The relationship between psychotherapy and psychiatry has been strained for some time now. Advances in neuroscience, genetics, and psychopharmacology have skewed psychiatry away from psychotherapy toward a “remedicalization” and an emphasis on medication as the primary tool in the psychiatrist's therapeutic armamentarium. Economic forces have contributed to this trend as well. Managed care companies often look for “quick fixes” and tend to favor pharmacotherapy over “the talking cures.”

The result has been unfortunate for the field. In an era in which a sophisticated understanding of the mind–brain interface is possible, psychiatry, at least in some quarters, has become increasingly reductionistic. The hegemony of biological psychiatry has encouraged a Cartesian dualism in which mind and brain are artificially separated from each other. Psychotherapy is seen as the treatment for “psychologically based” disorders, while medication is regarded as the treatment for “brain-based” disorders. This simplistic dualism overlooks the plain facts that psychotherapy must work by changing the brain and that the mind is the activity of the brain.

Nobel Prize winner Eric Kandel (1998) has been at the forefront of an emerging literature that regards psychotherapy as a biological treatment. Working with the marine snail Aplysia, Kandel stressed that synaptic connections can be permanently altered and strengthened through the regulation of gene expression when learning takes place. This conceptual understanding can be applied to psychotherapy as well. Learning takes place when psychotherapy is well conducted, and the changes in brain function that result now are being mapped. Goldapple et al. (2004) have even begun to chart the brain regions that are more profoundly affected by psychotherapy as compared with medication. In a study involving cognitive-behavioral therapy (CBT) and paroxetine for depressed patients, the investigators documented that therapy worked in a “top down” manner, with decreased metabolic activity in the medial, dorsal, and ventral frontal cortices, and increased activity in the anterior cingulate and hippocampus. Paroxetine appeared to work in a “bottom up” way, with decreased activity in the brain stem and subgenual cingulate and increased activity in the prefrontal cortex.

As psychotherapy becomes legitimized as a treatment that affects the brain, rather than mere hand holding or babysitting, a vision of the future emerges in which we can begin to imagine a time when we will be able to predict which patients will do better with psychotherapy, which will respond optimally to medication, and which may require both.

In a landmark study, a group of patients with chronic forms of major depression were treated with nefazodone, a form of CBT, or the combination of both in a randomized controlled trial (Nemeroff et al. 2003). Examined in totality, antidepressants and psychotherapy were roughly equal in their usefulness, but each was significantly less effective than combined treatment. When the data were examined in more detail, however, it became clear that a subgroup of patients did better with psychotherapy alone compared with nefazodone. Specifically, this group had a history of early childhood trauma, including physical or sexual abuse, neglect, or loss of parents at an early age. The combination of psychotherapy and pharmacotherapy was only marginally superior to psychotherapy alone among this group. The investigators concluded that the presence of childhood trauma was a strong indication for psychotherapy as an essential element in the treatment.

Changes have occurred in recent years at the level of psychiatric residency training programs. There has been a growing recognition that psychotherapy is a basic science of psychiatry (Gabbard and Kay 2001). The Residency Review Committee mandated training in several different forms of psychotherapy as part of the core competencies of psychiatry. Even those future psychiatrists who think they would like to treat patients with pharmacotherapy alone will be faced with the task of establishing a therapeutic alliance if they hope to have the patient take the medication as prescribed. Indeed, the quality of the therapeutic alliance has been shown to be a better predictor of outcome than any of the specific treatments or techniques used in the treatment of depression (Krupnick et al. 1996). Hence all residents are now required to be trained up to basic competency in psychotherapy.

While psychotherapy was long criticized as lacking an empirical base, that situation has gradually changed. Some forms of psychotherapy have been more rigorously tested than others in randomized controlled trials, but the rapidly growing base of efficacy studies has been encouraging (Beck 2005; Leichsenring et al. 2004). In addition, research combining medication and psychotherapy has become increasingly common and may be particularly relevant, given that one survey of practitioners found that the majority of patients receive both medication and psychotherapy (Pincus et al. 1999). Whether offered by one treater or two, combined treatment places special demands on the psychotherapist, a topic discussed thoroughly in this volume.

With the expanding literature empirically validating psychotherapy as a treatment, and the plethora of psychotherapies now in the marketplace, a comprehensive textbook of psychotherapeutic treatments in psychiatry has become of central importance, both to practitioners and to trainees in psychiatry and other mental health professions. Hence in one volume we have collected contributions from experts in all of the major psychotherapeutic approaches. The volume begins with a section on psychodynamic psychotherapy, followed by sections on CBT, interpersonal therapy, and supportive psychotherapy.

The section editors have ably assembled a cast of outstanding experts to write each of the chapters. In an effort to provide a consistent format for the student who wishes to study comparative psychotherapy using this textbook, the section editors were asked to organize the sections along similar lines—namely, with chapters on theory, technique, indications and efficacy, and the combination of psychotherapy with medication.

Psychotherapy is not only administered to individuals, of course. Many psychotherapists treat groups, families, and couples. Hence we also include a section that covers these modalities from the standpoint of diverse theories and techniques.

The book ends with a section on forms of psychotherapy integration, given that many psychotherapists are using amalgams of different types of therapy in their own practices. Moreover, specific brands that are integrated and defy easy classification, such as mentalization-based therapy and dialectical behavior therapy, are also included in this section. The integration of neuroscience with psychotherapy is considered to be one of the most exciting areas of research, as it reflects the ongoing effort to build bridges between psychological treatments and our understanding of the brain and neuroscience. Hence a chapter appears on this topic as well. Finally, professional boundaries are an essential component in the practice of all psychotherapy, so we devote a chapter to these risk management issues.

The result is one comprehensive resource that covers all the central psychotherapeutic approaches that are likely to be needed by psychiatrists, psychologists, social workers, and other mental health professionals. The book lends itself to use as a textbook by students as well as a reference book for experienced clinicians to pull off the shelf when needed.

A task of this nature requires a team of experts with special knowledge in diverse areas. I owe a special debt of gratitude to those colleagues who served as section editors: Jesse Wright, Judy Beck, John Markowitz, Arnold Winston, James Griffith, and Bernard Beitman. The assistance of Tina Coltri-Marshall was essential in keeping the project on track—she was the “glue” that kept this sprawling project in a state of cohesiveness throughout the extended period of time that it required. My assistant, Diane Trees-Clay, also was of great support in helping me attend to the multiple tasks inherent in a textbook like this one. Bob Hales and John McDuffie of American Psychiatric Publishing were steady sources of support in the planning and implementation as well. Finally, Greg Kuny worked closely in providing the editorial assistance to see the project fully realized.

I welcome the reader to the pages that follow. I hope you will share our excitement in the growth of the psychotherapy field and the inescapable conclusion that psychotherapeutic treatments are alive and well in psychiatry.

Glen O. Gabbard, M.D.

References

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Gabbard GO, Kay J: The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist? Am J Psychiatry 158:1956–1963, 2001
Goldapple K, Segal Z, Garson C, et al: Modulation of cortical-limbic pathways in major depression: treatment-specific effects of cognitive behavior therapy. Arch Gen Psychiatry 61:34–41, 2004
Kandel E: A new intellectual framework for psychiatry. Am J Psychiatry 155:457–469, 1998
Krupnick JL, Sotsky SM, Simmens S, et al: The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol 64:532–539, 1996
Leichsenring F, Rabung S, Leibing E: The efficacy of short-term psychodynamic psychotherapy in specific psychiatric disorders: a meta-analysis. Arch Gen Psychiatry 61:1208–1216, 2004
Nemeroff CB, Heim CM, Thase ME, et al: Differential responses to psychotherapy vs pharmacotherapy in patients with chronic forms of major depression and childhood trauma. Proc Natl Acad Sci 100:14293–14296, 2003
Pincus HA, Zarin DA, Tanielian TL, et al: Psychiatric patients and treatments in 1997: findings from the American Psychiatric Association Practice Research Network. Arch Gen Psychiatry 56:441–449, 1999