The role of psychotherapy in integrated care

The current emphasis on integrated psychiatric and medical care for people with mental illnesses raises hopes for more favorable clinical outcomes as well as concerns about the quality of the actual care being delivered. The author writes from the perspective of a long career as a psychiatrist and psychoanalyst in a full service medical building in which communication and, at times, collaboration between mental health and general health providers yielded significant benefits to patients. Psychotherapy played a major role in these favorable outcomes, as did accessibility to general medical services when needed and working relationships between physicians of different specialties. However, conditions in current integrated systems pose seemingly insurmountable obstacles to offering full service psychiatric care. The overwhelming disproportion between the numbers of patients in serious need and the available psychiatric resources creates wrenching clinical dilemmas. The hard-nosed administrative approaches to the challenge appear to leave out the factors of human relationships and the conditions necessary for effective psychotherapy beyond simple triage and ultra-brief supportive therapy in crises. Where it is possible for psychiatrists to work closely with other physicians, certain conditions are necessary to maintain the integrity of the psychotherapeutic relationship and the psychiatrist's psychotherapeutic skills.