From the Editor

What’s new in psychotherapy?

Psychotherapy is an area of psychiatry transformed over the past years.

Dr. Aaron Beck: not a Freudian

Last week, we looked at a major new paper on IPT. This week, we return to Dr. Paul Garfinkel’s book – the source of two past Readings – for an excellent chapter on psychotherapy.

Last week. A major new review of IPT.

This week. An overview of psychotherapy developments.

This chapter describes the evolution of psychotherapy, and its importance. It also notes the excellent opportunity for the mental health field – to embrace evidence-based treatments and to offer better care for our patients.


Psychotherapy and Practice

A Life in Psychiatry: Looking out, Looking in

Dr. Paul Garfinkel

Barlow Books, 2014

In the last 20 years, just as psychiatrists were running away from the talk therapies, particularly psychodynamically based ones, there’s been a growing body of scientific evidence that shows talk therapies work. In fact, there is overwhelming evidence that nondrug therapies can be a powerful way to handle psychiatric conditions if we specifically define which therapies for which types of problems. Psychiatrists today have a wide array of treatments beyond medications to offer individual patients. There is a huge opportunity for psychiatrists, presuming we take it.

Talk therapies are making a comeback in a scientific age because the evidence shows they are effective for specific problems. Cognitive behaviour therapy (CBT), developed in Philadelphia by Aaron Beck and his colleagues, including Brian Shaw, who came to the Clarke in the 1980s, examines the types of distorted thinking that may affect emotions and behaviour. Patients are helped by examining misguided thoughts and learning to challenge them. CBT has been proven to help people with depression, some anxiety disorders, and even bulimia. More than 70 clinical trials of CBT for unipolar depression leave no doubt that it’s effective—better than placebo and equal to medications for mild to moderate depressions. CBT also reduces the rate of relapse as well as or better than medications. It is useful for the eating disorders and addictions when modified for the specific problem. It is now being adapted for use as an aid to treatments for schizophrenia and bipolar illness. Research has also shown that behaviour therapies are of value in specific circumstances, such as desensitization to phobias or for compulsions.

Dr. Paul Garfinkel

So opens a book chapter by psychiatrist and founding CAMH CEO Paul Garfinkel.

In this chapter he makes several observations about psychotherapy:

· He considers interpersonal therapy, or IPT. “By the late 1980s, there was evidence for its real effectiveness, especially for depression in the context of acute relational problems, losses, and transitions.”

· “Another form of psychotherapy, supportive psychotherapy, is useful particularly when combined with medication and rehabilitation. It aids the patient in developing a greater understanding of his or her current situation, defining alternatives and fostering adaptive coping and resilience.”

· “Marsha Linehan of the University of Washington developed dialectal behavioural therapy (DBT), a treatment she wished she received when she was ill as an adolescent.”

· He notes the development of mindfulness-based stress reduction. “[In mindfulness meditation,] the focus is not to change ‘aberrant’ thoughts but to learn to experience them as internal phenomena separated from the self.”

Dr. Garfinkel notes that expanded role for these therapies. DBT, as example, was originally seen as useful for suicidal adolescents with borderline personality disorder – it’s been adapted for people with substance use disorders. Likewise a variant of mindfulness (MBCT) reduces relapse in people with recurrent depression.

Importantly, Dr. Garfinkel taps the rich literature on therapies, showing the robust evidence favouring these interventions:

· As noted above, more than 70 studies have demonstrated the effectiveness of CBT for depression.

· In one meta-analysis, “the person who received therapy is better off at the end than 80% of the persons who do not.”

· In another meta-analysis of 50 controlled studies for children and adolescents comparing evidence-based therapies and general support, there was a large benefit to the former.

Too many clinicians ignore the evidence for psychotherapy and rely too heavily on prescribing medications. This is a symptom of a major problem afflicting our profession. We have swung too far in the direction of prescribing drugs for mental illness and even for problems that are a normal part of the human condition.

Dr. Garkfinkel goes on to note the importance of other interventions, like stable housing and employment.

He goes on to paint an optimistic view of psychiatry – and the mental health field more broadly:

What an amazing time to enter the field of psychiatry. We now know how common the mental illnesses are. There is a real need for new, well-trained people in our field; jobs will be plentiful. As well, there is great variety in the type of work, and it is never boring. We are now able to draw understanding from complex fields to make psychiatric care and treatment comprehensible to patients and families, and to engage the public and our colleagues. We are becoming more able to battle the prejudice to our patients and the field, and we are advancing treatments dramatically. Someone entering the profession today will be certain to see remarkable increases in knowledge and continual therapeutic advances throughout their careers.

But he concludes with a bittersweet note:

There is no doubt that effective treatments now exist for people with mental illnesses. These have been evaluated in many scientific trials, and the results are overwhelming, if only psychiatrists use this evidence for the benefit of reducing the suffering of their patients.

A few thoughts:

1. Dr. Garfinkel describes the literature in this area with a readable and entertaining chapter.

2. It’s difficult not to share his optimism – and his concern.

3. To pick up on this point: consider the Puyat et al. paper published recently in The Canadian Journal of Psychiatry. Drawing on British Columbia data, the authors found that just 13% of patients with depression received CBT. So, as much as we wax poetic about the importance of therapy for people with mental health problems, the reality is that a slim minority of Canadian patients has access.

For decades, mental health care has been hampered by societal hesitation (stigma) and the limits of our medical science (well-intentioned but evidence-light treatments). Today the former fades and the latter is giving way to evidence-based treatments. But access remains deeply problematic.

5. How to move forward? Canada could look to other countries for ideas. In the United Kingdom, the NHS has expanded service with Improving Access to Psychological Therapies – a program that paid for itself by reducing societal costs. In Australia, the federal government has embraced technology and e-therapies.

The October issue of The Canadian Journal of Psychiatry opens with a “perspectives” paper on this topic.

You can find it here:

I’m a bit biased, but the paper seems quite timely.

5. Back to the book: Dr. Garfinkel has many, many observations about our field. I strongly recommend you read the whole book.

You can find it at Caversham Booksellers.

The book is also available at other bookstores.

(I note: from A Life in Psychiatry: Looking out, Looking in by Paul Garfinkel. Copyright © 2014 by Paul Garfinkel. Reprinted by permission of Barlow Book Publishing Inc. and the author.)

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.

Garfinkel Ch 23 .pdf