'If you talk about things you have not experienced, you are wasting your and other people's time. As you continue the practice of looking deeply, you will see this more and more clearly, and you will save a lot of paper and publishing enterprises and have more time to enjoy your tea and live your daily life in mindfulness.'(1)
Psychotherapy has been viewed as a core clinical activity of psychiatrists. (2-4) Is this still the case in our modern era, with more and more focus on pharmacotherapy? As we prepare for the Fellowship of the College of Psychiatrists of South Africa (FCPsych) to be the only exit examination to qualify as a psychiatrist in South Africa, it is prudent to reconsider this and related questions.
Is psychotherapy still a necessary and wanted skill?
We live in an exciting age in which our understanding of the biological aspects of psychiatric disorders is rapidly expanding. Simultaneously psychotherapy has received more and more attention as a very important aspect in the holistic treatment of psychiatric disorders, e.g. as combination treatment together with pharmacotherapy or add-on treatment in bipolar mood disorders. (3-7) Furthermore, different types of psychotherapy have been proven to be effective as single treatment in some of the
most common psychiatric disorders. (7, 8) Despite this, a recent study in the USA showed that over the decade 1998-2007 a decreasing proportion of mental health outpatients received psychotherapy, and those who did made fewer visits. (4) During the same period, a large and growing number of outpatients received psychotropic medications without psychotherapy. (4)
Adding fuel to this dispute, Professor Juan Mezzich, immediate past-president of the World Psychiatric Association (WPA), writes, 'The status of practicing psychiatrists is being diminished by managed care systems that reduce patients to diagnostic codes and reduce psychiatrists to technicians who just prescribe drugs.' Mezzich advocates a highly personalised approach to mental health care and health promotion. (9)
If there is only an academic, intellectual interest in the question about the place and practice of psychotherapy, one could find reasons both for and against it. If, however, one has a real, existential understanding of the suffering caused by mental illness, of the suffering and loneliness of the patient, then there is only one answer. Yes, psychotherapy should always be a core clinical activity of psychiatrists. The importance of this is emphasised by the following comments made by a despondent physician who had just been interviewed by a psychiatrist: 'I don't think he heard me ... Depression may be the disease, but it is not the problem. The problem is my life.... It's falling apart. My marriage. My relationship with my kids. My confidence in my research. My sense of purpose. My dreams. Is this depression? ... I want this depression treated, all right. There is something more I want, however. I want to tell this story, my story. I want someone trained to hear me. I thought that was what psychiatrists did.' (10) An I--Thou relationship, as described by the philosopher Martin Buber, is the most that you can offer someone. (11)
Psychotherapy and the training thereof is also emphasised by the College of Psychiatrists. In the Regulations for the FCPsych (SA), March 2011, the following is mentioned: 'For admission to Part II the candidate must present evidence of having submitted to the CMSA a Certificate of Training in which case histories of 3 psychotherapy cases (e.g. brief psychotherapy, long psychotherapy, cognitive behavioural therapy, family therapy or group therapy cases) and descriptions of practical experience are certified by the head of department as being adequate.' (12)
In the registrar workshop organised by the College in February 2011 the following was stated: 'The expectation is that, at the completion of their training, registrars should be competent in supportive psychotherapy, have had adequate practical exposure to cognitive behavioural therapy (CBT) and at least a good theoretical knowledge of the psychodynamic therapies. …