The newer psychotherapies and counselling

  The last 40 years have seen the development of a whole series of new psychotherapies that are radically different. They pay far less attention to understanding the past. The therapists are usually more directive – they give instructions and opinions, not just further encouragement to the patient to continue reflecting. Many involve specific exercises and ‘homework’ that is reviewed in sessions. They last months not years. The psychotherapist acts much like any other mental health professional and avoids the mystique surrounding psychodynamic therapists.

  Person-centred (often called Rogerian) counselling is one such approach. The distinction between counselling and psychotherapy is variable and unclear. Counselling is often offered at times of personal crisis to people we would not usually consider as ‘ill’. Its aims are more modest than those of formal therapies. It draws on the characteristics of a good therapist outlined above, and provides a ‘safe space’ for the individual to explore their concerns. Here the therapist is non-directive. They rarely give opinions or advise the patient what to do or think, and often simply repeat the patient’s last phrase as encouragement to continue reflecting. Counselling is a skill highly prized by many mental health professionals and clearly valued by patients.

Family and systems therapies and crisis intervention

  Family therapies have become very important in the treatment of psychiatrically ill children. Family therapists generally avoid implying a role for the family in causing the illness (see Chapter 5), but sometimes it is impossible for a patient to get better unless the family changes its way of responding. In anorexia nervosa, for instance, a family may have become so anxious about their daughter’s illness that they cannot allow her the freedom to take necessary risks and so mature. They may need help to back off and contain their anxiety. Sometimes the same can occur with adult patients where family therapy often helps couples shift the balance in their relationship. Family therapy usually relies on a ‘systems’ approach where the whole family is the focus, not the individual members.

  ‘Behavioural family management’ using a problem-solving approach helps families of schizophrenia patients. Patients break down more often if they live in highly emotional families – especially where there is tension and criticism. It may be very difficult for the family to avoid this, so the treatment is aimed at identifying flash-points in the relationships and finding alternative solutions (e.g. going into another room rather than arguing back). This has been shown to reduce breakdown rates by almost as much as medicine, but is protracted and difficult to do.

  Crisis therapy is in here with systems therapies because it deals with immediate issues. You don’t have to dig around in crisis or family therapy – it’s all there in front of you. Crisis therapy is dramatic, often ultra short-term, and handles strong emotions, often with limited attention to their origins. While the family therapies are generally well established there remain doubts about crisis therapy. Some researchers suggest, for example, that debriefing after trauma can even make things worse. Presumably it interferes with the healthy processes of forgetting distressing events.