xxAACP Newsletter, Volume 13, Number 2, Spring 1999

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There are many current challenges to the provision of psychotherapy services in the practice of community and public sector psychiatry. AACP members practice psychotherapy with a variety of patient populations, both with and without pharmacotherapy, in settings with limited funding. This experience has been replicated now in the private sector as well, due to managed care. The AACP's position arises from our awareness of the need to choose therapies of demonstrated efficacy across a broad variety of targeted high-risk patient groups and of the importance of identifying certain interventions as psychotherapy which require comprehensively trained clinicians for successful implementation.

1. Limits on the capacity to fund and provide psychotherapy in both public and private settings must be addressed by:

   • a.   Advocating for interventions common to community settings. These include individual, group, and family psychotherapies, both brief and long-term. The following examples are commonly used psychotherapeutic treatments: crisis stabilization, supportive therapies, the varieties of psychodynamically informed psychotherapy, cognitive and behavior therapies, dialectical behavior therapy, family system therapy, addiction-focused therapy, focused/intensive interventions that include clinical case management services, social skills training, psychoeducational multifamily group therapy, rehabilitation groups focused on housing or employment issues, and the psychotherapy provided during medication visits.

   • b.   Conducting, reviewing and publicizing research on the benefits of providing appropriate therapy and the effects of withholding indicated psychotherapy. Of special note is the need to demonstrate the effects of withholding therapy from patients at high risk for recurrent crisis and decompensation, including those with personality disorders, dual mental illness and substance abuse diagnoses, victims of trauma, seriously emotionally disturbed children and adolescents, and patients with severe and persistent mental illnesses.

   • c.   Studying the impact of restrictions induced by inadequate funding and precertification requirements. Direct restrictions, such as those due to extrinsic caps and those requiring external approval, and indirect restrictions, such as those imposed by inadequate capitation rates, force providers to eliminate psychotherapeutic modalities in order to retain medical treatments and emergency services.

   • d.   Promoting the use of therapies known to engage patients with the most difficult disorders.

2. Support for a broad concept of psychotherapy which recognizes it as a part of all psychosocial and interpersonal therapeutic interventions should include:

   • a.   Studying and promoting the necessity and technique of psychotherapy in the practice of pharmacotherapy.

   • b.   Studying and promoting treatments that include psychotherapy for severe illnesses. Many effective community-based treatments, such as assertive community treatment, social skills training, and other behavioral and rehabilitative modalities are informed by the principles of psychotherapy and include the conduct of psychotherapy. Clinicians should be appropriately trained, and supervision and medical direction should be available for less comprehensively trained clinicians.

   • c.   Promoting psychotherapies used in alternative settings. These include nursing homes, schools, jails and prisons, juvenile courts and detention facilities, volunteer clinics, telepsychiatry initiatives, and conditions requiring flexibility and creativity such as multi-service inner city programs and rural settings.

3. The importance of providing every patient with a comprehensively trained primary clinician should be supported by:
   • a.   Studying the impact of using lesser-credentialed lead clinicians. Resource-poor multidisciplinary settings are often compelled to reduce the level of training for a lead clinician from doctoral to master's to bachelor's level or below, and from persons with clinical expertise to persons whose original purpose was to serve as care coordinators.

   • b.   Determining through research in which clinical situations it is preferable for the psychiatrist to serve as the treating psychotherapist.

   • c.   Studying how the medical necessity for psychotherapy is determined or should be determined.

   • d.   Promoting medical direction in the treatment of populations with serious illness or risk for increased intensity of services. Psychiatrists should be utilized in the planning, provision, and outcomes monitoring of psychotherapies in multidisciplinary settings. The need for medical direction should be studied, with specific attention to psychiatric leadership in determining the necessity, modality, intensity, and duration of psychotherapy in organized care settings.

4. We call for the production of scholarly and public documents for use by psychiatrists to educate, advocate and negotiate funding for psychotherapy services.

5. Training and supervised experience in intensive individual psychotherapy must be preserved as an essential part of psychiatric residency training. This provides highly tuned skills of listening and observation and a sensitivity to the subtleties of interpersonal interactions, which are important in every aspect of the treatment of psychiatric disorders: evaluation, diagnosis, treatment planning, psychopharmacology, all models of psychotherapy, psychosocial rehabilitation, and systemic/interpersonal issues in the treatment process. In addition, this training enables the psychiatrist in hospital and community settings to provide supervision and consultation for other staff and wise leadership in a multidisciplinary treatment team.