The diagnosis of a psychiatric condition is very important, but it isn’t the whole story. All a diagnosis tells us, is what features a person has in common with everyone else who shares the same diagnosis. For example, a person with a diagnosis of Social Phobia has the same core diagnostic symptoms as everyone else with Social Phobia. However, it doesn’t tell us anything about the unique individual and what important factors may predispose, exacerbate or perpetuate their condition.
In order for treatment to be most effective, the psychiatrist needs to consider:
- What is the evidence-based treatment for this condition? What does the research tell us? What do the Treatment Practice Guidelines recommend? The therapist needs to be objective and not just rely on which therapies they are most familiar with. The treatment needs to be targeted to the condition and to the individual.
- Each individual presents with their own unique circumstances. There may be a family history of a particular condition and therefore a possible genetic predisposition. Or a person’s experience in childhood or adolescence may be important in his or her presentation. There may be a history of difficult relationships or interpersonal conflict more generally. Does a person’s health, fitness or substance abuse, for example, have an effect on their condition? Do they have adaptive or maladaptive styles of coping? How do they manage their emotions?
So, it is important to come to an objective understanding of which diagnoses are certain and what exactly we are treating. It is also vitally important to understand the various biological, psychological and social factors that are important with regard to each individual. We need to develop an understanding of how all these factors are connected. This will lead to a more sophisticated understanding of the person.
Once we have a sophisticated understanding of the person, and place this in the context of their life history to date, we can then develop a sophisticated management plan based on the best evidence. If we don’t ask about these details, then we will only have a limited understanding of the person and the management will be unsophisticated or only partially helpful at best.
The types of therapy practiced reflect the requirements of the individual, person-centered, evidence-based therapy as outlined above.
- Behavioural Therapy
- Cognitive Behavioural Therapy
- Acceptance and Commitment Therapy
- Psychodynamic Psychotherapy
Most people benefit from taking techniques from the different types of therapy and tailoring them to the individual’s specific clinical needs rather than using a standard formula with a particular therapy, which is the same for everyone. In Psychiatry, as with the rest of medicine there is no such thing as a “one approach fits all.”
People sometimes ask “do I have to take medication.” Or more bluntly, people sometimes say “I don’t want to take medication.”
It is important to work with the individual to find therapy that is evidence-based, but also acceptable to them. There are current patients who aren’t on any medication and no one should be coerced into taking something that they are uncomfortable with.
For the conditions where medication is an important therapeutic modality, sometimes the only thing that can be said is “The evidence strongly suggests that medication and psychotherapy are more effective than medication alone or psychotherapy alone etc.” There are some conditions that are virtually impossible to treat without medication and there is a duty of care to inform people, if this is the case.
The importance of regular exercise, interests and social interactions are a few examples of non-medication/non-psychotherapy factors that can assist people to recover. These and many other factors need to be considered for each person.
The importance of the clinical therapeutic relationship between doctor and patient has long been understood. This is the case not only in Psychiatry, but also in the other medical disciplines. However, it is perhaps most clearly evident in psychiatry. A strong therapeutic relationship is itself a powerful therapeutic agent towards improvement and recovery.
There are some conditions for which there is no one type of psychotherapy that is superior to another, but where the strength of the therapeutic relationship and regular sessions seem to be the most important factors.
Trust and respect need to be established over time and there are no short cuts. If a person can commit to regular appointments over time, there are generally better results than for those who visits are infrequent and irregular. However, infrequent and irregular appointments are still better to not coming at all and ignoring the difficulties!