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As a psychiatrist, I have been trained in the use of the biopsychosocial approach or model to the assessment and management of the people that seek my help.
According to this model, mental disorders (but also mental health difficulties) are rarely due to a single cause; mental illness usually develops through the complex interaction of biological (genes and chemical imbalances), psychological (personality and coping skills) and social factors (employment or financial problems).
Similarly, the biopsychosocial approach is helpful to the management of mental health difficulties and mental disorders. For these reasons, mental health teams are multidisciplinary and consist of a number of different professionals: doctors (psychiatrists), nurses, psychologists, psychotherapists, occupational therapists and social workers. A doctor’s role is to make a diagnosis and prescribe medication (biological treatment). Psychologists and psychotherapists deliver psychological therapies. Social workers and occupational therapists can help with practical and social problems.
In the UK, the NICE (National Institute for Health and Care Excellence) guidelines advocate the use of the biopsychosocial approach (psychosocial interventions and/or medication) in the management of a range mental disorders, including depression and anxiety. Yet, in practice, the expectation is that I prescribe medication to every patient.
There are, of course, certain conditions where medication should be the mainstay of a patient’s treatment. For example, psychotic disorders, such as schizophrenia or manic psychosis, usually improve with medication alone, but these disorders are relatively rare; furthermore, because patients lack insight (they do not know that they are mentally unwell), they wouldn’t come to an outpatient psychiatric clinic (these are the patients who are most likely to get sectioned and be detained to a psychiatric hospital).
On the contrary, non-psychotic disorders, such as depression, anxiety and personality disorders, are far more common. These patients are far more likely to seek help, for relief from their symptoms. From my clinical experience, these are also the patients that are more likely to benefit from therapy than medication.
Indeed, in the management of non-psychotic disorders, medication may have a very limited role to play; tablets may help provide some relief from the symptoms, but they will not necessarily treat the underlying cause. This is where psychotherapy comes to place; it can help by looking at underlying schemata and linking the current symptoms with the past and the root causes of a non-psychotic disorder.
Let’s take depression as an example. Research shows that depression is often associated with an imbalance of certain chemicals (serotonin) in the brain (biological factor), and that antidepressants work by increasing the availability of these chemicals. However, we all know that certain events in one’s life tend to trigger episodes of depression (a significant loss), whereas ongoing difficulties and stressors tend to perpetuate one’s symptoms (social factors). And let’s also not forget that certain individuals may be more prone to depression (psychological factor). For this reason, a holistic approach to the management of depression will have to go well beyond the prescription of antidepressant medication. From my experience, psychotherapy is usually the most important component in the holistic management of depression, as well as of other non-psychotic disorders.
To use a medical metaphor, let’s imagine someone breaking their leg. In the acute phase, they will need painkillers; they will also need a cast and crutches, until the fracture heals and they can start bearing weight walking again. However, they will also need physiotherapy to recover their strength, and of course the whole recovery process requires their active participation: even with the crutches, they will still need to do the walking. Something similar happens in the management of mental disorders. The painkillers, the cast and the crutches are akin to antidepressants and other medication for mental disorders. Physiotherapy is akin to psychotherapy.
But, what exactly do I mean by psychotherapy? In fact, there is a large number of psychological therapies: for example, psychoanalysis and psychodynamic or psychoanalytic psychotherapy, cognitive behavioural therapy (CBT), mindfulness-based therapies, such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR), art therapy, and counselling. These therapies differ both in their theory and the therapeutic approach used. Although they’re collectively known as ‘talking therapies’, some psychological therapies encourage ‘doing’ and learning practical skills, and not just ‘talking’; this is particularly true for CBT, mindfulness-based therapies, and art therapy.
Despite their different therapeutic approaches, different psychological therapies have a very important element in common: the relationship with the therapist (often called therapeutic relationship or alliance). Research shows that this plays a very important role in the outcome of therapy (whether it is successful or not) no matter what therapeutic approach has been used.
Another benefit (again irrespective of the type of psychotherapy) is that they encourage us to pay close attention to our internal world (feelings and thoughts) and this alone can often be therapeutic. Psychotherapies provide a space where this internal world can be acknowledged, validated, understood and explored, and I strongly believe that this is where one of their greatest benefits lies.
A challenge, however, is that psychological therapies do not provide a quick fix. Improving our well-being and mental health is a skill that can be learned and developed over the rest of one’s life. It is a skill that takes consistent daily practice just like learning a musical instrument, or a foreign language. It therefore requires time, effort (practice), persistence and patience (something that many patients may not be very keen on). In many ways, therapy is like gardening: we have to prepare the ground first, then plant the seed, ensure that they are adequately watered and nourished, and then wait patiently for the results.
Dr Alex Chatziagorakis is a London-based consultant psychiatrist and a member of the Royal College of Psychiatrists.
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