Although fewer than those for pharmacotherapy, the number of rigorously designed studies of psychotherapies is steadily growing. Despite the need for even more controlled psychotherapy trials, the lack of evidence of effectiveness is not evidence of a lack of effectiveness. In fact, some of the psychosocial treatments proposed in the American Psychiatric Association’s (APA) Practice Guidelines admittedly have not been well studied in randomized controlled studies.14
More studies that focus on the combined effects of biological and psychosocial treatments would enhance scientific evidence that supports clinical practice. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study has been hailed as an important move in that direction and is a valuable example of research that is applicable to patient care for physicians in training. In addition, a few studies have documented that psychological and pharmacological treatments have comparable outcomes in treatment of depression and that combined treatment is more effective than either treatment alone.15-17 Current biological studies have blurred the old boundaries between pharmacotherapy and psychotherapy with neuroimaging studies that show changes in brain function and structure. Abstract concepts such as learning and intrapersonal growth in psychotherapy now merge with those of neurogenesis and brain plasticity in neurobiology.
How successful have residency training programs been in incorporating psychotherapy education into their curricula? A recent survey of more than 200 psychiatry, psychology, and social work training programs explored the number that required or offered didactic and/or supervised training in evidence-based psychotherapy (EBT) and non-EBT, as defined by availability of treatment manuals and efficacy studies.18
The barriers to teaching EBT that were identified by residency training directors include lack of qualified faculty and absence of trainee interest. Nevertheless, more than 80% of the programs saw advantages in offering EBT, and almost two-thirds endorsed better results in patient care. More than 90% of psychiatry residency programs surveyed were in compliance with new CBT requirements. Although psychiatry training requires both didactics and clinical supervision in EBT more often than in other disciplines, psychotherapy requirements were fulfilled in their entirety by a minority (28.1%) of psychiatry programs. This finding suggests that there is a gap between research evidence for psychotherapy and actual clinical training.
The APA Committee on Psychotherapy by Psychiatrists recently developed the Y model for teaching the 3 competencies required by the RRC. The model is efficient, integrated, and evidence-based, and it does not pit one therapy against another. In the Y model, core processes are identified that are common to all psychotherapies (eg, empathic listening, identifying dysfunctional patterns, developing a formulation, attending to issues of boundaries, confidentiality, crisis management, involvement of significant others). The Y model assumes that therapy involves new learning and mastery of problems in the context of a human therapeutic alliance that is negotiated.
The stem of the Y consists of teaching the core features common to different psychotherapy schools as well as elements of brief and combined therapy. The 2 branches of the Y involve teaching specific features of CBT and psychodynamic therapy.19
Many experts agree that to achieve competency in a skill or practice it is best to introduce it as early as possible. In fact, several undergraduate medical school programs provide some introductory psychotherapy education, even though it is not required by the Liaison Committee on Medical Education, the official accrediting body for medical schools. According to the Association of American Medical Colleges, 40 medical schools in the United States and Canada reported some limited instruction in psychotherapy between 2006 and 2008 as part of the curriculum.20 This instruction occurred at varying times throughout the 4 years of medical school and was often part of a 1-hour session. These figures are probably lower than the actual number of medical schools that provide psychotherapy instruction: several do not add detailed curriculum information into Curriculum Management and Information Tool (CurrMIT). Thus, in some cases, the seeds are planted early for more definitive training in psychiatry residency and beyond.
Our profession is unique in that it provides both psychotherapy and pharmacotherapy for persons with mental disorders. Comprehensive psychotherapy training with didactics and supervision during residency should continue to be supported by our profession to preserve this fundamental treatment.
Such instruction is more likely to succeed when it is begun early on through continuing medical education or self-study programs, when psychiatrists are most open to adopting a psychological mindset and are least distracted by the demands of clinical practice. Psychotherapy training programs taken after residency training may help reinforce and refine skills learned and practiced during residency. Such training may encourage some clinicians to pursue specialized training in psychoanalysis and CBT or other interventions.