You should look up to your therapist

Psychotherapy in the USA: From Sigmund Freud to Dr. Phil

"Dr. Phil “has been the nation's therapist for over a decade. With the TV format “Dr. Phil Show “he contributed to the fact that modern psychotherapy in the USA has become a mass market phenomenon.

Psychotherapy experienced a steep rise in the USA. It is firmly anchored in everyday American life. But today, drugs are increasingly replacing conversation.

Big smile, thick mustache, light hair: the psychologist Phil McGraw alias Dr. Phil the Nation's Therapist. With the TV format “Dr. Phil Show “He contributed to the fact that modern psychotherapy in the USA has become a mass market phenomenon within just a few decades. Once an exclusive product, it has developed into "a basic component of the mainstream in American medical practice and a fixed point in our pop culture," said US journalist Scott Stossel a few years ago. Millions of US citizens visit their therapist every week - and spend several thousand dollars on the table every year.

History: World War II sensitizes Americans

Review: Up until the beginning of the 20th century, psychotherapy in the USA was a neglected phenomenon that was used exclusively in pastoral care. This changed from 1909, when the Austrian Sigmund Freud presented his thoughts on psychoanalysis on a trip to America at Clark University in the US state of Massachusetts. Several American scholars adapted Freud's approaches and spread them in the country, albeit initially almost predominantly in academic circles. In the US public, Freud and his psychotherapy initially remained a marginal phenomenon.

The entry of the US into World War II suddenly opened up US citizens' awareness of mental illness. Almost two million Americans, twelve percent of the conscripts, have been denied service to the Fatherland on the grounds of mental disorders. The return of traumatized veterans further raised awareness among the American population. Suddenly it was socially acceptable that injuries can be caused not only by weapons, but also by shock experiences and everyday problems. There were also many psychoanalysts and sociologists among the Jews who fled Germany and Austria to the USA because of the Nazi regime. They were not only familiar with Freud's teachings, but also with other therapies - and brought these teachings with them across the Atlantic to the United States.

Freudian thinking was initially dominant in therapy. The American media popularized the Austrian's teaching and gradually made it accessible to a wider public. In 1956 the renowned Time Magazine ennobled psychotherapy: It published a picture of Sigmund Freud on its cover. At the latest, the treatment of mental disorders through psychotherapy had arrived in the everyday life of Americans.

But therapy alternatives to Freud's psychoanalysis were already emerging at this time. The traumatized US soldiers made it clear that Freud's approaches were reaching their limits. Psychoanalysis was unable to cope with the Americans' high need for therapy. It was mastered by too few and was also considered to be too complex in its structure. In addition, the US psychologist B. F. Skinner (1904–1990) and others increasingly vehemently rejected Freud’s approach, according to which the unconscious is responsible for problems in the here and now. Skinner has become the most prominent exponent of behaviorism in the United States over the years. In 2002 the American Psychological Association posthumously named him the most important psychologist of the 20th century.

Freudian thinking was dominant in psychotherapy in the 1950s. The American media also made psychoanalysis available to the public. Photo: picture alliance / United Archives

Once in contact with psychotherapy, Americans were willing to experiment. In the 1940s and 50s, classical psychoanalysis developed into a strongly client-centered talk therapy in which patients were guided by self-understanding rather than diagnosis by others. Empathy and active listening were the focus of this approach, which was mainly promoted by the American psychologist Carl Rogers (1902–1987).

US citizens were particularly good at adopting behavioral therapy. It corresponded best to the pragmatic, solution-oriented American. They were looking for help in the acute situation and did not want to have to spend years working out in therapy what had gone wrong once in their lives. Behavioral therapy was particularly popular in the 1950s and 1960s.

From the 1970s onwards, American citizens were finally able to choose from a variety of therapy options and, in addition to individual discussions, also discovered working in groups for themselves. Group therapy and gestalt psychotherapy in particular experienced a high point in the 1970s. Couple and family therapies as well as DBT (Dialectical Behavioral Therapy) and EMDR (Eye Movement Desensitization and Reprocessing) experienced a boom from the 1980s. From this time on, drugs gradually became an integral part of treatment.

The abundance of therapy offers that had developed in the USA over the years manifested the departure from Freud’s approach. Nevertheless, there is no doubt that the many different forms of psychotherapy that still exist in the USA today can all be derived from the ideas of Sigmund Freud.

Criticism: Doubts about the effectiveness of psychotherapy

Despite its success, psychotherapy did not remain undisputed for long. As early as the 1970s, when the subject was very popular, a paper by a psychiatrist from the renowned John Hopkins University caused a sensation. In it he criticized the “charlatans” who played with the worries and fears of gullible people. Further studies questioned the effectiveness of psychotherapy - and thus Freud as a person. The increasing knowledge that medication could successfully treat mental problems did the rest to encourage doubters. At some point, very critical voices even claimed that the Americans' anger towards therapy was ultimately a job creation measure for the countless players who earn their money in the US system with the mental stress of others.

Jonathan Engel, professor at Baruch College in New York, comes to a different conclusion in his highly acclaimed book “American Therapy: The Rise of Psychotherapy in the United States” (2009): “Psychotherapy works. Numerous studies from the past half century have shown that the condition of two thirds of those who attend psychotherapy improves. ”Nonetheless, Engel writes in his work:“ Effective psychotherapy obviously needs little more than a willing patient and an intelligent and understanding counselor for regular, trusting discussions and meetings. "

Engel cites this assessment, among other things, on a study from 1979. At that time, an experiment at Vanderbilt University in Nashville in the US state of Tennessee caused a sensation. A group of 30 patients with mental problems was divided into two. Half were treated by trained psychotherapists, the other half by humanities professors. The result: Both groups reported exactly the same number of positive treatment results. Many other American studies also show that the treatment of mental problems is more about soft aspects than training, philosophy and techniques: warmth, empathy and the connection between therapist and patient.

Education: not just for psychologists and psychiatrists

A special feature in the USA is that the performance of psychotherapeutic treatments is not limited to psychologists and psychiatrists. Social workers and nurses as well as specially trained counselors are also allowed to work in psychotherapy if they have acquired appropriate additional training. However, there is no national law in the USA that regulates psychotherapy uniformly. It is up to the 50 states to define their principles. Inevitably, the content and conditions for training and practicing therapists differ. However, the following generally applies: Only those who are licensed to work may work as a psychotherapist. American law prescribes this.

In psychology, a four-year bachelor's degree is usually followed by a four- to six-year postgraduate degree in psychology, which ends with a doctorate. In addition, the prospective therapists have to work full-time under supervision for one to two years. At the end of the academic training there is the license examination "Examination for Professional Practice in Psychology" of the Association of State and Provincial Psychology
Boards recognized by all states. Some states also require additional exams and some work experience. A license is only valid for the state in which it was acquired. Quite a few states require their psychotherapists to continue training in order to be able to hold their therapist license.

Non-psychological “health care professionals” who want to provide psychotherapeutic services usually also have to have a doctorate in their subject, but at least they can present a master’s degree. They must also have received intensive training in psychology and psychotherapy - both academically and practically - and have mostly already worked under supervision in psychotherapy. Here, too, the following applies: The non-psychological psychotherapists must meet certain license criteria from their professional associations. The state in which the therapist intends to work decides whether these are sufficient or additional requirements must be met.

As a rule, the therapists specialize in a specific group of patients. This specialization is geared towards age groups (children or adults) or topics such as drug or alcohol addiction, depression or eating disorders.

Only those who are licensed as providers of psychotherapy can bill their services with private health insurers or state health care providers.

Today: increased use of drugs

The golden age of psychotherapy is over in the United States, even though millions of Americans continue to receive treatment. But for some years now, mental problems have increasingly been treated with medication, in many cases even exclusively. "The proportion of outpatient patient contacts in which only medication and no psychotherapy is used increased from 44 to 57 percent between 1998 and 2007," analyzes the American Psychological Association (APA), based on figures from the US government. The Psychologists Association reveals another figure: Between 1996 and 2008 alone, the number of prescriptions for antidepressants in the USA more than doubled. According to the APA, it rose from 55.9 to 154.7 million.

Because of this development, professional associations such as the APA feel compelled to revalue the importance of psychotherapy through image campaigns and to bring their successes back into the public consciousness. APA and co. Blame the pharmaceutical industry in particular for the loss of importance of psychotherapy. Over the past few years, the company has invested millions of advertising dollars in campaigns that ensured that the pill became en vogue in the USA instead of a longer-term therapy. The American healthcare system is also repeatedly criticized. In this psychotherapy is not remunerated well enough - but the massive use of drugs is promoted.

After all, US policy has recently resolved a massive problem in caring for patients with mental illness. Since the “Mental Health Parity and Addiction Equity Act” of 2008, insurers have had to treat mental and physical illnesses equally. Specifically, this means: You have to bear the costs of caring for mental illnesses to the same extent as you have to pay for other health problems. For many years before, the cost of treating mental problems was not covered by health insurers or was severely limited. Many US citizens simply couldn't afford to see a therapist.

Whether psychotherapy, medication or a mix of both approaches: the need for treatment across the Atlantic is great. According to official figures, an estimated 43 million Americans had mental illness in 2012. The US government assumes that almost eleven million US citizens have a need for therapy that has not yet been met.

Nora Schmitt-Sausen

Angel J: American Therapy. The Rise of Psychotherapy in the United States, New York / USA 2009.
The Psychotherapeutic Professions in the United States of America, by Abraham Wolf, Gabor Keitner, & Barbara Jennings. Retrieved online at: www.psychotherapyresearch.org/.
American Psychological Association: www.apa.org.
Mental Health Libary: www.counsellingresource.com.
National Institute of Mental Health: www.nimh.nih.gov.