Saturday, April 09, 2011

Psychiatry and Psychotherapy: We're still talking about it.


Over on PsychCentral, Dr. Ron Pies asks if psychiatry has really abandoned psychotherapy. He doesn't think so. Ron's post was inspired by Gardiner Harris' March 6th article in the New York Times that has had every psych-blogger buzzing and has made for countless undocumented shrinky conversations. Here at Shrink Rap, we didn't miss a beat.

Dr. Pies writes:

Let’s also acknowledge that the general trend reported by the Times — the diminishing use of psychotherapy by psychiatrists — is quite real. Over the past decade or so, the percentage of psychiatrists offering psychotherapy to all or most of their patients appears to have dropped. One study — very selectively cited in the Times article — found that “just 11 percent of psychiatrists provide talk therapy to all patients…”1 This was based on a study by Mojtabai and Olfson,3 which found a decline in the number of psychiatrists who provided psychotherapy to all of their patients — from 19.1% in 1996-1997 to 10.8% in 2004-2005. The study also found that the percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005, which “…coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications.”2

But the very same study found that almost 60% of psychiatrists were providing psychotherapy to at least some of their patients. Also, the threshold for considering a session “psychotherapy” was set quite high in the Mojtabai-Olfson study: the meeting had to last 30 minutes or longer. But as my colleague Paul Summergrad MD has pointed out, common practice and standard CPT billing codes (e.g., 90805) specifically include 20-30 minute visits for psychotherapy, with or without pharmacotherapy.4 Furthermore, Mojtabai and Olfson acknowledged that

“Some visits likely involved use of psychotherapeutic techniques but were not classified as psychotherapy in the current analysis. Psychotherapeutic techniques can be effectively taught and used in brief medication management visits by psychiatrists and other health care providers.”3 (p.968)

This last point was totally lost in the New York Times report. When I used to see patients for “medication checks” in my private practice, I would sometimes spend more time providing supportive psychotherapy than dealing with the medication issues, if the patient’s emotional needs warranted it. (If the patient was seeing another therapist in formal psychotherapy, I would try to remain an empathic listener, while encouraging the patient to raise the issue with the therapist). Furthermore, in providing medication for some severely personality-disordered patients, it is often impossible to maintain the therapeutic alliance without understanding the patient’s self-sabotaging defenses. As Glen Gabbard MD has observed, “…psychotherapeutic skills are needed in every context in psychiatry” — including during the much-maligned 15-20 minute “med check.”5

The cartoon is from the Wall Street Journal, sent to me by Moviedoc.

13 comments:

Anonymous said...

I am so tired of fake empathy and all that. Also so tired of pills and all that. No more shrinks of any stripe

Dinah said...

Dear Anonymous,
I have sad news: you've landed at the wrong blog. May I suggest something entirely different?
http://how-to-grow-tomatoes.blogspot.com/

All my best, and do come visit when you're in the mood for shrinks again.
Dinah

Counselling Melbourne said...

Thank you for this post. It is my view that psychiatry and psychotherapy can and often do meet. It seems to me unfortunate however when various psychological methodologies clash, or more accurately their personalities fight each other in turf wars and competitiveness.

Fat Bastard said...

Gluttony cures all.

kamikaze1 said...

I am relieved to hear that someone else is aware of how much uncompensated psychotherapy that the psychiatrist must do just to keep the average "med management" patient stable and willing to benefit from treatment . I recently spoke with another psychiatrist colleague of mine who is a practical shrink who happens to make a very honest living by seeing patients mostly for med management visits paid for by insurance companies. He sees about three or four patients per hour for med management visits. I mentioned to him that now due to federal mental parity legislation, we are no longer required to get prior authorizations for Med management plus psychotherapy visits. When the numbers were crunched, we both realized that it is probably still more profitable, by far, to see four pts for med mgmt only than to see as many as three patients per hour for med mgmt plus psychotherapy visits. We figure there is probably a difference of about 27 dollars per hour more for just seeing patients without psychotherapy. My psychoanalytically trained supervisors would probably tell me that I am masochistic for opting to do more work and get paid less for it. If I am masochistic , i become most aware of this fact when I see my high functioning borderline patient who tells me at the end of her session that she wants to go off all her meds because she cannot "afford" "psychotherapy. This is after returning from a trip to a foreign country the week prior.






By the way, if you are interested in hearing more about the practical effects of this legislation in my state, please visit me on my newly hatched blog at http://madshrinks on the couch.blogspot.com .

Anonymous said...

I see one psychiatrist for therapy and another for meds. Both are great. Except they don't seem to talk to each other. And they both make remarks now and again about the other as a result of their differing approaches. And yet they both agree that seeing both of them is the best thing for me. Go figure.

Sunny CA said...

I continue to be thankful that my psychiatrist is working past a normal retirement age and does 100% psychotherapy with 50 minute sessions for all but approximately 2 hour sessions to evaluate new patients. It is the psych drugs that are the "aside" not the psychotherapy. He has in my opinion, a healthy attitude about drug companies which includes awareness of the dishonesty in analysis and publication of drug research and dishonesty in promotion of their line of medications.

Milo said...

I am also very very grateful to be able to talk to my psychiatrist. It took me 12 years to find one that is just not focusing on drugging me up to my eyeballs... and I can not begin to tell you how my life has changed in the past two years as the result. A trusting relationship. If I am to go off any of my meds, he is the first one to find out and get to know about my concerns. I respect him and his opinions immensely and I really really do believe that a good psychiatrist is worth his/her weight in gold and all the precious stuff.

Sarebear said...

I do think it's a shame that more psychiatrists don't do psychotherapy, or much of it. Part of me wonders when my psychologist will retire, he could likely get SS in 4 years, and yeah I still see myself in therapy then. So I wonder, then, if I could eventually find a psychiatrist who does psychotherapy and pharmacotherapy, at that point, or in the year or two before; someone who also does a small proportion of just med checks, so I could transition to psychotherapy as well with him/her when my psychologist retires.

But with all the problems I've had finding a psychiatrist who is competent, and will listen, and will RESPECT me instead of brow-beating me like the current one does sometimes, that sounds like a very tall order around here. I'm having some vague thoughts of giving up on psychiatrists altogether, but I know that's black-and-white thinking . . . and not such a good idea seeing how nowadays I pretty much want to die.

Anonymous said...

A few years ago, I had to leave my psychiatrist due to a clinic policy change. When I found a new one, he asked me, "How were things with the first psychiatrist?" I shrugged and said, "Who can tell? I was only seen for 15-minute med checks."

The new psychiatrist later in the conversation asked me if it would "be okay" if he just saw me for 15-minute med checks. What was I supposed to say? Apparently, that was all that would be offered. And God forbid you need some help filling out a medical or legal form! You've got to pay a lot of additional fees for that amount of "shrink time." The scary thing is, I find this to be common practice.

Anonymous said...

I believe that a great problem with all doctors, particularly psychiatrists, is that a lot of them have never been on the other side. They are the experts with power and unless they have gone through some therapy themselves, have no idea of the other person in the room. The same is true of non - psychiatrists mds who prescribe tests and pills and such with no idea of how truly horrible many of those things are.

Carolyn Cummings said...

Unfortunately, where I work in the public sector, our psychiatrists are only scheduled for 15 minutes at a time, with the exception of the hour long evaluation at the beginning of treatment. It seems too bad, as many families who desperately need therapy are unwilling to come to therapy, but are faithfully willing to come to see the person who supplies their children with medication. This situation leaves us working constantly to improve the communication between the doctor's office and the therapists' offices. Somedays we do this well, somedays we don't.

Marc Handelman PhD said...

Under any circumstance a psychotherapists must always start off trying to meet their patients on an experiential level. Failing to do so leads to objectification and dehumanization referred to. Whatever psychological techniques are used, or physiological interventions such as medication are administered, a therapist’s primary task begins in finding access to the patient’s emotional state. A good therapist the experience of the on many levels. For more read this article