Keeping the Psyche in Psychiatry: Eight Years Later

Abstract

My first column as editor of this journal’s psychotherapy columns declared my prime objective in taking on the task: “Keeping the Psyche in Psychiatry.” 1,2 I am concerned about the practice by psychiatrists of well founded forms of psychotherapy in all psychiatric settings. I am a senior psychiatrist and psychoanalyst in private practice with a longstanding involvement in medical education and in professional organizations. To counterbalance my own perspective, I have often tried to write in more general terms than my own psychodynamic orientation. Invited guest columnists have written from the perspective of other schools of psychotherapy as well as other professional environments. Of course, I have not been alone in this quest. Numerous psychiatrists in leadership positions—from widely varying practice settings and all parts of the country, as well as academic psychiatrists and even some leaders in managed care—have expressed their concern about the fading role of psychotherapy and the decreasing interest in the patient’s personal narrative 3 in psychiatric practice. They lament the decline of the psychotherapy skill set in many recentlytrained psychiatrists. In my initial column, I highlighted the American Psychiatric Association’s Commission on Psychotherapy by Psychiatrists (COPP), of which I had been chair. COPP is now a committee of the same name reporting to the Council on Quality Care. It comments frequently on psychotherapy issues, writes or revises position statements, reviews practice guidelines, contributes to the design of psychiatric practice surveys, makes presentations at scientific meetings of the American Psychiatric Association, and has completed a paper differentiating the common, often supportive denominators of psychotherapies and their divergence into distinctively psychodynamic and cognitive-behavioral methodologies. COPP continues to be a respected voice for psychotherapy by psychiatrists in the American Psychiatric Association. However, it is only one of many forces at work to advance the cause. Now, almost 8 years later, what has been accomplished? In the past year, several major, longstanding efforts have come to fruition with beneficial implications for psychotherapy by psychiatrists. On the down side, a recent study shows that the trend continues for psychiatrists to provide psychotherapy for a smaller proportion of their patients, with more psychiatrists doing no psychotherapy at all. The well-rounded psychiatrist skilled in the full armamentarium of treatments is still an endangered species. Like the proverbial three-legged stool, the viability of psychotherapy by psychiatrists rests on the complex interaction of three bases—scientific support, availability of training, and financial reimbursement. However, in the new healthcare environment, a fourth leg is equally essential—privacy.