Psychotherapy and the Physical Methods of Treatment in Psychiatry

Abstract

It is only proper that I should begin this paper with a disclaimer. I am not a psychotherapist, nor am I one who has devoted much of his time to the physical methods of treatment. My only qualification to carry this burden at all is that I believe I am somewhat in a neutral position and have not been fired alone by either set of enthusiasms—neither those which activate the physical treatment experts, nor those which sustain the psychopathologists. Necessarily therefore what I have to say will be from a personal viewpoint, although of course not a detached one and I will apologize once for this and not again. The subject of this talk is obviously an important one and must be the concern of psychiatrists of all persuasions. Those who are psychotherapists cannot ignore the fact that the main mental disorders which constitute the serious core of psychiatric disability in the community are treated first and foremost by physical methods, insulin coma, E.C.T. and surgery, while those who are non-analytical psychiatrists cannot ignore the fact that the less serious but enormously more prevalent conditions are treated in the main by psychological methods. The question might be asked, are there then two types of psychiatric disorder, the one only treatable by a physical method, the other by a psychological method ? But this is a superficial view; with the greater sophistication of physical methods more and more patients who formerly were treated by psychotherapy are now subjected to some physical treatment, and conversely—and this is particularly evident from the American literature—more and more patients, particularly schizophrenics, formerly treated by insulin or surgery are now being subjected to psychoanalysis. Each side is therefore invading the territory of the other, but there is no common language or ground for discussion between them. Now of course there are many different forms of physical treatment, just as there are many different types of psychotherapy. Let me take the physical treatments first. We can I think divide them roughly into two classes. There are those which by their universal use for a special type of mental state or special group of symptoms have come to be regarded, rightly or wrongly, as almost a radical treatment for such conditions. For this group no psychopathological preconception regarding the patient, his problems, his methods of adaptation and defence are necessary. All that is needed is a clear statement of his symptomatology, its duration and course to enable the physician to determine the type of treatment. In this group therefore we can place insulin comas, E.C.T., and cerebral surgery of the leucotomy type. It is only necessary to demonstrate schizophrenic thought disorder and primary delusions of recent onset to arrive at the view that insulin treatment is advisable; on the other hand depressive affect, depressive sleep disorder and loss of weight, continuing beyond the reasonable period following a stress situation or the absence of a stress situation particularly in the involutional period of life will lead many to recommend E.C.T. without more ado. For chronic obsessional tension, rumination or distressing psychotic ideas interfering with adaptation, leucotomy or some modified form of surgery come to mind.