D.B. Dispatches

Psychotherapy’s Treatment Role Under Debate

The role of psychotherapy in a psychiatrist’s armamentarium seems to be a matter of debate in some circles. The issue is whether this a valuable skill essential to our role as psychiatrists or an anachronistic tool best left to nonmedical professionals while we focus on our biologically oriented skills.

In previous DB Dispatches columns I have quoted district branch newsletter articles whose writers have exhorted us to adapt to the economic realities of the times and consider new roles as members of mental health treatment teams—roles that leave psychotherapy to others. The two authors in this column, however, leave no doubt about their position on the importance of psychotherapy and our role as psychotherapists.

Dr. Anton C. Trinidad is a member of the Washington (D.C.) Psychiatric Society and voiced his opinion as a guest contributor in the President’s Column in the December 1997/January 1998 WPS Newsletter (Harold I. Eist, M.D., and Judith A. Novack, M.D., editors).

Dr. Trinidad is one of those pondering whether psychiatrists should still do psychotherapy. "A few years ago, it would have been inconceivable to ask this question," he observes. "Historically, psychotherapy has been viewed as the ‘gold standard’ of American psychiatry. Indeed, until recently, biological and hospital psychiatry was considered a somehow less prestigious line of work."

Spearheaded by the HMO movement, he explains, the health service system in the United States is presiding over a decline in and even the threat of elimination of the role of psychiatrists as psychotherapists.

"Many leaders of American psychiatry have implicitly or explicitly encouraged the trend of dominance by nonmedical psychotherapists, viewing ‘remedicalization’ of psychiatry as a safe harbor from the storms of managed care," Dr. Trinidad writes. But "we have made considerable progress in getting serious psychiatric illnesses accepted as comparable and equal to physical illnesses. Why then should we turn around and abandon responsibility for important facets of the care of our patients, including psychotherapy, to nonphysicians?. . .

"Many of our colleagues have already given up the practice of psychotherapy. Others have shunned the label psychiatrist altogether and have ‘reinvented’ themselves using affected designations such as ‘behavioral neuroscientist’ or ‘clinical neuro-psycho-pharmacologist’ to delineate self-perceived boundaries of what psychiatrists should do. While perhaps an effective short-term marketing strategy, this can only harm our profession in the long run by sending the message that psychotherapy is a homely, undesirable stepsister that deserves, at best, cursory attention."

Dr. Trinidad goes on to suggest that "the overemphasis on training in biological psychiatry and the deemphasis of formal training in the psychotherapies" account in large part for recent declines in the number of medical school graduates choosing careers in psychiatry. "Perhaps our younger colleagues recognize better than we do that if we give up psychotherapy, we give up a large part of our professional soul."

Indeed those younger colleagues do recognize the importance of psychotherapy in our everyday work as evidenced by an article that appeared in my own Louisiana DB newsletter this past fall. Writing in the Residents’ Column, PGY-3 resident Dr. Gregory T. Ciaccio of Tulane University describes how he came to this realization while seeing his first outpatients.

"So the patient has some depression; that’s easy. I’ll just start him on an SSRI. If that doesn’t work, I’ll try another one. Surely, one will work. But what if he can’t afford the medication or doesn’t want to take it? What if he just wants to ‘talk’? Well, I’ll try some psychotherapy. Yeah, that’s it. Let’s see, there’s supportive psychotherapy, cognitive-behavioral psychotherapy, and insight-oriented psychotherapy. This should be pretty easy. Gradually, I was faced with the stark reality. I really didn’t know how to do psychotherapy, short of supportive therapy with an empathic ear. Unlike much of what is learned in other specialties, psychotherapy is not taught in medical school."

Faced with this dilemma, Dr. Ciaccio then decided to do "what any good medical student or resident would do—read. That’s it, I’ll read some texts or journals; the answers must be there. Slowly, I came to a conclusion. Psychotherapy cannot simply be learned from a text; there are no cookbooks to follow. It is truly an art. An art learned through reading, lectures, supervision, and, most importantly, talking with patients. . . ."

Unfortunately for patients and psychiatrists, he points out, that art has been dropped as a crucial part of training. "Some departments are teaching less and less psychotherapy and instead are focusing on the volumes of new information on pharma-cologic treatments. There is nothing wrong with the latter. Indeed, science and economics demand that we are well versed in those treatments. But as residents we should demand that psychotherapy training remain an integral part of our curriculum. . . .

"Psychiatrists should not forget how to talk with their patients. And, more than talking, they need to be adept at psychotherapy. Indeed, many psychiatric illnesses appear to respond best to medications coupled with psychotherapy. They are not mutually exclusive or diametrically opposed treatment modalities. I feel fortunate to be in a program with a strong history in both psychodynamically oriented psychotherapy and biologic psychiatry. Hopefully, this tradition will not be lost in my program or in others. If we lose this heritage and art, our patients and our field will suffer."