Will the psychiatrist of the future know how to conduct skillful psychotherapy? This question would have been unthinkable a generation ago, but many trends have made it a serious matter. Amongst the havoc wrought by managed care is the current expectation that psychiatrists will offer fifteen-minute medication checks and in general not engage in psychotherapy, leaving what limited psychotherapy is allowed to non-medical clinicians. The rapidly expanding knowledge of neurobiology and psychopharmacology has led to a much greater emphasis on biological models in psychiatric residency training. Furthermore, psychiatric residents now rotate rapidly through a variety of short-term assignments and have few opportunities to develop psychotherapeutic relationships with patients over time.
Medical psychoanalysis is seriously affected by these trends, which have already drastically lowered the availability of psychiatrists for psychoanalytic training. Regrettably, a number of psychiatric members of the American have expressed their displeasure by not joining the American Psychiatric Association or by resigning from it. The withdrawal of analysts from the premier psychiatric organization diminishes the influence of psychiatrists who are deeply committed to preserving psychotherapy as an integral part of psychiatric practice. By their absence, psychoanalysts contribute to a self-fulfilling prophecy of the dominance of psychopharmacology within the field
APA leaders are in fact deeply concerned about the danger of dropping psychotherapy from the skills and identity of the psychiatrist. In 1996 the APA established a Commission on Psychotherapy by Psychiatrists (COPP), charged to reaffirm and strengthen the role of psychotherapy as a core skill of the psychiatrist. The commission has high visibility and significant power to effect its recommendations. It has been strongly supported by each successive APA president. Its membership includes prominent members of the American, along with leading researchers and teachers of cognitive-behavioral therapy, interpersonal psychotherapy, group therapy, and family/systems studies. The current chair is Jerry Kay, and the vice-chair is Glen Gabbard.
COPP rapidly became a focal point for activism by psychiatrists on behalf of psychotherapy. It formed a formal liaison with the Canadian Psychiatric Association and welcomed informal liaisons with organizations representing psychoanalysis; child and adolescent psychiatry; community psychiatry; directors of psychiatric residency training; group, family, and systems therapies; and a variety of APA minority caucuses. All contribute actively and take on tasks with enthusiasm, so that COPP has accomplished a great deal in its short existence.
A major role is keeping psychotherapy front and center in the priorities of the APA. COPP reviews position statements and practice guidelines and contributes to many activities to reinforce the appropriate influence of psychotherapy. COPP makes presentations at the huge APA annual meeting in May and the smaller Institute for Psychiatric Services in October. Continuing education is under development to build psychotherapy skills for practicing psychiatrists, especially those recently out of residency and international medical graduates.
COPP decided early to hit hard at the trend toward declining psychotherapy training for psychiatric residents. It obtained APA approval of a structured, modular training program using workbooks, tapes, and interview transcripts to convey core elements of all psychotherapies and prepare new residents for actual work with patients. To rebuild morale and develop new skills in teaching psychotherapy, COPP presents an annual Advanced Strategies Initiative for residency training directors just prior to the meeting of the American Association of Directors of Psychiatric Residency Training. One indication of reversing trends in residency training is a recently established requirement by the Psychiatric Residency Review Committee of the Accreditation Council for Graduate Medical Education that residents demonstrate competence in five modalities of psychotherapy, with psychodynamic psychotherapy heading the list.
Initiatives are also under way to improve psychotherapy research and bring studies closer to real-life experience. These involve the National Institute of Mental Health and the new American Psychiatric Institute for Research and Education, which conducts the APAs Practice Research Network.
What about managed care? Working with other APA components, COPP is now exploring contacts with managed care executives and business leaders to reverse the damaging trends in health care financing. An important part of this enterprise is assembling data. For example, the available studies show that splitting psychotherapy from pharmacological management by different clinicians does not save money. The incidence of malpractice actions rises in high-volume (and therefore short-session) practices disproportionately to the number of patients seen. It remains to be seen whether psychotherapy by psychiatrists in a managed care environment continues to be an oxymoron. But with COPP on the scene, psychotherapy by psychiatrists will not go down without a fight.
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Norman A. Clemens, M.D., is a training and supervising analyst in the Cleveland Psychoanalytic Institute, a Fellow of the Board on Professional Standards, a clinical professor of psychiatry at Case Western Reserve University, and Area 4 Trustee of the APA. He was chair of COPP from 1996 to 2000.