Psychiatrists today do much less psychotherapy than they did previously. Modern psychiatrists get much less training in psychotherapy; two recent editorials in leading psychiatric journals address these changes. (Psychotherapy: A Paradox, Myrna Weissman, American Journal of Psychiatry, 7/13 and Psychotherapy and ChildPsychiatry, Rachel Ritvo and Judith Cohen, American Journal of Child and Adolescent Psychiatry, 9/13). Each describes the change, how it came about and what has been lost.
Psychiatry first developed within a medical model, then developed extensively in a different dimension through the middle of the 20th century. This major shift came about through the influences of psychoanalysis, social science, and the humanities. It generated the psychotherapies.
Today psychiatry is shifting once again. It seeks to be centered on quantitative science and the study of the brain. Training and the funding of research has shifted away from studies of the mind and psychotherapy. Funding of services has shifted as well. As managed care came to believe that medication services were less expensive than psychotherapy, their funding strongly favored medication, with substantial impact on the amount of psychotherapy done by psychiatrists.
Is this a problem? Our editorial writers argue that much may be lost. Weissman states that research demonstrates that psychotherapy is at least as effective as medications in most disorders. For some high prevalence disorders, no medication is known. The teaching and supervision of development as a therapist was a cornerstone of residency training and a major source of the most able therapists.
There is much more to this beyond the question of how much psychotherapy psychiatrists do. Psychiatrists who are not trained in the use of psychotherapy are considered by many to lack something essential in their ability to engage, evaluate, and treat people with emotional problems, whether they actually do the psychotherapy or not. Ritvo and Cohen say:
The training and practice of psychotherapy require an understanding of the mind and its role in regulating emotions and behavior. Psychotherapy provides a depth of understanding of our patients and relational skills that inform all aspects of child psychiatric practice, including psychopharmacology.
An effective psychiatrist needs to understand the people he or she sees, their inner life and sentient experiences, their feelings, relationships, family.
However expert the psychiatrist, medications target problems crudely. Psychotherapy, in contrast, has great specificity. The patient’s accumulation of troubles and patterns appears in a shifting yet demanding way. Psychotherapy can go with this more specifically, addressing first one then another symptom or pattern or feeling or conflict as they present themselves and require response. The psychiatrist who has developed the ability to do psychotherapy is most likely to be one who can listen, understand, have empathy and give the specific person in need what he or she needs the most.