Pharmacotherapy Vs. Psychotherapy: An Educational Challenge in Current Psychiatric Training

Despite the fact that the swing of the pendulum toward biological psychiatry has led, in general, to a downgrading of psychotherapy within the realm of psychiatry, in current years a fresh debate regarding practice of psychotherapy by psychiatric residents and psychiatrists has gained a new place in the realm of academic training. Such kind of encouragement, for using psychotherapy on behalf of patients who are suffering from psychiatric complications, has instigated essential modification in the contemporary educational programs in different countries, including developing civilizations. In the present paper the exact condition and outlook of such an amendment has been discussed to understand that whether simple addition of a national curriculum can answer back, applicably, to increasing necessities of mental health in developing cultures, and how the honest exercise of psychological managements by psychiatrists can be improved.


Introduction
"Psychotherapy," wrote Freud, in his 1905 paper of that name, "is in no way a modern method of treatment. On the contrary, it is the most ancient form of therapy in medicine." He went on to explain that there is an old saying that certain diseases are cured not by medication, but by the "mentalinfluence" of the "personality of the physician." No one, of course, canreally trace the origins of psychotherapy, but they probably extend back to primitive medicine men, priests, and soothsayers [1].
According to the Oxford English Dictionary, the earliest use of the term "psychotherapeia," meaning "remedial influence of the mind," appeared in the 1850s. By 1897, in a textbook of mental disease, the term "psychotherapy" was defined as "every means and every possible agency which primarily affects the psychical rather than the physical organization of the patient in a curative direction." [1] . What has been confusing is that Freud used the words "psychoanalysis" and "psychotherapy" interchangeably for many years, and it was only considerably later that he and others sought to distinguish psychoanalysis from other psychotherapies.
In an early paper, On Psychotherapy, for example, Freud wrote that psychotherapy seems "positively unscientific and unworthy of a serious investigator" but asked his reader to allow him to defend it: "There are many ways and means of practicing psychotherapy, tothe method Breuer called 'cathartic,' but which I prefer to call 'analytic.'" [2]. It is well established that a majority of the effectiveness of psychotherapeutic treatments can be accounted for by the common elements that all psychotherapies share. The features shared by all include a healer-patient relationship, in which the different roles carry different expectations and a differential balance of power; a nonjudgmental, supportive acceptance of the patient; and an alliance of working together on shared goals. These common elements are rooted in the universal need for attachment and connection. Human brains are designed to seek out attachment when they feel isolated or threatened, and to reciprocally be moved by the pain and loneliness of those who reach out to us. Resting on this foundation, psychotherapies of many different stripes are able to provide an experience-sometimes as quickly as the initial session-of feeling comforted, finding hope, and experiencing an amelioration of the sense of being alone or marginalized by one's presenting difficulties. But if all therapies share these comforting elements, what accounts for the existence of so many different psychotherapies? The development of a specific psychotherapeutic method begins with the creation of a psychological model. Thus, psychotherapy is always a learning process, taking advantage of the brain's neuroplasticity and the related human capacity for durable change at the most fundamental levels of being. Yet, as in formal education settings, learning within psychotherapy is a unique process among individuals and requires a diverse range of approaches. One way to understand the wide array of psychotherapeutic methods, therefore, is as an attempt to accommodate the various learning styles [2]. In addition, what the therapist hopes the patient will learn in the course of treatment is remarkably diverse, and often rooted in very different fundamental ideas about the nature of psychopathology and about what defines an effective and satisfying life. As an example, the cognitive therapist believes patients need to learn about implicit maladaptive thoughts, which eventually, results in changes to deeply held belief systems that contribute to recurrent emotional distress and dysfunctional interpersonal engagement.
The psychoanalytic therapist, on the other hand, believes the most effective learning approach involves exploration of unconscious wishes and conflicts, which allows for the release of longstanding, self-imposed obstacles that hold people back from living life in the fullest way possible. In both instances, the aim is to relieve suffering and promote the growth and development that hopefully, will prevent suffering in the future. How this aim is achieved and the specific goals that occur within the treatment itself are quite different. Through the years, new psychotherapeutic approaches have been developed, usually borne out of a desire to fill an identified need in the treatment of mental illness [2]. But the situation is now shifting: we are becoming more cognizant of the boundaries of organic managements, particularly for longlasting ailments; there is a rising evidence base for the efficiency of certain psychological treatments; and patients have become more wishing of all-inclusive attention. Consequently, there is a new emphasis on psychosomatic characteristics of medicine with evolving motivations to re-integrate psychotherapeutic procedures into general medical practice [3].

Minor and Major Techniques in Psychotherapy
In this regard, simple psychotherapies are formal varieties of the therapeutic element of physician-patient interactions that consist of counseling, psycho-education, problem -solving skills and supportive psychotherapy. The technical, structured or major psychotherapies as well can be divided into two categories: those that have been derived from psychoanalysis (i.e. psychoanalytic or psychodynamic psychotherapy) and those which are founded on cognitive and behavioral theories. Also, there are several mixed or hybrid therapies, like Cognitive Analytic Therapy (CAT), Interpersonal Therapy (IPT), and Dialectical Behavioral Therapy (DBT). Other widespread well-known methods include Family therapy and Group therapy [2]. Generally, psychotherapy includes any kind of psychological intervention that is planned to enhance adaptive functioning and reduction of distress or maladaptive behavior [3].The objectives of treatment involve improving functioning and adjustment in both interpersonal and intrapersonal domains and decreasing maladaptive behaviors and different psychological and sometimes somatic complaints. Therapeutic goals are usually achieved by means of interpersonal processes and verbal interactions [3].

Research in Psychotherapy
The question of whether psychotherapy works has been definitely answered. There is a plethora of evidence from efficacy and effectiveness studies indicating that therapy is effective in alleviating emotional distress and behavioral dysfunction.
Questions being addressed by researchers include the relative importance of specific (e.g., interventions) versus nonspecific a distinct purpose, methodology, and interpretative context [5].
Efficacy studies evaluate the sufficiency of a specific treatment to reduce distress, symptoms, and impairment with a group of patients having a particular psychiatric disorder. To minimize the influence of confounding factors, efficacy studies are conducted using randomized clinical trial methodology in a controlled setting.
Patients are screened to control for excessive patient variability and are randomly assigned to interventions that are being compared. The treatment under investigation might be compared to no treatment, a waiting list, placebo, minimal intervention(e.g., psychoeducation), or an alternative treatment. Therapists are trained to conduct the competing treatments to maximize the integrity of putativetherapeutic ingredients. To achieve this, most efficacy studies usetreatment manuals, which direct (to some extent) the therapist with regardto the intervention offered.
Most studies also perform integrity checks, such as reviews of taped sessions, to see whether the therapy under study was actually implemented [5]. Effectiveness studies are concerned with whether psychotherapy delivered in actual clinical settings is effective in reducing the symptoms, distress, and dysfunction associated with mental illness. The experimental controls used in efficacy studies are absent in effectiveness studies, just as they are absent in community settings. (Indeed, most effectiveness studies are conducted in the community.) [5] In addition, hundreds of metaanalyses of psychotherapy have been conducted, and most have reached the same general conclusion: Psychotherapy is an effective intervention for psychiatric illness across diverse populations and settings. Most meta-analyses have focused on specific disorders (e.g., the efficacy of psychological treatment for bulimia nervosa) or on specific therapeutic approaches for various disorders (e.g., comparing CBT to other therapies). In general, meta-analytic studies have shown that psychological treatments are vastly more effective than no treatment (e.g., wait-list controls or minimal interventions), are about as effective as biomedical treatments for most disorders, and are about equally effective when compared to each other [6][7][8].

Psychotherapy and Pharmacotherapy: Completing or Competing Procedures
Perhaps the most consistent finding in comparative research into the treatment of mental illness is that combining psychological and biological treatments provides the maximum likelihood of benefit. While various meta-analyses have found psychotherapy and pharmacotherapy to be equivalent in efficacy at both posttreatment and follow-up, and combined psychotherapy and pharmacotherapy has been routinely found to be superior to either alone [9], some important variables as well are existent, which may well separate these two from each other (Table 1). On the other hand, like all other clinical managements, psychotherapy can have adverse in addition to beneficial effects. These are more probable with inexperienced and non-supervised psychotherapists and with psychotherapists who are in a situation to purposefully abuse the patients. It must not be overlooked that even well-delivered therapies can be ineffectual or detrimental. An example is asking improperly patients who have undergone a traumatic shock to talk about it in excessive detail to a therapist (so-called debriefing) [10].
Within the previous ten years, huge modifications have occurred in the field of counseling and psychotherapy.  According to a study, While 46% of psychiatric residents show interest in more psychodynamic psychotherapy teaching, only 22% exhibit interest in applied psychoanalysis. In this regard, most of them had mentioned the time and cost involved as reasons they would not pursue further training [16]. Though psychiatric residents usually thought that their training managers had sustained psychotherapy teaching, nearly 30% was not certain that other key academic leaders were similarly supportive [17].
As said by Cohen: "old-style programs are no longer sufficient to get apprentices ready for practice in the epoch of 'managed-care'.
Managed-care's stress on the delivery of mental health facilities at limited expenses necessitates particular practice abilities, mainly quick assessment, brief management, and the capability to document treatment consequences" [18]. What are the abilities required to respond to the necessities of a managed care setting?
In most preparation programs, an effort contains assisting learners improve interrogating and interaction abilities. Bradley and Fiorini, too, found that, in a review of mental health programs, the most often talked practical capabilities involved the micro-skills (like empathy, listening, reflection of feelings, and genuineness) that have been emphasized by Rogerian philosophy, too [18]. Accordingly, those with comorbid mental illnesses or with severely disabling disorders, such as schizophrenia, are the most likely to seek professional help. In contrast, a lack of insurance and concerns about how to pay for services decrease the likelihood of seeking treatment. However, the primary barriers to mental health care are psychological, perhaps primarily the stigma related to having a mental illness. Negative attitudes toward admitting that one has a psychiatric problem and toward seeking care from a specialty mental health provider have actually increased over the last five decades. Research suggests that this is related to the increasing conceptualization of mental health problems as medical, which may translate into the impression that the problem is permanent.
Consistent with this, most who seek care increasingly do so in the general medical sector rather than from a mental health specialist [19]. J. West' wrote a paper entitled "The Future of Psychiatric Education." In it he had foreseen that by 1984 most psychotherapy will be done by psychologists and social workers and much of today's office psychiatry by internists and family practitioners.
Though he notifies against losing the "expertise in psychodynamics accumulated over the past 90 years," he nonetheless sees future psychiatrists as much more of behavioral scientists, endocrinologists, and neurologists than their forerunners. He believes that upcoming psychiatrists will also be teachers for, and provide liaison to, many medical and mental health disciplines. Some financial factors have increased the credibility of West's forecasts as regards psychotherapy. First, psychiatrists are physicians. Hence, they and their services are usually very expensive. Also, according to Jerome Frank [20], no type of psychotherapy or psychotherapist has ever been proven better than any other. Therefore, one might ask, since social workers and psychologists usually charge lesser costs than psychiatrists, why not send patients to them? Undoubtedly, the managers of national health insurance might feel this way, as might patients incapable to pay for a psychiatrist's charge.
Briefly, increased economic and governmental pressures, together with an emergent requisite within medicine itself for the scientific and medical expertise, which only a physicianpsychiatrist can provide, might well push psychiatry in the path that had been anticipated by West. According to Bertram Brown [21], former Director of the National Institute of Mental Health, the era of the analyst and dynamicist in psychiatry seems to be done and the epoch of the biological psychiatrist is upon us. Brown states that during the past decades most developments in the field of psychiatry have been in biology, pharmacology and the treatment of psychoses-not in psychotherapy. So, the biological psychiatrists, he declared, are the final outcome of today's psychiatry [22]. In this regard, Massachusetts General Hospital's Chairman of Psychiatry, Thomas Hackett [23], goes a step further: "Unless we are at home in medicine, psychiatry is homeless." He feels that, apart from their medical teaching, psychiatrists have little more to offer to patients than social workers, lay therapists and clerics. Psychotherapy is now broken into many schools and divisions, and he notifies that if psychiatry does not get rid of psychotherapy and back into medicine, we are, in his words, "an endangered species." [22] Conversely, Sederer believes that psychotherapy, as like as moral therapy in past era, is very hard to do, and had felt that the medical model is very seductive, especially to medical students, for the reason that it includes a lesser amount of personal anxiety on a therapist's part [24].
Also, because biological management is cheaper than psychotherapy and places a lesser amount of emphasis on patients' accountabilities to play a part in their own treatment, and is likely to treat patients like children, biological psychiatry is likewise more acceptable or easier to do by psychiatrists. Therefore, he argued, with more and more people demanding psychiatric care, with the rising cost of health care, and with the increased need for psychiatric consultation within the medical setting, the aforesaid tendency, should psychiatrists ever stop learning and practicing psychotherapy, will push for continuation of the aforesaid separation. Once separated, he feels, these factors will maintain a perpetual split. According to Sederer: 'science is a form of humanism, but "scientism," the cult of science that worships technology for its own sake, is unidimensional and antihumanistic, and reduces man to a mechanistic, concrete, non-individual entity' [24]. But if the circumstances in industrialized states are so, then what will be as regards developing countries that wish to publicize psychotherapy from the initial point, based on printed textbooks or accredited literatures in developed countries. Previously in some earlier articles, in addition to accent on the requirement of national-based researches and modifications , the societal and educational difficulties concerning practicing or advancement of major psychotherapeutic methods in developing countries had been discussed [25].
At this point, once more, it deserves to be mentioned that, essentially, if practice of psychotherapy by psychiatrists is supposed to be an indispensable fact, then a renovation in the viewpoints of psychiatrists, too, appears to be indispensable. Fort On the other hand , when available meta-analyses have shown that psychotherapy, and 'Complementary and Alternative Medicine (CAM)' are effective, mainly or completely, because of circumstantial aspects rather than the definite disease-treating issues suggested by the therapy or therapists, and psychotherapists are the most important circumstantial feature and their effectiveness varies from zero to about 80%, and , also, studies have failed to detect what makes a good (i.e. fascinating) psychotherapist, expecting todays psychiatrist to spend enough time on psychotherapy or to trust its scientific value is not an easy task [26,27]. According to a study, therapists who provide Cognitive Behavior Therapy (CBT) -including the most experienced therapists -regularly leave the CBT techniques defined in treatment handbooks. 'Only 50% of the clinicians claiming to use CBT use a method that even approximates to CBT,' [28] ; such a practice is not in harmony with the evidence- Although psychiatrist may sometimes properly distinguishes that probing of unconscious struggles, intellectual biases, prime suppositions, and personal interactions are necessary for crucial modification of psychological processes, the abovementioned dynamics, stops psychiatrist from expending adequate amount of time and effort intended for psychotherapy. Such a recess or negligence in the first cases can be repetitive in future and will be turned finally into a fixed method of approach. Knowledge is not always equivalent to motivation and the later is not at all times correspondent to practice. Maybe, personal analysis of psychiatric residents or even encouraging them for using eligible psychotherapeutic facilities with regard to their own anxieties, will help them to sense more skillfully the usefulness of psychotherapy.
But according to a study, currently a significant minority of psychiatric residents pursues 'personal psychotherapy', mostly psychodynamic approach. While this number appears to be much smaller than in the past, residents identified training demands and financial cost as the top barricades to following psychotherapy [29].
Moreover, if setting permits, coaching psychotherapy for psychiatric residents or graduated psychiatrists by means of expert psychotherapist psychiatrist, in place of non-psychiatrist psychotherapists, appears to be a better method, for the reason that Nevertheless, if we consider the reducing practice of psychotherapy in the advanced societies, then we can foresee its sluggish advancement and possibly unclear prospect in developing countries. Even though in a new study and opposing to the existing facts, it has been proclaimed that 80.9% of psychiatrists in Canada continue to incorporate pharmacotherapy and psychotherapy in their clinical practice, and the delivery of psychotherapy among psychiatrists that have been graduated in the preceding 10 years has been greater than before, disregard to the rate of drop-out, since it has not discriminated simple approaches from structured, major or hybrid techniques, the conclusions can not be recognized as flawless [30].
Anyway, as has been stated by some lecturers like Macdonald , 'medical training, with its stress on intra-somatic functioning and negligence of a systematic understanding of the organism in total, and its affiliation to its coworkers and its surroundings, has restrictions as teaching for psychotherapists.' 'Clinical psychotherapist would be an applicable name for those physicians who sensed themselves free to use any psychological technique with or without the usage of the significant drugs and somatic treatments now obtainable.' According to him:' The psychotherapist should be subject to various inspirations other than merely ideas of Pavlov and Freud and their byproducts. For example, any course of teaching would be unfinished without an impact from the social researchers' [31]. Essentially, it must not be ignored that psychotherapeutic abilities are required in every situation in psychiatry since the same phenomena that appear in psychotherapy -like resistance, transference, countertransference, schema and automatic thoughts -appear in other circumstances too. Psychiatric residents should be educated that psychotherapeutic doctrines apply in all locations where psychiatric management is provided [32,33]. Anyway, the marriage between psychotherapy and psychiatry has always been a troubled one [23].
Descriptive psychiatry, came to life by Kraepelin, has habitually been in conflict with dynamic psychiatry, which had come to life by Freud. Psychotherapy is not at all easy to do, because, as Greenblatt has pointed out, it is very difficult for a person to learn how to deal with the deepest feelings of patients [23]. So, Descriptive psychiatry is much easier to do, as it places less emotive pressure on the therapist . On the contrary, Strain pointed out that the psychiatrist who consults with his medical colleagues is often asked to deal with emotions, doctor-patient issues, and environmental issues [34].
Without an understanding of psychodynamics and interpersonal interactions, the psychiatrist will be of limited value to his consulters. In addition, Dogherty has warned that the 'subjectobject' relationship between doctor and patient, inherent in the medical model, is very different from the personalized 'subjectsubject' relationship of psychotherapy [35].
According to Eisenberg, medicines alone are generally no cure for psychiatric illness; they merely diminish symptoms. "Brainless psychiatry," he asserted, is as bad as "mindless medicine." [23] Some believe that 'psychotherapy must be considered as a biological treatment that works by changing the brain and is therefore just as important as pharmacotherapy in terms of general treatment planning' [36]. While the current ' Accreditation Council for Graduate Medical Education' necessities for psychiatric residents follow an approach based on particular schools of psychotherapy (highlighting proficiency in psychodynamic therapy , cognitivebehavioral therapy, and supportive treatments), evidence shows that we are failing even in these efforts [37]. The considerations and strategies of such a policy should be decided by chief mental health and scholastic superintendents of each nation, by taking into account the existing high academic organizations, human resources, shortages and assets, community mental health centers or private clinics for providing psychotherapeutic services, and also national strains and problems. Lacking such an outline, advancement of psychotherapy as a useful healing tool is not imaginable.

Conclusion
In general, a balance between 'Evidence-Based Medicine' and the individual clinical experience with patients (Experience-Based Medicine) must be recognized within medical education, rather than supporting one against the other [38]. Past In spite of all of the existing endorsements, criticisms, advises, foresees, national curriculums, set of courses, and etc., while practice of psychotherapy by today's biological psychiatrists is an approvable, logical and possible expectation, its achievement, due to inherent or contextual inconsistencies between organic structure of medical attitude and practice, and psychological construction of psychotherapeutic philosophies and approaches, does not seem to be easily or efficiently attainable. Psychotherapy needs to be accomplished by enthusiasts, who practice that as a full job and see that as an intact therapeutic tool. Such a perspective can only be encouraged by interested instructors in apt learners, disregard to their present-day job or past education.