Monthly Archives: July 2008

Book Review: Online Therapy. A Therapist’s Guide to Expanding Your Practice

Online therapy is a fast emerging field. Performing a google search using the term ‘online therapy’ will reveal over 8 million results. A book by Derrig-Palumbo and Zeine helps to make sense of this very heterogenous but influential area.  The book is divided into two parts – the first part being on the theory and the second part on the practical aspects.

The opening chapter explores different psychotherapeutic approaches online. The highlight for me was reading a conversation with Albert Ellis (pioneer of rational emotive behavioural therapy) about how he conducts online therapy. There were also interviews with practitioners of other approaches included family brief therapy, solutions based therapy, imago relationship therapy, transpersonal therapy – all in the context of online therapy. A chapter on common questions tackles some of the tricky issues such as the difference between online therapy and face to face therapy, geographical separation and crises. A chapter on ‘Clinical Guidelines and Approaches’ is useful for face-to-face therapy as well as online therapy, organising the therapeutic process into phases. The examination of transference and countertransference issues online gives insight into these processes themselves. For instance, if a therapist takes more time to respond, it may seem that they are paying less attention (if there is no visual contact).The ‘Effectiveness of Different Modes of Online Therapy’ chapter looks at some of the evidence of different approaches both in terms of delivery systems e.g. text, video and also in terms of populations. For instance there is evidence to support the use of online therapy in insomnia and post-traumatic stress disorder.

In the second part of the book a number of practical issues are discussed including an overview of setting up an internet practice, ethics and legal issues as well as marketing. The book is also supported by detailed appendices including a section on published guidelines for online therapy. This second part of the book is geared towards an american market and highlights both the complexities of practice and the geographical distinctiveness of practice (e.g. in terms of legal issues).

References

Kathleene Derrig-Palumbo, Foojan Zeine. Online Therapy: A Therapist’s Guide To Expanding Your Practice. Norton. 2005.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

‘Demoralisation Syndrome’

Is demoralisation an illness? Illnesses by definition are our creations. In other words they are ‘social constructs’. The International Journal of Social Psychiatry publishes papers on the social aspects of psychiatry. In a 2006 paper by Briggs and MacLeod, a ‘demoralisation syndrome’ definition was used to assess its probable existence in a group of refugees in New Zealand. The authors describe a syndrome ranging from disheartenment through to despair and demoralisation.

The study which I would consider a pilot study involved looking at the psychiatric casenotes of 64 refugees. The people had answered questions about other conditions (e.g. depression) and the researchers looked at these answers to see if their responses met the criterion for demoralisation syndrome. In 86% of cases, there were sufficient responses to meet a probable diagnosis of demoralisation syndrome. They also looked at whether this was related to diagnosed illnesses in this group including depression and PTSD. They found that there was no significant association between the occurrence of probable ‘demoralisation syndrome’ and PTSD or depression, thus supporting this as a separate entity.

We might expect that there would be a greater degree of demoralisation in refugees depending on the reasons that they had moved. Locating to another country, leaving one’s life behind and starting again in a position of uncertainty (although we don’t know the specifics) might be expected to create demoralisation. However there are some problems. Firstly demoralisation may be a symptom rather than a syndrome. For example, if someone said that they were feeling tired we wouldn’t say that they had an illness. This may just be their experience for a limited period of time – part of the range of ‘healthy experiences’. The next point is that only the case notes were examined. The patients weren’t seen during the research and asked questions directly. There was also no comparison group and the sample size was relatively small.

Having said that, this was a creative study, using previously acquired data to investigate the existence of a demoralisation syndrome. The authors have raised questions that can be investigated in subsequent studies. Will we ever be able to say we have an illness when we are feeling despondent? Time will tell

References

Briggs L and MacLeod A. Demoralisation – A useful conceptualisation of non-specific psychological distress among refugees attending mental health services. International journal of Social Psychiatry. 2006. 52(6). 512-524.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.

CBT and Structured Care for Medically Unexplained Symptoms

A paper in the July 2008 issue of the British Journal of Psychiatry looks at interventions for medically unexplained symptoms. Medically unexplained symptoms are a tricky problem. As its name suggests, a patient reports symptoms to the doctor but no underlying cause is found. Research has shown that a number of people that present with such symptoms will continue to see the doctor about such symptoms for many years. In the study in the BJPsych, they trained some General Practitioners in Sri Lanka to be able to use Cognitive Behavioural Therapy for these symptoms. Cognitive Behavioural Therapy is a form of talking therapy which aims to change thinking and behaviour. In the study, 75 patients were given either structured care or CBT.

In structured care, the patient had to see the GP on at least three occasions regarding the symptoms. After this the GP saw them again and used whatever methods they thought appropriate to deal with the symptoms. In the other arm of the trial (patients were randomly assigned to the groups), patients again received 3 mandatory sessions and then the GP used CBT approaches.

A few of the patients dropped out of both parts of the study. However when they analysed the final results, the researchers found that CBT was no better than structured care on a number of measures. They also found that both approaches improved patient’s general health (GHQ scores), complaints of illness symptoms (BSI scores) and number of visits to GP compared to baseline.

The authors gave a number of plausible reasons for why the CBT group did no better. These included the brief training in CBT given to the GP’s, the possibility that the structured care might have also included CBT or that the structured care approaches may have been equally effective. The important finding though, was that if the GP’s focus on dealing with the symptoms in a structured way, it can lead to improvement for the patient.

References

Sumathipala A, S Siribaddana, M Abeysingha, P De Silva, M Dewey, M Prince and A Mann. Cognitive-behavioural therapy v structured care for medically unexplained symptoms: randomised controlled trial. The British Journal of Psychiatry. 193. 51-9. 2008.

Disclaimer

The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor.