Should Psychotherapy Become a Subspecialty of Psychiatry?

Psychotherapy can be both effective and life-transforming for individuals with mental disorders, but this modality may be losing ground in psychiatric practice and identity. Meta-analytic studies indicate that psychotherapy treatment effects for most disorders are equivalent to or stronger than those of psychopharmacology (1). However, the proportion of time spent by psychiatrists practicing psychotherapy has diminished steadily over recent decades (1, 2). Insurers and the general public often no longer consider psychotherapy as part of the core identity and skill set of psychiatrists, and arguably, neither do psychiatrists. Factors contributing to this trend include relatively poor reimbursement for psychotherapy, pressure from employers for psychiatrists to assume a strictly prescriber role, the reduced status of psychotherapy, and a vicious cycle in psychiatric residency training of diminishing time and resources spent teaching psychotherapy combined with fewer psychiatrist supervisors, mentors, and role models practicing psychotherapy. In this Viewpoint, we argue that by developing a subspecialized discipline of psychotherapy within psychiatry, we may build educational structures to ensure adequate training of psychiatrists in the psychotherapies, help to improve the status of psychotherapy, provide opportunities for advocacy, and maintain psychotherapy as a core skill set.

The biopsychosocial model is increasingly giving way to a dichotomous approach that dismisses the importance of the interpersonal aspects of psychiatric care. Marketing of pharmaceuticals and other factors have led medication to gain increasing favor in public opinion. For example, the National Institute of Mental Health has almost exclusively emphasized funding for biologically based mechanisms and psychopharmacology for “brain disorders” (3). A biologically reductionist perspective, however, cannot account for the complex interactions between biological and psychosocial determinants of illness and may disregard the impact of psychotherapy in remediating neural networks and restoring neurophysiology (4).

In the current environment, psychiatrists are encouraged to practice “at the top of their license,” while psychotherapy (now commonly referred to as counseling) is relegated to the least educated member of the interdisciplinary treatment team (5), thus further eroding the valuation of psychotherapy. There is evidence that combined treatment by a psychiatrist who provides both medication and psychotherapy may actually be more cost-effective than splitting the treatment among providers (6). Such combined treatment may be especially important for patients who have complex biological and psychosocial determinants to their illness. Despite its cost-effectiveness, a practice of combined treatment is currently difficult to sustain, because Medicare reimbursement for an hour of psychotherapy evaluation and management (E&M) services (codes 90836 and 99213) is 25% less than reimbursement for the same hour spent performing two E&M visits involving psychopharmacology (code 99214), and reimbursement is even less for an hour of psychotherapy without E&M services.

The preparedness of psychiatric graduates to practice psychotherapy is another factor eroding the role of psychotherapy in psychiatric practice. Psychotherapy, unlike psychopharmacology, is largely skill-based rather than knowledge-based and requires extensive one-on-one faculty time educating, observing, and providing feedback. The resource intensiveness of psychotherapy training, together with an increasing focus on neuroscience in psychiatric education, leads financially strapped programs to redistribute training resources away from psychotherapy, and few psychiatric residents graduate feeling truly competent to practice it.

With so many forces at work moving psychotherapy outside the realm of psychiatric practice and identity, a vicious cycle has been created. With diminishing time spent teaching and conducting psychotherapy, and a growing proportion of psychotherapy faculty from disciplines other than psychiatry, a dearth of mentors and role models gives residents the implicit message that psychotherapy is not part of what psychiatrists do. It will take strong advocacy, higher reimbursement, and higher status given to psychotherapy within psychiatry to reverse this course. One possible means to achieve these aims may be to recognize the specialized expertise that effective psychotherapy requires through creation of a board-certified subspecialized discipline in the field of psychiatry.

An argument against this proposal is that creating a subspecialty will move psychotherapy out of mainstream psychiatric training and practice, relegating it to an arcane art practiced by only a few psychiatrists. However, it can be argued that this is already happening, and at a rapid pace. As of 2008, less than a third of psychiatrist visits included psychotherapy (2). The creation of other subspecialties within psychiatry, such as geriatric, addiction, and consultation-liaison psychiatry, has not diminished residency training in these areas, which in contrast have mostly increased and gained status and influence through the establishment of specific councils within the American Psychiatric Association. This increased status has also been the experience in the United Kingdom, where medical psychotherapy is a recognized subspecialty of psychiatry and has become a platform for advocating for enhanced psychotherapy training during the general psychiatry residency.

There are many challenges to overcome in successfully implementing this subspecialty, including finding funding for psychotherapy fellowships and integrating the many competing schools of psychotherapy into a single training standard, and these challenges will require innovative solutions. In the United Kingdom, the first 3 years of training in psychiatry provide core training (which includes treatment of at least two psychotherapy clients) for all psychiatrists, and a further 3 years of training are for general adult psychiatry or one of five subspecialties: forensic psychiatry, child and adolescent psychiatry, geriatric psychiatry, intellectual disability psychiatry, or medical psychotherapy. The medical psychotherapy curriculum requires mastery of at least one psychotherapy modality within one of the three recognized major models (i.e., psychodynamic, cognitive-behavioral, and family and systemic therapy). It also requires understanding of the theoretical bases of all major modalities; ability to formulate and tailor treatments to different settings, disorders, and individual needs; and basic competency in applying at least two other psychotherapy modalities (7).

We believe the U.K. requirements provide a useful framework for structuring psychiatric psychotherapy fellowships in the United States. We propose that by the end of a psychotherapy fellowship, graduating psychiatrists will be able to do the following:

• achieve high empathic capacity, emotional intelligence and sophisticated interviewing and observational skills;

• integrate history and observations of patients with complex treatment needs into a biopsychosocial formulation;

• demonstrate familiarity with the theories and methods of the major schools of psychotherapy and recommend different psychotherapy modalities based on the formulation;

• demonstrate proficiency in one psychotherapy modality, including provision of effective delivery of the treatment in various settings when initiating, sustaining, and ending episodes of care; and

• demonstrate competent application of core skills in at least two additional psychotherapy modalities.

There are many advantages of creating a single certification mechanism for psychotherapy expertise, regardless of the particular psychotherapy modality that the psychiatrist emphasizes. Bringing all psychiatrists with special interest and expertise in psychotherapy together under one umbrella may create opportunities for advocacy with a single unified voice, greater status and recognition of enhanced psychotherapy skills, provision of psychotherapy training for all psychiatrists, and the potential for enhanced insurance reimbursement for psychotherapy in recognition of a higher skill set through fellowship training.