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Similarities and differences between the schools of psychotherapy

Billy Larsson Department of Psychology, Gteborg University, Sweden

In empirical research about psychotherapy it is usual to discuss similarities and differences between the schools of psychotherapy. It is more uncommon to analyze the historical roots for these discussions. This overview describes the subject of similarities and differences between the most common orientations in psychotherapy from a number of perspectives. First there is a discussion about how the founders of different psychotherapy schools have argued about this theme. Then the issue of how those questions have been analyzed by more recent clinicians is brought up. Finally a survey of this area based on empirical research is presented. An important conclusion is that the founders of psychotherapy have seen more similarities with other orientations than is usually acknowledged. Another conclusion is that the similarities between different schools of psychotherapy have increased, so in the future those different orientations will be replaced by a more common science of psychotherapy.

A common opinion about psychology is that psychology is new as a science, but old as a subject (Thomson, 1968, Leahey, 2001). This view entails that before the appearance of psychology with scientific demands, we already had two kinds of psychological theories: philosophical theories and theories embedded in folk-psychology. Although the word psychology appeared in the 1600s, folk-psychology is supposed to be at least as old as homo sapiens which is about 100 000 years old (Leahey, 2001). Psychology as a science on the other hand appeared in the late nineteenth century, with the scientific demands from experimental psychology and Freudian psychoanalysis.

The same dual phenomenon is probably true for psychotherapy. The term psychotherapy appeared at the end of the nineteenth century and was used for the first time in 1887 (Leahey, 2001) when a psychotherapeutic clinic was founded in Amsterdam, and the term was rapidly adopted by both writers and the public (Ellenberger, 1970). Nevertheless, psychotherapy as an activity seems to be very old. According to Enri Ellenberger (1974), primitive healing has its roots in prehistoric times, with a direct continuity from exorcism to magnetism, from magnetism to hypnosis and from hypnosis to newer dynamic therapies. Ellenberger also thinks that the oldest known representation of a healer is a picture in a cave in France, believed to have been painted about 15,000 B.C., but based on findings from more recently discovered caves,

No 1:36, 2 shamanism is now thought to have been depicted more than 30,000 years ago (Berg, 2005). Moreover, Jerome Frank (Frank & Frank, 1991) claims that the fundamental ingredients have been the same for all kinds of psychotherapy, irrespective of whether the psychotherapy is old or contemporary, and irrespective of whether the healer is called a shaman, priest or a scientifically educated psychotherapist.

Although psychotherapy has a long history, the history of professional psychotherapy in Sweden is rather short. Admittedly, Freuds psychoanalysis was introduced for Swedish physicians by Poul Bjerre as early as 1911, and a Finnish-Swedish psychoanalytical society was constituted 1934 (Johansson, 1999). Behavior therapy was introduced in the late 1960s and a behavior therapy association was founded in 1971 (st, 1996). Cognitive therapy was introduced in the early 1980s and a Swedish association for cognitive therapy was established in 1986 (Trneke, 2005). So during a large part of the twentieth century, Sweden only had a few hundred people working with psychotherapy, but since the 1980s this has changed dramatically.

The first Swedish education in psychotherapy at a university level started in 1978 (st, 1996), and in many professions working with people, such as psychologists, psychiatrists, priests and nurses, it became possible to have some basic training in psychotherapy. Since 1985/86 for those with this basic training, further training is available on a half-time basis for three years, which gives a certification qualification as a psychotherapist from the National Board of Health and Welfare. In 1991 there were 1 602 registered psychotherapists, in 1995 Sweden had 2 610 certified psychotherapists (Socialstyrelsen, 1996), and 2004 there were 4 517 registered psychotherapists (Westling, 2004). When this new psychotherapist education started, the training was totally dominated by psychoanalytically oriented therapy (Socialstyrelsen, 1990), but this changed rather soon. Now there are study programs with various approaches to psychotherapy, so the psychotherapist who wants to work with adults usually gets a certification with a special theoretical angle, such as psychodynamic, cognitive, or cognitive-behavior psychotherapist. This dividing up of the psychotherapists in different directions brings up the question of what the similarities and differences between the psychotherapy schools are, and utmost if this division is valuable, or if it exaggerates the differences and underestimates what psychotherapists have in common. These questions have not been the subject of research in Sweden, although some attempts in this direction have been made by Sandell and coworkers (2002, 2004). This subject area - similarities and differences between psychodynamic, cogni-

No 1:36, 3 tive, cognitive-behavioral and integrative/eclectic psychotherapists and concerning psychotherapists working with adults in individual psychotherapy, is now a research project at Gteborg University. In the international literature questions about similarities and differences between psychotherapy orientations have been given attention for both theoretical and empirical reasons. However, it is unusual to have a historical background regarding what the founders of the psychotherapy schools have thought about those questions, which has as a consequence an insufficient understanding of the historical roots for the recent discussion. The present study will therefore give the reader both a historical background to the recent research and an overview of this research.

More specifically, the aim is to give an overview of the similarities and differences between the most common psychotherapy schools. Three topics will be illuminated: (1) which ingredients are supposed to make psychotherapy effective, (2) are those proposed effective ingredients used in just one or also in other schools of psychotherapy, and finally, (3) the occurrence of theoretical differences is too obvious to be noticed, but theoretical similarities will be observed.

In the first part there will be a presentation of what the pioneers of the different psychotherapy schools have thought about the questions above. The next part is about what contemporary clinicians believe in the same areas. Finally, there will be a review of what scientific research has shown about what unites and what separates the different psychotherapy schools.

The founders
Psychodynamic therapy - Sigmund Freud Sigmund Freud regarded himself as a scientist who not only developed many theories, but also founded scientific psychotherapy. The view that Freud was a scientist was often criticized at the end of the twentieth century (Cioffi, 1998, Esterson, 1993, Webster, 1995), but Freuds own opinion will not be questioned here, because irrespective of whether Freuds work meets scientific standards or not, he laid the foundation for modern psychotherapy. Psychoanalysis has been made famous as the talking cure, although this quotation is ascribed to the patient Anna O, who was treated not by Freud himself, but by his colleague Joseph Breuer (Breuer & Freud, 1895). A talking cure was of course not something new as a psychotherapeutic tool viewed in a longer historical perspective, but in the early history of psychoanalysis

No 1:36, 4 somatic treatments were so popular, that Freuds proclamation of this special form of treatment was interesting news.

Freud described similarities and differences between psychoanalysis and other treatments in On Psychotherapy (1905), and returned to the subject in Introductory Lectures on PsychoAnalysis (1917). He recognized that psychotherapy had a long history, let me remind you that psychotherapy is in no way a modern method of treatment. On the contrary, it is the most ancient form of therapy in medicine. (1905, p. 258).

According to Freud, the reason why old forms of psychotherapy as well as Freuds new scientific psychotherapy could be effective was a common factor between them, namely the relationship to the physician. Freud emphasized that this relation has as a consequence that all physicians continually practice psychotherapy even when you have no intension of doing so and are not aware of it (Freud, 1905, p. 258). Freud emphasized this further in his remark concerning psychoneuroses in particular It is not a modern dictum but an old saying of physicians that these diseases are not cured by the drug but by the physician, that is, by the personality of the physician, inasmuch as through it he exerts mental influence. (1905, p. 259). Freud goes as far as to maintain that it is a justifiable endeavor of the physician to obtain command of this factor and to use and strengthen it, and This and nothing else is what scientific psychotherapy proposes. (1905, p. 259).

Freud valued different kinds of psychotherapy mainly because of the influence by Hippolyte Bernheim and the Nancy School (Ellenberger, 1970). Freud (1917) described those treatments as suggestive therapies, which were often hypnotic, and recognized that they could be effective. However, psychoanalysis, according to Freud, was different. He used the simile that suggestive therapies act like a cosmetic, while psychoanalysis is like surgery. In contrast to the mere suggestive therapies, psychoanalysis could overcome the resistance of the patient, and then get close to what had really happened to the patient. This was possible because of the transference from the patient to the psychoanalyst. Because of this difference between psychoanalysis and earlier treatments, Freud regarded psychoanalytic treatment as more effective than the mere suggestive psychotherapies and furthermore, maintained that psychoanalysis had a lasting effect.

No 1:36, 5 However, Freud saw positive similarities only when he made comparisons to older forms of treatments. When he made comparisons with other treatments like those developed by persons such as Jung and Adler, he emphasized the differences (Freud, 1918). This is presumably a consequence of the fact that those treatments were developed by persons who first admired Freud, and then become critical of Freuds theories and therapies. During Freuds lifetime behaviorism was a kind of academic psychology and seldom a kind of psychotherapy, so comparisons with behaviorism were not particularly appropriate. Regarding theories, Freud was interested in science, but the theories he referred to were mostly those theories which he had acquired during the ninetieth century and his education years, like evolutionary theories and sexology (Sulloway, 1979). Concerning contemporary academic psychology during the twentieth century, it seems that Freud was not particularly interested. Instead he preferred to develop his own theories in many areas.

The conclusions from this are that Freud maintained that: (1) different forms of psychotherapy could be effective, (2) the common factor behind this is the relation between the therapist and the patient, (3) psychoanalytic therapy differs from other forms of psychotherapy, because it includes the transference from the patient towards the therapist, and this transference enables psychoanalysis to get a better result than other forms of psychotherapy, (4) regarding theories Freud was keen on developing his own kind of theoretical system.

Behavior therapy B. F. Skinner and Joseph Wolpe Behavior therapy has its roots in the behaviorism of Watson and Skinner, though neither of them worked as clinicians. However, at a time when psychoanalysis was the major approach to psychotherapy, Skinner wrote about psychotherapy (1953). Skinners main interest was to show how psychoanalytic theories could be drafted in the terminology he had developed, although he also presented critical views on psychoanalysis. In particular, Skinner was interested in applying his theory to psychoanalytic therapy. According to Skinner, the patients difficulties resulted from punishment. The therapist, therefore, constitutes himself as a nonpunishing audience and does not criticize his patient in any way. If the patent criticizes the therapist he avoids any signs of counteraggression. As the therapist establishes himself as a nonpunishing audience, behavior that has hitherto been repressed begins to appear in the repertoire of the patient. This behavior which was previously punished can now disappear by extinction, and the patient will then feel less wrong, less guilty or less sinful.

No 1:36, 6 Skinner was also of the opinion that some positive effect came from the patients expectations of a relief from an aversive condition. Although Skinner had psychoanalysis in mind when he wrote about psychotherapy, the view Skinner presents is so general that it could also be valid for other psychotherapies.

From Watsons time to the 1950s a large number of behavioral principles were identified in the laboratories where behaviorism was developed. However, it was not until the late 1950s and early 1960s that those basic theories were explored with regard to their therapeutic applications. The people who first did this sometimes called themselves behavior modifiers. Soon, however one of Skinners students settled on the term behavior therapy, and a rapid development of this kind of psychotherapy ensued (Douger & Hayes, 2000). One of the earliest clinical books from this time, and the most influential, is Joseph Wolpes Psychotherapy by reciprocal inhibition (Wolpe, 1958).

Wolpe wanted to explain what reciprocal inhibition is, which he claimed has a central role in psychotherapy. Nonetheless, Wolpe acknowledged that cures from neuroses can be obtained by all kind of therapists, and he reviewed research evidence for this opinion. For that reason Wolpe drew the conclusion that the various procedures different therapists regard as vital to success are not vital at all; the effective factor must be something common to all therapeutic situations. The only common feature, according to Wolpe, is that the patient confidentially reveals and talks about his difficulties to a person he or she believes to have the knowledge, skill and desire to help him. In his discussion of abreaction Wolpe returns to the importance of the therapeutic relationship. He claims that it is only when the patient can feel the therapists sympathetic acceptance of him, that beneficial abreaction can occur.

A summary of those early standpoints from the precursors of behavior therapy has a lot in common with the summary about Freud. Both Skinner and Wolpe recognized that various kinds of therapy can be effective, and that the therapeutic relation is the most important factor in psychotherapy. In addition, Wolpe claimed that therapy founded in the tradition of behaviorism will have some of its own methods, which could enrich the psychotherapeutic field. When Skinner tried to explain phenomena in psychoanalysis with behaviorist terminology, he showed an early interest in theoretical integration.

No 1:36, 7 Humanistic-experiential psychotherapy Carl Rogers It has been suggested that the origin of humanistic psychotherapies might be dated to December 11, 1940, when Carl Rogers gave a speech where he was critical of many of the psychotherapy methods of the time (Cain, 2002). Rogers has been famous for formulating, in a somewhat outdated scientific language, what he called the six necessary and sufficient conditions for personality change, both in psychotherapy and in other situations (Rogers, 1957). Three of the six conditions concerned the therapist. The therapist: (1) should be congruent and integrated in the relationship, (2) experience unconditional positive regard for the patient, and (3) experience and communicate empathic understanding to the patient.

Rogers emphasized that those conditions were relevant not only for his own form of psychotherapy. If other kinds of psychotherapy were effective and used special methods, the essential ingredients would nevertheless be those six conditions. For example, if the analysis of dreams or hypnosis was remedial, it was because the therapist used those methods for mediating unconditional positive regard and empathic understanding to the patient. The opposite was true as well. All kinds of techniques could be used with a lack of empathy. This was also true for the psychotherapy Rogers had developed himself, client-centered therapy. This therapy was specialized to use those six conditions. However, client-centered-therapy also had its own specific techniques such as reflecting feelings, but Rogers acknowledged that those techniques were not a necessary ingredient in psychotherapy. Even reflecting feelings could be used in an effective or ineffective way, depending on the therapist, according to Rogers.

Thus, Rogers also saw great similarities between the different forms of psychotherapy. They could all be effective or ineffective depending on the therapists personal skills. If psychotherapy was effective, the effective ingredients were the same. Different kinds of therapists used different methods to do the same thing.

Cognitive psychotherapy Aaron Beck Aaron Beck is the founder of cognitive psychotherapy. Admittedly, rational-emotive therapy (RET), was formulated by Albert Ellis in the late 1950s (e g, Ellis, 1962), just before Beck started to develop cognitive therapy, and to some extent Beck was influenced by Ellis when he started to develop his approach to psychotherapy. However, Becks original theory of depression was founded in his clinical experiences, while at the same time many of the tech-

No 1:36, 8 niques in Becks therapy were directly borrowed from behavior therapy (Clark, Beck & Alford, 1999).

Beck has written extensively about similarities between cognitive therapy and other forms of psychotherapy. Regarding his view of the therapeutic relationship, Beck (1976) presented research from Rogers and Traux indicating that a successful outcome is facilitated if the therapist shows genuine warmth, acceptance and accurate empathy.

When Beck, Rush, Shaw and Emery (1979) wrote about cognitive therapy for depression, they described the therapeutic interaction as characterized by basic trust and emphasized the importance of rapport. They portrayed the cognitive psychotherapist in the following way: The aspiring cognitive therapist must be, first, a good psychotherapist. He must possess necessary characteristics such as the capacity to respond to the patient in the atmosphere of a human relationship with concern, acceptance and sympathy. No matter how proficient he is in the technical application of cognitive strategies, he will be severely hampered it he is not adequately endowed with these essential interpersonal characteristics. (Beck et al., 1979, p. 25). The authors also raise a word of caution. Cognitive and behavioral techniques can, especially to the neophyte therapist, seem deceptively simple. The danger with this is that the therapist may relate to the patient as one computer to another, rather than as one person to another. The therapist may then be regarded as mechanical and manipulative by the patient. Instead, techniques are intended to be applied in a tactful, therapeutic, and human manner by a fallible person the therapist.

The desirable characteristics of the therapist, according to Beck and coworkers (1979), are warmth, accurate empathy and genuineness. It is in his manner, tone of voice, and way of phrasing his words, that the therapist generally conveys his acceptance and warmth to the patient. Accurate empathy facilitates therapeutic collaboration. In his genuineness the therapist has to mix diplomacy with honesty. In contrast to Rogers formulation of the necessary and sufficient conditions in therapy, Beck and co-workers believe that these characteristics are necessary but not sufficient to produce an optimum therapeutic effect. (Beck et al., 1979, p. 45). Although Beck emphasized the therapists personal skills, he has also written that The same therapeutic program used by different therapists does not differ substantially from one to the other (Beck, 1976, p. 333). It seems then that Becks opinion is that the use of manuals in therapy will increase the similarities among therapists.

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Beck has also emphasized that the therapeutic situation produces a quieting down of hyperactivity. This effect can be the result of the therapists empathy and acceptance, specific relaxation instructions, or explicitly stated verbal approval (Beck, 1970). Beck and coworkers make a related remark Cognitive and behavior therapies probably require the same subtle therapeutic atmosphere that has been described explicitly in the context of psychodynamic therapy. (Beck et al., 1979, p. 50).

Beck has also written about the relationship between cognitive therapy and behavior therapy (Beck, 1970), and also made a comparison with psychoanalysis (Beck, 1976). He describes many similarities with behavior therapy. Cognitive and behavior therapists are more active in the therapeutic interview than other therapists, they focus on overt symptoms or behavior problems, do not draw substantially on reconstruction of childhood experience, and share the assumption that therapy can be effective without insight regarding the origin of the symptom (Beck, 1970). The similarities with psychoanalysis are that both are insight therapies in the sense that they are interested in introspective data from the patient. They also attempt to produce structural change by modifying the patients thinking, and they depend on working through of intrapsychic problems (Beck, 1976).

Thus, Becks view of psychotherapy expresses several opinions. He claims that different forms of psychotherapy can be effective and he emphasizes the personal qualities of the psychotherapist in a Rogerian way. At the same time, he maintains that cognitive methods of psychotherapy can make therapy more effective. Although he underlines the importance of the relationship and the therapists personal skills, he also proposes that the use of manuals in cognitive therapy will minimize differences between different cognitive therapists.

Conclusions about the founders Some conclusions can be drawn from this review of the founders in psychotherapy. Freud, Skinner, Wolpe, Rogers, and Beck all believed that different forms of psychotherapy can be effective, and that the principal explanation of this is the therapeutic relationship. Freud, Skinner, Wolpe and Beck also have in common the belief that one or more specific ingredients make their own kind of psychotherapy more effective than others. Rogers on the other hand does not claim he has specific effective ingredients. Instead, he considers differences in

No 1:36, 10 effectiveness between psychotherapists to be the result of differences concerning their own skills in using common factors of change in psychotherapy.

Recent clinical trends


Psychodynamic therapy Obviously there are a lot of clinical trends in psychoanalysis after Freud. Some of the most important developments are the British object relations theory and Heinz Kohuts self psychology. Those orientations are also well-known in Sweden, so this survey will be restricted to these two psychodynamic trends. Admittedly, the object relations theory is not so new, but is worth attention, because it is still influential. Besides this, after Kohut - during the 80s and on - no new important orientation of psychodynamic psychotherapy seems to have emerged. Undoubtedly, IPT (interpersonal therapy) has some of its origins in psychodynamic psychotherapy, but it is regarded more as a separate form of psychotherapy than a psychodynamic therapy (Gotlib & Schradley, 2000).

The object relations theorists mostly criticize the traditional Freudian view of the development of the child and of the therapeutic approach, with little interest in other psychotherapeutic schools than psychoanalysis. However, one of the leading advocates of object relation theory, Harry Guntrip, has made several interesting comments regarding other kinds of psychotherapy. His first view looks like an updated version of Freuds distinction between suggestive therapies and psychoanalysis. Guntrip utilizes a distinction between symptom-relieving treatment and psychotherapy. He thinks that the extensive mental ill-health in society is a reason to be grateful for any symptom-relieving treatment that can be proven to be helpful, like behavior therapy, drugs or ECT (electric convulsive treatment). Psychotherapy on the contrary, aims at something more fundamental; long-term stabilizing change in the total personality (Guntrip, 1968).

Some years later, Guntrip (1972) was more positive to behavior therapy. First, behavior therapy techniques are considered as valuable for suppressing symptoms, and desensitization is the psychologically most interesting technique. Aversion therapy is the most questionable method through there are cases in which I would not rule it out. (Guntrip, 1972, p. 276). Second and perhaps most interesting, Guntrip maintains that psychoanalysis can be seen as a highly personal process of desensitization of childhood fears of bad parents and/or traumatic

No 1:36, 11 situations, liberating personal growth potentials (Guntrip, ibid., p. 276). Third, Guntrip regards the study of habit and repertoires of behavior patterns in every day living is an important result of behaviorism, and something that psychoanalysis has failed to adequately take into account. Fourth, Guntrip notes that behaviorists are looking beyond symptoms, searching for causes and reasons, and this brings a common ground for behaviorism and psychoanalysis. However, according to Guntrip, the behaviorists have still not recognized that the causes and reasons may be found in a traumatic childhood, and emerge in dreams and symptoms. As is evident from this, Guntrip recognizes both the worth of some of the techniques in behavior therapy and the possibility to explain phenomena in psychoanalysis with behaviorist theory.

Besides this, Guntrip brings up research in the Rogerian tradition about the impact of the therapeutic relationship in psychotherapy with schizophrenics. This supports, Guntrip claims, the fundamental assumption on which psychoanalytic treatment rests, namely that a reliable and insight-promoting personal relationship can be therapeutic (Guntrip, 1971).

Like the object relations theorists, Kohut's main interest is to explain the relationship between his self psychology and traditional psychoanalysis, with little interest in other kinds of psychotherapy. Nevertheless, Kohuts theories are of interest here, and especially one work, How does analysis cure? is relevant (1984). Admittedly, Kohut regards empathy as more important than Freud did, and there are many similarities between Kohut and Rogers (Kahn, 1985). Kohutian psychotherapy has also been described as a deliberated combination of supportive and dynamic components (Roth & Fonagy, 2005). On the other hand, at a theoretical level, Kohut emphasizes that his opinion on change does not differ from Freuds. The cure is achieved by a process in three steps: optimal frustration, nonfulfillment of the need, and substitution of direct need fulfillment with a bond of empathy between self and selfobject. It does not seem like Kohuts interest in empathy makes him see more similarities with other forms of psychotherapy. Instead, he accentuates the fundamental similarities between his view and the view from Freud.

Regarding the question of which ingredients make psychotherapy work, the psychodynamic school seems to consider both the therapeutic relationship and psychoanalytical interpretations as effective, just as Freud did, but with an increasing emphasis on the therapeutic relationship. In an overview of empathy in psychoanalysis the authors conclude that there is a division in the psychoanalytic literature between conceptualizing the role of empathy as a di-

No 1:36, 12 rect curative agent or as an enabling factor that permits the operation of the supposed primary therapeutic factors of interpretation and insight. (Eagle & Wolitzky, 1997, p. 214). Emphasizing empathy underscores the similarity between psychodynamic psychotherapy and the other schools of psychotherapy, while an emphasis on interpretation accentuates the differences in relation to other schools, since interpretation often is dependent on psychoanalytic theories of child development. It seems obvious then that in object relations theory and self psychology, there is an increased emphasis on the therapeutic relationship, and a decreased emphasis on insight.

Concerning the theoretical development in psychodynamic theory, much of the debate in psychoanalysis has been metatheoretical. The theoretical interest has been directed towards questions such as if the clinical theory is better than the metapsychology (Gill & Holzman, 1976, Holt, 1981), and what kind of science psychoanalysis is, is it a hermeneutical science (Steele, 1979) interpreting the semantics of desire (Ricour, 1970) or is it an empirical science (Bowlby, 1979, Eagle, 1984, Eagle, Wolitzky & Wakefield, 2001). The last-mentioned trend is important because emphasis on psychoanalysis as an empirical science increases the similarities with the other psychotherapy schools.

If psychoanalysis is an empirical science, then it is possible to evaluate psychoanalysis in the same way as other therapies and theories. Steps in this direction have been taken through an increased acceptance in psychoanalysis of the diagnoses in the DSM-system, Diagnostic and Statistical Manual for of the Mental Disorders, (e.g. Gabbard, 1994, McCullough et al., 2003). This has facilitated psychotherapy research, and referring to scientific findings by psychodynamic psychotherapists seems to have become more common, also among those working in the object relation tradition (e.g. Stricker & Gooen-Piels, 2002). The view of psychoanalysis as an empirical science is also strong in the first volume of Comprehensive handbook of psychotherapy (Kaslow & Magnavita, 2002), devoted to psychodynamic/object relations therapies. In the final chapter, the volume editor Jefferey Magnavita (2002) brings up the future trends in contemporary psychodynamics. He describes the struggle to establish an empirically based science of psychodynamics, with help from audiovisual technology, empirical findings, treatment manuals, etc. According to Magnavita, the future change will consist of the relevance of neuroscience, building interdisciplinary bridges between for example cognitive science, affective science, developmental science and evolutionary science. He finishes the chapter by answering two questions. To the first question, if psychodynamics will continue to pro-

No 1:36, 13 vide fertile models to interdisciplinary thought, his answer is yes. The second question, if psychodynamic psychotherapy will remain as a separate school, is answered more tentatively. Magnavita claims that it may be more likely that there will be a convergence between all of the most common models of psychotherapy, which will lead to a continual blending of techniques that work, and an abandonment of those techniques which fail to prove their effectiveness.

Cognitive behavioral therapy Since the beginning of cognitive-behavioral therapy (CBT) in the late 70s, many new therapies, such as functional analytic therapy, FAP (Kohlenberg, 1987), dialectical behavior therapy, DBT (Linehan, 1993), acceptance and commitment therapy, ACT (Hayes, Strosahl & Wilson, 1999), mindfulness-based cognitive therapy for depression, MBCT, (Segal, Williams & Teasdale, 2001) and schema therapy (Young, Klosko & Weishaar, 2003) have appeared and are regarded as cognitive-behavior therapies. Many of these therapies have been described as examples of the third wave of behavior therapy (Hayes, 2004). The first generation of behavior therapy was concentrated on directly changing behavior. The second generation added changing of thoughts, and the third wave of behavior therapy is directed at changing the function of the thoughts, not their content. At the same time, also traditional cognitive therapy has of course developed, with for example an increased interest in personality disorders (Beck, Freeman & Davis, 2004) as well as the psychotherapeutic relationship (Leahy, 2001). Because so much of the interest in newer forms of cognitive and cognitive behavior therapy is thinking about thinking, this interest is also described as an interest in metacognition (Wells, 2000).

As a result of this development, regarding the question of what makes psychotherapy effective; two trends are obvious in contemporary CBT-therapies. One is that the usual techniques of cognitive therapy are effective, and therefore are used for more diagnoses, and often more complicated diagnoses. A handbook of interventions for chronic and severe mental disorders presents CBT-therapies for diagnoses such as schizophrenia, bipolar disorder, alcohol addiction and severe personality disorders (Hofmann & Tompson, 2002). The other trend is the use of new techniques. Examples of this are mindfulness in DBT and the techniques in ACT, described as creative hopelessness, control is the problem and cognitive fusion, which serve the purpose of making the patient more accepting of his or her thoughts and feelings.

No 1:36, 14 When it comes to the question if the effective ingredients in psychotherapy are used in other psychotherapies than CBT therapies, Marsha Linehans (1997) concept of validation is especially interesting, because validation has many similarities with Rogerss concept of empathy, but is more extensive. According to Linehan, validation can be considered at six levels: (1) listen and observing; (2) accurate reflection; (3) articulating the unverbalized; (4) validating in terms of sufficient (but not necessarily valid) causes; (5) validating as reasonable in the moment; and (6) treating the person as valid radical genuineness. The two first levels encompass what is usually defined as empathy. However, Linehan thinks that also the other levels are used by most therapists, but only the first four levels are usually discussed in the general psychotherapy literature. This means that Linehan considers she has brought together in a new concept, relevant phenomena from other forms of psychotherapy, and also uses those phenomena in a more systematic way in DBT compared to what is common in psychotherapy. In this way Linehan both creates bridges to other forms of psychotherapy, and gives validation a higher value in her new treatment than is common in other treatments, and especially in the CBT tradition.

On the theoretical level, the similarities with other kinds of therapy schools have increased. According to Beutler, Harwood and Caldwell (2001) the concept of dysfunctional cognitions/schemata/behaviors remains at the core of cognitive therapy. However, components which are common in many orientations of psychotherapy were regarded as established in cognitive therapy in the early 1990s. Examples of this are the role of defensive processes, an emphasis on the exploration of the therapeutic relationship and the patients interpersonal dynamics, facilitative aspects of affective arousal, and the developmental experiences in the formation of maladaptive schemata (Robins & Hayes, 1993), and this tendency has continued.

One example of this is an increased emphasis on avoidance. With the development of CBT for more complex diagnoses, the concept of avoidance has increased in importance. Patients with personal disorders are described as using both cognitive and affective avoidance (Young, 1999), and when Chadwick, Birchwood and Trower (1996) analyze delusions, voices and paranoia, they see these phenomena as defense-avoidance of negative believes about the self. In ACT avoidance is very important, especially experiential avoidance (Hayes, Strosahl & Wilson, 1999), and representatives for ACT refer to experimental research on the role of suppression of private experiences in depression, substance abuse and sequelae of child abuse (Hayes, Pankey, Gifford, Batten & Quiones, 2002). Hayes and coworkers (1999) also point

No 1:36, 15 out that avoidance has been recognized in many therapies, such as behavior therapy, clientcentered therapy, gestalt therapy and existential therapy.

Another interesting trend in cognitive therapy is the use of terminology common in psychodynamic theory about the interaction between the therapist and the patient, such as transference interpretation (Safran & Segal, 1990), countertransference (Hayes et al., 1999) and resistance, transference and countertransference (Leahy, 2001). However, some of the leading proponents of cognitive psychotherapy have expressed doubts about this, and do not use expressions like transference and countertransference, to avoid confusion with psychodynamic assumptions (Beck, Freeman & Davis, 2004).

Humanistic - experiential therapy Humanistic psychology has evolved into a broad movement. The major strands of humanistic psychotherapy are client-centered therapy, existential therapy and Gestalt therapy (Elliott, 2002), but it also includes therapies like psychodrama, transactional analysis and redecision therapy (Davis Massey, 2002). However, many of those therapies originally described as humanistic have recently been grouped together under the experiential umbrella (Elliott, Greenberg & Lietaer, 2004), with therapies such as client-centered therapy, Gestalt, existential and body-oriented therapies. All the major schools of humanistic psychotherapies were well established by the mid-1960s (Cain, 2002). However, during the last decades, the influence from humanistic psychotherapy has been reduced. Among the clinical psychologists in the USA in 2003, 1 % considered their primary theoretical orientation as existential/gestalt/ humanistic and 1 % as Rogerian (Norcross, Karpiak & Santoro, 2005). In the preface to a handbook of humanistic psychotherapy, Cain (2002) regards roughly 10 % of the psychologists and psychotherapists in the United States as humanistic. Rather paradoxically, it seems as if one problem for humanistic psychotherapy is its success. The more general themes in this psychotherapy, about the qualities of the therapist as formulated by Rogers and the emphasis on interpersonal themes, have been incorporated as a general aspect of psychotherapy (Davis Massey, 2002). In addition, a specific technique in this tradition, that of role-play, has been incorporated into cognitive psychotherapy (Freeman, Pretzer, Fleming & Simon, 1990).

The third volume of Comprehensive handbook of psychotherapy, is about humanistic, interpersonal and existential psychology (Kaslow, Massey & Davis Massey, 2002). According to Davis Massey (2002) the psychotherapies in the volume can be described in terms of what she

No 1:36, 16 calls the third, forth and fifth forces in psychotherapy. With the third force, Davis Massey refers to Maslows description of the humanistic, existential and phenomenological approaches as the third force (where psychoanalysis was the first force and behaviorism was the second force). Davis Massey regards the systemic family therapies, through stressing context, as the fourth force, and the integrative perspective as the fifth force. From this description of different forces it is obvious that humanistic, interpersonal and existential psychotherapy have similarities with other approaches. In a research review on experiential psychotherapies (Elliot, Greenberg & Lietaer, 2004) the authors also describe characteristics of these therapy methods; characteristics which are possible to recognize from other orientations. Important themes are focus on experiencing in therapy, the therapist as an expert on how the patient can handle his or her problems but not in the content of the patients experience, the therapeutic relationship as potentially curative, and a person-centered view which involves genuine concern and respect for each person.

According to Cain (2002), there have been many interesting developments during the last decades in humanistic therapy. Cain maintains that perhaps the most fundamental change is that Rogers premise of therapeutic nondirectiveness has been challenged as being too confining for both therapists and patients and not fully in keeping with the fundamental goals of humanistic therapy. Instead a strong case for process directiveness has been made. This means that patients often need assistance in how to process their experiences, so humanistic therapists nowadays can, in collaboration with their patients, propose a wide range of methods for processing the patients experience. The humanistic therapies have also evolved by crossfertilization within the humanistic family, where each therapy has benefited from incorporating and integrating some characteristics of other approaches. Furthermore, the view of empathy has become more compounded. Empathy is not just reflection; instead a view has evolved that empathy is a variety of more differentiated responses (Cain, 2002).

Davis Massey (2002) claims that in the future the humanistic, interpersonal and existential psychotherapies will contribute to a widening scope of science, and to bridging the eastern and western frames of reference. The latter ambition also holds true for DBT and ACT in the CBT- group. Finally, this tradition also insists on the value of evidence from psychotherapy research. Now advocates of humanistic psychology are also using meta-analysis of psychotherapy outcome studies, with the conclusion that humanistic therapies are equally effective as

No 1:36, 17 cognitive-behavioral and other forms of psychotherapy (Elliott, 2002, Elliott, Greenberg & Lietaer, 2004).

The developments in this tradition indicate that Rogers original view of psychotherapy is valuable but insufficient. Rogers insight regarding the importance of the therapeutic relationship has been preserved, but the role of experiencing has been accentuated and changes such as process directiveness have emerged, which increases the similarities with the other schools of psychotherapy.

Integrative psychotherapy According to a Swedish study, in 1995 24% of the psychotherapists in Sweden regarded themselves as eclectics (Sandell et al., 2004). In the United States the eclectic/integrative approach to psychotherapy is the most common orientation today, and has been so during many decades (Norcross, Karpiak & Santoro, 2005). In 1983 this orientation was organized as the Society for the Exploration of Psychotherapy Integration (SEPI). This is an interdisciplinary organization of professionals interested in approaches to psychotherapy that are not limited by a single orientation. SEPI publishes Journal of Psychotherapy Integration and this approach to psychotherapy has been presented in Handbook of psychotherapy integration first in 1992 and then in a second edition in 2005 (Norcross & Goldfried, 1992, Norcross & Goldfried, 2005). However, this orientation has a rather long history. About seventy years ago Saul Rosenzweig (1936) presented his explanation of how diverse methods in psychotherapy could be successful: although they looked different they had the same effective factors in common, such as catharsis and the therapists personality. Rosenzweigs opinion is still of great relevance today, and his now famous article is one of the earliest roots of the integrative movement.

Common factors are usually considered to be those components that are effective ingredients behind the positive outcome in different kinds of psychotherapy. For example, Weinberger (1995) mentions five possible common factors: the therapeutic relationship, expectations, confronting problems, mastery, and attribution of outcome. However, Lampropoulos (2000a) points out that common factors and therapeutic factors are not synonyms, because some factors common between therapists may not be therapeutic at all.

No 1:36, 18 The search for common factors is important not only for integrative psychotherapists, but in psychotherapy research as well. According to Lambert and Ogles (2004) common factors account for a substantial amount of improvement attained in psychotherapy. However, more empirical evidence is needed to examine the importance of common factors, as well as if elements specific to one school or technique have possible additional benefits.

Besides the interest in common factors, the integrative movement is interested in the use of different effective techniques, so called eclectical integration (Lazarus, 1967), and of theoretical integration. However, the integrative moment does not have a shared opinion as to which those common factors are, and their importance in psychotherapy. Neither has the integrative movement a common target regarding theoretical integration. Some of the integrationists believe it is possible to create a general transtheoretical theory (Prochaska & Norcross, 2003). Others think that only assimilative integration is a reasonable target, where the therapist is theoretically based in one therapy school, but has a willingness to incorporate perspectives or practices from other schools (Messer, 1992). The lack of a common view is due to the fact that the aim of the integrative movement is to explore the questions named here, and not to give a definite answer to the question of whether integration in psychotherapy is possible or not.

However, besides the organized integrative movement there are integrative trends from within the psychotherapy schools themselves, which then are examples of assimilative integration. Practitioners of cognitive therapy (Alford & Beck, 1997, Safran & Segal, 1990) as well as of cognitive-behavior therapy (Beutler, Harwood & Caldwell, 2001, Castonaguay, Newman, Borkovec, Grosse Holtforth & Maramba, 2005) utilize these therapies as appropriate examples of integrative attempts in psychotherapy. In psychodynamic therapy Anthony Ryle (1995, 2002) has tried to integrate cognitive techniques and developed Cognitive Analytic Therapy (CAT), and Stricker and Gold (2005) have described Assimilative psychodynamic psychotherapy. Furthermore, object relation theory has also been used in integrative attempts in psychotherapy (Sfvestad Nolan & Nolan, 2002).

Conclusions about clinical trends The conclusions from this overview of recent clinical trends seem obvious. The different psychotherapy schools have really influenced each other. As a result of this the schools have become more similar. These similarities concern both how to practice psychotherapy and in-

No 1:36, 19 creased theoretical similarities, e.g. the importance of avoidance of experience. Besides this, the field of psychotherapy has undergone an interesting and impressive development during the last decades.

The view from empirical science


The effectiveness of psychotherapy More than fifty years ago, Hans Eysenck (1952) published the first review on the effect of psychotherapy. Eysenck drew the conclusion that the available evidence failed to support the conclusion that psychotherapy has any positive effect, which resulted in a lot of objections and debate (e. g., Luborsky, 1954, Strupp, 1963). The judgment that psychotherapy is not effective is now an outdated view in science, mainly because many meta-analytic studies have been published since 1977 with the same result: psychotherapy usually has beneficial effects. The debate now is about the analysis of this positive effect, with primarily two questions: are there any differences in outcome between different treatments, and if there are differences, how to explain those differences.

To answer the question about if there are any differences or not, the traditional efficacy study - where for example one form of psychotherapy is compared with placebo and/or some other form of psychotherapy - is supplemented by meta-analyses. A meta-analysis is a quantitative study which attempts to summarize the results from many comparative studies. It converts the results from those studies to an effect size, so a comparison is possible.

The most well-known overview of research, which considers traditional studies as well as meta-analyses, is Bergin and Garfields Handbook of Psychotherapy and Behavior Change (Lambert & Ogles, 2004). Bruce Wampolds The great psychotherapy debate (2001) is mainly an overview of meta-analyses. There are interesting differences between the conclusions in Bergin and Garfields Handbook and in Wampolds work.

Wampold asserts two main points of view, critical to common opinions about psychotherapy. One is that there is no diversity in outcome between different forms of psychotherapy. The other position is that representatives of different schools of psychotherapy usually have a medical model of psychotherapy, while Wampold considers what he calls a "contextual model as more appropriate.

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If special ingredients in psychotherapy really have additional effects, is not an easy question to answer. Based on reviews of psychotherapy outcome research, Lambert (1992) describes in percent how different therapeutic factors contribute to the effect: extratherapeutic change accounts for 40 % of the improvement, common factors 30 %, techniques 15 %, and expectancy 15 %. This view has been criticized by Wampold (2001) because Lambert used no statistical procedures, a point Lambert himself was aware of. Instead, Wampold claims that at least 70 % are general effects and specific effects are at the most 8 %. However, Lamberts opinion is that his view is still correct, and supported by new research (Lambert & Barley, 2002). It should be noted that, irrespective of whether Lambert or Wampold is right, both share the opinion that common factors are more important than specific techniques are.

Although Wampold recognizes the possibility that specific techniques could have an impact, even if it is a small one, when he compares different psychotherapy methods, his conclusion is that there are no differences between different treatments. This opinion is general in the metaanalysis approach, ever since Smith and Glass (1977) presented the first meta-analysis. Admittedly, meta-analyses have often showed small differences in favor of cognitive and behavior therapies, but those effects have been explained by methodological factors such as more reactive criteria, and utmost as an effect of investigation allegiance (Lambert & Ogles, 2004). However, Lambert and Ogles conclusions are still a bit different from Wampolds conclusion. According to them, in meta-analyses about comparative effectiveness there is a strong tendency towards no differences, counterbalanced by indications that, under some circumstances, certain methods (generally cognitive behavioral) especially regarding anxiety disorders, or modes (family therapy) are superior. In the final chapter of the Handbook, the authors point to slowing relapse in schizophrenia and conduct disorder in adolescents, as examples of family therapy having a superior effect (Lambert, Garfield & Bergin, 2004).

However, according to Wampolds analysis of meta-analysis regarding treatment of anxiety, there is no differences in effectiveness for different treatments, although he admits that the comparisons often are between various cognitive treatments. Instead, Wampold accentuates that the differences in effectiveness are not between different treatments, but between psychotherapists from different orientations. When Lambert and Ogles (2004) summarize the research about differences in outcome between therapies, they too underline that there are important differences between therapists. The research suggests that differences exist also when

No 1:36, 21 treatment manuals are used. However, the authors emphasize that differences in effectiveness between therapists not only result from personal qualities, but are likely to reflect variations in technical skill as well. Because of this, Lambert and Ogles draw the conclusion that it is possible that too much energy is devoted to technique studies, and that studying interaction effects (therapist technique patient) would be more appropriate.

In addition, if there are differences in outcome between different kinds of psychotherapies, it could be difficult to discover these differences, because often outcome research has used small samples, which has lead to a lack of statistical power which could explain the absence of findings of differences, instead of a real lack of difference in outcome (Hill, & Lambert, 2004, Lambert & Ogles, 2004).

Regarding Wampolds second standpoint, the more philosophical question that a contextual model for psychotherapy is preferable to a medical model, only one remark is appropriate here. Wampold asserts that the medical model stipulates that (1) a patient is conceptualized to have a disorder or problem, and presented to a therapist with a particular theoretical orientation. The therapist (2) provides an explanation for the disorder, (3) a rationale for change, and (4) a treatment that contains specific therapeutic ingredients that are characteristic of the therapists theoretical orientation. Furthermore, in the medical model (5) the specific therapeutic ingredients are responsible for the patients progress; at least they will be overwhelmingly larger than the general effects. Wampold regards Freud, Beck etc. as proponents for the medical view, but even Rogers approach is seen as a medical model in many ways.

As an alternative, and one instantiation of the contextual model, Wampold calls attention to Jerome Franks view of psychotherapy (Frank & Frank, 1991). In this model specific ingredients are necessary, but it is not important which those specific ingredients are, as long as they are a part of a psychological theory. The reason for this is that the function of the specific ingredients are to offer a kind of myth in which the therapist can have faith and give the patient a sense of alliance with the healer.

The comment to this will be that Wampold does not back up his opinion with any quotations that Freud, Beck etc. regard the specific ingredients as the most important ingredients in their psychotherapy. Instead, as has been mentioned here earlier, Freud, Wolpe and Beck consider the relationship to the therapist as important, while their special methods have additional ef-

No 1:36, 22 fects, but they dont seem to express any opinion as to whether the common or the specific ingredients are the most important for the effectiveness of psychotherapy. In addition, Frank recognized the possibility of differences in outcome between different therapy methods himself (Frank, 1979, Frank & Frank, 1991), so Frank does not seem to be a supporter of a contextual model in Wampolds sense. The conclusion from this is that Wampold seems to subscribe to a myth about the founders in psychotherapy: that the founders valued the specific factors as more important than the common factors.

In sum, it is obvious that psychotherapy usually is an effective treatment. Perhaps there are differences in effectiveness in favor for cognitive-behavior therapy for some disorders. But regardless of whether this is true or not, therapists of different orientations can be effective, and important differences still exist between therapists, irrespective of the therapists theoretical orientation.

Effective elements in psychotherapy The American Psychological Associations Division 12 Task force has been given the mission to survey which the empirically supported treatments (ESTs) are. The attempts have received a great deal of criticism (for overviews of the debate, see Elliott, 1998, Lampropoulos 2000b). One reason for this is the uncertainty surrounding whether there actually are differences between different orientations or not, while there are considerable differences in the results between therapists with the same orientation, and this is true also when the therapists are competent in their particular method and have supervision (Luborsky, McLellan, Diguer, Woody & Seligman, 1997). As a result of the critique against the attempt to present ESTs, another APA division got the task to investigate which the empirically supported relationships, ESR, are. The results are presented in Psychotherapy relationships that work: therapist contribution and responsiveness to patients (Norcross, 2002).

As regards the empirical evidence, the book divides general elements of the therapy relationship into two groups: demonstrably effective elements and promising and probable effective elements. Four elements are classified as effective elements: (1) the alliance, (2) cohesion in group psychotherapy, (3) empathy and (4) goal consensus and collaboration. Seven elements are classified as promising elements: (1) positive regard, (2) congruence, (3) feedback, (4) repairing alliance ruptures, (5) self-disclosure, (6) the management of countertransference and (7) relational interpretations.

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Because those effective elements can occur in different forms of psychotherapy, researchers have become interested in finding out which the personal qualities among the therapists are that give rise to those effective elements.

Effective psychotherapists Nowadays there are a lot of research summaries about therapist variables, with different starting points. Bachelor and Horvath (1999) have a common factor perspective. Teyber and McClure (2000) contribute to a handbook surveying psychotherapy processes and practices for the 21st century. In the volume which is the result of the work from APAs Division 29 Task Force on Empirically Supported Therapy Relationships, Lambert and Barley (2002) write an overview chapter. Asay and Lambert (2002) contribute in a handbook of humanistic psychotherapy. In the fifth edition of the previously mentioned handbook of psychotherapy and behavior change, Beutler and coworkers (2004) advocate the use of better methods than in the earlier edition from 1994, and especially meta-research.

A common theme for the overviews is what distinguishes effective from less effective psychotherapists. One study shows that empathy was the most distinguishing variable on being an effective therapist (Lafferty, Beutler & Crago, 1989), another study that effective therapists showed more positive behaviors such as warmth, affirmation and understanding, and less blaming, attacking and rejecting (Najavits & Strupp, 1994). According to Beutler and coworkers (2004), friendly behaviors are associated with positive outcome, and a pattern of dominance-submission was frequent in patient-therapist dyads with poor outcome, where the therapists had low levels of positivity/friendliness, high levels of hostility, and the relationship was characterized by reciprocal, patient self-criticism. Excellent therapists (psychodynamic, humanistic as well as learning therapists) also seem to possess attributes such as selfintegration, anxiety management, conceptualizing skills, empathy, and self-insight, to a greater extent than therapists in general (Van Wagoner, Gelso, Hayes & Diemer, 1991).

In another study of characteristics of effective therapists, they were found to be distinguished by being more psychologically minded (as opposed to biologically oriented) and only rarely used medication, either alone or in combination with psychotherapy (Blatt, Sanislow, Zuroff & Pilkonis, 1996). Furthermore, they estimated that more, rather than less, therapy would be needed before treatment differences in their patients would be manifested.

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None of this contradicts the conclusion from an earlier study of therapist success, that the major agent of effective psychotherapy is the personality of the therapist, particularly the ability to form a warm, supportive relationship (Luborsky, McLellan, Woody, OBrien & Auerbach, 1985, p. 609), later repeated with slightly different wording: Thus, basic capacities for human relating warmth, affirmation, and a minimum of attack and blame may be at the center of effective psychotherapeutic intervention. (Najavits & Strupp, 1994, p. 121).

Furthermore, irrespectively of theoretical orientation, therapists seem to have similar reactions to conflicts in the therapy relationship, although important differences exist between individuals in how extensive the reactions are (Binder & Strupp, 1997). The problem of handling hostility from patients seems to be the same, because of the enormous difficulty that human beings, even highly trained therapists, have in dealing with interpersonal conflict in which they are participants. (ibid, p. 123). In fact, too much accentuation of theoretical elements can be an expression of the therapists personal difficulties in applying a psychotherapy method. A study of the effect from training in time-limited dynamic psychotherapy, found that therapists with hostile and controlling introjects showed the greatest technical adherence, and those therapists were also largely responsible for the increase of negative and complex communication which rose substantially after the training (Henry, Schacht, Strupp, Butler & Binder 1993). In cognitive therapy with depressed patients, therapeutic alliance and patients emotional experiencing was related to improvement, but focus on more specific cognitive features such as the link between distorted thoughts and negative emotions was, unexpectedly, correlated with negative outcome (Castonguay, Goldfried & Hayes, 1996). Explanations for this were that therapists dealt with strains in the alliance by increasing the use of the specific cognitive techniques, and then failed to use those techniques in a flexible way.

Findings like these suggest how important the personal qualities of the therapist are. There is evidence that effective therapists have more willingness to look critically at themselves and to admit when they have made mistakes, than less effective therapists (Najavits & Strupp, 1994). Furthermore, therapists with negative self-representations that is, who are self-blaming and neglectful towards themselves are more likely than therapists with positive selfrepresentations are, to engage in a countertherapeutic process characterized by subtly hostile and controlling interactions with their patients (Henry & Strupp, 1994). There is not necessarily a contradiction between these findings, because it is possible that a positive self-image fa-

No 1:36, 25 cilitates admitting mistakes, while a negative self-image either makes the individual prone to be too self-critical, or makes it too hard to admit any mistakes at all.

To summarize: the ideal therapist seems to be a warm and empathic person, with self-insight, a positive self-image, capable of self-critical reflexion, who avoids complicated communication with the patient, seldom contradicts the patient, and is more interested in psychotherapy than medication.

Similarities and differences between CBT, CT and PDT in practice Practical similarities and differences can exist in at least three ways. First, a phenomenon can appear only in one form of psychotherapy, and not at all in other orientations. For example, according to the theory in psychodynamic therapy (PDT) interpretation of dreams is valuable, while interest in dreams is of no theoretical interest in cognitive behavior therapy (CBT) or cognitive therapy (CT), so it is probable that interpretation of dreams is usual in PDTtherapies but does not exist in CBT or CT. Second, a phenomenon can appear on a more general level in several therapies, but have different expressions in different therapies. For example, one of Weinbergers five common factors in psychotherapy is confrontation or facing the problem (Weinberger, 1995). To motivate the patient to face problems is a general part of psychotherapy, but with different expressions. In PDT it is important to express fears in the therapeutic relationship, in CBT it is important to confront fears in exposure treatment outside the therapeutic relation. Finally, a phenomenon can be a part of several treatments, but to a different degree. For example, the therapeutic relationship seems to be important in different treatments, but is more in focus in PDT than in CBT and CT.

In two articles, Blagys and Hilsenroth have reviewed the comparative psychotherapy process literature, both theoretical and empirical, regarding what they call distinctive features between psychodynamic-interpersonal psychotherapy and cognitive-behavioral therapy. In the first article (Blagys & Hilsenroth, 2000), seven interventions stood out as distinguishing short-term psychodynamic-interpersonal therapy: (1) a focus on affect and the expression of patients emotions; (2) an exploration of patients attempts to avoid topics or engage in activities that hinder the progress of therapy; (3) the identification of patterns in patients actions, thoughts, feelings, experiences, and relationships; (4) an emphasis on past experiences; (5) a focus on a patients interpersonal experiences; (6) an emphasis on the therapeutic relationship; and (7) an exploration of patients wishes, dreams, or fantasies. In the other article (Blagys & Hilsenroth,

No 1:36, 26 2002), six techniques and interventions were found to distinguish CBT from psychodynamic interpersonal therapy: (1) use of homework and outside-of-session activities; (2) direction of session activity; (3) teaching of skills used by patients to cope with symptoms; (4) emphasis on patients future experiences; (5) providing patients with information about their treatment, disorder, or symptoms; and (6) an intrapersonal/cognitive focus.

Those articles are valuable as summaries, but it seems that they can give an exaggerated view of the differences between CBT and PDT.

First, the authors want to make a contribution to the understanding of distinctive factors in treatment versus common factors. But then it seems necessary to use the distinction between interventions which are distinctive in the sense unique for one kind of psychotherapy, and distinctive in the sense more important in one kind of psychotherapy than in another. This is because features which are more important in one kind of treatment than in another, can still be a therapeutic factor common for the psychotherapy schools, while a unique feature can not be a common factor.

For example, use of homework and outside-of session activities are probably unique for CT and CBT, but the third point about PDT, identification of patterns in the patients actions, thoughts, feelings, experiences, and relationships are obviously not unique for PDT, but are perhaps more important in PDT than in CBT.

Reviewing the practical similarities and differences between PDT and CBT (and sometimes also in comparison with CT) as a starting point, there is evidence for two conclusions. First, the view is strengthened that the differences between the orientations is often more a question of degree than a question of really unique features, and second, the differences seem to decrease when more experienced therapists are examined - but of course without disappearing completely.

In one analysis of similarities and differences in clinical practice between CT, CBT and PDT, two process datasets were used (Wiser, Goldfried, Raue & Vakoch, 1996). One, called the demonstration dataset, had a prototypic design and contained single-sessions with the same patient, with Aaron Beck (CT), Donald Meicenbaum (CBT) and Hans Strupp (PDT) as the

No 1:36, 27 therapists. The other dataset, referred to as the change session dataset, contained 18 CBT sessions and 13 PDT sessions with therapists appraised as particularly competent therapists.

When those two datasets were evaluated together there seemed to be more failures to find differences than findings of actual differences between the orientations. No differences were found between CBT and PDT concerning the degree in which these two types of therapists focused on the patients general thoughts, intensions, and themes in their lives. Nor were there any differences regarding how the CBT and the PDT therapists focused on offering therapeutic support or psychoeducational information. However, there were differences, differences in degree, in what the therapists were focusing on. The most general findings were that CT practitioners were most attuned to the patients cognitions about self, world and future, CBT practitioners were most attuned to behavior and emotions, and PDT practitioners to patterns and remote past. CT and CBT therapists were also focusing less on the patients past, and PDT therapists focused less on the patients future than CT and CBT therapists did.

Interestingly, there were many similarities between CBT and PDT, for example the depth of emotional experiencing was equal, while CT looked more distinct from PDT than CBT did. The authors also review a comparative-outcome study. They then give another example of how the same theme can be emphasized for different purposes in different schools. In both CBT and PDT the therapists try to challenge the patients view of reality, and while in CBT the effect was symptom relief, the reverse was the effect in PDT. This surprising result was clarified with an analysis of content. The CBT therapists message was that reality was not as bad as the patient thought, for example you are more courageous than you think, while the PDT therapists tried to reveal the patients own contribution to the problems, for example you must have contributed to the breakup of your marriage too. The authors conclude that perhaps in PDT the patients have to feel worse before feeling better. This is an example of how two kinds of psychotherapy can have a general theme in common, but nevertheless, the theme has different expressions in different psychotherapies.

In another study of carefully selected master therapists (Goldfried, Raue & Castonguay, 1998), with 22 cognitive-behavioral therapists and 14 psychodynamic-interpersonal therapists, the therapists had chosen clinically significant sessions, and especially clinically significant portions of the sessions. The authors made comparisons between both how the therapists of the two orientations acted during the sessions, and between how the clinically most signifi-

No 1:36, 28 cant portions of the sessions differentiate from the nonsignificant portions. There were differences between the two orientations. For example, the cognitive-behavior therapists were more likely to compare or contrast the patients functioning with the functioning of others, to encourage between-session experience and to work in a future time frame. By contrast, the psychodynamic-interpersonal therapists were more likely to focus on themselves, to highlight instances of more general themes in the patients life, and placed more emphasis on emotions during the significant portions of the session. However, the two orientations were different in only 15 % of the comparisons. On the other hand, 63 % of the comparisons between clinically significant versus nonsignificant portions of the session yielded differences. In the clinically significant portions of the sessions the clinicians appeared to reflect a blending of both orientations, and the interventions were less pure theoretically than in a manual-based treatment. For example, the therapists of both orientations focused more on the patients evaluation of their self-worth, their expectations of the future and their emotions. During the clinically significant portions, the therapists of both orientations were also more likely to encourage patients to view things more realistically. So in this study the similarities between these master therapists seemed more extensive than the differences, and the differences between the two orientations consisted of how much they focused on some themes.

A similar view appears in two articles concerning how sixty-five psychotherapists formulated case formulation and treatment plans in response to six patient vignettes. The investigation analyzed similarities and differences regarding both theoretical orientation; CBT or PDT, and level of experience; novice, experienced, and expert therapists (Eells & Lombart, 2003), as well as the quality of the case formulations (Eells, Lombart, Kendjelic, Turner & Lucas, 2005). There were some differences between the two therapy orientations. For example PDT therapists placed more emphasis on factors like coping/defenses and childhood history, and CBT therapists on symptoms and problems. CBT therapists also predicted greater improvements from therapy. However, expert therapists of both orientations had much in common, compared to the novice and experienced therapists. Regardless of theoretical orientation, the expert therapists demonstrated overall superiority of the case formulations skills. They also viewed the information available in the vignettes as less adequate than the other therapists did, and they recommend longer treatments than both novice and experienced therapists did.

In summary, it is hard to find unique characteristics of PDT in comparison with CT/CBT in the empirical literature, with the exception of the use of homework and outside-of-session ac-

No 1:36, 29 tivities in CT/CBT. To a great extent both orientations are interested in the same phenomena, but with different accentuation. The differences are more in degree than in the kind of ingredients, but of course, also differences in degree can be important. Nevertheless, the differences seem to decrease when therapists are more experienced, and therapists of both orientations seem to have the ability to adjust to the need of the individual patient.

Conclusions from empirical research Regarding conclusions from empirical research about psychotherapy we not only know that psychotherapy usually is effective, we also know that at least four elements are effective (the alliance, cohesion in group psychotherapy, empathy and goal consensus and collaboration) and furthermore we know how important the therapists personal qualities are. Besides the importance of these four elements and the personal qualities of the psychotherapist, it is unclear if specific ingredients have additional effects. Because of this, continued research concerning whether some forms of psychotherapy are more effective for some disorders or not is important, an approach used by Roth and Fonagy (2005).

Comprehensive summary of similarities and differences between the schools


The founders of the most important therapy schools of psychotherapy were aware of similarities as well as of differences between their own school and the orientation of others. Although the founders recognized the occurrence of common factors among different therapies, they generally focused more on what distinguished their own orientation from the others schools. Their followers have generally brought the orientations closer to each other regarding what they see as valuable elements in clinical practice (for example empathy and other aspects of the therapeutic relationship). Also with regard to some theoretical questions (such as the occurrence of a defense like avoidance) the views of the more prominent representatives of different schools have become more similar. At the same time, the followers have preserved their own theoretical approach and the idea of unique valuable elements in their own form of psychotherapy. As a consequence of increased similarities between the schools, an organized integrative movement has arisen. An important impetus for this development toward increased emphasis on similarities rather than differences has been the results from psychotherapy research. This has shown that: (1) different kinds of psychotherapy can be effective for many disorders, (2) effective as well as probably effective elements, which apparently can exist in different kinds of psychotherapy, have been identified, and (3) differences in effective-

No 1:36, 30 ness between psychotherapists can be at least equally important as differences between schools of psychotherapy. Although the similarities have increased and many psychotherapists nowadays regard themselves as integrative or eclectic, the idea of separate therapy schools still remains an important one within psychotherapy.

Conclusions for the future


Presumably this development towards increased similarities will continue, although it is difficult to predict in what way this will happen. Once upon a time - more exactly during the 1960s - we had three great schools of psychotherapy: psychodynamic therapy, behavior therapy and the humanistic therapies. However, compared with the 1960s, the field of psychotherapy now looks very different, due to the development of psychotherapy research, new theories of child development, the appearance of cognitive therapy, and a lot of creative thinking. As a result of this, many new forms of psychotherapy unite features from the older forms of psychotherapy schools.

Furthermore, the differences will probably become smaller in the future. According to Beitman, Goldfried and Norcross (1989) research indicates that the only difference between eclectic therapists and noneclectic therapists is that eclectic therapists are more experienced. Presumably the same is true for psychotherapy as a movement which is true for the individual: with a longer history integrative ambitions become more appropriate. An important step in this direction is the development of APT, affect phobia therapy (McCullough & Andrews, 2001). The therapists who developed this treatment were psychodynamic therapists interested in short-term dynamic psychotherapy (STDP), and APT contains psychodynamic themes such as the resolution of conflicts. At the same time the main theme in this therapy is the stepwise exposure to feelings and defense response prevention, a process the authors describe as systematic desensitization, using a term from behavior therapy. In APT psychotherapy sessions are videotaped and used as homework, and the authors maintain that they use interventions from cognitive, behavior, Gestalt, experiential therapy and self-psychology. This means that the integration in this therapy, which includes common factors, technical eclecticism and theoretical integration, is so extensive that it is nearly meaningless to characterize this therapy as belonging to one school of psychotherapy rather than another. APT has been used in treatment of personality disorders in the cluster C in the DSM diagnostic system and was equally effective as CBT (Svartberg, Stiles, & Selzer, 2004). If APT becomes influential then it will

No 1:36, 31 probably be more common in the future that psychodynamic therapy includes elements such as homework and exposure in treatment of many anxiety disorders. On the other hand, there is an increased focus on emotion in newer CBT therapies, and it is possible that this interest will increase in the future (Samoilov & Goldfried, 2000). So in a short time perspective a likely development is a continued blending of elements from different psychotherapy schools.

Regarding psychotherapy in a long-term perspective, it is probable that the process of integration will increase on a more theoretical level. Presumably the most important factor in this process is academic psychology, and not just psychotherapy research. The founder of modern psychotherapy, Freud, aimed to create not only a clinical theory, but also a general psychology. However, Freud had a skeptical attitude to whether psychoanalysis needed academic psychology, which delayed the integration of psychodynamic theory and academic psychology, but an expansion in that direction seems to be an inevitable development (Eagle, 1987, Kandel, 1998, Kandel, 1999, Wakefield, 1992, Westen, 1998). As a consequence of this, it will be more common to regard psychoanalysis as an empirical science. Integrative attempts seems to be frequent not only in the psychotherapy area, but in psychology generally, for example in developmental psychology (Green, 2003) and in personality psychology (Block, 2002, Mayer, 2005). Another result of increased influence from academic psychology would be that when clinicians continue to develop clinical theories, they will not only lean on their clinical experience, it will also be more common to use academic psychology to create theories. For instance, Westen (2000) has used theories on associative networks, affect regulation and social cognition, in an attempt to integrate psychodynamic and cognitive-behavioral theory and technique. Research-founded theories like John Bowlbys attachment theory and Daniel Sterns theory of the childs self development, have already been influential among clinicians from different schools of psychotherapy. It also seems as if clinical psychology and developmental psychology often are interested in the same subjects. For example, in psychoanalysis interest in the self has increased (Mitchell, 1991, Stolorow, 1995) and the self concept is common in cognitive psychology (Beck, Freeman & Davis, 2004, Leahy, 2001) and also in developmental psychology (Stern, 1985, Diamond & Marrone, 2003). These integrative trends in psychology indicate that psychotherapy might become more and more grounded in research in the future, and less and less based on the original theories from the different psychotherapy orientations, so psychotherapy will become a matter of applying a common empirical science (Grave, 1997).

No 1:36, 32 To conclude, the commonalities between the schools of psychotherapy have increased, new forms of psychotherapy have appeared with many differences from the original psychotherapy schools, and there are reasons to believe that in the future it will be less and less meaningful to classify orientations in psychotherapy with those concepts about psychotherapy schools, which were developed as a system of classification during the twentieth century.

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