Core Clinical Skills

Dr. Sidney Weissman’s Viewpoints column in the June 15 issue eloquently describes a disturbing trend of change in the identity of the psychiatrist. Many psychiatrists fresh out of training are simply not adept or even interested in providing full-service treatment that includes both psychotherapy and medications. Some psychiatrists who specialize in intensive psychotherapy do not use medications, although in my experience that aversion has diminished greatly. APA’s experience in its Business Relations Initiative reinforces Dr. Weissman’s observation: EAP and human resources personnel bitterly complain that they have great difficulty finding psychiatrists within their managed care networks who will see their employees and offer psychotherapy in addition to medication management.

It is puzzling, however, that Dr. Weissman takes a gratuitous and poorly informed swipe at APA’s Commission on Psychotherapy by Psychiatrists (COPP), which has aimed precisely at countering the trend he describes. COPP does not “argue for the need to learn how to practice implicitly intensive psychotherapy,” although like other psychotherapies, treatment should be available for those who need it. In clear recognition of “the realities of clinical practice,” COPP has emphasized learning the basic principles common to all psychotherapies, tailoring selection of therapy to the needs of the patient (whether cognitive-behavioral therapy, interpersonal therapy, psychodynamic, group, and so on—all approaches are well represented on COPP). Numerous presentations at APA’s annual meeting and the Institute for Psychiatric Services have emphasized short-term, focused treatments and the integration of medication management and psychotherapy by psychiatrists. COPP advocated for a fast track for development of the practice guideline on borderline personality disorder (which highlights dialectic behavioral as well as psychodynamic therapy), and supported the requirement for assessment of core competency of residents in five types of psychotherapy. COPP is well in tune with current clinical needs, as can be seen on APA’s Web site at www.psych.org under “Practice of Psychiatry.” We have raised the hope that the damaging trends Dr. Weissman describes can be reversed.