What are historical approaches to psychotherapy?
The term “psychotherapy” (originally “psycho-therapy”) came into use during the late nineteenth century to describe various treatments that were believed to act on the psychic or mental aspects of a patient rather than on physical conditions. It was contrasted with physical therapies such as medications, baths, surgery, diets, rest, or mild electrical currents, which, while they produced some mental relief, did so through physical means. The origins of psychotherapy have been variously traced. Some authors call attention to the practices of primitive witch doctors, to the exorcism rites of the Catholic Church, to the rhetorical methods of Greco-Roman speakers, to the naturalistic healing practices of Hippocrates, and to the Christian practice of public (and, later, private) confession.
One of the best argued and supported views claims a direct line of development from the practice of casting out demons all the way to psychoanalysis, the most widely recognized form of psychotherapy. The casting out of demons may be seen as leading to exorcism, which in turn led to the eighteenth century mesmeric technique (named for Franz Mesmer) based on the alleged phenomenon of “animal magnetism.” This led to the practice of hypnosis as a psychological rather than a physiological phenomenon and finally to the work of Sigmund Freud, a late nineteenth century Viennese neurologist who, in his treatment of functional disorders (signs and symptoms for which no organic or physiological basis can be found), slowly moved from the practice of hypnosis to the development of psychoanalysis.
There are two histories to be sought in the early forms of treatment by psychotherapy: One is an account of the relationship between a patient and a psychological healer; the other is the story of the specific techniques that the healer employs and the reasons that he or she gives to rationalize them. The latter began as religious or spiritual techniques and became naturalized as psychological or physiological methods. The prominence of spiritual revival during the mid- to late nineteenth century in the United States led to the rise of spiritual or mental healing movements (the healing of a disorder, functional or physical, through suggestion or persuasion), as demonstrated by the Christian Science movement. Religious healing, mental healing, and psychotherapy were often intertwined in the 1890s, especially in Boston, where many of the leading spokespersons for each perspective resided.
The distinction among these viewpoints was the explanation of the cure—naturalistic versus spiritualistic—and, to a lesser degree, the role or relationship between the practitioner and the patient. A psychotherapist in the United States or Europe, whether spiritualistic or naturalistic in orientation, was an authority (of whatever special techniques) who could offer the suffering patient relief through a relationship in which the patient shared his or her deepest feelings and most secret thoughts on a regular basis. The relationship bore a resemblance to that which a priest, rabbi, or minister might have with a member of the congregation. The psychotherapeutic relationship was also a commercial one, however, since private payment for services was usually the case. Freud came to believe that transference, the projection of emotional reactions from childhood onto the therapist, was a critical aspect of the relationship.
Initially, and well into the early part of the twentieth century, psychotherapists treated patients with physical as well as functional (mental) disorders, but by the 1920s, psychotherapy had largely become a procedure addressed to mental or psychological problems. In the United States, its use rested almost exclusively with the medical profession. Psychiatrists would provide therapy, clinical psychologists would provide testing and assessment of the patient, and social workers would provide ancillary services related to the patient’s family or societal and governmental programs. Following World War II, all three of these professions began to offer psychotherapy as one of their services.
One could chart the development of psychotherapy in a simplified, time-line approach, beginning with the early use of the term by Daniel H. Tuke in Illustrations of the Influence of the Mind upon the Body in Health and Disease in 1872, followed by the first use of the term at an international conference in 1889 and the publication of Freud and Josef Breuer’s cathartic method in Studien über Hysterie (1895; Studies in Hysteria, 1950). Pierre Janet lectured on “The Chief Methods of Psychotherapeutics” in St. Louis in 1904, and psychotherapy was introduced as a heading in the index to medical literature (the Index Medicus) in 1906; at about the same time, private schools of psychotherapy began to be established. In 1909, Freud lectured on psychoanalysis at Clark University. That same year, Hugo Münsterberg published Psychotherapy. James Walsh published his Psychotherapy in 1912. During the 1920’s, the widespread introduction and medicalization of psychoanalysis in the United States occurred. Person-centered therapy was introduced by Carl R. Rogers in 1942, and behavior-oriented therapy was developed by Joseph Wolpe and B. F. Skinner in the early 1950s.
Whatever form psychotherapy may take, it nearly always is applied to the least severe forms of maladjustment and abnormal behavior—to those behaviors and feelings that are least disturbing to others. When the patient has suffered a break with reality and experiences hallucinations, delusions, paranoia, or other behaviors that are socially disruptive, physical forms of treatment are often used. The earliest examples include trephining, a Stone Age practice in which a circular hole was cut into the brain cavity, perhaps to allow the escape of evil spirits. The best-known of the Greek theories of abnormal behavior were naturalistic and physicalistic, based on the belief that deviations in levels of bile caused mental derangement. The solution was bleeding, a practice that continued until the early nineteenth century. Rest, special diets, exercise, and other undertakings that would increase or decrease the relevant bile level were also practiced.
Banishment from public places was recommended by Plato. Initially, people were restricted to their own homes. Later, religious sanctuaries took in the mentally ill, and finally private for-profit and public asylums were developed. Institutions that specialized in the housing of the mentally ill began opening during the sixteenth century. Among the best-known institutions were Bethlehem in London (which came to be known as “Bedlam”), Salpêtrière in Paris, and later St. Elizabeth’s in Washington, DC. Beyond confinement, treatments at these institutions included “whirling” chairs in which the patient would be strapped; the “tranquilizing” chair for restraining difficult patients; the straitjacket, which constrained only the arms; rest and diet therapies; and hot and cold water treatments.
By the 1930s, electroconvulsive therapy (shock therapy) was invented; it used an electric charge that induced a grand mal seizure. During the same period, the earliest lobotomy procedures were performed. These surgeries severed the connections between the brain’s frontal lobes and lower centers of emotional functioning. What separates all these and other procedures from psychotherapy is the employment of physical and chemical means for changing behavior and emotions, rather than persuasion and social influence processes.
Periodic reforms were undertaken to improve the care of patients. Philippe Pinel, in the late eighteenth century, freed many mental patients in Paris from being chained in their rooms. He provided daily exercise and frequent cleaning of their quarters. In the United States, Dorothea Dix in the mid-1800s led a campaign of reform that resulted in vast improvement in state mental hospitals. In the 1960s and 1970s, some states placed restrictions on the use of electroconvulsive therapy and lobotomies, and the federal government funded many community mental health centers in an attempt to provide treatment that would keep the patient in his or her community. Since the 1950s, many effective medications have been developed for treating depressions, anxieties, compulsions, panic attacks, and a wide variety of other disorders.
Modern textbooks of psychotherapy may describe dozens of approaches and hundreds of specific psychotherapeutic techniques. What they have in common is the attempt of a person in the role of healer or teacher to assist another person in the role of patient or client with emotionally disturbing feelings, awkward behavior, or troubling thoughts. Many contemporary therapies are derivative of Freud’s psychoanalysis. When Freud opened his practice for the treatment of functional disorders in Vienna in the spring of 1886, he initially employed the physical therapies common to his day. These included hydrotherapy, electrotherapy (a mild form of electrical stimulation), massage, rest, and a limited set of pharmaceutical agents. He was disappointed with the results, however, and reported feeling helpless.
He turned to the newly emerging procedure of hypnosis that was being developed by French physicians. Soon he was merely urging his patients to recall traumatic episodes from childhood rather than expecting them to recall such memories under hypnosis. In what he called his pressure technique, Freud would place his hand firmly on a patient’s forehead, apply pressure, and say, “you will recall.” Shortly, this became the famous method of free association, wherein the patient would recline on a couch with the instruction to say whatever came to mind. The psychoanalytic situation that Freud invented, with its feature of one person speaking freely to a passive but attentive audience about the most private and intimate aspects of his or her life, was unique in the history of Western civilization.
Psychoanalysis was not the only method of psychotherapy to emerge near the end of the nineteenth century, as an examination of a textbook published shortly after the turn of the century reveals. James Walsh, then dean and professor of functional disorders at Fordham University, published his eight-hundred-page textbook on psychotherapy in 1912. Only two pages were devoted to the new practice of psychoanalysis. For Walsh, psychotherapy was the use of mental influence to treat disease. His formulation, and that of many practitioners of his time, would encompass what today would be termed behavioral medicine. Thus, the chapters in his book are devoted to the different bodily systems, the digestive tract, cardiotherapy, gynecological psychotherapy, and skin diseases, as well as to the functional disorders.
The techniques that Walsh describes are wide-ranging. They include physical recommendations for rest and exercise, the value of hobbies as diversion, the need for regimentation, and varied baths, but it is the suggestion and treatment of the patient rather than the disease (that is, the establishment of a relationship with detailed knowledge of the patient’s life and situation) that are the principal means for the relief and the cure of symptoms. A concluding chapter in Walsh’s book compares psychotherapy with religion, with the view that considering religion simply as a curative agent lessens its meaning and worth.
In the mid-twentieth century, two new psychotherapies appeared that significantly altered the field, although one of them rejected the term, preferring to call itself behavior therapy to distinguish its method from the merely verbal or “talk” therapies. The first was found in the work of psychologist Carl R. Rogers . Rogers made three significant contributions to the development of psychotherapy. He originated nondirective or person-centered therapy, he phonographically recorded and transcribed therapy sessions, and he studied the process of therapy based on the transcripts. The development of an alternative to psychoanalysis was perhaps his most significant contribution. In the United States, psychoanalysis had become a medical specialty, practiced only by psychiatrists with advanced training. Rogers, a psychologist, created a role for psychologists and social workers as therapists. Thus, he expanded the range of professionals who could legitimately undertake the treatment of disorders through psychotherapy. The title of his most important work, Counseling and Psychotherapy: Newer Concepts in Practice (1942), suggests how other professions were to be included. In the preface to his book, Rogers indicated that he regarded these terms as synonymous. If psychologists and social workers could not practice therapy, they could counsel.
Behavior therapy describes a set of specific procedures, such as systematic desensitization and contingency management, that began to appear in the early 1950s, based on the work of Joseph Wolpe, a South African psychiatrist, Hans Eysenck, a British psychologist, and the American experimental psychologist and radical behaviorist B. F. Skinner. Wolpe’s Psychotherapy by Reciprocal Inhibition appeared in 1958 and argued that states of relaxation and self-assertion would inhibit anxiety, since the patient could not be relaxed and anxious at the same time. It was argued that these were specific techniques based on the principles of learning and behavior; hence, therapeutic benefits did not depend on the nonspecific effects of mere suggestion or placebo. Behavior therapy was regarded by its developers as the first scientific therapy.
The rise of psychotherapy in all of its forms may be explained in a variety of ways. The cultural role hypothesis argues that psychotherapists are essentially a controlling agency for the state and society. Their function is to help maintain the cultural norms and values by directly influencing persons at the individual level. This view holds that whatever psychotherapists might say, they occupy a position in the culture similar to that of authorities in educational and religious institutions. A related view argues that psychotherapy arose in Western culture to meet a deficiency in the culture itself. Such a view holds that if the culture were truly meeting the needs of its members, no therapeutic procedures would be required.
Psychotherapy has been explained as a scientific discovery, although exactly what was discovered depends on one’s viewpoint. For example, behavior therapists might hold that the fundamental principles of behavior and learning were discovered, as was their applicability to emotional and mental problems. Others might hold that nonspecific or placebo effects were discovered, or at least placed in a naturalistic context. Another explanation follows the historical work of Henri Ellenberger and views psychotherapy as a naturalization of early religious practices: exorcism transformed to hypnotism transformed to psychoanalysis. The religious demons became mental demons and, with the rise of modern psychopharmacology in the 1950s, molecular demons.
More cynical explanations view psychotherapy as a mistaken metaphor. Recalling that the word was originally written with a hyphen, they argue that it is not possible to perform therapy, a physical practice, on a mental or spiritual object. Thus, psychotherapy is a kind of hoax perpetuated by its practitioners because of a mistaken formulation. Others suggest that the correct metaphor is that of healing and hold that psychotherapy is the history of mental healing, or healing through faith, suggestion, persuasion, and other rhetorical means. Whatever one’s opinion of psychotherapy, it is both a cultural phenomenon and a specific set of practices that did not exist prior to the nineteenth century and that have had enormous influence on all aspects of American culture.
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