Should Psychotherapy Remain Part of Psychiatry?

As we are making huge advances in neuroscience and genomics, the day may come when we can better understand the etiology of mental disorders and devise biologic treatments that target the underlying mechanisms. In one of his blogs, Tom Insel, M.D., immediate past director of the National Institute of Mental Health, wrote about changing the field of psychiatry into the field of clinical neuroscience.

I would argue that psychiatrists need to keep the practice of psychotherapy as one of their essential skills, even as the toolbox that psychiatrists use to diagnose and treat our patients will continue to deepen and expand. In the future, as we add modalities for diagnosis and treatment, we also need to improve on existing modalities.

Challenges to Keeping Psychotherapy as a Required Skill of Psychiatrists

In recent times, there has been a decline in psychotherapy training in most psychiatric residencies. Part of this is due to the increase in other requirements in training programs, and part of it is due to financial and economic factors of practice after completing residency. The truth is that psychiatrists can generate more income by doing 15- to 20-minute medication visits than by doing psychotherapy. In addition, in some team-based settings, the psychiatrist’s role is to prescribe medications. Psychiatrists, the most expensive members of the team, are not providing psychotherapy, which other less-expensive mental health professionals can provide.

I served as a senior examiner for the oral part of the ABPN specialty boards and watched candidates being examined throughout the United States. I can remember many times when the examiners asked a candidate to describe the best treatment for a depressed patient. As expected, the candidate would typically include psychotherapy in the list of recommended treatments. When the examiners asked questions about the techniques of various psychotherapies, it was not unusual (and not a reason for failure) for candidates to respond that they did not know the techniques because they did not do psychotherapy. Instead, they would refer patients to a psychologist or other mental health professional! The examiners realized that this response and practice was a reflection of what was being taught in ACGME-approved residencies.

An Institute of Medicine report on psychotherapy released in July 2015 (“Psychosocial Interventions for Mental Health and Substance Use Disorders—A Framework for Establishing Evidence-Based Standards”) looked at psychosocial treatments in psychiatry. It addressed some of the problems in the knowledge base for the field of psychotherapy: “Although a wide range of evidence-based psychosocial interventions is currently in use, most consumers of mental health care find it difficult to know whether they are receiving high-quality care. Providers represent many different disciplines and types of facilities, the delivery of care is fragmented, interventions are supported by varying levels of scientific evidence, performance metrics may or may not be used to measure the quality of care delivered, and insurance coverage determinations are not standardized” (Psychiatric News, August 7 and December 4, 2015).

The report points out that much of the research on evidence-based psychotherapies is done utilizing manualized treatments, but that in practice most psychotherapists do not stick to these manualized techniques. The findings in this report accurately address the heterogeneity of psychotherapies and the challenges for patients and therapists in knowing what treatment is best because there so many types of therapy, and the promoters of each type claim that their brand of therapy is best.

Use of Psychotherapy as Early Intervention, Treatment for Mental Disorders

Ongoing research has validated the use of psychotherapy as a skill to treat serious mental disorders, and this is unlikely to change, even as we develop more targeted neuroscientifically informed interventions. For example, the recent RAISE research (Recovery After an Initial Schizophrenia Episode) has shown that psychosocial interventions can improve outcomes. In addition, psychotherapy interventions have been shown to alter the circuitry of the brain.

I remember when clozapine was available in the United States only through an IND (investigational drug application). At that time, I was director of an inpatient psychiatric unit, and I was approached by members of the local chapter of the National Alliance on Mental Illness who wanted clozapine to be tried on their loved ones. I obtained an IND and started using it on patients who had been unresponsive to other medications and who had negative symptoms of schizophrenia. For some of the patients, clozapine had remarkable results. I remember distinctly the reaction of one of the family members who saw her adult son reading a newspaper in the day room. The shocked family member told me that her son had not read a newspaper in over 10 years! Now that this patient had a decrease in his negative symptoms and an increase in interest in the world around him, much still needed to be done in terms of therapeutics. Psychosocial treatments as well as psychotherapy became an essential part of this patient’s rehabilitation.

In addition, many studies have demonstrated that psychotherapy combined with psychotropic medications have an additive effect for many of the disorders that we treat. Moreover, even when psychiatrists have the role of prescribers, they often need to apply the principles of good psychotherapy training. Even in the context of a medication-oriented patient visit, psychotherapy principles can be used to further patient insight or motivation in the hopes of increasing medication effectiveness or compliance.

Future of Psychotherapy

So what is the future of psychotherapy as part of the practice of psychiatry? The 2014 APA resource document titled “Psychotherapy as an Essential Skill of Psychiatrists” states, “Of all mental health practitioners, only psychiatrists are privileged—and able—to provide all therapeutic modalities … and integrated comprehensive treatment.” The position statement on psychotherapy, passed by the Board of Trustees in December 2015, states that APA should advocate for psychiatrists “to be reimbursed by payers in a manner that integrates care and does not provide financial incentives for isolating biological treatments from psychosocial interventions.”

We also need to advocate for research on psychotherapy. In its report on psychosocial interventions, the Institute of Medicine committee offered a framework for use by the behavioral health field in developing efficacy standards for psychosocial interventions. The committee recommended that “psychosocial interventions be considered in terms of their elements of therapeutic change, and that these elements be subject to systematic reviews, quality measurement, and quality improvement efforts.”

In my opinion, it would be a huge mistake for psychiatrists to give up psychotherapy as one of our essential skills. Other disciplines would gladly provide this treatment instead of us. But we would lose the ability to provide one of our core treatments that are incredibly helpful to our patients. We also would lose the ability to provide one of the most rewarding modalities of psychiatric practice for those of us who chose psychiatry as a specialty because of the ability to develop relationships with patients and understand and treat them as whole human beings.

There is a growing but false dichotomy between neuroscientific and psychosocial interventions. We need to advocate for keeping psychotherapy in our toolbox, expanding research on the common elements of psychotherapy, and furthering its use in novel ways in different types of psychiatric conditions. ■