Description

• Psychotherapeutic and counseling interventions play an important role in the management of chronic and acute-onset diseases and disorders. They are typically the primary initial mode of evaluation and/or treatment for most mild to moderate psychiatric disorders that reach criteria using the DSM-5 (1) or ICD-11 diagnostic classification systems.
• Treatment and successful control of either medical or psychological conditions typically benefit from some form of professional counseling. Best outcomes occur when they are employed by a skilled practitioner. However, psychotherapy differs from generic counseling, which can take many forms and is delivered commonly in nonmedical settings. In recent years, attempts to integrate counseling and psychotherapy within primary care practices have increased.
• Counseling approaches are usually tailored to the specific presenting problem or issue and serve educational and emotional support functions. Typically, counseling in medical settings will be time-limited and problem-focused and often not intended to lead to major medical symptom relief or major behavioral changes but to improve patient coping.
• The goals of psychotherapy range from increasing individual psychological insight and motivation for change to reduction of interpersonal conflict in the marriage or family, reduction of chronic or acute emotional suffering, or reversal of dysfunctional or habitual behaviors. There are several general classes of psychotherapy, starting with individual, marital, or family approaches. In addition, a number of psychological theories guide various methods and treatment philosophies. The following is a brief overview of commonly used psychotherapeutic and counseling methods.
• Psychodynamic therapy: Unconscious conflict manifests as patient’s symptoms/problem behaviors:
  • Short term (4 to 6 months) and long term (≥1 year)
  • The focus is on increasing insight of underlying conflict or processes to initiate symptomatic change.
  • Therapist actively helps patient identify patterns of behavior stemming from existence of an unconscious conflict or beliefs and motivations that may not be accurately perceived by the individual.
• Cognitive-behavioral therapy (CBT): Patterns of thoughts and behaviors can lead to development and/or maintenance of symptoms. Thought patterns may not accurately reflect reality and may lead to psychological distress:
  • CBT aims at modifying thought patterns by increasing cognitive flexibility and changing dysfunctional behavioral patterns.
  • CBT encourages patient self-monitoring of symptoms and the precursors or results of maladaptive behavior.
  • Uses therapist-assisted challenges to patient’s basic beliefs/assumptions
  • May use exposure, a procedure derived from basic learning theories, which encourages gradual steps toward change, at a speed that is tolerated by the patient
  • CBT can be offered in group or individual formats, for adults or children.
  • A CBT practitioner attempts to combine practical interventions with emotional supports.
• Dialectical behavior therapy (DBT): Techniques such as social skills training, mindfulness, and problem solving are used to modulate impulse control and affect management:
  • DBT is a therapy approach that derives from CBT but emphasizes emotional control in relationships.
  • Originally used in treatment of patients with self-destructive behaviors (e.g., cutting, suicide attempts)
  • Seeks to change rigid patterns of cognitions and behaviors that have been maladaptive
  • Uses both individual and group treatment modalities
  • The DBT therapist takes an active role in interpretation and support.
• Interpersonal psychotherapy: Interpersonal relationships in a patient’s life are linked to symptoms. Therapy seeks to alleviate symptoms and improve social adjustment through exploration of patient’s relationships and experiences. The focus is on one of four potential problem areas:
  • Grief or loss
  • Interpersonal role disputes
  • Role transitions
  • Interpersonal deficits: Therapist works with the patient in resolving the problematic interpersonal issues to facilitate change in symptoms.
• Family therapy: focuses on the family as a unit of intervention
  • Uses psychoeducation to increase patient’s and family’s insight
  • Teaches communication and problem-solving skills
• Motivational interviewing (MI): focuses on motivation as a key to successful change process
  • Short-term and problem-focused; many therapists use MI prior to initiating other therapies.
  • Focuses on identifying discrepancies between goals and behavior, and the patient’s desire to change
  • “5 A’s” model is a brief counseling framework developed specifically for physicians to effect behavioral change in patients:
    • Assess for a problem.
    • Advise making a change.
    • Agree on action to be taken.
    • Assist with self-care support to make the change.
    • Arrange follow-up to support the change.
• Supportive and informational counseling (heterogeneous treatment)
  • Often focuses on situational factors maintaining symptoms
  • Often encourages the use of community resources
• Behavioral therapy: relatively nontheoretical approach to behavioral change or symptom reduction/eradication through application of principles of stimulus and response; MI is often performed at the onset of behavioral and parenting counseling or therapy.

Pediatric Considerations

• Important distinctions are made between psychotherapy and counseling for children/teens compared to adults/couples.
• The focus of evaluation must include attention to parent and family processes and factors. Interventions typically include interactions and sessions with parents as well as collateral work with teachers and other school personnel.
• Younger children will often be evaluated and diagnosed through behavioral descriptions provided by parents and other adults who know them well as well as through direct observation and/or play techniques. Children of all ages should be screened using behavioral checklists that are standardized and norm-referenced for age and gender.
• Any child or teenager who requests counseling should be interviewed initially by the primary care provider and referred appropriately. Most referrals will be in response to parental request, however.
• Psychotherapeutic interventions with the strongest empirical basis with children include behavior therapy/modification, CBT, and family/parenting therapy. Play therapy has the least empirical support but has been found to be useful for developing rapport and for treating trauma in younger children. Insight-oriented therapies appear to be more effective with older children (age ≥10 years).
• There is a controversy regarding the efficacy of psychopharmacologic treatment in preadolescents, although clear benefits have been demonstrated in some studies as well as clinical practice. Treatment guidelines for mild to moderate depressed mood and/or anxiety disorders typically recommend pediatric CBT initially, and studies have typically supported this approach in preteen and milder cases. Medications should be considered in more severe presentations.

Epidemiology

• 19 million adults suffer from clinical depression, and >20 million adults have a diagnosable anxiety disorder in the United States.
• One in four Americans report seeking some form of mental health treatment in their adult life. This includes generic counseling in nonmedical settings such as work, clergy, or school settings and also includes visits to primary care providers. It is estimated that between 3.5% and 5% of adults in the United States participate in formal mental health psychotherapy annually. Recent estimates emerging from the COVID-19 pandemic suggest these rates have increased since spring 2020.
• Public health experts report that the majority of those adults with diagnosable psychiatric disorders do not receive professional mental health services. This is due to multiple factors, including failure to identify, noncompliance with psychiatric referral, regional shortages of providers, economic or insurance barriers, and excessive time duration from referral to an available service.

Risk Factors

The need for psychotherapy or counseling services is associated with a host of socioeconomic and biogenetic factors, including the general effects of poverty, family or marital dysfunction, life stressors, medical diseases or conditions, and individual biologic predisposition to mental health disorders.

General Prevention

It is generally assumed that early identification and intervention of child and adolescent psychopathology increases the likelihood of reducing the risk for adult psychopathology, but this has not been sufficiently validated in all categories of psychological disorders. Data support such claims in disorders such as childhood ADHD, anxiety disorders, and habit disorders of childhood, however. A range of evidence-based therapies now exist that are designed for children and adults.