Yes, Psychotherapy Training During Residency Is an Essential Part of a Humanistic Psychiatry

SpicyTruffel/AdobeStock

FROM OUR READERS

As longtime academic psychiatrists, we commend Nicolas Badre, MD, and Eric Geier, MD, PhD, for their advocacy of psychotherapy training for psychiatry residents in their article, “Reclaiming the Narrative: Why Psychiatrists Must Learn Psychotherapy.”¹ Among our many areas of agreement, we wholeheartedly concur with their assertion that “…residencies must continue to provide high-quality psychotherapy training and supervision.” We also agree that, “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.” In our view, it is indeed unfortunate that, in recent decades, psychotherapy has become less widely used as a prominent component of psychiatric care.² Furthermore, we acknowledge that, in some residency programs, residents perceive departmental leadership as unsupportive of psychotherapy training, which is correlated with decreased interest in psychotherapy during training.³

Badre and Geier rightly note that training in evidence-based forms of psychotherapy is sometimes dominated by “generic worksheets and symptom scales” whose omnipresence may alienate and overwhelm patients rather than empowering them. Indeed, with respect to cognitive behavior therapy (CBT), we agree with Badre that we must avoid “turning [CBT] into an impersonal application of worksheets where patients feel unheard and uncared for. The issue isn't CBT itself, but how it's been implemented.”⁴

Finally, we agree with Badre and Geier that the “narrative model” of therapy as developed by Michael White and David Epston is a worthy and useful approach to helping patients understand themselves and their suffering. Incorporating the narrative approach into residency training is a useful recommendation.⁵ In short, we are in strong agreement with many of the core arguments and recommendations in Badre and Geier’s article.

All that said, we are troubled by several of the authors’ assertions which, in our view, are not supported by studies of psychiatric residency programs, or by our own extensive experience with residency training. We are also concerned that—despite the good intentions of the authors—some claims in their article may actually widen the very “split” the authors rightly seek to heal; namely, that between a “biological understanding” of our patients, and a “broader, more humanistic framework.” We also sense a subtle disparaging of the art and science of psychopharmacology. As David Mintz, MD, has explained, psychopharmacology—when practiced knowledgably and psychodynamically—entails far more than being a “prescriber.”⁶

Our Chief Concerns

The authors begin their article by asserting that, “…psychiatry has gotten to a place where trainees ask, “Why are we taught psychotherapy?” and “What is the point of [psycho]therapy?” The authors provide no supporting data to substantiate this claim. So, too, with their assertion that, “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…” We think this broad-brush assessment of both the state of psychiatry and that of our trainees is unduly pessimistic.

The authors’ impressions may accurately represent their personal experience with residents in their particular training program, but do not necessarily reflect national trends. Nor do they reflect our own extensive experience with resident education. We believe that most psychiatric residents well understand and appreciate the value of psychotherapy training and, indeed, want more of it.⁷ Contrary to Badre and Geier’s puzzling assertion that “…psychotherapy is secretly popular among trainees,” (italics theirs), survey data indicate that residents openly express their interest in psychotherapy. For example, in a survey of psychiatry residents (n=39) within a major metro region in the Northeast, participants “reported a strong interest in learning psychotherapy.”⁸ Furthermore, a 2011 survey of residents reported that 82% of them consider “psychotherapy to be integral to their identity as psychiatrists.”⁹ In another study, a fourth-year resident observed that¹⁰:

“As a resident physician, I (HK) have found my training psychodynamic psychotherapy to have been absolutely critical to my professional and personal development over these last few years…recognizing the utility of self-examination and self-reflection felt incredibly grounding and empowering in my work as a therapist.”

Moreover, contrary to Badre and Geir, we do not believe that psychiatry as a profession devalues psychotherapy, even as market forces and institutional pressures have tended to discourage its use. In spite of decreases, 47% of psychiatrists continue to provide psychotherapy (2010-2016 data), offering 45- to 60-minute psychotherapy sessions¹¹; and psychiatrists still provide about 34% of psychotherapy visits nationally.¹²

Our Tufts colleague, psychoanalyst (and nonpsychiatrist) Mark L. Ruffalo, MSW, DPsa, teaches in 2 residency programs. He recently wrote in this publication that¹³:

“It is becoming apparent that the strong emphasis on neuroscience in the 1990s and early 2000s is now giving way to a new psychiatric pluralism, one that increasingly views psychotherapy as a bona fide medical treatment and sees psychosocial factors as fundamental to understanding the causes and basic nature of psychopathology…Today, we see psychiatry with a resurgent interest in psychotherapy as a primary treatment for psychopathology, not merely an adjunctive treatment to the “real work” of pharmacotherapy. Psychiatry residents are increasingly interested in psychotherapy and in psychosocial modes of understanding.”

Importantly, training in psychodynamic, supportive, and cognitive behavior therapy remains a national requirement for all psychiatric residency programs.¹⁴ Furthermore, the recent American Psychiatric Association report, The Future of the Psychiatrist, asserts that psychotherapy skills will remain a cornerstone of our work. The report states, “We must preserve our skill, unique among physicians, in psychotherapeutic approaches…Training in psychotherapy essentials must remain part of our identity because it is critical to any therapeutic relationship, and necessary for us to competently supervise others providing this treatment.”¹⁵

Finally, we perceive a subtle but troubling disparagement of psychopharmacology in Badre and Geier’s claim that, "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." We see no factual basis for positing such a “narrative” and fear that this claim may perpetuate the stereotype of the reductionistic psychiatrist who endorses the (widely discredited) "chemical imbalance theory.”¹⁶ Moreover, the generic term, “prescriber” trivializes the art and science of providing medication in psychiatry, which entails far more than typing out a "script." Indeed, it requires the psychodynamic knowledge that helps us identify and work through the patient's resistances, fears, and fantasies about what medication will or will not do; as well as transference and countertransference issues surrounding the medication.^17,18

In our many decades of academic psychiatry, we have observed that most of our colleagues understand psychotherapy to be a biologically powerful treatment for a variety of mental illnesses, capable of altering brain function.¹⁹ They also appreciate, as David Mintz, MD, points out, that interpersonal factors such as the therapeutic alliance may profoundly affect the outcome of pharmacotherapy.²⁰ We have encountered few if any psychiatrists who claim that merely by prescribing medication, the patient's "brain abnormality" will be "corrected." Nor have we encountered psychiatrists who engage in “reducing patients to mere collections of neurons and biochemical processes,” to quote Badre and Geier.

Working Together to Heal the Biological-Psychological Split

Rather than furthering the notion of a deep conflict between biologically and psychotherapeutically-oriented psychiatrists, we believe psychiatrists should join forces and recognize that the increasing bureaucratization of psychiatry represents a threat to good psychiatric treatment of any kind. Recently, Desai et al have described how, in some mental health centers, treatment has ceased to be “person-centered.” Instead, “bureaucratic environments filled with procedures and paperwork” have led to the patient being seen as “…as an agenda item, paperwork, a unit of time, or a budget figure.”²¹

In our experience, such impersonal approaches can be just as destructive to efforts at pharmacotherapy. Patients are exquisitely sensitive to whether their psychiatrist appears to care, to listen to them, and to treat their beliefs as something more than mere symptoms and data. Optimal treatment requires that we find ways of resisting the current push to completely “systematize and mechanize” psychiatric practice. Instead, we need to work together with our patients to carve out a space for truly humane interactions and genuine healing.

This, we believe, is the overriding impulse behind Badre and Geier’s thesis. It should not be obscured or undermined by yet another telling of the outdated tale that psychiatry is deeply split between biology and psychology. In our experience, it is not. Every psychiatrist—not just those who identify primarily as psychotherapists—should support high quality psychotherapy training aimed at fostering a humanistic and pluralistic professional culture.

Dr Morehead 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 dmorehead@tuftsmedicalcenter.org.

Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books, including several textbooks on psychopharmacology. A collection of his works can be found on Amazon.

References

1. Badre N, Geier E. Reclaiming the narrative: why psychiatrists must learn psychotherapy. Psychiatric Times. July 25, 2025. https://www.psychiatrictimes.com/view/reclaiming-the-narrative-why-psychiatrists-must-learn-psychotherapy

2. Moran M. Study shows declining trend in psychotherapy by psychiatrists. Psychiatric News. 2022;57(2).

3. Zisook S, McQuaid JR, Sciolla A, et al. Psychiatric residents' interest in psychotherapy and training stage: a multi-site survey. Am J Psychother. 2011;65(1):47-59.

4. Badre N. Comment. Twitter/X. February 6, 2025. Accessed August 8, 2025. https://x.com/BadreNicolas/status/1887590669797237015

5. About narrative therapy. Narrative Therapy Center. Accessed August 8, 2025. https://narrativetherapycentre.com/about/

6. Mintz D. Psychodynamic psychopharmacology. Psychiatric Times. 2011;28(9).

7. Kovach JG, Dubin WR, Combs, CJ. Psychotherapy training: residents’ perceptions and experiences. Acad Psychiatry. 2015;39(5):567-574.

8. Lonergan BB, Duchin NP, Fromson JA, AhnAllen CG. Skills-based psychotherapy training for inpatient psychiatry residents: a needs assessment and evaluation of a pilot curriculum. Acad Psychiatry. 2020;44(3):320-323.

9. Lanouette NM, Calabrese C, Sciolla AF, et al. Do psychiatry residents identify as psychotherapists? A multisite survey. Ann Clin Psychiatry. 2011;23(1):30-39.

10. Giroux C, Khan H, Mcaskill G et al. Psychodynamic psychotherapy: a core learning component during psychiatric residency. Journal of Psychiatry Reform. 2022;11(6).

11. Tadmon D, Olfson M. Trends in outpatient psychotherapy provision by U.S. psychiatrists: 1996-2016. Am J Psychiatry. 2022;179(2):110-121.

12. Olfson M, McClellan C, Zuvekas SH, et al. Psychotherapy trends in the United States. Am J Psychiatry. 2025;182(5):483-492.

13. Ruffalo ML. Toward a new psychiatric pluralism: the resurgence of psychotherapy. Psychiatric Times. 2025;42(7).

14. ACGME Program Requirements for Graduate Medical Education in Psychiatry. Accessed August 8, 2025. https://www.acgme.org/globalassets/pfassets/programrequirements/2025-reformatted-requirements/400_psychiatry_2025_reformatted.pdf

15. Potash JB, McClanahan A, Davidson J, et al. The future of the psychiatrist. Psychiatr Res Clin Pract. 2025;7(2):80-90.

16. Pies RW. Debunking the two chemical imbalance myths, again. Psychiatric Times. 2019;36(8).

17. Pies RW. The psychodynamics of psychopharmacology: reimagining the “med check.” Carlat Publishing. September 12, 2023. Accessed August 8, 2025. https://www.thecarlatreport.com/articles/4489-the-psychodynamics-of-psychopharmacology-reimagining-the-med-check

18. Ruffalo ML, Morehead D. Psychotherapy: a core psychiatric treatment. Psychiatric Times. May 6, 2022. https://www.psychiatrictimes.com/view/psychotherapy-a-core-psychiatric-treatment

19. Gabbard GO. Through the times with Glen O. Gabbard, MD. Psychiatric Times. April 1, 2005. https://www.psychiatrictimes.com/view/through-times-glen-o-gabbard-md

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

21. Desai MU, Paranamana N, Dovidio JF, et al. System-centered care: how bureaucracy and racialization decenter attempts at person-centered mental health care. Clin Psychol Sci. 2023;11(3):476-489.