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
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
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
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
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.