Referral of patients for psychotherapy.
Authors: A C Skynner, D G Brown
Journal: BMJ (1981)

It is generally agreed that some 15% of the family practitioner's list of patients has an obvious psychiatric disorder,1 and another 10% a hidden one.2 But only a small proportion, varying from one in 10 to one in 20, of these are referred to psychiatrists. Those who are admitted to psychiatric units tend to be acutely and severely disturbed, even psychotic, unlike the bulk who are referred to the psychiatric services as outpatients and those who remain under the care of their general practitioner. These are suffering from either acute or chronic stress, and varying degrees of neurotic disability, personality problems, or psycho? somatic disorder. They are the patients for whom the temporary provision of a holding hospital environment and the suppression of acute symptoms with medication may be unnecessary or insufficient, perhaps even contraindicated as long-term solutions to the underlying problems. Psychotherapy at some level is often indicated. Range of psychotherapeutic techniques The range of psychotherapeutic techniques is now very great ?indeed, even bewildering: individual, group, family and marital, social therapy, behavioural psychotherapy, and a host of new fringe therapies.3 We here attempt to offer some conceptual guidelines to both general practitioners and psychia? trists in considering what established forms of psychotherapy would be appropriate for particular patients. We first considered presenting our ideas historically, beginning with the development of psychoanalysis at the turn of the century, the emergence of individual analytically based psycho? therapy after the first world war, and then of group psycho? therapy and of therapeutic community ideas (social therapy), particularly after the second world war, and, finally, family and marital therapy in the past two or three decades, during which time behavioural psychotherapy has also developed. Finally we chose to turn history on its head in presenting the concept of a series of sieves, or screens, ranging from coarse to fine. This entails examining the patient's problem as part of the disturbance in his living context, firstly, in his marriage or family, then in his general pattern of relationships with others, and, finally, within his internal world. Psychotherapy in the general sense is part of all medicine (or any well-conducted profession). This requires respectful interest in the patient, and recognition of his need for support by a helper who is concerned yet sufficiently detached to be objective. Cawley,4 in describing four different levels of psychotherapy, has called this general approach psychotherapy 1. It is synonymous with the art of medicine?what a good doctor does?and includes the ability to communicate with people with all sorts of back? ground and problems. It is the level too of support and counselling (see below). Psychotherapy 2?what a good psychiatrist does? goes further and includes an ability to communicate with people in all sorts of mental distress and disturbance. It draws on under? standing the role in the patient's problems of his development and patterns of personal relationships, and how these influence his presentation and way of seeking help. A repetition of past, often problematic, relationships within the doctor-patient relation? ship becomes a source of information, particularly in a more ill and disturbed patient, when it tends to reflect child-parent relationships (transference). Such transference is not deliberately fostered and explored as it is in psychotherapy 3, but rather monitored to keep it mildly and appropriately positive. A doctor's feelings (counter-transference) may be used at this level also as a source of important information in general practice, as the Balint group has shown so well.5-7 Psychotherapy 3 is the level of formal, dynamic psychotherapy stemming from the work of Freud, and deliberately explores unconscious conflicts and processes, such as transference, within a regular relationship of increasing intimacy and trust. This may be relatively short term, as in brief or focal psychotherapy, weekly for 10 to 40 sessions,8-10