Robert P. Roca
Psychotherapy consists of verbal and behavioral processes that are used for the purpose of relieving symptoms and resolving intrapersonal and interpersonal conflicts. Although many different techniques have been described, there are fundamental principles that are common to all. Generalist practitioners have many opportunities to use psychotherapy, both formally and informally.
General Principles
Demoralization
Most candidates for office psychotherapy suffer from demoralization, a painful sense of disappointment and
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personal inadequacy in the face of life circumstances. By the time such patients acknowledge their distress to the doctor, their usual problem-solving methods have failed and their usual sources of support have been exhausted. Demoralization can be formulated as the product of interactions between environmental stressors and personal vulnerabilities. Environmental stressors may be remediable (e.g., temporary unemployment) or irremediable (e.g., conjugal bereavement). Personal vulnerabilities may be constitutional (e.g., mental retardation) or learned (e.g., excessive dependency or perfectionism). Particular personal vulnerabilities make individuals susceptible to particular stressors. For example, an exceedingly dependent person may be especially sensitive to the death of a spouse; rigid, controlling parents may be especially distressed by the rebelliousness of their adolescent children.
Psychotherapy may be viewed as an interactive process intended to restore morale. It involves both cognitive and relational tasks. The primary cognitive task is to develop a working formulation of patients’ difficulties as products of environmental stressors and personal vulnerabilities, to appreciate the personal strengths and resources available to patients for problem-solving and amelioration of emotional distress, and to help patients apply these strengths and resources to regain a sense of mastery over life problems. Some strategies useful for these purposes are described in later sections of this chapter (see Psychosocial Treatment Techniques and Forms of Counseling).
The relational task is to promote in patients what Jerome Frank has called “expectant trust” (see Frank, athttp://www.hopkinsbayview.org/PAMreferences). This describes an attitude on the part of patients that their practitioner cares about them, is competent to help, is confident of their recovery, and is committed to remain available until relief is obtained. Expectant trust is an important element in psychotherapeutic success, and it is enhanced by several of the techniques described in this chapter. Its effective mobilization also requires an understanding of the concepts of transference and countertransference.
Transference
Patients’ expectations of their doctors have complex psychosocial roots. In part, they grow out of patients’ experiences with their parents in circumstances of fear, pain, and other forms of distress. As a result of these experiences, patients consciously and unconsciously may come to expect that new people in their lives, particularly caretakers, will treat them as their parents did. These expectations are known as transference phenomena: patients transfer expectations onto their health care practitioners. When the transferred expectations are positive (positive transference), practitioners have at their disposal a powerful resource in their work to help their patients feel better. Positive transference may partly explain placebo responses and must be borne in mind when the effects of new therapeutic interventions are being evaluated.
Not all transference phenomena are positive. Everyone experiences anger, frustration, and other painful emotions in response to the disappointments and deprivations that invariably accompany growing up. These experiences sometimes leave emotional residua that may contaminate the relationship of the patient with caretakers or authority figures such as their health care practitioner. For example, patients who were abandoned by their parents may unconsciously expect that their practitioner will also abandon them and may therefore cling to the doctor with pathologic dependency. Other sorts of early life experiences may lead to passivity, hostility, and compulsiveness. Negative expectations (negative transference), as well as positive expectations, may be transferred onto health care practitioners and may give rise to maladaptive reactions that complicate the practitioner–patient relationship and interfere with therapeutic success if not properly managed.
In psychotherapy, transference phenomena are regarded as tools and opportunities as well as potential obstacles. Psychological distress is often the result of interpersonal problems with family, friends, and associates. Transference phenomena create, in the presence of the psychotherapist, modified but reasonably accurate representations of patients’ current and past relationships. As patients, through transference, begin to treat the therapist as a significant person from the past, the therapist gains valuable insight into the roots of patients’ interpersonal difficulties and may ultimately use these insights to help patients improve their relationships.
The type and intensity of the transference and the opportunities for its use in treatment vary with the intensity of the therapeutic relationship and the frequency of visits. In short-term counseling, intense therapeutic relationships generally do not develop, and the transference is predominantly positive.
Countertransference
Health care practitioners, like their patients, must endure the tribulations of childhood and adolescence and may thereby develop positive and negative expectations that are transferred onto other people, including patients. These expectations, called countertransference, may compromise the ability of the practitioner to care for particular patients. For example, the practitioner son of an abusive alcoholic father may have such a personal emotional stake in promoting the abstinence of his male alcoholic patients that he becomes enraged and ineffective with them when they relapse. It is the responsibility of the practitioner to be aware of countertransference phenomena and to resist their intrusion into the doctor–patient relationship, particularly in the context of counseling. The practitioner may find psychotherapy helpful for this purpose.
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Psychosocial Treatment Techniques
Because the simple disclosure of emotional distress and its causes may bring considerable relief to patients, the process of psychosocial evaluation often has therapeutic value in itself. Chapter 19 describes general aspects of evaluation for psychosocial problems. This section describes the principal techniques used in counseling, and the following section describes the forms of planned counseling useful in office practice.
Establishing a Therapeutic Relationship
As noted earlier (see Transference), the therapeutic relationship recapitulates to some extent the parent–child relationship. Several elements are generic to an effective therapeutic relationship. The patient must trust the health care practitioner. Practitioners earn trust by showing interest consistently, accepting sensitive information without being judgmental, taking patients’ concerns seriously, and controlling inappropriate reactions to difficult patients (see Table 3.7 in Chapter 3). In addition to establishing trust, practitioners should ensure that their patients understand how to gain access to them and recognize limits regarding access during ongoing treatment. It is useful to reflect on whether these trust-promoting and condition-setting actions have been accomplished before embarking on counseling, and whether the access policies already established by the practitioner's office are appropriate to the counseling situation.
Identifying and Addressing Information Needs
Misinformation or lack of information causes much distress. Patients often come to the office with an unfounded fear of dread illness or a significant misunderstanding of an established condition. At times, a patient's own “explanatory model” of what is wrong dominates the picture (see Chapter 4). When careful interviewing reveals the need for information and explanation, health care practitioners provide a vital service by tailoring their teaching to patients’ needs and taking care to confirm that the information has been received and understood. Clear explanations of normal physiology, disease processes, and treatment regimens are often overlooked as powerful aids in counseling. Besides providing information, such explanations draw patients into collaborative relationships with their practitioners.
The following interventions are often therapeutic in themselves:
The son of a recently deceased diabetic patient thinks he also has diabetes and is greatly relieved by a negative workup for diabetes and a brief explanation of the implications of the result.
A woman with mitral valve prolapse who has adopted unnecessary activity limitations is greatly reassured to learn that her condition is benign and that she may resume valued activities.
A man with panic disorder is relieved to learn how hyperventilation may lead to neurologic symptoms.
A man with an anxiety disorder is helped to recognize that his symptoms are being intensified by an expected job layoff, alleviating his fear that he is “going crazy.”
A woman with major depression is greatly relieved when she is told the diagnosis, the plan to use gradually increasing doses of antidepressants, and the likelihood of significant improvement after a few weeks.
Eliciting and Responding to Feelings
It is critical for health care practitioners to be skillful in the management of emotions. Central to emotional management are a willingness to allow patients to discuss feelings in the office and an ability to listen empathically.
Empathic Listening
Patients are grateful when their practitioners take an obvious interest in what they are saying and the feelings that they are experiencing. Granting the patient time to reflect, remembering details of the history, responding with appropriate affect to situations described by the patient, and indicating what one has observed or heard about the patient's feelings are all actions that demonstrate concern, diminish the isolation that accompanies unexpressed feelings, and enhance the patient's self-esteem. For example,
A man with generalized anxiety disorder feels better after his practitioner listens to his account of his worries, summarized what he heard, and indicates that he understands how distressing the patient's symptoms are.
Legitimizing Feelings
Patients may feel embarrassed, isolated, or overwhelmed by their emotions. Legitimizing or normalizing emotions
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can be a powerful morale-enhancing intervention. For example,
“Most people in your situation have similar reactions. Yours is both normal and completely understandable.”
Encouraging the Expression of Feelings
Patients who have “held in” strong feelings about past or current experiences usually feel better after giving voice to these feelings. The practitioner can encourage a therapeutic expression of feelings by noting that the patient looks tense, angry, or depressed or by commenting that the experience that the patient has just described must have made the patient feel upset.
Problem-Solving
Demonstrating Respect and Facilitating Choice
When counseling a patient, the practitioner should obviously avoid a condescending, patronizing, or overbearing tone. As noted earlier (seeDemoralization), patients usually attempt to resolve their problems on their own before seeking professional help. Furthermore, they may describe themselves as usually able to handle problems. Inquiring about and acknowledging previous efforts, even when they have been unsuccessful, and supporting any voiced characterization of themselves as problem-solvers, can help prepare patients to take on current problems. The fundamental strategies for facilitated problem-solving involve helping the patient recognize assets (e.g., supportive people, enjoyed activities), identify options, and make reasonable choices. It is occasionally necessary to be more directive.
Encouraging Contingency Planning
Patients sometimes cannot see obvious solutions to distressing problems. Once becoming familiar with the pertinent facts, the practitioner may be able to help the patient make plans to deal with anticipated problems. In making contingency plans, it is useful to present hypothetical situations and to have the patient propose potential solutions. For example,
A woman who lives alone is distraught because her only child has hinted that she may not be able to get home for Christmas. The woman's practitioner encourages her to make alternative Christmas plans so that she will not be alone for the holiday if her daughter is in fact unable to come to visit. She telephones later in the week to say that she still does not know whether her daughter will be able to come for Christmas but has invited friends to her home for Christmas dinner, and feels much better.
Advising (Persuading)
The health care practitioner is considered by the patient to be an expert and should be willing to take advantage of that status under appropriate circumstances. Concrete recommendations may be especially helpful to patients whose decision-making ability may be impaired. For example,
A middle-aged man with major depression who is unrealistically dissatisfied with his job performance is tactfully persuaded to defer his decision about early retirement until his mood has improved.
Managing Abnormal Illness Behavior
Abnormal illness behavior is present when the patient's symptoms or impairments, and associated health-care seeking behavior, are disproportionate to detectable disease. Mild forms of such behavior are commonplace in medical practice. In its more chronic, severe and disabling manifestations, abnormal illness behavior forms the core of the somatoform disorders (see Chapter 21), conditions in which patients express emotional distress and psychological conflict in terms of somatic complaints and convictions of serious illness. The following general strategies are useful when psychosocial problems present mainly as abnormal illness behavior.
Redirecting the Patient–Practitioner Interaction to Include Relevant Psychosocial Issues
For patients with abnormal illness behavior, it is helpful to address relevant psychosocial issues, such as functional status, in addition to physical complaints. The following strategies are recommended:
The mood and physical well-being of a woman with long-standing depression (dysthymic disorder) and physical complaints improve after she is encouraged to take a job as a companion and housekeeper for an elderly woman who had a stroke.
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A patient with somatization disorder (see Chapter 21) and an unremarkable recent urinalysis states that she plans to see the urologist who took care of her friend's bladder problem. She is instead persuaded to come for brief weekly visits to her primary practitioner. At the weekly visits, the practitioner addresses briefly the urinary symptoms, but focuses primarily on the patient's efforts to keep her teenage daughter in school. He commends her for her successful handling of these and other domestic problems. Her urinary complaints gradually resolve.
Involving Family and Friends
Family members and close friends are potentially valuable clinical resources. When including family members and others in the care of a patient, it is vital to respect the patient's right to confidentiality. It is important to obtain the patient's permission to speak with others and, when appropriate, to include the patient in meetings with family members (see Table 3.1 in Chapter 3). The following are common interventions that may enhance the usefulness of these meetings.
Meeting the Family's Information Needs
Family and close friends may suffer greatly as a result of their loved one's illness and often have the same informational needs as the patient (see Identifying and Addressing Information Needs section). These needs must be met if they are to understand the needs and feelings of the patient and to participate in providing aftercare. For example,
A 70-year-old man with major depression tells his primary care practitioner that his son will probably call to ask for information. The son calls the practitioner and expresses concern that his father has been angrily criticizing his young grandchildren for petty reasons and that this is not the way he used to treat the children. Furthermore, the son is worried that his father must have an ulcer because he leaves the table rubbing his stomach and shaking his head after eating a few bites. The practitioner empathizes with the patient's son and explains that the behavior change is typical for a depressed man, that the antidepressant medication that has just been started should lead to some improvement within 2 to 3 weeks, that the history and physical examination did not reveal evidence of an ulcer, and that it is likely that his father will recover entirely within 2 to 4 months. The son is relieved and expresses the hope that things will go the way the practitioner predicts.
Enlisting the Family's Help
For some conditions in which the patient demonstrates a failure to make choices favoring improvement, the family may be instrumental in persuading the patient to accept needed treatment. For example,
The family of an alcoholic patient agrees to participate in a family intervention (see Chapter 28) to get the patient to accept alcoholism treatment.
Knowing and Using Community Resources
Support groups, recreational or vocational programs, and home health services are among the community resources that may be helpful to patients. A practitioner's awareness of and enthusiasm for a community resource can greatly influence its impact. For example,
The depressed and anxious wife of an alcoholic man experiences marked improvement in her symptoms after she becomes active in Al-Anon, a resource suggested by her practitioner.
At the suggestion of her practitioner, an elderly woman attends a medical day care program. This resource enables the patient to remain at home with her family and alleviates the patient's resentment toward family members who felt compelled to check on her frequently during the day.
Forms of Counseling
The treatment techniques described earlier in this chapter help at times in the care of all patients. Several forms of planned counseling, each of which integrates a number of these treatment techniques, are helpful in the care of selected patients.
Supportive Therapy
The purpose of supportive therapy is to help a patient cope with both ongoing medical problems and stressful life circumstances. Unlike short-term counseling (see next section), the duration of supportive therapy is open ended, and it is often incorporated into the routine management of a chronic disease.
Example: Supportive Therapy
A practitioner decides that supportive psychotherapy will be helpful in the long-term treatment of a diabetic patient with a history of poor compliance and multiple family problems. The patient is seen once a month for 20 minutes to monitor the patient's diabetes, enhance compliance, and review family problems. The verbal exchange during the visits includes a review of the medical regimen and glucose monitoring, check for new symptoms, brief review of what has occurred in the patient's life since the last visit, elicitation and acknowledgment of feelings, and discussion of ways to cope with existing family problems. In this manner, a significant supportive service is provided in the context of management of the patient's chronic disease.
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Short-Term Counseling
This form of intervention is especially useful in the treatment of the patient who accepts a psychological formulation for symptoms and who wants help in resolving a crisis related to those symptoms. The goals of treatment are to strengthen the patient's emotional defenses and to relieve symptoms without attempting to deal with long-standing intrapsychic conflicts.
It is usually important at the outset of counseling to establish a therapeutic contract, specifying the purpose, length, frequency, and cost (when relevant) of the sessions. These details form the boundaries within which the treatment will take place and may become significant during the course of treatment. Patients may react to the boundaries in terms of transference (see Transference section) by objecting to them or by attempting to change or violate them. Although there are exceptions, the boundaries generally should not be modified, because a change in the relationship between the patient and practitioner may arise as a result of transference. Most mental health professionals feel that the above contractual arrangements are important and should remain stable throughout the course of treatment, to enhance clarity and protect both the patient and provider.
The realities of practice usually require that sessions be brief (15 to 20 minutes) and limited in number (5 to 10). The short-term nature of treatment helps limit the emergence of negative transference and inappropriate dependency. Patients are usually seen individually, although at times, couples and families may be treated together (see Family Counseling). The aim of such short-term treatment is restoration of morale and relief of emotional distress, not personality change. Treatment should focus on problems that are conscious (i.e., readily accessible, not repressed) and current; one should gently divert patients from repeated recitations of past experiences and injuries. The interactive style should be natural and conversational rather than remote and analytical, and it should be tailored to enhance expectant trust (see Demoralization section). When appropriate, one should point out that the patient's emotional state is an understandable and valid reaction to difficult life circumstances, and that it will subside. In most cases, the practitioner's role is to facilitate problem-solving, not to prescribe solutions. To promote problem-solving, one should be prepared to help patients identify their strengths and resources, praise their demonstrations of adaptiveness, and help them explore how they might build on their strengths to solve problems. Patients should be encouraged to try options identified in the sessions by means of homework assignments carried out between sessions.
Throughout the course of short-term counseling, it is important to listen and screen for evidence of a complicating major psychiatric disorder, such as panic disorder, major depression, or alcoholism, because in these conditions, psychotherapy may need to be supplemented by pharmacotherapy or other interventions (see Chapters 22, 24, and 28).
Example: Short-Term Counseling
A 25-year-old woman came for evaluation because of severe leg pain. She had suffered a severe burn injury 1 year before and had experienced leg pain intermittently since then. The practitioner commented that she appeared tired and tense. At this, she became tearful and said that she and her husband had separated and that, although she felt this was for the best, she was extremely anxious and uncertain that she could manage on her own. She had frightened herself during the previous week by thinking that she might be better off dead.
The assessment revealed that she was not suicidal and did not meet criteria for major depression or panic disorder. The practitioner viewed the patient as demoralized and sought to identify the pertinent personal vulnerabilities and environmental stressors. On the basis of a long relationship, the practitioner knew the patient to be a quiet, self-conscious woman who depended on attractiveness as a source of self-esteem. She was also ambitious and hard-working and had enjoyed considerable occupational success. Her major stressor had been the burn injury. She had been spared facial disfigurement but had considerable scarring on her trunk and lower extremities, which she kept covered at all times. Another stressor was the dissolution of her marriage. She regarded this as a positive development, yet she became tearful when discussing it. When the practitioner pointed this out, she revealed that she was apprehensive about dating again. She felt certain that the scarring from her burns would make her unattractive to men and that she would therefore remain alone, unable to remarry and have children.
The practitioner responded that her distress was very understandable in view of the problems she had identified, especially her fears of future loneliness. The practitioner also told her that these fears might be premature and needed to be examined and proposed meeting weekly for five visits, 20 minutes each, to talk about her choices and assumptions. She agreed.
During the next session she complained about her dissolving marriage. After 5 to 10 minutes the practitioner praised her for having stuck with it as long as she had and for managing to hold a demanding job so successfully at the same time. She then spoke of compliments given her by coworkers, one of whom had always paid special attention to her. She was grateful for this now but insisted that no one would take an interest in her if he knew of her injuries. The practitioner asked her how she knew this, reiterated the position that her assumptions warranted exploration, and asked how she might comfortably undertake such an exploration. She considered some options and over the course of several weeks tried several of them, initially simply discussing her injury with others to assess people's responses to the news and finally allowing some friends to see her scarring. The practitioner praised her for her courage as she proceeded with these explorations and
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empathized with her as she dealt with feelings generated by recalling the accident and risking rejection by testing people's responses to her.
By the end of the allotted 5 weeks, she was no longer convinced that the future was hopeless. Although still anxious about the ongoing separation and her potential opportunity to date again, she was no longer feeling overwhelmed and believed herself capable of overcoming her self-consciousness about the injury. The practitioner acknowledged her progress and offered future support.
Family Counseling
The goals of this form of counseling are to facilitate effective communication among family members, bring to their awareness maladaptive patterns of behavior that may be destructive to one or more members of the family, and have family members develop more constructive patterns of behavior. The specific techniques are similar to those used in individual counseling.
Example: Family Counseling
A couple asked their family practitioner for help in dealing with their adolescent daughter, who was continually misbehaving at school and at home. Evaluation of the problem revealed that the parents considered the girl the “black sheep” of the family and had been inconsistent in setting behavioral limits. Counseling for the whole family was recommended. During the first session family members demonstrated their usual conflictual pattern of interaction in the presence of the practitioner: both parents and the other siblings attacked the daughter, blaming her for all of the family's troubles. The practitioner interrupted the attack and proposed that this exchange must resemble what goes on at home, indicated that the situation seemed uncomfortable for all who were present, and ventured that they would probably like to do something about it. After everyone concurred with these points, the practitioner shifted the focus to the development of a contract between the parents and their daughter designed to define the rules they expected her to follow and the consequences of violating the rules. The next session was a review of the parents’ and daughter's adherence to the contract. The parents reported that the daughter broke the contract by misbehaving, but one of the older siblings pointed out that the parents were inconsistent in their enforcement of the rules. This observation helped the family recognize that the girl's behavior was a shared responsibility within the family. Over the remaining sessions, the practitioner continued to encourage the family to establish fair rules to which all could adhere consistently. By focusing on the behavior of the entire family, the pressure on the daughter was relieved, destructive patterns of interacting were interrupted, and more constructive patterns were introduced.
Behavior Modification
The impact of office psychotherapy and the impact of the strategies for managing many medical problems described in this book depend on the elements essential to any change in a patient's behavior: being concerned about one's problem, becoming motivated to make a change, taking action to make a change, and maintaining the change. Chapter 4 describes the conceptual bases for promoting behavior change and skills for facilitating behavior change. Skills and interventions useful for addressing specific conditions are described in most of the chapters of this book.
Efficacy of Psychotherapy
There is good empirical support for the effectiveness of psychotherapy conducted by specially trained clinicians in the treatment of depression among outpatients. Studies of brief psychological treatments, primarily cognitive behavioral and interpersonal therapies, have shown rates of remission comparable to those associated with antidepressant medication in selected outpatients with depressive symptoms of mild to moderate severity (1,2). Moreover, there is evidence that psychotherapy enhances the effectiveness of antidepressant pharmacotherapy when both interventions are provided simultaneously (3). Although there has been little research on the effectiveness of psychotherapy conducted in primary care settings by primary care practitioners, at least one study has demonstrated that teaching primary care physicians communication skills and knowledge related to patients’ psychosocial issues resulted in a change, not only in their communication with patients, but a reduction in their patients’ emotional distress for as long as 6 months (4).
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.