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Anaesthesia => Psychiatry => Psychotherapy
Psychotherapy
INTRODUCTION
Psychotherapy, process of interaction between a therapist and patient aimed at dispelling distress arising through disorders of emotion, thinking, and behaviour.
THEORETICAL BACKGROUND
The concept of talking to a specific individual about personal problems underpins the catharsis (therapeutic release of emotions) of the Roman Catholic confessional. The work of Aristotle on catharsis was discussed in the Viennese society of the 1880s. The notion that the problems might not be in our immediate conscious appreciation has also been known for centuries.
deg; School of Psychoanalytical
Psychotherapy Sigmund Freud is generally regarded as the founder of psychotherapy. Although he did not invent it, it was his skill as a medical scientist and writer that enabled him to draw together the ideas prevailing in Vienna at the time and apply them to medical practice.
A: Freud
Freud used the hypnotic state, not for the purpose of suggestion, but to uncover painful and forgotten memories in his neurotic patients. By this technique, he not only attempted to help his patients but also collected the data from which he formulated psychoanalytic theory. Freud believed that during the course of a person's development unacceptable sexual and aggressive drives are forced out of consciousness. These repressed urges, constantly striving for release, are sometimes expressed as symptoms of neurosis.
Freud thought that such symptoms could be eliminated by bringing the repressed fantasies and emotions into consciousness. He first used hypnosis as the means of gaining access to the unconscious. He soon abandoned the technique, however, in favour of free association, a method in which patients were asked to report whatever thoughts came to their minds aboutdreams, fantasies, and memories. By interpreting these associations Freud helped his patients gain the insight into their unconscious that he believed to be curative.
Later he placed great value on what could be learnt from transference (the patient's emotional response to therapists), which in Freud's view reflected earlier feelings towards the patient's family members. Free association and transference reactions are still central features of Freudian psychoanalysis sessions. Some of Freud's most gifted followers disagreed with him on important aspects of theory and therapeutic technique and subsequently founded schools of their own.
B: Jung
Perhaps the most influential was Carl Gustav Jung, who believed that Freud overemphasized sexual instincts as a source of behaviour. Jung thought that non-sexual potentials within the person must be realized, or neuroses would develop. Jungian therapists attempt to help patients recognize their own inner resources for growth and for dealing with conflict. Techniques for solving immediate problems are varied and pragmatic. Dreams and art are used to draw out the patient's associations to the unconscious images that Jung believed are shared by all.
C: Adler
Alfred Adler also minimized the importance of instinctual sexual drives in behaviour. He believed that the smallness and helplessness of children produce feelings of inferiority in them and that in reaction to these feelings, many people strive for superiority. Countering this search for power and significance is the quality that he called social interest, that is, empathy and identification with other people. According to Adler, psychological disorders result from a faulty way of living, including mistaken opinions and goals and an underdeveloped social interest. The therapist's job, therefore, is to re-educate patients-to convince them of their errors and to encourage them to develop social interest.
D: Fromm, Horney, and Erikson
Several of Freud's followers elaborated theories of neuroses that emphasized the role of social and cultural influences in the formation of personality. These so-called neo-Freudians include Erich Fromm, Karen Horney, and Erik Erikson.
Fromm believed that the fundamental problem confronted by everyone is a sense of isolation deriving from the individual's separateness. The goal of life and of therapy, according to Fromm, is to orient oneself, establish roots, and find security by uniting with other people while remaining a separate individual.
Horney believed that neurotic behaviour blocks a person's inherent capacity for healthy growth and change. The job of therapy, in her view, is to disillusion the patient of such defence blockages, that is, to identify and clarify them, and then to help the patient mobilize innate constructive forces for change.
Erikson, like Horney, was convinced that human beings are capable of growth throughout their lives. Guiding such change is the person's ego, which can develop in a healthy way when given the right environment. Failing that, a person can acquire through therapy the basic trust and confidence needed for a healthy ego. Unlike traditional psychoanalysts, Erikson, who began practice as a child analyst, usually worked with a patient's family while treating the patient.
° Behaviourism
School In the 1950s another group of theorists, later known as behaviourists, became known in the field. They had become disenchanted with the lack of scientific fact and methodological rigour in the research supporting psychoanalytic theory, their disenchantment having first been raised by John B. Watson in the United States around the turn of the century. The main thrust behind the new theory was that human inner experiences could not be studied and evaluated as they were not observable in the strictly methodological sense. He proposed "behaviourism" as a basis for the objective study of human behaviour, and was influenced by the Russian physiologist Ivan Pavlov, who described how conditioning works in animals, and by Edward Lee Thorndike, who in the United States was investigating the effects of reward and punishment on animal behaviour. Watson's ideas were further refined by B. F. Skinner, who supported the idea that observed human behaviour was the only valid object of study, and Watson continued to research conditioning processes.
Behaviour therapists believe that behaviour of all kinds, normal and maladaptive, is learnt according to specifiable principles and that these same learning principles can be used to correct troublesome behaviour. Regardless of the specific technique they later use, behaviour therapists begin treatment by finding out as much as they can about the client's problem and the circumstances surrounding it. They do not infer causes or look for hidden meanings; rather, they concentrate on observable and measurable phenomena. On the basis of this behavioural analysis, they formulate hypotheses about the circumstances creating and maintaining the problem. They then set out to alter the circumstances, one by one, and observe whether the client's behaviour changes as a result.
A: Wolpe and Eysenck
In the 1950s, clinical applications of what was then termed learning theory were described by Joseph Wolpe in South Africa. He developed a technique known as systematic desensitization, which he used for treating symptoms caused by excessive anxiety. This method calls for helping the client to relax and then, gradually, to approach the situations or objects that are feared.
Hans Eysenck, working at the Institute of Psychiatry in London, defined behaviour therapy as the application of modern learning theory to the treatment of behavioural and emotional disorders. He described behaviour therapy as an applied science with testable theories that could be investigated experimentally and proved or disproved. In 1963 the discipline was sufficiently established to support its first journal, Behaviour Research and Therapy. Throughout the past three decades these ideas have grown beyond classical and operant conditioning to other areas of social psychology, developmental psychology, and experimental psychology. Albert Bandura in the United States formulated a social learning theory, through which he conceptualized self-regulatory mechanisms that have further influenced treatment methods. He used the behavioural approach to change beliefs and habits of thought that appeared to be the source of the client's distress.
° Cognitive Therapy School
The 1960s saw the development of a further therapeutic discipline known as cognitive therapy. Aaron Beck, a psychoanalyst, through careful clinical observation and experimentation described a model for understanding depression. This he viewed in terms of a person's faulty thinking, which he aimed to correct directly rather than attempting to understand its origins. His treatments have some elements in common with behaviour therapy. This has led to the development of cognitive-behaviour therapies practised by cognitive behavioural psychotherapists.
Many other schools of psychotherapy have come to exist with greater or lesser basis in science and drawing on psychoanalytic, cognitive-behavioural, and systems theories.
° New Approaches to Psychotherapy
In the late 1960s and the 1970s, a large number of new psychotherapeutic methods were devised and promoted. Many, like the earlier humanistic therapies, were born out of dissatisfaction with psychoanalytically oriented psychotherapy, which was considered too costly, too time consuming, and elitist. Some critics also believed that psychoanalytic practices were too intellectualized and rational, overly preoccupied with the past, and unnecessarily committed to preserving the Western values of individualism, achievement, and productivity. In reaction, they developed methods that emphasize emotion over reason and the present over the past and future. Others who became dissatisfied with psychoanalysis, such as Ellis and Beck, turned in a different direction and placed even more emphasis on the power of reason to overcome emotional disturbance.
Jerome Frank in 1971 described characteristics common to all the psychotherapies. He emphasized an intense confiding relationship with a helping person on the basis of a rationale which contains an explanation of the patient or client's distress, and of the methods for its release. Psychotherapy should provide new information about the nature and origins of the patient's problems and ways of dealing with them. It should instil hope in the patient that he or she can expect help from the therapist. There should arise an opportunity for the patient to experience success during the course of treatment and a consequent enhancement of the sense of mastery. It should facilitate emotional arousal in the patient.
° Current Research
The existence of a wide variety and great number of schools of psychotherapy has led to the development of an extensive literature describing the theory and practice of the individual disciplines. Increasingly, however, public expectation and economic considerations over health care are demanding assessment of the effectiveness of psychotherapies in the treatment of patients. As health-care practice is becoming "evidence-based", practitioners need to know the efficacy of the treatments they are using so that they may inform patients and plan effective, economic care.
This has led to rigorous studies comparing the various psychotherapies both with each other, and with drugs, in the treatment of many of the commoner mental disorders. Outcome studies evaluating the effectiveness of cognitive and behavioural therapies in the treatment of depression, phobias, and some personality disorders have shown these treatments to be as effective as drugs, with the effect often longer lasting. Collaboration is also allowing the results of smaller studies to be looked at as part of analyses, adding power of evidence to the studies' conclusions.
The evidence for the effectiveness of the longer psychotherapies which are interpretative and psychodynamic is less certain; however, research in group and family therapies is encouraging. With the rapid increase in unregulated counselling therapies available within National Health Service practice, much attention is being given to examining the usefulness of what is sometimes seen otherwise as common sense. The early results in some specialist areas suggest that this research is important, as some patients seem to do no better with counselling, but improve dramatically with cognitive therapy.
The future for many schools of psychotherapy will depend on continuing research, not only into theory and practice, but most importantly in audit and outcome studies of clinical efficacy and economic viability.
CURRENT TREATMENTS
The psychotherapies have most to offer people suffering from emotional, behavioural, and cognitive mental disorders such as depressive states, anxiety disorders, phobias, personality disorders, and eating disorders such as anorexia nervosa. They are less well suited to people with severe psychotic mental disorders, such as schizophrenia or bipolar affective disorder (manic depression), but cognitive and family therapies can sometimes have a role in these too. People with problematic addictive behaviours involving drug abuse, alcohol addiction, or gambling may be less suited to psychoanalytic therapies which delve deep into a patient's past, and be better helped by cognitive-behavioural strategies. It is therefore of fundamental importance that a patient's suitability be carefully assessed before that person is accepted for psychotherapy.
Broadly, there are four main groups of psychotherapy widely practised in the United Kingdom.
° Counselling or Supportive Psychotherapy
This aims to help the patient deal with current problems by focusing on solutions. The therapist may give advice and express sympathy and encouragement. Counselling approaches are appropriate for many of the problematic life events faced by people, such as bereavement, serious ill health, or marital breakdown. It can also be useful for people with mental disorder who are not assessed to be sufficiently robust for a more exacting psychotherapy.
Counselling skills are possessed by many health-care professionals and increasingly by people who undertake counselling courses. Many general practices and hospital trusts employ counsellors and they are also available through voluntary and charitable agencies. People may refer themselves or may be referred by doctors or other health professionals. Sessions are usually short and conclude over a number of weeks. In the voluntary sector, means-tested fees are customary.
Counselling is a major growth area in health care in the United Kingdom, perhaps reflecting emotional needs previously met in the family or through religion. Regulation of training and qualification remains incomplete, although there is an agency, the British Association of Counsellors.
° Psychoanalytic
Psychotherapy Also known as psychodynamic psychotherapy, this is an insight-directed or exploratory process aimed at helping the patient understand his or her current thoughts, feelings, and behaviours in terms of earlier life experiences and conflicts, both conscious and unconscious. It is suited to people with a wide range of emotional disorders, especially chronic anxiety and depression and personality and eating disorders.
There are three main levels of dynamic psychotherapy that are based on the professional background and training of the practitioner. Level one skills are present in most health professionals and counsellors and involve an awareness of the person as well as the problem. It suggests an ability to communicate and empathize with people from various backgrounds. It also demands an ability to recognize a patient's anxiety and to manage it by explaining the problem and reducing the irrational fear.
Level two skills are additionally possessed by psychiatrists and mental health social workers and include an ability to understand and communicate with patients suffering from psychological disorders. In addition they should recognize that a patient's current state of mind is influenced by previous experiences in a way that he or she is unaware of. There is an awareness of the phenomenon of transference, which is not used in the therapy beyond allowing the patient to see the therapist as a benevolent parental figure, thus reinforcing the therapeutic relationship.
Finally, additional level three skills are possessed by psychoanalytic psychotherapists. These include helping patients to face the truth and take responsibility for themselves and their relationships. The therapist focuses on the patient-therapist relationship as a way of exploring and understanding the patient's problems. The development of transference is encouraged. The patient develops feelings for the therapist that are in fact representative of previous feelings towards other important figures in the patients' lives. These are actively worked with in order to elucidate unconscious feelings and conflicts affecting the person's present life.
Psychoanalytic psychotherapists come from all backgrounds, often paramedical. Training is through an institute of psychoanalysis and takes several years. Initially, trainees are required to undergo their own analysis, usually for at least a year, before they can take part in seminars. In turn they begin to work under the supervision of a more experienced analyst.
Patients may self-refer or be referred by their doctors or other health professionals. Ideally they are assessed by an analyst other than the therapist they will ultimately see. They should have an appropriate disorder, be psychologically minded, able to reflect on themselves, and be committed to the process. They should not be actively suicidal and, generally speaking, should not have severe psychotic mental illness. Following the allocation of a therapist, sessions are usually for at least 50 minutes, four times a week, and may last from months to years. Much importance is attached to the consistency of the timing and venue which represent boundaries in the therapeutic experience. These rules are explained to the patient.
In the session the patient is encouraged to talk freely about any issues that come to mind. The therapist listens carefully to what is said and by detecting themes and sequences within the narrative, begins to understand the patient's unconscious processes. The patient is helped to link his or her current feelings to past experience by way of interpretations offered by the therapist; the process is dynamic and changes over time.
Through the development of transference, the analyst can discover earlier suppressed conflicts, wishes, and fantasies, and by interpretation help the patient re-establish a healthier dynamic equilibrium. This process is revisited many times during the therapy, a process known as "working through". In the final stages of treatment the therapist aims to resolve the neurotic attachment the patient has formed in the "resolution of transference". At each stage in the process, the dynamic changes occurring throughout ease the emergence of hitherto hidden thoughts, feelings, and impulses, all of which help the therapist understand the patient.
As psychoanalysis is time-consuming, expensive, and demanding of the patient (more usually referred to as the client) it should not be undertaken lightly.
° Behaviour Therapy
This has been used successfully to treat a wide variety of mental disorders, ranging from phobic anxiety disorders to chronic schizophrenia. Therapists are mainly drawn from psychology, nursing, and medical professional backgrounds and ideally undergo rigorous training and supervision.
Patients are carefully assessed by interview and their view of their symptoms carefully noted. Using guided imagery, where the patient is asked to visualize an anxiety-provoking image, and combining this with role-play, the therapist gains greater understanding of the symptoms by listening to how the patient thinks and feels in these situations. Physiological monitoring and self-monitoring by use of a diary help detect behavioural patterns in the patient's life which are functionally related to his or her problems.
Phobias are treated by, gradually and repeatedly, exposing the patient to the stimulus or cue that causes anxiety. At each exposure the patient is taught how to manage the resulting anxiety using a variety of techniques. Eventually, it is intended, the anxiety fades. Obsessional behaviours can be treated by preventing the patient from responding to his or her overwhelming desire to act on the obsession, and by managing the anxiety this desire causes. Anxiety management, cognitive restructuring, assertiveness, and social skills training all play an important role in the success of individual programmes. Patients with chronic schizophrenia can be motivated by token economies, which is a form of therapy based on rewarding desired behaviour with tokens that can be cashed in for real rewards, and most important, which can reinforce that desired behaviour. Behaviour therapy is highly effective in the treatment of psychological sexual dysfunctions (inability to function normally), such as impotence.
The number of sessions of treatment required varies with the disorder. The usual number of sessions varies between 10 and 20.
° Cognitive Therapy
This is often used in conjunction with behavioural therapy and has been well researched and validated as a form of treatment. It is gaining widespread use in the treatment of depressive disorders and has been found to be as effective as antidepressant medication in the treatment of mild to moderate depressive illness, and more likely to prevent relapse. It is also used with success in anxiety, eating, and addictive disorders, as well as in modifying beliefs surrounding psychotic experiences in the more severely mentally ill.
Therapists are drawn from medical, nursing, and psychological backgrounds and undergo training for diplomas in cognitive therapy conferred by recognized academic centres.
Aaron Beck's recognition that cognition (style of thinking) is amenable to investigation and treatment forms the basis of treatment. Depressed people have a negative view of themselves, the world, and the future-the cognitive triad. These negative beliefs in turn give rise to other cognitive distortions, which form systematic errors in reasoning. Examples of cognitive distortions include overgeneralization; magnification and minimization, arbitrary interference; selective abstraction; personalization; and dichotomous (split) thinking. Essentially there is a bias in the processing of information, which leads to the person drawing erroneous conclusions, which in the case of depression are automatic negative thoughts. Therapy is aimed at identifying the distorted thought patterns through interviews and generating a list of problems. Priorities for treatment are agreed and homework set. Cognitive restructuring aims to solve the problems, and the patient's confidence in the therapist grows with each success, thereby encouraging progress to more difficult problems. Usually treatments last between 10 and 20 sessions.
In addition to individual therapies, the principles of psychotherapy can be applied to groups.
° Group Therapy
This is used both at a supportive level (level one) and at a deeper psychoanalytic level (level three). Groups were first seen in general medical settings where patients recovering from similar complaints supported each other. In Europe group psychotherapy was first used by Jacob L. Moreno, a psychiatrist who had his patients act out their problems as a means of heightening their awareness of them. Moreno's "psychodrama" spread to other parts of the world and it is used for treating both neurotic and psychotic patients and also for training mental health professionals.
Moreno's development of psychodrama in the 1920s laid the foundation for modern group psychotherapy. Army officer selection in World War II further demonstrated the power of group therapy; after the war, the "Northfield Experiments" used small groups in the treatment of battle-related neurotic disorders.
Groups may be open, with new members joining and others leaving during the course of therapy, or closed where the group membership remains static for the period of treatment. The group is conducted by a therapist or pair of therapists and all members agree to rules (for example, strict confidentiality). The therapists help the group members understand themselves in terms of the relationships, conflicts, and tensions that occur within the group, and link these to other aspects of their personal functioning.
Nowadays groups are an economical and resource-friendly method of treatment and are used widely in general psychiatry, including the treatment of eating disorders, personality disorders, and for the treatment of drug and alcohol addiction.
° Family Therapies
These are focused on the family system rather than on the individual. The family network is seen as a system of interlocking triangles, where increasing tension between two individuals is modulated by their relationship with a third party. Through feedback, imbalances in the system are corrected and equilibrium restored. Families are open systems, which means tension and stress can be added to, and removed from, the system. Structural family therapists work at understanding the relationships within the family in terms of past experiences, whereas strategic family therapists concentrate on changing the system as it exists. This is achieved by a variety of techniques including re-enactment, homework, family sculpting, genograms, and behavioural modification.
The variety of psychotherapies available and currently practised is testimony to the uncertainties surrounding exactly how it works, and to the clear need for distressed people to have a means of talking about their problems built into their treatment.
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