Psychotherapy in psychiatry: Integration and assimilation

Psychotherapy and psychiatry continue to have an ambivalent relationship despite a consensus that good psychiatry is a blend of science and human narrative and good psychotherapy combines an understanding of psychological and biological processes. The underlying reasons for this ambivalence are complex, ranging from the ascent of psychobiological understanding of psychological process to the uncertain outcome in clinical practice of some psychotherapy treatments. Certainly throughout Europe and America the hegemony of the psychoanalytic paradigm has been replaced within psychiatric services by a biologically based psychiatry that lays claim to greater effectiveness and utility. And yet patients and clinicians continue to recognize a need for ‘talking therapies’ either alongside or as an alternative to biological treatments; psychological understanding and treatment continue to inform even the most biological of approaches. Psychotherapy itself has not been immune to all this ambivalence and has changed and adapted its methods to meet a new reality. This special edition of the Journal reflects some of these changes. In this issue of the Journal we review a number of areas of the inter-relationship between psychiatry and psychotherapy ranging from psychotherapy as a treatment in its own right to applications of psychotherapeutic understanding in the treatment of major psychiatric conditions. Effective practice of psychotherapy requires good training and a service organization to support treatment application and implementation so these too are reviewed (see Denman, [2007]; Kerr, Dent-Brown, Parry, [2007]). In sum, effective psychiatry requires psychotherapy. Gabbard in the opening paper of this special issue summarizes many of the problems inherent in the interface between general psychiatry and psychotherapy and points out that the psychiatrist is in poll position to integrate them in a way that no other mental health professional can match. Yet this is dependent on psychiatry embracing psychotherapy and psychotherapy assimilating psychiatry. That is what this special edition is about.

Adaptation and application

Psychotherapy has begun to adapt and change. A new reality is emerging in which psychological treatments stand beside biological and social treatments as important methods of intervention. There is increasing evidence that an integration of all three methods may improve outcome in more complex disorders such as schizophrenia (Turkington & Kingdon, [2000]) and personality disorder (Bateman & Tyrer, [2004]). The use of psychotherapy and psychotherapeutic understanding in both these serious conditions is discussed in this edition.

Schizophrenia

Rosenbaum and Harder ([2007]) recognize that early psychodynamic approaches to treatment of schizophrenia were probably misguided and lacked rigorous study based, as they were, on single case reports. A ‘case-history’ is a sophisticated creation, in which the events of a clinical encounter are filtered, shaped, tidied up, reflected upon, romanticized, condensed, and generally tailored to fit theoretical preconceptions, in ways that makes it highly unreliable and unreplicable as a source of information. There has been a slavish adherence to this out-dated paradigm in some areas of psychotherapy. The case history is not a method that can do justice to the potential impact of psychotherapy on mental function; reliance on the case history is inadequate and on its own it falls far short of the standards usually required for acceptance within the scientific community. This was demonstrated for psychodynamic therapy and schizophrenia by Gunderson (Gunderson, Frank, Katz, et al., [1984]; Stanton, Gunderson, Knapp, et al., [1984]) who compared the effects of exploratory, insight-oriented (EIO) and reality-adaptive, supportive (RAS) forms of psychotherapy on a sample of 95 schizophrenic patients after many practitioners had argued strongly for the use of psychodynamic therapy. Analyses of 2-year outcomes revealed a complex interaction between the type of psychotherapy provided and the domain of psychopathology affected. RAS psychotherapy exerted clear preferential effects in the areas of recidivism and role performance. The EIO psychotherapy exerted preferential, albeit more modest, action in the areas of ego functioning and cognition. Overall, however, the magnitude of the differences was low. The results highlighted the need for more focused studies of subgroups, and of process and contextual influences on outcome. This we now have from Rosenbaum and others who have managed to incorporate psychodynamic psychotherapy into clinical services and look at outcomes (Rosenbaum, Valbak, Harder, et al., [2005]). Integrated treatment and supportive psychodynamic psychotherapy in addition to treatment as usual may improve outcome after one year of treatment for people with first-episode psychosis, compared with treatment as usual alone. But we do not know how this advantage is mediated. So they address this in this edition of the journal suggesting that it is the therapeutic alliance, a concept that transcends specific types of therapy, that may be responsible for these improved outcomes along with a relationship with mental health professionals that restores a coherent sense of self – perhaps two aspects of the interaction between patients and professionals that have been neglected over the years as psychological treatments have been side-lined in many areas of psychiatric services (Holmes, [2002]).

Personality disorder

A further area in which psychotherapy has begun to excel is in the treatment of personality disorder. Indeed psychotherapy was identified as the treatment of choice for borderline personality disorder in the American Psychiatric Association Guidelines (Oldham, Phillips, Gabbard, et al., [2001]). This was the first time that a psychological treatment was recommended as the primary treatment for a mental disorder. The increasing evidence for the efficacy of psychotherapy in treatment of personality disorder is extensively reviewed here by Verheul & Herbrink ([2007]). They consider the impact of psychotherapy in four different formats and settings that are available for psychotherapy delivery, i.e., group psychotherapy, out-patient individual psychotherapy, day hospital psychotherapy, and in-patient psychotherapy. The results show that various psychotherapeutic treatments are of proven benefit in reducing symptomatology and personality pathology, and improving social functioning in patients with Cluster A, B, C, or not-otherwise-specified personality disorders. But there needs to be a word of caution here. It remains unclear which patients are best treated in which context. Wilberg and Karterud ([2007]) take up this theme in their paper discussing the role of day hospitals in the treatment of severe personality disorder.

Norway has an extensive network of day hospitals organized so that collection of data is part of routine clinical practice. Some of this work is reported here. Health services around the world have found it impossible to meet spiralling costs and so have sought to cut costs wherever they can. The development of out-patient services offering specific, evidence-based treatment methods for BPD, for example, Transference Focused Psychotherapy (TFP) (Clarkin, Kernberg, & Yeomans, [1999]) and Dialectical Behaviour Therapy (Linehan, [1993]) offered the opportunity for governments and healthcare organizations not only to reduce costs but also to do so on grounds of evidence. In-patient services had become complacent about research and paid the price. But this still left day hospitals as the Cinderella of psychiatric services quietly offering services but uncertain about their position and role in treatment, trapped between the less intensive out-patient programme, which might still overtake the day hospital programme (Smith, Ruiz-Sancho, & Gunderson, [2001]), and the extreme of prolonged in-patient treatment. Gradually accumulating evidence (see Wilberg & Karterud, [2007]; Bateman & Fonagy, [2001]) has suggested that day hospitals have their place in the treatment of borderline personality disorder although their role in other conditions remains unclear. Wilberg and Karterud make a plea for the development of more specific programmes, especially for avoidant personality disorder which has considerable personal and societal costs.

Psychotherapy and harm

Some treatment formats and settings may be helpful for some patients and yet damaging to others. Psychotherapy is a powerful intervention and there is, as yet, limited understanding of its possible harmful effects and some personality disorders, particularly borderline personality disorder may be sensitive to its effects.

Pharmacological studies, as part of the regular scrutiny of side effects, as a matter of course, explore the potential harm which a well-intentioned treatment may cause. In the case of psychological treatments we all too readily assume that at worse such treatments are inert but in any case they are unlikely to do harm. This may indeed be the case for most disorders where psychotherapy is used as part of a care plan. There may be particular conditions, however, where psychological therapy represents a significant risk to the patient. Those conditions characterized by limitations in the patient's capacity accurately to depict mental states in themselves and others (mentalize), specifically in the context of intense interpersonal relationships (Fonagy, Target, & Gergely, [2000]), are especially likely to be unduly influenced by well-intentioned interventions that focus on completing a partial and inaccurate picture of the world of mind (Bateman & Fonagy, [2004]). This negative effect may occur irrespective of model of psychotherapy, and borderline personality disorder may be uniquely sensitive because of the reduced capacity to monitor mental states; this makes psychotherapy the treatment of choice but simultaneously one which might cause unintentioned harmful effects (Fonagy & Bateman, [2006]).

To understand potential iatrogenic effects of psychotherapy further, the first step is to understand the processes underpinning psychopathology which can then be used to inform treatment innovation as well as to predict possible harmful interventions. Once pathological processes, biological or psychological or both, are known, treatment can be aimed at processes which directly bear on the onset and course of the clinical problem thereby minimizing the likelihood of harm (Kazdin, [2000]). This is discussed to some extent by Bateman et al. ([2007]) in comparing two promising psychotherapeutic treatments for borderline personality disorder, namely mentalization based therapy (MBT) (Bateman & Fonagy, [2006]) and cognitive analytic therapy (CAT) (Ryle, [1997]). Both approaches have a clearly elaborated developmental theory of BPD which links closely to practice. Interventions can therefore be developed to enhance the specific problems faced by the borderline patient rather than the patient having to adapt to the treatment. Over time it is likely that psychotherapies will be adapted in the same way to other disorders to make treatments more specific and hopefully more effective just as has already happened in depression for example, with excellent results when compared with pharmacological treatment (De Maat, Dekker, Schoevers, et al., [2006]). The second step would be to identify the processes by which a treatment method achieves change in order to focus psychotherapeutic treatments more specifically and enhance the development of more efficacious therapies. However, we have limited understanding of how therapies achieve change and often the mechanism of change remains unclear even if a therapy proves to be effective. More disturbingly, it does not seem to be related to cherished interventions used in cognitive and dynamic therapies (Castonguay & Beutler, [2006]; Orlinsky, Ronnestad, & Willutzki, [2004]). There is limited evidence for cognitive change in patients who improve from depression, for example, with cognitive therapy or increased insight in those who receive transference interventions in dynamic therapy (Ogrodniczuk, Piper, Joyce, et al., [2000]; Piper, Azim, Joyce, et al., [1991]; Piper, Joyce, McCallum, et al., [1993]).

Recent comparison studies have suggested that further review of mechanisms of change in psychotherapy is warranted. Per Hogland et al. ([2006]) randomly assigned 100 patients to either dynamic psychotherapy over one year, with a moderate level of transference interpretations, or to dynamic psychotherapy with no transference interpretations. The authors could not demonstrate differential treatment effects between the groups. However, contrary to expectation and to ‘received wisdom’ moderator analyses showed that transference interpretations were more helpful for patients with a lifelong history of less mature object relations. Small negative effects were observed for patients with mature object relations. Finally, moderator analyses indicated that treatment worked through different active ingredients for different patients implying that we can no longer expect simple causal explanations of treatment intervention and specificity of effect. In addition, if complex interventions give limited ‘added value’ to the effectiveness of psychotherapeutic treatment then the extensive training required to use them appropriately may not be warranted. Yet all psychiatrists need to learn basic skills in psychotherapy if they are to be able to treat patients effectively in their clinics, and some will want to develop their skills to a higher level to treat more complex patients and so engage in further training.

Training

Around the world psychiatrists have had an ambivalent relationship towards gaining competence in psychotherapy skills, often leaving psychological treatments to other mental health professionals. This is akin to operating with one hand tied behind your back. Sweeping changes in training of doctors in the UK is likely to have a marked effect on this process and similar changes are being hinted at elsewhere. Psychiatrists will no longer be able to complete training without attaining a series of basic psychotherapy competencies and being able to demonstrate their effective implementation. This is to be welcomed and may usher in a new era for psychotherapy and integration with psychiatry. Psychotherapy may have been missing, presumed dead, in the decade of the brain (Nemiroff, Kilh, & Berns, [1999]); but now it is being re-found, alive and well, prepared for the future and this edition of the International Review of Psychiatry attests to this.