Evidence of the efficacy of psychotherapy has increased dramatically in
recent years even as the place of psychotherapy in the identity, practice, and
training of psychiatrists is diminishing—a fact that was widely
recognized and just as widely deplored during a workshop at APA's 2009 annual
meeting in San Francisco in May.
It was a subject that brought out considerable passion as speakers and
attendees alike insisted that psychiatry brings a unique set of skills to the
biopsychosocial treatment of mental illness and that new evidence is showing
that psychotherapy works not only on the mind but on the brain. At the same
time, speakers acknowledged what some research evidence published last year
and presented at the meeting seemed to show—that psychotherapy by
psychiatrists is declining.
"There is growing evidence that psychotherapy is efficacious for a
range of individual disorders and for complex comorbid disorders," said
Eric Plakun, M.D., chair of APA's Committee on Psychotherapy by Psychiatrists."
We are also learning that psychotherapy is associated with brain
change. Though medications seem to work from the bottom up, psychotherapy
seems to work from the top down—from the cortex down to the molecular
level. In at least one study, therapy responders could be distinguished from
nonresponders by imaging studies.
"Yet there is also this evidence that psychotherapy is dwindling as
part of the identity, skill set, and training of psychiatrists," Plakun
said. "I think we can raise an interesting question of whether
psychotherapy by psychiatrists is an endangered species."
Plakun said that the trend is frustratingly at odds with what would appear
to be common sense. "Therapy by psychiatrists absolutely maximizes the
integration of mind and body, and it certainly also maximizes the possibility
of integrating prescribing of medications with psychotherapy.
"So the minimization of therapy, should it continue, is a loss to
psychiatry, but above all, it's a loss to our patients," Plakun said."
Are we offering our patients all we can if we aren't thinking about
biological treatments and psychosocial treatments, including
APA President Nada Stotland, M.D., served as a discussant at a workshop
on psychotherapy by psychiatrists at the annual meeting. There was widespread
agreement that the place of psychotherapy in the training and identity of
psychiatrists has diminished.
Credit: David Hathcox
There was poignancy to the workshop in that the Committee on Psychotherapy
by Psychiatrists was being "sunsetted"—it is one of a large
number of committees and other components that are being terminated as part of
an APA organizational restructuring to make APA more efficient (see
Thoughts on Reorganization).
The committee's charge will likely fall under the
Council on Research and Quality
Outgoing APA President Nada Stotland, M.D., who was trained analytically
and has a practice devoted to psychotherapy, was a discussant at the workshop.
She urged committee members and other members of APA to think about strategy
going forward and to communicate ideas to leadership. "We have to think
strategically and practically if we want a position that insurers should cover
psychotherapy by psychiatrists," Stotland said.
"We need to think about how exactly psychotherapy by psychiatrists is
going to be carried forward and to demand some accountability around this. In
no way will any of your leadership want to let that go away."
The trend away from psychotherapy by psychiatrists, acknowledged by most
speakers, appeared to be confirmed by research presented at the annual meeting
by Ramin Mojtabai, M.D.
Mojtabai and Marc Olfson, M.D., analyzed data from the 1996-2005
cross-sectional National Ambulatory Medical Care Survey to examine trends in
psychotherapy provision within nationally representative samples of visits to
office-based psychiatrists. Statistical analyses examined the time trend,
adjusting for patient, visit, and setting characteristics. Practice-level
analyses examined time trends in the percentage of psychiatrists who provided
psychotherapy to all, some, or none of their patients during a typical
They found that psychotherapy was provided in 5,597 of 14,108 visits
sampled during the 10-year period. The percentage of visits involving
psychotherapy declined from 44.4 percent in 1996-1997 to 28.9 percent in
At the practice level, the decrease in providing psychotherapy corresponded
with a decline in the number of psychiatrists who provided psychotherapy to
all of their patients, from 19.1 percent in 1996-1997 to 10.8 percent in
"This trend is attributable to a decrease in the number of
psychiatrists specializing in psychotherapy and a corresponding increase in
those specializing in pharmacotherapy—changes that were likely motivated
by financial incentives and growth in psychopharmacological treatments in
recent years," Mojtabai said.
He is an associate professor of psychiatry at Johns Hopkins University
Bloomberg School of Public Health.
Dissenting somewhat from the conventional wisdom was Glen Gabbard, M.D., a
renowned leader in psychoanalysis and psychodynamic therapy. He questioned
what he called "the myth of the med check," saying it was not
really possible to know what was happening between a therapist and patient
during a visit that might be coded by the office assistant as a"
medication check" and insisted that a great deal of important
psychotherapy may be going on during those visits.
"We make far too much of the distinction between psychotherapy and
medication," Gabbard said. "Patients don't make that distinction.
They are going to see their doctor. They don't say, 'I'm in a med check, so I
will only talk to you about the therapeutic effects of this medication. I
think there is a lot of psychotherapy going on during so-called medication
Moreover, he insisted that the principles of psychodynamic psychotherapy
are applicable in every area of psychiatric practice. "There is no type
of psychiatric practice that exists in a realm where psychodynamic
principles—transference, countertransference, resistance, the
therapeutic alliance—are irrelevant. So one of the things that I think
we need to emphasize as a major public relations effort about psychiatry is
that we are the integrators par excellence."
Gabbard agreed that psychiatry has "abdicated far too much ground to
other mental health professions." And he wondered if the economic forces
that have tended to drive the trend away from psychotherapy by psychiatrists
have served as a convenient out for patients and clinicians alike who would
rather avoid the difficult terrain of psychotherapy.
"As we know, the unconscious will always be resisted, and most of us
would rather ignore the parts of people that are filled with pain and terror
and aggression and rage," Gabbard said. "There is a powerful
incentive for us to turn away from the demons that inhabit people. If we can
get by on 10- or 15-minute med checks, maybe we won't have to look at that
Difficult as it may be to do psychotherapy, it is also rewarding, Gabbard
said. "I train my residents that while it is true you could make money
doing 15-minute medication checks, when you get to be 45 or 50, you will feel
like Sisyphus pushing the boulder up the mountain, and you will have a sense
of existential despair about your work," he said.
He said the satisfaction of doing psychotherapy and of getting to know
people in depth "is worth taking a financial hit for." And he
added, "We as psychiatrists didn't go into this for the money. We have
to keep track of why we like doing this, and it is because we get to know
people in depth." ▪