Psychotherapy in Psychiatry

Introduction

The delivery of biological, psychosocial and psychotherapeutic interventions remains central to the treatment of patients with psychiatric disorders.^1–3 It is therefore essential to manage the provision of these treatment modalities. Psychotherapy is therefore considered a core skill set for psychiatrists, and the Canadian Psychiatric Association (CPA) affirms the position of psychotherapy in psychiatry.

Canadian psychiatry has emphasized an integrated biopsychosocial approach to the assessment and management of mental health problems.^1–7 Psychiatrists must possess competence in evidence-supported treatments including psychotherapies.^7–9 Treatment strategies should consider the place of pharmacology, psychotherapy, and systemic interventions.^8,9 The inherent private nature of the practice of psychotherapy, and the often-competing theoretical schools contribute to ambiguity and differing definitions or descriptions of different therapies. Today, most psychotherapies and common factors have been operationally defined with greater clarity (e.g.^10–13), although some constructs remain more abstract. ¹⁴ Treatments should demonstrate both their efficacy and clinical- and cost-effectiveness, or benefit in real-world settings irrespective of their orientation.^15–18

The last few decades have witnessed a significant growth of research in psychotherapy. Randomized controlled trials and meta-analyses demonstrate that numerous psychotherapies can be effective for mood, anxiety, psychotic, substance misuse, eating, and personality disorders (e.g.^19–25). Research has contributed to treatment guidelines that recommend specific psychotherapies across the life span.^26–28 Research also demonstrates that common factors across therapies, including therapist interpersonal effectiveness, predict psychotherapy outcomes. ²⁹

The Goal of the Position Statement

The CPA affirms the role of psychotherapy as an integral and essential component of psychiatric care. The statement highlights the unique contributions psychiatrists can make when they are able to integrate psychological, psychosocial and biological approaches in a treatment plan. This position is also supported by the empirical literature and encourages evidence-based practice. The CPA identifies the importance of research into the effectiveness of all psychotherapeutic approaches, in turn shaping clinical practice. It reinforces the place of training in the psychotherapies for psychiatric residents. The CPA also defines psychotherapy as a medical act in psychiatry. The need to maintain professional standards of practice is recognized within psychotherapy and all aspects of psychiatric treatment. The statement acknowledges the history, current use and future potential of psychotherapy. Definitions and recommendations are structured to encompass the professional practice of the broad psychiatric community. This paper delineates general principles to guide the future development `and utilization of the psychotherapies as an integral part of psychiatric practice.

Definition and Background

Psychotherapy is the informed and intentional application of clinical methods and interpersonal stances derived from psychological principles and treatment approaches that focus on behaviours, cognitions, emotions, relationships and/or other personal characteristics. It is grounded in conceptual frameworks and theoretical orientations. ¹ The psychotherapies are distinct psychological treatments, many of which have been demonstrated to assist patients with specific psychiatric disorders and other psychological problems.^{1,4,10,11,13,14,27,30} In addition to specific clinical adherence guidelines that distinguish differing models of psychotherapy, there are common factors that cross differing modalities and which are important for optimizing outcomes. These include the therapeutic alliance, use of empathy, managing countertransference and patient expectations along with consensus on treatment goals.^{13,27,31–34} The psychotherapies, integrated into psychiatric practice as a component of a comprehensive treatment plan, can improve patient outcomes and experience of care.

Prior to the emergence of biological therapies, psychosocial and talk therapies were the primary tools of the psychiatrist. Theoretical schools helped to further our understanding of the psychopathology of individuals, families and groups, facilitating the development of theories and defining the practice of psychotherapeutic treatments. ³⁵ Over the past decades, psychotherapy has witnessed an expansion of cognitive-behavioural, affect- and, interpersonally-focused or relationally-oriented approaches, psychodynamic psychotherapy treatments and additional structured, goal-focused treatments.^{19–24,36,37} There is an acknowledgement of something unique that occurs between psychiatrist and patient, a process that allows for the relationship to become therapeutic. This is affected by its parameters and the interpersonal facilitative skills of the psychiatrist. The therapeutic alliance has consistently been shown to moderate outcomes, this then being an important element of the delivery of psychotherapy and psychiatric care.^{12,13,38–40}

Psychiatrists are medical specialists with training in medical, social and psychological aspects of psychopathology. They have additional unique skills to identify and treat the medical disorders that interfere with and affect thought processes, mood, relationships or behaviours. Given the numerous known medical and biological conditions that may have a psychological impact on patients, psychotherapy skills add considerably to the treatment process to enhance outcomes. A psychiatrist's knowledge and ability to prescribe biological treatments for psychiatric disorders has the potential to add further value to therapy. Psychotherapy is deliberate and distinguished from providing advice.

Discussion

Through the therapeutic relationship between psychiatrist and patient, change can be effected in the patient.^13,41 How that relationship is conducted is subject to rules governing physician–patient contact and follows established psychotherapeutic practice. The theoretical basis of the therapy and how it is practised may vary across circumstances. There is an expectation that psychotherapy is one of a psychiatrist's treatment skill sets and can be applicable to all socioeconomic and clinical population groups. Its use is determined by clinical need, justified by treatment outcome and an intervention determined by choice on the part of the parties involved.^42,43 However, the intervention selected should be supported by acceptable evidence. In addition to upholding fidelity standards, psychiatrists should have an ability to establish a therapeutic alliance, with an agreement on goals. ³³ Psychotherapies can be integrated with biological treatments and in many cases such as depression, anxiety, eating disorders, personality disorders, posttraumatic stress disorder (PTSD) and unresolved developmental trauma, this integrated treatment is the treatment of choice.^{20,27,30,37,44–48}

Psychotherapy has historically been delivered by a person, the therapist, to another person, the patient; however, online, telephone, tele-video and web-based formats are increasingly being used. ⁴⁸

The therapeutic alliance has also been understood historically as the transference and countertransference in psychodynamic therapy.^33,34 Although not all therapies adhere to understanding the therapeutic relationship in these terms, it is important to note that these concepts may offer a rich perspective in understanding the patient, the therapist and the therapeutic relationship, and are especially important in ensuring that boundary violations are not crossed and are discussed prior to beginning therapy. At its base, the strength of the therapeutic alliance can be linked to outcomes.

Much like other treatments, psychotherapy requires an appropriate initial assessment, indications for use, training and skill on the part of the psychiatrist. It should take into account the characteristics of the patient, some of which have been found to predict differential responses to specific forms of therapy.^{20,22,29,49–52} Some psychotherapies are more prescriptive and structured while others provide a less directive environment. In most therapies tools are available to assess the therapeutic alliance, adherence and treatment outcomes for quality, measurement-based care. ⁵³ The use of psychotherapy as a form of, or part of, treatment is deliberate and involves choice. The decision as to the type of psychotherapy and the frequency of the psychotherapeutic interactions should depend on the psychiatric disorder, the evidence base which supports the use of a specific therapy, the patient's ability to use the therapy and the therapist's interpersonal effectiveness and skill in delivering the intervention. As with any treatment that has efficacy, inappropriate use may have deleterious effects.^54,55

Randomized controlled trials have established psychotherapy modalities as effective treatments for specific psychiatric disorders, with effect sizes equivalent to and sometimes greater than pharmacotherapy treatments alone. In children and adolescents, psychotherapy is considered first line treatment. Choosing Wisely has been invaluable in providing guidance in this regard. ⁵⁴ Psychotherapy is superior to pharmacology in long term follow up of some conditions, especially in anxiety disorders.^{22,49,50,56–59} Empirically-supported psychotherapies include cognitive behavioural therapy (CBT),^37,60,61 interpersonal psychotherapy (IPT),^23,62 group psychotherapy, ⁶³ dialectical behaviour therapy (DBT),^24,25,64 mindfulness interventions, ⁶⁵ motivational interviewing (MI) ⁶⁶ and psychodynamic psychotherapy.^21,41,67 Psychotherapeutic principles can guide assessment and treatment decisions for improved outcomes of complex dynamics that can arise. ¹³ Benefits of using psychotherapy include decreased relapse rates, enhancing of patients’ resilience, self-esteem, relationships and quality of life, decreasing or remitting of symptoms and improved functioning.

Consensus treatment guidelines recommend psychotherapies for diagnoses such as mood and anxiety disorders, PTSD, substance use disorders, personality disorders, eating disorders and psychological trauma, either as monotherapy, or sequenced or combined with medication. CBT, IPT, DBT, MI, mindfulness-based interventions and psychodynamic psychotherapy are recommended in national and international consensus treatment guidelines for patients of differing psychiatric conditions (e.g. World Health Organization, ²⁶ the U.S.^68,69 Canada^27,28,57 and the United Kingdom (NICE) ⁷⁰ ).

Psychiatric treatment including evidence-supported psychotherapies should be geared to patients’ diagnoses, personal attributes and the social context. ⁴⁹ As with all treatments, ongoing research into effectiveness and efficacy is critical. Quality management strives to seek out the best therapy for the specific disorder or condition. In the past, the abstract theoretical basis and long-term open-ended psychotherapies made outcomes and processes more difficult to measure, giving rise to questions about their validity. ⁵⁴ Psychotherapy treatments informed by outcome and process research have evolved substantially, both methodologically and conceptually. ⁷¹ Research to date has demonstrated the efficacy of many psychotherapies alone, sequenced or combined with medication for numerous psychiatric disorders. ³¹ Despite challenges in conducting research in an area as complex as psychopathology, significant advances over the past several decades have produced robust instruments to assess complex constructs salient to psychiatric care such as the transference, the therapeutic alliance, depth of experiencing in sessions, attachment patterns of relating and others (e.g.^72,73).

As with any treatment or intervention, measurement and evaluation of outcomes needs to be considered by funders of healthcare, providers and educators. It is this type of research that will continue to solidify the place of psychotherapy as part of evidence-based medicine. In the training of future psychiatrists, we will require this evidence to continue to include psychotherapy training in curricula. Efficacy, measurement and evaluation of different types of psychotherapies will affect the type and nature of the training provided.

Longitudinal case-based clinical supervision of trainees and measurable skill acquisition is encouraged and effective methods of instruction should be utilized in the training process. ⁷⁴ Effective training approaches include modelling, coaching and feedback; the use of audio or video tapes in training; moving from past, process note driven supervision to performance-based observational, formative feedback to foster adaptive expertise and competence. ⁷⁵

Conclusion

The psychotherapies are treatments that can be delivered alone or in combination with other treatments. Competent delivery of psychotherapy requires an understanding of theoretical concepts and common factors, and skill acquisition using evidence-based teaching methods. Psychotherapy use in psychiatry needs to be guided through evidence-based practice, similar to that used to rank other medical treatments. As trained mental health professionals with both medical and psychotherapeutic skills, psychiatrists are uniquely situated to offer integrated medical and psychotherapeutic treatments that can benefit patients with more complex comorbid conditions. In some cases, a specific psychotherapy may be the focus of treatment, and in other cases medication may be all that is required and needed. Training in both biological treatments and the psychotherapies will permit psychiatrists to make evidence-informed decisions that will benefit patients.

Psychotherapy may focus on individuals, couples, families or groups across the life span. These treatments may differ in many ways, including orientation, strategy, frequency, locus of assumed change and therapeutic goals. The ability to competently deliver evidence-based, consensus guideline-recommended psychotherapy in the context of a positive therapeutic alliance remains a core skill set of Canadian psychiatrists.

It is the position of the CPA that the psychotherapies continue to be an integral part of the training and practice of psychiatry.