Psychotherapy conducted by psychiatrists

June 2021

Position statement 54


Summary

Psychotherapy is an evidence-based treatment essential to psychiatric practice.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has developed this position statement to recognise the importance of psychotherapy in the provision of mental health care and to provide evidence of its value in psychiatric practice, including longer-term psychotherapy. The statement reaffirms the RANZCP’s commitment to training psychiatrists in psychotherapy and supporting psychiatrists to use various psychotherapeutic treatment modalities in their practice.

Key messages

  • Psychotherapy is a modality of treatment that forms a core component of every psychiatric treatment.
  • There is strong evidence for the efficacy of psychotherapy for a wide range of mental disorders
  • Psychotherapy can provide benefits to people with mental disorders that other treatment cannot and therefore psychiatrists should always consider the value of psychotherapy when providing treatment.
  • Many people with mental disorders have significant comorbidity and histories of trauma, requiring psychotherapeutic intervention, including high-quality intensive long-term treatment.
  • Psychiatrists’ medical training complemented by their holistic perspective on mental health makes them ideally placed to ensure that people with mental disorders are provided with a balance of psychotherapy and other treatments appropriate to their needs.
  • Training and practice in psychotherapy is essential for all psychiatrists to embed psychotherapy as a core skill in all psychiatric practice.
  • Where psychiatrists provide treatment in collaboration with other mental health professionals, an aligned approach to psychotherapy is important.
  • Psychotherapy has demonstrated economic and societal benefits for its use including increased productivity and decreased hospital costs.
  • There is need for continuing research into psychotherapy including on the specific types of psychotherapy in relation to benefits and potential side effects for specific conditions.

Background

Psychotherapy (also called ‘talking therapy’) is a modality of treatment that forms a key component of every psychiatric treatment. During psychotherapy, psychiatrists and people with mental disorders work together to relieve psychopathological conditions and functional impairment through focus on the:

  • therapeutic relationship
  • attitudes, thoughts, affect, and behaviour of those being treated
  • social context and development.

Psychotherapy may be practised with an individual, or with a dyad (e.g. mother–infant), couples, family, group, or system. Psychotherapy is based on a number of different theoretical foundations, the most common of which are cognitive behavioural and psychodynamic therapy. Psychotherapy may be brief/focal or intensive. There are different forms of psychotherapy practised by psychiatrists. These include supportive psychotherapy, structured psychotherapies (for example Cognitive and Behavioural Psychotherapy, Mentalisation-Based Treatment, Acceptance and Commitment Therapy, Cognitive Analytic Therapy, Dialectical Behavioural Therapy and interpersonal therapy), and intensive psychodynamic psychotherapy and psychoanalysis.

In Australia, New Zealand, and internationally, the cost of mental disorders to the community in both human and economic terms is significant and continues to grow. (1, 2) Many mental disorders are complex and severe and involve significant comorbidity, requiring psychiatric treatment. A high percentage of individuals with these disorders have histories of trauma, and benefit from psychological intervention by psychiatrists. Treatments are often complex and resource intensive, yet are essential to a complete spectrum of care; such treatments may be the only viable treatment, and can be lifesaving. It can take more than a year, and several sessions a week, to get full benefit but the positive effects are often long lasting.

Psychotherapy, including intensive longer-term treatments, has been demonstrated to be cost-effective when compared to the costs of multiple hospital emergency attendances and psychiatric inpatient admissions, (3) and has been shown to diminish symptoms, improve occupational function and personal relationships. (4)

Evidence

The empirical evidence for the efficacy of psychotherapy for a wide range of mental disorders is very strong with the effect size between treated and untreated individuals produced by quantitative reviews ranging from 0.6 to 0.8.  In general, outcomes for different psychotherapies are equivalent and no form of psychotherapy has proven superior to any other.  (5-8) Psychotherapy has been found to be superior to treatment-as-usual and the benefits of psychotherapy not only endure but increase with time, a finding that has now emerged from at least five independent meta-analyses. (9-12)

There is considerable empirical evidence supporting the use of psychodynamic approaches. Psychodynamic psychotherapy benefits individuals who present with depression, eating disorders, panic, somatoform disorders, substance-related disorders, personality disorders and some forms of anxiety. (6, 13, 14)

More than 40 meta-analyses have been conducted on the outcomes of people with depression (15) with results indicating that most psychological treatments that have been studied produce substantial effects in terms of symptom reduction and increased well-being (16). Research examining the relative effectiveness of psychotherapy versus medication has generally found similar benefits (6, 17) and in depression, adding psychotherapy to the medication treatment regime can improve outcomes. (7)

Longer-term psychodynamic psychotherapy (one year and longer) benefits individuals with complex disorders where the severity manifests as a combination of syndromal and severe complex disorders (a generally high level of vulnerability to psychopathology). (6) In the treatment of people with borderline personality disorder for example, a number of studies have shown maintenance of improvement for at least five years after long-term psychotherapy. (18) Evidence is accumulating that, in order to be effective, interventions for treatment-resistant depression may need to be longer and more complex than first-line treatments of depression. (19) Longer follow-ups (20) demonstrate enduring improvement in depression scores and greater improvements on measures of social adjustment.

It is acknowledged that there are potential risks, side effects or adverse effects of psychotherapy however few empirical studies exist to assess these as side effects are multifold and can be difficult to detect (21-23). This is an area that requires further research and practice development.

Utility and benefits of psychotherapy conducted by psychiatrists

Psychotherapy is an important component of the overall treatment for low prevalence disorders such as schizophrenia and bipolar disorder. Equally, psychotherapy is an important component of the treatment of high prevalence disorders such as anxiety, depression and substance abuse. These disorders often occur at a time when individuals are establishing their own families and the potential for transgenerational transmission of mental health problems is maximal. The high prevalence disorders may be as debilitating as the psychoses.

In addition to the importance of the various psychotherapies as distinct diagnostic and treatment modalities, psychotherapy also informs and improves the general practice of psychiatry. A working knowledge of psychotherapy theory and practice helps psychiatrists to understand the interpersonal complexities of the doctor-patient relationship as well as relationships between staff and between the individuals and their families, whānau, or caregivers. Understanding how interpersonal patterns shape individual’s responses can lead to more positive and collaborative clinical interactions, increased medication compliance, greater understandings of how the person with a mental disorder may engage with a service and better understandings of how iatrogenic harm can be avoided. Some studies even suggest psychotherapy can produce better responses to medication. (24)

Cost-benefit economic analyses demonstrate financial savings resulting from the provision of longer-term psychotherapies, which can reduce patient emergency department presentations (often for treatment of deliberate self-harm and suicidality) and acute mental health services inpatient admissions. (25) The factors that contribute to the cost-effectiveness of extended intensive psychotherapy include savings from decreased sick leave, decreased medical costs and decreased hospital costs (25) as well as improved occupational function, the capacity to engage in personal relationships, positive self-esteem and wellbeing. (4) 

Adding psychotherapy to psychotropic medication yields significant health gains and is more cost-effective than medication alone. Psychotherapy can enhance the cost-effectiveness of psychotropic medications both by increasing compliance and also in terms of reducing admissions. (25) Decreased vulnerability to relapse leads to greater long-term economic benefits. (26)

The role of psychiatrists

The principles and practices of psychotherapy conducted by psychiatrists are underpinned by two of the central principles that define practice standards for mental health, which require that all mental health practitioners (including psychiatrists):

  • need to learn about and value the experience of patients, family members and/or carers
  • should recognise and value the healing potential in the relationship between the patient and service provider. (27)

Psychotherapy conducted by psychiatrists is distinguished from psychotherapy conducted by other practitioners in that it centres on a holistic approach to mental disorder based on general medical training, specialist psychiatry training, psychological insight and clinical experience as well as the social, cultural and interpersonal dimensions of mental disorder. Having both medical and psychiatric training provides a breadth of exposure to severe, complex and comorbid conditions, particularly in populations with personality disorders and a history of trauma, which is not provided by any other training. For people with severe and complex disorders, integrated treatment by one practitioner with a variety of specialist skills often results in improved outcomes.

Psychiatric training provides expertise in the relevant developmental and psychodynamic models that address the importance of early infant development and its complex role in the genesis of many forms of mental disorder. In particular, early infant experiences of trauma, abuse and disorders of attachment as well as complex traumas in later life may be addressed through psychotherapy, informed by the psychodynamic understandings which underpin each psychiatric treatment.

Psychiatrists’ training makes them ideally placed to ensure that people with mental disorders are provided with a balance of psychotherapy and medication appropriate to their needs. This is commonly required for those who are severely ill and allows optimally integrated treatment that reduces cost. Further, the training program is sufficiently broad to allow psychiatrists to develop knowledge of all forms of psychotherapy including evidence-based emerging treatments such as second and third wave cognitive behavioural therapies, as well as an understanding of which form is most appropriate for delivery (e.g. individual, group, family systems therapy).

With their understanding of psychodynamics, psychiatrists, all of whom are trained in psychotherapy, are in a key position to supervise junior doctors and trainees, understand cases and build team cohesion, thereby helping to prevent vicarious trauma. The RANZCP training requirements provide a foundation in psychotherapy for all psychiatry trainees, thereby embedding psychotherapy as a core skill in psychiatry training. In addition, advanced training in psychotherapy is offered to enable trainees and psychiatrists to further their education in this area.

Psychiatrists who are involved in designing and planning treatment programs value their integrated understanding of psychotherapy principles and apply this knowledge in the context of the local system. It is recognised that the psychiatrist may not be the individual who delivers therapy, as its regularly the case in New Zealand or in rural and remote areas. In these instances, where psychiatrists are working with other mental health professionals in providing treatment it is important to ensure good communication in line with the RANZCP Professional Practice Guideline, Best practice referral, communication and shared care arrangements between psychiatrists, general practitioners and psychologists. A collaborative approach to psychotherapy is an important part of care, and psychiatrists, who are trained in the biopsychosocial approach, can help ensure that the patient receives care that is aligned and minimises the risks of one aspect of a patient’s care undermining another.

Recommendations

The RANZCP recognises the importance of psychotherapy in the provision of mental health care and is committed to training psychiatrists in psychotherapy and supporting psychiatrists to use psychotherapeutic treatment modalities in their practice. Psychiatrists value the lived experience of people with mental disorder and the healing potential in the relationship between those being treated and the psychiatrist.

In acknowledgement of these facts, the RANZCP takes the following position:

  • Psychotherapy, as a key component of every psychiatric treatment, must be embedded in training for all psychiatrists.
  • Psychiatrists and psychiatry trainees interested in further study of psychotherapy should be supported to do so through advanced training. In addition, further study and training should be available at all levels in psychotherapy.
  • Psychotherapy conducted by psychiatrists should be valued as a core treatment modality in public and private practice.  It should be funded and widely available to the population with conditions that would benefit from this treatment across all service settings.
  • Psychiatrists have medical training which, when complemented by the biopsychosocial perspective on mental health, facilitates a holistic approach to mental health care. Psychiatrists are therefore ideally placed to ensure that people with mental disorder are provided with a balance of psychotherapy and medication treatment modalities appropriate to their needs.
  • Psychotherapy can provide benefits which other treatment modalities cannot and therefore psychiatrists should always consider the value of psychotherapy when providing treatment.
  • There is a need for continuing research into the efficacy and potential side-effects of psychotherapy including on the specific types and elements of psychotherapy in relation to benefits in specific conditions, as well as the cost-effectiveness of different types of psychotherapy for different conditions.

Further reading

Responsible committee: Faculty of Psychotherapy

  1. Hosie A, Vogl G, Hoddinott J, Carden J, Comeau Y. Crossroads: Rethinking the Australian mental health system. 2014.
  2. Doran CM, Kinchin I. A review of the economic impact of mental illness. Australian Health Review. 2019;43(1):43-8.
  3. Stevenson J, Meares R, D'angelo R. Five-year outcome of outpatient psychotherapy with borderline patients. Psychological Medicine. 2005;35(1):79.
  4. Wilczek A, Weinryb RM, Barber JP, Gustavsson JP, Åsberg M. Change in the core conflictual relationship theme after long-term dynamic psychotherapy. Psychotherapy Research. 2006.
  5. Beutler LE. Making science matter in clinical practice: Redefining psychotherapy. Clinical Psychology: Science and Practice. 2009;16(3):301-17.
  6. Fonagy P. The effectiveness of psychodynamic psychotherapies: An update. World Psychiatry. 2015;14(2):137-50.
  7. Pampallona S, Bollini P, Tibaldi G, Kupelnick B, Munizza C. Combined pharmacotherapy and psychological treatment for depression: a systematic review. Archives of general psychiatry. 2004;61(7):714-9.
  8. Wampold BE. The research evidence for the common factors models: A historically situated perspective.  The heart and soul of change: Delivering what works in therapy, 2nd ed: American Psychological Association; 2010. p. 49-81.
  9. Abbass AA, Kisely SR, Town JM, Leichsenring F, Driessen E, De Maat S, et al. Short-term psychodynamic psychotherapies for common mental disorders. Cochrane Database Syst Rev. 2014(7):Cd004687.
  10. Anderson EM, Lambert MJ. Short-term dynamically oriented psychotherapy: A review and meta-analysis. Clinical Psychology Review. 1995;15(6):503-14.
  11. de Maat S, de Jonghe F, Schoevers R, Dekker J. The effectiveness of long-term psychoanalytic therapy: a systematic review of empirical studies. Harv Rev Psychiatry. 2009;17(1):1-23.
  12. Leichsenring F, Rabung S, Leibing E. The efficacy of short-term psychodynamic psychotherapy in specificpsychiatric disorders: a meta-analysis. Archives of general psychiatry. 2004;61(12):1208-16.
  13. Leichsenring F. Are psychodynamic and psychoanalytic therapies effective?: A review of empirical data. The International Journal of Psychoanalysis. 2005;86(3):841-68.
  14. Milrod B, Leon AC, Busch F, Rudden M, Schwalberg M, Clarkin J, et al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. American Journal of Psychiatry. 2007;164(2):265-72.
  15. Cuijpers P, Dekker J. Psychological treatment of depression; a systematic review of meta-analyses. 2005.
  16. Cuijpers P, van Straten A, Andersson G, van Oppen P. Psychotherapy for depression in adults: a meta-analysis of comparative outcome studies. J Consult Clin Psychol. 2008;76(6):909-22.
  17. Hollon SD. The efficacy and effectiveness of psychotherapy relative to medications. American Psychologist. 1996;51(10):1025.
  18. Meuldijk D, McCarthy A, Bourke ME, Grenyer BF. The value of psychological treatment for borderline personality disorder: systematic review and cost offset analysis of economic evaluations. PLoS One. 2017;12(3).
  19. Hollon SD, Ponniah K. A review of empirically supported psychological therapies for mood disorders in adults. Depression and anxiety. 2010;27(10):891-932.
  20. Rawlins M. De testimonio: on the evidence for decisions about the use of therapeutic interventions. The Lancet. 2008;372(9656):2152-61.
  21. Linden M, Schermuly-Haupt M-L. Definition, assessment and rate of psychotherapy side effects. World Psychiatry. 2014;13(3):306.
  22. Berk M, Parker G. The elephant on the couch: side-effects of psychotherapy. Australian and New Zealand Journal of Psychiatry. 2009.
  23. Moritz S, Nestoriuc Y, Rief W, Klein JP, Jelinek L, Peth J. It can’t hurt, right? Adverse effects of psychotherapy in patients with depression. European archives of psychiatry and clinical neuroscience. 2019;269(5):577-86.
  24. McKay KM, Imel ZE, Wampold BE. Psychiatrist effects in the psychopharmacological treatment of depression. Journal of affective disorders. 2006;92(2-3):287-90.
  25. Lazar SG. The cost-effectiveness of psychotherapy for the major psychiatric diagnoses. Psychodynamic Psychiatry. 2014;42(3):423-57.
  26. Berghout CC, Zevalkink J, Hakkaart-Van Roijen L. The effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and their associated costs. Journal of Psychiatric Practice®. 2010;16(4):209-16.
  27. Department of Health. National Practice Standards for the Mental Health Workforce 2013. Melbourne, Australia Victorian Government Department of Health; 2013.


Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.