Psychotherapy: a new era
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Psychotherapy: a symposium edited by Anthony Bateman and Frank Margison Psychotherapy: a new era Anthony Bateman, Frank Margison Psychotherapy and psychiatry continue to have an ambivalent relationship despite a consensus that good psychiatry is a blend of science and human narrative, and that proerly practised psychotherapy requires under- standing psychological and biological processes. The reasons for this ambivalence are complex, ranging from an increased biological understanding of psychological process to the uncertain outcome of psychotherapy treat- ment. Throughout Europe, Australasia and the Americas the hegemony of the psychoanalytic approach has been replaced by a biologically-based psychiatry. Moreover, the latter lays claim to greater effectiveness and utility. Yet, patients and clinicians continue to recognize a need for ‘talking therapies’ either alongside or as an alterna- tive to biological treatment. We argue that psychological understanding informs even those approaches most rooted in the physical sciences. Such understanding is essential to engage people in a therapeutic alliance, to instil hope and positive expectations and, most crucially, to shed light on a set of treatment approaches which are of demonstrable effectiveness Psychotherapy has changed and adapted to meet a new reality; this special section reflects these changes. Far from being a spent cause, psychotherapy has altered its appearance, represented in various forms, become increasingly evidence-based and is being used as an effective treatment in its own right (see Guthrie below), as an adjunct to other treatment and as a body of know- ledge that illuminates clinical practice generally (see Garner below). Adaptation and change Such changes are central to future progress. Having been shown to be effective in specific disorders such as anxiety and depression [1,2], psychotherapy has begun to tackle more complex areas such as personality dis- order [3,4], substance misuse and chronic psychiatric conditions [5] and has been modified for different age groups (see Garner below). In doing so, psychotherapy provides a balance to a biological approach by focusing on developmental aspects of psychopathology which, once the domain of dynamic psychotherapy, have been adopted in cognitive approaches [6]. The result is less emphasis on pure theoretically driven models, which may have hampered developments in the past. A corol- lary has been the greater focus on integration, both theoretical and clinical. In modern psychotherapy ele- ments from traditional modalities are being brought together in a systematic way [7]. The interest in the developmental approach and inte- gration is reflected in two papers on aspects of border- line personality disorder (BPD). First, Van den Bosch and colleagues look for evidence, in a trial of dialectical behaviour therapy, that developmental insults in child- hood lead to symptoms in adulthood. Their work adds to our understanding of the interaction between childhood trauma and later problems, indicating that any link is far from simple. Secondly, Holmes, in considering an attachment perspective to BPD, suggests long-term implications occur for the type of attachment pattern that develops between child and caregiver and that its under- standing can lead to effective intervention. Evidence Anthony Bateman, Consultant Psychiatrist in Psychotherapy and Honorary Senior Lecturer (Correspondence) Royal Free and University College Medical Schools, Halliwick Unit, Barnet, Enfield, and Haringey Mental Health Trust, St Ann’s Hospital, St Ann’s Road, London N15 3TH. Email: [email protected] Frank Margison, Consultant Psychiatrist in Psychotherapy Manchester Mental Health and Social Care Trust, Gaskell Psycho- therapy Centre, Swinton Grove, Manchester, United Kingdom Received 13 November 2002; accepted 27 November 2002. Australian and New Zealand Journal of Psychiatry 2003; 37:512–514
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Transcript of Psychotherapy: a new era
Psychotherapy: a symposium edited by Anthony Bateman and Frank Margison
Psychotherapy: a new era
Anthony Bateman, Frank Margison
Psychotherapy and psychiatry continue to have anambivalent relationship despite a consensus that goodpsychiatry is a blend of science and human narrative,and that proerly practised psychotherapy requires under-standing psychological and biological processes. Thereasons for this ambivalence are complex, ranging froman increased biological understanding of psychologicalprocess to the uncertain outcome of psychotherapy treat-ment. Throughout Europe, Australasia and the Americasthe hegemony of the psychoanalytic approach has beenreplaced by a biologically-based psychiatry. Moreover,the latter lays claim to greater effectiveness and utility.Yet, patients and clinicians continue to recognize a needfor ‘talking therapies’ either alongside or as an alterna-tive to biological treatment. We argue that psychologicalunderstanding informs even those approaches mostrooted in the physical sciences. Such understanding isessential to engage people in a therapeutic alliance, toinstil hope and positive expectations and, most crucially,to shed light on a set of treatment approaches which areof demonstrable effectiveness
Psychotherapy has changed and adapted to meet anew reality; this special section reflects these changes.Far from being a spent cause, psychotherapy has alteredits appearance, represented in various forms, becomeincreasingly evidence-based and is being used as aneffective treatment in its own right (see Guthrie below),
as an adjunct to other treatment and as a body of know-ledge that illuminates clinical practice generally (seeGarner below).
Adaptation and change
Such changes are central to future progress. Havingbeen shown to be effective in specific disorders such asanxiety and depression [1,2], psychotherapy has begunto tackle more complex areas such as personality dis-order [3,4], substance misuse and chronic psychiatricconditions [5] and has been modified for different agegroups (see Garner below). In doing so, psychotherapyprovides a balance to a biological approach by focusingon developmental aspects of psychopathology which,once the domain of dynamic psychotherapy, have beenadopted in cognitive approaches [6]. The result is lessemphasis on pure theoretically driven models, whichmay have hampered developments in the past. A corol-lary has been the greater focus on integration, boththeoretical and clinical. In modern psychotherapy ele-ments from traditional modalities are being broughttogether in a systematic way [7].
The interest in the developmental approach and inte-gration is reflected in two papers on aspects of border-line personality disorder (BPD). First, Van den Boschand colleagues look for evidence, in a trial of dialecticalbehaviour therapy, that developmental insults in child-hood lead to symptoms in adulthood. Their work adds toour understanding of the interaction between childhoodtrauma and later problems, indicating that any link isfar from simple. Secondly, Holmes, in considering anattachment perspective to BPD, suggests long-termimplications occur for the type of attachment pattern thatdevelops between child and caregiver and that its under-standing can lead to effective intervention. Evidence
Anthony Bateman, Consultant Psychiatrist in Psychotherapy and HonorarySenior Lecturer (Correspondence)
Royal Free and University College Medical Schools, Halliwick Unit,Barnet, Enfield, and Haringey Mental Health Trust, St Ann’s Hospital,St Ann’s Road, London N15 3TH. Email: [email protected]
Frank Margison, Consultant Psychiatrist in Psychotherapy
Manchester Mental Health and Social Care Trust, Gaskell Psycho-therapy Centre, Swinton Grove, Manchester, United Kingdom
Received 13 November 2002; accepted 27 November 2002.
Australian and New Zealand Journal of Psychiatry 2003; 37:512–514
A. BATEMAN, F. MARGISON 513
is emerging that treatment of BPD using interventionsbased on attachment research is effective [4].
Evidence-based psychotherapy
The articles below illustrate the tension betweenembracing contemporary scientific scrutiny in which therandomised controlled trial is seen as the ‘gold standard’on the one hand and reliance on clinical description onthe other. The ‘gold standard’ has been received withenthusiasm in some branches of psychotherapy, mostnotably cognitive behaviour therapy, and increasinglypsychodynamic and interpersonal models. However, theseadvances do not preclude the value of detailed clinicalaccounts to illustrate what practitioners actually do andto illuminate the narrative structure of sessions intrinsicto all approaches.
We suggest that combining clinical description, processstudies on mechanisms of change and outcome researchis the way forward. It is often forgotten that the uni-versally accepted meta-analytic method was pioneeredin psychotherapy research [8]. There is room for furtherintegration of research methods in psychotherapy andlinks with the biological sciences. For example, psycho-therapy investigators have adopted an investigative toolfrom the biological sciences such as neuro-imaging.Although research has yet to bear fruit, the fact that it isbeing undertaken indicates that old barriers betweenresearch paradigms are disappearing.
Developments in treatment methods
Developments in cognitive behaviour therapy for psy-chosis have been widely reported [9,10]. In this issue wehighlight an approach from another theoretical sourcewhich is early in developmental terms with evidence atcase level. The model is worth examining since it offersways of using psychotherapeutic concepts in generalpsychiatric settings. Kerr and colleagues show that cog-nitive analytic therapy (CAT) can be adapted with patientswith psychosis. ‘Tools’ are used to engage the person ina collaborative dialogue, and to arrive at a working formu-lation. Moreover, psychotherapeutic principles can beused by a mental health team to promote a uniformapproach in a structured framework. In the past it has beendifficult to link psychotherapeutic work to the efforts ofthe rest of the clinical team. The research by Kerr
et al.
demonstrates that this is possible and can reduce negativeinteractions perpetuated by clashes between the dynamicsof the individual and those of the treatment system.
It is only after this developmental stage has beenrefined that we move to efficacy studies. Salkovskis [11]
refers to this as the ‘neck’ of the hourglass of treatmentdevelopment. A flaw in past research has been the rushfrom treatment description based on small clinical seriesto concepts being incorporated into training programs.
The need for psychotherapy research to be evaluatedas rigorously as any other treatment is obvious, but otherforms of testability can complement outcome studies.Margison and colleagues [12] argue that evidence-basedpractice has to be buttressed by practice-based evidencein which robust data are gathered from routine practice.This is exemplified by Van Den Bosch.
Psychotherapy has begun to adapt. A new reality isemerging in which psychological can stand beside bio-logical and social treatments. Evidence mounts that theirintegration may improve outcome in complex areas suchas schizophrenia [13] and personality disorder [14].Greater emphasis in psychotherapy research on practice-based evidence may yet be shown to have greater utilitythan evidence-based practice. Modifying interventionfor different age and ethnic groups is at an early stage butlooks promising. General psychiatry has begun to relearnprinciples pioneered in psychosocial nursing in an attemptto make acute psychiatric wards more therapeutic [15].Psychotherapy may have been missing, presumed dead,in the decade of the brain, but it has been re-found, aliveand well and prepared for the future [16].
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514 PSYCHOTHERAPY: A NEW ERA
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