by Terry Lynch
In January 2005 I conducted a three-hour seminar with a group of trainee and professional psychotherapists. The theme of the seminar was psychopathology, diagnosis and medication in current medical practice, and where the psychotherapist fits in vis-a-vie these issues. This was the first occasion on which I have been asked to present such a programme.
A degree of separation exists between the medical and the counselling professions which is not healthy, and certainly is not in the best interests of the consumer (the ‘patient’, or the ‘client’). Many therapists have little or no direct contact with GPs and psychiatrists. This schism exists at many levels, and assumes considerable importance regarding the care of clients on an ongoing basis. The current reality is that many clients are attending both doctors and therapists. GPs – and in my experience, many psychiatrists – have little understanding of the process of psychotherapy. Similarly, many therapists have little understanding of the medical approach to mental health problems. Consequently, neither the doctor not the therapist has a proper understanding of the other’s work.
The client may ultimately be the person who pays the price for this apparent (and sometimes very real) split in the services. Doctors tend to be very comfortable with the notion of prescribing medication for mental health problems. Having received little or no training in psychotherapy, many doctors know far less about psychotherapy than people might think. In keeping with the common human tendency to be suspicious of things we do not understand, many doctors are in my opinion excessively wary of counselling. This can leave the client feeling that, when it comes to counselling, they are ‘on their own’, as far as the doctor is concerned.
Similarly, there is much about the medical approach to mental health which therapists do not understand. Therapists frequently work with people who have been diagnosed as suffering from ‘depression’, or ‘clinical depression’. Less commonly, therapists will find themselves working with clients who have been diagnosed by as suffering from eating disorders, manic depression (bipolar disorder), schizophrenia, personality disorders, and other mental illness diagnoses. Many of these clients will have been prescribed medication.
In my opinion, any aspect of the client’s life which is ‘live’ within the client’s world, which affects the client’s presence within the consultation, is relevant to the process of therapy. This includes both the diagnosis of a particular mental health problem, and the medication which has been prescribed. There are many ways in which the diagnosis is relevant to the process of therapy, including the client’s perception and interpretation of the diagnosis. The medication people take is also relevant to the process of therapy. Different medications have different effects on people. Some drugs are primarily sedative, others have a stimulant effect. Some psychiatric drugs sedate to a major degree. Others tranquillise to a lesser degree. The central point here is that medication frequently has an effect on how people feel, on their level of anxiety, and on the degree to which they can be fully present within the client-therapist interaction.
Therefore, therapists might benefit from a greater understanding of both the medical approach to mental health problems, and of the medication which their clients may be taking. Within some counselling and psychotherapy training courses, trainees do not receive enough training in these areas to have sufficient understanding of the ways in which these issues impact on the therapist-client interaction. The medical approach to mental health problems and the medications prescribed are one of the few areas of the client’s life which is ‘out of bounds’ to the therapist’s understanding and training. This leaves a potential gap in the client-therapist dynamic, one which is not necessarily in the interest of clients.
It was with these issues in mind that I addressed the group. Throughout the talk, I attempted to convey an insight into the medical approach to mental health problems, to how doctors think and work. Another recurring theme which arose was how trainee therapists might best engage with doctors in their future work with clients.
In the introduction, we discussed definitions, for example, what terms such as psychopathology, neurosis, psychosis mean in simple English. We discussed the medical approach to health in general, including mental health problems, and the process and basis of the medical diagnostic process as it applies to mental health problems. Each course trainee received handouts on the various aspects of the meeting, which included an outline of what we discussed, and relevant references.
Given the frequency with which doctors diagnose depression, we spent some time exploring the medical understanding of, approach to, and criteria for the diagnosis of depression. We discussed the meaning of the term ‘clinical depression’ and the causes of depression, as understood by the medical profession. We explored the various ways in which depression may present to the GP, how the GP sets about diagnosing depression, the interventions used and recommended by doctors. We discussed antidepressant drugs; their effectiveness, and we touched on the type of research which has been carried out on these drugs. As with other areas during the talk, we explored alternative and complimentary approaches to depression.
Whilst therapists regularly work with people who have been diagnosed by doctors as suffering from depression, therapy work with people diagnosed as having manic depression/bipolar disorder takes place to a much lesser degree, even less so with people diagnosed as having schizophrenia. Both of these categories are generally considered to fall within the remit of medicine; counselling and psychotherapy are generally not considered to be beneficial for people so diagnosed. Consequently, many therapists have little contact with people diagnosed as having either manic depression or schizophrenia. This is unfortunate, since many people so diagnosed report that therapy work was of considerable help to them in their lives.
We discussed manic depression and schizophrenia. We explored the characteristics of both conditions, including the meaning of the terms themselves. We looked at the medical view regarding the cause of these conditions, and the interventions which are accepted as having value by the medical profession. Whilst exploring the ways in which psychotherapy can be of benefit to people diagnosed as having manic depression and schizophrenia, I repeatedly mentioned that this work is best left until the therapist is experienced and accredited. Given the delicate nature of this work, there is potential to do harm without adequate experience.
As with all topics discussed during the talk, we explored the potential of a broader, more holistic approach to and understanding of manic depression and schizophrenia, including the judicious use of medication, psychotherapy, and life-relevant issues such as relationships, confidence and assertiveness-building, and ways of helping people get their lives back on track and become empowered. Regarding manic depression and schizophrenia, we discussed the possibility that the experiences characteristic of these conditions might be understandable in the context of the person’s life. This was a common theme throughout the various topics we discussed.
We explored the meaning of terms used in connection with schizophrenia such as delusions, hallucinations, paranoia, and thought disorder. I presented the group with information they were not likely to have come across previously, such as the repeated research finding that outcomes from schizophrenia in under-developed, poorer countries are significantly better than in developed, westernised countries. We discussed the possible implications of these and other research findings during our meeting.
Therapists frequently find themselves working with people who are taking psychiatric medication. This medication may well be a ‘live’ issue in the therapy room; a relatively common effect of psychiatric medication is to change – to varying degrees, depending on the medication – how people feel, and how in touch with their feelings and experiences they are. Consequently, I spend a considerable amount of time on medication. I attempted to simplify this rather complicated area, focusing on what therapists need to know, what is relevant to the therapist-client interaction. We explored the various theories regarding how these drugs act, benefits and adverse effects. We discussed issues such as addiction and dependence. I suggested to the group that they get 1-2 good sources of information about psychiatric medication as a reference source. Whilst some therapists are familiar with the MIMS (the Irish doctors’ medication handbook), my personal preference would be a relatively up-to-date copy of the British National Formulary, which provides more information than MIMS, is well structured and organised, and easy to access. We also briefly touched on Electro-Convulsive Therapy (ECT, ‘Shock’ treatment). We touched on other relevant topics, such as the medical approach to anxiety, and the concept of ‘personality disorder’, as understood by the medical profession.
I sought to give the participants some insights into how doctors think, and how doctors process the information which their patients give them regarding their experience of distress. There was considerable interaction within the meeting, and some lively debate. I believe that all psychotherapy training courses and their trainees could benefit from including more training on the medical approach to mental health problems. Without such training, therapists have a lack of knowledge of an important part of the mental health care spectrum, one which frequently impacts upon the client-therapist relationship and work more than is sometimes realised – the medical approach to mental health problems. The medical approach to mental health problems is quite a vast area. Therapists do not need to study this vast area in depth, but I believe they do need to have a working understanding of the medical approach in as much as it is relevant to therapy work. Given the hands-on and experiential nature of psychotherapy training, in my opinion teaching sessions on the medical approach to mental health problems are best when they involve interaction and input from trainees and trainers, rather than in a more formal ‘lecture’ format.
I felt that the theme of the meeting was very valuable and important. Having worked as a GP for over ten years, and having completed psychotherapy training, I felt very comfortable being involved, having one foot in each ‘camp’, so to speak. I saw my role primarily to explore with the trainees the traditional medical approach to mental health problems, since this is what these trainees will find themselves engaging with on a regular basis in their work. Central issues here included the process by which doctors make psychiatric diagnoses, the various medications used, and the effects of medication which might be relevant within the therapist-client interaction.
It is in the client’s interest that all personnel with whom they are involved work in harmony with each other. We have some way to go on this. While there is an increasing realisation within medicine of the value of psychotherapy, there remains a chasm between the two approaches which is certainly not in the best interests of clients.
Terry Lynch works in mental health combining his psychotherapy training and fifteen years experience in general medical practice. A new, expanded edition of his book Beyond Prozac was published in April 2005 by Marino/ Mercier.