Saturday, November 29, 2008

Should Psychiatrists See Patients for Psychotherapy?

The trend is for psychiatrists to see patients for psychiatric evaluation, treatment with medications, and a medicalized version of psychiatric care, while parceling out psychotherapy to non-MD psychotherapists-- social workers, psychologists, licensed clinical counselors, nurse therapists, pastoral counselors (and anyone else who wants to listen...a bartender or two, perhaps the hair stylist).

Those readers who've been following Shrink Rap for a while know that I work in two types of outpatient settings: a community mental health center where I see people to treat their mental illnesses with medications, and a private psychotherapy practice where I use medications but I also provide psychotherapy to patients who want and need it. ClinkShrink sees patients in forensic settings (name your jail) and she sees a remarkably high volume of patients. She deals exclusively with medical issues-- patients may say or hear things that impact them positively, but the formal setting of therapy to talk, as a process over time, to resolve specific issues, to deal with past events, and to alter patterns of behavior, is not what she does. Roy has worked in many settings, but his current hat is as a Consultation-Liason psychiatrist in a large community hospital-- he mostly evaluates patients and makes treatment recommendations, but he doesn't see outpatients over long periods of time. He used to do that.

Psychiatrists (in the old days) used to see people for psychotherapy routinely, especially before medications were available. I think I was finished with medical school before I even knew that social workers saw clients for psychotherapy. I thought they met with families, worked for agencies, helped with disposition and obtaining benefits, and had a lot to do with foster children and protective services. I believed psychotherapy was the exclusive domain of psychiatrists and clinical psychologists. I simply didn't know.

I've talked here before about why I think, in a totally ideal world, that it's best for patients to see one person for psychotherapy and medications: one stop shopping is more convenient, psychiatric illnesses aren't 'explained' away without the offer of medications, the doc really gets to know the patient and learns to differentiate better what is, and what is not, a symptom of illness or medication side effects, and there isn't a set-up for patients who are prone to dividing their care-takers into good guys and bad guys.

The reality of the world is that psychiatrists are the most expensive mental health professionals, and in the shortest demand. They are more expensive to train, they often finish school heavily in debt, and there aren't enough to go around. And psychiatric residency programs, for the most part, don't emphasize psychotherapy training-- the resident has to pursue it. A psychiatry resident was recently telling me about a patient who wanted insight-oriented psychotherapy and the resident said, "We just don't have time in residency to do that." For those who know they want to pursue a career in research, spending a lot of time learning to do psychotherapy may not be a wise use of limited time. Some people might go as far to say that it's wrong to have psychiatrists doing psychotherapy, especially in shortage regions where there aren't enough shrinks to go around--- a lot more patients can be seen for quick med checks than for 4 times/week psychoanalysis (-- I'm not a psychoanalyst, by the way).

I believe that people should do what suits them, given the realistic constraints of their environment. I'm even okay with the psychiatrist beauty queen. With regard to psychiatrists doing psychotherapy: I like the work and there seems to be a demand for it. I also work in a clinic where the option does not exist to do this kind of work, but it does afford me the opportunity to see a different population of patients and to work as part of a team.

(Roy made me proof read this; my first draft was a disaster.)


Unknown said...

Funny you should write about this now Dinah. I have had a rash of people seeking treatment who have gotten quite perturbed with me when I tell them that I currently have no psychotherapy slots available, only medication evaluation slots and less frequent follow up slots.

I see a variety of patients in a variety of medical and psychological situations. And I see them in equally varied ways. I see some people for twice a week therapy (not many). I see some for full hour psychotherapy sessions every month. I see others for half hour sessions in all variety of frequencies.

But I still cannot please everybody. There are only so many hours in the day.

I think there is an Aesop's fable about that.

Rach said...

Dinah, I have to agree with you. While I am usually able to get an appointment with my psychiatrist within 48 hours, I'm now looking at 7-9 days. While it doesn't seem like a lot, the lack of physicians available is putting intense pressure on those docs able and willing to practise the art of psychotherapy (particularly here, where it falls within the provincial health insurance plan).

Anonymous said...

There are a few psychiatrists who do psychotherapy around here, but I suspect they cost much more than I could afford out-of-pocket, and my insurance would never cover such expensive treatment. It's probably not a practical arrangement for most doctors or patients these days, sadly.

But as to what psychiatrists should do? I think each should determine what type of practice would make him or her happiest and pursue that course until inclined to do otherwise.

Anonymous said...

I realize that psychiatrists are in short supply and high demand and that CURRENT training may not properly prepare them for psychotherapy, and I find that a shame. My old-school psychiatrist was trained as a Freudian psychoanalyst, though he pursued additional training and updated and modernized his psychotherapy through the years. He's the first psychiatrist I've seen for psychotherapy (previously had seen 1 meds-only psychiatrist), and he's far better than any other therapist I'd been to before, perhaps because of his training and experience and perhaps because of his intelligence or a combination of the two. A well-trained psycho-therapy oriented psychiatrist is the gold-standard of mental health care as far as I am concerned. I am a private pay patient.

Anonymous said...

We should all have experts for everything.
But we can't afford it.

An interesting comment:
one stop shopping is more convenient, psychiatric illnesses aren't 'explained' away without the offer of medications, the doc really gets to know the patient and learns to differentiate better what is, and what is not, a symptom of illness or medication side effects,
What I read from your above comment was - in psychotherapy - you get to know the person better and that aides in medication titration. But I also think it is an important part of the patient care that they feel the primary clinician actually has time to listen.
The difficulty in not having a one-stop is the communication and coordination that is required back and fore to get things done.
I've been following a little on nurse prescribers and I am interested in the practices of some consultant psychs who prescribe a range of medications and dosages to the patient that are then available to the nurse-therapist to titrate - so kind of like a delegated version of the psychiatrist consultation session - and discussion/consultation between the two clinicians occurs without waiting for the a 3 way back and fore process before the titration takes place.
Of course it won't cover all eventualities but it would help to overcome many of the constraints and I don't regard it as acting outside the clinical direction model - just enhancing it.
I'd be more reluctant to transcribe this to other disciplines.

Anonymous said...

For psychiatrists in training (residents) they should certainly be trained with psychotherapy. If they have to be able to screen and diagnose and indicate different forms of psychotherapy they need to know what it is about. In The Netherlands psychiatric residents also have to undergo psychotherapy (learning therapy), this is controversial in psychiatric Netherlands but a valuable training to my opinion.
For psychiatrists they should treat the difficult to treat with psychotherapy, those who have also an axis 2 disorder and/or use medication. These are mostly the very difficult patients not well suited for social workers and psychologists. Psychiatrists especially should use the more difficult forms of psychotherapy, psychoanalytic and supportive psychotherapy, for these difficult patients. See also:
Kind regards Dr Shock

Anonymous said...

In the team in which I work, the psychiatrists do a fair bit of listening, a load of explaining, a minimum of prescribing - but not CBT which is usually the province of the psychosocial team (consisting of occupational therapists, nurses, social workers and clinical psychologists).
I personally have never experienced psychotherapy of any type by a psychiatrist: the pdoc's I've seen have diagnosed and prescribed, while the psychologists I've seen have carried out the psychotherapy.
I'm not sure which works best - I think the lack of psychiatrists trained in psychotherapeutic 'talking therapies' is part of the problem, the overall lack of psychiatrists is another, and I do think the training of clinical psychologists and other allied health therapists is more in-depth than what our psychiatrists have.
It is great to know that there are some psychiatrists who enjoy psychotherapy - it makes a difference to the patient to know that they won't be sent away with a script only rather than spending time with someone who wants to know what's going on, and help the person make sense of it.
BTW I'm in New Zealand, so it is very different from the US, except that there are fewer psychiatrists available!

Aqua said...

I agree with Dr. Shock. Also, what happens when a patient is treatment resistant to medications and cannot afford psychotherapy?

I have tried so many meds and combos of meds. It's been 7 years of a MDE and finally..."maybe", the meds I'm on now are helping a bit.

Without my Psychiatrist also helping me with therapy I know I would not be here. I could not manage the hell of a 7 year treatment resistant depression. On top of that, previously, I tried so many psychotherapists and nothing helped.

I also cannot afford psycotherapy once or sometimes twice a I would have popped in for med appts and when nothing worked I would have given up. My pdoc doing psychotherapy, and being the good pdoc/therapist he is literally keeps me trying.

I definately believe in psychotherapy and medication management by the same person. How else does a pdoc "see" vs hearing about from a patients subjective experience, how the patient is behaving/reacting to a med regime?

Midwife with a Knife said...

Hm... so I'm not sure it's fair to make psychiatry residents have psychotherapy. After all, nobody made me have a gyn exam or give birth as part of my ob-gyn residency!

Midwife with a Knife said...

The other part of my comment: I think psychiatrists should develop whatever scope of practice they enjoy and are competant at, just like any other doc. Some of my friends like doing surgery for urinary incontinence. I never really learned enough about how to do a TOT (Trans-obturator-tape) to do it, and I really am not interested enough to pick it up now.

Some Gyns do office management of incontinence (which others farm out to their NPs who may or may not be as good at it), and more power to them.

I think psychiatrists are just like any other part of medicine in this regard.

Anonymous said...

Often, psychiatrists go to seminars and trainings in their area of specialization and often these are run not by other psychiatrists but by psychotherapists who may be psychologists or social workers with advanced training in that area. I believe that the fact that these practicioners cannot prescribe medication does not take away from the fact that they can be some of the best in the field when it comes to psychotherapy. Doctors go to school for however many years, social workers for fewer years, but that only counts years of formal training towards a degree (and the fact that the latter do not need to learn all about the deviated septums, septi??) and does not factor in all the training that can be done, and is done after the degree. Many social workers and psychologists have a great deal of experience and training and they are equipped to "do" psychotherapy. Many other social workers still only do casework and one would not see them for psychotherapy because they are not therapists. Many of the ones who are, have certifications from psychotherapy institutes beyond whatever school granted them their degree. It goes without saying that no matter which sort of therapist one chooses there will be those who are good at what they do and those who are not no matter how much training, no matter what the degree.
On the matter of one stop shopping: there are the pros whcih you mentioned but there are also times when it is preferable to have one person handle the meds and another do handle the therapy. In some cases, dealing with medication becomes an issue that interferes with the therapy.There are many possibe scenarios.I can think of a at least a dozen issues that can get the pt and or the therapist seriously off track. You can argue that a good therapist would work this through as part of the therapy but if that becomes the therapy it is a waste and best to have the meds dealt with outside the therapy.

Anonymous said...

I'd be curious to learn how efficacious psychotherapy (or any other talk therapy) is, and for what sorts of problems. Any ideas?

FooFoo5 said...

I agree with MWAK, do what you enjoy and in an area in which you have competence. And to me, the answer to your question seems simple enough: "If you are competent." While I wouldn't expect a psychologist or social worker to pass an examination on the intricacies of psychopharmacology, I would be fascinated to see a study of the number of psychiatrists who could pass the aspects of the psychology/SW licensing examinations specifically related to psychotherapy.

Look at the "modern curriculum" and talk to residents; they are not being trained to be "psychotherapists." And being trained to identify psychodynamics and utilize these dynamics in the course of treatment is significantly different than being trained as a therapist. While I strongly suspect that this began with an attempt to rescue psychiatry as a legitimate "medical" specialty, it does not strike me as particularly offensive to say other disciplines are more competent, if only because of their specific training in the process of psychotherapy.

To clarify my comment to one of your previous posts, my sense is that, while some psychiatrists are competent to practice psychotherapy, the "psychiatrist of the future" is not being trained nor will be expected to provide psychotherapy. Again, I personally take no offense to the role of diagnosis and medication management as an essential member of a community treatment team, and to see this role as "marginalized" psychiatry seems shortsighted.

The research literature is abundantly clear that the best outcomes include concurrent medication and psychotherapy. I strongly suspect that the number of providers leading to these outcomes is insignificant, but perhaps is the basis of a further post!

Dinah said...

Tigermom, I've never gotten my schedule fully efficient and I wouldn't even begin to know how to figure out meds vs therapy on the phone. Can you come slot my life?

I agree that other non-psychiatrist mental health professionals can be (and are) great psychotherapists.

FooFoo5: you make it sound like psychiatrists are necessarily not as good at psychotherapy as social workers -- did I misunderstand? Are other disciplines necessarily more competent?
And I can't imagine that a test score correlates with whether the patients feel therapy helps.

Dr. Pink Freud said...

New rule: If a colleague feels comfortable enough to criticize you're written work, he/she should be willing to make the revisions, or at least help. ;-)

Roy said...

Pink freud, don't even go there. I spent 3 hours yesterday with Dinah making revisions on the first 4 chapters of our book.

As to the topic of this post, there are some training programs that continue to stress the importance of psychotherapy training for their psychiatry residents. There are a few who continue to emphasize the utility of undergoing therapy oneself as part of the training program. However, I think that just being a psychiatrist doesn't automatically mean you are a good psychotherapist. Same goes for psychologists, social workers, counselors, and psych nurses.

And Midwife, these programs don't make you get therapy, but they may encourage it more or less strongly. I'm guessing, however, you may have suffered phlebotomy at the hands of your fellow med student.

Rach said...


Where have I been?

Unknown said...


I guess I should clarify. I already feel full and have a hard time scheduling current patients for follow ups, so I hesitate to take on a new patient without telling them up front that I know I cannot see them weekly for a 50 minute hour.

Every few weeks for a 50 minute hour is easier, but I cannot always guarantee a slot will be available on a given day or time of day.

I think the patient deserves to be seen as frequently as we both feel is right.

Anonymous said...

What an interesting discussion. *rubs hands eagerly* Pity we're out of time. LOL. I was a bit worried at the comment that psychiatrists are the gold standard of therapy. Yes, there are lots of excellent psychiatrists (including Roy, Dinah and Clinkshrink) but Dinah mentions how therapy gets sidelined in training. I think it really depends on the level of training. In SA, my experience is that well-trained psychologists are excellent at therapy but obviously defer to psychiatrists on all meds matters. Psychiatrists often make bad therapists but also really good ones. Some social workers are equally good (if thoroughly trained) but my thoughts here are that you need rigorous training here and a lifelong committment to your own personal and professional development. (BTW see my latest post on turning the tables in therapy - sorry, shameless punt!)

Rach said...

Tigermom, have you suggested that those people who want regular sessions book with you upfront... I know that I did that for months on end with my shrink when I needed a particular time - a Thursday lunch hour - it was the only time my schedule would allow for

Ladyk73 said...

I think everyone who works in the field of mental health should get some training in therapy, and have knowledge of the different kinds of stuff that is out there, and most important, the evidence behind it.

I think that each profession comes with a different skill. I think psychiatist are far better training with mental status exams, and the ability to tease out and diagnosis different forms of psychosis. I thank psychologists (clinical, not those cognitive scientists out there) are hands down the better psychotherapist to deal with neurosis, and private practice therapy.

I think social workers are best at family work and honestly, AXIS II disorders. I actally think psychologists are better trained it in....but there very maladaptive and agressive cluster B folks usually end up in social workers hands cause everyone else have kicked them out of their practice!

My little take on Social workers. Not all master level social workers are trained well psychotherapy. However if one is licenced as a clinical social worker (LCSW) they have had to have so many classes, training, passed tests, and have been in supervision for at least 3 years in most states.
Just my thoughts

Clueless said...

No matter what any clinician's education, training and background is some are suited to do psychotherapy and some are not.

As a social worker, I had many times where it would have been helpful for their psychiatrist to have psychotherapy skills. For some it was natural and others it was a huge stretch that no amount of training would have compensated for, yet they were excellent psychiatrists.

As a patient, I have had two different psychiatrist in my life. The first was very symptom and medication oriented and did not seem to understand how my psychotherapy was impacting some of my symptoms. After a 7 year break of not requiring medications, I needed to find another one as he was retired.

I found one who just by our telephone conversation I could tell that he was more psychodynamic. And, it ends up being that depending on my needs sometimes it is more psychotherapy or more medication/symptom oriented. He actually serves to supplement my therapy with my therapist. However, there does run the risk of splitting or having opposing viewpoints. If both are providing some psychotherapy, it is important that communication between the two is maintained when needed.