Wednesday, July 05, 2006

The Psychiatrist as Therapist

[by dinah]

I started this discussion when I agreed with Shiny Happy Person and her frustration with NP prescribers. Maybe I started this discussion with Perception vs. Reality where I referred to a NY Times article titled "Making Patients Happy Doesn't Make Them Well."

First let me say that I work in two settings: I have a solo private practice which is a bit of an idealized bubble-world where I practice psychiatry exactly as I want and I make all the rules (and I never argue with the boss!) and I work as an outpatient Community Psychiatrist, where split therapy is the rule. In this setting, patients are seen for psychotherapy by social workers, sometimes they also have case managers, and the psychiatrist sees them to assess symptoms and prescribe medications. If all is going well and no one is complaining, the patient is seen by a doc every 3 months. If things are not going well, the patient is seen more often, and in the clinic where I work now, the therapist usually is present during the medication management sessions and communication is good. This helps. I started my private practice so I would be able to see patients for psychotherapy, and keeping with my bubble-world wishes, I don't see patients who have another therapist. I've never told someone who is happy with their therapist to stop seeing them, I simply recommend they consult a psychiatrist who has a working relationship with their therapist.

The reality of the world (bubbles aside) is that there aren't enough psychiatrists for everyone in every income bracket in every locality to see a psychiatrist for psychotherapy. That's just how the world is and that's fine. The other reality is that often people in split therapy like their non-MD psychotherapists (and as many have pointed out, often they like them much better) and get good symptom relief from medications prescribed by a doctor who sees them for 15 minutes a month, and they are pleased with their care and have great outcomes.

So why do I think that the best care comes from having one practioner do both therapy and prescribe? Really, it's not the politically correct thing to believe, but I do anyway.

Here are some reasons:
  • One-stop shopping is more convenient.
  • It's probably cheaper than seeing a psychologist and a psychiatrist (most PhD level psychologists I know charge as much as psychiatrists).
  • A psychiatrist who does psychotherapy really gets to know the patients--they aren't just a compilation of symptoms listed on a page. Psychiatric symptoms are often very similar to normal reactions and a psychiatrist who knows a patient well gets a much better feel for when a "symptom" is something other than an indication that a medication needs to be adjusted. Similarly, people often explain away their symptoms and a psychiatrist who follows a patient closely gets familiar with symptoms that could easily be written off and not treated appropriately with medications.
  • Being in psychotherapy with a psychiatrist encourages the patient to look at the relationship; in split therapy the patient may avoid looking at important feelings, and if the dynamic gets set that the therapist is the good guy and the psychiatrist the bad guy, the therapist may collude with this in a way that stymies the patient's ability to progress.
  • Non-MD therapists (and alas, some psychiatrists) may overlook or explain away episodes of major mental illness such that the patient never gets an appropriate referral for medications. Here lies the risk of Perception versus Reality: a patient may have a perfectly good, caring, helpful relationship with a therapist, feel comforted and understood, but not get Cured (or managed, or have symptom reduction, or optimize their ability to function) because a diagnosis is missed.

So the comments last time, when I agreed with that Shiny Happy Person, talked about how psychiatrists are lousy therapists. Some psychiatrists are lousy therapists. Some psychiatrists have no interest in doing psychotherapy. Many psychiatric practices are not set up for the psychiatrist to do psychotherapy. Some psychiatrists are creeps.

Medications are sometimes helpful when prescribed by a creepy psychiatrist with the social skills of an iguana. Psychotherapy, however, requires some degree of connection, some sense that the therapist can empathize, and without this it simply doesn't work as a treatment modality. There's not a therapist out there who is the perfect therapist for every one, and some people don't like even the best of psychotherapists.

So for my ideal, politically incorrect bubble world: Patients get the best of care when they see a psychiatrist (one they like and are comfortable with) for both psychotherapy and medications.


Sarebear said...

Cool. I can see that.

I know my ologist and iatrist know each other and have worked together on common patients. The lady who got me access to them (as my iatrist doesn't accept new patients, I guess he's the "best" and so gets really booked) knows them both and they both worked in sync re her bipolar daughter.

I actually think it probably WOULD be less expensive for a one-stop shop, as well as provide a better, much more rounded picture for the iatrist. Altho my iatrist is $275 an hours, and my PhD ologist, very highly respected especially in the courts here and by the law enforcement agencies, charges $120.

Course, I wouldn't give up my ologist for anything, and despite the difficulties in my relationship with my iatrist, there's alot there, too (although much is dependent on how he works with me to resolve extremely problematic and trust-hurting things he did last time).

Anyhoo, sometimes I wonder though, especially recently, if iatrists would rather ologists didn't exist, or only exist to take up the slack . . . that'd be putting alot of people outta the way they make their living!! In the concrete, I'm hoping not, and that it's a more at least semi-abstract protecting your own profession and tuf/territory kinda thing (ala the New Mexico prescribing ologists issue) . . . . but I guess I'm biased since I love my ologist, lol!

Still, as I say, I think it'd be awesome to have a one stop shop.

I know you probably can't address most of my comment, for liability issues (just relatin' my experience, though) but the rest of it that isn't so personal about my experience, maybe you can respond to.

Anyhoo, nice post, and I do wish more iatrists WERE interested in "otherapy" hee hee, and just just in'n out medcheck.

Anonymous said...

Very few of the patients I have seen in psychotherapy also needed psychiatric meds. Some of that may be a self-selection process on their part as I do not accept third party payment. In the nearly 35 years I have been in practice, the vast majority of people I have seen are best classified as "the worried well" seeking therapy for problems in living, relationship issues, or personal growth. My guess is that people who go to psychiatrists for therapy are similarly engaged in a self-selection process involving how they understand their own issues.

There are also market forces at work for psychiatrists who don't do therapy and for patients seeking to have insurance pay for therapy. And there are turf issues as well.

There are good therapists who are also psychiatrists. No question about that. I see fewer of them among the younger psychiatrists I know as therapy training gets less and less time in residency.

Anonymous said...

Yes, Yes, Yes!!!! I was seeing a psychiatrist at the University health center where I was a graduate student. His last day was last Friday and I pine for him every day. I was seeing him nearly every week and have been on tons of meds in an attempt to successfully augment my Paxil 50mg.

I grew very attached to him even though I have a therapist I see through the other University where I work (for free!).

My psychiatrist would see me for 30 minutes which is waaaaaaaaay more than any psychiatrist has ever seen me for follow ups when I used my private insurance). Usually I was seen 5-15 minutes, tops. They never got to know me the way my beloved Dr. R did.

Consfusingly enough, a few weeks ago I was having a tearful breakdown in his office and he later mentioned that he didn't want to cause a "conflict of interest" with my therapist"? Huh?

He also said he was "upset" at not being able to follow me so maybe we were both upset?

I was confused but he still kept seeing me for 30 minute sessions until his departure.

I agree with this post so much and am grateful for it. Indeed, I wish my psychiatrist could see it.

I start seeing the new guy in 2 weeks. . .

katinkab said...

The only time I saw a psychiatrist for psychotherapy was when I was an inpatient at Stanford Hospital. He was my resident physician and visited me everyday he was at work. We had substantial talks about the causes and consequences of my illness. We had an instant connection and worked together in a way I had never worked and probably will never work with any other therapist. He told me we had a good rapport and believed that good psychiatrists do psychotherapy. I feel that I was lucky to have him as my physician and that my relationship with him was a gift.

Spiritual Emergency said...
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Spiritual Emergency said...
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HP said...

I think that's all well and good but most of my patients complain that their psychiatrists sit them down, tap away at their computer, produce them a prescription and show them the door.

Of course, this isn't representative of all psychiatrists but when this is the experience people face, then shared care is the best option.

Hearing this kind of thing certainly makes me think twice about who I refer people on to as well as whether I continue with shared care or feel confident in handing care over.

jcat said...

As always (!!), things seem to work other way 'round down here. Most psychiatrists do psychotherapy and meds, and I've only ever heard of one who discouraged patients from seeing other therapists as well.

Over the last few years I've seen 3 different p-docs. First one for 5 years, did therapy as well, we terminated mutually when I became involved in a business venture with him (growing vegetables hydroponically), and started living on his farm as well. I'm still in contact with him 10 years later, mostly as a friend, but every now and again I ask if I can see him as a doctor - those are set appointments, with a set topic, and I pay cash for them.
Second one I saw for nearly 7 years, also did therapy, I saw him weekly or biweekly when things weren't good, but still saw him every two or three months when life was ok, just to keep in touch and feel that he knew what the status quo was. After about 5 years, I said that I wanted to see a therapist other than him, because I was having difficulty talking to him about stuff - mostly because I wanted his opinion of me to be positive. He agreed, and went and found a t-doc for me who he regarded as good, and that worked nicely for a while. T-doc had explicit permission to contact him, and vice versa. P-doc relationship ended really badly though. I had ECT x 6, with the plan being to go to 10 or so, he took a week off and just didn't come back. All his office would say was that he was away for an unknown period. No referral, no continuation of Tx, just ...away.... I was post-ECT, lost, suicidal. Eventually my sister forced me into seeing p-doc #3, who is also about the top-rated on treating TRD and Bipolar in the country. He would only take me as an inpatient, so did that, and after a month was faced with dilemma of two p-docs. Turned out #2 had had a heart attack and surgery. So why couldn't his rooms have said that? I understand him not wanting the whole world to know he was sick, but sh**t! I'd been seeing him for 5 years already, there was absolutely nothing we didn't talk about, sometimes including his long term relationship issues and other personal stuff. Maybe we shouldn't have been there - but, fact remains, we were. So when he got back to work, I went to see him again. And he was so resentful of the fact that I'd been having problems while he was away from work, that I figured that maybe seeing new doc was worth pursuing. Went back to p-doc #2 once more, to tell him of my decision, and he was so nasty that i still cry two years on just thinking about it. Really vicious stuff, in areas that he knew would hurt.
P-doc #3 sticks to the medical model, with 30 minute appts, and while he is ok with discussing some issues, he prefers his patients to have a t-doc as well. Basically, I guess he just doesn't like people crying on his desk. He doesn't really talk to t-doc unless she makes him, but then...he is so busy that he doesn't talk to anyone unless he has to! Waiting list is normally about 4 months, to see him as a new patient. T-doc sends him a written report every 3 months, just so as he knows what's happening there.
I liked the 1-stop concept, but am now finding that maybe specialisation helps. The best diagnostician and/or psychopharmacology people aren't necessarily the best at therapy. And sometimes it works well to get more than one perspective on my molehills?

Anonymous said...

Wow what a great blog. I just found it and there are weeks' worth of cool reading here! And the podcasts are fantastic listening.

You hear lots of terrible things about the US health system in Australia, but hey when you realise what some of the individuals are like who work in it it gives you faith that the system could change one day.

So just going back in time - reading this one Dinah I wondered if you could say if it's relatively uncommon to see patients in your practice who are NOT on medication?

I've steadfastly refused medication for 3 years now (postnatal depression) and my therapist is a psychologist who is supportive of my refusal. In Australia my impression is that it's uncommon for ppl to see a psychiatrist unless they're in the hospital system or the justice system - most medication is handled by family GP's; I often wonder if I'd be medicated and not in need of psychotherapy if she were a psychiatrist.

manicmellou said...

I know I'm way behind here but I read this post and I agree. I have been looking for a Psychiatrist to have a therapeutic relationship with, however I have no idea how to begin the search. Any ideas?