An old premise of medical ethics obliges doctors to keep secret all the information obtained from the patient and especially during their hospitalization . This professional obligation is known as confidentiality. The confidentiality therapist-patient governs all situations except those where other legal or ethical principle dominates the principle of personal autonomy.
In addition to patients, psychiatrists have obligations to the society in which they live and the profession they practice. The breach of confidentiality is only justified by the priority of the global benefit of society over the patient’s autonomy or when patients threaten to harm themselves or others because of their disorder. In some situations, doctors must inform the authorities, as specifically required; the law. A psychiatrist may be forced to break confidentiality in a subpoena to appear as a witness before a; court.
As a rule, clinical information should be shared with other colleagues with the patient’s permission, preferably in writing (although oral permission may be sufficient in many cases). Each permit serves only one block of information, and permission must be obtained again for the following statements, even if they are from the same party. A group of professionals within the circle of confidentiality share information without requiring special patient permission. Such groups include, in addition to the doctor, other members who collaborate in the treatment of the patient, clinical supervisors and consultants. Outside this circle of confidentiality is the patient’s family, the lawyer and the previous therapist; Sharing information with these people requires the patient’s permission.
The maintenance of sexual relations between therapists and patient is a threat to the proper progress of treatment and is not considered ethical. In the event that the emotional relationship between a patient and his therapist makes the progression of the patient impossible, another professional should be sought to take care of the continuation of the treatment.
The evolution of psychiatry in this century has transformed an asylum psychiatric assistance, focused on hospitalization and asylum, into another community-centered one. In community psychiatry it is intended that hospitalization is only necessary for periods of limited duration, in specific circumstances, and always framed in a therapeutic approach and a comprehensive care program that tries to avoid the institutionalization of chronic and severe psychiatric patients.
Indications of hospitalization in acute units
The psychiatrist who treats a patient regularly or, failing that, the one who attends the hospital emergency must decide on the need to enter a given patient in an Acute Unit . In all cases, this decision and the clinical and legal conditions in which it takes place must be reasonably communicated to the patient (if he is able to understand).
The hospitalization of psychiatric patients in the acute care is usually indicated in the following circumstances:
The decision to enter the patient or not depends, usually on three factors:
- Suicidal risk of the patient in the immediate future.
- Need for treatment of basic psychiatric disease .
- Medical-surgical impact of a suicide attempt already carried out.
Among the suicides they usually enter:
- Patients with psychotic activity.
- Patients under the influence of drugs, especially hallucinogens.
- Patients who, after the autolytic attempt, lack family or social support.
- Patients who, after the autolytic attempt, maintain suicidal ideation or intention or; severe depressive symptomatology.
Presence of a critical element or somatic factor that acts as a cause of agitation and cannot be controlled on an outpatient basis.
Psychotic agitation, especially in cases of schizophrenia or mania, in which the family cannot control the patient. Occasionally, outpatient control may be attempted in one of these cases if the family can accept responsibility for medication control and the patient’s behavior, and nearby outpatient monitoring can be offered.
Alcohol withdrawal syndrome
Admission in this case is usually carried out in other hospital services other than psychiatry and the hospital psychiatrists tend to address the behavioral problems of these patients as consultants of the respective services. The recommended criteria for hospitalization in these cases are:
- Delirium Tremens (disorientation, visual hallucinations and agitation)
- Halluinosis (auditory hallucinations without disorientation)
- Seizures in a non-epileptic patient.
- Wernicke-Korsakoff encephalopathy (confusion, gait disturbance, ocular paralysis).
- Fever greater than 38.5º.
- Head trauma with loss of consciousness.
- Decreased level of wakefulness.
- Medical diseases (respiratory failure, hepatic decompensation, pancreatitis, gastrointestinal bleeding, malnutrition, etc …).
- Background of delirium, psychosis or seizures in alcohol withdrawal.
- Rejection of food to the point of putting health at risk
- Any psychiatric disorder that involves uncontrollable physical risk to a third party
- Need for electro convulsive therapy (ECT)
- Severe and unbalanced personality disorder that interferes with the patient’s functions
- Many other clinically serious circumstances in which treatment cannot be initiated or directed on an outpatient basis.
Psychotherapist and pharmacotherapy
For a very large percentage of patients, the best psychiatric treatment plan often involves the combination of medication and psychotherapy.
Indications of combined treatment
- Major depressive disorder.
- Bipolar disorder I and II.
- Distress disorder
- Obsessive compulsive disorder.
- Substance dependence
- Borderline personality disorder.
Two models are commonly used in current clinical practice to combine pharmacotherapy and psychotherapy: the models of one and two therapists. The model of a therapist implies that a psychiatrist carries psychotherapy and prescription of the medication with the same patient at the same time. The two therapist model divides the functions so that the psychotherapist and the doctor carrying the medication are different.
The two therapist model is indicated when the psychotherapist is not trained to prescribe medication or when the doctor prescribing psychotropic drugs is not experienced to provide psychotherapy. Another reason would be the economic reasons since psychotherapy carried out by a non-medical psychotherapist is usually less expensive.
Cognitive and behavioral psychotherapies
What are they?
Although cognitive and behavioral treatments; They have a theoretical approach and a different clinical practice, share many of its fundamental principles and, in many cases, are administered together with the intention of obtaining the greatest possible benefits for a given patient.
Unlike other psychotherapies, behavioral therapy focuses on the improvement of observable maladaptive behaviors of people (and avoids theorizing about the internal conflicts of people that are the basic work material in psychoanalysis). For behavioral therapists, as behaviors have been learned, unwanted ones (which in psychiatry would be called pathological) can be unlearned and replaced by relearning desired behaviors.
Cognitive therapy has had post-behavioral theory development and is partially based on it. The therapist, in addition to observing the patient’s behavior, observes what kind of thoughts he has and how he interprets the different events that arise in his world; These thoughts determine the patient’s way of feeling and behavior. Cognitive therapists are not interested in the cause of psychiatric problems, but approach the problem in a very direct and very practical way: as true; Inappropriate thoughts and interpretation habits lead to psychological or behavioral problems, the patient can be taught thinking strategies that preserve or relieve him of his depression, anxiety or eating disorder.
How does cognitive behavioral or behavioral therapy work?
The fundamental principle of these therapies is that what has been learned and is dysfunctional, abnormal or undesirable for whatever clinical reason, can be unlearned.
The first step is, then, to examine the behaviors, attitudes and thoughts of a specific patient and determine by analysis those to be treated.
Classical behaviorists start from the idea of people are likely to learn by conditioning, in the same way that dogs did in Paulov’s classical experiments .; People, in this way, would develop their behavior in a manner very similar to that of animals, although with greater complexity .; In the course of life, humans are subjects of a crowd; of prizes and punishments that shape the way they finally act; The complex training in rewards and punishments that life provides leads the human being to act without requiring immediate and continuous reward for it. In much of their behavior, human beings do not even associate; a certain way of acting with; immediate and specific rewards (for example, you go to work daily, without continually thinking about the end of the month payroll). If wrong behaviors have been reinforced and the right ones punished, misconduct may occur.
In the behavioral approach, if adequate attention is given, it is relatively easy to find a series of reinforcements that shape a particular behavior. In this treatment the therapist tries to be very specific when identifying the present problems. For example, review each and every one of the patient’s complaints in detail and make a list of everything that can and should be changed.
At the time of the intervention, the behavioral therapist has a series of techniques to deal with the problem:
- Systematic desensitization. It is based on the principle that the anxiety produced by a situation or object can be overcome by a gradual approach to the feared situation. In systematic desensitization, the patient is relaxed (with various methods) and, in a state of relaxation , the stimulus that causes the anxiety response is exposed.
- Gradual exposure It is similar to systematic desensitization except that it does not involve relaxation training and exposure is carried out in the context of real life, in real situations or objects.
- Flood. The therapist encourages the patient to deal directly with the feared situation, without gradual approach as in systematic desensitization or gradual exposure. The success of the procedure depends on the patient remaining in the situation that generates fear until he calms down and feels a sense of control.
- Participant modeling In the same way that irrational fears are acquired by learning, they can be unlearned by observing and imitating; to a fearless model who faces the feared object.
The ultimate goal of behavioral therapies is to turn the patient into his own therapist and train him to use only the techniques he learned during the treatment and; address in this way a threat of relapse.
In which cases does it work better?
These types of therapies are usually of choice in specific phobias, drug addiction, sexual problems and other disorders. In the case of specific phobias such as fear of heights, the first step is behavioral therapy. Usually this will constitute all the necessary treatment. Sexual dysfunctions, such as premature ejaculation or impotence; They also benefit from these therapies. Likewise, useful treatments are found in drug addictions as useful treatments to reduce anxiety, dependence, and as an effective method in learning alternative behaviors to combat stress. The Alcoholics Anonymous program uses a method for the treatment of alcoholism (called the “Twelve Step” program, which is basically a cognitive-behavioral therapy in a group format).
Behavioral therapies are also indicated in association with drugs such as clomipramine, fluoxetine or sertraline in obsessive-compulsive disorder.
For patients with depression, therapeutic recommendations will vary based on their severity. Severe depression, with significant weight loss, suicidal ideation and marked inhibition, requires inexcusably antidepressant medication. Moderate depressions respond well to medication, but cognitive behavioral therapy is an acceptable option in cases where for different reasons do not want to use drugs.
In many anxiety disorders cognitive behavioral therapy reduces; considerably anxiety and relieve social phobia. As in depression, the most severe disorders are often treated with medication .; The effectiveness of these therapies to avoid is not clear; relapses after remission of a panic disorder or social phobia.
How to know if it works?
One of the basic premises of cognitive behavioral treatment is that the results must be evident. Unlike psychodynamic therapy, cognitive therapy is directed directly towards symptoms of which the patient complains; The success of the treatment, for example, is assessed by the reduction of symptoms. In the case of phobias, for example, doctor and patient know that the treatment is giving the expected results if the patient is able to face, without needing to avoid it, the situation that frightened him.
Cognitive therapists often use scales to assess the progress of treatment; These scales are made with objective measuring elements that avoid the subjective assessment of disease symptoms . Most of these scales assign a different numerical value depending on the severity of the symptoms or the abnormal behavior that is considered, which allows the patient to be evaluated at different times of therapy.
Measurement scales are a diagnostic weapon of unquestionable value in cognitive therapies if they are used correctly by the professional who administers and interprets them.
Depending on the objectives, the total number of cognitive-behavioral therapy sessions needed is usually delimited; so that the patient can estimate the foreseeable time that will mediate until his improvement and, in case of financing, the total cost of his treatment.
Most treatments have an average duration of 3 to 6 months, with an approximate number of sessions of 20. At the beginning the frequency of appointments is usually greater and then the intervals between sessions are lengthened as the treatment progresses.
Many therapists offer a general script of what is going to be done in each session; of therapy that is very practical.
The way in which an agreement is reached on the bill is similar to that set out for psychoanalytic psychotherapy. The amount of the fees must be clarified at the beginning of the treatment.
The patient can telephone the therapist in the period between sessions if an emergency occurs or in other previously agreed circumstances.
Couples and family therapy
In the psychiatric treatments exposed so far it is assumed that there are two interlocutors: the doctor (or therapist) and the patient. In couple and family therapies three or more people are involved, some of whom may not present manifest emotional or behavioral problems. Family and couple therapies are special forms of group therapy that began to be used in the 50s.
There are 4 great indications for this type of therapy:
- When the patient is a child . In this case, family therapy can play a central role in treatment.
- When a stable marriage or couple has persistent relationship and coexistence difficulties, couples therapy can be the indication. When a family is broken as a result of internal fights or tensions, family therapy may be the appropriate option.
- As help and direction of families in which some of its members suffer from a mental illness , especially when it comes to schizophrenia, drug abuse, or other situations in which the illness of an individual inevitably affects the lives of their relatives. Family members need to be instructed about the disease and how to be a help for the sick.
- The so-called Family Orientation in psychiatry (which in turn has several theoretical orientations); It assumes that the family is present at the root of most psychiatric problems and proposes a wider range of treatable problems with this format.
When should it be considered?
The use of the term “couple therapy” (instead of the more traditional “marital therapy”) has its raison d’être in the fact that many of the relationships between individuals do not take place within the framework of a legally understood marriage. In any case, couples therapy is aimed at people who have a long-term relationship and who have difficulties living together. Whether the couple, whether or not they are married, or involving people of the same or different sex is not decisive.
Many differences or minor domestic incidents, even if repeated, do not indicate the need for professional couple therapy. The couple has many resources to resolve routine conflicts that must be mobilized beforehand. Serious and insoluble communication problems that have not yet irreversibly deteriorated the relationship and the desire to continue together, are the main indication of couples therapy.
Some common problems of the couple are born from the unreal expectations that people have about what marriage should be. Many of the initial differences that usually exist between the members of a couple usually disappear by healthy adaptation of one member to another, but it is not always the case and, sometimes, such adaptation does not occur or occurs in false. The usual ways of reacting to these experiences are:
- Silently support the differences as the relationship worsens, without doing anything about it.
- Accept that, although there is no critical problem, it is necessary to change something to maintain the vitality of the couple.
- Break the relationship and try to find a new one.
If things are not going well in a stable relationship, you can ask yourself: is there a recent problem that has altered the relationship in recent weeks? Have you tried to solve it reasonably? It is good to remember that; Most healthy couples go through periods of benign conflict that can last even months. On the other hand, if the problems affect fundamental issues of the relationship and do not seem to have a natural solution in the short or medium term, it is reasonable to go for help, even if the problem is recent.
When and how to start?
When each member has made an effort to approach the other and has failed, both continue to fight for most of their treatment, neither is happy, and the couple has resolved that they cannot solve their problems on their own; The next step is how to find a couple therapist?
How to find a couple therapist
The couple therapist requires proper training, a good dose of experience and special talent. To get references about it you can ask a couple who has done therapy with good results (this task can be difficult, since some couples prefer to hide that they need help). Another way to deal with the problem is to visit more than one professional and select one based on the experience gained. The first thing to keep in mind is that the professional has a degree in Psychiatry or Psychology(exceptionally other professionals also act as marriage counselors) and that they regularly dedicate themselves to treating couples. More complex is to find out if the therapist has the optimal characteristics to direct a specific couple therapy because each couple is surrounded by a series of circumstances that make it unique. It is a good indicator in this regard that the two members of the couple feel comfortable with the therapist and consider their comments helpful. The therapist will never “take sides” for either of the two members because the problems he deals with are from the couple rather than from a particular member. Although the reasons that drive a person to not feel comfortable with the therapist have no apparent logic, they can be reason enough to find another specialist.
What to expect from the first session?
Therapists can address this first contact very differently. Most prefer to see the couple together and then each one separately. At the end of the first session the therapist should be able to make a summary of the main problems that he considers exist in the couple. Obviously you can not expect that the therapist glimpses in this first contact everything that does not work well in the couple and the necessary steps to amend it.
Couple therapy: how it works
Partner therapies usually focus on practical problems; and objectives of the relationship. focusing on practical criteria. Frequently, an initial decision that; It is to be taken between the professional and the members of the couple whether or not it is worth saving the relationship. The professional is expected to be able to determine if there is a reasonable opportunity for the relationship to be restored satisfactorily, but the final decision in this regard is the responsibility of the members. In certain situations, it will be quite evident that a relationship has bottomed out. Partner therapy is not intended in these cases; maintain the relationship at any price; in fact, in some cases, it can show spouses that their union is unfeasible and that dissolving it is the least harmful to both. In these cases, the couple could continue working with the therapist to solve the difficulties of separating and obtaining a divorce. This last process has been called divorce therapy.
Couple therapy addresses the restructuring of the couple’s interaction. The so-called marriage council is considered an intervention of a more limited scope, which addresses a particular and usually unique family conflict, and is geared towards a specific task, such as the education of children.
Three types of couples therapy
There are many models of couples therapy. A simple classification admits three types (which in practice can be combined among them):
- The behavioral method approaches the couple with the intention of solving; problems changing the “way of doing things”; For example: program the time spent together, assign responsibilities, modify sexual patterns, etc … The therapist listens carefully to everything the couple says they do and proposes to introduce changes of a practical nature. Often, the therapist gradually introduces these changes as “tasks” to be performed between sessions.
- The cognitive approach begins with the analysis of the thoughts, attitudes and expectations that each member of the couple has of the other (and that the latter can ignore or fail to comply with); The therapist tries to realign these thoughts and expectations realistically so that both Members may feel more comfortable.
- The psychodynamic approach has its sources in psychoanalysis and usually works with the personality characteristics of the members of a couple. In the first moments of the relationship between them, falling in love obscures these unconscious aspects and hides the differences and tensions in this regard between the members of the couple. Over time, these differences emerge and cause problems in the relationship. The therapist’s job here is to bring to light and resolve certain deeply rooted aspects of the character and personality of each member that would have been formed in childhood and consolidated throughout life and that now collide.
The basic budgets of all family therapies are:
- All family members are interrelated.
- The parts of the family cannot be understood by isolating themselves from the rest of the system.
- The individual knowledge of each part does not allow us to understand family functioning.
- The family organization determines the behavior of its members.
Family therapy has several objectives:
- Resolve or reduce the pathogenic conflict and anxiety in interpersonal relationships.
- Increase the perception and satisfaction of the emotional needs of each family member.
- Promote appropriate relational roles between the sexes and between generations.
- Strengthen the capacities of individuals and family as a whole.
- Influence identity and family values so that members are oriented towards health and growth.
- Integrate the family into society (medical centers, schools, community groups, social organizations …
Function; of the demands of the patients and of the experience of the therapists the indication of this type of treatments can be more or less broad. It has been applied with good results in families with psychotic patients, families with psychosomatic disorders and drug addiction.
- It is more necessary in families with a high level of conflict.
- When the main psychopathological problem occurs in a family member, an individual treatment (prior or parallel) may be necessary.
- There must be some resistance to family work that is usually due to parents’ fears of being blamed for their children’s difficulties; for the entire family to be declared “sick” ;; to the opposition of a spouse to the family approach ;; and fear that the open discussion about a child’s behavior will have a negative influence on siblings. All these eventualities have to be foreseen and attended by the therapists.
- It must be accepted that everything that is revealed in the therapeutic session is known to all family members.
- The combination of the family approach with individual and pharmacological assistance can be very helpful in certain disorders.
Usually; All family techniques seek a more mature and functional family unit, which provides differentiation and independence to its members, elevates the acceptance of each other, and seeks the best possible family communication.
Group psychotherapy is a treatment in which people with emotional problems meet in a group led by a trained therapist and help each other to carry out behavior or personality changes. The group therapist directs the interactions of the group members to achieve their changes.
In any of its modalities, the objectives of group therapy are:
- Promote the mental health of its participants.
- Relieve the symptoms.
- Change interpersonal relationships, facilitating verbal expression; teach to relate to others ;; enhance favorable personal characteristics.
- Facilitate the understanding of others and their own difficulties.
The types of groups, their objectives, their techniques and indications are multiple: awareness groups (pregnant women), therapeutic groups (institutionalized psychotics), self-help groups (anonymous alcoholics) etc …
In psychodynamic counseling group psychotherapy, the therapist invites the participants in the session to speak freely. Group psychotherapy usually has a lower frequency than the individual (a weekly session usually), a predetermined time limit and the therapist usually takes a more active role in it.
Psychoanalytic counseling group psychotherapy is usually indicated in neurotic or personality disorders and; Its main objectives are the containment of anxiety and behavioral symptoms and some personality restructuring.
Advantages and disadvantages
Compared with individual therapies, group therapy has a number of Advantages and Disadvantages.
- The support of the rest of the components of the group and the therapist.
- The isolation reduction in which many patients live.
- The opportunity to observe psychological, emotional and behavioral responses and interaction between people; of the group.
- The lowest economic cost.
- It can become a substitute for real social life.
- It can create excessive dependence among group members.
- Pressure of the components of the group so that it is not abandoned, when it is no longer therapeutically necessary to remain in it.
|Parameters||Support Group Therapy||Group Analytical Therapy||group psychoanalysis|
|Frequency||1 week week||1-3 times per week||1-5 times per week|
|Duration||More than 6 months||1-3 or more years||1-3 or more years|
|Content||Environmental factors||Present and past life
Intra / extra group relationships
Intra group relations
|goals||Adaptation to the environment||Personality Reconstruction||Personality Reconstruction|
|Parameters||Transactional Group Therapy||Group Behavioral Therapy|
|Frequency||1-3 times per week||1-3 times per week|
|Duration||1-3 or more years||More than 6 months|
|Indications||Anxiety and psychotic disorder.||Phobias, passivity and sexual problems.|
|Content||The “here” and the “now.” Intra-group relations||Specific symptoms without focusing on causation|
|goals||Behavior adaptation||Relief of symptoms|
Different types of psychiatric admission are contemplated according to the Civil Code of the different countries. In Spain there are 2 types of entry procedures:
In this case, patients request admission (and accept it in writing) in a hospital psychiatry service by their own decision or on the advice of their doctor. If the psychiatry service is closed, admission implies accepting (in addition to the rest of the institution’s rules); not leaving the service without authorization; medical. The medical discharge takes place by decision of the doctor but the patient can request the discharge as a unilateral decision.
Involuntary admission can occur with an authorization or a court order issued to a family member or friend when the patient’s psychiatric state represents a danger to himself (for example, an uninhibited or suicidal patient) or to others (for example, a patient pathologically aggressive). The psychiatrist on duty at the institution visited by an urgent patient is also entitled to enter; a patient for risk reasons even if there is no judicial authorization. In any case, the hospital is obliged to inform the corresponding judge that such involuntary admission has occurred. A judicial commission (usually judge, secretary and forensic) must visit the patient in the center within 72 hours after admission and confirm or not, After talking with the patient and consulting the medical history, the legitimacy of said admission. The involuntary patient will have access to the advice of a lawyer and, where appropriate, could request a reevaluation or raise a habeas corpus.