Applied History of Psychology/Clinical Treatment

Psychotherapy

This section does not purport to cover all types of therapies of the last 100 years. It does, however, sketch a general picture of nine significant schools of thought. In doing so, the authors admit to their biases, whether personal affection for a particular type of therapy, or experience in one form over another. The common elements between the nine schools of therapy presented below include their unrelenting force in the way psychology is practiced today. The reader should also make note of the fact that only three approaches outlined in this section originated in Europe (Freud's Psychoanalysis, Existential Therapy, and Gestalt Therapy), as opposed to the other approaches which originated in the United States. Therefore, while reading this section, ask yourself the following questions:

• How did Freud's experience as a Jewish minority in Vienna impact Psychoanalysis?
• How did Frankl's experience as a Jewish minority impact Existential Therapy and how does this contrast with Psychoanalysis?
• In what way do the American approaches differ from European approaches, and how did these differences express themselves as all nine approaches evolved into what we practice today?
• How do current cultural trends influence the ways in which these therapies are practiced today?

Psychodynamic Therapy

Freud was born in 1856 in the town of Freiberg in Moravia, which is present day Czechoslovakia, and his family relocated to Vienna in Austria, where he lived and worked most of his life (Rychlak, 1981). He earned a medical degree from the University of Vienna and established a medical practice in Vienna as a neurologist, which is a specialist in the nervous system (Rychlak, 1981). Freud was highly creative and productive during his lifetime and his collected works fill 24 volumes (Corey, 2005). A remarkable fact that was revealed from his correspondence with his friend Wilhelm Fliess is that virtually all of Freud’s theoretical ideas had been sketched during the period of 1887 through just after the turn of the twentieth century, while the most creative period of his life was shortly following his father’s death in 1896 (Rychlak, 1981). This period marked a defining moment in Freud’s life as it was during this time in his life that he developed the theory of Oedipus complex.

The death of Freud’s father seems to have increased his numerous psychosomatic disorders, his exaggerated fear of dying and other phobias that troubled Freud throughout his life (Rychlak, 1981). During that emotionally difficult period Freud began a self-analysis, using a general approach that he had worked out for the study and treatment of neuroses (Rychlak, 1981). This was a turning point for Freud in that from this self-analysis one can trace the beginning of the psychotherapy procedure now called psychoanalysis. In the process of his self-analysis, in which Freud was exploring the meaning of his own dreams and examined his childhood memories, he came to realize that during his childhood he had experienced sexual feelings for his mother, who was attractive, loving, and protective, as well as intense hostility for his father (Corey, 2005). From this experience of analyzing himself as well as from observation of his patients as they worked through their own problems in psychoanalysis, he clinically formulated his theory of Oedipus complex (Corey, 2005).

According to the theory of Oedipus complex, the mother becomes the first ‘love-object’ of the child’s sexual instinct (Freud, 1920). According to Freud (1920), the erotic nature of this attachment to the mother is established when the little boy wants to sleep with his mother at night, insists on being in the room with her while she is dressing, or even attempts physical acts of seduction. Freud (1920) writes:

It is easy to see that the little man wants his mother all to himself, finds his father in the way, and shows his dissatisfaction when the latter takes upon himself to caress her, and shows his satisfaction when the father goes away or is absent. He often expresses his feelings directly in words and promises his mother to marry her (p. 90).

During puberty, an individual must free oneself from the parents in that a son must release his libidinal desires from his mother and reconcile himself with his father or free himself from the father’s domination (Freud, 1920). Freud (1920) emphasized, however, that this task is seldom accomplished in a satisfactory manner. It should be noted that although Freud also developed a theory of the female Oedipus complex, it was argued that Freud was definitely uncertain in his theory of female sexuality, which makes psychoanalysis more of a masculine than a feminine theory of personality (Rychlak, 1981). This once again emphasizes the fact that it was his self-analysis that heavily influenced the development of his theories.

Taking into account that Freud is considered the father of modern personality theory (Rychlak, 1981) one needs to appreciate the importance of the Oedipus complex as essential for Freud’s theory of personality. Freud (1920) believed that in ‘neurotics’ the detachment from the parents, which must take place during puberty, is not accomplished at all. In other words, the son remains dominated by his father and is incapable of transferring his libido from his mother to a new sexual object, which leads to a neurosis (Freud, 1920). In this way, the Oedipus complex was argued by Freud (1920) to be “the kernel of the neuroses” (p. 91).

From this, one can see that Freud’s self-analysis of his childhood experiences was a defining moment in life work. Freud himself was aware of the extent to which his self-analysis had affected his formulation of the theory of Oedipus complex, as can be seen from his correspondence with his friend, Wilhelm Fliess. In one of his letters to Fliess, which he wrote on October 15, 1897, Freud states:

My self-analysis is in fact the most essential thing I have at present and promises to become of the greatest value to me if it reaches its end…. Being totally honest with oneself is a good exercise. A single idea of general value dawned on me. I have found, in my own case too [the phenomenon of] being in love with my mother and jealous of my father, and I now consider it a universal event in early childhood, even if not so early as in children who have been made hysterical. (Freud, quoted by Masson, 1984, p. 272).

From that excerpt it appears that despite the fact that Freud saw the connection between his self-analysis and the theory he had developed, he nevertheless considered his discoveries about himself to be universal, believing that all young boys go through the experience of being in love with their mothers and jealous of their fathers, absence of resolution of which leads to neuroses later in their lives.

In this way one can see how Freud’s life circumstances, in particular, his father’s death and his subsequent self-analysis of his dreams and his childhood memories, led to the development of the theory of Oedipus complex, which is at the heart of Freud’s formulation of ‘neurosis’. The period of his life, when in the midst of his emotional and psychosomatic difficulties following his father’s death he found the strength to engage in self-analysis, led to the development of his famous theory of personality, which is a precursor of the modern personality theory.

Client Centred Therapy

Introduction

During the 1950's and 1960's, humanistic psychology was born. Human nature had been previously conceptualized by Freud, drawing attention to the dark forces of the unconscious, and Skinner, examining the effects of reinforcement on observable behavior. Humanistic psychology was born out of attempts to understand the conscious mind, motivation, human dignity, self-reflection and the capacity for growth. Humanistic psychology became known as "the third force" as an alternative to psychoanalysis and behaviorism.

The humanistic movement was led by Carl Rogers and Abraham Maslow. Maslow theorized that all people are motivated to fulfil a hierarchy of needs. Maslow theorized that once their basic needs are met, including hunger, thirst, sleep, safety, security, love and esteem, that humans strive for self actualization, the ultimate state of personal fulfillment. Maslow explains, "I think of the self-actualizing man not as an ordinary man with something added, but rather as the ordinary man with nothing taken away" (Hoffman, 174). Rogers argued that all humans are born with a drive to achieve this "self actualization" or full capacity and that the role of therapists is to facilitate this growth.

Client-centered therapies belong within the field of humanistic psychology. Carl Rogers is known as the father of client-centered therapy. Partly in response to the psychoanalytic and behavioral schools that emphasized interpretations or manipulations, Rogers developed a non-directive therapy focused on creating a reflective space for individuals to actualize their potential. He later changed the name of this therapy to "person-centred therapy".

In a paper written by Carl Rogers (1979), he reviews briefly the central hypothesis of his person-centred therapy. He suggests that each of us has within us the resources to achieve self-understanding, as well as to alter our self-concept, our basic attitudes, and our self-directed behaviour. Rogers (1979) proposes that these resources can be tapped only within a very specific type of environment which is characterized by what he refers to as "facilitative conditions".

According to Rogers (1979), there are three conditions that facilitate this growth: 1) Genuineness/Realness/Congruence; 2) Acceptance/Caring/Unconditional Positive Regard, and 3) Empathic Understanding.

Congruence refers to the therapist being transparent to the client, and not putting up a professional front. It would involve the therapist demonstrating congruence with what they are experiencing at the gut level, what is present in their awareness, and what they are expressing to the client. According to Rogers (1979), the more the therapist demonstrates congruence within the therapeutic environment, the more the client will be likely to change and grow in a positive manner.

Unconditional Positive Regard is the second facilitative condition and involves the therapist being with the client and accepting the client throughout therapy regardless of where they are at, and what feelings they are experiencing. Rogers (1979) believes that the more the client is prized in an unconditional manner, the more the client will be likely to grow and improve.

The final facilitative condition that Rogers (1979) proposed is empathy. Empathy within therapy has been one of the most researched facilitative conditions. Empathy refers to the idea that the therapist is able to capture sensitively and accurately the meaning and personal feelings that the client is experiencing. Additionally, empathy also implies that the therapist is able to successfully relay these feelings and the meaning they hold back to the client. At the very deepest level of empathic understanding, the therapist will not only be able to clarify the meaning of things in which the client is aware, but will also be able to clarify those things that are just below the client's awareness. Rogers (1979) believed that more empathic understanding was associated with greater improvements and growth within the therapy.

Development of Client Centered Therapies

Four Waves of Rogers' Therapy

Rogers' therapy/theory has undergone many changes over time. Of importance are four main periods in time that were marked by major changes. These changes are mentioned in Corey (2005) briefly, and more fully elaborated and discussed by Zimring and Raskin (1992) and Bozarth, Zimring and Tausch (2002).

During the 1940s, Rogers developed what was known as non-directive counselling. This was in response to the traditional directive psychoanalytic approaches of the time. Below is a list of the significant contributions put forth by Rogers in the first wave of his theory:

• emphasized that the therapist create a permissive and nondirective climate.
• challenged the concept that the "counsellor knows best".
• challenged traditional procedures used by many therapists like advice, suggestion, direction, persuasion, teaching, and interpretation.
• challenged the use of diagnostic procedures as he believed that they were often inaccurate, prejudicial, and misused.
• avoided sharing information about himself, and instead focused on reflecting and clarifying the clients' verbal/nonverbal communications.
• aimed to gain insight into the feelings expressed by the client.

During the 1950s, Rogers renamed his approach to counselling client-centered therapy. There are two features to note in this change. First, of course is the concept of "client-centred". Second, and equally important, is the change from using the term "counselling" to using the term "therapy". This changes marks a shift from an advice-giving model where a person is "counselled" to take some action to a more open-ended model where the client is not counselled to do or feel anything, but rather to explore whatever they feel is of value. At this time, a very important book was published by Rogers called "Client-centered Therapy" (Rogers, 1951), which began to reflect an emphasis on the client, rather than a therapist's use of directive methods. Also of significance during this period was:

• a shift from clarification of feelings to examining instead more heavily the phenomenological world of the client.
• a strong focus on the client's internal frame of reference in order to gain an understanding of how people behave.
• a strong focus on the actualizing tendency, as the basic motivating force that leads to client change.

Beginning somewhat in the late 1950s, but extending all the way into the 1970s, Rogers began to address what have become known as the necessary and sufficient conditions of therapy. During this time, among other books, Rogers published his nationally recognized book "On Becoming a Person" (1961). Of significance during this time period was:

• his hypothesis that the facilitative conditions were related to psychotherapy improvements. This prediction triggered decades of research in psychology and related fields.
• a strong focus on becoming one's experience was introduced, which involves an openness to experience, a trust in that experience, an internal locus of evaluation, and a willingness to be in process.
• the initial expansion of Rogers' ideas to education occurred and was called student-centered teaching.

The final phase, during the 1980s and 1990s, was marked by great expansion of Rogers' ideas to many facets of life. For this reason, Rogers changed the name of his approach to person-centered therapy. This time in history was of significance because it involved:

• an expansion to education, industry, conflict resolution, administrations.
• an influence on family, health care, and cross-cultural and racial activity.
• an involvement in politics, especially the search for world peace, which led to Rogers being nominated for the Nobel Peace Prize.

To this day, many researchers continue to be influenced by the seminal work conducted by Carl Rogers. To conclude, a list is provided below of current day researchers who have at the root of their work the ideas of Rogers (see Corey, 2005, pp. 183–184).

• Virginia Axline made use of Rogers' ideas to start working with children using a model of non-directive Play Therapy.
• Eugene Gendlin developed a technique known as focusing, in order to facilitate client experiencing within therapy.
• Laura Rice initiated a technique known as systematic evocative unfolding as a way of recreating and potentially gaining a better understanding of a particular troubling experience.
• Leslie Greenberg from York University, and his colleagues, have encouraged therapists to facilitate emotional change within therapy, and have also applied his emotion focused therapy to couples and families.
• Jeanne Watson from OISE/UT has demonstrated the importance of empathy within therapy, and has encouraged making use of empathy to tap cognitive, affective, and interpersonal issues within therapy.

Key Figures

Carl Rogers

• 1902: Born in Oak Park Ill.
• 1924: BA, University of Wisconsin
• 1928: M.A., Columbia University
• 1931: Ph.D. Columbia University, Psychotherapy
• 1940: Ohio State University, Columbus, professor of psychology
• 1944: President of the American Association for Applied Psychology
• 1945: University of Chicago, Chicago Ill. Professor psychology and executive secretary of the counselling center.
• 1946: President of the American Psychological Association
• 1955: Nicholas Murray Butler Silver Medal
• 1956: First President of American Academy of Psychotherapist and special contribution award, American Psychological Association
• 1957: professor in departments of psychology and psychiatry; University of Wisconsin
• 1960: member of executive committee, University of Wisconsin
• 1962: Fellow, Center for Advanced Study in the Behavioral Sciences
• 1964: selected as humanist of the year, American Humanist Association
• 1968: honorary doctorate, Gonzaga University
• 1971: D.H.L. , University of Santa Clara
• 1972: Distinguished Professional Contribution Award from APA
• 1974: D.Sc. university of Cincinnati
• 1975: D.Ph. University of Hamburg and DS.Sc. University of Leiden
• 1978: D.Sc. Northwestern University
• 1984: Union for Experimenting Colleges and Universities, Cincinnati
• 1987: Died of heart attack, associated with surgery for a broken hip, San Diego, California

from: http://www.muskingum.edu/~psych/psycweb/history/rogers.htm (some corrections made)

Carl Rogers' most famous and influential book was On Becoming a Person

Within this book, Carl Rogers highlights some significant learnings that he had accumulated over the thousands of hours he has spent with individuals in personal distress. These particular learnings are highlighted in a chapter entitled "This is Me". Rogers (1961) reports that these learnings has significance for him (at that point in his life/career), but admits that he is in no way attempting to present these learnings as a guide for anyone else. A brief description of each learning is helpful other to gain a deeper understanding of Carl Rogers, the researcher, the clinician, and the man. Each has been directly quoted from his book "On Becoming a Person" (Rogers, 1961).

• In my relationships with persons I have found that it does not help, in the long run, to act as though I were something that I am not.
• I find I am more effective when I can listen acceptantly to myself, and can be myself.
• I have found it of enormous value when I can permit myself to understand another person.
• I have found it enriching to open channels whereby others can communicate their feelings, their private perceptual worlds, to me.
• I have found it highly rewarding when I can accept another person.
• The more I am open to the realities in me and in the other person, the less do I find myself wishing to rush into "fix things".
• I can trust my experience.
• Evaluation for others is not a guide for me.
• Experience is, for me, the highest authority.
• I enjoy the discovering of order in experience.
• The facts are friendly.
• What is most personal is most general.
• It has been my experience that persons have a basically positive direction.
• Life, at its best, is a flowing, changing, process by which nothing is fixed.

Rogers describes these learnings as incomplete, scattered, and continuously changing. He also reports that he continues to learn and relearn them, and at times forgets to apply them. However, he mentions they are all of great importance to him and have become a large part of his inner values and ways of behaving.

Another significant, but often overlooked, contribution of Rogers was his advancement of research into psychotherapy. He was one of the first people to systematically study therapy. He pioneered the use of audiotapes in therapy, feeling that one of the best ways to improve therapeutic technique was to record and listen to sessions in detail. One of his most famous statements on this front was "The facts are friendly" (Rogers, 1961, p. 25).

Cognitive and Cognitive-Behavioral Therapy

Principles

Cognitive Therapy, as developed by Beck, is a psychotherapy quite distinct from other forms such as psychoanalytic or behavioral psychotherapy because it is based on an information-processing model of human behavior and psychopathology rather than a motivational or instinctual model. However, it should be noted that numerous cognitive/cognitive-behavioral therapies (CT/CBT) have emerged since the groundbreaking work of Aaron Beck and contemporaries such as Albert Ellis, and these differ in terms of their underlying assumptions concerning the nature of reality, knowledge (what we know and are aware we know), and causal mechanisms (see, for example, Mahoney, 1988). Common features of the cognitive/cognitive-behavioral therapies include (i) a collaborative relationship between therapist and patient, (ii) an emphasis on disturbances in cognitive processes as the key factor in psychological distress, (iii) a belief that one’s own cognitive activity can be accessed, monitored and reported, (iv) beliefs that cognition affects behavior and that behavior and affect can be therapeutically changed through efforts to change cognitions, and, finally, (v) a time-limited, problem focused, psycho-educationally based format that is adapted according to the specifics of distinct disorders (Dobson & Block, 1988).

Technical Features

The process of Beck’s Cognitive Therapy (which he formulated in the early 1960s – see Beck, 1963, 1964, 1967) can be viewed in hierarchical terms (Blackburn, 1992), with the initial focus in therapy sessions placed on the observable behaviors and symptoms that brought the client to treatment (historically the purview of the behavioral approach). This leads in later sessions to an examination of the client’s automatic thoughts (conscious or pre-conscious, but quite distinct from the psychoanalyst’s concept of the subconscious), elucidation of the cognitive processes underlying these automatic thoughts, and finally therapeutic work on the core belief systems and schemata that the client holds (with these latter three conceptual levels broadly consistent with the experimental and theoretical cognitive psychology movement that was gaining momentum at the time Beck was developing his ideas).

The aim of CT is to change the client’s habitual ways of processing types of information, to reduce the client’s general bias towards particular interpretations and attributions (whether associated with depressive, phobic, or otherwise dysfunctional thoughts) and to encourage re-evaluation of the client’s basic beliefs (or ‘schemata’) regarding the self, the future, and the world. This is achieved during sessions through in-depth discussion (and a Socratic questioning style) of the client’s experiences relating to the presenting problem and the client’s subjective interpretations of these experiences. Therapeutic gains are also sought between sessions with mutually agreed upon homework assignments involving a wide range of foci and activities, from keeping ‘thought’ and ‘feeling’ diaries to conducting in vivo experiments that test the client’s problem-related beliefs. It is only really in his recent adaptation of the therapy model for personality disorders (Beck, Freeman, Davis, & Associates, 2004), with its explicit focus on childhood experiences as the ultimate source of maladaptive schemata that Cognitive Therapy reaches beyond the client’s recent and present experiences. In this adaptation for personality disorders, developmental experiences are identified as important grist for the therapeutic mill and, in this respect, it shares a broader temporal focus with that more commonly associated with psychoanalytic therapy.

The focus on cognitive mechanisms to effect behavioral change is a key difference between the cognitive-behavioral and behavioral approaches to therapy, with the latter based instead on a stimulus-response (nonmediational) model. Indeed, cognitive mediation could be considered the defining feature of cognitive-behavioral theories of psychopathology and therapy. However, revealing their common basis in behavior therapy, many CBT models rely on behavioral therapeutic techniques and behavioral assessment procedures to determine clients’ progress. They also maintain the emphasis found in behavior therapy on outcome data, seeking to (i) remedy specific predefined problems with which the client presents and (ii) empirically document the therapeutic efforts. Such features are rather less characteristic of the psychoanalytic school of therapy. It is this shared focus between behavior and cognitive-behavioral therapies that greatly facilitated the growth of the treatment evaluation literature and allowed direct contrasts between these approaches and their relative efficacy for different clinical problems. Beck’s Cognitive Therapy model is consistent with these features. Beck deliberately sought to demonstrate an empirical basis from the outset which, over forty years, has resulted in a considerable body of experimental and clinical research testing the cognitive mediational model of psychopathology (Beck, 1992, 2005; Leahy & Dowd, 2002) and the efficacy of CT/CBT (Butler, Chapman, Forman, & Beck, 2006).

The psychoeducational element also clearly distinguishes CBT from many of the other schools of psychotherapy (such as psychoanalysis, with its provision of interpretation to the client by the therapist [Blanck, 1976; Brown & Pedder, 1996], or strategic and systemic family therapies, with their use of paradoxical methods [Minuchin & Fishman, 1981; Watzlawick, Weakland, & Fisch, 1974). Beck’s Cognitive Therapy model typifies this ‘educating process’; the client receives clear explanations early on in therapy of the model and underlying rationale as well as the therapeutic techniques and processes involved. In the 1960s this marked an important shift in psychotherapy away from an expert role for the therapist (whether based on the revealing insights of the psychoanalyst or the procedural direction given by the behavioral therapist). However, it did not amount to an embrace of the equality between therapist and client inherent in the Rogerian client-(later person-) centered approach (Rogers, 1979), which did away with the expert therapist on the basis of a quite different rationale. At least implicit in the educational emphasis within CT/CBT is the aim that clients will come to understand their problem and the means through which therapy works so that they can apply this knowledge and the skills acquired during treatment in a preventative fashion later on or in the event that they experience a recurrence of their problem (e.g., Beck et al., 1979). Indeed, outcome data suggests that relapse is less common in clients assigned to Cognitive Therapy compared with those assigned to antidepressant medication (Gloaguen, Cottraux, Cucherat, & Blackburn, 1998).

Historical Context

Emerging from the behavioral approach to psychotherapy, cognitive-behavioral adaptations can be seen to have occurred through the confluence of a variety of historical factors, a number of which are worth noting here. The first was the recognition arising in the 1950s and 1960s that a nonmediational model could not account for all human behavior (see, for example, Rotter’s [1954] concepts of internal and external foci of attributions, Kelly’s [1955] psychology of personal constructs, Bandura’s [1969, 1971] work on vicarious learning, and Mischel’s [Mischel, Ebbesen, & Zeiss, 1972] on delayed gratification). The second influence of particular note was the theoretical and empirical advances being made in the 1960s and 1970s on mediational models in laboratory-based cognitive psychology (Neisser, 1967; Paivio, 1971), which invited clinical adaptations (see, for example, the work of Lazarus and his colleagues [1966, Lazarus & Alfert, 1964]). The third influence that helped usher in the ‘cognitive evolution’ in psychotherapy (Blackburn, 1992) was the negative conclusions being drawn from a growing number of scientific investigations of psychoanalytic theory and therapy efficacy (see Eysenck, 1969, 1985; Kline, 1981; Luborsky, Singer, & Luborsky, 1975; and Rachman & Wilson, 1971). This lack of empirical support caused some practitioners to turn away and develop viable alternatives, with Ellis and Beck exemplary among these.

Indeed, the final major historical influence on the emergence of cognitive-behavioral approaches to psychotherapy to be discussed here was the work of Beck (1963, 1964, 1967) and Ellis (1962, 1970). It is of historical note that although the CT/CBT movement in psychotherapy is widely known to have developed from traditional behavior therapy (Dobson & Block, 1988), it must not be overlooked that Beck and Ellis came from backgrounds in psychoanalysis. Their rejection of psychoanalysis was all the more significant because it was the prevailing paradigm at that time in mental health care among North American and European psychiatrists (although the resurgence of biological models and pharmacological treatment was quite separately assailing the dominance of psychoanalysis in psychiatry in the same period, see Shorter, 1997). It is of additional historical interest that Beck and Ellis weren’t the first notables from within psychoanalysis to break with psychoanalytic thinking and introduce prescient cognitive ideas. Alfred Adler before them had already set a precedent (see, for example, Freud’s [1914] account of Adler’s perceived apostasy), and had explicitly implicated personal representations of external reality as integral to psychopathology (Adler, 1931), portending a central tenant of Beck’s theory.

Certainly, parallels can be drawn between psychoanalysis and the psychotherapeutic approach represented by Ellis and Beck; in explaining behavior, both implicate memory, attention, and decision-making (indeed, Freud’s own early work has been viewed as an attempt to forge a cognitive neuropsychology [Pribram & Gill, 1976]). But the clinical and empirical frustrations with psychoanalysis that Beck and Ellis experienced compelled their radical departure from the motivationally based psychoanalysis of their training.

Although both Ellis and Beck were aware of the literature documenting the practice of behavior therapy (traditionally the purlieus of psychologists), their grounding in psychoanalysis would have made it very difficult for them to simply embrace behaviorism’s exclusive focus on observable behavior or to view mental activity as being beyond the reach of science. Being former psychoanalysts their interest in mental activity remained paramount. Ellis and Beck’s background in psychoanalysis would actually have provided something of an intellectual protection against metaphysical behaviorism (Mahoney, 1974). As it was, neither individual’s thinking was encumbered by the theoretical foundations of behavior therapy. Unlike cognitively inclined behaviorists (such as Goldfried & Merbaum, 1973, and Rachlin, 1974) who felt impelled to redefine behavior therapy in order to accommodate the growing body of data supporting cognitive mediation theories, Beck and Ellis owed no loyalty (and had no acquired bias) toward the principles of behavior modification. Instead, the influence of philosophers such as Epictetus (the Greek Stoic) and Spinoza (the 17th century Dutch rationalist and ethicist) can be found in Ellis’ ideas. Indeed, Epictetus’ frequently quoted statement, that “We are disturbed not be events, but by the views which we take of them”, effectively captures the fundamental premise from which CT/CBT models were to grow.

Somewhat in contrast, Beck drew more explicitly on the psychological literature (including the work of Piaget, Kelly, and, later, Bandura) and selectively adopted those elements of behavior therapy that he found helpful (particularly the emphasis on experimental methodologies to investigate theory and practice) as he developed his own model. And so with a psychoanalytic training in common that they rejected, both Beck and Ellis charted new courses as eventual grandfathers of CT/CBT by complimentary rather than commensurate intellectual pathways.

In closing this brief overview it is worth noting that, quite apart from the personal legacies that Ellis and Beck are to leave behind, the CT/CBT movement that owes a considerable debt to their pioneering efforts remains tremendously influential in the psychotherapy field. In a recent US national survey of current practice and orientation among mental health practitioners, the majority of respondents endorsed CBT (or CBT used in conjunction with other methods) as their main approach (Psychotherapy Networker, 2007). Mindfulness (which has actually been used to revise more traditional CT models with promising results – see for example, Kenny & Williams, 2007, and Teesdale, Segal, & Williams, 1995) and psychoanalytic/psychodynamic psychotherapies were among the other models that were reportedly also widely practiced. Furthermore, in recent survey concerning trends in the field anticipated by psychotherapy experts, more psychotherapists were expected to endorse a CBT orientation, rather than any other psychotherapy model, over the next decade as their main approach (Norcross, Hedges, & Prochaska, 2002). According to the same survey, behavior therapy was also expected to increase in its number of adherents but the number practicing psychoanalytic psychotherapy was predicted to drop. Given their own eschewal of psychoanalysis, it seems likely that Beck and Ellis would welcome such developments. That a significant historical influence on the emergence of CT/CBT as a school of thought and an applied practice came from within the psychoanalytic fold in the persons of the iconoclastic Ellis and Beck would make such developments almost poignant.

Key Figure

Aaron Beck was born July 18, 1921 in Providence, Rhode Island, United States, to Russian Jewish immigrants. Beck’s birth, as the youngest of five children, was into a family marked by tragedy; a brother had already died in infancy as had a sister during the influenza pandemic in 1919. One consequence of these events was that Beck’s mother was severely depressed for periods of Beck’s childhood, providing him with his first exposure to a principal focus of his future career. Beck viewed himself as a replacement child, effectively easing his mother’s sense of loss. It seems fitting that Beck’s arrival apparently served as at least a partial cure for his mother’s depression, setting him on his life’s work at a very early age.

A childhood accident in which Beck’s arm was broken and became infected represents another important episode from which we can trace Beck’s later interest in and understanding of psychopathology. Beck’s condition had been serious and his recovery in hospital was long and arduous; he developed a number of phobias and anxieties as a result and his extended absence from school led him to believe he was stupid and inept (beliefs compounded by a harsh grade one teacher who held him back). But through self-help and hard work Beck eventually overtook his age-matched peers. Weishaar (1993) quotes Beck as recalling of his ‘comeback’, “psychologically it did show some evidence that I could do things, that if I got into a hole I could dig myself out” (p. 10). His school success over the next few years illustrated for the young Beck the power of disconfirming evidence in the face of negative thoughts and beliefs about oneself, a realization that became a corner stone of his later therapy model. As well, Beck considered the anger of this teacher and his mother’s mood swings to have been instrumental in developing his pronounced sensitivity to changes in others’ moods, a skill that his students and colleagues observed many years later to be a key feature of Beck’s therapy work (although somewhat less evident in his therapy writings).

It wasn’t until conversations many years later with David Barlow (the renowned behavior therapist and anxiety specialist) and his 1985 adaptation of his therapy model for anxiety disorders and phobias that Beck fully understood the phobias (of abandonment, of blood, and of surgery) he developed following his childhood accident and convalescence. Indeed, he wrestled with these for years, attributing his entry into medicine as partly an attempt to defeat them, and using his internship experiences on rotations in surgery and internal medicine to disconfirm the beliefs that underscored these phobias. Beck drew on his first-hand experience with phobias and anxiety, and also his bouts of mild depression (funding limitations and the loss of an office on campus marked a difficult period for him in the mid-1960s) as valuable experiences from which he gained insight as he wrote his books on the causes and treatment of there disorders (the first of which was published in 1967).

Beck graduated Phi Beta Kappa from Brown University in 1942 and completed his M.D. at Yale in 1946. Although initially interested in psychiatry, Beck could not embrace the Kraeplinian approach to psychiatry, which he found to be nihilistic. Nor was he wholly comfortable with what he considered to be the soft and esoteric approach of the Psychoanalytic School of Psychotherapy. His initial rejection of the latter reveals another key characteristic of Beck that set the stage for his venture toward an innovative theory of psychopathology and psychotherapy of his own. Weishaar (1993) quotes him as recalling, “It [psychoanalysis] was nonsense. I could not see that it really fitted. I always had a kind of rebellious thing… [but] this was probably the first time I was aware of it” (p. 14). His evidence-based training in internal medicine led him instead to pursue neurology with its precision and empiricism but a required rotation back in psychiatry meant his struggles with psychoanalytic thought and therapy were only really just beginning. However, he remained in psychiatry after the required six months, slowly ‘seduced’ by the manner in which psychoanalysts had interpretations and explanations for everything and by the promise of psychoanalysis as a cure for most conditions. Beck was even supervised by Erik Erickson, the renowned German psychoanalyst, during his two-year fellowship in psychiatry at the Austin Riggs Center in Massachusetts.

Beck was board certified in psychiatry in 1953 and began teaching in psychiatry at the University of Pennsylvania Medical School in 1954. After finishing his analytic training at the Philadelphia Psychoanalytic Institute he took a post as an assistant professor of psychiatry at Penn in 1959. At that point he set about researching the empirical basis of psychoanalytic theory, with the objective of convincing ‘hard-headed psychologists’, who Beck recognized as influential but rejecting of psychoanalysis, of its scientific validity. Beck focused on the dreams of depressed patients because he believed that the psychoanalytic theories of depression were both well-developed and testable (and he had a readily available depressed population with which to work). However, using procedures from experimental psychology (learnt from colleagues in psychology such as Seymour Feshbach), the collective evidence from these studies (which was quite the contrary to the retroflected hostility, need to suffer, and seeking of failure predicted by psychoanalytic theory), led Beck to view depressed patients instead as holding distorted views of themselves and reality. His research results matched his experiences with patients in therapy. Beck has pointed to the lack of empirical support as the reason for his moving away from the motivational basis and associated structures of psychoanalytic thinking. But according to his collaborator, Ruth Greenberg, his personality, particularly the aforementioned rebelliousness, would have undermined his ability to remain within the psychoanalytic fold for very long (Weishaar, 1993). Beck erred towards his own data rather than the psychoanalytic authorities of his day. Beck also liked to be in control, Greenberg recalled, something that he would have lacked while undergoing analysis himself; it is likely no coincidence that his Cognitive Therapy explicitly involves the patient in a collaboration with the therapist and makes the patient their own authority.

As he developed Cognitive Therapy, Beck drew on the work of psychologists (such as George Kelly and Jean Piaget in his initial formulations), finding support in the advances made with the emergence of cognitive psychology in the 1970s (including the work of individuals such as Albert Bandura), and later corresponding with fellow cognitively oriented theorists and therapists including Albert Ellis and Donald Meichenbaum. But what is interesting about his break with psychoanalytic thought and therapy is just how quickly and comprehensively he formulated his alternative model of psychopathology and therapy. As he recollects, “Within a couple of years, I really laid the framework for everything that’s happened since then. There’s nothing that I’ve been associated with since 1963 the seeds of which were not in the 1962 to 1964 articles” (Weishaar, 1993, p. 21).

In coming up with Cognitive Therapy, Beck described the process as having involved, first, observing his patients and developing ways to measure his observations; second, advancing a theory to explain these observations; third, devising interventions to address them; and, fourth, designing research to confirm or disconfirm the whole enterprise. The development and use of measures in psychotherapy (among which the most well known are the Beck Depression Inventory, Beck Anxiety Inventory, and Scale for Suicide Ideation) represents one area in which Beck’s pioneering efforts made a huge and influential contribution to the field more broadly. A second area in which Beck’s contribution is clear is in evaluation research work. From the beginning, Beck emphasized the importance of empirical evaluations of therapy, with the first study of his own Cognitive Therapy published in 1977 by Beck’s close collaborator, Shaw, and a recent review of 16 meta-analyses by Beck and his colleagues appearing in 2006. A third area representing another of his major contributions is reflected in Beck’s publication in 1979 of what was, essentially, a therapist’s ‘how-to’ guide to the treatment of depression. This book was based on the early training manual and its revisions that Beck had used as he recruited and trained his team of psychiatrists and psychologists in his clinical and research endeavors. The manualization of treatment approaches has greatly facilitated the training of psychotherapists and, since Beck’s initial efforts, has become a mainstay of treatment program evaluation research today (Woody & Sanderson, 1998), affording researchers a means to introduce and monitor treatment integrity and fidelity and so discern what differences truly exist between models and approaches under scrutiny.

It should be noted, however, that Beck’s ideas and therapy weren’t the only developments that undermined the dominance of psychoanalytic thought in psychiatry. Biological models of psychopathology and pharmacological treatments were (re-)emerging in the 1960s too. Indeed, it is interesting to note that the two articles Beck published in 1963 and 1964 in the journal Archives of General Psychiatry (articles in which he first set out his theory of depression, his clinical observations and evidence in support of it, and its application to psychotherapy), appeared alongside numerous articles about the biological basis and assessment of depression (e.g., Gibbons, 1964; Kurland, 1964; Wechsler et al., 1963). Of course, Beck wasn’t alone in his desire to better understanding and treating depression but he was quite distinct from others, in that he was putting forward his ideas about the role of cognition (combining the patient’s internal experience, specifically their accessible thoughts and feelings rather than the subconscious motivations emphasized by psychoanalytic thought, with an emphasis on empiricism borrowed from behavior therapy) at a time when North American psychiatry was quite distracted by a paradigm shift that was already under-way. Unlike Beck, his fellow ‘radicals’ in psychiatry (and their articles book-ending Beck’s in the 1960s) were struggling to give nature a place back at the table, turning from phenomenology to biological models and pharmacological treatments. It is of interest that these efforts eventually ushered in the renaissance of biological psychiatry in the 1970s (Shorter, 1997), with Beck’s work appearing conspicuously more at home in the context of the cognitive revolution in psychology, which also was taking place in that period.

It seems fitting to end this selective consideration of Beck’s biography and contributions as we started, by looking back at Beck’s family. Beck faced considerable resistance to his ideas throughout his career from the psychoanalytic and behavioral schools. Despite this resistance, and his own history of various phobias and depression, Beck was evidently a strong and determined individual, able to work for many years in relative isolation (although his preference has clearly been for collaborative efforts (see, for example, some of his key publications). It is in Beck’s parents that the source of these characteristics can be clearly seen. Turning first to Beck’s mother, Lizzie Temkin, we can see the same determination and autonomy that her youngest son showed later. The premature death of Beck’s grandmother meant Lizzie, as the oldest of nine, had to assume much of the responsibility of caring for the family, and she maintained her role as matriarch throughout her life. Although three of her brothers graduated from universities, her own aspiration to be a physician went unfulfilled. But her dominant and outspoken manner must have been an inspiration of sorts to Beck in later life as he persevered to develop and disseminate his research and psychotherapy.

In Beck’s father too, Harry Beck, a printer by trade, we can see the foundations of some of Beck’s characteristics. Harry was not nearly religious enough to endear himself to Lizzie’s father when their marriage was announced. This was, in part, due to Harry’s active involvement in the socialist movement (having been an anti-Bolshevik in his native Russia). Harry was also something of an intellectual in their Rhode Island community, serving as a regular host of meetings in which politics, philosophy, and literature were discussed, and later taking courses in literature and psychology at his son’s future alta mater, Brown University. All his sons inherited their father’s intellectual curiosity; Beck is known to have wide and eclectic reading interests. As well, it is interesting to note that just as his father regularly sought feedback on his poetry from his sons, Beck went on to regularly seek feedback on his ideas and manuscripts from his colleagues and students. Most notably in the context of these comments is the fact that Harry was a free-thinker, not merely someone who unquestioningly went along with prevailing wisdom and practice, just as his youngest son proved to be years later as a pioneer in the psychotherapy field.

Brief mention must also be made both of Beck’s prolific output (he has published over 500 articles and authored or co-authored 17 books, as reported on the website for the Beck Institute for Cognitive Therapy and Research), and also the plethora of major awards Beck has received over his lifetime (41 are noted on the Beck Institute website). These serve as testament to the considerable importance of his work. Of particular note are the awards he received from the American Psychological Association, in 1989, and from the American Psychiatric Association, in 2006, but also earlier and perhaps of greater historical interest, in 1979, at a time when the American Psychoanalytic School were strongly resisting the purging of its influence in the DSM (see Bayer & Spitzer, 1985) and whose adherents would not have been welcoming of any recognition of Cognitive Therapy. Indeed, Beck is the only individual to have been honored by both Associations.

Existential Therapy

Existential therapy is described as a philosophical approach (Corey, 2001), which differs from other therapies, such as cognitive behavioral therapy which consists of well-defined techniques. Ideas and themes are the basis of existential therapy, which stresses the basic conditions of human existence such as choice, the freedom and responsibility to shape one’s life, and self-determination. Of great importance is the quality of the therapeutic relationship. The role of the therapist is to “encourage clients to explore their options for creating a meaningful existence. We can begin by recognizing that we do not have to remain passive victims of our circumstances but instead can consciously become the architect of our life” (Corey, 2001, p. 143).

The basic dimensions of human condition as viewed by existential therapy:

• The Capacity for Self-Awareness: As our self-awareness increases, the greater our possibilities for freedom. A therapeutic goal is to expand the client’s awareness by increasing his/her capacity to live fully. Either expanding or restricting consciousness is viewed as a choice. The decision to expand the consciousness is seen as necessary for human growth.
• Freedom and Responsibility: Freedom to choose among alternatives in life shapes the client’s destiny. Therefore, the client is encouraged to accept responsibility for directing his/her life.
• Striving for Identity and Relationship to Others: Examining the ways in which the client has lost touch with their identity is important. This is accomplished by examining the courage to be, experiencing aloneness, experiencing relatedness, and a generally struggling with identity.
• The Search for Meaning: Looking for significance and purpose in life is paramount. Strategies for accomplishing this is examining the problem of discarding old values (i.e., those imposed by tradition), experiencing meaninglessness, and creating new meaning.
• Anxiety as a Condition of Living: The experience of anxiety is viewed as necessary for growth and motivation to change. Anxiety is believed to arise from awareness. An aim of therapy is not to eliminate anxiety, but to encourage clients to take a stance, make a decision, or take action.
• Awareness of Death and Nonbeing: Out of awareness of death, the client is encouraged to think significantly about life and evaluate how well they are living.

Existential therapy was not created by any one person or group. Instead, in the 1940’s and 1950’s this philosophy arose out of different schools of psychology and psychiatry spontaneously throughout Europe. The focus was on understanding the unique experience of being human.

Key Figures

Viktor Frankl (1905–1997) Viktor Frankl is most famous for his book Man’s Search for Meaning, which he wrote in 1946. In German editions, his book is titled From Concentration Camp to Existentialism. He contributed largely to the field of existential psychology by creating a school of psychotherapy in Vienna and his creation of Logotherapy. He dedicated his professional life to the topic of meaning, receiving 28 honorary doctorates from universities across the world and publishing over 32 books in the course of his life time (Harvey, 1998).

He was born March 26, 1905 in Vienna. Frankl describes announcing that he planned to be a physician when he was just 3 years old. At a very early age, Frankl became interested in psychology and psychiatry and prior to graduating high school had received a publication in the International Journal of Psychoanalysis as well as engaged in multiple correspondences with Sigmund Freud (Boeree, 1998). He attended the University of Vienna, specializing in neurology and psychiatry with a specific emphasis on the areas of depression and suicide (Harvey, 1998). During the year of 1924, Frankl was appointed President of the Sozialistische Mittelschuler Osterreich which spurred him to create a counseling program for students during times in the academic year when they were to receive their grades. This counselling program was deemed very successful due to the fact that there were no Viennese student suicide occurrences during Frankl’s tenure. In 1930 Frankl received his M.D. and in 1949 he received his Ph. D., both from the University of Vienna. He became an associate professor at the University of Vienna as well as a visiting professor at various universities in the United States including Harvard and Stanford.

In 1938, when Germany took control of Austria, Frankl was banned from treating Aryan patients due to his Jewish ethnicity, forcing him to spend the next two years privately practicing neurology and psychiatry (Boeree, 1998). Two years later, in 1940, Frankl became head of the neurological department of the Rothschild Hospital, which was the only hospital for Jews in Vienna during the Nazi regime. It was here that Frankl spared the lives of many patients by making false diagnoses in order to avoid policies at the time that insisted upon the euthanizing of mentally ill individuals (Boeree, 1998).

From 1942 to 1945 Frankl was a prisoner in Nazi concentration camps at Auschwitz and Dachau. During these three years, he lost many of his family members and friends at the hands of the Nazis. Within his family, he experienced the loss of both of his parents, his brother, and his wife due to the atrocities of the concentration camps.

Frankl had begun to develop theories and existential approaches to therapy before becoming a prisoner in the concentration camps. However, this experience solidified his views and became the basis for Logotherapy. “Frankl observed and personally experienced the truths expressed by existential philosophers and writers, including the view that love is the highest goal to which humans can aspire and that our salvation is through love” (Corey, 2001, p. 141). Frankl believed that we have choices in every situation, no matter how dire. Nothing can take a person’s spiritual freedom and independence. He stated that we always have the ability to choose our attitude and the experience that makes us human is the search for meaning and purpose. These ideas became the basis of Logotherapy.

Rollo May (1909–1994) Rollo May is touted as the “principal American spokesman of European existential thinking as it is applied to psychotherapy” (Corey, 2001, p. 142). Rollo May remembered his home life as being unhappy, which lead him to his interest in psychology and counselling (Corey). He studied with Alfred Adler in Vienna and while completing his doctorate degree, he became ill. He was diagnosed with tuberculosis and as a result spent two years in a sanatorium. During this two year period, he spent much of his time reading. He became interested in trying to understand anxiety since dealing with anxiety was an issue he was experiencing at this time. He published quite a few books during his lifetime. Two of his more popular books include The Meaning of Anxiety (1950) and Love and Will (1969).

Rollo May believed that psychotherapy should be centred on the goal of discovering meaning in clients’ lives. He suggested that this be accomplished by helping clients with problems of being rather than helping them to problem-solve. May described problems of being as including learning to cope with issues such as sex and intimacy, growing old, and facing death. He suggested that higher values (e.g., contributing to the betterment of society) should be paramount in therapy. He believed that if this focus of therapy was present in all psychotherapies, this would eliminate the need for therapy.

Irving Yalom

See Group Therapy Below.

Group Therapy

Irving Yalom, 1951 -

Home: New York City

School: Interpersonal, with a psychoanalytical background - although he uses a "Here and Now Focus." Yalom may claim himself to be an existentialist as his therapy deals with "existential factors", but he does not take a phenomenonlogical approach to therapy. He was educated at Stanford University, and was strongly influenced by psychodynamic and phonomenological thinking, as well as by other mental-health professionals, such as social workers. He has been extremely influential in the practice of group psychotherapies, and has published numerous books, including "The Theory and Practice of Group Psychotherapy" (1996) and existential Psychology". Yalom has also written a book on Nietzsche

Influences: Yalom was most notably influenced by Harry Stack Sullivan who believed that pathology derives from interpersonal perceptual problems. In dealing with these problems, Yalom, unlike Sullivan, sought to work them out in a group setting, with a "Here and Now Focus". In this focus, the therapist facilitates interaction in the group, with issues taking place in the group. Members are discouraged from talking about their past issues or events occurring outside the group. When one member of the group expresses some interactional problem, they are asked to find someone within the present group who is similar to a person they would deal with in their regular lives. Conflicts and other issues are worked out, in vivo.

During this interaction, Yalom asks clients to observe themselves in the interaction. What he is attempting to create here is what he calls a Self Reflective Loop. While observing what they do "here and now", what they are feeling, saying and doing, they may learn how they really act outside the group.

In Yalom's view, the group is a microcosm of other social groups, such as families, and even society itself. In order to reinforce the effects of the group, Yalom feels that therapy should become the most important event in a client's life (i.e., temporarily, for the duration of therapy).

In Yalom's group therapies, newness and experimentation during therapeutic interactions are emphasized. Members collect feedback as they try out new behaviors.

Yalom has outlined the processes underlying his group therapies, calling them the curative factors in group therapy. These are outlined below.

The Curative Factors in Groups Therapy

• Instillation of Hope: Establishing a sense among group members that change and resolution are possible.
• Universality: The sense that group members experience similar pain and struggles.
• Imparting of information: Group members share information about recovery, strategies, resources, and behaviours (i.e., what to do).
• Altruism: The very nature of the therapy, in which group members help each other (while getting help) is reciprocal. This reciprocity gives way to feelings of altruism - which in itself has the capacity to make one feel better.
• The corrective recapitulation of the primary family group: The group environment mimics the primary family, and the group member can therefore experience what it is like to be in a more supportive environment (if his/her family experiences were negative).
• Development of socializing techniques: Therapy is a place to be with others, to listen, and to talk to others. Therefore, Yalom views that very act ov socializing to be therapeutic.
• Imitative behavior: Therapy is a place where you can try behaviors that others have found successful. This process relates to the process of altruism mentioned above, in that group members can experiment in vivo with the advice they learn from others.
• Interpersonal learning: The process of learning how to adopt and take on other perspectives - other than one's own.
• Group cohesiveness: Being a part of a group instils a sense of belonging, which a priori includes a sense of being important to each other.
• Catharsis: Therapy should be a place to vent and explore feelings and get relief from them.

In Yalom's view, two processes work together to produce change: Group Cohesiveness and Catharsis. Cohesiveness is what causes members to cathect to the group - i.e. it is what makes their feedback emotionally motivating - and thus a force of change. When a member cathects to the group, s/he is motivated to change behaviors that are unacceptable to the group. When the group matters to the individual, the individual becomes more like the group, and thus changes. Therefore, the group must become important to all the group's members if cohesiveness is to be established.

Gestalt Therapy

Gestalt therapy is an experiential therapy which focuses on awareness and integration. This therapeutic orientation was developed in the 1940's by Fritz Perls and his wife, Laura. The overall goal of the therapy is to integrate the functioning of the body and mind. This approach is described as both phenomenological and existential (Corey, 2001). The phenomenological aspect of the therapy is that is focuses on the client's perception of reality. Existential ideas are present in the belief that the client is always in process of "becoming, remaking, and rediscovering themselves" (Corey, 2001, p. 195). Gestalt therapy is widely known for its use of experiments designed by the therapist to increase their client's self-awareness.

Therapeutic Goals (Zinker, 1978):

• Move toward increased awareness of themselves
• Gradually assume ownership of their experience (as opposed to making others responsible for what they are thinking, feeling, and doing)
• Develop skills and acquire values that will allow them to satisfy their needs without violating the rights of others.
• Become more aware of all of their senses.
• Learn to accept responsibility for what they do, including accepting the consequences of their actions.
• Move from outside support toward increasing internal support.
• Be able to ask for and get help from others and be able to give to others.

The therapist works with their client while focusing on the client's use of language. Aspects of language for the therapist to focus on include It talk, You talk, Questions, Language that denies power, Listening to client’s metaphors, and Listening for language that uncovers a story.

Techniques used in gestalt therapy:

• The Internal Dialogue Exercise: In order to integrate the client’s personality, the therapist works with splits in personality function (i.e. “top dog” and “underdog”). Conflicts between the two opposing poles in the personality can be resolved by using the empty-chair technique. The goal of internal dialogue exercises is to learn to accept polarities by exploring conflicts that exist within the client.
• Making the Rounds: This technique takes part in a group setting. Each individual is required to talk to each person by confronting, risking, disclosing, experimenting with new behaviour, which ultimately results in growth and change.
• The Reversal Technique: This technique is used to access that part of the client that has previously been denied. They are asked to act in a way that is the opposite of how they normally present themselves (e.g. act in the role of an exhibitionist for those who are excessively timid).
• The Rehearsal Exercise: This involves speaking to the therapist about “rehearsals” in terms of how the client wishes to behave. The goal of this technique is to help the client gain awareness regarding how they try to meet other's expectations, gain approval, and gain approval.
• The Exaggeration Exercise: In order to become more aware of subtle cues clients are sending through body language, the client is asked to exaggerate the body language repeatedly. This results in clarifying the inner meaning of the gesture thus intensifying the feelings underlying the behaviour.
• Staying with the Feeling: During key moments when clients speak about an unpleasant feeling, they are asked to stay with that feeling. They are encouraged to explore the feeling deeper, thus gaining tolerance of dealing with unpleasant feelings and making way for growth.
• Dream Work: Dreams are not analyzed and interpreted. Instead, they are relived as if they were occurring in the present moment. The belief is that the dream is a projection and by working through this projection, the client will understand themselves better.

Key Figures

Fritz Perls (1893–1970) Fritz Perls is known as the main originator of Gestalt therapy. He was born in Berlin and graduated with an MD with a specialization in psychiatry. He was a medic for the German Army in 1916 for World War I. He began psychoanalytic training in Vienna following the war. Of note, he was supervised by Karen Horney during this time. In 1946 he emigrated to the United States and broke away from the psychoanalytic tradition. He established the New York Institute for Gestalt Therapy in 1952.

Laura Perls (1905–1990) Laura Perls was born in Pforzheim, Germany. She was a concert pianist and attended law school in addition to completing a graduate degree in Gestalt psychology. She met Fritz in 1926 and they began to collaborate together creating Gestalt therapy.

Mindfulness Based Therapy

In the last thirty years, mindfulness-based interventions have gained tremendous popularity in the fields of behavioral medicine and clinical psychology (Kabat-Zinn, 2003). The impressive body of research literature examining the efficacy of interventions focusing specifically on the development of mindfulness practices and skills continues to grow (Baer, 2003; Grossman, Niemann, Schmidt, & Walach, 2004). This section on the history of mindfulness-based therapies first tracks the roots of mindfulness through various cultures and histories. Then, a brief review of the research literature examining it's application in clinical practice and recent development is offered.

Acknowledging multiple roots

Mindfulness is presented within psychology and behavioral medicine as a secular practice with Buddhist roots (Kabat-Zinn, 2003). What are thought to be the earliest surviving records of the teachings of the Buddha are contained in the Pali Cannon (Tipitaka). These were first passed down orally until around 100BCE, when they were committed to text (Robinson, Johnson, & Bhikkhu, 2005). By 250 BCE, the text was organised in three sets of teachings: The Vinyana consists of the precepts and directions for living for the monks and nuns; the Suttas consists of the discourses given by the Buddha; and the Abhidhamma consists of seven volumes about the working of the mind and consciousness. Many traditions of Buddhism emerged as a result of differing interpretations of the Buddha’s teachings. The two most commonly known schools are the Theravada or The Way of the Elders and Mahayana or The Greater Vehicle. The first teaching of the Buddha consists in the Four Noble Truths, which focus on human experience and the liberation from suffering through awakening. 1) There is dukkha (suffering), 2) The cause of dukkha is craving, 3) To cease suffering, one relinquishes that craving, 4) The path towards cessation of suffering is the Noble Eighfold path of right view, right resolve, right speech, right action, right livelihood, right effort, right mindfulness and right concentration. It is said that the Buddha based the following 45 years of teaching upon this foundation. There are many forms of meditation practices in Buddhism. Mindfulness meditation refers to the cultivation of moment-to-moment awareness. Cultivating mindfulness allows for a recognition of the transitory nature of all experience (e.g., thoughts, emotions, sensations) and for the development of a different relationship to these experiences (e.g., instead of tensing up in response to painful sensations leading to exacerbation of pain, allowing oneself to explore these sensations).

The roots of mindfulness practice are not limited to Buddhism. It is interesting to note that there are descriptions of spiritual practices that seem very similar to mindfulness practice throughout other cultures and religions. For instance, Australian Indigenous Elder Miriam-Rose Ungunmerr-Baumann (2002) speaks of Dadirri in the following ways: What I want to talk about is a special quality of my people. I believe it is the most important. It is our most unique gift. It is perhaps the greatest gift we can give to our fellow Australians. In our language this quality is called Dadirri. Dadirri is an inner, deep listening and quiet, still awareness. Dadirri recognises the deep spring that is inside us. We call on it and it calls to us. This is the gift that Australia is thirsting for. It is something like what you call ‘contemplation’. A big part of Dadirri is listening (cited in Atkinson, 2002).

Timeline - From the East to the West

Eastern Philosophical and Religious Beginning

• 6th Century BCE: the Indian sage Kapila founded the Vedic philosophy Samkhya. This philosophy taught that we have a true self (purusha) and a false-self; the true self is free from suffering, desire, thoughts, ideas etc. and the false-self lives in this unhappy state. The purpose of these teachings was for students to delve within to realise and become aware of the root of their suffering (i.e. the ego which keeps us trapped within the false self) and to then become one with the true self(purusha).(Armstrong,2007)
• End of the 5th Century BCE: Siddharta Gotama began his inner journey and discovers the middle path. The teachings of mindfulness (sati) begin to emerge, and in fact is thought by the Buddha as a precursor of meditation. He taught that introspective exercises allowed one to see the ebb and flow of their thoughts, desires, sensations etc., and thus see their impermanence and transitory nature. (Armstrong, 2007)
• 472 BCE: Aeschylus wrote the play The Persians, which forced Athenian audiences in Dionysia to see the battle at Salamis from the Persian point of view, showing them not as the enemy but also as people in mourning. This reflected Aeschylus’s conscious attempt to bring about empathy, in other words stepping outside oneself to see things from a different perspective, which is also the essence of mindfulness.
• 420-399 BCE: Socrates was using his dialectic of rigorous dialogue to get individuals to look inward and see their mistakes. In this way they would achieve ekstasis, which is stepping outside of one self, going beyond the self, and therefore transcending normal experience.

The Transition into the West

• 1775: America Revolution occurs; sects of occult Christianity begin to emerge and the early farmers of the Declaration of Independence and the Constitution were being influenced by the teachings of mystical Sufism and Jewish Kabballah, through their involvement in groups like the Rosecrucians. (Taylor, 2005)
• 1840s to 1880s: Asian ideas began to seep into Western taught during the era of transcendentalists (American literary movement that taught the need to return to nature) Ex. Henry David Thoreau and Ralph Waldo Emerson, both of who studied Vedantic scriptures. Also during this time Helena P. Blavatsky (founder of the International Theosophical Society)is credited for bringing Hindu text into the West by translating them into English.
• 1893: The World Parliament of Religion in Chicago was a landmark event that brought eastern practitioners to the west to speak publicly for the first time about meditation.
• 1890: Sarah Farmer of Portsmouth, New Hampshire had been teaching the ideas of meditation at the Greenacre School of Comparative Religion.
• 1900: The Sacred Books of the East series, edited by F. Max Mueller, which included Pali texts on Theravada Buddhism.
• 1904: Anagarika Dharmapala lectured at Harvard on Theravada Buddhist meditation.
• 1907: Soyen Shaku toured the US teaching Zen and principles of Mahayana Buddhism.
• 1920s: American pop culture was introduced to meditation by Paramahansa Yogananda, taught Kriya Yoga and developed a very extensive curriculum or manual of the practice of meditation, also Shoma Morita of Japan developed a psychotherapy based on Zen Buddhism.
• 1924: Gurdjieff, Georgian mystic also spread meditation.
• 1940s: Krishnamurti, who fled to America with several English writers and practitioners of meditation (Aldous Huxley, Gerald Heard, Christopher Isherwood
• 1941: Henrich Zimmer, Indologist and Sanskrit scholar (friend and confidant of Carl Jung) introduced comparative mythology and folklorist to the Bollingen Foundation, also brought the young Joseph Campbell there. This foundation translated Jung’s collected works as well as books by Zimmer, which Campbell edited. The most influential book brought out was the I Ching. (Taylor, 2005)
• 1950: Was a turning point for the interest in Asian philosophy and meditation; a Stanford professor of comparative mythology, Fredrick Speilberg, opened the California Institute of Asian Studies. Allan Watts, a student of Zen and former Episcopalian minister, soon joined the faculty and from there produced Psychotherapy East and West and the Meaning of Zen. (Talyor, 2005)

Also in the 1950s Micheal Murphy first came under the influence of Speilberg and began the practice of meditation. With the assistance of Abraham Maslow, Alan Watts, and other Murphy collaborated with Richard Price to launch the Esalen Institute: a centre of theory and research on various aspects of academia. There is also a work study program, which "...is designed to explore and apply human values and potentials." It also has one of the largest accumulation of meditation articles (10,000) of these 1253 were scientific and literary studies on meditation.

Zen Buddhism, because of Watts and D.T. Suzuki was also becoming big in the states around this time.

Other factors that indirectly effected Eastern ideas coming to the West:

• The rise of Communism in China (1921) and their take over of Tibet and Mongolia (1950s), Soviet Influence in India (1960s), saw a lot of eastern spiritual teachers moving to the West.
• One of the best known and most influential of these figures in the 14th Dalai Lama of Tibet, Tenzin Gyatso, he defined mindfulness as “…a state of alertness in which the mind does not get caught up in thoughts or sensations, but lets them come and go, much like watching a river flow by.” (Gyatso, 2003).
• 1960s mind expanding drugs were being used in a lot by post war baby boomers (approx. 40 million). "This led a lot of teens and twenties to begin to explore inward perception, experiments with alternate lifestyles, and questioning of the established cultural norms." (Taylor, 2005).
• The flux of eastern spiritual teachers and the use and experimentation of psychedelic drugs worked together to create an expansion for each other. Thus in the 1960s psychedelic drugs subside and in the 1970s meditation becomes an enduring part of that generation. From this a boom in the study of eastern thought begins to take place in the west.
• 1958: ALbert Ellis introduces Rational Psychotherapy, in which he advocates the relative acceptance of symptoms, self-acceptance etc. His therapy is now called Rational Emotive Behavioural Therapy (REBT).
• 1980s-1990s: Mindfulness began to really penetrate psychotherapy in two different directions:

1. More cognitive and scientific based use of it (i.e. Ellen Langer's use of mindfulness)

2. A humanistic approach, which encourages the over all well-being of the individual (i.e. Jon Kabat-Zinn)

The ancient teachings of the eastern world have always spoken about the attainment of oneness. This can be defined as a pinnacle of spiritual achievement that permanently unites the divine essence of the adept or bodhisattva (aspirant of Buddhahood or enlightenment), to the very source of all creation, the Absolute, Tao or God. In Buddhism, this process of enlightenment or true freedom (i.e. attainment of nirvana, samadhi etc.) can only be achieved through the Bodhicitta, literally meaning the ‘enlightenment of the mind’.

“Empty your mind of all thoughts.

Let your heart be at peace.

…

return to the common source.

Returning to the source is serenity.” (excerpt from the Tao Te Ching, Chapter 16).

The mind is a central theme not just in Buddhism, but dates back to some of the earliest eastern texts of the Aryans, the Vedas. In the most infamous of these text, the Mahabharata (The Great War), Arjuna can be seen wrestling with the act of killing his kin in the 18-day war that is to unfold. At first he patiently listens to the sacred advice of Lord Krishna, but ultimately must dig deep within to understand the concept of dharmic duty. This is the essence of mindfulness, the process of turning our undivided attention and perception to the mysteries that lay within, and ultimately where we will find our answers.

In the Mahabharata, what unfolded with Arjuna was not explicitly called mindfulness. It is not until some of the early Buddhist text that we begin to see this word emerge, particularly in the Suttras(Dryden & Still, 2006). It was the Pali word (the language of the early Buddhist texts) sati that was translated into what we refer to as "mindfulness" today. There have been debates over the translation of the word sati, some translations have included "self-possession", "concentration", or "mind development" (Dryden & Still, 2006). To make matters more complicated sati is often found or linked with another Pail word, sampajanna. " Sampajanna is sometimes translated [as]‘‘awareness,’’ so sati-sampajanna becomes ‘‘mindfulness and awareness,’’as though awareness is not automatically included as part of mindfulness." (Dryden & Still, 2006, p. 19). One Buddhist monk, Nanavira Thera, distinguishes "awareness" and "mindfulness" in the following way:

"Mindfulness is general recollectedness,not being scatter-brained; whereas awareness is more precisely keeping oneself under constant observation, not letting one’s actions (or thoughts, or feelings, etc) pass unnoticed." (Dryden & Still, 2006, p. 19).

The origin of the word 'mindfulness', although not without debate, is not as obscure as the introduction to this and other eastern concepts into western thought. Eastern ideas of meditation and other forms of introspective spiritual work began to emerge in the west (mostly the United States) "...during the era of the transcendentalists, especially between the 1840s and the 1880s, largely influencing the American traditions of spiritualism, theosophy, and mental healing." (Taylor,2004,p. 1). It really took root with the writings and works of Helena P. Blavatsky, co-founder of the International Theosophical Society. She began to translate Hindu texts into English making these eastern ideas more accessible to the readers in North America.

Furthermore, some who have used mindful concepts in their work acknowledge no influence of Buddhist ideas on their work, where as others do (Still, 2005).

Current Conceptualization

Mindfulness refers to a compassionate and non-judgemental moment-to-moment awareness of one’s experience. Mindfulness is different from but related to meditation. There are various forms of meditations generally divided in two broad categories: Receptive practices and concentrative practices (Goleman, 1976). Receptive meditation practice involve widening our perceptual field to become more aware of our experiences, including bodily sensations, feelings, thoughts, and our 5-sense perceptions. Concentrative meditation practices involve focusing the attention on an object (e,g., the breath or the flame of a candle) narrowing the field of attention, in order to attain states of rapture. In practice, mindfulness training involves formal meditation exercises including both concentrative (e.g., sitting mindfulness with focus on the breath) and receptive practices (e.g., being aware of any objects that manifests within the field of one’s awareness). Another important aspect of structured mindfulness training program the program is that participants are invited to integrate their mindfulness practice into their daily lives, so that they bring the same quality of attention to their work, personal care, and relationships.

Mindfulness and Therapy

Discussion of the integration of mindfulness into psychotherapy can be found as early as the 1960s, with the well-known works Psychotherapy East and West (Watts, 1960) and Psychoanalysis and Zen Buddhism (Suzuki, Fromm & DeMarino, 1960). Mindfulness is central to Hakomi (ref), Sensori-Motor Psychotherapy (ref), Core Process Psychotherapy (ref), Dialectical Behavior Therapy (ref), as well as Acceptance and commitment therapy (ref), to name a few.

There are also programs that focus specifically on mindfulness practices, the most popular and well-researched intervention being Jon Kabat-Zinn's (1982; 1990) Mindfulness-Based Stress Reducation program (MBSR) Mindfulness-based therapies have gained tremendous popularity in the last three decades.

The traditional MBSR program involves 8 weekly 2-hour group sessions as well as a full day silent retreat. During the training, participants learn formal mindfulness exercises and are expected to set aside time for practice, 45 minutes a day, 6 days a week. The exercises are designed to help participants augment their awareness of moment-to-moment experience, including sensations, feelings, thoughts, while cultivating compassion and love. In addition to the mindfulness exercises, participants are invited by the group leader to reflect on deepening one’s mindfulness practice, so it transforms one’s way of life, can support choices that are healthier, life-enhancing choices, in particular when confronted with challenges.

The initial impetus for the development of this program was Jon Kabat-Zinn's observation that many individuals with chronic health problems were not benefiting from allopathic medicine's interventions. Kabat-Zinn suggested to a group of doctors that they refer such individuals to the stress reduction program he created and he started gathering data to examine the effects of the intervention and found long-lasting effects (Kabat-Zinn 1982; Kabat-Zinn, Lipworth, Burney, & Sellers, 1987).

The benefits of participation in MBSR has been demonstrated for a number of physical and mental health problems including cancer, chronic pain, fibromyalgia, depression, anxiety, and disordered eating (for review see Baer, 2003 and Grossman et al., 2004).

Two similar programs have been developed in recent years: Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Wellness Education (MBWE).

MBCT was designed for individuals with history of recurrent major depressive disorder. Segal, Williams and Teasdale (2001) found that participation in MBCT prevented depressive relapse.

Philosophical Underpinning

The use of mindfulness in psychotherapy was for patience to achieve self-acceptance, awareness, non-judgement of self or others, and over all mental well-being. The idea behind this is that the person implementing this type of practice would have more choice and control in everyday life.

Principle behind Ellen Langer's use of Mindfulness captures most of the aims the implementation of this type of practice hopes to achieve,

"Self-acceptance is crucial to mental health. The absence of ability to unconditionally accept oneself can lead to a variety of emotional difficulties, including uncontrolled anger and depression. The person who is caught up in self-evaluation rather than self-acceptance may also be very needy and may devote considerable attention and personal resources to self-aggrandizement in order to compensate for perceived personal deficits. One of the simplest and most natural methods of reducing self-evaluation and replacing it with acceptance is to assume a mindset of mindfulness rather than mindlessness (Langer, 1989).” (Carson & Langer, 2006)

Thus mindfulness is about achieving a flexible cognitive state that results from drawing novel distinctions about the situation and the environment. (Carson & Langer, 2006). In this context one is aware and actively engaged in the present sensitive to both context and perspective, thus always noticing new things.The hallmarks condition of mindfulness for Langer are: (1) the ability to view both objects and situations from multiple perspectives, and (2) the ability to shift perspectives depending upon context. (Carson & Langer, 2006). As opposed to mindlessness, which pigeon holes a person experience through rigid rules, regulation, prior constructions, and most importantly does not allow a person to see beyond their personal experience and see things from a alternative perspective.

Even Jon Kabat-Zinn who used mindfulness from a more Buddhist mindset, had much of Langer's aims at heart. However, Kabat-Zinn was really looking for an approach that would not only help individuals overcome pain etc., but would help them achieve overall well-being. Mindfulness meditation as used by Kabat-Zinn helped individuals to pay attention to ones thinking, to observe it and to analyse it, which was what Buddha spoke about in his original teachings. This daily practice of being mindful would then allow patience to see within and that it is a flaw in their thinking, desires, etc. that is causing their suffering.

Principles

Key Figures

Jon Kabat-Zinn

Jon Kabat-Zinn is the founder and director of the Stress Reduction Clinic at the University of Massachusetts Medical Centre (UMCC) and the executive director of the UMCC Center for Mindfulness in Medicine, Health Care, and Society. He is also an Associate Professor of Medicine in the Division of Preventive and Behavioral Medicine.

His education include a Ph.D. in molecular biology from MIT (1971). His research from 1979 to 2002 has focused on the various applications of mindfulness meditation training for people suffering from conditions caused or exacerbated by stress.

Here are some of the awards he has received:

• 1998 Art, Science, and Soul of Healing Award from the Institute for Health and Healing, California Pacific Medical Center in San Francisco
• 2001 2nd Annual Trailblazer Aware for "pioneering work in the field of integrative medicine" from the Scripps Centre of Integrative Medicine in La Jolla, California.

His work has been featured on Bill Moyer series Healing and The Mind on PBS (1993).

Jon Kabat-Zinn is a leader in a number of societies including the Society of Behavioral Medicine, the Consortium of Academic Health Centres for Integrative Medicine, and the Mind and Life Institute.

Links to other sites of interest

Center for Mindfulness at the University of Massachusetts Medical School

Emotion-Focused Therapy (EFT)

Emotion-Focused Therapy (EFT) has also shown itself to be an effective treatment for a variety of psychological issues. For example, in a study on depression, Greenberg and Paivio (1995) reported clinically meaningful, stable gains for most clients treated with process-experiential therapy (a type of EFT), and that these gains were significantly greater improvements as compared to a psychoeducational group. In addition, Nieuwenhuis and Paivio (2001) investigated a 20-session EFT applied to adults with PTSD symptoms as a result of unresolved childhood abuse issues. Clients in the treatment group were compared to a wait-list control group. EFT clients showed significantly greater improvements than wait-list controls on measures of general anxiety and PTSD symptoms, global interpersonal problems, self-affiliation, and resolution of issues with abusive others. Several other studies have also shown EFT to be effective in treating PTSD symptoms (Soulier, 1995; Clarke, 1993; Davis, Elliott & Slatick, 1998). EFT works well with clients dealing with a variety of issues because often people have not been able to develop the skills necessary to process their emotions due to past trauma and/or early attachment experiences. EFT can help increase clients’ emotional intelligence and improve their emotional processing skills so they can better regulate their emotions (Watson, 2006). Clients move towards healing and wholeness in their lives as they learn to become aware of, label, express and reflect upon their emotions so that they may move more productively towards fulfilment of their needs, values and goals (Watson, 2006).

Solution Focused Brief Therapy

Solution Focused Brief Therapy (SFBT) is a relatively new therapeutic approach that has been developed over the past 30 years. Practicing SFBT requires that the therapist not pathologize or spend much time focused on the details of their client’s problems. Instead, therapists are to ask clients to work within their own definition of what they consider healthy believing that the client inherently understands themselves and knows what is best for them. A central tenant of this therapy is that individuals always have strengths that can be mobilized to improve their quality of living.

Therapy continues for as many sessions as the client determines they need, generally consisting of two or more sessions. The therapist asks the client when they would like to return at the end of the first session and then during additional sessions the client is asked if they think it would be helpful to return for additional sessions and if so, when. Therapists are empathic and supportive while listening carefully and in a non-judgemental manner. Therapists lead from one step behind by focusing on what is important to the client.

In thinking about facilitating change, clients are viewed to fall in one of or more than one of the following categories: visitor, complainant, or customer. Change is most likely to occur at the customer level where clients take responsibility for their own impact on their problem. SFBT suggests focusing on different strategies depending which category the client falls into.

Techniques of SFBT:

• Miracle Question: The miracle question is used to help clients formulate their own goals and amplify what clients want. An example of the miracle question is as follows: “Now, I want to ask you a strange question. Suppose that while you are sleeping tonight and the entire house is quiet, a miracle happens. The miracle is that the problem which brought you here is solved. However, because you are sleeping, you don’t know that the miracle has happened. So, when you wake up tomorrow morning, what will be different that will tell you that a miracle has happened and the problem which brought you here is solved? (de Shazer, 1988, p. 5).
• Scaling Questions: Use scaling questions to help clients detail steps that will be to get them closer to their goal. The client is asked to rate on a scale of 1 to 10, with 10 representing the problem being solved and 1 representing the problem at its worst, how they are feeling each session. It is explored with them what it would take to move up one step on the scale.
• Exception Seeking Questions: Help clients to identify and increase occurrences of exceptions by asking them details regarding what they and those involved were doing when things seemed a little bit better.
• Emphasizing Strengths: helps clients to feel that they have the ability to change. Increase clients’ access to their strengths by highlighting them throughout the session and summarizing them during feedback at the end of the session.
• Amplifying Solution Talk: By focusing on solutions, rather than details about the client’s problems, the client begins to explore new possibilities. They are able to focus on what they would like to be different rather than getting lost in their problem.

Key Figures:

Steve de Shazer (1940- ) graduated in 1971 with a MSSW from the University of Wisconsin-Milwaukee. He is the co-founder and Senior Research Associate at the Brief Family Therapy Center,and is co-developer of the Solution-Focused Brief Therapy Model. He is the author of the following books: Patterns of Brief Therapy, Keys to Solutions in Brief Therapy, Clues: Investigating Solutions in Brief Therapy, and Putting Difference to Work.

Insoo Kim Berg was born in Korea. She completed her MSSW in 1969 from the University of Wisconsin-Milwaukee. She has a clinical practice and also teaches the SFBT model. She is the Executive Director of Brief Family Therapy Center in Milwaukee. She has published several books over the past decade including Tales of Solutions(2001), Building Solutions in Child Protective Services(2000), and Interviewing for Solutions (1997 and 2001, 2nd ed).

Treatment Effectiveness

Research Findings

Historically, the question of interest was whether psychotherapy/counselling worked. To date, the research has been convincing that psychotherapy does indeed work, as a number of studies have demonstrated the efficacy and effectiveness of many types of psychotherapy, including humanistic, cognitive/behavioural/cognitive-behavioural, and psychodynamic therapies (see Lambert, 2004 for a review).

This area of investigation then turned to investigate which therapies worked best. Since this line of research began, many studies have been conducted that have demonstrated that a number of different types of psychotherapy have been shown to be effective. For instance, Smith and Glass (1977) did the first meta-analysis on this topic (also the first ever "meta-analysis") which essentially found that psychotherapy was effective. The controversial part, was that they all came out equally effective, despite vastly different theoretical underpinnings.

As a result of this, many researchers have narrowed down the area of investigation to look at: what the common factors are among each of the therapies, and what processes within psychotherapy are occurring that lead to improvements.

Just to illustrate a number of variables that have been posited to have an impact on therapy effectiveness, research has demonstrated that such things as the therapeutic alliance, therapist empathy, collaboration and consensus on goals, client expectations, symptom severity, psychotherapeutic techniques, therapist competence, and cohesion in group therapy, are related to outcome (see Lambert, 2004 & Norcross, 2002 for reviews).

Many other therapist and client variables, as well as within therapy processes have been shown to impact the therapeutic environment, so interested readers are directed to read the two books cited above for further details.

Additional brief comments, including mention of earlier research placing these variables in their historical context, illustrate how psychotherapy shares in common a number of key features and characteristics, although these often originated as explicit concerns on a particular school or approach. Examples of note include the therapeutic alliance, mentioned above, and the use of homework assignments. The latter generally refers to activities or tasks that the patient undertakes between therapy sessions. The focus of a task is usually agreed during therapy and is designed so that the patient can practice or develop a skill, explore or test an idea or belief, or prepare material concerning an issue, with this work then reviewed in the next therapy session.

As Kamins (2006) notes, “More than 70 years ago, behavioral therapists recognized the value and power of utilizing extratherapeutic time to enhance the outcome of therapy sessions” (p .189). By the 1960s and 1970s, homework assignments were integral to a number of behavioral (Shelton & Ackerman, 1974) and cognitive (Beck, Rush, Shaw, & Emery, 1979) therapy models. Shelton and Levy (1981) reported that 68% of more than 500 evaluation studies published in the early 1970s that they reviewed involved the use of homework assignments. In the intervening years, homework assignments have become most strongly associated with cognitive-behavioral psychotherapies, with their emphasis on belief testing and skill building (Startup & Edmonds, 1994). However, homework is also given to patients engaged in contemporary forms of psychodynamic psychotherapy, particularly brief formats of this approach (Badgio, Halperin, & Barber, 1999; Stricker, 2006), behavior therapy (Cox, Tisdelle, & Culbert, 1988), marital and family therapies (Carr, 1997; Dattilo, 2002), and more solution-focused approaches (Beyebach, Morejon, Palenzuela, & Rodriguez-Arias, 1996). In a recent survey of over 200 New Zealand psychologists (43% of whom described their primary theoretical orientation as psychodynamic, humanistic, interpersonal, or family-systems compared with 57% who endorsed a CBT approach) homework was reported as being incorporated into therapy in 57% of sessions (Kazantzis & Deane, 1999). Indeed, many psychotherapists now appear to view homework as a key element in the process of change (Kamins, 2006).

Psychotherapy evaluation research certainly supports this view although much of this empirical basis is for CBT. A brief selection of recent findings follows. Use of homework techniques was positively related to the magnitude of the effect size in a meta-analytic review of 40 studies evaluating CBT programs (skills training, problem solving, and multimodal interventions) for anger in children and adolescents (Sukhodolsky, Kassinove, & Gorman, 2004). In a meta-analysis of 24 studies evaluating cognitive-behavioral treatment for social phobia, only the effect size for cognitive restructuring combined with within-session and homework exposure exercises was significantly larger than the placebo effect size (Taylor, 1996). Homework (whether it was assigned or not in the treatment) was also a moderator in a meta-analysis of 31 studies demonstrating positive effects for problem-solving therapy (Malouff, Thorsteinsson, & Schutte, 2007). In a CBT program for Irritable Bowel Syndrome, symptom improvement at 3 months post-treatment was associated with greater quantity and quality of homework completed (Bogalo & Moss-Morris, 2006). Finally here, Gonzalez, Schmitz, and DeLaune (2006) found that homework compliance early in a CBT program for cocaine dependence was associated with lower attrition, although overall effect of homework compliance on post-treatment cocaine use was moderated by patients’ readiness to change, which underscores the importance of considering other process variables alongside homework in psychotherapy evaluation research.

Empircally-supported/empirically-validated Treatments

In 1993 Division 12 (Clinical Psychology) of the American Psychological Association (APA) published a list of "emprically-validated" treatments for a variety of mental health issues. The term used has since been changed to "empirically-supported" treatments and continues to be a contentious issue within the psychological community.

The original report of the Task Force on Promotion and Dissemination of Psychological Procedures was intended to identify the characteristics of studies which enabled us to deem them "efficacious". The report also include a list of examples of interventions that met these criteria.

The Task Force (initially headed by Diane Chambless) originally intended this report to be used to guide future research and training programs to ensure that students were taught empirically-supported treatments in graduate training programs. The initial report caused a significant furore, with insurance companies quick to only fund those treatments listed and researchers and practitioners who practiced and/or studied treatments not on the list, gravely offended.

Two issues have dominated the discussion on the use of this list. First, is the type of research required to qualify as supported under the task force's guidelines. Second, is that certain types of therapy consistently qualify under the criteria given their research histories and styles (i.e., cognitive-behaviour therapy) while others do not (i.e., psychodynamic therapies).

The two issues are closely linked, with certain types of therapy easier to "manualize" and briefer therapies easier to follow given the shorter time span involved. The list has also become a bit of a self-fulfilling prophecy with treatments deemed efficacious eligible for more funding, while treatments which have not made the list have a harder time gaining funding in order to do the research necessary to make it on the list.

A further issue is that although there is no list of "treatments that don't work" some feel that that has indeed become the situation with treatments not on the list considered ineffective, rather than "yet to be supported".

Psychopharmacology

Psychopharmacology is a growing industry for the treatment of symptoms related to mental health issues. Although medications can only be prescribed by physicians and psychiatrists, a seemingly growing number of clients seen by psychologists and psychotherapists are taking medication while attending therapy. The four categories of psychotropic medication are briefly described as follows:

Four Groups of Psychotropic Medication:

• Anxiolytic/hypnotics: These medications are used to induce sleep, as surgical anesthesia, and for the treatment of anxiety. Common anxiolytic/hypnotics include Diazepam and Nitrazepam.
• Antipsychotics: Also called neuroleptic drugs or major tranquilizers. They are generally used in treatment for those diagnosed with psychotic disorders or schizophrenia. Common antipsychotics include Chlorpromazine, Thioridazine and Risperidone.
• Mood Stabilizers: They are generally used in treatment for those diagnosed with a mood disorder, such as bipolar disorder. Common mood stabilizers include Lithium Carbonate and Carbamazepine.
• Antidepressants: Also called Selective Serotonin Reuptake Inhibitors (SSRI). Antidepressants are used in the treatment of clinical depression. Common Antidepressants include Fluoxetine (Prozac) and Sertraline (Zoloft).