Daniel Morehead, MD

In the spring, while the year was still young, 

 published a 7000-word essay entitled “Doctors Gave Her Antipsychotics. She Decided to Live With Her Voices.”

 Some of it recounted the tragic but ultimately heroic story of Caroline Mazel-Carlton, a woman with a long experience of auditory hallucinations who, after much 

, has become a powerful advocate for humane support and acceptance of those with similar experiences. The story, in the hands of author Daniel Bergner, is not hers alone, but rather the centerpiece of a quasi-editorial calling for a sea-change in psychiatric practice—a “fundamental paradigm shift” in our treatment of mental health.

Psychiatry Does Not Treat the Problem; Psychiatry Is the Problem—or Is It?

The story raises many complex issues, but the subtext woven through it will be familiar psychiatrists: Psychiatrists are “inflexible” and biological, maintaining a biomedical model of care that squelches all other approaches and stigmatizes patients with invalidating diagnoses. Claiming to be experts, psychiatrists wield a hierarchical authority that disempowers patients and causes them to avoid sharing their experiences for fear of being pathologized, controlled, and labelled with illness. This occurs not only in coercive involuntary treatment, but in “seemingly benign practitioner-patient relationships” that reduce patients to (you guessed it) “checklists of symptoms” rather than human beings. Psychiatrists then “pile up drugs” on suffering patients in “typical” fashion, inflicting terrible adverse effects in the process. And these drugs, as the story tells us, are “a resounding disappointment,” with “murky” evidence of efficacy and 

 like “pendulous breasts” in boys and young men.

Apparently, psychiatrists themselves have lost hope, as Bergner brings out the usual array of evidentiary exhibits: The history of biological psychiatry is a vast disappointment confronting “stark limitations,” while “something has gone wrong in contemporary… psychiatry,” according to even the 

. Finally, no negative portrayal of our field would be complete without Thomas Insel’s despairing assessment of his putatively fruitless tenure at the National Institute of Mental Health (NIMH) from 2002 to 2015, which failed to “move the needle” for better outcomes on behalf of those who actually suffer from mental illness.

What is the answer to this tragic mess? A new model practiced by Mazel-Carolton as well as a host of other organizations (at least 22) all over the world. These include the Afiya House and other similar peer-run houses, the Soteria model, and Mazel-Carolton’s own Hearing Voices Network. What is their approach? What should we do? Listen to individuals who have these symptoms. Do not judge individuals with these symptoms. Accept them as they are. Focus on “being with” instead of controlling them. Practice being “engaged, empathic, and curious.” Offer peer support—perhaps even AA-like support groups. In the process, rely less exclusively on medicines and more on community. Work for “mutual understanding and compromise.”

Does all of this shock you? Does it even surprise you? To me, it sounds strikingly like the way I was taught to be a psychiatrist. Empathy, understanding, and a nonjudgmental attitude were fundamental. We could never compel treatment—only the state had this power. Meanwhile, medicines were one among many treatments, but human connection, human community, and humane, respectful treatment were just as important. I was never trained to regard people as checklists of symptoms and never told that I should disregard or devalue their subjective experience. “Stop trying to fix your patients and just understand them!” This was the favored quote of my teachers from none other than Karl Menninger, one of the founders of modern American psychiatry, as well as the clinic where I trained.

The Grim Realities of Mental Health Treatment

And so, as a practicing psychiatrist, I carry these attitudes into treatment. I try to spend as much time listening to my patients as I possibly can. Treatment is always a mutual undertaking—an effort to find common ground as a common way forward. I offer my experience and expertise, and my patient does the same. We use medicine in an empiric fashion, going with what helps and getting rid of what does not. I recommend 

 for all my patients, with National Alliance on Mental Illness (NAMI) peer-support groups, online communities, self-education, and 12-step groups whenever appropriate.

Nevertheless, the realities of my subsequent career have at times been grim, and on many occasions desperate. Too many of my patients face unbearable anguish and life-threatening situations, with looming risks of suicidality, victimization, financial ruin, social ostracism, and jail. As their disease process advances, I try frantically to get them psychotherapy when most therapists avoid 

 (SMI); peer support, which is available sporadically at best; residential treatment when no insurance plan will pay for it; supported employment, which seems to only work for those who do not have SMI; and cognitive rehabilitation in the weak hope that it exists outside of medical journals.

Meanwhile, due to an overwhelming lack of resources, we do everything we can with pharmacotherapy, in the hope that some medication or combination of medications will make a substantial difference. And so, yes, a number of my severely ill patients have gotten loaded up on medications simply because their lives are hanging by a thread, and the only thread consistently supported by our system is 

What is my solution to all this? I’ll bet mine is the same as yours: Get serious about paying for true biopsychosocial treatment. You do not get something for nothing in this life, and you will not address chronic illnesses with pitiful crumbs of minimalist treatment that cost you little to nothing.

Meanwhile, while we wait for the fantasy of fully funded treatment to materialize, I would bet that we psychiatrists can heartily recommend the following: Let’s stop fighting amongst ourselves as a mental health movement. Let’s get rid of the binary of evil biological psychiatrist on one hand and nice people who like psychosocial treatment on the other. Let’s stop the false dichotomy of medications 

 peer support. How about we do all of the above, depending on what works best for each person? How about demanding support for the best biological, the best psychosocial, and the best peer-supported treatment as minimum acceptable treatment? How about realizing we are all on the same side, rather than either demonizing psychiatrists or ignoring the voices of those with mental illness?

And one more thing: Let’s stop implying that diagnosing a mental illness is invalidating and shaming to patients. Because that is exactly the same thing as 

 that having a mental illness is invalidating and shaming. It is not. It is simply part of being human.

 is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of 

Science Over Stigma: Education and Advocacy for Mental Health

, published by the American Psychiatric Association. He can be reached at 

1. Bergner, D. Doctors gave her antipsychotics. She decided to live with her voices. 

. May 17, 2022. Accessed September 14, 2022. 

https://www.nytimes.com/2022/05/17/magazine/antipsychotic-medications-mental-health.html

Articles

Let’s stop fighting amongst ourselves as a mental health movement and focus on biological as well as psychosocial treatment. 

Are Psychiatrists Pill Pushers? 

A frequent criticism of psychiatry is that psychiatrists do not learn, practice, or value psychotherapy. Even critics within the field routinely complain that psychiatry has “lost its mind,”

 whereas outside critics frequently portray toxic biological psychiatrists in competition with humane psychotherapists from other disciplines.

 The psychiatrist, as the story goes, is interested only in diagnosing and medicating patients—not in understanding, supporting, or working psychotherapeutically with them. This story, widely reported as fact in the media,

 is an outdated, harmful myth—one that discounts the realities of psychiatric training, the complexity of the psychiatric treatment relationship, and the resurgence of interest in psychotherapy among psychiatry residents.

In the mid-20th century, psychotherapy was the treatment of choice for most mental disorders. Even after the development of the first effective psychotropic medications in the 1950s and 60s, psychotherapy remained the mainstay of psychiatric treatment, especially in the psychoanalytically dominated United States. By the late 1980s, however, the field had shifted in a biological direction. The development of selective serotonin reuptake inhibitor antidepressants in particular led to great excitement in the promise of biological investigation and treatment. Nevertheless, psychotherapy continues to be practiced by psychiatrists, with some devoting their academic and clinical careers to the study and practice of psychotherapy.

The idea that psychiatry is divorced from psychotherapy is, in fact, divorced from reality. Here are 4 fundamental examples of the union between psychiatry and psychotherapy.

1. Psychiatry residents receive significant formal instruction in psychotherapy.

One of us (DM) is director of residency training at a psychiatry department in the Northeast; the other (MR) teaches in that program and serves as codirector of the psychotherapy track for a psychiatry residency program in Florida. As such, we have direct knowledge of the quality and extent of training psychiatry residents receive in psychotherapy. By contrast, most critics of psychiatry do not teach in psychiatry departments and have little to no firsthand knowledge of psychiatric residency curriculum.

Training in supportive, psychodynamic, and cognitive-behavioral psychotherapy is nationally mandated for all psychiatry residents.

 Residents must also learn to integrate psychotherapy with psychopharmacology and spend substantial time practicing psychotherapy during their outpatient training. They attend several yearlong didactic courses in psychotherapy and are individually assigned psychotherapy supervisors (many of whom are psychiatrists). Didactic instruction typically covers a range of psychotherapy topics, such as case clinical formulation, transference, countertransference, and psychotherapeutic technique. Clinically, residents see patients for short-term and longer-term psychotherapy treatments.

Approximately a quarter of psychiatry residencies also offer specific psychotherapy tracks for residents with particular interest in psychotherapy and for those who plan to pursue additional training in specific psychotherapies (eg, psychoanalytic training) postresidency.

 Many individuals, even mental health professionals, assume psychotherapy training is weaker for psychiatry than for other mental health disciplines such as psychology and social work. Yet a national survey published in 2006 showed that psychiatry compared favorably to other disciplines for evidence-based forms of therapy training.

 Thus, the claim that psychiatrists do not learn psychotherapy is false.

2. Psychotherapy is a part of almost all clinical interactions.

Although most psychiatrists nowadays do not offer traditional 45-minute or 60-minute psychotherapy appointments to all their patients,

 psychotherapy continues to be practiced in some form by most psychiatrists. From a psychodynamic perspective, every interaction between doctor and patient, even in the hospital setting, is an opportunity to relate to the patient psychotherapeutically. Sudak and Taormina

 have described the integration of cognitive-behavioral therapy into medication management visits, and Iannitelli et al

 have recently discussed the application of psychodynamic principles during psychopharmacological treatment.

Undoubtedly, most psychiatrists engage in some supportive psychotherapy even during brief visits and even if they do not formally label or bill the sessions as such. Moreover, in their study, Tadmon and Olfson10 found that 47% of psychiatrists continue to offer 45-minute to 60-minute psychotherapy sessions to patients. Thus, claims that psychotherapy has simply disappeared from psychiatric practice are false.

3. In the past decade, there has been a resurgence of interest in psychotherapy and psychosocial approaches among psychiatry residents.

A 2012 survey of residents reported that 82% of them consider “psychotherapy to be integral to their identity as psychiatrists.”

 Another survey showed that residents want more psychotherapy training rather than less.

 Our experience matches the results of such research. In fact, we have observed an increasing number of psychiatry residents interested in learning and practicing psychotherapy during the past decade.

In recent years, psychiatry has become a popular and competitive specialty choice among medical students, who describe their interest in learning the art of engaging deeply with suffering patients and combining psychosocial treatments with biological interventions. Many residents are particularly eager to learn psychotherapy methods and rightfully view psychotherapy as a core, foundational skill in the practice of clinical psychiatry. Meanwhile, some professional organizations are specifically devoted to the advancement of psychotherapy training within psychiatry, such as the American Academy of Psychodynamic Psychiatry and Psychoanalysis.

4. Many leading psychotherapy scholars are psychiatrists, and this has been the case for decades.

Some of the leading figures in American and global psychotherapy are psychiatrists, including Otto Kernberg, MD; Glen Gabbard, MD; and the recently deceased Aaron Beck, MD, father of cognitive-behavioral therapy. Several psychiatrists who are leading researchers in psychopharmacology have also undertaken research validating medical psychotherapy.

 Psychiatrists make up a significant percentage of membership of the American Psychoanalytic Association. They are also frequent presenters at national psychotherapy conferences and contributors to psychotherapy journals. The American Journal of Psychotherapy, a leading journal of psychotherapy theory and practice, is a journal of the American Psychiatric Association. Thus, the psychiatric profession remains integral to psychotherapy development and research.

Psychotherapy continues to be a core aspect of psychiatrists’ training and identity. Psychotherapy training also continues to be a substantial and mandatory component of residency training for all psychiatrists. Contrary to popular assumptions, it is not critical that all psychiatrists conduct traditional psychotherapy as part of their practice. No one becomes alarmed if all cardiologists do not practice cardiac catheterization, and no one should worry that “only” half of all psychiatrists currently offer traditional 45-minute psychotherapy sessions. But all psychiatrists should continue to support psychotherapy’s place in mental health treatment and in the holistic, biopsychosocial treatment that psychiatrists routinely offer.

For decades, critics and leading psychiatrists have worried that psychotherapy among psychiatrists will one day die out and be forgotten. Yet for decades, reports of its demise have been greatly exaggerated.

 is an instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and an adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is a psychoanalytic psychotherapist in private practice in Tampa, Florida.

is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association.

Unhinged: The Trouble with Psychiatry—A Doctor’s Revelations about a Profession in Crisis.

Of Two Minds: An Anthropologist Looks at American Psychiatry.

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill.

5. Harris G. Talk doesn’t pay, so psychiatry turns instead to drug therapy. 

https://www.nytimes.com/2011/03/06/health/policy/06doctors.html

6. Psychiatry: Program requirements and FAQs. Accreditation Council for Graduate Medical Education. Accessed May 4, 2022. 

https://www.acgme.org/specialties/psychiatry/program-requirements-and-faqs-and-applications/

Psychotherapy tracks in US general psychiatry residency programs: a proxy for trends in psychotherapy education?

8. Weissman MM, Verdeli H, Gameroff MJ, et al. 

National survey of psychotherapy training in psychiatry, psychology, and social work.

Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016.

Integrate brief CBT interventions into medication management visits.

12. Iannitelli A, Parnanzone S, Pizziconi G, et al. 

Psychodynamically oriented psychopharmacotherapy: towards a necessary synthesis.

13. Lanouette NM, Calabrese C, Sciolla AF, et al. 

Do psychiatry residents identify as psychotherapists? A multisite survey.

Psychotherapy training: residents’ perceptions and experiences.

Biological v. psychosocial treatments: a myth about pharmacotherapy v. psychotherapy.

16. Miklowitz DJ, Efthimiou O, Furukawa TA, et al. 

Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis.

A frequent criticism of psychiatry: psychiatrists do not learn, practice, or value psychotherapy. Is it true? 

Psychiatry and Psychotherapy: The Great Divorce That Never Happened

The shocking thing about psychiatric treatment is that it works. If you are a mental health professional, this “news” will not surprise you at all. But if you are someone outside our field, the news will come as a genuine revelation. And if you are a reader of periodicals such as 

, you will be stunned to learn that the following assertion is true: 

Psychiatric treatments are comparable to those in other branches of medicine.

 By this I mean that we have mental health treatments that are generally equal to the rest of medicine in scientific support, efficacy, and safety. Are our treatments perfect? Hardly. But they are fully in line with the rest of medicine.

I do not blame laypeople for believing that our treatments are ineffective or dangerous. There is a steady stream of books proclaiming this to be true,

 along with prominent articles such as, “How Much Do Antidepressants Help, Really?”

 and “Doctors Gave her Antipsychotics. She Decided to Live With Her Voices.”

 hardly represent antipsychiatry, they articulate a not-so-sneaking suspicion that there is something uniquely wrong with psychiatric treatments. Do they really work, 

 Aren’t they dangerous and toxic in the end? Wouldn’t we be better off without them, coping for ourselves rather than depending on pills and therapists?

Even nonpsychiatric physicians, who understand the reality of mental illness quite well, seem to be sympathetically doubtful of our ability to help. I remember talking to a neurologist friend who declared that he could never be a psychiatrist because it was “too depressing to see people come back time after time with the same problems.”

“Wait a minute,” I replied. “Don’t neurologists mostly treat things like strokes, multiple sclerosis, migraines, and seizures? These do not just go away with treatment.” This prompted an explanation from him about how meaningful it was to work with patients over the long term and see improved adjustment and quality of life. “Yeah,” I said, “that’s what we do in psychiatry.” But I was wrong. We do so much more than that in psychiatry.

The old argument is that we in psychiatry do not have cures for mental illnesses. And this is true. But it is also true of the other chronic illnesses that constitute our major public health problems in this country. Although we do have cures for many 

 illnesses like appendicitis and otitis media, we lack these for most 

 illnesses. We cannot cure heart disease, and we cannot cure diabetes. We do not have cures for high blood pressure, strokes, or most kinds of cancer either. Why is no one in despair about this? Why do we not see regular articles like, “Doctors Gave Her Antihypertensives. But She Decided to Live with High Blood Pressure”? The reason is that we have good treatments for all these chronic health conditions, and using such treatments is not a matter of galvanizing public debate. Yet precisely the same thing applies to the major mental illnesses that—for no legitimate reason—remain a matter of galvanizing public debate. We generally do not cure psychiatric illnesses. But we have good treatments for them all, and no one should despair of getting help.

How do we know this? In 2012, Leucht and colleagues conducted a major meta-analysis for the purpose of comparing psychiatric medicines to medicines commonly used in primary care.

 They combined the results of 94 independently published meta-analyses on both types of medications. They compared effect sizes to evaluate the overall difference between psychiatric and other commonly prescribed medications. The meta-analyses included common general medical conditions such as asthma and type 2 diabetes, and common psychiatric conditions such as schizophrenia and major depression. In all, medications for 20 general medical diseases and 8 psychiatric disorders were compared.

The result: There was no statistically significant difference in effect sizes between the 2 groups. On average, psychiatric medications were moderately effective (with a mean effect size of 0.49), just as medicines for other common medical conditions were moderately effective (with a mean effect size of 0.45). In other words, the prescriptions that patients carry out of a psychiatrist’s office are, on average, just as likely to help them as the prescriptions they take out of their primary care offices.

Psychiatric treatments work. Psychiatric medications work. And psychotherapy works as well. The past 30 years have seen an unheralded revolution in psychotherapy research. Commonly derided as unscientific “psychobabble” in the 1970s and 1980s, well-established forms of psychotherapy have now been scientifically validated in hundreds of published studies. Cognitive behavioral therapy (CBT),

 and various forms of psychodynamic psychotherapy

 are well-substantiated as treatments of common mental illnesses. And there is evidence that the medications and psychotherapy work better in tandem than individually, at least in the case of major depression.

 Moreover, we have less prominent but nevertheless empirically supported treatments such as psychoeducation, mindfulness, exercise, and peer support groups.

 We mix and match these medically legitimate treatments to our patients’ needs and preferences. This, in reality, is what psychiatric treatment looks like.

Contrary to the assumptions of our public intellectuals and media thought leaders, there is no lack of proven treatments for psychiatric illnesses. We can offer an array of scientifically supported treatments for all the major mental illnesses. What we lack is not an effective set of treatments, but a cure for the hearsay that feeds the ignorance, anxiety, and irrational skepticism of our public. What can we do? Speak up. As the only group of individuals who deeply understand the efficacy of mental health treatment, it falls upon us to thoroughly educate ourselves, our patients, their families, our advocacy organizations, and our communities. As always, good news is hard to sell. But reality is on our side, and this should be enough.

is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of

 Science Over Stigma: Education and Advocacy for Mental Health

, published by the American Psychiatric Association. He can be reached at

Lost Connections: Uncovering the Real Causes of Depression – and the Unexpected Solutions

2. Moyer MW. How much do antidepressants help, really? 

. April 21, 2022. Accessed June 22, 2022. 

https://www.nytimes.com/2022/04/21/well/antidepressants-ssri-effectiveness.html

3. Bergner D. Doctors gave her antipsychotics. She decided to live with her voices. 

https://www.nytimes.com/2022/05/17/magazine/antipsychotic-medications-mental-health.html#:~:text=Gave%20Her%20Antipsychotics.-,She%20Decided%20to%20Live%20With%20Her%20Voices.,medication%20and%20toward%20greater%20acceptance

4. Leucht S, Hierl S, Kissling W, et al. 

Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses.

5. Hofmann SG, Asnaani A, Vonk IJ, et al. 

The efficacy of cognitive behavioral therapy: a review of meta-analyses.

Dialectical behavior therapy is effective for the treatment of suicidal behavior: a meta-analysis

7. Leichsenring F, Luyten P, Hilsenroth MJ, et al. 

Psychodynamic therapy meets evidence-based medicine: a systematic review using updated criteria.

8. Cuijpers P, Noma H, Karyotaki E, et al. 

A network meta‐analysis of the effects of psychotherapies, pharmacotherapies and their combination in the treatment of adult depression.

Science over Stigma: Education and Advocacy for Mental Health

. American Psychiatric Association Publishing; 2021:151ff.

Is There a Cure for Ignorance? The Shocking Truth About Psychiatric Treatment

A frequent criticism of psychiatry is that psychiatrists do not learn, practice, or value 

. Even critics within the field routinely complain that psychiatry has “lost its mind,”

 while outside critics frequently portray “toxic” biological psychiatrists in competition with with humane psychotherapists from other disciplines.

 The psychiatrist, as the story goes, is interested only in diagnosing and medicating the patient—not in understanding, supporting, or working psychotherapeutically with him or her. This story, widely reported as fact in the media,

 is an outdated and harmful myth—one that discounts the realities of psychiatric training, the complexity of the psychiatric treatment relationship, and the resurgence of interest in psychotherapy among psychiatry residents.

In the mid-20th century, psychotherapy was the treatment of choice for most mental disorders. Even after the development of the first effective 

 in the 1950s and 60s, psychotherapy remained the mainstay of psychiatric treatment, especially in the psychoanalytically dominated United States. By the late 1980s, however, the field had shifted in a biological direction. The development of selective serotonin reuptake inhibitor (SSRI) antidepressants, in particular, led to great excitement in the promise of biological investigation and treatment. Nevertheless, psychotherapy continues to be practiced by psychiatrists, with some psychiatrists devoting the entirety of their academic and clinical careers to the study and practice of psychotherapy.

The idea that psychiatry is currently divorced from psychotherapy is, in fact, divorced from reality. Here are 4 fundamental examples of the union between psychiatry and psychotherapy:

One of us (DM) is director of residency training at a psychiatry department in the northeast, and the other (MR) teaches in that program and also serves as codirector of the psychotherapy track for a psychiatry residency program in Florida. As such, we have direct knowledge of the quality and extent of training psychiatry residents receive in psychotherapy. By contrast, most critics of psychiatry do not teach in psychiatry departments and have little to no firsthand knowledge of psychiatric residency curriculum.

 Residents must also learn to integrate psychotherapy with 

 and spend a substantial amount of time practicing psychotherapy during their outpatient training. They attend several year-long didactic courses in psychotherapy and are individually assigned psychotherapy supervisors (many of whom are psychiatrists themselves). Didactic instruction typically covers a range of psychotherapy topics, such as case clinical formulation, transference, countertransference, and psychotherapeutic technique. Clinically, residents see patients for both short-term and longer-term psychotherapy treatments.

Approximately 1 quarter of psychiatry residencies also offer specific psychotherapy tracks for residents with particular interest in psychotherapy and for those who plan to pursue additional training in specific psychotherapies (eg, psychoanalytic training) postresidency.

 Many individuals, even mental health professionals, assume psychotherapy training is weaker for psychiatry than for other mental health disciples such as psychology and social work. Yet a national survey conducted in 2006 showed that psychiatry compared favorably to other disciplines for evidence-based forms of therapy training.

While it is true that most psychiatrists nowadays do not offer traditional 45- or 60-minute psychotherapy appointments to all their patients,

 have described the integration of cognitive-behavioral therapy into “medication management” visits, and Iannitelli and colleagues

Undoubtedly, most psychiatrists engage in some supportive 

 during brief visits, even if they do not formally label or bill it as such. Moreover, Tadmon and Olfson

 found that 47% of psychiatrists continue to offer 45- to 60-minute psychotherapy sessions. Thus, claims that psychotherapy has simply disappeared from psychiatric practice are false.

Some of the leading figures in American and global psychotherapy are psychiatrists, including Otto Kernberg, MD; Glen Gabbard, MD; and the recently deceased 

Aaron Beck, MD, father of cognitive-behavioral therapy.

 Several psychiatrists who are leading researchers in psychopharmacology have also undertaken research validating medical psychotherapy.

 Psychiatrists comprise a significant percentage of membership of the American Psychoanalytic Association. They are also frequent presenters at national psychotherapy conferences and contributors to psychotherapy journals. 

a leading journal of psychotherapy theory and practice, is a journal of the American Psychiatric Association. Thus, the psychiatric profession remains integral to psychotherapy development and research.

Psychotherapy continues to be a core aspect of psychiatrists’ training and identity. Psychotherapy training also continues to be a substantial and mandatory component of residency training for all psychiatrists. Contrary to popular assumptions, it is not critical that all psychiatrists practice traditional psychotherapy as part of their practice. No one becomes alarmed if all cardiologists do not practice cardiac catheterization, and no one should worry that “only” half of all psychiatrists currently offer traditional 45-minute psychotherapy sessions. But all psychiatrists should continue to support psychotherapy’s place in mental health treatment, and its place in the holistic, biopsychosocial treatment that psychiatrists routinely offer.

For decades, both critics and leading psychiatrists have worried that psychotherapy among psychiatrists will one day die out and be forgotten. Yet for decades, reports of its demise have been greatly exaggerated.

is instructor of psychiatry at the University of Central Florida College of Medicine in Orlando and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston. He is a psychoanalytic psychotherapist in private practice in Tampa. He can be reached at 

is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of 

Science Over Stigma: Education and Advocacy for Mental Health, 

published by the American Psychiatric Association. He can be reached at 

Of Two Minds: An Anthropologist Looks at American Psychiatry. 

Mad in America: Bad Science, Bad Medicine, and the Enduring Mistreatment of the Mentally Ill. 

6. ACGME program requirements for graduate medical education in psychiatry. 2021. Accessed May 4, 2022. 

National survey of psychotherapy training in psychiatry, psychology, and social work. 

Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016. 

Psychodynamically oriented psychopharmacotherapy: towards a necessary synthesis. 

Do psychiatry residents identify as psychotherapists? A multisite survey. 

Psychotherapy training: residents’ perceptions and experiences. 

Biological v. psychosocial treatments: a myth about pharmacotherapy v. psychotherapy. 

Adjunctive psychotherapy for bipolar disorder: a systematic review and component network meta-analysis. 

Psychotherapy: A Core Psychiatric Treatment

Psychiatry as a medical discipline is a failure. Even worse, psychiatry constitutes a series of failures over its 2-century history. The 19th-century asylums movement failed. Kraepelin’s descriptive psychiatry failed at the turn of the century. The pluralistic psychiatry of Adolf Meyer failed, leading an 

 mentality up to and including lobotomies. The Freudian revolution ended in a “slow train wreck,”

 leaving psychiatry in embarrassing disrepute. And last of all, psychiatry’s so-called biological revolution fizzled out in failure, as drug companies abandoned a profession “in crisis.”

Just Because We Do Not Know Everything Does Not Mean We Do Not Know Anything

The DSM: Diagnostic Manual or Diabolical Manipulation?

Who says so? The writer of the most highly lauded and widely read history of psychiatry today, Professor Anne Harrington, PhD. The name of that history is 

 And as histories of medical specialties go, Harrington’s work is an undisputed home run. 

 and every major periodical in the country reviewed it favorably. Former National Institutes of Health Director Steven Hyman, MD, offered a back-cover blurb, and 

™ opined that “every psychiatrist should read it.”

Is the book really as negative as I have described? Yes and no. On one hand, Dr Harrington is a skillful writer who is clearly fluent in social and intellectual history. Reading this work was like diving into an extended 

 piece, such that “enthralling” is not an unfair description. And as the back cover tells us, Dr Harrington’s work is even-handed—at least on the surface. It is neither a polemic nor an exposé. Harrington takes a mostly agnostic approach to the controversies surrounding the field, speaking with a sort of sympathetic irony about psychiatry’s misadventures. And to her credit, she regularly empathizes with the perspective of patients and families, whether it is their suffering, their sense of mistreatment, or their sense of gratitude for successful treatment.

So, what is my beef with this universally lauded work? My problem is with its metanarrative, which is neither balanced nor accurate, whose misleading take-home message perpetuates a destructive picture of the state of our field. By giving our intelligentsia the impression that psychiatry is directionless and fundamentally inept, Dr Harrington inadvertently reinforces a cynicism about mental health treatment that is sadly out of date, and a despair about progress that undermines the hopes of individuals with mental illness and their families. In short, she reinforces the notion that psychiatry is particularly prone to corruption, “troubled,” and “in crisis,”

 a notion that continues to do damage to public mental health and public support of mental health treatment.

Does Dr Harrington really describe our history as a series of failures? Consider her own summary

“The 19th-century mental hospital has failed as a therapeutic institution? All right, forget about therapy, and focus on learning what you can from the brains of your patients… The anatomical research program has been a disappointment? No problem: Focus instead on… [Adolf Meyer’s pluralistic and pragmatic psychiatry. Does this lead to] more harm than good? That’s okay: The postwar world is in crisis and needs the insights provided by psychoanalysis and social science. Things haven’t worked out with the Freudians’ expansive social agenda? Psychiatry is on the brink of losing all credibility as a profession? Not to worry: Let the biologists take over!”

And the “false dawn” of the biological revolution? It has “now run into the sand as well,” leaving psychiatry shipwrecked and (you guessed it) “in crisis.”

Given this narrative, does our author truly believe that there has been no progress in psychiatry? In a 

™ interview, Dr Aftab put the question to her, suggesting that there has been a combination of progress 

 failed revolutions in psychiatry. In response, Dr Harrington doubled down on her narrative, stating that new generations of psychiatrists simply discard the lessons of the past. Even as new approaches uncover new truths, old truths and lessons are forgotten. Psychiatry remains locked in a barren cycle of becoming “more knowledgeable about some things and more ignorant about other things” through revolution after revolution.

In truth, Dr Harrington’s meta-narrative is demonstrably false. The asylum movement did not fail. It constituted a sustained advance over previous desperate and barbaric responses to severe mental illness, with a genuine effort to provide humane and helpful care. It declined only due to scandalous underfunding and the appearance of effective pharmacological agents. The neuroanatomical psychiatry that followed did not fail. Neuroanatomical research became a permanent and increasingly important aspect of psychiatric science, and it continues to progress along with the rest of 

Kraepelinian psychiatry—a longitudinal and symptomatic perspective on nosology—continues to be fundamental for psychiatric diagnosis and will remain so until neurobiological disease categories replace it. Psychodynamic (Freudian) psychiatry continues to thrive, along with numerous other scientifically validated psychological treatments (including 

 and dialectical behavior therapy). Indeed, psychotherapeutic approaches to mental illness are now better developed and tested than at any time in the history of psychiatry. Biological psychiatry did not die or even fade during the last decade. It continues to progress, as even a casual glance at any recent issue of a major psychiatric journal will show.

None of the lessons of the major schools of psychiatry have been abandoned. All these approaches have continued to advance and become parts of a larger whole. All psychiatry residents still receive extensive training in inpatient care (asylum psychiatry), neurobiology (anatomical psychiatry), 

 and diagnosis (Kraepelinian psychiatry), biopsychosocial treatment (Meyer’s psychobiology), 

 (Freudian psychiatry), and of course biological psychiatry. All of these are alive and well, so much so that Dr Harrington’s inability to acknowledge their survival and growth begins to appear perplexing, if not bizarre.

It does not take a great deal of reflection to recognize profound progress in psychiatry. Seventy-five years ago, there were no specific psychiatric medications, and the average stay in a psychiatric hospital was 11 years.

 Fifty years ago, psychotherapy was scientifically unproven while available medications were extremely difficult to tolerate. Regardless of psychiatry’s shortcomings, today is beyond a doubt the best time in human history for patients and families who face mental illness. If public intellectuals such as Dr Harrington are unwilling to say so, then we as psychiatrists should not be shy about setting the record straight. Failure to acknowledge psychiatry’s progress might be, after all, the most destructive failure of all.

The author wishes to thank Ronald W. Pies, MD, and Mark L. Ruffalo, DPsa, LCSW, for their review and comments on an earlier draft of this article.

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