Broadening the repertoire of psychological responses

Realistic management of adjustment disorders involves offering what has been called a 'menu of interventions'. (!Z) Unfocused 'support' is of limited value, because it does not encourage active secondary appraisal and experiments with different coping strategies. However, there are now many brief and flexible psychological therapies available, which may be suitable for use in the physically ill.

Psychiatric treatment of the physically ill, especially in hospital, requires a number of modifications to routine clinical practice, which are sometimes overlooked.

First, an extra effort has to be made to meet the family and carers. They may be reluctant to attend if there is hostility in the family, or if missed time from work is creating financial pressures, but failure to interview others makes it near-impossible to come to a full and accurate formulation of the problem.

Second, personal contact with the referrer is highly desirable. The 'real' question may not be that posed in the referral, and can only be identified by probing. Advice is much more likely to be followed if it is delivered face to face, and followed up with a later visit to check on compliance! This direct contact with non-psychiatric colleagues is one of the defining characteristics of liaison psychiatry, and its importance cannot be overemphasized.

Third, it must be recognized that the course of psychiatric treatment needs to be modified. Appointments will be missed, or interrupted, by the demands of physical treatment. And psychological issues may well not be resolved by a single clinical encounter; a relapse of illness may provoke a further episode with new features, and patients often have to return repeatedly to work through themes in therapy as they are re-challenged with new physical problems.

• Motivational interviewing is an approach developed to encourage people to attempt change in addictive behaviours. It may be useful in engaging people in demanding treatments, or in improving adherence to treatment regimes.

• Graded activity has been used to treat negative symptoms in mental illness like schizophrenia or depressive disorder. It is effective in improving function in chronic fatigue syndrome, and is worth using in other conditions where inactivity and passivity is out of proportion to physical disability.

• Anger management is a modification of cognitive-behaviour therapy, which may be useful where irritability or aggressive behaviour is complicating adjustment.

• Interpersonal therapy was initially developed for the treatment of depression, but it has obvious applications in the field of physical illness. In the terminology of interpersonal therapy, illness represents a role transition, and the focus in therapy is therefore on negotiating that transition with key others in the patient's life.(18)

• Family therapy and couples therapy are rarely considered (or available) for adults with physical illness, and yet many of the external resources needed for coping are in the family.

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