This is this is the first of a two-part discussion on the importance of psychotherapy training. Part 2 explores seven goals to implement into psychotherapy education in medical school: A Critical Moment in Psychiatry: The Need for Meaningful Psychotherapy Training in Psychiatry. —Ed.)
Throughout its history, psychiatry, probably more than any other medical specialty, has dealt with periods of drastic changes and adaptation demands affecting the theory and practice of the specialty. This situation has ignited heated theoretical debates, ideological battles, and intercultural collisions.1,2 Crises of this nature may be inevitable in a field that deals with elusive and complex human problems: mental illnesses, their affective and behavioral expressions, and their biological, psychological, and socio-cultural roots.
Substantial tension has arisen repeatedly over the past two centuries between biomedical and humanistic-psychological approaches to defining disorders, understanding their causes, and organizing techniques and systems of clinical care.1,3 Changes in theories and practices have deeply affected the organization of the field and induced a variety of challenges that, arguably, are more frequent than in other medical specialties.
Psychotherapy in psychiatric training
A topic of current discussions across the world is the place and role of the psychotherapy theory and practice in psychiatric education and training.4-6 Near the third decade of the 20th century in the wake of a decisive historical marker that many authors called the first psychiatric revolution— the advent and development of psychoanalysis7,8—psychotherapy knowledge skills were more or less widely accepted as essential core components in educating medical students and future psychiatrists. Freud’s approach considered human suffering arising from emotional wounds triggered by family and society as a central factor in the development of many psychiatric disorders and, most importantly, supported its recognition, understanding, acceptance, and efforts at resolution as critical components of a successful clinical intervention.
Psychoanalysis (and later its psychodynamic modalities) won academic recognition and came to dominate psychiatric training programs in European and American medical schools.9,10 Since the mid-20th century, however, efforts to redefine and promote descriptive and biomedical/neuroscientific models of psychiatric diagnosis and treatment have gradually gained ground, strongly encouraged by the considerable therapeutic power of new psychopharmacological agents.11,12
There are two reasons to consider the topic of psychotherapy education:
1. There is an emerging tendency to make applied psychopharmacology the primary basis of psychiatric treatment. Missing in such an approach is a thorough assessment and subsequent knowledge of the complex experiences and circumstances of patients with psychiatric illness.12
2. Invoking financial and time-constraint reasons, some psychiatric training programs have moved away from providing specific psychotherapy training as a core component of the psychiatrist’s work.13,14
As part of this discussion, this article will explore the multiplication of psychotherapeutic schools and the vicissitudes of their curricular presence and practice, the historical oscillations between acceptance and rejection, and the factors contributing to one and the other.
Unsteadiness of the psychiatry-psychotherapy relationship
As previously noted, the first several decades of the psychoanalytic or psychodynamic revolution were marked by the relatively rapid acceptance of a perspective that promised plausible and clinically useful methods of describing, understanding, and treating mental illnesses. It was widely considered a liberating movement against earlier dogmatic and less tolerant approaches toward mental illness. However, this movement largely ignored a biomedical perspective, much needed epidemiological and psychopathological perspectives, as well as neuropathology and pathophysiological data. Not surprisingly, such an exclusively psychological and greatly subjective approach spawned many branches and led to considerable fragmentation and conflicts, probably explainable by some of the very ingredients the doctrine helped to unveil.8,15,16
Thus, the re-awakening efforts to establish a biomedical-based psychiatry and to understand the pharmacodynamics of effective psychiatric medications, together with the introduction of impressive new molecular, genetic, and neuroimaging technologies in the last decades of the 20th century, plus diagnostic systems guided by solid descriptive-phenomenological principles,17 provided significant support to a substantial improvement in psychiatric education and the practice of clinical psychiatry, despite leaving out many unfulfilled expectations.
Furthermore, greater dichotomizations in the field were paradoxically reinforced by advances in sociocultural disciplines and their connections with clinical psychiatry.18-20 These advances generated a healthy skepticism about biomedical concepts in psychiatry, but also contributed to confusion and ambiguity about an appropriate balance between scientific and humanistic considerations. Psychotherapy, as a concrete tool for the understanding of individual patients and their treatment, has suffered in the process.
The major change in practice patterns included a growing dependence on a rapid diagnostic assessment followed by selection of seemingly appropriate medicinal treatment. A largely unanticipated result was a diminished emphasis on the clinical importance to understand the uniqueness and complexity of individual patients. Additional major contributing factors were structural and economic considerations: fewer patients needed prolonged institutional care, and many could be evaluated quickly and then become subjects of occasional, brief follow-up visits.14,21
Similarly, the training of more non-medical mental health professionals—some with prescribing privileges (notably psychiatric nurse-specialists) and others with expertise in psychotherapy—provided more accessible and less expensive clinical services backed by controlled trials or tested protocols. It has become increasingly clear that these various practical and economic considerations have contributed to the diminishing role of psychotherapy as a dominant training aspect of contemporary clinical practice.
The case against psychotherapy training in psychiatry
It has been reported that psychiatric trainees who disagree with the need for psychotherapy training are a silent majority. Some observers note that only around 11% of outpatient psychiatrists continue to practice psychotherapy extensively after residency.¹⁴ It is further argued that general medical knowledge, training in biostatistics, and the assessment of research findings required for an evidence-based practice are increasingly essential components of psychiatric training.14, 22-25 Consequently, a substantial curtailment of the psychotherapy curriculum has taken place in some training centers—even to the point of entirely eliminating it in the early residency years—while sometimes offering alternatives that include psychotherapy training as an elective in the fourth year and an elective fifth year of psychotherapy fellowships.
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