I write this as summer is ending; Congress has adjourned for its Labor Day recess and, barring a political miracle, major health reform is considered DOA, or at best (or worst) in a cryogenic coma, hoping to be warmed back to life in the next legislative year. As everyone related to psychoanalysis and to psychodynamic psychotherapy is aware, in the debate over benefits for mental illness one of the major battlegrounds has been the benefit to be provided for psychotherapy, especially long-term psychotherapy. The American Psychiatric Association, along with the American Psychoanalytic and other groups, has worked very hard to educate policy makers and the public about the nature, value, indications, and actual cost of psychotherapy and psychoanalysis. Within the field of psychiatry there are differences in degree of commitment to psychotherapy as a core rather than optional skill, and to the RRC requirement for psychotherapy training for general psychiatry. Yet psychodynamically based psychotherapy still seems to be the single most frequent intervention practiced by psychiatrists, and the APA has repeatedly affirmed its commitment to the support of psychotherapy as a core therapeutic modality, and to an understanding of psychodynamic principles as a core part of the knowledge base of psychiatry. At a meeting in July of APA officers and senior staff, psychotherapy was reaffirmed as a core part of psychiatry, but not without some hesitation and ambivalence being expressed.
As the issue of benefits for mental illness moved through Congress, we were successful in achieving parity coverage in the Moynihan and Mitchell proposals, and relatively generous coverage for outpatient psychotherapy in various other bills (e.g., 80/20 co-payment for successive but unlimited visits). But the controversy continues, benefits for psychotherapy remain debated and endangered, and the role and function of psychotherapy in the identity of the psychiatrist is increasingly at issue. At the same time, the usefulness, efficacy, broad applicability, special characteristics, and adjunctive benefits of psychotherapy all have been amply and repeatedly demonstrated, both anecdotally and by more scientific approaches. There is documentation that patients in psychoanalysis carry specific and serious diagnoses, are generally in analysis for definable periods of time, and generally improve significantly. There is such a thing as a rational and competent psychotherapy (including psychoanalysis) that operates according to theories, principles, guidelines, and procedures,
including ethical ones, and including the combination of psychotherapy with medication. So why does this problem exist? How has it come about? I would identify four major forces.
First and foremost, of course, is the revolution in the science of psychiatry, from a point where its roots lay almost exclusively in psychology to its current state, where they are predominantly biological. When I finished my psychiatry and child psychiatry residencies in 1962, and still when I completed psychoanalytic training in 1968, analytic training was important for academic careers, and most chairs of psychiatry departments were analytically trained or oriented. Almost the opposite is true today; if not an actual drawback, such training is of doubtful career advantage. A sea change has occurred in a relatively short time in the entire theoretical orientation of psychiatry, its diagnostic criteria and nomenclature, its scientific foundations, and its treatment possibilities, a change unparalleled in any other medical specialty. This is not only a source of great strength; it is also a source of competition and conflict.
A second force has been the remarkable generosity of analytically and psychodynamically trained psychiatrists and analytic institutes in willingly providing shortened training in psychodynamic psychotherapy to several generations of psychologists and social workers. The two rationales, or rationalizations, for this educational profligacy have been, first, that there was more demand than could ever be met by psychiatrists, and, second, that these trained psychotherapists would recognize the indications for analysis and would appropriately refer patients to their mentors. Of course, the actual result has been to contribute to the progressive demedicalization of psychotherapy, its separation from medical education and psychiatric residencies, and a growing uncertainty about the relationship between psychiatry and psychotherapy. An attempt was then made to repair the damage by coining the term “medical psychotherapy.”
A third, more recent, but increasingly compelling threat to psychotherapy is the growing role of capitated and managed care, especially affecting the treatment of mental illness. At least two major trends are evident: first, a general devaluation of psychotherapy, especially longer-term and psychoanalytic psychotherapy, with limits ranging anywhere from three sessions to twenty; and, second, a preference for the “less expensive” disciplines of psychology, social work, various forms of counseling, and sometimes nursing as the providers of psychotherapy, restricting the psychiatrist's role to assessment, crisis intervention, and the prescribing of medication.
Fourth, I would include the recent negotiated agreement (under the threat of antitrust litigation) to the nondiscriminatory admission of nonphysicians to full analytic training, so that many if not most institutes are now training more psychologists and social workers than psychiatrists, further energizing the controversy over psychotherapy's place at the core of psychiatry.
Despite all this, I still find it difficult to imagine a specialty of psychiatry that does not include psychodynamic theory as part of its core body of knowledge and that does not count basic competence in the conduct of psychotherapy among its core skills. I consider these components necessary and essential, though certainly not sufficient (as they once were), and I would consider the specialty of psychiatry impoverished were it to relinquish these components.
But even this does not convey the unique experience of satisfaction and reward that can accompany the conduct of successful psychotherapy—that feeling you have when you know, especially as a physician, that you have contributed to another persons growth, resolution of conflict, and greater capacity for love, work, and play; to a change in self-defeating or self-destructive patterns of behavior; and to an increase in autonomy and self-control. Psychiatrists whose training did not include psychotherapy, and who do not conduct is as part of their practice, cannot appreciate this experience and so wonder what all the fuss is about. They may view psychotherapy as something other disciplines should provide. For some, the affirmation of psychotherapy as a core component of psychiatry runs counter to hard-won scientific advances, remedicalization, and the increased respectability achieved by psychiatry over the past thirty years. But I see it just the opposite, and fall back on the by now trite but true observation that psychiatry should not have to lose its mind while finding its brain.
Jerry M. Wiener, M.D., is president of the American Psychiatric Association.