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“Is there one state-of-the-art treatment for depression? No, that was the dilemma I faced in trying to prepare for this talk,” Sidney Zisook, MD, told attendees at the 

“There is no state-of-the-art treatment because 

 [MDD] is such a broad, diverse, heterogeneous group of symptoms,” explained Zisook, who is distinguished professor at the University of California, San Diego, and a previous recipient of the 

. “In fact, there are 227 possible combinations of symptoms that will allow a person to meet the DSM criteria for major depressive disorder. And, in addition to the symptomatic heterogeneity, there are a host of other issues that affect this: severity—mild symptoms versus very severe problems; clinical features—are there anxious features, atypical features, or melancholic features? All of these may lead us to different approaches that we may take with that patient.”

Because of this heterogeneity and the many combinations, there are a number of issues and features that should be assessed for each patient. Zisook discussed a recent review that revealed 14 key areas: symptom profile, clinical subtypes, severity, neurocognition, functioning and quality of life, clinical staging, personality traits, antecedent and concomitant psychiatric conditions, physical comorbidities, family history, early and recent environmental exposures, protective factors, resilience, and dysfunctional cognitive schema.

Thus, the best care practice—which is really what makes for state-of-the-art treatment for MDD—begins and continues with a thorough history, Zisook said. “A really thorough history begins with lab studies, physical exam, etc,” he said. “But the initial assessment isn't enough. We want to repeat the workup for patients who aren't doing well over time. I can't tell you how many times in my career, when I redid my initial assessment 6 months down the line and somebody wasn't having a good response, how different that history was and how I now—for the first time—learned about their drinking history and the cocktails they had every night. Or their early life trauma that was very much affecting their day-to-day life as an adult, etc. So not only do you do good assessment to begin with, repeat it intermittently as you have a better relationship with the patient to get a better, fuller picture of who they are.”

This includes checking for coocurring conditions and ensuring treatment for those conditions, too, Zisook said.

Similarly, he said it is important to use measurement-based care to inform decisions. “Several studies

 have found that if you measure symptoms, if you measure side effects, even with a global side effect measure along the way, share those with the patients, and develop a diary of symptoms and tolerance, you'll actually end up with better results,” Zisook reported.

Then, clinicians should dip into the wide variety of choices from what he called the “2022 Antidepressant Tool Kit.” In terms of medications, Zisook said all FDA-approved antidepressants (ie, tricyclics, monoamine oxidase inhibitors, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, serotonin modulators, and atypical antidepressants, and novel nonmonoamines) are equally effective with some differing adverse effects.

When discussing medication treatment personalization, the topic of 

 often comes up, said Zisook. “There was a lot of excitement about pharmacogenetic testing a few years ago, a lot of that excitement has died down, because it hasn't really proven to have a dramatic impact on our ability to personalize medications,” he told attendees.

However, testing can provide information on the genes involved in the metabolism of antidepressants (eg, CYP2D6, 2C19, 1A2, 2C9, 342, and 2B6), how the drug may be metabolized in patients, and whether the medications should be used as usual, with caution, or with extra caution and increased monitoring. “If they [patients] are a very poor metabolizer, they may end up with a very high dose of the medication that you're providing in their system, and they may be more prone to significant side effects adversity and tolerance, etc. You may need to go slower or lower or avoid certain medications,” he advised attendees.

Brain stimulation options (ie, bright light therapy, electroconvulsive therapy, transcranial magnetic stimulation, and vagus nerve stimulation) are also effective strategies in the tool kit, he noted.

Furthermore, Zisook reminded attendees not to overlook the 

. “A recent survey showed only about 20% of psychiatrists do psychotherapy in their offices, even though we all know that psychotherapy plus meds better than meds alone.”

Lifestyle aids, like exercise, are also important, he noted. “I tell all my patients, ‘When you're feeling more energetic, when you're up to it, start exercising. Get out of the house, take advantage the sunlight.’ They may not be able to do it initially. But I plant the seed early on and go back to it.”

The therapeutic alliance is key, Zisook said, and sometimes may be overlooked. He shared results from an NIMH study that found psychiatrists can “augment the effects” of both the medications as well as placebo.

“Those patients who had the best results even with placebo were the ones that maximized the nontherapeutic, nonspecific factors that are common to psychotherapy that's effective, like developing a therapeutic alliance: getting a trustful, empathetic, and collaborative relationship with a patient,” he said.

“Take advantage of those factors—and yourself,” Zisook advised. “This may mean spending more than 20 minutes with a patient. It may mean seeing their family. It may mean talking about their life independent of their depressive symptoms. But that relationship is critical in helping many of our patients get better.”

Zisook concluded by reminding attendees of their network of support, and the importance of engaging colleagues as needed. “Never worry alone,” he said. “It's always so nice when you're treating people with depression—especially difficult to treat depression—to have a colleague, other people that you can work with, you can consult with, to talk about patients. And I've always found that a critical part of my overall practice.”

The clinical characterization of the adult patient with depression aimed at personalization of management. 

2. Rush AJ, Sackeim HA, Conway CR, et al. 

Clinical research challenges posed by difficult-to-treat depression.

8 Key Issues in the world of major depressive disorder. 

Psychiatrist effects in the psychopharmacological treatment of depression.

What Is State of the Art Treatment for MDD?

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 psychotherapy frame refers to the basic ground rules for psychotherapy: the attitude of the therapist toward the patient, boundaries, meeting arrangements, and other contractual elements of the psychotherapy relationship. It can be conceived of as the environment and relationship in which psychotherapy takes place. The late psychiatrist Robert Langs, MD, devoted much of his career to the study of the frame, the maintenance of which he described as the therapist’s “most fundamental arena of intervention.”

In the past few decades, as psychotherapy has broadened beyond its psychoanalytic and psychodynamic origins, the concept of the frame has become less known in psychotherapy training and practice. Indeed, many modern therapists have never heard the term or, alternatively, view discussions of it as archaic and reflecting a bygone era of psychotherapy. This unfortunate misunderstanding has led to a shift in the view of the psychotherapy relationship wherein, to borrow from Kernberg, many modern therapists “let it all hang out”

 and adopt a theoretically loose or unprincipled stance. Such therapists may talk about themselves, give advice, or impose their personal beliefs and worldviews onto patients.

Given these recent trends, it may be helpful to revisit the concept of the frame and, in particular, the therapist’s attitude toward the patient in the psychotherapy relationship. Such a discussion may be useful not only to psychotherapists, but also to psychiatrists who may find value in these ideas as they pertain to the psychiatric treatment setting.

The basic attitude of the psychotherapist toward the patient represents the most important element of the psychotherapy frame since it informs the therapist’s role in the treatment situation. An understanding of the therapeutic attitude yields information about other components of the frame, such as the establishment of boundaries and meeting arrangements.

The therapist is a professional and expert on the workings of the human mind who is consulted by the patient because the patient is having some difficulty in their experience of life. At times, this is due to psychiatric disorder. The therapist must remember that their role is that of expert or doctor—not friend or acquaintance. Although a liking for patients often evolves during the course of psychotherapy, the psychotherapy relationship is not a friendship. The therapist who seeks friends in psychotherapy may do so for a variety of reasons: loneliness, a dissatisfying personal life, or their own pathological narcissism. The boundaries between therapist and patient must be respected and the power differential not ignored.

Most individuals who become therapists are motivated by a desire to help others deal with the burdens of emotional despair. Although a desire to help is undoubtedly a necessary trait in a psychotherapist, it has long been recognized

a desire to help. The goal of psychotherapy is to 

from the constraints imposed on them by their conflicts, problems, and symptoms; it is not to help by doing anything 

the patient. To put it another way, in ethical psychotherapy, the therapist must 

Langs, commenting on these ideas, writes that the therapist

“avoids being too supportive, because he hopes not only to offer sustaining help but also, through his therapeutic attitude of being nonjudgmental, noncondemning, nonsubmissive, nonanxious, noncontrolling, firm, consistent, and realistic, to have a modifying effect on the patient’s personality. He knows that the constant playing of the note of supportiveness is not enough. He knows, further, that a too empathic or too profound sounding of this note may infantilize the patient.”

Perhaps the most dangerous risk of psychotherapy is that the therapist will use the patient as a tool or instrument to gratify their own narcissistic impulses. This can take many forms, from gross boundary violations to more subtle attempts to persuade, manipulate, and control, or to model the patient after oneself. The patient’s autonomy—their right to make their own decisions—must be accepted and protected by the therapist. The patient must be seen as an autonomous individual—not an object to be fixed or controlled. It has become fashionable for some therapists to proffer in advice-giving. This practice is countertherapeutic and antithetical to psychotherapy; it infantilizes the patient and promotes helplessness and passivity. It deprives the patient of the very thing psychotherapy aims to provide: freedom.

Freud, writing beautifully on this subject, reflects, “We refused most emphatically to turn a patient who puts himself into our hands in search of help into our private property, to decide his fate for him, to force our own ideals upon him, and with the pride of a Creator to form him in our own image and see that it is good.”

A vital feature of psychotherapy is therapeutic neutrality. What this means is that the therapist maintains an observing stance in relation to the patient and avoids taking sides with any the forces in conflict in the patient’s life. The reason for this is that such a stance helps the patient observe and reflect themselves and eventually to solve their own problems. This does not mean that the therapist is indifferent or blank; the notion of the “blank slate” therapist itself has always been somewhat of a myth. It should also be understood that absolute neutrality is impossible, but the concept should guide therapists in their interactions with patients.

Psychotherapy is a contractual relationship. It is essentially the keeping of promises. The therapist promises the patient to do certain things (to analyze, to aid in understanding, to provide a safe environment), and those things the therapist must do. The therapist also promises not to do certain things (to speak to third parties, to moralize, to control), and those things the therapist must not do. It is the contractual nature of the psychotherapy relationship that permits the other therapeutic work to occur, but the contract itself—and the therapist’s maintenance of it—is a significant therapeutic intervention.

The psychotherapist’s attitude vis-à-vis the patient represents a fundamental, and currently underappreciated, element of the psychotherapy frame. It is the attitude of the therapist that opens the door to good psychotherapeutic work; the therapist’s stance, too, is a key intervention, since it places the patient in an autonomous position and fosters introspection and self-initiated growth. The therapist must be neutral but not indifferent; firm but not judgmental; warm and empathic but not overly involved. They must recognize that the way to help the patient is through exploration—not imposition. They must be and do all of these things, but above all, they must respect the uniqueness and creativity of the patient as an individual human being.

2. Rankin C. Otto Kernberg on Psychoanalysis and Psychoanalytic Psychotherapy. 2000. Accessed June 27, 2022. 

https://www.psychotherapy.net/interview/otto-kernberg

An Elementary Textbook of Psychoanalysis. 

The Technique of Psychoanalytic Psychotherapy. 

6. Freud S. Lines of Advance in Psycho-Analytic Therapy. In: Strachey J, ed & trans. 

The Standard Edition of the Complete Psychological Works of Sigmund Freud. 

7. Yeomans F, Caligor E. What is neutrality in psychotherapy anyway? 

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.6a20

Let’s revisit the therapist’s attitude toward the patient in the psychotherapy relationship. 

The Therapeutic Attitude in Psychotherapy

in the United States. With that in mind, it is hard not to think about the refugee crisis and the separation of fathers from their families in Ukraine as precipitated by the Russian invasion. Worse yet is the plight of the refugee children of the fathers who have been killed in the fighting.

 article that ran on June 4, 2022, titled “

As Battles Rage, Ukraine Rejects Macron’s Pleas Not to Humiliate

.” The plea from the French President Emmanuel Macron came after about 100 days of the war on Ukraine instigated by Russia. Macron was concerned that if Russia was humiliated, the chances of reaching a diplomatic solution would lessen.

Ukraine’s foreign minister angrily responded that peace could best be obtained by Russia being “put in its place.” Who is right?

Many historians talk about how Germany’s humiliation as a result of the World War I peace terms produced a desire for underlying revenge, contributing eventually to the rise of 

 and World War II. The Marshall Plan after World War II took a different path of economically building the defeated countries, and Germany has since become a successful NATO partner.

In psychiatry, humiliation is a focus of the self-psychology developed by

. Narcissistic injuries could be caused by humiliation, with a possible outcome of narcissistic rage toward the humiliator. That can even happen inadvertently in psychotherapy with someone who has a 

Humiliation is generally defined as a feeling of being publicly ”put down” by another individual with more power. It can occur both in individuals and in groups, perhaps even for countries.

What are some of the antidotes to humiliation?

Seeking moderate and peaceful resolutions to conflicts;

From this analysis of humiliation, it would psychologically appear that President Macron is right and Ukraine’s foreign minister is wrong. If victories in the war lead to Ukraine humiliating Russia more than is part and parcel of any war, it is likely to evoke a desire for revenge sooner or later. Perhaps that is already happening.

is understandable given the invasion and the ensuing refugees,atrocities, and war crimes that have and continue to occur. Hopefully, however, Ukraine’s response was in the heat of the moment and not part of an ongoing strategy.

Besides our clinical expertise in helping refugees in their resettlement, humiliation is another of the areas in which psychiatrists who have expertise in politics can be of help.

 should be avoided at all costs. Dignity is priceless.

is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. To create a better world, he is an advocate for treating mental health issues related to climate instability, burnout, Islamophobia, and anti-Semitism. He serves on the Editorial Board of

It is important to consider the lessons from history and psychology as the war in the Ukraine continues. 

Humiliation and Dignity in Ukraine and Life

Psychotherapy: A Core Psychiatric Treatment

,” by Mark L. Ruffalo, MSW, DPsa, and Daniel Morehead, MD,

 on the role of psychotherapy in current practice and training might be too optimistic and not reflective of most of our experiences. A counterargument follows.

As the authors point out, a 2015 survey of psychiatry residents revelated that most residents want “significantly more” time in didactic instruction and clinical practice in psychotherapy, suggesting that the need is not being met.

 An earlier 2010 study was more foreboding, with more than a quarter of residents expressing concerns about the adequacy of time and resources given toward psychotherapy, and one-third of residents stating that they did not believe department leaders were supportive of psychotherapy.

With all due respect to Dr Ruffalo, when psychiatry trainees are taught psychotherapy by nonpsychiatrists, there may be a hidden curriculum that is learned that therapy is for nonphysicians to practice. This also deprives psychiatric trainees the role models in their own profession who continue to practice psychotherapy and reduces opportunities to teach the integration of psychotherapy with pharmacotherapy, implying an either/or treatment model rather than a combined model.

2. Therapeutic interactions, while helpful, are not the same as intentional psychotherapeutic medical procedures for specific conditions.

While brief interactions in other settings can contain psychotherapeutic moments, this is not the same as trying to promote long-lasting behavior change through targeted psychotherapy intervention. Giving someone a pain medication for a sore back and performing back surgery may both have the goal of pain alleviation, but these are different services with different goals and endpoints. It would be unfair to say that one act replicates or replaces the other.

To borrow the authors’ analogy about cardiac catheterizations, it would definitely matter how many cardiologists performed this procedure if we were in the middle of a cardiac health crisis that affected 1 in 4 Americans,

 and patients and referring providers continued to request these procedures, and too many cardiologists refused. It also makes a difference that psychiatrists are in the unique position of being able to provide concurrent psychotherapy and psychopharmacologic treatments. Previous studies have shown that integrated treatment by psychiatrists results in significantly lower treatment costs and fewer necessary appointments than when psychotherapy is split off to another provider.

 clearly show that, over the past 20 years, the percent of psychiatry visits involving psychotherapy has declined from 44% to 21%, and the number of psychiatrists who do not provide any psychotherapy at all has doubled from 27% to 53%. This likely has implications for the cost effectiveness and number of overall appointments required.

3. Psychiatry residents remain hungry for psychotherapy.

The question is, are they being fed adequately? The above-mentioned surveys highlight a need for therapy training. There are a significant number of efforts maintained by a variety of professional organizations specifically designed to promote and improve the teaching of psychotherapies in psychiatry training, most notably psychodynamic psychotherapy. Just in 2020, the APA Psychotherapy Caucus established the Training Advancement Initiative

 AACAP’s Psychodynamic Faculty Initiative,

 as endeavors designed to promote psychotherapy education. I am not sure if the original authors are saying all these efforts are unnecessary, but it does make one wonder where psychotherapy would be without these additional efforts. In comparison, psychopharmacology does not seem to require such efforts.

4. Relying on psychiatry’s past important figures may alienate trainees who want to learn evidence-based psychotherapies and question psychotherapy’s effectiveness.

The legacies of Babe Ruth and Jackie Robinson are not in themselves evidence that the current state of baseball is alive and well—and there actually 

 concerns with the current state of baseball.

 There have been significant gains in the evidence base for psychotherapy,

 in the past decade. Emphasizing this point may actually bode well for our field and may speak to current trainees whose medical schools emphasize evidence-based medicine. If we are going to advertise that our most novel and effective treatments were pioneered by figures who are retired or deceased, that does not necessarily suggest the current state of affairs is alive and well.

5. One need not look too far away to see that psychotherapy is under attack.

Canada, our universal health care-clad brethren to the North, recently had to fight back efforts by the government to scale back and limit the number of covered psychotherapy sessions per patient, regardless of diagnosis or treatment recommendations.

 Luckily, powerful community advocacy helped postpone such a decision for a couple of years. If we do not fight for psychotherapy, others will fight against it.

1. Psychotherapy remains an effective, evidence-based treatment for a variety of conditions.

2. More and more Americans are seeking help for those conditions.

3. Medical professionals trained to treat these conditions are offering it less and less often.

On the surface, that seems like a problem. The data that says whether the problem is exaggerated remains to be seen.

is an associate professor in the department of psychiatry at the University of Florida.

1. Ruffalo ML, Morehead D. Psychotherapy: a core psychiatric treatment. 

https://www.psychiatrictimes.com/view/psychotherapy-a-core-psychiatric-treatment

Psychotherapy training: residents’ perceptions and experiences. 

3. Calabrese C, Sciolla A, Zisook S, et al. 

Psychiatric residents' views of quality of psychotherapy training and psychotherapy competencies: a multisite survey. 

4. America’s health insurance plans: nearly 1 in 4 Americans with employer-provided coverage received mental health support in 2020. News release. May 13, 2022. 

https://insurancenewsnet.com/oarticle/americas-health-insurance-plans-nearly-1-in-4-americans-with-employer-provided-coverage-received-mental-health-support-in-2020

5. Goldman W, McCulloch J, Cuffel B, et al. 

Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression. 

Are psychiatrists cost-effective? An analysis of integrated versus split treatment. 

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

8. Goldman MP, John HV. Psychotherapy Caucus creates program to increase use of psychotherapy. February 4, 2022. Accessed May 20, 2022. 

https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.03.3.13

9. Victor J. Teichner Award. Accessed May 20, 2022. 

https://www.aapdp.org/education/teichner-scholars-program/

10. AACAP Psychodynamic Faculty Initiative. Accessed May 20, 2022. 

https://www.aacap.org/AACAP/Awards/Psychodynamic_Faculty_Initiative/Home.aspx

11. Psychoanalytic & Psychodynamic Teachers' Academy. Accessed May 20, 2022. 

12. What the heck is going on with the baseball? Everything you need to know about MLB's scoring drought. 

https://www.espn.com/mlb/story/_/id/33848888/what-heck-going-baseball-everything-need-know-mlb-scoring-drought

Evidence-based psychotherapy: advantages and challenges. 

The efficacy of psychodynamic psychotherapy. 

15. Villela RM. OPA Psychotherapy Initiative. Accessed May 20, 2022. 

https://www.eopa.ca/opa-groups/opa-initiatives/opa-psychotherapy-initiative

Is the Demise of Psychotherapy by Psychiatrists Really Exaggerated?

 develop their own jargons and theories, but the stages of treatment tend to be remarkably similar regardless of orientation and duration.

The patient knows things are not going well and that help is needed. The specific presenting problems are varied and very individual, but usually include some combination of symptoms, troubling behaviors, interpersonal friction, work problems, disappointment, 

, demoralization, increased stress, and/or a loss of support. The patient often has little awareness of underlying contributing factors and no idea what to do next.

As a result of the therapy—either in sessions, with 

between sessions, or ideally both—patients become increasingly aware of the emotions, thoughts, and behaviors that have created their problems, and also their reduced competence in dealing with them. They may be misinterpreting other people's motives, not recognizing their behaviors that have a negative impact on others, avoiding things that cannot be avoided, becoming too easily frustrated and demoralized, pushing people away, or any of the hundreds of ways people get stuck in vicious cycles of self-perpetuating, self-destructive behavior.

Stage 3: Corrective Emotional Experiences

Insight alone never cured anything except ignorance but becoming intellectually aware of what is causing the problem sets the stage for trying new ways of thinking, feeling, and behaving—both inside and outside the sessions. Chain reactions of corrective emotional experiences replace the downward spiraling caused by previous vicious cycles with virtuous cycles of recovery. Some corrective emotional experiences occur naturally within the context of 

, but most must come from deliberate efforts made by the patient to think in new ways, feel suppressed emotions, try new things, and stop avoiding feared situations.

If the therapy is successful, the new and healthier ways of thinking about, feeling, and acting competently in the world are internalized and become automatic.

Schools of therapy differ markedly in their theories of change, but they are very similar in their stages of change.

Crucial contextual factors in promoting change are also similar across therapies. There must be a strong therapeutic alliance. Patients must come with—or be induced to develop—at least some motivation for change and a positive expectation that therapy can help. The most effective therapies and therapists will not get very far in the process if the patient has fixed negative expectations and a fixed unwillingness to try new thoughts, feelings, and behaviors.

The stages of therapy interact with its duration in complex ways. Going from Stage 1 to Stage 2 is usually the maximal goal for patients seen only for evaluation, but some patients seen only once are able to carry forward the insight gained and achieve Stages 3 and 4 on their own through life experience or with additional later therapy. When they work well, brief treatments of 6 to 20 sessions can encompass all 4 stages. Stalemated long-term treatments may never get beyond the first or second stage. And this model of change does not apply to supportive treatments in which stability, not change, is the goal.


The best way to understand the different therapy schools is to study what they do in practice, not what they say in theory. All therapies, however seemingly different their specific techniques, succeed by facilitating corrective emotional experiences. The paths to achieve this may vary greatly, but their destination is the same.

, we discuss the issues covered in this blog in more depth. You can view the episode 

is professor and chair emeritus in the department of psychiatry at Duke University.

Despite their differences, all psychotherapies have these things in common—and are important to consider.

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