Psychotherapy skills in the real world
Authors: Julie Sladden
Publication date: 22 Jan 2005
Basic psychotherapy skills can be extremely useful in a doctor's everyday practice, says Julie Sladden. Here she outlines some of the different types and explains how you can put them to use
Ever thought about a career in psychotherapy? No? Well you're probably not alone. Psychotherapy is considered by some to be a Cinderella branch of medicine. It's “soft and fluffy,” wanting for evidence, and can anyone actually understand psycho speak? But psychotherapy skills can have a place in everyday practice—no matter what your specialty. And the good news is that you don't need to go off and train for years in psychotherapy to incorporate some simple skills and strategies into your practice. It's not only your patients that stand to gain—you may benefit too.
What is psychotherapy and why are there so many different types?
A working definition of psychotherapy is “the treatment of disease by psychological means”  or, in a nutshell, “talking therapy.” Psychotherapy falls into three basic groups: cognitive behaviour therapy, psychodynamic therapy, and “other” therapies (such as systemic, humanistic, interpersonal, solution focused, and creative therapies). That there are so many different types of psychotherapy reflects more that the mind is complicated and that different people respond to different forms of therapy, rather than implying that psychotherapy doesn't work.
Why do some medics have trouble accepting psychotherapy?
As medics we have been taught to practise evidence based medicine. However, some forms of psychotherapy have scant evidence and conducting research can be difficult. There are several reasons for this. Many of the components of successful psychotherapy are difficult to measure—for example, how do you measure a “therapeutic relationship.” Also, to quote a recent BMJ article, “Although research is legitimately and necessarily a public activity, much of what is important in psychotherapy is legitimately and necessarily private.”  But the situation is slowly improving. The Department of Health's review of psychological therapies has outlined recommendations, based on levels of evidence, for certain types of psychotherapy. 
Another barrier to accepting psychotherapy comes from ourselves. During our medical training we are taught to examine the facts, remain objective, and not to get emotionally involved. Indeed, this is a healthy coping strategy for certain periods of our medical careers. However, two things can happen: firstly, we may become unaware of the appreciable emotional factors affecting our patients' health and wellbeing; and secondly, more worryingly, we may find it difficult to turn our emotions back on. In reality, becoming aware of one's own thoughts and feelings towards a patient can be immensely helpful in working out what is going on with him or her.
What possible use is psychotherapy in the real world?
So, in an NHS full of needy patients and overbooked clinics where does psychotherapy fit in? The reality is that doctors in all disciplines see patients who would benefit from a few strategically directed questions. Gastroenterologists see patients with irritable bowel syndrome, dermatologists see people whose skin reacts to stress, and surgeons treat people with chronic conditions for which no cause can be found. As one general practitioner and psychotherapist put it to me, it's the interface between physical health and emotional wellbeing that is so fascinating and cannot be ignored.
So, here are a few psycho skills, and their potential applications, for you to consider.
Challenging negative thoughts... theirs and yours
Challenging distorted thinking and patterns of behaviour is the remit of cognitive behaviour therapy (CBT). CBT “helps create more positive and realistic attitudes to negative thoughts and emotions”  and has been shown to be useful in treating many different mental health problems.  It's easy to incorporate CBT skills into a consultation—for example, activity scheduling or challenging negative thoughts—and we too can benefit from examining our own patterns of thought and behaviour (see Further reading).
That sinking feeling...
Psychodynamic therapy is based on the premise that how you are today depends largely on your childhood and early life and the maladaptive behaviours you learnt at that time. By analysing that time and gaining insight, you get better. Psychodynamic skills can help us understand why some patients repeat relationship patterns with different partners, and also why some patients leave us feeling drained at the end of a consultation. For example, recognising and understanding transference (when the patient transfers feelings and attitudes from the past into the present) and counter transference (what the doctor feels in response to the patient) can be extremely useful in unearthing what issues need to be addressed so that the patient can move forward.
Looking for patterns instead of causes is the remit of systemic therapy.  By encouraging a patient to consider their role within a group and look from different perspectives, they gain insight and become able to move forward. For example, if patient X is unable to say what is “wrong”—you could begin by asking, “What would your partner say is wrong?” This form of questioning encourages the patient to move out of their circular thought processes and view the problem from a different perspective. Asking a patient to comment on the difference between his interpretation of the problem and his partner's encourages insight into how the problem affects individuals within the “system” differently.
Another psychotherapy which recognises that psychological symptoms occur within the context of interpersonal relationships is interpersonal therapy. This type of therapy focuses on the interface between interpersonal relationships and psychological symptoms by looking at specific stress areas in a patient's life. For example, a mother who has given up a career to stay at home with the children may be struggling with role transition. By allowing her to acknowledge the loss of her old role, and encouraging her to seek transition objects and build a support system by making new contacts, she may come to regard her new role as an opportunity for growth.
Solution focused therapy is based on “solution building” rather than “problem solving.” By looking at future hopes and current resources, the patient is encouraged to slowly build their own solution by taking small steps towards their future goal. Solution focused skills can be easily incorporated into a short consultation. For example, asking a patient to rate their situation on a scale of 1 to 10 creates an opportunity to encourage the patient. If they say three, then by asking them what three means you can help them to focus on the positives in their life that make the score a three and not a two, one, or zero. Then, by asking what a four would be, the patient is able look at what things could be changed to improve their situation in small, manageable steps.
Needs and resources
A “new kid” on the psychotherapy block is the human givens approach. It is based on the theory that humans have evolved with a set of distinct needs, which need to be met for health to prevail. Cofounder Ivan Tyrrell explains: “Humans have emotional needs to feel connected, they must feel secure, they must get food, and they must have status. If these needs are not met, mental health problems result. In essence, our treatment plan is to get those needs met. Humans also have innate resources—they are found in imagination, long term memory, our ability to learn through metaphor, and our dreaming brain. It's the understanding of innate human needs, plus the resources that nature has provided to get these needs met, that makes people healthy again.”
Already in use in the NHS
The human givens approach is already being used in the NHS. Farouk Okhai, consultant psychiatrist in psychotherapy, offers human givens psychotherapy in his department and has considerably reduced his psychotherapy waiting lists—purely, he believes, because of the rapid and lasting resolution of patients' psychological problems with the method. And proponents enthuse about its applications in busy clinic settings. Ross Brittleton, a human givens psychotherapist, says, “The HG [human givens] approach provides me with a wide range of techniques—including guided imagery, CBT methods, solution focused methods, relaxation techniques, and post-hypnotic suggestion—which can be used to make the patient feel better very quickly.”
The anecdotes are positive, so where's the evidence? Ivan Tyrrell comments: “People are starting to do it [research]—but we aren't doing it ourselves. If a plane is flying, you don't need to keep showing that it's possible to fly. In the same way we have shown that our method works and it works repeatedly. So it's up to people who want to provide evidence to do the research.”
Where to from here?
So, what if you're interested in finding out more about psychotherapy but you're not sure how to go about it? Well, the good news is that you don't have to go off and do a four year course to be able to incorporate some psychotherapeutic skills into your daily practice. Anyone who has sent their patient in the direction of a book store will know that there is a wealth of self help materials as well as books outlining basic techniques (see Further reading). If you like doing things “properly” there are many courses available, teaching numerous forms of psychotherapy—some are even done as short weekend courses (see Further information). Either way, even if you gain one extra skill in your treatment toolbox, it's not only your patients that stand to gain. Insight into the emotional world of our patients is a useful skill, but “knowing thyself” can be a powerful thing in a doctor's life too.
Jones P, Singh S, Aquino P. Cognitive behaviour therapy in practice. BMJ Careers 2003;326: 181-2.
Greenberger D, Padesky C. Clinician's guide to mind over mood. New York: Guilford, 1995. www.padesky.com
Iveson C. Solution-focused brief therapy. Advances in Psychiatric Treatment 2002;8: 149-57.
Judd F, Weissman M, Davis J, Hodkins G, Piterman L. Interpersonal counselling in general practice. AFP 2004;33: 332-7.
Griffin J, Tyrrell, I. Human givens: a new approach to emotional health and clear thinking. Chalvington, UK: Human Givens Publishing, 2003. www.humangivens.com
www.psychotherapy.org.uk—UK Council of Psychotherapists. Information on different types of psychotherapy, training, and member organisations
www.brieftherapy.org.uk—Brief Therapy Practice. Offers training in solution focused therapy from two-day courses to diploma
www.bacp.co.uk—British Association for Counselling and Psychotherapy. Information on accredited courses, publications, and research
www.bap-psychotherapy.org—British Association of Psychotherapists. Specialises in psychoanalytic psychotherapy training, including evening and weekend courses
www.psychnet-uk.com—Mental health and psychology directory. Useful for searching individual therapies
www.babcp.org.uk—British Association for Behavioural and Cognitive Therapies. Information and courses
- Krebs WA, ed. Collins Gem Australian English Dictionary . London: Collins, 1981.
- Goldbeck-Wood S, Fonagy P. The future of psychotherapy in the NHS. BMJ 2004;329: 245-6.
- Department of Health. Treatment choice in psychological therapies and counselling: evidence based clinical practice guideline (brief version) . London: Stationery Office, 2001.
- Jones P, Singh S, Aquino P. Cognitive behaviour therapy in practice. BMJ Careers 2003;326: 181-2.
Julie Sladden freelance medical journalist