Psychiatric perspectives on psychotherapy

Abstract

D URING MODERN TIMES, psychotherapy has held a central position within the practice of psychiatry. Recently, numerous questions have been raised regarding the efficacy and efficiency of the many psychotherapies. In order to clarify the continued importance of psychotherapy in psychiatric practice, this article presents a framework delineating the focus and goals of psychotherapy within four major task areas: medical, rehabilitative, educative-developmental and societal-legal. Within these areas, the physician-patient role relationship, and the perspectives that are adopted will be examined so that the many approaches to psychotherapy can be better understood. From the end of World War II until the mid 1960s psychotherapy generally was viewed as the most sophisticated tool in psychiatry’s technologic armamentarium. Within many psychiatric educational programs, proficiency in developing the skills required to become a competent psychotherapist was a central training goal. The 1960s witnessed a period of major social experimentation, some of whose programs had major impact upon psychiatry and psychotherapy. The passage of the Medicare, Medicaid and Community Mental Health Center Acts dramatically increased accessibility of services and changed the financing and structures of health care delivery. In psychiatric practice the consequences were enormous. In 1955, approximately 1.7 million episodes of care were provided with one-half of these services occurring in inpatient state and county mental hospitals. Less than one-quarter of the 1.7 million episodes in that year were provided in ambulatory mental health facilities. In 1975, almost 6.4 million episodes of care were provided in mental health facilities. The vast majority of these services were outpatient services. Community mental health centers accounted for 29% of services and organized outpatient psychiatric services accounted for 47% (about 20% of the total episodes were seen in private office practice). ’ During this period, insurance coverage for psychiatric illness and disorders was significantly increased, and ambulatory services were more adequately covered. In the early 1960s it was anticipated that the number of psychiatric patients presenting for service would massively exceed the capacity of psychiatrists to care for them, a prediction clearly borne out by history. Thus, the federal government began programs to dramatically increase the number and types of available nonmedical practitioners. The NIMH sponsored training for members