How is psychotherapy different from normal kindness?

  Much of what characterizes psychotherapy characterizes normal life. We all try to help our friends and family by being supportive and talking things through when they are upset. Many asylum doctors spent time in supportive conversations with their patients aiming to calm them and restore reason. This was broadly psychotherapeutic in aim. What is special about psychotherapies, however, is that there is an explicit agreement, almost a contract, between patient and therapist to set time aside to concentrate on it. They also follow a known and agreed approach, with clarity about what will happen and how long it will take.

  The National Health Service in England calls psychotherapy ‘talking treatments’ or ‘psychological treatments’ to avoid old sectarian arguments about what is ‘true’ psychotherapy. It has a rather helpful hierarchy:

  Type A comprises simple psychotherapeutic understanding employed during any treatment (e.g. counselling and support from a doctor prescribing antidepressants).

Type B involves dedicated sessions devoted exclusively to psychological understanding and emotional support. These use general psychotherapeutic principles but don’t follow a strict theory or have a prescribed number of sessions. An example would be a nurse having regular meetings with a depressed patient on the ward to talk through her situation.

Type C treatments are ‘psychotherapy proper’. Here the therapist has a recognized psychotherapy training and there is a clear, shared undertaking to pursue a specified course of that psychotherapy.

I’ve laboured this because some of the older psychotherapies are more evident in Type A and Type B treatments and are overlooked when not used as ‘proper’ Type C psychotherapies.

Sigmund Freud and the origins of psychoanalysis

  No story of psychotherapy can ignore Sigmund Freud. Love him or loathe him, he is a towering figure who has radically altered not just psychotherapy but how much of the Western world thinks. We met him in Chapter 2, forced to leave his research and make a living for himself in private practice in Vienna. Most of his clientele was ‘neurotic’ and most was female. The commonest problems he saw were either ‘neurasthaenia’ (lack of motivation, mild depression) or a series of ostensibly physical complaints (paralyses, pains, seizures, etc.) for which there was no identifiable physical cause. Before reaching Freud they would have been subject to exhaustive medical examinations and treatments without benefit.

  In over 50 years and 24 volumes of writing, Freud’s ideas changed significantly and they are sometimes contradictory. The outline that follows is, of necessity, simplified and partial but there are many detailed and accessible introductions (e.g. Anthony Storr’s Freud: A Very Short Introduction).

  Freud’s thinking was heavily influenced by the scientific models that surrounded him. Darwin’s Origin of Species had located mankind squarely in the natural world (not a special divine creation) so the mind became a legitimate subject for scientific investigation. The laws of thermodynamics (which gave rise to much of 20th-century physics) dominated scientific thinking then. These proposed that energy is never lost – simply transformed. Nineteenth-century Europe was economically booming; its industry driven by mechanical innovations such as trains, factory presses, ships’ engines, all based on harnessing ‘conserved energy’. Whether water, steam, or internal combustion engines, they all demonstrated the enormous power of damming up energy and channelling its escape through a restricted outlet. Freud’s ideas of the human mind are shot through with this metaphor – whether blocked instinctual drives or repressed memories, he believed our greatest destructive and creative achievements stemmed from forces denied their natural release.