I have long admired the columns on psychotherapy that my colleague and friend Drew Clemens has written for this Journal since 2001. I have also admired the Journal of Psychiatric Practice for its leadership in being perhaps the only general psychiatry journal to dedicate space to a column on psychotherapy. When Drew decided to step aside from the commitment to write these columns, I was delighted to accept the invitation that came from journal editor John Oldham to take responsibility for continuing them into the future. In this first column, I will offer a survey of where we are and a vision of what is to come.
In introducing the new column, it makes sense to introduce myself. Although I started medical practice as a primary care physician in rural Vermont after medical school at Columbia and a medical internship at Dartmouth, my experiences in primary care drew me back to an earlier interest in psychiatry, so I entered the biological psychiatry residency program at Dartmouth chaired by the late Gary Tucker. Biological psychiatry seemed like the direction to go at that time. I found psychiatry fascinating, absorbing, and engaging of my passion, but it was the experience with patients in individual and group psychotherapy that had the biggest effect on me—and, in my observation, on patients. I especially enjoyed learning about behavior therapy and psychoanalysis from skilled but often partisan teachers and supervisors who seemed to want to recruit me to their camp. In the end, it was the richness and depth of psychoanalytic work with the patients I found most challenging—those with complex, debilitating illnesses such as borderline personality disorder, especially those who struggled with suicide—that captured my interest. Hence, I sought the best postresidency training I could find to become more skilled at doing this work, entering a 4-year fellowship in psychoanalytic psychotherapy and psychoanalytic studies at the Austen Riggs Center. I have remained at Riggs for close to 40 years, although I have also valued opportunities to take on roles in organized psychiatry and psychoanalysis. I served both as a member and later as chair of the American Psychiatric Association (APA) Committee on Psychotherapy by Psychiatrists that ended in 2009 along with other APA components because of APA financial concerns. While chair, I witnessed (and participated in) some of the inevitable tensions between therapists from different theoretical persuasions. One conversation that I recall went pretty much like this:
Me: Cognitive behavioral therapy (CBT) assumes the role of the unconscious asymptotically approaches zero. Hence, you don’t have and don’t need concepts like countertransference.
Nationally known CBT teacher and researcher: In CBT we have something like countertransference. We call it the patient’s automatic thoughts about the therapist. Besides, psychoanalysis doesn’t help people.
Me: Of course it does. Remember, Aaron Beck trained at Riggs.
Nationally known CBT teacher and researcher: And he developed CBT because he could see what he was learning there didn’t help patients.
Fortunately for us, we both realized we were caught in a useless “circular firing squad” argument that was not advancing the need of the profession to understand more about the value of psychosocial treatments like psychotherapy. Subsequently, though, I remained curious about the recognition in CBT of the need for a concept like countertransference. Could it be that CBT and psychoanalysis had more in common than we realized? Bringing this question to the Committee began a process that led to the development of the Y-Model for teaching psychotherapy competencies based on their evidence-based nonspecific (eg, therapeutic alliance, empathic listening) and specific (eg, expressing and exploring underlying affects in psychodynamic therapy and learning to manage affects in CBT) core features—as described in a paper that was published in this journal.1 A number of residency programs now use this model to teach psychotherapy in a way that minimizes competition between schools and builds on nonspecific common factors that can be taught early in residency.2
Work like this is part of what made the Committee on Psychotherapy by Psychiatrists valuable. The unique convening authority of the APA brought together psychiatrist psychotherapy practitioners, teachers, and researchers from a range of schools of therapy to discover what they had in common, in the service of preserving and advancing psychotherapy as part of the identity, skills, and training of psychiatrists. With the end of the Committee, however, the APA was without a component to attend to the value of psychotherapy for psychiatrists, for psychiatry, and for psychiatric patients.
This might seem inconsequential in a field that was shifting dramatically toward a biomedical model to replace the previous biopsychosocial model, with a dramatic decline in provision of psychotherapy by psychiatrists, and a shift toward a practice model of diagnosis and prescribing in 15-minute medication checks.3 It was all going to be about biology. We hoped soon to find the genes that caused common mental disorders like depression and schizophrenia. According to this biomedical model of psychiatry, evidence-based treatments would be used to treat patients with specific disorders, and, in nearly all instances, the best treatments would be pills.
The problem is that none of these assumptions has been supported by emerging research.4 For example, despite the hope that we would find the genes that cause mental disorders, research teaches us that the genetics of mental disorders are highly complex and require thinking in terms of “gene-by-environment” interactions or epigenetics. It emerges, too, that early adverse experiences are profoundly powerful environmental contributors to later mental health, substance use, and even medical disorders. Despite our field’s preference for a model that is biomedical, research findings point us “back to the future” to “gene-by-environment interaction”—which turns out to be another way of saying “biopsychosocial.”
Further, despite the hope that evidence-based treatments for specific, single disorders would prove highly effective, we are discovering that comorbidity is the rule rather than the exception in our patients—despite the fact that, in the patient samples in randomized clinical trials, comorbidity is the exception rather than the rule. When patients have more than 1 disorder, the failure rates for our evidence-based treatments are quite high—higher still in patients with histories of early adversity—leading to recognition of the phenomenon of treatment-resistant illnesses.5
And when it comes to the best treatments being pills, we are confronted with evidence of overestimation of the benefits of medications through publication bias. For example, it has been suggested that the effectiveness of antidepressants has been overestimated by about a third when unpublished studies are included in data analyses.6 Meanwhile, as much as 75% of the effect of antidepressants is due to the placebo effect. (Darn those relationships with research personnel who keep administering scales and checking in about how patients are doing, those psychosocial interventions that seem to help patients even on placebo, and that approximate a form of supportive psychotherapy.) There is also evidence that those patients with early adversity respond better to therapy than to medications, and that the combination of medication and therapy may be optimal for many disorders, including disorders such as treatment-resistant depression.5
No one form of therapy seems to be superior to others. A recent “non-inferiority” study found no difference in effectiveness between CBT and psychodynamic therapy for major depressive disorder in a community mental health setting.7 Although there are a thousand studies showing that CBT works, there are also hundreds showing that psychodynamic therapy works—including evidence that both CBT and psychodynamic therapy are effective with patients with the most difficult treatment-resistant illness.8,9 Psychotherapy turns out to be quite a powerful treatment modality. In fact, psychotherapy is arguably a gene-by-environment interaction that we psychiatrists should know how to use with patients—not just depend on clinicians from other disciplines to do.
Given evidence that psychotherapy works and that the biomedical model needs some biopsychosocial revamping, and given the APA’s decision not to appoint a new Committee on Psychotherapy when APA finances improved after the publication of DSM-5, I spearheaded a grass roots effort that led to the establishment of an APA Psychotherapy Caucus in late 2014. Our original 10 members have grown to almost 300 members as of this writing—from medical students and residents to senior clinicians and researchers, from psychoanalysts to CBT therapists, to family and group therapists.10 The Psychotherapy Caucus is a “big tent” organization representing multiple schools of psychotherapy, a stance that I hope will be reflected in this column as well. It stands for the importance of psychotherapy by psychiatrists as part of the identity, skills, and training of psychiatrists, has an APA-managed list serve for intra-Caucus communication, meets at the APA annual meeting, and offers psychotherapy-themed presentations in the scientific program. The Caucus has also been fortunate to be the recipient of a grant from the Ernst and Gertrude Ticho Charitable Foundation to support the costs of its meetings. I invite interested psychiatrists to contact me if they wish to join. Look for more about the Psychotherapy Caucus in future columns.
Of course, it doesn’t matter whether therapy works if patients don’t have access to it. Reimbursement for psychotherapy has lagged, especially reimbursement for psychotherapy by psychiatrists when compared with reimbursement for prescribing. Despite the passage in 2008 of the Mental Health Parity and Addiction Equity Act or parity law, implementation of full parity has been slow. Under the parity law, barriers to treatment access for mental and substance use disorders must be comparable with those for medical and surgical disorders. The kind of quantitative limits (eg, limits on numbers of psychotherapy sessions that are not comparable with limits imposed, say, on appointments for people with diabetes) and nonquantitative limits (eg, higher utilization management burdens for access to psychotherapy than for access to diabetes follow-up visits) that are expressly forbidden by the parity law have continued largely unchallenged until recently. Some of this is because the “final rules” for parity have only recently been released, but I suspect that some of the difficulties also reflect the Obama administration’s reluctance to pursue parity violations aggressively against the same insurance companies it needs to support insurance exchanges under the Affordable Care Act. However, from the grass roots up, a number of lawsuits, including class action lawsuits, are taking on insurance companies about their parity violations—especially those involving denial of psychosocial treatments like psychotherapy and residential treatment. Media outlets such as the CBS program 60 Minutes and National Public Radio have begun to notice and pick up these stories.
Much has been done to re-establish the place of psychotherapy in psychiatry and related mental health disciplines, but much still needs to be done. It will take many efforts to accomplish this, but I hope this column will play a role. Undertaking this commitment, along with other similar work, was facilitated several months ago when Riggs named me its first Director of Biopsychosocial Advocacy. I see this role as involving advocacy in 2 directions: (1) clinical advocacy for the importance of psychotherapy and other psychosocial treatments as central parts of psychiatric thinking, training, and practice, and (2) social policy advocacy for full implementation of the parity law, which is very much part of ending stigma.
I see this role—and these columns—as part of another “big tent” approach to advocate for the value of psychotherapy and of psychosocial treatment more generally—not just for psychiatrists. Look for more on these issues in future columns. And if there is an issue you would like to see addressed here, please let me know.
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