Psychotherapy

   The last half of the eighteenth century saw a big upsurge of interest in using the doctor–patient relationship therapeutically, which is the essence of medical psychotherapy. In France after 1750, there had been much writing on "la médecine de l’esprit," or psychological medicine, and a number of English physicians had discoursed on the subject as well. The first systematic psychotherapies do not, however, appear until the 1880s.

   On "moral treatment," in the sense of psychological treatment, ca. 1800, see MORAL TREATMENT.

   Bernheim introduces the first systematic psychotherapy of "suggestion" (1883). Hippolyte Bernheim (1840–1919), professor of medicine at the University of Nancy in France, had learned from a general practitioner in Nancy (Ambroise-Auguste Liébeault [1823–1904]) how to reproduce "hysterical" phenomena with hypnotism, or "suggestion." Yet, Bernheim discovered as well that nonhypnotic suggestion, simply giving the patients instructions in a normal voice, could also produce and abolish hysterical phenomena. In an eight-part series of articles in the Eastern Medical Review (Revue Médicale de l’Est) in 1883, Bernheim explained that nonhypnotic suggestion had applications going beyond the treatment of hysteria. He asked rhetorically, "To what point are passions, instincts, tastes, and psychic faculties capable of being modi-fied by prolonged and skilfully conducted suggestive therapy, either in the waking state or under hypnosis?" (p. 93 from his 1884 book, On Suggestive Therapy under Hypnosis or in the Waking State [De la suggestion dans l’état hypnotique et dans l’état de veille]) .

   First modern use of term "psychotherapy" (1887). Under the influence of Bernheim and the "Nancy school," two Dutch physicians, Frederik Willem van Eeden (1860–1932) and Albert Willem van Renterghem (1845–1939), opened in 1887 a "clinic for suggestive psychotherapy" in Amsterdam. The clinic was devoted entirely to hypnotherapy, and the two doctors reported their first results in 1889 in the book Clinic in Suggestive Psychotherapy (Clinique de psycho-thérapie suggestive), published in Brussels.

   See Freudian Psychotherapy: Technique (from 1893).

   Dubois’ "rational psychotherapy" (1904). Paul Dubois (1848–1918), a family doctor in Berne, Switzerland, who drifted into psychotherapeutics via electrotherapy, was the wellspring of the most important international psychotherapy movement before Freud: Dubois’s rational psychotherapy, sometimes called "the persuasion method." Dubois, who shared the confidence of the liberal middle classes of the latenineteenth century in reason, believed that psychoneurosis could be overcome in rational discussions with patients about their personal histories and the origin of their symptoms. He became the professor of neuropathology in Berne in 1902, and in his influential book The Psychoneuroses and their Psychological Treatment (Les Psychonévroses et leur traitement moral) that he published 2 years later (1904), he wrote that "for neurasthenia there is another psychotherapy altogether [than Bernheim’s suggestion], a kind of psychological training that does not try to conjure away fatigue but to make it disappear by slowly suppressing its principal cause: emotivity" (p. xxiii). Dubois’s rational psychotherapy may be seen as an ancestor of today’s "cognitivebehavioral therapy."

   Jungian psychotherapy (from 1911). See Jung, Carl Gustav.

   "Milieu therapy": beginning of (1925). In 1918, August Aichhorn (1878–1949), a child-welfare specialist working for the city of Vienna in charge of organizing pediatric emergency services during the First World War, was asked to oversee a residential center for delinquent youth on the site of a former refugee camp in the Viennese suburb of Oberhollabrunn. Shortly thereafter, Aichhorn began his own training in psychoanalysis and attempted to model the education of these youngsters along psychoanalytic principles.

   His book about these experiences, Wayward Youth (published in 1925 in German as Verwahrloste Jugend and translated into English in 1935), represented the first attempt to implement the principles of milieu therapy, recognizing the therapeutic nature of interactions within the setting itself. (See Conduct Disorder.) Aichhorn and the school’s pediatric-psychiatrist consultant Erwin Lazar (1877–1932) first allocated the pupils [Zöglinge] into psychologically more or less homogeneous groups, then resolved to let the groups themselves undertake the work of reform: "The more that the collective life of the pupils in the group alone—without further pedagogic measures— therapeutically improves dissocialization, the better is the allocation to the groups. So the question is: which delinquents have to be sorted with which, in order to achieve from the simple act of living together the best preconditions for re-socialization?" (p. 187 of the German ed.).

   Aichhorn contrasted his own residential school with the typical Austrian reform schools for bad adolescents: "It was clear to us from the very beginning at the simple emotional level that we had to bring some fun [Freude] into the lives of boys and girls and young people from the ages of fourteen to eighteen. It had never occurred to any of us to see them as delinquents or even criminals from whom society had to be protected; for us they were people on whom life had imposed too great a burden, whose negative attitudes and hate of society was justified; a milieu therefore had to be created for them in which they could feel at ease. And in fact that just sort of happened automatically" (p. 192).

   Narcotherapy. See Barbiturates: narcotherapy (1930).

   Group psychotherapy. Since the nineteenth century, psychiatrists have realized that therapeutic benefits occur when patients work, play, and collaborate together. In 1842, William Alexander Francis Browne (1805–1885), who had just become medical officer of the newly established Crichton Royal Hospital in Dumfries, Scotland, began to encourage patients to stage amateur theatricals involving "farces, vaudevilles [and] comedies by members of their own community, by those participating in their own infirmities." He saw these efforts as an aspect of "mental therapeutics," "a means of calling forth neglected energies, of diffusing bustle, and expectation, and enjoyment where all is generally dead and dull and dark, of creating sources of happiness on the very limits . . . of surveillance" (Journal of Mental Science, 1864, p. 333). Beginning in 1911, Jakob Moreno-Lewy (1892–1974), at the time a medical student in Vienna, began organizing for young people, in entirely nonmedical settings such as taverns, a kind of impromptu theater, or "immediate" theater, that he called Stegreiftheater. He went on to train briefly in psychiatry under Wagner-Jauregg; in 1922, while serving as a factory doctor in the Viennese suburb of Bad Vöslau, Moreno established in the city center a permanent impromptu theater; he described his dramaturgical techniques the following year in the small book Impromptu Theater (Stegreiftheater). In passing he noted that impromptu techniques could have medical applications as well (later called "psychodrama"): "Life is the inhaling of the soul, impromptu the exhaling. Through inhaling, poisons (conflicts) arise; through impromptu they are once again discharged. On this basis rests its therapeutic significance" (p. 71). Yet, at this point he did not use the term "group therapy," however implicit it may have been in his approach.

   Moreno emigrated to the United States in 1925. At a luncheon for the National Committee on Prisons and Prison Labor in 1931, Moreno had suggested the introduction of group psychotherapy at Sing Sing Prison in New York State. This proposal received written form in the National Committee’s Application of the Group Method to Classification ("second edition") in 1932, and Moreno reprinted parts of it in 1971 under the title The First Book on Group Psychotherapy, "third edition." It must be pointed out, however, that group psychotherapy was already a reality at several U.S. institutions as early as 1930, although these innovations were not widely reported. In 1930, Louis Wender (1890–1966), chief psychiatrist at Hillside Hospital, then at Hastings-on-Hudson, introduced for economic reasons what he called "group psychotherapy": Sitting about and talking with the patients was cheaper than individual psychotherapy.

   In an article in Mental Hygiene in 1939, Paul Schilder explained that classical psychoanalysis was too long and expensive to be practical for most patients. "A year and a half ago," he said, "I began an experiment in group psychotherapy in the Out-Patient Department of the Psychiatric Division of Bellevue Hospital [in New York]." Groups of two to seven patients under the leadership of a physician would meet several times a week. The patients were encouraged to gain psychoanalytic insights, and they would have to file a written report after they had achieved them. Schilder also handed out "elaborate" questionnaires. Subsequent techniques of group therapy differed so radically from Schilder’s that it is difficult to see him as having priority with the concept of "group." Yet he appears to have popularized the phrase.

   Apparently ignorant of Schilder’s usage, in 1943 in the Lancet, two British military psychiatrists, Wilfred R. Bion (1897–1979) and John Rickman (1891–1951), seconded from the Tavistock Clinic and who had been at Northfield Military Hospital near Birmingham, described the analysis of "intra-group tensions" as the task of "group therapy." They wrote as though the term were already quite familiar. Bion drafted the part of the report dealing with rehabilitation ("therapeutic cooperation" at group meetings discussing the program) (p. 678) and Rickman the part on "group therapy in a small ward": He dilated upon patients’ "personal difficulties in putting the welfare of the group in the first place during their membership of group" (p. 680).

   "Therapeutic community" (from 1939). Also known as "milieu therapy" (see above). In 1938, Joshua Bierer (1901–1984), a Viennese psychologist who had trained with Alfred Adler (1870–1937) and had acquired experience doing group psychotherapy in Palestine in the 1920s and Vienna in the 1930s, fled to England. In 1939, he was taken on as a psychotherapist at Runwell Hospital, an asylum in Essex, where he proceeded to help the patients organize a self-governing social club, the first therapeutic community in a psychiatric setting. (He described this work in the Journal of Mental Science in 1941, then again in an article on "Group Psychotherapy" in the British Medical Journal in 1942.) Bierer referred to the technique as " ‘community’ treatment."

   Shortly thereafter, at Mill Hill Emergency Hospital, where part of the Maudsley Hospital had removed during the Second World War, Maxwell Jones (1907–1990), a young Scottish staff psychiatrist, noted that a self-help group the patients themselves had organized was having an energizing effect. He encouraged them to begin doing some psychodrama and, by 1944, it was clear to Jones that group interactions in and of themselves were therapeutically beneficial. Beginning in 1945, Jones and co-workers organized these ideas on a larger scale at the Southern Hospital at Dartford in Kent, where interest in "therapeutic communities" was now considerable. Jones described this work in 1952 in his book Social Psychiatry: A Study of Therapeutic Communities. The phrase "therapeutic community" itself was coined by English psychiatrist Thomas ("Tom") Main (1911–1990) in an article in the Menninger Clinic Bulletin in 1946 on a therapeutic "setting" he had encouraged at Northfield Military Hospital, as toward the end of the war he was appointed there. (See Tavistock Clinic.) Main’s concept emphasized close emotional contacts among staff themselves and between staff and patients. Under the subheading "a therapeutic community," he explained that "The Northfield Experiment is an attempt to use a hospital not as an organization run by doctors in the interests of their own greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the resocialization of the neurotic individual for life in ordinary society" (p. 67).

   Bion and John Rickman helped import the notion of group therapy to the Tavistock Clinic once they resumed work as staff members.

   The American story (after 1945). After the Second World War, the United States came to dominate the international psychotherapy story. Ironically, it was in psychotherapy systems practiced more by psychologists than psychiatrists that American psychiatry first started to make its world impact. After the Second World War, virtually no more novel psychotherapy systems originated in Europe: all were American. Owing little to Freud, Jung, or any of the other classic writers, the American psychotherapies disclaimed the doctor–patient hierarchy and could also be administered by psychologists and social workers to "clients." In international persective, they proved to be world-beaters.

   "Therapeutic community" in the United States (from the late 1940s.) Anglo-Saxon notions of therapeutic community crossed the Atlantic quickly. Beginning in the late 1940s, patient self-government in the United States blossomed at the Boston Psychopathic Hospital—in 1956 renamed the Massachusetts Mental Health Center ("Mass Mental")—under the leadership of assistant superintendent Robert W. Hyde (1910–?), who is also remembered for having brought research on LSD (see Hallucinogen) to the United States. In the mid-1950s, Milton Greenblatt (1914–1994), who had been on staff during this reform period and who became director of clinical psychiatry at Mass Mental, headed a team sponsored by the Russell Sage Foundation that aimed at implementing such reforms at other Massachusetts mental hospitals. Greenblatt’s 1955 report, From Custodial to Therapeutic Patient Care in Mental Hospitals, concluded that various new somatic therapies together with "the therapeutic use of the social environment" could return a large number of patients to the community. In 1961, these concepts received a powerful push in the United States with the report of the Joint Commission on Mental Illness and Health, Action for Mental Health. The commission had been struck in 1955 as a joint project of the American Medical Association and the American Psychiatric Association and was supported by Congress. Headed by Jack R. Ewalt (1910–), the Massachusetts commissioner of mental health, it was ultimately joined by 36 other organizations. Among the reports subcontracted by the joint commission, there was one on patient care by Brandeis University sociologist Morris S. Schwartz (1916–), who had been co-author with psychiatrist Alfred H. Stanton (1912–1983) in 1954 of an influential study of the hospital as social setting (The Mental Hospital). Their basic recommendation of the principles of the therapeutic milieu made it into the main 1961 report ("the new mental hospital: a therapeutic community," p. 46), although Schwartz’s book, cowritten with Charlotte Green Schwartz, Social Approaches in Mental Patient Care, was not published until 1964. The authors argued that creating a "therapeutic milieu" in a psychiatric hospital involved (1) making the institution as a whole "democratic, treatment-oriented [and] flexible"; (2) encouraging the staff to be "sympathetic, friendly, and respectful to patients"; and (3) using the milieu to achieve specific effects with patients, such as "accept[ing] the idea that he is ill, develop[ing] insight into the reasons for his illness," among other objectives (pp. 164–165).

   Carl Rogers’s "client-centered therapy" (from 1946). With Rogers, the transition of psychotherapy begins from the hands of physicians and psychoanalysts to those of clinical psychologists and psychiatric social workers. Rogers’s client-centered therapy was "humanistically" oriented, unlike theory-based Freudian, biological, and behavioral therapies, and opened a new chapter in the history of psychotherapy. As Harry Specht (1929–1995), Dean of the School of Social Welfare at the University of California at Berkeley, noted in the Social Service Review in 1991, "The journey of the [social work] profession over this century appears to end here [with Rogers] as social workers become part of the institution of popular psychotherapy, one of the major battalions in the armies of the secular priesthood to carry forth the tenets of the church of individual repair" (p. 353).

   Carl Rogers (1902–1987) graduated with a Ph.D. in clinical psychology at Columbia University in 1931 and taught at Ohio State University until 1945, when he went to the University of Chicago to start a counseling center. In 1940, in the Journal of Consulting Psychology, Rogers outlined some of his ideas without using the term "client-centered therapy." His landmark article, "Significant Aspects of Client-Centered Therapy," appeared in American Psychologist in 1946, describing a therapeutic procedure with a "predictable" outcome in which the therapist played only a "cathartic role." The article seized what was to be the core of Rogers’s approach and that of the human potential movement: "Within the client reside constructive forces whose strength and uniformity have been either entirely unrecognized or grossly underestimated." The therapy was orderly and predictable because the therapist simply relied upon those forces. Catharsis and insight in therapies were not new, he said. "But we have not known or recognized that in most if not all individuals there exist growth forces, tendencies toward self-actualization, which may act as the sole motivation for therapy." "All of these capacities I have described are released in the individual if a suitable psychological atmosphere is provided."

   After a brief stint at the University of Wisconsin, Rogers took a research position at an institute in La Jolla, California, remaining there until his death. Rogers’s first book on the subject was his Client-Centered Therapy (1951). As Rogers’s approach developed, it came to have the following features (as he explained in Silvano Arieti’s psychiatry textbook [1966]): (1) a therapeutic climate in which the therapist conveys to the patient his "congruence," or genuineness, his "unconditional positive regard" for the patient (meaning complete acceptance of the patient as he or she is); and a "sensitively accurate empathic understanding." (2) "Client-centered" meant the therapy’s focus on the patient’s "phenomenal world," the patient’s immediate thoughts and experiences rather than offering advice or interpretations from outside. (3) The central objective of therapy was change and growth in the human personality, feeding into the "human potential movement," with which Rogers’s name was closely associated alongside Friedrich ("Fritz") Perls (1893–1970) (see GESTALT THERAPY) and others.* By the early 1960s, it was clear to Rogers and his circle that this kind of growth could be stimulated in intensive group experiences, sometimes called "T-Groups," "Sensitivity Training Groups," "Basic Encounter Groups," and the like.

   Rogers thought of his client-centered approach as a kind of "third force" in American psychology, alongside Freudian psychoanalysis and behaviorism. Rogers played "a major role," as Peter Steinglass puts it, "in wresting the practice of psychotherapy from psychiatry alone and distributing it into the hands of psychology and other disciplines" (Steinglass in Kaplan, Comprehensive Textbook of Psychiatry, sixth ed., p. 1866).

   The term "milieu therapy" becomes popularized by Bruno Bettelheim (1948). Bettelheim (1903–1990), another Viennese, had studied psychology at the University of Vienna (he had a year of psychoanalysis with Richard Sterba [1898–1989]), then emigrated to the United States in 1939 where he began an academic career in the Chicago area teaching psychoanalytically oriented psychology, mainly at the University of Chicago. In 1944, he became director of the Sonia Shankman Orthogenic School, a residential treatment center for disturbed children at the university. Many of the children were autistic, and it was in this context that, in an article in the * Fritz Perls’s Gestalt therapy is the one exception to the claim that the postwar psychotherapy systems in the United States were homegrown.

   American Journal of Orthopsychiatry in 1948 on "A therapeutic milieu," he and collaborator Emmy Sylvester (1910–), a child psychiatrist and psychoanalyst, elaborated the term "milieu therapy": "A therapeutic milieu is characterized by its inner cohesiveness which alone permits the child to develop a consistent frame of reference. . . . Emphasis on spontaneity and flexibility . . . makes questions of schedule or routine subservient to the relevance of highly individualized and spontaneous interpersonal relationships" (p. 192). As the authors observed in the Psychoanalytic Review in 1949, "Milieu therapy is not new as a psychotherapeutic technique. It is no more than the application of psychoanalytical concepts to the specific task of creating a setting for emotionally disturbed children who are in need of residential treatment." Among Bettelheim’s many publications arising from the Orthogenic School, perhaps his best known is The Empty Fortress (1967). (See Autism.) The book had virtually nothing to say about therapeutic community and analogized at length between the situation of autistic children and concentration camp inmates: "Infantile autism is a state of mind that develops in reaction to feeling oneself in an extreme situation, entirely without hope," comparable to those death-camp prisoners, called by the prisoners "moslems," who too had abandoned hope (p. 68). The nature of the therapies Bettelheim actually practiced at his school has subsequently become enveloped in controversy (see Nina Sutton, Bruno Bettelheim: the Other Side of Madness, translated from French in 1995), but the principles that he enunciated in his publications have been highly influential.

   Family therapy (from 1956). Although mental-health professionals have always considered the patient’s relationship to other family members, "family therapy" as a field implies counseling various family members together in the same room, usually with schizophrenia as the focus. Nathan Ackerman (1908–1971) is generally considered the founder of the field. While a staff psychiatrist at the Menninger Clinic (where he had trained), in 1937 Ackerman wrote an article in the Bulletin of the Kansas Mental Hygiene Society on the centrality of the family in mental illness. The landmark event in the history of family therapy is his cofounding in 1956 of the "family mental health clinic" (of which he was director) at the Jewish Family Service in New York; he was also an associate clinical professor at Columbia University. In 1958, Ackerman wrote in his book The Psychodynamics of Family Life: Diagnosis and Treatment of Family Relationships, "Over a span of time the critical focus of conflict and anxiety may move from one family member to another or gravitate first to one family pair and then to another. . . . The patterns of interpersonal conflict within the family affect the vicissitudes of control of internalized conflict" (p. 11). In other words, it was the family as a whole, not the identified patient, that was ill.

   Simultaneously, a group was forming in Palo Alto, California, to examine the psychotherapy of schizophrenia. In 1952, Gregory Bateson (1904–1980), an anthropologist at the Palo Alto Veterans Administration hospital, had received a Rockefeller grant to study communication, and in 1954 he launched a research project on "schizophrenic communication." In 1956, Bateson, Donald D. Jackson (1920–1968), who was a psychiatrist and psychoanalyst, Jay Haley (1923–), a psychotherapist whom Bateson recruited for the schizophrenia project, and psychotherapist John H. Weakland (ca. 1919–1995) contributed an article to the first volume of the journal Behavioral Science, in which they described a family communications theory of schizophrenia. They maintained that within the family the patient is in a " ‘double bind’—a situation in which no matter what a person does, he ‘can’t win.’ " As part of this project, in 1959 Jackson founded the Mental Research Institute in Palo Alto, the focus of which was schizophrenia. Even though the leaders of family therapy declared their debt to the European psychoanalytic tradition, family therapy and Rogers’s client-centered therapy count as the first genuinely American contributions to the international science of psychiatry in the twentieth century. They owed little to psychoanalysis and instead, as "popular psychotherapies," had their roots in American "mind cure" traditions of the nineteenth century.

   Cognitive-behavioral therapy (CBT) (from 1963)

   (See Cognitive-Behavioral Therapy.)

   CBT in the United States is heavily associated with the work of psychiatrist Aaron Beck (1921–). Its roots go back to the work of Pierre Janet and Paul Dubois (1848–1918) at the turn of the century.

   "Interpersonal psychotherapy of depression" (from 1967). Inspired by the approach of Harry Stack Sullivan to interpersonal relations in illness, beginning in 1967 the members of the New Haven-Boston Collaborative Depression Research Project, led by Gerald Klerman, set out to develop a brief, focused form of psychotherapy for the ambulatory depressed patients in the project. They first field-tested the procedure on 150 "neurotic depressed female patients," finding no significant difference between those on the antidepressant amitriptyline (see Imipramine and Tricyclic Antidepressants) and those on psychotherapy (announcing their findings in 1974 in the American Journal of Psychiatry). After extensive field testing, there followed in 1984 a definitive manual of IPT: Interpersonal Psychotherapy of Depression: A Brief, Focused, Specific Strategy. The authors were Klerman, who died just before the book was published; his wife Myrna Weissman (1935–), a professor of psychiatric epidemiology at Yale University; and Bruce J. Rounsaville (1949–), a professor of psychiatry at Yale. As they explained, "We are convinced . . . that clinical depression occurs in an interpersonal context and that psychotherapeutic interventions directed at this . . . context will facilitate the patients’ recovery from the acute episode and possibly have preventive effects against relapse" (pp. 5–6). Although the authors acknowledged the influence of several psychoanalytic thinkers, they emphasized that IPT was not intended to work upon the unconscious, but rather upon "current disputes, frustrations, anxieties, and wishes" arising from the patient’s current social relations: "The work focuses on the ‘here-and-now’ " (p. 7).

   The discovery that psychotherapy produces brain changes (1996). A team of researchers at the University of California at Los Angeles led by Jeffrey M. Schwartz (1951–) of the department of psychiatry discovered that successful treatment of obsessive-compulsive disorder (OCD) with psychotherapy—cognitive-behavioral therapy—produced actual physiological changes (changed glucose metabolism) in those parts of the brain thought to be responsible for producing the symptoms of OCD; namely, the caudate nucleus and adjacent circuits. The research, published in the Archives of General Psychiatry in 1996, involved neuroimaging with positron emission tomography (PET) and a radiolabeled form of glucose. The discovery is of interest because it suggests the effectiveness of psychological treatments at the biological level.