Forget the stereotypes. The leather couch, the bearded psychoanalyst and the Viennese accent. Forget the Woody Allen jokes about years of analysis. Forget the trendy therapies like primal scream and rebirthing. And, yes, forget the people who go for treatment supposedly because they are just bored.
Psychotherapy today is likely to take place in a sunny office with Danish modern furniture and Eames chairs. Chances are patient and therapist will sit face to face, talking on a first-name basis, discussing various problems. It's likely that therapy will be for a limited time and may even include a contract between patient and therapist regarding the length and goals of treatment.
In the 80-some years since Sigmund Freud pioneered psychoanalysis, mental health care has evolved into a sophisticated scientific art. The new psychotherapy is less dogmatic and "more ecumenical," says Bethesda clinical psychologist Morris B. Parloff. It relies less on traditional psychoanalysis and more on a combination of techniques such as behavioral treatment, biological psychiatry and cognitive therapy.
Its appearance is being shaped by evolving theories -- including the notion that unresolved mental stresses are likely to emerge as physical problems. There is also the consumer demand for shorter treatment -- a demand spurred on by rising health care costs.
And as medical dollars shrink, those who administer psychotherapy are having to justify their efforts on the bottom line. Does it work? When is it most effective and for whom? Does it matter who gives therapy -- be it a psychiatrist trained in traditional psychoanalysis or a marriage and family therapist with a master's degree in social work?
The final verdict isn't in yet, but studies suggest that "the average person who received therapy [of any kind] was better off at the end of treatment than were 85 percent of the patients who did not receive such treatment," reported Parloff, former chief of the National Institute of Mental Health's section on personality research, in a paper published in 1982 in the American Journal of Psychiatry.
But psychotherapy is not always beneficial. Up to "7 percent of those who undergo psychotherapy are actually harmed by it," estimates Dr. T. Byrum Karasu, a New York psychiatrist who heads the American Psychiatric Association's national commission on psychiatric therapy. The effects range from sexual involvement (an absolute taboo under any circumstances between therapist and patient, even if it occurs after treatment has ended) to loss of trust and confidence to what Karasu says is the most common harm that occurs -- the "establishment and habituation of unnecessary dependency on the therapist."
Despite these potential problems, research shows that the vast majority of patients are helped by treatment. The ailments that seem to respond best to psychotherapy include certain depressions, mild to moderate anxieties, fear and simple phobias, compulsions, sexual dysfunctions, marital and job problems, and reactions to adolescence, midlife and aging.
"Nearly 500 rigorously controlled studies have shown, with almost monotonous regularity, that all forms of psychological treatments -- be they psychodynamic, behavioral or cognitive -- are comparably effective in producing therapeutic benefits with particular disorders," Parloff reported in the American Journal of Psychiatry.
Since the evidence seems to show that each of the three major types of treatment works, practitioners are more and more likely to rely on an approach that combines elements of each. The result is the emergence of more "generalists," says Karasu, who has a private practice in New York. And the focus is switching from following the structure of a certain type of therapy to using whatever therapeutic techniques will meet the needs of the patient.
"The old question -- 'Is the patient suitable for analysis?' -- is being replaced by the new question: 'What [therapy] will help the patient?' " he says.
Twenty percent of Americans suffer from a mental disorder, conclude studies by the National Institute of Mental Health. But despite this great need for treatment and the impressive gains in psychotherapy, only about "one in every five people suffering from a mental problem seeks help," reports Dr. Darrel Regier, director of clinical research at NIMH. Even more surprising: Slightly greater than half of those who seek treatment are likely to go to a general physician -- not a psychiatrist -- for help.
These figures lead mental health experts to conclude that there "is a capacity problem" -- not enough psychotherapists to go around. "It would be impossible for these specialists psychiatrists to see more than about 4 to 5 percent of the population in a given year," Regier says.
Then there is the estimated 5 percent of the population who see a psychotherapist regularly but don't technically meet all the requirements for having a mental disorder (as established by the American Psychiatric Association's Diagnostic and and Statistical Manual of Mental Disorders, DSM-III, the bible of psychiatric diagnoses). Some of these people, experts say, are members of the "worried well" -- those who see a therapist primarily for self-indulgent reasons. But others probably have early symptoms of a mental illness -- not enough to classify as a full-blown case, but just enough, perhaps, to benefit from some preventive care.
"We don't know what the impact is if a person comes in early for treatment or doesn't come in at all," says Regier. "That's what we'll be able to study. We are assuming -- as with most medical disorders -- that if you can identify and treat early, you can prevent the full-blown syndrome."
The three most common mental disorders, NIMH says, are anxiety disorders, (such as phobias); substance abuse (drugs and alcohol); and affective disorders such as depression and the severe psychosis known as manic depression.
People with these mental problems are apt to experience "neurotic suffering as intense as the pain of a broken leg," contends Dr. Christ Zois, chief of the New York Center for Dynamic Short-Term Psychotherapy.
The 20 percent who choose to try to alleviate their pain can look to a plethora of treatment options. More than 400 available therapies are based on these three classic treatment categories:
*Behavioral/Cognitive. A treatment approach that emphasizes problem solving and changes in habits. Behaviorists seek to find the problem and figure possible solutions, often relying on relaxation, biofeedback, assertiveness training and other practical techniques to make alterations in life styles. They rarely probe childhood memories.
*Psychodynamic. A technique that places great emphasis on childhood events as the root of current problems. In this type of therapy, which includes classical psychoanalysis, the mental health professional serves as interpreter and reflector for the patient, helping him or her examine how present feelings relate to early influences. Therapy includes dream analysis and free association. Among the proponents of these theories were Carl Jung and Sigmund Freud.
*Experiential. An approach that encourages the therapist to interact directly with the patient. "Here" and "now" are the buzzwords in this type of therapy, which focuses on helping patients get in touch with their feelings and explore the potential for growth. Confronting and resolving problems is a part of this therapy. The experiential approach includes a wide range of treatments, from Gestalt, which stresses the awareness of physical sensations and psychological needs.
Treatment options are offered by a range of mental health specialists with varied levels of education, licensing and ability, including psychiatrists, psychologists, social workers, pastoral counselors and psychoanalysts. Most are called therapists -- a shortened version of psychotherapist, the generic name for virtually all mental health professionals.
"Psychotherapy is not in itself a profession," Parloff says. "Instead, it is an activity engaged in by members of a number of different professions."
But although these varied professionals often go by the same title, they don't all see eye to eye. There's still rivalry between various groups of psychotherapists, particularly over which form of therapy and which type of therapist can offer the best treatment.
The most severe mental health disorders -- the psychoses and schizophrenia -- are still treated predominately by psychiatrists, the mental health professionals who hold medical degrees. Psychiatrists can prescribe medicine, and often team with other mental health professionals -- such as psychologists or social workers -- to do so. They can admit patients to hospitals and perform medical evaluations.
There is "controversy about the necessity of medical training for the conduct of psychotherapy," says Dr. Richard Michels, chairman of the psychiatry department at the Payne Whitney Psychiatric Clinic in New York. "Most people in the field believe that there are excellent psychotherapists who are not physicians."
"Degrees do not make someone a psychotherapist," says Karasu. "You may be able to find a good psychotherapist who is not a psychiatrist." People who practice psychotherapy, he says, should be specifically trained in psychotherapy under expert supervision.
How good therapy is depends on two major factors: the skill of the therapist and the receptiveness of the patient.
"There are windows of therapy," says Richard Samuels, a clinical psychologist from Oradell, N.J., and former president of the independent psychologist division for the American Psychological Association. "The best times to grow psychotherapeutically are at times of life changes." This includes such mental milestones as divorce, marriage, the birth of a child or the death of a parent or spouse.
Making life changes -- be it moving or going back to school or switching careers -- "is a sign that you are ready to move forward," Samuels says. "Feeling that you are in a rut is also a good time to come into therapy."
"Motivation is a very good factor, although the wiser people go when they feel fine. Stress and tension will be motivators. Unfortunately, when people come in under those conditions, they terminate stop therapy too soon. They terminate when stress is alleviated and therefore don't get the full benefit of their therapy.
"It takes a courageous person to come into therapy. It's really the weak people who are afraid to look at themselves. You have to work hard in therapy."
But the rewards can be worth it. "You can feel more comfortable, more assured, have a better understanding, be more optimistic and have a better sense of humor," he says.
Regardless of treatment, psychotherapy isn't the answer for everything. "One of the things that people unrealistically expect is that psychiatrists are going to get rid of all suffering," says Dr. Ralph Wittenberg, who heads the Washington Psychiatric Society's public information committee. "They think if they go to a psychiatrist or a therapist that they will never have a moment's anxiety, they'll never be sad again. Life will be beautiful. They'll get the formula that will cheat death. It will make them multimillionaires.
"And of course that's unrealistic."
The type of treatment also helps dictate how someone will grow in therapy. Take traditional psychoanalysis for example.
Psychoanalysis is a "long-term process that generally takes years," says Michels. "It's intensive, generally four or five times a week, and is appropriate for only a relatively small percentage of patients in the world. It's designed to deal with whatever neurotic symptoms might be troubling someone and in addition change the overall structure of someone's character and personality."
Then there is the family systems approach, used frequently by family therapists, psychologists, social workers and psychiatrists.
"In family systems, everything is all interconnected," says Craig Evert, a Florida family therapist and president of American Association for Marriage and Family Therapy. The family therapy approach believes, he says, that there are emotional and behavioral patterns handed down through generations, just as traditions are passed from parents to children. One "problem" member of a family may be subconsciously causing trouble to take focus off a larger conflict in the family.
Diane Sollee, a social worker with the American Association of Marriage and Family Therapists, compares the delicate balance of a family to that of a mobile. "Change the weight of one thing in a mobile," she says, "and the whole system has to change."
One of the newest treatments is short-term dynamic psychotherapy. "The idea that long-term problems necessitate long-term solutions is not true," contends Dr. Christ Zois, a New York psychiatrist. "We can treat those people in a much briefer way."
The average length of treatment is 40 weeks, meeting once a week. This type of therapy often involves a contract between patient and therapist outlining the problem and how long it will take to solve. Most practitioners videotape the sessions to show the patient as part of treatment.
"Therapy is clarification," he says. "Clarifying the problem. Clarifying how one has not served oneself in one's best interest."