Psychotherapy Subspecialty Ill Advised

In response to the Psychiatric News article “Should Psychotherapy Be a Psychiatric Subspecialty?”, supporters of subspecialization are motivated by a laudable enthusiasm for maintaining psychotherapy as a core function of psychiatry. But for many reasons, creating a subspecialty will undercut, not support, this goal.

British psychiatry is not a model for American psychiatry. As a senior medical student nearly 60 years ago, I spent three months at the University of Edinburgh. Psychotherapy was not a major component of British psychiatry, and it still is not. It was created as a supspecialty there precisely because it is not a major part of British psychiatry and never was.

Subspecialties struggle to attract trainees. There is no indication that a significant number of psychiatrists would extend their training for a new subspecialty. Moreover, psychotherapeutic skills take time to develop. In a one-year subspecialty training program, the longest one could see a patient is for one year—hardly long enough to develop skills as a psychotherapist. A residency provides enough time to develop psychotherapeutic skills over three and a half years.

Advanced postresidency training in psychotherapy is already available at any number of psychoanalytic institutes, which have psychotherapy training programs. A psychiatric subspecialty uses resources to create what is already available.

Finally, the decline in interest in psychotherapy by psychiatrists is partially related to economics. A psychiatrist can earn more seeing four medication-management patients in an hour than one patient in psychotherapy. Subspecialization does not address this reality.

Although we have focused on the need for substantial psychotherapy training, a more important need may be to ensure psychiatrists learn how to assess our patients’ complex psychology. We cannot effectively treat our patients by simply matching a patient’s behaviors and symptoms to those of the DSM. We must fully understand the psychology and biology of our patients before we can decide on a patient’s treatment. Without this understanding, one cannot learn to be a psychiatrist, let alone a psychotherapist. ■

SIDNEY WEISSMAN, M.D.

Chicago, Ill.