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Psychotherapy Under Microscope but Undeservedly So The role of psychotherapy in psychiatric practice and training is under scrutiny, said Jerald Kay, M.D., at APA's 2012 annual meeting today. A recent article about the national trends in outpatient psychotherapy described a less prominent role for psychotherapy by psychiatrists and a concomitant increase in patients receiving medication without psychotherapy. The latest results from the National Resident Matching Program are somewhat alarming in that there was a decrease from 670 American medical students in 2010 to 640 for 2011 and only 616 for 2012, said Kay, professor and chair of the Department of Psychiatry at Boonshoft School of Medicine and the Fredrick A. White Distinguished Professor Wright State University. Many training directors have opined that, although psychiatry experienced a recruitment crisis in the 1980s, this current one may reflect that psychiatry is no longer attracting the best and brightest of medical students because of the diminished emphasis on psychotherapy. Kay pointed out that a psychiatrist's psychodynamic orientation provides the framework of a basic science to appreciate the inner lives of patients that has been supported by the dramatic findings about the neurobiology of psychotherapy, including the centrality of learning and memory as they change behavior through brain plasticity. A psychodynamic approach, he said, rests upon the following beliefs: that people feel and behave for specific reason about which they are frequently unaware (implicit memory) that is shaped by events that determined how they experience themselves and their world, and that mastery of psychological pain and discomfort is compelling and accounts for why many patients behave consistently and predictably in often self-defeating and disappointing ways. Moreover, early attachment experiences have explicated precisely how they influence human behavior throughout the life cycle and, in the case of negative early relationships, predispose to psychopathology and significant deficits in the capacity to understand others as well as themselves. The power of the therapeutic relationship is predicated on the physician's ability to provide a safe forum characterized by commitment, respect, reliability, honesty, and empathy. It is this relationship, which can be taught effectively if not best within a dynamic framework, that psychological problems, feelings, and behaviors within and outside of the therapeutic endeavor can be safely explored, Kay told annual meeting attendees. Kay demonstrated principles of psychodynamic psychotherapy through a case presentation of a significantly depressed young adult treated with brief therapy. "Although the psychotherapy was the most central of interventions, medication was utilized as an adjunct treatment to facilitate the progress within the psychotherapy," he said. Given the exciting advances in cognitive neuroscience, he concluded, it is short-sighted to jettison psychodynamic psychotherapy as a significant treatment and a core clinical skill to be learned by all residents
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