The Role of Psychotherapy in the Treatment of Psychiatric Disorders

by Michael Schwartz, MD

While many of today’s consumers of mental health care tend to associate the practice of psychiatry with the prescription of medication only, this was not true in the past, nor is it true today. Psychotherapy has always been an important aspect of psychiatric practice.

In the first half of the twentieth century, the psychoanalytic model of psychiatric treatment was dominant. Such a model relied heavily upon psychotherapy as a treatment modality. The doctor and patient worked together to better understand significant developmental factors in the patient’s life. The psychoanalyst and patient also worked together to uncover the unconscious mental processes that influenced the patient’s characteristic emotional responses and behaviors in response to the variety of interpersonal or circumstantial challenges he or she was likely to face in everyday life.

Today, psychoanalysis is only one type of psychotherapy. Some of the more well-known kinds of psychotherapy are psychoanalysis, psychodynamic psychotherapy, cognitive-behavioral and behavioral psychotherapies, interpersonal psychotherapy and supportive psychotherapy. A person may be treated individually or as a member of a couple, family or group. Psychotherapy may be quite brief (one session to several weeks or months) or continue for longer periods (one year or longer). An individual may meet with his/her therapist on a weekly basis or several times each week.

The process of psychotherapy is more than just having someone to talk to about one’s problems. Implicit in the term “psychotherapy” is the idea that the therapist will be utilizing specific psychological techniques to help the patient change certain troubling patterns of emotional response or behavior. People often seek psychotherapy because of interpersonal or situational difficulties, but it is known that certain emotional or psychological symptoms can be treated effectively with psychotherapy. At times the efficacy of psychotherapy for treating specific symptoms can equal or surpass that of medication.

Although we encounter a variety of situations on a day-to-day basis, most individuals tend to respond to their internal and external environment in a manner that is both predictable and characteristic for that individual. Behavioral and emotional responses are over-learned through repetition: the good thing about this is that it allows the individual to respond rapidly without having to “think” about their response. The drawback is that it may deprive the individual of a more flexible approach to the variety of events that one must respond to, and if the over-learned behavior is maladaptive, it may lead to pain for both the individual and for those involved with that individual.

Over-learned behavior and the process of changing that behavior can be illustrated by the example of a tennis player who is playing poorly because of the way he or she is gripping the racquet. Once the tennis player gets used to gripping the racquet a certain way, it feels “right” even though the grip may be incorrect and cause the player to perform poorly. Once that grip feels comfortable, learning to change it may be quite difficult and may require several lessons with the pro and a lot of individual practice to change the grip. The same is true with the more complex kinds of behaviors that are addressed in psychotherapy. Even though the behaviors may be the source of discomfort to both patient and significant others, they may feel “right” to the patient and there is often significant resistance to change. Alteration of those over-learned patterns of emotional and behavioral response may require many sessions with the therapist and a lot of individual practice.

There are many kinds of psychotherapy, and there is debate as to whether the specific elements of these therapies are responsible for improvement or whether the “fit” between the patient and therapist is more important for the effectiveness of psychotherapy. Qualities that are important in a psychotherapist are intelligence, open-mindedness, an ability to be empathic as well as sympathetic, good communications skills and a broad-based knowledge of the human condition. Not all therapists are proficient at all kinds of specific psychotherapies, and this may be a consideration in choice of a therapist for some individuals.

Psychotherapy may be combined with psychotropic medications in a manner that produces superior results to the use of either one of these modalities alone. A psychiatrist is most qualified to prescribe such an approach, although the psychiatrist may not offer both kinds of treatment. Some psychiatrists prefer to be both psychotherapist and psychopharmacologist to a patient, whereas others may prefer to refer a patient to another psychiatrist or non-MD psychotherapist who may be more proficient in a certain kind of psychotherapy. From the patient’s perspective, it is important to feel comfortable with the therapist,

and to believe that the therapist has a genuine interest in listening to them, understanding things from their point of view, and helping them to achieve their goals. Therapists who unilaterally attempt to impose their own beliefs or solutions may not be acting in the patient’s best interest.

Dr. Schwartz is the Director of Residency Training and an Associate Professor of Clinical Psychiatry at Stony Brook University School of Medicine.

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