302 Psychotherapy
Psychotherapy
G C Smith
Monash University, Clayton, Victoria, Australia
ã 2007 Elsevier Inc. All rights reserved.
This article is a revision of the previous edition article by
G C Smith, volume 3, pp 310–315, ã 2000, Elsevier Inc.
Introduction
Psychotherapy as an Interpersonal Process
Modification of Feelings, Cognitions, Attitudes,
and Behavior
Troublesomeness of Phenomena
The Person Seeks Help
Help Is Sought from a Trained Professional
What Is the Difference between Psychotherapy
and Education?
Stress Management
The Schools of Psychotherapy
Methods of Delivery of Psychotherapy
The Efficacy of Psychotherapy
Glossary
Counseling A professional interpersonal process that
overlaps with psychotherapy but that
has as its focus specific problems or
adjustments.
Psychoanalysis A theory of mental development embrac-
ing the concepts of the unconscious as a
determinant of behavior, the use of
defenses against the emergence of uncon-
scious tendencies, and the phenomenon
of unconscious transference of relation-
ships with past objects to present rela-
tionships.
Psychoanalytic The application of a psychotherapeutic
practice method characterized by emphasis on
free association, transference, and inter-
pretation, aimed primarily at producing
greater self-awareness.
Psychotherapy An interpersonal process designed to
bring about modifications of feelings,
cognitions, attitudes, and behavior that
have proven to be troublesome to the
person seeking help from a trained pro-
fessional.
Stress disorder A mental disorder as defined by the
International Classification of Diseases
and the Diagnostic and Statistical
Manual of the American Psychiatric
Association.
Introduction
Psychotherapy is an interpersonal process designed
to bring about modifications of feelings, cognitions,
attitudes, and behavior that have proven to be
troublesome to the person seeking help from a trained
professional. This time-honored definition, attributed
to Strupp, is a condensation of the key issues of psy-
chotherapy. A wider view of psychotherapy includes
the concept of helping a person to become his or her
best possible self. Psychotherapy is a major compo-
nent of most stress management programs and treat-
ments for stress-related disorders.
Psychotherapy as an Interpersonal
Process
That one person can influence the way another feels,
thinks, and behaves is a fundamental assumption in
most cultures. Such influence can be either good or
bad. The notion that language is involved is implicit.
Psychotherapy is a professional refinement of this
language-based interpersonal process. It usually con-
sists of a verbal exchange, but may involve writing or
dramatic performance as well.
Modification of Feelings, Cognitions,
Attitudes, and Behavior
Psychotherapy aims at the modification of existing
feelings, cognitions (thoughts), attitudes, and behav-
ior. Psychotherapy avoids the issue of whether these
phenomena are inherited or acquired, and it takes
as given that they exist and are potentially modifi-
able. Nevertheless, there is an implied recognition
that there has already been a process at work creat-
ing these phenomena, with or without the conscious
awareness of the individual. Psychoanalysis and its
derivative psychotherapies take account of the origin
of these phenomena, but focus on their current mani-
festation in the transference, that is, on what occurs
between the patient and therapist.
Troublesomeness of Phenomena
Disturbances of feelings, thoughts, and behavior are
universal experiences. Psychotherapy deals with peo-
ple who feel troubled by their experience of these
phenomena, that is, people who are stressed and dis-
tressed. They may feel it directly, for example, in the
case of depressed mood, or indirectly, for example,

when an upsurge of aggression leads to relation-
ship problems or trouble with authorities. Stressed
people are usually troubled by disturbance of their
daily function. For the physically ill, stress may be
troublesome because of its impact on their illness.
The relationship between mental and physical states
is clearest in the case of clinical depression. Having an
episode of clinical depression at some stage in life at
least doubles the risk of developing a major medical
disorder such as coronary heart disease, stroke, or
diabetes. Once these disorders develop, the presence
of depression doubles the mortality rate and greatly
increases morbidity and health-care costs, as do poor
social support and poor social integration.
The Person Seeks Help
Psychotherapy as a form of interpersonal influence
depends on and makes use of the fact that the
troubled person seeks out help. In psychotherapies
based on psychoanalytic theory, this action is central
to the concept of transference. The person seeking
help has expectations of the therapist, based on both
the realistic knowledge of what the therapist has to
offer and on unrealistic expectations transferred to
the person of the therapist on the basis of relationship
with other key figures in the person’s life. This illus-
trates the fact that there is much going on in a
psychotherapeutic relationship that is unsaid yet
represented in language at some level and experienced
as feelings and attitudes.
Help Is Sought from a Trained
Professional
What differentiates psychotherapy from other forms
of positive interpersonal influence is that it is offered
within a formal set of parameters with an explicit
basis for its conduct. That does not necessarily mean
that it is valid, but it does mean that it is open to
scrutiny. The trained professionals come from a vari-
ety of backgrounds, including medicine (particularly
psychiatry), psychology, social work, nursing, and
education. Specific training in psychotherapy is usu-
ally taken as a postgraduate course. There are insti-
tutes within the field that are devoted to training
in and the development of psychotherapy. It is this
postgraduate training that produces the skills and
attitudes that differentiates professional psychother-
apy and professional counseling from the informal
counseling that many professionals provide in their
everyday work.
Another implication of the involvement of a trained
professional is that a code of ethics applies. Such
codes are likely to include statements about respect
Psychotherapy 303
for patients or clients, their values, their beliefs, their
uniqueness, and their right to self-determination. In
particular, psychotherapists are obliged to respect
and take account of cultural factors and to avoid
discrimination on the basis of such factors and beliefs.
There is a consensus that the practice of professional
psychotherapy requires ongoing supervision of some
sort, in which there can be scrutiny of the application
of these ethical principles. Supervision also addresses
adherence to protocols. A special feature of supervi-
sion of psychoanalytic psychotherapy is that there is
also scrutiny of the therapist’s reaction to the patient –
called countertransference.
What Is the Difference between
Psychotherapy and Education?
All forms of professional psychotherapy contain an
educational component, as does counseling, even
though education is not their aim. Even psychoana-
lytic psychotherapy, which deemphasizes the didactic
component, provides a model of thinking that the
patient or client may find that they have adopted. In
the sense that psychotherapy is explanatory, it is edu-
cational. The difference between psychotherapy and
education lies in the fact that psychotherapy deals
specifically with those matters that trouble the person
requesting it and uses techniques specific to that issue.
However, it must be acknowledged that much of
modern teaching, with its individualized programs
and greater sense of responsibility for the wider con-
cerns of the student, is psychotherapeutic in nature.
Many educational institutions are recognizing this by
introducing mental health studies into their training.
This does not mean that educators will become
professional psychotherapists; that would require
postgraduate training.
Stress Management
Stress management is the name given to an interven-
tion offered increasingly and to a wide variety of
target populations, including those at risk of stress
and those who have experienced it. Often given in a
group setting, it most frequently includes specific
psychotherapy techniques but also imagery and relax-
ation techniques and an educational component.
The Schools of Psychotherapy
Psychoanalytic Psychotherapy
Professional psychotherapy has its historical roots
in the development of psychoanalysis at the end of
the nineteenth century. Psychoanalysis as a prac-
tice is a form of psychotherapy. Psychoanalytic
304 Psychotherapy
psychotherapy is a term used to describe all forms of
psychotherapy that are based on the principles of
psychoanalysis. The expressions dynamic and psy-
chodynamic can be taken as a synonym for psycho-
analytic. The distinction between psychoanalysis and
psychoanalytic psychotherapy is indistinct, but it
centers on issues of frequency, technique, and goal.
Psychoanalysis is usually more intense in frequency
and length. Psychoanalytic psychotherapy uses mod-
ified analytic techniques and may mix them with
nonanalytic techniques. Psychoanalytic psychothera-
py is often more problem-focused and may be explic-
itly supportive.
The issue of whether a form of psychotherapy is
described as supportive is a complex one. All psy-
chotherapies are supportive in the sense that they
offer a containing framework in which a patient or
client can deal with his or her stresses and lessen his or
her distress. The concept of nondirectiveness is more
pertinent. In psychoanalytic psychotherapy, interven-
tions that contain suggestions or directions are usual-
ly avoided because they may interfere with the
achievement of greater self-awareness, a major goal
of psychoanalytic practice.
As the field of psychoanalysis developed various
theoretical streams, so there developed different
schools of practice of psychoanalysis and its deriva-
tive psychotherapies. Brief dynamic psychotherapy is
associated with the names Malan, Sifneos, Strupp,
Davanloo, Mann, and Horowitz. Klein, Winicott,
Balint, and Guntrip pioneered object relationships
theory and practice. Kohut developed self-theory.
Lacan emphasized the linguistic basis of the struc-
ture of the unconscious; schools of psychoanalysis
based on his teaching have wide support in Europe
and South America. Jung, with his emphasis on
universal symbols, spawned persisting schools of
psychoanalysis.
Psychotherapies Related to Psychoanalysis
Other theorists such as Carl Rogers, Aaron Beck, and
Harry Stack Sullivan focused on aspects of the sub-
jective and cognitive experiences with which psycho-
analysis dealt. They and others developed forms of
psychotherapy based on their theories.
Experiential therapy Client- or person-centered
therapy, existential therapy, Gestalt therapy, and
emotional-expressive therapies are the most well-
known examples of experiential therapy. They have
in common the assumption that human nature is
growth-oriented, and they focus on subjective experi-
ence. For instance, client-centered therapy is described
by Rogers as having parallels in existentialism. It
emphasizes the autonomy of clients (and thus avoids
use of the term patient). It also emphasizes the attitudi-
nal qualities of the therapist; warmth, empathy, and
genuineness.
Cognitive therapy Cognitive therapy assumes that
people can develop automatic erroneous thought
patterns and beliefs of which they are unaware and
that they consequently think and behave in ways that
are irrational. Albert Ellis developed the concept of
cognitive restructuring in his rational emotive thera-
py. Beck developed a similar technique, which is the
basis for that used by therapists today, in which the
patient or client is helped to identify these automatic
thoughts and to challenge them, using what has been
described as a Socratic dialog. There are both psycho-
analytic and phenomenological underpinnings to the
therapy. Ryle has developed cognitive analytic thera-
py, which emphasizes the psychoanalytic component.
Analyses of transcripts of therapists using cognitive
therapies show that they incorporate elements of
other therapies as well. The constructs of behavioral
therapy are often so interwoven with those of cogni-
tive therapy that the term cognitive-behavioral thera-
py has come to be used. Cognitive-behavioral therapy
is a major component of stress management programs
and of interventions for acute and chronic traumatic
stress disorder. It is widely used in the treatment of
psychiatric disorders in general.
Interpersonal psychotherapy Interpersonal psycho-
therapy is an eclectic blend of traditional clinical
approaches that has its roots in the work of Sullivan
and was operationalized by Gerald Klerman and col-
leagues. It focuses on current interpersonal issues,
particularly those related to grief, interpersonal role
disputes, role transitions, and interpersonal deficits.
It is, thus, particularly suited to those experiencing
stress. It is a brief form of therapy, originally used for
the treatment of depression but now applied to many
other forms of distress. It, together with cognitive-
behavioral therapy, was found to be as effective as
antidepressant medication for the treatment of mod-
erate depression in a large study conducted by the
National Institute of Mental Health in the United
States. Psychodynamic interpersonal therapy empha-
sizes the use of psychodynamic techniques. It has been
shown to be both efficacious and effective in the
physically ill; that is, it works in practice as well as
in experiments.
Behavioral Therapy
Behavioral therapy has its roots in classical learning
theory, with which the names of Pavlov and Skinner
are associated. It is also influenced by Bandura’s
theory of socially determined learning or modeling.

Watson and Wolpe’s early clinical work has now been
refined and operationalized into a therapy that focus-
es on current determinants of behavior and draws
on the principles of learning to develop individual
treatment strategies. Behavioral therapists are aware
of the fact that they cannot avoid completely the issue
of the meaning of the behavior targeted or the mean-
ing of the relationship between the therapist and
the patient.
Methods of Delivery of Psychotherapy
Psychotherapy can be delivered at all ages, and most
types of psychotherapy are applicable to all age
groups. Melanie Klein and Anna Freud were pioneers
of child psychotherapy. There is an emerging disci-
pline of old age psychotherapy.
Individual Therapy
Individual or one-to-one psychotherapy is the com-
monest application of psychotherapy, but psychother-
apy in small groups is an important form.
Couples Psychotherapy
Couples psychotherapy, for those in a relationship, is
used by therapists of most schools of psychotherapy.
Many therapists use an eclectic approach, combining
elements of various techniques. Sexual issues are
often an important focus.
Family Psychotherapy
Family psychotherapy, or family therapy as it is now
known, has its roots in psychoanalytic theory. It
began with the work of Bateson and colleagues
in the 1950s on the role of the family in cases of
schizophrenia. Salvador Minuchin and colleagues de-
veloped techniques based on a psychoanalytic con-
struct of the family, which focused on ways in which
one member could be carrying the anxiety for the
whole family. More recently, family therapy has
been strongly influenced by systems theory. The con-
struct of family is changing rapidly, and given that
each member of a family may come with different
needs, family therapists have to adapt their technique
to the situation.
Group Psychotherapy
Group psychotherapy can be said to have originated
during World War II. Psychoanalytically orientated
psychiatrists such as Foulkes and Bion used it in
England to manage stress-related cases of neurosis
more efficiently. The concepts and techniques that
they developed are influential today. The Tavistock
Institute in the United Kingdom has pioneered models
Psychotherapy 305
of applied psychoanalysis for work groups trying
to understand their social task. Such work forms
part of stress management programs. Other schools
of psychotherapy have developed group techniques.
In the United States, Rogers extended his client-cen-
tered therapy to its application in encounter groups.
Lewin developed methods for use in nonclinical situa-
tions. Behavioral therapy (e.g., for phobias) can be
delivered in groups.
The Efficacy of Psychotherapy
Studies on the efficacy of psychotherapy for stress
disorders as defined by international classifications
are limited in number. However, the vast literature
on the efficacy of psychotherapy in general is highly
pertinent because it addresses the issue of stress by
implication. Those diagnosed as having depression or
anxiety, the most frequently addressed disorders in
the research literature, are likely to have declared
stress to be their major symptom, and this will have
been acknowledged by their clinician when translat-
ing symptoms into a named problem or disorder.
Furthermore, even when a primary diagnosis of a
stress disorder is made, it is highly likely that a simul-
taneous diagnosis of depression, anxiety, or substance
abuse will also be made. Personality disorder is an-
other common comorbidity. The diagnoses of depres-
sion and anxiety imply distress, and the seeking of
therapy certainly does so. These conditions, rather
than the stress, may be the targets of psychotherapy.
However, the exploration of perceived stressors
and their effects forms an important part of all
psychotherapies.
Overview
Health-care providers and consumers in general seek
evidence of the efficacy of psychotherapy and justifi-
cation of its cost. The empirical study of a therapy as
complex as psychotherapy, applied as it is to such a
wide range of problems and people, is fraught with
methodological difficulties. Nevertheless, these diffi-
culties have been addressed sufficiently well for
Lambert and Ogles, in their review of efficacy and
effectiveness studies, to conclude that many psy-
chotherapies have been shown to have demonstrable
effects on clients in clinical trials that are statistically
significant and clinically meaningful and that speed
up the natural healing process as well as providing
coping strategies for future use. Although some clients
may achieve meaningful results after brief psychother-
apy (21 sessions), many need at least 50 sessions.
Other conclusions were that the effects of therapy
tend to be lasting, that psychotherapy patients show
gains that surpass those resulting from placebo
306 Psychotherapy
controls or no treatment, that psychotherapy can be
cheaper than medication, and that clients treated with
psychotherapy show 25% less medical service utiliza-
tion. However, they also conclude that average posi-
tive effects mask considerable variability in outcomes,
that not all are helped, and that some are harmed by
inept or inappropriate application.
Systematic and Meta-Analytic Studies
These conclusions were based on studies conducted
over the past 80 years. Many of the earlier ones were
naturalistic studies of therapy and follow-up. Some
used qualitative research of individual cases, a tech-
nique now much refined and becoming increasingly
important in the study of human behavior and expe-
rience in general. These techniques are particularly
useful for examining the process of psychotherapy
and the experience of patients or clients. Many of
the recent studies are experimental; that is, a research
plan is developed and clients are recruited for partici-
pation and follow-up, with monitoring of therapists
as well. Systematic overviews of experimental studies
group those that meet strict criteria for inclusion,
such as the requirement of random allocation of
clients to a treatment or control arm (randomized
controlled studies, RCTs). Both qualitative and quan-
titative reanalyses may be applied. The statistical
technique of meta-analysis is often used. It has meth-
odological problems, but it is generally accepted that
it provides a useful way of summarizing studies, albe-
it one that must be supplemented by more qualitative
analyses. Early meta-analytical studies found that the
average treated person is better off than 80% of the
untreated sample (effect size of 0.85 standard devia-
tion units). Lambert and Ogles conclude that studies
since then, which include those on other large sam-
ples and a reworking of the original study and use of
more sophisticated statistical techniques, have sup-
ported that finding in general but find lower but still
clinically significant effect sizes (0.4–0.6) for both
specific and general measures of outcome. The ana-
lyses on which these conclusions are based include
studies on a wide range of therapies, including all of
the mainstream ones, for specific disorders such as
anxiety and depression and for general problems such
as those of stress and personality. A wide range of
severity of psychopathology is included. By way of
perspective, effect sizes are similar to those found
for the use of antidepressants in depression and
pharmacological treatment of anxiety.
With respect to stress and its disorders, Ehlers and
Clark conclude that systematic reviews and meta-
analyses show that, contrary to the commonly held
view, single-session individual debriefing does not
reduce distress and is not effective in preventing
posttrauma symptoms. However, a course of up to
16 psychotherapy sessions may be more effective than
supportive counseling in ameliorating the severity of
acute symptoms and reducing subsequent posttrau-
matic stress disorder (PTSD), a chronic condition.
Bradley et al., in their systematic review of psycho-
therapy for PTSD, conclude that substantial effects
are found for psychotherapeutic intervention, with
the majority of individuals showing improvement
that was clinically meaningful; this was sustained
for at least 6 months.
Which Therapy for Which Patient?
The question of which therapy is best for which client
is only slowly being resolved. Relationship factors
(trust, warmth, acceptance, and human wisdom) are
probably crucial, even in the more technical therapies
that generally ignore them. In fact, it is becoming
clear that therapists in clinical trials as well as in
practice are eclectic in their adaptation of therapy
to suit client profiles. Lambert and Ogles conclude
that differences in outcome between various forms of
therapy are not as pronounced as might have been
expected and that it is premature to favor the so-
called empirically supported therapies over others.
(This term refers to a movement that advocates that
only those therapies with proven experimental sup-
port should be taught and funded.) Courses of psy-
chotherapy may be shown to be effective in clinical
trials, but they are not as efficient in clinical practice,
partly because they are too short. Emerging natural-
istic studies show a dose–response relationship such
that long-term therapy is required, at least to the
point of complete resolution of symptoms.
As previously discussed, stress and related disor-
ders constitute risk factors for the development of
physical illness and its outcome. Some work has
been done on specific psychotherapy techniques for
patients with physical and psychological comorbidity.
Studies mainly focus on psychoeducational interven-
tions. Health education and stress management pro-
grams produce significant positive effects on blood
pressure, cholesterol, body weight, smoking behavior,
physical exercise, and eating habits. Psychotherapy
for depression in diabetes is effective in relieving
symptoms and improving control. Early trials of
psychotherapy in patients with cancer showed an
increase in both well-being and survival time. Im-
proved physical treatments for cancer and the greater
availability of psychosocial treatments may explain
why later studies are finding no differences in survival
time, despite improvement in well-being and quality
of life.

What Are the Active Ingredients of Psychotherapy?
The work of Pennebaker and his colleagues has
shown that the writing down of accounts of stressful
experiences is accompanied by better outcome than is
achieved by writing about nonemotional matters.
This supports other evidence that suggests that af-
fective experiencing – catharsis – may to be an impor-
tant ingredient of psychotherapy. Cognitive mastery,
making sense of what is happening, also seems to be
important. A focus on strategies for behavioral con-
trol is the third major factor identified so far. But
there is an enormous amount of research that needs
to be done if the active ingredients of psychotherapy
are to be dissected out and the question ‘‘Which ther-
apy for which client by which therapist and how
much of it?’’ is to be answered. Consistent with this
realization, researchers are returning to a focus on
the ingredients of psychotherapy: what the therapist
and patient actually do, and what goes on between
them. Systematic reviews and meta-analyses will help
answer the questions, but the medical model
on which they are based is insufficient to address
this most human of experiences, that of someone’s
seeking help from a trained professional and entering
an interpersonal process designed to bring about
the modifications of feelings, cognitions, attitudes,
and behavior that have proved troublesome to the
person or, indeed, an individual’s seeking greater
self-awareness as a way of fulfilling him- or herself
better in his or her personal and social commitments.
See Also the Following Articles
Cognitive Behavioral Therapy; Coping Skills; Crisis
Intervention; Defensive Behaviors; Family Therapy;
Group Therapy; Reenactment Techniques; Trauma
Group Therapy.
Further Reading
Ablon, J. S. and Jones, E. E. (2002). Validity of con-
trolled clinical trials of psychotherapy: findings from
the NIMH Treatment of Depression Collaborative
Research Program. American Journal of Psychiatry 159,
775–783.
Psychotherapy 307
Bloch, S. (1996). An introduction to the psychotherapies.
Oxford: Oxford University Press.
Bradley, R., Greene, J., Russ, E., et al. (2005). A multi-
dimensional meta-analysis of psychotherapy for PTSD.
American Journal of Psychiatry 162, 214–227.
Duffy, M. (ed.) (1999). Handbook of counseling and psy-
chotherapy with older adults New York: John Wiley.
Ehlers, A. and Clark, D. M. (2003). Early psychological
interventions for adult survivors of trauma: a review.
Biological Psychiatry 53, 817–826.
Elkin, I., Shea, M. T., Watkins, J. T., et al. (1989). National
Institute of Mental Health Treatment of Depression
Collaborative Program: general effectiveness of treat-
ments. Archives of General Psychiatry 46, 971–982.
Hollon, S. D., Thase, M. E. and Markowitz, J. C. (2002).
Treatment and prevention of depression. Psychological
Science in the Public Interest 3, 39–77.
Kazdin, A. E. (2000). Psychotherapy for children and ado-
lescents: directions for research and practice. New York:
Oxford University Press.
Lambert, M. J. and Ogles, B. M. (2004). The efficacy and
effectiveness of psychotherapy. In: Lambert, M. J. (ed.)
Bergin and Garfield’s handbook of psychotherapy and
behavior change (5th edn.), pp. 139–193. New York:
John Wiley.
Markowitz, J. C. and Weissman, M. M. (2004). Interper-
sonal psychotherapy: principles and application. World
Psychiatry 3, 136–139.
Ong, L., Linden, W. and Young, S. (2004). Stress manage-
ment. What is it? Journal of Psychosomatic Research 56,
133–137.
Reinecke, M. A. and Clarke, D. A. (eds.) (2004). Cognitive
therapy across the lifespan. Cambridge, UK: Cambridge
University Press.
Roth, A. and Fonagy, P. (2005). What works for whom?
A critical review of psychotherapy research (2nd edn.).
New York: The Guilford Press.
Sandell, R., Blomberg, J. and Lazar, A. (2002). Time mat-
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Smith, G. C. (2003). The future of consultation-liaison
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Spiegel, D. (2002). Effects of psychotherapy on cancer sur-
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(2004). The empirical status of empirically supported psy-
chotherapies: assumptions, findings, and reporting in con-
trolled clinical trials. Psychological Bulletin 130, 631–663.