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Let's
Talk Facts About...
PSYCHOTHERAPY
Psychotherapy
is a process of discovery whose medical goal is to eliminate
or control troubling and painful symptoms so that the
patient can return to normal functioning. It also can
be used to help a person overcome a specific problem
or to stimulate overall emotional growth and healing.
In regularly scheduled sessions-usually 45-50 minutes
in length-a patient works with a psychiatrist or other
therapist to identify, learn to manage, and, ultimately,
overcome emotional and mental problems. Discussions
between patient and psychotherapist reveal the basis
of problems and enable the patient to better understand
him- or herself and gain relief from specific issues.
Psychotherapy is an active process requiring concentration,
energy, and commitment by both parties. Many patients
complete psychotherapy in 16 or fewer sessions, especially
for behavior-specific problems. Individual psychotherapy
takes place in the privacy of the doctor-patient relationship.
Psychotherapy also may be conducted in the context of
group, marital, or family treatment.
Although
the majority of people who undertake psychotherapy experience
significant improvement, there is nothing magical about
psychotherapy. It is not a procedure done by a therapist
to a patient; rather, it is a process between a therapist
and a patient in which the two work together.
Psychotherapy
is initiated after an individual has had a thorough
medical and psychological evaluation by a psychiatrist
or other physician and has received an initial diagnosis.
The psychiatrist will review the patient's medical records-or,
if these are not available, will take a medical history
and conduct a physical examination to identify any medical
conditions that might be affecting the individual's
mental and emotional functioning. Emotional disorders
can be caused by neurological or hormonal problems,
can be related to chronic illnesses such as heart disease,
or can represent the unwanted side effects of certain
medications. As is done with all illnesses, the psychiatrist
will interview the patient, asking for details about
symptoms-their severity and duration-and obtaining a
personal and family history. After all of this information
has been collected and analyzed, a diagnosis is made.
In many cases, psychotherapy will then be prescribed.
Many
kinds of emotional and mental problems can be helped
with psychotherapy: mood disorders (depression, bipolar
disorder [also known as manic depression]), anxiety
disorders (phobias, panic disorders, obsessive compulsive
disorder, posttraumatic stress disorder), eating disorders
(anorexia nervosa, bulimia, obesity), problems associated
with abuse of alcohol or drugs; problems related to
life circumstances and events, such as loss and grief,
marital difficulties, abuse or traumatic events, or
dealing with aging parents or adolescent children; mental
and emotional problems related to nonpsychiatric medical
illness; sexual disorders; sleep disorders; difficulties
in developing intimate relationships; disorders involving
disruptions in the functions of consciousness, identity,
and memory (dissociative disorders); personality disorders;
problems with functioning at work. In the case of severe
mental illness such as schizophrenia and other psychotic
disorders, psychotherapy is frequently used to help
patients understand and manage their illness. Armed
with this understanding, the patient is more likely
to remain in treatment and thus to avoid relapse.
Types
of Psychotherapy
Several types of psychotherapy are available, and-apart
from a few exceptions for specific conditions-no one
type is "better" than any other. As with other
medical situations, the psychiatrist's choice of therapies
depends on the patient's particular illness and circumstances.
Some types of psychotherapy concentrate on the here
and now; others focus on past experiences to achieve
insight into how problems arose and how they can be
overcome in the present.
In
determining which therapy or therapies are likely to
be most effective for a given patient, a psychotherapist
will take into account the nature of the problem being
treated and the patient's personality, cultural background,
and experiences. A therapist may use one type of therapy
to treat specific kinds of problems-for example, an
individual with an unreasonable fear of water is likely
to respond best to behavioral therapy. For other types
of problems, a therapist might use techniques derived
from several types of psychotherapy to treat the patient's
illness.
The
most frequently prescribed psychotherapies are psychodynamic,
interpersonal, cognitive, and behavioral.
Psychodynamic
therapy is used in treatment to help patients understand
themselves more fully. This approach may involve uncovering-and
learning to deal more effectively with-unconscious conflicts.
It may also involve assisting patients to understand
how certain types of adverse childhood experiences have
left them feeling incomplete, anxious, or plagued with
low self-esteem that interferes with realistic adult
functioning. This form of therapy is based on the premise
that our mental well-being is influenced by unconscious
conflicts, significant childhood experiences, and painful
feelings that are hidden behind a variety of defense
mechanisms.
Interpersonal
therapy is designed to improve the quality of the
patient's interpersonal world. The therapist helps the
patient to understand the underlying interpersonal themes
that appear to be involved in the onset and maintenance
of the illness. Common themes include unresolved grief,
transitions from one social or occupational role to
another, conflict between the patient and significant
individuals in his or her life, and deficiencies in
the capacity to relate to others.
Cognitive
therapy is employed in treatment to help patients
recognize and change thinking patterns that are harmful
or ineffective.
Behavioral
therapy is used to address a patient's specific
behaviors, substituting positive behaviors for harmful
or inappropriate ones.
Each
of these types of therapy may be conducted by a psychiatrist
in an individual, family, couples, or group setting.
Self-help groups also are available to patients and
to family members; such groups can supplement-but should
not be considered a substitute for-psychotherapy.
Medication
Medication is often used in conjunction with psychotherapy,
and in many disorders the combined treatment is better
than either alone. Both psychotherapy and medication
appear to act by altering brain functioning. With severe
disorders, various forms of psychotherapy can help the
patient to remain on medication and follow other elements
of the treatment plan.
Who
Provides Psychotherapy? Psychiatrists, psychologists,
clinical social workers, family and marriage counselors,
and other mental health professionals are trained and
licensed to provide psychotherapy. Highly skilled and
effective therapists may be found in each discipline.
However, psychiatrists are medical doctors with specialized
training in the diagnosis and treatment of mental and
emotional disorders. Only psychiatrists, as physicians,
are medically trained to perform and analyze medical
diagnostic tests, to evaluate the physical symptoms
of mental illness, and to take into account any other
medical illness occurring concurrently with the mental
disorder. Psychiatrists and other medical doctors may
prescribe medication. Child psychiatrists specialize
in working with children and adolescents; geriatric
psychiatrists work with older people.
Choosing
a Psychotherapist
For prospective patients, finding a psychiatrist with
whom they can work well is important. Good sources for
referrals include one's family physician, local psychiatric
societies, medical schools, and community mental health
centers. Friends and family members, too, may be able
to provide names of therapists about whom they have
heard or with whom they have worked successfully. As
is true when selecting other physicians-for example,
a pediatrician or internist-it is appropriate to speak
with several candidates. When choosing a psychotherapist,
prospective patients should assess their comfort level
with the therapist-can they feel relatively at ease
sharing intimate, personal feelings, thoughts, and experiences
with this person? Also important is the therapist's
education and training: the more, the better.
When
choosing a psychiatrist, patients need to understand
the terms and restrictions of their health care plan.
Many managed health care plans and fee-for-service insurance
plans limit patients' choice. Some plans restrict members'
choice to "inside the network" or plan psychiatrists
and require that patients first be evaluated by a "gatekeeper"-a
family doctor, or a social worker or other nonphysician
plan representative-to determine whether specialist
care is needed. Other plans permit patients to choose
a psychiatrist outside the plan's network but may require
patients to pay a larger portion of the cost. Patients
limited to selecting an inside-the-network psychiatrist
should seek recommendations from their primary care
physician.
Many
insurance plans pay a certain percentage-often 50%-of
a therapist's fee, up to a stated maximum; limit the
number of visits covered; and have an annual or lifetime
cap on the amount paid. Managed care companies often
limit the number of psychotherapy sessions a patient
may attend (e.g., 5-20 per year) and place restrictions
on the type of therapist a patient may see. Individuals
considering therapy should be aware that a new federal
law requires employers who offer mental health benefits
and who have 51 or more employees to provide the same
financial coverage for mental health problems-within
the same annual and lifetime limits-as for other medical
disorders. For more information on choosing a psychiatrist,
request a copy of Let's Talk Facts About Choosing a
Psychiatrist from the American Psychiatric Association.
When
selecting a health care plan, it is important that consumers
clearly understand the mental health benefits and coverage
provided. In addition to considering the size and quality
of the plan's "panel of providers," questions
to ask include whether the plan provides equal coverage
for mental and physical disorders, how many therapy
sessions are covered, how much copayment is required
per visit, whether members can consult a psychiatrist
without first being seen by a general-care "gatekeeper,"
whether the plan covers sessions with a psychiatrist
who is outside the plan's network, and whether the plan
protects confidential information. Patients' mental
health needs are best met when they have easy access
to a psychiatrist who is either the provider of treatment
or an intrinsic part of the treatment team.
Working
Effectively With a Psychotherapist
The relationship between patient and therapist is a
unique partnership. Psychotherapy can be successful
only when both partners are dedicated to achieving the
agreed-upon goal. Important to this partnership is mutual
trust, respect, and confidentiality. Confidentiality
is a basic requirement of psychotherapy and is emphasized
in the code of ethics of the American Psychiatric Association
and other professional mental health organizations.
Patients need to know that insurance companies and managed
care firms may ask for reports from a psychotherapist
to determine whether to continue to provide reimbursement.
Some patients prefer to pay for psychotherapy from their
own resources to avoid this violation of confidentiality.
Both
patient and therapist have clear responsibilities. The
patient must be candid and honest, willing to reveal
sometimes uncomfortable feelings and thoughts, to address
problems, to be open to new insights, and sometimes
to carry out prescribed "homework" activities.
The therapist must listen carefully; clarify, interpret,
and point out associations that may not be obvious;
and guide the patient to recognize and, where indicated,
modify patterns of behavior. Because the patient and
the therapist are full partners in the psychotherapy
process, both participate in making treatment decisions,
including the decision to end therapy.
The
patient-therapist partnership is truly special, but
it is not a friendship or a business relationship-the
therapist does not socialize or conduct business with
the patient. Although the patient is likely to share
very personal feelings and thoughts, under no circumstances
is intimate contact-most especially sexual relations-between
a patient and a therapist appropriate, acceptable, or
useful.
How
Long Does Psychotherapy Take?
The amount of time a patient spends in therapy depends
on several factors, the most important being the nature
of the illness or problem being treated and, for many
patients, the coverage terms and restrictions of the
health care delivery system. Depending on the mental
illness and the type of therapy selected by the therapist
and the patient, psychotherapy can require a few sessions
or can take much longer. Generally speaking, the more
severe or complicated the mental disorder, the longer
amount of time needed to complete psychotherapy. Short-term
therapy (16 or fewer sessions) is often prescribed for
relief of specific symptoms.
Depending
on the patient's problem and the type of psychotherapy
used, the process can sometimes be time-consuming and
expensive. However, several studies have demonstrated
that psychotherapy is ultimately cost-effective for
patients, their families, and society. The benefits
of undergoing treatment include decreased visits to
other doctors' offices, diagnostic laboratories, radiology
departments and hospitals for physical ailments that
are based in psychological distress; reduced need for
psychiatric hospitalization; lower use of sick days
and disability; and increased job stability. Conversely,
the costs of not treating mental disorders can be measured
in ruined relationships, job loss or poor performance
at work, personal anguish, substance abuse, unnecessary
medical procedures, psychiatric hospitalization, and
even suicide.
Despite
the personal and economic benefits of psychotherapy,
many insurance firms and managed care companies have
stringent limits on coverage and access to mental health
care. Such limits are short-sighted and harmful to patients,
families, employers, and society as a whole, because
mental disorders are often very responsive to treatment.
How
Do I Know if I Need Psychotherapy?
If you or someone you care about is experiencing emotional
or mental problems, professional help should be sought.
Only a thorough examination and evaluation by a family
physician or a psychiatrist can identify whether physical
conditions or medication side effects might be causing
or contributing to emotional problems.
Warning
Signs of Mental Illness
- Marked
personality change
- Inability
to cope with problems and daily activities
- Strange
or grandiose ideas
- Excessive
anxieties
- Prolonged
depression and apathy
- Marked
changes in eating or sleeping patterns
- Thinking
or talking about suicide or harming oneself
- Extreme
mood swings, high or low
- Abuse
of alcohol or drugs
- Excessive
anger, hostility, or violent behavior
A
person experiencing one or more of these warning signs
should be evaluated by a psychiatrist or other physician
as soon as possible-it's the first step toward feeling
better.
Bibliography
General
Information
Bloch, Sidney, Julian Hafner, Edwin Harari, et al. The
Family in Clinical Psychiatry. New York: Oxford University
Press, 1994.
Copeland,
M. The Depression Workbook. Oakland, CA: New Harbinger,
1992.
Hales,
Diane, and Robert E. Hales. Caring For The Mind: The
Comprehensive Guide to Mental Health. New York: Bantam
Books, 1995.
Mermier,
Martha Brinton. Coping With Severe Mental Illness: Families
Speak Out. Lewiston, NY: Edwin Mellen Press, 1993.
Quinn,
Brian. The Depression Sourcebook. Los Angeles, CA: Lowell
House, 1997.
Soukup,
James E. Understanding and Living with People Who Are
Mentally Ill: Techniques to Deal With Mental Illness
in the Family. Springfield, IL: Charles C Thomas, 1995.
Turnbull,
Ann P., Joan M. Patterson, and Shirley K. Behr. Cognitive
Coping, Families, and Disability. Baltimore, MD: Paul
H. Brookes, 1993.
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