Psychological Methods Of Treatment

Psychological methods are part of all psychiatric treatments, in some cases used alone, in others combined with drugs. These 'talking treatments' are counselling and various forms of psychotherapy used to relieve emotional distress and to help abuse survivors.

Psychological treatments can help you if you are recovering from abuse and/or suffering from PSTD, anxiety, panic, obsession, phobias, some forms of depression and other less serious illnesses. Working through these will give you an understanding that may help you to overcome your illness.

The Range Of Talking Treatments

The different types of psychotherapy can be categorised in several ways according to the aims of the therapy, the particular techniques used and the number of patients involved. Therapists with different specialist skills and qualifications will be used according to the purpose of the therapy and the techniques involved.

The aims of the therapy are listed from the simplest, where the therapist is seeking only to relieve your distress and to keep you going, through to the most ambitious in which the therapist is not simply trying to restore some function that has been lost as a result of a psychiatric illness, but also to reconstruct patterns of thinking and behaviour that may have existed long before the condition developed. The simplest forms of therapy may be undertaken by general practitioners, nurses or other professionals and involve not much more than the commonsense help that anyone would give to a distressed person. The therapies with more ambitious aims are undertaken by specialists such as psychiatrists or psychoanalysts.

The different therapies also involve different techniques which, again, are arranged in the table in order of complexity. Normally, the simpler therapies are undertaken by a wider range of therapists and use simple techniques such as counselling.

Most psychotherapy is on a one-to-one basis: patient and therapist. If the particular problem involves a spouse or partner, the therapist will often work with the couple together. If children are showing emotional difficulties as a result of disturbed relationships between parents, the therapist may decide to invite the whole family to the sessions. But these are really only extensions of the individual treatment, brought about by the nature of the problem.

One way of reducing costs and making better use of the available therapists is group therapy, in which 6 to 10 unrelated patients, usually with similar problems, attend the therapy sessions together. These group sessions are not only more economic but can have therapeutic advantages, as patients learn from each others' successes and failures.

Supportive Therapy

The aim of this treatment is to reduce distress and help you to keep going at difficult times. It is used to tide people over a short episode of illness or personal distress to support you if you face an illness or condition that cannot be treated, or to help you with a stressful situation for which there is no complete solution. For example, supportive therapy might help a carer faced with looking after a mentally ill son or daughter.

This kind of support can often be given by a relative or friend who will listen to your problems, sympathise with you and offer help. The relationship, however, is a difficult one and will work only if there is respect between you and your relative and the realisation by both of you that you must not become too dependent.

In many ways, it is easier for a doctor or other professional or trained counsellor to play the role of therapist. The professional therapist will have the advantage of training and experience and a more formal approach, bringing structure into the therapy and setting specific goals. Most general practitioners should be able to provide this service as part of primary health care.

Supportive therapy can be extremely successful in relieving the distress that patients feel, but some people think that therapy should go further to bring about a readjustment to new circumstances of life. Supportive therapy is usually given by a doctor, often a GP interested in psychiatric matters, or a nurse. It will start with a long interview of 30 to 45 minutes followed by a series of sessions of about 15 minutes which continue until all the major problems have been discussed.

Readjusting To Life

The majority of people, faced with stressful situations, require not simply to find relief to their distress but also help in searching for a new lifestyle which takes account of their changed circumstances or abilities. These problems are tackled with readjustment therapy, usually by means of counselling, a technique which is used for many different problems: reaching a difficult decision (for instance, ending a marriage); making an adjustment to changed circumstances (for example, a bereavement or discovery of a terminal illness); or to bring about a change to improve an unsatisfactory way of life (for example, giving up illicit drug taking).

Counselling uses the same approach as supportive therapy and the early part follows the same course. But it is then extended to encourage you to examine options, seek solutions and make decisions.

In effect, this is a process of guided self-help. The counsellor will explain the method and will review the results with you. The actual listing of problems, the selection of the one to be tackled first, listing of the possible solutions and the selection of the one most likely to succeed are all made by you, with encouragement by, but limited help from, the therapist. There are two 'loops', one of them examining each possible solution until one is found which evaluation shows to work. When the first problem has been solved, the second loop returns us to select the next problem and so on until all the solutions have been found. In carrying out this exercise, you can learn the strategy for solving future problems as well as tactics for dealing with the present situation.

Crisis intervention

This is a more dramatic form of readjustment therapy which is needed where the intensity of the distress and the problems surrounding it are so great that they can overwhelm you. The circumstances causing the acute distress may be involvement in a disaster (for example, a major transport accident or a fire); a physical or sexual assault; or multiple personal problems, such as bankruptcy combined with a marriage failure. Crisis intervention is often used where people have attempted suicide. The aim of crisis intervention is to reduce this extreme distress, to solve the problems of readjustment that occur and to prevent the development of post-traumatic stress disorder.

Crisis intervention uses the counselling methods including problem solving discussed above. But there are various elements, some of which may involve medication to lower anxiety and to promote sleep.

To many people, the most surprising feature of this intervention is the encouragement by the counsellor to recall and relive the traumatic event, even though this may produce severe emotions. It seems that this expression of emotion helps to shorten the period of reaction, whereas avoiding memories may lengthen it.

Restorative Treatments

Some of the psychological treatments have the rather more ambitious aim of restoring, to people with a variety of mental illness, the normal pattern of thinking and behaviour they had before their illness. Although some psychiatrists believe that medication is more effective for treating anxiety and related illnesses psychotherapy in various forms remains the most frequently used treatment. It is used for anxiety disorders, psychosexual disorders and some mild cases of depression. The three main methods used are behaviour therapy, cognitive therapy and brief psychodynamic therapy.

Behaviour Therapy

This form of therapy, which is normally undertaken by specialists, consists of identifying a prominent behavioural feature of your illness and persuading you to modify this by consciously behaving in a different way whenever the situation arises. For example, someone suffering from a phobia who fears and avoids spiders might be persuaded, little by little, to be exposed to them.

The difficulty in modifying behaviour is that the new response has to be learned by frequent practice over a long period and some people lose heart before the new pattern is learned. It is partly a matter of loss of motivation, and the therapist may be able to find ways in which you can reward yourself for your efforts. Another problem is that some people do not recognise all the occasions on which the abnormal behaviour arises and so allow the opportunity to pass without consciously correcting it.

Three general principles apply to all kinds of behaviour therapy. First, you gain confidence from dealing with smaller, simpler problems before tackling the more complex ones and the therapist will guide you to this end.

Second, if you are not able to identify all the occasions on which you are showing abnormal behaviour, the therapist will show you how to monitor your own behaviour and to keep a diary of the symptoms and your attempts to cope with them. This is called behavioural analysis and will give you a better insight into your problems and show you what progress has been made and the reason for any setbacks.

Third, the therapist will work hard to give you support to keep up the struggle to unlearn your abnormal behaviour. For example, the person with the spider phobia mentioned above might run away from, rather than look at or touch, a spider. If he regards this as a personal failure, his motivation may continue to be damaged. The therapist's approach is to make the whole process an interesting experiment in which the avoidance of the spider is part, demonstrating that there may be some additional aspect of the patient's fear that had been missed when the original behavioural analysis was carried out.

Relaxation Training

One of the techniques used in behavioural therapy to lower anxiety is relaxation, brought about by relaxing the muscles one by one; breathing slowly, as if asleep; and clearing the mind by concentrating on the process, repeating a phrase or imagining a restful scene.

When you have learned how to relax, perhaps after half a dozen sessions, you can do so on your own at times of stress. It is possible to obtain tape-recordings on how to relax so that you can learn how to do so at home.

Relaxation is a useful way of dealing with stressful situations and for mild anxiety, though not for fully developed anxiety or obsessional disorders.

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Exposure Techniques

These methods are mainly used for dealing with phobias and consist of persuading you to confront the situations you normally avoid. The method works well for simple phobias, but less well for the social phobias and agoraphobia. In these cases, exposure techniques are often combined with cognitive therapy discussed below.

The first step is to carry out behavioural analysis, as described above, to discover what provokes anxiety. You are encouraged to list the points, ranging from the least significant to the most. You will probably be taught how to relax, so that when exposed to these anxiety-provoking situations, starting with the most trivial, your anxiety is not too great. You will be encouraged to stay in the situation until your anxiety has subsided. If you are successful in enduring it, then, when next exposed to that situation, you will no longer be quite so anxious. Again, if you can allow your anxiety to subside while exposed to the situation, anxiety will be lower still on subsequent exposure. When the anxiety has been reduced sufficiently, you are ready to move up the list to the next situation. If you are unable to stay in the threatening situation until your anxiety has subsided, there will be no reduction in the level of anxiety during the next exposure. This method works best if you are exposed to the threatening situation every day. It is helpful if a friend or member of your family can assist, encourage success and maintain motivation if there are setbacks. It is not always practicable to place you in the exact situations that cause anxiety but the therapist may be able to help you to imagine that he is in such a situation.

Response prevention

Obsessional neuroses do not respond well to relaxation techniques but they can be treated effectively by response prevention. This form of therapy is based on the fact that if you can be persuaded to suppress your obsessional ritual hand-washing or whatever it may be - you will become very distressed in the short term, but gradually, usually within an hour, the anxiety decreases. If you have managed to resist the obsession for this (seemingly endless!) period, the symptoms will return less often and less intensely. It takes a lot of determination to avoid responding to the obsession for such a long time, and it is very helpful if a friend or member of the family can help. As you gain control over your rituals, the therapist may encourage you to confront stimuli that are known to provoke them.

Thought-stopping is a related treatment for cases in which you have obsessional thoughts but no rituals. The aim is to stop the obsessional thoughts by powerful distraction. For example, you may wear a rubber band round a wrist which you snap when thoughts arise.

Each snap will bring you back to earth briefly, but you may need many snaps to keep the thoughts at bay, leading gradually to a decline in the obsession. Thought-stopping is difficult and less effective in treating obsessional thoughts than response prevention is for ritualistic obsessions.

Cognitive Treatment

People suffering from emotional disorders frequently have characteristic recurrent thoughts. For instance, someone with mild depression following abuse may find himself frequently thinking about and re-examining his own personal failure. Others have recurrent thoughts about social embarrassment. It seems that these persistent thoughts can maintain symptoms of the illness and patterns of behaviour. The aim of cognitive therapy is to control or eliminate these rogue thought-patterns. It is widely used to treat anxiety disorders, some forms of depression and eating disorders.

Since many abuse survivors suffer both abnormal behaviour and recurrent thoughts, behavioural and cognitive treatments are often used in combination. The cognitive-behaviour theory is used mainly for anxiety disorders, eating disorders, abuse survivors and some cases of depression.

The therapist will first persuade you to keep a diary of thinking patterns, both before and during the abnormal behaviour. Having identified the rogue thinking, he will discuss it with you and challenge its logic. He may then ask you to consider another possible explanation and then to test that explanation. For example, someone who suffers panic attacks may feel he is having a heart attack; his thoughts scare him and he develops palpitations; the palpitations scare him further and the panic grows to grand proportions. Having discovered the pattern of thoughts, the therapist may ask how often the sufferer has had these attacks and how many of them were actual heart attacks. He encourages the sufferer to suggest an alternative explanation. Could it be that his anxiety about having a heart attack caused the palpitations which then confirmed and amplified his fears? The final stage is to let the sufferer see that, if he distracts himself from thinking about a heart attack, the palpitations and panic do not occur.

In the eating disorder bulimia nervosa, the sufferer fasts, gorges herself (most cases are young women), then makes herself vomit. The pattern is repeated frequently. The treatment is in two parts. The first is mainly behavioural, aimed at reestablishing, by the methods described above, a normal pattern of eating: three meals a day and no snacks. The second part identifies, through interviews and diaries, the thinking patterns that accompany the symptoms. The logical basis for these thoughts is challenged and you are encouraged to find and test an alternative explanation.

Brief Psychodynamic Therapy

Treatments of this type are given by psychiatrists and others with specialised training and use many of the methods of psychoanalysis. However, the course of treatment is relatively short, and is focused on one or more problems which you and therapist select. For this reason, it is called focal psychotherapy. It is used to treat people who have low self esteem or find it difficult to make relationships. These problems may be accompanied by other emotional disorders.

One of the main differences between this and other forms of therapy, such as counselling, is the different role played by the therapist. You are encouraged to speak freely about the problems on which you are focusing while the therapist plays a much less active role, responding more to the emotional content than the factual basis of what you are saying.

You are encouraged to talk about emotionally painful subjects, to review your own part in any problems that you ascribe to others, and to try to identify common themes. The therapist will also try to encourage you to understand how the present problems developed, in the belief that understanding more about the nature and origins of your ways of thinking and behaving may help you to find alternatives.

Another distinction between this and other forms of psychiatry is that here, the therapist encourages the development of a deeper relationship so that you may come to regard the therapist with similar feelings to those that you had with your parents. This intense relationship is called transference which may be positive, where the therapist is regarded as good and helpful, or negative, where he is not. Transference can have useful consequences, but it leaves the problems of how to end the treatment without leaving you dependent. It is not certain how effective these treatments are but they appear to help some people with problems with relationships.

Group Therapy

Mention was made earlier of group therapy both as a means of improving the productivity and lowering the cost of counselling, and because it has its own unique therapeutic features.

The groups usually contain six to ten people, most often selected because they have problems in common. Just as it is important that the relationship between the therapist and the patient does not become too intense, so the therapist must watch that the members of the group do not become too close and, particularly, that such relationships do not continue outside the group meetings.

Group therapy is used for the same purposes as individual psychotherapy. Group supportive treatment is used for patients with chronic disorders, such as psychiatric patients who are being treated at a day hospital. Group counselling is used, for example, for the treatment of rape victims and parents of handicapped children. Behavioural therapy may also be given to a group.

Some groups use other therapeutic methods, such as psychodrama, in which members act out their problems on the stage, and encounter groups, in which members of the group confront and question each other. There is no evidence that the confrontational method is beneficial; indeed, it may exacerbate the symptoms, especially in the short term

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