Wednesday, November 19, 2008

Is This It? Are We Talking Yet?

So a new patient presents with the usual chief complaint of: "I'd like to enter psychotherapy so I can better understand myself, my motivations, my patterns of behavior, and resolve any unconscious conflicts that may be hampering my ability to live life fully." Patent after patient, all day long.

In case you didn't catch my sarcasm, no one has EVER presented (to me) with such a request, perhaps because I'm not a psychoanalyst? People come because:

They are having psychiatric symptoms such as sustained sadness, irritability, panic attacks, anxiety... fill in the blank ....


Bad things are happening in their lives and they are having trouble coping.

So Roy has been talking about CPT coding-- the codes psychiatrists submit to insurance companies that explain what we do to get reimbursed-- and about new Diagnostic Criteria in the making. We talked about CPT coding on our soon-to-be released My Three Shrinks Podcast, and it got me thinking:

What makes it Psychotherapy? Roy pointed out that there is felt to be a problem with the CPT code 90862-- Medication Management, a code unique to psychiatry. The reimbursement is the same if you spend 5 minutes or 500 minutes with the patient managing their medications, there are no gradations, and clearly the slant is to pay docs more to see more patients for less time each. You can call it psychotherapy, and then time figures in-- there are codes for 25 minute therapy sessions and 50 minutes therapy sessions, but it all got me thinking.

So like what does make it psychotherapy? If a patient walks in the door for a session that is scheduled as a medication management session and the doctor asks, "How are you?" and the patient starts talking about a stressful circumstance they are dealing with in their lives and feels helped by the brief session: is that psychotherapy? How long does the session have to last? How regularly does it have to occur? Many people want sessions every other week or once a month because they can't afford weekly, or twice weekly, sessions or they can't logistically make the time in their lives. Other people don't even want to schedule that regularly, they call when they want to come in and the frequency of sessions varies with how they are doing. Even with irregular sessions, many people do really good work and make really substantial changes in how they deal with the world or how they let the world deal with them, and they find the sessions helpful, but it may not be an on-going process.

So what does make it therapy? The Psychiatric Times front page article this week is called The Decline of Psychotherapy-- it takes info from
National Trends in Psychotherapy by Office-Based Psychiatrists
Mojtabai and Olfson
Arch Gen Psychiatry.2008; 65: 962-970.
and it goes into statistics on how many (or how few) psychiatrists do therapy with all or some of their patients, all or some of the time, now versus way back when.

Psychotherapy is a treatment where the talking is part of the cure. From the best I can figure, if the psychiatrist calls it therapy, and the patient calls it therapy, then whatever transpires between the two is therapy, and hopefully someone finds it helpful.