Mass General Hospital Provides Great Therapy Training, But....

This is a brief note to respond to some understandable misinterpretations of both my New York Times Magazine article and my book, Unhinged.

My psychotherapy training at Mass General Hospital was excellent. As two young faculty members wrote in a recent letter to the Times in response to my article, MGH's psychiatry residency includes "three years of intensive, individual supervision in psychotherapy." That was true in the early 1990s as well. I saw a lot of therapy patients and received great supervision from such skilled psychiatrists/psychotherapists as Robert Abernathy, Paul Hamburg, Chris Gordon, and many others. Not to mention superlative psychopharmacology supervision from such consummate clinicians as Andrew Nierenberg and Carey Gross.

I also agree with Drs. Roffman and Levy (the authors of the Times letter) that psychiatry residencies throughout the country are doing a great job of ensuring that psychotherapy training remains a central part of the programs. For many years, the American Board of Psychiatry and Neurology has published a list of "core competencies" required of psychiatrists. These have always included psychotherapy. According to the latest version, all psychiatrists should be able to "conduct a range of individual, group, and family therapies using standard, accepted models, and to integrate these psychotherapies in multi-modal treatment, including biological and sociocultural interventions." Furthermore, in 2001, the Council in charge of all graduate medical education (the ACGME) instituted a specific requirement that all psychiatric residencies teach cognitive behavioral therapy, and by 2006, 90% of residencies had complied.

And yet, notwithstanding these laudable intentions and curricular changes, psychotherapy by psychiatrists declined sharply from 1997 (when 44% of all psychiatry visits included psychotherapy) to 2005 (when only 29% of such visits included therapy.) This is because great training during residency is necessary but not sufficient to bring therapy back to psychiatry. Once residents graduate, they have loans to pay off and they follow the money, and the money is found in short medication visits. And as with any complex skill, becoming an excellent therapist requires years and years of practice, most of it after residency.

One can always blame insurance companies for this state of affairs, but insurance companies reimburse more highly for med visits not because they are out to degrade mental health treatment, but because they believe they get more bang for the buck with meds. Based on the typical 6 to 8 week clinical trials, medications work as well as therapy for most conditions, and better for some. But studies are increasingly showing that--at least for non-psychotic disorders-- specific therapies work better than medication at preventing relapse over one or two years of follow up (see this study, for example). Good studies of therapy are hard to find, because drug companies are rarely willing to fund them. But I predict that as the evidence base for the long term efficacy of therapy expands, insurance reimbursement rates will improve as well.

In the meantime, however, my crystal ball reveals no impending great shift among psychiatry graduates toward therapy, no matter how many therapy supervisors residents are exposed to.

Bottom line: Psychiatry residencies do what they can to teach therapy skills, but the dominant culture among practicing psychiatrists remains medication-based, for a number of interwoven reasons including pharmaceutical marketing, insurance reimbursements, and the desire to be as "biomedical" as other doctors.