Psychotherapeutic treatment for rheumatoid arthritis one thousand years ago

Psychotherapy in the medically ill: a commentary

OBJECTIVE

To overview the field of psychotherapy in the medically ill. Rather than attempting a systematic review of this very extensive area, the article seeks to capture some of the main threads and issues of importance.

METHOD

The subject is looked at under four headings: (i) which illnesses have attracted research interest in psychotherapy; (ii) which outcome measures have been chosen; (iii) which modes of intervention have been used; and (iv) finally a review of the methodology and the results obtained.

RESULTS

Some illnesses have attracted much more psychotherapeutic interest than others; the differences are haphazard. Outcome measures on the whole have focused on coping with illness and psychological distress, with a smaller number looking at disease outcome. Only short-term changes have been sought in the main. The most commonly used modalities of therapy have been cognitive-behavioural; additionally, supportive information-giving and group therapy have been trialled. Benefit in terms of all these have been reported, but the majority of studies are weakened by major methodological shortcomings.

CONCLUSION

There is an overall paucity of well-designed studies that clearly demonstrate psychotherapy as an efficacious treatment in the medically ill. The field is hampered by the lack of a clear conceptual thread recognizing the long-term and diverse experience of patients with medical illness and relating this to the question of the part psychotherapy should play. Future work needs to concentrate on appropriate selection of patients who might benefit, as well as including a wider range of more clinically relevant outcome measures and more stringent methodology.

Encounter and psychotherapy: a look at the overlap

Human relations training has moved from the original T-group emphasis on group process, through focusing on the individual's mode of interacting in the group, to the use of the encounter situation for fostering personality change. Psychotherapy is moving out of the dyadic relationship into groups using increasing degrees of confrontation. The resulting overlap in group techniques calls for examination of the part each can play in the overlap area between the clear-cut functions of each specialty. The theoretical basis for differentiation lies in the respective models of awkward ("neurotic") behaviour: psychotherapy starts from the pathological and emphasizes intrapersonal structure, while encounter starts from full-functioning behaviour and emphasizes interpersonal interaction. Practical responsibilities can be divided between encounter and psychotherapy on the basis of the level achieved by an individual moving through a hierarchy of ascending personal achievement levels. Because of the high probability of individuals interchanging between encounter and psychotherapy, practitioners will need to have at least basic knowledge of both systems. Rapprochement could eventually come through the systematic extension of existential psychotherapy.