 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 e they can be examined, un- derstood, and learned from. We in turn have unconscious reactio ns to patients based on our past, ie countertransference. Errors from countertransference a rise when we react as though our patient were a signi \201 cant person in our early life39 6 (if our mother was an alcoholic we may be oversolicitous or reject- ing with alcoholics). Our reactions are also a key to our patient \200\231s feelings: if a patient makes us feel rejected (as alcoholics often do), perhaps that person himself was rejected as a child and turned to the bottle in compensation. Assessing suitability Psychological understandibilit y: The patient \200\231s diffi - culties must be understandable in psychological terms. Psy chological mind- edness: The capacity to think about problems in psychological terms. Moti- vation: There must be motivation for insight and change. Intelligence and verbal \202 ue ncy: The ability to communicate thoughts and feelings through talking. Introspectiveness: T he ability to re \202 ect and think about their feel- ings. Dreams: The capacity to rememb er dreams. Ego strength: The ability to tolerate frustrating or distressful feelings withou t engaging in impulsive behavior. Capacity to form relationships: There should be a history of at least one sustained relationship in the past or current life. Speci \201 c indicati ons \200 Dissociative/conversion disorders \200 Depression \200 Psy- chosomatic disor ders \200 Personality disorders \200 Relationship problems \200 Grief. Technique The therapist provides a secure frame \200\224a regular time and place and her own consistency and acceptingness. The patient narrates vignettes about himself and his life ( 3/session). The therapist listens carefully, to the stories and to her reactions to them. She then make s linking hypotheses, or in- terpretations that off er meaning. Previously inexplicable beh avior begins to make sense. Meanwhile, the patient forms a close relationship with the ther a- pist based on empathy, genuineness, and non-possessive warmth (shown ex- perimentally to be key factors) and sometimes challenge. These may be novel experiences for the patient th at can be internalized as he works through dif- \201 culties safely. Reactions to ending will bring up past unprocessed losses. 382 y r t a h c y s P i Psychodynamic therapy can be time-limited (brief dynamic psychothera- py) \200\224suitable for circumscribed problems, eg unmourned grief, or open-ended (BOX 3) eg if there are sever e personality disorders or complex needs.397 N=1053 In depression, 16 sessions seem to be n o better than 8.398 1 Abreaction: cathartic reliving of buried traumas; repressed terrors are made conscious an d tamed.399 2 Projecting our own undesirable impulses to another, so pretending that the su bjective is objective. 3 Displacement: redirection of an undesired intense emotion towards someone neutral and harmless. 4 Reaction formation: doing the opposite of true desires (eg training to be a pilot to cover up fear of \202 ying). 5 In sport, for example, we sublim ate (and make safe) brutal urges into rituals of formal competition. 383 The Id is king: Whenever he battles with his conscience \200\224he wins! Acting out: the oldest defense mechanism Acting out is making something happen or doing som ething instead of dealing with the corresponding feeling, eg when we unconsciously engage i n actions or any non-verbal communication, or take on psychosomatic symptoms, instead of ex amining our true feelings. We fail to acknowledge to ourselves what we really feel and expe rience.400 It is a kind of uncon- scious self-destructive anger and as such is the opposite to sublimation.5 For example, a client may become accident-prone, attempt suicide, or com- mit unconscious self-sabotage (eg destroying his friends or work). . w o r r o m o t t n e p e r We also \200\230act out \200\231 desires forbidden by our Super ego but intensely desired by our Id. We cope with pressure to do what we think is wrong simply by siding with our Id. Immaturity, cognitive short-sightedness, counter-sug- gestibility, and \200\230contrarian tendencies \200\231 all play a role in acting out.401 d n a w o n y r t a i h c y s P t i o d Patients often act out with us as an expression of transference. Joyce is stamping her foot saying \200\234You take such poor care of me. It shows you don \200\231t want me as a pat ient. Why not get rid of me? \200\235 A plea for love and a simultanous self-destructive at tempt to replicate past rejections?402 l l \200\231 I ! l l e h e h t Sexual acting out is common too, eg in institutionalized (motherless) fe- male adolescents, heterosexual acting out wards off regressive wishes, kin- dled by object loss, to reunite symbiotically with the pre-oedipal mother.403 t a h W \200\207 Cautions: when dynamic psychotherapy might not be right 1 Repeated admissions, many suicide attempts, repeated risk-taking, and severe somatization suggest insuffi cient ego strength for psychotherapy. ! t i 2 A history of repeated failed ventures or dropping out of relationships. 3 In general, pat ients with acute psychosis are less amenable. 4 Severely depressed patients may be too slow ed up and too unresponsive. 5 Over-sedation may hinder capacity to access feelings (?reduce doses). 6 Patients who are actively abusing alcohol or illicit drugs are problematic. 7 No real motivation to change or grossly unreal expectations of therapy. \201\201 Has psychoa nalysis changed the world? The world is no better than before psychoanalysis came along wit h its per- ceived promises of explaining us to ourselves and self-realization. Either the e xplanations are wrong or explaining things doesn \200\231t help \200\224or we have missed t he point of psychoanalysis. It may be charming to learn, for exam- ple, that the anorgasmia of a patient seen in today \200\231s clinic is explained by the speci \201 c psychodynami cs of an \200\230anal-retentive defense against pre-oedi- pal fears of anal-sadistic impul ses and fear of ego-loss \200\231.404 Likewise it is not clear that extended pre-orchidecto my counseling dwelling on anticipated narcissistic grief will actually improve outcomes.405 But note that as soon as we learn about the concept of narcissistic grief we never forget it: it \200\231s like a promise of eternal love; it assumes its own truth, and if we dare t o test it, it can only ever be us who are found to be wanting. Joyce: the young mother \200 \231s story Psychoanalysis took ages to get under way for a young mother happily named Joyc e, who had inexplicably severe eczema. But things started happening by interview 236. Laten t fears of being lesbian surfaced at this point and the psychiatrist was rewarded by the pe rfect sentence \200\234It used to be if I just thought of her, I could start scratching \200\235.406 But was the patient rewarded as well as the psychiatrist? It is impossible to know if any bene \201 ts were related to the speci \201 cs of the psychodynamic process \200\224or just to the extraordinary input of time and at- tention. Either way, though, we must accept that psychoanalysis has more than entered and populated our consciousness: it \200\231s made it into our uncon- scious \200\224so we cannot reject it, even if we want to . r o f y a p o t d a h e c y o J ! y o b h o \200 t u b , d l o g s e k i r t s t s i p a r e h t e h t e c y o J h t i w s n o i s s e s 6 3 2 r e t f A Sex therapy for couples This is an example of couple therapy: often the problem is not spec i \201 cally sexual, and sexual diffi culties may recede once other aspects of the relatio n- ship improve. Here, speci \201 c sexual dysfunctions are considered in the light of a m odernized Masters & Johnson approach using a model of sexual response entailing excitation, plateau, orgasm, and resolution.407 384 Start with a full (joint) description of the problem. This may be premature (or delayed) ej aculation, female frigidity (anorgasmia), erectile dysfunction, or dyspareunia (eg from spa sm \200\224vaginismus \200\224or other physical causes). How did the problem start (eg afte r childbirth)? Was there ever a time when sex oc- curred as desired? Is the problem part of some wider problem? What does your partner expect from you? Are you self-conscious or anxi ous during sex? Are there medical problems, eg ischaemic heart disease,408 or mastectomy; p rosthesis use is discouraged at intercourse as it delays confrontation with and acceptance of mastectomy. Techniques of body imagery and sensate fo- cus (below) have special roles he re.409,410 Sexual history Early experiences; present practices; any hints pointing to- ward s transexualism, commercial sex work, or drug abuse? Orientation to either or both sexes. D iffi culties with other partners? When did you meet? What attracted you to each other? Drug s Alcohol, hypotensives (erectile dysfunction, ED); SSRIs (delayed ejacula- tion); \200 -b lockers, \201 nasteride, the Pill, and phenothiazines (loss of libido). Other causes of E D: (OHCM p222): diabetes, cord pathology, prolactin \200\200, drugs. Principles of behavior al therapy for sexual diffi culties comprise: 1 De \201 ning the task which the couple wis hes to accomplish. 2 Reducing the task to a number of small, attainable steps. 3 Asking the couple to practice each small step in turn. 4 At the next session, discussing diffi cultie s encountered. 5 Ameliorating maladaptive attitudes. 6 Setting the next task. Example: prem ature ejaculation and vaginismus: (Both relate to perfor- mance anxiety, and vaginismus may be part of a generalized anxiety-defense mechanism).411 One sequence to agree with the cou ple might be: 1 A ban on attempted sexual intercourse (to remove fear of performance fail- ure). Education and \200\230permission \200\231 giving (ie to talk about and engage in \200\230safe \200\231 sexual fantasies) is vital. y r t a h c y s P i 2 Touching without genital contact, \200\230for your own pleasure \200\231, initially, wit h any non-genital part of the body, to explore the range of what pleases, and then to conce ntrate on whatever erogenous zones are found ( \200\230sensate focus \200\231). 3 Touching as above \200\230for your own and your partner \200\231s pleasure \200\231. 4 \200\230Homework \200\231 using a vaginal dilator and lubricating jelly. 5 Touching with ge nital contact, \201 rst in turn, later together. Problems in tak- ing the initiative may now surface. In premature ejaculation, the partner stimulates the penis, and as orgasm appr oaches the man signals to his part- ner, who inhibits the re \202 ex by squeezing his peni s at the frenulum. 6 Concentrate on playing down the distinction between foreplay and inter- course, so that anxiety at penetration is reduced. 7 Vaginal containment in the female superior position so that she can stop or withdraw when ever she wants. She concentrates on the sensation of the vagina being \201 lled. 8 Periods of pelvic thrusting, eg with a \200\230stop \200\223start \200\231 technique. NB : the evidence for such techniques is not all that good for premature ejacula- tion.412 For vaginismus, success rates of >93% have been obtained.413 Drugs such as sertraline (unlicen sed) can improve ejaculatory control.414 385 Sexual universals There is much more to helping people with sexual diffi culties than is ou tlined opposite: it is just one approach to one problem. Such behavioral approach- es may n ot be suited to dealing with forbidden, haunting, and disturbing sexual feelings, fantasies , and urges. Experiential psychotherapy and psycho- dynamic approaches are valid alternativ es.415 Also, we should not focus on performance of acts at the expense of promoting the qua lity of erotic con- nection and the attainment of transcendent levels of intimacy. Lust, ro mantic love, and attachment These are the 3 primary colors of the sexual realm \200\224mixe d in diff erent proportions at diff erent times in our lives to give millions of subtle or clashing tones. Each emotion-motivation system is associated with a speci \201 c constella tion of neural correlates and a distinct behavioral repertoire.416 Sex therapy has diff ere nt tasks in each of these areas. In any therapy the following universals need to be address ed: \200 Never assume that a patient is too old or too ill for sexual issues to be releva nt. \200\207Assume that everyone has a sex life, perhaps in fantasy only (fantasy is alway s found to be an important component of sexuality).417 \200 Treat sexual problems holisti cally \200\224eg there may be relevant medical, drug, y r t a i h c y s P or other psychopathologies (depression is common). Psychological approaches are always important, whatever is off ered by way of physical prop s or drugs such as sildena \201 l. Men randomized to receive group therapy + sildena \201 l had more successful intercourse than those receiving only sildena \201 l. Group psychot herapy also signi \201 cantly im- proves erectile dysfunction compared to sildena \201 l alone.418 \200 Psychological events have physical sequelae, and physical events have psy- chological sequelae. All pleasure, including all erotic pleasure, is either purely sensory or arises from associ ations of ideas: this off ers many points of intersection for nega- tive operators, such as distraction, spectatoring, guilt, anxiety, fear of fail- ure, pain, and inappropriate stim ulation. \200 As in all walks of life: \200\207when in doubt \200 communicate. This is t he basis of the salutogenesis approach to sexual health. Salutogenesis asks not what diseas e is present but how and individual or a couple stay healthy. And the answer is often \200 \230through communication \200\231 and \200\230by being intimate \200\231.419 Inti- macy m ay be a more powerful determinant of health than improved diet, stopping smoking, genetic v ulnerabilities, and prescription drugs.420 \200 All humans have a need to give as well as to take. Reawakening this in- stinct may be an important part of therapy.421 N=1 Systemic practice (family therapy) What used to be called family therapy is now better know n as systemic prac- tice, which is an evolving body of ideas and techniques focusing on a p erson \200\231s diffi culties within the context of the people and culture that surround th em. Therapy is based on the assumption that most people have the resources and potential fo r resolving life \200\231s diffi culties. Therapists may work with individuals or families. Screening rooms may be used where co-therapists observe family interactions during therapy via a one-way screen. 386 Its origins began in cybernetics.422 Behavior maintains itself by feedback loops, eg disrup tive behavior in a son draws divorcing parents together. This led to strategic therapy \200 \224the paradoxical approach where the symptom is prescribed so interrupting the behavior \200\223problem cycle. Structural thera- py 423,424 sought to be more objective. A family c an be described in terms of dimensions. Research interviews have given rise to a measure of \200\230expressed emotion \200\231 (EE) which is associated with severity of chronic illn ess in many dis- orders (eg schizophrenia, anorexia nervosa, cystic \201 brosis). Therapy includes prescribed exercises, eg parents may agree to go out for a meal at a secret locat ion. In an over-involved family, this strengthens parental executive sub- systems, providin g opportunity for disengagement and management of concomitant anxiety. Systemic family ther apy was pioneered by the Milan School, emphasizing family behavior according to \200\230my ths \200\231, \200\230scripts \200\231, and fam- ily secrets, which dominate the inter-gen erational transmission of repeating behaviors. Drawing a genogram (family tree) with the fa mily is a good way to reveal these. Hypothesizing, maintaining a neutral stance and the use of circular questioning are important components. Narrative therapies425 consider that kno wledge is developed by story-telling not through the logico-scienti \201 c method, working on the basis that there is no single truth about the reasons for problems but that \200 \230truths \200\231 are constructed via conversations between therapist and therapee. Peopl e can be maintained in problem-saturated lives by \200\230viewing themselves in the contex t of a domi- nant knowledge \200\231. By constructing an alternative knowledge, they can be liber- ated to challenge the problem. Narrative therapists help by restoring people \200 \231s control over their problems via externalizing the problem. Fecal soiling is popularly viewed as an act committed by the child as a response to family dys- function. But if it i s viewed as a struggle between the family and the problem by identifying the \200\230sneak y poo \200\231 as the enemy, then the family can be engaged in a battle against it. The use of written letters is also considered a useful tool. Brief solution focused therapy426 mak es use of a structured approach to draw on people \200\231s resilience, and motivate proble m solving. It centers conver- sations on solutions, not problems. \200\234If it works, do more of it. If it doesn \200\231t work do something diff erent. No problem happens all the time. \200\235 Session 2 and beyond Session 1 1 What \200\231s got better? 1 Why have you c ome? 2a Elicit: Ask about positive changes 2 How may we be of help? 2b Amplify: Ask for det ails on +ve changes 3 The miracle question (below) 2c Ensure he notices and values change 4 Exception questions 2d Start again. Ask what else is better. 5 Spectograms 3 Ending. How c an you get back on track? 6 Agreed achievable tasks y r t a h c y s P i \200\230Miracle \200\231 question: \200\234If you woke up and a miracle had occurred in t he night, how would you know? How would your life be diff erent? \200\235 Exception questio n: Search with the client for possible exceptions. Spectograms: \200\234On a scale of 0 to 10, how much would you like your miracle to happen? \200\235 \200\234What would have to h appen/What would you have to do to make your score move from 3 to 4? \200\235 387 Family structure and functioning427 Family structure is viewed by Minuchin424 as an invisib le set of functional demands that organize family interactions. These transactional pattern s are self-regulating in a way that attempts to return a family to its habitual mode and mi nimize anxiety. Dimensions of family functioning428,429 (McMaster model) The 6 dimen- sions allowing any practitioner to describe family functioning are: \200 Problem solving: Can the family act together to solve everyday emotional and practical problems? Can they identi fy a problem, develop, agree, and enact solutions, and evaluate their performance? Success may be depend- ent upon functioning in other dimensions. Congruence of verbal and non-verbal communications: Are communica- tions clear and direct o r are there hidden agendas or hidden meanings? Do people listen to one another? y r t a i h c y s P Roles: Who is in charge and how are executive decisions made? Who pro- vides for the family ? Who is concerned for the child \200\231s education and emo- tional development? Families may function most eff ectively when roles are appropriately allocated and responsibilities explicit. Affective involvement: Relationships in families tend to exist on a continu- um from over-i nvolved (enmeshed) to disinvolved (dis-engaged). Empathic involvement is ideal. This depend s on development, as greater involvement is needed for babies than adolescents. Enmeshment may lead a child to be so anxious about a parent that they feel unable to leave them, and a void school as a consequence. Affective responsiveness: How do individual family members respond emotionally to one anoth er both by degree and quality? Welfare feelings would include love, tenderness, and sympath y. Emergency feelings would include fear, anger, and disappointment. Behavioral control: How is discipline maintained? Is there negotiation? Is it \202 exible? Chaotic? Absent? (depends on quality of communication). Dysfunctional family patterns Triangulation: When parents are in con \202 ict, each demand s the child sides with them. When the child sides with one, they are automatically consider ed to be attacking the other. The child is paralyzed in a no-win state where every movement is a perceived attack on a parent. Scapegoating: When an individual is singled out by the family as the sole cause of the family troubles. This serves to temporarily bury con \202 icts that the family fear will overwhelm them. \200\200Expressed emotion: Derived from a f amily interview: re \202 ects hostility, emo- tional over-involvement, critical comments, and contact time. Comparing the psychotherapies430 Westen \200\231s dictum Beware making false dichotomies in to supported and unsupported therapies. Randomized trial methodologies don \200\231t suit a ll thera- pies.431 432 What follows does not entirely avoid the trap Westen alludes to. Als o be aware of many diff erent variations on a theme, eg cognitive and ana- lytic therapy (C AT) and DBT (dialectical behavior therapy).1 Principal recommendations and levels of eviden ce2 \200 Psychological therapy should be routinely considered as an option when as- 388 sessing mental health problems.B Patients who are adjusting to life events, illnesses, disabilities or losses may bene \201 t from brief therapies such as counseling.B Post-traumatic stress symptoms may be helped by psychological therapy, with most evidence f or cognitive-behavioral methods. Routine debrie \201 ng following traumatic events is not recommended.A Depression may be helped (but is often not cured) by cognitive therapy or interpersonal the rapy. A number of other brief structured therapies for depression may be of bene \201 t, s uch as psychodynamic therapy.A Anxiety disorders with marked symptomatic anxiety (agoraphobia, panic disorder, social phob ia, obsessive-compulsive disorders, generalized anxiety disorders) are likely to bene \201 t from cognitive-behavior therapy.A y r t a h c y s P Psychological intervention should be considered for somatic complaints with a psychological component with most evidence for CBT in the treatment of chronic pain and chronic fatigue. C i Eating disorders can be treated with psychological therapy. Best evidence in bulimia nervos a is for CBT, interpersonal therapy (IPT) and family therapy for teenagers. Treatment usual ly includes psycho-educational methods. There is little strong evidence on the best therapy type for anorexia.C Structured psychological therapies delivered by skilled practitioners can contribute to the longer-term treatment of personality disorders.C Evidence \200 Psychological therapy shows bene \201 ts over no treatment for a wide rang e of mental health diffi culties \200 There is evidence of counseling eff ectiveness in m ixed anxiety/depression, most eff ective when used with speci \201 ed client groups, eg po stnatal mothers, bereaved groups \200 CBT has been found helpful. Some evidence of effi c acy has been shown for other forms of psychological therapy. Single-session debrie \201 ng appears to be unhelpful in preventing later disorders \200 CBT and IPT (interpersonal ps ychotherapy) can eff ectively reduce symptoms of depression. Bene \201 t has also been fou nd for other forms of psychological therapy, including focal psychodynamic therapy, psychod ynamic interpersonal therapy and counseling \200 CBT eff ectively reduces symptoms of pan ic and anxiety. Behavior therapy and cognitive therapy both appear eff ective in treatment of obsessional problems \200 Psychological thera- pies have bene \201 t in a range of so matic complaints including gastrointestinal and gynecological problems. CBT has been found more eff ective than control therapies in improving functioning in chronic fatigue and chro nic pain \200 Effi - cacy of CBT and IPT in bulimia has been established. Individual ther apies have shown some bene \201 t in anorexia, with little to distinguish treatment types. Early onset of anorexia may indicate family therapy, and later onset, broadly based indivi dual therapy \200 A number of therapy approaches have shown some success with personality disorders, including dialectical behavior therapy, psychoanalytic day hospital program and therapeutic communities. 1 CAT is collaborative program for looking at the way a person th inks, feels and acts, and the events and relationships that underlie these experiences (oft en from childhood or earlier in life). It combines understandings from cognitive psychother apies and psychoanalytic approaches into an integrated whole. 2 A Based on a consistent \201 nding in a majority of studies in high-quality systematic reviews or evidence from hig h-quality studies. B Based on \211 1 high-quality trial, a weak or inconsistent \201 ndi ng in high-quality reviews or a consistent \201 nding in reviews that don \200\231t meet all the high-quality criteria. C Based on evidence from single studies that don \200\231t m eet all the criteria of \200\230high-quality \200\231. D Based on evidence from structured expert consensus. 389 Index on child mental health problems This section (to p398) deals with some aspects of chi ldhood mental health \200\224 but many issues in child psychiatry overlap with pages in the adult section of this chapter, and also with pediatrics. The psychiatry of attempted suici de is a good example. Many of these patients will be in the last phases of childhood, and i t is unclear which service will suit them best. As ever, take a holistic view of your patie nt, and design a care plan which takes these facets into account. Abuse, p146 Alcohol abuse , p363 Anorexia and bulimia, p348 Asperger \200\231s syndrome, p638 Attention de \201 cit disorder, p212 Autism, p394 Bedwetting, p211 Bullying, p395 Cultural issues in mental healt h, p492 Depression: children/adolescents, p390 Drug addiction, p362 Dyslexia, p396 Encopres is/enuresis, p210 & p211 Existential crises p390 Family therapy, p386 Holistic assessment p99 \200\223100 Language disorders, p215 Learning problems, p314, p364 Parasomnias, p392 Play therapy, p377 Psychosis and psychosis-like symp toms y r t a i h c y s P in children, p391 School refusal, p212 Sleep disorders, p392 Substance abuse, p362 Suicide, p338 Talking to young people about sex, p328 Tics & Tourette syndrome, OHCM p714 Mental health in adolescence Adolescents face major mental health challenges owing to exist ential crises (p390), changing looks, emerging sexualities, identity problems, exam pressur e, family break-up, ready availability of drugs and alcohol, media pressures, and the onset of adult responsibilities (eg when they get pregnant). Psychotic illness also often starts in adolescence, and may be partly related to urban stress (p391). What can we do to help? Pediatricians, psychologists, psychiatrists, coun- sellors, GPs, and so on all have a role of course \200\224but access to them depends on the fact that a problem has occurred. This is often a bit late \200\224which is why teachers have such an important role in promoting mental health. Some schools off er classroom-based workshops such as MasterMind: Em- power Yourself With M ental Health. MasterMind-type initiatives work by creating a toolbox for mental health by m aking a safe place for discussion of mental health and emotionally charged topics. The aim is to increase student knowledge of mental health issues, and to provide the tools to devel op and maintain mental health (eg techniques in de-stressing). Instructional materi- als ad dress topics identi \201 ed through needs assessment. These and other writ- ten exercises are combined with peer-teaching-peer group activities, individu- al assignments, and open d iscussion. Students can ask questions anonymously, and through interaction they build each other \200\231s self-esteem (provided they are not feeling totally negative). When these in terventions have been evaluated, it is found that students \200\231 enthusiasm and particip ation increases throughout the course, and they give high satisfaction scores to the topics covered.433 Of course, we all want to know what mental illness are prevented \200\224but this is to ask the wrong question. Mental health issues will never be cured or go away \200\224they are p art of what it means to be an adolescent. The question is more \200\234How are these adole scents adjusting to their self-made world? \200\235 and \200\234Is adolescence proving to be a humanizing or an alienating experience? \200\235 The answers to these questions are mo re metaphysical than quantitative. We often have the impression that the incandescent adolescent sitting in front of us is bur ning too brightly within his sullen shell \200\224and our foreknowl- edge of his impending death in a shoot-out, stabbing, or drug-overdose seems inevitable. \200 What is not inevit able is that he should go to his grave without anyone having tried to help. The following p ages may serve as a \201 rst step. Depression in children2% and adolescents5% Accepting that the big task of adolescence is fo rging new independent identi- ties, it comes as no surprise that the main signs of depressi on in this group spell ERSATZ: a German word we use to mean fake.1 Existential hopelessness related to dawning awareness of freedom to narrate one \200\231s own life and death; relat ionship & sexual problems; anger in the face of con \202 icting adult values; tearfulness when it all goes wrong, and overzealous attachment to false gods (eg causing body image dis satisfaction and self-harm). Features as seen in adults: Low mood Loss of interest and self -esteem Socially withdrawn Psychomotor retardation Tearful; feelings of guilt Anxiety Lack of enjoyment in anything 390 Features common in childhood: De \201 ance; running away from home Separation anxiety s chool refusal Complaints of boredom; poor school work Antisocial behavior Insomnia (often i nitial, not early waking) Hypersomnia Eating problems One-to-one interviewing is usually best. Consider the possibility of concealed factors (eg past child abuse, bullying, p395). Parents can be interviewed sepa- rately (ask the child \200\231s permission, and see the child alone, again, if appropriate, after seeing the pare nts, to report back: this helps avoid seeming to collude with the parents). NB: parents are often unaware of depression in their children. Assessment is often hard: questions may be answered by silence or a shrug. y r t a h c y s P i If not getting anywhere, keep listening, or off er silences \200\224but do not give up. Always ask about thoughts of suicide/self-harm. Any past attempts? 15 \200\22320% make furt her attempts ( \200\200risk if: conduct disorder, \200\200alcohol use, hopelessness, or in local authority care). Self-harm may be a form of communication \200\224a mes- sage in a b ottle; not always \200\230picked up \200\231 and sometimes it is diffi cult to decipher th e teenager \200\231s exact intentions. Refer urgently if risk is considered signi \201 can t. Adolescents with conduct disorders can be manipulative and extremely dif- \201 cult to assess \200\224an urgent second opinion is frequently of help. Management Ideally this sho uld be a combined approach: 1 Social: addressing sources of distress (eg bullying) and remo ving opportuni- ties for self-harm (eg no paracetamol at home). Improve sense of belonging- ness, especially if he/she feels on the margins of society (eg for reasons of sexuality, o r because of substance abuse).434