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By Mark Moran
Will psychiatrists be practicing psychotherapy in the 21st century?
Not unless current trends are reversed, a monumental effort that will require changing the minds not only of legislators, managed care companies, and employers, but of many psychiatrists--including leaders of APA.
So say a cadre of practitioners whose concern about the fate of psychotherapy is urgent.
"The role of psychiatrists in psychotherapy is gravely threatened, and if current trends continue, the next generation of psychiatrists may not even know what it really is, let alone be able to supervise it or prescribe it knowledgeably," said former APA Assembly Speaker Norman Clemens, M.D. "That would probably be the end of psychiatry as we know it."
It was that sense of emergency that led to the creation in June of the 12-member APA Commission on Psychotherapy by Psychiatrists, chaired by Clemens.
In an interview with Psychiatric News, Clemens outlined an ambitious agenda to ensure that "psychotherapy by psychiatrists will have a secure place in the health care system and in psychiatric training, with a widespread, solid sense of this as being integral to our profession."
Arrayed against the commission are the forces of for-profit managed care and a health care marketplace that demand narrowly defined, research-based, outcome-driven treatments, Clemens said.
He and other commission members said those forces have steadily eroded the caring dimension of health care, of which psychotherapy--with its intense focus on what Clemens calls "the whole person"--is the epitome.
Said commission member Jerald Kay, M.D., "Losing the conviction that words can heal within the context of a therapeutic relationship and in conjunction with medication would be a tragedy."
While the commission will have enough work combating the prejudices of managed care companies and third party payers, members of the panel believe that just as important will be winning the hearts and minds of psychiatrists.
"In one year I would like to see the commission raise the consciousness of the whole APA--leadership, staff, and membership--about psychotherapy, and shift from a defensive, beleaguered attitude to a positive and aggressive one, based on much improved awareness of data already at hand," said Clemens.
Why has the psychiatric profession become defensive about a type of treatment that was once at the core of its identity?
"People who are well informed in many areas of psychiatry--like the chairs of academic departments of psychiatry, the directors of residency training programs, and psychiatric researchers--do not have the same kind of familiarity with the psychotherapy research literature as they do with the biological literature," said Kay, who is editor of the Journal of Psychotherapy Practice and Research and a former president of the American Association of Directors of Psychiatric Residency Training.
"In my travels across the country giving grand rounds," Kay added, "I am struck by the knowledge deficit among many residents and faculty when it comes to psychotherapy process and outcome studies, familiarity with efficacious models of brief treatment, cost-offset studies with respect to medical illness, [and] the indications for certain types of psychotherapy for specific conditions. . . ."
A principal task of the commission, then, will be to undertake a survey of teaching programs to determine the state of psychotherapy training in residency. Preliminary impressions indicate that it varies from program to program.
"The state of psychotherapy training is inconsistent," said James Shore, M.D., chair of APA's Council on Medical Education and Career Development. "There are a few that have developed progressive programs emphasizing the short-term, focal therapies, which are the ones that most complement emerging psychiatric practice. Those programs also continue to provide a focus on psychodynamic issues."
Yet many more programs do not, Shore said.
"There is not a consensus in the field about what to teach or within APA on how to approach this because of the traditional split between psychoanalytic and psychopharmacologic schools," he said.
"Hopefully, the commission will be able to work with residency program directors to build a meaningful consensus around a curriculum that can take us into the 21st century."
How do tomorrow's psychiatrists view the future of psychotherapy and its role in the training of psychiatrists?
Commission member Eva Szigethy, M.D., Ph.D., a fourth-year resident at Case Western Reserve University, said she believes residents strongly favor an approach to patient care that combines psychotherapy and the use of medications.
Like Shore, she noted that psychotherapy training varies from program to program and added that some programs offer little more than a "skeleton" of psychotherapy training--"just enough to check off that category," she said.
Yet in an informal survey of her colleagues on APA's Committee of Residents and Fellows, Szigethy found that even biologically minded residents are interested in psychotherapy and see it as "critical to psychiatry's identity and what makes us unique from colleagues in other fields of medicine."
Generally, she said, residents want APA to assert that "yes, psychotherapy does belong to us--not solely to us, but it should not be pushed out of our identity as psychiatrists."
She suggested that curricula in Canada and elsewhere that successfully integrate psychotherapy training be investigated to see how they might be incorporated into American training programs.
Trained in neuroscience, but drawn as well to a psychodynamic approach to mental illness, Szigethy envisions the day when science will be able to discern neurobiological changes in the brain linked to psychotherapy.
"My dream is to be able to use imaging studies to show that, yes, just by talking, you can produce changes at the synaptic level," Szigethy said.
She and Kay noted that such findings have in fact already been demonstrated in a circumscribed way for cognitive and behavioral models of psychotherapy. Moreover, basic research has begun to elucidate a neurobiology of memory and other "higher order" mental processes; this research may someday lead to an understanding at the cellular level of how learning experiences--including psychotherapy--influence an ever-changing brain, Szigethy said.
That dream remains distant, however, and its elusiveness begs the question that has always bedeviled research on psychotherapy: How do you know the treatment is doing any good?
"Psychotherapy research is frequently much more consuming than studying the efficacy of psychopharmacological agents," said Kay. "A psychotherapy researcher has many more variables to juggle than his or her counterpart conducting drug studies. Of course, we have no analog of the pharmaceutical company when it comes to supporting psychotherapy research, nor do we have a very active federal program to fund psychotherapy research.
"We also do not have many centers that have a critical mass of psychotherapy researchers," Kay continued. "Much of the outstanding psychotherapy research is developed by psychologists, and psychiatrists are often not familiar with their literature."
In 1994 commission member Susan Lazar, M.D., as a member of the White House Task Force on Health Care Reform, helped compile a review of more than 40 studies of psychotherapy efficacy and cost-effectiveness. At the time, Lazar told Psyhciatric News that the cumulative import of the review is that "an artificially limited mental health benefit would be damaging to patients and not cost efficient" (Psychiatric News, July 1, 1994).
Lazar and colleagues' review is available from the Washington Psychiatric Society.
Kay and Clemens both noted that research on longer-term psychotherapies is hampered by the multiplicity of variables that affect course and outcome. This obstacle, they said, derives from the fact that the treatment is rarely targeted to resolving an isolated, discrete symptom--as, say, when a surgeon seeks to excise a tumor--but instead addresses complex issues involving much of the patient's mental functioning. Even when a discrete symptom is the focus of treatment, it is liable to involve multiple dimensions of a patient's experience.
Consequently, Clemens said, the forms of therapy most rigorously studied are those using "systematically structured, manual-based treatments such as interpersonal psychotherapy or cognitive behavior therapy, and some time-limited psychodynamic methods."
Is there any place, then, for longer-term psychodynamic psychotherapy?
Commission member Barton Blinder, M.D., a psychoanalyst and researcher with training in cognitive behavior therapy, said he believes there is a subset of patients for whom the most appropriate treatment will be long-term, psychoanalytically informed psychotherapy.
Those are patients, he believes, who "have had early developmental casualties in association with an early-onset Axis I disorder and an adverse environment."
Blinder and others said a challenge for the new commission and the field of psychiatry is to derive more specific indications: which patients need which kind of psychotherapy?
A report in the April 1994 edition of the American Journal of Psychiatry by Norman Doidge, M.D., and colleagues showed that psychoanalytic patients under a national health insurance program in Canada tended to have high rates of trauma and pathology and to have tried other forms of briefer treatment before resorting to analysis (Psychiatric News, May 6, 1994).
Moreover, Blinder and others on the commission say that the insights of psychoanalysis are vital to any kind of psychotherapy.
Kay noted that competent short-term therapy is not simply a matter of offering counseling in fewer sessions, but using psychodynamic insights in a more concentrated fashion.
"I have always maintained that good brief treatment, be it supportive or expressive, requires greater skills of the therapist than open-ended treatment," Kay said. "The brief therapist must be able to discern a focus for the treatment preferably in the first session, and certainly by the end of the second in most models. This requires that the therapist know what is important and what is unimportant. The ability to make this distinction comes with the experience of doing long-term psychotherapy."
Kay and Clemens said that transference--the phenomenon that forms the pith and marrow of psychoanalysis--is present not only in all forms of psychotherapy, short or long, but in any kind of transaction between a physician and a patient. It can exert a powerful influence on course and outcome of treatment, they said.
"The primary care physician who is not aware of the power of transference reactions may have big problems with compliance and adherence," Kay said. "The best nonpsychiatric physicians I have encountered are intuitive about these matters."
So the insights derived from psychotherapy--especially attention to transference--are critical even to the most biologically oriented treatment, Kay said.
Commission member Glenn Gabbard, M.D., who is Calloway Distinguished Professor of Psychoanalysis and Education at the Menninger Clinic, cites the example of a woman with bipolar disorder being treated with lithium. On successive visits the woman reports "forgetting" to take her medication; following some probing, it is revealed that her mother had been on lithium and had committed suicide.
The woman could be encouraged to resume her medication, Gabbard explained, only in the context of a beneficial relationship with her psychiatrist utilizing insights into the psychological motivations of her resistance to treatment.
Ultimately, then, psychotherapists and physicians of all kinds must engage a variable in the healing process that may be all but impossible to quantify or assess for cost: the relationship between the doctor and the patient.
Protection of this variable in an environment that increasingly seeks quantification and cost-assessment is the steep challenge of the Commission on Psychotherapy and the source of the commission's relevance beyond the confines of psychiatry.
In a debate at APA's 1996 annual meeting in New York, Clemens spoke about this irreducible factor in the science of healing: "The basic event in the health care transaction still has to be the interaction between the doctor and the patient. As such it is an unalterably human event, in which reimbursement can be only a remotely secondary factor. It is as qualitatively different from the life of business and money as is what a teacher does, or a priest, or a mother or father."
(Psychiatric News, December 6, 1996)