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Open mind: what kind of therapy and when should we seek it?

ROBIN HUGHES: Hello, this is Robin Hughes with the final program in the Open Mind series.

And as a result of many requests, we're going to finish the series on a practical note, by doing a kind of consumers' guide to therapy. I have two guests today-one a practising psychiatrist and one a clinical psychologist-and they're going to help clarify when it is that somebody is a suitable case for treatment and how you go about finding the right kind.

Dr Michael Diamond is a partner in one of Australia's most respected private psychiatric practices, and his answer to the question 'When should somebody seek therapy?' is realistic.

MICHAEL DIAMOND: Well, a simple answer to that would be along the lines of when they're able to, because people need to overcome a lot of personal prejudice, sometimes concern about being stigmatised, and sometimes people need to extend themselves in order to cope with a particular problem before they reach out for help. But I think, generally, that concept of coping is relevant here, and when people feel that their repertoire of coping skills has been exhausted or severely been depleted, that's the appropriate time.

One can turn that question round a little bit and look at why people resist seeking help, and that can sometimes give you a good answer as to whether they need to have assistance or not, and if people are being unduly resistant towards speaking about difficulties they're having, then that's usually a sign indicative of needing help.

ROBIN HUGHES: Now, if you've really got a very severe problem like a psychosis, like schizophrenia or manic depressive psychosis, what are the signs that emerge that really, there, you should be alert and think something's terribly wrong?

MICHAEL DIAMOND: Well let's start with somebody going through the early stages of a schizophrenic illness. Often it's very puzzling and people are literally confused. That confusion is often quite alarming, so there's a significant amount of distress and fear. For young people, it's often the time when the illness presents, and it's a very scary time because those things that they rely on to give their ordinary, everyday world some meaning - their vision, their thought processes, their other senses - become confused and they become distorted, and that often causes a great deal of distress. So the indicators-often there are people who are becoming detached, becoming very confused by their environment and often are very afraid.

And that fear sometimes presents as withdrawal. So what you see is somebody who is withdrawing from their relationships, their environment, their day-to-day activity. Those are some of the alerting features.

ROBIN HUGHES: So when you move beyond the major psychoses, what are some of the kinds of patterns of behaviour where you actually can help somebody? What are some of the major other categories that you find yourself dealing with on a regular basis?

MICHAEL DIAMOND: Well, the startling statistic to begin with is that one in three people on this planet, I believe, at some stage in their lives, will have an episode of major depression. And that's enormously frequent, and if that is the case, then it reflects, certainly in clinical practice where mood disturbance is probably the most common presenting symptom that one would see in the consulting room. And a lot of that would be dealt with not by psychiatrists but by general practitioners, by counsellors and even just informally through friends and family support, but, certainly mood disturbance is the major one. And very closely associated with and perhaps of similar frequency or just about, would be disorders of arousal, and by that I'm talking about anxiety, anxiety disorders.

The other big confounding factor in all of this is the use of non-prescribed medications as a form of self-treatment.

ROBIN HUGHES: Could you give me some examples of the ones that you encounter that you think are really pretty problematic for people to be self-dosing with?

MICHAEL DIAMOND: Well, the one we all know about and seldom talk about is alcohol, which is such a potent anti-anxiety substance, and that's endemic - we all use alcohol in our society in some shape or form, throughout life, so it's ubiquitous. The other popular drugs and forms of drug use would be cannabis, certainly would be amongst younger people. The minor tranquillisers as prescription drugs, the benzodiazepenes have long been favoured and their problems have become well known. And I think we have in our community people who use things like overwork and obsessional exercising as another form of dealing with anxiety, tension and sometimes disordered mood states.

ROBIN HUGHES: So if you realise that self-medication is not the way to go and you want to get help with your problem, how do you tell whether you really need therapy?

Dr Richard Bryant of the Psychology Department at the University of New South Wales approaches the question from the point of view of a researcher who is also a practising clinical psychologist.

Dr Bryant, how do you tell the difference between when you're simply sad and when you're depressed?

RICHARD BRYANT: The main reason we have of making that discrimination is really how much it's interfering with our lives. Everybody feels sad at times and that's a human response, but depression is something that actually interferes with our ability just to function. We'll probably have disturbed sleep, we won't be able to go to work, we won't be able to smile, we won't be able to do all the things that we typically can't do when we're very sad, but it's a much, much stronger emotion.

ROBIN HUGHES: And I suppose in a similar way, and again trying to paint a picture of the difference between something that is quite normal for all of us and something that makes you a case for treatment is: How do we tell the difference between anxiety-we couldn't really do anything without a bit of anxiety I suppose-and an anxiety disorder?

RICHARD BRYANT: Again if you talk to somebody who actually has an anxiety disorder, they will clearly tell you that they can't function in their lives. They can't leave their home, they can't concentrate, they can't relate to other people. They're the sort of symptoms that are just more extreme than what we would normally have when we're scared, but they're so extreme that the person just cannot get on with the basic functions of life.

I think we need to add though, that some people with some disorders, such as anxiety, have those disorders all their lives and it's something that they're used to, and so it is just part of who they are. So it's actually quite difficult for them to really recognise that: Hey, I have a problem and maybe I should go and get some help. But again, I would say the bottom line is that if it's really interfering with your ability to live, to function, to do the basic things that you want to do, then there's an indication that you might benefit from help.

ROBIN HUGHES: Well let me put to you again something that came from a listener who was trying to work out whether her adolescent son, who clearly preferred his room to the company of his parents, who had the kind of weird thoughts that a lot of adolescents do have, being a little bit out of the ordinary in the way that he went about things, whether he was somebody who might be incipiently schizophrenic.

RICHARD BRYANT: That's a common question, and it really relies on who's making the judgement about what's normal, what's abnormal, what needs help.

Again, I would come down to the judgment that is that problem actually interfering with that adolescent's ability to go to school, to relate to his or her peers, not necessarily to the parents, his ability to display a normal range of emotions. Now, this may not be exactly what the parents want, but really what we're talking about in terms of a psychological disorder is that the person is experiencing emotions or thoughts or behaviours that's impairing that person doing what that person would normally do, given their age and their culture and the normal things that we would expect.

What we would say is that if that person's ability to function within their own culture, within the realms of normality as that culture defines it, then we would say that person needs help.

If I can take that a little further, a common problem might be if somebody belongs to a particular religious group. We might think those religions are particularly strange, that they have strange ideas and they do strange practices, but within that particular religious group or church it actually might be considered quite normal and quite acceptable.

ROBIN HUGHES: A lot of people wonder why they can't pull themselves out of it. Why is it that someone, say, who's very depressed, seems to undergo almost a physiological change before your eyes, and although their minds are functioning perfectly well and they know that their situation isn't really a genuine cause for depression, they can't pull themselves out of it. Why is this the case?

RICHARD BRYANT: I think that's an experience that only somebody who's experienced that emotional disorder can really relate to, and I can appreciate how difficult it is for somebody who is a relative or a loved one of somebody in that situation. I think the main explanation for it is that it's part of the symptoms of the disorder that the person is a little bit helpless to change it.

Let's take depression as an example. One core symptom of depression is what we call listlessness or lack of motivation or lack of energy, and in a sense, the symptoms of the depression are so pervasive, are so strong, are so oppressive, that it's impossible in a sense, for the person just to turn over a new leaf and just get on with life. That's actually part of the problem of the disorder. It's very, very difficult to shake that, and that's really why it needs treatment. It's very difficult for therapists sometimes to motivate a client to actually push ahead and do the things that are required to actually change that apparent helplessness, but it is part of the condition.

ROBIN HUGHES: The next step, of course, if you have someone close to you who's suffering from this sort of thing, is to persuade them to go and get help. What should you do to suggest to someone they need help? I mean, sometimes in the workplace it's almost said in an accusing way, you know: Oh, you need treatment. That isn't very helpful, obviously, but what is the best way to approach somebody?

RICHARD BRYANT: I'd suggest a number of steps. I think Number One, clarify the person's motivation. What do they want? Do they want to get better? Do they want to stay the way that they are? I think once you've established that, then you can take it on to some further steps, if the person is actually wanting to feel different. And most people do want to feel different. Very, very few people I've ever met actually want to stay the way they feel. They may not want to take steps of going to therapy though. What I would do with somebody then is explain to them what therapy involves. The major reason why people avoid therapy is that it's this mysterious thing that they don't know what it involves, but they may have great fears about it. They may fear being locked away in an asylum or being given some terrible treatment. It may be something that they've read in a book or saw in a movie, and most of those misconceptions can typically be corrected a bit with just basic education that can be available from a G.P. or from any community mental health service.

Now if you've given the person information and education and encouragement and they still don't want to go for treatment, I think probably the next step would be to maybe talk to a mental health professional and ask their advice as to what's the best way that we can then encourage this person to go and see a doctor. What we often find is that if a client can actually meet somebody, just once, then it's a lot easier for the person to then take steps from there. But to make that initial assessment, and maybe to say to the relative or the loved one: Just see this person just once, just have a chat, no commitments, and let's just take it from there. And very often, we can start therapy if we don't sort of make a strong commitment to the person before they actually meet the therapist.

ROBIN HUGHES: Now, that's one side of the coin, somebody who's seriously in need of help who doesn't want to seek it, and you've got to persuade them to. The other side is an impression that one sometimes has, is that people, these days, have started running to therapists when perhaps they don't need it. I mean, do you see any of that, an over use of therapy by some people?

RICHARD BRYANT: I think there's no doubt that there is an overuse of therapy and I would say of particular therapies. It's fair to say that there are certain therapies that are very time-limited, that therapists have very strong views about how they spend their resources, and so some therapies tend to be - well, let me say abused - more often than others.

ROBIN HUGHES: You mean ones that go on forever?

RICHARD BRYANT: I think some that go on for ever. Let me say that I think some people are in very long-term therapy and they need it and they benefit from it. I suspect there are other people who are in long-term therapy. They probably find it reassuring and they probably get something out of it, and for them, that's fine. But I think we need to draw the distinction between enjoying therapy and needing therapy.

ROBIN HUGHES: So in your view, you don't really need to go to therapy just for unhappiness.

RICHARD BRYANT: Definitely not, definitely not. There's a distinction between unhappiness and depression. There's a distinction between an understandable fear and an anxiety disorder. There's very clear distinctions there, and I think if somebody wants to spend the money and see a therapist for many years, well, if they've got the money-I guess, good luck to them. But I'm not sure that's an appropriate way to be using our therapists because there are many people who do desperately need the help, and could well do with it.

ROBIN HUGHES: And of course our health care system has limited resources, doesn't it, in the sense that some people who really need help can't get it because the system is overloaded?

RICHARD BRYANT: It's a problem that many of us in the field are struggling with all the time. I'm not sure how often my telephone rings and somebody's saying: Can you please send this person to someone who can treat this problem? And I'll spend the next so many days talking to all my colleagues, trying to find somebody who's in the area and who's affordable that that person can see, and I'm afraid many times I can't really find an appropriate answer.

ROBIN HUGHES: And that's true right across the country in relation to mental health services?

RICHARD BRYANT: Oh, absolutely.

ROBIN HUGHES: So now, we've got someone close to us; they're clearly in need of professional help; they're not just in the category of someone that we might be able to help just by being friendly. Then how do you know who is the right person to go to?

RICHARD BRYANT: That's the $64,000 question, and picking a good

psychiatrist or psychologist or counsellor-it's a bit like picking a good builder or a good hairdresser. It's very hard to know until you actually get there and know the person and get to know what's actually happening.

Let me make some general comments. I think seeing a psychiatrist or a clinical psychologist are probably the optimal professions that people should aim for when they're wanting help with any kind of psychological disorder. Psychiatrists primarily deal with medication. Clinical psychologists don't. They typically use other techniques where they teach people skills and help them through talking. But they're the two groups who primarily are trained and have expertise in dealing with psychological disorders.

Now, of course, many psychiatrists and many clinical psychologists adopt very different approaches, very different techniques. Some of the common ones, for example, are psychoanalysis, which as you mentioned can take many, many years. Another very common form is cognitive behaviour therapy, which essentially teaches people skills to overcome the problem. It doesn't take so long, but essentially trains people how to cope with their own problems so that for the rest of their lives they can be a bit more self-sufficient in managing the problem.

And the third area is very much medication-based, and there are certain disorders, such as the schizophrenias and mania and severe depression, where really, medication is the most appropriate way to handle that problem.

ROBIN HUGHES: In relation to the evaluation of therapy, let's take a case like depression. Quite often, people do a combination of chemical therapy, taking some drug for it and, at the same time, retraining themselves through cognitive behaviour therapy. In those circumstances, when you actually do an evaluation of that, do you find that you do better with that kind of therapy than, for example, trying to get well yourself?

RICHARD BRYANT: Definitely. In terms of depression and also anxiety, we have a lot of research done now, a lot of very well-conducted research that's looking at medication, looking at cognitive behaviour therapy, looking at the different components of cognitive behaviour therapy, for us to try and understand what we really need to be providing people with to give them the quickest and the longest-lasting benefits. And I can't really give a global answer because there are so many different issues here-it's a very complex issue. But we can say that in terms of depression, for example, that cognitive behaviour therapy will help somebody a lot more than not giving them treatment, it will help them a lot more than just holding their hand and being a supportive friend, and it can also add to the benefit of anti-depressant medication.

ROBIN HUGHES: Now is it wise, then, for somebody who's suffering from

something to go along to a doctor and ask for a particular sort of therapy?

RICHARD BRYANT: Well, typically, a lot of people do come wanting a certain therapy or even wanting a certain problem addressed, but, really, it's up to the therapist to assess that person from scratch and understand what really is this person's problem. For example, somebody might come along with a sexual problem and say 'Look, I can't have sex properly; this really needs addressing', when, in reality, there might be an underlying problem in the relationship, and if we didn't deal with that problem in the relationship then the other problems wouldn't be corrected.

So, really, the person needs to talk to a therapist and have a full

assessment to understand what the problem is, and then the therapist and the client can work out together: This is the path we should go to try and solve this problem that we're agreeing on.

ROBIN HUGHES: Now, relationship problems raise another question, because that's another big area where people actually go for help, and they usually go for help to people called counsellors. What's the difference? What are we talking about here when we talk about counselling, and is there real value in going along for help with a relationship problem?

RICHARD BRYANT: Probably the main reason that counsellors are very often encountered in relationship problems as distinct from psychiatrists or clinical psychologists, is that a relationship problem is not a psychological disorder. It's something that many, many people have and I suppose most of us at some time in our lives do experience problems with relationships. We need advice, we need an impartial person to listen and resolve difficulties between partners, and somebody with expertise and training in that area.

For historical reasons, a lot of people who are involved in couples counselling aren't psychiatrists or psychologists, they come from other orientations, but since they're not dealing with really psychological disorders, they can be very, very skilled and very useful in actually helping people deal with their relationship issues.

ROBIN HUGHES: Now with all these different professionals - psychiatrists, psychologists and trained counsellors-what's most important, the scientific research base on which they act or their own personal intuitions as individual human beings?

RICHARD BRYANT: Let me say that I think all therapists need to maintain their humanity. You need to be slightly intuitive; you need to relate to the person as another person. If you lose that, then you lose the human touch. Having said that though, I think as professionals we need to be scientific, because when a client comes to see the therapist, the therapist has an enormous responsibility to provide that person with the best service available.

Now because of this, we need to rely on our scientific knowledge of what is the most appropriate treatment. Probably, everybody has heard of some very dramatic, nasty cases in the past where people have gone off to psychiatrists or psychologists or doctors or hospitals of some type, and got some terrible treatment, and, in the past, this has happened in most countries and it's been very unfortunate. The only way we can avoid that is by having standards, standards by which people who want to call themselves mental health professionals, must adhere to and must be trained and have knowledge and ongoing education in the up-to-date scientific advances of particular treatments.

ROBIN HUGHES: And so how can we as consumers, as people out there in the community, really needing in a way the most acute kind of help that you can need-you know, if you're in mental distress and you really need help-how can we find the people who are going to be properly registered, qualified people, and how can we be sure that we don't end up with a quack or someone who's not very good?

RICHARD BRYANT: I don't think there's any 100 per cent foolproof way of saying that I'm not going to end up with somebody that I'm not happy with. That aspect is a little bit of trial and error. But I would encourage people that when they go and see somebody, they are evaluating the therapist just as much as the therapist is evaluating them. It's very hard to work with someone that you don't get on with. And so I think that's fine, and some people do have to shop around a little bit before they find somebody who really suits them.

But generally speaking, somebody who is a registered psychiatrist or somebody who is a registered psychologist. And when I say registered, in all States in Australia, now, psychologists need to be registered with government authorities, but I think when you have a severe disorder that you're very worried about, do make the effort of seeing a clinical psychologist. Not all psychologists are clinical psychologists, but you want somebody who's been trained in clinical disorders. People can always contact the Australian Psychological Society who actually runs a toll-free referral information service if people are wanting somebody in their area, and we all know that all mental health professionals are a lot more easily accessible in some areas than others, and, especially in the more remote parts of Australia, it's a problem for people to find somebody appropriate.

ROBIN HUGHES: So if you have a problem and you live in a country area, is your best bet to go to your G.P.? Is that the best hope that you have of being referred on?

RICHARD BRYANT: I would say the G.P. typically knows who's available in the area who deals in certain areas. They're typically the first point of contact. I would say yes, the G.P. is a good starting point.

ROBIN HUGHES: What about public hospitals and public clinics and so on?

RICHARD BRYANT: Most public hospitals and most community health centres do have mental health professionals working in them. They typically have psychiatrists, clinical psychologists, social workers, a range of people that are there to provide a service. I think it's very worthwhile attending those people because they do have the basic requirements that I've been talking about. It's difficult sometimes to actually get in because of the demands on those services that you mentioned earlier, but if people can try then at least they will find somebody there who can see them.

MICHAEL DIAMOND: You shouldn't seek therapy, you should seek assessment, and by seeking a comprehensive assessment, then the appropriateness of therapy, the treatment options available to you, whether you should be treated individually, whether you might be treated with family, whether this is a systems problem in the sense that your problems may relate to what you do in your work life. The assessment is really the first step, and I think people sometimes decide to embark on particular therapies because it appeals to them.

If you look at that reality, people get drawn into things like motivational seminars, not because the motivational seminar is the treatment or interventional activity that they require most, but they would like to be more positive, more self-assured, more energetic people, and so they see this as an answer to their problem. But, in fact, it may relate far more to an untreated anxiety disorder, it may relate to a bad relationship with your mother, it may relate to a difficulty in a relationship where one is feeling overpowered and impotent, and so to simply go off and choose a therapy like one chooses a breakfast cereal may not actually be the most sensible way of going about it. And I think a really good, comprehensive assessment so that you can come to grips with the problems, you can clarify what it's about-and I'm talking about in the area now of people who aren't so acutely ill that they need immediate intervention, but people who are saying: Perhaps I need some assistance. I think a good, comprehensive assessment makes a lot of sense.

ROBIN HUGHES: And I hope that advice from Dr Michael Diamond and before that from Dr Richard Bryant helped you to make sense of what can be a perplexing area of life to deal with.

But before I finally close this last of the Open Mind series, there are a few people I would like to thank. At the ABC, first and foremost, Polly Rickard, also Amanda Armstrong and Janita Palmer for their professional help. Thanks also to all those who have taken part in the series or offered good advice. But especially thanks to you the listeners. Your enthusiastic response to Open Mind has been very encouraging to all of us.

And now it's goodbye from me, Robin Hughes. Norman Swan will be back next week with the Health report and everything will then be back to normal.