INTRODUCTION — Psychotherapy is a typically interpersonal treatment based on psychological principles. Specific therapies are often individualized to patients or groups with a psychiatric disorder, problem, or adverse circumstance .
There are many types of psychotherapy with varying methods and levels of empirical support. The choice of the most appropriate type of psychotherapy is in part based upon the patient’s specific problem or diagnosis.
An overview of psychotherapies for the nonpsychiatrist clinician is provided here. Psychotherapies for individual psychiatry disorders are reviewed in detail separately.
PSYCHOTHERAPIES — Although there are many named psychotherapies, most are derivations of a few basic types. Psychotherapies within each of these categories broadly share a similar explanatory model and set of techniques. However, therapies are frequently modified (and may be renamed) when applied to new conditions or populations. The psychotherapies that follow have been tested for efficacy to varying degrees in clinical trials with specific populations and disorders. The therapies in the trials are delivered by trained therapists using structured protocols [2,3].
●Cognitive and behavioral psychotherapies
●Dialectical behavior therapy
In some cases, psychotherapy may be more effective when administered in conjunction with medication. Efficacy data are described in detail separately under individual disorders.
Cognitive and behavioral therapies — Cognitive and behavioral therapies can be used individually or in combination as a program of interventions known as cognitive-behavioral therapy or CBT. CBT often includes education, relaxation exercises, exposure, coping skills training, stress management, or assertiveness training [4,5].
In cognitive therapy , the therapist helps the patient identify and correct distorted, maladaptive beliefs. Behavioral therapy draws from principles of learning to facilitate symptom reduction and improved functioning; the stimuli in focus may be real or imagined. Change may occur through learning, through decreased reactivity from repeated exposure to a stimulus, or through other mechanisms.
Individuals for whom CBT works best are generally highly motivated and value a problem-solving approach, because therapy requires that the patient learns the skills of self-observation. Patients learn cognitive and behavioral skills and practice them within and outside of the therapy setting.
CBT is an evidence-based treatment for psychiatric disorders including depression, generalized anxiety disorder, posttraumatic stress disorder, panic disorder, eating disorders, substance use disorder, and obsessive-compulsive disorder, as well as several medical conditions (eg, insomnia, smoking, low back pain) . These applications are discussed in detail separately. We list some representative topics illustratively given the large number of conditions treated with CBT. (See "Bulimia nervosa in adults: Cognitive-behavioral therapy (CBT)" and "Binge eating disorder: Cognitive-behavioral therapy (CBT)" and "Anorexia nervosa in adults: Cognitive-behavioral therapy (CBT)".)
More recent research on CBT has focused on establishing efficacious intervention for transdiagnostic co-occurring processes such as anxiety and emotional dysregulation [6,7], and randomized clinical trials have demonstrated the efficacy of such protocols [8-10].
Psychodynamic psychotherapy — Psychodynamic therapy primarily relies on developing patient insight . Psychodynamic psychotherapy is based upon the idea that childhood experiences, past unresolved conflicts, and previous relationships significantly influence an individual’s current situation in life. Adult relationships are understood to be a byproduct of unconscious patterns that begin in childhood. Psychodynamic psychotherapy uncovers the unconscious patterns of interpersonal relationships, conflicts, and desires with the goal of improved functioning .
Psychodynamic therapy is used for some psychiatric disorders, including depression, anorexia nervosa, and personality disorders . (See "Unipolar depression in adults: Psychodynamic psychotherapy" and "Borderline personality disorder: Psychotherapy", section on 'Transference-focused therapy'.)
Interpersonal psychotherapy — Interpersonal therapy (IPT) addresses interpersonal difficulties that lead to psychological problems [14,15]. Interpersonal psychotherapy focuses on the individual’s interpersonal life in four problem areas: grief over loss, interpersonal disputes, role transitions, and interpersonal skill deficits.
Interpersonal therapy is an evidence-based treatment for some psychiatric conditions, including depression  and eating disorders [17,18]. (See "Interpersonal Psychotherapy (IPT) for depressed adults: Indications, theoretical foundation, general concepts, and efficacy" and "Pediatric unipolar depression: Psychotherapy", section on 'Interpersonal psychotherapy for adolescents' and "Binge eating disorder in adults: Overview of treatment", section on 'Interpersonal psychotherapy'.)
Motivational interviewing — Motivational interviewing is a type of psychotherapy that is used in primary care and mental health care to encourage patients to change maladaptive behaviors . Derived from cognitive-behavioral and readiness-to-change models, motivational interviewing seeks to help patients recognize and make changes to these behaviors, matching strategies to the patient’s stage of readiness to change. Key elements of motivational interviewing include:
●Helping the patient identify discrepancies between his or her problematic behaviors and broader, personal values
●Accepting the patient’s resistance to change
●Enhancing the patient’s self-efficacy (ie, confidence in his or her capability to surmount obstacles and successfully change)
The intensity of motivational interviewing can vary, but efficacious models are approximately 60 minutes in length, delivered over one to five sessions. The use of motivational interviewing is growing, and has been applied to the treatment of substance use disorders, promoting lifestyle changes (eg, weight reduction, smoking cessation), and encouraging adherence to complex medical treatments (eg, heart failure self-management). It is often employed as an evidence-based adjunct to other interventions when encountering low levels of patient motivation to change [19,20].
●(See "Heart failure self-management".)
Dialectical behavior therapy — Dialectical behavior therapy (DBT) is a type of psychotherapy conducted in the context of mental health practice for patients with severe problems in emotional regulation, most commonly patients with borderline personality disorder . DBT includes skills training, mindful practice, and close monitoring of and intervention in crises that may develop. Sessions are typically more than once a week and supplemented with contacts between sessions as needed [22-24].
Supportive psychotherapy — Supportive psychotherapy or counseling is widely used in medical practice, eg, to help individuals cope with illness, deal with a crisis or transient problem, and maintain optimism or hope . Techniques vary but most models emphasize communication of interest and empathy; supportive therapy may also include guidance on available services, advice, respect, praise, and/or encouragement. The efficacy and administration of supportive psychotherapy for depression is discussed separately. (See "Unipolar depression in adults: Supportive psychotherapy".)
OTHER PSYCHOTHERAPIES — Other psychotherapies have shown less consistently positive results in clinical trials or may not have been rigorously tested. Widely used psychotherapies may vary as delivered by one therapist to the next. Mindfulness based therapies, such as mindfulness based stress reduction  and acceptance and commitment therapy , have accrued several positive findings in clinical trials .
Eclectic or integrative psychotherapy — In surveys of mental health clinicians in the United States and Canada, a majority of clinicians (psychiatrists, psychologists, social workers, and others) identified themselves as practicing an eclectic or integrative form of psychotherapy [28,29]. Eclectic and integrative therapists draw concepts and techniques from a variety of different types of therapy, including psychodynamic, cognitive, and behavioral approaches . Some are largely constructed from elements from evidence based therapies whereas others are not .
FORMAT OF PSYCHOTHERAPY — In addition to the orientation of therapy, treatment is offered in different formats. Therapy may be presented to the individual, a couple, a family unit, or in a group of individuals or peers who are not related.
There is generally no single preferred format, although there is evidence that some problems respond better or worse to different configurations. As an example, the preponderance of clinical experience and study data indicate that couple therapy is useful for couple problems [31,32]. Group therapy may be helpful for adults with a substance use disorder , whereas group therapy for adolescents with problem behavior may result in increased delinquency .
Individual therapy — Individual therapy is the most commonly practiced format of psychotherapy. Individual therapy allows for a confidential interaction between patient and provider, permitting maximal disclosure without fear of others listening or interrupting. Most of the evidence for practicing psychotherapy involves individual therapy.
Couple therapy — Couple therapy or marital therapy allows two partners to overcome relationship difficulties with the help of a therapist. Specific issues that may be addressed with couple therapy include sexual relations and parenting [31,35]. It is a valuable adjunctive treatment in some disorders such as depression [36-38], posttraumatic stress disorder , and substance use disorders , particularly when there is comorbid relationship distress .
Family therapy — Family therapies, in which family members are seen together in treatment, focus on the family system and its ability to help both family problems and individual psychopathology [41,42]. Family therapy attempts to correct distorted communications and impaired relationships as a means of helping the entire family, including the patient with the psychiatric disorder. Family therapy is complex in that it represents not only a format for therapy but a systemic orientation toward treatment in which family is viewed as a potential agent of change.
For patients with schizophrenia and bipolar disorder, family psychoeducation helps family members learn about the disorder, solve problems, and cope more constructively with the patient's illness and this, in turn, has a positive impact on patient compliance with treatments and functioning [43,44]. Using family therapy to treat depressed patients is discussed separately. (See "Unipolar depression in adults: Family and couples therapy".)
Group therapy — Group psychotherapy offers supportive networks for people who have similar difficulties [33,45]. Cognitive, psychodynamic, supportive, and psychoeducational techniques may be used. Group therapy is often used for bereavement, in patients with a substance use disorder, or in patients experiencing a chronic or life-threatening condition such as diabetes or cancer .
INDICATIONS FOR PSYCHOTHERAPY — We consider initiating or referring a patient for psychotherapy for the following purposes:
●Treatment of a psychiatric disorder, with the goal of reducing or ameliorating symptoms and improving functioning.
●Changing maladaptive thoughts, behaviors, or relationships.
●Providing support when a crisis, a difficult period, or a chronic problem impairs functioning.
●Enhancing a patient’s capacity to make behavioral changes, eg, losing weight, quitting smoking, or increasing adherence to medical treatment.
●Helping ameliorate a relational problem.
●Increasing family cooperation with treatment.
Patient improvement in psychotherapy varies by presenting disorder or problem, its severity and complexity, and the particular treatment provided in each case . The likelihood of improvement is discussed separately for individual disorders. We work with the patient to set realistic goals for treatment and periodically evaluate whether these goals are being met . If improvement does not occur within the planned duration of treatment, we reassess and consider other clinical options.
STAFF AND SETTING — Psychotherapy may be provided by many types of clinicians, including psychiatrists and other physicians, nurses, psychologists, social workers, counselors, and marriage and family therapists. Clinicians typically require specialized training to provide structured, evidence-based psychotherapies; the type of therapy a clinician provides cannot be assumed based on discipline. If asked by a patient or referring physician, therapists should provide information about the type of therapy they provide and training they have received.
Specialty care — Mental health clinicians who provide psychotherapy (including psychiatrists, psychologists, counselors, social workers, marriage and family therapists, and psychiatric nurses) may work in individual and group mental health practices and clinics, or within departments of mental health, psychiatry, or psychology departments in general-medical hospitals or ambulatory centers.
Primary care — The majority of patients receiving treatment for a nonpsychotic psychiatric disorder in the United States receive treatment in primary care rather than in the mental health specialty sector . Mental health care in primary care has distinctive characteristics compared to mental health specialty care including:
●Patients are much more likely to receive pharmacotherapy than psychotherapy in primary care, compared to the mental health specialty setting.
●Patients are more likely to be treated for depression or an anxiety disorder in primary care, and less likely to be treated for a psychotic disorder.
Because patients with psychiatric disorders frequently present in primary care, and mental health specialty care may be unavailable or unacceptable to the patient, numerous interventions have been developed and tested to enhance or expand mental health care in primary care. These models include training of primary care clinicians to provide evidence-based psychotherapy, as well as structural changes to primary care known as integrated care. Although numerous models have been studied, they are not widely implemented.
Primary care clinicians with psychotherapy training — Randomized trials have found that primary care clinicians and nurses who receive training in an evidence-based psychotherapy can achieve improved outcomes compared to a control intervention, particularly when working with patients with major depression or excessive alcohol use [49-57].
Because primary care clinicians are subject to competing demands and time constraints, researchers are working to identify patient subgroups that can be effectively treated with briefer versions of evidence-based psychotherapies (shorter session lengths and fewer sessions). Patients with more severe, complex, or refractory conditions may be better suited for referral to mental health specialty care.
Brief psychological treatments in primary care typically involve between two and ten sessions on a weekly basis . Most of these therapies are variations of cognitive-behavioral therapy used in the treatment of depression and anxiety disorders.
Integrated primary and specialty care — Integrated or collaborative care refer to the availability of mental health specialty care in the context of primary care . In its most basic form, integration may consist of co-location of clinicians. However, observational studies suggest that integrated models may be more effective if systematic communication and coordination occur between primary care and mental health clinicians .
Collaborative care is provided by teams of primary care clinicians and mental health specialists in the primary care setting. The structure and efficacy of collaborative care is reviewed separately. (See "Unipolar depression in adult primary care patients and general medical illness: Evidence for the efficacy of initial treatments", section on 'Collaborative care'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Depression in adults (Beyond the Basics)" and "Patient education: Depression treatment options for adults (Beyond the Basics)")
●Psychotherapy is an interpersonal treatment based on psychological principles. It is individualized to the patient, seeking to help him or her with a psychiatric disorder, problem, or adverse circumstance. There are different types of psychotherapy with varying methods and levels of supporting evidence. Psychotherapies shown to be effective for individual psychiatric disorders include (see 'Psychotherapies' above):
•Cognitive and behavioral psychotherapies
•Dialectical behavior therapy
●Psychotherapy can be useful intervention for the following indications (see 'Indications for psychotherapy' above):
•Treatment of a psychiatric disorder, with the goal of reducing or ameliorating symptoms and improving functioning.
•Changing maladaptive thoughts, behaviors, or relationships.
•Providing support when a crisis, a difficult period, or a chronic problem impairs functioning.
•Enhancing a patient’s capacity to make behavioral changes (eg, losing weight, quitting smoking, or increasing adherence to medical treatment).
•Helping ameliorate a relational problem.
•Increasing family cooperation in enhancing treatment.
●Psychotherapy is provided by many different types of clinicians, including psychiatrists and other physicians, nurses, psychologists, social workers, counselors, and marriage and family therapists. However, many types of psychotherapy require specialized training. If asked by a patient or referring physician, therapists should provide information about the type of therapy they provide and training they have received. (See 'Staff and setting' above.)
●The majority of patients receiving treatment for a psychiatric disorder in the United States do so in primary care rather than in the mental health specialty sector. Evidence-based psychotherapy is not generally available in primary care. Models of mental health care delivery in the primary care setting have been shown to be effective but have not been widely implemented. (See 'Primary care' above.)
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