Abstract
Psychotherapy and psychiatry continue to have an ambivalent relationship despite a consensus that good psychiatry is a blend of science and human narrative, and that proerly practised psychotherapy requires understanding psychological and biological processes. The reasons for this ambivalence are complex, ranging from an increased biological understanding of psychological process to the uncertain outcome of psychotherapy treatment. Throughout Europe, Australasia and the Americas the hegemony of the psychoanalytic approach has been replaced by a biologically-based psychiatry. Moreover, the latter lays claim to greater effectiveness and utility. Yet, patients and clinicians continue to recognize a need for ‘talking therapies’ either alongside or as an alternative to biological treatment. We argue that psychological understanding informs even those approaches most rooted in the physical sciences. Such understanding is essential to engage people in a therapeutic alliance, to instil hope and positive expectations and, most crucially, to shed light on a set of treatment approaches which are of demonstrable effectiveness
Psychotherapy has changed and adapted to meet a new reality; this special section reflects these changes. Far from being a spent cause, psychotherapy has altered its appearance, represented in various forms, become increasingly evidence-based and is being used as an effective treatment in its own right (see Guthrie below), as an adjunct to other treatment and as a body of knowledge that illuminates clinical practice generally (see Garner below).
Adaptation and change
Such changes are central to future progress. Having been shown to be effective in specific disorders such as anxiety and depression [1, 2], psychotherapy has begun to tackle more complex areas such as personality disorder [3, 4], substance misuse and chronic psychiatric conditions [5] and has been modified for different age groups (see Garner below). In doing so, psychotherapy provides a balance to a biological approach by focusing on developmental aspects of psychopathology which, once the domain of dynamic psychotherapy, have been adopted in cognitive approaches [6]. The result is less emphasis on pure theoretically driven models, which may have hampered developments in the past. A corollary has been the greater focus on integration, both theoretical and clinical. In modern psychotherapy elements from traditional modalities are being brought together in a systematic way [7].
The interest in the developmental approach and integration is reflected in two papers on aspects of borderline personality disorder (BPD). First, Van den Bosch and colleagues look for evidence, in a trial of dialectical behaviour therapy, that developmental insults in childhood lead to symptoms in adulthood. Their work adds to our understanding of the interaction between childhood trauma and later problems, indicating that any link is far from simple. Secondly, Holmes, in considering an attachment perspective to BPD, suggests long-term implications occur for the type of attachment pattern that develops between child and caregiver and that its understanding can lead to effective intervention. Evidence is emerging that treatment of BPD using interventions based on attachment research is effective [4].
Evidence-based psychotherapy
The articles below illustrate the tension between embracing contemporary scientific scrutiny in which the randomised controlled trial is seen as the ‘gold standard’ on the one hand and reliance on clinical description on the other. The ‘gold standard’ has been received with enthusiasm in some branches of psychotherapy, most notably cognitive behaviour therapy, and increasingly psychodynamic and interpersonal models. However, these advances do not preclude the value of detailed clinical accounts to illustrate what practitioners actually do and to illuminate the narrative structure of sessions intrinsic to all approaches.
We suggest that combining clinical description, process studies on mechanisms of change and outcome research is the way forward. It is often forgotten that the universally accepted meta-analytic method was pioneered in psychotherapy research [8]. There is room for further integration of research methods in psychotherapy and links with the biological sciences. For example, psychotherapy investigators have adopted an investigative tool from the biological sciences such as neuro-imaging. Although research has yet to bear fruit, the fact that it is being undertaken indicates that old barriers between research paradigms are disappearing.
Developments in treatment methods
Developments in cognitive behaviour therapy for psychosis have been widely reported [9, 10]. In this issue we highlight an approach from another theoretical source which is early in developmental terms with evidence at case level. The model is worth examining since it offers ways of using psychotherapeutic concepts in general psychiatric settings. Kerr and colleagues show that cognitive analytic therapy (CAT) can be adapted with patients with psychosis. ‘Tools’ are used to engage the person in a collaborative dialogue, and to arrive at a working formulation. Moreover, psychotherapeutic principles can be used by a mental health team to promote a uniform approach in a structured framework. In the past it has been difficult to link psychotherapeutic work to the efforts of the rest of the clinical team. The research by Kerr et al. demonstrates that this is possible and can reduce negative interactions perpetuated by clashes between the dynamics of the individual and those of the treatment system.
It is only after this developmental stage has been refined that we move to efficacy studies. Salkovskis [11] refers to this as the ‘neck’ of the hourglass of treatment development. A flaw in past research has been the rush from treatment description based on small clinical series to concepts being incorporated into training programs.
The need for psychotherapy research to be evaluated as rigorously as any other treatment is obvious, but other forms of testability can complement outcome studies. Margison and colleagues [12] argue that evidence-based practice has to be buttressed by practice-based evidence in which robust data are gathered from routine practice. This is exemplified by Van Den Bosch.
Psychotherapy has begun to adapt. A new reality is emerging in which psychological can stand beside biological and social treatments. Evidence mounts that their integration may improve outcome in complex areas such as schizophrenia [13] and personality disorder [14]. Greater emphasis in psychotherapy research on practicebased evidence may yet be shown to have greater utility than evidence-based practice. Modifying intervention for different age and ethnic groups is at an early stage but looks promising. General psychiatry has begun to relearn principles pioneered in psychosocial nursing in an attempt to make acute psychiatric wards more therapeutic [15]. Psychotherapy may have been missing, presumed dead, in the decade of the brain, but it has been re-found, alive and well and prepared for the future [16].