The aim of psychotherapy is to eliminate or relieve mental disorders and suffering related to them, to support psychological growth and development, to enhance the patient's capability to solve personal problems him-/herself and to help the patient to find new functional approaches in human relationships.
Psychotherapy may also be indicated as a preventive measure for persons who work in health care professions or in other tasks, where deepening of self-knowledge is important.
More than 400 different psychotherapy techniques have been described in literature. Most of these are applications of the six following main forms of psychotherapy:
Psychotherapy is used in the treatment of persons with a mental disorder or some other problem in which psychotherapeutic methods may be utilized. In addition to psychological manifestations, the disorder or problem may have somatic, interaction-related and social manifestations.
Epidemiology varies from country to country. According to Finnish data, 3-4% of working age population seeks medical attention in the health care services due to depression or anxiety of such type that psychotherapy according to research evidence would be a possible treatment option.Psychotherapy may also form a part of treatment in other disorders, e.g. bipolar disorder, multi-symptom disorders, alcohol and drug abuse problems as well as psychoses.
Annually around 10% of the population suffer from a depressive or anxiety disorder that might be treated with psychotherapy.
Psychotherapy may also be beneficial in persons suffering from personality disorder. Their estimated proportion in the population is 6-15%. There is, however, no reliable data about how many of these persons would need psychotherapy. It is, however, obvious that the need, demand and supply of psychotherapy are not in balance.
Appropriate psychotherapy is a highly important form of rehabilitation for reduced work or studying capacity caused by mental disorders.
Provision of psychotherapeutic services
At the primary level, service provision should include, besides actual psychotherapy, also lighter interactive therapies (e.g. psychoeducative groups, group interventions for children and families with children, cognitive and interpersonal group interventions in the schools).
In Finland, the Council for Choices in Health Care in Finland (COHERE http://palveluvalikoima.fi/en/council-for-choices-in-health-care-in-finland) has included psychotherapies and other methods of treatment and rehabilitation in the range of public health services in mental and substance use disorders.
A general practitioner should keep psychotherapy in mind, especially when a patient starts to have psychiatric symptoms. Psychotherapy is more effective if the diagnosis and treatment are early-phase.
If the primary level therapy is insufficient, the patient is referred, after consultation with a psychiatrist, for assessment in the specialized care.
In the specialized care, a treatment plan is drawn up together with the patient. Psychotherapy may be included as a part of the treatment plan.
Referring to psychotherapy
Assessing the need and reasons for psychotherapy requires specialist consultation.
Psychotherapy should be considered
if the patient has a mental disorder that impairs working capacity or studying capacity
in psychiatric disorders in youth
when medication and crisis interventions have no effect and the medication seems to have become long-term
when the problems are interpreted to be psychological and when the patient feels more need to change him/herself than modify his/her environment.
Combining psychotherapy and medication is often effective but psychotherapy can be carried out as the only form of treatment.
Psychodynamic (psychoanalytic) psychotherapies
Objective
To assess the effect of earlier experiences on the current models of functioning (thoughts, feelings, images, actions).
Therapy may be directed at unconscious conflicts of the mind, at developmental deficiencies and distortions in the psychological structures as well as at structures in the personal history that direct human relationships.
Goal
To help the patient to understand his way of outlining the world and to find alternatives that would work better and give more autonomy.
Method
Therapeutic alliance
Free association
Defence analysis and interpretation of transference, especially in relation to the therapist
There are several psychodynamic techniques that relate to the respective specific features of the different mental disorders being treated.
Indications
Indications include anxiety disorders, dissociative disorders, psychiatric symptoms due to somatic disease, dysthymia, adjustment disorders, and mild and moderate mood and personality disorders.
Personality disorders and comorbid states in which the traits of personality disorder play a significant role are a particularly important indication for psychotherapy. Comorbidity occurring with personality disorders is very common in most psychiatric diagnoses: 56% in anxiety disorder, 41% in phobia, 41% in severe depression, 22% in social phobia.
In mental disorders that threathen the ability to work, comorbidity associated with personality disorders should be taken into account when rehabilitation is planned.
Long-term psychodynamic psychotherapy has been shown to produce particularly good and sustained outcomes in the treatment of personality disorders, disorders with multiple symptomatology and disorders of prolonged duration.
Also randomized studies have shown that psychoanalytical psychotherapy is efficient in treating borderline personality disorder.
Duration of treatment
From months to several years
The sessions must be sufficiently frequent.
Forms of treatment
Psychoanalysis: 3-5 sessions a week for 4-6 years
Psychodynamic-/psychoanalytical-oriented individual psychotherapy: 1-3 sessions a week for 2-4 years
Psychodynamic brief psychotherapy: limited number of sessions (12-40), restricted focus
Mentalization-based therapy is a derivative of psychodynamic theory. Its effectiveness has been shown in the treatment of unstable and self-destructive features. The therapy aims at supporting the patient in recognizing and controlling his/her emotional reactions in a more efficient manner.
Balint group activity applies psychodynamic experience in the work of the general practitioner. A holistic approach to therapy, taking into account the psychosocial aspects of illness, is sought for under the lead of a supervisor.
Cognitive therapy aims at understanding and conceptualizing the patient's problems according to the cognitive model. Harmful thoughts and related difficult emotions are the target. By modifying the thoughts to be more flexible, changes in the emotional experience are also achieved.
Goal
To identify and alter personal cognitive distortions that cause symptoms. The patient learns to see the reality more clearly by examining one's own essential, distorted cognitions.
Method
Therapeutic sessions normally 1-2 a week for 1-3 years
In brief therapies the number of sessions is restricted (15-20).
Indications
Primarily used in depressive disorders. Other indications are anxiety, nervousness, panic disorder and substance abuse.
In the recent years the development of cognitive therapy has been characterized by a strong tendency to develop a systematic therapy process that fulfils the following three criteria:
The therapy is based on an extensive theory that is supported by research evidence.
The therapy is operationalized and the therapy process is linked to theoretical concepts.
The effect of the therapy has been proven by studies.
Cognitive therapy is the most extensively studied form of therapy, and its efficacy has been shown more clearly than that of other therapies in controlled, randomized studies. Studying the effect is made easier by standardized manuals that allow to repeat the therapy process in a controlled manner.
Family therapy
The roots of family therapy are in psychodynamic theory, cognitive theory and system-oriented family research.
Object
Disorders in the family interaction or in an individual family member
Goal
To modify interaction within the family, to find the strengths of the family.
Indications
Indicated especially in severe psychiatric disorders where problems of dependency are central.
In crisis interventions family therapy may solve a locked situation (e.g., crisis of divorce or child independence)
Interpersonal psychotherapy
Object
The basic idea is that mental disorders occur in a psychosocial, interpersonal setting. Interpersonal psychotherapy focuses on current interaction relationships. Transference and childhood experiences are not included in the therapy process, although their importance is not neglected. Current relationships are considered as the most essential ones and are thus in focus.
Indications
Developed initially only for the treatment of acute depression. The method has, however, been adjusted for use in other mental disorders.
Methods
Four main problem areas are emphasized :
conflicts in roles
interpersonal insufficiency
prolonged reaction to grief and
changes in roles.
Aim
To help the patient to develop coping strategies for social and interaction problems.
Duration
Usually limited to 12-16 weeks
Group psychotherapy
Many techniques used in individual therapy have been applied in groups. The methods used in group therapy can be psychodynamic, interpersonal and cognitive. Psychodrama is a special form of group therapy in which internal conflicts are processed in play-like processes.
Supportive psychotherapy
Object
Psychodynamic supportive psychotherapy is especially utilized in the treatment of patients with severe personality disorders.
Aim
Better control of the symptoms and a more realistic attitude towards the disease. Main themes include finding solutions to every-day problems: living, housekeeping, work. Solving acute family conflicts and sorting out age-specific developmental problems, such as relationships, sexuality, loneliness, hobbies, religious questions, is equally important.
Method
The main therapeutic element is the continuity of a supportive therapy relationship and regarding the patient primarily as a person. The theoretical foundation of supportive therapy can rise from several frameworks. The psychodynamic experience is probably most significant in understanding the patient and supervising the therapy process. Cognitive approach is also always important.
The process described here is a special clinical application of supportive psychotherapy that has a significant role in the treatment of psychoses.
Brief psychotherapies
Brief psychotherapy is a common name for a group of different techniques of psychotherapy restricted in time (5-20 sessions) that may be based on different theoretical backgrounds.
Psychotherapy has an essential role in the treatment of acute and post-traumatic stress disorder (PTSD) Acute Stress Reaction and Post-Traumatic Stress Disorder. Cognitive and psychodynamic therapies are not in conflict in the understanding and treatment of these disorders.
In the treatment after an acute trauma, it is often sufficient to shortly discuss through the traumatic event and give it a structure. Research evidence on the effectiveness of debriefing in the prevention of post-traumatic stress disorder is controversial. Besides the trauma itself, other factors also contribute to development of a prolonged disorder.
Cognitive psychotherapy has been shown to produce good results in the prevention of post-traumatic symptoms.
EMDR (eye movement desensitization and reprocessing) is a technique that has been developed on the basis of cognitive behavioural therapy and has attracted great attention. It is not an actual form of psychotherapy but an assistive technique for the therapy.
Crisis intervention and brief psychodynamic psychotherapy have been shown to be effective in the treatment of acute PTSD. Cognitive behavioural therapy is effective in the treatment of chronic PTSD.
It is estimated that approximately 10-20% of patients suffering from chronic stress disorder do not benefit from psychotherapy, but they should primarily be offered other types of psychiatric treatment.
Effectiveness of psychotherapies
Meta-analyses have shown that psychotherapy is highly effective. On average, more than 80% of patients who have received psychotherapy improve significantly compared with controls not receiving psychotherapy. The effect remains after 5 years. The effectiveness can be considered to be so high that it would be unethical to leave the patient without psychotherapy.
Only a few efficacy studies comparing different forms of psychotherapies with long-term follow-up have been done.
Comparison of different psychotherapy techniques using the methodology of effectiveness studies is a much more complicated research problem than, for example, the comparison of pharmacotherapies. The majority (99%) of studies on the effectiveness and efficacy of therapies assess brief therapies, and the effectiveness estimates are limited to the short-term results. Several dozens of meta-analyses assessing the effectiveness of psychotherapies by combining the results of hundreds of trials have been made. According to these studies the effectiveness of psychotherapy compared with a no-treatment group equals that of patients treated with psychopharmacological drugs.
Evidence on the effectiveness of long-term therapies has accumulated in naturalistic studies involving subjects with multiple symptoms, who are common in hospital settings. Meta-analysis showed no difference between the results of randomized and naturalistic studies focusing on the effectiveness of long-term psychodynamic therapies.
It has been possible to show the effectiveness of psychotherapeutic treatment methods also at the biological level, by using objectively measurable brain imaging techniques.
A randomized comparative trial of long-term and short-term therapies conducted in Finland suggests that there are significant differences between the two and that it is important to pay attention to the eligibility factors of the patients when therapy forms are chosen.
The Helsinki Psychotherapy Study is an internationally unique randomized trial comparing long-term and short-term psychotherapies. The compared therapies included brief solution-focused therapy, short-term psychodynamic psychotherapy, long-term psychodynamic psychotherapy and psychoanalysis. Psychiatric symptoms were reduced and work ability was improved in all four patient groups. Short-term therapies gave benefits more quickly, but during a longer follow-up the long-term therapies were more effective. Psychoanalysis was the most effective therapy form after 5 years from the start. The study suggests that short-term therapies serve another type of patients than long-term therapies, and careful patient selection is essential when psychotherapy is started.
Brief psychotherapies were effective in mild disorders without multiple symptoms.
Long-term psychodynamic psychotherapy was more effective than short-term therapies in patients who had deficiencies in the strength of self (the relationship between the realistic self and the ideal self, ease of interaction, control of emotions).
References
Knekt P, Lindfors O, Laaksonen MA, Raitasalo R, Haaramo P, Järvikoski A, Helsinki Psychotherapy Study Group. Effectiveness of short-term and long-term psychotherapy on work ability and functional capacity--a randomized clinical trial on depressive and anxiety disorders. J Affect Disord 2008 Apr;107(1-3):95-106. [PubMed]
Leichsenring F, Rabung S. Long-term psychodynamic psychotherapy in complex mental disorders: update of a meta-analysis. Br J Psychiatry 2011;199(1):15-22. [PubMed]