Core Clinical Skills

In his Viewpoints article in the June 15 issue, Sidney Weissman, M.D., recounted the story of a referral he made to another psychiatrist in the patient’s home area. This was a case of a man who would clearly be best served by psychopharmacological and psychotherapeutic (that is, “talk”) therapy with a psychiatrist knowledgeable in both areas, but the patient was able to find only psychiatrists who would do medication management, with the psychotherapy component to be provided by a nonmedical clinician.

Dr. Weissman concluded, “We have a brief window of opportunity to insist that each of us practice today in all of the core or basic therapies of our field. We must also insist that future psychiatrists be trained in these practices. Our failure to do so will mean that psychiatry will be reduced in its importance as a mental health profession.”

These conclusions are correct as far as they go. However, I would suggest that our profession’s advances in treatment effectiveness have increased the demand for quality psychiatric treatment services exponentially while the pool of psychiatrists providing treatment in the community has remained stagnant. I agree that many, if not most, patients are best served by the provision of regular psychotherapy in addition to psychopharmacological treatment. But if there are not enough psychiatrists to meet demand, is it not better to provide a half-hour visit once or twice a month to several patients in need, even if it means that they get their primary psychotherapy from someone else, than it is to provide one hour of treatment to a single patient once or twice a week?

Yes, we must stress competency in psychotherapy as part of the training of all new psychiatrists. Understanding psychodynamic, interpersonal, cognitive, and behavioral principles is vitally important even when providing treatment that is primarily psychopharmacological in nature. Over and above that, however, APA needs to push for the creation of more residency slots and to increase the number of physicians choosing psychiatry as a specialty by extolling the many virtues and joys of being a complete psychiatric physician. Only in this way can the supply of psychiatrists who possess the core competencies described by Dr. Weissman begin to approach the demand that our success has created.