Grand Rounds Report from the Department of Psychiatry – Prescribing Psychotherapy

by Academy of Clinical Excellence on March 27, 2011

Psychotherapy is a method common in some form to all cultures that address human suffering. The late Jerome Frank, a Hopkins psychiatrist, empirically studied psychotherapies that succeeded and failed to define several characteristics common to all successful therapies. In addition, he found that patients seek psychotherapy for reassurance, hope and support, much as they did in the past from the clergy. Frank concluded that psychotherapy – at its core - is Persuasion and Healing, the title he chose for his classic work on the subject. The practice and teaching of this powerful and timeless treatment has long been a central part of the mission of academic psychiatrists. However, recent evidence suggests that the use of psychotherapy as a treatment for patients with psychiatric conditions is diminishing, a phenomenon which would surely have interested and concerned Frank. Given that a central part of my mission as a psychiatrist is the practice and teaching of psychiatry and psychotherapy, it certainly concerns me.
 

For much of the 20th century, psychiatrist meant psychotherapist, and most psychiatrists practicing in the community provided psychotherapy only. In the early 1960s, psychiatrists often saw patients five days a week for individual psychotherapy. However, multiple forces have been at work to create a new generation of psychiatrists. Between 1996 and 2005 the percentage of psychiatry office visits involving psychotherapy decreased from about 44 percent (already a significant decline from the 1980s) to 29 percent, a 35 percent reduction in less than 10 years (Mojtabai and Olfson 2008). While this waning practice of psychotherapy among psychiatrists is attributed to several forces, the primary genesis is the increasing availability of medications that have become available to treat a number of psychiatric diseases.

 
 
As defined by Frank, psychotherapy involves a ritualized, emotionally-arousing encounter between an empathic healer and a suffering individual in which the healer persuades the individual to change attitudes and behaviors to relieve suffering. So many chronic medical conditions can be prevented and even cured when a patient is able to change his attitude and behavior. Although many psychiatrists have willingly abdicated the role of psychotherapist, all clinically excellent physicians embrace this role, as psychotherapy’s mission of hope has wide applicability to all patients seeking relief from suffering. These days, managed care bureaucracy and technologic innovation have the potential to overshadow the personal dimension of medicine. It is essential to convey to patients, caregivers and the larger society, the crucial role psychiatry and psychotherapy has to play in health care. As a member of the Miller-Coulson Academy, I hope to extend my passion for teaching the art of psychotherapy to a greater and more diverse group of health care professionals.
 
For a fuller discussion of the topic, see Dr. Chisolm's essay in the Spring 2011 issue of Perspectives in Biology and Medicine. This topic was also examined in a recent NYT article:http://www.nytimes.com/2011/03/06/health/policy/06doctors.html?_r=1&hp;
 
Margaret S. Chisolm, MD Assistant Professor Department of Psychiatry and Behavioral Sciences Johns Hopkins University School of Medicine

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