History of

Psychotherapy
& Theories of Change
Karen Bishop/Angelle Vella
What do we need to understand first?

To understand what psychotherapy is about we must first discuss:

o What in mental health well-being?

o How do we conceptualise mental health difficulties/problems?
o How have these ideas influenced our understanding of how people change?

o WE NEED TO LOOK AT HISTORY

 Historical background:
Beliefs and treatment of the mentally ill
 Greek physician Hippocrates (ca. 400BC)
promoted humane treatment. Tx based on
healing powers of nature: Mentally ill
patients were placed in pleasant
surroundings and given soothing baths.

 Lack of balance between positive and

negative energies

 Illness attributed to a disturbance in the

balance of bodily fluids (humorism).

Humour Season Organ Ancient name Modern MBTI Ancient characteristics

Blood spring liver sanguine artisan SP courageous, hopeful, amorous
Yellow bile summer spleen choleric idealist NF easily angered, bad tempered
Black bile autumn gall bladder melancholic guardian SJ despondent, sleepless, irritable
Phlegm winter brain/lungs phlegmatic rational NT calm, unemotional
Middle Ages-17th century: A spiritual matter
 Madness = in league with devil,
possession by spirits

 Diagnosis based on hearsay, unreliable

“tests”

 Treatment
 Prayer, exorcism, magic incantation
 Torture, starvation, and exile (sent to sea)
 Treated like animals and sentenced to burn
or hang
18th century: Moderate
enlightenment
 Mentally disordered people
= degenerates

 Treatment:
 Isolate mentally ill from
society
 Sometimes bloodletting
The 19th century: Attempts at reform

 Philippe Pinel (1745-1826)

 Reformed Paris mental hospitals:

 Removed restraints
 Treated mentally ill more humanely
 Some patients got better enough to leave
hospital
 Stressed “moral” understanding
 Developed individualized therapies based on
diagnosis and life history
 Insisted on drugs only as last resort
Somatic Treatments in the 1920s and 1930s
The 20th century

 New biological therapies introduced in 1930s

 Insulin-coma therapy (ICT)
 Electro-shock therapy (ECT)
 Frontal lobotomy

 Anti-psychotic drugs introduced in mid-1950s

Hospitals from a patient's perspective
 Rosenhan (1973): "On being sane in insane places”
 Sane people got into mental hospitals as patients
 Found very low interaction with staff
 Dehumanizing nature of interactions
 Normal behaviors interpreted pathologically
On Being Sane VIDEOS
 Rosenhan’s study spurned significant reform. Today’s
hospitals are more humane, but…
 Diagnosis rules the day
 Practically everyone is medicated
 Restraints & padded rooms used if patient at risk of self-harm
 Involuntary hospitalization legally permitted (though limited)
 What about Malta?
 The roots of the medical practise of psychiatry in
Malta can be traced back to the late 16th
century.
 Following the establishment of the Sacra
Infermeria at the Floriana Ospizio by the Knights
of St John in 1574, the ‘mentally insane’ were
placed in a specific area of the hospital.
 However, if patients became violent they would
be transferred to one of the basement wards.
 It is thought that these wards had grated
openings onto the street and passers-by would
tease and taunt the patients in order to rouse
them to a state of fervour.
 Before the construction of the present-day
psychiatric hospital, Mount Carmel Hospital,
psychiatric patients were also housed at Villa
Franconi, which was the former residence of Fra
Fabrizio Franconi, a Knight of the Order of St
John.
 The current psychiatric hospital in Malta,
Mount Carmel Hospital, is a large general
psychiatric hospital (with circa 500 in-
patients), which provides a unique
combination of the old psychiatric asylum
structure and modern day psychiatric
practice.
 The hospital was built in 1853 as an exact
replica of Wakefield Asylum in England;
the architect who built the hospital was
unlikely to have been an actual architect
and copied the design plans off the
already outdated 1818 English hospital.
 Over the years it has seen a number of
attempts at modernisation, however it is
still “essentially an asylum containing
mainly chronic, institutionalised patients.
 Most of the wards are locked, the sexes
segregated and with a leave system not
unlike the old 'hospital parole' system.
 The priest as
therapist?
 Who were the helping professionals
when individuals or families encountered
problems?
 The significance of confession and
absolution
 Shame and stigma at mental health
issues

 Professionals in the mental health field

started being introduced on the islands
in the 80’s.
What is psychotherapy?
 Psychotherapy is a form of treatment for problems
of an emotional nature in which a trained person
deliberately establishes a professional relationship
with a patient for the purpose of removing,
modifying, or retarding existing symptoms, of
mediating disturbed patterns of behavior, and of
promoting positive personality growth and
development (Wolberg, 1967).

 Psychotherapy is a planned activity of the

psychologist1, the purpose of which is to
accomplish changes in the individual that make
his/her life adjustments potentially happier, more
constructive, or both (Frank, 1982).
1 or other professional mental health service provider
What is psychotherapy?
 Interpersonal, relational intervention by trained therapists to aid in life problems
 Goal: increase sense of well-being, reduce discomfort
 Employs range of techniques based on relationship building, dialogue, communication and
behavior change designed to improve the mental of individual patient or group
 Some therapies focus on changing current behavior patterns
 Others emphasize understanding past issues
 Some therapies combine changing behaviors with understanding motivation
 Can be short-term with few meetings, or with many sessions over years
What can psychotherapy accomplish?
 Learn to identify and change behaviors or thoughts that adversely affect life
 Explore and improve relationships
 Find better ways to cope and solve problems
 Learn to set realistic goals
 Can be conducted with individual, couple, family or group of unrelated members who
share common issues
 Also known as talk therapy, counseling, psychosocial therapy or, simply, therapy
 Can be combined with other types of treatment, such as medications
All psychotherapies provide:

 A working alliance between patient and therapist

 An emotionally safe setting where the patient can feel accepted, supported, un-criticized
 A therapeutic approach that may either be strictly adhered to or modified according to
patient needs
 Confidentiality as integral to therapeutic relationship except with safety issues
Study: Common
Therapeutic Factors
(Lambert, 1992)
 Extratherapeutic change (40%) :
Client Factors (motivation,
severity of disturbance, ego
strengths, psychological
mindedness.)
 Therapeutic relationship (30%):
(Rogers: unconditional positive
regard, empathy and
congruence) (Freud: therapeutic
alliances)
 Expectancy (15%) : (hope)
 Techniques (15%)
ALL IS POLITICAL

Do not look at ideas

in a vacuum

Reflect on the social

and cultural
background around
them
 Mental health issues amongst men and women
Gender as a social construct influencing
how we live and perceive mental health
in ourselves and others.
Some final thoughts…

 Salvador Minuchin: «Don’t be too sure»

 No theory holds the key to all problems. No theory entirely explains what it
means to be human.

 When we get too sure about a theory, we close ourselves off to different
perspectives.
A very important
question to keep
asking myself:

 Why am I interested in becoming

a psychotherapist?
 What’s in it for me?