Where Has Psychotherapy Gone?

Stephen M. Strakowski, MD; John G. Gunderson, MD; David J. Reinhardt, PhD; Ruth R. Staten, PhD, APRN-CS


August 18, 2011

In This Article

Are Today's Psychiatrists Qualified?

Dr. Reinhardt: Please bear with me as I vent a bit.

I'm a bit in the dark on a couple of things. A general practitioner (GP) sends a patient to another physician (a surgeon or a psychiatrist) when they lack sufficient training to do the work themselves. The GP did have "basic training" consisting in, I assume, at least a few classes in surgery, and perhaps one formal class in psychiatry. The GP could, with the same reasoning that I'm seeing here, have opened a free clinic to practice a bit and develop expertise in surgery or psychiatry. This would in no way qualify them, in my mind at least, to practice those specialties. Are we all agreed that GPs should not be handing out antipsychotics without adequate training? Yet I'm reading here that the role of psychotherapist is a part time gig. Please allow me to fill you in a bit on psychology.

As a psychologist, I have taken 4 years of classes, 8 semesters of formal education in just the brain and mind, including 8 full semester classes in statistics and study design. That is not including on-the-job training, internship or clerkship, although we do have an additional 3 years of that. These are required classes. The field of psychology is not as "unscientific" as one might suppose. Review, for example, the bylines of most of the articles appearing in neurology and psychiatry journals. Competent psychotherapy is not something you pick up from a 9-session class on the brain, nor from practicing at a clinic until you get it right. If a psychiatrist desires to be a competent psychotherapist they should consider investing in more than a couple of weekend classes in the specialty. Yes, many psychiatrists do seek out additional training, although I suspect this is a very small percentage of the whole.

This does take us back to the question of if psychiatrists should do psychotherapy without extensive formal training in this specialty. Hopefully, you have the same strong feelings about GPs being competent psychiatrists without more training.

Dr. Staten: One of the aspects I have enjoyed most about being in psychiatry/mental health/behavioral health for 30+ years is the interdisciplinary approach to care, both inpatient and outpatient. I love working with students to help them understand this unique care/team approach -- that is not always a part of other disciplines. The common threads of our (psychiatrists, psychiatric nurses, psychologists, social worker, and others) preparation make for a wonderful foundation for caring for persons with behavioral health problems. For the most part, we hold the same core values and approaches to care, yet our differences bring such strength to what we offer to patients and each other. After being in a situation for many years where I was one of the few mental health professionals -- always trying to explain what we do, why we do it and why it is important to overall health -- I am in heaven to now be in a behavioral health department where we all value the same things and have a core set of skills that are common (basic psychotherapy skills) and unique talents that provide the best care one could hope for.

Having said all that, most of us do recognize individuals and professional groups for what they do bring to patient/client care. At this point, I do believe that all psychiatric/mental health/behavioral health disciplines should educate and prepare their students to engage in a certain level of psychotherapy. I think about all the underserved areas of our country that would be lucky to have one provider; if the provider could do little but offer medications, I think that would be a huge disservice to those for whom we care for.

I see the change moving toward levels of intervention and psychotherapy. We see brief interventions being applied by nonmental health providers in a variety of settings; a next level is being provided by mental health professionals who have backgrounds that are suitable to delivering both medication management and psychotherapy, and others who are experts in providing psychotherapy to the very difficult to treat patients (as well as others). I have a perfect example of a client who had as severe obsessive compulsive disorder (among other things) as I have seen in years. His first appointments were made with myself (a seasoned therapist and medication provider) and a therapist (a very seasoned, skilled one), but the client recognized that he needed someone more skilled in psychotherapy, so an appointment was made with a very experienced psychologist. I am hopeful that between some serious psychopharmacology and some very high level intense psychotherapy he will find some relief.

This is a critical conversation for psychiatry and psychiatrists, in terms of the way we all work together. I really just can't imagine a psychiatrist without psychotherapy skills, but that does seem to be a trend. We will lose something in the foundation of our work without that. I don't want to get off track, but I have some concern that this change has also affected -- to the detriment -- the inpatient care that patients receive. There are lots of reasons that inpatient care has changed, but I would like to see it be a more therapeutic environment all together.


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