Speculating on why fewer psychiatrists are using psychotherapy, Plakun said it could be a result of the shift away from the earlier emphasis on psychoanalysis to biological psychiatry, the growth in effective pharmacological treatments, the emergence of managed care, and the “quite possibly erroneous belief” that payers could save money by adopting the split-care model, in which psychologists and others provide the psychotherapy.
“Two studies cited in our paper suggest that split care may be less cost-effective compared to integrated care,” said Mojtabai. “But the issue hasn’t been studied fully,” and more research also is needed to compare the effectiveness of split care versus integrated care.
Plakun declares, “It is extremely powerful to have a psychiatrist who can do both the psychotherapy and the prescribing because it really allows the meaning of medications to come into the work.”
He described a patient who would not take medications the way he had prescribed them—she either overdosed or refused to take them at all.
“Finally through the process of therapy,” Plakun said, “we were able to have a conversation in which she said to me, ‘you have to understand that the way I was abused as a child had to do with forced oral rape, and I’m not letting you be in charge of what goes down my throat.’”
Plakun and the patient built a different kind of working alliance around the use of medications.
Plakun noted that the APA’s Committee on Psychotherapy is developing 2 surveys—1 for practicing psychiatrists and 1 for residents—to gather more definitive information about factors involved in psychotherapy’s decline. He expects the survey of psychiatrists to be finalized and sent to participants in APA’s Practice Research Network within the next 6 months. It will ask about the extent of the psychiatrist’s practice of psycho-therapy as well as possible obstacles (eg, financial disincentives or inadequate training).
The survey of residents (with 5 questions about the adequacy of their training and supervision in psycho-therapy) is part of a larger survey to be disseminated by the Committee on Residents and Fellows, Plakun said.
The psychotherapy committee also is proposing a component workshop on the topic for next May’s APA Annual Meeting in San Francisco.
Both Mojtabai and Plakun suggested improvements in psychotherapy training for residents.
Rather than just developing competence in different modalities, future psychiatrists should have a better sense of which disorders are more responsive to psychotherapy. This knowledge will be particularly beneficial when making referrals for psychotherapy, Mojtabai said. Because other mental health professionals will probably provide the bulk of psychotherapy, he added, psychiatrists should learn how to better communicate with those professionals over issues needing exploration in therapy.
Plakun recommended that psychotherapy be taught in a way that eliminates the warfare between proponents of specific psychotherapeutic approaches such as cognitive-behavioral therapy and psychodynamic therapy. He proposed the Y-model for teaching psychotherapy competencies, which was developed by members of the Committee on Psychotherapy and is available at the Web site of Austen Riggs Center, where he is director of admissions and professional relations (www.austenriggs.org/continuing_education/ymodel).
The model begins with common psychotherapeutic skills a psychiatrist needs, regardless of a particular psychotherapy approach, including negotiating a therapeutic alliance, understanding limits and boundaries, and prescribing medications as part of therapy. The model then compares and contrasts schools of therapy on the basis of their underlying theoretical assumptions, with technique following from theory.
There is growing evidence that various therapies provide effective treatment for numerous psychiatric disorders, according to Mojtabai and Plakun.
Behavioral treatments have been shown to be more effective than medications in the treatment of obsessive-compulsive disorder, Mojtabai said, and we have very good evidence that psychotherapy is as effective as medications for treating major depression.
Plakun added that psychotherapy has been shown to be an effective treatmentassociated with changes in the brain, as documented on imaging studies.
Results of major NIMH-funded studies also indicate the effectiveness of psychotherapy. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), for example, found that adults who received up to 30 sessions of family-focused therapy, cognitive-behavioral therapy, or interpersonal therapy plus medications recovered more rapidly from depressive episodes than participants who received only 3 psychoeducational sessions in addition to medication.
“It really is a loss to our patients if they aren’t getting psychotherapy,” Plakun said. “Moreover, psychiatrists are in a unique position to provide psychotherapy because they really have the medical training that allows them to integrate medication and therapy, mind, and body.”