|Psychiatric Illness, Treatment and Psychotherapy|
|Tuesday, 25 December 2007|
Page 1 of 3
Any contact between doctor and patient has psychological aspects. A simple act, such as writing a prescription, has a psychological meaning. This depends on the setting in which the act occurs, the way it is carried out and the respective psychological attitudes, conscious and unconscious, of patient and doctor towards each other. To one patient the prescription may convey only kindness and consideration. To another it may be seen as a gesture which silences him, which stops him talking about his troubles and, by implication, tells him to take them elsewhere.
Reassurance and Suggestion. Often the doctor deliberately tries to influence the patient's symptoms by psychological methods. He may try by persuasion, reassurance and encouragement. He may offer advice on the patient's management of everyday affairs. Sometimes he tries suggestion. This means that the doctor uses his authority and influence with the patient to convince him he is getting better or that a particular course of action will be helpful.
Abreaction. General discussion of the patient's difficulties may also help by allowing him to ‘get things off his chest’ and unburden himself to someone he can feel is an interested observer, yet who is more impartial than his family and friends. Sometimes the release of pent-up emotion during such discussion leads, at least, to temporary relief. This process is called ‘abreaction’.
Such methods can be termed ‘simple psychotherapy’, to distinguish them from the ‘dynamic’ treatments described below. It should be added that this distinction has nothing to do with efficacy.
Dynamic psychotherapy or interpretative psychotherapy covers those methods of treatment where an attempt is made to use the doctor-patient relationship to increase the patient's knowledge of himself. This means that some of his unconscious motivations are brought into consciousness. The basic assumption is that, if this is done, the patient's more pathological defenses, from which his symptoms result, become unnecessary.
The first form of dynamic psychotherapy was psycho-analysis. It will be discussed at some length, to help in understanding the modified and shorter techniques.
Psycho - analysis
A basic assumption in psycho-analysis is that there is a reason for all mental events, however haphazard they appear.
Free Association. In ordinary social conversation many ideas which occur to the speaker are not expressed, because they may be irrelevant, out of place, or in bad taste. But in psycho-analysis the patient is asked to tell the doctor everything that occurs to him -thoughts, feelings, fantasies, sensations-as he experiences them during the session and without any reservations whatsoever. This is known as `free association' and is the basic rule for the patient. The doctor's role is that of an interpreter. This means that he listens carefully to all that the patient tells him and, as occasion fits and the pattern of mental events becomes clear, interprets to the patient the emotional significance of what he says. The process is gradual, but this does not mean that there is any attempt to avoid painful or anxious feelings. These, like any others, must sooner or later be faced.
In its pure form, this treatment avoids any direct use of methods of influencing the patient. This means that the measures described as 'simple psychotherapy' are never deliberately practiced. Thus it is held, for example, that the best form of reassurance is a correct interpretation, since it shows the patient clearly that the doctor is in touch with his feelings.
Regression. Treatment is aided by a very remarkable fact. The situation fosters regression and in this way the patient's childhood, in a sense, is again accessible to observation, as more childish ways of thinking or feeling replace adult ones, and the patient behaves, often in spite of himself, as if the doctor were an important figure in his childhood, such as a parent. Surprisingly, this occurs irrespective of the age, sex or appearance of the doctor.
Transference. This displacement of feelings from a parent or other important person to the doctor is known as `transference'. Because it may have all the violent qualities of love and hate felt towards the original figure, the doctor-patient relationship can become the central and most important object of study. Consequently, one aim of the doctor is the interpretation of events occurring in the transference. From this he can try to show the relationship of these events to others in the patient's life, whether past or present.
Character Change. If treatment is successful there is usually some degree of character change, so that aspects of the patient's behavior which increased his difficulties are modified. This cannot happen quickly. Few analysts would expect substantial changes in less than eighteen months or two years, even when the patient attends for an hour five times a week.
Doctor and Patient. In orthodox psychoanalysis, the patient lies on a couch while the doctor sits out of sight, because it is thought that both patient and doctor are thereby more relaxed, the patient better able to concentrate on ‘free association’ with less distraction, and the doctor freer to devote his attention to the patient's productions and their meaning. Patients, of course, often try to discover whether the doctor approves or disapproves of what they are saying, and they may fancy that it is easier to do so when they can watch the doctor's facial expression. Perhaps we should add that during this treatment, and in all forms of dynamic psychotherapy, the doctor is careful not to express moral criticism, since this would be an attempt to influence the patient's behavior without trying to understand it. It would also seriously interfere with the patient's ability to follow the basic rule of free association.
As far as we can see at present, analysis is more likely to be useful in the neuroses than in the psychoses, though attempts are sometimes made to treat the latter. It is not usually indicated in people much older than forty or who are unintelligent. But the most serious disadvantages of psycho-analysis lie in its great length and in its expense.
Shorter Forms of Psycho-analysis
Because of the length of time and expense involved, psychiatrists have sought short cuts in interpretative psychotherapy. In these shorter techniques it is not always possible or desirable to avoid reassurance or advice. But almost without exception all forms of dynamic psychotherapy use the concept of transference in their work with the patient.
Sessions vary in length and frequency, but are usually from half to one hour once or twice a week. Most doctors agree that the longer the interval between sessions, the more difficult the task. If intervals are too long it becomes particularly hard to interpret the transference material correctly.
Modification of Pressing Conflicts. Before treatment itself starts, a careful history of the patient is taken and the likelihood of psychotherapy being helpful is assessed. Many doctors find it convenient to set themselves a particular goal in treatment. This need not be an ambitious one. It may be concerned with the modification of the patient's more pressing conflicts by interpretation of his more prominent defenses. It is unrealistic to set these goals too high. In general, less urgent conflicts will be ignored in short-term treatment.
In shorter methods of psychotherapy it may be necessary to direct the patient's attention to particular periods or aspects of his life, even when his free association is not leading in that direction. This may have to be done by questioning. But the emphasis will still be on interpretation of what the patient communicates to the doctor and especially of the transference relationship.
Face-to-Face Interview. In many forms of dynamic psychotherapy the couch is discarded in favor of a face-to-face interview. There are many practical reasons for this. One is that the use of a couch occasions much anxiety in itself, partly because it produces a greater degree of regression. Many psychiatrists prefer not to invite this state of affairs when they have less time than the analyst to deal with this situation. However, the face-to-face technique can be exacting for both parties and, while the doctor must be natural in his manner, he must try not to convey, unintentionally, attitudes detrimental to the patient's free expression.
No Rigid Rules. The kinds of dynamic psychotherapy vary greatly in detail as do the conditions in which they are practiced. However, certain basic conditions seem necessary. The patient's time must be respected; for example, it seems important for him to know in advance the times and duration of his sessions. Consistency in appointments is desirable. Free expression must never be discouraged. But when this has been said, it must be emphasized that there are no rigid rules in dynamic psychotherapy. Techniques need to be adaptable and imaginative. They call for great skill, which is why not every psychiatrist would care to use them.
Finally, more than anyone else, the psychiatric patient is inclined to feel that no one has time for him or is willing to help him. To feel that he can be respected as well as tolerated is in itself a corrective emotional experience.
Dynamic Group Psychotherapy
Before the Second World War some attempts had been made to treat small numbers of patients collectively in groups. An increasing emphasis on psychiatric treatment stimulated by the war revived interest in these methods.
Free Discussion. In dynamic group psychotherapy the patients, usually six to eight in number, sit in a circle together with the doctor. The length of the session varies, but in Great Britain it is usually an hour and a half. The ‘free association’ of individual therapy is replaced by ‘free discussion’-there is no set subject and the doctor does not direct the discussion. As in individual treatment, his role is essentially that of interpreter. Here again he tries to avoid those methods of influencing patients described on as ‘simple psychotherapy’.
Open v. Closed Groups. Groups are of two kinds: open and closed. In an open group patients may join and leave at different times during the course of the group. As each patient goes he is replaced by someone else, so that the composition of the group changes. In a closed group, on the other hand, all patients start and finish their treatment at the same time.
An open group can be rather unsettling for patients who need long-term treatment. A closed group is better for such people. Patients who seem able to benefit from two or three months' treatment are, on the other hand, perhaps best treated in an open group. An open group can also be useful for an initial period of observation and assessment. If found suitable, a patient can then be transferred to a closed group. A closed group may continue for anything from six months to a year, sometimes much longer. In the case of out-patients the group meets once or twice a week, but in a few in-patient centers five sessions a week are offered.
The Interpretation. The doctor may interpret the behavior of the group as a whole, or he may interpret that of a given individual. Most doctors prefer to interpret principally group behavior in the early stages, to help the group to work together as a coherent unit. But individual interpretations are important and will certainly be made as the group progresses. There are, of course, no rigid rules and the technique needs to be adapted to the situation prevailing in the group at the time.
As in individual therapy, special importance is placed on the interpretation of transference. Here again, the aim of treatment is to examine a current situation in an attempt to bring to light unconscious factors in the illness.
While patients with many different kinds of psychiatric illnesses can be helped in groups, there are indications that some patients with long-standing personality disorders can benefit more from group therapy than from individual treatment.
Other Forms of Group Therapy
There are other kinds of group therapy where no attempt is made to conduct the treatment on dynamic lines. Mutual discussion of personal problems is the usual basis of a supportive group. Some doctors conduct groups where the emphasis is on explanation rather than interpretation.
Some combine these methods and also include active counseling. Some hospitals use larger groups in which patient and staff-including nursing staff meet to discuss everyday problems of running the hospital. In groups such as this the patients often receive other forms of treatment as well.
In these methods, psychotherapy is used together with some form of stimulant, sedative or anxsthetic.
The patient lies on a couch and the doctor sits at his side. Most drugs are given by injection into a vein, usually in the forearm. In the case of an anesthetic such as ether, the patient's face is covered with a mask on to which the ether is dropped.
For Abreaction. One use of this method is to facilitate abreaction. If it is felt that the illness is largely concerned with a single disturbing episode (as in some wartime cases of battle neurosis), the patient may relive the disturbing scene, thus `abreacting' or giving vent to his pent-up emotions of fear, rage or grief. It is hoped that, if this is repeated a number of times, the individual can be brought to face his disturbing past more easily. The drugs which are often used for this purpose are those of the sedative group, and ether. In each case, the aim is to give just enough of the drug to make the patient drowsy and a little `drunk'. He can then usually be persuaded to relive the scene concerned without too much difficulty.
For Narcoanalysis. The sedative group of drugs is also used to facilitate exploration of those events in the patient's past which may have a special significance for the present neurosis. This is sometimes called `narcoanalysis'. Here the aim is to make the patient relaxed, so that he can survey his past without too much anxiety.
For Amnesia. An intravenous sedative can also be used for patients with a massive hysterical loss of memory. It is often possible, in this way, to re-establish the events of the period covered by the amnesia.
For Reticent Patients. When a patient finds it difficult to talk about himself and his difficulties a stimulant can be used. Methylamphetamine injected into a vein often makes a reticent person feel talkative.
Hallucinogens. A further group of drugs, the hallucinogens such as LSD (lysergic acid diethylamide), mescalin, and psilocybin, save been employed to enable a patient to relive his childhood. Their usefulness is at present under discussion.
'Truth Drugs'. These methods are sometimes described in newspapers as treatment with the `truth drug'. While their aim is indeed to help a patient tell the truth if this is repugnant or embarrassing to him, no drug yet discovered can make him do so if he does not wish to.
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