Is the Demise of Psychotherapy by Psychiatrists Really Exaggerated?

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The article, “Psychotherapy: A Core Psychiatric Treatment,” by Mark L. Ruffalo, MSW, DPsa, and Daniel Morehead, MD,¹ on the role of psychotherapy in current practice and training might be too optimistic and not reflective of most of our experiences. A counterargument follows.

1. Psychiatry residents may not receive sufficient formal instruction in psychotherapy.

As the authors point out, a 2015 survey of psychiatry residents revelated that most residents want “significantly more” time in didactic instruction and clinical practice in psychotherapy, suggesting that the need is not being met.² An earlier 2010 study was more foreboding, with more than a quarter of residents expressing concerns about the adequacy of time and resources given toward psychotherapy, and one-third of residents stating that they did not believe department leaders were supportive of psychotherapy.³

With all due respect to Dr Ruffalo, when psychiatry trainees are taught psychotherapy by nonpsychiatrists, there may be a hidden curriculum that is learned that therapy is for nonphysicians to practice. This also deprives psychiatric trainees the role models in their own profession who continue to practice psychotherapy and reduces opportunities to teach the integration of psychotherapy with pharmacotherapy, implying an either/or treatment model rather than a combined model.

2. Therapeutic interactions, while helpful, are not the same as intentional psychotherapeutic medical procedures for specific conditions.

While brief interactions in other settings can contain psychotherapeutic moments, this is not the same as trying to promote long-lasting behavior change through targeted psychotherapy intervention. Giving someone a pain medication for a sore back and performing back surgery may both have the goal of pain alleviation, but these are different services with different goals and endpoints. It would be unfair to say that one act replicates or replaces the other.

To borrow the authors’ analogy about cardiac catheterizations, it would definitely matter how many cardiologists performed this procedure if we were in the middle of a cardiac health crisis that affected 1 in 4 Americans,⁴ and patients and referring providers continued to request these procedures, and too many cardiologists refused. It also makes a difference that psychiatrists are in the unique position of being able to provide concurrent psychotherapy and psychopharmacologic treatments. Previous studies have shown that integrated treatment by psychiatrists results in significantly lower treatment costs and fewer necessary appointments than when psychotherapy is split off to another provider.^5,6 

The data by Tadman and Olfson⁷ clearly show that, over the past 20 years, the percent of psychiatry visits involving psychotherapy has declined from 44% to 21%, and the number of psychiatrists who do not provide any psychotherapy at all has doubled from 27% to 53%. This likely has implications for the cost effectiveness and number of overall appointments required.

3. Psychiatry residents remain hungry for psychotherapy.

The question is, are they being fed adequately? The above-mentioned surveys highlight a need for therapy training. There are a significant number of efforts maintained by a variety of professional organizations specifically designed to promote and improve the teaching of psychotherapies in psychiatry training, most notably psychodynamic psychotherapy. Just in 2020, the APA Psychotherapy Caucus established the Training Advancement Initiative⁸ to join with AADPRT’s Teichner Award,⁹ AACAP’s Psychodynamic Faculty Initiative,¹⁰ and APsaA’s Teacher’s Academy¹¹ as endeavors designed to promote psychotherapy education. I am not sure if the original authors are saying all these efforts are unnecessary, but it does make one wonder where psychotherapy would be without these additional efforts. In comparison, psychopharmacology does not seem to require such efforts.

4. Relying on psychiatry’s past important figures may alienate trainees who want to learn evidence-based psychotherapies and question psychotherapy’s effectiveness.

The legacies of Babe Ruth and Jackie Robinson are not in themselves evidence that the current state of baseball is alive and well—and there actually are concerns with the current state of baseball.¹² There have been significant gains in the evidence base for psychotherapy,¹³ including psychodynamic psychotherapy,¹⁴ in the past decade. Emphasizing this point may actually bode well for our field and may speak to current trainees whose medical schools emphasize evidence-based medicine. If we are going to advertise that our most novel and effective treatments were pioneered by figures who are retired or deceased, that does not necessarily suggest the current state of affairs is alive and well.

5. One need not look too far away to see that psychotherapy is under attack.

Canada, our universal health care-clad brethren to the North, recently had to fight back efforts by the government to scale back and limit the number of covered psychotherapy sessions per patient, regardless of diagnosis or treatment recommendations.¹⁵ Luckily, powerful community advocacy helped postpone such a decision for a couple of years. If we do not fight for psychotherapy, others will fight against it.

The data clearly show that:

1. Psychotherapy remains an effective, evidence-based treatment for a variety of conditions.

2. More and more Americans are seeking help for those conditions.

3. Medical professionals trained to treat these conditions are offering it less and less often.

On the surface, that seems like a problem. The data that says whether the problem is exaggerated remains to be seen.

Dr Shapiro is an associate professor in the department of psychiatry at the University of Florida.

References

1. Ruffalo ML, Morehead D. Psychotherapy: a core psychiatric treatment. Psychiatric Times. May 6, 2022. https://www.psychiatrictimes.com/view/psychotherapy-a-core-psychiatric-treatment

2. Kovach JG, Dubin WR, Combs CJ. Psychotherapy training: residents’ perceptions and experiences. Acad Psychiatry. 2015;39(5):567-574.

3. Calabrese C, Sciolla A, Zisook S, et al. Psychiatric residents' views of quality of psychotherapy training and psychotherapy competencies: a multisite survey. Acad Psychiatry. 2010;34(1):13-20.

4. America’s health insurance plans: nearly 1 in 4 Americans with employer-provided coverage received mental health support in 2020. News release. May 13, 2022. https://insurancenewsnet.com/oarticle/americas-health-insurance-plans-nearly-1-in-4-americans-with-employer-provided-coverage-received-mental-health-support-in-2020

5. Goldman W, McCulloch J, Cuffel B, et al. Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. Psychiatr Serv. 1998;49(4):477-482.

6. Dewan M. Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry. 1999;156(2):324-326.

7. Tadmon D, Olfson M. Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016. Am J Psychiatry. 2022;179(2):110-121.

8. Goldman MP, John HV. Psychotherapy Caucus creates program to increase use of psychotherapy. February 4, 2022. Accessed May 20, 2022. https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.03.3.13

9. Victor J. Teichner Award. Accessed May 20, 2022. https://www.aapdp.org/education/teichner-scholars-program/

10. AACAP Psychodynamic Faculty Initiative. Accessed May 20, 2022. https://www.aacap.org/AACAP/Awards/Psychodynamic_Faculty_Initiative/Home.aspx

11. Psychoanalytic & Psychodynamic Teachers' Academy. Accessed May 20, 2022. https://apsa.org/teachers-academy

12. What the heck is going on with the baseball? Everything you need to know about MLB's scoring drought. ESPN. May 4, 2022. Accessed May 20, 2022. https://www.espn.com/mlb/story/_/id/33848888/what-heck-going-baseball-everything-need-know-mlb-scoring-drought

13. Cook SC, Schwartz AC, Kaslow NJ. Evidence-based psychotherapy: advantages and challenges. Neurotherapeutics. 2017;14(3):537-545.

14. Shedler J. The efficacy of psychodynamic psychotherapy. Am Psychol. 2010;65(2):98-109.

15. Villela RM. OPA Psychotherapy Initiative. Accessed May 20, 2022. https://www.eopa.ca/opa-groups/opa-initiatives/opa-psychotherapy-initiative