Reclaiming the Narrative: Why Psychiatrists Must Learn Psychotherapy

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SPECIAL REPORT: PSYCHOTHERAPY

It is hard to believe that psychiatry has gotten to a place where trainees ask, “Why are we taught psychotherapy?” and “What is the point of therapy?” In the early 2000s, an astute anthropologist named T.M. Luhrmann looked at American psychiatry and titled her book about the field Of Two Minds.¹ These authors worry that today, the book would be called We’ve Made Up Our Minds. Some trainees in the field share that their supervisors discourage them from learning psychotherapy, and a psychiatrist has even written publicly that it is time to leave behind psychotherapy training in residency curricula.² Today’s residents are instead encouraged to pursue interventional psychiatry or integrated care, which have in common the deemphasis of the relationship between the psychiatrist and the patient.

Public Trust

Reducing patients to mere collections of neurons and biochemical processes exacts a toll on the therapeutic encounter. Such a narrow focus fosters an inauthentic dynamic and undermines the trust crucial to the patient-doctor relationship. This challenge is mirrored in psychiatry's struggle for public trust, often illustrated by cinematic portrayals that favor villainous depictions over heroic ones, and highlighted by the recent public comparison of psychotropic medication as a societal “threat.”³ A figure such as Patch Adams, played by Robin Williams in a 1998 movie, might seem to be an exception; however, he was not a psychiatrist and his heroism is notably framed as a direct rejection of a detached, impersonal approach.

The Split

By separating psychiatry from psychology, we endorse the myth that biology can be divorced from experience. Philosopher José Ortega, PhD, famously said, “I am myself plus my circumstances.”⁴ A brain in a vat has never existed and hopefully never will. Perpetuating this myth ignores reality and encourages splitting and externalization in our patients. This myth affects psychiatrists, too. Ignoring or dismissing half the equation creates constant dissonance. This may explain why psychotherapy is secretly popular among trainees. Many residents seek additional psychotherapy training beyond clinical and didactic requirements, pursue personal psychotherapy, and recommend psychotherapy-oriented practices to friends and family.

This split not only impacts the patient's ability to integrate their experiences but also limits the psychiatrist's diagnostic and therapeutic toolkit. Understanding the patient's subjective world, their history, and the meaning they ascribe to their symptoms is crucial for an accurate understanding of the patient. Psychotherapeutic skills enable the psychiatrist to elicit this information more effectively, build stronger therapeutic alliances, and tailor treatments that resonate with the patient’s uniqueness.

A Narrative Approach

The standard residency curriculum increasingly adopts evidence-based psychotherapies with manualized approaches. This risks viewing humans as computers, where neurons are hardware and everything else is software, requiring systematic code. We suspect Aaron T. Beck, MD, would struggle to recognize his cognitive behavioral therapy today, which burdens patients with generic worksheets and symptom scales to track hourly mood changes.

When residents under supervision ask about therapy's meaning, we say: To grasp therapy's purpose, you must understand life's purpose. Erik Erikson described life’s purpose as “the acceptance of one's one-and-only life cycle.”⁵ This can also be explained as embracing that it was OK to have been oneself without additions or substitutions. Narrative is how we comprehend who we are and what it means to be ourselves. To be a therapist is to be the doctor to a patient’s narrative.

Embracing a narrative approach does not mean abandoning biological understanding or evidence-based treatments; rather, it advocates for their integration within a broader, more humanistic framework. It recognizes that while medications can alleviate symptoms and structured therapies can teach coping skills, the deepest healing occurs when individuals make sense of their suffering within the context of their life story. A psychiatrist skilled in psychotherapy is able to help patients not just to function better, but to live more authentically.

That narrative might be the model for all forms of mental health treatment. To become a prescriber or to practice medication management is to create a narrative that one has a brain abnormality that will be corrected with psychotropic medications. To practice cognitive behavioral therapy is to create a narrative that one’s suffering is caused by cognitive distortions that can be eliminated by the substitution of more adaptive thoughts. It might be that none of these narratives is inherently superior or true. Our challenge might actually be to match each patient with the narrative most likely to improve their life.

The conceptualization of treatment as narrative is intrinsically more satisfying than the pursuit of being asymptomatic. Instead of seeking nothingness, seeking a narrative encourages an interesting life full of symptoms such as sadness, anger, guilt, fear, as well as their counterparts love, pride, and joy. So much of modern psychiatry seems to be an attempt at escaping a constantly expanding list of disorders, but it can be so much more than that: Psychiatry can provide an avenue to create a meaningful life.

As scientists continue to systematize and mechanize human existence, even to the point of claiming that our behavior is fully determined,⁶ there remains something within us that understands that we are more than highly sophisticated computers. Failing to engage with that part of our humanity harms patients and increases burnout in psychiatrists. David Mintz, MD, has written that for psychiatrists to practice “at the top of their license,”⁷ they must utilize psychotherapy tools in their approach. For future generations of clinicians to continue to practice in this manner, residencies must continue to provide high-quality psychotherapy training and supervision.

Concluding Thoughts

The current state of psychiatry, with its emphasis on biological interventions and the devaluation of psychotherapy, has led to a sense of discouragement among trainees and a questioning of the purpose of therapy. While evidence-based practices and manualized therapies have become prevalent, they can overlook the richness and depth of the human experience. Despite these challenges, there remains an underground popularity and recognition of the importance of psychotherapy among residents. We argue that the actual point of therapy lies in understanding the point of life itself—to achieve acceptance and a sense of one's own narrative—and that the integration of therapy into psychiatric practice will improve the lives of patients and the psychiatrists who serve them.

Dr Badre is a clinical and forensic psychiatrist in San Diego, California. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr Badre can be reached at his website, BadreMD.com. Dr Geier is a fourth-year psychiatry resident at University of California San Diego. His interests include psychotherapy, philosophy of psychiatry, and medical education.

References

1. Luhrmann TM. Of Two Minds: An Anthropologist Looks at American Psychiatry. Vintage; 2001.

2. Vernon J. Why psychotherapy training shouldn’t be part of psychiatry residency. Op-Med. October 15, 2017. Accessed May 7, 2025. https://opmed.doximity.com/articles/why-psychotherapy-training-should-not-be-part-of-psychiatry-residency-25ae32bb45ab

3. The White House. Executive order No. 14212: establishing the president's Make America Healthy Again Commission. February 13, 2025. Accessed May 7, 2025. https://www.whitehouse.gov/presidential-actions/2025/02/establishing-the-presidents-make-america-healthy-again-commission/

4. Ortega y Gasset J. Meditations on Quixote. WW Norton & Company; 1963.

5. Erikson EH. Eight ages of man. In: Childhood and Society. WW Norton & Company; 1950.

6. Sapolsky RM. Determined: A Science of Life Without Free Will. Penguin Press; 2023.

7. Mintz D. Practicing at the top of your license. Psychiatr News. 2023;58(12).