39

PSYCHOTHERAPY
Ang Wee Kiat, Anthony

Introduction Psychotherapy is a form of treatment based on the systematic use of a relationship between therapist and patient (as distinct from pharmacological or social methods) to produce change in feelings, thinking and behaviour. The advantage of this definition is that it highlights how the quality of the interpersonal relationship forms the basis for therapeutic efficacy, whatever techniques are employed to this end. As with all interpersonal relationships, communication is an intrinsic aspect of psychotherapy. The predominant medium of communication involves the use of spoken language. However, non-verbal means (e.g. body sculpting, drama, music, art and play) have been employed for psychotherapeutic purposes as well. Despite an overlap with counseling or empathic clinical interviews, the above definition highlights 3 distinguishing features of psychotherapy. Firstly, unlike counseling which is more often applicable to normal populations, psychotherapy as a form of treatment is rendered for clinical problems (e.g. depressive disorders). For this reason, counselors prefer to refer to persons seeking help as clients; whereas psychotherapists have less qualms to identify those they help as patients. Secondly, a psychotherapist makes systematic use of specific psychological theories to formulate and guide interventions. Thirdly, such interventions are intended to create change in the individual seeking help in an attempt to resolve the presenting problem of the patient. Counsellors generally view change as a by-product of empathic listening and beneficial presence with the client and are less likely to explicitly intervene to effect intended changes. As our society becomes more affluent, people are more likely to seek help from mental health professionals for a variety of problems including difficulties associated with modern living. It becomes less important to label such help rendered as counseling or psychotherapy.

The Goals of Psychotherapy In general, the goals of psychotherapy are as follows: (1) removal of distressing symptoms; (2) altering disturbed patterns of behaviour; (3) improved interpersonal relationships; (4) better coping with stresses of life; (5) personal growth and maturation.

Types of Psychotherapy Broadly, there are 4 different theoretical approaches adopted in psychotherapy. They have their basis in: (1) (2) (3) (4) psychoanalytic tradition; cognitive-behavioural theory; interpersonal or systemic theory; existential or gestalt philosophy.

Psychotherapy can be carried out in 4 modes, namely with: (1) individuals (2) couples (3) families (4) groups By convention and for historical reasons, individual psychotherapy is often identified by its theoretical orientation. Thus, we have 4 main types of individual psychotherapy, namely psychodynamic psychotherapy, cognitive-behavioural psychotherapy, interpersonal psychotherapy and existential/experiential psychotherapy for individuals. When the mode of delivery involves more than one person, the theoretical orientation is often left out in the reference (i.e. couple or marital therapy, family therapy and group therapy). Despite the diversity of techniques employed in psychotherapy, the following are beneficial functions that most, if not all effective psychotherapies have in common: (1) Developing a therapeutic relationship (2) Generating positive expectations (3) Facilitating cognitive and experiential learning (4) Facilitating emotional arousal and catharsis (5) Engendering a sense of mastery (6) Application of new skills developed

Levels of Psychotherapy To speak of the varying levels in psychotherapy suggests that intended changes for patients may be superficial, intermediate or deep. Psychoanalysis, with its ambitious goal of reconstructing character pathology by dealing with deep, hidden psychic issues from the past, and its frequency and duration of meeting with the patient, is taken as the deepest extent of psychotherapeutic exploration. The corollary is that techniques that rely less on psychoanalytic methods (e.g. exploration of the unconscious by free association, interpretation of the unconscious conflicts and transference) and forms of psychotherapy in which patients are seen less often or for shorter periods of time are assumed to have only modest effects. Thus, activities such as the unburdening of problems to a sympathetic listener, ventilation of feelings to a supportive helper, rational discussion of problems with the aim of arriving at practical solutions and having more information are presumed to fall short of what could be achieved through deep exploration and analysis. In a different sense, the level of psychotherapy could be used to indicate the level of training and sophistication of the practitioner. This ranges from level 1 of basic counseling, through an intermediate level 2 practised by many psychiatrists, psychologists, social workers and nurses, to specialist level 3 treatments. The assumption here is that the level 3 specialists have better skills and can deal better with more difficult clinical situations.

Effectiveness of Psychotherapy Although critics and skeptics have claimed that psychotherapy is no more effective than placebo treatment, the weight of scientific evidence argues against this position. Current research affirms that psychotherapy is an effective treatment for many psychiatric disorders.

Meta-analyses have been conducted of the efficacy of psychotherapies in depressive illness and other neurotic disorders. Such studies have consistently shown that the effect size for psychotherapy is around 1 standard deviation unit. This means that the average psychotherapy patient does better than do 85% of control subjects, but those undergoing placebo treatment are still 60% better off than no-treatment controls. Put another way, 70% of psychotherapy patients improve significantly, while 30% do not; 30% of controls improve spontaneously, while 70% remain the same. Placebo treatments do produce change (with effect sizes of around 0.5), supporting the view that non-specific factors as well as specific techniques are important in psychotherapy. Empathy, genuineness and warmth have been identified as desirable qualities of effective therapists regardless of whatever techniques are employed. It has been demonstrated that there is greater effectiveness if psychotherapy is delivered by trained therapists who pay attention to issues of engagement of patients than if rendered under ordinary clinical settings. Research has shown that patients are more satisfied with therapists who are perceived as showing care and concern. It has been suggested that patients who seek therapy are demoralized and that therapy is successful to the extent it leads to remoralization, i.e. renewed motivation on the part of the patient to adopt new measures to overcome their own problems. In other words, the effectiveness of psychotherapy is also determined by patient factors such as motivation to change and by the extent that the therapist and patient are able to collaborate towards a common goal.

Clinical Application Referral for Psychotherapy

How does a doctor in primary health or hospital practice decide which patients to refer for some form of psychotherapeutic intervention? In practice, referrals are made when the patient specifically requests for it or when the doctor senses the presence of psychological issues that need to be addressed but feels unable to address them for some reason (e.g. lack of time, lack of necessary psychotherapeutic skills). Indications for Psychotherapy

The role of the assessing psychiatrist or psychologist is then to address the question: What treatment, by whom, is most effective for this individual, with that specific problem, and under which set of circumstances? Put simply, the assessor seeks to determine which type of psychotherapeutic intervention is likely to be most appropriate and at what level. This calls for (a) expertise in a thorough psychiatric evaluation beyond just making a psychiatric diagnosis; (b) knowledge about the different forms of psychotherapy and the general indications for each; and (c) how to initiate the necessary referrals to appropriate services or individual psychotherapists. Evaluation of Psychotherapy

Very often the referring doctor fails to follow up with patients they have referred for psychotherapy. This is unwise from various points of view. Firstly, many patients do not even turn up for the first session and some patients drop out of therapy even under

the best hands. Secondly, psychotherapists need to be accountable to the referring doctor to a certain extent. Patients referred for psychotherapy may be vulnerable and may be exploited by unethical therapists since there is no licensing body for this profession at present. Thirdly, referring doctors can learn much by following up on the progress of patients undergoing psychotherapy, including insights into patients problems, and appreciating psychotherapeutic techniques.

References 1. 2. A Ang. Why Doctors Should Learn Counselling and Psychotherapeutic Skills. Singapore Medical Journal 1999, pp 128-9. Sidney Bloch (1996). An Introduction to the Psychotherapies. Second Edition. Oxford University Press.