Psychotherapy? Psicoterapia? Psychothérapie? психотерапия?

October 14, 2009 12:50 PM

With regards to psychotherapy, a common opinion I've noticed on MetaFilter is that Cognitive-Behavioral Therapy is perceived as being the most efficient way to go, in addition to being one of the very few therapies likely to be reimbursed by health insurance. However, this may be coming from a largely American perspective. As such, I'm curious: What are some major features of psychotherapy in countries other than the United States?

What are modes of therapy with which Americans might be familiar that are more popular elsewhere than they are in the US, and why are they more common in other places? Are there any psychotherapeutic traditions I as an American would be unlikely to have heard of or considered? Similarly, are there any therapeutic modalities that are distinctly American (or, in a less absolute sense, are more commonly found in the US or in Anglophone countries)? Within therapeutic modalities that might be familiar to us (CBT, psychodynamic, psychoanalytic), are there any schools or features of those modalities in other countries that may not be common in the United States? (For the last question, I have the general impression that French psychoanalysis is hella Lacanian, but have absolutely nothing of substance to back that up.)

On another train of thought: Who goes to get therapy—and who pays for it when they do? Are there places where psychotherapy is viewed with more or less stigma than it is in the United States?

I realize these are many, many questions, and I certainly don't expect to have all—or even most—of them answered. All-in-all, I'm just interested in learning more about how psychotherapy is perceived, researched, and practiced in places other than my home country... and why these psychotherapeutic landscapes may differ.

(For what it's worth, my own attempts to answer these questions have been rather fruitless, though I haven't the faintest of where to look. Some random searching on MeFi found me an interesting thread suggesting that psychoanalysis is really huge in Argentina. I also seem to recall an assertion I'll paraphrase as something like: "In France, psychoanalysis is therapy.")

posted by Keter to society & culture (17 comments total)

UK: CBT is the main treatment mode. It is available on the National Health Service, so essentially the government pays for it, but there's a 2-3 month waiting period and (if I understand right) it's only available for a limited time; after that you would have to pay for it yourself. Of course if you have insurance, it would be covered by that (but many insurance policies won't cover pre-existing conditions).
posted by Infinite Jest at 1:51 PM on October 14

This is said without looking up much by way of supporting research, the reason for the popularity of CBT is that it has actually been proven to be more effective than other forms of therapy. As an example, see this article on treating bulemia.

I can't speak for therapies outside of the US, but I hope that explains the enthusiasm seen for it here.
posted by Hactar at 1:54 PM on October 14

NZ: CBT is taught preferentially in New Zealand medical schools.
posted by schmichael at 2:00 PM on October 14

Hactar: Very fair point! I realize that my initial phrasing might imply that the primacy of CBT in the US psychotherapeutic scene is due wholly or mostly to cultural factors... I did not mean to imply this, but rather was trying to use CBT as my perceived touchstone for "standard" psychotherapy in the US.
posted by Keter at 2:14 PM on October 14

Part of the reason is that CBT is generally short, and so cheap, and so insurers will pay for it, and so people will use it.
posted by jeb at 2:32 PM on October 14 [1 favorite has favorites]

Tangent: CBT has a great track record for issues with behavioral components, such as binge-ing and purging. I would argue it is not "more effective" accross the board with more ambiguous issues, such as grief and loss. It's one of many cool toys in the mental health toybox.
posted by ShadePlant at 2:42 PM on October 14 [2 favorites has favorites]

Hactar: Very fair point! I realize that my initial phrasing might imply that the primacy of CBT in the US psychotherapeutic scene is due wholly or mostly to cultural factors... I did not mean to imply this, but rather was trying to use CBT as my perceived touchstone for "standard" psychotherapy in the US.

I can mostly only repeat my answer from the last thread, and urge you not to be too swayed by the proponents of CBT. CBT is a great modality, and it works well for many people. It is not, however, on balance, better than other psychotherapies. Both Michael Lambert and Bruce Wampold have written extensively on psychotherapy outcome, relative outcomes of different modalities, and the factors that contribute to psychotherapuetic success. Both have found that all psychotherapies work about as well as others, that it's all very successful, and that there is no convincing research that factors specific to individual modalities are correlated with successful outcome.

It isn't my intention to argue those points here, the research on this is very settled, although not popularly reported. I do think that the conclusions merit mention, though, because they suggest that there are a lot of cultural factors that contribute to what psychotherapies might be popular in a given culture. Above jeb suggests one reason CBT might be popular in the US. Another is that it is easily manualized, taught, and studied. These things all contribute to the number of studies that get published, and make it seem more relatively effective than it is.

I'd go further and suggest that the therapeutic culture in the US is actually less homogenized than it is in the UK, where single payer healthcare has a huge affect on what gets applied. I have worked in many different settings, with hundreds of patients who between then have seen hundreds of therapists (in the US). Not many (precise, I know) had been in strict CBT. I would hazard the guess that some of the talk on MeFi is related to a mini-cultural bias for a modality that focuses more on cognition than emotion, and which can be sort of algorithmically applied.

All of this is a long-winded way of getting back to reiterating another of my points from the Argentina question: psychoanalysis is much more popular in Continental Europe, and parts of South America, than it is here. As I said there, about 50% of the practicing analysts in the world are Lacanians, and Lacanian therapy is very different than is American analysis. It's much more fluid, and as such, much more easily accessible.

Since the outcome research demonstrates that all psychotherapies are about the same, cultural factors (along with personality) likely have a lot to do with which ones are typically chosen.
posted by OmieWise at 2:54 PM on October 14 [5 favorites has favorites]

In my very limited experience I had found that therapists with degrees in medicine were often shifting mostly away from talk therapy to dispensing drugs and some talk. The reason seems to be that insurance outfits assume talk approach not really science so that payments limited in amount of time allotted to therapy but drug dispensing is "hard science" --the real thing--and so insurance extended for longer period of time.

CBT does seem to get overall the best ratings for traditional therapy (talk).
posted by Postroad at 4:04 PM on October 14

The outcome research doesn't really demonstrate that all psychotherapies are about the same because in the real world, CBT gets people better much, much faster and with much less struggle and MUCH less expense in both time and money.

If you told me I could get pregnant by doing a year's worth of IVF for $50,000 involving shooting up hormones for weeks and having surgery to get the eggs or 3 months of IUI for $5000, no hormones, no surgery, I don't think I'd say the two approaches were "equally effective" even though the outcome is still a baby.

There is also very little research showing that psychoanalysis is effective-- maybe a dozen studies?-- but there are hundreds showing efficacy for CBT. Part of this, of course, is due to the fact that psychoanalysts didn't believe there was a need for research until they started being unable to get reimbursed because they couldn't prove that anything that they did helped.

It's true that the few studies that do compare approaches head to head find that therapist empathy is *more* important than any particular technique, however. But given that, why not go for the technique that has the most evidence, works fastest with least pain and is cheapest *and* choose a highly empathetic therapist?

I believe the dominance of CBT in most countries relates to these issues-- and that's why the UK's NHS went for it.
posted by Maias at 4:44 PM on October 14 [2 favorites has favorites]

The outcome research doesn't really demonstrate that all psychotherapies are about the same because in the real world, CBT gets people better much, much faster and with much less struggle and MUCH less expense in both time and money.

Well this is almost precisely beside the point, and the very reason that this question is germane. Just because you find speed of cure the most important thing does not mean that all people do. Mental illness, understood by the medical model in the US, is not necessarily seen the same way (indeed, certainly isn't) in the rest of the world. Our medical understanding of mental illness has so far borne relatively little fruit. We don't have physiological tests for it, we don't have targeted treatments for it (see the rapidly expanding use of "anti-psychotics" to treat depression), we have a set of treatments that seem to work by common, rather than specific, factors. It seems to me that to really consider the question all of those things also need to be taken into account, and not dismissed as inefficiencies.

Another way to say this is that if someone has the money to burn, and a horror of touching other people, I'm not comfortable saying that their baby is less their own just because it was conceived through IVF.
posted by OmieWise at 5:42 PM on October 14 [1 favorite has favorites]

In grad school, I read about a zillion international (sometimes even collaborative among people from several countries) studies--many longitudinal and even some cross-sectional--on CBT efficacy, all favorable. And it wasn't just found to be so by the length of time involved in treatment, but in the EFFECTIVENESS of the treatment in attaining the goal of extinguishing a negative thought pattern or encouraging an adaptive behavior, etc. and maintaining the gains over time.
posted by so_gracefully at 8:48 PM on October 14

Are there any psychotherapeutic traditions I as an American would be unlikely to have heard of or considered?

Two key variations on psychotherapy developed in Japan are Morita therapy and Naikan therapy.

I am unable to say how important they are in overall Japanese mental health applications, but Morita, at least, is strong enough to sustain annual conferences and research that appears in Western publications.
posted by dhartung at 9:26 PM on October 14 [1 favorite has favorites]

You may also be interested in the obverse of this question re psychotherapies: culture bound psychological syndromes. The wikipedia page has a lot of external links and references.
posted by OmieWise at 4:46 AM on October 15

The outcome research doesn't really demonstrate that all psychotherapies are about the same because in the real world, CBT gets people better much, much faster and with much less struggle and MUCH less expense in both time and money.

Well this is almost precisely beside the point, and the very reason that this question is germane. Just because you find speed of cure the most important thing does not mean that all people do.

It's certainly not besides the point if you want insurance or government to pay for it.


Mental illness, understood by the medical model in the US, is not necessarily seen the same way (indeed, certainly isn't) in the rest of the world. Our medical understanding of mental illness has so far borne relatively little fruit. We don't have physiological tests for it, we don't have targeted treatments for it (see the rapidly expanding use of "anti-psychotics" to treat depression), we have a set of treatments that seem to work by common, rather than specific, factors. It seems to me that to really consider the question all of those things also need to be taken into account, and not dismissed as inefficiencies.

I'm not dismissing any of that-- the research is pretty clear that having many high quality relationships is likely to be better than any therapy or medication in the long run because of the way our stress systems rely on social contact for modulation. Therapy and medication may of course help (and may be necessary before you can get a good support system)-- but if you don't have a social support network you aren't going to stay well. Friends are basically the best medicine-- and they are free.

And I think it's best that we not medicalize that. The addictions field made a big mistake by trying to medicalize this by institutionalizing 12 step programs as part of treatment.

Another way to say this is that if someone has the money to burn, and a horror of touching other people, I'm not comfortable saying that their baby is less their own just because it was conceived through IVF.

Both IUI and IVF do not require sex, so your point is moot.
posted by Maias at 5:46 PM on October 15

PS-- if you have a horror of touching other people, having a baby-- not a good idea as babies can literally die from lack of physical affection.
posted by Maias at 9:56 AM on October 18

I'm not sure what your point is. I was responding to your analogous hypothetical, which I perhaps should not have done, but which certainly constrained what I could talk about. You're correct that anaclitic depression is a serious problem for infants who are completely ignored, but I certainly wouldn't suggest otherwise.
posted by OmieWise at 2:44 PM on October 18

In Germany public health insurance covers the cost for the following three types of psychotherapy: behaviour therapy (this includes CBT), psychodynamic therapy and psychoanalysis (up to 300 hours). Other forms of therapy exist but one has to cover the cost oneself. The most popular type is still psychodynamic therapy.
posted by jfricke at 4:48 PM on October 27