Cognitive therapy was originally developed for the treatment of Depression and Anxiety. Since its early beginnings various clinicians and investigators have extended its use to a wide variety of disorders and populations. Systematic outcome studies have demonstrated its efficacy not only in the garden variety of disorders such as Depression, Anxiety and Panic but also in medical disorders such a low back pain, diabetes, chronic fatigue syndrome and chronic hypertension.
Anyone can perform brief or short-term therapy, but unless pivotal issues are addressed, the treatment will, at best, be too narrow and restricted. It is essential to employ empirically established methods whenever possible, but also to have a framework and rationale for on-the-spot inventiveness. This Invited Address will explain how to be precise and targeted while also ensuring that interactive healing processes are put into effect.
The author traces the evolution of psychodynamic theory over the past fifty years and demonstrates how various individuals and schools of thought have contributed to increasing conceptual clarity despite significant continuing differences. Along with these theoretical advances, there have been important changes in analytically-oriented therapeutic techniques.
In the early decades of the 20th century Freud's mastery of the craft of presenting a case enthroned a belief that anxiety disorders were caused by repressed emotional complexes and that recovery required the restitution of repressed ideas. This belief dominated psychotherapeutic practice, and even though little was to be seen in the way of success, any alternative was treated with scorn. Mid-century studies of experimental neuroses showed that these disturbances were the consequence of the learning of maladaptive anxiety and could be overcome by systematic counteraction by other emotions.
The major emphasis in contemporary psychoanalytic psychotherapy is on the early and consistent interpretation of the transference. A growing attention to countertransference analysis, to the risk of "indoctrinating" patients, to character analysis, to the analysis of unconscious meanings in the "here and now" also are dominant trends. Significant controversies continue regarding the importance of the "real" relationship, the therapeutic versus the resistant aspects of regression, the role of empathy, and the relation of historical to narrative truth.
For the past half-century there has been a remarkable and continual evolution in the theory and practice of psychotherapy. Now that evolution shows signs of becoming a revolution. Many elements of these changes are, as yet, only scantily represented in the literature, but they are the stuff of bull sessions, the more liberated case conferences and solitary, sometimes fearful, experimentations. This transition comes about from a variety of influences, among which three are particularly worthy of examination for what they suggest about what is likely to emerge a half-century from now.
The traditional assumption that only insight into the causes in the past can bring about a change in the present makes us blind for what Alexander & French called "the corrective emotional experience," i.e., chance events in the present that may lead to almost immediate solutions. A great number of Erickson's surprising results could be considered the outcome of "planned chance events," often in the form of behavior prescriptions similar to interventions in hypnotherapy (e.g., "speaking the clients's language," prescribing resistance, the use of reframing, paradoxical interventions, etc.).
Supervision and therapy are isomorphic processes. What supervision teaches is the process of creating change in people, and the very teaching of this process is itself an attempt to create change in the supervisee. Like families, therapists tend to confine themselves to selected segments of their possible repertory. Thus a major goal of supervision can be the expansion of the therapist's use of self.
Existential psychotherapy is more properly viewed as a therapy informed by a sensibiity to existential issues, rather than as a discrete, self-contained school of therapy. It addresses the anxiety embedded in our consciousness of the parameters of existence, especially in our confrontation with death, meaninglessness, freedom, and isolation. I shall discuss these concerns, particularly those with the greatest relevance to everyday therapy practice. I shall discuss the implications of the existential sensibility for the conduct of therapy and the therapeutic relationship. Genuineness and authenticity are necessary.
Focusing is bodily attention, not to mere sensations but to an at first unclear, implicitly complex bodily sense-of a situation, problem, or aspect of life. Therapy deepens immediately with many clients if asked what physical sense comes in the middle of the body in relation to what is being worked on. With half a minute of repeated direct attention, clients can assign a "quality-word," e.g., "heavy," "fluttery," or "tight." Then small steps come to say the crux of the problem. Each brings a slight (later large) "shift" and release, a direct sense of validity, although further steps may again change the whole problem.