March, 2005. At the recent annual meeting of the American College of Psychiatrists, one of the opening presentations was made by Steven Sharfstein, President-Elect of the American Psychiatric Association (APA). His talk, entitled "Implications of New Treatments and Payment Systems for the Practitioner," reviewed the radical changes in the landscape of clinical care that he has observed during the course of his career, changes familiar to many of us. Among the statistics he presented were comparisons of the mean number of visits per patient per month for U.S. psychiatrists in 1973 versus 1997 (6 versus 2), the mean number of minutes per patient visit in 1988 versus 2002 (55 versus 34), and the percent of patients receiving 20 or more psychotherapy visits during the year in 1987 versus 1997 (16% versus 10%). A common lament reflected in these numbers and well represented in the discussion from the floor was the erosion of time-time to be with our patients, to get to know them "inside out," and to work things through.
One type of treatment sometimes considered on the "endangered species" list is long-term psychotherapy, particularly in light of inadequate insurance coverage. Amassing a strong evidence base from randomized controlled trials of long-term psychotherapy, to see if the data could make the case for better funding, is unlikely (though not impossible) due to methodological challenges, as Clemens points out in his psychotherapy column in this issue of the Journal. However, we must rely not just on the important results of time-limited clinical trials, but also on sustained clinical wisdom that is transformed over time based on observed treatment effectiveness on a case by case basis.
Among the psychiatric disorders for which psychotherapy is often judged to be the treatment of choice are the personality disorders. In this issue of the Journal, Bender presents a thoughtful, detailed analysis of the central importance of the therapeutic alliance in the course of such treatment, underscoring the core interpersonal nature of personality psychopathology. As a valuable companion piece, Gutheil alerts us to the ever-present risk of an "adverse side effect" when providing psychotherapy to patients with personality disorders, that of deviating from compassionate objectivity and professional neutrality. Gutheil presents a useful list of risk management principles, a copy of which would be welcome in many active treatment charts as a quick-reference guide when working with these patients. Also in this issue, Lee and Hills apply a psychodynamic perspective to the common practice of collaborative treatment, reminding us of the influential role of each participant in treatment, and that none of us is immune to unconsciously motivated behavior.
John Oldham, MD