[Spring/Summer 1998; Vol. 25 No. 1]
The following article is based on several conversations with Robert W. Gibson M.D., and a review of his previous publications on related subjects.
Dr. Gibson is President Emeritus of Sheppard Pratt Hospital. In the fifty years since he graduated from medical school Dr. Gibson has occupied many leadership positions in psychiatry. In addition to his role at Sheppard, Dr. Gibson has been president of the Maryland Psychiatric Society and of The American Psychiatric Association. He also served for many years as a supervising and training analyst of the Washington Psychoanalytic Society.
Editor: Psychiatrists in Maryland, as elsewhere, under pressure from managed care are doing less and less psychotherapy. You have written on this and related subjects for many years, and predicted much of what we are now experiencing.1 Where are we heading? Should there, and will there be psychotherapy in psychiatry’s future?
Dr. Gibson: We must retain psychotherapy, but we’ll have to fight for it. It is the core of psychiatric treatment and I believe it must remain so. Under various pressures we are often leaving psychotherapy to others or abandoning it entirely. That is a fatal error because psychiatry without psychotherapy is lacking some of the main ingredients necessary to understand and relate to patients with mental problems.
Editor: What are some of the pressures psychiatrists are reacting to?
Dr. Gibson: Managed care in all its forms is a well-known force. I have never been a fan of managed care, but there’s much more to our problems than that.
Editor: What else is there?
Dr. Gibson: Managed care would not exist if not for fragmented delivery and runaway costs of medical services. Besides lower costs, the big payers such as business and government want to know what they’re getting for their money, just as with any other services they pay for.
Editor: What do they want?
Dr. Gibson: They want evidence of benefits from treatment, for example they want outcome measures. Mental health services, especially psychotherapy, have been obvious targets, because of vague and contradictory theories and practices, rising costs and poorly documented outcomes.
Editor: How can psychotherapists be expected to measure things as complex as the human mind and human behavior?
Dr. Gibson: Those holding the purse strings are not buying that excuse any longer. The human brain is said to be the most complex thing in the universe, yet neuroscience is progressing rapidly. Without objective evidence to support our views and methods in psychotherapy, we will have little credibility.
Editor: Please go on.
Dr. Gibson: The revolution in psychopharmacology, begun over forty years ago, continues as a transforming force in psychiatry. Those of us who were in psychiatry before it began can most appreciate what a difference modern drugs have made. It is an understatement merely to say that many patients owe their lives to them. Psychopharmacology has also provided a great stimulus for basic research in neuroscience.
Editor: Has it also been a stimulus to adopting more rigorous methods of evaluating psychotherapy?
Dr. Gibson: Yes it has, and that brings to mind some other things that have changed. Up into the early 1970’s psychiatrists were almost undisputed as leaders in mental health, including psychotherapy. This has changed. Since then, there has been a huge proliferation of psychotherapies and of non-medical therapists. Many of these therapists are in direct competition with psychiatrists.
Editor: How did this happen?
Dr. Gibson: We are partly responsible for it. In order to meet the great demand for our services in both public and private mental health, we helped to train many non-medical therapists to work with us as team members. Many of them are licensed and now prefer to work independently.
Editor: How many types of therapy are there?
Dr. Gibson: When I wrote about the subject in 1985 1 there were reported to be at least 250. Since then I have lost count, but the number keeps growing.
Editor: Are any of these newer therapies effective?
Dr. Gibson: Let’s start with an older “established “ form of therapy, psychoanalysis. Is it effective? The simple answer is “yes” at least for some patients, but it is difficult to provide scientific evidence in support of this assertion. Among the “newer” therapies, I understand that there are some, such as cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT) that have been shown to be effective in controlled studies. These therapies are very attractive to managed care, because they are focused and short term, therefore more measurable and cheaper than psychodynamic therapies.
Editor: It is often claimed that no type of psychotherapy really works.
Dr. Gibson: There will always be skeptics who can’t be convinced by any evidence. More surprising is the fact that some studies are said to show that nearly all of the widely used therapies work. I am unable to say if that’s true or not.
Editor: There is considerable professional rivalry between mental health disciplines. Are psychiatrists any better than others as therapists?
Dr. Gibson: A well trained psychiatrist is best equipped to help patients who need a therapist with medical knowledge and the ability to prescribe medication wisely. There is no reason to believe, however, that when psychotherapy alone is called for, a psychiatrist is always the best therapist. In fact, some investigators claim there is no evidence that one type of therapist is any more effective than another.
Editor: Doesn’t training make a difference?
Dr. Gibson: I’m told that according to some studies, the amount and type of training don’t make any difference in the effectiveness of a therapist.
Editor: Do you believe that’s really true?
Dr. Gibson: The scientific study of psychotherapy is still in its infancy. I am also skeptical about such findings, but we cannot win a scientific debate simply on the basis of opinion or authority. More and better research is required.
Editor: You have told us that not all patients need a psychiatrist for psychotherapy. Now let’s go back to the subject of prescribing psychotropic medication. Most prescriptions are written by family doctors and other physicians, rather than by psychiatrists. A powerful State regulatory agency, the Maryland Health Care Access and Cost Commission (HCACC) in its 1997 report suggests “ substituting prescription drugs for psychotherapy.” (TMPFall1997 “Trust HCACC”) Do you have any comments on this?
Dr. Gibson: Unfortunately, drugs are used that way to an increasing extent. It is unfair to patients, who always need a relationship with the prescribing physician to get the full benefit of treatment. In addition the physician cannot adequately diagnose and monitor the patient with only brief, occasional “med checks.” Psychotherapy is not a substitute for medication, and medication is not a substitute for psychotherapy.
Editor: Let’s turn to the subject of training psychiatric residents in psychotherapy. If there is so little market for these skills in psychiatry and so little reimbursement for it, why should a resident make the considerable effort necessary to learn it?
Dr Gibson: Psychotherapy is the royal road to learning about patients. It is both a therapeutic and an educational activity. Both patient and therapist learn from it. A psychiatrist who works with and/or supervises other mental health workers will have little credibility without psychotherapy skills. Even when the psychiatrist is primarily doing chemotherapy, some level of psychotherapeutic relationship is required if one is to understand the patient.
Editor: You have placed a lot of emphasis on the need for science and objectivity in psychiatry in order to meet the demands of third party payers. If we just concentrate on meeting these demands, aren’t we in danger of losing something?
Dr. Gibson: Yes, indeed we are. Science is not enough. In addition to science there is art. Both science and art must be guided by humane values and ethical principles. Recently I had the honor to serve as chair of a meeting of the Committee on Planning and Communication of the Group for Advancement of Psychiatry (GAP), dealing with the subject of managed care. Many of the issues we discussed today came up in the GAP meeting.2
Editor: Members of the Maryland Psychiatric Society will enjoy reading the GAP report. Thank you.
References:
Gerald D. Klee, M.D. , Editor