วารสารสมาคมจิตแพทย์แห่งประเทศไทย
Journal of the Psychiatrist Association of Thailand
ISSN: 0125-6985
บรรณาธิการ มาโนช หล่อตระกูล
Editor: Manote Lotrakul, M.D.

Chantima Ongkosit Krairiksh, M.D.*

 Abstract: Psychiatry in Thailand has undergone a major revolution during the past two decades to become an important member of the Thai healthcare system. The rapid progression in psychopharmacology seems to have obscured other treatment modalities. However, medication alone cannot overcome pain and miseries of life. Psychiatrists are special from other specialties in medicine by their understanding of the human mind and behavior with the special knowledge and skill of psychotherapy. In this article the author discussed of some important aspects of psychotherapy in Thailand such as the therapeutic setting, patients' characteristics, the diagnostic interview, patient selection, therapeutic modalities, and the goal of psychotherapy. While patients are encouraged to achieve independence, a balanced approach should be considered to prevent any disruption or alienation of the patient’s most important supporting system-the family.

J Psychiatr Assoc Thailand 1997 ; 42(3) : 150-55.

 Key words: psychotherapy, Thailand, culture

  Samitivej Hospital, Bangkok 10110

 จันทิมา องค์โฆษิต ไกรฤกษ์ *

 บทคัดย่อ จิตเวชศาสตร์ในประเทศไทยในช่วงสองทศวรรษที่ผ่านมามีความรุดหน้าไปมาก ปัจจุบันเป็นที่ยอมรับกันว่าเป็นสาขาวิชาทางการแพทย์ที่มีส่วนสำคัญในการช่วยเหลือผู้ป่วย ความก้าวหน้าในด้านการรักษาด้วยยา ดูเสมือนว่าจะทำให้การรักษาวิธีอื่นๆ ด้อยลงไป อย่างไรก็ตามยาไม่สามารถแก้ไขปัญหาชีวิตต่างๆ ของคนเราได้ ความเข้าใจสภาวะจิตใจและพฤติกรรมของคนเราตลอดจนความรู้และทักษะในการรักษาผู้ป่วยด้วยวิธีจิตบำบัดจึงเป็นเอกลักษณ์ซึ่งทำให้จิตแพทย์ต่างไปจากแพทย์สาขาอื่นๆ ที่อาจใช้ยาทางจิตเวชได้ดีเช่นกัน ในบทความนี้ผู้เขียนได้กล่าวถึงความสำคัญของการรักษาด้วยจิตบำบัด และองค์ประกอบต่างๆ ของการทำจิตบำบัดจากประสบการณ์การรักษาในโรงพยาบาลเอกชน ได้แก่ ข้อคำนึงด้านสถานที่ ลักษณะผู้ป่วย การสัมภาษณ์เพื่อการวินิจฉัย การคัดเลือกผู้ป่วย และรูปแบบวิธีการรักษา ซึ่งผู้เขียนมีความเห็นว่าผู้รักษาควรเลือกใช้ให้เหมาะสมกับลักษณะและปัญหาของผู้ป่วย และอาจปรับเปลี่ยนรูปแบบการรักษาได้ตามความคืบหน้าของการรักษา วัตถุประสงค์ของการรักษาควรคำนึงถึงความเป็นไปได้ ตามภูมิหลัง ค่านิยมและสภาพสังคมของผู้ป่วยแต่ละคน สิ่งสำคัญที่ควรตระหนักคือ สำหรับวัฒนธรรมไทยเราแล้วครอบครัวยังเป็นส่วนสำคัญในชีวิตของผู้ป่วย การทำจิตบำบัดมุ่งส่งเสริมให้ผู้ป่วยมีความเป็นตัวของตัวเอง พึ่งตนเองได้ ในขณะเดียวกันผู้ป่วยก็ยังคงสามารถปรับตัวได้ดีต่อคนรอบข้าง โดยเฉพาะคนในครอบครัว

วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2540; 42(3) : 150-55.

 คำสำคัญ จิตบำบัด วัฒนธรรม ประเทศไทย

  * โรงพยาบาลสมิติเวช กรุงเทพมหานคร 10110

 In the past two decades, psychiatry in Thailand has undergone a major evolution. From a neglected and often ridiculed status as being backward as well as unscientific, psychiatry has now emerged as an important and essential discipline in the practice of medicine. In this generation of new scientific discoveries of the biological and neurochemical basis of psychiatric disorders and more effective psychopharmacological agents, Psychiatry is no longer an outcast but becomes an important team member in the provision of health care, especially on the private practice setting. The data collected at Samitivej Hospital of the number of outpatients and inpatients of each medical specialty in 1996 shows that the total outpatient psychiatric patients visits was 10,142, an impressive figure considering the few number of psychiatrists practicing, an equivalent of approximately three full time psychiatrists, with no other trained parapsychiatric team members. Psychiatric in-patients totaled 108 cases in spite of the lack of in-patient psychiatric facilities.

Unfortunately, while the successful and effective psychopharmacological treatment has greatly contributed to this new psychiatric era, it appears to also be gradually replacing other psychiatric treatment modalities. Good psychiatric treatment should be an integration of the different treatment modalities as required by the patient, not just a simple choice between ‘either/or’ but ‘this/and’. Medication can effectively alleviate many psychiatric symptoms but it cannot overcome the pain and miseries of life, whether the cause is real and situational such as loss and grief of intrapsychic or neurotic such as low self esteem or guilt.

Psychiatry without a dynamic understanding of the patient is no longer psychiatry, it may as well become any other medical subspecialty such as neuro-endocrinology. The understanding of the human mind and behavior and the special knowledge and skill of psychotherapy forms the unique core of psychiatry. Without this skill, psychiatry will become extinct. The practice of psychotherapy here in Thailand will necessarily differ in some aspects from other countries especially of those in the West because of the basic differences inherent in the cultures.

Setting: Psychotherapy can be practiced in any medical setting that offers a safe, clean, comfortable atmosphere which provides privacy. My patients share all of the hospital facilities with other general patients to avoid discrimination or alienation. Regular hospital files are used to record the clinical findings, diagnosis and treatment. Confidential personal details and psychotherapeutic issues are not recorded in the general file and the therapist may wish to keep a separate file apart from the general hospital file. No psychiatric records can be released without the treating psychiatrist’s written permission. Patient signs a release of information to the psychiatrist for each and every request of his or her record after a verbal discussion.

The patients: Psychiatric patients seen in the practice is the heterogeneous group: economically, socially educationally. However, all patients must be treated equally and respectfully. Initially, referrals for treatment are usually made by other physicians. However, at a later stage, self referrals are more common. Reputation are spread through words of mouth and patients often specifically request to ‘TALK’ about their problems.

Diagnostic interview: All patients are first seen for a diagnostic interview where the focus is placed on a descriptive and mental status examination for the presence of psychiatric disorders and assessment of psychosocial stressors. The precipitating cause, relationship to significant figures, life events and changes need to be explored. Meanwhile, it is always essential to establish rapport, therapeutic alliance, mutual trust and confidence, the basic ingredients of the therapeutic success. In Thailand, where physicians are usually well respected, a considerate and caring psychiatrist can readily establish a positive doctor-patient relationship.

Patient selection: Every patient should be considered as a potential candidate for psychotherapy rather than vice versa. Only those with no psychosocial stressors and who can function adequately when symptoms have been alleviated by psychopharmacological agents are the patients who do not need psychotherapy. Most patients, however, have psychosocial stressors from mild to catastrophic levels that impair their psychological functioning but not all patients need intensive psychotherapy. Many will return to adequate functioning after some support and restoration of psychological equilibrium. Such supportive treatment, aiming to help the patient to reestablish the usual level of functioning, can be provided to the patients during their regular visits. Those who require more time, psychotherapy are scheduled for 30 minutes or 50 minutes individual psychotherapy. 

Absence of psychosocial stressors Presence of psychosocial stressor

psychotherapy not required psychodynamic assessment

consider psychotherapy 

Therapeutic modalities chosen for each patient are didactic, ranging from supportive psychotherapy to psychodynamically-oriented psychotherapy, behavioral therapy, cognitive therapy or transactional analysis. The goal is to provide the most effective and time-efficient treatment appropriate to that particular patient. Factors such as motivation, ability, psychological-mindedness, time constraints on both sides, and the treatment cost are all considered in the treatment planning of each patient.

The various treatment modalities available today has enabled a therapist to work more effectively and speedily with psychotherapeutic patients. A therapist needs to thoroughly understand the patient dynamically but the treatment offered should not be limited to psychodynamic psychotherapy only. There are many elements in a person. People have several dimensions and thus a psychiatrist should identify the dimension of the system in which help is needed whether it is the emotional or the thinking or the operation system and choose the appropriate treatment modality. Cognitive therapy focuses on changing a way a person thinks implies while behavioral therapy aims at the correction of the behavior. Transactional analysis has been successful in helping with communication and interpersonal relationship. Religious aspects can be implemented to facilitate acceptance. Treatment can consist of one or a combination of the different modalities going more in depth as the patient progresses.

In insight - oriented psychotherapy the therapy can begin with the focal therapy and to continue into longer term insight - oriented psychotherapy only if the patient can benefit significantly from further understanding as illustrated in the following clinical vignette.

 CASE 1

Mrs. A is a 28 year old married female business executive who sought my help for treatment of her depression precipitated by severe marital conflict. Her husband, Mr. B., has been rejecting and severely critical of her following her confession of having sexual relationship prior to knowing him. He had threatened to divorce her, acted overtly hostile and was also promiscuous, citing his disappointment in her as his justification. Supportive psychotherapy helped to lessen Mrs. A’s guilt and restore her self-esteem. She was able to see that not being a virgin when married does not necessary make her a bad unworthy person and her husband must also assume his responsibility in choosing to marry her in spite of her revelation. The couple was then seen for marital therapy. Which helped lessen the crisis. Both became aware that each has the option of leaving the marriage rather than remaining in a hateful relationship. Mr. B. was referred to another for further psychotherapy as he has difficulties with an intimate relationship as well as an immature and unrealistic expectation of life and others.

Mrs. A was found to be an intelligent, sensitive and psychological - minded person who wished to understand more of her behavior and unhappiness. Insight oriented psychotherapy helped her understand that her guilt, low self-esteem, her dependency and the need to be good stems from her own disturbed childhood in a dysfunctioning family. Being her father’s favorite made her an easy scapegoat for her mother who suffers from her father’s infidelities. She was made to feel responsible and to assume the burden of making everything right. Led by this chronic sense of failure, she became a victim to her guilt and sense of responsibility. She has been controlled and manipulated repetitively through life by this mechanism. Her insight and working through has enabled her to relate to others more constructively and to develop a sense of self and autonomy.

The goals of psychotherapy: Treatment goal should be set realistically within the framework of the patients’ personal background, culture and value systems. While a Thai therapist helps a patient achieve independence. Autonomy and a sense of self, he needs to be aware that the changes should be adaptive and not disruptive to the support systems or value systems. The therapist should recognize that the most important and reliable support for a Thai is still the family. Through the therapist, the patient can learn to achieve independence without becoming selfish; self-assertive but not ruthless or aggressive : To have an autonomy but still can care and have consideration for others. If the fine balance can be achieved then the therapist will not have go through the frustration that he has solved one set of problems only to face a new set of problems.

  Bibliographies

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3. Gabbard GO. Psychodynamic psychotherapy in clinical practices. the DSM-IV edition. Washington D.C.: American Psychiatric Press, 1994.

4. Guerin PJ. Family therapy: theory and practice. New York: Garder Press, 1976.

5. Harris TA. I’m OK-You’re OK. New York: Avon Books, 1969.

6. Ursano RJ. Concise guide to psychodynamic psychotherapy. Washington D.C.: American Psychiatric Press, 1991.