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

Is There a Solution?

Dr. Strakowski: Ruth, thank you for your comments; they are particularly germane. The critical need is to provide high-quality healthcare throughout the United States, and this need is particularly acute in many places out of the large cities off the coasts. In the end, most patients require programmatic care that involves astute pharmacology, skilled psychotherapy, general healthcare measures, and life skills training. For more severe conditions, these skills inevitably need to be provided by a quality team, but in many parts of the country such a team is unavailable.

I think getting back to the original question, several factors we've discussed have impacted the amount of psychotherapy provided by psychiatrists including change in treatment emphasis, demand for pharmacology, reimbursement and finances of healthcare, and availability. Dave seems to think that psychiatrists should "leave the therapy to the psychologists," but that ignores the fact that there are good therapists among many disciplines -- in the department I head, we have several very good CBT providers that include psychologists, master's in social work therapists, and psychiatrists, all of whom have taken steps to achieve excellence, long after their training was complete (as Ruth noted).

Dr. Reinhardt: I agree that there are many good psychotherapists to be found among many disciplines. Those therapists that have not studied the psychodynamics of less simple disorders, such as Axis II disorders like borderline personality disorder, schizophrenia, and nonsituational depressions, are practicing an intuitive form of therapy. This is often effective but far from scientific, and it can sometimes lead to disastrous consequences.

Didactic training plays an important part of physical medicine. It plays an even larger role in training to become a competent psychotherapist. Unlike physical medicine, where an intern can learn to identify a particular type of wart during grand rounds, psychotherapy is an intensely personal experience for the patient, which does not lend itself to the medical school model of on-the-job instruction. There can be no "wise old physician" looking on and keeping the patient safe in a very private therapy office.

As a psychologist, I am concerned that psychiatrists are "biting off too much." I have worked for many years in acute, subacute, and skilled nursing environments as part of a treatment team. Each of us need the support (and reminders) of other team members to fully understand the patient and do the best job. It is common for a specialist, working independently, to fail to spot often simple drivers of mood and behavioral disorders. Psychiatrists have their unique skills and unique role.

GPs have neither the office face time or the specialized training to consider all of the factors that may contribute to a mental health condition such as simple depression. They rely on a psychiatrist to look for and test such things as thyroid issues, hypothalamic imbalance, cellular magnesium levels, and the contribution of drugs such as beta blockers. Conditions such as dementias and psychosis require a competent psychiatrist to do even more detective work. Psychologists trust that the physical aspects have been carefully considered by other team members, although we are often disappointed in this.

As a psychologist, I too have my unique skills. Most physicians have no trouble acknowledging this, including, for example, neurologists, who include a workup by a neuropsychologist as necessary for diagnosing dementia in the ANA treatment guidelines. Competent psychotherapy depends on competent psychology. "Intuitive talk therapy" by someone inadequately trained is not competent healthcare.

Dr. Staten: It is clear to me that there is support for the training and development of psychiatrists as psychotherapists, and that we all agree that we must do a better job with research and documentation of outcomes related to the most effective and efficient care.

It does appear that without specific effort that the perception of psychiatrists as not doing therapy or being trained in therapy could become reality. I hope that this conversation and others will support a clear and continued commitment to psychiatrists having psychotherapy skills.

I have enjoyed the conversation.

Dr. Strakowski: Thank you, Ruth, Dave, and John for a lively discussion. With psychiatric conditions being 5 of the top 10 most disabling illnesses in the world, there is clearly a need for more clinicians of all stripes.

Editor’s Note:
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