Psychiatric training and treatment under the microscope

Debate has raged in Scandinavia this year about over-reliance on cognitive behavioural therapy in psychiatric treatment, and growing awareness of a prevalence of over-medication. With treatment approaches narrowing, university curricula in psychiatry and psychology have followed suit, with worrying implications for producing quality practitioners.

In March this year the Norwegian newspaper Morgenbladet published an article on how cognitive behavioural therapy, or CBT, has since the 1960s become the dominant treatment method in clinical psychiatry and psychology in Sweden and the UK, and soon also in Norway.

A large number of articles published over the summer confirmed this trend.

The lion’s share of research is conducted on CBT, and health authorities and universities disproportionately recommend this form of therapy. It was also noted that at universities in the UK and Sweden, CBT is often the only therapy form taught.

In Sweden a high-level psychiatric group under the Royal Science Society in 2009 referred to severe shortcomings in Swedish psychiatric research, and recommended strengthening of doctoral education, international collaboration and other measures at research hospitals.

And seven medical doctors-psychologists wrote an article in the Swedish newspaper Svenska Dagbladet in December 2011 arguing that the massive investment in CBT had “strangulated other therapies”.

Of the more than 40,000 patients with a psychiatric diagnosis or long-lasting pain prioritised by the Swedish government alliance for treatment since 2009, 85% were offered CBT and 15% multimodal rehabilitation.

In total 115,000 CBT treatments were financed by government from 2009-11, at a cost of SEK2.3 billion (US$338 million), the seven medical professionals wrote.

Debate on optimal treatment outcomes

The increasing ascendancy of CBT is only one of two trends being reported in the treatment of patients with mental health problems: the second is the increasing realisation that over-medication is a major problem.

Both issues are currently part of the overall debate in Scandinavia on how to achieve optimal treatment outcomes. This is particularly pertinent given the trend, across the whole of Europe, to minimise residential care for mental health patients.

With increased use of modern medicine there has been a reduction in inpatient psychiatric care units. For instance, over nine years the number of patients in the psychiatric system in Denmark increased by 48%, while the number of beds for such patients dropped by 22%.

The Danish press debate this summer has been intense, focusing on poor conditions for psychiatric patients, with over-medication, neglect, loneliness and suffering reported by patients. One patient compared the treatment received in a psychiatric inpatient clinic with that he received later, when treated for cancer – telling about two different hospital worlds.

The Danish newspaper Politiken, which started and fronted the debate this summer, warned against "the future psychiatry" – a new cultural framework for the treatment of patients, where medication, short-term-therapy and low-cost intervention methods dominate.

Martin Lund, chief psychiatrist for Copenhagen hospital clinics, responded: “We are supporting the movement towards the future psychiatry, as do the politicians. But we are not supporting over-medication.”

Goodbye to Freud?

Bjørn Bredal, a member of the Politiken team, asked: “Shall the future of psychology and psychiatry mean goodbye to Freud?

“How do you treat a severe depression? In a classical long-term slow therapy, with emphasis on the history of the patient and much talk and many words – or in a modern, quick therapy with much medicine and few words?”

In Politiken a chronicle was published arguing that the crisis in psychiatry stems from the neglect of and opposition to Freud's thinking over the past 30 years.

The chronicle called for a rejuvenation of psychodynamic clinical training and practice. The call is for a reorientation of Freud's work and not to rely solely on "drugs and chemistry and cognitive psychology" as “quick fixes”.

Professor of philosophy and editor of the journal Social Studies of Science, Sergio Sismondo of Queen’s University in Canada, commenting on the trend towards over-medication and its implications for university training, told University World News:

“It is time that curricula recognised again the broader circumstances in which patients live. Otherwise, psychiatrists will be responding to short- and medium-term difficulties in ways that reduce their patients' quality of life forever.”

And Professor Gary VandenBos, professor of clinical psychology and executive director of the American Psychological Association’s office of publications and databases, told University World News:

"No theory and technique of psychotherapy is perfect for each and every patient with any and all problems and diagnoses. All major approaches to psychotherapy have some patients or conditions that they are better for than others.

“Sound basic training in psychotherapy requires exposure to and training in at least three approaches to psychotherapy” – psychodynamic, CBT and some type of affect- or emotion-focused therapy. “Training in a ‘brand named’ therapy is a good starting point, but training in other approaches is needed.”

VandenBos concluded: “Experienced therapists end up calling themselves eclectic or integrative therapists – using concepts and techniques from different schools of therapy, matching the intervention with the actual clinical needs or problems of the patients."

Right treatment for the right patient

David Healy, professor of psychological medicine at Cardiff School of Medicine in Wales and author of numerous books and article on psychopharmacology, told University World News:

“The over-medication of patients in psychiatric care in Denmark, and emphasis on CBT in the treatment of patients in Sweden, both stem from a misunderstanding of what controlled trials show.

“These trials began in the 1950s with the aim of keeping patients safe – but they are now the main drivers of over-treatment and main way in which the problems linked to treatment are concealed.”

In an extensive evaluation (63,000 subjects) done for the Ministry of Social Affairs by researchers in the department of environmental medicine at the Karolinska Institute in Stockholm, a significant effect upon re-entry to work of the CBT-treated group was not demonstrated.

While some positive effects of treatment were found, project leader Hillevi Busch stated in an interview with Svenska Dagbladet that the evaluation demonstrated that those who had received treatment with CBT or multimodal rehabilitation, after one year had more days away from work than was the case for the control group that received no treatment.

And Jim Gottstein, president and CEO of the Law Project for Psychiatric Rights (PsychRights) told University World News: “Interestingly, the Open Dialogue approach, used in Western Lapland, is currently getting the best results in the world as far as is known, with 70% to 80% of people presenting with psychosis recovering.”

Gottstein said in that particular trial those being treated were given “psychotropic drugs in a very selective manner”.

He concluded: “Therapy is such an intensely personal activity that it is very important that there be a good fit. The main thing is for people [patients] to be made to feel safe, for their experiences to be validated, for them to be given the time they need, and for them to be given the type of support and help they want, with nothing forced upon them.”

Wolfgang Fleischhacker, MD, professor of psychiatry at the Medical University of Innsbruck and managing editor of the journal Psychiatrie und Psychotherapie, told University World News: “Rather than pitching one treatment modality against another one, it would be more important to emphasise that the real challenge is to find the right treatment for the right patient.”