February 5, 1999

By Norman A. Clemens, M.D.

Is the bio-psychosocial model of psychiatric practice becoming a thing of the past? If APA's Commission on Psychotherapy by Psychiatrists (COPP) can do anything about it, the answer is "No!" COPP's training initiatives are designed to make a difference.

There appears to be a steady erosion of the role of psychotherapy in the practice of psychiatry. Most commonly blamed for this are managed care and the heavy emphasis on neurobiology and psychopharmacology that have characterized the Decade of the Brain. Many psychiatrists, regardless of their specialized interests, express deep concern about this trend and its impact on the professional identity and skills of the psychiatrist. A major focus of concern is the development of future psychiatrists in psychiatric residency training. And most distressed about it are psychiatric residents themselves.

There are grounds for this distress. Residents are required to have an increasing range of experiences, all of which fractionate their time and locale of practice. The knowledge base in neurobiology and psychopharmacology is growing by leaps and bounds, and competition for resources and teaching time is fierce. Drying up of training grants throws the burden on departments of psychiatry to support themselves through clinical services, and psychotherapy is not a lucrative service. A managed-care model of treatment where the resident does evaluation and medication management, while other professionals conduct psychotherapy, if any is offered, devalues integrated psychotherapy and medication management by psychiatrists.

Surveys of residents through COPP and the American Association of Directors of Psychiatric Residency Training (AADPRT) in the last few years indicate that there remains widespread exposure to psychodynamic psychotherapy, cognitive-behavioral psychotherapy, and supportive therapy. This training, however, often falls far short of clinical competency in these forms of treatment. Fewer programs provide interpersonal psychotherapy, group therapy, and family therapy. There is considerable variation from one training program to another in the quality and intensity of psychotherapy training. Despite the overall trend, reports indicate that enthusiastic teachers are running active psychotherapy training programs in a number of residencies.

The surveys make clear that the vast majority of residents want psychotherapy training and that residency training directors consider it to be crucial. There is pressure for strengthened training in short-term, structured, problem-oriented treatments that have been systematically studied and are more acceptable in managed care environments, so that psychiatrists can offer the full range of available services and be more competitive with nonmedical clinicians. Experience with intensive, usually longer-term psychodynamic psychotherapy is also highly sought because of its value in understanding personality issues and treating conditions not amenable to brief therapy. It provides a substrate of knowledge of human development, psychic conflict, and transference/countertransference phenomena that can enrich and supplement other treatment methods. As the Psychiatric Residency Review Committee (PRRC) has revised training requirements, COPP and many other organizations have advocated for a continued strong emphasis on psychotherapy training. Indications are that this input has been heeded.

From the start, COPP has had representatives from APA's Committee on Residents and Fellows (CORF), one of whom, Eva Szigethy, M.D., conducted a survey of residents. Out of this has developed a strategy for psychotherapy training, which has as its guiding principle to define and support the phenomena and principles that are fundamental to all psychotherapies, such as the psychiatrist-patient working relationship, verbal or interactive communication, self-observation, work with emotions and thoughts, enhanced understanding, learning, mastery through repetition, more focused activity by the patient, and so on.

This strategy evolved into APA endorsement of a structured psychotherapy training program developed by a COPP member, Bernard Beitman, M.D. The curriculum uses modular sets of case studies, videos, readings, and discussions to introduce residents early in their careers to concepts fundamental to all psychotherapies before they actually start to see patients. Evaluation methodology is built in. The program is now undergoing multisite field testing.

The next step is the Advanced Strategies Initiative, "Integration and Specificity in Psychotherapy Education," developed by COPP members and coordinated by COPP Vice Chair Glen Gabbard, M.D. This exciting event will take place on Wednesday and Thursday, March 10 and 11, in Santa Monica, Calif., just prior to the AADPRT annual meeting. The purpose of the workshop is to develop a cadre of psychiatry residency instructors who are enthused about psychotherapy training, well informed about effective teaching methods, and cross-fertilized by their colleagues across the country.

Outstanding experts in the range of psychotherapeutic methods will work collegially with the participants. While presenting teaching methods for the specific psychotherapies, including psychodynamic, cognitive-behavioral, and interpersonal therapies, they will also discuss teaching methods that involve common elements and integrative strategies combining two or more of the specific approaches. Using videotaped vignettes to stimulate discussion, they will address critical issues in supervision. Integrating psychotherapy and medications, the 20-minute hour, new technologies, and measures of effectiveness are also on the agenda. An extensive syllabus and model courses for each psychotherapeutic method are in preparation.

Thanks to a generous grant from Pfizer, there will be no registration fee. For workshop registrants there are a limited number of hotel rooms available at a discounted rate of $179.50 plus tax. Registration forms can be obtained from Lisa Watford at APA at (202) 682-6834; e-mail: lwatford@psych.org; or fax: (202) 682-6102. No psychiatry residency program should fail to have at least one representative at this auspicious event, which we hope will reinvigorate psychotherapy training in modern psychiatry.

Dr. Clemens is chair of the APA Commission on Psychotherapy by Psychiatrists.