The need for a document which outlines how psychotherapy is and should be practised in the 1990s and into the next century emerged in response to four major phenomena – namely:

1 the realization that there were no written guidelines or standards for the practice of medical psychotherapy;

2 the changing forces that now influence health policy and funding, both in the United States and in Canada;

3 the potential for arbitrary de-insurance of some psychiatric procedures in the absence of agreed-upon standards, and without regard for the evidence showing the effectiveness of those procedures;

4 growing concern regarding the...

In order to establish standards for the practice of psychotherapy, it is essential first to define ʹpsychotherapy.ʹ Several issues must be addressed in formulating the definition. Should there be one definition that encompasses all psychotherapies practised by physicians, or should each specific form of psychotherapy be defined separately? Is there a distinction between medical psychotherapy and psychotherapy practised by non-medical therapists? How can the numerous forms of psychotherapy be classified? Can a definition be employed to differentiate psychotherapy from other forms of medical interventions that may not involve the same ethical constraints?

Only one of the current editions of the...

In general, standards of psychotherapeutic practice are based on two related components the ethical aspects and the technical aspects of professional practice

Ethical standards of practice are regulated by professional licensing bodies, such as the College of Physicians and Surgeons of Ontario (CPSO) Professional bodies, such as provincial and national medical and psychiatric associations, have also been instrumental in developing ethical standards The Canadian Medical Association (CMA) maintains a Code of Ethics and issues periodic policy summaries on ethical issues For example, the CMA has recently published a policy summary titled ʹThe Patient–Physician Relationship and the Sexual Abuse of...

Individual psychodynamic psychotherapy is based on principles derived from psychoanalytic theory and practice. Other terms for this form of treatment include ʹpsychoanalytic psychotherapy,ʹ ʹinsight-oriented psychotherapy,ʹ ʹuncovering psychotherapy,ʹ and ʹexpressive–supportive psychotherapy.ʹ Individual psychodynamic psychotherapy is the form most frequently practised by psychiatrists in North America (Luborsky, Docherty, Barber, & Miller, 1993). This form of treatment can be used alone or together with other treatments, including medication and conjoint psychotherapies (Gabbard, 1994). The guidelines described here frequently make reference, for empirical support, to chapter 4, ʹEmpirical Evidence for the Core Clinical Concepts and Efficacy of the Psychoanalytic Psychotherapies: An Overview.ʹ

Psychoanalytic psychotherapy...

There is a wealth of empirical evidence supporting the efficacy of the psychoanalytic psychotherapies and the core concepts on which they are based. Though there are more than a hundred different types of psychotherapy, a recent review of the forty major international psychotherapy research programs found that eighteen of these programs are mainly psychoanalytic in orientation (Beutler & Crago, 1991). Thus the psychoanalytic psychotherapies, from the various forms of face-to-face psychoanalytic (sometimes called ʹpsychodynamicʹ) psychotherapies to psychoanalysis, not only have been, but continue to be, among the most intensively studied treatments (Doidge, 1997; Sledge, 1997).

The psychoanalytic psychotherapies are the most...

Cognitive behavioural therapy (CBT) is a model of psychotherapy based on principles derived from learning theory and cognitive science. It includes a variety of strategies that are continually evolving, based on findings from empirical research. CBT differs from traditional psychotherapies in several respects. The main focus of CBT is identifying and changing variables that currently maintain problem behaviours, rather than those factors that may have initially contributed to the onset of a disorder. In addition, CBT tends to be conducted in fewer sessions than other psychotherapies. Treatment typically lasts from as little as one session (e.g., in the treatment of...

The goals of this chapter are to offer guidelines for the practice of brief psychodynamic psychotherapy by defining its goals, contrasting it with other short psychotherapeutic interventions, describing its theoretical underpinnings, summarizing the major schools of brief psychodynamic psychotherapy, detailing elements common to all the brief psychodynamic psychotherapies, focusing on indications and contraindications, précising its scientific basis, and commenting on training and credentialling. These guidelines are generic, and refer broadly to clinical situations where brief psychodynamic psychotherapy is generally recommended, rather than prescribed for any one specific disorder. It should also be borne in mind that, reflecting the paucity of...

Couple and family psychotherapy are interventions with two partners, with the nuclear family, or with the extended family. These interventions include therapy models based on different theories. Although couple and family therapy share features and require similar guidelines, differences are significant enough to base this chapter onHandbook of Psychotherapy and Behavior Change(Bergin & Garfield, 1994), and discuss them separately.

Physicians are frequently consulted by patients who seek help because of relational problems with their partners. The usual medical training provides little preparation for doctors facing these difficulties. Most practitioners use common sense and good intentions to help, but remain...

Group therapy encompasses a range of interventions that include focused psychoeducational groups, support groups, time-limited groups, and ongoing psychotherapy groups intended to change behaviour and character structure. This chapter focuses on the standard psychotherapy group for moderately disturbed ambulatory patients, which constitutes the core of group therapy. The principles that emerge from this model provide relevant practice guidelines for all types of group psychotherapy.

According to Yalom (1995), the enormous expansion of group approaches in the past ten years reflects the attempts of practitioners to identify unique patient problems and concerns, to devise suitable models of intervention, and to develop...

Supportive factors in psychotherapy refer to those attitudes, personal characteristics, and behaviours a therapist presents in his or her ongoing interaction with a patient that enable the development of a real relationship and a therapeutic alliance. In some supportive therapies, a mild transference may emerge but it is not evident in all supportive therapies. Thus, when a patient experiences support in an interaction with a therapist, he or she enters a safe space where change and development can be entertained and optimistically worked towards.

What is clear with experience and consistent with theoretical formulation is that support does not mean...

Why is it important for clinicians of varied backgrounds to have access to practice guidelines in the area of child and adolescent psychotherapy (hereinafter referred to as ʹchild therapy,ʹ and encompassing individual, family, and group formats unless otherwise specified)? On a practical note, there are simply too few subspecialists to meet the need of the child-psychiatric population (Offord, Boyle, & Racine, 1989; Heseltine, 1983; Cleghorn, Miller, & Humphrey, 1982). Mental health professionals who are not child psychiatrists can therefore expect to (and already do) treat a significant number of young people (Looney, Ellis, & Benedek, 1985; Parker, 1992). Often, however, these clinicians feel...

The inclusion of a chapter on the combined use of pharmacotherapy and psychotherapy in a book on the guidelines for psychotherapy reflects the general acceptance of an integrated treatment approach in most psychiatric disorders. Despite combined treatment being ʹtime-honoredʹ (Gabbard, 1990, p. 146) in the clinical practice of psychiatry, until recently there was significant polarization within psychiatry (Frances, Clarkin, & Perry, 1984; Klerman, 1991; Paykel, 1995). Those who viewed themselves as biologically oriented often ignored psychotherapy. Many of those practising and promoting psychotherapy as the treatment of choice in a broad range of psychiatric disorders were sceptical about the efficacy of...

In the last half of this century, psychiatric practice has been influenced by the development of increasingly effective biological treatments and the phenomenon of deinstitutionalization. Patients with severe and persistent mental illness, however, continue to experience considerable morbidity, and many fall through the cracks of service delivery. Currently, biological therapies and rehabilitation programs are the mainstay for this population, while a variety of psychotherapeutic interventions may facilitate optimum care. This chapter considers the role of psychotherapy in the treatment of persons with severe and persistent mental illness. Using schizophrenia as a model, it addresses issues of definition, efficacy, and practice...

Currently standards for psychotherapy training vary considerably among different training centres. This chapter reviews the challenges faced by training programs and proposes a strategy for meeting them. The strategy includes guidelines for: selection and training of supervisors; creation of effective clinical and training structures; curriculum development, including objectives for general psychiatrists and for psychiatrists specializing in psychotherapy; evaluation of trainees; and continuing education. The chapter contains an afterword on personal qualities of medical psychotherapists.

This chapter is not intended as the final word on psychotherapy training. Rather, it is intended to stimulate debate and collaboration between academic course directors and,...

Psychotherapy supervision is generally regarded as the most powerful tool for teaching and learning psychotherapy, and constitutes the core of any psychotherapy training program. It is a crucial part of the education that facilitates development of the identity of the trainee as a psychotherapist. The process involves a number of intimate relationships, in which the supervisee reveals the work that he or she has done with patients in the privacy of the office. Supervision takes place in an individual or a group format. It may utilize process notes, audio- or videotape, direct observation, or a combination of these.

Guidelines for...

Over the past three decades, cognitive behavioural therapy (CBT) has become one of the predominant forces in psychotherapeutic practice (Norcross, 1986). Empirical outcome research suggests that it is arguably the most efficacious psychological treatment for depression (Dobson, 1989) and anxiety disorders (Clark, 1989). Unfortunately, the psychotherapy training of psychiatry residents has dramatically lagged behind CBTʹs growing acceptance and influence. A recent survey of U.S. psychiatry postgraduate directors (Ritchie & White, 1992) found that only 54 per cent of programs offer any CBT and, even then, most residents treat fewer than five patients, which is grossly inadequate to acquire minimum proficiency in...

Throughout the twentieth century, there has been an evolution in the role and position of the sexes in society. The psychiatric understanding of gender has been influenced by contributions from anthropology, biology, psychiatry, psychoanalysis, psychology, and sociology. Through awareness and sensitivity, it is essential for psychotherapists to avoid some common biases about sex and gender. (Therapists must be equally sensitive to differences in race, culture, disability, poverty, and religious faith.) In order to enhance their understanding of patients and the patientʹs understanding of therapists, both male and female therapists must be cognizant of gender differences in the psychological development of...

According to one of the fieldʹs authorities (Wolberg, 1967), psychotherapy is ʹtreatment, by psychological means, of problems of an emotional nature in which a trained person deliberately establishes a professional relationship with the patient with the object of 1) removing, modifying, or retarding existing symptoms, 2) mediating disturbed patterns of behaviour, and 3) promoting positive personality growth and developmentʹ (p. 3).

This thirty-year-old definition articulates important goals for practice. However, radical changes in Canadian and U.S. society are challenging what once seemed unassailable philosophical tenets – the tenets of psychotherapeutic practice among them.

During the past two decades, immigration has...

The clear consensus of legal, ethical, and clinical opinion is that a therapist is ordinarily obligated to obtain his or her patientʹs informed consent to psychotherapy prior to initiating treatment. (Appelbaum & Gutheil, 1991; Sharpe, 1987;Zinermon v. Burch, 1990;Fleming v. Reid and Gallagher, 1991). Yet, although the obligation itself is clear, its basis and purpose are less so, and in practice it may sometimes be difficult to satisfy. The purpose of this chapter is to highlight and describe the obligation; to sketch the tensions or difficulties that it embodies; and to offer a concise, practical outline of what is...

This chapter reviews important issues of record keeping in psychiatry and psychotherapy. The basic requirements of medical-psychotherapy record keeping are outlined, and some of the more difficult aspects are illustrated.

Record keeping in psychotherapy is recognized as a valuable and important clinical task (Reynolds, Mair, & Fischer, 1992). Psychiatrists are expected to keep track of their patientsʹ progress solely through their records. The reasons therapists cite for producing and maintaining records range from purely medico-legal obligation to the desire to accurately record patient and therapist experiences and interactions. Although surveys suggest there is a direct correlation between the quality of mental...