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Residents' Forum
Psychotherapy by Psychiatrists: Here Today, Gone Tomorrow?
Alisa Busch, M.D.Member-in-Training Trustee
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Economic pressures are changing the education we receive and the services we deliver to our patients. The debate over whether psychiatrists should practice psychotherapy or be relegated to performing only medication checks on a multidisciplinary team is irrelevant if we do not adequately train future generations of psychiatrists in psychotherapy. In this month’s Residents’ Forum, Eva Szigethy, M.D., Ph.D., a first-year child and adolescent psychiatry fellow at Case Western Reserve University and a recipient of the American Psychoanalytic Association Fellowship, describes how these pressures affect our psychotherapy training and what you can do about it. Dr. Szigethy is the member-in-training representative to the APA Commission on Psychotherapy by Psychiatrists (COPP) and is our resident representative to the Psychiatry Residency Review Committee. She welcomes your input on this issue and will forward your concerns and ideas to COPP. Her e-mail address is eszigethy@aol.com.
If you wish to contact me about this or other subjects, I may be reached by phone at (410) 955-5549; fax: (410) 614-5914; or e-mail: abbusch@erols.com. If you would like to contribute to the Residents’ Forum, please fax or e-mail your double-spaced essays to me. All submissions will be considered.
By Eva Szigethy, M.D., Ph.D.
As psychiatry residents we are faced with the challenge of securing a well-rounded education during a time when mental health care delivery is rapidly changing. Market forces are pressuring psychiatrists to be more "efficient." This has translated into decreased treatment duration and diminished reimbursement for psychotherapy practice by psychiatrists.
Managed care organizations often espouse that it is more efficient (that is, less expensive) for a nonphysician to provide psychotherapy, and therefore they are reluctant to reimburse a psychiatrist for this procedure. Ironically, rather than being seen as complementary to good clinical care, the explosion of novel psychopharmacologic treatment options has further threatened the balance between biological and psycho-therapeutic paradigms. The result is a rapid restructuring of what used to be comprehensive psychiatric training and practice. Unfortunately, this restructuring may not be guided by clinical or educational needs.
In response to this troubling trend, APA organized the Commission on Psychotherapy by Psychiatrists (COPP). The commission’s goal is to preserve psychotherapy training so that future psychiatrists will continue to be experts in the integration of biological, psychological, and social aspects of the diagnosis and treatment of mental illness.
One of the commission’s first initiatives was to survey a group of psychiatry residents, assessing their attitudes about psychotherapy. Residents who attended the APA annual meeting in San Diego and the meeting of the Association of American Directors of Psychiatric Residency Training (AADPRT), and residents who are members of GrassMITS (the APA member-in-training [MIT] list serve) were invited to respond. A total of 106 residents completed the survey, with responses from all seven APA geographical areas.
Ninety-eight percent of respondents indicated that expertise in psychotherapy must remain an integral part of the core clinical skills for all general psychiatrists; that without that expertise, psychiatrists could not maintain their role as mental health care team leader; and that the practice of psychotherapy significantly impacted on their job satisfaction as psychiatrists. More than two-thirds of the residents said that a basic level of competence was essential in the following psychotherapeutic modalities: psychodynamic, cognitive-behavioral, interpersonal, group, and family therapy.
Unfortunately, although three-fourths of the respondents perceived that their program had the educational and financial resources to support a comprehensive training experience in psychotherapy, approximately half did not believe that they were getting adequate supervision in various types of psychotherapies.
In an effort to help maintain quality psychotherapy training, the commission is developing a program that will provide residency educators and interested residents with an intense week-long workshop on methods of psychotherapy training, supervision, and assessment of trainee competency. The further development of this project will be coordinated with AADPRT and the various APA councils and committees involved in graduate education. Several creative psychotherapy training models utilized by some residency programs also will be considered. For example, Bernard Beitman, M.D., at the University of Missouri-Columbia has proposed a modular system that is time-efficient, research informed, and outcome oriented. As another alternative for upgrading psychotherapy training, the commission will seek funding for the development of psychotherapy teaching tapes and software.
The trend of deemphasizing psychotherapy training during residency underscores the importance of individual residents being assertive about this issue. Advocacy for the preservation of psychotherapy can be accomplished in several ways:
The stakes are high, making it imperative that residents be proactive on our own behalf on this issue. If we’re not, then the next generation of psychiatrists will be unable to provide comprehensive psychiatric care and will be denied the intrinsic satisfaction of utilizing psychotherapeutic principles and techniques to understand human behavior and ease suffering.