After reading Dr Daniel Carlat’s heartfelt piece in the April 19, 2010, New York Times Magazine (“Mind Over Meds”), I was struck by several things. The first was Dr Carlat’s eloquence regarding the dilemmas of psychiatric practice. Second was how his experience may represent a generation of psychiatrists who were trained during an era of drug discovery wrapped in the exciting promise of “Biological Psychiatry.” Dr Carlat quotes prominent Harvard psychiatrist Leon Eisenberg in a trenchant summary of the 20th century as psychoanalytically oriented and “brainless” in its first half and “mindless” in its second half (characterized by “our current love affair with pills”).
Dr Carlat was trained at the Massachusetts General Hospital (MGH), long-time Mecca of psychiatric research and training. His entry into practice during the pharmaceutically pivotal 1990s may explain why he and many others are unfamiliar with the ongoing evolution of psychiatric training and practice outside MGH.
Yet Dr Carlat himself points out that in a study published at the end of that same decade, Dr Mantosh Dewan from our department at SUNY Upstate Medical Center used data supplied by insurance companies to demonstrate that when patients received both psychotherapy and drug therapy from the same psychiatrist, they required fewer sessions and had less total cost than when the treatment was split with non-MD psychotherapists.1
One limitation on retaining psychotherapy in the psychiatry curriculum is the time and expense of teaching it. While one can essentially read about advances in pharmacology and then incorporate them into practice, simply reading about psychotherapy doesn’t lead to competence. Adequate training in psychotherapy requires training manuals, demonstrations by master practitioners, intensive supervision, and moment by moment coaching of sessions with patients. Including psychotherapy training in the curriculum confronted training programs with the added need to devise ways beyond multiple choice exams to evaluate trainee competence—an expensive proposition.
In addition to the advent of biological psychiatry, the 1980s saw the rise of manual-based psychotherapies, such as Cognitive Behavioral Psychotherapy (CBT), Dialectical Behavior Therapy (DBT), and Interpersonal Therapy. Subjected to randomized controlled trials, these therapies proved as effective as drug treatment—often more so when combined with medication. Without the lavish support of drug companies and advertising, and with the added push of skewed fee schedules constructed by behavioral health managed care companies, patients remained relatively unaware that these psychotherapies could often be administered by their prescribing psychiatrists. Notwithstanding psychotherapy’s low profile and substantial training costs, many programs saw it as an important part of psychiatry’s heritage as well as an integral part of the psychiatrist’s therapeutic arsenal. Some psychiatry program directors became concerned that psychiatrists might lose both the ability to practice psychotherapy and the window of understanding it provides into the human condition. Consequently, they lobbied the Accreditation Council of Graduate Medical Education to require the teaching of psychotherapy in all residency training programs. They accomplished this in 2001 when the overhauled Program Requirements were published mandating that all programs demonstrate trainee competence in 5 broad kinds of psychotherapy.
Many programs meet this requirement with light attention to the process of learning psychotherapy, farming it out to 1 or 2 psychologists whom they pay to give lectures and carry a few treatment cases. By contrast, in programs like ours—which has always valued psychotherapy—there is a more extensive infrastructure in which to learn psychotherapy. For example, webcams in every office enable supervision and review of all cases. The files stream directly to a server where only the resident or supervisor can gain access to them. (Patients’ consent for recording for educational purposes is of course required.) We also use Lambert and Burlingame’s patient outcome questionnaire, the OQ45, which the patient completes before every session. This gives residents feedback on how the patient is progressing and provides warnings of suicidal or homicidal ideation, substance abuse, and impending failure of therapy. This questionnaire may be used with any type of therapy, and with most diagnoses.2
Finally, our program devotes an unusual amount of time to teaching psychotherapy, starting in the first year (PG1) with a weekly, 2-hour seminar. This is aimed at developing a therapeutic attitude and approach to all patients as well as assigning individual psychotherapy mentors. In the second year (PG2), trainees complete a 6-month course on Learning Psychotherapy, which introduces them to processes common to all evidence-based psychotherapies.3 PG2 trainees then progress to a 5-month seminar on CBT.
Robert Gregory, MD, our director of psychotherapy, conducts weekly seminars throughout the 45 weeks of the PG2 year on Biopsychosocial Formulation.4 Other courses include a 12-week seminar on Family Systems and Therapy with Carl Whitaker’s former co-therapist, David Keith, MD, and seminars on Systems-Centered Psychotherapy (SCT).5
In the 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, conducted by our Chairman Emeritus, Eugene Kaplan, MD. This is “topped off” in the PG4 year with sessions in Post-Freudian Personality Theory and Solution-Focused Therapy.6 Residents may also take electives in any of 3 Group Therapies (CBT, DBT, or SCT); Robert Gregory’s Dynamic Deconstructive Psychotherapy; or Family Therapy with David Keith, MD.
The development of manual-based psychotherapies, advanced recording technologies, and sophisticated tools for evaluating therapists’ performance and patients’ outcome have all enhanced our ability to bring a new generation of psychiatrists to competence in several psychotherapies before they complete their training. One can only imagine how someone of Dr Carlat’s eloquence and sensitivity could have enriched his psychotherapy training had he been exposed to a similar environment.
References1. Dewan M. Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry. 1999;156:324-326.