The Treatment of Psychiatric Illness, Psychological Treatment

The Treatment of Psychiatric illness, Psychological Treatment

General Measures or Simple Psychotherapy

Any contact between doctor and patient has psychological aspects. A simple act, such as writing a prescription, has a psychological meaning. This depends on the setting in which the act occurs, the way it is carried out and the respective psychological attitudes, conscious and unconscious, of patient and doctor towards each other. To one patient the prescription may convey only kindness and consideration. To another it may be seen as a gesture which silences him, which stops him talking about his troubles and, by implication, tells him to take them elsewhere.

Reassurance and Suggestion

Often the doctor deliberately tries to influence the patient's symptoms by psychological methods. He may try by persuasion, reassurance and encouragement. He may offer advice on the patient's management of everyday affairs. Sometimes he tries suggestion. This means that the doctor uses his authority and influence with the patient to convince him he is getting better or that a particular course of action will be helpful.

Abreaction

General discussion of the patient's difficulties may also help by allowing him to ‘get things off his chest’ and unburden himself to someone he can feel is an interested observer, yet who is more impartial than his family and friends. Sometimes the release of pent-up emotion during such discussion leads, at least, to temporary relief. This process is called ‘abreaction’.

Such methods can be termed ‘simple psychotherapy’, to distinguish them from the ‘dynamic’ treatments described below. It should be added that this distinction has nothing to do with efficacy.

Dynamic Psychotherapy

Dynamic psychotherapy or interpretative psychotherapy covers those methods of treatment where an attempt is made to use the doctor-patient relationship to increase the patient's knowledge of himself. This means that some of his unconscious motivations are brought into consciousness. The basic assumption is that, if this is done, the patient's more pathological defences, from which his symptoms result, become unnecessary.

The first form of dynamic psychotherapy was psycho-analysis. It will be discussed at some length, to help in understanding the modified and shorter techniques.

Psycho-analysis

A basic assumption in psycho-analysis is that there is a reason for all mental events, however haphazard they appear.

Free Association

In ordinary social conversation many ideas which occur to the speaker are not expressed, because they may be irrelevant, out of place, or in bad taste. But in psycho-analysis the patient is asked to tell the doctor everything that occurs to him -thoughts, feelings, fantasies, sensations-as he experiences them during the session and without any reservations whatsoever. This is known as `free association' and is the basic rule for the patient. The doctor's role is that of an interpreter. This means that he listens carefully to all that the patient tells him and, as occasion fits and the pattern of mental events becomes clear, interprets to the patient the emotional significance of what he says. The process is gradual, but this does not mean that there is any attempt to avoid painful or anxious feelings. These, like any others, must sooner or later be faced.

In its pure form, this treatment avoids any direct use of methods of influencing the patient. This means that the measures described as 'simple psychotherapy' are never deliberately practised. Thus it is held, for example, that the best form of reassurance is a correct interpretation, since it shows the patient clearly that the doctor is in touch with his feelings.

Regression

Treatment is aided by a very remarkable fact. The situation fosters regression and in this way the patient's childhood, in a sense, is again accessible to observation, as more childish ways of thinking or feeling replace adult ones, and the patient behaves, often in spite of himself, as if the doctor were an important figure in his childhood, such as a parent. Surprisingly, this occurs irrespective of the age, sex or appearance of the doctor.

Transference

This displacement of feelings from a parent or other important person to the doctor is known as `transference'. Because it may have all the violent qualities of love and hate felt towards the original figure, the doctor-patient relationship can become the central and most important object of study. Consequently, one aim of the doctor is the interpretation of events occurring in the transference. From this he can try to show the relationship of these events to others in the patient's life, whether past or present.

Character Change

If treatment is successful there is usually some degree of character change, so that aspects of the patient's behaviour which increased his difficulties are modified. This cannot happen quickly. Few analysts would expect substantial changes in less than eighteen months or two years, even when the patient attends for an hour five times a week.

Doctor and Patient

In orthodox psychoanalysis, the patient lies on a couch while the doctor sits out of sight, because it is thought that both patient and doctor are thereby more relaxed, the patient better able to concentrate on ‘free association’ with less distraction, and the doctor freer to devote his attention to the patient's productions and their meaning. Patients, of course, often try to discover whether the doctor approves or disapproves of what they are saying, and they may fancy that it is easier to do so when they can watch the doctor's facial expression. Perhaps we should add that during this treatment, and in all forms of dynamic psychotherapy, the doctor is careful not to express moral criticism, since this would be an attempt to influence the patient's behaviour without trying to understand it. It would also seriously interfere with the patient's ability to follow the basic rule of free association.

As far as we can see at present, analysis is more likely to be useful in the neuroses than in the psychoses, though attempts are sometimes made to treat the latter. It is not usually indicated in people much older than forty or who are unintelligent. But the most serious disadvantages of psycho-analysis lie in its great length and in its expense. It is not generally available under the National Health Service at present.

Shorter Forms of Psycho-analysis

Because of the length of time and expense involved, psychiatrists have sought short cuts in interpretative psychotherapy. In these shorter techniques it is not always possible or desirable to avoid reassurance or advice. But almost without exception all forms of dynamic psychotherapy use the concept of transference in their work with the patient.

Sessions vary in length and frequency, but are usually from half to one hour once or twice a week. Most doctors agree that the longer the interval between sessions, the more difficult the task. If intervals are too long it becomes particularly hard to interpret the transference material correctly.

Modification of Pressing Conflicts

Before treatment itself starts, a careful history of the patient is taken and the likelihood of psychotherapy being helpful is assessed. Many doctors find it convenient to set themselves a particular goal in treatment. This need not be an ambitious one. It may be concerned with the modification of the patient's more pressing conflicts by interpretation of his more prominent defences. It is unrealistic to set these goals too high. In general, less urgent conflicts will be ignored in short-term treatment.

In shorter methods of psychotherapy it may be necessary to direct the patient's attention to particular periods or aspects of his life, even when his free association is not leading in that direction. This may have to be done by questioning. But the emphasis will still be on interpretation of what the patient communicates to the doctor and especially of the transference relationship.

Face-to-Face Interview

In many forms of dynamic psychotherapy the couch is discarded in favour of a face-to-face interview. There are many practical reasons for this. One is that the use of a couch occasions much anxiety in itself, partly because it produces a greater degree of regression. Many psychiatrists prefer not to invite this state of affairs when they have less time than the analyst to deal with this situation. However, the face-to-face technique can be exacting for both parties and, while the doctor must be natural in his manner, he must try not to convey, unintentionally, attitudes detrimental to the patient's free expression.

No Rigid Rules. The kinds of dynamic psychotherapy vary greatly in detail as do the conditions in which they are practised. However, certain basic conditions seem necessary. The patient's time must be respected; for example, it seems important for him to know in advance the times and duration of his sessions. Consistency in appointments is desirable. Free expression must never be discouraged. But when this has been said, it must be emphasised that there are no rigid rules in dynamic psychotherapy. Techniques need to be adaptable and imaginative. They call for great skill, which is why not every psychiatrist would care to use them.

Finally, more than anyone else, the psychiatric patient is inclined to feel that no one has time for him or is willing to help him. To feel that he can be respected as well as tolerated is in itself a corrective emotional experience.

Dynamic Group Psychotherapy

Before the Second World War some attempts had been made to treat small numbers of patients collectively in groups. An increasing emphasis on psychiatric treatment stimulated by the war revived interest in these methods.

Free Discussion. In dynamic group psychotherapy the patients, usually six to eight in number, sit in a circle together with the doctor. The length of the session varies, but in Great Britain it is usually an hour and a half. The ‘free association’ of individual therapy is replaced by ‘free discussion’-there is no set subject and the doctor does not direct the discussion. As in individual treatment, his role is essentially that of interpreter. Here again he tries to avoid those methods of influencing patients described on as ‘simple psychotherapy’.

Open v. Closed Groups. Groups are of two kinds: open and closed. In an open group patients may join and leave at different times during the course of the group. As each patient goes he is replaced by someone else, so that the composition of the group changes. In a closed group, on the other hand, all patients start and finish their treatment at the same time.

An open group can be rather unsettling for patients who need long-term treatment. A closed group is better for such people. Patients who seem able to benefit from two or three months' treatment are, on the other hand, perhaps best treated in an open group. An open group can also be useful for an initial period of observation and assessment. If found suitable, a patient can then be transferred to a closed group. A closed group may continue for anything from six months to a year, sometimes much longer. In the case of out-patients the group meets once or twice a week, but in a few in-patient centres five sessions a week are offered.

The Interpretation

The doctor may interpret the behaviour of the group as a whole, or he may interpret that of a given individual. Most doctors prefer to interpret principally group behaviour in the early stages, to help the group to work together as a coherent unit. But individual interpretations are important and will certainly be made as the group progresses. There are, of course, no rigid rules and the technique needs to be adapted to the situation prevailing in the group at the time.

As in individual therapy, special importance is placed on the interpretation of transference. Here again, the aim of treatment is to examine a current situation in an attempt to bring to light unconscious factors in the illness.

While patients with many different kinds of psychiatric illnesses can be helped in groups, there are indications that some patients with long-standing personality disorders can benefit more from group therapy than from individual treatment.

Other Forms of Group Therapy

There are other kinds of group therapy where no attempt is made to conduct the treatment on dynamic lines. Mutual discussion of personal problems is the usual basis of a supportive group. Some doctors conduct groups where the emphasis is on explanation rather than interpretation.

Some combine these methods and also include active counselling. Some hospitals use larger groups in which patient and staff-including nursing staff meet to discuss everyday problems of running the hospital. In groups such as this the patients often receive other forms of treatment as well.

Drug-assisted Techniques

In these methods, psychotherapy is used together with some form of stimulant, sedative or anxsthetic.

The patient lies on a couch and the doctor sits at his side. Most drugs are given by injection into a vein, usually in the forearm. In the case of an anesthetic such as ether, the patient's face is covered with a mask on to which the ether is dropped.

For Abreaction

One use of this method is to facilitate abreaction. If it is felt that the illness is largely concerned with a single disturbing episode (as in some wartime cases of battle neurosis), the patient may relive the disturbing scene, thus `abreacting' or giving vent to his pent-up emotions of fear, rage or grief. It is hoped that, if this is repeated a number of times, the individual can be brought to face his disturbing past more easily. The drugs which are often used for this purpose are those of the sedative group, and ether. In each case, the aim is to give just enough of the drug to make the patient drowsy and a little `drunk'. He can then usually be persuaded to relive the scene concerned without too much difficulty.

For Narcoanalysis

The sedative group of drugs is also used to facilitate exploration of those events in the patient's past which may have a special significance for the present neurosis. This is sometimes called `narcoanalysis'. Here the aim is to make the patient relaxed, so that he can survey his past without too much anxiety.

For Amnesia

An intravenous sedative can also be used for patients with a massive hysterical loss of memory. It is often possible, in this way, to re-establish the events of the period covered by the amnesia.

For Reticent Patients

When a patient finds it difficult to talk about himself and his difficulties a stimulant can be used. Methylamphetamine injected into a vein often makes a reticent person feel talkative.

Hallucinogens

A further group of drugs, the hallucinogens such as LSD (lysergic acid diethylamide), mescalin, and psilocybin, save been employed to enable a patient to relive his childhood. Their usefulness is at present under discussion.

'Truth Drugs'

These methods are sometimes described in newspapers as treatment with the `truth drug'. While their aim is indeed to help a patient tell the truth if this is repugnant or embarrassing to him, no drug yet discovered can make him do so if he does not wish to.

Hypnosis

Hypnosis is used as an abreactive technique or for exploration, with the same aim as the administration of sedative drugs. Commonly, it is used to reinforce suggestion.

The technique varies: most hypnotists develop their own. One method is to ask the patient to relax, preferably on a couch. The hypnotist then stands in front of him and holds a small bright object in such a position that a very slight strain is imposed on the patient's eyes. The room is darkened a little. The hypnotist then repeatedly assures the patient that he can't keep awake, feels drowsy, is very relaxed, and so on. Once the patient is hypnotised, the hypnotist ‘suggests’ that the patient's disability will grow less or disappear and that he will not remember it in the waking state. Many sessions of treatment may be required.

The procedure is so frequently followed by relapse and so liable to produce an abnormal dependence on the hypnotist that many authorities consider it of little use in psychiatric illness.

Pavlovian and Learning Theory Methods

Conditioned Reflex

Pavlovian methods of treatment are based on Pavlov's discovery of the conditioned reflex and the branch of biology deriving from this. Pavlov demonstrated that an organism can be trained to respond automatically to a given stimulus and to repeat this response in an identical way on subsequent occasions. For example, whereas the mouth normally waters in response to food, an animal can be trained to salivate at the sound of a bell.

Attempts to apply findings of Pavlovian physiology to the treatment of certain psychiatric disorders have been made in recent years in Great Britain, Russia and the United States of America.

`Learning theory' makes use of Pavlovian ideas together with knowledge gained from watching young animals and young children and studying their processes of learning. Neurotic symptoms are regarded not as part of a disease process but as habits developed on the lines of conditioned reflexes.

Treatment aims, broadly speaking, at conditioning the patient to respond in new and more satisfactory ways, and at deconditioning him from undesirable responses. Many methods of treatment have been devised, of which the following are only examples.

Buzzer for Enuresis

One device which has been developed is designed to help nocturnal enuresis (bed-wetting). When the sleeping patient begins to pass urine an electric circuit is completed and a loud bell or buzzer, placed at the bedside, rings. This wakes the patient who can then complete urination in the toilet. This procedure is repeated nightly for several weeks. The patient then begins to associate a full bladder with the bell-ringing and with awakening. The hope is that, even when the device is withdrawn, the full bladder will now cause the patient to awaken and use the toilet.

Cat Phobia

A method of treating phobias has also been devised and recently applied in the case of a patient who was terrified of cats and everything connected with them. She was first shown furry materiais and later encouraged to touch them. Eventually she was able to hold and even stroke the material. She was soon prepared to tolerate photographs of cats. and later to stroke small kittens. In due course she was able to encounter cats without fear.

Other phobias have been treated in a similar way.

Writer's Cramp is one example of a hysterical condition which has been treated by related methods. In this case small, repeated electric shocks are passed which make maintenance of the `cramp' difficult. Eventually the patient may learn to use a pen without the intervention of the machine.

Aversion Therapy

A form of treatment known as `aversion therapy' has been used to treat alcoholics. The patient is given injections of a drug which causes vomiting; apomorphine and emetine are examples. He is given alcohol to drink just before the drug can be expected to work. Again, the hope is that in due course he will come to associate the drinking of alcohol so strongly with vomiting that such drinks will revolt him. The procedure may have to be repeated separately for beer, gin, whisky and so on.

Finally methods have also been evolved whereby some sexual perversions, notably fetishism, can be treated. These rely on training the patient to become actively averse to the article of clothing concerned instead of becoming excited by it. But it must, of course, be emphasised that none of these methods, even when successful, does anything to resolve the mental conflicts underlying the symptoms.

Occupational Therapy

This term is used to cover a wide range of activities in which patients participate, under the guidance of trained staff, as part of the treatment of medical, surgical and psychiatric illness. At its simplest it provides a series of handicrafts to occupy and divert patients who are bed-bound or otherwise incapacitated. More active and complex programmes are used for rehabilitation and retraining. Individual requirements of psychiatric patients differ greatly, but most in-patients and day patients need a full occupational regime at some stage in their treatment.

Graded Tasks

A patient recovering from a severe illness may be given a series of tasks which can be stimulating or soothing. These may be graded from simple to more complex tasks as the patient's condition improves, to give increasing exercise in concentration and the regaining of self-confidence. He or she may begin with undemanding work such as basket-making, proceed to handicrafts requiring more skill and later take up activities akin to his or her own work. Many occupational therapy departments can provide facilities for housecraft, woodwork, metal work and typing and clerical work. At this stage it is particularly encouraging for the patient if the work is of immediate use to the other patients or to the hospital.

Social Aspects

Patients in hospital for a considerable period tend to lose touch with social activities and with everyday responsibilities. This may impede return to full health. One aim of a psychiatric hospital is to provide for its less incapacitated patients the facilities for a full regime of work, social activity and physical exercise. It is usually helpful for the patient to feel that he retains responsibility for himself, and most hospitals encourage patients to arrange the details of their work and leisure, and to organise work projects and social activities such as dances and discussion groups.

Many of these patients enjoy music, and groups provide entertainment from ‘pop’ bands to church choirs.

The idea of the hospital as a small community of people representing both the family and civic group is an important one. Most psychiatric illnesses are characterised to some extent by an impairment of ability to live happily in reasonable harmony with relatives and society. Through the various activities described and particularly during the course of psychotherapy, the patient may be helped to improve his relationships with people, to function in a way both satisfying to himself and to the community, to accept the needs of the group when they conflict with his own, and to contribute to the group. His day-today experiences in the hospital community may be discussed in psychotherapy sessions and may give him a wider understanding of himself and his difficulties.

Acting a Role

Some additional occupational activities have special aims. In playreadings and psycho-drama, patients may gain understanding of personal problems by acting roles allotted to them. For example, a young girl playing the role of a mother may come to understand more clearly her own mother's interests and difficulties. Art therapy provides the satisfaction of self-expression and the patient may, in depicting his own experience and emotions, gain greater selfawareness.

Physical Treatments

Treatment by Drugs

The various drugs used in the treatment of psychiatric illness fall into four main categories: sedatives, stimulants, tranquillisers and antidepressants. They are all used empirically, that is, while they are known to have particular effects, the way in which they act is unknown or only partially known.

Of recent years many new drugs have been discovered and developed, notably the tranquillisers and the antidepressants. Some of them have greatly improved the management of many disorders and, in some illnesses, have appreciably altered the outlook. With other drugs, however, the initial optimistic claims have not been confirmed by medical experience. The greatest care is necessary in the close study of a new drug to establish its usefulness.

Sedatives

These are drugs which reduce the activity of the brain and the rest of the central nervous system. In small doses they reduce restlessness, feelings of anxiety and tension. In larger doses they induce sleep. In very large doses their effect is powerful enough to abolish breathing. Until the discovery of the tranquillisers they were the only medicaments available for the control of anxiety, restlessness and excitement.

They have certain disadvantages. They cause sleepiness, and sometimes depression in all but the smallest doses. There is a tendency for the system to become accustomed to them and larger doses may be required or addiction may develop.

This group includes many drugs having very similar effects, but which differ chiefly in the speed and duration with which they are effective. Medium and long-acting ones are used in relatively small doses for their calming effect. Medium and short-acting ones are used in larger doses to induce sleep in cases of insomnia or in sleep treatment.

Sedatives are usually taken by mouth, but they may be given by injection when a more marked and powerful effect results. The more commonly used sedatives are:

Chloral Hydrate

Tranquillisers. Tranquillisers have a calming effect in certain conditions and cause less drowsiness than the sedatives. They can therefore be used in larger doses, leaving the patient alert. They also have the advantage of not depressing respiration even in very large doses and they are to this extent safer than the sedatives. Tolerance and addiction are also much less likely to develop. Some tranquil lisers have a number of side-effects, including dryness of the mouth, fall in blood pressure and stiffness of the muscles.

Tranquillisers are frequently used in the treatment of anxiety or restlessness accompanying any psychiatric condition. The older tranquillisers are used chiefly in schizophrenia, mania and in organic states, being relatively ineffective in the psychoneuroses. Other tranquillisers, such as chlordiazepoxide (Librium) and thiopropazate (Dartalan) are more effective in these latter conditions.

In schizophrenia, these drugs may be strikingly effective in reducing disturbed behaviour, hallucinations, delusions and thought disorder.

The better known tranquillisers are:

Antidepressants

Their name is self-descriptive. Unlike the stimulants they have no effect on people who are not depressed. They may be used in cases where a mood of depression exists, whether in depressive illnesses or in neuroses with depression. They are frequently used for patients who would previously have been given electrical treatment .

Their side-effects include dryness of the mouth and fall in blood pressure. It is customary for these drugs to be taken in tablet form:

Stimulants

These drugs, especially the amphetamines, produce increased wakefulness, postpone the need for sleep and may increase the flow of mental activity. They do not, however, markedly improve a mood of severe depression. They may produce or increase anxiety. Amphetamines are sometimes given as an aid to slimming, because they tend to diminish appetite. In large doses, usually over a period of weeks or months, acute toxic confusional psychoses may be produced.

Patients with unstable personalities may become addicted to stimulants. Amphetamines are often prescribed combined with a small dose of sodium amytal in the same tablet. This counteracts the tendency for anxiety to be produced. The more commonly used stimulant drugs are:

Electroplexy

(Electroconvulsive Therapy)

The development of electroplexy arose out of the observation that spontaneous convulsions appeared to have a favourable effect on various sorts of mental illness. The supposed rarity of epilepsy in schizophrenia led to the conclusion that these two conditions were opposed to each other.

In 1936 the first attempts were made to treat schizophrenia with drug-induced convulsions. In 1938 the production of a convulsion using an electric shock was developed and this is the method commonly used now.

In modern techniques the treatment is usually administered under light anresthesia, such as may be used for dental extractions, and the muscular convulsion is reduced by a muscle-relaxant drug. The patient may sometimes be given this treatment as an outpatient. He receives an injection containing the anesthetic and the muscle relaxant, then an electric current of appropriate strength and duration is passed between two electrodes placed on his temples. The procedure takes a few minutes and the patient may be able to walk about after a short period of rest.

EIectroplexy is usually given two or three times a week, though in certain circumstances it may be given more frequently. Improvement usually begins after three or four treatments but a course of six to eight is usually necessary.

Electroplexy is used in the treatment of depressive illness, of mania and in schizophrenia. It is most effective in depressive illnesses, 80 per cent of cases making a complete and prompt recovery.

Insulin Coma Therapy

Insulin is a substance, produced in the pancreas, which controls the storage of sugar in the body. It is given by injection in the treatment of diabetes and in psychiatric treatments. One of its effects is to reduce the amount of sugar in the bloodstream and, in large doses, the reduction of blood sugar has the effect of producing coma.

Chance observations that a coma so produced had beneficial effects in cases of schizophrenia led to the use of insulin coma as a treatment for schizophrenia. The subsequent discovery of the tranquilliser drugs and of their efficacy in such illnesses, has reduced the need for insulin coma treatment, but it is still used for some patients.

Producing the Coma

Injections of increasing dosage are given on successive days until a coma is produced. Thereafter a coma is produced each day with the appropriate dosage until between 25 and 30 comas have been produced. Each coma is allowed to continue for half to one and a half hours, and is then interrupted by giving the patient sugar either by injection or by stomach tube.

Since great care is needed in order that the treatment may be given with the minimum of risk, insulin coma therapy is only given in special units under the supervision of specially trained staff. The best results are obtained in early acute cases of the disorder. There is usually a progressive improvement in schizophrenic symptoms and a steady gain in weight during the course of treatment.

Modified Insulin Treatment

Before the discovery of insulin coma treatment for schizophrenia, small doses of insulin given over a short period of time were known to have a sedative effect, to reduce tension, and to increase appetite and weight. Modified insulin therapy is therefore used in cases of psychoneurosis or mild depression where there is considerable tension and, in particular, if there has been weight loss. The treatment usually results in a general improvement in bodily health and in a feeling of well-being.

Prolonged Narcosis

(Sleep Treatment)

During attacks of severe anxiety or depression occurring in the course of a psychiatric illness, a period of continuous sleep is sometimes thought desirable. This can be induced by giving large doses of sedatives, or combinations of sedatives and tranquillisers, to achieve deep sleep for most of the day and night and heavy drowsiness for the remainder. The treatment may last for one or two weeks. It is necessary for the patient to be under close supervision in hospital.

Prolonged narcosis is usually given where the illness is reactive to extremely traumatic or painful circumstances which have become too much for the patient to cope with. It may tide him over the period of acute reaction. When this has been relieved, the patient is able to continue with other forms of treatment.

Brain Surgery in Psychiatry

Prefrontal Leucotomy (lobotomy) is the most commonly used of operations for the relief of psychiatric illness. Certain nerve fibres from the frontal lobes of the brain are cut, in order to reduce severe anxiety, tension, depression, or the excessive excitability and activity that occurs in some disorders. Various brain functions such as sensation or movement have been located in different part.

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