Lupine Publishers | Pharmacotherapy Vs. Psychotherapy: An Educational Challenge in Current Psychiatric Training
Abstract
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.
Introduction
“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.” He went on to explain that there is an old saying that certain
diseases are cured not by medication, but by the “mentalinfluence” of the “personality
of the physician.” No one, of course, canreally trace the origins of
psychotherapy, but they probably extend back to
primitive medicine men, priests, and
soothsayers [1]. 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.” [1] . What has been confusing is that Freud
used the words “psychoanalysis” and “psychotherapy” interchangeably for many
years, and it was only considerably later that he and others sought to distinguish
psychoanalysis from other psychotherapies. 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, tothe method
Breuer called ‘cathartic,’ but which I prefer to call ‘analytic.’” [2]. It is
well established that a majority of the effectiveness of psychotherapeutic
treatments can be accounted for by the common elements that all psychotherapies
share. The features shared by all include a healer–patient relationship, in
which the different roles carry different expectations and a differential
balance of power; a nonjudgmental, supportive acceptance of the patient; and an
alliance of working together on shared goals. These common elements are rooted
in the universal need for attachment and connection. Human brains are designed
to seek out attachment when they feel isolated or threatened, and to reciprocally
be moved by the pain and loneliness of those who reach out to us. Resting on
this foundation, psychotherapies of many different stripes are able to provide
an experience—sometimes as quickly as the initial session-of feeling comforted,
finding hope, and experiencing an amelioration of the sense of being alone or
marginalized by one’s presenting difficulties. But if all therapies share these
comforting elements, what accounts for the existence of so many different
psychotherapies? The development of a specific psychotherapeutic method begins
with the creation of a psychological model.
Each individual model is built upon a
unique conceptualization of how psychopathology evolves and what must happen to
achieve an effective and satisfying life, either through the resolution of the
psychopathology or in spite of the ongoing psychopathology. Thus, psychotherapy
is always a learning process, taking advantage of the brain’s neuroplasticity
and the related human capacity for durable change at the most fundamental
levels of being. Yet, as in formal education settings, learning within
psychotherapy is a unique process among individuals and requires a diverse
range of approaches. One way to understand the wide array of psychotherapeutic
methods, therefore, is as an attempt to accommodate the various learning styles
[2]. In addition, what the therapist hopes the patient will learn in the course
of treatment is remarkably diverse, and often rooted in very different
fundamental ideas about the nature of psychopathology and about what defines an
effective and satisfying life. As an example, the cognitive therapist believes
patients need to learn about implicit maladaptive thoughts, which eventually,
results in changes to deeply held belief systems that contribute to recurrent
emotional distress and dysfunctional interpersonal engagement.
The psychoanalytic therapist, on the
other hand, believes the most effective learning approach involves exploration
of unconscious wishes and conflicts, which allows for the release of longstanding,
self-imposed obstacles that hold people back from living life in the fullest
way possible. In both instances, the aim is to relieve suffering and promote
the growth and development that hopefully, will prevent suffering in the
future. How this aim is achieved and the specific goals that occur within the
treatment itself are quite different. Through the years, new psychotherapeutic
approaches have been developed, usually borne out of a desire to fill an
identified need in the treatment of mental illness [2]. But the situation is
now shifting: we are becoming more cognizant of the boundaries of organic
managements, particularly for longlasting ailments; there is a rising evidence
base for the efficiency of certain psychological treatments; and patients have
become more wishing of all-inclusive attention. Consequently, there is a new
emphasis on psychosomatic characteristics of medicine with evolving motivations
to re-integrate psychotherapeutic procedures into general medical practice [3].
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 [2]. Generally, psychotherapy includes any kind of psychological
intervention that is planned to enhance adaptive functioning and reduction of
distress or maladaptive behavior [3].The objectives of treatment involve
improving functioning and adjustment in both interpersonal and intrapersonal
domains and decreasing maladaptive behaviors and different psychological and
sometimes somatic complaints. Therapeutic goals are usually achieved by means
of interpersonal processes and verbal interactions [3].
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]. Two models of psychotherapy— the medical
model and the contextual model—have competed in the last two decades. The
medical model suggests that psychotherapies have specific ingredients that
address some problem within the patient and account for outcomes. In contrast,
the contextual model holds that therapies are effective owing to universal
relational and psychological factors, which vary according to the skills and
qualifications of therapists. Meta-analysis supports the contextual framework:
There are small, if any, differences among treatments; there is little evidence
for the specificity or necessity of any particular intervention; the therapeutic
relationship is a necessary aspect of treatment, regardless of the type of
psychotherapy; and therapists’ qualifications and contributions are a critical
factor in the outcome of psychotherapy [4].
There is emerging consensus on the
importance of patientfocused research, which uses research to inform case-based
treatment decisions about the effectiveness of a specific treatment with a
specific patient [4]. The principal goals of psychotherapy research are to
understand what the effective components of psychotherapy are and how they
work, to determine how patient and therapist factors influence outcome, to
improve the effectiveness of psychotherapeutic interventions, to guide the
development of new therapeutic techniques and evaluate their effectiveness, and
to inform public policies that increase the availability of quality mental
health care [4]. On the other hand, psychotherapy researchers distinguish
between efficacy and effectiveness research. Each has a distinct purpose,
methodology, and interpretative context [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.
To minimize the influence of confounding factors, efficacy studies are
conducted using randomized clinical trial methodology in a controlled setting.
Patients are screened to control for excessive patient variability and are
randomly assigned to interventions that are being compared. The treatment under
investigation might be compared to no treatment, a waiting list, placebo,
minimal intervention(e.g., psychoeducation), or an alternative treatment.
Therapists are trained to conduct the competing treatments to maximize the
integrity of putativetherapeutic ingredients. To achieve this, most efficacy
studies usetreatment manuals, which direct (to some extent) the therapist with
regardto the intervention offered.
Most studies also perform integrity
checks, such as reviews of taped sessions, to see whether the therapy under
study was actually implemented [5]. 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. The experimental controls used in efficacy studies are absent in
effectiveness studies, just as they are absent in community settings. (Indeed,
most effectiveness studies are conducted in the community.) [5] In addition,
hundreds of metaanalyses of psychotherapy have been conducted, and most have
reached the same general conclusion: Psychotherapy is an effective intervention
for psychiatric illness across diverse populations and settings. Most
meta-analyses have focused on specific disorders (e.g., the efficacy of psychological
treatment for bulimia nervosa) or on specific therapeutic approaches for
various disorders (e.g., comparing CBT to other therapies). In general,
meta-analytic studies have shown that psychological treatments are vastly more
effective than no treatment (e.g., wait-list controls or minimal
interventions), are about as effective as biomedical treatments for most
disorders, and are about equally effective when compared to each other [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 posttreatment and
follow-up, and combined psychotherapy and pharmacotherapy has been routinely
found to be superior to either alone [9], some important variables as well are
existent, which may well separate these two from each other (Table 1). On the
other hand, like all other clinical managements, psychotherapy can have adverse
in addition to beneficial effects. These are more probable with inexperienced
and non-supervised psychotherapists and with psychotherapists who are in a
situation to purposefully abuse the patients. It must not be overlooked that
even well-delivered therapies can be ineffectual or detrimental. An example is
asking improperly patients who have undergone a traumatic shock to talk about
it in excessive detail to a therapist (so-called debriefing) [10]. Within the
previous ten years, huge modifications have occurred in the field of counseling
and psychotherapy.
Psychotherapeutic Core Curriculum 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 drugfocused visits. In reality, over the past
ten years lots of psychiatrists in developed countries have shifted to more
medication checks and fewer psychotherapy visits [11]. Consequently, some
psychiatric instructors have stated worry that reduced attention to
psychotherapy teaching in residency has moved the career’s central
characteristics away from psychotherapy. Such a shift has caused one noticeable
professor to answer “yes” to the challenging label of his article, “Are
psychiatric educators ‘losing the mind?’” Others have proposed psychiatry could
play an important role in medicine by incorporating the mind- and
patient-centered applications of psychotherapy with neurobiological
developments [11].
Many of psychiatric instructors continue
to view obtaining the skills, knowledge, and outlooks underlying psychotherapy
as necessary elements for a psychiatrist’s role, disregard to upcoming practice
setting or professional objectives. Furthermore, consistent with the
‘Accreditation Council for Graduate Medical Education (ACGME) Residency Review
Committee (RRC) for Psychiatry 2008 Program Requirements’, all psychiatry
residents “should show ability in using ‘psychodynamic’, ‘supportive’, and
‘cognitive-behavioral’ psychotherapies to both ‘short-term’ and ‘long-term’
individual practice, as well as convincing acquaintance with couples, group,
family, and other individual evidence-based psychotherapies.” [11] But in
contrast, the practice of psychotherapy by psychiatrists has dropped around 20
% from 2002 -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].
Also, through the same period,
psychiatrists incorporated pharmacotherapy more firmly, with the usage of drug
therapy growing to 89% of responding psychiatrists in 2010, in comparison to
81% in 2002 and 54% in 1988 [13]. As said by an assessment, psychiatrists had
found pharmacotherapy to some extent more operative, with 87% saying that they
were pleased with the effectiveness or usefulness of pharmacotherapy, compared
with 76% who had the same verdict of psychotherapy [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 [13]. No doubt, there are numerous factors that
have unfavorably affected the place of, for example, ‘psychodynamic
standpoints’ within psychiatric practice and ‘psychoanalytic training’ over the
last generation. One consequence of these powers has been to produce a lost
generation of psychiatrists with slight familiarity or practice with
psychoanalytic treatments [14]. 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].
According to a study, While 46% of
psychiatric residents show interest in more psychodynamic psychotherapy
teaching, only 22% exhibit interest in applied psychoanalysis. In this regard,
most of them had mentioned the time and cost involved as reasons they would not
pursue further training [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]. As
said by Cohen: “old-style programs are no longer sufficient to get apprentices
ready for practice in the epoch of ‘managed-care’. Managed-care’s stress on the
delivery of mental health facilities at limited expenses necessitates
particular practice abilities, mainly quick assessment, brief management, and
the capability to document treatment consequences” [18]. What are the abilities
required to respond to the necessities of a managed care setting? In most
preparation programs, an effort contains assisting learners improve
interrogating and interaction abilities. Bradley and Fiorini, too, found that,
in a review of mental health programs, the most often talked practical
capabilities involved the micro-skills (like empathy, listening, reflection of
feelings, and genuineness) that have been emphasized by Rogerian philosophy,
too [18].
But regrettably, most psychotherapeutic
course books and mental health teaching programs do not address the requisite
for new abilities inclusively. This leaves apprentices with no satisfactory
background preparation. Texts have usually been lacking in creating a link
between the philosophies and the contemporary practical necessities of mental
health experts. Most writings present the schemes of psychotherapy and
counseling without considerable assistance on the subject of how they can be
modified to encounter the problems imposed by ‘managed-care’ necessities or in
work with various people. In the course of training period, particularly in
‘managed-care’ situations, the models of psychotherapy educated by apprentices
are of little aid in meeting clinical evaluation, treatment, and outcome
necessities [18]. Shortterm methods and procedures that have developed from
these models are not presented, nor is there enough emphasis on the
incorporation of theory and practice. This has caused a cutting off between
what apprentices learn from writings and the abilities they are anticipated to
apply under managed-care policy and duty strategies. Moreover, learners are
given little supervision in working with different subcultures or minority
groups [18].
Discussion
Approximately 25 percent of the US
population meets criteria for a psychiatric disorder in any given year, but
most do not seek any type of formal care. The likelihood of obtaining treatment
increases with emotional distress and functional impairment. Accordingly, those
with comorbid mental illnesses or with severely disabling disorders, such as
schizophrenia, are the most likely to seek professional help. In contrast, a
lack of insurance and concerns about how to pay for services decrease the
likelihood of seeking treatment. However, the primary barriers to mental health
care are psychological, perhaps primarily the stigma related to having a mental
illness. 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. Research suggests that this is related to
the increasing conceptualization of mental health problems as medical, which
may translate into the impression that the problem is permanent. Consistent
with this, most who seek care increasingly do so in the general medical sector
rather than from a mental health specialist [19].
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. He believes that upcoming psychiatrists will also be teachers for,
and provide liaison to, many medical and mental health disciplines. Some
financial factors have increased the credibility of West’s forecasts as regards
psychotherapy. First, psychiatrists are physicians. Hence, they and their
services are usually very expensive. Also, according to Jerome Frank [20], no
type of psychotherapy or psychotherapist has ever been proven better than any
other. Therefore, one might ask, since social workers and psychologists usually
charge lesser costs than psychiatrists, why not send patients to them?
Undoubtedly, the managers of national health insurance might feel this way, as
might patients incapable to pay for a psychiatrist’s charge.
Briefly, increased economic and
governmental pressures, together with an emergent requisite within medicine
itself for the scientific and medical expertise, which only a
physicianpsychiatrist can provide, might well push psychiatry in the path that
had been anticipated by West. According to Bertram Brown [21], 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. Brown states that during the past decades most
developments in the field of psychiatry have been in biology, pharmacology and
the treatment of psychoses-not in psychotherapy. So, the biological
psychiatrists, he declared, are the final outcome of today’s psychiatry [22].
In this regard, Massachusetts General Hospital’s Chairman of Psychiatry, Thomas
Hackett [23], goes a step further: “Unless we are at home in medicine,
psychiatry is homeless.” He feels that, apart from their medical teaching,
psychiatrists have little more to offer to patients than social workers, lay
therapists and clerics. Psychotherapy is now broken into many schools and
divisions, and he notifies that if psychiatry does not get rid of psychotherapy
and back into medicine, we are, in his words, “an endangered species.” [22]
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].
Also, because biological management is
cheaper than psychotherapy and places a lesser amount of emphasis on patients’
accountabilities to play a part in their own treatment, and is likely to treat
patients like children, biological psychiatry is likewise more acceptable or
easier to do by psychiatrists. Therefore, he argued, with more and more people
demanding psychiatric care, with the rising cost of health care, and with the
increased need for psychiatric consultation within the medical setting, the
aforesaid tendency, should psychiatrists ever stop learning and practicing
psychotherapy, will push for continuation of the aforesaid separation. Once
separated, he feels, these factors will maintain a perpetual split. According
to Sederer: ‘science is a form of humanism, but “scientism,” the cult of
science that worships technology for its own sake, is unidimensional and
antihumanistic, and reduces man to a mechanistic, concrete, non-individual
entity’ [24]. But if the circumstances in industrialized states are so, then
what will be as regards developing countries that wish to publicize psychotherapy
from the initial point, based on printed textbooks or accredited literatures in
developed countries. Previously in some earlier articles, in addition to accent
on the requirement of national-based researches and modifications , the
societal and educational difficulties concerning practicing or advancement of
major psychotherapeutic methods in developing countries had been discussed
[25].
At this point, once more, it deserves to
be mentioned that, essentially, if practice of psychotherapy by psychiatrists
is supposed to be an indispensable fact, then a renovation in the viewpoints of
psychiatrists, too, appears to be indispensable. Fort instance, psychotherapy
can not be expected to be established if it is not going to be supposed as a
complete career and in need of enthusiast followers. A modern psychiatrist is
more an organicminded physician who has been entirely and persistently educated
about psycho-pharmacotherapy through the entire educative program. Bases of
core curriculum of psychiatric residents, like inpatient and outpatient medical
practices, lectures, grand rounds, case presentations, journal clubs and other
didactic apparatuses and strategies, are commonly based on biological grounds
and Evidence Based Medicine (EBM). In the border of such a scholastic
perception and context, no one can anticipate abrupt jumping out of enthusiast
psychotherapist, except than a psychiatrist with individual preferences for
acquiring and performing ‘The talking cure’. The present programs commonly
create psychiatrists who are just acquainted with different techniques of
psychotherapy, and the related indications for referring patients to other
expert psychotherapists. A clinician who desires to practice psychotherapy,
disregard to the technique, should see and imagine that style of treatment as
the best manner that can aid the patient to get rid of his distresses, maybe
even a bit fanatically, to be able to practice doubtlessly. He should be
familiar with and accept its complications and variability, and do his career
without uncertainty and have a passionate energy to prove the profits of his
favored mode of psychotherapy methodically and progressively, in the frame of
EBM. Presently, all mental health careers (like psychiatry, clinical
psychology, social working and counseling) are advocating the outlook that
managements must always have an ‘evidence-based’ attitude and methodical
approach.
On the other hand and in keeping with the
existing evidences, a psychotherapeutic outlook may not be cultivated easily or
genuinely in the ground of organic psychiatry. It demands its specific and
psychotherapy-based journal clubs, case presentations, visits, lectures,
practices, researches, and so on. Such a course and attitude is not the same
for non-medically oriented experts and medicallyoriented psychiatrists, and
achievement of such a view is, for sure, more difficult for the second one. He
should initially conquer his interior doubts as regards the usefulness of
psychotherapy in comparison with the absolutely evidence-based pharmacotherapy,
and at that point, increase its position in his mind in competition with
pharmacotherapy, despite the whole existing dissimilarities.
On the other hand , when available
meta-analyses have shown thatpsychotherapy, 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].
According to a study, therapists who provide Cognitive Behavior Therapy (CBT) -
including the most experienced therapists - regularly leave the CBT techniques
defined in treatment handbooks. ‘Only 50% of the clinicians claiming to use CBT
use a method that even approximates to CBT,’ [28] ; such a practice is not in
harmony with the evidencebased expectations of modern psychiatrists.
Currently, psychiatrists are
unconsciously or consciously hooked on pharmacotherapy, a significant reason
that interferes with their innermost preferences for practice of psychotherapy
in the course of their usual appointments. In the present years, quick
improvement of symptoms and restoration of function are the most significant
issues that are generally wished by clienteles and the public. 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. Therefore, it is imaginable that in such statuses the psychotherapy
can not have in their minds the equivalent place or worth in comparison with
pharmacotherapy and it will be moved inevitably to the second or less
significant place. This context is sufficient for declining practice of
psychotherapy by psychiatrists, especially analytic or insight-oriented
methods, like psychoanalysis and psychoanalytic psychotherapy, which demands
adequate perseverance and time. 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.
Such a recess or negligence in the first cases can be repetitive in future and
will be turned finally into a fixed method of approach. Knowledge is not always
equivalent to motivation and the later is not at all times correspondent to
practice. Maybe, personal analysis of psychiatric residents or even encouraging
them for using eligible psychotherapeutic facilities with regard to their own
anxieties, will help them to sense more skillfully the usefulness of
psychotherapy. But according to a study, currently a significant minority of
psychiatric residents pursues ‘personal psychotherapy’, mostly psychodynamic
approach. While this number appears to be much smaller than in the past,
residents identified training demands and financial cost as the top barricades
to following psychotherapy [29].
Moreover, if setting permits, coaching
psychotherapy for psychiatric residents or graduated psychiatrists by means of
expert psychotherapist psychiatrist, in place of non- psychiatrist
psychotherapists, appears to be a better method, for the reason that it may
boost learners’ enthusiasm by means of identification with mentor, by way of
role-modeling. In accordance with the present circumstances in Iran, as a
typical developing country in the region, after inauguration of new academic
national core curriculum for formal education of psychotherapy to psychiatric
residents in the preceding seven years, excluding simple psychotherapies like
‘counseling’ , ‘supportive psychotherapy’, and ‘psycho-education’, no considerable
escalation in practice of structured , major, or hybrid psychotherapeutic
procedures, like ‘psychoanalysis’ , ‘psychoanalytic psychotherapy’, ‘brief
dynamic psychotherapy’, ‘CBT’, ‘DBT’, ‘IPT’ , ‘CAT’, ‘family therapy’ or ‘group
therapy’ by recently graduated psychiatrists was evident, in comparison with
the periods without such a course.
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 can not be recognized as flawless [30].
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.’ ‘Clinical psychotherapist would
be an applicable name for those physicians who sensed themselves free to use
any psychological technique with or without the usage of the significant drugs
and somatic treatments now obtainable.’ According to him:’ The psychotherapist
should be subject to various inspirations other than merely ideas of Pavlov and
Freud and their byproducts. For example, any course of teaching would be
unfinished without an impact from the social researchers’ [31]. Essentially, it
must not be ignored that psychotherapeutic abilities are required in every
situation in psychiatry since the same phenomena that appear in psychotherapy -
like resistance, transference, countertransference, schema and automatic
thoughts - appear in other circumstances too. Psychiatric residents should be
educated that psychotherapeutic doctrines apply in all locations where
psychiatric management is provided [32,33]. Anyway, the marriage between
psychotherapy and psychiatry has always been a troubled one [23].
Descriptive psychiatry, came to life by
Kraepelin, has habitually been in conflict with dynamic psychiatry, which had
come to life by Freud. Psychotherapy is not at all easy to do, because, as
Greenblatt has pointed out, it is very difficult for a person to learn how to
deal with the deepest feelings of patients [23]. So, Descriptive psychiatry is
much easier to do, as it places less emotive pressure on the therapist . 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 [34]. 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 ‘subjectobject’
relationship between doctor and patient, inherent in the medical model, is very
different from the personalized ‘subjectsubject’ relationship of psychotherapy
[35].
According to Eisenberg, medicines alone
are generally no cure for psychiatric illness; they merely diminish symptoms.
“Brainless psychiatry,” he asserted, is as bad as “mindless medicine.” [23]
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]. While the current
‘Accreditation Council for Graduate Medical Education’ necessities for
psychiatric residents follow an approach based on particular schools of
psychotherapy (highlighting proficiency in psychodynamic therapy ,
cognitivebehavioral therapy, and supportive treatments), evidence shows that we
are failing even in these efforts [37]. The considerations and strategies of
such a policy should be decided by chief mental health and scholastic
superintendents of each nation, by taking into account the existing high
academic organizations, human resources, shortages and assets, community mental
health centers or private clinics for providing psychotherapeutic services, and
also national strains and problems. Lacking such an outline, advancement of
psychotherapy as a useful healing tool is not imaginable.
Conclusion
In general, a balance between
‘Evidence-Based Medicine’ and the individual clinical experience with patients
(Experience- Based Medicine) must be recognized within medical education,
rather than supporting one against the other [38]. Past controversies regarding
the ability to examine scientifically various psychotherapeutic techniques have
largely been settled. Valid and reliable methods for measuring therapeutic
events and their effects have been developed. These have included intensive
analyses of patient and therapist variables, in-depth assessment of therapeutic
processes, and implementation of outcome measures that assess general distress,
symptoms related to specific disorders, and functional impairment in emotional,
cognitive, and behavioral domains. Controlled clinical trials comparing
replicable, distinct psychotherapeutic interventions are normative, as are
sophisticated analytic methodologies, including growth curve analysis,
timeseries panel analysis, and structural equation modeling.
Most significantly, various methods of
meta-analysistechniques that combine results across different studies to
evaluate the effectiveness of particular treatments for specific patients and
problems— have been applied to psychotherapy research [4]. In spite of all of
the existing endorsements, criticisms, advises, foresees, national curriculums,
set of courses, and etc., while practice of psychotherapy by today’s biological
psychiatrists is an approvable, logical and possible expectation, its
achievement, due to inherent or contextual inconsistencies between organic
structure of medical attitude and practice, and psychological construction of
psychotherapeutic philosophies and approaches, does not seem to be easily or
efficiently attainable. 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.
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