Bedside psychotherapy: Brief and surprisingly effective
A therapeutic alliance often develops within minutes
- create a new perspective
- increase self-esteem by emphasizing the patient’s strengths
- support coping mechanisms that worked in the past.
This approach also can help the patient understand that a psychiatric symptom is an understandable response when a previously successful adaptive method cannot be used.
Choosing a psychotherapy
Three factors—patient characteristics, therapist characteristics, and evidence—determine the psychotherapeutic approach.
Patient characteristics include ego functioning level and maturity, object relationship stability,13 history and experience of psychotherapeutic treatment, personality and coping style, and physical condition. For example:
- CBT and education may be effective for patients who cope through analytical thinking, controlling emotional expression, and managing situations.
- Psychodynamic methods may help those who cope through expressing feelings, self-reflection, and a wish to be understood.
Therapist characteristics include experience, preference, and degree of comfort in conducting each therapeutic approach, as well as time and schedule.
The goal of a resilience-building interview is to enable patients under stress to focus their attention and mobilize their emotions while answering each question.10,14 Here are sample questions, grouped by issues the psychiatrist wishes to address.
Countering isolation
- Who understands your situation?
- In whose presence do you feel peaceful?
Countering meaninglessness
- For whom or what does it matter that you continue to live?
Countering despair
- What keeps you from giving up on difficult days?
- From what sources do you draw hope?
Countering sorrow
- What sustains your capacity for joy in the midst of pain?
- What has this experience added to your life?
- Are there things that take your mind off your illness and comfort you?
Promoting resilience
- What part of you is strongest right now?
- What is still possible?
Promoting continuity of self/role preservation
- What should I know about you as a person that lies beyond this illness?
- How have you prevented this illness from taking charge of your life and identity?
- What did you do before you were sick that was important to you?
- What about yourself or your life are you most proud of?
- What have you learned about your life during your illness that you would want to pass along to others?
Evidence of efficacy. Psychiatric literature supports using CBT for depressive cognition in major depression,14 resilience-building interviews for demoralization,4 and behavioral therapy and relaxation for anxiety related to medical procedures.12
Case continued: Coming home
As Ms. T’s medical condition improved over several days and her discharge was planned, the psychiatrist began to emphasize practical issues, such as:
- limiting visitation to allow her time to grieve
- addressing her anxieties about outpatient treatment and moving in with her parents.
At discharge, Ms. T was taking citalopram, 40 mg/d, and clonazepam, 0.25 mg as needed. With this regimen, her nightmares and re-experiencing had decreased. The psychiatrist had treated Ms. T in the hospital for 21 days. She continued psychiatric care for acute stress disorder at a local outpatient center.
Related resources
- Academy of Psychosomatic Medicine. www.apm.org
- American Psychosomatic Society. www.psychosomatic.org
- Griffith JL, Griffith ME. Encountering the sacred in psychotherapy: how to talk with people about their spiritual lives. New York: Guilford Press, 2002.
- Dewan MJ, Steenbarger BN, Greenberg RP (eds). The art and science of brief psychotherapies: a practitioner’s guide. Washington, DC: American Psychiatric Publishing, 2004
Drug brand names
- Citalopram • Celexa
- Clonazepam • Klonopin
Disclosure
Dr. Lolak reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
Acknowledgments
The author thanks James Griffith, MD, and Thomas Wise, MD, for their valuable contributions to this article.
