Psychotherapy and the term “psychotherapy” will also

include “counseling”, unless one of

Counseling in Medical
their few differences is being
Practice emphasized. These differences
include longer duration and more
Digby Tanta
discussion of their relationship
Psychotherapy is a somewhat between therapist and patient in
indefinite term. It will be used here psychotherapy.
to refer to a psychological treatment
Indication and contraindications
in which the relationship between the
patient and the therapist is crucial to Psychological treatment is most
the success. Counseling, a term used effective when mood disorder is a
increasingly in medical and prominent symptom. It is, therefore,
paramedical work, is defined often indicated in anxiety states,
similarly to psychotherapy. There are other neuroses in which anxiety is a
three elements: principal feature, and persistent or
recurrent depression. Psychotherapy
 Providing help and support and
is not directly effective for the
an understanding listener for
treatment oh psychoses, of organic
someone who is concerned and
brain syndromes or of physical
perplexed
 Creating a climate so that the disorder, but may be indicated for the

client feels accepted, non- relief of secondary depression or

defensive and able to talk freely anxiety in physically ill people.

about himself and his feelings Psychotherapy, like most other

 Helping the client to gain clearer
psychological treatment, requires the
insight into himself and his
patient to attend in the treatment
situation so that he is better able
sessions, to remember them, and to
to help himself and draw on his
cooperate sufficiently with the
resources.
therapist. Psychotherapy is
In practice, there is considerable contraindicated when the patient is in
overlap between psychotherapy and intoxicated or so depressed, anxious
counseling and in this contribution or demented that attention and
memory are seriously impaired.
Other patient who are not suitable for
psychotherapy include patients who
do not enter voluntary into treatment,
patients who do so without any trust
in the therapist, and patients who are
convinced that their problem is not a
psychological one.
Training
The importance of the relationship
between therapist and patient in
psychotherapy and therefore of the
personality of the therapist. The
psychotherapist attempts to harness
the empathy force of the human
relationship, and to use it in the
treatment. Usually this involves
going beyond science in practical
knowledge based on anecdote.
Counseling skills can be taught by
broken down into components,
which may be taught every time, as
in the “micro training” approaches of
Ivey. More basic skills, taught first,
are subsumed by later, more complex
skills in a hierarchical fashion.
The skills of psychotherapy
Attending behavior: not only must
doctors assiduously attend to their
patients and their symptoms, they
must be seen to attend if the patient
is to feel understood, and thus
helped. Crucial behaviors indicative
of attentive and understanding
listening are:
 Culturally appropriate non-verbal
indications of careful listening;
for example, in Anglo-Saxon
culture, gazing at the another
person for much of the time that
theory are speaking, friendly tone
of voice, comfortable seating
distance, nods and other
responses to what the other
person is saying, a tolerance of
silence, and a relaxed but alit
posture
 Linking comments or questions
to what the patient has said
 Paraphrasing what has been said.
A fourth skill – appropriate use of
open and closed questions – is
considered later, as one of the
problem solving skills.
Responding to feeling: only about
50% of patients with significant
psychiatric symptoms are diagnosed
as having a psychiatric disorder
following a consultation with a
family practitioner, mainly because
many patients conceal psychological
symptoms and present only somatic
ones, unless they receive a positive
indication from the doctor that is
acceptable to talk about feelings.
One of the most important is the
doctor’s sensitivity to non-verbal
expressions of feeling, and to the
patient’s choice of words.
Patients who regularly consult a
doctor learn whether or not their
feelings are acceptable to him or her
and it seems likely that the doctor’s
ability to accept the patient’s feeling
without being impelled to act on
them is also a factor that influences
whether or not the patient expresses
them.
Problem – solving skills:
combination of good attending
behavior and appropriate response to
feeling are the basis of the empathy
or unconditional positive regard
which is considered to be the
effective elements in
counseling situations. However,
other skills are required
supplement them when information
needs to be obtained
communicated, as is generally the
case in medical practice.
Research suggests that patient
satisfaction and adherence to
treatment are increased when patient
and doctor have collaborative
relationship. Declaring the structure
of the interview at the beginning is
one of the skills that facilitate this.
The aim is to ensure that the patient
knows the doctor’s name, the names
and status of any witnesses, how
long the interview is likely to last,
and what information is likely to be
of interest to the doctor. Another skill
is problem definition; using open
questions to obtain the patient’s own
panoramic view of the difficulties
before narrowing down with closed
questions as more and more precise
the hypotheses about the diagnosis or the
etiology are tested. This hypothesis
must then be communicated in an
understandable way to the patient
and modified until agreement is
reached.
many
Asking the patient – “what were you
expecting me to do for you?” – can,
to
if not pose in a challenging spirit,
help the patient to able to structure
or
the interview them selves. The
combination of the formulation of
the problem and the patient’s request
is likely to generate several possible
solutions and each of these needs to conflict. According to the analytic
be explored with the patient if the account, feeling stuck, inadequate or
patient is to be a collaborator in the hopeless most commonly arises
treatment. Finally, the practical when there is, on the one hand, a
difficulties that the patient may have wish and on the other hand, a fear,
in applying the chosen solution need which so balance each other that no
consideration. definite action can be taken or choice
made.
Restoration of competence: most
interviews had to successful Occasionally, a person’s symptoms
negotiation. Such situations call for a are so inextricably tied up with the
further set of skills to supplement type of relationships that he forms
those previously considered. that one cannot be treated without
the other. This is considered in
Hopelessness is the element of
“long-term psychotherapy”, below.
depression that is most closely linked
to suicide. Helplessness – the fear of It has been argued that any
fear itself – is the feature that for psychotherapeutic stratagem for
many patients contributes more to an increasing competence is likely to be
anxiety state than anything else. Both equally effective, given that is
of these experiences are associated practiced with equal conviction and
with a loss of confidence in the skill, and has equal palatability to the
effective, coping self. The restoration patient, as long as it has these
of competence is therefore a key features:
element in all psychotherapy.
 An emotionally charged
Competence may be restored by a confiding relationship with a
prescribed behavior, by encouraging helpful person
positive thinking and combating self  A healing setting
 A rationale, conceptual scheme
defeating thoughts, by arousing and
or myth
discharging feeling, by the  A ritual
therapeutic alteration of social status,
Case history – restoring
or by recasting the problem as the
competence
expression of the motivational
 A 20-year-old university student past. The skills involved are
is desperate to do well in her final described in a later section on ‘focal
examinations, and studies for up to psychotherapy’
10 haours a day; she is beginning to
Management of relationship :
have memory problems, and to be
restoration of competence may be
irrationally afraid of going to the
achievable by uncovering the
library. In the past, similar feelings
conflict, or by treating the
have worsened progressively until
depression. More complex
she has an outburst of violence.
intervention requires training and
This student has a experience that most non-
motivational conflict between her psychiatrists will not have, and may
wish to succeed and her fear that indicate referral to a psychotherapist
however much work she does , she or trained counselor for the special
will not achieve that she wants. The skills required.
first step in restoring her confidence
The most common obstacle
is to translate her symptoms,
to recovery occurs when the patient’s
including the apparently involuntary
close relationship are bound up with
outbursts which have previously led
their motivational difficulties.
to queries about epilepsy, into
motivational terms. A variety of next The skills required to deal
steps are available which are with this situation are less explicitly
discussed more fully in the following defined than the other psychotherapy
section on ‘directive psychotherapy’. skills considered in this contribution.
In particular, the therapist must
Motivational cries may be
possess a sufficiently well-developed
recurrent, and competence in the
sense of personal autonomy to be
present predicament may be further
able to resist the imposition of a false
undermined by the memory of
relationship by the patient )described
previous incapacitating of similar
by Freud-influenced therapists as the
type. Restoration of competence in
‘transference’ of a relationship on to
these case generally requires not only
the therapist) without rejecting the
the unraveling of the present and the
patient.
 In the case example, below,
there is a constant temptation for the
therapist either to take a censorious
or belittling role, or to slip into trying
to compensate for the patient’s
earlier rejection by making him into
a special patient. In this case, rivalry
engendered by the temptation to cut
him down to the size and the
therapist’s own fear of humiliating
failure is only too easy to assuage by
making the patient special.
The skills required to deal
with ‘counter-transference’ problems
(emotional counter-reaction to the
emotional demands made by the
patient) are not well characterized
and the only recommendation that
can be made to the trainee
psychotherapist in this area is to have
some personal experience as a
patient, and to obtain some external
reference point either through
supervision with an experienced
practitioner or by going through
recording of treatment session after
they have occurred.
Case history – management of
relationship
Roberto came from a family
with a critical father and an over
involved mother who ha moved to
the UK from Europe. At school in
the UK, he had feel different from
the other children and not accepted
by them. He was overweight In his
early teens and shy in his dealings
with girls. His parents did not accept
his growing sexuality and he felt let
down that his mother did not
understand or help him with his
sexual insecurity and his father
seems like want him to be
independent
He was referred because of
his hallucination. He would look at
his girlfriend and see her appearance
change to one that he found
repulsive. This led him to insist that
she had her hair styled in a particular
way, and that she wore only certain
clothes. He would either become
furious with her if she refused or
would refuse to take her out.
He established a critical and
demanding relationship with the
therapist from the beginning of
treatment. He would be cross if there
were any alternations to the
arrangements, and regularly asked
the therapist to justify why he should
be coming to see him, on one
occasion saying that he was not
intending to come again unless the
therapist could explain why he was
having his ‘hallucinations’ more
convincingly than he had so far done.
He was also sensitive to anything
that he might interpret as a rebuff,
and usually ended the session by
looking at the clock with a sigh and
asking how he was going to get
through the next week. At first, he
gave graphic accounts of his sexual
exploits, which had included many
casual affairs as well as considerable
amount of autoeroticism, sometimes
involving the use of pornography or
visual images of girls that he had
seen and sometimes followed.
As the treatment progressed,
he began to talk about his constant
fear of being ridiculed which was so
intense that he would break off a
relationship, rather than ran the risk
of it. He began to see that his sexual
imaginings were a refuge from a
‘real’ world which often disappointed
him, and that his demands on his
girlfriend that she dress or look the
same as his imagined girls, became
more intense when she said let him
down in some way. He talked on his
‘hate’ for her and for his therapist,
and of his disappointment whit his
therapist for his inadequate attempts
to help him.
Structure and goal
The application of psychotherapy
skills is affected by how much
structure the therapist impose, and by
the therapist’s goals. If the structure
of the interview closely follows the
patient’s stream of consciousness or
free associations, the treatment will
range widely and will fallow
negative as well as positive feelings
to develop towards the therapist. This
is appropriate when the goal is to
change the patient’s style of personal
relationship, but not when the goal is
to acquire information with a view to
laying bare an emotional conflict, as
a step to the restoration of the
patient’s confidence and self-esteem.
Determining the predicament which
has rendered the patient helpless
requires a mixture of information
gathering and free association by the
patient, and therefore an intermediate
level of structure.
Directive psychotherapy
Directive psychotherapy is
directed towards symptom removal.
It is the simplest kind of Highly structured, with an
psychotherapy and usually involves a emphasis on the identification and
specific treatment procedure, such as expression of feelings (catharsis)
behavior therapy, cognitive therapy,
Restoration of competence
or interpretative therapy. Directive
psychotherapy works partly because Therapeutic activities are
the patient invests the prescribed to the patient which
psychotherapist’s advice or reinforce the patient’s coping
encouragement with special abilities and also provide a
significance, and the memory of the justification for change. Often, this
special interest or help obtained from involves translation of the symptoms
the doctor can be successfully set into expression of personal meaning
against the factors that are working of the symptoms.
against recovery. Listening to and
Management of relationship
understanding the patient, being an
authority, having a name for the The doctor accept the patient’s
problem, having a special technique view of him or her as an authority,
and having status all enter into the but uses this authority to succor and
process too. Response, if it occurs, is empower the patient. The progress of
always rapid; in fact, faith-healing, the treatment is reviewed when the
hypnosis, witch-doctor- planned number of meetings has
been reached, or when the
Skills of directive
prearranged goals of treatment have
psychotherapy
been achieved. Treatment can cease
Formulating the problem if the patient is confident that his or
her efforts have secured the
The therapist hears a detailed
improvement. If this is not the case,
account of the symptoms and
other treatments, including longer-
demonstrates to the patient that he is
term psychotherapy, may need to be
understood and that the treatment is
discussed.
at hand.

Interviewing
 In and other ‘magical’ practice which they originated to the
may will be variants of directive relationship with the doctor, and to
psychotherapy. the treatment situation.
Psychoanalysis are generally
Patient must be able to trust
suspicious of the result of directive
and depend on the doctor. The
psychotherapy, perhaps as a result of
therapist is wise to accept and even
these early failures. Two arguments
to heighten this dependence (this is
often put forward against directive
the only form of psychotherapy in
psychotherapy are that it only
which this is justified) to produce a
suppresses unresolved conflicts, so
stronger therapeutic response.
that symptoms consequently re-
Termination of treatment will,
emerge in a different guise, and the
however, lead to relapse unless the
patient does not truly recover, but
dependence has lessened by that
experience a transient improvement
time. This often occurs naturally, but
(the ‘transference cure’ or ‘flight into
may require deliberate steps by the
health’) which is sustained only as
doctor to foster the patient’s
long as the relationship with the
autonomy.
therapist is maintained. However,
Complications although these phenomena may
occur in particular patients, research
Sometimes, there are hitches in
suggests that they are the exceptions
directive psychotherapy. Either the
rather than the majority.
patient cannot abandon the
symptoms, or cannot trust and Predicaments
respect the doctor, or cannot give up
Symptoms re-emergence or
the relationship with the doctor once
relapse might occur because the
it has formed. The latter problem was
patient has other pressing difficulties
the one that confronted Freud and
(‘predicaments’) which the treatment
Breuer in their early experiments
has not addressed, or because the
with hypnosis, and led Freud to
patient’s difficulties are part of more
propose that feelings and wishes
pervasive difficulties in making
could be transferred from the
satisfactory relationship.
relationship and social situation in
 Predicaments are a little devil” by her family. this was
consequence of current social and
personal difficulties and being in a
predicament does not necessarily
imply long-standing disorder – a
difficulty in making satisfying
relationship, in contrast, does.
Predicaments are treated by focal
psychotherapy.
Case history- directive
psychotherapy
A 45-year-old married woman who
worked as a secretary was referred
with a 20-year history of binge-
eating followed by vomiting. She
seldom ate with her husband and son,
but the extent of her problem was
concealed from them. She was about
the normal weight for her age and
height. A careful psychiatric history
was taken, she was weighed, given
advice about the importance of
regular and normal meals, and was
asked to keep a diary of her diet,
feelings and episodes of vomiting. At
the next follow-up visit she said that
she was eating normally, and had not
vomited. She was feeling certain that
she could stop herself bringing again.
she suggested that her unusual eating
was the result of being trained “like a
credible to the doctor who thought of
her weight restriction as fulfilling the
family’s expectations.
focal psychotherapy
is the psychotherapy of patient in
predicament, it involves identifying
the factor within a situation and
assisting the patient to overcome
them. the psychotherapy of
predicament therefore takes longer
than directive psychotherapy, and the
primary activity of the therapist is to
negotiate rather than to direct
interviewing
moderately structured ; the patient
must not only feel free to talk about
symptoms, but also about his
personal circumstances. the focus is
on conflicting feelings, the interview
may extend over several sessions,
with more than one cycle of
assessment and treatment.
deciding who is involved
the therapist must decide whether
other people should be include in the
treatment
restoring competence
steps toward solving the predicament
are prescribed to the patient between
sessions, in the early session these
steps may be rehearsed using roles
olay if necessary.the feelings
engended in the patient by these
steps are discussed and interpreted
when they become obstacles to
problem solving
Management od relationships
the relationship is a collaborate one,
here is agreement about the length
and forms of treatment and both
doctor and the patient may take the
initiative in raising topics.
doctor’s opinions are put
hypothesis, to be discussed and
tested. the implicit assumption is that
both doctor and the patient are
working wholeheartedly to overcome
th predicament. if this is not the case,
then long term therapy may be
indicated.
case history-
pscychotheraphy
a 30 years old man who worked as a
doctor moved from an administration
job in community medicine into
family practice. and then he tired, at
first this was thought
psychosomatic, but after a high
calcium level was found on routine
screen, sarcoidosis was diagnosed.
he was treated with high dose of
corticosteroids and responded well.
and he gained weight , lost his libido,
and began to think that he was as
failure with at work and in his close
relationship and confided to his
practitioner that he had begun to
think that his life was too painful to
continue.
when he first saw the psychiatrist, his
corticosteroid had been consideraby
reduced and he was physically
the healthy. since his concentration and
as memory were both poor and he was
waking early morning, and there are
symptom of depression and anti
depressant was suggested , but
rejected by the patient.
a second d assessment interview was
arranged which his wife could
attend, she gave an even stronger
account of a depressive illness
focal developing over several months. he
was persuaded take the anti
depressant. he took two anti
depressant tablets only, but did
cooperate fully with role play of a
constructive confrontation with hi
to partner about the appointment id a
new receptionist and also agreed to decided upon at the next clinic, and
undertake tasks which would give the patient’s depression lifted.
him satisfaction. the psychiatrist was
also late for the following meeting, Long term psychotherapy
but the patient reported some on review of a patient’s history it
progress n that he had put up some sometimes becomes apparent that the
shelves and had tackled his partner. same predicament has recurred over
the psychiatrist thought that his and over again. alternatively, there
own lateness was unusual, and may be no predicament: the patient
perhaps reflected something in the complains instead that some recent
relationship with the patient. he circumstance has disclosed a ling
therefore raised it was no more than stating difficulty in making
could be expected from a busy satisfactory persona relationships,. it
colleague. the conversation then might also happen that shorter term
turned to the consultant who looked psychotherapy gets clogged with
after the patient’s sarcoidosis, whom persistent misunderstandings
the patient quite unexpectedly between patient and the therapist,
denounced for treating him like a and alerts the therapist to the
child, and in particular for failing to distortions that occurs in any close
answer any questions about the relationship that the patient attemots
duration of the corticosteroid to make. relationship difficulties of
treatment. it was soon apparent that this the may be sufficiently severe to
this issue was of considerable justify a diagnosis of a personality
importance to the patient. he detested disorders of some kind, but even the
his passivity, but felt forced into it,. milder subclinical disorders of
after a brief discussion, then patient personality can produce chronic or
decided to insist that he was given a recurrent mood disorders, social
time table for corticosteroid isolation and underachievement.
withdrawal, and the psychiatrist long term psychotherapy offers
wrote letter also requesting this. as it invaluable opportunities to observe
turned out, a timetable was easily how relationships problems are
expressed within the doctor-patient
relationship, and how the doctor’s long term psychotherapy
attitude to the patient can break
through the patient’s customary way problem solving skills
of relating to the others, making less structure and less explicit
room for new and more satisfying attention to problem than for other
patterns. most trainers would forms of therapy, through the rhythm
consider therefore, that experiences of listening followed vy paraphrasing
of long term is a prerequisite for all is broadly followed. attention skills
types of psychotherapy practice,. the and response to feelings are
whole aim of th along term therapist especially important, but may be
is to maintain a working relationship difficult because of string negative
with the patient. this simple goal can feelings by patient.
be extremely hard to achieve.
patients in long term therapy are restoring competence
there because they have not optimal levels of hopefulness, faith
succeeded in previous relationship in the therapist and security need ti
and will bring the same conflicts, be maintained. may involve
longings and frustration into their reduction of anxiety and restoration
relationship with the therapist that of competence by, fir example,
have drained the satisfaction from interpretation or increase in anxiety
previous ones. and challenge to competence by
the relationship between doctor and confrontation or other types of
patient is of a different kind from interpretation
that in shorter therapies. there is a
deliberate lack of imposed structure. The difficult patient
the therurapetic medium is the the relationship between doctor and
conversation or discourse led by the patient is nowhere more important
patient, during which the patient than in the treatment of those very
seeks to impose a particular account disturbed patients whose self
of themselves, the doctor and how destructiveness or other
things are generally. destructiveness provokes constant
anxiety. many of the reported case
strong suggest, however, that the
patients concerned would not have
survived without the of a psychiatrist
over a long period