Psychological Management Set against Pharmacotherapy: A Scholastic Challenge in Contemporary Psychiatric Training
Published on: 2019-12-24
Despite the fact that the swing of the pendulum toward biological psychiatry has led, in general, to a downgrading of psychotherapy within the realm of psychiatry, in current years a fresh debate regarding practice of psychotherapy by psychiatric residents and psychiatrists has gained a new place in the realm of academic training. Such kind of encouragement, for using psychotherapy on behalf of patients who are suffering from psychiatric complications, has instigated essential modification in the contemporary educational programs in different countries, including developing civilizations. In the present paper the exact condition and outlook of such an amendment has been discussed to understand that whether simple addition of a national curriculum can answer back, applicably, to increasing necessities of mental health in developing cultures, and how the honest exercise of psychological managements by psychiatrists can be improved.
KeywordsPsychiatry; Mental health; Psychotherapeia
Psychotherapy, wrote Freud, in his 1905 paper of that name, is in no way a modern method of treatment. On the contrary, it is the most ancient form of therapy in medicine . According to the Oxford English Dictionary, the earliest use of the term “psychotherapeia,” meaning “remedial influence of the mind,” appeared in the 1850s. By 1897, in a textbook of mental disease, the term “psychotherapy” was defined as “every means and every possible agency which primarily affects the psychical rather than the physical organization of the patient in a curative direction.” . In an early paper, On Psychotherapy, for example, Freud wrote that psychotherapy seems “positively unscientific and unworthy of a serious investigator” but asked his reader to allow him to defend it: “There are many ways and means of practicing psychotherapy, to the method Breuer called ‘cathartic,’ but which I prefer to call ‘analytic.’”  Consequently, there is a new emphasis on psychosomatic characteristics of medicine with evolving motivations to re-integrate psychotherapeutic procedures into general medical practice .
Minor and major techniques in psychotherapy
In this regard, simple psychotherapies are formal varieties of the therapeutic element of physician– patient interactions that consist of counseling, psycho-education, problem -solving skills and supportive psychotherapy. The technical, structured or major psychotherapies as well can be divided into two categories: those that have been derived from psychoanalysis (i.e. psychoanalytic or psychodynamic psychotherapy) and those which are founded on cognitive and behavioral theories. Also, there are several mixed or hybrid therapies, like Cognitive Analytic Therapy (CAT), Interpersonal Therapy (IPT), and Dialectical Behavioral Therapy (DBT). Other widespread well-known methods include Family therapy and Group therapy . Generally, psychotherapy includes any kind of psychological intervention that is planned to enhance adaptive functioning and reduction of distress or maladaptive behavior .
Research In Psychotherapy
The question of whether psychotherapy works has been definitely answered. There is a plethora of evidence from efficacy and effectiveness studies indicating that therapy is effective in alleviating emotional distress and behavioral dysfunction. Questions being addressed by researchers include the relative importance of specific (e.g., interventions) versus nonspecific (e.g., the alliance) curative factors, differential effects of treatment techniques (i.e., are some interventions more powerful for some clients or conditions), and the transfer of research methods and technology to actual practice [4,5].
Efficacy studies evaluate the sufficiency of a specific treatment to reduce distress, symptoms, and impairment with a group of patients having a particular psychiatric disorder. Therapists are trained to conduct the competing treatments to maximize the integrity of putative therapeutic ingredients . Effectiveness studies are concerned with whether psychotherapy delivered in actual clinical settings is effective in reducing the symptoms, distress, and dysfunction associated with mental illness  In addition, hundreds of meta-analyses of psychotherapy have been conducted, and most have reached the same general conclusion [6- 8].
Psychotherapy and pharmacotherapy: completing or competing procedures
Perhaps the most consistent finding in comparative research into the treatment of mental illness is that combining psychological and biological treatments provides the maximum likelihood of benefit. While various meta-analyses have found psychotherapy and pharmacotherapy to be equivalent in efficacy at both post-treatment and follow-up, and combined psychotherapy and pharmacotherapy has been routinely found to be superior to either alone , some important variables as well are existent, which may well separate these two from each other  (Table 1).
Table 1: Different variables related to outcome of psychotherapy.
Treatment Variables Related to Outcome
Patient Variables Related to Outcome
Patient Demographic Characteristics
Patient Cognitive Characteristics
Patient Clinical Characteristics
Psychotherapeutic prospectus and training of psychiatric residents
For many years, psychiatric training was the same with learning psychotherapy. As one psychiatrist had narrated, “In 1952, becoming a psychiatrist meant becoming a psychotherapist.” In contrast, present psychiatric apprentices planning their forthcoming practices face several choices for incorporating psychotherapy and psychopharmacology, involving providing principally drug-focused visits . Such a shift has caused one noticeable professor to answer “yes” to the challenging label of his article, “Are psychiatric educators ‘losing the mind” . But in contrast, the practice of psychotherapy by psychiatrists has dropped around 20 % from 2002 to 2010, maybe due to low repayment planes and the incapability of a lot of patients to pay for psychotherapy sessions out of pocket, based on outcomes from a 2010 study completed by 394 working psychiatrists [12,13]. Accordingly, although there was a new remarkable drop in the delivery of psychotherapy by means of psychiatrists in the United States of America, this tendency maybe is due to a decline in the number of psychiatrists specializing in psychotherapy and a parallel escalation in those focusing in pharmacotherapy - alterations that were probably inspired by economic reasons and growth in psycho-pharmacological managements in recent years . One consequence of these powers has been to produce a lost generation of psychiatrists with slight familiarity or practice with psychoanalytic treatments . In this regard, novel forces and priorities presently strengthened in educational psychiatry contradict the significance of psychodynamic psychotherapy and, by extension, its basic conceptions such as ‘unconscious’, ‘defense and resistance’, ‘transference and countertransference’, and ‘the past repeating itself in the present’. Parenthetically, a recent shift in academic world that prioritizes Evidence-Based Medicine (EBM) and a deficiency of psychiatrist investigators in the field of psychotherapy can be important threatening factors [15,16]. Though psychiatric residents usually thought that their training managers had sustained psychotherapy teaching, nearly 30% was not certain that other key academic leaders were similarly supportive [17,18].
Negative attitudes toward admitting that one has a psychiatric problem and toward seeking care from a specialty mental health provider have actually increased over the last five decades . J. West' wrote a paper entitled "The Future of Psychiatric Education." In it he had foreseen that by 1984 most psychotherapy will be done by psychologists and social workers and much of today's office psychiatry by internists and family practitioners. Though he notifies against losing the "expertise in psychodynamics accumulated over the past 90 years," he nonetheless sees future psychiatrists as much more of behavioral scientists, endocrinologists, and neurologists than their forerunners .
According to Bertram Brown , former Director of the National Institute of Mental Health, the era of the analyst and dynamicist in psychiatry seems to be done and the epoch of the biological psychiatrist is upon us [22,23]. Conversely, Sederer believes that psychotherapy, as like as moral therapy in past era, is very hard to do, and had felt that the medical model is very seductive, especially to medical students, for the reason that it includes a lesser amount of personal anxiety on a therapist's part [24,25]. On the other hand , when available meta-analyses have shown that psychotherapy, and ‘Complementary and Alternative Medicine (CAM)’ are effective, mainly or completely, because of circumstantial aspects rather than the definite disease-treating issues suggested by the therapy or therapists, and psychotherapists are the most important circumstantial feature and their effectiveness varies from zero to about 80%, and , also, studies have failed to detect what makes a good (i.e. fascinating) psychotherapist, expecting todays psychiatrist to spend enough time on psychotherapy or to trust its scientific value is not an easy task [26,27]. Such set of circumstances inspires and allows psychiatrists to return quickly to medicines or increasing their dosages if met with refractoriness or elongation of symptoms. Although psychiatrist may sometimes properly distinguishes that probing of unconscious struggles, intellectual biases, prime suppositions, and personal interactions are necessary for crucial modification of psychological processes, the abovementioned dynamics, stops psychiatrist from expending adequate amount of time and effort intended for psychotherapy [28,29]. Nevertheless, if we consider the reducing practice of psychotherapy in the advanced societies, then we can foresee its sluggish advancement and possibly unclear prospect in developing countries. Even though in a new study and opposing to the existing facts, it has been proclaimed that 80.9% of psychiatrists in Canada continue to incorporate pharmacotherapy and psychotherapy in their clinical practice, and the delivery of psychotherapy among psychiatrists that have been graduated in the preceding 10 years has been greater than before, disregard to the rate of drop-out, since it has not discriminated simple approaches from structured, major or hybrid techniques, the conclusions cannot be recognized as flawless . Anyway, as has been stated by some lecturers like Macdonald, ‘medical training, with its stress on intra-somatic functioning and negligence of a systematic understanding of the organism in total, and its affiliation to its coworkers and its surroundings, has restrictions as teaching for psychotherapists’ . Psychiatric residents should be educated that psychotherapeutic doctrines apply in all locations where psychiatric management is provided [32,33]. On the contrary, Strain pointed out that the psychiatrist who consults with his medical colleagues is often asked to deal with emotions, doctor-patient issues, and environmental issues . Without an understanding of psychodynamics and interpersonal interactions, the psychiatrist will be of limited value to his consulters. In addition, Dogherty has warned that the ‘subject-object’ relationship between doctor and patient, inherent in the medical model, is very different from the personalized ‘subject-subject’ relationship of psychotherapy . Some believe that ‘psychotherapy must be considered as a biological treatment that works by changing the brain and is therefore just as important as pharmacotherapy in terms of general treatment planning’ [36,37].
Presently, various methods of meta-analysis techniques that combine results across different studies to evaluate the effectiveness of particular treatments for specific patients and problems have been applied to psychotherapy research . Psychotherapy needs to be accomplished by enthusiasts, who practice that as a full job and see that as an intact therapeutic tool. Such a perspective can only be encouraged by interested instructors in apt learners , disregard to their present-day job or past education.
- American Psychological Association. Recognition of psychotherapy effectiveness. Psychotherapy. Chic. 2013; 50:102-109.
- Barlow DH, ed. Clinical handbook of psychological disorders: a step by step treatment manual. New York. Guilford Press. 2014.
- Harrison P, Geddes J, Sharpe M. Lecture Notes. Psychiatry, Tenth Edition, John Wiley and Sons Ltd. UK. 2010; 74-79.
- Gelo O, Pritz A, Rieken B. Psychotherapy research. foundations, process, and outcome. Berlin. Springer. 2015; 67-92.
- Chorpita BF, Daleiden EL, Ebesutani C, Young J, Becker KD, Nakamura BJ, et al. Evidence based treatments for children and adolescents. An updated review of indicators of efficacy and effectiveness. Clin Psychol Sci Prac. 2011; 18: 154-172.
- Hanrahan F, Field AP, Jones FW, Davey GC. A meta-analysis of cognitive therapy for worry in generalized anxiety disorder. Clin Psychol Rev. 2013; 33: 120-132.
- Boumparis N, Karyotaki E, Kleiboer A, Hofmann SG, Cuijpers P. The effect of psychotherapeutic interventions on positive and negative affect in depression. A systematic review and meta-analysis. J Affect Disorders. 2016; 202: 153-162.
- Cabral RR, Smith TB. Racial ethnic matching of clients and therapists in mental health services. A meta-analytic review of preferences, perceptions, and outcomes. J Couns Psychol. 2011; 58: 537-554.
- Wampold BE, Imel ZE. The Great Psychotherapy Debate. The Evidence for What Makes Psychotherapy Work. 2nd ed. New York. Routledge. 2015.
- Vocks S, Caffier BT, Pietrowsky R, Rustenbach SJ, Kersting A, Herpertz S, et al. Meta-analysis of the effectiveness of psychological and pharmacological treatments for binge eating disorder. Int J Eat Disord. 2010; 43: 205-217.
- Lanouette MN , Calabrese C , Sciolla AF , Bitner R , Mustata G , Haak J, et al. Do psychiatry residents identify as psychotherapists. A multisite survey. Annals of Clinical Psychiatr. 2011; 23: 30-39.
- Zoler ML. Percentage of Psychiatrists Doing Psychotherapy Dwindles. Internal Medicine News. 19, 2012.
- Mojtabai R, Olfson M. National trends in psychotherapy by office based psychiatrists. Arch Gen Psychiatr. 2008; 65: 962-970.
- Plakun EM. Finding psychodynamic psychiatry's lost generation. J Am Acad Psychoanal Dyn Psychiatr. 2006; 34: 135-150.
- Mellman LA. How endangered is dynamic psychiatry in residency training. J Am Acad Psychoanal Dyn Psychiatr. 2006; 34: 127-33.
- Katz DA, Kaplan M. Can psychiatry residents be attracted to analytic training. A survey of five residency programs. J Am Psychoanal Assoc. 2010; 58: 927-52.
- Calabrese C, Sciolla A, Zisook S, Bitner R, Tuttle J, Dunn LB, et al. Psychiatric residents views of quality of psychotherapy training and psychotherapy competencies. a multisite survey. Acad Psychiatr. 2010; 34: 13-20.
- Sue D, Sue DM. Foundations of counseling and psychotherapy. evidence based practices for a diverse society, John Wiley Sons, Inc. New Jersey. USA. 2008; 1-7.
- Flanagan JS, Flanagan RS. Study Guide for counseling and psychotherapy theories in context and practice skills, strategies, and techniques, second edition. John Wiley and Sons. Inc. New Jersey. USA. 2012; 7-9.
- Frank JD. Persuasion and Healing. A Comparative Study of Psychotherapy. Baltimore, Johns Hopkins Press. 1973.
- Brown BS. The life of psychiatry. Am J Psychiatry. 1976; 133: 489-495.
- Friedman MA. Psychiatry and psychotherapy is a divorce imminent. Commentary. West J Med. 1987; 129: 156-159.
- Hackett TP. The psychiatrist. In the mainstream or on the banks of medicine. Am J Psychiatry. 1977; 134: 432-434.
- Sederer L. Moral therapy and the problem of morale. Am J Psychiatr. 1977; 134: 267-272.
- Shafti SS. Psychoanalysis in Persia. Am J Psychotherapy. 2005; 59: 385-389.
- Hyland ME.A tale of two therapies. Psychotherapy and complementary and alternative medicine CAM and the human effect. Clin Med. 2005; 5: 361-367.
- Bahillo S, Alonso A, Bahíllo S, Birtle J. Therapist characteristics that predict the outcome of multi patient psychotherapy. Systematic review of empirical studies. J Psychiatr Res. 2014; 53: 149-56.
- Waller G, Stringer H, Meyer C. What cognitive behavioral techniques do therapists report using when delivering cognitive behavioral therapy for the eating disorders. J Consul Clin Psychol. 2012; 80: 171-175.
- Haak JL, Kaye D. Personal psychotherapy during residency training. A survey of psychiatric residents. Acad Psychiatr. 2009; 33: 323-326.
- Hadijpavlou G, Hernandes CAS, Ogrodniczuk JS, et al. Psychotherapy in Contemporary Psychiatric Practice. Canadian J Psychiatr. 2015: 45-53.
- Macdonald IJ. Who is a Psychotherapist. British Med J. 1966; 3: 585.
- Gabbard GO. Deconstructing the med check. Psychiatric Times. 2009.
- Friedman MA, Bedell JBD, Leventhal HE, Home R, Keitner GI, Miller IW, et al. Combined psychotherapy and pharmacotherapy for the treatment of major depressive disorder. Clin Psychol Sci Pract. 2004; 11: 47-68.
- Strain JJ. The medical setting. Is it beyond the psychiatrist. Am J Psychiatr. 1977; 134: 253-256.
- Dogherty EG, Marder SR, Kammen DPV. Psychotherapy and pharmacotherapy. Conceptual issues. Am J Psychiatr. 1977; 134: 529-533.
- Gabbard GO. Psychotherapy in psychiatry. Int Rev Psychiatr. 2007; 19: 5-12.
- Feinstein R, Heiman N, Yager J. Common factors affecting psychotherapy outcomes. Some implications for teaching psychotherapy. J Psychiatr Pract. 2015; 21: 180-189.
- Resch F, Fegert JM. Medical teaching in the area of conflict between evidence based medicine and experience based medicine. Z Kinder Jugend psychiatr Psychother. 2009; 37: 97-103.