Magazine article Clinical Psychiatry News

A Recent Study Shows That the Provision of Psychotherapy by Psychiatrists Has Declined Sharply. Is Psychiatry in Danger of Losing Psychotherapy as a Tool?

Magazine article Clinical Psychiatry News

A Recent Study Shows That the Provision of Psychotherapy by Psychiatrists Has Declined Sharply. Is Psychiatry in Danger of Losing Psychotherapy as a Tool?

Article excerpt

The idea of addressing these study results left me ambivalent--at first. Not only had I written about this for several years, but so had several very important leaders in American psychiatry.

In the 1960s, for example, Dr. Mort Reiser and Dr. Leon Eisenberg wrote seminal articles dealing with the question, "What is a psychiatrist?" Both men were icons in the field, and both bemoaned the waning role of psychotherapy in the psychiatric care of patients. In trying to define who we are, they addressed "biopsychosocial" as a key factor.

A few years later, Dr. George Engel wrote an important article in which he argued that all diseases, medical and psychiatric, are biopsychosocial and must be addressed from the social, psychological, and behavioral dimensions (Science 1977;196:129-36). He also made a brilliant argument comparing diabetes and schizophrenia as biopsychosocial. (In a conversation years later, Dr. Engel humbly explained that he did not invent the term biopsychosocial and gave me an exact reference for its origins.)

The term continues to be used to today. In his recent book on the history of modern psychiatry, "Changing American Psychiatry: A Personal Perspective" (Washington: American Psychiatric Publishing Inc., 2008). Dr. Melvin Sabshin discusses the concept by quoting Dr. Steven Sharfstein, who decried the current bio-bio-bio world of psychiatry a few years ago in his presidential address to the American Psychiatric Association.

All the writers on this subject over the last 50 years have addressed the need for psychiatrists and physicians to broaden their perspectives to better serve our patients. Yet every study shows that many psychiatrists do not do psychotherapy with patients. Instead, many of us opt to inform patients that we are medicating and referring them to psychologists or social workers for therapy.

The study under discussion demonstrates statistically the reduction in the use of psychotherapy in the care of patients by psychiatrists (Arch. Gen. Psychiatry 2008;65:962-70).

According to Dr. Ramin Mojtabai and Dr. Mark Olfson, the rate of visits provided by psychiatrists involving psychotherapy dropped from 44.4% in 1996-1997 to 28.9% in 2004-2005. "These trends highlight a gradual but important change in the content of outpatient psychiatric care in the United States and a continuing shift toward medicalization of psychiatric practice," Dr. Mojtabai and Dr. Olson wrote.

These data are not surprising. In 1959, when I entered training, all the department chairmen were psychoanalysts. Today, there are very few trained in this discipline. A critically important book by T.M. Luhrmann, "Of Two Minds" (New York: Random House, 2000), describes a psychiatric department in the city literally divided into two halves, one biomedical and the other psychoanalytic.

As I have written before, the issue here involves humanism--which I believe is an essential component of our work. For a psychiatrist to do his best work, he must embrace a humanistic approach to the patient. This expression of empathy is critical to the development of a therapeutic alliance, and patients are reassured when they believe that the psychiatrist understands their problems and conflicts.

If we are directive, controlling, punitive, or demanding in our words, tone, facial expressions, etc., the patients' sensors pick it up. They do not want to be criticized the way they are at home or at work, and most of them cannot respond to "orders" by carrying them out because their own ambivalence and indecisiveness are what drove them to the psychiatrist's office in the first place.

A coolness, often a severe attitude, and a willingness to listen convey a sense of humanistic caring for the patient are essential factors in good psychotherapy. It also requires a deep understanding of the dynamics of the illness, which often leads a psychiatrist to make correct and timely interpretations regarding the patient's problem. …

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