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Psychotherapy

Mental disorders, like many other medical illnesses, are not uncommon. In any given year, one out of five adult Americans experiences a mental illness or emotional problem severe enough to require treatment. These disorders impair how people feel, think and act, and interfere with their effectiveness at work and school and their relationships with friends and family.

Mental illness does not discriminate. It affects men, women, and children of all ages, races and economic positions.

An individual with mental illness may feel overwhelmed, numbed, or frightened by unwanted emotions or experiences. Relentless feelings of sadness, overpowering anxiety or loneliness, loss of a job, divorce, death of a loved one, abuse of alcohol or drugs-all are reasons to seek help from a psychiatrist.

Psychiatrists treat mental illnesses with psychotherapy and medication. Psychotherapy, or "talk therapy," is an effective and commonly prescribed method of treatment for mild to moderate cases of emotional and mental disorders. In more severe cases, psychotherapy is used in combination with medication. Research shows that most patients who receive psychotherapy experience improvement.

Sadly, too many people with emotional problems do not seek diagnosis and treatment. Their reasons include not recognizing their symptoms as a sign of illness, being embarrassed or fearful that "someone will find out" and that there will be negative consequences at school, work or home, and having inadequate health insurance coverage. If someone you know has emotional or mental problems, advise him or her to seek help from a psychiatrist or other physician. Once a mental disorder is properly diagnosed, psychotherapy can enable patients to function more effectively and comfortably.

What Is Psychotherapy? 

Psychotherapy is a process of discovery whose medical goal is to eliminate or control troubling and painful symptoms so that the patient can return to normal functioning. It also can be used to help a person overcome a specific problem or to stimulate overall emotional growth and healing. In regularly scheduled sessions — usually 45-50 minutes in length — a patient works with a psychiatrist or other therapist to identify, learn to manage, and, ultimately, overcome emotional and mental problems. Discussions between patient and psychotherapist reveal the basis of problems and enable the patient to better understand him- or herself and gain relief from specific issues. Psychotherapy is an active process requiring concentration, energy and commitment by both parties. Many patients complete psychotherapy in 16 or fewer sessions, especially for behavior-specific problems. Individual psychotherapy takes place in the privacy of the doctor-patient relationship. Psychotherapy also may be conducted in the context of group, marital or family treatment.

Although the majority of people who undertake psychotherapy experience significant improvement, there is nothing magical about psychotherapy. It is not a procedure done by a therapist to a patient; rather, it is a process between a therapist and a patient in which the two work together.

Psychotherapy is initiated after an individual has had a thorough medical and psychological evaluation by a psychiatrist or other physician and has received an initial diagnosis. The psychiatrist will review the patient's medical records — or, if these are not available, will take a medical history and conduct a physical examination to identify any medical conditions that might be affecting the individual's mental and emotional functioning. Emotional disorders can be caused by neurological or hormonal problems, can be related to chronic illnesses such as heart disease, or can represent the unwanted side effects of certain medications. As is done with all illnesses, the psychiatrist will interview the patient, asking for details about symptoms — their severity and duration — and obtaining a personal and family history. After all of this information has been collected and analyzed, a diagnosis is made. In many cases, psychotherapy will then be prescribed.

Many kinds of emotional and mental problems can be helped with psychotherapy: mood disorders (depression, bipolar disorder [also known as manic depression]), anxiety disorders (phobias, panic disorders, obsessive compulsive disorder, posttraumatic stress disorder), eating disorders (anorexia nervosa, bulimia, obesity), problems associated with abuse of alcohol or drugs; problems related to life circumstances and events, such as loss and grief, marital difficulties, abuse or traumatic events, or dealing with aging parents or adolescent children; mental and emotional problems related to nonpsychiatric medical illness; sexual disorders; sleep disorders; difficulties in developing intimate relationships; disorders involving disruptions in the functions of consciousness, identity and memory (dissociative disorders); personality disorders; problems with functioning at work. In the case of severe mental illness such as schizophrenia and other psychotic disorders, psychotherapy is frequently used to help patients understand and manage their illness. Armed with this understanding, the patient is more likely to remain in treatment and thus to avoid relapse.

Types of Psychotherapy 

Several types of psychotherapy are available, and — apart from a few exceptions for specific conditions — no one type is "better" than any other. As with other medical situations, the psychiatrist's choice of therapies depends on the patient's particular illness and circumstances. Some types of psychotherapy concentrate on the here and now; others focus on past experiences to achieve insight into how problems arose and how they can be overcome in the present.

In determining which therapy or therapies are likely to be most effective for a given patient, a psychotherapist will take into account the nature of the problem being treated and the patient's personality, cultural background and experiences. A therapist may use one type of therapy to treat specific kinds of problems — for example, an individual with an unreasonable fear of water is likely to respond best to behavioral therapy. For other types of problems, a therapist might use techniques derived from several types of psychotherapy to treat the patient's illness.

The most frequently prescribed psychotherapies are psychodynamic, interpersonal, cognitive and behavioral.

  • Psychodynamic therapy is used in treatment to help patients understand themselves more fully. This approach may involve uncovering — and learning to deal more effectively with — unconscious conflicts. It may also involve assisting patients to understand how certain types of adverse childhood experiences have left them feeling incomplete, anxious or plagued with low self-esteem that interferes with realistic adult functioning. This form of therapy is based on the premise that our mental well-being is influenced by unconscious conflicts, significant childhood experiences, and painful feelings that are hidden behind a variety of defense mechanisms.
  • Interpersonal therapy is designed to improve the quality of the patient's interpersonal world. The therapist helps the patient to understand the underlying interpersonal themes that appear to be involved in the onset and maintenance of the illness. Common themes include unresolved grief, transitions from one social or occupational role to another, conflict between the patient and significant individuals in his or her life, and deficiencies in the capacity to relate to others.
  • Cognitive therapy is employed in treatment to help patients recognize and change thinking patterns that are harmful or ineffective.
  • Behavioral therapy is used to address a patient's specific behaviors, substituting positive behaviors for harmful or inappropriate ones.

Each of these types of therapy may be conducted by a psychiatrist in an individual, family, couples or group setting. Self-help groups also are available to patients and to family members; such groups can supplement — but should not be considered a substitute for — psychotherapy.

Medication 

Medication is often used in conjunction with psychotherapy, and in many disorders the combined treatment is better than either alone. Both psychotherapy and medication appear to act by altering brain functioning. With severe disorders, various forms of psychotherapy can help the patient to remain on medication and follow other elements of the treatment plan.

Who Provides Psychotherapy? 

Psychiatrists, psychologists, clinical social workers, family and marriage counselors, and other mental health professionals are trained and licensed to provide psychotherapy. Highly skilled and effective therapists may be found in each discipline. However, psychiatrists are medical doctors with specialized training in the diagnosis and treatment of mental and emotional disorders. Only psychiatrists, as physicians, are medically trained to perform and analyze medical diagnostic tests, to evaluate the physical symptoms of mental illness, and to take into account any other medical illness occurring concurrently with the mental disorder. Psychiatrists and other medical doctors may prescribe medication. Child psychiatrists specialize in working with children and adolescents; geriatric psychiatrists work with older people.

Choosing a Psychotherapist 

For prospective patients, finding a psychiatrist with whom they can work well is important. Good sources for referrals include one's family physician, local psychiatric societies, medical schools and community mental health centers. Friends and family members, too, may be able to provide names of therapists about whom they have heard or with whom they have worked successfully. As is true when selecting other physicians — for example, a pediatrician or internist — it is appropriate to speak with several candidates. When choosing a psychotherapist, prospective patients should assess their comfort level with the therapist — can they feel relatively at ease sharing intimate, personal feelings, thoughts, and experiences with this person? Also important is the therapist's education and training: the more, the better.

When choosing a psychiatrist, patients need to understand the terms and restrictions of their health care plan. Many managed health care plans and fee-for-service insurance plans limit patients' choice. Some plans restrict members' choice to "inside the network" or plan psychiatrists and require that patients first be evaluated by a "gatekeeper" — a family doctor, or a social worker or other nonphysician plan representative — to determine whether specialist care is needed. Other plans permit patients to choose a psychiatrist outside the plan's network but may require patients to pay a larger portion of the cost. Patients limited to selecting an inside-the-network psychiatrist should seek recommendations from their primary care physician.

Many insurance plans pay a certain percentage — often 50% — of a therapist's fee, up to a stated maximum; limit the number of visits covered; and have an annual or lifetime cap on the amount paid. Managed care companies often limit the number of psychotherapy sessions a patient may attend (e.g., 5 to 20 per year) and place restrictions on the type of therapist a patient may see. Individuals considering therapy should be aware that a new federal law requires employers who offer mental health benefits and who have 51 or more employees to provide the same financial coverage for mental health problems — within the same annual and lifetime limits — as for other medical disorders.

When selecting a health care plan, it is important that consumers clearly understand the mental health benefits and coverage provided. In addition to considering the size and quality of the plan's "panel of providers," questions to ask include whether the plan provides equal coverage for mental and physical disorders, how many therapy sessions are covered, how much copayment is required per visit, whether members can consult a psychiatrist without first being seen by a general-care "gatekeeper," whether the plan covers sessions with a psychiatrist who is outside the plan's network, and whether the plan protects confidential information. Patients' mental health needs are best met when they have easy access to a psychiatrist who is either the provider of treatment or an intrinsic part of the treatment team.

Working Effectively With a Psychotherapist 

The relationship between patient and therapist is a unique partnership. Psychotherapy can be successful only when both partners are dedicated to achieving the agreed-upon goal. Important to this partnership is mutual trust, respect and confidentiality. Confidentiality is a basic requirement of psychotherapy and is emphasized in the code of ethics of the American Psychiatric Association and other professional mental health organizations. Patients need to know that insurance companies and managed care firms may ask for reports from a psychotherapist to determine whether to continue to provide reimbursement. Some patients prefer to pay for psychotherapy from their own resources to avoid this violation of confidentiality.

Both patient and therapist have clear responsibilities. The patient must be candid and honest, willing to reveal sometimes uncomfortable feelings and thoughts, to address problems, to be open to new insights, and sometimes to carry out prescribed "homework" activities. The therapist must listen carefully; clarify, interpret and point out associations that may not be obvious; and guide the patient to recognize and, where indicated, modify patterns of behavior. Because the patient and the therapist are full partners in the psychotherapy process, both participate in making treatment decisions, including the decision to end therapy.

The patient-therapist partnership is truly special, but it is not a friendship or a business relationship; the therapist does not socialize or conduct business with the patient. Although the patient is likely to share very personal feelings and thoughts, under no circumstances is intimate contact — most especially sexual relations — between a patient and a therapist appropriate, acceptable or useful.

How Long Does Psychotherapy Take? 

The amount of time a patient spends in therapy depends on several factors, the most important being the nature of the illness or problem being treated and, for many patients, the coverage terms and restrictions of the health care delivery system. Depending on the mental illness and the type of therapy selected by the therapist and the patient, psychotherapy can require a few sessions or can take much longer. Generally speaking, the more severe or complicated the mental disorder, the longer amount of time needed to complete psychotherapy. Short-term therapy (16 or fewer sessions) is often prescribed for relief of specific symptoms.

Depending on the patient's problem and the type of psychotherapy used, the process can sometimes be time-consuming and expensive. However, several studies have demonstrated that psychotherapy is ultimately cost-effective for patients, their families and society. The benefits of undergoing treatment include decreased visits to other doctors' offices, diagnostic laboratories, radiology departments and hospitals for physical ailments that are based in psychological distress; reduced need for psychiatric hospitalization; lower use of sick days and disability; and increased job stability. Conversely, the costs of not treating mental disorders can be measured in ruined relationships, job loss or poor performance at work, personal anguish, substance abuse, unnecessary medical procedures, psychiatric hospitalization, and even suicide.

Despite the personal and economic benefits of psychotherapy, many insurance firms and managed care companies have stringent limits on coverage and access to mental health care. Such limits are short-sighted and harmful to patients, families, employers and society as a whole, because mental disorders are often very responsive to treatment.

How Do I Know if I Need Psychotherapy? 

If you or someone you care about is experiencing emotional or mental problems, professional help should be sought. Only a thorough examination and evaluation by a family physician or a psychiatrist can identify whether physical conditions or medication side effects might be causing or contributing to emotional problems.

Warning Signs of Mental Illness 

  • Marked personality change
  • Inability to cope with problems and daily activities
  • Strange or grandiose ideas
  • Excessive anxieties
  • Prolonged depression and apathy
  • Marked changes in eating or sleeping patterns
  • Thinking or talking about suicide or harming oneself
  • Extreme mood swings, high or low
  • Abuse of alcohol or drugs
  • Excessive anger, hostility or violent behavior

A person experiencing one or more of these warning signs should be evaluated by a psychiatrist or other physician as soon as possible-it's the first step toward feeling better.

© Copyright 2000 American Psychiatric Association

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