 \201\201Fig 1. Inside the speech-bubble: The therapist is precariously supported by a trip od of con \201 dentiality, training and peer-based supervision. The couch hardly ever exists in practice, but it stands for a place where anything can happen \200\224where we sit side- by- side with our shadow selves and hear the stuff of dreams, nightmares, and realities, un - cushioned by workaday self-deceptions. It contains its own labyrinth. Miriam Longmore Behavioral therapy Behavioral therapy aims to change a person \200\231s behavior using one of several techniques depending on the condition. When used in conjunction with cogni- tive therapies (see p374) the term cognitive-behavioral therapy is used (CBT). Exposure/ \202 ooding/implosion Indication: Phobias. Technique: \200 The anxie- ty-provoking object or s ituation is presented in vivo or in imagination (pro- longed in vivo in \202 ooding). \200 Implosion involves imagined exposure to stimuli in a non-graded manner. \200 The pa tient then stays with the anxiety-provoking stimuli until there is habituation (ie he becom es accustomed to the anxiety by frequent exposure), and the avoidance response is extinguis hed. Relaxation training Indication: Mild/moderate anxiety. Technique: \200 A sys- tem of exercises & regular breathing to progressively relax individual muscle groups. Aim to achi eve relaxation in all postures: recumbency is easiest (?from \200\201baroreceptor load).35 6 \200 Link the relaxed state with pleasant, imagined scenes so that relaxation can be in duced by recalling the imagined scene. Systematic desensitization Indications: Phobic disor ders. Technique: Pa- tients form a hierarchy of fears about the phobic stimulus. Therapy us es graded exposure (least fearsome \201 rst) to real Wolpe 357 while patients perform rel axation or imagined stimuli,Joseph techniques until anxiety is extinguished. It is ethicall y less controversial than \202 ooding358 as progress up the hierarchy is only when patien ts are completely comfortable with the cur- rent level; eg \201 g 1 can be preceded by an almost neutral image, such as \201\203.359 Response prevention Technique: \200 Involves exposure to an anxiety-provok- ing stimulus (eg a toilet seat for patients fearing contami nation). \200 The patient is subsequently prevented from carrying out the usual compulsiv e behavior or ritual until the urge to do so has passed Indications: Obsessions. Thought st opping Technique: The patient is asked to ruminate and then taught to interrupt the obsessi onal thoughts by arranging a sudden intrusion, eg snapping an elastic band on the wrist. In dications: \200 Obsessional thoughts occurring without compulsive rituals. \200 Undesir ed sexually deviant thoughts. Aversion therapy/covert sensitization Technique: \200 Avers ive therapy involves producing an unpleasant sensation in the patient in association with a n aversive or noxious stimulus (eg electric shocks, chemically induced nau- sea, pain) with the aim of eliminating unwanted behavior. \200 Covert sensitiza- tion involves the use o f aversive stimuli in imagination (eg the approach of a policeman to arrest him/her for his /her undesirable behavior). Indications: \200 Alcohol dependence syndrome (disul \201 ra m used to induce nausea if alcohol is consumed). \200 Sexual deviations. Cautions: \200 Punishment procedures are gener- ally ineff ective unless patients are taught more appropr iate behaviors. Social skills training Technique: \200 Aims to modify a patient \200\231s social behav- iour in order to help overcome diffi culties in forming/maintaining relation - ships. \200 Video is used to de \201 ne and rate elements of a patient \200\231s behav ior in standard social encounters \200 The patient is then taught more appropriate behavi or by a combination of direct instruction, modeling, video-feedback and role play. Indicati ons: Patients with social de \201 cits due to a psychiatric disorder. Token economy Techni que: Positive reinforcement improves behavior: tokens are given when desirable behavior is displayed. These can later be exchanged for goods or privileges. Indications: \200 Childr en (p210) \200 Learning disabled patients \200 Addictive disorders \200 Chronic psych iatric disorders. Prob- lems: \200 Patients become mercenary as they only behave well in exchange for tokens. \200 It does not prepare people for a world where rewards are subtle and delayed. 372 y r t a h c y s P i Fig 1.366 JML. Modeling and role play Technique: The acquisition of new behaviors by the process of imitat ion. Indications: Lack of social skills and assertiveness. Behavior therapy in impulse cont rol disorders (sex, shopping, gambling) Hypersexuality after brain injury: Examples: two cl ients were troubled by inappropriate touching of the opposite sex, and a third involved exh ibition- ism. In one case of touching, feedback was used to decrease inappropriate touching . In the other case of touching, scheduled massage was used to shift stimulus control to an appropriate setting. In the case of exhibitionism, a com- bination of self-monitoring, pri vate self-stimulation, and dating-skills train- ing were used to suppress the behavior.360 Behavior therapy also has a role in paraphilias such as voyeurism and masochism/sadism. It is controversial when consent is an issue (eg following a court \200\231s recommendation). 373 Cognitive elements can be added with the aim of minimizing self-deception y r t a i h c y s P regarding the eff ects of paraphilia behavior.361 Exposure response therapy is used eg in o bsessive-compulsive behavior (eg obsessive cleaning of some putatively contaminated object) . The therapist gradually exposes the client to contaminated objects, preventing the compul - sion by reducing anxiety about contamination, eg by breathing techniques. CBT (cognitive- behavior therapy) helps change how we think and hence how we feel. Fig 2 is a vicious circl e if thoughts are negative and lead to hos- tile, negative actions. By de \201 ning these relationships, CBT lets us see how th oughts and feelings interact; by changing thoughts, t he cycle is broken or turned into a virtuous cycle \200\224eg to prevent relapse after volu ntary abstinence vis- -vis impulse control disorders (eg bulimia). For purely cognitive th erapy, see p374. Fig 2. CBT. The abstinence violation effect (AVE) is a pivotal construct describing our cognitive and aff ective response to re- engaging in self- or court-prohibited behavior. AVE refers to the client \200\231s belief that abstinen ce, once broken, always leads to relapse ( \200\234Now I \200\231ve eaten one chocolate the whole box must go \200\224and I then I \200\231ll have to empty the fridge and now I \200 \231m on the slippery slope leading straight to the ice-cream in the freez- er \200 \200 \235). The false creation of an all-or-none requirement, loss of feeling of con- trol, and ensuing failure resulting in guilt, self-blame and lowered self-esteem can all be tackled b y cognitive-behavior therapy, eg by identifying high-risk situations and \200\230off ence precursors \200\231.362 These may be feeling lonely and rejected, after a break-up with a p artner \200\224or stress at work. In the case of pedophilia, CBT can be combined with group therapy and one way to confront pedophiles with the reality of their off ence yet which is helpful because it provides their \201 rst opportunity to express their feelings, sexual fantasies and thoughts about pedophilia.363 In general, the eff ects of cognitive-behavior al treatment for the most serious forensic inpatients (arson, violence, rape) are sometimes quite good in terms of oppositional-de \201 ant/egotistical behaviors \200\224and there a re also (unreliable) improvements in psychopathological symptoms, person- ality traits, and coping.364 Cognitive therapy Key concepts Beck suggests that a person who habitually adopts ways of th inking with depressed or anxious cognitive distortions will be more likely to become depres sed or anxious when faced with minor problems. The cogni- tive distortions in cognitive the ory include: Arbitrary inference \200\224conclusions drawn with little or no evidence to su pport them. Selective abstraction \200\224 dwelling on insigni \201 cant (negative) detail while ignoring more important features or stimuli. Overgeneralization \200\224drawing glob al conclusions about worth/ability/performance on the basis of single facts. Magni \201 ca tion/mini- mization \200\224Gross errors of evaluation with small bad events magni \201 ed and large good events minimized. These mechanisms lead to distortions within the cognitive triad of the self, the world and the future. \200 In cognitive therapy, the patient \201 rst learns to identify cognitive distortions 374 from present or recent experiences with the use of daily records/diaries. The patient records such ideas and then learns to examine the evidence for and against them, ie tests out beliefs in real life. The patient is encouraged to undertake the pleasurable activities that were given up at the onset of depression or anxiety. In this way, cognitive restructuring takes place when the patient is able to identify, eval uate and change the distorted thoughts and associated behavior. Techniques \200 Patients are evaluated to get a good history and background information to better understand the nat ure of the diffi culties for which treatment is being sought. \200 Assessment tools or qu estionnaires may be used. \200 Treatment usually takes place on a weekly basis and focuse s on current is- sues. \200 A treatment plan is formulated with clear goals and objective s and progress is monitored. \200 The number of sessions varies with the type of dif- \201 culties being treated. \200 Patient \200\231s participate actively in their own ther apy. Indications365 General: \200 The patient prefers to use psychological interven- tion s, either alone or in addition to medication. \200 The target problems for CBT (extreme, unhelpful thinking; reduced activity; avoidant or unhelpful behav- iours) are present. \200 No improvement or only partial improvement has oc- curred on medication. \200 Side eff ects prevent a suffi cient dose of medication from being taken over an adequate period. \200 Signi \201 cant psychosocial problems (eg relationship problems, diffi culties at work or unhelpful behaviors such as self-cutting or alcohol misuse) are present that will n ot be adequately ad- dressed by medication alone. Speci \201 c: \200 Depression \200 G eneralized anxiety or panic disorder \200 Phobias \200 Ob- sessive-compulsive disorder \200 Post-traumatic stress disorder \200 Hypochondria- sis \200 Bulimia \200 Schizo phrenia \200 Bipolar aff ective disorder \200 Sexual abuse.366 Cautions: It is diffi cu lt to carry out therapy if the patient is feeling severely depressed and has very poor conc entration. There is a need to pace sessions so as not to disappoint or overwhelm the patien t. Patients may have diffi culty talking about their feelings of depression, anxiety, shame or anger. y r t a h c y s P i Evidence is increasingly available that CBT is as eff ective as pharmacologi- cal therapy f or mild to moderate depression, with the added advantage that relapses are less likely.367 In one study, GPs \200\231 knowledge of depression, and at- titudes towards its treatment s howed no major diff erence between interven- tion and control groups at 6 months \200\224ie training had no discernible impact on patients \200\231 outcomes.368 One reason for this m ay be that skills were indeed learned, but that there was insuffi cient time to apply these skills in ordinary general practice, where depression may be only one of a series of probl ems presented to the GP in a single 10-minute consultation. 375 Applying cognitive therapy, using the example of depression We respond to cognitive represe ntations of events, not raw data. Mood and thoughts can form a vicious cycle. Using the exa mple of depression: low mood leads to gloomy thoughts and memories (eg dwelling on exams yo u did badly in, rather than those in which you performed well). These gloomy thoughts make you feel more depressed (mood) and this lowering of mood makes your thoughts even more gloo my. Cognitive therapy tackles this cir- cle by tackling the thoughts. Take, say, the though t: \200\234I \200\231m a failure, and all my friends are avoiding me \200\235. In cognitiv e therapy the process is to: \200 Clarify the thought exactly; don \200\231t let it be ju st a vague negative belief. \200 Look for evidence for and against the proposition in the thought. \200 Look for other perspectives. \200 Come to a conclusion. NB: 6 sessions a re better than fewer.369 The therapist encourages the patient to \201 nd other explanatio ns by challeng- ing him, eg by examining what \200\234I \200\231m a failure \200\235 means . \200\234What are the main areas in your life? \200\235 \200\234What do you count as suc cess or failure? \200\235 Catastrophiz- ing denotes how we see disasters in small mishaps, eg \200\234he didn \200\231t like my hat he doesn \200\231t like me nobody likes me \200\235. There are many kinds of biased thinking that cognitive therapy helps us to recogn ize: eg black and white thinking, over-generalizing (as when one failure as a symbol of eve rything). y r t a i h c y s P N=104 Is it possible to apply these lessons in primary care? Yes; if full training is off ered. R andomized trials of CBT in primary care with less extensive training (4 half-days) and henc e with more realistic costs have been disappointing. The lesson is: if the bene \201 ts of CBT are to be brought to primary care, what is needed is time: time to learn a new skill, and, above all, time to exercise it. The NHS has been recruiting cognitive therapists to meet the needs of all those with modera te and severe depression and anxiety who might bene \201 t from it. Cost: 170 million. P rojected savings (by getting people back to work) 12 billion/yr. Until access is improved computerized CBT is one option. JML undergoes NICE-approved computerized cognitive therapy Depression Relief is a self-he lp, educational internet program for those feeling depressed. JML signed up for the course to bring readers a 1st -hand account. Initial assessment suggested he was signi \201 cantl y depressed as there was nowhere to say that his early-morning waking was not from depressi on but from eagerness to get on with authoring OHCS pages.etc etc Quite correctly, he was t old \200\234You may also wish to con- sider seeing your doctor or healthcare professional if your symptoms do not improve or become worse. You should de \201 nitely do this if you are feeling hopeless and don \200\231t want to go on \200 \200\235. Sections include: \200\234Taking the 1st step to controlling your depression \200\234; \200\234You can move your mood \200\235; \200\234Ac- tions speak louder than words \200\235; \200\234Focus on the positive \200\235; \200\234Rede \201 ne your problems \200\235; \200\234Don \200\231 t go blaming yourself \200\235; \200\234Relax away your sorrows \200\235; \200\234Us- ing your imagination \200\235; \200\234Get physical \200\235; \200\234Open up and share your feelings \200\235. . \200 w o n u o y e e s l l i w r e t u p m o c Here are some snippets to get the \202 avour: \200\234After a week or two of writing dow n your positive thoughts in your mood log, you will be ready to learn how to use these posi tive thoughts to change your negative thinking. \200\235 e h T Impression: professional; humorous (not too); surprisingly humanizing. Group psychotherapy Groups are interactive microcosms in which the patient can be confronte d by the eff ect his behavior and beliefs have on others, and be protected during his \201 rst attempts to change.1 This implies that group psychotherapy (as with all psychother apies) is only practical for those who want to change. General indications We know that the most suitable patients are: 1 Those who enter into the group voluntarily, not as a result of pressure from relatives or therapists; 2 Those who have a high expectation from the grou p, and do not view it as inferior to individual therapy; 3 Those who have adequate verbal a nd conceptual skills. See also psychodynamic psychotherapy p382. Speci \201 c indications \200 Personality disorders \200 Addictions370 Drug and alcohol dependence \200 Victim s of childhood sexual abuse \200 People with diffi culties in socialization \200 Major medical illnesses \200\224eg breast cancer.371 N=50 Technique Clearly the selection procedu re needs to be carried out by an expe- rienced psychotherapist. He will aim for a group of, say, 6 \200\2238 members balanced for sex, and avoiding mixing the extremes of age. He wil l decide if the group is to be \200\230closed \200\231, or whether it will accept new pati ents during its life. He will usually take on a co-therapist of the opposite sex, and he wi ll prepare the pa- tients in detail before the group starts. The life of the group (eg 18 m onths) will develop through a number of phases ( \200\230forming \200\231 \200\203 \200\230 norming \200\231 \200\203 \200\230storming \200\231). First there is a settling-in period w hen members seem to be on their best behavior, seeking to be loved by the therapist, and lo oking to him for directive counsel- ling (which he rarely provides). Next is the stage of c on \202 ict, as the patient strives to \201 nd his place in the group other than through dependency on the leader. Frustration, anger, and other negative feelings are helpful by t esting the group \200\231s trustworthiness. It is worth learning that expressing negative f eel- ings need not lead to rejection \200\224and this is a vital prelude to the next stage of intimacy, in which the group starts working together. 376 y r t a h c y s P i Typically the therapist steers the group away from outside crises and searches for antecede nt causes towards the here and now \200\224eg by asking \200\234Who do you feel closest to in the group? \200\235 or \200\234Who in the group is most like you? \200\235 \200\234Wh o would you say is as passive (or aggressive) as you are? \200\235 He/she must avoid sacri \201 cing spontaneity, and learn to use what the group gives, eg \200\234You seem very an gry that John stormed out just now \200\235. He avoids asking un- answerable questions, esp ecially those beginning \200\234Why? \200\235. He promotes inter- action, observation, and learning. Special methods used to augment this pro- cess include written summaries of grou p activities, video, and psychodrama. Intensive group cognitive therapy combines cognitive and group therapy (16 group sessions in 3 weeks). In social phobia, it \200\231s better tha n individual therapy.372 Cautions Those who are unlikely to bene \201 t include those with severe depres- sion, acute schizophrenia, or extreme schizoid personality (cold, aloof, hy per- sensitive introverts); hypochondriacs; narcissistic (self-admiring) or paranoid (suspi cious and pessimistic about the role of others); sociopathic types (they have low threshold s for frustration and little sense of responsibility) \200\224but so- ciopathy is diffi cul t to treat by any means, and group therapy may be the least bad option, as other members of the group may provide the only valid mirror that can be held up to these people, and other people may provide the impetus for change. See psychodynamic psychotherapy, p382. 1 Miriam was the threshing- \202 oor on which he threshed out all his beliefs. While he tr ampled his ideas upon her soul, the truth came out for him \200 because of her, he graduall y realized where he was wrong. And what he realized, she realized. \200\231DH Laurence p227 of Sons and Lovers But Lucy was mute. Can it be worth taking such a patient to group thera py? Mira accused her of not pulling her weight \200\224this was unhelpful \200\224but anoth er group mem- ber piped up with something like \200\234You can be in another world where t here \200\231s too much space and meaning to speak \200 she can only hear your complaining like dead leaves rustling. What you say may have force here \200 not where she is \200 lis ten to her silence. \200\235AS Byatt 2003 p77 of A Whistling Woman 377 Children don \200\231t say what they really think \200 They can \200\231t say what they hop e in case it \200\231s gone in a \202 ash if anyone truly says no. AS Byatt Babel Tower 1 44 Play therapy \200\207Through play a child becomes aware of what he or she knows. When that knowledge is disturbing, play can re-form, recast and redeem that knowl- edge.373 Parents hold the key cards for in \202 uencing a child \200\231s behavior \200\224love, mutually u nderstood channels of communication, systems of rewards, and knowledge of right and wrong. It is the families without these, which are most likely to need the help of professionals. \200\207Never underestimate a child \200\231s capac- ity for insight: don \200\231t expect children \200\231s methods of communicating insight to mesh with adult \200\231s. Play, ra ther than talk, may be its medium.374 The 10 rules: 1 Take time early on to make friends with the child. Don \200\231t rush. 2 Accept the child on his own terms \200\224exactly as he or she is. 3 Avoid questioning, praising, or blamin g. Be totally permissive. 4 Don \200\231t say \200\234Don \200\231t \200\235, and only res train to prevent serious imminent harm. 5 Show the child that he or she is free to express any feeling openly. 6 The responsibility for making choices is always the child \200\231s a lone. 7 Follow wherever the child leads: avoid directing the conversation. 8 Use whatever h e gives you. Re \202 ect his or her feelings back to him. 9 Encourage the child to move fr om acting-out his feelings in the real world, y r t a i h c y s P to expressing them freely in words and play. 10 Prepare the parents for change in the child. Child and therapist play together to give t he child a way to verbalize his in- nermost fantasies. As Virginia Axline explained to one of her 5-year-olds, play therapy is \200\234a time when you can be the way you want to be. A time you can use any way you want to use it. A time when you can be you \200\235.Axline V: Play Therapy Dibs: in Search of Self Evidence vis- -vis \200\230activity-based interventions \200\231 (broader than Axline \200\231s play therapy) is mixed: no eff ect on war-torn children,375 but good eff ects on social functioning after sexual abuse,376 neglect,377 and in autism.378 Art therapy Art therapy is the use of art materials for self-expression and re \202 ection in the presence of a trained art therapist. No previous experience or skill in art is need ed as the art therapist is not primarily concerned with making an aes- thetic or diagnostic assessment of the client \200\231s work. The chief aim is to eff ect change and growth in self-esteem through use of art materials in a safe and facilitating environment. Patients s top being patients, and take the initiative in externalizing pain and problems through self -expression.379 \200\207The person becomes his or her own therapeutic agent. What higher i deal is there in medi- cine? It is far ahead of our drug-based models of care, and taps int o ancient ideas about health, self-healing, and the proper relationship among humans.380 As ever, the relationship between therapist and client is vital, but art thera- py diff ers f rom other psychotherapies as it is a 3-way process between client, therapist and artifact. The therapist \200\231s evaluating of the art establishes the intellectual, spiritual, cult ural, and emotional status of clients in ways that are helpful to those who \201 nd it ha rd to express thoughts and feelings verbally.380 It can be a mistake for therapists to inte rpret the art: leave this to the client.381 Art therapists have good understanding of art p rocesses with sound ther- apeutic knowledge. They work with individuals and groups in resid ential or community settings, eg mental health (eg anorexia and dementia, where art therapy can improve interactive and coping skills),382 learning disabilities, child and family cen ters, palliative care, disaster zones,381 and in prisons. baat. co.uk NICE says we must always consider non-drug treatments for depression \200\224so what are th e experiences of UK primary care? In one setting with 3 artists in residence in Dursley (a ceramicist, a poet, and a painter) there was a reduction in anxiety, an increase in self-es teem, and fewer consultations from \200\230heartsink \200\231 patients.383 Art therapy als o helps coping in the context of cancer.384 Crisis intervention Occupying the interval between the spilling of our lives and their cong ealing into history, crisis intervention recognizes that moments of maximum change are time s of greatest therapeutic opportunity.1 Debate these questions: \200 What events have led to these diffi culties? Thoughts/actions in the last days. \200 What is his mental state now (p324)? Depressed? Suicidal? Psychotic? \200 In the past how has he been able to com bat stress and to resolve crises? \200 What solutions to this crisis have been tried? How have they failed? \200 Who are the signi \201 cant people in his life? Can you rely on any of them? Therapeutic strategy \200 If he has been very badly aff ected by the crisis, you may insist on postponing all nor- mal oblig ations/res- pon sibilities to allow concen trated contact ( \200\230intensive care \200\231) in a therapeutic environ- ment \200\224eg a hospital or crisis unit. 378 y r t a h c y s P i Take practical steps to safeguard patient \200\231s commitments (eg tra- nsport of children to foster parents). Choose the best way of lowering arousal (time spent talking is often preferable to administ ering anxiolytics, which may only serve to de- lay the natural process of adaptation). If t he patient is shocked, stunned, or mute, take time to establish the normal channels of comm unication. Fig 1. Crisis intervention teams must be responsive, imme- diate, accessible, and available out of hours \200\224anywhere. As soon as the person is receptive, promote a sense of hope about the out- come of the cris is. If there is no hope (a mother, consumed by grief, after losing all her children in a \201 re), then this too must be addressed. The next step is to encourage creative thinking about ways whereby the pa- tient might solv e the problems. Start by helping him think through the conse- quences of all options open t o him. Then help compartmentalize his proposed solutions into small, easily executed items of behavior. As the immediate crisis passes, and the patient has reasonable psychological functioning, i t will be necessary to put him back in charge of his own life. A pe- riod of counseling is likely to be appropriate. This is described on p380. Making a contract about therapy is imp ortant in encouraging the patient to transfer from the \200\230sick role \200\231 to a sel f-dependent, adult role. Crisis intervention often focuses on loss of face, loss of identity, or loss of faith \200\224in oneself, in one \200\231s religion, one \200\231s goals, or one \200\231s roots. Meta-analyzes suggest that crisis intervention is a viable part of home-care, and can be used during the acute phase of any mental illness.385 \200\207All home-care pac kages for severe mental illness need crisis management plans. Where implemented, this keeps the vulnerable in contact with staff (NNT \211\21013 over 1yr) and reduces family burden ( NNT \211\2103), and is a more satisfy- ing form of care for patients and families. It is al so said to be cheaper. In one trial,386 availability of a crisis-resolution team reduced ad mission rates from 59% to 22% at 8 weeks \200\224and was highly cost-eff ective. 1 See Sylvia Plath 1963 A Birthday Present in Ariel, Penguin, 50 \201\201 379 Acknowledging and using our own feelings \200\207Are you afraid of uncomfortable questions ? Here are some asked by a very experienced psychotherapist.1 ? Are you a saint? or have yo u ever ? Felt so bored and irritated by cer- tain patients you want to quit? ? Longed for the consultation to end, at any price? ? Can you say you have never felt a \202 icker of sexual interest in a pa- tient? y r t a i h c y s P ? Have you never imagined the death of certain patients and the relief that would bring, no t just to them but to us, their impotent carers? ? Have you never resented the de- mands of people for whom illness seems to have become a way of life? ? Whose thoughts have not some - times drifted off towards their own concerns \200\224to the need for sleep, food, or dist raction or to some fam- ily, career, or future plans? Fig 1. We may imagine doing all sorts of things to our patients. The crime is not the thoug ht but the deed. The vital thing is to not to bury these things but to know that they are j ust that: imaginings. Perhaps we can use them in the service of our work? If the stressed, isolated doctor had been aware of and able to voice his fantasies maybe he would not have e nd up in custody or in bed with his sexually abused, vulnerable and de- pressed patient. \200\207The key to good doctoring is not regulation or revalidation, but fos- tering the a bility to put ourselves in our patients \200\231 shoes. And we can use the feeling patients engender in us to understand how the patients nearest and dearest are frustrated, perplexe d and deluded. For example, excessive worry about a patient may be the result of being infe cted by the patient \200\231s anxiety \200\224 beyond what is reasonable. This is know as p rojective identi \201 cation. Why does bad or harmful practice continue, despite GMC guidelines? It is be- cause we are m otivated by forces of which we are unaware. 1 BMJ 2002; 325: 722.1. Good doctor, bad doctor \200\224a psychodynamic approach; Jeremy Ho lmes (whom we thank for permission to quote from his excellent article). Counseling Good novelists (and counselors) are somehow large enough to embody the world \200\224so their characters (clients) are not just recreated in their own image. Nothing hu man is alien to them. Such exercise of the imagination is what enables virgins to counsel p rostitutes \200\224 which they can, if they are submerged in and are fully aware of human a ff airs outside themselves. Indications After Yellow Painting by Barnett Newman. \200 Cur rent problems and stresses (eg experiencing acute psychological dis- 380 Fig 1. Nondirective counseling is a triptych of blanks: Where do you want to go? How will y ou get there? How will you know you have arrived? Just \201 ll in the blanks \200 . tress in response to life events or relationship problems). Brief anxiety disorders, especially when anxiolytic drugs not required. Technique \200 Pa inting the triptych ( \201 g 1) \200 Listening, understanding, and re- \202 ecting \200 Note how past stress has been coped with \200 Producing an agreed full list of prob lems \200 Rede \201 ning problems in terms of attainable goals \200 Use of therapeutic contracts to negotiate small behavior changes \200 Aim for adult relationships between p atient, family, and therapist, eg with a contract vis vis duties, frequency, and duratio n of therapy, and what is expected of the client (homework), eg learning anxiety-reducing t echniques, and carrying out rewards, eg cooking an extra-nice meal with the family if the c lient achieves an anxiety-provoking task such as shopping \200 Talking out (not acting ou t) an- ger in safe but cathartic ways \200 Reassurance. The therapist must not only give overt reassurance, but also by his demeanor he must reassure the patient that whatever he r eveals (eg incest or baby battering), he will not be con- demned. y r t a h c y s P i Not all counseling is nondirective: problem-solving models of counseling (BOX) are sometimes directive, and may be appropriate if you know the client well. Caution \200 \200\230Giving expert advice \200\231: patients may need medical, legal or \201 nancial advice. It may be best if this comes from a specialist agency not involved in the counselin g \200 Patients with personality disorder, where the problems are too deep seated to be c hanged by counseling. Here there must be an aware- ness of the need to refer such patients for more formal psychotherapy. Supportive psychotherapy There are many people who seem to need continuous psychotherapy, a s they that \201 nd daily activities pose unending stress. The smallest decisions are in- surmountable problems, and the patient, lacking even a glimmer of insight, seeks support a t every turn. What can we off er here? Indication Relevant to all forms of psychiatric diso rder. Technique \200 Listening to what (s)he is saying, picking up verbal and non- verbal cues. Ensure a reasonably full account of the situation and problems \200 Reassurance: r elieve fears, boost self-con \201 dence and promote hope, \200 Explain to a patient why they are experiencing certain symptoms \200 Guidance and sug- gestion with regard to a pa rticular problem \200 Expression of feelings eg anger, frustration and despair within a s upportive setting. Caution Patients can become dependent on the therapist and not be able t o cope when therapy comes to an end \200\224see p326 for how to deal with this. Where teste d against cognitive therapy, this less sophisticated therapy some- times comes out well, eg in long-term schizophrenia care,387 and also in care of adolescents with major depression \200\224but not in minor depression.388 381 Counseling in primary care Counseling has long been a central activity in primary care. Don \200\231t think of this as the expert handing down treatment to poor, benighted patients. It \200\231s more of a joint exploration between two humans who know each other reasonably well. On occasion, roles may be reversed \200\224for example, following a medical disaster, a doctor, who may be blameless, may become so relentlessly and excoriatingly self-question ing that despair ensues. In these circumstances, it has been known for counseling and suppo rt from the original victim or one of his or her relatives to restore the doctor to health, and avert resignation. Many UK general practices employ or have access to counselors. This huge growth re \202 ec ts the fact that people love to be listened to, and that GPs them- selves may not have the time or inclination to satisfy this need. It is hard to prove the eff ectiveness of counsel ing, especially as skills and training vary markedly. But this does not mean it is ineff ec tive. There are 3 facets to counseling in general practice: 1 In some patients, problem-sol ving strategies are used, with the counselor y r t a i h c y s P using a non-directive approach. 2 In fostering coping strategies, the therapist helps the patient to make the most of the position they are in (eg affl icted by a chronic disease). 3 In cognitive therapy, we concentrate on elucidating negative thinking, and help patients learn how to intervene in negative cycles of thinking. Randomized trial evidence: Counseling and cognitive-behavior therapy carried out in primary care are both more eff ective in treating depression than usual GP care in the short term. But in one study, there was no diff erence in outcome after 1 year.389 390 NB: \200\230no diff erence \200\231 may indicate that too few coun- selling sessions were off ered \200 \224or, perhaps that GPs were already eff ective counselors \200\224or maybe more focused c ounseling would be more eff ective.391 N=197 Therapeutic communities, and the example of substance misuse Therapeutic communities (TCs) are a popular treatment for the rehabilitation of IV drug users and dealing with personalit y disorders \200\224in both the USA and Europe. The rationale is that the bene \201 ts of peer-feedback (group therapy) can be magni \201 ed in the microcosm of a therapeutic commu nity. Also these communities provide a safe environment for those with complex needs. In trials of residential therapy vs therapeutic communities the latter can come out better vis vis staying off drugs and not reoff ending (eg if the \200\230resi- dential \200 \231 arm of the trial is prison).392 Life in a community is more bene \201 cial (vis vi s reoff ending or reusing drugs) if it is for 12 months compared with 6 months. After the t ime in the community, aim to give continuing aftercare.393 However, there is little evidenc e that TCs off er major bene \201 ts compared with other residential treatment, or that on e type of TC is better than another. European TCs adapt the early harsh behaviorism found in the US by concen- trating more on m ilieu-therapy and social learning emphasizing dialog and understanding. Either professional s or ex-addicts can provide input.394 Psychodynamic psychotherapy Key concepts: 1 The unconscious: Individual dynamic psychothera py is based on the premise that a person \200\231s behavior is in \202 uenced by unconscio us factors (thoughts, feelings, fantasies). Evidence for the existence of uncon- scious act ivity include \200 Dreams \200 Artistic and scienti \201 c creativity \200 Hysterica l symptoms (p334) \200 Abreaction1 \200 Parapraxes \200\224 \200\230slips of the tongue \200\231. 2 Psychological defenses: Our immune system protects our physical integrity, and our psychological vulnerabilities are shielded by psychological defenses. In both cases, o veractive defenses can lead to trouble, eg: Psychotic defenc- es: \200 Delusional project ion/paranoia \200 Denial \200 Distortion. Immature defenses: \200 Projection2 \200 Schizoid/autistic fantasy \200 Dissociation (p334) \200 Acting out (BOX) \200 Hypocho ndriasis \200 Passive aggression. Neurotic defenses: \200 Repression \200 Dis- placem ent3 \200 Reaction formation4 \200 Intellectualization. Mature defenses. \200 Al- tru ism \200 Humor \200 Suppression \200 Anticipation \200 Sublimation5.395 3 Transfere nce and countertransference: The past patterns (transfers) our present reactions to people. If we have trusted our parents, we will be likely to trust our doctors, teachers, and frie nds. The intense psychotherapeutic rela- tionship brings these assumptions to the fore wher