Psychotherapy

  It soon became clear that there was more to psychoanalysis than Freud’s original remote and neutral exploration of the unconscious. The relationships formed in this intense treatment were themselves found to be influential. Analysts began to explore these relationships and experimented with more active approaches and with different types of therapy (time-limited therapies, more structured therapies, therapies in groups and in families, etc.). These psychological approaches, in which the relationship was used actively through talking to promote self-awareness and change, are broadly understood as ‘psychotherapy’. Most of the early psychotherapies leant heavily on Freud’s theories (often called ‘psychodynamic psychotherapy’ to emphasize the impact of thoughts and feelings over time) but several of the newer ones do not. These (e.g. non-directive counselling, existential psychotherapy, transactional analysis, cognitive analytical and cognitive behaviour therapy) draw on a range of theoretical backgrounds.

  What they all have in common is that they use communication within a formalized and secure relationship to explore difficulties and find ways of either adapting to them or overcoming them. Most psychodynamic psychotherapies also require (like psychoanalysis) that the therapist undergoes a treatment themselves as part of the training. Psychoanalysis remains very tightly controlled, by defining strictly who becomes a psychoanalyst, but psychotherapy is a loose concept. Some schools of psychotherapy are strict about whom they admit but the title ‘psychotherapist’ could, until recently, be used by anyone. Most psychotherapists are not psychiatrists although most psychiatrists have some psychotherapy training and skills. Some psychiatrists even work mainly as psychotherapists. Chapter 4 is devoted to psychoanalysis and psychotherapy.

What is psychiatry?

  So if it is not psychology and not psychoanalysis or psychotherapy, what is psychiatry? There are overlaps with the other ‘psychs’ but there are some fundamental differences. First and foremost psychiatry is a branch of medicine – you can’t become a psychiatrist without first qualifying as a doctor. Having qualified, the future psychiatrist spends several years in further training. He or she works with, and learns about, mental illnesses in exactly the same way that a dermatologist would train by treating patients with skin disorders or an obstetrician by delivering babies. Within medicine, psychiatry is simply defined as that branch which deals with ‘mental illnesses’ (nowadays often called ‘psychiatric disorders’).

  Medicine is fundamentally a pragmatic endeavour. While drawing heavily on the basic biological sciences and scientific methods, the ultimate test of whether a treatment is right is if the patient gets better. We don’t have to know how the treatment works. Therefore the definition of psychiatry is not based on theory, as in psychology or psychoanalysis, but on practice. Whatever is viewed as mental illnesses (and this has changed over time), and whatever treatments are available for these illnesses, will determine what a psychiatrist is, and what he or she does.