ECPs and Psychotherapy: Battling the Obstacles

The Psychotherapy Committee of the Group for the Advancement of Psychiatry (GAP) deals with a paradox. On the one hand, the evidence base for the effectiveness of psychotherapy in psychiatric treatment is strong and getting stronger. On the other hand, fewer and fewer psychiatrists make psychotherapy an important part of their psychiatric practice. In a 2008 study by Mojtabai and Olfson, the percentage of psychiatrist office visits involving the provision of psychotherapy declined from 44 percent to 29 percent over a 10-year period from 1996 to 2005!

What intrigues the Psychotherapy Committee most right now is the exasperating incongruity between the robust evidence of effectiveness and diminishing practice of psychotherapy. In our view, this incongruity threatens the very identity of the psychiatrist. We suspect that many psychiatrists—even those who don’t talk much with patients any more—feel the same way but also feel helpless to resist the incentives to do check-box evaluations, write prescriptions, and spend less time talking with patients. In September 2014 the GAP Psychotherapy Committee wrote a special issue of Psychodynamic Psychiatry that analyzed many aspects of the situation in depth. One article in that issue was “Obstacles to Early Career Psychiatrists [ECPs] Practicing Psychotherapy.”

ECPs who work in high-volume systems for economic reasons are especially vulnerable to the trends, yet they have the strongest need and motivation to gain experience and develop skills in psychotherapy. This was borne out in the enthusiastic response to a recent effort by the American College of Psychoanalysts to recruit ECPs for virtual clinical rounds in psychodynamic psychotherapy by videoconference; after two articles in Psychiatric News, applications were received from 12 states, Washington, D.C., and India.

Medical graduates enter the field of psychiatry for many reasons, including concern about mental illness, a wish to help people who suffer from it, and the fact that psychiatry offers a fascinating, integrated perspective on both the subjective world of the mind and the objective workings of the body. Unfortunately, surveys in 2012 by Donna Sudak, M.D., and David Goldberg, M.D., and by Malkah Notman, M.D., and me demonstrated that residents’ training in formal psychotherapy varies greatly from one residency to another—despite the ACGME requirement for all residencies that residents acquire “competence” in cognitive-behavioral therapy (CBT), psychodynamic psychotherapy, and supportive psychotherapy.

Yet, it is crucial for psychiatrists to be skilled in providing psychotherapy, especially when medication is also indicated and for treatment-resistant and complex cases. Most graduating residents do not have enough experience to make them proficient psychotherapists, let alone to qualify them to manage or supervise psychotherapy services of other professionals. Nonetheless, when these residents become ECPs, many still have a passion for learning more and gaining in-depth experience in this challenging and nuanced form of treatment. But serious obstacles present themselves.

Because of the pressures of heavy educational debts, ECPs are likely to take salaried positions in community agencies that are faced with overwhelming service demands. Whether in private practice or in agencies, tilted insurance benefits pay much better for time spent on multiple brief medication visits than on psychotherapy services. There is great pressure for psychiatrists to do evaluation and medication management while nonmedical practitioners provide whatever psychotherapy is offered. Meticulous, rigidly detailed electronic-record keeping leaves little time for talk. Gone for the ECPs are the clinical satisfactions of providing integrated psychotherapy care that combines medication management based on thorough and ongoing knowledge of the patient with psychotherapy that meets the standards of a well-founded psychotherapeutic method. Even less likely is that employed ECPs are allowed to offer such psychotherapy when medications are not indicated.

In this writer’s experience, the world is full of patients (and their primary care doctors) urgently trying to find “a psychiatrist who talks with patients” after several unsatisfactory experiences with psychiatrists who confront patients with a computer screen bearing a check-off electronic health record and a prescription app. So ECPs who brave the world of private practice to be able to talk with their patients may be pleasantly surprised at the demand for their services that they encounter. But even in this environment, the adversely unbalanced nature of skimpy insurance reimbursement for psychotherapy coupled with intrusive management can make participation in third-party payment daunting. Consequently, surveys show that a large percentage of psychiatrists in private practice do not take insurance. Through its data-gathering and publications, the GAP Psychotherapy Committee has actively supported advocacy and legal interventions under the parity law that show some signs of bringing about favorable change.

What can ECPs do to assure the continued maturation of their needed psychotherapy skills? They are needed. They can use their clout to insist on terms of employment that allow them to do psychotherapy regularly when indicated or reserve time to do psychotherapy in other settings. They can do private practice that includes psychotherapy in medical settings adjacent to primary care practitioners; they will be welcomed. Importantly, they can seek out psychotherapy consultation or supervision with an experienced psychotherapist, or enroll in psychotherapy courses offered by psychoanalytic or CBT institutes or universities. Some obtain therapy for themselves, which is likely also to enhance their psychotherapy skills. For ECPs not geographically close to such resources, there may be peer-consultation arrangements or online consultation with reputable teachers (subject to the licensing laws of their state), or courses offered at professional meetings or through distance learning. Such efforts can lead to a far more enjoyable and rewarding career in psychiatry. ■