Rescuing an Essential Component of Psychiatry: Psychotherapy Training in Psychiatric Education

This is this is the first of a two-part discussion on the importance of psychotherapy training. Part 2 explores seven goals to implement into psychotherapy education in medical school: A Critical Moment in Psychiatry: The Need for Meaningful Psychotherapy Training in Psychiatry. -Ed.)

COMMENTARY

Introduction

Throughout its history, psychiatry, probably more than any other medical specialty, has dealt with periods of drastic changes and adaptation demands affecting the theory and practice of the specialty. This situation has ignited heated theoretical debates, ideological battles, and intercultural collisions.^1,2 Crises of this nature may be inevitable in a field that deals with elusive and complex human problems: mental illnesses, their affective and behavioral expressions, and their biological, psychological, and socio-cultural roots.

Substantial tension has arisen repeatedly over the past two centuries between biomedical and humanistic-psychological approaches to defining disorders, understanding their causes, and organizing techniques and systems of clinical care.^1,3 Changes in theories and practices have deeply affected the organization of the field and induced a variety of challenges that, arguably, are more frequent than in other medical specialties.

Psychotherapy in psychiatric training

A topic of current discussions across the world is the place and role of the psychotherapy theory and practice in psychiatric education and training.^4-6 Near the third decade of the 20^th century in the wake of a decisive historical marker that many authors called the first psychiatric revolution- the advent and development of psychoanalysis^7,8-psychotherapy knowledge skills were more or less widely accepted as essential core components in educating medical students and future psychiatrists. Freud’s approach considered human suffering arising from emotional wounds triggered by family and society as a central factor in the development of many psychiatric disorders and, most importantly, supported its recognition, understanding, acceptance, and efforts at resolution as critical components of a successful clinical intervention.

Psychoanalysis (and later its psychodynamic modalities) won academic recognition and came to dominate psychiatric training programs in European and American medical schools.^9,10 Since the mid-20^th century, however, efforts to redefine and promote descriptive and biomedical/neuroscientific models of psychiatric diagnosis and treatment have gradually gained ground, strongly encouraged by the considerable therapeutic power of new psychopharmacological agents.^11,12

There are two reasons to consider the topic of psychotherapy education: 

1. There is an emerging tendency to make applied psychopharmacology the primary basis of psychiatric treatment. Missing in such an approach is a thorough assessment and subsequent knowledge of the complex experiences and circumstances of patients with psychiatric illness.¹²

2. Invoking financial and time-constraint reasons, some psychiatric training programs have moved away from providing specific psychotherapy training as a core component of the psychiatrist’s work.^13,14

As part of this discussion, this article will explore the multiplication of psychotherapeutic schools and the vicissitudes of their curricular presence and practice, the historical oscillations between acceptance and rejection, and the factors contributing to one and the other.

Unsteadiness of the psychiatry-psychotherapy relationship

As previously noted, the first several decades of the psychoanalytic or psychodynamic revolution were marked by the relatively rapid acceptance of a perspective that promised plausible and clinically useful methods of describing, understanding, and treating mental illnesses. It was widely considered a liberating movement against earlier dogmatic and less tolerant approaches toward mental illness. However, this movement largely ignored a biomedical perspective, much needed epidemiological and psychopathological perspectives, as well as neuropathology and pathophysiological data. Not surprisingly, such an exclusively psychological and greatly subjective approach spawned many branches and led to considerable fragmentation and conflicts, probably explainable by some of the very ingredients the doctrine helped to unveil.^8,15,16

Thus, the re-awakening efforts to establish a biomedical-based psychiatry and to understand the pharmacodynamics of effective psychiatric medications, together with the introduction of impressive new molecular, genetic, and neuroimaging technologies in the last decades of the 20^th century, plus diagnostic systems guided by solid descriptive-phenomenological principles,¹⁷ provided significant support to a substantial improvement in psychiatric education and the practice of clinical psychiatry, despite leaving out many unfulfilled expectations.

Furthermore, greater dichotomizations in the field were paradoxically reinforced by advances in sociocultural disciplines and their connections with clinical psychiatry.^18-20 These advances generated a healthy skepticism about biomedical concepts in psychiatry, but also contributed to confusion and ambiguity about an appropriate balance between scientific and humanistic considerations. Psychotherapy, as a concrete tool for the understanding of individual patients and their treatment, has suffered in the process.

The major change in practice patterns included a growing dependence on a rapid diagnostic assessment followed by selection of seemingly appropriate medicinal treatment. A largely unanticipated result was a diminished emphasis on the clinical importance to understand the uniqueness and complexity of individual patients. Additional major contributing factors were structural and economic considerations: fewer patients needed prolonged institutional care, and many could be evaluated quickly and then become subjects of occasional, brief follow-up visits.^14,21

Similarly, the training of more non-medical mental health professionals-some with prescribing privileges (notably psychiatric nurse-specialists) and others with expertise in psychotherapy-provided more accessible and less expensive clinical services backed by controlled trials or tested protocols. It has become increasingly clear that these various practical and economic considerations have contributed to the diminishing role of psychotherapy as a dominant training aspect of contemporary clinical practice.

The case against psychotherapy training in psychiatry

It has been reported that psychiatric trainees who disagree with the need for psychotherapy training are a silent majority. Some observers note that only around 11% of outpatient psychiatrists continue to practice psychotherapy extensively after residency.¹â´ It is further argued that general medical knowledge, training in biostatistics, and the assessment of research findings required for an evidence-based practice are increasingly essential components of psychiatric training.^{14, 22-25} Consequently, a substantial curtailment of the psychotherapy curriculum has taken place in some training centers-even to the point of entirely eliminating it in the early residency years-while sometimes offering alternatives that include psychotherapy training as an elective in the fourth year and an elective fifth year of psychotherapy fellowships.

Many older psychiatrists are appalled by what they perceive as a decline in basic interviewing skills among their younger colleagues. In turn, many patients also complain about extremely and increasingly impersonal medication-check visits in which the bulk of an already very limited time is spent computer-documenting interactions with the physician. The most pervasive consequences of such are: the dehumanization of the doctor-patient relationship, the decline of empathy as a basic ingredient of the clinical encounter; the loss of a holistic approach to each patient’s condition; and an increasing prevalence of stereotyped, insufficiently individualized diagnostic and treatment protocols.²⁶ Even among educators and trainees interested in teaching and learning psychotherapy, there is an underlying sense that enthusiasm and support for psychotherapy training is waning (despite encouragement by organizations and agencies that regulate and supervise psychiatric training in North America and Europe, ie, the American Council of Graduate Medical Education [ACGME] in the US²â·).^14,25,28

It seems that the resulting professional or medical identity of young psychiatrists no longer reflects comprehensiveness but rather a body-mind fragmentation arising from reductionistic conceptualizations.²⁹Talking is considered too much when we possess technological tools to record the patient’s story, and understanding seems to be increasingly displaced by efforts to arrive at a formalistic diagnosis for which an inevitable pharmacological response is applied. Clinical follow-up is not a systematic and personalized dialogue aimed at measuring progress, but an actuarial listing as deficient or excessive as in a factory’s assembly-line scenario.

In short, the following is a list of factors that may be contributing to the questioning or even abandoning psychotherapy as an important component of the training, identity, professional competence, and job satisfaction of psychiatrists:

1. Academic needs. The time demands to adequately cover all the knowledge and expertise that a future psychiatrist must acquire during training present serious logistic challenges. Efforts to teach the latest clinical research findings (mostly neurobiological in nature) currently capture most of the formal content of training programs. Increasingly, diagnostic training is based on manualized approaches and assessment instruments consisting of symptom checklists rather than an individualized exploration of psychopathology.

2. Service demands. In the name of productivity, increasing numbers of patients are evaluated and treated in various settings with brief doctor-patient contacts in which much of the professional’s time is spent entering information into rigid and narrowly constrained electronic databases. This obviously discourages or severely limits a narrative documentation, summaries, and formulations that pursue an empathetic understanding of the individual patient’s challenges, strengths, and weaknesses.

3. Research findings. Current psychiatric research reports emphasize seemingly scientific biomedical topics more than descriptive or epidemiological studies; topics related to relevant psychological, social, or cultural areas are largely ignored as a result.

4. Public expectations. A somewhat paradoxical reality today is that “seeing a doctor” (even if for a short time) or “getting a prescription” as soon as possible seem to be higher in the list of patients’ expectations than a desire to “tell their story” within an accepting and supportive environment. Such expectations seem to reflect the patients’ efforts to adapt to overcrowded clinical settings that directly or indirectly emphasize a high productivity model, ie, an excessively elevated number of patients seen per hour.

5. Financial aspects. Practical realities support the impression that a psychopharmacological approach to clinical care is relatively efficient in terms of time and costs; in turn, this fosters the possibility of becoming an attractive business in contrast to a time-consuming psychotherapy-based practice. However, such models appear to be based on a willingness to seek and accept: a minimal knowledge of complex clinical problems; a declining interest in clinical outcomes as well as patient’s and clinician’s satisfaction and morale; or even financial losses related to early dropouts and missed appointments.

6. Competition. Growing numbers of non-psychiatric or non-medical professionals (eg, psychologists, physician assistants, social workers, nurse practitioners, psychiatric nurses, educators, and religious and other counselors) practice various forms of psychotherapy and can provide therapy at a lower cost than psychiatrists. The proliferation of psychotherapeutic schools, each and all of them advocating not only effectiveness but also rapid responses, minor costs, and favorable long-term outcomes, is another important factor. This diversity of psychotherapy providers may have resulted in the weakening of psychotherapy teaching in psychiatric residency training programs.

7. Changing practice patterns in general medicine. Even though a high proportion of problems seen by non-psychiatric physicians (eg, primary care doctors) are essentially behavioral or emotional in nature, there has been a decline in time per visit and a tendency to avoid dealing with such problems; this further diminishes the interest in psychosocial approaches throughout medicine in general. The risk is a greater avoidance of clinically responsible, comprehensive knowledge of individual patients, and a lack of concern for their emotional, social, and practical needs, including medication-modifiable symptoms.

What does this mean for the field of psychiatry, future psychiatrists, and patients? The next article will explore the characteristics of appropriate psychotherapy training programs to enable psychiatrists to continue to provide top quality mental health care.

Dr Alarcón is Emeritus Professor of Psychiatry, Mayo Clinic School of Medicine, Rochester, MN; and Honorio Delgado Chair, Universidad Peruana Cayetano Heredia, Lima, Perú. Dr Craig is a former member of the American Psychiatric Association, Clinical Practice Guidelines Committee, Washington DC. Dr Fitz is a former Faculty member of Tulane University School of Medicine, Department of Psychiatry in New Orleans, LA. Dr Baldessarini is Professor Emeritus of Psychiatry, Harvard University Medical School, and former Director of Research Mc Lean Hospital, Boston.

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