SynopsisThis paper describes a study of the outcome of psychotherapy with patients disabled by chronic obstructive airways disease giving rise to dyspnoea. Forty-three men and 22 women with severe COAD were randomly allocated for 8 weeks to one of three types of psychotherapy or to an untreated control group, and were followed up six months later. The group treated by a medical nurse without training in psychotherapy experienced sustained relief of dyspnoea but tended to undergo less psychodynamic change; psychiatric symptoms were reduced in those receiving supportive, but not analytical, psychotherapy. The psychosomatic mechanisms involved and the implications for medical and nursing practice and for liaison psychotherapy are discussed.
Twenty-eight patients who were admitted consecutively to a single-adult unit of the Cassel Hospital in 1977/8 were followed up 5 years after discharge. Those who were found to have improved at the end of treatment remained well 5 years later. These could be distinguished by their combination of neurotic psychopathology, considerable depression, superior intelligence, and lack of a chronic outpatient history. Patients who had improved 5 years after discharge did not show these characteristics, but had all spent at least 9 weeks on the waiting list and had the capacity to form close and helpful relationships. Patients who were judged to have improved were less dependent on the Health Service and their economic productivity was improved, often as a consequence of returning to education or training. Those who did not improve clinically continued to be admitted to hospital and tended to become less economically productive.
In a retrospective study of 28 successive admissions for in-patient psychotherapy, the following characteristics have been identified as predictors of favourable outcome: a diagnosis of neurotic psychopathology; superior intelligence; considerable depression; and minimal previous out-patient treatment. Two alternative sets of decision rules are presented which might be used as a guide in deciding whether to admit patients. More rigorous selection criteria are suggested in the common situation where the demand for treatment greatly exceeds the supply of facilities, but such criteria would result in the exclusion of a small proportion of borderline patients who might respond to in-patient psychotherapy and might otherwise prove untreatable.
Admission to hospital for psychotherapy facilitates communication with patients and allows more ways of influencing them than do conventional out-patient situations. Small and large groups can be added to individual interviews, and living together allows the development of many potentially therapeutic relationships with other patients and staff. This additional influence can be ignored. If it is assumed to be an integral part of treatment and organised rationally, the whole hospital becomes its instrument; psychotherapists, nurses, patients, domestic staff and administrators can be seen to be subordinate to that whole, and their traditional activities, attitudes to each other, and theories, are inevitably modified. Traditional boundaries between the roles of different workers become blurred, while how they get on with each other has important consequences for patients, so that their separate roles and functions must be clearly defined.
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