Psychotherapy Must Remain an Integral Part of Psychiatry

A century ago, psychotherapy was basically the only treatment psychiatry had to offer. Forty years ago, during my residency training, psychotherapy remained an essential part of psychiatric training and treatment. Today, psychotherapy in psychiatry is on the defensive,¹ shrinking in training curricula, neglected in research, and declining in psychiatric practice.² Why has this happened, and what should the field do about it?

The State of Psychotherapy

In some respects, the psychotherapy option has never been stronger. Since the golden era that began in the 1970s, clinical research trials have demonstrated efficacy for various manual-defined, time-limited psychotherapies for mood, anxiety, eating, trauma-based, and other disorders.³ We know that some psychotherapies work; evidence-based therapy (EBT) is generally as effective as pharmacotherapy for nonpsychotic disorders.⁴ For some disorders—obsessive-compulsive disorder,⁴ posttraumatic stress disorder,⁵ complicated bereavement, simple phobias—psychotherapy is the treatment of choice. Patients generally prefer psychotherapy to pharmacotherapy.⁶ Psychiatrists are the lone professionals with the enviable capability of providing combined psychotherapy and pharmacotherapy for chronic depression, bipolar disorder, and other syndromes.

Simultaneously, psychiatry has evolved in the areas of complex diagnosis, psychopharmacology, neuromodulation, and other treatments, competing with psychotherapy and shifting the focus of psychiatric training and scope of practice. If there are practical reasons why all psychiatrists are not specialized psychotherapists, this does not negate psychiatry’s responsibilities to stewardship of psychotherapy.

Despite its central role in care, psychotherapy by psychiatrists has declined.^2,7 Olfson and colleagues found that whereas between 1996–2002, 39% of psychiatric visits included psychotherapy, between 2010–2016, this had fallen to 29%.⁷ Between 2018 and 2021, more adults received psychotherapy (6.5%, rising to 8.5%), but fewer psychiatrists provided it (41%, declining to 34%).² Among the host of reasons:

1. pharmacotherapies and other competing evidence-based treatments;
2. the 1974 Employee Retirement Income Security Act (ERISA), ushering in the corporatization of medicine and rise of managed care,⁸ which disadvantageously reimburses psychotherapy, promoting instead brief pharmacotherapy checks in psychiatric practice;
3. increasing delegation of psychotherapy to nonmedical mental health therapists;
4. burgeoning neuroscience, codified in the neurobiological mechanism-driven National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC),⁹ diminishing psychotherapy research funding¹⁰;
5. psychotherapy increasingly appearing time-and labor-intensive and old-fashioned compared to flashier, newer treatments.¹

This retreat from psychotherapy has consequences in training, research, and patient care. In residency training curricula, other theoretical and clinical experiences are muscling psychotherapy aside. My own academic program, long a paragon of psychotherapy training, recently cut back psychotherapy teaching and supervision, shifting priorities and hollowing out residency training. The Accreditation Council for Graduate Medical Education (ACGME) once required “competence” [sic] in 5 psychotherapies for residents to graduate. Always more aspiration than reality, these requirements have now shrunken to building an alliance, supportive, psychodynamic, cognitive behavioral, and combined treatment.¹¹ Many programs pursue psychotherapy training less intensively than in the past. Diminished training emphasis likely translates to less subsequent practice. The psychotherapy immersion of my 1980s residency training at the Payne Whitney Clinic no longer exists.

In research, NIMH now focuses funding on neurobiological mechanisms while discounting patient environmental factors, decimating clinical trials and crippling psychotherapy research.^9,10 This impedes psychotherapy researchers not only from new discoveries but from building careers, hampering academic promotion. Fewer psychiatrist psychotherapy researchers means fewer clinical teachers or, alternatively, installing psychologist teachers and supervisors, who, however competent, are not ideal role models for psychiatric trainees. Lack of outcome research stagnates the psychotherapy clinical outcome literature. We need to know more about differential therapeutics: what treatment works for whom¹² and which among evidence-based treatments is preferable for a patient with a particular diagnosis.

Psychotherapy research is complicated. It requires rigor: treatment manuals to guide therapists on what to do and avoid; time limits, in themselves potent clinical interventions; competing teams of trained, equally experienced, allegiant, and adherent therapists; expert supervisors; adherence measures and raters, to ensure therapist adherence; and independent blinded outcome raters. As today’s clinical investigators age and retire, the decline in research support endangers survival of this invaluable, complex technology.

In clinical care, psychiatrists increasingly act as somatic treatment prescribers rather than psychotherapists, jettisoning a crucial part of their armamentarium. What do they do when multiple medication trials fail to relieve a major depression? So-called treatment-resistant depression (TRD) too often neglects an evidence-based psychotherapy (EBT) trial,¹³ perhaps because it is off the psychopharmacologist’s radar. Yet 2 or more medication trials may well meet “resistance” if the patient faces a toxic or abusive marriage or complicated bereavement. I believe the definition of TRD should require an EBT trial.¹³ Delegating psychotherapy to nonmedical colleagues often sacrifices crucial integration of care for the most complex patients. Nonphysicians often lack understanding of more medically complex patients, who may then suffer in split care. Psychiatry needs psychopharmacology experts, and such expertise demands focus, but fundamental understanding of psychotherapy informs high-quality psychopharmacology practice and facilitates a strong team-based approach to optimal patient care.

The COVID pandemic worsened social isolation, reduced social support, raised incidence of psychiatric disorders, and distanced therapist from patient with an overnight and persisting switch to virtual (Zoom) teletherapies, a grand forced public health experiment. We know too little about virtual psychotherapy, but it surely has disadvantages in distractibility and in distancing patient-therapist connection.^14,15 The advent of chatbot “therapists” raises new threats to patient safety and confidentiality. Thus, psychotherapy is under siege.¹

Why Is Psychotherapy Crucial?

Psychotherapy connects therapist to clinician, building the therapeutic alliance essential to all interventions. Gaining patient trust optimizes diagnostic accuracy, encouraging openness to reveal intimate secrets. Psychotherapy builds sufficient trust for patients to swallow medications.¹⁶ Whereas somatic treatments address internal, neural psychopathology, psychotherapy helps patients address life’s diagnosis-related environmental stressors: complicated bereavement after the death of a significant other; troubled marriages and relationships; major life transitions, such as job loss, divorce, or cancer diagnosis. I have seen the power of psychotherapy in my research, clinical practice, and personal therapy.

Psychotherapy is challenging, engaging, and gratifying. It helps you know the people behind the diagnoses; and to help those people understand their diagnoses, distinguish themselves from their diagnoses, and understand and help themselves. It grants overwhelmed patients a coherent, explanatory narrative (formulation) for their situation, which is inevitably more complex than a “chemical imbalance.” Psychotherapy promotes patient autonomy and mastery over their lives. Psychotherapy can of course be combined with pharmacotherapy, with the psychiatrist the ideal agent to deliver both. Psychotherapy is also time-intensive. It requires nuance, tolerating strong affects, deciding when and how to intervene (every intervention deflects the course of a therapy), adherence to a coherent theme and interventional approach, and avoiding the temptations of eclecticism.¹⁷

In addition to its shrunken role in research and residency training, its unfavorable practice reimbursement, and other challenges, psychotherapy has self-inflicted injuries from internecine fighting among “too many churches.” Zealots promoting the myriad diverse schools of psychotherapy, most of them theoretically driven and lacking empirical support, have been fighting one another since Freud’s early circle. Even amongst the minority of EBTs, adherents have trumpeted their own brand against alternatives. The pressures on the field leave no room for such psychotherapy infighting.

Why Should Psychiatrists Practice Psychotherapy?

For the benefit of their patients. Psychiatrists best understand the mind/body interface and are best equipped to treat the whole patient. Combined treatment works best when conducted by a single clinician. Psychiatrists treat the sickest patients, so psychiatrists are worth the extra cost. I encourage psychiatrists unfamiliar with evidence-based therapies like cognitive behavioral therapy, interpersonal therapy, and certain psychodynamic EBTs to learn them, as they’re powerful interventions. The many psychiatrists who consider themselves pure psychopharmacologists would be wise to inform themselves nonetheless about when to refer patients to which psychotherapies. Similarly, psychiatrists who lead treatment teams need knowledge of the range of therapies and how to differentially prescribe them through team members.

What Are the Costs of Psychiatry Abandoning Psychotherapy?

Psychiatrists who prescribe only medications and somatic treatments risk becoming less complete physicians, less perceptive of their patients, less able to treat them. Lack of psychotherapeutic skills, even when not delivering formal psychotherapy, impairs diagnostic skill, optimization of psychopharmacology adherence, and ability to deliver combined treatment and treat patients with complex medical comorbidity.¹⁸ Patients will view us as less empathic, more distanced and impersonal. And we will lose one of our most potent interventions to promote real change.

Psychotherapy is low tech, not flashy, hard to do well, emotionally and strategically challenging, and has its limits. Nonetheless, it is highly rewarding for both therapist and patient, central to our profession, and worth fighting for and preserving as a medical intervention.

What Can Be Done?

Psychiatrists can maintain excellence in psychotherapy alongside the growing number of other treatments the field claims. No psychiatrist can specialize in all aspects of patient care, but all should have broad knowledge of treatment options. Psychiatry and the public need to press to restore NIMH clinical research funding, including for psychotherapy. There is no psychotherapy industry comparable to Big Pharma to support research. The NIMH has historically been the world’s greatest supporter of clinical research, funding the trials that inform us of what we know today about efficacy and differential therapeutics. In the past two decades, it has drastically cut clinical research funding.^10,19 We know a fair amount but need to know much more.

Such funding would permit studying current clinical challenges. How does in-person treatment compare to virtual psychotherapy? To chatbot “therapy”? What are optimal psychotherapies to combine with therapeutic psychedelics? Does increasing access to care dilute the quality of psychotherapy delivered and consequent outcomes? We need to better understand tailoring EBTs for specific populations. (How to engage depressed, screen-addicted youth?) I have long felt that many patients who respond to pharmacotherapy for long chronic mood disorders need postmedication stabilization psychotherapeutic rehabilitation to discover who they are once euthymic, to learn to test their capacities and discount the pseudopersonality they attributed to chronic symptoms.²⁰ This has barely been studied.

Psychiatry needs more, not less, psychotherapy. It needs to expand resident clinical psychotherapy training in the era of neuroscience. Psychiatrists should mobilize clinicians and patients to redress biased insurance coverage, perhaps using the American Psychiatric Association Psychotherapy Caucus (QIPS@ psych.org) as a vehicle. And use psychotherapy more. Psychotherapy must remain integral to psychiatry.

Article Information

Published Online: September 28, 2026. https://doi.org/10.4088/JCP.26com16688
© 2026 Physicians Postgraduate Press, Inc.
J Clin Psychiatry 2026;87(4):26com16688
Submitted: August 31, 2026; accepted August 31, 2026.
To Cite: Markowitz JC. Psychotherapy must remain an integral part of psychiatry. J Clin Psychiatry 2026;87(4):26com16688.
Author Affiliations: New York State Psychiatric Institute and Columbia Vagelos College of Physicians & Surgeons, New York, New York.
Corresponding Author: John C. Markowitz, MD, Columbia University/New York State Psychiatric Institute, 30 West 70th St, Ste 1C, New York, NY 10023 ([email protected]).
Financial Disclosure: Dr Markowitz receives salary support from the New York State Psychiatric Institute.
Funding/Support: None.
Previous Presentation: This material was presented in the American Psychiatric Association Adolf Meyer Lecture in San Francisco, California, May 2026.