Recent reports have noted an alarming decrease in the practice of psychotherapy among psychiatrists. This trend may be largely the result of reduced reimbursement for psychotherapy treatments, a reductionist view of biological research, or less emphasis on “talking therapy” in residency training.1,2
In 2001, the Residency Review Committee (RRC) mandated psychotherapy training for psychiatry residents.3 Before the RRC’s mandated curriculum, psychotherapy training was often “hit or miss” among residency training programs.
Specific changes mandated by the RRC
In 2001, the RRC’s 5 original core competencies required that residents must be able to apply supportive,psychodynamic, cognitive-behavioral therapy (CBT), and brief psychotherapies as well as combined medication and psychotherapy, with exposure to family, couples, group, and other individual evidence-based psychotherapies. Finding trained faculty to teach all 5 competencies strained many residency programs. Economic limitations and funding cuts in university-based training programs often reduce residents’ time with clinical and research faculty, who are pressured to generate personal income and support operating costs for their institutions.
July 2007 updates of the core psychotherapy competencies require training in only 3 areas: psychodynamic therapy, CBT, and supportive therapy. Residents must have an equivalent of 12 months of full-time, organized, continuous, supervised clinical experience in the assessment, diagnosis, and treatment of outpatients in both short-term and long-term care.3
Medical training at all levels and in all medical specialties has increasingly emphasized the provision of evidence-based treatments. To boost acceptance and use of psychotherapy by residents, its effectiveness must be taught through the use of rigorous clinical trials. Randomized controlled trials of treatment with psychotropic medications for psychiatric disorders are well-funded and often easier to design and carry out than psychotherapy studies, which cannot be truly blinded to patients and therapists. However, it may be argued that exclusion criteria are more stringently used in drug studies than in psychotherapy research. As a result, drug trials are more likely to eliminate patients who are representative of those seen in real clinical practice.
The evidence base
There have been a modest number of positive studies on the treatment of various psychiatric disorders with shorter-term psychotherapies, including CBT, interpersonal therapy, short-term dynamic therapy, and other psychoanalytically oriented psychother-apies.4-12 These studies were conducted with and without concomitant psychiatric medications. In particular, there has been support for the effectiveness of CBT for many years.
Considering longer treatments, a meta-analysis shows the effectiveness of long-term psychodynamic psychotherapy versus short-term psychotherapy for treating complex mental disorders such as multiple or chronic Axis I disorders and personality disorders.13 Randomized controlled trials and observational studies were included in this study, and treat-ments lasted for at least 1 year or 50 sessions.
1. Kaplan A. The decline of psychotherapy. Psychiatr Times. 2008;25(13):1, 6-8.
2. Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970.
3. Accreditation Council for Graduate Medical Education. Graduate Medical Education Directory, 2001-2002. Chicago: American Medical Association; 2001.
4. Barlow DH, Gorman JM, Shear MK, Woods, SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA. 2000;283:2529-2536.
5. Thase ME, Friedman ES, Biggs MM, et al. Cognitive therapy versus medication in augmentation and switch strategies as second-step treatments: a STAR*D Report. Am J Psychiatry. 2007;164:739-752.
6. Beck AT. The current state of cognitive therapy: a 40-year retrospective. Arch Gen Psychiatry. 2005;62: 953-959.
7. Weissman MM, Klerman GL, Prusoff BA, et al. Depressed outpatients. Results one year after treatment with drugs and/or interpersonal psychotherapy. Arch Gen Psychiatry. 1981;38:51-55.
8. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry. 2004;61:1208-1216.
9. Abbass AA, Hancock JT, Henderson J, Kisely S. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2006;(4):CD004687.
10. Crits-Christoph P. The efficacy of brief dynamic psychotherapy: a meta-analysis. Am J Psychiatry. 1992;149:151-158.
11. Fonagy P, Roth A, Higgitt A. Psychodynamic psychotherapies: evidence-based practice and clinical wisdom. Bull Menninger Clin. 2005;69:1-58.
12. Milrod B, Leon AC, Busch F. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007;164:265-272.
13. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA. 2008;300:1551-1565.
14. American Psychiatric Association Practice Guidelines. http://www.psychiatryonline.com/pracguide/ pracguidetopic_7.aspx. Accessed October 6, 2009.
15. Robinson LA, Berman JS, Neimeyer RA. Psychotherapy for the treatment of depression: a comprehensive review of controlled outcome research. Psychol Bull. 1990;108:30-49.
16. Pampallona S, Bollini P, Tibaldi G, et al. Combined pharmacotherapy and psychological treatment for depression: a systematic review. Arch Gen Psychiatry. 2004;61:714-719.
17. Cuijpers P, van Straten A, Warmerdam L, Andersson G. Psychotherapy versus the combination of psychotherapy and pharmacotherapy in the treatment of depression: a meta-analysis. Depress Anxiety. 2009;26:279-288.
18. Weissman MM, Verdeli H, Gameroff MJ, et al. National survey of psychotherapy training in psychiatry, psychology, and social work. Arch Gen Psychiatry. 2006;63:925-934.
19. Austen Riggs Center Continuing Education. Y Model for Teaching Psychotherapy Competencies. http://www.austenriggs.org. Accessible with registration.
20. Association of American Medical Colleges. Curriculum Management and Information Tool. http://www.aamc.org/currmit. Accessible with registration.