Academic Psychiatry | 2019
Psychotherapy and the Professional Identity of Psychiatry in the Age of Neuroscience
Abstract
Interviewing for residency positions in psychiatry, I was asked repeatedly why I wrote in my application that I felt drawn to the field because I wanted to perform psychotherapy. Responses to this interest varied considerably. On one extreme, there are a handful of departments that regard psychotherapy as the core skill in clinical psychiatry, and at these places—I can think of a few—I had little explaining to do. On the other hand, there are a number of programs that vow to make psychotherapy as effectively optional as they can get away with. One chief resident told me in no uncertain terms that therapy didactics and supervision were “available” to residents only because the accreditation council requires them. Then there is the most common response, which I would describe as basically encouraging but imbuedwith skepticism. It reminds me of the way medical schools react when an entering student declares an interest in primary care for the poor. Every medical school wants these kinds of students in their class, but you can tell that the deans, having heard this before, are aware of the odds. They know that most of them, in keeping with the majority of like-minded medical students, will eventually get pulled in another direction [1, 2]. Rational students succumb to market forces; likewise, a psychiatry resident’s desire to perform psychotherapy might be replaced by other, more practical, considerations as they develop a career. (A notable exception exists in the handful of very large cities fostering a market for private practice therapy, but this is not the norm nationwide.) Before moving further, I should clarify that by psychotherapy I mean all of the deliberate interactions that might be thought of as “talking cures,” which take as axiom that we can bring about change in a patient’s experience by sharing in it. Psychotherapy is also a scientific discipline, based on measured observation, which has demonstrated beyond ambiguity that a therapist’s choice to sit with a patient, to utter (or not), and to listen with purpose [3] has therapeutic action [4]. In the modern landscape, psychotherapy runs the gamut from brief to prolonged, tightly framed to spontaneous, individual to collective, suggestive to analytic, and so on, but for my argument here (and perhaps for the benefit of patients [5]), these differences are not as important as their commonalities. By this definition, I do not think anyone disputes that many patients need psychotherapy. A common line from program directors is “we teach therapy because therapy works,” enumerating (and justifying) it as one of many tools in the therapeutic shed. They point out that beyond the role of psychotherapy in the conditions we see most commonly, several epidemiologically significant psychiatric disorders have no FDA-approved medication or somatic treatment but a wealth of evidence for psychotherapeutic intervention. Borderline personality disorder [6], specific phobia [7], somatoform disorders [8], and anorexia nervosa [9] come to mind. Of course, physicians are far from the only providers in the healthcare system. Our colleagues in internal medicine know that physical activity, nutrition counseling, and tobacco intervention programs are almost certainly more effective than some of the pharmacotherapies employed for similar ends. They are nonetheless delegated to professionals less scarce in the ecosystem because they come at an opportunity cost for prescribing physicians. Likewise, in American psychiatry, all residents learn the basics of the major branches of psychotherapy [10], but most practicing psychiatrists today do not perform therapy with their patients, even informally, and the number of psychiatrists who perform psychotherapy has declined substantially since the 1990s [11]. Some of this is because psychotherapy has the lowest professional barrier of the modes of intervention used in psychiatry. A medical doctor can offer as much talk therapy as their heart desires, but so can a clinical psychologist, a nurse practitioner, a psychiatric nurse, a social worker, a mental health counselor—and arguably also a minister, a vocational * Ren Belcher [email protected]