David Mintz, MD, authored "Meaning and Medication: Addressing Ambivalence in Pharmacotherapy" in
Psychiatric News.
This article was republished with permission from Psychiatric News © 2025 “We physicians cannot discard psychotherapy, if only because another person intimately concerned in the process of recovery—the patient—has no intention of discarding it.... A factor dependent on the psychical disposition of the patient contributes, without any intention on our part, to the effect of every therapeutic process initiated by a physician; most frequently it is favorable to recovery, but often it acts as an inhibition…. All physicians, therefore, yourselves included, are continually practicing psychotherapy, even when you have no intention of doing so and are not aware of it; it is a disadvantage, however, to leave the mental factor in your treatment so completely in the patient’s hands. Thus it is impossible to keep a check on it, to administer it in doses or to intensify it. Is it not then a justifiable endeavor on the part of a physician to seek to obtain command of this factor, to use it with a purpose, and to direct and strengthen it?”
—Sigmund Freud, “On Psychotherapy” (1905)
It is perhaps a bold move, in our current climate, to initiate a column in a psychiatric publication with a quote from Freud, even if it is a psychotherapy column. Some of my potential audience may already be prepared to discount what follows as unscientific or outdated.
I start here, however, because I believe that Freud’s wisdom on this point is as relevant now as it was 120 years ago and expresses something of the vision I have for this section. I believe that the psychotherapeutic skills learned in residency are indispensable to our practice as effective psychiatrists in any setting where we are engaging with patients, regardless of whether we are providing a formal, named psychotherapy. I suspect, too, that as the ideological pendulum of psychiatry swings between medical and behavioral poles, we are entering a period of integration between biomedically oriented and psychotherapeutic practices of psychiatry.
The Bio-Bio-Bio Model
I entered medical school in 1989, with a goal of practicing psychotherapy as a psychiatrist, still a common goal for a psychiatrist of that era. Within four months, President George H.W. Bush had declared by presidential proclamation the 1990s to be the “Decade of the Brain.” This was a time of tremendous neuroscientific optimism. For the first time, we were able to peer inside the functioning of the brain, and promising new medications were being launched almost every month. There was a feeling that we might be on the verge of defeating mental illness. The simultaneous introduction of managed care, with its focus on efficiency (often over effectiveness), helped drive a massive shift in psychiatric identity and practice. The bio-psycho-social model gave way to what former APA President Steven Sharfstein, M.D., dubbed the “bio-bio-bio model.”
Through the ’90s and ’00s, the role of the psychiatrist was redefined, with many psychiatrists—particularly those in urban coastal areas—rebranding themselves as “psychopharmacologists” and the vast majority focusing their practices on prescribing. Studies by Mark Olfson, M.D., M.P.H., and colleagues have tracked the declining practice of psychotherapy by psychiatrists over the last three decades (Mojtabai & Olfson, 2008; Olfson & Marcus, 2010; Tadmon & Olfson, 2022), with progressive reductions in the proportions of both psychiatrists providing psychotherapy and psychiatric visits devoted to psychotherapy.
This does not portend the end of psychotherapy. A consistent 13% of psychiatrists have continued to offer psychotherapy as a central modality (Tadmon & Olfson, 2022). Further, evidence-based practice, once used to pummel psychodynamic psychiatry, has since become its friend, replacing our exuberant optimism with a sober recognition that, as effective as medications are, they are seldom curative or as effective as we and our patients want them to be.
Even Tom Insel, M.D., who as director of the National Institute of Mental Health (NIMH) from 2002 to 2015 had singularly focused NIMH’s resources on biomedical targets, acknowledged in a 2017 interview that despite tens of billions of dollars invested, the agency had not “moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness” (Rogers, 2017). Consequently, the psychiatric pendulum, I believe, reached its biomedical apex at the very end of 2009 and has been swinging back toward an integrative position ever since.
The Patient as Person
Tadmon and Olfson (2022) suggest that 47% of psychiatrists still provide some psychotherapy, even if it is not their primary treatment modality. What Tadmon and Olfson do not address, however, is the amount of psychotherapy being offered in sessions that are a half-hour or less. To me, there is evidence that this is one of the directions in which we are moving. The limits of narrowly biomedical approaches, a growing awareness of the psychosocial determinants of health, and comparative research on effect sizes in pharmacologic and psychotherapeutic treatments are driving many to a recognition that mainstream biomedical treatments can be most effective when complemented by patient-centered, psychotherapeutically informed approaches that recognize and address the psychology of the patient-as-person, and not just patient as biological object.
Despite NIMH’s biomedical tilt, psychiatric research into psychosocial aspects of psychiatry care has resumed after a decades-long hiatus. Newer models of care delivery—including motivational interviewing, psychodynamic psychopharmacology, transference-focused psychotherapy, culturally competent approaches, and cognitive behavioral therapy adaptations—are specifically addressing the value of targeted psychosocial interventions in the context of pharmacotherapy. At the same time, teaching brief psychotherapeutic interventions across a range of treatment settings has been an increasing focus of the American Association of Directors of Psychiatric Residency Training’s Psychotherapy Committee in recent years, as a way to leverage psychotherapeutic skills in brief encounters. The “16-minute hour” (Dotson, et al., in press) may be one way that psychotherapy does not wither but adapts.
As Freud suggested in the epigraph to this column, we cannot discard psychotherapy. Every time that we speak, that we demonstrate empathy (or disinterest), that we partner with our patients (or direct them), we are shaping their psychology and how they respond to our treatments. The question is whether we will do this haphazardly or will “seek to obtain command of this factor, to use it with a purpose, and to direct and strengthen it.”
All this is to say something about a vision for this column. While a psychotherapy column is bound to address common “named” psychotherapies, I do not intend for this to be the focus. Beyond a big-tent approach that recognizes the value of all evidence-based psychotherapies, my vision is that the column will address larger questions about the practice of psychotherapy by psychiatrists, explore systemic issues that impact the practice of psychotherapy by psychiatrists, and especially focus on what developments in psychotherapy mean for the mainstream psychiatric practitioner, including those who do not view psychotherapy as their primary treatment modality but are oriented toward a patient-centered approach. ■
References
Mojtabai R, Olfson M:
National trends in psychotherapy by office-based psychiatrists.
Arch Gen Psychiatry 2008; 65(8):962-970.
Olfson M, Marcus SC:
National trends in outpatient psychotherapy.
Am J Psychiatry 2010; 167(12):1456-1463.
Dotson S, et al.: The 16-minute hour: combining abbreviated psychotherapy with medication visits. J Psychiatr Pract [in press].