Similarities and differences between the schools of psychotherapy

Billy Larsson

Department of Psychology, Göteborg University, Sweden

In empirical research about psychotherapy it is usual to discuss similari-ties and differences between the schools of psychotherapy. It is more un-common to analyze the historical roots for these discussions. This over-view describes the subject of similarities and differences between the most common orientations in psychotherapy from a number of perspec-tives. First there is a discussion about how the founders of different psy-chotherapy 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 orienta-tions 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 sub-

ject (Thomson, 1968, Leahey, 2001). This view entails that before the appearance of psychol-

ogy with scientific demands, we already had two kinds of psychological theories: philosophi-

cal theories and theories embedded in folk-psychology. Although the word “psychology” ap-

peared 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 psy-

chology and Freudian psychoanalysis.

The same dual phenomenon is probably true for psychotherapy. The term psychotherapy ap-

peared 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 magnet-

ism 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 scien-

tifically educated psychotherapist.

Although psychotherapy has a long history, the history of professional psychotherapy in Swe-

den is rather short. Admittedly, Freud’s psychoanalysis was introduced for Swedish physi-

cians 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 (Öst, 1996). Cognitive therapy was intro-

duced in the early 1980’s and a Swedish association for cognitive therapy was established in

1986 (Törneke, 2005). So during a large part of the twentieth century, Sweden only had a few

hundred people working with psychotherapy, but since the 1980’s this has changed dramati-

cally.

The first Swedish education in psychotherapy at a university level started in 1978 (Öst, 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 regis-

tered 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 psy-

chotherapy, 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 psy-

chotherapist. 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 psycho-

therapists working with adults in individual psychotherapy, is now a research project at Göte-

borg University. In the international literature questions about similarities and differences be-

tween 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 ingredi-

ents are supposed to make psychotherapy effective, (2) are those proposed effective ingredi-

ents 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 ob-

served.

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 criti-

cized at the end of the twentieth century (Cioffi, 1998, Esterson, 1993, Webster, 1995), but

Freud’s own opinion will not be questioned here, because irrespective of whether Freud’s

work meets scientific standards or not, he laid the foundation for modern psychotherapy. Psy-

choanalysis 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 psychothera-

peutic tool viewed in a longer historical perspective, but in the early history of psychoanalysis

No 1:36, 4

somatic treatments were so popular, that Freud’s proclamation of this special form of treat-

ment 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 Psycho-

Analysis (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 Freud’s new “sci-

entific psychotherapy” could be effective was a common factor between them, namely the re-

lationship 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 phy-

sicians that these diseases are not cured by the drug but by the physician, that is, by the per-

sonality 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 scien-

tific 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 effec-

tive. 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 psy-

choanalysis 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 Freud’s theories and therapies. During Freud’s lifetime be-

haviorism was a kind of academic psychology and seldom a kind of psychotherapy, so com-

parisons 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 twen-

tieth century, it seems that Freud was not particularly interested. Instead he preferred to de-

velop 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, al-

though he also presented critical views on psychoanalysis. In particular, Skinner was inter-

ested in applying his theory to psychoanalytic therapy. According to Skinner, the patient’s dif-

ficulties resulted from punishment. The therapist, therefore, constitutes himself as a nonpun-

ishing audience and does not criticize his patient in any way. If the patent criticizes the thera-

pist he avoids any signs of counteraggression. As the therapist establishes himself as a non-

punishing audience, behavior that has hitherto been repressed begins to appear in the reper-

toire of the patient. This behavior which was previously punished can now disappear by ex-

tinction, 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 patient’s 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 Watson’s time to the 1950’s a large number of behavioral principles were identified in

the laboratories where behaviorism was developed. However, it was not until the late 1950’s

and early 1960’s that those basic theories were explored with regard to their therapeutic appli-

cations. The people who first did this sometimes called themselves “behavior modifiers”.

Soon, however one of Skinner’s students settled on the term “behavior therapy”, and a rapid

development of this kind of psychotherapy ensued (Douger & Hayes, 2000). One of the earli-

est clinical books from this time, and the most influential, is Joseph Wolpe’s 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 re-

veals 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 therapist’s

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 behav-

iorism 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 Decem-

ber 11, 1940, when Carl Rogers gave a speech where he was critical of many of the psycho-

therapy 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 condi-

tions 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 psycho-

therapy. If other kinds of psychotherapy were effective and used special methods, the essen-

tial 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 mediat-

ing 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 tech-

niques 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 therapist’s personal skills. If psycho-

therapy 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, Beck’s original theory of de-

pression was founded in his clinical experiences, while at the same time many of the tech-

No 1:36, 8

niques in Beck’s therapy were directly borrowed from behavior therapy (Clark, Beck & Al-

ford, 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 re-

search from Rogers and Traux indicating that a successful outcome is facilitated if the thera-

pist 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 nec-

essary characteristics such as the capacity to respond to the patient in the atmosphere of a hu-

man 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 ade-

quately 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, tech-

niques are intended to be applied in a tactful, therapeutic, and human manner by a fallible per-

son – 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 pa-

tient. 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 therapist’s 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 Beck’s opinion is that the use of manuals

in therapy will increase the similarities among therapists.

No 1:36, 9

Beck has also emphasized that the therapeutic situation produces a quieting down of hyperac-

tivity. This effect can be the result of the therapist’s empathy and acceptance, specific relaxa-

tion instructions, or explicitly stated verbal approval (Beck, 1970). Beck and coworkers make

a related remark “Cognitive and behavior therapies probably require the same subtle therapeu-

tic 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 pro-

duce structural change by modifying the patient’s thinking, and they depend on “working

through” of intrapsychic problems (Beck, 1976).

Thus, Beck’s view of psychotherapy expresses several opinions. He claims that different

forms of psychotherapy can be effective and he emphasizes the personal qualities of the psy-

chotherapist 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 therapist’s 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 ingredi-

ents 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 Kohut’s self psy-

chology. 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 80’s and

on - no new important orientation of psychodynamic psychotherapy seems to have emerged.

Undoubtedly, IPT (interpersonal therapy) has some of its origins in psychodynamic psycho-

therapy, 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 develop-

ment of the child and of the therapeutic approach, with little interest in other psychotherapeu-

tic schools than psychoanalysis. However, one of the leading advocates of object relation the-

ory, Harry Guntrip, has made several interesting comments regarding other kinds of psycho-

therapy. His first view looks like an updated version of Freud’s distinction between sugges-

tive 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 rea-

son 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 con-

trary, aims at something more fundamental; long-term stabilizing change in the total personal-

ity (Guntrip, 1968).

Some years later, Guntrip (1972) was more positive to behavior therapy. First, behavior ther-

apy 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 re-

gards the study of “habit” and “repertoires of behavior patterns” in every day living is an im-

portant 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 psy-

chotherapy. Nevertheless, Kohut’s 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). Ko-

hutian 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 Freud’s. The cure is achieved by a

process in three steps: optimal frustration, nonfulfillment of the need, and substitution of di-

rect need fulfillment with a bond of empathy between self and selfobject. It does not seem like

Kohut’s interest in empathy makes him see more similarities with other forms of psychother-

apy. 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 interpreta-

tions as effective, just as Freud did, but with an increasing emphasis on the therapeutic rela-

tionship. 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 pri-

mary 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 dif-

ferences 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 psy-

choanalysis has been metatheoretical. The theoretical interest has been directed towards ques-

tions 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 simi-

larities 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 psycho-

dynamic 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 psy-

chotherapy (Kaslow & Magnavita, 2002), devoted to psychodynamic/object relations thera-

pies. 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 rele-

vance of neuroscience, building interdisciplinary bridges between for example cognitive sci-

ence, affective science, developmental science and evolutionary science. He finishes the chap-

ter 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 tech-

niques that work, and an abandonment of those techniques which fail to prove their effective-

ness.

Cognitive behavioral therapy

Since the beginning of cognitive-behavioral therapy (CBT) in the late 70’s, many new thera-

pies, such as functional analytic therapy, FAP (Kohlenberg, 1987), dialectical behavior ther-

apy, 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 de-

scribed as examples of the “third wave of behavior therapy” (Hayes, 2004). The first genera-

tion of behavior therapy was concentrated on directly changing behavior. The second genera-

tion added changing of thoughts, and the third wave of behavior therapy is directed at chang-

ing 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 disor-

ders (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 “metacog-

nition” (Wells, 2000).

As a result of this development, regarding the question of what makes psychotherapy effec-

tive; 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 addic-

tion 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, de-

scribed 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 Linehan’s (1997) concept of validation is espe-

cially interesting, because validation has many similarities with Rogers’s 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 mo-

ment; and (6) treating the person as valid – radical genuineness. The two first levels encom-

pass 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 valida-

tion 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 cogni-

tions/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 1990’s. Examples of this are the role of defensive processes, an

emphasis on the exploration of the therapeutic relationship and the patient’s interpersonal dy-

namics, 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 sup-

pression of private experiences in depression, substance abuse and sequelae of child abuse

(Hayes, Pankey, Gifford, Batten & Quiñones, 2002). Hayes and coworkers (1999) also point

No 1:36, 15

out that avoidance has been recognized in many therapies, such as behavior therapy, client-

centered therapy, gestalt therapy and existential therapy.

Another interesting trend in cognitive therapy is the use of terminology common in psycho-

dynamic theory about the interaction between the therapist and the patient, such as “transfer-

ence 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 psycho-

dynamic 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 hu-

manistic have recently been grouped together under “the experiential umbrella” (Elliott,

Greenberg & Lietaer, 2004), with therapies such as client-centered therapy, Gestalt, existen-

tial 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 influ-

ence 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 psycholo-

gists 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 em-

phasis 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, inter-

personal 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 re-

fers to Maslow’s 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 differ-

ent forces it is obvious that humanistic, interpersonal and existential psychotherapy have simi-

larities 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 patient’s experience, the therapeutic relationship

as potentially curative, and a person-centered view which involves genuine concern and re-

spect 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 confin-

ing 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 cross-

fertilization within the humanistic family, where each therapy has benefited from incorporat-

ing and integrating some characteristics of other approaches. Furthermore, the view of empa-

thy 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 psycho-

therapy 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 relation-

ship 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 ap-

proach 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 therapist’s personality. Rosenzweig’s opinion is still of great rele-

vance today, and his now famous article is one of the earliest roots of the integrative move-

ment.

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 fac-

tors 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 ac-

count 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 ele-

ments 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 theoreti-

cal 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 be-

lieve 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 exam-

ples 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 psycho-

therapy”. Furthermore, object relation theory has also been used in integrative attempts in

psychotherapy (Säfvestad Nolan & Nolan, 2002).

Conclusions about clinical trends

The conclusions from this overview of recent clinical trends seem obvious. The different psy-

chotherapy schools have really influenced each other. As a result of this the schools have be-

come 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 ef-

fective 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 Garfield´s Handbook of Psychotherapy and Behavior Change

(Lambert & Ogles, 2004). Bruce Wampold’s The great psychotherapy debate (2001) is

mainly an overview of meta-analyses. There are interesting differences between the conclu-

sions in Bergin and Garfield´s Handbook and in Wampold’s 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.

No 1:36, 20

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 ac-

counts 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, Lambert’s 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 meta-

analysis approach, ever since Smith and Glass (1977) presented the first meta-analysis. Ad-

mittedly, meta-analyses have often showed small differences in favor of cognitive and behav-

ior 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 Wampold’s conclu-

sion. According to them, in meta-analyses about comparative effectiveness there is a strong

tendency towards no differences, counterbalanced by indications that, under some circum-

stances, certain methods (generally cognitive behavioral) especially regarding anxiety disor-

ders, 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 Wampold’s 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 psycho-

therapists from different orientations. When Lambert and Ogles (2004) summarize the re-

search about differences in outcome between therapies, they too underline that there are im-

portant 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 pos-

sible that too much energy is devoted to technique studies, and that studying interaction ef-

fects (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 Wampold’s 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 orienta-

tion. 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

therapist’s theoretical orientation. Furthermore, in the medical model (5) the specific thera-

peutic ingredients are responsible for the patient’s progress; at least they will be overwhelm-

ingly 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 Frank’s view of psychotherapy (Frank & Frank, 1991). In this model specific ingredi-

ents 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 in-

gredients 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 don’t 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 him-

self (Frank, 1979, Frank & Frank, 1991), so Frank does not seem to be a supporter of a con-

textual model in Wampold’s sense. The conclusion from this is that Wampold seems to sub-

scribe 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 therapist’s theoreti-

cal orientation.

Effective elements in psychotherapy

The American Psychological Association’s 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 be-

tween different orientations or not, while there are considerable differences in the results be-

tween therapists with the same orientation, and this is true also when the therapists are compe-

tent 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 relation-

ship 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) re-

pairing alliance ruptures, (5) self-disclosure, (6) the management of countertransference and

(7) relational interpretations.

No 1:36, 23

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 start-

ing 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 APA’s 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 psy-

chotherapists. 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 co-

workers (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 self-

integration, 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.

No 1:36, 24

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 abil-

ity to form a warm, supportive relationship” (Luborsky, McLellan, Woody, O´Brien & Auer-

bach, 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 individu-

als in how extensive the reactions are (Binder & Strupp, 1997). The problem of handling hos-

tility from patients seems to be the same, because of “the enormous difficulty that human be-

ings, 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 therapist’s 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 communica-

tion which rose substantially after the training (Henry, Schacht, Strupp, Butler & Binder

1993). In cognitive therapy with depressed patients, therapeutic alliance and patients’ emo-

tional experiencing was related to improvement, but focus on more specific cognitive features

such as the link between distorted thoughts and negative emotions was, unexpectedly, corre-

lated 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 cog-

nitive 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 self-

representations are, to engage in a countertherapeutic process characterized by subtly hostile

and controlling interactions with their patients (Henry & Strupp, 1994). There is not necessar-

ily 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 communica-

tion 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 PDT-

therapies but does not exist in CBT or CT. Second, a phenomenon can appear on a more gen-

eral level in several therapies, but have different expressions in different therapies. For exam-

ple, one of Weinberger’s 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 ar-

ticle (Blagys & Hilsenroth, 2000), seven interventions stood out as distinguishing short-term

psychodynamic-interpersonal therapy: (1) a focus on affect and the expression of patient’s

emotions; (2) an exploration of patient’s attempts to avoid topics or engage in activities that

hinder the progress of therapy; (3) the identification of patterns in patient’s actions, thoughts,

feelings, experiences, and relationships; (4) an emphasis on past experiences; (5) a focus on a

patient’s interpersonal experiences; (6) an emphasis on the therapeutic relationship; and (7) an

exploration of patient’s 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 patient’s 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 dis-

tinctive in the sense more important in one kind of psychotherapy than in another. This is be-

cause 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 patient’s 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 de-

crease 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 ses-

sions 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 dif-

ferences 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 patient’s general thoughts, intensions, and themes in their lives. Nor were there

any differences regarding how the CBT and the PDT therapists focused on offering therapeu-

tic 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 prac-

titioners were most attuned to the patient’s cognitions about self, world and future, CBT prac-

titioners 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 patient’s past, and PDT

therapists focused less on the patient’s 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 patient’s 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 patient’s 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 thera-

pists, the therapists had chosen clinically significant sessions, and especially clinically signifi-

cant 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 differ-

ences between the two orientations. For example, the cognitive-behavior therapists were more

likely to compare or contrast the patient’s functioning with the functioning of others, to en-

courage 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 patient’s 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 orien-

tations, and the interventions were less pure theoretically than in a manual-based treatment.

For example, the therapists of both orientations focused more on the patient’s evaluation of

their self-worth, their expectations of the future and their emotions. During the clinically sig-

nificant portions, the therapists of both orientations were also more likely to encourage pa-

tients 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 improve-

ments 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 ingre-

dients, but of course, also differences in degree can be important. Nevertheless, the differ-

ences seem to decrease when therapists are more experienced, and therapists of both orienta-

tions 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 therapist’s personal qualities are. Besides the

importance of these four elements and the personal qualities of the psychotherapist, it is un-

clear if specific ingredients have additional effects. Because of this, continued research con-

cerning 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 similari-

ties 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 oc-

currence of a defense like avoidance) the views of the more prominent representatives of dif-

ferent 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 in-

creased emphasis on similarities rather than differences has been the results from psychother-

apy 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 ex-

ist 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 psychothera-

pists 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 diffi-

cult 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 ther-

apy and the humanistic therapies. However, compared with the 1960s, the field of psycho-

therapy 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 think-

ing. 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 Beit-

man, Goldfried and Norcross (1989) research indicates that the only difference between eclec-

tic therapists and noneclectic therapists is that eclectic therapists are more experienced. Pre-

sumably 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 sys-

tematic 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 treat-

ment 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 integra-

tion 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 psychol-

ogy. However, Freud had a skeptical attitude to whether psychoanalysis needed academic

psychology, which delayed the integration of psychodynamic theory and academic psychol-

ogy, 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 ex-

ample 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 theo-

ries. For instance, Westen (2000) has used theories on associative networks, affect regulation

and social cognition, in an attempt to integrate psychodynamic and cognitive-behavioral the-

ory and technique. Research-founded theories like John Bowlby’s attachment theory and

Daniel Stern’s theory of the child’s 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 psycho-

analysis interest in the self has increased (Mitchell, 1991, Stolorow, 1995) and the self con-

cept is common in cognitive psychology (Beck, Freeman & Davis, 2004, Leahy, 2001) and

also in developmental psychology (Stern, 1985, Diamond & Marrone, 2003). These integra-

tive 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.

References

Alford, B.A., & Beck, A.T. (1997). The integrative power of cognitive therapy. New York:

Guilford Press.

Asay, T. P., & Lambert, M. J. (2002). Therapist relational variables. In D. J. Cain & J. See-

man, (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 531-

557). Washington: American Psychological Association.

Bachelor, A., & Horvath, A. (1999). The therapeutic relationship. In M. A. Hubble, B. L.

Duncan & S. D. Miller (Eds.), The heart & soul of change: What works in therapy (pp. 133-

178). Washington: American Psychological Association.

Beck, A. T. (1970). Cognitive therapy: Nature and relation to behavior therapy. Behavior

Therapy, 1, 184-200.

Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International

Universities Press.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression.

New York: Guilford Press.

Beck, A.T., Freeman, A., Davis, D. D. & associates. (2004). Cognitive therapy of personality

disorders, 2nd ed. New York: Guilford Press.

Beitman, B. D., Goldfried, M. R., & Norcross, J, D. (1989). The movement toward integrating

the psychotherapies: An overview. American Journal of Psychiatry, 146:2, 138-147.

Berg, L. (2005). Gryning över Kalahari: Hur människan blev människa. Stockholm: Ord-

front.

Beutler, L. E., Harwood, T. M., & Caldwell, R. (2001). Cognitive-behavioral therapy and

psychotherapy integration. In K. S. Dobson (Ed.), Handbook of cognitive behavioral thera-

pies, 2nd ed. (pp. 138-170). New York: Guilford Press.

Beutler, L. E., Malik, M., Alimohamed S., Harwood, T. M., Talebi, H., Noble S., & Wong, E.

(2004). Therapist variables. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psy-

chotherapy and behavior change, 5th ed. (pp. 227-306). New York: Wiley.

No 1:36, 33

Binder, J. L., & Strupp, H. H. (1997). ”Negative process”: A recurrently discovered and un-

derestimated facet of therapeutic process and outcome in the individual psychotherapy of

adults. Clinical Psychology: Science and Practice, 4, 121-139.

Blagys, M. D., & Hilsenroth, M. J. (2000). Distinctive features of short-term psychodynamic-

interpersonal psychotherapy: A review of the comparative psychotherapy process literature.

Clinical Psychology: Science and Practice, 7, 167-188.

Blagys, M. D., & Hilsenroth, M. J. (2002). Distinctive activities of cognitive–behavioral ther-

apy: A review of the comparative psychotherapy process literature. Clinical Psychology Re-

view, 22, 671-706.

Blatt, S. J., Sanislow, C. A., Zuroff, D. C., & Pilkonis, P. A. (1996). Characteristics of effec-

tive therapists: Further analysis of data from the National Institute of Mental Health treat-

ment of depression collaborative research program. Journal of Consulting and Clinical Psy-

chology, 64, 1276-1284.

Block, J. (2002). Personality as an affect-processing system: Toward an integrative theory.

Mahwah, New Jersey: Lawrence Erlbaum Associates.

Bowlby, J. (1979). Psychoanalysis as art and science. International Review of Psychoanalysis,

6, 3-13.

Breuer, J., & Freud, S. (1895). Studies on hysteria. The standard edition of the complete psy-

chological works of Sigmund Freud, vol. 2.

Cain, D.J. (2002). Defining characteristics, history, and evolution of humanistic psychotherapies.

In D.J. Cain & J. Seeman. (Eds.), Humanistic psychotherapies: Handbook of research and prac-

tice (pp. 3-54). Washington: American Psychological Association.

Castonguay, L. G., Goldfried, M. R., Wiser, S., & Raue, P. J. (1996). Predicting the effect of cog-

nitive therapy for depression: A study of unique and common factors. Journal of Consulting and

Clinical Psychology, 64, 248-260.

Castonaguay, L. G., Newman, M. G., Borkovec, T. D., Grosse Holtforth, M., & Maramba, G.G.

(2005). Cognitive-behavioral assimilative integration. In J. C. Norcross & M. R. Goldfried

(Eds.), Handbook of psychotherapy integration, 2nd ed. (pp. 241-260). New York: Oxford Uni-

versity Press.

Chadwick, P., Birchwood, M., & Trower, P. (1996). Cognitive therapy for delusions, voices and

paranoia. Chichester: Wiley.

Cioffi, F. (1998). Freud and the question of pseudoscience. Chicago: Open Court.

Clark, D., A., Beck, A., T., & Alford, B., A. (1999). Scientific foundations of cognitive theory

and therapy of depression. New York: Wiley.

No 1:36, 34

Davis Massey, S. (2002). Humanistic, interpersonal, and existential psychotherapies: Review

and synthesis. In F. W. Kaslow. (Ed.-in-chief), R. F. Massey & S. Davis Massey (Vol.

Eds.), Comprehensive handbook of psychotherapy, vol, 3, interper-

sonal/humanistic/existential (pp. 699-717). New York: Wiley.

Diamond, N., Marrone, M. (2003). Attachment and intersubjectivity. London: Whurr Publish-

ers.

Douger, M. J., & Hayes, S. C. (2000). Clinical behavior analysis. In I. M. Douger (Ed.), Clinical

behavior analysis (pp. 11-25). Reno Nevada: Context Press.

Eagle, M. (1984). Recent developments in psychoanalysis: A critical evaluation. New York:

McGraw-Hill Book Company.

Eagle, M. (1987). The psychoanalytic and the cognitive unconscious. In R Stern, (Ed.), Theo-

ries of the unconscious and theories of the self (pp. 155-189). Hillsdale, N.J.: Analytic

Press.

Eagle, M., & Wolitzky, D. L. (1997). Empathy: A psychoanalytical perspective. In A. C.

Bohart & L. S. Greenberg (Eds.), Empathy reconsidered: New directions in psychotherapy

(pp. 217-244). Washington: American Psychological Association.

Eagle, M.N., Wolitzky, D.L., & Wakefield, J.C. (2001). The analyst's knowledge and authority: A

critique of the "new view" in psychoanalysis. Journal of the American Psychoanalytic Associa-

tion, 49, 457-489.

Eells, T. D., & Lombart, K. G. (2003). Case formulation and treatment concept’s among novice,

experienced, and expert cognitive-behavioral and psychodynamic therapists. Psychotherapy Re-

search, 13, 187-204.

Eells, T. D., Lombart K. G., Kendjelic, E. M., Turner, L. C., & Lucas, C. P. (2005). The quality of

psychotherapy case formulations: A comparison of expert, experienced, and novice cognitive-

behavioral and psychodynamic therapists. Journal of Consulting and Clinical Psychology, 4,

579-589.

Ellenberger, H. F. (1970). The discovery of the unconscious. New York: Basic Books.

Ellenberger, H. F. (1974). Psychiatry from ancient to modern times. In S. Arieti (Ed.), American

handbook of psychiatry, vol.1, the foundations, 2nd ed. (pp. 3- 27). New York: Basic Books.

Elliott, R. (1998). Editor’s introduction: A guide to the empirically supported treatments contro-

versy. Psychotherapy Research, 8, 115-125.

Elliott, R. (2002). The effectiveness of humanistic therapies: A meta-analysis. In D.J. Cain & J.

Seeman, (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 57-81).

Washington: American Psychological Association.

No 1:36, 35

Elliott, R., Greenberg, L. S., & Lietaer, G. (2004). Research on experiential therapies. In M. J.

Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change, 5th ed.

(pp. 493-539). New York: Wiley.

Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus: Lyle Stuart.

Esterson, A. (1993). Seductive mirage: An exploration of the work of Sigmund Freud. Chicago:

Open Court.

Eysenck, H. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychol-

ogy, 16, 319–324.

Frank, J. (1979). The present status of outcome studies. Journal of Consulting and Clinical Psy-

chology, 47, 310-316.

Frank, J. D., & Frank J. B. (1991). Persuasion and healing: A comparative study of psychotherapy,

3rd ed. Baltimore: John Hopkins University Press.

Freeman, A., Pretzer, J., Fleming, B., & Simon, K. M. (1990). Clinical applications of cognitive

therapy. New York: Plenum Press.

Freud, S. (1905). On Psychotherapy. The standard edition of the complete psychological works of

Sigmund Freud, vol. 7. London: Hogarth Press.

Freud, S. (1917). Introductory lectures on psycho-analysis. The standard edition of the complete

psychological works of Sigmund Freud, vol. 16. London: Hogarth Press.

Freud, S. (1918). From the history of infantile neurosis. The standard edition of the complete psy-

chological works of Sigmund Freud, vol. 18. London: Hogarth Press.

Gabbard, G. (1994). Psychodynamic psychiatry in clinical practice: The DSM-IV edition. Wash-

ington: American Psychiatric Press.

Gill, M. M., & Holzman, P. S. (1976). Psychology versus metapsychology. New York: Interna-

tional University Press.

Goldfried, M. R., Raue, P. J., & Castonguay, L. G. (1998). The therapeutic focus in significant ses-

sions of master therapists: A comparison of cognitive-behavioral and psychodynamic-

interpersonal interventions. Journal of Consulting and Clinical Psychology, 66, 803-810.

Gotlib, I. H., & Schradley, P. K. (2000). Interpersonal psychotherapy. In C. R. Snyder & R. E. In-

gram (Eds.), Handbook of psychological change: Psychotherapy processes & practices for the

21st century (pp. 258-279). New York: Wiley.

Grave, K. (1997). Research-informed psychotherapy. Psychotherapy Research, 7, 1-19.

Green, V. (2003). Emotional development in psychoanalysis, attachment theory and neuroscience.

Hove: Brunner-Routledge.

Guntrip, H. (1968). Schizoid phenomena, object relations and the self. London: Hogarth Press.

No 1:36, 36

Guntrip, H. (1971). Psychoanalytic theory, therapy and the self. New York: Basic Books.

Guntrip, H. (1972). Orthodoxy and revolution in psychology. Bulletin of British Psychological So-

ciety, 25, 275-280.

Hayes, S. C. (2004). Acceptance and commitment therapy and the new behavior therapies: Mind-

fulness, acceptance and relationship. In S.C. Hayes, V. M. Follette & M. M Linehan (Eds.),

Mindfulness and acceptance: Expanding the cognitive-behavioral tradition (pp. 1-29). New

York: Guilford Press.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy: An

experiential approach to behavior change. New York: Guilford Press.

Hayes, S. C., Pankey, J., Gifford, E. V., Batten, S. V., & Quiñones, R. (2002). Acceptance and

commitment therapy in experiential avoidance disorders. In F. W. Kaslow. (Ed.-in-chief), T. Pat-

terson (Vol. Ed.), Handbook of psychotherapy, vol. 2, cognitive and behavioral approaches (pp.

319-351). New York: Wiley.

Henry, W. P., Schacht, T. E., Strupp, H. H., Butler, S. F., & Binder, J. L. (1993). Effects of train-

ing in time-limited dynamic psychotherapy: Mediators of therapists´ responses to training. Jour-

nal of Consulting and Clinical Psychology, 61, 441-447.

Henry, W. P., & Strupp, H. H. (1994). The therapeutic alliance as interpersonal process. In A. O.

Horvath & L. S. Greenberg (Eds.), The working alliance: Theory, research & practice (pp. 51-

84). New York: Wiley.

Hill, C. E., & Lambert, M. (2004). Methodological issues in studying psychotherapy processes and

outcomes. I M. J. Lambert (Ed.), Bergin and Garfield´s handbook of psychotherapy and behav-

ior change (pp. 84–135). New York: Wiley.

Hofmann, S. G., & Tompson, M. C. (2002). Treating chronic and severe mental disorders: A

handbook of empirically supported interventions. New York: Guilford Press.

Holt, R. R. (1981). The death and transfiguration of metapsychology. International Review of Psy-

choanalysis, 8, 129-143.

Johansson, P-M. (1999). Freuds psykoanalys. Arvtagare i Sverige. Göteborg: Daidalos.

Kahn, E. (1985). Heinz Kohut and Carl Rogers: a timely comparison. American Psychologist, 40,

893-904.

Kandel. E. R. (1998). A new intellectual framework for psychiatry. American Journal of Psychia-

try, 154, 457- 469.

Kandel. E. R. (1999). Biology and the future of psychoanalysis: A new intellectual framework for

psychiatry revisited. American Journal of Psychiatry, 156, 505-524.

No 1:36, 37

Kaslow, F. W. (Ed.-in-chief) & Magnavita J. J. (Vol. Ed.). (2002). Comprehensive handbook of

psychotherapy, vol.1, psychodynamic/object relations. New York: Wiley.

Kaslow, F. W. (Ed.-in-chief), Massey, R. F., & Davis Massey, S. (Vol. Eds.). (2002). Comprehen-

sive handbook of psychotherapy, vol. 3, interpersonal/humanistic/existential. New York: Wiley.

Kohlenberg, R. J., & Tsai, M. (1987). Functional analytic psychotherapy. I N. S. Jacobson (Ed.),

Psychotherapy in clinical practise (pp. 338-443). New York: Guilford Press.

Kohut, H. (1984). How does analysis cure? Chicago: University of Chicago Press.

Lafferty, P., Beutler, L. E., & Crago, M. (1989). Differences between more or less effective psy-

chotherapists: A study of select therapist variables. Journal of Consulting and Clinical Psychol-

ogy, 57, 76-80.

Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic

therapist. In J.C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration

(pp. 94-129). New York: Basic Books.

Lambert, M. & Barley, D. E. (2002). Research summery on the therapeutic relationship and psy-

chotherapy. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 17-32). Oxford:

Oxford University Press.

Lambert, M. J., Garfield, S. L., & Bergin, A. E. (2004). Overview, trends, and future issues. In M.

J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change, 5th ed.

(pp. 805-821). New York: Wiley.

Lambert M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J.

Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change, 5th ed.

(pp.139-193). New York: Wiley.

Lampropoulos, G. L. (2000a). Definitional and research issues in the common factor approach to

psychotherapy integration: Misconceptions, clarifications, and proposals. Journal of Psychother-

apy Integration, 10, 415-438.

Lampropoulos, G. L. (2000b). A reexamination of the empirically supported treatments critiques.

Psychotherapy Research, 10, 474-484.

Lazarus, A. A. (1967). In support of technical eclecticism. Psychological Reports, 21, 415-416.

Leahey, T. H. (2001). A history of modern psychology, 3rd ed. Upper Saddle River, New Jersey:

Prentice-Hall, Inc.

Leahy, R. L. (2001). Overcoming resistance in cognitive therapy. New York: Guilford Press.

Linehan, M. M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New

York: Guilford Press.

No 1:36, 38

Linehan, M. M. (1997). Validation and psychotherapy. In A. C. Bohart & L. S. Greenberg (Eds.),

Empathy reconsidered: New directions in psychotherapy (pp. 353-392). Washington: American

Psychological Association.

Luborsky, L. (1954). A note on Eysenck’s article “The effects of psychotherapy: an evaluation.”

British Journal of Psychology, 2 54-59.

Luborsky, L., McLellan, T., Woody, G. E., O´Brien, C. P., & Auerbach, A. (1985). Therapist suc-

cess and its determinants. Archives of General Psychiatry, 42, 602-611.

Luborsky, L., McLellan, T., Diguer, L., Woody, G., & Seligman, D. A. (1997). The psychothera-

pist matters: Comparison of outcomes across twenty-two therapists and seven patient samples.

Clinical Psychology: Science and Practice, 4, 53-65.

Magnavita, J. J. (2002). Contemporary psychodynamics: Major issues, challenges, and future

trends. In F. W. Kaslow (Ed.-in-chief) & J. J Magnavita (Vol. Ed.), Comprehensive handbook of

psychotherapy, vol.1, psychodynamic/object relations (pp. 587-604). New York: Wiley.

Mayer, J. D. (2005). A tale of two visions: Can a new view of personality help integrate psychol-

ogy? American Psychologist, 4, 294-307.

McCullough, L., & Andrews, S. (2001). Assimilative integration: Short-term dynamic psychother-

apy for treating affect phobias. Clinical Psychology: Science and Practice, 8, 82-97.

McCullough, L., Kuhn, N., Andrews, S., Kaplan, A., Wolf, J., & Hurley, C. L. (2003). Treating af-

fect phobia: A manual for short-term dynamic psychotherapy. New York: Guilford Press.

Messer, S. B. (1992). A critical examination of belief structures in integrative and eclectic psycho-

therapy. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (pp.

130-168). New York: Basic Books.

Mitchell, S. A. (1991). Contemporary perspectives on self: Toward an integration. In Psychoana-

lytic Dialogues, 2, 121-147.

Najavits, L. M., & Strupp, H. H. (1994). Differences in the effectiveness of psychodynamic thera-

pists: A process-outcome study. Psychotherapy, 31, 114-123.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work. Oxford: Oxford University

Press.

Norcross, J. C., & Goldfried, M. R. (Eds.). (1992). Handbook of psychotherapy integration. New

York: Basic Books.

Norcross, J. C., & Goldfried, M. R. (Eds.). (2005). Handbook of psychotherapy integration,2nd ed.

New York: Oxford University Press.

No 1:36, 39

Norcross, J. C., Karpiak, C. P., & Santoro, S. O. (2005). Clinical psychologists across the years:

The division of clinical psychology from 1960 to 2003. Journal of Clinical Psychology, 61,

1467-1483.

Prochaska, J. O., & Norcross, J. C. (2003). Systems of psychotherapy: A transtheoretical analysis,

5th ed. Pacific Grove Ca.: Brooks/Cole.

Ricour, P. (1970). Freud & philosophy: An essay on interpretation. New Haven: Yale University

Press.

Robins, C. J., & Hayes, A. M. (1993). An appraisal of cognitive therapy. Journal of Consulting

and Clinical psychology, 61, 205-214.

Rogers, C. (1957). The necessary and sufficient conditions of therapeutic personality change.

Journal of Consulting Psychology, 21, 95-103.

Rosenzweig, S. (1936). Some implicit common factors in diverse methods in psychotherapy.

American Journal of Psychotherapy, 6, 412- 415.

Roth, A., & Fonagy, P. (2005). What works for whom?: a critical review of psychotherapy re-

search, 2nd ed. New York: Guilford Press.

Ryle, A., (1995). Cognitive analytic therapy: Developments in theory and practice. Chichiester:

Wiley.

Ryle, A., (2002). Introducing cognitive analytic therapy: Principles and practice. Chichiester:

Wiley.

Safran, J., & Segal, Z. (1990). Interpersonal process in cognitive therapy. New York: Basic Books.

Samoilov, A., & Goldfried, M. R. (2000). Role of emotion in cognitive-behavior therapy. Clinical

Psychology: Science and Practice, 7, 373-385.

Sandell, R., Carlsson, J., Schubert, J., Broberg, J., & Blomberg, J. (2002). Varieties of psycho-

therapeutic experience. European Psychotherapy, 3, 3-16.

Sandell, R., Carlsson, J., Schubert, J., Broberg, J., & Blomberg, J. (2004). Therapist attitudes and

patient outcomes: I. development and validation of the therapeutic attitudes scales (tasc 2). Psy-

chotherapeutic Research, 4, 469-484.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2001). Mindfulness-based cognitive therapy for

depression. New York: Guilford Press.

Skinner, B. F. (1953). Science of human behavior. New York: Macmillan Company.

Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American

Psychologist, 32, 752-760.

Socialstyrelsen, (1990). Utbildning för legitimation som psykoterapeut. Meddelandeblad, 19.

Socialstyrelsen, (1996). Psykoterapeuter – vad gör de? Psykiatriuppföljningen, 1996:2.

No 1:36, 40

Steele, R. S. (1979). Psychoanalysis & hermeneutics. International Review of Psychoanalysis, 6,

389-411.

Stern, D. N. (1985). The interpersonal world of the infant: A view from psychoanalysis and devel-

opmental psychology. New York: Basic Books.

Stolorow, R. D. (1995). An intersubjective view of self psychology. Psychoanalytic Dialogues, 3,

393-399.

Stricker, G., & Gooen-Piels, J. (2002). Integrative and object relations focused approaches to psy-

chotherapy: Theoretical concerns and outcome research. In I. Säfvestad Nolan, & P. Nolan,

(Eds.), Object relations & integrative psychotherapy: Tradition and innovation in theory and

practice (pp. 28-51). London: Whurr Publishers.

Stricker, G., & Gold, J. (2005). Assimilative psychodynamic psychotherapy. In J. C. Norcross &

M. R. Goldfried (Eds.), Handbook of psychotherapy integration, 2nd ed. (pp. 221-240). New

York: Oxford University Press.

Strupp, H. H. (1963). The outcome problem in psychotherapy revisited. Psychotherapy: Theory,

Research, and Practice, 1, 1-13.

Sulloway, F. (1979). Freud, biologist of the mind. New York: Basic Books.

Svartberg, M., Stiles, T. C., & Selzer, M. H. (2004). Randomized, controlled trial of the effective-

ness of short-term dynamic psychotherapy and cognitive therapy for cluster c personality disor-

ders. American Journal of Psychiatry, 161, 810-817.

Säfvestad Nolan, I., & Nolan, P. (Eds.). (2002). Object relations & integrative psychotherapy:

Tradition and innovation in theory and practice. London: Whurr Publishers.

Teyber, E., & McClure, F. (2000). Therapist variables. In C. R. Snyder & R. E. Ingham (Eds.),

Handbook of psychological change: Psychotherapy processes & practices for the 21st century

(pp. 62-85). New York: Wiley.

Thomson, R. (1968). The pelican history of psychology. Harmondsworth: Penquin books.

Törneke, N. (2005). KT, KBT, KPT och BT; ett försök att rita en karta. Sokraten, 3, 17-21.

Van Wagoner, S. L., Gelso, C. J., Hayes, J. A., & Diemer, R. A. (1991). Countertransference and

the reputedly excellent therapist. Psychotherapy, 28, 411-421.

Wakefield, J. C. (1992). Freud and cognitive psychology: The conceptual interface. In J. W. Bar-

ron, M. N. Eagle & D. L. Wolitzky (Eds.), Interface of psychoanalysis and psychology (pp. 77-

98). Washington: American Psychological Association.

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods and findings. London:

Lawrence Erlbaum.

No 1:36, 41

Webster, R. (1995). Why Freud was wrong: Sin, science and psychoanalysis. London: Harper

Collins.

Weinberger, J. (1995). Common factors aren´t so common: The common factors dilemma. Clinical

Psychology: Science and Practice, 2, 45-69.

Wells, A. (2000). Emotional disorders and metacognition: Innovative cognitive therapy. Chiches-

ter: Wiley.

Westen, D. (1998). The scientific legacy of Sigmund Freud: toward a psychodynamic informed

psychological science. Psychological Bulletin, 3, 333-371.

Westen, D. (2000). Integrative psychotherapy: Integrating psychodynamic and cognitive-

behavioral theory and technique. In C. R. Snyder & R. E. Ingham (Eds.), Handbook of psycho-

logical change: Psychotherapy processes & practices for the 21st century (pp. 217-242). New

York: Wiley.

Westling, B. (2004). Den tröstefulla debatten om den psykodynamiska terapins hegemoni har bara

börjat. Läkartidningen, 25, 2210-2212.

Wiser, S. L., Goldfried, M. R., Raue, P. J., & Vakoch, D. A. (1996). Cognitive and psychodynamic

therapies: A comparison of change processes. In W. Dryden (Ed.), Research in counselling and

psychotherapy (pp. 101-132). London: Sage.

Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford: Stanford University Press.

Young, J. E. (1999). Cognitive therapy for personality disorders: A schema-focused approach.

Florida: Professional Resource Press

Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner's guide.

New York: Guilford Press.

Öst. L-G. (1996). Beteendeterapins utveckling i Sverige under 25 år. Scandinavian Journal of Be-

haviour Therapy, 25, 101-115.