconscious aspects of our behavior, and second, he served as a role model for a successful therapist-patient relationship. This is evident in an excerpt from his paper comparing grieving with depression, "Mourning and Melancholia," first published in German in 1917 and translated into English in 1925:
"The melancholic displays something else besides which is lacking in mourning--an extraordinary diminution in his self-regard, an impoverishment of his ego on a grand scale. In mourning it is the world which has become poor and empty; in melancholia it is the ego itself. The patient represents his ego to us as worthless, incapable of any achievement and morally despicable; he reproaches himself, vilifies himself and expects to be cast out and punished. He abases himself before everyone and commiserates with his own relatives for being connected with anyone so unworthy. He is not of the opinion that a change has taken place in him, but extends his self-criticism back over the past; he declares that he was never any better. This picture of a delusion of (mainly moral) inferiority is completed by sleeplessness and refusal to take nourishment, and--what is psychologically very remarkable--by an overcoming of the instinct which compels every living thing to cling to life. It would be equally fruitless from a scientific and a therapeutic point of view to contradict a patient who brings these accusations against his ego. He must surely be right in some way and be describing something that is as it seems to him to be. Indeed, we must at once confirm some of his statements without reservation. He really is as lacking in interest and as incapable of love and achievement as he says. ... It may be, so far as we know, that he has come pretty near to understanding himself: we only wonder why a man has to be ill before he can be accessible to a truth of this kind" (Reproduced from a copy in the Library of the College of Physicians of Philadelphia by Merck Sharp & Dohme, 1972, p. 9).
Four aspects of this excerpt are noteworthy: first, his keen eye for detail which describes depression in fairly similar terms to those found in modern diagnostic books; second, his immediate acceptance of the person as is ("It would be equally fruitless from a scientific and a therapeutic point of view to contradict a patient who brings these accusations against his ego. He must surely be right in some way and be describing something that is as it seems to him to be. Indeed, we must at once confirm some of his statements without reservation."); third, his view that this behavior is an exception to normal behavior ("we only wonder why a man has to be ill before he can be accessible to a truth of this kind"); and fourth, this abnormal behavior is caused by activities going on beneath the surface ("his ego").
Regarding his ability to describe mental illness well (the first point, above), Freud, a medical doctor, is considered to be the first psychotherapist to not only attempt to classify pathological behavior, but to understand its causes.
The second aspect of the excerpt that is noteworthy, Freud's ability to connect with his patient is considered to be the most important quality for psychotherapists (Beutler, Machado, & Neufeldt, 1994). True, most people would want to persuade the patient that he is wrong and he is not as terrible a person as he thinks himself to be, but the brilliance in Freud's approach is precisely to do the opposite in order to convince the patient that he, the therapist, truly understands how he feels.
Regarding the third point, with few exceptions (such as postmodern MFTS), most psychotherapists subscribe to the view Freud expresses that there is such a thing as mental illness which is distinguished from normal behavior.
Finally, as to the fourth point highlighed from the excerpt, the role of unconscious factors such as the ego is widely accepted today throughout the psychotherapy field and is part of the layman's vocabulary as well.
Other psychoanalysts who had a profound impact on psychotherapy are: Erich Fromm <http://www.hrc.utexas.edu/multimedia/video/2008/wallace/fromm_erich.html>, Alfred Adler <http://ourworld.compuserve.com/homepages/hstein/>, Karen Horney <http://webspace.ship.edu/cgboer/horney.html>, Carl Jung <http://www.cgjungpage.org/>, Melanie Klein, Otto Rank <http://www.ottorank.com/>, Bruno Bettleheim <http://www.nybooks.com/articles/16807>, Harry Stack Sullivan <http://www.wawhite.org/history/brief_history_WAWI.htm>, and Karl Menninger <http://www.menningerclinic.com/about/early-history.htm>.
Behavioral
B.F. Skinner at Harvard published The Behavior of Organisms in 1938. He was doing research on how rats respond to pleasant or noxious stimuli, and, in the preface to the seventh printing in 1966, he stated, "The simplest contingencies involve at least three terms--stimulus, response, and reinforcer--and at least one variable (the deprivation associated with the reinforcer) is implied. This is very much more than input and output, and when all relevant variables are thus taken into account, there is no need to appeal to an inner apparatus, whether mental, physiological, or conceptual. The contingencies are quite enough to account for attending, remembering, learning, forgetting, generalizing, abstracting, and many other so-called cognitive processes."
Skinner is saying that one does not need to postulate a mind or mental proccesses to understand behavior because behavior is governed by the contingencies that precede and follow it. Although Skinner did not want to consider ideas, beliefs, and values as possible reinforcers, he recognized that most people do and wrote a very readable fictional book, Walden Two (McMillan, 1962) which does take values and beliefs into account as part of the reinforcement picture.
Soon, other researchers started applying the concepts of contingencies of reinforcement to schools, hospitals, prisons, and residential programs for juvenile delinquents. Teodoro Ayllon & Nathan Azrin described this application in The Token Economy (1960).
In spite of what may seem mechanistic in this approach, it is very powerful when used with children, especially in groups or children who may have lacked skilled discipline in earlier years. For that reason, behavior modification programs play a significant role in schools and parenting programs today. (See the Journal of Applied Behavior Analysis [JABA] archive which dates back to 1969 <http://www.pubmedcentral.nih.gov/tocrender.fcgi?journal=309&action=archive>.) In a 1993 review of the impact that JABA had on the therapy community over the 25 years of its existence, authors Victor G. Laties and F. Charles Mace note that such journals as J. of Consulting Psychology, J. of Autism & Developmental Disorders, J. of Learning Disabilities, J. of Speech & Hearing Disorders frequently cited its articles.
As the authors state, "Techniques and programs such as differential social reinforcment, token economies, prompt hierarchies, self-management, and effective and nonintrusive forms of time-out, have produced lasting changes in the delivery of psychological and educational services" (JABA, 26(4), p. 523, <http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1297881>). A quick look at the Summer 2008 titles for this journal <http://seab.envmed.rochester.edu/jaba/toc/cur/jabacurrent.php> shows that behavior modification is applied mostly to child-management issues.
Other well known behaviorists are Ivan Pavlov and John Watson of the 19th Century, Joseph Wolpe <http://findarticles.com/p/articles/mi_g2699/is_0006/ai_2699000655>, and Arnold Lazarus <http://findarticles.com/p/articles/mi_g2699/is_0005/ai_2699000528>.
Humanistic
Carl Rogers is considered one of the fathers of humanistic psychology. In his 1961 book, On Becoming a Person, he expressed his difficulty in finding an audience for his ideas since he felt caught between psychoanalysis and behaviorism: "I know I speak for only a fraction of psychologists. The majority--their interests suggested by such terms as stimulus-response, learning theory, operant conditioning--are so committed to seeing the individual solely as an object, that what I have to say often baffles if it does not annoy them. I also know that I speak to but a fraction of psychiatrists. For many, perhaps most of them, the truth about psychotherapy has already been voiced long ago by Freud, and they are uninterested in new possibilities (pp. vii-viii)." His concept was deceptively simple: Be a good listener and make the client central to the therapy process. He did not live to see that these principles would become the cornerstone of all good therapy regardless of theoretical orientation (Beutler, Machado, & Neufeldt, 1994).
Regarding client-centered psychology, Rogers explained, "In my early professional years I was asking the question, How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth (1961, p. 32)?"
Other noted humanist psychotherapists are: Abraham Maslow (1968), Victor Frankl (1959/1984), Sidney Jourard (1968), Rollo May (existential), Fritz Perls (gestalt), and Eric Berne (transactional analysis, 1964).
Humanistic psychology developed as an alternative way of perceiving human nature to both Freudianism and behaviorism. It is often referred to as the "third force" in psychology. More can be found about it at the Association for Humanistic Psychology<http://www.ahpweb.org/aboutahp/whatis.html>.
Cognitive
In 1961, Albert Ellis <http://nymag.com/nymetro/news/people/features/14947/> and Robert Harper published the book that would inaugurate cognitive therapy, The Guide to Rational Living. Their contention was that the choice of words that we use directs the way we feel. As an example, people often generalize without realizing it by saying such things as, "I can't stand her." Actually, the truth is that so-and-so bothers the speaker somewhat some of the time. The original statement is both an exaggeration and a generalization.
The authors describe the therapy process as follows: "When people say that 'That makes me anxious,' or 'You made me angry,' we help them see that 'I made myself anxious about that' and 'I angered myself about your behavior'" (p.xii). The authors thought of themselves as semanticists since they put such a heavy focus on words as the avenue to healing and they also classified themselves as humanists as distinct from behaviorists or Freudians (pp. ix-x). What Ellis and also Aaron Beck (below) would not realize then was the enormous influence that cognitive therapy would have on psychotherapy.
The other "father" of cognitive therapy is Aaron Beck <http://www.beckinstitute.org/FolderID/200/SessionID/%7B20510DC7-C0BB-45ED-809E-49FAA7E3DE18%7D/PageVars/Library/InfoManage/Guide.htm> whose approach paralleled the ideas of Ellis in that therapy contains "skills that involve identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors. . . Cognitive therapy helps people to identify their distressing thoughts and to evaluate how realistic the thoughts are. Then they learn to change their distorted thinking." He published Depression: Its Causes and Treatment in 1972.
Family Systems
Family systems is a unique approach to healing, built on the humanistic idea of understanding behavior from a non-pathologizing stance, while taking this point two steps further. First, as Salvadore Minuchen (1993) says, in contrast to his early training in individual therapy in which "We were deep-sea divers searching for motivation inside people," in working with whole families sitting together in a room, "We were suddenly unsure about the beginnings of behaviors or feelings since we could see them as responses to behavior or feelings of other family members, who were in turn responding to behaviors and feelings. We began to see all behavior as action, but aslo as reaction, a response that was also a point of departure" (p.29).
Second, the very act of having to juggle all the differing points of view, actions, and reactions of members of a family leads almost inevitably to call into question whose "reality" is the "right" one.
That is, the early family therapists noticed that when they would talk to only one member of a family, a particular incident would sound completely different than the way another family member would describe it. Not only would cause and effect become unclear, as Minuchen explains above, but truth itself would become perplexing.
As Caplan (1995) points out, "Ask ten people whether the object in the middle of your kitchen is a table and the chances are they will unaimously agree that it is. But ask ten people--even ten therapists--whether any particular person is normal and, if not, why they consider the person to be abnormal, and you will almost certainly get a large number of quite different replies" (p.34). This is because "normality is not real, like a table" (p. 34). Rather, as Edith Wyschogrod explains, normality is the result of what people think it is; it is arrived at by consensus, not objectively.
When members of a family present differing veiws of reality, it would not only be difficult for the therapist-as-outsider to choose which is the correct one, we can see that it would also be disrespectful for the therapist to believe one person in the family is "right" and the others, "wrong." Sampson (1993) stresses this point, saying, "For too long our major cultural and scientific views have been monologic and self-celebratory - focusing more on the leading protagonist and the supporting cast that he has assembled for his performances than on others as viable people in their own right. Time now to celebrate the other - not only to set the record straight but, of equal importance, to give voice, and in their own register and form, to those who have been condemned to silence" (p. ix).
We could say, then, that the family systems approach respects and gives voice to all views in the family and does not label any view as pathological. The therapist makes sense of family members' diverse views by recognizing the importance of history and context in how people develop. For example, Bradford Keeney (1983) explains, "To see a nagging husband without considering a withdrawing wife may lead to treating a 'nagger' rather than a nagging-withdrawing relationship system" (pp.37-38). Keeney's book is a tour-de-force in the science of logic as applied to clinical thinking.
For a grounding in this postmodern approach and/or its application to therapy, read also Gregory Bateson (1972); Kenneth Gergen (1991); Michael White & David Epston; Tom Andersen; Steve de Shazer; Luigi Boscolo, Gianfranco Cecchin, Lynn Hoffman, and Peggy Penn (1987); Paul Watzlawick, Janet Beavin Bavelas, and Don D. Jackson (1967); and Edith Wyschogrod (1990).
Other revolutionaries in the family therapy field are Virginia Satir <http://www.satirglobal.org/>, Murray Bowen (1988), Milton Erickson (1989), Jay Haley (1976), and Nathan Ackerman <http://www.abacon.com/famtherapy/profiles.html>.
WHERE TO WORK
Specialties also cut across clincial categories so that someone working in the corporate world could as readily be an industrial psychologist as an MFT. This is not as odd as it first seems considering that MFTs are highly familiar with how systems function. Families, after all, are systems. Thus, clinicians trained in the disciplines described above all could specialize and receive training targeted to working in:
1. school systems
2. agencies
3. hospitals
4. corporations
5. small business
6. the military
7. the legal system
8. private practice
PAYMENT METHODS
In the 1950s, therapy was the province of the weathly. They could visit the therapist several times a week for psychoanalysis, the method developed by Sigmund Freud, and pay for it out of pocket. Eventually, medical insurance carriers were willing to pick up the tab and had no strings attached. Thus, in the third quarter of the last century, psychotherapists did not have to explain to the insurer what they did to treat their patients and those patients were able to get the cost of their sessions fully covered by the insurance companies.
Thngs changed with the advent of Health Maintenance Organizations (HMOs). Because they were cost effective for employers, they had to scale back their benefits. This spawned an industry in which benefits administrators could be educated at the college-level without a background in any therapeutic discipline. They enforced company policy to limit numbers of visits and type of treatment. Clinicians found their income disappear while the quality of their work went down as well. They were compelled to spend an equal amount of time filling out paperwork for insurance companies or phoning them wanting to know why they hadn't gotten paid for therapy sessions. In compensation, they never had to advertise for clients as the insurance companies would send them a steady flow of people.
This is now changing once again with the increasing utility of the internet to reach people. Therapists who had no choice but to get reimbursement by insurance companies now have the flexibility to work independently. They may charge a high fee but use their discretion to take people in need at reduced rates in compliance with mandates to do so from the code of ethics of their professions. For the same reason, community mental health not-for-profit corporations may see an increase in usage because internet listings increase their visibility.
For these reasons, a person in need of psychotherapy services should not be put off by a high price tag or a lack of insurance. Such individuals should do a search for "free psychotherapy," or find the best therapists and ask them point blank for a price reduction. Some therapists have what is called a "sliding scale" which matches income with fee while others take a certain percentage of cases for a reduced price as a community service.
BIBLIOGRAPHY
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Andersen, T. (1991). The reflecting team: dialogues and dialogues about the dialogues. New York: Norton.
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Bateson, G. (1972). Steps to an ecology of mind. New York: Paladin Books.
Benjamin, L. (2005). A history of clinical psychology as a profession in America (and a glimpse at its future). Annual Review of Clinical Psychology, 1, 1–30.
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Sampson, E. E. (1993). Celebrating the other: A dialogic account of human nature. Boulder: Westview Press.
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Wyschogrod, E. (1990). Saints and postmodernism: Revisioning moral philosophy. Chicago: Chicago University Press.
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