A Problem of Dilution in Modern Psychotherapy

Written By: Dr. Yedidya Levy

The title therapist has become increasingly difficult to interpret. In contemporary mental health care, psychotherapy is delivered by professionals with substantially different educational backgrounds, degrees, licenses, theoretical orientations, and levels of clinical training. At the same time, the number of approaches described as psychotherapy has proliferated dramatically. By the end of the twentieth century, scholars had identified hundreds of distinct psychotherapeutic methods, with estimates ranging from approximately 400 to more than 600, depending on how individual approaches and variations are counted (European Association for Psychotherapy, n.d.; Norcross & Goldfried, 2019).

This proliferation creates a problem of dilution. The word therapist tells a prospective patient remarkably little about what treatment will actually involve. Nor does the name of a therapeutic modality necessarily tell the patient how the therapist understands psychopathology, what mechanisms are believed to produce change, what the goals of treatment are, or what evidence supports the intervention.

The ambiguity begins with the word psychotherapy itself. The American Psychological Association defines psychotherapy as a psychological service provided by a trained professional that uses communication and interaction to assess, diagnose, and treat dysfunctional emotional reactions, patterns of thinking, and behavior (American Psychological Association, 2023a). APA has also described psychotherapy more broadly as the intentional application of clinical methods and interpersonal stances derived from psychological principles to help people modify their behaviors, cognitions, emotions, or other personal characteristics in desirable directions (American Psychological Association, 2012; Norcross, 1990).

These definitions establish an important common ground, but they leave considerable room for variation in what happens inside the consulting room. Psychotherapy can involve sustained conversation, behavioral exercises, exposure, meditation, eye-movement procedures, drawing, movement, role-play, or other experiential techniques. There are also specialized forms of treatment involving animals and other structured experiential activities. The range of practices that can fall under the psychotherapeutic umbrella is therefore considerably broader than the traditional image of two people sitting in a room talking.

For the consumer, this creates an unusual problem. In most areas of medicine, a professional title provides at least some information about the practitioner's training and the type of intervention a patient is likely to receive. In psychotherapy, the same basic title can encompass substantially different educational pathways, theoretical commitments, and clinical practices.

The diffusion and ambiguity around what it means to be a “therapist” and practice “psychotherapy” means consumers of psychotherapy should be educated regarding the differences between good psychotherapy and “everything else.”

What to look out for:

1. A clear articulation of the personality/behavioral patterns causing distress

2. Distillation of a “therapy goal” related to personality/behavior

3. An understanding of how psychotherapy can achieve said goal

4. An individually tailored approach to therapy

5. A resilient therapeutic relationship

6. Openness about what constitutes success in therapy

7. Clear and professional boundaries

What to stay away from:

1. Therapy without clear goals, direction, or theory of change

2. Fluffy/meaningless language or promises about change

3. Affirmation without inquiry, curiosity, or challenge

4. Statements that reflect bias politically or religiously

5. Excessive dependence on techniques, acronyms, or worksheets

6. Therapy that cannot tolerate disagreement, anger, or honesty

References

American Psychological Association. (2012). Recognition of psychotherapy effectiveness. https://www.apa.org/about/policy/resolution-psychotherapy

American Psychological Association. (2023a). Psychotherapy. APA Dictionary of Psychology. https://dictionary.apa.org/psychotherapy

American Psychological Association. (2023b, December 12). Understanding psychotherapy and how it works. https://www.apa.org/topics/psychotherapy/understanding

European Association for Psychotherapy. (n.d.). Definitions appendix 2. https://www.psychotherapy-competency.eu/Appendices/appendix2.php

Norcross, J. C. (1990). An eclectic definition of psychotherapy. In G. R. VandenBos & A. E. J. Frank-McNeil (Eds.), The psychotherapy handbook (pp. 3–15). Jossey-Bass.

Norcross, J. C., & Goldfried, M. R. (Eds.). (2019). Handbook of psychotherapy integration (3rd ed.). Oxford University Press.