Andrew L. Foote, MD

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.

In 2001, the Residency Review Committee (RRC) mandated psychotherapy training for psychiatry residents.

 Before the RRC’s mandated curriculum, psychotherapy training was often “hit or miss” among residency training programs.

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.

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.

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.

 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.

 Randomized controlled trials and observational studies were included in this study, and treat-ments lasted for at least 1 year or 50 sessions. 

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.

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.

 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.

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.

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.

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.

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Recent reports have noted an alarming decrease in the practice of psychotherapy among psychiatrists. 

Andrew L. Foote, MD

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