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

So Who's Responsible for What?

Dr. Strakowski: In response to Ruth's and Dave's last emails, I'm not sure where the impression arose that psychiatrists don't get psychotherapy training. Psychotherapy supervision and delivery remain a major part of our training program, particularly in the 3rd and 4th years, and I would assume it's similar elsewhere. As noted previously, we have a specific clinic to attract good therapy patients for our residents. In response to Dave's comments, I have chaired a number of clinical psychologist graduate student dissertation committees, and the level of psychotherapy expertise that they exhibit at graduation is not particularly different than our senior residents. As John said, in the end, though, much of the training really occurs after residency/doctoral dissertation and is dependent on how much individuals, regardless of their professional stripe, want to learn about therapy and apply it in their practice.

Dr. Reinhardt: Thank you for your response, Stephen. Yes, certainly I agree that predoctoral psychology students, having not experienced intense on-the-job" training, are unlikely to have substantially more clinical expertise than a post degree, final year resident medical trainee. They will, however, have received 4 solid years of didactic training in mental health, disorders, and therapy approaches.

I have the utmost respect for a quality psychiatrist. Before taking on the role of another specialty, the role of psychiatrist in the treatment milieu may need better definition.

As I and my physician friends see it, the role of the psychiatrist is to be aware and look for medical causes of mood and behavioral issues, using the ever-expanding database of contributors, then refer back for treatment of suspected medical issues, or select and guide use of appropriate psychotropics, and refer to that other specialist, the psychotherapist.

In the recent article published on Medscape Psychiatry, a study was reported strengthening evidence that selective serotonin reuptake inhibitors carry a risk for birth defects. Another article detailed the usefulness of anti-inflammatories in treating depression, and the usefulness of soy in treating menopausal cognitive and mood symptoms. Sleep disturbance, linked to many psychiatric conditions, is shown to be influenced by blood sugar issues. Allergies are linked to depression and suicide completion. Finally, the Neurontin marketing issues, along with the recent reports of antidepressants as a class being essentially worse than useless in most cases spotlight the need for a statistically sophisticated approach to guiding medication selection and management. The reality that a finding of "significance" in a study only gives you an idea of any effect vs chance effect and tells nothing about effect size or usefulness of a particular chemical is often lost on those with only basic (or no) education in statistics. Competent psychiatry requires a great deal of education, continuing education, and experience.

When a depressed patient comes to me for that "other" kind of treatment, I want to feel reassured that medical issues such as hypothyroidism have been ruled out. My GP friends know they themselves lack expertise in these areas. They do not send patients to psychiatrists just to get a psychotropic ordered. This all ties into the concern voiced by Ruth, that patients may be followed too long for medication management.

Thank you for opening up the question regarding the amount of training received. It may be that I am making assumptions about this issue. Several years ago, when I was working with a large psychiatric practice, I was given the task of providing the training to third-year medical students as a clerkship site. For 30 days, these wide-eyed preclinicians would follow me around, observing, asking questions, and trying to become familiar with what mental health treatment was all about. Maybe things have changed, and I am misjudging. 

Steve, what is the extent of formal psychiatric training? Harvard Medical School (HMS) lists as required courses 4 weeks of psychiatry "rotation," in addition to a total of 136 hours of classroom training in "Nervous System and Behavior," and 39 classroom hours in "Psychopathology & Introduction to Clinical Psychiatry." Is HMS unusual in this regard?

As I pointed out in my earlier post, each specialty has its unique training and place in the milieu. Little is gained by downplaying the importance of this training just because they are seen as competition.

Dr. Strakowski: Dave, I think there is some misunderstanding about how psychiatrists are trained. Medical school and psychology graduate school really don't align similarly. Psychology graduate school (plus internship) is more like psychiatry residency. Medical school trains students to be physicians, but residency trains them to be specialists, eg, psychiatry. During residency, trainees receive 4 intensive years of didactics and "apprenticeship" in psychopharmacology and psychotherapy. Having trained both psychologists and psychiatrists (I have appointments in both departments here), at the time both groups come out of residency (psychiatrists) and internship (psychologists) they are similarly trained. As Ruth and I observed earlier, it is really the subsequent years post-training (in post-docs, practice, etc) that really refine their skills.

Dr. Staten: It is interesting to notice the twist that our conversation took from the original question that Steve posed to the current dialogue about training. if we can track back through our conversation -- and how quickly we turned to current curricular-training issues -- it seems that the perceptions about psychiatry and psychotherapy are quickly changing. If in practice, "psychotherapy is becoming increasingly rare," then the give and take between reality and what is taught (and valued) begins to take shape. Over time, will the fact that "psychotherapy is becoming an increasingly rare part of psychiatrist practice," influence or diminish what is taught in residencies, etc? Could it be a matter of degree (emphasis--not education)? Yes, psychotherapy should remain a part of psychiatric education and practice, but would it be at the same level as 1960 or 1970 or 1980 (with the changes and discoveries in neurosciences)? Likely not. Then how that plays out in one's practice or career will vary widely regardless of the discipline.

It seems at this point in time, to some degree all disciplines are exposed to practice and training in some type of psychotherapy(ies), but I concur with Steve's response, "much of the training really occurs after residency/doctoral dissertation and is dependent on how much individuals, regardless of their professional stripe, want to learn about therapy and apply it in their practice."

I sense that we are all seasoned practitioners who have seen the ebb and flow of our own careers be influenced by opportunities and interests that have varied over time. Thus our expertise has shifted and developed and has likely given us wonderful variety in what we have been able to do professionally. Whether psychologist, psychiatrist, advanced practice psychiatric nurse, or other mental health practitioner, we hope that the basic preparation and values and beliefs instilled in that process do give us flexibility for the changing demands and needs of those we serve and the opportunities that come our way.

There is more than enough need for all of the mental health providers; figuring out which patients will benefit from what treatments delivered by whom, in an efficient and effective manner is important. Perhaps that is another question for another discussion.


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