Of all medical specialties, perhaps it is the practice of psychiatry that has experienced the greatest change in the past 40 years. The psychiatrist who offers psychotherapy has become a rare and dying breed. Most psychiatrists in practice in the U.S. today function exclusively as psychopharmacologists, spending less than 30 minutes with patients once every few months.
But it was not long ago that virtually all psychiatrists devoted at least a portion of their practice to psychotherapy—and some provided it exclusively to all of their patients. Psychiatrists trained in what I call the “golden era” of psychiatry—the 1950s and 1960s—learned to harness the great power of both talk therapy and the art of psychopharmacology, and employed both in complementary fashion. They rarely turned to drugs as first-line treatment, almost always used them in combination with psychotherapy, and would never dream of a practice devoted entirely to seeing patients in 15-minute increments and prescribing drugs all day.
But the psychiatry of today barely resembles that old psychiatry. How and why did this change occur? In order to answer this question, one has to understand the history of the field.
In the 1970s and 1980s, psychiatry was facing increased competition from nonmedical social workers, psychologists, and counselors who could also provide psychotherapy but at a lower cost than their M.D. psychiatrist colleagues. In fact, there was increasing concern amongst psychiatrists that these nonmedical mental health professionals would eventually overtake psychiatry’s market share of the population.
Faced with this competition, and armed with the newly developed psychotropic drugs, organized and academic psychiatry began a concerted shift towards a more biomedical approach. Medications became the mainstay of treatment, electroconvulsive therapy made a resurgence, and psychotherapy went by the wayside. Some residency training programs cut psychotherapy from their curriculum entirely.
In the following decades, government and pharmaceutical company funding increased greatly in the areas of psychopharmacology, neuroscience, and behavioral genetics, and funding for psychotherapy and psychosocial interventions decreased nearly to the point of nonexistence. Studies that showed promise for psychosocial treatment of severe conditions like schizophrenia were defunded. Loren Mosher, M.D., head of the schizophrenia research division at NIMH, lost his job after advocating for psychotherapy-based treatment of the disorder.
As research in pharmacological treatment expanded, insurance companies stopped reimbursing for psychotherapy. It became much easier—and much more profitable—for psychiatrists to see four patients an hour instead of one. All of these factors have contributed vastly to psychiatric medicalization.
What we have been left with is a psychiatry that, as Morton Reiser, M.D., at Yale once pronounced, has become a “mindless” discipline (Lieberman, 2015). The journals lead with articles on brain imaging and pharmacology rather than unconscious processes and transference analysis. Within psychiatry at least, psychotherapy is dead. Brain has become king.
Yet I have found in my instruction of psychiatry residents that many have interest in psychotherapy and plan to incorporate it in some fashion in their future practice. I doubt that the same sentiment would have existed in the early 1990s, the “decade of the brain”. Perhaps the pendulum is swinging back towards a more psychosocial psychiatry.
One can only hope. Psychotherapy is not only good for patients, but it is good for psychiatry, too. A skilled psychopharmacologist must have, at the very least, basic knowledge of psychodynamics and psychotherapy to be able to prescribe effectively. And the warm, empathic relationship fostered in psychotherapy can be an avenue for change in patients—and a change in perception about psychiatry.
As psychiatrist Daniel Carlat (2010) has pointed out, fifteen minutes and a pill is not enough. It is time for a return of the psychiatrist as a skilled and competent psychotherapist. Our patients depend on it.
Carlat, D. (2010). Unhinged: The trouble with psychiatry—a doctor’s revelations about a profession in crisis. New York, NY: Free Press.
Lieberman, J. (2015). Shrinks: The untold story of psychiatry. Boston, MA: Little, Brown & Company.