Psychotherapy made perfect

In their recent assault on the technological paraphernalia of psychiatric interventions Bracken et al ^{Reference Bracken, Thomas, Timimi, Asen, Behr and Beuster1} asserted confidently that (in psychotherapy) ‘the evidence that non-specific factors, as opposed to specific techniques, account for nearly all the change in therapy is overwhelming’ (p. 431). I am not sure that many would disagree strongly with this in our present state of knowledge; the qualities of the therapist are more important than specific technical skills. But both are desirable, and anyone involved in psychotherapy research will be aware of the literature that good fidelity to treatment leads to better outcome than poor fidelity. ^{Reference Kingdon, Tyrer, Seivewright, Ferguson and Murphy2–Reference Erkkiä, Punkanen, Fachner, Ala-Ruona, Pöntiö and Tervaniemi4} When I was a postgraduate trainee our group carried out a little exercise in assessing which of the many glitterati adorning the consultant staff of the Maudsley and Bethlem Royal Hospitals we would choose to consult if we had a psychiatric illness. The winner by a country mile was not a world leader in research, policy or practice, but a well-rounded, modest, compassionate and approachable consultant whom all of us felt we could go to comfortably and confidently with our problems. He did not claim any special expertise in psychotherapy or any other branch of psychiatry, but few of us felt this mattered; it was the human qualities that counted.

In this issue we have many reminders of the importance of humanised skilled psychotherapy. From what I have heard, the Dorset service for personality disorders is well-regarded, and seen as flexible and facilitatory, but Clarke et al (pp. ) in describing the benefits of cognitive analytic therapy in the treatment of this group of disorders cannot properly address this non-specific element. But by not confining their study to those with borderline personality disorder and by ensuring that all their therapists reached minimum levels of competence, they were setting a benchmark for the training of others. Their results are encouraging but practitioners will know of many other therapies in the field that employ similar techniques (Mulder & Chanen, pp. ) and which may be equally good ^{Reference Bateman5} – what is most interesting in this area is that there are so few head-to-head comparisons of different psychotherapies and it seems likely that even when these are carried out ^{Reference Giesen-Bloo, van Dyck, Spinhoven, van Tilburg and Dirksen6,Reference Doering, Hörz, Rentrop, Fischer-Kern, Schuster and Benecke7} the allegiance of the therapist to the treatment ^{Reference Godfrey, Chalder, Ridsdale, Seed and Ogden3,Reference Luborsky, Diguer, Seligman, Rosenthal, Krause and Johnson8} has the tendency to distort the interpretation of the findings.

Where we are still remarkably ignorant is predicting how much psychotherapy is needed for an individual patient, and this is where the criticisms of Bracken et al carry some weight. It is pointless for a therapist to treat a patient for 10 sessions because this is set down in policy somewhere, when clinical common sense screams ‘add a few more’ to complete the job, and for many interventions we would be arrogant to specify how many sessions are going to be needed. ^{Reference Leichsenring and Rabung9–Reference Holmes11} What is encouraging is that psychotherapy in all its forms is now available to a large number of people who require this treatment, at least in high-income countries, as Jokela et al (pp. ) and Meadows & Tylee (pp. ) indicate. Technology has also enabled computerised therapy to replace, or add to, face-to-face contact but we still need to be reminded that this can never replace other treatments entirely, as Wagner et al (pp. ) have shown in the treatment of bulimia nervosa. Jeste & Palmer (pp. ) also emphasise the psychotherapeutic aspects in a model of positive old age psychiatry, and remind us that basic psychotherapy is an essential component of all good psychiatric care. Even the study by Van der Schaaf et al (pp. ), in examining the need for seclusion, demonstrates the importance of psychotherapy. One of my patients, who dreaded her stays in hospital, initiated a campaign to change the direction of the cameras in the nursing office – to point inwards rather than outwards – as her claim was that this would demonstrate the staff were spending almost all their time in the office rather than interacting with patients. Not a bad hypothesis, and even the critics of psychiatric technology might see some value here to reinforce their cause.