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IS PSYCHOTHERAPY MADE IRRELEVANT BY PSYCHOPHARMACOLOGY?
Stanley E. Greben, M.D., F.R.C.P.(C)
A BRIEF REVIEW OF CHANGING THERAPEUTIC ATTITUDES IN PSYCHIATRY
A century ago the number of specific treatments in psychiatry was very few.
Only in the 1950s did effective antipsychotic and antidepressant medications become
available. North American psychiatric opinion then favored psychoanalytic forms of
treatment as the most potent and rational approach. The chairmen of almost all
departments of psychiatry at that time were psychoanalysts, and biological therapies
were disparaged or even dismissed as interfering with effective psychotherapeutic
work. Today is the converse: psychotherapeutic treatment is regarded as suspect.
I suggest that effective psychiatry cannot result from the growth and elaboration
of any one treatment modality. Human psychiatric disorders have physical, emotional,
cultural, social, psychological and spiritual elements. Therefore treatment can
reasonably be expected to consist of comparable elements, i.e. the judicious combination
of various forms of treatment that have been shown to be effective through both basic
and clinical research (1).
This is not new, but bears repetition and reinforcement, because of two extreme
positions: while psychiatric residency training in North America is strong in both
biological and psychological aspects, residents often complete their training and
immediately subspecialize at only one end of the spectrum.
BASIC CLINICAL PRINCIPLES
I shall outline 14 principles that I consider essential to effective psychiatric
practice. These are inferred not only from my own work but from what patients have
said about their work with other therapists, and what practitioners have reported of
their results.
1.
Psychotherapy is an essential part of the practice of psychiatry. It would not
be excessive to say that it is the backbone of psychiatric work (2).
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2.
There is no evidence that any one form of psychotherapy is generally more
effective than any other. (3).
3.
Psychoanalysis is the most time-intensive form of psychotherapy and has
traditionally involved daily sessions. In my experience, however, many patients
gain as much when seen once a week, or even once a month. Infrequency of
sessions need not imply a lack of therapeutic effect.
4.
Effective psychotherapy of any type demands an active role of the practitioner.
5.
There are three areas for consideration in psychotherapy: the past, the
present and the therapeutic relationship. None of these should be neglected.
6.
The therapeutic relationship has in itself three dimensions. They are: the real
relationship, the therapeutic or working alliance and the transferencecountertransference distortions. Benefit will result from an examination of all
three.
7.
Interpersonal experience in the therapeutic relationship is highly significant.
When therapist and patient discuss what occurs between them considerable
therapeutic gain is achieved.
8.
One of the most powerful effects of helpful individual psychotherapy is the
resurrection of hope and trust. The corrective emotional experience of
finding one person, the therapist, to be honest, concerned, kind, predictable
and responsible is a potent therapeutic tool (4) (5).
9.
It is appropriate for a therapist’s character and values to become well known to
the patient. This need not interfere with the development of transference.
10.
When significant affective states are present in the patient, the use of medications
is called for. Relieving the patient of pain will not render him or her unwilling to
do the psychotherapeutic work. On the contrary, this frees the patient to engage
more successfully in psychotherapy.
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11.
When both psychotherapy and medications are employed, there is no reason that
the same psychiatrist should not provide both.
12.
Whereas not all patients require long-term treatment, there is considerable
practical justification for treating some individuals at length. Keeping a patient
out of hospital effects a very great economic gain in these expensive times.
Forestalling one suicide avoids generations of anguish for many others (6).
13.
A therapist should not keep him- or herself unavailable to the patients. When an
anxious patient can reach a therapist, this has a calming effect. Patients settle
down, flourish and grow when their emotional needs are met(7).
14.
It not only helps the patient to have a therapist willing to combine several forms
of treatment, but is also to the therapist’s advantage. The present trend toward
purely pharmacological solutions could eventually lead to demoralization of the
best of our young physicians.
A CLINICAL ILLUSTRATION
Georgia, now 47, first experienced depression in her early teens. To combat her
feelings of worthlessness she worked hard and eventually undertook a doctoral
program in biochemistry. To her great disappointment she did not complete the
program and soon afterward her chief symptom began, that of hallucinating a highly
critical woman’s voice. It taunted and mocked her and urged her to kill herself.
Sometimes she would cut herself or bang her head against a wall in frenzied frustration.
She also heard screams of anguish that she understood to express her pain and torment.
Her depressions deepened and became chronic, she lost weight, and had difficulty
sleeping. Her self-esteem was continuously low; she felt she had no right to exist, took
up too much space, breathed too much oxygen, and that she was a danger to those
around her.
Georgia’s early history contained both bad and good influences. Her mother
was constantly critical, and always gave her the feeling of being bad and unwanted.
Her maternal grandmother who lived in their home, told her when she was still a very
young child that she was a mistake, and should never have been born. Her older sister,
the only sibling, ignored or was cruel to Georgia. Because of these three women
Georgia feared, disliked and mistrusted all women. As a consequence, she hated being
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a woman and decided not to have children, having no doubt that she would be a
destructive and damaging parent.
On the other hand, her father was an excellent parent who loved, supported and
encouraged her throughout her life. An illustrative memory was of her first day at
school, the same school in which her father taught. She was frightened, and ran out of
her classroom into his, where he was teaching a class. He received her warmly, sat her
on his lap, and continued with the lesson.
When we met, Georgia had had eight hospital admissions for psychiatric
treatment, most of which were of several months’ duration. She received two courses
of ECT, during the first of which she reacted with an extended period of stupor. She
was often confined to seclusion rooms under constant observation, not because of
danger to others, but because of severe suicidal impulses. On one occasion, while
working in the laboratory, she consumed cyanide. Her life was saved only because she
worked at an excellent teaching facility.
Outside the hospital Georgia received excellent care from a psychiatric social
worker, James, and from a series of psychiatrists who prescribed several medications:
high doses of antidepressants, antianxiety and antipsychotic preparations, with antiParkinsonian medication to diminish the side-effects. These reduced, but did not
eliminate her symptoms. James conducted individual psychotherapy which was
interpersonal, supportive and exploratory. In addition he suggested distance running
which Georgia did with much initial reluctance. It was very beneficial, and she still
maintains this activity.
In my work with her I encouraged and supported her, pointing out how
unrealistic her negative feelings toward herself were. I also explored vigorously
whether it was possible to reduce or even eliminate the terrible, harassing symptom of
the tormenting voice. I took her through early events and memories, to try to reduce
the profoundly negative effect of the three destructive women. I underscored the
positive influence of her father. I showed her, that despite her negative views of
women she functioned admirably as a wife to her husband and as a friend, mostly to
men, but also to several women.
I introduced two other forms of treatment that also contributed to her gradual,
steady improvement. I used hypnosis for two reasons: first, to explore more fully her
childhood memories, and second, to help control the symptom of the voice and the
screams.
When she was frantic with the combined pain of depression and
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hallucinations, she could be helped to a moderate degree by the hypnosis, in person or
by telephone, diminishing for a time the severity of the voice and the screams. The
other helpful technique was a form of art therapy. I suggested that it might be calming
for her to resume painting, and helpful information arose out of her work. More
understanding emerged of her feelings of terror, anomie, hatred, despair and desolation
from our viewing and discussing her paintings.
Another therapeutic gain resulted from her giving up laboratory work. While
competent in science, it became apparent that she did not enjoy it. She had not
previously had the strength to contemplate a change. She began to write, something
she had always wanted to do but had feared was beyond her.
The most recent, and highly effective treatment was introduced during a second
very brief (12 day) hospital admission to hospital two years after we had begun our
work together. The hospital psychiatrist wondered whether he could talk with the
voice, and he did so briefly with the patient under hypnosis. The voice emerged as a
mature female personality; an angry, isolated part of Georgia that had been dissociated
to allow her to feel less of a “bad person.” In this personality resided all her rage and
aggressiveness, turned against herself. When I talked to her,the voice was at first
incensed and resentful, but soon touchingly expressed how moved she was that finally
someone would talk to her and that, to her relief, I did not hate her for having harassed
and tortured my patient, and did not want to destroy her.
Subsequently, I talked often with the voice, who informed me that she chose to
be called Lilith. She changed rapidly, from being resentful and vituperative, to being
cooperative, understanding and respectful of Georgia. The patient asked me if she
might have Multiple Personality Disorder, and I said this was probably so, though we
would be careful not to over-elaborate that condition through suggestion in the
treatment. With continued psychotherapy Georgia was more able to be assertive, Lilith
was less angry and lonely, and the patient had less of a feeling of being divided. The
hallucinated voice disappeared and, as a result, the patient was much less depressed
and anxious. As a consequence, she has been able to reduce her medication. At present
Georgia continues to change, to grow and to feel well an increasing portion of the time.
DISCUSSION OF THE TREATMENT
It is not unusual that a long-standing disorder or illness is dealt with by means of
several therapeutic modalities. Each modality makes a partial, yet significant,
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contribution to the patient’s improvement. Presumably, the etiology is multi-faceted:
the patient has an exceptional emotional sensitivity, there is likely some degree of
genetic vulnerability to depressive mood, and the psychosocial stresses on Georgia
were extreme.
The depression and anxiety could be aleviated only with the help of medications,
while psychotherapy was a key to understanding the origins of her problems and to
helping her make changes that would be to her benefit. The first two years of our
psychotherapeutic work allowed her to trust me sufficiently to permit both herself and
me to see the dissociated, hidden part of her. That initiated an integration that has led
to greater self-esteem, decreased depression, reduced suicidal intent, and a burgeoning
of creative energy.
I asked Georgia, when I was preparing this paper, to express her own view of
this treatment. She wrote:
I have been helped by various types of psychiatric therapy. These include
ECT, many medications, hypnosis, art therapy, and individual
psychotherapy. Of all these treatments, individual psychotherapy has
been by far the most powerful in effecting my recovery.
Much has been said about the psychotherapeutic relationship. It is
based on trust and mutual respect, and nothing can be achieved without
it. Within this context, it is the therapist’s discerning acceptance of the
whole patient that provides the most leverage for change and growth.
There was one pivotal session, during my extensive treatment, in which
my concept of myself was changed forever, and my peace of mind
expanded exponentially. In this session, I brought to my doctor the most
contemptible part of myself, and laid it at his feet. My denial of this part
had literally almost killed me: I considered it so terrible, that I would
rather have died than let anyone meet it. Many months of work were
required before I could bring my demon to the office. Even then, I was
almost sure that, when my doctor met with it, he would be repelled. Not
so. The It became a She. My doctor was kind to her, he accepted her, even
found her worthy of respect. This immediately relieved the most
troubling of my symptoms and provided space for rapid and fruitful
changes in my behavior. His nurturing acceptance of my whole self,
could never have been encapsulated, and taken b.i.d. Such things do not
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come in bottles. They are only found within the interaction of two human
beings. I sincerely hope that there is always a place for them in
psychiatry. Within a comprehensive therapeutic arsenal, psychotherapy
will always be a most powerful weapon.
Several weeks later, I asked Lilith if she would write her view of the treatment.
She wrote as follows:
I came into existence through pain and fear. I was made because it
was necessary. I was made out of all those things which were considered
“bad” when we were small. Love was meted out in tiny portions, and life
was very confusing for that little girl. In order to survive it was necessary
for her to put aside all those things which were bad, because she was so
desperate not to lose what little love there was. Those bad things became
me.
At first I was not truly separate, but as time went on, and the
separation worked for her, I crystallized. The barrier between us
hardened so that I was like the inside of an egg, stashed away in the attic
of her soul, dirty and despicable. Then she became afraid that I might get
out, and reveal her naked rage, so she thickened the shell even further. I
was alone and angry, and made of pain, and I had no way out. So I
started to talk to her. I really hated her for rejecting me, and I tried to
make her kill herself, so that I could die. Then her doctor wanted to talk
to me. I did not expect him to tolerate me, because I had tried to kill and
maim his patient, but not only did he accept me, he wanted to understand
me and was sad for my pain. It was incredible. Both she and I
immediately felt better. The relief was tremendous. As the barrier
between us became more porous, sometimes she would have to deal with
bouts of unspeakable anger. It was hard for her but she endured it, and
slowly we are coming together. She now has access to some of my
strength, and she does not let herself be walked on as she did before. It is
very satisfying for me to see that.
Recently, Georgia wrote this further follow-up:
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Since this paper was first written, Lilith and Georgia have formed
an alliance. They are integrated for much of the time now, and in this
passage, the pronoun ‘I’ shall indicate the composite whole.
Strange and new things have been happening as a result of this
alliance. I am not as intimidated as before. Many people respond to me in
more positive and receptive ways. This still surprises me. I do not think
these things would happen if Lilith were not now intimately involved in
my life.
Occasionally, I disintegrate. I can feel it happen, usually in
response to stress. Then the old feelings of guilt and worthlessness return,
and Lilith is gone. Even then, Georgia can still consult her. Lilith is very
realistic about the world and its people, and is not dismayed by it. If
Georgia does as Lilith suggests, it can mean that she, Georgia, responds to
the circumstance in less self-destructive ways than before. This allows us
to re-integrate sooner, and I reappear, whole and strong.
We all live only, in our minds - it is all the space we have. If that
space is a howling desert, filled with demons, and the harsh winds of
guilt, then life seems like a cruel joke. I am so very grateful that my space
is no longer a desert, but a garden - admittedly rather unkempt, but
capable of growth.
SUMMARY AND CONCLUSIONS
Psychiatrists and other health professionals today are fortunate to be practicing
when so many therapeutic tools are available. However, these should not be seen as
competitively exclusive but rather as mutually supportive.
In Georgia’s case each
therapeutic modality was effective to some degree. This is my basic thesis: that all
treatments have their own merits and limitations, but that psychotherapy has a unique
potential.
Teachers of psychiatry, as well as teachers of other medical specialties have the
responsibility to guide their students toward eclectic rather than only to narrowly
focused diagnostic and therapeutic modalities. Students should be encouraged to learn
more about more, not more about less. In this way those who follow us will reap the
rewards of more fulfilling careers, and their patients will benefit from more effective
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help.
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REFERENCES
1.
Greben, S.E. Psychotherapy and psychopharmacology: A positive combination
therapy. Keynote address. Annual Saskatchewan Psychiatric Association
Continuing Education Conference. Regina, April 24, 1992.
2.
Greben, S.E. The role of psychotherapy within psychiatry. Canadian Psychiatric
Association Bulletin 1992; 24:12-13.
3.
Greben, S.E. Psychotherapy today: Further consideration of the essence of
psychotherapy. The British Journal of Psychiatry 1987; 151:283-287.
4.
Frank, J.D. The role of hope in psychotherapy.
Psychiatry 1968; 5:383-395.
5.
Greben, S.E. The re-establishment of trust through psychotherapy. Canadian
Journal of Psychiatry 1984; 29:350-354.
6.
Malan, D.H. A Study of Brief Psychotherapy. London: Tavistock Publications,
International Journal of
1963.
7.
Greben, S.E. Unresponsiveness, the demon artifact of psychotherapy. American
Journal of Psychotherapy 1981; 35:244-250.