The Power of Plain Old Psychiatry

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AFFIRMING PSYCHIATRY

Generic Forms of Psychiatry

Psychiatry is regularly criticized for offering ineffective or unproven treatments. This criticism is demonstrably false. Medications, psychotherapy, and a host of other interventions constitute well-validated medical treatments for specific mental illnesses. But there is another more general aspect of psychiatric treatment which both critics and advocates of psychiatry regularly forget: the simple power of seeing a psychiatrist.

A psychologist colleague of mine once wrote a fine book with the subtitle, “Treating Trauma with Plain Old Therapy.”¹ Here, I will borrow his idea to discuss plain old psychiatry, the generic and implicit interventions that patients receive simply by virtue of seeing a competent psychiatrist for treatment. Whether patients ever take psychotropic medications or engage in explicit psychotherapy, all of them receive powerful treatment. In a previous column, I highlighted some of these treatment elements as factors in the so-called placebo effect.² Here, I would like to detail more of these elements and the substantial body of scientific evidence which stands behind them.

The Therapeutic Relationship/Alliance

The therapeutic relationship is not unique to psychiatry, but it is the basis for all psychiatric treatment. Psychiatrists (like other mental health professionals) have special expertise in forming positive, accepting, helping relationships with patients of every kind. Not surprisingly, multiple studies and meta-analyses have shown that a better therapeutic alliance and relationship are associated with decreased drop-outs, increased treatment adherence, and better treatment outcomes.³ While better attendance and adherence to treatment may not sound like therapeutic outcomes in themselves, 20% to 30% of patients drop out of mental health treatment prematurely, and 70% of those do so within the first 2 sessions.^4,5 Individuals who drop out of treatment have no chance of treatment success. Given the effort it takes to access mental health treatment in the first place, these numbers are substantial.

Of those that do remain in treatment, research across medical specialties (including psychiatry) has shown that patients adhere to prescribed medication regimens about 50% of the time.⁶ So simply staying with treatment is the biggest barrier to treatment success, and a positive therapeutic relationship is fundamental to this process.

Regarding treatment success, meta-analyses show that the therapeutic alliance is associated with psychotherapy success regardless of other factors.⁷ Interestingly, it is a significant contributor to the success of pharmacotherapy as well.⁸ Factors such as empathy, positive expectation, and joint decision making have been shown to make a difference across psychiatric treatments.³

Good Psychiatric Management

Borderline personality disorder (BPD) was once notorious among mental health clinicians for being excruciatingly difficult to treat. But after the success of dialectal behavior therapy (followed by validation of specific psychodynamic treatments), researchers also found that “good psychiatric care,” was quite successful. What is “good psychiatric care”? Competent general care tailored to BPD. Specifically, it is a “generalist model that medicalizes the disorder, emphasizes psychoeducation, and focuses on social adaptation.”⁹

Another generalist model, structured clinical management (SCM), has shown success in short and long-term trials comparing it with mentalization based therapy, an empirically validated psychodynamic treatment. SCM also emphasizes psychoeducation, along with social support and explicit safety planning.¹⁰ Such treatment interventions may be applicable across personality disorders generally, though research is currently lacking. Meanwhile, a general psychiatric approach has proven helpful for another classically difficult-to-treat disorder: anorexia nervosa. Specialist supportive clinical management was developed as a control group treatment for specific psychotherapies of anorexia. But it subsequently proved to be just as effective as other therapies in 4 randomized controlled trials. It utilizes psychoeducation, collaboration around treatment goals, and a nondirective supportive therapy approach.¹¹

To my knowledge, such generalist approaches have not been extensively tested for other disorders. But given the unexpected success of these approaches for BPD and anorexia, standard psychiatric management (adapted to each disorder and patient) is likely to provide substantial benefits for those seeing a psychiatrist for a variety of other disorders.

Psychoeducation

In psychiatric care of all kinds, psychoeducation is an organic component of the diagnostic process. Good psychiatric diagnosis connects patients’ experiences of distress with an explanation of their symptoms through the avenue of psychoeducation. This provides patients with a model for both understanding and addressing their psychiatric disorders. Psychoeducation functions as a doorway to other treatments, but in itself has measurable therapeutic power. For instance, psychoeducation (especially family psychoeducation) has shown measurable benefits for patients with major depression in multiple studies.^12,13

A recent meta-analysis found that psychoeducation reduced illness recurrence for patients with bipolar disorder.¹⁴ Even more strikingly, psychoeducation has proven to be an important therapeutic option for schizophrenia. In spite of the fact that schizophrenia symptoms show poor placebo response and are frequently resistant to medications, multiple reviews and meta-analyses have found that psychoeducation makes a difference.¹⁵ An important network meta-analysis found that both patient and family psychoeducation for schizophrenia decreased the odds of relapse at 1 year compared to treatment as usual.¹⁶ Finally, a review of 21 studies showed that dyadic psychoeducation for both dementia patients and their caregivers found positive benefits for both behavioral symptoms and quality of life.¹⁷

Common Factors of Therapy

Many specific psychotherapies have proven effective for mental illnesses. So many, in fact, that clinicians and researchers alike wonder if common elements between them are doing most of the work. For instance, Cuijpers et al found that no less than 15 different psychotherapies were likely to be effective for major depression.¹⁸ Meanwhile, researchers such as Wampold have long maintained that common factors make a more important contribution to efficacy than specific techniques, and offered evidence that factors such as empathy and collaboration around common goals produce a greater effect size than specific techniques.¹⁹ While Cuijpers et al tentatively suggested that common factors account for 50% of treatment effects, they and others have strongly cautioned that current research is inadequate to resolve this issue.^20,21 At the same time, no one doubts that common factors do play a role in the healing power of therapy. Such common factors are likely to be a part of most psychiatric treatment, since they may include elements such as the real relationship, reassurance, reality testing, and exploration of the internal frame of reference.²⁰

Supportive Therapy

Supportive psychotherapy “has rarely been studied as the primary treatment for anything.”²² Instead, it is a generic, nondirective approach which usually functions as a treatment comparator for more specific therapies which are being actively studied and promoted. One expert dubbed it the “Rodney Dangerfield” of therapies which gets little respect.²² At the same time, supportive therapy may be the most commonly used type of therapy by psychiatrists, and “it can be said that the basic principles of supportive therapy are at the heart of all doctor-client relationships…”²³ Supportive therapy is characterized by nonjudgemental acceptance, the careful use of information and advice, and supportive encouragement. Most psychiatrists take a generally supportive approach with most patients, unless other more specific approaches are used. Despite a lack of researcher allegiance, supportive psychotherapy has proven to be effective for major depression in a rigorous meta-analysis,²⁴ and has shown benefit for conditions such as body dysmorphic disorder²⁵ and social anxiety disorder.²⁶

Concluding Thoughts

All the above factors have substantial scientific evidence for their effects. But my point is not that these 5 factors are separate and work independently. In fact, they are heavily overlapping, and are most likely variations of one broad approach. But my point is that this broad approach is characteristic of how psychiatrists work in most settings with most patients, and that the above research demonstrates its therapeutic power in a variety of circumstances.

Psychiatry is a medical specialty which is relationally based. Psychiatrists are trained to relate to patients in a way that is respectful, reality-oriented, and therapeutic. Regardless of whether patient encounters occur in an emergency department, hospital floor, or outpatient office, psychiatrists habitually bring these general-purpose tools to bear. Patients who see a psychiatrist are likely to experience therapeutic effects simply by seeing a psychiatrist. More specific therapies are also proven to be effective and add to the overall power of treatment. Patients should be confident about what psychiatric care offers, regardless of whether they utilize any specific treatments, or even recognize that they are receiving therapeutic care. Why? Because science says so.

Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

References

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