The term psychological treatment is largely synonymous with psychotherapy, defined by Storr as ìthe art of alleviating personal difficulties through the agency of words and a personal professional relationshipî. Some psychotherapeutic techniques make use of actions, exercise, music or art as well as words. Psychotherapy may be carried out with individuals, groups, couples or families.

HISTORICAL BACKGROUND Medicine has always recognised the importance of the patient's confiding relationship with the physician, as enshrined in the Hippocratic Oath of Ancient Greece. This non-specific psychological aspect of treatment is especially important in psychiatry.

Through the years, more specific psychological approaches have been conceptualised, ranging from mediaeval notions of the ìcasting out of demonsî in mad people to the ìanimal magnetismî of Mesmer in the nineteenth century.

It was only a little over a hundred years ago, however, that a systematic theoretical base for psychological treatment was developed in Sigmund Freudís ìpsychoanalysisî. Although now little used in practice, psychoanalysis has been paramount in establishing the importance of psychological matters with the general public, and in providing one of the most enduringly interesting models of the mind.

The work of Freud and the post-Freudians is briefly described below.

Many of these ideas now look dated, seeming more like cultural movements than medical or scientific theories. Indeed, if one accepts the position that the definition of a scientific theory is that it is capable of being disproved by experiment, little of what is in the next section would be defined as science. However, many people continue to find these theories of great interest, and they have certainly been an important part of the development of psychiatry. The time is not yet arrived when it will be possible to have a proper training in psychiatry without at least an acquaintance with the terms.

Sigmund Freud (1856ñ1939) Freudís system of psychoanalysis forms the basis of modern psychodynamic psychotherapy. During psychoanalysis, in which 50-minute treatment sessions take place 3ñ5 times a week for several years, the patient talks about past and present events, emotions, dreams and fantasies, and uses ìfree associationî to recall repressed or forgotten material to conscious awareness. The therapistís interpretations relate to Freudís concepts, which include:

• The model of the mind: the structure of the mind is seen as having three parts: id (inherited, instinctive, largely unconscious, motivated by the ìpleasure principleî), ego (largely conscious, acting according to the ìreality principleî and using the ego defence mechanisms), superego (derived from introjection of authority figures, and equivalent to conscience).
• Stages of psychosexual development: in each of the oral, anal, oedipal and genital stages, the libido or sexual energy (asserted by Freud to be of prime importance in all areas of mental activity) is attached in a particular direction.
• Transference, in which attitudes derived from early relationships are projected onto the therapist.
• Resistance, in which the patient avoids exploration of a topic which is the subject of unconscious conflicts.
• Ego defence mechanisms: these are unconscious processes to reduce anxiety. They include denial, repression, rationalisation, projection, reaction formation, displacement, sublimation, intellectualisation, conversion, fixation, regression and introjection (see Glossary; they are particularly associated with the name of Anna Freud).
• Dreams, in which the real or ìlatentî content is converted into the ìmanifestî content by the mental ìcensorî using the mechanisms of condensation, displacement and symbolism.
• Parapraxes: mistakes and memory lapses in everyday life, which have unconscious significance (ìFreudian slipsî).
  

Carl Jung (1875ñ1961) Jungís system of psychotherapy, called analytical psychology, emphasises the exploration of dreams and the unconscious, and aims at ìindividuationî of the patient; this involves achieving harmony between the conscious and unconscious, and full experience of the self. Jungian concepts include:

• Libido, or general psychic energy, flowing between pairs of opposites such as progressionñregression, consciousñunconscious, extroversionñintroversion. If it is blocked in one direction pathology results, for example excess energy in the unconscious manifest as psychiatric illness.
• The unconscious mind, as revealed in dreams, with both personal and collective aspects, the latter including instincts, archetypes and universal symbols.
• Personality depends on the degree of extroversion and introversion and which of the ìfour functionsî ñ thinking, feeling, sensation and intuition ñ is most highly developed. There is an outward personality, or ìpersonaî, and an unconscious ìshadowî which has opposite characteristics.
  

Jungís book Man and his Symbols gives a readable, illustrated account of his life and work.

Melanie Klein (1882ñ1960) Klein worked with children under two years old, and believed that failure of psychological development at this time was the origin of neurosis in later life.

She described developmental stages: the paranoid-schizoid position related to the childís perception of its motherís breast first as a ìgood objectî which is introjected, then as a ìbad objectî onto which aggressive feelings are projected, followed by the depressive position when the child becomes aware that the good and bad mother are the same and must cope with the depressive anxiety of having attacked the needed good object.

Other ìneo-Freudiansî include Adler, Fromm, Reich, Erikson, Sullivan, Horney, Anna Freud, Winnicot and Fairbairn.

Supportive psychotherapy involves disc ussion of problems at a simple, practical level, which may include offering advice. Any good doctorñpatient relationship includes an element of supportive psychotherapy
.
Psychotherapy can be usefully combined with antidepressants, or other psychotropic drugs, for patients with formal psychiatric illness.

Many psychotherapists prefer to speak of ìclientsî rather than ìpatientsî, however the term ìpatientî is retained here for the sake of consistency with the rest of the book.

A wide variety of talking treatments is in use in the UK. Outside health services, many patients will consult counsellors and other types of a therapist. Many patients will pay alternative or complementary practitioners, but clearly this is beyond the scope of the present book.

I will concentrate below on the three main types of talking treatment provided in UK health services:

• counselling,
  
• CBT, and
  
• dynamic psychotherapy.

Many other named techniques exist, for example cognitive-analytical therapy (Ryle), interpersonal therapy (Klerman), client-centred therapy (Rogers), Gestalt therapy (Perl), psychodrama (Moreno), and transactional analysis (Berne), though some are largely practiced in the private sector rather than through the NHS. Current opinion emphasises the similarities between different schools of psychotherapy, rather than their differences.

Indications for Psychotherapy The patients who respond best are those suffering from neurotic symptoms or mild personality disorders who are well motivated to change, firmly committed to treatment, able to understand psychological concepts, prepared to take responsibility for decisions, reasonably intelligent and verbally fluent.

Critics might say that patients fulfilling all these criteria are not in pressing need of therapy. Contrary to previous belief, older patients can benefit as well as younger ones.

Contraindications for Psychotherapy Patients who have psychotic illnesses, are taking large quantities of drugs (prescribed or illicit) or alcohol, or have severe personality disorders are usually considered unsuitable.

Unwanted Effects of Psychotherapy

• Excessive dependence on therapy or the therapist.
• Intensive techniques may cause distress and, occasionally, precipitate acute psychiatric breakdown.
• Disorders for which physical treatments are required, for example severe depression, or medical illness presenting with psychological symptoms, may be missed, especially by non-medical therapists.
• Ineffective psychotherapy wastes time and money and lowers morale.
  

Unwanted effects should be infrequent with skilled assessment, and well-trained or closely supervised therapists.

Training of Psychotherapists Therapists usually train following initial qualification and experience in another profession such as psychiatry, psychology, nursing, other health care disciplines and social work.

Training requirements vary widely according to the school of therapy, and a period of personal therapy is required by some.

Desirable qualities in a therapist are the ability to be sympathetic but detached, non-judgmental, and honest. Therapy is more likely to be successful if patient and therapist like one another, so that a strong ìtherapeutic allianceî can develop.

NHS Provision of Psychotherapy Most mental health care services are organised around particular clinical problems and/or patient groups; only Departments of Psychotherapy are based around a particular form of treatment.

This somewhat ìspecialî status has extended to the type of psychotherapy offered, which until recently was mainly psychodynamic, carrying considerable prestige and exerting a strong influence on psychiatric education and training.

Recent years have seen a reaction against psychodynamic psychotherapy. Prospective randomised controlled trials have not generally shown superiority of this treatment over comparison conditions, such as waiting list controls. Brief structured psychotherapies of the cognitive and cognitive-behavioural types do, in contrast, appear more effective than control conditions.

The recent trends are therefore towards increased use of, and funding for, the latter types.

It seems reasonable that health care resources should be focused on treatments which have been shown to be effective (ìevidence-based medicineî), especially considering the greater cost of long courses of dynamic therapy. However, part of this movement may represent another swing of the biological/psychological pendulum in the history of psychiatry; too marked a shift away from the fascinating, if ìunscientificî, notions of psychodynamic psychotherapy may in the future be seen as counterproductive.

Planning and Practical Organisation of Therapy NHS psychotherapy sessions usually take place weekly and last 50 minutes. All sessions should preferably be at the same time on the same day of the week and in the same place. Punctuality by both patient and therapist is important. Interruptions, including phone calls, should be prevented. These practical rules provide patients with a secure framework in which to explore difficult issues.

Some therapists draw up a contract at the beginning to specify the patientís problems, goals of treatment, and proposed number of sessions.

Notes are written immediately afterwards, but not during the session itself. Details of the content of sessions should not be revealed to other people except in the context of supervision seminars.

Some individual types of psychotherapy will now be described.


A great deal of counselling is done in general practice, and in other settings. It has expanded greatly over the past 20 years or so. It is very popular with patients and GPs, and clearly fulfils a need for patients to talk things over with a trusted adviser.

Probably, this popularity is only partly to be seen in mental health terms. Social factors such as the family instability and reduction in involvement in organised religion may have meant that many individuals in distress do not have such ready access to their own means of support as did previous generations. Expectations and values have changed as well, the virtues of reticence (the traditional British ìstiff upper lipî) being replaced by a notion that it is intrinsically ìgood to talkî.

Counselling forms part of the valuable work done with patients by organisations such as the Citizens Advice Bureau (practical problems such as debt, housing, benefits, etc), Cruse (bereavement) and Relate (relationship problems).

Primary care counsellors need to be appropriately accredited and qualified, and to have regular supervision. They usually offer a limited number of sessions, typically six to eight, and practice in a non-directive, supportive way. Most patients probably do well.

From the perspective of secondary care, where patients who have not improved with counselling may be referred, there can be a perception that counsellors do sometimes inappropriately stir up old problems from the past. This can lead to the patient becoming more distressed and perhaps requiring referral, whether they would not otherwise have done so. Certainly, there is no evidence that provision of counselling and primary care leads to a reduction in workload in secondary care.

As regards effectiveness, in a large UK randomised trial, both counselling and cognitive behavioural therapy were more effective for depression than usual GP care, with no difference between the two types of talking therapy (2).

CBT has become established as the psychotherapy of choice, being perceived as effective and cost-effective.

It remains important to understand the twin strands of CBT. Behaviour therapy per se is now less prominent. However, cognitive therapy practitioners are happy to admit that their treatment involves components of behaviour therapy, for example activity scheduling, and that the term cognitive therapy is effectively shorthand for cognitive -behavioural therapy.

The principles of cognitive therapy and behavioural therapy will now be described, followed by an account of how they are brought together in CBT.

Cognitive therapy: is based on the work of Aaron Beck. Like most American psychiatrists of his era, his training was psychodynamic. However, he became frustrated with the lack of progress of patients under his care, in relation to the amount of input. He thus sought to address practically and directly, rather than through the convolutions of psychoanalysis, the maladaptive beliefs and attitudes presumed to contribute towards current symptoms.

Cognitive (Latin cogito: I think) therapy is based on the principle that thought influences mood, so that depression, anxiety and other symptoms arise from, or are perpetuated by, faulty thought patterns and beliefs.

The aim in therapy is to identify automatic negative thoughts which appear to be contributing to the symptoms, and encouraging the patient to reconsider them in the light of the evidence, and to try alternative viewpoints and behaviour patterns. This process should lead to better understanding of the symptoms, and more control over them. For some patients, exploration of visual images is an appropriate variant of this technique.

Beck originally described several types of maladaptive thinking patterns to be addressed in therapy, including:

• Selective abstraction: dwelling on only the negative aspects of a situation.
• Overgeneralisation: a single matter is wrongly assumed to have wide-ranging implications.
• Magnification: a trivial matter is exaggerated out of proportion.
• All-or-none reasoning: issues are seen as ìblack or whiteî with no middle ground.
• Arbitrary inference: things are assumed, without good evidence, to be negative.
  

Behaviour therapy is based on learning theory, a model of human and animal behaviour originating in the field of pure (non-clinical) psychology.

In the 1950s, workers such as Eysenck, Lazarus, Wolpe, Bandura, Marks and Rachman began to introduce these ideas into clinical practice as behaviour therapy. This involves the acquisition of desirable new behaviours as well as the loss of unwanted ones.

Behavioural therapy is a structured method, employing practical strategies to overcome current symptoms. The principle is changing behaviour, rather than addressing presumed underlying causes or accompanying thoughts and feelings. It was related to Pavolvian principles, where external changes had significant effects on the responses of the individual.

Common parlance such as ìget back on the horseî or ìuse makes masterî encapsulate the principle that doing a feared activity or entering a feared situation of itself causes subsequent fears to be less. This illustrates the principle of behaviour therapy.

Behaviour therapy was originally applied to those neurotic symptoms which could be regarded as ìmaladaptive learned responsesî, for example a monophobia (a phobia restricted to one specific object or situation) developing after a frightening experience. Behavioural techniques have since been applied to a much wider range of disorders, for example generalised anxiety states, obsessive-compulsive disorders, eating disorders, sexual problems, and the management of chronic disability caused by brain damage or schizophrenia.

Problems are defined, and objectives of therapy agreed, at the beginning. Progress during therapy is regularly assessed using measurable criteria: frequency of occurrence of a particular behaviour pattern or questionnaires to monitor mood change, for example.

Critics have claimed on theoretical grounds that, because the past events or unconscious conflicts which produced the symptoms are ignored, behaviour therapy cannot produce a lasting cure and that ìsymptom substitutionî will occur. In practice this seldom happens.

Behaviour therapy appears comparable in efficacy to other forms of psychotherapy, is often less time-consuming than other methods, and the patient need not be intelligent or verbally fluent to benefit.

Specific techniques include:

• Systematic desensitisation (graded exposure): progressive introduction to a feared object or situation, using an agreed hierarchy. For example, a person with a fear of spiders agrees with the therapist to encounter them first in imagination, then pictures, followed by a plastic one and then a real one.
• Flooding: immediate exposure to the feared stimulus in its full form. This is claimed to be as effective as graded exposure, but many patients find the prospect unacceptable.
• Modeling: the patient imitates the therapistís behaviour, for example in social skills or assertiveness training.
• Biofeedback techniques: to modify physiological variables such as heart rate, blood pressure and muscle tension. Some people find this helpful in controlling anxiety or pain.
• Response prevention: for compulsive behaviour. For example, the therapist prevents the obsessional patient from repeated hand-washing; the patientís anxiety initially rises, but then decays naturally when the feared consequence (such as infection) does not occur.
• Thought stopping: for obsessional thoughts. The patient learns to stop an obsessional train of thought, usually by ìswitchingî to another. This is very similar to the cognitive technique of ìdistractionî.
• Massed practice (satiation): the unwanted behaviour is repeated so often that the patient no longer wants to continue it.
• Aversion therapy: traditional forms are now seldom used for ethical reasons. They involved coupling an unwanted behaviour, such as substance misuse or deviant sexuality, with an unpleasant stimulus such as drug-induced vomiting or electric shock. Milder self-administered forms may be helpful, for example snapping an elastic band worn around the wrist can provide distraction from obsessional thoughts or from an unwanted behaviour such as overeating.
• Covert sensitisation: aversion therapy carried out in imagination only.
• Shaping (chaining): the separate learning of each stage in a complex process, for example a brain-damaged or learning-disabled patient learning to dress.
• Token economy regimes: rewards are given for desirable behaviour, and privileges withdrawn for undesirable behaviour. The approach has been used in the rehabilitation of chronic schizophrenics, but ethical considerations apply.
• Relaxation training: used in a variety of problems, mainly to manage anxiety. The patient tenses up and then progressively relaxes all muscle groups, while breathing regularly and deeply. This is a gradually acquired skill, which can be taught individually or in groups, or with the aid of commercially available audio- and video-tapes.
  

A course of behaviour therapy would typically involve several of the above components, for example a spider phobic might take part in a programme of graded exposure, and be given relaxation training to cope with attendant anxiety.

It seems likely that most behavioural treatments include some cognitive component, though some purists might not accept this.

CBT in practice CBT is brief (6ñ12 sessions), problem-oriented, and demands active participation both from the therapist, who provides a structured approach and sometimes a substantial educational input, and from the patient.

Structure is provided by several factors, including:

• Prior agreement on the number of sessions. Setting of agreed, tangible goals (such as a patient with social phobia going shopping alone).
• Planned structure for each session.
• Homework.
  

A typical session includes:

• Greeting.
• Setting agenda for session.
• Review of homework.
• Review of events since previous session.
• Feedback on last session.
• Problems to be addressed in session.
• Setting homework.
• Feedback.
  

Components of the therapy include:

• Cognitive techniques, for example:
• questioning negative automatic thoughts
• distraction techniques to take the patientís attention away from negative thoughts.
• Behavioural techniques:
• keeping a diary: simple notes on thoughts/feelings/activity to establish the influence of thoughts on mood
• activity scheduling: planning pleasurable experiences/activities.
  

Many of these are first tried out within the session, and then practised as agreed specific homework tasks.

The skill of the therapist lies not only in using these techniques and structures, but doing so in a sensitive and supportive way, for the building of a good rapport between patient and therapist is as essential here as in all kinds of therapy.

Trust in the therapist will encourage the patient to engage in prescribed tasks which are often anxiety-provoking or even unpleasant in themselves, such as going out for the socially phobic person, or challenging a negative self-concept for the depressed.

Indications for CBT Randomised controlled trials have shown that cognitive-behavioural therapy is effective in mild to moderate depression (3). Other trials have shown it to be effective for anxiety disorders (4, 5, 6), bulimia nervosa (7), and possibly also for somatoform disorders, and even in psychotic disorders. As well as treating an index episode, this therapy may have prophylactic value in preventing future episodes (secondary prevention).

Case Example

A man who had been made redundant from his job as a bank manager developed a depressive illness; retaining his private medical insurance for a limited time, he saw a psychiatrist privately. Declining medication, he was referred for cognitive therapy; the insurer agreed to pay for 10 one-hour sessions. The patient considered himself an utter failure at work, and extended this belief to all other aspects of his life (overgeneralisation), perceiving rejections where none were intended and becoming even more depressed in consequence. Objective consideration revealed that his redundancy was one of many in the bank, occasioned by transfer of jobs to foreign parts, rather than a personal rejection as he had assumed (arbitrary inference). Keeping a mood diary quickly convinced him of the connection between his thoughts and his depressed mood. He made rapid progress in the first three sessions, but then ìgot stuckî. Further cognitive work increased his insight but did not improve his mood. The therapist noticed his reluctance to set practical goals, and placed more emphasis on activity scheduling, especially pleasurable activities outside the home. By the end of therapy he had made further progress, and was happy with the outcome: patient and therapist agreed that residual symptoms (mainly social anxiety, lack of energy, and poor concentration) would continue to improve if he continued to practice the new thinking skills he had learnt, and to build up his social activities, which had previously been mainly related to his work.

Psychodynamic (interpretative): exploration of early life, and re-experiencing of habitual patterns in the current relationship with the therapist, are used to explain and relieve symptoms. Modern psychodynamic methods, though based on those of Freud and the post-Freudians, use shorter and more eclectic treatment, for example cognitive analytic therapy (Ryle).

Before a patient is taken on for psychodynamic therapy, a detailed initial assessment should be carried out by an experienced therapist. Presenting symptoms should be considered in the light of early experience, use of psychological defence mechanisms, and personality traits. Subsequent treatment may, in training units, be carried out by a more junior therapist under supervision.
Duration of treatment in the NHS, previously a year or more, now tends to be measured in months.

Technique, and Mechanisms of Change The therapist should take the role of a professional but sympathetic listener; avoid asking too many questions; and avoid imposing his or her own feelings and opinions through making moral judgements or giving direct advice. In contrast to cognitive and behavioural therapies, there is no explicit planned agenda to the sessions.

While improvement of current symptoms may result simply from the opportunity to talk and express feelings, more fundamental change usually requires the use of interpretations designed to help the patient be more aware of emotions and express them more clearly:

• Identifying and challenging defences against unacknowledged feelings: use of mental defence mechanisms (see Glossary).
• Pointing out discrepancies between stated wishes and actual behaviour, for example a patient may repeatedly say that he wishes to end an unsatisfactory relationship, but takes no practical steps to do so.
• Pointing out links between earlier life experiences and current problems, for example, a patientís silence in the face of marital problems might parallel his response as a child to difficulties between his parents.
• Comments on the transference between patient and therapist as revealed by the patientís behaviour within the session itself. Transference means the patient feels and behaves towards the therapist as towards important figures in the past. Transference can develop more easily if the therapistís real personal attitudes and circumstances are not revealed.
• Countertransference, the therapistís feelings and behaviour towards the patient, may also be utilised constructively if properly recognised. If not recognised, they can hinder the therapy.
  

Evaluation of Results As discussed above, randomised controlled trials suggest that psychodynamic therapy has little or no therapeutic effect additional to that of comparison conditions, in contrast to the more structured cognitive and behaviour therapies which have consistently demonstrated positive treatment outcomes. Psychodynamic therapists have responded by pointing out that there are difficulties evaluating the outcome, because:

• Neurotic disorders often remit spontaneously.
• Specific effects of psychotherapeutic technique are difficult to distinguish from non-specific benefits of regular individual attention.
• The content of treatment sessions is difficult to standardise because it varies with the individual characteristics of patient and therapist.
• Benefits of a subtle kind may not be detectable by standard questionnaires.
  

However, these considerations have not prevented cognitive-behavioural therapy being demonstrated as effective. Perhaps the only valid response is that the outcome criteria are not agreed between the two broad schools of psychotherapy; many psychodynamic patients do not fit into a formal diagnostic category, and may wish for therapy for personal development rather than symptom relief. In either case, it is becoming increasingly hard to justify expenditure of limited NHS psychiatric resources on individual psychodynamic therapy, though it is still available in the private sector.

GROUP THERAPY Group therapy is more powerful than individual therapy for some patients, and more economical of resources. Groups may use any of the techniques described above, for example analytical, cognitive, behavioural.

Selection criteria are similar to those for psychotherapy in general. Group therapy is especially suitable for patients whose main problems concern relationships with others, and patients with a shared problem: alcohol or drug misuse, anxiety, childhood sexual abuse for example. Shy patients who find it difficult to participate in group discussion may not benefit, whereas talkative patients may monopolise a group and arouse hostility from the other members, but a skilled therapist can encourage both types to play a more balanced part.

The therapist should facilitate trust and open disclosure, and encourage regular attendance. Factors likely to impede the groupís success, such as dropping-out, lateness, absences, socialisation outside the group, breaches of confidentiality and sub-grouping, should be discouraged.

Some therapists act as detached leaders, others participate more actively. Some groups have two co-therapists, preferably of equal status.

The same mechanisms operate as in individual therapy, but those treated in groups have the advantage of being able to share their problems and ways of coping with others similarly affected.

As the introduction of newcomers may retard progress and arouse hostility, ìclosedî groups with a fixed lifespan and the same members throughout are ideal, if not always practicable. A good size is 5ñ10 members. Outpatient groups usually meet once a week for 1ñ2 hours. Groups run on psychoanalytic lines may continue for two years or more. Groups using behavioural or cognitive techniques, for example anxiety management groups, last only 6ñ12 weeks. Inpatient units run on ìtherapeutic communityî lines use daily group therapy as the main method of treatment.

FAMILY AND MARITAL THERAPY Psychiatric symptoms are often exacerbated by a dysfunctional relationship between marriage partners, or within a larger family group. Common problems include:

• Scapegoating, in which one family member is automatically blamed for problems.
• Extremes of authority and dependency.
• Ambiguous communication styles.
• Family secrets.
• Gratification of one person through the illness of another.
• A shared stress, such as bereavement, affecting the whole family.
  

Systems theory has been influential; it views the family as a self-contained system, in which changes in one element are compensated for by complementary changes in others. Thus, problems in one family member can be addressed not only directly, but also by changing the response of the others.

There are various types of family therapy.Strategic therapy empahsises the role of the therapist in designing and evaluating the effects of therapy.

Recent trends within society, for example the replacement of traditional marriage by ìserial monogamyî, more mothers working outside the home, more men unemployed, and fewer old people in close contact with their children and grandchildren, have influenced the type of presenting problems and expectations of outcome.

Therapy involves regular meetings between family members and therapist(s). As with group therapy, a particular technique can be adopted, but general principles include:

• Encouraging clear communication between family members.
• Setting practical goals agreed by all parties.
• Emphasising positive aspects of relationships, and encouraging rewarding behaviour.
• Discouraging criticisms, especially repetitive ones about the past.
  

Role-play may be used to enable better appreciation of othersí points of view.
Good motivation by all participants, and a reasonable degree of goodwill and honesty between them, are prerequisites for success and the therapists should avoid taking sides.


Dialectical behaviour therapy DBT for borderline personality disorder (9) represents a novel way of seeking to help some of the most damaged and inaccessible psychiatric patients.

Certain software packages are already officially recommended for milder states of depression and anxiety (10). The internet offers a potentially confusing mixture of harmful and helpful information for patients (11); already, online CBT is in development ( e.g. 12).

1 Jung Man and his Symbols