Psychiatry residents need to learn psychotherapy

For years, I supervised residents. They would come in each week and tell me about a patient in crisis. If no one was in crisis, they’d say all their patients were fine and they didn’t know what to talk about, even though I had told them to pick a patient they saw weekly and either audio-record the sessions or take detailed process notes. Psychotherapy, I would say, is a process that occurs over time; it’s not always about the latest crisis. I once inspired a resident to record some sessions, but they were difficult to hear, and another resident took process notes, but those two were the exceptions.

I thought it was me, so I asked some other psychiatrists for suggestions. A psychoanalyst told me the residents were anxious about having their work scrutinized and I should address the anxiety. It seemed like a great idea, but it didn’t work. Another colleague suggested I tell them if they didn’t bring process notes, I would tell their training director. This tactic just didn’t feel right. Even the residents who were interested in learning psychotherapy were not seeing patients weekly, and one told me they were just too busy for regular psychotherapy sessions.

I finally realized that it wasn’t me. The residents were not primed to understand or do psychotherapy, and I was catching them too far along in the process. Many have no interest in ever seeing a patient for psychotherapy, and they’ve bought in to the idea that psychiatrists “manage meds.”

I believe that people in general, and psychiatrists in particular, should do what they like doing. I don’t believe that every psychiatrist in every setting needs to practice psychotherapy, and even if I did, no one would listen. I do, however, think that every resident should learn to do traditional (and I suppose that means psychodynamically-based) psychotherapy, even if they never plan to see another therapy patient after their training is complete. Let me tell you why I believe that:

  • Psychotherapy is a fundamental component in the treatment of mental illnesses. Psychiatrists should have a good understanding of what psychotherapy is, how it is done, what problems it treats effectively, what problems it does not address well, and what types of issues may come up in the course of a psychotherapy. It’s not just about symptoms and diagnoses — just as we don’t know whose depression will lift with Prozac and who will develop a discontinuation syndrome after stopping Paxil, the outcome of psychotherapy remains unpredictable and residents should treat a variety of patients in order to appreciate the variables that influence outcomes. I don’t believe this is something one can learn from a textbook.
  • Learning to do psychotherapy well prepares psychiatrists for interactions that will occur with patients outside of a traditional psychotherapy. It helps psychiatrists to learn the importance of active listening and understanding unspoken components of interactions, and these are important during even brief appointments.
  • There is a vocal (and growing) body of patients and ex-patients who feel they have been harmed by psychiatric treatments. It may be that patients who meet with psychiatrists for brief, time-pressured encounters are more likely to feel victimized by psychiatric treatments. The media feeds this anti-psychiatry frenzy when it portrays psychiatrists as being all about medications. Psychiatrists are no longer seen as being interested and caring, and this is not good for our profession.
  • When treatment is focused solely on diagnosis, symptoms, and medications, it leads psychiatrists to make decisions with tunnel vision. It further encourages patients to identify their symptoms as the result of illness and inadequate, or suboptimal, medication management and it leaves some patients to believe they have no ability to modify their own feelings or behaviors. Since most psychiatric symptoms are also part of the normal human experience in the absence of psychiatric illness, an understanding of the psyche on a richer level gives the psychiatrist a better understanding of how to approach human suffering and how to differentiate these experiences from psychiatric disorders.
  • What happens in psychotherapy can certainly influence the course of treatment.  A psychiatrist who is not trained in psychotherapy can not judge whether the therapy provided by other mental health professionals is adequate or appropriate and is certainly not able to direct treatment.
  • Good therapeutic skills enhance the therapeutic alliance and this may well improve both adherence to medication regimens and treatment outcomes.
  • There continues to be a demand for well-trained psychiatrists who can provide both psychotherapy and medications.

In case you’re wondering, the Accreditation Council on Graduate Medical Education program requirements for psychiatry is 35 pages long. The words “psychotherapy” and “psychotherapies” appear a total of four times.

Dinah Miller is a psychiatrist who blogs at Shrink Rap and co-author of Shrink Rap: Three Psychiatrists Explain Their Work.

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