Has Psychiatry Really Abandoned Psychotherapy? Behind the New York Times Story
Clearly, there is considerable room for improvement in training. On the other hand, a survey of 15 U.S. psychiatry residency programs (2006-2007) found that among 249 respondents, 82% viewed becoming a psychotherapist as “integral to their psychiatric identity.”8 Fifty-four percent planned to provide formal psychotherapy after graduation. Although this may prove overly-optimistic, given current insurance policies and market forces, the percentage is roughly comparable to the figure of 59.4%, which was the percentage of psychiatrists providing psychotherapy to at least some of their patients, according to the Mojtabai-Olfson study.3
At the best psychiatric residency programs, psychotherapy training is robust and intensive. For example, at SUNY Upstate Medical University where I teach, psychotherapy training starts in the first (PG1) year, with a weekly 2-hour seminar. In the second year (PG2), trainees complete a 6-month course on Learning Psychotherapy, which emphasizes processes common to all evidence-based psychotherapies. PG2 trainees then progress to a 5-month seminar on cognitive-behavioral therapy (CBT). Throughout the PG2 year, residents attend weekly seminars on the “biopsychosocial formulation”, and in the third (PG3) year, trainees enter the clinic, where they receive intensive supervision by a CBT supervisor and a Psychodynamic supervisor, each supervising 1 or 2 selected cases.
Trainees continue seminars with another 24 sessions on Theory and Practice of Individual Psychotherapy, followed, in the PG4 year, with sessions in Post-Freudian Personality Theory and Solution-Focused Therapy. To be sure — the SUNY Upstate program is exceptionally rigorous.9 Nevertheless, there are a number of psychiatry residency programs that provide intensive training in psychotherapy — including but not limited to the programs at Austin Riggs, McLean Hospital, California Pacific Medical Center and Sheppard-Pratt. Baylor College of Medicine teaches intensive psychodynamic therapy, and the Residency Review Committee for Psychiatry requires that three types of therapy must be taught in all residencies: long-term dynamic, CBT, and supportive therapy (J. Manring MD; Glen Gabbard MD, personal communications 3/31/11, 4/1/11).
Finally, one might well conclude, from the New York Times article, that psychotherapy and pharmacotherapy occupy two radically different realms — the “psychological” and the “biological”, respectively. In truth, this is a false dichotomy that has confused the public (and, alas, some clinicians) for the past 50 years. As Dr. Glen Gabbard has observed,
“Both psychotherapy supervisors and seminar instructors often convey that psychotherapy operates in a vacuum apart from medication, which is frequently prescribed by someone else, and that principles of neuroscience exist in a parallel universe with psychotherapy but in no way influence how one thinks about the patient while conducting psychotherapy. We now have abundant evidence that psychotherapy changes the brain .We also know that for many psychiatric disorders, combining psychotherapy and medication provides superior outcomes than either modality alone.”10
Sadly, neither the New York Times article nor the bedraggled psychiatrist it portrayed conveyed these nuances. Instead, pharmacotherapy was likened — incredibly — to an ape swinging a bone!
No doubt there are psychiatrists who practice in thrall to the almighty bottom line. No doubt, they believe they can do so without damage to their own souls and those of their patients. But I have known many more psychiatrists who refuse to sunder mind and body, and whose practice carefully interweaves empathy and chemistry. Many of them were my teachers, and many, my students. These are the real “doctors of the soul” — and even a poorly-researched article in the New York Times will not make them disappear.
Acknowledgments: The author would like to acknowledge the helpful information and perspectives provided by John Manring MD, Mantosh Dewan MD, Glen Gabbard MD, Steve Moffic MD, James Knoll MD, Paul Summergrad MD, Sidney Zisook MD, Robert Gregory MD, Mark Olfson MD, and Sharon Reif, PhD.
- Harris G: “Talk Doesn’t Pay, So Psychiatry Turns Instead to Drug Therapy”, New York Times, March 6, 2011.
- Knoll JL: Psychiatry: Awaken and return to the path. Psychiatric Times. March 21, 2011. Accessed at: http://www.psychiatrictimes.com/display/article/10168/1826785
- Mojtabai R, Olfson M: National Trends in Psychotherapy by Office-Based Psychiatrists. Arch Gen Psychiatry. 2008;65(8):962-970
- Summergrad P: A Missed Opportunity. Psychiatric Times (in press)
- Gabbard GO: Deconstructing the “Med Check.” Psychiatric Times. Sept. 3, 2009. Accessed at: http://www.psychiatrictimes.com/display/article/10168/1444238
- Reif S, Horgan C, Torres M, Merrick E, Types of Practitioners and Outpatient Visits in a Private Managed Behavioral Health Plan Psychiatric Services. 2010; 61:1066-1068.
- Calabrese C, Sciolla A, Zisook S et al: Psychiatric residents’ views of quality of psychotherapy training and psychotherapy competencies: a multisite survey. Academic Psychiatry 2010;34:13
- Lanouette NM, Calabrese C, Sciolla AF et al: Do psychiatry residents identify as psychotherapists? A multisite survey. Annals of Clinical Psychiatry. 2011; 23:30-39.
- Manring J: No, Psychiatry Has Not Lost Its “Mind”: Here, Psychotherapy Training Thrives. Psychiatric Times, June 2, 2010. Accessed at: http://www.psychiatrictimes.com/display/article/10168/1579811
- Gabbard GO: How Not to Teach Psychotherapy. Academic Psychiatry, 2005; 29:332-338.
Pies, R. (2011). Has Psychiatry Really Abandoned Psychotherapy? Behind the New York Times Story. Psych Central. Retrieved on April 26, 2015, from http://psychcentral.com/blog/archives/2011/04/03/has-psychiatry-really-abandoned-psychotherapy-the-story-behind-the-new-york-times-story/