Fighting for Psychotherapy by Psychiatrists: Join Us!
JOHN C. MARKOWITZ, M.D.
Published Online:26 Feb 2023https://doi.org/10.1176/appi.pn.2023.03.3.11
This text was posted in Psychiatric news by John C. Markowitz, M.D., professor of clinical psychiatry at the Columbia University Vagelos College of Physicians & Surgeons, a research psychiatrist at the New York State Psychiatric Institute, and a distinguished life fellow of APA. ISIPT think his message is important and therefore we like to post the text here as well.
Since Freud first invented it in the late 19th century, psychotherapy has been part of psychiatrists’ treatment armamentarium and professional identity. It was once their primary treatment intervention.
Psychiatrists long defined themselves by embracing the biopsychosocial model, with psychotherapy an implicit part of that outlook and practice. Unfortunately, however, psychotherapy by psychiatrists has been and remains under siege on several fronts. Research has documented a marked decline in psychotherapy practiced by psychiatrists, from 44.4% in 1996-1997 to 21.6% in 2015-2016 (Study Shows Declining Trend in Psychotherapy by Psychiatrists). That’s an alarming drop.
Why are psychiatrists no longer doing psychotherapy? Several factors probably play a role, including the following:
- Insurance bias: Insurance reimbursement has long rewarded brief medication checks relative to longer psychotherapy sessions, financially incentivizing prescribing medication over listening to patients and treating them in psychotherapy. Pharmaceutical advertising comes from pharmaceutical companies, not from psychotherapy organizations, and it influences our outlook and that of our patients. Many patients have caught this drift: You go to a psychiatrist for pills, not talk. Psychotherapy has increasingly been delegated to psychologists, social workers, and other mental health care workers.
- Dearth of investment in psychotherapy research: The National Institute of Mental Health has drastically shifted its research funding priorities over the past dozen years, largely abandoning clinical research in favor of neuroscience. Lack of funding has brought psychotherapy research in the United States to a halt. In consequence, academia is hiring more neuroscientists and fewer clinical teachers for our residents. This is true even among the shrinking number of training programs that actively promote psychotherapy training, as well as those that pay lip service to the psychotherapy training requirements of the Accreditation Council for Graduate Medical Education.
- Changing of the guard: The older generation of clinician teachers is retiring. Their academic replacements are more likely to be neurobiologically focused, diminishing the clinical teaching pool and depth of residency psychotherapy training.
- Zeitgeist: Psychotherapy can look old fashioned relative to mental health apps and transcranial magnetic stimulation.
- Professional factionalism: Psychotherapists have done themselves few favors. The history of psychotherapy since Freud’s circle has unfortunately been characterized by warring factions, with each branded sect fighting for prominence, rather than coming together to support the modality.
Paradoxically, this should be a golden age for psychotherapy by psychiatrists. Decades of clinical research have established the evidence basis of potent time-limited psychotherapies like cognitive-behavioral therapy (CBT), interpersonal psychotherapy (IPT), panic-focused psychodynamic psychotherapy (PFPP), and an alphabet soup of other acronyms. Psychotherapies on balance work as well as medications for commonly seen disorders like nonpsychotic depression and panic. They may have advantages over medications for patients with particular disorders, such as posttraumatic stress disorder, and, in particular, life situations (pregnancy, complicated bereavement, major life role transitions). Psychotherapies are powerful treatments, featured in treatment guidelines.
Moreover, spending time listening to patients helps clinicians to understand them and prescribe both psychotherapy and pharmacotherapy more assuredly. Combined treatment by a single professional—the psychiatrist—is surely more coordinated and likely more effective than split treatment. So psychotherapy, and a psychotherapeutic understanding of patients, is a good thing. Yet it’s imperiled.
As a longtime psychotherapy researcher and practitioner, I abhor seeing this grand and useful tradition fading from our profession. With pressure against psychotherapy coming from larger forces, we need to fight for the field on a broader level.
One forum within APA is the Caucus on Psychotherapy, headed by Jeffery Smith, M.D. This loose network boasts some 1,300 APA members. I’ve joined, and I encourage all interested psychiatrists to do the same. We can meet and work together to encourage the promotion of psychotherapies within our organization (Psychotherapy Caucus Creates Program to Increase Use of Psychotherapy).
As the current president of the International Society of Interpersonal Psychotherapy (ISIPT), I can happily report that this volunteer member organization is working hard to promote not just IPT but psychotherapy generally around the globe. Like the Academy of Cognitive and Behavioral Therapies (ACBT, to which I also belong) and the American Psychoanalytic Association (APsaA), the ISIPT offers periodic training courses and certifies therapists, trainers, and supervisors to ensure the precision and rigor of treatment and avoid the risks of eclecticism. (It’s good to know more than one psychotherapy, but it’s best to use each purely for a given patient.)
Like other such organizations, ISIPT has an advocacy role, responding to the handling of psychotherapy (not just IPT) in drafts of treatment guidelines and in health care policy proposals. Moreover, we are trying to coordinate with organizations like ACBT, APsaA, the Society for Psychotherapy Research, and APA to advocate jointly to protect and promote psychotherapy as a modality. A united front is more convincing than competing rivals.
I’m grateful that Psychiatric News prints columns like this one, offering an opportunity to remind psychiatrists of an important part of their heritage and treatment options. I encourage psychiatrists who practice psychotherapy not only to keep helping their patients in therapy, but further to get involved: in the APA Caucus on Psychotherapy, in teaching therapy to trainees and young practitioners, and in advocating for psychotherapy. ■