Psychotherapy in the new paradigms for psychiatry.

Psychiatry is confronting challenges to create sweeping new paradigms for itself. The author contends that the psychosocial knowledge and psychotherapeutic skills of the psychiatrist must be integral to those paradigms. Abandoning crude, descriptive diagnostic categories in favor of discrete, dimensional measures that personalize selective neurobiological treatment for each individual is part of one proposed paradigm-but psychotherapy, especially psychodynamic therapies, have provided personalized therapy for over a century, using nature's own resources (human relationships and communication) to modulate the patient's unique, fixed patterns of thought, emotion, and behavior regardless of DSM diagnosis. Similarly, beyond the genetic core, the role of development and experience in shaping mental health and illness includes both neurobiological and interpersonal processes that dynamically modulate neural networks and their mental epiphenomena. Psychosocial interventions, using natural pathways, are vital for both prevention and treatment. Another proposed paradigm embraces closer coordination of psychiatric services with primary care in organized systems, which would probably include non-medical psychotherapists as well. Psychiatrists cannot effectively oversee, supervise, partner, or consult with other physicians or therapists if they have no psychotherapeutic awareness. Even when the primary mode of treatment is biological, skilled handling of the doctor-patient relationship is vital to adherence, to helping the patient manage his or her personal life, and even to effectiveness of medication at recommended doses. There is no substitute for instruction and extensive first-hand experience in learning to conduct psychotherapy or psychologically informed patient care. In a psychiatric residency curriculum that is likely to contain greatly increased attention to clinical neuroscience, time for the psyche must be preserved. The new paradigm might require a lengthened residency or additional fellowship years, which must include appropriate attention to psychosocial learning and psychotherapeutic expertise.