Education Shapes Psychiatry Trainees’ Attitudes Toward Psychotherapy

The psychiatrist who also serves as a psychotherapist is becoming an endangered species, and a new nationwide study from Italy suggests the decline begins in the training clinic. In one of the most comprehensive investigations of its kind, researchers organized by the Youth Group of the Italian Society of Psychopathology surveyed 453 psychiatry residents and early-career psychiatrists and found that the quality and quantity of psychotherapy training they receive during residency strongly shapes whether they go on to embrace or abandon psychological treatment in their clinical practice. The findings, published open access in the journal Academic Psychiatry, paint a sobering picture of a generation of psychiatrists being handed the biological tools of the trade while the psychological half of their professional identity is left underdeveloped.

The numbers behind the crisis are striking. Between 1996 and 2016, the delivery of psychotherapy by psychiatrists fell by roughly 50 percent, and nearly half of psychiatrists no longer practice psychotherapy at all, even as international guidelines recommend it both as a first-line, standalone treatment and in combination with medication across a broad range of mental disorders. For conditions such as personality disorders and eating disorders, where pharmacotherapy plays a limited role, psychotherapy is the treatment of choice. Yet the new survey suggests that the pipeline of young clinicians equipped and motivated to provide those interventions is leaking at multiple points, and that the leaks are traceable to how training is structured rather than to any lack of enthusiasm among trainees themselves.

The study, led by Emanuele Cassioli and colleagues including senior author Alessio Maria Monteleone, was conducted as a cross-sectional, anonymous online survey administered between April 1 and September 25, 2023. The 453 respondents, with a median age of 31 and a majority of women at 56.3 percent, included 332 psychiatry residents and 121 early-career psychiatrists who had already completed their specialization, representing approximately 22 percent of all psychiatry residents in Italy at the time. First-year residents were deliberately excluded because they had not yet been exposed to the relevant coursework and clinical activities, and the sample was recruited through the network of the Italian Society of Psychopathology following a dedicated symposium at its 2023 national congress, with ethics approval from the University of Florence.

What respondents described about their residency training was, in a word, thin. Among specialists and senior residents, 45.5 percent reported receiving only theoretical instruction in psychotherapy, with no meaningful clinical application, and more than one-third reported never having received supervision at all. Those who could quantify their exposure reported a median of just one hour of psychotherapy teaching per month and roughly half an hour of monthly supervision. Perhaps most telling, 63 percent of respondents said they were never evaluated on their psychotherapy knowledge during the entirety of their residency. Overall satisfaction with psychotherapy training was modest, with median ratings of 4 out of 10 across every training stage, and at least half of the sample strongly agreed that they would have wanted more hours dedicated to training, supervision, evaluation, and supervised clinical practice.

Because Italy operates an incompletely regulated dual-pathway system, in which psychotherapy certification can be obtained either through basic residency requirements or through numerous private psychotherapy schools, the training landscape is extraordinarily heterogeneous. In the survey, 39.3 percent of participants had enrolled in or completed training at a private institution, and most of those programs lasted at least four years. The dominant reasons for choosing a private pathway were strikingly subjective: 78.7 percent cited personal attitudes toward a particular therapeutic orientation and 51.1 percent cited personal clinical experience, while only 37.1 percent cited the fact that the approach was evidence-based. The authors warn that this kind of idiosyncratic, unregulated system creates a concrete risk that future treatment choices will be driven by prescriber familiarity rather than by evidence of efficacy.

Personal experience with therapy itself emerged as a near-universal feature of the cohort. Two-thirds of participants, 66.4 percent, had undergone personal psychotherapeutic treatment, a practice many professional organizations consider an integral component of psychiatric education. More than half of these personal treatments followed psychoanalytic, psychodynamic, or Gestalt orientations, 20.6 percent were cognitive-behavioral, and the remainder spanned family-systemic, cognitive-constructivist, third-wave cognitive-behavioral, interpersonal, and other approaches. Notably, outside of residency and private programs, participants reported a median of zero hours of additional supervision over the preceding two years, suggesting that once formal training ends, most young psychiatrists stop seeking expert oversight of their therapeutic work entirely.

To untangle how these experiences shape clinical attitudes, the researchers deployed sophisticated statistical modeling. Beliefs about the causes of mental disorders were compressed using principal component analysis into three factors: trauma and adversity, biological and socioeconomic influences, and stress with maladaptive coping. Mixed-effects models, which accounted for participants being nested within their residency cities, then tested which factors predicted how effective respondents believed psychotherapy to be across eight diagnostic domains, each rated both as a standalone treatment and in combination with medication. The results were unambiguous: stronger belief in traumatic or stress-related etiologies was associated with greater perceived psychotherapy effectiveness, whereas attributions grounded in bio-environmental causes correlated with lower perceived effectiveness. Younger age and more advanced training stage were also independently linked to higher perceived effectiveness.

A second set of analyses using cumulative link models with cauchit links examined what predicted the inclination to actually integrate or directly provide psychotherapy in practice, focusing on specialists and third- and fourth-year residents. Two variables rose to the top: the number of patients the clinician had treated with psychotherapy during residency and overall satisfaction with psychotherapy training. In other words, hands-on caseload experience during training, not lectures alone, appears to be the engine that converts theoretical knowledge into clinical practice. Self-assessed confidence followed a similar trajectory, rising significantly from second year through specialization, and receiving a substantial boost, with a regression coefficient of 1.83, among those who had attended a private psychotherapy school.

The study also documented what young psychiatrists believe about psychotherapy’s reach. Respondents rated it as highly effective for anxiety disorders, eating disorders, and personality disorders, and rated combined psychotherapy-plus-medication approaches as effective for most other diagnoses. Yet the authors point to a structural blind spot at the regulatory level: both the Food and Drug Administration and the European Medicines Agency still define treatment-resistant depression solely on the basis of non-response to pharmacological treatment, ignoring the psychotherapeutic interventions that international guidelines recommend. This definitional narrowness, the researchers argue, both reflects and reinforces the marginalization of psychotherapy within mainstream psychiatric practice and helps explain why the unique role of the psychiatrist as an integrator of psychological and biological approaches is eroding.

The solution the authors propose is not to force every psychiatrist onto a couch with a patient, but to rebuild residency curricula around structured, supervised, evidence-based psychotherapy training, with clear standards for orientation coverage, clinical caseloads, supervision hours, and formal evaluation. Their data offer a compelling causal argument for doing so: the single strongest modifiable predictor of whether a young psychiatrist will use psychotherapy is the quantity and quality of psychotherapy experience accumulated during residency. In a mental health landscape where psychotherapy services, including telemedicine-delivered ones, are more available than ever but psychiatrists are increasingly stepping back from providing them, the study suggests that the future of integrated psychiatric care will be decided not in the clinic, but in the training school. If residency programs fail to teach, supervise, and evaluate psychotherapy, the next generation of psychiatrists will inherit a biologically rich but psychologically hollow profession, and patients with conditions that respond best to talking therapies will be the ones who pay the price.