Once upon a time, a young Connecticut woman was extremely bulemic and suicidal. The psychiatrist who treated her with psychotherapy believes that she was the sickest outpatient he had ever cared for. He said, "I think my ability to stay in a therapeutic relationship with her was what kept her alive."

This heady testimonial to the value of psychotherapy comes from outgoing APA President Allan Tasman, M.D. He related it at the annual meeting of the American Academy of Psychoanalysis in Chicago in May in a session titled "Toward the Future: Psychoanalysis and Psychiatry."

What’s more, drugs are no substitute for psychotherapy, Tasman asserted. For instance, there was a very anxious woman who met the DSM criteria for an anxiety disorder. She was tense and had difficulty sleeping, working, and making friends. During the first two hours of psychotherapy that Tasman conducted with her, he found a similarity between her boss and her father that made her very anxious. Tasman decided that she had some psychological conflicts that needed working through and suggested weekly psychotherapy although she had no health insurance to cover it. She thus saw him for 20 visits at her own expense. These sessions helped her resolve her conflicts, and as a result, her anxiety symptoms vanished. She told Tasman that the therapy had been far more helpful than she had anticipated. Yet if she had been simply placed on antianxiety drugs, the core of her illness would never have been addressed, he said.

Another argument against replacing psychotherapy with drugs, Tasman pointed out, is that studies are underscoring the advantages of treatments that combine medication and psychotherapy rather than rely on drugs alone.

Yet for all its virtues, the art of talk therapy—long a core of psychiatric practice—is in danger of becoming lost to future generations of patients, Tasman lamented. For instance, he was recently examining a candidate for board certification. The candidate seemed quite knowledgeable about the patient in question, yet his focus was mainly on DSM-IV symptoms, not on the antecedents of the patient’s illness. When Tasman broached the subject of treatment, the candidate discussed drugs and said nothing about psychotherapy, although the patient seemed to have some serious personality problems that would have warranted it.

In fact, the candidate was forthright in his disdain for talk therapy—he said it was something only for social workers to pursue. Tasman asked him what he would do if he were practicing in some rural area and a patient needed talk therapy. With a thin smile, the candidate replied: "I would look very hard for a social worker!" Unfortunately, such an attitude is not at all uncommon among psychiatry residents today, Tasman said.

And it’s not just scorn for talk therapy that detracts from psychiatry residents’ ability to do it but the fact that many simply don’t know how to do it, Tasman emphasized, even at its most basic.

So why aren’t psychiatry residents today learning how to do psychotherapy? One reason, Tasman said, is that some psychiatrists believe that understanding brain structure is more important than understanding the psyche—a position with which he disagrees. Another reason is that residency programs are emphasizing the learning of neuroscience at the expense of learning talk therapy.

But there seems to be a deeper cause for why residents can’t do talk therapy as well, Tasman contends: They are not learning how to put themselves in their patients’ shoes, so to speak, and when "we play down empathy, we lose essential data to understand our patients."

For instance, Tasman cited the case of a woman whom a psychiatry resident had diagnosed as having paranoid delusions and for whom he had prescribed antipsychotic medication. Yet the medication didn’t help her. Tasman talked with her, and in only five minutes, he was struck by her ability to relate to him, suggesting that she was not psychotic. Tasman then asked her a question he rarely asks patients: Had there been any changes in her neighborhood recently? She replied that there had been a drive-by shooting, and a child had been killed on her front porch. It was obvious that the woman was not suffering from delusions but was traumatized by this recent event, Tasman realized.

Why did Tasman discover this fact whereas the resident had not? "I used my own emotional response to the patient," he explained. "It allowed me to discover something about the patient that had not been discovered before."

The resident had apparently lacked this tool, leading Tasman to ask: "Where is empathy in our training programs? These skills have been lost."

So what can be done to keep psychotherapy in psychiatry training from going the way of the dodo bird? Tasman entreats psychoanalysts—many of whom departed from teaching residents during the 1970s and 1980s—to give it another go.

One positive development, he reported, is that as of next January psychiatry residency directors will have to certify that each resident graduate has at least some basic competency in psychotherapy. "It is going to be a very important change," he observed.

A psychoanalyst in the audience asked Tasman, "In the few hours we have to teach residents about psychodynamic therapy, what is the most important thing to teach?"

Tasman’s response: Interview a patient in front of residents and stress to them that the patient is more than a checklist of symptoms. If you do that right at the start, he said, you’ll imbue that outlook in your residents.