SHOULD PSYCHIATRISTS PRACTICE PSYCHOTHERAPY?

Vol 5 # 3

Alan Eppel, Pri Weerasekera, Karen Rowa

INTRODUCTION

Mental health services are likely to undergo major transformations in the next 5 to 10 years due to widespread social, economic and technological changes. Despite large investments in mental health and psychiatric services in many countries there has been limited progress in the mental health of populations.

Mental health reforms have not achieved the hoped for results. Progress in psychopharmacology made a very significant impact in the decades following the discovery of Chlorpromazine in the 1950’s  but this progress has stalled with no general qualitative breakthroughs in the development of new medications over the past 20 years.

In contrast there have been important developments in the field of psychotherapy. There has been extensive research on effectiveness and outcomes. There are good quality studies of CBT,IPT, EFT, DBT and psychodynamic therapies. Non-medical psychotherapy services have been funded by the National Health Service in the United Kingdom (Improving Access to Psychological Therapies) and Australia. Similar plans have been proposed in Quebec and Ontario.

The future role and scope of psychiatry has been reviewed by a commission of the World Psychiatric Association and Lancet Psychiatry. The commission was made up of mental health professionals, researchers and service users and examined therapeutic, societal, legal and funding dimensions. With regard to psychotherapy they concluded:

“The ongoing expansion of clinical research on psychotherapy interventions, both alone and in conjunction with other treatments, should lead to broader acceptance of the efficacy of psychotherapy. Unfortunately, the paucity of resources available to deliver psychotherapeutic treatments and the expense and time required to train skilled psychotherapists will substantially constrain most patients’ access to this form of treatment. Owing to the scarcity of high-quality psychotherapy research, psychiatrists are still unable to predict for which patients psychotherapy will be effective, nor which form of psychotherapy will be most appropriate for a specific patient.”

 In this edition of the Journal we have asked three psychotherapy educators and practitioners to address these questions:

Should psychiatrists practice psychotherapy in the future? If so which types of psychotherapy?

Is it possible to train psychiatrists adequately?

What roles will psychiatrists have vis a vis psychologists or other healthcare providers in provision of psychotherapy ? Who should provide which therapy to whom?

Should other modalities of intervention take precedence: biological treatments, the recovery model, community interventions?

KAREN ROWA

Karen Rowa is a psychologist at the Anxiety Treatment and Research Clinic at St. Joseph’s Healthcare Hamilton and an Associate Professor in the Department of Psychiatry and Behavioural Neurosciences at McMaster University.  She is the Training Director of the Clinical Psychology Residency Program at St. Joseph’s Healthcare in Hamilton, Ontario.  Dr. Rowa has published over 50 peer-reviewed articles and chapters, as well as two books in the area of anxiety disorders, hoarding disorder, and obsessive compulsive disorder.

I fully support that psychiatrists, along with many other regulated mental health professionals, might practice psychotherapy as part of their practice if they choose to do so and have the appropriate training and experience.   This practice could involve any form of evidence-based psychotherapy, so will again depend on the individual’s training, experience, setting, client population, etc.   Indeed, many psychiatrists have developed expertise in a particular form of psychotherapy and this expertise could be of great help to many patients.  Further, psychiatrists may be in a unique position to marry psychotherapy with their medical knowledge and training for particular patients with complex presentations. For example, patients with complicated medical presentations might benefit from receiving psychotherapy from someone who is integrating the potential influence of the medical condition on the presentation.

On the other hand, a practice with an exclusive focus on psychotherapy (to the exclusion of providing the other services that are unique to the training and skill set of psychiatry) loses some of the core skills fostered and developed within psychiatry.  The expertise and skills of psychiatrists are unique and important.  For example, it does not seem reasonable for family physicians to be tasked with medication decisions for complex psychiatric disorders when psychiatrists have specific training in the diagnosis and management of these presentations.  Psychiatrists also bring knowledge about other biological treatments that may be helpful for patients.  They can consider the influence of medical or biological factors when making diagnostic decisions and treatment plans.  They have seen, diagnosed, and treated mental health problems across the spectrum of acuity.  These roles are important and necessary within our medical system and cannot always be replicated by other specialties or disciplines.

As a psychologist, one may argue that my opinion could be unduly influenced by a proprietary ownership of psychotherapy, a strong part of the training of clinical psychologists.  However, I would make the analogous argument for most health care professions that practice psychotherapy; psychotherapy can be capably offered by multiple disciplines.  It is the value of a professional’s unique role and contribution that also should be preserved whether we are discussing psychologists, psychiatrists, social workers, nurses, occupational therapists, etc.  The practice of psychotherapy could be a part of any qualified and trained health professional’s role (for those legally able to practice psychotherapy), but the unique offerings of each profession are essential to maintain.

The next question concerns whether psychiatrists are provided adequate training in psychotherapy.  In current models of residency training, psychiatry residents are provided a strong overview and foundational knowledge across a range of therapeutic modalities.  They need to demonstrate basic competency in these modalities, usually by seeing a case under close supervision.  This model is an excellent start.  For psychiatrists who will not provide psychotherapy in their future practices, it seems perfectly adequate to have a strong understanding of what each therapy “looks like”, for whom the therapy will work, the most up-to-date evidence base for the therapy, etc. However, it is naïve to expect that this amount of training will provide a robust enough foundation for strong competency in any one particular therapy.  For most psychiatrists aiming for proficiency or expertise in a particular therapy, they will have to pursue additional training and experience (e.g., psychotherapy fellowships, ongoing workshops and supervision, etc.) and the burden of this will fall to the individual practitioner.

In closing, the arguments above are the opinions of a psychologist who has had the great privilege of working within multidisciplinary teams that have included psychiatrists for over 20 years.  The immense and unique value that my psychiatry colleagues (as well as other disciplines) have offered our teams has shaped my opinion that we need to preserve what is unique about all mental health professions.  Psychotherapy is important, helpful, and meaningful.  However, it is not unique.

PRI WEERASEKERA

Dr. Priyanthy Weerasekera is Professor and Postgraduate Psychotherapy Coordinator in the Department of Psychiatry and Behavioural Neurosciences, McMaster University. She obtained an MD from McMaster, and an M.Ed from Harvard University. With her colleagues she has developed an award-winning postgraduate psychotherapy training program. and developed an program of Psychotherapy Training e-Resources (PteR) which is being used by many academic institutions across North America, and internationally. Her major interest, and the focus of her many publications, continues to be in incorporating evidence-based teaching methods in psychotherapy training.

As an academic psychiatrist I have spent almost 30 years developing and coordinating an evidence-based psychotherapy program for psychiatry residents.  In order to maintain this program, I have spent a great deal of time reviewing the psychotherapy outcome and training literature.  There is a substantial body of research, that includes well-constructed meta-analyses including Cochrane reviews that have pointed to the effectiveness of many different forms of psychotherapy. Carefully designed studies have also examined effective training methods.  This literature can help answer some of the questions posed in this article.

First, I think it is important to point out that psychotherapy is not “owned” by any discipline. A brief history of psychotherapy reveals that contributions have been made by many professions: Freud (neurologist), the father of the first form of psychotherapy, psychoanalysis, which later became psychodynamic therapy; Aron Beck (psychiatrist)  founder of cognitive therapy for depression; Irvin Yalom (psychiatrist) developed Existential Psychotherapy and later expanded this to Group Psychotherapy; Nathan Ackerman (psychiatrist) founded family therapy; and  Myrna Weissman (social worker) developed Interpersonal Therapy, which was based on the work of Harry Stack Sullivan (psychiatrist). We also know of the many influential psychologists: Wolpe and Skinner (founders of behaviour therapy); Carl Rogers (developed client-centered therapy);  Les Greenberg (developed emotion-focused therapy); Marsha Linehan  (developed DBT); William Miller (developed Motivational Interviewing); and the list goes on.

Therefore, many mental health professionals have contributed to the field of psychotherapy, and no one discipline can claim ownership. However, I might add that it is our psychology colleagues who have advanced the field of psychotherapy, as they have carried out the difficult and essential research that has demonstrated the effectiveness of psychotherapy, and they continue to develop new models which have refined the earlier work.

Moving to the questions posed above I will address them in the order that makes sense.

Can psychiatrists be trained adequately? Three decades of psychotherapy research shows that all mental health professionals (psychiatrists, psychologist, social workers, mental health nurses, etc.) and learners within these professions, are able to reach competence in multiple forms of psychotherapies when assessed by validated therapist competence scales, and this includes psychiatry residents.  This has been well established.  In addition, closer to home, preliminary, unpublished data collected over 24 years at McMaster University indicate that psychiatry residents are able to attain competence (assessed by experts using validated therapist competence scales) in several forms of psychotherapy, including EFT, CBT for depression, CBT for Anxiety and IPT (results presented at Ontario Psychiatric Association meeting, 2019). It is important to differentiate between competence and proficient. Most training programs likely produce competent practitioners as defined by a therapist scale.  This level of competence has been associated with good patient outcomes. It is true that proficiency requires greater experience with many more cases, but the evidence that proficiency produces better outcomes is unclear. More experienced and proficient therapists do tend to do better with more complex, and difficult patients.

Of concern however is how the different professions compare with respect to training standards. Interestingly psychiatry is the only profession that has strict guidelines regarding comprehensive psychotherapy training. The Royal College (2006) mandates that psychiatry residents receive training in Supportive, CBT, Psychodynamic, DBT, Group, IPT, and Family; whereas the Canadian Psychological Association (CPA) and the Ontario College of Social Workers do not provide any specific psychotherapy guidelines for their trainees. Most clinical psychology programs train their learners in only 1 form of psychotherapy, mostly CBT, even though the CPA recommends training in more than one intervention.  .

Survey data (2006) of schools of different mental health professions (75% response) in the US revealed that psychotherapy requirements in psychiatry residency programs far exceeded that of Psychology and Social Work programs.  Over 90% of psychiatry programs required their residents to complete supervised psychotherapy training  in Psychodynamic, CBT, IPT, Group, Family etc. Figures were significantly lower for other specialties (11-50%). Interestingly 96% of psychiatry residency programs required residents to complete supervised CBT training compared to only 52% of psychology programs. A more current survey is needed to see if these figures have changed. Canadian data reveals similar training requirements for psychiatry residents but there is no data for the other specialties.

Therefore, the literature indicates that the standards for psychotherapy training for psychiatry residents are much more rigorous than the other professions, with programs requiring there trainees to complete clinical supervision in a wide range of therapies. Evidence indicates that psychiatry residents are also receiving more CBT supervision than students in clinical psychology programs, as this is not a requirement in clinical psychology programs, a very surprising finding.

Should Psychiatrists practice psychotherapy in the future? If so which types? Given the psychotherapy training that psychiatrists receive in residency, they are well placed to offer a variety of psychotherapies to patients with psychiatric disorders, if they chose to do so. These therapies include psychodynamic, CBT, IPT, group, family, DBT, etc.

What roles will psychiatrists have vis a vis psychologists or other healthcare providers in provision of psychotherapy? Psychiatrists are positioned to provide comprehensive assessments, and can conceptualize patients from a biopsychosocial model. This lends itself to a more integrated treatment plan which can include medications and different forms of psychotherapy. Psychiatrists may decide to provide medications while other health care professionals such as psychologists and social workers deliver psychotherapy. This model is likely common as a result of older psychiatrists not having received comprehensive psychotherapy training and financial pressures influencing their decision (poor funding for psychotherapy).  However, evidence from the US has shown that a fragmented treatment model, although common, does disrupt the therapeutic alliance, patient compliance, and increases overall health care costs.

When selecting a psychotherapy (or psychotherapies) for a particular patient, it is important to adopt a differential therapeutics perspective.  Research demonstrates that many psychotherapies are effective for the treatment of depression yet not all patients benefit from CBT or IPT or psychodynamic.  It is important to identify which therapy might be best suited for a specific patients. These are the more difficult questions and there is some research to help us make these decisions.

It is important that psychiatrists treat the more complex patients. These patients rarely improve with one form of treatment, and usually require medications and multiple psychotherapies. In some cases treatment may need to be delivered by one practitioner, particularly if there are trauma issues that make it difficult to have multiple health care providers. It is also important for psychiatrists to help with access. Patients need to be able to see psychiatrists for consultations and for treatment.

Who should provide which therapy to whom? Therapists who have comprehensive psychotherapy training may be better able to select which therapy is more suitable for a patient. If you are only trained in CBT, you can only see a patient from this perspective.  Similarly, if you only trained to deliver SSRIs for depression, then your medical treatment options for depression are limited. Selecting a psychotherapy for a patient is based on the patient’s diagnosis, comorbidities, personality variables, capacity to form a therapeutic alliance, resistance and reactance variables, and many other factors that have been empirically investigated. Not all patients benefit from CBT or IPT or psychodynamic. Many patients are unable to participate in group therapy.  However if CBT is indicated perhaps a psychologist may have greater expertise to deliver this. If it is family therapy therapy that is needed perhaps a social worker? But we must remember that these are not rigid rules. Psychotherapy, like all treatments should be delivered by a trained individual. It is the standard of training that is important, not the specialty.

Should other modalities of intervention take precedence: biological treatments, the recovery model, community interventions? All modalities should be considered.  If the evidence supports the use of a specific intervention either alone or integrated with other treatments, then they should be part of integrated psychiatric care.  It is also important that community interventions are not diluted. The UK-IAPT model (the delivery of CBT-light to patients with sub-threshold symptoms of depression and anxiety by counselors and psychologist), although initially considered effective, has demonstrated high early drop outs and significantly high relapse rates within 1 year. These models should not be applied elsewhere until long term research establishes that they are in fact effective.

In summary Mental Health Services are facing significant social and economic challenges. Research demonstrates that psychotherapy is an essential treatment for patients with psychiatric illnesses. As mental health professionals we must continue to ensure standards

in training to improve our competence in the delivery of psychotherapy.  We must work together as a multidisciplinary team to find the best delivery models, without dividing us as professionals.

ALAN EPPEL

Alan Eppel is a professor in the Department of Psychiatry and Behavioural Neurosciences, McMaster University. He has been a supervisor in psychodynamic psychotherapy at McMaster over the past 15 years. He is the author of Short-Term Psychodynamic Psychotherapy. He has a particular interest in integrating psychotherapeutic and psychopharmacological interventions for patients with complex psychiatric disorders.

Psychiatrists are medical specialists. It takes many years of training and experience to reach a peak level of performance. Psychiatrists are expert diagnosticians and are trained to consider a broad range of interacting domains: neurobiological, psychological, social, developmental.  Psychiatrists can make the best impact when they utilize their knowledge and skills to deal with the most complex and pressing psychiatric disorders.

Psychiatrists cannot practice well without a high level of psychotherapeutic skills. The therapeutic relationship between psychiatrist and patient is central to all other interactions. Psychiatrists need high quality training and the ability to establish a therapeutic alliance. They must be able to recognize and respond to emotions, and understand the multiple factors that can impact on the treatment relationship and on the outcomes of treatment.

I would propose that psychiatrists are best placed to undertake psychotherapy with the more complex patients that have major psychiatric disorders and high risks e.g. :

Patients with PTSD, those at high risk of suicide, those with Treatment Resistant Depression and those with multiproblem/ co-morbid presentations where a combination of psychotherapy and other forms of intervention such as psychopharmacology,  ECT and TMS may be required.

Psychiatric psychotherapy should conform to the best standards of evidence available. Outcome measures should be rated routinely to assess progress. Training in psychotherapy for psychiatrists needs to be rigorous. It must include direct observation by supervisors and audio or videotaping of sessions. 

There are areas of significant agreement among the three authors of this article but there are also some divergencies. The resolution of these differences can be attained by recourse to empirical study.

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