Special Article:

Psychotherapies in practice

When and what kind?

The problem of functioning

Our medications produce symptomatic benefit, but often not functional recovery. Patients’ symptoms may improve, but they often don’t return to normal lives in the sense of returning to their previous level of work or study, or in the sense of resuming or maintaining their previous level of interpersonal relationships.  For instance, despite almost complete symptomatic recovery from a manic episode, only about 40% of patients recover functionally two years later.  The majority have continued problems at home with their spouses and family, and aren’t able to be employed full-time.  Partial remission of symptoms, with some residual depression or cycling, generally  leads to incomplete functional recovery as well.

Sometimes we can’t do better, but we shouldn’t be complacent.  Patients want to be completely well, and many of them can be.  But more and more medications, partly due to worsened quality of life from side effects and partly due to limited efficacy, may not be the means to reaching that goal.  It’s not unreasonable to hope that psychotherapies and psychosocial interventions may help fill this gap, and lead to better functional recovery.

What kind of psychotherapy?

You might be tempted to conclude that therefore all patients should receive medications and psychotherapy, especially of the psychoanalytically-derived approach.  But matters are more complex. 

Psychotherapies can be, and are, studied empirically. Which have the most evidence of efficacy? In mood conditions, for example, the most common varieties, the supportive and psychoanalytically-oriented types, have...

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