Tuesday, July 12, 2011

Psychotherapy and Psychiatry: Keeping it Alive

This is part of a simultaneous 3 site post.

On Shrink Rap Today over on the Psychology Today website, I talk about how high-volume, rapid-care psychiatry shows us at our absolute worst, and I report on survey results about how psychiatrists in Maryland are practicing--- please be forewarned, this was from an emailed poll and the data was not validated or verified, but it is interesting! 

On Shrink Rap News over on the Clinical Psychiatry News website, I make a case for why psychiatry residents should be required to learn how to do psychotherapy even if they don't plan to practice it when they finish training.  

We really don't even have a precise definition of what "psychotherapy" is, and CPT coding has defined it in terms of time spent in a session and reimbursements.  A 50-minute session gets coded as 90807 which stands for "45-50 minute psychotherapy session with medication management on an outpatient basis in a physician's office."   The frequency doesn't matter, nor does the content of what transpires-- at least not for the CPT codes.  But certainly, not everyone who comes for a 50 minute sessions is actually in a formal insight-oriented psychotherapy.  Good care involves listening to the patient before making decisions about medications, and seeing 4 patients an hour, lined up on a conveyor belt, hour after hour, regardless of the patient's need to talk or the complexity of the case-- is no way practice psychiatry (and I personally wouldn't have the stamina).  Those who do it have bought in to an insurer's idea of how the world should work.    In fact, very few psychiatrists in Maryland reported that they practice this way, even if the media would have you believe that this is the norm in psychiatry.

I like to think of psychotherapy as a process over time where the talking itself is part of what heals.  Certainly there is something about talking openly about things which may be troubling, embarrassing, or leave one feeling vulnerable, which is helpful, particularly in a setting deemed to be safe and free from negative judgment.  From the psychiatrist's point of view, psychotherapy is about looking for patterns in thoughts, feelings, behaviors, or reactions, and bringing these patterns to the patient's awareness in a way that may allow him to change.  

Obviously, I think psychotherapy is important to psychiatry.  
Please do check out the other posts on Shrink Rap News and Shrink Rap Today.

You are invited  to comment on any, or all, of the websites.  
While you're here, please take our sidebar poll ----->
And  please do let us know if you have an active psychiatry blog or know of any for our list.

Thank you for participating in today's 3-ring psychotherapy post!


rob lindeman said...

"I like to think of psychotherapy as a process over time where the talking itself is part of what heals"

And you wouldn't be alone. This is the root and branch of psychiatry. If I were a shrink, and I were so religiously-inclined, every night when I hit my knees I'd pray for the return of talking therapy.

wv = strais, usually with "dire", the condition in which psychiatry finds itself

Anonymous said...

Either that Rob, or you could check out your local minyan for Mincha and Ma'ariv services. It will save your knees.
If you are really in dire strais, check out a little shteibel where everyone will talk that way.

jesse said...

Dinah, great post!

“Should psychiatry residents be required to learn psychotherapy?” My first, reflexive retort was “well, should cardiologists be required to learn to use a stethoscope?” It might seem that the difference is that psychotherapy is a treatment and the stethoscope is for diagnosis, but the similarities are closer than one might think.

The core of psychiatry is an understanding of how the mind functions. Yes, the mind itself is a function of the brain, and there are diseases of the brain that effect variously thinking, perception, affect, and so on, but still the interface between the psychiatrist and the brain is the mind. This has at least two dimensions: There are illnesses like schizophrenia in which the symptoms become evident through talking with the patient, and there are conditions in which the symptoms are primarily due to the software, the programming as it were, as opposed to the hardware.

Psychotherapy is as much a means of gathering data as it is of directly helping our patients. Through it we learn how tenaciously an idea can be held, the degree of resistance to change, the meaning of fantasies, hopes, dreams. Through working with our patients we learn how to be a careful listener, and can help the patient learn about. There is a great deal that is not on the surface and would never, and should never, come up in an initial interview.

We also learn when not to use medications. It is only through working with patients in this manner that we can see what change is possible through thinking and reflection. This also, then, allows us to use medications more rapidly and sensitively when warranted.

Talking with patients may seem old-fashioned and not so cost-effective, but there is no better way to learn what our patients need than by talking with them.

rob lindeman said...

As luck would have it, anon, I'm "captain Tuesday" at mincha/ma'ariv tonight at my shul. That means I'm responsible for making calls if we can't make a minyan. After which, some talking therapy might do me good.

Anonymous said...

Rob, all this time I thought you were a trombenik. Now I know better. Hope you get the minyan.

Novalis said...

I'm all for psychotherapy, but the fact is that there are plenty of other providers--psychologists, social workers--who provide it just as well as psychiatrists do. The question that insurers (and patients) can reasonably ask is, "Why should we pay a psychiatrist to do something for $150 an hour that someone else can do for $80 an hour?"

This isn't to say that psychiatrists shouldn't do psychotherapy, only that except for those catering to a boutique clientele, shrinks doing so might expect an income closer to, say, $80,000 than to $150,000. This kind of economic modesty is admirable, but it will never characterize the majority of psychiatrists.

Dinah said...

It finally happened: Rob agreed with something I said. Wow.

Jesse: Thank you. Great reply!

Novalis: I would contend that there are circumstances where it works better to have a single professional managing both meds and psychotherapy. I have such a 'boutique' practice and I see patients who are not wealthy: generally they have not done well with the split treatment model, or they've been difficult to stabilize. Insurance reimburses for a portion of their treatment, and sometimes that portion is 80%, and often they decrease the frequency of sessions when they are not in active distress. Unfortunately the split treatment model often involves very short sessions (?20 minutes) to manage medications...oh, float over to my psychology today post! And psychologists around here are not any cheaper than psychiatrists.

Zoe Brain said...

Hi Dinah

A few wildly divergent issues:

You speak of modifying feelings and modifying behaviours. Behaviours I can understand, that should be easy (from my ignorant viewpoint). Feelings, much harder, and requiring a longer-term effort.

$180 an hour? Wish there were psychs here who charged that little! $270 and up for the basic 1 hour or part thereof consultation here. Or at least it was, 4 years ago, when I last saw one.

I see you're in Baltimore. I've been trying to help some people in Maryland who have experienced high anxiety over this incident. There seems to be two distinct patterns - those still functional, but with flashbacks to similar experiences (PTSD?), and those now getting really dysfunctional, too afraid to leave their rooms (agorophobia/anxiety disorder? So much I don't know...).

They can't, in general, afford to seek professional help, but our efforts to help them aren't as effective as we'd like. Are there any online courses or something so bumbling amateurs like me don't inadverantly make things worse? We can't lie and tell them that these incidents are rare (though being videoed is) - too many reports from those experiencing flashbacks, we'd lose credibility.

It's been long enough now that those who were going to pick themselves up have done so. Nearly all have. There's a few though who seem to be in a bad place, and we can't get them out.

Naturally it's affecting me too, anger, frustration, and that might be compromising my ability to help. I don't know, too ignorant about matters psychological. Any tips, given that professional help is unavailable? How do *you* deal with situations that can't be fixed?

I'd make a lousy shrink. Rocket Science is so much easier than seeing people in pain and not being able to help.

None have suicidal ideation, I hope this is a temporary problem, but meanwhile they're hurting.

Anonymous said...

Novalis: Because non-psychiatrist therapists also charge $150 (or more).

witchtwi--- where the witches build their twehouses

Sideways Shrink said...

If I'm sitting in your living room and you really just had twins, Dinah, I would ask if there is anything I could do to help!
But, in lieu of that, I find that psychotherapy is a fundamental tool I use in assessing a patient regardless of whether they present for medication management or psychotherapy. I think this is because in my training in New York we were "strongly recommended" to be in therapy while we were training. Therapy is the building of narratives: in the relationship between therapist and patient and within the therapist and the patient. That is different from physical assessment. At the simplest level, understanding and interacting with how a patient feels about their diagnosis, previous shrinks, other people in their family who are on the medication I just suggested are crucial to the work.

I boldly assert that more than in any other field of medicine, patients take or do not take the medications we prescribe based on how well we have made them feel heard. Of course, how well we have listened to not just the symptoms for diagnosis and their narrative about medications and mental illness determines how well we choose the medication(s). It is phenomenologically nonsensical to me to look at a patient in some way where I separate their symptoms from their narrative, from how I feel about them, and from the relationship between us. How do those psychiatrists practice now who weren't interested enough in their patients to come to their supervision session without too many things to talk about to fit into the session? Why wouldn't they have just gone into medical neurology?

rob lindeman said...

Regarding fees for psychotherapy. Here's a novel idea: charge less to position yourself more competitively in the market. What, too simplistic?

Dinah said...

Rob (and others) -- from a shrink's point of view, there isn't a problem (I don't think)-- to the best that I'm aware, psychiatrists aren't having trouble finding patients, and those who will provide psychotherapy really aren't having trouble finding patients. The problem is that people with limited resources are having trouble getting any care, much less psychotherapy from psychiatrists, but the issue is more one of too much demand. Plus, since it's not an advertised commodity, or something that people shop for by price (I've never heard, The Shrink Down the Street charges $10/an hour less), it doesn't work. If anything, the opposite is true--- people want the best at any price, and people are picky about their shrinks.

Zoe-- if your Baltimore associates have no insurance and markedly limited resources, they might want to try The Pro Bono Counseling Project--- they offer free care to those without insurance or the financial means to pay for care.

rob lindeman said...

Regarding people with limited resources: how about charging less so that these people can afford talk therapy too? What? Too simplistic?

wv = jundlyza. I think I went to high school with that girl.

Anonymous said...

Licensed social workers trained in psychotherapy ,who are in private practice, charge plenty of money. Those who are agency or hospital based do not provide ongoing therapy, as a rule.

Steven Reidbord MD said...

In the two psychiatry residency programs here in San Francisco (UCSF and CPMC), psychotherapy training is alive and well. I lead an hour-long weekly seminar on psychodynamic therapy for CPMC residents that lasts half their 3rd year. Of course, there's no expectation that all residents will offer this treatment after training, although many do. Even future psychopharmacologists benefit from familiarity with these foundational psychiatric concepts, and from a deeper understanding of such issues as medication compliance, placebo effects, and "flight into health."

We need a psychiatry that is neither brainless or mindless. Medications and psychotherapy can both help patients. Psychiatrists are in a unique position to assess patients without prejudice, to recommend and provide whatever treatment is indicated in a particular case. But only if we know and appreciate the options available.

I have to confess, though, I'm a little curious why you posted this 3-site effort now. The hubbub over the NY Times article "Talk doesn't pay" was 4 months ago. Many bloggers, myself included, spoke up then about how this widely read article maligned psychiatry and painted an unrealistic picture of practice.

Dinah said...

By the time you're asking "why now?" well, you're interested in the process, rather than the content.

We had a lot to say when the Harris article came out (didn't everyone?), it really got people talking/blogging. I think it was this article that either inspired, or was the final thing that pushed us to do a Maryland practice survey---that took a little bit--. But you know, I read an article in the Psychiatric Times today --- I think it was a review of Unhinged, where a psychiatrist referred matter-of-factly to the 'fact' that psychiatrist treat 4 patients an hour (this is clearly not the norm here in Maryland) and I have seen numerous newspaper articles that reference the fact that psychiatrists no longer do psychotherapy. It's not helping our field. I guess I'm still thinking about it so I'm still writing about it. It inspired my interview with Dr. Mojtabai, and it may be the basis of one more CPN piece. Oh, and to add to that, since our book came out, we've had a lot of venom and 'hater' energy here at Shrink Rap (have you missed the noise?) it just furthers my theory that turning psychiatry into med check mania is not doing good things for us.

Steven Reidbord MD said...

Sure, I'm interested in process. Isn't everyone? ;-)

The Harris article did feel like a watershed, although I'd heard for years that dynamically-informed psychiatry is dying out. And really, Harris wrote an anecdotal piece about one poor sap who couldn't make his car payments, or whatever.

Nonetheless, I agree it's not helping our field one bit, and I appreciate your efforts both on the practice survey and in managing online vitriol. The dynamics of internet discourse is an interesting study in itself.

Zoe Brain said...



Thanks, I'll pass it on.

Anonymous said...

There is the request by some in various groups of people that psychotherapists lower their fees--this happens on this blog and in my practice with patients. One could speculate infinitely about each individuals psychodynamics in making this request besides the simple financial need they have. It is one thing to lack money to pay and another to ask a professional to discount their services: doesn't happen with orthopedic surgeons or pediatricians on advance of services. Then there is the pot shot of challenging psychotherapists to charge less for what the posting person feels to be a relatively useless and/or non-medical "service".
What both of these requesting "group members" fail to recognize is that psychotherapy is a time based endeavor generally 45-50 minutes. And to pay for living expenses, operating expenses (including one's own health insurance premiums), and student loans which are often sizable whether a psychiatrist or a Masters level psychotherapist, it it is not quite so simple to "drop the cost of a psychotherapy session".
The previous generations of psychiatrists simply do not know what the current generation of shrinks are up against. That is why there are an ever diminishing number of younger psychiatrists and their "cheap replacements" psych NPs. This is not discussed much on shrink blogs. The future is coming, right?

Anonymous said...

Thank you for your article. It is heartening to hear that USA psychiatrists are indeed still doing psychotherapy. It is easy here in Australia to get the impression that insurance companies in the USA have managed to transform psychiatric practice into soul less medication conveyer belt medicine. It is often more efficient for the patient to have the psychiatrist conduct both psychotherapeutic intervention and medications.